Porokeratoses

Management Strategy

Given the familial disposition of porokeratosis, a thorough family history needs to be retrieved. The patient’s immune function needs to be assessed, particularly with disseminated forms. Discontinuation of immunosuppression has led to resolution of lesions in some patients.

Treatment of porokeratoses may be indicated not only for cosmetic benefit and symptomatic relief, but also to prevent malignant transformation. Thus, treatment is dependent on the type and extent of porokeratosis and malignancy potential. Management should always include counseling avoidance of irradiation (ultraviolet or X-rays) and surveillance for signs of malignant transformation (squamous cell carcinoma, basal cell carcinoma, Bowen disease), particularly in immunocompromised patients.

Porokeratotic lesions are usually asymptomatic and may go unnoticed until presenting with symptoms, including pain and pruritus. Palmoplantar porokeratosis may cause functional disability due to pain and discomfort from mechanical stress on the lesions. Symptomatic relief can be achieved with topical corticosteroids , topical retinoids , and topical diclofenac . Pruritus associated with disseminated lesions is often responsive to topical corticosteroids.

Localized porokeratoses can be responsive to ‘surgical’ methods such as cryotherapy , laser , curettage and cautery , or excision , but these can leave patients with significant scarring and recurrence is common, especially when numerous porokeratoses are present. Topical 5-fluorouracil , imiquimod , and vitamin D analogs are helpful, but response rates are partial in DSAP. 5-Fluorouracil and imiquimod can induce marked inflammatory reactions, which are necessary for efficacious response. Thus, it might be more efficacious to use these modalities under occlusion, treating one area at a time.

Systemic retinoids have been effective in localized and extensive porokeratoses, but there have been reports of exacerbation in preexisting lesions. Recurrence is common on discontinuation of therapy, and a long-term maintenance dose may be required. This might also reduce the potential for malignant transformation.

Few reports on the use of topical ingenol mebutate show a great response for both PM and DSAP. Topical diclofenac does provide some pruritus relief in DSAP and genital porokeratosis, but only partial improvement has been observed with limited benefit. A recent report on the use of topical cholesterol/lovastatin for DSAP may prove to be promising if the results are found to be consistent. There are also reports on the effectiveness of topical retinoids , dermabrasion , ultrasonic surgical aspiration , radiofrequency surgery , various lasers, and intense pulse light (IPL ), cantharidin , corticosteroids , tacrolimus , and topical photodynamic therapy . Treatments in combination have included CO ₂ laser and photodynamic therapy , 5-fluorouracil and imiquimod , and calcipotriol with adapalene .