International Journal of Advanced and Integrated Medical Sciences

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Role of Narrow-band Ultraviolet B Phototherapywith Topical Tacrolimus 0.03% for Treatmentof Childhood Vitiligo
  IJAIMS
ORIGINAL ARTICLE
Role of Narrow-band Ultraviolet B Phototherapywith Topical Tacrolimus 0.03% for Treatmentof Childhood Vitiligo
1Ambika Dixit, 2Prerna Yadav, 3Praveen K Rathore, 4Sapna Goyal
1Junior Resident (2nd Year), 2Junior Resident (1st Year)3,4Professor
1-4Department of Dermatology, Venereology and LeprosyRohilkhand Medical College & Hospital, Bareilly, Uttar PradeshIndia
Corresponding Author:
Prerna Yadav, Junior Resident(1st year), Department of Dermatology, Venereology andLeprosy Rohilkhand Medical College & Hospital, Bareilly, UttarPradesh, India,
e-mail: dr.prernayadav25@gmail.com
10.5005/jp-journals-10050-10071
 
ABSTRACT
Vitiligo in children is a challenging disease to treat, as fewersafe options are available compared with the adult population.The combination of topical tacrolimus (0.03%) with narrowbandultraviolet B (NBUVB) phototherapy is a safer optionand hence we decided to explore this in our study. The extentof repigmentation was assessed at baseline, 12 weeks, and24 weeks by photographic documentation. We observedthat out of 16 patients, 3 (18.75%) had < 25% repigmentation,7 (43.75%) had 25 to 75% repigmentation, and 6 (37.5%)achieved >75% repigmentation. Combined therapy with topicaltacrolimus and NBUVB phototherapy is an excellent and safemodality in childhood vitiligo.
Keywords: Childhood vitiligo, Narrow-band ultraviolet B,Tacrolimus.
How to cite this article: Dixit A, Yadav P, Rathore PK, Goyal S.Role of Narrow-band Ultraviolet B Phototherapy with TopicalTacrolimus 0.03% for Treatment of Childhood Vitiligo. Int J AdvInteg Med Sci 2017;2(1):37-39.
Source of Support: Nil
Conflicts of Interest: None
 
 

INTRODUCTION

Vitiligo is an acquired condition of depigmentation resultingfrom progressive loss of melanocytes.1 It can begin atany age, but in the majority of cases it becomes apparentbetween the age of 20 and 30 years.1 Children affectedwith vitiligo suffer from psychological trauma with aprofound effect on their quality of life.2 There are varioustreatment modalities available for the adult population.However, fewer safe options are available in pediatricpopulation. Narrow-band ultraviolet B (NBUVB) radiationis a safe treatment modality, i.e., often used two tothree times weekly as monotherapy or in combinationwith other drugs. An alteration of immune surveillancehas been proposed as a primary event resulting in dysfunctionand destruction of melanocytes.3 Topical tacrolimusinhibits expression of several inflammatory T-cellcytokines. Our study aims to evaluate the synergisticeffect of topical tacrolimus 0.03% and NBUVB therapyin childhood vitiligo.

 
MATERIALS AND METHODS

This was an open, prospective, nonrandomized studycarried out in the outpatient department of Dermatology,Venereology, and Leprosy, Rohilkhand Medical College &Hospital, Bareilly, India. Totally 16 children (10 females,6 males) with vitiligo between the age group of 5 and14 years were included (Table 1). Children with any photosensitizingdisorder, premalignant lesion, dysplasticnevi, and claustrophobia were excluded from this study.Written consent was taken from parents. Relevant historyand complete general and cutaneous examination weredone. The parents and children were shown the phototherapyunit and were briefed about the procedure,advantages, safety, and limitations. The children wereinstructed to apply tacrolimus 0.03% ointment over thevitiliginous lesions in the evening. Concomitant NBUVBwas given twice weekly on nonconsecutive days. Thestarting dose given was 150 mJ/cm2 with an incrementdose by 10% at each visit. The patients were advised toapply sunscreen throughout the day. Photographic documentationwas done at baseline, 12, and 24 weeks. Theresponse was graded as group I: < 25% repigmentation,group II: 25 to 75% repigmentation, and group III: >75%repigmentation.4

Table 1: Duration of vitiligo
Role of Narrow-band Ultraviolet B Phototherapy with Topical Tacrolimus 0.03% for Treatment of Childhood Vitiligo

International Journal of Advanced & Integrated Medical Sciences, January-March, Vol 2, 201737

Ambika Dixit et al

Equipment used: Whole body, 24 tubes, Phillips TL01/100 W fluorescent lamp, 6-feet chamber.

RESULTS

Out of 16 patients, 3 (18.75%) had < 25% repigmentation,7 (43.75%) had 25 to 75% repigmentation, and6 (37.5%) achieved >75% repigmentation (Table 2, Figs 1to 3). The response to therapy was noted more overthe lesions involving trunk and limbs than those onface, hands, and feet. Follicular and peripheral type ofrepigmentation was observed in the patients. The repigmentedcolor was found to be similar to the surroundingnormal skin.

Table 2: Response to NBUVB therapy with tacrolimus 0.03%
Role of Narrow-band Ultraviolet B Phototherapy with Topical Tacrolimus 0.03% for Treatment of Childhood Vitiligo

 
All patients were compliant and good tolerability wasobserved. Minimal side effects were observed and hence,permanent discontinuation of therapy was not done.

Only 1 (6.25%) patient developed burning sensationfollowed by pruritus after irradiation with NBUVB. Thiswas resolved by topical application of emollient andtapering the irradiation dose.

DISCUSSION

Vitiligo in pediatric age group is a challenging conditionto treat as most of the treatment modalities available foradult population have serious side effects.

Narrow-band ultraviolet B with the emission spectrumof 311-312 nm is a safe modality in children and hasminimal side effects. It remains a gold standard in thetreatment of vitiligo. It acts on epidermal pigment cells.5Narrow-band ultraviolet B is shown to directly stimulatehair follicle-derived neural crest stem cells to differentiateinto melanocyte lineage.5 It enhances the mobility ofNCCmelan5 cells via upregulation of pp125FAK (protein)as well as increased melanin formation and also tyrosinaseexpression.5


Role of Narrow-band Ultraviolet B Phototherapy with Topical Tacrolimus 0.03% for Treatment of Childhood Vitiligo
Figs 1A to C: Response at 0, 12, 24 weeks respectively.

Role of Narrow-band Ultraviolet B Phototherapy with Topical Tacrolimus 0.03% for Treatment of Childhood Vitiligo
Figs 2A and B: Responses at 0 and 24 weeks respectively

38IJAIMS

Role of Narrow-band Ultraviolet B Phototherapy with Topical Tacrolimus 0.03% for Treatment of Childhood Vitiligo

Role of Narrow-band Ultraviolet B Phototherapy with Topical Tacrolimus 0.03% for Treatment of Childhood Vitiligo
Figs 3A to C: Repigmentation at 0, 12, and 24 weeks respectively


Tacrolimus is a topical immunomodulator andinhibits calcineurin action, thereby preventing T-cellactivation and production of various inflammatorycytokines. Topical tacrolimus downregulates proinflammatorycytokines, namely interleukin (IL)-2, IL-3, IL-4,IL-5, interferon gamma, tumor necrosis factor alpha andgranulocyte-stimulating factor.6 Topical tacrolimus is safeand has no serious adverse effects. Tacrolimus has anadded advantage over corticosteroids as it can be used forprolonged period of time without much adverse effects.

Dayal et al7 performed an open label study on20 children, 4 to 14 years of age group, with symmetricalvitiligo lesions over 24 weeks to assess the efficacy ofthe synergistic combination of tacrolimus 0.03% ointmentwith NBUVB phototherapy. They found a statisticallysignificant difference in the mean percentage ofrepigmentation at 4 and 6 months between combinationtherapy and NBUVB monotherapy.

Our study showed appreciable improvement over thevitiliginous lesions in children with good complianceand cumulative dose. The response started appearing asappreciable erythema after the first two to three dosesin most children. The first repigmented lesion usuallyappeared around 3 weeks of starting the therapy. Therepigmentation observed matched well with the color ofthe surrounding skin. Acral sites and face showed < 25%repigmentation in contrast to lesions on trunk and limbs.

Our study has a limitation of being an open labelnonrandomized model. There is a paucity of literatureavailable for the concomitant use of NBUVB with topicaltacrolimus in pediatric cases of vitiligo. Hence, it needsto be studied in detail.

 
CONCLUSION

Our study concludes that the combination of NBUVBphototherapy with topical tacrolimus 0.03% is a safe andhighly effective treatment modality for childhood vitiligo,wherein the treatment options are very limited.

REFERENCES
  1. Geel, N., Speeckaert, R. Acquired pigmentary disorders.Volume 3, 9th edition. In: Griffiths, C.; Barker J, Bleiker T,Chalmers R, Creamer D., editors. Rook's textbook of dermatology.UK. Wiley Blackwell; 2016. p. 88.
  2. Majid I. Targeted NBUVB phototherapy in childhood vitiligo:a study in 35 children. Pigment Disord 2014;1:101.
  3. Prasad, D. Kumaran, S.M. Depigmentary and hypopigmentarydisorders. Volume 2, 4th edition. In: Sacchidanand, S.,editor. IADVL textbook of dermatology. Mumbai: Bhalani;2015. p. 1313.
  4. Kumar YH, Rao GR. Narrow-band ultraviolet B in childhoodvitiligo: an open, prospective, uncontrolled study in28 children of South India. Indian J Paediatr Dermatol 2015Jan;16(1):17-22.
  5. Reich A, Medrek K. Effects of narrow band UVB (311nm) irradiation on epidermal cells. Int J Mol Sci 2013Apr;14(4):8456-8466.
  6. Sisti A, Sisti G, Oranges CM. Effectiveness and safety oftopical tacrolimus monotherapy for repigmentation in vitiligo:a comprehensive literature review. An Bras Dermatol2016 Apr;91(2):187-195.
  7. Dayal S, Sahu P, Gupta N. Treatment of childhood vitiligousing tacrolimus ointment with narrowband ultraviolet bphototherapy. Pediatr Dermatol 2016 Nov;33(6):646-651.


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