Lasers and Light Devices in Dermatology: An Update in Office Based Procedures. Cory A. Dunnick, M.D. University of Colorado Denver.

Transcription

1 Lasers and Light Devices in Dermatology: An Update in Office Based Procedures Cory A. Dunnick, M.D. University of Colorado Denver Objectives 1. Identify different types of Phototherapy and conditions commonly treated with this modality 2. Understand the concept of Photodynamic Therapy and how it is used to treat Actinic keratoses and skin cancer 3. Update the audience on new applications of lasers in the treatment of common skin conditions 1

2 Phototherapy Broad band UVB (BBUVB) Narrow Band UVB (NBUVB) Psoralen plus UVA (PUVA) Topical vs. Systemic Oxsoralen Lotion UVA-1 Sun and the Skin Infrared: 750 nm 1mm Visible Light: nm UVA: nm UVB: nm UVC: nm 2

3 Fitzpatrick Skin Types I. Never tans, always burns II. Tans with difficulty, usually burns III. Average tanning, sometimes burns IV. Easily tans, rarely burns V. Very easy to tan, very rarely burns VI. Never burns 3

4 Psoriasis Treatment Localized Disease Calcipotriol (Vit D3 analog) Corticosteroids Topical Retinoids Phototherapy UVB/NBUVB PUVA Widespread disease +/- Psoriatic Arthritis Methotrexate Cyclosporin Systemic Retinoids Biologics Anti-T lymphocyte Anti-TNF alpha 4

5 Incidence: 0.5-2% Acquired depigmented patches due to loss of melanocytes Commonly seen in periorificial and acral locations Microscopic finding is a complete absence of melanocytes Vitiligo CLINICAL 5

6 Vitiligo REPIGMENTATION WITH NB-UVB Alopecia Areata CLINICAL: NON-SCARRING ALOPECIA Occurs as round or oval patches of hair loss Short exclamation point hairs, broader at the distal end Hairs often re-grow with depigmentation 6

7 Clinical subtypes Patchy focal Ophiasis pattern Diffuse variant Alopecia totalis Alopecia universalis Alopecia Areata CLINICAL Cutaneous T cell Lymphoma (CTCL) 7

8 Excimer Laser Ultraviolet B ray source Xenon-Chloride lamp emitting non-coherent, monochromatic 308-nm light Benefits compared to traditional phototherapies No oral psoralens Treatment interval less frequent (every 7-15 days) Treatment may be limited to small areas of skin May be used for psoriasis, alopecia areata, CTCL, vitiligo, atopic dermatitis Psoriasis KOEBNER REACTION 8

9 Photodynamic Therapy (PDT) MECHANISM PDT requires a photosensitizer, light energy and oxygen Photosensitizer accumulates in the target cells and absorbs light Energy is transferred to oxygen and highly reactive oxygen species Leads to cell and tissue damage by inducing necrosis and apoptosis as well as production of inflammatory mediators and immunomodulatory effects are induced. Photosensitizers Aminolevulinic acid (ALA) Methyl ester of ALA (methyl-5- amino-4-oxopentanoate or MAL) 9

10 Photosensitizers These photosensitizers are not photoactive by themselves, but show a preferential intracellular accumulation inside the altered cells. They are metabolized in the heme biosynthesis pathways to photosensitizing porphyrins. These porphyrins are metabolized to photodynamically inactive heme within h. Light Sources Blue light Red light Intense pulsed light (IPL) Pulsed dye lasers Diode Lasers 10

11 Photodynamic Therapy PHOTOREJUVENATION ALA-PDT with IPL vs. IPL alone 16 patients, split face design, 3 treatments at monthly intervals 3 months after the final treatment, the authors reported on a higher improvement in the ALA-PDT-IPL side than in the IPL alone side for all facets of photodamage crow s feet appearance (55% vs. 29.5%) tactile skin roughness (55% vs. 29.5%), mottled hyperpigmentation (60.3% vs. 37.2%) and telangiectasias (84.6% vs. 53.8%). clearance rate of AKS (78% vs. 53.6%). Photodynamic Therapy In the United States, ALA (Levulans Kerastick) is approved for PDT of actinic keratoses (AK) in combination with blue light. Tumor thickness should not exceed 2 3mm in order to induce sufficient necrosis of deep tumor tissue. 11

12 BCC Various studies concerning ALA/MAL-PDT for BCC have been performed over the years (5, 13, 25, 26, 71 74). The weighted average complete clearance rates calculated from 12 studies (follow-up periods: 3 36 months) were 87% for superficial BCC (n =826) and 53% for nodular BCC (n= 208) (5, 22). Actinic Keratosis (Intraepidermal neoplasia) Most common pre-malignant skin neoplasm 1 out of 1000 within 1 year develop into squamous cell carcinoma if untreated 12

13 Cryosurgery Liquid nitrogen (boiling point of -196 C) Topical 5-fluoruracil Topical Imiquimod Topical Diclofenac Photodynamic therapy Sun protection Actinic Keratosis TREATMENT Actinic Keratoses 13

14 Actinic Keratosis TREATMENT For therapy of single lesions, cryotherapy might be favorable. PDT may be the first choice for field treatment of multiple AKs, in particular the scalp PDT field treatment is often preferred by patients compared to topical chemotherapy (5-FU) or immune modulators (Aldara) because the patient does not have to take care of the treatment over weeks Photodynamic Therapy ACTINIC KERATOSES 110 patients with 748 lesions were treated with a 20% ALA After 1 month, 76% lesions showed a complete remission After 2 months, 72% lesions showed a complete remission 2 months The recurrence rate after 1 year was 19%. 14

15 Bowen s Disease SQUAMOUS CELL CARCINOMA IN SITU Non-melanoma Skin Cancer TREATMENT Topical 5-fluoruracil Topical Imiquimod Cryosurgery Photodynamic Therapy Electrodessication and Curettage Excision Mohs micrographic surgery Radiation 15

16 Basal Cell Carcinoma Most common malignancy in the US More than 2 million new cases of nonmelanoma skin cancer are diagnosed annually Locally invasive, but rarely metastasize Basal Cell Carcinoma SUPERFICIAL (15%) 16

17 Basal Cell Carcinoma NODULAR (75%) Atopic Dermatitis Stepwise management of patients with atopic dermatitis Dry skin only Skin hydration, emollients, avoidance of irritants, identification and addressing of specific trigger factors Mild to moderate AD Topical steroids and calcineuron inhibitors Antihistamines Moderate to severe AD UV therapy Recalcitrant, severe AD Systemic therapy 17

18 Is there a safe way to tan? There is no safe way to tan. Every time you tan, you damage your skin and this damage accumulates over time. Accumulated damage accelerates the aging process (wrinkles and age spots) and also increases your risk for all types of skin cancer. 18

19 Tanning Facts Tanning occurs when the skin produces pigment to protect from UV radiation Indoor tanning devices can emit UV radiation levels up to 15x greater than what one is exposed to outdoors Indoor tanners are particularly susceptible to skin burning because of concentrated UV Indoor Tanning Regulation Federal govt. regulates manufacture and labeling of tanning devices States regulate indoor tanning facilities 19

20 AADA Position Statement: Indoor Tanning No minor should be permitted to use tanning devices A Surgeon General s warning should be placed on all tanning devices UV radiation can cause skin cancer and other nonreversible forms of damage to the skin Regular inspections for defects by the health dept. Adequate training for tanning device operators to recognize skin injury and skin type Operators should limit exposure times according to manufacturer recommendations No person or facility should advertise safe tanning or similar wording Skin Cancer Prevention Wear a Hat A hat with at least a 2- to 3-inch brim all around is best Protect Your Skin With Clothing Dark colors and tightly woven fabrics provide better sun protection Wear Sunglasses 20

21 Skin Cancer Prevention Use Sunscreen Use sunscreen and lip balm with an SPF of 15 or higher. Reapply every 2 hours and after swimming or sweating. Use sunscreen even on hazy or overcast days. Apply 20 to 30 minutes before you go outside. Don t stay out in the sun longer because you re using sunscreen. Protect Children Skin Cancer Prevention Seek Shade However, sunlight (and UV rays) can come through clouds, can reflect off water, sand, concrete, and snow, and can reach below the water's surface. Avoid Other Sources of UV Light Don't use tanning beds and sun lamps. Sunless tanners are okay Avoid Harmful Chemicals Arsenic can be found in well water, pesticides and herbicides, some medicines, and even herbal remedies. 21

22 Skin Cancer Prevention Get Vitamin D safely through healthy diet That may include vitamin supplements Check your birthday suit on your birthday Self skin examinations See a dermatologist if you notice anything changing, growing or bleeding The End 22