Milaria apocrine and laser

Fox Fordyce disease – an adverse effect of laser hair removal?

Diana Ayala MSC Epidemiology, Resident Aesthetic Medicine University of Rosario

A possible causal relationship between laser/IPL hair removal and Fox Fordyce disease has been reported ^1 – 7 . Although the ages of onset of the disease and the usual consultation for laser hair removal coincide for most cases, we summarize 9 of the 11 existing reports relating laser and Fox Fordyce disease.

There is no known increase in the incidence of the disease despite the millions of laser hair removals that have been performed over the past 20 years, but the cases presented have a relationship of close and late temporality.

Reported cases

11 cases have been reported, the latest one published in Colombia about a 26-year-old patient with a history of 6 sessions of IPL hair removal ¹ 6 months before presenting symptoms only in the armpits and not in the pubis, where she was also treated. A series of 5 cases published in 2016 ² had an interval of onset of symptoms ranging from 2 months to 4 years after hair removal treatments with IPL, diode lasers and Alexandrite. In this series, one case presented symptoms after 5 years of IPL only in the armpits. Another case, 42 years of age, was similar to the one presented in Colombia, after 4 sessions of hair removal in the armpits and groin, 6 months after sessions with the Alexandrite laser. Another case presented with exposure to unknown equipment 4 years before the symptoms appeared, a following case presented only in the groin 2 months after 3 sessions with diode laser, the last case, a 38-year-old patient received treatment with an unknown laser and the symptoms appeared 3 months after the last session. Only two cases were confirmed with biopsy. The authors concluded that despite the temporal relationship, a causal relationship could not be established with the cases presented since none had photographs prior to the laser. There is another case outside this study, 29 years old who developed symptoms one month after 3 sessions with 810 diode laser hair removal only in the armpits despite joint treatment in the groin ³ . A final and more dramatic case occurred in a 27-year-old woman who developed symptoms three months after 2 sessions with 810 diode laser in the three treated areas: armpits, groin and periumbilical region with diagnosis confirmed by pathology tests, but like all the previous ones, without pre-laser photos ⁴ .

The evidence

When reviewing the existing literature regarding this possible association between Fox Fordyce Disease and hair removal with light devices, case reports are found, which from the point of view of evidence-based medicine, are the studies with the lowest level of evidence to establish causality ⁸ .

In order to establish a causal link between hair removal with light devices and the occurrence of miliaria apocrine, it is necessary to carry out observational studies (cohort) with a statistically significant population sample, which include a control group and in which a long-term follow-up of the subjects is carried out before, during and after the hair removal treatment. In this way, it could be stated with greater statistical certainty whether Fox Fordyce disease can be an adverse effect of hair removal with laser or intense pulsed light.

Other limitations of case reports include the absence of a control group, which means that statistical inferences cannot be made or null hypotheses tested. Furthermore, they do not have a population sample from which results can be extrapolated to the general or study population. Likewise, due to their design, these types of publications may be subject to selection and publication bias, as well as the presentation of incomplete clinical histories that do not have accurate data or adequate photographic records.

For these reasons, it is necessary to understand that case reports are descriptive studies that allow for formulating research questions and describing the clinical characteristics of patients with rare diseases, but they do not allow for affirming or proving any type of causality.

The concept of causality

In order to call a certain factor a “cause”, it must increase the probability of occurrence (incidence) of a disease ⁹ . However, in epidemiological terms, establishing a causal relationship is not so easy since it is not unidirectional and there may be other associated factors. Therefore, in the statistical analysis of a study, it is necessary to take into account biases, associations and confounding variables in order to establish causal links accurately.

Fox Fordyce Disease

Apocrine miliaria, also known as Fox Fordyce disease, is a rare disease that mainly affects postpubertal women between the ages of 13 and 35 ¹⁰ . Although its etiopathogenesis is poorly understood, it has been described as an obstructive disorder of the apocrine gland duct, caused by the presence of a keratin plug in the follicular wall. This causes an accumulation of glandular secretion with subsequent rupture of the duct and leakage of the contents into the underlying dermis, generating a secondary inflammatory state ^11 , 12 .

Clinically, it presents as very pruritic normochromic or yellow perifollicular papules that appear in areas with a high concentration of apocrine glands such as the axillae, pubic region, inguinal region, perineum, labia majora, areolas, and the periumbilical region ³ . Although its etiology is unknown, a possible relationship with estrogen concentration has been described, since the itching improves with the menstrual cycle, pregnancy, and the use of oral contraceptives ^13 – 15 . However, a specific hormonal alteration has not been identified ^13 – 15 .

Pathological examination is mandatory because it can be simulated by other entities such as syringomas, lichen amyloid, lichen nitidus, contact dermatitis or infectious folliculitis ¹¹ .

Image taken from: Hanner S., Schneiderbauer R., Enk A. et al. Axilläre und perimamilläre Fox-Fordyce-Erkrankung (apokrine Miliaria) bei einer 19-jährigen Patientin · Der Hautarzt (2018-04-01) 69: 313-315.

Photos

Image taken from: Hanner S., Schneiderbauer R., Enk A. et al.  Axilläre  und  perimamilläre Fox – Fordyce – Erkrankung  ( apokrine Miliaria ) bei einer  19 – jährigen Patientin  · Der  Hautarzt  ( 2018 -04-01)  69 :  313 -315.

Image taken from: Kao PH, Hsu CK, Lee JY. Clinicopathological study of FoxFordyce disease. J Dermatol 2009; 36:485–90. doi: 10.1111/ j.1346-8138.2009.00689.x.

Literature

1. Fox-Fordyce disease after laser therapy: radiofrequency, a treatment option. Rev Asoc Colomb Dermatol. 2018; 26 : 1 (January – March), 36-39.
2. Sammour R, Nasser S, Debahy N, El Habr C. Fox-Fordyce disease: An under-diagnosed adverse event of laser hair removal? J Eur Acad Dermatol Venereol. 2016; 30(9): 1578-82.
3. Bernad I, Gil P, Lera JM, Giménez-de Azcárate A, Irarrazával I, Idoate MA. Fox-Fordyce disease as a secondary effect of laser hair removal. J Cosmet Laser Ther. 2014;16:141-3.
4. Helou J, Maatouk I, Moutran R, Obeid G. Fox-Fordyce-like disease following laser hair removal appearing on all treated areas. Lasers Med Sci. 2013;28:1205-7.
5. Tetzlaff MT, Evans K, DeHoratius DM, Weiss R, Cotsarelis G, Elenitsas R. Fox-Fordyce disease following axillary laser hair removal. Arch Dermatol. 2011;147:573-6.
6. Alés-Fernández M, Ortega-Martínez de Victoria L, García-Fernández de Villalta MJ. Lesions in the armpit after hair removal using intense pulsed light. Fox-Fordyce disease. Actas Dermosifiliogr. 2015;106:61-2.
7. Yazganoğlu KD, Yazici S, Büyükbabani N, Ozkaya E. Axillary Fox-Fordyce-like disease induced by laser hair removal therapy. J Am Acad Dermatol. 2012;67:e139-40.
8. Hassan Murad M, Asi N, Alsawas M, Alahdab F. New evidence pyramid. Evidence-Based Medicine. 2016 Jun 23. Available from, DOI: 10.1136/ebmed-2016-110401
9. Kamangar F, Causality in Epidemiology. Arch Iran Med. 2012 Oct;15(10):641-7
10. Hanner S., Schneiderbauer R., Enk A. et al.  Axilläre und  perimamilläre Fox – Fordyce – Erkrankung  ( apokrine Miliaria ) bei einer  19 – jährigen Patientin Der  Hautarzt  ( 2018 -04-01)  69 :  313 -315.
11. Kao PH, Hsu CK, Lee JY. Clinicopathological study of FoxFordyce disease. J Dermatol 2009; 36:485–90. doi: 10.1111/ j.1346-8138.2009.00689.x.
12. Apoeccrine sweat duct obstruction as a cause for Fox-Fordyce disease. J Am Acad Dermatol 2003;48:453-5.
13. Kronthal HL, Pomeranz JR, Sitomer G. Fox-Fordyce disease: treatment with an oral contraceptive. Arch Dermatol 1965; 91: 243–245.
14. Cornbleet T. Pregnancy and apocrine gland diseases: hidradenitis, Fox-Fordyce disease. AMA Arch Derm Syphilol 1952; 65:12–19.
15. Turner TW. Hormonal levels in Fox-Fordyce disease. Br J Dermatol 1976; 94: 317–318.