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- Materials and Methods
Abstract: Background: Little data exist about the efficacy of phototherapy in childhood dermatoses. Objective: To report our experience with pediatric patients treated with phototherapy. Methods: The study included children ≤17 years of age, who were treated in our phototherapy unit between 1985 and 2005. Data were retrospectively collected. Results: The study included 113 patients (50 boys, 63 girls) with a median of age of 13 years (range: 3–17 yrs). Narrow-band ultraviolet-B (34.6%), and ultraviolet-B (33.1%) were the most common treatments administered to the patients. Indications for phototherapy were psoriasis in 53.5%, vitiligo in 20.5%, pityriasis lichenoides in 14.2%, alopecia areata in 7.9%. Response was achieved in 92.9% of the psoriasis patients treated with narrow-band ultraviolet-B, in 83.3% treated with psoralen plus ultraviolet-A, and in 93.3% with ultraviolet-B. All the pityriasis lichenoides chronica patients who received narrow-band ultraviolet-B responded to the treatment and seven of nine treated with ultraviolet-B had a response. Response was achieved in 57% of the vitiligo patients treated with psoralen plus ultraviolet-A and in 50% of vitiligo patients treated with narrow-band ultraviolet-B. Of the 10 alopecia areata patients, two responded to psoralen plus ultraviolet-A. Among all the patients, erythema was the most common adverse effect. Conclusion: Phototherapy is a well-tolerated treatment for childhood dermatoses, and is especially efficacious in psoriasis and pityriasis lichenoides chronica patients.
In some childhood dermatologic disorders, particularly psoriasis and pityriasis lichenoides chronica (PLC), phototherapy is reported to be effective (1), and in terms of side effects it is comparable to systemic treatments. Short-term side effects of phototherapy, which include erythema, burning, pruritus, and xerosis, are usually mild and transient. Long-term effects of major concern are premature aging of the skin and increased carcinogenesis (1). The most common fear clinicians experience, when considering administering phototherapy to children, is the long-term risk of carcinogenesis. The association of nonmelanoma skin cancers with phototherapy in adults is well established (2–4). The risk of nonmelanoma skin cancer is reported to be related to patient race and type of phototherapy. One study has shown that the risk (especially squamous cell carcinoma) is significant, particularly in the Caucasian population (5). Recently, Murase et al (6) reported that there is no increased risk of nonmelanoma skin cancer in the Asian and Arabian-African populations after long-term PUVA therapy. In contrast, the risk of basal cell carcinoma does not increase with prolonged phototherapy, and the risk of melanoma in phototherapy patients remains contentious (3,5,6). Some studies showed UVB carcinogenicity in animals and revealed that narrowband UVB is more carcinogenic than broadband UVB (7). Despite numerous studies about the safety of phototherapy in adults, studies on the long-term risks of phototherapy in children are lacking. Epidemiologic studies have confirmed the relationship between sun exposure and melanoma in children (8,9), but the relationship between childhood sunburns and subsequent melanoma is unclear. A recent study stated that the number of sunburn events is more critical than the age at which they occur (10).
Prolonged life expectancy, the possibility of requisite repeated treatment courses for recurrent disorders, and the inconveniences associated with administering phototherapy to pediatric cases has limited the use of phototherapy in children. Therefore, little data exist about the efficacy of phototherapy in childhood. We report our 20-year experience (1985–2005) with pediatric patients treated with phototherapy.
Materials and Methods
- Top of page
- Materials and Methods
In our department, phototherapy is used in children for conditions that are widespread, severe, and difficult to control with other treatments. This study included 113 children ≤17 years of age who were treated in our phototherapy unit between 1985 and 2005. Patients above 12 years of age, and/or those resistant to UVB or narrow-band UVB therapy were given PUVA. Since the advent of narrow-band UVB in 1998, it has been preferred modality at our clinic in most cases, except alopecia areata. Data were retrospectively collected following a review of the patients’ phototherapy charts. In our phototherapy unit, a dermatologist and two technicians work together. The technicians administer the treatment, record the doses, and consult the dermatologist when a response and/or side effect occurs. Consequently, the demographic data of the patients, data about phototherapy sessions, doses and any adverse events as well as responses are recorded in a special phototherapy chart.
A Waldmann UV 8001K cubicle with 27 UVA and 13 UVB fluorescent lamps was used for PUVA and UVB treatments (Waldmann Lichttechnik Gmbtt, Schwenningen, Germany).
A Dr. K. Hoenle cabin (D-8033, RingoDermalight, Martinsried, Germany) equipped with 45 Philips TL100W/01 fluorescent lamps (Philips, Eindoven, The Netherlands) was used for narrow-band UVB and PUVA therapy.
Initially, all treatments were given three times per week and were reduced to twice or once per week when the patients responded. Narrow-band UVB was initially administered at 70% of the minimal erythema dose and treatment continued with 20% dose increases at each subsequent session. For PUVA the initial dose was 0.5 J/cm2, followed by subsequent increments of 0.5 J/cm2. PUVA was administered only to children >12 years of age. UVB treatment began with a dose of 0.1 J/cm2 and was subsequently increased by 0.01–0.03 J/cm2 per treatment, according to a standard protocol.
During the treatments all the patients wore UV-blocking goggles and their genitals were shielded from UV exposure. They were advised to protect themselves from sunlight throughout the treatment period.
Psoriasis was considered generalized if 30–50% of the body surface was involved. In PLC patients distribution was categorized as central if the face, trunk, and inguinal region were involved, peripheral if the upper and lower extremities, palms, and soles were involved, and when both the trunk and extremities were involved the distribution was characterized as diffuse, based on Gelmetti et al (11).
Vitiligo distribution was categorized as generalized if there was more than one general area of involvement, localized if it was restricted to one area, and segmental if it had a dermatomal distribution. Alopecia totalis was considered as total loss of scalp hair and alopecia universalis was considered as loss of all body hair.
In psoriasis and PLC patients, if there was >75% improvement in the rash, which led to a decrease in the frequency of treatment, it was considered a response. Response was accepted as >50% re-pigmentation in vitiligo patients and light colored vellus-type hair growth on >50% of the alopecic area in alopecia areata patients.
Percentages were calculated based on the cases for which clinical features were known. All the analyses were performed with spss v.11.5 with Statistical Package for Social Sciences (SSPS Inc., Chicago, IL, USA). Krusskal–Wallis, Mann–Whitney U-test, and student’s t-test were used for comparison of the groups.
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- Materials and Methods
The study included 113 patients (50 boys, 63 girls) aged 13–17 years (median: 13 yrs) who received a total of 127 courses of treatment. Patients <12 years of age constituted 38.9% of the group (Fig. 1). Patients were given phototherapy for psoriasis, PLC, vitiligo, alopecia areata, and other diseases.
Narrow-band UVB (34.6%) and UVB (33.1%) were the most common treatments administered to the patients (Fig. 2). Indications for phototherapy were psoriasis in 53.5% (n = 68) of the patients, vitiligo in 20.5% (n = 26), PLC in 14.2% (n = 18), alopecia areata in 7.9% (n = 10), and other diseases in the remainder (3.9%, n = 5) (Fig. 3).
Psoriasis (n = 68)
Psoriasis (53.5% of the study population) was the most common indication for which phototherapy was used in this study. Median age of the psoriasis patients was 12 years (range: 5–17 yrs) and 64.7% (n = 44) were girls. UVB phototherapy was the most common treatment modality applied (n = 30, 44.1%), followed by narrow-band UVB (n = 28, 41.2%), and seven patients (three with guttate, three with plaque and one with guttate and plaque type) (10.3%) were treated with PUVA. In addition, two patients with palmoplantar involvement were treated with topical meladinine and UVA, and one patient was treated with local UVA (data not shown). The most common presentation was guttate-type psoriasis, which was seen in 59 patients (86.8%), seven of whom also had plaques. All the patients with guttate psoriasis and plaque psoriasis (n = 6) had generalized involvement. Diagnosis was made clinically in all the patients, which was confirmed by histopathologic examination in 12 patients. Response was achieved in 92.9% of the patients treated with narrow-band UVB (n = 26), in 83.3% treated with PUVA (n = 5), and in 93.3% treated with UVB (n = 28). The mean number of treatments required for a response in psoriasis patients was 28 with PUVA treatment, 18.5 with UVB, and 16 in those treated with narrow-band UVB, and the differences were not statistically significant (p = 0.5) (Table 1). Mean number of treatments required for a response was 36.5 (n = 4) in plaque-type and 16 in guttate psoriasis (t = 0.02).
Table 1. Features of the Patients with Psoriasis
| Phototherapy (n = 68)||Age (yrs)||No. sessions||No. sessions for response||Treatment duration (mos)|| Total dose (J/cm2)|| Max. dose (J/cm2)|| Response rate (%)|
|PUVA (n = 7)||15 ± 0.7||108 ± 68.5||28 ± 22.8||27.7 ± 26.3||498.8 ± 377||5.2 ± 2.0||83.3 (n = 5)|
|Narrow-band UVB (n = 28)||12 ± 2.5||25.8 ± 10.6||16 ± 6.6 || 3 ± 1.4|| 20 (3–85)||1 (0.3–6)||92.9 (n = 26)|
|UVB (n = 30)||11 ± 3.6||28.8 ± 13.3||18.5 ± 8.3|| 4 (1–8)|| 21 ± 15.7||0.82 (0.2–8.2)||93.3 (n = 28)|
Pityriazis Lichenoides Chronica (n = 18)
Mean age of the PLC patients was 9.9 years (range: 3–16 yrs) and the male to female ratio was 3.5:1 (14 vs 4). Diffuse distribution was noted in 40% (n = 4), and the remainder had either central (n = 3, 30%) or peripheral (n = 3, 30%) distribution. Diagnosis was confirmed by histopathologic examination in seven patients. UVB, the most common treatment for PLC, was given to 66.7% (n = 12) of the patients, followed by narrow-band UVB (27.8%, n = 5) and PUVA (5.6%, n = 1). The mean duration of UVB treatment was 3.7 months (range: 2–9 mos). The patients received a median cumulative dose of 11 mj/cm2 (range: 4–60 mj/cm2) and the mean number of treatments for response was 18. Mean maximum dose was 0.72 ± 0.32 mj/cm2. Response was achieved in 83.3% (n = 10) of the patients. All five children who were treated with narrow-band UVB responded and the mean number of treatments for response was 22. One patient who received PUVA, however, did not respond to the treatment as he continued to have new lesions, which were later controlled by systemic steroids.
Vitiligo (n = 26)
Of the 26 vitiligo patients (12 boys, 14 girls), nine (34.6%) were treated with narrow-band UVB, eight (30.8%) with PUVA, and nine with topical meladinine and UVA. Generalized distribution was noted in 61% (n = 11) of the patients and the remainder had localized disease (n = 7). Response (>50% re-pigmentation) was achieved in 57% of the vitiligo patients treated with PUVA (n = 4) and 50% of those treated with narrow-band UVB (n = 4); median number of treatments for response was 24.5 (range: 17–106) and 14 (range: 9–107), respectively (Table 2). Of the nine patients treated with topical meladinine and UVA, only two had re-pigmentation.
Table 2. Features of the Patients with Vitiligo
| Phototherapy (n = 26)||Age (yrs)||No. sessions||No. sessions for response||Treatment duration (mos)|| Total dose (J/cm2)|| Max. dose (J/cm2)|| Response rate (%)|
|PUVA (n = 8)||16 (14–16)||105.2 ± 62.5||24.5 (17–106)||17.3 ± 11.8||303 ± 235||3.5 ± 1.9||57 (n = 4)|
|Narrow-band UVB (n = 9)||10.6 ± 3.3|| 84.8 ± 58.3||14 (9–107)|| 8.5 ± 5.8|| 70 (9–301)||1.48 (0.82–3.34)||50 (n = 4)|
|Topical meladinine with UVA (n = 9)||13 ± 1.6|| 50 (25–159)||23.7 ± 34|| 7 (3–33)||256 ± 227||4.2 ± 1.7||28.5 (n = 2)|
Alopecia Areata (n = 10)
All the patients with alopecia areata were treated with PUVA, except for two who received only UVA because of the side effects of psoralen. PUVA was administered for alopecia areata (n = 3, 30%), alopecia totalis (n = 4, 40%), and alopecia universalis (n = 3, 30%). Median age of the patients was 15 years (range: 10–16 yrs). Mean duration of PUVA treatment was 8.7 months (range: 2–21 mos), mean cumulative dose was 271.7 ± 98.5 mj/cm2, and mean total sessions was 48.5 (range: 26–65). Only two patients (30%) responded with complete hair growth, both of whom had alopecia universalis, and their mean total PUVA sessions was 56.
Other Disorders (n = 5)
Other disorders included mycosis fungoides (n = 1), lichen planus (n = 1), pityriazis lichenoides et varioliformis acuta (PLEVA) (n = 1), pigmented purpuric dermatitis (n = 1), and parapsoriasis (or chronic superficial perivascular dermatitis) (n = 1). The patient with mycosis fungoides, a 15-year-old male, received PUVA treatment and >75% improvement of the rash occurred at the 30th session. Even though his lesions improved markedly, he was given long-term maintenance therapy, as our treatment protocol is long-term maintenance therapy for patients with mycosis fungoides to prevent relapse. The total number of treatments he received was 373, with a cumulative dose of 1400 mj/cm2. The patient was completely clear of the disease, both clinically and histopathologically at the end of the treatment; however, he relapsed 6 years later.
Concomitant medications such as keratolytics, topical corticosteroids, and topical calcipotriol were given to 43 patients (35%) (Table 3).
Table 3. Distribution of Concomitant Medication Use
|Concomitant medication||Psoriasis (n)||Vitiligo (n)||PLC (n)||Other (n)|
|Keratolytics (salicylic acid preparations) (n = 11)||11||–||–||–|
|Topical corticosteroids (n = 24)||17||2||4||1|
|Topical calcipotriol (n = 7)||3||4||–||–|
|Oral retinoid (n = 1)||1||–||–||–|
|Total (n = 43)||32||6||4||1|
Among all the patients and treatment modalities, erythema (51.6%) was the most common adverse effect, which occurred in 76% of patients treated with narrow-band UVB, and in 40% and 33% of those treated with UVB and PUVA, respectively (p = 0.001). Pruritus and burning occurred in 24 (18%) and 12 (9%) patients, respectively.
Multiple Treatment Courses
Of the 113 children in this study, 11 (10%) received >1 treatment course. Of these, seven had psoriasis, three had PLC, one had alopecia areata, and one had vitiligo. In patients who received >1 treatment course for psoriasis and PLC, the mean number of courses was 2.1 (range: 2–3).
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- Materials and Methods
Studies regarding the efficacy of phototherapy in children with inflammatory skin disorders are scarce. The literature contains mostly reviews and advice from experts in the field (1,12). To the best of our knowledge this is the largest study of children treated with phototherapy. In this study the mean number of treatments required for a response in psoriasis patients was 28 with PUVA, 18.5 with UVB, and 16 with narrow-band UVB. In addition, the response rate in psoriasis patients was 83.3% with PUVA, 93.3% with UVB, and 92.9% with narrow-band UVB. Plaque-type psoriasis required more sessions (36.5) than guttate psoriasis (16) for a response and the difference was statistically significant. In vitiligo patients >50% re-pigmentation was noted in 57% of the patients treated with PUVA and in 44.4% of those treated with narrow-band UVB. All the PLC patients (100%) who received narrow-band UVB responded to the treatment, whereas 77.8% of those treated with UVB had a response; mean number of treatments for response was 22 and 18, respectively.
Phototherapy is usually recommended for children with psoriasis who fail to respond to conventional treatments (13). Tay et al (14) reported good results in children with UVB therapy, especially for psoriasis and PLC. According to their study, the mean number of treatments required for clearance of psoriasis in 10 children (six with guttate psoriasis, four with chronic plaque-type) was 36. They reported that patients with chronic plaque psoriasis required higher doses for clearance and longer duration of treatment to clear (mean: 17 wks). The response rate in other studies range between 65% and 88%, with a mean of 19–25 treatments for clearance (15–17).
Vitiligo, which usually begins between 4 and 8 years of age (18,19), is a challenging disease for dermatologists due to the lack of efficacious treatments. Phototherapy is one of the most preferred treatment modalities for vitiligo, yet the literature contains few studies about the efficacy of its use in childhood vitiligo (20–22). Systemic PUVA is not recommended for children <12 years of age because of its systemic side effects; therefore, topical PUVA is preferred in young children. In the absence of more effective treatments, it has been suggested that a 3-month trial period of PUVA treatment may be used to assess treatment response (1). Currently, narrow-band UVB seems to be a valuable and safe treatment option for childhood vitiligo, as it is well tolerated, and side effects are minimal and transient. Kanwar et al (21) reported a 75% marked to complete re-pigmentation in 20 children treated with narrow-band UVB and the average number of courses required for 50% re-pigmentation was 34. In another study, >75% re-pigmentation was noted in 58% of 51 children treated with narrow-band UVB (22).
Pityriasis lichenoides chronica is a reactive lymphocytic disorder that often occurs during childhood. According to the literature, phototherapy is a good alternative for childhood PLC patients who do not respond to conventional treatments (11,14,23,24). Mean number of UVB treatments for clearance ranges between 26 and 33.2 (23,24). In a study of narrow-band UVB therapy (6), it was reported that 66.6% of the patients with pityriasis lichenoides (PLC and PLEVA) had excellent or good responses with an average of 19 treatments for clearance.
Treating alopecia areata with PUVA has been reported to be ineffective (25,26); however, Whitmont and Cooper (27) reported promising results with complete hair regrowth occurring in 53% of alopecia totalis and 55% of alopecia universalis patients. Our results were not satisfactory because of only two alopecia universalis patients showed regrowth of their hair.
In conclusion, this study has some limitations because of its retrospective nature but despite this we think that it is a valuable addition to the literature due to the size of the study population. This study showed that phototherapy is an effective and well-tolerated treatment modality for childhood dermatoses, especially psoriasis, PLC, and vitiligo. Although narrow-band UVB therapy had similar outcomes as UVB treatment, we would like to point out that narrow-band UVB therapy was the most common modality that caused erythema; therefore, it should be used vigilantly. As the carcinogenic potential of phototherapy remains to be elucidated, it should be used cautiously in selected children.