British Association of Dermatologists and British Photodermatology Group Guidelines For Narrowband Ultraviolet B Phototherapy 2022

BJD
GUIDELINES British Journal of Dermatology
British Association of Dermatologists and British

Photodermatology Group guidelines for narrowband
ultraviolet B phototherapy 2022*
Victoria Goulden,1 Tsui C. Ling,2 Parastoo Babakinejad,3 Robert Dawe,4 Ewan Eadie iD ,4 Hiva Fassihi iD ,5
Adam Fityan iD ,6 Trish Garibaldinos,5 Sally H. Ibbotson iD ,4 Ljuba Novakovic,5 7 Emma Rush,8
Sophie C. Weatherhead iD ,3 Heather Whitehouse iD ,1 Maria Hashme,9 M. Firouz Mohd Mustapa iD ,9
and Lesley S. Exton iD 9 on behalf of the British Association of Dermatologists’ Clinical Standards Unit
1
Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
2
Photobiology Unit, Dermatology Centre, University of Manchester and Salford Royal NHS Foundation Trust, Manchester, M6 8HD, UK
3
Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
Downloaded from https://academic.oup.com/bjd/article/187/3/295/6966564 by guest on 16 March 2023

4
Scottish Photobiology Service, Photobiology Unit, University of Dundee & NHS Tayside, Ninewells Hospital & Medical School, Dundee, DD1 9SY, UK
5
Department of Photodermatology, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, SE1 9RT, UK
6
University Hospital Southampton NHS Foundation Trust, Southampton, SO10 6YD, UK
7
Queen Elizabeth Hospital, Lewisham & Greenwich NHS Trust, London, SE18 4QH, UK
8
Vitiligo Support UK, London, UK
9
Clinical Standards Unit, British Association of Dermatologists, Willan House, London, W1T 5HQ, UK
Correspondence Linked Comment: P. Wolf. Br J Dermatol 2022; 187:285–286.

Victoria Goulden.
Emails: [email protected], [email protected]
Accepted for publication

1. Purpose and scope
7 May 2021 The overall objective of the guideline is to provide up-to-date,
evidence-based recommendations for the use of narrowband
V.G. and T.C.L. share first authorship.
ultraviolet B (NB-UVB) phototherapy in adults, young people
and children. The document aims to
Produced in 1997 by the British Photodermatology Group and the British Association
of Dermatologists (BAD). Reviewed and updated 2004, 2022. • offer an appraisal of all relevant literature up to 18 Febru-
ary 2021, focusing on any key developments;
This is an updated guideline prepared for the British Association of Dermatologists
• address important, practical clinical questions relating to
(BAD) Clinical Standards Unit, which includes the Therapy & Guidelines subcommit-
the primary guideline objective;
tee. Members of the Clinical Standards Unit who have contributed are N.J. Levell
(Chair, Therapy & Guidelines subcommittee), B. McDonald (BAD Assistant Honorary
• provide guideline recommendations and, if appropriate,
Secretary 2019–21), S.L. Chua, A. Daunton, H. Frow, P. Laws, I. Nasr, A. Theri- research recommendations.
anou, M. Hashme (Information Scientist), Z. Kiaee (Guideline Research Fellow), L.S. The guideline is presented as a detailed review with high-
Exton (Senior Guideline Research Fellow) and M.F. Mohd Mustapa (Director Clinical
lighted recommendations for practical use in the clinic and at
Standards).
home (see Section 3), in addition to an updated patient infor-
*Plain language summary available online mation leaflet (available on the BAD Skin Health Information
website: https://www.skinhealthinfo.org.uk/a-z-conditions-
DOI 10.1111/bjd.21669 treatments).
NICE has renewed accreditation of the process used by the Bri-

tish Association of Dermatologists to produce clinical guide-
lines. The renewed accreditation is valid until 31 May 2026 2. Methodology
and applies to guidance produced using the processes described
in ‘Updated guidance for writing a British Association of Der-
matologists clinical guideline: the adoption of the GRADE This set of guidelines has been developed using the BAD’s rec-
methodology 2016’. The original accreditation term began on
12 May 2010. More information on accreditation can be ommended methodology.1 Further information can be found
viewed at www.nice.org.uk/accreditation.
in Appendix T (see Supporting Information) with reference to
the AGREE II instrument (www.agreetrust.org)2 and GRADE
(http://www.gradeworkinggroup.org). Recommendations
were developed for implementation in the UK National Health
Service (NHS).
The Guideline Development Group (GDG) established sev-
eral clinical questions pertinent to the scope of the guideline
Ó 2022 British Association of Dermatologists. British Journal of Dermatology (2022) 187, pp295–308 295
296 BAD and BPG guidelines for UVB phototherapy 2022, V. Goulden et al.
and a set of outcome measures of importance to patients, consensus was reached based on the specialist clinical experi-
ranked according to the GRADE methodology (see Section 2.1 ence of the consultants on the GDG.
and Appendix A; see Supporting Information). The GDG con- The Supporting Information contains the summary of find-
sisted of 10 consultant dermatologists, a medical physicist, a ings with forest plots (Appendix B), tables Linking the Evi-
phototherapy nursing sister, three patient representatives and a dence To the Recommendations (LETR) (Appendix C), GRADE
technical team (consisting of an information scientist, a guide- evidence profiles indicating the overall certainty of the evi-
line research fellow and a project manager providing method- dence (Appendix D), summaries of the included studies and
ological and technical support). narrative findings for noncomparative studies (Appendixes E–
A systematic literature search of the PubMed, MEDLINE, P), the PRISMA flow diagram (Appendix Q), critical appraisal
Embase, Cochrane and AMED databases was conducted to of the included systematic reviews (Appendix R) and a list of
identify key articles on NB-UVB to 18 February 2021. The excluded studies (Appendix S). The strength of recommenda-
search terms and strategies are detailed in Appendix V (see tion is expressed by the wording and symbols shown in
Supporting Information). Additional references relevant to the Table 1.
topic were also isolated from citations in the reviewed litera-

ture and the previous editions of the guidelines.3,4 Data
2.1 Clinical questions and outcomes
extraction and critical appraisal, data synthesis, evidence sum-
maries, lists of excluded studies and the PRISMA diagram were The GDG established two clinical questions pertinent to the
prepared by the technical team (Appendixes B–S; see Support- scope of the guideline. See Appendix A for the full review
ing Information). The overall certainty of the evidence from protocol.
the included studies was graded according to the GRADE sys-
tem (high, moderate, low or very low certainty). An addi- Review Question 1. In people with skin diseases (including, but
tional targeted literature search (for randomized controlled not limited to psoriasis, vitiligo, eczema, hand and foot dermatoses, lichen
trials and systematic reviews) was conducted on 29 March planus, mycosis fungoides, pityriasis lichenoides, subacute and nodular prurigo,
2022; no new publications were identified that would have pruritus, chronic spontaneous urticaria, alopecia areata, progressive macular
materially affected the recommendations (Appendix V). hypomelanosis and morphoea/localized scleroderma), what are the clinical
The recommendations are based when possible on evidence effectiveness/efficacy, safety and tolerability of NB-UVB pho-
drawn from systematic reviews of the literature pertaining to totherapy, as monotherapy or in combination with another
the clinical questions identified, following discussions with treatment, compared with other light-based therapy including
the entire GDG and factoring in all four factors that would the excimer laser and lamp, topical therapy, retinoid therapy,
affect its strength rating according to the GRADE approach conventional systemic immunosuppression or immunomodu-
(i.e. balance between desirable and undesirable effects, overall lation, biological therapy, placebo, no treatment or NB-UVB
certainty of the evidence, patient values and preferences, and in combination with a different treatment?
resource allocation). All GDG members contributed towards
drafting and/or reviewing the narratives and information in Review Question 2. In people with photodermatoses (including
the guideline and Supporting Information documents. When polymorphic light eruption, solar urticaria, actinic prurigo, chronic actinic der-
there was insufficient evidence from the literature, informal matitis, hydroa vacciniforme, erythropoietic protoporphyria and photoaggravated
Table 1 Strength of recommendation ratings
Strength Wording Symbol Definition

Strong recommendation for ‘Offer’ (or similar, e.g. ‘use’, ↑↑ Benefits of the intervention outweigh the risks; most patients would
the use of an ‘provide’, ‘take’, ‘investigate’ choose the intervention while only a small proportion would not;
intervention etc.) for clinicians, most of their patients would receive the
intervention; for policymakers, it would be a useful performance
indicator
Weak recommendation for ‘Consider’ ↑ Risks and benefits of the intervention are finely balanced; most
the use of an patients would choose the intervention, but many would not;
intervention clinicians would need to consider the pros and cons for the
patient in the context of the evidence; for policymakers it would
be a poor performance indicator where variability in practice is
expected
No recommendation Θ Insufficient evidence to support any recommendation
Strong recommendation ‘Do not offer’ ↓↓ Risks of the intervention outweigh the benefits; most patients
against the use of an would not choose the intervention while only a small proportion
intervention would; for clinicians, most of their patients would not receive the
intervention
British Journal of Dermatology (2022) 187, pp295–308 Ó 2022 British Association of Dermatologists.
BAD and BPG guidelines for UVB phototherapy 2022, V. Goulden et al. 297
eczema), what are the clinical effectiveness/efficacy, safety and patient representatives. For further information on the word-
tolerability of NB-UVB phototherapy, as monotherapy or in ing used for recommendations and strength of recommenda-
combination with another treatment, used prophylactically and tion ratings see Table 1. The evidence for recommendations is
to treat active disease, compared with photoprotective measures based on the studies as listed (for details and discussion of the
including sunscreen, topical and oral corticosteroids, other evidence see Appendixes B–P).
light-based therapies, systemic immunosuppression, other topi- The clinical efficacy and appropriateness of other treatment
cal and oral anti-inflammatory/immunomodulator agents, bio- modalities should also be considered, taking into account the
logical therapy, placebo, no treatment or NB-UVB in patient’s diagnosis, age and comorbidities, and patient choice.
combination with a different treatment? The GDG is aware of the lack of high-quality evidence for
some of these recommendations.
Outcomes GPP indicates a Good Practice Point: recommendations
The GDG also established a set of outcome measures of derived from consensus.
importance to patients for each review question. These were Strong recommendations marked with an asterisk (*) are
agreed by the patient representatives and ranked by them based on the available evidence, and/or consensus based on

according to the GRADE methodology5 and data on these specialist experience.
extracted from the included studies (Appendixes B–P). Out-
comes ranked 7, 8 or 9 are critical for decision making, those
General (applies to all treated conditions)
ranked 4, 5 or 6 are important but not critical for decision
making, and those ranked 1, 2 or 3 not generally important R1 (GPP) Explain the potential benefits and harms of NB-
for decision making. UVB and provide a patient information leaflet (e.g. https://
www.skinhealthinfo.org.uk/a-z-conditions-treatments) to can-
Review question 1: skin diseases didates prior to choosing the treatment.
Disease improvement [e.g. ≥ 75% improvement in Psoriasis R2 (GPP) All centres should have a phototherapy protocol in
Area and Severity Index (PASI) or Eczema Area and Severity place for treatment and to address episodes of symptomatic
Index (EASI), or ≥ 50% repigmentation] (9) erythema and other adverse effects.
Serious adverse events: acute and chronic (9) R3 (↑↑) Carry out minimal erythema dose (MED) testing or
Change in psychological wellbeing or quality of life [e.g. test a small area before starting treatment to ascertain a safe
Dermatology Life Quality Index (DLQI)] (9) starting dose of NB-UVB.
Disease-specific physician assessment [e.g. PASI, EASI, R4 (GPP) All phototherapy devices (including handheld
Severity Weighted Assessment Tool (SWAT), Physician’s devices) should be evaluated and safety checked by medical
Global Assessment (PGA)] (8) physics, and irradiance measurements should be carried out at
Disease-specific patient self-assessment (8) regular intervals appropriate for the frequency of use.
Sustained clearance and benefit (6) R5 (GPP) All phototherapy centres should consider providing
Treatment tolerability (6) a home phototherapy service, within an appropriate gover-
Reduction of other therapy (6) nance framework and particularly where there is geographical
Convenience of treatment (5) need.
Minor adverse events (3) R6 (GPP) Offer skin cancer surveillance at appropriate inter-
vals to people identified as having received more than 500
Review question 2: Photodermatoses whole-body NB-UVB treatments, particularly those individuals
Serious adverse events: acute and chronic (9) with other coexisting risk factors for skin cancer.
Change in psychological wellbeing or quality of life (e.g. R7 (↓↓) Do not offer NB-UVB phototherapy to people who
DLQI) (9) are taking ciclosporin, mycophenolate, azathioprine or oral
Disease-specific physician assessment (8) tacrolimus (see contraindications) for their skin disease or
Disease-specific patient self-assessment (8) other conditions, either as combination therapy or as rescue
Change in sun tolerance (7) therapy to control flares.
Sustained clearance and benefit (6) R8 (GPP) Continue at least daily use of an emollient during a
Treatment tolerability (6) course of NB-UVB to prevent and alleviate skin dryness and
Reduction of other therapy (6) pruritus.
Convenience of treatment (5) R9 (GPP) The use of an emollient should generally be
Minor adverse events (3) avoided for at least 2 h before NB-UVB, particularly in people
with psoriasis, as this may reduce UV transmission in the skin.
[However, in people with eczema, consistent treatment of the
3. Summary of recommendations
skin barrier defect outweighs any reduction in UV transmis-
The following recommendations and ratings were agreed sion and these individuals should use emollient following
upon unanimously by the core members of the GDG and their usual routine (see R17).]
Ó 2022 British Association of Dermatologists. British Journal of Dermatology (2022) 187, pp295–308
Psoriasis Eczema
R10 (↑↑) Offer NB-UVB to people with psoriasis who have an R16 (↑↑) Offer NB-UVB as first-line phototherapy to people
inadequate response to topical therapy, or when topical ther- with eczema who have an inadequate response to topical ther-
apy is not suitable, prior to offering systemic immunosuppres- apy alone, prior to offering systemic immunosuppression or
sion or immunomodulation therapies, including psoralen plus immunomodulation therapies, including PUVA.
ultraviolet A (PUVA). R17 (GPP) Emollients and, if necessary, short-term intermit-
R11 (↑) Consider adding NB-UVB to a selected systemic psori- tent topical corticosteroids should continue to be used during
asis treatment (i.e. acitretin, methotrexate, fumaric acid esters, a course of phototherapy for eczema.
apremilast or biologics) as a short-term rescue therapy to con- R18 (GPP) Stabilize severe, acute flares of eczema prior to
trol flares, if psoriasis is normally well controlled on these commencing NB-UVB therapy by optimizing topical therapy,
treatments. the use of systemic corticosteroids and/or antibiotics as appro-
R12 (↑) Consider combination therapy of NB-UVB and aci- priate.
tretin in adults and young people with severe chronic psori- R19 (GPP) Consider adding NB-UVB to methotrexate or

asis, but this must be avoided in anyone of childbearing another suitable systemic immunomodulatory medication
potential. (avoid with ciclosporin, mycophenolate, azathioprine and
tacrolimus) as a short-term rescue therapy to control flares, if
eczema is normally well controlled on these treatments.
Vitiligo
R13 (GPP) Inform people with vitiligo who are eligible for Palmoplantar dermatoses
NB-UVB of the requirements (depending on local protocols: a
pretherapy assessment, medical photographs taken prior to R20 (↑) Consider NB-UVB in people with palmoplantar psori-
and during follow-ups usually every 3 months, two to three asis who have an inadequate response to topical therapy when
sessions weekly possible for up to 1 year), and the likely PUVA is contraindicated.
response depending on the affected anatomical site (e.g. the R21 (↑) Consider NB-UVB in people with palmoplantar
face and trunk achieve better repigmentation than acral sites). eczema who have an inadequate response to topical therapy
R14 (↑↑) Offer NB-UVB (whole body or localized, e.g. home- when PUVA is contraindicated.
based handheld) as first-line phototherapy to people with viti- Θ There is insufficient evidence to recommend NB-UVB in
ligo who have an inadequate response to topical therapy and/ people with palmoplantar pustulosis.
or have extensive or progressive disease. As a prolonged
course is generally required, discuss the risk–benefit ratio, par-
Lichen planus
ticularly for children.a This may be combined with a cal-
cineurin antagonistb (more evidence for tacrolimus) or R22 (↑) Consider NB-UVB in people with cutaneous lichen
intermittent potent topical corticosteroid,c on localized sites planus who have an inadequate response to topical therapy.
for a time period appropriate to the body site.
[aThere is a lack of data on the skin cancer risk for high
Morphoea (localized scleroderma)
cumulative exposures in children with less deeply pigmented
skin (Fitzpatrick skin types I–III), hence the risk–benefit ratio R23 (↑) Consider NB-UVB in people with morphoea (local-
needs to be carefully considered. bPrior to combination NB- ized scleroderma) when an alternative and more effective pho-
UVB and topical tacrolimus treatment, advise patients that totherapy or systemic therapy is not available or is
there is a theoretical increased risk of skin cancer with this contraindicated.
combination of treatment. A shared decision should be made
with the person with vitiligo, taking into account other alter-
Mycosis fungoides
natives, the individual’s personal and family history of risk of
skin cancer and the impact of the vitiligo. cThere is strong evi- R24 (↑↑) Offer NB-UVB to people with mycosis fungoides for
dence of a limited effect for combination NB-UVB and potent treatment of patches or plaques; however, PUVA is more
topical corticosteroid, as well as a high risk of loss of response effective for thicker plaques of mycosis fungoides.
upon stopping treatment. Prior to this combination, consider
the risk–benefit ratio of the prolonged use of potent topical
Pityriasis lichenoides
corticosteroid.]
R15 (↑) Consider oral steroids (see vitiligo guidelines for R25 (↑) Consider NB-UVB in people with pityriasis liche-
specific treatment protocol)6 in combination with NB-UVB in noides chronica (PLC) and pityriasis lichenoides et vario-
people with rapidly progressive vitiligo to arrest activity of liformis acuta (PLEVA) who have an inadequate response to
the disease, after careful consideration of risks and benefits. topical therapy.
R37 (GPP) NB-UVB phototherapy should be discussed with

Progressive macular hypomelanosis
people with chronic spontaneous urticaria who have an inade-
R26 (↑) Consider NB-UVB in people with progressive macular quate response to other treatments.
hypomelanosis. R38 (↑) Consider NB-UVB in people with symptomatic dermo-
graphism who have an inadequate response to first-line therapy.
Subacute and nodular prurigo H1-antihistamines should generally be combined with pho-
totherapy.
R27 (↑) Consider NB-UVB in people with subacute prurigo
who have an inadequate response to topical therapy.
R28 (↑) Consider NB-UVB in people with nodular prurigo Insufficient evidence to support any recommendation
who have an inadequate response to topical therapy when an
Θ There is insufficient evidence to recommend NB-UVB for
alternative and more effective phototherapy is not available or
the treatment of the following conditions (see LETR in
is contraindicated.
Appendix C for a full list):

Photodermatoses • Acne
• Acquired perforating dermatosis
R29 (↑↑) Offer NB-UVB prophylactic phototherapy to people
• Alopecia areata
who are severely affected by polymorphic light eruption and
• Cutaneous amyloidosis
have an inadequate response to photoprotection.
• Cutaneous plasmacytosis
R30 (↑↑) Offer* NB-UVB prophylactic phototherapy as a treat-
• Eosinophilic pustular folliculitis
ment option to people with erythropoietic protoporphyria.
• Erythema annulare centrifugum
R31 (↑) Consider NB-UVB prophylactic phototherapy, after
• Graft-versus-host disease
photoinvestigation and specific recommendation from a spe-
• Granuloma annulare
cialist photobiology centre, in people with chronic actinic
• Hailey–Hailey disease
dermatitis who have an inadequate response to photoprotec-
• Keratosis lichenoides chronica
tion and topical therapy.
• Lichen nitidus
[Current evidence exists mainly for people with Fitzpatrick
• Lichen sclerosus
skin type IV and above combined with the use of emollients
• Notalgia paraesthetica
and topical or oral corticosteroid.]
• Pigmented purpuric dermatoses
R32 (↑) Consider NB-UVB prophylactic phototherapy, after
• Pregnancy-induced dermatoses
photoinvestigation and advice from a specialist photobiology
• Pruritic papular eruption in HIV
centre, in people with solar urticaria who have an inadequate
• Scleroedema
response to photoprotection and a second-generation H1-anti-
• Seborrhoeic dermatitis
histamine at a dose of up to fourfold the licensed dose.
• Subcorneal pustular dermatosis
R33 (GPP) Consider NB-UVB prophylactic phototherapy, after
photoinvestigation and specific recommendation from a spe-
cialist photobiology centre, in people who have an inade-
List of key future research recommendations
quate response to photoprotection and topical therapy for the
following conditions: The following list outlines future research recommendations
(FRRs).
• Actinic prurigo
FRR1 Randomized controlled trials (RCTs) evaluating NB-UVB
• Photoaggravated eczema
vs. PUVA for the treatment of people with
• Hydroa vacciniforme
• Hyperkeratotic plaque psoriasis
Pruritus • Lichenified eczema
• Nodular prurigo
R34 (↑↑) Offer NB-UVB to people with pruritus associated
• Palmoplantar psoriasis
with severe kidney disease where other interventions have
• Palmoplantar eczema
failed or are not appropriate.
• Generalized granuloma annulare
R35 (↑) Consider NB-UVB in people with idiopathic or sec-
ondary pruritus (when the underlying cause cannot be cor- FRR2 RCTs evaluating NB-UVB and placebo vs. NB-UVB in
rected), who have an inadequate response to topical therapy. combination with acitretin for the treatment of people with
psoriasis.
Chronic urticaria FRR3 RCTs to evaluate NB-UVB, PUVA and UVA1 for people
with eczema according to disease pattern, in particular,
R36 (↑) Consider NB-UVB in people with chronic sponta- whether specific phototherapy may be more effective in acute
neous urticaria. H1-antihistamines should generally be com- flares of eczema, chronic lichenified eczema or nodular prur-
bined with phototherapy. igo.
FRR4 Determine the action spectrum for phototherapy in • Disorders with a genetic predisposition to skin cancers
eczema. (Gorlin syndrome and albinism)
FRR5 Determine the safety of prolonged courses of NB-UVB • Concomitant oral immunosuppressive medication, in par-
for vitiligo, particularly in children. ticular ciclosporin, azathioprine, mycophenolate mofetil
FRR6 Large, prospective studies with long-term follow-up of and tacrolimus. However, following careful consideration
people treated with NB-UVB to establish skin cancer risk cor- of the risk–benefit ratio, NB-UVB could be used in some
related with cumulative number, dose, frequency of expo- people taking specific immunosuppressive medications
sures, age, skin type and ethnicity. such as methotrexate or biological therapies
FRR7 Further research into patient and disease characteristics • People medically unfit and unable to safely stand in the
influencing therapeutic response to NB-UVB. whole-body NB-UVB cubicle (e.g. those with severe car-
diovascular or respiratory disease, and those with poorly
controlled epilepsy)
4. Introduction
As far back as 1400 BC, sunlight has been harnessed to treat

skin disease,7 but phototherapy’s modern inception began in Relative contraindications
the 19th century when renowned physician Niels Finsen used
• Hereditary dysplastic naevus syndrome
UV radiation to treat lupus vulgaris. In 1925, Goeckerman
• Lupus erythematosus
described the benefits of treating psoriasis using UV rays in
• Previous exposure to arsenic or ionizing radiation
combination with crude coal tar,8 but it was not until the
• Past excessive exposure to natural sunlight, sunbeds or
1970s that broadband UVB (BB-UVB) became established as a
phototherapy
treatment for inflammatory skin disease. A paradigm shift
• Previous significant use of oral immunosuppressive medi-
occurred in 1988 with the introduction of NB-UVB initially to
cation in the form of ciclosporin, azathioprine, mycophe-
treat psoriasis.9,10 Parrish and Jaenicke demonstrated that the
nolate mofetil or tacrolimus
most effective therapeutic UV wavelength for the treatment of
• Current premalignant skin lesions
this condition was 313 nm.11 Fluorescent NB-UVB photother-
• Current and past history of nonmelanoma skin cancer
apy lamps with an emission spectrum that peaks between 310
• Current and past history of melanoma skin cancer
nm and 311 nm were then originally introduced by Philips,
• Strong family history of skin cancer (melanoma or non-
although NB-UVB phototherapy lamps have since been pro-
melanoma) at a young age
duced by other manufacturers.
UV radiation has been shown to have potent immunomodu- NB-UVB phototherapy should generally be avoided in
latory properties, which involve multiple mechanisms in both patients with a past personal history of melanoma or with a
the innate and adaptive immune systems. It has a significant current melanoma or nonmelanoma skin cancer; however,
immunosuppressive effect on T-cell function and induces anti- cases should be assessed on an individual basis and NB-UVB
gen-specific tolerance that depends on interactions between could be considered in those individuals where therapeutic
antigen-presenting cells, mast cells and keratinocytes.12 In addi- options are limited and the benefit of the treatment outweighs
tion to the immunomodulatory effects of UV, recent studies the potential risks.
have demonstrated other key effects of phototherapy to be NB-UVB phototherapy can be given with caution to people
proapoptotic, antipruritic, antifibrotic and propigmentary, pro- with dermatoses that may be photoaggravated, such as der-
moting clinical improvement in various skin diseases.13 matomyositis, photoaggravated eczema, Darier disease and
NB-UVB is now the most commonly used type of pho- transient acantholytic dermatoses, pityriasis rubra pilaris and
totherapy, and numerous studies have demonstrated its effec- active herpes simplex. It can be used in people taking poten-
tiveness in the treatment of psoriasis.14,15 NB-UVB treatment tially photosensitizing medications as long as MED testing is
has also become an established treatment for other inflamma- performed before treatment is started.
tory dermatoses such as eczema, as well as for many other NB-UVB phototherapy is not contraindicated in childhood
conditions including vitiligo, cutaneous T-cell lymphoma and (see Section 11), pregnancy or breastfeeding (see Section 10).
the photodermatoses.16–18 In addition, there are no risks of treating people with pace-
makers in situ.
4.1 Contraindications
There are a number of absolute contraindications to the use of 5. Place in the treatment pathway
NB-UVB phototherapy. These include
NB-UVB is usually considered after no response or inadequate
• Photogenodermatoses (xeroderma pigmentosum, Cockayne response to topical therapy, or if the condition is deemed to
syndrome, trichothiodystrophy, Bloom syndrome and be too extensive for topical therapy to treat adequately. It is
Rothmund–Thomson syndrome) also a relatively safe and cost-effective second-line option
compared with immunosuppressive, immunomodulating or In the UK, two studies in Tayside demonstrated home UVB
biological therapies and should be offered before these treat- phototherapy to have similar outcomes to hospital-based pho-
ment options. totherapy.29 The estimated costs to the hospital ranged from
NB-UVB is generally considered before PUVA for many der- £229 to £314 per course (£307 to £422 per effective course for
matoses such as psoriasis and eczema due to its better safety psoriasis), compared with £114 for outpatient therapy (£149
profile and relative ease of treatment without the need for oral per effective course for psoriasis). However, the total cost to soci-
medication and eye protection following treatment. However, ety (hospital and patient costs) is around £410 per course, com-
for certain indications, NB-UVB is significantly less effective pared with an estimated £550 for outpatient phototherapy.30
than PUVA and should be considered only if PUVA is not Home-based phototherapy may also be considered for peo-
available. These indications include thicker plaque-stage myco- ple with vitiligo.31,32 This can be undertaken using either
sis fungoides, granuloma annulare, and hand and foot der- whole-body units or handheld and non-handheld devices for
matoses. PUVA is still also an important second-line localized areas.33–36 A prospective study showed no significant
phototherapy for the treatment of many dermatoses, as lack of difference in repigmentation rates between home-based and
adequate response to NB-UVB does not predict lack of hospital-based phototherapy, and only minimal adverse effects

response to PUVA.19 and similar health-related quality-of-life scores.37 A random-
In psoriasis, national UK guidelines (National Institute for ized controlled trial of home interventions (HI-Light Vitiligo
Health and Care Excellence – NICE) state that NB-UVB should Trial) found that combination treatment with home-based
be offered to people with plaque or guttate-pattern psoriasis handheld NB-UVB and potent topical corticosteroid was likely
that cannot be controlled with topical treatments alone. Sys- to be superior to potent topical corticosteroid monotherapy in
temic treatment should be offered if NB-UVB phototherapy the treatment of localized vitiligo.38
results in an unsatisfactory response or is poorly tolerated, if It is important to recognize that there are increased safety
there is rapid relapse following phototherapy, if access is diffi- concerns in the home setting that should be carefully consid-
cult for logistical reasons, or if the person is at especially high ered. To obtain optimal patient outcomes and ensure robust
risk of skin cancer.20 safety, careful patient selection and training should be
In eczema, for children under the age of 12 years, national ensured, along with remote but close monitoring by experi-
UK guidance (NICE) suggests considering phototherapy or enced phototherapy nurses supported by a hospital-based pho-
systemic treatments for severe atopic eczema when other man- totherapy team, which must include medical physics expertise
agement options have failed or are inappropriate, or if there is and use a clear governance framework. Recent experience of
a significant negative impact on quality of life.21 For adults setting up a new service has been reported,39 and a useful
with eczema, the NICE guidance does not specifically discuss model for setting up a home phototherapy service is described
the use of phototherapy or systemic therapy. In general, UVB by Hung et al.40 An alternative way to improve convenience
phototherapy is recommended after failure of topical therapy, and access to phototherapy services for patients is to enable
before consideration of systemic or biological therapy. the patient to self-administer their own treatment in the hos-
In vitiligo that has not responded to or is unsuitable for pital setting. In a pilot study, 20 selected people with eczema
topical therapy, NB-UVB is the first-choice modality of pho- and psoriasis took ownership of treatment by self-administer-
totherapy, over PUVA, due to higher efficacy and a better ing their UVB phototherapy at hospital. This was safe and
safety profile.6 effective and enabled them to take greater control of atten-
dance times for UVB phototherapy.41
6. Improving access
7. Light sources and dosimetry
There is increasing evidence for the cost efficacy of NB-UVB
phototherapy,14,22 but convenience and availability remain an While fluorescent phototherapy lamps are most commonly
issue, and any approach that improves patient access to effec- used, NB-UVB can be delivered by other sources such as an
tive, safe treatment should be a priority.23–25 One option for excimer laser/lamp or filtered broadband lamp (further details
improving access is providing home treatment; however, the in Appendix U; see Supporting Information). Such lamps are
availability of this form of treatment is currently limited in generally used for targeted therapy rather than whole-body
the UK.26,27 irradiation.42–45 Regardless of the method of illumination,
In a pragmatic, multicentre, randomized, controlled, nonin- accurate dosimetry (measurement) is critical for efficient and
feriority study comparing home vs. outpatient UVB photother- safe treatment delivery. Measurement techniques will vary
apy for mild-to-severe psoriasis in the Netherlands (PLUTO), depending on the NB-UVB source, and published guidelines
105 patients were followed up for 1 year after phototherapy. are available.46,47 It is important that, as part of a quality
The authors found no significant difference between the effi- assurance system, there are regular quality control measure-
cacy of outpatient and home treatment as assessed by ≥ 50% ments performed on the cabinet to ensure the accuracy and
improvement in PASI or Self-Administered PASI, with no sig- consistency of the UV dose delivered.48 Accurate measurement
nificant differences in adverse effects.28 is required for employee safety, in order to compare
anticipated occupational exposure to exposure limit values. during courses of phototherapy.64 The frequency of erythema
This is completed as part of a risk assessment as required by varies according to body site65,66 and may increase in the
the control of artificial optical radiation at work regulations presence of photosensitizing medication.67 Erythema develops
2010.49 within 3–5 h following exposure to UVB, peaks between 12
and 24 h and resolves by 72 h,68 although this may vary
depending on the intensity of the UV exposure.69,70
8. Protocols for treatment delivery
The risk of phototoxic drug eruptions can be minimized by
Phototherapy protocol variables include initial dose, frequency taking a careful drug history and carrying out MED testing
of treatment, incremental regimen, maximum dose, number prior to treatment. Individuals also need to be instructed to
of exposures, and potentially a ‘tailing-off’ period of treat- check with staff before commencing any new medication
ment. There is a lack of good-quality study evidence to guide while receiving phototherapy.
decision making for many of these variables. Studies in people Provocation of photodermatoses. Polymorphic light eruption (PLE) may
with psoriasis predominantly with skin phototypes I and II develop during treatment with NB-UVB. In a retrospective sur-
support the need for a test dose on a small area, principally vey, the provocation rate with NB-UVB was 195% in 113

for safety reasons.50 Routine MED testing will allow identifica- patients with PLE, compared with 07% in 974 patients with
tion of people with photosensitivity induced by medication, other diagnoses.71 In the event of flaring, dose reduction and
or previously unrecognized photodermatoses such as chronic cautious escalation help to lower PLE recurrence. The application
actinic dermatitis prior to treatment. This will help prevent of a potent topical steroid to commonly affected sites immedi-
sensitive people from burning during treatment and identify ately following each treatment may further reduce the inci-
whether people require further phototesting.51,52 dence.72
For people with psoriasis, the use of 20% increments has To minimize the risk of triggering lupus erythematosus,
been shown to be only slightly less effective than 40% incre- autoantibody screening should be considered prior to pho-
ments, but importantly it was associated with fewer episodes totherapy in any individual with relevant symptoms or with a
of symptomatic erythema.53 Treatment three times weekly is known family history of lupus.
not significantly less effective than five times weekly, and was The provocation of other previously undiagnosed photoder-
associated with fewer symptomatic erythema reactions,54 matoses by NB-UVB, such as chronic actinic dermatitis, can be
while treatment twice weekly is as effective as three times severe but occurs less frequently. This cannot be consistently
weekly, but the duration of treatment is more prolonged.55 A predicted from the patient’s history, but the presence of a
study from Turkey showed that, for psoriasis, maintenance reduced MED should prompt assessment for coexistent photo-
NB-UVB did not result in longer remission.56 sensitivity prior to treatment.
There is limited study evidence for specific protocols to Reactivation of herpes simplex virus (HSV) and HSV keratitis can
treat other conditions. In atopic eczema, a comparative study occur as a result of NB-UVB treatment.73,74 In people with a
demonstrated that a low-increment regimen can work as well history of HSV infection, the use of prophylactic aciclovir and
as higher increments.57 facial shielding during treatment should be considered.
Examples of commonly used protocols in the UK are avail- Pruritus during NB-UVB is commonly reported61,75 but may
able on the NHS Scotland Photonet website.58 arise directly from the underlying disease.4
It is important that protocols are used only as a guide, as devi- The development of bullae limited to psoriatic plaques with sparing
ation from protocols will be necessary for optimum results in of the surrounded nonlesional skin during NB-UVB therapy is
many individual patients. This is particularly the case for condi- a recognized but uncommon complication of therapy. It is
tions other than psoriasis and will vary according to the clini- hypothesized to reflect the enhanced penetration of UVB
cian’s individual expertise in treating particular conditions. through lesional skin due to the reduction in acanthosis and
desquamation during treatment.76,77
Idiopathic guttate hypomelanosis-like hypopigmented macules and freckling
9. Adverse effects
have been reported to occur in NB-UVB phototherapy, includ-
NB-UVB is considered a safe treatment modality with a rela- ing in people with cutaneous T-cell lymphoma.78–80
tively low risk of adverse effects.59,60
9.2 Delayed adverse effects
9.1 Short-term adverse effects
Photoageing presenting as coarse wrinkling or cutaneous atrophy81
Erythema is the most commonly experienced adverse effect, is a recognized delayed adverse effect of exposure to UVB.82
although its reported rate differs throughout the literature.61– Photocarcinogenesis. The potential risk of skin cancer with PUVA
63
Erythema is usually recorded using a semiquantitative grad- is well established with evidence from both the European and
ing system consisting of E0 (no erythema), E1 (barely percep- American literature, but the risks with NB-UVB are less clear.
tible asymptomatic), E2 (well defined with mild discomfort), Mouse studies indicated that NB-UVB may have a two times
E3 (well defined and painful) and E4 (painful erythema, with higher risk of inducing skin cancer compared with BB-UVB
bullae). E3 and E4 sunburn-type reactions occur infrequently per MED;9,83–85 however, in clinical practice, the number of
MEDs required for a NB-UVB treatment course is usually less During pregnancy the use of facial shielding during treat-
than one-third of that required for BB-UVB, resulting in the ment may help to limit the exacerbation of melasma.
overall skin cancer risk probably being lower than that of BB- NB-UVB can also be safely used in women who are breast-
UVB.86 This is borne out in clinical studies. A systematic feeding.
review that included only four studies was unable to identify
an increased risk of skin cancer following NB-UVB.87
11. Narrowband ultraviolet B phototherapy in
People with vitiligo will usually have prolonged courses
children
and there is only limited evidence to support the long-term
safety of high cumulative exposures of NB-UVB in people The general efficacy, tolerability and short-term safety in chil-
with vitiligo, although a retrospective study of 15 people with dren have been demonstrated in several retrospective
skin types IV–VI receiving between 200 and 600 treatments reviews.100–102
with a mean follow-up of 835 months did not detect any There is no arbitrary lower age at which children can be
skin cancers.88 There are special considerations for treatment treated with NB-UVB, but children would need to be able to
of children (see Section 11). be safely left alone in the cabinet for treatment and be capable

The NICE-accredited BAD Service Guidance and Standards of complying with all the required safety measures including
for Phototherapy Units 201648 currently recommends greater eye protection requirements; this would generally be around
than 500 UVB exposures as the threshold to trigger considera- the age of 6 years or above.
tion of skin cancer screening review. It may be appropriate to Although formal long-term safety data are lacking, the rela-
treat past these arbitrary threshold numbers after clinical tively low incidence of skin cancers reported in people treated
assessment by a consultant dermatologist and discussion with with NB-UVB in childhood is reassuring. While there is no
the individual patient of the risks and benefits of the various long-term evidence to show an increased risk of melanoma in
treatment options. those treated with NB-UVB in childhood, overall numbers are
The incidences of genital tumours in men exposed to PUVA and small. There is a suggestion of a positive association between
BB-UVB are approximately 163 and 46 times higher than in the childhood sunburn reactions and subsequent risk of mela-
general population, respectively.89 No evidence exists separately for noma. It is therefore likely to be of increased importance that
NB-UVB inducing genital tumours, but it is prudent to cover male MED testing is carried out in children before treatment and
genitalia during treatment. There is no standard material used for that consideration is given to choosing treatment protocols
shielding genitalia, but studies of UV transmittance suggest that dar- that reduce the risk of symptomatic erythemal episodes.
ker-coloured materials such as polyester (close weave type and high There is a lack of studies on the treatment of vitiligo with NB-
thread count) offer better protection.90 UVB in children. As this condition generally requires a prolonged
Eye photodamage. Exposure of the eye to NB-UVB can result in course and sometimes repeated treatments, photocarcinogenesis
acute and chronic photodamage.91 Photokeratitis92 and photo- may be a particular concern. However, a retrospective study using a
conjunctivitis93 may occur acutely, while chronic exposure is hospital database has demonstrated safety in terms of skin cancer
linked to the development of pterygium and cataract forma- risk, at least in the medium term for people with skin types IV–VI.88
tion.94 For this reason the use of UV-protective goggles is rec- A systematic review of treatment options for childhood pso-
ommended during treatment. Only negligible amounts of riasis103 demonstrates NB-UVB phototherapy to be effective
UVB are transmitted through the eyelids, and therefore NB- based on data from two open-label studies104,105 and three
UVB phototherapy can be safely used with the eyes closed in retrospective reviews.101,106,107 This efficacy is also confirmed
those with eyelid dermatoses, providing eyelid closure is com- in a retrospective study.108
plete and people adhere to this advice.90,95 For any patient in In atopic eczema, there is good evidence of the efficacy of NB-
whom that is not possible, the use of UV-protective contact UVB in children. A number of noncomparative studies that
lenses can be considered. Soft lenses are preferable to gas-per- included both children and adults (n = 296) looked at NB-UVB
meable ones due to complete coverage of the cornea.96 as a monotherapy102,106–114 or in combination with UVA.101
These agreed that NB-UVB is effective in moderate, severe and
chronic atopic dermatitis/eczema. A further study compared the
10. Use in pregnancy
outcome of children with moderate-to-severe eczema treated
Significant reductions in folic acid levels through photodegra- with NB-UVB to children who had declined this treatment (con-
dation have been reported following high cumulative NB-UVB trol group) and showed NB-UVB to be effective.115 Conse-
doses (118 J cm 2 following 36 sessions of NB-UVB in the quently, the national UK guidance (NICE) suggests considering
management of psoriasis).97 Measurement of folic acid levels phototherapy as second-line therapy for children under the age
either with or without supplementation should be considered of 12 years with severe atopic eczema.21
in women trying to conceive. For women of childbearing age In the childhood photodermatoses, there is some evidence for
receiving prolonged whole-body NB-UVB courses (e.g. > 30 the use of NB-UVB in PLE,72,106,116 although this is less well
treatments) folate supplementation should be considered, and established than for adults. There are also case series supporting
the need for supplementation reinforced for those receiving the use of NB-UVB in erythropoietic protoporphyria and to a les-
NB-UVB in the first trimester of pregnancy.98,99 ser extent in actinic prurigo and hydroa vacciniforme.106,117,118
In MF, there are 28 retrospective case series (n = 600), separately in the 2015 BAD guidelines on the measurement of
which included 100 children or young adults (see UV radiation levels in UV phototherapy.46
Appendix J12). These demonstrated NB-UVB as monother-
apy or in combination with topical corticosteroids to be an
13. Recommended audit points
effective treatment option for early-stage MF.
Anxiety about the treatment may be a problem for some chil- The service delivery aspect of phototherapy is covered in
dren,106 but this can usually be managed by a clear explanation and depth in the NICE-accredited BAD Service Guidance and Stan-
a pretreatment visit to the unit. A patient information leaflet specifi- dards for Phototherapy Units 2016.48 This includes recom-
cally for children is also very helpful. Support from the parents is mendations on referral and patient assessment, consent, staff
essential and children may be reassured that the phototherapy cabi- training, clinical management, equipment, governance and
net is open topped and the child will be able to communicate with audit.
the parent standing outside the cabinet during treatment. Recommended audit points are as follows.
In the last 30 consecutive cases of people treated with NB-
UVB, is there clear documentation of

12. Safety and governance
1 People with psoriasis
Skin sunburn-type reactions secondary to phototherapy are an
a having initially demonstrated inadequate response to
important cause of litigation and as such clinical governance
topical therapy
and safety are of paramount importance.119,120 In England
b having NB-UVB prior to consideration of systemic
(2016–2021) there were 25 episodes of litigation related to
immunosuppression or immunomodulation therapies
definite or likely burning from phototherapy out of 327 cases
2 People with eczemas
(personal communications from Nick Levell: GIRFT Dermatol-
ogy lead).
topical therapy
Hospital-based NB-UVB should be administered by a trained
b having NB-UVB prior to consideration of systemic
phototherapist, who in 2022 will be either a first-level registered
immunosuppression or immunomodulation therapies
nurse or a physiotherapist registered with the Health and Care Pro-
c having continued topical therapy during the course of
fessions Council. All staff administering UVB are required to
NB-UVB
undertake an initial period of supervised training and to be signed
d with severe, acute flares having been stabilized prior
off as competent for all relevant areas at the end of this period. All
to instituting NB-UVB
staff should continue to receive annual education and an annual
3 People with vitiligo
appraisal, and attend a recognized phototherapy update or course
every 3 years. Further guidance can be found in the Service Guid-
topical therapy
ance and Standards for Phototherapy Units document.48
b having extensive or progressive disease
Patients should be given an education session prior to treat-
4 The provision of a patient information leaflet (https://
ment and should be provided with written patient information
www.skinhealthinfo.org.uk/a-z-conditions-treatments)
leaflets prior to starting their treatment. Educational sessions are
typically nurse led but have been shown to be as effective if pro- The audit recommendation of 30 cases per department is to
vided as a patient-specific e-learning session, with the latter reduce variation in the results due to a single patient and to
showing improved consistency.121 Patients should sign a consent allow benchmarking between different units (Appendix W;
form to indicate their understanding of side-effects and safety see Supporting Information).
procedures during treatment, such as keeping goggles on and
wearing the same clothing during the sessions, where relevant.
14. Stakeholder involvement and peer review
Accurate, clear and timely documentation of any patient
examination, routine treatment checks, doses given and side- The draft document was made available for comments to the
effects observed must be made at each patient visit. BAD membership, the British Photodermatology Group (BPG),
For home phototherapy, careful patient selection is the British Dermatological Nursing Group (BDNG), the Primary
required. Training and ongoing remote supervision and sup- Care Dermatological Society (PCDS), the British Society for Pae-
port during the course of treatment by a trained and experi- diatric Dermatology (BSPD), the British Society for Medical Der-
enced phototherapist are essential, along with the use of matology (BSMD), the Psoriasis Association (PA), the Psoriasis
standardized treatment protocols, documentation and appro- and Psoriatic Arthritis Alliance (PAPAA), the National Eczema
priate governance frameworks.26,29,30,40,122 Society (NES), the UK Cutaneous Lupus Group (UKCLG), the
Unintentional UVB exposure to staff and public should be lim- Vitiligo Society, Vitiligo Support UK, Lymphoma Action and the
ited by measures such as curtains around cabinets to control UV British Porphyria Association (BPA). All comments were actively
scatter from walls and ceilings, and an assessment of environ- considered by the GDG. Following further review, the finalized
mental scatter should be made in line with The Control of Artifi- version was sent for peer review by the Clinical Standards Unit
cial Optical Radiation at Work Regulations 2010.49 The safety of of the BAD, made up of the Therapy & Guidelines subcommit-
the cabinets, their outputs and the local environment is covered tee, prior to submission for publication.
15. Limitations of the guideline Data availability

This document has been prepared on behalf of the BAD and is The data are available in the Supporting Information.
based on the best data available when the document was pre-
pared. It is recognized that under certain circumstances it may
be necessary to deviate from the guidelines and that the results Supporting Information
of future studies may require some of the recommendations Additional Supporting Information may be found in the online
herein to be changed. Failure to adhere to these guidelines version of this article at the publisher’s website:
should not necessarily be considered negligent, nor should
adherence to these recommendations constitute a defence Appendix A Review protocol.
against a claim of negligence. Appendix B Forest plots.
Appendix C Linking Evidence To Recommendations (LETR).
16. Plans for guideline revision Appendix D GRADE evidence tables.

Appendix E Psoriasis: summary of included studies.
The proposed revision for this set of recommendations is Appendix F Vitiligo: summary of included studies.
scheduled for 2027; where necessary, important interim Appendix G Eczema/atopic dermatitis: summary of included
changes will be updated on the BAD website. studies.
Appendix H Hand and foot dermatoses: summary of included
Acknowledgments studies.
Appendix I Lichen planus: summary of included studies.
We are very grateful to all three patient representatives,
Appendix J Mycosis fungoides/cutaneous T-cell lymphoma:
including Ms India Angra and Ms Emma Rush, for their input
summary of included studies.
in formulating the clinical questions, ranking of the outcomes,
Appendix K Pityriasis lichenoides: summary of included
reviewing the evidence and formulating the recommendations,
studies.
and the Vitiligo Support UK members for their input in rank-
Appendix L Subacute prurigo: summary of included studies.
ing the outcomes and providing details of their experiences.
Appendix M Pruritus: summary of included studies.
We thank Zahra Kiaee (guideline research fellow) for her help
Appendix N Chronic spontaneous urticaria: summary of
with summarizing the papers from the top-up search, as well
included studies.
as all of those who commented on the draft during the con-
Appendix O Other skin diseases excluding photodermatoses:
sultation period.
summary of included studies.
Appendix P Photodermatoses: summary of included studies.
Funding sources Appendix Q PRISMA diagram: study selection.
Appendix R Critical appraisal of included systematic reviews:
None. Development of this guideline was funded indepen-
AMSTAR 2.
dently by the British Association of Dermatologists.
Appendix S Papers excluded from quantitative analysis.
Appendix T Methodology.
Conflicts of interest Appendix U Light sources and dosimetry.
Appendix V Search strategy.
The following interests were declared over the duration of the
Appendix W Audit standards, data items and data collection
guideline development: V.G.: past chair of the British Photoder-
methodology.
matology Group (nonspecific). R.D.: member of Photonet, the
NHS Scotland Managed Clinical Network for UV phototherapy
(specific). E.E.: (i) member of Photonet, the NHS Scotland Man- References
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British Association of Dermatologists and British Photodermatology Group Guidelines For Narrowband Ultraviolet B Phototherapy 2022

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GUIDELINES British Journal of Dermatology

British Association of Dermatologists and British

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Correspondence Linked Comment: P. Wolf. Br J Dermatol 2022; 187:285–286.

Accepted for publication

NICE has renewed accreditation of the process used by the Bri-

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Table 1 Strength of recommendation ratings

Strength Wording Symbol Definition

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R37 (GPP) NB-UVB phototherapy should be discussed with

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15. Limitations of the guideline Data availability

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