Consensus on the safety and risks of laser and intense pulse light treatments in patients with vitiligo: An e-Delphi study

Laser and intense pulse light (IPL) treatments carry the risk of inducing new vitiligo lesions (Koebner phenomenon).1van Geel N. Speeckaert R. Mollet I. et al.In vivo vitiligo induction and therapy model: double-blind, randomized clinical trial.Pigment Cell Melanoma Res. 2012; 25: 57-65Crossref PubMed Scopus (32) Google Scholar This, combined with the paucity of literature available and the absence of guidelines, leads to a reluctance in dermatologists to perform laser or IPL treatments in patients with vitiligo.2Post N.F. Van Broekhoven N.X. Bekkenk M.W. Wolkerstorfer A. Laser- and intense pulsed light (IPL)-induced vitiligo patches: a systematic review of the literature - short report.Lasers Med Sci. 2022; 37: 3733-3737Crossref PubMed Scopus (2) Google Scholar,3Post NF, van Broekhoeven NX, Lommerts JE, et al. Expert opinion about laser and Intense Pulsed Light-induced vitiligo: a cross-sectional survey study. Arch Dermatol Res. Published online. Mar 25, 2023. https://doi.org/10.1007/s00403-023-02611-8Google Scholar Therefore, consensus is required to assist clinicians in their decision making. The primary aim of this study was to achieve a consensus-based guideline on how to use lasers and IPL safely in patients with vitiligo. Our secondary aim was to achieve a consensus on the prevention and treatment of laser/IPL-induced vitiligo. An e-Delphi study, with 51 items, was performed. The consensus was achieved when ≥70% of participants agreed with the item. From the 18 invited dermatologists, an international panel of 17 vitiligo experts from 12 countries participated in this e-Delphi study. All participants completed both e-Delphi rounds and 10 (58.9%) attended the online consensus meeting. A detailed description of the methods can be found in the Supplementary Material (available via Mendeley at https://data.mendeley.com/datasets/4t3f8rdvcm/4/files/35695162-cd45-461c-9f1e-405f74225b11). Thirty-two items reached consensus (62.8%) (Tables I and II). We agreed that every laser/IPL treatment, even in ideal circumstances, poses a risk of inducing vitiligo in predisposed patients. This risk should be discussed with the patient before the treatment. Moreover, the panelists agreed to withhold laser/IPL treatment from patients with vitiligo, unless there is stability for >1 year and no activity signs are present.Table I"Consensus in" of the laser and intense pulse light treatments in patients with vitiligo eDelphi study–questionnaire rounds I and II#ItemFirst round %Second round %1aReformulated: How strongly do you agree that a progressive, and persistent (without treatment) depigmentation (total loss of melanin pigment) that occurs within 3 mos at the site of laser treatment is defined as laser/IPL-induced vitiligo?N.A.88.22Please choose the statement that defines the right timeframe in which laser/IPL-induced vitiligo should occur? Laser-induced vitiligo occurs between 0-3 mos88.23When patients with vitiligo ask for a laser/IPL treatment, how strongly do you agree3bTo discuss the risks of inducing vitiligo?1003dTo base your advice on the aggressiveness of the laser/IPL treatment (ie, how high the risk of epidermal or dermal damage is)?82.33gTo treat when vitiligo is stable for at least 1 yr and no activity signs are present?52.976.63iReformulated: the absence of activity signs (Koebner phenomenon, pinpoint/confetti-like lesions, and hypochromic borders) reduces the risk of laser/IPL-induced vitiligo?70.63lThose patients who developed de-novo vitiligo after laser treatment should be considered as a total contraindication to continue any laser/IPL treatment of the skin?76.83 mTo perform a test spot in patients with vitiligo before extensive laser/IPL treatment?76.53nThat the decision for laser/IPL treatment should be on the basis of the severity of the treatment indication, the expected benefit of the treatment, and the risk for inducing vitiligo?94.15How strongly do you agree that:5aA recent (<12 mos) history of signs of the Koebner phenomenon is relevant to the risk of the laser/IPL treatment?82.35bHypochromic borders are relevant for the risk of the laser/IPL treatment?76.45cSigns of pinpoint/confetti such as depigmentation are relevant for the risk of the laser/IPL treatment?88.37How strongly do you agree that active vitiligo should be considered a contraindication to any laser/IPL treatment of the skin?82.48How strongly do you agree that the following criteria increase the likelihood of a patient developing laser/IPL -induced vitiligo?8k- ulcer/erosion after laser treatment88.28l- blister after laser treatment76.48 m- crust after laser treatment76.49If a new vitiligo spot occurs after a laser/IPL treatment, how strongly do you agree to start early intervention/treatment of the vitiligo?10010How strongly do you agree to treat laser/IPL-induced vitiligo similar to normal vitiligo?76.511How strongly do you agree to advice of preventive treatment (starting within 1 wk after laser treatment)11bTo prevent laser/IPL-induced vitiligo after a laser/IPL treatment with complications (such as blistering, crusting, ulceration, or erosion)?58.882.313Reformulated question: How strongly do you agree to treat laser/IPL- induced vitiligo with the following therapeutics?13atopical corticosteroids (nonfacial)82.313bTopical calcineurin inhibitors (facial)10013cNB–UV-B (extensive depigmentations)76.5Concensus in = ≥70% of participants agreed.IPL, Intense pulse light; NB, Narrowband-UVB. Open table in a new tab Table IIResults of the laser and intense pulse light treatments in patients with vitiligo in the e-Delphi study–consensus meeting∗Items in green font color indicate consensus reached. Items in red font color indicate no consensus was reached, and therefore, excluded.#Item% Yes, % No1When patients with vitiligo ask for a laser/IPL treatment, do you agree not to treat unless there is stability for >1 yr and no activity signs are present?100, -2Do you agree to distinguish between patients with preexisting vitiligo from de-novo depigmentation in the definition of laser/IPL-induced vitiligo?56, 443Every laser/IPL treatment, even in ideal circumstances, has a risk of inducing vitiligo patches.100, -IPL, Intense pulse light.∗ Items in green font color indicate consensus reached. Items in red font color indicate no consensus was reached, and therefore, excluded. Open table in a new tab Concensus in = ≥70% of participants agreed. IPL, Intense pulse light; NB, Narrowband-UVB. IPL, Intense pulse light. To minimize laser/IPL-induced vitiligo, a mixed approach is advised, and the experts emphasize that shared decision making is important. The clinician must consider the aggressiveness of the laser/IPL treatment, regarding the risk of causing epidermal damage as well as individual patient-related risk factors, including pinpoint/confetti, such as depigmentation; a recent (<12 months) history of the Koebner phenomenon; and hypochromic borders. Test spots in predisposed patients before extensive treatment can help reduce the risk of extensive laser/IPL-induced vitiligo and help establish appropriate individual laser settings. Participants agreed that posttreatment complications, such as ulcers/erosions, blisters, and crusts increase the risk. This is in line with previous research stating that epidermal damage increases the risk of developing vitiligo lesions at the treatment site.1van Geel N. Speeckaert R. Mollet I. et al.In vivo vitiligo induction and therapy model: double-blind, randomized clinical trial.Pigment Cell Melanoma Res. 2012; 25: 57-65Crossref PubMed Scopus (32) Google Scholar,3Post NF, van Broekhoeven NX, Lommerts JE, et al. Expert opinion about laser and Intense Pulsed Light-induced vitiligo: a cross-sectional survey study. Arch Dermatol Res. Published online. Mar 25, 2023. https://doi.org/10.1007/s00403-023-02611-8Google Scholar In agreement with general recommendations for vitiligo, the panelists recommend a Wood lamp examination before starting laser/IPL treatment in a vitiligo patient to detect timely possible vitiligo lesions and progression. Regarding treatment, the panelists advise dermatologists that laser/IPL-induced vitiligo should be treated similarly to normal vitiligo (topical steroids [nonfacial], topical calcineurin inhibitors [facial], Narrowband–UVB [extensive depigmentation]). Finally, preventive treatment (within 1 week after the laser/IPL treatment) should be started when complications such as blistering, crusting, ulceration, and erosion occur in a patient with vitiligo to prevent laser/IPL-induced vitiligo. These recommendations are expert-based and provided by dermatologists specialized in the field of vitiligo. They can be used as a guideline for clinicians to improve clinical care and decision making when treating patients with vitiligo with a laser/IPL or when laser/IPL-induced vitiligo occurs. None disclosed. We would like to extend our gratitude to the following vitiligo experts who participated in this e-Delphi study: Dr Michelle Rodrigues, Prof Dr Marwa Abdallah, Prof Dr Marcel Bekkenk, Dr Viktoria Eleftheriadouand Dr Samia Esmat, Prof Dr Khaled Ezzedine, Prof Dr Nanja van Geel, Dr Iltefat Hamzavi, Prof Dr Julien Seneschal, Prof Dr Giovanni Leone, Dr Jung Min Bae, Dr Amit G. Pandya, Prof Dr Thierry Passeronand, Dr Noufal Raboobee, Dr Caio César Silva de Castro, and Dr Steven Thng.