IADVL
Indexed with PubMed and Science Citation Index (E) 
 
Users online: 1810 
     Home | Feedback | Login 
About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe What's New Contact  
  Navigate here 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
 Resource links
   Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
   Article in PDF (114 KB)
   Citation Manager
   Access Statistics
   Reader Comments
   Email Alert *
   Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
   Introduction
   Methods
   Results
   Discussion
   Acknowledgements
   References
   Article Tables

 Article Access Statistics
    Viewed5164    
    Printed117    
    Emailed10    
    PDF Downloaded478    
    Comments [Add]    
    Cited by others 17    

Recommend this journal

 


 
BRIEF REPORT
Year : 2008  |  Volume : 74  |  Issue : 4  |  Page : 357-360

An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo


Department of Dermatology and STD, Dr. RML Hospital, New Delhi, India

Correspondence Address:
H K Kar
D-II / A-71, South Moti Bagh, New Delhi-110 021
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0378-6323.42905

Rights and Permissions

  Abstract 

Background: Several modalities of treatment have been tried in vitiligo with varied results; however, Indian data on comparative studies of two or more therapies are limited. Aims: We compared different phototherapy methods with an oral steroid as an adjunct to determine the method with the best tolerability and efficacy. Methods: Eighty-six patients with progressive vitiligo were randomly assigned to different study groups according to a continuous selection method over a period of one year. Group 1 was given OMP + PUVA, group 2 OMP + UVB (NB), group 3 OMP + UVB (BB) and group 4 was given OMP alone. Each patient was followed up for six months and then released from treatment. Clinical evaluation was made at the end of three and six months. Results: In group 1 (OMP + PUVA), marked improvement was seen in 18.51% while moderate improvement was seen in 66.66% of the patients. Marked improvement was seen in 37.03% in group 2 (OMP + NB-UVB) while 44.44% had moderate improvement. In group 3 (OMP + BB UVB), 8.33% showed marked improvement while moderate improvement was seen in 25% of the patients. Marked and moderate improvement was seen in 5 and 10% of group 4 (OMP) patients, respectively. Conclusions: Our study compared four treatment modalities in vitiligo patients, out of which oral minipulse of steroids (OMP) only had an adjunct value and was not very effective by itself. Narrow band UVB has a definite edge over broad band UVB and should be preferred when both options are available. NB-UVB and PUVA showed comparable efficacy.


Keywords: Oral Minipulse, PUVA, Narrow Band (UVB), Broad Band UVB, Vitiligo


How to cite this article:
Rath N, Kar H K, Sabhnani S. An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo. Indian J Dermatol Venereol Leprol 2008;74:357-60

How to cite this URL:
Rath N, Kar H K, Sabhnani S. An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo. Indian J Dermatol Venereol Leprol [serial online] 2008 [cited 2017 Jun 24];74:357-60. Available from: http://www.ijdvl.com/text.asp?2008/74/4/357/42905



  Introduction Top


Vitiligo is a common idiopathic disorder characterized clinically by white macules on the skin. [1] Several modalities of treatment have been tried with varied results; however, Indian data on comparative studies of two or more therapies are limited. Phototherapy is quite effective, and while many patients may not experience complete repigmentation, 50-75% repigmentation can be routinely expected in vitiligo of recent onset. [2] As many patients will achieve only partial repigmentation even with the best of therapies, therapies may be cycled or combined to achieve higher overall repigmentation rates and to minimize side effects of therapy. [3] The aims of vitiligo therapy are two-fold: to repigment and remit disease progression. We have carried out a comparative study of different phototherapy methods with oral steroids as adjunct to determine the method with the best tolerability and efficacy.


  Methods Top


A total of 86 patients were included in the study. These patients were in the age group of 10-50 years and had progressive vitiligo involving 25-50% of the body surface area. Exclusion criteria were patients with diabetes and hypertension, > 50% body surface area involvement, and those with history of photosensitivity and photodermatitis.

Patients were assigned to four study groups and all four groups received oral minipulses (OMP) of betamethasone, 0.1 mg/kg body weight twice weekly on two consecutive days for three months followed by tapering of the dose by 1 mg every month over the following three months.

Group 1
consisted of 27 patients, all of whom received OMP as described above, along with psoralen with ultraviolet A light (PUVA) therapy in the form of 8-methoxypsoralen 0.6 mg/kg on alternate days plus UVA 320-400 nm from a Waldman W UV-7001 K phototherapy whole body chamber having both UVA and UVB (BB) tubes. The initial dose was 0.5 J/cm 2 UVA with increments of 0.2 J/cm 2 for every third dose (up to a maximum of 6 J/cm 2 ).

Group 2 also consisted of 27 patients who, in addition to OMP, received narrow band UVB (NB-UVB). The initial dose was 0.3 J/cm 2 with increments of 0.1 J/cm 2 in every dose (up to a maximum of 3 J/cm 2 ) using a Waldmann W UV 1000 L whole body phototherapy chamber containing NB-UVB (Phillips TL01) tubes. Doses were given thrice weekly in order to maintain an optimal constant dose with minimal erythema.

Group 3 consisted of 12 patients who were given OMP and broad band UVB (290-320 nm) on alternate days using the same chamber used for Group 1. Initial dose was 0.05 J/cm 2 with increments of 0.02 J/cm 2 for every third dose. Phototherapy was given thrice weekly and efforts were made to maintain an optimal constant dose with minimal erythema. There were fewer patients in this group because no new patients were assigned due to the excessive erythema observed in six patients.

Group 4 consisted of 20 patients who were given only OMP.

Patients were randomly assigned to different study groups according to a continuous selection method over a period of one year. Each patient was treated for six months and then released from the above scheduled treatment regimens.

Clinical evaluation was made at the end of three and six months. Improvement was categorized as marked (> 75% repigmentation), moderate (50-75% repigmentation), mild (25-50% repigmentation) and poor or no (< 25% repigmentation) improvement. Side effects were noted in every case.


  Results Top


At the end of three months , there was moderate improvement in four (14.8%) patients in group 1 (OMP + PUVA) while mild improvement was seen in 11 (40%) patients; the remaining twelve patients showed < 25% improvement.

In group 2 (OMP + NB-UVB) patients, there was marked improvement in five (18.51%) patients and moderate improvement in ten (37.03%) patients [Table 1]. Mild improvement was seen in 11 (40.74%) patients while one patient showed < 25% improvement.

Moderate improvement was seen in four group 3 (OMP+BB UVB) patients (33.33%) and mild improvement in three patients (25%). Four patients had < 25% improvement whereas one patient dropped out of the study.

In group 4 (OMP alone), moderate improvement was seen in two patients (10%) and mild improvement in 17 patients (85%); one patient dropped out of the study.

At the end of six months, marked improvement was seen in five group 1 (OMP + PUVA) patients (18.51%) while moderate and mild improvement was seen in 18 (66.66%) and four (14.8%) patients respectively. In this group, side effects such as nausea and weight gain (Cushingoid habitus) were experienced by 11 patients (40.74%) and excessive erythema and blistering were observed in five patients (18.51%) in whom one to three doses were skipped and treatment later resumed with a reduced dose. Roughness of the skin was present in 20 patients (74.07%); all patients had perilesional hyperpigmentation.

Marked improvement was seen in ten patients (37.03%) in group 2 (OMP + NB-UVB).

Twelve patients (44.44%) had moderate improvement, while five patients (18.51%) showed mild improvement. All patients (100%) were tanned, while weight gain was experienced by ten patients (37.03%).

In group 3 (OMP + BB UVB), only one patient (8.33%) showed marked improvement, while moderate and mild improvement was seen in three (25%) and five patients (41.66%) respectively. Three patients dropped out of the study because of side effects that included excessive erythema in six patients (50%) and weight gain in five patients (41.66%).

Out of 20 group-4 (OMP alone) patients, marked improvement was seen in only one patient (5%). Moderate and mild improvement occurred in two (10%) and 15 (75%) patients (10%) respectively. Two patients dropped out due to weight gain and ten patients (50%) experienced weight gain.

Group-2 patients demonstrated more marked improvement than other patients. The Chi Square test was applied with the help of SPSS-12 and found that only the comparison between group-2 and group-4 was statistically significant at a 5% level of significance.

More group-1 patients had marked to moderate improvement than other groups [Table 2]. The Chi Square test was applied with the help of SPSS-12 and found that while the group-1 vs group-2 and group-3 vs group-4 comparisons were not significant at a 5% level of significance, the group 1 vs group 4 and group 2 vs group 4 comparisons were highly significant at 5% level of significance.


  Discussion Top


Phototherapy using oral psoralens and UVA (320-400 nm) has been in use for a very long time. The ultraviolet A radiation (UVA) can be either from an artificial source or from natural sunlight (PUVASOL). [4]

Narrow band UVB (NB-UVB) utilizes the effective UVB range and excludes erythema-inducing rays, thus having a definite edge over broad band UVB. The advantages of NB-UVB phototherapy are shorter sessions and suitability in children and pregnancy. No oral psoralens are required and there is no phototoxicity, xerosis, or hyperkeratosis as seen with PUVA. [5] The effect of NB-UVB was first highlighted in a study by Westerhof and Nieweboer-Krobotova in 1997. [6] They compared topical PUVA with NB-UVB and found that 67% of patients receiving narrow band UVB showed repigmentation after four months in comparison to 46% of cases receiving topical PUVA. In that 1997 study , 8% of the patients showed > 75% repigmentation after three months with NB-UVB. In our study, there was marked improvement in five (18.51%) patients and moderate improvement in ten (37.03%) patients after three months of administering narrowband UVB along with OMP. The mechanism of pigmentation following UVB radiation is still unknown. It has been suggested that endothelin and tyrosinase expressed by keratinocytes may play a role in the resulting pigmentation. [7] Njoo, Bos and Westerhof carried out an open study with narrow band UVB in 51 children with generalized vitiligo for one year. They reported > 75% repigmentation in 53% of their patients. [8] More than 75% repigmentation was also reported in a recent study by Kanwar et al , who followed up 26 children with generalized vitiligo receiving narrow band UVB. [9]

Njoo et al , did a meta-analysis of nonsurgical pigmentation therapies in vitiligo. They found that repigmentation occurred in 51% of patients on oral PUVA, in 57% of those on BB UVB and in 63% of patients on narrow band UVB. [10] In our study after three months, > 50% of the patients receiving narrow band UVB showed marked and moderate improvement while only 14.8% showed moderate improvement with PUVA (both having OMP as an adjunct). After six months, we found that > 85% patients of patients undergoing PUVA treatment showed moderate to marked improvement while > 81% of those receiving narrow band UVB showed moderate to marked improvement. This highlighted the fact that although narrow band UVB causes faster repigmentation, both PUVA and narrowband UVB have comparable effects over time. Pasricha and Khaitan tried oral minipulses of betamethasone in 1993. They reported 26-50% repigmentation in 25% of their patients, 51-75% repigmentation in 7.5% and > 75% repigmentation in 15% of the patients. [11] In our study, we gave twenty patients oral minipulses (OMP) and marked improvement was seen in only one patient (5%). Moderate improvement occurred in two patients (10%) while mild improvement was seen in 15 patients (75%). In contrast, > 75% improvement was seen in group 2 (NB-UVB + OMP) patients, an observation that was statistically significant at a 5% level of significance when compared to group 4 (OMP) patients after three and six months. Statistical analysis of marked to moderate improvement (> 50% repigmentation) was done with the help of SPSS-12 using the Chi square test. It was found that only the Group 1 vs Group 2 and Group 3 vs Group 4 comparisons were not significant at a 5% level of significance. Group 1 vs Group 4 and Group 2 vs Group 4 comparisons were highly significant at a 5% level of significance.

It was found that, out of the four treatment modalities , OMP has only an adjunct value and helps in the arrest of the disease progress, but has no significant, intrinsic repigmenting efficacy. Our patients experienced side effects such as tanning, erythema due to ultraviolet therapy and bloating, weight gain due to oral steroids-all of which were reported in earlier studies too. [8],[9],[11]

This study is being reported for its uniqueness in that no study has been reported, to date, that compares these four modalities along with oral minipulses of steroids. However, an extensive study with a larger population and longer follow-up period is warranted for more conclusive evidence.


  Acknowledgements Top


Financial and material support for this study was provided by Pool Section, Human Resource Development (HRD) group, Council of Scientific and Industrial Research (CSIR), Pusa, New Delhi.

 
  References Top

1.Grimes PE. Diseases of hypopigmentation. In: Sams YM, Lynch PJ, editors. Principles and practice of dermatology, 2 nd ed. New York: Churchill-Livingstone; 1996. p. 873-85.  Back to cited text no. 1    
2.Hercogova J, Buggiani G, Prignano F, Lotti T. A rational approach to the treatment of vitiligo and other hypomelanoses. Dermatol Clin 2007;25:383-92.  Back to cited text no. 2    
3.Lecha M. Use of UVB in vitiligo. In: Lotti T, Hercogova J, editors. Vitiligo: Problems and solutions. New York: Marcel Dekker, Inc.; 2004. p. 341-5.  Back to cited text no. 3    
4.Parrish JA, Fitzpatrick TB, Shea C, Pathak MA. Photochemotherapy of vitiligo: Use of orally administered psoralens and a high-intensity long-wave ultraviolet light system. Arch Dermatol 1976;112:1531-4.  Back to cited text no. 4  [PUBMED]  
5.Morison WL, Baugham RD, Day RM, Forbes PD, Hoenigsmann H, Krueger GG, et al . Consensus workshop on the toxic effects of long-term PUVA therapy. Arch Dermatol 1998;134:595-8.  Back to cited text no. 5    
6.Westerhof W, Nieweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs topical psoralen plus UV-A. Arch Dermatol 1997;133:1525-8.   Back to cited text no. 6    
7.Imokawa G, Miyagishi M, Yada Y. Endothelin-1 as a new melanogen: Co-ordinated expression of its gene and the tyrosinase gene in UVB exposed human epidermis. J Invest Dermatol 1995;105:32-7.  Back to cited text no. 7  [PUBMED]  
8.Njoo M D, Bos JD, Westerhof W. Treatment of generalized vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol 2000;42:245-53.  Back to cited text no. 8    
9.Kanwar AJ, Dogra S. Narrow-band UVB for the treatment of generalized vitiligo in children. Clin Exp Dermatol 2005;30:332-6.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Njoo MD, Spuls PI, Bos MD, Westerhof W, Bossuyt PM. Nonsurgical pigmentation therapies in vitiligo: Meta-analysis of the literature. Arch Dermatol 1998;134:1532-40.  Back to cited text no. 10    
11.Pasricha JS, Khaitan BK. Oral mini-pulse therapy with betamethasone in vitiligo patients having extensive or fast-spreading disease. Int J Dermatol 1993;31:753-7.  Back to cited text no. 11    



 
 
    Tables

  [Table 1], [Table 2]

This article has been cited by
1 The Safety and Efficacy of Narrow Band Ultraviolet B Treatment in Dermatology: A Review
Anna Sokolova,Andrew Lee,Saxon D Smith
American Journal of Clinical Dermatology. 2015; 16(6): 501
[Pubmed] | [DOI]
2 Narrowband ultraviolet B phototherapy in combination with other therapies for vitiligo: mechanisms and efficacies
M. Yazdani Abyaneh,R.D. Griffith,L. Falto-Aizpurua,K. Nouri
Journal of the European Academy of Dermatology and Venereology. 2014; 28(12): 1610
[Pubmed] | [DOI]
3 Treatment of vitiligo with NB-UVB: A systematic review
Bi-Huan Xiao,Yan Wu,Yan Sun,Hong-Duo Chen,Xing-Hua Gao
Journal of Dermatological Treatment. 2014; : 1
[Pubmed] | [DOI]
4 Concise review of recent studies in vitiligo
Mohamed Allam,Hassan Riad
Qatar Medical Journal. 2013; 2013(2): 10
[Pubmed] | [DOI]
5 Guidelines for the management of vitiligo: the European Dermatology Forum consensus
A. Taieb,A. Alomar,M. Böhm,M.L. Dell’Anna,A. De Pase,V. Eleftheriadou,K. Ezzedine,Y. Gauthier,D.J. Gawkrodger,T. Jouary,G. Leone,S. Moretti,L. Nieuweboer-Krobotova,M.J. Olsson,D. Parsad,T. Passeron,A. Tanew,W. van der Veen,N. van Geel,M. Whitton,A. Wolkerstorfer,M. Picardo
British Journal of Dermatology. 2013; 168(1): 5
[Pubmed] | [DOI]
6 Evidence-Based, Non-Surgical Treatments for Vitiligo
Robert M. Bacigalupi,Anna Postolova,Ronald S. Davis
American Journal of Clinical Dermatology. 2012; 13(4): 217
[Pubmed] | [DOI]
7 Which outcomes should we measure in vitiligo? Results of a systematic review and a survey among patients and clinicians on outcomes in vitiligo trials
V. Eleftheriadou,K.S. Thomas,M.E. Whitton,J.M. Batchelor,J.C. Ravenscroft
British Journal of Dermatology. 2012; 167(4): 804
[Pubmed] | [DOI]
8 Phototherapy in vitiligo
Medhat El-Mofty,Wedad Mostafa,Samia Esmat,Randa Youssef,Manal Bosseila,Rehab A. Hegazy
Journal of the Egyptian Women's Dermatologic Society. 2012; 9(3): 123
[Pubmed] | [DOI]
9 Guidelines for designing and reporting clinical trials in vitiligo
González, U., Whitton, M., Eleftheriadou, V., Pinart, M., Batchelor, J., Leonardi-Bee, J.
Archives of Dermatology. 2011; 147(12): 1428-1436
[Pubmed]
10 Vitiligo: A comprehensive overview
Lesley M. Felsten, Ali Alikhan, Vesna Petronic-Rosic
Journal of the American Academy of Dermatology. 2011; 65(3): 493
[VIEW] | [DOI]
11 Quantitative optical coherence tomography of skin lesions induced by different ultraviolet B sources
Zhiming Liu, Zhouyi Guo, Zhengfei Zhuang, Juan Zhai, Honglian Xiong, Changchun Zeng
Physics in Medicine and Biology. 2010; 55(20): 6175
[VIEW] | [DOI]
12 Update on childhood vitiligo :
Nanette B Silverberg
Current Opinion in Pediatrics. 2010; 22(4): 445
[VIEW] | [DOI]
13 Photo(chemo)therapy for vitiligo | [Vitiligoda foto(kemo)terapi]
Özarmaǧan, G., Yazganoǧlu, K.D.
Turkderm Deri Hastaliklari ve Frengi Arsivi. 2010; 44(sup 2): 97-104
[Pubmed]
14 Assessment of the effect of narrowband UVB and broadband UVB on mice skin using optical coherence tomography
Liu, Z., Guo, Z., Zhai, J., Xiong, H., Zeng, C., Jin, Y.
Proceedings of SPIE - The International Society for Optical Engineering 7519. 2009;
[Pubmed]
15 Vitiligo: What general physicians need to know
Gawkrodger, D.J.
Clinical Medicine, Journal of the Royal College of Physicians of London. 2009; 9(5): 408-409
[Pubmed]
16 Current and emerging therapy for the management of vitiligo
Borderé, A.C., Lambert, J., Van Geel, N.
Clinical, Cosmetic and Investigational Dermatology. 2009; 2: 15-25
[Pubmed]
17 Vitiligo: what general physicians need to know
D. J. Gawkrodger
Clinical Medicine. 2009; 9(5): 408
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
Previous article Next article

    

Online since 15th March '04
Published by Wolters Kluwer - Medknow