Unconventional use of fractional ablative CO2 laser in facial cutaneous sarcoïdosis

Dear Editor, Sarcoidosis is a chronic granulomatous disease which affects 20–35% of cases and could be the sole manifestation of the disease (Tchernev, 2006). Cutaneous sarcoidosis is a cosmetically displeasing condition affecting the patient’s quality of life. Usually cutaneous sarcoidosis is treated with either topical or systemic therapies with an unpredictable response. The use of ablative fractional CO2 laser in the treatment of cutaneous sarcoidosis has been rarely reported in the literature. Herein we report a case of facial cutaneous sarcoidosis successfully treated with ablative fractional CO2 laser. A female patient aged 49 year old with a past medical history of diabetes was referred to our department for facial cutaneous plaques. Dermatological examination revealed two infiltrated papulo-nodular plaques on the cheeks (Figure 1). They were slowly growing in size since 6 months and were not painful. A skin biopsy taken from the papulo-nodular plaque of the cheek was performed revealing multiple dermal non caseating granulomas suggestive of cutaneous sarcoidosis. Laboratory tests were normal except for elevated levels of angiotensin converting enzyme. Tuberculin skin testing was negative. Chest X Ray was also normal. The patient was initially treated with topical corticosteroids for 2 months with no results. She was then scheduled to be treated with hydroxychloroquine. Ophthalmologic examination done before initiating hydroxychloroquine found anomalies in the vision field of the patient contraindicating the use of the treatment. As the facial lesions were very displeasing, laser therapy was proposed to the patient as an experimental approach. The patient was treated with ablative fractional CO2 laser (CO2 Limmer laser). Three sessions were performed with a 2-month interval. The session was performed under local anesthetic using 125 mm handpiece, 10 mm spot, 25% density, and 10 Watts energy. At the end of the procedure, the wound was covered with topical fusidic acid ointment. The patient was seen 2 weeks after laser treatment. Neither scar nor pigmentary disorders were noted (Figure 2). After the third session, there was a complete resolution of the two facial plaques with no signs of relapse after 6 months follow-up. The present case illustrates that fractional resurfacing appears to be a new promising modality for an effective treatment of localized and stable nodular cutaneous sarcoidosis with a safe and acceptable side effect profile. Fractional photothermolysis was recently introduced as a new concept of laser tissue interaction by Manstein, Herron, Sink, Tanner, and Anderson (2004). It creates hundreds to thousands of dense micro thermal zones while sparing surrounding tissue. As a result, epidermal repair is rapid. Patients should be forewarned that numerous laser treatments may be necessary before the desired results are seen. Fractional photothermolysis could induce remodeling of dermal granulomas, collagen or both as seen in our patient (Laubach, Tannous, Anderson, & Manstein, 2006). In fact, ablative fractional resurfacing produced an immunomodulatory and dermal tissue effect