Dermatol Ther (Heidelb) (2016) 6:315–324

DOI 10.1007/s13555-016-0130-9

PATIENT GUIDE

The Patient’s Guide to Psoriasis Treatment. Part 2:

PUVA Phototherapy
Benjamin Farahnik . Mio Nakamura . Rasnik K. Singh .
Michael Abrouk . Tian Hao Zhu . Kristina M. Lee . Margareth V. Jose .
Renee DaLovisio . John Koo . Tina Bhutani . Wilson Liao

Received: May 6, 2016 / Published online: July 29, 2016

Ó The Author(s) 2016. This article is published with open access at [Link]

ABSTRACT have shown that patients who viewed videos

explaining the treatment procedures for various
Background: PUVA treatment is medical conditions had a greater understanding
photochemotherapy for psoriasis that of their treatment and were more active
combines psoralen with UVA radiation. participants in their health.
Although PUVA is a very effective treatment Objective: To present a freely available online
option for psoriasis, there is an absence of guide and video on PUVA treatment designed
patient resources explaining and for patient education on PUVA.
demonstrating the process of PUVA. Studies Methods: The PUVA treatment protocol used at
Enhanced content To view enhanced content for this the University of California—San Francisco
article go to [Link] Psoriasis and Skin Treatment Center as well as
C9D4F0600C816B7E.
available information from the literature was
B. Farahnik (&) reviewed to design a comprehensive guide for
College of Medicine, University of Vermont, patients receiving PUVA treatment.
Burlington, VT, USA
e-mail: [Link]@[Link] Results: We created a printable guide and video
resource that reviews the benefits and risks of
M. Nakamura
K. M. Lee
M. V. Jose

R. DaLovisio
J. Koo
T. Bhutani
W. Liao PUVA, discusses the three types of PUVA
Department of Dermatology, Psoriasis and Skin (hand–foot soak, full body soak, and systemic),
Treatment Center, University of California-San
Francisco, San Francisco, CA, USA demonstrates the PUVA process, and provides
practical tips for safe use.
R. K. Singh
David Geffen School of Medicine at UCLA, Conclusion: Online media and video delivers
University of California-Los Angeles, Los Angeles, material in a way that is flexible and often
CA, USA
familiar to patients. This new format is
M. Abrouk beneficial for prospective patients planning to
School of Medicine, University of California-Irvine,
Irvine, CA, USA undergo PUVA treatment, health-care
providers, and trainees who want to learn
T. H. Zhu
Keck School of Medicine, University of Southern more about this treatment.
California, Los Angeles, CA, USA
316 Dermatol Ther (Heidelb) (2016) 6:315–324

Keywords: Guide; OxsoralenÒ; Patient research was done as early as 1970 for the
education; Phototherapy; Psoralen; Psoriasis; treatment of vitiligo [5].
PUVA; Ultraviolet A; UVA PUVA is used to treat a range of skin diseases
in addition to psoriasis, including eczema,
vitiligo, mycosis fungoides, prurigo nodularis,
INTRODUCTION
and graft-versus-host disease [6]. PUVA is
Psoriasis is one of the most common chronic exceptionally effective. It has been shown to
inflammatory skin conditions, affecting 3–4% reduce the Psoriasis Area and Severity Index by
of the adult US population [1]. Untreated 75% or more (PASI-75) in 80% of patients,
psoriasis can reduce social, occupational, and which is comparable to many of the biologic
overall well-being [2]. Despite the availability of medications available today [7]. This makes
topical, oral, and systemic treatments, many PUVA particularly useful as a second-line agent
patients with psoriasis, especially those with when topical medications or UVB phototherapy
moderate-to-severe generalized psoriasis, are have failed. As PUVA does not affect the
not adequately treated with an effective, immune system, it may be a more appropriate
long-term treatment regimen [3]. therapy for some patients compared to other
PUVA, or psoralen plus ultraviolet A (UVA) oral and systemic treatments, which can have
radiation, is one of the oldest, most effective the potential to cause immune suppression [7].
treatments for psoriasis. It is also known as As part of PUVA therapy, psoralen
photochemotherapy, as it combines the use of methoxsalen may be applied topically or taken
psoralens, a group of plant-derived compounds orally prior to exposure to UVA light. At the
that make the skin more sensitive to light, and University of California–San Francisco (UCSF)
exposure of skin to a source of high-intensity, Psoriasis and Skin Treatment Center, a specific
long-wavelength, ultraviolet (UV) light. UV formulation of methoxsalen called OxsoralenÒ
light is a type of light given off by the sun’s Ultra (Valeant Pharmaceuticals North America
rays and can be divided into UVC LLC, Bridgewater, NJ, USA) is used as it has
(200–280 nm), UVB (280–320 nm), and UVA better bioavailability compared to other
(320–400 nm). Both UVA and UVB are used for formulations of methoxsalen. There are three
phototherapy today. Sunlight has been utilized types of PUVA therapy: systemic PUVA
throughout centuries to treat various skin (methoxsalen taken orally), hand and foot
conditions, with one Indian medical text from soak PUVA (methoxsalen dissolved in water
1500 BC describing a treatment combining for hand/foot soaking), and bath PUVA
herbs (likely containing psoralens) and natural (methoxsalen dissolved in a bath tub for
sunlight to treat a vitiligo-like skin condition whole body soaking). All three forms of PUVA
[4]. Researchers first noticed that UV light has may be administered in an outpatient setting,
an interesting effect of delaying the rapid such as a specialized dermatologic clinic, and
growth of skin cells in people with psoriasis. patients may schedule their visits at their
They then demonstrated the effectiveness of convenience.
topical psoralens followed by UVA light in PUVA treatment is administered over the
clearing psoriatic plaques in 1974, though long term in two separate phases: an initial
Dermatol Ther (Heidelb) (2016) 6:315–324 317

clearing phase and a maintenance phase. For We will now describe important safety
each method of PUVA, during the initial considerations, the flow of treatment,
clearing phase, patients will be treated two to appropriate skin care, and possible side effects
three times weekly, with a minimum of 48 h in of PUVA therapy.
between each session. A general estimate for
clearance is 25–30 treatment visits, or within
METHODS
9–15 weeks [8–10]. However, this estimate will
vary based on diagnosis, severity of disease, We reviewed the PUVA therapy treatment
patient compliance with phototherapy protocol used at the UCSF Psoriasis and Skin
treatments, and the overall treatment regimen. Treatment Center. We also performed an
When it is determined that the psoriasis is 95% English language literature search using
clear, the patient will be placed on a Pubmed including the key words ‘‘PUVA’’, or
maintenance schedule for continuing ‘‘Oxsoralen’’ or ‘‘psoralens’’ and ‘‘phototherapy’’
treatment. During the maintenance schedule, or ‘‘UVA’’ or ‘‘ultraviolet A’’, to identify relevant
the optimal dosing of light will be held constant articles to design a comprehensive guide for
and the frequency of treatments will be steadily patients receiving PUVA treatment.
decreased to as low as once per month [8, 11]. This article does not involve any new studies
Ultimately, patients can discontinue PUVA of human or animal subjects performed by any
treatments if in stable remission. Patients can of the authors. All photos are printed with the
return to PUVA treatments at the clearing consent of the subject(s).
schedule should they experience a flare of the
psoriasis.
RESULTS AND DISCUSSION
The initial dosing of UV radiation at the
UCSF Psoriasis and Skin Treatment Center is Overview
based on the patient’s skin color and reaction to
sun exposure, also known as a Fitzpatrick skin Every PUVA therapy treatment visit will
type, and will be determined by the medical involve the patient, as well as a coordinated
team. The initial dose exposure is generally care team consisting of nurses, support staff,
within 0.5–6 J/cm2 and may increase by and/or doctors. The first portion of PUVA
0.5–2.5 J/cm2 [11]. Throughout the treatment, treatment, involving methoxsalen (Oxsoralen
the medical team may adjust the dosing based Ultra), will be undertaken by the patient and
on the control of disease, skin redness, or burns the second portion, involving UVA radiation,
to maximize the safety and effectiveness of light will be administered by the nurse. Methoxsalen
treatment. Furthermore, the medical team may will be prescribed by the physician and
suggest a combination treatment consisting of patients should have the prescription filled
PUVA with topical vitamin D analogs, topical prior to starting PUVA treatment. Patients
corticosteroids, topical retinoids, oral retinoids, receiving oral systemic PUVA should set aside
or other systemic medications [11–13]. Of note, at least 15 min for each appointment, while
however, cyclosporine and methotrexate are patients receiving hand and foot soak PUVA or
typically not used in conjunction with PUVA bath PUVA should set aside at least 45 min
therapy [11, 12]. (Table 1).
318 Dermatol Ther (Heidelb) (2016) 6:315–324

Table 1 Overview of PUVA phototherapy Table 2 Safety precautions for PUVA phototherapy

Three types of PUVA therapy: systemic PUVA (taken Disclosure of all current medications, herbs, and
orally), hand and foot soak PUVA, and bath PUVA supplements
Initial frequency of 2–3 sessions per week Disclosure of any history of skin cancer
Appointments last between 15–45 min Eye examinations required prior to PUVA therapy and
Minimum 48-h interval between each session annually thereafter

Clearance rates around 80%, typically requiring 25–30 Eye protection with goggles
sessions Face shielding with towel
Oxsoralen Ultra prescription must be filled prior to the Male genital coverage with cone or towela
first treatment visit Will not be used during pregnancy
Administered in 2 separate phases: clearing phase and
PUVA psoralen plus ultraviolet A
maintenance phase a
Unless an exception has been granted
PUVA psoralen plus ultraviolet A

should not be used in pregnant women, and

Safety Precautions women who become pregnant while on PUVA
will need to stop their treatment. Contraception
It is essential for the nursing staff and is recommended to women of childbearing age
physicians to be aware of all current patient who wish to continue PUVA treatments
medications, including herbs and supplements, (Table 2).
and any new prescriptions prior to and during
the course of PUVA treatment, as some Flow of Treatment
medications or supplements may
photosensitize the skin. In such cases, the Every patient receiving UVA light therapy will
UVA dose will be reduced accordingly. The check in at the front desk and gather all
medical team should also be made aware of any necessary supplies, including goggles, a gown,
history of skin cancer prior to starting towels, and genital covering for men. Patients
phototherapy treatments, as PUVA may receiving hand and foot soak PUVA or bath
increase the risk of skin cancer. As UVA PUVA should also get a measuring cup and
exposure to the eyes can cause cataracts [11], additional towels. Prior to stepping into the
goggles are required while in the light box. UVA light box, patients receiving the three
However, important to note is that cataracts different types of PUVA will follow three
have only been observed in animal studies, different protocols, as described below.
while studies following human PUVA patients For systemic PUVA treatment, patients must
have found no increased risk of cataracts when take methoxsalen by mouth 75 min prior to
proper eye protection is used [14]. Furthermore, each of their scheduled appointment times.
if no disease is present on the face, a towel is Methoxsalen may be taken at home or
used to cover the face. Men receiving UVA light anywhere the patient feels comfortable, so
should use proper genital shielding to reduce long as it is taken 75 min prior to entering the
the risk of genital skin cancer. Finally, PUVA light box. The dose of methoxsalen is modified
Dermatol Ther (Heidelb) (2016) 6:315–324 319

for each patient based on individual body in the tubs should only be done from the
weight, at a ratio of 0.4–0.6 mg/kg of weight. shoulders down to the feet. The face should
Each patient should follow the specific never be soaked. After soaking for 30 min,
instructions written on the prescription patients should carefully step out of the bath
(Table 3a). and dry off without showering off the bath
For hand and foot soak PUVA, patients will use solution. Patients may then drain the solution
their measuring cup to mix 10 mg of methoxsalen and notify the nursing staff that they are ready
with 2 quarts of warm water for just hands or feet, for the light box treatment (Table 3c; Fig. 2).
or 20 mg of methoxsalen with 4 quarts of warm Once patients are ready for the light
water for both hands and feet (the exact mixture treatment, they will be guided by the nurses to
ratio may vary; each patient should follow the the UVA light box. Patients treated with hand
specific instructions written on the prescription). and foot soak PUVA will be using a specialized
Water can come from a warm water sink or can be light box that accommodates only the hands
microwaved. Mixing the methoxsalen with warm and/or feet. Those being treated with systemic
water will cause the pill to dissolve and the or bath PUVA will step into a whole body light
solution will turn into a light aquamarine color. box. After making sure that all safety
It is helpful if the nurse demonstrates this process precautions are followed, including goggles
during the initial treatment visits. The nurse will and genital shielding, the nurse may wrap the
want to examine the hands and feet prior to patient’s face in a towel. The nurse will position
soaking in solution to determine a proper light the patient in a way that will maximize light
dose. After making the solution, the affected areas penetration and this position will be
on the hands and/or feet will be soaked within the maintained during the entire light treatment
solution for 30 min prior to light exposure. After to clear the disease effectively and prevent
soaking, the solution should be discarded into the burns. The nurse will then set the light
sink and hands and feet dried prior to returning to settings according to the patient’s needs. Light
the nurses’ station for the UVA treatment. will shine on the patient for several seconds to
Patients should only dry, not rinse off, after minutes depending on the patient’s individual
soaking (Table 3b; Fig. 1). dose. While in the light box, it is important for
Bath PUVA involves soaking in a bathtub for patients to keep their eyes closed and goggles
30 min prior to light exposure. Patients will on, and bulbs should not be touched. Following
dissolve 50 mg of methoxsalen in a measuring the UVA light treatment, the patient may return
cup filled with hot water. The solution should to the dressing room to get dressed and the
be mixed until an aquamarine-colored solution treatment session is complete. At each
is formed. This solution will then be added to a subsequent treatment session, the dose of light
bathtub that is prefilled with 100 L of warm (duration of light treatment) will be adjusted
water. Nursing staff will demonstrate this depending on the patient’s reaction to the
process during the initial treatment visits. The previous treatment session.
nurse will want to examine the skin prior to
soaking in solution to determine a proper light Post-phototherapy Skin Care
dose. Timers will be available in each bathroom,
so that patients may be able to time their soak It is important to take good care of the skin after
for 30 min. It is important to note that soaking each treatment session. Methoxsalen can cause
320 Dermatol Ther (Heidelb) (2016) 6:315–324

Table 3 Flow of treatment for PUVA phototherapy

(a) Oral systemic PUVA
Patient ingests Oxsoralen Ultra 75 min prior to appointment
↓
Patient checks in at front desk
↓
Patient gathers supplies (gown, towels, goggles, genital coveragea)
↓
Patient changes into gown and nurse examines patients skin
↓
Patient enters UVA box
↓
Nurse adjusts light box settings
↓
Patient undergoes session
(b) Hand and foot soak PUVA
Patient checks in at front desk
↓
Patient gathers supplies (gown, towels, goggles, measuring cup, genital coveragea)
↓
Patient mixes 10 mg of Oxsoralen Ultra with 2 quarts of warm water
↓
Patient changes into gown and nurse examines patients skin prior to soaking
↓
Affected areas of hands/feet soaked in Oxsoralen Ultra solution for 30 min
↓
Patients should dry, not rinse, after soaking then retrieve nurse
↓
Patient enters hands and/or feet into UVA box
↓
Nurse adjusts light box settings
↓
Patient undergoes session
(c) Bath PUVA
Patient checks in at front desk
↓
Patient gathers supplies (gown, towels, goggles, measuring cup, genital coveragea)
↓
Patient mixes 50 mg of Oxsoralen Ultra in a cup with warm water
↓
Patient changes into gown and nurse examines patients skin prior to soaking
↓
Oxsoralen Ultra solution is added to a bathtub prefilled with 100 L warm water
↓
Patients should soak only from shoulders down to feet for 30 min
↓
Patients should dry, not rinse, after soaking then retrieve nurse
↓
Patient enters UVA box
↓
Nurse adjusts light box settings
↓
Patient undergoes session
PUVA Psoralen plus ultraviolet A
a
Genital coverage may be required for male patients unless an exception has been granted
Dermatol Ther (Heidelb) (2016) 6:315–324 321

Fig. 1 Hand and foot soak PUVA treatment procedure Fig. 2 Bath PUVA treatment procedure

the skin to become more sensitive to light and, Care should be taken to avoid scrubbing the
therefore, patients are more susceptible to skin, as any trauma or breakdown of the skin
sunburn. Patients should avoid exposure to can potentially cause worsening of psoriasis in a
sunlight, even through window glass, for 24 h process called the Koebner phenomenon.
after treatment with PUVA. Patients should Patients should limit makeup and nail polish
apply sunscreen with Sun Protection Factor on areas receiving treatment to allow full light
(SPF) of 15 or above to any sun-exposed skin penetration. While perfume and colognes are
for at least 24 h after PUVA treatment. fine when applied to clothes, they should not be
Sunscreen should be reapplied every 1.5 h if applied to skin, as some of the chemicals may be
outdoors. Patients should also use moisturizers photosensitizing and may increase the risk of
and lotions on the affected areas at least twice burning during PUVA treatment. Lastly, it is
daily as part of their routine skin care regimen. important to limit sunbathing during the
322 Dermatol Ther (Heidelb) (2016) 6:315–324

Table 4 Post-phototherapy skin care for PUVA Table 5 Side effects of PUVA phototherapy
phototherapy
Side effect Signs/symptoms
Avoid exposure to sunlight and use sunscreen of SPF 15 Short term
or higher for at least 24 h after PUVA
Burning Redness, tenderness, tightness,
Moisturize skin twice daily and frequently in between blistering
treatments
Noticeable 24–72 h after
Avoid scrubbing skin hard or tearing off skin treatment
Limit nail polish and makeup on areas receiving Itching Usually mild and relieved with
treatment emollients
Avoid perfumes and colognes directly on skin Nausea Unique to oral systemic PUVA
Avoid sunbathing during the clearing stage of PUVA Reduced by consuming
treatment Oxsoralen Ultra with
PUVA psoralen plus ultraviolet A, SPF sun protection protein, milk, or full meal
factor Tanning Skin darkening

clearing stage of PUVA treatment to reduce the Long term

risk of sunburn, which can interfere with the Photoaging Coarseness, wrinkling, laxity,
PUVA treatment regimen (Table 4). increased fragility, freckling
Cataracts Blurry vision, as though looking
Side Effects through frosted glass
Theoretical risk that has not
There are some risks and possible side effects of been confirmed in humans
PUVA treatment. Some of the potential with proper eye protection
short-term side effects include burning, Non-melanoma and Unusual shaped growths or
itching, and pigmentation of the skin. Burns, melanoma skin lumps may appear to grow
which often appear as redness, tenderness, and cancers quickly over time
blistering, may start 24–72 h after treatment in Genital skin cancer possible,
up to 10% of patients during the clearance but prevented with shielding
phase [15]. For mild burns, a topical
PUVA psoralen plus ultraviolet A
corticosteroid cream or ointment may be
applied as directed. Mild itching is common studies on humans with proper eye protection
and can usually be relieved with topical have not confirmed an increase in the risk of
emollients. A moderate-to-deep tan may cataracts with UVA exposure [14]. Skin aging
develop while on treatment, but often fades changes may include dryness, wrinkling, and
6–8 weeks after stopping treatment. Nausea is freckling, which may disappear after treatment is
the most common side effect unique to stopped, though freckling may persist
systemic PUVA and may be reduced by taking indefinitely. PUVA can lead to an increased risk
methoxsalen with protein, milk, or a full meal. of non-melanoma and melanoma skin cancers,
Long-term risks of PUVA treatment include particularly among light-skinned individuals
cataracts, skin aging changes, and skin cancer. and those who have previously received X-rays
Cataracts are considered a theoretical risk, as or Grenz rays [16]. The risk of genital skin cancer
Dermatol Ther (Heidelb) (2016) 6:315–324 323

may also be increased, but may be prevented with of the work as a whole, and have given final
proper shielding (Table 5) [17]. approval for the version to be published.

Disclosures. John Koo is a speaker for

CONCLUSIONS
AbbVie, Leo, and Celgene, and conducts
PUVA treatment is a very effective and safe research for Amgen, Janssen, Novartis,
treatment option for patients whose psoriasis is Photomedex, Galderma, Pfizer, and Merck.
not well controlled on topical therapies alone. Tina Bhutani is an advisor for Cutanea and
PUVA may also be a viable option for patients conducts research for Abbvie, Janssen, and
who have failed UVB therapy. PUVA requires Merck. Wilson Liao conducts research for
patient compliance with consistent treatments Abbvie, Janssen, Novartis, and Pfizer, and
for 9–15 weeks to achieve maximal results. receives funding from the NIH (R01AR065174,
When administered and monitored properly, U01AI119125). John Koo, Tina Bhutani, and
PUVA can help patients safely achieve clearance Wilson Liao have no stocks, employment, or
and in many cases provide long-lasting board memberships with any pharmaceutical
remission. The effectiveness of PUVA is company. Benjamin Farahnik, Mio Nakamura,
comparable to some of the most effective Michael Abrouk, Tian Hao Zhu, Rasnik K. Singh,
biologic agents available today for the Kristina M. Lee, Margareth V. Jose, and Renee
treatment of moderate-to-severe psoriasis. It is DaLovisio have nothing to disclose.
our hope that this guide can serve as a valuable
Compliance with Ethics Guidelines. This
resource for patients considering or preparing
article does not involve any new studies of
for PUVA treatment and the health-care
human or animal subjects performed by any of
providers who treat these patients.
the authors. All photos are printed with the
consent of the subject(s).
ACKNOWLEDGMENTS Open Access. This article is distributed
under the terms of the Creative Commons
We would like to thank Tim Sarmiento for
Attribution-NonCommercial 4.0 International
producing, directing, and editing the
License ([Link]
educational video that accompanies this
by-nc/4.0/), which permits any noncommercial
manuscript. We would also like to thank the
use, distribution, and reproduction in any
amazing staff and nurses from the UCSF
medium, provided you give appropriate credit
Psoriasis and Skin Treatment Center for
to the original author(s) and the source, provide
inspiring and helping to make the video
a link to the Creative Commons license, and
possible. We thank Olivia Chen for her help
indicate if changes were made.
reviewing the Spanish translation of the
accompanying video. No funding or
sponsorship was received for publication of
this article. All named authors meet the REFERENCES
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