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ORIGINAL ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 1  |  Page : 17-22

Narrow-band ultraviolet B in childhood vitiligo: An open prospective uncontrolled study in 28 children of South India


1 Department of Dermatology, Raja Rajeswari Medical College and Hospital, Kambipura, Bengaluru, Karnataka, India
2 Department of Dermatology, GSL Medical College and General Hospital, Rajahmundry; Departments of Dermatology, Surya Skin Care and Research Centre, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication16-Jan-2015

Correspondence Address:
G Raghurama Rao
Surya Skin Care and Research Centre, Naoroji Road, Maharanipeta, Visakhaptanam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.149424

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  Abstract 

Background: Management of vitiligo in children is difficult as therapeutic options are restricted when compared to that in adult patients. Selection of treatment should be careful in these patients with the aim to achieve best results with minimal side effects. Only few studies have been performed to evaluate the efficacy and safety of narrow-band ultraviolet B (NBUVB) therapy in children with vitiligo.
Aims: The purpose of this study was to know the efficacy and safety of NBUVB in children with vitiligo of age group ranging from 3 to 16 years.
Methods: Twenty-eight patients (12 males, 16 females), aged 3-16 years with vitiligo were included in the study between years 2011 and 2013 and were treated twice weekly with NBUVB. The starting dose was 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 another 12 months for stability of repigmentation.
Results: Analysis of our study showed that a majority of our cases, 22 (78.6%) had > 75% to complete repigmentation, about 4 (14.2%) achieved 26-75% moderate repigmentation and 2 (7.2%) had < 25% mild repigmentation. Adverse effects were transient and minimal. Only one child developed depigmentation of repigmented sites during 1-year follow-up.
Conclusion: Our study proves that NBUVB therapy is safe and effective tool in the management of childhood vitiligo, with good stability of repigmentation.

Keywords: Childhood vitiligo, narrow-band ultraviolet B, South India


How to cite this article:
Kumar Y H, Rao G R. Narrow-band ultraviolet B in childhood vitiligo: An open prospective uncontrolled study in 28 children of South India. Indian J Paediatr Dermatol 2015;16:17-22

How to cite this URL:
Kumar Y H, Rao G R. Narrow-band ultraviolet B in childhood vitiligo: An open prospective uncontrolled study in 28 children of South India. Indian J Paediatr Dermatol [serial online] 2015 [cited 2019 Dec 13];16:17-22. Available from: http://www.ijpd.in/text.asp?2015/16/1/17/149424


  Introduction Top


When choosing appropriate therapies for dermatologic conditions in the pediatric population, clinicians must not only consider disease severity and morphology also the general systemic safety profile of the treatment. Narrow-band ultraviolet B (NBUVB), ranging from 311 to 313 nm, is a safe and efficacious treatment option for several photoresponsive conditions in adults. NBUVB represents a notable advance in phototherapy and is considered more efficacious than broadband ultraviolet B in the treatment of psoriasis, mycosis fungoides, and vitiligo. NBUVB also has been increasingly tested in the pediatric population as a therapy for diseases, including vitiligo and atopic dermatitis. [1],[2],[3],[4],[5] In 1997, Westerhof and Nieuweboer-Krobotova [6] were the first to study the effect of NBUVB in vitiligo. In 2000, Njoo et al. [7] and 2005, Kanwar and Dogra [8] reported NBUVB therapy to be safe in childhood vitiligo. Herein we report our study conducted in 28 South Indian children with vitiligo, our experience in management of vitiligo with NBUVB its safety, efficacy, and outcome.


  Methods Top


Our study group included 28 cases of generalized and localized vitiligo. The study was prospective, open and nonrandomised. 28 children (12 males, 16 females) of vitiligo, with ages ranging from 3 to 16 years, were included from January 2011 to 2013. Children with a history of photosensitizing disorders, sensitive to photosol therapy, and suffering from claustrophobia were not included. All these patients were advised to stop any previous treatment for at least 8 weeks before NBUVB monotherapy.

A complete general and systemic examination was carried out to know the associated systemic diseases. A thorough dermatological examination was carried out taking note of the number of depigmented macules were charted in a pictorial diagram and the approximate percentage of body surface area was calculated using "Rule of Nine." Cases of vitiligo were classified as generalized and localized vitiligo. Relevant hematological and biochemical investigations were carried out in all the patients.

Before starting NBUVB therapy, all the patients with parents were taken around the phototherapy units and were counseled regarding the safety profile, the importance of adherence and compliance and limitations of therapy to alleviate the anxiety of the children.

Equipment Used

  • Whole Body, Surya 240 NB Unit (V Care UV Therapy Unit, Bengaluru, India) with 24 tubes (TL-01) - 100 W, 6 ft - for generalized vitiligo
  • Multipurpose Localized Unit (V Care UV Therapy Unit, Bengaluru, India) with 16 NB tubes (TL-01) - 20 W, 2 ft - for localized vitiligo.



  Treatment Protocols Followed Top


As all patients were of skin type IV and V, the minimal erythema dose (MED) was not calculated and the initial dose of 150 mJ/cm 2 was started and the treatment was administered 2 times/week on nonconsecutive days. The irradiation dose was increased by 20% for each subsequent visit till the optimal dose was achieved to obtain minimal erythema in the lesions. If symptomatic erythema, burning pain or blistering developed, the irradiation dose was decreased by 20%. During treatment, the affected parts were only exposed, and the genitalia and other uninvolved areas were protected. Similarly, the eyes were protected by UV-blocking goggles. If significant depigmentation was present on the eyelids and if patients or parents insisted on treating these areas, the patients were advised to keep their eyes closed during treatment. All the patients were asked to use sunscreens during daytime.

The maximum period of treatment was 12 months or earlier if 75% or greater repigmentation was achieved. Maintenance therapy once in a week for 4 weeks and once in 2 weeks for another 4 weeks was given. If there was no repigmentation even after 6 months of therapy, NBUVB was discontinued. All the patients were examined by the same dermatologist at 4 weeks intervals, and lesional photographs were taken at baseline and thereafter to document the pattern and extent of repigmentation. All the patients were followed-up for 12 months after termination of therapy to observe the stability of repigmentation. Computerized phototherapy data of all the patients was maintained.

The patient response to NBUVB therapy was grouped as Group A - <25% repigmentation, Group B - 25-75% repigmentation and Group C - >75% repigmentation. Response to treatment was assessed by comparing the photographs of before and after therapy. Patient compliance was scored as Score 1 - <25 treatments, Score 2 - between 25 and 50 treatments, Score 3 - between 50 and 75 treatments and Score 4 - >75 treatments. Data recorded in each of these patients were compared and evaluated at the end of therapy and during follow-up.

Of the 28 patients, 12 (42.8%) were males and 16 (51.2%) were females and their ages ranged from 3 to 16 years [Table 1]. The duration of disease ranged from 1-month to 8 years, with a mean duration of 4 years. 4 (14.2%) patients had a family history of vitiligo, none of the children had any systemic disease association. Majority of the children treated were of localized variety, 6 (21.4%) patients had generalized vitiligo, 4 (14.2%) patients had acral/acrofacial type, 10 (35.8%) had focal, and 8 (28.6%) had segmental type of vitiligo [Table 2]. Localized vitiligo lesions were treated with multipurpose localized NBUVB unit with adequate protection of the nonaffected areas with sunscreens and tailor made garments. Of the 28 patients, 26 (92.8%) received NBUVB therapy for 6-12 months. 2 (7.2%) patients had therapy for <3 months because of satisfactory repigmentation.
Table 1: Age and sex distribution


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Table 2: Duration of vitiligo


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  Results Top


Of the 28 patients, 2 (7.2%) had 25% repigmentation, 4 (14.2%) achieved 25-75% repigmenation and 22 (78.6%) had more than 75% repigmentation [Figure 1] [Figure 2] [Figure 3] [Figure 4]. Of these 28 cases, only one case showed depigmentation of repigmented sites.
Figure 1: Generalized vitiligo treated with multipurpose narrowband ultraviolet B panel for children with claustrophobia

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Figure 2: Facial vitiligo showing depigmentation over nose, above the eyelids and lips

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Figure 3: Best response (>75% repigmentation) of facial vitiligo with excellent cosmetic color match with the surrounding skin after 44 exposures

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Figure 4: A case of generalized vitiligo showing large islands of depigmentation over the trunk

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Certain anatomic sites responded better than others. The best response (i.e. >75% repigmentation) was achieved with lesions located on the face and neck, followed by the trunk, back, arms, and legs. The lesions over the knees, elbows, and other bony prominences seldom showed more than 75% repigmentation. The lesions on the hands, digits, feet, toes, and lips showed < 25% repigmentation. Patients with leukotrichia in the depigmented lesions were resistant to treatment. Focal vitiligo responded earlier, and best response was achieved followed by facial, segmental, acral, and generalized vitiligo [Figure 5] [Figure 6] [Figure 7] [Figure 8].
Figure 5: Repigmentation of lesions with good cosmetic match, best response (>75% repigmentation) noted after 72 exposures

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Figure 6: A case of focal vitiligo over the left side of buttock showing perifollicular repigmentation

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Figure 7: Focal vitiligo treated with panel narrow-band ultraviolet B, best response (>75% repigmentation) after 28 exposures

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Figure 8: Good stability of repigmentation seen after 12 months of follow-up

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Repigmentation in a majority of the cases was follicular in nature, and a few repigmentation occurred from the periphery. Most patients experienced that the initial repigmentation was darker. Few weeks later, in all the cases, the repigmented color matched well with the normal skin, giving a good cosmetic appearance. The disease activity had significantly decreased after NBUVB therapy. Before therapy, most patients, 12 (42.8%), had active disease, whereas after therapy, the disease had stabilized in all of the cases. The response to therapy was faster and good in children with a short duration of the disease. The duration of disease ranged from 1-month to 8 years with a mean duration of 4 years. 26 patients had duration of vitiligo of 5 years, or less and 2 patients had duration of vitiligo of more than 5 years [Table 3].
Table 3: Clinical types of vitiligo


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Periodic and systematic analysis was done for the recorded phototherapy data of all patients for any relation between the response and the number of exposures, duration of treatment and the compliance [Table 4].
Table 4: Response to NBUVB therapy in relation to phototherapy data


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The adverse side effects were minimal, and none of the patients required cessation of therapy. 3 (10.6%) patients reported mild erythema/burning/pruritus and 8 (28.6%) patients complained of xerosis. All these side effects were mild and resolved on tapering the irradiation dose or with topical application of an emollient. All the patients had good stability of repigmentation with only 1 (2.8%) patient developed depigmentation of repigmented sites during the follow-up period of 12 months.


  Discussion Top


Vitiligo can be a challenging condition to treat in children because of a lack of markedly efficacious treatments and limited available data in pediatric patients. [1],[2] NBUVB may be a safe and preferred treatment option for children with vitiligo because it is generally well-tolerated with minimal side effects. Though, psoralen and ultraviolet A (PUVA) is also a treatment option for vitiligo but may be considered second line to NBUVB because of the associated higher side effects. NBUVB therapy is now a more or less established and recommended phototherapy for generalized vitiligo, pregnant women, and children because of the high safety profile. [3],[4],[5] Determination of MEDs is essential for rational treatment with UV light. Serish and Srinivas reported that the mean MED for NBUVB was 300 mJ/cm 2 for the Indian adults skin. [9] In the present study, although MED was not calculated, the NBUVB therapy in children was started with an initial dose of 150 mJ/cm 2 . The optimal NBUVB irradiation regimen has yet to be defined. Hence, large-scale studies are warranted to establish the standard protocol of NBUVB therapy in children.

Literature review showed, 20 children treated with NBUVB for vitiligo, 75% of patients achieved marked or complete repigmentation after an average 34 phototherapy treatments. [10] In another study, NBUVB was used to treat 9 pediatric patients with either localized or generalized vitiligo. [11] Response, which was defined as >50% repigmentation, was achieved in 44% of those patients. The median number of treatments required for response was 14 but ranged widely among patients from 9 to 107 treatments. Thus, NBUVB can represent a preferred treatment option for children with vitiligo.

Brazzelli et al. [12] studied 10 Caucasian Italian children (six boys, four girls, mean age 9.7 years ± 2.67). Treatment mean term was 5.6 months; frequency was 3 times a week on nonconsecutive days or only twice a week. The percentage of repigmentation was evaluated by comparing photographs taken before, during, and after the treatment, and showed a repigmentation level higher than 75% in 5 patients (5/10, 50%) and between 26% and 75% in 3 patients (3/10, 30%). No significant relationships between repigmentation grades and variables such as skin type, positive family history, and disease extension were observed.

Tan et al. [13] conducted a prospective analysis of children (<16-year-old), in 116 children received phototherapy with a total of 144 courses. Mean age was 11.0 years with the majority being European and having skin phototype II. Treatment was effective in the majority of children (72%). Most received only one course. For responders, the mean number of treatments was 32.4. The mean dose per treatment to achieve clearance was 886 mJ/cm 2 and the mean maximum treatment dose per treatment was 1328 mJ/cm 2 . All children tolerated treatment well with 36% developing brief, minimally symptomatic, erythema. This study concluded that phototherapy is an effective and well-tolerated treatment modality in children.

In this particular study, the lesser number of exposures (51 ± 19) were required to achieve 25-75% repigmentation and hence lesser cumulative dose compared to the observations reported in other western studies. [6],[7],[11],[12],[13],[14] Our study and other Indian studies [8],[9],[10] showed that dark skin (Fitzpatrick type IV and V) requires lesser number of exposures and cumulative dose to achieve 25-75% repigmentation when compared with white skin (Fitzpatrick I and II). It has also been observed in our study that with good adherence to therapy and compliance, with more number of exposures and cumulative dose faster and good response can be achieved.

We have also observed during the course of therapy that initially, in some patients, newer lesions used to develop but while continuing the therapy, newer lesions cease to appear, and the disease was stabilized. This could be due to the immunomodulatory effect of NBUVB, although the precise mechanisms are still not known.

In our study also certain anatomical sites such as face, neck, trunk, and back responded faster, with better repigmentation to NBUVB therapy, and poor response was observed over the acral areas. The repigmentation achieved in all the cases was cosmetically accepted and matched with the surrounding normal skin, unlike in PUVA therapy. In this way, NBUVB therapy is superior to oral PUVA therapy.

In our study panel, NBUVB equipment was used in children and patients with localized vitiligo and children with claustrophobia. This particular NBUVB equipment was found to be useful and handy, particularly in the pediatric age group, and similar results were obtained. It has been observed that the majority of children responded faster with good repigmentation (>75%), with lesser number of exposures and cumulative dose of NBUVB.

The adverse effects in our study were minimal, and none of the patients required discontinuation of therapy. The adverse effect profile observed in our study was similar to that reported in the literature. [6],[7],[8],[9],[10],[11],[12],[13],[14],[15] All these studies, including ours, clearly establish the safety profile of NBUVB therapy. During the follow-up period of 12 months, of the 28 patients, only 1 patient developed depigmentation of repigmented sites. However, our study group consisted of only 28 patients to be conclusive, but the results show that children with recent onset of vitiligo have a better response to the therapy. We feel that NBUVB therapy is a valuable and safe option for the treatment of pediatric vitiligo, and should be started as soon as possible. Further large-scale studies are warranted, and long-term follow-up is needed to observe the stability of repigmentation.

Childhood vitiligo with its profound psychological effects on both the child and parent, psychological approaches needs to be assessed to see if they can help sufferers. Quality-of-life and coping mechanisms may improve over time in patients with vitiligo. Cognitive behavioral therapy strategies rather than avoidance or concealment may be associated with better coping. Schwartz et al. [16] observed a higher frequency of shyness to change, fear for strangers and predominant fear in children with vitiligo in comparison to healthy siblings. The child's perception about illness and difficulties in interaction with other children must be noted at every visit to the clinician and addressed accordingly.


  Conclusions Top


This study establishes that NBUVB therapy is an effective and safe modality to treat vitiligo in children with cosmetically acceptable repigmentation especially in South Indian skin types. Therefore, all the patients and parents should be properly educated and counseled before offering NBUVB therapy. Adherence and good compliance are prerequisites for this therapy to achieve satisfactory repigmentation.

 
  References Top

1.
Pugashetti R, Koo J: Phototherapy in pediatric patients: choosing the appropriate treatment option. Semin Cutan Med Surg 2010;29:115-20  Back to cited text no. 1
    
2.
Dogra S, De D. Phototherapy and photochemotherapy in childhood dermatoses. Indian J Dermatol Venereol Leprol 2010;76:521-6.  Back to cited text no. 2
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Kanwar AJ, Kumaran MS. Childhood vitiligo: Treatment paradigms. Indian J Dermatol 2012;57:466-74.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
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Tamesis ME, Morelli JG. Vitiligo treatment in childhood: A state of the art review. Pediatr Dermatol 2010;27:437-45.  Back to cited text no. 4
    
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Palit A, Inamadar AC. Childhood vitiligo. Indian J Dermatol Venereol Leprol 2012;78:30-41.  Back to cited text no. 5
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6.
Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs topical psoralen plus UV-A. Arch Dermatol 1997;133:1525-8.  Back to cited text no. 6
    
7.
Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol 2000;42:245-53.  Back to cited text no. 7
    
8.
Kanwar AJ, Dogra S. Narrow-band UVB for the treatment of generalized vitiligo in children. Clin Exp Dermatol 2005;30:332-6.  Back to cited text no. 8
    
9.
Serish, Srinivas CR. Minimal erythema dose (Med) to narrow band ultraviolet-B (NB-UVB) broad band ultraviolet-B (BB-UVB) - A pilot study. Indian J Dermatol Venereol Leprol 2002;68:63-4.  Back to cited text no. 9
    
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Hercogová J, Buggiani G, Prignano F, Lotti T. A rational approach to the treatment of vitiligo and other hypomelanoses. Dermatol Clin 2007;25:383-92, ix.  Back to cited text no. 10
    
11.
Kanwar AJ, Dogra S, Parsad D, Kumar B. Narrow-band UVB for the treatment of vitiligo: An emerging effective and well-tolerated therapy. Int J Dermatol 2005;44:57-60.  Back to cited text no. 11
    
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Ersoy-Evans S, Altaykan A, Sahin S, Kölemen F. Phototherapy in childhood. Pediatr Dermatol 2008;25:599-605.  Back to cited text no. 12
    
13.
Brazzelli V, Prestinari F, Castello M, Bellani E, Roveda E, Barbagallo T, et al. Useful treatment of vitiligo in 10 children with UV-B narrowband (311 nm). Pediatr Dermatol 2005;22:257-61.  Back to cited text no. 13
    
14.
Tan E, Lim D, Rademaker M. Narrowband UVB phototherapy in children: A New Zealand experience. Australas J Dermatol 2010;51:268-73.  Back to cited text no. 14
    
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Kishan Kumar YH, Rao GR, Gopal KV, Shanti G, Rao KV. Evaluation of narrow-band UVB phototherapy in 150 patients with vitiligo. Indian J Dermatol Venereol Leprol 2009;75:162-6.  Back to cited text no. 15
    
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Schwartz R, Sepúlveda JE, Quintana T. Possible role of psychological and environmental factors in the genesis of childhood vitiligo. Rev Med Chil 2009;137:53-62.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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