dence of recurrence at follow-up.7,8 CO2 laser treatment has also been used successfully in other types of porokeratosis, including linear porokeratosis.9,10 Besides the CO2 laser, the 585 nm pulsed-dye laser and Nd:YAG laser have been reported to be effective for various forms of porokeratosis.1
The use of ablative fractional CO2 laser for the treatment of porokeratosis of Mibelli has several advantages compared to other therapeutic options such as systemic agents or surgical excision, as it is minimally invasive, can be used to treat areas of extensive involvement, and lacks significant side effects. Furthermore, a single treatment session may be sufficient to achieve complete clearance and the potential for post-laser scarring can be minimized as the laser parameters can be customized.7 Postoperative application of vitamin C, E, and ferulic acid serum has been shown to promote more rapid wound healing after fractional ablative laser treatment.11
This case report highlights the clinical utility of using real-time, high-resolution, non-invasive imaging techniques to establish a diagnosis of porokeratosis. In this case, by using OCT to identify the cornoid lamella and using RCM to examine the distinct morphologic features of porokeratosis, we were able to confirm a diagnosis of porokeratosis, avoiding the need for an invasive biopsy for histopathological examination. The hallmark of dermoscopy diagnosis of porokeratosis is the presence of a peripheral white rim, corresponding to the cornoid lamella, which can also be identified on OCT.1,5 On RCM imaging of porokeratosis, the presence of sharp demarcation and hyper-refractile border at the level of the corneal layer corresponds in histopathology to the presence of the cornoid lamella.5
In conclusion, the use of the CO2 laser in porokeratosis of Mibelli is a therapeutic modality that is minimally invasive, offers fast and durable results, delivers clinical results, and is associated with patient satisfaction. Clinicians should consider the use of ablative fractional CO2 laser to treat focal porokeratosis lesions with consideration of the size of the lesion, anatomical location, and risk of malignant transformation. To date, there are no treatment guidelines or universal consensus on the optimal treatment for porokeratosis, with the therapeutic armamentarium consisting of a variety of topical agents, systemic medications, and surgical modalities. The approach to treatment for porokeratosis should be individualized with consideration of the functional and aesthetic impact and patient preferences.
The use of ablative fractional CO2 laser for the treatment of porokeratosis of Mibelli has several advantages compared to other therapeutic options such as systemic agents or surgical excision, as it is minimally invasive, can be used to treat areas of extensive involvement, and lacks significant side effects. Furthermore, a single treatment session may be sufficient to achieve complete clearance and the potential for post-laser scarring can be minimized as the laser parameters can be customized.7 Postoperative application of vitamin C, E, and ferulic acid serum has been shown to promote more rapid wound healing after fractional ablative laser treatment.11
This case report highlights the clinical utility of using real-time, high-resolution, non-invasive imaging techniques to establish a diagnosis of porokeratosis. In this case, by using OCT to identify the cornoid lamella and using RCM to examine the distinct morphologic features of porokeratosis, we were able to confirm a diagnosis of porokeratosis, avoiding the need for an invasive biopsy for histopathological examination. The hallmark of dermoscopy diagnosis of porokeratosis is the presence of a peripheral white rim, corresponding to the cornoid lamella, which can also be identified on OCT.1,5 On RCM imaging of porokeratosis, the presence of sharp demarcation and hyper-refractile border at the level of the corneal layer corresponds in histopathology to the presence of the cornoid lamella.5
In conclusion, the use of the CO2 laser in porokeratosis of Mibelli is a therapeutic modality that is minimally invasive, offers fast and durable results, delivers clinical results, and is associated with patient satisfaction. Clinicians should consider the use of ablative fractional CO2 laser to treat focal porokeratosis lesions with consideration of the size of the lesion, anatomical location, and risk of malignant transformation. To date, there are no treatment guidelines or universal consensus on the optimal treatment for porokeratosis, with the therapeutic armamentarium consisting of a variety of topical agents, systemic medications, and surgical modalities. The approach to treatment for porokeratosis should be individualized with consideration of the functional and aesthetic impact and patient preferences.
DISCLOSURE
Dr. Jagdeo is a consultant for SkinCeuticals-L'Oréal.
REFERENCES
- Sertznig P, Von Felbert V, Megahed M. Porokeratosis: present concepts. J Eur Acad Dermatology Venereol. 2012;26(4):404-412.
- Ferreira FR, Santos LDN, Tagliarini FANM, Lira ML de A. Porokeratosis of Mibelli--literature review and a case report. An Bras Dermatol. 2017;88(6 Suppl 1):179-182.
- Weidner T, Illing T, Miguel D, Elsner P. Treatment of porokeratosis: a systematic review. Am J Clin Dermatol. 2017;18(4):435-449.
- Kanitakis J. Porokeratoses: An update of clinical, aetiopathogenic and therapeutic features. Eur J Dermatology. 2014;24(5):533-544.
- González S, ed. Reflectance Confocal Microscopy of Cutaneous Tumors. 2nd ed. Boca Raton, FL: CRC Press; 2017.
- Sasson M, Krain AD. Porokeratosis and cutaneous malignancy: A review. Dermatologic Surg. 1996;22(4):339-342.
- Groot DW, Johnston PA. Carbon dioxide laser treatment of porokeratosis of mibelli. Lasers Surg Med. 1985;5(6):603-606.
- Rabbin P, Baldwin H. Treatment of Porokeratosis of Mibelli with CO2 laser vaporization versus surgical excision with split-thickness skin graft. J Dermatol Surg Oncol. 1993;19(3):199-202.
- Hunziker T, Bayard W. Carbon dioxide laser in the treatment of porokeratosis. J Am Acad Dermatol. 1987;16(3 Pt 1):625.
- Barnett JH. Linear porokeratosis: Treatment with the carbon dioxide laser. J Am Acad Dermatol. 1986;14(5):902-904.
- Waibel JS, Mi QS, Ozog D, et al. Laser-assisted delivery of vitamin c, vitamin e, and ferulic acid formula serum decreases fractional laser postoperative recovery by increased beta fibroblast growth factor expression. Lasers Surg Med. 2016;48(3):238-244.
AUTHOR CORRESPONDENCE
Jared Jagdeo MD MS jrjagdeo@gmail.com
