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Treatment of adenoma sebaceum with the copper vapor laser
THERAPY Treatment of adenoma sebaceum with the copper vapor laser Andrew J. Kaufman, MD, Roy C. Grekin, MD, John K. Geisse, MD, and Ilona J. Frieden, MD San Francisco, California Background: ‘Angiofibromas of the central part of the face (adenoma sebaceum) occur pathognomonically in tuberous sclerosis, causing significant cosmetic and hygienic morbidity. Treatment has included excision, dermabrasion, cryosurgery, carbon dioxide laser, and argon laser. Copper vapor lasers emit light at 5 11 nm (green) and 578 nm (yellow), useful for treating pigmented and vascular lesions, respectively. Objective: Because of the vascular nature and progressive pigmentation of adenoma sebaceum, we examined the utility of the copper vapor laser in treating this disorder. Methods: Nine patients with adenoma sebaceum were treated with the copper vapor laser. Individual lesions were treated with the yellow light (578 nm) at 0.4 to 0.6 mW. Pigmented lesions or lesions resistant to treatment were treated with the green light (511 nm) at 0.4 to 0.9 mW. Intervals between treatments were at least 6 weeks. Results: Good to excellent cosmetic results were seen in all treated patients. Scarring or hyperpigmentation occurred in none of the patients. Most patients required additional treatments with the copper vapor laser as new lesions developed. Conclusion: The copper vapor laser is safe and effective for the treatment of adenoma sebaceum in tuberous sclerosis. (J AM ACAD DERMATOL1995;33:770-4.) Tuberous sclerosis is a rare neurocutaueous disease classically described by a triad of adenoma sebaceum, mental retardation, and epilepsy. Transmitted in an autosomal-dominant pattern with variable
expression, nearly two thirds of cases are caused by new mutations. Tuberous sclerosis is manifested by the growth of benign tumors or hamartomas, most commonly of the skin, brain, heart, and kidney. Cutaneous changes are a primary characteristic of the disease. Ash-leaf hypomelanotic macules on the trunk and extremities occur before any other skin findings and are most reliably present in afflicted patients beginning in infancy.’ A second dermatologic manifestation, adenoma sebaceum, was first described as a distinct clinical entity by Balzer and Menetries in 1885 and Pringle3 in 1890. Adenoma sebaceum develops after the age of 5 years in most patients with tuberous sclerosis. These lesions are
small, erythematous
to tan, telangiectatic
located on the cheeks, chin, nasolabial folds, nose, and sometimes the central part of the forehead; they are neither adenomatous nor sebaceous. Named from a misinterpretation of the microscopic appearance of these papules,2 “adenoma sebaceum” actually represents multiple facial angiofibromas.4 These lesions cause considerable
cosmetic and hygienic
morbidity for patients. Treatment of these angiofibromas of tuberous sclerosis has included curettage,2 cryosurgery,5~ 6 chemical peel, dermabrasion,7-12 shave excision,12 and argon13-15 and carbon dioxide16-19 laser ablation. We believed the copper vapor laser may be beneficial in treating the angiofibromas of tuberous sclerosis because of its selectivity for vascular or pigmented structures. We report our experience with its use in nine patients with the multiple facial angiofibromas
of tuberous
sclerosis.
papules BACKGROUND
From the Department Francisco, School Reprint requests: San Francisco,
of Dermatology, of Medicine.
Roy C. Grekin, CA 94143.
University
MD, Box 03 16,400
Copyright 0 1995 by the American Academy 0190-9622/95 $5.00 + 0 16/l/65428
770
of California Parnassus
of Dermatology,
at San Ave., Inc.
Selective photothermolysis is a concept fmding utility in several recently developed lasers.20 In selective photothermolysis a chosen laser produces a light of specific wavelength that is preferentially absorbed by the target chromophore but minimally ab-
Journal of the American Academy of Dermatology Volume 33, Number 5, Part 1
Kaufman et al. 771
Table I. Clinical and treatment characteristics of nine patients with adenoma sebaceum treated with the copper vapor laser Patient
Age h-1
Sex
Previous treatment
Power (watts)
2
12 11
F F
Argon laser None
0.38-0.40 0.40-0.60
3
28
M
0.50
4
22
M
Dennabrasion, electrodesiccation Shave excision
5
19
F
0.40-0.86
6
24
F
Derrnabrasion; carbon dioxide laser None
1
0.40-0.58
0.45-0.50
7
12
M
None
0.60-0.64
8 9
13 14
F M
None None
0.49-0.55 0.46
sorbed by surrounding tissue. In addition, the duration of time that the laser energy is delivered to the target must be long enough to deliver adequate thermal energy to the target but brief enough to prevent heat transfer and damage to surrounding tissue. In practice the laser exposure duration (pulse width) must be less than the target’s thermal relaxation time, limiting nonspecific spread of thermal damage to surrounding tissue. The copper vapor laser emits light at two wavelengths simultaneously: 5 11 run (green) and 578 nm (yellow).21 By filtering one wavelength can be delivered at a time. The copper vapor laser has been used to treat a number of vascular and pigmented lesions. As the absorption spectrum of oxyhemoglobin peaks at 577 nm, the yellow light (578 nm) is used to treat port-wine stains,22>23 telangiectases,22-24 and other vascular malformations. The absorption of melanosomes is broader, extending between 200 and 1200 nm and decreasing with wavelength. Subsequently, the green light (5 11 nm) has been used to treat lentigines, ephilides, and seborrheic keratoses.23 The yellow light targets oxyhemoglobin and finds greater utility in treating vascular lesions. Light is delivered in short pulses of 20 nsec duration of a frequency of 15,000 pulses per second. The beam can be further shuttered mechanically to attenuate tissue damage resulting from additive thermal energy.
Light (W
No. of treatments
ReSUltS
Yellow (578) Yellow (578) and green (511) Yellow
5 9
Excellent
9
Very good
Yellow and green Yellow and green
5
Excellent
5
Excellent
Yellow and
2
Very good
4
Very good
3 1
Excellent (Test area)
green Yellow and green Yellow Yellow
Excellent
We used the yellow light to selectively target the vascular component of the angiofibromas of tuberous sclerosis. Resistant telangiectatic papules, hyperpigmented papules, and lesions in patients with type IV or V skin were treated with the green beam of the copper vapor laser. METHODS Nine patients with adenoma sebaceum associated with tuberous sclerosis were treated with the copper vapor laser (Innovative Health Concepts, Inc., Pleasanton, Calif.). The expression of tuberous sclerosis varied among the patients, ranging from the full triad of mental retardation, epilepsy, and angiotibromas to only multiple coalescent angiofibromas in a characteristic distribution. Previous treatment included the argon laser, dermabrasion, electrodesiccation, shave excision, and carbon dioxide laser ablation (Table I). Test areas were used to gauge response to power and light used. Angiofibromas were treated with the yellow light (578 nm) with power settings beginning at 0.40 W and increasing at subsequent visits as necessary. Spot size was usually 150 or 267 pm, and the beam was mechanically gated to be on 200 msec and off 100 msec. Patients with vascular papules resistant to gradual increase of the power of the yellow light (maximum 0.60 w>, hyperpigmented papules, and Fitzpatrick type IV and V &in25 were treated with the green light (5 11 urn). The green light was
Journal
772
Kaujinan
et al.
of the American
Academy
of Dermatology November 1995
Fig. 1. Patient 1. A, Before tseatment. B, Same patient after five treatments with copper vapor laser.
begun also at 0.40 W with a 150 pm spot size in a continuous (rather than gated) delivery. Papules were treated until the vascular component disappeared (yellow light) or until slight graying developed on the surface of the pigmented lesions (green light). Anesthesia was used in most patients, consisting of EMLA application under occlusion, regional blocks with lidocaine, or both. Thin supertlcial crusting developed after 2 to 3 days, and healing occurred within 1 to 2 weeks. Patients were examined after 4 to 8 weeks for further treatment. Results were based on decreased erythema, flattening of papules, and loss of hyperpigmentation. Good to excellent results were observed in all treated patients (Figs. 1 and 2). No patients had scarring or hyperpigmentation. One patient had transient hypopigmentation of a treated area, which resolved within 4 weeks. DISCUSSION
Multiple angiofibromas over the central part of the face occur in approximately 90% of patients with tuberous sclerosis. Rather than being adenomatous growths or of sebaceous origin, these papules are similar to the solitary angiofibromas or fibrous papules seen frequently in adults. On histologic evaluation they consist of steflate tibroblasts and an increased number of dilated telangiectases.4 This
vascular component makes them amenable to treatment with the yellow light of the copper vapor laser. The yellow light represents energy at 578 nm and targets selectively the 577 nm absorption peak of oxyhemoglobin. At this wavelength the absorption of melanin and surrounding tissue is minimal. This treatment contrasts with the use of the carbon dioxide or argon lasers as previously described treatments of adenoma sebaceum. 13-r9 The carbon dioxide laser emits energy in the infrared spectrum at 10,600 m-n. Laser energy in this range is absorbed by water. When the beam is focused, the laser cuts through tissue. In a defocused mode the laser vaporizes tissue. Carbon dioxide laser vaporization of adenoma sebaceum is an effective treatment but carries with it the risk of scarring or permanent pigmentary change associated with the nonselective destruction of tissue and spread of thermal damage beyond the lesional borders. The argon laser emits energy in the visible spectrum at 488 and 514 nm. The 514 nm beam can be effective in treating both vascular and pigmented lesions, but unlike the copper vapor laser the argon laser emits a continuous-wave beam. The copper vapor laser can therefore deliver a greater amount of energy to the target chromophore with less spread to surrounding tissue by taking advantage of the concept of thermal relaxation time. Other previously described treatments of adenoma sebaceum have included curettage, dermabrasion, chemical
Journal of the American Academy of Dermatology Volume 33, Number 5, Part 1
KauJinan et al.
773
Fig. 2. Patient 3. A, Before treatment. B, Same patient after nine treatments with copper vapor laser.
peel, shave excision, and cryosurgery. Like the carbon dioxide laser these modalities carry significant risk of scarring and pigmentary change resulting from nonselective destruction of tissue. The copper vapor laser is an effective treatment of adenoma sebaceum. The principle of selective photothermolysis allows the laser beam to deliver energy specific for the target chromophore. The copper vapor laser emits energy at 5 11 and 578 nm, selective for pigmented and vascular lesions, respectively. By choosing an appropriate energy source and limiting the duration energy is delivered by pulsing and mechanically shuttering the beam, high energy levels can be delivered to the target while spread to adjacent tissue is minimized and the risk of scarring or pigmentaiy change is decreased. Treatment of angiotibromas with the copper vapor laser is slightly different from the usual selective laser therapy. Although the laser beam is specifically absorbed by vascular or pigmented components, excess energy is purposely delivered such that damage to the fibrous tissue occurs. In essence this therapy has two components. It combines components of selective photothermolysis in that specific wavelengths are used to target oxyhemoglobin or pigment. The second component goes beyond selective photothermolysis in that excess energy is purposely delivered to the target chromophore so that it may radiate away from
the chromophore, causing nonselective destruction of surrounding tissue. We believe that this represents an advantage over the use of the flash lamp-pumped dye lasers in that their futed pulse width prevents the delivery of excess energy needed to affect the nonselective destruction of tissue surrounding the absorbing chromophore. Although the copper vapor laser is rapidly pulsed at 10,000 to 15,000 pulses per second, it more closely resembles a continuouswave laser in its function as opposed to flash lamppumped dye lasers and therefore requires experience to prevent scarring and to achieve the appropriate therapeutic dosing. With experience the physician can judge the amount of energy necessary to achieve lesional flattening without damage to surrounding nonlesional skin. Treatment would likely have to be continued on an intermittent basis as new lesions developed. Unlike dermabrasion, shave excision, curettage, and chemical peels, the posttreatment recovery period is short, generally requiring only 3 to 5 days for reepithelialization and 1 to 2 weeks for complete fading of erythema. In addition, the highly focused beam is more precisely delivered than cryosurgery, shave excision, or curettage and therefore can treat more lesions more quickly with less surrounding tissue damage than these modalities. Thus the copper vapor laser is effective in treating the cosmetic and hygienic morbidity of adenoma seba-
Journal
774
Kaufman
et al.
ceum and should also be effective in the treatment of solitary angiofibromas. When available, it should be considered as a frontline therapeutic choice for these lesions. REFERENCES 1. Fitzpatrick TB, Szabo G, Hori Y, et al. White leaf-shaped macules, earliest visible signs of tuberous sclerosis. Arch Dermatol 1968;98:1-6. 2. Batzer F, Menetrier P. Etudes sur un caf d’adenomes sebaces de la face et du cuir chevelu. Arch Physiol 1885;7:56476. 3. Pringle JJ. A case of congenital adenoma sebaceum. Br J Dermatol 1890;2:1-14. 4. Nickel WR, Reed WB. Tuberous sclerosis: special reference to the microscopic alteration in the cutaneous hamartomas. Arch Dermatol 1965;85:89-106. 5. Dvir E, Hirshowitz B. The use of cryosurgery in treating the fibrous papules of tuberous sclerosis. Ann Plast Surg 1979; 4: 158-60. 6. DaSilva Oliveira A, Da Silva Picoto A, Verde SF, et al. Treatment of adenoma sebaceum by cryosurgery. J Dermat01 Surg Oncol 1980;6:586-7. 7. Earhart RN, Nuss DD, Martin RJ, et al. Dermabrasion for adenoma sebaceum. J Dermatol Surg Gncol1976;2:412-4. 8. Morgan JE, Mulliken JB. Dermabrasion and limited excision of the fibrous papules of tuberous sclerosis. Plast Reconstr Surg 1977;59: 124-6. 9. Roenigk HH Jr. Dermabrasion for miscellaneous cutaneous lesions (exclusive of scarring from acne). J Dermatol Surg Oncol 1977;3:322-8. 10. Eichmann F, Blank A. Dermabrasion of lesions of adenoma sebaceum. J Dermatol Surg Oncol 1981;7:884-5. I 1. Menon PA. Dermabrasion for the management of angiofibromas in tuberous sclerosis. J Dermatol Surg Oncol 1982;8:984-5. 12. Drake DB, Morgan RF, Cooper PH. Shave excision and
13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
of the American
Academy
of Dermatology November 1995
dermabrasion for facial angiofibroma in tuberous sclerosis. Ann Plast Surg 1992;28:377-80. Amdt DA. Adenoma sebaceum: successful treatment with the argon laser. Plast Reconstr Surg 1982;70:91-3. Pasyk KA, Argenta LC. Argon laser surgery of skin lesions iu tuberous sclerosis. Ann Plast Surg 1988;20:426-33. Apfelberg DB. Adenoma sebaceum. In: Atlas of cutaneous laser surgery. New York: Raven Press, 19921266-9. Janniger CK, Goldberg DJ. Angiofibromas in tuberous sclerosis: comparison and treatment by carbon dioxide and argon laser. J Dermatol Surg Oncol 1990;16:3 17-20. Weston J, Apfelberg DB, Maser MR, et al. Carbon dioxide laserbrasion for treatment of adenoma sebaceum in tuberous sclerosis. Ann Plast Surg 1985;15:132-7. Wheeland RG, Bailin PL, Kantor GR, et al. Treatment of adenoma sebaceum with carbon dioxide laser vaporization. J Dermatol Surg Oncol 1985;11:861-4. Spenter CW, Achauer BM, Vander Kam VM. Treatment of extensive adenoma sebaceum with a carbon dioxide laser. Ann Plast Surg 1988;20:586-9. Anderson RR, Parrish JA. Selective photo-thermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-7. Innovative Health Concepts, Inc. Product information literature. Pleasonton, Calif. Pickering JW, Walker PHB, Halewyn CN. Copper vapour laser treatment of port-wine stains and other vascular matformations. Br J Plast Surg 1990;43:273-82. Dinehart SM, Waner M, Flock S. The copper vapor laser for treatment of cutaneous vascular and pigmented lesions. J Dermatol Surg Gncol 1993;19:370-5. Key JM, Waner M. Selective destruction of facial telangiectasias with a copper vapor laser. Arch Otolaryngol 1992;118:509-13. Pathak MA, Fitzpatrick TB. Preventive treatment of sunbum, dermatoheliosis, and skin cancer with sun-protective agents. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al., eds. Dermatology in general medicine. New York: McGrawHill, 1993: 1964: 1689-717.
expression, nearly two thirds of cases are caused by new mutations. Tuberous sclerosis is manifested by the growth of benign tumors or hamartomas, most commonly of the skin, brain, heart, and kidney. Cutaneous changes are a primary characteristic of the disease. Ash-leaf hypomelanotic macules on the trunk and extremities occur before any other skin findings and are most reliably present in afflicted patients beginning in infancy.’ A second dermatologic manifestation, adenoma sebaceum, was first described as a distinct clinical entity by Balzer and Menetries in 1885 and Pringle3 in 1890. Adenoma sebaceum develops after the age of 5 years in most patients with tuberous sclerosis. These lesions are
small, erythematous
to tan, telangiectatic
located on the cheeks, chin, nasolabial folds, nose, and sometimes the central part of the forehead; they are neither adenomatous nor sebaceous. Named from a misinterpretation of the microscopic appearance of these papules,2 “adenoma sebaceum” actually represents multiple facial angiofibromas.4 These lesions cause considerable
cosmetic and hygienic
morbidity for patients. Treatment of these angiofibromas of tuberous sclerosis has included curettage,2 cryosurgery,5~ 6 chemical peel, dermabrasion,7-12 shave excision,12 and argon13-15 and carbon dioxide16-19 laser ablation. We believed the copper vapor laser may be beneficial in treating the angiofibromas of tuberous sclerosis because of its selectivity for vascular or pigmented structures. We report our experience with its use in nine patients with the multiple facial angiofibromas
of tuberous
sclerosis.
papules BACKGROUND
From the Department Francisco, School Reprint requests: San Francisco,
of Dermatology, of Medicine.
Roy C. Grekin, CA 94143.
University
MD, Box 03 16,400
Copyright 0 1995 by the American Academy 0190-9622/95 $5.00 + 0 16/l/65428
770
of California Parnassus
of Dermatology,
at San Ave., Inc.
Selective photothermolysis is a concept fmding utility in several recently developed lasers.20 In selective photothermolysis a chosen laser produces a light of specific wavelength that is preferentially absorbed by the target chromophore but minimally ab-
Journal of the American Academy of Dermatology Volume 33, Number 5, Part 1
Kaufman et al. 771
Table I. Clinical and treatment characteristics of nine patients with adenoma sebaceum treated with the copper vapor laser Patient
Age h-1
Sex
Previous treatment
Power (watts)
2
12 11
F F
Argon laser None
0.38-0.40 0.40-0.60
3
28
M
0.50
4
22
M
Dennabrasion, electrodesiccation Shave excision
5
19
F
0.40-0.86
6
24
F
Derrnabrasion; carbon dioxide laser None
1
0.40-0.58
0.45-0.50
7
12
M
None
0.60-0.64
8 9
13 14
F M
None None
0.49-0.55 0.46
sorbed by surrounding tissue. In addition, the duration of time that the laser energy is delivered to the target must be long enough to deliver adequate thermal energy to the target but brief enough to prevent heat transfer and damage to surrounding tissue. In practice the laser exposure duration (pulse width) must be less than the target’s thermal relaxation time, limiting nonspecific spread of thermal damage to surrounding tissue. The copper vapor laser emits light at two wavelengths simultaneously: 5 11 run (green) and 578 nm (yellow).21 By filtering one wavelength can be delivered at a time. The copper vapor laser has been used to treat a number of vascular and pigmented lesions. As the absorption spectrum of oxyhemoglobin peaks at 577 nm, the yellow light (578 nm) is used to treat port-wine stains,22>23 telangiectases,22-24 and other vascular malformations. The absorption of melanosomes is broader, extending between 200 and 1200 nm and decreasing with wavelength. Subsequently, the green light (5 11 nm) has been used to treat lentigines, ephilides, and seborrheic keratoses.23 The yellow light targets oxyhemoglobin and finds greater utility in treating vascular lesions. Light is delivered in short pulses of 20 nsec duration of a frequency of 15,000 pulses per second. The beam can be further shuttered mechanically to attenuate tissue damage resulting from additive thermal energy.
Light (W
No. of treatments
ReSUltS
Yellow (578) Yellow (578) and green (511) Yellow
5 9
Excellent
9
Very good
Yellow and green Yellow and green
5
Excellent
5
Excellent
Yellow and
2
Very good
4
Very good
3 1
Excellent (Test area)
green Yellow and green Yellow Yellow
Excellent
We used the yellow light to selectively target the vascular component of the angiofibromas of tuberous sclerosis. Resistant telangiectatic papules, hyperpigmented papules, and lesions in patients with type IV or V skin were treated with the green beam of the copper vapor laser. METHODS Nine patients with adenoma sebaceum associated with tuberous sclerosis were treated with the copper vapor laser (Innovative Health Concepts, Inc., Pleasanton, Calif.). The expression of tuberous sclerosis varied among the patients, ranging from the full triad of mental retardation, epilepsy, and angiotibromas to only multiple coalescent angiofibromas in a characteristic distribution. Previous treatment included the argon laser, dermabrasion, electrodesiccation, shave excision, and carbon dioxide laser ablation (Table I). Test areas were used to gauge response to power and light used. Angiofibromas were treated with the yellow light (578 nm) with power settings beginning at 0.40 W and increasing at subsequent visits as necessary. Spot size was usually 150 or 267 pm, and the beam was mechanically gated to be on 200 msec and off 100 msec. Patients with vascular papules resistant to gradual increase of the power of the yellow light (maximum 0.60 w>, hyperpigmented papules, and Fitzpatrick type IV and V &in25 were treated with the green light (5 11 urn). The green light was
Journal
772
Kaujinan
et al.
of the American
Academy
of Dermatology November 1995
Fig. 1. Patient 1. A, Before tseatment. B, Same patient after five treatments with copper vapor laser.
begun also at 0.40 W with a 150 pm spot size in a continuous (rather than gated) delivery. Papules were treated until the vascular component disappeared (yellow light) or until slight graying developed on the surface of the pigmented lesions (green light). Anesthesia was used in most patients, consisting of EMLA application under occlusion, regional blocks with lidocaine, or both. Thin supertlcial crusting developed after 2 to 3 days, and healing occurred within 1 to 2 weeks. Patients were examined after 4 to 8 weeks for further treatment. Results were based on decreased erythema, flattening of papules, and loss of hyperpigmentation. Good to excellent results were observed in all treated patients (Figs. 1 and 2). No patients had scarring or hyperpigmentation. One patient had transient hypopigmentation of a treated area, which resolved within 4 weeks. DISCUSSION
Multiple angiofibromas over the central part of the face occur in approximately 90% of patients with tuberous sclerosis. Rather than being adenomatous growths or of sebaceous origin, these papules are similar to the solitary angiofibromas or fibrous papules seen frequently in adults. On histologic evaluation they consist of steflate tibroblasts and an increased number of dilated telangiectases.4 This
vascular component makes them amenable to treatment with the yellow light of the copper vapor laser. The yellow light represents energy at 578 nm and targets selectively the 577 nm absorption peak of oxyhemoglobin. At this wavelength the absorption of melanin and surrounding tissue is minimal. This treatment contrasts with the use of the carbon dioxide or argon lasers as previously described treatments of adenoma sebaceum. 13-r9 The carbon dioxide laser emits energy in the infrared spectrum at 10,600 m-n. Laser energy in this range is absorbed by water. When the beam is focused, the laser cuts through tissue. In a defocused mode the laser vaporizes tissue. Carbon dioxide laser vaporization of adenoma sebaceum is an effective treatment but carries with it the risk of scarring or permanent pigmentary change associated with the nonselective destruction of tissue and spread of thermal damage beyond the lesional borders. The argon laser emits energy in the visible spectrum at 488 and 514 nm. The 514 nm beam can be effective in treating both vascular and pigmented lesions, but unlike the copper vapor laser the argon laser emits a continuous-wave beam. The copper vapor laser can therefore deliver a greater amount of energy to the target chromophore with less spread to surrounding tissue by taking advantage of the concept of thermal relaxation time. Other previously described treatments of adenoma sebaceum have included curettage, dermabrasion, chemical
Journal of the American Academy of Dermatology Volume 33, Number 5, Part 1
KauJinan et al.
773
Fig. 2. Patient 3. A, Before treatment. B, Same patient after nine treatments with copper vapor laser.
peel, shave excision, and cryosurgery. Like the carbon dioxide laser these modalities carry significant risk of scarring and pigmentary change resulting from nonselective destruction of tissue. The copper vapor laser is an effective treatment of adenoma sebaceum. The principle of selective photothermolysis allows the laser beam to deliver energy specific for the target chromophore. The copper vapor laser emits energy at 5 11 and 578 nm, selective for pigmented and vascular lesions, respectively. By choosing an appropriate energy source and limiting the duration energy is delivered by pulsing and mechanically shuttering the beam, high energy levels can be delivered to the target while spread to adjacent tissue is minimized and the risk of scarring or pigmentaiy change is decreased. Treatment of angiotibromas with the copper vapor laser is slightly different from the usual selective laser therapy. Although the laser beam is specifically absorbed by vascular or pigmented components, excess energy is purposely delivered such that damage to the fibrous tissue occurs. In essence this therapy has two components. It combines components of selective photothermolysis in that specific wavelengths are used to target oxyhemoglobin or pigment. The second component goes beyond selective photothermolysis in that excess energy is purposely delivered to the target chromophore so that it may radiate away from
the chromophore, causing nonselective destruction of surrounding tissue. We believe that this represents an advantage over the use of the flash lamp-pumped dye lasers in that their futed pulse width prevents the delivery of excess energy needed to affect the nonselective destruction of tissue surrounding the absorbing chromophore. Although the copper vapor laser is rapidly pulsed at 10,000 to 15,000 pulses per second, it more closely resembles a continuouswave laser in its function as opposed to flash lamppumped dye lasers and therefore requires experience to prevent scarring and to achieve the appropriate therapeutic dosing. With experience the physician can judge the amount of energy necessary to achieve lesional flattening without damage to surrounding nonlesional skin. Treatment would likely have to be continued on an intermittent basis as new lesions developed. Unlike dermabrasion, shave excision, curettage, and chemical peels, the posttreatment recovery period is short, generally requiring only 3 to 5 days for reepithelialization and 1 to 2 weeks for complete fading of erythema. In addition, the highly focused beam is more precisely delivered than cryosurgery, shave excision, or curettage and therefore can treat more lesions more quickly with less surrounding tissue damage than these modalities. Thus the copper vapor laser is effective in treating the cosmetic and hygienic morbidity of adenoma seba-
Journal
774
Kaufman
et al.
ceum and should also be effective in the treatment of solitary angiofibromas. When available, it should be considered as a frontline therapeutic choice for these lesions. REFERENCES 1. Fitzpatrick TB, Szabo G, Hori Y, et al. White leaf-shaped macules, earliest visible signs of tuberous sclerosis. Arch Dermatol 1968;98:1-6. 2. Batzer F, Menetrier P. Etudes sur un caf d’adenomes sebaces de la face et du cuir chevelu. Arch Physiol 1885;7:56476. 3. Pringle JJ. A case of congenital adenoma sebaceum. Br J Dermatol 1890;2:1-14. 4. Nickel WR, Reed WB. Tuberous sclerosis: special reference to the microscopic alteration in the cutaneous hamartomas. Arch Dermatol 1965;85:89-106. 5. Dvir E, Hirshowitz B. The use of cryosurgery in treating the fibrous papules of tuberous sclerosis. Ann Plast Surg 1979; 4: 158-60. 6. DaSilva Oliveira A, Da Silva Picoto A, Verde SF, et al. Treatment of adenoma sebaceum by cryosurgery. J Dermat01 Surg Oncol 1980;6:586-7. 7. Earhart RN, Nuss DD, Martin RJ, et al. Dermabrasion for adenoma sebaceum. J Dermatol Surg Gncol1976;2:412-4. 8. Morgan JE, Mulliken JB. Dermabrasion and limited excision of the fibrous papules of tuberous sclerosis. Plast Reconstr Surg 1977;59: 124-6. 9. Roenigk HH Jr. Dermabrasion for miscellaneous cutaneous lesions (exclusive of scarring from acne). J Dermatol Surg Oncol 1977;3:322-8. 10. Eichmann F, Blank A. Dermabrasion of lesions of adenoma sebaceum. J Dermatol Surg Oncol 1981;7:884-5. I 1. Menon PA. Dermabrasion for the management of angiofibromas in tuberous sclerosis. J Dermatol Surg Oncol 1982;8:984-5. 12. Drake DB, Morgan RF, Cooper PH. Shave excision and
13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
of the American
Academy
of Dermatology November 1995
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