INTRODUCTION — Lasers and intense pulsed light (IPL) are used for the treatment of multiple cutaneous vascular lesions including telangiectasias, port wine stains (PWS; also called port wine birthmarks), and infantile hemangiomas. During treatment, the absorption of light energy by intravascular oxyhemoglobin leads to heating and coagulation of lesional blood vessels. The responses of vascular lesions to therapy are influenced by the type of light source used, the clinical characteristics of the target lesion, and patient-specific factors (eg, skin color, patient age).
Although laser and IPL therapy can result in clinical benefits, treatment is not innocuous. Cutaneous and ocular damage can occur if clinicians are not vigilant. The use of appropriate equipment settings, skin cooling mechanisms, and other safety measures minimize the occurrence of adverse events due to treatment.
The types of lasers used in the treatment of vascular lesions as well as the efficacy and clinical use of lasers for the treatment of PWS, infantile hemangiomas, and telangiectasias will be discussed here. The general principles of medical lasers, the principles of light therapy for the treatment of skin, and laser and light therapy for lower extremity telangiectasias and veins are reviewed elsewhere. (See "Basic principles of medical lasers" and "Principles of laser and intense pulsed light for cutaneous lesions".)
PRINCIPLES — The theory of selective photothermolysis describes the method through which lasers or intense pulsed light (IPL) can be used to selectively destroy specific targets in the skin while minimizing damage to other cutaneous structures [1]. In concordance with this theory, light energy must be delivered in a manner that results in preferential absorption of light by light-absorbing molecules (chromophores) located within the target. The absorption of light energy by chromophores leads to heating and coagulation of the target. In order to limit collateral damage, the diffusion of heat to adjacent tissues must also be minimized. The principles of laser and light therapy for cutaneous lesions are reviewed in greater detail elsewhere. (See "Principles of laser and intense pulsed light for cutaneous lesions".)
The major chromophore targeted during therapy of vascular lesions is generally oxyhemoglobin, although absorption by other hemoglobin species including deoxyhemoglobin and methemoglobin can also occur. Significant light absorption by oxyhemoglobin occurs in the range of yellow and green light; peak absorption occurs at 418, 542, and 577 nm [1]. A lower peak of light absorption by oxyhemoglobin occurs in the near-infrared light range. Thus, lasers that emit wavelengths of light near the primary absorption peaks of oxyhemoglobin, such as the 585 or 595 nm pulsed dye and the 532 nm frequency-doubled neodymium:yttrium aluminum garnet (Nd:YAG) lasers, are often favored for the treatment of vascular lesions. Infrared-range lasers (1064 nm Nd:YAG, alexandrite, or diode) can also be effective for this indication but are associated with a greater risk for tissue damage and ulceration.
The potential for light absorption by melanin, another chromophore ubiquitously present in the skin, must be considered prior to the treatment of vascular lesions. Light absorption by melanin progressively increases as wavelengths of light decrease, leading to a relatively higher risk of dyspigmentation secondary to melanin absorption with the use of shorter wavelengths of light. This is of particular concern in patients with dark skin, in whom epidermal melanin is abundant. Epidermal skin cooling techniques and adjustments to laser settings can be used to reduce the incidence of adverse effects secondary to epidermal melanin absorption [2]. Absorption of light by epidermal melanin can also affect the efficacy of treatment through reducing the amount of light that reaches vessels in the dermis. (See "Principles of laser and intense pulsed light for cutaneous lesions", section on 'Skin cooling'.)
Although the absorption of light by superficial chromophores can influence the amount of light that reaches deep tissues, the wavelength of emitted light is a critical factor for determining the depth to which light penetrates the skin. Longer wavelengths of light are capable of penetrating the skin more deeply than shorter wavelengths. As an example, in a patient with Fitzpatrick skin type II (table 1), light with a 585 nm wavelength may penetrate roughly 0.65 mm into the skin, while 595 nm may reach a depth of approximately 1 mm [2]. (See "Principles of laser and intense pulsed light for cutaneous lesions", section on 'Wavelength'.)
Because short wavelengths of light penetrate the skin only superficially, long wavelengths, such as those in the near-infrared range, are required to reach vessels that are deeper than the upper dermis. This feature plus a relatively high risk of light absorption by epidermal melanin are the primary reasons that lasers with wavelengths near the 418 nm peak of oxyhemoglobin light absorption are generally avoided in the treatment of vascular lesions. Since target vascular lesions often contain vessels at variable depths, using lasers of different wavelengths over the course of several treatments can be useful for achieving desired clinical effects.
Other laser settings that influence the efficacy of laser and light therapy for vascular lesions include the pulse duration, fluence (energy delivered per unit area), and spot size. Pulse durations equal to or shorter than the vessel thermal relaxation time (time required for a target to lose accumulated heat) are often used to reduce the risk of damage to surrounding structures. Pulse durations that exceed a structure's thermal relaxation time allow the diffusion of heat to adjacent structures, increasing the risk for collateral damage in the skin. The thermal relaxation times for vessels in port wine stains (typically 10 to 300 microm in diameter) range from 1 to 10 ms [3,4]. (See "Principles of laser and intense pulsed light for cutaneous lesions", section on 'Pulse duration'.)
The pulse duration also affects clinical responses to treatment. Short pulse durations (eg, 0.45 ms) often result in rapid heating and rupture of target vessels, contributing to the appearance of post-treatment purpura, which some cosmetic patients treated for telangiectasias find undesirable. In contrast, long pulse durations deliver light energy over a longer period and allow slower heating of target vessels, preventing sudden vessel rupture and reducing the risk of purpura. Long pulses may also be useful for the destruction of large vessels; large structures lose heat slowly, and the accumulation of heat that occurs over long pulse durations may facilitate coagulation of larger vessels.
The appropriate laser or IPL setting for the amount of energy delivered to the skin per unit area (fluence) is an important factor for efficacious and safe treatment of vascular lesions. The energy delivered must be sufficient for the chromophore to absorb enough heat to induce vessel coagulation but should not reach levels that induce excessive damage to the skin. Skin cooling mechanisms can be used to reduce the risk of skin damage associated with the use of high fluences [2]. (See "Principles of laser and intense pulsed light for cutaneous lesions", section on 'Fluence'.)
The term "spot size" is used to describe the size of the area through which light is delivered. Large spot sizes minimize scattering of light as it enters the skin, allowing more light to reach the target structure. Large spot sizes also facilitate the treatment of large lesions. A small spot size may be preferred for the treatment of a small, focal telangiectasia. (See "Principles of laser and intense pulsed light for cutaneous lesions", section on 'Spot size'.)
VASCULAR LASERS — A variety of lasers are used for the treatment of vascular lesions. Specific laser characteristics determine the most appropriate clinical settings for use.
Yellow and green light lasers — High peaks for the absorption of light by oxyhemoglobin occur within the range of yellow and green light. Thus, lasers that emit light in this range are commonly used for the treatment of vascular lesions. However, the restricted depth of penetration of light emitted from these lasers may limit their efficacy for the destruction of vessels located below the superficial dermis. Dyspigmentation is also a risk associated with the use of these lasers, given the relatively high absorption of light in this range by melanin. (See 'Principles' above.)
Pulsed dye laser — The flashlamp-pumped pulsed dye laser (PDL; 585 to 600 nm) has a long history of safe and effective use for vascular lesions. Original 577 nm PDLs were commonly used with pulse durations of approximately 0.45 ms, which is much shorter than the thermal relaxation time of small, superficial vessels (1 to 10 ms). Use of short pulse durations minimizes collateral damage in the skin but also often leads to rapid heating of vessels and vessel rupture, contributing to the appearance of post-treatment temporary purpura. Longer pulse PDLs (595 to 600 nm, pulse duration ≥1.5 ms) slowly heat target vessels and can be used without the formation of purpura. However, subpurpuric protocols with long-pulse PDLs may be less effective for the treatment of telangiectasias [5,6], and clinical experience suggests similar effects in the treatment of port wine stains (PWS). (See 'Clinical use' below.)
Frequency-doubled Nd:YAG (KTP) lasers — The frequency-doubled neodymium:yttrium aluminum garnet (Nd:YAG) laser, also known as the potassium titanyl phosphate (KTP) laser, consists of light from an Nd:YAG laser that is passed through a KTP crystal. The wavelength of this laser is 532 nm, near the 542 nm absorption peak of oxyhemoglobin. Pulse durations of frequency-doubled Nd:YAG lasers are in the millisecond range, which allows treatment of vascular lesions without the formation of purpura. However, the short wavelength results in a lower depth of skin penetration compared with PDLs. Light emitted by frequency-doubled Nd:YAG lasers is also absorbed to a greater extent by melanin, augmenting the risk of dyspigmentation, particularly in patients with dark skin.
Near-infrared lasers — A secondary, lower peak for the absorption of light by oxyhemoglobin occurs in the near-infrared range (720 to 1200 nm). There is also a small deoxyhemoglobin absorption peak between 750 to 800 nm. Alexandrite (755 nm), diode (800 to 980 nm), and long-pulsed Nd:YAG (1064 nm) lasers are used to capitalize on this absorption and can be effective for the treatment of vascular lesions [7]. The relatively long wavelengths of light emitted by these lasers penetrate the skin to greater depths than is possible with PDL or frequency-doubled Nd:YAG lasers. Thus, these lasers are generally utilized when vessels deep in the skin are targeted. Pulse durations of these near-infrared lasers are in the millisecond range, facilitating the treatment of larger vessels.
A disadvantage of near-infrared lasers is that the relatively lower absorption of light by hemoglobin species in this light range demands the use of higher fluences during treatment of vascular lesions [8]. This leads to a greater risk of inadvertent scarring compared with PDLs.
Dual wavelength lasers — Dual wavelength lasers including an Nd:YAG/KTP laser that emits 1064 and 532 nm light simultaneously, and a sequentially firing 595 and 1064 nm dual wavelength device have been used for the treatment of resistant vascular lesions [8,9].
Intense pulsed light — Intense pulsed light sources (IPLs) are non-laser flashlamp devices that produce incoherent, broad bands of light ranging from 515 to 1200 nm. Selective light filters can be used to restrict the emitted wavelengths to a narrower range for a more specific tissue effect.
IPLs have versatility, as they generate a wide range of light wavelengths, pulse durations, and pulse sequences. However, treatment of some types of vascular lesions with IPL can require more sessions than laser therapy to achieve the same clinical effect (see 'Other lasers and intense pulsed light' below). Another potentially detrimental feature of IPL is the emission of wavelengths of light highly absorbed by epidermal melanin, which leads to a relatively high risk of pigmentary adverse effects. Use of skin cooling techniques during IPL therapy is essential for reducing this risk.
PORT WINE STAINS — Port wine stains (PWS) are congenital capillary malformations characterized by pink to erythematous to violaceous patches (picture 1A-C). Although the term "port wine stain" is commonly used, patients may prefer the term "port wine birthmark," as "stain" has a negative connotation [10]. Lesions may be extensive, and papular and nodular components often develop during adulthood. PWS can lead to psychologic distress in some patients, and complications such as nodules, bleeding, pyogenic granulomas, and tissue hypertrophy can occur in mature lesions [11,12]. Isolated lesions do occur, but PWS may also be associated with several syndromes that should be considered when these patients present. (See "Capillary malformations (port wine stains) and associated syndromes".)
Laser therapy is the standard of care for the treatment of PWS. Previously established treatments, such as cryotherapy, electrocautery, and excision, resulted in unacceptable scarring.
Efficacy of pulsed dye laser — Pulsed dye lasers (PDLs) are the lasers used most commonly for the treatment of PWS. While other lasers have also been used for treatment of PWS, the PDL has a long history of safety and efficacy. (See 'Other lasers and intense pulsed light' below.)
Multiple treatments are usually required to achieve maximum lightening of PWS, and complete clearance is uncommon [13-15]. In one study of 76 patients with PWS, overall clinical improvement of 79 percent was achieved after an average of nine treatments [16]. Characteristics that may indicate a lower likelihood for a complete response include:
●Older child or adult [13,17-19]
●Darker skin type
●Location on trunk or extremity [20]
●Location on central face (medial cheek, upper lip, nose) rather than on other facial areas [21]
●Violaceous, nodular, and hypertrophic lesions [22,23]
Patient age — The ideal timing of treatment of PWS is controversial [24]. Although an uncontrolled study of 89 patients with PWS treated with PDL found no difference in the degree of improvement in patients of varying ages (0 to 31 years) [25], the results of multiple studies suggest that very young children may require fewer treatments for lesion clearance and may be more likely to achieve greater overall lightening:
●In an uncontrolled study of 73 children treated with a 577 or 585 nm PDL for PWS, those aged three months to six years exhibited better responses after the first treatment than those aged 7 to 14 years (55 versus 44 percent lesion lightening) [13].
●In an uncontrolled study of 35 children (age 3 months to 14 years) treated with a 577 nm PDL, children under the age of seven required fewer treatments for optimal response than older children (5.8±1.1 versus 7.1±1.1 treatments) [17].
●In a series of 83 children with facial lesions treated with a 577 or 585 nm PDL, patients who were treated while under the age of one year were more likely to have complete clearance of PWS with treatment than older patients (32 versus 18 percent achieved complete clearance) [18].
●In an uncontrolled study of 91 children with facial PWS treated with a 585 nm PDL, the mean decrease in lesion size after the first five treatments was greater in patients less than one year old than in those aged one to six years or greater than six years (63, 48, and 54 percent reductions in lesion size, respectively) [19].
Treatment also appears to be well-tolerated in young infants:
●In a retrospective study of 49 infants less than or equal to six months of age, treatment with a 595 nm PDL with dynamic cooling led to an average percentage of lesion clearance of 89 percent. No patients developed atrophy or scarring [26].
●In a prospective study of 12 children ages 6 to 30 weeks treated with PDL, 10 had greater than 50 percent lightening of PWS after 2.9±1.4 treatments [27]. No patients experienced scarring, atrophy, or dyspigmentation.
●In a retrospective study of 197 patients, the mean age at time of first treatment was 3.4 months [28]. After an average of 9.8 treatments, 26 percent achieved 100 percent clearance, and an additional 41 percent achieved 76 to 99 percent clearance. None of the patients experienced permanent pigment change or scarring.
Greater efficacy of treatment in young children may be related to a variety of factors, including increased hemoglobin concentration (in the first 6 to 12 months of life), especially hemoglobin F, and the presence of thinner skin and smaller lesional vessels in this population, when compared with older individuals. PWS often develop thickening and nodularity as patients age, and lesions with these changes may be more difficult to treat [12,23,29-31]. The relatively smaller size of lesions in young children may also be a factor [18,19]. We typically aim to begin treatment of PWS within the first month of life.
Lesion location — Lesion location may affect the response to treatment. In a retrospective study of 259 adults and children with PWS on the head and neck, centrofacial lesions (medial cheek, upper lip, and nose) responded less favorably to treatment than other areas of the face (mean percentage lightening 71 versus 82 percent) [21]. Lesions involving the V2 dermatome also responded less favorably than other dermatomes of the face and neck (mean percentage lightening 74 versus 82 percent).
A subsequent uncontrolled study of 91 patients supported the finding that centrofacial PWS tend to respond less favorably than lesions in other sites; percentage decreases in the size of forehead, peripheral facial, and centrofacial lesions following 577 or 585 nm PDL therapy were 100, 58, and 48 percent, respectively [19].
Lesion characteristics — Nodular, or very large lesions may exhibit increased resistance to PDL therapy [18,19,22]. Treatment with other types of lasers can be beneficial in the management of resistant, nodular, or hypertrophied lesions, where longer wavelengths may be beneficial. However, these longer wavelengths do have a higher incidence of adverse effects and should be used with caution. (See 'Other lasers and intense pulsed light' below.)
Dark skin — Treatment of PWS in patients with dark skin presents specific challenges. Absorption of laser energy by epidermal melanin inhibits light delivery to underlying PWS vessels [2]. In addition, the potential for hypopigmentation or hyperpigmentation as a consequence of laser therapy is more likely, and once present, is often more apparent in patients with dark skin. Use of appropriate laser settings and epidermal cooling techniques helps to minimize this risk. (See 'Clinical use' below.)
Long-term efficacy — Lesions may recur after treatment. In a 10-year follow-up study of 51 patients treated with PDL for PWS, lesions were significantly darker at follow-up than at the time of the last treatment [32]. However, treated lesions remained significantly lighter than they were prior to the start of treatment, supporting the existence of long-lasting beneficial effects of treatment.
Clinical use — Although PDLs are the standard of care for PWS, a lack of studies evaluating the efficacy of specific laser parameters, the continued evolution of laser technology, and variations in patient skin color and lesion characteristics have precluded the development of standardized treatment guidelines. In general, appropriate parameters for PDL treatment of PWS include [33]:
●Wavelength: 585 to 600 nm
●Pulse duration: 0.45 to 10 msec
●Fluence: 4.5 to 12 J/cm2
●Spot size: at least 7 mm
The 595 nm PDL with variable pulse durations has become the laser most frequently used for the treatment of PWS. Compared with the traditional 585 nm PDL, light from the 595 nm PDL is able to penetrate the skin to a slightly greater depth. In addition, the ability to deliver pulse durations in the millisecond range (typically 1.5 to 10 ms) may facilitate the destruction of larger vessels. Despite these theoretical advantages of the 595 PDL, studies conflict on whether treatment with the 595 nm PDL is clinically more effective than the 585 nm short-pulsed laser [34-37]. However, a case report and the results of a small prospective study suggest that some patients who have failed to improve adequately with the 585 nm PDL benefit from treatment with a 595 nm long-pulsed PDL [38,39].
Appropriate initial PDL fluence settings vary. Factors such as patient age, skin color, lesion morphology, lesion location, average vessel size, laser type, and laser spot size determine the correct fluence setting. Adequate epidermal cooling techniques reduce the risk of epidermal damage and scarring and allow the use of higher fluences in the hands of experienced clinicians. Epidermal cooling is particularly important in patients with dark skin, in whom inadequate cooling is likely to result in hyperpigmentation or hypopigmentation.
When treating a PWS on the cheek in an older child or adult with Fitzpatrick skin phototype II (table 1), appropriate initial fluence settings for a 595 long-pulsed PDL with a 10 mm spot size and a dynamic epidermal cooling mechanism generally range from 5.5 to 7.5 J/cm2. Lower initial fluences are typically used for young children, individuals with dark skin, and lesions in areas at higher risk for cutaneous damage, such as the eyelid and nonfacial lesions. Depending on the response to treatment, fluences can be increased by 0.5 J/cm2 with subsequent treatments, if desired results are not achieved and no adverse effects are noted [2].
Large spot sizes (≥7 mm) are generally preferred, as they minimize light scattering, and thus allow greater delivery of light energy to target structures. Large spot sizes also facilitate the treatment of large PWS. Although the impact of patient-positioning during treatment has not been specifically studied, we typically place the treatment site in a dependent position (eg, Trendelenburg position for facial lesions) immediately prior to treatment to increase local blood volume, which theoretically may increase the size of the vascular target.
Treatment should be performed in a methodical fashion, with care to maintain the position of the laser perpendicular to the surface of the skin (picture 2). This also ensures the proper delivery of cooling when using lasers with integrated cooling technology. Overlapping pulses by approximately 10 percent reduces the amount of untreated space [2].
The frequency with which treatments are administered varies in the literature, ranging from every few weeks to every few months. We typically administer PDL treatments every three to six weeks for facial lesions. Other clinicians have used shorter intervals successfully. In a retrospective study of 24 infants with facial PWS (Fitzpatrick skin phototype I to III), treatment intervals of two, three, or four weeks were effective for improving PWS and were well-tolerated [40].
We may use longer intervals (six to eight weeks) for patients with dark skin types (Fitzpatrick phototype IV or higher) or with extremity lesions, if there is postinflammatory pigmentation change. Longer time intervals between sessions allow for treatment and improvement of hyperpigmentation. Hyperpigmentation can reduce treatment efficacy. (See 'Precautions' below.)
Treatment can be continued until lesions are clear or nearly clearly or until no further improvement is noted; typically, 3 to more than 15 sessions are required [2]. Variations in vessel size and depth within a particular lesion promote the value of utilizing more than one set of PDL parameters over the course of treatment of a PWS [34].
Retreating areas during the same treatment session (multiple pass technique) may also be beneficial for facial lesions [41]. The pulse duration or laser wavelength can also be altered with subsequent passes. Multiple passes should only be performed by clinicians experienced in laser treatment due to an increased risk for scarring, as heat accumulates in the skin. The risk for scarring with this technique may be higher for lesions in nonfacial locations.
Local or general anesthesia or administration of pain medications prior to treatment may be used as needed. Pain medications that inhibit clotting, such as nonsteroidal anti-inflammatory agents, should be avoided. The US Food and Drug Administration (FDA) has issued a warning regarding use of general anesthetics in children under three years of age [42]. Risks and benefits of use of general anesthesia should be discussed with parents/caregivers. (See 'Anesthesia' below.)
Precautions — Tissue response should be watched closely with initial pulses and throughout treatment. Immediate purpura is often the desired tissue response during PDL treatment for PWS (picture 3). However, when longer pulse durations are utilized (3 ms or more) to target larger blood vessels, less purpura is noted. PDL-induced purpura typically resolves within 10 to 14 days [43]. The appearance of a gray or white color on the skin after the delivery of a laser pulse denotes epidermal injury and should be avoided.
Local edema and sunburn-like pain are common after treatment. Elevation, ice packs, nonprescription oral analgesics, and bland topical emollients are useful for decreasing patient discomfort [2]. Post-treatment sun avoidance should be recommended to reduce the risk of subsequent hyperpigmentation. For patients with skin color classified as Fitzpatrick phototype III or higher as well as patients with lighter skin who develop post-treatment hyperpigmentation (table 1), we sometimes prescribe daily application of a bleaching cream, such as hydroquinone 4%, between treatment sessions to further decrease the risk of this adverse effect. Daily application of hydroquinone should begin immediately after the resolution of purpura and can continue until the next treatment. Because irritant dermatitis can also induce hyperpigmentation, we decrease the frequency of application or discontinue topical bleaching agents in patients who develop skin irritation secondary to these drugs.
Blistering, scarring, cutaneous atrophy, and hypopigmentation are additional potential adverse effects of PDL therapy.
Other lasers and intense pulsed light — In patients who fail to improve with PDL, other laser therapies can be tried [8,44-46]. In a prospective study of 30 patients with PWS resistant to PDL, lesion color improved at least 25 percent in 16 patients (53 percent) after treatment with a modulated 532 nm frequency-doubled neodymium:yttrium aluminum garnet (Nd:YAG) laser [47]. Scarring, hyperpigmentation, and prolonged time to healing occurred in six patients (20 percent).
Near-infrared lasers, such as the alexandrite, diode, and 1064 nm Nd:YAG lasers have also been used for the treatment of PWS, and may be particularly useful for violaceous or nodular lesions [8,48-52]. However, the risk of scarring is significant at the relatively high fluences required to treat vascular lesions with near-infrared lasers. (See 'Near-infrared lasers' above.)
The efficacy of PDL was compared with intense pulsed light (IPL) in a randomized, side-by-side comparison trial of 20 patients who had not been previously treated with either therapy. A single treatment with a 595 nm PDL was superior to IPL for the induction of lesion clearance [53]. However, a pilot study found that IPL may have benefit for some patients with PWS; out of 15 patients with PDL-resistant PWS, six (40 percent) achieved more than 75 percent clearance with IPL [54]. In general, our preference is to use lasers rather than IPL for the treatment of PWS.
Emerging therapies — Combined modality lasers (eg, 595 and 1064 nm) [8], photodynamic therapy [55-58], combination therapy with PDL and a fractionated erbium-doped yttrium aluminum garnet (Er:YAG) laser [59], and the combination of PDL plus topical agents with antiangiogenic properties, such as imiquimod [60,61] or rapamycin [62,63], may have benefit for the treatment of PWS. Further studies are necessary to explore the efficacy and safety of these therapies in PWS. A small randomized trial in which 22 children were randomly assigned to treatment with either PDL followed by topical timolol (an inhibitor of neoangiogenesis used for the treatment of infantile hemangiomas) or PDL alone found that topical timolol did not significantly improve the likelihood of treatment success [64]. The identification of a somatic mutation in GNAQ associated with the majority of PWS may lead to development of additional treatment options [65].
INFANTILE HEMANGIOMAS — Infantile hemangiomas are the most common benign vascular tumors in children. Lesions are present at birth or become evident during the first several weeks of life. Infantile hemangiomas may be superficial, deep, or may have a mixture of superficial and deep components (picture 4A-G) [66]. Superficial hemangiomas typically present as bright red papules, plaques, or nodules. Deep lesions appear as flesh-colored or bluish subcutaneous nodules. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications" and "Infantile hemangiomas: Evaluation and diagnosis".)
The natural history of infantile hemangiomas (rapid proliferation over the course of months followed by involution over the course of a few to several years) raises questions about the need for therapy [67]. Many uncomplicated infantile hemangiomas are managed conservatively, with close observation for the development of complications. For high-risk hemangiomas (eg, large lesions at increased risk of scarring, disfigurement, or functional impairment), oral propranolol is the first-line therapy [68]. (See "Infantile hemangiomas: Management".)
However, there are situations where lasers can be an additional therapeutic option. Based on the available data, beneficial effects of laser therapy are most likely to occur in patients with small, superficial, or ulcerated lesions.
Efficacy of pulsed dye laser
Overview — Pulsed dye lasers (PDLs) are the most common lasers used for the treatment of infantile hemangiomas. However, study results vary on their efficacy [69-74]. Interpretation of the literature is further complicated by the natural course towards lesional involution, variations in laser settings among studies, and the evolution of laser technology over time [69,71].
Although a beneficial effect of PDL therapy has been reported in a meta-analysis of 13 observational studies [75], the contradictory results of a randomized trial raised controversy over the use of PDL for this indication [72]. The trial found that the number of children with complete infantile hemangioma clearance at one year was significantly greater in the group treated with a 585 nm PDL without epidermal cooling technology (fluence 6 to 7.5 J/cm2, spot size 3 to 5 mm, pulse duration 0.45 ms) than in the observation group (30 versus 5 percent, respectively). However, no difference between the groups was detected when the sum of patients with either complete clearance or minimal residual signs of infantile hemangioma at one year were analyzed. In addition, lesion redness was the only objective measure that was found to significantly improve with treatment, and adverse effects of skin atrophy and hypopigmentation occurred at a higher rate in the treated group. Given the lack of use of modern epidermal cooling techniques and the small spot sizes used, the applicability of the results to current practice have been questioned.
Integrated cooling techniques allow the safe use of higher and potentially more effective fluences. This fact, plus the theoretical potential for deeper skin penetration with the 595 nm PDL compared with the 585 nm PDL, led to the use of 595 nm PDLs with integrated cooling technology for the treatment of infantile hemangiomas. The following studies support the use of these lasers:
●In a randomized trial of 121 infants with hemangiomas, the efficacy of a 595 nm PDL with cryogen spray cooling technology (fluence 9 to 15 J/cm2, spot size 7 mm, pulse duration 10 to 20 ms) was compared with a 585 nm PDL without cooling technology (fluence 5.5 to 7 J/cm2, spot size 7 mm, pulse duration 0.45 ms) [76]. Although similar numbers of patients achieved complete or near complete lesion clearance at one year (approximately 60 percent), patients treated with the 595 nm laser were found to have shorter periods of maximum lesion proliferation (106 versus 177 days) and a lower risk for laser-induced hypopigmentation, hyperpigmentation, and textural skin changes.
●In a retrospective study of 90 patients with 105 superficial or superficial and deep hemangiomas, treatment with a 595 nm PDL with a dynamic spray cooling device (fluence 6.2 to 14 J/cm2, spot size 7 or 10 mm, pulse duration 0.45 or 1.5 ms) appeared to be beneficial [69]. Among the study patients, 85 percent exhibited near complete or complete clearance of lesion color and 64 percent exhibited near complete or complete resolution of lesion thickness (mean number of treatments = 6.7±4.5).
PDL may provide added benefit during infantile hemangioma treatment with propranolol. In a retrospective review of facial-segmental infantile hemangiomas treated with propranolol and PDL and controls treated with propranolol alone, infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance more often than when PDL followed propranolol or when propranolol was used alone [77]. In addition, combined treatment achieved near-complete clearance after fewer days of propranolol (92 days for concurrent treatment versus 288 for propranolol alone). Cumulative propranolol dose until near-complete clearance was lower in the concurrent treatment group than in the propranolol alone group (149 versus 401 mg/kg).
Lesion stage and patient age — The ideal timing of PDL therapy in infantile hemangiomas remains uncertain. Beneficial effects of early PDL therapy are supported by the results of a prospective study of 165 children treated with a 585 nm PDL. In this study, involuting hemangiomas were more likely to lighten in color than actively proliferating lesions and required fewer treatments to achieve improvement [73]. Some authors have suggested that early treatment of infantile hemangiomas (prior to the proliferative stage) also may inhibit the proliferation of deeper components [33]. However, studies conflict on the validity of this theory [72-74,78]. (See "Infantile hemangiomas: Management".)
Although patient age often loosely correlates with lesion stage, age may not be an independent determining factor for the efficacy of treatment. In a prospective study of 548 children (age 3 to 36 months) with 692 proliferating hemangiomas who were treated with a 585 nm PDL, mean scores for response to treatment did not differ according to patient age [74].
Superficial involuting lesions may respond best to treatment, indicating that when desired, PDL may be useful for accelerating clinical resolution of actively involuting lesions [73]. (See 'Involuting and resolved lesions' below.)
Superficial versus deep — Superficial hemangiomas may be more likely to respond completely to laser therapy than deeper lesions [69,74], an observation that is consistent with the known limits of penetration PDL light into the skin. In a prospective study of 165 children with 225 infantile hemangiomas, complete clearance of lesions followed 585 nm PDL therapy in 52 out of 153 (34 percent) superficial hemangiomas (mean number of treatments for complete response = 1.6±1.1) [73]. In contrast, none of 54 mixed cutaneous-subcutaneous hemangiomas exhibited complete clearance.
Another prospective study of 548 children with infantile hemangiomas also found higher rates of complete responses to 585 nm PDL therapy in superficial lesions; complete remissions occurred most frequently in small superficial hemangiomas (43 percent) [74]. Larger superficial lesions, cutaneous nodular, and mixed (cutaneous and subcutaneous) lesions resolved in 19, 15, and 7 percent of cases, respectively.
Superficial lesions may also respond more favorably to the slightly more deeply penetrating 595 long-pulse PDL. Although a retrospective study of 90 patients with 105 superficial or deep hemangiomas treated with the laser every two to eight weeks found that ≥75 percent improvements in color occurred in similar proportions of patients with superficial or mixed lesions (approximately 80 percent), greater reductions in lesion thickness were observed in superficial lesions [69]. Lesion thickness was reduced by at least 75 percent in 78 and 40 percent of lesions, respectively.
As noted above, there is insufficient evidence to conclude that early treatment of infantile hemangiomas influences the risk for the development of deep components. (See 'Lesion stage and patient age' above.)
Ulceration — The efficacy of PDL for the treatment of ulceration in infantile hemangiomas is supported by uncontrolled studies (picture 4E-F) [79-82]. Since fewer infantile hemangiomas are treated with laser due to the use of beta blockers, treatment of ulcerated lesions may be the most common utilization of lasers for infantile hemangioma management. As little as one treatment may be required to induce healing [80,81]. In one study of 78 children with ulcerated infantile hemangiomas, 71 (91 percent) responded to therapy with 585 nm PDL [82]. An earlier retrospective study found less dramatic results; 11 out of 22 treated children exhibited definite improvement [79]. Pain reduction is another potential benefit of PDL treatment. In a series of nine infants with ulcerated hemangiomas, pain appeared to improve in all patients after one treatment with a 585 nm PDL [80].
In contrast, PDL therapy occasionally has also been associated with the development of ulceration in hemangiomas [72]. (See 'Precautions' below.)
Clinical use — Commonly used parameters for the PDL in the treatment of infantile hemangiomas are as follows:
●Wavelength: 585 to 595 nm
●Fluence: 5 to 7.5 J/cm2 (settings outside of this range are appropriate in some clinical settings)
●Pulse duration: 0.45 to 6 ms
●Spot size: 5 to 12 mm
We typically use a 595 nm PDL and select laser settings based upon multiple factors, including lesion stage (proliferating versus involuting), lesion location, and patient skin type. Low fluences (around 5 J/cm2) should be used for proliferating lesions to minimize risk of ulceration. The initial fluence setting should also be reduced for patients with dark skin and lesions in areas with thin skin (eg, eyelid).
The often undulating surface of infantile hemangiomas requires the clinician to play close attention to the correct positioning of the laser in relation to the skin (picture 2). Integrated skin cooling mechanisms are required and should be utilized to minimize the risk of epidermal damage during treatment.
Treatments can be performed at two- to four-week intervals in rapidly proliferating or ulcerated lesions. Stable or involuting lesions may be treated less frequently every four to six weeks. Treatment is often performed without anesthesia; however, in occasional cases local or general anesthesia may be necessary for safe and effective treatment. (See 'Anesthesia' below.)
Precautions — Temporary local swelling is a common adverse effect [33]. Application of ice packs and elevation of the affected area may reduce symptoms. However, infants may be upset by the cold sensation of ice. Hyperpigmentation or hypopigmentation is another potential consequence of PDL treatment. Severe pain, scarring, and life threatening hemorrhage have rarely been reported in patients treated with PDL for hemangiomas [83].
Although PDLs are used for the treatment of ulceration in hemangiomas, treatment occasionally induces ulceration [83]. The use of large spot sizes with low fluences and epidermal cooling mechanisms may help to minimize the risk of ulceration. Patients with diffuse segmental hemangiomas may be at increased risk for ulceration [83,84].
Other lasers — Frequency-doubled neodymium:yttrium aluminum garnet (Nd:YAG) (KTP) lasers have been used for the treatment of hemangiomas. However, a retrospective study in which 50 infants with 62 superficial infantile hemangiomas were treated with a 585 nm PDL or a frequency doubled Nd:YAG (532 nm) found that treatment with the PDL was more effective [85]. Successful treatment of deep infantile hemangiomas with intralesional KTP bare fibers has been reported [86,87].
Some authors have suggested the cautious use of 1064 nm Nd:YAG laser for thicker infantile hemangiomas [33]. In one uncontrolled study of a sequential laser system that delivered 595 nm PDL and 1064 nm Nd:YAG light, excellent improvement occurred in 18 out of 25 hemangiomas involving the skin and mucous membranes of the head and neck (72 percent) [88]. However, the relatively high risk of scarring associated with the 1064 Nd:YAG and the risk of eye injury when this device is used in the periorbital area must be considered seriously, prior to attempting treatment with this laser [33]. Infantile hemangiomas with a deep component are generally best treated with beta blockers [68].
Involuting and resolved lesions — Hemangiomas in the involutional phase may benefit from treatment with PDL to hasten resolution of residual redness [73].
Fractionated lasers may be effective for improving fibrofatty residua that remain after involution of hemangiomas [89,90]. Fractional laser therapy appeared to be beneficial in a series of five children with involuted hemangioma residua who were treated with an ablative fractional CO2 laser [90]. In addition, in an 18-year-old woman with residual fibrofatty tissue and redundant skin at the site of a previous facial hemangioma, treatment with a nonablative 1440 nm fractionated laser led to marked clinical improvement [89].
TELANGIECTASIAS AND THE RED FACE — Telangiectasias are common lesions that present as 0.1 to 1 mm diameter vascular dilatations that are visible on the skin (picture 5). Telangiectasias occur spontaneously or arise in the setting of other conditions, such as cutaneous photodamage, rosacea, connective tissue or liver disease, radiation, hereditary hemorrhagic telangiectasia, and long term topical corticosteroid therapy [91]. Patients with numerous telangiectasias on the face frequently present with a complaint of facial redness.
Telangiectasias and secondary facial redness do not require treatment, but lesions that are cosmetically distressing for patients can be removed with electrocautery or lasers. Lasers provide quick and effective therapy, particularly for multiple telangiectasias, large areas with telangiectasias, or lesions that have failed to resolve after electrocautery.
Clinical use — A variety of light sources are effective for the treatment of telangiectasias. PDLs are among the most commonly used; however, frequency-doubled neodymium:yttrium aluminum garnet (Nd:YAG) lasers and IPL are also effective. Lasers with longer wavelengths, such as the alexandrite, diode, and Nd:YAG are useful for targeting larger vessels that are located deeper in the skin. Laser spot sizes, and in some cases, the spot shape (round versus elliptical), can be adjusted to conform to the size or shape of the target vessel.
PDL therapy can result in temporary purpura, which is viewed as unfavorable by many patients (picture 3). Purpura can be minimized or eliminated by use of longer pulse durations (≥6 ms) [92]; however, treatment with subpurpuric laser settings may be less efficacious, contributing to the need for additional treatment sessions [5].
The efficacy of purpura-inducing versus subpurpuric PDL settings was investigated in the following studies:
●In a split-face comparison study of nine patients with facial telangiectasias and erythema treated with a 595 nm long-pulse (6 ms) PDL, purpuric fluences were more effective at reducing vessel diameter and arborization of telangiectasias than multiple passes with subpurpuric laser settings [5]. Subpurpuric fluences were more effective for the reduction of background erythema.
●In a split-face, nonblinded randomized trial in which patients were treated with a 595 nm PDL (10 ms pulse duration) at either purpuric or subpurpuric fluences, purpura-inducing treatments were more effective. The greatest benefit of treatment was observed in thick, dense telangiectasias [6].
Multiple passes or judicious pulse stacking can be used to improve treatment response when longer pulse durations are utilized [41,93]. Pulse stacking involves the immediate delivery of repeated pulses (usually two to three) to the same treatment area in an attempt to increase cumulative heating of the target vessels, while allowing sufficient time for epidermal cooling between pulses. Multiple passes and pulse stacking techniques should only be used cautiously. Cutaneous damage may occur if incorrect settings are used or if the skin response to treatment is not properly monitored.
Millisecond pulsed 532 nm frequency-doubled Nd:YAG lasers and IPL can also be used to treat facial telangiectasias with minimal to no purpura [94].
Precautions — As in other settings, the risks of laser therapy for telangiectasias include pigmentary alteration, blistering, ulceration, and scarring. Risks of ulceration and scarring are higher with long wavelength lasers, such as the 1064 nm Nd:YAG and 755 nm alexandrite lasers.
ROSACEA ASSOCIATED ERYTHEMA — Rosacea is a multi-faceted disease that can present with a variety of cutaneous morphologies, including telangiectasias, erythema, inflammatory acneiform lesions, and rhinophyma.
Rosacea-associated telangiectasias are managed similarly to other telangiectasias. Laser and light sources also are commonly used for facial erythema secondary to rosacea, and based upon our clinical experiences, treatment also can provide relief from accompanying symptoms of burning and stinging. (See 'Telangiectasias and the red face' above.)
Multiple light based treatments are generally required to achieve the desired clinical response. Intermittent therapy is often necessary to maintain improvement after the completion of a successful treatment course. Although some patients require retreatment every three months, others maintain disease control with treatments separated by several years.
OTHER CONSIDERATIONS
Safety — Protective eyewear is essential for all individuals present in the treatment room. Clinical personnel must wear laser safety goggles that specifically protect against the wavelength of the laser used.
Patient protective eyewear depends on the location to be treated. If nonfacial areas are to be treated, patients may wear laser safety goggles similar to those of the clinical staff. For treatment of the face outside of the periorbital area, protective pads specific for laser procedures or metal goggles padded with a thin layer of gauze can be used. Corneal shields inserted with the aid of ocular anesthetic drops and lubricant are required when the eyelid or immediate periorbital area is treated. Appropriate sizing and placement of the patient's eyewear should always be confirmed prior to starting a procedure.
Eye injury has been reported when long pulsed longer wavelength (755 and 1064 nm) lasers were used within the bony orbit, even with appropriate eye protection [95]. Use of these devices in the periorbital area should be avoided or approached with extreme caution.
Lasers have been reported to cause flash fires [96]. To avoid this, flammable substances should be avoided in the treatment area. Fire extinguishers should be immediately available.
Anesthesia — Anesthesia generally is not required for small lesions. Topical anesthetics can be used, although some preparations (eg, eutectic mixture of lidocaine and prilocaine, EMLA) may blanch the vessels. This may remove the target, minimizing treatment response. Local anesthetic injections or regional nerve blocks can also be utilized; however, epinephrine (a vasoconstrictor) should be avoided to prevent vessel constriction and target removal.
General anesthesia may be helpful to ensure safe and complete treatment of large lesions (PWS or infantile hemangiomas) in infants, children, and some adults. The multiple treatments required and the use of protective eyewear, especially corneal shields, can be difficult for children. General anesthesia is routinely used for large lesions in children over the age of six months at the author's academic center.
General anesthesia performed by experienced anesthesiologists in otherwise healthy children has been reported to be quite safe, although there are some risks. The US Food and Drug Administration (FDA) has issued a warning regarding use of general anesthetics in children under three years of age [42]. Families should be provided information to make informed decisions. One study reported no serious adverse events in a multicenter report of 881 dermatologic procedures performed on children aged 2 months to 18 years with general anesthesia [97,98]. In another study, 363 infants were randomly assigned to receive awake-regional anesthesia and 359 to receive sevoflurane-based general anesthesia during inguinal herniorrhaphy, and neurodevelopmental outcome was assessed at two years of age. No difference in neurodevelopmental outcome was noted.
SUMMARY AND RECOMMENDATIONS
●Lasers and intense pulsed light (IPL) are treatment options for a variety of vascular lesions, including port wine stains (PWS), infantile hemangiomas, and telangiectasias. (See 'Introduction' above.)
●The efficacy of lasers and IPL for vascular lesions stems from the absorption of light by oxyhemoglobin and other hemoglobin species (deoxyhemoglobin and methemoglobin) in lesional vessels. Yellow and green light and, to a lesser extent, near-infrared light are preferentially absorbed by hemoglobin species. Light sources that emit light in these ranges generally are used for the treatment of vascular lesions. (See 'Principles' above.)
●Pulsed dye lasers (PDLs) are commonly used for the treatment of vascular lesions. For young patients with PWS who desire treatment, we recommend treatment with PDL over other therapies as first-line treatment (Grade 1B). We typically utilize a 595 nm PDL with pulse duration of 0.45 ms or greater and an integrated mechanism to cool the epidermis. Multiple treatments are required to achieve significant improvement.
●Millisecond pulsed near-infrared lasers such as the 755 nm alexandrite or 1064 neodymium:yttrium aluminum garnet (Nd:YAG) laser may be useful for the treatment of thick or nodular PWS. However, the risk of scarring with long wavelength lasers exceeds risk with PDL, and the use of these lasers for PWS should be restricted to experienced clinicians. Other treatment options for PWS include the 532 nm frequency-doubled Nd:YAG laser, diode laser, and intense pulsed light (IPL).
●PWS in young children and lesions in certain locations may be more likely respond to therapy. Recurrence of PWS after treatment may occur. (See 'Efficacy of pulsed dye laser' above.)
●Laser treatment may be beneficial for select infantile hemangiomas. Small superficial, ulcerated, or involuting lesions exhibit the best responses to therapy. Evidence conflicts on whether early treatment of superficial hemangiomas inhibits future growth. (See 'Infantile hemangiomas' above.)
●For ulcerated infantile hemangiomas that fail to heal with local wound care, treatment with PDL is an option. In some cases, a single treatment is sufficient to induce healing of an ulcer. (See 'Ulceration' above.)
●Telangiectasias are common, benign vascular lesions that are amenable to laser therapy. PDL and other vascular lasers can be effective for these lesions. (See 'Telangiectasias and the red face' above.)
