DERMATOLOGICAL SURGERY & LASERS DOI 10.1111/J.1365-2133.2004.06259.

Becker’s naevus: a comparative study between erbium:

YAG and Q-switched neodymium:YAG; clinical and
histopathological findings
M.A. Trelles, I. Allones, G.A. Moreno-Arias* and M. Vélez
Instituto Médico Vilafortuny and Antoni de Gimbernat Foundation, Av. Vilafortuny, 31, E-43850 Cambrils, Spain
*Centro Médico Teknon, Barcelona and Espitau Val d’Aran, Vielha, Spain

Summary

Correspondence: Background Becker’s naevus (BN) may represent a distressing cosmetic handicap
Mario A. Trelles. and a challenging issue regarding treatment.
E-mail: imv@laser-spain.com Objectives To compare clinical and histopathological findings of patients with BN
treated with two different lasers: an erbium:yttrium–aluminium–garnet (Er:YAG)
Accepted for publication
6 May 2004 system vs. a neodymium:YAG (Nd:YAG) laser.
Patients and methods In this prospective and comparative study we present the clin-
Key words: ical and histopathological evolution during a 2-year follow-up of 22 patients
hamartoma, laser, melanocytic lesions, naevus, with BN treated with only one pass of the Er:YAG laser (n ¼ 11) or three treat-
organoid naevus, pigmentary lesions
ment sessions with the Q-switched Nd:YAG system (n ¼ 11).
Conflict of interest: Results Clinical evaluation 2 years after treatment with the Er:YAG laser showed
None declared. complete clearance (100%) in 54% of the patients (n ¼ 6) and clearance of
> 50% in 100% of the subjects. In relation to Nd:YAG laser treatments our
Footnote: results echo those of other authors. Numerous sessions are necessary to get an
This paper was partially presented at the 8th acceptable clinical clearance rate. Only one patient showed marked clearance
meeting of the Association de Recherche en
(51–99%) after three treatment sessions. Moderate (26–50%) and mild (1–25%)
Esthétique et Plastique, 14 November 2003,
Paris, France. clearance was observed in 45Æ5% (n ¼ 5) and 27Æ3% (n ¼ 3) of the patients.
Conclusions Both Er:YAG and Nd:YAG are safe tools to treat BN. However, in terms
of pigment removal, one pass with Er:YAG is a superior technique to three treat-
ment sessions with the Nd:YAG.

Becker’s naevus (BN) can represent a distressing cosmetic han-
dicap and a challenging issue regarding treatment. Treatment
of melanocytic lesions with ablative lasers can produce scar-
ring1 due to excess heat propagation or unspecific thermal
damage. The erbium:yttrium–aluminium–garnet (Er:YAG)
laser is a nonspecific pigment-ablative laser system that targets
intra- and extracellular water with controlled thermal damage.
It can remove epidermal and dermal lesions with minimal
wound healing complications. These are desirable qualities
when treating BN or other melanocytic pigment lesions with a
laser system.
Pigment-specific laser systems such as alexandrite, ruby and
neodymium:YAG (Nd:YAG) are more precise tools. However,
they can also lead to pigmentary changes such as postinflam-
matory hyperpigmentation and hypopigmentation.2 Moreover,
owing to the various treatment sessions often necessary when
applying the Q-switched laser system, most patients experi-
ence slow or less successful wound healing leading to less
acceptable final results.
In this prospective and comparative 2-year follow-up
study we present the clinical and histopathological evolution
of 22 patients with BN treated with either a single pass of
the Er:YAG laser (n ¼ 11) or with three consecutive
treatment sessions with a Q-switched Nd:YAG laser (n ¼
11).
Patients and methods
Twenty-two patients with BN were included in this study
carried out between 1997 and 2001. Patients were randomly
assigned to either group (Er:YAG or Nd:YAG). Laser treat-
ment was performed each time by the same physician
(M.A.T.).
All patients signed an informed written consent form
agreeing to participate in this study. Clinical evaluation
before treatment included skin phototype (Fitzpatrick scale),
measurement and colour assessment of the lesion (light or
dark brown pigmentation), presence or absence of terminal

308
2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp308–313
 Becker’s naevus: Er:YAG vs. Q-switched Nd:YAG, M.A. Trelles et al. 309
hair (fine vs. coarse), and hair density [mild (+), moderate
(++) or marked (+++)]. A test was performed under local
anaesthesia with mepivacain 2% without adrenaline (Scandin-
ibsa 2%; INIBSA, Madrid, Spain) diluted with saline serum
1 : 3 mL on an area of affected skin measuring 6 · 6 cm.
Patients were instructed to avoid direct sunlight, to apply a
fine layer of an ointment made of a medium-strength steroid
and an antibiotic, prednicarbate plus gentamicyn (Flutenal
Gentamicina; Recordate-España, S.L., Madrid, Spain), and to
cover the area with a transparent sheet of polyethylene film
every 24 h until the first clinical evaluation, 5 days postoper-
atively.3 Then, patients applied a moisturizing cream, every
2 h, until their crusts fell off. Additional clinical evaluations
were performed at the 10th and at the 15th days after treat-
ment in order to investigate re-epithelization and erythema.
Then if the patient was satisfied with the appearance of the
new skin, treatment of the entire BN was performed under
local anaesthesia followed by the same postsurgical treatment
modalities as mentioned above. Further clinical and photo-
graphic evaluations were performed 5, 10 and 15 days after
laser treatment. After re-epithelization, patients were instruct-
ed to apply sunscreen with sun protection factor (SPF) 15
three times per day. Clinical and photographic evaluations
were performed every 3 months for a period of 2 years. In
the case of repigmentation, an additional examination was
recommended.
Histopathology
A biopsy on affected skin was performed before as well as
immediately after treatment and 2 years postoperatively. Speci-
mens were processed using the conventional haematoxylin
and eosin technique. An independent blinded observer per-
formed the histological evaluation. The pretreatment histological
evaluation included the presence or absence of hyperkeratosis,
elongation of rete ridges, melanin concentration, pigment
incontinence, dermal melanophages and bundles of
smooth muscles. Immediately postoperatively, histological
specimens were principally obtained to ascertain the depth
of tissue ablation. Two years postoperatively histological
specimens were taken to perform tissue analysis by using
again the same parameters as the pretreatment histological
evaluation.
Photography
Digital photographs were taken with the same camera settings
and lighting conditions (Mavica MVC-FD91; Sony, Japan)
before treatment, immediately after treatment, and 6, 12, as
well as 24 months postoperatively. Photographic evaluation by
an independent blinded observer included the pres-
ence ⁄absence of light ⁄dark pigment, terminal ⁄vellus-like hair,
hypopigmentation and scarring. Finally, pigment clearance
was scored according to the following scale: none (0%), mild
(1–25%), moderate (26–50%), marked (51–99%), complete
(100%).

2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp308–313
Er:YAG
Eleven patients were treated with an Er:YAG laser system (Der-
maK; Lumenis, Yokeheman, Israel) according to the following
protocol: 2940-nm wavelength, 3-mm beam spot with a colli-
mated handpiece, fluence energy of 28 J cm)2, 10 Hz repeti-
tion rate, and 50% overlapping, one pass only. Treatment at
the same fluence energy but with 0–10% overlapping was
applied to the transitional area between BN and normal skin.
Only one treatment session was performed with the Er:YAG.
The test area did not receive any additional treatment.
Q-switched Nd:YAG
Eleven patients were treated with a Q-switched Nd:YAG system
(Medlite IV; ConBIO, Etiwanda, CA, U.S.A.) according to the
following protocol: 1064-nm wavelength, spot size of 3 mm,
10 ns, fluence energy of 10 J cm)2, repetition rate of 10 Hz,
and 10% overlapping. A total of three treatment sessions were
performed at 2-month intervals, including the test area.
Questionnaire
Post-treatment evaluation included a questionnaire which was
filled out by patients during the 2-year follow-up period
assessing the percentage of treatment speed, discomfort, secre-
tion, repigmentation, erythema and efficacy (81–100%, very
good; 61–80%, good; 41–60%, fair; 21–40%, bad; 0–20%,
very bad).
Results
Patients
Individuals in the Er:YAG group included one female and 10
males. The mean age was 25Æ7 years (range 20–38) while the
skin phototype ranged from II to IV (II, n ¼ 3; III, n ¼ 6; IV,
n ¼ 2). The majority of lesions (n ¼ 8) were located on the
right shoulder ⁄arm, scapula or pectoral region, while three
lesions were located on the left counterparts. Lesion colour
varied between light (n ¼ 6) and dark brown (n ¼ 5). The
size of the BN ranged from 225 to 625 cm2 (mean 446 cm2).
Hair quality was fine in six subjects and coarse in five subjects.
Hair density was graded mild in four, moderate in five and
marked in two subjects.
The Nd:YAG group included one female and 10 males. The
mean age was 26Æ55 years (range 19–35). Skin phototypes
included type II (n ¼ 4), III (n ¼ 5) and IV (n ¼ 2). In six
subjects the lesion was on the left shoulder, scapula or pec-
toral region, while for the remaining subjects (n ¼ 5) it
occurred on the opposite counterparts. Lesion size ranged
from 270 to 720 cm2 (mean 478 cm2). Five subjects had
light brown lesions, while in six they were dark brown. The
associated hair was fine in six individuals and coarse in five.
Hair density was assessed as mild in three, moderate in six,
and marked in two subjects.
310 Becker’s naevus: Er:YAG vs. Q-switched Nd:YAG, M.A. Trelles et al.
Clinical results
Test spot
Er:YAG At the 5-day assessment, the exudation phase had fin-
ished. Ten days after treatment lesions had completely healed
in all patients, and at the 15-day evaluation all patients present-
ed erythema in the treated areas.
Nd:YAG Superficial crusting was observed in all patients at
the 5-day assessment. Crusts peeled off between days 7 and
10 after treatment. By the 15-day evaluation, mild erythema
was observed in all patients.
Treatment
Clinical evaluation of lesions in the two study groups 5, 10
and 15 days after treatment revealed each time the same char-
acteristics as described above.
Er:YAG Treated skin appeared smooth but slightly clearer
and with mild erythema when compared with untreated sur-
rounding skin. Hypopigmentation and erythema gradually dis-
appeared in the following 2 months. The clinical evaluation
performed 3 months after treatment showed complete healing
of treated skin in all patients. Erythema was not observed at 6,
9, 12, 15, 18 and 24 months postoperatively while hair
regrowth was reported after 2 months postoperatively in the
same areas as observed before treatment. Nevertheless, no sig-
nificant variations were noticed in terms of colour and diam-
eter. In most patients, skin colour and texture were normal
2 years postoperatively. However, partial mild brown pigmen-
tation was noticed in five patients. No further treatment was
requested by patients with residual pigmentation.
Nd:YAG Three months after three treatment sessions skin was
seen to have healed completely. Pigment was progressively
detected in scattered areas at 6, 9, 12, 15, 18 and 24 months
postoperatively. In two patients, no clearance was observed
after treatment. Hair regrowth was reported by all patients
between 1Æ5 and 2 months after the last treatment session.
The quality of hair after treatment was the same as before
treatment.
Photographic and clinical evaluations performed by an inde-
pendent blinded observer 2 years postoperatively are shown in
Figure 1.
100
80
Er:YAG
60
%
40
20
Nd:YAG
1 2 3 4 5 10 16 24 months
Fig 1. Pigment clearance: Er:YAG vs. Nd:YAG.

2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp308–313
Regarding patients’ evaluation, treatment efficacy of the
two laser systems 1 month after surgery was rated by all
patients of the two study groups as very good (81–100%).
However, 2 months after surgery, patients of the Nd:YAG
group rated treatment results as bad (21–40%). At the final
evaluation after 2 years all patients of this group were con-
tent with the treatment result achieved. In contrast, assess-
ment of treatment efficacy by patients of the Er:YAG group
during the 2-year follow-up was constantly rated as good
(61–80%).
Discomfort was experienced in both study groups (21–40%
or ‘bad’) while erythema and secretion production were
scored higher by patients treated with Er:YAG laser (61–80%
or ‘good’ vs. 21–40% or ‘bad’). Finally, the speed of treat-
ment scored much higher in the Er:YAG group (81–100% or
‘very good’) than in the Nd:YAG group (41–60% or ‘fair’).
Side-effects and complications
Crust formation and erythema were observed in both groups,
in most cases crusts peeling off after 1 week postoperatively.
However, erythema lasted longer in patients treated with the
Er:YAG laser (3 months vs. 15 days). No bacterial, viral or
fungal infections were observed. Three patients developed tex-
tural changes and superficial fibrosis after Nd:YAG treatment.
No clinical scarring was observed. A mild difference in skin
colour was observed in the transitional area between BN and
normal skin in patients treated with the Er:YAG laser.
Histopathology
Histological evaluation prior to treatment in both groups
showed mild to marked hyperkeratosis, a mild papilliform
epidermis, elongation of rete ridges, and basal hyperpigmenta-
tion without melanocytic proliferation. Dermal findings includ-
ed vascular dilatation with prominent endothelial cells, mild
perivascular lymphoplasmocyte or lymphohistiocyte infiltrate,
and scattered melanophages. Hair follicles and sebaceous
glands were normal. Neither incontinentia pigmenti nor
smooth muscles were observed (Fig. 2a).
Immediate post-treatment evaluation in the Er:YAG group
showed the ablation of epidermis and superficial dermis with
the preservation of hair follicles (Fig. 2b).
Histological evaluation performed immediately after treat-
ment in the Nd:YAG group showed partial ablation of the epi-
dermis and the preservation of hair follicles (Fig. 3a).
Histological evaluation performed 2 years after treatment in
the Er:YAG group demonstrated normal epidermis or slight
hyperkeratosis. Mild dilatation of capillaries was also observed.
However, the elongation of rete ridges, melanocytic prolifer-
ation, basal ⁄dermal hyperpigmentation were not observed
(Fig. 2c).
Histological evaluation performed 2 years after treatment in
the Nd:YAG group showed persistent hyperkeratosis, the
elongation of rete ridges and basal layer hyperpigmentation
(Fig. 3b).
 Becker’s naevus: Er:YAG vs. Q-switched Nd:YAG, M.A. Trelles et al. 311

Fig 2. (a) Histopathological findings of a Beckers’ naevus before treatment. (b) Er:YAG leads to complete ablation of the epidermis and papillary
dermis (immediately after treatment). (c) After 2-year follow-up. (a–c: haematoxylin and eosin, original magnification · 200).

a b

Fig 3. Nd:YAG: (a) Immediate histopatho-

logical evaluation showed partial epidermal
ablation. (b) Two-year follow-up
histopathology showed slight hyperkeratosis,
mild elongation of the rete ridges and
persistence of basal layer hyperpigmentation.
(a and b: haematoxylin and eosin, original
magnification · 200).

any complications when superficial skin conditions are treat-

Discussion
Becker’s naevus is an uncommon hamartoma that may repre-
sent a distressing factor for the patient and a treatment chal-
lenge for the physician. In the past, treatment of this skin
condition included mechanical abrasion, surgical excision or
cryotherapy. However, final cosmetic results were unfavour-
able and defective scarring or repigmentation was common
after treatment.4,5 At the beginning of the laser era, unspecific
systems such as argon or CO2 lasers were used to treat BN.6
Nevertheless, scarring or permanent hypopigmentation were
observed.7 The development of more pigment-specific laser
systems led to BN treatment with almost no permanent side-
effects. However, many treatment sessions were necessary to
achieve acceptable clinical pigment clearance.8 In some cases,
complete repigmentation was observed after the last treatment
session of a BN.9 More rarely, complete clearance could be
observed after persistent treatment of a pigmented lesion with
high fluence energy.10 Moreover, high costs not only in eco-
nomic terms but also in patients’ undergoing endless treat-
ment with Q-switched laser systems prompted us to apply a
more efficient and less expensive method to eliminate pigment
in BN.
The Er:YAG laser system emits a 2940-nm wavelength that
targets intra- and extracellular water.11 This is a useful tool
to remove superficial skin lesions associated with photodam-
age, inducing dermal protein contraction and stimulating col-
lagen synthesis that finally leads to skin remodelling.12 Even
though the Er:YAG is not a pigment-specific laser system, it
can cause superficial skin resurfacing with controlled thermal
damage to surrounding tissue leading to the removal of epi-
dermal and dermal lesions with an uneventful healing pro-
cess. Clinical results range from good to excellent without
ed or skin resurfacing is performed with only one single
pass of this laser.13 Crusts and erythema are common and
temporary. In most cases superficial crusts peel off 1 week
after treatment, while erythema usually resolves within 1–
3 months.14 Other side-effects include temporary hypo- and
hyperpigmentation, secondary infection and, more rarely,
defective scarring.15
In this study we compared clinical and histopathological
results in patients with BN who underwent either Er:YAG or
Nd:YAG laser treatment.
In accordance with epidemiological data, all patients of this
study had BNs within the characteristic locations (shoulder,
scapula or pectoral region) which were typical in colour (light
or dark brown). Moreover, local hypertrichosis with terminal
fine or coarse hair was also observed in all patients.2
During Er:YAG treatment we used a fluence energy of
28 J cm)2 in only one-pass mode to treat the entire lesion.
The high fluence energy selected led to the ablation of the
epidermis and papillary dermis preserving hair follicles and
sebaceous glands (Fig. 2b). Healing was uneventful in all
patients. Crust formation resolving after 1 week and transient
erythema or hypopigmentation of less than 3 months in dur-
ation are in accordance with other reports.16 The initial mild
post-treatment hypopigmentation may be explained by the
removal of melanocytic structures of the basal layer of the epi-
dermis and by temporal dysfunction of remaining melanocytes
in the deep portion of the hair follicle. Transient erythema is
due to persistent capillary vasodilatation17 and usually resolves
within 3 months.18 Overlapping of 50% was used to treat the
whole lesion. However, a 0–10% overlapping procedure was
applied in the periphery 2 mm beyond the lesion’s border in
order to decrease the likelihood of skin colour change in the

2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp308–313
312 Becker’s naevus: Er:YAG vs. Q-switched Nd:YAG, M.A. Trelles et al.
transitional area of BN and normal skin. Er:YAG was applied
in only one-pass mode. However, 50% overlapping in fact
corresponds to a double pass that leads to ablating the epider-
mis completely and partially ablating the papillary dermis.19
Such ablation destroys epidermal pigmentary cells and mel-
anophages in the upper dermis, which causes the clinical
clearance of the lesion. Moreover, this process induces epider-
mal restructuring as evidenced in histopathological studies
2 years later. Clinical evaluation 2 years after treatment
showed complete clearance (100%) in 54% of the patients
(n ¼ 6), while clearance of more that 50% was obtained in
100% of the subjects. Repigmentation was mild and no fur-
ther treatment was requested by any of the patients. Slow pig-
ment reappearance noticed after 2 years can be explained by
the persistence of viable melanocytes in deep hair follicles that
remained unchanged after Er:YAG treatment as evidenced in
the histological studies performed immediately after laser abla-
tion.
Our Nd:YAG laser treatment results are similar to those of
other authors.20 Numerous sessions are necessary to achieve
an acceptable clinical clearance rate.21,22 Only one patient
showed marked clearance (51–99%) after three treatment ses-
sions. Moderate (26–50%) and mild (1–25%) clearance was
observed in 45Æ5% (n ¼ 5) and 27Æ3% (n ¼ 3) of the
patients.
According to this clinical observation, the one-pass mode of
the Er:YAG laser is superior to three consecutive treatment ses-
sions of Nd:YAG in terms of pigment removal. However, ery-
thema lasts longer in patients treated with Er:YAG than with
Nd:YAG. In spite of excellent cosmetic outcome, patients
should be aware of potential residual mild permanent hypo-
pigmentation in Er:YAG-treated areas.23

2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp308–313
Fig. 4. Becker’s naevus: (a) Before treatment
and (b) after one treatment session with the
Er:YAG (2 years’ follow-up).
Fig 5. Becker’s naevus: (a) Before treatment
and (b) after three treatment sessions with the
Nd:YAG system (2 years’ follow-up).
Patients rated treatment efficacy as very good in both
groups after 1 month of laser treatment. However, rating of
treatment efficacy dropped drastically to 0–20% (very bad) in
the Nd:YAG group, while the Er:YAG group patients consid-
ered it was very good or good during the same follow-up per-
iod. Speed of treatment, erythema and secretions were rated
much higher in the Er:YAG group than in the Nd:YAG group.
Discomfort was rated equally in both groups. Repigmentation
was rated considerably higher in the Nd:YAG group than in
the Er:YAG.
In conclusion, both Er:YAG and Nd:YAG are safe tools to
treat BN. However, in terms of pigment removal, the one-pass
mode procedure with Er:YAG is a superior technique to the
procedure of three consecutive treatment sessions with the
Nd:YAG laser (Figs 4 and 5).
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