Laser, light therapy useful in combating signs of sun exposure on chest, neck

July 1, 2010

Photoaging of the neck and chest is a common concern among patients. One of the most frequent clinical presentations is poikiloderma of Civatte (PC). First described by French dermatologist Achille Civatte in 1923, it is characterized by brown to pink patches of superficial atrophy, telangiectasia and mottled hyper- and hypopigmentation.

Key Points

Photoaging of the neck and chest is a common concern among patients. One of the most frequent clinical presentations is poikiloderma of Civatte (PC). First described by French dermatologist Achille Civatte in 1923, it is characterized by brown to pink patches of superficial atrophy, telangiectasia and mottled hyper- and hypopigmentation.

A histopathological study of 50 patients with PC offers insight into its etiopathogenesis. Investigators found that all samples exhibited solar elastosis, and more than 90 percent showed dilated blood vessels and melanophages laden with melanin in the papillary dermis, as well as atrophy of the epidermis (Katoulis, et al. Br J Dermatol. 2002;147(3):493-497). These three targets of photoaging of the chest and neck are important to take into account when choosing the appropriate treatment modality for patients.

Treatment options

Chemical peels and topical retinoids can improve the texture and appearance of mild to moderate PC. However, these treatments may require lengthy application with little to no improvement in the vascular component.

Intense pulsed light (IPL) is also an attractive option for the management of PC, as its endogenous chromophores include both hemoglobin and melanin. In 2008, Rusciani et al reported that of 175 patients with PC treated with IPL, 80 percent experienced improvement in the vascular and pigmented components with only transient side effects (Rusciani, et al. Dermatol Surg. 2008;34(3):314-319). They concluded that IPL is a safe and effective device for PC management, but advised that experience is required to select among the multiple treatment parameters to obtain optimal results.

As the skin in the neck and chest area is much thinner and lacks the sebaceous glands density present on the face, treatments with any laser or light device in this area should be done at less aggressive settings. These "lighter" settings include lower fluences and longer pulse widths than those traditionally used on the face.

In many cases, the chest will have confluent photodamage. In these circumstances, we use an IPL with a longer wavelength cutoff (590 nm instead of 560 nm) to avoid the striping sometimes seen with initial treatments of severely tanned or photodamaged areas.

Fractional resurfacing

A relatively new option for PC patients is fractional laser resurfacing. Nonablative fractional photothermolysis (NAFP) for PC was first reported in a 2006 case by Behroozan et al where a single treatment with a 1,550 nm device resulted in clinical improvement in erythema and dyschromia with no adverse events at two-month follow-up (Behroozan, et al. Dermatol Surg. 2006;32(2):298-301). Though the wavelengths used in NAFP do not directly target hemoglobin, improvements in abnormal vasculature are seen in PC, striae and scars.

Additionally, patients may note a clinical improvement in the textural changes of photoaging of the chest, even without the presence of PC. It is important to note that dramatic tightening of the neck is not seen with the nonablative devices. Lower-density treatments, as used in all off-face locations, should be used in the chest and neck areas.

A recent report by Tierney and Hanke found that in addition to the aforementioned benefits of NAFP, one to three treatments with an ablative fractional CO2 laser (10,600 nm) offered a majority of their 10 patients improvement in skin texture and a reduction in laxity (Tierney, et al. J Drugs Dermatol. 2009;8(6):527). At the University of Miami, an ablative YSGG device (2,790 nm) was used on the chest in 10 patients in a low-fluence double-pass method for photoaging. There were no long-term complications demonstrated in any of the patients treated (poster presentation at the 2010 annual meeting of the American Society for Lasers in Medicine and Surgery).

However, ablative fractional resurfacing of the neck and upper chest is not without risk of complication. In 2009, Fife et al reviewed four patients who experienced complications with ablative fractional photothermolysis. Two developed fibrotic bands overlying the platysma and scarring of the neck area (Fife, et al. Lasers Surg Med. 2009;41(3):179-184). The authors hypothesize that the laser may have penetrated the thin epidermis and dermis of the neck, thereby affecting the underlying musculature. They recommend using extra caution in the delicate upper chest/neck area by utilizing low energy and density.

The use of laser and light devices for the treatment of photoaging of the neck and chest, including poikiloderma of Civatte, is both safe and effective. Choices depend on the type of photoaging present, with vascular lesions targeted best by the PDL and IPL devices. Pigmentary abnormalities respond well to both IPL and the nonablative fractional devices, whereas textural changes are more amenable to treatment with the nonablative fractional devices.

Fractional ablative resurfacing of the neck and chest can bring dramatic clinical results, including skin tightening, but it must be done with caution. Consideration of the depth of the skin and relative lack of subcutaneous fat in this area is important in order to avoid scarring.

As laser and light source technologies continue to rapidly evolve, physicians and their patients will have more effective therapeutic options for addressing photoaging of the neck and chest.

Joely Kaufman, M.D., is assistant professor of clinical dermatology at the University of Miami Miller School of Medicine and director of lasers for the University of Miami Cosmetic Group.

Jeremy B. Green, M.D., is the chief resident in the department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine.

Lisa Grunebaum, M.D., is an assistant professor of otolaryngology/facial plastic and reconstructive surgery at the University of Miami Miller School of Medicine.