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Role of the argon laser in treatment of lymphocytoma cutis
Volume 14 Number 2, Part 1 February, 1986
17.
18.
19.
20.
in exsanguinating liver injury. Surg Forum 23:350-352, 1972. Arnoff BL: The carbon dioxide laser in head and neck and plastic surgery: Advantages and disadvantages, in Goldman L, editor: The biomedical laser: Technology and clinical applications. New York, 1981, SpringerVerlag New York Inc., pp. 239-254. Ascher PW, Ingolitsch E, Walter G, et al: Ultrastructural findings in CNS tissue with CO 2 Jaser, in Kaplan 1, editor: Laser surgery, vol. Ill. Jerusalem, Israel, 1978, Jerusalem Academic Press, pp. 81-90. Ben-Bassat M, Ben-Bassat M, Kaplan I: A study of the ultrastructural features of the cut margin of skin and mucous membranes specimens excised by carbon dioxide laser. J Surg Res 21:77-84, 1976. Bailin PL: Use of the CO 2 laser for non-PWS cutaneous
Treatment of acne keloidalis nuchae with laser
21. 22. 23. 24.
lesions, in Arndt KA, Noe JM, Rosen S, editors: Cutaneous laser therapy: Principles and methods. Chichester, England, 1983, John Wiley & Sons, Ltd., pp. 187199. Bailin PL, Ruiz-Esparza J: CO 2 laser treatment of a massive keloid: A case report and preliminary comment on a series. J Dennatol Surg Oneal. (In press.) Wheeland RG, Kantor GR, Bailin PL, et al: Treatment of earlobe keloids with the carbon dioxide laser: A report of 14 cases. (Submitted for publication.) Bailin PL, Ratz JL, Lutz-Nagey L: CO 2 laser modification of Mohs' surgery. J Dermatol Surg Oneal 7:621623, 1981. Bailin PL, Ratz JL: The CO 2 laser, in Ratz JL, editor: Lasers in cutaneous medicine and surgery. Chicago, 1985, Year Book Medical Publishers, Inc. (In press.)
Role of the argon laser in treatment of lymphocytoma cutis Ronald G. Wheeland, M.D., F.A.C.P.,* Gary R. Kantor, M.D.,* Philip L. Bailin, M.D.,* and Wilma F. Bergfeld, M.D.** Cleveland, OH Lymphocytoma cutis characteristically appears as persistent reddish purple papules, nodules, or plaques. Response to treatment is variable and recurrences are common. We report the use of the argon laser as a modality that improved cosmetic appearance and alleviated symptoms of lymphocytoma cutis but that failed to provide complete histologic clearing of the inflammatory cells. (J AM ACAD DERMATOL 14:267-272, 1986.)
Lymphocytoma cutis is a benign lymphoreticular proliferation within the skin that may be difficult to distinguish both clinically and histologically from malignant lymphoma. Synonyms for lymphocytoma cutis include Spiegler-Fendt sarcoid, cutaneous pseudolymphoma, and lymphadenosis benigna cutis. Treatment of this persistent entity has included penicillin, I hydroxychloroquine, 2 topical, intralesional, and oral corticosteroids, 3 light protection cream, 4 local radiotherapy, From the Departments of Dermatology* and Pathology, ** Cleveland Clinic Foundation. No reprints available.
topical nitrogen mustard, systemic chemotherapy, surgical excision, and cryotherapy.5 The argon laser has previously been reported to provide an effective form of therapy for inflammatory conditions such as granuloma faciale. 6,7 Through a relatively select form of vascular damage, which results from the absorption of laser thermal energy by hemoglobin, the argon laser can be used with minimal effect on adjacent tissues. Since the lesions of lymphocytoma cutis appear clinically to have an increased vascularity over normal tissue because of the reddish purple color of the papules, plaques, and nodules, we elected to use the argon laser to treat this entity.
267
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Wheeland et al
CASE REPORT The patient is a healthy 30-year-old white man with a 3-year history of slowly enlarging, slightly painful, pruritic nodules of the chest, upper portion of the back, and the shoulder. He reported that in 1977 two similar lesions had been excised from the forehead and back and had recurred. The review of symptoms was noncontributory. There was no history of seizures or past use of phenytoin, and he denied long-term use of medication. The physical examination at the time of initial presentation showed two 5-cm red-purple nodules of the upper portion of the back, a 3-cm nodule of the mediosuperior aspect of the right shoulder, and a 5 x 10em violaceous plaque on the laterosuperior aspect of the right shoulder (Fig. 1). Complete blood count, serum chemistry profile, sedimentation rate, rheumatoid factor, antinuclear antibody, rapid plasma reagin, and results of urinalysis, chest x-ray, and bone marrow biopsy were normal or negative. The pathologic examination of two punch biopsy specimens from representative lesions of the upper portion of the back and the shoulder showed a normal epidermis and a normal papillary dermis. Although no germinal centers were identified, a diffuse lymphocytic and histiocytic inflammatory infiltrate with slight vascular proliferation extended to the deep reticular dermis (Fig. 2). Immunohistochemistry study showed weakly positive reactions for kappa, lambda, and T cells but a strongly positive Ia reaction. This mixed inflammatory infiltrate with histiocytic preponderance was thought to be compatible with the clinical diagnosis of lymphocytoma cutis. The patient was initially treated with hydroxychloroquine, 200 mg given orally once daily. Although some slow regression of existing lesions occurred over a period of 3 months, new painful, pruritic nodules and plaques continued to develop. A trial of intralesional corticosteroids provided only slight improvement in symptoms. Hydroxychloroquine was discontinued after
Journal of the American Academy of Dermatology
slow, progressive enlargement of the plaque on the right shoulder was noted. Because of past failure with this patient's antimalarial and intralesional steroid therapy, as well as persistent symptoms and continued enlargement of his lymphocytoma cutis lesions, an attempt was made to induce regression with the argon laser. With 1% plain lidocaine local anesthesia, a series of small test sites were treated on a representative lesion of the upper portion of the back with the use of a variety of irradiance levels and exposure times. Postoperatively there was minimal pain, and wound care consisted of twice daily cleansings with 3% hydrogen peroxide followed by application of ointment consisting of polymyxin B sulfate and bacitracin zinc (Polysporin) and the use of a Telfa dressing. Complete reepithelialization occurred within 1 week. At the 3-month follow-up visit the greatest degree of lightening had been obtained by delivering slightly overlapping impacts with the 2-mm probe using 3.5 watts, 0.2-second pulses, and an irradiance of 111 watts/cm z. These same parameters were subsequently used to treat all additional lesions of lymphocytoma cutis. Each treatment site showed significant immediate blanching, whereas the degree of permanent blanching 5 months after treatment was 60% to 70% and was associated with the flattening of each treatment site and the resolution of discomfort and pruritus. The patient did well until approximately 8 months after the initial argon laser treatment, when he reported slight discomfort, swelling, and a return of redness within one previously treated area on the superior aspect of the right shoulder. The physical examination at that time showed several small, reddish purple, 3-4 mm papules within a larger, indurated plaque on the right shoulder. All other treated lesions, however, continued to show an excellent clinical response and remained flat with nearly normal skin color (Fig. 3). Because of the apparent failure of argon laser therapy to completely control the patient's disease,
Fig. 1. Pretreatment clinical appearance of a raised, red to violaceous plaque of the superior aspect of the right shoulder. Fig. 2. Pretreatment histologic appearance from a representative plaque showing a diffuse, dense lymphocytic and hi~tiocytic inflammatory infiltrate throughout the reticular dermis with slight vascular proliferation. (Hematoxylin-eosin stain; X 25.) Fig. 3. Appearance of the same lesion identified in Fig. 1. Eight months after laser phototherapy, the lesion demonstrated faint residual erythema but complete flattening of the plaque, without a sign of recurrence. Fig. 4. Posttreatment histologic appearance of the lesion described in Figs. 1 and 3. Note residual dense reticular dermal lymphocytic infiltrate with sparing of the superficial reticular and papillary dermis. (Hematoxylin-eosin stain; X 25.)
Volume 14 Number 2, Part 1 February, 1986
Argon laser in lymphocytoma cutis 269
Figs. 1-4. For legends, see opposite page.
270
Journal of the American Academy of Dermatology
Wheeland et al
Table I. Cutaneous vascular lesions treated with
Table III. Miscellaneous cutaneous lesions
argon laser
treated with argon laser
Benign lesions Acne rosacea, rhinophyma Adenoma sebaceum Angiokeratoma Angioma serpiginosum Cavernous and capillary hemangioma Cherry angioma Postrhinoplasty red nose Port-wine stain Glomangioma Pyogenic granuloma Spider ectasia Telangiectasia (hereditary hemorrhagic) Venous lake Malignant lesions Angiosarcoma Kaposi's sarcoma
Benign lesions Comedonal cyst Fibrous papule Granuloma faciale Keloids and hypertrophic scars Lymphangioma circumscriptum Sebaceous hyperplasia Syringoma Tattoo Verruca vulgaris Xanthelasma Malignant lesions Basal cell carcinoma follicular, perivascular, and periappendageal distribution (Fig. 4). DISCUSSION
Table II. Cutaneous pigmented lesions treated with argon laser Benign lesions Cafe au lait spot Giant hairy nevus Lentigines Nevi (nevocellular and epidermal) Nevus of Ota Peutz-Jeghers spot Seborrheic keratosis Malignant lesions Lentigo maligna Melanoma Pigmented basal cell carcinoma 3-mm punch biopsy specimens were taken from the site
of apparent recurrence on the superior aspect of the right shoulder and from a site of apparent total clinical clearing on the lateral aspect of the right shoulder. Both biopsies showed strikingly similar histopathologic features consisting of focal acanthosis with normal epidermal thickness and rete pattern. Thick sclerotic collagen bundles were present within the mid and deep reticular dermis, but the papillary and superficial reticular dermis was composed of normal-appearing, lighter-staining, finely branched fibers. The papillary and superficial reticular dermis was clear of inflammatory infiltrate to an average depth of 0.4 to 1.2 mm, which represented between 12% and 29% of the entire skin thickness. Throughout the deeper dermis were foci of moderately dense inflammatory cells having a peri-
Lymphocytoma cutis may occur in both localized and disseminated 3 forms. The localized type is far more common and typically affects the face, earlobes, and nasal tip. Individual lesions may regress spontaneously but may recur in 50% of the cases at the original or distant sites. S Although the exact cause of lymphocytoma cutis is unclear, some cases can apparently be induced by drugs such as phenytoin 8 •9 or mephenytoin, 9 insect bites,10.11 trauma,l\ hyposensitization allergy injections, 1 1,12 herpes zoster infection,13 and tattoos. 14 Since lymphocytoma cutis may be difficult to distinguish histologically from malignant lymphoma, differentiating criteria have been described. s.ls These include the presence of numerous sharply defined germinal centers, abundant polychrome bodies (nuclear dust within follicles) ,5.11,12 and vascular proliferation with endothelial cell swelling. 5,15 The argon laser emits an intense blue-green light with two peak emission bands at wavelengths of 488 and 514 nm. Two chromatophores of the skin, hemoglobin and melanin, have maximum absorption spikes within the emission range of the argon laser and selectively absorb argon laser energy. In cutaneous surgery the argon laser has proved Useful in the treatment of a variety of vascular l 6-40 (Table I) and pigmented36.37.39,4H3 (Table II) le-
Volume 14 Number 2, Part 1 February, 1986
sions. In addition, through nonselective photocoagulation, many other avascular and nonpigmented lesions have also been successfully treated with the argon laser (Table III). 44-47 Complications of argon laser therapy are generally minimal and consist of hypertrophic scarring, atrophy, and hypo- and hyperpigmentation. 48,49 Since lymphocytoma cutis is characterized clinically by a reddish-purple discoloration, presumably caused by increased vascularity or vascular dilatation, we attempted to use the argon laser to selectively treat several persistent lymphocytoma cutis plaques that had proved resistant to prior conservative medical management. We theorized that the argon laser could produce regression of lymphocytoma cutis lesions by its relatively specific thermal effects on blood vessels, resulting in photocoagulation similar to that seen in treatment of port-wine stains. Although our patient had a favorable clinical response, the argon laser-treated sites showed histologic resolution of the infiltrate only to an average depth of 0.4 to 1.2 mm; the deeper inflammatory component persisted. These findings are similar to those in previous studies of port-wine stains treated with the argon laser,26.50 in which histologically confirmed thermal injury was limited to the upper 1 mm of the dermis. This study may have relevance in other cuta~ neous lesions treated with the argon laser, since our findings suggest that at least for argon laser phototherapy of infiltrative or inflammatory conditions of the skin, clinical responsiveness may not always imply histologic resolution. This fact may be crucial in the laser treatment of premalignant or malignant lesions in which a favorable therapeutic response may be monitored only clinically because histologic evaluation of tissue is not always practical or possible. We conclude that the argon laser may be a useful modality for "camouflaging" resistant lymphocytoma cutis lesions, especially for cosmetically important areas such as the face. Complete resolution or cure, however, is not obtained because any infiltrate deeper than 1.0 to 1.5 mm, which is the limit of the photocoagulating effect of the argon laser, is likely to persist. Furthermore, histologic confirmation of lymphocytoma cutis should be firmly established before argon laser photoco-
Argon laser in lymphocytoma cutis
271
agulative therapy is chosen, since this treatment may be incomplete and rare cases of associated benign and malignant infiltrates have been reported. 15 REFERENCES 1. Andersen BL, Brandrup F, Petri J: Lymphocytoma cutis: A pseudomalignancy treated with penicillin. Acta Derm Venereol (Stockh) 62:83-85, 1982. 2. Stoll DM: Treatment of cutaneous pseudolymphoma with hydroxychloroquine. J AM ACAD DERMATOL 8:696-699, 1983. 3. Self SJ, Carter VH, Noojin RO: Disseminated lymphocytoma cutis. Arch Dermatoll00:459-464, 1969. 4. Frain-Bell W, Magnus IA: A study of the photosensitivity factor in cutaneous lymphocytoma. Br J Dermatol 84:2531, 1971. 5. Evans HL, Winkelmann RK, Banks PM: Differential diagnosis of malignant and benign cutaneous lymphoid infiltrates. Cancer 44:699-717,1979. 6. Apfelberg DB, Maser MR, Lash H, Rivers J: The argon laserfor cutaneous lesions. JAMA 245:2073-2075, 1981. 7. Apfelberg DB, Maser MR, Lash H, Flores J: Expanded role of the argon laser in plastic surgery. J Dermatol Surg Oncol 9:145-151, 1983. 8. Charlesworth EN: Phenytoin-induced pseudolymphoma syndrome. Arch Dermatol 113:477-480, 1977. 9. Schreiber MM, McGregor JG: Pseudolymphoma syndrome. Arch Dermatol 97:297-300, 1968. 10. Allen AC: Persistent "insect bites" (dermal eosinophilic granulomas) simulating lymphoblastomas, histiocytosis, and squamous cell carcinomas. Am J Pathol 24:367-387, 1948. 11. Mach KW, Wilgram GF: Characteristic histopathology of cutaneous Iymphoplasia (lymphocytoma). Arch Dermatol 94:26-32, 1966. 12. Bernstein H, Shupack J, Ackerman AB: Cutaneous pseudolymphoma resulting from antigen injections. Arch Dermatol110:756-757, 1974. 13. Sanchez JL, Mendez JA, Palacio R: Cutaneous peudolymphoma at the site of resolving herpes zoster. Arch DermatoI117:377, 1981. 14. B1umetal G, Okun MR, Ponitch JA: Pseudolymphomatous reaction to tattoos. J AM ACAD DERMATOL 6:485488, 1982. 15. Caro WA, Helwig EB: Cutaneous lymphoid hyperplasia. Cancer 24:482-502, 1969. 16. Apfelberg DB, Maser MR, Lash H: Argon laser management of cutaneous vascular deformities. West J Med 124:99-101, 1976. 17. Goldman L, Dreffer R, Rockwell RJ, Perry E: Treatment of portwine marks by an argon laser. J Dermatol Surg 2:385-388, 1976. 18. Goldman L, Dreffer R: Laser treatment of extensive mixed cavernous and port-wine stains. Arch Dermatol 113:504-505,1977. 19. Apfelberg DB, Maser MR, Lash H: Argon laser treatment of cutaneous vascular abnormalities: Progress report. Ann Plast Surg 1:14-18, 1978. 20. Apfelberg DB, Maser MR, Lash H: Treatment of nevi
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24. 25. 26. 27. 28. 29. 30.
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aranei by means of an argon laser. J Dermatol Surg Oncol 4:172-174, 1978. Goldman L: Laser treatment of multiple progressive glomangiomas. Arch Dennatol 114:1853-1854, 1978. Apfelberg DB, Maser MR, Lash H: Extended clinical use of the argon laser for cutaneous lesions. Arch DermatoI115:719-721, 1979. Noe JM, Barsky SH, Geer DE, et al: Port-wine stains and the response to argon laser therapy: Successful treatment and the predictive role of color, age, and biopsy. Plast Reconstr Surg 65:130-136, 1980. Cosman B: Experience in the argon laser therapy of portwine stains. Plast Reconstr Surg 65:119-129, 1980. Noe JM, Finley J, Rosen S, Arndt KA: Postrhinoplasty "red nose": Differential diagnosis and treatment by laser. Plast Reconstr Surg 67:661-664, 1981. McBurney EI, Leonard GL: Argon laser treatment of port-wine hemangiomas: Clinical and histologic correlation. South Med J 74:925-926, 1981. Lyons GD, Owens RE, Mouney DF: Argon laser destruction of cutaneous telangiectatic lesions. Laryngoscope 91:1322-1325, 1981. Arndt KA: Argon laser therapy of small cutaneous vascular lesions. Arch Dennatol118:220-224, 1982. Apfelberg DB, Master MR, Lash H, et al: The role of the argon laser in the management of hemangiomas. Int J Dermatol 21:579-589, 1982. Dixon JA: Argon laser treatment of port-wine stains, in Arndt KA, Noe JM, Rosen S, editors: Cutaneous laser therapy: Principles and methods. Chichester, England, 1983, John Wiley & Sons, Ltd., pp. 109-128. Hulsbergen Henning JP, van Gernert MJC: Rhinophyma treated with argon laser. Lasers Surg Med 2:211-215, 1983. Hobby LW: Further evaluation of the potential of the argon laser in the treatment of strawberry hemangiomas. Plast Reconstr Surg 71:481-485, 1983. Landthaler M, Raina D, Waidelich W, Braun-Falco 0: Laser therapy of venous lakes (Bean-Walsh) and telangiectasias. Plast Reconstr Surg 73:78-83, 1984. Touquet VLR, Carruth JAS: Review of the treatment of port-wine stains with the argon laser. Lasers Surg Med 4:191-199, 1984. Kitzmiller KW: Laser treatment of tattoos and angiomas. J Med Assoc Oa 59:385-386, 1970.
Journal of the American Academy of Dermatology
36. Goldman L: Effects of new laser systems on the skin. Arch Dermatol 108:385-390, 1975. 37. Apfelberg DB, Maser MR, Lash H, Rivers JL: Progress report on extended clinical use of the argon laser for cutaneous lesions. Lasers Surg Med 1:71-83, 1980. 38. Riefkohl R: The role ofthe argon laser in plastic surgery. NC Med J 45:220-221, 1984. 39. Landthaler M, Haina D, Waidelich W, Braun-Falco 0: A three-year experience with the argon laser in dermatotherapy. J Dermatol Surg Oneal 10:456-461, 1984. 40. Dixon JA, Rotering RH, Huether SE: Patient's evaluation of argon laser therapy of port-wine stain, decorative tattoo, and essential telangiectasia. Lasers Sllrg Med 4:181190,1984. 41. Goldman L, Siler VE, Blaney D: Laser therapy in melanomas. Surg Gynecol Obstet 124:49-56, 1967. 42. Ohshiro T, Maruyama Y, Nakajima H, et al: Treatment of pigmentation of the lips and oral mucosa in PeutzJeghers' syndrome using ruby and argon lasers. Br J Plast Surg 33:346-349, 1980. 43. Arndt KA: Argon laser treatment of lentigo maligna. J AM ACAD DERMATOL 10:953-957, 1984. 44. Landthaler M, Haina D, Waidelich W, Braun-Falco 0: Argon laser therapy of verrucous nevi. Plast Reconstr Surg 74:108-113, 1984. 45. Apfelberg DB, Maser MR, Lash H: Argon laser treatment of decorative tattoos. Br J Plast Surg 32:141-144, 1979. 46. Arndt KA: Adenoma sebacellm: Successful treatment with the argon laser. Plast Reconstr Surg 70:91-93, 1982. 47. Henderson DL, Crowwell TA, Mes LG: Argon and carbon dioxide laser treatment of hypertrophic and keloid scats. Lasers Surg Med 3:271-277, 1984. 48. Apfelberg DB, Flores JT, Maser MR, Lash H: Analysis of complications of argon laser treatment for port-wine hemangiomas with reference to striped techniques. Lasers Surg Med 2:357-371, 1983. 49. Dixon JA, Heuther S, Rotering R: Hypertrophic scarring in argon laser treatment of port-wine stains. Plast Reconstr Surg 73:771-777, 1984. 50. Apfe1berg DB, Kosek J, Maser MR, Lash H: Histology of port-wine stains following argon laser treatment. Br J Plast Surg 32:232-237, 1979.
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Bound volumes of the JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY are available to subscribers (only) for the 1986 issues from the Publisher at a cost of $47.00 ($60.00 international) for volume 14 (January-June) and volume 15 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in jorce to qualify. Bound volumes are not available ill place oj a regular journal subscription.
17.
18.
19.
20.
in exsanguinating liver injury. Surg Forum 23:350-352, 1972. Arnoff BL: The carbon dioxide laser in head and neck and plastic surgery: Advantages and disadvantages, in Goldman L, editor: The biomedical laser: Technology and clinical applications. New York, 1981, SpringerVerlag New York Inc., pp. 239-254. Ascher PW, Ingolitsch E, Walter G, et al: Ultrastructural findings in CNS tissue with CO 2 Jaser, in Kaplan 1, editor: Laser surgery, vol. Ill. Jerusalem, Israel, 1978, Jerusalem Academic Press, pp. 81-90. Ben-Bassat M, Ben-Bassat M, Kaplan I: A study of the ultrastructural features of the cut margin of skin and mucous membranes specimens excised by carbon dioxide laser. J Surg Res 21:77-84, 1976. Bailin PL: Use of the CO 2 laser for non-PWS cutaneous
Treatment of acne keloidalis nuchae with laser
21. 22. 23. 24.
lesions, in Arndt KA, Noe JM, Rosen S, editors: Cutaneous laser therapy: Principles and methods. Chichester, England, 1983, John Wiley & Sons, Ltd., pp. 187199. Bailin PL, Ruiz-Esparza J: CO 2 laser treatment of a massive keloid: A case report and preliminary comment on a series. J Dennatol Surg Oneal. (In press.) Wheeland RG, Kantor GR, Bailin PL, et al: Treatment of earlobe keloids with the carbon dioxide laser: A report of 14 cases. (Submitted for publication.) Bailin PL, Ratz JL, Lutz-Nagey L: CO 2 laser modification of Mohs' surgery. J Dermatol Surg Oneal 7:621623, 1981. Bailin PL, Ratz JL: The CO 2 laser, in Ratz JL, editor: Lasers in cutaneous medicine and surgery. Chicago, 1985, Year Book Medical Publishers, Inc. (In press.)
Role of the argon laser in treatment of lymphocytoma cutis Ronald G. Wheeland, M.D., F.A.C.P.,* Gary R. Kantor, M.D.,* Philip L. Bailin, M.D.,* and Wilma F. Bergfeld, M.D.** Cleveland, OH Lymphocytoma cutis characteristically appears as persistent reddish purple papules, nodules, or plaques. Response to treatment is variable and recurrences are common. We report the use of the argon laser as a modality that improved cosmetic appearance and alleviated symptoms of lymphocytoma cutis but that failed to provide complete histologic clearing of the inflammatory cells. (J AM ACAD DERMATOL 14:267-272, 1986.)
Lymphocytoma cutis is a benign lymphoreticular proliferation within the skin that may be difficult to distinguish both clinically and histologically from malignant lymphoma. Synonyms for lymphocytoma cutis include Spiegler-Fendt sarcoid, cutaneous pseudolymphoma, and lymphadenosis benigna cutis. Treatment of this persistent entity has included penicillin, I hydroxychloroquine, 2 topical, intralesional, and oral corticosteroids, 3 light protection cream, 4 local radiotherapy, From the Departments of Dermatology* and Pathology, ** Cleveland Clinic Foundation. No reprints available.
topical nitrogen mustard, systemic chemotherapy, surgical excision, and cryotherapy.5 The argon laser has previously been reported to provide an effective form of therapy for inflammatory conditions such as granuloma faciale. 6,7 Through a relatively select form of vascular damage, which results from the absorption of laser thermal energy by hemoglobin, the argon laser can be used with minimal effect on adjacent tissues. Since the lesions of lymphocytoma cutis appear clinically to have an increased vascularity over normal tissue because of the reddish purple color of the papules, plaques, and nodules, we elected to use the argon laser to treat this entity.
267
268
Wheeland et al
CASE REPORT The patient is a healthy 30-year-old white man with a 3-year history of slowly enlarging, slightly painful, pruritic nodules of the chest, upper portion of the back, and the shoulder. He reported that in 1977 two similar lesions had been excised from the forehead and back and had recurred. The review of symptoms was noncontributory. There was no history of seizures or past use of phenytoin, and he denied long-term use of medication. The physical examination at the time of initial presentation showed two 5-cm red-purple nodules of the upper portion of the back, a 3-cm nodule of the mediosuperior aspect of the right shoulder, and a 5 x 10em violaceous plaque on the laterosuperior aspect of the right shoulder (Fig. 1). Complete blood count, serum chemistry profile, sedimentation rate, rheumatoid factor, antinuclear antibody, rapid plasma reagin, and results of urinalysis, chest x-ray, and bone marrow biopsy were normal or negative. The pathologic examination of two punch biopsy specimens from representative lesions of the upper portion of the back and the shoulder showed a normal epidermis and a normal papillary dermis. Although no germinal centers were identified, a diffuse lymphocytic and histiocytic inflammatory infiltrate with slight vascular proliferation extended to the deep reticular dermis (Fig. 2). Immunohistochemistry study showed weakly positive reactions for kappa, lambda, and T cells but a strongly positive Ia reaction. This mixed inflammatory infiltrate with histiocytic preponderance was thought to be compatible with the clinical diagnosis of lymphocytoma cutis. The patient was initially treated with hydroxychloroquine, 200 mg given orally once daily. Although some slow regression of existing lesions occurred over a period of 3 months, new painful, pruritic nodules and plaques continued to develop. A trial of intralesional corticosteroids provided only slight improvement in symptoms. Hydroxychloroquine was discontinued after
Journal of the American Academy of Dermatology
slow, progressive enlargement of the plaque on the right shoulder was noted. Because of past failure with this patient's antimalarial and intralesional steroid therapy, as well as persistent symptoms and continued enlargement of his lymphocytoma cutis lesions, an attempt was made to induce regression with the argon laser. With 1% plain lidocaine local anesthesia, a series of small test sites were treated on a representative lesion of the upper portion of the back with the use of a variety of irradiance levels and exposure times. Postoperatively there was minimal pain, and wound care consisted of twice daily cleansings with 3% hydrogen peroxide followed by application of ointment consisting of polymyxin B sulfate and bacitracin zinc (Polysporin) and the use of a Telfa dressing. Complete reepithelialization occurred within 1 week. At the 3-month follow-up visit the greatest degree of lightening had been obtained by delivering slightly overlapping impacts with the 2-mm probe using 3.5 watts, 0.2-second pulses, and an irradiance of 111 watts/cm z. These same parameters were subsequently used to treat all additional lesions of lymphocytoma cutis. Each treatment site showed significant immediate blanching, whereas the degree of permanent blanching 5 months after treatment was 60% to 70% and was associated with the flattening of each treatment site and the resolution of discomfort and pruritus. The patient did well until approximately 8 months after the initial argon laser treatment, when he reported slight discomfort, swelling, and a return of redness within one previously treated area on the superior aspect of the right shoulder. The physical examination at that time showed several small, reddish purple, 3-4 mm papules within a larger, indurated plaque on the right shoulder. All other treated lesions, however, continued to show an excellent clinical response and remained flat with nearly normal skin color (Fig. 3). Because of the apparent failure of argon laser therapy to completely control the patient's disease,
Fig. 1. Pretreatment clinical appearance of a raised, red to violaceous plaque of the superior aspect of the right shoulder. Fig. 2. Pretreatment histologic appearance from a representative plaque showing a diffuse, dense lymphocytic and hi~tiocytic inflammatory infiltrate throughout the reticular dermis with slight vascular proliferation. (Hematoxylin-eosin stain; X 25.) Fig. 3. Appearance of the same lesion identified in Fig. 1. Eight months after laser phototherapy, the lesion demonstrated faint residual erythema but complete flattening of the plaque, without a sign of recurrence. Fig. 4. Posttreatment histologic appearance of the lesion described in Figs. 1 and 3. Note residual dense reticular dermal lymphocytic infiltrate with sparing of the superficial reticular and papillary dermis. (Hematoxylin-eosin stain; X 25.)
Volume 14 Number 2, Part 1 February, 1986
Argon laser in lymphocytoma cutis 269
Figs. 1-4. For legends, see opposite page.
270
Journal of the American Academy of Dermatology
Wheeland et al
Table I. Cutaneous vascular lesions treated with
Table III. Miscellaneous cutaneous lesions
argon laser
treated with argon laser
Benign lesions Acne rosacea, rhinophyma Adenoma sebaceum Angiokeratoma Angioma serpiginosum Cavernous and capillary hemangioma Cherry angioma Postrhinoplasty red nose Port-wine stain Glomangioma Pyogenic granuloma Spider ectasia Telangiectasia (hereditary hemorrhagic) Venous lake Malignant lesions Angiosarcoma Kaposi's sarcoma
Benign lesions Comedonal cyst Fibrous papule Granuloma faciale Keloids and hypertrophic scars Lymphangioma circumscriptum Sebaceous hyperplasia Syringoma Tattoo Verruca vulgaris Xanthelasma Malignant lesions Basal cell carcinoma follicular, perivascular, and periappendageal distribution (Fig. 4). DISCUSSION
Table II. Cutaneous pigmented lesions treated with argon laser Benign lesions Cafe au lait spot Giant hairy nevus Lentigines Nevi (nevocellular and epidermal) Nevus of Ota Peutz-Jeghers spot Seborrheic keratosis Malignant lesions Lentigo maligna Melanoma Pigmented basal cell carcinoma 3-mm punch biopsy specimens were taken from the site
of apparent recurrence on the superior aspect of the right shoulder and from a site of apparent total clinical clearing on the lateral aspect of the right shoulder. Both biopsies showed strikingly similar histopathologic features consisting of focal acanthosis with normal epidermal thickness and rete pattern. Thick sclerotic collagen bundles were present within the mid and deep reticular dermis, but the papillary and superficial reticular dermis was composed of normal-appearing, lighter-staining, finely branched fibers. The papillary and superficial reticular dermis was clear of inflammatory infiltrate to an average depth of 0.4 to 1.2 mm, which represented between 12% and 29% of the entire skin thickness. Throughout the deeper dermis were foci of moderately dense inflammatory cells having a peri-
Lymphocytoma cutis may occur in both localized and disseminated 3 forms. The localized type is far more common and typically affects the face, earlobes, and nasal tip. Individual lesions may regress spontaneously but may recur in 50% of the cases at the original or distant sites. S Although the exact cause of lymphocytoma cutis is unclear, some cases can apparently be induced by drugs such as phenytoin 8 •9 or mephenytoin, 9 insect bites,10.11 trauma,l\ hyposensitization allergy injections, 1 1,12 herpes zoster infection,13 and tattoos. 14 Since lymphocytoma cutis may be difficult to distinguish histologically from malignant lymphoma, differentiating criteria have been described. s.ls These include the presence of numerous sharply defined germinal centers, abundant polychrome bodies (nuclear dust within follicles) ,5.11,12 and vascular proliferation with endothelial cell swelling. 5,15 The argon laser emits an intense blue-green light with two peak emission bands at wavelengths of 488 and 514 nm. Two chromatophores of the skin, hemoglobin and melanin, have maximum absorption spikes within the emission range of the argon laser and selectively absorb argon laser energy. In cutaneous surgery the argon laser has proved Useful in the treatment of a variety of vascular l 6-40 (Table I) and pigmented36.37.39,4H3 (Table II) le-
Volume 14 Number 2, Part 1 February, 1986
sions. In addition, through nonselective photocoagulation, many other avascular and nonpigmented lesions have also been successfully treated with the argon laser (Table III). 44-47 Complications of argon laser therapy are generally minimal and consist of hypertrophic scarring, atrophy, and hypo- and hyperpigmentation. 48,49 Since lymphocytoma cutis is characterized clinically by a reddish-purple discoloration, presumably caused by increased vascularity or vascular dilatation, we attempted to use the argon laser to selectively treat several persistent lymphocytoma cutis plaques that had proved resistant to prior conservative medical management. We theorized that the argon laser could produce regression of lymphocytoma cutis lesions by its relatively specific thermal effects on blood vessels, resulting in photocoagulation similar to that seen in treatment of port-wine stains. Although our patient had a favorable clinical response, the argon laser-treated sites showed histologic resolution of the infiltrate only to an average depth of 0.4 to 1.2 mm; the deeper inflammatory component persisted. These findings are similar to those in previous studies of port-wine stains treated with the argon laser,26.50 in which histologically confirmed thermal injury was limited to the upper 1 mm of the dermis. This study may have relevance in other cuta~ neous lesions treated with the argon laser, since our findings suggest that at least for argon laser phototherapy of infiltrative or inflammatory conditions of the skin, clinical responsiveness may not always imply histologic resolution. This fact may be crucial in the laser treatment of premalignant or malignant lesions in which a favorable therapeutic response may be monitored only clinically because histologic evaluation of tissue is not always practical or possible. We conclude that the argon laser may be a useful modality for "camouflaging" resistant lymphocytoma cutis lesions, especially for cosmetically important areas such as the face. Complete resolution or cure, however, is not obtained because any infiltrate deeper than 1.0 to 1.5 mm, which is the limit of the photocoagulating effect of the argon laser, is likely to persist. Furthermore, histologic confirmation of lymphocytoma cutis should be firmly established before argon laser photoco-
Argon laser in lymphocytoma cutis
271
agulative therapy is chosen, since this treatment may be incomplete and rare cases of associated benign and malignant infiltrates have been reported. 15 REFERENCES 1. Andersen BL, Brandrup F, Petri J: Lymphocytoma cutis: A pseudomalignancy treated with penicillin. Acta Derm Venereol (Stockh) 62:83-85, 1982. 2. Stoll DM: Treatment of cutaneous pseudolymphoma with hydroxychloroquine. J AM ACAD DERMATOL 8:696-699, 1983. 3. Self SJ, Carter VH, Noojin RO: Disseminated lymphocytoma cutis. Arch Dermatoll00:459-464, 1969. 4. Frain-Bell W, Magnus IA: A study of the photosensitivity factor in cutaneous lymphocytoma. Br J Dermatol 84:2531, 1971. 5. Evans HL, Winkelmann RK, Banks PM: Differential diagnosis of malignant and benign cutaneous lymphoid infiltrates. Cancer 44:699-717,1979. 6. Apfelberg DB, Maser MR, Lash H, Rivers J: The argon laserfor cutaneous lesions. JAMA 245:2073-2075, 1981. 7. Apfelberg DB, Maser MR, Lash H, Flores J: Expanded role of the argon laser in plastic surgery. J Dermatol Surg Oncol 9:145-151, 1983. 8. Charlesworth EN: Phenytoin-induced pseudolymphoma syndrome. Arch Dermatol 113:477-480, 1977. 9. Schreiber MM, McGregor JG: Pseudolymphoma syndrome. Arch Dermatol 97:297-300, 1968. 10. Allen AC: Persistent "insect bites" (dermal eosinophilic granulomas) simulating lymphoblastomas, histiocytosis, and squamous cell carcinomas. Am J Pathol 24:367-387, 1948. 11. Mach KW, Wilgram GF: Characteristic histopathology of cutaneous Iymphoplasia (lymphocytoma). Arch Dermatol 94:26-32, 1966. 12. Bernstein H, Shupack J, Ackerman AB: Cutaneous pseudolymphoma resulting from antigen injections. Arch Dermatol110:756-757, 1974. 13. Sanchez JL, Mendez JA, Palacio R: Cutaneous peudolymphoma at the site of resolving herpes zoster. Arch DermatoI117:377, 1981. 14. B1umetal G, Okun MR, Ponitch JA: Pseudolymphomatous reaction to tattoos. J AM ACAD DERMATOL 6:485488, 1982. 15. Caro WA, Helwig EB: Cutaneous lymphoid hyperplasia. Cancer 24:482-502, 1969. 16. Apfelberg DB, Maser MR, Lash H: Argon laser management of cutaneous vascular deformities. West J Med 124:99-101, 1976. 17. Goldman L, Dreffer R, Rockwell RJ, Perry E: Treatment of portwine marks by an argon laser. J Dermatol Surg 2:385-388, 1976. 18. Goldman L, Dreffer R: Laser treatment of extensive mixed cavernous and port-wine stains. Arch Dermatol 113:504-505,1977. 19. Apfelberg DB, Maser MR, Lash H: Argon laser treatment of cutaneous vascular abnormalities: Progress report. Ann Plast Surg 1:14-18, 1978. 20. Apfelberg DB, Maser MR, Lash H: Treatment of nevi
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Journal of the American Academy of Dermatology
36. Goldman L: Effects of new laser systems on the skin. Arch Dermatol 108:385-390, 1975. 37. Apfelberg DB, Maser MR, Lash H, Rivers JL: Progress report on extended clinical use of the argon laser for cutaneous lesions. Lasers Surg Med 1:71-83, 1980. 38. Riefkohl R: The role ofthe argon laser in plastic surgery. NC Med J 45:220-221, 1984. 39. Landthaler M, Haina D, Waidelich W, Braun-Falco 0: A three-year experience with the argon laser in dermatotherapy. J Dermatol Surg Oneal 10:456-461, 1984. 40. Dixon JA, Rotering RH, Huether SE: Patient's evaluation of argon laser therapy of port-wine stain, decorative tattoo, and essential telangiectasia. Lasers Sllrg Med 4:181190,1984. 41. Goldman L, Siler VE, Blaney D: Laser therapy in melanomas. Surg Gynecol Obstet 124:49-56, 1967. 42. Ohshiro T, Maruyama Y, Nakajima H, et al: Treatment of pigmentation of the lips and oral mucosa in PeutzJeghers' syndrome using ruby and argon lasers. Br J Plast Surg 33:346-349, 1980. 43. Arndt KA: Argon laser treatment of lentigo maligna. J AM ACAD DERMATOL 10:953-957, 1984. 44. Landthaler M, Haina D, Waidelich W, Braun-Falco 0: Argon laser therapy of verrucous nevi. Plast Reconstr Surg 74:108-113, 1984. 45. Apfelberg DB, Maser MR, Lash H: Argon laser treatment of decorative tattoos. Br J Plast Surg 32:141-144, 1979. 46. Arndt KA: Adenoma sebacellm: Successful treatment with the argon laser. Plast Reconstr Surg 70:91-93, 1982. 47. Henderson DL, Crowwell TA, Mes LG: Argon and carbon dioxide laser treatment of hypertrophic and keloid scats. Lasers Surg Med 3:271-277, 1984. 48. Apfelberg DB, Flores JT, Maser MR, Lash H: Analysis of complications of argon laser treatment for port-wine hemangiomas with reference to striped techniques. Lasers Surg Med 2:357-371, 1983. 49. Dixon JA, Heuther S, Rotering R: Hypertrophic scarring in argon laser treatment of port-wine stains. Plast Reconstr Surg 73:771-777, 1984. 50. Apfe1berg DB, Kosek J, Maser MR, Lash H: Histology of port-wine stains following argon laser treatment. Br J Plast Surg 32:232-237, 1979.
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