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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 157-161

Evaluation of narrowband ultraviolet B phototherapy in patients with generalized lichen planus


Department of DVL, GSL Medical College, Rajahmundry, Andhra Pradesh, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Dr. Raghurama Rao Gandikota
Department of DVL, GSL Medical College, Rajahmundry - 533 296, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_21_18

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  Abstract 


Background: Lichen planus (LP) is a chronic inflammatory pruritic dermatosis affecting people of all ages and both sexes. Various therapeutic modalities have been tried in acute generalized LP with limited success. Currently, narrowband ultraviolet B (NB-UVB) therapy is being used to treat various inflammatory diseases. There are limited published studies in the literature to evaluate the efficacy of NB-UVB therapy in LP.
Aim: To evaluate the efficacy, tolerability, and safety of NB-UVB therapy in acute generalized LP in both children and adults clinically and to observe relapse on follow-up.
Materials and Methods: This was a prospective, open, and nonrandomized study. The study group included 70 patients of both sexes with a mean age group of 5–65 years. For the purpose of the study, a template of 5 × 5 cm with a high density of lesions was taken in addition to general response and photographic evaluation before and after treatment. A starting dose of 150 mJ/cm2 was started given twice weekly on nonconsecutive days with a 20% increment on every third exposure. The clinical response was graded on a four-point scale (excellent to poor). All cases who responded were observed for a period of 6 months for relapse. Appropriate statistical methods were employed.
Results: In this study, excellent response was seen in 35 patients (mean: 25.7 exposures), good response in 11 patients (25.3 exposures), fair response in 9 patients (50 exposures), and poor response in 5 patients (50 exposures) (P-value = 0.000). A relapse rate of 9% after 6 months of follow-up and 36% after 1-year follow-up was observed (P-value = –0.002).
Limitations: As the sample size of this study is small, large studies are needed to establish the efficacy of NB-UVB therapy in acute generalized LP.
Conclusion: NB-UVB therapy is an effective and safe modality of treatment for acute generalized LP in both children and adults. Approximately, 20–25 exposures are needed to get good response. Prolonged remission is obtained with NB-UVB therapy.

Keywords: Acute generalized lichen planus, clinical response, narrowband ultraviolet B phototherapy, relapse


How to cite this article:
Arumilli KP, Gandikota RR, Arumilli PC. Evaluation of narrowband ultraviolet B phototherapy in patients with generalized lichen planus. J NTR Univ Health Sci 2018;7:157-61

How to cite this URL:
Arumilli KP, Gandikota RR, Arumilli PC. Evaluation of narrowband ultraviolet B phototherapy in patients with generalized lichen planus. J NTR Univ Health Sci [serial online] 2018 [cited 2018 Dec 18];7:157-61. Available from: http://www.jdrntruhs.org/text.asp?2018/7/3/157/241280




  Introduction Top


Lichen planus (LP) is a chronic inflammatory pruritic dermatosis accounting for approximately 1% of all dermatologic disorders among patients seeking dermatologic care. The management of generalized LP is often challenging unlike that of the localized forms. Various therapeutic modalities, such as systemic corticosteroids, retinoids, cyclosporine, dapsone, griseofulvin, etc., have been tried with varying response and serious side effects. Of late, narrowband ultraviolet B (NB-UVB) therapy has been found to be an effective and safe modality to treat various inflammatory diseases.[1] Till date, no studies are available to evaluate the efficacy, tolerability, and safety of NB-UVB therapy in the treatment of generalized LP in Indian patients. Very few studies have been published on this subject in world literature.[2],[3],[4],[5],[6],[7] In view of the paucity of experience of NB-UVB therapy in generalized LP, this study has been undertaken to evaluate the efficacy, tolerability, and safety of NB-UVB phototherapy.


  Materials and Methods Top


This study was approved by the Institutional Ethics Committee and consent from all patients was obtained before starting the study. The study period was for 2 years including follow-up. This study was prospective, open, and nonrandomized. The study group included 70 patients of all ages and both sexes with generalized LP. Patients with more than 50% body surface area involvement and patients with systemic diseases such as diabetes and hypertension were also included. Patients who are on immunosuppressive drugs, or having photosensitive disorders, personal or family history of cutaneous malignancies, or suffering from claustrophobia were excluded. Detailed history and demographic data were taken, and general and systemic examinations were carried out. Those who were on various topical and systemic therapies were asked to stop these medicines for a period of 2 weeks before NB-UVB therapy. Relevant hematological and biochemical investigations were carried out in all patients.

For the purpose of clinical evaluation, lesional count was taken into consideration for which a 5 × 5 cm template with maximum number of lesions was used as the study area in a patient. The number of active and palpable lesions were counted in the study area at the start of treatment and every 10 exposures thereafter till the end of treatment. At the same time, clinical photograph of the template (study area) and body lesions were taken. Simultaneously, the entire body was also examined for response. Grading of clinical response is shown in [Table 1].
Table 1: Grading of clinical response

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Equipment used

  1. Whole-body NB-UVB unit with 24 tubes (TL-01) 100 W/6 ft (Philips) – for adults
  2. NB-UVB panel with 12 tubes (TL20W/01-RS) 4 ft (Philips) – for children


Treatment protocol

Standard NB-UVB therapy safety measures were followed, such as wearing UV blocking goggles, protection of genitalia, etc. As most of the patients were of Fitzpatrick's skin type IV and V, the minimal erythema dose was not calculated. The whole body including the area of study (template) was exposed to NB-UVB. A starting dose of 150 mJ/cm 2 was started in all patients. The exposures were given twice weekly on nonconsecutive days, with a 20% increment in the dose on every third exposure. The maximum duration of treatment was 50 exposures or 6 months, whichever is earlier. When the patients got a satisfactory response (either good or excellent response), the treatment was stopped even before 50 exposures. If no response was noticed after 50 exposures or 6 months, patient was withdrawn from the study. All cases who responded to the treatment were observed for a period of 6 months to 1 year for relapse of lesions anywhere over the body.

Statistical methods

The statistical analysis was performed by using Statistical Package for the Social Sciences (SPSS) 16.0 software trial version and MS Excel 2007. The descriptive analysis was presented in the form of mean ± standard deviation (SD) and percentages. Student's t-test was performed to compare the means and the Chi-square test was performed to find the association among the study variables. P < 0.01 was considered statistically significant.


  Results Top


Out of 70 patients, there were 37 males and 33 females, with ages ranging from 5 to 65 years and an average age of 32.6 years. There were six diabetics. The mean duration of the disease was 1.3 months. There were 16 children <12 years of age in the study group. Ten patients dropped out of the study after few exposures and 60 completed the study including follow-up. The clinical response of 60 patients details is given in [Table 2].
Table 2: Details of clinical response

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Clinical photographs before and after treatment are shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 1: (a)Template before NB-UVB therapy. (b) After 25 exposures

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Figure 2: (a) Before NB-UVB therapy. (b) After 20 exposures

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Figure 3: (a) Before NB-UVB therapy. (b) After 25 exposures

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Figure 4: (a) Before NB-UVB therapy. (b) After 20 exposures

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Adverse effects

Six patients complained of erythema, burning sensation, and blistering, following 5–10 exposures. These were treated by topical corticosteroids and the treatment was restarted with 50% of the dose after a period of 1 week.

Follow-up

Fifty-five patients who have responded to NB-UVB therapy were followed up for a period of 6 months. In 5 patients (9%) relapse was noticed after a mean duration of 3.2 months of discharge from treatment. In 30 patients, who were followed up to a period of 1 year, relapse was observed in 11 patients (36%) after a mean duration of 8.4 months of discharge from treatment.

Statistical analysis

The results of statistical analysis are mentioned in [Table 3] and [Table 4].
Table 3: Clinical analysis

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Table 4: Analysis of relapse

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The mean difference between the number of lesions before and after treatment with NB-UVB was statistically highly significant (P = 0.000) among both children and adults.

There is a statistically significant (P = 0.002) association of relapse with the follow-up time.


  Discussion Top


Various therapeutic modalities have been tried in the management of generalized LP with varying results and limited success. These modalities are also associated with various adverse effects. NB-UVB therapy is the administration of ultraviolet radiation in the wavelength of 311 nm. NB-UVB radiation is absorbed by the DNA and urocanic acid, thereby altering the antigen presenting cell activity. As LP is an immunological disorder, NB-UVB phototherapy with all its effects on the immune system would be a valid alternative for the therapy of generalized LP. There are many advantages of NB-UVB in comparison with psoralen ultraviolet A (PUVA) with a lower risk for nonmelanoma cutaneous malignancies. Very few studies [2],[3],[4],[5],[6],[7] were published on this subject in world literature. The previous workers have measured clinical response on the basis of body surface area involvement and pruritus. But, in our study, a template of 5 × 5 cm was taken as the study area for accurate counting of lesions before and after therapy and to get an objective and accurate measure of efficacy. The response seen over the template was also reflected in other areas of body involvement. Pruritus was not considered for evaluation in this study, as generalized LP is very difficult to manage without systemic antihistamines, and NB-UVB therapy is a prolonged treatment modality.

In this study, excellent response (76–100% decrease in lesions in study area) was seen in 35 patients after a mean of 24.7 exposures and a mean cumulative dose of 5200 mJ/cm 2, good response (51–75% decrease) was seen in 11 patients after a mean of 25.3 exposures and a mean cumulative dose of 5350 mJ/cm 2, fair response (26–50% decrease) was seen in 9 patients after a mean of 50 exposures and a mean cumulative dose of 9800 mJ/cm 2, and poor response (0–25% decrease or increase in lesions) was seen in 5 patients after a mean of 50 exposures and a mean cumulative dose of 9950 mJ/cm 2. Flattening of lesions with residual pigmentation was observed. There was a statistically highly significant reduction (P-value = 0.000) in the number of lesions before and after treatment in both children and adults. Pruritus was also reduced after approximately 10 exposures of NB-UVB, and there was no need for antihistamines during the rest of the treatment in majority of the patients. Truncal lesions cleared earlier than the acral lesions. In 50 patients, the same response was reflected in other areas of involvement. In 10 patients, a variable response was observed.

Taneja and Taylor [2] were the first to report the efficacy of NB-UVB therapy of LP. They successfully treated 5 patients with a mean of 40 exposures and a mean cumulative dose of 82.7 J/cm 2, with minimum side effects. They also observed that truncal lesions cleared faster than acral lesions. Saricoaglu et al.[3] observed that after 30 exposures, 50% of 10 LP patients responded completely. Habib et al.[4] retrospectively reported the efficacy of NB-UVB therapy in the treatment of disseminated LP. They observed that a median of 30 exposures resulted in a complete response (disappearance of more than 90% of the lesions) in 11 of 20 patients (55%) and a partial response (disappearance of at least 50%) in four (20%), yielding an overall response rate of 75%. In a study of 10 patients treated with NB-UVB therapy, Wackernagel et al.[5] evaluated and compared the short- and long-term therapeutic effect of PUVA vs NB-UVB in patients with disseminated LP. They observed that, even though oral PUVA produced a better initial response rate, both PUVA and NB-UVB were effective in treatment of LP with similar long-term outcomes. A recent retrospective analysis of 50 patients with generalized LP by Pavlotsky et al.[6] treated by broad or NB-UVB, respectively, showed that complete response was achieved in 70%, and 85% of those were in remission after a median of 34.7 months. The complete response rate and need for higher cumulative dose were not influenced by sex, age, and skin type. Iraji et al.[7] found NB-UVB (up to 9 J/cm 2 three times a week) to be more effective than oral prednisolone 0.3 mg/kg for the treatment of generalized LP in a 6-week randomized clinical trial in 46 patients. Our study and the above studies show that an average of 25 exposures are needed to get good response.

In this study, children responded faster with less number of exposures and less cumulative dose when compared to adults. This finding is statistically significant. The coefficient of variance of number of lesions after treatment of children (CV = 166) is more compared to adults (CV = 128). In addition, no adverse effects were observed in children.

Transient side effects such as erythema and burning sensation were noticed in 6 patients and were easily treated with topical corticosteroids. In previous studies, similar side effects were reported. On the whole, the compliance of patients with this treatment is very good.

In this study, the relapse rate was 9% after 6 months of follow-up, whereas a relapse rate of 36% after 1 year of follow-up was observed. Pavlotsky et al.[6] observed a long-term remission in 85% patients after a median of almost 3 years. Hence, this study and other previous studies show that prolonged remission can be obtained with NB-UVB therapy.

It is unlikely that our study outcomes were due in any way to spontaneous remission, because the lesions responded relatively quickly (10 weeks) to NB-UVB therapy. It has been observed that spontaneous remission can occur in LP over 15 months.


  Conclusions Top


Though the exact mechanism of improvement of LP remains elusive, various studies, including ours, suggest NB-UVB therapy as an alternative, viable, and safe treatment for generalized LP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sardana K, Goel K. Systemic treatment of lichen planus. In: Khopkar U, Valia A, editors. Lichen planus. 1st ed. NewDelhi: Jaypee brothers; 2013. p. 210-7.  Back to cited text no. 1
    
2.
Taneja A, Taylor CR. Narrowband UVB for lichen planus treatment. Int J Dermatol 2002;41:282-3.  Back to cited text no. 2
    
3.
Saricaoglu H, Karadogan SK, Baskan EB, Tunali S. Narrowband UVB therapy in the treatment of lichen planus. Photodermatol Photoimmunol Photomed 2003;19:265-7.  Back to cited text no. 3
    
4.
Habib F, Stoebner PE, Picot E, Peyron JL, Meynadier J, Meunier L. Narrowband UVB phototherapy in the treatment of widespread lichen planus. Ann Dermatol Venereol 2005;132:17-20.  Back to cited text no. 4
    
5.
Wackernagel A, Legan FL, Hofer A, Quehenberger F, Ked H, Wolf P. Psoralen plus UVA vs UVB-311 nm for the treatment of lichen planus. Photodermatol Photoimmunol Photomed 2007;23:15-9.  Back to cited text no. 5
    
6.
Pavlotsky F, Nathansohn N, Kriger G, Shipro D, Trau H. Ultraviolet-B treatment for cutaneous lichen planus: Our experience with 50 patients. Photodermatol Photoimmunol Photomed 2008;24:83-6.  Back to cited text no. 6
    
7.
Iraji F, Faghihi G, Asilian A, Siadat AH, Larijani FT, Akbari M. Comparison of the narrowband UVB versus systemic corticosteroids in the treatment of lichen planus: A randomized clinical trial. J Res Med Sci 2011;16:1578-82.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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