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Haemangiomas
based on the PDL. The PDL is still the gold standard for treating port wine Nelson et al. demonstrated
10
improvements in terms of tolerability
stains, especially in children and newborns. Its efficiency and (more and effectiveness when cryogen cooling spray was added to a
importantly for children) tolerability explain why this laser is the first PDL. They analysed treatment with PDL of 164 children with
choice when treating children or newborns. haemangioma, one half using a cryogen spray cooling, the other
half with the laser alone and no cooling device. The authors
We know that its penetration inside lesions is not very deep (around concluded that the cooling device improved tolerability and
1mm), so it is logical that its efficacy on thick lesions, and especially on permitted the use of higher fluences, increasing the efficacy and
the deep component, is not significant. Its effectiveness is much higher reducing the number of treatments. Permanent adverse effects
were not observed.
A study by Frieden et al.
7
listed 12 cases of side effects after PDL
A study by Frieden et al. listed 12 cases
therapy. In 11 of 12 cases, no cooling device was used. Only
of side effects after pulsed dye laser
one case of atrophic reaction was noticed when the cooling device
was used.
therapy. In 11 of 12 cases, no cooling
device was used.
There is another point of discussion; when we are examining a child
with a haemangioma we have to wait for five to 10 years before
being able to conclude on the sequelae. So, if we consider the lesions
that did not receive any laser treatment, the fact that the rate of
when used to treat telangiectatic and flat lesions. In order to do this, we sequelae was low tends to prove that those lesions were benign. In
have to decide to treat very early, during the first weeks. Eventually, we order to be able to draw firm conclusions, we probably need a study
may be able to use Nd: Yag lasers in order to treat more deeply. The with a 10-year follow-up, but this is very difficult to organise.
tolerability profile of this laser is possible in newborns, but it could have
a place in treating deep lesions on older children. The strategy of early Two Other Studies Offer Arguments
treatment with the PDL presents two difficulties: the problem of the for the Laser Treatment
relationship with paediatricians, who have to send the newborns to Landthaler et al.
11
published a study that included long-term results of
dermatologists very fast; and the fact that we have to convince the PDL treatment in 617 cases of haemangioma. The aim of the
parents that we propose to treat a non-impressive lesion to avoid treatment was to induce regression or obtain inhibition of further
sequelae without knowing the future of this lesion. At this stage, we growth. With an average of 2.5 treatments, the authors achieved their
cannot know whether this lesion will later turn to atrophy or laxity. objectives in 96% of cases. In 13.6% of cases, regression was
complete. The results were better on superficial lesions. In their
At the same time, we cannot forget that some studies insist that laser conclusion, the authors, who have huge experience with laser
therapy could induce atrophy of the skin. The main study in this area therapy, recommend early treatment.
was published in 2002 in The Lancet by Batta et al.
9
The aim was to
compare the wait and see policy with PDL treatment. This was a Another study, by Kono et al.,
4
compared PDL therapy using
prospective, randomised, controlled trial. It enrolled 121 children short pulse durations (0.45–6 milliseconds) with therapy using long
between one and 14 weeks of age. Sixty were treated, and 61 were pulse durations (10–20 milliseconds). The rate of complete clearance
not, and the children were followed up for one year. The clinical
criteria were the rate of completely clear lesions, residual signs,
pigmentary abnormalities, atrophy, ulceration, infections, the
proportion of children whose parents considered the haemangioma
When examining a newborn with a flat,
to be a problem and the characteristics of the lesions. A panel of five
parents made an independent assessment of severity. According to
telangiectatic haemangioma, it is not
this study, the conclusions do not side with laser treatment. In terms
possible to determine the future
of efficacy, there were no significant differences between the laser
strategy and the wait and see policy if we consider the rate of
(in terms of sequelae) of the lesion.
complete or almost complete clearance. In terms of side effects, the
rate of atrophy (28 versus 8%) and hypopigmentation (45 versus 15%)
was higher in the laser treatment group. The only benefit of the laser
treatment was a bigger improvement in terms of redness. or minimal residual signs at one year was 54% for the short pulse
durations versus 65% with the long pulse durations. Comparing the
The parent panel validated the study, and the authors concluded that side effects, the authors noticed that tolerability was improved with
“PDL treatment in complicated haemangioma is not better than the wait the long pulse durations in terms of hypopigmentations,
and see policy”. If we appreciate the high quality of this study, we can hyperpigmentations and textural changes. This study demonstrates
also have some reservations, as the authors used PDLs with high the importance of the choice of parameters.
energies and short pulse durations without a cooling device. We know
how much the latter improves tolerability, especially in children. It is What Are the Risks Involved in the
difficult to compare the different PDLs because some use high fluencies ‘Wait and See’ Policy?
whereas others use lower fluencies in order to protect the epidermis When examining a newborn with a flat, telangiectatic haemangioma,
and dramatically reduce the rate of side effects. it is not possible to determine the future (in terms of sequelae) of the
74 EUROPEAN DERMATOLOGY
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