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From the Department of Dermatology , Chang Hua Christian HospitalAccepted for publication: January 25, 2007Reprint requests: Kuo-Chia Yang, MD, Department of Dermatology, Chang Hua Christian Hospital, No. 135 Nan Hsiao Street,Chang Hua 500, Taiwan. R.O.C. TEL: 886-4-7238595-7232 FAX: 886-4-7289233

Use of CO2 Laser in the Treatment of PeriungualFibromas of Tuberous Sclerosis Complex

Chen-Hsi Hung Kuo-Chia Yang

CASE REPORTA 47-year-old woman came to our dermatological out-patient department due to multiple tender

tumors on her toes for years. On physical examination, she was found to have firm, discrete, red-brown,telangiectatic papules, extending from the nasolabial furrows to the cheeks (Fig. 1). In addition, firm,flesh-colored excrescences emerging from the toenail folds were present (Fig. 2). She developed theseextensive facial tumors when she was in the kindergarten. The periungual papules first appeared about10 years ago. They ranged from 3mm to 10mm in size, and were located on her 7 toes (left: 1st, 2nd,3rd, 5th , total 5 lesions, and right: 1st, 4th, 5th, total 5 lesions) and the left 3rd finger. The lesions werepainful and bled upon contact, resulting in difficulty on shoe wearing. Skin biopsy of her left cheek andleft toe were arranged, and the pathological results revealed angiofibroma on her face and periungualfibroma on her left toe respectively.

Fig. 1Appearance of thepatient’s face.

Fig. 2 Multiple periungualtender tumors of thetoes prior to lasertreatment.

Fig. 3 Appearance of woundsimmediately followinglaser vaporization.

Fig. 4 Follow up at 6 months.

172 Dermatol Sinica, Jun 2007

DISCUSSIONSince Maiman invented the first Ruby

laser in the world in 1960, various laser applica-tions have emerged rapidly. The usage of laserin skin treatment has developed very well. TheCO2 laser has also been frequently used in skindisease. Reviewing the medical literature, manyarticles have been published on the use of theCO2 laser for the treatment of skin lesions.Some of the articles mentioned the use of theCO2 laser to treat periungual disease, for exam-ple: ingrown toenail, periungual or subungualwarts, etc. These diseases have in common sub-ungual or periungual location, where traditionalmethods of surgical operation, electrocurettageor cryotherapy may be time consuming or mayinjure adjacent normal tissue and blood vesselseasily. We used a focused laser beam to vapor-ize the lesions without injuring the adjacent nor-mal tissue. At the same time, the laser beam indefocused mode may be used to seal 0.5 mmarterioles or 1.0 mm venules. This reducesbleeding,1 allowing a bloodless surgical field.2

Postoperative wound care is easy; and postoper-ative pain, edema and infection are also mini-mized.3

The patients of tuberous sclerosis complex(TSC) are prone to getting periungual fibromaover the toes. They are often painful and ten-der, affecting patients’ ability to walk or wearfootgear. Some authors consider surgical exci-sion of periungual fibroma as the treatment ofchoice traditionally,4 but the process is verycomplicated. We attempted to use CO2 laser totreat periungual fibromas of TSC, with somepotential advantages. First, efficiency: in ourcase, after local anesthesia of lesions with 1%xylocaine, we used CO2 laser to treat 10 lesionsof the 7 toes (Fig. 3), which took 6 minutes 6seconds. On average, each lesions took 36 sec-onds. Using traditional surgical excision to treat10 lesions of the 7 toes may take quite a longtime. Therefore, using CO2 laser saves a lot oftime. Second, there was decreased blood lossduring treatment and reduced postoperativecomplications. No severe postoperative pain orinfections were noted. Third, regarding safety

concerns, all the operators wore glasses duringoperation, and the patient’s eyes were coveredwith 5 pieces of normal saline rinsed gauzes.The patient has been followed up for 6 monthsafter the operation, with no recurrance of peri-ungual fibromas (Fig. 4).

According to the above advantages, wepropose CO2 laser as an alternative new thera-peutic modality for the treatment of periungualfibromas of TSC.

REFERENCES1. Kao MC: Clinical use of Laser in neurosurgery.

Bulletin Laser Med Soc R.O.C.1: 24, 1985.2. Yang KC: Large head and neck basal cell carcino-

ma: treatment with the carbon dioxide laser ---Case report. Dermatol Sinica. 5: 33-36, 1987.

3. Bellack GS, Shapshay SM. Management of facialangiofibromas in tuberous sclerosis: use of thecarbon dioxide laser. Otolaryngol Head Neck Surg94: 37-40, 1986.

4. Ward PE, McCarthy DJ. Periungual fibroma. Cutis46: 118-124, 1990.

Dermatol Sinica, Jun 2007 173

From the Department of Dermatology , Kaohsiung Medical University and1 Armed Forces Tso-Ying General Hospital.Accepted for publication: November 02, 2006 Reprint requests: Gwo-Shing Chen, M.D., Department of Dermatology, Kaohsiung Medical University. No.100, Shih-Chuan 1stRd., Kaohsiung, Taiwan, R.O.C.TEL: 07-3208214 FAX: 07-3216580

Numerous Minute Round Glistening Papules onPhotodistributed Skin in a 4-year-old Boy

Chien-Te Lin1 Kung-Kai Lin Gwo-Shing Chen

CASE REPORTA 4-year-old boy experienced numerous minute, round, glistening, flat-topped, flesh-colored to

pink or reddish-brown papules, 1 to 3 mm in diameter, on the face, dorsa of hands, extensor aspects offorearms and lower legs of 2 year’s duration (Fig. 1). There was a history of summer exacerbation withoccasional pruritus. No other part of the body was affected. The palms, soles, nails, mucous mem-branes, and scalp were spared. He had been in good health and there was no previous history of atopicdermatitis, lichen planus or similar lesions.

The histopathological findings showed a circumscribed granulomatous infiltrate which was com-posed of lymphocytes, histiocytes and some Langhans-type giant cells. The granulomatous infiltrateapproximated the lower surface of the epidermis and was confined to a widened dermal papilla. Theoverlying epidermis was thin with diminished granular layer, and a prominent vacuolar alteration of thebasal cell layer with focal subepidermal cleft formation was also noted. The adjacent rete ridges extend-ed downward and seem to clutch the dermal infiltrate in the manner of a claw clutching a ball (Fig.2). The immunofluorescence study was negative.

Fig. 1There are numerousminute, round, glis-tening, flat-topped,flesh-colored to pinkor reddish-brownpapules, 1 to 3 mmin diameter, on theface (A), dorsa ofhands (B), extensoraspect of forearmand lower leg (Cand D).

Fig. 2Microscopically, it showed a circumscribed granulomatous

infiltrate composed of lymphocytes, histiocytes and someLanghans-type giant cells. The infiltrate approximated thelower surface of the epidermis and was confined to awidened dermal papilla. The overlying epidermis was thinwith diminished granular layer, and a prominent vacuolaralteration of the basal cell layer with focal subepidermalcleft formation was also noted. The adjacent rete ridges wereelongated and seemed to clutch the dermal infiltrate in themanner of a “claw clutching a bali”. (H&E x200)

Resident Forum

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DIAGNOSIS: Actinic Lichen Nitidus

DISCUSSIONActinic lichen nitidus is a rare photodis-

tributed variant of lichen nitidus that appearsmore common in dark-complexioned individu-als with a history of exacerbation after signifi-cant sun exposure during the summer months.1

It is seen in both pediatric and adult patients.The lesions may improve with sun protectionand topical steroids, however, recurrences arecommon during subsequent summer seasons.Classic lichen nitidus (LN) is an uncommonchronic inflammatory condition of unknowncause. The dermatosis consists of multiple, dis-crete, minute, round, flat-topped, flesh-coloredto pink or reddish-brown glistening papules 1 to3 mm in diameter that are commonly found onthe flexural surfaces of the arms and the wrists,lower abdomen, breasts, the glans and shaft ofthe penis, and other areas of the genital regionor may occur in a generalized form occasionally.

Before the description of actinic lichennitidus by Hussain in 1998,2 summertime actiniclichenoid eruption was first described by Bediin 1978.3 Other synonyms such as lichen nitidusactinicus or photosensitive lichen nitidus wereproposed by Kanwar and Kaur.4 Hussain alsosuggested that the term summertime actiniclichenoid eruption should be replaced with actiniclichen nitidus because not only is the latter termdescriptive but it also reflects the parallelismbetween classic lichen planus (LP) and LN onthe one hand, and actinic LP and actinic LN onthe other.2

Since sunlight is incriminated as a precipi-tating and perpetuating factor in lichen planus,especially of the actinic variety, it is possiblethat it may also play a role in the etiology oflichen nitidus, especially in patient like ours inwhom the lesions are limited to photosensitiveareas.

The diagnosis of actinic lichen nitidus iseasily established based on the characteristicmorphology, distribution, and clinical history.The pathognomonic microscopic changes ofskin biopsy will confirm the diagnosis. Direct

immunofluorescence examination is usuallynegative.

The treatment modalities, mostly from iso-lated case reports, include topical and systemicsteroids, topical tacrolimus, systemic cetirizine,levamisole, astemizole, etretinate, itraconazole,cyclosporine, topical dinitrochlorobenzene.Clinical improvement of palmoplantar lichennitidus with acitretin 75 mg (0.75 mg/Kg) dailytreatment was also reported by Lucker et al.5

The authors speculated that the down-modula-tion of lymphocyte activation by acitretin basedon the findings of a concentration-dependentinhibition of DNA synthesis in mitogen-stimu-lated lymphocytes and inhibiting the antigen-presenting properties of epidermal cells in vitro.Furthermore, sun protection appears to be moreimportant therapeutically than topical steroid inactinic lichen nitidus.

The presented patient was treated with oralacitretin 12.5 mg (0.66 mg/Kg) daily for 5weeks, and clobetasol propionate ointmentapplied locally twice a day with sun-protectionmeasurement. The lesions partially resolvedover two months.

REFERENCES1. Glorioso S, Jackson SC, Kopel AJ, et al.: Actinic

lichen nitidus in 3 African American patients. JAm Acad Dermatol 54: S48-S49, 2006.

2. Hussain K: Summertime actinic lichenoid erup-tion, a distinct entity, should be termed actiniclichen nitidus. Arch Dermatol 134: 1302-1303,1998.

3. Beti TR: Summertime actinic lichenoid eruption.Dermatologica 157: 115-125, 1978.

4. Kanwar AJ, Kaur S: Lichen nitidus actinicus.Pediatr Dermatol 8: 94-95, 1991.

5. Lucker GPH, Koopman RJJ, Steijlen PM, et al.:Treatment of palmoplantar lichen nitidus withacitretin. Br J Dermatol 130: 791-793, 1994.

Dermatol Sinica, Jun 2007 175

From the Department of Dermatology, National Taiwan University Hospital1 and College of Medicine,2 National TaiwanUniversity, Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and ComputerScience, National Taiwan University3

Accepted for publication: December 12, 2006Reprint requests: Tsen-Fang Tsai, M.D., Department of Dermatology, National Taiwan University Hospital;7 ,Chung-Shan SouthRoad, Taipei 100, TaiwanTEL: 886-2-23562141 FAX: 886-2-23934177 E-mail: tftsai@ha.mc.ntu.edu.tw, tftsai@yahoo.com

Several Erythematous Papules with a 1.5-cm Sized NoduleScattering on the Face of an Old Woman

Shiou-Han Wang 1, 3 Tsen-Fang Tsai1, 2

CASE REPORTA 67-year-old woman presented with a 4-month history of asymptomatic papules on the face. She

was a housewife with unremarkable past medical history. On physical examination, these dome-shapedpapules were variably sized with erythematous hue, and some of them showed tendency to confluence.They were disseminated on the periorbital and paranasal regions. Both cheeks were also involved. Alarge brownish red nodule measuring 1x1.5-cm in size was noted on the right upper eyelid. Somepapules were confluent and developed a 1.5-cm long transverse nodule on the left upper eyelid (Fig. 1).A biopsy was taken from the right eyelid and sent for histopathologic examination, including acid-faststain and diastase periodic acid Schiff reaction (Fig. 2). Microscopic examination showed granuloma-tous inflammation with perifollicular granulomas and focal caseous necrosis in the dermis. Neithermycobacterial bacilli nor hyphae of fungi were demonstrated.

Fig. 1(A) Variably sized erythematous dome-shaped papules onthe face with tendency to confluence. (B) A large brownishred nodule measuring 1x1.5-cm in size on the right uppereyelid. (C) Cheeks involvement. (D) Scattered papules onthe perioral and paranasal regions.

Fig. 2(A)(B)(C)(D) The histopathology and special stain of thenodule on the right upper eyelid and the papule on the perio-ral region showed similar findings with superficial perifol-licular granulomatous inflammation and caseous necrosis.(C)(D) Stains for mycobacterial bacilli and hyphae of fungidemonstrated negative results.

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DIAGNOSIS: Acne Agminata (lupus mil-iaris disseminatus faciei, LMDF)

DISCUSSIONLMDF, as known as acne agminata, is a

self-limited disease of unknown etiology.LMDF usually occurs on the face, but extrafa-cial presentations have been reported.1, 2 It clini-cally shows discrete brown papules of diameterabout 1-3 mm.3 A 1.5 cm nodular lesion waspresent in this case, which is a rare feature. It ischaracterized by superficial granulomatousinflammation with central caseation necrosis inthe perifollicular granulomas.1

LMDF may have a multifactorial aetiolo-gy. Mycobacterium tuberculosis or its productsmay cause a caseous necrosis and thus maybeone of several possible causes.4 Some authorsview LMDF as a variant of granulomatousrosacea or a presentation related to Demodexfolliculitis. Others suggest it as a new independ-ent entity and proposed a new term: FacialIdiopathic GranUlomas with RegressiveEvolution (FIGURE).1 Misago et al. postulatedLMDF as a common adult form, granulomatousperiorificial dermatitis as a rare childhood form,and perioral dermatitis as a peculiar form exac-erbated by topical corticosteroids.5

There are no randomized controlled stud-ies available for the treatment of LMDF. Theusual first-line therapy is oral tetracyclines withvariable success rates. Dapsone, low dose pre-donisolone, clofazimine and isotretinoin haveall been tried in some cases.6, 7 Our case wastreated with a regimen of oral tetracycline (1000mg/d). The skin lesions showed satisfactoryresponse to this therapy subjectively by thepatient, and most papules resolved successfullywith sequela of scarring after 8 months of treat-ment. Recently, the 1450-nm diode laser hasbeen shown to improve LMDF.7

REFERENCES1. Hillen U, Schroter S, Denisjuk N, et al.: Axillary

acne agminata (lupus miliaris disseminatus facieiwith axillary involvement). J Dtsch Dermatol Ges4: 858-860, 2006.

2. Farrar CW, Bell HK, Dobson CM, et al.: Facialand axillary acne agminata. Br J Dermatol 149:1076, 2003.

3. Moloney FJ, Egan CA: Case 3. Acne agminata(lupus miliaris disseminatus faciei). Clin ExpDermatol 28: 685-686, 2003.

4. Nino M, Barberio E, Delfino M: Lupus miliarisdisseminatus faciei and its debated link to tubercu-losis. J Eur Acad Dermatol Venereol 17: 97, 2003.

5. Misago N, Nakafusa J, Narisawa Y: Childhoodgranulomatous periorificial dermatitis: lupus mil-iaris disseminatus faciei in children? J Eur AcadDermatol Venereol 19: 470-473, 2005.

6. Goh BK, Tan HH: Doxycycline in the treatment ofacne agminata. Clin Exp Dermatol 28: 677-679,2003.

7. Jih MH, Friedman PM, Kimyai-Asadi A, et al.:Lupus miliaris disseminatus faciei: treatment withthe 1450-nm diode laser. Arch Dermatol 141: 143-145, 2005.