Correspondence
Treatment of Port-Wine Stains
N Engl J Med 1998; 339:635-636August 27, 1998
- Article
To the Editor:
Van der Horst et al. (April 9 issue)1 report no additional benefit from early treatment of port-wine stains with the pulsed-dye laser, which is in contradistinction to our experience2 and that of others. Several issues should be raised about the methods of the study, which may account for the unexpected results.
The authors enrolled consecutive patients in their treatment groups without controlling for the types or locations of the lesions. There were more “hypertrophic” lesions in the younger treatment groups (29 percent) than in the older treatment groups (18 percent). Hypertrophy of port-wine stains in childhood has not been reported previously, suggesting that lesions with an arterial or venous component may have been treated. Such lesions are known to be poorly responsive to pulsed-dye laser treatment. Van der Horst et al. also failed to control for the location of lesions on the head and neck, which we have reported3 to affect the response to pulsed-dye laser treatment.
The use of ice cubes to cool lesions during treatment may have led to chilling of dermal vessels in younger patients, who have thinner skin, thereby interfering with the efficacy of laser treatment. By treating port-wine stains only partially at each visit and by requiring several sessions to treat the entire port-wine stain, van der Horst et al. provided few complete treatments early on, potentially missing a therapeutic window of opportunity, when the skin is thinner and the stain smaller.
The treatment technique and technology that were used are outdated. Improved therapeutic outcomes4 have been demonstrated with the use of larger spot sizes — 7 to 10 mm — rather than the 5-mm spot size used by van der Horst et al. Additional benefit has been derived from the use of longer wavelengths (595 nm, as compared with 585 nm) and longer pulse durations (1.5 msec, as compared with 0.45 msec), in particular for hypertrophic lesions. Selective epidermal cooling can be achieved with cryogen-spray cooling, which is now being utilized in conjunction with 585-nm and 595-nm pulsed-dye laser treatment, decreasing the pain of treatment and the time needed for recovery.5
5 ReferencesArielle N.B. Kauvar, M.D.
Roy G. Geronemus, M.D.
317 E. 34th St., New York, NY 100161
van der Horst CMAM ,Kos ter PHL ,de Borgie CAJM ,Bossuyt PMM ,van Gemert MJC . Effect of the timing of treatment of port-wine stains with the flash-lamp-pumped pulsed-dye laser. N Engl J Med 1998;338:1028-1033
Full Text | Web of Science | Medline2
Ashinoff R ,Geronemus RG . Flashlamp-pumped pulsed dye laser for port-wine stains in infancy: earlier versus later treatment. J Am Acad Dermatol 1991;24:467-472
CrossRef | Web of Science | Medline3
Renfro L ,Geronemus RG . Anatomical differences of port-wine stains in response to treatment with the pulsed dye laser. Arch Dermatol 1993;129:182-188
CrossRef | Web of Science | Medline4
Kauvar ANB ,Waldorf HA ,Geronemus RG . Effect of 7 mm vs 5 mm spot size on pulsed dye laser treatment of port wine stains and hemangiomas. Lasers Surg Med 1995;7:56-56 abstract.5
Kauvar ANB ,Grossman MC ,Bernstein LJ ,Kovacs SO ,Quintana AT ,Geronemus RG . The effects of cryogen spray cooling on pulsed dye la-ser treatment of vascular lesions. Lasers Surg Med 1998;10:45-45 abstract.
Author/Editor Response
The authors reply:
To the Editor: At the start of our study it was clear from other series involving small numbers of patients that port-wine stains in children could be treated safely with the flash-lamp–pumped pulsed-dye laser.1 Our prospective study, using objective color measurements and validated instruments to measure disfigurement, tested the hypothesis that port-wine stains in children could be treated more effectively than those in adults.2,3
We included patients with capillary malformations alone. We defined hypertrophic port-wine stains in this population as lesions that were abnormally swollen in comparison with the healthy skin on the contralateral side. Patients with combined malformations (venous, arteriovenous, and lymphatic) were excluded. In our opinion, patients with Sturge–Weber syndrome have capillary malformations, and there is no evidence that treatment of port-wine stains that are part of such a syndrome is less effective than treatment of port-wine stains that are not part of a syndrome.
Before beginning treatment, we recorded the extent and location of the port-wine stain in each patient. We made an anatomical diagram of the face and neck in 64 regions and then regrouped these regions into 18 principal regions. We evaluated the response to treatment of the port-wine stain in relation to these regions within the age groups. We did not observe differences in responses that were related to the anatomical locations of the port-wine stains. In determining the response to treatment, we found that the initial size and depth of the lesion were more important predictive factors than the location of the lesion.
We only used gauze drenched in ice water, not ice cubes, for a short period after the laser pulses. The question is whether the vascular response to this type of pain relief differs from the vasoconstriction induced by a eutectic mixture of lidocaine and prilocaine (Emla cream), which is not known to interfere with the efficacy of treatment.4
Therapy was standardized; therefore, we did not change the laser settings during the study period.5 The use of a faster laser with a larger spot size (7 mm) would not have influenced the use of general anesthesia in our youngest age groups. In children with port-wine stains that could be treated partially during one visit, the entire lesion was treated within six to eight weeks. We included only a few children under the age of one year; therefore, it is still unclear whether such patients will ultimately have better treatment results than those treated at an older age. The additional benefit of the use of longer wavelengths and pulse durations remains to be established. Nonetheless, our main conclusion — that treatment of port-wine stains in early childhood is effective, but not more so than treatment at a later age — is unlikely to change.
5 ReferencesChantal M.A.M. van der Horst, M.D.
Corianne A.J.M. de Borgie, M.Sc.
Patrick M.M. Bossuyt, Ph.D.
Academic Medical Center, 1100 DE Amsterdam, the Netherlands1
Ashinoff R ,Geronemus RG . Flashlamp-pumped pulsed dye laser for port-wine stains in infancy: earlier versus later treatment. J Am Acad Dermatol 1991;24:467-472
CrossRef | Web of Science | Medline2
Koster PHL, Bossuyt PMM, van der Horst CMAM, Gijsbers GHM, van Gemert MJC. Assessment of clinical outcome following pulsed dye laser treatment of port-wine stains: a comprehensive questionnaire. Plast Reconstr Surg (in press).
3
Koster PHL, Bossuyt PMM, van der Horst CMAM, Gijsbers GHM, van Gemert MJC. Characterization of port wine stain disfigurement. Plast Reconstr Surg (in press).
4
Bjerring P ,Andersen PH ,Arendt-Nielsen L . Vascular response of human skin after analgesia with EMLA cream. Br J Anaesth 1989;63:655-660
CrossRef | Web of Science | Medline5
Verkruysse W . Two `585 nm' pulsed dye lasers hardly emit 585 nm light. Lasers Surg Med 1995;7:56-56 abstract.
- Citing Articles (4)
Citing Articles
1
Kira Minkis, Roy G. Geronemus, Elizabeth K. Hale. (2009) Port wine stain progression: A potential consequence of delayed and inadequate treatment?. Lasers in Surgery and Medicine 41:6, 423-426
CrossRef2
Xavier Dray, Isabelle Fajac, Thierry Bienvenu, Ariane Chryssostalis, Philippe Sogni, Dominique Hubert. (2007) Association of Pancreas Divisum and Recurrent Acute Pancreatitis With the IVS8-5T-12TG Allele of the CFTR Gene and CFTR Dysfunction. Pancreas 35:1, 90-93
CrossRef3
(2007) Redarkening of Port-Wine Stains 10 Years after Laser Treatment. New England Journal of Medicine 356:26, 2745-2746
Full Text4
(2002) Laser Literature Watch. Journal of Clinical Laser Medicine <html_ent glyph="@amp;" ascii="&"/> Surgery 20:3, 151-181
CrossRef
