Commentary: Treatment of Cutaneous Lupus Erythematosus Using the Pulsed Dye Laser

Abstract

The authors have indicated no significant interest with commercial supporters.T he prospective study by Truchuelo Díez and colleagues 1 points the way ahead. For the first time, histologic and immunohistologic examinations have been conducted and their results correlated with the similarly excellent clinical results.The treatment of cutaneous lupus erythematosus (CLE) using the pulsed dye laser (PDL) was described for the first time by the group of Pablo Boixeda and Maria Nunez. 2 Since then (15 years ago!), there have been only a few studies 1-7 on this topic, but they have consistently confirmed the excellent results of the method.The exact reason for the effectiveness of pulsed light at a wavelength of 585-595 nm of PDL in the treatment of CLE lesions is unclear. With laser therapy, the applied light is monochromatic, and there is strong evidence that the induced pathogenic mechanisms are different from those caused by irradiation over an ultraviolet spectrum. 4 The suggested working mechanism of PDL (selective photothermolysis) is selective destruction of the cutaneous microvasculature, which might modulate the inflammatory network, leading to regression of CLE lesions. 1 Legitimate questions are why PDL has not become a standard method or even the criterion standard in CLE therapy and why it has not been included in the official guidelines of dermatologic associations, even though it is a simple and effective method with minor side effects. To answer the questions, an analysis might help, based on a thorough search of the literature in the relevant databases (MEDLINE and the Cochrane Library). The search terms cutaneous lupus erythematosus treatment, cutaneous lupus erythematosus pulsed dye laser, and wrinkle treatment were employed. From 2005 to 2010, we found 547 relevant articles for cutaneous lupus erythematosus (CLE), seven relevant articles with the combination of CLE and PDL, and 191 relevant articles for the cosmetic treatment of wrinkles on these databases.It seems that conservative conventional dermatologists do not see or recognize the achievements of innovative laser therapy or that they simply do not know about them and thus do not implement them in their therapy regime, or it may be they have scruples about offering medically indicated services as direct-payment services because, in most cases, insurance companies do not pay for such therapies. For another thing, many dermatologists who mostly provide laser therapy have veered away from conventional dermatology and are dedicated to the therapy of cosmetic indications and ''treatment'' of patients with body dysmorphic disorders. This might be why their interest in treatments of inflammatory dermatological diseases such as CLE and other, not primarily cosmetic-aesthetic dermatological indications seems to have diminished.

Laser Therapy in the Treatment of Connective Tissue Diseases: A Review

“…To our knowledge, there have been no reports of the use of lasers in the ultraviolet A or B spectrum, namely, the excimer laser, because wavelengths in these spectrums are known to be photosensitizing in LE, although there have been numerous reports of the use of lasers with wavelengths in the visible light spectrum (PDL, argon, and intense pulsed light (IPL) with a 515‐nm filter), which were relatively well tolerated. These findings may support the hypothesis that monochromatic laser light is unlikely to be photosensitizing in LE and, if administered correctly, may be a safe treatment option in select patients …”

“…The authors acknowledge the lack of use and reporting of lasers in treatment of LE and that laser medicine is not considered in treatment algorithms despite evidence to support that it is well tolerated and effective. Reasons that Raulin and colleagues proposed for PDL not reaching mainstream therapy for cutaneous LE include lack of awareness or interest on the part of dermatologists with little knowledge or experience with lasers or that those with the experience have a greater interest in the treatment of cosmetic and aesthetic concerns …”

“…Reasons that Raulin and colleagues proposed for PDL not reaching mainstream therapy for cutaneous LE include lack of awareness or interest on the part of dermatologists with little knowledge or experience with lasers or that those with the experience have a greater interest in the treatment of cosmetic and aesthetic concerns. 7 Continuous-wave lasers, although no longer routinely used as first-line laser therapy for most cosmetic and medical indications, have been shown to result in successful treatment in patients with cutaneous LE. Two studies used the 488/514-nm argon laser in six patients with DLE and achieved complete resolution in two and 60-70% improvement in another two.…”

“…These findings may support the hypothesis that monochromatic laser light is unlikely to be photosensitizing in LE and, if administered correctly, may be a safe treatment option in select patients. 7 Adverse events after laser treatment of cutaneous LE have been reported, specifically with CO 2 lasers, argon lasers, and PDL. Several of these were reported in the 1980s and 1990s, with technology, parameters, and techniques that have since become outdated and probably do not reflect current use of generally longer pulse durations and lower fluence settings.…”

The role of lasers in connective tissue and inflammatory dermatoses: A 10-year retrospective review of 60 patients in a UK tertiary laser clinic

“…[ 11 ] Raulin et al . [ 12 ] challenged as to why PDL has not been incorporated into the conventional treatment algorithms in the context of LE and suggested that in part dermatologists may not be aware or appreciate the full use of lasers and therefore do not implement laser therapy in their treatment regimes. We would agree that we anticipated having treated more LE patients in our laser clinic, but it is possible that cases were not referred due to a lack of awareness.…”