AT WCPD 2017

CHICAGO (FRONTLINE MEDICAL NEWS) – Multiple laser and light options are available to treat children with infantile hemangiomas, port wine birthmarks, and angiofibromas, according to Kristen M. Kelly, MD.

“Combination treatments with procedures and medications can improve treatment in many cases,” Dr. Kelly said at the World Congress of Pediatric Dermatology.

Dr. Kelly , professor of dermatology and surgery at the University of California, Irvine, said that the use of lasers and other light sources for infantile hemangiomas has dramatically decreased since propranolol, timolol, and other beta-blockers have become available. Most children are candidates for beta-blocker therapy, she said, but for those who are not, the pulsed dye laser (PDL) may be a good option. She also considers using the PDL for ulcerated lesions. “Of course concern comes up, because lasers can sometimes cause ulcerations, so you have to be aware of that,” she said.

In her clinical opinion, the PDL is a good adjunct to beta-blocker treatment when a superficial component to infantile hemangioma exists. It allows you to achieve more complete removal, she noted, and can decrease the time required for beta-blocker therapy. PDLs also are good for when there is recurrence as a beta-blocker is tapered or stopped, and for treating residua such as redness or textural changes that may be left after beta-blocker therapy.

“For the more proliferative phase of infantile hemangiomas, I’ll use a larger spot size: 10-12 mm, and short pulse durations: 0.45 to 1.5 milliseconds, and low energies,” Dr. Kelly said. “I would start with an energy of 5 or 5.5 J/cm2. I may creep that up a little with time, but I don’t feel that you need to use very high energies. For lesions that are starting to involute, you could consider higher energies.”

Consider the combination of PDL and propranolol for patients who have a superficial component, for ulcerated lesions, or for rapidly progressing lesions that are not responding to your treatment. “You can also use the combination of PDL and timolol,” she said. “Starting treatment can avoid the need for reconstruction later.”

Dr. Kelly then discussed her approach to treating port wine birthmarks. She almost exclusively uses the PDL and the 755-nm Alexandrite lasers for these lesions. “For some of the resistant lesions, I’ll consider some of the combined treatments, like the combined 1064/532 nm system,” she said. “If I have really young patients, I use the PDL almost exclusively. I find the Alexandrite laser useful when I have thicker lesions that have hypertrophied.”

For optimal effect, she recommends treating lesions as early as possible and increasing chromophore target by placing patients with facial lesions in the Trendelenburg position during treatment sessions. Her preferred PDL parameters are a wavelength of 585 nm or 595 nm with a pulse duration of 0.45 to 1.5 milliseconds for the vast majority of lesions. “I try to vary the pulse duration over time, so if I’m getting a great result with 0.45 milliseconds, I’ll do that a couple of times,” Dr. Kelly said. “Once I feel I’ve reached a plateau, I might change to 1.5 milliseconds, or consider doing a second pass.”

Whenever possible she uses larger spot sizes and chooses the level of energy based on the type of lesion she’s treating. “I think it’s important to look for an endpoint,” she said. “I like to see deep purpura but I don’t like to see gray, because I feel that’s where you’re going to get epidermal injury or [there is] the chance for scarring and dyspigmentation, which can be permanent in some patients.”

Patients with port wine birthmarks require 3-15 treatments or more, typically 4 weeks apart. “Some people do 2- or 3-week intervals; that’s something to consider,” Dr. Kelly said. “In a darker-skinned patient with hyperpigmentation, I will use longer intervals, especially on an extremity that may take a little longer to heal.”

Alternative treatments are being studied, including the use of lasers in combination with antiangiogenic agents. “Rapamycin has been looked at most extensively, and it’s been shown to have a significant benefit,” she said.

According to Dr. Kelly, a new device for treating port wine birthmarks is being developed that combines pulse dye laser, Nd:YAG, and radiofrequency. “The potential advantage of this is that when we use the PDL alone, we probably cannot get very deep into those vessels,” she said. “The combination of the PDL and radiofrequency may allow us to more completely coagulate these vessels and get better response.”

Dr. Kelly closed her presentation by discussing angiofibromas, disfiguring skin lesions that are associated with tuberous sclerosis and have a fairly rapid recurrence. Topical and/or oral rapamycin are treatment options, but so are laser and light sources. She cited approaches published by Roy Geronemus MD, of the Laser and Skin Surgery Center of New York, and his associates, which included PDL treatment with a 10-mm spot size delivered at 7.5 J/cm2 with a pulse duration of 1.5 ms, and dynamic cooling spray duration of 30 ms ( Lasers Surg Med 2013;45:555-7 ). This was followed by ablative fractional resurfacing with a 15-mm spot size at 70 mJ per pulse and 40% coverage. Other treatment options for angiofibromas include pinpoint electrosurgery to papular, fibrotic lesions and topical rapamycin ointment twice a day.

Dr. Kelly disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Cynosure, Syneron Candela, and Novartis. She is a consultant for MundiPharma, Allergan, and Syneron Candela, and has received research funding from the American Society of Laser Medicine and Surgery, the National Institutes of Health, the Sturge-Weber Foundation, and the UC Irvine Institute of Clinical and Translational Science.