Medical Phototherapy Malpractice and Legal Precedents in North America (1983–2025)

1.

Ultraviolet (UV) phototherapy remains a cornerstone of dermatologic therapy for a wide range of inflammatory and neoplastic skin disorders [1, 2, 3]. Despite its long safety record, phototherapy remains technique‐dependent, characterized by narrow therapeutic windows, variable dose‐escalation protocols, and routine delegation to nursing staff or technicians, factors that may contribute to medicolegal risk for physicians, who retain oversight responsibility. Despite its broad use, no focused systematic analysis of legal precedents involving phototherapy exists [4, 5]. To address this gap, we analyzed US and Canadian court decisions involving medical phototherapy.

We conducted a retrospective cross‐sectional review of reported civil cases retrieved from the LexisNexis database through June 2025. Search terms included “phototherapy,” “PUVA,” “UVB,” “nb‐UVB,” “excimer,” and “photodynamic therapy,” cross‐referenced with malpractice and dermatology‐related terms. Included cases involved physicians, nurses, technicians, or facilities delivering phototherapy. Excluded were duplicates, disciplinary hearings, and cases without relevance to dermatology.

Of 150 retrieved cases, 54 were directly related to phototherapy. Thirty cases pertained to incarcerated patients alleging deliberate indifference due to delays or failures to initiate or resume dermatologist‐recommended phototherapy, most commonly for cutaneous T‐cell lymphoma or psoriasis. Nine additional cases involved intellectual property disputes concerning phototherapy devices and were excluded. The remaining 15 cases (13 from the United States and 2 from Canada) met inclusion criteria for detailed analysis, spanning 1983 to 2025.

Jurisdictions represented included Illinois (n = 4), New York (n = 3), Louisiana (n = 2), Florida (n = 1), Washington, DC (n = 1), North Dakota (n = 1), Indiana (n = 1), British Columbia (n = 1), and Alberta (n = 1). Psoralen plus ultraviolet A (PUVA) and narrowband‐UVB were the most frequently implicated modalities, followed by excimer and photodynamic therapy (PDT). The predominant clinical indications were psoriasis and cutaneous T‐cell lymphoma (CTCL), followed by others, including vitiligo, lichen planus, and lichen simplex chronicus.

The most frequent allegations (11 of 15, 73%) involved improper administration or dosing errors, inadequate or absent informed consent, and failure to protect untreated body sites (Table 1). Less common claims included fraudulent billing or upcoding (2 of 15, 13%), criminal sexual misconduct during treatment (1 of 15, 7%), and patient‐initiated defamatory online reviews (1 of 15, 7%). Physical injuries predominated, including first‐, second‐, and third‐degree burns, photosensitivity reactions, and ocular injury. Other alleged harms included disease progression and psychological distress.

TABLE 1.

Representative examples of major allegation patterns identified among phototherapy‐related legal cases from the United States and Canada.

Allegation category	Example
Improper administration or technical error	Incorrect dosing or rapid escalation (e.g., PUVA dose increased by 0.5 J/cm2 on consecutive days)—Multiple consecutive sessions exceeding standard limits—Continued treatment despite worsening rash or adverse reaction—Failure to perform skin typing or adjust protocols accordingly
Inadequate informed consent	Failure to disclose phototoxic or carcinogenic risks—Omission of discussion on alternative therapies—Lack of documented consent prior to phototherapy
Lack of protection or safety measures	Omission of face or eye shields during UV exposure—Failure to protect untreated body sites or genital areas—Inadequate supervision of nursing staff or technicians—Lack of equipment maintenance or monitoring during therapy
Fraudulent or improper billing practices	Misclassification of UVB sessions as PUVA for reimbursement—Upcoding routine sessions as complex procedures—Billing for subtherapeutic or non‐performed sessions—Recording exaggerated session frequency or duration
Defamation and online misconduct	Patient‐initiated defamatory online reviews alleging that phototherapy was ineffective and primarily performed to “milk the insurance” or generate unwarranted billing claims
Criminal or sexual misconduct	Inappropriate physical examination and manipulation of intimate areas during phototherapy (criminal sexual assault)

Abbreviations: PUVA, Psoralen plus ultraviolet A; UVB, Ultraviolet B.

Most verdicts favored the defendants. Four cases resulted in trial‐level verdicts for the plaintiffs (one later reversed on appeal), largely involving failures in informed consent, documentation, or supervision (Table 2).

TABLE 2.

Summary of reported court decisions in which trial judgments favored plaintiffs across the United States and Canada.

Jurisdiction & Year	Plaintiff	Defendant	Phototherapy	Indication	Allegation	Harm	Ruling	Key notes
Dakota, 2022	Dermatologist	Male patient	nb‐UVB	Unknown	Defamatory online reviews alleging lack of phototherapy efficacy and insurance fraud	Unknown	For Plaintiff $7731.50 total awarded: permanent injunction ordering defendant to remove online postings
New York, 1983	Adult male patient	Resident physician	PDT (proflavine)	Herpes infection	Lack of informed consent about cancer risk	Phobia of developing cancer	For plaintiff at initial ruling regarding lack of consent with 200,000$ award; Appeal court reversed and vacated the decision	Court emphasized that physicians cannot be held liable for failing to disclose unknown risks
Aberta, 2002	Adult male patient	Physician & Nurse	PUVA	LSC	Failure to obtain informed consent Improper administration Lack of supervision and documentation.	First‐ and second‐degree burns and scarring	For Plaintiff Award: $18,570.03 CAD	Informed consent must include phototoxic risks Nursing liability in delegated phototherapy administration also extends to physicians Clarified that failure to document skin typing and tailor treatment protocol can independently constitute negligence.
British Columbia, 1987	Adult female patient	Physician	PUVA	Vitiligo	Inadequate informed consent	Burn	For Plaintiff Award: $2991,62 USD	Informed consent must warn patients of potential risks including burn

Abbreviations: CAD, Canadian dollar; CTCL, Cutaneous T‐cell lymphoma; LSC, Lichen simplex chronicus; nb‐UVB, Narrowband ultraviolet B; PDT, Photodynamic therapy; PUVA, Psoralen plus ultraviolet A; USD, United States dollar.

Our analysis highlights four lessons: First, informed consent must explicitly address phototoxic risks, potential burns, and long‐term carcinogenic risk. Courts in both the US and Canada recognized consent omissions as independent negligence even when the procedure itself met technical standards. Second, delegated phototherapy remains the physician's legal responsibility. Dermatologists are vicariously liable for staff actions and must verify use of goggles, shields, and dosimetry logs. The failure to ensure compliance, even by trained assistants, was interpreted as potential negligence. Third, accurate billing and supervision documentation carry legal weight. Courts treated fraudulent coding and lack of treatment records as evidence of systemic misconduct. Fourth, cases involving prisoners present challenges in institutional settings, including inconsistent access to phototherapy, lapses in continuity, and administrative barriers. These cases demonstrate how deviation from dermatologist‐recommended phototherapy can be litigated as deliberate indifference. Finally, with expanding home phototherapy use and an aging population with cancer‐related or inflammatory disease requiring light‐based therapies, malpractice risk will likely increase unless standardized protocols, consent templates, and documentation practices become more uniform.

This review was limited to publicly available court decisions and likely underrepresents out‐of‐court settlements, arbitration outcomes, or unpublished lower‐court rulings. Nevertheless, it provides a valuable overview of real‐world medicolegal precedents relevant to dermatologists who perform or supervise phototherapy.

Funding

The authors have nothing to report.

Ethics Statement

This study analyzed publicly accessible court decisions obtained through LexisNexis, a subscription‐based legal research database. Institutional review board approval and patient consent were not required.

Conflicts of Interest

The authors declare no conflicts of interest.

Barnawi G., Nukaly H., Lazarowitz R., et al., “Medical Phototherapy Malpractice and Legal Precedents in North America (1983–2025),” International Journal of Dermatology 65, no. 6 (2026): 1266–1268, 10.1111/ijd.70223.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.