Case Experience of 308-nm Excimer Laser Therapy Compatibility With PUVA and Oral Bexarotene for the Treatment of Cutaneous Lesions in Mycosis Fungoides
April 2013 | Volume 12 | Issue 4 | Case Reports | 487 | Copyright © April 2013
Jing Huang BS, Shawn Cowper MD, Jeremy Moss MD PhD, and Michael Girardi MD
Department of Dermatology, Yale University School of Medicine, New Haven, CT
Little is known about the safety and effectiveness of excimer laser therapy when used in conjunction with other therapies in the treatment of mycosis fungoides (MF) lesions. We describe the use of adjunctive excimer laser therapy in combination with psoralen plus ultraviolet A (PUVA) and oral bexarotene for the treatment of recalcitrant and sanctuary plaques in a patient with MF. In our patient, this regimen successfully induced clinical and histologic resolution in MF plaques with minimal side effects limited to mild, short-lived tenderness and, rarely, local erythema. Our experience suggests that adjunctive excimer laser therapy with PUVA and oral bexarotene has the potential to be a safe, well-tolerated, and effective focal treatment regimen for cutaneous MF lesions. J Drugs Dermatol.
Mycosis fungoides (MF), the most common form of cutaneous T-cell lymphoma (CTCL), is a neoplasm of epidermotropic CD4+ T lymphocytes. Early MF typically presents as limited patches and plaques and is generally treated with skin-directed therapies such as topical modalities or phototherapy, including broadband ultraviolet B (BB-UVB) and narrow band UVB (NB-UVB), and photochemotherapy (psoralen plus ultraviolet A [UVA]).1 Oral bexarotene, systemic interferon γ, and spot electron beam therapy may be used in refractory cases or in patients with more extensive or higher-stage disease.2 Lesions that fail conventional phototherapy treatment may include sanctuary lesions, eg, those that persist in relatively photoprotected areas such as the eyelids, inguinal flexure, and gluteal cleft, as well as recalcitrant, nonsanctuary lesions.3
Xenon chloride (XeCl) excimer laser, which delivers fully monochromatic light of 308 nm (ie, within the UVB range), was approved by the US Food and Drug Administration in 2000 for the treatment of psoriasis. Case studies of excimer-treated MF lesions have reported complete clinical resolution of patch-plaque lesions with accompanying histopathologic improvements, including marked decreases in inflammatory infiltrate, loss of epidermotropism, and absence of Pautrier microabscesses.4
Herein, we report for the first time the use of excimer laser therapy in combination with other therapies in the treatment of MF lesions. Our experience highlights the 2-fold novelty of using excimer laser: 1) in the treatment of sanctuary and recalcitrant lesions and 2) as an adjunctive therapy to psoralen plus ultraviolet A (PUVA) and oral bexarotene.
A 61-year-old gentleman presented with a several month history of erythematous, pruritic patches and plaques involving his hips, arms, and thighs. Biopsy of a thigh lesion revealed a bandlike infiltrate of T-lymphocytes with focal intraepidermal collections (Figure 1A), which, in conjunction with his clinical picture, was consistent with patch-phase MF (stage IA). Over the next 3 years, the patient achieved clinical remission on PUVA and oral bexarotene (225 mg every day). However, he experienced an exacerbation of his disease during a national psoralen shortage, when he received NB-UVB in lieu of PUVA. During this period, adjunctive 308-nm XeCl excimer laser (XTRAC Excimer Laser; PhotoMedex, Montgomerville, PA) was initiated to