- Best Results6-12 months
- Treatment Recovery0 days
- Procedure Time2-8 minutes
- Skin SpecialistDr Davin Lim
- Duration of ResultsLong-term
- Back to WorkImmediately
- CostNil (Medicare)
Phototherapy is the mainstay for treating vitiligo. The most researched wavelength is 311 nm or narrowband. This treatment is covered under Medicare & has a success rate of up to 90%. This treatment should be combined with anti-inflammatory topicals as well as pigment cell stimulating creams. Most patients can expect to see a difference as early as 4 weeks after commencing therapy.
FactsFacts on Vitiligo Phototherapy
- Phototherapy with UVB 311 nm is gold standard for vitiligo
- Phototherapy should be combined with topical therapy
- Most vitiligo patients will have good to excellent responses
- Poor prognostic indicators include long standing patches, acral vitiligo, absence of dark hairs, segmental vitiligo
- Treatments take 2-8 minutes to perform
- Phototherapy sessions are bulk billed with no expense for the patient
How successful is Vitiligo Phototherapy for treating?
The success rate of up to 90% can be achieved with phototherapy & medically prescribed creams. The prognosis for re-pigmentation in vitiligo follows a complex algorithm.
Good to excellent outcomes can be achieved in facial vitiligo & depigmentation of recent onset. The presence of pigmented hair follicles is a good prognostic sign. Within facial areas, better outcomes are achieved on areas away from the lips.
Moderate outcomes can be expected with vitiligo involving the trunk & proximal limbs. Poor prognosis (10 to 20% chance of re-pigmentation) for vitiligo on the hands & feet.
What other treatments are combined with phototherapy?
Phototherapy is always combined with creams as this combination has the highest success rate for pigment formation. Creams such as corticosteroids, tacrolimus, & pimecrolimus can suppress the attack from immune cells. Topicals such as vitamin D & tacrolimus can aid pigment cell migration.
Topical antioxidants including pseudocatalase, vitamin E, green tea & ginkgo biloba can reduce oxidative stress to cells. These can be combined with phototherapy.
How does phototherapy re-pigment vitiligo?
Narrowband phototherapy is one of the most understood treatments for vitiligo. It works by-
- Suppression of immune cells (T Cells) in the upper layers of skin.
- Stimulation of cells called melanocytes to produce melanin
- Migration of melanocytes from the hair follicle & adjacent skin.
- Activation of neural stem cells in the follicles to form melanocytes
The first signs that phototherapy is working occurs around the hair follicle, a phenomenon called perifollicular repigmentation
How much do treatments cost?
Phototherapy in Australia is covered under Medicare. There is no charge for patients who have a Medicare card. If you do not hold Medicare, sessions are $120 per week. Factor in 20 weeks of therapy.
Some private health insurance companies cover this treatment.
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How many treatments will it take to notice a difference?
As reflected in the literature, up to 20 sessions over a course of 8-10 weeks is required to notice a difference. The first signs that phototherapy is working can be seen around hair follicles. This treatment ‘wakes up’ the pigment cells that hide in the deeper layers. Over time the edges of lesions will move to the centre, resulting in re-pigmentation of patches.
During your initial visit I will take photos of some (not all) of vitiligo affected areas. This will act as a reference point during latter follow ups. Remember, the chances of re-pigmentation is highest on the face, intermediate on the trunk & lowest for hands/feet.
What is the ideal time interval between phototherapy sessions?
Ideally phototherapy should be conducted three times a week. Studies have shown that alternate day sessions give the best results.
Are lasers better than phototherapy?
There are pros and cons regarding laser treatments for vitiligo. The major advantage is the fact that we can specifically target areas of vitiligo without treating unaffected areas. This reduces cumulative doses of UV. Lasers do not provide superior outcomes compared to narrowband phototherapy.
The major disadvantage of lasers is that they take up a lot more time for both patient & dermatologist. Costing is also prohibitive, at $200 per treatment, or up to $600 per week. Most patients require 50 sessions. It adds up. Phototherapy is bulk billed, hence there is no out of pocket expenses for the patients.
What is the difference between home vs clinical phototherapy?
The biggest difference between home & specialist phototherapy is precision of wavelength, & energy. Specialist units are calibrated by technicians to deliver one specific wavelength of light, namely 311 nm. Home devices deliver a wider range of spectrums that are non-calibrated.
The energy delivery of our phototherapy units is highly efficient, delivering over a hundred millijoules in less than ten seconds. This energy is precisely quantified & incrementally increased in units of five millijoules.
What is the difference between clinical phototherapy & sunbeds?
One gives you cancer & the other does not. Reason enough? Tanning beds deliver mixed wavelengths including UVB (broad spectrum) as well as UVA (tanning wavelength). UVA also destroys collagen & accelerates skin aging.
Phototherapy is delivered with one wavelength, namely 311 nm, omitting other damaging wavelengths. That’s the difference.
What are the side effects of phototherapy?
Side effects are uncommon with clinical narrowband phototherapy as the computer controls the doses. Reported side effects include-
- Skin darkening (more common)
- Dry itchy skin (more common)
- Cold Sore re-activation (rare)
- Burning (rare)
- Blisters (very rare)
What is the end point of phototherapy?
There are two types of protocols for phototherapy. One involves sub erythemal dosing calculated via MED or more accurately 50-70% of minimal erythema dose. This means that you are not red/slightly burnt following this treatment. This is a safer end point in the context of vitiligo.
The second protocol requires more understanding & patient follow up (hence more expense), this is called minimal erythema dosing. This means you are on the edge of a very mild sunburn reaction. Hence you may be red & ever so slightly ‘burnt’ after each session. This is a higher risk treatment as your vitiligo can worsen if you receive a burn. If you are risk averse don’t push me for this protocol as I will need to follow you up more frequently (from a safety point of view).
What is the safety data of phototherapy?
Guidelines will vary depending on what papers you read. For skin type 1-2 up to 200+ sessions are the upper limit. For skin type 3+, there is no upper limit.
Investigations to date have shown that skin cancer rates are not increased following narrowband phototherapy. Accelerated photoaging is minimal as the action spectrum is in the UVA (deeper) wavelength.
Should phototherapy be maintained when full pigmentation occurs?
There is no evidence that prophylactic maintenance of phototherapy increases remission time for vitiligo (unlike psoriasis). Once you have achieved full remission or 85% plus, I will decrease your intervals then stop.
You can safely recommence narrowband UV phototherapy if vitiligo comes back, albeit at a lower dose.
Do I test dose before commencing phototherapy?
No. I do not test dose as I am experienced in starting this treatment. I am well aware of protocols using MED or minimal erythema dosing. In the vast majority of cases I can calibrate phototherapy based upon skin type.
What are some helpful hints for patients undergoing UVB?
These tips & tricks can ensure that your treatments go smoothly with the highest chances of re-pigmentation.
- Be motivated. It takes up to 20 sessions to notice an improvement. Medicare gives you this treatment for free, turn up to your sessions.
- Wear the same clothing. If you expose hidden areas to UVB midway through your phototherapy sessions, you may burn.
- Use the creams I have prescribed as directed.
- Moisturising before phototherapy increases light transmission. This improves outcomes.
- Exfoliation once a week reduces dead cell build up, further enhancing this treatment.
- Covering unaffected areas will reduce delayed tanning.
Is phototherapy for everyone?
It is a safe treatment for most, but not all. You cannot have this treatment if you have-
- A personal history of any light sensitive condition. This only pertains to conditions that are in the UVB action spectrum. I can modulate some doses to harden your skin prior to full dose.
- A personal or family history of melanoma, this is different from skin cancers.
This treatment is safe if you are breastfeeding, pregnant or taking medicines including doxycycline & Accutane. I just modify the dose. Most medications have the action spectrum in the longwave UVA.
What are other UV devices used for vitiligo?
These are largely historical, however in some third world countries older UV sources are still used. They include broad band UVB & UVA lamps. The latter requires 8MOP creams or psoralen.
Newer UVA1 devices are available. They require 10 to 15 times longer dosing. This wavelength penetrates deeper into the skin & are of limited value in the management of vitiligo.
Excimer 308 can be delivered as monochromatic lasers, or condensed light. They are useful for treating isolated patches of vitiligo, however they are costly to the patient as it is not covered under Medicare.
How to commence phototherapy?
As per Medicare guidelines, you will require a referral to see me prior to phototherapy. Reception can guide you through this process. During the consultation I will –
- Take a history
- Order investigations if required
- Prescribe topicals
- Order a starting & escalation phototherapy program based upon your skin type
In the majority of cases, you can commence on phototherapy the same day as the consultation. Phototherapy treatment is bulk billed, the initial consultation carries an out-of-pocket contribution.
Davin’s Viewpoint on Phototherapy
Narrowband phototherapy forms the mainstay of treating vitiligo. In Australia this treatment is bulk billed (most dermatologists). This is a tremendous saving for patients. I think we are one of the only countries in the World that does this.
Though phototherapy is the Gold Standard for treating vitiligo, not all patients will respond. A good prognosis can be expected for early vitiligo patches on the face & neck. This especially applies to areas with some pigmentation within the hair follicles as melanocytes are sourced from this area. Exceptions on the face include perioral/lips & pre-post ear areas as these areas are more resistant to therapy. Poor responders are profiled with vitiligo involving acral areas – namely hands and feet.
Phototherapy sessions are ideally spaced on alternate days, namely three times a week. I frequently prescribe two sessions per week (not on alternate days) as patients are sometimes too busy to attend during the weekdays. As per international guidelines, I perform 20 sessions, then review. Ideally patients should be on anti-inflammatory topicals as well as melanocyte stimulating creams, as well as phototherapy.
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