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Case Report/Case Series |

Dystrophic Calcification and Accentuated Localized Argyria After Fractionated Carbon Dioxide Laser Therapy of Hypertrophic Scars

Amanda R. Shaub, MD1; Patrick J. Brown, MD2; Todd T. Kobayashi, MD2; Michael R. Lewin-Smith, MD3; George P. Lupton, MD3; Chad M. Hivnor, MD2
[+] Author Affiliations
1University of Chicago Medical Center, Chicago, Illinois
2San Antonio Uniformed Services Health Education Consortium, Lackland Air Force Base, San Antonio, Texas
3The Joint Pathology Center, Silver Spring, Maryland
JAMA Dermatol. 2014;150(3):312-316. doi:10.1001/jamadermatol.2013.8044.
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Importance  Fractionated, ultrapulsed carbon dioxide (CO2) laser therapy is a powerful tool for the treatment of scars. Common adverse effects of this therapeutic modality have been previously documented. We describe 2 unreported adverse effects of ultrapulsed CO2 laser treatment of mature scars in a patient previously treated with silver-impregnated dressings.

Observations  A teenage survivor of toxic epidermal necrolysis presented with faint but diffuse dyschromia clinically and histologically consistent with localized argyria secondary to silver-impregnated dressings used years earlier. The patient was subsequently treated with fractionated CO2 for her scarring, but her hyperpigmentation worsened with each treatment. A subsequent biopsy specimen revealed a zone of dystrophic calcification with adjacent pseudo-ochronotic fibers that were not appreciated on biopsy specimens taken before CO2 laser treatment, suggesting unique complications not previously reported.

Conclusions and Relevance  We present 2 unique complications secondary to ultrapulsed, fractionated CO2 laser treatment in a patient previously treated with silver-impregnated dressings: (1) the appearance of pseudo-ochronotic fibers in areas of worsening pigmentation and (2) evidence of dystrophic calcification limited to columns of fractionated laser ablation. Therefore, a history of argyria or treatment with silver-impregnated dressings should be considered before treatment with fractionated CO2 lasers.

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Figure 1.
Left Thigh Treated With Ultrapulsed Carbon Dioxide Laser Therapy

Left thigh before (A) and after (B) sequential treatments with ultrapulsed carbon dioxide laser therapy. B, Note the geometric configuration (short arrow) of hyperpigmentation. This hyperpigmentation may correspond to the square spot size used during deep fractionated laser treatment. The long arrow indicates overall increased hyperpigmentation.

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Figure 2.
Biopsy Specimen From a Sun-Protected Site That Received at Least 2 Ultrapulsed Carbon Dioxide Laser Treatments

A, Note the regular pattern of calcification corresponding with tissue ablated using the deep fractional setting on the laser (arrows) (hematoxylin-eosin, original magnification ×20). B, Pseudo-ochronotic fibers can be seen (arrows) surrounding the calcifications (hematoxylin-eosin, original magnification ×100).

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Figure 3.
Biopsy Specimen From a Sun-Protected Site That Received at Least 2 Ultrapulsed Carbon Dioxide Laser Treatments.

A, Scanning electron micrograph (SEM) of an unstained section mounted on a carbon disk showing white silver-containing calcifications in the superficial dermis (white circle) (original magnification ×270). B, Energy dispersive x-ray analysis (EDXA) from the particle circled in white in panel A, showing the presence of silver (Ag), sulfur (S), calcium (Ca), phosphorus (P), oxygen (O), sodium (Na), and carbon (C). C, An SEM showing white silver-containing granules (white square) associated with the basement membrane of a sweat gland (original magnification ×1000). D, An EDXA from the particle within the white square in panel C, showing the presence of silver (Ag), selenium (Se), and oxygen (O).

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Figure 4.
Biopsy Specimen From a Sun-Protected Site That Received at Least 2 Ultrapulsed Carbon Dioxide Laser Treatments

A, Specimen of sun-protected site (hematoxylin-eosin, original magnification ×40). Arrows indicate pseudo-ochronotic fibers, which are highlighted by darkfield illumination. B, Same field viewed under darkfield illumination, showing accentuation of pseudo-ochronotic fibers (arrows). C, An energy dispersive x-ray analysis map for silver showing short linear deposits compatible with the distribution of pseudo-ochronotic fibers seen in the biopsy specimen from the thigh (original magnification ×3500).

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