Nontuberculous Mycobacterial Infection after Fractionated CO₂ Laser Resurfacing

Donna A. Culton, Anne M. Lachiewicz

, Becky A. Miller, Melissa B. Miller, Courteney MacKuen, Pamela Groben, Becky White, Gary M. Cox, and Jason E. Stout

Author affiliations: Author affiliations: University of North Carolina, Chapel Hill, North Carolina, USA (D.A. Culton, A.M. Lachiewicz, M.B. Miller, C. MacKuen, P. Groben, B. White); Duke University Medical Center, Durham, North Carolina, USA (B.A. Miller, G.M. Cox, J.E. Stout)

Abstract

Nontuberculous mycobacteria are increasingly associated with cutaneous infections after cosmetic procedures. Fractionated CO₂ resurfacing, a widely used technique for photorejuvenation, has been associated with a more favorable side effect profile than alternative procedures. We describe 2 cases of nontuberculous mycobacterial infection after treatment with a fractionated CO₂ laser at a private clinic. Densely distributed erythematous papules and pustules developed within the treated area within 2 weeks of the laser procedure. Diagnosis was confirmed by histologic analysis and culture. Both infections responded to a 4-month course of a multidrug regimen. An environmental investigation of the clinic was performed, but no source of infection was found. The case isolates differed from each other and from isolates obtained from the clinic, suggesting that the infection was acquired by postprocedure exposure. Papules and pustules after fractionated CO₂ resurfacing should raise the suspicion of nontuberculous mycobacterial infection.

Nontuberculous mycobacteria (NTM) are increasingly associated with cutaneous and soft tissue infections after cosmetic and spa procedures, such as liposuction, mammoplasty, blepharoplasty, mesotherapy, and whirlpool footbaths during pedicures (1–5). These infections are often difficult to diagnose, resulting in major treatment delays (4,6). Fractionated CO₂ laser resurfacing is a widely used cosmetic procedure that minimizes the appearance of rhytides (skin wrinkles) and acne scars, and compared with older laser procedures, fractionated CO₂ resurfacing is associated with less downtime and a lower rate of infectious and noninfectious complications (7–9). Although fractionated CO₂ laser therapy is associated with decreased rates of postprocedure infection, infections such as herpes simplex virus, bacterial, and candidal infections have been reported (8–10). Palm et al. recently reported the first case of NTM infection caused by Mycobacterium chelonae after treatment with a fractionated CO₂ laser for facial resurfacing (11). Given the length of time from the procedure to the diagnosis (≈2 months), a source of NTM infection was not sought.
We report 2 additional cases of NTM infection after treatment with fractionated CO₂ resurfacing at the same private clinic and an extensive environmental investigation to identify a source of infection. This study received formal exemptions from review by the Institutional Review Boards of the University of North Carolina and Duke University Medical Center.