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
8-
n
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
w-
dr
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
8-
n
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.
5-
c
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
w-
up
pe
rio
d,
on
ly
th
e
us
e
of
ov
er
-
th
e-
co
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
w-
up
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
t-
liv
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
8-
n
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
1-
n
m
U
V-
B
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
8-
n
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
8-
n
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
8-
n
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
e-
sc
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.

Submissions

Clinicians, local and regional societies, residents,

challenges in management
established
nonjustified and 4 sets of the illustrations.
and submitted
not submit color prints unless accompanied by original
accompanied by the required
Authors." Material for this section should be submitted to George
Dermatologic Surgery Center Inc, 14377