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Treatment frequency and dose

1. What is the best weekly frequency of NBUVB treatment for vitiligo?

Although there is currently no direct comparison of NBUVB phototherapy protocols twice a week and 3 times a week, studies on excimer laser therapy have not found differences in the final color reproduction levels of the above two frequencies. . The effect of complex color depends on the total number of treatments. In contrast, the frequency of phototherapy 3 times a week causes the complex color to occur earlier 4 . Similar results were obtained in phototherapy studies in patients with psoriasis5. Treatments twice a week may be more convenient, less expensive, and can increase the patient capacity of a busy phototherapy center. However, patients who are emotionally anxious due to slow onset of treatment are more likely to use the regimen three times a week because it will work faster. A comparative study of these two treatment frequency protocols is currently underway.

2. What strategy should I use for the initial dose?

From the expert's point of view, there is currently no clear consensus on this issue. Although the optimal strategy for selecting the initial dose is based on the minimum spot size (MED) for each patient, it is difficult to measure the minimum spot size for each patient. Based on a comparative analysis of phototherapy guidelines for multiple institutions and a discussion by the Vitiligo Working Group Phototherapy Committee, we recommend a fixed phototherapy starting dose of 200 mJ/cm2 regardless of skin type, which is convenient for operation and avoids phototoxic reactions. Given the natural differences in MED for different skin types, selecting a corresponding fixed starting dose based on different skin types is another dose selection strategy6. Because of the greater risk of phototoxic reactions in dark-skinned people, this method is more suitable for areas with darker skin color.

3. What is the maximum acceptable dose for each treatment of the face and torso skin?

The maximum acceptable dose for a single treatment of the face is 1500 J/cm2, while the maximum acceptable dose for a single treatment of the torso is 3000 J/cm2. This dose recommendation is based on a literature review, guidelines for the treatment of each center, and a discussion by the Vitiligo Working Group Phototherapy Committee. Although some individuals can withstand higher doses, there is a long-term lack of cancer risk in the literature on vitiligo and psoriasis, so caution is needed. These upper dose limits are also suitable for higher skin types, as light tolerance does not depend entirely on skin type.

4. What is the total number of maximum phototherapy that can be accepted by vitiligo patients?

For patients with SPTs type IV and VI, we recommend not setting the upper limit for the total number of treatments. For patients with SPTs type I to III, more research data on the risk of skin malignancy are needed before making recommendations. The current literature on the risk of non-malignant melanoma skin tumors in patients with vitiligo is not completely consistent 7-9. Most of the studies, even in patients with light skin color, did not find an increase in the incidence of skin cancer in patients with vitiligo. Most of the studies on the incidence of skin cancer after NBUVB treatment are retrospective studies, and mainly from the literature related to psoriasis. Similarly, the study did not find an increase in the incidence of skin cancer after NBFOB treatment by 10-12. Before this question can finally be answered, a large sample of the risk of skin cancer incidence in vitiligo patients and a long enough follow-up clinical study are needed.

5. How much treatment is needed before evaluating the treatment response or stopping treatment?

A treatment course for NBUVB is defined by the number of treatments. At least 18-36 phototherapy sessions are required before assessing the response to treatment. ��48 NBUVB phototherapys need to be completed before terminating phototherapy due to non-response to treatment. Some patients may have a slower response to treatment through observation by committee members. Therefore, before stopping phototherapy, consider completing ��72 treatments13.

Dose adjustment

6. How to choose the range of dose increase without erythema?

The therapeutic dose should be increased by 10-20%. This is the most common increase in the number of recommendations reported in the literature2, and is a consensus reached between the phototherapy committee and the expert group.

7. What is the optimal dose adjustment plan after erythema?

The expected therapeutic response to phototherapy is the appearance of pink asymptomatic erythema with a duration of less than 24 hours. Once this reaction occurs, the current dose of erythema should be maintained and the therapeutic dose increased by 10-20%. Patients with high skin classification of SPTs may be able to tolerate a much larger dose. If an asymptomatic bright red patch appears, you should wait until the affected lesion becomes pale pink, and the phototherapy dose is the last dose. If symptomatic erythema, such as pain and blisters, occurs, wait until the erythema becomes pale and continue the phototherapy, at which time the phototherapy dose is the last tolerable dose. Although NBUVB bulbs only release very small amounts of UVA, patients with unexplained phototherapy-related erythema should be cautiously asked if they are using photosensitizing drugs such as tetracyclines, quinolones, sulfonylureas, Hydrochlorothiazide and phenothiazine, or furanocoumarin, a kind of organic complex produced by certain plants that induces light-sensitive human body, including celery, grapefruit and parsley. In addition, up to one-third of vitiligo patients do not adapt well to phototherapy, which means they can't tolerate increasing doses of phototherapy and the risk of photoburning is greater14. It is necessary to identify these patients as early as possible, as they may be more suitable for other treatments or for the replacement of phototherapy doses.

8. How to adjust the dose of phototherapy after the interruption of treatment?

If only 4-7 days are interrupted, the treatment dose should be maintained until the previous treatment is continued; if the treatment is interrupted for 8-14 days, then the dose should be reduced by 25% compared to the previous one when the treatment is restarted; if the treatment is interrupted 15 times -21 days, the dose should be reduced by 50% compared to the previous time when the treatment is restarted; if the treatment is interrupted for more than 3 weeks, the phototherapy dose should be restored to the initial dose during retreatment. This dose adjustment protocol is consistent with the second edition of the Guidelines for Phototherapy for Psoriasis and Other Phototherapy Reactive Skin Diseases in the dose adjustment protocol for vitiligo patients.

9. How to adjust the dose after the equipment is commissioned or replaced with a new one?

The dose should be reduced by 10%-20% compared to the previous one.

Maintenance treatment and follow-up

10. What evaluation indicators should be used during the initial treatment and follow-up?

A series of photographed records should be used during baseline severity and follow-up to establish vitiligo to assess treatment response and disease stability. According to the consensus of the expert group, it should be taken every 3 months under ideal conditions. Taking photos with a digital camera or tablet and uploading them to a patient's medical record file can make this job easier. Some scoring systems, such as the Vitiligo Area Scoring Index or the Vitiligo European Task Force Assessment, can be used to quantitatively assess the level of treatment response.

11. What kind of phototherapy recommendations should be given to patients after NBUVB phototherapy?

Patients with any skin type should be advised to use a broad-spectrum sunscreen with a sun protection index ��30 after phototherapy and supplement the sunscreen every 2 hours according to the guidelines of the American Dermatology Association Sunscreen to avoid exposure to sunlight. To reduce the risk of excessive UV exposure and phototoxic reactions.

12. Which topical products should be avoided before performing NBUBC phototherapy?

All topical products other than mineral oil should be avoided within 4 hours before phototherapy, as they may reduce phototherapy activity or interfere with NBUVB penetration. Mineral oil enhances the light penetration of dry and thickened areas such as the elbows and knees.

13. Once an optimal response to treatment occurs, how do you choose the right NBUVB treatment regimen to maintain treatment?

Once NBUVB phototherapy is used to achieve optimal recoloration levels, we recommend a gradual reduction in therapeutic dose by the following methods: 2 weeks of phototherapy in the first month of complete recoloration; 1 month reduction in the 2nd month; The third and fourth months continue to decrease once every other week; if there is still no disease recurrence after the fourth month of treatment, the phototherapy can be stopped. This strategy identifies patients at risk of recurrence and restores the frequency of treatment three times a week.

14. What is the recommended follow-up frequency in order to monitor adverse reactions and recurrence after NBUVB phototherapy?

For patients with SPTs I-III, we recommend a weekly skin examination to monitor adverse reactions to phototherapy including skin malignancies. For patients with SPTs IV-VI, annual follow-up examinations are not required because there are no reports of malignant skin tumors in this group of patients. All patients should return to the clinic for retreatment if the symptoms recur.

safety

15. What is the minimum age for NBUVB phototherapy in children?

We recommend that you be able to stand alone in the treatment room and close your eyes or wear an eye socket. You can receive NBUTB phototherapy, which is usually 7-10 years old. It has also been suggested that for younger children, treatment can be done in the treatment room by an adult, but this is not an ideal solution because incomplete occlusion may result in unnecessary UV exposure for adults. For some patients, however, this may be the only way to ensure that they are treated. Since the adult may block part of the exposed part of the child, the position should be changed during the phototherapy process to ensure that all areas can be illuminated. In this case, comprehensive photoprotection must be provided to accompanying adults, including the use of UV protective goggles. It is very important for children with vitiligo to perform phototherapy as soon as possible, because NBUVB can improve the stability of the disease, promote complex color and improve the quality of life, and has the least side effects. The incidence of skin cancer in children receiving NBUVB treatment requires a long-term follow-up study to further assess the safety of this treatment regimen in the treatment of vitiligo in children.

16. How to use NBUTB phototherapy for patients with eyelid lesions?

In the study of the effects of NBUTB on the eye, treatment for up to 13 months did not find that it would significantly reduce the patient's visual acuity, increase cataracts, or increase the complications of the anterior or posterior segment of the eyeball17. Because phototherapy is a very effective method for the treatment of eyelid lesions, and in vitro experiments have confirmed that the UVB through the eyelid specimens is negligible, it is very important that the vitiligo lesions of the eyelids can receive phototherapy. Therefore, we recommend that patients with vitiligo with orbital lesions close their eyes during NBUVB phototherapy.

17. What are the recommendations for the protection of special parts during the treatment of NBUVB?

If the face is not affected by vitiligo skin lesions, it is recommended that the face should be covered during the NBUTB treatment. Male genitalia should also be covered and protected as it may increase the risk of malignant genital tumors. Fourteen patients with malignant genital tumors reported having undergone psoralen + UVA phototherapy (PUVA) in patients with psoriasis, however, some of these patients were also exposed to high doses of UVB (greater than 300 exposures)18. To prevent female areola from being burned, sunscreen can be applied before phototherapy, especially for patients with SPTsI-III.

Adjuvant therapy

18, in order to stabilize the control of vitiligo, what other treatment methods can be used in conjunction with NBUWP?

In order to induce stable symptoms of vitiligo, oral glucocorticoids, oral antioxidants, and topical treatments can be selected. Classical hormonal pulse therapy is oral dexamethasone for 2 consecutive days per week for several weeks or months, and the program has been shown to block disease progression20. Patients should be reminded of the side effects of oral hormones and encourage patients to strengthen vitamin D and calcium supplements during oral administration of hormones. Antioxidants commonly used in the treatment of vitiligo include ginkgo leaves, lipoic acid, white velvet water keel extract and the like. Studies have found that the use of white velvet water keel extract in combination with phototherapy can increase the therapeutic effect 21 . Topical treatments such as topical glucocorticoids can also be combined with phototherapy. Any adjuvant therapy that may increase skin light sensitivity in the UVB illumination range during NBUVB light should be avoided.

19. How to treat dry skin or skin thickening caused by NBUVB treatment?

Skin dryness caused by NVUVB induction can be treated with an emollient or mineral oil, while topical topical hormones or keratolytic agents can be used to treat skin thickening secondary to NBUVB. More research is needed to confirm the role of emollients, keratolytics and hormones in improving skin pigment regeneration in skin thickened areas.

In short, although NBUBB plays a major role in the treatment of vitiligo, there is no consensus on its specific implementation. This can be seen in a number of different treatment manuals developed for different SPT skin types, socioeconomic levels, and the needs of different health care systems. And there is currently no control study. This study developed an expert consensus with broad applicability to help dermatologists apply NBUTB phototherapy for vitiligo. However, these are just guidance. Ultimately all treatment must rely on the patient and the attending doctor to reach an agreement. The study also highlights areas where more research is needed to guide future research and develops a safe and effective treatment protocol for the treatment of vitiligo in NBUVB.