Aesth. Plast. Surg.
28:428–430, 2004
DOI: 10.1007/s00266-004-0024-6
Carbon Dioxide Laser Therapy for an Inflammatory Linear Verrucous Epidermal
Nevus: A Case Report
Ersin Ulkur, M.D.,1,2 Bahattin Celikoz, M.D.,1 Fuat Yuksel, M.D.,1 and Huseyin Karagoz, M.D.1
Istanbul, Turkey
Abstract. The treatment of an inflammatory linear verru-
cous epidermal nevus (ILVEN), an uncommon type of
epidermal nevus, is still controversial. The use of laser
therapy is a recently reported method. Although various
results have been reported with the use of the laser in the
treatment epidermal nevis, the authors have not seen any
report on the use of the carbon dioxide laser in ILVEN
treatment. They present case of ILVEN treated with the
carbon dioxide laser. All symptoms (erythema, excoriation,
granulation, and pruritus) disappeared. Instead, a pale
pigmentation was seen.
Key words: Carbon dioxide laser—Epidermal nevus—IL-
VEN
Epidermal nevi are hamartomas that result from ex-
cess production of keratinocytes or skin appendages,
and arise from the pluripotential germinative basal
cell layer. Three other forms of epidermal nevi can be
distinguished: darier-like epidermal nevus, linear
porokeratosis, and inflammatory linear verrucous
epidermal nevus (ILVEN).
Described in 1971 by Altman and Mehregan [3],
ILVEN is a relatively uncommon skin disorder [3]. It
is a benign hyperplasia of the epidermis with an un-
known cause that most commonly involves the lower
extremities [3,19]. Different treatments for ILVEN
have been described, but it still is a matter of dispute.
We present a carbon dioxide laser treatment of a
patient with ILVEN disease.
Correspondence to Ersin Ulkur, M.D., GATA Haydarpasa
Egitim Hastanesi Plastik ve Rekonstruktif, Cerrahi klinigi
ve yanik unitesi, 34668, Istanbul, Uskudar, Turkey; email:
eulkur@yahoo.com
Case Report
A 30-year-old man presented with large, erythema-
tous, scaly, excoriated papules and plaques of ILVEN
on the posterior aspect of his right buttock and thigh
(Fig. 1). The lesions had been present from birth,
slowly growing more exophytic until after puberty.
The man was in good health and had no other
cutaneous, neurologic, ocular, or skeletal abnormal-
ities. The lesions had been treated unsuccessfully with
topical steroids, topical keratolytic agents, and oral
antihistamines to lessen the severe pruritus. A diag-
nosis of ILVEN was confirmed by biopsy of the le-
sion.
A small lesion on the medial side of the right
buttock was treated with a carbon dioxide laser.
When the test area showed significant improvement,
all the lesions were treated. During the procedure,
carbon dioxide laser safety precautions were followed
in the operating room. The treatments were per-
formed with the patient under general anesthesia. The
skin of the ILVEN areas was prepared with povi-
done-iodine topical antiseptic solution and draped in
a routine sterile fashion. The areas were wiped with
saline-soaked gauze and dried with a gauze sponge.
The lesions were ablated evenly by one pass of a
flash-scan carbon dioxide laser (Sharplan 150 XJ
SilkTouch; Sharplan Lasers, Needham, MA, USA)
with an F 260 Hand-piece, 34 W on SilkTouch mode.
Three passes were applied in every session. After each
pass, the treated areas were wiped with saline-soaked
gauze and dried with a gauze sponge. Although a
spot size of 6 mm was used on the edges of the le-
sions, a 9-mm spot size was used on the center. The
laser was set in repeat mode at 0.3 seconds off. The
areas receiving laser treatment were closed with
nonadherent dressing.
At 5 weeks after a single laser treatment, the pa-
tientÕs pruritus had improved significantly, and the
E. Ulkur et al.
Fig. 1. Erythematous, scaly, excoriated papules and pla-
ques on the posterior aspect of the right buttock and thigh.
skin lesions showed partial resolution. Three ses-
sions of carbon dioxide laser treatment were applied
with 6-week intervals. After a third laser treatment,
there was no erythema, no excoriation, and no
granulation. Instead, a pale pigmentation was ob-
served (Fig. 2). In addition, the patient experienced
no further pruritus despite the cessation of his top-
ical and oral antihistamine therapy. There was no
sign of recurrence after 18 months of follow-up
evaluation.
Discussion
Epidermal nevi may be keratinocytic, follicular,
sebaceous, apocrine, or eccrine in origin. The most
common form of epidermal nevis is the verrucous
epidermal nevus, which usually appears sporadically,
presents in early childhood, and occurs as linear
bands along the lines of Blaschko [9]. Inflammatory
linear verrucous epidermal nevus is an uncommon
variant of the verrucous epidermal nevus. Although
the cause and pathogenesis are not known exactly, it
is thought to be associated with upregulation of
429
Fig. 2. After three sessions of carbon dioxide laser treat-
ment, there was no erythema, no excoriation, and no
granulation. Instead, a pale pigmentation was seen. There
was no sign of recurrence during the 18 months follow-up
period.
interleukin 1, interleukin 6, tumor necrosis factor-a,
and intercellular adhesion molecule 1 [20].
The diagnosis of ILVEN is based on clinical pre-
sentation and histology. It is distinguished from the
other clinical subtypes by the intense erythema and
pruritus, which create a psoriasiform or eczematous
appearance. The clinical presentation in the reported
patient fulfills the classic criteria for the diagnosis of
ILVEN established by Altman and Mehregan [3] in
1971, and later modified by Morag and Metzker [14]
in 1985: unilateral, linear verrucous eruption
accompanied by intense pruritus; early age of onset;
and refractoriness to treatment. Microscopic exami-
nation was performed for the reported patient, and
histologic findings of hyperkeratosis, papillomatosis,
and acanthosis, with elongation of the rete ridges,
were consistent with the diagnosis of ILVEN.
The treatment of ILVEN is difficult and often
unsatisfactory. The wide variety of treatment options
shows that managing this disease is challenging. A
review by Fox and Lapins [7] describes various
430
approaches to the treatment of epidermal nevi. These
authors present two types of treatment methods:
surgical and medical management. Although they
found that the surgical methods, excision and deep
dermabrasion, were the most effective at clearing the
lesions, they observed that these approaches resulted
in significant scarring.
Other authors have reported good results with
medical management [5,8,11,16,20], but most medical
approaches are not effective or only partially effec-
tive. Findings have shown that ILVEN is resistant to
most topical steroids with or without occlusion, int-
ralesional steroids, topical tretinoin under occlusion,
podophyllin ointment, 5-fluorouracil cream, and tar
preparations [7].
The use of laser therapy for the treatment of IL-
VEN is a more recently reported method. Various
results have been reported with the use of the laser for
epidermal verrucous nevus treatment [9,10]. Limited
depth of coagulation, which affords protection of the
underlying dermis and a theoretically decreased risk
of scar formation, can be achieved with the argon
laser, but its effectiveness is limited [9]. The use of the
585-nm pulsed dye laser is reported to ameliorate all
symptoms associated with ILVEN, but with only
slight diminution in the size [2]. Experience with the
use of ruby laser also is reported with little benefit [15].
Although some good results with the use of carbon
dioxide laser to treat epidermal nevis are reported
[12,15,17], we are not aware of any report on carbon
dioxide laser use in the treatment of ILVEN disease.
Because the advantages of the carbon dioxide laser in
the removal of superficial skin lesions (exact ablation
with minimal damage to surrounding tissue) are well
established [1,4,6,13], we decided to try carbon
dioxide laser vaporization.
Selection of the laser type for the treatment of such
cutaneous lesions is very important. A subtype of the
epidermal nevus, ILVEN has deeper components.
Use of lasers (e.g., argon laser) with limited depth of
coagulation to decrease the risk of scar formation is
not appropriate for ILVEN treatment. The carbon
dioxide laser imparts high energy to a small area, thus
allowing exact ablation of lesions with minimal
damage to surrounding normal tissue [18]. In the
reported patient, the depth of coagulation with the
carbon dioxide laser was sufficient to improve the
symptoms. However, a pale pigmentation remained
at the location of the ILVEN. Although recurrence is
possible, the symptomatic improvement seen in this
patient continued to be evident 18 months after the
laser treatment.
We suggest that the carbondioxide laser treatment
should be used to manage large ILVEN that cannot
be closed primarily after resection. The effectiveness
of the laser should be tested before it is used to treat
the entire area.
Carbon Dioxide Laser Therapy
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