New approach in the treatment of refractory vitiligo: CO2 laser combined with betamethasone and salicylic acid solution

Efficacy and safety of fractional CO2 laser combined with 308 nm excimer laser in non-segmental vitiligo: a meta-analysis with trial sequential analysis

OBJECTS

The study aimed to assess the effectiveness and safety of fractional CO2 laser and 308 nm excimer laser in non-segmental vitiligo.

MATERIALS AND METHODS

We carried out a systematic literature search in databases: Embase, Web of Science, PubMed, Wanfang and CNKI. Randomized controlled trials (RCTs) comparing the combined treatment of fractional CO2 and 308 nm excimer lasers with other treatments for non-segmental vitiligo were included. The primary outcomes were re-pigmentation rate and side effects.

RESULTS

Twelve RCTs involving a total of 1,064 patients were included. Our results showed significantly higher rates of excellent response (≥75% re-pigmentation) (RR = 1.53, 95%CI: 1.31, 1.78; p < .001) and good response (50-75% re-pigmentation) (RR = 1.14, 95%CI: 1.03, 1.26; p = .015) in combined treatment group than the control group. A subgroup analysis considering control treatment suggested that, the combination treatment yielded a superior rate of excellent response when compared to either fractional CO2 laser or 308 nm excimer laser. It also demonstrated a superior rate of good response compared to the fractional CO2 laser, while showing a comparable effect to 308 nm excimer laser alone. Regarding safety, the adverse event rates were comparable between the two groups (RR = 0.67, 95%CI: 0.43, 1.07; p = .093). Meta-regression analysis indicated that none of these potential factors (mean age, gender, disease onset and vitiligo subtype) had any significant effect on excellent response rate. Results of trial sequential analysis (TSA) for excellent response rate suggested that current conclusions regarding combination treatment are adequate, and additional explorations are unlikely to alter the conclusion.

CONCLUSION

Our results suggested that, the combined treatment of fractional CO2 and 308 nm excimer lasers seems to be an effective and well-tolerated modality for non-segmental vitiligo. It significantly improves the re-pigmentation rate without posing serious side effects. More high-quality, large-scale RCTs are warranted to further validate these results and explore the long-term efficacy and safety of this treatment approach.

Triple combination of fractional carbon dioxide laser, 308-nm excimer lamp, and platelet-rich plasma in refractory vitiligo: A randomized split-body comparative study

Objectives

Vitiligo significantly impacts patients' quality of life. Current evidence indicates that combination therapy results in faster improvement, enhancing patient adherence to treatment and leading to higher satisfaction among patients. In this study, we compare the efficacy of combined fractional carbon dioxide (FCO2) laser and excimer lamp with platelet-rich plasma (PRP) or topical tacrolimus in patients with refractory vitiligo.

Material and Methods

This is a prospective, single-blind, randomized split-body clinical trial involving 41 patients with resistant focal patches of vitiligo vulgaris. Each patient had two similar lesions randomly assigned to receive either a combination of FCO2 laser, excimer lamp, and intradermal PRP injections or a combination of FCO2 laser, excimer lamp, and topical 0.1% tacrolimus (applied twice daily for 12 weeks). The FCO2 laser and PRP treatments were administered in three monthly sessions, and the excimer lamp was used twice a week over 12 weeks. The efficacy of treatment was assessed based on the physician's assessment and patient's satisfaction.

Results

Despite significant improvement in both treatment groups during the course of treatment, the PRP group showed significantly superior efficacy (more than 50% improvement) compared to the tacrolimus group (56.1% and 26.8%, respectively). Furthermore, the PRP group exhibited greater improvement in resistant acral areas compared to the tacrolimus group (51.2% and 19.5%, respectively).

Conclusion

The combination of FCO2, an excimer lamp, and PRP demonstrates superior efficacy, particularly in resistant acral areas. As a result, this combination can be recommended in difficult-to-treat areas in patients with vitiligo.

Fractional CO2 Laser Versus Microneedling Combined with Narrowband Ultraviolet and Topical Steroid for Treating Non-Segmental Vitiligo in Treatment-Resistant Localizations: A Comparative Randomized Clinical Trial Study

Introduction: Vitiligo poses a significant challenge, particularly in treatment-resistant areas such as acral regions. This study aimed to evaluate the effectiveness and safety of combining fractional CO2 laser and microneedling with conventional therapies for non-segmental vitiligo in resistant areas. Methods: A randomized clinical trial with a paired design was conducted on 84 individuals with non-segmental vitiligo and treatment-resistant lesions. Participants in two separate groups received various combinations of interventions, including narrowband ultraviolet B (NB-UVB) and topical steroid (Clobetasol ointment) as conventional treatments, with fractional CO2 laser or microneedling as add-ons for four symmetrical treatment-resistant lesions. The treatment duration was 16 weeks, followed by observation until six months post-intervention for each patient, and it focused on assessing the percentage of repigmentation, safety, patient satisfaction, and potential adverse effects. Results: The results of the study revealed a significant difference in average efficacy, with treatments involving fractional CO2 laser and microneedling compared with other interventions without them showing a higher percentage of repigmentation. No notable distinction in repigmentation patterns was observed, except for slightly higher marginal repigmentation with microneedling. Side effects, including pain, burning sensation, and erythema, were more frequent, with no significant difference between the groups. Itching and crusting had a significant difference in the two groups. Patient satisfaction levels were comparable, with the first group slightly more than the second. Conclusion: In conclusion, combining NB-UVB and topical steroid therapies with the fractional CO2 laser or microneedling seems to be effective for vitiligo treatment in resistant areas. Attention to variations in patients' characteristics and specific body locations is necessary when applying these modalities. This study provides valuable insights into novel approaches for managing vitiligo and highlights the potential benefits of these innovative treatments in combination with conventional therapy.

Clinical efficacy of CO2 fractional laser combined with compound betamethasone in treating vitiligo and its impact on inflammatory factors

Objective

To analyze the clinical efficacy of CO2 fractional laser combined with compound betamethasone in treating vitiligo and its impact on inflammatory factors.

Methods

The clinical treatment effects, levels of inflammatory factors [interleukin-17 (IL-17), interferon-gamma (IFN-γ), interleukin-10 (IL-10)], prognosis regarding repigmentation and relapse, psychological health (satisfaction).

Results

① Clinical treatment effects: the total effective rate in Group A was 92.73%, Group B was 74.55%, and Group C was 67.27%, with Group A showing significantly higher effectiveness than Groups B and C (p < 0.05). ② Inflammatory factors: prior to treatment, there was no significant difference in IL-17, IFN-γ, and IL-10 levels among the three groups (p > 0.05); after 3 and 6 months of treatment, the levels of IL-17 and IFN-γ decreased significantly while IL-10 levels increased significantly across all three groups, with Group A showing a more pronounced change compared to Groups B and C (p < 0.05). ③ Prognosis regarding repigmentation and relapse: after 3 and 6 months of treatment, Group A exhibited significantly higher repigmentation rates compared to Groups B and C (p < 0.05); in terms of relapse, Group A had a relapse rate of 5.45%, Group B had 21.82%, and Group C had 23.64%, with Group A showing significantly lower relapse rates compared to Groups B and C (p < 0.05). ④ Quality of life and psychological health: at the end of the 6 month follow-up, the quality of life and psychological health of patients in Group A were significantly higher than those in Groups B and C (p < 0.05). ⑤ Occurrence of adverse reactions: the incidence of adverse reactions was 12.73% in Group A, 10.91% in Group B, and 9.09% in Group C, with no significant difference observed among the three groups (p > 0.05).

Conclusion

The application of CO2 fractional laser combined with compound betamethasone in vitiligo patients demonstrates significant efficacy. Compared to sole treatment with CO2 fractional laser or compound betamethasone injections, this combined approach further improves the levels of inflammatory factors in vitiligo patients, reduces the risk of relapse, enhances skin repigmentation, improves quality of life, psychological well-being, without increasing the risk of related adverse reactions. This combined approach merits clinical promotion and application.

Management of the refractory vitiligo patient: current therapeutic strategies and future options

Vitiligo is an autoimmune disease that leads to disfiguring depigmented lesions of skin and mucosa. Although effective treatments are available for vitiligo, there are still some patients with poor responses to conventional treatment. Refractory vitiligo lesions are mostly located on exposed sites such as acral sites and lips, leading to significant life stress. Understanding the causes of refractory vitiligo and developing targeted treatments are essential to enhance vitiligo outcomes. In this review, we summarized recent treatment approaches and some potential methods for refractory vitiligo. Janus kinase inhibitors have shown efficacy in refractory vitiligo. A variety of surgical interventions and fractional carbon dioxide laser have been widely applied to combination therapies. Furthermore, melanocyte regeneration and activation therapies are potentially effective strategies. Patients with refractory vitiligo should be referred to psychological monitoring and interventions to reduce the potential pathogenic effects of chronic stress. Finally, methods for depigmentation and camouflage may be beneficial in achieving uniform skin color and improved quality of life. Our ultimate focus is to provide alternative options for refractory vitiligo and to bring inspiration to future research.

1927nm fractional thulium fiber laser combined with 30% salicylic acid for the treatment of acne and acne scars: A prospective, randomized, and split-face study

OBJECTIVES

Patients with acne usually develops acne scars subsequently, early intervention of scars is crucial in acne management. 1927nm fractional thulium fiber laser (TFL) is effective in scars improvement and chemical peels with 30% supramolecular salicylic acid (SSA) can be applied for the treatment of acne. The purpose of this study is to evaluate and compare the efficacy and safety of TFL monotherapy versus the concomitant application of TFL and 30% SSA on acne and acne scars.

MATERIALS AND METHODS

Thirty-three patients with acne and acne scars were enrolled, and two sides of the face were randomly divided to receive either TFL and SSA chemical peeling or TFL. Four sessions of TFL treatments were applied with 4-week intervals for both sides, SSA combined treatment side received eight SSA chemical peels with 2-week intervals additionally. GAGS, ECCA score, the number of acne lesions, melanin index (MI) and erythema index (EI), transepidermal water loss (TEWL), and side effects were recorded at Weeks 0, 4, 8, 12, and 18. Satisfaction of patients was recorded on both sides at the end of the study.

RESULTS

Thirty patients completed the study. Both control group (TFL monotherapy) and SSA group (TFL combined with SSA chemical peeling) significantly improved GAGS and ECCA score. SSA group showed higher efficacy in terms of GAGS and ECCA score, acne lesion count, TEWL, MI, EI, and satisfaction than control group. All the side effects were temporary and tolerable, no adverse effects were observed.

CONCLUSIONS

Both TFL and the TFL combined with 30% SSA chemical peeling are safe and effective for the treatment and prevention of acne and acne scars, though the combined group has higher efficacy.

Has the core outcome (domain) set for vitiligo been implemented? An updated systematic review on outcomes and outcome measures in vitiligo randomized clinical trials

BACKGROUND

In 2015, a major achievement in vitiligo research was the development of an internationally agreed upon core outcome domain set for randomized clinical trials (RCTs). Three outcomes were identified as being essential: repigmentation, side-effects/harms and maintenance of gained repigmentation. Four items were further recommended for inclusion. The following recommendations then followed: repigmentation should be assessed by measuring the percentage of repigmentation in quartiles (0-25%, 26-50%, 51-79%, 80-100%) and cosmetic acceptability of the results should be assessed using the Vitiligo Noticeability Scale.

OBJECTIVES

The primary objective of this study was to assess uptake of the core outcome domain set for RCTs in vitiligo. Secondary objectives were to update the systematic review on outcomes reported in vitiligo RCTs, and to assess whether repigmentation and cosmetic acceptability of the results were measured using the above-mentioned recommended scales.

METHODS

We searched PubMed, Cochrane Library (CENTRAL and Systematic Reviews) and ClinicalTrials.gov for vitiligo RCTs between November 2009 and March 2021. Screening and data extraction were independently performed on title and summary by two researchers. All outcomes and outcome measures reported in eligible RCTs were retrieved and collated.

RESULTS

In total, 174 RCTs were identified: 62 were published between 2009 and 2015, and 112 were published between 2016 and 2021.Thirty-eight different outcomes were reported. Repigmentation was the primary outcome in 89% of trials (150 of 169). Forty-nine different tools were used to measure repigmentation. Side-effects and harms were reported in 78% of trials (136 of 174). Maintenance of gained repigmentation was reported in only 11% of trials (20 of 174) and duration of follow-up varied greatly from 1 to 14 months. Cosmetic acceptability of the results and cessation of disease activity were assessed in only 2% of trials (four of 174). Quality of life of patients with vitiligo was assessed in 13% of trials (22 of 174). Finally, only 11 of 112 RCTs (10%) published between 2016 and 2021 reported all three essential core outcome domains (repigmentation, side-effects and maintenance of gained repigmentation) and none of the trials reported both essential and recommended core outcome domains.

CONCLUSIONS

Efforts are still needed to close the gap between set recommendations and RCT outcome reporting.

Research trends and hotspot analysis of fractional carbon dioxide laser: A bibliometric and visualized analysis via Citespace

INTRODUCTION

There is limited basic research on carbon dioxide (CO₂ ) fractional laser, indicating blind spots in CO₂ fractional laser treatment of certain diseases. This study aimed to organize previous literature, summarize the current research, and speculate on possible future development.

METHODS

We searched document data on fractional CO₂ lasers from the Web of Science core collection database and retrieved 928 articles from 2004 to 2021. CiteSpace software was used to analyze the main institutions, authors, subject hotspots, and research frontiers in global CO₂ fractional laser research.

RESULTS

The results revealed that 928 related papers were published in the past 18 years (2004-2021), and the number has increased annually. The publications were written by 3239 authors from 626 institutions in 60 countries/regions. The United States (US) dominates this field (312 documents), followed by Italy (289), and South Korea (88). Lasers in Surgery and Medicine is the journal with the most publications and citations, and Uebelhoer is the central author. The main research hotspots include vulvovaginal atrophy, fractional photothermolysis, keloids, drug delivery, gene expressions, facial acne scarring, resurfacing, vitiligo, and photo damage.

CONCLUSION

Using CiteSpace, this paper draws a map of authors, institutions, and keywords in fractional CO₂ laser from 2004 to 2021; summarizes the main authors, institutions, research hotspots, and cutting-edge topics of global fractional CO₂ laser technology in recent years; and summarizes the current application status of global fractional CO₂ laser in disease treatment. It also provides new ideas for the future application and research of fractional CO₂ lasers.

Safety and Efficacy of High-Dose Fractional Erbium: Yttrium Aluminium Garnet Laser in Stable Vitiligo

Objective: Evaluate the treatment outcome of vitiligo patients receiving a standard regimen of high-dose biweekly fractional 2940 nm erbium:yttrium aluminium garnet (YAG) laser applications as an add-on to various treatment modalities. Materials and methods: The authors extracted the study population's clinical images before treatment and 3rd-month control from their clinical archive and used the medical records. The primary outcome measure was 50% repigmentation at 3rd-month follow-up. Institutional ethical committee approved the study. Results: Of the evaluated 28 patients, 18 were eligible with 31 treatment regions. All patients received at least one topical agent [steroids, calcineurin inhibitors, or 5-fluorouracil (5-FU)] and 11 patients received either targeted ultraviolet B (UVB) or narrow-band UVB. Of the 31 study regions, 88.8% (8/9) of facial; 77.7% (7/9) of dorsal hand; 75% (3/4) of limb; and 25% (2/8) of finger lesions achieved 50% repigmentation at 3rd-month control. The facial and dorsal hand lesions' treatment responses were higher than finger lesions (p = 0.008 and 0.03, respectively). Upon evaluating adjuvant treatment modalities, all of the treatment regions receiving targeted UVB (n = 4) or topical 5-FU (n = 5) achieved the primary endpoint, whereas severe irritation limited the topical use of 5-FU. The most common adverse effects were mild oozing and crusting related to laser treatments. Conclusions: Even with high-energy settings, fractional erbium: YAG laser does not induce the Koebner phenomenon. Although controlled trials are required to make firm conclusions, fractional erbium: YAG laser was an effective and safe adjunctive option for stable vitiligo in a real-life setting.

The efficacy of fractional carbon dioxide laser combined with narrow-band ultraviolet B phototherapy for non-segmental vitiligo: a systematic review and meta-analysis

Fractional carbon dioxide (CO₂) laser has been used with conventional treatments for vitiligo, demonstrating more effectiveness compared with conventional treatments alone. Especially, fractional CO₂ laser combined with narrow-band ultraviolet B (NB-UVB) was shown to induce more improvement compared with NB-UVB monotherapy for treating stable non-segmental vitiligo. However, the effectiveness of fractional CO₂ laser plus NB-UVB for the treatment of non-segmental vitiligo remains controversial. Therefore, this study aimed to confirm the safety and efficacy of fractional CO₂ laser combined with NB-UVB compared with NB-UVB monotherapy in stable non-segmental vitiligo. We searched the data from different databases, including Cochrane, Embase, and PubMed up to January 2020. Four randomized controlled trials (RCTs) for comparison between fractional CO₂ laser plus NB-UVB and NB-UVB monotherapy in patients with stable non-segmental vitiligo were included. We performed meta-analyses for repigmentation improvement and patient satisfaction as well as subgroup analyses based on acral or non-acral vitiligo, according to the PRISMA guidelines. The combination treatment showed more superior results than NB-UVB monotherapy (≥ 75% repigmentation, RR 4.60, 95% CI 1.19-17.74; ≥ 50% repigmentation, RR 2.24, 95% CI 0.45-11.17; < 25% repigmentation, RR 0.81, 95% CI 0.60-1.08). Also, fractional CO₂ laser plus NB-UVB significantly improved acral and non-acral vitiligo compared with NB-UVB monotherapy (standard mean difference (SMD) 1.24, 95% CI 0.66-1.82; SMD 1.14, 95% CI 0.67-1.60, respectively), while it increased markedly patient satisfaction compared with NB-UVB monotherapy (SMD 1.12, 95% CI 0.66-1.58). Collectively, this meta-analysis suggested that fractional CO₂ laser combined with NB-UVB might be more effective for treating non-segmental vitiligo than NB-UVB monotherapy.

A Review Article About Some Herbs Affecting Vitiligo Based on Avicenna's Canon

BACKGROUND

Vitiligo is a pigmentary disorder characterizing by white macules due to loss of melanocytes. Vitiligo affects about 1 to 4% of people around the world. The treatment of vitiligo has a high cost and the long process of treatment in spite of no complete remedy. It has various psychological side-effects such as depression and anxiety affecting the quality of life seriously. Avicenna in his Canon treated these patients over a thousand years ago. This study aimed to introduce some herbal drugs in vitiligo based on the Canon of Avicenna besides the conventional medical treatments.

METHODS

This is a review study, according to the Canon with the term Baras and also searching through the electronic websites with the keywords vitiligo, treatment, and herbal drugs.

RESULTS

The study found some herbs affecting the vitiligo from the Canon.

CONCLUSION

The researchers suggest conducting clinical trials on the patients with vitiligo based on the Canon besides the conventional techniques to obtain a better result in the treatment.

Platelet-rich plasma versus combined fractional carbon dioxide laser with platelet-rich plasma in the treatment of vitiligo: a comparative study

Purpose

The aim of this study was to assess the efficacy of platelet-rich plasma (PRP) vs combined fractional CO₂ (Fr: CO₂) laser with PRP in the treatment of stable nonsegmental vitiligo (NSV) lesions.

Patients and methods

This prospective, randomized, intrapatient, comparative controlled study was conducted between June 2014 and June 2016 at National Institute of Laser Enhanced Sciences (NILES), Cairo University, Cairo, Egypt. Thirty NSV patients were treated with PRP, Fr: CO₂ laser, and combined Fr: CO₂ laser with PRP. Intrapatient lesions were divide randomly into four groups. Each group was treated by one modality. The fourth group served as a control.Patients received six treatment sessions with 2-week interval for 3 months and were followed up after 3 months.

Results

A highly significant reduction was demonstrated through vitiligo analysis by computer-assisted grid (VACAG) in the combined Fr: CO₂ laser with PRP and in the PRP only groups than other groups. These results were confirmed by mean improvement score by physician (MISP) and by VAS with no statistical difference between them. The combined Fr: CO₂ laser with PRP group showed minimal side effects. Regardless of the modalities, better improvement was seen in the trunk than the face, extremities, and acral lesions with significant reduction in all regions. Face showed maximum response with combined Fr: CO₂ laser with PRP. Trunk showed higher response with PRP. Upper limbs showed highest response with combined Fr: CO₂ laser with PRP. Lower limbs showed the highest improvement with Fr: CO₂ laser.

Conclusion

According to our study, combined Fr: CO₂ laser with PRP achieved superior repigmentation than intradermal (ID) PRP. However, Fr: CO₂ alone showed poor improvement. Combined ablative Fr: CO₂ laser and PRP therapy followed by sun exposure could be used effectively and safely to treat refractory NSV.

A preliminary study of fractional CO2 laser added to topical tacrolimus combined with 308 nm excimer lamp for refractory vitiligo

Fractional CO₂ laser has been proposed recently to be effective and well tolerated in patients with refractory vitiligo. In this preliminary, prospective study, 21 patients with multiple, localized, refractory, non-segmental vitiligo lesions were randomized to receive either tacrolimus ointment plus 308 nm excimer lamp (control), with or without the addition of fractional CO₂ laser. There was no statistically significant improvement in the repigmentation on the laser side compared to the control side. Treatment was generally well-tolerated; only localized adverse effects were noted. Overall the triple combination therapy was not superior to tacrolimus ointment plus 308 nm excimer lamp. Treatment failure may reflect insufficient penetration of tacrolimus ointment through the holes created by fractional CO₂ laser on the skin.

Fractional CO2 laser contributes to the treatment of non-segmental vitiligo as an adjunct therapy: a systemic review and meta-analysis

The treatment of stable non-segmental vitiligo is often challenging, which new therapies are being searched. Multiple clinical trials have proposed the benefits and safety of using fractional carbon dioxide (CO2) laser as an adjunct therapy to conventional treatments. This study aimed to evaluate the safety and efficacy of fractional carbon dioxide laser as a combination therapy to conventional treatments in patients with stable non-segmental vitiligo. A literature search using PubMed, EMBASE, and the Cochrane Library was performed for comparative studies among vitiligo patients treated with additional fractional CO2 laser. Clinical outcomes in the selected studies were compared, and a meta-analysis was performed via Review Manager version 5.3, according to the PRISMA guidelines. Six studies with a total of 184 patches/patients were included in the present meta-analysis. The combination therapy group had significantly superior results than that of the control group (≥ 75% re-pigmentation, risk ratio [RR] 2.80, 95% confidence interval [CI] 1.29-6.07; ≥ 50% re-pigmentation, RR 2.26, 95% CI 1.23-5.9; < 25% re-pigmentation, RR 0.57, 95% CI 0.43-0.75). Limitations of the study included the small number of studies and sample size, inadequate blinding of participants, and variation between therapy protocols. Meta-analysis revealed that using fractional CO2 laser in combination with conventional treatments is efficient and safe, and may be considered as an adjunct therapeutic option for patients with refractive non-segmental vitiligo.