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Narrowband UV-B Phototherapy vs
Photochemotherapy in the Treatment
of Chronic Plaque-Type Psoriasis
A Paired Comparison Study
Adrian Tanew, MD; Sonja Radakovic-Fijan, MD; Michael Schemper, PhD; Herbert Ho¨nigsmann, MD
Objective: To compare the therapeutic efficacy of nar-
rowband (TL-01) UV-B phototherapy vs photochemo-
therapy (psoralen–UV-A [PUVA]) in patients with chronic
plaque-type psoriasis.
Design: Open, nonrandomized, intraindividually con-
trolled paired comparison study.
Setting: Phototherapeutic unit in a university hospital.
Patients: Twenty-five patients with chronic plaque-
type psoriasis.
Interventions: Paired irradiations with threshold ery-
themogenic doses of narrowband UV-B and PUVA were
given to the patients’ dorsal aspect including the arms
and legs. Treatment was performed 3 times weekly until
complete or almost complete clearing with one or both
regimens or over a maximum period of 18 exposures.
Main Outcome Measures: Assessment of the Psoriasis
Area and Severity Index (PASI) in each half of the patient’s
dorsal aspect before and after treatment with the 2 regimens.
Results: The median pretreatment PASI score of 16
(range, 6.2-23.4) was reduced by 84% to 2.5 (range,
0-12.6) by the narrowband UV-B treatment and by 89%
to 1.8 (range, 0-8.2) by the PUVA treatment. Statistical
analysis of these data showed a tendency for PUVA
being superior to narrowband UV-B although the differ-
ence remained below the level of significance (P= .17).
However, a clear effect of the pretreatment PASI score
on the therapeutic outcome was found. Patients with
higher baseline PASI scores responded significantly bet-
ter to PUVA than to narrowband UV-B (P= .03).
Conclusions: Our data demonstrate that in many pa-
tients with plaque-type psoriasis, narrowband UV-B is
comparably as effective as PUVA and, given the lack of
photosensitizer-related adverse reactions and the possi-
bly lower long-term cancer risk, can be considered as first-
line treatment. Treatment with PUVA, on the other hand,
remains the mainstay for patients with high PASI scores
who do not respond or whose psoriasis cannot be con-
trolled adequately by narrowband UV-B.
Arch Dermatol. 1999;135:519-524
CONVENTIONAL photo-
therapy with broadband
UV-B and photochemo-
therapy (psoralen–UV-A
[PUVA]) are very effi-
cient and widely used treatment modali-
ties for psoriasis. The choice of treatment
depends on the type and severity of pso-
riasis, the patient’s age and general health,
and the consideration of treatment-
associated long-term risks. Comparative
studies have shown that PUVA is thera-
peutically more effective than broadband
UV-B radiation.1-4 Conversely, treatment
with UV-B is much easier to perform, re-
quires less precautions to prevent acute ad-
verse reactions, and seems to harbor a con-
siderably lower carcinogenic potential than
PUVA.5-7 Based on these differences, broad-
band UV-B phototherapy is primarily in-
dicated in patients with mild to moderate
psoriasis, whereas for severe forms of
PUVA is indicated.
This rough distinction between the
use of phototherapy and PUVA for pso-
riasis had to be reevaluated when in the
early 1980s a fluorescent lamp emitting
narrowband UV-B between 311 and 313
nm (referred to as the TL-01 lamp) was
developed by Philips to improve the effi-
cacy of phototherapy.8,9 The rationale for
manufacturing such a lamp was derived
from action spectra studies for the pho-
totherapy of psoriasis in which longer
wavelengths in the UV-B region were in-
dicated to have the best ratio of antipso-
For editorial comment
see page 589
STUDY
From the Divison of Special and
Environmental Dermatology,
Department of Dermatology
(Drs Tanew, Radakovic-Fijan,
and Ho¨ nigsmann), Section of
Clinical Biometrics,
Department of Medical
Computer Sciences
(Dr Schemper), University of
Vienna Medical School, Vienna,
Austria.
ARCH DERMATOL / VOL 135, MAY 1999
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riatic to erythemogenic activity.10,11 Several authors sub-
sequently investigated the therapeutic effectiveness of
narrowband UV-B by either comparing the treatment re-
sults for the new lamp with those from previous trials
using broadband UV-B12 or by means of bilateral com-
parison studies.13-19 These investigations confirmed the
efficacy of narrowband UV-B treatment and showed that
it provides for faster clearing, less burning reactions, and
longer periods of remission12 than conventional broad-
band UV-B phototherapy. The relative efficacy of nar-
rowband UV-B in comparison to PUVA was investi-
gated by van Weelden et al20 in a pilot study of 10 patients
with widespread psoriasis vulgaris.On average the same
results were found with both treatments. Green et al21
treated 3 groups of 15 patients each with either narrow-
band UV-B or etretinate plus narrowband UV-B or etreti-
PATIENTS AND METHODS
Twenty-five patients with skin type II or III who con-
sented to participate after having received full informa-
tion on the setup and the purpose of the trial were con-
secutively enrolled in this open paired-comparison study.
All of these patients had generalized, chronic plaque-type
psoriasis in a largely symmetrical distribution and had not
received any specific antipsoriatic treatment within the last
4 weeks prior to the study. At the beginning and at the end
of the study the Psorias Area and Severity Index (PASI)
score22 was determined separately for each half of the pa-
tient’s dorsal aspect (hereafter, half-side).
HALF-SIDE TREATMENT
The PUVA treatment was performed with a liquid prepa-
ration of 8-methoxypsoralen (methoxsalen) (Oxsoralen;
Gerot Pharmazeutika, Vienna, Austria) at a dosage of 0.6
mg/kg. Prior to the initiation of the half-side comparison
first the minimal erythema dose of narrowband UV-B
(MEDTL-01) and subsequently the minimal phototoxic dose
(MPD)23 were determined in each patient. Treatment was
given 3 times weekly on Monday, Wednesday, and Friday
in an irradiation unit for supine therapy. No additional spe-
cific systemic or local antipsoriatic therapy was given; how-
ever, the patients were allowed to apply emollients after
the treatments.
To reduce the patient’s additional expenditure on time,
the half-side comparison was performed only on the dor-
sal side of the whole body that included the dorsal aspect
of the arms and legs. On each treatment day the patient first
received the narrowband UV-B irradiation on the right side
of the dorsal aspect. During the irradiation the rest of the
body was covered by 4 layers of white, tightly woven cot-
ton that completely prevented the transmission of UV light.
Immediately after the UV-B exposure, the patients in-
gested the psoralen capsules. One hour later, the left side
of the patient’s dorsal aspect and subsequently the whole
ventral aspect were exposed to UV-A, while the body area
previously treated with narrowband UV-B was shielded from
receiving additional UV-A radiation. The initial irradia-
tion dose was 1 MEDTL-01 and 1 MPD. Patients with a nega-
tive MPD test were treated with a skin type–based initial
UV-A dose of 1 J/cm2for skin type II and 2 J/cm2for skin
type III. Subsequent dose adjustments were based on the
patient’s history and the clinical examination and aimed
at eliciting or maintaining a slight erythematous reaction
with both treatments. The irradiation dose was unaltered
when the patients reported or still had erythema and was
increased by 20% in skin type III and by 10% in skin type
II patients, respectively, in the absence of an erythema-
tous response. Owing to the different time courses of
erythema formation, the narrowband UV-B dose was in-
creased, when required, at each visit, whereas the PUVA
dose was adjusted not earlier than 72 hours after the last
treatment.
The half-side treatment was performed until com-
plete or almost complete (minimally infiltrated, nonscal-
ing residual plaques) clearing occurred in the narrow-
band UV-B– and/or PUVA-treated skin areas or over a
maximum period of 18 exposures. Patients who at the end
of the study had not achieved complete or almost com-
plete clearing with one or both treatments were either con-
tinued on the more effective regimen, or, when both treat-
ments had given an equal result, on the subjectively preferred
regimen until complete clearing occurred. No mainte-
nance treatment was added.
RADIATION SOURCES, IRRADIANCE
MEASUREMENTS, AND PHOTOTESTING
Phototesting and treatment with narrowband UV-B was done
with a Waldmann UV 3003 lay down irradiation unit (Wald-
mann; Werk fu¨ r Lichttechnik, Schwenningen, Germany)
equipped with 15 Philips TL 100W / 01 fluorescent tubes.
The MEDTL-01 was determined by exposing the patient’s but-
tocks to a geometrical dose range between 141 and 566 mJ/
cm2. The irradiance at skin level was, on average, 3.85 mW/
cm2and measured with an IL 1700 research radiometer
(International Light, Newburyport, Mass) and NS 313–
filtered SD 240 probe with a spectral response from 308 to
318 nm (half-power points) and a peak sensitivity at 313
nm.
Subsequent to the the MEDTL-01 testing, the MPD was
assessed with a Waldmann PUVA 500 irradiation unit
equipped with 10 Philips TLK 40W / 09N UV-A lamps. The
irradiance at skin level was 10.5 mW/cm2as measured with
a Waldmann UV meter whose spectral sensitivity corre-
sponds to the spectral emission of the UV-A lamps. The
UV-A dose range was 0.5 to 5 J/cm2for skin types I or II
and 1.5 to 9 J/cm2for skin types III or IV.
A Waldmann PUVA 4000 lay down unit equipped
with 40 Sylvania FR 90 T 12 / PUVA fluorescent tubes
was used for the therapeutic irradiations. The irradiance
was on average 12.6 mW/cm2as measured by an inte-
grated radiometer.
STATISTICAL METHODS
Within the framework of a hierarchical model an analysis
of covariance was performed using the GLM program of
SAS. Thus, the possible effect of the baseline PASI score,
the treatment, and the interaction between the baseline PASI
score and treatment were analyzed taking into account the
block structure of the study (each patient receiving both
treatments).
ARCH DERMATOL / VOL 135, MAY 1999
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nate plus PUVA. They observed a 100% sucess rate in
the etretinate-PUVA group as opposed to a 93% success
rate in the etretinate-narrowband UV-B group and an 80%
success rate in the narrowband UV-B monotherapy group.
A direct comparison between narrowband UV-B and
PUVA was not included in that study.
The present investigation was undertaken to evalu-
ate on a larger scale the therapeutic potential of narrow-
band UV-B phototherapy in relation to PUVA and to de-
termine whether in patients with moderate to severe
chronic plaque-type psoriasis, narrowband UV-B pho-
totherapy may serve as an effective therapeutic alterna-
tive to PUVA.
RESULTS
All patients completed the study. Of these, 21 patients
consistently had a comparable number of erythemo-
genic events with both treatments during the study
period, whereas in 4 patients the PUVA-induced ery-
thema occurred only after 8 to 13 exposures and on
fewer occasions than with narrowband UV-B. Since it
was the aim of the study to compare the therapeutic
efficacy of equierythemogenic dosages, these latter 4
patients were excluded from evaluation. The remaining
21 patients were of skin types II (7 patients) or III (14
patients), with a median duration of psoriasis of 17
years (range, 1-46 years). In all these patients, the
MEDTL-01 was within the range of test doses with a
median of 400 mJ/cm2(range, 141-566 mJ/cm2). The
MPD test gave a negative result in 3 of the 21 patients.
The median MPD of the remaining 18 patients was 1.5
J/cm2(range, 0.5-5 J/cm2).
The treatment results summarized in Figure 1
show the PASI score of each patient at baseline and
after treatment with PUVA and narrowband UV-B,
respectively. The overall response to PUVA was slightly
superior to narrowband UV-B phototherapy. After a
median of 15 exposures (range, 6-18 exposures) and 38
days (range, 18-53 days), the median baseline PASI
score of 16 (range, 6.2-23.4) was reduced by 84% to 2.5
(range, 0-12.6) by the narrowband UV-B treatment and
by 89% to 1.8 (range, 0-8.2) by the PUVA treatment
(Table). The median cumulative doses of narrowband
UV-B and UV-A were 12.7 J/cm2(range, 1.8-22.3 J/cm2)
and 40.1 J/cm2(range, 6.9-87.5 J/cm2), respectively. By
analysis of covariance, no significant difference was
found in the overall efficacy of the 2 regimens (P= 017).
25
20
15
10
5
0123456789101112131415161718192021
Patients
Psoriasis Area Severity Index Score
Baseline
Narrowband UV-B
PUVA
Figure 1.
The Psoriasis Area and Severity Index scores of all patients arranged in order of increasing magnitude before and after treatment with narrowband UV-B
and psoralen–UV-A. There was a significantly better response to psoralen–UV-A than to narrowband UV-B with increasing baseline score (
P
= .03 by covariance
analysis).
Treatment Results*
Initial UV
Dose, J/cm2
Final UV
Dose, J/cm2
Total UV
Dose, J/cm2
No. of
Exposures
Treatment
Duration, d
PASI† Score
Baseline Final
Narrowband UV-B 0.4 (0.14-0.57) 1.42 (0.48-2.45) 12.7 (1.8-22.3) 15 (6-18) 38 (18-53) 16.0 (6.2-23.4) 2.5 (0-12.6)
Psoralen–UV-A 1.5 (0.5-5.0) 3.1 (0.9-8.6) 40.1 (6.9-87.5) 15 (6-18) 38 (18-53) 16.0 (6.2-23.4) 1.8 (0-8.2)‡
*
Values are medians (ranges).
†
PASI indicates Psoriasis Area and Severity Index.
‡P
= .17 by analysis of covariance.
ARCH DERMATOL / VOL 135, MAY 1999
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However, when the patients were stratified according to
their pretreatment PASI score the correlation to treat-
ment response was significant. With increasing PASI
scores the patients’ psoriasis cleared better with PUVA
than with narrowband UV-B phototherapy (P= .03)
(Figure 1).
In the direct left to right comparison, 4 patients
showed a better response to narrowband UV-B, 6 re-
sponded equally to both treatments (Figure 2), and 11
had a greater degree of clearing with PUVA (Figure 3).
The half-side differences were, however, slight in most
patients. Complete or almost complete clearing was in-
duced on the dorsal half-side by PUVA in 9 patients and
by narrowband UV-B in 7, respectively (2-tailed p = 0.75
by Fisher exact test).
Irrespective of the treatment modality, a higher re-
duction of the PASI score (P,.001) and a higher prob-
ability to clear completely within the study period (P= .03)
was found for patients with lower pretreatment PASI scores.
Only few and minor side effects occurred during the
study period. In the initial phase of treatment, 3 pa-
tients experienced moderate nausea after the ingestion
of the psoralen capsules which, however, did not neces-
sitate any specific antiemetic treatment and subsided spon-
taneously during the later course of treatment. One pa-
tient reported itching in both the narrowband UV-B– and
PUVA-treated skin areas. Another patient developed le-
sional blistering24 on the right side of her back after 14
irradiations with narrowband UV-B.
COMMENT
The development of the TL-01 lamp with a higher
therapeutic potential than conventional broadband
UV-B sources as well as the increasing awareness of
the carcinogenic risk associated with long-term
PUVA6,7 have led to a continuously growing use of
narrowband UV-B phototherapy in psoriasis. With
regard to the relative therapeutic effectiveness of nar-
rowband UV-B and PUVA, however, only sparse data
are available.20,21 Such information is particularly
important for patients with moderate to severe chronic
plaque-type psoriasis as, besides the palmoplantar and
the rare erythrodermic and pustular forms of psoriasis,
it is this type of psoriasis where PUVA is primarily
indicated.
The only half-side comparison study on narrow-
band UV-B vs PUVA conducted so far was published by
van Weelden et al20 in 1990. They treated 10 patients
with widespread psoriasis vulgaris twice weekly with
slightly erythemogenic dosages over a maximum period
of 4 weeks. Within the relatively short study period “on
average no significant difference was found between the
overall therapeutic effectiveness of narrowband UV-B
and PUVA.” However, the therapeutic result differed
depending on the body site. Whereas the lesions on the
trunk responded better to narrowband UV-B the
oppposite was true for the psoriatic plaques on the arms
Figure 2.
Left, A patient before treatment. Right, The same patient after 14 treatments and a treatment duration of 35 days. Almost complete clearing with
psoralen–UV-A (left side) and narrowband UV-B (right side). The total UV doses were 87.5 J/cm
2
and 10.6 J/cm
2
, respectively.
Figure 3.
Left, A patient before treatment. Right, The same patient after 18 treatments and a treatment duration of 44 days. Notable improvement with
psoralen–UV-A (left side) moderate improvement with narrowband UV-B (right side). The total UV doses were 48.5 J/cm
2
and 16.9 J/cm
2
, respectively.
ARCH DERMATOL / VOL 135, MAY 1999
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and legs. These findings indicated that PUVA might be
more effective for lesions that are more recalcitrant to
therapy.
In our study treatment was given thrice weekly over
a maximum period of 18 exposures. To apply bioequiva-
lent doses of both irradiations, we followed a slightly ery-
themogenic dosimetry as was done in the trial by van
Weelden et al.20 The overall improvement, ie, the reduc-
tion of the median pretreatment PASI score, did not dif-
fer significantly between the 2 regimens. However, a posi-
tive correlation between the magnitude of the baseline
PASI score and the probability to clear better with PUVA
treatment was found indicating that in patients with high
PASI scores, PUVA is more likely to induce complete or
almost complete remission.
Taken together, our data demonstrate that in many
patients, in particular those with moderate or moderate
to severe psoriasis, narrowband UV-B is comparably as
effective as PUVA whereas in the more severely af-
fected, PUVA is superior. This is in agreement with pre-
vious studies that by retrospective or direct comparison
found a similar efficacy of narrowband UV-B relative to
PUVA in psoriasis19,20 but also revealed that in a subset
of patients treatment with PUVA is required to achieve
a satisfactory response.25
The use of narrowband UV-B offers some major
advantages owing to the fact that it does not depend
on the concomitant administration of a photosensi-
tizer. In oral PUVA psoralen intolerance reactions, the
variability of the psoralen levels, hepatic diseases, and
drug interactions have to be taken into account. In
addition, the systemic photosensitization necessitates
adequate eye protection and prolonged sun avoidance.
With bath PUVA many of these disadvantages are
obviated; however, the requirement of the bathing
procedure limits the broader use of this treatment
modality.
Controversial data are found in the literature on the
incidence and severity of burning reactions under nar-
rowband UV-B treatment. Compared with broadband
UV-B, both a lower12,17 as well as a higher fequency26 of
burning episodes or more intense erythematous reac-
tions19 were reported. Differences in the irradiation pro-
tocol and the patient’s skin type seem to be important in
this regard. In our study, none of the patients experi-
enced a severe burning episode with either one of the 2
regimens.
The consideration of treatment-associated long-
term risks, in particular the carcinogenic potential, is a
central issue in the choice of treatment for patients with
psoriasis. The assessment of cancer risk resulting from
the clinical use of narrowband UV-B is based on retro-
spective studies on broadband UV-B–treated pa-
tients6,7,27,28 and on mouse studies comparing the carci-
nogenicity of broadband vs narrowband UV-B.13,29-31 These
data suggest that the cancer risk of equitherapeutic doses
of narrowband UV-B is not greater than that of broad-
band UV-B and substantially lower than that of PUVA.32,33
This assumption has recently gained further support from
an in vitro study indicating that phototherapy with nar-
rowband UV-B does not produce more DNA damage than
treatment with broadband UV-B.34
Considering the good therapeutic efficacy and the
low profile of acute and possibly also long-term side ef-
fects, we consider narrowband UV-B as first-line treat-
ment for patients with moderate to severe plaque-type
psoriasis. Psoralen–UV-A on the other hand, remains the
mainstay for patients with severe psoriasis whose con-
ditions do not respond or cannot be controlled ad-
equately by narrowband UV-B. The optimum treatment
protocol for narrowband UV-B and, in particular, the av-
erage duration of remission are yet to be determined in
larger patient cohorts.35 In addition, prospective fol-
low-up studies are required to assess the long-term risks
in humans associated with therapeutic exposures to nar-
rowband UV-B radiation.
Accepted for publication November 23, 1998.
Corresponding author: Adrian Tanew, MD, Division
of Special and Environmental Dermatology, Department of
Dermatology, University of Vienna Medical School, Wa¨hr-
inger Gu¨rtel 18 - 20, A - 1090 Vienna, Austria (e-mail:
a.tanew@akh-wien.ac.at).
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ARCHIVES Web Quiz
Be sure to visit the Archives of Dermatology’s World Wide Web site (http://www.ama-assn.org/derm) and try your
hand at our new Clinical Challenge interactive quiz. We invite visitors to make a diagnosis based on selected
information from an Off-Center Fold case scheduled to be published in the following month’s print edition of the
ARCHIVES. The first visitor to e-mail our Web editor with the first correct answer wins an Archives of Dermatology CD-ROM
and will be recognized in the print journal and on our Web site. A full discussion of the case featured in the quiz can be
found in the following month’s print edition of the journal.
ARCHIVES Web Quiz Winner for March 1999:
Our congratulations to the winner of our Clinical Challenge, Angela Bowers, MD, University of Texas Southwestern Medi-
cal Center at Dallas.
ARCH DERMATOL / VOL 135, MAY 1999
524
©1999 American Medical Association. All rights reserved.
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