Combination of 308-nm xenon chloride excimer laser and topical calcipotriol in vitiligo

The efficacy of combined phototherapy with topical therapy in vitiligo: a network meta-analysis

BACKGROUND

The comparative effects of phototherapy and topical therapy in patients with vitiligo remain unclear. A network meta-analysis (NMA) was conducted to assess which combination therapy was more beneficial for patients with vitiligo.

METHODS

This study analyzed phototherapy, including narrowband ultraviolet B (NB-UVB) and 308-nm excimer laser/light (EL) combined with topical therapies. Randomized controlled trials were sourced from PubMed, Embase, and Cochrane Library. Data analysis was based on a random-effects model, and surface under the cumulative ranking (SUCRA) curves employed to assess the efficacy of the interventions.

RESULTS

This NMA included 27 trials, with a total of 2417 lesions (patches). According to the results of the SUCRA, for achieving ≥50% repigmentation, the top three combination therapies were phototherapy combined with antioxidants (SUCRA 87.7), corticosteroids (SUCRA 69.6), and calcineurin inhibitors (SUCRA 52.5), while for ≥75% repigmentation, the leading therapies were phototherapy combined with antioxidants (SUCRA 89.0), calcineurin inhibitors (SUCRA 70.3), and fractional CO2 laser (SUCRA 63.6).

CONCLUSIONS

This meta-analysis suggests that combining phototherapy with topical antioxidants, corticosteroids, or calcineurin inhibitors may offer superior outcomes for vitiligo patients. This study provides a reference for clinicians to develop personalized treatment plans for patients with vitiligo.

Efficacy and safety of micro-needling combined with topical 5-fluorouracil and excimer light vs. excimer light alone in treatment of non-segmental vitiligo: A comparative study

BACKGROUND/PURPOSE

Vitiligo is one of the most challenging dermatological diseases with little improvement promises. Various modalities of treatment both medical and surgical have been used in the treatment of vitiligo. Some proved to be effective, others with controversial results and the rest were effective less. The aim of the present study was to evaluate the additional effect of topical 5-fluorouracil after micro-needling to excimer light (308 nm) in treatment of non-segmental vitiligo.

METHODS

Fifty patients were included in the present study, only 33 patients continued the treatment for 6 months. Two patches were selected in every patient to be treated, one patch with micro-needling then application of 5 FU and excimer (Group A), and the other with excimer only (Group B).

RESULTS

The treatment with the combination of micro-needling then application of 5 FU and excimer showed significant earlier response versus excimer alone. Also, the percentage of re-pigmentation was higher in the patches treated with the combination especially in the face and trunk. The combination of 5 FU after micro-needling and Excimer is more suitable for localized and focal vitiligo.

CONCLUSION

Topical 5 FU after micro-needling is a promising, rapid, and cost-effective therapeutic strategy for treatment of non-segmental vitiligo It had limited side effects, and the best response was reported for lesions affecting face and trunk.

The use of lasers in vitiligo, an overview

Various types of lasers have been demonstrated to be effective in the treatment of vitiligo. The mode of action of these lasers is just as varied as the purpose of intervention. Many clinicians are not aware of the unique opportunity these lasers offer to improve the outcomes of vitiligo treatment. To date, no clear overview exists of the use of lasers in vitiligo treatment. Thus, the aim of this review is to discuss the various types of lasers and provide an overview of the evidence for their efficacy. We found good evidence from a systematic review that the excimer laser is effective, induces repigmentation rates comparable to NB‐UVB and has improved outcomes when combined with calcineurin inhibitors. Ablative lasers are commonly used for tissue graft or melanocyte–keratinocyte cell graft transplantation. They provide safe, fast and uniform denudation of the epidermis with propitious repigmentation outcomes. We found conflicting evidence from two systematic reviews regarding the efficacy of fractional ablative lasers for improving outcomes of NB‐UVB therapy, a systematic review including only fractional ablative lasers provided evidence for efficacy. Q‐switched nanosecond lasers have shown to be safe and effective for inducing depigmentation, although recurrence is common, and most studies were small and retrospective. Despite proven efficacy and safety, laser treatments are relatively expensive and suited for limited body surface areas and selected cases. Each type of laser has benefits and risks associated and should, therefore, be individually chosen based on location, extent, activity and type of vitiligo.

Treatment protocols and efficacy of combined laser with medical treatment modalities in vitiligo

BACKGROUNDS

Nowadays, lasers are used for treatment of vitiligo in difficult-to-treat areas and refractory lesions. Combination of lasers with other medical modalities can provide higher efficacy, faster response rate, and higher compliance of patients to treatment.

AIM

In this article, we reviewed articles regarding safety, efficacy, and treatment protocols of combined laser with other medical modalities.

METHODS

We searched articles with relevant key words in Google scholar and PubMed. Inclusion criteria were articles in English language since January 2000 until March 2021that evaluate combination of laser with other topical or systemic medical treatments.

RESULTS

A total of 42 articles evaluated efficacy of lasers [excimer, carbon dioxide (CO₂ ), erbium-doped yttrium-aluminum-garnet (Er:YAG), and non-ablative resurfacing laser] combined with topical or systemic medical treatment modalities. Effective response rate (more than 50% improvement) varied between 7.7% and 92%. Initial repigmentation observed between 4 and 13 weeks after beginning of treatment.

CONCLUSION

Combination of laser with medical modalities leads to more rapid repigmentation, superior efficacy, and better compliance of patients with localized non-segmental type of vitiligo compared to monotherapy. Combination of excimer laser with topical therapy might be suggested for recalcitrant vitiligo lesions in face and neck. Combination of fractional ablative resurfacing lasers with topical therapy, especially 5-flurouracil, can be recommended particularly in recalcitrant acral and bony prominent areas. Further studies are required to achieve conclusive evidence in order to define the best stage of vitiligo for laser therapy and most effective combined treatment regimen.

308nm excimer lamp monotherapy for lip vitiligo-a short case series

Vitiligo is a common depigmenting condition that carries a high psychosocial morbidity, especially when it occurs over exposed areas like lips. Many of the current topical and systemic therapies are less effective in lip vitiligo, and surgical modality remains the mainstay of treatment of lip vitiligo. The 308-nm excimer laser in combination with topical calcineurin inhibitors and calcipotriene is effective in the treatment of lip vitiligo. This case series provide further evidence to support effectiveness of 308-nm excimer lamp even as monotherapy in darker individuals with lip 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.

[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.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Concise review of recent studies in vitiligo

Vitiligo is an acquired pigmentry disorder of the skin and mucous membranes which manifests as white macules and patches due to selective loss of melanocytes. Etiological hypotheses of vitiligo include genetic, immunological, neurohormonal, cytotoxic, biochemical, oxidative stress and newer theories of melanocytorrhagy and decreased melanocytes survival. There are several types of vitiligo which are usually diagnosed clinically and by using a Wood's lamp; also vitiligo may be associated with autoimmune diseases, audiological and ophthalmological findings or it can be a part of polyendocrinopathy syndromes. Several interventions are available for the treatment for vitiligo to stop disease progression and/or to attain repigmentation or even depigmentation. In this article, we will present an overall view of current standing of vitiligo research work especially in the etiological factors most notably the genetic components, also, types and associations and various and newer treatment modalities.