Treatment of Portwine Marks by an Argon Laser LEON GOLDMAN, M.D., RONALD D R EFFER , B.S., R.J. ROCKWELL, JR., M .SC, AND EDW ARD PERRY, M.F.A.
Although the treatment o f the ordinarily incurable port wine birthmark by lasers has been practiced fo r more than 10 years, recent therapeutic investigations have been carried out particularly with the argon laser. Argon lasers now available fo r medical purposes produce treatment spots that are small. For certain practical reasons, at present, only relatively small portwine marks can be treated effectively. With trained personnel and proper safety measures, the treatment is safe fo r the patient and the operator. The treatment as yet is not proved to be better with the argon laser because the ruby laser and even an incoherent infrared thermal coagulator can produce similar and often larger cleared areas. It is recommended for the present that treatment o f portwine marks by argon lasers be restricted to investigation in medical centers where critical evaluations, control studies, and more powerful laser systems can be developed.
S i n c e t h e p o r t w i n e m a r k is as yet an incurable, disfiguring lesion, especially on the face, any contribu tions to feasible therapy should be welcome. The derm a tologist as well as the general practitioner and the pediatrician should be kept informed about current developments in therapy for this persistent and distress ing lesion so that proper advice may be given to anxious patients and parents. Usually no treatment is advised. Tattooing with titanium dioxide or zinc oxide particles is still done occasionally by plastic surgeons. This procedure results
From the Robert S. Marx Laser Diagnostic and Treatment Facility of the Laser Laboratory, D epartm ent of Dermatology, University of Cincinnati Medical Center, Cincinnati, Ohio 45267.
in an irregular mottled pattern. Moreover, it can not be used on the eyelids where extirpation by laser can be attempted. Excisional surgery is often done in adult life when connective tissue changes in the portwine mark result in nodular and pendulous areas which can be ablated. At present and mainly, portwine spots are covered with heavy theatrical make-up creams, like Covermark® or Erase®. Unless the preparations are suited to an affected individual’s own skin color and texture, commercial make-up creams are usually not satisfactory for many patients. With mixed types of lesions, such cavernous nodules or acquired telangiec tatic elevations in the portwine marks, the cosmetic results are never satisfactory. Also, efforts to have parents get afflicted children to use covering prepara
J. Dermatol. Surg. 2:5 November 1976
385
ARGON LASER
tions early in life as a routine daily procedure are rarely successful. Because of the cosmetic distress of portwine marks and because therapy is a challenge, investigative studies with treatment by lasers were begun more than twelve years ago in our Laser Laboratory.1-2 The animal test model for our program of treatment by lasers was the chicken comb. This is a superior biological test model than is tattooed patterns on rabbits or miniature pigs.3 Because of the absorption spectrum of hemoglobin, it was theorized that the argon laser, emitting electromag netic energy at 488.8 nm to 512.5 nm, would be much more effective than other laser systems. Initial studies have been done with the ruby laser and, five years ago, with the argon laser. In recent months the argon eye laser, used for the treatment of ophthalmic disorders, has also been used to treat portwine marks. Extensive studies have been done at Palo Alto by Apfelberg.4 Recently, commercial models have been developed particularly for dermatologic use. The mechanism of the laser reaction is, for the most part, a superficial, nonspecific thermal coagulation necrosis. There is, in brief, superficial necrosis, thrombo sis, and, at times, extravasation of blood. The deeper vascular plexuses are not affected. These changes produce blanching of the skin color through a change in the optical quality of the tissue. For this reason, as with any use of the laser, controls have always been neces sary. Such controls are also used to produce nonspecific thermal coagulation necrosis. In brief, three types of therapy have been used at the Laser Laboratory for the treatment of portwine marks. These include: 1. the ruby laser—694.3 nm 2. the argon laser—488.8-512.5 nm 3. recently, as control—the infrared coagulator, developed by N ath3 and M uhlbauer.G Electrodesiccation and cryosurgery were given up sometime ago as treatments for the portwine mark. Experiences with the ruby and argon lasers have been reported previously.12 Large whitish areas, 2.1 cm2 have been produced by the ruby laser. Occasionally adverse reactions in a series of more than 200 patients have resulted in revascularization and hypertrophic scarring of the lip and the chin that subsided gradually. Cosmet ically, the round impact areas produce a reticulated appearance to the treated portwine marks. This is difficult to correct, even with subsequent laser impacts. In general, the ruby laser has been effective for the treatment of small unilateral forms of portwine marks. More than five years ago, research and development was begun with the argon laser. The current series with the argon laser treatment consists of 112 patients. Two types of argon laser beams have been used. These are
386
J. Dermatol Surg. 2:5 November 1976
the 3-watt argon laser used previously, and the new Spectra-Physics argon laser with a Nath Flexible Fiber, giving outputs up to 6 watts and a beam diameter 1.5 mm. A second beam form has a diffusing lens that gives beam diameters of 3-4 mm. In 1971, we reported that the argon laser would have to be more powerful to be more practical. Lasers are hazardous to the eye12 and safety measures are necessary. These include the use o f a special area for the treatment, area control, and safety glasses made specially for the laser type used. Instruction in the use of the laser, frequent measurements of output, and training in laser safety are essential. When eyelids have to be treated, special silvered plastic cups are used in the eye with topical anesthesia. Under such safety measures, the laser is safe for both the patient and the operator. Special operative release forms are required to be signed by the patient or by parents. Because of the need for eye safety, treatments in children are given only after age 6 or 7 because cooperation on the part of the patient is necessary. Local ring anesthesia is given for a small area; general anesthesia is preferred for extensive treatments. The usual precautions for general anesthesia are the same as those for electrosurgery. Initial trials are done in small areas of the lesion to determine the initial response to the laser. The spots are immediate, small, white crusts that gradually fall off after a period of 7-10 days. Then a soft, white spot develops if the laser has been effective. The usual postoperative care consists of dry dressings and the avoidance of cosmetic covering until the crusts come off. It has been the experience that with the use of this laser, relatively small portwine marks can be treated. After initial tests with the argon laser, as with the ruby laser, more extensive treatments may be given. In the current series of 112 patients, there were 36 patients with 50% of facial involvement; 40 with 25%; 25 with 10%; and 11 with 5% or less. General anesthesia was used only in 8 patients since in-patient services were discontinued because of lack of funds. In this series, 10 patients had no improvement—4 in the 50% involvement group, 4 in the 25%, and 2 in the 5% group. Four patients were cleared completely. Two patients in this series had hypertrophic scarring of the lip. In our experience this subsides gradually. Again, because of lack of funds and subsequent transfer of the laser equipment for cancer research, the laser treatment facility was discontinued in August, 1976. Training sessions for argon laser treat ment have been given to plastic surgeons and to derma tologists. The complications of the argon laser treatment are few and slight. There has been less hypertrophic scarring
F I G U R E I. The special diffusing lens for treatment by an argon laser that gives beam diameters o f 4-5mm. The patient has telangiectasia following the StevensJohnson syndrome.
F I G U R E 2. (A) Portwine mark (50% involvement) 2 years after treatment with a ruby laser, showing targe white spots.
F IG U R E
F I G U R E 2 (B) Three years after begin ning o f treatment with an argon laser; the patient is still under treatment.
3. (B) The treated areas on
11/6/75.
1
F I G U R E 3. (C) M arked improvement even with highlights, 5/6/76. Patient is still under treatment.
3. Port wine mark involving about 35% o f the face. (A ) Onset o f treat ment with an argon laser on 3 /1 6 / 75. F IG U R E
F I G U R E 4. A port wine mark at the base over the neck 3 months after treating with an argon laser. Treatment is still continuing.
6
5. A small portwine mark. (A) Before treatment with an argon laser on 11/13/75. F IG U R E
5. (B) Appearance on 4/8/76. The patient is still under treatment.
F IG U R E
J. Dermatol. Surg. 2:5 November 1976
387
ARGON LASER
rod, and a Teflon tip of 15 mm in diameter is used. This contact infrared burning of the portwine mark produces the same general thermal coagulation necrosis and superficial scarring that are seen in the biopsies of portwine marks treated by the laser. Careful regulation of the pressure, the duration, and the power output must by done to avoid deep scars. Infiltration anesthesia is used. The initial studies of Miihlbauer should be contin ued, especially since the initial results may be as good, and the cost is trivial. The infrared coagulator of Nath has also been used effectively for hemostasis in the operating room. SUMMARY
F I G U R E 6. Approximate measurements fo r extent o f facial involvement o f portwine marks.
of the lip and chin than with the ruby laser. Occasion ally, small, pitted scars develop. As yet, revascularization of the whitened areas has not been observed after treatments with argon lasers. Even with repeated treatment, and we have used more than 860 impacts at one time in adults without anesthe sia, reticulated appearances have occurred. It is evident that to be practical, large areas have to be treated over a long period of time. This increases tremendously the cost of the laser and its flexibility, since higher power supplies and water cooling are necessary. There is also a need for comparative controls. The most useful control at the present time is the use of the infrared coagulator developed by N ath5 and by Mtihlbauer.(i An infrared beam with a coolant collar, a quartz
388
J. Dermatol Surg. 2:5 November 1976
Because of the resistance of portwine marks and the effects of the laser, it is recommended that these expen sive and sophisticated instruments be used at medical centers and that they be used initially for critical evaluation of the laser’s performance standards, its safety, and with comparative controls. Controls should include not only different modalities producing superfi cial thermal coagulation necrosis but, also, where possi ble, plastic and reconstructive surgery, and at times, a combination of laser and surgery. REFEREN CES 1. 2. 3.
4. 5. 6.
Goldman, Leon and Rockwell, R.J., Jr. Lasers in Medicine. New York, Gordon and Breach, 1971, pp. 331-334. Goldman, Leon. Applications of the Laser. Cleveland, CRC Press, pp. 190-191. Ritter, E.J., Goldman, Leon, Richfield, D., et al. The chicken comb and wattle as experimental model for investigative argon laser therapy of angiomas Acta Derm. Venereol. 49:304-308, 1969. Apfelberg, David B. Personal communication. Nath, Gunther. Personal communication. Miihlbauer, W., Nath, G. and Keritmar, A. Light treatment of hemangiomas. In: Proceedings o f the Sixth International Con gress of the International Confederation for Plastic and Recon structive Surgery, Paris, August, 1975.
Although the treatment o f the ordinarily incurable port wine birthmark by lasers has been practiced fo r more than 10 years, recent therapeutic investigations have been carried out particularly with the argon laser. Argon lasers now available fo r medical purposes produce treatment spots that are small. For certain practical reasons, at present, only relatively small portwine marks can be treated effectively. With trained personnel and proper safety measures, the treatment is safe fo r the patient and the operator. The treatment as yet is not proved to be better with the argon laser because the ruby laser and even an incoherent infrared thermal coagulator can produce similar and often larger cleared areas. It is recommended for the present that treatment o f portwine marks by argon lasers be restricted to investigation in medical centers where critical evaluations, control studies, and more powerful laser systems can be developed.
S i n c e t h e p o r t w i n e m a r k is as yet an incurable, disfiguring lesion, especially on the face, any contribu tions to feasible therapy should be welcome. The derm a tologist as well as the general practitioner and the pediatrician should be kept informed about current developments in therapy for this persistent and distress ing lesion so that proper advice may be given to anxious patients and parents. Usually no treatment is advised. Tattooing with titanium dioxide or zinc oxide particles is still done occasionally by plastic surgeons. This procedure results
From the Robert S. Marx Laser Diagnostic and Treatment Facility of the Laser Laboratory, D epartm ent of Dermatology, University of Cincinnati Medical Center, Cincinnati, Ohio 45267.
in an irregular mottled pattern. Moreover, it can not be used on the eyelids where extirpation by laser can be attempted. Excisional surgery is often done in adult life when connective tissue changes in the portwine mark result in nodular and pendulous areas which can be ablated. At present and mainly, portwine spots are covered with heavy theatrical make-up creams, like Covermark® or Erase®. Unless the preparations are suited to an affected individual’s own skin color and texture, commercial make-up creams are usually not satisfactory for many patients. With mixed types of lesions, such cavernous nodules or acquired telangiec tatic elevations in the portwine marks, the cosmetic results are never satisfactory. Also, efforts to have parents get afflicted children to use covering prepara
J. Dermatol. Surg. 2:5 November 1976
385
ARGON LASER
tions early in life as a routine daily procedure are rarely successful. Because of the cosmetic distress of portwine marks and because therapy is a challenge, investigative studies with treatment by lasers were begun more than twelve years ago in our Laser Laboratory.1-2 The animal test model for our program of treatment by lasers was the chicken comb. This is a superior biological test model than is tattooed patterns on rabbits or miniature pigs.3 Because of the absorption spectrum of hemoglobin, it was theorized that the argon laser, emitting electromag netic energy at 488.8 nm to 512.5 nm, would be much more effective than other laser systems. Initial studies have been done with the ruby laser and, five years ago, with the argon laser. In recent months the argon eye laser, used for the treatment of ophthalmic disorders, has also been used to treat portwine marks. Extensive studies have been done at Palo Alto by Apfelberg.4 Recently, commercial models have been developed particularly for dermatologic use. The mechanism of the laser reaction is, for the most part, a superficial, nonspecific thermal coagulation necrosis. There is, in brief, superficial necrosis, thrombo sis, and, at times, extravasation of blood. The deeper vascular plexuses are not affected. These changes produce blanching of the skin color through a change in the optical quality of the tissue. For this reason, as with any use of the laser, controls have always been neces sary. Such controls are also used to produce nonspecific thermal coagulation necrosis. In brief, three types of therapy have been used at the Laser Laboratory for the treatment of portwine marks. These include: 1. the ruby laser—694.3 nm 2. the argon laser—488.8-512.5 nm 3. recently, as control—the infrared coagulator, developed by N ath3 and M uhlbauer.G Electrodesiccation and cryosurgery were given up sometime ago as treatments for the portwine mark. Experiences with the ruby and argon lasers have been reported previously.12 Large whitish areas, 2.1 cm2 have been produced by the ruby laser. Occasionally adverse reactions in a series of more than 200 patients have resulted in revascularization and hypertrophic scarring of the lip and the chin that subsided gradually. Cosmet ically, the round impact areas produce a reticulated appearance to the treated portwine marks. This is difficult to correct, even with subsequent laser impacts. In general, the ruby laser has been effective for the treatment of small unilateral forms of portwine marks. More than five years ago, research and development was begun with the argon laser. The current series with the argon laser treatment consists of 112 patients. Two types of argon laser beams have been used. These are
386
J. Dermatol Surg. 2:5 November 1976
the 3-watt argon laser used previously, and the new Spectra-Physics argon laser with a Nath Flexible Fiber, giving outputs up to 6 watts and a beam diameter 1.5 mm. A second beam form has a diffusing lens that gives beam diameters of 3-4 mm. In 1971, we reported that the argon laser would have to be more powerful to be more practical. Lasers are hazardous to the eye12 and safety measures are necessary. These include the use o f a special area for the treatment, area control, and safety glasses made specially for the laser type used. Instruction in the use of the laser, frequent measurements of output, and training in laser safety are essential. When eyelids have to be treated, special silvered plastic cups are used in the eye with topical anesthesia. Under such safety measures, the laser is safe for both the patient and the operator. Special operative release forms are required to be signed by the patient or by parents. Because of the need for eye safety, treatments in children are given only after age 6 or 7 because cooperation on the part of the patient is necessary. Local ring anesthesia is given for a small area; general anesthesia is preferred for extensive treatments. The usual precautions for general anesthesia are the same as those for electrosurgery. Initial trials are done in small areas of the lesion to determine the initial response to the laser. The spots are immediate, small, white crusts that gradually fall off after a period of 7-10 days. Then a soft, white spot develops if the laser has been effective. The usual postoperative care consists of dry dressings and the avoidance of cosmetic covering until the crusts come off. It has been the experience that with the use of this laser, relatively small portwine marks can be treated. After initial tests with the argon laser, as with the ruby laser, more extensive treatments may be given. In the current series of 112 patients, there were 36 patients with 50% of facial involvement; 40 with 25%; 25 with 10%; and 11 with 5% or less. General anesthesia was used only in 8 patients since in-patient services were discontinued because of lack of funds. In this series, 10 patients had no improvement—4 in the 50% involvement group, 4 in the 25%, and 2 in the 5% group. Four patients were cleared completely. Two patients in this series had hypertrophic scarring of the lip. In our experience this subsides gradually. Again, because of lack of funds and subsequent transfer of the laser equipment for cancer research, the laser treatment facility was discontinued in August, 1976. Training sessions for argon laser treat ment have been given to plastic surgeons and to derma tologists. The complications of the argon laser treatment are few and slight. There has been less hypertrophic scarring
F I G U R E I. The special diffusing lens for treatment by an argon laser that gives beam diameters o f 4-5mm. The patient has telangiectasia following the StevensJohnson syndrome.
F I G U R E 2. (A) Portwine mark (50% involvement) 2 years after treatment with a ruby laser, showing targe white spots.
F IG U R E
F I G U R E 2 (B) Three years after begin ning o f treatment with an argon laser; the patient is still under treatment.
3. (B) The treated areas on
11/6/75.
1
F I G U R E 3. (C) M arked improvement even with highlights, 5/6/76. Patient is still under treatment.
3. Port wine mark involving about 35% o f the face. (A ) Onset o f treat ment with an argon laser on 3 /1 6 / 75. F IG U R E
F I G U R E 4. A port wine mark at the base over the neck 3 months after treating with an argon laser. Treatment is still continuing.
6
5. A small portwine mark. (A) Before treatment with an argon laser on 11/13/75. F IG U R E
5. (B) Appearance on 4/8/76. The patient is still under treatment.
F IG U R E
J. Dermatol. Surg. 2:5 November 1976
387
ARGON LASER
rod, and a Teflon tip of 15 mm in diameter is used. This contact infrared burning of the portwine mark produces the same general thermal coagulation necrosis and superficial scarring that are seen in the biopsies of portwine marks treated by the laser. Careful regulation of the pressure, the duration, and the power output must by done to avoid deep scars. Infiltration anesthesia is used. The initial studies of Miihlbauer should be contin ued, especially since the initial results may be as good, and the cost is trivial. The infrared coagulator of Nath has also been used effectively for hemostasis in the operating room. SUMMARY
F I G U R E 6. Approximate measurements fo r extent o f facial involvement o f portwine marks.
of the lip and chin than with the ruby laser. Occasion ally, small, pitted scars develop. As yet, revascularization of the whitened areas has not been observed after treatments with argon lasers. Even with repeated treatment, and we have used more than 860 impacts at one time in adults without anesthe sia, reticulated appearances have occurred. It is evident that to be practical, large areas have to be treated over a long period of time. This increases tremendously the cost of the laser and its flexibility, since higher power supplies and water cooling are necessary. There is also a need for comparative controls. The most useful control at the present time is the use of the infrared coagulator developed by N ath5 and by Mtihlbauer.(i An infrared beam with a coolant collar, a quartz
388
J. Dermatol Surg. 2:5 November 1976
Because of the resistance of portwine marks and the effects of the laser, it is recommended that these expen sive and sophisticated instruments be used at medical centers and that they be used initially for critical evaluation of the laser’s performance standards, its safety, and with comparative controls. Controls should include not only different modalities producing superfi cial thermal coagulation necrosis but, also, where possi ble, plastic and reconstructive surgery, and at times, a combination of laser and surgery. REFEREN CES 1. 2. 3.
4. 5. 6.
Goldman, Leon and Rockwell, R.J., Jr. Lasers in Medicine. New York, Gordon and Breach, 1971, pp. 331-334. Goldman, Leon. Applications of the Laser. Cleveland, CRC Press, pp. 190-191. Ritter, E.J., Goldman, Leon, Richfield, D., et al. The chicken comb and wattle as experimental model for investigative argon laser therapy of angiomas Acta Derm. Venereol. 49:304-308, 1969. Apfelberg, David B. Personal communication. Nath, Gunther. Personal communication. Miihlbauer, W., Nath, G. and Keritmar, A. Light treatment of hemangiomas. In: Proceedings o f the Sixth International Con gress of the International Confederation for Plastic and Recon structive Surgery, Paris, August, 1975.
