Exploring Aesthetic Interventions: Managing Sebaceous Hyperplasia in a Transplant Patient
Sebaceous hyperplasia is a common skin condition that usually presents as umbilicated yellow pink papules on the forehead and cheeks of older individuals. It can also sometimes present in younger individuals, and on the upper trunk, clavicles, neck, areola and vulva.1
Sebaceous hyperplasia is thought to be caused by a decrease in the circulating levels of androgen associated with aging, leading to slowing of sebocyte turnover and crowding of the sebocytes within the sebaceous gland.
Ultraviolet radiation and immunosuppression have also been postulated as co-factors in causing sebaceous hyperplasia, and familial cases have also been reported.2 Microscopically, it presents as large, mature sebaceous lobules grouped around a central dilated duct. The sebocytes are smaller than usual.3
Transplant recipients, particularly those on long-term cyclosporine, are prone to marked sebaceous hyperplasia of the face.4-8 Here, we present a patient with diffuse sebaceous hyperplasia of the face treated with a combination of electrocautery and CO2 laser resurfacing.
Case Report
The patient was referred to our clinic for definitive treatment of sebaceous hyperplasia that had been steadily appearing on his face since his kidney and pancreas transplant in 1996. His medical history was significant for actinic keratoses, squamous cell carcinoma, diabetes mellitus, anemia and hypertension.
His medications included cyclosporine, mycophenolate mofetil, trimethropin/ sulfamethoxazole, aspirin, atorvastatin, prednisone, enalapril, metoprolol, etidronate, itraconazole, ferrous gluconate, Duac gel, vitamin D, multivitamins, calcium and tropicamide ophthalmic drops. He had been previously treated with 0.1% tazarotene cream.
Physical exam revealed multiple 2-mm to 3-mm yellow-pink papules with a central dell over his forehead, temples, cheeks, and nose. The papules were too numerous to count.
Starting in January 2006, he came to our clinic for cosmetic destruction of these lesions with electrocautery.9 Despite some improvement after three sessions of electrocautery, targeting around 15 lesions per session, he continued to have new lesions and persistence of older lesions (Figures 1a, 1b, 1c). At this time, full-face resurfacing was done with CO2 laser. The patient understood all possible risks and side effects of laser resurfacing, as well as possible recurrence of lesions. However, he was quite distraught with the number of lesions on his face and wanted treatment.
On Feb. 12, 2007, the patient underwent combined treatment of electrocautery (Bovie Aaron 900 High Frequency Desiccator, 2.9 W) and full-face CO2 resurfacing with an Ultrapulse CO2 laser (Lumenis) with the 8-mm computer pattern generator scan at settings of 250 to 300 mJ, 60 W power, density of 5 and pattern of 29.10
After post follow-up at 1, 7, and 13 weeks, the patient had fully healed and showed marked improvement and resolution of the lesions of sebaceous hyperplasia (Figures 2a, 2b, 2c).
The patient was very satisfied with the results but also understood the probability of some gradual recurrence and the possibility of needing further treatments.
Discussion
Sebaceous hyperplasia has been reported to occur in 1% of the general population, but is as high as 10% to 29.9% in patients receiving long-term immmunosuppression with cyclosporin A.1-8 Because patients undergoing organ transplants are usually given cyclosporine, they have a higher prevalence of sebaceous hyperplasia than the general population. One recent study also found that renal transplant patients with sebaceous hyperplasia have a higher prevalence of non-melanoma skin cancers (45.7%) versus those without a history of sebaceous hyperplasia (7.3%).8 Another study also showed that dermatologic skin conditions, such as sebaceous hyperplasia dry skin, itch, hypertrichosis, acne, genital warts and herpes simplex 1, had a significant impact on the quality of life of renal transplant patients (p<0.05).7 In addition, visible, infectious and cosmetic skin lesions seemed to have more of an impact on quality of life than a history of skin cancer in this patient population.7
Our particular patient was quite distraught at having so many lesions of sebaceous hyperplasia. To treat these lesions, he was willing to undergo combination treatments with electrocautery9 and to have his face fully resurfaced with the CO2 laser.10 Although he is quite pleased with current results, other treatments may be needed in the future. Treatments that can also be considered for sebaceous hyperplasia include: topical chemical treatments (i.e., trichloroacetic acid), cryotherapy, other laser treatments (i.e., pulsed-dye and argon lasers), shave excision, oral and topical retinoids, and photodynamic therapy.1,2,4-16
Conclusion
In conclusion, here we have presented how a combination of electrocautery and CO2 laser full-face resurfacing can help reduce lesions of sebaceous hyperplasia in a patient on chronic immunosuppression to maintain a renal-pancreas transplant.
