Pediatric Dermatology Vol. 32 No. 5 e217–e218, 2015
Long-Pulsed Neodymium-Doped Yttrium Aluminum Garnet Laser for Glomuvenous Malformations in Adolescents Abstract: Currently there exist few reported cases where lasers are used successfully to treat glomuvenous malformations in adolescents. In the two cases described here, we provide evidence that the longpulsed neodymium-doped yttrium aluminum garnet laser is an effective and safe alternative treatment for these lesions. Our case series is unique because it focuses on adolescents, the population that most often seeks treatment for this dermatologic condition.
There are few reported cases in which lasers have been used successfully to treat glomuvenous malformations (GVMs) in adolescents. In two cases described herein, we provide evidence that the long-pulsed neodymiumdoped yttrium aluminum garnet (Nd:YAG) laser is an effective and safe alternative treatment for these lesions. Our case series is unique because it focuses on adolescents, the population that most often seeks treatment for this dermatologic condition. GVMs can be painful and cosmetically unappealing. Therapeutic options include surgery, sclerotherapy, and laser modalities. We describe two cases treated using a long-pulsed Nd:YAG laser for effective treatment of GVMs in two adolescent girls, defined as a reduction in pain and plaque size and improved cosmesis. These patients were ideal candidates because they had extensive but superficial involvement of their malformations. The use of Nd:YAG laser results in good aesthetic and functional outcomes and little to no downtime and is well tolerated in this population. Patient 1 is a 16-year-old Caucasian girl (Fitzpatrick skin type II) who presented with painful, pebbly, blue nodules and plaques distributed on her flank, back, thigh, and tympanic membrane (Fig. 1). Sitting exacerbated the pain. Her father and several paternal relatives were affected. A biopsy specimen revealed collections of glomus cells with dilated vasculature. Magnetic resonance imaging (MRI) demonstrated
DOI: 10.1111/pde.12631
© 2015 Wiley Periodicals, Inc.
lesions radiologically consistent with GVM in the skin and adipose tissue. Long-pulsed Nd:YAG laser was administered to the thigh lesions using perilesional lidocaine in two sessions. Settings were a 12-mm spot size, 30-ms pulse duration, and 50–60 J/cm2, with cryogen cooling spray. Palpable papulonodules, pain, and tenderness completely resolved (Fig. 2). The patient was pleased and declined further treatment. Patient 2 is a 12-year-old Hispanic girl (Fitzpatrick skin type IV) who presented with congenital pebbly purple plaques in a segmental distribution on the right thigh to foot. The lesions were asymptomatic but were increasing in size and number. A biopsy specimen was consistent with GVMs. MRI demonstrated lesions radiologically consistent with GVMs in the skin and subcutaneous fat. She underwent seven sequential treatments at 1- to 2-month intervals with perilesional lidocaine. Test spot treatment was first performed in three small areas, given her darker skin type, at settings of a 12-mm spot size, 30-ms pulse duration, and 50–56 J/cm2, with cryogen cooling spray. Double pulsing was administered in one area. At follow-up, the lesions treated with higher fluency had ulcerated slightly and the area that had been double pulsed had scarred. The patient was apprehensive about the laser at first, so we did the treatment in stages and in different anatomic locations. The settings were similar to those above, with a fluency of 50–54 J/cm2, titrating to immediate shrinkage of the lesion, resulting in flattening of the palpable papulonodules and plaques. GVMs can be sporadic or familial and occur because of loss-of-function mutations in the GLMN gene (1–3). Treatment options include sclerotherapy and surgery; various laser modalities have also been described (4). Sclerotherapy may require multiple treatments, often necessitating anesthesia, and produces postoperative inflammation and discomfort. Surgery results in scarring, and postoperative downtime may be significant. Options may be further limited in children; ideally, scarring and the need for repetitive painful treatments would be minimized. Nd:YAG laser can be extremely effective in the treatment of venous malformations. Reports on laser modalities for GVMs exist (4,5) but are rare in children and teens. We describe long-pulsed Nd: YAG laser as monotherapy for GVMs in children and adolescents. Risks include pain and discomfort during and after the treatment, temporary edema, bleeding, infection (if ulceration occurs), and most significantly, potential scarring. The clinical endpoint during the procedure is visible tissue retraction and a subtle lightening and flattening response. Double
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(5–7 mm) with higher energies for smaller lesions; we did not have this handpiece available. Also, it may be beneficial to elongate the pulse duration for darker skin types, although we had no adverse dyspigmentation with the settings listed above. Treatment of GVMs using long-pulsed Nd:YAG laser is a reasonable option in young patients because it is effective and is less invasive and potentially safer than traditional modalities. REFERENCES Figure 1. Glomuvenous treatment.
malformations
before
laser
Figure 2. Glomuvenous treatment.
malformations
after
laser
pulsing and pallor should generally be avoided because these may lead to scarring. Test spots can be helpful in guiding appropriate treatment settings, especially when large lesions or darker skin types are involved. Some experts use smaller spot sizes
1. Henning JS, Kovich OI, Schaffer JV. Glomuvenous malformations. Dermatol Online J 2007;13:17. 2. Brauer JA, Anolik R, Tzu J et al. Glomuvenous malformations (familial generalized multiple glomangiomas). Dermatol Online J 2011;17:9. 3. Boon LM, Mulliken JB, Enjolras O et al. Glomuvenous malformation (glomangioma) and venous malformation: distinct clinicopathologic and genetic entities. Arch Dermatol 2004;140:971–976. 4. Nguyen TV, Becker EM, Miller WA et al. Plaque-type glomuvenous malformations successfully treated using combined pulsed dye laser and neodymium-doped yttrium aluminum garnet laser. Dermatol Surg 2014;40:89–92. 5. Redondo P, Aguado L, Martinez-Cuesta A. Diagnosis and management of extensive vascular malformations of the lower limb: Part II. systemic repercussions [corrected], diagnosis, and treatment. J Am Acad Dermatol 2011;65:909–923; quiz 924. Jaren Trost, M.D.* z Colin Buckley, MD.* Aimee C. Smidt, MD.*,† Departments of *Dermatology and †Pediatrics, School of Medicine, University of New Mexico, Albuquerque, New Mexico Address correspondence to Jaren Trost, M.D., Department of Dermatology, University of New Mexico School of Medicine, Albuquerque, NM 87131, or e-mail: [email protected]. Colin Buckley passed away since the writing of this article.
Long-Pulsed Neodymium-Doped Yttrium Aluminum Garnet Laser for Glomuvenous Malformations in Adolescents Abstract: Currently there exist few reported cases where lasers are used successfully to treat glomuvenous malformations in adolescents. In the two cases described here, we provide evidence that the longpulsed neodymium-doped yttrium aluminum garnet laser is an effective and safe alternative treatment for these lesions. Our case series is unique because it focuses on adolescents, the population that most often seeks treatment for this dermatologic condition.
There are few reported cases in which lasers have been used successfully to treat glomuvenous malformations (GVMs) in adolescents. In two cases described herein, we provide evidence that the long-pulsed neodymiumdoped yttrium aluminum garnet (Nd:YAG) laser is an effective and safe alternative treatment for these lesions. Our case series is unique because it focuses on adolescents, the population that most often seeks treatment for this dermatologic condition. GVMs can be painful and cosmetically unappealing. Therapeutic options include surgery, sclerotherapy, and laser modalities. We describe two cases treated using a long-pulsed Nd:YAG laser for effective treatment of GVMs in two adolescent girls, defined as a reduction in pain and plaque size and improved cosmesis. These patients were ideal candidates because they had extensive but superficial involvement of their malformations. The use of Nd:YAG laser results in good aesthetic and functional outcomes and little to no downtime and is well tolerated in this population. Patient 1 is a 16-year-old Caucasian girl (Fitzpatrick skin type II) who presented with painful, pebbly, blue nodules and plaques distributed on her flank, back, thigh, and tympanic membrane (Fig. 1). Sitting exacerbated the pain. Her father and several paternal relatives were affected. A biopsy specimen revealed collections of glomus cells with dilated vasculature. Magnetic resonance imaging (MRI) demonstrated
DOI: 10.1111/pde.12631
© 2015 Wiley Periodicals, Inc.
lesions radiologically consistent with GVM in the skin and adipose tissue. Long-pulsed Nd:YAG laser was administered to the thigh lesions using perilesional lidocaine in two sessions. Settings were a 12-mm spot size, 30-ms pulse duration, and 50–60 J/cm2, with cryogen cooling spray. Palpable papulonodules, pain, and tenderness completely resolved (Fig. 2). The patient was pleased and declined further treatment. Patient 2 is a 12-year-old Hispanic girl (Fitzpatrick skin type IV) who presented with congenital pebbly purple plaques in a segmental distribution on the right thigh to foot. The lesions were asymptomatic but were increasing in size and number. A biopsy specimen was consistent with GVMs. MRI demonstrated lesions radiologically consistent with GVMs in the skin and subcutaneous fat. She underwent seven sequential treatments at 1- to 2-month intervals with perilesional lidocaine. Test spot treatment was first performed in three small areas, given her darker skin type, at settings of a 12-mm spot size, 30-ms pulse duration, and 50–56 J/cm2, with cryogen cooling spray. Double pulsing was administered in one area. At follow-up, the lesions treated with higher fluency had ulcerated slightly and the area that had been double pulsed had scarred. The patient was apprehensive about the laser at first, so we did the treatment in stages and in different anatomic locations. The settings were similar to those above, with a fluency of 50–54 J/cm2, titrating to immediate shrinkage of the lesion, resulting in flattening of the palpable papulonodules and plaques. GVMs can be sporadic or familial and occur because of loss-of-function mutations in the GLMN gene (1–3). Treatment options include sclerotherapy and surgery; various laser modalities have also been described (4). Sclerotherapy may require multiple treatments, often necessitating anesthesia, and produces postoperative inflammation and discomfort. Surgery results in scarring, and postoperative downtime may be significant. Options may be further limited in children; ideally, scarring and the need for repetitive painful treatments would be minimized. Nd:YAG laser can be extremely effective in the treatment of venous malformations. Reports on laser modalities for GVMs exist (4,5) but are rare in children and teens. We describe long-pulsed Nd: YAG laser as monotherapy for GVMs in children and adolescents. Risks include pain and discomfort during and after the treatment, temporary edema, bleeding, infection (if ulceration occurs), and most significantly, potential scarring. The clinical endpoint during the procedure is visible tissue retraction and a subtle lightening and flattening response. Double
e217
e218 Pediatric Dermatology Vol. 32 No. 5 September/October 2015
(5–7 mm) with higher energies for smaller lesions; we did not have this handpiece available. Also, it may be beneficial to elongate the pulse duration for darker skin types, although we had no adverse dyspigmentation with the settings listed above. Treatment of GVMs using long-pulsed Nd:YAG laser is a reasonable option in young patients because it is effective and is less invasive and potentially safer than traditional modalities. REFERENCES Figure 1. Glomuvenous treatment.
malformations
before
laser
Figure 2. Glomuvenous treatment.
malformations
after
laser
pulsing and pallor should generally be avoided because these may lead to scarring. Test spots can be helpful in guiding appropriate treatment settings, especially when large lesions or darker skin types are involved. Some experts use smaller spot sizes
1. Henning JS, Kovich OI, Schaffer JV. Glomuvenous malformations. Dermatol Online J 2007;13:17. 2. Brauer JA, Anolik R, Tzu J et al. Glomuvenous malformations (familial generalized multiple glomangiomas). Dermatol Online J 2011;17:9. 3. Boon LM, Mulliken JB, Enjolras O et al. Glomuvenous malformation (glomangioma) and venous malformation: distinct clinicopathologic and genetic entities. Arch Dermatol 2004;140:971–976. 4. Nguyen TV, Becker EM, Miller WA et al. Plaque-type glomuvenous malformations successfully treated using combined pulsed dye laser and neodymium-doped yttrium aluminum garnet laser. Dermatol Surg 2014;40:89–92. 5. Redondo P, Aguado L, Martinez-Cuesta A. Diagnosis and management of extensive vascular malformations of the lower limb: Part II. systemic repercussions [corrected], diagnosis, and treatment. J Am Acad Dermatol 2011;65:909–923; quiz 924. Jaren Trost, M.D.* z Colin Buckley, MD.* Aimee C. Smidt, MD.*,† Departments of *Dermatology and †Pediatrics, School of Medicine, University of New Mexico, Albuquerque, New Mexico Address correspondence to Jaren Trost, M.D., Department of Dermatology, University of New Mexico School of Medicine, Albuquerque, NM 87131, or e-mail: [email protected]. Colin Buckley passed away since the writing of this article.
