Studies on Nail Psoriasis, Veins, Acne and More
Nail Psoriasis Responds to Pulsed Dye Laser
Nail abnormalities are evident in up to 50% of patients with skin psoriasis and may be the first manifestation of the disease. Nail psoriasis is challenging to treat, which may be due to the difficulty of topical treatment to penetrate through the nail plate, and the long-term treatment necessary for achieving any clinical benefit due to the slow growth rate of the nail plate. Excimer laser has been approved for the treatment of psoriasis since 2000. Pulsed dye laser (PDL) in psoriasis has shown good response rates, with extended remissions.
A recent study evaluated and compared the effect of PDL versus excimer laser as treatment modalities for nail psoriasis. The findings showed that PDL demonstrated a good response for treating nail psoriasis with few side effects compared to excimer laser, reported researchers in Dermatology and Therapy.
Forty-two patients affected by symmetrical nail psoriases in 2 to 5 fingernails of both hands were enrolled in the 12-week study. A total of 304 nails changes, 148 with excimer laser and 156 with PDL were treated. The right hand nails were treated with excimer laser twice weekly and the left hand nails were treated with PDL once every 4 weeks for 12 weeks. The patients were then followed-up 12 weeks later. Nail Psoriasis Severity Index (NAPSI) scores were recorded at baseline, weeks 4, 8 and 12 and then at week 24. Patients were also asked to grade the clinical response to each treatment.
The mean NAPSI scores in nails treated with the excimer laser were 29.8 at baseline, reduced to 16.3 at week 24. Statistically significant nail improvement was noted in most patients treated with PDL. The NAPSI scores dropped from 29.5 at baseline to 3.2 at week 24. PDL was shown to be a good alternative treatment compared with excimer laser. Of the patients treated with PDL, 34 hands (81%) achieved NAPSI-50, and 23 (55%) achieved NAPSI-75 at week 12, while complete recovery was shown in 6 (14%) hands. Only 16 (38%) hands treated with excimer laser achieved NAPSI-50, while no hand achieved NAPSI-75 at week 12. In general, subungual hyperkeratosis and onycholysis improved significantly, while nail pitting was least responsive. Oil drops and splinter hemorrhages showed moderate response.
The researchers concluded, “Results of the excimer laser in nail psoriasis are poor and time-consuming. Whereas, PDL has an excellent response for treating nail psoriasis, with minimal side effects.”
Al-Mutairi N, Noor T, Al-Haddad A. Single blinded left-to-right comparison study of excimer laser versus pulsed dye laser for the treatment of nail psoriasis. Dermatol Ther (Heidelb). Published online ahead of print July 3, 2014.
Study Compares Treatments for Varicose Veins
Results from a study published online in the British Journal of Surgery showed 1-year treatment with endovenous steam ablation (EVSA) was not inferior to that of endovenous laser ablation (ELVA) for great saphenous varicose veins.
In the randomized trial, patients with primary great saphenous vein reflux were randomized to ELVA (940 mm) or EVSA. A total of 227 legs were treated (N=117 for EVSA and N=110 for EVLA); 36 legs treated with EVSA received a low dose and the remaining 81 received a higher dose. The primary endpoints were treatment success (vein obliteration) at 52 weeks, and Venous Clinical Severity Score (VCSS) at 12 weeks. Secondary endpoints were pain, treatment satisfaction, duration of analgesia use and days lost from daily activities, changes in Aberdeen Varicose Vein Questionnaire (AVVQ) and EQ-5D scores after 12 weeks and complications at 2 and 12 weeks.
At 1 year, the researchers found that the treatment success rate after high-dose EVSA was not inferior to that of ELVA (92% vs 96%, respectively). Changes in VCSS after 12 weeks were similar (−2.69 vs −2.51, respectively). AVVQ, EQ-5D and EQ VAS scores improved equally 12 weeks after both treatments. Outcomes for the secondary endpoints found that patients treated with EVSA reported less post-procedural pain, fewer days of analgesia use, more satisfaction with therapy, and had a shorter recovery time. As for complications, the rates were comparable between both patient groups.
van den Bos RR, Malskat WS, De Maeseneer MG, et al. Randomized clinical trial of endovenous laser ablation versus steam ablation (LAST trial) for great saphenous varicose veins. Br J Surg. Published online ahead of print June 30, 2014.
Combination Therapy for Actinic Keratoses in OTRs
Research has shown that topical photodynamic therapy (PDT) for actinic keratoses is hindered by pain during illumination and inferior efficacy in organ transplant recipients (OTRs). A recent study assessed ablative fractional laser-assisted daylight PTD (AFL-dPDT) compared with dPDT, conventional PDT (cPDT) and AFL alone in field treatment of actinic keratoses in OTRs. The findings were reported online in the British Journal of Dermatology.
The study included 16 patients with 542 actinic keratoses (grade 1-3) in field-cancerized skin of the scalp, chest and extremities treated. In each patient, 4 areas in the same region were randomized to 1 treatment with AFL-dPDT, dPDT, cPDT and AFL. AFL was delivered with 2,940 nm ablative fractional laser at 2.3 mJ/pulse, 1.15W, 2 stacks, 50 microsecond pulse-duration, 2.4% density. In dPDT and AFL-dPDT, methylaminolevulinate was applied for 2.5 hours without occlusion during daylight exposure. For cPDT, methylaminolevulinate occluded for 3 hours followed by red light (630 nm) irradiation at 37 J/cm2. The primary endpoint was complete lesion response 3 months post-treatment.
After 3 months, the results showed complete lesion response for actinic keratoses were 74% after AFL-dPDT, 46% after dPDT, 50% after cPDT and 5% after AFL (P<0.001). Complete lesion response in AFL-dPDT, dPDT and cPDT were also significantly different (P=0.004). The researchers also observed erythema and crusting were more intense following AFL-dPDT compared with dPDT and cPDT, but only transient hypopigmentation was noted.
AFL-dPDT is a novel PDT modality that “enhances complete lesion response with excellent tolerability compared to dPDT and cPDT” in this patient population, concluded the researchers.
Togsverd-Bo K, Lei U, Eriendsson AM, et al. Combination of ablative fractional laser and daylight mediated photodynamic therapy for actinic keratosis in organ transplant recipients — a randomized controlled trial. Br J Dermatol. Published online ahead of print June 28, 2014.
PDL Effective for Children’s Port-Wine Stains
Although it is painful, the gold standard for port-wine stains in children is pulsed dye laser (PDL). To limit pain in small children, sedation may be given. In a new study, researchers evaluated the efficacy of this approach and the risks of sedation, as well as the level of satisfaction of parents.
The retrospective, observational study included 18 children treated with PDL while under sedation between 2003 and 2011. The researchers evaluated the efficacy of treatment by comparing photographs of lesions before and after treatment and using a questionnaire sent to parents. In all, 111 laser sessions were performed with sedation.
The findings showed that PDL for port-wine stains was effective, with an improvement rate of 6.2/10 (in terms of color and area) in the comparison of photographs. The parents indicated a positive impression with the mean parent satisfaction score of 6.6/10. Pain was controlled due to sedation. Adverse events were reported in 27.8% of children and for 4.5% of PDL sessions. One case of severe hypoxemia was observed and resolved without sequelae.
“This study suggests that the procedure may be proposed for small children in order to reduce pain, with a good risk-benefit ratio for sedation,” concluded the researchers. “More studies are needed to better qualify pain management for children under PDL treatment.”
Fenot M, Maillard H, Célérier P, Maxaud A, Bénéton N. Port-wine stains treated by pulsed-dye laser with sedation: A retrospective observational efficacy and safety in 18 children. Ann Dermatol Venereol. 2014;141(6-7):419-428.
Novel Photosensitizer for Acne
Results from a small study showed that chlorophyll-a photodynamic therapy for the treatment of acne vulgaris is effective and safe with minimal side effects. Chlorophyll-a is a novel photosensitizer. The findings were reported online in the Journal of the American Academy of Dermatology.
The study included 24 patients with acne on both sides of the face. During a 4-week period, 8 treatment sessions were performed. Half of the face was irradiated using a blue and red light-emitting diode after topical application of chlorophyll-lipoid complex. The other half of the face underwent only light-emitting diode phototherapy. A blinded examiner assessed the lesion counts and acne severity. The researchers also evaluated sebum secretion, safety and histologic changes.
Facial acne improved on both treated sides, according the to the researchers. On the chlorophyll-a photodynamic therapy-treated side, there were significant reductions in acne lesion counts, acne severity grades and sebum levels compared with the side treated with light-emitting diode phototherapy alone. Side effects were tolerable in all the cases. n
Song BH, Lee DH, Kim BC, et al. Photodynamic therapy using chlorophyll-a in the treatment of acne vulgaris: A randomized, single-blind, split-face study. J Am Acad Dermatol. Published online ahead of print June 12, 2014.
NBLP Increases Café-au-lait Macules, Study Shows
Neonatal blue light therapy (NBLP) showed no significant influence on the development of melanocytic nevi, but café-au-lait macules prevalence was elevated in young children, which was a new finding, according to researchers.
NBLP is an effective treatment for hyperbilirubinaemia. Concerning the influence on melanocytic nevi, conflicting studies have been published, leading researchers to assess the role of NBLP according to the incidence of melanocytic nevi in 104 preschool children age 5 to 6 years. The case group consisted of 52 NBLP-exposed children, while 52 children in the control group never had NBLP and was matched regarding age, gender, gestational age and skin phototype. Six dizygotic twins were included with 1 twin having NBLP, respectively. The researchers recorded nevi count, presence of freckles, café-au-lait macules, skin phototype and previous history of sun exposure.
Reporting the findings in the European Journal of Pediatrics, the researchers found no significant association between nevi count and exposure to NBLP (median nevi count 17.0 vs 18.5 in controls). Additionally, no significant difference was found in the dizygotic twin pairs with a median nevi count of 10.0 with NBLP compared to 14.5 without NBLP. The researchers noted that a significantly higher prevalence of café-au-lait macules was found in children with NBLP compared with the control group (mean count 0.5 vs 0.2, respectively; P=0.001). Predictors for the melanocytic nevi count was attributed to skin phototype, sun exposure and vacations in the South.
The researchers suggested differences with comparable studies regarding age, differentiation between nevi and other pigmented lesions as well as dose and type of NBLP need further investigation.
Wintermeier K, von Poblotzki M, Genzel-Boroviczény O. Neonatal blue light phototherapy increases café-au-lait macules in preschool children. Eur J Pediatr. Published online ahead of print June 20, 2014.
Limited Data on Combination Therapy for Aging Face
Facial aging is a gradual process that involves a complex interaction of factors including cutaneous photodamage and laxity, subcutaneous tissue volume loss and bony resorption. The use of intense pulsed light, microfocused ultrasound and poly-L-lactic acid have been shown to significantly improve these features. How these therapies work in combination with the treatment of facial aging was the aim of a recent study published in the Journal of Cosmetic Dermatology.
After reviewing the use of intense pulsed light, microfocused ultrasound and poly-L-lactic acid the researchers found that despite their extensive individual safety record, there is limited data on combination therapy with these minimally invasive modalities. They concluded that based on the findings, these 3 therapies may be performed in a single treatment session to target multiple tissue planes concurrently without increased adverse events.
Friedmann DP, Fabi SG, Goldman MP. Combination of intense pulsed light, Sculptra, and Ultherapy for treatment of the aging face. J Cosmet Dermatol. 2014;13(2):109-118.