| Background: Vitiligo is an autoimmune disorder resulting in achromic skin patches and whitening of hair growing over them which result from melanocyte destruction in the lesions.Vitiligo equally affects both males and females and can initiate at any age although geographically there is some amount of variability in the age of onset.The first line treatment of vitiligo includes the application of topical corticosteroid therapy which has some benefits including its low cost and easy application methods.But the hindrance to this is the appearance of various side effects such as skin atrophy,striae and telangiectasia after long periods of treatment.The introduction of the fractional ablative carbon dioxide laser has an added advantage by producing microscopic cannaliculi vertically in the targeted site.The microscopic cannaliculi caused by the fractional ablative laser is produced as deep as the dermis hence improving the absorption and the spread of drugs which are applied topically.Several studies using laser have been made with good results.However,this is the first study that evaluates the effectiveness of carbon dioxide fractional laser in combination with 308 nm lamp and topical steroid.Objective: To see the effect of fractional carbon dioxide laser in combination with308 nm lamp therapy and topical steroid and compare it with the results of using only308 nm lamp and topical steroid.Other specific objectives were to see the adverse reactions,to determine the satisfaction rates,to calculate the duration it takes for the whole treatment,to observe the repigmentation patterns and to calculate the final costs of the two methods.Method: Twenty patients were selected who had a history of non-segmental vitiligo with stable refractory lesions having no improvement despite more than one year of conventional treatments.They were divided into two groups.The first group was named as the treatment group,the participants of which received 308 nm lamp therapy,topical steroid and fractional carbon dioxide laser.The second group,named as the control group was given 308 nm lamp therapy and topical steroid only.The study was conducted at the Skin Out Patient Department of The First Part of the First Affiliated Hospital of Dalian Medical University in Dalian from June 2016 to January 2018.Diagnosis of vitiligo cases was made on the basis of history and clinical examination.The patients presenting to the Dermatology OPD with vitiligo stable lesions were asked the screening questions.Clinical assessment was done by the same individual at baseline,at three months and at the end of six months.Objective analysis was done with Physicians Grading Score(PGS)and subjective analysis was done with Visual Analogue Scale(VAS).Results: All twenty patients,ten in each group,were included in the whole study with a total of twenty six individual lesions,thirteen in each group.According to our study,the treatment group showed significantly better repigmentation than the control group.At six months,the treatment group showed excellent repigmentation in 9(69.2%)lesions and marked repigmentation in 4(30.8%)lesions while the control group showed excellent repigmentation in just 1(7.7%)lesion and marked repigmentation in 5(38.5%)lesions.In our study,we found that the face and trunk had the best response to treatment while that of the upper limb had the worst response.The VAS was not 0 at three or six months for any of the patients indicating that there was no patient who was ‘not satisfied at all' with the treatments received.Also the satisfaction scale increased to the maximum in 2(15.4%)of the cases in the treatment group indicating that fractional laser has the capability to make patients ‘completely satisfied' with the treatment.It was also noted that the VAS did not decrease with time in any of the patients indicating that the overall satisfaction of all the patients improved with the treatment although the rate of improvement was variable.We took note of the fact that none of the patients in the control group were able to attain a VAS of 10 at any point in the duration of treatment indicating the importance of adding fractional laser to the treatment of 308 nm lamp therapy in non-segmental vitiligo.We also calculated the total duration it took for all the lesions to attain a maximum PGS level.The results showed that the majority of the patients in the treatment group had reached a PGS of 4 by six months.The remaining four patients reached PGS 4 by eight months at least.In the control group,only one patient had reached maximum PGS by six months.The rest achieved PGS 4 level by eighteen months with facial lesions attaining the same level by an average of about 12 months.The cost depended mainly on two factors;the 308 nm lamp sessions and the fractional carbon dioxide laser session.The 308 nm lamp sessions depended mainly on the number of sites while the fractional carbon dioxide laser sessions depended on the total area and on the number of sites involved.After statistical analysis we safely concluded that there is a significant difference between the treatment group and control group with the cost of doing fractional carbon dioxide laser by our proposed method being cheaper than the cost for the control method.To our knowledge this is the first study done with fractional carbon dioxide laser and 308 nm lamp to compare the costs with the control.Conclusion: The use of fractional carbon dioxide laser combined with 308 nm lamp and topical steroid could be a novel therapeutic approach for patients with non-segmental vitiligo. |
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