Conference Coverage

Lasers Have Role in Pediatric Care, Expert Says


 

FROM THE ANNUAL MEETING OF THE FLORIDA SOCIETY OF DERMATOLOGIC SURGEONS

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.

Immediate results with a laser can be beneficial, which provides great relief for parents. "I tell them the goal is to stop the growth, stop the darkening, and stimulate the involution, " he said.

Children With Nevi

Lasers also can treat nevi of Ota, Dr. Izakovic said, but there is some variability in outcome; however, satisfying results can be achieved.

The issue surrounds complete ablation of a regular nevus with laser energy. He said he prefers to reserve laser treatment for children who first had a biopsy to rule out malignancy. Another option is to remove the nevus surgically and test the sample for any relevant pathology. "Always check what you remove histologically when you remove nevi," he said.

Several Q-switched lasers, such as a ruby 694 nm, an alexandrite 755 nm, and an Nd:YAG 1,064 nm, are appropriate for nevi treatment. Remember that anesthesia might be indicated because treatment with a Q-switched laser can be painful, he said.

Pediatric Vitiligo

Children with vitiligo can likewise see improvement following laser treatment, Dr. Izakovic said. Among the newer options is the use of an excimer laser 308 nm by itself or in combination with topical therapies. The use of this device is increasing for the treatment of vitiligo, especially on isolated small areas of the face, neck, or head, he said.

"There are some good responses after a couple of treatments. You can see signs of repigmentation," he noted.

Other Uses

Rarer instances include PDL 585-nm treatment of striae. "This only treats the erythematous part and it’s not an overwhelming effect," Dr. Izakovic said. Café au lait spot lightening is another marginal indication for lasers that is not yet fully supported in the literature.

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