New advances in pediatric dermatologic surgery

Chicago - Pediatric dermatologists from Children's Memorial Hospital in Chicago gave updates on dermatologic surgery in children at the AAD's Academy '05, and Annette Wagner, M.D., spoke with Dermatology Times about the key points and what they mean for dermatologists.

Information presented by Je-rome M. Garden, M.D., professor of pediatrics and dermatology at Northwestern University, Chicago, reveals that there is no good laser system currently available for the treatment of many congenital lesions in children. The reason, according to Dr. Wagner, attending pediatric dermatologist at the Chicago hospital, is that the lesions observed in children, such as congenital nevi, café au lait spots or some vascular malformations, are, by virtue of their congenital nature, much deeper in the skin than lasers can penetrate without a high risk of scarring.

"That makes successful treatment much more difficult," she says.

"We have not been very successful in causing any kind of permanent removal of café au lait pigmentation," she says.

Laying the groundwork

This brings up another important aspect of dermatologic surgery for children: discussing outcome expectations with the family.

"It's important for the family to have realistic expectations," Dr. Wagner says. "Even if the patient gets better, there is a high likelihood that (these lesions) will recur over time."

It's crucial to do test spots prior to proceeding with any treatment in a child to ensure that the treatment won't cause worsening rather than improvement, especially in facial lesions.

With close to 200 different acne laser machines on the market designed to treat the skin disease, the lure to rely on this form of treatment as a primary modality is tempting. But Dr. Garden cautions dermatologists to use care in choosing certain systems for use on children.

"There's no question that when you shine certain lights on acne you will improve inflammation - there's good evidence that this is the case," Dr. Wagner explains. "But dermatologists must also look at the practicality of using this as the main therapy in pediatric patients. Laser treatment is not always the best choice in pediatrics - it might be better used as an adjunct for our current therapeutic approaches like oral antibiotics and topical medications."

Pulsed dye and port wine stains

Vascular pulsed dye lasers, on the other hand, have been around a long time and are still used as the standard of care in the treatment of port wine stains on the faces of children.

"This is considered the standard of care," Dr. Wagner says. "Any child with a facial port wine stain should be treated. Typically, multiple treatments with a pulsed dye laser are optimal for maximum improvement. These have not changed much over the years."

Today, the success rate of treating port wine stains in most children is quite high, whether using the 585 laser or the newer 595 nm pulsed dye lasers. According to Dr. Garden, some pediatric patients have benefited equally well from either wavelength, although the 585 may be a more effective tool for babies and young children with port wine stains.

New approaches

Experimental approaches are under way that may alter the success rates of lasers in children, including ways to use photodynamic therapy for different lesions as well as ways to protect the epidermis so that higher energy can be delivered deeper. Researchers are also looking at new ways to deliver energy to the vessels in children with port wine stains without injuring the skin surface. One improvement already under way involves lasers with cryogen units that spray cold onto the surface of the skin to protect the outer skin layers.

Until these improvements are well established, dermatologists, as well as the parents of pediatric patients, need to have a more realistic perspective on the capabilities of the laser systems available now, according to Dr. Wagner.