Narrowband UVB phototherapy for early-stage mycosis fungoides: evaluation of clinical and histopathological changes

Background Early‐stage (IA, IB, IIA) mycosis fungoides (MF) has long been treated with various agents including topical potent steroids, nitrogen mustard, carmustine, oral psoralen plus UVA (PUVA), broadband UVB, electron‐beam radiotherapy, interferon‐α and retinoids. However, each of these modalities is associated with various side‐effects. Narrowband UVB (NB‐UVB) therapy has the same effect but is safer to use than the other methods. Objective Our purpose in this prospective study was to determine the effects of NB‐UVB in early‐stage MF both clinically and histopathologically. Materials and methods Twenty‐three patients (20 men, three women, aged 27–78 years) with clinically and histologically confirmed MF were enrolled. Patients received NB‐UVB therapy three times a week. Clinical and histological responses, cumulative doses, total number of treatments, side‐effects and duration of remission period were noted. Results Six patients had stage IA MF, 15 patients stage IB and two patients stage IIA. Eighteen patients had patch stage and five patients had plaque stage histopathologically. All of the patients in the patch group had a complete response (CR). In the plaque group, three patients (60%) had a CR and two (40%) had partial (PR) or no clinical response (NR). The clinical response between patch and plaque groups was statistically significant. Regarding the histopathological findings, 17 (94.4%) had complete clearing and only one (5.6%) patient had a partial improvement in the patch group. In the plaque group, one (20%) patient had complete clearing and four (80%) patients had partial or no improvement. The difference between the two groups was statistically significant. In the patch group, the mean cumulative dose was 90.15 J/cm² and the mean number of treatments was 35.33. In the plaque group, the mean cumulative dose was 90.67 J/cm² and the mean total number of treatments was 39.40. The differences were not statistically significant, either between the mean cumulative dose or the mean number of treatments. The mean duration of follow‐up was 10.87 months (range 1–25 months). Only one of the patients had a relapse. Conclusions NB‐UVB therapy for patients with early‐stage MF is an effective and safe treatment with the effect lasting for months. We suggest that clinical clearance correlates with histological improvement except for patients in the plaque stage.     

Narrowband UVB phototherapy for small plaque parapsoriasis

BACKGROUND: Narrowband UVB (NB-UVB) phototherapy has been shown to be effective for the treatment of various dermatoses. OBJECTIVE: To analyze the effects of NB-UVB phototherapy for small plaque parapsoriasis (SPP). METHODS: The response of 45 patients (24 females, 21 males, age range 20-58 years) with histologically confirmed SPP were assessed. NB-UVB therapy was given 3-4 times weekly. The initial treatment dose was 70% of the minimal erythema dose. The doses were increased gradually with a standard increment of 20/10/0. Clinical response was determined as follows: complete response (CR), at least 90% clearing of skin lesions; partial response (PR), at least 50% but less than 90% clearing and no response (NR), less than 50% clearing. The follow-up period was 6-24 months after the treatment. RESULTS: NB-UVB treatment led to CR in 33 of 45 patients (73.3%) with a mean cumulative dose of 14.3 J/cm(2) (range 3.2-24.1 J/cm(2)) after a mean number of 29 exposures (range 16-51 sessions); PR in 12 of 45 (26.6%) with a cumulative dose of 15.6 J/cm(2) (range 10.4-23.3 J/cm(2)) after a mean number of 29.4 exposures (range 25-50 sessions). Nineteen patients with CR had skin phototype II, 13 had type III and 1 had type I. Among the patients with PR, 7 had skin phototype II and 5 had type III. Postinflammatory hyperpigmentation was observed in 51% of the patients. Relapses occurred in six patients within a mean time of 7.5 months (2-12 months). CONCLUSION: NB-UVB phototherapy has several advantages over treatment with broadband UVB and PUVA. NB-UVB therapy for patients with SPP is an effective, safe and practical alternative treatment modality. Further larger studies with longer follow-up periods are necessary to determine the proper clinical response and long-term complications of NB-UVB therapy in this disease.     

Narrowband UVB phototherapy for psoriasis: Results with fixed increments by skin type (as opposed to percentage increments)

Many authors currently advocate 10-20% dosage increments between phototherapy sessions when treating psoriasis with narrowband ultraviolet B (UVB). However, such regimens are associated with a risk of significant erythema. In order to reduce this risk, a fixed increment regimen was developed using increments ranging from 30 mJ/cm2 for skin type II to 150 mJ/cm2 for type VI. Starting doses, also based on skin type, range from 180 to 400 mJ/cm2. Data from 20 patients with moderate to severe plaque psoriasis [13 male, 7 female, age range 17-74, skin types II (3), III (10), IV (3), V (1), VI (3)] completing 27 courses of phototherapy of more than 3 weeks' duration between 8/96 and 12/97 were compared. Complete, or near-complete clearing occurred in 8/13 courses (62%) with a frequency of attendance (during the initial 24 sessions) of >2.5 sessions per week, 4/8 (50%) with a frequency of 2.0-2.5, and 1/6 (17%) with a frequency of <2.0. In the subset of patients taking low-dose oral retinoids, rates of clearing were higher. Overall, 10 of 20 patients (50%) cleared, usually within 24-30 sessions. The average maximum dosage in such cases was 1400 mJ/cm2. There were only 13 instances of minor erythema, and 1 instance of severe erythema resulting in desquamation and requiring interruption of treatment. This was due to the inadvertent administration of an excessive 300 mJ/cm2 increment to a type VI patient. In summary, using a conservative fixed increment regimen, clearing of psoriasis is possible while minimizing the risk of serious erythema. Results are enhanced when patients attend 3 phototherapy sessions per week.     

Narrowband UVB phototherapy in children: A New Zealand experience

Background: Phototherapy is effective for many dermatoses in adults, but there is a paucity of data for its use in children. Objectives: To review the efficacy and tolerability of narrowband UVB phototherapy in children at a tertiary centre in New Zealand, and determine if there were any factors that differentiated responders from non‐responders. Methods: A prospective analysis of children (<16 years old) who had undergone phototherapy over a 15‐year period. Results: 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. Atopic dermatitis was the most common indication for treatment followed by psoriasis, pityriasis lichenoides, nodular prurigo, morphea, vitiligo, urticaria pigmentosa and erythropoietic porphyria. 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/cm² and the mean maximum treatment dose per treatment was 1328 mJ/cm². All children tolerated treatment well with 36% developing brief, minimally symptomatic, erythema. Only two children experienced exacerbations of their underlying dermatoses. Conclusions: This study shows that phototherapy is an effective and well‐tolerated treatment modality in children.     

Narrowband UVB therapy for vitiligo: does the repigmentation last?

BACKGROUND: Since 1997, a number of trials have shown promising results in treating generalized vitiligo with narrowband ultraviolet B (UVB) both in adults and children. However, there is little knowledge concerning the duration and permanency of the treatment-induced repigmentation. OBJECTIVE: Our main objective was to perform a follow-up trial of successfully treated patients receiving narrowband UVB for generalized vitiligo. METHODS: We have investigated to what degree the treatment-induced repigmentation remains stable for up to 2 years post-treatment. We performed an initial open trial including 31 patients with generalized vitiligo. They received narrowband UVB thrice weekly for up to 12 months. Patients experiencing > 75% repigmentation were defined responders and were included in the follow-up trial. Responders were followed every 6 months for up to 2 years after cessation of treatment. We observed the pigmentation status and registered any changes indicating loss of pigmentation and relapse. RESULTS: Eleven of the 31 treated patients were included in the follow-up trial. Six patients had relapse and five patients had stable response 24 months after cessation of treatment. Four out of six relapses were within 6 months post-treatment. CONCLUSION: In our study population of 31 patients with generalized vitiligo, five patients (16%) experienced > 75% stable repigmentation 2 years after cessation of a treatment programme of up to 1 years narrowband UVB therapy.     

Narrowband UVB (311 nm, TL01) phototherapy for pityriasis lichenoides

Background/purpose: Narrowband (NB) UVB (NB-UVB) phototherapy has recently demonstrated high levels of efficacy and tolerability in a variety of skin diseases. The purpose of the present study was to assess the efficacy of NB-UVB phototherapy in the management of pityriasis lichenoides (PL).
Methods: The therapeutic response in 31 PL patients (23 pityriasis lichenoides et varioliformis acuta; PLEVA, eight pityriasis lichenoides chronica; PLC) treated with NB-UVB phototherapy between 2000 and 2007 was assessed.
Results: NB-UVB treatment led to a complete response (CR) in 15 out of 23 PLEVA patients (65.2%) with a mean cumulative dose of 23 J/cm² after a mean number of 43.4 exposures and a partial response (PR) in eight patients (34.8%) with a cumulative dose of 15.6 J/cm² after a mean number of 32.3 exposures. NB-UVB treatment led to CR in seven out of eight PLC patients (87.5%) with a mean cumulative dose of 18.4 J/cm² after a mean number of 45.8 exposures and PR in one patient (12.5%) with a cumulative dose of 9.1 J/cm² after a mean number of 19 exposures. Relapses occurred in four PL patients within a mean time period of 6 months.
Conclusion: NB-UVB therapy is an effective, safe and practical alternative treatment modality for the management of PLEVA and PLC.     

Efficacy of narrowband UVB vs. PUVA in patients with early‐stage mycosis fungoides

Introduction Mycosis fungoides (MF) is a non‐Hodgkin’s T‐cell lymphoma of the skin that often begins as limited patches and plaques with slow progression to systemic involvement. Narrowband ultraviolet (UV) B therapy has been proven to be an effective short‐term treatment modality for clearing patch‐stage MF. The effect of psoralen plus long‐wave ultraviolet A (PUVA) in the treatment of patch‐ and plaque‐type MF has also been thoroughly documented. Objectives The purpose of this study was to compare the efficacy and safety of narrowband UVB and PUVA in patients with early‐stage MF. Methods We analysed the response to treatment, relapse‐free survival and irradiation dose in 114 patients with histologically confirmed early‐stage MF (stage IA, IB and IIA). Results A total of 95 patients were treated with PUVA (83.3%) and 19 with narrowband UVB (16.7%). With PUVA, 59 patients (62.1%) had a complete response (CR), 24 (25.3%) had a partial response (PR) and 12 (12.6%) had a failed response. Narrowband UVB led to CR in 12 (68.4%) patients, PR in 5 (26.3%) patients and a failed response in 1 (5.3%) patient. There were no differences in terms of time to relapse between patients treated with PUVA and those treated with narrowband UVB (11.5 vs. 14.0 months respectively; P = 0.816). No major adverse reactions were attributed to the treatment. Conclusions Our results confirm that phototherapy is a safe, effective and well‐tolerated, first‐line therapy in patients with early‐stage cutaneous T‐cell lymphoma, with prolonged disease‐free remissions being achieved. It suggests that narrowband UVB is at least as effective as PUVA for treatment of early‐stage MF.     

Narrowband UVB phototherapy as a novel treatment for Netherton syndrome

Netherton syndrome (NS) is a rare congenital ichthyosis that is characterized by impaired skin barrier function. Topical medications are cautiously used in NS since toxicity from systemic absorption is a major concern. Narrowband ultraviolet B phototherapy is an alternative therapeutic option that demonstrated its beneficial and practical use in a patient with NS.     

Bexarotene and narrowband ultraviolet B phototherapy combination treatment for mycosis fungoides

Combination therapy for mycosis fungoides (MF) has the potential to be synergistic, improve therapeutic efficacy and reduce toxicities. We present a patient with MF who improved on combination therapy with bexarotene and narrowband ultraviolet B (NB-UVB) therapy. The patient is an 81-year-old Caucasian male who initially presented with stage IB MF. After temporary improvement with NB-UVB phototherapy, he progressed to develop plaques and tumors. Psoralen and ultraviolet A therapy was contraindicated because of ophthalmologic disease. Addition of bexarotene 300 mg daily led to rapid clinical improvement in combination with NB-UVB. Interruption of NB-UVB during a prolonged hospitalization led to a clinical flare of lesions, despite continued treatment with bexarotene. Reinitiating NB-UVB was associated with clinical improvement. This report demonstrates that combination treatment with oral bexarotene and NB-UVB therapy may represent a safe alternative for the treatment of plaque-stage MF.     

Modulation of ultraviolet (UV) transmission by emollients: relevance to narrowband UVB phototherapy and psoralen plus UVA photochemotherapy

BACKGROUND: Patients with psoriasis undergoing or about to undergo ultraviolet (UV) phototherapy and photochemotherapy often have thick scale on their plaques which can prevent the penetration of UV radiation. Emollients are used to moisturize the skin and to prevent or reduce some of the milder side-effects ('dryness', itching) sometimes experienced during UV therapy. However, emollients can alter the UV transmission of skin and thus may alter the clinical effects of phototherapy and photochemotherapy. OBJECTIVES: We tested 30 of the topical emollients in the British National Formulary (BNF) using a standard in vitro technique used to test sunscreens. We also surveyed U.K. phototherapy units to establish routine practice for emollient use in phototherapy and photochemotherapy. METHODS: We used a standard in vitro technique to measure the monochromatic protection factors (MPFs) of 30 non-bath emollients from the BNF. An application rate of 2 mg cm-2 was used. For the assessment of effects during narrowband UVB (TL-01) phototherapy, the mean of the protection factors at 310 and 315 nm was calculated; for psoralen plus UVA photochemotherapy the mean UVA protection factor was used. A questionnaire survey was used to assess routine practice concerning emollient use prior to phototherapies in phototherapy units throughout the U.K. RESULTS: In the UVA range, 17 of the 30 emollients gave protection factors of 1.2 or above. In the UVB range, 23 of 30 had an MPF of 1.2 or above. Yellow soft paraffin had the highest protection factor in the UVB range. Of 78 centres surveyed, 57 returned completed questionnaires (73%). Seventeen of 57 (30%) centres routinely used emollients immediately prior to administering phototherapy treatments. The remaining 40 of 57 (70%) did not. Forty-five (79%) responding centres recommended the use of emollients after phototherapy. CONCLUSIONS: This study has revealed considerable variability in the practice of emollient use before phototherapy treatments. Although the majority of centres included in this study did not routinely use emollients, almost one third did. Our in vitro measurement of 30 emollients revealed marked variation in UV transmission, with many emollients blocking sufficient UV to affect the response to therapy.     

Narrowband UVB therapy as an effective treatment for Schamberg's disease

A 33-year-old man presented with a 3-month history of a widespread pigmented purpuric eruption over his trunk and limbs. The clinical presentation and histology were consistent with a diagnosis of Schamberg's disease. The rash initially cleared following a short course of oral prednisolone at 25 mg daily for 3 weeks, which was weaned over the subsequent 4 weeks. Topical mometasone furoate ointment 0.1% daily was also applied to active areas. The rash recurred when prednisolone was reduced to below 5 mg per day. To prevent a further recurrence with weaning prednisolone, narrowband UVB therapy was commenced three times per week. The patient was continued on UV therapy over the next 5 months. The rash would flare after 2 to 3 weeks without treatment. The frequency of UV therapy was weaned and the patient remained clear on as little as one treatment every 2 weeks. Any further reduction, however, was associated with a recurrence. Narrowband UVB therapy should be considered for difficult or persistent cases of pigmented purpuric eruption.     

Narrow band UVB (311 nm), psoralen UVB (311 nm) and PUVA therapy in the treatment of early-stage mycosis fungoides: a right-left comparative study

BACKGROUND: Psoralen ultraviolet A (PUVA) is a widely used first-line therapy for treatment of early cutaneous T-cell lymphoma. Narrow band UVB (UVB-NB) (311 nm) has been recently introduced as another effective line of treatment. It is postulated that the efficacy of UVB-NB could be enhanced by addition of psoralen. AIM: The aim of the present work was to compare the clinical and histopathologic efficacy of PUVA and UVB-NB in the treatment of early-stage MF (stages IA, IB and IIA), and to evaluate whether psoralen adds to the efficacy of UVB-NB or not. Patients and Methods: Twenty patients (stage IA, IB or IIA) were divided into two equal groups: group I received UVB-NB on the right body half vs. PUVA on the left side of the body for 48 sessions, and group II received PUVB-NB on the right side of the body vs. PUVA on the left side for 36 sessions. The sessions were administered three times weekly. RESULTS: In group I, almost equal results were obtained on both sides, i.e., UVB-NB and PUVA were equally effective in the treatment of early stages of MF, both clinically and histopathologically. In group II, PUVB-NB was found to be as effective as conventional PUVA in the treatment of early-stage mycosis fungoides, also on both clinical and histopathological grounds. CONCLUSION: UVB-NB phototherapy should be included among the initial therapeutic options of mycosis fungoides in view of its efficacy, convenience, and likelihood of fewer long-term adverse effects. Addition of psoralen does not seem to enhance its therapeutic efficacy.     

Spectrophotometric intracutaneous analysis as an early non-invasive predictor of efficacy in the phototherapy of psoriasis

Background: Phototherapy is generally effective for psoriasis but individual responsiveness and optimal treatment duration for disease clearance are unpredictable. However, easy, rapid and non-invasive plaque assessment by spectrophotometric intracutaneous analysis (SIAscopy), a novel multispectral skin imaging technique, may now make prediction feasible.
Objectives: The early prediction of psoriatic plaque clearance during phototherapy by SIAscopy.
Methods: Sixteen psoriatic plaques in 10 psoriasis patients were serially assessed SIAscopically during phototherapy for punctate dots representing the dilated papillary dermal blood vessels characteristic of active psoriasis, and the results compared with the clinical findings.
Results: All plaques showing full SIAscopic clearance at early follow-up also showed complete or almost complete clinical clearance, and remained the same thereafter. All showing no SIAscopic clearance at early follow-up showed at most partial clinical clearance, and also remained the same thereafter. All showing only partial SIAscopic clearance at early follow-up also showed just partial clinical clearance, but then generally progressed to full SIAscopic and clinical clearance.
Conclusions: SIAscopy of psoriatic plaques at early follow-up during patient phototherapy enables good prediction of likely later clinical clearance, thereby potentially avoiding unnecessary further treatment. A larger confirmatory study is now needed.     

Optimized UVB treatment of psoriasis: a controlled, left-right comparison trial

In a randomized, controlled, left-right comparison study, 20 patients with chronic plaque psoriasis were treated with UVB. One side of the body received UVB in a conventional regimen with fixed dose increments, the other side was given UVB doses according to measurements of skin pigmentation. Skin pigmentation was quantified by the skin reflectance technique. The relationship between skin pigmentation and sensitivity to UV radiation was used to optimize and individualize the initial UVB exposure dose. Clinical outcome, initial, final and cumulative UVB doses, time to 50% reduction in PASI score, and side-effects were compared. The consequence of the optimization of the UVB doses with a skin reflectance meter was that the initial UVB dose was significantly higher than in the conventional UVB regimen. PASI scoring demonstrated a more rapid improvement during the first 2 weeks of treatment on the half body receiving the optimized treatment compared to the other side (P < 0.05). This new technique offers the same therapeutical advantages and security as a dose regimen guided by minimal erythema dose testing. However, measurement of skin pigmentation by skin reflectance is a quick method which can be operated easily by nurses.     

Tumor necrosis factor-α-converting enzyme as a potential mediator of the influence of smoking on the response to treatment with narrowband ultraviolet B in psoriasis patients

Purpose: The aim of the study was to analyze the relationship between smoking and the treatment with narrowband ultraviolet B (NB‐UVB) in psoriasis patients and to examine the role of the soluble tumor necrosis factor‐α receptor type one (sTNF‐R1) in plasma and that of TNF‐α‐converting enzyme (TACE) released from peripheral blood mononuclear cells (PBMC) in this relationship. Methods: The study has been conducted among 45 inpatients with plaque‐type psoriasis vulgaris and 36 inpatients with other chronic inflammatory skin disorders from similar social background (controls). Taking into account the number of cigarettes smoked daily and the duration of smoking, subjects were classified as mild, moderate and heavy smokers. The severity of psoriasis was assessed using psoriasis area and severity index (PASI) score, concentrations of sTNF‐R1 and TACE (expressed in ng/ml) – with quantitative sandwich enzyme immunoassays before (T₀) and after 20 NB‐UVB irradiations (T₂₀). Results: The pretreatment concentration of sTNF‐R1 was 2.55±0.17 in patients and 1.79±0.13 in controls (P<0.05) and that of TACE – 2.62±0.34 and 1.29±0.25, P<0.05, respectively. PASI score correlated with sTNF‐R1 and with TACE concentrations (R=0.40 and R=0.38, P<0.05, respectively). PASI score, sTNF‐R1 and TACE concentrations were similar in mild, moderate and in heavy smokers. PASI score and TACE concentration declined significantly after treatment in three groups; the lowest TACE concentration at T₂₀ was noticed in mild smokers, the highest in heavy smokers (0.86±0.26 and 1.91±0.20, P<0.05, respectively). The post‐treatment PASI score correlated with the intensity of smoking and with TACE concentration (R=0.50 and R=0.47, P<0.05, respectively). The strong correlation between the pretreatment TACE concentration and the treatment outcome was observed in heavy smokers (R=0.63, P<0.05). Conclusions: The baseline TACE concentration in PBMC may be of value in predicting the response to the treatment with NB‐UVB in smoking psoriasis patients. Smoking may adversely influence this treatment and TACE may be one of mediators in this influence.