PracticalDermatology

When Erum N. Ilyas, MD of Montgomery Dermatology, LLC in suburban Philadelphia wanted to expand treatment options for psoriasis patients, she considered several options, including traditional phototherapy units. But light boxes were large and intended to treat extensive areas of involvement. While they are effective for a certain population of psoriasis patients, Dr. Ilyas noticed that in her practice, “Most patients needed localized or targeted treatment, which light boxes don’t really provide.”

With some research, Dr. Ilyas, whose practice is split about one-third cosmetic and two-thirds medical, settled on the XTRAC excimer laser (PhotoMedex), which is intended to treat patients with up to 20 percent Body Surface Area (BSA) involvement by delivering a highly targeted therapeutic level of UVB light to areas of the skin without harming the surrounding tissue. Given that the practice already has lasers for cosmetic uses, XTRAC was an easy integration.

Targeted Therapy

Dr. Ilyas noted that among her psoriasis patients, there were many with plaques that were resistant to treatment or who had plaques in anatomic areas that caused discomfort or functional impairment, but they weren’t candidates for conventional systemic or biologic therapies. Others had BSA involvement in the 10-20 percent range, where topical therapy can become cumbersome. These patients are all potential candidates for excimer laser therapy. Similarly, many patients with vitiligo have sub-optimal response to traditional interventions. Excimer laser is an alternative option for these individuals.

Unlike cosmetic laser therapies, XTRAC therapy for psoriasis is covered by insurance. “Other lasers are out of pocket,” Dr. Ilyas observes, “but most patients for whom I recommend XTRAC are covered.” She says that XTRAC’s patient support center has proven helpful in identifying coverage for existing patients and helping to bring in new patients who have coverage. Given the wide coverage for the procedure, its documented efficacy, and its convenience, she felt it would benefit many of her existing patients—and perhaps others who were not adequately managed.

Attracting Patients

The XTRAC patient support center is part of a recently launched comprehensive direct-to-consumer and physician education campaign by PhotoMedex called Live Clear. Live Free. Launched in select markets, including Philadelphia, the program includes direct-to-consumer advertisements and promotions that direct interested patients to a website or call center where they can learn more about treatment, explore their insurance coverage options, find a provider, and even be scheduled for an appointment.

The initiative has brought patients into Dr. Ilyas’ office. Many, but not all, have been candidates for XTRAC and ultimately received treatment. The program’s main benefit is that it gets patients to see a dermatologist, Dr. Ilyas suggests. “We always have to evaluate the patients, educate them, and make sure they understand expectations,” she says. “Even patients with localized involvement of psoriasis may have underlying associated conditions, such as psoriatic arthritis, which will require different approaches to overall management.”

For patients with less extensive involvement who are treatment naïve or have not been under a physician’s care for some time, a trial of topical therapy is probably indicated, Dr. Ilyas notes. But those who fail treatment, for whom topical therapy is cumbersome, or who can’t or won’t use systemics, the laser is a reasonable choice. Dr. Ilyas notes that the laser can be especially useful for certain anatomic locations, such as the inframammary area or gluteal cleft.

For patients with more extensive involvement, it is important to discuss all treatment options, including conventional systemics and biologics, Dr. Ilyas maintains. “A lot of patients shy away form these, especially for localized disease,” she observes.

Patient education about laser therapy and setting appropriate expectations are key, according to Dr. Ilyas. “Patients will require 10 to 20 treatments, typically, to see optimal results. Treatments are provided two to three times per week, and patients should see some improvement within three to four treatments,” she says. Patients must, therefore, commit to the treatment schedule. “If patients are not getting better by the tenth treatment, it may be time to consider other options,” Dr. Ilyas adds.

Most patients, once clear, can go about six to eight and sometimes up to 12 weeks without treatment before needing another brief series of maintenance treatments or a full course of laser sessions.

Dr. Ilyas does not personally advertise excimer laser therapy for psoriasis and vitiligo, but she does post information on her website and has informational brochures throughout the office. In addition to the patients directed to her practice by the patient call center, many existing patients learn about and pursue laser therapy simply as a result of conversations in the clinic.

An Unmet Need

“I am surprised by the number of patients who are presenting for treatment of vitiligo,” says Dr. Ilyas. Not having previously offered light therapy in the practice, she did not have many vitiligo patients. The patient call center, however, has directed many patients to her clinic. Many are concerned about vitiligo in cosmetically evident sites like the periorbital or perioral areas.

For both vitiligo and psoriasis, excimer laser therapy offers a relatively safe option for patients, especially children. Light is targeted, reducing overall exposure to light and the risks of UV exposure. It also reduces exposure to topical or systemic drugs, and their associated risks. Pediatric patients—and many adults—find the idea of laser therapy to be “not intimidating,” and therefore are often willing and eager to undergo treatment.

Dr. Ilyas is especially pleased with results she obtained using the excimer laser to treat psoriasis in a five-year-old with a prosthetic leg. The patient developed psoriasis at the stump, which was recalcitrant to various treatments. “Laser did beautifully,” Dr. Ilyas says. “The patient was excited about the treatment and especially pleased with the outcome.”

A Growth Experience

Dr. Ilyas says that incorporating XTRAC has been a, “smooth transition over the past year.” She expanded her patient base and enhanced the care she provides patients, who overall have expressed satisfaction with laser treatment.

Excimer laser therapy, “provides an effective therapeutic option that suits many patients’ needs safely, practically, and economically,” Dr. Ilyas says. Because practices pay for the laser on a per-use basis, adding the device into practice was not a daunting proposition, she says.