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Psoriasis
Table 2: XTRAC
®
Ultra Dosage Protocol for Subsequent Treatments
Determining Dose for Subsequent Treatments of Psoriasis
Clinical Observation No Effect Minimal Effect Good Effect Considerable Improvement Moderate/Severe Erythema
No erythema from Slight erythema from Mild to moderate Significant improvement with With or without blistering
12 to 24 hours and no 12 to 24 hours but no erythema response plaque thinning or reduced
plaque improvement significant improvement from 12 to 24 hours scaliness or pigmentation
Change from Prior Treatment Dose
Typical dosing change Increase dose by 25% Increase dose by 15% Maintain dose Maintain dose or reduce dose Reduce dose by 25% (treat
by 15% (reduction intended around any blistered area;
to minimise hyperpigmentation do not treat blistered area
effect and/or to avoid until healed with crust
increased erythema) disappeared)
XTRAC® Clinical Reference Guide. Dosing guideline for targeted UVB phototherapy of psoriasis. XTRAC treatment guidelines 12-95359-01 rev. C.
Figure 3: Hyperpigmentation Following 12 Weeks of codes for laser treatment for inflammatory skin diseases are as
Twice-weekly Excimer Laser Treatment
follows: 96920 for BSA up to 250ft
2
, 96921 for BSA from 250 to 500ft
2
and 96922 for BSA >500ft
2
. Notably, the use of medical lasers is
regulated on a state-by-state basis and some states require laser
treatments to be delivered by a physician. Physicians should consult
with their state medical board to determine local regulations.
Conclusion
Excimer laser therapy represents a novel therapeutic modality that has
demonstrated efficacy in the treatment of mild to moderate psoriasis.
The number of treatments required to achieve clearance is typically
much lower compared with NB-UVB phototherapy, provided that the
clinician conducts optimally aggressive laser therapy. Clinical studies
demonstrate significant improvement of plaque psoriasis and clearance
This patient’s hyperpigmentation resolved after four weeks. following 10 or fewer treatments. The reduced number of treatments
required is partly due to the fact that psoriatic lesions can be treated with
hyperpigmentation (see Figure 3). Such adverse effects are generally supraerythemogenic doses, as demonstrated by the dose–response
well tolerated. In a multicentre study by Feldman et al., erythema study where up to 16 multiples of MED were used to treat psoriatic
(50.8% of patients), blistering (45.2% of patients) and hyper- plaques.
7
The laser’s ability to deliver many MED multiples to a targeted
pigmentation (37.9% of patients) were the most frequent side effects area in under a few minutes has proved to be beneficial for patients with
noted.
8
Patients may use class 1 topical steroids twice daily on areas of localised, resistant plaques on the elbows and knees, recalcitrant to
irritation, erythema and blistering until symptoms have resolved. A topical medications or conventional phototherapy. Compared with NB-
major concern regarding phototherapy is the potential increased risk of UVB phototherapy (generally requiring 25–30 treatment sessions until
skin cancer. Compared with other modes of phototherapy, excimer clearance), excimer laser therapy may represent a more convenient
laser is relatively new and thus long-term safety data regarding skin treatment option.
16
Another disadvantage of conventional NB-UVB is that
cancer risk are limited. However, it is notable that with targeted laser it requires large areas of unaffected, non-psoriatic skin to be exposed to
therapy only lesional skin is exposed to UVB irradiation, essentially UV light. With the excimer laser, physicians have the ability to exclusively
sparing the non-involved skin. Furthermore, long-term studies on treat psoriatic skin, possibly reducing long-term risks of photodamage
conventional broad-band UVB phototherapy have failed to demonstrate and potential carcinogenicity. While laser treatment can result in sparing
an increased risk of skin cancer.
15
Long-term follow-up of large numbers of uninvolved skin, fewer treatments and lower cumulative UV dosage,
of patients treated with the excimer laser is needed to confirm the some authors feel that it may result in an increase in other adverse
apparent safety of laser treatment in terms of skin cancer risk. events.
17
Common side effects experienced by patients are generally
limited to erythema and hyperpigmentation at lower doses and blistering
Coding and Regulation at higher doses, e.g. eight to 16 multiples of MED.
7
Overall, 308nm
Excimer laser therapy has been approved by the US Food and Drug excimer laser is considered a safe and efficacious treatment for plaque
Administration (FDA) for mild, moderate and severe psoriasis. psoriasis, showing great promise for the future. Further long-term
Currently, insurance companies reimburse patients with <10% BSA studies are warranted to evaluate its safety profile, along with its
affected, and some Blue Cross Blue Shield policies cover patients with potential for treatment of moderate to severe plaque psoriasis and
up to 20% BSA affected. The Current Procedural Terminology (CPT) its role in combination therapy. ■
1. Parrish JA, Jaenicke KF, J Invest Dermatol, 6. Bonis B, et al., Lancet, 1997;350:1522. 12. Morison WL, et al., Photodermatol Photoimmunol
1981;76(5):359–62. 7. Asawanonda P, et al., Arch Dermatol, 2000;136:619–24. Photomed, 2006;22:181–3.
2. van Weelden H, et al., Br J Dermatol, 1980;103(1):1–9. 8. Feldman SR, et al., J Am Acad Dermatol, 2002;46:900–906. 13. Novak Z, et al., J Photochem Photobiol B, 2002;67:32–8.
3. Lee E, et al., Int J Dermatol, 2005;44(5):355–60. 9. Trehan M, Taylor CR, J Am Acad Dermatol, 2002;47:701–8. 14. Taneja A, et al., Arch Dermatol, 2003;139:759–64.
4. Avrillier S, et al., J Photochem Photobiol, 1990;B6:249–57. 10. Gerber W, et al., Br J Dermatol, 2003;149(6):1250–58. 15. Koo JYM, et al., Skin Allergy News Suppl, 2001;32(2):1–15.
5. Muller-Stolzenburg N, Muller GJ, Biomed Tech (Berl), 11. Nistico SP, et al., J Eur Acad Dermatol Venereol, 16. Adrian RM, et al., Arch Dermatol, 1980;117:623–6.
1989;34:131–8. 2006;20:523–6. 17. Kollner K, et al., Br J Dermatol, 2005;152:750–54.
14 EUROPEAN DERMATOLOGY
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