0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Observation | ONLINE FIRST

Ablative Fractional Resurfacing for Involuted Hemangioma Residuum FREE

Lori A. Brightman, MD; Jeremy A. Brauer, MD; Vitaly Terushkin, MD; Christopher Hunzeker, MD; Kavitha K. Reddy, MD; Elliot T. Weiss, MD; Julie K. Karen, MD; Elizabeth K. Hale, MD; Robert Anolik, MD; Leonard Bernstein, MD; Roy G. Geronemus, MD
[+] Author Affiliations

Author Affiliations: Laser & Skin Surgery Center of New York (Drs Brightman, Brauer, Hunzeker, Reddy, Weiss, Karen, Hale, Anolik, Bernstein, and Geronemus), New York Eye and Ear Infirmary (Drs Brightman and Geronemus), and The Ronald O. Perelman Department of Dermatology, New York University School of Medicine (Drs Terushkin, Karen, Hale, and Geronemus), New York, New York.


Arch Dermatol. 2012;148(11):1294-1298. doi:10.1001/archdermatol.2012.2346.
Text Size: A A A
Published online

ABSTRACT

Background Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas.

Observations All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance.

Conclusion While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

Figures in this Article

Hemangiomas are benign vascular tumors that are present in approximately 13% of infants at birth and up to 5% to 10% of children by the age of 1 year.14 Much debate has centered on whether to treat hemangiomas given their natural tendency to spontaneously involute over time. Without intervention, approximately 15% to 40% of hemangiomas will involute, with resultant textural changes of the skin.5,6 Until recently, effective therapies to improve the appearance of these residual skin changes have been lacking.

The typical progression of hemangiomas includes a proliferative growth phase followed by gradual spontaneous involution.7 During the proliferative phase, which may last up to 12 months of age, hemangiomas undergo rapid growth. The involutional phase typically begins between 12 and 18 months, and it is estimated that complete involution of hemangiomas occurs at a rate of 10% per year.8 Accordingly, 50% of hemangiomas involute by the age of 5 years, 70% by the age of 7 years, and so on. However, multiple studies have shown that not all hemangiomas resolve completely.9,10 Many hemangiomas partially involute, leaving behind residual telangiectasia, epidermal atrophy, or redundant fibrofatty tissue.

Lasers have proved to be a valuable tool in treating hemangioma residuum. In the early 1990s, the pulsed dye laser (PDL) was shown to effectively treat telangiectasia and erythema.11 However, it has not been found to be efficacious in treating the epidermal atrophy and the fibrofatty residual that are seen with some involuted hemangiomas. Ablative lasers, including the carbon dioxide (CO2) laser and the erbium:YAG laser, are effective in the treatment of scars, photodamaged skin, rhytides, and dychromia. They require prolonged recovery periods, however, and are associated with the potential for infection, scarring, and permanent dyspigmentation, making them a less than ideal treatment for hemangioma residuum. The risk for adverse effects with ablative lasers is greater in children who have fewer appendageal structures (in particular on nonfacial anatomical locations), which are necessary for repopulating the ablated tissue.12 Nonablative laser penetration is confined to the upper portion of the dermis, with minimal adverse effects and downtime. Compared with ablative lasers, nonablative lasers are limited in their depth of penetration; therefore, these lasers cannot produce substantial remodeling of the dermis compared with ablative lasers.

Unlike ablative laser resurfacing, which vaporizes and heats tissue in layers, fractional photothermolysis creates distinct columns of thermal injury in the epidermis and dermis, which are referred to as microthermal zones.13 Microthermal zones are surrounded by healthy, uninjured tissue, which allows rapid healing and minimal adverse effects.14 Improvement in the appearance of a residual hemangioma has been reported with a nonablative fractionated 1440-nm erbium-doped fiber laser.15 A newer 30-W ablative fractional CO2 laser combines the efficacy of ablative CO2 lasers with the safety profile of a fractional photothermolysis system. The laser delivers microthermal zones, partially vaporizing the skin and creating a surrounding cylindrical zone of coagulation. This treatment, referred to as ablative fractional resurfacing (AFR), stimulates the production of new collagen and the proliferation of myoblasts in the dermis. Subsequent tissue remodeling occurs, resulting in a reduction in tissue laxity and epidermal atrophy and an overall improvement in the appearance of the hemangioma residuum.12 In this case series, we propose the use of AFR for the treatment of textural skin changes resulting from involuted hemangiomas.

REPORT OF CASES

CASE 1

A 5-day old girl who was born without any lesions developed hemangiomas of the left and right preauricular cheek area as well as in the beard distribution. The lesions grew rapidly for the next 3 months and tapered off for the following 3 months. At the time of initial evaluation, the patient was 6 months old and had already undergone 1 PDL treatment for ulcerations and multiple courses of intralesional and oral prednisone. On physical examination, she was noted to have erythematous telangiectatic plaques measuring approximately 15.0 × 18.0 cm (Figure 1A). She was treated 23 times with a 595-nm PDL (Vbeam; Syneron/Candela) over the course of 5 years to reduce erythema and telangiectases. A pulse duration of 3.0 ms, spot sizes ranging from 7 to 12 mm, and fluences of 7.5 to 12.5 J/cm2 were used while the patient was under general anesthesia. Subsequently, also with the patient under general anesthesia, AFR (Fraxel Re:pair; Solta Medical Inc) was used to treat the fibrofatty residuum and the epidermal atrophy. She has undergone 13 treatments, with settings ranging from 25 to 40 mJ and total 0.5 to 10 kJ, with a 15-mm tip and 30% to 40% coverage, over the course of 3½ years (Figure 1B).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Involuted infantile hemangioma before (A) and after (B) ablative fractional resurfacing treatments of patient 1. A, Fibrofatty involuted hemangioma residuum before the first treatment. B, Hemangioma after 6 of 13 ablative fractional resurfacing treatments, with substantial reduction in hemangioma residuum.

CASE 2

Patient 2 was noted to have hemangiomas in the right parotid region, lower lip, tongue, and left preauricular area as early as 6 weeks. She had bleeding and ulceration of the lower lip at the age of 3½ months, requiring hospitalization. Before presenting for evaluation at our center at the age of 4 years, she had undergone 3 excisional procedures. On physical examination, she was noted to have a 4.0 × 3.0-cm slightly atrophic, telangiectatic, thin plaque on the right preauricular cheek area and a 3.0 × 2.0-cm hypertrophic, erythematous plaque involving the lower vermillion and cutaneous lip area. She was treated 4 times under general anesthesia with a 595-nm PDL (Vbeam; Syneron/Candela) to reduce erythema and telangiectases. Settings included pulse durations of 0.45 to 1.5 ms, with a spot size of 10 mm and fluences of 8 to 9 J/cm2. Under general anesthesia, she subsequently had 3 treatments of AFR (Fraxel Re:pair; Solta Medical Inc), with settings of 20 mJ and total 0.29 to 2 kJ, with a 15-mm tip and 20% to 30% coverage to reduce the fibrofatty residuum and epidermal atrophy.

CASE 3

The hemangioma of our third patient first appeared as a minute red macule above the medial aspect of her left eyebrow at 2 weeks of age. The lesion, which was then diagnosed as a hemangioma, rapidly enlarged over the following 3 months before stabilizing in size. No treatment was received, and the lesion involuted gradually, with the erythema resolving by the age of 8 years. Substantial fibrofatty residuum remained at the site of the hemangioma, which prompted the patient's mother to seek further treatment. The patient presented with a 1.0-cm-diameter, skin-colored, elevated rubbery nodule on her left lower medial forehead area, just above her eyebrow, 2 weeks after her 10th birthday. Under general anesthesia, the patient has received 5 AFR treatments (Fraxel Re:pair; Solta Medical Inc) over 19 months, with settings ranging from 30 to 40 mJ and total 7.5 to 8 kJ, with a 12- to 15-mm tip and 30% to 40% coverage, as well as 3 treatments with a 595-nm PDL (Vbeam; Syneron/Candela) pulse durations of 0.45 to 1.5 ms, 7- to 12-mm spot sizes, and energies of 6 to 11.5 J/cm2. These treatments have resulted in considerable flattening of the fibrofatty residual.

CASE 4

Patient 4 developed a left submental pinpoint red papule 2 days after birth that rapidly enlarged over the following 8 months. No medical or surgical treatment was administered. The hemangioma remained stable in size until the age of 4 years, at which time the lesion began to gradually involute. At the age of 13 years, she presented for consultation with a 4.0-cm, atrophic, yellow-brown plaque in the left submental area. She has received 2 AFR treatments (Fraxel Re:pair; Solta Medical Inc), with settings of 40 mJ and total 10 kJ, with a 15-mm tip and 30% to 40% coverage, resulting in improvement in skin texture and a reduction in skin redundancy. She and her mother noted a “tremendous improvement.”

CASE 5

Patient 5 was born with a hemangioma involving his left cheek and orbit that was treated during its proliferative phase with prednisone and laser therapy at the age of 2 months by an outside physician in the Dominican Republic (Figure 2A). At 4 years old, he presented with an involuted hemangioma with residuum, including multiple atrophic scars and diffuse hyperpigmentation of the left cheek, measuring 60 cm2 (Figure 2B). Over a 1 year period, he was treated 3 times under general anesthesia with AFR (Fraxel Re:pair; Solta Medical Inc), with settings ranging from 25 to 40 mJ and total 0.4 to 1.0 kJ, with a 15-mm tip and 40% coverage. These treatments resulted in exceptional improvement in texure and color (Figure 2C).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Involuted infantile hemangioma before (A and B) and after (C) ablative fractional resurfacing treatments of patient 5. A, Hemangioma present at birth. B, Fibrofatty involuted hemangioma residuum before first treatment. C, Hemangioma after series of 3 ablative fractional resurfacing treatments, with substantial reduction in hemangioma residuum.

RESULTS

All 5 patients tolerated the procedure well, with no incidence of infection, scarring, or pigmentary alteration. Immediate, transient posttreatment oozing and crusting were reported to resolve within 2 to 3 days. Posttreatment adverse effects included moderate erythema and edema, with pinpoint petechiae that resolved by days 5 through 7. Independent assessments were performed by 3 blinded physicians who were not involved in the treatment. Baseline and follow-up photographs were evaluated for improvement in color, texture, and overall cosmetic appearance according to a 4-point scale (1, 0%-25%; 2, 25%-50%; 3, 50%-75%; and 4, 75%-100%) after a series of AFR treatments. All patients were found to have at least 50% to 75% improvement, and 2 patients had 75% to 100% improvement in the degree of atrophy, topographical abnormalities, and pigmentary changes. Furthermore, all patients reported improved cosmetic appearance of the treatment areas (Table).

Table Graphic Jump LocationTable. Demographic and Treatment Data

COMMENT

Infantile hemangiomas are vascular tumors that develop in the newborn period, grow rapidly, and then gradually involute. Understanding the progression of these lesions, many parents and physicians choose to observe rather than treat hemangiomas. Unfortunately, the involutional process is often imperfect, and patients may be left with residual skin changes such as telangiectases, atrophic wrinkling, yellow or brown discoloration, and fibrofatty redundancy of the skin. Hemangiomas treated with surgical excision, intralesional or systemic medications, or PDL can also be left with posttreatment residuum. The PDL has been used to treat residual telangiectases and erythema11; however, effective treatments to target the disfiguring textural changes of the skin associated with involuted hemangiomas are lacking.

Older resurfacing technologies, such as the CO2 laser or the erbium:YAG laser, carry substantial risk of infection, scarring, and permanent pigmentary alteration, along with prolonged downtime, complications that make these technologies a less than ideal choice for treating hemangioma residuum. Ablative fractional resurfacing represents a major advance in laser resurfacing. Its proven efficacy in the treatment of rhytides, acne, atrophic scarring, and melasma led us to postulate that substantial improvement could be achieved in the treatment of hemangioma residuum.16,17 The clinical improvement achieved in this case series is secondary to excess tissue volume reduction by means of ablation as well as textural changes induced by remodeling over time by means of neocollagenesis.16,17

As demonstrated in this case series, AFR can safely and effectively improve the epidermal atrophy, fibrofatty residual, and overall appearance of hemangioma residuum. The fractional CO2 technology allows quick recovery and is of particular importance in children, who possess fewer pilosebaceous units that act as reservoirs for epidermal replacement. As documented, there were no adverse effects, including delayed hypopigmentation, as can occur with fully ablative procedures. With appropriate candidates, procedure technique, and parameters specific to each case, there is seemingly a low risk for delayed hypopigmentation, which has been well documented by Hunzeker et al.16 The long period of time over which these laser treatments were administered makes it difficult, in the absence of internal controls, to discern whether the clinical improvement was solely a result of the laser treatments, as the role of natural involution cannot be adequately assessed. Larger studies with extended follow-up are needed to further examine the benefits of treatment; however, at the present time, we believe that AFR should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

ARTICLE INFORMATION

Correspondence: Lori A. Brightman, MD, Laser & Skin Surgery Center of New York, 317 E 34th St, New York, NY 10016 (lbrightman@laserskinsurgery.com).

Accepted for Publication: May 25, 2012.

Published Online: August 20, 2012. doi:10.1001/archdermatol.2012.2346

Author Contributions: Drs Brightman, Brauer, Terushkin, and Geronemus had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Brightman, Terushkin, Hunzeker, and Geronemus. Acquisition of data: Brightman, Brauer, Terushkin, Hunzeker, and Reddy. Analysis and interpretation of data: Brightman, Brauer, Terushkin, Weiss, Karen, Hale, Anolik, Bernstein, and Geronemus. Drafting of the manuscript: Brightman, Brauer, and Terushkin. Critical revision of the manuscript for important intellectual content: Brightman, Brauer, Terushkin, Hunzeker, Reddy, Weiss, Karen, Hale, Anolik, Bernstein, and Geronemus. Administrative, technical, and material support: Brightman. Study supervision: Brightman, Weiss, Karen, Hale, Anolik, Bernstein, and Geronemus.

Financial Disclosure: Dr Brightman has been an investigator for Solta and Syneron and has received honoraria from Solta, Syneron, Candela, Dusa, Lutronics, and Invasix. Dr Weiss has been an investigator and a consultant for Litheria. Dr Hale has been a consultant for Merck, sanofi-aventis, and Guthy-Renker. Dr Geronemus has been an investigator for Solta, DUSA, Syneron, Palomar, Cynosure, Invasix, Lithera, Kythera, and L’Oreal and has received honoraria from Solta.

REFERENCES

Jacobs AH, Walton RG. The incidence of birthmarks in the neonate.  Pediatrics. 1976;58(2):218-222
PubMed
Pratt AG. Birthmarks in infants.  AMA Arch Derm Syphilol. 1953;67(3):302-305
PubMed   |  Link to Article
Jacobs AH. Strawberry hemangiomas; the natural history of the untreated lesion.  Calif Med. 1957;86(1):8-10
PubMed
Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children.  N Engl J Med. 1999;341(3):173-181
PubMed   |  Link to Article
Enjolras O, Riche MC, Merland JJ, Escande JP. Management of alarming hemangiomas in infancy: a review of 25 cases.  Pediatrics. 1990;85(4):491-498
PubMed
Holmdahl K. Cutaneous hemangiomas in premature and mature infants.  Acta Paediatr. 1955;44(4):370-379
PubMed   |  Link to Article
Bruckner AL, Frieden IJ. Hemangiomas of infancy.  J Am Acad Dermatol. 2003;48(4):477-496
PubMed   |  Link to Article
Mulliken JB, Fishman SJ, Burrows PE. Vascular anomalies.  Curr Probl Surg. 2000;37(8):517-584
PubMed   |  Link to Article
Bowers RE, Graham EA, Tomlinson KM. The natural history of the strawberry nevus.  Arch Dermatol. 1960;82(5):667-680
Link to Article
Lister WA. The natural history of the strawberry naevi.  Lancet. 1938;1:1429-1434
Link to Article
Ashinoff R, Geronemus RG. Capillary hemangiomas and treatment with the flash lamp–pumped pulsed dye laser.  Arch Dermatol. 1991;127(2):202-205
PubMed   |  Link to Article
Tannous Z. Fractional resurfacing.  Clin Dermatol. 2007;25(5):480-486
PubMed   |  Link to Article
Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury.  Lasers Surg Med. 2004;34(5):426-438
PubMed   |  Link to Article
Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments.  Dermatol Surg. 2008;34(3):301-307
PubMed   |  Link to Article
Blankenship CM, Alster TS. Fractional photothermolysis of residual hemangioma.  Dermatol Surg. 2008;34(8):1112-1114
PubMed   |  Link to Article
Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser resurfacing: our experience with more than 2000 treatments.  Aesthet Surg J. 2009;29(4):317-322
PubMed   |  Link to Article
Weiss ET, Chapas AM, Brightman L,  et al.  Successful treatment of atrophic postoperative and traumatic scarring with carbon dioxide ablative fractional resurfacing: quantitative volumetric scar improvement.  Arch Dermatol. 2010;146(2):133-140
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Involuted infantile hemangioma before (A) and after (B) ablative fractional resurfacing treatments of patient 1. A, Fibrofatty involuted hemangioma residuum before the first treatment. B, Hemangioma after 6 of 13 ablative fractional resurfacing treatments, with substantial reduction in hemangioma residuum.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Involuted infantile hemangioma before (A and B) and after (C) ablative fractional resurfacing treatments of patient 5. A, Hemangioma present at birth. B, Fibrofatty involuted hemangioma residuum before first treatment. C, Hemangioma after series of 3 ablative fractional resurfacing treatments, with substantial reduction in hemangioma residuum.

Tables

Table Graphic Jump LocationTable. Demographic and Treatment Data

References

Jacobs AH, Walton RG. The incidence of birthmarks in the neonate.  Pediatrics. 1976;58(2):218-222
PubMed
Pratt AG. Birthmarks in infants.  AMA Arch Derm Syphilol. 1953;67(3):302-305
PubMed   |  Link to Article
Jacobs AH. Strawberry hemangiomas; the natural history of the untreated lesion.  Calif Med. 1957;86(1):8-10
PubMed
Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children.  N Engl J Med. 1999;341(3):173-181
PubMed   |  Link to Article
Enjolras O, Riche MC, Merland JJ, Escande JP. Management of alarming hemangiomas in infancy: a review of 25 cases.  Pediatrics. 1990;85(4):491-498
PubMed
Holmdahl K. Cutaneous hemangiomas in premature and mature infants.  Acta Paediatr. 1955;44(4):370-379
PubMed   |  Link to Article
Bruckner AL, Frieden IJ. Hemangiomas of infancy.  J Am Acad Dermatol. 2003;48(4):477-496
PubMed   |  Link to Article
Mulliken JB, Fishman SJ, Burrows PE. Vascular anomalies.  Curr Probl Surg. 2000;37(8):517-584
PubMed   |  Link to Article
Bowers RE, Graham EA, Tomlinson KM. The natural history of the strawberry nevus.  Arch Dermatol. 1960;82(5):667-680
Link to Article
Lister WA. The natural history of the strawberry naevi.  Lancet. 1938;1:1429-1434
Link to Article
Ashinoff R, Geronemus RG. Capillary hemangiomas and treatment with the flash lamp–pumped pulsed dye laser.  Arch Dermatol. 1991;127(2):202-205
PubMed   |  Link to Article
Tannous Z. Fractional resurfacing.  Clin Dermatol. 2007;25(5):480-486
PubMed   |  Link to Article
Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury.  Lasers Surg Med. 2004;34(5):426-438
PubMed   |  Link to Article
Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments.  Dermatol Surg. 2008;34(3):301-307
PubMed   |  Link to Article
Blankenship CM, Alster TS. Fractional photothermolysis of residual hemangioma.  Dermatol Surg. 2008;34(8):1112-1114
PubMed   |  Link to Article
Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser resurfacing: our experience with more than 2000 treatments.  Aesthet Surg J. 2009;29(4):317-322
PubMed   |  Link to Article
Weiss ET, Chapas AM, Brightman L,  et al.  Successful treatment of atrophic postoperative and traumatic scarring with carbon dioxide ablative fractional resurfacing: quantitative volumetric scar improvement.  Arch Dermatol. 2010;146(2):133-140
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 3

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles