Hemangioma Laser Treatment: Benefits And Side Effects

Introduction

Haemangiomas are the most common benign (non-cancerous) tumour of the skin caused by endothelial proliferation. They are collections of small abnormal blood vessels forming lumps under the skin, often referred to as strawberry marks due to their clinical appearance. 

There are different types of haemangiomas: 

Congenital haemangiomas which are visible from birth, and infantile haemangiomas which appear later in infancy. 

Infantile haemangiomas affect about 4% to 5% of new-borns and are more common in Caucasian females, in premature babies, in low-birth-weight babies, and multiple births. 

Haemangiomas can occur in any part of the body, however, 60% of them occur in the head/neck area. Haemangiomas can be either superficial, deep or both. Superficial haemangiomas are usually a raised, reddish, or bright-red area of skin, which feels quite warm, whereas deep haemangiomas appear bluish in colour due to the abnormal blood vessels being deeper in the skin. Mixed haemangiomas are combination of both superficial and deep haemangiomas. They are quite common and grow rapidly with an extensive area of involvement.^1,2,3,4,5

Haemangiomas may be present as a faint red mark at birth (birthmark) or may appear in the first weeks or months after birth. 

Haemangiomas typically go through three phases: proliferation, plateau, and involution. 

Proliferation phase takes place in the first 6-12 months with the fastest growth occurring the in the first 3-4 months. When the haemangioma reaches its largest size, it enters the plateau phase which is its stable period of development. 

At the end of the first year of life, involution phase begins which can last for several years (typically 5-7 years). During this phase, the haemangioma starts to shrink and fade losing its firmness and changing colour from bright red to dull red to white colour. At the end of the involution phase most haemangiomas will eventually flatten and disappear, and therefore will not require any treatment.

Nevertheless, there are some exceptions where treatment is necessary. These include Ulcerated haemangiomas, Haemangiomas near the eye, Haemangiomas on the lips, Haemangiomas obstructing the airway.^1,2

Haemangiomas can be treated with oral beta blockers, topical beta-blockers, corticosteroids, cryotherapy, surgery, and lasers. 

Since 2008, the first line of treatment for infantile haemangiomas (IHs) is the use of systemic propranolol which has high efficacy rates and safety profile with minimal side effects. However, with the use of systemic propranolol, some infantile haemangiomas involute only partially forming residual haemangiomas leading to cosmetic disfigurement. Moreover, some of the patients experience rebound growth after propranolol discontinuation and in some rare cases, propranolol causes side effects such as hypoglycaemia, hypotension, bradycardia, diarrhoea, and hyperkalaemia. 

For small, uncomplicated superficial haemangiomas, topical beta-blockers such as Timolol gel could be used as a first-line treatment. 

On the contrary corticosteroids such as prednisone /prednisolone, cannot be used as first-line treatment due to the potential side effects including cataracts, gastritis, retardation, and adrenal suppression. It is mainly used as adjunctive therapy when oral propranolol is contraindicated.^6,7

Surgical excision of haemangiomas is usually considered after the patient did not respond to any of the pharmacologic therapies or if the lesion is posing an immediate threat to life or function such as periocular, visceral, or scalp lesions.⁸ Nevertheless, due to the postoperative complications, laser therapy has proved to be superior to surgery.⁹

Understanding hemangioma laser treatment

Laser treatment for residual IHs and vascular malformations has been routinely practised since 1980. Laser therapy is indicated for the treatment of superficial proliferating haemangiomas. It is also the gold standard in the treatment of ulcerated IHs due to its high success rate. 

Moreover, it is an important additional treatment option for those with residual and recurrent haemangiomas as well as for patients that are at risk of side effects to propranolol. The goal of laser therapy is to accelerate the regression and reduce the size of the lesion to minimal by maximizing vascular destruction while minimising injury to the surrounding healthy tissue.

Laser radiation targets chromophores, which are the part of a molecule responsible for its colour. In the laser treatment of vascular lesions including haemangiomas, the targeted chromophore is haemoglobin. Haemoglobin has absorption peaks at different wavelengths including, 418, 542, 577, and another one in the near-infrared portion of the spectrum (700 to 1100nm). Haemoglobin absorbs the light energy from lasers and converts it into thermal energy (heat). The generated heat can cause either photomechanical or photothermal damage. 

In photomechanical damage, the heat causes the blood to boil damaging the blood vessels which results in haemorrhage. This in turn is seen as purpura after treatment. 

In photothermal damage, the heat causes intravascular coagulation which is clinically presented as immediate blanching or darkening of the vessels followed by oedema and erythema.^6,7,10

There are different types of lasers including: Pulsed dye laser (PDL). Neodymium: Yttrium-Aluminium-Garnet (Nd: YAG) laser, Carbon dioxide laser, Argon laser, Potassium titanyl phosphate (KTP), Intense pulsed light (IPL). Laser clinical applications are determined by the laser’s wavelength, pulse durations, and how the target skin tissue absorbs it.^6,7

Pulse dye laser (PDL) 

It is the most used laser for cutaneous vascular lesions. PDL is based on the concept of selective photo thermolysis and has two wavelengths of 585 and 595nm with pulse duration of 0.45 to 40 milliseconds. With the 585nm laser, penetration depth ranges between 0.8 and 1.2mm, which is enough for treating superficial haemangiomas and other superficial vascular lesions like rosacea and telangiectasia. Moreover, it is safe to be used on haemangiomas in the facial area since dermis depth ranges between 0.6 and 0.9mm. Numerous studies have proven PDL as an effective treatment for IHs with response rates of 80-90%.

Nd: YAG laser

A long-pulsed laser (LP) within the millisecond time range which is considered a safe and effective treatment for various lesions. The way Nd:YAG LP laser works is by causing photocoagulation of vascular lesions including IHs, dilated blood vessels, prominent facial capillaries, and spider haemangiomas. 

Mechanism: Nd:YAG laser’s active medium is a crystal composed of four elements (yttrium, aluminium, and garnet doped with neodymium ions). The Nd:YAG laser functions at a wavelength of 1064nm in the near-infrared region of the electromagnetic spectrum.

Haemoglobin and oxyhaemoglobin act as absorbing chromophores, where they absorb the laser energy which eventually causes heat diffusion from inside the blood vessel to its walls (target). Additionally, water inside the vessel walls acts as an additional chromophore absorbing the laser energy.

The 1064 nm wavelength can reach a maximum depth of 10mm making Nd: YAG laser more suitable for deep haemangiomas compared to PDL which operates at 590-595nm wavelengths, reaching a depth of only 1.2mm. Moreover, the 1064nm infrared light is more readily absorbed by oxyhaemoglobin with low absorption by melanin, which means photo thermolysis of the haemoglobin chromophore occurs without damaging the epidermis. 

Carbon dioxide laser

Has a wavelength of 10,600nm targeting the water inside the blood vessels. Once the water absorbs the laser energy, it quickly heats up and vaporizes, destroying the tissue structure. It was noted that the aesthetic outcome was better with CO2 laser than Nd:YAG laser. Carbon dioxide  laser can also treat the fibro-fatty tissue and atrophic plaques left after haemangioma regression.

Argon laser

It is a green light with a wavelength of 514 nm and a penetration depth of 0.5 mm. It was previously used for superficial haemangioma but has been recently discontinued due to the higher rate of side effects like scarring and dyschromia (irregular skin discolouration).

Intense pulsed light (IPL)

IPL has high-intensity light sources that can emit polychromatic light and radiate non-coherent light in a spectrum ranging from 500 nm to over 1200 nm. Using filters, the emitted light could be minimised in range of 515 and 590 nm and can be used in single or more pulses in the millisecond range.  

IPL  is able to split the energy into two or three pulses with different pulse delays, providing the skin time to cool down, resulting in fewer side effects. A cooling device that helps to minimize side effects such as erythema is used. IPL can be used for treatment of benign venous malformations, telangiectasia port wine stains, and haemangioma.

IPL with OPT (optimal pulse technology) might become the new standard for the treatment of haemangiomas. This is due to its squared pulse technology that targets haemoglobin as the endogenous chromophore in haemangiomas conforming to the principles of selective photo thermolysis.

KTP

KTP laser has a solid medium, emitting a green light at a wavelength of 532 nm (almost at the haemoglobin absorption peak) with pulse durations ranging from 1 to 100ms (slow heat conduction to blood vessel without rupture of blood vessel walls). Indication is mainly superficial haemangiomas, as well as laryngeal/subglottic haemangiomas. However, this laser has many side effects such as oedema, purpura, hypo- or hyperpigmentation, crusting, blistering, and scabbing.

Laser therapy has proven to be effective mainly in the treatment of superficial proliferating haemangiomas. It accelerates the regression and reduces the size of the lesion, creating favourable situations for subsequent treatments such as pharmacotherapy. 

Laser therapy effectiveness ranges from 77% to 100% and the smaller the lesion, the better the result. PDL is often used for residual refractory haemangioma after propranolol treatment. Nd:YAG laser is often used for medically refractory lesions with a significant subcutaneous component. 

PDL laser and Nd:YAG laser are considered the most efficient lasers for haemangioma treatment. PDL system has the best-documented safety record in laser systems. 

However, due to PDL’s limited penetration depth, it is only effective in the treatment of superficial haemangiomas (< 1.2 mm deep). If PDL is used on a deep haemangioma (thickness > 1.2 mm), then only the superficial component of the haemangioma would be treated, while the deeper component may still grow. 

For subcutaneous and up to 2cm deep haemangiomas, the Nd: YAG laser would be the most suitable laser. Combined therapy with PDL and Nd:YAG laser has also been found effective in treating haemangioma.^7,11

Benefits of hemangioma laser treatment

Laser therapy aims for the complete destruction of the lesion regardless of the type and size of haemangioma involved. It is a minimally invasive procedure that is simple to use and can be repeated every 2 weeks for actively proliferating lesions and every 1-2 months for stable lesions. Lasers are characterized as targeted and precise as they operate at a specific wavelength, one that is close to the absorption peak of their targeted chromophore (haemoglobin in case of hemangioma).

This way the vascular destruction is confined to the targeted lesion without affecting the adjacent cells. Laser treatment has several advantages over surgical intervention including:

• Minimal scarring and complete lesion regression hence improved cosmesis and aesthetic outcomes
• Less post-operative infection and bleeding
• Decreased duration of anaesthesia required
• Shorter post-operative hospital stays
• Less post-operative pain^9,10

Side effects and risks of hemangioma laser treatment

Laser treatment is generally not painful and is similar to small flicks on the skin with a rubber band. It is tolerated by most adults; however, children might find it difficult to require some form of anaesthesia, either local using an anaesthetic cream or general anaesthesia. There is no risk of infection unless the patient already has an active infection. 

Some of the side effects associated with the use of PDL include purpura formation, hypopigmentation and hyperpigmentation and skin atrophy. 

Nd:YAG laser has longer wavelengths and hence penetrates the deeper components of haemangiomas, targeting the vessels there. However, this intense penetration imposes deep thermal hazards, causing several side effects such as swelling, blistering, and crust formation, erythema, pain, postoperative bleeding, and atrophic scar. 

Severe side effects such as tissue necrosis and scarring are very often observed by the uncritical use of laser systems.^6,7

Preparation and recovery

The patient should be counselled about the possible side effects. According to the size of the haemangioma involved and the psychological state of the child, anaesthesia might be local or general. Treatment duration differs according to the depth of the haemangioma and the pulse settings of the laser. It could take 8-9 sessions up until the lesion shrinks. 

Each application is comprised of steps where every step takes seconds to complete. The number of steps varies according to the characteristics of the treated lesion.⁹ After laser radiation, the treated area may be sore, swollen, red or bruised. 

This usually resolves in 7-14 days after laser treatment. It is advised to cover the treated areas with panthenol ointment or any non-perfumed moisturizer to improve hydration, reduce skin itching and inflammation, and accelerate epidermal wound healing. 

Moreover, povidone-iodine solution is recommended in the case of blistering or crusting. Simple pain relief might be required such as ice packs or paracetamol.⁶

Factors affecting treatment outcome

Laser therapy works best if started between six months and one year of age. However, there are patients for whom laser therapy is contraindicated. These include:

• Photo-aggravated skin diseases
• Active local infection
• Psoriasis and vitiligo, due to the possibility of the Kobner phenomenon
• Keloidal tendencies
• Patient treated with isotretinoin
• Not cooperative patient⁷

One of the factors indicating laser therapy success is the choice of the laser to use which in turn depends on the size, location, and depth of the haemangioma involved. As described above, there are different lasers with different wavelengths and pulse durations to suit the different types of haemangiomas.⁶ Another factor is the physician's experience and skill in selecting the type of laser and the specific laser parameters for each patient. For example:

Wavelength when treating patients of darker skin colour, it is preferred to choose a laser with a longer wavelength. This is because melanin is a competing chromophore to haemoglobin at shorter wavelengths. And since people with darker skin have melanin in abundance, using a laser at a short wavelength will let melanin absorb the laser energy and result in side effects like hyperpigmentation or hypopigmentation.

Pulse duration to obtain good results with minimal side effects, the physician should select an appropriate pulse duration. It should be less than the thermal relaxation time (TRT), which is the time required for the target tissue to lose about 63% of the incidental thermal energy.

Fluence which is the energy delivered per unit area (joules/cm²). The deeper the targeted tissue is, the more fluence is required.

Cooling to protect the epidermis, appropriate cooling measures should be used, including ice packs, cryogen spray,cold-air chiller device or chilled sapphire tips.⁷

Summary

Haemangiomas are common benign tumours that occur in infancy. Most haemangiomas involute by themselves, however, sometimes treatment might be necessary. Systemic beta blocker propranolol is the first line of treatment for patients with haemangiomas. 

It causes haemangiomas to regress with satisfactory aesthetic results, but not in all cases, unfortunately. Some patients get a partial response, experience rebound growth, or have a contraindication to propranolol. In this circumstance, laser therapy is the best option. 

There are different laser systems with different wavelengths and penetration depths. However, the mechanisms are similar. PDL and Nd:YAG laser are the most commonly studied. Laser therapy has proven its important role in the treatment of residual and refractory lesions.