Is “hybrid laser” a breakthrough in treating atrophoderma vermiculatum?

INTRODUCTION

Atrophoderma vermiculatum (AV) is a rare, slowly progressive, benign follicular disorder primarily affecting children and adolescents.¹ It manifests as erythematous, follicular papules that eventually evolve into atrophic scars with a characteristic reticular or honeycomb pattern.^1,2 AV typically affects the cheeks, preauricular regions, and temples,^1,3 and may rarely extend to the limbs. The etiology is unclear, but genetic and environmental factors likely contribute to its development. Although it is a benign disorder, AV can significantly impair a patient’s quality of life due to its cosmetic impact that reflects on social and psychological aspects. Treatment is often aimed at improving the appearance of scars, with therapies ranging from topical treatments to advanced laser modalities. Here, we report a case of successful treatment of AV using a hybrid laser.

CASE REPORT

A 13-year-old female, Fitzpatrick skin type IV, presented with multiple asymptomatic, irregularly shaped, depressed patches on her left cheek, which had been present for the past 10 years. The lesions were stable in size and appearance, with no recent changes. There was a history of a tiny red rash over the same region for 3–6 months before the onset of lesions. There was no history of trauma, viral exanthems, or induration before the onset of lesions. She had received intermittent treatment with topical retinoids, but there was no significant improvement. The patient’s medical history included mild atopic dermatitis, which required minimal treatment. There was no family history of similar conditions.

The patient was conscious of the scars, which were causing psychological distress. On physical examination, multiple well-demarcated, oval, round, or irregularly shaped skin-colored, honeycomb-like atrophic scars were observed on the left cheek, measuring 1–2 mm in diameter and 0.5–1 mm in depth. The lesions were uninflamed, with minimal hyperpigmentation in some areas [Figure 1]. There was no involvement of the scalp, eyebrows, or eyelashes. Differential diagnoses considered were morphea, traumatic scarring, and atrophia maculosa varioliformis cutis, all of which were ruled out due to the absence of prior induration, trauma, and the presence of tiny eruptions before the development of scars.

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Figure 1:

A 13-year-old female with atrophoderma vermiculatum presented with multiple, asymptomatic, well demarcated, irregularly shaped depressed patches resembling a honey-comb pattern, on her left cheek.

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A biopsy was never performed due to parental preference, considering her young age and cosmetic concerns. The diagnosis was made on a characteristic clinical presentation, including grouped, pitted, atrophic scars with a reticulated pattern predominantly over the cheeks. The routine laboratory tests were normal. Given the patient’s dissatisfaction with the cosmetic appearance of her scars and their stability for a long time, laser therapy was offered.

The patient underwent four sessions using the hybrid laser at 1-month intervals at the Celestee Skin, Laser, and Hair Clinic, Hyderabad, India. Photographs of the affected area were taken under standard and constant light settings, before each session. A eutectic mixture of local anesthesia was applied to the target area for 40 min to ensure the patient’s comfort. The target area was then cleansed with a betadine solution before laser treatment. The hybrid laser system was used with the ProScan Hybrid applicator (Alma Laser Ltd., Israel), which combines both ablative carbon dioxide (CO₂) (10600 nm) laser and non-ablative (1570 nm) laser in a sequential side-by-side pattern. The CO₂ laser was set to a power of 18 Watts, with 1-ms pulse duration, reflecting the energy of 18 mJ delivered per pulse, while the 1570 nm laser was set to a power of 8 Watts with a 3-ms pulse duration, reflecting the energy of 24 mJ per pulse. The lasers were delivered in a grid mode over the affected areas of the left cheek. Post-procedure, the patient was instructed to apply an antibiotic cream twice daily for 3 days and use sun protection with sun protection factor (SPF) 30+ in as possible between sessions.

Immediately after each treatment, mild erythema and edema were noted, with no bleeding or significant complications. By the end of the fourth session, there was a marked reduction in the depth and prominence of the atrophic scars [Figure 2]. The patient and parents were highly satisfied with the cosmetic outcome, and no adverse events were reported during the follow-up period.

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Figure 2:

A 13-year-old female showing visible improvement in terms of depth of atrophic scars after four sessions of hybrid laser treatment.

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DISCUSSION

AV is a rare follicular disorder that typically begins in childhood or adolescence. It was first described by Winer⁴ and later elaborated by Martens⁵ and Arndt.⁶ It is characterized by keratotic follicular papules that progress onto reticular, atrophic scars. The condition primarily affects the cheeks, preauricular regions, and temples, though rare cases have been observed on the limbs. AV is considered a variant of keratosis pilaris atrophicans (KPAs) and can be differentiated from other follicular disorders, such as KPAs faciei and keratosis pilaris spinulosa decalvans, by its characteristic clinical and histopathological features.

The pathogenesis of AV remains poorly understood, but several factors are thought to contribute. Genetic factors, including autosomal dominant inheritance in some cases, may predispose individuals to AV. Environmental factors such as mechanical trauma or ultraviolet radiation may also play a role in triggering the condition. Autoimmune mechanisms have been suggested but are not substantiated.

Diagnosis of AV is primarily clinical, with characteristic erythematous follicular papules that eventually evolve into the hallmark honeycomb or worm-eaten atrophic scars. Dermoscopy may reveal bizarre and polymorphic perifollicular scarring, sometimes with a pink or red background.⁷ Histological examination typically shows superficial dermal atrophy with a vermiculate pattern of epidermal changes. The dermis exhibits subtle fibrosis with no signs of inflammation or granuloma formation.⁷

The differential diagnosis includes atrophia maculosa varioliformis cutis (AMVC), morphea, acne scars, and discoid lupus erythematosus. In AMVC, scarring occurs without prior inflammation, while morphea presents with more indurated, sclerotic early lesions. Acne scars tend to follow active acne lesions and exhibit varied scar morphology. Discoid lupus erythematosus is associated with erythema, scaling, and follicular plugging, and its histology shows basal layer damage, which is absent in AV.

Management of AV is primarily cosmetic, as the condition does not have a known causative therapy. Conservative treatments such as topical steroids, retinoids, and systemic therapies have been mentioned in medical literature, yet with limited efficacy. More aggressive treatments, including cryotherapy, dermabrasion, and laser therapy, are employed for cosmetic improvement. Among these, laser therapy has shown the most promise, particularly fractional lasers.

Previously, combining ablative and non-ablative lasers has shown impressive results in treating various skin conditions. However, these studies involved using separate devices.⁸ Recent advances have combined both ablative and non-ablative technologies in a single hybrid device, which allows clinicians to effectively treat a wide range of indications, taking advantage of the benefits of both lasers.⁹ These utilize the complementary mechanisms of both lasers, stimulating collagen remodeling and skin rejuvenation while minimizing damage to surrounding tissues. The CO₂ laser provides surface ablation and remodeling, while the 1570 nm laser penetrates deeper into the dermis, promoting collagen production and increasing dermal thickness.

The hybrid approach has been shown to offer enhanced results with fewer complications compared to using ablative lasers alone.¹⁰ The usage of two wavelengths in a sequential pattern allows for effective treatment of deeper dermal structures while minimizing surface damage. The hybrid lasers in a fractional mode create microscopic thermal zones that stimulate collagen production while preserving surrounding healthy tissue, leading to minimal downtime and faster recovery.

CONCLUSION

AV is a rare, benign condition characterized by atrophic, honeycomb-like scars that primarily affect the cheeks and preauricular regions. Diagnosis is clinical, with histopathology playing a role in distinguishing AV from other skin conditions. Treatment is largely cosmetic, with laser therapy offering significant improvement. In this case, hybrid laser therapy combining CO₂ and 1570 nm diode lasers resulted in a marked reduction in scar depth and prominence, with a favorable risk–benefit profile. There were previous case reports on the treatment of AV with ablative fractional laser systems. This case report is the first of its kind and underscores the efficacy of hybrid fractional laser systems in managing AV and improving cosmetic outcomes.