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Multiple Trichoepitheliomas

INITIAL PRESENTATION

A 49-year-old white female presented with multiple facial nodules, which first appeared when she was a teenager. Numerous family members had similar lesions and carried a diagnosis of familial trichoepitheliomas. The patient had no other medical problems.

Physical examination revealed numerous pink, 2- to 8-mm papules predominantly in a midface distribution (forehead, cheeks, chin, nose, and cutaneous upper lip). Larger nodules measuring 12 to 18 mm were present on her nose and chin. (Figure 1A, B).

Figure 1A. Multiple trichoepitheliomas predominantly on the midface.

Figure 1B. Multiple trichoepitheliomas.

The patient was treated with dermabrasion in the 1980s, which was relatively unsuccessful. She had five treatment sessions with a continuous wave CO2 laser from 1988 to 1990 with good success in flattening the lesions. They remained relatively unobtrusive until recently when some of the existing lesions began to grow larger and new lesions began to develop. Although benign, the patient’s multiple facial nodules had become disfiguring and she desired further treatment.

THERAPY

Surgical excision is the standard treatment for complete removal of single trichoepitheliomas. In this case, excision was impractical because of the large number of lesions and disfiguring scarring that would result. Because previous treatment with laser surgery had been helpful, an attempt was made to flatten out the lesions using the CO2 laser.

The day before the procedure, the patient started prophylactic treatment with dicloxacillin 500 mg twice daily for one week and valacyclovir 500 mg twice daily for two weeks. Anesthesia was obtained with 1% lidocaine with epinephrine local infiltration and infraorbital and mental blocks. Metal eye shields were put in place. The first treatment session used the continuous wave (CW) CO2 laser at 15W with the 1-mm spot used at a defocused distance in order to make the beam diameter similar to that of the lesion. Smaller papules were treated with one to six passes until the lesions appeared to be flush with the skin. Larger papules and nodules were unroofed with electrosection, and a #15 blade was used to tease out the bulk of the lesions. The Ultrapulse CO2 laser (Coherent, Inc., Santa Clara, CA) was then used in the short pulsed mode to go over all treated areas at 400 mJ with the 3-mm spot. (Figure 2A, B) The patient tolerated the procedure well. (Figure 3)

Figure 2A. Immediately postprocedure with the CO2 laser and electrosection of larger nodules.

Figure 2B. Three days postprocedure.

Figure 3. Three months postprocedure (Session 1) showing some remaining papules and nodules.

A second treatment session four months later employed the continuous wave CO2 at 12W and three to four passes, followed by a single pass with the CO2 at 450 mJ, short pulse mode, with the 3-mm spot. (Figure 4). Energy from the CW CO2 was always found to be much more effective in flattening the lesions as compared to when used in the short pulse-resurfacing mode. The patient healed well and was pleased with her cosmetic improvement. (Figure 5)

Figure 4. Immediately postprocedure (Session 2) with the CO2 laser.

Figure 5. Moderately good cosmetic improvement after two sessions with CO2 laser surgery

FOLLOW UP

The patient has retained good clearance of the majority of the treated lesions at a three-year follow-up. She has continued to develop additional trichoepitheliomas, and a few of the previously treated lesions have returned. She plans to undergo a third treatment session using the above protocol in the future. (Figure 6)

Figure 6. The patient has retained good clearance of the treated lesions at three year follow-up

CONTRIBUTORS

Melissa A. Bogle, MD, Laser and Cosmetic Surgery Center of Houston, Houston, Texas
Jeffrey S. Dover, MD, FRCPC, SkinCare Physicians, Chestnut Hill, Massachusetts; Section of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Department of Dermatology, Dartmouth Medical School, Hanover, New Hampshire
Kenneth A. Arndt, MD, SkinCare Physicians, Chestnut Hill, Massachusetts; Section of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Department of Dermatology, Dartmouth Medical School, Hanover, New Hampshire; Department of Dermatology, Harvard Medical School, Boston, Massachusetts

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