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© Our Dermatol Online 3.2018 241

How to cite this article: Thomaidou E, Katz M, Leibovici V. Two cases of disseminated superfi cial actinic porokeratosis (DSAP) and treatment literature review. Our Dermatol Online. 2018;9(3):241-248.Submission: 16.10.2017; Acceptance: 13.01.2018DOI:10.7241/ourd.20183.3

Two cases of disseminated superfi cial actinic Two cases of disseminated superfi cial actinic porokeratosis (DSAP) and treatment literature reviewporokeratosis (DSAP) and treatment literature reviewElena Thomaidou1, Marian Katz2, Vera Leibovici1

1Department of Dermatology, Hadassah- Hebrew University Medical Center, Jerusalem, Israel, 2Meuhedet Sick Fund, Jerusalem, Israel

Corresponding author: Dr. Vera Leibovici, E-mail: Rveralibo@hadassah.org.il

INTRODUCTION

Disseminated superficial actinic porokeratosis (DSAP) was first described by Chernosky and Freeman [1]. Clinically, DSAP is characterized by asymptomatic multiple papules with annular keratotic rim distributed symmetrically on the sun-exposed areas, and facial involvement is a rare presentation1. Malignant degeneration has been described in 7% to 11% of porokeratoses cases, with squamous cell carcinoma being the most common [2-4]. Histological hallmark is the cornoid lamella, which is formed by clonal hyperproliferation of atypical keratinocytes [3]. Underlying the cornoid lamella, the granular layer is thinned or absent and keratinocytes are oedematous with spongiosis, and dermal lymphocytic infiltrate

may also be evident [5]. Dermoscopy examination demonstrate single or double “white track” structure at the margin corresponding to the cornoid lamella, and the red dots, globules, and lines are enlarged capillary vessels that can be observed because the epithelium is atrophic [6].

Xia and colleagues using a genomewide search in a large Chinese family, identified a locus at chromosome 12q23.2-24. 1 responsible for disseminated superficial actinic porokeratosis [7]. Therefore, DSAP is an inherited dermatologic disorder with lesions appearing in genetically predisposed individuals after adequate exposure to ultraviolet radiation or immunosuppression in the third and fourth decades of life [8].

ABSTRACT

Background: Disseminated superficial actinic porokeratosis (DSAP) is characterized by asymptomatic multiple papules with annular keratotic rim distributed symmetrically on the sun-exposed areas. Many approaches have been proposed in the past for treating DSAP, but the therapy is still a challenge for every physician, mostly because of the frequent relapses of the disease and the multiplicity of the skin lesions. Material and Methods: Two case reports were reported emphasizing the challenges of treatment approach. Therefore, a systemic English literature review was conducted searching Medline database using PubMed Central and Ovid software as search interface to collect evidence based on the various treatment modalities for DSAP. Results: The initial search yielded 146 articles, but only the relevant case reports, case series and studies relating to the treatment of DSAP have been described and summarized in a table. For each different therapy the efficacy of each treatment, side effects, cost-effectiveness and authors’ recommendations were reported. Conclusion: Several factors need to be considered prior to physicians’ decision of the most appropriate treatment for each patient like age, the extent of body surface area involvement, patients’ medical history and social situation, the available resources, the side effects and cost- effectiveness of each treatment. However, l the exact value of each treatment is difficult to determine owing to the lack of controlled studies evaluating their efficacy. Due to few incidences of squamous cell carcinoma, patients need to be followed up and monitored closely for any early detection of recurrence or possible onset of malignancies.

Key words: Porokeratosis; Keratinizing disorders; Lasers; Photodynamic therapy

Original Article

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© Our Dermatol Online 3.2018 242

A variety of approaches have been proposed to treat DSAP, but the therapy is still a challenge for every physician, mostly because of the multiplicity of the skin lesions and the frequent relapses of the disease [9]. Herein, we present two case reports with a great dilemma in treatment approach, following by an update literature review.

CASES

Case 1: An eighteen four-year-old man presented in our clinic with 6-month history of bilateral symmetrical erythematous skin lesions on the lower and upper extremities. The skin eruptions were associated with photosensitivity and moderate pruritus. The patient had a background medical history of hypercholesteremia, hypertension, ischemic heart disease, congestive heart disease, diabetes mellitus type 2, non-alcoholic fatty liver, chronic renal failure and glaucoma.

On examination bilateral erythematous scaly papules with annular configuration, well –demarcated borders and central atrophy were seen on the shins, thighs and forearm (Figs. 1a and 1b). Dermoscopy examination revealed a white like track structures at the periphery of the lesion with a mild hyperpigmentation in the inner side and with some red globules, and lines at the periphery (Fig. 2). On histological examination cornoid lamella was found in the stratum corneum with focal loss of granular layer, prominent lichenoid, superficial perivascular lymphocytic infiltrate and background elastosis (Figs. 3a and 3b).

Case 2: An eighteen one-year-old man with background history of diabetes mellitus type 2, bronchiectasis, asthma, ischemic heart disease, aortic stenosis and mitral insufficiency was examined in our clinic due to 3-year history of annular non-pruritic lesions on the shins. In the past, he was treated with steroid intralesional injections without any improvement.

On examination, there were multiple annular erythematous lesions with central clearing and elevated borders on the shins (Figs. 1c and 1d). Histological examination revealed cornoid lamella with absence of the granular layer. The intervening epidermis between the cornoid lamellae was thin and in the upper dermis there were perivascular mononuclear and lichenoid cells.

According to the clinical and histological presentation, both of our patients were diagnosed with disseminated superficial actinic porokeratosis. Their clinical presentation, risk of malignancy, medical history and

their social situation was considered for choosing the most appropriate treatment for the patient.

Prior to the study, patient gave written consent to the examination and biopsy after having been informed about the procedure.

METHOD

A systemic English literature review was conducted in June 2017 searching Medline database using PubMed Central and Ovid software as search interface to collect

Figure 2: A “white track” structures can be identifi ed at the periphery of the lesion with a brownish pigmentation in the inner side and with some red globules, and lines at the periphery.

Figure 1: (a-d) Bilateral erythematous scaly papules with annular confi guration on the shins, thighs and forearm with well – demarcated borders and central atrophy.

a b c d

Figure 3: (a and b) Cornoid lamella was found in the stratum corneum with focal loss of granular layer, prominent lichenoid, superfi cial perivascular lymphocytic infiltrate and background elastosis.(Hematoxylin and Eosin, 40×, 400x).

a b

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© Our Dermatol Online 3.2018 243

Au

tho

rT

ype

of

stu

dy

Th

erap

yN

um

ber

o

f p

atie

nts

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e o

f p

at ie

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han

ism

of

acti

on

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cac

yS

ide

effe

cts

Co

stA

uth

ors

’ rec

om

men

dat

ion

s

Top

ical

trea

tmen

t

Vla

chou

et a

l.,

2008

10

Cas

e se

ries

Top

ical

D

iclo

fena

c 3%

851

-79

Dic

lofe

nac

exer

ts it

s ac

tion

via

inhi

bitio

n of

pro

stag

land

in

synt

hesi

s by

inhi

bitin

g cy

cloo

xyge

nase

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CO

X-1

) an

d cy

cloo

xyge

nase

-2 (C

OX

-2),

ca

usin

g in

hibi

tion

of a

rach

idon

ic a

cid

met

abol

ism

, the

reby

re

duct

ion

of th

e tu

mor

igen

ic e

ffect

s of

its

met

abol

ites

Com

plet

ion

of th

e th

erap

y:

6/8

patie

nts

had

no im

prov

emen

t an

d 2

had

part

ial i

mpr

ovem

ent

Pru

ritus

Ery

them

aIn

expe

nsiv

e A

non

-inva

sive

, gen

eral

ly w

ell

tole

rate

d an

d re

lativ

ely

safe

topi

cal

ther

apy,

but

the

resu

lts d

o no

t su

ppor

t its

effe

ctiv

enes

s on

DS

AP

Mar

ks e

t al.,

20

09 1

1O

pen-

labe

l, m

ultic

ente

r pi

lot s

tudy

17N

/A12

nd w

eesk

: 7/1

3 pa

tient

s ha

d a

decr

ease

in n

umbe

r of

lesi

ons,

an

d 1

patie

nt h

ad a

sta

ble

num

ber

of le

sion

s on

the

targ

et

area

Com

plet

ion

of th

e th

erap

y (2

4th

wee

k): 3

/10

patie

nts

had

a de

crea

se in

num

ber

of le

sion

s,

and

1 pa

tient

had

a s

tabl

e nu

mbe

r of

lesi

ons

Der

mat

itis

Ery

them

aT

he d

ata

impl

ies

that

the

trea

tmen

t pr

ovid

ed s

ome

prot

ectio

n ag

ains

t di

seas

e pr

ogre

ssio

n, a

nd it

wou

ld b

e he

lpfu

l in

the

abse

nce

of d

esira

ble

alte

rnat

ives

Ote

ro-R

ivas

et a

l.,

2016

12

Lette

r to

the

Edi

tor

182

Com

plet

ion

of th

e th

erap

y (1

2nd

wee

k): a

lmos

t all

lesi

ons

had

clea

red

and

only

som

e er

ythe

mat

ous

mac

ules

per

sist

ed

No

side

effe

cts

It is

a w

ell-t

oler

ated

and

saf

e to

pica

l th

erap

y w

ith e

xcel

lent

res

ults

in th

e tr

eatm

ent o

f DS

AP

and

it c

ould

be

usef

ul in

som

e se

lect

ed p

atie

nts

Aru

n, P

ears

on,

Cha

lmer

s 20

11 1

3C

ase

repo

rtIm

iqui

mod

5%

cr

eam

168

Tol

l-lik

e re

cept

or (

TLR

) ag

onis

t, st

imul

atin

g th

e in

nate

imm

une

resp

onse

by

activ

atin

g an

tigen

-pre

sent

ing

cells

to

pro

duce

inte

rfer

on

and

othe

r cy

toki

nes

and

chem

okin

es. I

t may

su

ppre

ss o

r sw

itch

off t

he

abno

rmal

mut

ant g

enes

th

roug

h its

imm

unol

ogic

al

effe

cts

Com

plet

ion

of th

e th

erap

y (8

th

wee

k): s

light

sup

erfi c

ial s

carr

ing

and

resi

dual

ery

them

a, b

ut n

o ev

iden

ce o

f the

orig

inal

con

ditio

n

Sup

erfi c

ial

scar

ring

Res

idua

lE

ryth

ema

Inex

pens

ive

It m

ay b

e a

usef

ul tr

eatm

ent

optio

n, b

ut it

sho

uld

be in

trod

uced

ca

utio

usly

, and

an

appl

icat

ion

freq

uenc

y of

thre

e tim

es a

wee

k sh

ould

be

used

initi

ally

to a

void

ex

cess

ive

infl a

mm

atio

n

Ria

d et

al.

2013

14

Cas

e re

port

1

19

Com

plet

ion

of th

e th

erap

y:

only

few

lesi

ons

with

a p

artia

l re

spon

se a

nd n

o re

laps

e af

ter

2 ye

ars

Ery

them

a,P

rurit

usN

/A

Har

rison

, Sto

llery

19

94 1

5Le

tter

to th

e E

dito

r C

alci

potr

iol

368

-85

Vita

min

D3

anal

ogs

may

in

duce

gen

es c

ritic

al fo

r ke

ratin

ocyt

e di

ffere

ntia

tion,

su

ch a

s tr

ansg

luta

min

ase

or in

volu

crin

; and

may

in

hibi

t pro

lifer

atio

n by

in

duci

ng s

phin

gom

yelin

hy

drol

ysis

and

mod

ulat

ion

of p

rote

in k

inas

e C

act

ivity

Com

plet

ion

of th

e th

erap

y:

impr

ovem

ent v

arie

d be

twee

n 50

an

d 75

%, w

hich

was

mai

ntai

ned

for

up to

6 m

onth

s in

2/3

pat

ient

s

Ski

n irr

itatio

n In

expe

nsiv

eN

/A

Bak

ardz

hiev

, K

avak

lieva

, P

ehliv

anov

, 20

12 1

6

Lette

r to

the

Edi

tor

Cal

cipo

trio

l1

73C

ompl

etio

n of

the

ther

apy:

afte

r 6-

mon

th p

atie

nt w

as fr

ee o

f le

sion

s

Non

-rep

orte

dIn

expe

nsiv

eG

ood

resp

onse

of D

SA

P to

ca

lcip

otrio

l has

doc

umen

ted.

Tab

le 1

: R

evie

w o

f tre

atm

ents

mod

aliti

es. D

SA

P -

Dis

sem

inat

ed S

uper

fi cia

l Act

inic

Por

oker

atos

is; N

/A –

Non

-App

licab

le. ;

MA

L-P

DT

- M

ethy

l-am

inol

evul

inat

e P

hoto

dyna

mic

The

rapy

.; A

LA-P

DT

- A

min

olae

vulin

ic a

cid

Pho

tody

nam

ic T

hera

py; N

d: Y

AG

- n

eody

miu

m-d

oped

yttr

ium

alu

min

ium

gar

net

Con

td...

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© Our Dermatol Online 3.2018 244

Tab

le 1

: (C

ontinued

)

Au

tho

rT

ype

of

stu

dy

Th

erap

yN

um

ber

o

f p

atie

nts

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e o

f p

at ie

nts

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han

ism

of

acti

on

Effi

cac

yS

ide

effe

cts

Co

stA

uth

ors

’ rec

om

men

dat

ion

s

Böh

m, L

uger

, B

onsm

ann,

19

99 1

7

Cas

e re

port

Tac

alci

tol

140

Com

plet

ion

of th

e th

erap

y:

5-m

onth

lesi

ons

had

com

plet

ely

fade

d an

d on

ly fe

w in

visi

ble

lesi

ons

wer

e no

ticea

ble

on

palp

atio

n

Non

-rep

orte

d V

itam

in D

3 an

alog

s m

ay h

elp

to r

educ

e th

e lo

ng-t

erm

ris

k of

m

alig

nant

tran

sfor

mat

ion.

Nak

amur

a et

al.,

20

14 1

8 C

ase

repo

rtC

alci

potr

iol a

nd

adap

alen

e1

63C

ompl

etio

n of

the

ther

apy:

afte

r 3

mon

ths

skin

lesi

ons

impr

oved

su

bsta

ntia

lly

Hyp

erpi

gmen

tatio

nT

he la

ck o

f sig

nifi c

ant a

dver

se

effe

cts

and

clin

ical

effi

cacy

, ind

icat

es

that

the

trea

tmen

t may

rep

rese

nt a

us

eful

opt

ion

Tch

erne

v et

al.,

20

17 1

9C

ase

repo

rt

Cal

cipo

trio

l/be

tam

etha

sone

ge

l

180

Com

plet

ion

of th

e th

erap

y: a

fter

2 m

onth

s al

mos

t ful

l res

olut

ion

of th

e cl

inic

al s

ympt

oms

and

with

out t

he a

ppea

ranc

e of

fres

h le

sion

s

No

side

effe

ct

The

lack

of s

igni

fican

t adv

erse

ef

fect

s in

the

patie

nt, a

s w

ell a

s th

e go

od to

lera

nce

and

the

sign

ifica

nt

clin

ical

impr

ovem

ent,

indi

cate

s th

at

this

trea

tmen

t opt

ion

is b

enefi

cial

for

the

ther

apy

of D

SA

P

Sys

tem

ic T

hera

py

Kar

inie

mi,

Stu

bb,

Lass

us,

1980

20

Cas

e re

port

Aro

mat

ic r

etin

oid

184

Vita

min

A d

eriv

ativ

es

may

par

ticip

ate

in th

e di

ffere

ntia

tion

of th

e ep

ider

mal

cel

ls a

nd

enha

nce

kera

tiniz

atio

n,

lead

ing

to r

educ

tion

of th

e m

itotic

act

ivity

Com

plet

ion

of th

e th

erap

y:

afte

r th

e 40

th d

ay, t

he p

rurit

us

had

stop

ped

entir

ely,

and

the

lesi

ons

had

clea

red

so th

at th

e sc

aly

thre

ad-li

ke b

orde

r ha

d di

sapp

eare

d

Mild

che

ilitis

Hai

r lo

ssIn

expe

nsiv

eN

/A

Lude

ra-Z

imoc

h,

Rub

isz-

Brz

ezin

ska,

19

89 2

1

Cas

e re

port

155

Com

plet

ion

of th

e th

erap

y:

afte

r th

e 3rd

mon

th, c

linic

al

impr

ovem

ent l

aste

d fo

r se

vera

l m

onth

s an

d th

eir

follo

wed

by

less

pro

noun

ced

but p

rogr

essi

ve

reap

pear

ance

of c

linic

al

sym

ptom

s

N/A

N/A

Car

mic

hael

, Tan

, 19

90 2

2C

ase

repo

rtE

tret

inat

e1

55C

ompl

etio

n of

the

ther

apy:

af

ter

the

2nd m

onth

mar

ked

impr

ovem

ent i

n th

e sc

alin

g, b

ut

trea

tmen

t sto

pped

due

to s

ide

effe

cts

Hai

r th

inni

ngD

igita

te k

erat

oses

N/A

Pho

tody

nam

ic T

hera

py (

PD

T)

Cav

icch

ini,

Tou

rlaki

, 200

6 9

Lette

r to

the

Edi

tor

MA

L-P

DT

150

Top

ical

met

hyl

amin

olev

ulin

ate

(MA

L),

phot

osen

sitiz

ing

drug

w

ith a

ppro

pria

te li

ght

dose

can

res

ult t

o hi

ghly

re

activ

e ox

ygen

spe

cies

le

adin

g to

sel

ectiv

e ce

ll da

mag

e an

d in

dire

ctly

st

imul

ate

infl a

mm

ator

y ce

ll m

edia

tors

Com

plet

ion

of th

e th

erap

y: a

fter

the

12th

mon

th, n

o ne

w le

sion

s oc

curr

ed, a

nd a

str

ikin

g cl

inic

al

impr

ovem

ent w

as o

bser

ved

with

onl

y a

slig

ht r

esid

ual

hype

rpig

men

tatio

n

Bur

ning

sen

satio

nH

yper

pigm

enta

tion

Exp

ensi

veM

AL-

PD

T s

how

ed h

igh

effi c

acy

and

good

cos

met

ic o

utco

me

with

a h

igh

patie

nt s

atis

fact

ion

leve

l

Con

td...

www.odermatol.com

© Our Dermatol Online 3.2018 245

Au

tho

rT

ype

of

stu

dy

Th

erap

yN

um

ber

o

f p

atie

nts

Ag

e o

f p

at ie

nts

Mec

han

ism

of

acti

on

Effi

cac

yS

ide

effe

cts

Co

stA

uth

ors

’ rec

om

men

dat

ion

s

Fer

nand

ez-G

uarin

o et

al.,

200

9 23

Lette

r to

the

Edi

tor

MA

L -P

DT

655

-74

Com

plet

ion

of th

e th

erap

y:

afte

r 2

wee

ks: 2

/6 s

how

ed n

o re

spon

d, 4

/6 s

how

ed s

light

re

duce

rou

ghne

ss

No

side

effe

cts

wer

e no

ted

Exp

ensi

veD

SA

P w

ith M

AL-

PD

T s

ugge

st th

at

this

trea

tmen

t may

not

be

prom

isin

g fo

r th

is d

erm

atos

is

Sal

as e

t al.,

20

16 2

Cas

e re

port

2

58,7

3C

ompl

etio

n of

the

ther

apy:

afte

r 10

mon

ths

good

res

ults

rem

aine

d an

d no

evi

denc

e of

rec

urre

nce

in

the

trea

ted

lesi

ons

No

side

effe

cts

wer

e no

ted

Tw

o ca

ses

of D

SA

P tr

eate

d su

cces

sful

ly w

ith d

aylig

ht-P

DT

with

no

rec

urre

nce

afte

r 10

mon

ths

Nay

eem

uddi

n et

al.,

200

2 24

Cas

e se

ries

ALA

-PD

T

342

-59

5-am

inol

aevu

linic

ac

id (

5-A

LA)

is a

pro

-dru

g,

whi

ch r

elat

ivel

y se

lect

ivel

y is

take

n up

by

som

e sk

in

dise

ases

and

it h

as th

e sa

me

mec

hani

sm o

f act

ion

with

MA

L w

hen

com

bine

w

ith a

ppro

pria

te li

ght d

ose

Com

plet

ion

of th

e th

erap

y:

Afte

r th

e se

cond

trea

tmen

t 3/

3 pa

tient

s de

cide

d no

t to

con

tinue

the

trea

tmen

t be

caus

e 2/

3 di

d no

t res

pond

, 1/

3 ha

d po

st -

infl a

mm

ator

y hy

perp

igm

enta

tion

Dis

com

fort

,S

kin

peel

ing

Pig

men

tary

ch

ange

s

Exp

ensi

ve

The

res

ults

of A

LA-P

DT

in th

ese

thre

e pa

tient

s su

gges

ts th

at th

is

trea

tmen

t mod

ality

may

not

be

suita

ble

for

DS

AP

Boi

y , d

e W

itte,

R

oela

ndts

201

0 25

Cas

e re

port

H

yper

icin

-PD

T1

54H

yper

icin

is a

pho

to-a

ctiv

e dy

e or

igin

atin

g fr

om

the

herb

Hyp

eric

um

perf

orat

um (

St.

John

’s

wor

t)

Com

plet

ion

of th

e th

erap

y: A

fter

thre

e tr

eatm

ents

, litt

le o

r no

cl

inic

al im

prov

emen

t was

not

ed

Ery

them

a E

xpen

sive

Top

ical

hyp

eric

in-P

DT

doe

s no

t em

erge

as

a pr

omis

ing

trea

tmen

t fo

r D

SA

P

Lase

rs a

nd L

ight

s

Lolis

, &

Mar

mur

, 20

08 3

Cas

e re

port

Q-s

witc

hed

ruby

la

ser

(694

nm)

148

N/A

Com

plet

ion

of tr

eatm

ent:

mos

t of

the

lesi

ons

decr

ease

E

ryth

ema

Hyp

erpi

gmen

tatio

n E

xpen

sive

R

uby

lase

r (6

94 n

m)

has

a gr

eat

degr

ee o

f pen

etra

tion,

allo

win

g it

to tr

eat p

igm

ente

d le

sion

s w

hich

occ

ur d

eepe

r in

the

derm

is

affe

ctin

g m

ainl

y po

st –

infl a

mm

ator

y hy

perp

igm

enta

tion

of th

e le

sion

Itoh,

& N

akag

awa,

20

07 2

6C

ase

repo

rt1

61N

/AC

ompl

etio

n of

trea

tmen

t: m

ost

of th

e le

sion

s im

prov

ed w

ith n

o re

sidu

al s

kin

lesi

ons

Hyp

erpi

gmen

tatio

nT

he Q

-sw

itche

d ru

by la

ser

(QS

RL)

m

ay b

e us

eful

for

the

trea

tmen

t of

DS

AP

Lui ,

201

0 27

Cas

e re

port

Q

-sw

itche

d N

d: Y

AG

la

ser

(532

nm)

156

N/A

C

ompl

etio

n of

trea

tmen

t: go

od

impr

ovem

ent o

f mos

t of t

he

lesi

ons

with

pat

ient

sat

isfa

ctio

n an

d un

chan

ged

resu

lts a

fter

9 m

onth

s fo

llow

up

N/A

N/A

Ros

enbl

um,

2013

28

Cas

e re

port

Erb

ium

and

ne

odym

ium

YA

G

lase

rs

162

N/A

Com

plet

ion

of tr

eatm

ent:

good

im

prov

emen

t of t

he m

ajor

ity o

f th

e le

sion

s

Ery

them

a N

/A

Tab

le 1

: (C

ontinued

)

Con

td...

www.odermatol.com

© Our Dermatol Online 3.2018 246

Au

tho

rT

ype

of

stu

dy

Th

erap

yN

um

ber

o

f p

atie

nts

Ag

e o

f p

at ie

nts

Mec

han

ism

of

acti

on

Effi

cac

yS

ide

effe

cts

Co

stA

uth

ors

’ rec

om

men

dat

ion

s

Ros

s et

al.,

20

16 2

9C

ase

repo

rtF

ract

iona

l 19

27nm

thul

ium

fi b

er la

sers

246

,65

N/A

Com

plet

ion

of tr

eatm

ent:

No

new

le

sion

s, d

ecre

ase

the

thic

knes

s of

rem

aini

ng le

sion

s

Ede

ma

Ery

them

a E

xpen

sive

It is

con

veni

ent a

nd s

afe

with

nea

rly

no d

ownt

ime

or m

orbi

dity

ass

ocia

ted

with

pig

men

t or

text

ural

def

ects

. C

ondu

ctin

g m

ultip

le tr

eatm

ents

ve

rsus

one

and

mor

e ag

gres

sive

tr

eatm

ent a

re n

eede

d du

e to

the

poor

wou

nd h

ealin

g pr

oper

ties

on

the

low

er e

xtre

miti

es

Chr

astil

et

al.,

2007

30

Cas

e re

port

Fra

ctio

nal

Pho

to-t

herm

olys

is

247

,48

The

stim

ulat

ory

effe

cts

of fr

actio

nal r

esur

faci

ng

on d

erm

al c

olla

gen

rem

odel

ing

and

epid

erm

al

rege

nera

tion,

in a

dditi

on

to th

e re

vers

al e

ffect

s on

ph

otod

amag

ed s

kin,

are

m

echa

nism

s th

at m

ight

ex

plai

n th

e su

cces

sful

tr

eatm

ent o

f DS

AP

Com

plet

ion

of tr

eatm

ent:

grea

ter

than

50%

impr

ovem

ent o

f the

le

sion

s w

as n

oted

and

full

patie

nt

satis

fact

ion

Ery

them

aN

/A

Nob

orio

, M

orita

, 20

11 3

1Le

tter

to th

e E

dito

r C

O2

183

N/A

Com

plet

ion

of tr

eatm

ent:

maj

ority

of

lesi

ons

disa

ppea

r, s

atis

fy

patie

nt a

nd n

o re

curr

ence

on

the

follo

w u

p

N/A

C

O2

lase

r th

erap

y is

mos

tly

effe

ctiv

e, b

ut s

ever

e sc

arrin

g is

an

occ

asio

nal a

dver

se e

ffect

s of

co

nven

tiona

l CO

2 la

ser

irrad

iatio

n

Kim

et a

l.,20

11 3

2C

ase

repo

rtC

O2+

PD

T

261

,62

N/A

Com

plet

ion

of tr

eatm

ent:

maj

ority

of

lesi

ons

disa

ppea

r w

ith n

o re

curr

ence

on

the

follo

w u

p

Hyp

erpi

gmen

tatio

nA

ggra

vatio

n of

m

elas

ma

Ove

rall,

PD

T w

as fo

und

to r

emov

e so

me

of th

e re

mna

nt r

ims

of D

SA

P

follo

win

g C

O2

lase

r ab

latio

n, b

ut

the

degr

ee o

f im

prov

emen

t was

not

st

rikin

g. U

sing

MA

L-P

DT

to C

O2

lase

r va

poriz

atio

n, m

ultip

le s

essi

ons

of tr

eatm

ent a

re r

equi

red,

and

co

mpl

icat

ions

ass

ocia

ted

with

PD

T

rais

ed s

ome

conc

ern

Ric

ci, R

osse

t, P

aniz

zon,

199

9 33

Cas

e re

port

Gre

nz r

ays

177

X-r

ays

are

know

n to

hav

e an

tipro

lifer

ativ

e ac

tivity

by

inhi

bitio

n of

the

DN

A

synt

hesi

s, p

artic

ular

ly

in a

bnor

mal

cel

ls,

apar

t fro

m th

eir

pote

nt

anti-

infla

mm

ator

y ef

fect

Com

plet

ion

of tr

eatm

ent:

afte

r tw

o ye

ars

they

wer

e ex

celle

nt

outc

omes

, no

recu

rren

ce

Pru

ritus

E

xpen

sive

It m

ay b

e a

usef

ul o

ptio

n in

the

man

agem

ent o

f eld

erly

pat

ient

s w

ith

DS

AP

Tab

le 1

: (C

ontinued

)

www.odermatol.com

© Our Dermatol Online 3.2018 247

evidence based on the various treatment modalities for DSAP. In addition, studies that have been commonly cited in the literature and review articles were included as citation search engine to identify subsequent publications, which were relevant for the literature review. The following medical terms and text world were used: “Disseminated superficial actinic porokeratosis”, “porokeratosis”, “laser”, “photodynamic therapy”, “diclofenac”, “calcipotriol”, “imiquimod”, “retinoid”, “photodynamic therapy”, “lasers”. The keywords were combined using multiple combinations. Articles that did not mention treatment approaches, which were not published in English or were not available, have not been included for the purposes of this literature review. Any discrepancies about data evaluation of the selected articles were resolved after discussion between the authors.

RESULTS

The initial search yielded 146 articles, but only the relevant case reports, case series and studies relating to the treatment of DSAP have been described below and summarized in Table 1. For each different therapy the efficacy of each treatment, side effects, cost effectiveness and authors’ recommendations were reported.

DISCUSSION

Traditional topical treatment approaches include topical treatments like diclofenac [10-12], imiquimod [13-14] and calcipotriol [15-19]. Oral retinoids [20-22] and cryotherapy [15] were used in the past with no any satisfied results. Newer treatment of photodynamic therapy (PDT) [2,9,23-25] and lasers [3,26-32]

have been introduced in the recent years with some desirables results. A literature review was conducted five years ago assessing the level of evidence for some therapeutic modalities. However, still the exact value of each treatment is difficult to determine owing to the lack of controlled studies evaluating their efficacy [5].

Several factors need to be considered for choosing the most appropriate treatment for each patient, like the age, the extent of body surface area involvement, patients’ medical history and their social situation, the available resources in dermatology departments, the side effects and cost effectiveness of each treatment approaches. Systemic treatment might not be an option if patients have complicated medical background and

take multiple medications, due to possible interactions of retinoids with their regular medications. Expensive treatment like different types of lasers can be discussed with the patients but usually are not considered due to the high cost and lack of experienced centres. PDT therapy showed poor outcome in several studies (e.g. six out of nine patients had none or minimal response with MAL- PDT, all patients had no response with ALA-PDT and Hypericin-PDT), thus it is not recommended frequently [2,9,23-35].

Following a thorough discussion among physicians in our clinic, both patients started on topical treatment with calcipotriol/betamethasone gel with partial resolution. Patients are under follow up and they will be monitored closely for any possible onset of malignancies. In conclusion, there are several options available for treating DSAP, but always the best approach should be tailored to every patient. There is still a great need for further controlled studies with a greater sample size to draw conclusions on the effects of these novel treatments for DSAP.

Statement of Human and Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent

Informed consent was obtained from all patients for being included in the study.

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Copyright by Elena Thomaidou, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Source of Support: Nil, Confl ict of Interest: None declared.