**2.4 Fractional CO2 laser for ablation modalities**

As you know, vitiligo therapy is challenging though there is no definitive cure regime. Ablation therapy has recently been coalesced into combination therapy for vitiligo. These ablation modalities contains dermabrasion, erbium-YAG resurfacing, and ablative CO2 laser treatment. Ablation modalities are not curative but they are useful to induce Koebner phenomenon to increase curative topical regimes. Fractional ablative laser has worked as a principle of photothermolysis to moderate skin resurfacing. Firstly, beneficial effect of fractional CO2 laser on vitiligo is postulated to detachment of epidermis will release of cytokines and growth factors for immune response that plays a role as mitogens for melanogenesis. Additionally, fractional CO2 laser via photothermolysis could decrease to skin surface so that absorb topical treatments and also increase efficacy of narrowband UVB treatment. Koebner's phenomenon defined as the development of isomorphic lesions at traumatized uninvolved skin due to that fractional modalities to be concluded follicular hyperpigmentation as a different addition for pathogenesis. King et al. published a metanalysis, they determined ablation modalities (ER-YAG or fractional CO2 laser) manage faster and effective repigmentation than the traditional methods that have explained via four different such as more penetration, skin remodeling, melanocyte migration and cytokine secretion [30]. Despite of that Koebner phenomenon

has not seen in stable lesions so that individual remedy should be chosen. In a recent article Yuan et al. aim to investigate three different fractional laser types. Ablative fractional laser consist of CO2 lasers have much more satisfied results than non-ablative lasers [31]. On the contrary, Mofty et al. evaluated that TCA peeling depends on Koebner phenomenon redounded repigmentation is much more cheap, easier and effective than ablative CO2 laser [32]. Lu Li et al. has tried different model with CO2 laser. They applied sequentially CO2 laser during half month interval and used twice daily betamethasone then took NUVB. They checked the response rate at the baseline, 3th and 6th month and also found repigmentation more than half of the patients to compare without betamethasone ointment. They suggested patient got tolerable pain and gain more satisfied repigmentation rate than ER YAG laser is expected [33]. Helou et al. concerned a different modality contains CO2 laser three times 1 month apart following that sunlight tanning at least 2 hours has also significant results. These different opinions will be future play as an easy to apply due to cost-benefit analysis [34]. Nevertheless, there is no defined protocol for ablation to stimulate melanocyte transmission.

More advanced ablation modalities could combine with other topical remedies to optimize results. Feily et al. comprised two group stable refractory vitiligo patients got autologous transplantation and phototherapy alone or with fractional CO2 laser. They found perifollicular repigmentation was statistically significant detectable in CO2 laser group before the transplantation [35]. Vachiremon et al. suggested that fractional ablative CO2 laser could combine with NUVB to shorten duration time of recovery and increase the penetration of light immunomodulation and also topical clobetasol propionate ointment [36]. Additionally that, acral part could not reach the treatments so that alternatives should try. By using CO2 laser, clinicians have seen lesser hypertrophic scars than ERYAG laser also so that treatment of choice in ablative lasers could manifested. Mohamed et al. searched the combination of 5-Fluorouracil cream and CO2 laser due to ablation of dermis to penetrate cream to migrate melanocytes in acral vitiligo patients. They declined that combination treatment is safe and tolerable technique for these resistant types [37]. Chen et al. investigated the topical tacrolimus combination with CO2 laser, they suggested tacrolimus would be good option with ablation therapies, also [38]. Using with CO2 laser, hypertrophic scarring was not reported because of the superficial ablation that means removing only the epidermis, avoiding the dermis.

As a summary, ablation-based combination therapy is safe and might be more effective than treatments without ablation therapy for increment of repigmentation.

#### **2.5 Erbium laser for ablation modalities**

The Er:YAG laser emits light at 2940 nm, with the water affinity being nearly 15 times greater than that of the CO2 laser. Use of the Er:YAG laser requires more skill than does use of the CO2 laser as the clinical endpoints allowing the laser surgeon require to intervene further penetration into the reticular dermis, are not seen with Er:YAG laser ablation. Furthermore, the plateau response of diminishing ablation characteristic of the CO2 laser is not seen with the Er:YAG laser [1, 24]. Lotti et al. used a different innovation in a ablative model with Fraxel Erbium Laser (fractional erbium laser) make epidermal erosion 1 day after apply topical latanoprost solution and finally use UVA laser. The patients have nine sessions so on 90% of them obtained a repigmentation rate higher than 75% [39]. Bayoumi et al. tried to use erbium laser firstly for aiming dermabrasion after that 48 hours hydrocortisone 17-butyrate cream applied three times a day daily for 3 weeks followed by a 1-week steroid-free interval and narrowband UVB treatment was performed on both sides

**15**

nance therapies [48].

*Lasers in the Treatment of Vitiligo*

sponsiveness patients.

*DOI: http://dx.doi.org/10.5772/intechopen.83836*

twice weekly for 12 weeks. They succeed in refractory lesions due to Koebner' phenomenon almost half of the lesions treated at least 50% repigmentation rate and more than 16% achieved a complete or almost complete repigmentation [40]. As a point of view, that difference from non-treated part, dermabrasion has induced penetration of UVB and topical steroid so it cause enhancement of melanocyte stimulation. For example Yan et al. have a different perspective they insisted on energy should be set at the level of at least 1200 mJ. They divided four parts such as one of them is control group given NUVB and other three of them took different frequency of energy to calibrate most effective and least painful method of these modality. They found better response at the medium or high energy protocols [41]. Mohtari et al. tried to find a unresponsiveness vitiligo part a new modality that is firstly used ER:YAG laser than applied clobetasol or 5-FU dressing and found better cosmetic results via ablation [42]. As expected, periungual vitiligo hard places to treat responded well. Two-thirds of the patients (66.7%) showed moderate to

On the whole, the acral regions were considered the most resistant to traditional

Depigmentation is the unique treatment choice who develop vitiligo more than 90% body surface area, for the term "universal vitiligo" is commonly used. Topical agent such as MBEH (monobenzyl ether of hydroquinone) has main role to epidermal ablation and resurfacing. Laser therapies depend on therapies via difference to intact areas such as epidermal and dermal types. Specifically, Q switch laser could achieve faster depigmentation compared with chemical agents and the decrease the risk of scar formation. Q-switched Nd:YAG (QS ND:Yag) laser can deliver energy at two different wavelengths of 1064 and 532 nm in nanosecond pulses to cause both a

Majid et al. followed up 15 patients covered more than 80% depigmentation areas whole body who have not respond MBEH least 3 months, They focused on Q-switch laser at 532 nm for epidermal component for need any session took 6th week arrival while continuing MBEH topical agents use has rapid onset improvement and minimal adverse effect [44]. Komen et al. has published a questionnaire about the result of Q switch (QS) Ruby laser that concluded 48% of the treated patients showed >75% depigmentation after a mean of 13 months' follow-up. This is the first study that comparison between active vitiligo during QS Ruby laser treatment have properly better results than stable vitiligo [45]. As a choice of MBEH, sometimes, the depigmentation site has gave up to fight immune system and looked more darker so that clinicians has to improve concentration. Modi et al. rather to use 532-nm Q-switched neodymium-doped yttrium aluminum garnet (QS Nd:Yag) laser via 2 sessions with 15 weeks intervals have good results. They offer to give 3 or 4 months apart to allow for maximal treatment response [46]. Majid et al. has followed up 25 patients with universal vitiligo from 2 to 5 years and determined QS-Nd:Yag laser leads to a long-term therapeutic effect in a majority of cases when used at 532-nm wavelength. Less than one third of cases during the follow-up period could preserve the therapeutic benefit achieved with laser treatment [47]. Boukari et al. has followed patients for 36 months depigmented 20 lesions via Q Switch laser and determined that risk of depigmentation parts mainstays in sun exposed areas have need mainte-

treatment modalities. According to that, ER:YAG laser with topical corticoid, tacrolimus or 5-FU application could be promising treatment modality for unre-

marked repigmentation via ER:YAG after dressing 5-FU [43].

photothermolytic and photoacoustic damage to melanocytes [1, 24].

**2.6 Q-switch laser for depigmentation modalities**

#### *Lasers in the Treatment of Vitiligo DOI: http://dx.doi.org/10.5772/intechopen.83836*

*Depigmentation*

has not seen in stable lesions so that individual remedy should be chosen. In a recent article Yuan et al. aim to investigate three different fractional laser types. Ablative fractional laser consist of CO2 lasers have much more satisfied results than non-ablative lasers [31]. On the contrary, Mofty et al. evaluated that TCA peeling depends on Koebner phenomenon redounded repigmentation is much more cheap, easier and effective than ablative CO2 laser [32]. Lu Li et al. has tried different model with CO2 laser. They applied sequentially CO2 laser during half month interval and used twice daily betamethasone then took NUVB. They checked the response rate at the baseline, 3th and 6th month and also found repigmentation more than half of the patients to compare without betamethasone ointment. They suggested patient got tolerable pain and gain more satisfied repigmentation rate than ER YAG laser is expected [33]. Helou et al. concerned a different modality contains CO2 laser three times 1 month apart following that sunlight tanning at least 2 hours has also significant results. These different opinions will be future play as an easy to apply due to cost-benefit analysis [34]. Nevertheless, there is no defined

More advanced ablation modalities could combine with other topical remedies

As a summary, ablation-based combination therapy is safe and might be more effective than treatments without ablation therapy for increment of repigmentation.

The Er:YAG laser emits light at 2940 nm, with the water affinity being nearly 15 times greater than that of the CO2 laser. Use of the Er:YAG laser requires more skill than does use of the CO2 laser as the clinical endpoints allowing the laser surgeon require to intervene further penetration into the reticular dermis, are not seen with Er:YAG laser ablation. Furthermore, the plateau response of diminishing ablation characteristic of the CO2 laser is not seen with the Er:YAG laser [1, 24]. Lotti et al. used a different innovation in a ablative model with Fraxel Erbium Laser (fractional erbium laser) make epidermal erosion 1 day after apply topical latanoprost solution and finally use UVA laser. The patients have nine sessions so on 90% of them obtained a repigmentation rate higher than 75% [39]. Bayoumi et al. tried to use erbium laser firstly for aiming dermabrasion after that 48 hours hydrocortisone 17-butyrate cream applied three times a day daily for 3 weeks followed by a 1-week steroid-free interval and narrowband UVB treatment was performed on both sides

to optimize results. Feily et al. comprised two group stable refractory vitiligo patients got autologous transplantation and phototherapy alone or with fractional CO2 laser. They found perifollicular repigmentation was statistically significant detectable in CO2 laser group before the transplantation [35]. Vachiremon et al. suggested that fractional ablative CO2 laser could combine with NUVB to shorten duration time of recovery and increase the penetration of light immunomodulation and also topical clobetasol propionate ointment [36]. Additionally that, acral part could not reach the treatments so that alternatives should try. By using CO2 laser, clinicians have seen lesser hypertrophic scars than ERYAG laser also so that treatment of choice in ablative lasers could manifested. Mohamed et al. searched the combination of 5-Fluorouracil cream and CO2 laser due to ablation of dermis to penetrate cream to migrate melanocytes in acral vitiligo patients. They declined that combination treatment is safe and tolerable technique for these resistant types [37]. Chen et al. investigated the topical tacrolimus combination with CO2 laser, they suggested tacrolimus would be good option with ablation therapies, also [38]. Using with CO2 laser, hypertrophic scarring was not reported because of the superficial ablation that means removing only the epidermis,

protocol for ablation to stimulate melanocyte transmission.

**14**

avoiding the dermis.

**2.5 Erbium laser for ablation modalities**

twice weekly for 12 weeks. They succeed in refractory lesions due to Koebner' phenomenon almost half of the lesions treated at least 50% repigmentation rate and more than 16% achieved a complete or almost complete repigmentation [40]. As a point of view, that difference from non-treated part, dermabrasion has induced penetration of UVB and topical steroid so it cause enhancement of melanocyte stimulation. For example Yan et al. have a different perspective they insisted on energy should be set at the level of at least 1200 mJ. They divided four parts such as one of them is control group given NUVB and other three of them took different frequency of energy to calibrate most effective and least painful method of these modality. They found better response at the medium or high energy protocols [41]. Mohtari et al. tried to find a unresponsiveness vitiligo part a new modality that is firstly used ER:YAG laser than applied clobetasol or 5-FU dressing and found better cosmetic results via ablation [42]. As expected, periungual vitiligo hard places to treat responded well. Two-thirds of the patients (66.7%) showed moderate to marked repigmentation via ER:YAG after dressing 5-FU [43].

On the whole, the acral regions were considered the most resistant to traditional treatment modalities. According to that, ER:YAG laser with topical corticoid, tacrolimus or 5-FU application could be promising treatment modality for unresponsiveness patients.

#### **2.6 Q-switch laser for depigmentation modalities**

Depigmentation is the unique treatment choice who develop vitiligo more than 90% body surface area, for the term "universal vitiligo" is commonly used. Topical agent such as MBEH (monobenzyl ether of hydroquinone) has main role to epidermal ablation and resurfacing. Laser therapies depend on therapies via difference to intact areas such as epidermal and dermal types. Specifically, Q switch laser could achieve faster depigmentation compared with chemical agents and the decrease the risk of scar formation. Q-switched Nd:YAG (QS ND:Yag) laser can deliver energy at two different wavelengths of 1064 and 532 nm in nanosecond pulses to cause both a photothermolytic and photoacoustic damage to melanocytes [1, 24].

Majid et al. followed up 15 patients covered more than 80% depigmentation areas whole body who have not respond MBEH least 3 months, They focused on Q-switch laser at 532 nm for epidermal component for need any session took 6th week arrival while continuing MBEH topical agents use has rapid onset improvement and minimal adverse effect [44]. Komen et al. has published a questionnaire about the result of Q switch (QS) Ruby laser that concluded 48% of the treated patients showed >75% depigmentation after a mean of 13 months' follow-up. This is the first study that comparison between active vitiligo during QS Ruby laser treatment have properly better results than stable vitiligo [45]. As a choice of MBEH, sometimes, the depigmentation site has gave up to fight immune system and looked more darker so that clinicians has to improve concentration. Modi et al. rather to use 532-nm Q-switched neodymium-doped yttrium aluminum garnet (QS Nd:Yag) laser via 2 sessions with 15 weeks intervals have good results. They offer to give 3 or 4 months apart to allow for maximal treatment response [46]. Majid et al. has followed up 25 patients with universal vitiligo from 2 to 5 years and determined QS-Nd:Yag laser leads to a long-term therapeutic effect in a majority of cases when used at 532-nm wavelength. Less than one third of cases during the follow-up period could preserve the therapeutic benefit achieved with laser treatment [47]. Boukari et al. has followed patients for 36 months depigmented 20 lesions via Q Switch laser and determined that risk of depigmentation parts mainstays in sun exposed areas have need maintenance therapies [48].

In conclusion, QS Nd:YAG laser at 532-nm wavelength seems to be a safe and effective treatment in depigmenting approach to universal vitiligo. The safety and long-term benefit achieved should qualify QS laser treatment as first-line treatment who did not respond topical bleaching creams. Moreover, QS laser combine with topical bleaching creams and sunscreen use, can achieve rapid satisfactory therapeutic outcome in universal vitiligo.
