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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Phototherapy consists of the therapeutic use of ultraviolet &#40;UV&#41; radiation&#46; It can be performed with exposure to sunlight&#44; ultraviolet A &#40;UVA&#41; or ultraviolet B &#40;UVB&#41; radiation&#46; The wavelengths administered and the UV radiation doses vary according to the proposed indication&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Ultraviolet radiation &#40;UVR&#41; encompasses wavelengths ranging from 200 to 400&#8239;nm&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is divided into&#58;</p><p id="par0020" class="elsevierStylePara elsevierViewall">UVA &#40;320&#8211;400&#8239;nm&#41;&#44; which is subdivided into UVA2 &#40;320&#8211;340&#8239;nm&#41; and UVA1 &#40;340&#8211;400&#8239;nm&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">UVB&#44; subdivided into broadband UVB &#40;290&#8211;320&#8239;nm&#41; and narrowband UVB &#40;NB-UVB&#41;&#44; from 311 to 313&#8239;nm&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">UVC &#40;200&#8211;290&#8239;nm&#41;&#44; which is blocked by the ozone layer and by the oxygen of the atmosphere and which is not used for phototherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The benefits of phototherapy have been recognized since the 20<span class="elsevierStyleSup">th</span> century BCE&#46; Although psoriasis is the most frequent indication&#44; phototherapy has been used successfully in several other dermatoses&#44; such as atopic dermatitis&#44; vitiligo&#44; cutaneous T-cell lymphoma&#44; and cutaneous sclerosis&#44; among others&#46; Using controlled and repeated UV exposures&#44; it is possible to induce regression or control the evolution of these dermatoses&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Most of the time&#44; phototherapy is used in combination with topical or systemic medications for better disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Just like any other therapy&#44; it has side effects&#46; Most of the time&#44; they are acute and transient&#44; including erythema and burns&#44; and attention should be paid to possible adverse events during treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Accessibility to the phototherapy unit is an important limiting factor for undergoing this type of treatment&#44; despite the degree of satisfaction reported by users&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">History</span><p id="par0055" class="elsevierStylePara elsevierViewall">For many centuries&#44; sunlight treatment or heliotherapy has been instituted for the treatment of skin diseases&#46; In Egypt and India&#44; 3&#44;500 years ago&#44; people had the habit of using plant extracts or seeds&#44; with subsequent exposure to the sun for the treatment of skin diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the 19<span class="elsevierStyleSup">th</span> century&#44; the modern era of the use of light started&#46; Downes and Blunt&#44; in 1877&#44; published results of research in which exposure to light inhibited fungal and bacterial growth&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the 20<span class="elsevierStyleSup">th</span> century&#44; phototherapy was recognized as a medical science after Niels Finsen received the Nobel Prize of Medicine in 1903&#46; Twenty years later&#44; William Henry Goeckerman started using a lamp that emitted mainly UVB&#44; together with coal tar to treat psoriasis&#46; This treatment became very popular and was used for decades&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The increase in the effectiveness of phototherapy started in 1947&#44; with the isolation of 8-Methoxypsoralen &#40;8-MOP&#41; and 5-Methoxypsoralen &#40;5-MOP&#41;&#44; derived from the Ammi Majus Linn flower&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">There are reports on the use of this plant that dates back to the 13<span class="elsevierStyleSup">th</span> century&#44; when the Arab physician Ibnal-Bitar mentioned in his book &#8220;Mofradat El-Adwiya&#8221; the effects of ingesting Ammi Majus extracts&#44; followed by exposure to sunlight&#44; for vitiligo repigmentation&#46; This treatment was the oldest form of what is currently called photochemotherapy&#44; a modality defined as the ingestion of a psoralen followed by exposure to UVA &#40;320&#8211;400&#8239;nm&#41;&#46; In 1974&#44; the term PUVA &#40;Psoralen-ultraviolet A&#41; was created by Thomas B&#46; Fitzpatrick and John Parrish to name this therapeutic modality&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The development of photochemotherapy with PUVA paved the way for the research into new modalities&#46; NB-UVB radiation &#40;311&#8211;313&#8239;nm&#41; was discovered in 1988&#44; gradually replacing broadband UVB &#40;290&#8211;320&#8239;nm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Phototherapy started being used in Brazil in the 1980s&#46; It was also in this decade that a new type of phototherapy was introduced&#44; extracorporeal photochemotherapy&#44; initially for the treatment of cutaneous erythrodermic T-cell lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A major advance in the field of phototherapy was the development of UVA1 lamps &#40;340&#8211;400&#8239;nm&#41;&#44; which occurred in the early 1990s&#46; Used mainly for the treatment of atopic dermatitis and scleroderma&#44; this modality of treatment does not require the use of psoralen&#44; thanks to its greater penetrating power&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">More recently&#44; in 1997&#44; phototherapy with an excimer laser &#40;UVB - 308&#8239;nm&#41;&#44; a subtype of NB-UVB&#44; was introduced for the treatment of psoriasis and is currently used in other diseases&#44; such as vitiligo&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">From the heliotherapy practiced in Ancient Egypt to the development of the excimer laser&#44; phototherapy has been part of the therapeutic arsenal of Dermatology&#44; establishing its importance in clinical practice&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Mechanism of action</span><p id="par0105" class="elsevierStylePara elsevierViewall">UVR is absorbed by the chromophores &#40;molecules that have the capacity to absorb certain wavelengths&#41;&#44; such as DNA&#44; nucleotides&#44; lipids&#44; amino acids&#44; trans-urocanic acid&#44; and melanin&#46; UVR causes changes in the structure and function of chromophores&#46; The molecules thus modified are called photoproducts&#44; which participate in apoptosis&#44; inflammation&#44; immunosuppression&#44; and photocarcinogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The depth reached in the skin by each radiation type depends directly on its wavelength&#46; UVB radiation &#40;broadband and NB-UVB&#41; has a shorter length&#44; being absorbed by the epidermis and the superficial portion of the dermis&#46; The UVA waves &#40;1 and 2&#41; have a longer length&#44; penetrating up to the dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Both UVA &#40;PUVA or UVA1&#41; and UVB &#40;broadband and NB-UVB&#41; have immunosuppressive and antiproliferative effects&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The reduction in the number of macrophages&#44; 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which modifies the immune reaction pattern&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">UVA &#40;PUVA and UVA1&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">The UVA wavelength is not so easily absorbed by the DNA molecule&#46; It acts mainly through other chromophores&#44; generating free radicals &#40;reactive oxygen species&#41;&#44; which cause indirect damage to the genetic material&#44; promoting DNA degradation&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">PUVA</span><p id="par0160" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Always performed after the administration of psoralens&#44; furocoumarin compounds that act as chromophores for UVA&#46; After exposure to UVA&#44; they absorb photons&#44; become activated and covalently bind to the DNA bases&#46; Thus&#44; they form cross-linked pairs&#44; which have an antiproliferative&#44; antiangiogenic and apoptotic effect&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Stimulates melanogenesis&#44; although the mechanism of action is not known&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Induces the apoptosis of T cells infiltrated into the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Induces the expression of collagenase-1 in dermal fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Reduces the synthesis of collagen I and III&#44; leading to an antifibrotic effect&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">UVA1</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Prevents direct damage to the DNA&#44; as it has the lowest energy within the UV spectrum&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Induces apoptosis of lymphocytes&#44; mast cells and Langerhans cells&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Inhibits the expression of cytokines associated with Th2 response&#44; such as IL-5&#44; IL-13 and IL-31&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Reduces collagen and hydroxyproline levels&#44; proportionally to the utilized dose&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Activates collagenases&#44; which participate in the breakdown of dermal collagen&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Changes the quality of collagen&#44; reducing its density&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Inhibits fibroblast activity&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li></ul></p><p id="par0230" class="elsevierStylePara elsevierViewall">In scleroderma&#44; it can induce neovascularization and decrease apoptosis of endothelial cells&#46; This factor&#44; associated with the other above mentioned mechanisms of action&#44; makes UVA1 to be frequently prescribed for sclerosing skin diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">It is important to note that the effects of UVR on the human body do not change abruptly from one spectrum to another&#46; In fact&#44; these effects are continually changing from one wavelength to another and can even add up&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Types of phototherapy</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">UVA</span><p id="par0240" class="elsevierStylePara elsevierViewall">UVA rays &#40;320&#8211;400&#8239;nm&#41; are subdivided into&#58;</p><p id="par0245" class="elsevierStylePara elsevierViewall">UVA1 &#40;340&#8211;400&#8239;nm&#41; reaches the epidermis&#44; the middle and deep dermal components&#44; especially blood vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">UVA2 &#40;320&#8211;340&#8239;nm&#41; resembles UVB&#44; with more superficial penetration&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">PUVA</span><p id="par0255" class="elsevierStylePara elsevierViewall">Before the development of UVA1 lamps&#44; the UVA phototherapy that was in use was PUVA&#44; a method that by definition requires the use of psoralens&#46; Psoralen is a photosensitizing substance that can be used systemically via the oral route &#40;capsule&#41; or topically&#46; The latter route employs psoralen in cold cream&#44; alcoholic solution&#44; emulsion&#44; or diluted &#40;in a full or partial bath&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For patients with gastric intolerance&#44; there is the possibility of the systemic use of psoralen through rectal administration &#40;suppository&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Treatment with systemic PUVA &#40;oral or rectal administration&#41; involves the use of methoxypsoralen two hours before exposure to UVA radiation&#44; usually performed 2 to 3 times a week&#46; The radiation dose is progressively increased until a mild erythematous reaction occurs&#46; After the session&#44; it is necessary to maintain skin and eye photoprotection for 24&#8239;hours&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Topical PUVA therapy &#40;applying psoralen in cold cream&#44; solution or emulsion to the lesions only&#41; is an option in case of localized dermatoses&#46; This type of administration&#44; while less practical for the patient&#44; prevents the gastrointestinal side effects of oral medication&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">PUVA Bath</span><p id="par0270" class="elsevierStylePara elsevierViewall">PUVA bath is a topical phototherapy as effective as oral PUVA therapy&#46; It is a good option for patients with extensive injuries&#44; but with contraindications for systemic therapy&#46; The technique consists of exposure to UVA radiation after the patient has bathed in a bathtub containing 100 liters of warm water and 37&#46;5&#8239;mL of 1&#37; 8-methoxypsoralen&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> 8-MOP is more soluble in water&#44; allowing the phototoxic effect to quickly disappear after the treatment&#44; with rinsing in running water&#44; without the need to use photoprotection measures after the session&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The PUVA bath is mainly indicated for moderate to severe plaque psoriasis and chronic dermatoses of the palmoplantar region&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">UVA1</span><p id="par0275" class="elsevierStylePara elsevierViewall">Phototherapy with UVA1&#44; unlike PUVA&#44; omits UVA2 and does not require the use of psoralens&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">It is divided into 3 energy ranges&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">Low dose&#58; 10&#8211;20&#8239;J&#47;cm<span class="elsevierStyleSup">2</span></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Intermediate dose &#62;20&#8211;70&#8239;J&#47;cm<span class="elsevierStyleSup">2</span></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">High dose &#62;70&#8211;130&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li></ul></p><p id="par0300" class="elsevierStylePara elsevierViewall">This modality was seldom used by most Dermatology departments worldwide&#44; as it implied high heat emission and prolonged time of exposure&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> The lamps were made of high-emission metal halides &#40;Sellamed 4000&#8239;W&#44; Sellas Medizinische Ger&#228;te GmbH&#44; Ennepetal&#44; Germany&#41;&#44; which were not available in Brazil&#46; They emitted high doses of energy &#40;130&#8239;J&#47;cm&#178; in a single dose&#41;&#44; are now in disuse&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Currently&#44; in Brazil&#44; there is a type of UVA-1 lamp that alleviates these disadvantages&#46; It is the UVA-1 fluorescent lamp&#44; marketed by Philips &#40;TL10R 100&#8239;W&#44; Philips&#41;&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">UVA1 application has protocols that change according to the disease to be treated&#44; but treatment is usually performed 3 to 5 times a week&#44; with doses starting between 20&#8211;30&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#44; with progressive increase&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">The time of exposure during the session is calculated by the ratio between the number of Joules and the emission power of the lamp&#44; assessed by the radiometer in mW&#46; As an example&#44; considering that the current UVA1 lamps emit 20&#8239;mW&#44; to calculate the patient&#39;s exposure time&#44; receiving 0&#46;5&#8239;J&#47;cm&#178;&#44; we first transform 0&#46;5&#8239;J into 500&#8239;mJ and then divide the desired dose of 500&#8239;mJ by 20&#8239;mW&#44; which results in 25 seconds&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">The use of the radiometer is essential&#44; as it says how many mW the lamp emits&#46; As the lamps lose their emission capacity over time&#44; this implies a dose adjustment and an increase in the time of exposure&#44; requiring the periodical substitution of the lamps&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> This is valid for all types of phototherapy&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">UVA1 is a good option for the treatment of inflammatory and autoimmune diseases&#46; The treatment can be carried out exclusively through this modality or in combination with conventional therapies&#46; It can be carried out on children&#44; pregnant women and patients with contraindications to the use of psoralens &#40;not employed in this modality&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">UVA1 has fewer adverse effects than PUVA&#44; as it omits UVA2 which&#44; like UVB&#44; has the ability to cause erythema and carcinogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">UVB</span><p id="par0335" class="elsevierStylePara elsevierViewall">UVB radiation corresponds to wavelengths between 290 and 320&#8239;nm&#46; It is divided into broadband UVB &#40;290&#8211;320&#8239;nm&#41; and NB-UVB &#40;311&#8211;313&#8239;nm&#41;&#46; It is indicated for psoriasis&#44; atopic dermatitis&#44; renal and hepatic pruritus&#44; parapsoriasis&#44; mycosis fungoides&#44; vitiligo&#44; acute and chronic graft-versus-host disease&#44; among others&#46; As it does not involve the administration of psoralens&#44; it can be indicated for children and pregnant women&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16&#44;17</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Currently&#44; broadband UVB is in disuse&#46; Most centers use NB-UVB&#44; which is more effective than broadband UVB&#44; mainly in the treatment of psoriasis&#44; atopic dermatitis and vitiligo&#44; with less potential to generate adverse events&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;18</span></a> The NB-UVB dose that can cause hyperplasia&#44; edema&#44; burning and the depletion of Langerhans cells is 5 to 10-fold higher than the broadband UVB dose&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">Treatment with UVB &#40;broadband and NB-UVB&#41; can be applied 3 to 6 times a week&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; in most centers&#44; it is performed 2 to 3 times a week&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">There are two ways to determine the initial radiation dose&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1</span><p id="par0355" class="elsevierStylePara elsevierViewall">Determination of the Minimum Erythematous Dose &#40;MED&#41;&#58; the minimum amount of irradiation necessary to cause erythema&#46; The therapy is started with 70&#37; of the MED&#46; This method is in disuse due to practical limitations&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2</span><p id="par0360" class="elsevierStylePara elsevierViewall">Beginning the therapy with a standard radiation dose according to the patient&#39;s phototype&#46; This method is currently the most widely used&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li></ul></p><p id="par0365" class="elsevierStylePara elsevierViewall">After defining the initial dose&#44; every one or two sessions&#44; the radiation dose is increased by 10&#37; to 30&#37; until there is asymptomatic erythema&#46; The peak of the erythematous reaction occurs between 12 and 24&#8239;hours after radiation exposure&#46; Eye protection is essential&#44; but only during the phototherapy session&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">In the event of disease recurrence or worsening&#44; the frequency of treatment should be increased and&#44; in some cases&#44; the dose should be elevated&#44; according to each patient&#8217;s tolerance&#46; Upon reaching remission&#44; maintenance therapy is generally not indicated&#44; with the exception of mycosis fungoides&#44; which may require prolonged treatment to maintain disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Other types of phototherapy</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Excimer laser and lamp</span><p id="par0375" class="elsevierStylePara elsevierViewall">This phototherapy model was introduced in the therapeutic arsenal of Dermatology in 1997&#46; As a subtype of NB-UVB&#44; with a wavelength of 308&#8239;nm&#44; it was approved for the treatment of psoriasis&#44; atopic dermatitis and vitiligo in the United States&#46; It is effective for several other localized &#40;less than 10&#37; of body surface&#41; and chronic inflammatory dermatoses&#46; It can be performed in places that are difficult to access with traditional phototherapies&#44; such as the scalp&#44; and palmoplantar skin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">Laser phototherapy is directed to the lesion through a tip with a spot measuring 14 to 30&#8239;mm in diameter&#44; sparing healthy skin&#46; This characteristic allows higher doses to be administered from the beginning&#46; Therefore&#44; fewer adjuvant treatments are needed and long-term side effects are reduced&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its emission depends on a mixture of xenon and chloride gas&#44; which form unstable &#8220;excited dimers&#8221;&#40;excimer&#41;&#46; When dissociated&#44; these dimers produce a coherent wavelength of 308&#8239;nm&#44; which penetrates primarily the epidermal cells and&#44; secondarily&#44; into fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">The excimer lamp&#44; on the other hand&#44; emits inconsistent light and&#44; consequently&#44; requires a longer time than the laser to emit the same fluency&#46; As advantages&#44; it allows the treatment of more extensive areas&#44; with lower operational costs&#44; as well as being easier to transport&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">Both the excimer laser and the excimer lamp have shown similar or superior effectiveness to NB-UVB in the treatment of psoriasis and vitiligo&#46; In atopic dermatitis&#44; despite promising results in relation to pruritus improvement&#44; the European and American guidelines do not endorse its use&#44; due to the scarce number of studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0395" class="elsevierStylePara elsevierViewall">More recently&#44; the role of the excimer laser in the treatment of alopecia areata has been investigated&#46; The results are promising and the absence of significant side effects&#44; especially when compared to traditional therapies &#40;corticotherapy and topical immunotherapy&#41;&#44; encourages its use&#46; Further studies are still necessary to determine whether the excimer lamp would have the same effectiveness as the excimer laser in this usage&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ultraviolet &#8220;combs&#8221;</span><p id="par0400" class="elsevierStylePara elsevierViewall">They are mainly indicated for the treatment of scalp psoriasis&#46; Patients with seborrheic dermatitis also benefit from this therapy&#46; This method allows the direct application of light to the scalp&#46; The accessories are removable and similar to combs&#44; easy to sterilize&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Most devices emit NB-UVB and although scientific studies are lacking on their therapeutic effectiveness&#44; there have been no reports of acute or chronic side effects after the adequate use of the method&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Home treatment</span><p id="par0410" class="elsevierStylePara elsevierViewall">Home phototherapy with UVB can be prescribed for selected patients&#44; who show adequate cognition and treatment adherence&#46; However&#44; worldwide&#44; some factors negatively influence on the prescription of this therapy&#44; such as difficulty in controlling the equipment&#44; as well as the duration of sessions performed by the patient&#44; in addition to the lack of an adequate reimbursement system&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Less conventional phototherapy methods&#44; such as heliotherapy &#40;exposure to sunlight&#41;&#44; with or without psoralen&#44; have been recommended in situations when conventional phototherapy is not feasible for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Clinical and laboratory tests prior to phototherapy</span><p id="par0420" class="elsevierStylePara elsevierViewall">Before choosing the phototherapy type&#44; a complete assessment of the patient is essential&#46; Dermatological examination of the entire integument should be performed to assess the dermatosis severity and extent&#44; determine the phototype and the degree of photodamage&#46; It is also important to describe in the patient&#8217;s record the aspect for any nevi he presents at the examination and also detect premalignant or malignant skin lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0425" class="elsevierStylePara elsevierViewall">A previous examination of the eyes of the patient is essential&#46; If an abnormality is detected&#44; the follow-up should be performed at least once a year with an ophthalmologist&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">The laboratory tests that should be requested for this phototherapy modality include kidney and liver function&#44; in addition to beta-HCG to rule out any pregnancy&#46; In the case of concomitant therapy with retinoids&#44; a lipid profile should be requested&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">The request for the ANF test is debatable&#46; If there is a family history of or suspected collagen disease&#44; it is advisable to request it&#46; Otherwise&#44; it is not part of the previous exams for phototherapy&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Indications</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Psoriasis</span><p id="par0440" class="elsevierStylePara elsevierViewall">Psoriasis is the disease that is most commonly treated with phototherapy&#46; In addition to being effective&#44; phototherapy is considered a safe option&#46; It is usually indicated when topical treatments do not show good results or are not practical for the patient&#44; such as those with extensive psoriasis&#46; It is the only viable therapeutic option in cases of severe psoriasis affecting individuals with contraindications for systemic treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">Currently&#44; NB-UVB is the therapeutic modality of choice&#46; Studies have shown its greater effectiveness compared to broadband UVB&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Regarding UVA1&#44; further studies are needed to compare its effectiveness with other types of phototherapy&#44; given the small number of patients included in the studies done so far&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0450" class="elsevierStylePara elsevierViewall">NB-UVB is considered the first-choice treatment for pregnant women with extensive disease&#46; It can be used with caution in children&#44; but it is not the first choice&#44; as the possible carcinogenic potential and anxiety in young children are limiting factors for this group&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">The excimer laser&#47;lamp is useful in the treatment of lesions affecting less than 10&#37; of the body surface&#44; such as palms&#44; soles&#44; elbows and knees&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> It has the same effectiveness as PUVA for the treatment of non-pustular palmoplantar psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0460" class="elsevierStylePara elsevierViewall">PUVA can be used topically or systemically&#44; being indicated for stable plaque psoriasis&#46; Despite being highly effective&#44; it has a worse tolerance profile than NB-UVB and there is greater evidence of carcinogenic potential&#44; therefore&#44; it is considered a second-line option for psoriasis treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In some cases&#44; phototherapy can be combined with oral retinoids&#44; reducing treatment time&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0465" class="elsevierStylePara elsevierViewall">The mechanism of action of phototherapy in the treatment of psoriasis is not completely understood&#46; UVB &#40;broadband and NB&#41; is known to induce apoptosis of pathogenic T lymphocytes and keratinocytes&#44; leading to reduced epidermal hyperproliferation and local and systemic immunosuppression&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;30</span></a></p><p id="par0470" class="elsevierStylePara elsevierViewall">NB-UVB inhibits the Th17 pathway&#44; which is crucial for disease pathogenesis&#46; Moreover&#44; it increases stability and restores regulatory T-cell function&#46; Accumulated doses of this modality are believed to reduce levels of plasmin&#44; a potent inflammatory activator&#44; contributing to its therapeutic effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;30</span></a></p><p id="par0475" class="elsevierStylePara elsevierViewall">It is believed that UVA1 induces T-cell apoptosis and reduces inflammatory cytokine levels&#44; such as TNF-&#945; and INF-&#947;&#46; Additionally&#44; UVA1 has been shown to inhibit the activity of antigen-presenting cells and to reduce the amount of Langerhans cells in the epidermis&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0480" class="elsevierStylePara elsevierViewall">The treatment should be discontinued when complete disease remission is achieved or if there is no response&#46; Phototherapy provides high rates of patient satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0485" class="elsevierStylePara elsevierViewall">The duration of remission correlates with the reduction in Psoriasis Area and Severity Index &#40;PASI&#41; at the end of treatment&#46; PASI reduction is on average 70&#37; when NB-UVB is applied and 80&#37; when treated with PUVA&#44; results comparable to those seen with immunobiological drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Vitiligo</span><p id="par0490" class="elsevierStylePara elsevierViewall">Vitiligo is an acquired pigmentation disorder&#44; characterized by the loss of epidermal melanocytes&#46; In most cases&#44; it behaves in a chronic and stable manner&#44; with short periods of progression&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0495" class="elsevierStylePara elsevierViewall">NB-UVB and PUVA phototherapy constitute the main treatment modalities for this dermatosis&#46; Currently&#44; NB-UVB is the first-line treatment for the generalized form&#46; For localized disease&#44; the excimer laser and the excimer lamp are more adequate&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0500" class="elsevierStylePara elsevierViewall">Yones et al&#46; demonstrated the superiority of NB-UVB phototherapy over PUVA in a randomized clinical trial&#46; In that study&#44; patients treated with NB-UVB had a 50&#37; higher repigmentation rate than patients treated with PUVA after six months of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0505" class="elsevierStylePara elsevierViewall">In addition to its superior effectiveness&#44; treatment with NB-UVB has other advantages over PUVA&#58; the lack of a photosensitizer&#44; lower cumulative dose and fewer adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0510" class="elsevierStylePara elsevierViewall">Nevertheless&#44; phototherapy with NB-UVB does not always bring satisfactory results&#46; Lesions on the face&#44; neck and trunk are more sensitive to phototherapy&#44; while those on the hands&#44; feet&#44; elbows and knees are more resistant&#44; with minimal results&#46; A minimum of six months of treatment is required to assess the patient&#39;s response to therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0515" class="elsevierStylePara elsevierViewall">In recent years&#44; several studies on the combination of NB-UVB with topical calcineurin inhibitors or vitamin D analogs have shown good response&#44; suggesting that topical agents can produce synergistic effects when combined with phototherapy&#44; increasing their effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Lymphomas</span><p id="par0520" class="elsevierStylePara elsevierViewall">Cutaneous T-Cell Lymphomas &#40;CTCL&#41; are a heterogeneous group of non-Hodgkin&#39;s lymphomas of the skin&#44; with the mycosis fungoides &#40;MF&#41; subtype being the most common variant&#46; Initially&#44; it appears as erythematous patches and plaques and can progress to skin tumors&#46; Extracutaneous involvement is present in some cases&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0525" class="elsevierStylePara elsevierViewall">The United States Cutaneous Lymphoma Consortium recommends phototherapy as a monotherapy regimen for patients with early stages of CTCL&#47;mycosis fungoides &#40;stage IA-IIA&#41;&#44; and in combination with systemic therapies for refractory early disease or advanced disease&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Several systemic agents can be safely combined with phototherapy&#44; mainly interferon-alpha and retinoids&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0530" class="elsevierStylePara elsevierViewall">Determining the type of phototherapy to be used&#44; among PUVA&#44; NB-UVB and extracorporeal photochemotherapy will depend on the stage of the disease&#44; the patient&#39;s preference and the methods availability&#46; UVA shows better skin penetration than UVB&#44; and patients with thicker plaques&#44; darker skin and folliculotropic T-cell lymphoma may benefit more from PUVA&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0535" class="elsevierStylePara elsevierViewall">The immediate relief that many patients experience due to the decrease in the size and number of lesions&#44; as well as an improvement in pruritus&#44; is significant&#46; <a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0540" class="elsevierStylePara elsevierViewall">The phototherapy treatment regimen for CTCL involves 3 phases&#58; induction&#44; consolidation and maintenance&#46;</p><p id="par0545" class="elsevierStylePara elsevierViewall">The first phase may last longer than in other dermatoses treated with phototherapy&#46; The second phase&#44; the consolidation one&#44; lasts from one to three months&#46; This phase can maximize the potential for histopathological and molecular clearance &#40;including loss of the dominant T-cell clone&#41;&#46; During the last phase&#44; the maintenance one&#44; the frequency and dose of treatment are kept constant&#46; It is still controversial whether a prolonged maintenance phase after disease remission can reduce recurrence rates&#44; since there is insufficient data for such assertion&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0550" class="elsevierStylePara elsevierViewall">PUVA is the initial choice of phototherapy for CTCL chosen by many specialists&#46; It is effective for early MF&#44; with estimated response rates of 85&#37; for stage IA and 65&#37; for stage IB&#46; Treatment time with PUVA varies from two to four months&#44; with two to three sessions per week&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0555" class="elsevierStylePara elsevierViewall">Despite being in disuse&#44; broadband UVB is a good option for patients with stage IA of the disease and fair skin &#40;phototypes I and II&#41;&#46; However&#44; in the hypopigmented variant of MF&#44; the response is limited&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0560" class="elsevierStylePara elsevierViewall">As for the excimer laser&#44; there have been several reports showing the benefits of its use&#59; however&#44; the follow-up was short&#44; being reserved for sites not easily accessible to phototherapy or topical medications&#44; such as acral surfaces or intertriginous areas&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0565" class="elsevierStylePara elsevierViewall">Further studies&#44; with better standardization&#44; are needed to determine the ideal phototherapy regimen&#44; regarding effectiveness and long-term safety&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Parapsoriasis</span><p id="par0570" class="elsevierStylePara elsevierViewall">Parapsoriasis is a chronic inflammatory skin disorder whose etiology remains unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0575" class="elsevierStylePara elsevierViewall">Previous studies have shown that this disease probably represents different stages of a lymphoproliferative disorder&#46; It has been considered as a separate entity or as the initial form of MF&#44; although this remains debatable&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0580" class="elsevierStylePara elsevierViewall">Skin-targeted therapies are the main therapeutic options for the management of parapsoriasis and early-stage MF&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0585" class="elsevierStylePara elsevierViewall">Phototherapy is indicated for all types of parapsoriasis and its clinical variants&#46; In general&#44; NB-UVB is the preferred treatment modality&#46; PUVA should be used in patients with thick plaques&#44; high phototypes and those not responsive to UVB&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0590" class="elsevierStylePara elsevierViewall">In the case of patients who cannot tolerate or do not respond to PUVA or NB-UVB therapy&#44; low-dose UVA1 therapy seems to be a safe and effective alternative&#46; However&#44; the therapeutic regimen is not established&#44; due to the few studies assessing this therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Scleroderma</span><p id="par0595" class="elsevierStylePara elsevierViewall">Scleroderma is a chronic connective tissue disease&#44; whose etiology remains unknown&#46; It is characterized by intense collagen deposition in the dermis and&#44; in some cases&#44; in internal organs&#46; The main treatment objective is to increase skin elasticity&#44; improving patient mobility and quality of life&#44; in addition to delaying disease evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0600" class="elsevierStylePara elsevierViewall">As a therapeutic option&#44; phototherapy is safe&#44; as its effect is directed at the skin&#44; without the risk of systemic complications&#46; It represents an effective alternative for individuals who are refractory to topical or systemic treatments&#46; Those with contraindications to immunosuppressive therapy also benefit from the method&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0605" class="elsevierStylePara elsevierViewall">Several studies have shown that phototherapy effectiveness depends on the applied UVR dose&#46; In areas protected from solar radiation&#44; slower response to this therapy is observed&#46; As for the patient&#39;s phototype&#44; it seems to have no influence on treatment response&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0610" class="elsevierStylePara elsevierViewall">Several phototherapy modalities can be used in the treatment of sclerodermas&#44; such as PUVA&#44; UVA1 and NB-UVB&#46; Topical PUVA can be used in the localized forms and systemic PUVA in generalized ones&#46; NB-UVB is a viable option for scleroderma treatment&#44; especially for lesions in the inflammatory phase&#44; with superficial sclerosis&#46; The preference&#44; however&#44; is for UVA1 radiation&#44; as it shows deeper penetration into the dermis and the fact that there is a larger number of studies demonstrating its effectiveness&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;41</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Atopic dermatitis</span><p id="par0615" class="elsevierStylePara elsevierViewall">Atopic dermatitis &#40;AD&#41; is a common&#44; recurrent&#44; relapsing&#44; chronic inflammatory disease&#46; AD management includes avoiding triggering factors&#44; trying to compensate for skin barrier defects&#44; and maintaining anti-inflammatory therapy &#40;topical corticosteroids and calcineurin inhibitors&#41;&#46; When these first-line approaches are unsuccessful&#44; systemic treatment or phototherapy should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0620" class="elsevierStylePara elsevierViewall">Phototherapy has shown to be useful in the treatment of moderate to severe AD&#46; The currently used modalities are NB-UVB&#44; UVA1&#44; PUVA and excimer laser&#47;lamp&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0625" class="elsevierStylePara elsevierViewall">Phototherapy has been classified as &#8220;Strength of Recommendation B&#8221; and &#8220;Level of Evidence II&#8221; in the treatment of AD&#46; It is a second-line treatment&#44; which should be reserved for cases in which behavioral and topical measures have failed&#44; as numerous factors can limit its usefulness and effectiveness&#44; including cost and access&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0630" class="elsevierStylePara elsevierViewall">It acts by decreasing colonization by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; improving the skin barrier function&#44; reducing pruritus and tissue inflammation&#46; Recent experimental studies have shown that its immunomodulatory effects include&#58; decreased expression of IL-5&#44; IL-13 and IL-31&#44; as well as the induction of T-cell apoptosis and dendritic cell reduction&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0635" class="elsevierStylePara elsevierViewall">The first modality of phototherapy used for AD treatment was broadband UVB&#44; in 1970&#59; however&#44; due to its erythematogenic potential and low effectiveness&#44; it fell into disuse&#46; Morison et al&#46; were the first to use PUVA for cases of refractory AD&#44; with therapeutic success&#46; Phototherapy can be used as monotherapy or in combination with emollients and steroids&#46; Its use can reduce the need for topical or systemic immunosuppressants&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0640" class="elsevierStylePara elsevierViewall">The doses and frequency of PUVA sessions &#40;topical or systemic&#41; are similar to those used for psoriasis&#46; This type of phototherapy is not the main choice of treatment for AD&#44; because it does not show the best results and due to its mutagenic potential&#46; Thus&#44; it should be administered for short periods&#46; The mechanism of action of PUVA phototherapy is yet to be fully understood&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0645" class="elsevierStylePara elsevierViewall">When treatment is carried out with UVA1&#44; the average dose is the most indicated in most references&#46; At this dose&#44; the adverse effects are reduced and treatment becomes more tolerable&#46; UVA1 has a more intense effect than UVB&#44; so it is more appropriate for patients with acute AD&#46; However&#44; the first UVA1 lamps were expensive and required more space and adequate ventilation machinery&#44; making them inaccessible in some centers&#46; Regarding the mechanism of action of UVA1 therapy&#44; the suppression of inflammatory cytokines&#44; such as IL-5&#44; IL-13 and IL-31 has been observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0650" class="elsevierStylePara elsevierViewall">The best UVA1 dose in cases of AD exacerbation is a matter of debate&#46; Retrospective studies have shown a reduction in SCORAD &#40;Scoring Atopic Dermatitis&#47;Atopic Dermatitis Severity Index&#41; with both high and medium doses of UVA1&#46; However&#44; more prospective studies with larger samples are needed to establish the ideal dose&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a></p><p id="par0655" class="elsevierStylePara elsevierViewall">NB-UVB has been used successfully since 1990 in AD&#46; Currently&#44; it is considered by most dermatologists as the first-line phototherapy modality for the treatment of AD&#44; due to its availability&#44; safety&#44; easy administration&#44; and effectiveness&#46; This therapy reduced SCORAD and the need for topical corticosteroid use in several randomized studies&#46; These benefits persisted for up to 6 months after the treatment regimen termination&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0660" class="elsevierStylePara elsevierViewall">The excimer laser is another treatment modality that can be used&#46; Its use for 10 weeks has shown good results compared to clobetasol propionate&#46; The excimer lamp in combination with emollients resulted in AD severity score improvement within a 4-week period&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0665" class="elsevierStylePara elsevierViewall">Considering the low accessibility to UVA1 devices when compared to other phototherapy modalities&#44; NB-UVB provides the most successful and cost-effective treatment for patients with AD&#44; with a proven improvement in the Health-Related Quality of Life &#40;HRQoL&#41; and the Dermatological Quality of Life Index &#40;DLQI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Photodermatoses</span><p id="par0670" class="elsevierStylePara elsevierViewall">Phototherapy is an effective method to prevent seasonal outbreaks of photodermatoses&#46; In general&#44; the NB-UVB and PUVA doses are lower than the ones used for other dermatoses&#46; It is a safe therapy&#44; but it can cause skin rashes in a minority of patients&#44; which does not limit treatment or worsen the prognosis&#46; De Argila Fern&#225;ndez-Dur&#225;n recommends the use of oral corticosteroids in the first days of treatment to prevent disease exacerbation&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0675" class="elsevierStylePara elsevierViewall">Polymorphic light eruption &#40;PLE&#41;&#58; NB-UVB has become the first-line therapy according to several authors because it is a practical method&#46; It can be used even in the most severe cases&#46; PUVA can also be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0680" class="elsevierStylePara elsevierViewall">Actinic prurigo&#58; NB-UVB or PUVA are viable options in extensive cases or those refractory to other therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0685" class="elsevierStylePara elsevierViewall">Hydroa vacciniforme&#58; some reports have shown symptoms relief in patients with this photodermatosis&#44; but in most cases&#44; this disease is resistant to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0690" class="elsevierStylePara elsevierViewall">Chronic actinic dermatitis&#58; phototherapy is considered a second-line option&#44; reserved for patients with contraindications for systemic immunosuppression or as prophylaxis&#46; In such cases&#44; it is possible to choose treatment with low-dose PUVA alone or in combination with topical and oral corticosteroid therapy for a prolonged period&#46; NB-UVB can also be used&#44; as well as UVA1 radiation&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0695" class="elsevierStylePara elsevierViewall">Solar urticaria&#58; phototherapy can be used to prevent future crises since PUVA or NB-UVB induce phototolerance&#46; In view of the risk of anaphylaxis&#44; the minimum urticarial dose with the radiation intended for use should be tested&#44; before starting the treatment&#46; Additionally&#44; the concomitant use of antihistamines is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Pityriasis Lichenoides</span><p id="par0700" class="elsevierStylePara elsevierViewall">Pityriasis lichenoides chronica &#40;PLC&#41; is an uncommon dermatosis&#44; of unknown etiology&#44; for which phototherapy is one of the main treatments&#44; particularly in the most extensive disease&#46; There have been studies that corroborated the use of PUVA&#44; NB-UVB and broadband UVB for this disease&#46; NB-UVB is an effective treatment for the diffuse and chronic forms&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0705" class="elsevierStylePara elsevierViewall">There are small studies reporting the high effectiveness of treatment with NB-UVB&#44; broadband UVB and PUVA&#46; Despite the satisfactory results&#44; due to the few cases included in these studies&#44; it is not possible to draw a precise conclusion&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Other phototherapy indications</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Uremic pruritus</span><p id="par0710" class="elsevierStylePara elsevierViewall">The mechanism of action of phototherapy in reducing the pruritus is unclear&#46; NB-UVB decreases the production of IL-2&#44; a cytokine related to pruritus&#44; induces apoptosis of dermal mast cells and reduces the release of neuropeptides&#44; such as substance P&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Recent studies have shown that NB-UVB phototherapy can be considered an effective therapeutic option in the treatment of uremic pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Polycythemia vera</span><p id="par0715" class="elsevierStylePara elsevierViewall">Pruritus is the most common symptom of polycythemia vera &#40;PCV&#41;&#46; Although its pathogenesis is not understood&#44; it is believed that platelet and erythrocyte overproduction play a central role&#46; The platelets aggregated in the skin vessels store and release prostaglandins and serotonin&#44; both of which are involved in pruritus&#46; There are studies evaluating the effectiveness of both NB-UVB and broadband UVB&#44; as well as PUVA in these cases&#46; Most studies included a small number of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><p id="par0720" class="elsevierStylePara elsevierViewall">NB-UVB phototherapy has shown a good risk&#47;benefit ratio in the treatment of polycythemia vera-associated pruritus&#46; However&#44; further studies are needed to determine the ideal therapeutic regimen&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Prurigo nodularis</span><p id="par0725" class="elsevierStylePara elsevierViewall">The excimer laser has been reported in the literature as a treatment modality that resulted in prurigo nodularis improvement&#46; Larger investigations with long-term follow-up are needed to fully support its use&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Graft-versus-host disease</span><p id="par0730" class="elsevierStylePara elsevierViewall">Graft-versus-host disease &#40;GVHD&#41; represents a complex immune response involving several organs&#46; The disease occurs mainly in allogeneic hematopoietic stem-cell transplantation&#46; The first-line treatment is carried out with high-dose corticosteroids&#44; alone or in combination with other immunosuppressants&#44; showing numerous side effects and increasing the risk of infections&#46; In this sense&#44; phototherapy plays an important role&#44; as the treatment is directed at the skin&#44; with few side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p><p id="par0735" class="elsevierStylePara elsevierViewall">Its mechanism of action in these cases remains unknown&#44; but apoptosis&#44; antiproliferative and immunomodulatory effects seem to be involved&#46; NB-UVB and UVA1 have been used more frequently in GVHD treatment&#44; due to the safety of the methods and the important clinical response&#46; One of the great advantages of associating phototherapy in the treatment is that it allows the reduction of corticosteroid doses&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0740" class="elsevierStylePara elsevierViewall">The following parameters must be considered when choosing the treatment modality&#58; type&#44; extent&#44; and depth of the lesions&#44; the possible involvement of other organs and use of concomitant medication&#46; The treatment regimen is usually performed at lower doses than for other diseases&#46; Phototherapy is effective in the treatment of both the acute and chronic phases&#44; and in the prevention of graft-versus-host disease in adults and children&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Phototherapy and HIV</span><p id="par0745" class="elsevierStylePara elsevierViewall">UVR is known to suppress the immune system and modify cytokine patterns&#46; Moreover&#44; exposure to UV rays is likely to increase viral replication&#46; The main concern is the phototherapy indication in the early&#47;intermediate disease stages when the patient still has a detectable viral load&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a></p><p id="par0750" class="elsevierStylePara elsevierViewall">There are some conditions that occur in HIV-infected patients which respond well to UVR use&#44; such as psoriasis&#44; eosinophilic folliculitis&#44; eczema&#44; and pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> The choice of UVR treatment should evaluate items such as skin lesion responsiveness and photosensitivity caused by some antiretrovirals&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a></p><p id="par0755" class="elsevierStylePara elsevierViewall">The risk-benefit ratio varies depending on the HIV disease stage&#46; Existing data in advanced-stage patients suggest that treatment with NB-UVB or PUVA is not associated with clinical deterioration in the short term&#46; In patients with an undetectable viral load&#44; phototherapy may be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> It should be noted that phototherapy seems to worsen the prognosis of patients with Kaposi&#39;s sarcoma and&#44; therefore&#44; this modality is contraindicated for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Phototherapy and carcinogenesis</span><p id="par0760" class="elsevierStylePara elsevierViewall">Based on the mechanisms of action discussed in this review article&#44; it is possible that UV radiation may have mutagenic potential&#46; The reason for this concern is that workers exposed to sunlight have a higher incidence of melanoma and non-melanoma skin cancer&#44; especially individuals with a low phototype&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0765" class="elsevierStylePara elsevierViewall">Studies have shown that PUVA induces cutaneous oncogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A 10-fold increase in the risk of squamous cell carcinoma &#40;SCC&#41; has been reported when more than 150 treatments were performed &#40;or a maximum cumulative dose of 1000&#8211;1500&#8239;J&#47;cm&#41;&#46; There is also scientific evidence of an increase in actinic keratoses&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26&#44;60</span></a></p><p id="par0770" class="elsevierStylePara elsevierViewall">The risk of BCC&#44; even in patients who received high doses of PUVA&#44; is lower than that of SCC&#46; The increased risk of melanoma after PUVA treatment is manifested 15 years after starting of the therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0775" class="elsevierStylePara elsevierViewall">Although there is abundant evidence for PUVA dose-related skin cancer risk&#44; studies investigating the risk of photocarcinogenesis with NB-UVB and UVA1 are limited to retrospective studies and case reports&#46; According to the available evidence&#44; NB-UVB seems&#44; in general&#44; to be the safest phototherapy modality&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0780" class="elsevierStylePara elsevierViewall">It should be noted that the combination of phototherapy and cyclosporine &#40;including a history of cyclosporine use&#41; should be avoided&#44; considering the increased carcinogenic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Other adverse effects</span><p id="par0785" class="elsevierStylePara elsevierViewall">The adverse effects can be short-term or long-term ones&#46; The most common acute adverse effect is erythema&#46; If it is caused by PUVA&#44; it appears between 48 and 72&#8239;hours after exposure and is usually prolonged&#46; The erythema caused by UVB radiation occurs early&#44; within the first 24&#8239;hours after exposure&#46; If the erythema is mild and asymptomatic&#44; the last dose used should be maintained&#46; If there is severe erythema or if it is associated with pain&#44; the treatment should be discontinued until the condition improves&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0790" class="elsevierStylePara elsevierViewall">In the long term&#44; skin photoaging is an adverse effect inherent to all forms of phototherapy&#44; being more intense with UVA&#44; as it reaches deeper layers of the dermis&#46; It is known that the lower the phototype&#44; the greater the susceptibility to photoaging&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Skin pigmentation changes also occur&#44; with the formation of solar lentigines&#44; both with PUVA and NB-UVB&#46;</p><p id="par0795" class="elsevierStylePara elsevierViewall">Pruritus may occur as a side effect&#46; There are 2 types&#44; one that depends on cutaneous xerosis and improves with emollient use and another with an idiopathic cause&#44; which is rare&#44; contraindicating the continuation of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0800" class="elsevierStylePara elsevierViewall">Regarding the PUVA modality&#44; gastrointestinal intolerance can occur with 8-MOP&#44; usually being dose-dependent&#46; The use of antiemetics and administration of psoralen after food intake attenuates this effect&#46; Occasional symptoms include vertigo or headache&#46; Intolerance reactions are specific to oral 8-MOP and can be prevented by replacing it with 5-MOP&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0805" class="elsevierStylePara elsevierViewall">With PUVA&#44; it is important to assess the risk of developing cataracts&#44; and eye protection must be used during the session and for 12&#8239;hours after treatment&#44; as 8-MOP can be detected in the lens up to 12&#8239;h after ingestion&#46; A rare occurrence during treatment with this modality is acral blisters&#44; which can develop in patients exposed to severe mechanical stress due to loosening of the dermo-epidermal junction&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0810" class="elsevierStylePara elsevierViewall">The side effects of phototherapy rarely lead to its contraindication&#44; but it may happen&#46; The risk-benefit ratio for each case should be assessed and phototherapy&#44; whenever possible&#44; should be considered&#44; since its benefits frequently outweigh the risks&#46;</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Financial support</span><p id="par0815" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Authors&#39; contributions</span><p id="par0820" class="elsevierStylePara elsevierViewall">Norami de Moura Barros&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0825" class="elsevierStylePara elsevierViewall">Lissi&#234; Lunardi Sbroglio&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0830" class="elsevierStylePara elsevierViewall">Maria de Oliveira Buffara&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0835" class="elsevierStylePara elsevierViewall">Jessica Lana Concei&#231;&#227;o e Silva Baka&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0840" class="elsevierStylePara elsevierViewall">Allen de Souza Pessoa&#58; design and planning of the study&#59; critical review of the manuscript&#46;</p><p id="par0845" class="elsevierStylePara elsevierViewall">Luna Azulay-Abulafia&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; effective participation in research orientation&#59; critical review of the manuscript&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Conflicts of interest</span><p id="par0850" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "History"
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          "titulo" => "Mechanism of action"
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              "identificador" => "sec0020"
              "titulo" => "UVB &#40;broadband&#44; NB-UVB and excimer laser&#41;"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "UVA &#40;PUVA and UVA1&#41;"
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            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "PUVA"
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            3 => array:2 [
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              "titulo" => "UVA1"
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          "identificador" => "sec0040"
          "titulo" => "Types of phototherapy"
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              "titulo" => "PUVA"
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              "titulo" => "PUVA Bath"
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              "titulo" => "UVA1"
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              "identificador" => "sec0065"
              "titulo" => "UVB"
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          "titulo" => "Other types of phototherapy"
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            0 => array:2 [
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              "titulo" => "Excimer laser and lamp"
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              "titulo" => "Ultraviolet &#8220;combs&#8221;"
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              "titulo" => "Home treatment"
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              "titulo" => "Clinical and laboratory tests prior to phototherapy"
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          "titulo" => "Indications"
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              "titulo" => "Psoriasis"
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              "titulo" => "Vitiligo"
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            2 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Lymphomas"
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              "identificador" => "sec0115"
              "titulo" => "Parapsoriasis"
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            4 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Scleroderma"
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              "identificador" => "sec0125"
              "titulo" => "Atopic dermatitis"
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            6 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Photodermatoses"
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              "titulo" => "Pityriasis Lichenoides"
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          "titulo" => "Other phototherapy indications"
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            0 => array:2 [
              "identificador" => "sec0145"
              "titulo" => "Uremic pruritus"
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            1 => array:2 [
              "identificador" => "sec0150"
              "titulo" => "Polycythemia vera"
            ]
            2 => array:2 [
              "identificador" => "sec0155"
              "titulo" => "Prurigo nodularis"
            ]
            3 => array:2 [
              "identificador" => "sec0160"
              "titulo" => "Graft-versus-host disease"
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            4 => array:2 [
              "identificador" => "sec0165"
              "titulo" => "Phototherapy and HIV"
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              "identificador" => "sec0170"
              "titulo" => "Phototherapy and carcinogenesis"
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          "titulo" => "Other adverse effects"
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    "fechaRecibido" => "2019-12-03"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:3 [
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            1 => "PUVA therapy"
            2 => "Ultraviolet therapy"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Of all the therapeutic options available in Dermatology&#44; few of them have the history&#44; effectiveness&#44; and safety of phototherapy&#46; Heliotherapy&#44; NB-UVB&#44; PUVA&#44; and UVA1 are currently the most common types of phototherapy used&#46; Although psoriasis is the most frequent indication&#44; it is used for atopic dermatitis&#44; vitiligo&#44; cutaneous T-cell lymphoma&#44; and cutaneous sclerosis&#44; among others&#46; Before indicating phototherapy&#44; a complete patient assessment should be performed&#46; Possible contraindications should be actively searched for and it is essential to assess whether the patient can come to the treatment center at least twice a week&#46; One of the main method limitations is the difficulty that patients have to attend the sessions&#46; This therapy usually occurs in association with other treatments&#58; topical or systemic medications&#46; Maintaining the regular monitoring of the patient is essential to identify and treat possible adverse effects&#46; Phototherapy is recognized for its benefits and should be considered whenever possible&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Barros NM&#44; Sbroglio LL&#44; Buffara MO&#44; Baka JLCS&#44; Pessoa AS&#44; Azulay-Abulafia L&#46; Phototherapy&#46; An Bras Dermatol&#46; 2021&#59;96&#58;397&#8211;407&#46;</p>"
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        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology&#44; Hospital Universit&#225;rio Pedro Ernesto&#44; Universidade do Estado do Rio de Janeiro&#44; Rio de Janeiro&#44; RJ&#44; Brazil&#46;</p>"
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Continuing Medical Education
Phototherapy
Norami de Moura Barros
Autor para correspondência
norami.barros@gmail.com

Corresponding author.
, Lissiê Lunardi Sbroglio, Maria de Oliveira Buffara, Jessica Lana Conceição e Silva Baka, Allen de Souza Pessoa, Luna Azulay-Abulafia
Department of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Phototherapy consists of the therapeutic use of ultraviolet &#40;UV&#41; radiation&#46; It can be performed with exposure to sunlight&#44; ultraviolet A &#40;UVA&#41; or ultraviolet B &#40;UVB&#41; radiation&#46; The wavelengths administered and the UV radiation doses vary according to the proposed indication&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Ultraviolet radiation &#40;UVR&#41; encompasses wavelengths ranging from 200 to 400&#8239;nm&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is divided into&#58;</p><p id="par0020" class="elsevierStylePara elsevierViewall">UVA &#40;320&#8211;400&#8239;nm&#41;&#44; which is subdivided into UVA2 &#40;320&#8211;340&#8239;nm&#41; and UVA1 &#40;340&#8211;400&#8239;nm&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">UVB&#44; subdivided into broadband UVB &#40;290&#8211;320&#8239;nm&#41; and narrowband UVB &#40;NB-UVB&#41;&#44; from 311 to 313&#8239;nm&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">UVC &#40;200&#8211;290&#8239;nm&#41;&#44; which is blocked by the ozone layer and by the oxygen of the atmosphere and which is not used for phototherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The benefits of phototherapy have been recognized since the 20<span class="elsevierStyleSup">th</span> century BCE&#46; Although psoriasis is the most frequent indication&#44; phototherapy has been used successfully in several other dermatoses&#44; such as atopic dermatitis&#44; vitiligo&#44; cutaneous T-cell lymphoma&#44; and cutaneous sclerosis&#44; among others&#46; Using controlled and repeated UV exposures&#44; it is possible to induce regression or control the evolution of these dermatoses&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Most of the time&#44; phototherapy is used in combination with topical or systemic medications for better disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Just like any other therapy&#44; it has side effects&#46; Most of the time&#44; they are acute and transient&#44; including erythema and burns&#44; and attention should be paid to possible adverse events during treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Accessibility to the phototherapy unit is an important limiting factor for undergoing this type of treatment&#44; despite the degree of satisfaction reported by users&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">History</span><p id="par0055" class="elsevierStylePara elsevierViewall">For many centuries&#44; sunlight treatment or heliotherapy has been instituted for the treatment of skin diseases&#46; In Egypt and India&#44; 3&#44;500 years ago&#44; people had the habit of using plant extracts or seeds&#44; with subsequent exposure to the sun for the treatment of skin diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the 19<span class="elsevierStyleSup">th</span> century&#44; the modern era of the use of light started&#46; Downes and Blunt&#44; in 1877&#44; published results of research in which exposure to light inhibited fungal and bacterial growth&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the 20<span class="elsevierStyleSup">th</span> century&#44; phototherapy was recognized as a medical science after Niels Finsen received the Nobel Prize of Medicine in 1903&#46; Twenty years later&#44; William Henry Goeckerman started using a lamp that emitted mainly UVB&#44; together with coal tar to treat psoriasis&#46; This treatment became very popular and was used for decades&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The increase in the effectiveness of phototherapy started in 1947&#44; with the isolation of 8-Methoxypsoralen &#40;8-MOP&#41; and 5-Methoxypsoralen &#40;5-MOP&#41;&#44; derived from the Ammi Majus Linn flower&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">There are reports on the use of this plant that dates back to the 13<span class="elsevierStyleSup">th</span> century&#44; when the Arab physician Ibnal-Bitar mentioned in his book &#8220;Mofradat El-Adwiya&#8221; the effects of ingesting Ammi Majus extracts&#44; followed by exposure to sunlight&#44; for vitiligo repigmentation&#46; This treatment was the oldest form of what is currently called photochemotherapy&#44; a modality defined as the ingestion of a psoralen followed by exposure to UVA &#40;320&#8211;400&#8239;nm&#41;&#46; In 1974&#44; the term PUVA &#40;Psoralen-ultraviolet A&#41; was created by Thomas B&#46; Fitzpatrick and John Parrish to name this therapeutic modality&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The development of photochemotherapy with PUVA paved the way for the research into new modalities&#46; NB-UVB radiation &#40;311&#8211;313&#8239;nm&#41; was discovered in 1988&#44; gradually replacing broadband UVB &#40;290&#8211;320&#8239;nm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Phototherapy started being used in Brazil in the 1980s&#46; It was also in this decade that a new type of phototherapy was introduced&#44; extracorporeal photochemotherapy&#44; initially for the treatment of cutaneous erythrodermic T-cell lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A major advance in the field of phototherapy was the development of UVA1 lamps &#40;340&#8211;400&#8239;nm&#41;&#44; which occurred in the early 1990s&#46; Used mainly for the treatment of atopic dermatitis and scleroderma&#44; this modality of treatment does not require the use of psoralen&#44; thanks to its greater penetrating power&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">More recently&#44; in 1997&#44; phototherapy with an excimer laser &#40;UVB - 308&#8239;nm&#41;&#44; a subtype of NB-UVB&#44; was introduced for the treatment of psoriasis and is currently used in other diseases&#44; such as vitiligo&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">From the heliotherapy practiced in Ancient Egypt to the development of the excimer laser&#44; phototherapy has been part of the therapeutic arsenal of Dermatology&#44; establishing its importance in clinical practice&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Mechanism of action</span><p id="par0105" class="elsevierStylePara elsevierViewall">UVR is absorbed by the chromophores &#40;molecules that have the capacity to absorb certain wavelengths&#41;&#44; such as DNA&#44; nucleotides&#44; lipids&#44; amino acids&#44; trans-urocanic acid&#44; and melanin&#46; UVR causes changes in the structure and function of chromophores&#46; The molecules thus modified are called photoproducts&#44; which participate in apoptosis&#44; inflammation&#44; immunosuppression&#44; and photocarcinogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The depth reached in the skin by each radiation type depends directly on its wavelength&#46; UVB radiation &#40;broadband and NB-UVB&#41; has a shorter length&#44; being absorbed by the epidermis and the superficial portion of the dermis&#46; The UVA waves &#40;1 and 2&#41; have a longer length&#44; penetrating up to the dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Both UVA &#40;PUVA or UVA1&#41; and UVB &#40;broadband and NB-UVB&#41; have immunosuppressive and antiproliferative effects&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The reduction in the number of macrophages&#44; 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furocoumarin compounds that act as chromophores for UVA&#46; After exposure to UVA&#44; they absorb photons&#44; become activated and covalently bind to the DNA bases&#46; Thus&#44; they form cross-linked pairs&#44; which have an antiproliferative&#44; antiangiogenic and apoptotic effect&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Stimulates melanogenesis&#44; although the mechanism of action is not known&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Induces the apoptosis of T cells infiltrated into the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Induces the expression of collagenase-1 in dermal fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Reduces the synthesis of collagen I and III&#44; leading to an antifibrotic effect&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">UVA1</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Prevents direct damage to the DNA&#44; as it has the lowest energy within the UV spectrum&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Induces apoptosis of lymphocytes&#44; mast cells and Langerhans cells&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Inhibits the expression of cytokines associated with Th2 response&#44; such as IL-5&#44; IL-13 and IL-31&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Reduces collagen and hydroxyproline levels&#44; proportionally to the utilized dose&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Activates collagenases&#44; which participate in the breakdown of dermal collagen&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Changes the quality of collagen&#44; reducing its density&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Inhibits fibroblast activity&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li></ul></p><p id="par0230" class="elsevierStylePara elsevierViewall">In scleroderma&#44; it can induce neovascularization and decrease apoptosis of endothelial cells&#46; This factor&#44; associated with the other above mentioned mechanisms of action&#44; makes UVA1 to be frequently prescribed for sclerosing skin diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">It is important to note that the effects of UVR on the human body do not change abruptly from one spectrum to another&#46; In fact&#44; these effects are continually changing from one wavelength to another and can even add up&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Types of phototherapy</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">UVA</span><p id="par0240" class="elsevierStylePara elsevierViewall">UVA rays &#40;320&#8211;400&#8239;nm&#41; are subdivided into&#58;</p><p id="par0245" class="elsevierStylePara elsevierViewall">UVA1 &#40;340&#8211;400&#8239;nm&#41; reaches the epidermis&#44; the middle and deep dermal components&#44; especially blood vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">UVA2 &#40;320&#8211;340&#8239;nm&#41; resembles UVB&#44; with more superficial penetration&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">PUVA</span><p id="par0255" class="elsevierStylePara elsevierViewall">Before the development of UVA1 lamps&#44; the UVA phototherapy that was in use was PUVA&#44; a method that by definition requires the use of psoralens&#46; Psoralen is a photosensitizing substance that can be used systemically via the oral route &#40;capsule&#41; or topically&#46; The latter route employs psoralen in cold cream&#44; alcoholic solution&#44; emulsion&#44; or diluted &#40;in a full or partial bath&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For patients with gastric intolerance&#44; there is the possibility of the systemic use of psoralen through rectal administration &#40;suppository&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Treatment with systemic PUVA &#40;oral or rectal administration&#41; involves the use of methoxypsoralen two hours before exposure to UVA radiation&#44; usually performed 2 to 3 times a week&#46; The radiation dose is progressively increased until a mild erythematous reaction occurs&#46; After the session&#44; it is necessary to maintain skin and eye photoprotection for 24&#8239;hours&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Topical PUVA therapy &#40;applying psoralen in cold cream&#44; solution or emulsion to the lesions only&#41; is an option in case of localized dermatoses&#46; This type of administration&#44; while less practical for the patient&#44; prevents the gastrointestinal side effects of oral medication&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">PUVA Bath</span><p id="par0270" class="elsevierStylePara elsevierViewall">PUVA bath is a topical phototherapy as effective as oral PUVA therapy&#46; It is a good option for patients with extensive injuries&#44; but with contraindications for systemic therapy&#46; The technique consists of exposure to UVA radiation after the patient has bathed in a bathtub containing 100 liters of warm water and 37&#46;5&#8239;mL of 1&#37; 8-methoxypsoralen&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> 8-MOP is more soluble in water&#44; allowing the phototoxic effect to quickly disappear after the treatment&#44; with rinsing in running water&#44; without the need to use photoprotection measures after the session&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The PUVA bath is mainly indicated for moderate to severe plaque psoriasis and chronic dermatoses of the palmoplantar region&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">UVA1</span><p id="par0275" class="elsevierStylePara elsevierViewall">Phototherapy with UVA1&#44; unlike PUVA&#44; omits UVA2 and does not require the use of psoralens&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">It is divided into 3 energy ranges&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">Low dose&#58; 10&#8211;20&#8239;J&#47;cm<span class="elsevierStyleSup">2</span></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Intermediate dose &#62;20&#8211;70&#8239;J&#47;cm<span class="elsevierStyleSup">2</span></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">High dose &#62;70&#8211;130&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li></ul></p><p id="par0300" class="elsevierStylePara elsevierViewall">This modality was seldom used by most Dermatology departments worldwide&#44; as it implied high heat emission and prolonged time of exposure&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> The lamps were made of high-emission metal halides &#40;Sellamed 4000&#8239;W&#44; Sellas Medizinische Ger&#228;te GmbH&#44; Ennepetal&#44; Germany&#41;&#44; which were not available in Brazil&#46; They emitted high doses of energy &#40;130&#8239;J&#47;cm&#178; in a single dose&#41;&#44; are now in disuse&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Currently&#44; in Brazil&#44; there is a type of UVA-1 lamp that alleviates these disadvantages&#46; It is the UVA-1 fluorescent lamp&#44; marketed by Philips &#40;TL10R 100&#8239;W&#44; Philips&#41;&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">UVA1 application has protocols that change according to the disease to be treated&#44; but treatment is usually performed 3 to 5 times a week&#44; with doses starting between 20&#8211;30&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#44; with progressive increase&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">The time of exposure during the session is calculated by the ratio between the number of Joules and the emission power of the lamp&#44; assessed by the radiometer in mW&#46; As an example&#44; considering that the current UVA1 lamps emit 20&#8239;mW&#44; to calculate the patient&#39;s exposure time&#44; receiving 0&#46;5&#8239;J&#47;cm&#178;&#44; we first transform 0&#46;5&#8239;J into 500&#8239;mJ and then divide the desired dose of 500&#8239;mJ by 20&#8239;mW&#44; which results in 25 seconds&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">The use of the radiometer is essential&#44; as it says how many mW the lamp emits&#46; As the lamps lose their emission capacity over time&#44; this implies a dose adjustment and an increase in the time of exposure&#44; requiring the periodical substitution of the lamps&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> This is valid for all types of phototherapy&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">UVA1 is a good option for the treatment of inflammatory and autoimmune diseases&#46; The treatment can be carried out exclusively through this modality or in combination with conventional therapies&#46; It can be carried out on children&#44; pregnant women and patients with contraindications to the use of psoralens &#40;not employed in this modality&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">UVA1 has fewer adverse effects than PUVA&#44; as it omits UVA2 which&#44; like UVB&#44; has the ability to cause erythema and carcinogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">UVB</span><p id="par0335" class="elsevierStylePara elsevierViewall">UVB radiation corresponds to wavelengths between 290 and 320&#8239;nm&#46; It is divided into broadband UVB &#40;290&#8211;320&#8239;nm&#41; and NB-UVB &#40;311&#8211;313&#8239;nm&#41;&#46; It is indicated for psoriasis&#44; atopic dermatitis&#44; renal and hepatic pruritus&#44; parapsoriasis&#44; mycosis fungoides&#44; vitiligo&#44; acute and chronic graft-versus-host disease&#44; among others&#46; As it does not involve the administration of psoralens&#44; it can be indicated for children and pregnant women&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16&#44;17</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Currently&#44; broadband UVB is in disuse&#46; Most centers use NB-UVB&#44; which is more effective than broadband UVB&#44; mainly in the treatment of psoriasis&#44; atopic dermatitis and vitiligo&#44; with less potential to generate adverse events&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;18</span></a> The NB-UVB dose that can cause hyperplasia&#44; edema&#44; burning and the depletion of Langerhans cells is 5 to 10-fold higher than the broadband UVB dose&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">Treatment with UVB &#40;broadband and NB-UVB&#41; can be applied 3 to 6 times a week&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; in most centers&#44; it is performed 2 to 3 times a week&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">There are two ways to determine the initial radiation dose&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1</span><p id="par0355" class="elsevierStylePara elsevierViewall">Determination of the Minimum Erythematous Dose &#40;MED&#41;&#58; the minimum amount of irradiation necessary to cause erythema&#46; The therapy is started with 70&#37; of the MED&#46; This method is in disuse due to practical limitations&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2</span><p id="par0360" class="elsevierStylePara elsevierViewall">Beginning the therapy with a standard radiation dose according to the patient&#39;s phototype&#46; This method is currently the most widely used&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li></ul></p><p id="par0365" class="elsevierStylePara elsevierViewall">After defining the initial dose&#44; every one or two sessions&#44; the radiation dose is increased by 10&#37; to 30&#37; until there is asymptomatic erythema&#46; The peak of the erythematous reaction occurs between 12 and 24&#8239;hours after radiation exposure&#46; Eye protection is essential&#44; but only during the phototherapy session&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">In the event of disease recurrence or worsening&#44; the frequency of treatment should be increased and&#44; in some cases&#44; the dose should be elevated&#44; according to each patient&#8217;s tolerance&#46; Upon reaching remission&#44; maintenance therapy is generally not indicated&#44; with the exception of mycosis fungoides&#44; which may require prolonged treatment to maintain disease control&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Other types of phototherapy</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Excimer laser and lamp</span><p id="par0375" class="elsevierStylePara elsevierViewall">This phototherapy model was introduced in the therapeutic arsenal of Dermatology in 1997&#46; As a subtype of NB-UVB&#44; with a wavelength of 308&#8239;nm&#44; it was approved for the treatment of psoriasis&#44; atopic dermatitis and vitiligo in the United States&#46; It is effective for several other localized &#40;less than 10&#37; of body surface&#41; and chronic inflammatory dermatoses&#46; It can be performed in places that are difficult to access with traditional phototherapies&#44; such as the scalp&#44; and palmoplantar skin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">Laser phototherapy is directed to the lesion through a tip with a spot measuring 14 to 30&#8239;mm in diameter&#44; sparing healthy skin&#46; This characteristic allows higher doses to be administered from the beginning&#46; Therefore&#44; fewer adjuvant treatments are needed and long-term side effects are reduced&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its emission depends on a mixture of xenon and chloride gas&#44; which form unstable &#8220;excited dimers&#8221;&#40;excimer&#41;&#46; When dissociated&#44; these dimers produce a coherent wavelength of 308&#8239;nm&#44; which penetrates primarily the epidermal cells and&#44; secondarily&#44; into fibroblasts&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">The excimer lamp&#44; on the other hand&#44; emits inconsistent light and&#44; consequently&#44; requires a longer time than the laser to emit the same fluency&#46; As advantages&#44; it allows the treatment of more extensive areas&#44; with lower operational costs&#44; as well as being easier to transport&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">Both the excimer laser and the excimer lamp have shown similar or superior effectiveness to NB-UVB in the treatment of psoriasis and vitiligo&#46; In atopic dermatitis&#44; despite promising results in relation to pruritus improvement&#44; the European and American guidelines do not endorse its use&#44; due to the scarce number of studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0395" class="elsevierStylePara elsevierViewall">More recently&#44; the role of the excimer laser in the treatment of alopecia areata has been investigated&#46; The results are promising and the absence of significant side effects&#44; especially when compared to traditional therapies &#40;corticotherapy and topical immunotherapy&#41;&#44; encourages its use&#46; Further studies are still necessary to determine whether the excimer lamp would have the same effectiveness as the excimer laser in this usage&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ultraviolet &#8220;combs&#8221;</span><p id="par0400" class="elsevierStylePara elsevierViewall">They are mainly indicated for the treatment of scalp psoriasis&#46; Patients with seborrheic dermatitis also benefit from this therapy&#46; This method allows the direct application of light to the scalp&#46; The accessories are removable and similar to combs&#44; easy to sterilize&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Most devices emit NB-UVB and although scientific studies are lacking on their therapeutic effectiveness&#44; there have been no reports of acute or chronic side effects after the adequate use of the method&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Home treatment</span><p id="par0410" class="elsevierStylePara elsevierViewall">Home phototherapy with UVB can be prescribed for selected patients&#44; who show adequate cognition and treatment adherence&#46; However&#44; worldwide&#44; some factors negatively influence on the prescription of this therapy&#44; such as difficulty in controlling the equipment&#44; as well as the duration of sessions performed by the patient&#44; in addition to the lack of an adequate reimbursement system&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Less conventional phototherapy methods&#44; such as heliotherapy &#40;exposure to sunlight&#41;&#44; with or without psoralen&#44; have been recommended in situations when conventional phototherapy is not feasible for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Clinical and laboratory tests prior to phototherapy</span><p id="par0420" class="elsevierStylePara elsevierViewall">Before choosing the phototherapy type&#44; a complete assessment of the patient is essential&#46; Dermatological examination of the entire integument should be performed to assess the dermatosis severity and extent&#44; determine the phototype and the degree of photodamage&#46; It is also important to describe in the patient&#8217;s record the aspect for any nevi he presents at the examination and also detect premalignant or malignant skin lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0425" class="elsevierStylePara elsevierViewall">A previous examination of the eyes of the patient is essential&#46; If an abnormality is detected&#44; the follow-up should be performed at least once a year with an ophthalmologist&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">The laboratory tests that should be requested for this phototherapy modality include kidney and liver function&#44; in addition to beta-HCG to rule out any pregnancy&#46; In the case of concomitant therapy with retinoids&#44; a lipid profile should be requested&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">The request for the ANF test is debatable&#46; If there is a family history of or suspected collagen disease&#44; it is advisable to request it&#46; Otherwise&#44; it is not part of the previous exams for phototherapy&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Indications</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Psoriasis</span><p id="par0440" class="elsevierStylePara elsevierViewall">Psoriasis is the disease that is most commonly treated with phototherapy&#46; In addition to being effective&#44; phototherapy is considered a safe option&#46; It is usually indicated when topical treatments do not show good results or are not practical for the patient&#44; such as those with extensive psoriasis&#46; It is the only viable therapeutic option in cases of severe psoriasis affecting individuals with contraindications for systemic treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0445" class="elsevierStylePara elsevierViewall">Currently&#44; NB-UVB is the therapeutic modality of choice&#46; Studies have shown its greater effectiveness compared to broadband UVB&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Regarding UVA1&#44; further studies are needed to compare its effectiveness with other types of phototherapy&#44; given the small number of patients included in the studies done so far&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0450" class="elsevierStylePara elsevierViewall">NB-UVB is considered the first-choice treatment for pregnant women with extensive disease&#46; It can be used with caution in children&#44; but it is not the first choice&#44; as the possible carcinogenic potential and anxiety in young children are limiting factors for this group&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0455" class="elsevierStylePara elsevierViewall">The excimer laser&#47;lamp is useful in the treatment of lesions affecting less than 10&#37; of the body surface&#44; such as palms&#44; soles&#44; elbows and knees&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> It has the same effectiveness as PUVA for the treatment of non-pustular palmoplantar psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0460" class="elsevierStylePara elsevierViewall">PUVA can be used topically or systemically&#44; being indicated for stable plaque psoriasis&#46; Despite being highly effective&#44; it has a worse tolerance profile than NB-UVB and there is greater evidence of carcinogenic potential&#44; therefore&#44; it is considered a second-line option for psoriasis treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In some cases&#44; phototherapy can be combined with oral retinoids&#44; reducing treatment time&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0465" class="elsevierStylePara elsevierViewall">The mechanism of action of phototherapy in the treatment of psoriasis is not completely understood&#46; UVB &#40;broadband and NB&#41; is known to induce apoptosis of pathogenic T lymphocytes and keratinocytes&#44; leading to reduced epidermal hyperproliferation and local and systemic immunosuppression&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;30</span></a></p><p id="par0470" class="elsevierStylePara elsevierViewall">NB-UVB inhibits the Th17 pathway&#44; which is crucial for disease pathogenesis&#46; Moreover&#44; it increases stability and restores regulatory T-cell function&#46; Accumulated doses of this modality are believed to reduce levels of plasmin&#44; a potent inflammatory activator&#44; contributing to its therapeutic effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;30</span></a></p><p id="par0475" class="elsevierStylePara elsevierViewall">It is believed that UVA1 induces T-cell apoptosis and reduces inflammatory cytokine levels&#44; such as TNF-&#945; and INF-&#947;&#46; Additionally&#44; UVA1 has been shown to inhibit the activity of antigen-presenting cells and to reduce the amount of Langerhans cells in the epidermis&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0480" class="elsevierStylePara elsevierViewall">The treatment should be discontinued when complete disease remission is achieved or if there is no response&#46; Phototherapy provides high rates of patient satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0485" class="elsevierStylePara elsevierViewall">The duration of remission correlates with the reduction in Psoriasis Area and Severity Index &#40;PASI&#41; at the end of treatment&#46; PASI reduction is on average 70&#37; when NB-UVB is applied and 80&#37; when treated with PUVA&#44; results comparable to those seen with immunobiological drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Vitiligo</span><p id="par0490" class="elsevierStylePara elsevierViewall">Vitiligo is an acquired pigmentation disorder&#44; characterized by the loss of epidermal melanocytes&#46; In most cases&#44; it behaves in a chronic and stable manner&#44; with short periods of progression&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0495" class="elsevierStylePara elsevierViewall">NB-UVB and PUVA phototherapy constitute the main treatment modalities for this dermatosis&#46; Currently&#44; NB-UVB is the first-line treatment for the generalized form&#46; For localized disease&#44; the excimer laser and the excimer lamp are more adequate&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0500" class="elsevierStylePara elsevierViewall">Yones et al&#46; demonstrated the superiority of NB-UVB phototherapy over PUVA in a randomized clinical trial&#46; In that study&#44; patients treated with NB-UVB had a 50&#37; higher repigmentation rate than patients treated with PUVA after six months of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0505" class="elsevierStylePara elsevierViewall">In addition to its superior effectiveness&#44; treatment with NB-UVB has other advantages over PUVA&#58; the lack of a photosensitizer&#44; lower cumulative dose and fewer adverse effects&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0510" class="elsevierStylePara elsevierViewall">Nevertheless&#44; phototherapy with NB-UVB does not always bring satisfactory results&#46; Lesions on the face&#44; neck and trunk are more sensitive to phototherapy&#44; while those on the hands&#44; feet&#44; elbows and knees are more resistant&#44; with minimal results&#46; A minimum of six months of treatment is required to assess the patient&#39;s response to therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0515" class="elsevierStylePara elsevierViewall">In recent years&#44; several studies on the combination of NB-UVB with topical calcineurin inhibitors or vitamin D analogs have shown good response&#44; suggesting that topical agents can produce synergistic effects when combined with phototherapy&#44; increasing their effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Lymphomas</span><p id="par0520" class="elsevierStylePara elsevierViewall">Cutaneous T-Cell Lymphomas &#40;CTCL&#41; are a heterogeneous group of non-Hodgkin&#39;s lymphomas of the skin&#44; with the mycosis fungoides &#40;MF&#41; subtype being the most common variant&#46; Initially&#44; it appears as erythematous patches and plaques and can progress to skin tumors&#46; Extracutaneous involvement is present in some cases&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0525" class="elsevierStylePara elsevierViewall">The United States Cutaneous Lymphoma Consortium recommends phototherapy as a monotherapy regimen for patients with early stages of CTCL&#47;mycosis fungoides &#40;stage IA-IIA&#41;&#44; and in combination with systemic therapies for refractory early disease or advanced disease&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Several systemic agents can be safely combined with phototherapy&#44; mainly interferon-alpha and retinoids&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0530" class="elsevierStylePara elsevierViewall">Determining the type of phototherapy to be used&#44; among PUVA&#44; NB-UVB and extracorporeal photochemotherapy will depend on the stage of the disease&#44; the patient&#39;s preference and the methods availability&#46; UVA shows better skin penetration than UVB&#44; and patients with thicker plaques&#44; darker skin and folliculotropic T-cell lymphoma may benefit more from PUVA&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0535" class="elsevierStylePara elsevierViewall">The immediate relief that many patients experience due to the decrease in the size and number of lesions&#44; as well as an improvement in pruritus&#44; is significant&#46; <a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0540" class="elsevierStylePara elsevierViewall">The phototherapy treatment regimen for CTCL involves 3 phases&#58; induction&#44; consolidation and maintenance&#46;</p><p id="par0545" class="elsevierStylePara elsevierViewall">The first phase may last longer than in other dermatoses treated with phototherapy&#46; The second phase&#44; the consolidation one&#44; lasts from one to three months&#46; This phase can maximize the potential for histopathological and molecular clearance &#40;including loss of the dominant T-cell clone&#41;&#46; During the last phase&#44; the maintenance one&#44; the frequency and dose of treatment are kept constant&#46; It is still controversial whether a prolonged maintenance phase after disease remission can reduce recurrence rates&#44; since there is insufficient data for such assertion&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0550" class="elsevierStylePara elsevierViewall">PUVA is the initial choice of phototherapy for CTCL chosen by many specialists&#46; It is effective for early MF&#44; with estimated response rates of 85&#37; for stage IA and 65&#37; for stage IB&#46; Treatment time with PUVA varies from two to four months&#44; with two to three sessions per week&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0555" class="elsevierStylePara elsevierViewall">Despite being in disuse&#44; broadband UVB is a good option for patients with stage IA of the disease and fair skin &#40;phototypes I and II&#41;&#46; However&#44; in the hypopigmented variant of MF&#44; the response is limited&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0560" class="elsevierStylePara elsevierViewall">As for the excimer laser&#44; there have been several reports showing the benefits of its use&#59; however&#44; the follow-up was short&#44; being reserved for sites not easily accessible to phototherapy or topical medications&#44; such as acral surfaces or intertriginous areas&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0565" class="elsevierStylePara elsevierViewall">Further studies&#44; with better standardization&#44; are needed to determine the ideal phototherapy regimen&#44; regarding effectiveness and long-term safety&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Parapsoriasis</span><p id="par0570" class="elsevierStylePara elsevierViewall">Parapsoriasis is a chronic inflammatory skin disorder whose etiology remains unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0575" class="elsevierStylePara elsevierViewall">Previous studies have shown that this disease probably represents different stages of a lymphoproliferative disorder&#46; It has been considered as a separate entity or as the initial form of MF&#44; although this remains debatable&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0580" class="elsevierStylePara elsevierViewall">Skin-targeted therapies are the main therapeutic options for the management of parapsoriasis and early-stage MF&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0585" class="elsevierStylePara elsevierViewall">Phototherapy is indicated for all types of parapsoriasis and its clinical variants&#46; In general&#44; NB-UVB is the preferred treatment modality&#46; PUVA should be used in patients with thick plaques&#44; high phototypes and those not responsive to UVB&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0590" class="elsevierStylePara elsevierViewall">In the case of patients who cannot tolerate or do not respond to PUVA or NB-UVB therapy&#44; low-dose UVA1 therapy seems to be a safe and effective alternative&#46; However&#44; the therapeutic regimen is not established&#44; due to the few studies assessing this therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Scleroderma</span><p id="par0595" class="elsevierStylePara elsevierViewall">Scleroderma is a chronic connective tissue disease&#44; whose etiology remains unknown&#46; It is characterized by intense collagen deposition in the dermis and&#44; in some cases&#44; in internal organs&#46; The main treatment objective is to increase skin elasticity&#44; improving patient mobility and quality of life&#44; in addition to delaying disease evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0600" class="elsevierStylePara elsevierViewall">As a therapeutic option&#44; phototherapy is safe&#44; as its effect is directed at the skin&#44; without the risk of systemic complications&#46; It represents an effective alternative for individuals who are refractory to topical or systemic treatments&#46; Those with contraindications to immunosuppressive therapy also benefit from the method&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0605" class="elsevierStylePara elsevierViewall">Several studies have shown that phototherapy effectiveness depends on the applied UVR dose&#46; In areas protected from solar radiation&#44; slower response to this therapy is observed&#46; As for the patient&#39;s phototype&#44; it seems to have no influence on treatment response&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0610" class="elsevierStylePara elsevierViewall">Several phototherapy modalities can be used in the treatment of sclerodermas&#44; such as PUVA&#44; UVA1 and NB-UVB&#46; Topical PUVA can be used in the localized forms and systemic PUVA in generalized ones&#46; NB-UVB is a viable option for scleroderma treatment&#44; especially for lesions in the inflammatory phase&#44; with superficial sclerosis&#46; The preference&#44; however&#44; is for UVA1 radiation&#44; as it shows deeper penetration into the dermis and the fact that there is a larger number of studies demonstrating its effectiveness&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;41</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Atopic dermatitis</span><p id="par0615" class="elsevierStylePara elsevierViewall">Atopic dermatitis &#40;AD&#41; is a common&#44; recurrent&#44; relapsing&#44; chronic inflammatory disease&#46; AD management includes avoiding triggering factors&#44; trying to compensate for skin barrier defects&#44; and maintaining anti-inflammatory therapy &#40;topical corticosteroids and calcineurin inhibitors&#41;&#46; When these first-line approaches are unsuccessful&#44; systemic treatment or phototherapy should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0620" class="elsevierStylePara elsevierViewall">Phototherapy has shown to be useful in the treatment of moderate to severe AD&#46; The currently used modalities are NB-UVB&#44; UVA1&#44; PUVA and excimer laser&#47;lamp&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0625" class="elsevierStylePara elsevierViewall">Phototherapy has been classified as &#8220;Strength of Recommendation B&#8221; and &#8220;Level of Evidence II&#8221; in the treatment of AD&#46; It is a second-line treatment&#44; which should be reserved for cases in which behavioral and topical measures have failed&#44; as numerous factors can limit its usefulness and effectiveness&#44; including cost and access&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0630" class="elsevierStylePara elsevierViewall">It acts by decreasing colonization by <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#44; improving the skin barrier function&#44; reducing pruritus and tissue inflammation&#46; Recent experimental studies have shown that its immunomodulatory effects include&#58; decreased expression of IL-5&#44; IL-13 and IL-31&#44; as well as the induction of T-cell apoptosis and dendritic cell reduction&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0635" class="elsevierStylePara elsevierViewall">The first modality of phototherapy used for AD treatment was broadband UVB&#44; in 1970&#59; however&#44; due to its erythematogenic potential and low effectiveness&#44; it fell into disuse&#46; Morison et al&#46; were the first to use PUVA for cases of refractory AD&#44; with therapeutic success&#46; Phototherapy can be used as monotherapy or in combination with emollients and steroids&#46; Its use can reduce the need for topical or systemic immunosuppressants&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0640" class="elsevierStylePara elsevierViewall">The doses and frequency of PUVA sessions &#40;topical or systemic&#41; are similar to those used for psoriasis&#46; This type of phototherapy is not the main choice of treatment for AD&#44; because it does not show the best results and due to its mutagenic potential&#46; Thus&#44; it should be administered for short periods&#46; The mechanism of action of PUVA phototherapy is yet to be fully understood&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0645" class="elsevierStylePara elsevierViewall">When treatment is carried out with UVA1&#44; the average dose is the most indicated in most references&#46; At this dose&#44; the adverse effects are reduced and treatment becomes more tolerable&#46; UVA1 has a more intense effect than UVB&#44; so it is more appropriate for patients with acute AD&#46; However&#44; the first UVA1 lamps were expensive and required more space and adequate ventilation machinery&#44; making them inaccessible in some centers&#46; Regarding the mechanism of action of UVA1 therapy&#44; the suppression of inflammatory cytokines&#44; such as IL-5&#44; IL-13 and IL-31 has been observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;43</span></a></p><p id="par0650" class="elsevierStylePara elsevierViewall">The best UVA1 dose in cases of AD exacerbation is a matter of debate&#46; Retrospective studies have shown a reduction in SCORAD &#40;Scoring Atopic Dermatitis&#47;Atopic Dermatitis Severity Index&#41; with both high and medium doses of UVA1&#46; However&#44; more prospective studies with larger samples are needed to establish the ideal dose&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a></p><p id="par0655" class="elsevierStylePara elsevierViewall">NB-UVB has been used successfully since 1990 in AD&#46; Currently&#44; it is considered by most dermatologists as the first-line phototherapy modality for the treatment of AD&#44; due to its availability&#44; safety&#44; easy administration&#44; and effectiveness&#46; This therapy reduced SCORAD and the need for topical corticosteroid use in several randomized studies&#46; These benefits persisted for up to 6 months after the treatment regimen termination&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0660" class="elsevierStylePara elsevierViewall">The excimer laser is another treatment modality that can be used&#46; Its use for 10 weeks has shown good results compared to clobetasol propionate&#46; The excimer lamp in combination with emollients resulted in AD severity score improvement within a 4-week period&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p><p id="par0665" class="elsevierStylePara elsevierViewall">Considering the low accessibility to UVA1 devices when compared to other phototherapy modalities&#44; NB-UVB provides the most successful and cost-effective treatment for patients with AD&#44; with a proven improvement in the Health-Related Quality of Life &#40;HRQoL&#41; and the Dermatological Quality of Life Index &#40;DLQI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Photodermatoses</span><p id="par0670" class="elsevierStylePara elsevierViewall">Phototherapy is an effective method to prevent seasonal outbreaks of photodermatoses&#46; In general&#44; the NB-UVB and PUVA doses are lower than the ones used for other dermatoses&#46; It is a safe therapy&#44; but it can cause skin rashes in a minority of patients&#44; which does not limit treatment or worsen the prognosis&#46; De Argila Fern&#225;ndez-Dur&#225;n recommends the use of oral corticosteroids in the first days of treatment to prevent disease exacerbation&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0675" class="elsevierStylePara elsevierViewall">Polymorphic light eruption &#40;PLE&#41;&#58; NB-UVB has become the first-line therapy according to several authors because it is a practical method&#46; It can be used even in the most severe cases&#46; PUVA can also be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0680" class="elsevierStylePara elsevierViewall">Actinic prurigo&#58; NB-UVB or PUVA are viable options in extensive cases or those refractory to other therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0685" class="elsevierStylePara elsevierViewall">Hydroa vacciniforme&#58; some reports have shown symptoms relief in patients with this photodermatosis&#44; but in most cases&#44; this disease is resistant to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0690" class="elsevierStylePara elsevierViewall">Chronic actinic dermatitis&#58; phototherapy is considered a second-line option&#44; reserved for patients with contraindications for systemic immunosuppression or as prophylaxis&#46; In such cases&#44; it is possible to choose treatment with low-dose PUVA alone or in combination with topical and oral corticosteroid therapy for a prolonged period&#46; NB-UVB can also be used&#44; as well as UVA1 radiation&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0695" class="elsevierStylePara elsevierViewall">Solar urticaria&#58; phototherapy can be used to prevent future crises since PUVA or NB-UVB induce phototolerance&#46; In view of the risk of anaphylaxis&#44; the minimum urticarial dose with the radiation intended for use should be tested&#44; before starting the treatment&#46; Additionally&#44; the concomitant use of antihistamines is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Pityriasis Lichenoides</span><p id="par0700" class="elsevierStylePara elsevierViewall">Pityriasis lichenoides chronica &#40;PLC&#41; is an uncommon dermatosis&#44; of unknown etiology&#44; for which phototherapy is one of the main treatments&#44; particularly in the most extensive disease&#46; There have been studies that corroborated the use of PUVA&#44; NB-UVB and broadband UVB for this disease&#46; NB-UVB is an effective treatment for the diffuse and chronic forms&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0705" class="elsevierStylePara elsevierViewall">There are small studies reporting the high effectiveness of treatment with NB-UVB&#44; broadband UVB and PUVA&#46; Despite the satisfactory results&#44; due to the few cases included in these studies&#44; it is not possible to draw a precise conclusion&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Other phototherapy indications</span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Uremic pruritus</span><p id="par0710" class="elsevierStylePara elsevierViewall">The mechanism of action of phototherapy in reducing the pruritus is unclear&#46; NB-UVB decreases the production of IL-2&#44; a cytokine related to pruritus&#44; induces apoptosis of dermal mast cells and reduces the release of neuropeptides&#44; such as substance P&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Recent studies have shown that NB-UVB phototherapy can be considered an effective therapeutic option in the treatment of uremic pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Polycythemia vera</span><p id="par0715" class="elsevierStylePara elsevierViewall">Pruritus is the most common symptom of polycythemia vera &#40;PCV&#41;&#46; Although its pathogenesis is not understood&#44; it is believed that platelet and erythrocyte overproduction play a central role&#46; The platelets aggregated in the skin vessels store and release prostaglandins and serotonin&#44; both of which are involved in pruritus&#46; There are studies evaluating the effectiveness of both NB-UVB and broadband UVB&#44; as well as PUVA in these cases&#46; Most studies included a small number of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p><p id="par0720" class="elsevierStylePara elsevierViewall">NB-UVB phototherapy has shown a good risk&#47;benefit ratio in the treatment of polycythemia vera-associated pruritus&#46; However&#44; further studies are needed to determine the ideal therapeutic regimen&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Prurigo nodularis</span><p id="par0725" class="elsevierStylePara elsevierViewall">The excimer laser has been reported in the literature as a treatment modality that resulted in prurigo nodularis improvement&#46; Larger investigations with long-term follow-up are needed to fully support its use&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Graft-versus-host disease</span><p id="par0730" class="elsevierStylePara elsevierViewall">Graft-versus-host disease &#40;GVHD&#41; represents a complex immune response involving several organs&#46; The disease occurs mainly in allogeneic hematopoietic stem-cell transplantation&#46; The first-line treatment is carried out with high-dose corticosteroids&#44; alone or in combination with other immunosuppressants&#44; showing numerous side effects and increasing the risk of infections&#46; In this sense&#44; phototherapy plays an important role&#44; as the treatment is directed at the skin&#44; with few side effects&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p><p id="par0735" class="elsevierStylePara elsevierViewall">Its mechanism of action in these cases remains unknown&#44; but apoptosis&#44; antiproliferative and immunomodulatory effects seem to be involved&#46; NB-UVB and UVA1 have been used more frequently in GVHD treatment&#44; due to the safety of the methods and the important clinical response&#46; One of the great advantages of associating phototherapy in the treatment is that it allows the reduction of corticosteroid doses&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0740" class="elsevierStylePara elsevierViewall">The following parameters must be considered when choosing the treatment modality&#58; type&#44; extent&#44; and depth of the lesions&#44; the possible involvement of other organs and use of concomitant medication&#46; The treatment regimen is usually performed at lower doses than for other diseases&#46; Phototherapy is effective in the treatment of both the acute and chronic phases&#44; and in the prevention of graft-versus-host disease in adults and children&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Phototherapy and HIV</span><p id="par0745" class="elsevierStylePara elsevierViewall">UVR is known to suppress the immune system and modify cytokine patterns&#46; Moreover&#44; exposure to UV rays is likely to increase viral replication&#46; The main concern is the phototherapy indication in the early&#47;intermediate disease stages when the patient still has a detectable viral load&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a></p><p id="par0750" class="elsevierStylePara elsevierViewall">There are some conditions that occur in HIV-infected patients which respond well to UVR use&#44; such as psoriasis&#44; eosinophilic folliculitis&#44; eczema&#44; and pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> The choice of UVR treatment should evaluate items such as skin lesion responsiveness and photosensitivity caused by some antiretrovirals&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a></p><p id="par0755" class="elsevierStylePara elsevierViewall">The risk-benefit ratio varies depending on the HIV disease stage&#46; Existing data in advanced-stage patients suggest that treatment with NB-UVB or PUVA is not associated with clinical deterioration in the short term&#46; In patients with an undetectable viral load&#44; phototherapy may be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> It should be noted that phototherapy seems to worsen the prognosis of patients with Kaposi&#39;s sarcoma and&#44; therefore&#44; this modality is contraindicated for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Phototherapy and carcinogenesis</span><p id="par0760" class="elsevierStylePara elsevierViewall">Based on the mechanisms of action discussed in this review article&#44; it is possible that UV radiation may have mutagenic potential&#46; The reason for this concern is that workers exposed to sunlight have a higher incidence of melanoma and non-melanoma skin cancer&#44; especially individuals with a low phototype&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0765" class="elsevierStylePara elsevierViewall">Studies have shown that PUVA induces cutaneous oncogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A 10-fold increase in the risk of squamous cell carcinoma &#40;SCC&#41; has been reported when more than 150 treatments were performed &#40;or a maximum cumulative dose of 1000&#8211;1500&#8239;J&#47;cm&#41;&#46; There is also scientific evidence of an increase in actinic keratoses&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26&#44;60</span></a></p><p id="par0770" class="elsevierStylePara elsevierViewall">The risk of BCC&#44; even in patients who received high doses of PUVA&#44; is lower than that of SCC&#46; The increased risk of melanoma after PUVA treatment is manifested 15 years after starting of the therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0775" class="elsevierStylePara elsevierViewall">Although there is abundant evidence for PUVA dose-related skin cancer risk&#44; studies investigating the risk of photocarcinogenesis with NB-UVB and UVA1 are limited to retrospective studies and case reports&#46; According to the available evidence&#44; NB-UVB seems&#44; in general&#44; to be the safest phototherapy modality&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0780" class="elsevierStylePara elsevierViewall">It should be noted that the combination of phototherapy and cyclosporine &#40;including a history of cyclosporine use&#41; should be avoided&#44; considering the increased carcinogenic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Other adverse effects</span><p id="par0785" class="elsevierStylePara elsevierViewall">The adverse effects can be short-term or long-term ones&#46; The most common acute adverse effect is erythema&#46; If it is caused by PUVA&#44; it appears between 48 and 72&#8239;hours after exposure and is usually prolonged&#46; The erythema caused by UVB radiation occurs early&#44; within the first 24&#8239;hours after exposure&#46; If the erythema is mild and asymptomatic&#44; the last dose used should be maintained&#46; If there is severe erythema or if it is associated with pain&#44; the treatment should be discontinued until the condition improves&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0790" class="elsevierStylePara elsevierViewall">In the long term&#44; skin photoaging is an adverse effect inherent to all forms of phototherapy&#44; being more intense with UVA&#44; as it reaches deeper layers of the dermis&#46; It is known that the lower the phototype&#44; the greater the susceptibility to photoaging&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Skin pigmentation changes also occur&#44; with the formation of solar lentigines&#44; both with PUVA and NB-UVB&#46;</p><p id="par0795" class="elsevierStylePara elsevierViewall">Pruritus may occur as a side effect&#46; There are 2 types&#44; one that depends on cutaneous xerosis and improves with emollient use and another with an idiopathic cause&#44; which is rare&#44; contraindicating the continuation of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0800" class="elsevierStylePara elsevierViewall">Regarding the PUVA modality&#44; gastrointestinal intolerance can occur with 8-MOP&#44; usually being dose-dependent&#46; The use of antiemetics and administration of psoralen after food intake attenuates this effect&#46; Occasional symptoms include vertigo or headache&#46; Intolerance reactions are specific to oral 8-MOP and can be prevented by replacing it with 5-MOP&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0805" class="elsevierStylePara elsevierViewall">With PUVA&#44; it is important to assess the risk of developing cataracts&#44; and eye protection must be used during the session and for 12&#8239;hours after treatment&#44; as 8-MOP can be detected in the lens up to 12&#8239;h after ingestion&#46; A rare occurrence during treatment with this modality is acral blisters&#44; which can develop in patients exposed to severe mechanical stress due to loosening of the dermo-epidermal junction&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0810" class="elsevierStylePara elsevierViewall">The side effects of phototherapy rarely lead to its contraindication&#44; but it may happen&#46; The risk-benefit ratio for each case should be assessed and phototherapy&#44; whenever possible&#44; should be considered&#44; since its benefits frequently outweigh the risks&#46;</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Financial support</span><p id="par0815" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Authors&#39; contributions</span><p id="par0820" class="elsevierStylePara elsevierViewall">Norami de Moura Barros&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0825" class="elsevierStylePara elsevierViewall">Lissi&#234; Lunardi Sbroglio&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0830" class="elsevierStylePara elsevierViewall">Maria de Oliveira Buffara&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0835" class="elsevierStylePara elsevierViewall">Jessica Lana Concei&#231;&#227;o e Silva Baka&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0840" class="elsevierStylePara elsevierViewall">Allen de Souza Pessoa&#58; design and planning of the study&#59; critical review of the manuscript&#46;</p><p id="par0845" class="elsevierStylePara elsevierViewall">Luna Azulay-Abulafia&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; effective participation in research orientation&#59; critical review of the manuscript&#46;</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Conflicts of interest</span><p id="par0850" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "History"
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              "titulo" => "UVB &#40;broadband&#44; NB-UVB and excimer laser&#41;"
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            1 => array:2 [
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              "titulo" => "UVA &#40;PUVA and UVA1&#41;"
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              "titulo" => "PUVA"
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          "identificador" => "sec0040"
          "titulo" => "Types of phototherapy"
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              "titulo" => "PUVA"
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              "titulo" => "PUVA Bath"
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              "titulo" => "UVA1"
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              "titulo" => "UVB"
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          "titulo" => "Other types of phototherapy"
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              "titulo" => "Excimer laser and lamp"
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              "titulo" => "Ultraviolet &#8220;combs&#8221;"
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              "titulo" => "Home treatment"
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              "titulo" => "Clinical and laboratory tests prior to phototherapy"
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          "titulo" => "Indications"
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              "titulo" => "Psoriasis"
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              "titulo" => "Vitiligo"
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              "identificador" => "sec0110"
              "titulo" => "Lymphomas"
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              "identificador" => "sec0115"
              "titulo" => "Parapsoriasis"
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              "identificador" => "sec0120"
              "titulo" => "Scleroderma"
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              "identificador" => "sec0125"
              "titulo" => "Atopic dermatitis"
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              "identificador" => "sec0130"
              "titulo" => "Photodermatoses"
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              "titulo" => "Pityriasis Lichenoides"
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          "titulo" => "Other phototherapy indications"
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              "identificador" => "sec0145"
              "titulo" => "Uremic pruritus"
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            1 => array:2 [
              "identificador" => "sec0150"
              "titulo" => "Polycythemia vera"
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            2 => array:2 [
              "identificador" => "sec0155"
              "titulo" => "Prurigo nodularis"
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            3 => array:2 [
              "identificador" => "sec0160"
              "titulo" => "Graft-versus-host disease"
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              "identificador" => "sec0165"
              "titulo" => "Phototherapy and HIV"
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              "titulo" => "Phototherapy and carcinogenesis"
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          "titulo" => "Other adverse effects"
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            1 => "PUVA therapy"
            2 => "Ultraviolet therapy"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Of all the therapeutic options available in Dermatology&#44; few of them have the history&#44; effectiveness&#44; and safety of phototherapy&#46; Heliotherapy&#44; NB-UVB&#44; PUVA&#44; and UVA1 are currently the most common types of phototherapy used&#46; Although psoriasis is the most frequent indication&#44; it is used for atopic dermatitis&#44; vitiligo&#44; cutaneous T-cell lymphoma&#44; and cutaneous sclerosis&#44; among others&#46; Before indicating phototherapy&#44; a complete patient assessment should be performed&#46; Possible contraindications should be actively searched for and it is essential to assess whether the patient can come to the treatment center at least twice a week&#46; One of the main method limitations is the difficulty that patients have to attend the sessions&#46; This therapy usually occurs in association with other treatments&#58; topical or systemic medications&#46; Maintaining the regular monitoring of the patient is essential to identify and treat possible adverse effects&#46; Phototherapy is recognized for its benefits and should be considered whenever possible&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Barros NM&#44; Sbroglio LL&#44; Buffara MO&#44; Baka JLCS&#44; Pessoa AS&#44; Azulay-Abulafia L&#46; Phototherapy&#46; An Bras Dermatol&#46; 2021&#59;96&#58;397&#8211;407&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology&#44; Hospital Universit&#225;rio Pedro Ernesto&#44; Universidade do Estado do Rio de Janeiro&#44; Rio de Janeiro&#44; RJ&#44; Brazil&#46;</p>"
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