Effect of Fluticasone Proprionate 0.05% on Narrow Band UV-B in Active Vitiligo

Overview

Rationale: Vitiligo vulgaris is a common acquired pigment disorder, which is characterised by the development of depigmented macules. It develops probably due to immunedestruction of melanocytes. Most effective therapies are immunsuppresive: 1. local immunesuppressives like corticosteroids and calcineurin inhibitors 2. phototherapy like PUVA and NB-UVB phototherapy. NB-UVB is the first choice A synergistic effect of UVA and topical corticosteroids (fluticasone proprionate 0.05% cream) has been described by Westerhof et al. in 1999. To our knowledge to date there are no publications comparing NB-UVB combined with a topical corticosteroid and NB-UVB alone. Objective: The objective of this study is to evaluate the clinical effects (onset and degree of repigmentation) of fluticasone proprionate 0.05% cream (thrice weekly) on NB-UVB phototherapy twice weekly for a period of 12 months. Study design: Prospective single blinded randomised controlled study. Study population: Consecutive patients ≥ 18 years, diagnosed with active vitiligo vulgaris who will receive NB-UVB phototherapeutic treatment at the Netherlands Institute for Pigment Disorders at the Academic Medical Centre (AMC), University of Amsterdam. Methods: The patient will be randomised for either NB-UVB phototherapy and fluticasone proprionate 0.05% cream or NB-UVB phototherapy alone for 12 consecutive months. Main study parameters/endpoints: The onset and degree of repigmentation is assessed by digital image analysis of a target lesion and blinded global physician assessment. Furthermore, the patients and doctors satisfaction will be assessed and changes of immunohistochemical parameters will be analysed in skin biopsies. Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Subjects participating in the study will be asked to visit the institute 4 times. The time investment will be 20 minutes per visit. Additionally, patients will be asked for consent to take punch biopsies (3 mm) at the beginning and at the end of the treatment period. Hence, skin biopsies are not compulsory for participation in this study. Patients may chose to participate in the clinical non invasive part of the study. Known side effects of the NB-UVB phototherapy are redness, pruritus, xerosis cutis, burning sensation and conjunctivitis. These side-effects however, are largely dose-dependent and avoidable. Corticosteroid associated systemic side-effects (suppression of the adrenocortex) will be minimized by treating only a limited body surface \[a maximum of 30% body surface\] and by using an intermittent application scheme of three days a week in the long term treatment. The regions which are known to have a higher absorption are excluded (periorbital, axillary, inguinal and genital area). Both topical corticosteroids and NB-UVB are part of the Dutch and British guidelines for the treatment of vitiligo. There is no presumptive evidence or indication that the combination of these therapies may result in a higher risk of side effects. All together the burden due to the study is low and the risk for systemic or local side effects is low.