but had not noticed any changes or improvement. The patient denied any other medications, allergies, family history of skin cancer, or other significant history.
Biopsy of the facial lesion at the initial visit revealed perivascular and focally perifollicular lymphocytic infiltrate with small mounds of parakeratosis. Given the patient's history of HED, the facial rash was diagnosed as HED milia-like papules that coalesce into plaques. The patient was offered fractional CO2 ablative laser (DEKA SmartXide DOT, Calenzano (FI), Italy) with laser-assisted drug delivery (LADD) of triamcinolone 0.1% ointment. After discussion of risks, benefits, and alternatives to treatment, the patient agreed to complete three laser treatments at six-week intervals. Gentle skin care was recommended, including use of daily sunscreen and discontinuation of adapalene.
Description of Treatment Method
The patient was instructed to bring the following prescriptions to each treatment visit: topical lidocaine 2.5% and prilocaine 2.5% cream, mupirocin ointment, and triamcinolone 0.1% ointment. The patient was also given a course of 1 gram oral valacyclovir twice daily for 10 days starting one day prior to each procedure, oral cephalexin 500 mg four times daily for two weeks starting on the day of the procedure, and applied mupirocin topical ointment three times daily to the treated area for three days.
At each visit, topical lidocaine 2.5% and prilocaine 2.5% cream were applied to the treatment area including bilateral cheeks, chin, and upper cutaneous lip under occlusion for one hour prior to procedure. The facial skin was then thoroughly cleansed and de-greased with alcohol pads. Proper laser protective eyewear was worn by the patient and providers.
The CO2 laser treatments were performed with the following settings: power 15 W, DOT mode, spacing 500 micrometer, repeat 2.0 seconds, Stack 1, scanning dwell 500 microseconds, hexagon shape, size 100%, and ratio 10/10. One pass of laser treatment with feathering to smooth the edges was administered at each of the three total treatment visits. After each session, triamcinolone 0.1% ointment was applied to the treated areas. Post-operative care was reviewed after each procedure and the patient was instructed to avoid sun.
The patient tolerated the procedures well with no complications. The patient reported mild discomfort during the procedure that did not warrant discontinuation of treatment and no serious adverse events. At the two-week follow-up visit following the final treatment, physical exam revealed decreased milia-like papules and coalescing plaques, improved dyspigmentation, and smoother, flattened skin tone (Figure 2). The patient expressed high satisfaction with the results and improved quality of life.
DISCUSSION
We present successful treatment of HED-associated milia-like papules and coalescing plaques using a combination approach with fractional CO2 ablative laser and LADD of triamcinolone 0.1% ointment. There is limited evidence in the literature for safe and effective treatments improving HED-related facial skin aesthetics. One case report of a 27-year-old Chinese male patient documented the use of fractional CO2 laser treatment.4 The patient received three laser treatments for hyperplastic sebaceous glands at six-month intervals and reported marked improvement in facial skin aesthetic appearance.4 Our method is differentiated from this documented case as we used LADD to enhance the aesthetic outcome and minimize post-inflammatory pigmentary alteration (PIPA) from CO2 laser. Our literature search did not reveal any additional reports of laser treatment for HED. The facial skin rashes caused by HED demonstrate an unmet clinical need in dermatology.
Fractional CO2 ablative lasers emit wavelengths of 10,600 nm with water as the target chromophore.5 This treatment is often used for skin rejuvenation and resurfacing to improve skin texture, tone, and rhytids and to treat scars and photodamage.5 CO2 lasers are ablative lasers that vaporize portions of the epidermis and allow for new skin to form in its place.6 These effects may help improve the appearance of sebaceous hyperplasia, miliaria, and dyspigmentation in patients with HED.
Patients should be counseled on the risks of CO2 laser before beginning treatment, including dyspigmentation, burning, pain, erythema, scarring, infection, and potential outbreaks for patients with herpes simplex virus (HSV).5,7,8 We recommend performing test spots and the use of conservative laser parameters to help mitigate side effects such as dyspigmentation. To help enhance procedure-related comfort, we advise a one-hour incubation of topical lidocaine 2.5% and prilocaine 2.5% cream under occlusion. Additional local anesthetic injections can be administered based
