DOI: 10.1111/j.1468-3083.2010.03879.

x JEADV

ORIGINAL ARTICLE

Comparison of the therapeutic effects of narrow band

UVB vs. PUVA in patients with pityriasis lichenoides
F. Farnaghi, H. Seirafi, 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 defined. 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 findings 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, five 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 insignificant, 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

Conflict of interest
None.

Background systemic dapsone,8 methotrexate13 and systemic steroids10 have

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 pity-
riasis 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 devel-
opment of necrotic lesions as well as fever and other serious sys-
temic problems.4 This disorder may be acral5 or present during
pregnancy.6 Although it is generally a benign disorder, severe sys-
temic involvement may develop.7 The disorder usually follows a
chronic course with periodic alterations in severity and acute exac-
erbations 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
been used with different success rates. Treatment with photothera-
py 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 ther-
apeutic effects of these two methods in Iranian patients with PLC.
Material and methods
Patients with PLC based on clinical findings confirmed via path-
ological examination were selected if they fulfilled the following
inclusion criteria: generalized disease involving at least 60% of
the total body surface (based on Nine’s 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 vascu-
lar disorder or cutaneous malignancies, positive antinuclear anti-
body tests, impaired liver or renal function tests and if they

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914 Farnaghi et al.

failed to pass routine ophthalmological assessment by an oph- Patient response

thalmologist. Patients treated in every measure including photo-
sensitizing 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 con-
firmed 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 proto-
cols for each treatment option receptively.
NB-UVB protocol
All patients received 200 mJ ⁄ m2 for the first 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 sensa-
tion, the dose of NB-UVB was decreased by 50%. In the case of
severe side-effects such as severe erythema, burning or photo-sen-
sitivity, 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 1–1.5 J ⁄ m2 for skin
types I–III Fitzpatrick and 2 J ⁄ m2 for patients with IV–V skin
types. The dose increment was 2 J every two sessions. Maximum
treatment sessions for both groups were 60.
Complete response was defined as more than 90% resolution
in skin lesions (papulo-squamous and plaque lesions). Partial
response was defined as resolution of 50–90% in skin lesions. Poor
response was taken as less than 50% reduction in lesions.
If patient’s 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 defined 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 enrol-
ment in this study, either with topical corticosteroids (five
patients, 33%) or with oral erythromycin (five 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).

Table 1 Demographic characteristics of patients

Patient Group Age Gender Skin Previous Degree of involvement Number of Outcome
index type treatment (based on Nine’s Rule; %) treatment (clearance %)
sessions
1 A 16 M III – 75 32 >90
2 A 28 F II TC 70 40 >90
3 A 36 F III TC 80 60 80
4 A 32 M III OE 75 30 >90
5 A 48 F III TC 70 35 >90
6 A 50 M IV – 90 32 >90
7 A 32 M IV – 80 36 >90
8 A 19 F III OE 85 35 >90
9 B 30 M III OE 70 36 >90
10 B 29 M III TC 70 38 >90
11 B 18 F II – 80 60 60
12 B 42 M IV OE 75 60 75
13 B 25 F III OE 80 20 >90
14 B 34 M III – 85 38 >90
15 B 27 F III TC 70 36 >90
Group A: NB-UVB group; group B: UVA group; TC, topical steroid; OE, oral erythromycin.

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Therapeutic effects of NB-UVB and PUVA
Table 2 Therapeutic results in brief
Response
rate
(complete) Erythema
Group A (NB-UVB) 87.5% (NS) 12.5% (NS)
Group B (UVA) 71.4% 14.2%
NS, not significant.
*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, five 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).
Discussion
As a whole, phototherapy is probably the most successful therapy
and may be considered as first-line therapy in proper situations.15
There are several studies indicating the effectiveness of both
PUVA14,16,18–21 and NB-UVB22–24 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 first one that compares the
therapeutic effects of these two options in non-paediatric patients.
As mentioned above, there were no significant 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 five 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 finding 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 trea-
ted with PUVA. Equivalent rates were reported in other studies
focusing on the effects of phototherapy in PLC.23,24,27 The rela-
tively 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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915
Side-effects Mean Mean
treatment Recurrence
Burning sensation Other* sessions rate
37.5% (NS) – 37 ± 11 (NS) 42.8% (NS)
28.5% – 40 ± 16 40%
tapering schedule after remission. This study failed to show any
significant 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 NB-
UVB and PUVA are acceptable for treating this disorder. Other
studies with a larger sample size may be able to show significant
differences.
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