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Fractional Photothermolysis for Treatment of Poikiloderma of Civatte

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Fractional Photothermolysis for Treatment of Poikiloderma of Civatte Fractional Photothermolysis for Treatment of Poikiloderma of Civatte Ãy Ãz DANIEL S. BEHROOZAN, MD, LEONARD H. GOLDBERG, MD, FRCP, Ã y ÃJ AORIENNE S. GLAICH, MD, TIANHONG DAI,PHD, AND PAUL M. FRIEDMAN,MD The author have indicated no significant interest with commercial supporters. oikiloderma of Civatte refers We report the successful treatment The treatment area was thor- Pto a change in the skin where of poikiloderma of Civatte on the oughly cleansed before the proce- there is atrophy, hyper- and neck using fractional photo- dure using a gentle, abrasive skin hypopigmentation, and dilation thermolysis. In contrast to selec- cleanser. OptiGuide Blue (Scho- of fine blood vessels (telangiect- tive photothermolysis, which aims lAR Chemistry, West Henrietta, asia).1,2 These alterations often to produce bulk thermal injury in NY, USA), an FDA-certified cause cosmetic disfigurement particular targets within the skin, water-soluble tint, was applied to most commonly in middle-aged or fractional photothermolysis cre- the treatment area to highlight the elderly women with a fair com- ates thousands of targeted micro- contours of the skin so as to allow plexion.1,2 Several treatment thermal treatment zones (MTZ) the Intelligent Optical Tracking modalities, based on the theory of and spares the surrounding tis- System to detect contact with the selective photothermolysis,3 in- sue.14,15 To the best of our skin and to adjust the treatment cluding argon lasers, potassium knowledge, this is the first re- pattern with respect to hand piece titanyl phosphate (KTP) lasers, ported case of fractional photo- velocity. Thirty percent topical pulsed dye lasers, and intense thermolysis for the treatment of lidocaine ointment was applied pulsed light devices, have been poikiloderma of Civatte. for 1 hour before treatment. A used to treat this condition in the single treatment with the 1,550 nm past.4–13 Clinical experience has wavelength Fraxels, SR laser shown that complete clearing is (Reliant Technologies Inc., Case Report difficult to achieve. Moreover, Mountain View, CA) at a pulse depending on the modality A 55-year-old Caucasian female energy of 8 mJ and a final density used, adverse effects such as scar- patient with Fitzpatrick type II of 2,000 MTZ/cm2 was per- ring with irregular hypopigmen- skin presented with a 3-year his- formed. During treatment, the tation, postinflammatory tory of poikiloderma of Civatte on patient noted mild pain, which hyperpigmentation, post- the neck that had previously been she described as thermal treatment purpura, mottled ap- untreated (Figure 1). The past in nature and which was allevi- pearance, crusting and erythema medical history was unremark- ated by a temporary pause in have been reported.4–13 Multiple able. The patient denied any per- treatment. Additionally, post- sessions with these treatments are sonal or family history of keloid operative edema was noted, usually necessary to obtain opti- formation, or recent isotretinoin which resolved within 24 hours. mal clearing.2,6,10 use. Follow-up results at 2 weeks ÃDermSurgery Associates, Houston, TX; yDivision of Dermatology, David Geffen School of Medicine at UCLA, Los Angeles, CA; zDepartment of Medicine (Dermatology), University of Texas, MD Anderson Cancer Center, Houston, TX; yDepartment of Bioengineering, Rice University, Houston, TX; JDepartment of Dermatology, University of Texas Medical School, Houston, TX & 2006 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing ISSN: 1076-0512 Dermatol Surg 2006;32:298–301 DOI: 10.1111/j.1524-4725.2006.32061.x 298 BEHROOZAN ET AL degree of satisfaction paralleled the physician’s assessment of improvement. A 2-month follow- up revealed persistence of im- provement (Figure 3). Discussion Ideally, an effective treatment of poikiloderma of Civatte improves both vascular and pigmentary components of the condition. In selective photothermolysis, visible laser irradiation is the choice for treatment, as both hemoglobin and melanin are targeted at these wavelengths.16 However, studies Figure 1. Poikiloderma of Civatte on the neck before treatment have shown that the therapeutic with fractional photothermolysis. outcomes are variable.4–13 The blue-green argon laser was revealed a significant clinical all texture of her neck based on the first laser system used for improvement in the degree of independent physician clinical as- treating poikiloderma of Civatte. erythema, dyschromia, and over- sessment (Figure 2). The patient’s Although it offered improvement, this treatment had significant side effects, most notably scarring.4,5 The 532 nm KTP laser introduced later was an improvement, although complicated by cases resulting in occasional hypopig- mentation.6 The advent of pulsed dye lasers emitting at 585–595 nm has lead to more effective and re- producible treatment of poikilo- derma of Civatte. However, post- treatment purpura may be en- countered and may last several days. Uncommonly, scarring and mottled hypopigmentation have also been reported.2,7–11 Intense pulsed light with a broad wave- Figure 2. Two weeks following a single treatment with eight length spectrum of 515–1,200 nm passes at a density of 250 MTZ/cm2 and a fluence of 8 mJ. Both an has most recently been success- independent physician evaluator and the patient reported a sig- nificant clinical improvement in the degree of erythema, fully utilized for the treatment dyschromia, and overall texture. of poikiloderma of Civatte; 32:2:FEBRUARY 2006 299 FRACTIONAL PHOTOTHERMOLYSIS FOR POIKILODERMA may induce scarring and hypo- pigmentation, is unlikely. This may especially be beneficial for the treatment of Fitzpatrick-type IV–VI individuals. Additionally, the ‘‘fractional’’ laser avoids bulk heating of the skin dermis, which is seen in conventional pulsed mid-infrared lasers. For a typical density of 2,000 MTZ/cm2 at 8 mJ, approximately 18% of the treated area is actually heated with fractional photothermolysis. This reduces the risk of irreversi- ble nonspecific thermal injury to Figure 3. Two-month follow-up photograph demonstrating per- the dermis, which may also result sistence of improvement following fractional photothermolysis. in scarring. By adjusting the opti- cal focal depth and/or the energy erythema, purpura, and crusting photothermolysis produces an of the laser, high local radiant have been described.12,13 array of microscopic regions of exposure can be achieved.14 thermal injury surrounded by un- Hence, different tissue compart- Incomplete clearing of poikilo- injured dermal tissue. This ‘‘frac- ments (e.g., blood vessels, dermal derma of Civatte is a result of tional’’ treatment was originally melanin, and sebaceous glands) at poor penetration of visible laser motivated by the faster wound various depths of the skin can be irradiation depth in blood. For healing response during skin re- arbitrarily selected as the targets example, the light penetration juvenation if the entire area were for photothermolysis. With an depths in blood at 532 and treated at once, a result of small appropriate MTZ density, an 585 nm wavelengths are approxi- injury regions and short migratory effective macroscopic treatment mately 37 (absorption coeffi- paths for keratinocytes.14 Recent can be achieved. cient 266 cmÀ1) and 52 mm clinical studies indicate that frac- (absorption coefficient tional photothermolysis is effec- There are two hypotheses as to 191 cmÀ1),17 while the tive in treating fine wrinkles, the targeting of dermal vascular ectatic blood vessels of poi- epidermal dyschromia, and re- structures. Fractional photo- kiloderma of Civatte are approx- modeling acne scars.18–24 How- thermolysis emits a wavelength imately 100 mm in diameter.12 As ever, no reports on the efficacy of that largely targets water. As wa- a result, large blood vessels can- this modality on the treatment of ter is a large component of blood not be completely coagulated, re- poikiloderma of Civatte have vessels, it seems logical to con- sulting in incomplete clearing of been described. clude that irradiance at 1,550 nm poikiloderma of Civatte. may lead to fractional photother- The 1,550 nm wavelength emitted mal microvascular destruction Unlike the modalities based on from the fractional photo- with clinical benefits. Secondly, selective photothermolysis, which thermolysis laser largely targets the microthermal zones of injury aim to achieve homogeneous tissue water and not melanin. in the dermis produced by this thermal injury in a particular tar- Therefore, nonspecific thermal device may randomly result in get within the skin, fractional injury to the epidermis, which frequent direct hits to the dermal 300 DERMATOLOGIC SURGERY BEHROOZAN ET AL vasculature. Laubach and collea- 2. Geronemus R. Poikiloderma of Civatte. tissue depths. Laser Surg Med gues25 recently reported histo- Arch Dermatol 1990;126:547–8. 2005;36:1–11. pathologic evidence of damage to 3. Anderson RR, Parrish JA. Selective pho- 16. Knappe V, Frank F, Rohde E. Principles tothermolysis: precise microsurgery by of lasers and biophotonic effects. Photo- dermal vasculature in patients selective absorption of pulsed dye laser. med Laser Surg 2004;22:411–7. Science 1983;220:524–7. undergoing fractional photo- 17. Van Gemert MJC, Welch AJ, Pickering thermolysis to support the latter 4. Goldman L, Bauman WE. Laser test JW, Tan OT. Laser treatment of port treatment for postsolar poikiloderma. wine stains. In: Welch AJ, van Gemert hypothesis. It is likely that Arch Dermatol 1984;120:578–9. MJC, eds Optical-thermal response of both hypotheses work synergis- laser-irradiated tissue. New York: 5. Oldbricht SM, Stern RS, Tang SV, Noe Plenum Press, 1995:789–830. tically to produce reduction in JM, Arndt KA. Complications of cuta- telangiectasias as seen in this neous laser surgery: a survey. Arch 18. Rokhsar CK, Tse Y, Fitzpatrick R. Frac- Dermatol 1987;123:345–9. tional photothermolysis on the treatment case report. of scars. Laser Surg Med 6. Batta K, Hinson C, Cotterill JA, Foulds 2005;362(S17):30. IS. Treatment of poikiloderma of Civatte The rapid improvement of the with potassium titanyl phosphate (KTP) 19.
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