Journal of Cosmetic and Laser Therapy
ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: http://www.tandfonline.com/loi/ijcl20
Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments Nicholas A. Ross, Lara E. Rosenbaum, Nazanin Saedi, Kenneth A. Arndt & Jeffrey S. Dover To cite this article: Nicholas A. Ross, Lara E. Rosenbaum, Nazanin Saedi, Kenneth A. Arndt & Jeffrey S. Dover (2016): Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments, Journal of Cosmetic and Laser Therapy, DOI: 10.3109/14764172.2015.1063657 To link to this article: http://dx.doi.org/10.3109/14764172.2015.1063657
Published online: 28 Jan 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijcl20 Download by: [137.189.171.235]
Date: 07 March 2016, At: 06:03
Journal of Cosmetic and Laser Therapy http://dx.doi.org/10.3109/14764172.2015.1063657
CASE REPORT
Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments Nicholas A. Ross1, Lara E. Rosenbaum2, Nazanin Saedi1, Kenneth A. Arndt3,4,5, and Jeffrey S. Dover4,5,6 1Department
of Dermatology & Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA, USA; 2Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 3Department of Dermatology, Harvard Medical School, Boston, MA, USA; 4Department of Dermatology, Brown Medical School, Providence, RI, USA; 5Department of Dermatology, Dartmouth Medical School, Hanover, NH, USA; 6Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA ABSTRACT
ARTICLE HISTORY
Downloaded by [] at 06:03 07 March 2016
Disseminated superficial actinic porokeratosis (DSAP) is an inherited disorder of keratinization readily diagnosed through clinical and histologic examination. While generally benign in nature, the lesions can have profound psychosocial implications for patients. Although no cure exists, a number of treatment modalities, from topical medications to laser and light devices, have been reported with variable success. The authors report two cases of DSAP treated with the 1927-nm thulium fiber fractional laser along with a review of the treatment literature for DSAP. This therapy is convenient and safe with nearly no downtime or morbidity associated with pigment or textural changes.
Introduction Disseminated superficial actinic porokeratosis (DSAP), the most common porokeratosis, is an autosomal dominant disorder of keratinization. Both sporadic and inherited cases have been linked to ultraviolet exposure (1–3). DSAP shows a slight female predominance and typically affects those in the third and fourth decades of life (4). Multiple skin-colored or brownishred macules and papules arise on the limbs, shoulders, and back. These can expand, radially, forming a thin keratotic rim and atrophic center. While most patients are asymptomatic, approximately one-third of patients experience stinging sensations or pruritus (1,5). Although malignant degeneration is uncommon (6,7), widespread distribution of these benign lesions can have profound psychosocial implications for patients. A number of treatment modalities, from topical medication to laser and light devices, have been reported with variable success (Table 1) (8–13).Therapeutic response, however, appears to remain unpredictable. The authors report two cases of DSAP treated with the fractional 1927-nm thulium fiber laser demonstrating its potential to reduce lesion burden.
Received 9 July 2014 Accepted 8 June 2015 KEYWORDS
1927-fractional laser; disseminated superficial actinic porokeratosis; fractional laser; non-ablative laser
Both legs were treated with a fractional 1927-nm thulium fiber laser (Fraxel Dual, Solta Medical, Hayward, CA) with settings of 10 mJ, level 3 (density 30%), and 8 passes. Topical lidocaine 30% ointment was applied to the treatment site for one hour preprocedurally with intermittent monitoring for signs of toxicity. The patient tolerated this well without adverse events. The patient noted improvement after the first treatment (Figure 2). After three treatments, at 4–6 weeks intervals, the total lesion burden and thickness of remaining lesions were reduced; both the patient and treating physician noted overall cosmetic improvement (Figure 2). Treatment sites continued to improve for several months following the final treatment. At 12-month follow-up there were no signs of worsening. Adverse effects were mild edema and erythema, lasting three days. Table 1. Reported DSAP treatment modalities. Modality Topical therapies
Agent 5-fluorouracil (16) Imiquimod (9,14) Vitamin D3 analogs (19,20) Retinoids (21) Diclofenac gel 3% (19,20) Retinoids (21) Photodynamic therapy (22–24) 532 nm Nd:YAG laser (27) 694 nm Q-switched ruby laser (25,26) 1,550 nm erbium-doped fiber fractional laser (10) 1,927 nm thulium fiber laser† 2,940 nm Q-switched Er:YAG laser (12) 10,600 nm CO2 ablative laser (24,28)
Patient 1
Systemic therapies Laser and light modalities
A 46-year-old female with Fitzpatrick skin type II presented with a 5-year history of biopsy-proven DSAP. On examination, there were discrete pink macules with peripheral scale on her lower extremities bilaterally (Figure 1). She reported minimal improvement with previous treatment by liquid nitrogen and topical tazarotene 0.1% gel.
†Reports presented in this case series.
CONTACT Nazanin Saedi [email protected] Department of Dermatology & Cutaneous Biology, Thomas Jefferson University, 833 Chestnut Street, Suite 740, Philadelphia, PA 19107, USA. Color versions of one or more of the figures in the article can be found online at http://www.tandfonline.com/ijcl © 6 Taylor & Francis Group, LLC
2
N. A. ROSS ET AL.
Topical lidocaine 30% ointment was applied to the treatment sites for one hour pre-procedurally with intermittent monitoring for signs of toxicity. The patient tolerated this well without adverse events. Her legs and arms were treated with a fractional 1927-nm thulium fiber laser (Fraxel Dual, Solta Medical, Hayward, CA) with 10 mJ, level 2 (density 20%), and 6 passes to the former and 10 mJ, level 3 (density 30%), and 8 passes to the latter. The patient received a total of one treatment for her legs and four treatments for her arms (4–12 weeks apart). Patient and physician evaluation noted a reduction in the lesion burden as well as decreased thickness in the remaining lesions, resulting in overall cosmetic improvement. At 4-month follow-up, there were no signs of new lesions or worsening. Adverse effects were mild edema and erythema, lasting two days.
Downloaded by [] at 06:03 07 March 2016
Discussion
Figure 1. Discrete pink macules with peripheral scale scattered on the bilateral lower extremities at initial presentation.
Patient 2 A 65-year-old female with Fitzpatrick skin type II and a known history of DSAP presented with discrete pink-to-brown macules with peripheral scale on her chest, and upper and lower extremities. Of note, her mother and sister also had DSAP. Prior to presentation, treatment with the 1550-nm non-ablative fractionated laser (Fraxel Restore, Solta Medical, Hayward, CA) gave only modest improvement.
Figure 2. Photograph after three treatments (4–6 weeks intervals); note the decreased lesion burden as well as the decrease in thickness and erythema of the remaining lesions.
The 1927-nm fractional laser is FDA approved for treatment of actinic keratosis (13). Given similarities of pathology between actinic keratosis and DSAP, the laser may be logically suited for treatment of DSAP. The 1927-nm wavelength penetrates to approximately 300 mm. Low-energy treatment settings (10 mJ), corresponding to a penetration depth of 196 mm, are most suitable given the superficial location of the pathology in DSAP. In addition, a fractional laser was selected for treatment because its mechanism, whereby microscopic columns of thermal injury are created leaving the surrounding skin intact, engenders a rapid wound healing response in the lower extremity, avoiding significant downtime or morbidity compared with ablative lasers. Reports of various topical therapies for DSAP demonstrate promising results. Imiquimod 5%, an immunomodulator, has been shown to effectively improve texture, color, and appearance of scars of facial lesions and textural improvement of leg lesions (9,14). Due to its antineoplastic properties, this agent can also theoretically treat carcinomas arising within DSAP (14). Topical ingenol mebutate gel, FDA approved for treatment of actinic keratosis, is both cytotoxic and locally immunogenic (8,11). Likely due to similarities in pathology, it has anecdotally proven to be effective in the treatment of DSAP (15). These therapies must be used with caution to avoid retarded healing, ulceration, and scarring. Other reported modalities include topical glucocorticoids, 5-fluorouracil (5-FU), diclofenac gel 3%, vitamin D3 analogs, and retinoids (9,16–21). Systemic retinoid treatment may prove useful in cases with widespread lesions (21). Laser and light modalities have also demonstrated efficacy in treatment of DSAP. Photodynamic therapy (PDT), including 5-aminolevulinic acid (5-ALA)-PDT, methyl aminolevulinate (MAL)-PDT, and hypericin-PDT, has shown mixed results (22– 24). Reported laser therapies for DSAP include ablative CO2, Q-switched ruby, Q-switched Nd:YAG, Er:YAG, and fractional erbium-doped fiber lasers (12,24–28). While the CO2 laser promises more dramatic and immediate outcomes, the therapy is painful, requires a prolonged healing time, and may not completely remove lesions. Additionally, the risk of post-treatment hyperpigmentation and scarring with CO2 laser therapy is higher than non-ablative alternatives.
Journal of Cosmetic and Laser Therapy
Downloaded by [] at 06:03 07 March 2016
Overall, there are many treatment modalities for DSAP with variable efficacy. The fractional 1927-nm laser can be effective in treating superficial processes such as actinic keratoses and DSAP, but it is not first line. Specifically, in these two cases of DSAP, the appearance of some lesions improved, while others remained unchanged and a few may even have worsened. Furthermore, the response of “non-fractional” pathology to fractional lasers requires further investigation to elucidate the pathways involved in the response. Photodynamic therapy (PDT), imiquimod, and 5-FU are likely more effective. However, in certain cases, such as these two patients, alternative treatment modalities are necessary. Treatment with the 1927-nm laser also provides improved skin texture. Therapy is convenient and safe with nearly no downtime or morbidity associated with pigment or textural defects. Conducting multiple treatments versus one, more aggressive treatment due to the poor wound healing properties on the lower extremities, proved useful. Further studies may delineate the efficacy of this treatment in a large, diverse population as well as document post-treatment histologic changes.
Declaration of interest The authors have nothing to disclose, financially, relational, or otherwise.
References 1. Chernosky ME, Freeman RG. Disseminated superficial actinic porokeratosis (DSAP). Arch Dermatol. 1967;96(6):611–624. 2. Cockerell CJ. Induction of disseminated superficial actinic porokeratosis by phototherapy for psoriasis. J Am Acad Dermatol. 1991; 24(2 Pt 1):301–302. 3. Neumann RA, Knobler RM, Jurecka W, Gebhart W. Disseminated superficial actinic porokeratosis: experimental induction and exacerbation of skin lesions. J Am Acad Dermatol. 1989;21(6):1182–1188. 4. Sertznig P, von Felbert V, Megahed M. Porokeratosis: present concepts. J Eur Acad Dermatol Venereol. 2012;26(4):404–412. 5. Palleschi GM, Torchia D. Porokeratosis of Mibelli and superficial disseminated porokeratosis. J Cutan Pathol. 2008;35(2):253–255. 6. Lee HR, Han TY, Son SJ, Lee JH. Squamous Cell Carcinoma Developing within Lesions of Disseminated Superficial Actinic Porokeratosis. Ann Dermatol. 2011;23(4):536–538. 7. Maubec E, Duvillard P, Margulis A, Bachollet B, Degois G, Avril MF. Common skin cancers in porokeratosis. Br J Dermatol. 2005;152(6):1389–1391. 8. Anderson L, Schmieder GJ, Werschler WP, Tschen EH, Ling MR, Stough DB, et al. Randomized, double-blind, double-dummy, vehiclecontrolled study of ingenol mebutate gel 0.025% and 0.05% for actinic keratosis. J Am Acad Dermatol. 2009;60(6):934–943. 9. Arun B, Pearson J, Chalmers R. Disseminated superficial actinic porokeratosis treated effectively with topical imiquimod 5% cream. Clin Exp Dermatol. 2011;36(5):509–511.
3
10. Chrastil B, Glaich AS, Goldberg LH, Friedman PM. Fractional photothermolysis: A novel treatment for disseminated superficial actinic porokeratosis. Arch Dermatol. 2007;143(11):1450–1452. 11. Lebwohl M, Swanson N, Anderson LL, Melgaard A, Xu Z, Berman B. Ingenol mebutate gel for actinic keratosis. N Engl J Med. 2012;366(11):1010–1019. 12. Rosenblum J, Roenigk HH, Jr. Erbium laser for the treatment of disseminated superficial actinic porokeratosis: a case report. Dermatol Surg. 2013;39(10):1543–1545. 13. Weiss ET, Brauer JA, Anolik R, Reddy KK, Karen JK, Hale EK, et al. 1927-nm fractional resurfacing of facial actinic keratoses: a promising new therapeutic option. J Am Acad Dermatol. 2013;68(1): 98–102. 14. Riad H, Mansour K, Sada HA, Shaika SA, Ansari HA, Mohannadi HA. Disseminated superficial actinic porokeratosis on the face treated with imiquimod 5% cream. Case Rep Dermatol. 2013;5(3):283–289. 15. Sikora B. SkinCare Physicians. Personal Communication, July 8, 2012. 16. Shelley WB, Shelley ED. Disseminated superficial porokeratosis: rapid therapeutic response to 5-fluorouracil. Cutis. 1983;32(2):139–140. 17. Harrison PV, Stollery N. Disseminated superficial actinic porokeratosis responding to calcipotriol. Clin Exp Dermatol. 1994;19(1):95. 18. Bohm M, Luger TA, Bonsmann G. Disseminated superficial actinic porokeratosis: treatment with topical tacalcitol. J Am Acad Dermatol. 1999;40(3):479–480. 19. Vlachou C, Kanelleas AI, Martin-Clavijo A, Berth-Jones J. Treatment of disseminated superficial actinic porokeratosis with topical diclofenac gel: a case series. J Eur Acad Dermatol Venereol. 2008;22(11):1343–1345. 20. Marks S, Varma R, Cantrell W, Chen SC, Gold M, Muellenhoff M, et al. Diclofenac sodium 3% gel as a potential treatment for disseminated superficial actinic porokeratosis. J Eur Acad Dermatol Venereol. 2009;23(1):42–45. 21. Danno K, Yamamoto M, Yokoo T, Ohta M, Ohno S. Etretinate treatment in disseminated porokeratosis. J Dermatol. 1988;15(5):440–444. 22. Boiy A, de Witte PA, Roelandts R. Topical treatment of disseminated superficial actinic porokeratosis with hypericin-photodynamic therapy: a case report. Photodiagnosis Photodyn Ther. 2010;7(2): 123–125. 23. Nayeemuddin FA, Wong M, Yell J, Rhodes LE. Topical photodynamic therapy in disseminated superficial actinic porokeratosis. Clin Exp Dermatol. 2002;27(8):703–706. 24. Kim HS, Baek JH, Park YM, Kim HO, Lee JY. Photodynamic Therapy Combined with CO(2) Laser Vaporization on Disseminated Superficial Actinic Porokeratosis: A Report of 2 Cases on the Face. Ann Dermatol. 2011;23(Suppl 2):S211–S213. 25. Lolis MS, Marmur ES. Treatment of disseminated superficial actinic porokeratosis (DSAP) with the Q-switched ruby laser. J Cosmet Laser Ther. 2008;10(2):124–127. 26. Itoh M, Nakagawa H. Successful treatment of disseminated superficial actinic porokeratosis with Q-switched ruby laser. J Dermatol. 2007;34(12):816–820. 27. Liu HT. Treatment of lichen amyloidosis (LA) and disseminated superficial porokeratosis (DSP) with frequency-doubled Q-switched Nd:YAG laser. Dermatol Surg. 2000;26(10):958–962. 28. Noborio R, Morita A. Split-face trial of CO(2) laser-induced ring abrasion and high-dose tacalcitol in the treatment of disseminated superficial actinic porokeratosis. J Dermatol. 2012;39(10):879–880.
ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: http://www.tandfonline.com/loi/ijcl20
Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments Nicholas A. Ross, Lara E. Rosenbaum, Nazanin Saedi, Kenneth A. Arndt & Jeffrey S. Dover To cite this article: Nicholas A. Ross, Lara E. Rosenbaum, Nazanin Saedi, Kenneth A. Arndt & Jeffrey S. Dover (2016): Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments, Journal of Cosmetic and Laser Therapy, DOI: 10.3109/14764172.2015.1063657 To link to this article: http://dx.doi.org/10.3109/14764172.2015.1063657
Published online: 28 Jan 2016.
Submit your article to this journal
Article views: 15
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijcl20 Download by: [137.189.171.235]
Date: 07 March 2016, At: 06:03
Journal of Cosmetic and Laser Therapy http://dx.doi.org/10.3109/14764172.2015.1063657
CASE REPORT
Disseminated superficial actinic porokeratosis improved with fractional 1927-nm laser treatments Nicholas A. Ross1, Lara E. Rosenbaum2, Nazanin Saedi1, Kenneth A. Arndt3,4,5, and Jeffrey S. Dover4,5,6 1Department
of Dermatology & Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA, USA; 2Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 3Department of Dermatology, Harvard Medical School, Boston, MA, USA; 4Department of Dermatology, Brown Medical School, Providence, RI, USA; 5Department of Dermatology, Dartmouth Medical School, Hanover, NH, USA; 6Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA ABSTRACT
ARTICLE HISTORY
Downloaded by [] at 06:03 07 March 2016
Disseminated superficial actinic porokeratosis (DSAP) is an inherited disorder of keratinization readily diagnosed through clinical and histologic examination. While generally benign in nature, the lesions can have profound psychosocial implications for patients. Although no cure exists, a number of treatment modalities, from topical medications to laser and light devices, have been reported with variable success. The authors report two cases of DSAP treated with the 1927-nm thulium fiber fractional laser along with a review of the treatment literature for DSAP. This therapy is convenient and safe with nearly no downtime or morbidity associated with pigment or textural changes.
Introduction Disseminated superficial actinic porokeratosis (DSAP), the most common porokeratosis, is an autosomal dominant disorder of keratinization. Both sporadic and inherited cases have been linked to ultraviolet exposure (1–3). DSAP shows a slight female predominance and typically affects those in the third and fourth decades of life (4). Multiple skin-colored or brownishred macules and papules arise on the limbs, shoulders, and back. These can expand, radially, forming a thin keratotic rim and atrophic center. While most patients are asymptomatic, approximately one-third of patients experience stinging sensations or pruritus (1,5). Although malignant degeneration is uncommon (6,7), widespread distribution of these benign lesions can have profound psychosocial implications for patients. A number of treatment modalities, from topical medication to laser and light devices, have been reported with variable success (Table 1) (8–13).Therapeutic response, however, appears to remain unpredictable. The authors report two cases of DSAP treated with the fractional 1927-nm thulium fiber laser demonstrating its potential to reduce lesion burden.
Received 9 July 2014 Accepted 8 June 2015 KEYWORDS
1927-fractional laser; disseminated superficial actinic porokeratosis; fractional laser; non-ablative laser
Both legs were treated with a fractional 1927-nm thulium fiber laser (Fraxel Dual, Solta Medical, Hayward, CA) with settings of 10 mJ, level 3 (density 30%), and 8 passes. Topical lidocaine 30% ointment was applied to the treatment site for one hour preprocedurally with intermittent monitoring for signs of toxicity. The patient tolerated this well without adverse events. The patient noted improvement after the first treatment (Figure 2). After three treatments, at 4–6 weeks intervals, the total lesion burden and thickness of remaining lesions were reduced; both the patient and treating physician noted overall cosmetic improvement (Figure 2). Treatment sites continued to improve for several months following the final treatment. At 12-month follow-up there were no signs of worsening. Adverse effects were mild edema and erythema, lasting three days. Table 1. Reported DSAP treatment modalities. Modality Topical therapies
Agent 5-fluorouracil (16) Imiquimod (9,14) Vitamin D3 analogs (19,20) Retinoids (21) Diclofenac gel 3% (19,20) Retinoids (21) Photodynamic therapy (22–24) 532 nm Nd:YAG laser (27) 694 nm Q-switched ruby laser (25,26) 1,550 nm erbium-doped fiber fractional laser (10) 1,927 nm thulium fiber laser† 2,940 nm Q-switched Er:YAG laser (12) 10,600 nm CO2 ablative laser (24,28)
Patient 1
Systemic therapies Laser and light modalities
A 46-year-old female with Fitzpatrick skin type II presented with a 5-year history of biopsy-proven DSAP. On examination, there were discrete pink macules with peripheral scale on her lower extremities bilaterally (Figure 1). She reported minimal improvement with previous treatment by liquid nitrogen and topical tazarotene 0.1% gel.
†Reports presented in this case series.
CONTACT Nazanin Saedi [email protected] Department of Dermatology & Cutaneous Biology, Thomas Jefferson University, 833 Chestnut Street, Suite 740, Philadelphia, PA 19107, USA. Color versions of one or more of the figures in the article can be found online at http://www.tandfonline.com/ijcl © 6 Taylor & Francis Group, LLC
2
N. A. ROSS ET AL.
Topical lidocaine 30% ointment was applied to the treatment sites for one hour pre-procedurally with intermittent monitoring for signs of toxicity. The patient tolerated this well without adverse events. Her legs and arms were treated with a fractional 1927-nm thulium fiber laser (Fraxel Dual, Solta Medical, Hayward, CA) with 10 mJ, level 2 (density 20%), and 6 passes to the former and 10 mJ, level 3 (density 30%), and 8 passes to the latter. The patient received a total of one treatment for her legs and four treatments for her arms (4–12 weeks apart). Patient and physician evaluation noted a reduction in the lesion burden as well as decreased thickness in the remaining lesions, resulting in overall cosmetic improvement. At 4-month follow-up, there were no signs of new lesions or worsening. Adverse effects were mild edema and erythema, lasting two days.
Downloaded by [] at 06:03 07 March 2016
Discussion
Figure 1. Discrete pink macules with peripheral scale scattered on the bilateral lower extremities at initial presentation.
Patient 2 A 65-year-old female with Fitzpatrick skin type II and a known history of DSAP presented with discrete pink-to-brown macules with peripheral scale on her chest, and upper and lower extremities. Of note, her mother and sister also had DSAP. Prior to presentation, treatment with the 1550-nm non-ablative fractionated laser (Fraxel Restore, Solta Medical, Hayward, CA) gave only modest improvement.
Figure 2. Photograph after three treatments (4–6 weeks intervals); note the decreased lesion burden as well as the decrease in thickness and erythema of the remaining lesions.
The 1927-nm fractional laser is FDA approved for treatment of actinic keratosis (13). Given similarities of pathology between actinic keratosis and DSAP, the laser may be logically suited for treatment of DSAP. The 1927-nm wavelength penetrates to approximately 300 mm. Low-energy treatment settings (10 mJ), corresponding to a penetration depth of 196 mm, are most suitable given the superficial location of the pathology in DSAP. In addition, a fractional laser was selected for treatment because its mechanism, whereby microscopic columns of thermal injury are created leaving the surrounding skin intact, engenders a rapid wound healing response in the lower extremity, avoiding significant downtime or morbidity compared with ablative lasers. Reports of various topical therapies for DSAP demonstrate promising results. Imiquimod 5%, an immunomodulator, has been shown to effectively improve texture, color, and appearance of scars of facial lesions and textural improvement of leg lesions (9,14). Due to its antineoplastic properties, this agent can also theoretically treat carcinomas arising within DSAP (14). Topical ingenol mebutate gel, FDA approved for treatment of actinic keratosis, is both cytotoxic and locally immunogenic (8,11). Likely due to similarities in pathology, it has anecdotally proven to be effective in the treatment of DSAP (15). These therapies must be used with caution to avoid retarded healing, ulceration, and scarring. Other reported modalities include topical glucocorticoids, 5-fluorouracil (5-FU), diclofenac gel 3%, vitamin D3 analogs, and retinoids (9,16–21). Systemic retinoid treatment may prove useful in cases with widespread lesions (21). Laser and light modalities have also demonstrated efficacy in treatment of DSAP. Photodynamic therapy (PDT), including 5-aminolevulinic acid (5-ALA)-PDT, methyl aminolevulinate (MAL)-PDT, and hypericin-PDT, has shown mixed results (22– 24). Reported laser therapies for DSAP include ablative CO2, Q-switched ruby, Q-switched Nd:YAG, Er:YAG, and fractional erbium-doped fiber lasers (12,24–28). While the CO2 laser promises more dramatic and immediate outcomes, the therapy is painful, requires a prolonged healing time, and may not completely remove lesions. Additionally, the risk of post-treatment hyperpigmentation and scarring with CO2 laser therapy is higher than non-ablative alternatives.
Journal of Cosmetic and Laser Therapy
Downloaded by [] at 06:03 07 March 2016
Overall, there are many treatment modalities for DSAP with variable efficacy. The fractional 1927-nm laser can be effective in treating superficial processes such as actinic keratoses and DSAP, but it is not first line. Specifically, in these two cases of DSAP, the appearance of some lesions improved, while others remained unchanged and a few may even have worsened. Furthermore, the response of “non-fractional” pathology to fractional lasers requires further investigation to elucidate the pathways involved in the response. Photodynamic therapy (PDT), imiquimod, and 5-FU are likely more effective. However, in certain cases, such as these two patients, alternative treatment modalities are necessary. Treatment with the 1927-nm laser also provides improved skin texture. Therapy is convenient and safe with nearly no downtime or morbidity associated with pigment or textural defects. Conducting multiple treatments versus one, more aggressive treatment due to the poor wound healing properties on the lower extremities, proved useful. Further studies may delineate the efficacy of this treatment in a large, diverse population as well as document post-treatment histologic changes.
Declaration of interest The authors have nothing to disclose, financially, relational, or otherwise.
References 1. Chernosky ME, Freeman RG. Disseminated superficial actinic porokeratosis (DSAP). Arch Dermatol. 1967;96(6):611–624. 2. Cockerell CJ. Induction of disseminated superficial actinic porokeratosis by phototherapy for psoriasis. J Am Acad Dermatol. 1991; 24(2 Pt 1):301–302. 3. Neumann RA, Knobler RM, Jurecka W, Gebhart W. Disseminated superficial actinic porokeratosis: experimental induction and exacerbation of skin lesions. J Am Acad Dermatol. 1989;21(6):1182–1188. 4. Sertznig P, von Felbert V, Megahed M. Porokeratosis: present concepts. J Eur Acad Dermatol Venereol. 2012;26(4):404–412. 5. Palleschi GM, Torchia D. Porokeratosis of Mibelli and superficial disseminated porokeratosis. J Cutan Pathol. 2008;35(2):253–255. 6. Lee HR, Han TY, Son SJ, Lee JH. Squamous Cell Carcinoma Developing within Lesions of Disseminated Superficial Actinic Porokeratosis. Ann Dermatol. 2011;23(4):536–538. 7. Maubec E, Duvillard P, Margulis A, Bachollet B, Degois G, Avril MF. Common skin cancers in porokeratosis. Br J Dermatol. 2005;152(6):1389–1391. 8. Anderson L, Schmieder GJ, Werschler WP, Tschen EH, Ling MR, Stough DB, et al. Randomized, double-blind, double-dummy, vehiclecontrolled study of ingenol mebutate gel 0.025% and 0.05% for actinic keratosis. J Am Acad Dermatol. 2009;60(6):934–943. 9. Arun B, Pearson J, Chalmers R. Disseminated superficial actinic porokeratosis treated effectively with topical imiquimod 5% cream. Clin Exp Dermatol. 2011;36(5):509–511.
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