Physicians disagree on appropriate age for laser treatment of port wine stains
San Francisco — After more than 20 years of widespread use, pulsed dye lasers remain the therapy of choice in treating port wine stains in children and infants.
"We're talking about a very long track record," says Ilona J. Frieden, M.D., professor of dermatology and pediatrics, University of California, San Francisco.
Still, she says, there have been no significant developments in recent years, and there is some disagreement regarding when treatment of port wine stains should begin.
"After the initial breakthrough of selective photothermolysis in the late 1980s, which ushered in the modern era of laser therapy, most of the developments over the past 20 years have been incremental rather than a major breakthrough," she says.
Cooling devices, for instance, now allow treatments at higher fluences. Lasers have become faster and more wavelengths for treatment have also been introduced.
There is presently a broad consensus that the 595 mm flashlamp-pumped pulsed dye laser is the initial treatment of choice for infants and young children with port wine stains.
When to begin?
The age to begin treatment of port wine stains is a much-debated topic for a number of reasons, according to Dr. Frieden.
"There is evidence to suggest that early treatment results in better efficacy, but that is controversial," she says. "Some studies have been published that suggest the skin is a little thinner in young infants, and that you can penetrate a little deeper into the blood vessels if you start early, but that has to be weighed against other factors."
Simply getting an appointment made can be challenging for parents, Dr. Frieden says, so many infants don't begin treatments before a few months of age.
"Treatment is not a medical emergency, and we don't want their parents to think they have missed a window of opportunity if we don't start treatment at a few weeks of age," she says. "Another issue is the need for general anesthesia. Usually, if treatment requires general anesthesia, I defer treatments until at least 4 to 6 months of age when the risk for general anesthesia in young infants goes down."
Dr. Frieden says she believes treatment at an early age is reasonable, because the child usually doesn't remember the procedure, and to the extent that disfigurement can be diminished, "it's nice to do that sooner rather than later.
"If you believe the people who say that you get better long-term results with earlier treatment, then waiting until a child is older might be risky," she says. "Personally, I think that the long-term results are more a function of location, size and the depth of the blood vessels. Those are all aspects that have been well-described as being primary risk factors for response and duration of response."
Care, not cure
While today's lasers have an excellent safety record, are helpful in lightening port wine stains and have a very low risk of adverse events — particularly scarring — most patients don't get complete clearance.
In fact, a significant number of minority patients experience re-darkening over time, but this can be unpredictable as to when it occurs and to whom, Dr. Frieden says.
"It's important to discuss both the benefits as well as the potential limitations of the current therapies right from the start," she says. "Parents and children need to understand that our goal is not to cure this condition, because in most cases, we don't cure it. Our goal, rather, is to improve it."
"The pulsed dye laser only penetrates approximately 1 millimeter into the skin, so if you have a port wine stain that is deeper than that, you won't be reaching them with that laser."