Pulse-Dye Laser Followed by Betamethasone-Calcipotriol and Fractional Ablative CO2-Laser-Assisted Delivery for Nail Psoriasis

Lasers for the treatment of nail psoriasis: a systematic review

This systematic review assesses the evidence concerning laser treatments for nail psoriasis (NP), a prevalent condition among individuals with cutaneous psoriasis that notably affects their quality of life. Traditional treatments have limitations in terms of drug delivery and poor patient adherence, leading to interest in laser therapies for their targeted approach, extended treatment intervals, and the potential to enhance topical medication effectiveness. The MEDLINE, Embase, Web of Science, and Cochrane Library databases were searched. English-language randomized and non-randomized controlled trials with full-text availability were included. Data on the laser type, treatment protocol, Nail Psoriasis Severity Index (NAPSI) outcomes, and adverse events were extracted, and nail bed and matrix features and patient satisfaction were assessed. The primary effect measure was a percentage reduction in NAPSI scores from baseline. Nineteen studies involving the pulse dye laser (PDL), long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser and fractional carbon dioxide laser (FCL) were identified. Lasers, particularly those used in conjunction with topical agents, have shown favorable results. PDL effectively lowered NAPSI scores, and the Nd:YAG laser had comparable effectiveness but more discomfort. FCL also shows promise, particularly for topical drug delivery. PDL and Nd:YAG laser treatment were more effective at reducing nail bed features, whereas FCL was effective at reducing both nail bed and matrix features. Overall, lasers are promising treatment alternatives for NP, with similar NAPSI outcomes to topical therapies and intralesional injections.

Laser microporation facilitates topical drug delivery: a comprehensive review about preclinical development and clinical application

INTRODUCTION

Topical drug delivery is highly attractive and yet faces tissue barrier challenges. Different physical and chemical methods have been explored to facilitate topical drug delivery.

AREAS COVERED

Ablative fractional laser (AFL) has been widely explored by the scientific community and dermatologists to facilitate topical drug delivery since its advent less than two decades ago. This review introduces the major efforts in exploration of AFL to facilitate transdermal, transungual, and transocular drug delivery in preclinical and clinical settings.

EXPERT OPINION

Most of the preclinical and clinical studies find AFL to be safe and highly effective to facilitate topical drug delivery with little restriction on physicochemical properties of drugs. Clinical studies support AFL to enhance drug efficacy, shorten treatment time, reduce pain, improve cosmetic outcomes, reduce systemic drug exposure, and improve safety. Considering most of the clinical trials so far involved a small sample size and were in early phase, future trials will benefit from enrolling a large group of patients for thorough evaluation of the safety and efficacy of AFL-assisted topical drug delivery. The manufacturing of small and less costly AFL devices will also facilitate the translation of AFL-assisted topical drug delivery.

Laser-Assisted Drug Delivery: A Systematic Review of Safety and Adverse Events

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.

Investigating the efficacy and safety of calcipotriol/betamethasone dipropionate foam and laser microporation for psoriatic nail disease-A hybrid trial using a smartphone application, optical coherence tomography, and patient-reported outcome measures

There is a lack of efficacious topical treatments for patients suffering from psoriatic nail disease (PND). We investigated the efficacy of Calcipotriol-Betamethasone Dipropionate (Cal/BD) foam with and without ablative fractional laser (AFL) in patients with PND. A total of 144 nails from 11 patients were treated in a 24-week long, open-label, randomized, intra-patient controlled proof-of-concept hybrid trial. In addition to daily Cal/BD foam application, half of each patient's psoriatic nails were randomized to receive optical coherence tomography (OCT)-guided AFL treatment at baseline, 6-, and 12-week follow-ups. In-clinic assessment (N-NAIL), patient-reported outcomes (PROMs), and drug consumption were supplemented by remote evaluation of 15 subclinical OCT features, smartphone app-based safety monitoring, and photo-based assessment (NAPSI). After 24 weeks of Cal/BD foam treatment, patients achieved a significant improvement (p < 0.001) in both clinical (N-NAIL -76%, NAPSI -68%) and subclinical (OCT -43%) PND severity as well as a 71% reduction in PROMs. AFL-assisted Cal/BD treatment led to higher clinical (N-NAIL -85%, NAPSI -78%) and OCT-assessed (-46%) reduction of PND signs than Cal/BD alone (N-NAIL -66%, NAPSI -58%, OCT -37%), but did not reach statistical significance. Smartphone app images documented adverse events and mild local skin reactions, particularly erythema (75%), laser-induced swelling (28%), and crusting (27%). This hybrid trial demonstrated a reduction in clinical NAPSI and N-NAIL scores, subclinical OCT features, and PROMs, suggesting that Cal/BD foam is a safe and efficacious treatment for PND. Larger trials are warranted to prove the clinical benefit of AFL pretreatment as a Cal/BD delivery enhancer.

S2k guideline: Laser therapy of the skin

This guideline aims to improve the efficiency and safety of lasers and optical radiation sources with similar effects (especially IPL). Laser therapy of skin lesions with an increased amount of melanocytes should be performed with caution. Laser treatment of pigmented melanocytic nevi is not recommended. The guideline contains recommendations regarding the treatment of lentigines and café-au-lait spots, non-pigmented dermal nevi, Becker nevus, nevus of Ota/Hori/Ito and melasma. Further recommendations focus on the treatment of skin lesions without an increased amount of melanocytes (ephelides, postinflammatory hyperpigmentation including berloque dermatitis, seborrheic keratoses, traumatic/decorative tattoos and metallic deposits), hypopigmentation (vitiligo), benign non-pigmented neoplasms (fibrous papule of the nose, nevus sebaceus, epidermal nevus, neurofibroma, sebaceous gland hyperplasia, syringoma, xanthelasma palpebrarum), inflammatory dermatoses (acne papulopustulosa/conglobata, acne inversa, granuloma faciale, lichen sclerosus, lupus erythematosus, psoriasis vulgaris, rosacea, rhinophyma), wrinkles/dermatochalasis/striae, hypertrichosis, scars (atrophic, hypertrophic; keloids, burn/scald scars), laser-assisted skin healing, onychomycosis, precancerous lesions and malignant tumors (actinic keratoses/field cancerization, cheilitis actinica, basal cell carcinoma), vascular skin lesions (angiokeratoma, angioma, hemangioma, malformation, spider veins, granuloma telangiectaticum (pyogenic granuloma), rubeosis (erythrosis interfollicularis colli, ulerythema ophryogenes), nevus flammeus, telangiectasias and Osler's disease (hereditary hemorrhagic telangiectasia) and viral skin lesions (condylomata acuminata, mollusca contagiosa, verrucae planae juveniles/vulgares/ verrucae palmares et plantares).

Vergleich der fraktionierten laserunterstützten Medikamentengabe und der intraläsionalen Injektion von Triamcinolonacetonid bei Nagelpsoriasis

HINTERGRUND UND ZIELE

Die Behandlung der Nagelpsoriasis ist wegen mangelnder Penetration topischer Therapeutika durch die Nagelplatte häufig unbefriedigend. Daher sind innovative Methoden zur adäquaten Verabreichung des Arzneimittels in den Nagel erforderlich. In dieser Studie vergleichen wir die Wirksamkeit der intraläsionalen Corticosteroid-Injektion mit topischer Applikation nach fraktionierter CO₂ -Laser-Behandlung bei Fingernagelpsoriasis.

PATIENTEN UND METHODEN

In der Studie wurden 36 Patienten mit Fingernagelpsoriasis in zwei Gruppen eingeteilt. Bei Gruppe A wurden die Nägel mit intraläsionalen Injektionen von Triamcinolon behandelt, in Gruppe B durch fraktionierte CO₂ -Lasertherapie, gefolgt von topischer Applikation des Arzneimittels in sechs Sitzungen. Die Beurteilung erfolgte anhand des NAPSI und eines dermatoskopischen Scores.

ERGEBNISSE

Beide Modalitäten führten zu signifikanter Besserung der Psoriasis an Nagelmatrix und Nagelbett. Statistisch signifikante Unterschiede zwischen den Gruppen bestanden weder klinisch noch dermatoskopisch. Die Laserbehandlung war mit signifikant geringeren Schmerz-Scores (P = 0,03) und höherer Patientenzufriedenheit (P = 0,007) verbunden.

SCHLUSSFOLGERUNGEN

Die fraktionierte CO₂ -Laser-unterstützte Applikation topischer Steroide könnte eine effektive und gut verträgliche Therapie der Nagelpsoriasis sein, die eine der intraläsionalen Injektion vergleichbare Wirksamkeit hat.

Comparison of fractional laser-assisted drug delivery and intralesional injection of triamcinolone acetonide in nail psoriasis

BACKGROUND AND OBJECTIVES

The treatment of nail psoriasis is often unsatisfactory due to poor penetration of topical therapeutics through the nail plate. The development of innovative methods that provide adequate delivery of the drug into the nail is warranted. In this study, we aim to compare the efficacy of intralesional corticosteroid injection versus its topical application after fractional CO₂ laser in the treatment of fingernail psoriasis.

PATIENTS AND METHODS

The study included 36 patients with fingernail psoriasis divided into two groups. The nails in group A were treated with intralesional injection of triamcinolone acetonide while the nails in group B received fractional CO₂ laser therapy followed by topical application of the drug for six sessions. The evaluation was performed using NAPSI and dermatoscopic scores.

RESULTS

Both modalities yielded a significant improvement of the nail matrix and bed psoriatic signs. No statistically significant difference was found between the two groups by both clinical and dermatoscopic assessment. The laser treatment was associated with significantly lower pain scores (P = 0.03) and higher patient satisfaction (P = 0.007).

CONCLUSIONS

Fractional CO₂ laser-assisted delivery of topical corticosteroids can be a potentially effective and well-tolerated therapeutic modality in the treatment of nail psoriasis with comparable efficacy to intralesional injection.

Fractional CO2 Laser-Assisted Delivery Versus Intralesional Injection of Methotrexate in Psoriatic Nails

BACKGROUND

Nail psoriasis has a major negative impact on physical and psychological aspects of the patient's life. Treatment is often unsatisfactory because of difficult penetration of the drug into the nail.

OBJECTIVE

To evaluate and compare the efficacy of laser-assisted delivery of methotrexate versus its intralesional injection in fingernail psoriasis.

MATERIALS AND METHODS

Twenty-eight patients with fingernail psoriasis were divided into 2 groups of 14 patients each. Group A was treated with intralesional injection of methotrexate while Group B received fractional CO2 laser followed by topical application of methotrexate. The treatment was given at a 2-week interval for 6 sessions. The improvement of nail psoriasis was assessed by clinical and dermoscopic evaluation.

RESULTS

At the end of treatment, both laser-assisted delivery and intralesional injection of methotrexate were associated with statistically significant improvement of psoriatic signs. No statistically significant difference was found between the 2 groups regarding total nail psoriasis severity Index (p = .18), matrix score (p = .38), bed score (p = .23), and dermoscopic score (p = .78). However, the pain and subungual hematoma were significantly less in the laser group (p < .001 and p = .03, respectively).

CONCLUSION

Fractional CO2 laser-assisted delivery of methotrexate can be an effective and well-tolerated alternative to intralesional injection in nail psoriasis.

Fractional CO2 laser ablation leads to enhanced permeation of a fluorescent dye in healthy and mycotic nails-An imaging investigation of laser-tissue effects and their impact on ungual drug delivery

Purpose

Conventional oral antifungal therapies for onychomycosis (OM) often do not achieve complete cure and may be associated with adverse effects, medical interactions, and compliance issues restricting their use in a large group of patients. Topical treatment can bypass the systemic side effects but is limited by the physical barrier of the nail plate. Ablative fractional laser (AFL) treatment can be used to improve the penetration of topical drugs into the nail. This study visualized the effects of laser ablation of nail tissue and assessed their impact on the biodistribution of a fluorescent dye in healthy and fungal nail tissue.

Methods

For the qualitative assessment of CO₂ AFL effects on healthy nail tissue, scanning electron microscopy (SEM), coherent anti‐Stokes Raman scattering microscopy (CARS‐M), and widefield fluorescence microscopy (WFM) were used. To quantitate the effect of laser‐pretreatment on the delivery of a fluorescent dye, ATTO‐647N, into healthy and fungal nail tissue, ablation depth, nail plate thickness, and ATTO‐647N fluorescence intensity in three nail plate layers were measured using WFM. A total of 30 nail clippings (healthy n = 18, fungal n = 12) were collected. An aqueous ATTO‐647N solution was directly applied to the dorsal surface of 24 nail samples (healthy n = 12, fungal n = 12) and incubated for 4 hours, of which half (healthy n = 6, fungal n = 6) had been pretreated with AFL (30 mJ/mb, 15% density, 300 Hz, pulse duration <1 ms).

Results

Imaging revealed a three‐layered nail structure, an AFL‐induced porous ablation crater, and changes in autofluorescence. While intact fungal samples showed a 106% higher ATTO‐647N signal intensity than healthy controls, microporation led to a significantly increased fluorophore permeation in all samples (p < 0.0001). AFL processing of nail tissue enhanced topical delivery of ATTO‐647N in all layers, (average increase: healthy +108%, fungal +33%), most pronounced in the top nail layer (healthy +122%, fungal +68%). While proportionally deeper ablation craters correlated moderately with higher fluorescence intensities in healthy nail tissue, fungal samples showed no significant relationship.

Conclusion

Fractional CO₂ laser microporation is a simple way of enhancing the passive delivery of topically applied ATTO‐647N. Although the impaired nail plate barrier in OM leads to greater diffusion of the aqueous solution, AFL can increase the permeability of both structurally deficient and intact nails.

Efficacy of combined fractional carbon dioxide laser and topical tazarotene in nail psoriasis treatment: A randomized intrapatient left-to-right study

BACKGROUND

Treatment of nail psoriasis is disappointing; due to poor penetrability of topical therapies and variable efficacy of systemic therapies. Fractional carbon dioxide laser (FCL) may enhance penetration of topical therapy for nail psoriasis.

OBJECTIVE

To evaluate the efficacy and safety of FCL plus topical tazarotene versus tazarotene monotherapy in the treatment of nail psoriasis.

METHODS

Twenty-seven patients with bilateral fingernail psoriasis randomly received 3 sessions of FCL at four-week interval plus once-daily tazarotene 0.1% gel for one hand, and once-daily tazarotene 0.1% gel only for 3 months on the other hand. The primary outcome was modified Nail Psoriasis Severity Index (mNAPSI) at 3 and 6 months compared to baseline, and the secondary outcomes included dermoscopic examination and patient global assessment. Adverse events were reported.

RESULTS

The total, nail matrix, and nail bed mNAPSI scores were significantly improved at 3 and 6 months by both regimens, but they decreased more after FCL/tazarotene combination (p = 0.001, p = 0.023, and p = 0.001, respectively). Combination therapy showed faster improvement of nail matrix signs and greater efficacy for nail bed signs. The dermoscopic features of the nail plate were the most responsive after both treatments. The combined therapy was more effective in improving the dermoscopic nail bed features. Patient's global assessment scores were significantly higher after the combined therapy. Both treatments were well tolerated.

CONCLUSION

Fractional CO₂  laser is an effective and well-tolerated treatment for nail psoriasis; it improves the outcomes of topical tazarotene especially in nail bed lesions.