D G C © 2008

Updated May 08

R.A. SHEEHAN-DARE M.D. ChB F.R.C.P.

Lasers have been the treatment of choice for the majority of port wine stains (PWS) for many years now. However, with so many laser (and some non-laser) devices now available, how should we advise our patients?

When should the patient be referred?

Port wine stains can be treated at any age, but it is not always best to treat in the very young. Occasionally PWS regress without treatment particularly when the forehead and eyelids are affected in the mid-line. Sometimes the diagnosis cannot be made with certainty in very young children and it may be necessary to wait in order to establish the diagnosis and advise about prognosis and optimum treatment.

Parents of young children often have many questions, which are better answered sooner rather than later, and an early referral is appropriate in all cases, even if treatment is subsequently delayed.

Which laser is best?

The answer to this question depends on the characteristics of the PWS and its previous treatment. Different approaches may be required for previously untreated PWS compared with PWS which have previously had many treatments or nodular PWS which often present in later life.

Previously untreated PWS are best treated initially with 585 nm pulsed dye lasers, which are now available in the majority of laser centres. Although other lasers have been advocated for this group of patients such as 595 nm pulsed dye lasers, KTP lasers or intense pulsed light sources, evidence of superiority is either lacking or favours the 585 nm pulsed dye laser. The majority of PWS improve with a series of treatments, but complete clearance is rare and some show no discernible response.

Previously treated PWS, which have failed to progress with the 585 nm pulsed dye laser after numerous treatments sometimes improve when treated with a KTP laser or 595 nm/600 nm pulsed dye lasers. There is no good evidence so far to suggest that intense pulsed light is helpful in these circumstances. Treatment in 585 nm resistant PWS occasionally produces a good response, but it is often only modest and again complete clearance is most unlikely.

Nodular or hypertrophic PWS sometimes require a different approach with local surgical or carbon dioxide laser treatment either alone or in combination with the above.

When should treatment start?

Laser treatment can be initiated as soon as the first few weeks of life. However, any treatment in children is likely to require an anaesthetic, which is usually a general anaesthetic in the very young or those with larger lesions. If a general anaesthetic is required, a delay until the child is 6 months or over may be advised depending on the facilities available.

Sometimes, particularly with lighter PWS or those who have lightened after a few treatments, the blood vessels empty under general anaesthetic making location and treatment of the lesion impossible. These children must wait until they can tolerate treatment without anaesthetic.

There is some limited evidence regarding treatment responses, which favours earlier rather than later treatment. Theoretically treatment should be carried out before an age where adverse psychological effects are seen. However, the age at which adverse psychological effects occur cannot be established with any confidence. It seems probable that this is at a time when social circles expand perhaps at 7-8 years of age. Nevertheless, on an individual basis, parents’ preferences and the child’s tolerance of the procedure are paramount, and ultimately determine when treatment commences.

When should treatment finish?

After the first few treatments to each affected site the response to treatment slows down and may become quite modest until no further response is seen. In these circumstances, the risks of treatment and anaesthetic together with the psychological morbidity of the treatment and its aftermath must be carefully weighed against likely benefit. Parents need clear advice and support with the difficult decision to terminate treatment. Testing is helpful in demonstrating the degree of further improvement anticipated with further treatments. An offer to reconsider treatment at a later date if the lesion changes or new technology emerges is often a comfort to parents and patients whose response to treatment has ground to a halt. Many will require advice and support to manage the psychological consequences of whatever residual disfigurement remains.

Dr R.A. Sheehan-Dare M.B. ChB. F.R.C.P.

Consultant Dermatologist

Hon. Senior. Clinician, Lecturer Dermatology,

Leeds Dermatology Laser Centre,

Dermatology Department,

Leeds General Infirmary,

Great George Street,

Leeds LS1 3EX