ORIGINAL ARTICLE

The Vitiligo Working Group

recommendations for narrowband
ultraviolet B light phototherapy
treatment of vitiligo
Tasneem F. Mohammad, MD,a Mohammed Al-Jamal, MD,b Iltefat H. Hamzavi, MD,a
John E. Harris, MD, PhD,c Giovanni Leone, MD,d Ra ul Cabrera, MD,e Henry W. Lim, MD,a
Amit G. Pandya, MD, and Samia M. Esmat, MDg
f

Detroit, Michigan; Riyadh, Saudi Arabia; Worcester, Massachusetts; Rome, Italy;

Santiago, Chile; Dallas, Texas; Cairo, Egypt

Background: Treatment of vitiligo with narrowband ultraviolet B light (NBUVB) is an important

component of the current standard of care. However, there are no consistent guidelines regarding the
dosing and administration of NBUVB in vitiligo, reflected by varied treatment practices around the world.

Objective: To create phototherapy recommendations to facilitate clinical management and identify areas
requiring future research.

Methods: The Vitiligo Working Group (VWG) Phototherapy Committee addressed 19 questions regarding
the administration of phototherapy over 3 conference calls. Members of the Photomedicine Society and a
group of phototherapy experts were surveyed regarding their phototherapy practices.

Results: Based on comparison and analysis of survey results, expert opinion, and discussion held during
conference calls, expert recommendations for the administration of NBUVB phototherapy in vitiligo were
created.

Limitations: There were several areas that required further research before final recommendations could
be made. In addition, no standardized methodology was used during literature review and to assess the
strength of evidence during the development of these recommendations.

Conclusion: This set of expert recommendations by the VWG is based on the prescribing practices of
phototherapy experts from around the world to create a unified, broadly applicable set of recommenda-
tions on the use of NBUVB in vitiligo. ( J Am Acad Dermatol http://dx.doi.org/10.1016/j.jaad.2016.12.041.)

Key words: expert recommendation; narrowband phototherapy; pigmentation; UVB; vitiligo.

From the Departments of Dermatology at Henry Ford Hospital,a
Detroit; Prince Sultan Military Medical City,b Riyadh; The
University of Massachusetts Medical School,c Worcester; The
San Gallicano Institute,d Rome; The Clinica Alemana de
Santiago de Chilee; The University of Texas Southwestern
Medical Center,f Dallas; and Cairo University,g Kasr Al Aini
Hospital.
Funding sources: None.
Dr Mohammad is a subinvestigator for Allergan, Ferndale
Laboratories, and Estee Lauder. Dr Hamzavi is an investigator
for Clinuvel, Estee Lauder, Allergan, Ferndale Laboratories, and
Johnson and Johnson, and has received equipment from
Johnson and Johnson. Dr Lim is a consultant for L’Oreal, Pierre
Fabre, and Mitsubishi Tanabe, and an investigator for Estee
Lauder, Ferndale, and Allergan. Drs Leone, Pandya, Al Jamal,
Harris, Cabrera, and Esmat have no conflicts of interest to
declare.
Presented at PigmentaryCon 2016, April 2, 2016, Delhi, India.
Drs Mohammad and Al-Jamal contributed equally to this article.
Accepted for publication December 23, 2016.
Reprint requests: Iltefat H. Hamzavi, MD, Henry Ford Hospital,
Department of Dermatology, 3031 W Grand Blvd, Ste 800,
Detroit, MI 48202. E-mail: ihamzav1@hfhs.org.
Published online February 15, 2017.
0190-9622/$36.00
Ó 2017 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2016.12.041

1
2 Mohammad et al J AM ACAD DERMATOL
n 2017

INTRODUCTION Hospital, University of Texas Southwestern Medical

The use of narrowband ultraviolet B light Center, and University of Massachusetts Medical
phototherapy (NBUVB), first reported in 1997 by School, while San Gallicano Institute in Rome and
Westerhof and Nieuweboer-Krobotova,1 has Kasr Al-Aini Hospital Cairo University represented
become the mainstay of treatment for widespread the Mediterranean region. The Clinica Alemana
vitiligo because of its efficacy and favorable side de Santiago de Chile represented South America
effect profile. Although widely used, a previous (Table I). Based on discussion by the VWG
literature review by Madigan Phototherapy Committee, re-
et al2 showed there is little sponses of the phototherapy
consistency in dosing or CAPSULE SUMMARY experts, review of photo-
frequency, and they iden- therapy protocols, and the
d There are no consistent guidelines
tified several areas for further current literature, expert
regarding the administration of
discussion. recommendations for the
narrowband ultraviolet B phototherapy
administration of photo-
to patients with vitiligo.
PURPOSE therapy in vitiligo were
d This paper presents a set of expert developed (Table II).
The Vitiligo Working
recommendations on the use of
Group (VWG) Phototherapy
narrowband ultraviolet B phototherapy Discussion points
Committee, which includes
for this condition. Areas of agreement
experts from different areas
of the world with diverse d This unified methodology will facilitate included the excellent safety
patient populations, has clinical practice and direct research in profile of NBUVB and deem-
developed expert recom- areas lacking evidence-based data. ing the use of minimal ery-
mendations to create a uni- thema dose (MED) testing in
fied methodology to facilitate determining the initial dose
clinical practice and direct research in areas where a for each patient unnecessary. However, there were
paucity of evidence-based data exists. also differences of opinion, likely because of varia-
tions in skin types, economic resources, prevalence
of health insurance, and the availability of solar
METHODS radiation in various regions of the world. Centers
The VWG Phototherapy Committee expanded the treating patients with darker Fitzpatrick skin photo-
12 questions proposed by Madigan et al,2 which types (SPTs) used higher starting doses and dose
focused on issues such as dosing phototherapy, increments. Centers with high patient volume and
defining a course of phototherapy, and treatment populations with lower socioeconomic profiles used
unresponsiveness, to 21 questions that were later fewer sessions per week. Despite these constraints,
condensed to 19 questions. These questions were the VWG Phototherapy Committee created expert
addressed over 3 conference calls with discussion recommendations for an integrated flexible protocol
aimed to create recommendations or suggest areas of that can be used by phototherapists around the
future research. world.
A comparison of phototherapy protocols from
multiple institutions was also performed. A survey Frequency and dosing
created by the members of the VWG Phototherapy 1. What is the optimal weekly frequency of NBUVB
Committee with these questions was distributed to treatment in patients with vitiligo?
members of the Photomedicine Society and a panel Although no direct comparison of twice versus
of 10 phototherapy experts (defined by a publication thrice weekly regimens using NBUVB photother-
profile of $3 publications on phototherapy and apy exists, studies using excimer laser have not
vitiligo). Final recommendations and areas for future shown a difference in the final degree of repig-
research were based upon comparison and analysis mentation between the 2 dosing frequencies.3,4
of survey results, expert opinion, and discussion Repigmentation is dependent on the total num-
held during conference calls. ber of sessions, with earlier onset of pigmenta-
tion associated with thrice weekly dosing.4
THE CONSENSUS Similar results have been observed in studies of
Six phototherapy experts responded to our sur- patients with psoriasis.5 However, a twice-
vey. In addition, a comparison of phototherapy weekly regimen may be more convenient, less
protocols from multiple institutions was performed. costly to patients, and increase patient capacity at
Centers in the United States included Henry Ford busy phototherapy centers. The psychological
Table I. Comparison of phototherapy protocols for vitiligo

VOLUME jj, NUMBER j

J AM ACAD DERMATOL
University of Texas
University of Massachu- Southwestern Medical Cairo University Kasr Al Clinica Alemana de San Gallicano Dermatolog-
Henry Ford Hospital setts Medical School Center Aini Hospital Santiago de Chile ical Institute
Initial monitoring TSH, thyroid peroxidase Review of systems for TSH and thyroid VASI, VETF, and VIDA VASI and BSA scoring, VETF scoring,
antibodies, ANA in other autoimmune antibodies scoring, photography, photography, TSH,
nonphotoadaptors diseases/ photography, complete blood and thyroid
photosensitivity complete blood cell count, ANA, TSH, T4, antibodies
count, blood sugar, TgAb, antithyroid
liver and renal peroxidase antibody
function tests, and and blood sugar, and
consent consent
Follow-up monitoring BSA estimate every Clinical examination, BSA estimate every VIDA scoring and VASI and BSA scoring, Photography monthly
3 months tolerance to 3 months photography photography every and VETF scoring
treatments every monthly VASI, VETF, 24, 48, 72, and 96 every 3 months
6-8 weeks and VIDA scoring sessions
every 3 months
MED All patients considered All patients considered All patients considered Based on unaffected Based on unaffected Based on unaffected
SPT I (400 mJ/cm2) SPT I (400 mJ/cm2) SPT I (400 mJ/cm2) skin and dependent skin: SPT I skin and skin and dependent
on skin type photosensitivity on SPT
history
Treatment frequency 3 times/week 2-3 times/week 3 times/week 3 times/week 3 times/week 2 times/week
Starting dose 70% of MED for skin 200 mJ/cm2 200 mJ/cm2 500 mJ/cm2 unless SPT 200 mJ/cm2 70% of MED in SPTs
type I OR I/II, then 300 mJ/cm2 III-IV; 50% of MED
2
280-300 mJ/cm in SPT II
Dose escalation 15% at each 50 mJ/cm2 at each 15% at each 20% at each 20 mJ/cm2 at each SPT II 10% at each
subsequent visit subsequent visit subsequent visit subsequent visit subsequent visit subsequent visit;
SPT III 20% at each
subsequent visit;
SPT IV 30% at each
subsequent visit; and
SPT [IV 40% at each
subsequent visit
Maximum dose 1000 mJ/cm2 (face); 2500 mJ/cm2 5000 mJ/cm2 No maximum as long 5000 mJ/cm2 No maximum
3000 mJ/cm2 (body) there is ongoing treatment dose:

Mohammad et al 3
repigmentation, there is progressive
maximum treatment increase based on
period 1-2 years individual tolerance
to erythema
Dose adjustments for erythema
No erythema Increase dose as Increase dose as Increase dose as Increase dose as Increase dose as Increase dose as
directed directed directed directed directed directed
Continued
Table I. Cont’d

4 Mohammad et al
University of Texas
University of Massachu- Southwestern Medical Cairo University Kasr Al Clinica Alemana de San Gallicano Dermatolog-
Henry Ford Hospital setts Medical School Center Aini Hospital Santiago de Chile ical Institute
Light pink erythema Maintain same dose Maintain same dose Maintain same dose. If Increase dose by 10% Increase dose by Maintain same dose
(desired erythema resolves in 10 mJ/cm2
response to \24 hours, may
phototherapy) increase dose by
5-10%
Moderate erythema Decrease dose by 15% Decrease dose by Decrease dose by 15% Hold dose until Maintain same dose Maintain same dose
25 mJ/cm2 erythema becomes
light pink
Severe erythema/ Physician evaluation Physician evaluation, Physician evaluation Hold treatment for 2 Hold treatment and Hold treatment and
blisters restart phototherapy sessions and then physician evaluation physician evaluation
at a 15% decrease in restart phototherapy
dose at last tolerated dose
Dose adjustment for missed sessions
1-2 sessions Maintain previous dose Maintain previous dose Maintain previous dose Maintain previous dose Maintain previous dose Maintain previous dose
1-2 weeks Decrease dose by 33% Decrease dose by 25% Decrease dose by 20% Decrease dose by 25% Decrease dose by 30% Decrease dose by 30%
2-4 weeks Decrease dose by 66% Decrease dose by 50- Decrease dose by 40% Decrease dose by 50% Decrease dose by 50% Decrease dose by 50%
75%
[4 weeks Restart at initial dose Restart at initial dose Restart at initial dose Restart at initial dose Restart at initial dose Restart at initial dose
Assessment of 3 months 6-12 weeks 36 sessions 36 sessions 24 sessions 3 months
response to
treatment
Maintenance regimen Physician discretion Physician discretion Biweekly for 4 weeks, No fixed protocol. No fixed protocol No maintenance
then once weekly for Applied only for regimen
4 weeks, then every those who recur
other week for soon after stopping
2 months, and then the sessions
stop
Definition of treatment No repigmentation No repigmentation No repigmentation No repigmentation No repigmentation \10% repigmentation
failure after 48 sessions after 4-6 months after 36 sessions after 48 sessions after 48 sessions after 3 months
OR \25% OR \25%
repigmentation after repigmentation after

J AM ACAD DERMATOL
60 sessions 72 sessions
Face cover Yes, if face is spared Yes, if face is spared Yes, if face is spared Yes, if face is spared Yes, if face is spared Yes, if face is spared
Goggles Yes, unless eyes are Yes Yes, unless eyes are Yes Yes, unless eyes are Yes, unless eyes are
affected affected affected affected
Genital protection Yes, protect areola in Yes, protect areola in Yes, but only in men Yes Yes, protect areola in Yes, but only in men

n 2017
women both women and both women and
men men by applying
sunscreen
J AM ACAD DERMATOL Mohammad et al 5
VOLUME jj, NUMBER j

distress patients experience with slow re-

ANA, Antinuclear antibody; BSA, body surface area; MED, minimal erythema dose; SPF, skin protective factor; SPT, Fitzpatrick skin phototype; T4, thyroxine; TgAb, thryoglobulin antibodies; TSH,
No topical applications

Decrease dose by 20% Decrease dose by 10% Check irradiance with Adjust dose according Adjust dose according Decrease dose by 30%
sponses to treatment makes thrice weekly

301 sunscreen if

Hold for physician

the morning of

dosing optimal, because results are seen more

expecting sun
phototherapy

quickly. Studies comparing these 2 treatment

evaluation
exposure
Apply SPF 30 sunscreen Apply SPF
regimens are currently underway.
2. With regard to initial dosing, what strategy
should be used?
There was no clear consensus on this point
based on expert opinion. Although the optimal
strategy for initial dosing would be based on
Hold for physician
No topical applications Avoid application
4 hours before

each individual’s MED, determining the MED

phototherapy

to calibration for each patient is cumbersome. Based on a

evaluation

review of institutional phototherapy protocols

thyroid-stimulating hormone; VASI, Vitiligo Area Scoring Index; VETF, Vitiligo European Task Force Assessment; VIDA, Vitiligo Disease Activity Score.
and discussion amongst the VWG Phototherapy
Committee, we recommend a fixed dosing pro-
tocol where phototherapy is initiated at 200 mJ/
cm2 regardless of skin type, which is convenient
and avoids phototoxic reactions. Fixed dosing
Decrease dose by 20% According to case
the morning of

based on skin type is another dosing strategy

phototherapy

exposed sites

to calibration
sunscreen to
Apply SPF 30 sunscreen Apply SPF 30 sunscreen Apply SPF 30 sunscreen Apply physical

that accounts for the inherent differences in the

response

MED of various skin types.6 The risk of

phototoxic reactions is greater, making this
method more suitable for areas with darker
skin types.
meter. If higher than

3. What is the maximum acceptable dose per

phototherapy with

old bulbs, reduce

treatment for the face and for the body?

the exception of
Avoid application
4 hours before

The maximum acceptable dose for the face in a

dose by 20%

given treatment is 1500 mJ/cm2, while the

mineral oil

maximum dose for the body is 3000 mJ/cm2.2

This recommendation was based on a
combination of literature review, review of
phototherapy center protocols, and discussion
among the VWG committee members. Although
Physician discretion

higher doses may be tolerated by individuals,

if expecting sun
No topical applications Avoid application
4 hours before
phototherapy

there are no long-term studies on cancer risk in

the vitiligo or psoriasis literature, and therefore
exposure

caution is advised. These dose limits also apply

to higher skin types because photoadaptive
capacity is not completely dependent on skin
type.
4. What is the maximum number of acceptable
of phototherapy

Hold for physician

exposures for patients with vitiligo?

We recommend no ceiling for exposures in
the morning

evaluation

patients with SPTs IV to VI. In patients with

SPTs I to III, additional data are needed
regarding the risk of cutaneous malignancy
before a recommendation can be made.
Currently, the literature is conflicting regarding
Use of topicals before

the risk of nonmelanoma skin cancer in patients

recommendation

with vitiligo.7-9 Most of these studies did not

Photosensitizing

New light bulbs

find an increased incidence of skin cancer, even

medication
Postexposure
treatment

in light-skinned patients. Studies investigating

the incidence of skin cancers after treatment
taken

with NBUVB are largely retrospective and come

from the psoriasis literature. Again, most studies
6 Mohammad et al J AM ACAD DERMATOL
n 2017

Table II. The Vitiligo Working Group phototherapy recommendations

Frequency of administration
d Optimal: 3 times per week

d Acceptable: 2 times per week

d Level of evidence: IIA

Dosing protocol
2
d Initiate dose at 200 mJ/cm regardless of constitutive skin type

d Increase by 10-20% per treatment

d Fixed dosing based on SPT is another acceptable dosing strategy that takes inherent differences in the minimal

erythema dose of various skin types into account

d Level of evidence: IB

Maximum acceptable dose

d Face: 1500 mJ/cm2

d Body: 3000 mJ/cm

2

d Level of evidence: IV

Maximum number of exposures

d SPTs IV-VI: No limit

d SPTs I-III: More data on the risk of cutaneous malignancy is needed before a recommendation can be made

d Level of evidence: IV

Course of NBUVB
d Assess treatment response after 18-36 exposures

d Minimum number of doses needed to determine lack of response: 48 exposures

d Because of the existence of slow responders, $72 exposures may be needed to determine lack of response to phototherapy

d Level of evidence: III

Dose adjustment based on degree of erythema

d No erythema: increase next dose by 10-20%

d Pink asymptomatic erythema: hold at current dose until erythema disappears then increase by 10-20%

d Bright red asymptomatic erythema: stop phototherapy until affected areas become light pink, then resume at last

tolerated dose
d Symptomatic erythema (includes pain and blistering): stop phototherapy until the skin heals and erythema fades to a

light pink, then resume at last tolerated dose

d Level of evidence: IB

Dose adjustment following missed doses

d 4-7 days between treatments: hold dose constant

d 8-14 days between treatments: decrease dose by 25%

d 15-21 days between treatments: decrease dose by 50%

d Over 3 weeks between treatments: restart at initial dose

d Level of evidence: IV

Device calibration or bulb replacement

d Decrease dose by 10-20%

d Level of evidence: IV

Outcome measures to evaluate response

d Serial photography to establish baseline severity, disease stability, and response to treatment

d Validated scoring systems, such as the VASI or VETF, to quantify degree of response

d Level of evidence: IB

Posttreatment recommendations
d Application of sunscreen

d Avoidance of sunlight

d Level of evidence: IV

Topical products before phototherapy

d Avoid all topical products for 4 hours EXCEPT mineral oil

d Mineral oil can be used to enhance light penetration in areas of dry, thickened skin, such as the elbows and knees

d Level of evidence: IV

Tapering NBUVB after complete repigmentation has been achieved

d First month: phototherapy twice weekly

d Second month: phototherapy once weekly

Continued
J AM ACAD DERMATOL Mohammad et al 7
VOLUME jj, NUMBER j

Table II. Cont’d

d Third and fourth months: phototherapy every other week
d After 4 months: discontinue phototherapy
d Level of evidence: IV

Follow-up
d SPTs I-III: yearly follow-up for total body skin examination to monitor for adverse effects of phototherapy, including

cutaneous malignancy
d SPTs IV-VI: no need to return for safety monitoring as no reports of malignancy exist with this group

d All patients: return upon relapse for treatment

d Level of evidence: IV

Minimum age for NBUVB in children

d Minimum age is when children are able to reliably stand in the booth with either their eyes closed or

wearing goggles
d Typically around 7-10 years of age depending on the child

d Level of evidence: III

Treatment of eyelid lesions

d Keep eyes closed during treatment, using adhesive tape if necessary

d Level of evidence: III

Special sites
d Cover face during phototherapy if uninvolved

d Shield male genitalia

d Protect female areola with sunscreen prior to treatment, especially in SPTs I-III

d Level of evidence: III

Combination treatment for stabilization

d Oral antioxidants

d Topical treatments

d Oral pulse corticosteroids

d Level of evidence: IB

Treatment of NBUVB induced skin changes

d Xerosis: emollient or mineral oil

d Skin thickening: topical corticosteroids or keratolytics

d Level of evidence: IV

Levels of evidence: IA, evidence from metaanalysis of randomized controlled trials; IB, evidence from at least one randomized controlled trial;
IIA, evidence from at least one controlled study without randomization; IIB, evidence from at least one other type of experimental study; III,
evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, and case-control studies; IV, evidence
from expert committee reports or opinions or clinical experience of respected authorities, or both.
NBUVB, Narrowband ultraviolet B light phototherapy; SPT, Fitzpatrick skin phototype; VASI, Vitiligo Area Scoring Index; VETF, Vitiligo
European Task Force Assessment.

did not find an increased risk of skin cancer
after NBUVB phototherapy.10-12 Studies of inci-
dence data in a large number of patients with
vitiligo with adequate follow-up are necessary
before this question can be answered.
5. How many sessions are required before
assessing treatment response or discontinuing
phototherapy?
A course of NBUVB is defined by the number of
exposures. At least 18 to 36 exposures are
necessary before assessing treatment response.
Before discontinuing phototherapy because of
the lack of a response, $48 NBUVB sessions
should be administered. According to the ob-
servations of committee members, some pa-
tients may be slow responders. Therefore, $72
sessions may be considered before stopping
phototherapy.13
Dose adjustment
6. What increment should be used for dose esca-
lation in the absence of perceptible erythema?
The subsequent dose should be increased by
10% to 20%. This is the most commonly
used escalation reported in the literature,2
with agreement being reached among the
phototherapy committee and expert panel.
7. What is the ideal practice for dose adjustment
following erythema?
The desired response to phototherapy is pink
asymptomatic erythema lasting \24 hours.
Once achieved, the current dose should be
8 Mohammad et al
held until erythema disappears, at which time
the dose can be increased by 10% to 20%.
Higher increments may be tolerated by patients
with darker SPTs. For bright red asymptomatic
erythema, phototherapy should be held until
the affected areas become light pink. Photo-
therapy can then be resumed at the previous
dose used. In the event of symptomatic ery-
thema, which includes pain and blistering,
phototherapy should be held until erythema
fades to a light pink, at which time treatment
can be resumed at the last tolerated dose.
Although NBUVB bulbs have extremely low
ultraviolet A light output, in patients who
develop unexplained phototherapy-related er-
ythema, it is prudent to question patients
regarding photosensitizing medications, such
as tetracyclines, fluoroquinolones, sulfonyl-
ureas, hydrochlorothiazide, and phenothia-
zines, as well as ingestion of furanocoumarins,
which are photosensitizing organic compounds
produced by certain plants, such as celery,
grapefruit, and parsley. In addition, up to one-
third of patients with vitiligo are nonphotoa-
dapters, meaning they are unable to tolerate
increased doses of NBUVB at subsequent ex-
posures and are at higher risk for developing
burns.14 Early identification of these individuals
is necessary because they may benefit from
additional therapies and alternative dosing of
phototherapy.
8. What is the ideal practice for dose adjustment
following missed doses?
If 4 to 7 days pass between treatments, then the
dose should be held constant. The dose should
be decreased by 25% if 8 to 14 days pass
between treatments. For a lapse in treatment
of 15 to 21 days, the dose should be decreased
by 50%. If [3 weeks have passed between
treatments, then phototherapy should be
resumed at the initial dose. This dosing strategy
is consistent with the second edition of the
Phototherapy Treatment Protocols for Psoriasis
and Other Phototherapy-Responsive Dermatoses
for patients with vitiligo.15
9. What is the ideal practice for dose adjustment
after device calibration or insertion of a new
bulb?
The dose should be reduced by 10% to 20%.
Maintenance and follow-up
10. What evaluation measures should be used
during initial and follow-up visits?
Serial photography should be used to establish
baseline severity of vitiligo and at follow-up
J AM ACAD DERMATOL
n 2017
visits to assess treatment response and disease
stability. Ideally, this should occur approxi-
mately every 3 months based upon consensus
of the expert panel. Using a digital camera or
tablet to upload pictures into the patient’s file
can make this process easier. Validated scoring
systems, such as the Vitiligo Area Scoring
Index or Vitiligo European Task Force
Assessment, can be used to quantify the
degree of response.
11. What postexposure recommendations should
be given to patients after treatment with
NBUVB?
All patients regardless of SPT should be
advised to apply a broad-spectrum sunscreen
with a skin protection factor of $30, with
reapplication every 2 hours according to the
American Academy of Dermatology sunscreen
guidelines, and to avoid sunlight to decrease
the risk of additional UVB exposure and
phototoxic effects.
12. What topical products should be avoided
before treatment with NBUVB phototherapy?
All topical products should be avoided with
the exception of mineral oil for $4 hours
before phototherapy because of the possibility
of deactivation or interference with transmis-
sion of NBUVB. Mineral oil can be used to
enhance light penetration in areas of dry,
thickened skin, such as the elbows and knees.
13. Once a plateau in response has been
observed, what is the appropriate mainte-
nance regimen for NBUVB phototherapy?
Once maximum repigmentation has been
achieved with NBUVB phototherapy, we
recommend tapering the dose as follows: the
first month after complete repigmentation is
achieved, continue phototherapy twice
weekly. Reduce the frequency to weekly
during the second month, and further decrease
to every other week sessions during the third
and fourth months. Phototherapy can be
discontinued beyond this point if there is no
disease recurrence. This strategy enables the
identification of patients who are at risk
for relapse and the timely resumption of
phototherapy at a frequency of 3 times per
week.
14. What is the recommended frequency of
follow-up after completion of treatment with
NBUVB phototherapy to monitor for adverse
effects and relapse?
For SPTs I to III, we recommend yearly follow-
up for total body skin examination to monitor
for adverse effects of phototherapy, including
J AM ACAD DERMATOL Mohammad et al 9
VOLUME jj, NUMBER j

cutaneous malignancy. Patients with SPTs IV should also be shielded because of the possible
to VI do not require yearly follow-up, because risk of genital malignancy. Fourteen cases of
no reports of malignancy exist with this group. genital malignancy were presented in psoriasis
All patients should return to clinic upon patients treated with psoralen plus ultraviolet A
relapse for treatment. light phototherapy. However, some of these
patients had also been exposed to high levels of
Safety
UVB ([300 exposures).19 To protect the female
15. What is the minimum age for children to start
areola from burns, sunscreen may be applied
treatment with NBUVB phototherapy?
before phototherapy, especially in patients with
We recommend that children who are able to SPTs I to III.
reliably stand in the booth with either their
eyes closed or wearing goggles can receive
Adjunct therapies
phototherapy. This typically occurs around 7
18. What therapies can be used in combination
to 10 years of age. The possibility of adults
with NBUVB for stabilization of vitiligo?
remaining inside the booth with younger
To induce stabilization, oral pulse corticoste-
children has been raised but is not ideal,
roids, oral antioxidants, and topical treatments
because incomplete shielding may result in
can be used. Pulse dosing typically involves
unnecessary exposure of the adult. However, taking dexamethasone for 2 consecutive days
this may be the only way to ensure coopera-
per week for several weeks to months and has
tion of some children. Because adults partially
been shown to halt disease progression.20
shield the patient, the child must be turned
Patients should be cautioned about side effects
during phototherapy to ensure that the entire
of oral corticosteroids and encouraged to
area is treated. In these instances, complete
increase vitamin D and calcium intake for the
photoprotection of the accompanying adult,
duration of treatment. Commonly used
including the use of ultraviolet lighte
antioxidants in vitiligo include gingko biloba,
protective goggles, is essential. Initiating pho- alpha-lipoic acid, and Polypodium leucotomos
totherapy quickly in the pediatric population is
extract. Studies on the combination of P
important, because treatment with NBUVB
leucotomos extract with NBUVB phototherapy
improves disease stability, repigmentation,
showed increased efficacy of combination
and quality of life with minimal side effects
treatment.21 Topical therapies, such as corti-
in children with vitiligo.16 Long-term follow-
costeroids, can also be used in conjunction
up studies need to be performed on the
with phototherapy. Any adjunct therapies that
incidence of skin cancer in pediatric
increase photosensitivity in the UVB range
patients receiving NBUVB treatment to further should be avoided while using NBUVB
assess safety of this treatment modality in
phototherapy.
children.
19. What therapies can be used for treatment of
16. What is the recommendation for use of NBUVB
dry or thickened skin induced by treatment
phototherapy in patients with eyelid lesions?
with NBUVB phototherapy?
Studies on the ocular effects of NBUVB did not
NBUVB-induced xerosis can be treated with
show a significant decrease in visual acuity,
an emollient or mineral oil, whereas topical
increase in cataracts, or increased anterior and
corticosteroids or a keratolytic agent can treat
posterior segment complications over the thickening of the skin secondary to NBUVB.
course of 13 months of therapy.17 Because
Additional research needs to be performed on
phototherapy is an effective treatment for eyelid
the effects of emollients, keratolytics, and
lesions and in vitro examination has shown
corticosteroids in improving repigmentation
negligible penetration of UVB through eyelid
in thickened skin.
specimens, it is important for eyelid lesions to
be treated.18 Therefore, we recommend that In conclusion, although NBUVB forms the back-
patients with eyelid lesions keep their eyes bone of vitiligo treatment, no consistent protocols for
closed during treatment. its administration exist. This is reflected by a wide
17. What is the recommendation for protection of array of protocols that address the needs of different
special sites during treatment with NBUVB SPTs, socioeconomic standards, and health insur-
phototherapy? ance systems. A deficiency of controlled studies also
If uninvolved, the face should be covered exists. In this study, we created broadly applicable
during NBUVB phototherapy. Male genitalia expert recommendations to assist dermatologists in
10 Mohammad et al
the treatment of vitiligo with NBUVB phototherapy.
However, these are only guidelines. Ultimately, all
treatment decisions must be based on an agreement
between a patient and the managing physician. This
work also highlights areas requiring additional study
to direct future research and create safe and effective
treatment protocols for the use of NBUVB in vitiligo.
The authors thank Lauren Madigan, MD, for identifying
treatment gaps in the use of phototherapy for vitiligo,
which led to the initiation of this project, as well as the
phototherapy experts, including Imran Majid, MD,
Davinder Parsad, MD, Wedad Mostafa, MD, and Medhat
El-Mofty, MD. We also thank Henry Ford Hospital, the
University of Texas Southwestern Medical Center, the
University of Massachusetts Medical School, San
Gallicano Institute, Kasr Al-Aini Hospital Cairo University,
and Clinica Alemana de Santiago de Chile phototherapy
centers for their invaluable assistance.
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