DOI: 10.1111/j.1468-3083.2010.03879.

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ORIGINAL ARTICLE

Comparison of the therapeutic effects of narrow band UVB vs. PUVA in patients with pityriasis lichenoides
F. Farnaghi, H. Seira, A.H. Ehsani,* M.-E. Agdari, P. Noormohammadpour
Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran *Correspondence: A.H. Ehsani. E-mail: ehsanih@sina.tums.ac.ir

Abstract
Background and aims Pityriasis lichenoides (PL) is a self-limiting papulosquamous skin disorder with chronic course. Best therapeutic options are yet to be dened. Phototherapy is one of the most prevalent treatments and the aim of this study was to compare the therapeutic effects of the two main phototherapy options: psoralen plus ultraviolet A (PUVA) and narrow band UVB (NB-UVB). Material and methods Patients with PLC based on clinical ndings and pathology, involving at least 60% of total body surface, were enrolled if they were not pregnant, lactating women and had not contraindication for phototherapy. Based on simple randomization, they received either PUVA or NB-UVB, and patients responses were recorded. Results A total of 15 patients including eight males (53%) and seven females (47%) were enrolled in the study and were randomized into groups A and B, each including four patients. In group A, seven patients had complete response (87.5%) and one patient had partial response (12.5%). Among patients in group B, ve patients had complete response (71.4%) and two patients (28.6%) had partial response (P > 0.05). Conclusion As the difference between the two groups is insignicant, it seems that both options are acceptable for treating this disorder. Received: 22 June 2010; Accepted: 27 September 2010

Keywords
chronic, NB-UVB, Pitiriasis lichenoides, PLC, Psoriasis, PUVA

Conict of interest
None.

Background
Pityriasis lichenoides (PL) is a self-limiting papulosquamous skin disease consisting of a spectrum of clinical manifestations, ranging from pityriasis lichenoides et varioliformis acuta (PLEVA) to pityriasis lichenoides chronica (PLC) and including intermediate or overlapping forms.1 The disease is slightly more common in men and is observed mainly in children2 and young adults.3 Two major types may be distinguished: a chronic relapsing variant called PLC and an acute subtype or PLEVA characterized by the rapid development of necrotic lesions as well as fever and other serious systemic problems.4 This disorder may be acral5 or present during pregnancy.6 Although it is generally a benign disorder, severe systemic involvement may develop.7 The disorder usually follows a chronic course with periodic alterations in severity and acute exacerbations in some patients.8,9 Many treatment options including topical corticosteroids,10 oral antibiotics including tetracycline,11 topical calcineurin inhibitors such as tacrolimus,12 as well as

systemic dapsone,8 methotrexate13 and systemic steroids10 have been used with different success rates. Treatment with phototherapy including psoralen and UVA (PUVA)14,15 and narrow band UVB16,17 also is among the options with acceptable results and side-effects. The aim of the present study was to compare the therapeutic effects of these two methods in Iranian patients with PLC.

Material and methods

Patients with PLC based on clinical ndings conrmed via pathological examination were selected if they fullled the following inclusion criteria: generalized disease involving at least 60% of the total body surface (based on Nines Rule) and failed to respond to other modalities of treatment including topical and systemic measures. Patients were excluded if they were pregnant or lactating women and if they had a history of collagen vascular disorder or cutaneous malignancies, positive antinuclear antibody tests, impaired liver or renal function tests and if they

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failed to pass routine ophthalmological assessment by an ophthalmologist. Patients treated in every measure including photosensitizing agents; topical and systemic corticosteroids, PUVA or UVB within 3 months before entering the study or under 18, also were excluded. All patients provided informed consent. The Ethics Committee of the Department of Dermatology revised the study and conrmed that it agreed with the Declaration of Helsinki. Enrolled patients were divided into two groups based on simple randomization. Group A received treatment with NB-UVB whereas group B was treated with PUVA based on separate protocols for each treatment option receptively.
NB-UVB protocol

Patient response

Complete response was dened as more than 90% resolution in skin lesions (papulo-squamous and plaque lesions). Partial response was dened as resolution of 5090% in skin lesions. Poor response was taken as less than 50% reduction in lesions. If patients skin lesions cleared before completing 60 treatment sessions, they were observed for 3 months to determine any recurrence. Detection of more than 10 new lesions was dened as recurrence.

Results
A total of 15 patients including eight males (53%) and seven females (47%) were enrolled in the study. They were randomized into two groups: group A consisting of eight patients [four males (50%) and four females (50%)] received NB-UVB and group B including seven patients [(four males (57%) and seven females (43%)] received PUVA therapy as mentioned previously. The mean age of the patients was 32.7 16 years for group A and 29.4 12 years for group B (P > 0.05). Table 1 shows detailed demographic characteristics of patients. Some of the patients received previous therapy no earlier than 3 months before enrolment in this study, either with topical corticosteroids (ve patients, 33%) or with oral erythromycin (ve patients, 33%). Others received no treatment before the commencement of the study. Mean treatment sessions was 37 11 for group A and 40 16 for group B (P > 0.05). One patient in each group experienced mild skin erythema while three patients in group A and two in group B experienced burning sensation after phototherapy. All patients were treated with mild topical steroids and the symptoms resolved quickly (Table 2).

All patients received 200 mJ m2 for the rst time and then three times weekly. We arrived at this initial dose based on our previous experience with Iranian patients. The dosage of NB-UVB was increased by 10% in every treatment session. In the case of mild side-effects including mild to moderate erythema, burning sensation, the dose of NB-UVB was decreased by 50%. In the case of severe side-effects such as severe erythema, burning or photo-sensitivity, the treatment was stopped. If one or two sessions were missed, the dose was unchanged, and if more than three sessions were missed the dose was decreased by 75%.
PUVA protocol

Patients received 8-MOP 0.6 mg kg at least 90 min before the commencement of UVA. The dosage selected 11.5 J m2 for skin types IIII Fitzpatrick and 2 J m2 for patients with IVV skin types. The dose increment was 2 J every two sessions. Maximum treatment sessions for both groups were 60.

Table 1 Demographic characteristics of patients

Patient index 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Group Age Gender Skin type III II III III III IV IV III III III II IV III III III Previous treatment TC TC OE TC OE OE TC OE OE TC Degree of involvement (based on Nines Rule; %) 75 70 80 75 70 90 80 85 70 70 80 75 80 85 70 Number of treatment sessions 32 40 60 30 35 32 36 35 36 38 60 60 20 38 36 Outcome (clearance %) >90 >90 80 >90 >90 >90 >90 >90 >90 >90 60 75 >90 >90 >90

A A A A A A A A B B B B B B B

16 28 36 32 48 50 32 19 30 29 18 42 25 34 27

M F F M F M M F M M F M F M F

Group A: NB-UVB group; group B: UVA group; TC, topical steroid; OE, oral erythromycin.

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Table 2 Therapeutic results in brief

Response rate (complete) Group A (NB-UVB) Group B (UVA) 87.5% (NS) 71.4% Side-effects Erythema 12.5% (NS) 14.2% Burning sensation 37.5% (NS) 28.5% Other* Mean treatment sessions 37 11 (NS) 40 16 Mean Recurrence rate 42.8% (NS) 40%

NS, not signicant. *Including severe burns, bulla and skin pigmentary changes.

In group A, seven patients had complete response (87.5%) and one patient had partial response (12.5%). Among patients in group B, ve patients had complete response (71.4%) and two patients (28.6%) had partial response (P > 0.05). No severe side-effect was seen during the study. After the end of the study, all patients were followed up for 3 months. Recurrence rates were 42.8% (three patients) in group A and 40% (two patients) in group B (P > 0.05).

tapering schedule after remission. This study failed to show any signicant difference between these two treatment options. Considering equivalent success rates and low treatment side-effects as well as comparable recurrence rates, it seems that both NBUVB and PUVA are acceptable for treating this disorder. Other studies with a larger sample size may be able to show signicant differences.

References Discussion
As a whole, phototherapy is probably the most successful therapy and may be considered as rst-line therapy in proper situations.15 There are several studies indicating the effectiveness of both PUVA14,16,1821 and NB-UVB2224 in the treatment of PLC. These studies reported different success rates. For instance, Siew25 reported about 80% response in patients with PLC and Tay24 reported complete remission in all of their patients using UVB. Pinton15 reported good response to UVA-1 in patients with PLC. Spontaneous resolution may happen during the course of PLC26,27 and this confounds interpretation of results. To the best of our knowledge, this study is probably the rst one that compares the therapeutic effects of these two options in non-paediatric patients. As mentioned above, there were no signicant differences in response and recurrence rates between the two groups. The success rate was 87.5% for patients treated with NB-UVB and 71.4% for patients treated with PUVA. These rates are comparable with other studies referenced above. For instance, the mean healing rate in PLC patients treated with NB-UVB was 87.5%, 93% and 100% in large studies16,17,23,24 which is close to our results (87.5%). On the other hand, the response to UVA therapy at least in one study15 is reported to be about 60% (three of ve patients) and this rate is to some extent in the range of our study (71.4%). From the view point of side-effects, we had no record of severe instances, except for little irritation, erythema, burning sensations, and all were managed easily. Moreover, this nding matches with other studies supporting phototherapy as a safe and effective therapeutic option.15,16,20 Recurrence rates in our study were approximately 42.8% in patients treated with NB-UVB and 40% in patients treated with PUVA. Equivalent rates were reported in other studies focusing on the effects of phototherapy in PLC.23,24,27 The relatively high recurrence rates in the literature as well as in this study may be attributed to the lack of maintenance therapy and or slow
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