Vascular Anomalies

Vascular malformations

Capillary malformations (CM) also known as port wine stains (PWS), are complex heterogeneous vascular lesions with significant psychosocial comorbidities which are best treated early in infancy. The most recent Cochrane Review included 5 randomised controlled trials confirming the pulsed dye laser (PDL) as the laser of first choice for CM. In its latest iteration the Vbeam Perfecta™ 595nm pulsed dye laser is very quick, is well tolerated and has an effective cryogen spray skin cooling system. General anaesthetic is not normally required, particularly with options of additonal topical anaesthesia and forced air cooling with the Zimmer™ device. The 595nm wavelength has deeper penetration with loss of only minimal oxyhaemaglobin selectivity. For thicker and bluer (often more mature) port wine stains, the Nd:YAG 1064nm long pulsed laser, ExcelV™, is an excellent alternative and for thin red lesions the KTP 532nm. Sequential emission of two wavelengths (PDL/Nd:YAG) may give benefit by addressing methaemaglobin generated by the PDL. Another approach showing promise for resistant PWS is the 755nm Alexandrite laser. The Lumenis M22™ intense pulsed light device which covers multiple wavelengths with filtered poly-chromatic light is another option and for vascular nodules the CO2 laser may have a role. Combination treatments can also be used. Recent research suggests that shorter intervals between treatments (as short as 2 weeks for the pulsed dye laser) may give optimal results. All vascular malformations must be properly evaluated before treating to rule out any associated meningeal or neurological disease. Topical rapamycin suppresses angiogenetic pathways and may be a useful adjuvant to accelerate residual erythema clearance of CM following PDL.

Telangiectasia

Superficial red and individual telangetasia can be safely addressed with the KTP 532nm laser. The new ExcelV™ has integrated skin contact cooling through a sapphire window which protects the skin surface much more effectively than older KTP lasers. Any deeper, blue or arterial telangectasia requires the longer wavelength Nd:YAG 1064nm laser which in the ExcelV™ format operates through the same saphire window and can be used sequentially with the KTP laser. When multiple telangeictasia occur on a background of erythema, the Vbeam Perfecta™ 595nm pulsed dye laser is preferred and is effective at non-purpuric settings with pulse stacking or multiple passes and for erythema with minimal telangiectasia the Lumenis M22™ IPL device is an option but due to discomfort and increased skin injury risk from superficial light scatter is best used together with additional forced aircooling (Zimmer™) and sometimes topical anaesthesia. Peri-alar telangiectases tend to recur.

Haemangiomas

Haemangiomas in infancy have a female predominance and have obscure pathogenesis but are structually similar to human placental blood vessels. The natural history is of spontaneous resolution but the more ‘significant’ lesions are now treated medically with betablockers which induce vasoconstriction apoptosis of endothelial cells and reduce fibroblastic activity. Microsclerotherapy is the treatment of coice for leg veins but for small veins which are difficult to canulate or for telangiectatic matting not due to venous hypertension the Excerl V 1064nm is useful with attention to surface cooling. For thinner involuting lesions, vascular laser treatments may be considered. The CO2 laser may help to manage redundant, ulcerating or haemorrhaegic lesions.

Erythema

Conditions such as carcinoid syndrome and phaeochromocytoma must sometimes be excluded on clinical and biochemical grounds. Where vaso-reactivity is an issue with ocasional ‘bright’ erythema (particularly of the cheeks) intense pulsed light works well so long as the erythema is treated in an ‘active’ phase. There is still confusion about the role of rubrifactants such as capcasin in enhancing treatment results. Sometimes medical treatments with clonidine or betablockers may be required as an alternative or additional treatment to control vasoreactivity. Recently the topical alpha agonist brimolidine has shown promise with up to 12 hours of erythema reduction. A condition of adolescence, erythromelanosis faciei, does respond to laser treatments as does keratosis pilaris rubra and its variants although the keratotic component may require additional keratoytics or resurfacing.

For more information about this condition, please contact the Solais team below...