Leonard Bernstein, MD, a Dermatologist at Laser and Skin Surgery Center of NY talks about port wine stains, the best way to treat them, and when.
Interview conducted by Ivanhoe Broadcast News in September 2019.
Could you describe what a port-wine stain is and what causes it?
BERNSTEIN: A port-wine stain is a birthmark that is composed of small blood vessels in the skin. You see this at birth. It is probably due to a genetic mutation that we have no knowledge of how, why or how it occurs. It occurs in about one in 200 to one in 300 children, equally both between boys and girls. There are some variations of port-wine stains or capillary vascular malformations that can have more serious consequences, such as Sturge-Weber syndrome, where we have kids who have the capillary vascular malformation or port-wine stain involving the skin. But they can also have systemic issues such as glaucoma of the eye or neurological problems such as mental delay or seizure disorders due to deeper involvement of the brain.
For most kids, is this just a cosmetic problem or can there be underlying health issues?
BERNSTEIN: The natural course of a capillary vascular malformation, or port-wine stain, is a flat pink or reddish patch at birth, which will stay flat for several decades. However, 60 to 70 percent of people with port-wine stains will develop hypertrophy, or thickening of the skin, made to vascular blebs as they get older which can cause bleeding with minor trauma.
So, this is something that really needs to be treated?
BERNSTEIN: This is a medical condition. This is the abnormal collection of vessels in the skin that continue to grow and dilate the vessels as they get older. The thickening of the skin can also include thickening of the muscles. You can have a thickening of the lip, eye structure, and bone structure of the face. You can also have a lot of asymmetry. The major concerns we have for children besides the obvious cosmetic and medical concerns of hypertrophy and thickening of the skin is a psychosocial aspect of having a port-wine stain. Kids are teased and are subject to bullying from having abnormalities, or differences, with their friends. This is important to treat these things early to try and eliminate the problem.
Where are these malformations usually seen on the body?
BERNSTEIN: Port-wine stains can occur anywhere on the body. Most port-wine stains we see on the face. In our recent study, 70 percent or more of the patients had port-wine stains involving the face. The differences in areas will affect the effectiveness of therapy. So, areas on the face, including the forehead and jawline will do better in terms of therapy versus central face distal extremities which have poor results.
What is the standard treatment and how early should people start getting treatment?
BERNSTEIN: The history of port-wine stains and treatment goes back to the mid-80’s. The stages of treatment were using argon lasers, or lasers that are beams of light which go through the skin and target the blood vessels. The actual target is hemoglobin, which carries oxygen in the blood cells. We target those cells. It transfers heat to the blood vessels and destroys the vessels from within. These lasers caused lots of scarring. The advent of the pulsed dye laser in the late mid-80’s allowed us to selectively destroy the vessels without injuring the surface of the skin. Today, we use the V-Beam perfecter laser, which is one of the lasers we’ve been using for the last 10 years or so that has allowed us to selectively target the vessels using different spot sizes, therefore, increasing the spot size of the vessels.
How does the V-Beam work?
BERNSTEIN: The V-Beam perfecter is a laser that targets the hemoglobin within the blood vessel. The laser goes through the skin and heats up the blood. That heat expands and destroys the lining of the vessel, hopefully destroying the vessel wall. The selectivity of the laser prevents us from injuring the surface of the skin so we can safely treat children of all skin color.
How precise and careful do you have to be with the laser to not cause damage?
BERNSTEIN: The nice thing about the pulsed dye laser in treating port-wine stains is there’s such a high density of vessels in these areas that you’re not injuring normal skin. So, when we treat port-wine stains, we do extend a little beyond the border of the port-wine but do not injure the skin in the process. The density is so great that the energy is concentrated in those areas involved.
You mentioned there is an updated version of the device, I’m assuming, for an improved look, or ease of use, or even a better outcome for patients. Can you explain?
BERNSTEIN: The V-Beam Prima is the updated version of the V-Beam perfecter. It allows us to have higher energies and larger spot sizes. One of the new and interesting things that have occurred over the last 20 years with the V-Beam laser is the larger spot size and ability to change the duration of the beam on the skin. So, we can target different sized vessels. In the early 80s through late 80s, the lasers were fixed with one pulsation. So, we were targeting basically one-sized vessel and the results were not nearly as good. As the V-Beam perfecter was developed, we were able to increase the pulse width, the duration of the beam on the skin and three different sized vessels. And, with spot size comes greater depth of penetration.
What does that mean in terms of treating the patient?
BERNSTEIN: In terms of the earlier use of the pulsed dye lasers back in the 80s and 90s, they were using a 5-millimeter spot size, which is a very small spot size. As we’re able to expand the spot size now to 15 millimeters, which is essentially 20 times larger a spot size, we’re able to cover a much larger ground, faster. Treating a 5-millimeter area of half of a face would take us probably close to 10 minutes. Treating a 15-millimeter spot with the V-Beam Prima would take us less than a minute.
Talk to me about why that speed is important, especially when you’re treating these tiny patients.
BERNSTEIN: Treating infants and toddlers with laser is very safe and effective. We don’t have problems or complications in terms of scarring, infections, or breaking of the skin surface. What’s great about this is the large response size allows us to treat larger areas faster. The treatment of an infant is safe, but it does have a feel of a rubber band snapping on the surface of the skin. So, if we can treat a child in less than 30 seconds, there’s a little bit of discomfort that’s tolerable. Most children will be a little upset during the treatment, but they recover very quickly. In the old days when we treated for 30 minutes, it was more of a traumatic experience for children.
Walk me through exactly what you’ll do when you treat a patient.
BERNSTEIN: If a child is in the room with their parent, we will protect the eyes, which is the most important thing with lasers. The parents and the doctors will all wear special goggles to protect their eyes. The infant’s eyes are covered, protected with a nurse dedicated for that purpose. The child is laid on the table. The treatment encompasses just a pulsation on the surface of skin generally between 15 to 60 seconds. The skin color will become bruised initially after treatment, which lasts about seven to 10 days after each session. This is a result of injury to the blood vessel. Then, the treatment is over. If the child has a port-wine stain involving the area around the eye, we need to be extra careful with the eye. We’ll insert a special metal ocular shield under the eyelid which takes roughly five seconds and is totally painless. It allows us to safely treat around the eye without injury to the eye.
What is the laser doing to the blood vessel? Can you explain in layman’s terms what is lightening the appearance of the skin?
BERNSTEIN: The port-wine stain is a very high density of small blood vessels. The laser is essentially injuring or heating up those vessels, destroying and eliminating them. That eliminates the redness. The redness is strictly due to increased blood flow through the skin.
What are the benefits of having this new device? Faster treatment times?
BERNSTEIN: The most important thing about treating early in infant and early toddler is that the treatments are quick, fast, and efficient in terms of treatment. We can hopefully eliminate the port-wine stain significantly before they reach the age of recognition of the birthmark, before they reach school age, or before they have to deal with the psychosocial aspects of having a port-wine stain.
Is there anything that you would want to make sure people know?
BERNSTEIN: The most important thing is that the early treatment of port-wine stains has been debated with pediatricians, pediatric dermatologists, dermatologists and now anesthesiologists. The biggest concern they have is that treating early is harmful to the child in terms of causing pain, discomfort and perhaps long-term association with negativity with physicians. The consensus among pediatricians and pediatric dermatologists is to treat late, to treat when the children are older. There are issues of treating under general anesthesia. Over the last several years, it has been reported that treatment under general anesthesia for children under age 3 can cause potentially long-term neurological problems. We disagree with some of these studies but understand that the concept is out there, and we must discuss this with patients and parents. So, a lot of doctors will wait until age three or four to treat. When we treat at less than one year of age, the skin is relatively thin. The spot size of the area of involvement is relatively small as the child is small. Treatments are faster than treating a 3-year-old. When treating children aged 2, 3 or 4, it becomes harder to do a treatment in an office setting, which case we need to bring them to a hospital and sedate them where there is more risk in abusing anesthesia. So, treatment early we found is much more effective because we can treat a small area with a faster treatment session.
You mentioned some of the concerns would be this deep-rooted or long-lasting fear of doctors and nurses and medical settings. Is there any literature that supports this?
BERNSTEIN: There’s lots of information about pain perception in children in other areas, perhaps in the vaccinations and needle phobias. In terms of our own patients that we’ve treated over the past quarter century, some of these patients we’ve seen as they grew up from infancy to young adolescence. There is no fear. They come to the office. They greet us with a smile. They lie down on the bed, and they have their treatments. There’s no fear. And the pain is minimal. It feels like a grand stamp on the surface of skin. Ten minutes after they leave the office, they’ve forgotten about the procedure.
How long has the new device been out?
BERNSTEIN: The Prima is a very new device. It’s been out for less than a year. It’s a new device that will offer tremendous change for the future of port-wine stains.
END OF INTERVIEW
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