Table of Contents    
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 184-188  

Clinical experience using neodymium-doped yttrium aluminum garnet laser in cutaneous vascular malformations among Indian patients


1 Aesthetic Metamorphosis Clinic, Kolkata, West Bengal, India
2 Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
3 Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
4 Avinash Institute of Craniofacial and Reconstructive Surgery, Kolkata, West Bengal, India

Date of Web Publication18-Jul-2019

Correspondence Address:
Jayanta Bain
Nihar Apartment, 3/30 Government Colony, Rahara, Kolkata - 700 118, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_188_18

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   Abstract 


Introduction: Cutaneous vascular anomalies are relatively common in clinical practice with varied clinical features and deformity. Various treatment modalities are used to manage this condition. Aims and Objectives: In this study, our aims were to evaluate the outcome of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser in this type of vascular malformations. Materials and Methods: This was a prospective study conducted in the Department of Plastic Surgery in our institute from January 2014 to December 2015 among the patients having cutaneous vascular malformations. Results: There were total 34 patients; 20 patients were females and 14 were males. Sixteen were adults (>18 years) and 11 patients were below 1 year of age. Among different types of lesions, 23 (67.7%) were vascular malformations and 11 (32.3%) were hemangiomas. Most of the lesions (58.7%) showed positive effect of laser treatment as it becomes flat. All (100%) hemangiomas, i.e., infantile hemangioma and pyogenic granuloma become flat. However, 41.3% lesions showed no significant change in height. Among them, 58.3% were venous malformations, 25% capillary malformations, and 16.7% capillary venous malformations. Skin color was not changed in color among 58.9% cases. About 58.9% cases showed no skin texture changes (atrophic/hypertrophic). Excellent-to-fair outcome was observed among 64.8% cases. Conclusion: Nd:YAG laser therapy on cutaneous hemangiomas and vascular malformations is a good therapeutic option among Indian patients.

Keywords: Hemangioma, neodymium-doped yttrium aluminum garnet laser, vascular malformations


How to cite this article:
Bain J, Sarkar A, De A, Biswas BK, Murmu M. Clinical experience using neodymium-doped yttrium aluminum garnet laser in cutaneous vascular malformations among Indian patients. J Nat Sc Biol Med 2019;10:184-8

How to cite this URL:
Bain J, Sarkar A, De A, Biswas BK, Murmu M. Clinical experience using neodymium-doped yttrium aluminum garnet laser in cutaneous vascular malformations among Indian patients. J Nat Sc Biol Med [serial online] 2019 [cited 2019 Oct 19];10:184-8. Available from: http://www.jnsbm.org/text.asp?2019/10/2/184/262945




   Introduction Top


Cutaneous vascular anomalies are common in clinical practice of plastic surgeons. These patients usually present with wide-range clinical features in terms of age, size, and anatomical involvement, with varied degree of cosmetic, physiological, and physical deformity. In most of the cases, accurate diagnosis is possible by correlating history and clinical examinations. However, to describe vascular anomalies, different authors had used overlapping and confusing terminologies which often make very difficult to understand the disease. In 1982, Mulliken and Glowacki described the biological classification system which simplified the previous classifications.[1] They divided vascular anomalies into hemangioma (increased endothelial turnover and proliferations) and vascular malformations (congenital lesions with normal endothelial characteristics). They have been further subclassified by the identity of vessels found within the lesion (i.e., venous, arterial, lymphatic, capillary, or mixed) and upon blood flow within the lesion (i.e., high flow and low flow).

There are various treatment modalities for these lesions such as medical, surgical, and sclerotherapy. Since the last two decades, several reports are made from the Western world on the use of various types of lasers for the management of cutaneous vascular malformations; however, such study from Indian subcontinent is very few, probably because of high treatment cost and lack of technical expertise among treating physicians and other associated factors. In the last few years, our institute has started neodymium-doped yttrium aluminum garnet (Nd:YAG) laser therapy clinic for the management of cutaneous vascular anomalies among suitable patients in a very low cost. Hence, in this study, we have tried to evaluate our experience in terms of efficacy and benefit of this new treatment modality, especially in this part of Indian populations.


   Materials and Methods Top


Study design

This was a prospective study conducted in the Department of Plastic Surgery in our institute from January 2014 to December 2015. A total number of patients were 34.

Inclusion criteria

Patients at any age group who have slow-flow cutaneous hemangioma/vascular malformations were included in the study.

Exclusion criteria

Large-channel high-flow vascular malformations; pregnant female, epilepsy, using drugs such as isotretinoin, nonsteroidal anti-inflammatory drugs, anticoagulant systemic steroids, and vincristine, patients having keloidal tendency, having history of bleeding coagulopathies.

Parameters evaluated

History and clinical examinations, reduction in size, change in color, changes in skin elasticity/texture, and number of Nd:YAG laser session were evaluated in the study. Manual measuring was done by tapes and calipers. High-resolution photography was taken for every patient before treatment, during every session, and after completion of treatment with similar speed, flash, and focal length.

System specification

For treatment, we used the IPL™ Quantum DL (Lumenis) is a Nd:YAG laser system. Light source was Nd:YAG laser, wavelength: 1064 nm, fluence range: 90–150 Jules/cm 2, repetition rate: 0.5 Hz, spot size: 6 mm, and cooling system of approximately +3°C and −4°C.

Mode of Treatment

Two modes were used.

Direct mode

This method was used for superficial lesions. The laser beam was directly focused on surface of the superficial vascular lesions, using energy of 7–9 W, in pulse mode, setting punctual energy every few millimeters, and which was instantly followed by cooling.

Transcutaneous mode

This method was used over lesion having to 2–3 cm depth with higher energy (30–40 W). Epidermis was protected from heat damage by placing a crystal clear ice cubes between the skin and laser beam. Pressure was applied onto the lesion to further extend the depth of reach of the laser beam.

Postlaser treatment care and follow-up

To decrease pain and swelling, cold pack was used. Patients advised to avoid sunlight and to apply highest factor sunscreen for 1 month and to use antiseptic ointments during the healing period (7–10 days). Patients were asked to return 3 weeks after each treatment session or examination of the effect of the treatment and for additional treatment, if necessary. If there was partial clearance, treatment was continued with the same parameter. If no change was noted, fluence was increased 10% and/or other parameters changed. Six sessions were over 6–8 months were carried on to observe the effect of Nd:YAG laser or to the patients' satisfactions with the result of treatment.


   Results Top


There were total 34 patients; 20 (58.9%) patients were females and 14 (41.1%) were males. Among deferent age groups, 16 (47.1%) were adults (>18 year) and 11 (32.3%) patients were below 1 year of age. Among different types of lesions, 23 (67.7%) were vascular malformations and 11 (32.3%) were hemangiomas (infantile hemangioma/pyogenic granuloma). Most of the lesions (52.9%) were present since birth; 29.4% lesion appeared after birth to 5 years of age and only 17.7% lesions appeared after age of 5. Most (57.9%) venous malformations showed slow progressions; 40% capillary malformations hand no progression, and rapid progression was seen exclusively among all infantile hemangiomas (100%). Head and neck was the most commonly (70.6%) involved site, followed by trunk (17.6%). In head and neck, the most common lesions were venous malformations (37.5%), followed by infantile hemangioma (20.9%).

Nearly 87.5% infantile hemangioma and all (100%) venous and all (100%) capillary venous malformations were treated by transcutaneous mode. All (100%) pyogenic granuloma and 71.4% capillary malformations were treated by direct mode. All (100%) capillary venous malformations, 91.7% venous malformations, 87.5% infantile hemangioma, and 85.8% capillary malformations needed 4–6 sessions of laser therapy. Single session was sufficient to treat only 2 (5.9%) cases.

Most of the lesions (58.7%) showed positive effect of laser treatment as it becomes flat. All (100%) the vascular tumors, i.e., infantile hemangiomas [Figure 1] and pyogenic granuloma become flat. However, 41.3% lesions showed no significant change in height. Among them, 58.3% were venous malformations, 25% were capillary malformations, and 16.7% were capillary venous malformations. Ectatic dilatation of capillary malformations immediately becomes flat following the first session of laser therapy [Figure 2].
Figure 1: (a and b) Rapidly proliferating infantile hemangioma

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Figure 2: (a-c) Ectatic dilatation of capillary malformation

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Effect of laser on skin color was good in most of the cases as there was no change in color among 58.9% cases; however, 41.1% cases showed pigmentary alterations; among them, 20.5% cases' color becomes lighter, and in 23.6% cases, the lesion became hypopigmented. Among the individual groups of lesions, 87.5% of infantile hemangioma and 66.6% of pyogenic granuloma showed pigmentary alterations, whether as vascular malformations (83.3%) [Figure 3], capillary venous malformations (75%), and capillary malformations (57.1%) are most likely to resist pigmentary changes.
Figure 3: (a and b) Venous malformation over lip

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Effect of laser on skin texture was also good in most of the cases as 58.9% cases showed no skin texture changes (atrophic/hypertrophic) following laser therapy. Among the individual groups of lesions, skin texture of 83.3% vascular malformations, 75% capillary venous malformations, and 57.1% capillary malformations [Figure 4] was unaffected following laser therapy. However, in 41.1% lesions, there were skin texture changes; among them, atrophic skin was seen in 75% infantile hemangioma and 66.7% pyogenic granuloma [Figure 5].
Figure 4: (a and b) Capillary malformation over left side of face

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Figure 5: (a and b) Pyogenic granuloma

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Outcomes were graded under four headings. Excellent outcome was seen among 35.2% cases. Almost 17.7% cases showed good outcome, 11.8 showed fair outcome, and 35.2% showed poor outcome. Pyogenic granuloma showed excellent outcome in all (100%) cases. Among infantile hemangioma, 50% showed good and 50% showed excellent outcome. Poor outcome was mostly seen among capillary venous malformations (75%), capillary malformations (57.1%), and venous malformations (41.7%).


   Discussion Top


According to the biological classification, we found that 32.3% cases were hemangioma and 67.75% cases were vascular malformations. In most of the studies, they were found in all ages, but they were most common in pediatric age group and females. We also found 52.9% cases aged <18 years, and 58.9% are females. Among specific subgroups, most authors have reported that hemangiomas are more common among females, and there is no sex difference among vascular malformations; however, we found both hemangiomas (54.5%) and vascular malformations (60.9%) common among females; this contradictory finding in vascular malformations may be due to less number of study populations. Regarding the anatomical distribution, in our study, most lesions were solitary and more common in the head-and-neck region consistent with reports from other authors.[2],[3]

Conventionally, the hemangiomas and slow-flow vascular malformations are treated by beta-blocker, intralesional or systemic steroids, vincristine, sclerotherapy, and surgery, often using in combinations. Lasers are used to treat since the 1960s in the Western world, but probably because of high technical requirement, training, and high expanses of the machine, they are still not very commonly used in this part of the world. There are different types of laser (argon, copper, pulsed-dye laser PDL, etc.) described in literature for treatment of hemangiomas and vascular malformations. Most lasers target the higher picks of oxyhemoglobin (418, 542, and 577 nm), but in this range, significant amount of energy is also absorbed by melanin too; thus, in darker skin (Fitzpatrick III–V) individuals, there remains a chance of posttreatment hypopigmentation of skin; thus, these lasers may not be suitable for Indian populations, where darker skin is more common; another concern with these lasers is that because of small wavelength, these lasers cannot penetrate deep into the skin and hence cannot be applied on deeper lesions.[4],[5],[6]

The Nd:YAG laser which has the wavelength of 1064 nm targets the lower picks of the absorption spectrums of oxyhemoglobin in the infrared range (700–1,100 nm). Because the Nd:YAG laser has long wavelength (1064 nm), it can also penetrate deep up to 6 cm to thermocoagulate deeper blood vessels.[7] In addition, as very little light is absorbed by melanin at this spectrum, the risk of pigmentary alteration is low with Nd:YAG laser. In our study also, we have seen that in 55.9% cases, there were no pigmentary changes; only 23.6% cases showed hypopigmentation, which is expected to become normal within 1–2 years.[8]

In our study, we have used direct and transcutaneous mode of laser energy delivery modes as we do not have intralesional laser therapy systems. Around 82.3% patients required multiple (4–6 sessions) to get the desired effect as also reported by some study [6] though an another study reported a clearance of 75%–100% achieved in a single session.[9] Among 34 patients, 29 (85.2%) patients have lesions that were verrucous or raised than surrounding; after treatment, 17 (58.7%) showed flattening, indicating positive response; excellent (100%) response was seen among hemangioma group; this may be due to the fact that the coagulating action on laser may have induced early involution of infantile hemangiomas. In our study, we have seen that lesion which is elevated or have a deep part (capillary venous malformations) most likely to require more sessions but still may show poor result; these type lesions may be better treated by intralesional laser therapy, as the deeper endothelium can be easily reached to be coagulated by this method.[10]

In most of the cases (58.9%), there were no changes in skin texture, and 47.1% patients had atrophic scars. However, different studies report wide range of scaring, some author reports atrophic scars only in 5.8% patients,[6] whether as another study reports atrophic scars occurred in as high as 66.7% infantile hemangioma cases.[11] We found that in the lesions (infantile hemangiomas and pyogenic granulomas) where 100% of lesions cured, among them, 72.8% showed atrophic changes in skin texture. This may not be just because of the adverse effect of laser, as some author suspected that the infantile hemangioma, epically in Indian populations, the lesion is already infected, ulcerated and devoid of epithelium in bound to be healed by scaring.[12],[13] Besides the type of lesions, amount of energy is also an important factor deciding scar formations, as in a case of capillary malformations, increase of fluence was evident by button-type scar formations.

Overall, 52.9% patients showed fair-to-excellent outcome (>50% resolution); in our study, in a similar studies, some authors [6] found total resolution in 65.5% patients; and in another study,[14] they found that 71.5% of patients showed >50% improvement; however, among hemangiomas, they found excellent outcome in 80% cases, whereas we got 100% excellent-to-good results in this subgroup.

Our study has several limitations; first, study population was small, though we got a good number of cases, and many patients were lost during study so have to exclude them; second, longer follow-up is necessary to see the recurrence and to observe the repigmentation and any changes on the atrophic scars. Furthermore, because of unavailability of intralesional laser therapy, we have to exclude a group of patients having deep-seated lesions, and this was also a limitation of our study. Furthermore, this study was an observational study, so we were not been able to compare it with other conventional methods of treatment to study its benefit over them.


   Conclusion Top


Direct and transcutaneous mode of Nd:YAG laser therapy on cutaneous hemangiomas and vascular malformations is a good therapeutic option among Indian patients; overall good-to-excellent result was seen among most cases, but infantile hemangiomas respond better; however, some lesions may show pigmentary and atrophic skin changes. A multicenter and larger study is necessary to explore the full therapeutic benefit of this modality in Indian populations.

Ethical clearance

This paper is based on the study titled “Role of Nd:YAG Laser in Management of Cutaneous Vascular Malformations: A Prospective Study,” which conducted by the corresponding author as thesis/dissertation, as a part of his postdoctoral course M. Ch. (Plastic Surgery). The above-mentioned study was approved by the Institutional Ethical Committee of “Institute of Post Graduate Medical Education and Research,” Kolkata, vide letter no “Inst/IEC/566 Dated: 15.01.2014.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: A classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:412-22.  Back to cited text no. 1
    
2.
Adamic M, Troilius A, Adatto M, Drosner M, Dahmane R. Vascular lasers and IPLS: Guidelines for care from the European Society for Laser Dermatology (ESLD). J Cosmet Laser Ther 2007;9:113-24.  Back to cited text no. 2
    
3.
Fraulin FO, Flannigan RK, Sharma VK, McPhalen DF, Harrop RA. The epidemiological profile of the vascular birthmark clinic at the Alberta children's hospital. Can J Plast Surg 2012;20:67-70.  Back to cited text no. 3
    
4.
Landthaler M, Hohenleutner U, el-Raheem TA. Laser therapy of childhood haemangiomas. Br J Dermatol 1995;133:275-81.  Back to cited text no. 4
    
5.
Kim KH, Rohrer TE, Geronemus RG. Vascular lesions. In: Goldberg DJ, editor. Procedure in Cosmetic Dermatology: Laser and Lights. Vol. 1. Pennsylvania: Saunders; 2005. p. 11-29.  Back to cited text no. 5
    
6.
Vlachakis I, Gardikis S, Michailoudi E, Charissis G. Treatment of hemangiomas in children using a Nd: YAG laser in conjunction with ice cooling of the epidermis: Techniques and results. BMC Pediatr 2003;3:2.  Back to cited text no. 6
    
7.
Srinivas CR, Kumaresan M. Lasers for vascular lesions: Standard guidelines of care. Indian J Dermatol Venereol Leprol 2011;77:349-68.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Zhong SX, Tao YC, Zhou JF, Liu YY, Yao L, Li SS, et al. Infantile hemangioma: Clinical characteristics and efficacy of treatment with the long-pulsed 1,064-nm neodymium-doped yttrium aluminum garnet laser in 794 Chinese patients. Pediatr Dermatol 2015;32:495-500.  Back to cited text no. 8
    
9.
Nuño-González A, Naz-Villalba E, Vicente-Martín FJ, Sánchez-Gilo A, Gutiérrez-Pascual M, Gómez de la Fuente E, et al. Treatment of mucosal vascular malformations with variable-pulse neodymium: Yttrium-aluminum-garnet laser. Actas Dermosifiliogr 2011;102:717-21.  Back to cited text no. 9
    
10.
Ulrich H, Bäumler W, Hohenleutner U, Landthaler M. Neodymium-YAG laser for hemangiomas and vascular malformations – Long term results. J Dtsch Dermatol Ges 2005;3:436-40.  Back to cited text no. 10
    
11.
Yuan RT, Jia MY, Feng YY, Shang W, Li NY. Early laser intervention of hemangioma in facial and neck regions of infant. Hua Xi Kou Qiang Yi Xue Za Zhi 2008;26:166-7, 171.  Back to cited text no. 11
    
12.
Chamlin SL, Haggstrom AN, Drolet BA, Baselga E, Frieden IJ, Garzon MC, et al. Multicenter prospective study of ulcerated hemangiomas. J Pediatr 2007;151:684-9, 689.e1.  Back to cited text no. 12
    
13.
Goleria KS. Capillary hemangioma of infancy In: Goleria KS, editor. The Hemangiomas and Vascular Malformations of Head and Neck. New Delhi: JAYPEE Brothers Medical Publishers Private Limited.; 2012. p. 24-37.  Back to cited text no. 13
    
14.
Civas E, Koc E, Aksoy B, Aksoy HM. Clinical experience in the treatment of different vascular lesions using a neodymium-doped yttrium aluminum garnet laser. Dermatol Surg 2009;35:1933-41.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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