XTRAC EXCIMER LASER

A laser is no more than a beam of light that is absorbed preferentially by certain tissues depending upon the wavelength chosen. In this case the wavelength is 308 nanometers which is within the UVB range. Rather than walking into an ultraviolet light box, whether UVA or UVB, and being exposed to a broad range of wavelengths, we have chosen the specific wavelength alone that treats psoriasis best. This way, the heat, possible pain and possible inducement of skin cancers is dramatically reduced. In addition, rather than treating your whole body in a light box that may expose the rest of you to unneeded treatment, the laser treats specifically only the targeted thick plaques. It is not a magic wand that erases all psoriasis, nor is it ionizing radiation such as x-rays. Any light, specifically this wavelength, acts as an anti-inflammatory agent and anti-proliferative agent for the psoriasis cells. In a recent study of 35 patients using this laser, all 35 improved! 45% experienced more than 90% clearing! This also works for palmoplantar psoriasis (dyshidrotic eczema or pustular hand and foot dermatosis of Andrews), because in some patients this is the only form of psoriasis they get. This is typically the small blistering, bubbling, tapioca-type of blisters that you get on your hands, soles, or fingertips. In 54 patients with this disease receiving a total of 10 sessions (every 7-14 days), all 54 patients improved. 31 patients had complete remission!

The laser can be used anywhere you have psoriasis - the elbows, knees and even the scalp. It also helps vitiligo by stimulating the melanocytes to produce more pigment.

A great advantage of this treatment is that it does not involve topical steroids which can be absorbed and can thin the skin. Long term steroids have many unwanted side effects. It also avoids the use of the new biologics which can suppress the immune system and have heart related side effects. (Some patients may still stay on some of these if needed while using the laser.)

Some patients have extensive psoriasis that does require other treatments including PUVA (oral psoralens with UVA light), widespread application of steroids or vitamin D analogs (Dovonex) or oral medications such as the retinoids. Still others may need injectable biologics such as etanercept (Enbrel). For patients with plaque-type psoriasis however this treatment is ideal. In fact, the Excimer laser treatments can be used in combination with any of the above treatments for resistant areas.

It is critical that all appointments be kept because the success of this therapy depends on a relatively strict maintenance schedule. No one treatment will ever clear psoriasis. In fact, there is no cure for psoriasis. It must also be understood that the vast majority of patients will experience significant improvement, but there is no guarantee of 100% clearing in any patient whether of all of their disease or any given plaque. Psoriasis can be a lifelong disease and further treatment sessions may be necessary at additional full charges in effect at that time.

Most treatment sessions will occur twice a week for 3-5 weeks with preferably 48-72 hours spacing between treatments. On average, 6-12 treatments are necessary for optimal results. Studies have shown that 84% of patients have greater than 75% improvement with 10 or fewer treatments.

No anesthesia is necessary and most patients do not experience any sensation. Some patients do feel warmth and others a slight sunburn type of sensation 12-24 hours after treatment. In rare cases there has been temporary hyperpigmentation and scaling, itching, tenderness, flaking, and scabs with occasional weeping. All of these can be treated.

EXCIMER FOR VITILIGO OR WHITE SPOTS

The Excimer laser has also been recommended to help improve vitiligo. Vitiligo is an autoimmune disease wherein the body's own defense or immune system attacks its own melanocytes or pigment-producing cells. They don't make pigment unless those areas are white. There are other causes of whitened skin including eczema and irreparable sun damage as well.

The Excimer laser may help this by stimulating new pigment-making cells to either grow or migrate.

The Excimer laser as used for vitiligo is typically not covered by any insurance company or Medicare. You will have to pay our office directly for these treatments.

SIDE EFFECTS

Side effects can include a sunburn type of reaction or blistering. There are rare patients whose psoriasis may get worse upon exposure to light, and we can only know this once they have been treated. If you have a history of this worsening with any kind of light, even sunlight, please tell us. You should not be treated.

You should not have any laser or any light based therapy if you have any photosensitive diseases such as lupus erythematosus, porphyria, or albinism. You must stop any photosensitive medicines at least two days before your treatment unless your prescribing doctor told you not to. Always check! These include anti-arthritis drugs such as gold or methotrexate: any antibiotic from the tetracycline group including Tetracycline, Minocycline, Doxycycline, Vibramycin, Doryx, Solodyn, and Dynacin; acne medicines including Accutane, Cipro, or any of the "quinolone medications"; oral antifungals including Griseofulvin; anti-arrhythmia drugs including Chlorpromazine; NSAIDs including Naprosyn, Advil; St. John's Wort; diuretics.

If treating vitiligo or any white spot, in dark skinned individuals there is some risk of hyperpigmentation (darkening) on the surrounding normal skin. Any laser is potentially inflammatory to some degree, and such inflammation could darken (or lighten) any normal skin - particularly if it was dark to begin with. Because of this, we will initially do some small test areas at the very center of the white spots to be treated rather than trying to treat the entire white spot all at once. If we do see improvement in the white spots we may try to expand our treatment zone, but this always remains a risk.

Sometimes vitiligo an occur on the face - particularly near the lips. If so there is the risk that any type of treatment can flare or worsen underlying herpes whether known or not.

If you have ever had herpes or think you may have (cold sores or fever blisters), inform Dr. Coverman or our staff prior to scheduling your appointment. We will give you a series of anti-herpes pills to take the day before the treatment, the day of, and the day after. This should help or suppress or prevent herpes from flaring, but there are no guarantees. A herpes flare could cause pain, pigment, infection, and scarring.

Initially during the actual treatment you may feel nothing at all. Within 14-24 hours there may be a sunburned type of reaction although this could occur any time during therapy. Certain drugs may increase the chance of this sunburn reaction, so let our staff know every medicine you are taking prior to each treatment. In some cases, this additional photosensitization may actually speed up and improve the results of your treatment anyway. Typically you will feel nothing at all during the treatment and the sunburn type of reaction (a warm possibly burning sensation at the treatment site) may not occur until 24 hours later.

Blistering may occur.

There may be increased pigmentation (or even loss of pigmentation if there was a blistering sunburn type of reaction).

Any form of UV light - whether under light bulbs, behind a window, or even outdoors can cause an increase incidence of skin cancer later in life in some patients. This usually occurs after many treatments and in older people. It also usually occurs in people with fair or freckled skin. One of the beauties of this treatment is that we are only treating the psoriatic plaques and not all the rest of your skin as with normal ultraviolet light boxes. Ultraviolet light treatments may also cause premature aging over time as well as freckling and pigmentation. Again, we are only treating the plaques. The rest of your skin is spared.

Ultraviolet rays may damage the eyes and increase the risk of cataracts. This is completely preventable by wearing the protective eye goggles that you will be given during your treatment.

ALTERNATIVES

Alternatives can include the use of topical , oral and injectable steroids, topical vitamin D derivative (Dovonex), other non-steroidal anti-inflammatories (Atopiclair, Mimyx, Bionect, Elidel, Protopic), UVA, UVA+psoralen (PUVA), UVB alone, narrow-band UVB, oral medications including Methotrexate and Soriatene (these can have serious bone marrow and liver complications). The biologics (Enbrel and others) can have immunosuppressive and heart related side effects.

There are very few alternatives for the treatment of vitiligo - anti-inflammatories such as topical steroids, Elidel, or Protopic can be used - the success can be modest, minimal or zero. There are experimental procedures wherein normal cells are grafted into the vitiliginous areas but this is only being done at university centers.

FEES

Please understand that this is a very expensive laser that has its own costs and part of the fees you will pay will be reimbursed to the laser company simply for the use of their laser. If you have insurance, many of the insurance companies now allow this treatment and pay for it - they should! In the long run, it will actually save them money since they won't have to buy expensive medications. (A course of Enbrel would cost up to $1000.)

On the other hand, many insurance companies don't understand this and you may find it very difficult to get your treatment with the Excimer laser reimbursed. They probably just want you to use the cheapest, generic, topical steroid forever, whether it thins your skin or not. It is cheaper for them. Some companies have very extensive lists of exclusion criteria and only after you have "failed" a whole list of other treatments will they allow you to use the Excimer laser and get reimbursed for it. Some of them even require you to use the dangerous drug Methotrexate or Soriatene (which can be associated with severe birth defects even years after you finish taking it) or require you to try and fail some of the biologics which can be extremely dangerous and expensive. Please understand that we can only accept their criteria and offer this treatment to you if they allow it and if you meet their conditions (which are sometimes impossibly strict to qualify for). We personally think this is very short-sighted of them as well as dismissive of your well being and comfort. It becomes a matter of simple economics, and we feel that even the economic factors alone will benefit them more than they would ever realize. We will go to bat for you, but please understand we are not able to write a specific pleading letter for every single patient because every patient's needs and circumstances are different. We will fill out the appropriate paperwork for you at no charge; we will strongly state your case if we can. If there is a problem we would urge you to go to your human resources or insurance specialists at your company and remind them why you are paying so much money out of your hard-earned salary for your insurance premiums. Hopefully you would demand that appropriate care be given. We, too, are aware of increasing medical costs, and it is our sincere belief that for resistant plaque-type psoriasis this is one of the safest, easiest, and best treatments available. It will actually save your insurance company money! That should get their attention.

TREATMENT DAY

There is no preparation required. We will set you up on a schedule, and if you alert our front desk personnel when you arrive, we will simply get you back to the laser room as soon as possible. Our aestheticians or medical assistants will set you up, set the appropriate parameters, check with you about your previous response or lack thereof, and set the laser accordingly. They will perform the treatment for you - Dr. Coverman and Jennifer have trained our staff how to use this laser, and they have attended the very same teaching sessions that we have. All OSHA parameters will be followed including appropriate eyewear for your protection.

As stated above, generally you won't feel anything and you may come in your normal work clothes or otherwise. If necessary we will give you a gown or drape so that we can get to the exposed necessary areas, and you may leave the office and go right back to work immediately after your treatment. You won't need any special bandages and you may resume all normal activities including showering and swimming. We would obviously ask you to avoid excess trauma - trauma makes psoriasis flare anyway. Sports such as wrestling, rugby and soccer are not exactly the best idea - any trauma or infection is going to make psoriasis worse. Normal jogging or working out at the gym is fine. 24 hours before your treatment session, discontinue any of the medicines stated in the list above. If you do take medicines that are photosensitizing such as tetracyclines or other medicines in our previous list, you may resume those immediately after your treatment.

DO NOT APPLY ANY CREAMS OR SUNSCREENS TO THE INVOLVED AREAS BEFORE YOUR TREATMENT. WE WANT THE LIGHT TO PENETRATE!

During the treatment itself which may take up to 20 minutes depending upon the area we need to treat, you will simply sit or lie while one of our staff guides the laser wand over your lesions. The entire process is comfortable and uncomplicated. It is generally completely painless. If your scalp is doing to be treated, we highly suggest you do a double shampoo of your scalp prior to the treatment. Shampoo once, rinse it out, and shampoo again with a different shampoo. The more plaque we can "get out of the way," the deeper and more efficiently the laser light will penetrate. Dry your scalp well afterwards!

FOLLOW-UP

Please understand there is no guarantee of cure of this disease. There is none. Hopefully this will give you a long term remission, but there is no guarantee of percentage of improvement per lesion, per plaque or overall after any given session or all the sessions are completed. You may need another series of sessions at some point in the future if you want them, and there is no danger in repeating this whole series over and over. Obviously you may resume prior topical therapies that we have recommended or even continue them during the treatments if we instruct you to.

Dr. Coverman or Jennifer would like to see you periodically, even during your treatments. Generally we would like to see you once a month anyway and to save you a trip you may certainly schedule an appointment with Jennifer or Dr. Coverman on the day of one your treatment visits. Please let our staff know what you will be making these two separate appointments. There is a regular office charge to see Dr. Coverman or Jennifer at these specific visits. Once your psoriasis is well controlled, Dr. Coverman or Jennifer probably won't need to see you that often anyway, and they will discuss this with you at that time.

Please remember that certain things exacerbate psoriasis: excess sunlight to the point of sunburn; oral alcohol; stress; infection; and trauma. Always be aware of these factors. Psoriasis is not contagious.

Even if there is repigmentation in part or all of the vitiliginous areas, that is no guarantee that the pigmentation will last or continue. Some areas may repigment - others may not. Others may repigment and then lose their pigment all over again anyway. The Excimer laser will not cure this disease - it may only help localized treated areas. Treating any area with the Excimer laser does not prevent vitiligo or other similar problems from appearing anywhere else. There is no cure.

This is an ultraviolet light-based treatment. DO NOT sunburn afterwards! Plan vacation schedules around the 4-5 week period if possible.

YOU MAY CONTINUE TO APPLY ANY PRIOR CREAMS WE MAY HAVE USED PREVIOUSLY IF YOU ARE DRY OR ITCHING, JUST DO NOT DO SO BEFORE ANY TREATMENT SESSION!

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