Phototherapy

5 Phototherapy

Sarah Copperwheat RN PGDip

Phototherapy is a therapeutic treatment for a variety of dermatoses, including psoriasis, eczema, mycosis fungoides (an unusual form of skin malignancy) and vitiligo. It involves the controlled administration of non-ionising radiation to the skin in the form of ultraviolet A (UVA) or ultraviolet B (UVB) wavelengths of light.1 UVB is absorbed mainly by the epidermis, while UVA penetrates the deeper layers of the dermis. UVA is usually given as a combination treatment with psoralen, a plant extract that sensitises the skin to light – this is known as PUVA. Ultraviolet light has been used to treat skin conditions for millennia. Up to 3500 years ago, Egyptian and Indian healers used ingestion of plant extracts or seeds in addition to sunlight to treat skin problems.2

The phototherapy clinic is a potentially hazardous environment with powerful UV light sources that can burn both patients and staff if not delivered properly. Therefore, all services must be supported by clear safety protocols along with scopes of practice and specific competency frameworks for staff, with access to specialist support and governance. SOP should be in place to ensure machine safety, including machine maintenance, service dates, how to use the machine in a step-by-step method and comprehensive infection control measures.

Nursing role

Delivering phototherapy has long been a nursing role. Once a patient has consented to and been referred for therapy, nursing teams take on the responsibility of delivering safe and effective care.

Scope of practice. There are roles within phototherapy for band 4 nurses upwards; however, it is a firm recommendation that anyone who works independently with patients receiving phototherapy should be at least band 6. Table 5.1 outlines the roles and responsibilities of dermatology nurses in phototherapy by band, with each band building on the skills outlined in the previous band. Membership of the BDNG is strongly recommended to help keep up to date with evidence-based practice and to be aware of training opportunities.

While band 6 nurses and above can work independently within a phototherapy unit, there should always be access to appropriate clinical support from medical staff in case of adverse events or a

TABLE 5.1

Roles and responsibilities of dermatology nurses in phototherapy

Band Clinical skills*

4 • Organises appointments • Chaperones • Assists with safety and infection control • Abides by all safety standards 5 • Delivers phototherapy under supervision (while competence is achieved) • Delivers phototherapy independently alongside someone more senior in the phototherapy unit (after competence is demonstrated) • Provides patient support and education • Attends clinical governance meetings and ensures annual phototherapy updates 6 • Delivers phototherapy independently without the presence of more senior staff in the phototherapy unit • Independent prescriber • Leads the nursing team (in the absence of a band 7 nurse), contributing to the day-to-day and overall management of the phototherapy unit • Contributes to the development of education in the unit (monitors adverse events, involved in audits, patient education) 7/8 • Ensures the smooth and safe running of the phototherapy department, including monitoring of staff competence within the unit • Leads on Trust-wide issues related to safety and service delivery • Develops a clinical governance programme and ensures it is delivered • Leads on liaison with named medical consultant for phototherapy

*Each band builds on the skills outlined in the previous band.

deterioration in the patient’s condition. If needed, remote supervision can be arranged.

Direct patient care roles. The phototherapy nurse’s role starts with assessment of the patient to ensure it is safe for them to receive phototherapy. This will require taking a thorough history of previous phototherapy courses, sun exposure, and current and previous medications. The referring consultant will have obtained the patient’s consent for the treatment after outlining possible long-term effects and ensuring they have realistic expectations about the frequency and length of treatment (usually 2–3 times weekly for a minimum of 10 weeks). However, it is important that the phototherapy nurse obtains a second consent after ensuring that the patient knows about the possible immediate adverse effects, what they can and cannot do while having treatment and what they will experience when attending an appointment.

Calculation and delivery of the appropriate dose will depend on the patient’s skin type and skin disease, while safe delivery of the treatment course will require adjustments depending on the patient’s response. The phototherapy nurse will need to keep clear and accurate records, including a note of any adverse events.

The decision of when to discharge the patient will depend on the number of treatments and response to treatment. It is important that the phototherapy nurse organises appropriate follow up to review outcome or to instigate a different treatment modality if phototherapy has not been successful.

Phototherapy nurses must be aware of lifetime limits for both UVB and PUVA, as well as the referral process for skin monitoring when this limit is reached. In this respect, it is also important to liaise with other units to share treatment numbers and dosages (joules) so that cumulative amounts can be recorded. Photonet, the National Managed Clinical Network for Phototherapy in Scotland, is an excellent example of a national system for recording and monitoring cumulative doses.3

The patient care setting. Phototherapy is predominantly delivered in a secondary care, outpatient setting. For hospital phototherapy, consideration must be given to the cost of parking, the patient’s

ability to attend the unit 2–3 times a week, and the overall length of treatment courses. These factors should all be discussed before the patient starts phototherapy to ensure the best treatment pathway is selected. Home phototherapy, which is particularly useful for patients who need to travel long distances to access treatment, has been trialled in a number of places with some good results.4

Competencies

To ensure patients receive optimum care, phototherapy nurses need a good general dermatological knowledge so that they can assess the skin properly, understand how different skin conditions respond to light therapy and advise patients on the use of dermatological treatments. In addition to their dermatological knowledge, nurses working in phototherapy must develop technical abilities to manipulate phototherapy equipment and have confidence to perform regular calculations to ensure correct dose delivery.

Competence must be achieved before a nurse can perform phototherapy independently. When training to achieve competence, the nurse must work under the supervision of a colleague already competent to carry out phototherapy; all patients seen together must be co-signed. A nurse is deemed competent when they possess the knowledge, skills and abilities required for lawful, safe and effective professional practice. Competence can usually be achieved after 3 months of supervised practice (pro rata for part-time workers), but this time frame can be increased as required.

The competency framework must be revisited at each annual appraisal to ensure the nurse is still competent.

Core knowledge domains

Alongside general dermatological nursing are some further core knowledge domains, as outlined below.

Monitoring erythema. Erythema is the skin’s natural response to UV light, and it is normal for patients to have some mild erythema after treatment. However, there is a fine line between a normal response and an adverse effect. As such, the phototherapy nurse must develop the skills needed to assess skin erythema. Being able to grade erythema appropriately will determine the course of treatment (that

is, the speed with which treatment is stepped up). If done incorrectly, the patient may receive suboptimal treatment or may be repeatedly overtreated.

An erythema grading chart5 is a helpful tool to guide practice and, ideally, should include images of erythema in non-white skin. Phototherapy nurses must work as a team to ensure a standardised approach to erythema monitoring to ensure safe and effective treatment for patients. Clear documentation is a critical part of this.

Minimal erythema dose testing. The starting dose of UVB phototherapy is critical to the treatment’s effectiveness; getting it right ensures that the patient is not over- or undertreated. Finding the starting dose that is suitable for the individual’s skin is determined in one of two ways, by: • skin type, using the Fitzpatrick skin type scale (a less accurate method)6 • minimal erythema dose (MED) testing.5

MED testing exposes a small area of normal skin to a range of UVB doses. It is performed with a handheld unit that is calibrated in a factory or by an in-house physicist. The patient’s skin is then examined 24 hours later to evaluate the erythema responses to the different strengths of UVB exposure (Figure 5.1). The starting dose of phototherapy is 70% of the dose that gives the mildest visible erythema.

The MED device allows for a more accurate starting dose, which in turn can reduce the number of treatments needed to obtain the best outcome.7 Ensuring that all team members measure erythema in the same way, using the same technique, is critical. The UV outputs from both the MED device and UV machine must correspond, so they must be calibrated at the same time. If they are not, the MED will not reflect the dose given by the UV machine, with potentially hazardous consequences. Currently, MED testing using UVA doses is unavailable in a handheld unit.

Patient support and education. Phototherapy nurses see patients on a regular basis (at least twice a week during treatment) and are therefore in an excellent position to provide health-promoting advice and psychological support. Chronic skin conditions can have

(a) (b)

Figure 5.1 (a) The MED device is held lightly but firmly on the selected area of skin. It switches off automatically at the end of the exposure time. (b) 24 hours later, the skin is examined, and the MED is calculated. Reproduced courtesy of Dr Jonathan Batchelor, University of Nottingham, UK.

a significant effect on patients’ quality of life, affecting their mood, sleep patterns and relationships. However, the psychological impact of the disease is often overlooked and not addressed during short consultation times with clinicians. The phototherapy unit provides an environment in which this can be addressed and the phototherapy nurse can provide support, including signposting to support groups where appropriate.

The rapport built between nurse and patient during treatment can also facilitate discussion of important lifestyle issues, such as stopping smoking, reducing alcohol consumption and losing weight, enabling appropriate advice to be given.

Monitoring patient outcomes is a good way of assessing the effect of treatment on patients and can help to determine whether they need further therapeutic interventions, such as biological therapies. Specific disease assessment tools such as the Psoriasis Area and Severity Index (PASI) and Eczema Area and Severity Index (EASI) should be used at the beginning, during and end of treatment. In addition to helping determine appropriate subsequent treatment for individual patients, the information obtained from these types of tools helps to inform audit data (see below). See Chapter 6 for further details of the EASI and PASI (pages 96–7).

Patient photos can also be very useful for monitoring progress and can help to reassure patients that the severity of disease has reduced since the start of treatment.

Quality of life should also be assessed, as patients with skin conditions may require additional psychological support. The Dermatology Life Quality Index (DLQI) is a validated questionnaire with which patients can self-assess the impact of their skin problem on different aspects of their daily life.8 See Chapter 6 for further details of the DLQI (see page 99).

Review of service

The BAD has a set of audit criteria that can be used to monitor standards within phototherapy units.9 The criteria cover referral and patient assessment, patient information and consent, staff training and education, clinical management and monitoring, equipment and facilities, clinical governance and audit, discharge protocol and skin cancer surveillance. These standards can help to ensure that existing services provide safe and effective delivery of care to patients and that new services are set up in a way that ensures patient safety and optimises treatment.

In addition to the BAD’s standards, the following audit measures can be used to monitor the effectiveness of phototherapy services. • Audit DLQI/PASI scores before and after treatment. • Number of patients seen. • Waiting list times (are these within guidelines?). • Patient satisfaction issues, such as: – Were appointment times satisfactory? – Did patients have to wait at appointment times or were they seen promptly? – Was privacy maintained? – Did the treatment help? – Were all questions answered?

Staff training and education. Phototherapy services must have sufficient, appropriately registered, qualified and experienced medical, nursing and other clinical and non-clinical staff to provide appropriate services in all respects at all times. The BAD criteria recommend that all phototherapists should undergo some form of

educational activity in phototherapy at least once a year, including attending a recognised course at least once every 3 years. In addition, all phototherapy staff must have an annual appraisal and a personal development plan for their continuing professional development.

Equipment and facilities. The treatment room should be kept at 16–25oC. There should be adequate spacing for ease of access to phototherapy machines (Figure 5.2), and there needs to be enough space for the patient to undress and dress with privacy (with assistance if required), either with a curtained area (with disposable curtains) or a cubicle. Indeed, the patient’s privacy and dignity should be maintained at all times through the effective use of screens, blankets and appropriate clothing.

There should be adequate air conditioning and ventilation above machines. All equipment must be regularly calibrated and checked for electrical safety. The bulbs in phototherapy cabins are fitted with acrylic or glass guards as standard to prevent direct contact.

Using equipment safely. Accurate recording of exposure measurements facilitates comparison of results between phototherapy centres and assists in the safe transfer of patients between units. Machines must be cleaned in between patients, and their output should be checked and documented each morning before patient use.

(a) (b)

Figure 5.2 (a) A UVB cabinet, used to treat patients with moderate-to-severe psoriasis. (b) A UVA unit used to treat psoriasis or eczema of the hands and feet; reproduced courtesy of Norfolk and Norwich University Hospitals.

Staff need to work at a distance from the machines when they are in use and occupational exposure to UV radiation must be assessed and kept below recommended limits.9

Patient safety is paramount and includes ensuring that they: • can stand unaided during treatment, as the handles inside the machine are not weight-bearing • stand in the same position for each treatment session • do not take anything into the machine with them • stand still during treatment (some machines have a sensor that cuts power when movement is detected) • wear goggles to prevent future cataracts; if the eye area needs to be treated then the patient must keep their eyes closed • wear dark-coloured underwear to protect their genitals (men).

Career progression: next steps

For some nurses, providing phototherapy for patients with skin diseases will be the only contact they have with dermatology patients, while for others it will form just part of their role as a dermatology nurse. As discussed above, all staff must have an annual review that includes a phototherapy update, during which specific targets for knowledge and skill acquisition should be set, including a good underpinning knowledge of the dermatological conditions treated with phototherapy and all relevant therapeutic interventions.

To progress to band 6 in phototherapy, consider the following: • Complete a recognised course in phototherapy: for example,

BDNG e-learning (visit the BDNG website for more information) or one of the phototherapy courses provided by Newport

Phototherapy Training.10 The BDNG also has a photodermatology subgroup offering contact, support and training. Photonet also provides an online module and yearly study days.3 • Develop the leadership skills and confidence required to take on increased responsibility within the team: for example, independently manage the phototherapy unit on a day-to-day basis and supervise other members of staff. • Manage the smooth running of the phototherapy unit: for example, arrange machine maintenance, monitor infection control strategies, undertake audits and organise patient satisfaction questionnaires.

• Gain knowledge of the different dermatological conditions and how UV light affects them. Understand what can be considered a satisfactory response to a course of phototherapy and when to feel confident to stop treatment (that is, when it is no longer therapeutic).

To progress to band 7 in phototherapy consider the following: • Gain a recognised qualification, such as an MSc in dermatology.

Modules within the MSc can be used independently to demonstrate an underpinning knowledge and evidence base for treatments and conditions. • Qualify as an independent nurse prescriber so that necessary treatments (particularly topical therapies) can be prescribed for patients undergoing phototherapy in a timely manner. • Develop further managerial skills by leading audits and managing staffing within the phototherapy unit. • Lead clinical governance within phototherapy, ensuring appropriate developmental opportunities such as educational meetings, learning from adverse events and discussing issues raised from incident reports.

The future

Phototherapy is an effective treatment modality, but since the introduction of biological drugs there have been concerns that it may become a less relevant treatment option. The first biologics arrived 20 years ago, yet phototherapy still has a significant place in the patient treatment pathway. Indeed, it may be an important treatment step before patients are given systemic or biological treatments. Some data also suggest that implementing and/or widening phototherapy services may lead to significant cost savings, making it an attractive treatment option for healthcare providers.11

Key points – phototherapy

• Phototherapy is a potentially dangerous environment, so clear standards and procedures need to be in place to ensure the safety of staff and patients. • There is clear career progression within phototherapy, which involves the development of clinical, leadership and managerial skills. • For phototherapy to be delivered safely, nurses must have signed-off competencies accompanied by an annual performance review that includes a phototherapy update. • During a course of phototherapy, nurses have regular and frequent contact with patients. This facilitates patient education and support for issues directly related to their skin condition but also other lifestyle and mental health wellbeing issues. • Auditing against clear standards helps to ensure safety and a high quality of care within the phototherapy department.

References and resources

1. Rathod DG, Muneer H,

Masood S. Phototherapy. In:

StatPearls [Internet]. StatPearls

Publishing, 2022. www.ncbi. nlm.nih.gov/books/NBK563140, last accessed 23 March 2022. 2. Hönigsmann H. History of phototherapy in dermatology.

Photochem Photobiol Sci 2013; 12:16–21. 3. Photonet. National Managed

Clinical Network for

Phototherapy in Scotland. Turas e-Learning Course. Photonet, 2022. www.photonet.scot. nhs.uk/elearning-course, last accessed 23 March 2022. 4. Cameron H, Yule S, Dawe RS et al. Review of an established

UK home phototherapy service 1998–2011: improving access to a cost-effective treatment for chronic skin disease. Public

Health 2014;128:317–24. 5. Palmer R, Garibaldinos T,

Hawk J [updated by Sarkany R].

MPD and MED testing.

In: Phototherapy Guidelines.

St John’s Institute of

Dermatology, 2009:5. www.phototherapysupport.net/ wp-content/uploads/2020/01/

Phototherapy-Guidelines.pdf, last accessed 24 June 2022.

6. DermNet NZ. Fitzpatrick Skin

Prototype. www.dermnetnz.org/ topics/skin-phototype, last accessed 24 June 2022. 7. Heckman CJ, Chandler R,

Kloss JD et al. Minimal erythema dose (MED) testing.

J Vis Exp 2013;(75):e50175. 8. Finlay AY, Khan GK.

Dermatology Life Quality

Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–16. 9. British Association of

Dermatologists. Service

Guidance and Standards for

Phototherapy Units. British

Association of Dermatologists, 2016. https://cdn.bad.org.uk/ uploads/2021/12/29200202/

Phototherapy-Service-Guidance -and-Standards-20193.pdf, last accessed 12 July 2022.

Further reading and resources

Campbell J. Safe and effective use of phototherapy and photochemotherapy in the treatment of psoriasis. Br J Nurs 2020;29:547–52. DermaTools. Comprehensive digital tools to monitor dermatologic conditions. Developed by dermatologists for dermatologists and patients. www.dermavalue.com Menter A, Smith C, Barker J et al. Phototherapy and photochemotherapy. In: Fast Facts: Psoriasis, 4th edn. S. Karger Publishers Ltd, 2014:65–73. The South East of England Phototherapy Network. www.phototherapysupport.net

10. Newport Phototherapy

Training. Courses for Healthcare

Professionals. Newport

Phototherapy Training, 2022. www.newportphototherapy training.co.uk, last accessed 4 April 2022. 11. Foerster J, Dawe R.

Phototherapy achieves significant cost savings by the delay of drug‐based treatment in psoriasis. Photodermatol

Photoimmunol Photomed 2020;36:90–6.

© S. Karger Publishers Ltd 2023