Steven Paul Nistico

Vitiligo Treatment with Monochromatic Excimer Light and Tacrolimus: Results of an Open Randomized Controlled Study

BACKGROUND DATA Narrow band ultraviolet B (UVB) is an effective and safe option for the treatment of vitiligo. However, a complete and long-lasting repigmention of vitiligo patches is difficult to achieve. Combined treatments with novel sources of phototherapy and topical agents represent possible new strategies. OBJECTIVE The purpose of this study was to compare the efficacy of combined tacrolimus and 308-nm excimer light (MEL) vs 308-nm MEL monotherapy in treating vitiligo in a controlled study. METHODS Fifty-three patients affected by vitiligo were enrolled in this open prospective study. Patients were divided into three groups: Group I included 20 patients treated with MEL 308 nm twice weekly and oral vitamin E; Group II included 20 patients treated with MEL 308 nm twice weekly combined with 0.1% tacrolimus once a day and oral vitamin E; and Group III included 13 patients treated only with oral vitamin E. Efficacy was assessed at the end of 12 weeks based on the percentage of repigmentation. RESULTS Fifty-two patients completed 12 weeks of treatment. Group I (MEL + vitamin E) showed a moderate repigmentation in 35% of patients, good repigmentation in 30%, excellent repigmentation in 25%, and poor repigmentation in 10%; Group II (MEL + tacrolimus 0.1%+ vitamin E) presented moderate repigmentation in 25% of patients, good repigmentation in 40%, excellent repigmentation in 30%, and poor repigmentation in 5%; Group III (vitamin E) showed moderate repigmentation in 16% and 84% did not show signs of repigmentation. CONCLUSIONS Our results demonstrate that the combination treatment of 0.1% tacrolimus ointment plus 308-nm MEL and 308-nm MEL monotherapy are effective, safe, and well tolerated for the treatment of vitiligo compared to treatment with vitamin E. Furthermore, this study suggests that an association with topical immunomodulators could enhance the clinical response in vitiligo, especially in more resistant anatomical sites.

Different applications of monochromatic excimer light in skin diseases.

BACKGROUND Ultraviolet radiation has been used for curative purposes in dermatologic conditions, especially in the last 30 years. OBJECTIVES We analyzed the efficacy of monochromatic excimer light in psoriasis, palmoplantar pustulosis, vitiligo, mycosis fungoides and alopecia areata, and to examine potential new indications. METHODS Two hundred seventy-nine patients with common and persistent skin diseases were enrolled in an open prospective study: 152 patients with stable and localized plaque psoriasis, 47 with palmoplantar psoriasis, 7 with palmoplantar pustulosis, 32 with vitiligo, 11 with prurigo nodularis, 9 with mycosis fungoides stage Ia, 8 with alopecia, 5 with localized scleroderma, 5 with genital lichen sclerosus, and 3 with granuloma annulare. The 308 nm excimer light was used at a power density of 48 mW/cm(2). An average of 12 sessions (range, 6-18), one session per week, was performed and yielded a total dose range of 4-12.5 J/cm(2). Clinical response was assessed using photos, biopsies, and specific clinical scores. Patients were monitorized for 6 and 12 months for psoriasis, 12 months for mycosis fungoides, and 4 months for the remaining conditions. RESULTS We observed complete remission in more than 50% of patients with plaque psoriasis and palmoplantar dermatoses, respectively, complete remission in all patients affected by mycosis fungoides, excellent repigmentation in one third of vitiligo patients, hair regrowth in three patients with alopecia areata, an overall improvement in prurigo nodularis, a partial remission in patients affected by localized scleroderma, and a complete remission in most of the patients with genital lichen sclerosus and granuloma annulare. CONCLUSIONS Our study confirms the use of monochromatic excimer light as a valid choice for the treatment of psoriasis, vitiligo, and mycosis fungoides; we also observed and report for the first time that monochromatic excimer light produces a therapeutic response in prurigo nodularis, localized scleroderma, genital lichen sclerosus, and granuloma annulare.

UVA-1 laser in the treatment of palmoplantar pustular psoriasis.

OBJECTIVE The purpose of this study was to assess the efficacy of monochromatic UVA laser in the treatment of palmoplantar pustular psoriasis (PPP). BACKGROUND DATA UVA-1 laser (355 nm) has been reported to be safe and effective in the treatment of psoriasis, but the range of potential applications has not been fully explored. METHODS Thirty-three patients were enrolled in an open prospective study. Patients were treated from two to four times weekly at a fixed dose of 80-140 J/cm(2). Follow-up was 3 months. Clinical remission was observed in all patients who completed the study, with limited side effects (mild post-treatment erythema). CONCLUSIONS We report for the first time that UVA-1 laser produces a therapeutic response in PPP.

Complete Resolution of Erythrodermic Psoriasis in an HIV and HCV Patient Unresponsive to Antipsoriatic Treatments after Highly Active Antiretroviral Therapy (Ritonavir, Atazanavir, Emtricitabine, Tenofovir)

Background: Psoriasis is a chronic, inflammatory disease affecting 2-3% of the worldwide population, and it may worsen with HIV or be detected as HIV cutaneous manifestation. HIV-related psoriasis shows a severe and prolonged clinical course with more frequent exacerbations. The management of this condition is challenging because im-munomodulating and immunosuppressant agents may have variable and partial efficacy, and therefore, antiretroviral treatment represents a potential adjunctive therapeutic option. Results: In the case we report, the HIV test was shown to be crucial for driving the therapeutic approach. Indeed, antiretroviral agents have been proven to be effective in the treatment of HIV+ psoriasis as first-line therapy. Conclusion: The HIV test should be considered in high-risk patients affected by severe psoriasis and resistant to conventional and biological treatments.

Flash-lamp pulsed-dye laser treatment of keloids: results of an observational study.

OBJECTIVE Flash lamp pulsed dye laser (FPDL) was used in a selected group of patients with hypertrophic scars and keloids. Objective of the study was to assess the efficacy on a large number of cases. BACKGROUND DATA FPDL is a nonablative technology, typically used in vascular malformation therapy because of its specificity for hemoglobin. METHODS A total of 59 patients (33 males and 26 females, mean age 37.5 years) affected by hypertrophic postsurgical scars and keloids, underwent from four to six treatment sessions with a flash lamp pumped pulsed dye laser. Clinical follow-up was performed 6 months after the last treatment. Results were judged by blind observers. RESULTS A total of 29 patients out of 59 (49.1%) achieved excellent clearance, 15 patients (25.4%) achieved good to moderate clearance, and 12 patients (20.4%) obtained slight improvement. Only three subjects (5%) had little or no removal of their lesion. Treatment was well tolerated with minor and transient side effects. CONCLUSIONS FPDL is known as a safe and effective treatment for different dermatological lesions in which skin microvessels play a key role in pathogenesis or development. This laser was effective when applied to hypertrophic scars and keloids. Further studies in a larger set of patients, however, are required to assess a standardized and reproducible method for treating these lesions.

Deep pulse fractional CO2 laser combined with a radiofrequency system: results of a case series

OBJECTIVE The purpose of this study was evaluation of the safety and efficacy of this new combined technology that adds deep ablation to thermal stimulation. BACKGROUND DATA Minimally ablative or subablative lasers, such as fractional CO2 lasers, have been developed in an attempt to achieve the same clinical results observed with traditional ablative lasers, but with fewer side effects. Despite being an ablative laser, the system used in this study is able to produce a fractional supply of the beam of light. Fractional ablation of skin is performed through the development of microscopic vertical columns surrounded by spared areas of epidermis and dermis, ensuring rapid wound healing and minimum down time. Simultaneous synchronized delivery of a radiofrequency (RF) current to the deeper layers of the skin completes the therapeutic scenario, ensuring an effective skin tightening effect over the entire treated area. METHODS Nine adult patients were treated for wrinkles and acne scars using this new laser technology. An independent observer evaluated the improvement using a five point scale. RESULTS All patients had good results in terms of improvement of skin texture, with mild and transitory side effects. CONCLUSIONS This novel combined system produced improvement in wrinkles and acne scars, with progressive enhancement of skin tone and elasticity.

Effects of TNF-α and IL-1 β on the activation of genes related to inflammatory, immune responses and cell death in immortalized human HaCat keratinocytes.

The present experiments were designed to characterize by microarray analysis the transcriptional responses of human keratinocytes (HaCat) to TNF-α and IL-1β, given alone or in combination, in order to better understand the mechanisms underlying inflammatory, immune responses and cell death in which both cytokines play a pathophysiological role. Significant differences in the percentage and quality of genes dysregulated by TNF-α and IL-1β were shown. Both cytokines activated a series of genes involved in inflammatory, immune response as well as in cell death. In our experimental conditions, TNF-α, in contrast to IL-1β, did not induce a significant level of apoptosis in keratinocytes. However, given together both cytokines produced a significant decrease in apoptotic cells and synergistic transcriptional response which was due to the activation of several specific genes occurring after application of each cytokine. TNF-α and IL-1β evoked apoptotic effect and transcriptional responses were linked to the stimulation of their specific receptors since a pre-treatment with monoclonal antibodies vs TNF-α and/or IL-1β receptors was able to significantly reduce them.

Cost-efficacy analysis of 3% diclofenac sodium, ingenol mebutate, and 3.75% imiquimod in the treatment of actinic keratosis:

Actinic keratosis (AK) is a clinical condition characterized by keratinocytic dysplastic lesions of the epidermis, affecting individuals chronically exposed to sunlight. Topical therapies allow the treatment of a whole area of affected skin and currently include diclofenac sodium gel, 5-fluorouracil cream, 5-fluorouracil and acetylsalicylic acid solution, imiquimod cream, and ingenol mebutate gel. Due to the comparable efficacy of 3% diclofenac, ingenol mebutate, and 3.75% imiquimod in treating AK multiple lesions, a pharmacoeconomic evaluation of cost-effectiveness of the three treatments was needed. A cost-efficacy analysis comparing 3% diclofenac sodium with ingenol mebutate and 3.75% imiquimod was performed. In this analysis, efficacy data were combined with quality-of-life measurement derived from previous studies as well as the costs associated with the management of these lesions in Italy. Patients’ demographics and clinical characteristics were assumed to reflect those from the clinical studies considered.

Update of calcineurin inhibitors to treat inverse psoriasis: A systematic review

Inverse psoriasis commonly involves skin fold areas including the axillae, perianal skin, intergluteal cleft, inframammary, genital/inguinal, abdominal, and retroauricular folds. Topical calcineurin inhibitors are indicated for the treatment of atopic dermatitis but have also been studied in the treatment of psoriasis. The object of the present study is to define the efficacy of topical calcineurin inhibitors in the treatment of psoriasis. We checked for English‐vernacular articles conveyed since 1990 in PubMed, Ovid/Cochrane, and Embase using “tacrolimus,” “pimecrolimus,” or “topical calcineurin inhibitors,” and “psoriasis” as keywords. Eight double‐blind studies and seven open studies displayed the ampleness of topical tacrolimus in psoriasis. Included studies demonstrated a considerable efficacy of topical administration of tacrolimus and pimecrolimus in the treatment of psoriasis, especially for facial, genital, and intertriginous areas. The role of topical tacrolimus and pimecrolimus in the treatment of psoriasis seems to be promising as shown by the results of double‐blind and open studies. Because these agents do not cause cutaneous atrophy, they have a special role in facial, genital, and intertriginous psoriatic lesions. Both agents await additional investigation to determine their roles.

Fluorescent light energy: Treating rosacea subtypes 1, 2, and 3

Kleresca® biophotonic platform utilizing fluorescent light energy effectively decreased the inflammatory and erythematous reaction common in rosacea subtypes 1, 2, and 3. Kleresca® may be considered as a single treatment for rosacea, targeting multiple features, or combined with invasive methods for an enhanced normalizing and healing profile of the skin.