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Aetna considers excimer and pulsed dye laser treatment medically necessary for persons with mild-to-moderate localized plaque psoriasis affecting 10 % or less of their body area who have failed to adequately respond to 3 or more months of topical treatments, including at least 3 of the following:
- Corticosteroids (e.g., betamethasone dipropionate ointment and fluocinonide cream);
- Keratolytic agents (e.g., lactic acid, salicylic acid, and urea);
- Retinoids (e.g., tazarotene);
- Tar preparations; and/or
- Vitamin D derivatives (e.g., calcipotriene).
No more than 13 laser treatments per course and 3 courses per year are generally considered medically necessary. If the person fails to respond to an initial course of laser therapy, as documented by a reduction in Psoriasis Area and Severity Index (PASI) score or other objective response measurement, additional courses are not considered medically necessary.
Aetna considers combinational use of pulsed dye laser and ultra-violet B (UVB) experimental and investigational for the treatment of persons with localized plaque psoriasis because of insufficient evidence in the peer-reviewed literature.
Aetna considers the excimer laser or pulsed dye laser experimental and investigational in the treatment of forms of psoriasis other than plaque psoriasis because of insufficient evidence in the peer-reviewed literature.
Aetna considers laser treatment cosmetic for the following indications (not an all-inclusive list):
- Pearly penile papules
Aetna considers laser treatment experimental and investigational for the following indications because of insufficient evidence in the peer-reviewed literature (not an all-inclusive list):
- Atopic dermatitis
- Eczematous lesions
- Facial warts (verrucae)
- Granuloma annulare
- Granuloma faciale
- Herpes simplex labialis
- Hidradenitis suppurativa
- Jessner lymphocytic infiltration of the skin
- Keratosis pilaris
- Lichen sclerosus
- Lupus erythematodes
- Morphea (scleroderma of the skin)
- Mycosis fungoides
- Necrobiotic xanthogranuloma
- Pilonidal sinus disease
- Prurigo nodularis
- Reticular erythematous mucinosis
- Spongiotic dermatitis
- Vulval intraepithelial neoplasia.
Aetna considers laser treatment of acne scarring as cosmetic.
Psoriasis is a chronic skin disease that generally appears as patches of raised red skin covered by a flaky white buildup. Although the exact cause is unknown, psoriasis is thought to be due to an immunologic dysfunction, which accelerates the growth cycle of skin cells, causing them to accumulate faster than they can be shed.
Approximately 80 % of persons with psoriasis have "plaque psoriasis". Plaque psoriasis can appear on any skin surface, although the knees, elbows, scalp, trunk and nails are the most common locations. There are several other types of psoriasis, and between 10 % and 30 % of people with psoriasis also develop psoriatic arthritis.
Treatments for psoriasis can be divided into 3 basic categories:
- sunlight and topical agents (corticosteroids, calcipotriene, anthralins, tazarotene, coal tar, salicylic acid, moisturizers);
- phototherapy (broad-band ultraviolet-B [UVB], PUVA); and
- systemic medications (methotrexate, oral retinoids, cyclosporine).
Excimer lasers [XTRAC Excimer Laser Treatment System, (PhotoMedex, Carlsbad, CA) and EX-308 Excimer Laser System (Ra Medical Systems, Carlsbad, CA)] have been cleared by the Food and Drug Administration based on 510(k) applications for treatment of mild-to-moderate localized psoriasis. Both the XTRAC and the EX-308 are hand-held laser devices that use xenon chloride sources and provide intense, targeted UVB light. The potential benefits over standard UVB treatments are in terms of more rapid clinical response and more targeted therapy, avoiding the side effects of UV light exposure to unaffected skin. This procedure is usually repeated at least twice-weekly for 2 to 4 weeks.
There is evidence from controlled clinical trials of the effectiveness of excimer laser treatment of mild-to-moderate psoriasis. However, the comparative effectiveness of topical and laser treatment of psoriasis is unknown because these treatments have not been directly compared in a prospective clinical study. In addition, there is no adequate evidence of the effectiveness of laser therapy in combination with topical therapy. There is also limited evidence of the durability of the response to laser treatment of psoriasis. There is some evidence that a significant proportion of patients with psoriasis that is refractory to topical therapies may respond to laser treatment.
Asawanonda et al (2000a) reported on a dose-response study involving 13 patients with psoriasis plaques. Varying numbers of excimer pulses were delivered at fixed doses with a range of fluences from sub-erythemogenic to supra-erythemogenic. Lesions remained in remission with as few as a single high fluence (up to 16 times the minimal erythemogenic dose (MED)) treatment, whereas recurrences occurred in lesions treated with multiple doses of lower fluences shortly after cessation of treatment. The duration of remissions seen with the high fluences was 6.5 months. Based on these findings, the authors stated that "[w]e speculate that the ideal approach for localized, limited plaques may well be single or at most a few 'high-dose' treatments, whereas for widespread psoriasis several 'medium-dose' treatments may make more sense".
Feldman et al (2002) reported on a multi-center study of the excimer laser involving 124 patients with stable mild-to-moderate plaque-type psoriasis; 32 of whom dropped out of the study before completing the course of treatment. Patients were scheduled twice-weekly for a total of 10 treatments. Seventy-two percent of patients who completed the treatment course achieved at least 75 % clearing in an average of 6.2 treatments. Eighty-four percent of patients reached improvement of 75 % or better after 10 or fewer treatments. Side effects included erythema in half of the 124 patients, blisters in 56 %, hyper-pigmentation in 47 %, and erosion in 31 %. Other side effects included pain, sunburn sensation, scaling, itching, tenderness, flaking, peeling, vesicles, disease flare, scab, and weeping lesions. The authors concluded that the excimer laser appears to be safe and effective for psoriasis, and has an advantage over conventional photo-chemotherapy in that it requires fewer visits and targets only the affective areas of skin, sparing the surrounding uninvolved skin.
Erceg and colleagues (2013) systematically reviewed all available literature concerning PDL treatment for inflammatory skin diseases and proposed a recommendation. These investigators searched for publications dated between January 1992 and August 2011 in the database PubMed. All studies reporting on PDL treatment for an inflammatory skin disease were obtained and a level of evidence was determined. Literature search revealed 52 articles that could be included in this study. The inflammatory skin diseases treated with PDL consisted of: psoriasis, acne vulgaris, lupus erythematodes, granuloma faciale, sarcoidosis, eczematous lesions, papulopustular rosacea, lichen sclerosis, granuloma annulare, Jessner lymphocytic infiltration of the skin, and reticular erythematous mucinosis. The effectiveness of PDL laser treatment for these inflammatory skin diseases was described and evaluated. However, most conclusions formulated were not based on RCTs. The authors concluded that PDL treatment can be recommended as an effective and safe treatment for localized plaque psoriasis and acne vulgaris (recommendation grade B). However, for all other described inflammatory skin diseases, PDL appeared to be promising, although the level of recommendation did not exceed level C.
Verne and colleagues (2016) noted that granuloma annulare (GA) is a benign asymptomatic dermatosis that typically manifests in papules arrayed in annular arrangements. Many methods of treatment have been used with variable degrees of success, but finding a consistent and long-term treatment has proven a challenge. These researchers evaluated the latest published research on the use of lasers in the treatment of GA. They carried out a systematic search of the National Library of Medicine's PubMed database to identify relevant articles; 7 reports met the inclusion criteria for the review. Evidence for the use of PDL, fractional photothermolysis, and Excimer laser in the treatment of GA was found. Findings were limited by a lack of well-designed clinical trials objectively evaluating the use of lasers in the treatment of GA. The literature review found a number of case reports and case series that reported successful outcomes of the use of lasers in the treatment of GA. The authors concluded that the promising results reported in the literature, coupled with the lack of a well-designed review on this topic, reflect the importance of this article to the dermatologic literature as it emphasized the need for larger and better-designed studies on the use of lasers to treat GA.
Maranda and colleagues (2016) noted that facial verruca plana, or flat warts, are benign skin papillomas caused by human papillomavirus (HPV) infections. A large portion of cases are refractory to treatment and can cause psychosocial distress in patients. Laser and light modalities offer an alternative therapeutic approach that has not been extensively explored. These investigators systematically reviewed PubMed for studies describing treatment of facial verruca plana using lasers, photodynamic therapy (PDT) and infrared coagulation. Final inclusion and review of 18 studies suggested laser and light therapies to have considerable potential in the treatment of this recalcitrant condition. In particular, yttrium aluminum garnet lasers, infrared coagulation and photodynamic therapies have been reported to demonstrate efficacy. The authors concluded that further studies with larger power are needed to determine which method should be established as the alternative treatment of choice for recalcitrant facial verrucae.
Vachiramon and associates (2016) stated that keratosis pilaris (KP) is a common condition that can often be cosmetically disturbing. Topical treatments can be used with limited effectiveness. In a prospective, randomized, single-blinded, intra-individual, comparative study, these investigators evaluated the safety and effectiveness of fractional CO2 laser for the treatment of KP. This trial was conducted on adult patients with KP. A single session of fractional CO2 laser was performed to one side of arm whereas the contralateral side served as control. Patients were scheduled for follow-up at 4 and 12 weeks after treatment. Clinical improvement was graded subjectively by blinded dermatologists. Patients rated treatment satisfaction at the end of the study. A total of 20 patients completed the study. All patients stated that the laser treatment improved KP lesions. At 12-week follow-up, 30 % of lesions on the laser-treated side had moderate-to-good improvement according to physicians' global assessment (p = 0.02). Keratotic papules and hyper-pigmentation appeared to respond better than the erythematous component; 4 patients with Fitzpatrick skin type V developed transient pigmentary alteration. The authors concluded that fractional CO2 laser treatment may be offered to patients with KP; dark-skinned patients should be treated with special caution. They stated that further studies are needed to find the optimum parameter, appropriate frequency, and suitable treatment sessions of fractional CO2 laser for KP.
The main drawbacks of this study were the small sample size and the short follow-up time of 3 months. Thus, a conclusion cannot be drawn as to how long the laser effect would last and whether recurrence would occur. Moreover, these researchers did not count the actual keratotic lesions and skin roughness was inaccessible through the evaluation by 2D photography. Finally, this study was performed in Asian subjects with Fitzpatrick skin types III to V; hence, this laser setting cannot be applied to all skin types.
Miguel and colleagues (2017) stated that necrobiotic xanthogranuloma (NXG) is an uncommon non-Langerhans cell histiocytosis involving skin and extra-cutaneous tissues. The lesions are usually asymptomatic and commonly appear in the peri-orbital area. Paraproteinemia is closely associated with NXG and its pathogenesis remains unclear. NXG prognosis is poor with several treatments showing variable results. Treatment of monoclonal gammopathy with alkylating agents does not necessarily influence the activity of the skin disease and vice versa. These researchers summarized all reported treatments of NXG of the skin, with or without underlying malignant condition and based on articles from the PubMed database using the query 'necrobiotic xanthogranuloma treatment', both in English and German, about 'human' subjects and published between 1980 and 2014, documenting adequate treatment for NXG. Mainly individual case reports, small case series and retrospective studies were found. Therapeutic options include topical and systemic corticosteroids, thalidomide, high-dose intravenous immunoglobulin (IVIG), chlorambucil, cyclophosphamide, fludarabine, rituximab, melphalan, infliximab, interferon alpha, cladribine, hydroxychloroquine, azathioprine, methotrexate, laser therapy, radiotherapy, surgery, PUVA, plasmapheresis and extracorporeal photopheresis. The authors concluded that RCTS and studies on long-term outcomes after treatment were not found and are needed to focus on in the future.
Kraeva and colleagues (2016) noted that rhinophyma, a late complication of rosacea, is a chronic, progressive dermatological condition. The classic presentation of rhinophyma is nodular, thickened skin over the distal nose, and is often accompanied by underlying erythema secondary to inflammation. Due to the unpleasant esthetic and disfiguring appearance, rhinophyma may be associated with a significant negative psychosocial impact, resulting in decreased patient quality-of-life (QOL). Treatment of rhinophyma is challenging as topical and systemic pharmacotherapies have shown limited effectiveness. These investigators presented a case of a 39-year old African-American male with longstanding, mild rhinophyma, who was successfully treated with 2 sessions of fractionated CO2 laser. They also reviewed the medical literature on fractionated CO2 laser treatment of rhinophyma. To the best of their knowledge, this was the first report of successful treatment of rhinophyma using fractionated CO2 laser in an African-American man. The authors believed that fractionated CO2 laser may be a safe and effective treatment modality for rhinophyma in skin of color patients (Fitzpatrick IV to VI) and early intervention with fractionated CO2 laser to prevent rhinophyma worsening may yield better results than late intervention. These preliminary findings need to be validated by well-designed studies.
Shumaker and co-workers (2012) stated that skin compromised by traumatic scars and contractures can manifest decreased resistance to shearing and other forces, while increased tension and skin fragility contribute to chronic erosions and ulcerations. Chronic wounds possess inflammatory mediator profiles and other characteristics, such as the presence of biofilms, that can inhibit healing. These investigators reported the findings of 3 patients with multiple traumatic scars related to blast injuries who received a course of ablative fractional laser resurfacing (AFR) for potential mitigation of contractures, poor pliability, and textural irregularity. Patients also had chronic focal erosions or ulcerations despite professional wound care. All patients experienced incidental rapid healing of their chronic wounds within 2 weeks of their initial ablative fractional laser treatment. Healing was sustained throughout the treatment course and beyond and was associated with gradual enhancements in scar pliability, texture, durability, and range of motion. The authors concluded that the unique pattern of injury associated with ablative fractional laser treatment may have various potential wound-healing advantages. These advantages included the novel concept of photo-microdebridement, including biofilm disruption and the stimulation of de-novo growth factor secretion and collagen re-modeling. The authors concluded that If confirmed, traditional wound and scar treatment paradigms could shift toward earlier intervention with anticipated benefits in rehabilitation and a more favorable trajectory for wound healing. Moreover, they stated that prospective studies are needed to clarify any potential role for AFR as an adjunct to traditional wound management and in applications for the management of traumatic scars in general.
Basnett and associates (2015) noted that Leishmaniasis is a vector borne disease; its manifestations range from localized skin ulceration to lethal visceral disease. With increased global travel, cutaneous leishmaniasis (CL) is becoming more common in developed nations. However, current therapeutic options are limited. These investigators reported on the case of a 16-year old girl who presented with several non-tender, non-healing CL wounds on her bilateral upper and lower extremities; AFR was used in conjunction with topical paromomycin via laser-assisted delivery to treat the largest non-healing CL wound on the patient's distal lower extremity. Upon follow-up after 2 treatments with AFR, the patient's wound healed completely without evidence of infection and with minimal scarring. The authors concluded that AFR with laser-assisted delivery of topical paromomycin represents a novel therapeutic option for resistant, non-healing CL wounds. The technique may prove additionally useful for concurrent mitigation of scarring related to CL. These preliminary findings need to be validated by well-designed studies.
Phillips and colleagues (2015) stated that treating post-traumatic lower extremity wounds can be challenging, especially in elderly patients. Recently, the use of fractional carbon dioxide (CO2) laser has been shown to improve wound healing in scar-related wounds. These researchers used this treatment modality in post-traumatic wounds that were slow to heal in 3 elderly patients. Each wound underwent 1 fractional CO2 laser treatment. The wound base was treated at 30 mJ and 5 % density. The entire wound edge and 1 to 2 cm into the normal surrounding skin were treated at 50 mJ and 5 % density. One pass was completed at 150 Hz per treatment. Treatments were well-tolerated with only mild discomfort. Each wound healed by 60 % or greater within 3 weeks. No AEs were reported aside from mild and transient erythema at site of treatment. The authors concluded that fractional CO2 laser treatment appeared to accelerate healing in each of these post-traumatic wounds; it may be a helpful adjunct in non-healing post-traumatic wounds. Moreover, they stated that controlled studies are needed to further validate this modality as a 2nd-line treatment for difficult-to-heal lower-extremity wounds.
Krakowski and co-workers (2016) stated that AFR is an emerging therapy for chronic wounds. In a case-series study, these researchers reported the successful use of AFR to facilitate the healing of chronic wounds in 2 pediatric patients. These patients had chronic wounds within scars that were treated with a micro-fractionated CO2 laser in a single pass at a pulse energy of 50 mJ and a treatment density of 5 %; 1 patient had 1 treatment and the other had 2 treatments 1 month apart. Ablative fractional laser resurfacing led to rapid healing of chronic wounds in both patients. The wounds remained epithelialized after 9 months in 1 patient and 4 months in the other. There were no complications. The authors concluded that the combination of tolerability and efficacy observed in these cases introduced AFR as a potential promising adjunct to existing treatments for chronic, non-healing wounds in the pediatric population.
Ved at kortlægge en behandlingsplan i samråd med læge og lægehus får alle patienter den hjælp, de har brug for, for at kunne få bugt med deres symptomer på bedste vis
Der findes i dag intet lægemiddel, der helt helbreder psoriasis eller psoriasisartrit. Ved at kortlægge en behandlingsplan i samråd med læge og lægehus får alle patienter den hjælp, de har brug for, for at kunne få bugt med deres symptomer på bedste vis. Gennem en veltilpasset behandling har patienterne gode forudsætninger for et godt liv. Behandlingsmetoden kan variere kraftigt mellem mennesker, hvor psoriasis kan ytre sig i både mild og alvorlig grad. Ved at kigge på patientens almene helbredstilstand, sygdomsgraden og patientens alder, kan man finde den rette behandling. Det er vigtigt at søge lægehjælp, hvis man har vedvarende udslæt, der er tørre, røde og skaller af.
Psoriasis kommer i såkaldte anfald og indebærer, at der er perioder, hvor generne er værre og andre, hvor symptomerne er små. Psoriasispatienter lærer efter et stykke tid, hvordan deres krop fungerer og kan gennem dette lettere kortlægge, hvilke metoder, der hjælper bedst på generne. Hvis man for nyligt har fået diagnosen psoriasis, er det oftest ikke lige let at vide nøjagtigt hvilken behandlingsform, der passer en bedst. Det er derfor vigtigt at teste én behandlingsmetode ad gangen i en væsentlig tidsperiode for at se, om metoden hjælper.
Uafhængigt af graden af psoriasis er det grundlæggende for hver aktiv behandling at udslættene blødes op, så metoden får den bedste virkning. Ved regelmæssigt at anvende blødgørende cremer eller salver, bad eller sauna, løses udslættene op.
- – Receptpligtige cremer og salver
- – Lysbehandling (UVB- eller PUVA-behandling)
- – Indvortes behandling (tabletter, injektioner, drop)
- – Biologiske lægemidler
- – Bucky-behandling
Hvis man lider af en mildere form for psoriasis, kan det være tilstrækkeligt at fugte huden med almindelig fugtighedscreme og regelmæssigt at eksfoliere huden via bad eller sauna. Ved mere udtalt psoriasis skal man anvende salver eller cremer, der indeholder kortison og/eller D-vitamin. Når denne form for lokale alternativer ikke hjælper mod psoriasis, anbefales lysbehandling med ultraviolette stråler eller en kombination af lysbehandling og tabletform, PUVA-behandling, hvis lysbehandling alene ikke fungerer. Ved alvorlig psoriasis er indvortes behandling med tabletter eller injektioner et alternativ. Denne trappetrinsmodel anvendes for trinvist at finde alternativer, som fungerer for den respektive patient og ikke belaste kroppen unødigt. I en senere fase kan man gå tilbage til visse metoder og kombinere alternativer for at få den bedst mulige virkning og mindske eventuelle bivirkninger.
Receptpligtige cremer og salver fungerer for mange
De fleste mennesker, der får psoriasis, anvender receptpligtige cremer eller salver som eneste behandlingsmetode eller i kombination med andre alternativer. Udvortes behandling med cremer eller salver er den mest almindelige behandlingsmetode ved psoriasis. For at lindre generne skal man regelmæssigt smøre sig grundigt ind i de områder, hvor udslættet findes. For at lægemidlerne skal have den bedste virkning anbefales det regelmæssigt at bade eller anvende sauna for at afhjælpe afskalning.