title: Effects of a preceding fractional carbon dioxide laser on the outcome of combined local narrowband ultraviolet B and topical steroids in patients with vitiligo in difficult-to-treat areas.
abstract: OBJECTIVE
  Conventional treatment of vitiligo on hands and feet often produces an unsatisfactory result. Various ablative treatment methods were tried with favorable results in facial, neck, and truncal areas. The aim of this study is to evaluate the efficacy and safety of combined fractional CO2 laser, narrowband UVB (NB-UVB) phototherapy, and topical clobetasol propionate in managing stable vitiligo in difficult-to-treat areas.
  
  
  METHODS
  A prospective randomized-intraindividual study was conducted on 27 patients with 27 pair-lesions of non-segmental vitiligo on both hands. The lesions were randomized to receive treatment with fractional CO2 laser, NB-UVB phototherapy, and 0.05% clobetasol propionate cream (Group A) or NB-UVB phototherapy and 0.05% clobetasol propionate cream (Group B). Fractional CO2 laser was performed at 1-week interval for 10 sessions. NB-UVB phototherapy was administered twice weekly for 20 sessions. Patients were evaluated 12 weeks after the last treatment. Outcome was evaluated objectively based on standard digital photographs, patient satisfaction, and adverse events.
  
  
  RESULTS
  Twenty-six patients completed the study. Six vitiligious lesions (23.1%) in group A achieved good to excellent repigmentation compared with one lesion (3.9%) in group B (P = 0.065). The overall mean improvement score was 1.35 (± 1.38) in group A and 0.50 (± 0.95) in group B (P = 0.0004). Patients' satisfaction score was significantly higher for the lesions in group A than group B. Lesions on the dorsum of the hand showed a higher response rate than those on the fingers. No serious side-effects were noted.
  
  
  CONCLUSIONS
  This study demonstrates that adding fractional CO2 laser treatment to NB-UVB phototherapy and topical steroids improves the repigmentation rate of vitiliginous lesions on hands in some patients. This technique may be offered to vitiligo patients who are unresponsive to other treatments.
authors.affiliation: Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Vasanop
authors.initials: V
authors.lastname: Vachiramon
authors.affiliation: Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Chayada
authors.initials: C
authors.lastname: Chaiyabutr
authors.affiliation: Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Pinyo
authors.initials: P
authors.lastname: Rattanaumpawan
authors.affiliation: Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Silada
authors.initials: S
authors.lastname: Kanokrungsee
mesh_terms: D000279:Administration, Cutaneous; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use*; D002990:Clobetasol / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D054020:Lasers, Gas / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome; D014467:Ultraviolet Therapy / Q000379:methods*; D014820:Vitiligo / Q000628:therapy*
chemical_list: D000893:Anti-Inflammatory Agents; D002990:Clobetasol
keywords: fractional laser; laser; narrowband ultraviolet B; phototherapy; vitiligo