Laser Tx for Port-Wine Stains Safe Without Anesthesia in Infants

Pulsed dye laser (PDL) treatment without general anesthesia was safe and effective for infants with port-wine stains (PWS), according to a single-center review.

In the retrospective study of 197 infants who underwent PDL, 25.9% had complete clearance of their vascular birthmark, with a mean score of 4.78 on the 5-point visual analog scale (VAS), reported Roy Geronemus, MD, of Laser & Skin Surgery Center in New York City, and colleagues.

And 41.1% had lesion improvements of 76% to 99% (mean VAS score 3.91), they wrote in JAMA Dermatology.

For the remaining patients:

• 22.3% had improvements of 51% to 75% (mean VAS score 2.86)
• 6.6% had improvements of 26% to 50% (mean VAS score 2.12)
• 4.1% had improvements of 0% to 25% (mean VAS score 0.78)

“Treating PWS during infancy allows for treatment without general anesthesia as it is easier to hold the patient still during the treatment,” the authors explained. “Uncooperative older children are more challenging to keep immobilized during laser treatment, and many receive PWS treatments under general anesthesia.”

In the study, mean age at the start of treatment was 3.38 months, with the youngest starting at 5 days old.

The paper supports the current evidence base that frequent and early, short treatment intervals of PDL is effective in reducing the visibility of PWS, said Jennifer Schoch, MD, of the University of Florida in Gainesville, who was not involved in the research.

“It is exciting to see that the authors noted significant improvements in PWS of the trunk and extremities as well, as many dermatologists feel that these PWS do not respond to PDL as well as facial PWS,” Schoch told MedPage Today.

Mean VAS score was 3.65 in the overall study group, and was similar for both facial lesions and those of the trunk and extremities (3.69 vs 3.57, respectively).

“The trick may be in earlier treatment,” said Schoch, adding that in late infancy — around 10 to 11 months — it usually becomes nearly impossible to accomplish PDL without general anesthesia.

In late 2016, the FDA warned against “repeated or lengthy use” of general anesthesia in children under age 3 years, due to possible negative effects on brain development, “a caution that is highly relevant for the treatment of PWS with PDL,” wrote Erin Mathes, MD, and Ilona Frieden, MD, both of the University of California, San Francisco, in an editorial that accompanied the study.

It is generally accepted that PDL is a painful procedure, and the pain increases as the size of PWS grows because more pulses are needed, they explained. While dynamic cooling devices may lessen pain, they do not get rid of it entirely. Mathes and Frieden cautioned that pain during infancy could potentially have effects on the developing neural circuitry that lead to long-lasting variations in pain perception.

“Even though the short-term or long-term effects of repeated PDL treatment on emotions and pain perception have not been studied systematically, we cannot assume that there is no effect,” the editorialists wrote.

They noted that while some of the patients in the study continued treatment into their second year, “our own experience is that by age 12 to 15 months, many infants show signs of fear and struggle more with laser treatments, particularly if multiple treatment sessions have already occurred.”

Schoch said “studies examining the psychological impact of these repetitive procedures on infants would be helpful, to reassure us that we are not trading the low risks of anesthesia for other psychological effects.”

The researchers evaluated 197 patients, 62.9% of whom were girls. About 75% of the participants had facial lesions, while 25% had PWS of the trunk and extremities, and 41.1% had periocular lesions. The patients received an average of 10 treatments.

For their study, Geronemus’s group evaluated medical records of infants ≤1 year treated with PDL for PWS from 2000 to 2017 at a single high-volume laser facility. Patients were followed for 1 year from the time of their first treatment. None of the cohort experienced irreversible pigmentary changes or scarring.

They also found that presence of a first branch of the trigeminal nerve lesion (V1) was linked with a higher rate of improvement (VAS grade 0.55, 95% CI 0.25-0.84, P<0.001).

Study limitations included the retrospective design and lack of a control group. Geronemus told MedPage Today that the review included few patients with darker skin types — just two had Fitzpatrick V-VI skin types, while 90.9% were types I-III. He also noted the limited follow-up window. “One of our goals is to go back and see how these children did with additional treatment beyond the cutoff,” he said.