Fractionated Carbon Dioxide Laser Treatment of Fibroelastolytic Papulosis With Excellent Cosmetic Result and Resolution of Pruritus

A 63 year old Caucasian man with past medical history of hyperlipidemia, hypertension, diabetes mellitus type II, and benign prostatic hyperplasia presented to dermatology clinic with a chief complaint of pruritic papules on the left posterior lateral neck present for several years, and the patient sought diagnosis and treatment for this skin condition. Of note, pruritus was causing significant discomfort. He had no history of cardiovascular, gastrointestinal, or ocular disorders. His medications were non-contributory. There was no family history of similar lesions.

Physical examination revealed multiple, 4 to 5 millimeter, flesh-colored papules coalescing into a cobblestone-patterned plaque (Figure 1). Histological evaluation revealed reduced elastic fibers in the papillary dermis. A diagnosis of fibroelastolytic papulosis (FEP) was made based upon clinical and histological correlation.

Patient received three treatments with DEKA SmartXide DOT HP fractional CO₂ laser (DEKA Medical, San Francisco, CA) approximately three months apart (Table 1). There were no treatment complications and wound care with white petrolatum and triamcinolone 0.1% ointment was applied twice daily to facilitate healing.

Patient returned to dermatology clinic one month after each treatment. After the first treatment, patient reported a significant improvement of his pruritus. After the third treatment, patient was asymptomatic and the treated area became a smooth flesh-toned patch (Figure 2). The patient had no recurrence of skin lesions or pruritus six-months post-completion of fractionated CO₂ laser treatment.

We present this case of FEP successfully treated with fractionated CO₂ laser, as FEP is a rare skin condition lacking effective treatment. FEP is a clinical entity that encompasses two clinically and histologically similar dermatological conditions including pseudoxanthoma elasticum (PXE)-like papillary dermal elastolysis (PXE-PDE) and white fibrous papulosis of neck (WFPN).1 FEP presents as asymptomatic to mildly pruritic whitish-yellow papules that coalesce into a cobblestone-patterned plaque and resemble “plucked chicken skin.” The papules are cosmetically undesirable, and pruritus may cause significant discomfort for patients. On histology, the hallmark of FEP is marked decrease or absence of elastic fibers in the papillary dermis.¹

PXE-PDE was first described in 1992.² PXE-PDE has only been described in elderly women with yellowish papules that formed a cobblestone-patterned plaque. PXE-PDE usually manifests in flexural regions including neck, supraclavicular, scalp, axilla, antecubital fossa, abdomen, and inguinal region.^2-4 Histologically, PXE-PDE reveals papillary dermal elastolysis without dermal fibrosis, as demonstrated by lack of oxytalan and eulanin elastic fibers in the papillary dermis.^3,5 One study has suggested the presence of scattered melanophages within the papillary dermis that is devoid of elastic fibers as a clue to diagnosis of PXE-PDE.⁶ Patients with PXE-PDE usually present with mild to moderate pruritus, and