Fractional carbon dioxide laser versus low-dose UVA-1 phototherapy for treatment of localized scleroderma: a clinical and immunohistochemical randomized controlled study

Abstract

Morphea is a rare fibrosing skin disorder that occurs as a result of abnormal homogenized collagen synthesis. Fractional ablative laser resurfacing has been used effectively in scar treatment via abnormal collagen degradation and induction of healthy collagen synthesis. Therefore, fractional ablative laser can provide an effective modality in treatment of morphea. The study aimed at evaluating the efficacy of fractional carbon dioxide laser as a new modality for the treatment of localized scleroderma and to compare its results with the well-established method of UVA-1 phototherapy. Seventeen patients with plaque and linear morphea were included in this parallel intra-individual comparative randomized controlled clinical trial. Each with two comparable morphea lesions that were randomly assigned to either 30 sessions of low-dose (30 J/cm) UVA-1 phototherapy (340-400 nm) or 3 sessions of fractional CO laser (10,600 nm-power 25 W). The response to therapy was then evaluated clinically and histopathologically via validated scoring systems. Immunohistochemical analysis of TGF-ß1 and MMP1 was done. Patient satisfaction was also assessed. Wilcoxon signed rank test for paired (matched) samples and Spearman rank correlation equation were used as indicated. Comparing the two groups, there was an obvious improvement with fractional CO laser that was superior to that of low-dose UVA-1 phototherapy. Statistically, there was a significant difference in the clinical scores (p = 0.001), collagen homogenization scores (p = 0.012), and patient satisfaction scores (p = 0.001). In conclusion, fractional carbon dioxide laser is a promising treatment modality for cases of localized morphea, with proved efficacy of this treatment on clinical and histopathological levels.

Localized scleroderma – current treatment options

“…Shalaby et al have published the results of a study conducted in a group of 17 patients with localized scleroderma (plaque and linear types), in whom two comparable localized scleroderma lesions were treated by UVA-1 phototherapy (low doses: 30 J/cm 2 , 30 exposures) or fractional CO 2 laser procedures (10, 600 nm, 25 W, 3 exposures) [25]. The lesions subjected to irradiation were selected on the basis of identical morphological features [25].…”

“…Shalaby et al have published the results of a study conducted in a group of 17 patients with localized scleroderma (plaque and linear types), in whom two comparable localized scleroderma lesions were treated by UVA-1 phototherapy (low doses: 30 J/cm 2 , 30 exposures) or fractional CO 2 laser procedures (10, 600 nm, 25 W, 3 exposures) [25]. The lesions subjected to irradiation were selected on the basis of identical morphological features [25]. Clinical effects were evaluated clinically using the Localized Scleroderma Assessment Tool (LoSCAT) score: localized scleroderma lesions treated by CO 2 laser showed very good response to therapy in 7 cases, good response in 9 cases, and fair response in 1 case; lesions treated by UVA-1 exhibited good response in 6 cases, fair response in 10 cases, and no response in 1 case; level of patient satisfaction -significantly higher for CO 2 laser treatment; ultrasound assessment -significantly higher degree of reduction in skin thickness associated with CO 2 laser treatment; histopathological evaluation -significantly higher improvement with respect to collagen homogenization for CO 2 laser treatment and significantly reduced inflammatory infiltrate after UVA-1 treatments; and immunohistochemical assessment -no statistically significant differences between CO 2 laser and UVA-1 treatments with regard to the effect on the level of TGF-β and MMP1 expression [25].…”

“…Shalaby i wsp. przedstawili wyniki badania u 17 pacjentów z twardziną ograniczoną (plackowatą i linijną), u których dwa porównywalne ogniska chorobowe zostały poddane fototerapii UVA1 (małe dawki 30 J/cm 2 , 30 ekspozycji) lub zabiegom z zastosowaniem lasera frakcyjnego CO 2 (10, 600 nm, 25 W, 3 ekspozycje) [25]. Naświetlane ogniska dobierano w taki sposób, aby morfologia wykwitów była identyczna [25].…”

“…przedstawili wyniki badania u 17 pacjentów z twardziną ograniczoną (plackowatą i linijną), u których dwa porównywalne ogniska chorobowe zostały poddane fototerapii UVA1 (małe dawki 30 J/cm 2 , 30 ekspozycji) lub zabiegom z zastosowaniem lasera frakcyjnego CO 2 (10, 600 nm, 25 W, 3 ekspozycje) [25]. Naświetlane ogniska dobierano w taki sposób, aby morfologia wykwitów była identyczna [25]. Efekty kliniczne porównywano na podstawie wyników w skali LoSCAT (Localized Scleroderma Assessment Tool): ogniska twardziny ograniczonej poddawane działaniu lasera CO 2 wykazały bardzo dobrą odpowiedź na terapię w 7 przypadkach, dobrą -w 9, słabą -w 1; wykwity naświetlane UVA1 wykazały dobrą odpowiedź w 6 przypadkach, słabą -w 10, brak -w 1; satysfakcja pacjentów była istotnie większa w przypadku lasera CO 2 , ocena ultrasonograficzna wykazała istotnie większy stopień redukcji grubości skóry w przypadku lasera CO 2 , ocena histopatologiczna -istotnie większy stopień poprawy w zakresie homogenizacji kolagenu w przypadku lasera CO 2 i istotnie mniejszy naciek zapalny po naświetlaniach UVA1, ocena immunohistochemicznabrak istotnych statystycznie różnic między laserem CO 2 i UVA1 w zakresie wpływu na poziom ekspresji TGF-β i MMP1 [25].…”

Cosmetical treatments of connective tissue disorders

“…Fractional ablative lasers (FALs) are described as beneficial in morphea by creating microscopic treatment zones that eliminate part of the homogenized or fibrotic tissue, thus ameliorating skin tightness. Additionally, FALs facilitate collagen remodeling and dynamic wound healing (Shalaby et al, ).…”