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A Rare, Unforeseen Complication of Facial Skin Resurfacing

A Rare, Unforeseen Complication of Facial Skin Resurfacing

By Marilynn Larkin

NEW YORK (Reuters Health) – Erosive pustular dermatitis (EPD), a rare condition that typically affects actinically damaged skin on the scalp, may also emerge on the face after cosmetic resurfacing, researchers have found.

Dr. Frank Wang of University of Michigan Medical School, Ann Arbor, and colleagues describe three women in their practice who presented with prolonged facial erosions after cosmetic resurfacing. They came to the clinic for treatment of the wounds between 2010 and 2016.

“While the healing process following these types of (resurfacing) procedures is usually a few weeks, these patients experienced non-healing, crusted sores on their face for months to years,” Dr. Wang told Reuters Health by email. “We found that treatment can be challenging.”

As reported in JAMA Dermatology, online August 16, the first woman was in her fifties and had undergone blepharoplasty and full-face, fully ablative carbon dioxide (CO2) laser resurfacing. She seemed to heal normally, but six weeks after the procedures, she developed an erosion on her forehead that spread, during the following month, to other facial areas. Treatment with antibiotics and prednisone was ineffective.

On clinic presentation six months after the procedure, she had evidence of “fairly aggressive” resurfacing along with erythematous patches with weeping erosion and scattered pustules, according to the published report. After punch biopsy, swab culture and blood tests were inconclusive, the team reached a diagnosis of EPD. Four years later, after various treatments, she still had persistent crusting and mild erythema.

The second woman was in her sixties, had undergone upper-eyelid blepharoplasty, and also had full-face, fully ablative CO2 laser resurfacing. After near-complete healing, she developed erosions and crusting along the forehead and jawline. Treatment included various antifungal, antiviral and antibacterial agents. A year after the procedure, she again presented to the clinic with bright erythema, scattered erosions, and crusting. She was diagnosed with EPD and treated with various ointments and valacyclovir, and her symptoms slowly healed over the next year.

The third woman, also in her sixties, had undergone a full-face chemical peel, blepharoplasty and a face lift, after which she seemed to heal completely. About 10 weeks after the procedures, she developed erythematous patches and crusting on the cheeks and temples, which persisted for two years. She was diagnosed with EPD, and after a three-month course of treatment with various antibacterial and antiviral topical medications, her skin slowly improved within the next four years.

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“Time plus local wound care seems to be imperative to healing of the skin,” Dr. Wang said. “Anti-inflammatory topical and systemic medications may be needed to speed up the healing process. The cause of this condition is not clear but seems to be related to poor wound healing elicited by the trauma of skin resurfacing, rather than an infection.”

“Although the majority of laser resurfacing procedures are not associated with any unexpected complications,” he added, “we want to alert both patients and physicians to this uncommon condition following resurfacing procedures.”

Dr. Omer Ibrahim of SkinCare Physicians, Chestnut Hill, Massachusetts, coauthor of an accompanying editorial, told Reuters Health, “The exact mechanism by which EPD develops is unknown; however, some theories exist. Some researchers believe EPD is a chronic state of inflammation and delayed wound healing due to the body’s inability to heal itself, and sun-damaged skin has been shown to lack normal healing capabilities. Some researchers have theorized that autoimmune mechanisms also play a role in the development of EPD.”

“Although the exact pathophysiology behind EPD is unknown,” he said by email, “what is known is that EPD tends to occur after an insult to the skin that compromises/damages the epidermis, reaching the underlying dermis.”

“These insults can be surgical (like ablative laser resurfacing with a CO2 laser, destruction of skin cancers, hair transplants, and medium-to-deep chemical peels), traumatic (burns, wounds after trauma, and severe contact dermatitis leading to epidermal injury), or even infectious (EPD has been reported after Zoster/shingles),” he explained.

The diagnosis is one of exclusion, he said, and “treatment is notoriously difficult. The course can be long and arduous; tincture of time is just as important as any medication to treat this condition.”

In the editorial, Dr. Ibrahim and colleagues suggest that treatments beyond those noted in the study may prove useful, including systemic biologics such as infliximab, surgery to alter the wound environment, and laser treatment.


JAMA Dermatol 2017.

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