Kenneth A. Arndt

Milia en plaque of the Nose: Report of a Case and Successful Treatment With Topical Tretinoin

Milia are benign, superficial keratinaceous cysts that present as fine, small white papules. Milia en plaque is a rare, challenging-to-treat variant most often seen in the posterior auricular region. A total of 9 cases of milia en plaque have been reported in the pediatric literature to date. We report a case of milia en plaque of the nose in a 7-year-old boy, a novel site of involvement in the pediatric population, and successful treatment with the use of topical tretinoin. Topical retinoids offer an effective treatment option for the management of milia en plaque in the pediatric population.

Successful treatment of disfiguring hemosiderin-containing hyperpigmentation with the Q-switched 650-nm wavelength laser.

Report of a Case A63-year-oldwhitewomanpresentedwith a 3-year history of progressive dark facial discoloration. Findings from physical examination included prominent brown patches coveringmuch of her face (Figure, A) andyellow-orangeplaquesonherbreasts. The facial pigmentation also had a slight yellow tint. The result from a biopsy performed in 2009 had been interpreted as plane xanthoma. The patient was found to have an IgG λ monoclonalgammopathyandwas laterdiagnosedashavingchronic lymphocytic leukemia not requiring treatment. Selected areas had been treatedwith the pulsed-dye laser (595 nm) and 3-millisecond alexandrite laser (755 nm) without benefit. We performed a skin biopsy of the cheek, which revealed a dermal histiocytic infiltrate with scattered xanthomatous cells, Toutongiantcells,andperivascular lymphocytic inflammation.Aniron stainwaspositivewithin someof thehistiocytes andgiant cells, consistentwithhemosiderin, and thepresenceofdermalmelanophages wasconfirmedbyaFontana-Massonstain.Thebreast lesionsshowed similarchanges,withpalisadinggranulomaswithcentralnecrosis,cholesterol clefts, andscatteredextravasatederythrocytes.The findings werecompatiblewithadiagnosisofnecrobioticxanthogranuloma.The darkpigmentationseenclinically appeared tobecausedby thecombination of hemosiderin andmelanin. The patient sought treatment for the disfiguring intense pigmented patches that covered most of her face, which severely affected her quality of life. She is an astronomer and could not examine telescopesbecauseher thickmakeup transferred to their lenses. The patient stopped swimming laps at the local pool because she worriedthatchildrenwould findherappearance frightening,andshe experienced a great deal of social discomfort.

Picosecond laser with specialized optic for facial rejuvenation using a compressed treatment interval

Studies using a 755u2009nm picosecond laser with a focus lens array have been reported to be effective for facial wrinkles and pigmentation. This study reports the safety and efficacy using a shorter interval of 2–3 weeks between treatments. Nineteen female subjects and one male subject, primarily Fitzpatrick skin types II and III (one skin type I), who had mild to moderate wrinkles and sun‐induced pigmentation were enrolled and treated using the 755u2009nm PicoSure Laser with focus lens array. The skin was cleansed then wiped with an alcohol wipe prior to treatment. Lidocaine 30% ointment and/or forced air cooling could be used to increase subject comfort. Adjacent pulses, with minimal overlap (10% or less), were delivered to the full face. Subjects received four treatments, performed at 2–3‐week intervals. The laser energy used was 0.71u2009J/cm2. The physician administered 3–7 passes with an average total of 6,253 pulses per treatment. Follow‐up visits occurred at 1 and 3 months post‐last treatment at which the physician scored satisfaction and improvement and subjects scored satisfaction and likelihood to recommend to others. The most common side effects were mild swelling, pain, redness, and crusting, most of which subsided within hours of the treatment, with the latest resolving within 48 hours. This is similar to a previous reported study (Weiss et al. ASLMS 2015) where treatments were performed every 6 weeks with side effects resolving within 24 hours. At the 1 and 3 month follow‐up visits, 94% (nu2009=u200919) and 93% (nu2009=u200915) of subjects scored themselves as satisfied or extremely satisfied with their overall results and 81% and 93% were likely to recommend the treatment based on global assessment, respectively. The treating physician was satisfied with 93% of subjects overall results. Three blinded evaluators were able to correctly identify the baseline from post‐treatment photographs in 77% of the subjects at the 1 month follow‐up and 69% of the subjects at the 3 month follow‐up, on average. The average treatment pain score was 4.2 on a 1–10 scale. A compressed treatment interval expedites results without increasing side effects and resulted in a high physician and subject satisfaction rate. Lasers Surg. Med. 48:723–726, 2016.

Challenges to laser-assisted drug delivery: Applying theory to clinical practice: CHALLENGES TO LASER-ASSISTED DRUG DELIVERY

The percutaneous penetration of topically applied compounds can be enhanced using external chemical or physical sources and thus laser‐assisted drug delivery is a burgeoning area of interest within the field of dermatology.

Bullae in Comatose and Non-comatose Patients

Sir, I read with interest the article by Kim et al. discussing two cases of coma-associated bullae with eccrine gland necrosis in patients without drug intoxication (1). The first case was a 4-year-old boy who had been in a motor vehicle accident and the second a 53-year-old man semi-comatose after severe alcohol ingestion. The authors mention that Kato et al. first reported bullous skin disease lesions in patients without drug history in 1996. The history of bullae as a cutaneous sign of injury reflecting a variety of neurologic diseases and other conditions actually goes back to the time of Napoleon. During the occupation of Berlin in 1806, Larry, the Emperor’s surgeon, noted such lesions over pressure points in soldiers comatose from carbon monoxide intoxication (2). In 1973, my colleagues and I reported seven cases and reviewed this interesting area (3). Etiologic agents already identified at that time included carbon monoxide, barbiturates, a large variety of other central nervous system depressants and diseases, and immobilization of man and animals secondary to accidents such as have taken place during wartime. We also demonstrated that the histologic findings include not only subepidermal bullae but focal necrosis 236 Letters to the Editor

Pathophysiology and Treatment Considerations for Erosive Pustular Dermatosis

In this issue of JAMA Dermatology, Mervak et al1 describe the rare condition of erosive pustular dermatosis (EPD) that presented in a series of patients after undergoing fully ablative carbon dioxide laser resurfacing or deep chemical peel. Several weeks to months after the procedure, the patients exhibited facial nonhealing erythematous plaques with overlying pustules, erosions, and yellow crust. Results of histologic and microbial work-up were nondiagnostic, which was consistent with EPD. Each patient experienced an arduous and lengthy healing regimen, as is expected with this difficult diagnosis. The authors conclude that tincture of time and reassurance in addition to antibiotics, anti-inflammatories, and immunomodulators are warranted in the treatment of EPD.1 In the wake of increasing demand for elective surgical treatments, this case series highlights an important and fortunately rare adverse effect of ablative procedures. This phenomenon begs the questions, Are these cases underreported? What is the pathophysiology of EPD? What other options exist for treatment?