Treatment of vitiligo with the 308-nm excimer laser: a pilot study

308 nm excimer laser and tacrolimus ointment in the treatment of facial vitiligo: a systematic review and meta-analysis

This study aimed to investigate the effects and safety of 308 nm excimer laser (308 nm EL) and tacrolimus ointment (TO) in the treatment of facial vitiligo (FV). We searched Cochrane Library, PUBMED, EMBASE, CNKI, and WANGFANG from inception to June 1, 2023. Outcomes included overall response rate (ORR), total adverse reaction rate (TARR), recurrence rate at 3-month (RR-3) and recurrence rate at 6-month (RR-6). The outcome data were presented as odds ratios (OR) with 95% confidence intervals (CI). The risk of bias was assessed by Cochrane risk-of-bias tool and data analysis was performed by RevMan 5.4 software. This study included a total of 19 trials involving 2085 patients. When comparing 308 nm EL monotherapy with 308 nm EL plus TO, significant differences in the ORR (OR = 4.29, 95% CI [2.97, 6.19], I2 = 0%, P < 0.001), RR-3 (OR = 0.18, 95% CI [0.05, 0.69], I2 = 0%, P = 0.01), and RR-6 (OR = 0.38, 95% CI [0.14, 1.03], I2 = 39%, P = 0.06) were found between the two managements. When comparing TO monotherapy with TO plus 308 nm EL, its results showed significant differences in the ORR (OR = 4.21, 95% CI [2.90, 6.11], I2 = 0%, P < 0.001), TARR (OR = 0.42, 95% CI [0.22, 0.81], I2 = 4%, P = 0.009), and RR-3 (OR = 0.32, 95% CI [0.01, 8.03], P = 0.49) between the two modalities. The results of this study suggest that the combination of 308 nm EL and TO is more effective than either treatment alone for the treatment of FV.

Vitiligo Treatments: Review of Current Therapeutic Modalities and JAK Inhibitors

Vitiligo is a chronic autoimmune disease characterized by loss of pigment of the skin, affecting 0.5-2% of the population worldwide. It can have a significant impact on patients' quality of life. In recent years, there has been significant progress in our understanding of the pathogenesis of vitiligo. It is believed that vitiligo develops due to a complex combination of genetics, oxidative stress, inflammation, and environmental triggers. Conventional treatments include camouflage, topical corticosteroids, topical calcineurin inhibitors, oral corticosteroids, phototherapy, and surgical procedures, with the treatment regimen dependent on the patient's preferences and characteristics. With increased understanding of the importance of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway in the pathogenesis of vitiligo, treatment has expanded to include the first US FDA-approved cream to repigment patients with vitiligo. This review summarizes our understanding of the major mechanisms involved in the pathogenesis of vitiligo and its most common available treatments.

S1 Guideline: Diagnosis and therapy of vitiligo

Vitiligo is a common skin disorder characterized by immune-mediated destruction of melanocytes. Non-segmental vitiligo, the most common clinical subtype, has usually a chronic course and often results in significant psychosocial consequences for the affected patient. Early recognition, awareness of comorbidity, precise assessment of disease extent and activity, evaluation of impairment of quality of life as well as rapid initiation of treatment based on currently available evidence-based therapies are crucial cornerstones in the management of vitiligo. This S1 guideline helps German dermatologists to better diagnose and treat vitiligo.

A Lower Irradiation Dose of 308 nm Monochromatic Excimer Light Might Be Sufficient for Vitiligo Treatment: A Novel Insight Gained from In Vitro and In Vivo Analyses

A 308 nm monochromatic excimer light (MEL) is widely used to treat patients with vitiligo. However, dose optimization still needs to be clarified. This study aimed to obtain objective evidence regarding various doses of MEL irradiation, induced cell level changes in vitro, and skin level alterations in vivo. Cultured human keratinocytes were irradiated with MEL using various doses. After irradiation at low doses, stem cell factor, endothelin-1, and glycoprotein nonmetastatic melanoma protein B, factors that activate and protect melanocytes, were found to be significantly elevated in keratinocytes. After irradiation using medium and high doses, inflammatory cytokines were induced. The amount of ATP released and the level of inflammasome activation, which are known to be related to interleukin-1β activation, were also increased. The back skin of guinea pigs and mice were irradiated with MEL at varying doses. After irradiation, an increase of epidermal melanin and epidermal melanocytes was confirmed, using the minimal erythemal dose or less. In rhododendrol-induced leukoderma guinea pigs, a much lower dose of MEL irradiation was effective, when compared with the effective dose for control guinea pigs. Our results suggest that a lower irradiation dose of MEL might be sufficient and more suitable for repigmentation in vitiligo treatment.

Pilot Study on the Use of the "Monocyte-Rich" Platelet-Rich Plasma in Combination with 1927 nm Fractional and 308 nm Excimer Lasers for the Treatment of Vitiligo

Background and objectives: Vitiligo is an acquired chronic and idiopathic skin disorder, characterized by selective loss of melanocytes and resulting in a cutaneous depigmentation. Treatment for vitiligo remains a challenge for dermatologists; thus, it is frustrating both for physicians and patients. The objective of this study was to evaluate a combination treatment characterized by the use of a leukocyte-rich platelet-rich plasma, which is particularly rich in monocytes (defined here as monocyte-rich PRP), in combination with a 1927 nm fraxel laser and a 308 nm excimer laser. Materials and Methods: Treatment with monocyte-rich PRP combined with 1927 nm fraxel laser and 308 nm excimer laser was performed in nine sessions in 80 days and the median follow-up of the patients was 10 months. A total of 27 Caucasian patients were included in the present study. The median age of patients was 41 years, ranging between 20 and 69 years. Results: A re-pigmentation occurred in 16 cases (59%) with a reduction of the Vitiligo Extent Score (VES) and absence of re-pigmentation in untreated areas. Performing a rank correlation between VES and re-pigmentation in the treated areas, we found that there was a significant correlation (p < 0.0001). The presence of progressive vitiligo (p = 0.1) and the anatomic areas (p = 0.1) did not influence the treatment. Untreated areas did not show any improvement of the depigmented lesions, except in one case (p < 0.0001). Conclusions: in this report, we show for the first time how PRP rich in monocytes, in combination with laser therapies, gives a long therapeutic response, which persists even after 10 months of follow-up.

Vitiligo: What's old, what's new

Vitiligo is an acquired pigmentary disorder afflicting 0.5-2% of the world population for both sexes and all races with a capricious and unpredictable course. It has a complex etiology and varies in its manifestation, progression and response to treatment. Even if the precise aetiology and pathobiology of the disease are complex and still debated, recent evidence supports that vitiligo is a T CD8+ cell-mediated autoimmune disease triggered by oxidative stress. To date no clinical, biological and histological criteria allow us to establish the prognosis with certainty. The choice of the best therapy for adult and childhood vitiligo is based on various factors, such as the patient's age, psychological condition and expectations, distribution and extension of skin lesions, type of vitiligo (stable or not) and availability and cost of therapeutic options. Since vitiligo has a deep psychological impact on patients and their quality of life, treating the disease is very important. As dermatologists, we have important goals in the treatment of vitiligo patients: stabilization of the disease progression, repigmentation of the lesions and especially the persistence of the aforementioned repigmentation. Although several medical and surgical therapeutic options have been proposed, no definite cure has yet been developed and the long-term persistence of repigmentation is unpredictable. We review the different therapeutic options with particular attention on the recurrence rate.

Comparison of the efficacy of broad-band targeted UVB phototherapy and topical psoralen with targeted UVA phototherapy in localized vitiligo

Aim of the study is to compare efficacy of targeted broad-band UVB phototherapy and topical psoralen with targeted UVA phototherapy treatments in localized vitiligo for 3 months prospectively. The cases with symmetrical vitiligo lesions were included in the study. Broad-band targeted UVB was applied on one side and targeted UVA phototherapy with topical psoralen on the other side. Twenty-two patients who were diagnosed with localized vitiligo were enrolled in this study. These cases consisted of 6 (27.3%) females and 16 (72.7%) males aging between 17 and 69 (34.22 ± 14.15). Fifty-four lesions (27 left, 27 right) were compared for treatments. After the first month of the treatments, the sides of the lesions were compared in order to evaluate improvement. Percentages of success were 25% for targeted broad-band UVB microphototherapy and 75% for topical psoralen with targeted UVA microphototherapy. When the two treatment methods were compared with each other, a significant difference was found in terms of treatment response (P = .017). At the end of the third month, the success rates were 37.5% for targeted broad-band UVB microphototherapy and 62.5% for topical psoralen with targeted UVA microphototherapy, however a statistically significant difference was not determined between the two treatments (P > .05). Both targeted broad-band UVB phototherapy and topical psoralen with targeted UVA phototherapy provided repigmentation for localized vitiligo at the end of the third month. Our investigation shows that both treatments are safe and they provide repigmentation with a limited response.

Comparative efficacy between localized 308-nm excimer light and targeted 311-nm narrowband ultraviolet B phototherapy in vitiligo: A randomized, single-blind comparison study

BACKGROUND

There are limited data to compare efficacy between recent 308-nm excimer and conventional 311-nm narrowband ultraviolet B (NB-UVB) light in the treatment of vitiligo.

OBJECTIVE

To compare efficacy between 308-nm excimer light and 311-nm NB-UVB in patients with symmetrical vitiligo lesions.

METHODS

Thirty-six symmetrically paired vitiligo lesions on the same anatomical area were enrolled. One side of the symmetrical lesions was treated with localized 308-nm excimer light, and the opposite side was treated with targeted 311-nm NB-UVB assigned randomly by computer. All lesions were treated with the same protocol, for 48 sessions. Repigmentation was evaluated using Vitiligo Area Scoring Index (VASI) and grading the repigmentation was carried out with three independent investigators.

RESULTS

Thirty-six symmetrically vitiligo lesions were randomly treated, one side with 308-nm excimer light and the opposite side with 311-nm NB-UVB. After 48 sessions, a significantly lower VASI score and a higher grade of repigmentation were observed in 308-nm excimer light-treated side (P < .001). Nine lesions (25%) treated with 308-nm excimer light and only five lesions (13.89%) treated with 311-nm NB-UVB achieved excellent repigmentation. The 308-nm excimer light and 311-nm NB-UVB-treated sides rapidly obtained 25% repigmentation within a mean of 19.42 sessions and 26.25 sessions, respectively (P = .002). There was no significant difference in mean cumulative UV dosage (P = .065). Side effect as phototoxicity was similar in both sides (P = .08).

CONCLUSION

Localized 308-nm excimer light appears to be more effective and also more rapidly induces repigmentation than targeted 311-nm NB-UVB for treatment of vitiligo.

308-nm Excimer Laser Plus Platelet-Rich Plasma for Treatment of Stable Vitiligo: A Prospective, Randomized Case-Control Study

Purpose

308-nm excimer laser has a confirmed treatment effect on vitiligo. Platelet-rich plasma (PRP) is an autologous preparation which contains a variety of growth factors. The effect of 308-nm excimer laser combined with PRP on vitiligo has been rarely reported. This study investigated the effect of PRP combined with 308-nm excimer laser on stable vitiligo.

Patients and Methods

A total of 60 patients with localized stable vitiligo who received treatment at Beijing Friendship Hospital and Xi’an Vitiligo Specialist Hospital between May 2019 and January 2020 were consecutively enrolled. They were equally randomized into three groups according to different treatment methods: intradermal PRP injection (group I), 308-nm excimer laser alone (group II), and 308-nm excimer laser plus PRP injection (group III). All treatments lasted for 3 months. At 3 months after treatment, clinical assessments were performed in terms of the visual analogue scale (VAS) score, repigmentation response and side effects.

Results

The VAS scores showed significant differences among the three groups (P<0.001), with the highest score in group III, followed by group II and then group I. Repigmentation responses also showed significant differences among the groups (P<0.001), and the best effect was observed in group III. No side effects were reported in any of the groups.

Conclusion

The effect of PRP combined with 308-nm excimer laser on stable vitiligo is significantly better than that of PRP and 308-nm excimer laser alone. It is safe and satisfactorily tolerant.

308-nm excimer laser: a hopeful and optional therapy for pityriasis versicolor

BACKGROUND

Pityriasis Versicolor (PV) is known as a superficial fungal infection. It is suggested that resistant strains to azoles may be developed and hence, the treatment would be difficult. This study aimed to evaluate the efficacy of excimer laser (308 nm) as an alternative therapy for PV.

MATERIALS AND METHODS

This is a prospective intra-patient left-to-right, randomized, placebo-controlled study conducted on 26 patients with bilateral lesions which are not responding to the PV standard treatment. Patients were randomly assigned to right or left-side therapy for a duration of 8 weeks with either excimer laser (308 nm three times weekly) or topical placebo. Clinical assessment and mycological evaluation were performed before the initiation of treatment and at the fourth and eighth week of therapy.

RESULTS

A decrease in the mean clinical score of cases was recorded from 7.1 at the baseline evaluation to 1.56 after 4 weeks and to 1.96 after 8 weeks of treatment. At week 4, there was a statistically significant reduction in the clinical scores compared with pretreatment scores and with the placebo group (p < .001).

CONCLUSION

308-nm excimer laser can be considered as a hopeful and optional therapy for PV.

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.

A comparative clinical trial to evaluate efficacy and safety of the 308-nm excimer laser and the gain-switched 311-nm titanium:sapphire laser in the treatment of vitiligo

BACKGROUND/PURPOSE

Ultraviolet B (UVB) laser irradiation in a targeted manner is a reasonable treatment option for localized vitiligo. Recently, narrow-band UVB gain-switched 311-nm titanium:sapphire lasers (TSL) were developed for the treatment of localized vitiligo. We aimed to compare efficacy, patient satisfaction, and safety between the conventional 308-nm excimer laser (EL) and gain-switched 311-nm TSL in patients with vitiligo.

METHODS

The 13-paired lesions from 10 patients who had small vitiligo patches were included in this prospective intra-patient comparison trial. Each pair was randomly assigned to each laser treatment group and treated twice weekly for 12 weeks. The global photographic assessments by dermatologists, objective numerical assessments by imaging analyzer, and patient's satisfaction were used to evaluate the effectiveness. Adverse effects were also investigated at every visit.

RESULTS

All treated lesions showed improvement of about 50% after 12 weeks. There was no significant difference between EL- and TSL-treated groups. Patient satisfaction and preference among the groups were also similar. Regarding safety, there were no serious adverse effects requiring cessation of the treatments; however, the severity score for persistent erythema (lasting >24 hours) was significantly lower in the TSL group than in the EL group.

CONCLUSIONS

The gain-switched 311-nm TSL exhibited similar efficacy to the 308-nm EL in treating vitiligo as well as improved safety. Therefore, the 311-nm TSL is considered as a candidate device to replace the EL as a new and promising treatment option for localized vitiligo.

The expression change of RORγt, BATF, and IL-17 in Chinese vitiligo patients with 308 nanometers excimer laser treatment

This study aims to explore the expression of RORγt, BATF, and IL-17 in Chinese vitiligo patients with 308 nm excimer laser treatment. One hundred and sixty-four vitiligo patients treated with 308 nm excimer laser were enrolled as Case group and 137 health examiners as Control group. Quantitative real-time polymerase chain reaction and immunohistochemistry were conducted to detect the expressions of RORγt, BATF, and IL-17. Expression of RORγt, BATF, IL-17A, and IL-17F were higher in Case group than Control group, with the diagnostic accuracy of 88.04, 87.38, 97.34, and 89.04%, respectively. Pearson correlation analysis showed a positive correlation in RORγt, BATF, IL-17A, and IL-17F mRNAs in vitiligo patients. Moreover, their expressions were higher in active vitiligo patients than stable ones. Besides, the expressions of RORγt, BATF, IL-17A, and IL-17F in vitiligo skin were significantly higher than those in non lesional skin and normal controls. After treatment, their expressions were significantly decreased. Active vitiligo and the high expressions of RORγt, BATF, and IL-17F were the independent risk factors for the ineffectiveness of 308 nm excimer laser treatment. The expressions of RORγt, BATF, IL-17 were significantly enhanced in vitiligo patients, which were correlated with the activity of vitiligo and 308 nm excimer laser therapeutic effects.

Utility of dermoscopy for evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in localized vitiligo patients

The aim of the present study was to assess the function of dermoscopy in evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in patients with localized vitiligo. A total of 147 patients with localized vitiligo (progressive disease, n=92; stable period, n=55) were enrolled and received combination therapy for 12 weeks. The condition of the skin lesions was monitored by dermoscopy and visual observation. At the initial visit, skin lesions were observed in 61 progressive and 19 stable patients. Residual perifollicular pigmentation was more abundant in progressive-stage patients than in stable-stage patients, whereas the presence of perilesional hyperpigmentation was obviously lower in patients with progressive vitiligo. After 12 weeks of combination therapy, marked differences in residual perifollicular pigmentation were identified between the progressive- and stable-stage patients. Dermoscopy and visual observation indicated that the 12-week treatment efficacy in patients with progressive disease was significantly higher than in those with stable disease and that assessment by dermoscopy was superior to visual observation at 8 or 12 weeks of treatment. Binary logistic regression analysis revealed that the disease stage, vitiliginous areas and disease course were risk factors associated with the treatment efficacy of the combination therapy. In conclusion, dermoscopy may be used as an effective means of vitiligo therapy assessment to provide an accurate and scientific evaluation of treatment efficacy for localized vitiligo patients.

[The 308 nm Excimer laser : Treatment of vitiligo and hypopigmentation]

Use of the 308 nm Excimer laser to treat hypopigmentation and vitiligo is usually superior to conventional ultraviolet (UV) therapy with regard to results and safety. It is particularly advantageous because specific areas of skin can be targeted without burdening the rest of the skin. Fewer sessions with lower cumulative doses are required. Various combination therapies can improve the outcome; selection criteria such as early initiation of treatment and more frequent sessions with shorter intervals make it easier to decide which patients should be treated and how to achieve the greatest benefit.

Phototherapy and Combination Therapies for Vitiligo

Vitiligo is a disease characterized by disappearance of melanocytes from the skin. It can negatively influence the physical appearance of affected individuals, and may profoundly affect a person's psychosocial function and quality of life. Therefore, vitiligo should not be considered as merely a condition that affects a patient's appearance, but needs to be actively treated in patients who seek medical help. Phototherapy has been used as the main treatment modality for patients with vitiligo. Different forms of phototherapy for vitiligo include broadband UVB, narrowband UVB, excimer light and excimer laser, and psoralen plus UVA.

Comparison of the efficacy of 308-nm excimer lamp monotherapy with topical tacrolimus or clobetasol 17-propionate combination therapies in localized vitiligo

BACKGROUND

In recent years, excimer light treatments have come to the fore in localized vitiligo because of their high efficacy and safety.

OBJECTIVE

We aimed to evaluate the efficacy of 308-nm excimer lamp as a monotherapy and its combination with tacrolimus 0.1% or clobetasol 17-propionate 0.05% ointment in localized vitiligo.

METHODS

We performed a retrospective study including a total of 82 patients who were treated with excimer lamp monotherapy (EL group) (n = 30), excimer lamp + topical tacrolimus (EL + T group) (n = 29), or excimer lamp + topical clobetasol 17-propionate (EL + CS group) (n = 23). We used digital morphometric analysis for the evaluation of repigmentation.

RESULTS

Median healing rate after 24 sessions was significantly higher in EL + T group (69%) than EL (42.5%) and EL + CS (44%) groups (P = 0.008 and P = 0.032). There were not any patients with face lesions in EL + CS group, so when these patients were excluded, EL + T and EL + CS groups had higher healing rates than EL group (P = 0.037 and P = 0.043). It was confirmed that combination with tacrolimus was superior to clobetasol-17 propionate (P = 0.048) with multivariate regression analysis.

CONCLUSION

We noted that 308-nm excimer lamp therapy was efficacious; adding topical tacrolimus or topical clobetasol-17 propionate could increase response to treatment.

Treatment of vitiligo with 308-nm excimer laser: our experience from a 2-year follow-up of 979 Chinese patients

BACKGROUND

The 308-nm excimer laser had been proved to be a time-efficient and potent therapeutic alternative for the management of vitiligo. Different results had been reported in different ethnic populations.

OBJECTIVE

To investigate the efficacy and related contributing factors of 308-nm excimer laser in Chinese vitiligo patients.

METHODS

A total of 979 Chinese patients (3478 lesions) with progressive-stage vitiligo who had received 308-nm excimer laser treatment were recruited from the vitiligo clinic of Shandong Provincial Hospital of Dermatology &Venereology from 2012 to 2014. Efficacy of treatment was evaluated at the end of session by two independent dermatologists based on the before and after images taken. Repigmentation was graded on a 4-point scale: grade 1, poor repigmentation (0-25%); grade 2, moderate repigmentation (26-50%); grade 3, good repigmentation (51-75%); grade 4, excellent repigmentation (76-100%).

RESULTS

The mean grade of repigmentation was 2.29, 44.22% showed less than 25% repigmentation, 16.27% showed 26-50% repigmentation, 5.95% showed 51-75% repigmentation and 33.55% showed more than 76% repigmentation. The repigmentation of facial lesions was better than lesions located elsewhere (P < 0.0001), the best response was noted in the periorbital region, while lesions on hands and feet showed poor repigmentation (P < 0.0001). The degree of repigmentation was negatively correlated with disease duration (r = -0.268, P < 0.001), age (r = -0.095, P < 0.001) and shape of lesions (r = -0.114, P < 0.001), whereas it was positively correlated with treatment frequency (r = 0.270, P < 0.001). Lesions with concurrent poliosis were more likely resistant to treatments.

CONCLUSION

308-nm excimer laser appears to be an effective and safe treatment in Chinese vitiligo patients. The clinical response and treatment efficacy was affected by many factors such as age, affected anatomical area, shape of the lesion, disease duration and treatment frequencies.

A retrospective study of the utility of targeted phototherapy in vitiligo

BACKGROUND

Targeted phototherapy is a recent advance in the treatment of vitiligo, involving selective treatment of vitiligo patches with no effect on surrounding areas. Although it has been in use for a few years, little data is available regarding its safety and efficacy.

AIMS

A retrospective study to determine efficacy and safety of targeted phototherapy in vitiligo.

METHODS

One hundred and thirty four patients (male: 53, female: 81) who received targeted phototherapy and completed 11 or more sittings were included. Treatment was given once a week using the Lumera phototherapy system, a broadband ultraviolet B source, starting at 150 mJ/spot and after excluding a sunburn reaction, with increments of 50 mJ every week up to a maximum of 1000 mJ/patch. Chi-square test for linear trends was used for statistical analysis.

RESULTS

The most common sites involved were the legs and a majority (70.9%) had non-segmental vitiligo. Response was mild in 78 (58.2%) patients, moderate in 50 (37.3%) and excellent in 6 (4.5%) patients. Response was directly proportional to the number of sittings with more patients showing moderate and excellent responses with an increase in the number of sittings. The most common site for an excellent response was the trunk while the lower limbs were involved in most cases with a moderate or mild response. Side effects were seen in 27 (20.2%) patients, the commonest being erythema.

LIMITATIONS

This is a retrospective uncontrolled study. Further, the effects of adjuvant treatment were not assessed.

CONCLUSIONS

Targeted phototherapy is a useful treatment for vitiligo with mild adverse effects, though response is mild or moderate and appears to be directly proportional to the number of treatments received.

Review of narrowband ultraviolet B radiation in vitiligo

Vitiligo is a common, acquired pigmentary disorder of unknown etiology with great impact on patient’s appearance and quality of life. It presents a therapeutic challenge to many dermatologists. Photochemotherapy using psoralen and ultraviolet A (UVA) therapy, topical and oral immunosuppresants, as well as cosmetic camouflage are also commonly employed with varying clinical efficacy. Phototherapy is a popular treatment option, which includes both of the generalized ultraviolet B (UVB) therapies, broadband UVB and narrowband UVB (NB-UVB). It has been used favorably, both alone as well as in combination with other agents like topical calcineurin inhibitors, vitamin-D analogs. Combination therapies are useful and may provide quicker regimentation and treat vitiligo with an additive mechanism of action than UVB phototherapy. Advances in technology may lead to the continuing use of UVB phototherapy as a treatment for vitiligo through the development of sophisticated devices and delivery systems as well as innovative application methods. These will provide increased therapeutic options for all vitiligo patients, particularly those with refractory disease. In this article, I have reviewed the available data pertaining to efficacy and safety issues for NB-UVB as monotherapy, its comparison with psoralen plus UVA and other modes of phototherapy, combination regimens that have been tried and future prospects of NB-UVB in vitiligo.

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.

Combination therapy with 308-nm excimer laser, topical tacrolimus, and short-term systemic corticosteroids for segmental vitiligo: A retrospective study of 159 patients

BACKGROUND

Segmental vitiligo (SV) is characterized by a unilateral and localized distribution, early onset, and stable disease after rapid progression. And SV is often associated with poor response to various treatment modalities.

OBJECTIVE

We sought to evaluate the effectiveness of combination therapy with 308-nm excimer laser, topical tacrolimus, and short-term systemic corticosteroids for SV, and to search for factors associated with the treatment response.

METHODS

A retrospective interventional case-series study was performed on 159 patients with SV who were treated with the combination therapy for more than 3 months.

RESULTS

The rate of 75% or more repigmentation was 50.3% after a median treatment duration of 12.1 months; 36.5% and 13.8% of the patients showed nearly complete (75%-99%) and complete (100%) repigmentation, respectively. Multivariable analysis showed the following to be independent factors with poor response: disease duration longer than 12 months (odds ratio 0.372, 95% confidence interval 0.157-0.882, P = .025), poliosis (odds ratio 0.494, 95% confidence interval 0.247-0.988, P = .046), and plurisegmental subtype (odds ratio 0.175, 95% confidence interval 0.065-0.474, P = .001).

LIMITATIONS

This was a retrospective study.

CONCLUSION

The combination therapy is effective for SV. Prolonged disease duration, poliosis, and plurisegmental subtype were shown to be independent prognostic factors of poor response in patients with SV.

Treatment of vitiligo with NB-UVB: A systematic review

OBJECTIVE

To assess the effect and safety of NB-UVB for vitiligo using an evidence-based approach.

METHODS

Randomized controlled trials (RCTs) on the treatment of vitiligo with NB-UVB were identified by searching PubMed and the Cochrane Library. The primary outcome was re-pigmentation degree.

RESULTS

A total of seven RCTs involving 232 participants with vitiligo were included in this systematic review. The methodological qualities of included studies were generally moderate. Two trials compared narrow-band ultraviolet B (NB-UVB) with UVA control, showing no significant differences between two methods on the number of patients who achieved >60% re-pigmentation [relative risk (RR) = 2.50, 95% confidence interval (CI): 0.11-56.97, p > 0.05]. Two trials compared NB-UVB with psoralens plus UVA (PUVA) control, and no difference was seen between the two treatments on the number of patients who achieved >50 re-pigmentation (RR = 1.16, 95% CI: 0.64-2.11, p > 0.05) or >75% re-pigmentation (RR = 2.00, 95% CI: 0.89-4.48, p > 0.05). Three trials compared NB-UVB with 308-nm excimer light/laser (EL) control, and again no significant difference was found between the two methods (p > 0.05). The adverse events of NB-UVB in the included studies were slight and tolerated.

CONCLUSION

NB-UVB showed equivalent efficacies to UVA, PUVA or 308-nm EL control in the treatment of vitiligo. Side effects of NB-UVB were acceptable. More RCTs were needed to validate the results.

Excimer UV radiation in dermatology

Ultraviolet B (UVB 290-320 nm) radiation has been used in the treatment of different skin diseases. Light sources with narrowband UVB output spectrum have been developed with the aim of increasing the rates of “beneficial to side effect” profile of the treatment. Narrowband UVB phototherapy using fluorescent lamps (TL01, 311&#x2213;2nm) has been widely adopted over the past 10 years. Monochromatic Excimer Light (MEL) represents a new source of narrow-band UVB emitting at 308 nm and guarantees a safe and effective approach to different chronic and recurrent skin diseases thanks to its potent and selective immunosuppressant action.

Correlation of clinical efficacy and psychosocial impact on vitiligo patients by excimer laser treatment

BACKGROUND AND OBJECTIVES

Vitiligo is a difficult disease to treat. Recently, a 308-nm excimer laser has been shown to be effective in treating vitiligo. In addition, the patients with vitiligo have impairment in their quality of life. The aim of the study was to investigate the clinical efficacy, safety, and psychosocial impact after treating vitiligo with the 308-nm excimer laser.

DESIGN AND SETTINGS

A prospective clinical trial conducted at dermatology clinics of hospitals affiliated with Qassim University, Saudi Arabia, from May 2012 to February 2013.

PATIENTS AND METHODS

Forty-eight patients with 105 vitiliginous patches were treated using a 308-nm excimer laser. The treatment was performed twice per week for a maximum of 48 treatments or 100% repigmentation of lesions whichever was achieved first. The assessment of the clinical response and recording of side effects were performed biweekly.

RESULTS

Out of 105 lesions in these patients, 63 lesions (60.0%) achieved over 75% repigmentation by laser treatment, 12 lesions (11.4%) showed 51% to 75% repigmentation, 9 lesions (8.6%) showed 26% to 50% repigmentation, and another 9 lesions (8.6%) showed 1% to 25% repigmentation, while 12 lesions (11.4%) showed no repigmentation. The average (+/-standard deviation [SD]) number of sessions needed to achieve repigmentation was 16.8 (8.0), whereas the average (+/-SD) number of sessions needed to realize Grade IV repigmentation was 20.2 (15). The type of repigmentation varied between lesions. Diffuse repigmentation was the most common pattern and occurred in 34 lesions (36.6%). Facial lesions responded better than lesions located elsewhere. Skin type did not play a statistically significant role (P=.07) in the lesions response to treatment. All side effects were mild and disappeared shortly after end of treatment sessions.

CONCLUSION

The clinical data indicate that the treatment of vitiligo using the 308-nm excimer laser is effective and safe and improves psychosocial quality of life. Lesion location, duration of disease, and treatment duration are factors affecting the clinical and psychological outcome.

Comparison of the 308-nm excimer laser with the 308-nm excimer lamp in the treatment of vitiligo--a randomized bilateral comparison study

BACKGROUND

Vitiligo is an acquired pigment disorder characterized by areas of depigmented skin resulting from the loss of epidermal melanocytes. Recently, several investigations have documented the benefits of excimer phototherapy (e.g., using the 308-nm excimer laser or the 308-nm excimer lamp) for the treatment of vitiligo.

AIM

To compare the effectiveness of the 308-nm excimer laser with the 308-nm excimer lamp in the treatment of vitiligo patients.

METHODS

This intervention study was designed as a randomized self-control trial. Fourteen subjects with 48 symmetrical vitiligo lesions were enrolled in this study. One lesion was treated with the 308-nm excimer laser, and its counterpart was treated with the 308-nm excimer lamp. Lesions were treated three times a week with the same dose on both sides for a total of 20 sessions.

RESULTS

All of the patients completed the study, and 48 lesions were treated. The two treatments exhibited similar results in terms of repigmentation.

CONCLUSIONS

The 308-nm excimer lamp and the 308-nm excimer laser exhibited similar efficacies in treating vitiligo.

WITHDRAWN: Comparision between 308-nm excimer laser and 308-nm excimer lamp in the treatment of vitiligo - a randomized self control study

Ahead of Print article withdrawn by publisher.

Successful treatment with 308-nm monochromatic excimer light and subsequent tacrolimus 0.03% ointment in refractory plasma cell cheilitis

Plasma cell cheilitis is a chronic inflammatory disease that presents with erythema, erosions, ulcers and occasional nodules within the mucosa, including the lips. It is histopathologically characterized by dense plasma cell infiltration in the lamina propria of the mucous membranes. Several treatments for plasma cell cheilitis have been reported, including topical steroids, topical antibiotics or topical tacrolimus. However, 308-nm monochromatic excimer light (MEL) has never been reported as a treatment option, while it was reported to be very effective in treating erosive oral lichen planus. We report a 62-year-old man who had chronic plasma cell cheilitis on the lower lip, which was refractory to topical and systemic corticosteroid. The lesion and severe pain were significantly improved by the treatment with nine sessions of 308-nm MEL twice per week with a total dose of 1120 mJ/cm(2). However, the lesion gradually worsened after treatment frequency was reduced to once per month. Subsequent tacrolimus 0.03% ointment cleared the lesion completely in a month and no recurrence was observed a year later. Refractory plasma cell cheilitis and concomitant severe pain quickly responded to 308-nm MEL when administrated twice per week. Because the long interval between each MEL treatment seemed ineffective to improve the lesion, appropriate frequency and adequate total dose of MEL treatment may be necessary for a successful treatment.

Irradiance, but not fluence, plays a crucial role in UVB-induced immature pigment cell development: new insights for efficient UVB phototherapy

Light exposure modulates development of living organisms. In the field of medicine, light has frequently been used for regenerative purposes. Excimer light (308 nm) has demonstrated superior efficacy in treating vitiligo, a condition requiring development of melanoblasts and a model for studying nerve cell regeneration, as compared to narrow-band ultraviolet B (NBUVB; 311 nm). Using mouse-derived melanoblast cells to examine the pro-differentiation effects of these two light sources, we demonstrated that at equivalent fluence, excimer light induces melanoblast differentiation, while NBUVB failed to so. Mechanistically, activation of aryl hydrocarbon receptor pathway and nuclear translocation of epidermal growth factor receptor are involved in pro-differentiation effects of excimer light. Reduction in irradiance by filter abrogated the effects of excimer light in melanoblasts, even when equivalent fluence was delivered by the same light source. As ultraviolet B (UVB) irradiation is closely associated pigment cell development, future therapy employing UVB for pigmentation purposes should incorporate irradiance as a crucial specification.

A review of monochromatic excimer light in vitiligo

Phototherapy is a mainstay of vitiligo treatment and has varying rates of efficacy. Narrowband ultraviolet (UV) B (NB-UVB) and UVA have been used for decades, but it is only recently that monochromatic excimer light (MEL) was developed for use in dermatology and adapted for the treatment of vitiligo. The specific 308-nm radiation wavelength is delivered in a targeted form by the xenon-chloride excimer laser and is also available in an incoherent form that is commonly referred to as the excimer lamp. MEL administered by both laser and lamp has shown efficacy superior to NB-UVB for the treatment of vitiligo and induces more changes at the cellular level than conventional UVB modalities. The excimer laser is effective in adults and children with vitiligo in all skin types as monotherapy or in combination with other established vitiligo therapeutics. Treatment regimens studied included excimer laser two to three times weekly for up to 36 weeks. Patients commonly achieved > 75% repigmentation. The laser has also been used in combination with topical corticosteroids, calcineurin inhibitors and vitamin D analogues, as well as surgery, thus further expanding treatment options for patients with vitiligo. The excimer lamp has been used for treatments one to three times a week for up to 24 weeks and was found to be equal to excimer laser in a head-to-head comparison. It has also been used in combination with topical corticosteroids and oral vitamin E. Both MEL modalities have a limited adverse side-effect profile. Long-term effects are yet to be determined; however, based on available data on UVB phototherapy as well as the properties of MEL devices, there is probably only a minimal increased malignancy risk.

Vitiligo: an update on current pharmacotherapy and future directions

INTRODUCTION

Vitiligo is a common pigmentary skin disorder, characterized by the appearance of white macules on the skin, mucosal or hair. Treatment is often a tough challenge and involves a wide range of therapies.

AREAS COVERED

This review focuses on available first- and second-line pharmacological treatments for vitiligo. In particular, the mechanisms of action, the main indications, the efficacy and the most important side effects are reviewed. Moreover, a brief discussion is provided, regarding other nonpharmacological treatments, such as phototherapy and surgical options, due to their importance and successful outcomes in vitiligo treatment. Finally, a concise overview regarding the future directions in vitiligo therapy is presented.

EXPERT OPINION

The promising outcomes reported here demonstrate that it is possible to achieve a satisfactory and often stable repigmentation of vitiligo lesions. Topical corticosteroids, calcineurin inhibitors, phototherapy and photochemotherapy represent the first-line therapeutic options, due to their safety and efficacy, whereas vitamin D analogues, targeted phototherapy, oral corticosteroids and surgery should be used as second-line therapies. Other therapies, such as antioxidants, can be used in association with other therapeutic options, whereas depigmenting agents should be used only in cases of extensive vitiligo, recalcitrant to other treatments.

Role of phototherapy in patients with skin of color

Phototherapy has proven to be one of the most versatile and effective treatment options for a variety of inflammatory and pigmentary skin diseases. However, the use of these treatment modalities in patients of color requires some special considerations. The modality chosen, the dosing of the treatment and duration of treatment are all issues to be considered for patients of color treated with ultraviolet phototherapy. In addition, there are some diseases which are more commonly seen in patients of color. These diseases may have better treatment outcomes using newer phototherapeutic options such as the long pulsed Nd:YAG laser or UVA1. As our population in the United States becomes more diverse it would behoove all dermatologists to acquaint themselves with the special circumstances of treating ethnic patients with phototherapy.

Tetrahydrocurcuminoid cream plus targeted narrowband UVB phototherapy for vitiligo: a preliminary randomized controlled study

OBJECTIVE

The aim of this study was to compare the efficacy of targeted narrowband UVB phototherapy plus topical tetrahydrocurcuminoid with that of targeted narrowband UVB monotherapy for induction of repigmentation in vitiligo.

BACKGROUND DATA

The 308-nm excimer laser and targeted narrowband UVB phototherapy have recently been shown to be effective in repigmenting vitiligo. Studies have suggested that the combination of the 308-nm excimer laser and various topical treatments is more effective than UV monotherapy in the treatment of vitiligo.

MATERIALS AND METHODS

Ten subjects with focal or generalized vitiligo were enrolled in this study. Two similar lesions were treated with either targeted narrowband UVB plus topical tetrahydrocurcuminoid cream or targeted UVB alone. The UV treatments were carried out twice a week for 12 weeks. The degree of repigmentation, documented by monthly digital photography, was assessed by a blinded dermatologist.

RESULTS

On completion of the study, statistically significant repigmentation, compared with baseline, occurred in both treatment groups. The overall degree of repigmentation was slightly better in the combination group at 8 and 12 weeks (p = 0.078 and 0.158 respectively). Adverse effects were minor and well tolerated.

CONCLUSION

Targeted narrowband UVB phototherapy plus topical tetrahydrocurcuminoid cream was slightly more effective than targeted narrowband UVB monotherapy for vitiligo located in UV-sensitive areas. However, the differences in degrees of repigmentation did not reach statistically significant levels.

308-nm excimer lamp vs. 308-nm excimer laser for treating vitiligo: a randomized study

BACKGROUND

The 308-nm excimer laser and 308-nm excimer lamp have both been shown to be effective in treating vitiligo but a direct comparison has never been performed.

OBJECTIVES

To test the equivalence of these two devices for treating nonsegmental vitiligo.

PATIENTS AND METHODS

A randomized monocentric study was undertaken. One lesion was treated with the 308-nm excimer laser and its counterpart with the 308-nm excimer lamp. Lesions were treated twice weekly with the same dose on both sides for a total of 24 sessions. The evaluation was done by two independent physicians blinded to the treatment on direct light and ultraviolet light photos.

RESULTS

Twenty patients were included: 17 completed the study and 104 lesions were treated. The two treatments showed similar results in terms of efficacy for a repigmentation of at least 50% (P = 0.006). The lamp induced more erythema than the laser.

CONCLUSIONS

The 308-nm excimer lamp and laser showed a similar efficacy in treating vitiligo. For the same fluence, the lamp induced more erythema suggesting photobiological differences between the two devices.

Therapeutic evaluation of UVB-targeted phototherapy in vitiligo that affects less than 10% of the body surface area

BACKGROUND

Current treatments for vitiligo include different therapeutic modalities, such as corticosteroids, immunomodulators, pseudocatalase, skin grafts, diverse types of phototherapy [ultraviolet B (UVB), psoralen plus UVA (PUVA), narrow-band UVB (NB-UVB)], and, recently, targeted phototherapy. After a literature search, we found only two studies using different targeted broad-band UVB units for the treatment of vitiligo.

OBJECTIVE

To evaluate the repigmentation response induced with broad-band, UVB-targeted phototherapy used as monotherapy in patients with vitiligo affecting less than 10% of the skin surface.

METHODS

Twelve patients were recruited for treatment with 30 sessions of UVB-targeted phototherapy administered twice weekly. The assessment of repigmentation was made from a comparison of baseline photographs with those after 30 sessions by two independent investigators. Morphometric analysis was performed using a computer program.

RESULTS

Repigmentation with an average of 66.25% was obtained on lesions of the face, and of 31.5% on the neck, trunk, and genitalia. On the extremities, there was no repigmentation. Itching, a burning sensation, erythema, desquamation, and transitory hyperpigmentation were observed in some patients. Minimal blistering and ulceration were observed in one patient.

CONCLUSION

Targeted UVB phototherapy seems to be effective for the repigmentation of vitiligo in lesions located on the face, to a lesser degree on the trunk, and with no response in acral lesions; there were minimal adverse effects that did not require discontinuation of treatment.

Treatment of localized persistent plaque psoriasis with incoherent narrowband ultraviolet B phototherapy

PURPOSE

This study evaluated the efficacy of targeted UVB phototherapy treatment of chronic persistent psoratic plaques with localized incoherent UVB phototherapy.

METHODS

Sixteen subjects were enrolled. The final group was composed of eight men and seven women, each having one to seven chronic, stable psoriatic plaques. Each plaque was treated with fluences ranging from 3 to 7 MED using a fibre-coupled incoherent phototherapy device twice weekly for a maximum of 13 sessions. Assessments with a combination of three scores, each on a scale from 0 to 4, for scaling, erythema and induration (SEI score) were performed.

RESULTS

The patients received from 6 to 13 sessions (mean 9.6). The SEI score decreased by 3.3 (p = 0.01). This reduction was equally detected in all subscores. In a few patients, blistering and burning sensation after some sessions were noted.

CONCLUSION

Localized UVB phototherapy is an effective treatment option for persistent plaques of psoriasis. Compared with conventional UVB, localized phototherapy has the added safety benefit of virtually eliminating unwanted exposure of the healthy tissue to UVB.