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

Ultraviolet (UV) phototherapy remains a cornerstone of dermatologic therapy for a wide range of inflammatory and neoplastic skin disorders [1-3]. 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. 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). For Plaintiff $7731.50 total awarded: permanent injunction ordering defendant to remove online postings Failure to obtain informed consent Improper administration Lack of supervision and documentation. 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. For Plaintiff Award: $2991,62 USD 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. The authors have nothing to report. 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. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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