The following rebuttal by Dr. Stuart Nelson and Dr. Roy Geronemus was published in the New England Journal of Medicine in response to an article about the recurrence of Port Wine Stains (PWS) after pulsed dye laser treatment. At this year’s conference in Irvine, several physicians spoke about the pathology, progression and treatment of PWS. To summarize what was presented, after a PWS is treated using the pulsed dye laser, the vessels that are targeted by the laser will not necessarily come back, but rather new, deeper vessels will work their way up to the top of the skin thus making “some” stain appear. It is important to understand this because many people believe that PWS will always come back and, therefore, they should not have laser treatment. This is not true. While the laser does not “cure” the PWS, it offers the most hope for clearance, for keeping the skin from thickening and cobbling and for maintaining the best aesthetic outcome for the patient (comment by Linda Rozell-Shannon, President and Founder of the Vascular Birthmarks Foundation, 11/8/07).
Comments from Dr. Stuart Nelson and Dr. Roy Geronemus:
“We reviewed “Redarkening of Port-Wine Stains 10 Years after Pulsed-Dye-Laser Treatment” by Huikeshoven et al (NEJM 2007;356:1235-1240) with great interest and would offer our comments.
Unfortunately, the laser technology utilized by Huikeshoven’s group was the Candela SPTL1b, which is now considered obsolescent for port wine stain (PWS) laser therapy. This device did not utilize dynamic cooling, which allows the clinician to use safely much higher light dosages. Very likely, the light dosages in current use from lasers that are available today are a factor of more than two higher than those used in the Huikeshoven study. Moreover, other laser parameters such as wavelength, pulse duration and spot size were also “fixed” and could not be adjusted to tailor the needs of each individual patient’s lesion. PWS blood vessels are heterogeneous in terms of their sizes and depths. Consequently, the ability to vary the parameters with each treatment session and amongst different patients results in better clinical results. It is our belief that the more lesion clearing obtained, the less likely the chance of recurrence.” NOTE: This statement now has been qualified to mean that the vessels that are treated may not recur but new ones will find their way to the surface of the skin and cause “some” stain to appear like the PWS has returned. This is not true. New, deeper vessels are migrating to the surface of the skin. So, the stain appears but it is comprised of new vessels, not necessarily the ones that were treated by the laser. (Linda Rozell-Shannon, 11/8/07).
According to Nelson and Geronemus, “Multiple devices are now available for PWS treatment, each with its own unique wavelength and pulse duration. Both parameters affect the depth and degree of heating in PWS vessels of different sizes. At our institutions, we have multiple lasers including the Gemini, four Candela pulsed dye lasers (SPTL1-b, ScleroPLUS, C-Beam and V-Beam, and Perfecta), Lumenis VersaPULSE and the Cynosure dual-wavelength Cynergy Multiplex on our permanent equipment inventories.
Commonly, several devices are used during an extended treatment protocol in order to destroy vessels of different sizes. When therapy is first initiated, we commonly use shorter wavelengths and pulses to target the typical small (30-50 mm) diameter vessels seen in pediatric PWS. Thereafter, longer wavelengths and pulses are used to target the residual larger and deeper PWS blood vessels.
When patients are referred to our centers after previous treatments at other institutions, we always review all previous medical records to determine which laser device was used. Changing the wavelength or pulse duration of the laser can result in substantial PWS fading not previously observed with single device therapy.
Two notable items from the Huikeshoven study deserve further comment. First, the average age of the patients treated ten years ago with the SPTL1b device was 13. Studies have recently shown that aggressive treatment of infants and young children at earlier ages improves PWS clearance. There are two important “optical” advantages to treating patients at as young an age as possible: 1) less cumulative ultraviolet light exposure results in less epidermal melanin which competes for the absorption of laser light; and 2) less collagen in the skin results in less light being back-scattered out of the skin. The end result of both advantages is that in younger patients more light penetrates deeper into the skin to destroy targeted PWS blood vessels. Second, it has also been documented that there can be anatomical variation in terms of the response to laser therapy. For example, the central face does not respond as completely or as quickly to laser therapy as the lateral face, and PWS located in this area are more likely to recur.
The Huikeshoven study is helpful in educating patients and their families, as well as medical professionals, that it is possible to encounter PWS darkening after laser therapy. However, we believe that the benefits of laser therapy far outweigh the risks of no treatment. If left untreated, many port wine stains often become incompatible with normal life due to the development of bumps (vascular nodules) on the skin surface which can often bleed spontaneously with incidental trauma. Improvements in laser technology over the past decade, including the use of multiple laser devices through an extended treatment protocol and selective epidermal cooling permitting the use of higher light dosages, have expedited lesion clearing. Finally, a more aggressive approach to treating infants and young children at earlier ages has also demonstrated great promise.” (2007)
J. Stuart Nelson, M.D., Ph.D., Irvine, CA
Roy G. Geronemus, M.D., New York, NY