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Erosive pustular dermatosis may occur after facial trauma, cosmetic resurfacing

A recent case series elucidated several clinical factors and treatment options for erosive pustular disorder.

The researchers aimed to further understand what they described as a “rare condition” by assessing three women who experienced prolonged facial erosions after fully ablative carbon dioxide laser procedures or medium-depth chemical peel, according to the findings. The participants were evaluated at a single dermatology clinic at an academic medical center between Sept. 10, 2010, and May 6, 2016. They had experienced non-healing facial erosions after undergoing procedures.

Clinical features, histopathological findings, laboratory results, treatment approaches and final diagnosis information for the three patients all underwent analysis.

Initial considerations for diagnosis for this patient group included infection, immunobullous disorders and other pustular dermatoses. Possibly due to the lack of specificity of histologic features, both topical and systemic therapies, including corticosteroids, dapsone, isotretinoin and/or antibiotics, were used. Results showed that the healing process benefitted from watchful waiting.

Erosive pustular dermatosis should be considered as a diagnosis in patients with non-healing wounds after ablative procedures, according to the researchers. While anti-inflammatory agents should be considered, simply recognizing this dermatosis is important, they concluded.

Omer Ibrahim, MD, Kenneth A. Arndt, MD, and Jeffrey S. Dover, MD, FRCPC, of SkinCare Physicians in Massachusetts, wrote an accompanying editorial.

“In the wake of increasing demand for elective surgical treatments, this case series highlights an important and fortunately rare adverse effect of ablative procedures,” they wrote, and raised several questions, including whether it is under-reported.

“In our own practice, we have seen similar non-healing wounds after aggressive cryotherapy or electrodessication and curettage in the treatment of non-melanoma skin cancers on the face or scalp,” they wrote. “In addition, we have seen in consultation

chronic, erosive facial [erosive pustular dermatosis] several weeks to months after fully ablative laser resurfacing.”

Pustules may not appear on physical examination, while erosions and crust are universally occurring telltale signs, according to Ibrahim and colleagues

“Although the exact pathogenesis of [erosive pustular dermatosis] remains unknown, an aberrant wound healing response in the setting of actinically damaged skin seems to be a consistent theme in its presentation,” they wrote.

Some findings have indicated an association with matrix metalloproteinase 3 (MMP-3) in non-healing lesions, according to Ibrahim and colleagues. “Although a small piece

in the larger complex puzzle of [erosive pustular dermatosis] origin, this clinical finding points toward [erosive pustular dermatosis] as driven at least in part by the skin’s

incapacity to heal itself, whether because of insufficient blood flow, necrosis, or even autoimmunity,” they wrote. “Furthermore, the propensity of [erosive pustular dermatosis], a non-healing wound, to appear in actinically damaged skin should be of no surprise because it has been long known that the normal immune and reparative response to physical and oxidative damage is impaired in UV light–exposed skin.”

Ibrahim and colleagues added that another important histologic feature of this condition is that hair follicles are not destroyed.

“Therefore, when viewing [erosive pustular dermatosis] as a milieu of keratinocytes, macrophages, neutrophils, and lymphocytes gone ‘haywire,’ the repertoire of anti-inflammatory and immunomodulatory treatments that Mervak et al described makes theoretical sense,” they wrote.

Systemic biologic therapies such as infliximab may be useful in this population, as may surgical intervention and photodynamic therapy, they noted.

“Viewing [erosive pustular dermatosis] as a chronic wound that lacks the capability to

heal itself may be beneficial, and a wide array of modalities other than the few reported may apply in treating [erosive pustular dermatosis],” Ibrahim and colleagues concluded. – by Rob Volansky

Disclosures: The authors report no relevant financial disclosures.

The editorialists report no relevant financial disclosures.