ARTICLE
ll dye lasers permit the treatment of port-wine stains, which are classic
indications for dye laser, while hemangiomas are hardly ever treated.
The third generation of dye laser emits light with a wavelength of 595 nm
and offers the best performance for treating hemangiomas. Hemangiomas
represent the most common benign tumor in infancy, and ulceration represents
their most frequent complication [1]. Thirty eight percent of the lesions
are localized on the head and neck, often in periorificial localization
causing functional problems [2]. Hemangiomas usually appear a few days
to weeks after birth. They are present at birth in 2.6% of mature newborns.
Initially, lesions may be small red spots or nodules. Subsequent proliferation
during the first 9 months of life, rarely beyond 18 months,
may lead to a large, or disfiguring or ulcerated birthmark, with pain
and the necessity for steroid therapy [3]. Such an evolution is seen in
8 to 12% of all children during the first 12 months, and in up to
22% of premature infants with a birth weight lower than 1 kg [2,
3]. Complications appear during this proliferative phase : bleeding,
functional impairment, interference with vital functions due to the obstruction
of eyes, nose, throat, ear, or anus. The subsequent period of regression
persists for up to 10 years. Findings show that a normal skin texture
is present in only 50% of children. In the other 50% of patients, residual
skin changes remain, like telangiectasia, hyperpigmentation, atrophy,
sagging, fibrofatty tissue residuum, or scarring. All active therapeutic
methods have a substantial risk of side-effects : local therapies
include surgery, embolisation, sclerotherapy, magnesium seeding, X-ray,
carbon dioxide snow, liquid nitrogen ; or systemic treatments using
corticosteroids or interferon. Surgery is limited to patients in whom
function is impaired. The obligatory regression of the hemangiomas has
been the major argument in favour of allowing spontaneous involution in
the lesions. Flashlamp-pumped pulsed dye laser which is the "gold standard"
for treatment of port wine stains, is now recommended in the treatment
of hemangiomas for preventing complications and cosmetic disfigurement.
The comparison of hemangioma treatment via pumped dye laser (585 nm)
and frequency-doubled Nd : YAG (532 nm) does not show any differences
[4], however there are no reports of treatment with a third generation
pulsed dye laser (wavelength of 595 nm) [5-7].
Materials and methods
Clinical data
In a prospective study, we treated 16 patients with 22 cutaneous
hemangiomas from July 2000 to February 2002 (over a 19-month period),
with a mean follow-up of 22.44 months (10 to 42 months).
Our purpose was to review the therapeutic response of ulcerated hemangioma
to the third generation pulsed dye laser. We recorded 10 cases of
ulcerated hemangioma, 5 with bleeding, and 4 superficial (1 for
esthetic reasons). The female/male sex ratio was 3 :1 (12 girls,
and 4 boys). Patients were aged from 1 to 15 months, for
a mean of 4.9 months. They were Caucasians of European or Maghrebian
origin (phototype II to V). Each patient was evaluated by chart review.
The following variables were extracted : age, gender, anatomic localization,
involved area, complications at time of the first consultation, number
of treatments, hemangioma texture and color, ulceration and improvement
after laser therapy. Photographs were taken under standardized conditions
before and after treatment.
The primary measure of efficacy was the quantitative assessment of improvements
in lesional volume, texture and color. The outcome was evaluated on the
following scale : 0 no improvement. 1, poor (0-25% improvement) ;
2, fair (26-50% improvement) ; 3, good (51-75%) ; and 4, excellent
(76-100%) ; and on the efficiency on the ulceration.
Laser therapy
We used a 595 nm, Dermobeam 2000® laser (from Deka©
MELA Calenzano, Italy), associated with a skin cooling system (Spray)
[7]. The treatment was made on the ulcerated area and 5 mm around
the same. Two passages were made with a 10% overlap. Laser energy was
delivered to the skin through an optical fiber and lens which focused
the beam. The spot size was 7mm, the energy density (fluence J/cm2)
from 4 to 8 J/cm2. This was purpuragenic fluence.
The emission modality (repetition rate) was repeated at 0.5 Hz. We
initially chose a long pulse duration of 30 msec in only 2 patients,
but in the majority of cases it was 0.5 ms. The pressurized gas (tetrafluoroethane
C2H2F4) was in a frozen bottle. This
synthetic ice is non-flammable, non-toxic, and environment-friendly. The
cryogen content was 200 ml per bottle. A length of 100% (= 40 ml
of freezing gas at one pulse), permits 5000 pulse laser. Cryogen
spurts were sprayed onto the target through an electronically controlled
solenoid valve positioned approximately 20 mm from the skin surface.
The spurt covered an almost circular, 15 mm diameter area. The SmartSpray
Cooling system parameters were : freezing, flood, duration, and advance.
The duration of the cryogen spurt, and the delay between cryogen delivery
and laser illumination were controlled by a programmable digital delay
generator. The spray pulse length was from 60%. The delay (advance or
anticipation) was 10 ms. This allowed for a safe delivery of higher
energy fluences by limiting the cooling epidermis, while leaving the temperature
of the vessels unchanged. The consequent anesthetic effect limits the
need for additional topical, local or general anesthetic. Generally, 10 to
30 msec prior to each laser pulse are needed. This epidermal cooling
minimizes the risk of adverse effects, such as hyperpigmentation (23%
without cooling method), hypopigmentation, and scars.
Results
We tried to evaluate the therapeutic response of ulcerated hemangiomas
to 595 nm wavelength pulsed dye laser. Pain disappeared totally in
10/12 cases of ulcerated hemangiomas after 1 or 2 treatments
(Figs. 1, 2, 3). Healing
was obtained in all 10/12 cases, with 1 to 4 treatments
(1 to 2 in 90 % of cases) at intervals of 2 to 8 weeks
(Fig. 3). We observed
no adverse effects ; however there were 2 failures deriving
from excessive pain with ulcerated hemangiomas due to of the significance
of the subcutaneous component. These mixed hemangiomas remained unchanged.
They had a very deep ulceration with secondary infection. These 2 cases
showed a proliferation of the subcutaneous component, and required general
corticoids (1 to 2 mg/kg/day for 1 to 3 months). Children
were examined about 10 to 15 days after the first treatment,
in order to evaluate the residual pain, and continue the treatment until
the cessation of pain (as early as the 1° session, in the majority
of cases), and for healing ulceration, which can be achieved after 4 treatments
(Fig. 3 a-b).
Two patients had hemangiomas on the nose and one on the nasal tip, the
so-called "Cyrano" angioma. These 3-month-old girls with an ulcerated
hemangioma of the upper lip of 1 month's duration underwent 4 sessions
of flashlamp-pumped pulsed dye laser, 2 weeks apart. An improvement
was noted after two treatments and the lesion showed a major size and
color improvement over a total treatment period of 3 months.
Laser therapy was always effective on severe bleeding, but frequent recurrences
were observed and it was necessary to treat hemangiomas until the end
of the cicatrisation.
Discussion
The first report of laser being used in the treatment of hemangiomas in
early infancy was made with the argon laser (wavelength : lambda = 488 and
514 nm) [8, 9]. The therapeutic effect was limited to superficial
lesions, because of the relatively shallow penetration of argon laser.
Nd :Yag
laser is effective for thick hemangiomas because of the deep penetration
of its wavelength (lambda = 1064 nm) [10]. The Nd :Yag
laser has also has been used for intralesional coagulation principally
in German studies [11]. The KTP laser (lambda = 532 nm)
is an alternative choice in the regression phase [4]. To decrease the
risk of nonspecific thermal damage to the epidermis and papillary dermis,
the flashlamp-pumped pulsed dye laser (lambda = 575-600 nm)
has been used [12]. The wavelength of 595 nm corresponds to an absorption
peak of hemoglobin (the major chromophore in blood) [13]. The pulse energy
is mainly absorbed by blood vessels, and converted to heat causing thermal
damage and thrombosis of the target vessels. A pulse width of 450 mus
is below the thermal relaxation time of the target tissue. The flashlamp-pumped
pulsed dye laser selectively destroys ectatic blood vessels without any
significant side effects [13]. The beam limited the depth of penetration,
which did not exceed 0.7 mm. Laser therapy is indicated for hemangiomas
only in rare instances [1]. For refractory ulceration, that fails to heal
after 2 weeks of specialized dressing, low fluences are available
[4-7]. The efficiency of flashlamp-pumped pulsed dye laser is very high
in this case. For aesthetic risk due to the localization, such as philtrum,
columella, nasal margin or nasal tip, as in 3 of our cases [14].
Flashlamp pulsed dye laser is also a successful treatment of diffuse neonatal
hemangiomatosis [15]. We can also treat residual telangiectasia. No uniformly
effective treatment modality was found, but generally a 7-mm spot size
can be used with a 0.5 to 6 msec pulse duration ; and a
fluence of 5 to 7 J/cm2. In many cases several techniques
could be used as a follow-up. Traditional conservative management of hemangiomas
is based on the spontaneous involution by the age of from 3 to 7 years
[2, 3]. But the final development cannot be predicted in initial lesions.
In our patients no success was obtained in treating hemangiomas with a
significant subcutaneous component [5]. The influence of flashlamp-pumped
pulsed dye laser on the subcutaneous part of hemangiomas is practically
nil [12]. Other treatment is necessary as in rapidly progressive compound
lesions. Not all hemangiomas require laser treatment. We can limit the
indications of flashlamp-pumped pulsed dye laser to non inflammatory or
telangiectatic ulcerated hemangiomas, large hemangioma, and localization
risk (on the face, or peri orificial&ldots;). Maceration and frictional
stress are the major factors in ulceration [2-3]. However, telangiectatic
or inflammatory hemangiomas can spontaneously lead to ulceration. In this
case persistent ulcerations may develop immediately after treatment with
the flashlamp-pumped pulsed dye laser [1]. Hemangiomas occur in the proliferative
phase, and perhaps ulcerations might have developed without treatment,
the skin injury induced by the laser playing a role in precipitating or
causing ulceration [6]. Sometimes the association of laser and corticosteroids
is necessary, and we believe that this association is synergistic just
like our cases of "cyrano" hemangioma. We have noted that with the use
of corticosteroids in areas treated with flashlamp-pumped pulsed dye laser,
involvement of hemangiomas is more rapid. This generally allows for the
use of low doses of corticosteroids (1 mg/kg/day) for less time (1 month)
[2, 3]. In rapidly growing tumors, the combination of corticosteroids
with flashlamp-pumped pulsed dye laser using the SmartSpray Cooling system
can be beneficial [7]. Hemangiomas with a deep component do not benefit
from flashlamp-pumped pulsed dye laser, as its efficiency is limited by
the depth of vascular injury [5, 13]. Furthermore, early therapeutic intervention
with pulsed dye laser may fail to prevent proliferative growth of the
deeper or subcutaneous component despite early intervention [5].
The aim of treatment in hemangiomas is to stop further progression and
to induce regression in order to prevent complications. It is possible
to achieve this in 96.6 % of the treated lesions with the flashlamp-pumped
pulsed dye laser 585 nm [13]. We can now recommend early active laser
treatment in ulcerated and/or painful hemangiomas following failure after
1 week of sufficient topical treatment, and initial and small lesions,
especially in periorificial localization, in order to prevent unpredictable
severe complications [4, 12]. However, according to our study, we have
no grounds for suggesting preventive treatment for all cases, and consequently
cannot recommend this [16, 17]. A recent study compared treatment with
pulsed dye laser 585nm with a wait-and-see policy [16]. It was a prospective,
randomized controlled trial in which 121 infants, aged 1-14 weeks,
were enrolled with early hemangiomas, and followed up to age 1 year.
All infants completed the study. The number of children whose lesions
showed complete clearance or minimum residual signs at 1 year was
not significantly different in the pulsed dye laser 585nm treated and
observation groups. However, PDL treated infants were more likely to have
skin atrophy and hypopigmentation. The only objective measure of resolution
that improved with pulsed dye laser 585 nm treatment was hemangioma
redness. So for the moment pulsed dye laser 585 nm treatment in uncomplicated
hemangiomas is no better than a wait-and-see policy.
The flashlamp-pumped pulsed dye laser 585 nm was the therapy of choice,
only when there was an indication for treatment of hemangioma (ulceration
principally) [12]. The frequency doubled Nd :YAG laser has been recommended
for pursuing further treatment in the regression phase of hemangiomas
in order to optimize the cosmetic appearance [4]. For young children,
we prefer the 595 nm flashlamp-pumped pulsed dye laser due to its
low incidence of side effects and pain, thanks to its wavelength and dynamic
skin cooling system (Spray) [7]. However for the moment there is no superiority
of 595 nm flashlamp-pumped pulsed dye laser, under second generation
585 nm.
CONCLUSION
In conclusion, the 595 nm flashlamp-pumped pulsed dye laser with
contact cryotherapy has proved to be an effective method with few side
effects in the early treatment of risk-related superficial hemangiomas
in infancy, and for ulcerated hemangiomas without a subcutaneous component
[1, 5].
Special thanks to Pr Laurent MISERY for correcting this work.
Article accepted 23/12/2002REFERENCES
1 - Kim HJ, Colombo M, Frieden IJ. Ulcerated hemangiomas: clinical characteristics
and response to therapy. J Am Acad Dermatol 2001; 44: 962-72.
2 - Cohen A. hemangiomas in infancy and childhood. Pediatr Ann
1987; 16: 17-26.
3 - Enjolras O, Mulliken JB. The current management of vascular birthmarks.
Pediatr Dermatol 1993; 10: 311-33.
4 - Raulin C, Greve B. Retrospective clinical comparison of hemangioma
treatment pumped (585 nm) and frequency-doubled Nd:YAG (532 nm).
Laser Surg Med 2001; 28: 40-3.
5 - Poetke M, Philipp C, Berlien HP. Flashlamp-pumped pulsed dye laser
for hemangiomas in infancy (treatment of superficial versus mixed hemangiomas).
Arch Dermatol 2000; 136: 628-32.
6 - Hohenleutner S, Badur-Ganter E, Landthaler M, Hohenleutner U. Long
term results in the treatment of childhood hemangioma with flashlamp-pumped
pulsed dye laser: an evaluation of 617 cases. Laser Surg Med
2001; 28: 273-7.
7 - Chang CJ, Kelly KM, Nelson JS. Cryogen spray cooling and pulsed dye
laser treatment of cutaneous hemangiomas. Ann Plast Surg 2001;
46: 577-83.
8 - Apfelberg DB, Maser MR, Lash H. Argon laser management of cutaneous
vascular deformities. West J Med 1976; 124: 99-104.
9 - Hobby LW. Further evaluation of the potential of argon laser in the
treatment of strawberry hemangiomas. Plast Recontrs Surg 1983;
71: 481-9.
10 - Werner AJ, Lippert BM, Hoffmann P, Rudert H. Nd: Yag laser therapy
of voluminous hemangiomas and vascular malformation. Adv Otorhinolaryngol
1995; 49: 75-80.
11 - Achauer BM, Chang CJ, Vander Kam VM, Boyko A. Intralesional photocoagulation
of periorbital hemangiomas. Plast Reconstr Surg 1999; 103: 11-6.
12 - Garden JM, Bakus AD, Paller AS. Tretament of cutaneous hemangiomas
by the Flashlamp-pumped pulsed dye laser: prospective analysis. J Pediatr
1992; 120: 555-60.
13 - Hohenleutner U, Hilbert M, Wlotzke U, Landthaler M. Epidermal damage
and limited coagulation depth with the flashlamp-pumped pulsed dye laser:
a histochemical study. J Invest Dermatol 1995; 104: 798-802.
14 - Cho S, Lee SY, Choi JH, Sung KJ, Moon KC, Koh JK. Treatment of "Cyrano"
angioma with pulsed dye laser. Dermatol Surg 2001; 27: 670-2.
15 - Endo H, Kawada A, Aragane Y, Yamashita Y, Isogai R, Yudate T. The
succesful treatment of diffuse neonatal hemangiomatosis with a flashlamp
pulsed dye laser. Pediatr Dermatol 2001; 18 (2): 146-8.
16 - 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 2002;
17 (360): 521-7.
17 - Hohenleutner U, Landthaler M. Laser treatment of childhood haemangioma:
progress or not ? Lancet 2002; 17 (360): 502-3.
|
Summary
Pictures