Phototherapy involves the exposure of the involved skin to a short-wave ultraviolet light known as UVB. UVB occurs naturally in sunlight; it is the part of the sunlight, which causes sunburns.
The dosage of UVB will be determined on many factors such as type of skin, disease, age, and type of equipment. The time is gradually increased until the desired result is achieved. At all times, while inside the phototherapy light box, special protective eyewear must be worn. Men will also protect their scrotum area.
The side effects to ultra-phototherapy B are, during treatment the psoriasis can sometimes get temporarily worse before getting better. The skin may itch and get red due to overexposure (sunburn). The long-term risk in developing skin cancer(s) from long-term exposure to UVB is unknown. Also, long-term exposure can cause freckling and loss of skin elasticity. During the course of therapy, your skin will be evaluated.
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dermatologic care. Numerous studies have noted significant quality of life issues in patients with psoriasis. Psoriasis varies in severity from mild to moderate to severe disease. Mild psoriasis vul-garis involves disease activity of less than 2% body surface area, moderate disease between 2% and 10%, and severe psoriasis generally involves greater than 10% body surface area. Genetics, biochemical pathways, and the immune system are known to be involved in the pathogenesis of psoriasis. In psoriasis, faulty immune signals are thought to accelerate the skin growth cycles. This leads to an increase in the amount of skin cells, which pile up on the skin surface faster than the body can shed them - in 3-4 days instead of the normal 28 days. Much of the recent evidence into the pathogenesis of psoriasis suggests that psoriasis is a T-cell-mediated disease.
A variety of treatment options exist for patients suffering from psoriasis. Most of the treatments are safe and effective. These treatments improve the psoriatic skin and reduce the symptoms associated with psoriasis, mainly swelling, erythema, flaking, and pruritis. These therapies (Table 6.3) often lead to a remission in the skin condition. A step-ladder approach to psoriasis therapy is commonly used by most clinicians. (Table 6.3). With this approach to the
Table 6.3. Treatment options for psoriasis vulgaris
Step 1: Topical Therapy Topical corticosteroids Topical coal tar
Topical calcepotriene (Vitamin D) Topical vitamin A derivatives Topical anthralin Topical salicylic acid Natural sunlight
Step 2: Phototherapy/lasers Ultraviolet B (UVB) light Narrowband UVB B Clear (Lumenis) Xtrac (PhotoMedex) excimer laser PUVA (psoralen plus ultraviolet A light)
Step 3: Systemic medications Methotrexate Oral retinoids Cyclosporine
Biologic drugs - alefacept (Amevive) Efalizumal (Raptiva) Etanercept (Enbrel) Infliximal (Remicade)
use of phototherapy, a variety of new lasers and light sources are being evaluated.
The major light sources being used for the treatment of psoriasis are the BClear (Lumenis) and the Xtrac (PhotoMedix). Clinical trials with the XTrac, a 308-nm excimer laser, have shown significant clearing of psoriatic plaques. Feld-man et al. (Feldman et al. 2002) reported on a multicenter analysis with 124 patients at five centers. Seventy-two percent of patients demonstrated 75% or greater clearance in 6.2 treatments or less. Eighty-four percent achieved improvement of 75% or better after ten treatments. Other investigators also showed significant clearance using the excimer laser in 11 patients after 1 month of therapy; five patients remained disease free at a 4-month follow-up (Figs. 6.17, 6.18). The BClear is a narrowband UVB device which delivers the UVB in a focused, fiber-optic delivery system. This allows the UVB to be delivered only to diseased tissue, leaving healthy tissue alone. Such an approach leads to the potential for less treatment sessions. Potential adverse effects and the development of skin cancers may also be lessened. This device produces UVB light in the 290- to 320-nm range with most emitted wavelengths between 311 and 314 nm. The device may deliver light either in a single pulse mode or continuous pulse mode. Pulse widths of 0.5, 1.0, 1.5, and 2.0 s exist. Fluences range from 50 to 800 mJ and spot sizes up to 16 x 16 mm exist for the device. Several clinical trials have shown significant clearances with this targeted UVB system. (Figs. 6.19, 6.20).
A variety of leukodermas of the skin have also been treated with both the excimer laser and targeted UVB systems. Leukodermas of the skin are defined as loss of skin pigment from a disease process (i. e., vitiligo) or secondary to an injury pattern to the skin (including loss of pigment from burns, surgical procedures, and following laser resurfacing procedures). Other skin concerns, such as idiopathic guttate hypome-lanosis and hypopigmented stretch marks are also being evaluated with these technologies. Vitiligo is a pigmentation disorder in which
Fig. 6.19. a Psoriasis before narrowband UVB targeted therapy. b Psoriasis after ten narrowband UVB targeted therapy treatments
Fig. 6.22. a Vitiligo before narrowband UVB targeted therapy. b Vitiligo after four narrowband UVB targeted therapy treatments melanocytes in the skin, mucous membranes, and the retina of the eye may be destroyed. As a result, white patches of skin can appear on different parts of the body. The cause of vitiligo is unknown; genetics may play a role and vitiligo is often associated with autoimmune diseases. Vitiligo affects between 1 and 2% of the world population, or between 40 and 50 million people worldwide. All races and both sexes are equally affected. A variety of therapies are available in an attempt to repigment those affected with vitiligo. The 308-nm excimer laser has shown promising results in the treatment of vitiligo. Spencer et al. (Spencer et al. 2002) evaluated 18 patients with vitiligo. Twenty three patches of vitiligo, in 12 patients, received at least six treatments with the excimer laser. A response rate of 57% was noted. Eleven patches, in six patients, received 12 treatments and had an 82% response rate. (Fig. 6.21). A targeted narrowband UVB device can also be used for repigmentation. Initial clinical reports support its usefulness in the treatment of vitiligo (Fig. 6.22).
■ Hypopigmented Stretch Marks
Hypopigmented stretch marks (striae) are often seen in dermatologic and cosmetic clinics. Vascular stretch marks are easy to treat with a variety of vascular lasers and IPLs. Hypopigmented stretch marks are more difficult to treat. Goldberg and his group (Sarradet et al. 2002) treated ten patients with mature hypopigmented striae using the 308 nm excimer laser. Repigmentation was noted in all study participants; acceptable results were seen in 70% of the individuals. The targeted UVB device may improve this loss of
Fig. 6.23. a Hypopigmented stretch marks before narrowband UVB targeted therapy. b Hypopigmented stretch marks after four narrowband UVB targeted therapy treatments
pigmentation. We also have evaluated 50 individuals who after ten treatments were noted to have between 30 and 40% repigmentation. (Figs. 6.23,6.24).
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