Fractional Photothermolysis for Treatment ofPoikiloderma of Civatte

DANIEL S. BEHROOZAN, MD,�y LEONARD H. GOLDBERG, MD, FRCP,�z

AORIENNE S. GLAICH, MD,� TIANHONG DAI, PHD,y AND PAUL M. FRIEDMAN, MD�J

The author have indicated no significant interest with commercial supporters.

Poikiloderma of Civatte refers

to a change in the skin where

there is atrophy, hyper- and

hypopigmentation, and dilation

of fine blood vessels (telangiect-

asia).1,2 These alterations often

cause cosmetic disfigurement

most commonly in middle-aged or

elderly women with a fair com-

plexion.1,2 Several treatment

modalities, based on the theory of

selective photothermolysis,3 in-

cluding argon lasers, potassium

titanyl phosphate (KTP) lasers,

pulsed dye lasers, and intense

pulsed light devices, have been

used to treat this condition in the

past.4–13 Clinical experience has

shown that complete clearing is

difficult to achieve. Moreover,

depending on the modality

used, adverse effects such as scar-

ring with irregular hypopigmen-

tation, postinflammatory

hyperpigmentation, post-

treatment purpura, mottled ap-

pearance, crusting and erythema

have been reported.4–13 Multiple

sessions with these treatments are

usually necessary to obtain opti-

mal clearing.2,6,10

We report the successful treatment

of poikiloderma of Civatte on the

neck using fractional photo-

thermolysis. In contrast to selec-

tive photothermolysis, which aims

to produce bulk thermal injury in

particular targets within the skin,

fractional photothermolysis cre-

ates thousands of targeted micro-

thermal treatment zones (MTZ)

and spares the surrounding tis-

sue.14,15 To the best of our

knowledge, this is the first re-

ported case of fractional photo-

thermolysis for the treatment of

poikiloderma of Civatte.

Case Report

A 55-year-old Caucasian female

patient with Fitzpatrick type II

skin presented with a 3-year his-

tory of poikiloderma of Civatte on

the neck that had previously been

untreated (Figure 1). The past

medical history was unremark-

able. The patient denied any per-

sonal or family history of keloid

formation, or recent isotretinoin

use.

The treatment area was thor-

oughly cleansed before the proce-

dure using a gentle, abrasive skin

cleanser. OptiGuide Blue (Scho-

lAR Chemistry, West Henrietta,

NY, USA), an FDA-certified

water-soluble tint, was applied to

the treatment area to highlight the

contours of the skin so as to allow

the Intelligent Optical Tracking

System to detect contact with the

skin and to adjust the treatment

pattern with respect to hand piece

velocity. Thirty percent topical

lidocaine ointment was applied

for 1 hour before treatment. A

single treatment with the 1,550 nm

wavelength Fraxels, SR laser

(Reliant Technologies Inc.,

Mountain View, CA) at a pulse

energy of 8 mJ and a final density

of 2,000 MTZ/cm2 was per-

formed. During treatment, the

patient noted mild pain, which

she described as thermal

in nature and which was allevi-

ated by a temporary pause in

treatment. Additionally, post-

operative edema was noted,

which resolved within 24 hours.

Follow-up results at 2 weeks

& 2006 by the American Society for Dermatologic Surgery, Inc. � Published by Blackwell Publishing �ISSN: 1076-0512 � Dermatol Surg 2006;32:298–301 � DOI: 10.1111/j.1524-4725.2006.32061.x

2 9 8

�DermSurgery Associates, Houston, TX; yDivision of Dermatology, David Geffen School of Medicineat UCLA, Los Angeles, CA; zDepartment of Medicine (Dermatology), University of Texas, MDAnderson Cancer Center, Houston, TX; yDepartment of Bioengineering, Rice University, Houston,TX; JDepartment of Dermatology, University of Texas Medical School, Houston, TX

revealed a significant clinical

improvement in the degree of

erythema, dyschromia, and over-

all texture of her neck based on

independent physician clinical as-

sessment (Figure 2). The patient’s

degree of satisfaction paralleled

the physician’s assessment of

improvement. A 2-month follow-

up revealed persistence of im-

provement (Figure 3).

Discussion

Ideally, an effective treatment of

poikiloderma of Civatte improves

both vascular and pigmentary

components of the condition. In

selective photothermolysis, visible

laser irradiation is the choice for

treatment, as both hemoglobin

and melanin are targeted at these

wavelengths.16 However, studies

have shown that the therapeutic

outcomes are variable.4–13

The blue-green argon laser was

the first laser system used for

treating poikiloderma of Civatte.

Although it offered improvement,

this treatment had significant side

effects, most notably scarring.4,5

The 532 nm KTP laser introduced

later was an improvement,

although complicated by cases

resulting in occasional hypopig-

mentation.6 The advent of pulsed

dye lasers emitting at 585–595 nm

has lead to more effective and re-

producible treatment of poikilo-

derma of Civatte. However, post-

treatment purpura may be en-

countered and may last several

days. Uncommonly, scarring and

mottled hypopigmentation have

also been reported.2,7–11 Intense

pulsed light with a broad wave-

length spectrum of 515–1,200 nm

has most recently been success-

fully utilized for the treatment

of poikiloderma of Civatte;

Figure 1. Poikiloderma of Civatte on the neck before treatmentwith fractional photothermolysis.

Figure 2. Two weeks following a single treatment with eightpasses at a density of 250 MTZ/cm2 and a fluence of 8 mJ. Both anindependent physician evaluator and the patient reported a sig-nificant clinical improvement in the degree of erythema,dyschromia, and overall texture.

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erythema, purpura, and crusting

have been described.12,13

Incomplete clearing of poikilo-

derma of Civatte is a result of

poor penetration of visible laser

irradiation depth in blood. For

example, the light penetration

depths in blood at 532 and

585 nm wavelengths are approxi-

mately 37 (absorption coeffi-

cient � 266 cm�1) and 52 mm

(absorption coefficient

� 191 cm�1),17 while the

ectatic blood vessels of poi-

kiloderma of Civatte are approx-

imately 100mm in diameter.12 As

a result, large blood vessels can-

not be completely coagulated, re-

sulting in incomplete clearing of

poikiloderma of Civatte.

Unlike the modalities based on

selective photothermolysis, which

aim to achieve homogeneous

thermal injury in a particular tar-

get within the skin, fractional

photothermolysis produces an

array of microscopic regions of

thermal injury surrounded by un-

injured dermal tissue. This ‘‘frac-

tional’’ treatment was originally

motivated by the faster wound

healing response during skin re-

juvenation if the entire area were

treated at once, a result of small

injury regions and short migratory

paths for keratinocytes.14 Recent

clinical studies indicate that frac-

tional photothermolysis is effec-

tive in treating fine wrinkles,

epidermal dyschromia, and re-

modeling acne scars.18–24 How-

ever, no reports on the efficacy of

this modality on the treatment of

poikiloderma of Civatte have

been described.

The 1,550 nm wavelength emitted

from the fractional photo-

thermolysis laser largely targets

tissue water and not melanin.

Therefore, nonspecific thermal

injury to the epidermis, which

may induce scarring and hypo-

pigmentation, is unlikely. This

may especially be beneficial for

the treatment of Fitzpatrick-type

IV–VI individuals. Additionally,

the ‘‘fractional’’ laser avoids bulk

heating of the skin dermis, which

is seen in conventional pulsed

mid-infrared lasers. For a typical

density of 2,000 MTZ/cm2 at

8 mJ, approximately 18% of the

treated area is actually heated

with fractional photothermolysis.

This reduces the risk of irreversi-

ble nonspecific thermal injury to

the dermis, which may also result

in scarring. By adjusting the opti-

cal focal depth and/or the energy

of the laser, high local radiant

exposure can be achieved.14

Hence, different tissue compart-

ments (e.g., blood vessels, dermal

melanin, and sebaceous glands) at

various depths of the skin can be

arbitrarily selected as the targets

for photothermolysis. With an

appropriate MTZ density, an

effective macroscopic treatment

can be achieved.

There are two hypotheses as to

the targeting of dermal vascular

structures. Fractional photo-

thermolysis emits a wavelength

that largely targets water. As wa-

ter is a large component of blood

vessels, it seems logical to con-

clude that irradiance at 1,550 nm

may lead to fractional photother-

mal microvascular destruction

with clinical benefits. Secondly,

the microthermal zones of injury

in the dermis produced by this

device may randomly result in

frequent direct hits to the dermal

Figure 3. Two-month follow-up photograph demonstrating per-sistence of improvement following fractional photothermolysis.

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vasculature. Laubach and collea-

gues25 recently reported histo-

pathologic evidence of damage to

dermal vasculature in patients

undergoing fractional photo-

thermolysis to support the latter

hypothesis. It is likely that

both hypotheses work synergis-

tically to produce reduction in

telangiectasias as seen in this

case report.

The rapid improvement of the

telangiectatic component of poi-

kiloderma of Civatte with frac-

tional photothermolysis further

underscores the versatility and

potential benefits of this new

technology. Additionally, the un-

complicated treatment of non-

facial skin areas with a paucity of

pilosebaceous glands, such as the

neck, is an exciting consideration,

particularly given the historical

avoidance of these anatomic lo-

cations given the risks of scarring

and dyschromia with other abla-

tive techniques. Although frac-

tional photothermolysis was an

effective and safe modality in the

treatment of poikiloderma of

Civatte for the patient presented

in this case report, further larger,

long-term studies are needed to

better elucidate the efficacy and

safety of fractional photo-

thermolysis treatment for poi-

kiloderma of Civatte and to opt-

imize treatment parameters.

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Address correspondence and reprintrequests to: Paul M. Friedman, MD,DermSurgery Associates, 7515 S.Main Street, Suite 210, or e-mail:pmfriedman@dermsurgery.org.

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