Blast Off: Treatment of Seborrheic Keratoses with an Alexandrite 755-nm Laser After Color Enhancement Jaclyn Hess, MD,* Angela Macri, DO,** David George Jackson, PhD,*** Jonathan S. Crane, DO, FAAD, FAOCD****

*Dermatology Resident, PGY-2, New Hannover Regional Medical Center, Wilmington, NC **Dermatology Resident, PGY-2, OMNEE/Sampson Regional Medical Center, Clinton, NC ***Medical Student, 2nd year, University of Miami Miller School of Medicine, Miami, FL ****Dermatology Residency Program Director, OMNEE/Sampson Regional Medical Center, Clinton, NC; Dermatology Assistant Professor, Campbell University School of Osteopathic Medicine, Buies Creek, NC; Senior Attending, New Hanover Regional Medical Center, Wilmington, NC

Disclosures: None Correspondence: Angela Macri, DO; [email protected]

Abstract Seborrheic keratoses are common skin lesions affecting a majority of the population over 50 years old. Patients often present for removal of these lesions for cosmetic reasons. Many treatment modalities have been used in the past, including lasers, which have had only moderate success in removing SKs efficiently. In this case, we colored on several SKs with a black marker and then treated them with a 755-nm, long-pulsed alexandrite laser to remove them from the skin surface in a single session.

settings included a spot size of 18 mm, fluence of in the removal of SKs, particularly non-selective, Introduction 2 Seborrheic keratoses (SKs) are epidermal tumors 20 J/cm , and pulse duration of 3 ms. In all, 523 ablative lasers such as the erbium:YAG and CO2; derived from keratinocytes and consisting of pulses were used. however, adverse effects such as pain and hyper/ multiple histological subtypes. These benign hypopigmentation may occur, especially in patients After the treatment, the SKs formed superficial lesions are typically 0.5 cm to 1 cm in diameter, with darker skin. blisters and fell off within 10 days (Figure 4). round or oval and slightly elevated, with a “stuck 1 The patient experienced minimal pain during the Lasers work by targeting specific chromophores on” appearance. They often range in color from treatment and stated that it was tolerable. She in the skin that absorb the energy and convert yellow-tan to brown-black. Current literature applied double antibiotic ointment (polymyxin B/ it to heat, thereby destroying the lesion. This suggests these growths are more prevalent in the bacitracin topical) to the treated areas, and within process is called selective photothermolysis. The Caucasian population and that men and women are two weeks she noticed a dramatic improvement in major chromophores of the skin include melanin, equally affected. Elderly people are most frequently the appearance of the SKs. Several months later, hemoglobin, and water. Melanin, located in the affected by these lesions. Risk factors apart from old she was still thrilled with the improvement but epidermis, is the target chromophore in seborrheic age may include UV-light exposure and genetic started to see recurrence in some areas where the keratoses. It has an absorption spectrum of 600 nm predisposition, though the influence of these factors previous SKs had been. We believe this is most to 1100 nm. has yet to be determined. likely because she underwent only one treatment. The alexandrite laser has a wavelength of 755 nm Patients often seek removal of these lesions for 8 and therefore targets the melanin in SKs. Kim cosmetic reasons. Several treatments have been Discussion Although SKs do not spontaneously regress, they and colleagues treated 216 SKs with an alexandrite used to remove SKs, including liquid nitrogen, can be removed. Patients with large numbers of laser and observed marked improvement in most electrocautery, erbium:YAG laser, CO laser, 2 2 SKs will require many treatments, so it is important lesions. We found that treating the lesions with diclofenac gel, retinoic-acid microneedles, and 2-7 to choose a treatment that can be well-tolerated an alexandrite laser alone yielded unsatisfactory dermabrasion. Most modalities require many when used repeatedly. Lasers have been successful results, most likely due to insufficient pigment in treatments, often with unsatisfactory results. Our case shows that laser treatment preceded by application of black marker to the lesion can be an efficient means of SK removal. Case Report A 64-year-old white female presented to our office with many brown, verrucous, “stuck on”- appearing lesions located on the chest, back (Figure 1), abdomen, arms and legs, consistent with SKs. The lesions had been present for more than 10 years but had recently become irritated and pruritic after catching on her clothing. The lesions had been treated in the past with liquid nitrogen, but the patient had developed areas of Figure 1 Figure 3 hyperpigmentation from the treatment and was interested in other options. She had heard about lasers for the treatment of other skin conditions and wanted to know if a laser would be helpful in the treatment of SKs. Knowing that lasers target a specific chromophore to heat and destroy conditions of the skin, we postulated that if we colored the surface of SKs with a dark-colored marker, the laser would target that pigment and destroy the tissue.

We chose to treat the patient with a 755-nm alexandrite laser (Candela GentleLASE). Her SKs were colored in using a black permanent marker (Figure 2) before undergoing one round of treatment with the laser (Figure 3). Laser Figure 2 Figure 4

HESS, MACRI, JACKSON, CRANE the SKs. Coloring the lesions with a black marker References before treatment imparted more pigment, so the 1. Hafner C, Vogt T. Seborrheic keratosis. J Dtsch lesions absorbed more energy, and the SKs were Dermatol Ges. 2008 Aug;6(8):664-77. heated and destroyed more effectively. Side effects of treatment include crusting or hyperpigmentation 2. Kim YK, Kim DY, Lee SJ, Chung WS, Cho at the treatment site (our patient exhibited mild SB. Therapeutic efficacy of long-pulsed 755-nm erythema), but these side-effects typically resolve alexandrite laser for seborrheic keratoses. J Eur within one to two days (as was the case with our Acad Dermatol Venereol. 2014 Aug;28(8):1007-11. patient).2 Alexandrite lasers also typically cause less 8 scarring and hypopigmentation than cryosurgery 3. Apfelberg DB, Maser MR, Lash H, Rivers or ablative lasers. For our patient, treatment with JL. Progress report on extended clinical use of the the laser was more tolerable than cryosurgery. We argon laser for cutaneous lesions. Lasers Surg Med. have treated dozens of patients with this augmented 1980;1:71–83. technique in the past, with consistently satisfactory results. The recurrence of some of the SKs in this 4. Fitzpatrick RE, Goldman MP, Ruiz-Esparza case could have indicated that multiple treatments J. Laser treatment of benign pigmented lesions were needed in order to target the base of the lesion using a 300 nsecond pulse and 510 wavelength. J for complete clearance. We have also had success Dermatol Surg Oncol. 1993;19:341–7. using this method to treat warts that do not have dark areas in them. 5. Gurel MS, Aral BB. Effectiveness of erbium:YAG laser and cryosurgery in seborrheic Culbertson performed diode-laser ablation with keratoses: Randomized, prospective intraindividual red-marker color enhancement on 326 patients comparison study. J Dermatolog Treat. and 1,567 SKs and achieved complete resolution 2015;26:477-80. of 93% of the lesions.9 This is the only other documented report of using color enhancement 6. Aktaş H, Ergin C, and Keseroğlu HÖ. Diclofenac with a laser to treat SKs. To date, there are no gel may be a new treatment option for seborrheic reports of using color enhancement with an keratosis. Indian Dermatol Online J. 2016;7:211-2. alexandrite laser or with the application of black pigment to aid in energy absorption. 7. Hirobe S, Otsuka R, Iioka H, Quan YS, Kamiyama F, Asada H, Okada N, Nakagawa S. Conclusion Clinical study of a retinoic acid-loaded microneedle There are many ways to treat seborrheic keratoses. patch for seborrheic keratosis or senile lentigo. Life The 755-nm alexandrite laser is a valid method Sci. 2016;168:24-7. of removal, especially on non-pigmented lesions color-enhanced with black permanent marker. 8. Mehrabi D, Brodell RT. Use of the alexandrite This technique is a novel approach to treating laser for treatment of seborrheic keratoses. large numbers of typically difficult-to-eradicate Dermatol Surg. 2002;28:437–9. seborrheic keratoses. 9. Culbertson GR. 532-nm diode laser treatment of seborrheic keratoses with color enhancement. Dermatol Surg. 2008;34(4):525-8.

BLAST OFF: TREATMENT OF SEBORRHEIC KERATOSES WITH AN ALEXANDRITE 755-NM LASER AFTER COLOR ENHANCEMENT