THE CUTTING EDGE

SECTION EDITOR: GEORGE J. HRUZA, MD; ASSISTANT SECTION EDITORS: LYNN A. CORNELIUS, MD; JON STARR, MD Treatment of Faciale With the 585-nm Pulsed Dye Laser

Christie T. Ammirati, MD; George J. Hruza, MD; Division of Dermatology, Washington University School of Medicine, St Louis, Mo

The Cutting Edge: Challenges in Medical and Surgical Therapeutics

REPORT OF A CASE tasias of granuloma faciale suggested that it might be ame- nable to treatment with this laser. The lesion underwent 2 treatments, spaced 2 months 41-year-old white man with a long his- apart, with a flashlamp-pumped pulsed dye laser tory of acne rosacea was referred for (SPTL-1b; Candela Laser Corp, Wayland, Mass). A wave- evaluation of a persistent erythematous length emission of 585 nm and a pulse duration of 450 lesion on his nose. The lesion had been microseconds were used. The treatments were per- present for 2 years and had proved resis- formed with 5 mm minimally overlapping spots at 8.0 tantA to topical and oral antibiotic therapy. Examina- J/cm2 for the first treatment and 8.5 J/cm2 for the second tion of the patient’s face revealed malar erythema, scat- treatment. No anesthesia was needed and there was no tered acneiform papules, and an absence of significant postoperative discomfort. Follow-up 2 months comedones, consistent with mild acne rosacea. On the after the second pulsed dye laser treatment (Figure 2) dorsum of the nose, there was a discrete 2-cm, and at 6 years (Figure 3) confirmed clinical eradica- reddish-brown, indurated plaque with prominent tel- tion of the lesion without scarring or pigmentary change. angiectasias (Figure 1). The clinical differential diag- nosis included granuloma faciale, , and dis- COMMENT coid . Histopathologic findings were consistent with granuloma faciale and revealed a The term granuloma faciale was first coined by Pinkus2 in mixed infiltrate in the papillary and reticular dermis 1952. Formerly, this rare cutaneous disorder had been composed of neutrophils, eosinophils, plasma cells, called of the skin. While granu- lymphocytes, and monocytes. There was an overlying loma faciale has been reported in children and adult wom- Grenz zone noted, as well as associated leukocytoclas- en,3 the typical patient is a middle-aged white man. Clini- tic . cally, granuloma faciale presents as a reddish-brown or violaceous plaque on the face, often with follicular accen- THERAPEUTIC CHALLENGE tuation and superficial telangiectasias. The sites of predi- lection are the sides (30%) and tip (7%) of the nose, pre- auricular area (22%), cheeks (22%), forehead (15%), tip Granuloma faciale is a benign granulomatous process that of the nose (7%), and helix of the ear (4%).4 Extrafacial is frequently resistant to therapy. Multiple medical and granuloma faciale has also been reported but is rare.5,6 The surgical modalities have been suggested, but none have clinical differential diagnosis includes sarcoidosis, dis- been consistently efficacious. The prominent facial lo- coid lupus erythematosus, lymphocytic infiltrate of Jess- cation of this lesion required that the posttreatment re- ner, polymorphous light eruption, rosacea, lymphoma cuffs, sidual be cosmetically acceptable as well. Our challenge histiocytosis X, erythema elevatum diutinum, infectious was to treat this patient’s persistent and disfiguring le- granuloma, and basal cell carcinoma.7-10 Histologically, sion effectively, yet minimize the risk for scarring, dys- granuloma faciale displays a dense polymorphous infil- pigmentation, or systemic adverse effects. trate of the upper two thirds of the dermis. Eosinophils may be present but are not essential for diagnosis. There SOLUTION is sparing of the , with a notable Grenz zone and a leukocytoclastic vasculitis in the upper dermis.11 The 585-nm pulsed dye laser is the treatment of choice Response to therapy is variable. Medical modalities for a variety of vascular lesions.1 It uses the concept of that have been proposed include colchicine,12 dap- selective photothermolysis to target the oxyhemoglobin sone,13-16 antimalarials,7,17 gold injections,4 isoniazid,4,12 clo- within blood vessels, while minimizing collateral dam- fazimine,18,19 topical psoralen with UV-A,20 and cortico- age. The reddish-brown color and prominent telangiec- steroids in topical,14,17 intralesional,3,7,17,21 and systemic

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Figure 1. Pretreatment appearance of granuloma faciale on the dorsum of Figure 3. No clinical recurrence of granuloma faciale at 6-year follow-up. the nose. Note interim progression of underlying rhinophyma.

fective for the selective destruction of vascular lesions, especially pediatric port-wine stains,29,30 superficial hem- angiomas,30 and telangiectasias.31 Its unsurpassed safety profile and efficacy are attributable to its ability to achieve selective photothermolysis.32-34 The 585-nm pulsed dye laser emits energy that is strongly absorbed by oxyhe- moglobin, and its 450-microsecond pulse duration is shorter than the 1- to 5-microsecond thermal relaxation time of blood vessels 50 to 100 µm in diameter.35 In the case presented herein, the lesion had a dis- tinct reddish-brown hue and prominent telangiectasias, which suggested that it might respond to the 585-nm pulsed dye laser. The result was persistent clinical eradication of the lesion without evidence of scarring or pigment change at the 6-year follow-up. Since the time that our patient was Figure 2. Clinical resolution 2 months after the second 585-nm pulsed dye laser treatment. treated, the short-pulsed or scanned carbon dioxide and erbium:YAG lasers for skin resurfacing have been added forms.4,7,12 None of them have been consistently effective, to the surgeon’s armamentarium. It is our belief that these and a large proportion of them have substantial well- lasers, with their precise depth control, may also provide known adverse effects, such as hemorrhagic gastroenteri- safe and effective treatment options for granuloma fa- tis, blood dyscrasias, oculotoxicity, nephrotoxicity, pe- ciale. Further studies will be needed to confirm this. ripheral neuropathy, skin discoloration, actinic damage, In summary, we report a case of granuloma faciale , and adrenal suppression.22 Surgical treatments on the nose of a white man that was successfully treated have included wide excision,2,20 cryotherapy,23-25 radia- by the 585-nm pulsed dye laser. Because of the nonin- tion,4,7,21 electrodesiccation with and without curettage,4 vasive nature of this laser, there was minimal postopera- and dermabrasion.4,26 These modalities have been used with tive discomfort and no complicated wound care. Persis- varying degrees of success, and all pose a significant risk tent clinical eradication for 6 years was achieved without for permanent pigmentary changes and scarring. scarring, permanent pigmentary alteration, or systemic One of the first lasers used to treat granuloma fa- morbidity. The 585-nm pulsed dye laser provided safe ciale was the carbon dioxide laser. This infrared laser va- and effective treatment for this often-resistant lesion and porizes tissues in a nonselective manner and has the warrants further investigation on a larger scale. associated risks of hypopigmentation and scarring. Whee- land et al27 reported the successful treatment of granu- REFERENCES loma faciale with this laser. Other investigators, how- ever, were unable to reproduce their results. In a side- 1. Ross BS, Levine V J, Ashinoff R. Laser treatment of acquired vascular lesions. by-side comparison of electrosurgery, carbon dioxide laser, Dermatol Clin. 1997;15:385-396. and dermabrasion, Dinehart et al28 noted a recurrence in 2. Pinkus H. Granuloma faciale. Dermatologica. 1952;105-85-99. 3. Pedace FJ, Perry HO. Granuloma faciale: a clinical and histopathologic review. all 3 sites at 1 year. Also, the argon laser was thought to Arch Dermatol. 1966;94:387-396. be a promising treatment for granuloma faciale. Apfel- 4. Johnson WC, Higdon RS, Helwig EB. Granuloma faciale. Arch Dermatol. 1959; berg et al12 reported total and complete resolution of 79:42-52. granuloma faciale with the argon laser, but their treat- 5. Sears JK, Gitter DG, Stone MS. Extrafacial granuloma faciale. Arch Dermatol. 1991; 127:742-743. ment was complicated by a white collagenous . 6. Rusin L J, Dubin HV, Taylor WB. Disseminated granuloma faciale. Arch Derma- The pulsed dye laser, with a wavelength of 585 nm tol. 1976;121:1575-1577. and a pulse duration of 450 microseconds, is highly ef- 7. Black Cl. Granuloma faciale. Cutis. 1977;20:66-68.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 8. Horn T. Long-standing erythematous facial plaques: granuloma faciale. Arch Der- of different treatment modalities. Arch Otolaryngol Head Neck Surg. 1990;116: matol. 1985;121:1553-1554, 1556-1557. 849-851. 9. Phillips DK, Hymes SR. Recurrent facial plaques following full-thickness graft- 29. Levine V J, Geronemus RG. Adverse effects associated with the 577 and 585 ing: granuloma faciale. Arch Dermatol. 1992;130:1433-1434, 1436-1437. nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: a 10. Kolbusz RV, Pearson RW. Solitary plaque on the cheek: granuloma faciale. Arch study of 500 patients. J Am Acad Dermatol. 1995;32:613-617. Dermatol. 1993;129:634-635, 637. 30. Garden JM, Geronemus RG. Dermatologic laser surgery. J Dermatol Surg On- 11. Mehregan A, Hashimoto K, Mehregan D. Pinkus’ Guide to Dermatohistopathol- col. 1990;16:156-168. ogy. 6th ed. East Norwalk, Conn: Appleton & Lange; 1995:239-240. 31. Polla LL, Tan OT, Garden JM, Parrish JA. Tunable pulsed dye laser for the treat- 12. Apfelberg DB, Druker D, Maser M, Lash H, Spence B Jr, Deneau D. Granuloma ment of benign cutaneous vascular ectasia. Dermatologica. 1987;174:11-17. faciale: treatment with the argon laser. Arch Dermatol. 1983;119:573-576. 32. Tan OT, Sherwood K, Gilchrest BA. Treatment of children with port wine stains 13. Anderson CR. Dapsone in granuloma faciale. Lancet. 1975;1:642. using the flashlamp-pulsed dye laser. N Engl J Med. 1989;320:416-421. 14. Goldner R, Sina B. Granuloma faciale: the role of dapsone and prior irradiation 33. Badow RJ, Walker NPJ, Markey AC. Treatment of proliferative hemangioma with on the cause of the disease. Cutis. 1984;33:478-480. the 585 nm pulsed dye laser. Br J Dermatol. 1996;134:700-704. 15. Guill MA, Aton JK. Facial granuloma responsive to dapsone therapy. Arch Der- 33. Geronemus RG. Pulsed dye laser treatment of vascular lesions in children. J Der- matol. 1982;118:332-335. matol Surg Oncol. 1993;19:303-309. 16. van de Kerkhof PCM. On the efficacy of dapsone in granuloma faciale. Acta Derm 34. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by Venereol. 1994;74:61-62. selective absorption of pulsed radiation. Science. 1983;220:524-527. 17. Brown M. Granuloma faciale. Arch Dermatol. 1974;110:477-478. 18. Jacyk WK. Facial granuloma in a patient treated with clofazimine. Arch Derma- tol. 1981;117:597-598. 19. Wollina U, Karte K, Geyer A, Stuhlert A, Bocker T. Clofazimine in inflammatory Submissions facial dermatosis: granuloma faciale and lipogranulomatosis subcutanea (Rothman- Makai). Acta Derm Venereol. 1996;76:77-79. 20. Hudson LD. Granuloma faciale: treatment with topical psoralen and UVA. JAm Clinicians, local and regional societies, residents, and fel- Acad Dermatol. 1983;8:559. lows are invited to submit cases of challenges in man- 21. Arundell FD, Burdick KH. Granuloma faciale treated with intradermal dexameth- agement and therapeutics to this section. Cases should asone. Arch Dermatol. 1960;82:437-441. follow the established pattern. Submit 4 double-spaced 22. Wolverton SE, Wilkin JK. Systemic Drugs for Skin Diseases. Philadelphia, Pa: copies of the manuscript with right margins nonjusti- WB Saunders Co;1991. fied and 4 sets of the illustrations. Photomicrographs and 23. Graham GF, Stewart R. Cryosurgery for unusual cutaneous neoplasms. J Der- illustrations must be clear and submitted as positive color matol Surg Oncol. 1977;3:437-442. transparencies (35-mm slides) or black-and-white prints. 24. Franks, AG. Diagnosis: facial granuloma with eosinophils. Arch Dermatol. 1960; 82:1019-1020. Do not submit color prints unless accompanied by origi- 25. Zacarain SA. Cryosurgery effective for granuloma faciale. J Dermatol Surg On- nal transparencies. Material should be accompanied by col. 1985;11:11-13. the required copyright transfer statement, as noted in “In- 26. Bergfeld WF, Scholes HT, Roenigk HH. Granuloma faciale: treatment by der- structions for Authors.” Material for this section should mabrasion: report of a case. Clev Clin Q. 1970;37:215-218. be submitted to George J. Hruza, MD, Director, 14377 27. Wheeland RG, Ashley JR, Smith D, Ellis D, Wheeland D. Carbon dioxide laser Woodlake Dr, Suite 111, St Louis, MO 63017. treatment of granuloma faciale. J Dermatol Surg Oncol. 1984;10:730-732. 28. Dinehart SM, Gross DJ, Davis CM, Herzberg AJ. Granuloma faciale: comparison

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