|Year : 2014 | Volume
| Issue : 2 | Page : 74-78
308 nm excimer lamp in combination with topical tacrolimus: A retrospective study of its efficacy and safety in childhood vitiligo
BS Chandrashekar, N Shobha, P Jagadish, Vani Vasanth, ML Rajashekar, MA Sandeep
Department of Dermatology, Cutis, Academy of Cutaneous Sciences, Bangalore, India
|Date of Web Publication||27-Aug-2014|
B S Chandrashekar
#5/1, 4th Main Road, MRCR Layout, Near Veeresh Theatre Behind Godrej Interio, Vijaynagar, Bengaluru - 560 040, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Vitiligo is a chronic, polygenic dyschromia that presents with multiple depigmented macules and patches. Among the various therapeutic modalities for treatment of vitiligo in children, phototherapy as one of the mainstay treatments has varying therapeutic efficacy. There is limited data regarding the use of combination of tacrolimus and 308 nm excimer lamp for treatment of vitiligo in children.
Aim: The aim of the present study is to retrospectively assess the efficacy and tolerability of 308 nm Excimer lamp in combination with topical tacrolimus to treat vitiligo in children below 17 years with skin type III, IV and V.
Methods: Case sheets and photographs of 47 vitiligo patches from 24 children (male = 9, female = 15), <17 years were evaluated in this study. Data of patients with active disease and stable vitiligo not treated previously were chosen for this study. The patches were treated with topical tacrolimus daily and excimer lamp thrice weekly, for a maximum of 20 sittings.
Results: Of the 47 patches, 35 patches achieved repigmentation accounting to 74.4% of the total patches. The repigmentation response was good in ultraviolet (UV) sensitive areas but minimal in UV resistant areas. All the patches retained pigmentation during the follow-up period of 12-18 months.
Conclusion: The degree of repigmentation achieved with topical tacrolimus and excimer lamp in a period of 4-6 weeks is much higher than other contemporary vitiligo therapies in children. This dual therapy of topical tacrolimus and 308 nm Excimer lamp is a safe and effective therapy showing an early response, for localized vitiligo in children.
Keywords: 308 nm excimer lamp, childhood vitiligo, repigmentation, topical tacrolimus
|How to cite this article:|
Chandrashekar B S, Shobha N, Jagadish P, Vasanth V, Rajashekar M L, Sandeep M A. 308 nm excimer lamp in combination with topical tacrolimus: A retrospective study of its efficacy and safety in childhood vitiligo. Indian J Paediatr Dermatol 2014;15:74-8
|How to cite this URL:|
Chandrashekar B S, Shobha N, Jagadish P, Vasanth V, Rajashekar M L, Sandeep M A. 308 nm excimer lamp in combination with topical tacrolimus: A retrospective study of its efficacy and safety in childhood vitiligo. Indian J Paediatr Dermatol [serial online] 2014 [cited 2019 May 23];15:74-8. Available from: http://www.ijpd.in/text.asp?2014/15/2/74/139503
| Introduction|| |
Vitiligo is a chronic, idiopathic acquired disorder which is characterized by progressive loss of melanocytes from the epidermis and the epidermal appendages. However successful treatment of vitiligo in all patients is still a mirage, although various combination modalities like topical steroids, immunomodulators, phototherapy and surgical therapies are commonly used. In the majority of patients, it affects the psychosocial development and quality of life resulting in a low self-esteem. Global prevalence of vitiligo is 1-3%.  In 50% of affected patients, the onset is below 20 years of age,  further adding on to parental apprehensions and anxiety. Therefore, it is very important that childhood vitiligo is diagnosed and treated at the appropriate time.
Patients with vitiligo often present with abnormalities of both humoral and cell-mediated immunity. Tacrolimus, a topical immunomodulator, modulates the immune system by inhibiting T-cell activation through down regulation of the transcription genes encoding proinflammatory cytokines, namely interleukin (IL)-2, IL-3, IL-4, IL-5; interferon-γ; tumor necrosis factor-α; and granulocyte-macrophage colony-stimulating factor. Tacrolimus 0.1% is Food and Drug Administration approved for atopic dermatitis and is used off label for several other dermatologic conditions, such as vitiligo and psoriasis. Although the mechanism of action of tacrolimus has been elucidated, data describing how tacrolimus modulates the cutaneous milieu remain unknown. 
The 308 nm excimer lamp generates single wavelength ultraviolet B (UVB) radiation with a spot size of 2 cm × 2 cm and a pulse repetition rate up to 200 Hz. It has an adjustable exposure time. The 308-nm wavelength is particularly effective at inducing apoptosis of T-lymphocytes and stimulation of melanocyte migration and proliferation from the niche located in the hair follicles.  It stabilizes the progression of the disease and induces an early repigmentation with face lesions responding the earliest and best. 
A repigmentation rate of >75% in 20-60% of patients is achieved, depending on dosage and location of treatment. A major limitation to widespread use of 308-nm excimer lamp therapy is the difficulty in treating patients with a large body surface area (BSA), cost of treatment and equipment. 
A combination of topical tacrolimus and excimer lamp is an effective modality to treat vitiligo in adults. However its efficacy in children is less explored.
| Aim|| |
To retrospectively assess the efficacy and tolerability of 308 nm Excimer lamp in combination with topical tacrolimus to treat vitiligo in children below 17 years with skin type III, IV and V.
| Methods|| |
Case sheets and photographs of 47 vitiligo patches in 24 children (male = 9, female = 15), less than 17 years were included in the study. Data of patients with active disease and stable vitiligo, previously not treated were chosen for this study.
Treatment had started with one minimal erythema dose (equivalent to 150 mJ/cm 2 ) and was increased in a stepwise pattern by 100 mJ/cm 2 every sitting until redness had developed, in which case the dose was kept constant, reduced or skipped (if burning or blistering developed). Treatment was given thrice a week. A total of 20 sittings were completed. Topical tacrolimus was used for all patches on a daily basis during the therapy. The eyes were protected with UV protective glasses.
Photographs of 47 patches involving the face and neck, lips and scalp, trunk, limbs and extremities, which were taken at baseline, 2 nd , 4 th and 6 th week of treatment, were evaluated for erythema and obtaining repigmentation scores. The repigmentation was graded on a 5 point scale, (0-4) assessed according to [Table 1].
| Results|| |
47 vitiligo patches in 24 children were evaluated for repigmentation on a 5 point scale (0-4) as shown in [Table 1]. Of the 47 patches 35 patches have shown repigmentation, accounting to 74.4% of the total patches. [Figure 1] depicts the percentage of patches that have achieved 0-4 grades of repigmentation. Some of the patches began repigmentation as early as the 4 th sitting itself [Figure 2] a and b] and achieving more repigmentation on further excimer sittings. All patches responded by the 12 th week of the treatment except for the patches on palms, soles and scalp. The varied response of all vitiligo patches from different body sites, to excimer lamp is depicted in [Figure 3] and [Table 2].
|Table 2: The repigmentation grades at different body sites after 20 sittings of excimer lamp therapy |
Click here to view
|Figure 1: Pie chart depicting the overall repigmentation grades achieved in 20 sittings of excimer lamp therapy|
Click here to view
|Figure 2a and b: Pictures before the excimer treatment and after 4th sitting depicting the start of repigmentation|
Click here to view
|Figure 3: Bar chart showing grades of repigmentation at different sites following excimer lamp treatment|
Click here to view
The Facial Region
Seven out of 19 patches had 76-100% repigmentation (Grade 4), 4 patches showed a repigmentation of Grade 3. 5 patches had a 25-50% of repigmentation, i.e. Grade 2 and 3 patches showed Grade 1 improvement. All the patches in the facial region responded to the excimer lamp. Complete repigmentation of the periocular region is shown in [Figure 4].
|Figure 4a and b: Grade 4 repigmentation before the excimer treatment in 4a and after 20 sittings of the excimer treatment in 4b|
Click here to view
The Trunk Region
Five out of 8 patches had 76-100% repigmentation (Grade 4), 2 patches showed a repigmentation of Grade 3. 1 patch showed Grade 1 improvement. All the patches in the trunk region responded to the excimer lamp.
Out of 4 patches in the limbs, 2 patches showed Grade 3 repigmentation and two patches showed a repigmentation of Grade 4.
The Extremities (Fingers, Toes, Palms and Soles)
Out of nine patches in this region, only two patches showed Grade 1 repigmentation and the other 7 had no repigmentation at all.
The Lips and Scalp
Like the extremities, this area too showed comparatively poor response to excimer lamp treatment as shown in [Figure 5]. Out of 5 patches in the lips one had Grade 3 repigmentation and one patch showed Grade 1 repigmentation. Both the patches in the scalp showed no regimentation. All the patients in our study retained the pigmentation during the 12-18 months follow-up period.
|Figure 5a and b: Grade 0 repigmentation in the lips region before the excimer laser treatment 5a and after 20 sittings of the excimer treatment 5b|
Click here to view
| Discussion|| |
Of all the modalities available for treating vitiligo in children, phototherapy is the mainstay and is associated with varying rates of efficacy. NBUVB is helpful in patients who have >20% of BSA involvement. It requires regular sessions several times a week for about a year to achieve expected therapeutic response. Targeted 308 nm excimer monotherapy is an alternative therapy which actively controls the disease progression and also induces repigmentaion in a short duration. In a study by Ostovari et al., the effectiveness of the 308-nm excimer lamp treatment was not affected by patient age, suggesting that this modality may be useful in the pediatric population.  Excimer lamp has the advantage of delivering high intensity radiation to the diseased skin, thus reducing the exposure of normal skin to radiation side effects. 
Ostovari et al. and Taneja et al.'s studies found that UV sensitive areas achieved 75% repigmentation versus UV resistant areas showing 16% repigmentation. , In our study all the 21 UV sensitive patches (face, neck and limbs) showed repigmentation, of which 15 patches (=71.4%) showed Grade 3 and 4 (>50%) repigmentation. Of the 16 UV resistant patches (lips, palms, soles, fingers and toes) 4 patches (=25%) showed repigmentation of Grade 3 and 1 [Figure 2].
Westerhof and Nieuweboer-Krobotova conducted a study with UVB 311-nm therapy in which 8% of patients achieved more than 75% repigmentation on 3 months treatment.  Studies by Hofer et al. with excimer showed more than 75% repigmentation in 13% of patients with 30 treatment sessions.  These data indicate that repigmentation is achieved within 30 treatment sessions. This is comparable to our study where a repigmentation response was noted as early as the fourth sitting, with increasing pigmentation on continuing treatment (74.4% repigmentation of 35/47 patches over 7 weeks treatment), with an average dose of 500 mJ/cm 2 in UV sensitive areas. However the UV resistant areas showed a minimal response with an average dose as high as 1400 mJ/cm 2 . We could observe that if repigmentation did not begin by the 12 th sitting then probably further sittings with excimer or alternate phototherapy are not beneficial.
When compared with excimer lamp monotherapy, topical tacrolimus with excimer lamp acts synergistically reducing the duration of clinical response. ,
Side-effects were noted in 6 patches (face, neck and lips) cautioning the slow increment in the dose of radiation during therapy. Erythema, peeling and burns were observed in 2 patches, [Figure 6] erythema alone was noticed in 4 patients. Peri-lesional hyperpigmentation was noted in some patches which reduced following discontinuation of therapy.
|Figure 6a-c: Pictures before excimer therapy in 6a, 6b showing of erythema and burns following the 9th sitting. Grade 4 improvements was seen by the end of 15th sitting depicted in 6c|
Click here to view
However, further prospective studies with a larger study population and a control group can be conducted to study the effect of excimer therapy in children.
| Conclusion|| |
Since UV sensitive areas have shown 75-100% repigmentation, primarily children with vitiligo patches in UV sensitive areas can be considered for excimer therapy. Moreover, Excimer lamp is preferable in children as it prevents claustrophobia, which is otherwise experienced with NBUVB chamber.
For patches that don't respond to 20 sittings of excimer lamp, an alternate therapy should be considered. Topical tacrolimus and excimer lamp act synergistically, thereby reducing the duration of clinical response.
308 nm excimer lamps can be safely used, with an effective and early response in childhood vitiligo, minimizing the exposure to radiation thus resulting in cosmetically satisfying results.
| References|| |
|1.||Hadi SM, Spencer JM, Lebwohl M. The use of the 308-nm excimer laser for the treatment of vitiligo. Dermatol Surg 2004;30:983-6. |
|2.||Cho S, Zheng Z, Park YK, Roh MR. The 308-nm excimer laser: A promising device for the treatment of childhood vitiligo. Photodermatol Photoimmunol Photomed 2011;27:24-9. |
|3.||Kawalek AZ, Spencer JM, Phelps RG. Combined excimer laser and topical tacrolimus for the treatment of vitiligo: A pilot study. Dermatol Surg 2004;30:130-5. |
|4.||Patel NS, Paghdal KV, Cohen GF. Advanced treatment modalities for vitiligo. Dermatol Surg 2012;38:381-91. |
|5.||Zhang XY, He YL, Dong J, Xu JZ, Wang J. Clinical efficacy of a 308 nm excimer laser in the treatment of vitiligo. Photodermatol Photoimmunol Photomed 2010;26:138-42. |
|6.||Ostovari N, Passeron T, Zakaria W, Fontas E, Larouy JC, Blot JF, et al. Treatment of vitiligo by 308-nm excimer laser: An evaluation of variables affecting treatment response. Lasers Surg Med 2004;35:152-6. |
|7.||Taneja A, Trehan M, Taylor CR. 308-nm excimer laser for the treatment of localized vitiligo. Int J Dermatol 2003;42:658-62. |
|8.||Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs topical psoralen plus UV-A. Arch Dermatol 1997;133:1525-8. |
|9.||Hofer A, Hassan AS, Legat FJ, Kerl H, Wolf P. The efficacy of excimer laser (308 nm) for vitiligo at different body sites. J Eur Acad Dermatol Venereol 2006;20:558-64. |
|10.||Passeron T, Ostovari N, Zakaria W, Fontas E, Larrouy JC, Lacour JP, et al. Topical tacrolimus and the 308-nm excimer laser: A synergistic combination for the treatment of vitiligo. Arch Dermatol 2004;140:1065-9. |
|11.||Passeron T, Ostovari N, Zakaria W, Ortonne J. Connection of tacrolimus and 308 nm excimer laser in treating vitiligo. J Am Acad Dermatol 2004;50:138. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]