Port wine stain strategies

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Port wine stain strategies
Oct 1, 2007
By:Bob Roehr
Dermatology Times

National report Û Pediatric dermatology is rapidly evolving and has had some growing pains, and the area of laser treatment of port wine stains and hemangiomas is no exception, says Lawrence F. Eichenfield, M.D., chief of pediatric and adolescent dermatology at Rady Children's Hospital in San Diego and the University of California, San Diego.

"I really believe that when you look at specialty pediatric dermatology, it was vascular lasers that moved the field into dermatologic surgery, setting up a great number of patients who are undergoing a large set of procedures, many of which are performed under general anesthesia or sedation," Dr. Eichenfield says.

While the laser procedure is good at reducing the coloration of port wine stain, most patients will see residual coloration.

"The occasional patient will have complete clearance; in some of these we wonder whether it was a true port wine stain or just a variant of a large nevus simplex," Dr. Eichenfield postulates.

Standard still subpar

The pulsed dye laser is considered to be the standard of treatment, with initial lasers generating a wavelength of 585 nanometers and newer equipment at 585 to 595 nanometers.

Larger-diameter vasculature tends to respond better to the higher wavelength. There is some variability among patients in response to both wavelengths and no good predictor as to which will be better for an individual patient.

Pulse durations generally range from 450 to 1,500 microseconds.

Dr. Eichenfield tells Dermatology Times that after six to eight treatments, many physicians "start to change the parameters to see if they can get any more lightening in the area."

It appears that 30 percent to 50 percent of all children who undergo treatment for port wine stains have either a recurrence or darkening of the site over time. However, there are limited studies on this phenomenon.

Options in treating stubborn port wine stains include increasing the wavelength, higher fluences, higher fluences with cryogen cooling Û as a way to minimize epidermal damage Û overlap of treatment areas and increased central venous pressure as a way to increase blood flow to the skin to generate more of a vascular target.

Managing recalcitrant stains

Refractory port wine stains and hypertrophic port wine stains remain problematic for practitioners.

The 1,064 Nd:YAG laser has been used on some patients with good results, but its utilization in pediatric patients is still quite limited.

Dr. Eichenfield prefers to defer treatment during the first few months of life. He generally initiates treatment at about 4 to 6 months, with the goal of completing six to eight treatments by 18 to 24 months of age.

"The safety of anesthesia is equivalent at any age beyond a few months of life, and the treatments and postoperative purpura do not disrupt a young child's life very much, unlike treating an older child or adolescent. The first two years of life may be a window of opportunity where the parents are conscious of the intervention, but the children may not be," which can be an attractive reason to address the situation early, Dr. Eichenfield notes.

He says lasers are not considered to be the primary tool in treating hemangiomas, though they can be effective in treating remnant hemangioma and ulcerated hemangiomas.

"But only consider laser with trepidation for rapidly proliferating and extrasuperficial or deep lesions," he warns.

The skinny on sedation

The trend is to use general anesthesia or unconscious sedation for elective pediatric surgery that cannot be accomplished with the patient awake, with or without topical and local injection anesthetics.

The Food and Drug Administration (FDA) recently ordered five companies to stop compounding topical anesthetic creams because the agents were linked to seizures, irregular heartbeats and two deaths, Dr. Eichenfield notes.

He speculates, "It is probably the mixture of agents Û lidocaine, petracaine, benzocaine and primacaine Û and this risk is clearly greater in small children

A prospective study of 30,000 sedations, conducted primarily in children's hospitals and pediatric units, found that deep sedation generally is safe and effective.

Be that as it may, caution is paramount, Dr. Eichenfield notes, and dermatologic practices are certainly not exempt.

"There are side effect rates that would be fine if you are a pediatric anesthesiologist running a sedation unit," he says, "but probably not fine if you are attempting to do such things in your own office. The safety of the practice depends upon the systems in place."

Fickle topical treatment

Molluscum contagiosum presents its own series of challenges. A Cochrane review found no single treatment intervention to be particularly better than another.

Dr. Eichenfield says recent studies of imiquimod have found absorption rates of children to be similar to those of adults, and that "The levels were not very high and are not dangerous."

The bad news is that while there was a trend toward improvement using imiquimod compared to vehicle, in a large prospective study it did not reach statistical significance. Clearance was about 20 percent to 31 percent.

Dr. Eichenfield's standard practice for treating molluscum is cantharidin, applied for four hours at an office visit and then washed off.

Dr. Eichenfield says that in his experience, this treatment regimen is "highly effective."

Reflecting the confusion in the literature in treating molluscum contagiosum, Dr. Eichenfield explains that several options are available, and much boils down to physician preference.