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Hidradenitis suppurativa treated with a long-pulsed Alexandrite laser
DERMATOLOGICA SINICA 32 (2014) 115–117
Contents lists available at SciVerse ScienceDirect
Dermatologica Sinica journal homepage: http://www.derm-sinica.com
CORRESPONDENCE
Hidradenitis suppurativa treated with a long-pulsed Alexandrite laser Dear Editor, A 19-year-old man who presented with hidradenitis suppurativa (HS) for 1 year in 2011 was healthy except for a history of being a hepatitis B carrier. Recurrent pain and discharge affected the patient’s daily life. Physical examination revealed a tender, beansized, erythematous deep-seated nodule with suppuration (Figure 1A, arrow), and another sinus tract (Figure 1A, arrowhead) with an intermittent release of serous, purulent, or blood-stained discharge, and frequent foul odors over the left axilla. The patient’s Fitzpatrick skin type was IV and the disease severity was Stage II according to the Hurley scaling system. The lesions improved slightly and recurred frequently under tetracycline 1 g/day, intralesional steroids (triamcinolone 5 mg), and incision and drainage therapies for more than 2 months. Three sessions of a long-pulsed Alexandrite laser (GentleLase Laser; Candela Corp. Canton, MA) with parameters of 22–24 J/ cm2-18 mm (fluence-spot size) were applied to the left axilla. Two to three stacking passes were administered directly on each of the HS lesions. We chose the energy based on the energy for epilation and the Fitzpatrick skin type. The immediate endpoint was erythema around the lesions. A dynamic cooling device was set at 30/20/0. The interval between each session was 4 weeks. This procedure was performed under topical anesthesia with favorable tolerance. After 2 weeks of the first session, a dramatic improvement in pain and discharge was noted, in which the nodule and sinus tract subsided. However, a slight recurrence of the HS lesions was noted at 1 month after laser treatment, and a biopsy specimen was obtained from one of the recurrent lesions (Figure 1B, arrowhead). Histologic examination revealed a mixed infiltration of multinucleated giant cells, lymphocytes, histiocytes, and plasma cells. Free hair remnants within the mid-dermis were surrounded by lymphocytes (Figure 2). Another two sessions of the long-pulsed Alexandrite laser were implemented, and continued improvement was observed with each subsequent laser session (Figure 1C). During the laser treatment, the patient was on an intermittent regimen of oral tetracycline for his facial acne. After 8-month follow-up, there was no recurrence of HS on the left axilla. However, HS occurred over the right axilla (Figure 1D) after laser treatment on the left axilla. The HS lesions on the right axilla were still severe under oral antibiotics (Figure 1E and F), whereas HS lesions on the left axilla (lasertreated side) improved without recurrence (Figure 1C). HS, a chronic, relapsing, painful inflammation and suppuration skin disease, causes significant morbidity and life impairment. According to the consensus of the HS Foundation in 2009, the diagnosis of HS is made by typical appearance, topography, chronicity, and recurrence. The Hurley scaling system divides HS into three
stages according to its severity, presence of abscess, tract formation, and cicatrization.1 The pathogenesis of HS is initiated by follicular occlusion, followed by perifollicular inflammation, follicular infundibulum rupture, and abscess formation, resulting in sinus tract formation and scarring. The apocrine glands, previously thought to be the inciting factor, seem to be secondary factors.2 Treatment modalities, including conservative, medical, and surgical strategies, are mostly of limited effectiveness and recurrences often occur. Our patient received serial treatments consisting of systemic antibiotics, anti-inflammatory agents, and incision with drainage. Despite these treatments, recurrent pain and purulent discharge persisted. Unlike other immunosuppressive and biologic agents, the laser device provides the advantages of local treatment without systemic side effects. Carbon dioxide laser excision with secondary healing is used to treat mild to moderate diseases. Its superiority compared to classic surgery is still under debate. Long duration of wound healing, scar formation, and recurrences are the main drawbacks of carbon dioxide laser excision.1 In a recent study analysis, the long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was demonstrated to improve HS at a success rate of 72.7%.3 The absence of open wounds, less scarring, and prevention of new lesion formation make the long-pulsed Nd:YAG laser a promising treatment. Similar responses of the 755-nm Alexandrite laser in our case included obvious improvement in discharge and pain; no recurrence or exacerbation exhibited after a course of laser therapy. The biopsy results of mixed inflammation and remnants of hair follicles at 4 weeks following the first laser treatment session were also similar.3,4 However, a slight recurrence after the first session of long-pulsed Alexandrite laser therapy was not mentioned in the long-pulsed Nd:YAG laser treatment. Instead, initial worsening with increasing inflammation and drainage was noted during the first week after the long-pulsed Nd:YAG laser treatment.3,4 In our patient, the HS discharge became dry immediately and nodules subsided gradually after the laser treatment. The possible mechanism of laser therapy in HS is deocclusion of the follicular unit by destruction of the hair shaft and decrease of inflammatory lesions by photothermolysis. Statistical studies on epilation have shown that the long-pulsed Alexandrite laser provides more efficiency and less injury than the Nd:YAG laser dose because of less absorptive competition with melanin and an appropriate wavelength to reach hair shaft depths.5 Theoretically, the Alexandrite laser should provide better results than the Nd:YAG laser for treating HS. In contrast to the results of a 22-patient, prospective, randomized controlled trial of HS treatment with the
1027-8117/$ – see front matter Copyright Ó 2013, Taiwanese Dermatological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.dsi.2013.04.007
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Correspondence / Dermatologica Sinica 32 (2014) 115–117
Figure 1 Left axilla-laser treatment side. (A) Prior to laser treatment, a nodule (arrow) and another sinus tract (arrowhead) are present. (B) Four weeks after the first laser session, mild recurrence is noted. A biopsy was obtained from one of the recurrent lesions (arrowhead). (C) At 8-month follow-up after three monthly laser sessions, only red and brown pigmentation exhibit no recurrence. Right axilla-antibiotics treatment side. (D) New onset HS lesion. (E) Four weeks since onset. (F) Seven months after onset, recurrent and extensive lesions are present.
Figure 2 One month after laser treatment. (A) Infiltration consists of histiocytes, lymphocytes, plasma cells, and multinucleated giant cells (hematoxylin-eosin stain; original magnification: 20); (B) Free hair remnants within dermis are surrounded by lymphocytes (hematoxylin-eosin stain; original magnification: 200).
Correspondence / Dermatologica Sinica 32 (2014) 115–117
Nd:YAG laser showing necessity for four monthly laser sessions,4 our case exhibited obvious improvement of HS after the first session of the long-pulsed Alexandrite laser (Figure 1B). Our patient received two additional treatment sessions and exhibited further improvement without recurrence in the 8-month follow-up (Figure 1C). In conclusion, our histopathology results corresponded to the suggested mechanism of the long-pulsed Nd:YAG laser for treating HS, including deocclusion of the hair follicle followed by drainage of the inflammatory lesion and destruction of the follicular unit. The long-pulsed Nd:YAG laser has been shown to be a treatment advance for this highly disabling condition in both clearing preexisting lesions and preventing new eruptions. Based on the concept of epilation and our case observations, we propose that the longpulsed Alexandrite laser may provide at least the same efficacy as that of the Nd:YAG laser. Large randomized clinical studies are warranted to clarify the role and indication of the Alexandrite laser for the treatment of HS. Ya-Chu Tsai, Shu-Hui Wang, Po-Hsuan Lu, Tsung-Hua Tsai* Department of Dermatology, Far Eastern Memorial Hospital, New Taipei, Taiwan * Corresponding author. No. 21, Sec. 2, Nanya S. Rd., Banqiao Dist., New Taipei City 220, Taiwan. Tel.: þ886 956117070. E-mail address: [email protected] (T.-H. Tsai)
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Conflicts of interest: The authors declare that they have no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in this article.
References 1. Revuz J. Hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2009;23: 985–98. 2. Sellheyer K, Krahl D. Hidradenitis suppurativa is acne inversa! An appeal to (finally) abandon a misnomer. Int J Dermatol 2005;44:535–40. 3. Xu LY, Wright DR, Mahmoud BH, Ozog DM, Mehregan DA, Hamzavi IH. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment. Arch Dermatol 2010;147:21–8. 4. Mahmoud BH, Tierney E, Hexsel CL, Pui J, Ozog DM, Hamzavi IH. Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser. J Am Acad Dermatol 2010;62:637–45. 5. Rao J, Goldman MP. Prospective, comparative evaluation of three laser systems used individually and in combination for axillary hair removal. Dermatol Surg 2005;31:1671–6.
Received: Dec 3, 2012 Revised: Apr 20, 2013 Accepted: Apr 30, 2013
Contents lists available at SciVerse ScienceDirect
Dermatologica Sinica journal homepage: http://www.derm-sinica.com
CORRESPONDENCE
Hidradenitis suppurativa treated with a long-pulsed Alexandrite laser Dear Editor, A 19-year-old man who presented with hidradenitis suppurativa (HS) for 1 year in 2011 was healthy except for a history of being a hepatitis B carrier. Recurrent pain and discharge affected the patient’s daily life. Physical examination revealed a tender, beansized, erythematous deep-seated nodule with suppuration (Figure 1A, arrow), and another sinus tract (Figure 1A, arrowhead) with an intermittent release of serous, purulent, or blood-stained discharge, and frequent foul odors over the left axilla. The patient’s Fitzpatrick skin type was IV and the disease severity was Stage II according to the Hurley scaling system. The lesions improved slightly and recurred frequently under tetracycline 1 g/day, intralesional steroids (triamcinolone 5 mg), and incision and drainage therapies for more than 2 months. Three sessions of a long-pulsed Alexandrite laser (GentleLase Laser; Candela Corp. Canton, MA) with parameters of 22–24 J/ cm2-18 mm (fluence-spot size) were applied to the left axilla. Two to three stacking passes were administered directly on each of the HS lesions. We chose the energy based on the energy for epilation and the Fitzpatrick skin type. The immediate endpoint was erythema around the lesions. A dynamic cooling device was set at 30/20/0. The interval between each session was 4 weeks. This procedure was performed under topical anesthesia with favorable tolerance. After 2 weeks of the first session, a dramatic improvement in pain and discharge was noted, in which the nodule and sinus tract subsided. However, a slight recurrence of the HS lesions was noted at 1 month after laser treatment, and a biopsy specimen was obtained from one of the recurrent lesions (Figure 1B, arrowhead). Histologic examination revealed a mixed infiltration of multinucleated giant cells, lymphocytes, histiocytes, and plasma cells. Free hair remnants within the mid-dermis were surrounded by lymphocytes (Figure 2). Another two sessions of the long-pulsed Alexandrite laser were implemented, and continued improvement was observed with each subsequent laser session (Figure 1C). During the laser treatment, the patient was on an intermittent regimen of oral tetracycline for his facial acne. After 8-month follow-up, there was no recurrence of HS on the left axilla. However, HS occurred over the right axilla (Figure 1D) after laser treatment on the left axilla. The HS lesions on the right axilla were still severe under oral antibiotics (Figure 1E and F), whereas HS lesions on the left axilla (lasertreated side) improved without recurrence (Figure 1C). HS, a chronic, relapsing, painful inflammation and suppuration skin disease, causes significant morbidity and life impairment. According to the consensus of the HS Foundation in 2009, the diagnosis of HS is made by typical appearance, topography, chronicity, and recurrence. The Hurley scaling system divides HS into three
stages according to its severity, presence of abscess, tract formation, and cicatrization.1 The pathogenesis of HS is initiated by follicular occlusion, followed by perifollicular inflammation, follicular infundibulum rupture, and abscess formation, resulting in sinus tract formation and scarring. The apocrine glands, previously thought to be the inciting factor, seem to be secondary factors.2 Treatment modalities, including conservative, medical, and surgical strategies, are mostly of limited effectiveness and recurrences often occur. Our patient received serial treatments consisting of systemic antibiotics, anti-inflammatory agents, and incision with drainage. Despite these treatments, recurrent pain and purulent discharge persisted. Unlike other immunosuppressive and biologic agents, the laser device provides the advantages of local treatment without systemic side effects. Carbon dioxide laser excision with secondary healing is used to treat mild to moderate diseases. Its superiority compared to classic surgery is still under debate. Long duration of wound healing, scar formation, and recurrences are the main drawbacks of carbon dioxide laser excision.1 In a recent study analysis, the long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser was demonstrated to improve HS at a success rate of 72.7%.3 The absence of open wounds, less scarring, and prevention of new lesion formation make the long-pulsed Nd:YAG laser a promising treatment. Similar responses of the 755-nm Alexandrite laser in our case included obvious improvement in discharge and pain; no recurrence or exacerbation exhibited after a course of laser therapy. The biopsy results of mixed inflammation and remnants of hair follicles at 4 weeks following the first laser treatment session were also similar.3,4 However, a slight recurrence after the first session of long-pulsed Alexandrite laser therapy was not mentioned in the long-pulsed Nd:YAG laser treatment. Instead, initial worsening with increasing inflammation and drainage was noted during the first week after the long-pulsed Nd:YAG laser treatment.3,4 In our patient, the HS discharge became dry immediately and nodules subsided gradually after the laser treatment. The possible mechanism of laser therapy in HS is deocclusion of the follicular unit by destruction of the hair shaft and decrease of inflammatory lesions by photothermolysis. Statistical studies on epilation have shown that the long-pulsed Alexandrite laser provides more efficiency and less injury than the Nd:YAG laser dose because of less absorptive competition with melanin and an appropriate wavelength to reach hair shaft depths.5 Theoretically, the Alexandrite laser should provide better results than the Nd:YAG laser for treating HS. In contrast to the results of a 22-patient, prospective, randomized controlled trial of HS treatment with the
1027-8117/$ – see front matter Copyright Ó 2013, Taiwanese Dermatological Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.dsi.2013.04.007
116
Correspondence / Dermatologica Sinica 32 (2014) 115–117
Figure 1 Left axilla-laser treatment side. (A) Prior to laser treatment, a nodule (arrow) and another sinus tract (arrowhead) are present. (B) Four weeks after the first laser session, mild recurrence is noted. A biopsy was obtained from one of the recurrent lesions (arrowhead). (C) At 8-month follow-up after three monthly laser sessions, only red and brown pigmentation exhibit no recurrence. Right axilla-antibiotics treatment side. (D) New onset HS lesion. (E) Four weeks since onset. (F) Seven months after onset, recurrent and extensive lesions are present.
Figure 2 One month after laser treatment. (A) Infiltration consists of histiocytes, lymphocytes, plasma cells, and multinucleated giant cells (hematoxylin-eosin stain; original magnification: 20); (B) Free hair remnants within dermis are surrounded by lymphocytes (hematoxylin-eosin stain; original magnification: 200).
Correspondence / Dermatologica Sinica 32 (2014) 115–117
Nd:YAG laser showing necessity for four monthly laser sessions,4 our case exhibited obvious improvement of HS after the first session of the long-pulsed Alexandrite laser (Figure 1B). Our patient received two additional treatment sessions and exhibited further improvement without recurrence in the 8-month follow-up (Figure 1C). In conclusion, our histopathology results corresponded to the suggested mechanism of the long-pulsed Nd:YAG laser for treating HS, including deocclusion of the hair follicle followed by drainage of the inflammatory lesion and destruction of the follicular unit. The long-pulsed Nd:YAG laser has been shown to be a treatment advance for this highly disabling condition in both clearing preexisting lesions and preventing new eruptions. Based on the concept of epilation and our case observations, we propose that the longpulsed Alexandrite laser may provide at least the same efficacy as that of the Nd:YAG laser. Large randomized clinical studies are warranted to clarify the role and indication of the Alexandrite laser for the treatment of HS. Ya-Chu Tsai, Shu-Hui Wang, Po-Hsuan Lu, Tsung-Hua Tsai* Department of Dermatology, Far Eastern Memorial Hospital, New Taipei, Taiwan * Corresponding author. No. 21, Sec. 2, Nanya S. Rd., Banqiao Dist., New Taipei City 220, Taiwan. Tel.: þ886 956117070. E-mail address: [email protected] (T.-H. Tsai)
117
Conflicts of interest: The authors declare that they have no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in this article.
References 1. Revuz J. Hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2009;23: 985–98. 2. Sellheyer K, Krahl D. Hidradenitis suppurativa is acne inversa! An appeal to (finally) abandon a misnomer. Int J Dermatol 2005;44:535–40. 3. Xu LY, Wright DR, Mahmoud BH, Ozog DM, Mehregan DA, Hamzavi IH. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment. Arch Dermatol 2010;147:21–8. 4. Mahmoud BH, Tierney E, Hexsel CL, Pui J, Ozog DM, Hamzavi IH. Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser. J Am Acad Dermatol 2010;62:637–45. 5. Rao J, Goldman MP. Prospective, comparative evaluation of three laser systems used individually and in combination for axillary hair removal. Dermatol Surg 2005;31:1671–6.
Received: Dec 3, 2012 Revised: Apr 20, 2013 Accepted: Apr 30, 2013