Dermatosis papulosis nigra: treatment options

Journal of Drugs in Dermatology, Jan, 2007 by Mary P. Lupo

Abstract

Dermatosis papulosis nigra (DPN) is a very prevalent skin condition among certain ethnic groups, especially African-Americans and Afro-Caribbeans. The histology is not significantly different from that of seborrheic keratosis. DPN does not pose any health dangers, but patients often seek removal due to aesthetic concerns since it occurs commonly on the face. When performing any elective procedure, it is important that great care is taken to prevent complications so as to not merely exchange one defect for another such as a scar or discoloration. This article will outline options for management of this common cosmetic problem.

Introduction

Dermatosis papulosis nigra (DPN) presents as flat to raised, sometimes pedunculated pigmented lesions on the face, neck, and chest of African-Americans and other ethnic groups with darker skin tones. The texture is usually smooth. Due to the inherent protective melanin in their skin, these ethnic groups do not typically present with cosmetic complaints of wrinkling and elastosis caused by ultraviolet damage. DPN, however, is a source of great consternation for these groups. The increase in the number of these lesions with age, the preponderance of them on the face, and patients' fears that they are "turning into their mothers," prompts many of them to seek removal of these benign growths. Since removal is elective, it is important not to give the patient a new defect such as a scar or discoloration.

Histology and Clinical Presentation

The histology of DPN is similar to seborrheic keratosis. In one study, the incidence in black patients was found to be 77%, with a 2:1 predominance in females. (1) The size of the lesions can vary, but typically range from 1 to 5 mm (Figure 1). There is typically a family history of these growths, and the number of lesions usually increases with age. This prompts patients to seek correction since the increasing number and irregular pigment in the face make them look older.

Treatment Options

Since these lesions are histologically and biologically benign, any treatment is elective and considered medically unnecessary. Lesions can be lightly desiccated with low settings and if pedunculated, can easily be removed with a sharp, fine scissors. Bleeding can be a problem, especially if multiple lesions are excised or the patient is on aspirin therapy. Using lidocaine with epinephrine when performing excision with scissors reduces discomfort and bleeding, but increases the time for the procedure. Cryosurgery, with its high incidence of pigment change, should be avoided. The use of the Iridex 532 diode laser has been by far the fastest, most effective, and safe treatment used in my practice since 1997.

The patient is placed in the laser room and informed consent is obtained. The areas to be treated are cleansed and all traces of make-up removed. The patient is placed in a supine position and protective goggles are worn. The fiberoptic hand piece with its small spot size is ideal for delivering laser energy in a precise manner. I use the 700-mn handpiece set at 12 J/[cm.sup.2], 3 watts, and a 6-Hz repetition rate. This results in a pulse duration of 15 msec. No topical anesthetic or gel has been found to be necessary. Other physicians have used 8 J/[cm.sup.2], 3 watts, and a 4-Hz repetition rate along with a chilled gel for anesthesia. (2) A distinct "popping" sound is usually audible signaling the destruction of the lesion by the absorption of the laser energy in the pigmented cells. The lesion then appears ashen in color leaving the texture dry and rough. Repeat treatments and additional sessions are scheduled at 3-week intervals.

Posttreatment Care and Management of Complications

Results using the Iridex 532-diode laser give excellent results (Figures 2-3). Posttreatment the patient is advised to cleanse the area with a gentle cleanser such as Cetaphil or CeraVe, and to avoid face cloths and all abrasive cleansers until the crust comes off. This typically occurs in 3 to 7 days. Picking at treated areas must be avoided, and the use of sunscreens is advised. In almost 10 years of use, I have seen no postinflammatory hypo- or hyperpigmentation using this laser. The use of hydroquinone or retinoids for such complications would be recommended, should they occur. The effectiveness of these agents for postinflammatory hyperpigmentation has been well-documented. (3) Hypopigmentation is poorly managed, but usually spontaneously resolves after several months.

Summary

DPN is a common condition seen in darker skin types. The condition is benign, but patients often seek removal of lesions in order to have a more even color and texture to their skin. The use of a 532-diode laser has proven to be a safe and effective option for the elective treatment of these lesions.

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References

1. Grimes PE, Arora S, Minus HR, Kenney JA. Dermatosis papulosis nigra. Cutis. 1983;32:385-392.

2. Spoor TC. Treatment of dermatosis papulosis nigra with the 532 diode laser. Cosmet Derm. 2001;14:21-23;2001.