Key Takeaways
- Face/neck: NB-UVB or excimer + tacrolimus 0.1% is first-line; consider label-eligible topical JAK for added speed in limited BSA.
- Trunk/limbs: NB-UVB backbone; pulse mid-potency steroids off-face; tacrolimus for folds or long-term maintenance.
- Acral: excimer targeting rims + steroid pulses; manage expectations, longer timelines; add tacrolimus between light sessions.
- Maintenance: proactive tacrolimus on relapse-prone sites; NB-UVB taper; mini excimer “booster” cycles for border reactivation.
Sequencing & “Sandwich” Strategies
- NB-UVB 311 nm: 2–3×/week; escalate per erythema; shield uninvolved skin.
- Excimer 308 nm: 2–3×/week to active rims, per protocol.
- Topical timing: apply tacrolimus (or JAK) on non-light days or ≥8–12 h away from light; steroids can be pulsed evenings on non-light days.
- “Sandwich” concept: Light → rest day with tacrolimus/JAK → light (repeat). For steroids, use short cycles (“weekend therapy” or 2 weeks on / 1–2 weeks off) off-face.
Face/Neck Algorithm
| Step | Intervention | Notes |
|---|---|---|
| 1 | NB-UVB 2–3×/wk or Excimer 308 nm | Expect perifollicular islands by 4–8 weeks |
| 2 | Tacrolimus 0.1% nightly on off-light days | Face-sparing; reduces steroid need |
| 3 | Optional topical JAK (label-eligible) | Use when small facial BSA fits label |
| 4 | Moisturizers/barrier care | Improves comfort and adherence |
Trunk & Non-Acral Limbs
- Backbone: NB-UVB 2–3×/wk for 24–48 sessions, extend if responding.
- Steroid pulses: mid-potency 1–2×/day for 2 weeks, then break; alternate with tacrolimus to minimize atrophy.
- Excimer add-on: use for stubborn rims or scattered focal macules.
Acral (Hands/Feet)
- Targeted excimer 308 nm to borders + steroid pulses (short cycles).
- Tacrolimus on off-light days; emphasize friction reduction and protection at work/sport.
- Longer timelines; consider surgery only when stable and expectations aligned.
Where JAK Fits
- Consider topical JAK for label-eligible limited facial disease, especially when rapid cosmetic recovery is prioritized.
- Combine with NB-UVB cautiously (separate days/times) and monitor local irritation.
Maintenance & Relapse Prevention
- Proactive tacrolimus 2–3 nights/week on face/neck after successful fill-in.
- NB-UVB taper → weekly → q2wk; schedule excimer boosters for rim “sparkle.”
- Use TRM-informed plans with early “rescue” slots.
Dosing Tables (framework)
| Modality | Typical start | Escalation/Duration | Notes |
|---|---|---|---|
| NB-UVB 311 nm | Low dose per phototype | +10–20% per session as tolerated; 24–48 sessions | Goggles; moisturize; hold if erythema >24h |
| Excimer 308 nm | Per device protocol | 2–3×/wk; 6–12 weeks initial | Focus on active rims |
| Tacrolimus 0.1% | Thin layer nightly (off-light days) | 12–24 weeks then maintenance 2–3×/wk | Face/folds friendly |
| Mid-potency steroid | 1–2×/day | 2 weeks on → 1–2 weeks off | Off-face; watch atrophy |
| Topical JAK (facial) | Per label | Reassess at 8–12 weeks | Small BSA limits; monitor irritation |