Use of Excimer in Dermatology

蔡呈芳 臺大醫院皮膚部

History of phototherapy
• 照光療法的發現,是因為多數患者於夏季乾癬 位自然改善,而自古以來就有於地中海或死海 泡海水日曬治乾癬的習俗,因此才逐漸衍生出 人造光線,尤其是紫外線的光照療法。 • 最早的人造光療源自1903年,用於皮膚結核病 的治療 • 1925,新的石英水銀蒸氣燈,美國梅育診所 (Mayo Clinic)蓋克曼(Goeckerman)醫師用於乾癬 的照光治療,,並利用煤焦油的多樣療效,來增 強光照療效,所以人們又叫做蓋克曼療法。 • 1974,美國 Fitzpatrick 醫師提出PUVA療法 • 1981,Parrish發現窄頻UVB311之特殊療效

Types of Phototherapy
• Natural sunlight phototheapy (Heliotherapy, Tomesa therapy) • Broad-band UVB • Narrow-band UVB • PUVB • UVAB • PUVA • UVA-1: 30 - 50 - 130 J/cm2 • Excimer laser & Light

窄波段UVB治療乾癬之機制

光照療法原理
• • 細胞的核DNA會吸收紫外線,形成pyrimidine雙體及pyrimidine(6-4) pyrimidone光 產物 免疫功能的調節 – 誘發細胞釋放及製造免疫調控因子:表皮的角質細胞放出第10及6介白質、促 黑色激素、前列腺素E2,這些物質本身就有消炎的作用。Arch Dermatol Res 2005; 297: 39–42 – 改變細胞表面的分子構造,特別是讓角質細胞及直接負責免疫的蘭格罕氏細 胞上的ICAM物質減少,而ICAM可以吸引及刺激引起乾癬發炎T細胞前來作 用 – 引發細胞表面感受器的改變,如第一介白質,讓細胞對原本引起發炎的刺激 反應降低 – 最後一方面則是誘發致病細胞如T淋巴細胞的凋零死亡,也連帶的讓發炎物質 第三型干擾素減少J Exp Med. 1999;189:711-8 – 抑制角質細胞產生RANTES,可能因此調控發炎作用Arch Dermatol Res. 2005 Nov 12;:1-4 角質細胞非免疫作用 – 直接對細胞核DNA作用,使細胞中的去氧核醣核酸合成減少 – 使調節細胞週期的p53蛋白質形成,使增生速度受抑制

• 準分子雷射紫外線的治療原理,基本上也是一種照光療 法,只是將目前的窄波UVB療法再加以發揚光大,變成 308nm的單一波長強光,讓UVB中對乾癬特別有療效的波 長,局部高能量照射來治療。此種治療方式最早是在一九 九七年由Bonis提出,用八到十六倍的照射劑量,一次就可 能有效,但會造成嚴重曬傷。目前建議方法是,每週二 次,十次療效:八十位患者中,百分之八十四患者改善大 於百分之七十五,至於副作用方面,百分之五十點八有紅 腫現象,百分之四十五點二起水泡,百分之三十七點九變 黑,百分之二十五破皮,不過照射時倒不會有明顯不適或 疼痛,頂多是溫熱感。準分子雷射紫外線的機器昂貴,加 上耗材、專利,以及需由醫師操作,是故平均每次照光費 用高達二百美金,此種機器是點狀逐點照射,因此只適用 於小範圍且病情穩定患者。

Excimer
J Drugs Dermatol. 2004 Sep-Oct;3(5):522-5.
The term excimer derives from the expression excited dimer. dimer A dimer is a molecule formed by the combination of two atoms, a polymer composed only of two components.
Excimers are molecules that are able to bind with other atoms only when electronically excited, such as in an unstable electron configuration. The excimer,therefore, has an extremely short lifetime (10 thousand millionths of a second). When the excitation energy decreases, the excimers emit an ultraviolet photon of extremely precise energy.

Excimer: emitted wavelength Examples of excimers molecules and their
Excimer
ArF KrF XeF XeCl ArO XeO

Wavelength (nm)
193 248 351 308 558 558

Excimer
F2 Kr2 Xe2 KrCl KrO

Wavelength (nm)
157 146 72 222 556

Major Models
• • • • • • Company: Product, spot size, pulse duration Inpro(德國):DEx308, ?, 8ns Dermalight: Excimer 308 , 2 cm2, 60ns Photomedex: XTRAC, 3.2 cm2, 30ns Wavelight: TALOS, 10/20/25mm, 60ns Ra Medical Systems: PHAROS, 1.8 cm x 1.8 cm sq. to 2 mm round, ?

XTRAC Laser
• Monochromic Excimer laser • 308nm wavelenght
– middle of narrow band UVB (305-311 nm) range – proven to be effective in treating psoriasis

• site specific fiberoptic delivery system
– cable of high doses delivery, without involving healthy skin
Parrish JA, Jaenicke JS. JID 1981; 76: 359-62

UV-excimer laser for psoriasis
• • • • • • • clear as little as 1 treatment, clear > 4 months Major technologic achievement
– UV stable, flexible fiberoptics – Designed for localized treatment

more rapid clearing 6 MED well tolerated by psoriasis plaques spare healthy surrounding skin from UVB rays – decrease risk of photoaging – decrease risk of skin cancer decrease in the number of treatments – 6-10 with XTRAC vs 30-40 with regular phototherapy Fewer treatments due to ability to administer high doses given to plaques

Excimer laser vs Excimer light
Excimer lasers are more maintenance costs are higher. expensive and their

Laser therapy requires long treatment session times, because the power and size of the spot are small, on average. Excimer lasers must be used with gas cylinders containing a mixture of He/Xe/Cl. Chlorine is dangerous. The management and disposal of these toxic substances requires specific arrangements and precautions.

Publications about 308nm wavelength in the treatment of Psoriasis

Who are good candidates for this treatment
• Patients with 10-20% body coverage or mild/moderate cases • patients with stable plaque type psoriasis • people without a history of Koebnerization

Contraindications
• • • • Photosensitivity disorders history of keloid formation history of melanoma history of invasive squamous cell carcinoma

Is the treatment painful?
• No anesthesia is necessary • most people do not experience any sensations • slight warmth may be felt by some patients • slight sunburn sensation 4-10 hours after treatment

XTRAC for psoriasis
• low energy, no carbonization,one electron transfer instead of 2 electrons (bond breakage) • start with 3MED, biw • use mineral oil very sparingly to plaques for better penetration • descale with Lachydrin • Remove any makeup, deodorants, or lotions from skin • use a decreasing agent if plaques are thick – this allows laser to penetrate skin easiler • apply mineral oil before treatment • 80/124 complete, average 6.2 times, 75% clearance

Potential side effects of laser treatment
• Common side effects were tolerated quite well. These included: • Temporary hyper-pigmentation • blistering - similar to a sunburn • erythema • erosion • pain • unsatisfactory results

How many treatments are necessary?
• Important to allow 2-5 weeks for treatment regimen • treatments should be 2X’s per week, minimally 48-72 hours apart • on average 4-10 treatments are necessary • studies have shown that 84% of the people have 75% improvement in equal to or less than 10 treatments

Minimal erythema dose test
• Patients will come in the day before treatment for a skin test • six different levels of power will be tested on healthy skin • patients need to return 24 hours later to have test read to determine doe to start treatment of plaques

Determine Fitzpatrick skin type
• • • • • • Type I - fair, always burns type II - burns easily, tans minimally type III - burns moderately, tan gradually type IV - burns minimally Type V - rarely burns, tans to dark Type VI - never burns

MED [Minimal Erythema Dose]
Before starting with the treatment it is necessary to determine the MEDMEL@308nm. This value depends on the phototype of the patient:

PHOTOTYPE I 4 s = 200 mJ/cm2 PHOTOTYPE II 5 s = 250 mJ/cm2 PHOTOTYPE III 6/7 s = 300/350 mJ/cm2 PHOTOTYPE IV 7/8 s = 350/400 mJ/cm2

Minimal Eythema Dose (MED)
• • • • Radiation source Dose increment Field size Nature of skin
– pigmentation, previous exposure, site

• Definition of erythema • Time of reading • Ambient illumination

308-nm excimer laser for the treatment of psoriasis: induration-based dosimetry
Arch Dermatol. 2003 Jun;139(6):759-64

• Each plaque was treated 2 times a week, with an initial dose based solely on the induration component of the modified Psoriasis Area and Severity Index score for that lesion. Subsequent treatments were twice a week with dosage increments up to 50%, based on the change in induration. Four final consolidation doses were given once the induration score was reduced to zero. • RESULTS: Eighteen subjects were treated. There were 4 dropouts because of various scheduling problems. In the remaining 14 subjects, 44 plaques received a mean of 10 treatments (range, 4-14). Treatments were quick and well tolerated. The mean cumulative dose was 8.8 J/cm2 (range, 2.2-22.8 J/cm2). Compared with controls, treated plaques showed significant improvement (P<.001). The only adverse event was a mild sunburn-like reaction in 2 subjects after 1 treatment.

Efficacy of the 308-nm excimer laser for treatment of psoriasis: results of a multicenter study.
J Am Acad Dermatol. 2002 Jun;46(6):900-6. • • a multicenter open trial from 5 dermatology practices (one university-based and 4 private practices). Up to 30 patients per center with stable mild to moderate plaque-type psoriasis constituted the study population. The initial UVB dose was based on multiples of a predetermined minimal erythema dose. Subsequent doses were based on the response to treatment. Treatments were scheduled twice weekly for a total of 10 treatments. The main outcome measure was 75% clearing of the target plaque. Time to clearing was analyzed by Kaplan-Meier methods, accounting for truncated observations. RESULTS: 124 patients were enrolled in the study, and 80 completed the entire protocol. The most common reason for exiting from the study was noncompliance. Of the patients who met the protocol requirements of 10 treatments or clearing, 72% (66/92) achieved at least 75% clearing in an average of 6.2 treatments. Eighty-four percent of patients (95% confidence interval [CI], 79%-87%) reached improvement of 75% or better after 10 or fewer treatments. Fifty percent of patients (95% CI, 35%-61%) reached improvement of 90% or better after 10 or fewer treatments.

First protocol used with Excilite® system in the treatment of vulgar psoriasis
• After determining the MEDsMEL@308nm for each subject, treatments have been administered starting from 1 or 2 MEDsMEL@308nm and progressively increasing the dose (3 - 10 seconds) at each session (2 – 3 times at week), up to a maximum of 20 MEDsMEL@308nm at the twentieth treatment session. • Each subject has been treated 15 to 20 times, over a maximum period of 12 weeks.

New protocol used with Excilite® system in the treatment of vulgar psoriasis
Treatments have been administered starting from: 4 MEDMEL@308nm : in case of lesions in cutaneous photo-resistant areas
such as elbows, knees and the backs of hands.

2.5 MEDMEL@308nm: in case of lesions in areas such as lower limbs,
buttocks, abdomen, breastbone area, front side of upper limbs and scalp (with shaved hair).

2 MEDMEL@308nm: for lesions in lower limbs in case of patients with
vascular troubles.

3 MEDMEL@308nm: for back lesions and for the back side of upper limbs.

New protocol used with Excilite® system in the treatment of vulgar psoriasis
Dose increase at each session: 5 – 12 seconds Frequency of sessions: 1 every 1 - 2 weeks

Effective treatment of scalp psoriasis using the excimer (308 nm) laser Photodermatol, Photoimmunol Photomed 22: 181, 2006

• Thirty-five patients were treated and all had failed intensive topical therapy. Manual separation of hair was used to provide access to the treatment site. Starting doses ranged from 300 mJ/cm2 (type I) to 1000 mJ/cm2 (type IV) with treatment twice weekly. • All patients improved. Seventeen/35 (49%) of patients cleared>95% (mean: 21 treatments; range: 6–52) and 16/35 (45%) cleared 50–95%. Phototoxicity in the form of erythema and blistering occurred in all patients, particularly around the ears and nape of neck.

A 308-nm excimer laser for the treatment of scalp psoriasis. Lasers Surg Med. 2004;34(2):136-40.
• Adult subjects with scalp psoriasis unresponsive to class I topical steroids used in conjunction with medicated shampoos were treated with 308-nm excimer laser pulses in conjunction with a hair blower that parted the obstructing hair twice a week for up to 15 weeks. Half of the scalp served as a control. • Starting doses were based on standard minimal erythema dose (MED)'s with subsequent increments of up to 20%. • Thirteen subjects completed the study without adverse events. Two were dropped due to lack of compliance. At the end of the investigation, the difference in the mean modified PASI scores between the control and treated sites was 4.0 (<0.0001).

A maintenance protocol for psoriasis plaques cleared by the 308 nm excimer laser. : J Dermatolog Treat. 2004 Apr;15(2):94-7
• • This prospective case series, conducted at a university-based dermatology practice, enrolled five adults with stable, mild-to-moderate plaque-type psoriasis vulgaris. Patients received 308 nm UVB doses to affected areas. Initial dosing was based on multiples of a pre-determined minimal erythema dose (MED). Delivered fluences were 100, 150, 200, 250, 300 and 350 mJ/cm(2), corresponding to MED levels of 1 through 6. Subsequent doses were based on response to treatment. Induction treatments were scheduled biweekly for a total of 15 treatments. After improvement of disease, tapering began as follows: one treatment per week for 4 weeks, one treatment every other week for 4 weeks, and one final treatment 4 weeks later for a total of seven treatments. One month after the second month of the taper (total of six treatments), no flares were noted and four out of five patients had no flares per PASI scores. No patients, either at the end of induction or at any interval during the taper, met the definition of a 50% rebound of PASI scores.

• •

The Efficacy of 308nm Laser Treatment of Psoriasis Compared to Historical Controls Dermatology Online Journal 7(2): 4 • • • • PASI75:72% Number of days to PASI75:36 d Mean baseline PASI of study population: 6 Adverse event
– – – – Erythema 51% Blister 45% Hyperpigmentation 38% shallow erosion 25%

Excimer laser versus narrow-band UVB (311 nm) in the treatment of psoriasis vulgaris.
Dermatology. 2006;213(2):134-9. • In this prospective right/left comparative, open, single-blinded trial, selected psoriasis plaques of 16 patients were treated with the excimer laser whereas the rest of the body was treated with UVB narrow-band phototherapy. • A modified PASI score was used to evaluate the results. • After 12 treatments, 15 patients were evaluated. In 2 patients no difference between the two body sides was observed. In 9 patients the laser-treated lesions showed better results, whereas in 4 patients the side treated with 311-nm UVB showed more clearing. The mean reduction in PASI score was 5.6 and 4.9, respectively (difference not significant).

Comparison of the 308-nm excimer laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis BJD 152; 750, 2005
• Materials and methods Fifteen patients with plaque psoriasis were enrolled in the study (first regime). Three different psoriatic lesions were treated with the 308-nm excimer laser, the 308-nm excimer lamp or 311-nm narrowband UVB three times per week. UVB doses were increased slowly and stepwise (1, 1, 2, 2, 3, 3, …multiple MEDs). Sixteen patients were enrolled in the second regime. Two plaques were treated with the 308-nm excimer laser or with the 308-nm lamp with an accelerated scheme (2, 2, 4, 4, 6, 6, …multiple MEDs) three times per week. We increased the UVB doses every second treatment (first and second regime) during the whole treatment. If blistering occurred, the blistered plaque was not treated on the next scheduled treatment. At every third visit and 1, 2 and 4 months after the last treatment a Psoriasis Severity Index (PSI) score was assigned in both regimes. Results Using Friedman analysis, the PSI scores did not show a statistically significant difference (P > 0·05) comparing 308-nm laser therapy, 308-nm lamp therapy and 311-nm narrowband therapy after 10 weeks in the first regime. The mean number of treatments to achieve clearance was 24. With the accelerated scheme, clearance could be achieved with fewer treatments and with half the cumulative dose of the first regime. Nevertheless, the side-effects such as blistering and crusting were also increased.

A 308-nm monochromatic excimer light in the treatment of palmoplantar psoriasis JEADV 20;523, 2006
• Methods Fifty-four patients (29 male and 25 female) affected by PP were treated with MEL every 7–14 days. A mean number of 10 sessions was performed with an increase of the dose depending on patient's skin type and response. • Results All 54 patients completed the treatment. After 4 months of MEL we observed a complete remission in 31 patients, a partial remission in 13 patients, and a moderate improvement in 10 patients. • Conclusions These results suggest that MEL can be considered as a valid therapeutic option for treatment of selected forms of PP.

窄波段B光 (narrow-band UVB) 治療白斑之機制

Wu, Ching-Shuang, Yu, Chia-Li, Wu, Chieh-Shan, Lan, Cheng-Che E. & Yu, Hsin-Su (2004) Narrow-band ultraviolet-B stimulates proliferation and migration of cultured melanocytes. Experimental Dermatology 13 (12), 755-763.

窄波段B光治療白斑之機制
• 誘導黑色素細胞增生 • 加強黑色素細胞移動

Experimental Dermatology 2004; 13 : 755-763.

誘導黑色素細胞增生
• 窄波段B光可刺激角質細胞釋放bFGF 與 ET-1
– bFGF (basic fibroblast growth factor)
• 黑色素細胞的天然 mitogen

– ET-1 (endothelin-1)
• 可刺激黑色素細胞的DNA synthesis

Experimental Dermatology 2004; 13 : 755-763.

加強黑色素細胞移動
• 窄波段B光可刺激黑色素細胞 phosphorylated FAK (p125FAK) 的表現
– 局部的adhesion kinase (FAK) 對細胞移動非 常重要

• 誘導黑色素細胞上清液表現MMP-2
– MMP-2 : Matrix metalloproteinase-2 – MMP-2的活性可加強黑色素細胞的移動
Experimental Dermatology 2004; 13 : 755-763.

Vitiligo
Phototherapy with peak emission at 311-313 nm is recent and it was initially used for psoriasis. Since then, this light source has also been found useful in the treatment of vitiligo. A recent report on a trial using the 308 nm excimer laser in vitiligo has been published by Spencer and coll.(1). The authors conclude that the degree of repigmentation in a period of 2 to 4 weeks is much higher than that achieved with any other current vitiligo therapy and that the xenon-chloride excimer laser may represent a new treatment modality for the management of stable vitiligo.

Spencer JM, Nossa R, Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: a pilot study. J Am Acad Dermatol 2002; 46:727-31

(1):

Treatment of Vitiligo with 308-nm xenon-chloride excimer laser: therapeutic efficacy of different initial doses according to treatment areas. J Dermatol. 2004 Apr;31(4):284-92.
• We evaluated the clinical efficacy of the 308-nm excimer laser treatment for various body areas, using different initial UV doses. One hundred forty vitiligo patches from 69 patients were assigned to 4 groups; face and neck, trunk, extremities, and acral and joint areas. They were then treated twice a week, using different initial UV doses. The rate of repigmentation continued to increase with the number of treatments up to 20 sessions, and then showed plateaus between 20 to 30 sessions. On the other hand, the lesions in acral and joint areas showed the worst responses throughout the treatment sessions. Our findings extend previous observations that the 308-nm excimer laser is an effective treatment option for patients with vitiligo. However, further studies will be needed to determine the optimal dosing and administration method, especially for acral and joint areas.

Publication about MEL@308nm in the treatment of Vitiligo
G Leone, P Iacovelli, A Paro Vidolin, M Picardo.

“Monochromatic Excimer Light 308 nm (MEL) in the treatment of vitiligo: a pilot study.”
J Eur Acad Dermatol Venereol 2003 Sep; 17(5): 531-7

Optimal weekly frequency of 308-nm excimer laser treatment in vitiligo patients.
• METHODS: In this prospective, university-based hospital study over 12 weeks we enrolled 14 patients. Each had at least three stable vitiligo lesions in the same body area. The three stable vitiligo lesions in each subject were randomly assigned to receive excimer laser treatment once (1 x), twice (2 x) and three times (3 x) weekly, respectively. The initial ultraviolet (UV) dose was 50 mJ cm(-2) less than the 308nm minimal erythematous dose in vitiligo skin. The UV dose was increased at each treatment session according to the erythematous response to the previous treatment. RESULTS: Thirteen subjects were treated for at least 6 weeks; seven were treated for all 12 weeks. At 6 weeks, the repigmentation rates for treated lesions were 8% (1/13) after 1 x weekly treatment, 23% (3/13) after 2 x weekly treatment and 62% (8/13) after 3 x weekly treatment (P = 0.0134; 3 x vs. 1 x weekly); at 12 weeks, these rates were 46% (6/13), 62% (8/13) and 69% (9/13), respectively (P = NS; 3 x vs. 1 x weekly). Repigmentation initiation correlated with treatment number, regardless of frequency (P = NS). Repigmentation occurred earliest in the most frequently treated lesions (P = 0.0336). At 12 weeks, the projected repigmentation rates for 1 x, 2 x and 3 x weekly treatment approached each other (60%, 79% and 82%, respectively); the mean repigmentation grades (on a scale of 0-5) for 1 x, 2 x and 3 x weekly treatment were 1.7, 2.4 and 3.3, respectively (P = 0.018; 3 x vs. 1 x weekly).

Br J Dermatol. 2005 ;152(5):981-5.

Treatment of atopic dermatitis with the xenon chloride excimer laser. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):657-60.
• BACKGROUND: Narrow-band ultraviolet B phototherapy is an effictive and safe treatment for atopic dermatitis. We have previously found that the 308 nm xenon chloride excimer laser was more effective than the narrow-band ultraviolet B light for the treatment of psoriasis, suggesting that ultraviolet B laser might offer advantages over narrow-band ultraviolet B. OBJECTIVE: The purpose of this study was to evaluate the therapeutic efficacy of the 308 nm excimer laser in atopic dermatitis. PATIENTS AND METHODS: Fifteen patients with atopic dermatitis (less than 20% body area involvement) were treated with a xenon chloride excimer laser (XTRAC laser, Photomedex Inc.) twice weekly. The severity of the atopic dermatitis was assessed via (i) a clinical score characterizing the intensity of erythema, infiltration, lichenification and excoriation; (ii) the quality of life, determined by means of a questionnaire; and (iii) a visual linear analogue scale, with which the patients scored the severity of their pruritus. RESULTS: After 1 month of laser therapy, the clinical scores were significantly lower than the initial values. Similar decreases were observed for the quality of life and pruritus scores. No serious or unpleasant side-effects were observed. CONCLUSION: These results suggest that the xenon chloride excimer laser is an effective and well-tolerated treatment for localized atopic dermatitis.

Evaluation of a novel 308-nm monochromatic excimer light delivery system in dermatology: a pilot study in different chronic localized dermatoses. British Journal of Dermatology 152 (1), 99-103.
Alopecia areata. (a) One week after 308-nm monochromatic excimer light treatment with 7 minimal erythema doses (MED), showing intense erythema and peeling. (b) After an additional 6 MED weekly for 6 weeks, complete regrowth was observed and was still present at the 6month follow-up visit.

Evaluation of a novel 308-nm monochromatic excimer light delivery system in dermatology: a pilot study in different chronic localized dermatoses. British Journal of Dermatology 152 (1), 99-103.
Figure 5. Length of remission after treatment with 308-nm monochromatic excimer light. PPPP, palmoplantar pustular psoriasis; P, plaque-type psoriasis; Atopic, chronic atopic dermatitis of the palms; Nonatopic, chronic nonatopic dermatitis of the hands; AA, alopecia areata. *P < 0·05 vs. the maximal percentage improvement observed after treatment.

Efficacy of 308-nm monochromatic excimer light in different dermatoses
Dermatosis Mean number of MED per treatment 13 11·8 Mean number Mean of treatments improveme nt (%) 5·3 5·3 7·3 12·5 47% 79% 54% 46%

Plaque-type psoriasis (n = 7) Palmoplantar pustular psoriasis (n = 17)

Chronic atopic dermatitis 13 of the palms (n = 8) Chronic nonatopic dermatitis of the hands (n = 10) Alopecia areata (n = 8) 8·4

9·1

3·1

47·5%

MED, minimal erythema dose. Improvement was calculated as: 1 − (posttreatment score/baseline score).

Low-dose excimer 308-nm laser for the treatment of oral lichen planus. Arch Dermatol. 2004 Apr;140(4):415-20. • A single-center, before-after trial in nine patients with symptomatic, biopsy-proven OLP, unresponsive to conventional therapies in MGH • Eight participants completed the entire study, and 1, despite early improvement, did not complete the study because of hospitalization for an unrelated reason.Intervention • an initial dose of 100 mJ/cm(2) once a week. • Five patients demonstrated overall excellent clinical and subjective improvement after 7 treatments. Two participants with nonerosive OLP were deemed fair responders. The only poor responder in the study also had chronic active hepatitis C infection. • for the responders, remission times ranged from 2 to 17 months. • Treatments were painless and well tolerated

• Treatment of erosive oral lichen planus by the 308 nm excimer laser. Lasers Surg Med. 2004;34(3):205. • Treatment of oral lichen planus with the 308-nm UVB excimer laser--early preliminary results in eight patients. Lasers Surg Med. 2003;33(3):158-60.

• The safety and efficacy of the 308-nm excimer laser for pigment correction of hypopigmented scars and striae alba. Arch Dermatol. 2004 Aug;140(8):955-60. • Histologic and ultrastructural analysis of ultraviolet B laser and light source treatment of leukoderma in striae distensae. Dermatol Surg. 2005 Apr;31(4):385-7. • 308-nm Excimer laser treatment of mature hypopigmented striae. Dermatol Surg. 2003 Jun;29(6):596-8; discussion 598-9.

Mycosis fungoides & Lymphomatoid papulosis
• 308-nm excimer laser for the treatment of lymphomatoid papulosis and stage IA mycosis fungoides. Photodermatol Photoimmunol Photomed. 2006 Jun;22(3):168-71 • Efficacy of the 308-nm excimer laser in the treatment of mycosis fungoides. Arch Dermatol. 2004 Oct;140(10):1291-3 • Efficacy of monochromatic excimer laser radiation (308 nm) in the treatment of early stage mycosis fungoides. Br J Dermatol. 2004 Oct;151(4):877-9. • Monochromatic excimer light (308 nm) in patch-stage IA mycosis fungoides. J Am Acad Dermatol. 2004 Jun;50(6):943-5.

The excimer laser in dermatology and esthetic medicine Hautarzt. 2004 Jan;55(1):48-57 • Mycosid fungoides • Lymphomatoid papulosis • Oral lichen planus • Prurigo nodularis • Stria distnesae • Alopecia areata • psoriasis vulgaris • • • • vitiligo atopic eczema light-sensitive dermatoses post-operative hypopigmentation • parapsoriasis en plaque • Chronic palmar atopic dermatitis • palmoplantar pustular psoriasis

Summary
• Photo and systemic treatments
– effective but costly and risky – UVB is the least painful laser in cosmetic field – Useful in patients with limited disease