Vascular lesions are skin malformations that occur as visible, permanent dilated cutaneous blood vessels. They are of two types, the congenital vascular lesions and the acquired ones. The congenital types can be further divided into two forms:

1. Hemangiomas, which are the most common form of congenital vascular malformations
2. True vascular malformations

In the US, 40000 children are born with congenital vascular lesions and deformities every year. Among them, up to 5% suffer from hemangiomas, in an M:F ratio of 1:3. Hemangiomas that occur in the first weeks after birth usually involute naturally by the age of 5 to 10 years, leaving behind a fibro fatty deposit. It has been estimated that 60% of hemangiomas generally involute by six years of age.

Initially haemangiomas were left untreated at an early stage since they often involute naturally after a first year of growth. In fact, there is still varying opinions about how early to treat hemangiomas. However, there is a consensus about early treatment of hemangiomas that are associated with functional or structural complications and those located in appearance related body parts like the face. Treatment does not aim to achieve total correction but rather a check on the further growth of the hemagiomas.

Before we go into the details of laser treatment of hemangiomas it is important to know a little about its clinical features and types.

Clinical characteristics of hemangiomas

Hemangiomas are characterized by the following features:

• Endothelial cell hyperproliferation
• Vascular deformities but with normal endothelial cell progress
• Vessel wall disorder
• Hemagiomas are either superficial, subcutaneous or a combinations of superficial and deep types
• Uncommon forms are generally inherited or rapidly involuting hemangiomas (RICH) or noninvoluting hemangiomas (NICH) and telangiectatic and arteriovenous malformation (AVM)-like hemangiomas

Types of hemangiomas

Hemangiomas are categorized according to their distribution as:

• localized
• segmental
• diffuse
• intramuscular

Since the localized spread does not involve structural deformities, hence it occurs with lesser complications. In the segmental and diffuse forms, there are greater complications.

Laser treatment of hemangiomas

Lasers have most successfully corrected telangiectatic-type hemangiomas. LPTDL with longer wavelengths and pulses have been used effectively in hemangioma patients. The general laser setting using the FPDL are coinciding pulses of 5–9 J/cm2 and a spot size of 7 mm. Localized lesions can be subjected to laser without anesthesia, but larger, complicated spreads (like segmental and diffuse forms) and those around the eyes should be done with general anesthesia. Current developments have reported long-pulsed dye laser to be more effective than the usual FPDL.

Combination treatment of laser (PDL) and corticosteroids are also often used. Surgical intervention has also been a choice especially in cases with excess fibro fatty tissue deposits and superfluous skin left behind after involution. Surgical intervention should be done at an early stage, when the features of the child and body appearance are at a formative phase. Carbon dioxide laser are used in the cosmetic correction of the surgical scar and PDL used for the removal of telangiectasia deposits.

One of the main factor on which hemangioma treatment is based, is the phase of the lesion, which is categorized as:

• Initial macular blemish
• Stage of vigorous growth
• Involution stage
• Involuted hemangiomas

Below is an overview of the stage-wise potential laser treatments.

Initial macular blemish

If the early macular lesions are treated, the progression of hemangioma maybe arrested, pain reduced (in ulceration) and complication prevented, with a 70 % success rate in children. The laser settings involve pulses of 595 nm, 6–7 J/cm2, combined with epidermal cooling. Successive sessions at 2 to 3 week gaps have proved most effective.

Stage of vigorous growth

This stage generally occurs between 3 and 9 months of age and is often accompanied with ulceration, bleeding and infection. Pulsed dye laser has proved the best treatment in this stage. A low fluence of 6 J/cm2 is enough to hinder ulceration and ensure proper healing. Deep or a combination of superficial and deep hemangiomas should be strictly left untreated during the growing phase.

Involution and involuted stage

Though the procedure involved in the involution of hemangiomas is still not very clear, it is known to be accompanied by ulceration. The various types of lasers that have proved effective in this stage are:

• PDL treatment: After the involution, the leftover telangiectasia is best corrected with pulsed dye laser, with the standard settings for a cosmetic clearance. However, since lasers have limited penetration, they fail to work in case of deep hemangiomas. Moreover, it has side effects such as ulceration, combined with scarring and hypopigmentation.
• Cw-Nd:YAG lasers: These are often used to correct exophytic ulcerated and subcutaneous haemangiomas, under general anesthesia. However, it is associated with side effects such as scarring or nerve clotting. It has proved successful in checking the growth of hemangiomas in 70% of patients.
• The pulsed Nd:YAG laser: This has been the latest development in the treatment of haemangiomas.