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Treatment of hypopigmentation of differing etiologies in patients with dark skin types has limited efficacy and variable safety profiles. These treatment modalities include the excimer laser, 1,550-nm erbium-doped laser with concomitant topical treatments, and autologous melanocyte transplantation. Fractional lasers have recently been reported to treat hypopigmentation from scars effectively.

Our case highlights the safety and efficacy of nonablative fractional laser treatment of iatrogenic hypopigmentation secondary to intralesional steroid injections.

A 28-year-old woman with Fitzpatrick skin type VI developed a hypopigmented patch at the site of past treatment of a hypertrophic scar with intralesional steroids on the leg (Figure 1). The hypopigmentation failed to improve after 1 year, which included a 2-month trial of tacrolimus 0.1% ointment twice daily. The patient was treated three times at 4-week intervals with the 1,540-nm fractionated laser using a compression handpiece (Starlux 1540 nm XD optic handpiece, Palomar, Burlington, MA). Treatment parameters for all three sessions were 55 mJ, 15 ms, 25 microthermal zones per cm2, three passes with 50% overlap.

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Figure 1. Before treatment: a circular hypopigmented patch extending inferiorly in a curvilinear distribution resembling lymphatic spread on the posterior leg.

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Significant repigmentation was noted after only two treatments (Figure 2). The patient was very satisfied with the results. Side effects were limited to mild pain during the treatment and mild post-treatment erythema.

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Figure 2. After two treatments: significant repigmentation with resolution of the curvilinear streak.

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Discussion

  1. Top of page
  2. Discussion
  3. References

Iatrogenic hypopigmentation commonly results from topical, intradermal, or even intra-articular steroid injections. Treatment for iatrogenic hypopigmentation is limited. Previous reports have shown some efficacy using the 308-nm excimer laser for the treatment of chemical leukoderma.[1] Another study demonstrated improvement in hypopigmented scars using the 1,550-nm erbium-doped fractionated laser followed by topical bimatoprost and tretinoin or pimecrolimus.[2] Treatment strategies directed at repigmentation using autologous melanocyte transplantation,[3] as in vitiligo, is not a practical or cost-effective option.

Efficacy in treating hypopigmentation secondary to acne and burn scars with fractional lasers has been demonstrated.[4] In 2003, fractional photothermolysis was developed to induce small columns of thermal damage called microthermal zones. Selective thermal damage is limited to the epidermis and dermis, where the target chromophore (water) resides. Because there is interspersed unaffected tissue, the overall downtime and post-treatment erythema is less than with the standard nonfractionated laser.

There is debate regarding what the mechanism behind pigmentary improvement in hypopigmented scars using fractionated laser treatment is. The nonablative fractional laser may induce melanocyte migration from normal skin into the induced microthermal zones of injury, increasing the overall pigmentation.[4] Histologic studies are needed to document the healing process and confirm movement of melanocytes into the treated area. Furthermore, the optic handpiece specific to the device that we used confers additional dermal compression. Displacement of the competing interstitial water chromophore reduces the laser light scatter, resulting in deeper fractional treatment zones. Although the exact benefit that this may have on repigmentation is unknown, a greater depth of penetration may enhance melanocyte migration, improving the efficacy of repigmentation.

Our case highlights a novel treatment using a 1,540-nm fractionated laser to treat steroid-induced hypopigmentation. Treatments were very well tolerated, with only mild pain during treatment and post-treatment erythema as temporary side-effects. Furthermore, this patient of Fitzpatrick skin type VI, did not develop any postinflammatory hyperpigmentation on the skin immediately adjacent to the hypopigmentation. Although the patient was extremely pleased with the cosmetic outcome after two treatments, a third treatment was performed for complete repigmentation. Fractionated nonablative 1,540-nm laser is a safe and effective method to treat iatrogenic hypopigmentation, a common yet often refractory problem.

References

  1. Top of page
  2. Discussion
  3. References