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Pulsed dye laser mostly safe for hemangioma.

Scottsdale, Ariz. -- The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions.

The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity.

Typical treatment for infantile hemangiomas uses short pulses (0.45-1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigrnentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112-5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said.

Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas.

Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7-7 J/[cm.sup.2].

The worst complications, however, occurred in the 12th infant who received 595-nm pulsed dye laser therapy using fluences of 7-12 J/[cm.sup.2] with a dynamic cooling device (Lasers Surg. Med. 2006; 38:116-23).

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than are localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration.

Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device.

The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "it's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, Dr. Metz emphasized.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/[cm.sup.2], 7.5 J/[cm.sup.2], and 8.5 J/[cm.sup.2] at 5 days of age.

Treatment at 11 days of age with 53 pulses of 9 J/[cm.sup.2] also went well.

The problems arose after treatment at 21 days of age with 80 pulses of 12 J/[cm.sup.2], Dr. Metz said.

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1-2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing.

These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies, the physician commented.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted.

Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers.

Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.


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Title Annotation:Clinical Rounds
Author:Boschert, Sherry
Publication:Pediatric News
Geographic Code:1USA
Date:Mar 1, 2007
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