Plexin B2 tissue expression and related gene polymorphisms in psoriasis and their relation to NB-UVB and Acitretin therapy

Psoriasis is a chronic, immune-mediated, hyperproliferative skin disease. Etiopathogenesis of psoriasis is not well understood. Plexin B2 was found to have effects on CD100-mediated T-cell morphology and expressed in the immune system. It may play a role in the pathogenesis of psoriasis. To assess the tissue level of plexin-B2 and plexin B2 related gene polymorphism which is signal regulatory protein gamma (SIRPγ-rs71212732) in psoriatic patients before and after NB-UVB, acitretin therapy alone or in combination and to detect correlation between level of tissue plexin B2 and disease severity and improvement. This single blinded randomized controlled trial was carried on 50 psoriatic patients and 50 healthy controls. Psoriasis Area and Severity Index score (PASI) was used to evaluate the disease severity. Tissue plexin-b2 level was measured using ELISA and SIRPγ-rs71212732 (T\C) was assessed using TaqMan™ assays and real-time PCR. A significant lower tissue plexin-B2 level was observed in control group (2.9 ± 0.6 pg/g) than cases (25.8 ± 2.8, pg/g) (p < 0.001). Also, a significantly higher tissue plexin-B2 level was observed in sever psoriasis (32.7 ± 3.8 pg/ml) in than moderate psoriasis (13.6 ± 2.1 pg/ml, p = 0.001). Tissue plexin B2 was positively correlated with diseases severity. Significantly higher (TC& TT) genotypes and mutant (C) allele among patients compared to the controls, p < 0.001 for all. Tissue plexin-b2 level was high in psoriasis vulgaris with positive correlation with disease severity and decreased after treatment. This may indicate a role of plexin-b2 in psoriasis vulgaris pathogenesis.

Frequency of skin cancer among psoriasis, vitiligo, and mycosis fungoides patients treated with narrowband ultraviolet B phototherapy

BACKGROUND

Narrowband ultraviolet B (NB-UVB) phototherapy is a popular and relatively contemporary treatment option. However, only a few studies to date have explored the potential risk of skin cancer following NB-UVB treatment.

OBJECTIVE

This study aimed to investigate the potential long-term risk of skin cancer in patients treated with NB-UVB.

METHODS

This cohort study included patients with psoriasis, vitiligo, and mycosis fungoides treated with NB-UVB at two university hospitals in Israel in 2000-2005. Patients were followed up for skin cancer for at least 10 years. Data were extracted from the hospital and community medical records.

RESULTS

A total of 767 patients were included in this study: 509 with psoriasis, 122 with vitiligo, and 136 with mycosis fungoides. The mean follow-up duration was 13 years. Among these patients, 4.43% developed skin cancer during the follow-up (3.93% had psoriasis, 2.46% had vitiligo, and 8.09% had mycosis fungoides). Old age and fair skin type were the only significant independent risk factors for skin cancer. There was no significant difference in the mean number of NB-UVB treatments among patients who developed skin cancer and those who did not (99.09 vs. 94.79, respectively).

CONCLUSION

No association was observed between the number of NB-UVB treatments and carcinogenesis in any study group. Age is a significant risk factor, and older patients treated with NB-UVB should be followed up carefully.

The Ultraviolet Irradiation of Keratinocytes Induces Ectopic Expression of LINE-1 Retrotransposon Machinery and Leads to Cellular Senescence

Retrotransposons have played an important role in evolution through their transposable activity. The largest and the only currently active human group of mobile DNAs are the LINE-1 retrotransposons. The ectopic expression of LINE-1 has been correlated with genomic instability. Narrow-band ultraviolet B (NB-UVB) and broad-band ultraviolet B (BB-UVB) phototherapy is commonly used for the treatment of dermatological diseases. UVB exposure is carcinogenic and can lead, in keratinocytes, to genomic instability. We hypothesize that LINE-1 reactivation occurs at a high rate in response to UVB exposure on the skin, which significantly contributes to genomic instability and DNA damage leading to cellular senescence and photoaging. Immortalized N/TERT1 and HaCaT human keratinocyte cell lines were irradiated in vitro with either NB-UVB or BB-UVB. Using immunofluorescence and Western blotting, we confirmed UVB-induced protein expression of LINE-1. Using RT-qPCR, we measured the mRNA expression of LINE-1 and senescence markers that were upregulated after several NB-UVB exposures. Selected miRNAs that are known to bind LINE-1 mRNA were measured using RT-qPCR, and the expression of miR-16 was downregulated with UVB exposure. Our findings demonstrate that UVB irradiation induces LINE-1 reactivation and DNA damage in normal keratinocytes along with the associated upregulation of cellular senescence markers and change in miR-16 expression.

Efficacy of using oral methotrexate with phototherapy in the treatment of vitiligo in comparison with single phototherapy treatment: A double-blinded randomized controlled trial

BACKGROUND

Vitiligo is an acquired skin disease with a worldwide prevalence of 0.5%-2% and a tendency to involve both genders. Although the exact pathologic mechanism is unknown, there is some evidence for the role of autoimmunity in this disease. Based on this theory, various immunosuppressive agents, such as topical or systemic corticosteroids and phototherapy (including narrowband ultraviolet B), are used. Methotrexate is another immunosuppressant that has recently become popular as a single treatment for vitiligo; however, the synergistic effect and its superiority over other treatments are two crucial factors that are still obscure. This study aimed to compare the efficacy of methotrexate+ NB-UVB versus placebo+ NB-UVB in vitiligo patients.

METHODS

In this double-blinded, randomized controlled trial, 42 patients were randomly allocated into two groups: the first group received three times weekly NB-UVB plus placebo, and the second group was treated with three times weekly NB-UVB in combination with a weekly dose of 12.5 mg MTX. The total duration of treatment was 6 months, patients were followed up every 2 months, and the assessment tools were VASI (repigmentation indicator) and VIDA (disease activity indicator) scores.

RESULTS

Both treatment groups showed improvement in VASI and VIDA scores during 6-month follow-up, but no statistical significance was found between the two treatment methods.

CONCLUSION

This study demonstrated that both treatment modalities were equally effective, and further studies are required to evaluate the efficacy of MTX with other medications with longer follow-up and a larger sample size.

Efficacy of prostaglandin E2 versus prostaglandin F2 alpha assisted with narrowband-UVB in stable vitiligo

In the recent decades, prostaglandins were recommended as a new therapeutic modality of stable vitiligo with promising efficacy. Therefore, we designed the current work to compare the significance of two different subtypes of prostaglandins [prostaglandin E2 (PGE2) versus prostaglandin F2 alpha (PGF2α)], assisted with NB-UVB phototherapy, in treatment of stable vitiligo. This study was conducted on 30 patients with stable non-segmental vitiligo. Three approximately similar vitiliginous areas were chosen in each patient and assigned into 3 groups. Each group treated with intradermal injection of either PGE2 (group I), PGF2α (group II), or saline as placebo (group III) at frequency once/week for 12 weeks. Concomitantly, all groups received NB-UVB phototherapy twice weekly for 3 months. The outcomes of this study discovered that the therapeutic efficacy of intradermal injection of either PGE2 or PGF2α assisted with NB-UVB phototherapy was comparable with non-significant difference between them in spite of being significantly higher than NB-UVB alone. However, there were a significantly earlier onset of repigmentation and higher degree of satisfaction regarding areas treated with PGE2 than those treated with PGF2α. In conclusion, both PGF2α and PGE2 intradermal injection could be considered as quite simple and affordable techniques in the treatment of stable vitiligo with no reported side effects and good patient satisfaction.

Phototherapy and DNA Damage: A Systematic Review

Phototherapy has gained popularity in the recent decades for the treatment of various immune-mediated dermatological conditions since it is more-cost effective and less toxic compared to systemic therapies. This systematic review aims to inform dermatology providers of the risks and benefits of phototherapy, especially in patients at risk for malignancies. Ionizing energy from phototherapy results in DNA photolesions, namely of cyclobutane pyrimidine dimers (CPDs) and 6-4 photoproducts (6-4PPs). Without adequate repair, these mutations increase the risk for carcinogenesis. Additionally, phototherapy can also indirectly cause DNA damage through the formation of reactive oxygen species (ROS), which damage of several structural and functional proteins and DNA. When choosing a phototherapy modality, it also important to take into consideration the side effect profiles associated with each modality. For instance, a 10-fold higher dose of NB-UVB is required to produce a similar amount of CPDs compared with BB-UVB. Patients who undergo UVA with psoralen (PUVA) can be susceptible to developing skin malignancies up to 25 years after receiving their last treatment. It would behoove providers to consider optimal radiation dosage given each patients' level of skin pigmentation and potential for photoadaptation. Additionally, there are measures have been proposed to minimize deleterious skin changes, such as a 42-degree Celsius heat treatment using a 308nm excimer laser prior to UVB phototherapy and low frequency, low intensity electromagnetic fields along with UVB. However, as performing routine skin exams, remain paramount in the prevention of phototherapy-induced neoplasia.

A predictive model of the requisite minimal erythema dose between 308-nm monochromatic excimer light and 311-nm narrowband Ultraviolet-B light

BACKGROUND

There are limited data in the relationship between the minimal erythema dose (MED) of 308-nm monochromatic excimer light (MEL) and 311-nm Narrowband UVB (NB-UVB).

OBJECTIVE

To establish a predictive model of the relationship between MEDs of both wavelengths.

METHODS

An MED test was performed on the back of 40 healthy Thai volunteers. One side was irradiated with 308-nm MEL, and the opposite side was irradiated with 311-nm NB-UVB. The correlation and a predictive model of the relationships were then analyzed.

RESULTS

There was a positive correlation in the MED of both wavelengths (r = 0.82, p < 0.001). A predicted MED of 308-nm MEL was based on Y = 62.421 + 0.439X, where Y and X were a predicted MED of 308-nm MEL and an actual 311-nm NB-UVB, respectively. This model could predict an MED of 308-nm MEL by using an actual MED of 311-nm NB-UVB with a root mean square difference of 13.64%, and a mean bias difference of 0.63%.

LIMITATION

All volunteers were Fitzpatrick's skin phototype type IV. The predictive model might not generalize to other skin phototypes.

CONCLUSION

We established a predictive model of the relationship between MED of 308-nm MEL and 311-nm NB-UVB with acceptable accuracy.

Role of streptococcal infection in the etiopathogenesis of pityriasis lichenoides chronica and the therapeutic efficacy of azithromycin: a randomized controlled trial

The exact aetiology of pityriasis lichenoides chronica (PLC) remains unknown. While phototherapy is the most investigated therapeutic modality, azithromycin has been used scarcely. The aim of this study is to evaluate the therapeutic efficacy of azithromycin in the treatment of PLC compared to NB-UVB and evaluating the presence of streptococcal infection as a possible etiological factor in PLC patients. The study was designed as a randomised controlled trial. Twenty-four patients with PLC were randomly allocated into either azithromycin (n = 13, standard dose every 10 days) or NB-UVB (n = 11, thrice weekly) groups. End of study (EOS) was either complete clearance of lesions or a maximum of 8 weeks. Therapeutic efficacy was defined as percent reduction in lesions and was calculated for the rash as a whole, erythematous papules alone, and hypopigmented lesions alone and graded into complete, very-good, good, poor or no response. Anti-streptolysin O titre (ASOT), anti-deoxyribonuclease B titre (anti-DNaseB) and throat culture were evaluated at day 0. No significant difference existed between both groups as regards therapeutic efficacy. At EOS, NB-UVB achieved significantly more percent reduction in the extent of hypopigmented lesions and consequently in the rash as a whole (p = 0.001, p = 0.034, respectively). The extent of the rash as a whole was significantly less in the NB-UVB at EOS (p = 0.029, respectively). The effect of NB-UVB on hypopigmented lesions appeared early at week 4 of treatment. Only two patients, one from each group, relapsed during the 3 month follow-up. Evidence of recent streptococcal infection was present in 79% of the cases, mainly in the form of elevated ASOT (94.7%). It was significantly more encountered in young children (< 13 years) (p = 0.03) and was associated with more extent of erythematous papules and consequently with more extent of the rash as a whole (p = 0.05 and p = 0.01, respectively). It did not affect outcome of therapy at EOS. Azithromycin did not show more favorable response in patients with recent streptococcal infection. Therapeutic efficacy of azithromycin is comparable to NB-UVB in treatment of PLC; however, NB-UVB is superior in management of hypopigmented lesions. It is highly suggested that PLC could be a post streptococcal immune mediated disorder.Registration number: ClinicalTrials.gov, NCT03831269.

Vitamin D Receptor Expression in Chronic Plaque Psoriasis Before and After Narrowband Ultraviolet B Phototherapy

Background/Purpose

Psoriasis is a multifactorial disease. It is a combination of genetic, immunological, and environmental factors. Vitamin D receptor (VDR) is a nuclear receptor that regulates epidermal cell growth through the inhibition of proliferation and induction of keratinocytes terminal differentiation. Aim of the study was to investigate the effect of Narrow-band UVB (NB-UVB) therapy on VDR expression in the skin of psoriasis patients.

Materials and Methods

Forty patients with different severities of psoriasis were assessed using the psoriasis area and severity index (PASI) score. Lesional and non-lesional skin biopsies were obtained from each patient before NB-UVB therapy, and then a third lesional biopsy was performed after completing 24 sessions of NB-UVB. Immunohistochemistry for VDR was performed on all specimens.

Results

There was a significant decrease in VDR expression in psoriatic lesions compared to that in non-lesional skin before treatment. A statistically negative correlation was detected between the degree of VDR expression before treatment and PASI score, family history, and duration of psoriasis. There was a significant increase in VDR expression at the sites of psoriasis lesions post-NB-UVB therapy compared to pretreatment lesional skin.

Conclusion

VDR expression was down-regulated in psoriatic lesions compared to non-lesional skin, and NB-UVB therapy improved VDR expression in psoriasis skin lesions.

Comparison of NB-UVB combination therapy regimens for vitiligo: A systematic review and network meta-analysis

BACKGROUND

Vitiligo was an autoimmune disease and some guidelines for the management of vitiligo encouraged the use of NB-UVB combination therapies to enhance repigmentation.

OBJECTIVES

To compare the effectiveness of current NB-UVB combination regimen at the improvement in repigmentation through a systematic review and network meta-analysis.

METHODS

We searched the electronic databases for randomized controlled trials related to NB-UVB combination therapy for vitiligo till October 2022. STATA15.0 software was applied to carrying out data analysis.

RESULTS

A total of 28 eligible studies involving 1194 participants were enrolled in the analysis. The NMA results revealed that compared with NB-UVB, carboxytherapy [OR = 32.35, 95% CI (1.79, 586.05)], Er: YAG laser+ topical 5% 5-FU [OR = 10.74, 95% CI (4.05, 28.49)], needling/micro-needling [OR = 3.42, 95% CI (1.18, 9.88)], betamethasone intramuscular injection [OR = 3.08, 95% CI (1.17, 8.13)], topical tacrolimus [OR = 2.54, 95% CI (1.30, 4.94)], and oral Chinese herbal medicine compound [OR = 2.51, 95% CI (1.40, 4.50)] integrated with NB-UVB were more efficacious in excellent to complete repigmentation response rate (≥75%). Besides, NB-UVB+ Er: YAG laser+ topical 5% 5-FU [OR = 0.17, 95% CI (0.04, 0.67)] and NB-UVB+ needling/micro-needling [OR = 0.24, 95% CI (0.06, 0.88)] were less likely evaluated as ineffective repigmentation response (≤25%).

CONCLUSIONS

All combination therapies ranked higher than NB-UVB monotherapy in inducing successful repigmentation and avoiding failed treatment in patients with vitiligo. Comprehensive consideration, NB-UVB+ Er: YAG laser+ topical 5% 5-FU and NB-UVB+ needling/microneedling would be the preferred therapeutic approaches.

The use of Janus kinase inhibitors and narrowband ultraviolet B combination therapy in non-segmental vitiligo

Vitiligo is a depigmentation disorder of the skin that occurs secondary to the destruction of melanocytes by an immune-mediated process. Vitiligo clinically presents with depigmented macules and patches, most commonly on the face, acral sites, and genitalia. It can be characterized as generalized or localized based on distribution. The localized form can be further divided into segmental (linear, band-like, or Blaschkoid) and non-segmental vitiligo. The classical treatment of vitiligo includes topical steroids, pulsed oral steroids in unstable vitiligo, phototherapy, a combination of steroid therapy and phototherapy, surgical grafting, as well as intentional depigmentation therapy in severe cases. However, recent advances in understanding the immune mechanisms implicated in the pathogenesis of vitiligo have led to the use of an FDA-approved topical Janus kinase (JAK) inhibitors for vitiligo. Despite this novel therapy advancement, we recommend the addition of narrowband ultraviolet B (NB-UVB) to JAK inhibitors in patients with extensive and progressive lesions, or those not fully responsive to JAK inhibitor monotherapy.

Influence of narrow-band ultraviolet B therapy on sirtuin 1 expression in lesional skin of patients with chronic plaque psoriasis: Relation to clinical improvement and interferon-γ expression

BACKGROUND

Reduced sirtuin 1 (Sirt1) expression in psoriasis was previously reported, and its activation was associated with disease improvement. Narrow-band ultraviolet B (NB-UVB) downregulates several pro-inflammatory cytokines such as interferon-γ (IFN-γ) and influences keratinocyte differentiation in psoriasis.

OBJECTIVES

The aim of this study was to study the in vivo influence NB-UVB treatment on Sirt1 expression in psoriatic skin in relation to disease improvement and IFN-γ expression.

METHODS

Twenty-six patients with chronic plaque psoriasis were evaluated, and psoriasis area severity index (PASI) was calculated. Skin biopsies were taken from lesional skin of the patients before and after 3 months of treatment with NB-UVB and from 26 controls, where the distribution and immunohistochemistry (IHC) scores of Sirt1 and IFN-γ were determined.

RESULTS

After 3 months of treatment, Sirt1 distribution and epidermal IHC score were significantly higher, whereas Sirt1 dermal IHC score and IFN-γ distribution, epidermal and dermal IHC scores were significantly lower than the pre-treatment values. Before and after 3 months of NB-UVB therapy, PASI showed a significant negative correlation with Sirt1 distribution and epidermal IHC score; and a significant positive correlation with interferon-γ distribution and epidermal IHC score. Moreover, Sirt1 distributions were negatively correlated with the corresponding interferon-γ distributions. Conclusions The detected upregulation of epidermal Sirt1 following NB-UVB therapy possibly represents another mechanism by which NB-UVB can act in psoriasis and also highlights the role of Sirt1 upregulation in psoriasis treatment.

Pretreatment with an Aerosol Foam Containing Calcipotriene and Betamethasone Strongly Improves the Efficacy of Narrow-Band UVB Phototherapy

BACKGROUND

Narrow-band (NB) UVB has been combined with a number of topical treatments. However, there have been no specific data regarding treatment results of a fixed combination of calcipotriene 50 μg/g plus betamethasone 0.5 mg/g aerosol foam (Cal/BD) combined with NB-UVB phototherapy so far.

OBJECTIVES

To assess the efficacy of Cal/BD foam coupled to twice-weekly NB-UVB and whether this combined regimen requires fewer UVB treatments and a lower cumulative UVB dose compared to phototherapy alone.

METHODS

This cross-sectional, prospective, parallel-group study enrolled 187 consecutive moderate-to-severe psoriatic patients who were allocated to two groups in a 1:2 ratio. The overall duration of the treatment cycle was 12 weeks. At baseline and after 2, 4, 8 and 12 weeks, we registered the modified (not considering head lesions) PASI, the number of Cal/BD applications, the NRS score for itching and the adverse effects.

RESULTS

The combined regimen was more effective in clearing psoriasis [final mPASI: 2.1 (0; 8.2) versus 4.4 (0; 19.6); p < 0.01] and reducing itching [(final NRS score for itching: 0 (0; 3) versus 1 (0; 4); p < 0.01]. Fewer exposures [12 (4; 20) versus 24 (8; 24); p < 0.01] and a lower cumulative UVB dose [6.1 (5.4; 9.3) J cm^-2 versus 13.1 (9.8; 19.7) J cm^-2; p < 0.01] were required. A higher number of patients achieved complete clearance [47 (74.6%) versus 58 (46.8%) patients (p < 0.001)]. Both treatments were well tolerated without acute adverse effects.

CONCLUSION

Cal/BD + NB-UVB is a very effective treatment that produces a rapid improvement in clinical lesions and itching and can be considered a valuable alternative to systemic treatments for psoriasis.

Narrowband Ultraviolet B Combined with Topical Simvastatin Solution in the Treatment of Vitiligo: A Case Report

Background: Phototherapy is one of the treatments for vitiligo. To be specific, the combination of narrowband ultraviolet B (NB-UVB) with topical preparations has currently become the most common therapeutic modality. Moreover, the research on new topical drug has been a hot issue in the field of vitiligo. Objective: At present, simvastatin has been considered as a potential therapeutic agent for the treatment of vitiligo. To the best of our knowledge, this is the first case report concerning the successful application of NB-UVB combined with topical simvastatin in the treatment of vitiligo. Methods: In this article, a clinical case report was presented, where the patient was not responsive to NB-UVB but was markedly responsive to the treatment of UVB combined with topical simvastatin. Results: A 34-year-old Chinese female patient with vitiligo was cured by NB-UVB combined with topical simvastatin solution. Conclusions: NB-UVB combined with topical simvastatin may be a potential treatment against vitiligo. This research was approved by the Medical Ethics Committee of Third People's Hospital of Hangzhou.

Assessment of CXCL10 Before and After Narrow Band UVB Phototherapy in Non-Segmental Vitiligo Patients

Background

Vitiligo is a common depigmenting skin disorder characterized by white macules and patches accompanied by local melanocyte loss, caused by autoimmune destruction. Vitiligo is classified into two major forms: segmental vitiligo (SV) and non-segmental vitiligo (NSV). It was also found that the IFN-ȣ/CXCL10 axis is functionally required for both progression and maintenance of the disease. Chemokine 10 (CXCL10) is a pro-inflammatory chemokine which was found to be elevated in the serum of vitiligo patients. UVB has been found to be a useful therapy that results in rapid repigmentation in NSV patients.

Objectives

To evaluate CXCL10 in vitiligo patients before and after narrow band UVB (NB-UVB) phototherapy, which if targeted could provide new insights for therapeutic intervention for vitiligo.

Patients and Methods

The study included 25 active NSV patients who were able to comply with the study protocol in the Center of Excellence, Dermatology Outpatient Clinic, National Research Center, Egypt (February 2020-2021). All recruited patients were subjected to documentation of complete history. Dermatological assessment of vitiligo lesions, including vitiligo area score index (VASI) score, CXCL10 and extent of the disease were performed. A 3 mm punch biopsy from active vitiligo lesion (site of biopsy) was taken before and after treatment by NB-UVB, and then immunohistochemical staining was performed to evaluate expression of CXCL10.

Results

After treatment by NB-UVB there was a significant decrease in VASI score, extent of the disease and CXCL10 expression.

Conclusion

The decrease in CXCL10 levels could be attributed to the effect of NB-UVB which leads to decrease in IFN-γ level, necessary to release CXCL10 through its pathway resulting in repigmentation and decrease in the extent of the disease and VASI scores.

High-Throughput RNA Sequencing Reveals the Effect of NB-UVB Phototherapy on Major Inflammatory Molecules of Lesional Psoriasis

OBJECTIVE

To identify the narrowband ultraviolet B (NB-UVB)-induced molecular mechanisms that may account for their anti-inflammatory efficacy, gene expression and transcriptome profiling, which were performed using advanced molecular techniques.

METHODS

This research was conducted on patients with moderate-to-severe plaque-type psoriasis who received NB-UVB treatment. RNA sequencing (RNA-Seq) was conducted to assay the transcriptomes and identify the differentially expressed transcripts that had been enriched during the major pathway analysis.

RESULTS

Clinical improvement of psoriasis by NB-UVB therapy is linked to the suppression of the "immunological signaling pathways" and "cell cycle regulatory, growth and proliferation pathways" which are critical to the pathogenesis of the disease. In addition, these results were further substantiated by demonstrating that NB-UVB therapy has a significant effect on keratinocyte differentiation and affects the regulation of genes and inflammatory mediators that are related to cell proliferation and apoptosis. Moreover, NB-UVB phototherapy is also involved with the downregulation of toll-like receptors signaling in lesional psoriasis.

CONCLUSION

NB-UVB is an effective treatment for psoriasis. Our study supports the conclusion that the clinical effectiveness of NB-UVB therapy is based on the suppression of a broad range of inflammatory signaling pathways, gene expression of inflammatory cytokines and increased expressions of anti-inflammatory signaling pathways in psoriatic skin. This is the first study that applied advanced molecular techniques to investigate phototherapy as a new key to unlock genetic knowledge and create novel information. Ultimately, the goal is to increase medical knowledge and improve the patient care of psoriasis.

Combination of carboxytherapy with narrowband-ultraviolet B in the treatment of recalcitrant areas of vitiligo: A randomized clinical trial

Carboxytherapy has been used in the treatment of autoimmune skin diseases such as psoriasis and morphea. Carboxytherapy has antioxidant effects, and leads to better tissue oxygenation, and release of growth factors. In this article, we decided to evaluate efficacy of combined carboxytherapy and narrowband-ultraviolet B (NB-UVB) compared to NB-UVB alone in the treatment of vitiligo. This is a prospective, split-body double-blind comparative study performed in patients with generalized stable vitiligo in acral areas and extremities referred to dermatology clinic of Afzalipour hospital in Kerman University of Medical Sciences. NB-UVB was performed three times a week in non-consecutive days for 4 months. In each patient, one lesion was randomly treated with carboxytherapy (weekly sessions for total of 16 sessions). Efficacy of treatment was evaluated by percentage of repigmentation of the lesions. Chi-square test and analysis of variance test (ANOVA) were used to compare efficacy of treatment based on demographic features of the patients and clinical features of the lesions, respectively. Twenty-eight patients with mean age of 32.35 ± 7.37 years old completed the study. At the end of the treatment, 37% of the patients in combination therapy group demonstrated more than 75% improvement compared to 0% in the monotherapy group (p = 0.001). There was no significant difference between either demographic features of the patients (age, sex, and skin phototypes) or duration of disease with efficacy of the treatment in both groups. Combination of carboxytherapy with NB-UVB leads to higher percentage of repigmentation and patients' satisfaction compared to monotherapy with NB-UVB.

Efficacy of NB-UVB in Progressive Versus Non-Progressive Non-Segmental Vitiligo: A Prospective Comparative Study

Introduction:

Narrow-band (NB) ultraviolet B (UVB) phototherapy has been shown to halt disease progression in vitiligo, but whether there is any difference in the response to NB-UVB seen in patients with progressive vitiligo versus non-progressive vitiligo has not been evaluated.

Objectives:

To evaluate the effect of NB-UVB on progressive versus non-progressive non-segmental vitiligo.

Study Design:

Prospective observational comparative study.

Duration:

April 2016-November 2017.

Methods:

Adult patients having non-segmental vitiligo involving 2-50% body surface area were divided into two subsets; patients developing >5 lesions in the last 1 month or >15 lesions in the last 3 months (progressive vitiligo, Group I) and patients with static disease for the last 6 months (non-progressive vitiligo, Group II). Both groups were treated with NB-UVB for 6 months (26 weeks) cumulatively and its efficacy in halting disease progression, re-pigmentation, side effects and psychosocial impact were evaluated.

Results:

Nineteen out of 24 patients with progressive vitiligo had arrest of disease progression. Rest five patients developed lesions at a slower pace. Group II had earlier onset of re-pigmentation, while Group I had more NB-UVB fluence (34.73 J/cm² vs 25.2 J/cm², P value = 0.034), more time for the fluence to be fixed (P value = 0.001) and more pruritus (P value = 0.001).

Conclusions:

NB-UVB has the potential to halt disease progression in some patients with progressive vitiligo; but is associated with more total NB-UVB fluence and time taken for fixing it. Progressive vitiligo patients have more pruritus as compared to patients with non-progressive vitiligo.

Implications of narrowband ultraviolet B treatment on psoriasis severity and serum levels of angiopoietin-2: A cross-sectional controlled study

BACKGROUND

Psoriasis is a chronic inflammatory hyper proliferative skin disease. Angiogenesis play an important role in Psoriasis pathogenesis, occurring even before plaque formation. Angiopoietins play an important role in angiogenesis and hence are described as angiogenic factors.

AIMS

To evaluate serum levels of angiopoeitin 2 (Ang-2) following treatment with narrowband ultraviolet B (NBUVB) in patients with moderate-severe plaque psoriasis and correlate it to psoriasis area and severity index (PASI).

PATIENTS/METHODS

This cross sectional study included 38 patients complaining of moderate to severe plaque psoriasis and 38 healthy controls. Psoriasis area and severity index (PASI) was determined and was correlated to serum levels of Ang-2 before and after treatment with NBUVB.

RESULTS

PASI scores and serum values of angiopoietin 2 demonstrated a significant difference between the baseline and at the end of the 12 weeks NBUVB treatment. A statistically significant positive correlation was established between psoriasis severity and Ang-2 serum levels before and after treatment.

CONCLUSION

The study demonstrated a potential contribution of Ang-2 in the pathogenesis of psoriasis, as well as its usefulness as a biomarker of psoriasis severity.

Intravenous immunoglobulin-induced severe vesicular eczematous eruption successfully treated with narrow band-ultraviolet B therapy

Intravenous immunoglobulins (IVIg) are increasingly being used to treat a wide spectrum of dermatological and neurological autoimmune diseases. Although the administration of IVIg does not usually result in severe adverse reactions, side effects of IVIg reportedly occur in 6-13% of patients. Most reported cases were not severe, and IVIg is considered a relatively safe drug. Some reports described a vesicular eczematous eruption caused by IVIg that was cured by applying topical steroid ointments or systemic steroids. Herein, we present, to the best of our knowledge, the first case of severe vesicular eczematous eruption all over the body induced by IVIg that was unresponsive to topical steroid ointment and was subsequently treated with narrow band-ultraviolet B (NB-UVB) therapy successfully. NB-UVB was started at a dose of 400 mJ/cm² once a week, and swift improvement was observed. The skin rash disappeared in the first 2 months, and the pathogenesis of IVIg-induced eczematous eruption remains unelucidated. No change in eosinophils and complement levels were observed in our case. Given the increase in the widespread use of IVIg, we have shown that NB-UVB therapy is a candidate choice for the treatment of IVIg-induced severe vesicular eczematous eruption.

Diet-Related Phototoxic Reactions in Psoriatic Patients Undergoing Phototherapy: Results from a Multicenter Prospective Study

Vegans and vegetarians often consume foods containing photosensitizers capable of triggering phytophotodermatitis. The potential effect of vegan and vegetarian diets on the response of psoriatic patients undergoing phototherapy is not well characterized. We assessed clinical outcomes of vegan, vegetarian and omnivore adult psoriatic patients undergoing band ultraviolet B phototherapy (NB-UVB). In this multicenter prospective observational study, we enrolled 119 adult, psoriatic patients, of whom 40 were omnivores, 41 were vegetarians and 38 were vegans, with phototherapy indication. After determining the minimum erythemal dose (MED), we performed NB-UVB sessions for 8 weeks. The first irradiation dosage was 70.00% of the MED, then increased by 20.00% (no erythema) or by 10.00% (presence of erythema) until a maximum single dose of 3 J/cm² was reached and constantly maintained. All the enrolled patients completed the 8 weeks of therapy. Severe erythema was present in 16 (42.11%) vegans, 7 (17.07%) vegetarians and 4 (10.00%) omnivores (p < 0.01). MED was lowest among vegans (21.18 ± 4.85 J/m²), followed by vegetarians (28.90 ± 6.66 J/m²) and omnivores (33.63 ± 4.53 J/m², p < 0.01). Patients with severe erythema were more likely to have a high furocumarin intake (OR 5.67, 95% CI 3.74-8.61, p < 0.01). Vegans consumed the highest amount of furocumarin-rich foods. A model examining erythema, adjusted for gender, age, skin type, MED, phototherapy type, number of phototherapies and furocumarin intake, confirmed that vegans had a lower number of treatments. Vegans had more frequent severe erythema from NB-UVB, even after adjustment of the phototherapy protocol for their lower MED. Assessing diet information and adapting the protocol for vegan patients may be prudent.

Downregulation of interleukin 36γ and its cleaver cathepsin G following treatment with narrow-band ultraviolet B phototherapy in psoriasis vulgaris

BACKGROUND

Growing evidence suggests the important role of IL-36 in the pathogenesis of psoriasis. Cathepsin G is a neutrophil-derived protease that can activate IL-36γ.

OBJECTIVE

To assess the expression of IL-36γ and cathepsin G in psoriasis and to quantify the impact of treatment with narrow-band ultraviolet B phototherapy (NB-UVB) on their levels.

METHODS

This case-control study involved 26 patients with moderate-severe psoriasis and 25 healthy volunteers. Psoriasis patients eligible for phototherapy received 24 NB-UVB sessions. Punch skin biopsies were obtained from all participants at recruitment and after phototherapy from patients. Real-time PCR was utilized for quantitative assessment of IL-36γ and cathepsin G expression in tissue samples.

RESULTS

The expression of IL-36γ and cathepsin G was significantly higher in psoriasis before NB-UVB therapy compared to controls (p < .001). Both proteins decreased significantly with clinical improvement following NB-UVB therapy compared to baseline (p < .001). However, their expression after treatment was still higher than controls (p < .001).

CONCLUSION

IL-36γ and cathepsin G expression is upregulated in psoriatic lesions, supporting their role as mediators of inflammation in psoriasis. Downregulation of IL-36γ and cathepsin G is a possible mechanism for psoriasis improvement after NB-UVB therapy. IL-36 and cathepsin G can be considered as therapeutic targets for psoriasis.

Altered circulating memory T cells in vitiligo cases followed NB-UVB therapy

Background

Vitiligo represents a commonly diagnosed autoimmune disease caused by the depletion of epidermal melanocytes. Many subsets of T cells contribute to vitiligo pathogenesis, including resident and circulating memory T cells.

Objectives

To analyze the amounts of CD4⁺ and CD8⁺memory T‐cell subsets in peripheral blood specimens from vitiligo patients and alterations caused by narrowband ultraviolet B (NB‐UVB) phototherapy.

Methods

Circulating CD4⁺ and CD8⁺ central memory T (T_CM) and effector memory T (T_EM) cell frequencies in 33 patients with non‐segmental vitiligo and 16 healthy donors were evaluated by flow cytometry. Related chemokine levels were also detected.

Results

Peripheral blood CD4⁺ T_CM and CD8⁺ T_CM counts were markedly reduced in vitiligo cases while they were higher in active vitiligo compared with stable vitiligo cases. Circulating CD8⁺ T_CM frequency in vitiligo was closely related to disease duration. Interestingly, CD4⁺ T_CM and CD8⁺ T_CM frequencies, alongside CXCL9 and CXCL10 amounts in peripheral blood of patients with vitiligo, were significantly decreased after NB‐UVB phototherapy.

Conclusions

Decreased frequencies of circulating CD4⁺ T_CM and CD8⁺ T_CM by NB‐UVB suggest a possible immunosuppressive effect of phototherapy. The chemokines CXCL9 and CXCL10 are the bridge between circulating and skin resident memory T cells. NB‐UVB blocks the homing of circulating memory T cells into vitiligo lesions by down‐regulating CXCL9 and CXCL10. Targeting the above proteins could provide novel, durable treatment options to cure and prevent flares of this disease.

Role of resolvin D1 in psoriasis before and after narrowband ultraviolet B phototherapy: A case-control study

Resolvin D1 (RvD1) is an endogenous lipid mediator that originated from docosahexaenoic acid that stimulates a bimodal mechanism in the anti-inflammatory activity in addition to regulation of the inflammatory reaction. The study aimed at assessing the tissue level of RvD1 in psoriasis to study its role in the etiopathogenesis of psoriasis, studying the action of NB-UVB on the level of resolvin D1 in psoriasis, and raising the possibility of using resolvin D1 as a new therapy for psoriasis in the future. This case-control study included 20 psoriasis patients and 20 healthy controls. Patients took narrowband ultraviolet B (NB-UVB) for 36 sessions. Skin biopsies were taken before and after treatment from patients and from controls to assess the expression of RvD1 by a quantitative real-time polymerase chain reaction. Our findings revealed a statistically significant difference (P < .001) between psoriasis patients (either before or after treatment) and controls with lower levels of RvD1 in psoriasis patients. On comparing the RvD1 levels in psoriasis patients before and after treatment, a statistically significant increase was detected after treatment (P < .001). Tissue RvD1 levels in psoriasis patients were lower than healthy controls and increased after NB-UVB treatment in psoriasis patients. Thus, it is suggested that RvD1 might have a role in the etiopathogenesis of psoriasis. Moreover, the significantly up-regulated tissue levels of RvD1 in patients after treatment with NB-UVB highlighted a novel mechanism of phototherapy-mediated response in psoriasis by up-regulating RvD1 level.

Evaluation of the Langerhans cells role in vitiligo and its relationship to NB-UVB

BACKGROUND

Langerhans cells (LCs) are antigen-presenting cells that are characterized by CD1a and CD207/langerin expression. The disturbance in the communication network among keratinocytes, melanocytes, and antigen-presenting cells may be involved in vitiligo pathogenesis.

AIMS

The current work aims to detect and quantify LCs in involved skin of patients affected by vitiligo before and after treatment with NB-UVB using CD1a immunohistochemistry, in addition to correlate percentage of LCs with the clinicopathological parameters.

METHODS

Twenty vitiligo patients and 10 age and sex matched controls were investigated. Patients were received NB-UVB thrice weekly for 12 weeks.

RESULTS

There was a significant reduction in LCs percentage in skin affected by vitiligo before treatment in comparison with normal skin. About 65% (13/20) of vitiligo patients responded to NB-UVB, and the liability to respond was correlated with LCs percentage in specimens before treatment. However, there was no statistical difference between specimens before and after treatment regarding LCs percentage.

CONCLUSIONS

Reduction in LCs in vitiligo may be a sign of active disease and melanocytes destruction. The percentage of LCs affects response to NB-UVB since higher percentage is associated with greater response to therapy. Therefore, modulation of LCs as a type of immunotherapy could be beneficial in improvement of vitiligo.

A comparative study of combined microneedling and narrowband ultraviolet B phototherapy versus their combination with topical latanoprost in the treatment of vitiligo

Regardless of the continuous discovery of innovative modalities for the treatment of vitiligo, none of them ensure excellent therapeutic outcome. Microneedling had been suggested either singly or concomitantly with other therapeutic modalities for vitiligo with encouraging results. Latanoprost, a prostaglandin F2-alpha (PGF2α), and their analogues are recently recommended for vitiligo treatment. This study was designed to assess the therapeutic efficacy of microneedling in combination with NB-UVB phototherapy versus their combination with latanoprost in vitiligo. It was conducted on 50 patients presented with stable bilateral localized nonsegmental vitiligo. In every patient; two bilateral, nearly symmetrical lesions were selected and treated by microneedling (12 sessions at 2-week interval) followed by topical application of latanoprost 0.005% solution on one side, and topical saline (as placebo) on the other side. In addition, all patients received concomitant NB-UVB phototherapy (three sessions/week) for 6 months. Significant clinical improvement of vitiligo lesions with significant increase in the degree of repigmentation were reported in response to both treatment regimens. Latanoprost in combination with microneedling and NB-UVB provides more significant therapeutic outcomes than combined microneedling and NB-UVB. In conclusion, topical latanoprost 0.005% enhances the therapeutic efficacy of combined microneedling and NB-UVB phototherapy in localized stable nonsegmental vitiligo.

NB-UVB plus oral Polypodium leucotomos extract display higher efficacy than NB-UVB alone in patients with vitiligo

Polypodium leucotomos displayed a synergic effect with NB-UVB in psoriasis, but its application on vitiligo remains understudied. The aim of this study was to investigate whether oral supplementation with leaves extract of Polypodium leucotomos (PL) improves narrow band (NB) UVB phototherapy-induced repigmentation. Forty-four patients with generalized vitiligo were enrolled in this randomized, prospective, placebo controlled study. Twenty-three patients were randomly selected to receive combined treatment with NB-UVB phototherapy and 480 mg oral PL twice daily while 21 patients received NB-UVB phototherapy combined with placebo. All subjects were treated with NB-UVB twice weekly for 6 months. Our results demonstrated that oral PL combined with NB-UVB improved repigmentation as well as increased the response rate compared with patients treated with NB-UVB alone (47.8% vs 22%). Our study suggests that oral supplementation of PL and NB-UVB phototherapy enhance the extent of repigmentation.

Oxidative stress and the cholinergic system in non-segmental vitiligo: Effect of narrow band ultraviolet b

BACKGROUND

Despite exhaustive research, melanocyte disappearance and the evolution of vitiligo remain enigmatic, and although multi-factorial, oxidative stress appears as a major player. The role of cutaneous cholinergic system in vitiligo pathogenesis has also been reported in some studies.

OBJECTIVE

To evaluate and correlate the influence of phototherapy on cutaneous cholinergic system and oxidative stress in vitiligo.

METHODS

Acetyl choline (ACh), its receptors; nicotinic (nAChR) and muscarinic (mAChR); acetylcholine esterase (AChE) and H₂ O₂ levels were estimated in de-pigmented and re-pigmented lesions of 30 vitiligo patients before and after NB-UVB phototherapy and in 30 controls. ACh and H₂ O₂ levels were measured by colorimetry. AChE and acetylcholine receptors expression were measured by quantitative real-time PCR.

RESULTS

Mean ACh and H₂ O₂ levels were significantly higher in vitiligo lesions before NB-UVB (P < .001) whereas AChE enzyme level was significantly lower (P < .001) compared to both re-pigmented and control skin. Additionally, mean mAChR was significantly higher and mean nAChR was significantly lower in vitiligo lesions before NB-UVB versus controls and re-pigmented skin (P < .001). Also, H₂ O₂ and AChE showed negative correlation whereas ACh and mAChR showed significant positive correlation. Although all the studied parameters showed significant changes after treatment and subsequent re-pigmentation, a significant difference continued to exist between all vitiligo skin and controls.

CONCLUSION

Cholinergic system is strongly involved in vitiligo pathogenesis through H₂ O₂ inhibition of AChE which could be reversed by NB-UVB. Moreover, the strong activation of mAChRs may reflect genetic and/or acquired errors, direct up-regulation by ACh and H₂ O₂ or both.

Randomized clinical trial of combined therapy with oral α-lipoic acid and NB-UVB for nonsegmental stable vitiligo

Vitiligo is associated with oxidant stress and α-lipoic acid (ALA) is an antioxidative agent. To evaluate the efficacy and safety of oral ALA in combination with NB-UVB phototherapy on nonsegmental stable vitiligo. The prospective, multi-center, parallel controlled, double-blind randomized clinical trial was conducted from 2012 to 2014, in seven comprehensive tertiary hospitals in China. The patients were randomized into oral ALA group or placebo group at a dose of 300 mg daily for 6 months. All of them received NB-UVB phototherapy three times weekly. The repigmentation rate was evaluated by 4-point grading scale of improvement: >98%, 50-98%, 10-49%, <10%. A total of 133 patients were enrolled in the study, including 72 cases in treatment group and 61 cases in control group. In treatment group, 2.04% (1/49) patients achieved ≥50% improvement at 1-month after enrollment (M1), and the percentage of patients increased to 8.51% (4/47), 14.0% (6/43), and 37.8% (14/37) at M2, M3, and M6, respectively. In control group, the percentages were similar at all timepoints. No significant difference was seen between the two groups (P > .05). For elder patients, younger patients, male or female, no significant differences were found between treatment group and control group at all timepoints. ALA did not show additional benefit to NB-UVB therapy in the treatment of nonsegmental stable vitiligo. More studies should be done to identify other protocols of ALA or other types of antioxidants for stable vitiligo.

Autologous noncultured, nontrypsinized melanocyte-keratinocyte graft homogenized in plasma gel followed by narrow-band ultraviolet B therapy for stable vitiligo: A novel technique

There is a continuous need for modifications of epidermal cell grafting techniques treating stable vitiligo to make it easier, more economic, and with better outcome. To evaluate the efficacy and safety of noncultured, nontrypsinized epidermal cell graft homogenized with plasma gel, followed by narrow band-ultraviolet B (NB-UVB) in treatment of stable vitiligo, about 40 patients with stable vitiligo underwent harvesting of epidermal cells from the donor site by dermabrasion then the harvested cells were prepared, homogenized with autologous plasma gel, and applied to the abraded recipient, followed by 16 NB-UVB sessions after complete healing. Patches within the same anatomical site received only NB-UVB as controls. The percentage of improvement ranged from 23.33% to 100% with more than 75% uniform, homogenous repigmentation in 65% of patients. Donor site healed completely with normal skin. Noncultured, nontrypsinized epidermal cell grafting technique homogenized with plasma gel followed by NB-UVB sessions gave positive responses and was well tolerated in different body sites in stable resistant vitiligo.

Doxycycline Combined with NB-UVB Phototherapy for Acquired Reactive Perforating Collagenosis

Background

Acquired reactive perforating collagenosis is a rare skin disease characterized by the discharge of collagen fibers through the epidermis. There is no standard treatment for this disease currently. Here, we report a case of ARPC that has been successfully treated and cured.

Case Description

A 32-year-old man developed severe itching papules on his torso and limbs for 3 months. Skin lesions were keratotic papules scattered on the limbs and trunk, with a diameter of 3 to 12 mm. Some lesions had umbilical recesses and the shape of a crater with positive isomorphic reactions. The patient scratched his severe itching lesions which merged into large ones. This patient had histories of hypertension and dilated cardiomyopathy with mild congestive heart failure. The clinical presentation and histopathology of skin lesions met Faver’s diagnostic criteria for ARPC.

Treatment

Oral Doxycycline 100mg/d, NB-UVB phototherapy 3 times a week with initial dose 400mJ/cm², gradually increased to 1200mJ/cm²(total cumulative dose 16700J/cm²).

Outcomes

After a week of treatment, the patient’s itching symptoms were significantly reduced and stopped presenting any new skin lesions. Most of the lesions healed in 6 weeks of treatment.

Lessons

Doxycycline combined with NB-UVB may be an effective treatment for ARPC.

Comparison of responses of melanocyte lineages from p75(+) and p75(-) human scalp-derived neural crest stem cells under phototherapy

Phototherapy is an effective therapeutic option in the treatment of vitiligo; however, responses varied among the different types. The underlying mechanism has scarcely been investigated. To investigate and compare the effects of phototherapy on the mutation of melanocyte lineage differentiated from human scalp-derived neural crest stem cells (HS-NCSCs) with p75 neurotrophin receptor expression positive and p75 neurotrophin receptor expression negative group in vitro, the HS-NCSCs were isolated from fetal scalp tissue, which is identified by immunofluorescent staining. The p75(+) and p75(-) cells from HS-NCSCs were isolated by magnetic cell sorting, respectively. The embryonic neural crest stem cell biomarkers were detected by RT-PCR. Narrow-band UVB (NB-UVB) was used to irradiate the cells. Cell proliferation was evaluated by cell count. Tyrosinase, Tyrp1, and Tyrp2 gene expression were measured by quantitative RT-PCR. Tyrosinase and GRCR protein levels were investigated by Western blot analysis. The electrophoretic strip showed that Sox2, Oct4, Sox10, and Nestin of p75(+) HS-NCSCs were brighter than the p75(-) HS-NCSCs. After the same dose radiation with NB-UVB, the cell proliferation of p75(+) group showed less inhibitory rate compared with the p75(-) HS-NCSCs. The tyrosinase mRNA and protein expression of differentiated melanocytes increased significantly in the group of p75(+) HS-NCSCs compared with the p75(-) group. The melanocytic mutation of p75(+) HS-NCSCs increased significantly compared with the p75(-) HS-NCSCs under NB-UVB, which indicated there were more melanocyte precursors in the differentiated cells from p75(+) HS-NCSCs. This may provide new insights for the different repigmentation efficacy of segmental and non-segmental vitiligo.

The efficacy of fractional carbon dioxide laser combined with narrow-band ultraviolet B phototherapy for non-segmental vitiligo: a systematic review and meta-analysis

Fractional carbon dioxide (CO₂) laser has been used with conventional treatments for vitiligo, demonstrating more effectiveness compared with conventional treatments alone. Especially, fractional CO₂ laser combined with narrow-band ultraviolet B (NB-UVB) was shown to induce more improvement compared with NB-UVB monotherapy for treating stable non-segmental vitiligo. However, the effectiveness of fractional CO₂ laser plus NB-UVB for the treatment of non-segmental vitiligo remains controversial. Therefore, this study aimed to confirm the safety and efficacy of fractional CO₂ laser combined with NB-UVB compared with NB-UVB monotherapy in stable non-segmental vitiligo. We searched the data from different databases, including Cochrane, Embase, and PubMed up to January 2020. Four randomized controlled trials (RCTs) for comparison between fractional CO₂ laser plus NB-UVB and NB-UVB monotherapy in patients with stable non-segmental vitiligo were included. We performed meta-analyses for repigmentation improvement and patient satisfaction as well as subgroup analyses based on acral or non-acral vitiligo, according to the PRISMA guidelines. The combination treatment showed more superior results than NB-UVB monotherapy (≥ 75% repigmentation, RR 4.60, 95% CI 1.19-17.74; ≥ 50% repigmentation, RR 2.24, 95% CI 0.45-11.17; < 25% repigmentation, RR 0.81, 95% CI 0.60-1.08). Also, fractional CO₂ laser plus NB-UVB significantly improved acral and non-acral vitiligo compared with NB-UVB monotherapy (standard mean difference (SMD) 1.24, 95% CI 0.66-1.82; SMD 1.14, 95% CI 0.67-1.60, respectively), while it increased markedly patient satisfaction compared with NB-UVB monotherapy (SMD 1.12, 95% CI 0.66-1.58). Collectively, this meta-analysis suggested that fractional CO₂ laser combined with NB-UVB might be more effective for treating non-segmental vitiligo than NB-UVB monotherapy.

Efficacy of oral methotrexate (MTX) monotherapy vs oral MTX plus narrowband ultraviolet light B phototherapy in palmoplantar psoriasis

Palmoplantar psoriasis (PPP) is a chronic, inflammatory dermatosis of the palms and/or soles with significant morbidity. It is notoriously difficult to treat and unresponsive to traditional topical agents. We aim to compare the effect of oral methotrexate (MTX) monotherapy vs MTX plus narrowband ultraviolet light B (NB-UVB) in the treatment of recalcitrant PPP. This was a comparative clinical trial involving 90 patients of PPP. Eligible patients were randomly assigned to one of the two treatment groups. We aim patients in group A received 10 mg oral MTX weekly, and patients in group B received oral MTX 10 mg weekly and NB-UVB sessions twice weekly for 12 weeks. There was a statistically significant difference in reduction of modified PPP Area Severity Index (m-PPPASI) of patients in MTX plus NB-UVB at week 12. The mean m-PPPASI at week 12 was 3.66 ± 2.11 in MTX plus NB-UVB group and 6.51 ± 2.04 in MTX only group (P < .001). Marked improvement (m-PPPASI 75) was achieved in 20 (44.44%) patients in MTX plus NB-UVB group compared with 6 (13.3%) in MTX monotherapy group (P < .001). Combination of MTX and NB-UVB phototherapy helps to attain a better clinical response (reduction in m-PPPASI score) than MTX monotherapy in the treatment of recalcitrant PPP.

Balneotherapy with Chinese herbal medicine prolongs the remission period in patients with psoriasis vulgaris

This study aimed to evaluate whether the supplementary balneotherapy with Chinese herbal medicine (CHM) could facilitate the treatment of psoriasis vulgaris and thus be beneficial for long-term remission from the symptoms. Two hundred psoriasis vulgaris patients with moderate-to-severe plaque psoriasis from January 2013 to June 2014 were evenly divided into two groups: the consolidated therapy group (CTG) and unconsolidated therapy group (UTG); the remission period of the two groups was compared. There was no significant difference in Psoriasis Area Severity Index (PASI) score between the two groups at the beginning and the end of the treatment. However, the average remission time in CTG was 10.99 months, which was significantly longer than that of 7.94 months in UTG (P = .001). After a correction of age, course of disease, skin type as well as PASI baseline value using a COX model, we found that the risk of recurrence of psoriasis vulgaris in UTG was higher than that in the CTG (P < .001). No adverse reactions were discovered when combing the two treatments together. The combined treatment of CHM balneotherapy and narrowband ultraviolet B could significantly prolong the remission time in patients with psoriasis vulgaris.

Value of silicone gel in prevention of cobblestoning following punch minigrafting in vitiligo

Background: Cobblestoning is the most common complication of minipunch grafting.Objective: To assess the value of silicone gel application following minipunch grafting and the histopathological and immunohistochemical changes in cases with cobblestoning.Methods: Minipunch grafting was performed in two similar vitiligo lesions in 27 cases with stable vitiligo. After healing, silicone gel was applied twice daily on one lesion while zinc oxide ointment was applied to the other lesion serving as a control. Four biopsies were taken from each case; normal, vitiliginous skin before treatment and the two treated lesions 3 months after therapy, for histopathology and immunohistochemical staining for MMP9 & tenascin-C.Results: Repigmentation occurred in 19 cases (70.7%). The number of lesions showing excellent and good response was significantly higher on the silicone gel side (p < .001). In 20 cases, cobblestoning either occurred or was absent on both sides. Histopathologically, cobblestoning was similar to hypertrophic scarring. Both markers were elevated after therapy on both sides with no significant difference in percentage change between lesions showing positive and negative cobblestoning.Conclusion: Silicone gel application after minigrating improved the final response with no significant effect on the occurrence of cobblestoning. Cobblestoning resembled hypertrophic scarring histopathologically.

Our Choice: study protocol for a randomized controlled trial for optimal implementation of psoriasis treatment by the integration of Chinese and western medicine

BACKGROUND

Plaque psoriasis is a refractory inflammatory skin disease. The common therapies used to treat plaque psoriasis in traditional Chinese medicine (TCM) and western medicine (WM) have distinct characteristics and advantages. Although a combination of TCM and WM therapies, adjusted to the clinical situation, is widely used, there are no systematic studies on the hierarchical selection of this treatment combination based on the severity of skin lesions. We therefore designed a randomized clinical trial to focus on the sequence of internal and external treatments of TCM in patients with mild-to-moderate plaque psoriasis and to optimize the integration of Chinese and western medicine for the treatment of patients with severe plaque psoriasis, thereby achieving high-level clinical evidence and establish treatment norms for the integrated use of Chinese and western medicines.

METHODS

In this proposed multicenter, single-blinded, randomized controlled trial, 108 patients with mild-to-moderate plaque psoriasis will be randomly assigned to two groups in a 1:1 ratio to receive either internal or external TCM treatment, and 270 patients with severe plaque psoriasis will be randomly assigned to three groups in a 1:1:1 ratio to receive treatment with TCM or WM, or TCM + WM. All enrolled patients will receive 8 weeks of treatment. Follow-up assessments will be done 8 weeks after the treatment. The primary outcome of this study is the evaluation of efficacy and relapse rate, based on the Psoriasis Area and Severity Index, and the secondary outcome measures include determination of the affected body surface area, physician's global assessment, pruritus scores (determined using a visual analog scale), TCM symptom score, Dermatology Life Quality Index, patient-reported quality of life score and incidence of serious adverse events.

DISCUSSION

This study will provide high-level clinical evidence for internal and external TCM treatment optimization and will contribute to establishing norms for the integration of Chinese and western Medicines.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03941431. Registered on 8 May 2019.

Successful treatment of verruca plana with NB-UVB: A case report

Verruca plana is a kind of benign proliferative skin disease that generally occurs in exposed parts, but the treatment of warts poses a therapeutic challenge for physicians, as there is no method, among numerous approaches, that has been proven effective for completely curing this disease. We report a case of verruca plana cured by narrow-band ultraviolet B (NB-UVB), which provides a new treatment of verruca plana.

Study the effect of erbium:YAG laser plus topical 5-flurouracil in stable vitiligo resistant to NB-UVB phototherapy

BACKGROUND

NB-UVB phototherapy is still an effective treatment in vitiligo but requires more than 1 year for its completion. Topical 5-flurouracil could improve the proliferation and migration of melanocytes. Laser-assisted dermabrasion results in stimulation of the inactive melanocytes present at the outer root sheath of the lower portion of the hair follicle, which migrates upward until they reach the surface of the skin.

OBJECTIVE

To evaluate the effect of Er:YAG laser skin ablation followed by topical 5-flurouracil on the outcome of NB-UVB phototherapy as a short term technique in resistant and stable vitiligo.

METHODS

The current study included 40 patients suffering from bilateral stable vitiligo resistant to NB-UVB. For each patient, one side of the body subjected to 4 months NB-UVB sessions (control side). While the other side of the body subjected to one session of Er:YAG laser ablation combined with topical 5% 5-flurouracil application under occlusion followed by NB-UVB sessions for 4 months after complete re-epithelization. Outcomes were evaluated objectively based on standard digital photographs, histopathological examination, patient satisfaction, and adverse effects.

RESULTS

There was a statistically significant improvement in the repigmentation in laser side compared with control side. Histopathological examination revealed expression of prominent melanin pigmentation, with marked expression for Melan-A in laser side, whereas these findings were negative in control side.

CONCLUSION

Er:YAG laser ablation, followed by 5FU application before NB-UVB phototherapy for vitiligo, is a safe and tolerable technique that improves the outcome of short-term NB-UVB therapy and is expected to increase patient compliance.

Phototherapy achieves significant cost savings by the delay of drug-based treatment in psoriasis

BACKGROUND

Although used for decades in psoriasis, access to phototherapy is becoming increasingly restricted. Besides patient inconvenience, this is in large part to do with a perception of "high cost." We previously reported a comprehensive analysis of direct and indirect phototherapy treatment cost. However, no robust data exist on the actual savings associated with providing phototherapy in the treatment pathway.

OBJECTIVES

To quantify the cost savings achieved by phototherapy by delaying alternative treatments.

METHODS

Costs accruing through the UK-wide established treatment pathway with and without phototherapy were analysed. Direct and indirectly incurred drug treatment costs were calculated using drug tariff, laboratory cost, estate rates and clinic review costs. To enhance reliability, ranges of cost scenarios were calculated by varying parameters such as drug dosing.

RESULTS

Medium annual cost savings per patient were £2200 [range: £1800-£2900] for NB-UVB, and £3700 [range: £2500-£5300] if both NB-UVB and PUVA courses were administered, respectively. As the provider treated 656 ± 76 patients per year during the 6-year observational window, this amounted to savings of £Mio 2.4 [range: £Mio 1.6-£Mio 3.4], even excluding additional non-modelled drug-associated costs (eg diagnostics, adverse event management). Since we only consider cost savings by delay of drug treatment for the duration of phototherapy, drug price reductions through biosimilar introduction only have a small effect. We provide spreadsheets allowing adaptation cost savings projections by varying input variables.

CONCLUSIONS

Healthcare providers may achieve significant cost savings by implementing and/or widening access to phototherapy.

Evaluation of using fractional CO2 laser plus NB-UVB versus NB-UVB alone in inducing marginal repigmentation of vitiligo lesions

Background: Vitiligo is a common depigmenting skin disorder, characterized by patchy loss of skin color and finding effective treatment has remained a challenging issue. Methods: A paired (half-body) randomized clinical trial study was done to compare the efficacy and the safety of narrowband ultraviolet B (NB-UVB) plus fractional CO₂ versus NB-UVB alone in stimulation of marginal repigmentation of vitiliginous patches. One side of the body was randomly treated with a fractional CO₂ laser and NB-UVB twice weekly, while the other side was exposed only to NB-UVB with the same manner. Results: Thirty patients with the nonsegmental stable vitiligo and mean age of 43 ± 15 years completed a 16-week treatment period with NB-UVB on one side of the body and fractional CO₂ laser therapy with NB-UBV on the other side. In addition to the higher rate of response in the combination side compared to the monotherapy side of the body (p < .001), repigmentation was greater in the combination side rather than the NB-UVB monotherapy side (p = .002). In the combination treated side, marginal repigmentation pattern was more frequently seen than perifollicular pattern (p < .001) and more frequently than monotherapy side (p < .001). Conclusion: The fractional CO₂ laser combined with NB-UVB seems to be a more effective therapeutic option for treatment than NB-UVB alone for inducing marginal repigmentation.

The impact of therapeutic modalities on patients with atopic dermatitis, psoriasis and vitiligo treated with phototherapy in the Jagiellonian University Outpatient Clinic

Phototherapy involves repeated exposure of the skin to ultraviolet light and is commonly used in various dermatological diseases such as: psoriasis, atopic dermatitis and vitiligo. It constitutes a highly preferable treatment modality due to acceptable benefit/risk ratio.

AIM

The aim of the study is to characterize parameters such as: number of PUVA or NB-UVB sessions, cumulative doses of phototherapy, values of minimal erythema doses (MED), periods of the year during phototherapy sessions in patients with vitiligo, atopic dermatitis and psoriasis attending the Jagiellonian University Outpatient Clinic.

MATERIALS AND METHODS

This was a retrospective study of 50 Caucasian patients who attended the Department of Dermatology of the Jagiellonian University Outpatient Clinic over a period of one and a half years (from November 2016 to May 2018).

RESULTS

We report that PUVA-therapy is more effective in achieving complete remission (CR) of skin lesions in patients with atopic dermatitis and vitiligo, compared to NB-UVB irradiations. In all patients enrolled to the study, apart from psoriatic patients treated with NB-UVB, the cumulative doses of UVA+P/NB-UVB were significantly higher during autumn/winter time than spring/summer time. Patients with vitiligo required higher cumulative doses and they needed more phototherapy sessions regardless the method of phototherapy in order to achieve CR, compared to other patients. The patients with psoriasis required, statistically significant, faster NB-UVB dose enhancement in order to maintain the efficacy of treatment than those with other diseases.

CONCLUSIONS

Phototherapy constitutes an efficient, safe and accessible (in Poland and many other countries) method of therapy but there is still much to be discovered about the factors that affect its efficacy. Finding out more data relating to this issue could enable more effective treatment planning for particular patients and it would have an important economic impact.

The Effectiveness of Narrow Band Uvb (Nb-Uvb) In the Treatment of Pityriasis Lichenoides Chronica (PLC) In Vietnam

AIM

This prospective clinical study presents the experiences with NB-UVB monotherapy in the treatment of PLC on Vietnamese patients.

METHODS

We enrolled at National Hospital of Dermatology and Venereology (NHDV), Vietnam, 29 PLC patients with generalised disease involving at least 60% of the total body surface (based on Nine's Rule) and/or failed to respond to other modalities of treatment. Patients were treated with NB-UVB followed the guideline of the psoriatic treatment of AAD-2010, three times weekly.

RESULTS

A complete response (CR) was seen in 24 out of 29 PLC patients (82.8%) with a mean cumulative dose of 9760.5 mJ/cm² after a mean treatment period of 4.6 weeks (13.8 ± 7.4 exposures). Mild side effects were observed: 69% erythema minimum, 55.2% irritation related to dry skin. No severe side effects were seen during the study. No relapses occurred in 24 CR patients within a mean period of 3 months after the last treatment.

CONCLUSION

NB-UVB therapy is an effective and safe option for the treatment and management of PLC.

The Decline of PUVA Therapy in Vietnam: Effective Treatment of Narrow Band UVB in Vietnamese Vitiligo Patients

AIM:

To examine the efficacy and safety of Narrowband ultraviolet B (NB-UVB) in Vietnamese vitiligo patients.

METHODS:

We recruited thirty-one patients (14 males, 17 females), aged from 7 to 67 years, with both segmental vitiligo (SV) and non-segmental vitiligo (NSV), treated three times weekly with NB-UVB. The starting dose for adults from 15 years old and children less than 15 years old was 200 mJ/cm² and 150 mJ/cm², respectively, with 50 mJ/cm² and 20 mJ/cm² dose increments at each subsequent visit, respectively, until mild erythema lasting less than 24 hrs reported by patient, given for a period of 6 months. Response to therapy was assessed based on VASI score changes.

RESULTS:

Based upon our results, 38.7% (12/31) of patients achieved a very good response of more than 50% VASI changes, 41.9% (13/31) obtained a good response (VASI changed from 25 to 50%). Total good and very good response to therapy significantly increased with prolonged treatment, increasing from 19.4% to 64.5% and 80.6% after 2, 4 and 6 months, respectively. Localised NSV patients obtained good and very good response significantly more frequently than generalised NSV (55.6% versus 18.2%). Adverse effects were minimal, of which one case developed herpes simplex, and 4 cases reported mild photo burn reaction which completely disappeared after adjusting the dose.

CONCLUSION:

NB-UVB therapy is an effective and safe tool in the management of Vietnamese vitiligo patients.

Acitretin combined with NB-UVB in the treatment of cutaneous CD30-positive anaplastic large cell lymphoma

Cutaneous CD30⁺ lymphoproliferative disorders represent a spectrum of skin lymphatic reticular proliferative diseases, including lymphomatoid papulosis (LYP), primary cutaneous anaplastic large cell lymphoma (PC-ALCL), and borderline lesions between them. Although they all express CD30 as a phenotypic marker and share overlapping immunophenotypic features, they differ in clinical manifestations, pathological features, treatment, and prognosis. LYP is a kind of benign disease characterized by recurrent papules and nodules, and may spontaneously regress. PC-ALCL presents with solitary tumor or local grouped nodules characterized by large T-cells and may completely or partially resolve in fewer than half of cases. We reported a case of patient with clinical manifestation and pathologic features consistent with LYP in its early stages, which later turned into PC-ALCL. This patient was treated with acitretin combined with NB-UVB and had an obvious response.

Management of resistant halo nevi

BACKGROUND

Halo nevus (HN) is a rare dermatologic disorder characterized by typical whitish rim surrounding an existing melanocytic nevus resembling halo. It is a cosmetic problem that may be linked to vitiligo, and it is advised to remove these nevi in order to avoid development of vitiligo.

OBJECTIVES

The aim of the present study is to evaluate the cosmetic outcome after nevus removal and leukoderma dermabrasion with epithelial graft followed by narrow-band ultraviolet B (NB-UVB) phototherapy as management of resistant halo nevi and avoidance of development of vitiligo.

PATIENTS AND METHODS

Ten patients with persisting halo nevi were selected as candidates in this study. Superficial dermabrasion was carried out using proper diamond fraises on depigmented rim and then punch biopsy probes with suitable size were used to harvest the nevus. Thiersch graft was prepared and applied on the dermabraded depigmented area. After 1 week of the procedure, patients were exposed to NB-UVB twice weekly and were followed up for 3 months.

RESULTS

Repigmentation was noticed in 2 weeks and was nearly fully accomplished in all 10 patients within the 3-month period. No other vitiligo lesions developed during this period in all patients except for one case.

CONCLUSION

Excision of Sutton's nevus with combined dermabrasion and Thiersch grafting followed by phototherapy is a good aesthetic maneuver in treating halo nevi and helps in avoiding further vitiligo depigmentation.

Home interventions and light therapy for the treatment of vitiligo (HI-Light Vitiligo Trial): study protocol for a randomised controlled trial

INTRODUCTION

Vitiligo is a condition resulting in white patches on the skin. People with vitiligo can suffer from low self-esteem, psychological disturbance and diminished quality of life. Vitiligo is often poorly managed, partly due to lack of high-quality evidence to inform clinical care. We describe here a large, independent, randomised controlled trial (RCT) assessing the comparative effectiveness of potent topical corticosteroid, home-based hand-held narrowband ultraviolet B-light (NB-UVB) or combination of the two, for the management of vitiligo.

METHODS AND ANALYSIS

The HI-Light Vitiligo Trial is a multicentre, three-arm, parallel group, pragmatic, placebo-controlled RCT. 516 adults and children with actively spreading, but limited, vitiligo are randomised (1:1:1) to one of three groups: mometasone furoate 0.1% ointment plus dummy NB-UVB light, vehicle ointment plus NB-UVB light or mometasone furoate 0.1% ointment plus NB-UVB light. Treatment of up to three patches of vitiligo is continued for up to 9 months with clinic visits at baseline, 3, 6 and 9 months and four post-treatment questionnaires.The HI-Light Vitiligo Trial assesses outcomes included in the vitiligo core outcome set and places emphasis on participants' views of treatment success. The primary outcome is proportion of participants achieving treatment success (patient-rated Vitiligo Noticeability Scale) for a target patch of vitiligo at 9 months with further independent blinded assessment using digital images of the target lesion before and after treatment. Secondary outcomes include time to onset of treatment response, treatment success by body region, percentage repigmentation, quality of life, time-burden of treatment, maintenance of response, safety and within-trial cost-effectiveness.

ETHICS AND DISSEMINATION

Approvals were granted by East Midlands-Derby Research Ethics Committee (14/EM/1173) and the MHRA (EudraCT 2014-003473-42). The trial was registered 8 January 2015 ISRCTN (17160087). Results will be published in full as open access in the NIHR Journal library and elsewhere.

TRIAL REGISTRATION NUMBER

ISRCTN17160087.