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Skin Vitiligo Psoriasis Phototherapy NEW PRODUCT
• Other factors
– epidermal thickness
– vascular supply
• What are Melanocytes?
– Melanocytes are special cells in our skin that
specialize in making a molecule called melanin.
• What is Melanin?
– Melanin is something called a pigment, which is the
molecule that gives our skin colour a darker shade.
MELANIN
• What does melanin actually do?
– Melanin protects our skin from the damaging
Ultraviolet (UV) rays from the sun.
– Going sun tanning induces your body to produce
more melanin, which is why people who return from
tanning look darker.
– More melanin in the skin is the reason why people
who are darker usually do not get sunburned.
• In our skin, we all have around the same number of
melanocytes, which are the cells that produce melanin.
• However, the melanocytes in each of our bodies produce
different amounts of melanin.
– The more melanin you have in your skin, the darker
your skin colour will be.
Which has more melanocytes??
Lentigo
Hyperpigmenta
tion Iatrogenic
hyperpigmentatio Pregnancy mask
n
Post-acneic or
cicatricial
hyperpigmentatio
n
Hypopigmentati
on Vitiligo
Vitiligo
Vitiligo
Hypopigmentation disorders
• Vitiligo
• Unknown etiology
ÀAutoimmune disorder
ÀGenetic link
ÀDifficult to cure
Genetic Links
ÀPolygenic nature, multifactorial inheritance
ÀAutosomal and not linked to race or sex
ÀLinked to other autoimmune diseases
ÀWeakly heritable
Signs and Symptoms
Vitiligo lesions are characterized as follows:
• White or depigmented macules and patches
• Usually well demarcated
• Round, oval, or linear in shape
• Borders may be convex [1]
• Range from millimeters to centimeters in size
• Enlarge centrifugally over time at an unpredictable rate
Types of Vitiligo
Diagnosis
• Clinical findings, biopsy is occasionally needed for differentiating
vitiligo from other hypopigmenting or depigmenting disorders
• Microscopic examination of involved skin shows a complete absence
of melanocytes in association with a total loss of epidermal
pigmentation
LAB TESTS
• Thyroid panel consisting of thyroid-stimulating hormone (TSH), free
triiodothyronine (T3), and free thyroxine (T4) levels
• Antinuclear antibody
• Antithyroid peroxidase antibody
• CBC count with differential
VITILIGO PATHOPHYSIOLOGY
Treating Vitiligo
ÀLong and difficult process, rarely 100% effective on individual
ÀOften involves sunlight or ultraviolet light
ÀPhysical and chemical methods
ÀCosmetics
ÀDepigmentation
ÀPsychological counseling
Treatment of Vitiligo
Therapy Options-1
Therapy Options-2
Treatment Steps
Step 1 (Inhibiting Principle Mechanism
Depigmentation)
Corticosteroid/Tacrolimus/UV Immunosuppression and
B Preventing Immune activation
Step 2 (Promoting Principle Mechanism
Repigmentation)
UVB/Surgery Stimulating Melanogenesis,
Melanocyte Proliferation
Vitiligo Treatment Guidelines
Psoriasis
PSORIASIS
Erythematous lesions with loose, silvery-white scales
Removing scale can induce punctate bleeding: Auspitz sign
Papules can coalesce in pruritic patches / plaques
Nails and joints may be affected
1923 - William Henry Goeckrman - artificial BB-UVB + topical coal tar for psoriasis
1984 - Van Weelden, Baart de la Faille, Young and van der Leun demonstrated
clinical efficacy of NB-UVB, ushering the NB-UVB era
• The sun emits all kinds of rays: cosmic rays, gamma rays, x-rays, ultraviolet rays(UV),
infrared rays(IR), microwaves, short radio waves(SRW) and long radio waves(LRW).
What is UV Light?
• Light is essential for life on earth.
• UV is part of the EM spectrum between
visible light and X-ray.
• Approximately 10% of the sun power is
emitted in the UV range.
• UVA (400-320nm), UVB (320-280nm),
UVC (280-100nm).
• Shorter wavelength = higher energy
• High energy UVC mostly absorbed by the
ozone layer
Why UVB is better?
How does Phototherapy/UVB work in
Psoriasis?
How does Phototherapy work in Vitiligo?
Same as Tanning Process
EFFECT
Types of Phototherapy
• PUVA/PUVASOL (Psoralen Ultra Violet A band therapy/PUVA with Sunlight)
• Narrow band UVB (Narrow Band Ultra Violet B Band therapy)
• BB UVB (Broad Band Ultra Violet B Band therapy)
• Photodynamic therapy
• Excimer laser
• UV light Targeted phototherapy
• Monochromatic light machines
• Low-level lasers
PUVA/PUVASOL
• Topical PUVA: With PUVA, a person either soaks in a bath or
applies a lotion containing psoralen, which makes the skin more
receptive to the UV light treatment that follows.
• Studies have not shown an increased incidence of cataracts under eye protection, so
this preventive measure seems to achieve the desired effect.
Continued..
• Phototoxic reactions are delayed, with an erythema reaction peaking 48 to 72 hours after
irradiation. Therefore, accurate UVA dosimetry is distinctly required for PUVA therapy as over
dosage can easily lead to skin necrosis.
• Sometimes, the patient's extremities (in particular the lower extremities) arc exposed to higher
doses than the trunk.
• Early side effects: Oral PUVA is generally well tolerated; however, a number of potentially
serious side effects exists :
• Phototoxic reactions : a prodromal state with general malaise and itch precedes the rash.
• GI symptoms (ie, nausea and vomitus) are not uncommon but can often be improved by intake
of 8-MOP with some food , especially milk.
Continued..
• Rarely, increase in transaminase levels in the liver, and, thus liver function tests should routinely be
performed before starting oral PUVA.
• Late side effects: PUVA in the long term leads to a photoaged skin pattern with elastosis,
poikiloderma, and lentigines.
• Of concern is the induction of Non Melanoma Skin Cancers , which is proven and occurs in more
than 25% of PUVA-treated patients.
• Whether melanoma can be induced by PUVA has not been clarified.
All patients who received several course of oral PUVA should enter a long-term-follow up program
for at least 25 years
Targeted phototherapy
• Targeted therapy may either use broadband UVB, NB-UVB Excimer(308) laser or light
beams, NB-UVB (311 nm), or UVA1.
• Concentrated phototherapy
• Focused phototherapy
• Microphototherapy
Excimer laser
• Uses Xe Cl2 gas
• 308 nm wavelength
• Previously used in cardiology and ophthalmology
• Delivery system may be fibre optic/water guided
• Very quick delivery
• Initial reports claimed response with in 1-3 exposures in psoriasis and vitiligo
• works in resistant lesions and scars
• Very expensive-Rs10 to 15 lac
• Huge machine-over 120 kgs
• High maintenance cost
• Frequent replacement of Xe CL2 gas
• Frequent breakdown of fibre optic cables
• Not effective in peripheral vitiligo
UV-B PHOTOTHERAPY
• BB-UVB: Fluorescent lamps are used.
• Wavelengths <300 nm are implicated in causing non melanoma skin
cancers and inducing erythema.
• NB-UVB: 308-313 nm wavelength
• Philips TL-10 lamp with an emission spectrum (311-312 nm).
• 5-10 fold less potent than BBUVB for erythema induction, hyperplasia,
edema and Langerhans cell depletion from the skin.
• More suppressive effect than BBUVB.
• Adv:NB-UVB schedules can be tailored according to patient skin type
and local experience
• Disadv
– The bulbs/tubes need to be replaced after 1000hrs
– Many don’t do so as each tubes cost around Rs. 100,000/-
Monochromatic excimerlight (IPL) machines
• Excilite( 304 nm), Pxlite( 308 nm)
• Use monochromatic light (intense pulse light)
• LARGE TREATMENT SURFACE: 36*14 cm
• more reasonable in cost
• Easier maintenance
• In a pilot study of 37 patients, Thirty-five patients (95%)
showed signs of repigmentation within first 8 treatments.
COMPARISON
Type PUVA BB-UVB NB-UVB Excimer Laser
• Combines two novel molecules into a topical cream producing a “topical band pass filter”
Presilux
• Composition: Not a Drug(Registered as Cosmetic Product)
• NO ACTIVE PHARMACEUTICAL INGREDIENT
Check for weather condition Apply Presilux Apply the SPF 300 sunscreen and cover the non affected area
Proceed outside Expose skin to direct daylight for 20-30 minutes Return inside.
Directions for use
• Apply as needed
• Apply Presilux cream to affected skin area(s) in accordance with your doctor's instructions
• Allow affected area(s) of skin to receive exposure to daylight preferably between 10am to 2pm
following application of Photocil cream
• Use accompanying dosimeter or mobile app in accordance with your doctor's instructions to
monitor sun exposure
USE
• Indicated for vitiligo and psoriasis
• Allows penetration of therapeutic radiation while filtering out most non-therapeutic radiation
from daylight and artificial light
Novel topical cream delivers safe and effective sunlight therapy for Vitiligo by selectively filtering damaging ultraviolet
radiation
Andy Goren MD, Antonio Salafia MBBS, John McCoy PhD, Sharon Keene MD, Torello Lotti MD. Dermatologic Therapy (In Press)
Andy Goren MD, Antonio Salafia MBBS, John McCoy PhD, Sharon Keene MD, Torello Lotti MD. Dermatologic Therapy (In Press)
• Patients can receive therapy at their convenience and at an affordable cost per treatment
• Stop use and ask doctor if condition worsens or symptoms do not improve after more than 7 days
• If swallowed, get medical help or contact a Poison Control Center right away
PRESILUX PLACE IN THERAPY
Vitiligo Treatment Guidelines
Psoriasis Treatment Guidelines
How should a clinician choose between topical
and systemic drug therapy?
Determine disease severity
Measure affected body surface area
≤3%: mild
3%-10%: moderate
≥10% or serious adverse affect on QOL: severe
Determine the location of lesions
Consider affect on QOL
Mild disease: topical therapies
Moderate-to-severe disease: systemic and topical therapies;
biologics if systemic fail / can’t be used
What is the role of phototherapy?
when disease substantially affects QOL
Efficacious and cost-effective
Not immunosuppressive like systemic drugs
Affects Langerhans cells directly, cytokines indirectly
Don’t use with photosensitive disorders
Is there a role for combination drug therapy
and phototherapy?
Improves efficacy and decreases toxicity of a potentially hazardous combination agent
• Attempting to “capture” the sun’s therapeutic properties led to the development of artificial UV
light sources
• Artificial light sources have inherit limitations in the daily lives of humans
• Revolutionary photochemistry (Presilux) harnesses the power of natural sunlight for NB-UVB
therapy opening a new window in phototherapy
References
• http://environ.andrew.cmu.edu/m3/s2/02sun.shtml (accessed on 01/JUl/2019).
• https://share.upmc.com/2014/07/infographic-abcs-uv-difference-uva-uvb-uvc/ (accessed on 01/JUl/2019).
• https://www.fda.gov/radiation-emitting-products/tanning/ultraviolet-uv-radiation (accessed on 01/JUl/2019).
• Leone G, Iacovelli P, Paro Vidolin A, Picardo M.J. Monochromatic excimer light 308 nm in the treatment of vitiligo: a pilot study. Eur Acad Dermatol Venereol.
2003 Sep;17(5):531-7.
• Rai R. Phototherapy: An update. Indian J Dermatol Venereol Leprol. 2009 Jul 8;75:634-7.
• Hönigsmann H. History of phototherapy in dermatology. Photochemical & Photobiological Sciences. DOI: 10.1039/c2pp25120e
• Pathak MA, Fitzpatrick TB. The evolution of photochemotherapy with psoralens and UVA (PUVA): 2000 BC to 1992 AD. J Photochem Photobiol B:Biol
1992;14:3- 22
• Roelandts R. The history of photochemotherapy. Photodermatol Photoimmunol Photomed 1991;8:184-9.
• Lim HW and Hexsel CL. Vitiligo: To treat or not to treat. Arch Dermatol 2007 May; 143:643-6.
• Parsad D. Vitiligo: Treatment With Narrowband Ultraviolet B: NBUVB as Monotherapy in Vitiligo. MD Faculty and Disclosures CME Released: 08/03/2010;
Valid for credit through 08/03/2011.
• Vitiligo - Management and Therapy. Edited by Dr. Kelly KyungHwa Park, ISBN 978- 953-307-731-4.
• El Miedany Y. Recent developments in management of psoriatic arthritis. Curr Rheumatol Rev. 2005;1(1):9–19.
• Agar N. Melanogenesis: a photoprotective response to DNA damage?Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis. 2005
Apr;571(1–2):121–132.