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Narrow band UVB phototherapy in dermatology Sunil Dogra, Amrinder Jit KanwarDepartment of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
Address for correspondence: Dr. A. J. Kanwar, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of MedicalEducation & Research, Chandigarh - 160102, India. E-mail: email@example.com for the treatment of psoriasis and uremic pruritus.5However, broad band UVB phototherapy was less The first report of the use of ‘phototherapy’ in the efficient for treating psoriasis than PUVA and so never treatment of skin disorders dates from 1400 BC from achieved popularity. The breakthrough came after 1988 India when patients with vitiligo were given certain when narrow-band UVB (NB-UVB) phototherapy was plant extracts (whose active ingredients included introduced for the treatment of psoriasis by van psoralens) and then exposed to the sun.1 The real interest in the use of ultraviolet (UV) irradiation in thetreatment of various skin diseases started in the 19th century when Niels Finsen received the Nobel Prize(1903) for his therapeutic results with UV irradiation A potential advance in UVB-based phototherapy has in lupus vulgaris, the only dermatologist ever to be been the introduction of fluorescent bulbs (Phillips awarded one.2 This marked the start of modern model TL-01) that deliver UVB in the range of 310 to phototherapy. It was used in thermal stations for the 315 nm, with a peak at 312 nm. It has a relatively narrow treatment of tuberculosis, in the treatment of leg ulcers spectrum of emission which when compared with the in wartime, and various other skin diseases.3 It was a older broad band UVB source has a reduction in very long journey from the use of plant extracts and erythemogenic wavelengths in the 290-305 nm range sun exposure to treat vitiligo to the use of oral and 5-6 fold increased emission of the longer UVB psoralens and total body UVA-irradiation cabins (PUVA) wavelengths, thereby resulting in a higher to treat various skin diseases. In a landmark development, in 1974 Parrish et al reported the usefulrole of high intensity UVA tubes in combination with oral psoralens in the treatment of psoriasis leading towhat is now known as PUVA therapy.4 In the skin, NB-UVB radiation is absorbed by DNA andurocanic acid and alters antigen presenting cell activity.
The history of UVB phototherapy is not as old as the NB-UVB is about 5-10 fold less potent than broad band history of photochemotherapy. Wiskemann introduced UVB for erythema induction, hyperplasia, edema, irradiation cabin with broad band UVB tubes in 1978 sunburn cell formation and Langerhans cell depletion How to cite this article: Dogra S, Kanwar AJ. Narrow band UVB phototherapy in dermatology. Indian J Dermatol Venereol Leprol 2004;70:205-9.
Received: May, 2004. Accepted: July, 2004. Source of Support: Nil.
Indian J Dermatol Venereol Leprol July-August 2004 Vol 70 Issue 4 [Downloaded free from http://www.ijdvl.com on Monday, April 13, 2009]
Dogra S, et al: UVB phototherapy in dermatology from the skin. It has a relatively more suppressive effect than broad band UVB on systemic immune responsesas judged by natural killer cell activity, NB-UVB schedules can be tailored according to patient lymphoproliferation and cytokine responses.8 The skin type and local experience. There are two regimens mechanism of action of NB-UVB phototherapy has not that are most commonly used; the first involves been completely understood. In psoriatics, NB-UVB determination of the individual’s minimum erythema phototherapy lowers peripheral natural killer cell dose (MED) by means of a separate bank of TL-01 tubes.
activity, lymphocyte proliferation and immune Often 70% of the MED value is used for the first regulatory cytokine production by both Th1 (IL-2, IFN- treatment; thereafter therapy is given three times or γ) and Th2 (IL-10) T-cell populations.8,9 more in a week with 40, 20 or 10% incrementsdepending on local experience and skin type tolerance.
Similar to PUVA therapy, NB-UVB may exert its effects Another approach, as commonly practiced in India, in vitiligo in a two-step process. Both steps may occur involves a standard starting dose (280 mJ/cm2), with simultaneously, the first being the stabilization of the stepwise increase (usually 20%) depending upon the depigmenting process and the second, the stimulation patient’s erythema response. In the photodermatoses, of residual follicular melanocytes.10,11 The well- the approach is more cautious with only 10% documented immunomodulating effects of UV incremental regimen on sun-exposed sites.9 In case of radiation can explain the stabilization of the local and mild erythema, the irradiation dose is held constant systemic abnormal immune responses.12 It is also likely for subsequent treatments or until resolution of that NB-UVB, similar to PUVA therapy, stimulates the symptoms. The goal of therapy is to achieve persistent dopa-negative, amelanotic melanocytes in the outer asymptomatic erythema. In case of painful erythema hair “root sheaths, which are activated to proliferate,” “with or without edema/blistering, further treatment produce melanin and migrate outward to adjacent is” withheld till the symptoms subside. After resolution depigmented skin resulting in perifollicular of overdose symptoms, the dose administered is 50% repigmentation.11 The ability of NB-UVB radiation to of the last dose and subsequent increments should be systemically suppress the major components of cell mediated immune function is thus likely to be linkedto its beneficial effect in several inflammatory skin In India, vitiligo is associated with marked social stigma,thus demanding its effective management. NB-UVB is NB-UVB phototherapy cabins contain fluorescent TL- a new addition to the armamentarium of therapies for 01 (100 W) tubes as the source of irradiation. The cost vitiligo. Clinical experience with NB-UVB in vitiligo is of a chamber and lamps show considerable variations limited, with only a few published reports.13,14,15,16 between countries and distributors. NB-UVB cabins However, initial results have been encouraging and available commercially either incorporate TL-01 alone there is a growing interest in its use in vitiligo or in combination with UVA tubes. Combination worldwide. While earlier reported studies have chambers take longer to administer a treatment dose.
evaluated its role mostly in Western population, our Thus, although they provide flexibility, they may experience in Indian patients is further evidence of its represent an unsatisfactory compromise for a busy efficacy in the treatment of vitiligo.17,18 phototherapy unit. Recently, shorter tubes of NB-UVBhave also become available in small area treatment In 1997, Westerhof and Nieuweboers-Krobotova13 first equipments (hand and foot unit, NB-UVB comb) for the reported the use of NB-UVB phototherapy for the treatment of vitiligo. In their comparative study, 67% Indian J Dermatol Venereol Leprol July-August 2004 Vol 70 Issue 4 [Downloaded free from http://www.ijdvl.com on Monday, April 13, 2009]
Dogra S, et al: UVB phototherapy in dermatology of patients undergoing NB-UVB phototherapy showed episodes, increased efficacy and longer remission when repigmentation compared with 46% of patients compared with broad band sources.22 When NB-UVB receiving topical PUVA after 4 months of therapy. In a phototherapy and PUVA were compared, there was little recently published study, NB-UVB was reported to be overall difference in efficacy.23,24 Coven et al compared effective and safe in childhood vitiligo.14 In this open the therapeutic effectiveness of half-body exposures trial, 51 children with generalized vitiligo were treated to NB-UVB or broad band UVB in moderate to severe twice weekly with NB-UVB radiation therapy for a psoriasis.25 Clinical resolution was achieved in 86% of maximum period of 1 year, resulting in more than 75% sites treated with NB-UVB vs. 73% treated with broad overall repigmentation in 53% of patients and band UVB including faster clearing and more complete Scherschun et al retrospectively analyzed their Although treatment with NB-UVB is reported to be experience of treating vitiligo with NB -UVB highly effective in clearing psoriasis patients, whether administered as monotherapy 3 times a week.15 Five this therapy represents a modest advance or a real of their seven patients achieved more than 75% breakthrough is not clear. If NB-UVB is to replace PUVA repigmentation with a mean of 19 treatments, whereas therapy in the treatment of more severe psoriasis, it the remaining two patients had 50% and 40% must not only achieve a comparable clearance rate in repigmentation after 46 and 48 treatments respectively.
psoriasis, but it must also maintain remission at a In a recent meta-analysis of non-surgical therapies in comparable frequency of treatment. At present, small generalized vitiligo by Njoo et al,19 higher success rates studies do provide some hope in this respect.26 were observed with NB-UVB (63%) than with oral PUVA(51%). As in the western population, NB -UVB phototherapy produces a cosmetically good color Fortunately atopic dermatitis (AD) is less severe in the match in Indian patients.18 Its distinct advantages over Indian population and can be mostly managed by PUVA include the lack of psoralen related side effects topical therapies.27 Recently NB-UVB has been reported and precautions, cosmetically better color match, and to be effective for the treatment of AD and is one of its safety in children. However, the relative stability of the first line therapies in moderate-to-severe AD in NB-UVB induced repigmentation over PUVA, its western countries.28,29 To optimize the patient’s maximum safe duration and cumulative dose allowed personal comfort, air conditioning is incorporated into the irradiation cabin.30 Available data indicate that NB-UVB seems to be a promising modality for the treatment of moderate-to-severe atopic dermatitis and is favorably The NB-UVB lamp was developed as a ‘new’ UVB accepted by patients. It offers an effective alternative phototherapy source with an emission spectrum within the therapeutic waveband for psoriasis phototherapy.
NB-UVB phototherapy has a higher ratio of therapeutic to erythemogenic activity, resulting in increased Prophylactic low dose NB-UVB has been found to be efficacy, reduced incidence of burning and longer useful in various predominantly UVA induced remission. Results from two therapeutic action photosensitivity disorders like polymorphic light spectroscopy studies indicated that wavelengths of the eruption, actinic prurigo, hydroa vacciniforme and the range 295-320 nm are effective in clearing psoriasis, cutaneous porphyrias by providing a ‘hardening whereas shorter wavelengths are more erythemogenic, photoprotective’ effect. A typical course involves 10- 15 treatments given in early spring.31 We have also therapeutic.20,21 Subsequent clinical studies have tended observed a beneficial role of NB-UVB in patients with to report significantly greater improvement of psoriasis airborne contact dermatitis to Parthenium hysterophorus, with NB-UVB including reduced incidence of burning a frustrating problem for both the patient and the Indian J Dermatol Venereol Leprol July-August 2004 Vol 70 Issue 4 [Downloaded free from http://www.ijdvl.com on Monday, April 13, 2009]
Dogra S, et al: UVB phototherapy in dermatology Table 1: Narrow band UVB responsive dermatoses
The general advantages of NB-UVB therapy over PUVA (*Dermatoses that may flare up)
include safe use in children and pregnant women, no need for post-treatment eye protection, no drug ParapsoriasisGeneralized lichen planusPityriasis rosea As with other forms of UV exposure, in addition to the expected immediate sunburn effects, chronic NB-UVB Seborrheic dermatitisPityriasis rubra pilaris exposure is likely to increase photoaging and the risk of carcinogenesis.8 Presently there is insufficient human data available to provide recommendations regarding the safe maximum NB-UVB dose. However, according to a dose response model it has been calculated that the long-term risk for carcinogenesis with its use may physician.32 Other less frequently tried indications are be less than that of PUVA therapy.38 Clinical experience with NB-UVB is limited and currently there is noestablished safe limit for its maximum safe duration of use in vitiligo. Njoo et al recommend that responsivepatients can be given this treatment for a maximum of In psoriasis, NB-UVB has been used in combination with 24 months.37 After the first course of one year, they topical therapies like tar, dithranol, calcipotriol and recommend a resting period of three months to tazarotene. There are some reports suggesting faster minimize the annual cumulative dose of UVB. In clearance, but the benefit of their combination with children, the maximum duration allowed is 12 months.
NB-UVB over NB-UVB used alone in the treatment of Subsequently, if required, only limited areas should be psoriasis is still debatable.33,34 However, it should be exposed. If no response is observed after six months, remembered that for most patients an attractive feature further therapy should be discouraged. Further, the risk of NB-UVB monotherapy is the absence of topical of cutaneous malignancies in vitiligo can be reduced therapy. There is hardly any published information on by skin saving principles, i.e. covering the parts that the role of combination therapy in vitiligo. Broad band have repigmented satisfactorily and shielding the UVB has also been used in combination with psoralen (PUVB),35 but its comparative efficacy and safety overNB-UVB and PUVA remain to be determined.
Fitzpatrick TB, Pathak MA. Historical aspects of methoxsalen and other furocoumarins. J Invest Dermatol 1959;31:229-31.
Roelandts R. The history of phototherapy: Something new In Europe, NB-UVB phototherapy is being increasingly under the sun? J Am Acad Dermatol 2002;46:926-30.
used for the treatment of various skin diseases Saleeby CW. Sunlight and health. 3rd Ed. London: Nisbet & Co; including psoriasis. Irradiation with this source has been Parrish JA, Fitzpatrick TB, Tanenbaum L, Pathak MA.
found to be superior to conventional broad band UVB Photochemotherapy of psoriasis with oral methoxsalen and in psoriasis, producing longer remissions, a lower long-wave ultraviolet light. N Engl J Med 1974;291:1207-11.
incidence of burning and possibly a lower risk of UV Wiskemann A. UVB-Phototherapie der Psoriasis mit einer fur carcinogenesis.25,36 In an important attempt to develop die PUVA-Therapie entwickelten Stehbox. Z Hautkr evidence-based guidelines for the treatment of vitiligo, van Weelden H, De La Faille HB, Young E, van der Leun JC. A NB-UVB therapy was recommended as the most new development in UVB phototherapy of psoriasis. Br J effective and safest therapy for generalized vitiligo.37 Indian J Dermatol Venereol Leprol July-August 2004 Vol 70 Issue 4 [Downloaded free from http://www.ijdvl.com on Monday, April 13, 2009]
Dogra S, et al: UVB phototherapy in dermatology Green C, Ferguson J, Lakshmipathi T, Johnson BE. 311 nm UVB 23. Van Welden H, Baart de la Faille H, Young E, Van der Leun JC.
phototherapy—an effective treatment for psoriasis. Br J A new development in UVB phototherapy for psoriasis. Br J El-Ghorr AA, Norval M. Biological effects of narrow-band (311 24. Fischer T. UV-light treatment of psoriasis. Acta Derm Venereol nm TL01) UVB irradiation: a review. J Photochem Photobiol 25. Coven TR, Burack LH, Gilleavdeau R, Keogh M, Ozawa M, An appraisal of narrow band (TL-01) UVB phototherapy. British Krueger JG. Narrow-band UV-B produces superior clinical and Photodermatology Group Workshop Report (April 1996). Br J histopathological resolution of moderate to severe psoriasis in patients compared with broad band UV-B. Arch Dermatol 10. Norris DA, Horikawa T, Morelli JG. Melanocyte destruction and repopulation in vitiligo. Pigment Cell Res 1994;7:193-203.
26. Van Weelden H, Baart de la Faille, Yoong E, Van der Leun JC.
11. Cui J, Shen LY, Wang GC. Role of hair follicles in the Comparison of narrow band UV-B phototherapy and PUVA repigmentation of vitiligo. J Invest Dermatol 1991;97:410-6.
photochemotherapy (PUVA) in the treatment of psoriasis. Acta 12. Fitzpatrick TB. Mechanisms of phototherapy in vitiligo. Arch 27. Kanwar AJ, Dhar S. Severity of atopic dermatitis in India. Br J 13. Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs. psoralen plus UV-A. Arch Dermatol 28. Hjerppe M, Hasan T, Saksala I, Reunala T. Narrow-band UVB treatment in atopic dermatitis. Acta Derm Venereol 14. Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo in children with narrow-band (TL-01) UVB radiation 29. Grundmann-Kollmann M, Behrens S, Podda M, Peter RU, therapy. J Am Acad Dermatol 2000;42:245-53.
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useful and well-tolerated treatment for vitiligo. J Am Acad 30. George SA, Bilsland DJ, Johnson BE, Ferguson J. Narrow-band (TL-01) UVB air conditioned phototherapy for chronic severe 16. Tjioe M, Gerritsen MJ, Juhlin L, van de Kerkhof PC. Treatment adult atopic dermatitis. Br J Dermatol 1993;128:49-56.
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an effective preventative treatment for the photodermatoses.
17. Dogra S, Parsad D. Combination of narrow band UV-B and 32. Dogra S, Parsad D, Handa S. Narrowband ultraviolet B in topical calcipotriene in vitiligo. Arch Dermatol 2003;139:393.
airborne contact dermatitis: a ray of hope! Br J Dermatol 18. Kanwar AJ, Dogra S, Parsad D, Kumar B. Narrow band UVB for treatment of vitiligo; an emerging effective and well-tolerated 33. Molin L. Topical calcipotriol combined with phototherapy for psoriasis: the results of two randomized trials and a review of 19. Njoo MD, Spuls PI, Bos JD, Westerhof W, Bossuyt PM.
the literature. Calcipotriol-UVB Study Group. Dermatology Nonsurgical repigmentation therapies in vitiligo: meta-analysis of the literature. Arch Dermatol 1998;134:1532-40.
34. Lebwohl M, Ali S. Treatment of psoriasis. Part 1. Topical therapy 20. Trembath RC, Clough RL, Rosbotham JL, Jones AB, Camp RD, and phototherapy. J Am Acad Dermatol 2001;45:487-98.
Frodsham A, et al. Identification of a major susceptibility locus 35. Mofty ME, Zaher H, Esmat S, Youssef R, Shahin Z, Bassioni D, on chromosome 6p and evidence for further disease loci et al. PUVA and PUVB in vitiligo - are they equally effective? revealed by a two stage genome-wide search in psoriasis. Hum Photodermatol Photoimmunol Photomed 2001;17:159-63.
36. Koo J, Lebwohl M. Duration of remission of psoriasis therapies.
21. Bos JD, Hulsebosch HJ, Krieg SR, Bakker PM, Cormane RH.
Immunocompetent cells in psoriasis: in situ 37. Njoo MD, Westerhof W, Bos JD, Bossuyt MM. The development immunophenotyping by monoclonal antibodies. Arch of guidelines for the treatment of vitiligo. Arch Dermatol 22. Morganroth GS, Chan LS, Weinstein GD, Voorhees JJ, Cooper 38. Slaper H, Schothorst AA. Van der Leun JC. Risk evaluation of KD. Proliferating cells in psoriatic dermis are comprised UVB therapy for psoriasis: comparison of calculated risk for primarily of T cells, endothelial cells, and factor XIIIa UVB therapy and observed risk in PUVA-treated patients.
perivascular dendritic cells. J Invest Dermatol 1991;333-40.
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