Cryosurgery and hair transplantation to epidermal verrucous naevus

HC Hanumanthiah

 Skin Care Clinic, No.99, 3rd Main, KEB Lay Out BTM 1st Stage, Bangalore - 560 076, Karnataka, India

Correspondence Address:
H C Hanumanthiah
Skin Care Clinic, No.99, 3rd Main, KEB Lay Out BTM 1st Stage, Bangalore - 560 076, Karnataka
India

Introduction

Epidermal verrucous naevus is a type of keratinocyte hamartoma present at birth or occurring later in life. It is seen at any site but is less common on the head and neck. Epidermal verrucous naevus is seen as vertical, linear or S-shaped and does not normally cross midline. In the case under discussion, it resembled the hood of a cobra, and was located over the right side of the scalp. The various treatment modalities are excision and grafting, cryotherapy, and electrofulguration. Cryotherapy followed by hair transplantation was planned due to patient acceptance and location.

Case Report

A 35-year-old man presented with a cobra hood - shaped asymptomatic verrucous lesion over the right side of the scalp, above and in front of the right ear of 15 years duration. Clinically it was diagnosed as epidermal verrucous naevus. Patient was advised to go for cryosurgery followed by hair transplantation. After all the investigations, including blood VDRI and HIV tests consent of the patient was taken. The naevus was first treated with cryotherapy using liquid nitrogen gay painbrush spray technique, once in two weeks The entire lesion was regressed after five such sittings. Subsequently the patient was posted for hair transplantation using mini punches. [Figure - 1], [Figure - 2]

Pre operatively nature of the procedure, likely complications, total duration, approximate sitings required or expected result were explained in his own language. Broad spectrum antibiotic was started one day prior to the procedure along with injection and xylocaine test dose. On the day of procedure patient was advised to take head bath with shampoo after trimming the hairs at donor site to length of 2mm. [Figure - 3], [Figure - 4]

Procedure

After surgical preparation of donor area i.e., (occiput) with iodine and spirit, 1 % xylocaine with adrenaline was injected. This was followed by injection of normal saline intradermally and subcutaneously to cause edema of scalp tissue. Punch grafts of size 4.5 mm were taken by using manual punch in horizontal rows, where the hairs have been trimmed at 2-3 mm apart, parallel to direction of hair shafts. So taken grafts were stored in kidney tray over gauze soaked in normal saline. Bleeding was controlled with pressure, followed by dressing with double layered sofratulle.

Hairline was marked on recipient area after surgical preparation. Recipient chambers were made by using 4 mm manual punch at a distance of 3-4 mm following anaesthetisation by injecting 1% xylocaine with adrenaline. The trimmed donor grafts were then placed into the recipient chambers using a jeweler′s forceps, so that the graft′s level was adjacent to the surrounding skin level and their short clipped hairs pointing in the direction of the surrounding hairs. After maintaining hemostasis securing graft dressing was done with double-layered sofratulle. Patient was advised to continue antibiotic and antiinflammatory drugs for 7 days. Dressing was removed on the tenth day. Patient was asked to lightly shampoo the scalp followed by daily application of 2% minoxidil. The cosmetic end-result was good at fourth month, and it is now planned to go for second sitting of hair transplantation.

Discussion

Definitive therapy for epidermal verrucous naevus is surgical excision and grafting. The main aim of treatment is for cosmetic purpose. Surgical excision and grafting is likely to be difficult due to its location. In view of maximum cosmetic benefit, convenience, economy and safety, cryotherapy was used to treat verrucous lesion followed by hair transplantation to bald area.