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Long-term prognosis of vitiligo patients on narrowband UVB phototherapy

To the Editor: We read with interest the CME article on vitiligo that mentioned the paucity of long-term follow-up data of narrowband ultraviolet B (NB-UVB) therapy in vitiligo.1 Although there are no established treatment caps for NB-UVB, the suggested limit for skin types I-III is arbitrarily set at 200 treatments. While there is no set limit for skin types IV-VI, the recommendation for number of treatments should be based on clinician discretion and patient consent. We have observed that long-term NB-UVB in vitiligo patients is safe. This is important because these patients often require more than 12 to 24 months of treatment for repigmentation.

The University of California San Francisco Department of Dermatology Psoriasis and Skin Treatment Center has been treating vitiligo patients with NB-UVB for nearly a decade. A retrospective review of current NB-UVB vitiligo patients revealed 10 patients (6 female, 4 male; skin types II-IV) who had NB-UVB treatment for 33 to 93 months. Age at onset was from 8 to 59 years old, with disease duration between 3 and 33 years. Number of visits ranged from 201 to 744 with current dosing between 865 and 2,875 mJ/cm2 per treatment. Over time, none of our patients developed suspicious lesions or nonmelanoma skin cancer (NMSC).

It has been reported from a review of vitiligo patients with skin types I-II (n = 477), independent of whether or not they had used phototherapy, that individuals with vitiligo have a non-statistically significant increased risk of NMSC than the general population; however, no cases were reported in non-Caucasians.2 Only 2 of the 6 NMSCs identified were on vitiliginous skin, which supports existing evidence that NMSC in vitiliginous lesions is rare.3 Furthermore, vitiliginous skin is observed to be less susceptible to photodamage.3

After years of experience reviewing the available follow-up data drawn from all dermatology patients treated with NB-UVB phototherapy, we found that the general consensus is that NB-UVB does not significantly increase risk of NMSC compared with the general population.

Furthermore, 3 of our patients (skin types II-IV) have a history of systemic psoralen and ultraviolet A (PUVA) therapy with treatment duration ranging from 24 to 60 months, followed by NB-UVB (52-72 months). We found no evidence of NMSC in these patients. In Caucasian-based population studies, long-term PUVA therapy is an established risk factor for NMSC, particularly in patients with skin types I-II.4 However, the carcinogenic risk of PUVA in Asian and Arabian-African populations is not substantiated; data suggest that pigmented skin may confer photoprotection.4

Moreover, it is common to use topical pimecrolimus and/or tacrolimus as adjuncts to NB-UVB. Recent evidence suggests that topical pimecrolimus and tacrolimus do not increase risk of NMSC in adults.5 Therefore, this combination should not have a cumulative carcinogenic effect.

NB-UVB is likely to be a safe long-term phototherapy option for patients with vitiligo as it is expected that they will require more visits over a long period of time to appreciate the results of therapy. Current guidelines may not be adequate, and long-term follow-up data are needed.

References

Felsten, L.M., Alikhan, A., and Petronic-Rosic, V. Vitiligo: A comprehensive overview Part II: Treatment options and approach to treatment. J Am Acad Dermatol. 2011; 65: 493�C514

View in Article | PubMed | Scopus (24)

Hexsel, C.L., Eide, M.J., Johnson, C.C., Krajenta, R., Joacobsen, G., Hamzavi, I. et al. Incidence of nonmelanoma skin cancer in a cohort of patients with vitiligo. J Am Acad Dermatol. 2009; 60: 929�C933

View in Article | PubMed | Scopus (16)

Nordlund, J.J. Nonmelanoma skin cancer in vitiligo patients. J Am Acad Dermatol. 2009; 61: 1080�C1081

View in Article | PubMed | Scopus (6)

Murase, J.E., Lee, E.E., and Koo, J. Effect of ethnicity on the risk of developing nonmelanoma skin cancer following long-term PUVA therapy. Int J Dermatol. 2005; 44: 1016�C1021

View in Article | CrossRef | PubMed | Scopus (29)

Margolis, D.J., Hoffstad, O., and Bilker, W. Lack of association between exposure to topical calcineurin inhibitors and skin cancer in adults. Dermatology. 2007; 214: 289�C295

View in Article | CrossRef | PubMed | Scopus (66)

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