|Year : 2017 | Volume
| Issue : 3 | Page : 160-165
Laser treatment of infantile hemangiomas
Michelle Si Ying Ng, Yong-Kwang Tay
Department of Dermatology, Changi General Hospital, Singapore
|Date of Web Publication||7-Jun-2017|
Michelle Si Ying Ng
Blk 43 Sims Drive, #04-209, S'380043
Source of Support: None, Conflict of Interest: None
Infantile hemangiomas (IHs) are the most common benign soft tissue tumor of infancy and childhood. Many patients seek early treatment to halt progression of tumor growth and accelerate regression to achieve quick resolution with good cosmetic outcomes. We reviewed literature through PubMed search on the treatment strategies for IH and share our experience in the field of laser treatment of IH. Treatment strategies for IH include both pharmacological, laser, and surgical interventions depending on the stage and severity of the lesion. Various laser beams have been attempted with varying effects and effectiveness. The 595-nm pulsed dye laser therapy has been most widely utilized owing to its great efficacy but minimal adverse effects. It works by targeting oxyhemoglobin chromophore in blood vessels located within the dermis, causing photothermal damage of these target vessels stimulating quick involution without damaging surrounding healthy skin. It is especially useful in treating ulcerated superficial facial hemangiomas that necessitate rapid healing to avoid unsightly scarring. It has a good safety profile but small risk of epidermal burn, blistering, postinflammatory pigment changes, and scarring remains in those with darker skin types treated with higher fluences and short-pulsed duration. Combination treatment with 1064 nm neodymium-doped yttrium aluminum garnet laser, oral propranolol, and even corticosteroids remains an option, especially in treatment of deep, large, and functionally threatening IH. Careful consideration in consultation with the child's parents given the complexities and potential complications surrounding treatment should always be considered. Laser treatment remains an appropriate treatment for rapidly growing IH in exposed locations at early presentation.
Keywords: Infantile hemangioma, laser, neodymium-doped yttrium aluminum garnet, pulsed dye laser, treatment
|How to cite this article:|
Ng MS, Tay YK. Laser treatment of infantile hemangiomas. Indian J Paediatr Dermatol 2017;18:160-5
| Introduction|| |
Infantile hemangiomas (IHs) are the most common benign soft tissue tumor seen in infancy and childhood; ulceration is the most frequent complication during the rapid growth phase when the hemangioma outgrows its blood supply. Many patients seek treatment early to inhibit growth, to accelerate regression, and to achieve the best possible cosmesis.
Given that most hemangiomas regress without sequelae, the management of IH remains controversial. Some authorities advocate early intervention to ameliorate the impact of larger and more severe hemangiomas, while others favor a more conservative approach as intervention occasionally worsens outcome. However, treatment is necessary for complicated lesions such as ulceration, infection, vision obstruction, feeding, and breathing difficulties as well as facial lesions. Treatment options include topical timolol, oral propranolol, corticosteroids, and laser therapy.
The goal of laser therapy is to maximize vascular destruction while minimizing injury to the surrounding healthy epidermis and dermal tissues. Several types of lasers including pulsed dye laser (PDL), neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, carbon dioxide laser, argon laser, and fractional photothermolysis have been attempted with varying effects.,, Of these lasers, PDL is most widely utilized owing to its high efficacy and good safety profile.,
This review article seeks to review the literature regarding the use of PDL in the treatment of IH. Our experiences in utilizing laser therapy in the treatment of IH will also be discussed.
| Data Sources and Selection|| |
We searched MEDLINE database through PubMed from 2005 to December 2015 using a combination of controlled vocabulary and key terms related to treatment for IH (e.g., IH, laser, PDL, Nd:YAG, timolol, propranolol, corticosteroid). We also handsearched the reference lists of included articles and recent reviews of interventions for IH to identify potentially relevant articles.
| Data Extraction and Synthesis|| |
We initially extracted relevant articles in English with appropriate and comparable study population, characteristic, intervention characteristics, and baseline and outcome data of interests from eligible studies. This is followed by a thorough review of the extracted data for accuracy and completeness.
| How Do Lasers Work?|| |
The major chromophores in the skin include oxyhemoglobin, melanin, and water, each with a different absorption spectrum. In vascular lesions such as hemangiomas, the major chromophore is the oxyhemoglobin found in blood vessels.
Intravascular oxyhemoglobin has an absorption coefficient curve with peaks at 418, 524, 577, and 1064 nm [Figure 1]. At the first and second peaks, the melanin absorption is equally high, and therefore, these wavelengths should not be used. The spectrum between 580 and 590 nm is most useful clinically. Thus, PDL with a wavelength of 595 nm is at present considered to be the gold standard laser used for the treatment of vascular lesions.
|Figure 1: The absorption spectrum of the major chromophores in the skin as a function of wavelength|
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Flashlamp-pumped PDL has a wavelength of 585 or 595 nm, allowing the selective destruction of the blood vessels while keeping the overlying skin intact.
Laser devices emit wavelengths near the target peaks to induce photomechanical and photothermal damage of the target tissue. PDL works through the same principle. The basic principle is the preferential absorption of laser light by hemoglobin and its subsequent conversion into thermal energy leading to coagulation of blood vessels. When the 595-nm PDL is absorbed by its target chromophore, oxyhemoglobin, the heat that is generated coagulates the target vessels while keeping the overlying skin intact. With successive treatments, the blood vessels progressively shrink, gradually decreasing in size till they eventually diminish.
Multiple clinical studies have demonstrated success rates as high as 93% with the use of PDL for treatment of proliferating hemangiomas, with few associated complications.
| Our Laser Experience|| |
Choice of Laser
Laser therapy is recognized as the gold standard treatment in the treatment of ulcerated IH owing to its high success rates., In our practice, PDL is used as first-line therapy in the treatment of ulcerated or superficial facial hemangiomas. It is also used as an adjunct when first-line topical timolol or oral propranolol treatment does not achieve satisfactory results. We use 595-nm PDL as the laser of choice as it is effective in treating superficial hemangiomas, with high success rates and good cosmetic outcomes. PDL stimulates vessel involution and accelerates healing of ulcerated hemangiomas to good effect. Pain control can be achieved in 2–3 days and rapid healing of ulcerations (as much as 75%) occurs in the short span of 2 weeks. PDL has also been shown to stimulate the production of dermal collagen and elastic fibers in the superficial dermis, preventing the atrophy of laser-treated skin.,
Although therapeutic efficacy has been demonstrated with the use of PDL therapy in ulcerated hemangiomas, we emphasize that PDL therapy should be targeted at the entire hemangioma and not merely the ulcerated area. This is to reduce the likelihood of recurrence in the surrounding residual vessels. PDL treatment of residual vessel telangiectasia after hemangioma involution has also been shown to result in excellent treatment outcomes. This goes a long way toward improving cosmetic outcomes for patients.
From our experiences [Figure 2], using the 595-nm PDL at moderately high fluences of 10.5–14.5 J/cm 2 with a short pulse duration of 1.5–3 ms is as equally effective as compared to a longer pulse duration of 10 ms. We use a spot size of 7 mm with dynamic cooling device (DCD) spray duration of 50 ms with a delay of 30 ms for short pulse settings, and DCD spray duration of 40 ms with a delay of 20 ms for the longer pulse settings. A higher cooling setting was used with the shorter pulse durations to provide more epidermal protection at higher fluences. This is particularly pertinent for our Asian patients who have darker skin, allowing us to mitigate complications such as blisters, ulceration, and scarring.
|Figure 2: Treatment response achieved with treatment using pulsed dye laser (a), timolol topical solution (b), and oral propranolol (c). (a) Before and after treatment of a left preauricular mixed infantile hemangioma with pulsed dye laser at settings: 595 nm pulsed dye laser: 7 mm, 10–12 J/cm2, 1.5 ms, 50/30, with a total of seven treatment sessions. The bulk of the superficial tumor has resolved leaving minimal deeper subcutaneous component. (b) Before and after treatment of a left dorsum of foot superficial infantile hemangioma with timolol maleate 0.5% eye drops solution. The bulk of the tumor has resolved but some hemangioma can still be seen at the toes. The treatment duration was 6 months. (c) Before and after treatment of a right wrist superficial infantile hemangioma with oral propranolol. The bulk of the tumor has resolved leaving minimal vascularity seen at the edges. The treatment duration was 5 months|
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How long we maintain our patients on laser therapy is highly dependent on the growth stage of the hemangiomas. The treatment is repeated every fortnight for actively proliferating lesions and every 1–2 months for stable lesions. An average of eight laser sessions (range 3–14) is required to achieve optimal cutaneous healing and hemangioma involution with the shorter pulse settings, with a mean of nine sessions (range 4–14) when the longer pulse settings are used. Treatment duration also differs depending on hemangioma depth. Owing to its more deeply seated location, mixed hemangiomas require more treatment sessions (4–5 on average) for involution compared to its more superficial counterparts.
The use of PDL, however, is limited to superficial IH due to its maximum depth of only 1.2 mm penetration into the skin. More deeply seated hemangiomas necessitate the use of longer wavelengths which have greater penetration depth. Long-pulse 1064 nm Nd:YAG lasers have been used to treat deeper hemangiomas with good outcomes. Notably, adverse effects such as ulceration, infection, bleeding, and scarring are not entirely uncommon if these lasers are delivered too intensely and extensively.,
Therefore, in the treatment of mixed and deeper hemangiomas, combined use of 595 nm PDL and 1064 nm Nd:YAG lasers yield better results compared to single laser treatments. It allows for laser intensity to be modulated, with the higher intensity Nd:YAG used for targeting deeper lesions, and PDL for the more superficial ones. A combined sequential dual wavelength laser has been tried successfully for the treatment of IH with good effect.
Our efforts to treat mixed hemangiomas with PDL alone showed poorer treatment results although combination therapy with other treatment modalities has been shown to improve outcomes. The combination of PDL with oral propranolol has shown to result in a synergistic therapeutic effect, resulting in a more rapid and enhanced clearance of lesions.,
Side Effect Profile
The more common side effects experienced with PDL include erythema, edema, and purpura. These lasted for about 1 week in the short-pulsed duration group but many shorter (only 2–3) days in the long-pulsed duration group. We did not observe any blistering, ulceration, or hypertrophic scarring with any of our laser-treated patients.
In patients with darker skin phototypes, i.e., Fitzpatrick type IV and above, a slightly higher incidence of side effects was seen when shorter pulse durations were used. Thus, appropriate counseling and greater caution would need to be exercised, especially when shorter pulse durations need to be employed in this specific subgroup of darker skin patients.
| Treatment Alternatives|| |
Specific disease characteristics such as lesion size, location, type, rate of growth as well as age, functional impact, and IH subtype influence the ultimate treatment choice.
In cases of rapidly proliferating deep or mixed IH, or hemangiomas that compromise critical bodily functions (vision/airway), treatment adjuncts on top of laser therapy should always be considered. These include topical application of timolol, systemic medical therapy such as oral propranolol, corticosteroids, surgical excision or debulking procedures, intra-arterial embolization, or intralesional corticosteroid injections.
Topical preparations such as timolol maleate (TM), a nonselective β-adrenergic antagonist, are now widely accepted as an effective therapy for uncomplicated superficial and mixed IH due to its excellent efficacy and good safety profile.,
Beta-adrenergic antagonists, such as oral propranolol, have been one of the most commonly employed treatment modalities for IHs. It is often used as first-line treatment for large, segmental, and complicated hemangiomas. However, it can be associated with hypoglycemia, cardiac, and respiratory side effects.
Oral corticosteroids are effective and quick in reducing the size of IH, but potential side effects include cataracts, gastritis, growth retardation, and adrenal suppression can occur. Owing to these serious systemic side effects and the variable response rates, it is no longer used as first-line treatment but as an adjunctive therapy if the use of oral propranolol is contraindicated.
Intralesional corticosteroid therapy effectively shrinks the lesion but carries a risk of atrophy and depigmentation of treated skin, adrenal suppression, failure to thrive, and arterial occlusion.
Overall, the risks of intralesional therapies and systemic medical/surgical treatment are higher than that of laser therapy. Hence, such adjunct therapies are primarily indicated in complicated hemangiomas and should not be employed as first-line therapy for proliferating superficial IH. The clinical characteristics of each and every IH would thus need to be carefully evaluated before the institution of any form of treatment for the best results with minimal adverse effects.
| Combination Treatment|| |
Because of the limitations of laser therapy and the potential permanent complications of unarrested HI growth, complicated hemangiomas are often treated with combination therapy for maximum therapeutic efficacy. This includes a beta-adrenergic antagonist (topical TM/oral propranolol) together with PDL treatment. Combination treatments may have potential benefits, including greater efficacy, synergistic effects, and lower toxicity. However, owing to a lack of sufficient comparative studies, the consensus on the safest and most effective modality of treatment still remains highly controversial and strongly contested.
Timolol Maleate 0.5% + Pulsed Dye Laser
Asilian et al. conducted a double-blind study on thirty infants aged 1–12 months old comparing the effectiveness of PDL treatment alone versus a combination therapy of PDL with 0.5% topical timolol gel treatment. The author reported a statistically significant reduction in the mean size of the hemangiomas as well as an improvement in the visual analog scores of the hemangiomas. The adverse effects reported were the same in both groups and were mostly changes in texture and/or pigmentation.
In another study, Park et al. performed a retrospective 3-year review of 140 IH patients treated with topical TM 0.5% solution alone compared with combination therapy of both TM and PDL. The author reported significantly improved outcomes (P = 0.018) in the group with combination therapy compared to topical treatment alone. From their data, it is also suggested that the combination treatment response was increased considerably in the first 1–3 months of life. This also suggests the necessity of early treatment of IH for better treatment outcomes.
Propranolol + Pulsed Dye Laser
Reddy et al. conducted a retrospective review of a group of IH infants comparing the treatment responses of oral propranolol alone (n = 8) with combination therapy of both oral propranolol and PDL (n = 17, of whom 12 were treated with the two therapies concurrently and 5 were treated with propranolol treatment followed by PDL). IH treated with combination therapy of oral propranolol and PDL showed a greater clearance than those treated with propranolol alone. 100% of IH treated with combination therapy achieved complete or near-complete clearance compared to 38% in the oral propranolol arm. This clearly reflects the more favorable response of IH toward combination compared to monotherapy. Sequence of treatment in combination therapy is also of utmost importance. Patients treated concurrently with both oral propranolol and PDL responded more completely and quickly compared to those treated sequentially, first with oral propranolol followed by PDL. Nonetheless, sequential treatment still proved to be more efficacious compared to monotherapy with oral propranolol alone.
| Conclusion and Recommendations|| |
The treatment of IH should be considered carefully in consultation with the child's parents given the complexities and potential complications surrounding treatment. Laser therapy remains to be one of the most effective modalities of treatment. Early laser treatment can safely and effectively reduce the proliferation of superficial hemangiomas, promote involution, and improve cosmesis. Therefore, laser therapy may be an appropriate treatment modality for rapidly growing IH in exposed locations at early presentation.
595-nm PDL is one good modality to consider for early management of superficial proliferative and ulcerative hemangiomas. It can also be considered as an adjunctive therapy to oral propranolol to improve treatment outcomes while shortening treatment duration.
Till date, the optimal parameters for the treatment of IH using PDL are still highly contested. In our experience, however, we found that operating PDL at a setting of moderately high fluences with either short or long pulse durations has shown similar rates of clearing although the incidence of adverse outcomes was slightly higher when shorter pulse durations were used. Kono et al. shared a similar experience with the same settings and also proved it to be safer and more effective in the treatment of early childhood hemangiomas in Asian patients. In situ ations where lesions continue to enlarge despite laser therapy, supplementary pharmacotherapy such as topical timolol or oral propranolol should be considered.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]