Eruptive Keratoacanthomas After Jessners and Trichloroacetic Acid Peel for Actinic Keratosis

Abstract

The authors have indicated no significant interest with commercial supporters. K eratoacanthomas, characterized as a subtype of squamous cell carcinoma (SCC) or a separate benign lesion, remain a management quandary in terms of how to treat these lesions. In our patient, the appropriate therapy was no treatment. Jessner's and trichloroacetic acid (TCA) peel is a medium-depth chemical peel used on facial and nonfacial skin for treatment of actinic keratoses, photoaging, pigment dyschromias, and melasma. Side effects or complications of TCA peel include erythema, peeling, hyperpigmentation, herpes simplex virus type 1 reactivation, scarring, and keratoacanthomas. Trauma to the skin caused by chemical peels, thermal burns, fractional photothermolysis, and cryotherapy, have all been reported to cause keratoacanthomas. 1-4 Here we present a case of eruptive keratoacanthomas after Jessner's and TCA peel for actinic keratoses that resolved spontaneously. Case ReportA 62-year-old Caucasian man, who was a previous smoker with a history of SCC of the tongue, had undergone chemotherapy and radiation and been cancer free for longer than 5 years. He was well known to our dermatology service for treatment of cutaneous nonmelanoma skin cancers. He had a strong history of sun exposure but no current immunosuppression. He had undergone multiple treatments with cryotherapy and topical 5-fluorouracil but continued to exhibit extensive actinic damage. Because of the recalcitrant nature of his actinic keratoses, we proceeded with a Jessner's and TCA peel to his dorsal arms and hands. The areas were degreased with acetone using a 4 by 4-in gauze. A thin layer of Jessner's was applied, followed by two layers of TCA 35% so that a level 2 frost was achieved. Cool saline-soaked gauze was applied to the treated areas for comfort, followed by petrolatum ointment.Two weeks after treatment, the patient returned to clinic with areas of erosion and exuberant granulation of the dorsal wrists and erythema in the remaining treatment area. He reported that the healing process was somewhat painful, and he had been applying petrolatum jelly to the entire treated area twice daily, as instructed.Two weeks later, he returned with verrucous nearly confluent plaques and crusted papules on his dorsal arms and hands ( Figure 1A). Three lesions were biopsied and were found to be consistent with *All the authors are affiliated with the Division

Eruptive keratoacanthomatous atypical squamous proliferations (KASPs) arising in skin graft sites

“… 3 Eruptive KAs within sites of diffuse trauma caused by fractional photothermolysis, medium-depth chemical peels, tattoos, and photodynamic therapy with microdermabrasion have been reported suggesting a role of pathergy triggering these neoplasms. 4 , 5 , 6 , 7 , 8 Pathergy has also been described as a precipitant of KAs in the Grzybowski subtype. It is unclear to what degree pathergy may have triggered atypical squamous proliferation development in our patient or if trauma may have caused chronic inflammation that promoted the growth of these neoplasms within vulnerable sites in an already predisposed individual.…”