Guideline for the Diagnosis and Management of Vitiligo

D.J. Gawkrodger; A.D. Ormerod; L. Shaw; I. Mauri-Sole; M.E. Whitton; M.J. Watts; A.V. Anstey; J. Ingham; K. Young

Disclosures

The British Journal of Dermatology. 2008;159(5):1051-1076. 

In This Article

In All Patients With Vitiligo, What is the Efficacy of a Course of Narrowband UVB Including High-intensity Light Sources Compared With Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score?

Introduction

Phototherapy with UVB has been used in the treatment of vitiligo for many years. Phototherapy with broadband UVB appeared less effective than PUVA and was less frequently used. In the early 1990s, NB-UVB became widely available in Europe due to its widespread use in psoriasis. NB-UVB appeared to be more effective for treating vitiligo than the broadband UVB that it replaced. It is only recently that the efficacy of NB-UVB in the treatment of vitiligo has been assessed objectively in clinical trials. By convention, NB-UVB is usually given three times each week. An arbitrary limit of 200 NB-UVB treatments for vitiligo has been suggested, although in practice most patients have fewer.[57]

NB-UVB has the advantage for patients of being more acceptable than PUVA because they do not need to take oral medication before exposure to radiation or to wear protective sunglasses. Both PUVA and NB-UVB require a great degree of commitment by the patient. This should be explained at the time of consultation.

Methods

Nine studies identified using a computer-assisted search are included in the evidence table.

Evidence Statements

Nine studies were assessed, two of which[31,57] follow the study design of an RCT. The study by Hamzavi and Shapiro[31] is of limited importance due to the small patient numbers, and the fact that most of the patients were white. This study did, however, establish that NB-UVB is an effective treatment for vitiligo compared with no treatment (P<0·001). It also highlighted the differential response within patients according to body site.

The most important study, by Yones etal.,[57] was the first double-blind, randomized trial of oral PUVA vs. NB-UVB therapy in vitiligo. It demonstrated therapeutic efficacy for both treatment modalities. However, NB-UVB was more effective, easier to administer and produced a better colour match. Vitiligo relapse was reported following both treatments in some patients by 12months post-therapy.

Three of the remaining seven studies included 50 or more patients, but all three were methodologically weak. The largest, by Menchini etal.,[58] was an open study of 734 patients treated with a filtered xenon arc lamp which was claimed to deliver UVB. There were no controls and no attempt to analyse responses statistically. None the less, the authors claimed that this treatment was 'highly effective with no side-effects'. The second largest study, by Westerhof and Nieuweboer-Krobotova,[59] included 175 patients. Response was compared with baseline and no attempt was made to analyse results statistically. The authors concluded that TL-01 phototherapy was as efficient as topical PUVA in inducing repigmentation in vitiligo, but with fewer side-effects. The third largest report, an open study of NB-UVB in the treatment of 51 children with vitiligo, concluded that this was a safe and effective treatment.[22]

The final four reports are small open studies which are not objective or controlled. Three describe responses to the Excimer laser.[60,61,62] Each study reports a positive response (i.e. repigmentation) but no data are presented on the amount of repigmentation, or cosmetic acceptability or permanence. A small study that made a good attempt to assess the responses objectively concluded that NB-UVB was effective at treating vitiligo while broadband UVB was not.[19]

Evidence to Recommendations

There is good evidence that some patients with vitiligo respond well to phototherapy with NB-UVB. A single randomized double-blind trial comparing oral PUVA with NB-UVB has convincingly demonstrated the superiority of NB-UVB over PUVA. Twelve-month follow-up showed that some patients relapsed and ended up with worse vitiligo than they had before PUVA (28%) or NB-UVB (12%) started. However, maintenance of >75% repigmentation of surface area was seen in 24% in the PUVA group and 36% in the NB-UVB group.

Recommendations

  1. NB-UVB phototherapy should be considered for treatment of vitiligo only in children or adults who cannot be adequately managed with more conservative treatments.

    Grade of recommendation D
    Level of evidence 4

     

  2. A trial of NB-UVB therapy should be considered for children or adults with widespread vitiligo, or localized vitiligo associated with a significant impact on patient's QoL. Ideally, this treatment should be reserved for patients with darker skin types.

    Grade of recommendation D
    Level of evidence 3

     

  3. Before starting treatment, children, their parents and carers, and adults should be made aware that there is no evidence that NB-UVB phototherapy alters the natural history of vitiligo. They should also be made aware that not all patients respond to this treatment, and that some body sites, such as the hands and feet, respond poorly in all patients. They should also be informed of the limit to the number of treatments due to possible side-effects.

    Grade of recommendation D
    Level of evidence 3

     

  4. If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should be used in preference to oral PUVA.

    Grade of recommendation A
    Level of evidence 1+

     

  5. Evidence is lacking to define an upper limit for the number of treatments with NB-UVB for patients with vitiligo. Taking into account the published data for patients with psoriasis (see below) and in view of the greater susceptibility of vitiliginous skin to sunburn and possible photodamage (due to absence of melanin), it is advised that safety limits for NB-UVB for the treatment of vitiligo are more stringent than those applied to psoriasis, with an arbitrary limit of 200 treatments for skin types I-III. This could be higher for skin types IV-VI at the discretion of the clinician and with the consent of the patient.

    Grade of recommendation D
    Level of evidence 3

     

  6. It is recommended that physicians prescribing NB-UVB for vitiligo monitor response closely with the assistance of serial clinical photographs (every 2-3months), more easily to identify patients who fail to respond adequately or in whom the disease progresses during treatment.

    Grade of recommendation D
    Level of evidence 3

     

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