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Successful Treatment with UVA 1 Laser of Non - Responder Vitiligo Patients

The Authors discuss their experience in treating non-responder vitiligo patients with a UVA-1 laser. Laser Alba 355® is an innovative device of target UVA - 1 phototherapy. The present report suggests that UVA1 laser could be an applicable therapeutic option in patients with vitiligo, also for the ones who did not respond to the more conventional phototherapies.


Introduction
Vitiligo is an important cutaneous pigmentary disorder, characterised by the progressive loss of melanocytes and/or by their dysfunction, resulting in hypopigmented skin areas which progressively become amelanotic. Despite new researches and progress, the pathogenesis of vitiligo is still enigmatic. Nowadays most evidence support that vitiligo is a Tcell-mediated autoimmune disease, maybe triggered by oxidative stress, and associated with an underlying genetic predisposition [1] [2][3] [4].
Clinically, the condition is characterized by milk-white macules and patches, varying in size, form, and distribution. Because of the clinical appearance of the patients, vitiligo is often associated with psychological distress and reduction of patient's life quality index [5].  The aim of this multicenter observational study was to evaluate the efficacy and safety of Laser Alba 355 in the treatment of 21 patients affected by vitiligo vulgaris, who had been unsuccessfully treated with other conventional phototherapies.

Patients and Methods
We evaluated 21 subjects (14 female, seven male), aged from 23 to 48 years, who suffered from stable or active vitiligo vulgaris for more than three years and less than six years. Lesions were variously localised ( Table 2). In the past, all of them have been treated with different phototherapies, without good clinical results. In details, 18 patients had been treated with a complete session of PUVA therapy; the other 3 stopped the treatment because of the gastric toxicity of psoralen. Successively, all patients completed the treatment with UVB broadband of clinical responses; patients had been successively treated with narrowband UVB (311nm) total body. None of them achieved a repigmentation rate more than 30%. In the recent past (5 months), none of them had been treated for the cutaneous disease.
We decided to treat the patients with UVA -1 laser using Laser Alba 355®, a laser technology based on UVA -1 spectrum with a wavelength of 355 nm (Table 3). They had been irradiated once a week at a dosage of 120 J/cm², for 24 weeks. The time of emission and spot diameters were regulated by the operator, based on the clinical characteristics of the patients.
For all patients, digital photographs of the vitiliginous lesions have been obtained before the start and at each treatment session. The response to the treatment was determined by assigning to each lesion a 0% score before therapy and a second percentage value at the end of the same, to represent the level of repigmentation (Table 4).

Results
At the end of the treatment, we evaluated the repigmentation rate achieved by every single patient treated with Laser Alba 355®. 17 patients (81%) achieved excellent results, with a re -pigmentation rate bigger than 75%. Three patients (14%) achieved a marked improved of the clinical findings with a repigmentation rate between 50-75%. Only one patient showed minimal response to the phototherapeutic treatment.
No differences in repigmentation had been described for the different localisation of the lesions.
In general, the treatment had been well tolerated by all patients. Besides a mild, transient, post-therapy erythema and itching sensation, we did not observe other side effects.

Discussion
In this multicenter study, we evaluated the treatment of 21 patients affected by a stable or active form of localised vitiligo with Laser Alba 355®, an innovative targeted phototherapy device, with a peak of emission of 355 nm [7].
Like common UVA -1 device, the biological effects of UVA -1 laser are mainly mediated by the formation of reactive oxygen intermediates, during the mitochondrial oxidative phosphorylation, which may damage DNA, lipids, proteins and cellular organelles. This fact may exert different biochemical effects, such as inhibition of immune responses and stimulation of melanocytes [8] [9].
The most important advantage in the use of Laser Alba 355®, is the possibility to treat only skin lesions, sparing uninvolved skin areas. This fact allows the operator to use higher doses achieving better results in less time and in a safer way, reducing the side effects due to radiation.
In conclusion, laser Alba 355® is an innovative device of target UVA -1 phototherapy. The present report suggests that UVA1 laser could be an applicable therapeutic option in patients with vitiligo, also for the ones who did not respond to the more conventional phototherapies.