308 nm excimer laser and lamp phototherapy in vitiligo and new … · 2014-09-28 · 308 nm excimer...
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308 nm Excimer laser and lamp phototherapy
in
Vitiligo and new indications
Klaus Fritz ,MD,PHDDermatology and Laser Centers Landau (D)President European Society of Laser dermatologyAssociat Professor (inv.).University Bukarest(Ro)
Consultant and lecturer at universities Bern(CH) and Osnabrueck (D)Assoc. Visiting Prof. University hospital Tokuda ,Sofia (BG)
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Braod band light sources:Waldmann UV 21 and UV lamp
Excimer Xtrac laser
monochromatic
290–320 nm with peak
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Excimer Laser
X Trac laser“Ultra”
308nm , 30 nsec ,XeClGas :
Spot Size: 4 cm2
FiberopticLaser Delivery:
V Trac lamp
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Excimer laser compared to
broad band light sources
Less erythema,
less hyperpigmentation,
better improvement
with monochromatic laser wavelenght
09.11.2011
Excimer MED Light source MEDSame Joules
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XTRAC Laser Compared to VTRAC Excimer lamp
XTRAC® (Laser) VTRACTM (Lamp)
Wavelength 308nm Same 2nm
Output Pulsed laser Continuous lamp
Minimal Erythema DoseErythema at 18-27% lower dose with VTRAC than
with XTRAC
Psoriasis Expected Tx to get 75-100% clear
6-10 8-13*
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09.11.2011
Skin type 3 : before and after 16 sessions ,
starting 100 mJ – end 700 mJ
Laser assisted therapy of
vitiligo
with and without melanocyte transplantation
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Potent topical steroid
Camouflaging cosmetics
Topical pimecrolimus or tacrolimus
Depigmentation with p-(benzyloxy)phenol (MBEH)
Psoralen with ultraviolet A (PUVA) therapy
Narrowband UVB phototherapy
Skin-grafting
Autologous epidermal suspension applied to laser-abraded lesions
Expanding the autologous cells in tissue culture prior to grafting
Transfer of suction blisters
Guideline for the diagnosis and management of vitiligo.
Br J Dermatol 2008 Nov;159(5):1051-76. 09.11.2011
Vitiligo Therapy according to guide lines
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09.11.2011K. Fritz
Modern therapeutic options include treatment with topical immunomodulators (tacrolimus, pimecrolimus), analogues of vitamin
D3,
excimer laser and surgery/transplantation.
Current state of vitiligo therapy –evidence-based analysis of the literature
Tobias Forschner 1 , Stefan Buchholtz 1 , Eggert Stockfleth 1
Journal der Deutschen Dermatologischen GesellschaftVolume 5 Issue 6, Pages 467 - 475 May 2007
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UV in Vitiligo - Mechanism of action
not completely elucidated
active melanocytes in epidermis are destroyed,
inactive (dopanegative) melanocytes in the outer
root sheaths of hair follicles are not affected.
Repigmentation is initiated by activation,
proliferation and migration of these
UV Increases fibroblast growth factor and
endothelin-1 from keratinocytes
Migration stimulated by increased expression of matrix metalloproteinase-2 activity from melanocytes
Immunosuppressive activity
Klaus FRITZ - Germany
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• UV B 308 nm targets T-cell infiltrates in the epidermis and dermis
• is more effective than UV B 311nm
• Penetrates as deep as PUVA
Nonlesional Skin Psoriatic Plaque
CD3+ T Cells CD3+ T Cells CD8+ T CellsKrueger JG. J Am Acad Dermatol 2002; 46: 1-23.
Novak Z , Bonis B , Kemeny L Xenon chloride ultraviolet B laser is more effective in treating psoriasis and in inducing T cell apoptosis than narrow-band ultraviolet B J Photochem Photobiol B: 2002Biology 67 (2002) 32–38
308 nm Laser
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psoriatic skin after monochromatic excimer light therapy is
Associated with significant T-cell depletion and alterations of
apoptosis-related molecules
Klaus FRITZ - Germany
CD 3 (top) and CD 4 (below) cellsbefore, after 24 + 48 h
Excimer
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psoriatic skin after monochromatic excimer light therapy is
Associated with significant T-cell depletion and alterations of
apoptosis-related molecules
Klaus FRITZ - Germany
Expression of Ki-67before and after
Excimer
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Friedman Vitiligo Protocol
09.11.2011
Starting Dosage
for
Mj / cm2
MED Multiplier
Levels
Periocular 100mj or (1-1)
Face, Scalp, Ear, Neck,
Axilla Bikini
150mj or (2-1)
Arm, Leg, Trunk 200mj or (3-1)
Wrist 250mj or (4-1)
Elbow 300mj or (5-1)
Knee 350mj or (6-1)
Hands, Feet 400mj or (3-2)
Finger, Toes 600mj or (5-2)
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Friedman Tx Protocol for Vitiligo
Protocol
Erythema <24 hour increase by 50mj
Erythema 24-48 hours = This is the “Optimum”
Treatment fluence should be kept at same fluence as previous treatment
Erythema 48-60 hours decrease by 50 mj
Erythema 60-72 hours Treatment should be postponed
09.11.2011 KLaus Fritz
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Excimer in Vitiligo
Sessions are performed 2 - 3 times/week a week for 4 -36 weeks.
Repigmentation faster with 3x/ week
Rate of repigmentation depends on total numbers of sessions
Repigmentation > 75% usually in 15% - 50%
Klaus FRITZ - Germany
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Results of excimer laser and lamp in vitiligo - according to clinical studies -
Score 1 1-25% repigmenation Score 2 26-50% repigmentation
Score 3 51-75% repigmenation Score 3 76-100% repigmentation
Most of the studies use a four score system
to evaluate repigmentation
Klaus FRITZ - Germany
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63 Patients, 2x/week,30 tx,
61.4% achieved >75% Repigmentation, 9.1% 51–75% Repigmentation, 22.7% 26–50% Repigmentation 6.8% 1–25% Repigmentation.
Repigmentation and duration of vitiligo ≤ 2 years : 100.0% >2 years : 46.2% ( P<0.05).
Excimer results
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Repigmentation in korean patients skin type 3 or 4
50% of lesions 51-75% = score 3 ,
12.5% show >75% = score 4
80% of improving lesions are located on the face
best result after
6 months for head and neck
8 months for extremities.
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>75% repigmentation
in
20.7% ( Alotaibi et al )
29 % (Esposito et al)
33 % (Atul et al )
61.4 % (Xiu-Yung et al)
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Complete repigmentation
in
7% ( suhyun et al)
25% (Suhail Hadi et al)
Klaus FRITZ - Germany
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09.11.2011
The result of vitiligo treatment with
308nm Excimer Laser -Face
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09.11.2011
The result of vitiligo treatment with
308nm Excimer Laser - Neck
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09.11.2011
3The result of vitiligo treatment with
308nm Excimer Laser - Trunk
Courtesy Kwang Ho Choi, Seoul, Korea
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09.11.2011 KLaus Fritz
2
The result of vitiligo treatment with
308nm Excimer Laser - Neck
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09.11.2011
2
The result of vitiligo treatment with
308nm Excimer Laser - Trunk
Courtesy Kwang Ho Choi, Seoul, Korea
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Excimer result and skin type
better outcome in patients with
darker skin (type III-VI vs I-II)
Klaus FRITZ - Germany
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09.11.2011
Before After 5 Treatments
After 18 Treatments After 29 TreatmentsCourtesy David Friedman Jerusalem
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09.11.2011Courtesy David Friedman
Jerusalem
Before After 5 Treatments
After 18 TreatmentsAfter 29 Treatments
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Repigmentation responding to
Phototherapy in general and Excimer Laser
Location
Face does best, hands and feet worst
Skin type:
dark skin reacts better than light skin
Plaque size
Small react better than large
Patients history
New spots respond better than old ones
age:
children better than adults
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32 Patients after 30 treatments
09.11.2011 KLaus Fritz
location number More than 50 % More than 75 %
face 24 76 72
Head/neck 5 80 60
Genital 4 75 50
legs 15 60 46
Body
Hand/Foot
5
5
40
20
40
0
James M. Spencer,Robert Nossa
"Treatment of vitiligo with the 308-nm excimer laser: A pilot study JAAD June 2002
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Excimer results and location
Significantly better in UV sensitive areas face, neck, back, breast, and armcompared with UV-resistant areas knees, elbows,wrists, hands, ankles, and feet.
among UV-resistant areas,knees, elbows, and wrists do better thanhands, ankles,and feet.
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09.11.2011
The result of vitiligo treatment with 308nm Excimer Laser – Hands/Forearm
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frequency of treatments /week and results
75% repigmentation (187 patients) in
0% treated every 14 days :
26% treated 2 times/week:
32 % treated 3 times/week:
more frequent treatments show better results.
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Structure of Repigmentation
Similar in both : NB-UVB and excimer laser-treated Groups.
Most frequent repigmentation pattern : perifollicular type,
followed by marginal, diffuse, and combined, in that order.“
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Vitiligo , resistent to tx since 25 years, skin type 2 :
after 32 sessions of Excimer Laser
400 mJ 1x / Week
09.11.2011 KLaus Fritz Laserdermatologie
The result of vitiligo treatment with
308nm Excimer Laser - Trunk
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Skin type 2 : 26 sessions
09.11.2011
The result of vitiligo treatment with
308nm Excimer Laser - Trunk
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- Vitiligo in childhood -
30 patients : 2x/week,100 – 2100 mJ, 7,7 months (Pharos)
56 % improvement > 50 %
12,5 % improvement > 75 %
Best: face,neck trunk
The 308-nm excimer laser:
- a promising device for the treatment of childhood vitiligo -.
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Side effects
Minimal, usually erythema
blisters and pruritus occasionally.
generally well tolerated and side
Klaus FRITZ - Germany
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NB UVB versus Excimer laser 308 nmin vitiligo
15 patients, split body NB vs. Excimer 308 nm , 6 months 2x/week
308-nm Excimer laser more effective in
Vitiligo than NB-UVB
Laser induces repigmentation earlier
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Excimer laser vs Excimer lampin vitiligo
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.
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Relapse in Vitiligolittle data
In 1 out of 9 – however data not reliable because:
Relapse started soon after Excimer therapy was discontinued
Probably no relapse, but stop of treatment in progressive vitiligo
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Combinations in Vitiligo
Hydrocortisone : Recalcitrant vitiligo of the face and
neck may benefit from the combination (84 patients)
in vitiligo:Calcipotriol + UV B no significant effects
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48 vitiligo patients,randomized,
comparing
(group A) 308-nm excimer laser+ topical 1% pimecrolimus cream 2x/day with
(group B) excimer laser therapy 2x/week
after 30 weeks Grade 3or 4 repigmentation achieved
group A 71% of patients
Group B 50% in (p = 0.001).
Combination excimer laser and pimecrolimus : better
AB
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0.1% tacrolimus plus 308-nm excimer laser is superior to 308-nm laser mono (P<.002).
UV sensitive > 75 % Repigmentation
in 77% vs 57 % patients
In UV not sensitive :
Excimer+tacrolimus = in 60 %
Excimer only 0 %
09.11.2011
The efficacy of the 308-nm excimer laser monotherapy in vitiligo also confirmed, for UV-sensitive areas.
Combination excimer laser and tacrolimus : much better
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Kawalek AZ; Spencer JM; Phelps RGCombined excimer laser and topical tacrolimus for the treatment of vitiligo: a pilot study.Dermatologic surgery : official publication for American Society for Dermatologic Surgery (et al.); VOL: 30 (2 Pt 1); p. 130-5 /2004
RESULTS:
20 vitiliginous patches ,6 subjects
50 % of patches 75% repigmentation
compared 20% for the placebo .
Subjects repigmented faster (19%) with combination therapy
09.11.2011
Combination excimer laser and tacrolimus : much better
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Excimer and Khellin
Excimer 308 nm, alone and/or combined with
Khellin 4% offered encouraging results
and it may be considered
Klaus FRITZ - Germany
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Stretch marks
•10 women age 20 –45 Fitzpatrick skintype 1 – 4 hypopigmented Striae
•6 – 9 sessions :100 % showed initial repigmentierung , in 70 %
Repigmentation due to an increase in melanin pigment, hypertrophy of
melanocytes and an increase in melanocytes.
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Halo Nävus
308-nm Excimer laser can treat Halo Nevi,
effectively esp. on the face
21 sessions, 80 % repigmentation, > 400 mJ
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09.11.2011
Scar managment:
1. Ablation of hypertrophic areas with
Er:Yag laser
2. Pulsed dye 2 tx for erythema and antiproliferation
3. Xtrac 306 nm Excimer for repigmentation
18 tx at 300 – 400 mJ
4. Silicone gel
Courtesy KLaus Fritz (D)
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postinflammatory hypopigmentationsafter mollusca contagiosa
09.11.2011
Courtesy KLaus Fritz (D)
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Pretreatment
Post Face Lift Scar
Pre t Post 8 Treatments
50 – 75% improvement in 10 treatments
Friedman PM,Geronemus RG,Use of 308 nm excimer laser for postresurfacing
leucoderma.Arch Derm 2001;137 : 824 -825
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Klaus FRITZ - Germany
melanocyte transplantation +
308 nm Excimer Laser Photherapy
Needs 3 procedures
Isolation
cultivation
application
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Isolation
- ways of grafting .
Punch biopsy grafting
ultra thin skin grafting
Excisions
Suction blisters
Isolation from outer root hairshafts
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5 hairs/ 1 cm ² needed
Our procedure
anagen scalp hair follicles are plucked
fermented and centrifuged in solution
without cultivation onsite
ORS-Mc = outer rootsheath melanocytes;
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Klaus FRITZ - Germany
1. Ablation 2. Autologous ORS epidermal
melanocyte suspension
applied to laser-ablated lesions
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Implantation on receiving site
Punch implants = minimal surgery
complete ablation bei CO2
Suspension of cultured melanocytes
Mesh applied cultured melanocytes
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Klaus FRITZ - Germany
311 nm Excimer laser UV – stimulation
post melanocate transplantation
After re-epithelisation,treated areas of Vililigo were
irradiated with suberythematogenous doses
of 3l1 nm resp 308 nm UVB 2-3 times weekly.
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Klaus FRITZ - Germany
Maintenance: combination therapy
Potent topical steroid
Topical pimecrolimus or tacrolimus
Narrowband UVB phototherapy + excimer laser
(less effective: Psoralen with ultraviolet A (PUVA) therapy )
Psychological interventions
Guideline for the diagnosis and management of vitiligo.BrJ Dermatol 2008 Nov;159(5):1051-76.
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Diseases reported to respond to these treatments
include, but are not limited to, the following:
Phototherapy
a) Psoriasis
b) Eczema
c) Photodermatoses
d) Pruritus
e) Pityriasis rosea
f) Lichen planus
g) Pityriasis lichenoides
h) Acne
i) Parapsoriasis
j) Pruritic eruptions of HIV infection
k) Other
Photochemotherapy
a) Psoriasis
b) Mycosis fungoides
c) Vitiligo
d) Eczema
e) Photodermatoses
f) Lichen planus
g) Pityriasis lichenoides
h) Parapsoriasis
i) Pruritic eruptions of HIV infection
j) Pruritus, other causes
k) Alopecia areata
l) Other
09.11.2011KLaus Fritz Inselspital Bern
Laserdermatologie J AM ACAD DERMATOL 1994;31:643-8
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FDA approval for Eczema
09.11.2011
Reynolds NJ, Franklin V, Gray JC, Diffey BL, Farr PM :
Narrow-band ultraviolet B and broadband ultraviolet A phototherapy in adult atopic eccema: a randomised controlled trial. Lancet (2001) 357, 2012-2016
severe atopic eczema, well tolerated.”
Courtesy KLaus Fritz (D)
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308 nm excimer laser treatment of Chronic Eczema
No improvement after topical corticosteroids
Since 10 years
8 sessions of excimer laser starting with 300 mJ, end 1200 mJ
Cumulative dose 4500 mJ
09.11.2011
Courtesy KLaus Fritz (D)
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Seborrhoic Eczema
4 sessions
200-300-300-300 mJ
Courtesy KLaus Fritz (D)
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09.11.2011
Scrotal eczema
8 sessions , 200 to 600 mJ , cumulative 3200 mJ
Courtesy KLaus Fritz (D)
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Seborrhoic Eczema
Cleared after 3 sessions : 200 –300 –500 mJ
Courtesy KLaus Fritz (D)
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Spezial locationretroauricular
09.11.2011
6 sessions 200 to 800 mJ/session, cumulative 2900 mJ
Courtesy KLaus Fritz (D)
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Lid
09.11.2011
Courtesy Dr Mueller Steinmann
5 times 200 mJ
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Prurigo12 sessions , 300 to 1200 mJ ,cumulative 6 J
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Pruritus renalis undergoing dialysis 4 years
09.11.2011
Courtesy KLaus Fritz (D)
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Severe inflammatory acne
week 8 of pregnancy
09.11.2011
post 3 sessions of Xtrac Excimer Laser 350 mJ/cm2 per session
Courtesy KLaus Fritz (D)
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Severe inflammatory acne
week 8 of pregnancy
post 8 sessions of Xtrac
Excimer Laser 350 mJ/cm2 per session
09.11.2011
Courtesy KLaus Fritz (D)
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Guide lines of the DDG = German Dermatologic Society Acne and subtypes
Hyperceratosis of follicle
• Genetics
1 st line factors
Hyperplasia of sebaceous gland
2 nd line factors
Effect of excimer 308 nm UV
External influence
psyche
Inflammation and immune response
Microbiological factors
Acne
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Fluhr JW, Gloor MThe antimicrobial effect of narrow-band UVB (313 nm) and UVA1 (345-440 nm)
radiation in vitro.
Photodermatol Photoimmunol Photomed 1997 Oct-Dec;13(5-6):197-201.
Two new UV lamps were investigated with respect to their antibacterial
effectiveness in vitro. Propioni (n = 20 strains) and Micrococcaceae (n = 16
strains) bacteria extracted from acne patients were applied to RCM and
sheep blood agar plates and irradiated with a narrow-band UVB lamp (TL
100W/10R) at a wavelength of 313 nm and a UVA1 lamp (TL 01) at a
wavelength of 345-440 nm. The precisely defined energy levels were, in the
case of narrow-band UVB, 0.00, 0.30, 0.50, 1.00, 2.00 and 3.00 J/cm2 and,
in the case of UVA1, 0.00, 2.50, 5.00, 7.50, 10.00 and 20.00 J/cm2. UVA1
inhibited neither the growth of Propioni nor Micrococcaceae bacteria. In
contrast, the growth of Micrococcaceae was inhibited already at a dosage
of 0.30 J/cm2 of narrow-band UVB (P < 0.05), highly significant from 0.50
J/cm2 (P < 0.01) and to a maximum of 2.2 powers of 10 at 3.00 J/cm2
compared with non-radiated control plates. Propioni bacteria were
significantly inhibited at the minimum dosage of 0.30 J/cm2 of narrow-band
UVB (P < 0.01) and to a maximum of 2.8 powers of 10 at 3.00 J/cm2.
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inflammatory acne
09.11.2011
Pre tx post 5 sessions 200 –300 mJ
Courtesy KLaus Fritz (D)
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09.11.2011
Courtesy KLaus Fritz (D)
inflammatory acne
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inflammatory acne
Courtesy KLaus Fritz (D)
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Pre post 3 tx 400/500/600 mJ
Courtesy Dr Mueller Steinmann
Rosacea papulosa
„ off label use“
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Perioral dermatitis.
09.11.2011
„ off label use“
Pre post 4 tx 200/300/300/300 mJ 308 nm eximer laser 2 weeks
Courtesy Dr Mueller Steinmann
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09.11.2011 Courtesy KLaus Fritz
3 Sessions at 200 – 300 mJ
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Folliculitis sclerotisans nuchae
09.11.2011
Pre post 7 tx 300 - 800 mJ 308 nm eximer laser 2.5 weeks
Before resistant to various therapeutic approaches
Courtesy KLaus Fritz
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Folliculitis capitis
09.11.2011
Pre post 3 tx 400/500/600 mJ 308 nm eximer laser 2 weeks
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09.11.2011
308 nm EXCIMER LASER 12 sessions of 200 – 800 mJ
Lichen ruber planus
Courtesy KLaus Fritz
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09.11.2011
Lichen ruber planus
308 nm EXCIMER LASER 12 sessions of 200 – 800 mJ
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Alopecia areata
09.11.2011
Post 12 tx with 500 mJ/session
excimer laser 1x/week
Courtesy KLaus Fritz
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... regrowth in „ trichoscan fotofinder“
09.11.2011
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09.11.2011
Post 26 tx with 350 -800mJ/session
excimer laser 2x / week
Alopecia areata
Courtesy KLaus Fritz
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Fast relief from pruritus
308 EXCIMER SYSTEM
Wollenschläger I, Ockenfels HM: Targeted UVB-308 therapy with excimer laser in the treatment of atopic dermatitis and other inflammatory dermatoses
Hautarzt 2009, 60 (11): 898 -906
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CASE 03
Dyshidrotic dermatitis: 500mJ/cm2
Before 48 hrs after 7 days after inductionstart maintenance
Photographs: Dr. Gröne, Germany
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15.06.2009 21.09.2009 24.09.2009 01.10.2009
CASE 04
Lichen simplex chronicus: 400 mJ/cm2
Photographs: Dr. Gröne, Germany
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Morbus Grover: < 800 mJ/cm2
Before 48 hrs after 7 days after inductionstart maintenance
Photographs: Dr. Gröne, Germany
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REM = reticular erythematous mucinosis
Case report : 73 J, 100 -500 mJ , 1x/week, - 1 month
improvement, 3 months clearing
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Lymphomatoid Papulosis
308-nm excimer laser can be considered
3x/week,14 sessions,up to 450 mJ
09.11.2011
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Mycosis Fungoides
10 lesions / 5 patients , up to a maximum of 10 applications
cumulative dose 600 – 1500 mJ
09.11.2011
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Summary
308nm Excimer laser
provides an effective and safe UVB therapy
Combination therapies improve
results and reduce dosage of UV B and systemic medication
Excimer laser therapy will be applied to
an increasing number of dermatoses that respond to phototherapy or photochemotherapy
09.11.2011
Thank You
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Klaus FRITZ - Germany