- Best Results4-12 months
- Treatment Recovery1-6 days
- Procedure Time2-10 minutes
- Skin SpecialistDermatologist
- Duration of ResultsVariable
- Back to Work1-5 days
Lasers For Vitiligo
Lasers including excimer 308 nm & fractional lasers are novel treatments for vitiligo. They should be viewed as last line management before surgical revision or Recell therapy. They remain as research modalities and are academic. Read more to understand why I prefer phototherapy as first line management for vitiligo.
FactsFact on lasers for vitiligo
- Laser therapy is a novel treatment for vitiligo
- The most widely studied is the 308-excimer laser
- Fractional lasers have also been used in recalcitrant cases of vitiligo
- Narrowband UVB is covered under Medicare
- Combination therapy with creams & phototherapy gives the best result
- The biggest downside of laser is the costs as it is not covered under Medicare
- Phototherapy achieves similar results compared to lasers, without expense
How do lasers treat vitiligo?
There are two main types of lasers used for vitiligo. The most popular is excimer 308. This delivers monochromatic light to the areas devoid of pigmentation. This laser can-
- Suppress the inflammation in the upper layers of skin.
- Stimulate pigment cells to produce more pigment.
- Stimulate melanocytes to migrate from the hair follicle & surrounding skin.
- Stimulate germ stem cells to differentiate & from pigment producing cells.
Another laser for vitiligo is termed fractional laser resurfacing. This laser works by-
- Stimulation of germ cells from the hair follicle.
- Non-selective destruction of melanocytes or pigment cells.
- Stimulation of new melanocytes.
- Providing increased absorption of topicals including psoralen & anti-inflammatories.
How good are lasers in the context of vitiligo?
They do not offer an advantage over narrowband phototherapy. The advantage of excimer laser is the fact that it can treat discrete areas, whilst sparing unaffected skin. This reduces exposure to normal skin & can reduce colour discrepancies due to tanning.
The major disadvantage of lasers is that they are not covered under Medicare. One trial of excimer 308 involving 50 sessions is just over $10,000 AUD. Compared this to narrowband phototherapy with a cost of zero dollars (believe it or not it is fully covered under Medicare in Australia). The results from excimer 308 & phototherapy are comparable. If you are so inclined for me to use a laser, I will do so, however it does put you out of pocket close to 20K per year.
I have used fractional lasers in the context of vitiligo over the past 12 years. I have had very little in the way of success. Fractional lasers may have a role in increasing absorption of certain chemicals including psoralens.
Why is phototherapy a better option?
As reflected in the literature, phototherapy gives similar outcomes compared to excimer lasers, with much less expense. The downside of phototherapy is the fact that unaffected skin is also treated. With careful use of sunscreen & clothing, collateral treatment areas can be minimised.
Another factor that favours phototherapy is the cost. In Australia, Medicare covers this treatment, saving patients over $7,900 per year. Factor 2 years treatment, & the cost saving is tremendous. Excimer 308 by definition is 3 nanometres away from narrowband phototherapy. This means there is no Medicare cover.
What is my experience with lasers for vitiligo?
I have used both excimer 308 & fractional lasers to treat vitiligo. I do agree with the papers that 308 excimer offers little advantage in the context of end results. My experience with lasers for vitiligo is summarized below-
Excimer laser: is a novel treatment. The advantage of this laser is the ability to treat smaller areas without exposure to UVB to unaffected areas. Used cautiously, it does not increase the incidence of blistering. The time taken to treat (including chit-chatting to the patient) ranges from 5 to 12 minutes. The number of sessions for response is about 20-30 sessions. It is not cost effective for the patient as each treatment is around $200. Phototherapy is more efficient & provides similar results. This is reflected in the literature. The cost for Medicare card holders is zero.
Fractional Erbium & CO2 lasers. I have done a trial on 10 patients. I have only had a good result in one. Again, given the time & expense, phototherapy is a better option. Fractional lasers can be used to increase absorption of psoralens; however, this is largely academic. Recent studies have demonstrated that simple microneedling is equally, if not more effective compared to fractional laser resurfacing.
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How long before I see a change?
The literature suggests that up to 48 sessions of excimer laser are required to notice a change. This equates to 25 weeks of therapy.
Fractional laser resurfacing requires 4-8 sessions to notice a difference. Fractional lasers are best combined with topicals including tacrolimus, CS, vitamin D as well as phototherapy.
What is the logic behind excimer lasers for vitiligo?
The 308 nm of excimer is very close to the 311 nm of narrowband phototherapy. This wavelength works by-
- Suppression of immune cells (T Cells) in the upper layers of skin.
- Stimulation of pigment cells called melanocytes.
- Migration of melanocytes from the hair follicle & adjacent skin.
- Activation of neural stem cells in the follicles to form melanocytes
The 308 wavelengths can be achieved with excimer laser or more frequently nowadays monochromatic light from a UV source. The logic behind focused light or monochromatic laser is that the spot size delivery is limited to the treatment areas. This means normal skin is not treated, hence there is minimal collateral damage. This advantage is loss if large areas require treatment.
Can I cure vitiligo?
No. If the condition goes, it is because your body’s immune system is normalizing. Remission or temporary remission is a more accurate description. Of course, avoiding stress, both emotional and oxidative, will help.
What creams are used in conjunction with lasers & phototherapy?
Dermatologists will prescribe one of five creams for the management of vitiligo-
- Anti-inflammatory CS ointment & creams.
- Calcipotriol or vitamin D
- PGE analogues
- Psoralens/ MOP-8
- 5 FU (rarely done)
Topical therapy combined with phototherapy provides the best results.
How much are vitiligo treatments?
The most cost effective & effective treatment for vitiligo is actually free (technically your Medicare contribution covers this). Narrowband phototherapy is covered under Medicare with no out of pocket expense to the patient. If you do not hold a Medicare card, your out-of-pocket cost is around $128 per week.
Laser treatments are around $200 per session. You will require up to 50 sessions (this is why phototherapy is cost effective). Fractional laser resurfacing starts at $690 per session. I highly discourage you from considering fractional lasers as it is not cost effective. Patients require 2-6 sessions to gauge success. Fractional lasers should be combined with phototherapy.
Davin’s Viewpoint on Lasers & Vitiligo
Been there and done that. I had the excimer 308 back in 2015. Illumination of affected areas of vitiligo with sparing of non-affected skin is an advantage. This advantage is lost when there are large areas involved. Used cautiously the increased rate of blistering (often quoted as 15-27%) is not seen. The downside is that with conservative fluences, more treatments are required. As reflected in the literature the result is not superior to narrowband phototherapy. The current literature supports 2-3 treatments per week, for a total of 50 trial treatments.
The disadvantage of excimer is the cost to the patients, as by definition this is not narrowband UVB (UVB adds another 3 nanometres to the excimer wavelength). This 3 nm difference accounts for $10,000 AUD difference expenses over 6 months. That’s 20K per year!
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