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Hypertrophic scarring resulting from flashlamp-pumped pulsed dye laser surgery
Drief communications Hypertrophic scarring resulting from flashlamp-pumped pulsed dye laser surgery James M. Swinehart, MD Denver, Colorado The flashlamp-pumped tunable dye laser represents a major advance in the treatment of port-wine stains and other vascularmalformations.' Its superiorityoverpreviously available laser therapy (both carbon dioxide and argon) has been clearlydemonstrated,withsignificant or completefadingoflesions, evenin children.' Previous experience with the carbon dioxide and argon lasers has demonstrated that, although effective in most instances these lasers have a significantly higher risk of hypertrophic scarring than that reported with the flashlamppumped tunable dye laser.' The flashlamp-pumped tunable dye laserwasdesigned to minimize these and other risks. Its 577 or 585 nm wavelength corresponds to the beta absorption peak of ~xy'hemoglobin, a wavelength at whichmelaninhas only limited absorption," In addition,its 450 msecpulseduration is significantly less than the thermal relaxation time From the Denver Dermatology Center. Reprint requests: James M. Swinehart, MD, 950 E. Harvard Ave., Suite 630, Denver, CO 80210.
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of the targeted vascular structures and minimizes extravascularnecrosis and damage. The laserisselective for oxyhemoglobin in instancesin which the patient's skin is not heavilypigmented and at the proper energy dose. Although the incidence of side effectsfrom this laser has been extraordinarilylow, some have been reported. Theseincludehyperpigmentation and hypopigmentation, cutaneousinfection, pyogenic granuloma and "rare cutaneous depression."? Initially, scarring from the tunable dye laser had not been seen," More recently, however, a "limited scar"was reported after treatment of an isolated area with an energydensitygreater than 11.0joulesj em', althoughsubsequent treatment ofthis patient withenergy densities in the range of 5.5 to 7.5joules/em- revealedno scarring,"Another report described"isolated, superficial, depressed scars" in 2 of 35 childrentreated with the tunable dye laser,reportedly in areas traumatized within24 hours after laser treatment.' Although hypertrophic scarring from flashlamp-pumped tunable dye lasertherapy has not been previously reported, one case of a persistent hypertrophic scar from this laser therapy is presented. Case report .A 27~year-old white man had an extensive congenital portwmestain that covered much ofhis neck, chest, back, upper abdomen,and forearms. The lesion wasentirely macular and me-
Fig. 1. Hypertrophic scar in center spotof three tunable dyelaser testareas on anterior aspect.of the chest (6.0 joules/car' laterally, 6.5 joules/em- centrally, and 7.0 joules/em? medically.) 845
846
Journal of the American Academy of Dermatology
Briefcommunications
dium violet-red. The patient was in excellent health and had not reported any previous incidence of abnormal scarring or keloid formation. The patient had no evidence or history of acne or other inflammatory skin disease in this area. Laser test spots were performed in an area in which side effects would be most likely and improvement most visible, namely, the anterior aspect of the chest. An area free of nevomelanocytic pigmented lesions was selected as a test site. The Candela SPTL-l flashlarnp-pumped tunable dye laser (Candela Corp., Wayland, Mass.) was used for this purpose (585 nm wavelength, 5 mm spot, fixed focal length guide, and 450 msec pulse duration). The energy f1uence was calculated immediately before therapy with an Ophir meter (Ophir Co., Jerusalem, Israel). Three adjacent test spots were performed on the left anterior aspect of the chest, on clinically normal skin, each with five barely overlapping 5 mm pulses: 6.0 joules/em? laterally, 6.5 joules/em- centrally, and 7.0 joules/em- medially. No "error code" was noted on the laser readout. The skin was not prepared before treatment, and standard operating techniques were otherwise followed. Immediately after treatment, a characteristic purple-gray color was noted; the group of three lesions was covered with Vigilon dressing for 24 hours and subsequently left uncovered by the patient except for antibiotic ointment. There was no history of trauma to the lesions. Examination at the I -week interval revealed mild crusting in all three areas, indicating possible thermal damage to the treated areas. An examination at the 3-week interval, however, revealed a firm, smooth, indurated, nontender shiny red plaque, 1.3 em in diameter, only in the central of the three sites, consistent with a hypertrophic scar. Although a biopsy was not performed, the hypertrophic scar persisted unchanged for 5 months (Fig. I).
Discussion. This hypertrophic scar in a tunable dye laser test spot is not only unique, but unusual because energy densities greater than, and lower than, the causative density (6.5 joules/cm-) failed to produce a similar scar. AU three spots were treated identically in the postoperative period by the patient, who denies any trauma to the lesion. Possible causes of the hypertrophic scar might include (1) localized infection (although this was not evident clinically); (2) the overlapping of adjacent test pulses, producing localized, pinpoint thermal damage; (3) the location of the test spots (i.e., on the anterior aspect of the chest); (4) a possible occasional tendency of the laser to abnormally "spike" a single pulse at a level higher than that set on the machine, even when calibration was performed immediately before treatment. The observed hypertrophic scar could also have resulted from a malfunction in the power meter, although the test spot performed several seconds later did not produce a scar. (5) It is possible that the test area could have been situated over a lentigo that was otherwise obscured by the color of the patient's port-wine stain. REFERENCES
1. Morelli JG, Tan OT, Garden J, et aI. Tunable dye laser (577
nm) treatment of port wine stains. Lasers Surg Med 1986; 6:94-9.
2. Tan OT. Dye-laser treatment of children with port-wine stains [Letter]. N Engl J Med 1989;321 :902. 3. Tan OT, Carney JM, Margolis R, et al. The histologic responses of port-wine stains treated by argon, carbon dioxide, and tunable dye lasers. Arch Dermatol 1986;122:101622. 4. Glassberg E, Lask GP, Tan EML, et at. The flashlamppumped 577-nm pulsed tunable dye laser: clinical efficacy and in vitro studies. J Dermatol Surg Oneol 1988;14: 1200-8. 5. Garden JM, Polla LL, Tan OT. The treatment of port-wine stains by the pulsed dye laser. Arch Dermatol1988;124:88996. 6. Garden JM, Tan OT, Parrish JA. The pulsed dye laser: its use at 577 nm wavelength. J Dermatol Surg Oncol 1987; 13:134-8. 7. Tan OT, Sherwood K, Gilchrest BA. Treatment of children with port-wine stains using the flashlamp-pulsed tunable dye laser. N Engl J Med 1989;320:416-21.
IgA autoantibodies bind to pemphigus vulgaris antigen in a case of intraepidermal neutrophilic IgA dermatosis Catherine Prost, MD,a, b Liliane Intrator, BA,e Janine Wechsler, MD,d Celeste Lebbe, MD,a Martine Bagot, MD,a Jean-Claude Roujeau, MD,a Louis Dubertret, MD,b and Jean Revuz, MDa Creteil, France Huff et al.' described, as a new entity, a patient with an intraepidermal vesiculopustular disease characterized by intraepidermal neutrophils and extensive IgA deposits. As stated by Katz,2 characterization of the antigens to which the IgA antibodies bind might help clarify the relation of this disease to other autoimmune blistering dermatoses. Twelve other cases with intraepidermal IgA deposits have been reported.l" In none of them were target antigens of IgA further characterized by both immunoelectron microscopy and Western immunoblot. We report a case similar to Huff's. Case report A 85-year-old woman was admitted with a pruritic eruption. Isolated or grouped pustulo-bullous lesions were associated with superficial erosions, crusted areas, and irregular erythematous plaques. The lesions involved all parts of the skin except the distal extremities bu t were most dense in flexural areas. Mucous membranes were spared. In addition, our case, like that described by Huff, displayed an unusual combination of features, including extensive intercellular IgA deposits in the lower to middle epidermis, blisters in the mid epidermis, minimal acantholysis, the prominence of neutrophils as the primary inflammatory cells, and responsiveness to dapsone. No circulating From the Dermatology Service,' Unite INSERM,b and the Departments of Immunology? and Pathology," H6pital Henri Mondor. Reprint requests: Catherine Prost, MD, Unite INSERM U 312, H6pita! Henri Mondor, Creteil, 94010. France.
16/4/30607
16/4/31554
of the targeted vascular structures and minimizes extravascularnecrosis and damage. The laserisselective for oxyhemoglobin in instancesin which the patient's skin is not heavilypigmented and at the proper energy dose. Although the incidence of side effectsfrom this laser has been extraordinarilylow, some have been reported. Theseincludehyperpigmentation and hypopigmentation, cutaneousinfection, pyogenic granuloma and "rare cutaneous depression."? Initially, scarring from the tunable dye laser had not been seen," More recently, however, a "limited scar"was reported after treatment of an isolated area with an energydensitygreater than 11.0joulesj em', althoughsubsequent treatment ofthis patient withenergy densities in the range of 5.5 to 7.5joules/em- revealedno scarring,"Another report described"isolated, superficial, depressed scars" in 2 of 35 childrentreated with the tunable dye laser,reportedly in areas traumatized within24 hours after laser treatment.' Although hypertrophic scarring from flashlamp-pumped tunable dye lasertherapy has not been previously reported, one case of a persistent hypertrophic scar from this laser therapy is presented. Case report .A 27~year-old white man had an extensive congenital portwmestain that covered much ofhis neck, chest, back, upper abdomen,and forearms. The lesion wasentirely macular and me-
Fig. 1. Hypertrophic scar in center spotof three tunable dyelaser testareas on anterior aspect.of the chest (6.0 joules/car' laterally, 6.5 joules/em- centrally, and 7.0 joules/em? medically.) 845
846
Journal of the American Academy of Dermatology
Briefcommunications
dium violet-red. The patient was in excellent health and had not reported any previous incidence of abnormal scarring or keloid formation. The patient had no evidence or history of acne or other inflammatory skin disease in this area. Laser test spots were performed in an area in which side effects would be most likely and improvement most visible, namely, the anterior aspect of the chest. An area free of nevomelanocytic pigmented lesions was selected as a test site. The Candela SPTL-l flashlarnp-pumped tunable dye laser (Candela Corp., Wayland, Mass.) was used for this purpose (585 nm wavelength, 5 mm spot, fixed focal length guide, and 450 msec pulse duration). The energy f1uence was calculated immediately before therapy with an Ophir meter (Ophir Co., Jerusalem, Israel). Three adjacent test spots were performed on the left anterior aspect of the chest, on clinically normal skin, each with five barely overlapping 5 mm pulses: 6.0 joules/em? laterally, 6.5 joules/em- centrally, and 7.0 joules/em- medially. No "error code" was noted on the laser readout. The skin was not prepared before treatment, and standard operating techniques were otherwise followed. Immediately after treatment, a characteristic purple-gray color was noted; the group of three lesions was covered with Vigilon dressing for 24 hours and subsequently left uncovered by the patient except for antibiotic ointment. There was no history of trauma to the lesions. Examination at the I -week interval revealed mild crusting in all three areas, indicating possible thermal damage to the treated areas. An examination at the 3-week interval, however, revealed a firm, smooth, indurated, nontender shiny red plaque, 1.3 em in diameter, only in the central of the three sites, consistent with a hypertrophic scar. Although a biopsy was not performed, the hypertrophic scar persisted unchanged for 5 months (Fig. I).
Discussion. This hypertrophic scar in a tunable dye laser test spot is not only unique, but unusual because energy densities greater than, and lower than, the causative density (6.5 joules/cm-) failed to produce a similar scar. AU three spots were treated identically in the postoperative period by the patient, who denies any trauma to the lesion. Possible causes of the hypertrophic scar might include (1) localized infection (although this was not evident clinically); (2) the overlapping of adjacent test pulses, producing localized, pinpoint thermal damage; (3) the location of the test spots (i.e., on the anterior aspect of the chest); (4) a possible occasional tendency of the laser to abnormally "spike" a single pulse at a level higher than that set on the machine, even when calibration was performed immediately before treatment. The observed hypertrophic scar could also have resulted from a malfunction in the power meter, although the test spot performed several seconds later did not produce a scar. (5) It is possible that the test area could have been situated over a lentigo that was otherwise obscured by the color of the patient's port-wine stain. REFERENCES
1. Morelli JG, Tan OT, Garden J, et aI. Tunable dye laser (577
nm) treatment of port wine stains. Lasers Surg Med 1986; 6:94-9.
2. Tan OT. Dye-laser treatment of children with port-wine stains [Letter]. N Engl J Med 1989;321 :902. 3. Tan OT, Carney JM, Margolis R, et al. The histologic responses of port-wine stains treated by argon, carbon dioxide, and tunable dye lasers. Arch Dermatol 1986;122:101622. 4. Glassberg E, Lask GP, Tan EML, et at. The flashlamppumped 577-nm pulsed tunable dye laser: clinical efficacy and in vitro studies. J Dermatol Surg Oneol 1988;14: 1200-8. 5. Garden JM, Polla LL, Tan OT. The treatment of port-wine stains by the pulsed dye laser. Arch Dermatol1988;124:88996. 6. Garden JM, Tan OT, Parrish JA. The pulsed dye laser: its use at 577 nm wavelength. J Dermatol Surg Oncol 1987; 13:134-8. 7. Tan OT, Sherwood K, Gilchrest BA. Treatment of children with port-wine stains using the flashlamp-pulsed tunable dye laser. N Engl J Med 1989;320:416-21.
IgA autoantibodies bind to pemphigus vulgaris antigen in a case of intraepidermal neutrophilic IgA dermatosis Catherine Prost, MD,a, b Liliane Intrator, BA,e Janine Wechsler, MD,d Celeste Lebbe, MD,a Martine Bagot, MD,a Jean-Claude Roujeau, MD,a Louis Dubertret, MD,b and Jean Revuz, MDa Creteil, France Huff et al.' described, as a new entity, a patient with an intraepidermal vesiculopustular disease characterized by intraepidermal neutrophils and extensive IgA deposits. As stated by Katz,2 characterization of the antigens to which the IgA antibodies bind might help clarify the relation of this disease to other autoimmune blistering dermatoses. Twelve other cases with intraepidermal IgA deposits have been reported.l" In none of them were target antigens of IgA further characterized by both immunoelectron microscopy and Western immunoblot. We report a case similar to Huff's. Case report A 85-year-old woman was admitted with a pruritic eruption. Isolated or grouped pustulo-bullous lesions were associated with superficial erosions, crusted areas, and irregular erythematous plaques. The lesions involved all parts of the skin except the distal extremities bu t were most dense in flexural areas. Mucous membranes were spared. In addition, our case, like that described by Huff, displayed an unusual combination of features, including extensive intercellular IgA deposits in the lower to middle epidermis, blisters in the mid epidermis, minimal acantholysis, the prominence of neutrophils as the primary inflammatory cells, and responsiveness to dapsone. No circulating From the Dermatology Service,' Unite INSERM,b and the Departments of Immunology? and Pathology," H6pital Henri Mondor. Reprint requests: Catherine Prost, MD, Unite INSERM U 312, H6pita! Henri Mondor, Creteil, 94010. France.
16/4/30607