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; Jason E. Stout


Emerging Infectious Diseases. 2013;19(3) 

In This Article


NTM are environmental organisms that are increasingly associated with systemic and cutaneous disease in humans. NTM-induced cutaneous disease typically occurs after injections, such as tattoos, botulinum toxin, and mesotherapy, or after minor surgical procedures in which breaks in the skin barrier occur.[1,3,5,12–15] These organisms also have been associated with whirlpool footbaths before pedicures.[2,4,16] In these cases, shaving before a whirlpool footbath was associated with increased rates of infection, presumably caused by microbreaks in the skin, which enable easy inoculation.[2,16,17] NTM are ubiquitous in soil and water and have been detected in municipal water sources throughout the United States.[16,18,19] They are also found in biofilms and, in the whirlpool footbath associated cases, seem to thrive in nutrient-rich water contaminated by skin debris, which accumulates on bath filters.[2,4,16,17]

Eradication can be difficult because these organisms are resistant to most disinfectants.[4,20,21] Cutaneous infection with NTM is most often caused by M. marinum and rapidly growing mycobacteria that belong to 1 of 3 species groups: M. abscessus, M. chelonae, and M. fortuitum.[22–24] Diagnosis is difficult and often requires histologic evaluation and tissue samples for culture. Delays in diagnosis are common and can lead to delays in treatment.[6] Species identification can be difficult and requires sequencing of multiple genes because of homology between Mycobacterium spp. family members.[25–27] More than 120 NTM species have been identified, including ≈30 isolates in the past decade whose names might be unfamiliar to many clinicians.[28] These organisms are also resistant to many antimicrobial drugs, a factor that complicates treatment.

In the past 5 years, fractionated CO2 laser resurfacing has become the preferred procedure for rhytides, photodamage, and acne scars.[9] This procedure combines the efficacy of ablative laser resurfacing with a more favorable side effect profile than traditional ablative therapy. Studies have shown a high degree of safety and efficacy and lower rates of hypopigmentation, scarring, and infectious complications.[7–10,29] This technology is based on the principle of creating narrow columns of tissue damage known as microthermal treatment zones, which are evenly distributed over the treated area. Localized epidermal necrosis and collagen denaturation occur in each column but the stratum corneum remains intact. Decreased disruption of the epidermal barrier and areas of viable tissue around each microthermal treatment zone enable more rapid healing and reduce the risk of infection.

Although infections with fractionated CO2 laser therapy are less common than with traditional ablative laser, they do occur.[10] Infection with herpes simplex virus was reported in 1.7% of all cases and in 4.6% of cases in which the patient had a history of oral herpes but no antivirus prophylaxis was given.[8] Bacterial complications, including Staphylococcus spp. and Pseudomonas spp. infections, and Candida spp. infections have also been reported, although at low rates.[10]

Palm et al. reported the first case of NTM infection after fractionated laser resurfacing.[11] The causative agent was identified as M. chelonae 3 months after the onset of acneiform eruptions. The patient received multidrug treatment and showed some clinical improvement. She eventually underwent therapy with a pulsed dye laser and showed a decrease in erythema and scarring. A possible source of NTM infection was not sought in this case.

We report 2 additional cases of NTM infection with M. abscessus and M. chelonae after fractionated CO2 laser resurfacing. Both patients showed development of erythematous papules and pustules ≈10–14 days after the procedure, but the extent of skin involvement varied between the 2 patients. For both patients, a diagnosis was made within 1–2 weeks by histologic examination and tissue culture. Early treatment with multidrug therapy specific for the most likely mycobacterial pathogens was initiated while susceptibility testing was performed. In both patients, treatment was continued for >4 months.

Results of a thorough epidemiologic investigation showed no evidence that transmission of the NTM infections occurred during the fractionated resurfacing procedure. The 2 patient isolates belonged to 2 different species, and neither matched the isolate obtained from the fractionated laser apparatus. Furthermore, none of the isolates from environmental water at the clinic matched either patient isolate. Although the absence of evidence does not definitively rule out common source transmission during the procedure, it does make it more likely that infection occurred elsewhere after the procedure.

The source of these infections remains unclear. It is possible that the causative NTM isolates were transiently present in the environment but were not detected because of lag times between procedures and environmental investigations. Furthermore, limitations of environmental sampling and culture for mycobacteria did not enable us to rule out a common source of infection at the time of the procedure. Detailed environmental sampling of the home was not permitted by the first patient and was not sought for the second patient. Several alternative environmental sources for infection are possible (aerosols from sinks, toilets, water fountains, and sanding dust for case-patient 1). Although there was no evidence to support exposure during the fractionated laser procedure, an NTM species was isolated from the tubing of the machine. Therefore, the tubing leading to the smoke filter is a potential reservoir for NTM because it is changed infrequently and can contain skin debris within the corrugated tubing.

Patients should be explicitly advised of the risk for NTM infection after fractionated laser resurfacing, and physicians should be highly suspicious of such infections during the postprocedure period. Although incubation periods reported for postprocedure NTM have been reported as 9–10 days, other cutaneous NTM infections may be found <3 months after the presumed exposure.[16] Thus, late manifestations might be possible. Biopsy specimens for histologic evaluation and tissue culture are critical for making an accurate diagnosis. Suppurative neutrophilic and granulomatous dermatitis should raise suspicion for NTM infection, even if results of staining for acid-fast bacilli are negative. As shown by these cases and the case described by Palm et al.,[11] identification of gram-positive rods during routine histologic examination might suggest NTM infection because these organisms can be weakly gram positive.

Empiric therapy specific for NTM should be considered while awaiting biopsy and culture results for patients with suspicious lesions. However, prophylactic therapy before or after the procedure with active agents against NTM is not recommended. The efficacy of such treatment in preventing infection remains unknown, and the risk for antimicrobial drug–associated side effects likely outweighs any theoretical benefit. Although there is no standard treatment for cutaneous NTM infections, multidrug therapy is usually necessary to minimize the development of drug resistance. Antimicrobial drug susceptibility testing should be conducted to tailor therapy, and treatment should be continued for 4–6 months.

When these infections occur, systematic observation of the procedure should be performed. Specifically, attention should be paid to any liquids or ointments that may contact the skin of a patient during or just after the procedure (particularly multiuse vials or containers) and the proximity of the procedure room to potentially aerosol-generating water sources. Environmental sampling with mycobacterial culture of such liquids seems to be a reasonable first step in identifying a source (although it did not identify a source in this study).

Furthermore, strict postprocedure wound care is critical to minimize risk for NTM infection. It is prudent to advise patients to avoid any municipal water sources for the first 72 h after the procedure (although this time interval is arbitrary). Bottled water, which may not be sterile, could harbor small amounts of NTM. Use of sterile water or sterile saline for postprocedure cleansing is recommended. First and foremost, physicians must remain aware of this potential complication of fractionated laser resurfacing and be highly suspicious even if initial histologic and culture results do not identify microbial pathogens.

Dr Culton is an assistant professor in the Department of Dermatology at the University of North Carolina at Chapel Hill. Her primary research interests include immunology and autoimmunity of the skin and unusual manifestations of atypical mycobacterial skin infections.