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  Port wine stain laser treatment

Port-wine stains (PWS) are tender vascular (blood vessel) deformities in the surface of the dermis. PWS is a congenital vascular deformity and is of the capillary kind.

PWS is present at birth and do not obscure on their own. It occurs as a permanent stain, which grows darker at the age of 10–14 years. If it is not treated at this early stage, by the age of 20 the lesions mature into a blemishing hypertrophy accompanied by varying nodular formations.

Lasers are considered an effective means of correcting PWS by lightening the scars and decreasing their number and size, though achieving only a partial clearance. The pulsed tuneable dye laser (PDL) has become the standard treatment of PWS proving high effectiveness and minimum side-effects.

The first-generation PDLs with 577 nm or 585 nm wavelengths and 0.45 ms pulse width, have proved the safest and most efficient among PDLs. However, in many patients where the PWS scars are unmanageable, various other wavelengths have also been experimented with.

The search for better correction of the resistant types, has led to research and improvisation of the initial PDL formulations. Many other types of lasers and non-coherent light sources have also been tried out in PWS treatment, with varying results. Despite the laser types, the number of laser applications required to achieve a satisfactory outcome is still variable. However, before we go into the details of the various treatment options, it is important to know certain key diagnostic principles involved in laser treatment of PWS.

Morphological prognostic factors: This includes the location of the blood vessels that require treatment. The ones with superficial depth respond better to the lasers. The location helps determine how well the PWS will respond to the laser.

The gross color of PWS: Lasers are supposedly more effective on red lesions than pink or purple ones.

Location and size of PWS: PWS lesions on the head and neck are considered more receptive to lasers, than other body locations. Then again, wider lesions require to be subjected to greater laser exposure than thinner lesions.

Age of the patient: This is still a debated factor. Though some early studies have reported that treatment of PWS is more effective at younger ages, there has been a counterpoint that treatment at an early stage would be futile since there is bound to be PWS enlargement during the growing years.

Once these prognostic factors have been dealt with, the various laser therapy options are:

Second generation pulsed dye lasers

Second-generation pulsed dye lasers are adaptations of the original PDL mechanisms. The key areas of adaptations are in longer pulse widths, longer wavelengths, higher fluences and use of potent cooling mechanisms. Some of these lasers wavelengths (with variations in other parameters such as pulse, fluences, exposure period etc.) that been experimented with and have proved effective in the treatment of PWS are:

  1. The Sclerolaser with 595 nm wavelength
  2. PDL with 600 nm wavelength
  3. Second-generation long-pulsed tuneable dye laser (LPTDL) with wavelengths between 585 to 600 nm.

However, in most of the cases one cannot pinpoint the exact modification that has improved the effectiveness of the therapy, especially if there is a variation in various settings simultaneously and the study group is small. Moreover, theses modifications are also case specific with different patients responding to different alterations in wavelengths, pulse widths and fluences.

Second-generation PDLs have also proved significantly beneficial in the treatment of PWS cases that have failed to respond to first-generation PDLs. These second-generations PDLs are:

  1. PDL with a longer pulse width
  2. High fluence long-pulsed dye laser with cryogen cooling, but with greater side effects. LPTDL at 595 nm with dynamic cooling proved substantially effective, with the highest fluence and shortest pulse showing best results.

Multiple pass treatment

Multiple pass laser irradiation is a current development in laser-assisted PWS correction. This process implements two PDL pulses for every laser sitting, the first of 590–600 nm of 1.5 ms and the second of 585 nm of .45 ms. Hypothetically, the first application aims the vessels at greater depth and the second pass aims the superficial and smaller vessels. This method was reported to be highly effective in four hypertrophic PWS patients, who were subjected to three to five laser sessions. They also showed maximum tolerance and minimum side-effects.

Other lasers

Despite the effectiveness of PDLs in PWS treatment, there are various lesions that remain unmanageable and resistant. The alternative laser-assisted options applicable in such cases are:

  1. The potassium titanyl phosphate (KTP) laser of 532 nm wavelength
  2. Longer wavelength lasers such as the Alexandrite (wavelength of 755 nm) and Nd:YAG (wavelength of 1064 nm), especially in patients with large, deeper PWS warps and advanced cases.

Laser treatment of PWS is evolving each day with more research to comprehend vascular responses of PWS to various lasers types. The aim is to customize laser therapy to individual patient requirements by adapting both the kind of laser and its associated settings. Moreover, this also includes the very vital factor of patient comfort and satisfaction, as at the end of it all this is what makes a treatment dynamic and effective.

 

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