Managing Port-Wine Stains

Occurring in roughly three out of every 1,000 newborns, port-wine stains (PWS) are birthmarks that often present with a flat, pink appearance. Depending on size and location, there are a variety of treatment approaches to port-wine stains, including freezing, surgery, and radiation. Energy devices have emerged as a primary treatment approach that, if used properly, can provide effective results.

WHAT UNIQUE CHALLENGES DO PORT WINE STAINS POSE FOR TREATMENT?

There are a number of potential challenges in treating PWS, according to Dr. Ross, such as the difficulty of achieving complete clearance. “My experience has been that treatment should be carried out as early as two months of age and treatments ultimately should be carried out approximately every six to 12 weeks until the lesion is reasonably clear,” notes Dr. Ross. “Our clearance rates typically are up to 60 percent to 80 percent after six to eight treatments,” he continues. However, he further observes that treatment success depends on a number of factors, such as the patient's overall skin pigment and location of the port-wine stain. “Various articles have pointed out, for example, that central facial lesions or central facial portions, particularly along the nose and central face, are more resistant to treatment,” Dr. Ross says. “There is also great variability in responses to treatment. Darker-skinned patients present a problem because of the epidermis being an absorptive of light.” This can largely be overcome by the use of aggressive cooling, either in the form of cold air, contact cooling, or cryogen spray cooling, according to Dr. Ross.

WHAT LASER SYSTEMS ARE AVAILABLE FOR THE TREATMENT OF PORT-WINE STAINS?

Dr. Ross says the pulsed dye laser is the still the gold standard, particularly for pediatric patients and for treating the typically salmon-pink or red port-wine stains. “The pulsed dye laser enjoys a good safety profile, particularly with the addition of surface cooling over the past 10 years. In addition, it is typically well-adapted to treat port-wine stains in children as the vessel size typically is not as large as in adults and nodules are unusual,” he notes. Other lasers that have been used in children with PWS include the Alexandrite laser and the neodymium-YAG laser, as well as intense pulse light, the 810nm diode laser, and a long pulse green laser, such as the frequency double neodymium- YAG laser at 532nm, Dr. Ross says.

“The lighter port-wine stains or pinker port-wine stains typically respond best to the visible light wavelengths including IPL, pulsed dye laser, and KTP, and if you had an older child or a child with some premature nodules and port-wine stain, one could consider using the Alexandrite laser or neodymium-YAG laser,” Dr. Ross observes.

“I would caution that the longer wavelength lasers, particularly the Alexandrite and neodymium-YAG certainly can cause problems with excessive fluences, including deep scars. These should be used with some trepidation, ” Dr. Ross says. “Certainly the neodymium-YAG can be used to treat nodules, but even then only with very low fluences.”

The Alexandrite laser can be used, but should be used very conservatively because there is a very fine line between undertreatment and overtreatment, notes Dr. Ross. “Ultimately, these are two lasers where I do feel that test spots probably are still indicated. The pulsed dye laser has such a good safety record that certainly test spots in experienced hands are not necessary.”

HOW DO DIFFERENT LASERS AND WAVELENGTHS PROVIDE DIFFERENT RESULTS?

“The visible light devices (including the 532nm laser, the pulsed dye laser at 595nm, and the KTP lasers) all provide relatively similar results, although I feel that in very fine, light, pink portwine stains, shorter pulse is important and even purpuric settings can work more effectively,” says Dr. Ross. He continues that these features are exclusively within the domain of the pulsed dye laser at this point.

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E. Victor Ross, MD is Director, Scripps Clinic Laser and Cosmetic Dermatology Center, Carmel Valley, CA and Past President of the American Society for Laser Medicine and Surgery (ASLMS).