Porokeratosis Treatment & Management

Updated: Sep 24, 2018
  • Author: Amarateedha Prak LeCourt, MD; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

The approach to treatment must be individualized, based on the size of the lesion and the anatomical location, the functional and aesthetic considerations, the risk of malignancy, and the patient's preference. Protection from the sun, use of emollients, and watchful observation for signs of malignant degeneration may be all that is needed for many patients. If lesions are widespread and medical treatment is desired, several medications have potential benefit.

Topical 5-fluorouracil

Topical 5-fluorouracil can induce remission in all forms of porokeratosis. [69, 70] Treatment must be continued until a brisk inflammatory reaction is obtained. Enhancement of penetration, which heightens the response, may be achieved by occlusion or the addition of topical tretinoin, tazarotene, or salicylic acid. [71] Recurrences may be seen.

Topical vitamin D-3 analogues

Both calcipotriol and tacalcitol have been shown to be effective after 3-6 months of treatment of disseminated superficial actinic porokeratosis (DSAP). [72, 73, 74]

Immunomodulators

Topical imiquimod cream has been shown to be effective for treating classic porokeratosis of Mibelli (PM). [75, 76]

Ingenol mebutate has shown efficacy in the treatment of PM. [77]

Calcineurin inhibitors

Tacrolimus (0.1%) was shown to be effective for treating linear porokeratosis. A single case report showed complete resolution of associated pain, pruritus, and paresthesias, as well as cosmetic improvement. [78]

Topical retinoids

Topically applied retinoids (tretinoin, tazarotene) may be beneficial for improving the abnormality in keratinization that causes cornoid lamellation, thereby reducing the hyperkeratosis of the edge of the lesions. It is also thought to improve the percutaneous absorption of other topically applied medications, rendering them somewhat more effective.

Diclofenac gel

Diclofenac gel 3% (Solaraze), may be effective for DSAP. [79]

Oral retinoids

The use of oral retinoids (isotretinoin, etretinate, and acitretin) in patients who are immunosuppressed, who are at higher risk for malignant degeneration, may reduce the risk of carcinoma in porokeratotic lesions.

Oral isotretinoin at 20 mg daily combined with topical 5-fluorouracil is reported to be effective for DSAP and porokeratosis palmaris et plantaris disseminata (PPPD), but it causes burning, itching, and painful erosions.

Prior to the removal of etretinate from the US market, conflicting reports of etretinate efficacy were published. Reports of etretinate efficacy are conflicting. Etretinate at doses of 75 mg/d for 1 week followed by 50 mg/d was shown to be helpful in linear porokeratosis and symptomatic PM. Higher doses of 1 mg/kg/d were reported to exacerbate lesions of DSAP after 4-6 weeks of treatment. [80] Even when etretinate therapy is successful, relapses may occur. Digitate keratoses were reported to develop after the use of etretinate for DSAP. [81]

Acitretin, a second-generation monoaromatic retinoid that is the active metabolite of etretinate, is likely to have results similar to those of etretinate. A case of systematized linear porokeratosis with good response to acitretin has been reported. [82, 83]

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Surgical Care

Surgical treatment is essential for porokeratosis lesions that have undergone malignant transformation. No studies showing the value of prophylactic nonexcisional surgical treatment in reducing the incidence of malignancy within porokeratosis have been reported. Surgical modalities other than excision may improve cosmesis and/or function but are frequently followed by relapses.

Excision is most appropriate when malignant degeneration develops.

Cryotherapy is helpful for porokeratosis lesions with minimally raised cornoid lamellae, such as disseminated superficial actinic porokeratosis (DSAP) and porokeratosis palmaris et plantaris disseminata (PPPD). It is a minimally invasive method of inducing resolution for large numbers of lesions.

Electrodesiccation and curettage can be used to treat small lesions or when cryosurgery is ineffective.

Diamond fraise dermabrasion has been used with conflicting reports of efficacy. It was effective in improving the appearance of linear porokeratosis in one patient, but a child with a large porokeratosis of Mibelli (PM) lesion had recurrence after treatment. [84]

Various types of laser therapy have been used. A rapid recurrence reportedly followed carbon dioxide laser ablation. The 585 nm flashlamp-pumped pulsed dye laser was shown to help one patient with linear porokeratosis. Another patient with PM with an underlying hemangioma had good improvement of the hemangioma but no change in the porokeratosis after treatment. The frequency-doubled Nd:YAG laser was shown to be helpful for one patient with disseminated superficial porokeratosis (DSP). Two cases of disseminated superficial actinic porokeratosis were successfully treated with the 1927-nm thulium fiber fractional laser. [85] The Q-switched ruby laser has been reported to be effective in the treatment of DSAP and PM. Benefits of laser therapy include convenience and safety, with nearly no downtime or morbidity associated with pigment or textural changes. [85, 86, 87]

Ultrasonic surgical aspiration was shown to be effective in the treatment of vulvar porokeratosis in one patient.

Photodynamic therapy with methyl aminolevulinate has been reported to be successful for DSAP and linear porokeratosis. [88]

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Long-Term Monitoring

Regularly monitoring patients for the development of malignant transformation is essential, especially in the setting of immunosuppression. Squamous cell or basal cell carcinomas can be aggressive in patients who are immunosuppressed.

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