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Case Report
Efficacy of diode laser for treating acne keloidalis nuchae Girish K. ShahConsultant dermatologist, Mumbai, India.
Address for correspondence: Dr. Girish K. Shah, Consultant dermatologist, The Skin and Laser Centre, G-4, Arvind Apartment, L. T. Road,Opp. T. B. Zavery, Behind Neelam hotel, Borivali (w), Mumbai, Maharashtra - 400092, India. E-mail: drgkshah@vsnl.net Acne keloidalis nuchae is usually treated with oral antibiotics, local antiseptics or intralesional steroids but with limited success. I assessed the efficacy of diode laser for treating the inflammatory and keloidal papules of acne keloidalis nuchae in two cases. The lesions in both the cases showed about 90 to 95% clearance after 4 treatment sessions at one to one and half month intervals. No new lesions were observed during the follow up period of six months after the last laser treatment. Thus, after clearing bacterial infection, laser hair epilation can be used as the first line of therapy for treating papules of acne keloidalis nuchae. This is the first attempt at treating acne keloidalis nuchae with a diode KEY WORDS: Acne keloidalis, Diode laser.
Early lesions of AK show a follicular and peri-follicularinfiltrate at the upper one-third of the hair follicle on Acne keloidalis nuchae (AK), also known as folliculitis histopathology, while advanced lesions show a keloidalis, is a chronic inflammatory process involving granulomatous infiltrate around broken hair fragments.
the hair follicles of the nape of the neck. It is Hence any treatment that destroys the hair follicle is characterized by the presence of papules and pustules likely to improve this condition. The use of laser hair arranged in irregularly linear groups just below the epilation is widely recommended for chronic follicular hairline. The disease persists for many years as new inflammatory conditions like pseudofolliculitis barbae.
papules continue to form at intervals and they heal Hence I decided to use a diode laser for the reduction leaving behind hypertrophic or keloidal papules.
of terminal hair in patients with AK. I describe twopatients whose papules of AK were treated effectively Many treatment modalities like oral and local antibiotics and intralesional steroids have been usedto treat this condition but with limited success. In severe cases surgical excision or carbon dioxide laserablation followed by healing by secondary intention A 50-year-old school principal presented at my clinic How to cite this article: Shah GK. Efficacy of diode laser for treating acne keloidalis nuchae. Indian J Dermatol Venereol Leprol 2005;71:31-4.
Received: June, 2004. Accepted: September, 2004. Source of Support: Nil. Conflict of interest: None declared.
Indian J Dermatol Venereol Leprol Januar y-Februar y 2005 Vol 71 Issue 1 [Downloaded free from http://www.ijdvl.com on Thursday, December 04, 2008]
Shah GK: Efficacy of diode laser for treating acne keloidalis with papules and nodules on the nape of the neck of 3 complaint of many painful papules and nodules on the years’ duration (Figure 1). A diagnosis of AK had been nape of the neck of 2 years’ duration (Figure 2). He had made 3 years earlier based on the clinical and been diagnosed as a case of AK on clinical grounds and histopathological findings. The patient had taken many had been treated with oral antibiotics and topical oral antibiotics for prolonged periods and had also tretinoin 0.025% cream for 10 months. He had also received 6 intralesional triamcinolone injections about received 3 intralesional injections of triamcinolone 6 months back without any benefit. He had not received acetonide 10 mg/ml at monthly intervals during these any treatment for the past 6 months.
10 months. He had discontinued all treatments as hehad continued to develop new papules and nodules.
On examination, multiple small follicular papules were On examination he had multiple papules on the nape seen on the nape of his neck. Some were small and of the neck. Most of them were smooth and fleshy while fleshy while others had a keloidal appearance. On the a few showed keloidal changes. On clinical grounds he basis of the clinical and histopathological findings the Both patients were treated with laser hair epilation with the diode laser (LightSheer diode laser, Lumenis Inc.
A 36-year-old businessman visited my clinic with a USA). The treatment was started after seven days of Figure 1: Papular lesions of acne keloidalis in case 1: pre-
Figure 2: Case 1 - one month after 4 sessions of diode laser
treatment
Figure 3: Similar lesions in case 2: pre-treatment
Figure 4: Case 2 - one month after 4 sessions with diode laser
Indian J Dermatol Venereol Leprol Januar y-Februar y 2005 Vol 71 Issue 1 [Downloaded free from http://www.ijdvl.com on Thursday, December 04, 2008]
Shah GK: Efficacy of diode laser for treating acne keloidalis oral antibiotics. All hair on the nape of neck were closely tissue, producing multiple fragments that are seen late trimmed. The first and second treatments were given in the lesions.[4] A foreign body response continues at 23 fluence and 100 ms pulse width while the third and fourth treatments were given at 26 fluence and100 ms pulse width. After each treatment the patients Different medical treatments like broad-spectrum were given ice compresses for 10 minutes and were antibiotics, oral and intralesional steroids and topical advised to use a sunscreen with SPF 30 during the retinoic acid combined with a class 2 or 3 corticosteroid daytime and topical tretinoin cream 0.025% combined cream have been used with disappointing results.
with betamethasone dipropionate cream 0.05% at night.
Although surgical treatment, like excision followed by Treatment was repeated at 4-6 week intervals for 4 secondar y intention healing, gives cosmetically sittings. Pre-treatment and post- treatment acceptable results,[5] it has a long recovery period. Laser photographs were taken during each visit.
therapy with carbon dioxide has been tried with somesuccess.[6] Patient 1 had 95% clearance (Figure 3) and patient 2had about 90% clearance (Figure 4) of papules in the The diode laser works on the principle of selective nape area one month after the fourth treatment. A few photothermolysis.[7] It emits the 810 nm wavelength fine, soft hairs were present in both patients after 1 that is well absorbed by the melanin present in hair month of the last treatment while grey colored hair follicles and hair shafts. Delivery of high fluences persisted in patient 1 at the end of 4 treatments. Patient combined with a proper pulse width leads to a rapid 2 had burns at the site of treatment but this subsided rise of temperature and subsequent heat transfer to within 7 days. Both patients had no other side effects adjacent tissues. A rise of temperature above 70° C like hypo - or hyperpigmentation. The papules causes necrosis of the follicles’ regenerative decreased in number and reduced in size as the hair grew thinner with each treatment. No new lesionsappeared once the treatment was initiated or even Our patients of AK treated with the diode laser showed during the 6 months period after the last treatment.
a gradual decrease in the size and number of papules.
This improvement was associated with transient but total loss of terminal hair in the occiput and thengrowth of hair that were thinner and softer than the AK is characterized by the occurrence of keloidal original hair. At the end of six months of starting follicular papules and plaques on the nape of the neck, treatment both our patients had cosmetically especially in black males. While the exact cause of AK acceptable results. Though laser treatment in dark is not yet known, frequently suggested etiological skinned individuals can cause pigmentary changes, possibilities are short haircuts along the posterior none of our patients had long term pigmentary hairline and penetration of cut hair into the skin, as in pseudofolliculitis,[1] constant irritation by shirt collars,[2]and chronic low-grade bacterial infection.[2] Sperling The improvement observed following laser hair et al suggest that AK is a primary form of scarring epilation is probably because of coagulation necrosis of the viable hair follicles and fragmented hair shaftspresent in the deep dermis. As the hair becomes thinner Histologically, there is a follicular and perifollicular and softer following laser hair epilation, it loses its infiltrate at the upper third of the hair follicle. A more strength to penetrate the skin and hence the number advanced lesion shows rupture of the follicle and the of new eruptions decreases. As the healing process in development of a granulomatous infiltrate around a AK is regarded as hypertrophic scarring rather than broken hair fragment.[4] The lower portion of the follicle keloidal,[9] one would expect improvement in the scar is not affected until the later stages of the disease and once the fragmented hair are removed from the these hair continue to proliferate beneath fibrous inflammation site. We did not observe any new lesions Indian J Dermatol Venereol Leprol Januar y-Februar y 2005 Vol 71 Issue 1 [Downloaded free from http://www.ijdvl.com on Thursday, December 04, 2008]
Shah GK: Efficacy of diode laser for treating acne keloidalis probably because regrowing hair were thin and soft.
Sperling LC, Homoky C, Pratt L, Sau P. Acne keloidalis is a form of primar y scarring alopecia. Arch Dermatol Laser hair epilation is a relatively painless procedure and requires no post-procedure care. There are hardly Herzberg AJ, Dinehart SM, Kerns BJ, Pollack SV. Acne keloidalis.
any side effects associated with laser treatment and it Transverse microscopy, immunohistochemistry, and electron gives cosmetically acceptable results. Though laser hair microscopy. Am J Dermatopathol 1990;12:109-21.
Califano J, Miller S, Frodel J. Treatment of occipital acne epilation treatment has been used successfully by keloidalis by excision followed by secondary intention healing.
several workers in the treatment of pseudofolliculitis Arch Facial Plast Surg 1999;1:308-11.
barbae,[10,11] there are no reports of its use for the Kantor GR, Ratz JL, Wheeland RG Treatment of acne keloidalis treatment of AK. The pulse dye laser has been used in nuchae with carbon dioxide laser. J Am Acad Dermatol treatment of keloids and hypertrophic scar,[12] but not Anderson RR, Parrish JA. Selective photothermolysis: precise for AK. This is probably the first report that the principle microsurgery by selective absorption of pulse radiation.
of laser hair epilation has been applied in the treatment of AK in patients with skin type IV and V. Hence I suggest Anvari B, Tannenbaum BS, Milner TE, Kimel S, Svaasand LO, that laser hair epilation should be considered as the Nelson JS. A theoretical study of the thermal response of skinto cryogen spray cooling and pulsed laser irradiation: first line treatment for AK, a condition otherwise Implication for treatment of port wine stain birth-marks. Phys difficult to treat. Treatment should be started as early as possible to avoid the morbidity associated with late Vasily DB, Breen PC, Miller OF 3rd. Acne keloidalis nuchae: Report and treatment of a severe case. J Dermatol Surg Oncol1979;5:228-30.
10. Yamauchi PS, Kelly AP, Lask GP. Treatment of pseudofolliculitis barbae with Diode laser. J Cutan Laser Ther 1999;1:109-11.
11. Weaver, Seymour M, Sagaral, Emelou C. Treatment of Smith AO, Odom RB. Pseudofolliculitis capitis. Arch Dermatol Pseudofolliculitis Barbae Using the Long-Pulse Nd: YAG Laser on Skin Types V and VI. Dermatol Surg 2003;29:1187-91.
George AO, Akanji AO, Nduka EU, Olasode JB, Odusan O.
12. Paquet P, Hermanns JF, Piérard GE. Effect of the 585 nm Clinical, biochemical and morphologic features of acne Flashlamp-Pumped Pulsed Dye Laser for the Treatment of keloidalis in a black population. Int J Dermatol 1993;32: Keloids. Dermatol Surg 2001;27:171-4.
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