Management of Lymphangioma Circumscriptum via Combined Laser Therapy in Pigmented Skin: A Case Report

Introduction

Lymphangioma circumscriptum (LC) is a rare, benign lymphatic malformation of the reticular dermis, characterized by the presence of superficial cutaneous cysts and representing an uncommon entity within the broader spectrum of vascular anomalies [1–3]. LC may be congenital, arising from developmental anomalies of the lymphatic system, or acquired via lymphatic damage [1]. Clinically, it presents as scattered clusters of translucent, thin-walled vesicles, producing the classic “frog spawn” appearance [4]. Commonly located on the thighs and axillae, this debilitating condition causes chronic swelling, exudation, pain, and frequent secondary infections, all of which substantially affect quality of life [1,5,6].

A wide array of treatment approaches has been reported for this condition, including surgical excision, incision and drainage, injection of sclerosing agents [7,8], electrocautery, cryotherapy, radiofrequency ablation [9,10], and various laser modalities [2,10–14]. Among these methods, surgical excision has been considered the first-line treatment [4,5], offering the potential for definitive management with lower recurrence rates [3]. However, this approach carries risks of infection, nerve damage, and pronounced aesthetic disfigurement, particularly in deeper or complex lesions that often require extensive tissue removal [1,5].

Given that treatment efficacy for LC is frequently dictated by its inherent clinical variability, we present a case detailing the management of extensive LC in an atypical location (medial scapular region) in a young patient with a dark skin type (Fitzpatrick Type V). Considering the specific challenges presented – particularly the high risk of scarring and hyperpigmentation associated with dark skin types [15–18], further exacerbated by the lesion’s atypical site [19,20] – combined laser therapy was selected to optimize penetration depth while minimizing epidermal damage [2,21].

To our knowledge, the simultaneous use of mixed laser technology, specifically combining an ablative CO2 laser with a non-ablative erbium glass (1540 nm) laser, for the treatment of LC has not been documented, particularly in patients with pigmented skin. This mixed approach may offer the benefit of combining the ablative precision of the CO2 laser with the controlled thermal effect of the erbium glass laser, potentially improving efficacy and safety profiles in this challenging patient population [22–24]. The present report aims to highlight the application and immediate outcomes of this combined modality, suggesting its relevance for future clinical practice and research protocols.

Case Report

PATIENT INFORMATION:

A 13-year-old Asian female patient, Fitzpatrick phototype V, presented to our clinic with a 5-month history of multiple reddish and pigmented papules located in the right medial scapular region. The lesion was previously untreated and non-tender; it showed no discharge (Figure 1C). The patient’s medical history was notable for a seizure disorder, managed with levetiracetam 250 mg twice daily for the preceding 7 years. Given this history, a thorough clinical evaluation was conducted. Neurological clearance was obtained prior to proceeding, thus ensuring that no underlying concerns would complicate the diagnosis or subsequent treatment.

After initial assessment, a punch biopsy from the mid-scapular region was performed. Histopathological examination confirmed the diagnosis of LC, characterized by thin-walled, dilated lymphatic channels measuring <1 cm (microcystic) within the dermis (Figure 1A, 1B). Differential diagnoses were systematically excluded. Verruca vulgaris and verrucous nevus were ruled out due to the absence of characteristic epidermal changes. Cutaneous tuberculosis was excluded based on the lack of granulomas or necrosis. Finally, verrucous hemangioma, angiokeratoma circumscriptum, and capillary aneurysm were removed from consideration because the dermal vessels were lymph-filled, rather than blood-filled.

TREATMENT RATIONALE:

After histopathological confirmation, the therapeutic approach was guided by the lesion’s size and location in the medial scapular region, considering the patient’s age and phototype. The identification of microcystic channels (<1 cm) ruled out sclerotherapy, which lacks a targetable cavity for effective injection. Surgery was similarly dismissed due to the high risk of recurrence and hypertrophic scarring in a high-tension anatomic site.

To prioritize the patient’s quality of life and clinical outcome, the primary objective was to minimize the total number of interventions. A combined laser approach (erbium glass and CO2) was selected over single-modality treatments [15,16,19,20]. This technique leverages the dual action of CO2 for precise surface ablation and erbium glass for controlled deep thermal remodeling [21,22,24]. The thermal component is pivotal because it effectively targets deep lymphatic channels that lack specific chromophores. By incorporating a non-ablative element, the total optical energy delivered is modulated, minimizing epidermal trauma and substantially reducing the risk of post-inflammatory pigmentary changes. This synergistic mechanism of action aligns with previous clinical observations in which combinations of different energy modalities were successfully utilized to reach deep lymphatic structures while sparing superficial layers [25].

TREATMENT PROTOCOL:

After histopathological diagnosis and confirmation of clinical suitability, formal informed consent was obtained from the patient’s legal guardian. The patient subsequently underwent laser treatment to manage the cutaneous lesions.

Following local anesthesia induction with 2% lidocaine and 1: 200,000 adrenaline, the lesion was treated using a Youlaser MT system (Quanta System SpA, Samarate, Italy), which combines erbium glass (1540 nm) and CO₂ (10 600 nm) lasers in simultaneous mode. Specifically, the erbium glass laser was set at 4.0 W power, with a 1-millisecond pulse duration and 4 mJ energy. The CO₂ laser was set at 15 W power, with a 0.25-millisecond pulse duration and 3.8 mJ energy. The spot size was fixed at 200 μm, and the Toff parameter was fixed at 6 milliseconds (total energy 7.8 mJ/dot).

The therapeutic strategy followed a response-guided protocol consisting of a single treatment session followed by close clinical monitoring to evaluate the need for further intervention. The patient was monitored over a 2-month period to exclude early recurrence and remains under active clinical surveillance to ensure long-term stability.

Treatment outcomes were qualitatively assessed through clinical and photographic evaluation at multiple time points: before the procedure, immediately after, and at 1-week, 2-week, and 2-month follow-up intervals. Images were captured using an Apple iPad Pro (11-inch), operating on iPadOS version 18.5. Standardized photography conditions, including consistent lighting, distance, and positioning, were maintained across all time points to ensure comparability.

OUTCOME AND CLINICAL OBSERVATIONS:

As shown in Figure 1C, prior to treatment, the patient displayed multiple erythematous and pigmented papules in the right medial scapular region. Immediately following treatment, as illustrated in Figure 2A, a substantial reduction in vesicles was noted, with crusting and mild erythema in the treated areas. The treatment was well tolerated, and the patient reported only moderate pain.

During follow-up, transient erythema and crusting resolved within the first week post-treatment. At 2 months after treatment, near-complete resolution of the lesions was observed (Figure 2D), with appreciable clinical regression and a favorable cosmetic outcome. No post-treatment pain or scarring was noted. Hypopigmentation (Figure 2C) resolved by the final follow-up with adjuvant use of topical tacrolimus (Figure 2D).

POST-TREATMENT CARE:

Following initial treatment, a comprehensive post-treatment care regimen was implemented. This regimen involved the application of Mupimesh ointment – a topical formulation containing 2% mupirocin and chitocol – twice daily for 2 weeks. Application commenced immediately after natural detachment of the scab.

Subsequently, post-inflammatory hypopigmentation developed in the treated area. To address this issue, topical tacrolimus 0.03% was initiated. Consistent application of tacrolimus 0.03% resulted in complete repigmentation of the affected area during subsequent follow-up assessments. This outcome highlights the efficacy of topical tacrolimus in managing post-inflammatory hypopigmentation in the present context (Figure 2D). The patient has been advised to attend follow-up once every 6 months for 2 years.

Discussion

LC presents a therapeutic challenge because of its recurrent nature, as well as its potential functional and aesthetic impacts on patients’ lives. Although various treatment modalities have been utilized with diverse outcomes, the pursuit of an approach that maximizes efficacy while minimizing adverse effects and recurrence remains a priority. Surgery, historically considered the “gold standard,” offers the highest potential for cure but is often complicated by extensive scarring, nerve damage, and aesthetic deformities, particularly in deep or complex lesions [1,5]. Furthermore, recurrences are common even after excision due to partial resection of deep lymphatic cisterns [10,26]. In this challenging context, laser therapy – particularly ablative technology – has emerged as a promising alternative. In a pioneering report, Tsilika and colleagues were the first to document the use of a fractional ablative erbium laser to treat this type of lesion [13]. Although the treatment was successful, the authors suggested that a CO2 laser might have been more effective. Its superior photocoagulative capacity ensures deeper action, offering a safer and more effective approach, particularly for larger lesions [2,27].

The use of CO2 laser monotherapy presents distinct advantages, particularly regarding pain management. The sealing of nerve endings during tissue vaporization results in minimal post-procedural pain relative to surgery. Furthermore, its ability to coagulate vessels and lymphatic channels reduces blood loss and effectively addresses chronic symptoms (eg, burning and pruritus); complete wound closure is achieved within 3 to 6 weeks [2]. However, reliance solely on ablative CO2 laser therapy frequently leads to scarring, textural changes, and pigmentary alterations (eg, post-inflammatory hyperpigmentation). Periodic maintenance sessions are often necessary. Other lasers, such as pulsed dye, are less effective against LC due to their superficial penetration and the lack of a specific optical chromophore in clear lymphatic vesicles [12,28].

To overcome the limitations of single-laser use, synergistic approaches have been explored. In particular, the combination of lasers and radiofrequency – as observed in diode laser plus radiofrequency systems – has demonstrated efficacy because the color-nonselective radiofrequency current efficiently heats transparent lymphatic vessels, addressing the chromophore limitation and optimizing deep heat transfer to the cisterns. Clinical studies have shown “excellent” (75–100%) resolution in approximately two-thirds of patients (phototypes II–IV). However, this approach has been associated with side effects, including transient swelling and pain in all patients, ulceration and scarring in some cases, and the need for up to 3 treatment sessions [25,29].

In this case report, we evaluated the synergistic combination of ablative CO2 (10 600 nm) and non-ablative erbium glass (1540 nm) lasers, complemented by the use of topical tacrolimus in the post-treatment phase to minimize the risk of post-inflammatory hyperpigmentation. To the best of our knowledge, no previous studies have explored the treatment of LC using combined CO2 and erbium glass technology. However, literature concerning other dermatologic applications suggests that this dual-wavelength approach can optimize laser-tissue interaction. Specifically, this system increases dermal tissue coagulation by approximately 40% compared with CO2 alone [22], effectively rebalancing the ablation-to-coagulation ratio [21,24]. By enabling precise control over thermal injury, this synergy promotes faster, less traumatic healing, thus reducing scar formation and preventing post-inflammatory hyperpigmentation [17,18]. Furthermore, the non-ablative 1540 nm component facilitates neocollagenesis, which is essential for effective dermal remodeling, as supported by recent clinical and laboratory studies [22,30].

In the present case, the patient demonstrated appreciable clinical regression and a satisfactory cosmetic outcome at the 2-month follow-up. Although these observations are limited to a single case with a short monitoring period, the patient’s clinical course appears consistent with the literature on dual-wavelength systems. Specifically, the post-procedural phase was characterized by the absence of post-treatment pain or hypertrophic scarring; transient symptoms resolved within 2 weeks. These findings may support the hypothesis that a rebalanced ablation-to-coagulation ratio minimizes tissue trauma and optimizes the inflammatory response, thereby facilitating favorable healing without complications [21,24].

Regarding the potential for recurrence, definitive evaluation remains premature; however, it is notable that no additional sessions have been required within the initial 2-month period. This outcome suggests that the combined laser approach represents a valid therapeutic option for the treatment of superficial or mixed LC, particularly in patients with higher cosmetic risk, such as those with darker phototypes [17,18].

However, it is important to emphasize that these findings represent a preliminary observation derived from a single case with specific clinical characteristics. Therefore, this approach should not be generalized to all LC variants. Although CO2 and erbium lasers are individually documented in the literature, their simultaneous combination for LC treatment remains relatively unexplored and may represent a substantial advancement. Given the recurrent nature of the condition, longer follow-up is required to confirm long-term effectiveness. Furthermore, larger and more diverse cohorts are necessary to validate these preliminary results and more definitively establish the role of this combined modality relative to current surgical and single-wavelength standards.

Conclusions

The combination of CO2 and erbium glass lasers offers a potential non-surgical alternative for superficial or mixed LC. The clinical outcome observed in this case is encouraging, but it is important to acknowledge that this report represents a single-patient experience with a relatively short follow-up period. Consequently, although this combined laser strategy appears to be a novel and potentially valuable approach, definitive conclusions regarding its long-term efficacy, recurrence prevention, and comparative superiority over established treatment modalities cannot yet be drawn. Further studies involving larger patient cohorts and extended follow-up are necessary to validate these preliminary findings and better define the role of this technique in the management of LC, particularly among patients with pigmented skin.