308 nm excimer lamp in combination with topical tacrolimus: A retrospective study of its efficacy and safety in childhood vitiligo
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1 ORIGINAL ARTICLE 308 nm excimer lmp in comintion with topicl tcrolimus: A retrospective study of its efficcy nd sfety in childhood vitiligo BS Chndrshekr, N Shoh, P Deprtment of Dermtology, Cutis, Acdemy of Cutneous Sciences, Bnglore ABSTRACT Vitiligo is chronic, polygenic dyschromi tht presents with multiple depigmented mcules nd ptches. Among the vrious therpeutic modlities for tretment of vitiligo in children, phototherpy s one of the minsty tretments hs vrying therpeutic efficcy. There is limited dt regrding the use of comintion of tcrolimus nd 308 nm excimer lmp for tretment of vitiligo in children. The im of the present study is to retrospectively ssess the efficcy nd tolerility of 308 nm Excimer lmp in comintion with topicl tcrolimus to tret vitiligo in children elow 17 yers with skin type III, IV nd V. Methods: Cse sheets nd photogrphs of 47 vitiligo ptches from 24 children (mle = 9, femle = 15), <17 yers were evluted in this study. Dt of ptients with ctive disese nd stle vitiligo not treted previously were chosen for this study. The ptches were treted with topicl tcrolimus dily nd excimer lmp thrice weekly, for mximum of 20 sittings. Results: Of the 47 ptches, 35 ptches chieved repigmenttion ccounting to 74.4% of the totl ptches. The repigmenttion response ws good in ultrviolet (UV) sensitive res ut miniml in UV resistnt res. All the ptches retined pigmenttion during the follow-up period of months. Conclusion: The degree of repigmenttion chieved with topicl tcrolimus nd excimer lmp in period of 4-6 weeks is much higher thn other contemporry vitiligo therpies in children. This dul therpy of topicl tcrolimus nd 308 nm Excimer lmp is sfe nd effective therpy showing n erly response, for loclized vitiligo in children. Key words: 308 nm excimer lmp, childhood vitiligo, repigmenttion, topicl tcrolimus INTRODUCTION itiligo is chronic, idiopthic cquired disorder which is chrcterized y progressive loss of melnocytes from the epidermis nd the epiderml ppendges. However successful tretment of vitiligo in ll ptients is still mirge, lthough vrious comintion modlities like topicl steroids, immunomodultors, phototherpy nd surgicl therpies re commonly used. In the mjority of Quick Response Code Access this rticle online Wesite: DOI: / ptients, it ffects the psychosocil development nd prevlence of vitiligo is 1 3%. [1] In 50% of ffected ptients, the onset is elow 20 yers of ge, [2] further dding on to prentl pprehensions nd nxiety. Therefore, it is very importnt tht childhood vitiligo is dignosed nd treted t the pproprite time. normlities of oth humorl nd cell medited immunity. Tcrolimus, topicl immunomodultor, modultes the immune system y inhiiting T cell ctivtion through down regultion of the ADDRESS FOR CORRESPONDENCE Dr. BS Chndrshekr, #5/1, 4 th Min Rod, MRCR Lyout, Ner Veeresh Thetre Behind Godrej Interio, Vijyngr, Bengluru , Krntk, Indi. E-mil: cutisclinic@gmil.com 74
2 trnscription genes encoding proinflmmtory cytokines, nmely interleukin (IL) 2, IL 3, IL 4, γ α grnulocyte mcrophge colony stimulting fctor. pproved for topic dermtitis nd is used off lel for severl other dermtologic conditions, such of ction of tcrolimus hs een elucidted, dt descriing how tcrolimus modultes the cutneous milieu remin unknown. [3] The 308 nm excimer lmp genertes single spot size of 2 cm 2 cm nd pulse repetition rte up to 200 Hz. It hs n djustle exposure time. The 308 nm wvelength is prticulrly effective t inducing poptosis of T lymphocytes nd stimultion of melnocyte migrtion nd prolifertion from the niche locted in the hir follicles. [4] It stilizes the progression of the disese nd induces n erly repigmenttion with fce lesions responding the erliest nd est. [5] is chieved, depending on dosge nd loction of 308 nm excimer lmp therpy is the difficulty in cost of tretment nd equipment. [4] lmp is n effective modlity to tret vitiligo in dults. However its efficcy in children is less explored. AIM To retrospectively ssess the efficcy nd tolerility tcrolimus to tret vitiligo in children elow 17 yers METHODS Cse sheets nd photogrphs of 47 vitiligo ptches in 24 children (mle = 9, femle = 15), less thn 17 yers were included in the study. Dt of ptients with ctive disese nd stle vitiligo, previously not treted were chosen for this study. Tretment hd strted with one miniml erythem dose (equivlent to 150 mj/cm 2 ) nd ws incresed in stepwise pttern y 100 mj/cm 2 every sitting until redness hd developed, in which cse the dose ws kept constnt, reduced or skipped (if urning or listering developed). Tretment ws given thrice tcrolimus ws used for ll ptches on dily sis protective glsses. neck, lips nd sclp, trunk, lims nd extremities, which were tken t seline, 2 nd, 4 th nd 6 th week of tretment, were evluted for erythem nd otining repigmenttion scores. The repigmenttion ws grded on 5 point scle, (0 4) ssessed ccording to Tle 1. RESULTS 47 vitiligo ptches in 24 children were evluted for repigmenttion on 5 point scle (0 4) s shown in Tle 1. Of the 47 ptches 35 ptches hve shown repigmenttion, ccounting to 74.4% of the totl tht hve chieved 0 4 grdes of repigmenttion. Some of the ptches egn repigmenttion s erly s the 4 th ptches responded y the 12 th week of the tretment except for the ptches on plms, soles nd sclp. The vried response of ll vitiligo ptches from different Tle 2. Tle 1: The grding repigm enttion Grdes Repigmenttion ( % ) Tle 2: The repigmenttion grdes t different ody sites fter 20 sittings of excimer lmp therpy Grde of repigmenttion Totl ( 47) Fce nd neck Trunk Lims Lips Plms, soles, fingers nd toes Sclp Averge dose (mj/ cm 2 )
3 Seven out of 19 ptches hd % repigmenttion the excimer lmp. Complete repigmenttion of the the ptches in the trunk region responded to the excimer lmp. Out of 4 ptches in the lims, 2 ptches showed Out of nine ptches in this region, only two ptches no repigmenttion t ll. The Lips nd Sclp Like the extremities, this re too showed comprtively poor response to excimer lmp tretment s shown in repigmenttion. Both the ptches in the sclp showed retined the pigmenttion during the months follow up period. DISCUSSION Of ll the modlities ville for treting vitiligo in children, phototherpy is the minsty nd is involvement. It requires regulr sessions severl times week for out yer to chieve expected therpeutic response. Trgeted 308 nm excimer monotherpy is n lterntive therpy which ctively controls the disese progression nd lso induces repigmention in short durtion. In study y Ostovri et l., the effectiveness of the 308 nm excimer lmp tretment ws not ffected y ptient ge, suggesting tht this modlity my e useful in the peditric popultion. [6] dvntge of delivering high intensity rdition to the disesed skin, thus reducing the exposure of norml skin to rdition side effects. [2] Ostovri et l. nd Tnej et l sensitive res chieved 75% repigmenttion versus [6,7] neck nd lims) showed repigmenttion, of which plms, soles, fingers nd toes) 4 ptches (=25%) ptients chieved more thn 75% repigmenttion on 3 months tretment. [8] Studies y Hofer et l. with excimer showed more thn 75% repigmenttion in 13% of ptients with 30 tretment sessions. [9] These dt indicte tht repigmenttion is chieved within 30 tretment sessions. This is comprle to our study where repigmenttion response ws noted s erly s the fourth sitting, with incresing pigmenttion on continuing tretment (74.4% repigmenttion of 35/47 ptches over 7 weeks tretment), with n verge dose of 500 mj/cm 2 in showed miniml response with n verge dose s high s 1400 mj/cm 2 repigmenttion did not egin y the 12 th sitting then proly further sittings with excimer or lternte phototherpy re not eneficil. topicl tcrolimus with excimer lmp cts synergisticlly reducing the durtion of clinicl response. [10,11] Figure 1: Pie chrt depicting the overll repigmenttion grdes chieved in 20 sittings of excimer lmp therpy Side effects were noted in 6 ptches (fce, neck nd lips) cutioning the slow increment in the dose of rdition 76
4 Figure 2 nd : Pictures efore the excimer tretment nd fter 4 th sitting depicting the strt of repigmenttion Figure 3: Br chrt showing grdes of repigmenttion t different sites following excimer lmp tretment Figure 4 nd : Grde 4 repigmenttion efore the excimer tretment in 4 nd fter 20 sittings of the excimer tretment in 4 Figure 5 nd : Grde 0 repigmenttion in the lips region efore the excimer lser tretment 5 nd fter 20 sittings of the excimer tretment 5 considered. Topicl tcrolimus nd excimer lmp ct synergisticlly, therey reducing the durtion of clinicl response. Figure 6-c: Pictures efore excimer therpy in 6, 6 showing of erythem nd urns following the 9 th sitting. Grde 4 improvements ws seen y the end of 15 th sitting depicted in 6c ws noted in some ptches which reduced following discontinution of therpy. However, further prospective studies with lrger study popultion nd control group cn e conducted to study the effect of excimer therpy in children. CONCLUSION repigmenttion, primrily children with vitiligo in children s it prevents clustrophoi, which is excimer lmp, n lternte therpy should e c 308 nm excimer lmps cn e sfely used, with n effective nd erly response in childhood vitiligo, minimizing the exposure to rdition thus resulting in cosmeticlly stisfying results. REFERENCES 1. Hdi SM, Spencer JM, Lewohl M. The use of the 308 nm excimer lser for the tretment of vitiligo. Dermtol Surg et l. Tretment of vitiligo y 308 nm excimer lser: 77
5 et l. Topicl tcrolimus nd the 308 nm excimer How to cite this rticle: Chndrshekr BS, Shoh N, Jgdish P, Vsnth V, Rjshekr ML, Sndeep MA. 308 nm excimer lmp in comintion with topicl tcrolimus: A retrospective study of its efficcy nd sfety in childhood vitiligo. Indin J Peditr Dermtol 2014;15:74-8. Source of Support: Nil, Conflict of Interest: None declred Announcement iphone App A free ppliction to rowse nd serch the journl s content is now ville for iphone/ipd. The ppliction provides Tle of Contents of the ltest issues, which re stored on the device for future offline rowsing. Internet connection is required to ccess the ck issues nd serch fcility. The ppliction is Comptile with iphone, ipod touch, nd ipd nd Requires ios 3.1 or lter. The ppliction cn e downloded from id ?ls=1&mt=8. For suggestions nd comments do write ck to us. 78
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