Results of argon laser treatment of port-wine stains: a method of assessment

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Results of argon laser treatment of port-wine a method of assessment A. A. QUABA North East Thames Regional Plastic Surgery Centre, St Andrew’s

Hospital, Billericay,

Essex

Summary-In this review of over 100 cases of argon laser treated port-wine stains, four parameters, including lesion colour, skin texture, make-up habits and scarring, are assessed and changes allocated appropriate numbers. The sum of these numbers is used to classify results as Excellent, Good, Fair or Poor, and these were found to correlate well with the level of patient satisfaction,

Results of argon laser treatment of port-wine stains (PWS) depend on a number 6f factors. These include age, lesion characteristics, laser output parameters, operator’s technique and any manipulation (e.g. cooling) of the PWS. Although most clinical studies contain a reasonably clear account of these factors, comparison of results between different series remains difficult since criteria used in assessment are not clear-cut and vary from one author to another. Between 1983 and 1987 a total of 318 patients with a variety of cutaneous vascular malformations were seen and treated at the North East Thames Plastic Surgery Centre, Billericay. This paper describes a method which was developed primarily to assess results of treatment of port-wine stains which formed the majority (190) of these malformations. With minor modifications, the same method was found to be equally useful in evaluating the response of other cutaneous lesions to laser therapy.

the treatment of 104 patients, assessed 11 months postoperatively, are outlined in Table 3. Discussion It has been widely accepted that the response of port-wine stains to laser treatment may be graded as Excellent, Good, Fair or Poor depending mainly Table 1 Parameter Colour

Make-up

Texture

Scarring

Method of assessment Changes in colour, make-up habits and skin texture as well as the level of scarring are assigned scores according to the degree of change and its desirability (Table 1). The composite score of these four parameters is used to classify the overall result as Excellent, Good, Fair or Poor (Table 2). The assessor allocates the scores after discussing changes in each parameter with the patient in the presence of a relative or friend and an experienced nurse who are all shown sets of comparable pretreatment and follow-up colour photographs. Examples are shown in Figures l-4 and the results of

Chunge

Score

11 Pigmentation Nil-Slight change Moderate lightening Marked lightening Total blanching

__ I

More difficult to apply No change Easier or lighter No longer needed

-1

Worse Nil Better

_.

; Cl I 1

I 1 _. ; 0

Table 2

125

I 7

0

Hypertrophic Atrophic Nil

Cnmposire score

0

Rcwlt

5-6

Excellent

3-4

Good

l-2

Fair

-1-o

Poor

- 2 or less

Unacceptable

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Figure l-The result in this patient is rated “Excellent” despite some residual colour (a score of 5). Reduction of sponginess, especially of that part of the PWS affecting the right cheek, contributed to improved skin texture. Note total blanching at the periphery of the main lesion and residual colour in its centte. Also, what looks like hypopigmentation is in fact a result of preexisting tattooing which has become more obvious following lightening of the red-purple colour (System 1000 Dermatologic Argon Laser-Coherent).

on the degree of colour lightening, modified in some studies by the incidence of scarring. Table 4 summarises how various authors (Apfelberg et al., 1981; Gilchrest et al., 1982; Landthaler et al., 1984; Table 3

6

6

Good

Excellent

40

38

Fair

54

52

Poor

4

4

104

100

Mean follow-up

I I months

Craig et al., 1985) classify their results. Some of the criteria are poorly defined, there is significant variation between the various authors, particularly as to what constitutes a.fair or poor result, and their systems are not sufficiently flexible to allow for all possible combinations of changes which could follow laser therapy. There is no doubt that the primary objective of laser therapy is to get the stain to lighten as much as possible and that the main hazard is hypertrophic scar formation. These must be the two main yardsticks used in any assessment; however, the advantages and risks of treatment go beyond changes in colour and scarring. Alterations in skin

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Figure 2-Treatment of a large, smooth and contluent PWS in a young patient is particularly difficult. The result in this 23-year-old patient is assessed as “Good”. Wearing of make-up is easier not only because of the overall blanching but also the “removal” of the stain from the central face (inner canthus. side of the nose and upper lip) and the feathering out of its sharp outline (System 1000 Dermatologic Argon Laser-Coherent).

texture and the impact of these and other changes on make-up habits can have a significant bearing on patients’ contentment and, not infrequently, make the difference between success and failure. In fact. the addition of these two parameters was

prompted by patients’ comments made frequently during their follow-up visits. Colour remains the main criterion. Although changes are difficult to quantify, carefully standardised pre- and post-treatment photographs can be

Table 4

Good

EvceNenr Apfelberg Gil&rest

1981 1982

Landthaler Craig 1985

1984

Total blanching scarring Identical skin

without

to uninvolved

Fair

Good lightening scarring Marked

Minimal scarring

without

improvement

Poor changes

Slight improvement

Undesirable

and

result

Nearly total blanching without scar formation

Marked lightening without scar

Moderate lightening with textural changes

Moderate lightening with scar formation

Virtually

Considerably

Slight colour change

Virtually

removed

paler

no change

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Fig. 3 Figure &A more extensive and darker PWS in a 2%year-old patient. Treatment was completed in three stages, starting in the preauricular area. The power density used in treating the cheek, lower lip-chin and anterior neck had to be reduced to avoid the textural changes, seen in the preauricular area. which resulted from a higher-than-average dose of laser. There is no significant reduction in the bulk of the lower lip but note the better definition of the lip-vermilion junction. There is total blanching of the original red-purple colour (f3) but significant hypopigmentation especially in the cervical area (- I) (System 1000 Dermatologic Argon Laser-Coherent).

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Fig. 4 Figure 6Hypertrophic scarring appeared two months following the treatment of PWS in this 14-year-old girl. Marked lightenrng of the stain itself was offset by the increased difficulty in applying make-up and by the colour of the hypertrophic scar. There is no significant textural change in the treated skin surrounding the area of localised scarring. The scar responded to Triamcinolone injections (System 1000 Dermatologic Argon Laser-Coherent).

extremely helpful in documenting changes which are so gradual that otherwise they can be difficult to appreciate by the patient or close relative. Colour photography has its own pitfalls, but other methods such as spectrophotometric assessment may not be practical in a clinial setting; such were not used at Billericay. While it is not uncommon to achieve “normallooking skin” after a square centimetre test patch, total blanching of colour after full treatment of a confluent port-wine stain of any significant size (occupying a full cosmetic unit or an anatomical area) is very exceptional and is given the high score of 3. We could not achieve this in any of our patients without adverse textural or pigmentory

changes. Lightening is considered Moderate when there is definite and pleasing change in colour (around 50% lightening). Marked lightening is anything approaching total blanching (around 7580% improvement). Included in the score for colour are pigmentory changes. Permanent undesirable change in skin pigmentation decreases any score made by lightening by one point. Olbricht et al. (1987) stated that pigmentory changes after argon laser occur so frequently that some authors would not consider them a complication. The blue-green light of the argon laser is absorbed by melanin in melanocytes and this can lead to hyper- or hypo-pigmentation. The former is usually temporary while the latter

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scribed in this paper defines a scar as atrophic when can be permanent. Pigmentory changes, should it is localised, whitish and depressed and as they occur, are usually associated with encouraging hypertrophic when it is elevated and pink-red in lightening of the red-purple colour of the port-wine stain and the score assigned to colour would be the colour. A negative score (1 or 2 depending on the type of the scar) is incurred when scarring affects a sum of the two (Table 1). Some patients, particularly those with large and significant portion (10% or more) or occupies a smooth port-wine stains, complain specifically of prominent and cosmetically sensitive part of the treated area. increased difficulty in applying cosmetic camouCareful preoperative assessment should identify flage after laser therapy. Others abandon it comand document scars or any other undesirable change pletely. A large proportion of patients, especially caused by previous treatments such as Thorium-X females, continue to use cosmetic cover even after or tattooing. Lightening which follows successful “successful” treatment of their stains. Applications of such make-up can become easier, less time- laser treatment can throw such pre-existing changes consuming, cheaper and more natural-looking by into focus. Care should be taken not to reduce the composite score by attributing them to the laser avoiding thick layering. Improvement in make-up technique can be attributed to a combination of therapy. The author’s method can be used to evaluate factors. These include overall lightening of colour, favourable textural changes, feathering out of a results of treatment of lesions other than port-wine stains. Adjustments can be made when any of the sharp outline (better blending with surrounding four parameters is not applicable to a particular normal skin) and, in extensive lesions, “removal” of those parts of the stain where the wearing of patient or lesion; composite score can then be make-up can be quite awkward, such as the central calculated as a percentage of the total score possible face, the temples and skin adjacent to hairlines. in the absence of the parameter which is not This is particularly true when such areas form the applicable to that particular situation (Fig. 5). periphery of the stain which is more responsive to The main criticism of the method is that it is the laser than is the centre (Fig. 2). largely subjective, relying on patients’ comments, It can be argued that modifications in make-up operator’s clinical judgement and the third party’s habits simply reflect changes in colour, texture and (acquaintance and nurse’s) impressions. However, scarring and may not merit consideration as a compared with systems of assessment currently separate parameter in assessment. Nevertheless, its available, it is flexible, gives a more elaborate addition provides valuable objective evidence of definition of parameters and, by including a scoring the degree of success and gives patients more say in system, introduces an element of objectivity. The assignment of results. Not infrequently, patients flexibility of the system can accommodate a are pleased with the result of treatment, the main measure of disagreement between the assessor, the benefit of which has been to enable them to wear patient and the third party (Table 2). Major make-up more easily and efficiently. differences are uncommon but final judgement is The laser can have a favourable or an adverse for the patient in scoring Make-up and Texture, for effect on skin texture. Reduction of skin coarseness the assessor in Scarring and for a majority in Colour. or sponginess of some port-wine stains is desirable and carries a positive score of 1. Fine nodules tend to disappear with ease, while the size of the larger Conchsion ones can be reduced. On the other hand, shininess of the skin and minor wrinkling can follow the With recognition of its limitations, a scoring system for designating results of laser treatment into treatment of smooth and confluent stains, especially Excellent, Good, Fair and Poor is described. It is those situated on the extremities. These changes hoped that this report may stimulate further are obviously undesirable and merit a negative attempts to standardise methods of assessment of score. Scar formation is the most serious hazard of laser therapy to facilitate meaningful comparison of results from different treatment centres. treatment. Its extent is difficult to quantify. Dixon et al. (1984) described a “scarring index” which is based on the size, elevation and colour of the scar. Acknowledgements Gilchrest et al. (1982) used a scoring system to All patients were seen and treated at the argon laser clinic. St grade scarring in test patches. The method de- Andrew’s Hospital, Billericay. The laser programme was

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Fig. 5 Figure %Following laser therapy of this rather unusual form of leg telangiectasia, total blanching of the colour was complemented by improved texture, The patient never considered wearing make-up prior to treatment and, in evaluating the result, this parameter was not considered. A score of4 is the maximum possible in this situation and hence the outcome is rated “Excellent”. (System 1000 Dermatologic Argon Laser-Coherent). initiated and supervised by Mr A. F. Wallace. The author would like to thank Mr M. E. J. Hackett, Mr J. V. Harvey Kemble, Mr B. C. Sommerlad, Mr C. C. Walker and Mr A. F. Wallace for allowing him to see and treat their patients. and Staff Nurse N. Keefe for her help in running the clinic and in the assessments. Members of the Photographic Department were responsible for the quality and standardisation of the colour pictures. The substance of this paper was presented at the Third

International Congress of the European Laser Association, Amsterdam, in Novement 1986, at the British Association of Plastic Surgeons Winter Meeting, London, in December 1986 and at the British Medical Laser Association Fifth Annual Conference, Edinburgh, in January 1987. The author acknowledges the generous contribution made by Coherent (UK) Ltd. Cambridge Science Park, Milton Road. Cambridge CB4 4FR. towards the cost of reproducing the colour photographs.

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References Apfelberg, D. B., Maser, M. R., Lash, H. and Rivers, J. (1981). The argon laser for cutaneous lesions. State of the art. Journal of the American Medical Association, 245, 2013. Craig, R. D. P., Purser, J. M., Lessells, A. M. and Hufton, A. P. (1985). Argon laser therapy for cutaneous lesions. British Journal of Plastic Surgery, 38. 148. Dixon, J. A., Huether, S. and Rotering R. (1984). Hypertrophic scarring in argon laser treatment of port-wine stains. PIastic and Reconstructive Surgery, 13, 77 1. Gilchrest, B. A., Rosen, S. and Noe, J. M. (1982). Chilling portwine stains improves the response to argon laser therapy. Plastic and Reconstructive Surgery, 69,278. Landthaler, M., Haina, D., Waidelich, W. and Braun-Falco, 0. (1984). A three-year experience with the argon laser in dermatotherapy. Journal of Dermatology and Surgical Oncology, 10.456.

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Olbricht, S. M., Stem, R. S., Tang, S. V., Not, J. M. and Amdt, K. A. (1987). Complications of cutaneous laser surgery. Archives of Dermatology, 123,345.

The Author A. A. Quaba, FRCSEd(Plast), Consultant Plastic Surgeon, Bangour General Hospital, Broxburn, West Lothian EH52 6LR; formerly Senior Registrar, North East Thames Regional Plastic Surgery Centre, St Andrew’s Hospital, Billericay. Essex. Requests

for reprints

to the author at Broxburn.

Paper received 3 June 1988. Accepted 13 July 1988 after revision