Capillary malformations, such as Port Wine Stains
(PWS) consist of vessels stretched and enlarged
beyond their normal size, a condition called ectasia.
Video microscopies show three patterns of ectasia.
These are ectasias of the vertical vessels, ectasia
of the deeper horizontal vessels and an ectasia
pattern of varying degrees, consisting of both
vertical and horizontal vessels. Recognition of
these patterns is important, since the type of
pattern determines the response to the laser treatment.
PWS can be life threatening at times, but their
major effect is functional disablement due to gradual
hypertrophy and disfigurement.
The flash-pumped PDL of the 80s has been improved
with the addition of a dynamic skin protection
cooling device allowing higher power densities,
needing lesser number of treatments and producing
greater clearance. It was and still remains the
mainstay of port wine stain treatment.
Children respond well to PDL treatment, which
carries low risk of side effects, such as hypopigmentation
or scarring. Incidence of hypopigmentation is 1.4%,
incidence of atrophic scarring is 4.3% and incidence
of hypertrphic scarring is 0.7%. About 65% of patients
given laser treatment are likely to achieve 50%
to 90% clearance and 15% are likely to show 90%
lesion clearance. However, multiple treatments,
ranging from 8 to 10, are needed to achieve a significant
degree of lesion clearance. Children above the
age of one year may safely be given general anesthesia
to reduce trauma, which is a big problem in patients
of that age.
Though far from ideal, PDL remains the standard
treatment for PWS in children even after significant
progress made in the last twenty years. Four to
twelve treatments are still needed and in more
than half the cases, lesions are resistant to treatment.
Resistant PWS lesions may give better response
to long wave PDL with higher power density and
cryogenic cooling. PDL is more effective in superficial
lesions. In adult PWS and resistant PWS, more penetrating
lasers, such as, alexandrite and Nd: YAG may be
Venous malformations can be acquired or congenital.
They are characterized by localized or diffused
enlargement of vessels and always appear as combined
venous lymphatic malformations. If the venous malformation
is congenital, then the lesion distribution is
often multifocal and if acquired, they are found
on lips. Both the acquired and the congenital types
can be treated with PDL, but there are good non-
laser treatments also. The laser treatment of more
extensive venous malformations consists of initially
debulking by laser treatment and then surgical
excision. Multiple treatments may be needed as
venous malformations tend to recur.
Pure arterial malformations are rare. In children
fast flow arterlovenous malformations (AVM) are
most common. While present at birth they are evident
only later in life. They commonly occur in the
intracranial region and less commonly in regions,
such as, the extremities, trunk and the viscera.
They initially appear as dimly visible macular
erythema resembling PWS. AVM expands in puberty
or due to infection or trauma. Clinically, AVM
appears as papules and nodules with bleeding, ulceration
and persistent pain. Laser treatment of AVM may
not have a high success rate because of the high
flow of these lesions.
Lymphatic malformations are of three types. These
are microcystic lymphatic malformations, macrocystic
lymphatic malformations and a type combining both
the microcystic and the macrocystic lymphatic malformations.
The lesions characteristically appear at birth
or at least before the age of two. The clinical
appearance of lymphatic malformations are that
of a firm mass containing macroscopic to microscopis
vesicles and channels filled with serosanguinous
fluids. Extensive lymphatic malformations at the
extremities may lead to lymphedema. Histologically,
lymphatic malformations consist of abnormal enlarged
lymphatic channels. Lymphatic malformations do
not involute spontaneously. They may expand or
contract according to the flow of the lymphatic
fluid and the presence of inflammation or intralesional
Laser treatment is used in lymphatic malformations
to primarily minimize the symptoms. This is done
by reducing lymphatic drainage in superficial lesions
in microcystic lymphatic malformations. In the
combined microcystic and macrocystic lymphatic
malformations, laser treatment is done to minimize
Carbon dioxide laser treatment produces superficial
fibrosis. The mixed lymphatic malformations may
benefit from a treatment that uses carbon dioxide
laser in combination with PDL or Nd: YAG laser.
Laser treatment may also be successful in reducing
the complications of chronic leakage, such as infection
which occur in attempts to avoid the long term
use of prophylactic antibiotics as a preventive
Generally, for intralesional bleeding, conservative
management is advised. The pain during treatment
is best managed by rest and analgesics. Severe
bacterial infection should be immediately treated