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Treatment & Options

Lasers in the Treatment of Hemangiomas and Other Benign Vascular Lesions of the Skin

Lasers have become a treatment of choice for some types of hemangiomas, and may be preferred even when a lesion ulcerates. During the first six months of life, 5-10% of hemangiomas ulcerate during their rapid growth phase. the ulcerated lesion is painful, may bleed and is at risk for bacterial infection. Traditional therapy includes daily wound car, topical antibiotics, and local or systemic steroids. To the regimen may be added treatment of the ulcerated lesion with a vascular-specific laser pulsed tunable dye laser. Laser treatment has been found to accelerate healing and reduce pain within few days, often after a single laser treatment. Anogenital hemangiomas of infancy are sometimes referred for laser treatment if they ulcerated and become infected. Laser-treated lesions heal in one to five weeks.

Laser treatment offers the possibility for early intervention in treatment of the strawberry hemangioma, while the lesion is very small. Traditional management of theis common birthmark is to observe its growth over a period of weeks, months, or years, awaiting the involution and disappearance that often occurs (70% will do so by age seven). Symptomatic lesions have been treated with topical steroids fro palliation. If observation is the chosen course of treatment, the pediatrician and plastic surgeon need to reassure the child's parents that spontaneous regression is often the case. Laser treatment is an option if the hemangioma ulcerates, if spontaneous regression is not seen after a reasonable period of time or if the lesion progresses toward disfigurement. Lesions of the head and neck have the highest priority for laser treatment, to prevent disfigurement. If early intervention with a laser is the treatment of choice to prevent maceration or ulceration, the best results with the flashlamp-pumped pulsed dye laser are seen when the lesions are small and flat.

Other vascular lesions of infants and children that may be amenable to laser treatment include:

Important to the success of treatment is the selection of a laser of the most appropriate type and wavelength, at the most effective energy output.

Port-wine stain, which occurs at an incidence of about 0.3% of live births, is one of the relative success stories of laser treatment.

From the early days of the ruby laser to today's flashlamp-pulsed dye lasers, the port-wine stain has been successful in children under four years of age, and the best response has been seen in lesions of the face, neck and torso, with hand and arm lesions less responsive to laser intervention. Topical anesthetic helps to control pain associated with laser treatment of port-wine stain.

Large and/or life-threatening lesions demand an interdisciplinary approach involving the plastic surgeon, pediatrician and hematologist.

Because facial vascular anomalies are, in fact, often more than "skin deep," diagnosis, evaluation and treatment planning should include imaging. Magnetic resonance imaging (MRI) is a good initial technique to triage patients with facial vascular anomalies for appropriate management, including observation, endovascular therapy or surgical excision. MRI has been found superior to computed tomography (CT) and angiography for demonstrating the precise anatomic extent of facial vascular anomalies and their relationship to adjacent soft tissue. CT is superior for demonstrating trophic bone changes. Angiography is superior in determining the nidus and exact nature of collateral structures in arteriovenous malformations.

Pigmented Lesions of the Skin

Congenital nevi occur in about 1% of infants. Most are small; large nevi are rare. While congenital nevi can be recognized at birth or shortly thereafter, the question of malignancy or nonmalignancy usually cannot be resolved immediately. Up to 5% of infants with large congenital nevi will develop melanoma in the lesion; 80% of the transformations will occur before age seven. Melanoma is sometimes present at birth, in which case immediate surgical excision is necessary if the diagnosis is made and confirmed. diagnostic accuracy has been found to vary by medical and surgical specialty; in a large, retrospective study, plastic surgeons and dermatologists had the highest level of accuracy.

Dysplastic nevi are an important risk factor for melanoma and family members may be at increased risk of melanoma. Physicians involved in the care of patients with dysplastic nevi should be prepared to counsel family members regarding the need for long-term observation.

Large, congenital nevi in infants thus pose a significant risk of early malignancy or malignant transformation later. A large pigmented and sometimes hairy nevus also has a profound psychological effect on a child. Hair growth and crevices in the nevus can cause itching, intertrigo and a foul odor, adding to the child's problems of social acceptance and emotional stability.

These lesions can be difficult to treat, and may require referral to a center with significant experience in treating them. Removal of the lesion usually begins as soon as possible. Total excision of large congenital nevi with removal of all nevus cells at the base of the excision reduces the risk of melanoma, and is more likely to prevent the regrowth of anomalous hair. Because multiple operations and skin grafting are often required, treatment is complex and may not be completed before age seven to 10, although it is always a goal to complete the procedure before school age.

Tissue expansion has been used as an alternative to excision-plus-grafting in the treatment of large congenital nevi. The tissue expanders are placed under the patient's skin several months before excision is undertaken. Then, as the nevus is removed in steps over time, the flap is expanded serially to cover the surgical defect. The technique has been used to treat giant pigmented nevi covering as much as 40% of the body. The complication rate is low.

Lasers have not been widely used in the treatment of giant nevi. Some success has been reported in laser treatment of pigmented birthmarks of the head and neck in children and in treatment of verrucous, but no keratotic epidermal nevi.

Port-Wine Stains

After several years of exploring treatment options, the current treatment of choice is laser therapy. A yellow-light laser, such as the pulse-dye lasers (candela/cynosure) is absorbed by the red color of the capillaries, heating up the vessels from the inside and thus causing selective obliteration of the vessels. The average patient can expect an 80% fade of the lesion after 6 to 8 treatments. There are also, occasionally, a few patients who are yellow-light resistant and will not fade. The best response to laser therapy generally occurs on the face and neck. The less impressive results occur further from the heart (i.e., extremities).

Klippel-Trenaunay Syndrome

There is no total cure for Klippel-Trenaunay Syndrome. However, a sequential pneumatic tourniquet and compression garments may be used to help with symptomatic control of swelling. MRI and CT scans may outline the extent of involvement, but surgical debulking is beneficial only in rare cases. Indications for radiologic studies of organs and bones are best decided by clinical evaluation. Recently, advances have been made with radiologic injection of a caustic agent into the abnormal veins with subsequent reduction in the size of the vessels. This may be repeated and although not a permanent one, it remains in many instances the best treatment alternative.

Children's Medical Center of Dallas offers various areas of support to children and their families. A Child Life specialist is available to assist the patient, siblings, and parents in addressing the psychosocial concerns that accompany medical care. They facilitate coping and the adjustment of children and families by providing play experiences and to encourage family involvement.

A social worker is also available if families have questions regarding the family's ability to optimally meet the child's special health care needs.