Management of linear verrucous epidermal nevus with topical 5-fluorouracil and tretinoin

Clinical Efficacy of 5-Fluorouracil and Bleomycin in Dermatology

Bleomycin and 5-fluorouracil (5-FU) are widely used in various dermatological disorders. Both drugs are well-recognized as antineoplastic drugs and exert their effect by blocking the cell cycle. Topical and intralesional formulations are available and have been studied in both non-neoplastic and cancerous lesions. However, data comparing the effect of bleomycin and 5-FU in the dermatological disorders are limited. This review outlines the action mechanisms of both drugs and compares their clinical efficacies in a wide range of dermatologic diseases including hypertrophic scar, wart, skin cancer, vascular malformation, hemangioma, and vitiligo, and discusses the overall safety of the drugs. Intralesional bleomycin treatment is effective in hypertrophic scars and warts, but intralesional 5-FU may also be considered since it is cheaper and less painful. Moreover, intralesional 5-FU and bleomycin injection is a viable option for premalignant lesions (i.e., actinic keratosis) and inoperable skin cancers. Both bleomycin and 5-FU have been applied as treatment adjuncts for vitiligo, with 5-FU showing a slightly better outcome. Both agents have a good safety profile, and no serious side effects have been reported following their use in the field of dermatology.

Linear verrucous epidermal nevi-effects of carbon dioxide laser therapy

Linear epidermal nevus is a congenital malformation characterized by linear, often one-sided arrangement. The lesions are localized along the Blaschko's lines, are present at birth, or appear in early childhood. They can be single or multiple, and have various colors-from skin color to dark brown. These lesions persist through the whole life making a significant cosmetic defect. Here, we present three clinical cases of epidermal nevus treated with CO2 laser. In a female patient, verrucous, dark brown skin eruptions were observed at the back of earlobe and down the neck. In the cases of the male patients, the lesions were located in the area of the neck and left blade. The removal of nevi was performed in stages, by cutting and evaporation using a CO2 laser. A very good therapeutic effect was obtained. CO2 laser treatment is the method of choice for the removal of extensive epidermal nevi. It is characterized by high efficacy and safety.

Epidermal nevus syndromes

The term epidermal nevus syndrome (ENS) has been used to describe the association of epidermal hamartomas and extracutaneous abnormalities. Although many continue to use the term "ENS," it is now understood that this is not one disease, but rather a heterogeneous group with distinct genetic profiles defined by a common cutaneous phenotype: the presence of epidermal and adnexal hamartomas that are associated with other organ system involvement. One commonality is that epidermal nevi often follow the lines of Blaschko and it appears the more widespread the cutaneous manifestations, the greater the risk for extracutaneous manifestations. The majority of the extracutaneous manifestations involve the brain, eye, and skeletal systems. The CNS involvement is wide ranging and involves both clinical manifestations such as intellectual disability and seizures, as well as structural anomalies. Several subsets of ENS with characteristic features have been delineated including the nevus sebaceus syndrome, Proteus syndrome, CHILD syndrome, Becker's nevus syndrome, nevus comedonicus syndrome, and phakomatosis pigmentokeratotica. Advances in molecular biology have revealed that the manifestations of ENS are due to genomic mosaicism. It is likely that the varied clinical manifestations of ENS are due in great part to the functional effects of specific genetic defects. Optimal management of the patient with ENS involves an interdisciplinary approach given the potential for multisystem involvement. Of note, epidermal nevi have been associated with both benign and malignant neoplasms, and thus ongoing clinical follow-up is required.

Epidermal nevi treated by carbon dioxide laser vaporization: A series of 25 patients

BACKGROUND

Epidermal nevi are benign proliferations of epidermis. Numerous treatment modalities have been tried, but no ideal treatment is yet available.

OBJECTIVE

To report our experience with CO(2) laser vaporization in the treatment of verrucous epidermal nevi, and to identify which factors could have influence in long-term results.

METHODS

A total of 25 patients were treated with the CO(2) laser in the superpulsed mode, focalized at 2 W/cm(2). The patients were between 3 and 41 years old (mean: 17 years). A total of 44% of lesions were <20 cm(2), 40% measured between 20 and 100 cm(2) and 16% were >100 cm(2). The follow-up was 4-79 months (mean: 28 months). In 76% of patients, multiple treatment sessions were required.

RESULTS

Good results were achieved in 92% of patients with soft, flattened nevi and in only 33% patients with keratotic nevi. In addition, 87% of the latter had moderate results and 12.5% had poor results.

CONCLUSION

We conclude that the CO(2) laser in superpulsed mode is an effective and safe treatment for verrucous epidermal nevi and provides fewer recurrences than other laser therapies. We also believe that the most determining factor for the cosmetic result is thickness of the nevus.

Perivulvar inflammatory linear verrucous epidermal nevus (ILVEN) treated with CO 2 laser

Inflammatory linear verrucous epidermal nevus (ILVEN) is a type of epidermal nevus with the onset usually at early childhood. It is generally rather persistent with pruritus as a prominent symptom and is resistant to various treatments. We report a case of disfiguring ILVEN of the vulvar area, which was treated successfully with low fluence CO2 laser. The patient remains improved 2 years following laser therapy.

[CO2 laser therapy of verrucous epidermal nevus]

INTRODUCTION

Verrucous epidermal nevus are benign epidermal hyperplasias. Their treatments are disappointing because of recurrences and anaesthetic scars. The aim of this study was to evaluate the efficacy of continuous carbon dioxide laser in the treatment of verrucous epidermal nevus.

MATERIAL AND METHODS

It was a retrospective study concerning all patients treated for epidermal verrucous nevus by carbon dioxide laser from 1991 to 2003. Several criteria were evaluated by the patients, a dermatologist and a staff (external observers). Aesthetic result, recurrences, pain due to treatment and global result were evaluated by the patients when they came back.

RESULTS

Twenty-one patients (12 F and 9 M), medium age 20.4, were evaluated with a 40.4 months follow-up (7 to 165 months). The epidermal verrucous nevus was situated on the neck or on the head for 62% of them (n = 13). Among these 21 patients, 86% (n = 19) estimated their skin as "cured" or "nearly normal" or "much improved". The rate was the same for the dermatologist. As for the staff, thanks to photos, only 53% of results were satisfying. The recurrences were never complete, but moderate in 38% of patients. Five patients, medium age 12,5, had hypertrophic scars. Among them, three were only partially hypertrophic.

DISCUSSION

A literature review has been made. Our satisfaction rates (nearly 90%) were slightly higher than other studies rates using carbon dioxide laser (74%) or other types of lasers (87%). The medium follow-up was longer than the one of other laser CO2 studies (26.7 months) or other lasers studies' (15.8 months). This study shows that continuous wave carbon dioxide laser is an easy and effective treatment of verrucous epidermal nevus. Aesthetic results are satisfying but moderate recurrences often occur. To prevent hypertrophic scars, we suggest to exclude teenagers.

Epidermal nevus syndromes

The term "epidermal nevus syndrome" (ENS) has been used to describe the association of epidermal hamartomas and extra-cutaneous abnormalities. Epidermal nevi follow the lines of Blaschko. The majority of the extra-cutaneous manifestations involve the brain, eye, and skeletal systems. Several subsets with characteristic features have been delineated including the nevus sebaceous syndrome, Proteus syndrome, CHILD syndrome, Becker nevus syndrome, nevus comedonicus syndrome, and phakomatosis pigmentokeratotica. Epidermal nevi have been associated with benign and malignant neoplasms. Advances in molecular biology have revealed that the manifestations of ENS are due to genomic mosaicism. It is likely that the varied clinical manifestations of ENS are due in great part to the functional effects of specific genetic defects. Optimal management of the patient with ENS involves an interdisciplinary approach. Amelioration of the cutaneous features of ENS has been difficult but there have been advances, especially in the use of lasers.

Carbon dioxide laser therapy for an inflammatory linear verrucous epidermal nevus: a case report

The treatment of an inflammatory linear verrucous epidermal nevus (ILVEN), an uncommon type of epidermal nevus, is still controversial. The use of laser therapy is a recently reported method. Although various results have been reported with the use of the laser in the treatment epidermal nevis, the authors have not seen any report on the use of the carbon dioxide laser in ILVEN treatment. They present case of ILVEN treated with the carbon dioxide laser. All symptoms (erythema, excoriation, granulation, and pruritus) disappeared. Instead, a pale pigmentation was seen.

Epidermal naevi treated with pulsed erbium:YAG laser

Epidermal naevi are common and can cause marked cosmetic disability. Ablative laser treatment may be successful in their removal, but may result in significant scarring. Surprisingly the erbium:YAG laser is rarely reported for this indication even though it produces minimal tissue damage. We report our experience using this laser to treat six patients with epidermal naevi. Patients (five female, one male; aged 4-41 years) underwent treatment with pulsed 2940 nm erbium:YAG laser at 0.4-0.45 J/cm(2), 2 mm spot size at 4 pulses/s. All six patients had excellent cosmetic results at follow up ranging from 6 to 60 months. The favourable results were dependent on selection of cases with superficial or small, discrete lesions which could be ablated accurately. The erbium:YAG laser is therefore an effective treatment for relatively nonverrucous or papular epidermal naevi.

Er:YAG Laser Treatment of Verrucous Epidermal Nevi

BACKGROUND

The term verrucous epidermal nevi refers to benign hyperplasia of the epidermis. Numerous treatment modalities have been tried, but no ideal treatment is yet available. We would like to present our experience with Er:YAG laser ablation in the treatment of verrucous epidermal nevi.

OBJECTIVE

The purpose of this study is to assess the long-term results of Er:YAG laser treatment of verrucous epidermal nevi.

METHODS

Twenty patients with verrucous epidermal nevi were treated with Er:YAG laser. Twelve patients were treated with the variable-pulsed Er:YAG laser, a 5-mm handpiece at the setting of 7.0 to 7.5 J/cm2, at a 500-micros pulse duration. The dual-mode Er:YAG laser, with a 2-mm handpiece at the setting of 6.3 J/cm2, at a 350-micros pulse duration (25 microns ablation), was used in eight patients. The laser was fired at 5 Hz until all epidermal nevi were removed. The results of treatment were evaluated for the changes of skin lesions, texture, and color by physicians over a 24-month period.

RESULTS

After a single laser treatment, successful elimination of the verrucous epidermal nevi was observed in 15 patients. Five patients (25%) showed a relapse within 1 year after the treatment. Postoperative healing time was 7 to 10 days. Erythema occurred in all patients after the laser treatment and subsided in 2 months. Postinflammatory hyperpigmentation occurred in two patients (10%). One patient (5%) experienced transient hypopigmentation. Mild to moderate postoperative acne flare-up occurred in one patient (5%) with facial lesions. No other adverse effects, including scarring, were observed.

CONCLUSION

The Er:YAG laser ablation is an effective, safe, and nonscarring method for the treatment of verrucous epidermal nevi.

Full-thickness surgical excision for the treatment of inflammatory linear verrucous epidermal nevus

Inflammatory linear verrucous epidermal nevus (ILVEN) is a benign cutaneous hamartoma characterized by intensely erythematous, pruritic, inflammatory papules that occur as linear bands along the lines of Blaschko. Because of its chronic and unremitting symptomatology, patients with ILVEN seek medical treatment for relief of discomfort as well as concerns regarding cosmetic appearance. Reported therapeutic approaches include topical agents, dermabrasion, cryotherapy, laser therapy, and partial-thickness excision. Unfortunately, no one therapy has been successful consistently. Medical management is often unsatisfactory, because improvement tends to be temporary. Surgical modalities have met with better success in relief of symptoms but at the risk of marked scarring and a high rate of recurrence. Furthermore, the occurrence of extensive ILVEN or localization to certain anatomic regions has been considered previously a relative contraindication to excision. The authors report 4 patients with extensive ILVEN treated successfully with full-thickness surgical excision. Our report underscores the effectiveness of this surgical modality for the definitive treatment of ILVEN.

Topical tretinoin and 5-fluorouracil in the treatment of linear verrucous epidermal nevus

Treatment of a linear verrucous epidermal nevus using topical 0.1% tretinoin cream and 5% 5-fluorouracil in a young patient is described. In 1994, successful topical therapy using this combination was described in the management of an inflammatory linear verrucous epidermal nevus. We report another case in which treatment of a noninflamed epidermal verrucous nevus with 0.1% tretinoin and 5% 5-fluorouracil resulted in significant improvement. An updated summary of the literature discussing management of epidermal nevi is presented.

A verrucous lesion on skin grafted after necrotizing fasciitis in a diabetic patient successfully treated with combined topical 5-FU and tacalcitol

Many complications of diabetes mellitus involve the feet. These include infections, neuropathy, vasculopathy, and poor wound healing. Neuropathy causes chronic pressure or friction on an area of sensory loss and occasionally causes verrucous skin lesions. We describe a diabetic patient, complicated by necrotizing fasciitis, who developed a verrucous skin lesion on a skin graft site. The verrucous skin lesion was treated successfully with combined topical 5-fluorouracil and vitamin D3 application.