Ciclosporin is an immunosuppressive drug that has been associated with several secondary skin alterations. These include hair follicle changes (hypertrichosis, keratosis pilaris, acne, and folliculitis) and gingival hyperplasia.1 However, very few cases of eruptive multiple sebaceous hyperplasia (MSH) secondary to ciclosporin have been reported. Among the possible therapies for MSH, treatment with CO2 ablative laser and pulsed dye laser (PDL) has been described on only a few occasions. We describe 2 cases treated with PDL, which has the advantage of offering excellent results with a better safety profile and greater patient comfort.

A 41-year-old man with skin phototype IV had started immunosuppressive therapy with ciclosporin at a dose of 140 mg/d after undergoing liver transplant. A few months later he presented with a rash consisting of dozens of yellowish umbilicated papular lesions that were clinically and histologically compatible with MSH and remained unchanged months later though the dose of ciclosporin was halved. The lesions were mainly located on the forehead, cheeks, chin, and upper back (Figure 1). He received 3 sessions of PDL treatment (Cynergy Multiplex, Cynosure, Inc., Westford, MA) with a beam diameter of 5 mm, a pulse duration of 2 ms, and a fluence of 15 J/cm2. On the larger lesions 2 passes were made with a 1-minute interval between pulses. Continuous airflow cooling (Cryo5 Zimmer Medizinsysteme GmbH, Neu-Ulm, Germany) was applied at maximum level. A complete response was obtained in more than 75% of the lesions and a partial response in the rest. No crusting, blistering, or secondary pigmentary changes developed. The patient only presented minimal atrophic scarring. We found no recurrence of the treated lesions at the 6-month follow-up despite continuing treatment with ciclosporin at a dose of 75 mg/d (Figure 2).

Figure 1.

Patient 1, showing facial multiple sebaceous hyperplasia secondary to maintenance immunosuppressive therapy using ciclosporin.

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Figure 2.

Patient 1 after treatment with pulsed dye laser. He continued with the immunosuppressive therapy.

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The second case was a 41-year-old man with skin phototype II-III treated with immunosuppressive therapy using ciclosporin at a dose of 150 mg/d after kidney transplantation, who had lesions similar in appearance and distribution to those of the previous case. A diagnosis of MSH was made, and he received treatment with PDL in 2 sessions, using identical parameters to those of the previous case. The response was very good, with total disappearance of more than 75% of the lesions and no associated adverse effects. The remission persisted 4 months after treatment.

MSH is a benign proliferation of the sebaceous glands that in most cases is idiopathic and affects the elderly. However, it has been observed in patients treated with systemic corticosteroids, on hemodialysis, and in conditions such as Torre syndrome, X-linked hypohidrotic ectodermal dysplasia syndrome, and pachydermoperiostosis. In some cases reported in the literature, the authors suggest a possible association with ciclosporin.2 Although the lesions are benign, they may have major cosmetic and psychological effects on the patients because they are located mainly in the facial region. It is therefore very important to eradicate them. The treatment options traditionally used include surgical excision, curettage, cryotherapy, cautery, and CO2 laser, all of which are aggressive and involve a high risk of scarring and pigmentary changes. Photodynamic therapy using PDL, intense pulsed light, and red or blue light-emitting diodes has also been used recently with good results.2,3 The advantage of these procedures is that they avoid post-treatment purpura; the disadvantages are greater pain and higher cost, and possibly the need for a greater number of sessions to obtain results.2 PDL has recently been described in the successful treatment of sebaceous hyperplasia and of other multiple and benign skin lesions, such as xanthelasma, angiofibromas, and molluscum contagiosum.4–6 PDL eliminates MSH quickly, easily, and painlessly (without anesthesia) and only involves a transient purpuric effect. It therefore avoids the risks of the traditional techniques described above. Most lesions disappear after a single treatment. The effect of PDL could be explained by its selective action on the telangiectatic component of the lesion, leading to destruction of the vessels that nourish the sebaceous hyperplasia. This treatment was recently described with in vivo confocal microscopy imaging before and after treatment with PDL, showing that a few minutes after application of the beam the vessels surrounding the sebaceous duct were replaced by amorphous and coagulated material.7

In conclusion, PDL is a fast, painless, well-tolerated, and safe therapeutic option for the treatment of MSH.