Lasers Med Sci (2012) 27:1103–1106
DOI 10.1007/s10103-012-1101-8
BRIEF REPORT
Low-level laser therapy on the treatment of oral
and cutaneous pemphigus vulgaris: case report
Eliana Maria Minicucci & Hélio Amante Miot &
Silvia Regina Catharino Sartori Barraviera &
Luciana Almeida-Lopes
Received: 6 December 2011 / Accepted: 11 April 2012 / Published online: 27 April 2012
# Springer-Verlag London Ltd 2012
Abstract Pemphigus vulgaris is a chronic autoimmune mu-
cocutaneous disease that initially is manifested by painful
intraoral erosions and ulcers which spread to other mucosa
and the skin, generally more than 5 months after oral lesion
manifestation. The treatment consists of prednisone alone or
in combination with an immunosuppressive agent, and the
clinical response is perceived within 2 to 4 weeks. Low-
level laser therapy has been effective in accelerating the
healing of injured tissue, thus inducing cell proliferation
and increasing ATP, nucleic acid, and collagen synthesis.
We reported two cases of pemphigus vulgaris that received
systemic treatment associated with low-level laser therapy
for oral and cutaneous lesions. We observed prompt analge-
sic effect in oral lesions and accelerated healing of oral and
cutaneous wounds. Therefore, the present report suggests
LLLT as a noninvasive technique that should be considered
as an adjuvant therapy in oral and skin disorders in patients
with PV.
Keywords Low-level laser therapy . Pemphigus . Wound
healing
E. M. Minicucci (*) : H. A. Miot : S. R. C. S. Barraviera
Department of Dermatology and Radiotherapy, Botucatu School of
Medicine of São Paulo State University–UNESP,
Distrito de Rubião Júnior s/n,
18 618-000 Botucatu, SP, Brazil
e-mail: eminicucci@hotmail.com
L. Almeida-Lopes
NUPEN–Research and Education
Center for Photo Therapy in Health Sciences,
São Paulo, Brazil
Introduction
Pemphigus is a group of rare, potentially life-threatening
autoimmune mucocutaneous diseases characterized by blis-
tering that affects stratified squamous epithelium and results
in cutaneous or mucosal blistering [1]. Though rare, pem-
phigus vulgaris (PV) is the most common disease in this
group and the one that usually affects the mouth. There are
less than 0.1–0.5 PV cases/100,000 individuals each year. It
occurs in both genders and primarily manifests in adults
during the fifth or sixth decade of life [2].
The etiology and pathogenesis of PV are not completely
elucidated; however, there is a reasonably strong genetic
background [3] in which ethnic groups such as Ashkenazi
Jews and populations from the Mediterranean and India are
particularly susceptible [4]. Human leukocyte antigens class
II alleles are also linked to PV [5].
PV is characterized by intra-epithelial blister formation
that results from breakdown of the cellular adhesion be-
tween epithelial cells or acantholysis [6]. PV usually affects
the mouth, on average 5 months before skin lesions develop.
Blisters, which rapidly lead to chronic and painful erosions
and ulcers [7], are seen mainly in the buccal mucosa, palate,
tongue ventrum, and lips [8]. The lesions cause discomfort
and difficulties in feeding, swallowing, and speaking. Lasers
have been used in therapy and diagnostics in many areas
such as surgery, oncology, physiotherapy, ophthalmology,
dentistry, dermatology, pain control, and biostimulation [9].
Wound healing and tissue repair are complex processes
that involve a dynamic series of events including clotting,
inflammation, granulation tissue formation, epithelization,
collagen synthesis, and tissue remodeling [10]. Low-level
laser therapy (LLLT), also known as photostimulation [11],
has been effective in accelerating the healing of injured
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Fig. 1 a Erosions in the tongue
ventrum and lip. b After 4 days
of LLLT
tissue [12], inducing cell proliferation [13] and increasing
the synthesis of ATP, nucleic acid, and collagen [14].
This report shows the effect of LLLT, expressed as
pain reduction and the healing of oral cutaneous ero-
sions in PV.
Case 1 A 46-year-old male was referred to the Department
of Dermatology with a 2-month history of painful
oral erosions. After this period, blisters appeared
on the skin. On intraoral exam, erosions were ob-
served in the buccal mucosa, tongue ventrum, and
lips. At skin examination, blisters and ulcers were
observed on the trunk, abdomen, and limbs.
Case 2 A 42-year-old male was referred to the Department
of Dermatology with a 4-month history of painful
oral erosions. After this period, the blisters appeared
on the skin. Intraoral exam revealed erosions in the
buccal mucosa, palate, tongue ventrum, and lips in
Fig. 1a. The skin examinations showed blisters and
ulcers on the trunk, abdomen, limbs, face, and head.
In both cases, the diagnosis of PV was made after evaluat-
ing the biopsy and direct immunofluorescence. The patients
received systemic therapy with prednisone and dapsone
diamino-diphenyl sulfone. To decrease oral pain and stimulate
oral and cutaneous-erosion healing, we proposed LLLT with
the diode laser—Flash Laser I DMC Equipamentos LTDA,
São Carlos, Brazil, emitting at 660 nm, 100 mW output power,
2 J per point, fluency of 35 J/cm2 per point, and time of 20 s
per point. The laser was applied uniformly by scanning three
to four points above and around each blister, and erosion
approximately 6 mm from the oral mucosa and skin was
observed. The LLLT was applied in all the oral erosions. In
the skin, before LLLT, the blisters were emptied with a sterile
Fig. 2 a Erosions in the skin. b
After 6 days of LLLT
Lasers Med Sci (2012) 27:1103–1106
insulin needle as shown in Fig. 2a. The laser treatment was
continued daily until oral healing and diminution of skin
lesions that occurred after seven and ten sessions, respectively,
as shown in Figs. 1b, 2b, and 3a, b.
In the diagnosis, the patients complained of difficulties in
feeding and swallowing caused by oral pain. They reported
an immediate decrease of approximately 70 % of oral pain
after the first laser therapy session when the patients
returned to feed. The total disappearance of oral pain was
observed after the third session.
In the first case, the patient is being followed for 3 years;
he is taking 5 mg prednisone/day, and there is no evidence
of disease until the time. In another case, after 7 months of
treatment, the patient had died of complication of immuno-
suppressive therapy.
Discussion
The vesiculobullous, erosive, or ulcerative oral lesions in
PV can be difficult to distinguish clinically from other
mucocutaneous diseases, so that delays in diagnosis are
common [15]. Oral ulcerating disorders are typically painful
causing important limitations. Pemphigus is a disease that
greatly affects quality of life of the patients [16]. In this
report, the diagnosis of PV was confirmed when the patients
arrived at the Department of Dermatology with skin lesions.
However, the first oral symptoms had been present at least
2 months prior to the examination.
The use of LLLT in the treatment of various disorders has
increased significantly during the last 10 years. We report
two cases of faster healing of LLLT-induced oral and skin
wounds in patients with PV.
Lasers Med Sci (2012) 27:1103–1106
Fig. 3 a Blisters were emptied.
b Blisters before LLLT
Studies of diabetic patients have demonstrated a beneficial
influence of laser light on wound healing. In vitro and in vivo
investigations have explored not only the molecular mecha-
nisms by which LLLT forms reactive oxygen species [17, 18];
activates enzymes, mainly ATPases [19]; stimulates calcium
and mitosis [20]; and augments formation of mRNA and
protein secretion [21], but also the mechanism by which this
type of phototherapy stimulates collagen production,
increases fibroblastic and keratinocyte proliferation and mo-
tility, capillary proliferation, and epithelization [12, 17, 22].
LLLT has been used successfully to impair microcircula-
tion and wound healing, especially in cases where tradition-
al treatments had previously failed [12, 22, 23]. Laser and
other light sources produced favorable results in the healing
of venous ulcers [24].
PV is potentially lethal, and its treatment requires maxi-
mum doses of systemic immunosuppressants to bring the
disease under control [25]. LLLT accelerated the healing of
oral lesions while the pain decreased considerably after the
first session so that the patients could return to normal
eating.
In the skin erosions, it was observed that when the
blisters were emptied with a sterile insulin needle before
LLLT, the lesions healed rapidly without ulcers. But when
the blisters spontaneously broke open, LLLT accelerated
scab formation and prolonged healing time, in relation to
punctured blisters.
The present report suggests LLLT as a noninvasive tech-
nique that should be considered as an adjuvant therapy in
oral and skin disorders in patients with PV.
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