Lasers or light sources for treating port‐wine stains
Port‐wine stains are birthmarks caused by malformations of blood vessels in the skin. Port‐wine stains manifest themselves in infancy as a flat, red mark and do not regress spontaneously but may, if untreated, become darker and thicker in adult life. The profusion of various lasers and light sources makes it difficult to decide which equipment is the best for treating port‐wine stains.
To study participant satisfaction, clinical efficacy, and adverse effects of the treatment of port‐wine stains by lasers and light sources.
We searched the following databases up to April 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), LILACS (Latin American and Caribbean Health Science Information database, from 1982), and reference lists of articles. We also searched online trials registries for ongoing trials and contacted trial authors where appropriate.
Randomised clinical trials (RCTs) of lasers or light sources for the treatment of port‐wine stains.
Data collection and analysis
Our outcomes of interest were participant satisfaction, reduction in redness of the port‐wine stain as determined by clinical evaluation, and short‐ and long‐term adverse effects of the treatments. Three authors independently extracted data and assessed trial quality.
We included 5 RCTs involving a total of 103 participants; all of the trials used a within‐participant design. The interventions and outcomes were too varied to be combined statistically. All trials used the pulsed dye laser for comparisons.
None of the studies focused on participant satisfaction, which was one of our primary outcomes, but participant preference was evaluated in three of five studies. Participants preferred the pulsed dye laser to intense pulsed light based on the clinical effect. They marginally preferred the Neodymium:YAG (yttrium‐aluminium‐garnet) (Nd:YAG) laser to the pulsed dye laser due to shorter lasting purpura, and pulsed dye laser in conjunction with cooling was preferred to treatment with pulsed dye laser alone.
All trials examined short‐term efficacy of less than six months after treatments with the pulsed dye laser, intense pulsed light, and Nd:YAG laser. The pulsed dye laser was evaluated in all five trials. Depending upon the setting of the pulsed dye laser, this resulted in more than 25% reduction in redness. This was after 1 to 3 treatments for up to 4 to 6 months postoperatively in 50% to 100% of the participants. There was only one study each of intense pulsed light and Nd:YAG laser.
Two trials had no occurrence of long‐term adverse effects, i.e. six months after treatment. Three trials reported pigmentary alterations in 3% to 24% of the participants, with the highest percentage occurring in Chinese participants with darker skin types. In one study one participant experienced scarring of the skin caused by a too‐high dose of the laser used. Short‐term side‐effects included pain, crusting, and blistering in the first two weeks after treatment.
The pulsed dye laser leads to clinically relevant clearance of port‐wine stains. A limited number of RCTs evaluated the efficacy from intense pulsed light and other laser types. High‐quality RCTs are needed to assess individual efficacy from different lasers and light sources, as well as participant satisfaction.
Annesofie Faurschou, Anne Braae Olesen, Jo Leonardi‐Bee, Merete Haedersdal
Plain language summary
Treatment of port‐wine stains with lasers or light sources
Port‐wine stains are birthmarks caused by malformations of blood vessels in the skin. They manifest themselves in infancy as flat, red marks on the skin and do not disappear spontaneously but may, if untreated, become darker and thicker by middle age with a 'cobblestone appearance'.
Different lasers and light sources are used to lighten the port‐wine stains by a reduction in redness. However, it is unclear which treatment gives the best results. Our aim with this systematic review was to assess the benefits and harms of the various lasers and light sources available. We found 5 randomised controlled trials, involving 103 participants, which we included in our review. All of the included trials assessed the effectiveness of the interventions using a within‐participant design. These trials assessed the pulsed dye laser, intense pulsed light, and Nd:YAG laser. Only the pulsed dye laser was assessed in all five trials.
None of the studies focused on participant satisfaction which was our primary outcome. Depending upon the setting of the pulsed dye laser, more than 25% lightening (i.e. by reduction in redness) of port‐wine stains occurred. This was after 1 to 3 treatments for up to 4 to 6 months postoperatively in 50% to 100% of the participants of the trials. Substantial evidence is lacking for other laser types and intense pulsed light.
Side‐effects were rare in the included trials, but 3 trials reported pigmentary alterations in 3% to 24% of the participants, with the highest percentage occurring in Chinese participants with darker skin types. In one study one participant experienced scarring of the skin due to a too‐high dose of the laser used. Short‐term side‐effects included pain, crusting, and blistering in the first two weeks after treatment. Two trials reported no occurrence of long‐term adverse effects, i.e. six months after treatment.
Annesofie Faurschou, Anne Braae Olesen, Jo Leonardi‐Bee, Merete Haedersdal
Implications for practice
The pulsed dye laser is currently the treatment of choice for port‐wine stains. This review does not provide evidence for any change to this approach.
Participants preferred the pulsed dye laser to intense pulsed light based on the clinical effect. They marginally preferred the Nd:YAG laser to the pulsed dye laser due to shorter‐lasting purpura, and pulsed dye laser in conjunction with cooling was preferred to treatment with pulsed dye laser alone.
Treatment with the pulsed dye laser resulted in more than 25% reduction in redness for up to 4 to 6 months postoperatively in 50% to 100% of the participants included in the randomised clinical trials assessed for this review. However, no randomised trials have evaluated long‐term efficacy and adverse effects beyond six months. Little evidence was found for treatment with intense pulsed light and the Nd:YAG laser, both of which reduced redness of port‐wine stains in one study each. Complete clearance of the port‐wine stains was not obtained in any trials, but all trials evaluated only one to three treatments, which is in contrast to the clinical setting where people are usually treated more than three times.
Short‐term adverse effects were scarcely reported and included immediate pain, purpura, swelling, and crusting. Long‐term adverse effects lasting longer than 6 months were not described in any of the trials but 3 of 5 trials reported pigmentary alterations in 3% to 24% of the participants, in particular in Chinese patients with darker skin types. One participant treated with a too‐high dose of the Nd:YAG laser had scarring of the skin. None of the trials provided evidence for the influence of age, colour of the port‐wine stains, and skin types on treatment outcome. Differences in serious long‐term adverse effects were not addressed by any of the included studies as no studies examined long‐term adverse effects beyond six months, and the number of participants was too low for such analyses to be carried out.
Implications for research
This review only included 5 randomised clinical trials with a total of 103 participant and short‐term evaluations of less than 6 months. Moreover, the pulsed dye laser was the only laser investigated in more than one trial. High‐quality studies are thus needed, in particular studies with a larger number of participants, with longer follow up times, and evaluating other lasers and light sources than just the pulsed dye lasers. Focus should be on participant satisfaction as this end point is the most important due to the psychological impact the cosmetic appearance of port‐wine stains may have on an individual.
A number of issues need to be addressed: the age of the individual at treatment and the response of different types of port‐wine stains to treatment, as well as the influence of different skin types. Also, questions about the number of, and the intervals between, treatments, as well as the differences between treatments in terms of long‐term adverse effects remain to be answered. Such trials may constitute a basis for individualised treatment parameters for participants with different subtypes of port‐wine stains and thus optimise treatment efficacy with a minimised occurrence of adverse effects.