The World of UV Phototherapy

Posts Tagged ‘Vitiligo’

Dr. James Nordlund

Today I was reading the Winter Newsletter from Vitiligo Support International and one of the articles was edited and vetted by Dr. James Nordlund here in Cincinnati.

An often-expressed concern of both vitiligo patients and dermatologists is whether having vitiligo increases one’s risk for non-melanoma and/or melanoma skin cancer and if ultraviolet light therapy is a safe treatment. Though there are limited, but growing data, on this subject, key observations have been made which can help both the individual with vitiligo and dermatologist to better assess this risk. To effectively address the question, the information has been separated into these categories.

• Do vitiligo patients in general have an increased incidence of skin cancer?
• Do vitiligo patients have an increased risk of non melanoma skin cancer (NMSC) in their depigmented lesions?
• Do vitiligo patients have an increased risk of melanoma and/or NMSC in their “normal” skin?

Melanin is the substance that gives the skin its color, with darker skin having higher melanin levels. Melanin acts as a sunscreen and protects the skin from ultraviolet light which helps prevent sunburn damage that could result in DNA changes and, subsequently, melanoma. The assumption by many has been that that because the depigmented skin affected by vitiligo has no melanin, that the patient would be more susceptible to some types of skin cancer.

Because there are no melanocytes in depigmented skin, it would be biologically impossible to develop in depigmented skin a melanoma the most serious type of skin cancer. The other forms, the so called basal epithelioma, could develop but are easily treated and are not life threatening.

Unfortunately there are no great statistical studies on cancer in vitiligo. However most research and/or observations indicate that while non melanoma skin cancers do occur in vitiligo patients, they are very rare and melanomas in the normal skin occur at most, in no greater incidence than within the normal population.
An interesting observation on this subject was reported in the book Vitiligo: A Monograph on the Basic and Clinical Science, by Seung-Kyung Hann and James J. Nordlund. Dr. Nordlund observed that in East African countries near the equator, where few work indoors and sunscreen is unavailable, that people with vitiligo not only do not appear to get skin cancer, they exhibit little sun damage to their skin. Other studies also agree that vitiligo patients generally do not demonstrate sun-induced skin damage, despite the lack of protective melanin in the skin.

Ultraviolet light, both natural sunlight and artificial light in PUVA, Excimer laser and narrowband UVB, is an important therapeutic tool for vitiligo. To date, most studies agree that light used in accordance with a supervised treatment plan is a safe, effective method for treating vitiligo. More long term studies will be needed to further assess any skin cancer risk from these treatments.

VSI would like to thank Dr. James J. Nordlund, Professor of Dermatology, Group Health Associates, Cincinnati, OH and Wright State School of Medicine, for his significant contributions to, and medical review of this article.

Today I received an email from Lori Mitchell whose daughter April Mitchell has had Vitiligo for many years. April’s one of the few who have come to grips with the challenge and embraced it.

See the Video >> Beauty through the Eyes of April Mitchell << CLICK HERE >>

Cheryl and I have met April and Lori at several Vitiligo conferences over the years. Lori has written a book called “DIFFERENT - Just Like Me”

April and Lori are remakable people in an ever changing world.

Please watch the video!

Chris

Recently I became aware of a blog that’s been running for some time, the blog focuses on Vitiligo and the author whose name is not published on the blog does have a couple of articles on UVB NB used in Vitiligo Treatment. The blog can be found at http://www.vitiligoskindisorder.com. The UVB NB article that I found is http://www.vitiligoskindisorder.com/treating-vitiligo-with-puva-vs-narrowband-uvb/

I’ll keep reading this blog for a while but it would be nice to know who is publishing it and why?

TITLE: Evaluation of narrow-band UVB phototherapy in 150 patients with vitiligo

Link to full article <Click Here>
PDF of Article <Click Here>

AUTHORS: Y Hari Kishan Kumar¹, G Raghu Rama Rao¹, K.V.T Gopal, G Shanti, K Veerabhadra Rao

Background: Very few studies have been performed to evaluate the efficacy and safety of narrow-band ultraviolet B (NBUVB) therapy in Indian patients with vitiligo and are of small sample size.

Aims: The purpose of this study is to know the efficacy and safety of NBUVB in 150 vitiligo patients of various age groups.

Methods: One hundred fifty patients (69 males, 81 females), aged 3-70 years, with vitiligo were treated twice weekly with NBUVB. The starting dose was 250 mJ/cm 2 in adults and 150 mJ/cm 2 in children, with 20% dose increments at each subsequent visit given for a maximum period of 1 year and were followed-up for 6 months for stability of repigmentation. Statistical methods were employed to establish the relation between the response and the number of exposures, duration of treatment, cumulative dose and the compliance.

Results: Analysis of our study showed that a majority of our cases, about 73, achieved 25-75% repigmentation, with an average of 51 ± 19 exposures, 51 had <25% repigmentation, with an average of 19 ± 11 exposures and 26 had >75% repigmentation, with an average of 74 ± 24 exposures. Good response to therapy was directly associated with good compliance, more number of exposures and increasing cumulative dose, which was statistically significant (P < 0.01). Adverse effects were minimal. Only three patients developed depigmentation of repigmented sites during follow-up.

Conclusion: Our study proves that NBUVB therapy is an effective and safe tool in the management of vitiligo, with good stability of repigmentation and cosmetic appearance.

The breakthrough came after 1988 when narrow-band UVB (NB-UVB) phototherapy was introduced for the treatment of psoriasis…

Narrow band UVB phototherapy in dermatology

AUTHORS: Sunil Dogra, Amrinder Jit Kanwar
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India

Full Article < Click Here >

The first report of the use of ‘phototherapy’ in the treatment of skin disorders dates from 1400 BC from India when patients with vitiligo were given certain plant extracts (whose active ingredients included psoralens) and then exposed to the sun. The real interest in the use of ultraviolet (UV) irradiation in the treatment of various skin diseases started in the 19th century when Niels Finsen received the Nobel Prize (1903) for his therapeutic results with UV irradiation in lupus vulgaris, the only dermatologist ever to be awarded one. This marked the start of modern phototherapy. It was used in thermal stations for the treatment of tuberculosis, in the treatment of leg ulcers in wartime, and various other skin diseases. It was a very long journey from the use of plant extracts and sun exposure to treat vitiligo to the use of oral psoralens and total body UVA-irradiation cabins (PUVA) to treat various skin diseases. In a landmark development, in 1974 Parrish et al reported the useful role of high intensity UVA tubes in combination with oral psoralens in the treatment of psoriasis leading to what is now known as PUVA therapy.

The history of UVB phototherapy is not as old as the history of photochemotherapy. Wiskemann introduced irradiation cabin with broad band UVB tubes in 1978 for the treatment of psoriasis and uremic pruritus. However, broad band UVB phototherapy was less efficient for treating psoriasis than PUVA and so never achieved popularity. The breakthrough came after 1988 when narrow-band UVB (NB-UVB) phototherapy was introduced for the treatment of psoriasis by van Weelden et al and Green et al.

A friend and colleague of mine received “the Achievement Award from the American Skin Association (ASA) for his work studying vitiligo and pigment cell biology.”

Ray Boissy chairs the National Vitiligo Foundation (www.nvfi.org) which is now based here in Cincinnati. The announcement was made yesterday in the University of Cincinnati’s Deans List publication.

The announcement reads:

See http://healthnews.uc.edu/publications/deanslist/?/8616/ 

Raymond Boissy, PhD, professor of dermatology and cell biology, has received a 2009 Achievement Award from the American Skin Association (ASA) for his work studying vitiligo and pigment cell biology. Boissy was recognized for his contributions to the scientific understanding of the skin disorder, which causes white patches on the skin due to pigment loss. He is currently studying the etiology and cell biology of the disease. Boissy received an award plaque at the Society for Investigative Dermatology meeting this month in Montreal. The achievement award is one of a series of ASA awards recognizing outstanding work that brings significant improvement in the treatment available to people suffering from specific skin disorders. Boissy, who also serves as the director of basic science research at the College of Medicine, has published over 100 scientific papers and 30 review articles and book chapters and has helped edit a book titled “The Pigmentary System: Physiology and Pathophysiology.” He is the past secretary/treasurer of the PanAmerican Society for Pigment Cell Research and is currently the chair of the National Vitiligo Foundation.

It’s great to have an independent source ratify what we’ve known for years. UV Phototherapy at home is safe, well tolerated and here in the USA, very cost effective for the patient and the insurance company that sometimes is paying the bill.

Since the publishing of the article on May 7th by the British Medical Journal on the effectiveness of UVB Treatment in the home, the Internet has been buzzing with articles written by a host of reviewers on the subject. Most are simply referring to the original article but many are commenting. Most if not all of the postings I’ve seen on various blogs and publications show strong support for the use of UVB Narrowband Therapy in the home.

This of course is like music to my ears. Many of you know that I run a business offering UV Phototherapy Products for use in the home. See www.HomePhotoTherapy.com. So of course I’m a little biased.

The actual heading of the article is “Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study)”

The finding by the researchers who followed 196 patients was “Ultraviolet B phototherapy administered at home is equally safe and equally effective, both clinically and for quality of life, as ultraviolet B phototherapy administered in an outpatient setting. Furthermore, ultraviolet B phototherapy at home resulted in a lower burden of treatment and led to greater patients’ satisfaction. “

This statement flies in the face of many dermatologists that say that they believe that treatment at home is the wrong approach because they believe that patients will not be compliant at home. It’s interesting to note that many of the derms who make such ridiculous statements have phototherapy systems in their offices or clinic and they draw some of their income for the sale of time in their own phototherapy systems. I guess it shows that even doctors like to make a dollar.

Treatment at home is ultimately much less expensive to the patient and the insurance company than in-clinic treatment. Typical home equipment can range from $600.00 to $7000.00 with most folks spending perhaps $2500.00 on a home system. In clinic rates can vary from a low of $25.00 to a high of $90.00 PER TREATMENT. I we take an average of let’s say $40.00/treatment with three treatments a week then that’s $120.00/week and in 20 weeks ($2400.00), the typical home system would be paid for. That does not include the costs of parking, car mileage, time of work.

Visit www.HomePhotoTherapy.com to see some home systems. Remember most folks over a lifetime require treatment sometimes several times a year, perhaps for a lifetime.

The absolute best way to have UV Treatment is in the home.

<Link to original article>

The three diseases that we see UVB NB prescribed for most often are Eczema, Psoriasis and Vitiligo. People being treated with UVB NB for Eczema and Psoriasis typically  see results very quickly while those with Vitiligo have a tougher row to hoe. With Vitiligo, we typically see re-pigmentation begin after forty to sixty treatments, remember with treatments usually ocurring three times a week we’re looking at 12 to 20 weeks before re-pigmentation begins. It usually begins with freckling in the white areas and then over time the freckles expand to cover the area. Treatment will most likely continue for a year or more to fill in all/most areas that will re-pigment.

Folks with Psoriasis and Eczema usually respond quickkly to treatment and begin to see results with in the first week or so and treatments then continue for a month or two with most people clearing within a few months.

Here’s a page at National Psoriasis Foundation on UVB Phototherapy
Excerpt from page “Several studies indicate that narrow-band UVB clears psoriasis faster and produces longer remissions than broad-band UVB. Narrow-band UVB may be effective with fewer treatments per week than broad-band UVB. Narrow-band UVB is also emerging as an alternative to PUVA, the light-sensitizing medication psoralen plus exposure to ultraviolet light A. Although not as effective as PUVA, narrow-band UVB is easier for people to undergo and may be safer over the long term. The use of narrow-band UVB may increase as doctors and patients learn more about its effectiveness and safety…” See http://www.psoriasis.org/treatment/psoriasis/phototherapy/uvb.php

With Eczema and Psoriasis, what do you do when clearing has happened?

1. Wait for a re-occurence and start treatments again or
2. Perform a weekly maintenance dose at perhaps 75% of the last treatment time.

In either case, check with your dermatologist or medical professional. As a reminder, please read our disclaimer.

I received an email last night which reminded me that I have not discussed treatment areas and response to treatment.

I’ll begin by saying that the areas of our bodies with few hair follicles such as the hands, feet, knees and elbows are the toughest areas to treat with any form UVB NB. It’s the hair follicles that harbor the last remaining melanocytes and it is the melanocytes that help color our skin.

That being said, the other areas such as the face, neck, torso, arms, legs etc seem to respond well to treatment for perhaps 70% to 80% of people with Vitiligo.

I’m asked often “Should I use sunblock or mask the areas that are not affected by Vitiligo?” There are at least two answers to this question and you should check with your dermatolgist as to what s/he would prefer.

There are a couple of things that can go wrong if you start masking or covering areas that have not depigmented:

1. If you fail to cover an area that you have been covering in the past, there is a very high likelihood/risk of sunburn and
2. although there have been few studies on this, if an area is starting to de-pigment and you expose it to UVB Narrowband during treatment, then perhaps it will never develop.

The choice to cover or not to cover is between you and your dermatologist. Safety is an issue. UVB appears to be safer than PUVA/UVA. I discuss a little of the safety aspect elsewhere in my blog. See http://www.uvbnarrowband.com/?p=117

Narrowband UVB was safer and more effective than PUVA for vitiligo therapy.

Phototherapy employing sunlight and plants that contain natural psoralens was first used for vitiligo thousands of years ago, and it continues to be a first-line treatment today. Investigators conducted a randomized, double-blind trial to compare two of the most popular forms of phototherapy for vitiligo in 50 patients with nonsegmental vitiligo who received either PUVA or narrowband UVB (NB-UVB) therapy (25 patients in each group).

After treatment (maximum, 144 sessions), subjects in both groups had significant reductions in the extent of vitiligo-involved body surface area. Although between-group differences were not statistically significant, improvement occurred more rapidly and tended to be greater with NB-UVB. After 48 treatments in patients who received that many sessions, the median percentage of improvement in affected body-surface area was slightly more than 20% in the PUVA-treated patients and more than 50% in the narrowband-treated group. The color of the repigmented skin matched excellently the color of uninvolved skin in all NB-UVB recipients but in only 44% of PUVA recipients. Erythema occurred more often with PUVA phototherapy than with NB-UVB therapy (in 96% vs. 68%, respectively). The PUVA recipients received a median of 47 treatments and the narrowband UVB patients, a median of 97; the authors suggest that this is because of the greater efficacy and fewer adverse effects experienced by NB-UVB recipients.

Comment: This study clearly demonstrates that for vitiligo repigmentation, NB-UVB is safer and more effective than PUVA. Other randomized, controlled trials have shown at least some efficacy with targeted phototherapy, topical and systemic steroids, topical calcineurin inhibitors, and calcipotriene combined with PUVA. A number of reports show success with surgical repigmentation procedures, as well. Although we are making progress in treating this vexing disease (especially with calcineurin inhibitors and phototherapy), we still have a long way to go. At best, 75% of patients respond, and in most instances, this response is only partial. A breakthrough in the management of this disease would be greatly welcomed by both patients and doctors. An accompanying editorial provides a nice evidence-based review of existing therapies for vitiligo.

— Craig A. Elmets, MD

Published in Journal Watch Dermatology June 1, 2007