The treatment of vitiligo has historically been a therapeutic challenge, and attempts to increase the efficacy of known monotherapies has led to the testing of various combination treatments. The 308-nm excimer lamp was first used to treat vitiligo in 2003, at which time it demonstrated clinical efficacy [13]. Since then, many trials have utilized the lamp for the treatment of vitiligo as monotherapy and as part of combination therapy regimens [14,15,16]. Different results have been reported in different ethnic populations. In our study, once-weekly excimer lamp treatments induced a 31.29% repigmentation percentage in 24 patches at 12 weeks posttreatment; over 87.5% of vitiligo lesions showed different degrees of repigmentation at 4–8 weeks after treatment initiation. Of the lesions treated with the excimer lamp only, mean initial repigmentation occurred at 6.6 treatment sessions, which was later than in those treated with the combination therapy. Combination therapies are therefore widely applied in clinical practice to increase the effectiveness of excimer phototherapy and reduce treatment time.
Fire needle therapy originated from traditional Chinese medicine and has been used for millennia as an alternative treatment for various diseases and maladies. In recent decades, fire needle therapy has been reported as a treatment of vitiligo and has achieved good results [17]. The mechanism of repigmentation is speculated to be related to the inflammation induced by fire needle therapy, which might stimulate the migration of melanocytes to the depigmented area [18,19,20,21]. However, the diameters of traditional fire needles are > 0.6 mm, which easily causes pain and scarring. The needle also needs to be burned in the flame of an alcohol burner lamp before puncture, which is time- and labour-consuming. If the operation is not performed carefully, there may be hidden risks of burns and fire. These drawbacks limit the applications of fire needles in vitiligo treatment.
The disadvantages of fire needle therapy inspired us to replace this method with electrocautery instruments. Electrocautery is driven by electric energy, and the needling tip can be instantly heated to high temperature and maintained at constant temperature, which makes it possible to puncture lesions continuously. This technological improvement gives EC needling many advantages over traditional fire needle therapy, such as less time intensive, easy to perform and lower costs. In addition, the finer needling tip reduces the pain caused by pricking and improves patient compliance. We have previously compared the effect of EC needling and traditional fire acupuncture in the treatment of vitiligo and found a similar efficacy in both therapies regarding the inducation of repigmentation (data not shown).
In our study, the efficacy of EC needling was comparable to that of the excimer lamp, with lesions treated with the excimer lamp and and those treated with EC needling achieving a similar repigmentation percentage (Fig. 2). However, the EC needling group required fewer treatment sessions than the excimer lamp group for initial repigmentation (Fig. 4), which indicates that EC needling was faster in terms of initiating repigmentation than the excimer lamp. Surprisingly, our data showed that the repigmentation percentage of vitiligo lesions in the combination group was significantly higher than that in the EC needling group (P = 0.027) or excimer lamp group (P = 0.005), and the number of treatments required for initial repigmentation was significantly lower in the combination group than in the excimer lamp group (P = 0.019). These results suggest that the combination treatment was more effective in initiating and achieving excellent repigmentation than excimer lamp monotherapy. In addition, combination therapy could reduce the side effects of excimer lamps, such as photosensitivity, photoaging and photocarcinogenesis.
We postulate that the mechanisms of repigmentation induced by excimer lamps following EC needling are as follows. The various types of cytokines and growth factors secreted during the wound healing process after EC needling therapy may play a role in mitosis in melanocytes. Recent studies have proposed that wounding induces melanocyte regeneration at the site of injury via the Wnt signalling pathway [22], and the migration of melanoblasts and melanocytes towards the site of injury has been observed under live imaging [20]. In addition, stimulation of hyperpigmentation by burn injury in response to inflammation has been reported [23]. However, the mechanisms involved in the increased effectiveness of excimer lamps when combined with EC needle therapy are still poorly understood, and further investigations are required.
Some of the patients in this study who were treated with EC needling experienced slight pain, burning sensations, erythema and crustation. However, all of these complications disappeared within 1 day, except for crustation, and this adverse effect usually disappeared within 1–2 weeks. Other complications, such as infection, scarring, the Koebner phenomenon, and the aggravation of vitiligo lesions, were not observed in this study. Despite encouraging results, additional studies are required in a larger series of patients to adapt the protocol and to confirm the results.
Limitations
This study was limited by the small population and was conducted in a non-blinded manner with a short-term follow-up period. Hence, further research should be carried out by using a long-term, double-blinded clinical trial with a larger sample size to confirm the advantage of the combination treatment over the excimer lamp as monotherapy.