308nm Excimer Laser For The Treatment Of Scalp Psoriasis

308-nm Excimer Laser for the Treatment of Scalp Psoriasis Samir N. Gupta, MD, FRCPC; Charles R. Taylor, MD From the Massachusetts General Hospital, Harvard Medical School, Boston. Arch Dermatol. 2004;140:518-520. REPORT OF A CASE

A 49-year-old white woman presented with a 20-year history of scalp psoriasis. Over the years, she had tried numerous topical treatments, such as 0.05% clobetasol propionate solution with 0.005% calcipotriene solution for 3 months, as well as various tar- and salicylic acid–based shampoos, with no success. She stated that the itching associated with her scalp psoriasis had worsened over the past year, often keeping her awake at night. She had abandoned medical treatment for 6 months. She was otherwise in good health and was not taking any medications. There was no family history of skin disease. Physical examination revealed thick, hyperkeratotic, scaly, erythematous, confluent plaques almost completely covering the scalp, including the postauricular area, clinically consistent with scalp psoriasis. THERAPEUTIC CHALLENGE Our challenge was to find a safe, effective treatment for the patient's scalp psoriasis, thereby relieving the itching caused by her condition.

S O L U TI O

N W e op te d

to tr ea t th e pa tie nt wi th a 30 8n m ex ci m er la se r (X tr ac ; Ph ot o M ed ex , Ra dn er, Pa )

th at ha s a fib er op tic ha nd pi ec e co nn ec te d to a sc al p de liv er y de vi ce (P ho to M ed ex )

(Fi gu re 1) . Th e sc al p de liv er y de vi ce fu nc tio ns by di sp la ci ng ha ir th at is int er fe ri ng wi th

ac ce ss of th e la se r be a m to th e sc al p. It lo ok s an d op er at es lik e a bl o wdr ye r bu t

do es no t de liv er an y he at to th e sc al p.

Wi th ful l ap pr ov al of ou

r in sti tu tio na l re vi e w bo ar d, inf or m ed co ns en t w as ob tai ne d. Th e pa tie nt' s sc al p w as

m ap pe d us in g cl ea r pl as tic te m pl at es . I m m ed iat el y be fo re tr ea t m en t, a sc or e

of 9 w as no te d on th e m od ifi ed Ps ori as is Ar ea an d Se ve rit y In de x (P A SI ), w hi ch is us ed

to as se ss er yt he m a, in du ra tio n, an d sc ali ng (0 , no ne ; 1, sli gh t; 2, m od er at e; 3, se ve re ;

an d 4, ve ry se ve re ). H alf of th e lar ge ps ori ati c pl aq ue w as tr ea te d wi th th e 30 8n m ex ci

m er la se r us in g th e sc al p de liv er y de vi ce ; th e ot he r ha lf se rv ed as a co nt rol . Mi ne

ral oil w as ap pli ed to bo th ar ea s be fo re th e tr ea t m en t be ga n. A 2. 5c m sp ot siz e w as us

ed , wi th pu ls es de liv er ed in a 25 % ov erl ap pi ng fa sh io n. Th e ini tia l do se ad mi ni st er ed w as

20 0 m J/ c m 2

,

an d su bs eq ue nt do se s w er e in cr ea se d in cr e m en tal ly by 50 to 20 0 m J/

c m 2

ba se d on th e pa tie nt' s tol er an ce , ie, th e se ns ati on an d/ or cli ni ca l ap pe ar an ce of bu

rn in g. H er fin al do se w as 36 00 m J/ c m 2

.

Th e ps ori ati c pl aq ue w as to be tr ea te d 2 ti m es

pe r w ee k, ev er y 48 to 72 ho ur s, fo r up to 30 tr ea t m en ts or un til cli ni ca l cl ea ri ng w as no

te d ( m od ifi ed PA SI sc or e, 3 ). O ur pa tie nt re qu ire d on ly 22 tr ea t m en ts be fo re cl ea ri ng

oc cu rr ed . Th e av er ag e ti m e of ea ch pa inl es s tr ea t m en t w as le ss th an 10 mi nu te s. Be

tw ee n tr ea t m en ts an d du ri ng th e fol lo wup pe rio d, on ly th e us e of ov er th eco un te r

an tid an dr uf f sh a m po os w as all o w ed . Cli ni ca l im pr ov e m en t w as de fin ed as an y re

du cti on in th e ba se lin e m od ifi ed PA SI sc or e. O ur pa tie nt ex pe rie nc ed cli ni ca l im pr ov e m en

t as ea rly as tr ea t m en t 8. Re m ar ka bl y, a 90 % im pr ov e m en t in he r m od ifi ed PA SI sc or

e w as no te d at tr ea t m en t 23 (Fi gu re 2 an d Fi gu re 3) , re pr es en tin g ap pr ox im at el y 11

w ee ks of tr ea t m en t ( m od ifi ed PA SI sc or e, 0) . At thi s po int , sh e re po rt ed si gn ifi ca nt

im pr ov e m en t in he r pr ur itu s. Co nv er se ly, th e un tr ea te d si de (Fi gu re 2 an d Fi gu re 4) re

m ai ne d thi ck , sc al y, an d ex tr e m el y itc hy . Th e en tir e pr oc ed ur e w as ex tr e m el y

w ell tol er at ed . A su btl e, tr an si en t, mi ld bu rn in g se ns ati on oc cu rr ed on ly w he n hi gh er flu

en ce s w er e us ed . Th e pa tie nt di sc on tin ue d tr ea t m en t af te r he r co nd iti on cl ea re d.

In th e fol lo wup pe rio d as se ss m en ts w er e pe rf or m ed ev er y 3 w ee ks , an d no fu rt he r

tr ea t m en ts w er e ad mi ni st er ed to eit he r th e tr ea te d or th e un tr ea te d si de of he r sc

al p. Th e ar ea th at w as tr ea te d wi th th e ex ci m er la se r w as sti ll fr ee of ps ori as is af te r

10 w ee ks .

C O M M E N T Ps ori as is of th e sc al p is a co m m on ye t dif fic ult

co nd iti on to tr ea t. O ve rly in g de ns e ha ir, in ac ce ssi bil ity to U V ex po su re , an d no nc o m pli

an ce wi th tr ea t m en t th at of te n in vo lv es m es sy , m al od or ou s to pi ca l m ed ic ati on s

ar e fa ct or s th at fr eq ue ntl y li mi t th er ap eu tic su cc es s. Ps ori as is of th e sc al p of te n bri

ng s pa tie nt s to de r m at ol og ist s be ca us e of itc hi ng , sc ali ng , ha ir lo ss , an d bl ee di ng

.1 To pi ca l m ed ic ati on s, su ch as ta r sh a m po os , st er oi d so lut io ns , an d oil s, ha ve be en

th e m ai ns ta ys of th e tr ea t m en t of sc al p ps ori as is. U nf or tu na tel y, so m e pa tie nt s si

m pl y do no t re sp on d to thi s fo r m of th er ap y, an d co m pli an ce re qu ire s a lot of ti m e an

d m oti va tio n. As id e fr o m to pi ca l m ed ic ati on s, fe w tr ea t m en t m od ali tie s ex ist fo r

th e tr ea t m en t of sc al p ps ori as is. Ph ot ot he ra py , w hil e ex ce lle nt fo r bo dy ps ori as is, pr

ov es rel ati ve ly in eff ec tiv e fo r th e sc al p in pa tie nt s wi th ou t cl os el y sh av ed he ad s, be ca

us e th e ha ir ca us es m ec ha ni ca l hi nd ra nc e fo r lig ht ac ce ss . Ev en w he n tr ad iti on al ph

ot ot he ra py ca n be us ed fo r th e tr ea t m en t of sc al p ps ori as is, no ni nv ol ve d ar ea s of th

e sc al p an d fa ce ar e of te n in ad ve rt en tly ex po se d. Sy st e mi c th er ap ie s th at ar e us ed

to co nt rol ps ori ati c le si on s el se w he re on th e bo dy wi ll im pr ov e sc al p le si on s bu t ar e

ra rel y in di ca te d so lel y fo r sc al p ps ori as is. 2

It is cl ea r th at ne w an d in no va tiv e tr ea

t m en t m od ali tie s ar e re qu ire d fo r th e tr ea t m en t of sc al p ps ori as is. Ex ci m er la

se rs sh ar e th e co m m on fe at ur e of pr od uc in g ph ot on s fr o m un st ab le ex cit ed ga s di m

er s. Th e te r m ex ci m er is de riv ed fr o m th e un io n of ex cit ed an d di m er . Fo r th e 30 8-

n m ex ci m er la se r, th e ga s di m er is xe no n ch lor id e. D ec o m po sit io n of thi s sh or tliv

ed un st ab le di m er is re sp on si bl e fo r th e pr od uc tio n of a co lli m at ed be a m of ph ot on s

wi th a w av el en gt h of 30 8 n m .T he pr ot ot yp e 30 8n m ex ci m er la se r us ed in thi s ca se

ha s th e ab ilit y to pr od uc e 20 to 40 na no se co nd tr ai ns of pu ls es wi th a re pe tit io n ra te

of up to 20 0 Hz . Th e m ec ha ni s m of ac tio n is no t en tir el y kn o w n, bu t w e sp ec ul at e

th at it m ay be si mi lar to th at of na rr o w ba nd 31 1n m U VB ph ot ot he ra py , w hi ch op er at

es wi thi n th e ac tio n sp ec tr u m fo r ps ori as is. 3

Th e la se r ha s th e ad va nt ag e of be in g

ab le to de liv er lig ht to sp ec ifi c ar ea s, in a us er fri en dl y, hi gh ly eff ici en t m an ne r, wi th ou

t ex po si ng no r m al sk in to po te nti all y ha r mf ul ra di ati on . Th e 30 8n m ex ci m er la se

r w as fir st re po rt ed to be us ef ul in th e tr ea t m en t of ps ori as is in 19 97 .4 Si nc e th en , do

se re sp on se rel ati on sh ip s ha ve be en in ve sti ga te d. Fo r tr un ca l ps ori as is, it ha s be en de m

on str at ed th at flu en ce is th e si ng le m os t im po rt an t de te r mi na nt in cli ni ca l cl ea ri ng .5

Th e nu m be r of tr ea t m en ts, on th e ot he r ha nd , is no t as im po rt an t. Al so , fo r tr un k

ps ori as is, dif fe re nt pl aq ue ch ar ac te ris tic s ca n be so m e w ha t pr ed ict iv e of re sp on se . Th

ic ke r, sc ali er pl aq ue s te nd to re sp on d m or e sl o wl y. Th is fin di ng pa ral lel s w ha t w e no

te d in th e pr es en t ca se . O ur pa tie nt , w ho ha d ex tr e m el y thi ck sc al y pl aq ue s, re qu

ire d 23 tr ea t m en ts be fo re cl ea ri ng w as no te d. Po te nti al ad ve rs e eff ec ts wi th th e 30 8-

n m ex ci m er la se r in cl ud e pa in, bu rn in g, bli st eri ng , an d di sc ol or ati on . O ur pa tie nt re

po rt ed no ad ve rs e eff ec ts ot he r th an so m e mi ld tr an si en t bu rn in g at hi gh er flu en ce s. Al

so , sh e ex pe rie nc ed no ad ve rs e eff ec ts fr o m th e us e of th e sc al p bl o w er de liv er y de

vi ce , w hi ch w or ke d ve ry w ell in pa rti ng th e ha ir. Th e 30 8n m ex ci m er la se r ha s be

en ap pr ov ed by th e Fo od an d Dr ug Ad mi ni str ati on fo r th e tr ea t m en t of pl aq ue ps ori as is. Th

is ca se re po rt re pr es en ts th e fir st eff or t at tr ea tin g sc al p ps ori as is wi th th e 30 8n m ex

ci m er la se r co up le d to a un iq ue sc al p de liv er y de vi ce . Th is sp ec ial sy st e m pr ov id ed

a us er fri en dl y, no ve l, sa fe, an d eff ec tiv e tr ea t m en t fo r ou r pa tie nt wi th re ca lci tr an

t sc al p ps ori as is. La rg esc al e tri al s wi ll be ne ce ss ar y to fu rt he r su bs ta nti at e ou r ob

se rv ati on s an d op ti mi ze do si m et ry fo r th e tr ea t m en t of sc al p ps ori as is us in g thi s

no ve l tr ea t m en t m od ali ty.

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