Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 16-25
Published Online November 2013 (http://www.scirp.org/journal/jcdsa)
http://dx.doi.org/10.4236/jcdsa.2013.33A2005
Open Access JCDSA
PUVA versus NB-UVB in Management of Vitiligo,
Clinico-Immuno-Pathological Study
Sameh K. Attia, Sherif S. Awad, Siham Yacoub
Department of Dermatology and Venereology, Minia University, Minya, Egypt.
Email: sherifu@rocketmail.com
Received September 3rd, 2013; revised October 1st, 2013; accepted October 9th, 2013
Copyright © 2013 Sameh K. Attia et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Phototherapy is the most common ly used modality in the treatment of vitiligo. Oral PUVA is the classi-
cal treatment and the NB-UVB is a recently introduced form excluding the shorter erythemogenic wavelengths. Aims:
This study was designed to compare the effects of PUVA and NB-UVB clinically and imm uno-pat hologi cally i n managing
non segmental vitiligo. Patients/Methods: Thirty vitiligo patients were divided randomly into two groups and treated
either by oral PUVA or by narrow band UVB for 4 months, and evaluation was done clinically and immuno-pathologi-
cally. Results: One patient in PUVA group (3.3%) failed to respond to therapy while 29 patients (93.3%) improved
including all NB-UVB cases. Excellent repigmentation was achieved in 6.7% in PUVA group and 66.6% in NB-UVB
group; good repigmentation was achieved in 60% in PUVA and 20% in NB-UVB while 26.7% in PUVA and 13.3% in
NB-UVB showed mild repigmentation. The color matching was excellen t in all NB-UVB patients. Recurrence and ac-
tivation of vitiligo were demonstrated in some NB-UVB cases and were less in PUVA treated cases. Microscopic ex-
amination revealed persistence of dermal lympho-histiocytic infiltrate and the interface changes in biopsies from
vitiliginous lesions treated with NB-UVB more than with PUVA. Conclusions: NB-UVB provides significant better
results than oral PUVA in managing non-segmental vitiligo. Although NB-UVB therapy gives a rapid effect, yet the
observation of recurrences and d evelopment of new lesions of vitiligo were less sign ificant with PUVA. It was also ob-
served that PUVA has better immuno-modulatory effect on vitiligo than NB-UVB and may give better response on a
longer period of time.
Keywords: PUVA; Vitiligo; NB-UVB
1. Introduction
Vitiligo is an acqu ired pigmentary disorder characterized
by loss of melanocytes from the skin and subsequent
development of depigmented patches of variable sizes,
which may enlarge and coalesce to form extensive areas
of leukoderma [1].
Treatment modalities aim to stimulate melanocyte pro-
liferation or interfere with inflammatory factors affecting
melanocyte structure or function; however, no single
treatment method has been found to be consistently ef-
fective, with relatively few side effects [2]. Ultraviolet
irradiation is among the many possible approaches and is
divided into ultraviolet A (UVA) (320 - 400 nm), ultra-
violet B (UVB) (290 - 320 nm) and ultraviolet C (UVC)
(200 - 290 nm) [3]. PUVA (psoralen followed by irradia-
tion with UVA) has be en a well established management
of non-segmental vitiligo since the last century [4]. Nar-
row-band UV-B therapy was introduced recently as new
light therapy which emits a concentrated UVB source of
311 nm and has been shown to have a profound thera-
peutic efficacy for the treatment of skin conditions in-
cluding vitiligo [5].
The aim of this work is to study and to compare the
effects of PUVA versus narrow band UVB (NB-UVB)
treatment on vitiligo patients clinically and immuno-
pathologically.
2. Patients and Methods
This study was conducted on 30 vitiligo patients attend-
ing the out-patient clinic of Dermatology & Venereology
Department, Minia University Hospital after obtaining
their consen t and approv al of the local ethical committee.
These patients were divided randomly into two groups:
15 patients were treated by PUVA and 15 patients were
PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study 17
treated by NB-UVB.
Vitiligo patients included in the study had non seg-
mental vitiligo in generalized or localized forms. Exclu-
sion criteria enclosed: patients receiving treatment in the
last 2 months, patients with light sensitive or aggravated
dermatoses, patients with or giving past history of skin
tumors, patients with aphakia or cataract. PUVA treat-
ment group also excluded children, pregnant or lactating
female patients and patients with abnormal liver or renal
functions.
All patients were subjected to full history taking in-
cluding, general clinical examination including: abdomi-
nal, chest, cardiac, ophthalmological and ENT examina-
tion, dermatological examination including the type and
extent of vitiligo and complete routine laboratory inves-
tigations, including complete blood picture and liver and
kidney function tests. Repeated laboratory tests were
performed every two months after starting treatment in
patients w ho were treated by PU VA.
In PUVA group, the patient ingested 8-MOP at a dose
of 0.4 mg/kg of body weight/session on a full stomach 1
and half hour before UVA exposure. The UVA cabinet
used was UV compact irradiation cabinet COSMEDICO
Medizintechnik, GP-42, Germany. Patients received 2
PUVA sessions/week. The starting dose was 2 J/cm2,
which is a common starting dose for patients in similar
skin type [6] and 25% dose increment was provided
every next session [7 ] guided by the p atients response till
asymptomatic erythema was observed. Erythema reading
for PUVA treated patients was performed at 72 hours
after UVA irradiation [6]. The last previous reading was
utilized as the therapeutic dose throughout the 4 months
of therapy. Patients were instructed to wear protective
goggles during UVA exposure and sunglasses for 12 hours
after the session. The genital area was shielded in all cases.
In NB-UVB group, patients received 2 NB-UVB ses-
sions/week. The starting dose was 0.574 J/cm2, which is
the starting dose of skin type IV, according to manufac-
ture instructions and 25% dose increment was done every
next session guided by th e patients’ response, till asymp-
tomatic erythema was observed. Erythema reading for
NB-UVB treated patients was performed at 24 hours
after UVB irradiation [8], the previous dose was utilized
as the therapeutic dose throughout the 4 months of ther-
apy. NB-UVB phototherapy cabinet used was COS-
MEDICO Medizintechnik, GH-8 ST, Germany, contain-
ing fluorescent TL-01 (100 W) tubes as the source of
irradiation.
Every patient was photographed before the start of
treatment then repeatedly every two months throughout
PUVA and NB-UVB treatment.
Skin biopsies were harvested from each patient before
PUVA and NB-UVB therapy (1 biopsy from the center
of the vitiliginou s area) and after 4 months of PUVA and
NB-UVB therapy (2 biopsies; one from the non-responding
areas and the other biopsy from the repigmented areas).
Three and half millimeter punch skin biopsies were used
to obtain all samples after Mepivacaine HCL 3% local
anesthesia. Biopsies were fixed in 10% formalin and
embedded in paraffin blocks and sectioned by microtome
into 5 µm thick sections. The resulting sections were
mounted on glass slides and subjected to histopathologi-
cal examination using Hematoxyline-Eosin, Fontana
Masson and immunohistochemical staining using mela-
noma antigen recognized by T-lymphocyte (MART-1),
CD3, CD20 and CD68.
MART-1 antibody (1:100, Neomarker, Fremont, CA
94539, USA) recognizes an 18 KD molecular weight
MART-1 antigen which is present in endoplasmic re-
ticulum of melanocytes. It has been found to localize to
melanosomes suggesting a role in melanosomes biogene-
sis and it is useful for biological studies on melanocytes
and melanoma cells as well as for the development and
monitoring of immunotherapy for the patients with
melanoma [9]. CD3 marker (1:200, Dako, code No./M
7254) is a Pan-T lymphocyte marker. It recognizes CD3
antigen which is a pan-T cell antigen, composed of 5
invariable polypeptide chains. CD20 marker (1:400, Da-
ko, code No./M 0755) is a pan-B lymphocyte marker. It
recognizes CD20 antigen which is present in the B lym-
phocyte. CD68 marker (1:300, Neomarkers Fremont, CA,
Lot: 397P601A) recognizes CD68 antigen which is pre-
sent in the cytoplasm of histiocytes. This marker is im-
portant for identifying histiocytes in tissue sections.
After 2 and 4 months of therapy, we evaluated the pa-
tients subjectively into improvement or failure. The pa-
tients who showed improvement were evaluated objec-
tively by using an instrument called planimeter. The im-
proved patients were divided into three groups; excellent
group of patients when improvement ranged between
70% - 100%, good repigmentation group of patients
when improvement ranged between 40% & 70%, and
mild repigmentation group of patients when improve-
ment is less than 40%. Planimeter is a measuring instru-
ment used to measure the area of an irregular plane fig-
ure on a map or photograph . A pointer on the planimeter
is used to trace around the boundary of the shape. This
induces a movement in another part of the instrument and
a reading of this is used to establish the area of the figure.
The resulting data were analyzed with SPSS statistical
package version 12.0 (SPSS Inc., Chicago) for windows
(Microsoft Corporation, Redmond). Data were expressed
as mean ± standard deviation. Comparison between
groups of data was done by independent samples (un-
paired) t-test or ANOVA (between 2 or more groups).
Comparison between baseline data and after treatment was
done by paired t-test. The difference between compared
groups was expressed as probability of value (p value).
Open Access JCDSA
PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study
18
The difference was considered significant if p < 0.05.
3. Results
The present study was conducted on 27 female patients
(90%) and 3 male patients (10%). The age of these pa-
tients at the time of examination ranged from 7 to 52
years old. The duration of the disease prior to photother-
apy ranged from 2 months to 8 years. A positive family
history of vitiligo was present in 5 (16.6%). Regarding
skin Fitzpatrick types; 2 patients (6.6%) were skin type
III, 20 patients (66.7%) were skin type IV, 8 patients
(26.7%) were skin type V.
In PUVA treated patients, 13 female patients (86.7%)
and 2 male patients (13.3%) were included. The age of
these patients at the time of examination ranged from 21
to 52 years, with a mean of 29.8 (±1 2.09) years. The du-
ration of the disease prior to PUVA ranged from 2
months to 8 years, with a mean of 37.73 months ± 29 SD.
A positive family history of vitiligo was present in 4 pa-
tients (26.7%). The erythemogenic dose ranged from
4.883 to 7.629 J/cm2 and the therapeutic dose of PUVA
ranged from 3.906 to 6.104 J/ cm2 (Table 1). As regard
skin type, 1 patient (6.7%) was skin type III, 11 patients
(73.3%) were skin type IV and 3 patients (20%) were
skin type V (Table 1).
In NB-UVB treated patients, 14 female patients
(93.3%) and 1 male patient (6.7%) were in this study.
The age of these patients at the time of examination
ranged from 7 to 45 years with a mean of 16.2 years ±
11.02 SD. The duration of the disease prior to NB-UVB
ranged from 2 months to 8 years with a mean of 30.53
months ± 26.27 SD. A positive family history of vitiligo
was present in 1 patient (6.7%). The erythemogenic dose
ranged from 1.752 to 3.422 J/cm2 and the therapeutic
dose of UVB ranged from 1.402 to 2.737 J/cm2 (Table 1).
Regarding skin typ e, 1 patient (6.7%) was skin type III, 9
patients (60%) were skin type IV, and 5 patients (33.3%)
were skin type V (Table 1).
At the end of the second month of PUVA therapy im-
provement of the lesions occurred in 14 patients while 1
patient did not improve at all. Improvement ranged from
6 % to 37% with a mean of 17.1 3 ± 10.08 SD.
At the end of the fourth month of therapy 1 patient
(3.3%) failed to respond to therapy and the 14 patients
(93.3%) showed improvement which ranged from 10%
to 70% with a mean of 39.2 7 ± 18 .4 1 SD (Table 2).
At the end of the second month of NB-UVB therapy
all 15 patients showed improvement ranging from 12%
to 90% with a mean of 45.4 ± 21.57 SD. This difference
in the range of improvement between the two study
groups (PUVA and NB-UVB) after 2 months therapy
was statistically significant; p value = 0.0005.
At the end of the fourth month of therapy all 15 pa-
tients showed improvement which ranged from 23% to
Table 1. Data of the patients included in each group.
Items PUVA NB-UVB
Age of patients at the
start of treatment21 to 52 yrs
Mean of 29.8 ± 12.09 7 to 45 yrs
Mean of 16.2 ± 11.02
Sex 13 females (86.7%)
and 2 males (13.3%) 14 females (93.3%)
and 1 male (6.7%)
Family history 4 patients (26.7%) 1 patient (6.7%)
Skin type Type III: 1 (6.7%)
Type IV: 11 (73.3%)
Type V: 3 (20%)
Type III: 1 (6.7%)
Type IV: 9 (60%)
Type V: 5 (33.3%)
Duration of vitiligo
prior to treatment2 ms to 8 yrs
Mean of 37.73 ± 29 2 ms to 8 yrs
Mean of 30.53 ± 26.27
The therapeutic dose3.906 to 6.104 J/cm2 1.402 to 2.737 J/cm2
Table 2. Percentage of improvement after 2 and 4 months.
Study groups
Percentage of improvementNB-UVB PUVA p-value*
Range 12 - 90 6 - 37
Mean ± SD45.4 ± 21.57 17.13 ± 10.080.0005
Percentage of
improvement
after 2 monthsp-value - - -
Range 23 - 98 10 - 70
Mean ± SD73.27 ± 24.94 39.27 ± 18.410.0002
Percentage of
improvement
after 4 monthsp-value** 0. 0001 0.0005 -
*Comparison between NB-UVB and PUVA groups; **Comparison between
% of improvement after 2 months and after 4 months.
98% with a mean of 73.2 7 ± 24 .94 SD . This d if f erence in
the range of improvement between the two study groups
(PUVA and NB-UVB) after 4 months therapy was statis-
tically significant; p value = 0.0 002 (Table 2).
Improved patients were divided into three groups (Ta-
ble 3):
Excellent repigmentation (70% - 100%): in 1 patient
(6.7%) in PUVA group and in 10 patients (66.7%) in
NB-UVB gr oup.
Good repigmentation (40% - 70%): in 9 patients (60%)
in PUVA group and in 3 patients (20%) in NB-UVB
group.
Mild repigmentation (less than 40%): in 4 patients
(26.7%) in PUVA group and in 2 patients (13.3%) in
NB-UVB gr oup.
The perifollicular repigmentation was the predominant
type of repigmentation observed in both PUVA and NB-
UVB treated groups. It occurred in all improved patients
(100%) who were treated either by PUVA or NB-UVB.
Only 1 patient (6.7%), who was treated with NB-UVB,
showed combination of both perifollicular repigmenta-
tion and peripheral repigmentation. Diffuse repigmenta-
tion was not observed in any patien t.
The assessment of color match in comparison with the
Open Access JCDSA
PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study 19
Table 3. Degree of repigmentation after treatment.
Degree of
repigmentation PUVA group
N = 14 NB-UVB group
N = 15
Excellent repigmentation 1 patient (6.7%) 10 patien t s (66.7%)
Good repigme n t a t i o n 9 patients (60%) 3 patients (20%)
Mild repigmentation 4 patients (26.7%) 2 patients (13.3%)
patient’s unaffected sk in was excellent for all 15 patients
(100%) in the NB-UVB group and for only 8 patients
(57.2%) out of the 14 improved patients in the PUVA
group while the remaining 6 patients (42.8%) showed
dark hyperpigmentation of the treated vitiliginous area
than the patient’s unaffected skin.
The side effects were minimal and did not warrant dis-
continuation of the therapy in any of the 30 patients. All
patients in each group developed erythema, showing that
both regimens were equally erythemogenic. Pruritus oc-
curred in 4 patients (26.7%) in the PUVA group com-
pared with 3 patients (20%) in the NB-UVB group. Pho-
todermatitis with scaliness and eczematous reaction was
observed only in 1 patient (6.7%) who was treated with
NB-UVB.
Throughout the study, recurrence of the vitiliginous
patches at the same site of treatment occurred in 1 patient
(6.7%) in the PUVA group compared with 3 patients
(20%) in the NB-UVB group. New lesions developed in
other sites in 1 patient (6.7%) in the PUVA group com-
pared with 4 patients (26.7%) in the NB-UVB group.
Seven patients (46.7%) who were treated with PUVA,
developed nausea during the course of therapy and mi-
nimization of the dose of 8-MOP in those patients was
performed to decrease the sensation of nausea. One fe-
male patient (6.7%) who was treated with PUVA th erapy
developed elevation in the liver enzymes after 4 months
of treatment and stopped the therapy (Table 4).
Histopathological Findings
Before treatment (Table 5, Figure 1), microscopic ex-
amination of involved skin in vitiligo showed no basal
melanization in 22 (73.3%) of the 30 biopsies while 8
(26.7%) showed basal melanization. With Fontana-
Masson stain, similar ratio of basal pigmentation was
demonstrated. Hyperkeratosis was present in 12 biopsies
(40%). Interface changes and epidermal vacuolization
was found in 4 biopsies (13.3%), all were included in
PUVA group of patients.
Dermal infiltrates composed mainly of mononuclear
cells (Lympho-histiocytic); seven biopsies (46.7%) in
PUVA group and 7 biopsies (46.7%) in NB-UVB group
showed sparse infiltrate, 7 biopsies (46.7%) in PUVA
group and 5 biopsies (33.3%) in NB-UVB group showed
moderate infiltrate, and 1 biopsy (6.7%) in PUVA group
Table 4. Side effects reported in the study groups.
NB-UVB group
N = 15 PUVA group
N = 15 Side effects
3 patients (20%)4 patients (26.7%) Pruritus
1 patient (6.7%)0 (0%) Photo dermatitis
0 (0%) 7 patients (46.7 %) Nausea
0 (0%) 1 patient (6.7%) Elevation in the liver enzymes
3 patients (20%)1 patient (6.7%) Recurrence at the same
site of treatment
4 patients (26.7%)1 patient (6.7%) New lesions in other sites
Table 5. Histopathological findings in the center of the
vitiliginous lesions before treatment.
Vitiligo center
Histopathological chan gesPUVA
(n = 15) NB-UVB
(n = 15) Total
(n = 30)
Hyperkeratosis 7 biopsies
(46.7%) 5 biopsies
(33.3%) 12 biopsies
(40%)
Basal melanization 5 biopsies
(33.3%) 3 biopsies
(20%) 8 biopsies
(26.7%)
Interface changes 4 biopsies
(26.7%) 0 (0%) 4 biopsies
(13.3%)
Melanophages 7 biopsies
(46.7%) 4 biopsies
(26.7%) 11 biopsies
(36.7%)
Eosinophils 1 biopsy
(6.7%) 0
(0%) 1 biopsies
(3.3%)
Sparse 7 biopsies
(46.7%) 7 biopsies
(46.7%) 14 biopsies
(46.7)
Moderate 7 biopsies
(46.7%) 5 biopsies
(33.3%) 12 biopsies
(40%)
Lymphohistiocytic
infiltrate
Dense 1 biopsy
(6.7%) 3 biopsies
(20%) 4 biopsies
(13.3%)
Figure 1. The center of vitiliginous area before treatment;
H&E staining showing almost no basal melanization, hy-
perkeratosis and sparse superficial dermal lympho-histio-
cytic infiltrate (upper left, ×10). CD20 stained section
showing negative lymphocytic staining (upper right, ×20).
CD3 stained section showing mild positive lymphocytic
staining (lower left, ×20). CD68 stained section showing
strong positive lymphocytic staining (lower right, ×20).
Open Access JCDSA
PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study
Open Access JCDSA
20
and 3 biopsies (20%) in NB-UVB group showed a denser
infiltrate. Melanophages appeared in the upper dermis in
7 biopsies (46.7%) in PUVA group and in 4 biopsies
(26.7%) in NB-UVB group (Figure 2). Eosinophils ap-
peared in the infiltrate in only 1 biopsy (6.7%) in PUVA
group.
After treatment (Table 6, Figures 3 and 4), 29 biop-
sies were obtained from the repigmented areas (14 in
PUVA group and 15 in NB-UVB group), and anothe r 24
biopsies were obtained from the non-responding depig-
mented areas of the vitiliginous lesions (14 in PUVA
group and 10 in NB-UVB group). The remaining 5 im-
proved patients in NB-UVB group showed complete
repigmentation with no non-pigmented islands to obtain
biopsies.
The non-responding areas after treatment showed no
basal melanization in 21 biopsies (87.5%) of 24 biopsies
and the presence of basal melanization in 3 biopsies
(12.5%) (1 of 14 biopsies in PUVA group and 2 of 10
biopsies in NB-UVB group) while the repigmented areas
of the vitiliginous lesions showed the presence of basal
melanization in all 29 biopsies (100%). Melanin was de-
tected using Fontana Masson stain in same ratio of biop-
sies. Hyperkeratosis was present in 3 biopsies (12.5%) of
the non-responding areas (1 biopsy in PUVA gro up and 2
biopsies in NB-UVB group) and was present in 2 biop-
sies (6.89%) of 29 biopsies of the repigmented areas (1
biopsy in PUVA group and in 1 biopsy in NB-UVB group).
Interface changes and epidermal vacuolization were
more manifested in biopsies obtained from cases treated
with NB-UVB than in biopsies obtained from cases
treated with PUVA (Figures 3 and 4) an d were found in
3 biopsies (12.5%) of the non-responding areas (1 biopsy
in PUVA group and 2 biopsies in NB-UVB group) and
were found in 11 biopsies (37.9%) of the repigmented
areas (4 biopsies in PUVA group and 7 biopsies in NB-
UVB group).
Sparse infiltrate was present in 14 biopsies (58.33%);
11 biopsies (78.57%) in PUVA group and 3 biopsies
(20%) in NB-UVB group, moderate infiltrate was present
in 8 biopsies (33.34%); 3 biopsies (21.43%) in PUVA
group, and in 5 biopsies (50%) in NB-UVB group and
dense infiltrate was present in 2 biopsies (8.33%) in NB-
UVB group only.
Melanophages appeared in 7 biopsies (29.16%) of 24
biopsies; 4 biopsies (28.6%) in PUVA group and in 3
biopsies (30%) in N B-UVB group. Eosinophils app eared
in the infiltrate in 4 biopsies (16.66%) in PUVA group
only.
Regarding the repigmented areas of the vitilig inous le-
sions; sparse infiltrate was present in 10 biopsies (3 4.48%)
of 29 biopsies; 7 biopsies (50%) in PUVA group and 3
biopsies (30%) in NB-UVB group, moderate infiltrate
was present in 16 biopsies (55.17%); 7 biopsies (50%) in
PUVA group and 9 biopsies (60%) in NB-UVB group
and dense infiltrate was present in 3 biopsies (20%) in
NB-UVB group only.
Melanophages appeared in 22 biopsies (75.8%) of 29
biopsies; 10 biopsies (71.43%) in PUVA group and in 12
biopsies (80%) in NB-UVB group.
Interface changes appeared in 11 biopsies (37.9%); 4
biopsies (28.6%) in PUVA group and 7 b iopsies (46.7%)
in NB-UVB group.
Using Fontana-Masson staining melanin was detected
in all 29 biopsies (100%) of the repigmented areas after
treatment (Figure 4).
Immunohistochemical findings using MART-1 anti-
body; biopsies from the center of the vitiliginous area
before treatment showed:
MART-1 negative basal staining (Figure 2) was dem-
onstrated in 22 biopsies (73.3%) of 30 and the presence
of MART-1 positive cells in 8 biopsies (26.7%) out of 30
biopsies taken from center of the vitiliginous lesions.
Biopsies from the non- responding ar eas after treatment
Table 6. Histopathological changes after treatment in the non-responding and repigmented areas of the vitiliginous lesions.
Non-responding areas Repigmented areas
Histopathological chan ges PUVA (n = 14) NB-UVB (n = 10)Total (n = 24) PUVA (n =14) NB-UVB (n = 15) Total (n =29)
Hyperkeratosis 1 biopsy (7.14%) 2 biopsies (20%)3 biopsies (12.5%)1 biopsy (7.14%)1 biopsy (6.7%) 2 biopsies (6.89%)
Basal melanization 1 biopsy (7.14%) 2 biopsies (20%)3 biopsies (12.5%)14 biopsies (100%)15 biopsies (100%) 29 biopsies (100%)
Interface changes 1 biopsy (7.14%) 2 biopsies (20%)3 biopsies (12.5%)4 biopsies (28.6%)7 biopsies (46.7%) 11 biopsies (37.9%)
Melanophages 4 biopsies (28.6%) 3 biopsies (30% )7 biopsies (29.16%)10 biopsies
(71.43%) 12 biopsies (80%) 22 biopsies (75.8%)
Eosinophils 4 biopsies (28.6%) 0 ( 0%) 4 biopsies (16.66%)0 (0%) 0 (0%) 0 (0%)
Sparse 11 biopsies
(78.57%) 3 biopsies (30%)14 biopsies (58.33%)7 biopsies (50%)3 biopsies (2 0 % ) 10 biopsies (34.48%)
Moderate 3 biopsies (21.43%) 5 biopsies (50%)8 biopsies (33.34%)7 biopsies (50%)9 biopsies (60%) 16biopsies (55.17%)
Lymphohistiocytic
infiltrate:
Dense 0 (0%) 2 biopsies (20%)2 biopsies (8.33%)0 (0%) 3 biopsies (2 0 % ) 3 biopsies (10.34%)
PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study 21
Figure 2. MART-1 immune-staining of vitiligo center show-
ing no basal melanization with considerable melanophages
in the dermis immunologically stained (×40).
Figure 3. The repigmented area after treatment with NB-
UVB (×20): H&E staining showing basal melanization and
moderate upper dermal lympho-histiocytic infiltrate with
interface activity (upper left). CD20 stained section showing
negative lymphocytic staining (upper right). CD3 stained
section showing mild positive lymphocytic staining (lower
left). CD68 stained section showing very strong positive
lymphocytic staining (lower right).
showed MART-1 negative staining in all biopsies except
for 3 biopsies (12.5%).
Biopsies from repigmented areas after treatment
showed presence of MART-1 positive cells in all 29 bi-
opsies (100%) taken from repigmented areas after treat-
ment with PUVA and NB-UVB (Figure 4). MART-1
stain also demonstrated the striking presence of melano-
phages in the dermis (Figure 2).
Immunohistochemical findings (Figures 1 and 3) re-
vealed that CD68-positive cells were the most abundant
cells in all b iopsies, i.e. the vitiliginous areas before trea t-
ment, the non-responding areas after treatment and the
repigmented areas after treatment. CD3-positive cells were
Figure 4. The repigmented area after treatment (×20): After
PUVA; H&E stained section showing basal melanization
and sparse superficial dermal lympho-histiocytic infiltrate
(Upper left). After NB-UVB; H&E stained section showing
basal melanization and moderately dense dermal lympho-
histiocytic infiltrate with interface activity (upper right).
MART-1 immune-stained section after PUVA treatment
showing positive basal staining (lower left). Fontana-Mas-
son staining after treatment showing the presence of basal
melanization (lower right).
also detected in similar biopsies, but CD3-positive cells
were less abundant than the CD68-positive cells. No sig-
nificant CD20-positive cells were observed in all biop-
sies. These findings demonstrated the striking presence
of histiocytes besides T-lymphocytes in the dermal infil-
trate.
4. Discussion
Phototherapy is one of the most commonly used treat-
ments for vitiligo with appreciated success rates and low
incidence of side effects. It is also highly recommended
after surgical grafting treatments to guarantee success
[10].
Oral PUVA is the combined use of a photosensitizing
chemical compound and non-ionizing electromagnetic
radiation, and this combination induces a beneficial re-
sult not produced by either alone [6]. NB-UVB is a more
recent phototherapy modality which was developed to
remove the shorter erythemogenic wavelengths and to
use a concentrated UVB source of 311 nm. NB-UVB has
been reported to be effective and safe in vitiligo [11].
In this study we tried to have clinical objectiv e evalua-
tion of improvement after phototherapy by using a pla-
nimeter to calculate percentage of improvement and ca-
tegorize the resulting numbers into descriptive terms for
overall evaluation.
Clinical evaluation showed that only 1 patient (3.3%)
failed to respond to therapy (PUVA group) while the re-
maining 29 patients (93.3%) demonstrated improvement
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PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study
22
ranging from excellent to mild repigmentation. The pre-
sent study demonstrated that NB-UVB group patients
showed statistically significant better results than oral
PUVA group patients. Similar success rates were ob-
tained in previous comparative studies demonstrating
superiority of NB-UVB to PUVA [7,12]. In our study we
also demonstrated the faster response to NB-UVB which
provided considerable repigmentation (up to 90%) after
only 2 months of therapy compared to mild improvement
(up to 37%) in the PUVA group after same period.
Another dramatic finding was the difference in the
color matching between the two modalities of treatment,
which was excellent in all patients treated with NB-UVB
while 42.8% of patients treated with oral PUVA showed
darker unsightly repigmentation of the treated vitiligi-
nous areas compared to the patient’s unaffected skin.
This hyperpigmentation has been reported previously too
[7]. The predominan ce of perifollicular repigmentation as
a main pattern of repigmentation after both modalities
was clearly demonstrated.
The starting doses of NB-UVB in previous studies
varied considerably, ranging from 75 mJ/cm [13] to 740
mJ/cm [12], although these differences may reflect varia-
tions in calibration. Some studies used starting doses
based on the minimum erythema dose [14]. In other re-
ported studies the starting dose was based on skin typing
[15]. In the present study, the starting dose was 0.574
J/cm2 based on patients' main skin type (type 4). The
therapeutic dose range d from 1.40 2 t o 2.737 J/cm2.
The first exposure dose for PUVA treated patients in
previous reported studies was based on minimal photo-
toxic dose (MPD) to ensure a safe starting dose [16]. In
other reported studies, the starting dose was based on
skin typing [17]. In the present study the starting dose
was 2 J/cm2 based on patients’ main skin type. The thera-
peutic dose ranged between 3.906 and 6.104 J/cm2. In
other previous reported studies, the therapeutic dose did
not exceed 5 J/cm2 for PUVA and 2 J/cm2 for NB-UVB
[7]. The higher therapeutic doses utilized here may be
correlated to the darker skin type and skin tolerance to
radiation in our locality due to intensive sun exposure
throughout th e year.
The PUVA patients were older than the NB-UVB pa-
tients due to the exclusion criteria used in selecting its
patients. Age was not found to influence the outcome of
vitiligo therapy with oral PUVA and NB-UVB in previ-
ous studies [18]. However, the presumption that the ear-
lier the patient was treated, the better was the response
also exists [19] and we agree that the age factor cannot
be denied when co mparing results in vitiligo cases.
Oral PUVA is not recommended for children younger
than 12 years [4,6]. The phototoxic potential of psoralen
is of great concern in children where avoidance of exces-
sive sun exposure may be difficult to regulate, again, the
risk of carcinogenesis and premature aging of skin can-
not be neglected in children with long-term use. On the
other hand, NB-UVB has been reported to be effective
and safe in childhood vitiligo [11]. In the presen t study, 8
(80%) out of 10 children developed more than 75%
overall repigmentation after 4 months of NB-UVB ther-
apy. Thus, higher success rates were observed with NB-
UVB radiation therapy.
NB-UVB therapy offers other advantages over oral
PUVA therapy that makes it preferable for most patients.
In particular, PUVA therapy requires the use of eye pro-
tection after treatment sessions, cannot be used in preg-
nancy, is contraindicated in patients with hepatic im-
pairment or who are taking warfarin or phenytoin, and
requires the somewhat inconvenient prior administration
of psoralen. Of greatest concern however, is the potential
of PUVA to cause non-melanoma and melanoma skin
cancer [20], although in our vitiligo patien ts this was not
detected at all for several years of UV therapy (data not
shown), perhaps because of the skin type and genetic
background in our locality. Nevertheless, it is important
to mention that NB-UVB seems to be considerably safer
than PUVA in required number of treatment sessions as
higher success rates can be achieved as early as 2 months
of therapy. Although risks for cutaneous malignancies
are reported with PUVA, however, to date there is insuf-
ficient data available to provide recommendation regard-
ing a safe maximum narrow band UVB dose.
The general histological picture of vitiligo before
treatment revealed the presence of hyperkeratosis in 40%
of vitiligo skin biopsies. Th is finding was noticed in pre-
vious studies [21]. Hyperkeratosis declined after treat-
ment, down to 12.5% of the non-responding areas and in
6.89% of the repigmented areas (with no significant dif-
ference between the 2 study groups). The presence of
hyperkeratosis in a lower ratio after treatment may be
due to the return of the epidermal turn over rate due to
the stoppage of the keratinocytes degeneration and death
process.
Basal melanization was detected in vitiligo skin in
26.6%. Kim et al. (2008) found remaining melanocytes
in 12% vitiligo sk in cases by using MART-1 stain. In the
present study, using MART-1 antibody for immunohis-
tochemical staining of melanocytes, MART-1 positive
cells were found in the vitiligo skin in a higher percent-
ages than in previous studies. After 4 months of photo-
therapy treatment, basal melanization appeared in all
biopsies of the repigmented areas and was present in
12.5% of the non-responding areas of the vitiliginous
lesions after treatment.
The present study demonstrated the presence of mod-
erate to dense perivascular and perifollicular lympho-
histiocytic infiltrate in 53.3% of vitiliginous skin. This
existence of the inflammatory infiltrate in the vitilig inous
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PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study 23
area confirms the role of the immunological inflamma-
tory process in initiation of the disease, which was de-
scribed in previous literature [22]. After treatment, biop-
sies from the non-responding areas of the vitiliginous
lesions treated with NB-UVB showed the presence of a
moderate to dense lympho-histiocytic infiltrate in 70% of
biopsies compared with 21.43% of biopsies taken from
the non-responding areas of the vitiliginous lesions
treated with PUVA. Biopsies from the repigmented areas
after treatment with NB-UVB showed moderate to dense
dermal lympho-histiocytic infiltrate in 80% of biopsies
compared to 50% of cases treated with PUVA. The over-
all density was higher in NB-UVB treated cases.
Comparison of the responding pigmented islands and
the non responding depigmented spots; it was obvious
that lympho-histiocytic infiltrates, interface changes and
melanophages were in significant higher levels in healed
areas while in low levels in the non repigmented islands.
These pathological findings seem strictly correlating to
existence of melanocytes and melanin in the epidermis
which represents the targeted antigen in such cases (Ta-
ble 6).
All sections before treatment did not show staining for
CD20 confirming that the B lymphocytes do not have a
main role in the pathogenesis of vitiligo while CD3
staining was positive in most sections demonstrated that
T lymphocytes play a major role in the disease patho-
genesis. Staining cells positively again with CD68 dem-
onstrated that histiocytes and macrophages have a main
bulk in the infiltrate.
After treatment, similar staining for CD3 and CD68
with absence of CD20-positive cells was well demon-
strated. Staining for CD3 & CD68 was correlated to lym-
pho-histiocytic density in H&E stained sections with
higher ratio in NB-UVB treated group.
Interface changes and epidermal vacuolization ap-
peared in the present study in 13.3% of pretreated vitiligo
skin. Epidermal vacuolization occurs as a result of the
interface changes where the dermal lympho-histiocytic
cells attack the melanotic basal cells leading to cell de-
generation and epidermal vacuolization. After treatment,
an increase in interface changes and basal vacuolization
was found in both the non-responding and the repig-
mented areas of NB-UVB cases more than the non-re-
sponding and the repigmented areas of PUVA cases.
Significant higher levels of interface changes and vacu-
olization in NB-UVB treated patients were correlating to
the density of lympho-histiocytic infiltration.
H & E and MART-1 stains revealed the presence of
considerable dermal melanophages in 36.6% of vitiligo
skin before and also after treatment. Other previous
studies revealed the presence of melanophages but in
lower ratios [21]. Ackerman et al. (1997) reported that
the presence of melanophages in th e papillary dermis is a
helpful clue to exclude vitiligo from the differential di-
agnoses of a hypopigmented or depigmented lesion [23].
The striking presence of melanophages in vitiligo in the
present study contradicts that view. The higher percent-
ages of melanophages could be related to the darker skin
type of the patients with epidermis containing higher
melanin levels which after the in terface activity an d basal
vacuolization drop into dermis to be targeted by histio-
cytes and macrophages. More melanophages were dem-
onstrated in biopsies of repigmented areas in both treated
groups due to the higher epidermal melanin contents and
the attacking infiltrates in the dermis.
The more dense lympho-histiocytic infiltrates and
more interface changes with basal vacuolization findings
in NB-UVB cases may correlate with the higher recur-
rence and reactivation ratio of vitiligo in such patients.
Thus, a more potent immunological suppression by
PUVA over NB-UVB is demonstrated and could explain
higher recurrence and development of new lesions in
NB-UVB group of patients (NB-UVB group 46.7%,
PUVA group 13.4%). Therapeutic effect of PUVA in
vitiligo was related to selective cytotoxicity and apop-
tosis of inflammatory cells, apart from its ability to in-
duce melanocytes migration to the epidermis from the
outer root sheath of the hair through the action of im-
mune cytokines and inflammatory mediators released
[24]. Lymphocytic suppression by PUVA therapy is well
documented, offering an explanation for the clinical re-
sponse that PUVA produces in other lymphocyte-rich
skin diseases such as psoriasis [25].
Vitiligo is an unstable disease and its activity is usu-
ally unpredicted but related to immunological stimulation
and subsequent destruction of new melanocytes. Detect-
ing active cases after both modalities needed to be done
in a further study to confirm further advantage of a
method to another, although we expect that PUVA will
be superior in such cases due to its ability to reduce im-
munological inflammatory infiltrates with subsequent
clinical decline in disease activity and less development
of new lesions as described previously in the results
(Figure 4, Tables 3 and 4).
5. Conclusions
In conclusion, NB-UVB treatment can provide statisti-
cally significant better results than PUVA. Distinct ad-
vantages over PUVA include the lack of psoralen-related
side-effects and precautions, a cosmetically better color
match, and safety in children. Although NB-UVB ther-
apy gives a more rapid effect than oral PUVA therapy,
yet PUVA therapy was accompanied by significant less
recurrence and less development of new vitiligo lesions.
The dermal infiltrates, composed mainly of T cells and
Histiocytes, with the interface changes persisted after th e
Open Access JCDSA
PUVA versus NB-UVB in Management of Vitiligo, Clinico-Immuno-Pathological Study
24
NB-UVB repigmentation more than in the PUVA treated
areas. Thus, PUVA may provide better immuno-modu-
latory effect on vitiligo than NB-UVB and may give bet-
ter response regarding the disease reactivation and recur-
rence. A combination of UVA and NB-UVB bulbs in
same treating cabinets maybe recommended obtaining
better treatment results.
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