Successful Treatment of Porokeratosis With Ablative Fractional Carbon Dioxide Laser and Vitamin C, E, and Ferulic Acid Serum
November 2019 | Volume 18 | Issue 11 | Case Reports | 1174 | Copyright © November 2019
Julie K. Nguyen MD,a,b Silvia Mancebo MD,a Brady Bleicher MD,b,c and Jared Jagdeo MD MSa,b
aDepartment of Dermatology, SUNY Downstate Medical Center, Brooklyn, NY
BDermatology Service, VA New York Harbor Healthcare System – Brooklyn Campus, Brooklyn, NY
cDepartment of Dermatology, Mount Sinai Medical Center, New York, NY
evifor porokeratosis.3 Based on a limited number of case reports and cases series available in the literature, porokeratosis of Mibelli shows the best clinical outcomes after treatment with imiquimod cream.3
Herein, we report a case of a patient who had multiple lesions consistent with porokeratosis of Mibelli that were each successfully treated with a combination of ablative fractional carbon dioxide (CO2) laser and topical application of an antioxidant serum.
A 51-year-old male with Fitzpatrick skin phototype 2 presented to dermatology clinic for evaluation of a chronic rash. He reported the occurrence of focal, red, scaly lesions on his left hand, face, and right arm. The onset of these lesions was unclear, but they remained unchanged despite the use of topical clobetasol. His past medical history included celiac disease and hyperlipidemia, and medications included gemfibrozil. Physical examination revealed three annular, pink, erythematous plaques (approximately 1.0 x 1.0 cm) with a raised scaly border distributed on the left dorsal hand, right forehead superior to the eyebrow, and right dorsal forearm (Figure 1A-C).
The lesion on the forearm was visualized under dermoscopy, optical coherence tomography (OCT), and reflectance confocal microscopy (RCM). Dermoscopy revealed the presence of a peripheral white rim and multiple dotted vessels over an erythematous center and superficial white scales (Figure 2A). OCT (VivoSight, Michelson Diagnostics Ltd, Kent, UK) showed a cornoid lamella (Figure 2B). RCM (VivaScope 3000, Caliber I.D., Rochester, NY) showed an atypical honeycomb pattern and architectural disarray at the corneal level (Figure 2C). Based on the clinical presentation and morphologic features identified on in vivo skin imaging modalities, the diagnosis of porokeratosis
of Mibelli was made. A skin biopsy was deferred. Although the lesions were asymptomatic, the patient was concerned about the aesthetic appearance and requested treatment.
The individual lesions were treated with ablative fractional CO2 laser resurfacing (Fraxel Repair, Solta Medical, Hayward, CA). Two days prior to the procedure, he was started on prophylaxis with valacyclovir (1 g twice daily for 7 days) and cephalexin (500 mg four times daily for 14 days). For each focal site of porokeratosis, the lesion received three passes of the laser at 70 mJ with 35% coverage. An additional pass was performed at 50 mJ with 30% coverage along with feathering at the edges. A topical formulation of 15% L-ascorbic acid, 1% alpha-tocopherol, and 0.5% ferulic acid serum (C E Ferulic, SkinCeuticals Inc, Garland, TX) was applied immediately after the procedure, and the patient was instructed to re-apply it twice daily for two days. At a two months follow-up visit, clinical examination of the affected areas showed complete clearance of the lesions (Figure 1D-F), and repeat in vivo imaging of the lesion on the forearm showed normal skin (images not shown).
There is a paucity of clinical studies evaluating therapeutic modalities for porokeratosis. The use of CO2 laser ablation for the treatment of porokeratosis has been previously documented in isolated case reports.3 Successful treatment of porokeratosis of Mibelli with the CO2 laser has been reported with good clinical and aesthetic outcomes, including histological confirmation of complete resolution of porokeratosis features and no evi