The Efficacy of 311-NM Narrowband Ultraviolet B (NB-UVB) and Topical Agents or Lasers Combination Therapy versus NB-UVB Monotherapy for Vitiligo: A Systematic Review and Meta-analysis of Randomised Controlled Trials

Abstract

Introduction: Even though there is the availability of multiple treatment modalities for vitiligo still its treatment remains challenging. Combination therapies of Narrowband Ultraviolet B (NB-UVB) and various topical agents or lasers are widely used in the treatment of vitiligo. Aim: To compare the efficacy of NB-UVB and topical agents including calcineurin inhibitors, antioxidants, corticosteroids, vitamin-D3 analogues and 5-fluorouracil or lasers combination therapy versus NB-UVB monotherapy for vitiligo. Materials and Methods: Data source: This was randomised controlled trials which was conducted to revealed the efficacy of NB-UVB alone or in combination with topical agents or lasers for vitiligo, manual searches of reference lists and, computerised searches of the PubMed (from 2000 to 2018) Science direct (from 1985 to 2018) and Cochrane Central Register of Controlled Trials (from 2005 to 2017) were conducted with keywords “NB-UVB” or “narrowband ultraviolet B”, “Vitiligo”. Study eligibility criteria: In this study, full-text articles of clinical randomised controlled trials RCTs published in English language literature were selected. Participants: Out of 549 studies, 12 studies with a total of 460 patches or patients were included in the review based on the inclusion and exclusion criteria. Apart from included 12 studies, other 537 studies were excluded due to the following reasons: inappropriate after the title and abstract screening, improper intervention and improper outcome measures, published only in abstract form, not a combination therapy, not an RCT. Intervention: For this systemic review and meta-analysis, application of NB-UVB monotherapy for one group and the combination of NB-UVB with any topical agents or lasers for another group also having treatment success (≥75% regimentation) as the primary outcome and treatment failure (<25% regimentation) as the secondary outcome were selected. Study appraisal and synthesis methods: Out of 549 studies, 22 studies were assessed for methodological quality and finally, 12 studies with a total of 460 patches or patients were included in the review based on the inclusion and exclusion criteria. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). Results: In this study, 12 randomised controlled trials comprising a total of 460 patches/patients were analysed. The obtained results suggested that combination therapy is superior compared to monotherapy in form of regimentation except calcipotriol combined with NB-UVB. Among all combination therapy, the combination of NB-UVB and antioxidants (2 studies: RR 1.77, 95% CI 0.93 to 3.35; number needed to treat 4.68, 95% CI 2.22 to 41.69) moreover topical calcineurin inhibitors (3 studies: RR 1.79, 95% CI 1.06 to 3.01; number needed to treat 10.7, 95% CI 5.85 to 62.49) was superior to NB-UVB monotherapy for vitiligo. Apart from these, success rate in other combination can’t be predicted because the presence of high level heterogeneity (three studies: NB-UVB combined with fractional CO2 laser group) or could not find heterogeneity as single study (four studies: Others group; NBUVB combined with ER:YAG laser ablation and 5-fluorouracil, NB-UVB combined with topical steroid and dermabrasion, NBUVB combined with 5-fluorouracil injection, NB-UVB combined with calcipotriol ointment). Limitation: The verdicts of this study are limited by small numbers of randomised controlled trials and heterogeneities among included studies. Conclusion: In conclusion, adding antioxidant and topical calcineurin inhibitors on NB-UVB yields significantly superior outcomes than NB-UVB monotherapy. For soundest clarification, more large-scale, high-quality, double-blind RCTs regarding the efficacy of topical agents or lasers plus NB-UVB combination therapy should be planned.

Keywords

• antioxidants
• calcineurin inhibitors
• calcipotriol
• laser therapy
• ultraviolet therapy
• vitiligo