Michela Troiano

Targeted and combination treatments for vitiligo Comparative evaluation of different current modalities in 458 subjects

ABSTRACT:  The current treatment of vitiligo is not satisfactory according to the opinions of both the patient population and the dermatologists. Recently, combination therapies have been introduced, which are both systemic and targeted (microphototherapy). To evaluate the effects of topical treatments given alone or in combination with 311‐nm narrow‐band microphototherapy. We evaluated the efficacy and safety of: (1) 311‐nm narrow‐band microphototherapy;(2) tacrolimus 0.1% ointment twice a day; (3) pimecrolimus 1% cream twice a day; (4) betamethasone dipropionate 0.05% cream twice a day; (5) calcipotriol ointment 50 µg/g twice a day; and (6) 10%l‐phenylalanine cream twice a day, for the treatment of exclusively vitiligo patches. A 311‐nm narrow‐band microphototherapy (Bioskin®) was given alone or in combination with the above‐mentioned popular local treatments. Four hundred and seventy patients suffering from vitiligo that affected less than 10% of the skin surface were evaluated. The patients were divided into 11 groups according to the selected treatment modalities. Four hundred and fifty‐eight patients completed the study period of 6 months. Excellent repigmentation (> 75%) was achieved by 72% of the patients in group 1, 76.5% in group 2, 76.1% in group 3, 90.2% in group 4, 75.6% in group 5, 74.8% in group 6, 61% in group 7, 54.6% in group 8, 71.2% in group 9, 59.1% in group 10, and 29.3% in group 11. Marked repigmentation (50–75%) was evident in 19.8% of the patients in group 1, 18.2% in group 2, 20.1% in group 3, 6.7% in group 4, 14.1% in group 5, 11.3% in group 6, 16.1% in group 7, 18.4% in group 8, 25% in group 9, 10.6% in group 10, and 8.1% in group 11. Moderate results (25–50% repigmentation) were seen in 4.6% of the patients in group 1, 3.3% in group 2, 2.7% in group 3, 2.2% in group 4, 7.4% in group 5, 10.1% in group 6, 18.4% in group 7, 21.7% in group 8, 2.1% in group 9, 27.1% in group 10, and 55% in group 11. Finally, minimal (< 25%) or no response was achieved in 3.6% of the patients in group 1, 2% in group 2, 1.1% in group 3, 0.9% in group 4, 2.9% in group 5, 3.8% in group 6, 4.5% in group 7, 5.3% in group 8, 1.75% in group 9, 3.2% in group 10, and 7.6% in group 11. Side effects were skin atrophy (76% in group 4 and 81% in group 9), stinging and burning (groups 2, 3, 7, and 8). Targeted combination therapies in vitiligo are remarkably more effective than single treatments. When single treatments are considered alone, 311‐nm narrow‐band UVB microfocused phototherapy and 0.05% betamethasone dipropionate cream are the most effective treatments in our study. When combined therapies are chosen, 0.05% betamethasone dipropionate cream plus 311‐nm narrow‐band UVB microfocused phototherapy apparently give the highest repigmentation rate. In the short term, the only side‐effects registered have been cutaneous atrophy with corticosteroid cream, and stinging and burning with 0.1% tacrolimus ointment and, less frequently, with 1% pimecrolimus cream.

Fractional CO2 laser: a novel therapeutic device upon photobiomodulation of tissue remodeling and cytokine pathway of tissue repair

Minimally ablative fractional laser devices have gained acceptance as a preferred method for skin resurfacing. Notable improvements in facial rhytides, photodamage, acne scarring, and skin laxity have been reported. The aim of the present work was to compare how different CO2 laser fluences, by modulating the secretory pathway of cytokines, are able to influence the wound‐healing process, and how these fluences are associated with different clinical results. Eighteen patients, all with photodamaged skin, were treated using a fractional CO2 laser (SmartXide DOT, Deka M.E.L.A., Florence, Italy) with varying laser fluences (2.07, 2.77, and 4.15 J/cm2). An immunocytochemical study was performed at defined end points in order to obtain information about specific cytokines of the microenvironment before and after treatment. The secretory pathway of cytokines changed depending on the re‐epithelization and the different laser fluences. Different but significant improvements in wrinkles, skin texture, and hyperpigmentation were definitely obtained when using 2.07, 2.77, and 4.15 J/cm2, indicating fractional CO2 laser as a valuable tool in photorejuvenation with good clinical results, rapid downtime, and an excellent safety profile.

Photodynamic therapy: Off-label and alternative use in dermatological practice

Photodynamic therapy (PDT) is a treatment technique that permits the clearance of different skin lesions with high success rates in many dermatological diseases. Worldwide recognized uses for PDT in dermatology include non-melanoma skin cancer, actinic keratoses, acne vulgaris, photorejuvenation, and hidradenitis suppurativa. In the European Union, and in the USA, its indication is for the treatment of nonhyperkeratotic actinic keratoses (AKs) of the face and scalp, for basal cell carcinoma and for Bowens disease. However, due to its intriguing mechanism of action, many dermatologists have begun to look at the use of PDT in photorejuvenation, acne vulgaris and hidradenitis suppurativa. Moreover, clinicians have to learn how to maximize this kind of therapy to treat other dermatologic entities, and many anecdotic reports can already be found in the literature. This paper aims to briefly but critically review these reports to give the dermatologist a useful guide to what could be the future experiences in PDT and how to target their efforts in clinics and research.

In vivo non-invasive monitoring of collagen remodelling by two-photon microscopy after micro-ablative fractional laser resurfacing.

Non-linear optical microscopy is becoming popular as a non-invasive in vivo imaging modality in dermatology. In this study, combined TPF and SHG microscopy were used to monitor collagen remodelling in vivo after micro-ablative fractional laser resurfacing. Papillary dermis of living subjects, covering a wide age range, was imaged immediately before and forty days after treatment. A qualitative visual examination of acquired images demonstrated an age-dependent remodelling effect on collagen. Additional quantitative analysis of new collagen production was performed by means of two image analysis methods. A higher increase in SHG to TPF ratio, corresponding to a stronger treatment effectiveness, was found in older subjects, whereas the effect was found to be negligible in young, and minimal in middle age subjects. Analysis of collagen images also showed a dependence of the treatment effectiveness with age but with controversial results. While the diagnostic potential of in vivo multiphoton microscopy has already been demonstrated for skin cancer and other skin diseases, here we first successfully explore its potential use for a non-invasive follow-up of a laser-based treatment.

Infliximab efficacy in nail psoriasis. A retrospective study in 48 patients.

Background  Nail psoriasis occurs in up to half of psoriatic patients and can lead to significant physical impairment and pain. To date, patients and clinicians are actually dissatisfied by current therapeutic approaches.

Vascular based non conventional dye laser treatment for basal cell carcinoma

ABSTRACT:  Basal cell carcinoma is the most common skin tumor in humans which can be removed in a variety of ways (depending on the type of the lesion, the affected area, and depth of the lesion). Laser therapy offers another option to the traditional methods of treatment; thus, the purpose of this work is to valuate the efficacy of dye laser in a selected group of patients affected by superficial basal cell carcinoma. We suggest that the success of pulse dye laser treatment lies in the fact that as all tumors, basal cell carcinomas contain an increased number of dilated blood vessels. Twenty patients (eight males and 12 females) with superficial basal cell carcinoma were given five treatments with a flashlamp‐pumped pulse dye laser every 20 days. The clinical follow up was 12–24 months after the fifth treatment. A complete response was obtained in 16 patients out of 20. Three recurrences and one no response was observed during the study. Pulse dye laser is effective and safe in the treatment of superficial basal cell carcinoma

Intense pulsed light in the treatment of non‐aesthetic facial and neck vascular lesions: report of 85 cases

Background  Intense pulsed light (IPL) treatment is one of the most effective procedures for patients with non‐aesthetic vascular lesions in addition to signs of skin photoageing, and it has been reported as very successful in the treatment of telangiectasias, spider nevi, erythrosis, and above all, rosacea and poikiloderma. Its use is based on the principle of selective photothermolysis, which exploits the haemoglobin absorption peak among its range of wavelengths.

Melasma: Treatment with 10% tretinoin peeling mask

Background  Melasma is one of the most frequently acquired hyperpigmentation disorders clinically characterized by symmetrical brown patches on sun exposed areas. The first approach is an avoidance of sun exposure and inflammation combined with a use of photoprotection. Patient treatment is particularly difficult and challenging, and necessitates consideration of many therapies, including tretinoin to obtain an amelioration of this important skin condition.

Cutaneous mastocytosis: successful treatment with narrowband ultraviolet B phototherapy

Mastocytosis is an heterogeneous group of conditions characterized by an increased number of mast cells in the skin or, less frequently, in other organs such as the liver, spleen, lymph nodes, bone marrow, lungs and gastrointestinal system. The commonest clinical skin forms are urticaria pigmentosa (UP), solitary mastocytoma, diffuse cutaneous mastocytosis and teleangectasia macularis eruptive perstans. According to consensus statements on diagnostics, treatment recommendations and response criteria, the diagnosis of mastocytosis in the skin (MIS) is a multistep process. We report our experience of managing UP, the commonest form of cutaneous mastocytosis, with narrowband ultraviolet B (NB-UVB) therapy, and highlight the difficulties in management of this disease. Seven patients (five women, two men) with the typical skin rash of UP and a positive Darier sign were admitted to our hospital. Four patients were aged < 16 years, and three were aged > 16 years. Mean ± SD age at onset ⁄ admittance was 20.86 ± 14.85 years (range 8–44), and age at start of treatment was 26.43 ± 11.50 (range 17–46); time between onset and start of treatment ranged from 1 to 9 years. Symptoms included pruritus, and no systemic symptoms were present. Histological examination of biopsies from the patients found an increase in spindle-shaped mast cells in the dermis, which stained positive with Giemsa stain. Examination of a bone-marrow biopsy found no involvement. Serum tryptase level was < 20 ng ⁄ mL. All patients underwent 12 sessions of narrowband ultraviolet (UVB) phototherapy. The first dose was based on the patient s minimal erythema dose (MED) according to their Fitzpatrick skin phototype. As all our patients were phototype III and IV, the MED range was 30–35 and from 40 to 60 mJ ⁄ cm, respectively. Patients were started on a low dose (70–80% of MED) initially; if this was well tolerated, it was increased progressively by 20% of the previous dose each time. Each cycle consisted of 12 consecutive treatments, and each cycle was repeated three times. The goal of treatment was to cause suppression of the disease process, in particular the itch, without causing additional discomfort. After the first cycle, a dramatic improvement in the cutaneous lesions was seen and a reduction in pruritus was reported by the patients (Figs 1a–d). Currently there is no safe, effective ablative treatment for mast cells or any effective mast-cell stabilizing drugs.

Highlights of Thirty-Year Experience of CO2 Laser Use at theFlorence (Italy) Department of Dermatology

The CO2 laser has been used extensively in dermatological surgery over the past 30 years and is now recognised as the gold standard for soft tissue vaporization. Considering that the continuous wave CO2 laser delivery system and the newer “superpulsed” and scanned CO2 systems have progressively changed our practice and patient satisfaction, a long range documentation can be useful. Our experience has demonstrated that the use of CO2 laser involves a reduced healing time, an infrequent need for anaesthesia, reduced thermal damage, less bleeding, less inflammation, the possibility of intra-operative histologic and/or cytologic examination, and easy access to anatomically difficult areas. Immediate side effects have been pain, erythema, edema, typically see with older methods, using higher power. The percentage of after-treatment keloids and hypertrophic scars observed was very low (~1%) especially upon the usage of lower parameters. The recurrence of viral lesions (condylomas and warts) have been not more frequent than those due to other techniques. Tumor recurrence is minor compared with radiotherapy or surgery. This method is a valid alternative to surgery and/or diathermocoagulation for microsurgery of soft tissues. Our results are at times not consistent with those published in the literature, stressing the concept that multicentric studies that harmonization methodology and the patient selection are vital.