Sunil Dogra Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Dermatology is one of the many medical specialties, which evolved from the general internal medicine during the course of nineteenth century. In the beginning of 20 th century, dermatology was well established as a separate discipline in Europe and United States; however, in India it was only after 1960s that it started getting the recognition as a specialty. Until recently, dermatology remained a purely medical field in India, although our Western counterparts have been working on its surgical dimensions. In India, the last 15-20 years have witnessed a tremendous growth in its surgical component and dermatologists have widely adopted various surgical and cosmetic procedures in their clinical practice and associations like Association of Cutaneous Surgeons of India (ACSI) and Cosmetology Society - India (CSI) have been established
What is Happening ?
In India, dermatology is becoming one of the most competitive residency program to enter for the past several years and each year, all dermatology residency positions are quickly filled with the top scorers. Among medical graduates, this specialty is now no more a subject of 'no other choice' rather it has become the 'subject of choice'. The awareness about the impact of skin diseases and the crucial role of 'skin specialist' is growing not only in general population but also among colleagues from other specialties. With the constant increase in demand of specialists in dermatology and the residents having 'controllable lifestyle' away from the primary care fields, there are more dermatology residents than ever. With this strong academic strength of young dermatologists in India, there should be no lack of intellectual curiosity, which should initiate the induction of more of them in basic dermatology. Unfortunately, this is not the current trend. In many settings, cosmetic and dermatosurgery procedures are supplementing the basic dermatological care but in others they are nearly replacing it. Though training in dermatologic and cosmetic surgery is now an integral part of the postgraduate training in dermatology, as more trainees pursue surgically oriented fellowship trainings, the proportions could continue to evolve in favor of surgical component of the specialty. [2]
Shortage of academic dermatologists in the workforce has been noticed worldwide. [3],[4] In United States, ever since 1970s, there has been a shortage in the field of academic dermatology, which is still growing. In a 1977 report, there were 338 full-time academic dermatologists in the United States and in 2004, this number was only 982. [5] More than one-quarter of dermatologists in United Sates now spend less than half of their time with patients having medical dermatologic conditions. [6] A similar concern about the reduced availability of academic dermatologists has been expressed in UK. [7] Limited growth in the medical dermatology workforce has occurred at a time when increasing need for dermatologic services is being felt for an enlarging and aging population. In countries like United States, patients seeking a cosmetic botulinum toxin injection have more rapid access to dermatologists than those seeking both routine and urgent dermatology appointments. [7]
These tremors are felt more at times when there is explosion of knowledge on molecular/genetic basis of diseases and fast emerging advanced diagnostic and treatment modalities are becoming available (like immunomodulatory drugs, biologicals, gene therapy, novel drug delivery systems, stem cell revolution, etc.), which have increased our ability to improve care of our patients and are having a profound impact on the practice of dermatology. This drift of interest of the dermatologist toward dermatosurgery and cosmetic dermatology is occurring even when medical dermatology has yet to achieve the pinnacle of excellence, especially in India. The effects of tedious and slow growth of medical dermatology have been amplified by a broadening scope of practice into surgical and cosmetic dermatology.
There will more likely be many ill consequences of this 'shortage' of academic dermatologists. Primarily, it will adversely affect patient access to basic skin specialists and hence affect the quality of dermatological care as more and more dermatologists increase their time spent in surgical and possibly cosmetic dermatology. Other possible fall out could be an increasing dependence on nondermatologists and quacks for treatment of skin diseases. As patients and referring doctors have to face increasing delays in access, there has been a substantial influx of other clinicians into dermatology offices. [8] Recently, some allied specialists like immunologists, rheumatologists, geriatric care physicians, etc. are extending their domain in managing many skin conditions. Our infatuation with cosmetic dermatology and a developing tendency of refraining from 'dry' more challenging and less lucrative basic dermatology, more legally hostile environment of healthcare management, and the encroachment by other medical specialties, may ultimately reduce resources for research and lead to trivialization and marginalization of the specialty. [9] This will also adversely affect the basic research and other academic activities in the medical colleges and institutions. It may add to the frustrations of a 'difficult skin patient' seeking basic dermatological care. Other medical specialists may also experience sad results of this trend, which frequently seek advice for quality diagnosis of many patients or for an immunocompromised host with 'some skin rash'. If fewer dermatology residents are pursuing careers in medical dermatology and clinical research, where will the next generation of clinical investigators and scientists come from? Will there be sufficient numbers of academic dermatologists to train future generations of dermatology residents?
What are the Reasons ?
This fascination for cosmetic surgery appears to be mainly driven by the increasing demand for cosmetic-related dermatologic problems, or problems purely related to body image with the desire to look more beautiful. [4] Though practiced earlier also, the enhanced desires to always look young and delay the normal processes like aging, dermatologic surgery in this process has also been rejuvenated. [10] This trend has been observed in many developing nations as well. Dermatologists selectively improve access for these patients because of higher relative payments for cosmetic services. Physicians try to schedule these patients more quickly lest they lose interest. While medical dermatology is indeed challenging for accurate diagnosis and proper treatment, with many difficult to treat and incurable conditions; dermatosurgery and cosmetic dermatology, however, are seductive for dermatologists with faster and advertisable/demonstrable results and higher earnings.
Over the last three decades, with advances in our specialty, residents may have had broader experiences in basic and clinical research, specialty clinics, and academic philosophies; however, these may not have been appealing enough to the residents in motivating them to opt for medical dermatology. Perhaps more vocal academicians are needed to influence more residents to nurture medical dermatology practice.
In a survey, many chairs and chiefs agreed that too much time spent in patient care leaves little time for academic pursuits. [11] Buckley et al , [12] reported that academic physicians spending greater than 50% of their time seeing patients have cited insufficient time for the activities of research, teaching, and mentoring needed for a successful academic career. They also reported the expressed dissatisfaction by the residents with their careers, slower career progress, and that they were less likely to be at the rank of professor. If jobs of academic dermatologists are becoming more and more like private practice, with little or no time for academic pursuits, the greater income potential and autonomy afforded by a private office setting may appear more attractive. A report of two surveys in 1984 and 1989 showed that new graduates who entered private practice saw three negative factors about academics: restricted income, lack of 'control', and the political climate. [13] Perception of a restricted income was the strongest negative factor, which probably must have magnified many times now 18 years after this report, with higher medical education costs and the attraction for cosmetic dermatology at its peak. [14] The demand-supply phenomenon is growing fast and recent years have witnessed enormous investment and promotion by beauty-care product industry all over the world. In major international dermatology conferences the leading cosmetics and medical lasers companies are the biggest sponsors.
Dermatosurgery and Cosmetic Dermatology is not a Less Scientific Subspecialty
It is not contentious that cosmetic dermatology and dermatosurgery is less intellectual than the real, ethical, and even moral practice of medical dermatology. Dermatosurgery procedures, like every other aspects of dermatology, involve careful analysis of the patient in order to make a proper evaluation. We know that it may be possible to train a preschooler to aim a laser at a patient's face, however, making sure that the appropriate laser is being used with the appropriate settings for any patient or selection of a most appropriate dermatosurgery procedure for a particular condition will require years of training and thorough understanding of cutaneous anatomy, biology, pathology, and pharmacology. Advancing the frontiers in areas like laser, Mohs' surgery, soft tissue removal and augmentation, and hair transplantation, dermatosurgery is a rapidly growing field and also offering bountiful research opportunities. Undoubtedly, a dermatologist with balanced and adequate knowledge of all subspecialties with a strong foundation of basic dermatologic science will certainly be in a better position to manage a patient than those with a focused approach on instruments and machines. [2],[15]
For better or for worse, we must accept that dermatology is now partly a surgical field. The issue is not whether dermatologists should or should not perform surgery but that they should be competent to do so. Dermatology residency should be restructured so that an appropriate time is devoted to dermatosurgery to enable residents acquire correct skills and experience. Patients may be better served by a dermatologist with surgical acumen who is able to provide all their dermatologic care, thus eliminating the need for frequent referrals to a surgeon. [16] Nevertheless, the place of medical dermatology is indisputable and the growth of any subspecialty including dermatosurgery and cosmetic dermatology should not be at its expense.
What Can/Should be Done ?
What are the solutions to halt this declining interest in medical dermatology? It appears that there are two separate problems which need attention: attracting new graduates to academic dermatology and then retaining them, the latter may be the more pressing of the two. [17] A way to better reimburse academic dermatologists must be found, in order to lessen the widening gap in incomes between academics and private practice. [18] For the others, efforts should be directed to those factors that are easier to correct. These include improving residents' perceptions and experiences with effective mentors, role models, and career guidance. [19] Are we providing appropriate role models for the trainees? Is it a lack of exposure to the different career opportunities that has resulted in this narrowing of focus? It is not surprising that many residents would choose not to pursue a career in academic dermatology if they are unaware of what that career can lead to. As a community, we need to be more effective at communicating to our residents the excitement and value of discovery and the challenging and fulfilling career that awaits those who choose to pursue this career option. We must continue to communicate with, recruit, and mentor our younger colleagues to ensure that past successes continue in the future. We also need to identify residents interested in research or academic dermatology early in their residency training. Academic dermatologists should look for opportunities within the clinic to demonstrate to their residents the value of research relevant to patient care. Efforts should be made for retention of suitable talent, providing a more nurturing and congenial environment, and to improve job satisfaction both in terms of availability and promotion. [20] Dedicated academic dermatology centers of excellence are necessary to promote research on skin biology, propagate skills of medical dermatology and therapeutics, establish referral centers for patients with rare skin conditions, and to ensure the best training for the next generation of dermatologists.
Conclusion
Medical dermatology has flourished tremendously over the past 50 years, however, the recent trend of disproportionate growing interest in dermatosurgery and cosmetic dermatology among graduating residents and those practicing dermatology threatens to undermine this glorious record and the future of our specialty. There is a significant loss of interest in academic career by dermatology residents. Some important reasons are poor financial reimbursement in practice of basic medical dermatology, lack of mentors, role models, and career guidance. Strategies should be developed to cultivate future researchers and teacher-clinicians. Dermatosurgery and cosmetic dermatology are now integral part of dermatology science and efforts should be made for the further progress in this field. However, we as a dermatologist community must understand the importance of 'medical dermatology,' ensure that further research, discoveries and therapeutics continue to evolve and appropriate dermatological skills are nurtured, lest they are lost in the glitters and glory of dermatosurgery and cosmetic dermatology. Let us try to strike a judicious balance between academics and cosmetology.
References
1. Thappa DM. History of Dermatology, Venereology and Leprology in India. J Postgrad Med 2002;48:160-5. [PUBMED] 2. Dogra S, Kanwar AJ. Dermatology at a turning point: Need to preserve medical dermatology. Indian J Dermatol 2003;48:121-2. 3. Olerud JE. Academic workforce in dermatology. Arch Dermatol 2007;143:409-10. [PUBMED] [FULLTEXT] 4. Singer N. More doctors turning to the business of beauty. New York Times; November 30, 2006. p. A1. 5. Wu JJ, Ramirez CC, Alonso CA, Mondoza N, Berman B, Tyring SK. Dermatology residency program characteristics that correlate with graduates selecting an academic dermatology career. Arch Dermatol 2006;142:845-50. 6. Kimball AB. Is academic dermatology in crisis? The largest shortage of dermatologists, the longest hours for physicians, and the highest waiting times for patients are in academic dermatology. J Am Acad Dermatol 2005;52:AB4. 7. Resneck JS Jr, Lipton S, Pletcher MJ. Short wait times for patients seeking cosmetic botulinum toxin appointments with dermatologists. J Am Acad Dermatol 2007;57:985-9. [PUBMED] [FULLTEXT] 8. Coleman WP 3rd. Dermatologic extenders or dermatologic pretenders. Dermatol Surg 2002;28:781-2. [PUBMED] [FULLTEXT] 9. Resneck J Jr. Too few or too many dermatologists? Difficulties in assessing optimal workforce size. Arch Dermatol 2001;137:1295-301. 10. Alam M, Dover JS. On beauty: Evolution, psychosocial considerations and surgical enhancement. Arch Dermatol 2001;137:795-807. [PUBMED] [FULLTEXT] 11. Loo DS, Liu CL, Geller AC, Gilchrest BA. Academic dermatology manpower: Issues of recruitment and retention. Arch Dermatol 2007;143:341-7. [PUBMED] [FULLTEXT] 12. Buckley LM, Sanders K, Shih M, Hampton CL. Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine: Results of a survey. Arch Intern Med 2000;160:2625-9. [PUBMED] [FULLTEXT] 13. Bergstresser PR. Perceptions of the academic environment: A national survey. J Am Acad Dermatol 1991;25:1092-6. [PUBMED] 14. Wu JJ. Current strategies to address the ongoing shortage of academic dermatologists. J Am Acad Dermatol 2006;56:1065-6. 15. Alam M. Dermatologic surgery training during residency: Room for improvement. Dermatol Surg 2001;27:508-9. [PUBMED] [FULLTEXT] 16. Callen JP. Should Dermatologic surgery training in residency be expanded? Dermatol Surg 2001;27:509-10. [PUBMED] [FULLTEXT] 17. Resneck JS Jr, Tierney EP, Kimball AB. Challenges facing academic dermatology: Survey data on the faculty workforce. J Am Acad Dermatol 2006;54:211-6. [PUBMED] [FULLTEXT] 18. Salary differences in academic versus private practice dermatology: Do they explain the large numbers of new residency graduates entering private practice over academic dermatology? J Am Acad Dermatol 2005;52:AB4. 19. Reck SJ, Stratman EJ, Vogel C, Mukesh BN. Assessment of residents' loss of interest in academic careers and identification of correctable factors. Arch Dermatol 2006;142:855-8. 20. Rubenstein DS, Blauvelt A, Chen SC, Darling TN. The future of academic dermatology in the United States: Report on the resident retreat for future physician-scientists, June 15-17, 2001. J Am Acad Dermatol 2002;47:300-3.
Wednesday, April 8, 2009
Targeted phototherapy
Venkataram Mysore
Centre for Advanced Dermatology, Bangalore, India
Abstract
Phototherapy is one of the most important therapeutic modalities in dermatology. This field has seen several major advances in the recent years, the most recent being targeted phototherapy. Targeted phototherapy, which includes laser and nonlaser technologies, delivers light/laser in the ultraviolet spectrum, of specific wavelength, specifically targeted at the affected skin and thereby avoids many of the side effects of conventional phototherapy. The treatment has been claimed to be effective, quick, and needing fewer treatment sessions. The article reviews this new mode of phototherapy.
Keywords: Excimer laser, excimer light, phototherapy, psoriasis, targeted phototherapy, vitiligo
How to cite this article:Mysore V. Targeted phototherapy. Indian J Dermatol Venereol Leprol 2009;75:119-25
How to cite this URL:Mysore V. Targeted phototherapy. Indian J Dermatol Venereol Leprol [serial online] 2009 [cited 2009 Apr 8];75:119-25. Available from: http://www.ijdvl.com/text.asp?2009/75/2/119/48655
Introduction
Phototherapy is used for a wide variety of skin diseases. There has been considerable progress in cellular and cutaneous photobiology leading to improved understanding of different photodermatoses and their treatment. However, the developments in phototherapy have been comparatively slow, as reflected in a recent publication that "developments in phototherapy have not kept pace with scientific progress, as has been the case with radiotherapy" [1]
Nevertheless, the last two decades have seen significant technological advances, expanding the options while treating a patient who needs phototherapy [Table 1]. The most important of these advances have been narrowband ultraviolet B (UVB) (311 nm) phototherapy and, more recently, targeted phototherapy [2],[3],[4] This article reviews the subject of targeted phototherapy in the light of the author's experience during the last 4 years.
Disadvantages of Conventional Phototherapy
Conventional phototherapy consists of delivery of light energy by tube lights to the affected area. [3] Different machines used for this purpose include whole body cabinets, hand and foot machines, scalp machines, etc. These machines have the following disadvantages:
Exposure of uninvolved areasSlow delivery system and lengthy treatment sessions Multiple and frequent visits to clinicDifficulty in treating certain areas (such as genitalia, oral mucosa, ear, etc)Difficulty in treating children who may feel intimidated by the large machinesLarge office space required to house the bulky machines
A new technique called targeted phototherapy which seeks to overcome these disadvantages has now become available [3],[4],[5],[6] Also called concentrated phototherapy, focused phototherapy, microphototherapy, this modality involves application of light energy directly focused on, or targeted at, the lesion through special delivery mechanisms such as fiber-optic cables. The term 'targeted phototherapy' includes different technologies such as excimer laser, intense pulse light systems, and UV light sources with improved hand-held delivery systems.
Advantages of Targeted Phototherapy
Several advantages have been claimed for targeted phototherapy: [5]
Exposure of involved areas only and sparing of uninvolved areas, thus minimizing acute side effects such as erythema and long-term risk of skin cancer over unaffected skinQuick delivery of energy and thereby shortened duration of treatmentDelivery of higher doses (super-erythemogenic doses) of energy because uninvolved areas are not exposed, higher doses of energy can be delivered selectively to the lesions, thereby enhancing efficacy and achieving faster responseThis has been claimed to shorten duration of treatment, leading to less frequent visits to clinic, and thereby lessen the inconvenience for the patientThe maneuverable hand piece allows treatment of difficult areas such as scalp, nose, genitals, oral mucosa, ear, etc.Easy administration for children as delivery is hand-held Targeted phototherapy machines occupy less space
However, targeted phototherapy devices have certain disadvantages; they are more expensive. Also, they are not adequate to treat extensive areas in view of the cost of treatment and time involved in treatment. They are not recommended for use if lesions occur over more than 10% of the body area. [5]
Mechanisms of Action
Most targeted phototherapy devices (laser or nonlaser type) emit radiation in the UVB range, with peak emission in the narrowband wavelength (around 308-311 nm), while some light-based nonlaser machines emit UVA radiation also. Hence mechanisms of action of targeted phototherapy systems are similar to those in conventional UVB/UVA therapy. [7],[8],[9],[10] UV light has been shown to have several effects on both epidermal and dermal cells, which explains its efficacy in treatment of cutaneous diseases such as psoriasis, vitiligo, and lymphoma. UVB radiation has been previously shown to induce DNA damage and pyrimidine dimer formation. Apoptotic mechanisms may be involved in the destruction of susceptible epidermal and dermal cells by UV light. UVB radiation has several effects on skin, such as induction of alteration in cytokine production, local immunosuppression, stimulation of melanocyte-stimulating hormone, increased melanocyte proliferation, and melanogenesis. UVB radiation also enhances production of vitamin D metabolites, which stimulate melanogenesis. UVA radiation may also produce similar effects. Targeted phototherapy may induce all these effects in a more aggressive way, because of delivery of supererythemogenic doses of radiation. [4],[5],[6] It has also been suggested that their enhanced efficacy may be due to their ability to deliver the energy to deeper dermal levels, and targeted therapy may therefore affect hidden target cells such as melanocytes. [6]
Different Types of Targeted Phototherapies
As mentioned earlier, targeted phototherapy may be achieved by different sources such as laser (excimer), IPL (excimer light), and UV light [Table 1].
Excimer Laser
First used in medicine for its ability to produce cold tissue ablation, excimer laser found applications in cardiology, ophthalmology, orthopedics, and dermatology [4] The word 'excimer' refers to 'excited dimer.' These lasers operate in the ultraviolet range, and examples include the 193-nm argon-fluoride; 248-nm krypton-fluoride; 351-nm xenon-fluoride; and of particular interest to dermatology, the 308-nm xenon-chloride laser. These lasers utilize a mixture of a noble gas and a halogen as a lasing material. The pulse repetition rate of the laser can be set up to 200 Hz with 3 mJ/cm 2 of energy per pulse. A pilot study in 2002 [6] showed significant benefits in vitiligo. Twenty-nine patches of vitiligo from 18 patients were treated 3 times a week for a maximum of 12 times with excimer laser, with parameters 120-nanosecond, 20-Hz pulse with a 10×10-mm spot size and a power output of 60 mW of laser light. Exposure time was 2 seconds, increased by 2 seconds at every other visit. Twenty-three vitiligo patches had 6 treatments, with some repigmentation in 57% of the treated patches. Eleven vitiligo patches from 6 patients had 12 treatments, with some repigmentation in 82% of the treated patches. Lesions which were previously resistant to treatment with other modalities also responded to excimer laser. The study concluded that "the degree of repigmentation in a period of 2 to 4 weeks is much higher than that achieved with any other present vitiligo therapy. The xenon-chloride excimer laser may represent a new treatment modality for the management of stable vitiligo". These results were confirmed by other studies, which showed benefit with excimer laser in patients of localized vitiligo who had been unsuccessfully treated with other modalities of treatment. [11]
In psoriasis too, the efficacy of excimer laser has been confirmed by several reports [12],[13],[14] Localized resistant lesions of psoriasis over elbow and knees were reported to be cleared in as few as 1 to 3 exposures, with moderately long remission. [12] Scalp psoriasis was also shown to respond well. [13] In another study which studied patient satisfaction, 55% of patients reported overall satisfaction and 25% reported that laser treatments were better than any other treatment they had tried. [14] Side effects reported, though usually mild, included burning pain during and after treatment, severe erythema, and blistering of skin. [14]
Excimer laser has been reported to be effective in other dermatoses also, such as oral lichen planus, [15] alopecia areata, [16] atopic dermatitis, [17] mycosis fungoides, and lymphomatoid papulosis. [18] Interestingly excimer laser has been found to be effective in hypopigmented striae [19],[20],[21] and hypopigmented scars, [19] conditions generally considered difficult to treat. Increase in melanin pigment, hypertrophy of melanocytes, and an increase in melanocytes within striae, leading to darkening of striae, were reported after use of excimer laser. [18] These results, if confirmed by larger data, will open up exciting new avenues for treatment of these important and common cosmetic problems.
After a period of initial excitement, subsequent studies have led to a reappraisal of the role of excimer laser in psoriasis [22],[23] and vitiligo [24],[25] Comparison of excimer laser, excimer lamp, and 311-nm narrowband UVB in patients with psoriasis showed similar clearance and no statistically significant difference in results after 10 weeks of treatment. [22] The study did show enhanced clearance rate in the laser group of patients when treated by an accelerated scheme of administration, but these patients also had higher rate of side effects such as blistering and crusting. The study concluded that "the only advantage of laser seems to be the ability to treat exclusively the affected skin and with a reduced cumulative dose, thus perhaps reducing the long-term risk of carcinogenicity" A large study of 140 patients with vitiligo treated by excimer laser showed excellent results in UV-sensitive areas, while UV-resistant areas such as acral lesions and lesions in joint areas responded poorly. [24]
Excimer laser machines have been introduced by companies such as Photomedex and Wave Light Technologies. However, the machines had several disadvantages such as high cost, huge weight and bulk, and difficulties in maintenance. These factors and the less-than-impressive data stated earlier justify the observation by James Fergusson that "in both theory and practice, this treatment is effective and the excimer 308-nm laser effected faster clearance at a lower cumulative dose and spared unaffected skin from unnecessary exposure. The blistering response may raise a problem for patients. Controlled trials are needed. I suspect that until such information is available, this expensive, high-tech treatment will remain confined to specialist centres". [26] This indeed has been the case and despite its introduction in 2002, the technology is available only in few centres.
Monochromatic Excimer Light (IPL) Therapy
Other forms of targeted light therapy have been introduced, such as IPL therapy with wavelength of 304 nm (excilite: Deka) and 308 nm (Pxlite). These machines are less bulky, cheaper, and have a comparatively larger treatment surface in contrast to excimer laser. Several studies have been published which demonstrate their efficacy. In a pilot study of excimer light in 37 patients of vitiligo, Leone et al, [27] obtained initial repigmentation in the first 8 treatments and excellent repigmentation in 50% of patients at 6 months. Some patients who had not previously responded to narrowband UVB therapy were also found to respond. The results were comparable to excimer laser and superior to narrowband phototherapy. Another study demonstrated the efficacy of excimer light in a number of UV-responsive conditions such as palmoplantar psoriasis, atopic dermatitis, and alopecia areata. [28] IPL was also shown to induce apoptotic and immunohistochemical changes in psoriatic skin.[29] Thus excimer light is a promising, effective, and cheaper alternative to excimer laser.
Light-Based (Nonlaser, Non -IPL) Targeted Phototherapy
Advances in technology have now permitted delivery of conventional noncoherent light (broadband or narrowband light) targeted at lesions. Many such machines have been marketed in recent years (Sallman, Theralight, multilight, curelight, Bioskin, B-clear, etc). Most of these machines use a conventional high-pressure burner emitting UV light and fiber-optic cable systems to deliver energy directly targeted at the lesion. Their spot sizes range from 1 to 3 cm. These machines have multiple delivery programs and automatic calibration for quick delivery of predetermined dosages, so that treatment time is short. They are considerably smaller in size than the laser machines, with less maintenance problems, and are also cheaper. An added advantage of some of these machines over the excimer light or laser is that both UVA and UVB (narrowband) spectra are available. Several studies have been published on the efficacy of these systems in both vitiligo and psoriasis. [30],[31],[32],[33],[34],[35],[36]
Each of the different commercially available systems has its advantages and disadvantages, which are discussed below.
Dualight
(Previously called Theralight) emits both UVA radiation in the range 330-380 nm and UVB in the range 290-330 nm with peak at 303 nm 5 The system has a 2-meter long fiber-optic delivery system, with a spot size of 4 cm 2 . UVA intensity is 10-550 mW/cm² for 3.63-cm² exit aperture, while UVB intensity is 50-250 mW/cm² for 3.63-cm² exit aperture.
B clear targeted photoclearing system
B clear system is mercury-based noncoherent UVB radiation with a therapeutic wavelength of 290 to 320 nm and pulse width of 0.5 to 2.0 seconds. Fluence ranges from 50 to 800 mJ/cm 2 in increments of 10 mJ/cm 2 . Its disadvantage is that only UVB range is available, unlike Dualight, which delivers both UVA and UVB ranges. [30]
Bioskin
Lotti et al reported efficacy of a targeted narrowband UVB device in vitiligo in 1999. [31] Bioskin consisted of a mercury arc lamp with wavelength 280 to 320 nm and peak at 311 nm and a delivery system consisting of liquid-component optical fiber with spot size 1 cm in diameter. Seventy-five percent repigmentation was achieved in 5 of the 8 patients with segmental vitiligo, after 6 months' treatment. A large study in 734 patients [32] showed 75% or more improvement in nearly 70% of the patients and total repigmentation in 21% of the subjects. No patient showed acute or chronic side effects.
Author's experience
The author has used a targeted phototherapy device procured from the German company Salmann in 75 patients since 2003. This system is a lightweight, tabletop machine, with a weight of 9.3 kg, a fiber-optic delivery cable of length 2 meters, and spot size of 1 cm. It delivers UVA in the range 340-360 nm and UVB with a peak at 313 nm. It can deliver 100 mJ of UVB in 6 seconds. It does not have an automated delivery system as in B clear or Dualight machines and is therefore slower, but is also cheaper. In the author's experience, targeted phototherapy is a very useful adjuvant to conventional phototherapy devices and provides many advantages [Table 2]. Importantly, it is of a great value addition in dermatological practice and enables the clinician to treat many patients with resistant lesions and lesions in difficult areas, which are otherwise difficult to treat by conventional UVB machines. Another advantage is in treating children, who may feel intimidated by the large phototherapy machines. The machine is effective particularly in areas such as face, knee, trunk, eyelids, etc. but is not effective in UV-resistant areas such as fingertips. The biggest advantage is the ability to deliver energy without risk of acute or chronic side effects on unaffected skin. Thus patients, particularly those who have apprehensions about taking UV therapy, feel more comfortable with these machines. However, despite these advantages, they cannot replace the whole body machines and hand-foot machines, as large areas cannot be treated with targeted phototherapy. The higher cost of the machines is also an important consideration in the Indian situation.
Conclusion
[Table 2] summarizes the role of targeted phototherapy in current practice. As new data emerge, the role of this modality both in diseases such as vitiligo, [37] psoriasis [38],[39] and also in new indications such as acne [40] and stretch marks [41] continues to evolve. New technologies continue to emerge, such as new low-level helium neon laser system (reported to be effective in segmental vitiligo). [42] It is obvious that both targeted laser and nonlaser phototherapies represent exciting advances in dermatotherapy.
References
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The similarity of action spectra for thymidine dimmers in human epidermis and erythema suggests that DNA is the chromophore for erythema J Invest Dermatol 1998;111:982-8 8. Cooper KD. Cell mediated immunosuppressive mechanisms induced by UV radiation photochemistry and photobiology. Photochem Photobiol 1996;63:400-5 9. Yaron I Yaron R, Oluwole SF, Hardy MA. UVB radiation of human derived peripheral blood lymphocytes induces apoptosis but not T cell anergy. Cell immunol 1996;168:258-66 10. Freeman SE, Gange RW, Sutherland JC, Matzinger EA, Sutherland BM. Production of pyrimidine dimmers in DNA of human skin exposed in situ to UVA radiation. J Invest Dermatol 1987;88:430-3. 11. Taneja A, Trehan M, Taylor CR. 308-nm excimer laser for the treatment of localized vitiligo. Int J Dermatol 2003;42:658-62. 12. Asawanonda P, Anderson RR, Chang Y, Taylor CR. 308-nm excimer laser for the treatment of psoriasis: A dose-response study Arch Dermatol 2000;136:619-24. 13. Morison WL, Atkinson DF, Werthman L. Effective treatment of scalp psoriasis using the excimer (308 nm) laser Photodermatol. Photoimmunol Photomed 2006;22:181-3 14. Rodewald EJ, Housman TS, Mellen BG, Feldman SR Follow-up survey of 308-nm laser treatment of psoriasis. Lasers Surg Med 2002;31:202-6. 15. Kollner K, Wimmershoff M, Landthaler M, Hohenleutner U. Treatment of oral lichen planus with the 308-nm UVB excimer laser-early preliminary results in eight patients. Lasers Surg Med 2003;33:158-60 16. Gundogan C, Greve B, Raulin C. Treatment of alopecia areata with the 308-nm xenon chloride excimer laser: Case report of two successful treatments with the excimer laser. Lasers Surg Med 2003;33:158-60. 17. Baltas E, Csoma Z, Bodai L, Ignacz F, Dobozy A, Kemeny L. Treatment of atopic dermatitis with the xenon chloride excimer laser. J Eur Acad Dermatol Venereol 2006;20:657-60. 18. Kontos AP, Kerr HA, Malick F, Fivenson DP, Lim HW, Wong HK. 308-nm Excimer laser for the treatment of lymphomatoid papulosis and stage IA mycosis fungoides Photodermatol Photoimmunol Photomed 2006;22:168-71 19. Goldberg DJ, Sarradet D, Hussain M. 308-nm Excimer laser treatment of mature hypopigmented striae. Dermatol Surg 2003;29:596-8 20. Goldberg DJ, Marmur ES, Schmults C, Hussain M, Phelps R. Histologic and ultrastructural analysis of ultraviolet B laser and light source treatment of leukoderma in striae distensae. Dermatol Surg 2005;31:385-7. 21. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, Geronemus RG. The safety and efficacy of the 308-nm excimer laser for pigment correction of hypopigmented scars and striae alba. Arch Dermatol 2004;140:955-60. 22. Kφllner K, Wimmershoff MB, Hintz C, Landthaler M, Hohenleutner U. Comparison of the 308-nm excimer laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis. Br J Dermatol 2005;152:750-4. 23. Rivort J. Experience with excimer laser. J Drugs Dermatol 2006;5:550-4 24. Choi KH, Park JH, Ro YS. Treatment of Vitiligo with 308-nm xenon-chloride excimer laser: Therapeutic efficacy of different initial doses according to treatment areas. J Dermatol 2004;31:284-92 25. Passeron T, Ostovari N, Zakaria W, Fontas E, Larrouy JC, Lacour JP, et al . Topical tacrolimus and the 308-nm excimer laser: A synergistic combination for the treatment of vitiligo Arch Dermatol 2004;140:1065-9. 26. Ferguson J. The 308-nm excimer laser is practical therapy for psoriasis. J Watch Dermatol January 14, 2003. 27. Leone G, Iacovelli P, Paro Vidolin A, Picardo M. Monochromatic excimer light 308 nm in the treatment of vitiligo: A pilot study. J Eur Acad Dermatol Venereol 2003;17:531-7 28. Aubin F, Vigan M, Puzenat E, Blanc D, Drobacheff C, Deprez P, et al . Evaluation of a novel 308-nm monochromatic excimer light delivery system in dermatology: A pilot study in different chronic localized dermatoses. Br J Dermatol 2005;152:99-103. 29. Bianchi B, Campolmi P, Mavilia L, Danesi A, Rossi R, Cappugi P. Monochromatic excimer light (308 nm): An immunohistochemical study of cutaneous T cells and apoptosis-related molecules in psoriasis. J Eur Acad Dermatol Venereol 2003;17:408-13. 30. Gilles PR. Technical evaluation of fibre optically delivered light for lesion targeted high dosage UVB phototherapy B-clear application note 2 Lumenis inhouse publication 2002 31. Lotti TM, Menchini G, Andreassi L. UV-B radiation microphototherapy: An elective treatment for segmental vitiligo. J Eur Acad Dermatol Venereol 1999;13:102-8. 32. Menchini G, Tsoureli-Nikita E, Hercogova J. Narrow-band UV-B micro-phototherapy: A new treatment for vitiligo. J Eur Acad Dermatol Venereol 2003;17:171-7 33. Kaur M, Oliver B, Hu J, Feldman SR. Nonlaser UVB-targeted phototherapy treatment of psoriasis. Cutis 2006;78:200-3. 34. Toll A, Vιlez-Gonzαlez M, Gallardo F, Gilaberte M, Pujol RM. Treatment of localized persistent plaque psoriasis with incoherent narrowband ultraviolet B phototherapy. J Dermatol Treat 2005;16:165-8. 35. Asawanonda P, Charoenlap M, Korkij W. Treatment of localized vitiligo with targeted broadband UVB phototherapy: A pilot study. Photodermatol Photoimmunol Photomed 2006;22:133-6 36. Amornpinyokeit N, Asawanonda P. 8-methoxypsoralen cream plus targeted narrowband ultraviolet B for psoriasis Photodermatol Photoimmunol Photomed 2006;22:285-9 37. Hadi S, Tinio P, Al-Ghaithi K, Al-Qari H, Al-Helalat M, Lebwohl M, et al Treatment of vitiligo using the 308-nm excimer laser. Photomed Laser Surg 2006;24:354-7 38. He YL, Zhang XY, Dong J, Xu JZ, Wang J. Clinical efficacy of a 308 nm excimer laser for treatment of psoriasis vulgaris. Photodermatol Photoimmunol Photomed 2007;23:238-41 39. Lapidoth M, Adatto M, David M. Targeted UVB phototherapy for psoriasis: a preliminary study. Clin Exp Dermatol 2007;32:642-5 40. Noborio R, Nishida E, Kurokawa M, Morita A. A new targeted blue light phototherapy for the treatment of acne. Photodermatol Photoimmunol Photomed 2007;23:32-4. 41. Sadick NS, Magro C, Hoenig A. Prospective clinical and histological study to evaluate the efficacy and safety of a targeted high-intensity narrow band UVB/UVA1 therapy for striae alba. J Cosmet Laser Ther 2007;9:79-83 42. Yu HS, Wu CS, Yu CL, Kao YH, Chiou MH. Helium Neon laser irradiation stimulates migration and proliferation in melanocytes and induces repigmentation in segmental vitiligo. J Invest Dermatol 2003;120:56-64.
Centre for Advanced Dermatology, Bangalore, India
Abstract
Phototherapy is one of the most important therapeutic modalities in dermatology. This field has seen several major advances in the recent years, the most recent being targeted phototherapy. Targeted phototherapy, which includes laser and nonlaser technologies, delivers light/laser in the ultraviolet spectrum, of specific wavelength, specifically targeted at the affected skin and thereby avoids many of the side effects of conventional phototherapy. The treatment has been claimed to be effective, quick, and needing fewer treatment sessions. The article reviews this new mode of phototherapy.
Keywords: Excimer laser, excimer light, phototherapy, psoriasis, targeted phototherapy, vitiligo
How to cite this article:Mysore V. Targeted phototherapy. Indian J Dermatol Venereol Leprol 2009;75:119-25
How to cite this URL:Mysore V. Targeted phototherapy. Indian J Dermatol Venereol Leprol [serial online] 2009 [cited 2009 Apr 8];75:119-25. Available from: http://www.ijdvl.com/text.asp?2009/75/2/119/48655
Introduction
Phototherapy is used for a wide variety of skin diseases. There has been considerable progress in cellular and cutaneous photobiology leading to improved understanding of different photodermatoses and their treatment. However, the developments in phototherapy have been comparatively slow, as reflected in a recent publication that "developments in phototherapy have not kept pace with scientific progress, as has been the case with radiotherapy" [1]
Nevertheless, the last two decades have seen significant technological advances, expanding the options while treating a patient who needs phototherapy [Table 1]. The most important of these advances have been narrowband ultraviolet B (UVB) (311 nm) phototherapy and, more recently, targeted phototherapy [2],[3],[4] This article reviews the subject of targeted phototherapy in the light of the author's experience during the last 4 years.
Disadvantages of Conventional Phototherapy
Conventional phototherapy consists of delivery of light energy by tube lights to the affected area. [3] Different machines used for this purpose include whole body cabinets, hand and foot machines, scalp machines, etc. These machines have the following disadvantages:
Exposure of uninvolved areasSlow delivery system and lengthy treatment sessions Multiple and frequent visits to clinicDifficulty in treating certain areas (such as genitalia, oral mucosa, ear, etc)Difficulty in treating children who may feel intimidated by the large machinesLarge office space required to house the bulky machines
A new technique called targeted phototherapy which seeks to overcome these disadvantages has now become available [3],[4],[5],[6] Also called concentrated phototherapy, focused phototherapy, microphototherapy, this modality involves application of light energy directly focused on, or targeted at, the lesion through special delivery mechanisms such as fiber-optic cables. The term 'targeted phototherapy' includes different technologies such as excimer laser, intense pulse light systems, and UV light sources with improved hand-held delivery systems.
Advantages of Targeted Phototherapy
Several advantages have been claimed for targeted phototherapy: [5]
Exposure of involved areas only and sparing of uninvolved areas, thus minimizing acute side effects such as erythema and long-term risk of skin cancer over unaffected skinQuick delivery of energy and thereby shortened duration of treatmentDelivery of higher doses (super-erythemogenic doses) of energy because uninvolved areas are not exposed, higher doses of energy can be delivered selectively to the lesions, thereby enhancing efficacy and achieving faster responseThis has been claimed to shorten duration of treatment, leading to less frequent visits to clinic, and thereby lessen the inconvenience for the patientThe maneuverable hand piece allows treatment of difficult areas such as scalp, nose, genitals, oral mucosa, ear, etc.Easy administration for children as delivery is hand-held Targeted phototherapy machines occupy less space
However, targeted phototherapy devices have certain disadvantages; they are more expensive. Also, they are not adequate to treat extensive areas in view of the cost of treatment and time involved in treatment. They are not recommended for use if lesions occur over more than 10% of the body area. [5]
Mechanisms of Action
Most targeted phototherapy devices (laser or nonlaser type) emit radiation in the UVB range, with peak emission in the narrowband wavelength (around 308-311 nm), while some light-based nonlaser machines emit UVA radiation also. Hence mechanisms of action of targeted phototherapy systems are similar to those in conventional UVB/UVA therapy. [7],[8],[9],[10] UV light has been shown to have several effects on both epidermal and dermal cells, which explains its efficacy in treatment of cutaneous diseases such as psoriasis, vitiligo, and lymphoma. UVB radiation has been previously shown to induce DNA damage and pyrimidine dimer formation. Apoptotic mechanisms may be involved in the destruction of susceptible epidermal and dermal cells by UV light. UVB radiation has several effects on skin, such as induction of alteration in cytokine production, local immunosuppression, stimulation of melanocyte-stimulating hormone, increased melanocyte proliferation, and melanogenesis. UVB radiation also enhances production of vitamin D metabolites, which stimulate melanogenesis. UVA radiation may also produce similar effects. Targeted phototherapy may induce all these effects in a more aggressive way, because of delivery of supererythemogenic doses of radiation. [4],[5],[6] It has also been suggested that their enhanced efficacy may be due to their ability to deliver the energy to deeper dermal levels, and targeted therapy may therefore affect hidden target cells such as melanocytes. [6]
Different Types of Targeted Phototherapies
As mentioned earlier, targeted phototherapy may be achieved by different sources such as laser (excimer), IPL (excimer light), and UV light [Table 1].
Excimer Laser
First used in medicine for its ability to produce cold tissue ablation, excimer laser found applications in cardiology, ophthalmology, orthopedics, and dermatology [4] The word 'excimer' refers to 'excited dimer.' These lasers operate in the ultraviolet range, and examples include the 193-nm argon-fluoride; 248-nm krypton-fluoride; 351-nm xenon-fluoride; and of particular interest to dermatology, the 308-nm xenon-chloride laser. These lasers utilize a mixture of a noble gas and a halogen as a lasing material. The pulse repetition rate of the laser can be set up to 200 Hz with 3 mJ/cm 2 of energy per pulse. A pilot study in 2002 [6] showed significant benefits in vitiligo. Twenty-nine patches of vitiligo from 18 patients were treated 3 times a week for a maximum of 12 times with excimer laser, with parameters 120-nanosecond, 20-Hz pulse with a 10×10-mm spot size and a power output of 60 mW of laser light. Exposure time was 2 seconds, increased by 2 seconds at every other visit. Twenty-three vitiligo patches had 6 treatments, with some repigmentation in 57% of the treated patches. Eleven vitiligo patches from 6 patients had 12 treatments, with some repigmentation in 82% of the treated patches. Lesions which were previously resistant to treatment with other modalities also responded to excimer laser. The study concluded that "the degree of repigmentation in a period of 2 to 4 weeks is much higher than that achieved with any other present vitiligo therapy. The xenon-chloride excimer laser may represent a new treatment modality for the management of stable vitiligo". These results were confirmed by other studies, which showed benefit with excimer laser in patients of localized vitiligo who had been unsuccessfully treated with other modalities of treatment. [11]
In psoriasis too, the efficacy of excimer laser has been confirmed by several reports [12],[13],[14] Localized resistant lesions of psoriasis over elbow and knees were reported to be cleared in as few as 1 to 3 exposures, with moderately long remission. [12] Scalp psoriasis was also shown to respond well. [13] In another study which studied patient satisfaction, 55% of patients reported overall satisfaction and 25% reported that laser treatments were better than any other treatment they had tried. [14] Side effects reported, though usually mild, included burning pain during and after treatment, severe erythema, and blistering of skin. [14]
Excimer laser has been reported to be effective in other dermatoses also, such as oral lichen planus, [15] alopecia areata, [16] atopic dermatitis, [17] mycosis fungoides, and lymphomatoid papulosis. [18] Interestingly excimer laser has been found to be effective in hypopigmented striae [19],[20],[21] and hypopigmented scars, [19] conditions generally considered difficult to treat. Increase in melanin pigment, hypertrophy of melanocytes, and an increase in melanocytes within striae, leading to darkening of striae, were reported after use of excimer laser. [18] These results, if confirmed by larger data, will open up exciting new avenues for treatment of these important and common cosmetic problems.
After a period of initial excitement, subsequent studies have led to a reappraisal of the role of excimer laser in psoriasis [22],[23] and vitiligo [24],[25] Comparison of excimer laser, excimer lamp, and 311-nm narrowband UVB in patients with psoriasis showed similar clearance and no statistically significant difference in results after 10 weeks of treatment. [22] The study did show enhanced clearance rate in the laser group of patients when treated by an accelerated scheme of administration, but these patients also had higher rate of side effects such as blistering and crusting. The study concluded that "the only advantage of laser seems to be the ability to treat exclusively the affected skin and with a reduced cumulative dose, thus perhaps reducing the long-term risk of carcinogenicity" A large study of 140 patients with vitiligo treated by excimer laser showed excellent results in UV-sensitive areas, while UV-resistant areas such as acral lesions and lesions in joint areas responded poorly. [24]
Excimer laser machines have been introduced by companies such as Photomedex and Wave Light Technologies. However, the machines had several disadvantages such as high cost, huge weight and bulk, and difficulties in maintenance. These factors and the less-than-impressive data stated earlier justify the observation by James Fergusson that "in both theory and practice, this treatment is effective and the excimer 308-nm laser effected faster clearance at a lower cumulative dose and spared unaffected skin from unnecessary exposure. The blistering response may raise a problem for patients. Controlled trials are needed. I suspect that until such information is available, this expensive, high-tech treatment will remain confined to specialist centres". [26] This indeed has been the case and despite its introduction in 2002, the technology is available only in few centres.
Monochromatic Excimer Light (IPL) Therapy
Other forms of targeted light therapy have been introduced, such as IPL therapy with wavelength of 304 nm (excilite: Deka) and 308 nm (Pxlite). These machines are less bulky, cheaper, and have a comparatively larger treatment surface in contrast to excimer laser. Several studies have been published which demonstrate their efficacy. In a pilot study of excimer light in 37 patients of vitiligo, Leone et al, [27] obtained initial repigmentation in the first 8 treatments and excellent repigmentation in 50% of patients at 6 months. Some patients who had not previously responded to narrowband UVB therapy were also found to respond. The results were comparable to excimer laser and superior to narrowband phototherapy. Another study demonstrated the efficacy of excimer light in a number of UV-responsive conditions such as palmoplantar psoriasis, atopic dermatitis, and alopecia areata. [28] IPL was also shown to induce apoptotic and immunohistochemical changes in psoriatic skin.[29] Thus excimer light is a promising, effective, and cheaper alternative to excimer laser.
Light-Based (Nonlaser, Non -IPL) Targeted Phototherapy
Advances in technology have now permitted delivery of conventional noncoherent light (broadband or narrowband light) targeted at lesions. Many such machines have been marketed in recent years (Sallman, Theralight, multilight, curelight, Bioskin, B-clear, etc). Most of these machines use a conventional high-pressure burner emitting UV light and fiber-optic cable systems to deliver energy directly targeted at the lesion. Their spot sizes range from 1 to 3 cm. These machines have multiple delivery programs and automatic calibration for quick delivery of predetermined dosages, so that treatment time is short. They are considerably smaller in size than the laser machines, with less maintenance problems, and are also cheaper. An added advantage of some of these machines over the excimer light or laser is that both UVA and UVB (narrowband) spectra are available. Several studies have been published on the efficacy of these systems in both vitiligo and psoriasis. [30],[31],[32],[33],[34],[35],[36]
Each of the different commercially available systems has its advantages and disadvantages, which are discussed below.
Dualight
(Previously called Theralight) emits both UVA radiation in the range 330-380 nm and UVB in the range 290-330 nm with peak at 303 nm 5 The system has a 2-meter long fiber-optic delivery system, with a spot size of 4 cm 2 . UVA intensity is 10-550 mW/cm² for 3.63-cm² exit aperture, while UVB intensity is 50-250 mW/cm² for 3.63-cm² exit aperture.
B clear targeted photoclearing system
B clear system is mercury-based noncoherent UVB radiation with a therapeutic wavelength of 290 to 320 nm and pulse width of 0.5 to 2.0 seconds. Fluence ranges from 50 to 800 mJ/cm 2 in increments of 10 mJ/cm 2 . Its disadvantage is that only UVB range is available, unlike Dualight, which delivers both UVA and UVB ranges. [30]
Bioskin
Lotti et al reported efficacy of a targeted narrowband UVB device in vitiligo in 1999. [31] Bioskin consisted of a mercury arc lamp with wavelength 280 to 320 nm and peak at 311 nm and a delivery system consisting of liquid-component optical fiber with spot size 1 cm in diameter. Seventy-five percent repigmentation was achieved in 5 of the 8 patients with segmental vitiligo, after 6 months' treatment. A large study in 734 patients [32] showed 75% or more improvement in nearly 70% of the patients and total repigmentation in 21% of the subjects. No patient showed acute or chronic side effects.
Author's experience
The author has used a targeted phototherapy device procured from the German company Salmann in 75 patients since 2003. This system is a lightweight, tabletop machine, with a weight of 9.3 kg, a fiber-optic delivery cable of length 2 meters, and spot size of 1 cm. It delivers UVA in the range 340-360 nm and UVB with a peak at 313 nm. It can deliver 100 mJ of UVB in 6 seconds. It does not have an automated delivery system as in B clear or Dualight machines and is therefore slower, but is also cheaper. In the author's experience, targeted phototherapy is a very useful adjuvant to conventional phototherapy devices and provides many advantages [Table 2]. Importantly, it is of a great value addition in dermatological practice and enables the clinician to treat many patients with resistant lesions and lesions in difficult areas, which are otherwise difficult to treat by conventional UVB machines. Another advantage is in treating children, who may feel intimidated by the large phototherapy machines. The machine is effective particularly in areas such as face, knee, trunk, eyelids, etc. but is not effective in UV-resistant areas such as fingertips. The biggest advantage is the ability to deliver energy without risk of acute or chronic side effects on unaffected skin. Thus patients, particularly those who have apprehensions about taking UV therapy, feel more comfortable with these machines. However, despite these advantages, they cannot replace the whole body machines and hand-foot machines, as large areas cannot be treated with targeted phototherapy. The higher cost of the machines is also an important consideration in the Indian situation.
Conclusion
[Table 2] summarizes the role of targeted phototherapy in current practice. As new data emerge, the role of this modality both in diseases such as vitiligo, [37] psoriasis [38],[39] and also in new indications such as acne [40] and stretch marks [41] continues to evolve. New technologies continue to emerge, such as new low-level helium neon laser system (reported to be effective in segmental vitiligo). [42] It is obvious that both targeted laser and nonlaser phototherapies represent exciting advances in dermatotherapy.
References
1. Diffey BL. Ultraviolet phototherapy of skin diseases. Physics and Engineering in Medicine in the New Millennium, IPEM; 2000. p. 65-7. 2. Bethea D, Fullmer B, Syed S, Seltzer G, Tiano J, Rischko C, et al. Psoralen photobiology and photochemotherapy: 50 years of science and medicine. J Dermatol Sci 1999;19:78-88 3. Hamzavi I, Lui H. Using light in dermatology: An update on lasers, ultraviolet phototherapy, and photodynamic therapy. Dermatol Clin 2005;23:199-207. 4. Spencer JM, Hadi SM. The excimer lasers. J Drugs Dermatol 2004;3:522-5 5. Grimes PE. Advances in the treatment of vitiligo: Targeted phototherapy. Cosm Dermatol 2003;16:18-22 6. Spencer JM, Nossa R, Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: A pilot study. J Am Acad Dermatol 2002;46:727-31. 7. Young AR, Chadwick CA, Harrison GL, Nikaido O, Ramsden J, Potten CS. The similarity of action spectra for thymidine dimmers in human epidermis and erythema suggests that DNA is the chromophore for erythema J Invest Dermatol 1998;111:982-8 8. Cooper KD. Cell mediated immunosuppressive mechanisms induced by UV radiation photochemistry and photobiology. Photochem Photobiol 1996;63:400-5 9. Yaron I Yaron R, Oluwole SF, Hardy MA. UVB radiation of human derived peripheral blood lymphocytes induces apoptosis but not T cell anergy. Cell immunol 1996;168:258-66 10. Freeman SE, Gange RW, Sutherland JC, Matzinger EA, Sutherland BM. Production of pyrimidine dimmers in DNA of human skin exposed in situ to UVA radiation. J Invest Dermatol 1987;88:430-3. 11. Taneja A, Trehan M, Taylor CR. 308-nm excimer laser for the treatment of localized vitiligo. Int J Dermatol 2003;42:658-62. 12. Asawanonda P, Anderson RR, Chang Y, Taylor CR. 308-nm excimer laser for the treatment of psoriasis: A dose-response study Arch Dermatol 2000;136:619-24. 13. Morison WL, Atkinson DF, Werthman L. Effective treatment of scalp psoriasis using the excimer (308 nm) laser Photodermatol. Photoimmunol Photomed 2006;22:181-3 14. Rodewald EJ, Housman TS, Mellen BG, Feldman SR Follow-up survey of 308-nm laser treatment of psoriasis. Lasers Surg Med 2002;31:202-6. 15. Kollner K, Wimmershoff M, Landthaler M, Hohenleutner U. Treatment of oral lichen planus with the 308-nm UVB excimer laser-early preliminary results in eight patients. Lasers Surg Med 2003;33:158-60 16. Gundogan C, Greve B, Raulin C. Treatment of alopecia areata with the 308-nm xenon chloride excimer laser: Case report of two successful treatments with the excimer laser. Lasers Surg Med 2003;33:158-60. 17. Baltas E, Csoma Z, Bodai L, Ignacz F, Dobozy A, Kemeny L. Treatment of atopic dermatitis with the xenon chloride excimer laser. J Eur Acad Dermatol Venereol 2006;20:657-60. 18. Kontos AP, Kerr HA, Malick F, Fivenson DP, Lim HW, Wong HK. 308-nm Excimer laser for the treatment of lymphomatoid papulosis and stage IA mycosis fungoides Photodermatol Photoimmunol Photomed 2006;22:168-71 19. Goldberg DJ, Sarradet D, Hussain M. 308-nm Excimer laser treatment of mature hypopigmented striae. Dermatol Surg 2003;29:596-8 20. Goldberg DJ, Marmur ES, Schmults C, Hussain M, Phelps R. Histologic and ultrastructural analysis of ultraviolet B laser and light source treatment of leukoderma in striae distensae. Dermatol Surg 2005;31:385-7. 21. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, Geronemus RG. The safety and efficacy of the 308-nm excimer laser for pigment correction of hypopigmented scars and striae alba. Arch Dermatol 2004;140:955-60. 22. Kφllner K, Wimmershoff MB, Hintz C, Landthaler M, Hohenleutner U. Comparison of the 308-nm excimer laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis. Br J Dermatol 2005;152:750-4. 23. Rivort J. Experience with excimer laser. J Drugs Dermatol 2006;5:550-4 24. Choi KH, Park JH, Ro YS. Treatment of Vitiligo with 308-nm xenon-chloride excimer laser: Therapeutic efficacy of different initial doses according to treatment areas. J Dermatol 2004;31:284-92 25. Passeron T, Ostovari N, Zakaria W, Fontas E, Larrouy JC, Lacour JP, et al . Topical tacrolimus and the 308-nm excimer laser: A synergistic combination for the treatment of vitiligo Arch Dermatol 2004;140:1065-9. 26. Ferguson J. The 308-nm excimer laser is practical therapy for psoriasis. J Watch Dermatol January 14, 2003. 27. Leone G, Iacovelli P, Paro Vidolin A, Picardo M. Monochromatic excimer light 308 nm in the treatment of vitiligo: A pilot study. J Eur Acad Dermatol Venereol 2003;17:531-7 28. Aubin F, Vigan M, Puzenat E, Blanc D, Drobacheff C, Deprez P, et al . Evaluation of a novel 308-nm monochromatic excimer light delivery system in dermatology: A pilot study in different chronic localized dermatoses. Br J Dermatol 2005;152:99-103. 29. Bianchi B, Campolmi P, Mavilia L, Danesi A, Rossi R, Cappugi P. Monochromatic excimer light (308 nm): An immunohistochemical study of cutaneous T cells and apoptosis-related molecules in psoriasis. J Eur Acad Dermatol Venereol 2003;17:408-13. 30. Gilles PR. Technical evaluation of fibre optically delivered light for lesion targeted high dosage UVB phototherapy B-clear application note 2 Lumenis inhouse publication 2002 31. Lotti TM, Menchini G, Andreassi L. UV-B radiation microphototherapy: An elective treatment for segmental vitiligo. J Eur Acad Dermatol Venereol 1999;13:102-8. 32. Menchini G, Tsoureli-Nikita E, Hercogova J. Narrow-band UV-B micro-phototherapy: A new treatment for vitiligo. J Eur Acad Dermatol Venereol 2003;17:171-7 33. Kaur M, Oliver B, Hu J, Feldman SR. Nonlaser UVB-targeted phototherapy treatment of psoriasis. Cutis 2006;78:200-3. 34. Toll A, Vιlez-Gonzαlez M, Gallardo F, Gilaberte M, Pujol RM. Treatment of localized persistent plaque psoriasis with incoherent narrowband ultraviolet B phototherapy. J Dermatol Treat 2005;16:165-8. 35. Asawanonda P, Charoenlap M, Korkij W. Treatment of localized vitiligo with targeted broadband UVB phototherapy: A pilot study. Photodermatol Photoimmunol Photomed 2006;22:133-6 36. Amornpinyokeit N, Asawanonda P. 8-methoxypsoralen cream plus targeted narrowband ultraviolet B for psoriasis Photodermatol Photoimmunol Photomed 2006;22:285-9 37. Hadi S, Tinio P, Al-Ghaithi K, Al-Qari H, Al-Helalat M, Lebwohl M, et al Treatment of vitiligo using the 308-nm excimer laser. Photomed Laser Surg 2006;24:354-7 38. He YL, Zhang XY, Dong J, Xu JZ, Wang J. Clinical efficacy of a 308 nm excimer laser for treatment of psoriasis vulgaris. Photodermatol Photoimmunol Photomed 2007;23:238-41 39. Lapidoth M, Adatto M, David M. Targeted UVB phototherapy for psoriasis: a preliminary study. Clin Exp Dermatol 2007;32:642-5 40. Noborio R, Nishida E, Kurokawa M, Morita A. A new targeted blue light phototherapy for the treatment of acne. Photodermatol Photoimmunol Photomed 2007;23:32-4. 41. Sadick NS, Magro C, Hoenig A. Prospective clinical and histological study to evaluate the efficacy and safety of a targeted high-intensity narrow band UVB/UVA1 therapy for striae alba. J Cosmet Laser Ther 2007;9:79-83 42. Yu HS, Wu CS, Yu CL, Kao YH, Chiou MH. Helium Neon laser irradiation stimulates migration and proliferation in melanocytes and induces repigmentation in segmental vitiligo. J Invest Dermatol 2003;120:56-64.
Emergence of dermatology in India
Devinder Mohan Thappa, Rashmi Kumari Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India
Introduction
Dermatology, the science of the skin and its appendages, is one of the many specialties that evolved from general internal medicine during the course of the nineteenth century. Till this time, physicians with few exceptions, were little concerned with the skin, apart from the exanthematic eruptions of acute fevers. During the last decades of that century, contributions of some, such as Heberden, Cullen, and Hebra, laid the foundations on which the pioneer specialist dermatologists of the following century were able to build. [1] In India, dermatology as a specialty came into prominence only in the twentieth century, although skin diseases like leprosy, viral fevers like measles and chicken pox (amma), psoriasis, and vitiligo (ven kushtam or white leprosy) were recognized long back. Major strides in the etiology, pathogenesis, and treatment of skin disorders took place during the twenty first century. Today, dermatology is a well-developed specialty with established departments in various medical colleges and hospitals. Growing numbers of dermatologists render their services to the general population throughout the country and many have specialized into various subspecialties like pediatric dermatology, dermatosurgery and cosmetic dermatology, and dermatopathology. Contributions to the world dermatology by many Indian doctors are applaudable, although some lacunae still remain.
Ancient Practices in Dermatology
In India, therapeutics of dermatoses were known and practiced by our ancient physicians for centuries, Charaka Samhita [2] contains one chapter on the subject. This is a famous ancient medical treatise dealing with basic principles of Ayurveda, one of the four vedas dealing with the knowledge of health. In this ancient book, worshipful Atreya Punarvasu has described eighteen dermatoses [3] and attributed them to the preponderance of morbid humorus (vata, pitta, and kepha) causing disturbance of body elements resulting in diseases. Knowledge of infections and allergens, etc. did not exist in those days. In the absence of specific remedies, therapies used were mostly empherical and often unsatisfactory.
Ayurvedic dermatology was later influenced by the Unani system imported into the country with the invasion by Muslims. Concoctions, Karhars, and blood purifiers were chiefly resorted to. Both the Ayurvedic and the Unani systems were practiced side-by-side, along with the barbers (Jarahs, in local language). While the former two relied mainly on purification of blood, the barbers mainly laid emphasis on cauterization of skin lesions and burning out the disease with its root. Their cheapness and easy accessibility attracted the ignorant and the illiterate, but less so the educated. [1]
Medical charlatans selling panaceas for cutaneous ailments and faith healers were commonly seen then and similar outlets still continue to persist even in this age of scientific progress due to dearth of dermatologists in the backward areas. Also, even today, there is no dearth of herbalists in the country. Main indigenous herbs used were seem , chraita , myrobalans (trifla), amala , embelia , Indian berry , bapchi , catechu , and centella . Most of the herbs were processed unesthetically with cow dung and urine, etc. [1]
Poultices and plant(s)/tree(s) exudates, particularly oak and garlic, were also used extensively. Exact statistics are not available about the number of skin patients treated by vaids , hakims , barbers, medical charalatans , herbalists, faith-healers, and quacks as there are no records or statistics maintained by the practitioners of these ancient and indigenous arts, but the number is definitely not small by any means. The treatment in most diseases was, at best, symptomatic and, at worst, dangerous. Not excluding the olden days, even at present times, chemical dermatitis, erythroderma, and drug eruptions caused by these unscientific preparations are common problems in any dermatological clinic in India. [1]
British Legacy in Progress of Dermatology
The health authorities in British-India became aware of the prevalence of dermatoses and venereal diseases in the latter part of the nineteenth century. Accordingly, Dr. Vandyke Carter, [4] Surgeon Major, HMS Indian Medical Services, was requisitioned to take stock of the situation. This, perhaps, was the first scientific endeavor to study dermatoses in the Indian subcontinent, where hardly any statistics were available. The problem was further compounded by the social taboos attached to the skin diseases. That was the time when afflicted patients preferred either to conceal their illness or sought treatment from quacks; however, it was difficult to lay hands on the mission. It was, therefore, considered imperative to commission Fox and Farquar in the year 1872, to precisely determine the prevalence and pattern of dermatoses in India, and to coordinate with the specialists in England so as to bring about uniformity in the nomenclature, diagnostic methods, and therapeutic regimen. [5]
Information regarding the incidence and etiology of endemic skin diseases in India was later compiled in a book by Tilbury Fox. [1]
Early Progress of Dermatology in India
Growth of dermatology in the twentieth century can be studied by reviewing the transactions of the different medical societies, reports of Civil Surgeons and Army, report of the Sanitary Commissioner, Government of India, Indian Medical Gazette, and report of the Carmichael Tropical School of Medicine. All this while, dermatology was not established as a specialty and scientific, specific drugs being used were indeed very few.
Some of the oldest skin departments in the country got established in Calcutta (Kolkata), Madras (Chennai), and Bombay (Mumbai) for decades. Others are of recent origin. A skin research department with various units (including mycology) developed in the School of Tropical Medicine and Carmichael Hospital for tropical diseases since 1924 under the guidance of Late. Lt. Col. Acton. [1] Leprosy work was mainly carried out by Christian missionaries in different parts of India including a specialized department in the School of Tropical Medicine, Calcutta, headed by Dr. Muir. In 1977, small pox was declared eradicated in India.
Substantial progress has been achieved by eminent workers in this field, mainly postindependence. Growth of medical education and the establishment of the skin departments in teaching and also general hospitals provided the necessary impetus to the development of dermatology services in this country.
The first chair of dermatology was established at Grant Medical College, Jamshedji Jeejebhoy Hospital (JJ Hospital), Bombay, in 1895. Major C. Fernandez, M.D. (Brussels), who was earlier trained under Unna, Brocq, and Darier, made the creation of this chair possible through his pioneering efforts. Befittingly, he was the first occupant of this distinguished chair, and the honor of "Founder of Indian Dermatology" is rightfully bestowed on him. In the latter part of the nineteenth century, the health authorities in the then British-India became aware of the need to have data on the prevalence of dermatoses and venereal diseases. [4],[5] The second department, at the School of Tropical Medicine in Calcutta, was started in 1923, after a gap of nearly 28 years, under the patronage of Dr. Ganpati Panja and Col. Acton. Subsequently, in 1926, the department of dermatology and venereology was established at Seth Goverdhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Bombay. Dr. A.C. Rebello as honorary dermatologist and venereologist headed it. During the period from 1956-1974, the status of the specialty was further elevated and steps were taken by state Governments to set up departments of dermatology and venereology in medical institutions. [6] The establishment of the All India Institute of Medical Sciences with a separate department for dermatology in 1960 under the stewardship of Professor KC. Kandhari, was a conspicuous landmark. The contributory health scheme and the employees state insurance scheme have got their own dermatologists. This development is significant along with the growth of other specialties in the metropolis of India.
Postgraduate Teaching in India
Bombay lead the way in postgraduate education. From its inception in 1926, Seth GS Medical College had the post of honorary dermatologist and venereologist and an honorary lecturer. It also had an extern to assist the physician in the outpatient department. As the work in the department increased, an appointment of a resident registrar was made in 1930. In 1931, the house physician to the department of dermatology was appointed. The honorary dermatologist was entrusted the task of taking lectures and clinical demonstrations for the medical undergraduates.
In 1942, Bombay University appointed a committee to frame rules and regulations for a diploma in dermatology and venereology (DVD). It was a course of one-year duration and the first DVD examination was held in October 1945. In 1947, the College of Physicians and Surgeons (Bombay) allowed candidates to appear for their fellowship examinations in dermatology and venereology.
During the 1950s, some specialists appeared on the Indian scene. They had either qualified the Masters in Medicine with DVD (Bombay), or Diploma in Venereology (DV) from Madras University. Some had also qualified the membership examination of the Royal College of Physicians, UK, with dermatology and venereology as special subjects. These specialists now established the departments of dermatology in various medical colleges and hospitals. Notable among them were Dr. A.S. Thambiah (Madras Medical College), Dr. Sharat C. Desai (KEM Medical College), Dr. J.C. Shroff (JJ Hospital, Bombay), Dr. T.K. Mehta (Topiwala Medical College, Bombay), Dr. P.N. Behl (Irwin Hospital, Delhi), Dr. B.N. Banerjee, Dr. K.D. Lahiri (Calcutta Medical College), Dr. K.C. Kandhari (Amritsar Medical College, Punjab), Dr. K.N. Saxena (Agra), and Dr. M.P. Mathur (Jaipur). Soon, more than 80% of these posts were elevated to professor.
In 1956, AIIMS was established in New Delhi under an act of the parliament. It had departments of different medical specialties. In 1960, Prof. Kandhari was selected to head the department of dermatology and venereology [Table 1]. He took upon itself the responsibility to train teachers in the specialty so that they could man independent departments in medical colleges elsewhere in the country. It is interesting to note that many institutions are now headed by distinguished teachers trained at AIIMS. In 1961, the Indian Academy of Medical Sciences was established (now the National Academy of Medical Sciences) by the leading medical educationists. Distinguished members of different specialties were founding members. Dermatology was represented by Dr. R.V. Rajam, Dr. P.N. Rangiah, and Prof. K.C. Kandhari.
Thus, the stage had been set for beginning postgraduate teaching in the specialty. Since then, many more medical colleges have been recognized for training of postgraduates. A problem that has become evident over the years is the lack of uniform standards of education and nomenclature of the specialty and its various qualifications. Furthermore, the facilities in the form of outdoor and indoor services, laboratories, accommodation, and ancillary staff are too meager in some institutions even for undergraduate training. Postgraduate training in such institutions is unlikely. The postgraduate training program is designed to incorporate didactic lectures; bedside clinical demonstrations of inpatient cases and discussions of outpatient cases; seminars and journal clubs; instant office procedures; histopathology; and research, including thesis or dissertation. Several books and monographs have been written for under and postgraduate training based on patterns of dermatoses in India. Another milestone in Indian dermatology was the plan of the IADVL textbook project by Prof. R.G. Valia and Prof. Leslie Marquis in order to fill a lacuna in teaching of dermatology. [7] Its first edition was published in 1994. The third edition is about to be made available in the year 2008 for benefit of the postgraduates.
Presently, all the institutes having venereology department have been merged with the dermatology department and teaching institutes impart training to all postgraduates in all the three disciplines - dermatology, venereology, and leprosy. There is a great need for uniformity in postgraduate courses in dermatology. Like American Board of Dermatology, Indian Board of Dermatology may be set up for these purposes. [8] Research facilities in postgraduate teaching departments are still meager in this country. Very few institutions can claim of good research facilities in dermatology for first-rate work.
It is desirable to have uniform nomenclature for postgraduate qualifications (degree and diploma) in the specialty awarded by various universities across the country. Diplomate of national board (DNB) also awards degrees equivalent to M.D. in dermatology, venereology, and leprosy.
In spite of having some share in the curriculum, dermatology remains a neglected subject because of its noninclusion in the qualifying examination at MBBS level. Knowledge of dermatology in interns and young practicing doctors has been found to be negligible. In fact, there has been no uniform standard of teaching for undergraduates anywhere in India until recently, when Medical Council of India (MCI) set new guidelines for MBBS teaching and curriculum content in dermatology, venereology, and leprology. [8]
Substantial contributions have been made in the study of leprosy in India by Muir, Rogers, John Lowe, and Dharmendra in the School of Tropical Medicine, Calcutta. In such centers, specialized work is being done at School of Tropical Medicine, Calcutta, Leprosy Hospital Chingleput, Madras, and Vellore. Paul Brand at Vellore has made a great contribution in the treatment of crippled leprosy patients by reconstructive surgery. [6]
Original work has also been done in this country on syphilis, lymphogranuloma venerum, donovanosis, mycotic infections, and vitiligo by group of workers in Madras, Calcutta, and Delhi.
Contributions of Dr. J.S. Pasricha need to be remembered in independent India. His contribution in exploration of various causes of contact dermatitis is worth mentioning. [9] He also modified concept of pulse therapy to achieve cures in some of the most fatal and the so-called incurable diseases such as pemphigus, systemic sclerosis, and systemic lupus erythematosus. [10]
IADVL Remembers Luminaries
It is befitting to remember those revered dermatologists and great teachers who made major contributions during their life time, but they are not with us anymore [Table 2].
Present ERA of Dermatology
Our triple specialty (dermatology, venereology, and leprology) has come of age and now a number of subspecialties/superspecialties have made significant strides over the last few years. [19]
Whereas there was ample interest in STDs and leprosy 40-years ago, today there is a significant emphasis on dermatosurgery, dermatopathology, pediatric dermatology, contact and occupational dermatoses, cosmetology, HIV medicine, and lasers - a paradigm shift of interest. This gives you an idea of which direction dermatology is heading and it is for us as an association to nurture these emerging interests. For this, we need to start from the basics, which is to try and lay emphasis on the proper training of students in dermatology. We need to advise the board of studies of our universities to update the curriculum in dermatology to include those subjects of current interest. It should also prescribe a period of hands-on experience in those subjects before completion of the course. [21]
Since 20-30% of cases in pediatric practice have dermatological problems, a need was felt to constitute Indian Society for Pediatric Dermatology (ISPD). [22] It came into existence in 1996 and two years later the first issue of Indian Journal of Pediatric Dermatology rolled out of the press. [23] The first national conference on pediatric dermatology was organized in November 1996. From then on, the organization holds a national conference every year. A full-fledged Journal, "Indian Journal of Pediatric Dermatology" (IJPD), dealing exclusively with issues pertaining to pediatric dermatology was first published in 1998 and two issues are published each year giving the dermatologists a new forum to discuss and highlight various cases and issues pertaining to pediatric cases.
Until recently, dermatology remained purely a medical specialty in India, although our Western counterparts worked exhaustively on its surgical dimensions. [24] The last 20 years or so have witnessed a tremendous growth and dermatologists have adopted various surgical techniques and associations like Association of Dermatological Surgeons of India (now, Association of Cutaneous Surgeons of India), and Cosmetology (now Cosmetic Dermatology) Society-India (CSI) have been established. Advent of lasers in India for treating various skin diseases is relatively new, but the number of these laser clinics are mushrooming, especially in big cities. [25]
In this era of globalization, the mantra to success is quality control. For the comprehensive development of our specialty, the most important quality control measures need to be aimed at teaching institutes. Other fields that require quality control are cosmeceuticals and pharmaceuticals. Leave aside the mention of ingredients of cosmetics, the herbal umbrella provides impunity to incorporate harmful chemicals. [19]
A disturbing trend that one comes across these days is the enormous amount of propaganda in the lay press about 'cures' for a number of skin conditions by alternate system of medicines. While we have no quarrel with any other system of medicine, false information has to be counteracted by giving the public the correct information in the press by way of informed articles. [20]
Although, in Western countries and USA, dermatology is a much coveted subject with huge allocation of funds and ample research opportunities, in India this subject has not received its due attention. Even today, the dermatologist in India has a wide armentarium of drugs and technologies available to their Western counterparts. This has made the options of therapy for many skin disorders much wider than before.
The advent of corticosteroids in 1950s has helped us treat a number of inflammatory skin conditions, leaving behind a large number of untreatable conditions like vascular and pigmented nevi, tumors, scars, tattoos, and unwanted hair. All these conditions are now treatable with the help of lasers. However, the exorbitant cost of this equipment has put these tools in the hands of business enterprises that will treat only conditions of commercial interest. [20]
Recent advent of evidence-based medicine has made the dermatologist ponder about the correct application of modern scientific knowledge in the clinical practice of our discipline. Here, therapeutic approaches to disease are recommended on a review of the available scientific studies that have been suitably designed, carefully conducted, scrupulously analyzed, and more importantly, correctly interpreted. This should allow good quality scientific information to contribute to our decision-making in clinical practice.
We are privileged to have witnessed a historical moment - the end of the twentieth century and the dawn of a new millennium. Although significant progress has been made, there is a lot to be done. Running through the pages of a contemporary textbook of dermatology, we are disappointed to realize that most skin conditions remain of unknown or obscure, or incompletely understood etiology and pathogenesis. We have felt embarrassed to admit to our patients that we are almost unaware of what causes common dermatoses, such as psoriasis, vitiligo, alopecia areata, or atopic dermatitis. We must strongly hope that, in the twenty first century, emphasis should be placed on revealing and elucidating the etiopathogenesis of skin diseases. This will be the key for definitive treatment and, most importantly, for effective prevention.
The human life span has considerably extended, resulting in a growing proportion of elderly people in the population. Necessary adjustments in dermatological services should be implemented in order to face this new reality. Prevention of skin changes of chronoaging is an issue of increasing concern, and steps in this direction include the recognition of solar radiation as an important inducing factor of aging and the beneficial effect of topical retinoids in both extrinsically and intrinsically aged skin. In addition to aging of the population and excessive sun exposure, the depletion of the ozone layer is expected to result in an explosive rise in nonmelanoma skin cancer (NMSC) incidence.
Teaching of future dermatologists, and their continued education, especially via use of the computers and internet, and how to keep up with the new information are the new challenges facing our colleagues. [26]
Community Dermatology in India
Forty years ago, there was just a score of dermatologists in India. In 1991, Ministry of Health and Family Welfare put their number around 2000 for a population of 843 million. Now the situation is much better. However, these dermatologists are concentrated in the cities and large towns. The rural population, which is around 80% of the total, has no easy access to a dermatologist. [25]
Regarding the quantum of dermatological problems in the community, a reliable estimate is that one in twenty people has a skin disease in India. [27] An analysis of records of out-patient attendances of primary healthcare centers had found that 25-35% of these patients had dermatological problems. [28] Ten common skin diseases seen in primary health centers are scabies, pediculosis, tinea, leprosy, vitiligo, pityriasis versicolor, pityriasis alba, dermatitis, urticaria, impetigo, and boils. [25]
Conclusions
Dermatology is a very dynamic subject with multiple advances in various fields including dermatosurgery, dermatopathology, genetics and molecular research, melanocyte research, Lasers, cosmetic dermatology, etc.. Availability of various new therapies including lasers, botox, dermal fillers, biologicals, and immunoglobulins for treatment of various disorders have created a lot of excitement among the young dermatologists although the senior and eminent dermatologists still prefer to restrict themselves to the time-tested older therapies. Napolean Bonaparte said "glory is fleeting but obscurity is forever" so to conclude, we pay our respect to scores of dermatologists who silently served their patients. They may not have found their names in pages of history but shall be remembered by their patients in their hearts for the services rendered to them. There is certainly a need for rediscovering the best in the old indigenous systems of India and their incorporation into the modern practice. As Einstein put it "concern for man himself and his fate must always form the chief interest in all technical endeavors. Never forget this in the midst of your diagnosis and quotations". [1]
References
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