How to manage syringomas?

Management of Syringomas

CO2 laser ablation is the treatment of choice for syringomas, offering excellent cosmetic results with minimal scarring and low recurrence rates when properly performed. 1, 2

Treatment Approach

First-Line Treatment: CO2 Laser Ablation

CO2 laser should be performed using either superficial ablation or a multiple-drilling technique, both of which have demonstrated superior outcomes compared to traditional methods. 1, 2

Superficial Ablation Technique

• Settings: 5 watts power, 0.2 second scan time, 3mm spot size 1
• Technique: Perform 2 passes initially; some lesions may require up to 4 passes 1
• For multiple lesions: The entire affected periorbital area can be treated in one session 1
• Expected outcomes: Complete elimination of lesions with no recurrence at 1-24 months follow-up 1

Multiple-Drilling Method

• Technique: Create multiple small drill holes into each syringoma using focused CO2 laser 2
• Advantages: Excellent cosmetic results without scarring, erythema, or pigmentary changes 2
• May require: Repeated applications for optimal results 2

Alternative CO2 Laser Approach

• Superpulsed CO2 laser can be used with calculated energy density of 1 J/cm² per lesion 3
• Delivery: Single pulses to each lesion separately under microscopic guidance 3
• Outcomes: No recurrences at 2-year follow-up with no scarring or pigmentary changes 3

Second-Line Treatment: Intralesional Electrodesiccation

For patients who cannot access laser therapy, intralesional electrodesiccation offers a reliable alternative with minimal scarring. 4

• Technique: Insert epilating needle deeply to the level of the reticular dermis and deliver short bursts of low-voltage electrodesiccation 4
• Advantages: Safe, non-scarring method with lesion-free results maintained beyond 24 months 4

Special Consideration: Darker Skin Types

For African American patients or those with darker skin phototypes, combination therapy with trichloroacetic acid (TCA) pretreatment followed by CO2 laser reduces the risk of thermal damage and pigmentary complications. 5

• Rationale: TCA pretreatment removes surface bulk, reducing the number of laser passes needed and minimizing thermal injury to surrounding normal skin 5
• Expected outcome: Acceptable cosmetic results without significant side effects, though complete ablation may not always be achieved 5

Common Side Effects and Management

Expected Post-Treatment Course

• Superficial scabbing: Appears within 1 week, resolves spontaneously 3
• Prolonged erythema: Most common side effect, typically resolves within 1 month 1, 3
• Pain and edema: Minimal to absent 3

Retreatment Considerations

• Approximately 40% of patients may require repeat spot treatments for residual or incompletely treated lesions 1
• Retreatment is safe and can be performed using the same technique 2

Critical Pitfalls to Avoid

• Avoid traditional methods such as simple excision, standard electrodesiccation and curettage, or dermabrasion, as these have higher rates of scarring and recurrence 1, 3
• Do not use excessive laser passes in darker skin types without TCA pretreatment, as this increases risk of thermal damage and pigmentary changes 5
• Ensure adequate depth of treatment to reach the dermal location of syringomas while avoiding excessive depth that causes scarring 4

Long-Term Outcomes

• Recurrence rates are low when CO2 laser is properly performed, with patients remaining lesion-free for 1-24 months or longer 1, 2, 3
• Scarring is rare with appropriate laser technique 1, 2, 3
• Functional complications such as ectropion do not occur with proper periorbital treatment 3