Today’s Treatments for
Port Wine Stains

F ew developments in modern medicine have had the kind of impact that laser therapies have had on the treatment of port wine stains (PWS). Previously untreatable, PWS now respond dramatically to laser treatments and physicians can significantly reduce or even eliminate PWS for the majority of their patients. Despite these remarkable results, physicians continue to explore new options to deal with this often-incapacitating condition. With an eye toward improving the level of clearing, reducing undesirable side effects, and treating PWS that resist traditional approaches, pioneering researchers are developing innovative methods to treat PWS. Today, new types of lasers and other treatment methods, such as intense pulsed light, are offering new hope to patients who have not responded to traditional laser treatment. Two treatment methods that have produced proven results with PWS are pulsed dye laser and intense pulsed light. Treatments and Limitations In the last several years, the pulsed dye laser (PDL) has become the treatment of choice for most PWS. The results achieved with PDLs can be dramatic, and the incidence of scarring or loss of pigments is acceptably low. Newer treatment approaches, including the use of multiple laser types and intense pulsed light to treat persistent PWS are offering even greater relief to patients. However, there are limitations to these treatments that physicians must understand and considerations in the use of these devices. The age of the patient, the location of the PWS and the response of the patient to earlier treatments are all important factors when treating with a PDL. Past Options In the early days of laser treatment of PWS, the results were generally extremely encouraging, with most resulting in a significant reduction in the appearance of the hemangiomas. Unfortunately, these early lasers had a relatively high incidence of hypertrophic scarring and hypopigmentation. This occurred primarily because the early lasers emitted a continuous wave laser that did not allow the tissue to recover. The revolutionary change that took place was the development of the theory of selective photothermolysis, which states that by properly selecting the wavelength and duration of a laser pulse, a vascular target can be destroyed with little or no damage to surrounding tissue because the target absorbs more of the laser energy. This led to the development of the PDL, which, unlike a continuous laser, emits laser energy in pulses that can be timed to allow recovery of the tissue before the next pulse is emitted, resulting in little or no scarring and pigmentary loss. With a PDL, the wavelength, duration and the power of each pulse, as well as the duration of the pause between pulses can be precisely tuned to have maximum effect on the target with minimal disruption of surrounding tissue. According to Dr. Roy Geronemus, a pioneer in the use of use of PDLs for treating PWS and president of the American Society of Dermatologic Surgery, the newer PDL offers better results with fewer side effects. “Generally, with PDL treatment of a port wine stain, the stratum corneum remains intact, though there are some minor changes to the basal layer of the epidermis,” says Dr. Geronemus. “In most cases, the thermal injury is confined to the target blood vessel itself and the immediate perivascular area.” Dr. Geronemus began investigating PDLs as a treatment option in 1985 and has continued to work with PDLs since. His efforts have contributed greatly to the knowledge of these devices and the acceptance of PDLs as the standard for treatment of PWS. Deciding Factors on the Type of Device Currently, manufacturers offer a variety of PDLs. These devices vary in the range of features that they offer and in how they allow the operator to control the duration, wavelength, strength and sequence of the pulses. While a number of considerations need to go into the decision about the type of device to employ, there are some key factors. Devices that allow for longer pulse widths may provide deeper penetration in terms of vascular injury. There are some indications that the long-pulse widths will help clear or lighten some resistant PWS that have failed to respond significantly to the shorter pulse widths. Being able to control the spot sizes covered by the laser may prove beneficial. Larger spot sizes, in the 10-mm range, allow more optical scatter and some deeper penetration and should result in greater clearing. Anatomical Location of The Port Wine Stain The anatomical location of the port wine stain can dramatically affect the results achieved through laser treatment. • Facial port wine stains. The central portion of the face responds more slowly than the rest of the face. This may be related to skin thickness or the deeper location of blood vessels. The PDL is generally only effective to a depth of 1.2 mm. • Port wine stains on the body. Port wine stains react to treatment differently depending on location. The areas on the upper chest, and the breast area, re-spond very quickly, as does the upper back. However, the extremities are much slower to respond, and they require additional treatments. Important Consideration Perhaps the most important consideration in the treatment of PWS is the age of the patient. Aside from the obvious benefit of eliminating at an early age a potentially psychologically debilitating condition, there are significant medical and practical reasons to treat patients at the earliest possible age. Since port wine stains tend to enlarge and deepen and develop conditions such as hypertrophic lesions, treating at an early stage reduces the risks and increases the effectiveness of the treatment. “If you’re going to see somebody with a port wine stain on the body, not only is it much easier to treat the smaller surface areas, but treatment is almost always more effective in younger patients,” explains Dr. Geronemus. “Treatment, even with infants, is safe. We have enough evidence to show that with younger patients, we have greater clearing with fewer treatments.” Dr. Geronemus has treated patients as young as 3 or 4 months old, and follow-ups show that recurrence of the PWS is rare. “Young patients can be effectively treated in the office using a topical anesthetic and with the patient being held by a nurse or parent,” says Dr. Geronemus. “If treating larger areas or if working around the eyes, we may consider general anesthesia.” However, Dr. Geronemus does add a word of caution for physicians considering the use of lasers to treat PWS in children. “I would not recommend the continuous wave dye lasers, or any of the continuous wave lasers, in the treatment of children,” he explains. “The incidence of scarring and hypopigmentation is too significant, particularly compared to the standard of care achieved with the use of a PDL in those early age groups.” Typically, the PDL leaves purpura immediately after treatment, but this is transient and seems to be a necessary side effect of the treatment. In cases where steps were taken to minimize the occurrence of purpura, the clearing achieved was significantly reduced as well. In fact, in cases where no purpura was observed, there was no clearing of the PWS. Generally, it would appear that the best results could be obtained with a pulse of 1.5 ms, which causes the appropriate level of purpura. Other side effects such as hyperpigmentation and hypopigmentation are generally transient, although some permanent hypopigmentation can occur during aggressive treatment of the neck, chest, and upper thighs. In addition, physicians should carefully screen patients for medications. There has been at least one case of hypertrophic scarring and keloid formation as a result of treatment on a patient who was on Accutane. Reducing Side Effects The use of dynamic cooling during treatment is critical to reduce the seriousness of side effects. “Complications from this particular laser are very rare in our experience,” says Dr. Geronemus. “Of 500 patients who came in following treatment in the mid-1990s, we found essentially zero instance of hypertrophic scarring.” Dynamic cooling also allows for higher energy fluences and also protects the skin from significant injury as well as providing some anesthetic relief, particularly in children or if treating the face or large areas. When using a PDL, physicians should be aware of the potential fire hazard, especially in an oxygen-enriched environment — even when firing at a remote site distant from the oxygen source. When using an oxygen source, doctors must use a closed source, such as a laryngeal airway or an endotracheal tube. Even with a closed source, laser-ignited fires are a danger and areas such as nasal cannulas should be covered with a wet drape. “If you’re using an endotracheal tube in the operating room, I suggest that the endotracheal tube be protected with a wet gauze because if you look at a capnograph, you will see some leakage of oxygen and carbon dioxide around the endotracheal tube, even though it’s a closed system,” says Dr. Geronemus. “In our practice, we use a laryngeal mask airway, eliminating the need for endotracheal tubes. With an experienced anesthesiologist, the mask can minimize or even eliminate leaking dramatically reducing the risk of fire.” Doctors should protect all hair-bearing areas whether using oxygen or not. If treating around the eyebrows, use a non-flammable viscous ointment such as Surgilube or KY jelly. Patients should also remove all makeup. Doctors have reported that pulsed dye lasers can ignite mascara. Gauze and sponges are less of an issue with the PDL compared to other ablative lasers. The Pulsed Dye Laser’s Effectiveness How effective is the PDL? A number of studies have been conducted showing results that vary from 40% to 100% clearing. However, subjective judgments and improper applications of the treatment often appeared to skew the study results. While it is doubtful that a 100% success rate is possible in anything more than a handful of patients, a physician using the proper laser, tuned to the appropriate wavelength, fluence and so on should expect to achieve greater than 40% clearing with the vast majority of patients. The duration of the treatment regimen varies from patient to patient, but most see considerable improvement after three or four treatment sessions. However, a sizable percentage of patients can achieve only a certain level of clearing — and it is often a lower level of clearing — and will not realize significant clearing beyond that level, regardless of the number of treatments. Unfortunately, many of those patients are reluctant to stop treatment, even when results are barely perceptible. “Patients will endure 20 or 30 treatments hoping to get more clearing,” explains Dr. Geronemus. “But regardless of the number of treatments, those patients will not get clearing greater than 80% or 90%, or even less. It can be extremely difficult to convince those patients to stop further treatment.” For patients with persistent PWS that resist conventional treatments, there are a number of treatment approaches that can yield results. Often a combination of treatments involving the use of multiple laser types can provide significant clearing. “With a mature port wine stain, I will combine laser systems, where we will use one of the 532 nm lasers or even an alexandrite laser, in conjunction with a pulsed dye to get the thicker components,” says Dr. Geronemus. “We’ll treat the flatter components of mild or hypertrophic components with the PDL at higher energy fluences.” Using Intense Pulsed Light as an Option A promising approach to the treatment of resistant PWS is the use of intense pulse light (IPL). IPL generators use a laser or other energy source to generate a controlled pulse of intense light. Many studies seem to indicate that IPL can produce improvement in port wine stains that are resistant to IPL treatments. “What appears to make it more effective is that there may be deeper and broader penetration of the most effective wavelengths of the light,” explains Dr. Robert Weiss, of the Johns Hopkins University School of Medicine. “The strong infrared component of the light may also contribute to its effectiveness.” Current studies indicate that most patients with resistant PWS will respond positively to IPL treatments. Some studies report success rates of 75% to 100% clearing, though a 50% clearing is the most likely result with the majority of patients. While a slight hypopigmentation is common after IPL, many patients seem willing to accept it. “We’ve had a number of patients who have come to us who have tried other methods and got a certain amount of improvement but reached a threshold,” says Dr. Weiss. “With these patients, even if they do have a little bit of change in the epidermis, they’re so gratified to have the discoloration improved that they would be much less likely to report dissatisfaction.” However, as with IPL, there appears to be a treatment threshold beyond which no noticeable improvement can be achieved regardless of the number of treatments. “About 20% of patients fail to get any further clinical improvement beyond a certain point,” says Dr. Weiss. “No matter how we manipulate the parameters, we are unable to go any further.” There are a number of IPL devices available from several manufactures. All are software controlled, and allow operators to control energy levels, pulse duration and sequence. Many of the devices have thermoelectric cooling allowing for the use of smaller quantity of gel, resulting in more consistent results. More Promising Outlooks Offering effective treatment and a low level of side effects, pulsed dye lasers are today’s treatment of choice for port wine stains, producing dramatic results for the majority of patients. For persistent or large, mature port wine stains, a multi-pronged approach involving the use of a variety of laser types and IPL can achieve beneficial results that a single approach cannot produce. Regardless of the treatment type, physicians who understand the nature of the condition and who can make the appropriate choices in treatment approaches can dramatically improve the appearance and well being of most of their PWS patients. “There are certainly limitations on the extent of clearing that you can promise to your patients, and they must realize that some areas will respond better than others,” says Dr. Geronemus. “But it is important to understand that you can make a huge difference for patients for the remainder of their lives with the appropriate use of this technology.”