Practice Trends

ORLANDO – Lasers can effectively target and treat several well-known pediatric skin conditions and, thanks to advances in technology, potentially treat more in the near future, according to Dr. Jan Izakovic.

The right laser in skilled hands can improve port wine stains, superficial hemangiomas, and nevi, he said at the annual meeting of the Florida Society of Dermatologic Surgeons. Children with vitiligo, likewise, can experience repigmentation with appropriate laser treatment, based on evidence in the literature and personal experience, he added.

In contrast, the use of lasers for striae, café au lait spots, and other potential indications is supported only by smaller case report–type studies, said Dr. Izakovic, codirector of pediatric dermatology at the University of Miami.

Port Wine Stains

The pulsed dye laser (PDL) is a frequent player in Dr. Izakovic’s armamentarium. When a child presents with a port wine stain, for example, he said he treats them with 585-nm or 595-nm PDLs. Nd:YAG and intense pulsed light (IPL), as well as a combination approach, are other options.

"I usually do a small test area first, and eventually increase the energy in small increments if there is no or too little effect," Dr. Izakovic said. Treatments should be scheduled at 4- to 6-week intervals. The total number of sessions will vary. "You can have great success after one or two treatments, but I wouldn’t tell parents that up front," he said.

About 70%-80% lightening of the port wine stain is realistic. Ultimately, success depends on the color, site, and thickness of the lesion. "The whiter the skin and the redder the port wine stain, the better your outcome will be," Dr. Izakovic said.

"Pain is usually minimal and momentary," but counsel patients on possible effects so they know what to expect, he advised. Purpura associated with PDL treatment generally resolves in 10-12 days, for example. Also, "you can expect to see the white dots fully formed 3-4 weeks post treatment. Tell patients you will address the leftovers at the next session," Dr. Izakovic said.

A comparison study found lightening of port wine stains to be similar with either PDL or IPL (Br. J. Dermatol. 2009;160:359-64). However, PDL was associated with better overall efficacy and was preferred by patients.

IPL has the advantage of only rarely causing purpura, Dr. Izakovic said.

Although he has not used combination therapy, Dr. Izakovic said better outcomes might be possible when PDL treatment is combined with photodynamic therapy, imiquimod, or rapamycin.

Hemangioma Treatment

PDL 585-nm or 595-nm devices can also treat superficial hemangiomas or ulcerated hemangiomas, or improve residual erythema or telangiectasia following involution of a hemangioma, he said. Although some physicians might be reluctant to treat a superficial eyelid hemangioma with PDL, there is some support for this as well in the literature (Dermatol. Surg. 2010;36:590-7).

Lasers can be used in a combination approach with other therapies such as oral propranolol or steroids, Dr. Izakovic said. "[With lasers] you are helping with the superficial part of it." PDL energy at the highest setting penetrates to a maximum of 1.5 mm.

12/20/11  

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FROM THE ANNUAL MEETING OF THE FLORIDA SOCIETY OF DERMATOLOGIC SURGEONS

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