1,064-Nm Q-Switched Neodymium-Doped Yttrium Aluminum Garnet Laser and 1,550-Nm Fractionated Erbium-Doped Fiber Laser for the Treatment of Nevus of Ota in Fitzpatrick Skin Type IV

of 5
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
  COMMUNICATIONS AND BRIEF REPORTS 1,064-nm Q-Switched Neodymium-Doped Yttrium AluminumGarnet Laser and 1,550-nm Fractionated Erbium-DopedFiber Laser for the Treatment of Nevus of Ota in FitzpatrickSkin Type IV M EGAN  N. M OODY , MD,   J ENNIFER  M. L ANDAU  BS,  I RENE  J. V ERGILIS -K ALNER  MD,  y L EONARD  H. G OLDBERG  MD,  yz D ENISE  M ARQUEZ  PA-C,  AND  P AUL  M. F RIEDMAN , MD yz y The authors have indicated no significant interest with commercial supporters  . N evus of Ota, or oculodermal melanocytosis,typically presents as a blue–black, brown, orgray patch on the face along the distribution of theophthalmic or maxillary branches of the trigeminalnerve. It is a congenital lesion that is present at birth inthe majority of cases; otherwise, it tends to appear inthe teen years. 1,2 Treatment options for thesenevi include bleaching creams, cryotherapy, surgery,and lasers, with varying degrees of success being re-ported. Lasers have recently been found to be the mosteffective treatment modality for this condition. 1,3–5 Most commonly, Q-switched (QS) lasers have beenused, including the QS ruby (QSRL), QS neodymium-dopedyttriumaluminumgarnet(QSNd:YAG),andQSalexandrite (QSAL) lasers. 1–5 The Q-switched mecha-nism has the advantage over other options in that itallows for the laser to be used at higher energies with ashorterpulseduration,whichlimitsnonspecificthermaldamage and scarring. 3 More recently, a fractionated1,440-nm Nd:YAG laser was reported to effectivelytreat one patient with nevus of Ota. 6 We report thesuccessful treatment of nevus of Ota in two patientswith Fitzpatrick skin type (FST) IVusing serial therapywith a 1,064-nm QS Nd:YAG laser and a 1,550-nmfractionated erbium-doped fiber laser. Case 1 A 29-year-old Hispanic woman with FST IV wasseen for the evaluation of a 4-  1-cm gray–bluepatch on her right infraorbital cheek, which byappearance was clinically consistent with a nevusof Ota (Figure 1A). She reported that the lesion hadbeen present since birth. Her medical history wasotherwise unremarkable.Over 2 years, the patient received nine treatmentsusing a 1,064-nm QS Nd:YAG laser (Medlite,HOYA ConBio, Fremont, CA). Response to treat-ment plateaued 6 months after the final QS Nd:YAGsession, so we decided to attempt nonablative frac-tional technology. The patient subsequently under-went four treatments using a 1,550-nm fractionatederbium-doped fiber laser (Fraxel re:store, SoltaMedical, Haywood, CA). Before each treatment, thearea was cleansed with a mild soap (Cetaphil GentleSkin Cleanser; Galderma Laboratories, L.P., TX).Triple anesthetic cream (benzocaine 10%, lidocaine6%, tetracaine 4%; New England CompoundingCenter, Framingham, MA) was applied to the treat-ment area for half an hour before treatment with the &  2011 by the American Society for Dermatologic Surgery, Inc.    Published by Wiley Periodicals, Inc.   ISSN: 1076-0512    Dermatol Surg 2011;37:1163–1167     DOI: 10.1111/j.1524-4725.2011.02000.x 1163  Derm Surgery Associates, Houston, Texas;  y Department of Dermatology, Weill Cornell Medical College, Methodist Hospital, Houston, Texas;  z Department of Dermatology, University of Texas, Houston, Texas;  y Dermatology & LaserSurgery Center, Houston, Texas  1,064-nm QS Nd:YAG laser and for 1 hour underocclusion before treatment using the 1,550-nmfractionated erbium-doped fiber laser.The treatment sessions with the 1,064-nm QSNd:YAG laser used a 4-mm spot size and fluencesranging from 5.9 to 7.2J/cm 2 at an average intervalof 2.3 months (most often at 2-month intervals). Thetreatment sessions using the 1,550-nm fractionallaser used a 15-mm spot size for a total of 0.13 to0.24kJ at fluences ranging from 6.0 to 10.0mJ andtreatment levels of 4 to 7, corresponding to 11% to20% surface area coverage. These treatments werespaced an average of 1.8 months apart (also mostoften at 2-month intervals). A cooling device(Zimmer Elektromedizin Cryo 5; Zimmer MedizinSystems, Irvine, CA) was concomitantly used toprotect the epidermis and minimize patient discom-fort (fan power 2–4; 4–6 inches from the skin sur-face). After each treatment session, the patient wascounseled with regard to strict sun avoidance and theneed for daily broad-spectrum sunscreen with UVAand UVB protection (minimum sun protection factorof 45) on treated areas.Wound care after each treatment included a topicalgel (Bionect gel 0.2%; JSJ Pharmaceuticals, Inc.,Charleston, SC) used on the treated areas for 3 to 5days as needed. The only side effect reported duringtreatments was mild to moderate pain. Minimalerythema and edema noted immediately after treat-ments resolved within 48 hours. Significant im-provement was noted after the series of treatmentsusing the 1,064-QS Nd:YAG laser, although thepatient desired further improvement, which wasaccomplished after additional treatment sessionsusing the 1,550-nm fractionated erbium-doped fiberlaser (Figure 1B). At the follow-up visit 12 monthsafter the final laser treatment session, we noted thatsignificant improvement in the nevus of Ota wasmaintained without any visible evidence of recur-rence (Figure 1C). Case 2 A 27-year-old Asian woman with FST IV was seenfor evaluation of a 5-  5-cm speckled light brown–gray patch on her right infraorbital cheek, which byappearance was clinically consistent with a nevus of Ota (Figure 2A). The patient had scleral involve-ment, so close follow-up with an ophthalmologistwas arranged. She reported that the lesion had beenpresent since birth and recently appeared to begradually enlarging. She underwent two treatmentsusing the 1,064-nm QS Nd:YAG laser (Medlite).Response to treatment was minimal, so we decidedto use a sequential approach with the 1,064-nm QSNd:YAG laser followed immediately on the sameday by a treatment session with the 1,550-nm frac-tionated erbium-doped fiber laser (Fraxel re:store). Figure 1.  (A) Baseline photos of patient with nevus of Ota. (B) After last Q-switched neodymium-doped yttrium aluminumgarnet laser treatment with improvement of the nevus of Ota. (C) After last fractional laser treatment with enhancedimprovement of the nevus of Ota. DERMATOLOGIC SURGERY1164TREATMENT OF NEVUS OF OTA IN FITZPATRICK SKIN TYPE IV  Before each treatment, the area was cleansed using amild soap (Cetaphil Gentle Skin Cleanser). Tripleanesthetic cream (benzocaine 10%, lidocaine 6%,tetracaine 4%; New England Compounding Center)was applied to the treatment area for 1 hour underocclusion before treatment with the 1,064-nm QSNd:YAG laser; the patient was then immediatelytreated with the 1,550-nm fractionated erbium-doped fiber laser.After the first two treatment sessions with the 1,064-nm QS Nd:YAG laser, both lasers were used on thesame day at an average treatment interval of 3.2months. The treatment sessions with the 1,064-nmQS Nd:YAG laser used a 4-mm spot size and afluence of 4J/cm 2 . The treatment sessions with the1,550-nm erbium-doped fractional laser used a 15-mm spot size, for a total of 0.24 to 0.48kJ deliveredat fluences ranging from 6.0 to 15.0mJ, and treat-ment levels of 5 to 6, corresponding to 14% to 17%surface area coverage. A cooling device (ZimmerElektromedizin Cryo 5) was concomitantly used toprotect the epidermis and minimize patient discom-fort (fan power 2–4; 4–6 inches from the skin sur-face). The postoperative protocol was identical tothat described for case 1 above. Erythema and edemawere noted immediately after treatments, althoughthese effects were mild and resolved completelywithin 48 hours. Significant improvement was notedafter six sequential treatment sessions with the1,064-QS ND:YAG followed immediately bytreatment with the 1,550-nm fractionated erbium-doped fiber laser; complete clearance was notedafter 10 sessions. At 8-month follow-up afterthe final laser treatment session, we noted thatsignificant improvement in the nevus of Otawas maintained without any visible evidence of recurrence (Figure 2B). Discussion Nevus of Ota, also known as oculodermal me-lanocytosis and nevus fuscoceruleus ophthalmo-maxillaris, is a congenital lesion that is present atbirth or gradually appears within the first 2 decadesof life. 1,2 It is predominately a disease of Asianwomen, although it has been reported in other eth-nicities. It affects approximately 0.2% of the Asianpopulation, with a 5:1 predominance in woman. 2 Histologically, it is a dermal lesion, characterized byelongated dendritic melanocytes scattered through-out the papillary and upper portion of the reticulardermis. 1,2 Multiple treatment options have beenexplored, including topical bleaching agents, Figure 2.  (A) Baseline photos of patient with nevus of Ota. (B) Eight months after final combination laser treatment sessionwith clearance of the nevus of Ota. 37:8:AUGUST 2011 1165MOODY ET AL  cryotherapy, microsurgery, and more recently, lasertherapy. 1 The use of lasers is advantageous becauseof the efficacy and lack of adverse side effects,especially scarring.Because nevus of Ota is predominately a disease of Asians (typically FST III–IV), treatment needs to beapproached carefully. QSRL has been shown to bean effective treatment for nevus of Ota in more than50% of subjects. 4 Multiple reports have furtherreaffirmed the success of different QS lasers fortreatment of these nevi. 1,3,6 The QS laser delivershigh energy through short pulses, limiting the risk of further dyspigmentation or scarring. 3 Although it isgenerally recommended to proceed with cautionwhen using a laser to treat patients with FST III to V,previous authors report high success levels andminimal side effects when using the 1,064-nm QSNd:YAG, which is the preferred choice for dark-skinned patients because of its epidermal sparing. 4 Other QS lasers, such as QSAL and QSRL functionat lower wavelengths, which are more readilyabsorbed by melanin, increasing the risk of dyspig-mentation. 1 With the introduction of fractionatedlaser technology, an additional option for the treat-ment of darker skin types was secured, and in 2008,it was reported that a fractionated 1,440-nmNd:YAG laser resulted in complete clearance of onepatient’s nevus of Ota. 6 Our cases exemplify the use of a serial therapytreatment approach to accomplish significantimprovement of nevus of Ota using the 1,064-nm QSNd:YAG laser and the 1,550-nm fractionatederbium-doped fiber laser. In the first case, afterobserving no further response 6 months after thefinal treatment with the 1,064-nm QS Nd:YAG laser,we decided to see whether fractionated laser tech-nology would yield further improvement in ourpatient’s condition. In the second case, we treatedthe patient sequentially with both lasers on the sameday. In both cases, the combination was an idealtreatment regimen, considering that it targetspigment through two different, yet seemingly syner-gistic mechanisms. The 1,064-nm QS Nd:YAG laserfunctions using selective photothermolysis of mela-nin, which results in injury to epidermal and dermalmelanosomes. 3 Fractional photothermolysis isbelieved to function through a ‘‘melanin shuttle’’mechanism, which results in the elimination of melanin pigment from the skin with other photo-coagulation debris through MTZs created by thelaser. 7–9 Because nevus of Ota is a dermal lesion,specifically located in the papillary and upper por-tion of the reticular dermis, treatment options needto allow adequate dermal penetration. Both of thelasers used on this patient have settings that, whenadjusted accordingly, ensure sufficient depth to tar-get the pigmentary characteristic of this lesion. 1,2 We report near-complete clearance of an infraorbitalnevus of Ota after serial therapy using 1,064-nm QSND:YAG laser treatments followed by 1,550-nmfractionated erbium-doped fiber laser treatments andcomplete clearance of an infraorbital nevus of Otaafter sequential same-day therapy with 1,064-nm QSND:YAG laser treatments followed immediately by1,550-nm fractionated erbium-doped fiber laser inpatients with FST IV. This combination therapy ap-proach adds to the currently available options forsuccessful and safe laser treatment of nevus of Ota inFST IV. Further long-term, prospective studies with alarger study population are indicated to better un-derstand the efficacy of this serial therapy for thetreatment of nevus of Ota and to determine optimaltreatment settings. References 1. Chan HH, Kono T. Nevus of Ota: clinical aspects and manage-ment. Skinmed 2003;2:89–96.2. Hidano A, Kajama H, Ikeda S, Mizutani H, et al. Natural history of nevus of Ota. Arch Dermatol 1967;95:187–95.3. Tse Y, Levine VJ, McClain SA, Ashinoff R. The removal of cutaneous pigmented lesions with the Q-switched ruby laserand the Q-switched neodymium: yttrium-aluminum-garnetlaser. A comparative study. J Dermatol Surg Oncol 1994;20:795–800.4. Geronemus RG. Q-switched ruby laser therapy of nevus of Ota.Arch Dermatol 1992;128:1618–22.5. Alster TS, Williams CM. Treatment of nevus of Ota by theQ-switched alexandrite laser. Dermatol Surg 1995;21:592–6. DERMATOLOGIC SURGERY1166TREATMENT OF NEVUS OF OTA IN FITZPATRICK SKIN TYPE IV
Similar documents
View more...
Related Search
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks

We need your sign to support Project to invent "SMART AND CONTROLLABLE REFLECTIVE BALLOONS" to cover the Sun and Save Our Earth.

More details...

Sign Now!

We are very appreciated for your Prompt Action!