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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:[email protected].
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