Surgical Care
Therapeutic intervention for Becker nevus primarily is for cosmetic reasons. Patients present with complaints related to hypertrichosis and/or hyperpigmentation.
Q-switched ruby laser (694 nm) has been used with variable success in the treatment of both the hypertrichosis and hyperpigmentation of Becker nevus. [9, 10, 11] Histopathologic analysis of lesional skin after laser treatment showed selective damage of superficially located melanocytes but a persistence of adnexal melanocytes. Remaining pigment cells may account for the transient improvement noted clinically.
A prospective study [12] demonstrated the superiority of an Er:YAG laser (n= 11) over a Q-switched Nd:YAG system (n = 11) in the treatment of Becker nevus. Evaluation 2 years after treatment showed that 54% of subjects treated with the Er:YAG laser showed complete clinical clearance, while a clearance of greater than 50% occurred in 100% of the subjects. By comparison, none of the patients who received 3 treatments with the Nd:YAG laser system cleared completely and only one person had marked improvement. Supporting evidence for the role of the 2940-nm Er:Yag laser in the treatment of Becker nevus comes from a small case series from Saudi Arabia. [13] Using this device, seven patients completed a single split-lesion treatment with follow-up to a year. All patients experienced some decrease in pigmentation in the range of 25-75%. Although the authors reported no hyperpigmentation or repigmentation, images from the paper show persisting depigmentation in the test areas performed prior to the full intervention in several of the subjects. [13]
A long-pulsed 755-nm alexandrite laser was evaluated in 11 Korean patients with Becker nevus. [14] Two patients had excellent responses, 5 had good responses, and 4 had fair responses. Hair density simultaneously decreased with treatment in all patients. Fifteen patients with Becker nevus underwent 8 sessions of hair removal with low-fluence, high-repetition-rate diode lasers (808-810 nm). [15] All participants experienced significant hair reduction at 6 and 12 months, with no adverse events reported.
Eleven adult patients with Becker nevus were included in a prospective, randomized, controlled, observer-blinded, split-lesion trial. In each patient, 2 similar square test regions were randomized to either ablative factional laser therapy at 10 mJ/microbeam, coverage 35-45%, and topical bleaching (to reduce laser-induced postinflammatory hyperpigmentation), or topical bleaching alone. Treatment was moderately effective in some patients. However, postinflammatory hyperpigmentation and relatively negative patient-reported outcomes still preclude ablative fractional laser therapy from being a standard therapy. [16] These results have been observed by this author, and the concern of both postinflammatory hyperpigmentation and hypopigmentation should be discussed with the patient prior to treatment.
In 2016, three patients with Becker nevus (two hypertrichotic) were treated using a combination approach with a 1550-nm Er-doped nonablative fractional laser and a long-pulsed 1064-nm Nd:YAG laser in a sequential manner over time. [17] Although these individuals had a clinical improvement of greater than 75%, follow up was limited (3-18 mo). Patients should be advised that over time (months to several years), pigment may recur at the treated site (author's personal observations).
In sum, laser treatment of Becker nevus yields variable results and further studies are needed to determine the best way to reduce the appearance of these lesions without causing postlaser dyschromia or scarring. [18]
Also see the Medscape article Laser Treatment of Benign Pigmented Lesions.
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Becker nevus of chest wall with associated hypertrichosis. Courtesy of Jason K. Rivers, MD.
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Becker nevus demonstrating smooth muscle bundles in the dermis. Courtesy of Jason K. Rivers, MD.
