Successful Treatment of Disfiguring Hemosiderin-Containing Hyperpigmentation With the Q-Switched 650-nm Wavelength Laser

Report of a Case A63-year-oldwhitewomanpresentedwith a 3-year history of progressive dark facial discoloration. Findings from physical examination included prominent brown patches coveringmuch of her face (Figure, A) andyellow-orangeplaquesonherbreasts. The facial pigmentation also had a slight yellow tint. The result from a biopsy performed in 2009 had been interpreted as plane xanthoma. The patient was found to have an IgG λ monoclonalgammopathyandwas laterdiagnosedashavingchronic lymphocytic leukemia not requiring treatment. Selected areas had been treatedwith the pulsed-dye laser (595 nm) and 3-millisecond alexandrite laser (755 nm) without benefit. We performed a skin biopsy of the cheek, which revealed a dermal histiocytic infiltrate with scattered xanthomatous cells, Toutongiantcells,andperivascular lymphocytic inflammation.Aniron stainwaspositivewithin someof thehistiocytes andgiant cells, consistentwithhemosiderin, and thepresenceofdermalmelanophages wasconfirmedbyaFontana-Massonstain.Thebreast lesionsshowed similarchanges,withpalisadinggranulomaswithcentralnecrosis,cholesterol clefts, andscatteredextravasatederythrocytes.The findings werecompatiblewithadiagnosisofnecrobioticxanthogranuloma.The darkpigmentationseenclinically appeared tobecausedby thecombination of hemosiderin andmelanin. The patient sought treatment for the disfiguring intense pigmented patches that covered most of her face, which severely affected her quality of life. She is an astronomer and could not examine telescopesbecauseher thickmakeup transferred to their lenses. The patient stopped swimming laps at the local pool because she worriedthatchildrenwould findherappearance frightening,andshe experienced a great deal of social discomfort.