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      Tools & Reference>Dermatology

      Porokeratosis Treatment & Management

      Updated: Dec 19, 2024
      • Author: Amarateedha Prak LeCourt, MD; Chief Editor: William D James, MD  more...
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      Treatment

      Approach Considerations

      The approach to treatment must be individualized on the basis of the following factors:

      • Size and anatomic location of the lesion
      • Functional and aesthetic considerations
      • Risk of malignancy
      • Patient preference

      For many patients, protection from the sun, use of emollients, and watchful observation for signs of malignant degeneration may be all that is needed. If lesions are widespread and medical treatment is desired, several medications have potential benefit. [57] For porokeratosis lesions that have undergone malignant transformation, surgical treatment is essential.

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      Medical Care

      Topically applied agents that might yield improvement in some patients include 5-fluorouracil (5-FU), vitamin D3 analogues, immunomodulators (eg, imiquimod), statins plus cholesterol, [58]  and retinoids. The use of oral retinoids (isotretinoin, etretinate, and acitretin) in immunosuppressed patients, who are at higher risk for malignant degeneration, may reduce the risk of carcinoma in porokeratotic lesions.

      Topical 5-fluorouracil

      Topical 5-FU can induce remission in all forms of porokeratosis. [59]  Treatment must be continued until a brisk inflammatory reaction is obtained. Enhancement of penetration, which heightens the response, may be achieved by occlusion or the addition of topical tretinoin, tazarotene, or salicylic acid. [60] Recurrences may be seen.

      Topical vitamin D3 analogues

      Both calcipotriol and tacalcitol have been shown to be effective after 3-6 months of treatment of disseminated superficial actinic porokeratosis (DSAP). [61, 62, 63]

      Immunomodulators

      Topical imiquimod cream has been shown to be effective for treating classic porokeratosis of Mibelli (PM). [64, 65]  Ingenol mebutate has shown efficacy in the treatment of PM. [66]

      Calcineurin inhibitors

      Tacrolimus (0.1%) has been shown to be effective for treating linear porokeratosis. A case report described complete resolution of associated pain, pruritus, and paresthesias, as well as cosmetic improvement. [67]

      Topical retinoids

      Topically applied retinoids (eg, tretinoin and tazarotene) may be beneficial for improving the abnormality in keratinization that causes cornoid lamellation, thereby reducing the hyperkeratosis of the edge of the lesions. They are also thought to improve percutaneous absorption of other topically applied medications, thereby rendering these medications somewhat more effective.

      Diclofenac gel

      Diclofenac gel 3% may be effective for treating DSAP. [68]

      Topical statins plus cholesterol

      Some studies have found value in topical application of a statin combined with cholesterol cream. [58] In one case series, topical lovastatin plus cholesterol yielded near-complete clearance of DSAP and moderate improvement in porokeratosis palmaris et plantaris disseminata (PPPD) and linear keratosis after 4 weeks. [69]  A randomized controlled trial found this same combination to be safe and effective but noted that topical lovastatin alone appeared to be as effective as the combination. [70] An open-label split-body clinical trial reported success with a combination of simvastatin and cholesterol. [71]

      Oral retinoids

      The combination of oral isotretinoin 20 mg/day and topical 5-FU has been reported to be effective for DSAP and PPPD, but it causes burning, itching, and painful erosions.

      Before etretinate was removed from the US market, conflicting reports of its efficacy were published. A regimen of 75 mg/day for 1 week followed by 50 mg/day was shown to be helpful for linear porokeratosis and symptomatic PM. Higher dosages of 1 mg/kg/day were reported to exacerbate DSAP lesions after 4-6 weeks of treatment. [72] Even when etretinate therapy was successful, relapses were noted. Digitate keratoses were reported to develop after the use of etretinate for DSAP. [73]

      Acitretin, a second-generation monoaromatic retinoid that is the active metabolite of etretinate, appears to have results similar to those of etretinate. Cases of systematized linear porokeratosis with good response to acitretin have been reported. [74, 75]

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      Surgical Care

      Surgical treatment is essential for porokeratosis lesions that have undergone malignant transformation. Excision is most appropriate when malignant degeneration develops. Surgical modalities other than excision may improve cosmesis, function, or both but are frequently followed by relapses. Studies have not shown prophylactic nonexcisional surgical treatment to have value for reducing the incidence of malignancy within porokeratosis. 

      Cryotherapy is helpful for porokeratosis lesions with minimally raised cornoid lamellae (eg, DSAP and PPPD). It is a minimally invasive method of inducing resolution for large numbers of lesions.

      Electrodesiccation and curettage can be used for treatment of small lesions or for cases where cryosurgery is ineffective.

      Diamond fraise dermabrasion has been used with conflicting reports of efficacy. It was effective in improving the appearance of linear porokeratosis in one patient, but a child with a large PM lesion had recurrence after treatment. [76]

      Reported benefits of laser therapy have included convenience and safety, with nearly no downtime or morbidity associated with pigment or textural changes. [77, 78, 79]  Various types of laser therapy have been used.

      Rapid recurrence was reported after carbon dioxide laser ablation. The 585-nm flashlamp-pumped pulsed dye laser was shown to help one patient with linear porokeratosis. Another patient with PM with an underlying hemangioma had good improvement of the hemangioma but no change in the porokeratosis. The frequency-doubled Nd:YAG laser was helpful for one patient with disseminated superficial porokeratosis (DSP). Two cases of DSAP were successfully treated with the 1927-nm thulium fiber fractional laser. [77]  The Q-switched ruby laser was reported to be effective in the treatment of DSAP and PM.

      Ultrasonic surgical aspiration was shown to be effective in the treatment of vulvar porokeratosis in one patient.

      Photodynamic therapy with methyl aminolevulinate has been reported to be successful for DSAP and linear porokeratosis. [80]

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      Long-Term Monitoring

      Regularly monitoring patients for the development of malignant transformation is essential, especially in the setting of immunosuppression. Squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) can be aggressive in patients who are immunosuppressed.

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