ADVANCES IN DERMATOLOGIC SURGERY -
Editors: Jeffrey S. Dover, MD and Murad Alam, MD
The Use of Lasers in the Pediatric Population
K. Mariwalla, MD1, J. S. Dover, MD, FRCPC2-4
1Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
2Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
3SkinCare Physicians of Chestnut Hill, Chestnut Hill, MA, USA
4Department of Medicine (Dermatology), Dartmouth Medical School, Hanover, NH, USA
Over the past 2 decades, there have been numerous advances in laser therapy of birthmarks in the pediatric population.
Concerns regarding efficacy, overall benefit, and side-effects linger. We present our opinion, based upon decades of clinical
experience, on the role of lasers to treat port wine stains, superficial hemangiomas, and café au lait macules in children.
hemangioma, café au lait macules, pediatrics
Port Wine Stains
Port wine stains (PWSs) are congenital vascular
malformations composed of ectatic capillary-like vessels in
the papillary dermis that occur in 0.3% of newborns. They
can vary in size (millimeters to >50% body surface area) and
color (flat pink patches to “cobblestoned” purple plaques)
as the patient ages. Children with PWSs should be treated
early to prevent adverse sequelae to their psychological
Observable reduction in PWS size and color is achieved through
laser therapy by selective vascular damage. The pulsed dye laser
(PDL) is the laser of choice due to its low risk of scarring or
pigmentary alteration1,2 and relatively high rates of clearing.
Which Laser Is Best for Children?
In one study, use of the 595nm PDL with 1.5msec pulse width
and fluences up to 11-12J/cm2 with a dynamic cooling spray
resulted in >75% clearance of PWSs in 63% of patients under
the age of 12 months, after four treatments.3 Lack of controlled
trials with single parameter variation make it difficult to
ascertain optimal settings in this area. The addition of a dynamic
cryogen cooling device (DCD) has advanced the treatment of
PWSs by allowing for epidermal protection via surface cooling and resultant heat accumulation in vessels. Recently Bernstein
and Brown, using the 585nm PDL with DCD at a 1.5msec
pulse duration, demonstrated an average 68% subjective and
69% objective improvement in 83 previously untreated PWSs
after approximately four treatments.4 Additional devices,
including the 1064nm Nd:YAG are now also being tested for
PWS combination treatment.5
We routinely start with the largest available spot size (10mm),
a pulse duration of 1.5msec, and fluence of 7.5J/cm2 with
the V-Beam laser (Candela) and then, depending on the
outcome, we may reduce the spot size to 7.0mm and vary
the fluence from 9-14J/cm2 or 6-8.5J/cm2 with the V-Star
laser (Cynosure). Treated tissue should appear dark purple
but not assume a grayish hue, which may indicate potential
overtreatment. This temporary purpura may last 7-10 days.
Will It Work?
Certain favorable prognostic features are known about PWSs.
We advocate early treatment; success is likely due to thinner
skin in infants, as well as smaller and more superficial vessels
leading to improved clearance in fewer treatment sessions.6
Based on current studies, >50% improvement has been
reported after an average of four treatments per patient.3,4,7
- Mark treatment site because reactive erythema often clouds otherwise distinct borders.
- Treat edge of PWS first to prevent inadvertent treatment of unaffected adjacent skin.
- Aim the laser tangentially to the skin surface when treating central areas to avoid the uneven, lattice-like appearance of partially treated areas.8
- For darker skin types, waiting as long as 3 months between treatment sessions is recommended to permit postinflammatory hyperpigmentation, if present, to resolve.
- The risk of hypertrophic and atrophic scarring exists but is extraordinarily low. Cutaneous atrophy that may rarely appear within 1-2 months following PDL treatment usually resolves within a 3- to 18-month period.
- In dark-skinned individuals, epidermal sloughing can develop following treatment, requiring wound care and leading to pigmentary change.
- Clearance is location dependent (see next page).
Table 1: Use of the PDL to treat port wine stains
Red lesions appear to clear more with the PDL than pink
or purple lesions and lesions on the head and neck respond
more favorably than those on the trunk and lower extremities.
Furthermore, the midline facial area responds better than the
lateral face and neck.
PWSs rarely clear completely even with a series of treatments,
but optimal improvement is usually achieved with repeat
sessions every 4-8 weeks. PWSs may respond, (to a lesser
degree) in skin types IV and V with lower fluences and
multiple treatments, though the risk of pigmentary alteration
is more common than that in lighter skin tones (see Table 1).
Superficial hemangiomas are benign proliferations of
endothelial tissue with an incidence of almost 10% by the
age of 1 year. They are frequently located on the head or neck
and if not present at birth, usually appear shortly thereafter,
showing a female-to-male predominance. The natural history
of these hemangiomas has two phases, proliferating (marked
by significant growth during the first 7 months of life) and
involuting (pallor within the lesion followed by involution and
residual atrophic telangiectatic skin with fibrofatty tissue in
some cases). Complications such as ulceration, obstruction of
vital structures, and recurrent bleeding can occur. Laser therapy
can prevent such complications and provide psychological
relief for pediatric patients and their parents during the first few
years of life. Early treatment reduces the chance that the lesion
will reach its full size and minimizes the risk of fibrofatty
Which Laser Is Best for Children?
The short-pulsed (0.45-1.5msec) PDL (either 585nm or
595nm) with dynamic or air cooling is the treatment of choice
for hemangiomas comprised mostly of superficial vessels.9
Since the depth of selective photothermolysis with the 585nm
PDL is 1.2mm, deeper components of hemangiomas may
progress. Better results are often achieved with larger spot
sizes (7mm, 10mm).10 Newer long-pulsed Nd:YAG lasers
may be more effective but further study is necessary.
Will It Work?
Although opinions differ regarding the treatment of
hemangiomas in patients younger than 4 months old11 (as hemangiomas may spontaneously resolve within the first
year of life), long-term studies have not been carried out
using objective observers nor have data regarding significant
improvement vs. clearance been reported. We advocate
early intervention given the minimal risks associated with
laser therapy and the notion that the most effective time for
treatment is during the proliferation phase. Some evidence
suggests lesions less than 3mm may resolve better than
thicker lesions.12 As in treatment of PWSs, the basic principles
of depth and size apply to efficacy of laser therapy. Multiple
treatments may be needed to achieve maximal clearing and
are recommended to begin during the rapid proliferating
phase in 2-3 week intervals. During the involuting phase,
treatments can be spread out to every 1-2 months.
Ulceration and subsequent pain is a frequent complication in
5%-14% of all infantile hemangiomas and though compelling
data do not exist to support the use of a single therapy,13
faster rates of resolution may occur with the PDL14,15 than
with Nd:YAG lasers, potentially due to increasing rates of
reepithelialization. In our practice, we always start with
biologic dressings and add PDL if this fails.
Café au Lait Macules
Café au lait macules (CALMs) are benign hyperpigmented
areas, present at birth in 2% of all newborns (up to 1/3 of
black neonates).16 While they can be markers for underlying
disease such as neurofibromatosis, isolated CALMs are
recognized as a common finding in many infants and may
increase in size over time. The exact etiology of the macules
is unknown. Cosmetic improvement can be achieved by use
of any of the short-pulsed lasers which selectively destroy
Which Laser Is Best for Children?
Laser therapy for CALMs is considered safe but there is
no data to suggest that treatment of CALMs in infancy is
required. The best choice is the Q-switched pigment-specific
laser. Efficacy studies on the Q-switched Nd:YAG lasers
(532nm or 1064nm), the Q-switched alexandrite (755nm),
and the Q-switched ruby laser (694nm) show that each of
these lasers works with varying degrees of efficacy;17 to date
no study comparing the Q-switched lasers has been carried
out. Wheeland and Schmults18 recommend the Q-switched 532nm Nd:YAG laser, though it is worth mentioning that the
risk of purpura and postoperative abradement of the treated
area may be unacceptable to parents of pediatric patients.
- Best for non-tan skin phototypes I – III.
- Topical or intradermal local anesthetics are often required.
- All children and their parents should be given laser-specific optically coated glasses.
- Always determine treatment parameters with a test spot, which should be evaluated after 4-8 weeks.
- Begin with the lowest energy fluence that produces a visible response. Do not overlap areas.
- Hyperpigmentation can occur, but usually improves with the passage of time or the application of topical bleaching creams.
- Risk of hypopigmentation is higher with the Q-switched ruby laser than for the Q-switched alexandrite and the Qswitched Nd:YAG at 1064.19
- The area may appear abraded after treatment. Wound care should be started and continued until the area is completely reepithelialized. Treatment area should heal within 5-14 days.
Table 1: Use of Q-switched lasers to treat café au lait macules
Will It Work?
Clinical experience with repeated Q-switched laser treatments
has been inconsistent, with total clearing occurring in
approximately 50% of patients and recurrence and patchy
pigmentation occurring in the other half.19 The risk of
repigmentation exists for all CALMs though the mechanism
behind this is unknown. It appears that if total clearing is
achieved repigmentation is rare, though an exact percentage
has not been uniformly reported. The key to successful
treatment is to use relatively low fluences and perform multiple
treatment sessions 6-8 weeks apart. It is generally agreed that
results seen at 12 months after the last treatment are usually
lasting.20,21 Given the risk of pigmentary alteration, skin
types IV-VI should generally not be treated, as CALMs are
often less apparent and the risk of pigment change outweighs
cosmesis. In all skin types, the risk of postinflammatory
hypopigmentation exists, and if this occurs, a delay in further
treatments until the pigmentation normalizes is recommended
(see Table 2).
While additional long-term studies may be needed to assess
the efficacy of laser therapy in the pediatric population, our
experience suggests that laser use in children for the treatment
of port wine stains, superficial hemangiomas, and café au lait
macules has not only been well tolerated by patients but also
successful with minimal side-effects.
- Levine VJ, Geronemus RG. Adverse effects associated with the 577- and 585-nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: a study of 500 patients. J Am Acad Dermatol 32(4):613-7 (1995 Apr).
- Kim KH, Rohrer TE, Geronemus RG. Vascular lesions. In: Dover JS, Goldberg DJ, editors. Procedures in Cosmetic Dermatology, Laser and Lights. Volume 1. China: Elsevier Saunders p11-27 (2005).
- Geronemus RG, Quintana AT, Lou WW, Kauvar AN. High-fluence modified pulsed dye laser photocoagulation with dynamic cooling of port wine stains in infancy. Arch Dermatol 136(7):942-3 (2000 Jul).
- Bernstein EF, Brown DB. Efficacy of the 1.5 millisecond pulse-duration, 585nm, pulsed-dye laser for treating portwine stains. Lasers Surg Med 36(5):341-6 (2005 Jun).
- Ahcan U, Zorman P, Recek D, Ralca S, Majaron B. Port wine stain treatment with a dual-wavelength Nd:YAG laser and cryogen spray cooling: a pilot study. Lasers Surg Med 34(2):164-7 (2004).
- Lanigan SW, Taibjee SM. Recent advances in laser treatment of port-wine stains. Br J Dermatol 151(3):527-33 (2004 Sep).
- Kelly KM, Nanda VS, Nelson JS. Treatment of port wine stain birthmarks using the 1.5-msec pulsed dye laser at high fluences in conjunction with cryogen spray cooling. Dermatol Surg 28(4):309-13 (2002 Apr).
- Lam SM, Williams EF 3rd. Practical considerations in the treatment of capillary vascular malformations, or port wine stains. Facial Plast Surg 20(1):71-6 (2004 Feb).
- Ashinoff R, Geronemus RG. Capillary hemangiomas and treatment with the flash lamp-pumped pulsed dye laser. Arch Dermatol 127(2):202-5 (1991 Feb).
- Selecting a laser to treat vascular lesions. In: Dover JS, Arndt KA, Geronemus RG, Alora MB, editors. Illustrated Cutaneous & Aesthetic Laser Surgery. Second Edition. Stamford: Appleton & Lange. p231-40 (2000).
- Batta K, Goodyear HM, Moss C, Williams HC, Hiller L, Waters R. Randomised controlled study of early pulsed dye laser treatment of uncomplicated childhood haemangiomas: results of a 1-year analysis. Lancet 360(9332):521-7 (2002 Aug 17).
- Garden JM, Bakus AD, Paller AS. Treatment of cutaneous hemangiomas by the flashlamp-pumped pulsed dye laser: prospective analysis. J Pediatr 120(4 Pt 1):555-60 (1992 Apr).
- Kim HJ, Colombo M, Frieden IJ. Ulcerated hemangiomas: clinical characteristics and response to therapy. J Am Acad Dermatol 44(6):962-72 (2001 Jun).
- Morelli JG, Tan OT, Weston WL. Treatment of ulcerated hemangiomas with the pulsed tunable dye laser. Am J Dis Child 145(9):1062-4 (1991 Sep).
- Scheepers JH, Quaba AA. Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years’ experience. Plast Reconstr Surg 95(2):305-12 (1995 Feb).
- Chang MW, Levine N, Trout C. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. Volume 1. Spain: Mosby p975-1004 (2003).
- Grossman MC, Anderson RR, Farinelli W, Flotte TJ, Grevelink JM. Treatment of café au lait macules with lasers. A clinicopathologic correlation. Arch Dermatol 131(12):1416-20 (1995 Dec).
- Wheeland R, Schmults C. Pigmented lesions and tattoos. In: Dover JS, Goldberg DJ, editors. Procedures in Cosmetic Dermatology, Laser and Lights. Volume 1. China: Elsevier Saunders p41-66 (2005).
- Stratigos AJ, Dover JS, Arndt KA. Laser treatment of pigmented lesions – 2000: how far have we gone? Arch Dermatol 136(7):915-21 (2000 Jul).
- Alster RS. Complete elimination of large café au lait birthmarks by the 510 nm pulsed dye laser. Plast Reconstr Surg 96:1660-4 (1995).
- Levy JL, Mordon S, Pizzi-Anselme M. Treatment of individual café au lait macules with the Q-switched Nd: YAG: a clinicopathologic correlation. J Cutan Laser Ther 1(4):217-23 (1999 Dec).
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