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Zhang L, Zhang J, Wang X, Zhao Z, Li Z, Miao G, Lv C. Clinical efficacy of CO 2 fractional laser combined with compound betamethasone in treating vitiligo and its impact on inflammatory factors. Front Med (Lausanne) 2024; 11:1408409. [PMID: 39050532 PMCID: PMC11266084 DOI: 10.3389/fmed.2024.1408409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024] Open
Abstract
Objective To analyze the clinical efficacy of CO2 fractional laser combined with compound betamethasone in treating vitiligo and its impact on inflammatory factors. Methods The clinical treatment effects, levels of inflammatory factors [interleukin-17 (IL-17), interferon-gamma (IFN-γ), interleukin-10 (IL-10)], prognosis regarding repigmentation and relapse, psychological health (satisfaction). Results ① Clinical treatment effects: the total effective rate in Group A was 92.73%, Group B was 74.55%, and Group C was 67.27%, with Group A showing significantly higher effectiveness than Groups B and C (p < 0.05). ② Inflammatory factors: prior to treatment, there was no significant difference in IL-17, IFN-γ, and IL-10 levels among the three groups (p > 0.05); after 3 and 6 months of treatment, the levels of IL-17 and IFN-γ decreased significantly while IL-10 levels increased significantly across all three groups, with Group A showing a more pronounced change compared to Groups B and C (p < 0.05). ③ Prognosis regarding repigmentation and relapse: after 3 and 6 months of treatment, Group A exhibited significantly higher repigmentation rates compared to Groups B and C (p < 0.05); in terms of relapse, Group A had a relapse rate of 5.45%, Group B had 21.82%, and Group C had 23.64%, with Group A showing significantly lower relapse rates compared to Groups B and C (p < 0.05). ④ Quality of life and psychological health: at the end of the 6 month follow-up, the quality of life and psychological health of patients in Group A were significantly higher than those in Groups B and C (p < 0.05). ⑤ Occurrence of adverse reactions: the incidence of adverse reactions was 12.73% in Group A, 10.91% in Group B, and 9.09% in Group C, with no significant difference observed among the three groups (p > 0.05). Conclusion The application of CO2 fractional laser combined with compound betamethasone in vitiligo patients demonstrates significant efficacy. Compared to sole treatment with CO2 fractional laser or compound betamethasone injections, this combined approach further improves the levels of inflammatory factors in vitiligo patients, reduces the risk of relapse, enhances skin repigmentation, improves quality of life, psychological well-being, without increasing the risk of related adverse reactions. This combined approach merits clinical promotion and application.
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Affiliation(s)
| | | | | | | | | | | | - Chao Lv
- Dermatology Department, Affiliated Hospital of Hebei Engineering University, Handan, China
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2
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Wang X, Wu W, Chen J, Li C, Li S. Management of the refractory vitiligo patient: current therapeutic strategies and future options. Front Immunol 2024; 14:1294919. [PMID: 38239366 PMCID: PMC10794984 DOI: 10.3389/fimmu.2023.1294919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/30/2023] [Indexed: 01/22/2024] Open
Abstract
Vitiligo is an autoimmune disease that leads to disfiguring depigmented lesions of skin and mucosa. Although effective treatments are available for vitiligo, there are still some patients with poor responses to conventional treatment. Refractory vitiligo lesions are mostly located on exposed sites such as acral sites and lips, leading to significant life stress. Understanding the causes of refractory vitiligo and developing targeted treatments are essential to enhance vitiligo outcomes. In this review, we summarized recent treatment approaches and some potential methods for refractory vitiligo. Janus kinase inhibitors have shown efficacy in refractory vitiligo. A variety of surgical interventions and fractional carbon dioxide laser have been widely applied to combination therapies. Furthermore, melanocyte regeneration and activation therapies are potentially effective strategies. Patients with refractory vitiligo should be referred to psychological monitoring and interventions to reduce the potential pathogenic effects of chronic stress. Finally, methods for depigmentation and camouflage may be beneficial in achieving uniform skin color and improved quality of life. Our ultimate focus is to provide alternative options for refractory vitiligo and to bring inspiration to future research.
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Affiliation(s)
| | | | | | | | - Shuli Li
- *Correspondence: Shuli Li, ; Chunying Li,
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Ng WHS, Smith SD. Laser-Assisted Drug Delivery: A Systematic Review of Safety and Adverse Events. Pharmaceutics 2022; 14:pharmaceutics14122738. [PMID: 36559233 PMCID: PMC9787022 DOI: 10.3390/pharmaceutics14122738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Laser-assisted drug delivery (LADD) is an increasingly studied and applied methodology for drug delivery. It has been used in a wide variety of clinical applications. Given the relatively low barrier to entry for clinicians as well as ongoing research in this area, the authors aimed to review outcomes relating to safety in laser-assisted drug delivery. A systematic review was conducted, with the databases PubMed, Medline and Embase searched in September 2022. Included articles were those that mentioned laser-assisted drug delivery in human subjects that also reported adverse effects or safety outcomes. There were no language-based exclusions. Conference abstracts and literature reviews were excluded. The results were then tabulated and categorized according to the application of LADD. In total, 501 articles were obtained. Following deduplication, screening, and full text review 70 articles of various study designs were included. Common findings were erythema, oedema, pain, and crusting following LADD. Several notably more severe adverse effects such as generalized urticaria, infection, scarring and dyspigmentation were noted. However, these events were varied depending on the clinical use of LADD. Relevant negatives were also noted whereby no studies reported life-threatening adverse effects. Limitations included limited details regarding the adverse effects within the full texts, lack of follow-up, and risk of bias. In conclusion, there were multiple adverse effects that clinicians should consider prior to carrying out LADD, where treatment goals and patient tolerability should be considered. Further evidence is needed to quantitatively determine these risks.
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Affiliation(s)
| | - Saxon D. Smith
- ANU Medical School, ANU College of Health and Medicine, Australian National University, Canberra, ACT 2601, Australia
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4
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Investigation of optimal energy or density of a fractional CO2 laser system in the treatment of stable non-segmental vitiligo. Complement Ther Clin Pract 2022; 49:101684. [DOI: 10.1016/j.ctcp.2022.101684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/13/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
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5
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Mohammadi S, Amiri R, Khalili M, Iranmanesh B, Aflatoonian M. Treatment protocols and efficacy of combined laser with medical treatment modalities in vitiligo. J Cosmet Dermatol 2021; 21:3272-3291. [PMID: 34766697 DOI: 10.1111/jocd.14602] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUNDS Nowadays, lasers are used for treatment of vitiligo in difficult-to-treat areas and refractory lesions. Combination of lasers with other medical modalities can provide higher efficacy, faster response rate, and higher compliance of patients to treatment. AIM In this article, we reviewed articles regarding safety, efficacy, and treatment protocols of combined laser with other medical modalities. METHODS We searched articles with relevant key words in Google scholar and PubMed. Inclusion criteria were articles in English language since January 2000 until March 2021that evaluate combination of laser with other topical or systemic medical treatments. RESULTS A total of 42 articles evaluated efficacy of lasers [excimer, carbon dioxide (CO2 ), erbium-doped yttrium-aluminum-garnet (Er:YAG), and non-ablative resurfacing laser] combined with topical or systemic medical treatment modalities. Effective response rate (more than 50% improvement) varied between 7.7% and 92%. Initial repigmentation observed between 4 and 13 weeks after beginning of treatment. CONCLUSION Combination of laser with medical modalities leads to more rapid repigmentation, superior efficacy, and better compliance of patients with localized non-segmental type of vitiligo compared to monotherapy. Combination of excimer laser with topical therapy might be suggested for recalcitrant vitiligo lesions in face and neck. Combination of fractional ablative resurfacing lasers with topical therapy, especially 5-flurouracil, can be recommended particularly in recalcitrant acral and bony prominent areas. Further studies are required to achieve conclusive evidence in order to define the best stage of vitiligo for laser therapy and most effective combined treatment regimen.
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Affiliation(s)
- Saman Mohammadi
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Rezvan Amiri
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Khalili
- Department of Dermatology, Kerman University of Medical Sciences, Kerman, Iran
| | - Behzad Iranmanesh
- Department of Dermatology, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahin Aflatoonian
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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Botsali A, Caliskan E. Safety and Efficacy of High-Dose Fractional Erbium: Yttrium Aluminium Garnet Laser in Stable Vitiligo. PHOTOBIOMODULATION PHOTOMEDICINE AND LASER SURGERY 2021; 39:600-606. [PMID: 34546107 DOI: 10.1089/photob.2021.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: Evaluate the treatment outcome of vitiligo patients receiving a standard regimen of high-dose biweekly fractional 2940 nm erbium:yttrium aluminium garnet (YAG) laser applications as an add-on to various treatment modalities. Materials and methods: The authors extracted the study population's clinical images before treatment and 3rd-month control from their clinical archive and used the medical records. The primary outcome measure was 50% repigmentation at 3rd-month follow-up. Institutional ethical committee approved the study. Results: Of the evaluated 28 patients, 18 were eligible with 31 treatment regions. All patients received at least one topical agent [steroids, calcineurin inhibitors, or 5-fluorouracil (5-FU)] and 11 patients received either targeted ultraviolet B (UVB) or narrow-band UVB. Of the 31 study regions, 88.8% (8/9) of facial; 77.7% (7/9) of dorsal hand; 75% (3/4) of limb; and 25% (2/8) of finger lesions achieved 50% repigmentation at 3rd-month control. The facial and dorsal hand lesions' treatment responses were higher than finger lesions (p = 0.008 and 0.03, respectively). Upon evaluating adjuvant treatment modalities, all of the treatment regions receiving targeted UVB (n = 4) or topical 5-FU (n = 5) achieved the primary endpoint, whereas severe irritation limited the topical use of 5-FU. The most common adverse effects were mild oozing and crusting related to laser treatments. Conclusions: Even with high-energy settings, fractional erbium: YAG laser does not induce the Koebner phenomenon. Although controlled trials are required to make firm conclusions, fractional erbium: YAG laser was an effective and safe adjunctive option for stable vitiligo in a real-life setting.
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Affiliation(s)
- Aysenur Botsali
- Department of Dermatology, Gulhane Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ercan Caliskan
- Department of Dermatology, Gulhane Faculty of Medicine, University of Health Sciences, Ankara, Turkey
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7
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Botsali A, Caliskan E. Management of recalcitrant vitiligo in Vogt-Koyanagi-Harada syndrome: Adjuvant ablative fractional laser. Pediatr Dermatol 2020; 37:514-516. [PMID: 32131141 DOI: 10.1111/pde.14108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The course of dermatologic findings in Vogt-Koyanagi-Harada disease is variable. Herein, we report the remarkable repigmentation of widespread facial vitiligo lesions in an adolescent girl with Vogt-Koyanagi-Harada disease. The patient was treated with a combination of fractional erbium:YAG laser, topical tacrolimus, and phototherapy.
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Affiliation(s)
- Ayşenur Botsali
- Dermatology Department, Gülhane School of Medicine, Health Sciences University, Ankara, Turkey
| | - Ercan Caliskan
- Dermatology Department, Gülhane School of Medicine, Health Sciences University, Ankara, Turkey
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8
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Taneja N, Sreenivas V, Sahni K, Gupta V, Ramam M. A cross-sectional study of spontaneous repigmentation in vitiligo. Indian J Dermatol Venereol Leprol 2019; 86:240-250. [PMID: 31793491 DOI: 10.4103/ijdvl.ijdvl_409_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Spontaneous regression is well documented in several chronic skin diseases such as psoriasis, alopecia areata, and atopic dermatitis. However, information on vitiligo is scarce. Aims We studied the frequency, extent, and factors affecting spontaneous repigmentation in vitiligo. Methods A cross-sectional descriptive study was undertaken in 167 patients with vitiligo with an emphasis on history of spontaneous repigmentation. Where available, photographs documenting spontaneous repigmentation were also obtained. Repigmentation was defined as spontaneous if it occurred when the patient was off treatment for at least 3 consecutive months. Results Spontaneous repigmentation occurred in 36 (21.5%) patients with complete repigmentation in 6 (3.6%) patients. The extent varied from 0.5% to 100% (mean, 35.4 ± 37.9%) of vitiliginous skin. It occurred after 3 months to 47 years (mean, 8.7 ± 9.5 years) of onset of vitiligo and persisted for 2 months to 27 years (mean, 4.4 ± 6.2 years). Diffuse repigmentation was the most common pattern observed in 20 (55.6%) patients and there was a good color match in 26 (72.2%) patients. Likelihood of spontaneous repigmentation was 3.5 times greater in patients with more than 3 years of stable disease (P = 0.001). Limitations The chief limitation was the dependence on patient recall for the data, except when documented by images. Conclusion Spontaneous repigmentation occurs in one-fifth of patients with vitiligo. In some patients, the repigmentation is clinically significant and long-lasting. Considering its frequency and extent, spontaneous repigmentation should be taken into account both when evaluating novel interventions and counselling patients about the course of the disease.
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Affiliation(s)
- Neha Taneja
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - V Sreenivas
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Kanika Sahni
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishal Gupta
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
| | - M Ramam
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
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9
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del Río-Sancho S, Castro-López V, Alonso MJ. Enhancing cutaneous delivery with laser technology: Almost there, but not yet. J Control Release 2019; 315:150-165. [DOI: 10.1016/j.jconrel.2019.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 12/30/2022]
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10
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King YA, Tsai TY, Tsai HH, Huang YC. Wirksamkeit einer ablationsbasierten Kombinationstherapie bei Vitiligo: Eine systematische Übersichtsarbeit und Metaanalyse. J Dtsch Dermatol Ges 2019; 16:1197-1210. [PMID: 30300497 DOI: 10.1111/ddg.13657_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Yih-An King
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Tsung-Yu Tsai
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsiou-Hsin Tsai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yu-Chen Huang
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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11
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King YA, Tsai TY, Tsai HH, Huang YC. The efficacy of ablation-based combination therapy for vitiligo: A systematic review and meta-analysis. J Dtsch Dermatol Ges 2018; 16:1197-1208. [DOI: 10.1111/ddg.13657] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/19/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Yih-An King
- Department of Dermatology; Taipei Medical University Hospital; Taipei Taiwan
| | - Tsung-Yu Tsai
- Department of Dermatology; Wan Fang Hospital, Taipei Medical University; Taipei Taiwan
| | - Hsiou-Hsin Tsai
- Department of Dermatology; Taipei Medical University Hospital; Taipei Taiwan
| | - Yu-Chen Huang
- Department of Dermatology; Wan Fang Hospital, Taipei Medical University; Taipei Taiwan
- Department of Dermatology, School of Medicine, College of Medicine; Taipei Medical University; Taipei Taiwan
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12
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Chiu YJ, Perng CK, Ma H. Fractional CO 2 laser contributes to the treatment of non-segmental vitiligo as an adjunct therapy: a systemic review and meta-analysis. Lasers Med Sci 2018; 33:1549-1556. [PMID: 29696444 DOI: 10.1007/s10103-018-2516-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
The treatment of stable non-segmental vitiligo is often challenging, which new therapies are being searched. Multiple clinical trials have proposed the benefits and safety of using fractional carbon dioxide (CO2) laser as an adjunct therapy to conventional treatments. This study aimed to evaluate the safety and efficacy of fractional carbon dioxide laser as a combination therapy to conventional treatments in patients with stable non-segmental vitiligo. A literature search using PubMed, EMBASE, and the Cochrane Library was performed for comparative studies among vitiligo patients treated with additional fractional CO2 laser. Clinical outcomes in the selected studies were compared, and a meta-analysis was performed via Review Manager version 5.3, according to the PRISMA guidelines. Six studies with a total of 184 patches/patients were included in the present meta-analysis. The combination therapy group had significantly superior results than that of the control group (≥ 75% re-pigmentation, risk ratio [RR] 2.80, 95% confidence interval [CI] 1.29-6.07; ≥ 50% re-pigmentation, RR 2.26, 95% CI 1.23-5.9; < 25% re-pigmentation, RR 0.57, 95% CI 0.43-0.75). Limitations of the study included the small number of studies and sample size, inadequate blinding of participants, and variation between therapy protocols. Meta-analysis revealed that using fractional CO2 laser in combination with conventional treatments is efficient and safe, and may be considered as an adjunct therapeutic option for patients with refractive non-segmental vitiligo.
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Affiliation(s)
- Yu-Jen Chiu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, 19/F, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei, 11217, Taiwan
- Department of Surgery, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Cherng-Kang Perng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, 19/F, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei, 11217, Taiwan
- Department of Surgery, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsu Ma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, 19/F, No. 201, Sec. 2, Shipai Rd., Beitou Dist, Taipei, 11217, Taiwan.
- Department of Surgery, School of Medicine, National Yang Ming University, Taipei, Taiwan.
- Department of Surgery, National Defense Medical Center, Taipei, Taiwan.
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Lotti T, Wollina U, Tchernev G, Valle Y, Lotti J, França K, Satolli F, Rovesti M, Tirant M, Lozev I, Pidakev I, Gianfaldoni S. An Innovative Therapeutic Protocol for Vitiligo: Experience with the Use of Fraxel Herbium Laser, Topical Latanoprost and Successive Irradiation with UVA - 1 Laser. Open Access Maced J Med Sci 2018; 6:49-51. [PMID: 29483980 PMCID: PMC5816313 DOI: 10.3889/oamjms.2018.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 12/02/2022] Open
Abstract
Despite the continuous introduction of innovative therapies for vitiligo, today none of them provide constant and excellent results in term of repigmentation. The authors report their experience in treating a localised form of vitiligo with a new protocol consisting in the use of a Fraxel Herbium laser, and in the following application of topical Latanoprost solution and, one day after, in lesional irradiation with UVA1 laser.
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Affiliation(s)
- Torello Lotti
- University G. Marconi of Rome, Dermatology and Venereology, Rome, Italy
| | - Uwe Wollina
- Städtisches Klinikum Dresden, Department of Dermatology and Venereology, Dresden, Sachsen, Germany
| | - Georgi Tchernev
- Medical Institute of Ministry of Interior Department of General, Vascular and Abdominal Surgery, Sofia, Bulgaria.,Onkoderma - Policlinic for Dermatology and Dermatologic Surgery, Sofia, Bulgaria
| | - Yan Valle
- Vitiligo Research Foundation, New York, United States
| | - Jacopo Lotti
- University G. Marconi of Rome - Dept. of Nuclear, Subnuclear and Radiation Physics, Rome, Italy
| | - Katlein França
- University of Miami School of Medicine, Miami, Florida 33136-1015 United States and Centro Studi per la Ricerca Multidisciplinare e Rigenerativa, Università Degli Studi "G. Marconi", Rome, Italy
| | - Francesca Satolli
- Universita degli Studi di Parma Dipartimento di Medicina Clinica e Sperimentale, Department of Dermatology, University of Parma, Parma, Italy
| | - Miriam Rovesti
- Universita degli Studi di Parma Dipartimento di Medicina Clinica e Sperimentale, Department of Dermatology, University of Parma, Parma, Italy
| | - Michael Tirant
- Psoriasis & Skin Clinic, 374 Nepean Highway Frankston Victoria, Melbourne, Australia
| | - Ilia Lozev
- Medical Institute of Ministry of Interior, Department of General, Vascular and Abdominal Surgery, General Skobelev 79, 1606 Sofia, Bulgaria
| | - Ivan Pidakev
- Medical Institute of Ministry of Interior, Department of General, Vascular and Abdominal Surgery, General Skobelev 79, 1606 Sofia, Bulgaria
| | - Serena Gianfaldoni
- University G. Marconi of Rome - Dermatology and Venereology, University G. Marconi of Rome, Rome, Italy
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