Photobiomodulation, Photomedicine, and Laser Surgery

Volume XX, Number XX, 2020 Case Reports

ª Mary Ann Liebert, Inc.
Pp. 1–4
DOI: 10.1089/photob.2020.4812

Long-Term Follow-Up for Q-Switched

Nd:YAG Treatment of Nevus of Ota:
Are High Number of Treatments Really Required?
A Case Report
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Ester Del Duca, MD,1,2 Tizianno Zingoni, MS,1 Luigi Bennardo, MD,2 Cosimo Di Raimondo, MD,1
Virginia Garofalo, MD,1 Mario Sannino, MD,1 Nerella Petrini, MD,3 Giovanni Cannarozzo, MD,1
Luca Bianchi, MD,1 and Steven Paul Nisticò, MD1,2

Abstract

Objective: Q-switched laser is considered a gold standard treatment for Nevus of Ota (NO). We report how few
laser sessions in long intervals of time may achieve satisfying outcomes reducing the rate of possible procedure-
linked side effects such as burning, cornea injuries, or hyperpigmentation.
Background: NO represents a congenital dermal melanocytosis in the trigeminal distribution majorly occurring
in Asian individuals. Multiple reports have shown efficacy and safety of Q-switched laser for the treatment of
this condition, but they were based on an empiric regimen, often leading to unnecessary overtreatments. At the
best of our knowledge, no long-term follow-up observations of single laser sessions have been conducted to
assess the proper intervals and number of treatments.
Materials and Methods: A 36-year-old Asian woman, Fitzpatrick skin type IV with clinical diagnosis of NO,
was treated with 1064 nm 6 ns Q-switched laser one session per year for a total of two sessions. Clinical result
was valued by two physicians independently using standardized and polarized light. No use of general anes-
thesia or sedation was needed in our experience. Corneal shields have been used.
Results: After only two sessions of the Q-switched laser performed 1 year apart, the result was excellent with a
95% of clinical response. No side effect was observed.
Conclusions: In our experience, Q-switched Nd:YAG laser is an effective treatment for NO with no necessity
of high number of treatments. A larger population is needed to confirm this preliminary result.

Keywords: Q-switched, Nd:YAG, Nevus of Ota, laser therapy, blue lesion

Introduction experience psychosocial distress.4 Thus, a gold standard

treatment for this high-impact condition is strongly pursued.

N evus of Ota (NO), along with nevus of Ito, blue nevus,

and Mongolian spot, is considered a congenital dermal
melanosis, even though it can also occur later in life.1 This
benign lesion is characterized by dermal melanocytosis and
its clinical presentation is characterized by a blue–black or
light brown hyperpigmented macules or patch in a trigeminal
distribution.2 It has been estimated to occur in about 0.035%
of Asian individuals,3 although it also appears in other pop-
ulation.4 Females are more often affected, prevalence 5:1.5
Because of is high cosmetic impact, individuals with NO may
In the past decade, safety and efficacy of Q-switched
Nd:YAG laser have been widely demonstrated in many
different conditions such as melasma,6 tattoo removal,7 hair
removal,8 skin rejuvenation,9 and onychomycosis.10 Based
on the principles of selective photothermolysis, NO can be
treated successfully using the Q-switched lasers sources and
the Q-switched Nd:YAG laser is still considered one of the
best choice for dealing with dermal and mixed epidermal–
dermal pigmented lesions.11 Nevertheless, the effectiveness
of this treatment widely fluctuates according to different

1
Laser Unit, Department of Dermatology, University of Rome Tor Vergata, Rome, Italy.
2
Department of Dermatology, University Magna Graecia of Catanzaro, Catanzaro, Italy.
3
Department of Dermatology, University of Florence, Florence, Italy.

1
 2 DEL DUCA ET AL.
Table 1. Patient’s Demographic Characteristic
Gender Female
Age 36
Ethnicity Asian
Type of lesion Nevus of Ota with neither meningeal
nor tympanic, ocular, oral mucosa
involvement
Comorbidity None
Assessment Nd:YAG laser.
Spot size 4 · 4 m
Fluence 4 J/cm2
Wavelength 1064 nm
Side effects None
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parameters such as interval between sessions and number of
sessions that are not standardized yet.12 Moreover, despite
the progress in the development of newer technologies the
high rate of relapses and side effects such as burning,
scarring, or postinflammatory hyperpigmentation suggest
the necessity of further study to better sew protocols less
prone to procedural risk of side effects for the patient.13 This
case report aims to create a proof of concept for further
studies on new schemes of treatment for the management of
pigmented lesions with Q-switched laser. We report how
few laser sessions in long intervals of time achieve satisfying
outcomes reducing the rate of possible procedure-linked side
effects such as burning, cornea injuries, or hyperpigmentation.
Materials and Methods
We used the 1064 nm Nd:YAG nanosecond laser
(SynchroQS4—DEKA M.E.L.A. Srl, Florence, Italy) to
treat an Asian woman, Fitzpatrick skin type IV, demo-
graphic details are listed in Table 1. Before enrolling the
patient information from patient’s medical record was col-
lected, including magnetic resonance imaging (MRI) to rule
out meningeal or ocular involvement.
The following parameters were applied: spot size 4 · 4 m,
fluence 4 J/cm2, and wavelength 1064 nm. No sedation or
local anesthesia was needed. Before and after each session
the patient was visited and photographed with a professional
dermatological camera with and without polarized light
(Anthology—DEKA M.E.L.A., Florence, Italy). Treatment
was then performed with short pauses, to allow patient to
rest. Clinical outcomes were evaluated using pre- and post-
treatment comparisons of photographs and at the follow-up
visit. Multi-spectral three-dimensional (3D) image analysis
(Antera 3D) was used to assess the improvement in melanin
pigment in the skin.
Each photo was evaluated by two independent physicians.
Assessment was done using a visual analog scale (VAS)
consisting of five levels of treatment response according to
percentage of pigmentary lightening: none (Grade 0; 0%
improvement), poor (Grade 1; 1–25% improvement), fair
(Grade 2; 26–50% improvement), good (Grade 3, 51–75%
improvement), and excellent (Grade 4, 76–100% improve-
ment; Fig. 1). Pain-VAS was used to assess patient’s treat-
ment experience. Laser parameters, side effects, and adverse
events were recorded in patient diary and summarized in
Table 1.
Results
We treated an Asian woman, Fitzpatrick skin type IV
with no meningeal or tympanic, ocular, oral mucosa in-
volvement was detected by MRI. At a 20-month follow-up,
after two laser sessions performed 1 year apart, an excellent
result was assessed by both dermatologists, VAS 94% and
96%, respectively, mean value of improvement 95%. Multi-
spectral analysis performed by Antera 3D showed an ap-
preciable reduction of melanin. No side effects were no-
ticed, no post-treatment pigmentation at the 20-month
follow-up visit (Fig. 2). No relapse of the NO was observed.
Pain-VAS was assessed after each treatment and a value of 3
was measured. After each session erythematous suffusion
was observed, without blistering, bleeding, or crusting. The
bruise-like reaction lasted *14 days followed by complete
resolution. A cold bandage was applied after each session
for 20 min and a B12-based barrier cream was prescribed twice
a day for 10 days.14 No long-term side effect was observed
(such as the formation of scars or hypo-/hyperpigmentation).
Discussion
Q-switched Nd:YAG laser specifically target melano-
somes in melanocytes, keratinocytes, and melanophages; its
ultrashort pulse width and adjustable spot size are key fac-
tors that allow effective targeting of dermal pigment.15 The
laser intervals allow the pigment removal by the macro-
phages and this is a gradual process of clearing that may
take over several months.16 Currently the interval between
treatment sessions is operator based. In the recent literature
we found different protocols setup usually going from
monthly based to every 6-month sessions with fluences
varying from 0.4 to 7 J/cm2.17–19 The majority of the trials
used a 2- or 3-month laser session interval, reporting quite a
few adverse events such as transient hyperpigmentation,
swelling, burning sensation, thin dry crust formation, min-
imal bleeding, and purpura after the treatment.20 On the base
of recent studies on macrophagic dynamic activity,21 we set
up a protocol of one session every 12 months until satisfying
outcomes that were achieved after only two sessions and a
4 J/cm2 fluence. In fact, according to histopathological
studies, treatment interval may be more important than the
number of treatments in lightening the pigmentation.16 An
excessive number of sessions and reduced intervals between
sessions can, therefore, increase the risk of side effects that
alter the final result especially in patients with dark skin
type.22 In our case we did not experience any adverse event
on the skin. This was potentially because of the absence
FIG. 1. Visual analog scale
 LOW NUMBER OF LASER SESSIONS TO TREAT NEVUS OF OTA
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FIG. 2. Pre- and post-treatment images of Nevus of Ota
treated with Q-switched Nd:YAG laser. (A, D) Pre- and
post-treatment clinical pictures taken in normal and polar-
ized light at baseline. (B, E) Clinical pictures taken in
normal and polarized light at 12-month follow-up; (C, F)
clinical pictures taken in normal and polarized light at
20-month follow-up, after the second and last laser session.
(G–I) 3D multi-spectral images for detection of melanin at
baseline (left), 12-month follow-up (center), and 20-month
follow-up (right). 3D, three-dimensional.
of overtreatment of delicate areas such as periocular skin.
The range of side effects that may be experienced using a
Q-switched Nd:YAG laser may vary from persistent red-
ness, to blistering, scarring due to burning and postin-
flammatory dyschromia.22
Conclusions
Treatment of NO could spare psychological and social
distress.23 Nevertheless, there is resistance to treat hypo-
dermal melanosis especially in the periocular region. It is
likely due to fear of complications, recurrences, and side
effects such as scars or hypopigmentation, which are more
likely observed in darker skin tone and potentially more
impactful in children and young woman. For this reason,
minimizing the number of sessions avoiding higher risk of
side effects is a high ranked priority in the standardization of
NO treatment.
Because of the side effects of repetitive laser stimuli on
the skin it is vital to find newer effective treatment less
aggressive than what currently available in medicine. Our
report suggests that Q-switched laser treatment performed
once a year may show the same efficacy of the more used
3-month interval protocol possibly reducing the rate of side
effects linked to laser procedures. It may represent a proof
of concept for further investigation on the proper timing of
laser sessions for the treatment of dermal hyperpigmenta-
3
tion. We acknowledge our case is limited by the number of
patients and further studies need to take in consideration
different ethnicities and nevi locations. Our reports may
warrant larger cohort studies to assess the efficacy and
higher safety of long-interval laser sessions of Q-switched
laser for the treatment of NO compared with the current
clinical practice.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.
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Address correspondence to:
Ester Del Duca, MD
Laser Unit
Department of Dermatology
University of Rome ‘‘Tor Vergata’’
Viale Oxford, 81
Rome 00133
Italy
E-mail: ester.delduca@gmail.com
Received: January 16, 2020.
Accepted after revision: March 3, 2020.
Published online: August 4, 2020.