treatment for vitiligo in 2 geriatric patients

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Journal of General - Procedural Dermatology & Venereology Journal of General - Procedural Dermatology & Venereology Indonesia

Indonesia

Volume 4

Number 2 Vol. 4, No. 2 (June 2020) Article 8

6-30-2020

Narrowband ultraviolet B phototherapy combined with topical Narrowband ultraviolet B phototherapy combined with topical treatment for vitiligo in 2 geriatric patients

treatment for vitiligo in 2 geriatric patients

Rinadewi Astriningrum

Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia – Dr. Cipto Mangunkusumo National Central General Hospital Jakarta, Indonesia

Lili Legiawati

Vivianne Chandrakesuma

Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia – Dr.

Cipto Mangunkusumo National Central General Hospital Jakarta, Indonesia Shannaz Nadia Yusharyahya

Follow this and additional works at: https://scholarhub.ui.ac.id/jdvi

Part of the Dermatology Commons, Integumentary System Commons, and the Skin and Connective Tissue Diseases Commons

Recommended Citation Recommended Citation

Astriningrum, Rinadewi; Legiawati, Lili; Chandrakesuma, Vivianne; and Nadia, Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia – Dr. Cipto Mangunkusumo National Central General Hospital Jakarta, Indonesia Shannaz Yusharyahya (2020) "Narrowband ultraviolet B phototherapy combined with topical treatment for vitiligo in 2 geriatric patients," Journal of General - Procedural

Dermatology & Venereology Indonesia: Vol. 4: No. 2, Article 8.

DOI: 10.19100/jdvi.v4i2.217

Available at: https://scholarhub.ui.ac.id/jdvi/vol4/iss2/8

This Article is brought to you for free and open access by UI Scholars Hub. It has been accepted for inclusion in Journal of General - Procedural Dermatology & Venereology Indonesia by an authorized editor of UI Scholars Hub.

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J Gen Proced Dermatol Venereol Indones. 2020:4(2); 96-100

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Case Report

Narrowband ultraviolet B phototherapy combined with topical treatment for vitiligo

in 2 geriatric patients

Rinadewi Astriningrum, Lili Legiawati, Vivianne Chandrakesuma, Shannaz Nadia Yusharyahya

Email : rinadewi_astriningrum@yahoo.com,

Abstract

Background: Narrowband ultraviolet B (NB-UVB) become the mainstay of widespread vitiligo therapy due to its great efficacy and safety compared with other modalities. The use of NB-UVB for vitiligo has been widely studied in adult patients, while studies on geriatric patients specifically are still very limited. This report aims to show the immediate response after the initial treatment, side effects of therapy, and other problems that were encountered during therapy in two geriatric patients with vitiligo who have been followed up for more than 12 months.

Case Illustration: We reported two geriatric patients with vitiligo treated with NB-UVB phototherapy combined with topical treatment for more than 12 months. The first patient was 68-year-old woman, with Fitzpatrick skin type IV, who had vitiligo on her face, both lower arms and hands, and both legs and feet. The second patient was a 61-year-old man with Fitzpatrick skin type IV who had generalized vitiligo. The first repigmentation occurred on the 5^th session in the first patient and on the 6^th session in the second patient, using a cumulative dose of 1223 mJ/cm² and 1541 mJ/cm², respectively.

Discussion: After NB-UVB phototherapy, there was a great improvement on the face in both patients, followed by the trunk and legs. However, the duration of treatment needed to achieve homogeneous repigmentation is longer in geriatric patients than in the general population.

Conclusion: NB-UVB was well tolerated and showed good clinical response to treat vitiligo in the elderly.

However, little is known about the safety and efficacy of phototherapy in elderly patients with vitiligo.

Keywords: Geriatric, narrowband, phototherapy, therapy, vitiligo

Background

Vitiligo is a chronic acquired pigmentation disorder characterized by depigmented macules and patches on the skin due to the loss of melanocytes in the epidermis. It is estimated that 0.1 to 4% of the population from various regions of the world are affected, regardless of the gender and race.^1,2 It can manifest as localized or generalized skin lesions affecting various regions of the body including the face, and with its chronic nature, it contributes to a major psychosocial impairment and decreased quality of life.² An autoimmune process is believed to be the

mechanism by which vitiligo occurs, along with other factors, such as genetic and metabolic abnormalities and oxidative stress possibly playing roles.^3,4 However, the exact etiology is still unknown, and currently, there is no known definite cure for vitiligo.^3,5 The peak age of onset of vitiligo is reported to be between 10 and 30 years old.⁶ However, a meta-analysis of population- or community-based studies revealed that the prevalence of vitiligo in the age group of 60 years or above was higher than that in the age group below 40 years, 0.7% and 0.2%, respectively. An increased prevalence was observed in the older age group because vitiligo is a chronic disease

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and is life-long in most cases.⁴ Indonesia, as well as the United Nations, defines the elderly or geriatrics as those who have reached the age of 60 or above.^7,8

Several treatment modalities are available for vitiligo, including topical and systemic corticosteroids and immunomodulators and various phototherapies such as narrowband ultraviolet B (NB-UVB), psoralen plus ultraviolet A (PUVA), broadband ultraviolet B (BB-UVB), and targeted phototherapy using excimer laser.^2,3 Recently, NB-UVB has become the mainstay of widespread vitiligo therapy due to its great efficacy and safety compared with other treatment modalities.^6.9 The use of NB-UVB for vitiligo has been widely studied in adult and pediatric patients, but studies on geriatric patients specifically are still very limited. NB-UVB presents with several side effects such as erythema, itching, burning, and pain, which are generally well tolerated and disappear spontaneously (5).

However, structural and physiological changes in aging skin may lead to an enhanced sensitivity to ultraviolet exposure and delayed erythema response, which results in an increased risk of side effects.¹⁰ Therefore, we report two geriatric patients with vitiligo treated with NB-UVB phototherapy combined with topical treatment for more than six months. This report shows the administered doses, clinical response, and side effects of therapy, as well as other problems that were encountered during therapy in both patients.

Case Report

The first patient is a 68-year-old woman with skin type IV. She first presented to our clinic with vitiligo on the face, both lower arms and hands, and both legs and feet that had been present for one year. There was no family history of vitiligo or autoimmune comorbidities. She was previously treated in another hospital with topical treatments but had no improvement, so she was referred to our hospital. She was then prescribed an ointment mixture of liquor carbonis detergens (LCD) 3%

and ichthammol 1% and desoximethasone ointment 0.25% and was instructed to sunbathe for 15 minutes every morning. She had only less than 50% repigmentation after several months with good compliance. Therefore, she was prescribed NB-UVB phototherapy twice a week with an initial dose of 200 mJ/cm² and 10%

increment at every session if there is no erythema. She was also prescribed an ointment mixture of LCD 3% and ichthammol 1% in petrolatum to be applied twice a day. First new repigmentation occurred after the 5^th session on

the legs at a cumulative dose of 1223 mJ/cm². The maximum dose of NB-UVB treatment was 1120 mJ/cm², which was achieved at the 47^th session, in which she experienced slight erythema on the vitiligo patches on the hand for a few hours, and then it resolved. The dose was maintained for 22 sessions. However, improvement was not seen on the hands and fingers. Therefore, she was given an additional localized NB-UVB phototherapy on the hands with an initial dose of 200 mJ/cm² and 10% dose increment. There was no improvement on the hands until the dose has reached 2000 mJ/cm² after 30 sessions, and the dose was maintained.

After 12 months of phototherapy, consisting of 42 localized and 98 whole-body phototherapy sessions, the patient had reached a homogenous repigmentation (more than 50%) on the face and legs but had only partial repigmentation (less than 50%) on the hands and fingers. Erythema and pain occurred only once in whole-body phototherapy sessions, and no side effects occurred in localized phototherapy sessions.

While the patient was on phototherapy, she was started on simvastatin, a photosensitizing medication. However, no side effects occurred due to its consumption. The patient refused to continue the phototherapy due to time and financial constraints. Thus, phototherapy was terminated, and the patient used topical treatments only, which included clobetasol cream 0.05% on the face and a combination of LCD 3%

and ichthammol 1% in petrolatum on alternate days, with clobetasol propionate cream 0.05% on hands and legs.

The second patient was a 61-year-old man with Fitzpatrick skin type IV who has vitiligo on the face, neck, trunk, both lower arms, both hands, and both legs and feet. He had vitiligo for one year. He had no family history of vitiligo. He hadnever received treatment for vitiligo and was prescribed NB-UVB starting at 200 mJ/cm² with 10% increment twice a week. He was also prescribed an additional topical treatment, clobetasol propionate cream 0.05% and tacrolimus 0.1% ointment. His first repigmentation occurred on the face after the 6^th session at a cumulative dose of 1541 mJ/cm². The first erythema episode occurred at the 18^th session at 998 mJ/cm² and a cumulative dose of 9052 mJ/cm². There was erythema and burning pain on the neck for approximately 24 hours, so the phototherapy was postponed for one week and then continued with a 25% reduction of the last dose after symptoms had subsided. After 22 sessions, more than 50% repigmentation was seen mostly on the trunk, but less than 50%

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repigmentation occurred on the hands and feet.

Therefore, he was prescribed additional localized NB-UVB phototherapy on the hands and feet starting at 200 mJ/cm² with 10% increment. The additional dose of localized phototherapy was maintained at 512 mJ/cm² for six months and less than 50% repigmentation was achieved. The whole-body phototherapy reached the highest dose of 1384 mJ/cm² at the 53^rd session, where he experienced erythema and pain on the neck for two days. After 19 months of phototherapy consisting of 133 whole-body phototherapy sessions and an additional 116 localized NB-UVB phototherapy sessions, localized phototherapy reached a maximum dose of 2822 mJ/cm² at that time, and continued repigmentation was observed for the next two months. During that period, the whole-body phototherapy dose was maintained at 1135 mJ/cm², when the patient experienced erythema on vitiligo patches, and repigmentation occurred without any side effects. During his phototherapy treatment, he never consumed any photosensitizing medications. However, he had experienced six episodes of erythema and pain on the neck, two episodes on the chest, three episodes on the fingers, and two episodes on the face. According to our protocol, if slight erythema occurred within 24 hours after treatment, the phototherapy dose was maintained. However, if the erythema lasted more than 24 hours, along with complaints of stinging, itchy, or burning sensation, phototherapy was discontinued and the subsequent treatment dose reduced by 25%. The neck was covered during the phototherapy to avoid developing erythema in the last three months. He also had two episodes of herpes simplex on his back while on NB-UVB treatment which resulted in the whole-body phototherapy being postponed until the situation had resolved.

The patient continued with his phototherapy and almost never missed a session. At the time this case report was written, more than 50%

repigmentation had occurred on his face, neck, chest, back, abdomen, both arms, and legs, but there was less than 50% repigmentation on the hands and feet.

Discussion

The skin of the elderly is different than adults and could therefore respond differently to ultraviolet light exposure. Immunosenescence and changes in the morphology of keratinocyte and size of blood vessels may lead to a reduced erythema response triggered by ultraviolet light exposure.¹¹ These changes could affect the minimal erythema dose (MED) that would be the initial dose received by the elderly patients. Nevertheless, a study

conducted in Indonesia comparing the MED in the adults and elderly patients did not find significant differences. In the study, the mean 24-hour MED in the group with Fitzpatrick skin type IV was 702

± 340 mJ/cm² .¹²

The initial dose of phototherapy in the elderly as well as adult patients is approximately determined based on the skin types or MED test. Some authors recommended an initial dose starting from 50% of the MED instead of the standard 70% and cautious dose increment. ¹³In this case report, 75% of the MED was administered as an initial dose, which was 200 mJ/cm². A dose increment of 10% was administered in every session twice weekly if there was no erythema. In this case report, the first repigmentation occurred on the 5^th session in the first patient and the 6^th session in the second patient, with a cumulative dose of 1223 mJ/cm² and 1541 mJ/cm², respectively. In both patients, homogenous repigmentation (more than 50%) occurred on the face, trunk, and legs, but there was only partial repigmentation (less than 50%) on the hands and feet. Thus, localized NB-UVB phototherapy was directed at the hands and feet, but the results were not satisfying.

Whole-body phototherapy reached a maximum dose of 1120 mJ/cm² (47^th session) and 1384 mJ/cm² (53^rd session) in the first and second patients, respectively. According to the standard protocol for NB-UVB treatment for vitiligo, a dose should not exceed 600 mJ/cm² unless otherwise adjusted by the doctor.¹⁴ In this case report, dose increments higher than 600 mJ/cm² were given cautiously until slight erythema occurred. These dose increments were 1120 mJ/cm² and 1384 mJ/cm² for the first and second patients, respectively. Phototherapy side effects such as erythema and pain occurred in both patients.

Thus, phototherapy was continued with the dose reduced by 25% the last administered dose after the adverse events had resolved.

Topical treatments for vitiligo include corticosteroids, coal tar, calcineurin inhibitors, and vitamin D analogs. Ichthammol (shale tar) has been used in the past and is still being used today as an anti-inflammatory agent, but its exact mechanism of action is unknown.¹⁵ Combination therapies improve repigmentation.¹⁶

In this report, both patients were treated with topical treatments and phototherapy.

Phototherapy combined with topical treatments had caused therepigmentation to occur within the first two months after starting treatment in both patients.

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Studies evaluating the use of NB-UVB phototherapy in adult patients with vitiligo have been widely available, but little is known about its safety and efficacy in geriatric patients. To our knowledge, there is only one study evaluating the use of NB-UVB phototherapy in geriatric patients with vitiligo. A retrospective study from the same hospital on nine patients (including the two patients in this case report) revealed that the median number of sessions to achieve initial repigmentation was six sessions (range: 3–14 sessions), and the median cumulative dose to reach initial repigmentation was 1500 mJ/cm².¹⁷ Another study, including 25 patients aged 18–64 years with vitiligo, reported that repigmentation was achieved after a median number of 97 sessions (range: 16–200 sessions) and a median cumulative dose of 69000 mJ/cm². The reported cumulative dose administered to achieve repigmentation was much more higher compared with our cumulative dose. This could be explained by the difference in age groups of the study subjects and the study design.¹⁸ Similar to the studies evaluating the use of NB-UVB phototherapy in adult patients with vitiligo, the regions on the face responded the fastest, followed by the trunk, while the hands and feet showed the slowest response.^3,6,19 Skin of the elderly is more sensitive to ultraviolet exposure and has a slower healing response. Therefore, clinicians need to be more cautious about the side effects (e.g., erythema, burning, and pain) when administering phototherapy to these patients. In this case report, with appropriate dose adjustments, phototherapy could still be continued in the two patients after the symptoms had subsided.

The duration of treatment in order to achieve homogeneous repigmentation seems to be longer in geriatric patients compared with the general patient population. A clinical trial studied 25 patients with age ranging from 12 to 37 years with Fitzpatrick skin types III–V who received NB-UVB phototherapy. They found that the majority of patients (36%) achieved 26–50% repigmentation in six months (20), while, in this case report, both patients achieved homogenous repigmentation after 12 months and 19 months of NB-UVB treatment.²⁰

Conclusion

We reported two geriatric patients with vitiligo who received NB-UVB phototherapy and it was well tolerated and effective. We noted that good patient’s compliance was an important contributing factor for successful phototherapy

treatment in geriatric patients. Hands and feet were less responsive to treatment than face, neck, and trunk. However, little is known about the safety and efficacy of phototherapy in elderly patients with vitiligo. Therefore, further investigation is needed.

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