Nevus Comedonicus: A Novel Approach to Treatment JASON GIVAN, MD, M. YADIRA HURLEY, MD,
AND
DEE ANNA GLASER, MD
The authors have indicated no significant interest with commercial supporters.
N
evus comedonicus is postulated to result from a hamartomatous proliferation of pilosebaceous tissue. This rare developmental abnormality results in the clinical appearance of grouped, often linearly arrayed, elevated follicular openings. With time, the follicular openings fill with dark keratin plugs, imparting the appearance of open comedones.1
Kofmann first described nevus comedonicus in 1895.2 The initial U.S. report was in 1914, from White, who referred to the disorder as nevus follicularis keratosus.3 Subsequently, the condition has been termed comedone nevus, nevus acneiformis unilateralis, and nevus zoniforme.1 The treatment of nevus comedonicus remains challenging. Numerous therapies have been reported in the literature, including surgical excision, dermabrasion, manual extraction of keratin, application of ammonium lactate lotion, application of topical retinoic acid or keratolytic agents, and oral isotretinoin.4 Ineffectiveness, potential adverse effects, or both restrict each of these treatment modalities. We report the first successful use of the 1,450-nm diode laser (Smoothbeam, Candela Corporation, Wayland, MA) in the treatment of nevus comedonicus.
Case Report A 48-year-old Caucasian woman presented to the Division of Cosmetic and Laser Surgery, Department of Dermatology, Saint Louis University, for evaluation of an asymptomatic ‘‘rash’’ involving her left neck. The lesion had been present for approximately
2 years. She could recall no inciting factor and denied any previous history of cutaneous abnormality involving the region.
Upon clinical examination, the patient’s left neck demonstrated multiple comedones and follicularbased skin-colored to yellow-hued papules in a linear distribution (Figure 1). The clinical differential diagnosis included nevus comedonicus and, less likely, nevus sebaceous. A punch biopsy was performed. Histologically, a dilated follicular infundibulum with keratinous plug consistent with nevus comedonicus was seen (Figure 2). Treatment options were reviewed with the patient, and she was started on topical retinoid therapy. In addition, she was offered a trial of treatment with the 1,450-nm diode laser. Her initial laser treatment was performed 1 month after her initial evaluation with biopsy and 1 week after she began topical retinoid therapy. She received four treatments with the 1,450nm diode laser. All treatments were conducted using single-pass method at the following laser settings: 14 J/cm, 6-mm spot size, 35-ms cooling device delay. Mild erythema and edema were noted immediately after each treatment session. The patient noted significant improvement in skin texture after each successive treatment. Objectively, the lesion improved, with a progressive decrease in surface area involvement and improved cutaneous texture. The lesion was 80% reduced after her third laser treatment session (Figure 3) and clinically resolved after her fourth treatment session. A post-treatment punch biopsy was performed immediately after her fourth treatment. To minimize the possibility of sample
All authors are affiliated with Department of Dermatology, Saint Louis University, St. Louis, Missouri & 2010 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2010;36:721–725 DOI: 10.1111/j.1524-4725.2010.01537.x 721
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Figure 1. Linear papular plaque of the left neck.
bias, an attempt was made to target any residual textural irregularity, but upon histopathological examination, no abnormality was noted in the biopsy specimen (Figure 4). The patient returned 13 months after her initial series of four treatments with the 1,450-nm diode laser. She reported a mild recurrence of cutaneous textural irregularity. Objectively, several 1-mm minimally elevated skin colored papules were present (Figure 5). She received one additional treatment with the 1,450-nm diode laser, at settings as previously detailed, with complete resolution of the papules.
Discussion Paithankar and colleagues first reported the 1,450nm diode laser as a safe and effective treatment option for acne vulgaris in 2002. Based upon thermal transfer calculations, they determined that a 1,450-nm wavelength laser pulse would effectively result in maximal thermal coagulation of tissue at a
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Figure 2. Punch biopsy of left neck papular plaque (hematoxylin and eosin; 40).
depth of 435 mm below the stratum corneum. With the sebaceous unit and associated follicular infundibulum anatomically located at a depth of approximately 400 mm, the investigators postulated selected injury to these structures and surrounding connective tissue by a laser pulse of 1,450 nm. Histological validation of thermal injury to the upper dermis was achieved using a rabbit ear model. Clinically, the investigators demonstrated statistically significant improvement of inflammatory acne vulgaris lesions on the back of male study participants using the 1,450-nm diode laser. Thus, it was
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Figure 3. Skin-colored papular plaque of the left neck showing marked improvement in texture.
concluded that alteration of the pilosebaceous unit, the origin of acne vulgaris, resulted in the observed reduction of acneiform lesions by the 1,450-nm diode laser.5 Although not formally studied in isolation, comedones are generally speculated to be much less responsive to treatment with the 1,450-nm laser, but subjectively, participants in studies of inflammatory acne vulgaris have noted a decrease in comedonal lesions with the 1,450-nm laser.6 In contrast to the lesions of acne vulgaris, nevus comedonicus is hypothesized to represent a localized benign hamartoma of the pilosebaceous unit. Lesions typically occur on the face, trunk, neck, or upper extremity. Half of cases are present at birth, with the majority presenting during childhood. Adult onset is rare and often associated with trauma or irritation.7 Our patient denied any history of trauma to the involved region. She has been a registered nurse for many years and frequently drapes a
Figure 4. Punch biopsy of left neck at site of previous papular plaque (hematoxylin and eosin; 40).
stethoscope around her neck. It is possible that the chronic low-grade irritation created by the rubber stethoscope tubing may have exacerbated a subclinical nevus comedonicus to the point of clinical manifestation. The constituent papules of nevus comedonicus are histologically ‘‘undeveloped hair follicles,
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Figure 5. Left neck with minimal recurrence of skin-colored papular plaque 13 months after treatment.
presenting as dilated invaginations filled with keratin and devoid of hair shafts.’’7 The rudimentary follicles are incapable of producing terminal hair or functional sebaceous glands. The structures are able to produce keratin, which accumulates within its luminal opening.1 Therefore, the individual papules, filled with dark keratin plugs and clinically resembling open comedones, are not ‘‘true’’ comedones. Although no published reports specifically addressing comedonal response to 1,450-nm laser treatment exist, many consider the comedonal lesions of acne vulgaris to be less amenable to this therapy than corresponding inflammatory lesions, although some authors have reported subjective decreases in comedonal lesion counts by study participants when the 1,450-nm laser was used for inflammatory acne vulgaris.6 In the aforementioned report, Friedman and colleagues speculated that comedonal lesion density
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may be reduced using photocoagulation of the hair follicle, with subsequent reduction in new comedone formation. It is conceivable that the rudimentary follicular structures present in nevus comedonicus possess a susceptibility to photocoagulation produced by the 1,450-nm diode laser. If accurate, this may at least partially account for our patient’s excellent therapeutic response. Furthermore, nonablative lasers, such as the 1,450-nm diode laser, have been demonstrated histologically to stimulate collagen production and remodeling in the upper dermis through thermal injury.5 Several reports have documented atrophic scar reduction, presumably by way of subcicatricial collagen remodeling and stimulation, after treatment with the 1,450-nm diode laser.8–10 Because the undeveloped follicular structures of nevus comedonicus consist merely of simple epidermal invaginations, we hypothesize that sublesional collagen remodeling and production contributed significantly to the therapeutic efficacy of the 1,450-nm laser in our case. Sublesional collagen stimulation and subsequent production would result in diminution or elimination of constituent epidermal invaginations, with resultant improvement in skin texture and reduction of central keratin accumulation. This mechanistic sequence is analogous to that previously demonstrated in the successful nonablative laser treatment of atrophic scarring. Therefore, we conclude that the amalgamation of sublesional dermal collagen proliferation, as well as follicular photocoagulation, resulted in our patient’s excellent therapeutic response. Nevus comedonicus remains a rare lesion that is frequently problematic from a therapeutic standpoint. A myriad of minimally effective treatment options have been previously reported in the literature. We are encouraged by the excellent therapeutic response achieved in our case with the 1,450-nm diode laser and remain optimistic that subsequent cases may respond in a similar fashion.
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References 1. Lefkowitz A, Schwartz RA, Lambert WC. Nevus comedonicus. Dermatology 1999;199:204–7. 2. Kofmann S. Ein Fall von seltener Localisation und Verbreitung von Comedonen. Arch Derm Syph 1895;32:177–8. 3. White CJ. Nevus follicularis keratosis. J Cutan Dis 1914;32:187– 90. 4. Milton GP, DiGiovanna JJ, Peck GL. Treatment of nevus comedonicus with ammonium lactate lotion. J Am Acad Dermatol 1989;20:324–8. 5. Paithankar DY, Ross EV, Saleh BA, et al. Acne treatment with a 1,450 nm wavelength laser and cryogen spray cooling. Lasers Surg Med 2002;31:106–14. 6. Friedman PM, Jih MH, Kimyai-Asadi A, Goldberg LH. Treatment of inflammatory facial acne vulgaris with the 1450-nm diode laser: a pilot study. Dermatol Surg 2004;30:147–51. 7. Pierson D, Bandel C, Ehrig T, Cockerell CJ. Benign epidermal tumors and proliferations. In: Bolognia JL, Jorizzo JL, Rapini RP, et al., editors. Dermatology. Edinburgh: Mosby; 2003. p. 1712–3.
8. Tanzi EL, Alster TS. Comparison of a 1450-nm diode laser and a 1320-nm Nd:YAG laser in the treatment of atrophic facial scars: a prospective clinical and histologic study. Dermatol Surg 2004;30:152–7. 9. Chua SH, Ang P, Khoo LS, Goh CL. Nonablative 1450-nm diode laser in the treatment of facial atrophic acne scars in type IV to V Asian skin: a prospective clinical study. Dermatol Surg 2004;30:1287–91. 10. Jih MH, Friedman PM, Kimyai-Asadi A, Goldberg LH. Successful treatment of a chronic atrophic dog-bite scar with the 1450-nm diode laser. Dermatol Surg 2004;30:1161–3.
Address correspondence and reprint requests to: Dee Anna Glaser, MD, Saint Louis University Department of Dermatology, 1755 S. Grand Blvd, Dermatology – Fourth Floor, St Louis, MO 63104, or e-mail:
[email protected]
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