Pharmacology and Therapeutics
Argon Laser Treatment of Small Keratoacanthomas in Difficult Locations Reinhard A. NeuiTiann, M.D., and Robert M. Knobler, M.D.
Abstract: Seventeen patients (mean age, 64.7 years) with sol- that are not characterized by their high contents of red itary keratoacanthomas (KA) located on the face and auricles blood cells or melanin. We report on a successful cliniwere treated with the argon laser. All lesions were less than 10 cal study to treat small KA by means of the argon laser. mm in diameter and had been present for 2-10 weeks (mean, 3.8 weeks). The diagnosis was made clinically and was confirmed by histology. The lesions were treated with the argon laser using the continuous exposure technique with a power setting of 4.5 watts (W) and a beam diameter of 1 mm. Complete re-epithelializatlon occurred within 14-21 days. Excellent treatment results were achieved in 65% of the patients. Thirtyfive percent healed with mild scarring. During a follow-up period of 2 years no recurrences were noted. The use of the argon laser for removal of small KAs in difficult locations, which would often require invasive surgery, appears to be an effective additional treatment modality.
Keratoaeanthomas (KA) are rapidly evolving benign tumors of the skin usually occurring in older persons and as solitary lesions. These bud- or dome-shaped nodules show a predilection for the sun-exposed areas of the skin. A striking diagnostic feature is the central keratin-filled crater. Histology shows a horn-filled invagination of the epidermis surrounded by irregular epidermal proliferations with different degrees of keratinization. Sometimes accurate histological differentiation from squamous cell carcinoma is difficult.' Various treatment modalities have been reported including excision, curettage, cryotherapy, or application of 5-fluorouraeil.^ The argon laser is mainly used for the treatment of vascular and pigmented skin disorders because of its relatively selective absorption in erythrocytes and melanin. Still, the concentrated local nonspecific thermal effect can be used for the precise destruction of lesions
From the Department of Dermatology II, University of Vienna, Vienna, Austria. Address correspondence to: Reinhard A. Neumann, M.D., Department of Dermatology II, University of Vienna, Alserstrasse 4, A-1090 Vienna, Austria. December 1990, Vol. 29, No. 10
Figure 1. Histology of the left part of the tumor shows a eentral keratin-filled crater surrounded by epidermal proliferations with a high degree of keratinization. Note the charaeteristie epidermal "lip" extending over the side of the tumor (H&E; X25). 733
734
International Journal of Dermatology • December 1990
Vol. 29
Table 1. Patient Characteristics and Results of Laser Therapy Patient No.
Age Sex
(yr)
Localization
F F
85 71 62 52 48 79 51 68 73 54 69 87 49 65 63 51 74
Forebead Forehead Auricle Auriele Auricle Eyelid Eyelid Nose Nose Nose Nose Cbeeks Cheeks Upper lip Chin Chin Chin
1 2 3 4 5
M
6
F
7
M F F M
8 9 10 11 12 13 14 15 16 17
F F
F M F F
F M M
Duration (wk)
Size (mm)
3 4 2 10 4 2.5 3 2.5 5
9 7 5 9 9 4 5 8 7
3
6
-\-\-
5 5 5 6 7 8 8
-f-f-f-f-l-l-l-l-
-1-
-H-t-
-1-
2.5 2 3 > 4
3.5 4 6
Results -H-f -f-t+4-h +-h-\-
Scar
-1-
-f-^-l-
-\-\-\-l--l-t-
4-t-t-F-f-
-l-f-l-t-f -1-
-1-h
-\-f
Results: -I-, moderate; -^-l-, good; -\-+-t-, excellent.
Scar: +, scar formation; - : no sear formation.
Materials and Methods
tained during laser treatment was examined. In all patients the diagnosis of KA was confirmed bistologically (Fig. 1). A Coherent 920 S argon laser (Coherent Medieal Group, Palo Alto, CA) with dermatologieal equipment was used for treatment. Treatment was performed under local anesthesia (intradermal injections of mepivacain 2%). Using the continuous exposure technique, a power setting of 4.5 watts (W) (at handpiece) and a beam diameter of 1 mm were selected; tbe irradianee was about 570 W/em^. With the focused laser beam tbe tumors first were cut off and saved for histological analysis tben tbe bases were coagulated. The wound was covered with a dressing and ointment eontaining betamethasone and gentamycin. This procedure was repeated daily until total re-epithelialization. Patients were evaluated onee a montb for 6 months and tben every 3 montbs for 2 years.
Seventeen patients (11 women and 6 men) were treated witb the argon laser (Table 1). Tbeir ages ranged from 48 to 87 years (mean age, 64.7 years). All patients presented with solitary lesions on different areas of the face and on tbe auricles (Table I). The period from the time of onset to the time of treatment ranged from 2 to 10 weeks (mean, 3.8 weeks). Due to early diagnosis, lesions were small (all less than 10 mm in diameter). One patient reported pretreatment witb cautery followed by a recurrence. The diagnosis was based on the typical clinieal picture of the tumor and a characteristic history of rapid growtb. In four patients where the clinieal diagnosis was questionable, a puneh biopsy was performed prior to treatment. In the otber patients the tumor material ob-
Figure 2. (A) Keratoacanthoma on the left upper eyelid with the typieal central keratin-filled crater. (B) Excellent result after one argon laser treatment showing no residual scarring.
No. 10
Small Keratoacanthomas • Neumann and Knobler
Figure 3. (A) K.eratoaeanthoma on the forehead before argon laser therapy. (B) Hxeellent result with only slight depression after laser treatment.
Figure 4. (A) Keratoacanthoma of 5 weeks' duration. (B) Result after one argon laser application showing slight scarring.
735
736
International Journal of Dermatology • December 1990
Results (Figs. 2-4) Excellent results with no residual scarring were obtained in ten patients (65%). In seven patients (35%) removal of the tumor was followed by a slight scar formation. Residual mild hypopigmentation in our series occurred at a rate of 15%. Usually wound healing was complete 14-21 days after laser treatment, and patients reported no complaints during the postoperative period. In all patients one treatment session was sufficient for removal of the KA. After a follow-up of 2 years there were no signs of recurrence in any of our patients.
Vol. 29
mented skin lesions such as xanthelasma of the eyelids, hyperplasia of the sebaceous glands, and verrucae vulgares." Our data show that argon laser therapy is an effective method of treating KA with lesions less than 10 mm in diameter with excellent cosmetic results and a high cure rate. Difficult locations, which would often require complicated surgery, are easier to treat with the argon laser and therefore there is appreciably less discomfort for the patient. We suggest that patients be carefully observed for at least 2 years after surgery. References
Discussion The rapid growth and development of KA usually in exposed and visible areas of the skin alarms the patient who is anxious to have the tumor removed as soon as possible. It is advisable to treat KA and not to wait for spontaneous regression since KA may last for many years and the resulting scar is often less satisfactory.-''* Curetage, cautery, and cryotherapy are recognized treatment alternatives for removal of KA, as opposed to total excision.' Other forms of treatment such as local or intralesional 5-fluorouracil or systemic retinoids are very time-consuming and do not produce better results.^'"'^ It is imperative that an histological examination be done in any lesion where the clinical diagnosis is questionable and a squamous cell carcinoma is suspected. In light of 30 years' experience, Rook and Whimster state "that in the very great majority of cases an accurate diagnosis can be established, sparing the patient the discomfort and disfigurement of needless overtreatment."^ The blue-green light of the argon laser (488 and 514 nm) is strongly absorbed by hemoglobin and melanin and converted to heat, resulting in thermal destruction of vascular and pigmented skin disorders.^"''' In the present study these selective properties of the argon laser were not critical for effective treatment. Using the nonspecific thermal effect the tumors were cut off and then the bases were coagulated. The nonspecific coagulation effect of the argon laser has been used with good results in previous reports in the treatment of nonvascular and nonpig-
1. Lever WF, Schaumburg-Lever G. Keratoaeanthoma. In: Lever WF, Sehaumburg-Lever G, eds. Histopathology of the Skin. 6th ed. Philadelphia: JB Lippineott, 1983:506-509. 2. Ebner H, Miseher P. The local treatment of the keratoaeanthoma with 5-fluoro-uracil. Hautarzt. 1975;26:585-588. 3. Venkei T, Sugar J. Krebsartige Proliferation des Keratoakanthoms (Keratoakanthom C). Derm Wsehr. 1958; 137:620-628. 4. Venkei T, Sugar J. Uber Keratoakanthome von prakarzinomatosem Charakter (Keratoakanthom A und B). Dtsch Med Wochenschr. 1958;138:957-965. 5. Ghadially FN. Keratoacanthoma. In: Fitzpatrick TB, Eisen AZ, WoIfT F, et al, eds. Dermatology in General Medieine. New York: McGraw-Hill, 1987:766-772. 6. Odom RB, Goette DK. Treatment of keratoacanthomas with intralesional fluorouracil. Areh Dermatol. 1978;114:1779-1783. 7. Haydey RP, Reed ML, Ozubow LM, et al. Treatment of keratoacanthoma with oral 13-cis-retinoie acid. N Engl J Med. l980;303:560-562. 8. Rook A, Whimster I. Keratoacanthoma—a thirty year retrospeet. BrJ Dermatol. 1979; 100:41-47. 9. Noe JM, Barsky SH, Geer DE, et al. Port-wine stains and the response to argon laser therapy: Sueeessful treatment and the predictive role of eolor, age, and biopsy. Plast Reeonstr Surg. 1980;65:130-136. 10. Apfelberg DB, Maser RM, Lash H. Extended clinical use of the argon laser for eutaneous lesions. Areh Dermatol. 1979; 115:719-721. 11. Arndt KA. Argon laser therapy of small eutaneous vascular lesions. Areh Dermatol. 1982; 118:220-224. 12. Landthaler M, Haina D, Waidelieh W, et al. Argon laser therapy of verrueous nevi. Plast Reconstr Surg. I984;74:108-l 11. 13. Landthaler M, Haina D, Waidelieh W. Argonlasertherapie des Adenoma sebaeeum. Hautarzt. 1982;33:340-342. 14. Newton JA, McGibbon DH. The treatment of multiple angiokeratomas with the argon laser. Clin Exp Dermatol. 1987;12:23-25. 15. Landthaler M, Haina D, Waidelieh W, et al. A three-year experienee with the argon laser in dermatotherapy. J Dermatol Surg Oncol. 1984; 10:45 5-461.
Argon Laser Treatment of Small Keratoacanthomas in Difficult Locations Reinhard A. NeuiTiann, M.D., and Robert M. Knobler, M.D.
Abstract: Seventeen patients (mean age, 64.7 years) with sol- that are not characterized by their high contents of red itary keratoacanthomas (KA) located on the face and auricles blood cells or melanin. We report on a successful cliniwere treated with the argon laser. All lesions were less than 10 cal study to treat small KA by means of the argon laser. mm in diameter and had been present for 2-10 weeks (mean, 3.8 weeks). The diagnosis was made clinically and was confirmed by histology. The lesions were treated with the argon laser using the continuous exposure technique with a power setting of 4.5 watts (W) and a beam diameter of 1 mm. Complete re-epithelializatlon occurred within 14-21 days. Excellent treatment results were achieved in 65% of the patients. Thirtyfive percent healed with mild scarring. During a follow-up period of 2 years no recurrences were noted. The use of the argon laser for removal of small KAs in difficult locations, which would often require invasive surgery, appears to be an effective additional treatment modality.
Keratoaeanthomas (KA) are rapidly evolving benign tumors of the skin usually occurring in older persons and as solitary lesions. These bud- or dome-shaped nodules show a predilection for the sun-exposed areas of the skin. A striking diagnostic feature is the central keratin-filled crater. Histology shows a horn-filled invagination of the epidermis surrounded by irregular epidermal proliferations with different degrees of keratinization. Sometimes accurate histological differentiation from squamous cell carcinoma is difficult.' Various treatment modalities have been reported including excision, curettage, cryotherapy, or application of 5-fluorouraeil.^ The argon laser is mainly used for the treatment of vascular and pigmented skin disorders because of its relatively selective absorption in erythrocytes and melanin. Still, the concentrated local nonspecific thermal effect can be used for the precise destruction of lesions
From the Department of Dermatology II, University of Vienna, Vienna, Austria. Address correspondence to: Reinhard A. Neumann, M.D., Department of Dermatology II, University of Vienna, Alserstrasse 4, A-1090 Vienna, Austria. December 1990, Vol. 29, No. 10
Figure 1. Histology of the left part of the tumor shows a eentral keratin-filled crater surrounded by epidermal proliferations with a high degree of keratinization. Note the charaeteristie epidermal "lip" extending over the side of the tumor (H&E; X25). 733
734
International Journal of Dermatology • December 1990
Vol. 29
Table 1. Patient Characteristics and Results of Laser Therapy Patient No.
Age Sex
(yr)
Localization
F F
85 71 62 52 48 79 51 68 73 54 69 87 49 65 63 51 74
Forebead Forehead Auricle Auriele Auricle Eyelid Eyelid Nose Nose Nose Nose Cbeeks Cheeks Upper lip Chin Chin Chin
1 2 3 4 5
M
6
F
7
M F F M
8 9 10 11 12 13 14 15 16 17
F F
F M F F
F M M
Duration (wk)
Size (mm)
3 4 2 10 4 2.5 3 2.5 5
9 7 5 9 9 4 5 8 7
3
6
-\-\-
5 5 5 6 7 8 8
-f-f-f-f-l-l-l-l-
-1-
-H-t-
-1-
2.5 2 3 > 4
3.5 4 6
Results -H-f -f-t+4-h +-h-\-
Scar
-1-
-f-^-l-
-\-\-\-l--l-t-
4-t-t-F-f-
-l-f-l-t-f -1-
-1-h
-\-f
Results: -I-, moderate; -^-l-, good; -\-+-t-, excellent.
Scar: +, scar formation; - : no sear formation.
Materials and Methods
tained during laser treatment was examined. In all patients the diagnosis of KA was confirmed bistologically (Fig. 1). A Coherent 920 S argon laser (Coherent Medieal Group, Palo Alto, CA) with dermatologieal equipment was used for treatment. Treatment was performed under local anesthesia (intradermal injections of mepivacain 2%). Using the continuous exposure technique, a power setting of 4.5 watts (W) (at handpiece) and a beam diameter of 1 mm were selected; tbe irradianee was about 570 W/em^. With the focused laser beam tbe tumors first were cut off and saved for histological analysis tben tbe bases were coagulated. The wound was covered with a dressing and ointment eontaining betamethasone and gentamycin. This procedure was repeated daily until total re-epithelialization. Patients were evaluated onee a montb for 6 months and tben every 3 montbs for 2 years.
Seventeen patients (11 women and 6 men) were treated witb the argon laser (Table 1). Tbeir ages ranged from 48 to 87 years (mean age, 64.7 years). All patients presented with solitary lesions on different areas of the face and on tbe auricles (Table I). The period from the time of onset to the time of treatment ranged from 2 to 10 weeks (mean, 3.8 weeks). Due to early diagnosis, lesions were small (all less than 10 mm in diameter). One patient reported pretreatment witb cautery followed by a recurrence. The diagnosis was based on the typical clinieal picture of the tumor and a characteristic history of rapid growtb. In four patients where the clinieal diagnosis was questionable, a puneh biopsy was performed prior to treatment. In the otber patients the tumor material ob-
Figure 2. (A) Keratoacanthoma on the left upper eyelid with the typieal central keratin-filled crater. (B) Excellent result after one argon laser treatment showing no residual scarring.
No. 10
Small Keratoacanthomas • Neumann and Knobler
Figure 3. (A) K.eratoaeanthoma on the forehead before argon laser therapy. (B) Hxeellent result with only slight depression after laser treatment.
Figure 4. (A) Keratoacanthoma of 5 weeks' duration. (B) Result after one argon laser application showing slight scarring.
735
736
International Journal of Dermatology • December 1990
Results (Figs. 2-4) Excellent results with no residual scarring were obtained in ten patients (65%). In seven patients (35%) removal of the tumor was followed by a slight scar formation. Residual mild hypopigmentation in our series occurred at a rate of 15%. Usually wound healing was complete 14-21 days after laser treatment, and patients reported no complaints during the postoperative period. In all patients one treatment session was sufficient for removal of the KA. After a follow-up of 2 years there were no signs of recurrence in any of our patients.
Vol. 29
mented skin lesions such as xanthelasma of the eyelids, hyperplasia of the sebaceous glands, and verrucae vulgares." Our data show that argon laser therapy is an effective method of treating KA with lesions less than 10 mm in diameter with excellent cosmetic results and a high cure rate. Difficult locations, which would often require complicated surgery, are easier to treat with the argon laser and therefore there is appreciably less discomfort for the patient. We suggest that patients be carefully observed for at least 2 years after surgery. References
Discussion The rapid growth and development of KA usually in exposed and visible areas of the skin alarms the patient who is anxious to have the tumor removed as soon as possible. It is advisable to treat KA and not to wait for spontaneous regression since KA may last for many years and the resulting scar is often less satisfactory.-''* Curetage, cautery, and cryotherapy are recognized treatment alternatives for removal of KA, as opposed to total excision.' Other forms of treatment such as local or intralesional 5-fluorouracil or systemic retinoids are very time-consuming and do not produce better results.^'"'^ It is imperative that an histological examination be done in any lesion where the clinical diagnosis is questionable and a squamous cell carcinoma is suspected. In light of 30 years' experience, Rook and Whimster state "that in the very great majority of cases an accurate diagnosis can be established, sparing the patient the discomfort and disfigurement of needless overtreatment."^ The blue-green light of the argon laser (488 and 514 nm) is strongly absorbed by hemoglobin and melanin and converted to heat, resulting in thermal destruction of vascular and pigmented skin disorders.^"''' In the present study these selective properties of the argon laser were not critical for effective treatment. Using the nonspecific thermal effect the tumors were cut off and then the bases were coagulated. The nonspecific coagulation effect of the argon laser has been used with good results in previous reports in the treatment of nonvascular and nonpig-
1. Lever WF, Schaumburg-Lever G. Keratoaeanthoma. In: Lever WF, Sehaumburg-Lever G, eds. Histopathology of the Skin. 6th ed. Philadelphia: JB Lippineott, 1983:506-509. 2. Ebner H, Miseher P. The local treatment of the keratoaeanthoma with 5-fluoro-uracil. Hautarzt. 1975;26:585-588. 3. Venkei T, Sugar J. Krebsartige Proliferation des Keratoakanthoms (Keratoakanthom C). Derm Wsehr. 1958; 137:620-628. 4. Venkei T, Sugar J. Uber Keratoakanthome von prakarzinomatosem Charakter (Keratoakanthom A und B). Dtsch Med Wochenschr. 1958;138:957-965. 5. Ghadially FN. Keratoacanthoma. In: Fitzpatrick TB, Eisen AZ, WoIfT F, et al, eds. Dermatology in General Medieine. New York: McGraw-Hill, 1987:766-772. 6. Odom RB, Goette DK. Treatment of keratoacanthomas with intralesional fluorouracil. Areh Dermatol. 1978;114:1779-1783. 7. Haydey RP, Reed ML, Ozubow LM, et al. Treatment of keratoacanthoma with oral 13-cis-retinoie acid. N Engl J Med. l980;303:560-562. 8. Rook A, Whimster I. Keratoacanthoma—a thirty year retrospeet. BrJ Dermatol. 1979; 100:41-47. 9. Noe JM, Barsky SH, Geer DE, et al. Port-wine stains and the response to argon laser therapy: Sueeessful treatment and the predictive role of eolor, age, and biopsy. Plast Reeonstr Surg. 1980;65:130-136. 10. Apfelberg DB, Maser RM, Lash H. Extended clinical use of the argon laser for eutaneous lesions. Areh Dermatol. 1979; 115:719-721. 11. Arndt KA. Argon laser therapy of small eutaneous vascular lesions. Areh Dermatol. 1982; 118:220-224. 12. Landthaler M, Haina D, Waidelieh W, et al. Argon laser therapy of verrueous nevi. Plast Reconstr Surg. I984;74:108-l 11. 13. Landthaler M, Haina D, Waidelieh W. Argonlasertherapie des Adenoma sebaeeum. Hautarzt. 1982;33:340-342. 14. Newton JA, McGibbon DH. The treatment of multiple angiokeratomas with the argon laser. Clin Exp Dermatol. 1987;12:23-25. 15. Landthaler M, Haina D, Waidelieh W, et al. A three-year experienee with the argon laser in dermatotherapy. J Dermatol Surg Oncol. 1984; 10:45 5-461.
