Author disclosures Alejandro Ariel Gru is a paid consultant for Seattle Genetics and has an ongoing relationship with Innate Pharma. John Zic is a site principal investigator for clinical trials for products from Elora and Galderma. The other authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. The manufacturers did not provide equipment or other forms of material support.
Marianne Tawa. We would start out with narrow band UVB therapy for patients with > 10% body surface area involvement. When applying topical corticosteroids to wider surface areas of the patient’s body is no longer feasible or effective, we recommend the initiation of narrow band UVB phototherapy. This is preferred because of its lessor adverse effect (AE) profile as far as nonmelanoma skin cancer risk. Patients commence narrow band UVB 3 times per week, with a goal of getting the patient into remission over a matter of months and then slowly tapering the phototherapy so that they get to a maintenance of once weekly.
Realizing that narrow band UVB may not penetrate deeper plaques or effectively reach folliculotropic variant of CTCL, we would employ PUVA, (psoralen and UVA). Patients are expected to protect their eyes with UVA glasses and remain out of the sun 24 hours following PUVA treatments. The cost of the methoxsalen can be an issue for some patients. Nonmelanoma skin cancer risks are increased in patients undergoing long-term PUVA treatments. Routine skin cancer surveillance is key.
There are monetary, time, and travel demands for patients receiving phototherapy. Thus, many CTCL patients are moving toward home-based narrow band UVB units supervised by their treating dermatologist. Other skin-directed treatment options, aside from topical corticosteroids and phototherapy, would include topical nitrogen mustard, imiquimod, and localized or total skin electron beam radiation.
John Zic. Here in Nashville, some of our veterans travel hundreds of miles to get to our center. It’s not practical for them to come here for the narrow band UVB phototherapy. Veterans can get approval through the VA Choice programs to have phototherapy performed by a local dermatologist closer to home. We also have had many veterans who choose to get home narrow band UVB phototherapy, which can be quite effective. Narrow band UVB phototherapy is among the most effective therapies for patients with generalized patches in particular, and maybe some with just a few plaques.
Medium potency topical steroids are not as helpful as superpotent topical steroids such as clobetasol, dipropionate ointment, or betamethasone dipropionate ointment. Usually, I tell patients to apply it twice a day for 8 weeks. You must be careful because these high-potency topical steroids can cause thinning of the skin, but it’s rarely seen, even in patients that may use them for 8 weeks if they’re applying them just to their patches and thin plaques. There are a few other topicals. There’s bexarotene gel, which is a topical retinoid, and mechlorethamine or nitrogen mustard gel that are available as topicals. Both of those can be helpful if patients have < 10% body surface area of patches or plaques because they can apply that at home.
Because of the excellent prognosis for patients in early stages, this is an area we want to try to avoid doing harm. For patients with advanced disease, what are some of the decisions that you think about in recommending a patient to get radiation therapy?
