Laser Update: The Use of a 308-nm Excimer Laser to Treat Vitiligo in a Child
From ancient times, vitiligo has carried significant social and psychological stigma. Its prevalence has been estimated to be between 1% to 4%.1 Treatments for this disease have largely been sub-optimal, either because of low efficacy or high economic and time costs associated with them. However, one treatment that has been recently used to treat vitiligo has been demonstrated to have significant promise.
We report a case of a child treated with a 308-nm excimer laser and discuss implications for more widespread use of this device.
Patient Case
Presentation
A 7-year-old African America female presented for evaluation of a depigmented patch on her nose (Figure 1). The depigmentation had been present for approximately 12 months and had been progressing. Her past medical history was unremarkable, and her thyroid functions were normal. Family history was negative for vitiligo or other autoimmune diseases.
Previous Treatments Considered and Undergone
Treatments that had been utilized included topical tacrolimus 0.1% and 2.5% hydrocortisone cream. Neither of these treatments had any effect on the appearance of the depigmentation. Therapeutic options included the use of intralesional steroid injections, PUVA, narrow band UVB, blister grafting, topical immunomodulators, topical calcipitriol and topical steroids. Intralesional steroids carried risk for depigmentation of adjacent areas and skin atrophy, so was deemed not acceptable. PUVA (with either topical or oral psoralen administration) has a relatively low success rate, requires significant time commitment and has numerous potential complications that were not considered acceptable for this child. Blister grafting was considered and would have been a viable alternative, but the parents did not want to subject their child to this procedure. Topical immunomodulators and topical steroids had been used without significant success.
Laser Treatment
After a discussion of the potential risks and benefits with the parents, it was decided to treat the vitiligo with an excimer laser. The laser utilized was the 308-nm excimer UVB laser (XTRAC Photomedex, Montgomerysville, PA) one time per week. Her initial dose was 100 mJ/cm2 with a slowly escalating dose as tolerated up to 900 mJ/cm2. She received a total of 29 treatments over 8 months. After the final treatment, pigment was entirely restored to pre-vitiligo appearance (Figure 2). The patient’s pigmentation was stable and treatments were stopped.
Discussion
Clinical Studies
Pioneering work in the use of excimer lasers for the treatment of skin disease was performed by Asawanonda et al, who used this laser to treat psoriasis with good results.2 A pilot study performed by Spencer et al demonstrated the safety and efficacy of excimer lasers for the treatment of vitiligo.3 This study concluded that the “degree of repigmentation in a period of 2 to 4 weeks is much higher than with any other present vitiligo therapy.” Although this study did not evaluate children, its conclusions suggest that the 308-nm xenon chloride laser may be an effective modality for this patient population.
A subsequent clinical trial concluded that the excimer laser was appropriate therapy for vitiligo in “UV-sensitive areas” including the face.4 The definition of UV sensitive areas included the “face, neck, arm and leg excluding extremities and bony prominences that are usually resistant to phototherapy.”
Significantly, the authors concluded that no variable other than UV sensitivity — including race, sex, age or duration of disease — correlated with the response to therapy. The complications reported in this study were minor and did not include the types of burns seen when this laser was used for the treatment of vitiligo in UV-sensitive areas in other studies. The authors speculate that this was because they increased fluence every two visits, thereby enabling the skin to adjust to the gradually increasing energy. Based on this and other data, it seems reasonable to treat children who suffer from vitiligo in cosmetically sensitive, UV-sensitive areas.
Patient Selection
Given the failure of prior treatments and the significant stigma associated with the depigmentation in this child, excimer laser was a reasonable alternative. It remains to be defined exactly what circumstances and which populations are suitable for this treatment. Clinical trials using excimer laser in children who have vitiligo in UV-sensitive areas would help to determine who is and who is not a good candidate for this treatment.
Financial Considerations/Managed Care Coverage
Financial considerations for this treatment may also present a barrier. Although some managed care companies consider vitiligo treatments to be medically necessary, there is no consensus regarding payment for the use of the excimer laser by these carriers. It is possible that a clinical trial that included a cost/benefit analysis would prompt carriers to cover treatments. At the present time, many managed care carriers do not cover the use of the excimer laser for the treatment of vitiligo.
Conclusion
Results of excimer lasers for the treatment of vitiligo have been well documented. The laser has the potential to restore pigment to individuals affected by this disease. Its ability to repigment the skin of our patient produced dramatic results that greatly altered her life. Further information regarding the appropriate use of this device appears warranted. It would also be helpful to have information regarding the cost/benefit analysis of this procedure when compared with more standard treatments.
From ancient times, vitiligo has carried significant social and psychological stigma. Its prevalence has been estimated to be between 1% to 4%.1 Treatments for this disease have largely been sub-optimal, either because of low efficacy or high economic and time costs associated with them. However, one treatment that has been recently used to treat vitiligo has been demonstrated to have significant promise.
We report a case of a child treated with a 308-nm excimer laser and discuss implications for more widespread use of this device.
Patient Case
Presentation
A 7-year-old African America female presented for evaluation of a depigmented patch on her nose (Figure 1). The depigmentation had been present for approximately 12 months and had been progressing. Her past medical history was unremarkable, and her thyroid functions were normal. Family history was negative for vitiligo or other autoimmune diseases.
Previous Treatments Considered and Undergone
Treatments that had been utilized included topical tacrolimus 0.1% and 2.5% hydrocortisone cream. Neither of these treatments had any effect on the appearance of the depigmentation. Therapeutic options included the use of intralesional steroid injections, PUVA, narrow band UVB, blister grafting, topical immunomodulators, topical calcipitriol and topical steroids. Intralesional steroids carried risk for depigmentation of adjacent areas and skin atrophy, so was deemed not acceptable. PUVA (with either topical or oral psoralen administration) has a relatively low success rate, requires significant time commitment and has numerous potential complications that were not considered acceptable for this child. Blister grafting was considered and would have been a viable alternative, but the parents did not want to subject their child to this procedure. Topical immunomodulators and topical steroids had been used without significant success.
Laser Treatment
After a discussion of the potential risks and benefits with the parents, it was decided to treat the vitiligo with an excimer laser. The laser utilized was the 308-nm excimer UVB laser (XTRAC Photomedex, Montgomerysville, PA) one time per week. Her initial dose was 100 mJ/cm2 with a slowly escalating dose as tolerated up to 900 mJ/cm2. She received a total of 29 treatments over 8 months. After the final treatment, pigment was entirely restored to pre-vitiligo appearance (Figure 2). The patient’s pigmentation was stable and treatments were stopped.
Discussion
Clinical Studies
Pioneering work in the use of excimer lasers for the treatment of skin disease was performed by Asawanonda et al, who used this laser to treat psoriasis with good results.2 A pilot study performed by Spencer et al demonstrated the safety and efficacy of excimer lasers for the treatment of vitiligo.3 This study concluded that the “degree of repigmentation in a period of 2 to 4 weeks is much higher than with any other present vitiligo therapy.” Although this study did not evaluate children, its conclusions suggest that the 308-nm xenon chloride laser may be an effective modality for this patient population.
A subsequent clinical trial concluded that the excimer laser was appropriate therapy for vitiligo in “UV-sensitive areas” including the face.4 The definition of UV sensitive areas included the “face, neck, arm and leg excluding extremities and bony prominences that are usually resistant to phototherapy.”
Significantly, the authors concluded that no variable other than UV sensitivity — including race, sex, age or duration of disease — correlated with the response to therapy. The complications reported in this study were minor and did not include the types of burns seen when this laser was used for the treatment of vitiligo in UV-sensitive areas in other studies. The authors speculate that this was because they increased fluence every two visits, thereby enabling the skin to adjust to the gradually increasing energy. Based on this and other data, it seems reasonable to treat children who suffer from vitiligo in cosmetically sensitive, UV-sensitive areas.
Patient Selection
Given the failure of prior treatments and the significant stigma associated with the depigmentation in this child, excimer laser was a reasonable alternative. It remains to be defined exactly what circumstances and which populations are suitable for this treatment. Clinical trials using excimer laser in children who have vitiligo in UV-sensitive areas would help to determine who is and who is not a good candidate for this treatment.
Financial Considerations/Managed Care Coverage
Financial considerations for this treatment may also present a barrier. Although some managed care companies consider vitiligo treatments to be medically necessary, there is no consensus regarding payment for the use of the excimer laser by these carriers. It is possible that a clinical trial that included a cost/benefit analysis would prompt carriers to cover treatments. At the present time, many managed care carriers do not cover the use of the excimer laser for the treatment of vitiligo.
Conclusion
Results of excimer lasers for the treatment of vitiligo have been well documented. The laser has the potential to restore pigment to individuals affected by this disease. Its ability to repigment the skin of our patient produced dramatic results that greatly altered her life. Further information regarding the appropriate use of this device appears warranted. It would also be helpful to have information regarding the cost/benefit analysis of this procedure when compared with more standard treatments.
From ancient times, vitiligo has carried significant social and psychological stigma. Its prevalence has been estimated to be between 1% to 4%.1 Treatments for this disease have largely been sub-optimal, either because of low efficacy or high economic and time costs associated with them. However, one treatment that has been recently used to treat vitiligo has been demonstrated to have significant promise.
We report a case of a child treated with a 308-nm excimer laser and discuss implications for more widespread use of this device.
Patient Case
Presentation
A 7-year-old African America female presented for evaluation of a depigmented patch on her nose (Figure 1). The depigmentation had been present for approximately 12 months and had been progressing. Her past medical history was unremarkable, and her thyroid functions were normal. Family history was negative for vitiligo or other autoimmune diseases.
Previous Treatments Considered and Undergone
Treatments that had been utilized included topical tacrolimus 0.1% and 2.5% hydrocortisone cream. Neither of these treatments had any effect on the appearance of the depigmentation. Therapeutic options included the use of intralesional steroid injections, PUVA, narrow band UVB, blister grafting, topical immunomodulators, topical calcipitriol and topical steroids. Intralesional steroids carried risk for depigmentation of adjacent areas and skin atrophy, so was deemed not acceptable. PUVA (with either topical or oral psoralen administration) has a relatively low success rate, requires significant time commitment and has numerous potential complications that were not considered acceptable for this child. Blister grafting was considered and would have been a viable alternative, but the parents did not want to subject their child to this procedure. Topical immunomodulators and topical steroids had been used without significant success.
Laser Treatment
After a discussion of the potential risks and benefits with the parents, it was decided to treat the vitiligo with an excimer laser. The laser utilized was the 308-nm excimer UVB laser (XTRAC Photomedex, Montgomerysville, PA) one time per week. Her initial dose was 100 mJ/cm2 with a slowly escalating dose as tolerated up to 900 mJ/cm2. She received a total of 29 treatments over 8 months. After the final treatment, pigment was entirely restored to pre-vitiligo appearance (Figure 2). The patient’s pigmentation was stable and treatments were stopped.
Discussion
Clinical Studies
Pioneering work in the use of excimer lasers for the treatment of skin disease was performed by Asawanonda et al, who used this laser to treat psoriasis with good results.2 A pilot study performed by Spencer et al demonstrated the safety and efficacy of excimer lasers for the treatment of vitiligo.3 This study concluded that the “degree of repigmentation in a period of 2 to 4 weeks is much higher than with any other present vitiligo therapy.” Although this study did not evaluate children, its conclusions suggest that the 308-nm xenon chloride laser may be an effective modality for this patient population.
A subsequent clinical trial concluded that the excimer laser was appropriate therapy for vitiligo in “UV-sensitive areas” including the face.4 The definition of UV sensitive areas included the “face, neck, arm and leg excluding extremities and bony prominences that are usually resistant to phototherapy.”
Significantly, the authors concluded that no variable other than UV sensitivity — including race, sex, age or duration of disease — correlated with the response to therapy. The complications reported in this study were minor and did not include the types of burns seen when this laser was used for the treatment of vitiligo in UV-sensitive areas in other studies. The authors speculate that this was because they increased fluence every two visits, thereby enabling the skin to adjust to the gradually increasing energy. Based on this and other data, it seems reasonable to treat children who suffer from vitiligo in cosmetically sensitive, UV-sensitive areas.
Patient Selection
Given the failure of prior treatments and the significant stigma associated with the depigmentation in this child, excimer laser was a reasonable alternative. It remains to be defined exactly what circumstances and which populations are suitable for this treatment. Clinical trials using excimer laser in children who have vitiligo in UV-sensitive areas would help to determine who is and who is not a good candidate for this treatment.
Financial Considerations/Managed Care Coverage
Financial considerations for this treatment may also present a barrier. Although some managed care companies consider vitiligo treatments to be medically necessary, there is no consensus regarding payment for the use of the excimer laser by these carriers. It is possible that a clinical trial that included a cost/benefit analysis would prompt carriers to cover treatments. At the present time, many managed care carriers do not cover the use of the excimer laser for the treatment of vitiligo.
Conclusion
Results of excimer lasers for the treatment of vitiligo have been well documented. The laser has the potential to restore pigment to individuals affected by this disease. Its ability to repigment the skin of our patient produced dramatic results that greatly altered her life. Further information regarding the appropriate use of this device appears warranted. It would also be helpful to have information regarding the cost/benefit analysis of this procedure when compared with more standard treatments.
