- Email: [email protected]
Flashlamp-pumped pulsed dye laser for port-wine stains in infancy: Earlier versus later treatment
I
I
II9
I
J
I
I
Flashlamp-pumped pulsed dye laser for port-wine stains in infancy: Earlier versus later treatment Robin Ashinoff, MD,* and Roy G. Geronemus, M D New York, New York Twelve children, 6 to 30 weeks of age (average 14.9 weeks), with port-wine stains of the head and neck were treated with the flashlamp-pumped pulsed dye laser at 585 nm and 450 microsecond pulse duration. Ten of 12 patients (83%) showed more than 50% lightening of their port-wine stains after 2.9 treatment sessions (2.9 __+1.4 [ ___standard deviation]). Forty-five percent of the patients demonstrated 75% or more lightening of their lesions after a mean of 3.8 treatments (+ 1.6). No lesions in this group cleared completely after a mean of 2.8 treatments. Treated skin was identical in texture to normal skin in all patients. There was no evidence of depressed scars, atrophy, hyperpigmentation, or hypopigmentation in the treated areas. These results indicate that pulsed dye laser treatment of port-wine stains can be undertaken safely in infancy. (J AM ACADDERMATOL1991;24:467-72.)
Port-wine stains (PWSs) affect 0.3% to 0.5% of newborns 1, 2 and are a congenital malformation of the superficial dermal vasculature, with ectatic capillary to venular-sized vessels in the papillary and upper reticular dermis. 3, 4 The skin discoloration is usually, but not always, visible at birth. The PWS is fiat and sharply demarcated in infancy and grows proportionately with the child. The color ranges from light pink to deep red in infancy or childhood and gradually darkens to a deep purple in middle age; coincidentally, the surface of the lesion becomes raised and nodular. 4"6 In addition, pyogenic granulomata are a frequent complication of PWS, especially intraoral lesions. 7 Patients often complain of bleeding after minor trauma to PWS. There may also be associated hypertrophy of the soft tissue and bone underlying the stain. Histologically, there is a correlation between age progression and an increase in the vascular area, mean vessel area, and percentage of vessels containing erythrocytes.6 In addition, a significant decrease in perivascular nerve density in PWS has been demonstrated; this may account for the decreased neural modulation of vascular tone and subsequent dilation of dermal vessels. 8 Collagen From the Department of Dermatology, New York University Medical Center. Reprint requests: Dr. Roy G. Geronemus, New York University Medical Center, Department of Dermatology, 560 First Avenue, New York, NY 10016. *Dr. Ashinoff is a Fellow in Dermatologic Surgery at the New York University Medical Center, Department of Dermatology.
l~/1/zs3n
degeneration that accompanies age can also weaken the supporting dermis and allow abnormal vessels to dilate. Persons with P W S suffer a considerable degree of psychological morbidity because most PWS occur on the face. 9-11 Treatment of children at the earliest possible age, especially before formal education begins and the child is forced to interact with many other children, could prevent considerable psychological impairment, prevent later complications, and provide for a more complete response. Therefore we have undertaken a study of 12 children who came for their first laser treatment between the ages of 6 and 30 weeks to study whether the earliest possible treatment of P W S with the flashlamp-pumped pulsed dye laser (PDL) is efficacious ar)d safe. MATERIAL AND METHODS Patients All children younger than 12 months of age who came for treatment of a PWS at the New York University Medical Center between January 1988 and November 1989 were included in the study. All patients were treated with the flashlamp-pumped pulsed dye laser. Parental informed consent was obtained before the procedure and risks and benefits were explained to parents. All treated patients were included in the final analysis. Laser A Candela SPTL-1 flashlamp pumped pulsed dye laser (Candela Corp., Wayland, Mass.) was used, with rhodamine in methanol as the dye, an emission wave467
468
Journal of the American Academy of Dermatology
Ashinoff and Geronemus
Fig. 1. Patient 9 before PDL treatment at age 12 weeks. Fig. 2. Patient 9 after three P D L treatments at age 28 weeks.
length of 585 nm, and a pulse duration of 450 microseconds. The laser beam was transmitted down a 1 mm fiber and, by the use of a planoconvex lens, was focused as a circular 5 m m spot. Energy densities were measured with an energy meter (Ophir, Jerusalem, Israel) calibrated to • 10% accuracy. Treatment protocol On the initial visit a test site of approximately 4.0 em 2 was selected on involved skin and exposed to 5.75 to 6.50 joules/cm 2 depending on the patient's age and the color of the lesion. The darker lesions were treated with the higher power densities. When the eyelid and neck were treated, the power density was decreased to 0.25 joule/ cm 2. Treatments were performed with a maximum spot overlap of 10%. The test site was evaluated at 1 month and, depending on the size of the involved area, a portion of or the entire PWS was treated; treatment was then repeated at 6- to 8-week intervals until the desired degree of lightening was achieved, If the response was not adequate, the power density was increased by 0.25 to 0.5 joule/cm 2 in later treatments. If the eyelids were treated, a gold-plated sterling silver eye-shield was used to protect the globe. The children were held by their parents and were given no premedication or local anesthetic. When five of the patients reached 6 months of age, their parents elected to have the P D L treatments done with the children under general anesthesia with a combination of halothane, nitrous oxide, and oxygen.
Immediately after treatment, the treated area turned blue-gray with a surrounding erythematous flare. Purpuric areas were noted in several hours; this took 7 to 14 days to resolve. Some edema was noted after treatment, especially in the periorbital area, which resolved in 24 to 72 hours. No textural changes after treatment were seen in treated skin. After treatment, mupirocin 2% ointment (Bactroban) was applied and then covered with a polyethylene oxide-water dressing (Vigilon). Parents were instructed to apply mupirocin ointment twice daily and to cleanse the area with hydrogen peroxide 3% if a crust formed. Parents were also instructed to keep their children's fingernails short to avoid trauma to the treated areas.
Photographs were taken of all patients before and 2 to 3 months after each treatment (Figs. 1,2, 3, and 4). Pretreatment and posttreatment photographs were projected simultaneously on a screen and evaluated by two medical photographers, one dermatologist not involved in this study, and the two investigators. Data were evaluated and organized according to a pattern similar to that of Garden et al. 12 Lesional lightening was assessed as the percentage of reduction in lesional color relative to normal skin color in 5% gradients with 100% rating used when the treated area was completely cleared to normal skin color. Scarring and atrophy were graded as follows: 0, no scars; + 1, epidermal alterations; +2, sclerosis; +3, hypertrophic scar. Depressions, hypopigmentation, and hyperpigmentation were recorded as present or absent. PWSs were judged as pale pink, red, or purple. These color ratings
Volume 24 Number 3 March 1991
PDL for port-wine stains in infants
469
Fig. 3. Patient 2 before PDL treatment at age 9 weeks. Fig. 4. Patient 2 after three PDL treatments at age 26 weeks.
were assigned a numeric designation as follows: 1, pale pink; 2, red; 3, purple. RESULTS
The characteristics of each patient are detailed in Table I. The patient groups consisted of six boys and six girls with an average age of 14.9 weeks at the start of PDL treatments and an average age of 45.6 weeks at the time of the last treatment. Eleven of the 12 patients had fair skin, whereas one patient had a darker complexion. This patient happened to have a 90% lightening, probably because she was one of the youngest patients. None of the patients had evidence of Sturge-Weber syndrome or glaucoma. The mean area of the PWSs was 65.9 cm 2 (range 8 to 168 cm2). Eight lesions were light pink and four were red. Overall the mean color value of the PWSs was 1.33 +_ 0.5 (mean + one standard deviation). In general, the red lesions required more treatments than the light pink lesions to achieve the same degree of lightening. The overall mean number of PDL treatments was 2.8 __ 1.4. The mean energy density used was 6.20 _+ 0.16 joules/cm 2. The mean percent lightening of the PWSs was 70.2 _+ 2.6. No patient showed less than 25% lightening. Two patients (18%) experienced between 26% and 49% lightening of their lesions after 2.5 _+ 0.7 treatments; five
patients (42%) experienced 50% to 74% tightening of their lesions after a mean of 2.0 + O.7 treatments; and five patients (42%) experienced more than 75% lightening of their lesions after a mean of 3,8 + 1.6 treatments. Overall 83% (10 of 12) of the patients showed 50% or more lightening of their lesions after a mean of 2.8 _+ 1.4 treatments. None of the patients experienced scarring, atrophy, hyperpigmentation, or hypopigrnentation. In general, the areas of the P W S s on the cheek or upper lip required more treatments than the neck or periocular areas to achieve the same degree of lightening. DISCUSSION
Numerous therapies have been used to treat PWS. These include excision and grafting, dermabrasion, cryosurgery, radiation therapy, and tattooing, all of which have uniformly yielded unsatisfactory results. The carbon dioxide laser] 3q7 neodymium:YAG laser, ta copper vapor laser (578 nm), ~9 and argon laster 6, 2o have been used to treat PWS in children; cosmetic results have been poor. The argon laser especially has been used extensively to treat PWS in children and adults. Because the argon laser's maximum output is at 488 and 514 nm and these wavelengths are absorbed strongly by he-
470
Journal of the American A c a d e m y of Dermatology
Ashinoff and Geronemus
T a b l e I. S u m m a r y of patients' characteristics
Patient/ Sex
Age (wk) at test treatment
Age (wk) last treatn~nt
1/F
12
40
2/F
9
26
3/F 4/M 5/M 6/M
12 8 8
36 20 88 24
7/F
24
40
8/M
30
40
9/F
12
28
10/M ll/F
20 24
88 72
12/M
14
32
6
J_ocation of PWS
Right side of forehead, eyelid Right side of face and neck Right cheek Left cheek Right cheek Right cheek, nose and eyelid Right side of forehead, cheek Right side of forehead Forehead, nose, upper lip Entire face Right cheek, forehead Right cheek, forehead
Average energy density
Mean % lightening of PWSf
Color of PWS*
Total No. of treatments
10 • 6
1
2
6.38
70•
10 X 8
1
3
6.00
85+_0
10 X 6 1• 8 10 x 8 10 • 8
1 1 2 1
3 2 3 2
6.08 6.25 6.00 6.00
33 68 67 36
10 x 8.5
1
2
6.25
81 + 2 . 2
2 X4
1
1
6.50
71 _.+ 2.2
6 X8
2
3
6.17
90 • 3.5
12 • 14 10 X9
2 2
6 5
6.29 6.30
76 • 8.2 93 + 2.7
6• 4
1
2
6.25
72.5 +_ 2.9
Size of PWS (cm)
(Uem~)
+_ 2.9 __. 4.5 • 4.5 • 8.2
*Color of PWS is rated as follows: 0, normal skin color; I, pale pink; 2, red; 3, purple. ~'This mean value is calculated from the values given by five evalaators.
moglobin, in theory the argon laser should be effective in treatment. 21' 22 M u c h data have been accumulated on the treatment of P W S with the argon laser ~. 13, 2o, 23, ~4 In facial and neck lesions, clinical improvement has been seen in 60% to 75% of patients.S0, 23, zs However, hypertrophic scarring, which is the chief complication of argon laser therapy, occurs in 9% to 26% of patients. 6, 20, 22, 24 Consideration of factors predictive of hypertrophic scarring has revealed that patients younger than 17 years of age with pale pink lesions and with lesions that histologically show less vascularity are the group likely to have a poor result. 6 This group therefore includes infants and children. Scheibner et al. 19 reported better results with the continuous-wave (577 nm) dye laser with magnification and tracing vessels with a small spot size and very low dosages. This technique is time-consuming and tedious and would be unsuitable for the treatment of young children. The PDL, when compared with the argon laser, is the only one that produces intravascular thrombus formation without epidermal and dermal damage.n, 16,26-30 The P D L has now been studied ex-
tensively and is generally accepted as the treatment of choice for macular PWSs. 12, 27-33 In accordance with the theory of selective photothermolysis, 34 the PDL selectively causes blood vessel damage. By virtue of a maximum emission wavelength of 577 rim, which is one of the three wavelengths of light maximally absorbed by oxyhemoglobin, and a pulse duration less than 1 msec, 3~which is less than the thermal relaxation time of dermal vessels, 35 the PDL is ideally suited for selective damage of these vessels. Recently, however, one study has shown that by increasing the laser's emission wavelength to 585 nm, deeper vascular destruction, maintenance of specificity, and, therefore, a better clinical response could be achieved.36 Several clinical trials with the P D L have been reported. One earlier study by Tan and Stafford29 involved 65 patients of all ages with PWS. All patients were successfully treated without any permanent changes in skin texture. Garden et al. a2 treated 52 patients with PWS and 73% of these patients had a 50% or greater lightening of their lesions with no evidence of permanent scarring. Glassberg et al. 27
Volume 24 Number 3 March 1991
studied 28 patients with P W S and showed an overall lightening response o f 93%; only one patient had scarring because of a technical error in miscalibration of energy density. T h e study by T a n et al. 32 of 35 children aged 3 months to 14 years with P W S showed a 100% rate of complete response after an average of 6.5 laser treatments. All patients in this study had light pink to red lesions, which are known to respond more favorably. 12 In contrast, another study from this institution of 73 patients with P W S between the ages of 3 months to 14 years showed 87% of these patients had a 50% or more lightening of their lesions after an average of 2.5 treatments. 37 These results are more consistent with those of G a r d e n et al.12 T h e study by Tan and Stafford 29 and the previous report of children from this institution do agree that patients younger than 7 years of age require fewer treatments to attain the same degree of response. Several factors contribute to a greater response in younger patients. The lesions in children are smaller overall and the vessels are more superficial and of small diameter. Although our sample size is small, it is consistent with previous reports 32, 36thatindicatedthatyounger patients required fewer treatments to achieve the same response. W e have shown that infants only a few weeks old undergo P D L with little morbidity and are likely to have a m u c h less evident lesion by the time they are psychologically aware. N o n e of our p a t i e n t s experienced permanent scarring, atrophy, hyperpigmentation, or hypopigmentation. There were also no ill effects noted in those children in whom general anesthesia was used. It is important that pediatricians, who usually have the first opportunity to counsel parents of infants with P W S , become aware that early P D L treatment is safe and effective. W e believe that there is sufficient evidence to support the earliest possible treatment of P W S to prevent physical and psychological complications. However, a prospective clinical trial is necessary to confirm these data. REFERENCES 1. Jacobs AH, Walton RG. The incidenceofbirthmarks in the neonate. Pediatrics 1976;58:218-22. 2. Pratt AG. Birthmarks in infants. Arch Dermatol 1953; 67:302-5. 3. Barsky SH, Rosen S, Geer DE, et al. The nature and evolution of port wine stains: a computer-assistedstudy. J Invest Dermatol 1980;74:154-7.
PDL for port-wine stains in infants
471
4. Mulliken JB. Capillary (port-wine) and other telangieetatic stains. In: Mulliken JB, Young A_E, eds. Vascular birthmarks--hemangiomas and malformations. Philadelphia: WB Saunders, 1988:179-95. 5. Tang SV, Gilchrest BA, Noe JM, et al. In vivo spectrophotometric evaluation of normal, lesional and laser treated skin in patients with port-wine stains. J Invest Derrnatol 1983;80:420-3. 6. Noe JM, Barsky SH, Geer DE, et al. Port wine stains and the response to argon laser therapy: successful treatment and the predictive role of color, age and biopsy. Plast Reconstr Surg 1980;65:130-6. 7. Swerliek RA, Cooper PH. Pyogenic granuloma (lobular capillary hemangioma) within port-wine stains. J AM ACAD DERMATOL1983;8:627-30. 8. Smoller BR, Rosen S. Port-wine stains: A disease of altered neural modulation of blood vessels? Arch Dermatol 1986; 122:177-9. 9. Lanigan SW, Cotterill JA. Psychological disabilities amongst patients with port wine stains. Br J Dermatol 1989;121:209-15. 10. Harrison AM. The emotional impact of a vascular birthmark. In: Mulliken JB, Young AE, eds. Vascular birthmarks--hemangiomas and malformation. Philadelphia: WB Saunders, 1988:455-62. 11. Heller A, Rafman S, Zvagulis I, et al. Birth defects and psychosocial adjustment. Am J Dis Child 1985;139:25763. 12. Gat'den JM, Polla LL, Tan OT. The treatment of port-wine stains with the pulsed dye laser. Arch Dermatol 1988; 124:889-96. 13. Dixon JA, Huether S, Rotering R. Hypertrophic scarfing in argon laser treatment of port-wine stains. Plast Reconstr Surg 1984;73:771-7. 14. Van Gemert MJC, Welch A J, Tan OT, et al. Limitations of CO2 lasers for treatment of portwine stains. Lasers Surg Med 1986;6:76-83. 15. Buecker JW, Ratz JL, Richfield DF. Histology of portwine stains treated with carbon dioxide laser. J AM ACAD DERMATOL1984;10:1014-9. 16. Tan OT, Carney M, Margolis R, et al. Histologic response of port-wine stains treated by argon, carbon dioxide and tunable dye lasers. Arch Dermatol 1986;122:1016-22. 17. Ratz JL, Bailin PL, Levine HL. CO2 laser treatment of portwine stains: a preliminary report. J Dermatol Surg Oncol 1982;8:1039-44. 18. Dixon JA, Gilbertson JJ. Argon and neodymium:YAG laser therapy of dark nodular portwine stains in older patients. Lasers Surg Med 1986;6:5-11. 19. Seheibner A, Applebaum J, Wheeland RG. Treatment of port wine hemangiomas in children. Lasers Surg Med 1989;l(suppl):42. 20. Cosman B. Experience in the argon laser therapy of port wine stains. Plast Recenstr Surg 1980;65:119-29. 21. Arndt KA, Noe JM, Northam DBC, et al. Laser therapy. J AM ACADDERMATOL1981;5:649-54. 22. Apfelberg DB, Kosek J, Maser MR, et al. Histology of port wine stains followingargon laser treatment. Br J Plast Surg 1979;32:232-7. 23. Goldman L. The argon laser and the port wine stain. Plast Reconstr Surg 1980;65:137-9. 24. Apfelberg DB, Maser MR, Lash H, et al. The argon laser for cutaneous lesions. JAMA 1981;245:2073-5. 25. Goldman L, Dreffer R. Laser treatment of extensive mixed
472
Ashinoff and Geronemus
cavernous and port wine stains. Arch Dermatol 1977; 113:504-5. 26. Landthaler M, Haina D, Brurmer R, et al. Effects of argon, dye and Nd:YAG lasers on epidermis, dermis and venous vessels. Lasers Surg Med 1986;6:87-93. 27. Glassberg E, Lask GP, Tan EML, et al. The flashlamppumped 577-nm pulsed tunable dye laser: clinical efficacy and in vitro studies. J Dermatol Surg Oncol 1988;14: 1200-8. 28. Morelli JG, Tan OT, Garden J, et al. Tunable dye laser (577 nm) treatment of port wine stains. Lasers Surg Meal
1986;6:94-9. 29. Tan 0 % Stafford "1"3.Treatment of port-wine stains at 577 rim: clinical results. Meal Instrum 1987;21:218-21. 30. Garden JM, Tan OT, Kerschmann R, et al. Effect of laser pulse duration on selective cutaneous vascular injury. J Invest Dermatol 1986;87:653-7. 31. Tan OT, Gilchrest BA. Laser therapy for selected cutaneous vascular lesions in the pediatric population: a review. Pediatrics 1988;82:652-62.
Journal of the American Academy of Dermatology
32. Tan OT, Sherweod K, Gilchrast BA. Treatment of children with port-wine stains using the flashlamp-pulsed tunable dye laser. N Engl J Med 1989;320:416-21. 33. Dover JS, Arndt KA, Geronemus RG, et al. Dye lasers. In: Illustrated cutaneous laser surgery: a practitioner's guide. Norwalk Corm: Appleton & Lange, 1990:108-20. 34. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-7. 35. Tan CY, Statham B, Marks R, et al. Skin thickness measurements by pulsed ultrasound: its reproducibility, validation and variability. Br J Dermatol 1982;106:657-67. 36. Tan 0 % Murray S, Kurban A. Action spectrum of vascular specific injury using pulsed irradiation. J Invest Dermatol 1989;92:868-71. 37. Reyes BA, Geronemus RG. Treatment of port-wine stains during childhood with the flashlamp-pumped pulsed dye laser. J AM ACAD DERMATOL 1990;23:1142-8.
I
II9
I
J
I
I
Flashlamp-pumped pulsed dye laser for port-wine stains in infancy: Earlier versus later treatment Robin Ashinoff, MD,* and Roy G. Geronemus, M D New York, New York Twelve children, 6 to 30 weeks of age (average 14.9 weeks), with port-wine stains of the head and neck were treated with the flashlamp-pumped pulsed dye laser at 585 nm and 450 microsecond pulse duration. Ten of 12 patients (83%) showed more than 50% lightening of their port-wine stains after 2.9 treatment sessions (2.9 __+1.4 [ ___standard deviation]). Forty-five percent of the patients demonstrated 75% or more lightening of their lesions after a mean of 3.8 treatments (+ 1.6). No lesions in this group cleared completely after a mean of 2.8 treatments. Treated skin was identical in texture to normal skin in all patients. There was no evidence of depressed scars, atrophy, hyperpigmentation, or hypopigmentation in the treated areas. These results indicate that pulsed dye laser treatment of port-wine stains can be undertaken safely in infancy. (J AM ACADDERMATOL1991;24:467-72.)
Port-wine stains (PWSs) affect 0.3% to 0.5% of newborns 1, 2 and are a congenital malformation of the superficial dermal vasculature, with ectatic capillary to venular-sized vessels in the papillary and upper reticular dermis. 3, 4 The skin discoloration is usually, but not always, visible at birth. The PWS is fiat and sharply demarcated in infancy and grows proportionately with the child. The color ranges from light pink to deep red in infancy or childhood and gradually darkens to a deep purple in middle age; coincidentally, the surface of the lesion becomes raised and nodular. 4"6 In addition, pyogenic granulomata are a frequent complication of PWS, especially intraoral lesions. 7 Patients often complain of bleeding after minor trauma to PWS. There may also be associated hypertrophy of the soft tissue and bone underlying the stain. Histologically, there is a correlation between age progression and an increase in the vascular area, mean vessel area, and percentage of vessels containing erythrocytes.6 In addition, a significant decrease in perivascular nerve density in PWS has been demonstrated; this may account for the decreased neural modulation of vascular tone and subsequent dilation of dermal vessels. 8 Collagen From the Department of Dermatology, New York University Medical Center. Reprint requests: Dr. Roy G. Geronemus, New York University Medical Center, Department of Dermatology, 560 First Avenue, New York, NY 10016. *Dr. Ashinoff is a Fellow in Dermatologic Surgery at the New York University Medical Center, Department of Dermatology.
l~/1/zs3n
degeneration that accompanies age can also weaken the supporting dermis and allow abnormal vessels to dilate. Persons with P W S suffer a considerable degree of psychological morbidity because most PWS occur on the face. 9-11 Treatment of children at the earliest possible age, especially before formal education begins and the child is forced to interact with many other children, could prevent considerable psychological impairment, prevent later complications, and provide for a more complete response. Therefore we have undertaken a study of 12 children who came for their first laser treatment between the ages of 6 and 30 weeks to study whether the earliest possible treatment of P W S with the flashlamp-pumped pulsed dye laser (PDL) is efficacious ar)d safe. MATERIAL AND METHODS Patients All children younger than 12 months of age who came for treatment of a PWS at the New York University Medical Center between January 1988 and November 1989 were included in the study. All patients were treated with the flashlamp-pumped pulsed dye laser. Parental informed consent was obtained before the procedure and risks and benefits were explained to parents. All treated patients were included in the final analysis. Laser A Candela SPTL-1 flashlamp pumped pulsed dye laser (Candela Corp., Wayland, Mass.) was used, with rhodamine in methanol as the dye, an emission wave467
468
Journal of the American Academy of Dermatology
Ashinoff and Geronemus
Fig. 1. Patient 9 before PDL treatment at age 12 weeks. Fig. 2. Patient 9 after three P D L treatments at age 28 weeks.
length of 585 nm, and a pulse duration of 450 microseconds. The laser beam was transmitted down a 1 mm fiber and, by the use of a planoconvex lens, was focused as a circular 5 m m spot. Energy densities were measured with an energy meter (Ophir, Jerusalem, Israel) calibrated to • 10% accuracy. Treatment protocol On the initial visit a test site of approximately 4.0 em 2 was selected on involved skin and exposed to 5.75 to 6.50 joules/cm 2 depending on the patient's age and the color of the lesion. The darker lesions were treated with the higher power densities. When the eyelid and neck were treated, the power density was decreased to 0.25 joule/ cm 2. Treatments were performed with a maximum spot overlap of 10%. The test site was evaluated at 1 month and, depending on the size of the involved area, a portion of or the entire PWS was treated; treatment was then repeated at 6- to 8-week intervals until the desired degree of lightening was achieved, If the response was not adequate, the power density was increased by 0.25 to 0.5 joule/cm 2 in later treatments. If the eyelids were treated, a gold-plated sterling silver eye-shield was used to protect the globe. The children were held by their parents and were given no premedication or local anesthetic. When five of the patients reached 6 months of age, their parents elected to have the P D L treatments done with the children under general anesthesia with a combination of halothane, nitrous oxide, and oxygen.
Immediately after treatment, the treated area turned blue-gray with a surrounding erythematous flare. Purpuric areas were noted in several hours; this took 7 to 14 days to resolve. Some edema was noted after treatment, especially in the periorbital area, which resolved in 24 to 72 hours. No textural changes after treatment were seen in treated skin. After treatment, mupirocin 2% ointment (Bactroban) was applied and then covered with a polyethylene oxide-water dressing (Vigilon). Parents were instructed to apply mupirocin ointment twice daily and to cleanse the area with hydrogen peroxide 3% if a crust formed. Parents were also instructed to keep their children's fingernails short to avoid trauma to the treated areas.
Photographs were taken of all patients before and 2 to 3 months after each treatment (Figs. 1,2, 3, and 4). Pretreatment and posttreatment photographs were projected simultaneously on a screen and evaluated by two medical photographers, one dermatologist not involved in this study, and the two investigators. Data were evaluated and organized according to a pattern similar to that of Garden et al. 12 Lesional lightening was assessed as the percentage of reduction in lesional color relative to normal skin color in 5% gradients with 100% rating used when the treated area was completely cleared to normal skin color. Scarring and atrophy were graded as follows: 0, no scars; + 1, epidermal alterations; +2, sclerosis; +3, hypertrophic scar. Depressions, hypopigmentation, and hyperpigmentation were recorded as present or absent. PWSs were judged as pale pink, red, or purple. These color ratings
Volume 24 Number 3 March 1991
PDL for port-wine stains in infants
469
Fig. 3. Patient 2 before PDL treatment at age 9 weeks. Fig. 4. Patient 2 after three PDL treatments at age 26 weeks.
were assigned a numeric designation as follows: 1, pale pink; 2, red; 3, purple. RESULTS
The characteristics of each patient are detailed in Table I. The patient groups consisted of six boys and six girls with an average age of 14.9 weeks at the start of PDL treatments and an average age of 45.6 weeks at the time of the last treatment. Eleven of the 12 patients had fair skin, whereas one patient had a darker complexion. This patient happened to have a 90% lightening, probably because she was one of the youngest patients. None of the patients had evidence of Sturge-Weber syndrome or glaucoma. The mean area of the PWSs was 65.9 cm 2 (range 8 to 168 cm2). Eight lesions were light pink and four were red. Overall the mean color value of the PWSs was 1.33 +_ 0.5 (mean + one standard deviation). In general, the red lesions required more treatments than the light pink lesions to achieve the same degree of lightening. The overall mean number of PDL treatments was 2.8 __ 1.4. The mean energy density used was 6.20 _+ 0.16 joules/cm 2. The mean percent lightening of the PWSs was 70.2 _+ 2.6. No patient showed less than 25% lightening. Two patients (18%) experienced between 26% and 49% lightening of their lesions after 2.5 _+ 0.7 treatments; five
patients (42%) experienced 50% to 74% tightening of their lesions after a mean of 2.0 + O.7 treatments; and five patients (42%) experienced more than 75% lightening of their lesions after a mean of 3,8 + 1.6 treatments. Overall 83% (10 of 12) of the patients showed 50% or more lightening of their lesions after a mean of 2.8 _+ 1.4 treatments. None of the patients experienced scarring, atrophy, hyperpigmentation, or hypopigrnentation. In general, the areas of the P W S s on the cheek or upper lip required more treatments than the neck or periocular areas to achieve the same degree of lightening. DISCUSSION
Numerous therapies have been used to treat PWS. These include excision and grafting, dermabrasion, cryosurgery, radiation therapy, and tattooing, all of which have uniformly yielded unsatisfactory results. The carbon dioxide laser] 3q7 neodymium:YAG laser, ta copper vapor laser (578 nm), ~9 and argon laster 6, 2o have been used to treat PWS in children; cosmetic results have been poor. The argon laser especially has been used extensively to treat PWS in children and adults. Because the argon laser's maximum output is at 488 and 514 nm and these wavelengths are absorbed strongly by he-
470
Journal of the American A c a d e m y of Dermatology
Ashinoff and Geronemus
T a b l e I. S u m m a r y of patients' characteristics
Patient/ Sex
Age (wk) at test treatment
Age (wk) last treatn~nt
1/F
12
40
2/F
9
26
3/F 4/M 5/M 6/M
12 8 8
36 20 88 24
7/F
24
40
8/M
30
40
9/F
12
28
10/M ll/F
20 24
88 72
12/M
14
32
6
J_ocation of PWS
Right side of forehead, eyelid Right side of face and neck Right cheek Left cheek Right cheek Right cheek, nose and eyelid Right side of forehead, cheek Right side of forehead Forehead, nose, upper lip Entire face Right cheek, forehead Right cheek, forehead
Average energy density
Mean % lightening of PWSf
Color of PWS*
Total No. of treatments
10 • 6
1
2
6.38
70•
10 X 8
1
3
6.00
85+_0
10 X 6 1• 8 10 x 8 10 • 8
1 1 2 1
3 2 3 2
6.08 6.25 6.00 6.00
33 68 67 36
10 x 8.5
1
2
6.25
81 + 2 . 2
2 X4
1
1
6.50
71 _.+ 2.2
6 X8
2
3
6.17
90 • 3.5
12 • 14 10 X9
2 2
6 5
6.29 6.30
76 • 8.2 93 + 2.7
6• 4
1
2
6.25
72.5 +_ 2.9
Size of PWS (cm)
(Uem~)
+_ 2.9 __. 4.5 • 4.5 • 8.2
*Color of PWS is rated as follows: 0, normal skin color; I, pale pink; 2, red; 3, purple. ~'This mean value is calculated from the values given by five evalaators.
moglobin, in theory the argon laser should be effective in treatment. 21' 22 M u c h data have been accumulated on the treatment of P W S with the argon laser ~. 13, 2o, 23, ~4 In facial and neck lesions, clinical improvement has been seen in 60% to 75% of patients.S0, 23, zs However, hypertrophic scarring, which is the chief complication of argon laser therapy, occurs in 9% to 26% of patients. 6, 20, 22, 24 Consideration of factors predictive of hypertrophic scarring has revealed that patients younger than 17 years of age with pale pink lesions and with lesions that histologically show less vascularity are the group likely to have a poor result. 6 This group therefore includes infants and children. Scheibner et al. 19 reported better results with the continuous-wave (577 nm) dye laser with magnification and tracing vessels with a small spot size and very low dosages. This technique is time-consuming and tedious and would be unsuitable for the treatment of young children. The PDL, when compared with the argon laser, is the only one that produces intravascular thrombus formation without epidermal and dermal damage.n, 16,26-30 The P D L has now been studied ex-
tensively and is generally accepted as the treatment of choice for macular PWSs. 12, 27-33 In accordance with the theory of selective photothermolysis, 34 the PDL selectively causes blood vessel damage. By virtue of a maximum emission wavelength of 577 rim, which is one of the three wavelengths of light maximally absorbed by oxyhemoglobin, and a pulse duration less than 1 msec, 3~which is less than the thermal relaxation time of dermal vessels, 35 the PDL is ideally suited for selective damage of these vessels. Recently, however, one study has shown that by increasing the laser's emission wavelength to 585 nm, deeper vascular destruction, maintenance of specificity, and, therefore, a better clinical response could be achieved.36 Several clinical trials with the P D L have been reported. One earlier study by Tan and Stafford29 involved 65 patients of all ages with PWS. All patients were successfully treated without any permanent changes in skin texture. Garden et al. a2 treated 52 patients with PWS and 73% of these patients had a 50% or greater lightening of their lesions with no evidence of permanent scarring. Glassberg et al. 27
Volume 24 Number 3 March 1991
studied 28 patients with P W S and showed an overall lightening response o f 93%; only one patient had scarring because of a technical error in miscalibration of energy density. T h e study by T a n et al. 32 of 35 children aged 3 months to 14 years with P W S showed a 100% rate of complete response after an average of 6.5 laser treatments. All patients in this study had light pink to red lesions, which are known to respond more favorably. 12 In contrast, another study from this institution of 73 patients with P W S between the ages of 3 months to 14 years showed 87% of these patients had a 50% or more lightening of their lesions after an average of 2.5 treatments. 37 These results are more consistent with those of G a r d e n et al.12 T h e study by Tan and Stafford 29 and the previous report of children from this institution do agree that patients younger than 7 years of age require fewer treatments to attain the same degree of response. Several factors contribute to a greater response in younger patients. The lesions in children are smaller overall and the vessels are more superficial and of small diameter. Although our sample size is small, it is consistent with previous reports 32, 36thatindicatedthatyounger patients required fewer treatments to achieve the same response. W e have shown that infants only a few weeks old undergo P D L with little morbidity and are likely to have a m u c h less evident lesion by the time they are psychologically aware. N o n e of our p a t i e n t s experienced permanent scarring, atrophy, hyperpigmentation, or hypopigmentation. There were also no ill effects noted in those children in whom general anesthesia was used. It is important that pediatricians, who usually have the first opportunity to counsel parents of infants with P W S , become aware that early P D L treatment is safe and effective. W e believe that there is sufficient evidence to support the earliest possible treatment of P W S to prevent physical and psychological complications. However, a prospective clinical trial is necessary to confirm these data. REFERENCES 1. Jacobs AH, Walton RG. The incidenceofbirthmarks in the neonate. Pediatrics 1976;58:218-22. 2. Pratt AG. Birthmarks in infants. Arch Dermatol 1953; 67:302-5. 3. Barsky SH, Rosen S, Geer DE, et al. The nature and evolution of port wine stains: a computer-assistedstudy. J Invest Dermatol 1980;74:154-7.
PDL for port-wine stains in infants
471
4. Mulliken JB. Capillary (port-wine) and other telangieetatic stains. In: Mulliken JB, Young A_E, eds. Vascular birthmarks--hemangiomas and malformations. Philadelphia: WB Saunders, 1988:179-95. 5. Tang SV, Gilchrest BA, Noe JM, et al. In vivo spectrophotometric evaluation of normal, lesional and laser treated skin in patients with port-wine stains. J Invest Derrnatol 1983;80:420-3. 6. Noe JM, Barsky SH, Geer DE, et al. Port wine stains and the response to argon laser therapy: successful treatment and the predictive role of color, age and biopsy. Plast Reconstr Surg 1980;65:130-6. 7. Swerliek RA, Cooper PH. Pyogenic granuloma (lobular capillary hemangioma) within port-wine stains. J AM ACAD DERMATOL1983;8:627-30. 8. Smoller BR, Rosen S. Port-wine stains: A disease of altered neural modulation of blood vessels? Arch Dermatol 1986; 122:177-9. 9. Lanigan SW, Cotterill JA. Psychological disabilities amongst patients with port wine stains. Br J Dermatol 1989;121:209-15. 10. Harrison AM. The emotional impact of a vascular birthmark. In: Mulliken JB, Young AE, eds. Vascular birthmarks--hemangiomas and malformation. Philadelphia: WB Saunders, 1988:455-62. 11. Heller A, Rafman S, Zvagulis I, et al. Birth defects and psychosocial adjustment. Am J Dis Child 1985;139:25763. 12. Gat'den JM, Polla LL, Tan OT. The treatment of port-wine stains with the pulsed dye laser. Arch Dermatol 1988; 124:889-96. 13. Dixon JA, Huether S, Rotering R. Hypertrophic scarfing in argon laser treatment of port-wine stains. Plast Reconstr Surg 1984;73:771-7. 14. Van Gemert MJC, Welch A J, Tan OT, et al. Limitations of CO2 lasers for treatment of portwine stains. Lasers Surg Med 1986;6:76-83. 15. Buecker JW, Ratz JL, Richfield DF. Histology of portwine stains treated with carbon dioxide laser. J AM ACAD DERMATOL1984;10:1014-9. 16. Tan OT, Carney M, Margolis R, et al. Histologic response of port-wine stains treated by argon, carbon dioxide and tunable dye lasers. Arch Dermatol 1986;122:1016-22. 17. Ratz JL, Bailin PL, Levine HL. CO2 laser treatment of portwine stains: a preliminary report. J Dermatol Surg Oncol 1982;8:1039-44. 18. Dixon JA, Gilbertson JJ. Argon and neodymium:YAG laser therapy of dark nodular portwine stains in older patients. Lasers Surg Med 1986;6:5-11. 19. Seheibner A, Applebaum J, Wheeland RG. Treatment of port wine hemangiomas in children. Lasers Surg Med 1989;l(suppl):42. 20. Cosman B. Experience in the argon laser therapy of port wine stains. Plast Recenstr Surg 1980;65:119-29. 21. Arndt KA, Noe JM, Northam DBC, et al. Laser therapy. J AM ACADDERMATOL1981;5:649-54. 22. Apfelberg DB, Kosek J, Maser MR, et al. Histology of port wine stains followingargon laser treatment. Br J Plast Surg 1979;32:232-7. 23. Goldman L. The argon laser and the port wine stain. Plast Reconstr Surg 1980;65:137-9. 24. Apfelberg DB, Maser MR, Lash H, et al. The argon laser for cutaneous lesions. JAMA 1981;245:2073-5. 25. Goldman L, Dreffer R. Laser treatment of extensive mixed
472
Ashinoff and Geronemus
cavernous and port wine stains. Arch Dermatol 1977; 113:504-5. 26. Landthaler M, Haina D, Brurmer R, et al. Effects of argon, dye and Nd:YAG lasers on epidermis, dermis and venous vessels. Lasers Surg Med 1986;6:87-93. 27. Glassberg E, Lask GP, Tan EML, et al. The flashlamppumped 577-nm pulsed tunable dye laser: clinical efficacy and in vitro studies. J Dermatol Surg Oncol 1988;14: 1200-8. 28. Morelli JG, Tan OT, Garden J, et al. Tunable dye laser (577 nm) treatment of port wine stains. Lasers Surg Meal
1986;6:94-9. 29. Tan 0 % Stafford "1"3.Treatment of port-wine stains at 577 rim: clinical results. Meal Instrum 1987;21:218-21. 30. Garden JM, Tan OT, Kerschmann R, et al. Effect of laser pulse duration on selective cutaneous vascular injury. J Invest Dermatol 1986;87:653-7. 31. Tan OT, Gilchrest BA. Laser therapy for selected cutaneous vascular lesions in the pediatric population: a review. Pediatrics 1988;82:652-62.
Journal of the American Academy of Dermatology
32. Tan OT, Sherweod K, Gilchrast BA. Treatment of children with port-wine stains using the flashlamp-pulsed tunable dye laser. N Engl J Med 1989;320:416-21. 33. Dover JS, Arndt KA, Geronemus RG, et al. Dye lasers. In: Illustrated cutaneous laser surgery: a practitioner's guide. Norwalk Corm: Appleton & Lange, 1990:108-20. 34. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-7. 35. Tan CY, Statham B, Marks R, et al. Skin thickness measurements by pulsed ultrasound: its reproducibility, validation and variability. Br J Dermatol 1982;106:657-67. 36. Tan 0 % Murray S, Kurban A. Action spectrum of vascular specific injury using pulsed irradiation. J Invest Dermatol 1989;92:868-71. 37. Reyes BA, Geronemus RG. Treatment of port-wine stains during childhood with the flashlamp-pumped pulsed dye laser. J AM ACAD DERMATOL 1990;23:1142-8.