Lasers in Surgery and Medicine 46:443–448 (2014)
Fractional Laser for Vitiligo Treated by 10 600 nm Ablative Fractional Carbon Dioxide Laser Followed by Sun Exposure J. HElou, I. Maatouk, G. Obeid, R. Moutran, F. StEphan, and R. Tomb Department of Dermatology, Hoˆtel-Dieu de France, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
Background: Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo. Objective: To investigate the effects of fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV). Methods: Ten patients presenting refractory NSV were enrolled in this study. The patients underwent three sessions, one month apart, of fractional CO2 laser therapy on the affected areas of the skin (L-group). Five days after each laser treatment, patients were asked to expose themselves to the sun for 2 hours on a daily basis. Objective and subjective clinical assessments were performed at the beginning and at the end of the treatment. The L-group was then compared to a control group (C-group) that consisted of vitiligo lesions in the same patients but with sun exposure as the exclusive therapy. Results: Compared to the C-group, the L-group showed better improvement in both objective and subjective assessments. There were no noticeable adverse events in terms of scarring and Koebner phenomenon among others. Conclusions: All patients treated with both, laser sessions and sun exposure, improved their chronic NSV lesions. Improvement was less significant in patients who exhibited vitiligo lesions over articular surfaces such as elbows and underarms. The best results were observed in vitiligo plaques located on the face, neck and legs. Consequently, fractional CO2 laser followed by sun exposure could be considered as an alternative modality for the treatment of refractory vitiligo, especially in sunny regions. Lasers Surg. Med. 46:443–448, 2014. ß 2014 Wiley Periodicals, Inc.
mented macules and patches that occur secondary to selective destruction of melanocytes [5,6]. Vitiligo may appear at any age with a prevalence of approximately 0.5–1% of the general population, where 50% of the patients are affected before 20 years of age. The risk of developing the disease is independent of skin type, race, or sex [5–9]. Many patients with vitiligo have a resistant disease despite numerous conventional and novel treatments such as Excimer laser, dermabrasion, etc [10]. Thus, new therapeutic approaches are required. The clinical benefits of Erbium-YAG (Er:YAG) laser, commonly proposed for skin resurfacing, has been reported in the literature. However, resurfacing lasers (either Er:YAG or CO2) incurs long-term wounds. Fractionated lasers represent a new modality for skin resurfacing based on the theory of fractional photothermolysis introduced by Manstein et al. [11]. These lasers were shown to be efficient in treating facial photoaging changes as well as scars, and have an improved safety and recovery profile compared with traditional CO2 laser resurfacing [12,13]. Fractionated lasers do not ablate the entire epidermis and thereafter leave intact skin between coagulated necrotic columns. This characteristic facilitates the skin healing process. To the best of our knowledge, only one trial has been conducted using ablative fractional CO2 laser for the treatment of vitiligo followed by UVB phototherapy [14]. Sun exposure is a convenient alternative in sunny countries and might spare patients frequent visits to hospitals. In this article, we investigated the effects of the fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV). Ten adult patients with NSV were enrolled in this study. All patients had refractory lesions with no improvement despite more than one year of conventional treatments which included NB-UVB phototherapy, topical steroids
Key words: laser CO2; fractional; vitiligo; depigmentation; non-segmental; carbon dioxide; laser
BACKGROUND Vitiligo affects all races and has been recognized for centuries due to its clearly visible phenotype [1–4]. It is an acquired disorder of the skin and mucous membranes characterized by well circumscribed depigß 2014 Wiley Periodicals, Inc.
Correspondence to: I. Maatouk, Department of Dermatology, Hoˆtel-Dieu de France, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon. E-mail: [email protected] Accepted 12 May 2014 Published online 30 May 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22260
HELOU ET AL.
444
and calcineurin inhibitors. All patients remained stable within the preceding year. The medical history in relation to keloids was collected for our patients and all were made aware of the associated risks. Three sessions of fractional CO2 laser therapy using a ten 600 nm fractional CO2 laser (FX_Lumenis, Inc., Santa Clara, CA), 1 month apart between June 2012 and October 2012, were performed on vitiligo lesions. The treatment settings were pulse energy of 100 mJ, frequency 125 Hz, one pass, spot size 6 for the first session then adjusted upon the lesion size, density 3. Cooling was not used. There was no pre-medication except for antiviral treatment (Valacyclovir 500 mg twice daily for 5 days). During the first 5 days following the laser session, patients were asked to avoid hot water over the treated area and to use “Thermal Water” instead. At the end of the 5-day period, they were asked to have a sun exposure for 2 hours daily (between 3 and 6 PM) on the lesions. The non-affected skin was protected with sunscreen. Vitiligo lesions treated with laser followed by sun exposure were called “Lasergroup” (L-group). Photographs were obtained before any treatment, as a baseline measure, and then 2 months after the final laser session. Clinical assessments are categorized as either “Objective” or “Subjective.” Objective clinical assessments were made by one blinded dermatologist using photos of the patients at baseline and at the end of the treatment. Each patient had 2 photos. Depending on the extent of repigmentation, the response to the treatment was graded as: no or minimal (
Fractional Laser for Vitiligo Treated by 10 600 nm Ablative Fractional Carbon Dioxide Laser Followed by Sun Exposure J. HElou, I. Maatouk, G. Obeid, R. Moutran, F. StEphan, and R. Tomb Department of Dermatology, Hoˆtel-Dieu de France, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
Background: Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo. Objective: To investigate the effects of fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV). Methods: Ten patients presenting refractory NSV were enrolled in this study. The patients underwent three sessions, one month apart, of fractional CO2 laser therapy on the affected areas of the skin (L-group). Five days after each laser treatment, patients were asked to expose themselves to the sun for 2 hours on a daily basis. Objective and subjective clinical assessments were performed at the beginning and at the end of the treatment. The L-group was then compared to a control group (C-group) that consisted of vitiligo lesions in the same patients but with sun exposure as the exclusive therapy. Results: Compared to the C-group, the L-group showed better improvement in both objective and subjective assessments. There were no noticeable adverse events in terms of scarring and Koebner phenomenon among others. Conclusions: All patients treated with both, laser sessions and sun exposure, improved their chronic NSV lesions. Improvement was less significant in patients who exhibited vitiligo lesions over articular surfaces such as elbows and underarms. The best results were observed in vitiligo plaques located on the face, neck and legs. Consequently, fractional CO2 laser followed by sun exposure could be considered as an alternative modality for the treatment of refractory vitiligo, especially in sunny regions. Lasers Surg. Med. 46:443–448, 2014. ß 2014 Wiley Periodicals, Inc.
mented macules and patches that occur secondary to selective destruction of melanocytes [5,6]. Vitiligo may appear at any age with a prevalence of approximately 0.5–1% of the general population, where 50% of the patients are affected before 20 years of age. The risk of developing the disease is independent of skin type, race, or sex [5–9]. Many patients with vitiligo have a resistant disease despite numerous conventional and novel treatments such as Excimer laser, dermabrasion, etc [10]. Thus, new therapeutic approaches are required. The clinical benefits of Erbium-YAG (Er:YAG) laser, commonly proposed for skin resurfacing, has been reported in the literature. However, resurfacing lasers (either Er:YAG or CO2) incurs long-term wounds. Fractionated lasers represent a new modality for skin resurfacing based on the theory of fractional photothermolysis introduced by Manstein et al. [11]. These lasers were shown to be efficient in treating facial photoaging changes as well as scars, and have an improved safety and recovery profile compared with traditional CO2 laser resurfacing [12,13]. Fractionated lasers do not ablate the entire epidermis and thereafter leave intact skin between coagulated necrotic columns. This characteristic facilitates the skin healing process. To the best of our knowledge, only one trial has been conducted using ablative fractional CO2 laser for the treatment of vitiligo followed by UVB phototherapy [14]. Sun exposure is a convenient alternative in sunny countries and might spare patients frequent visits to hospitals. In this article, we investigated the effects of the fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV). Ten adult patients with NSV were enrolled in this study. All patients had refractory lesions with no improvement despite more than one year of conventional treatments which included NB-UVB phototherapy, topical steroids
Key words: laser CO2; fractional; vitiligo; depigmentation; non-segmental; carbon dioxide; laser
BACKGROUND Vitiligo affects all races and has been recognized for centuries due to its clearly visible phenotype [1–4]. It is an acquired disorder of the skin and mucous membranes characterized by well circumscribed depigß 2014 Wiley Periodicals, Inc.
Correspondence to: I. Maatouk, Department of Dermatology, Hoˆtel-Dieu de France, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon. E-mail: [email protected] Accepted 12 May 2014 Published online 30 May 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22260
HELOU ET AL.
444
and calcineurin inhibitors. All patients remained stable within the preceding year. The medical history in relation to keloids was collected for our patients and all were made aware of the associated risks. Three sessions of fractional CO2 laser therapy using a ten 600 nm fractional CO2 laser (FX_Lumenis, Inc., Santa Clara, CA), 1 month apart between June 2012 and October 2012, were performed on vitiligo lesions. The treatment settings were pulse energy of 100 mJ, frequency 125 Hz, one pass, spot size 6 for the first session then adjusted upon the lesion size, density 3. Cooling was not used. There was no pre-medication except for antiviral treatment (Valacyclovir 500 mg twice daily for 5 days). During the first 5 days following the laser session, patients were asked to avoid hot water over the treated area and to use “Thermal Water” instead. At the end of the 5-day period, they were asked to have a sun exposure for 2 hours daily (between 3 and 6 PM) on the lesions. The non-affected skin was protected with sunscreen. Vitiligo lesions treated with laser followed by sun exposure were called “Lasergroup” (L-group). Photographs were obtained before any treatment, as a baseline measure, and then 2 months after the final laser session. Clinical assessments are categorized as either “Objective” or “Subjective.” Objective clinical assessments were made by one blinded dermatologist using photos of the patients at baseline and at the end of the treatment. Each patient had 2 photos. Depending on the extent of repigmentation, the response to the treatment was graded as: no or minimal (
