NBUVB and Skin Cancer Incidence in Vitiligo Psoriasis

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Chia Brian Keng Yong (Orcid ID: 0000-0002-9033-5546)
Incidence of skin malignancies in patients with

vitiligo or psoriasis who received narrowband
ultraviolet B phototherapy (308nm/311nm): a
retrospective review of 3730 patients
Brian KY Chia, MBBS (Hons), MRCP (UK), M Med (Int Med)
Yik Weng Yew, MBBS, MPH (Harvard, USA)
Xiahong Zhao, PhD
Wei-Sheng Chong, MBBS, MMed (Int Med), MRCP (UK), FAMS, FRCP (Edin)
Tien Guan Steven Thng, MBBS, MRCP (UK), FRCP (Edin)
National Skin Centre, Singapore
Correspondence:
Brian Keng Yong Chia
1 Mandalay Road, Singapore 308205
E-mail: brianchia87@gmail.com
Phone: +65-62534455
Keyword: UVB, NBUVB, cancer, Singapore
Word count: 2659
Figures: 0
Table: 4
Running section head: Original article
Funding: none declared
Conflict of interest: none declared
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
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Abstract
Background:
Previous studies regarding the risk of skin malignancy with NBUVB have been performed in
Caucasian patients but few studies have been conducted in Asians.
Aims:
To determine the risk of skin cancer in Asian patients with psoriasis and vitiligo receiving
NBUVB phototherapy.
Methods:
We performed a 9-year retrospective study including all patients with psoriasis and vitiligo
receiving NBUVB (either 311nm wavelength through cabin phototherapy or 308nm through
excimer lamp phototherapy) at the National Skin Centre.
We matched the identification numbers of patients to the National Registry of Diseases Office
database and collected data on all skin cancers diagnosed
Results:
A total of 3730 patients were included. During the course of the study, 12 cases of skin cancer
were diagnosed, of which 10 were basal cell carcinomas, and 2 were squamous cell carcinomas.
No cases of melanoma were detected in the study.
The age-standardized incidence of skin cancer in psoriasis and vitiligo patients who received
phototherapy was 47.5 and 26.5 respectively, which is higher than the incidence of skin cancers
in the general population.
Risk of skin malignancy was positively correlated with the cumulative (p=0.008) and
maximum dose of phototherapy (p=0.011) as well as previous systemic treatments (p=0.006).

Limitations
Limitations include a relatively short follow- up period as well as the lack of quantification of
solar exposure.
Conclusions:
NBUVB phototherapy in Asian skin increases the risk of skin malignancy. The risk of skin
malignancy is higher with psoriasis patients, greater cumulative and maximal dose of
phototherapy as well as use of systemic therapy. Despite the increased risk, the absolute
number of skin malignancies remains low, especially for vitiligo patients, with no cases of
melanoma diagnosed – a reassuring finding that phototherapy remains a safe alternative in
the treatment of psoriasis and vitiligo.

Introduction
Narrowband ultraviolet B (NBUVB) phototherapy was first introduced in the 1980s. Since
then, it has been efficacious in the treatment of psoriasis,(1) vitiligo,(2) atopic dermatitis(3)
and many other inflammatory skin disorders.
NBUVB has predominantly been studied in Caucasian populations (4-10) with mixed results.
Of these, 1 study identified a small but significant increase in the risk of basal cell
carcinomas (BCC)(6) which was attributed to ascertainment bias, another found that there
could be an increased risk of non-melanoma skin cancers (NMSCs)(10) whilst another found
that there were a noteworthy number of NMSCs though there was no comparison to a control
population.(9). The remaining 3 studies found no significant association between NBUVB
and risk of skin malignancy. There have been far fewer studies performed in Asian
patients(11, 12)
The aim of our study is to investigate the risk of skin cancer in patients receiving NBUVB
phototherapy for psoriasis and vitiligo in our dermatology centre in Singapore with diverse
ethnicities in a predominantly Asian population.
Methods
We performed a retrospective study including all patients with psoriasis and vitiligo receiving
NBUVB phototherapy for a 9-year period from 2004 to 2013 at the National Skin Centre,
Singapore. We included both patients who had received whole body as well as localized
phototherapy. We define patients with whole body phototherapy as patients who underwent
phototherapy treatment with a cabin-type phototherapy lamp with a wavelength of 311nm
and patients with localized phototherapy as those who underwent treatment with the excimer
lamp with a wavelength of 308nm. Patients who had previously received PUVA treatment
were excluded. We also excluded patients who had a pre-existing skin cancer prior to
initiation of phototherapy.
Their electronic medical records were reviewed and a standardized questionnaire was filled
up for data collection and tabulation. The following information was collected and analyzed:
patient demographics including age, gender, race and Fitzpatrick skin type; primary treatment
indication (either psoriasis or vitiligo); phototherapy related treatment factors including
number of treatments, dosage per session, cumulative dosage, maximum dosage; other
treatment received including topical therapy and systemic therapy.
We matched the identification numbers of patients to the database of the National Registry of
Diseases Office (NRDO), the centre in Singapore responsible for collection of data regarding
newly diagnosed malignancies. It is legally mandatory to notify all newly diagnosed cases of
malignancies in Singapore including but not limited to basal cell carcinomas, squamous cell
carcinomas, in-situ squamous cell carcinomas, melanomas and in-situ melanomas. Failure to
do so may invite financial penalties. We included in our study all melanoma and non-
melanoma skin cancers which were diagnosed from 2004 to 2016 (the latest data available
from the NRDO). We collected information including: primary site, histological type, cancer
grade as well as cancer stage. The age standardized rate of skin malignancies in our study
population was compared against the incident rate in the Singapore population. This study
was approved by our centre’s institutional review board.
Statistical methods
Bivariate analyses using Fisher’s exact tests were used to compare the differences between
nominal variables such as gender, race, and Fitzpatrick skin types. Wilcoxon rank-sum test
was used to compare differences for variables in interval/ratio scale such as age, number of
phototherapy treatments performed and cumulative dose of phototherapy.

Both crude (CR) and age-standardized (ASR) skin cancer incidence rates per 100,000-person-
year with 95% confidence intervals (CIs) were calculated for the study population. The ASRs
in years 2004-2016 and 2008-2012 were standardized to the year 2010, and the ASRs in years
2004-2007 were standardized to the year 2005. The Department of Statistics Singapore
resident population was used as the standard population for comparison.(13).
A p-value of less than 0.05 was considered statistically significant. The statistical analysis
was performed using R statistical software version 3.5.3.(14)
Results
Patient demographics
A total of 3730 patients were included in our study. This comprised 2163 patients with
psoriasis and 1567 patients with vitiligo. Compared to psoriasis patients, vitiligo patients
were younger (median age 36 years vs 40 years) with a higher proportion of females (48.1%
vs 30.8%). In both groups, most patients were Chinese (65.3%) with Fitzpatrick skin type 4
(95.3%). Data on patient demographics is summarized in Table 1.
Phototherapy
Most psoriasis patients received whole body NBUVB phototherapy (96.9%) whilst most
vitiligo patients received targeted phototherapy (64.8%). Median number of treatments was
higher for vitiligo patients (50 vs 41) but this difference was not statistically significant.
Psoriasis patients received significantly higher phototherapy dosages compared to vitiligo
patients (median session dose 600mJ/cm2 vs 59 mJ/cm2 (p<0.001), median cumulative dose
79229 mJ/cm2 vs 14536 mJ/cm2 (p<0.001) and median maximum dose 3415 mJ/cm2 vs 500
mJ/cm2 (p<0.001). The information is summarized in Table 1

Adjunctive treatment
33% of psoriasis patients had received adjunctive systemic therapy compared to vitiligo
patients in whom no patients received adjuvant systemic therapy. These included
methotrexate (28.3%), cyclosporine (3%), acitretin (10.4%), etanercept (0.5%), hydroxyurea
(0.9%), adalimumab (0.6%) and ustekinumab (1.2%).
Skin malignancy
From 2004 to 2016, a total of 10 patients (0.5%) with psoriasis and 2 patients (0.1%) with
vitiligo were diagnosed with skin cancer. The site of involvement was the face in 4 patients,
the trunk in 1 patient, the upper limbs in 3 patients, the lower limbs in 2 patients and in 2
patients the site of involvement was not specified. In psoriasis patients, 2 out of the 10
patients had squamous cell carcinoma (SCC) whereas the remainder had BCCs. In vitiligo
patients, both patients had BCCs. There were no cases of melanoma in our study. The grade
of the cancer was well differentiated in 3 cases, moderately differentiated in 1 case and
unspecified in the remaining 8 cases. 7 out of the 12 cases had stage 1 cancer whereas the
staging of the remaining 5 was unknown. The information above is summarized in Table 2.
We calculated the incidence of skin cancer for patients with psoriasis and vitiligo for the time
period from 2004 to 2016. These figures were compared against the incident rate of skin
malignancies in the general Singapore population during the same time period.(13) For the
rest of this article, the skin cancer incidence will be reported in figures per 100 000 person-
years unless otherwise stated.

There were a total of 6728 cases of skin cancer diagnosed in the general population with an
incidence rate of 14.1 (95% CI 13.8-14.4). Comparatively, 10 psoriasis patients and 2 vitiligo
patients were diagnosed with skin cancer during the same period with an age-standardized
incidence rate of 47.5 (95% CI 17.1-77.8) and 26.5 (95% CI 0-65.3) respectively. In
particular for psoriasis patients, the lower threshold of the 95% confidence interval exceeded
that of the general population. Interestingly, there were no skin malignancies reported in
female vitiligo patients during the entire course of the study.
The comparative incidences of skin malignancy are summarized in Table 3.
Association of skin malignancy with phototherapy
The risk of skin malignancy was positively correlated with the cumulative and maximum
dose of phototherapy as well as previous systemic treatments. The median cumulative dose in
patients with skin cancer was 311240mJ/cm2 compared to 39481 mJ/cm2 in patients who did
not develop skin cancer (p=0.008). The median highest dose of phototherapy was 5095
mJ/cm2 in patients with skin cancer compared to 2062 mJ/cm2 in patients without skin cancer
(p = 0.011). 50% of patients with skin cancer had received systemic therapy compared to
19% of patients without skin cancer (p=0.006). The median number of phototherapy
treatments was higher in patients with skin cancer compared to those without (86 vs 45) but
this difference was not statistically significant. (p=0.092). There was no difference in the 2
groups in terms of use of topical therapy or Fitzpatrick skin type. The results are summarized
in Table 4.
Discussion
Psoriasis patients have a higher incidence of skin malignancy
In our study, the incidence of skin malignancy is higher in psoriasis patients compared to the
general Singapore population. In earlier published studies on NBUVB phototherapy, 2
studies by Weischer et al.(5) with 195 psoriasis patients and Black et al.(7) with 484 patients
both did not show any increased risk of skin malignancy. In the study by Man et al.(6) with
1908 patients, a small but significant increased risk of BCCs was observed but this was
attributed to ascertainment bias. In the largest study by Hearn et al.(8) with 3867 patients, a
small increased risk of BCCs was noted but this association was not significant when patients
who had also received PUVA were excluded.
While the higher skin phototypes of Asian patients would theoretically confer some
protection against skin cancer, our study observed an increased risk of skin malignancy. One
possible reason for this greater risk could be the substantially higher dose of NBUVB
required for treatment. In the studies by Weischer et al.(5) and Man et al.(6) the median
cumulative dose was 4480mJ/cm2 and 13 377mJ/cm2 respectively. This is in comparison to
our study where the median cumulative dose was 79229mJ/cm2 for psoriasis patients and
14536mJ/cm2 in vitiligo patients. Thus, while a higher skin phototype may confer protection
against skin cancers, this may be offset by higher doses of phototherapy.
Another possible reason for our positive study is our large sample size. Although NBUVB
appears to be associated with increased skin cancer risks, the absolute risk is small with a
total of 12 cases reported in 3730 patients. Hence, it is likely that earlier studies with fewer
number of patients may have been underpowered to find this association.
A third possibility of ascertainment bias may also account for this observed increase in skin
cancer incidence. Patients undergoing phototherapy at our centre, particularly those with
multiple treatments, will likely receive increased surveillance for skin cancers compared to
the general population.
Vitiligo patients have an increased risk of skin malignancy compared to the general
population, but lower than that of psoriasis patients
Compared to the general population, the incidence of skin cancer is increased in vitiligo
patients, which suggests that phototherapy may still increase the risk of skin cancer in this
group of patients despite innate protective mechanisms. Earlier epidemiological studies have
demonstrated a reduced risk of both melanoma and NMSCs in vitiligo patients. (15, 16) The
postulated mechanism of protection against NMSCs in vitiligo include reduced
photodamage(17, 18), higher levels of wild-type p53 in keratinocytes(19, 20) increased levels
of glutathione peroxidase, superoxide dismutase and decreased levels of transforming growth
factor-β and interleukin-10(21) as well as induction of autoimmunity through the reduction of
regulatory T-cell activity from the inhibition of cytotoxic T-lymphocyte–associated protein 4
and PD-1(22-24), all of which are thought to confer protection against NMSCs. The
difference in skin cancer incidence between female and male vitiligo patients might be
attributed to gender related differences in sun protection measures.
More importantly however, only 2 patients (both male) were diagnosed with skin cancer in
the vitiligo group throughout the course of the study. This does raise the specter of whether
the observed increased in skin cancer incidence and gender differences is simply due to a
chance occurrence. Further studies with larger patient numbers and longer follow-up will be
required to ascertain these study findings.
Vitiligo patients appear to have a lower risk of skin malignancy compared to psoriasis
patients but higher than that of the general Singapore population. Interestingly, no female
vitiligo patients were diagnosed with skin cancer through the course of the study. (15-21) In
addition to the innate protective mechanisms in vitiligo patients, however, there may be a few
other reasons why vitiligo patients have a lower incidence of skin cancer compared to
psoriasis patients.
Firstly, vitiligo patients generally have a substantially lower cumulative dose of NBUVB due
to decreased melanization and hence increased minimal erythema dose (MED). In our study,
the median session dose and median cumulative dose of phototherapy in vitiligo patients was
59mJ/cm2 and 14 536mJ/cm2 respectively compared to psoriasis patients (600mJ/cm2 and 79
229mJ/cm2 respectively).
Secondly, approximately one-third of psoriasis patients had received systemic treatment
compared to vitiligo patients, in whom no patient was on systemic therapy. Systemic
treatments such as cyclosporine have been known to increase the risk of skin malignancies in
transplant patients(25-27). Our study also demonstrated a positive correlation between use of
systemic therapy and risk of skin malignancy (odds ratio 4.25, p =0.006). Unfortunately, due
to the NRDO policy of releasing only anonymized aggregate data, we were unable to
determine which systemic agent in particular accounts for the higher risk of skin malignancy.
Risk of development of skin malignancy positively correlated with higher cumulative dose,
maximum dose and use of systemic therapy
There was a positive correlation between risk of skin malignancy and higher cumulative and
maximum dose of phototherapy, as well as use of systemic treatment. Earlier studies on
NBUVB have either been negative(5, 7, 8) or did not examine the relation of cumulative dose
to the risk of development of skin malignancy. Dose-dependent malignancy risks have been
demonstrated on earlier studies with PUVA(4, 28-37) as well as 1 study on risk of genital
skin malignancies with UVB phototherapy.(30) We believe that whilst NBUVB phototherapy
may not be as carcinogenic as PUVA or broad band UVB (BBUVB), the mechanisms that
contribute to the skin malignancy remain similar and findings from these studies can also be
extrapolated to NBUVB.
On the other hand, maximum dose of phototherapy may not be an independent risk factor for
the development of skin malignancy as it seems biologically implausible that a single session
with high dose phototherapy would add significantly to the risk of skin malignancy. Instead, a
higher maximum dose may simply imply an association with more severe disease, therefore
being positively correlated with higher cumulative dose and greater use of systemic agents,
both of which are risk factors for the development of skin malignancy.
Subtypes of skin malignancy found
Our study did not identify any patients who developed melanoma skin cancer, This is
consistent with epidemiological data showing that melanoma is generally a rare condition in
our population.(38) Moreover, majority of the cases of melanoma in our population are of the
acral-lentiginous subtype(39), which are not thought to be related to ultraviolet (UV)
exposure.(40) Our study found that majority of skin malignancies diagnosed (83.3%) were
BCCs with the rest being SCCs. This is a reassuring finding suggesting that even if the risk of
skin malignancies is increased with NBUVB, the vast majority of them are BCCs which
remain eminently treatable with early diagnosis and heightened surveillance.
Study limitations
Limitations of our study include a relatively short follow-up period. The lag period from
exposure to the development of skin malignancies may be quite prolonged hence a longer
period of follow-up may allow for a more accurate determination of the risk of skin cancer,
particularly in vitiligo patients where the number of patients diagnosed was few.
A second limitation of our study is the lack of quantification of solar exposure. This is a
limitation of the retrospective nature of our study but an accurate quantification of the
exposure would be challenging even for a prospective case design.
A third limitation of our study pertains to our use of NRDO data. NRDO only permits the
release of aggregated, anonymized information. Hence, it was not possible for us to analyze
aspects of patients with skin malignancies including if the site of the malignancy
corresponded to where phototherapy was performed (in the case of localized phototherapy).
Conclusion
Overall, our study demonstrates that NBUVB phototherapy in Asian skin does increase the
risk of skin malignancy. The risk of skin malignancy appears to be higher for psoriasis
patients compared to vitiligo patients. This risk appears to be related to cumulative and
maximal dose of phototherapy as well as concurrent or previous systemic therapy. The
incidence of skin malignancy in vitiligo is reduced compared to psoriasis patients but higher
than the general population. Despite the increased risk, the absolute number of skin
malignancies remains low, especially for vitiligo patients, with no cases of melanoma
diagnosed – a reassuring finding that phototherapy remains a safe alternative in the treatment
of psoriasis and vitiligo.

Psoriasis Vitiligo Total
p-value
(n = 2163) (n = 1567) (n = 3730)
Gender <0.001
Fema le 667 (30.8%) 755 (48.1%) 1422 (38.1%)
Ma l e 1496 (69.2%) 813 (51.9%) 2309 (61.9%)
Age <0.001
Mea n ± s d 41 ± 15 36 ± 18 38 ± 16
Medi an (min, max) 40(5,86) 36(2,83) 38(2,86)
Race <0.001
Chi nese 1422 (65.8%) 1011 (64.5%) 2433 (65.3%)
Ma l a y 228 (10.6%) 101 (6.4%) 329 (8.8%)
Indian 290 (13.4%) 278 (17.8%) 568 (15.2%)
Others (Ca ucasian, Eurasian, etc) 223 (10.2%) 177 (11.3%) 400 (10.7%)
Skin Type <0.001
I 2 (0.1%) 39 (2.5%) 41 (1.1%)

II 7 (0.3%) 2 (0.1%) 9 (0.2%)
III 24 (1.1%) 7 (0.5%) 31 (0.8%)
IV 2060 (95.2%) 1495 (95.4%) 3555 (95.3%)
V 59 (2.7%) 18 (1.2%) 77 (2.1%)
VI 11 (0.5%) 6 (0.4%) 17 (0.5%)
Light Source <0.001
Loca l ized phototherapy 67 (3.1%) 1016 (64.8%) 1083 (29.0%)
Whol e body phototherapy 2096 (96.9%) 551 (35.2%) 2647 (71%)
Number of Treatments received 0.093
mea n ± s d 83 ± 110 74 ± 80 79 ± 98
median (min, max) 41(0,1141) 50(0,628) 45(0,1141)
Session dosage (mJ/cm2) <0.001
mea n ± s d 697 ± 533 173 ± 306 476 ± 520
median (min, max) 600(0,7000) 59(0,4263) 375(0,7000)
Cumulative dose (mJ/cm2) <0.001
mea n ± s d 243088 ± 414746 68430 ± 150159 169713 ± 341516
median (min, max) 79229(0.25,6257019) 14536(22,1361066) 39656(0.25,6257019)
Max dose (mJ/cm2) <0.001
mea n ± s d 4217 ± 8392 1555 ± 2929 3099 ± 6794
median (min, max) 3415(0.25,350350) 500(22,44172) 2077(0.25,350350)
Table 1: Demographics as well as dosimetry of psoriasis and vitiligo patients receiving

NBUVB phototherapy (311nm cabin phototherapy or 308nm excimer lamp phototherapy)
Note: P values are for comparison between psoriasis and vitiligo groups
Psoriasis Vitiligo
Primary Site
Ski n of other a nd unspecified parts of face 3 (30.0%) 1 (50.0%)
Ski n of trunk 1 (10.0%) 0 (0.0%)
Ski n of upper l imb and shoulder 2 (20.0%) 1 (50.0%)
Ski n of lower l imb a nd hip 2 (20.0%) 0 (0.0%)
Not otherwise specified 2 (20.0%) 0 (0.0%)
Tota l 10 (100.0%) 2 (100.0%)
Histological Diagnosis
Squa mous cell ca rcinoma 2 (20.0%) 0 (0.0%)
Ba s al cell carcinoma 8 (80.0%) 2 (100.0%)
Tota l 10 (100.0%) 2 (100.0%)
Grade of skin cancer
Wel l 3 (30.0%) 0 (0.0%)
Modera te 1 (10.0%) 0 (0.0%)
Not otherwise specified 7 (60.0%) 2 (100.0%)
Tota l 10 (100.0%) 2 (100.0%)
Stage of skin cancer
Sta ge I 5 (50.0%) 2 (100.0%)
Unknown 5 (50.0%) 0 (0.0%)
Tota l 10 (100.0%) 2 (100.0%)
Table 2: Skin malignancies in patients with psoriasis and vitiligo

Total All
Male Female
Cancer
Number CR ASR CR ASR CR ASR
Ps ori asis + Vi tiligo 12 38.0 (21.6, 40.0 (16.2, 55.5 (30.7, 56.4 (21.2, 8.5 (1.2, 11.5 (0.0,
66.9) 63.8) 100.2) 91.6) 60.5) 34.2)
Ps ori asis 10 52.5 (28.2, 47.5 (17.1, 67.6 (35.2, 58.9 (18.4, 17.4 (2.5, 23.6 (0,
97.5) 77.8) 129.8) 99.3) 123.8) 69.8)
Vi ti ligo 2 16.0 (4.0, 26.5 (0, 30.7 (7.7, 40.7 (0, 99.8) 0.0 (0.0, 0.0 (0.0,
63.9) 65.3) 122.9) 0.0) 0.0)
Na ti onal Registry of 6728 14.1 (13.8, 14.4) 15.7 (15.2, 16.2) 12.5 (12.1,13.0)
Di s eases Singapore
population
Table 3: Non-melanoma Skin Cancer Incidence Rate per 100,000 person years from 2004 to
2016 with 95% confidence intervals
Note: CR refers to crude skin cancer incidence rates per 100 000 person-years and ASR
refers to age-standardized (ASR) skin cancer incidence rates per 100 000 person-years
No Skin Cancer Skin Cancer Total p-
(n = 3718) (n = 12) (n = 3730) value
Cumulative dose (mJ/cm2) 0.008
mea n ± s tandard deviation 168631 ±339522 504940 ± 680482 169713 ± 341516
median (min, max) 39481 (0.25, 6257019) 311240 (112, 2310049) 39656 (0.25, 6257019)
Maximum dose (mJ/cm2) 0.011
mea n ± s tandard deviation 3093 ± 6803 4799 ± 2695 3099 ± 6794
median (min, max) 2062 (0.25, 350350) 5095 (75, 8700) 2077 (0.25, 350350)
Number of treatments received 0.092
mea n ± s tandard deviation 79 ± 98 120 ± 110 79 ± 98
median (min, max) 45 (0, 1141) 86 (2, 350) 45 (0, 1141)
Systemic Treatment 0.006
No 3010 (81.0%) 6 (50.0%) 3016 (80.9%)
Yes 708 (19.0%) 6 (50.0%) 714 (19.1%)
Topical Treatment 0.384
No 475 (12.8%) 0 (0.0%) 475 (12.7%)
Yes 3243 (87.2%) 12 (100.0%) 3255 (87.3%)
Fitzpatrick skin Type 1.000
I 41 (1.1%) 0 (0.0%) 41 (1.1%)
II 9 (0.2%) 0 (0.0%) 9 (0.2%)
III 31 (0.8%) 0 (0.0%) 31 (0.8%)
IV 3543 (95.3%) 12 (100.0%) 3555 (95.3%)
V 77 (2.1%) 0 (0.0%) 77 (2.1%)
VI 17 (0.5%) 0 (0.0%) 17 (0.5%)
Table 4: Comparison of risk factors between patients with skin cancer and those without
Note: P values are for comparison between groups with skin cancer and those without skin
cancer
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NBUVB and Skin Cancer Incidence in Vitiligo Psoriasis

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NBUVB and Skin Cancer Incidence in Vitiligo Psoriasis

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16000781, ja, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/phpp.12844 by National University Of Singapo, Wiley Online Library on [08/11/2022].

Incidence of skin malignancies in patients with

National Skin Centre, Singapore

Brian Keng Yong Chia

1 Mandalay Road, Singapore 308205

Keyword: UVB, NBUVB, cancer, Singapore

Word count: 2659

Running section head: Original article

Funding: none declared

Conflict of interest: none declared

Caucasian patients but few studies have been conducted in Asians.

excimer lamp phototherapy) at the National Skin Centre.

database and collected data on all skin cancers diagnosed

No cases of melanoma were detected in the study.

in the general population.

maximum dose of phototherapy (p=0.011) as well as previous systemic treatments (p=0.006).

melanoma diagnosed – a reassuring finding that phototherapy remains a safe alternative in

the treatment of psoriasis and vitiligo.

and many other inflammatory skin disorders.

population.(9). The remaining 3 studies found no significant association between NBUVB

ethnicities in a predominantly Asian population.

phototherapy treatment with a cabin-type phototherapy lamp with a wavelength of 311nm

indication (either psoriasis or vitiligo); phototherapy related treatment factors including

treatment received including topical therapy and systemic therapy.

was approved by our centre’s institutional review board.

phototherapy treatments performed and cumulative dose of phototherapy.

resident population was used as the standard population for comparison.(13).

was performed using R statistical software version 3.5.3.(14)

(95.3%). Data on patient demographics is summarized in Table 1.

Psoriasis patients received significantly higher phototherapy dosages compared to vitiligo

mJ/cm2 (p<0.001). The information is summarized in Table 1

patients in whom no patients received adjuvant systemic therapy. These included

methotrexate (28.3%), cyclosporine (3%), acitretin (10.4%), etanercept (0.5%), hydroxyurea

(0.9%), adalimumab (0.6%) and ustekinumab (1.2%).

years unless otherwise stated.

female vitiligo patients during the entire course of the study.

The comparative incidences of skin malignancy are summarized in Table 3.

Association of skin malignancy with phototherapy

general Singapore population. In earlier published studies on NBUVB phototherapy, 2

who had also received PUVA were excluded.

cumulative dose was 4480mJ/cm2 and 13 377mJ/cm2 respectively. This is in comparison to

against skin cancers, this may be offset by higher doses of phototherapy.

number of patients may have been underpowered to find this association.

the general population.

population, but lower than that of psoriasis patients

postulated mechanism of protection against NMSCs in vitiligo include reduced

of glutathione peroxidase, superoxide dismutase and decreased levels of transforming growth

factor-β and interleukin-10(21) as well as induction of autoimmunity through the reduction of

regulatory T-cell activity from the inhibition of cytotoxic T-lymphocyte–associated protein 4

attributed to gender related differences in sun protection measures.

required to ascertain these study findings.

59mJ/cm2 and 14 536mJ/cm2 respectively compared to psoriasis patients (600mJ/cm2 and 79

Secondly, approximately one-third of psoriasis patients had received systemic treatment

compared to vitiligo patients, in whom no patient was on systemic therapy. Systemic

maximum dose and use of systemic therapy

maximum dose of phototherapy, as well as use of systemic treatment. Earlier studies on

Subtypes of skin malignancy found

acral-lentiginous subtype(39), which are not thought to be related to ultraviolet (UV)

remain eminently treatable with early diagnosis and heightened surveillance.

exposure would be challenging even for a prospective case design.

maximal dose of phototherapy as well as concurrent or previous systemic therapy. The

of psoriasis and vitiligo.

I 2 (0.1%) 39 (2.5%) 41 (1.1%)