Chapter 12: Poikiloderma of Civatte

INTRODUCTION

Poikiloderma of Civatte (POC) is a condition that is attributable to chronic sun exposure of the neck and the chest. The severity of findings is dependent on the duration and intensity of sun exposure, constitutive skin color (Fitzpatrick skin type), and the capacity to tan.

EPIDEMIOLOGY

Incidence: common

Age: most frequently observed in persons older than 40 years

Sex: slight female predominance

Race: most common in fair-skinned individuals (skin phototypes I and II); rarely seen in darker-skinned individuals (skin phototypes IV–VI)

Precipitating factors: chronic sun exposure including intentional sun exposure since youth and occupational exposure; trauma; chronological aging

PATHOGENESIS

Ultraviolet B (UVB) is the most damaging UV radiation, with high dose ultraviolet A (UVA) contributing to the noted changes. In addition, visible and infrared radiations have been shown to augment the action of UVB.

PHYSICAL EXAMINATION

Telangiectases, mild atrophy, reticulated hyperpigmentation, and hypopigmentation affecting the lateral and posterior aspect of the neck, anterior chest, and jawline. Submental neck is spared. Perifollicular sparing noted (Figs. 12.1 and 12.2).

DERMATOPATHOLOGY

Epidermal acanthosis with flattening of the dermal–epidermal junction. Focal increase in epidermal basal cell melanocytes; irregular basal cell hyperpigmentation. Dermal collagen breakdown with formation of amorphous masses and increase in glycosaminoglycans. Telangiectasia noted.

DIFFERENTIAL DIAGNOSIS

Rothmund–Thomson syndrome; radiation dermatitis; Kindler syndrome; Bloom’s syndrome; Ataxiatelangiectasia.

COURSE

Chronic progressive course with continued sun exposure.

KEY CONSULTATIVE QUESTIONS

• Past and current sun exposure history

• Occupation

• Hobbies/sporting activities

• Underlying medical conditions

• H/o radiation therapy

• Past treatments and response

MANAGEMENT

Prevention: strict sun avoidance.

TREATMENT

• Topical therapy: daily sunscreen application with UVB/UVA coverage.

• Laser therapy: great caution must be followed with any laser treatment administered to minimize the risk of scar formation, dyspigmentation, “finger-printing” or treatment skip areas, and textural changes. The neck is particularly prone to scarring given fewer pilosebaceous units. A test site is recommended. Multiple sessions are generally required.

  Laser fluences should be lowered by approximately 25% to 30% of facial parameters to avoid adverse effects.

  • – Pulsed dye ...