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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: [email protected]
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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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
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
-1 (
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
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
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...
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© 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.
REFERENCES
1. Chernosky ME, Freeman RG. Disseminated superfi cial actinic porokeratosis (DSAP). Arch Dermatol. 1967;96:611–24.
2. Salas T, Hernandez-Gil J, Lopez A, Dorado M, Ruiz J, Garcia E, et al. Two cases of disseminated superfi cial actinic porokeratosis treated with daylight-mediated photodynamic therapy. Dermatol Ther. 2016;29:484-5.
3. Lolis MS, Marmur ES. Treatment of disseminated superfi cial actinic porokeratosis (DSAP) with the Q-switched ruby laser. J Cosmet Laser Ther. 2008;10:124-7.
4. Maubec E, Duvillard P, Margulis A, Bachollet B, Degois G, Avril MF. Common skin cancers in porokeratosis. BrJ Dermatol. 2005;152:1389–91.
5. Skupsky H, Skupsky J, Goldenberg G. Disseminated superfi cial actinic porokeratosis: a treatment review. J Dermatolog Treat. 2012;23:52-6.
6. Zaballos P, Puig S, Malvehy J. Dermoscopy of disseminated superfi cial actinic porokeratosis. Arch of Dermatol. 2004;140:1410.
www.odermatol.com
© Our Dermatol Online 3.2018 248
7. Xia JH, Yang YF, Deng H, Tang BS, Tang DS, He YG, et al. Identification of a locus for disseminated superficial actinic porokeratosis at chromosome 12q23.2-24.1. J Invest Dermatol. 2000;114:1071-4.
8. Aird GA, Sitenga JL, Nguyen AH, Vaudreuil, A, Huerter, CJ. Light and laser treatment modalities for disseminated superfi cial actinic porokeratosis: a systematic review. Lasers Med Sci. 2017;32:945-52.
9. Cavicchini S, Tourlaki A. Successful treatment of disseminated superfi cial actinic porokeratosis with methyl aminolevulinate-photodynamic therapy. J Dermatolog Treat. 2006;17:190-1.
10. Vlachou C, Kanelleas AI, Martin-Clavijo A, Berth-Jones J. Treatment of disseminated superfi cial actinic porokeratosis with topical diclofenac gel: a case series. J Eur Acad Dermatol Venereol. 2008;22:1343-5.
11. Marks S, Varma R, Cantrell W, Chen SC, Gold M, Muellenhoff M, et al. Diclofenac sodium 3% gel as a potential treatment for disseminated superfi cial actinic porokeratosis. J Eur Acad Dermatol Venereol. 2009;23:42-5.
12. Otero-Rivas MM, Rodriguez-Lojo R, Castineiras-Mato IM, Lueiro-Vilarino M, Juarez-Casado Y, Fernandez-Diaz ML. Successful management of disseminated superfi cial actinic porokeratosis with diclofenac sodium 3% gel. Dermatol Ther. 2017;30(3).
13. Arun B, Pearson J, Chalmers R. Disseminated superfi cial actinic porokeratosis treated effectively with topical imiquimod 5% cream. Clin Exp Dermatol. 2011;36:509-11.
14. Riad H, Mansour K, Sada HA, Shaika SA, Ansari HA, Mohannadi HA. Disseminated superfi cial actinic porokeratosis on the face treated with imiquimod 5% cream. Case Rep Dermatol. 2013;5:283-9.
15. Harrison PV, Stollery N. Disseminated superficial actinic porokeratosis responding to calcipotriol. Clin Exp Dermatol. 1994;19:95.
16. Bakardzhiev I, Kavaklieva S, Pehlivanov G.Successful treatment of disseminated superfi cial actinic porokeratosis with calcipotriol. Int J Dermatol. 2012;51:1139-42.
17. Bohm M, Luger TA, Bonsmann G. Disseminated superficial actinic porokeratosis: treatment with topical tacalcitol. J Am Acad Dermatol. 1999;40:479-80.
18. Nakamura Y, Yamaguchi M, Nakamura A, Muto M. Calcipotriol and adapalene therapy for disseminated superfi cial actinic porokeratosis. Indian J Dermatol Venereol Leprol. 2014;80:373-4.
19. Tchernev G, Chokoeva AA, Ivanova B, Mangarov H, Vidolova NG. Disseminated superfi cial actinic porokeratosis (DSAP): signifi cant improvement after local administration of calcipotriol/betamethasone gel?”. Wien Med Wochenschr. 2017;167:85-8.
20. Kariniemi AL, Stubb S, Lassus A. Treatment of disseminated superfi cial actinic porokeratosis with a new aromatic retinoid (Ro 10-9359). Br J Dermatol. 1980;102:213-4.
21. Ludera-Zimoch G, Rubisz-Brzezinska J. [A case of superfi cial
disseminated actinic porokeratosis treated with an aromatic retinoid] Przegl Dermatol.1989;76:54-7.
22. Carmichael AJ, Tan CY. Digitate keratoses--a complication of etretinate used in the treatment of disseminated superfi cial actinic porokeratosis. Clin Exp Dermatol. 1990;15: 370-1.
23. Fernandez-Guarino M, Harto A, Perez-Garcia B, Martin-Gonzalez M, Urrutia S, Jaen P. Photodynamic therapy in disseminated superfi cial actinic porokeratosis. J Eur Acad Dermatol Venereol. 2009;23:176-7.
24. Nayeemuddin FA, Wong M, Yell J, Rhodes LE. Topical photodynamic therapy in disseminated superficial actinic porokeratosis. Clin Exp Dermatol. 2002;27:703-6.
25. Boiy A, de Witte P. A, Roelandts R. Topical treatment of disseminated superfi cial actinic porokeratosis with hypericin-photodynamic therapy: a case report. Photodiagnosis Photodyn Ther. 2012;7:123-5.
26. Itoh M, Nakagawa H. Successful treatment of disseminated superficial actinic porokeratosis with Q-switched ruby laser. J Dermatol. 2007;34:816-20.
27. Liu HT. Treatment of lichen amyloidosis (LA) and disseminated superfi cial porokeratosis (DSP) with frequency-doubled Q-switched Nd: YAG laser. Dermatol Surg. 2000:26:958-62.
28. Rosenblum J. Erbium laser for treatment of disseminated superfi cialactinic porokeratosis. Dermatol Surg. 2013;39:1543-5.
29. Ross NA, Rosenbaum LE, Saedi N, Arndt KA, Dover JS. Disseminated superfi cial actinic porokeratosis improved with fractional 1927-nm laser treatments. J Cosmet Laser Ther. 2016;18:53-5.
30. Chrastil B, Glaich AS, Goldberg LH, Friedman PM. Fractional photothermolysis: a novel treatment for disseminated superfi cial actinic porokeratosis. Arch Dermatol. 2007;143:1450-2.
31. Noborio R, Morita A. Split-face trial of CO2 laser-induced ring abrasion and high-dose tacalcitol in the treatment of disseminated superfi cial actinic porokeratosis. J Dermatol. 2011;39:879–80.
32. Kim HS, Baek JH, Park YM, Kim HO, Lee JY. Photodynamic therapy combined with CO2 laser vaporization on disseminated superfi cial actinic porokeratosis: a report of 2 cases on the face. Ann Dermatol. 2011;23:211–3.
33. Ricci C, Rosset A, Panizzon RG. Bullous and pruritic variant of disseminated superfi cial actinic porokeratosis: successful treatment with Grenz rays. Dermatol. 1999;199:328–31.
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.