Journal of Cosmetic and Laser Therapy, 2014; Early Online: 1–3
CASE REPORT
A case of solitary angiokeratoma successfully treated with a 1064-nm long-pulsed Nd:YAG laser Zekayı Kutlubay1, GÖkhan GÖkler2, Murat KÜÇÜktas¸3, Burhan Engİn1 & Server Serdaroglu1 J Cosmet Laser Ther Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
1Department
of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey, 2Private Working Dermatologist, Istanbul, Turkey, and 3Private Working Dermatologist, Bursa, Turkey Abstract Angiokeratomas are vascular malformations that are clinically or histologically verrucous, with superficial vessels just beneath the epidermis. Solitary angiokeratomas occur most commonly as a small, warty, black papule on the lower extremities. Various therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy, may be used for their treatment. A 13-year-old girl presented to the laser clinic for the treatment of her lesions that were present for two months. A 1064-nm long-pulsed Nd:YAG (yttrium aluminium garnet) laser was used to treat the patient’s lesions. We performed two laser treatment sessions at a 4-week interval. We saw the patient 1 month after the last treatment session and obtained successful cosmetically acceptable results. No recurrence was observed over a follow-up period of 3 months. Long-pulsed Nd:YAG laser is more effective for the treatment of hyperkeratotic angiokeratomas due to deeper skin penetration of laser. Long-pulsed Nd:YAG laser is an effective and safe therapeutic option for the treatment of solitary angiokeratomas. Key Words: long-pulsed Nd:YAG laser, solitary angiokeratomas
Angiokeratomas are vascular malformations that exhibit reactive hyperplasia and are clinically or histologically verrucous, with superficial vessels just beneath the epidermis. The five clinical variants of angiokeratomas have been demonstrated as follows: (1) solitary and multiple, (2) circumscriptum, (3) Fordyce, (4) Mibelli, and (5) corporis diffusum. Solitary angiokeratomas occur most commonly as a small, warty, black papule on the lower extremities, but may occur anywhere on the body. The lesions are thought to result from injury/trauma to or chronic irritation of the wall of a venule in the papillary dermis. Solitary lesion may be confused with melanoma due to their dark color. Dermoscopy will readily distinguish these two entities. Histopathology of angiokeratoma reveals marked dilatation of the papillary dermal vessels congested with erythrocytes from large lacunae only in the papillary dermis. It is seen in association with an acanthotic, variably hyperkeratotic epidermis. Elongated rete ridges may partially or completely enclose vascular
channels, and a collarette may be present at the margin of the lesions (1,2). The pathophysiology of angiokeratomas remains unknown, although it has been proposed that an increase in venous pressure may contribute to their formation. In differential diagnosis; angiokeratomas should be distinguished from hemangiomas, papular spider angiomas, pyogenic granulomas, eruptive angiomas, hereditary hemorrhagic telangectasia, melanoma, molluscum contagiosum, warts, and other human papilloma virus (HPV) infections. Many therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy may be used for the treatment of angiokeratomas (3,4).
Case report A 13-year-old girl was admitted to our outpatient clinic for the treatment of her lesions that were present for 2 months. Her medical history was
Correspondence: Zekayi Kutlubay, MD, Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafa Pasa, Fatih, 34098 Istanbul, Turkey. Tel: 00902124143000-21546. E-mail: [email protected] (Received 25 July 2014; accepted 16 September 2014) ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd. DOI: 10.3109/14764172.2014.968585
MCLT_A_968585.indd 1
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Z. Kutlubay et al.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
2
Figure 1. Lesion before the laser treatment. Figure 3. Four weeks after the second laser session.
unremarkable and her systemic examination was normal. Dermatological examination showed an itchy, intermittently bleeding, red-purple-colored medium-sized papules in front of her right upper leg (Figure 1). The diagnosis was based on clinical findings and dermoscopic examination. The patient was admitted to our department without any prior treatment. A 1064-nm long-pulsed Nd:YAG laser (Cutera Altus®) was used to treat the patient’s lesions. We used a handpiece with contact cooling spot size: 3–5 mm, energy: 80–130 J/cm2, and pulse duration: 10–20 ms. Totally, we performed two laser treatment sessions at a 4-week interval. We observed the patient 1 month after the last treatment session and obtained successful cosmetically acceptable results (Figures 2 and 3). No recurrence was observed over a follow-up period of 3 months.
Figure 2. Four weeks after the first laser treatment session.
MCLT_A_968585.indd 2
Discussion Treatment of angiokeratomas is usually performed for cosmetic purposes. Many therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy, may be used for the treatment of angiokeratomas. Excision may not be suitable for large lesions. Cryotherapy and electrocoagulation may lead to residual hypo- or hyperpigmentation and scarring (3). Various laser systems have been used for the treatment of angiokeratomas. Angiokeratoma cases treated with different lasers were reported in the literature as clinical trials or case reports. Those reported lasers including carbondioxide laser (5), 578-nm copper vapor laser (6), long-pulsed Nd:YAG laser (7,8), 940-nm diode laser (9), 585-nm pulsed dye laser (10,11), and combined erbium:YAG and 532-nm Potassium titanyl phosphate (KTP) laser (12). Usually, the pulsed dye lasers were used for the treatment of vascular disorders, although they had limited depth of penetration and did not usually completely cure or remove the lesion. Long-pulsed Nd:YAG laser is more effective for the treatment of hyperkeratotic angiokeratomas due to deeper skin penetration of laser beam. In the treatment of these lesions, the Nd:YAG laser may provide an advantage over the pulsed dye laser (10,13). Long-pulsed Nd:YAG laser systems allow the delivery of a macropulse consisting of a series of synchronized minipulses. The macropulses vary depending on the size and depth of vascular structures. The laser emits a beam having wavelength of 1.064 nm, which penetrates into large vascular
10/15/2014 2:51:36 PM
Solitary angiokeratoma
structures and causes minimal damage to the surrounding tissue (14). The long-pulsed Nd:YAG laser is a highly effective treatment modality for solitary angiokeratomas. In general, a two-session treatment is enough for complete improvement of solitary lesions. We propose that long-pulsed Nd:YAG laser is an effective and safe therapeutic option for the treatment of solitary angiokeratomas.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. References 1. Hohenleutner H. Malformations of vessels, fat, and connective tissue. In: Burgdorf WHC, Plewig G, Wolff HH, Landthaler M, editors. Braun-Falco’s dermatology. 3rd ed. Heidelberg: Springer; 2009. p. 798–799. 2. Detmar M, Hirakawa S. Vascular biology. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Bolognia dermatology’s. 2nd ed. London: Mosby Elsevier; 2008. p.1623–1624. 3. Schiller P, Itin P. Angiokeratomas: an update. Dermatology. 1996;193:275–282. 4. Larralde MM, Luna PC. Fabry disease. In: Wolff K, Goldsmith LA, Katz SI, Gilhrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s dermatology in general medicine. 7th ed. New York: McGraw Hill; 2008. p. 1285.
MCLT_A_968585.indd 3
3
5. Del Pozo J, Fonseca E. Angiokeratoma circumscriptum naeviforme: successful treatment with carbon-dioxide laser vaporization. Dermatol Surg. 2005;31:232–236. 6. Lapins J, Emtestam L, Marcusson JA. Angiokeratomas in Fabry’s disease and Fordyce disease: successful treatment with Copper vapour laser. Acta Derm Venereol. 1993;73:133–135. 7. Sommer S, Merchant WJ, Sheehan-Dare R. Severe predominantly acral variant of angiokeratoma of Mibelli: response to longe-pulse Nd:YAG (1064 nm) laser treatment. J Am Acad Dermatol. 2001;45:764–766. 8. Civaş E, Koç E, Aksoy B, Aksoy HM. Report of two angiokeratoma of Fordyce cases treated with a 1064 nm long-pulsed Nd:YAG laser. Photodermatol Photoimmunol Photomed. 2009;25:166–168. 9. Meissner M, Kaufmann R. Therapy for angiokeratoma of Fordyce with the 940-nm diode laser. Aktuelle Urol. 2012;43:121–122. 10. Lapidoth M, Ad-El D, David M, Azaria R. Treatment of angiokeratoma of Fordyce with pulsed dye laser. Dermatol Surg. 2006;32:1147–1150. 11. Oni G, Mahaffey P. Treatment of angiokeratoma of the vulva with pulsed dye laser therapy. J Cosmet Laser Ther. 2010; 12:51–52. 12. Bechara FG, Jansen T, Wilmert M, Altmeyer P, Hoffmann K. Angiokeratoma Fordyce of the glans penis: combined treatment with erbium:YAG and 532 nm KTP (frequency doubled neodmyium: YAG) laser. J Dermatol. 2004;31:943–945. 13. Ozdemir M, Baysal I, Engin B, Ozdemir S. Treatment of angiokeratoma of Fordyce with long-pulse neodymium-doped yttrium aluminium garnet laser. Dermatol Surg. 2009;35:92–97. 14. Landthaler M, Hohenleutner U. Laser therapy of vascular lesions. Photodermatol Photoimmunol Photomed. 2006;22: 324–332.
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CASE REPORT
A case of solitary angiokeratoma successfully treated with a 1064-nm long-pulsed Nd:YAG laser Zekayı Kutlubay1, GÖkhan GÖkler2, Murat KÜÇÜktas¸3, Burhan Engİn1 & Server Serdaroglu1 J Cosmet Laser Ther Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
1Department
of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey, 2Private Working Dermatologist, Istanbul, Turkey, and 3Private Working Dermatologist, Bursa, Turkey Abstract Angiokeratomas are vascular malformations that are clinically or histologically verrucous, with superficial vessels just beneath the epidermis. Solitary angiokeratomas occur most commonly as a small, warty, black papule on the lower extremities. Various therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy, may be used for their treatment. A 13-year-old girl presented to the laser clinic for the treatment of her lesions that were present for two months. A 1064-nm long-pulsed Nd:YAG (yttrium aluminium garnet) laser was used to treat the patient’s lesions. We performed two laser treatment sessions at a 4-week interval. We saw the patient 1 month after the last treatment session and obtained successful cosmetically acceptable results. No recurrence was observed over a follow-up period of 3 months. Long-pulsed Nd:YAG laser is more effective for the treatment of hyperkeratotic angiokeratomas due to deeper skin penetration of laser. Long-pulsed Nd:YAG laser is an effective and safe therapeutic option for the treatment of solitary angiokeratomas. Key Words: long-pulsed Nd:YAG laser, solitary angiokeratomas
Angiokeratomas are vascular malformations that exhibit reactive hyperplasia and are clinically or histologically verrucous, with superficial vessels just beneath the epidermis. The five clinical variants of angiokeratomas have been demonstrated as follows: (1) solitary and multiple, (2) circumscriptum, (3) Fordyce, (4) Mibelli, and (5) corporis diffusum. Solitary angiokeratomas occur most commonly as a small, warty, black papule on the lower extremities, but may occur anywhere on the body. The lesions are thought to result from injury/trauma to or chronic irritation of the wall of a venule in the papillary dermis. Solitary lesion may be confused with melanoma due to their dark color. Dermoscopy will readily distinguish these two entities. Histopathology of angiokeratoma reveals marked dilatation of the papillary dermal vessels congested with erythrocytes from large lacunae only in the papillary dermis. It is seen in association with an acanthotic, variably hyperkeratotic epidermis. Elongated rete ridges may partially or completely enclose vascular
channels, and a collarette may be present at the margin of the lesions (1,2). The pathophysiology of angiokeratomas remains unknown, although it has been proposed that an increase in venous pressure may contribute to their formation. In differential diagnosis; angiokeratomas should be distinguished from hemangiomas, papular spider angiomas, pyogenic granulomas, eruptive angiomas, hereditary hemorrhagic telangectasia, melanoma, molluscum contagiosum, warts, and other human papilloma virus (HPV) infections. Many therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy may be used for the treatment of angiokeratomas (3,4).
Case report A 13-year-old girl was admitted to our outpatient clinic for the treatment of her lesions that were present for 2 months. Her medical history was
Correspondence: Zekayi Kutlubay, MD, Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafa Pasa, Fatih, 34098 Istanbul, Turkey. Tel: 00902124143000-21546. E-mail: [email protected] (Received 25 July 2014; accepted 16 September 2014) ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd. DOI: 10.3109/14764172.2014.968585
MCLT_A_968585.indd 1
10/15/2014 2:51:35 PM
Z. Kutlubay et al.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
2
Figure 1. Lesion before the laser treatment. Figure 3. Four weeks after the second laser session.
unremarkable and her systemic examination was normal. Dermatological examination showed an itchy, intermittently bleeding, red-purple-colored medium-sized papules in front of her right upper leg (Figure 1). The diagnosis was based on clinical findings and dermoscopic examination. The patient was admitted to our department without any prior treatment. A 1064-nm long-pulsed Nd:YAG laser (Cutera Altus®) was used to treat the patient’s lesions. We used a handpiece with contact cooling spot size: 3–5 mm, energy: 80–130 J/cm2, and pulse duration: 10–20 ms. Totally, we performed two laser treatment sessions at a 4-week interval. We observed the patient 1 month after the last treatment session and obtained successful cosmetically acceptable results (Figures 2 and 3). No recurrence was observed over a follow-up period of 3 months.
Figure 2. Four weeks after the first laser treatment session.
MCLT_A_968585.indd 2
Discussion Treatment of angiokeratomas is usually performed for cosmetic purposes. Many therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy, may be used for the treatment of angiokeratomas. Excision may not be suitable for large lesions. Cryotherapy and electrocoagulation may lead to residual hypo- or hyperpigmentation and scarring (3). Various laser systems have been used for the treatment of angiokeratomas. Angiokeratoma cases treated with different lasers were reported in the literature as clinical trials or case reports. Those reported lasers including carbondioxide laser (5), 578-nm copper vapor laser (6), long-pulsed Nd:YAG laser (7,8), 940-nm diode laser (9), 585-nm pulsed dye laser (10,11), and combined erbium:YAG and 532-nm Potassium titanyl phosphate (KTP) laser (12). Usually, the pulsed dye lasers were used for the treatment of vascular disorders, although they had limited depth of penetration and did not usually completely cure or remove the lesion. Long-pulsed Nd:YAG laser is more effective for the treatment of hyperkeratotic angiokeratomas due to deeper skin penetration of laser beam. In the treatment of these lesions, the Nd:YAG laser may provide an advantage over the pulsed dye laser (10,13). Long-pulsed Nd:YAG laser systems allow the delivery of a macropulse consisting of a series of synchronized minipulses. The macropulses vary depending on the size and depth of vascular structures. The laser emits a beam having wavelength of 1.064 nm, which penetrates into large vascular
10/15/2014 2:51:36 PM
Solitary angiokeratoma
structures and causes minimal damage to the surrounding tissue (14). The long-pulsed Nd:YAG laser is a highly effective treatment modality for solitary angiokeratomas. In general, a two-session treatment is enough for complete improvement of solitary lesions. We propose that long-pulsed Nd:YAG laser is an effective and safe therapeutic option for the treatment of solitary angiokeratomas.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Universitat de Girona on 12/16/14 For personal use only.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. References 1. Hohenleutner H. Malformations of vessels, fat, and connective tissue. In: Burgdorf WHC, Plewig G, Wolff HH, Landthaler M, editors. Braun-Falco’s dermatology. 3rd ed. Heidelberg: Springer; 2009. p. 798–799. 2. Detmar M, Hirakawa S. Vascular biology. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Bolognia dermatology’s. 2nd ed. London: Mosby Elsevier; 2008. p.1623–1624. 3. Schiller P, Itin P. Angiokeratomas: an update. Dermatology. 1996;193:275–282. 4. Larralde MM, Luna PC. Fabry disease. In: Wolff K, Goldsmith LA, Katz SI, Gilhrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s dermatology in general medicine. 7th ed. New York: McGraw Hill; 2008. p. 1285.
MCLT_A_968585.indd 3
3
5. Del Pozo J, Fonseca E. Angiokeratoma circumscriptum naeviforme: successful treatment with carbon-dioxide laser vaporization. Dermatol Surg. 2005;31:232–236. 6. Lapins J, Emtestam L, Marcusson JA. Angiokeratomas in Fabry’s disease and Fordyce disease: successful treatment with Copper vapour laser. Acta Derm Venereol. 1993;73:133–135. 7. Sommer S, Merchant WJ, Sheehan-Dare R. Severe predominantly acral variant of angiokeratoma of Mibelli: response to longe-pulse Nd:YAG (1064 nm) laser treatment. J Am Acad Dermatol. 2001;45:764–766. 8. Civaş E, Koç E, Aksoy B, Aksoy HM. Report of two angiokeratoma of Fordyce cases treated with a 1064 nm long-pulsed Nd:YAG laser. Photodermatol Photoimmunol Photomed. 2009;25:166–168. 9. Meissner M, Kaufmann R. Therapy for angiokeratoma of Fordyce with the 940-nm diode laser. Aktuelle Urol. 2012;43:121–122. 10. Lapidoth M, Ad-El D, David M, Azaria R. Treatment of angiokeratoma of Fordyce with pulsed dye laser. Dermatol Surg. 2006;32:1147–1150. 11. Oni G, Mahaffey P. Treatment of angiokeratoma of the vulva with pulsed dye laser therapy. J Cosmet Laser Ther. 2010; 12:51–52. 12. Bechara FG, Jansen T, Wilmert M, Altmeyer P, Hoffmann K. Angiokeratoma Fordyce of the glans penis: combined treatment with erbium:YAG and 532 nm KTP (frequency doubled neodmyium: YAG) laser. J Dermatol. 2004;31:943–945. 13. Ozdemir M, Baysal I, Engin B, Ozdemir S. Treatment of angiokeratoma of Fordyce with long-pulse neodymium-doped yttrium aluminium garnet laser. Dermatol Surg. 2009;35:92–97. 14. Landthaler M, Hohenleutner U. Laser therapy of vascular lesions. Photodermatol Photoimmunol Photomed. 2006;22: 324–332.
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