Port wine stains clear faster with shorter pulsed dye laser treatment intervals
At the 31st annual conference of the American Society for Lasers in Medicine and Surgery, Robert Anolik, M.D., procedural dermatology fellow, Laser & Skin Surgery Center of New York, presented the results of a retrospective study that included 24 infants treated for PWS with a 595 nm pulsed dye laser (Vbeam Perfecta, Candela) at intervals of every two, three or four weeks (eight children per treatment group).
The analyses showed good safety for all three treatment intervals, reaffirmed the efficacy of early PDL treatment for clearing PWS and suggested that repeating the treatment sooner rather than later (every two or three weeks versus every four weeks) could provide a better response without any need for increasing the total number of treatment sessions.
"Several light and laser systems can be used to treat PWS, but the PDL is generally considered the gold standard," Dr. Anolik says. "However, while a previous study by Roy Geronemus, M.D., and coworkers demonstrated the benefits of early versus delayed treatment (Chapas AM, Eickhorst K, Geronemus RG. Lasers Surg Med. 2007;39(7):563-568) and that approach is endorsed elsewhere in the literature, there has not been agreement on the optimal interval for repeating treatment.
"In theory, performing the treatment at more frequent intervals in infancy would best capitalize on the benefits of early treatment and thereby might provide a better response. The results of the present study are consistent with that idea while also demonstrating the safety of increasing treatment frequency," he says.
"However, even if the efficacy was the same in all three groups, we feel early, frequent treatment is warranted because it expedites the time to lesion resolution. Therefore, it may avoid the need for general anesthesia, because younger infants can be held still more easily during the treatment, and it may also prevent the child from experiencing negative psychosocial consequences associated with having a disfiguring PWS," he says.
Dr. Geronemus tells Dermatology Times that subsequent to that publication, he had begun to "push the envelope" by repeating the laser sessions more frequently in order to best take advantage of the window of opportunity provided by early treatment of PWS. He says there are multiple factors that may account for a better treatment response at a younger age.
"The younger the child, the smaller the birthmark, but also the thinner the skin and the less chance there will be pigment present from sun exposure," Dr. Geronemus says. "Therefore, the laser energy needs to penetrate less deeply to reach its target, and there will be less melanin as a competing chromophore in the skin that could potentially interfere with the treatment benefit. Furthermore, the more immature blood vessels in a younger infant may be more susceptible to destruction from the laser treatment." Dr. Geronemus is director, Laser & Skin Surgery Center of New York, and clinical professor of dermatology, New York University Medical Center.
"Based on our previous research, our mantra for treating infants with PWS was originally 'out of the hospital nursery and into the office.' Now we also have evidence to support advocating treating at shorter intervals as well," Dr. Geronemus says.
The children in the study were treated with a laser equipped with a dynamic cooling spray using a 10 mm spot size, 1.5 ms pulse width and energies ranging from 8.5 J/cm2 to 9.5 J/cm2. Dr. Geronemus says the parameters are close to settings for adults.
"Some surgeons back off on the PDL energy due to concern about potential complications in these young infants. However, we have found it is possible to treat safely with settings close to those used in adults," he says.
Side effects in the pediatric patients were limited to transient erythema, edema, bruising and postinflammatory hyperpigmentation, but there were no permanent pigmentary changes or cases of scarring or infection.
Results from a previously published study from the United Kingdom (Tomson N, Lim SPR, Abdullah A, et al. Br J Dermatol. 2006;154(4):676-679) using a split-lesion design also support the efficacy and safety of PDL treatment at short intervals.
The investigators in that trial directly compared two treatment sessions, one at a two-week interval and the other at a six-week interval, and found the more frequent approach was well-tolerated and generally more effective.
Dr. Anolik says published results from a survey of dermatologic laser surgeons conducted in the United Kingdom in 2000 showed wide variation in practice patterns for treatment of PWS, but 84 percent of respondents considered two to three months the optimum treatment interval (Mahendran R, Sheehan-Dare RA. J Dermatolog Treat. 2004;15(2):112-117).
Disclosures: Dr. Geronemus serves on the medical advisory board for Candela. Dr. Anolik reports no relevant financial interests.
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