Approach Considerations
Therapeutic modalities that have been suggested include topical and systemic medications, phototherapy, electrodessication, dermabrasion, cryosurgery, and lasers. However, evidence from randomized, controlled trials is lacking, and effictiveness is based on small studies and case reports. No standardized treatment has been established. [5] With the growing appreciation of the importance of pruritus as the primary trigger for the deposition of amyloid, treatment modalities are often directed toward the relief of pruritus.
Medical Care
Sedating antihistamines have been found to be moderately effective. Topical dimethyl sulfoxide (DMSO), a chemical solvent, and intralesional steroids are beneficial if combined with other modalities. DMSO has been used with moderate success, but failures have also been reported. [18, 19, 20] Pandhi et al and Lim et al reported a lack of effect with DMSO treatment for cutaneous amyloidosis. [21, 22]
Treatment with ultraviolet B (UV-B) light can provide symptomatic relief. [23] Yusek et al reported improvement with transcutaneous electrical nerve stimulation. [24] Terao et al evaluated the effects of topical tocoretinate on lichen amyloidosis and macular amyloidosis lesions. The outcome was very good for 4, good for 2, moderate for 2, and poor for 2 of 10 treated patients. [25]
Surgical Care
Aggressive strategies proposed for the removal of amyloid include laser vaporization, dermabrasion, and excision of individual lesions. However, lesions and pruritus usually promptly recur after these treatments. Electrodessication and curettage provided an acceptable result in one report. [26]
In a prospective, side-by-side, controlled, clinical trial study, Ostovari et al used the Q-switched Nd:YAG laser (532 nm and 1064 nm) in 20 patients with a clinical diagnosis and pathology confirmation of macular amyloidosis. Using colorimetric score assessment and digital photographs before laser therapy and 8 weeks after treatment, they concluded that the 2 lasers are effective in reducing the degree of macular amyloidosis pigmentation, with the 532-nm laser being more effective than the 1064-nm laser. [27] In another study, ND:YAG laser (1064 nm) treatment repeated monthly for 7 months successfully reduced hyperpigmentation in a woman with recalcitrant macular amyloidosis. However, Triluma (fluocoinolone actetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) prescribed for maintenance to prevent recurrence caused a reaction followed by recurrence of the original lesion. [28]
Significant improvements were observed in 16 patients treated treated by fractional CO2 using either superficial ablation or deep rejuvenation. Both modes were effective in reducing pigmentation, thickness, itching, and amyloid deposits However, superficial ablation offered a greater reduction of pigmentation with significantly reduced pain. [29]
A case report of pulse dyed laser (PDL) treatment in a 57-year-old man with recalcitrant macular amyloidosis who was treated with 3 sessions of PDL at 2-week intervals showed improvement after each treatment, with decreased amyloid aggregation and skin hyperpigmentation. This resulted from a decrease in collagen and dermatan sulfate synthesis similar to the mechanism behind the reduction of the size of hypertrophic scars. [30]
-
Reddish brown patch on the back characteristic of macular amyloidosis. Courtesy of Hon Pak, MD, and reviewed by Ross Levy, MD.
-
Another patient with macular amyloidosis on the back. Courtesy of Hon Pak, MD, and reviewed by Ross Levy, MD.
-
Reticulated pattern of pigmentation on the shoulder of a patient with macular amyloidosis. Courtesy of Hon Pak, MD, and reviewed by Ross Levy, MD.
-
Close-up of the above patient's eruption. Courtesy of Hon Pak, MD, and reviewed by Ross Levy, MD.
