Photodynamic therapy for acne conglobata of the buttocks: Effective antiinflammatory treatment with good cosmetic outcome

Lettersto the Editor

Photodynamic

therapy for

acne

conglobata

of

the

buttocks:

Effective

_{antiinflammatory}

treatment

with

_good

cosmetic

outcome

Sir,

Acne

_conglobata is an uncommon difficult-to-treat severe

inflammatoryacnevariantthataffects_deepskintissue,causing swelling, bleeding, purulent discharge and pain.' Several

therapeutic options have been used with variable results, often _leaving residual _disfiguring scars. Here, we report a case

of

_{histologically proven}acne_conglobataina_16-year-old

Caucasianmanwitha5-monthhistory

of

sudden-onsetpainful nodular cysticeruption on the buttocks.History didnotreveal anydrug usage orpredisposinghereditary factors. Previous treatmentswithoral_{minocycline (4 weeks), topical} retinoid and _{systemic isotretinoin (0.5 mg/kg/d)} were ineffective. Examination revealed _multiple’ inflamed nontender suppurative nodules localized on the _{buttocks [Figure}

_la]

and_{lateral aspects}

of

the_{pelvis, withspontaneous bleeding} and purulent discharge. Nolesions were detected elsewhere on _physical examination. Such _{protracted painful eruption} severelyaffected thepatient’squality

of

life, interfering with daily activities. We,therefore,decidedtostart_photodynamic therapy as monotherapy because

of

its_{antiinflammatory}and

antimicrobial effects as

well

asits

_ability

to reduce therisk

of

_disfiguring scars.

After

awritten informedconsent, 10% S-aminolaevulinic acid in_polyethylene

_glycol

ointmentwas applied in occlusion for3 hon thebuttocks; irradiationwas

then _{applied with} diode red _light at 630 nm

_{(S630, Alpha}

Strumenti, Milan,

Italy)

for8 min, withatotal _lightdose

of

75Vem?. Fluorescence,detected_{using violetlight}at405nm, was_{localized with highintensity, especially}in_inflammatory nodules.Thepatientwastreated _every2weeks foratotal

of

sixtreatments_{over a period}

of

three_{months. Intense pain and}

inflammation_{were reported after the first}twosessions

_(visual

analog scale mean values

of

10/10 and 8/10, respectively)

and _{were managed} with oral paracetamol and topical application

of

corticosteroids, while only minimal discomfort wasrecorded atthe successive _exposures.

At

theend

of

the treatment period, a remarkable improvement

of

the

clinical

featureswas observed,with healing

of

thecutaneousnodules andno _noteworthyadverse event _[Figure

_lb].

At

6 months’ follow-up, a _{lasting remission with favorable cosmetic}

results was observed _[Figure

_lc].

_{Photodynamic therapy}

typically

involves topical application

of

the_{photosensitizing} prodrug aminolaevulinic acid or its methylated ester, converted_bytheheme_{biosynthetic pathway predominantly} to protoporphyrin

IX

and _{activated by light}

of

_appropriate

wavelength to produce reactive oxygen species, especially singletoxygen, which triggerapoptosis and necrosis

of

target

cells. Inadditiontoestablished indications in nonmelanoma

skin cancer, photodynamic therapy is usedwith increasing

Letters to the Editor

frequency in several inflammatorydermatoses aswell as in

wound_healing.*4The_{greater absorption}

of

aminolaevulinic acid _together with higher production

of

_{protoporphyrin}

IX

in hair

follicles

_{compared to other tissues seems} to

be the mechanism

of

action in inflammatory diseases

of

the _{pilosebaceous} unit such as chronic

folliculitis

and

hidradenitis _{suppurativa.*°} In _{our patient, photodynamic}

therapy was very effective to prevent scars as well.

This

striking cosmetic outcome may be the consequence

of

a

Figure La:Skin lesionsbeforephotedynamie therapy

Figurelc:Skin lesionsat6months”follow-up

combination

of

antiinflammatory effect, immunomodulatory activity and _{keratinocyte photoactivation with subsequent} paracrine induction

of

matrixmetalloproteinasesproduction

in fibroblasts, favoringthe_remodeling

of

thedermalmatrix architecture. _{The good tolerability, high safety profile} and absence

of

durable sideeffects render_{photodynamictherapy}

a valid_{therapeutic option for acne conglobata;} its use atan

early stage

of

the disease may accelerate resolution

of

the

cysticlesions,reducingtheriskand theseverity

of

disfiguring

scars.

Declarationof patient consent

The authors _certify that _they have obtained all _appropriate

patient consent forms. In the form, the patient hasgiven his

consent for_{his images and other}

clinical

information to be reported in thejournal. The patient understands that name andinitials

will

not be_publishedand dueefforts

will

be made toconceal_{identity, butanonymitycannot be guaranteed.}

Financial supportand_sponsorship

Nil.

Conflicts of interest

Therearenoconflicts

of

interest.

Francesco Borgia, Mario

Vaccaro,

Roberta Giuffrida, Serafinella

P.

Cannavò

Department ofClinicaland Experimental Medicine, DermatologyUnit,

University Hospital“G.Maruno, Messina,Italy

Correspondence: Dr.Francesco _Borgia,

Department of Clinical andExperimental Medicine,

Dermatology Unit, University Hospital “G. Martino,”

Via ConsolareValeria, Messina98125,Italy.

E-mail: fborgia@unime.it

References

l1. _Wang HW, LvT, Zhang LL, Guo MX, _Stepp H, Yang K, et al.

Prospective study of topical 5-aminolevulinic acid photodynamic

therapy forthetreatmentofmoderate to_{severe acne vulgaris in Chinese}

patients. JCutanMed Surg 2012;16:324-33.

2. _{Borgia F, Vaccaro} M, Cantavenera LG, Aragona E, Cannavò SP.

Ulcerative necrobiosis lipoidica successfullytreated_{with photodynamic}

therapy: Case report andliterature review. Photodiagnosis Photodyn

Ther 2014;11:516-8.

3. _{Borgia F, Vaccaro M, FotiA,Giuffrida R,}CannavòSP.Zoon’sbalanitis

successfully treated with photodynamic therapy: Case report and

literature_{review. Photodiagnosis Photodyn}Ther2016;13:347-9.

4. _{Borgia F,} Giuffrida R, Vaccaro M, Lentini M, Cannavò SP.

Photodynamic therapy in lupus miliaris disseminatus faciei’s scars.

DermatolTher 2016:29:320-4.

5. Andino Navarrete R, HassonNisis A, ParraCares J. Effectiveness

ofS-aminolevulinic acid photodynamic therapy in the treatmentof

hidradenitis suppurativa: A report of5 cases. Actas Dermosifiliogr

2014;105:614-7.

Letters to the Editor

6. _BorgiaF, SaittaC, VaccaroM,FranzèMS,Lentini M,Cannavò SP,

et_{al. Nodular-cystic eruption} in courseofsorafenibadministration

for hepatocarcinoma: An unconventional skin reaction requiring

unconventional treatment. Int

J

Immunopathol Pharmacol

2017;30:327-31.

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Indian_{Journal ofDermatology;Venereology}andLeprology| Volume84 | Issue5 | September-October2018 619

Quick ResponseCode: Website:

www.ijdvl.com DOI:

10.4103/ijdv.IJDVL_683_17

La]

How to cite this article: Borgia F, Vaccaro M, Giuffrida R,

Cannavò SP. _{Photodynamic therapy for acne} conglobata of the buttocks: Effective antiinflammatory treatmentwith _{good cosmetic}

outcome.Indian JDermatolVenereol Leprol 2018;84:617-9.

Received:September, 2017.Acceptedì:April,2018.

©2018 Indian Journalof_{Dermatology,Venereologyand Leprology}|Published by