Capillary malformations

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 more effective.

Venous malformations

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.

Arterial malformations

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

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 bleeding.

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 spontaneous bleeding.

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 measure.

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 by antibiotics.