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Treatment of blue nevi with the Q-switched ruby laser
Journal of the American Academy of
DERMATOLOGY VOLUME
32 NUMBER
2 PART 2
FEBRUARY
1995
Treatment of blue nevi with the Q-switched ruby laser Sandy S. Milgraum, MD, Meyer E. Cohen, MD, and Michael J. Auletta, MD New Brunswick,
New Jersey
The common blue nevus is a benign, localized collection of dermal melanocytes. To date, re moval required excisional surgery to eliminate pigment that usually extends into the retie ular dermis. We report the successful long-term elimination of common blue nevi on the nasal skin of two patients whose lesions were treated with the laser emission of 694 nm energy from the Q-switched ruby laser. (J AM ACAD DERMATOL 1995;32:307-10.)
Blue nevi represent a benign dermal melanocytic process that typically is seen as a well-circumscribed, blue macule or papule. Their treatment is usually
excisional surgery to eliminate the pigment that often extends into the reticular dermis.’ Basedon the concept of selectivethermolysiq2 the Q-switched ruby laser emitting
light at 694 nm pri-
marily targets melanosomes when skin is irradiattd39 4 Use of this laser was first directed toward the
removal of dermal carbon pigment present in amateur tattoos.5y 6 With
technical
improvements
the
Q-switched ruby laser has been shown to be effective in removing black tattoo pigment.7$ 8 More recently
this laser has been used to treat nevus of Ota with good to excellent results.9ylo Thesepreviousstudies suggestthat theQ-switched ruby laser may be effective in treating other conditions characterized by the presence of melanocytic pigment. To our knowledge, this is the first study to evaluate the effectiveness of the Q-switched ruby laser light to treat blue nevi and provide data on the permanence of pigment removal. Fig. 1. Patient 1. Blue nevus on nasal tip before treat-
ment. From the Division School.
of Dermatology,
Robert
Wood Johnson
Medical
Reprint requests: Sandy Milgraum, MD, Division of Dermatology, Robert Wood Johnson Medical School, 8 1 Brunswick Woods Dr., East Brunswick, NJ 08816. Copyright 0190-9622/95
@ 1995 by the American $3.00 + 0
16/4/56432
Academy
of Dermatology,
Inc.
CASE REPORTS
Two patients who requested removal of biopsy-proven benign blue nevi were treated. After informed consent was obtained, the patients underwent treatment with the 307
308 Milgraum et al.
Journal of the American Academy of Dermatology February 1995
Fig. 2. Skin biopsy specimen from patient 1 showsdendritic melanocytes with dense accumulations of melanin granules. (X40.)
Fig. 3. Patient 2. Blue nevus on right side of nose before treatment.
Q-switched ruby laser (Spectrum Medical Technologies, Natick, Mass.). at 28 nsec, 0.5 Hz, and 5 mm spot size. Reevaluation was done at 6 and 12 months after treatment. Patient 1. A 38-year-old woman, skin type II, had a 1.o X 1.O cm blueblack macule on the nasal tip for 12 years (Fig. 1). It had been unresponsive to treatment with liquid nitrogen. A biopsy specimen revealed a benign common blue nevus (Fig. 2). After the patient received anesthesia with 1% lidocaine with epinephrine, she underwent treatment with the Q-switched ruby laser. Initially, she was treated with fluences of 4.0 J/cm2 in 20% overlapping pulses. Six weeks later the remaining pigment was treated with 5.0 J/cm2 in 20% overlapping pulses. After another 6 weeks the remaining pigment was treated with 7.5 J/cm2 in 20% overlapping pulses. Patient 2. An 8-year-old girl, skin type II, had a 1.O X 0.8 cm blue-black lesion on the right side of the nose (Fig. 3). The lesion had been treated unsuccessfully several times with liquid nitrogen. A biopsy specimen confirmed the diagnosis of a benign common blue nevus.
After the patient received a local anesthetic, the lesion was treated with the Q-switched ruby laser. Initial treatment was with fluences of 5 J/cm2 in 20% overlapping pulses. The persisting pigmentation was retreated after 6 weeks with 8 J/cm2 in 20% overlapping pulses. A third treatment after 6 weeks with 8.5 J/cm2 in 20% overlapping pulses resulted in total clearing. RESULTS Use of the Q-switched ruby laser on nasal skin produces significant discomfort; therefore a local anesthetic before treatment is necessary. Immediately after treatment there was noticeable blanching of the pigment. Mild bleeding, which was controlled with pressure, occurred after treatment. Both patients had the same response. Approximately 50% of the pigment was removed after one treatment. After the second treatment, only 25% of the pigment re mained. Complete clearing of the remaining pigment was achieved after the third treatment, without scarring. Clinical improvement was maintained for 2 years after therapy (Figs. 4 and 5).
Journal of the American Academy of Dermatology Volume 32, Number 2, Part 2
Fig. 4. Patient I,1 year after treatment
with Q-switched
ruby laser. DISCUSSION
Three types of cutaneous blue nevi have been described.’ The most frequently encountered is the common blue nevus,which is often lessthan 1 cm in diameter and usually only slightly elevated from the surrounding skin surface. Histologically it is characterized by the presence of many dendritic melanocytes, grouped in irregular bundles containing numerous melanin granules. Melanocytes are predominantly found in the dermis, although extension into the subcutaneous tissue can occur. The epidermis is usually normal. Melanophages are frequently seen.Malignant degeneration is not thought to occur in common blue nevi.’ The cellular type of blue nevi usually is seen as a larger blue nodule. 6 1’ Microscopically, cellular blue nevi contain aggregates of large spindle-shaped cells consisting of abundant pale cytoplasm with little melanin.’ Melanophages containing large melanin granules are seen.Melanocytes may extend into the subcutaneous tissue and rarely show atypia.’ Ma-
Milgraum
et al.
309
Fig. 5. Patient 2,1 year after treatment with Q-switched ruby laser.
lignant degeneration has rarely been reported in cellular blue nevi. A combined nevus is the third type of blue nevus, which is a dermal blue nevus and an overlying melanocytic nevus. Removal of blue nevi usually requires full-thicknessexcision becauseof the depth to which the pigment extends. More superficial treatments such as cryotherapy or shaveexcision are usually unsuccessful in removing the pigment,12 as demonstrated in the two patients described in this article. Our results suggest that staged removal of pigment with the Q-switched ruby laser is effective in the treatment of blue nevi. By limitation of the pulse width to 20 nsec, organelle-specific damage can be limited to melanosomes. This has been demonstrated in guinea pig skin in which the use of the Q-switched ruby laser causesmelanosomal disruption and vacuolization of pigment-containing cells.t3 In human skin treatment with the Q-switched ruby laser preferentially affects well-melanized melanosomes14that are
310
Milgraum
et al.
present in abundance in blue nevi, making them an ideal target. Although use of various lasers with shorter wavelengths has been effective in treating pigmented lesions,the Q-switched ruby laser is partitularly well suited to remove blue nevi becauseof deeper penetration of the 694 nm light into skin. Controversy exists about the use of lasers to depigment melanocytic nevi because not all melanocytes are removed. lo A biopsy specimen should be obtained before treatment. Common blue nevi do not have a premalignant potential’ and can be safely treated with the Q-switched ruby laser. Cellular blue nevi are rarely premalignant, but are best treated with excisional surgery if significant cellular atypia is present. REFERENCES
1. Lever WF, Schaumburg-Lever G. Histopathologyof the skin.7th ed.Philadelphia:JB Lippincott, 1990:777-80. 2. AndersonRR, ParrishJA. Selectivephotothermolysis: precisemicrosurgeryby selective absorptionof pulsedirradiation.Science1983;22:524-7. 3. PollaLL, MargobsRJ, DoverJS, et al. Melanosomes are the primary targetof Q-switchedruby laserirradiationin guineapig skin.J InvestDermatol1986;89:281-6. 4. Murphy GF, ShepardRS, Paul BS, et al. Organelle
Journal of the American Academy of Dermatology February 1995
specific injury to melanin-containing cell in human skin by pulsed laser irradiation. Lab Invest 1983;49:680-5. 5. Goldman L, Wilson RG, Hornby P, et al. Radiation from a Q-switched ruby laser. J Invest Dermatol 1965;44:69-7I. 6. Reid WH, McL&d PJ, Ritchie A, et al. Q-switched ruby laser treatment of black tattoos. Br J Plast Surg 1990;43: 663-9. 7. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plast Surg 1990;43:663-9. 8. Taylor CR, Gange RW, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol 1990; 126:893-9. 9. Goldberg DJ, Nychay SG. Q-switched ruby laser treatment of nevus of Ota. J Dermatol Surg Oncol 199218: 817-21. 10. Geronemus RG. Q-switched ruby laser therapy of nevus of Ota. Arch Dermatol 1992;128:1618-22. 11. Rhodes AR. Neoplasms: benign neoplasias, hyperplasias, and dysplasias of melanocytes. In: Fitzpatrick TB, Eisen AZ, WolfF K, et al., eds. Dermatology in general medicine. 3rd ed. Ne York: McGraw-Hill, 1987;922-5. 12. MelanocytiF nevi and neoplasms. In: Arnold HL, Odom RB, James,WD,eds.Andrews’diseases of the skin.8th ed. Philadelphia:WB Saunders,1990:829-30. 13. DoverJS, MargolisRF, PollaLL, et al. Pigmentedguinea pigskinirradiatedwith Q-switchedruby laserpulses. Arch Dermatol1989;125:43-9. 14. Hruza GJ, DoverJS, Flotte TJ, et al. Q-switchedruby laser irradiation of normal human skin. Arch Dermatol 1991;127:1799-1805.
DERMATOLOGY VOLUME
32 NUMBER
2 PART 2
FEBRUARY
1995
Treatment of blue nevi with the Q-switched ruby laser Sandy S. Milgraum, MD, Meyer E. Cohen, MD, and Michael J. Auletta, MD New Brunswick,
New Jersey
The common blue nevus is a benign, localized collection of dermal melanocytes. To date, re moval required excisional surgery to eliminate pigment that usually extends into the retie ular dermis. We report the successful long-term elimination of common blue nevi on the nasal skin of two patients whose lesions were treated with the laser emission of 694 nm energy from the Q-switched ruby laser. (J AM ACAD DERMATOL 1995;32:307-10.)
Blue nevi represent a benign dermal melanocytic process that typically is seen as a well-circumscribed, blue macule or papule. Their treatment is usually
excisional surgery to eliminate the pigment that often extends into the reticular dermis.’ Basedon the concept of selectivethermolysiq2 the Q-switched ruby laser emitting
light at 694 nm pri-
marily targets melanosomes when skin is irradiattd39 4 Use of this laser was first directed toward the
removal of dermal carbon pigment present in amateur tattoos.5y 6 With
technical
improvements
the
Q-switched ruby laser has been shown to be effective in removing black tattoo pigment.7$ 8 More recently
this laser has been used to treat nevus of Ota with good to excellent results.9ylo Thesepreviousstudies suggestthat theQ-switched ruby laser may be effective in treating other conditions characterized by the presence of melanocytic pigment. To our knowledge, this is the first study to evaluate the effectiveness of the Q-switched ruby laser light to treat blue nevi and provide data on the permanence of pigment removal. Fig. 1. Patient 1. Blue nevus on nasal tip before treat-
ment. From the Division School.
of Dermatology,
Robert
Wood Johnson
Medical
Reprint requests: Sandy Milgraum, MD, Division of Dermatology, Robert Wood Johnson Medical School, 8 1 Brunswick Woods Dr., East Brunswick, NJ 08816. Copyright 0190-9622/95
@ 1995 by the American $3.00 + 0
16/4/56432
Academy
of Dermatology,
Inc.
CASE REPORTS
Two patients who requested removal of biopsy-proven benign blue nevi were treated. After informed consent was obtained, the patients underwent treatment with the 307
308 Milgraum et al.
Journal of the American Academy of Dermatology February 1995
Fig. 2. Skin biopsy specimen from patient 1 showsdendritic melanocytes with dense accumulations of melanin granules. (X40.)
Fig. 3. Patient 2. Blue nevus on right side of nose before treatment.
Q-switched ruby laser (Spectrum Medical Technologies, Natick, Mass.). at 28 nsec, 0.5 Hz, and 5 mm spot size. Reevaluation was done at 6 and 12 months after treatment. Patient 1. A 38-year-old woman, skin type II, had a 1.o X 1.O cm blueblack macule on the nasal tip for 12 years (Fig. 1). It had been unresponsive to treatment with liquid nitrogen. A biopsy specimen revealed a benign common blue nevus (Fig. 2). After the patient received anesthesia with 1% lidocaine with epinephrine, she underwent treatment with the Q-switched ruby laser. Initially, she was treated with fluences of 4.0 J/cm2 in 20% overlapping pulses. Six weeks later the remaining pigment was treated with 5.0 J/cm2 in 20% overlapping pulses. After another 6 weeks the remaining pigment was treated with 7.5 J/cm2 in 20% overlapping pulses. Patient 2. An 8-year-old girl, skin type II, had a 1.O X 0.8 cm blue-black lesion on the right side of the nose (Fig. 3). The lesion had been treated unsuccessfully several times with liquid nitrogen. A biopsy specimen confirmed the diagnosis of a benign common blue nevus.
After the patient received a local anesthetic, the lesion was treated with the Q-switched ruby laser. Initial treatment was with fluences of 5 J/cm2 in 20% overlapping pulses. The persisting pigmentation was retreated after 6 weeks with 8 J/cm2 in 20% overlapping pulses. A third treatment after 6 weeks with 8.5 J/cm2 in 20% overlapping pulses resulted in total clearing. RESULTS Use of the Q-switched ruby laser on nasal skin produces significant discomfort; therefore a local anesthetic before treatment is necessary. Immediately after treatment there was noticeable blanching of the pigment. Mild bleeding, which was controlled with pressure, occurred after treatment. Both patients had the same response. Approximately 50% of the pigment was removed after one treatment. After the second treatment, only 25% of the pigment re mained. Complete clearing of the remaining pigment was achieved after the third treatment, without scarring. Clinical improvement was maintained for 2 years after therapy (Figs. 4 and 5).
Journal of the American Academy of Dermatology Volume 32, Number 2, Part 2
Fig. 4. Patient I,1 year after treatment
with Q-switched
ruby laser. DISCUSSION
Three types of cutaneous blue nevi have been described.’ The most frequently encountered is the common blue nevus,which is often lessthan 1 cm in diameter and usually only slightly elevated from the surrounding skin surface. Histologically it is characterized by the presence of many dendritic melanocytes, grouped in irregular bundles containing numerous melanin granules. Melanocytes are predominantly found in the dermis, although extension into the subcutaneous tissue can occur. The epidermis is usually normal. Melanophages are frequently seen.Malignant degeneration is not thought to occur in common blue nevi.’ The cellular type of blue nevi usually is seen as a larger blue nodule. 6 1’ Microscopically, cellular blue nevi contain aggregates of large spindle-shaped cells consisting of abundant pale cytoplasm with little melanin.’ Melanophages containing large melanin granules are seen.Melanocytes may extend into the subcutaneous tissue and rarely show atypia.’ Ma-
Milgraum
et al.
309
Fig. 5. Patient 2,1 year after treatment with Q-switched ruby laser.
lignant degeneration has rarely been reported in cellular blue nevi. A combined nevus is the third type of blue nevus, which is a dermal blue nevus and an overlying melanocytic nevus. Removal of blue nevi usually requires full-thicknessexcision becauseof the depth to which the pigment extends. More superficial treatments such as cryotherapy or shaveexcision are usually unsuccessful in removing the pigment,12 as demonstrated in the two patients described in this article. Our results suggest that staged removal of pigment with the Q-switched ruby laser is effective in the treatment of blue nevi. By limitation of the pulse width to 20 nsec, organelle-specific damage can be limited to melanosomes. This has been demonstrated in guinea pig skin in which the use of the Q-switched ruby laser causesmelanosomal disruption and vacuolization of pigment-containing cells.t3 In human skin treatment with the Q-switched ruby laser preferentially affects well-melanized melanosomes14that are
310
Milgraum
et al.
present in abundance in blue nevi, making them an ideal target. Although use of various lasers with shorter wavelengths has been effective in treating pigmented lesions,the Q-switched ruby laser is partitularly well suited to remove blue nevi becauseof deeper penetration of the 694 nm light into skin. Controversy exists about the use of lasers to depigment melanocytic nevi because not all melanocytes are removed. lo A biopsy specimen should be obtained before treatment. Common blue nevi do not have a premalignant potential’ and can be safely treated with the Q-switched ruby laser. Cellular blue nevi are rarely premalignant, but are best treated with excisional surgery if significant cellular atypia is present. REFERENCES
1. Lever WF, Schaumburg-Lever G. Histopathologyof the skin.7th ed.Philadelphia:JB Lippincott, 1990:777-80. 2. AndersonRR, ParrishJA. Selectivephotothermolysis: precisemicrosurgeryby selective absorptionof pulsedirradiation.Science1983;22:524-7. 3. PollaLL, MargobsRJ, DoverJS, et al. Melanosomes are the primary targetof Q-switchedruby laserirradiationin guineapig skin.J InvestDermatol1986;89:281-6. 4. Murphy GF, ShepardRS, Paul BS, et al. Organelle
Journal of the American Academy of Dermatology February 1995
specific injury to melanin-containing cell in human skin by pulsed laser irradiation. Lab Invest 1983;49:680-5. 5. Goldman L, Wilson RG, Hornby P, et al. Radiation from a Q-switched ruby laser. J Invest Dermatol 1965;44:69-7I. 6. Reid WH, McL&d PJ, Ritchie A, et al. Q-switched ruby laser treatment of black tattoos. Br J Plast Surg 1990;43: 663-9. 7. Reid WH, Miller ID, Murphy MJ, et al. Q-switched ruby laser treatment of tattoos: a 9-year experience. Br J Plast Surg 1990;43:663-9. 8. Taylor CR, Gange RW, Dover JS, et al. Treatment of tattoos by Q-switched ruby laser. Arch Dermatol 1990; 126:893-9. 9. Goldberg DJ, Nychay SG. Q-switched ruby laser treatment of nevus of Ota. J Dermatol Surg Oncol 199218: 817-21. 10. Geronemus RG. Q-switched ruby laser therapy of nevus of Ota. Arch Dermatol 1992;128:1618-22. 11. Rhodes AR. Neoplasms: benign neoplasias, hyperplasias, and dysplasias of melanocytes. In: Fitzpatrick TB, Eisen AZ, WolfF K, et al., eds. Dermatology in general medicine. 3rd ed. Ne York: McGraw-Hill, 1987;922-5. 12. MelanocytiF nevi and neoplasms. In: Arnold HL, Odom RB, James,WD,eds.Andrews’diseases of the skin.8th ed. Philadelphia:WB Saunders,1990:829-30. 13. DoverJS, MargolisRF, PollaLL, et al. Pigmentedguinea pigskinirradiatedwith Q-switchedruby laserpulses. Arch Dermatol1989;125:43-9. 14. Hruza GJ, DoverJS, Flotte TJ, et al. Q-switchedruby laser irradiation of normal human skin. Arch Dermatol 1991;127:1799-1805.