Search

Background: Multiple exposures to general anesthesia may be neurotoxic to the developing brain. This relationship has not been evaluated in children undergoing laser surgery for vascular anomalies., Objective: To evaluate the prevalence of neurodevelopmental abnormalities in children who received multiple laser procedures under general anesthesia before the age of 4 years for the treatment of vascular anomalies., Methods and Materials: Retrospective chart review of patients with contact of parents for telephone interview., Results: Thirty-three patients were eligible. Average age at the time of survey was 7.8 years. Twenty-three (84.8%) patients were female, with average age at the time of first treatment at 1.9 years. Average number of treatments received before the age of 4 years was 6.7. Anesthetics included inhalational nitrous oxide and isoflurane and intravenous propofol. Seven patients carried one or more of the following diagnoses: attention-deficit hyperactivity disorder (3.0%), anxiety (6.1%), behavioral disorder (3.0%), language disorder (3.0%), speech disorder (3.0%), and motor disorder (6.1%). These prevalence rates are similar to those found in the US population., Conclusion: This is the first report on the prevalence of neurodevelopmental disorders in children undergoing multiple laser treatments under general anesthesia. Although the study sample is small, no increased risks when comparing with prevalence rates reported in the literature were noted.

Novel strategies are urgently needed to address the millions of nonmelanoma skin cancers treated in the United States annually. The need is greatest for those patients who are poor surgical candidates or those prone to numerous nonmelanoma skin cancers and therefore at risk for marked disfigurement. Traditional treatment strategies include electrosurgery with curettage, radiation therapy, cryotherapy, excision, and Mohs micrographic surgery. Alternatives to traditional treatment, including topical medications and light or laser therapies, are becoming popular; however, there are various degrees of efficacy among these alternative tactics. These alternatives include topical retinoids, peels, 5-fluorouracil, imiquimod, photodynamic therapy, and lasers. The purpose of this paper is to review the available data regarding these alternative strategies and permit the reader to have a sense of which therapies are reasonable options for care., (2011 Elsevier Inc. All rights reserved.)

Background: Hemangiomas are common skin tumors of infancy that have undergone recent changes in nomenclature, methods of evaluation, and treatment., Objective: To review the nomenclature, epidemiology, evaluation, and treatment of common hemangiomas., Methods: A literature search was conducted utilizing MEDLINE and the Cochrane library databases. Text search words used were "hemangioma" and "infancy." The clinical experience of the authors was also used to formulate the review., Results: There have been many advances in nomenclature and therapeutic options for children with hemangiomas. Hemangiomas are proliferative tumors of infancy that should be distinguished from structural malformations, such as port-wine stains and lymphangiomas., Conclusion: Natural involution remains a viable treatment option for the majority of patients with uncomplicated hemangiomas. Excisional surgery, laser, and pharmacologic remedies are indicated for a subset of complicated hemangioma patients.

Background: The Q-switched ruby laser has been used successfully to treat a variety of benign pigmented lesions. In this study, congenital nevi (diameter, < or = 5 cm) in 18 prepubertal children were treated with the Q-switched ruby laser., Observations: Photographic evaluation revealed an average of 57% clearance of pigmentation in all treated nevi by the fourth treatment session and an average maximum clearance of 76% after approximately eight sessions. Greater than 90% clearance of pigment was attained in five patients. Partial repigmentation was seen in all patients who were followed up after discontinuation of therapy. Findings from histopathologic studies, obtained from one patient, revealed reduction of nevus cells in papillary dermis and upper reticular dermis that correlated with clinical lightening. There was no such reduction in the lower reticular dermis. side effects were limited to transient erythema and hypopigmentation., Conclusions: The Q-switched ruby laser effectively lightens and may clear pigmentation and eliminate superficial nevus cells from small and medium congenital nevi safely without scarring. However, these results are not permanent. The Q-switched ruby laser may be a viable alternative for providing cosmetic improvement for unresectable lesions, but it should not be considered definitive treatment. Additional studies are needed to address the long-term results of this therapy.

Background: The flashlamp-pumped pulsed dye laser (577,585 nm) with 300 to 450 microseconds pulsewidths has been demonstrated to effectively and safely treat port-wine stains, telangiectases, and superficial hemangiomas in children., Objective: The objective of this manuscript is to review the indications of the pulsed dye laser in the treatment of vascular lesions in children., Conclusion: Pulsed dye laser treatment of port-wine stains can remove or lighten the lesions with multiple treatment sessions. Spider telangiectases respond with complete resolution, usually within one to two treatment sessions. Superficial hemangiomas respond quite easily and effectively with the pulsed dye laser, while a more variable response is noted in deeper hemangiomas, early proliferative lesions, and ulcerated hemangiomas. This procedure is safe with a low incidence of scarring and pigmentary alteration.

We cared for an infant girl with the clinical constellation of supraumbilical midabdominal raphe, sternal atresia, and cutaneous facial and upper trunk hemangioma. This is the first report of this clinical association in the dermatologic literature. The vascular component of the disorder responded to flashlamp-pumped pulsed dye laser therapy and to systemic interferon alfa-2a (Roferon-A).

Hemangiomas are common vascular lesions in children. The flashlamp-pumped pulsed dye laser has shown excellent results in the treatment of port-wine stains and, more recently, superficial (capillary) hemangiomas. Four patients with clinically evident superficial hemangiomas illustrate the point that early treatment with this laser may not preclude growth of a deeper component of the lesions.

Background and Design: Anecdotal reports and clinical observations have suggested that the response of port-wine stains to treatment with the pulsed dye laser is variable and dependent on the anatomical location of the lesion. To investigate anatomical variation in response to treatment, a retrospective study of 259 adults and children with port-wine stains of the head and neck treated with the pulsed dye laser was undertaken. Evaluation was performed by comparing simultaneously projected pretreatment and completion-treatment photographs. Anatomical differences in response were evaluated in three ways: (1) by anatomical subdivision of the head and neck into regions, (2) by dermatomal distribution, and (3) by response for midline lesions. The head and neck was subdivided into eight anatomical regions, which were independently evaluated for response. In addition, response for individual dermatomes and for midline lesions was evaluated. Response in all cases was assessed by determining the percentage of lightening from 0% to 100% (where 100% represents complete response) at the completion of treatment. Response grades were also assigned, using grades poor (0% to 25% lightening), fair (26% to 50% lightening), good (51% to 75% lightening), or excellent (76% to 100% lightening)., Results: One hundred thirty-seven adults and 122 children were included in the study. Evaluation by subdivision of the head and neck into regions revealed that in adults and children the centrofacial regions (medial aspect of the cheek, upper cutaneous lip, and nose) responded less favorably than the other grouped regions (periorbital, forehead/temple, lateral aspect of the cheek, neck, and chin); the centrofacial regions showed a good response (mean lightening, 70.7%) while the other grouped regions of the head and neck showed an excellent response (mean lightening, 82.3%). Evaluation by dermatomal distribution revealed that dermatome V2 showed a good response (mean lightening of 73.8%), while combined dermatomes V1, V3, and C2/C3 showed an excellent response (mean lightening of 82.4%). Evaluation of midline lesions revealed excellent responses in adults and children (mean lightening, 92.4%)., Conclusions: Port-wine stains of the head and neck in adults and children demonstrate differences in response to treatment with the pulsed dye laser according to their anatomical location. Centrofacial lesions and lesions involving dermatome V2 in adults and children respond less favorably than lesions located elsewhere on the head and neck. Midline lesions respond very favorably in adults and children.

Increasing evidence supports the association of squamous cell carcinoma of the finger and nail bed with human papillomavirus infection. We treated 12 patients with squamous cell carcinoma of the finger and nail bed, none of whom was originally diagnosed as having a malignant lesion. Half of the patients were referred for carbon dioxide laser ablation of what was believed to be a recalcitrant verruca vulgaris. Our objective was to evaluate these lesions for the presence of human papillomavirus by in situ hybridization techniques and the polymerase chain reaction. This is the first report of use of the polymerase chain reaction to detect human papillomavirus in formalin-fixed, paraffin-embedded specimens of periungual squamous cell carcinoma. Seven of the 12 lesions were evaluated for the presence of human papillomavirus by both in situ hybridization and the polymerase chain reaction. Five of the seven periungual lesions were found to contain human papillomavirus type 16 but not type 18 DNA with use of the polymerase chain reaction technique. In situ hybridization failed to identify human papillomavirus in any of these patients' tumors. Our data confirm the association between human papillomavirus and squamous cell carcinoma of the periungual region and suggest that biopsies should be performed on chronic, isolated lesions of the finger in adults before therapy is initiated.

The development and use of various laser systems for the treatment of carcinomas of the skin constitute a relatively new therapeutic approach. Because the skin is a readily accessible organ, it is an excellent site at which to attempt different therapeutic modalities. What is truly astounding has been the development of specific lasers designed to treat certain dermatologic problems. Because the field of laser biotechnology is still rapidly emerging, it is very likely that new lasers and modifications of existing ones will improve our ability to treat skin cancer and precancerous conditions.

Twelve children, 6 to 30 weeks of age (average 14.9 weeks), with port-wine stains of the head and neck were treated with the flashlamp-pumped pulsed dye laser at 585 nm and 450 microsecond pulse duration. Ten of 12 patients (83%) showed more than 50% lightening of their port-wine stains after 2.9 treatment sessions (2.9 +/- 1.4 [+/- standard deviation]). Forty-five percent of the patients demonstrated 75% or more lightening of their lesions after a mean of 3.8 treatments (+/- 1.6). No lesions in this group cleared completely after a mean of 2.8 treatments. Treated skin was identical in texture to normal skin in all patients. There was no evidence of depressed scars, atrophy, hyperpigmentation, or hypopigmentation in the treated areas. These results indicate that pulsed dye laser treatment of port-wine stains can be undertaken safely in infancy.

A patient with epidermodysplasia verruciformis died of intracranial invasion by squamous cell carcinoma (SCC). A biopsy of clinically normal skin had revealed perineural invasion by malignant keratinocytes. Because SCCs arising in patients with epidermodysplasia verruciformis may be biologically aggressive, it is best to excise them with careful control of the surgical tissue margins.

Strawberry, or capillary, hemangiomas are common vascular neoplasms, with an incidence of approximately 2.6% in neonates. They usually develop in the first few weeks of life, so that between 1 month and 1 year the incidence rises to between 8.7% and 10.1%. These lesions may grow quite large in the first year of life, and they may ulcerate or obstruct a vital organ or function. The great majority will spontaneously regress after the first year of life. Parents are often alarmed at the sight of these hemangiomas and need reassurance that the great majority will regress spontaneously. Treatments such as cryosurgery, irradiation, radium instillation, corticosteroid therapy, or surgical excision are often ineffective or cause significant morbidity. We describe 10 children with capillary hemangiomas treated with the flash lamp-pumped pulsed dye laser. The patients ranged in age from 7 weeks to 5.5 years at the beginning of laser therapy. The patients underwent 3.1 +/- 1 (mean +/- SD) laser treatments, with a mean regression of the lesions of 69.9% +/- 4.5%. All patients demonstrated some diminution in the size and color of their hemangiomas after the treatments, and there were no ill effects, such as ulceration, hemorrhage, infection, or scarring. There was no evidence of hyperpigmentation or hypopigmentation. Pulsed dye laser therapy should be considered as an option in the treatment of capillary hemangiomas, preferably prior to their full evolution. It is also a useful therapeutic approach in those hemangiomas that are slow to regress in older children.

New lasers and improved laser delivery systems have allowed for the safe and effective treatment of port-wine stains in patients of all ages. The satisfactory results obtained by laser treatment have increased the number of patients seeking consultation regarding their birthmarks. It is imperative that physicians recognize the various medical syndromes and problems associated with port-wine stains. A review of 415 patients with facial port-wine stains has revealed hypertrophy and/or nodularity in 65% of patients by the fifth decade of life, which increases significantly the morbidity of these lesions. It is believed that laser treatment will minimize the medical and psychologic complications that result from the natural evolution of port-wine stains.

Seventy-three patients between the ages of 3 months to 14 years (average age 6 years 2 months) with port-wine stains were treated with the flashlamp-pumped pulsed dye laser. More than 75% lightening was achieved with an average of 2.5 treatments in 33 patients (45%), 50% to 74% lightening after an average of 1.7 treatments in 31 (42%), 26% to 49% lightening after 2 treatments in 5 (7%), and less than 25% lightening after 1 treatment in 4 (5%). The overall average lightening after one treatment was 53%. The percentage of lightening increased as the number of treatments increased. Three patients had 100% clearance of the port-wine stain. Patients aged between 3 months and 6 years (44 patients) had a better response after the first treatment (55% lightening) than did patients aged between 7 and 14 years (29 patients with a 48% lightening; p = 0.027). Complications included cutaneous depressions in four patients, hyperpigmentation in 16 patients, and hypopigmentation in three patients. All complications were transient and disappeared completely.

EMLA cream (Eutectic Mixture of Local Anesthetics) is a new topical anesthetic composed of 25 mg lidocaine and 25 mg prilocaine in an oil-in-water emulsion cream. It has been found to be very effective for local anesthesia prior to venepuncture, minor surgical procedures, and pulsed dye laser (PDL) therapy for port-wine stains (PWS) in children. However, since EMLA may cause vasoconstriction of cutaneous vessels, we tried to determine whether pretreatment with EMLA decreases the efficacy of subsequent PDL treatment. We report eight patients between the ages of 4 and 32 years with PWS who received two test site treatments prior to PDL treatment. One site was pretreated with EMLA cream under occlusion for 60 minutes and then left unoccluded for 15 minutes prior to PDL test treatment. The other site, in the same area of the PWS and patient's body, was not pretreated with EMLA. The test sites were compared 6-8 weeks later to determine whether EMLA decreased the degree of lightening of the PWS compared to the non-EMLA-treated site. We conclude that EMLA is an effective topical anesthetic for PDL treatment of PWS and does not adversely affect the efficacy of the treatment.

Porokeratosis of Mibelli is a disorder of epidermal proliferation in which an abnormal clone of cells expands in a centrifugal manner. We present a case of porokeratosis of Mibelli with an underlying hemangioma that was treated with a 585 nm flashlamp-pumped pulsed dye laser. The underlying hemangioma responded well to laser therapy while the porokeratosis remained unchanged. The implications of this for the pathogenesis of porokeratosis and the specificity of the pulsed dye laser are discussed.

Microcystic adnexal carcinoma (MAC) is a recently described rare adnexal neoplasm showing benign histologic features but a locally aggressive behavior. It has most commonly been reported to occur on the face but it has also been noted in the axilla and buttock. We describe a 41-year-old white male with a 5-year history of MAC on the scalp and treatment by Mohs micrographic surgery. To our knowledge, this is the first case of MAC reported to occur on the scalp.