Treatment of inverse psoriasis with the 308 nm excimer laser

Roles of calcitonin gene-related peptide in the skin, and other physiological and pathophysiological functions

Skin immunity is regulated by many mediator molecules. One is the neuropeptide calcitonin gene-related peptide (CGRP). CGRP has roles in regulating the function of components of the immune system including T cells, B cells, dendritic cells (DCs), endothelial cells (ECs), and mast cells (MCs).

Herein we discuss actions of CGRP in mediating inflammatory and vascular effects in various cutaneous models and disorders.

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CGRP can help to recruit immune cells through endothelium-dependent vasodilation.

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CGRP plays an important role in the pathogenesis of neurogenic inflammation.

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Functions of many components in the immune system are influenced by CGRP.

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CGRP regulates various inflammatory processes in human skin by affecting different cell-types.

Inverse Psoriasis: From Diagnosis to Current Treatment Options

Inverse psoriasis represents a clinical variant of psoriasis that is sometimes difficult to diagnose due to its clinical similarity with other skin disorders involving the folds, mainly including mechanical intertrigo, fungal and bacterial infections, contact dermatitis, seborrheic dermatitis, and lichen planus. Dermoscopy represents a useful tool for an enhanced non-invasive diagnosis. The treatment of inverse psoriasis may be challenging and include topical corticosteroids, topical calcineurin inhibitors, vitamin D analogs, traditional oral systemic therapies such as cyclosporine and methotrexate, and biologic therapies.

[The 308 nm Excimer laser for the treatment of psoriasis and inflammatory skin diseases]

Overall, the 308 nm Excimer laser enables not only a more effective and safer UVB therapy than classical UV phototherapy, but also targeted irradiation in higher doses with a lower cumulative load, which results in faster healing of mainly circumscribed skin changes. This also applies to therapy-resistant residual lesions which, despite systemic therapy, did not diminish. Combination therapies usually improve the result and enable the dose of UVB and systemic medication to be reduced. Excimer laser therapy can be used for an increasing number of skin diseases, especially those that respond to phototherapy or photochemotherapy.

Excimer laser for the treatment of psoriasis: safety, efficacy, and patient acceptability

Introduction

The 308 nm excimer laser is a widely used device throughout the field of dermatology for many diseases including psoriasis. Although the laser has demonstrated clinical efficacy, there is a lack of literature outlining the safety, efficacy, and patient acceptability of the excimer laser.

Methods

A literature search on PubMed was used with combinations of the terms “excimer”, “excimer laser”, “308 nm”, “psoriasis”, “protocol”, “safety”, “efficacy”, acceptability”, “side effects”, and “dose”. The search results were included if they contained information pertaining to excimer laser and psoriasis treatment and description of the safety, efficacy, and patient acceptability of the treatment.

Results

The 308 nm excimer laser is generally safe and well tolerated with minimal side effects including erythema, blistering, and pigmentary changes. It has a range of efficacies depending on the protocol used with several different treatment protocols, including the induration protocol, the minimal erythema dose protocol, and the newer minimal blistering dose protocol.

Conclusion

Although the excimer laser is not a first-line treatment, it remains an excellent treatment option for psoriasis patients and has been demonstrated to be an effective treatment with little to no side effects.

The role of lasers and intense pulsed light technology in dermatology

The role of light-based technologies in dermatology has expanded dramatically in recent years. Lasers and intense pulsed light have been used to safely and effectively treat a diverse array of cutaneous conditions, including vascular and pigmented lesions, tattoos, scars, and undesired hair, while also providing extensive therapeutic options for cosmetic rejuvenation and other dermatologic conditions. Dermatologic laser procedures are becoming increasingly popular worldwide, and demand for them has fueled new innovations and clinical applications. These systems continue to evolve and provide enhanced therapeutic outcomes with improved safety profiles. This review highlights the important roles and varied clinical applications that lasers and intense pulsed light play in the dermatologic practice.

Single Blinded Left-to-Right Comparison Study of Excimer Laser Versus Pulsed Dye Laser for the Treatment of Nail Psoriasis

Introduction

Nail psoriasis is relatively difficult to treat. Excimer laser has been approved for the treatment of psoriasis since 2000. Pulsed dye laser (PDL) in psoriasis therapy has shown good response rates, with extended remissions. This is the first study assessing both the excimer and PDL lasers in nail psoriasis.

Methods

In a comparison study, excimer laser versus PDL for the treatment of nail psoriasis was evaluated in 42 patients. The right hand nails were treated with excimer laser twice weekly and the left hand nails were treated with PDL once every 4 weeks, for total 12 weeks. The patients were then followed up after a further 12 weeks. Nail Psoriasis Severity Index (NAPSI) scores were recorded at baseline, weeks 4, 8, and 12, and then at week 24. Patients were also asked to grade the clinical response to each treatment.

Results

A total of 304 nail changes, 148 with excimer laser and 156 with PDL, were treated. The mean NAPSI score in nails treated with excimer laser was 29.8 at baseline, reduced to 16.3 at week 24. In PDL-treated nails, the NAPSI scores dropped from 29.5 at baseline to 3.2 at week 24. NAPSI improvement was significantly greater in PDL than excimer (P = 0.001; Wilcoxon signed-rank test). Thirty-four (81%) hands achieved NAPSI-50, and 23 (55%) achieved NAPSI-75 at week 12, while complete nail recovery was shown in 6 (14%) hands treated with PDL. Regarding the hands treated with excimer laser, only 16 (38%) hands achieved NAPSI-50, while no hands achieved NAPSI-75 at week 12. In general, subungual hyperkeratosis and onycholysis improved significantly, while nail pitting was least responsive. Oil drops and splinter hemorrhages showed moderate response.

Conclusions

When compared to excimer laser, PDL demonstrated a good response for treating nail psoriasis, with minimal side effects.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0057-y) contains supplementary material, which is available to authorized users.

Inverse psoriasis: case presentation and review

Inverse psoriasis is a rare form of psoriasis that affects between 3% and 7% of psoriasis patients. Its appearance and distribution in the flexural skin folds makes it a difficult disease to diagnose, and because it is thought of as a variant of psoriasis, there are very few studies that deal with it exclusively. We present a short case report of inverse psoriasis and a review of the literature on various facets of this disease: epidemiology, histology, clinical presentation, differential diagnosis, and treatment.

Treatment of intertriginous psoriasis: from the Medical Board of the National Psoriasis Foundation

BACKGROUND

Involvement of areas of the skin fold is common in patients with psoriasis although the exact incidence is unknown. This report summarizes studies regarding the therapy of intertriginous psoriasis.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to arrive at a consensus on therapy for intertriginous or inverse psoriasis.

METHODS

Reports in the literature were reviewed regarding psoriasis affecting the skin-fold areas and its therapy.

LIMITATIONS

There are few evidence-based studies on the treatment of intertriginous psoriasis.

RESULTS

The recommended short-term (2-4 weeks) therapy for inverse psoriasis is low- to mid-potency topical steroids. For long-term therapy, topical calcipotriene (calcipotriol) or one of the immunomodulating agents, pimecrolimus or tacrolimus, is favored.

CONCLUSIONS

Low- to mid-potency topical steroids are recommended as first-line, short-term treatment. It is recommended that their use should either be of limited duration (less than 2-4 weeks) or that the lowest effective strength be used intermittently for long-term care to minimize the potential for risks. Calcipotriene (calcipotriol), pimecrolimus, and tacrolimus, while not as highly efficacious as topical steroids, are associated with fewer long-term risks and are therefore recommended for long-term therapy when feasible.

Use of the 308-nm excimer laser for psoriasis and vitiligo

The 308-nm excimer laser represents the latest advance in the concept of selective phototherapy. It emits a wavelength in the UV-B spectrum and thus shares the same indications as conventional phototherapy. Like other laser devices, the 308-nm excimer laser emits a monochromatic and coherent beam of light, can selectively treat a lesion while sparing surrounding healthy skin, and can deliver high fluencies. Clinicians have taken advantage of these properties to treat dermatologic disorders since 1997, with psoriasis and vitiligo attracting most attention. Initially, high fluencies (minimal erythemal dose, 8-16) were used, with excellent clinical results, to treat psoriasis vulgaris. The significance of side effects and the potential long-term carcinogenic risk associated with such fluencies have resulted in medium doses (about 3 minimal erythemal dose) being recommended, however. Interestingly, taking advantage of the selectivity of the laser, newer treatment protocols adapt the dose to the lesion and not to the minimal erythemal dose, as is the case for conventional phototherapies. Many prospective study series have also shown the efficacy and the good tolerance of the 308-nm excimer laser in the treatment of localized vitiligo. Induced rates of repigmentation seem to be higher than with narrowband UV-B. Moreover, the selectivity of the treatment prevents irradiation of healthy skin and limits unsightly tanning of surrounding skin. Aesthetically pleasing results are usually not achieved in extremities and bony prominences, which are not good indications for this technique. Combining the 308-nm excimer laser with 0.1% tacrolimus ointment has provided very interesting results, which need to be confirmed in larger series. The absence of actual data concerning the long-term risk for skin cancer after this treatment means that it should be considered with caution. Combination with topical steroids appears to be synergistic and potentially reduces long-term side effects; again, prospective data are lacking.

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.

Le laser excimer à 308 nm en dermatologie

THE EFFICACY OF THE 308 NM EXCIMER LASER in the treatment of common psoriasis has been demonstrated. THE DOSES USED have progressively decreased, hence, limiting the adverse events that appear redhibitory with high doses. THE ADAPTATION OF THE DOSES not to the patients themselves but to each of the plaques treated should reduce the number of sessions and the cumulated close necessary to obtain clinical remission. THE 308 NM EXCIMER LASER is effective and tolerance is good in the treatment of vitiligo. It should be proposed for limited vitiligo and essentially of the "UV sensitive" areas, which have shown aesthetically correct percentage of repigmentation. THE PLACE AND INTEREST of its association with other treatments, notably with topical tacrolimus, remains to be defined. Although the results obtained in the treatment of vitiligo are promising, they have to be confirmed in larger cohorts and ensure the absence of median and long term side effects. This therefore limits its use in combined treatments in the context of controlled clinical traits. THE 30 NM EXCIMER LASER IS AN EFFECTIVE AND WELL TOLERATED TREATMENT in localised and non-nodular forms of mycosis fungoid (MF). Although the number of patients treated is limited, the clinical and histological cure observed demonstrates the interest of this new technique in the treatment of MF. These results must be confirmed in a greater number of patients. THE 308 NM EXCIMER LASER is an interesting therapeutic alternative in the treatment of plaques of alopecia areata, erosive oral lichen planus, post-surgical hypopigmentation, vergetures and localised forms of atopic dermatitis. Because of the sparcity of data and in the absence of long term follow-up, it must not be proposed in first intention.

Ultraviolet B 308-nm excimer laser treatment of psoriasis: a new phototherapeutic approach

BACKGROUND

Excimer laser-derived 308-nm ultraviolet (UV) B therapy is a new alternative for treating psoriasis by phototherapy. Some studies have been made showing the effectiveness of intralesional phototherapy technology in treating psoriasis. However, there has been no information available so far with regard to the cumulative dosage on a larger group of patients and on therapy optimized treatment strategies.

OBJECTIVES

One hundred and twenty psoriatic patients were treated according to standard protocol to define the effectiveness. Our aim was to develop new parameters and determine whether effectiveness could be improved and whether treatment exposure, the cumulative UVB dose and adverse effects could be minimized.

METHODS

Initially, the excimer laser's effectiveness in treating psoriasis was evaluated in an open prospective study according to standard protocol. This included 120 adult patients (67 female/53 male) with chronic plaque psoriasis and < 20% involved body surface. The initial dose was based on three multiples of a predetermined minimal erythema dose (MED). Patients were treated twice a week for the first 3 weeks, then once a week until clearance was achieved. The main parameters were the initial starting dose, psoriasis area and severity index (PASI), the number of treatments needed, the time in treatment and the cumulative dose needed to clear psoriatic plaques. Thereafter, 43 patients were treated as a second comparable group. Therapy began with a starter dose, defined as MED-I. MED-I was defined as a UVB 308-nm dose which provoked a visible increase in erythema after 24 h. In addition, the epidermal thickness of the plaques was measured on an individual basis by 20-MHz ultrasound and correlated to the MED-I.

RESULTS

Of the patients who met the standard protocol, 65.7% were at least 90% clear after a maximum of 10 treatments; an even greater number (85.3%) showed a > or = 90% improvement in PASI after 13 sessions, while 14.7% of patients had only a < or = 50% PASI improvement. The cumulative UVB dose was 11.25 +/- 4.21 J cm-2 and the average treatment time was 7.2 weeks. Patients treated individually with the MED-I starter dose showed nearly identical rates of clearance (83.7%), but were clear in 7.07 +/- 2.15 sessions with a cumulative dose of 6.25 +/- 4.02 J cm-2.

CONCLUSIONS

The majority of our patients benefited greatly from laser-derived 308-nm UVB therapy, which cleared skin lesions faster than conventional phototherapy. As this therapy targets only the involved skin, the thickness of the plaques and individual MED-I should determine the initial dose, thus increasing the effectiveness of the therapy. We propose that light therapy sparing uninvolved skin will become predominant in the future.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.