Monochromatic excimer light (308 nm) in patch-stage IA mycosis fungoides

Beyond the Booth: Excimer Laser for Cutaneous Conditions

The excimer laser has emerged as an efficacious treatment modality for many dermatologic diseases. The excimer laser is an alternative to standard narrowband ultraviolet B (NBUVB) phototherapy treatment in patients with limited disease. In comparison to standard NBUVB, the excimer laser requires fewer treatment sessions, has reduced treatment duration, requires a lower cumulative UVB dose, and limits UVB exposure to lesional skin. This review addresses the mechanism, safety, application, and efficacy of the excimer laser for the treatment of these conditions.

Skin Directed Therapy in Cutaneous T-Cell Lymphoma

Skin directed therapies (SDTs) serve important roles in the treatment of early stage cutaneous T-cell lymphoma (CTCL)/mycosis fungoides (MF), as well as managing symptoms and improving quality of life of all stages. There are now numerous options for topical therapies that demonstrate high response rates, particularly in early/limited MF. Phototherapy retains an important role in treating MF, with increasing data supporting efficacy and long-term safety of both UVB and PUVA as well as some newer/targeted methodologies. Radiation therapy, including localized radiation and total skin electron beam therapy, continues to be a cornerstone of therapy for all stages of MF.

Perplexing Rash: Challenges to Diagnosis and Management of Mycosis Fungoides

Mycosis fungoides is the most ubiquitous form of cutaneous T-cell lymphoma. Diagnosis is arduous, as early phases often resemble common inflammatory dermatoses. The principal histologic features of MF include medium to large-sized cerebriform mononuclear cells in single or small clusters in the epidermis. Treatment modalities are prodigious and relapses are common. The authors present a case of a 69-year-old man with mycosis fungoides, followed by a review of diagnostic modalities and phototherapeutic interventions for patients with this condition. According to literature reports, monochromatic excimer light therapy is the most advantageous and well-tolerated phototherapy modality for patients with early patch stage mycosis fungoides.

Guidelines for phototherapy of mycosis fungoides and Sézary syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium

BACKGROUND

Ultraviolet light (UVL) is a long established treatment for mycosis fungoides (MF) and Sézary syndrome (SS), subtypes of cutaneous T-cell lymphoma (CTCL). Treatments have traditionally included broadband, narrowband ultraviolet B light (UVB) and psoralen plus ultraviolet A light photochemotherapy (PUVA), but more recently, treatment options have expanded to include UVA1 and excimer laser. UVL is used either as monotherapy or as an adjuvant to systemic therapy, demonstrating efficacy in many cases that equal or surpass systemic medications. Despite its utility and duration of use, the current practice of using UVL guidelines for psoriasis to treat patients with MF/SS is problematic because the goals of prolonging survival and preventing disease progression are unique to CTCL compared to psoriasis.

OBJECTIVES

We sought to develop separate guidelines for phototherapy for MF/SS for both clinical practice and for clinical trials.

METHODS

Literature review and cutaneous lymphoma expert consensus group recommendations.

RESULTS

This paper reviews the published literature for UVB and UVA/PUVA in MF/SS and suggests practical standardized guidelines for their use.

LIMITATIONS

New standardization of phototherapy.

CONCLUSIONS

These guidelines should allow the comparison of results with phototherapy in MF/SS across different stages of patients, centers, and in combination with other agents in practice and in clinical trials.

Emerging treatment options for early mycosis fungoides

Mycosis fungoides is a candidate for skin-directed therapies in its initial stages. In recent years, therapeutic options outside of the normal treatment recommendations such as topical imiquimod, topical tazarotene, topical methotrexate, excimer light sources, and photodynamic therapy have been published with variable results. These alternatives have been useful in cases of localized mycosis fungoides that do not respond to routine treatments; nevertheless, more studies on these methods are still needed. This article summarizes the literature and data that are known so far about these treatments.

Management of cutaneous T cell lymphoma: new and emerging targets and treatment options

Cutaneous T cell lymphomas (CTCL) clinically and biologically represent a heterogeneous group of non-Hodgkin lymphomas, with mycosis fungoides and Sézary syndrome being the most common subtypes. Over the last decade, new immunological and molecular pathways have been identified that not only influence CTCL phenotype and growth, but also provide targets for therapies and prognostication. This review will focus on recent advances in the development of therapeutic agents, including bortezomib, the histone deacetylase inhibitors (vorinostat and romidepsin), and pralatrexate in CTCL.

Innovative therapy of cutaneous T-cell lymphoma: beyond psoralen and ultraviolet light and nitrogen mustard

Cutaneous T-cell lymphoma is a malignancy of skin-homing T cells. This unique population of lymphocytes requires alternative therapies to those used in nodal lymphomas. Although phototherapy and nitrogen mustard have been standard treatments for decades, newer therapies have been arriving with increased frequency. Moreover, some therapies, currently used to treat other diseases, have been used with good effect. These innovative therapies are discussed, with review of current data and examples of how these therapies may be used today.

Traitement du mycosis fongoïde par le laser excimer à 308 nm : étude anatomo-clinique chez dix malades

BACKGROUND

Mycosis fungoides is a cutaneous T-cell lymphoma. The early stages have a good prognosis but pose therapeutic problems due to chronic disease status and the frequent recurrence of lesions. We performed a retrospective clinical and histological study in 10 patients presenting mycosis fungoides in order to evaluate the efficacy of 308 nm excimer laser in this indication.

METHODS

Ten patients with mycosis fungoides confirmed by histological examination were included. Treatment by 308 nm excimer laser was performed on a total of 29 lesions (25 patch-stage, 3 plaques and 1 nodule). After determination of the minimal erythemal dose, sessions were started twice weekly gradually increasing in accordance with tolerability. Clinical follow-up was performed and histological and immunohistological analysis was done, if possible, before and after treatment and at the end of the follow-up.

RESULTS

Eighty-six percent of patch-stage or plaque lesions had completely cleared up by the end of treatment and 14% had cleared up partially, with a global response rate of 100%. The mean number of sessions was 15 (6 to 46 sessions) corresponding to a mean treatment duration of 2 months. The mean cumulative dose was 5 J/cm2 (1.3 to 16.1 cm2). Follow-up was performed in 19 lesions for a median period of 15 months (8 to 26 months). Persistent complete clearance was observed in 13 of 19 (68%) lesions (12 patch-stage and 1 plaque). Continued partial clearance was noted in 3 lesions (1 patch-stage and 2 plaques) (16%). Two lesions (both patch-stage) (11%) showed relapse 7 months after the end of treatment. The sole nodule in the study showed no response to treatment. Histological and immunohistological were consistent with clinical results and showed histological healing where lesions had clinically disappeared, except for one case with persistence of a few mycosis cells in the epidermis despite a clinical appearance of healing.

DISCUSSION

This study demonstrates the efficacy of 308 nm excimer laser in stage Ia of mycosis fungoides. Given its limited availability and high cost, 308 nm excimer laser may be used as second-line therapy after failure of treatment with topical steroids.

Long-term clearance of patch-stage mycosis fungoides with the 308-nm laser

In order to investigate the effectiveness of the 308-nm xenon chloride laser in the treatment of patch-stage mycosis fungoides that is refractory to topical steroids, we conducted a prospective, histologically controlled, open-label pilot study. Eight patients with stage 1A or 1B cutaneous T-cell lymphoma that was unresponsive to application of potent topical steroids received 20 treatments with the laser over 10 weeks and were then followed up for a minimum of 30 months. Three patients had a complete clinical and histological response and remained free of disease after 30 months A further three patients had complete clinical and histological clearance of disease, but experienced relapse within the 30 months follow-up period. One patient withdrew from the study and one had a partial response. Further research to establish the role of the 308-nm laser in the treatment of MF appears justified.

Narrowband UVB phototherapy for early-stage mycosis fungoides: evaluation of clinical and histopathological changes

BACKGROUND

Early-stage (IA, IB, IIA) mycosis fungoides (MF) has long been treated with various agents including topical potent steroids, nitrogen mustard, carmustine, oral psoralen plus UVA (PUVA), broadband UVB, electron-beam radiotherapy, interferon-alpha and retinoids. However, each of these modalities is associated with various side-effects. Narrowband UVB (NB-UVB) therapy has the same effect but is safer to use than the other methods.

OBJECTIVE

Our purpose in this prospective study was to determine the effects of NB-UVB in early-stage MF both clinically and histopathologically.

MATERIALS AND METHODS

Twenty-three patients (20 men, three women, aged 27-78 years) with clinically and histologically confirmed MF were enrolled. Patients received NB-UVB therapy three times a week. Clinical and histological responses, cumulative doses, total number of treatments, side-effects and duration of remission period were noted.

RESULTS

Six patients had stage IA MF, 15 patients stage IB and two patients stage IIA. Eighteen patients had patch stage and five patients had plaque stage histopathologically. All of the patients in the patch group had a complete response (CR). In the plaque group, three patients (60%) had a CR and two (40%) had partial (PR) or no clinical response (NR). The clinical response between patch and plaque groups was statistically significant. Regarding the histopathological findings, 17 (94.4%) had complete clearing and only one (5.6%) patient had a partial improvement in the patch group. In the plaque group, one (20%) patient had complete clearing and four (80%) patients had partial or no improvement. The difference between the two groups was statistically significant. In the patch group, the mean cumulative dose was 90.15 J/cm(2) and the mean number of treatments was 35.33. In the plaque group, the mean cumulative dose was 90.67 J/cm(2) and the mean total number of treatments was 39.40. The differences were not statistically significant, either between the mean cumulative dose or the mean number of treatments. The mean duration of follow-up was 10.87 months (range 1-25 months). Only one of the patients had a relapse.

CONCLUSIONS

NB-UVB therapy for patients with early-stage MF is an effective and safe treatment with the effect lasting for months. We suggest that clinical clearance correlates with histological improvement except for patients in the plaque stage.

Irradiation therapy: from UV light to electron beam

Irradiation therapy represents one of the mainstay treatment modalities in cutaneous T-cell lymphomas. For the patch and plaque stages UV therapy is mostly used. Among UV light treatment broadband UVB is less effective than narrow band UVB. If these modalities are not sufficient, then PUVA therapy is indicated and might be used in even more advanced stages, including the erythrodermic stage of the disease. For resistant cases and remaining tumors, conventional radiotherapy or electron beam therapy is the treatment of a choice. If the disease is widespread, total skin electron beam radiation gives excellent results. One should not forget the possibility of combining UV therapy with radiotherapy or electron beam radiation, or with chemo- and immunotherapy respectively.

Controlled study of excimer and pulsed dye lasers in the treatment of psoriasis

BACKGROUND AND OBJECTIVES

The excimer laser delivers high energy monochromatic ultraviolet (UV) B at 308 nm. Advantages over conventional UV sources include targeting of lesional skin, reducing cumulative dose and inducing faster clearance. Studies of the pulsed dye laser (PDL) in psoriasis report between 57% and 82% response rates; remission may extend to 15 months. To our knowledge, this is the first study assessing both excimer and PDL in psoriasis.

METHODS

We conducted a within-patient controlled prospective trial of treatment of localized plaque psoriasis. Twenty-two adult patients, mean Psoriasis Area and Severity Index 7.1, were recruited. Fifteen patients completed the full treatment, of which 13 were followed up to 1 year. Two selected plaques were treated with excimer twice weekly and V Beam PDL, pretreated with salicylic acid (SA), every 4 weeks, respectively. Two additional plaques, treated with SA alone or untreated, served as controls. The primary outcome measures were: (i) changes in plaque-modified Psoriasis Activity and Severity Index (PSI) scores from baseline to end of treatment; (ii) clinical response to treatment (CR(T)), assessed by serial photographs; (iii) percentage of plaques clear at the end of treatment; and (iv) percentage of plaques clear at 1-year follow-up. The secondary outcome measures were: (i) number of laser treatments to clearance; (ii) time to relapse; (iii) frequency of side-effects; and (iv) qualitative observations with SIAscope.

RESULTS

The mean improvement in PSI was 4.7 (SD 2.1) with excimer and 2.7 (SD 2.4) with PDL. PSI improvement was significantly greater in excimer than PDL (P = 0.003) or both control plaques (P < 0.001). CR(T) indicated 13 patients responded best with excimer, two patients best with PDL, and in seven patients there was no difference between the two lasers. CR(T) was significantly greater for excimer than PDL (P = 0.003) or both controls (P < 0.001). CR(T) was also significantly greater for PDL than SA alone (P = 0.004) or untreated control (P =0.002). Nine (41%) patients cleared with excimer, after mean 8.7, median 10 weeks treatment. Seven of these nine patients were followed up to 1 year; four remained clear, two relapsed at 1 month, and one at 6 months. Six (27%) patients cleared with PDL, after mean 3.3, median four treatments. All six patients were followed up to 1 year; four remained clear, one relapsed at 4 months and one at 9 months. Despite common side-effects including blistering and hyperpigmentation, patient satisfaction was high. Serial images obtained with the SIAscope during treatment indicated different mechanisms of action of the two lasers.

CONCLUSIONS

Excimer and V Beam PDL are useful treatments for plaque psoriasis. Although the excimer appears to be on average more efficacious, a subset of patients may respond better to PDL. Long-term remission is achievable with both lasers.