[Downloaded free from http://www.ijpd.in on Tuesday, November 21, 2017, IP: 180.246.76.

43]

REVIEW ARTICLE

Laser treatment of infantile hemangiomas

Michelle Si Ying Ng, YongKwang Tay
Department of Dermatology, Changi General Hospital, Singapore

ABSTRACT

Infantile hemangiomas(IHs) are the most common benign soft tissue tumor of infancy and childhood. Many patients seek
early treatment to halt progression of tumor growth and accelerate regression to achieve quick resolution with good cosmetic
outcomes. We reviewed literature through PubMed search on the treatment strategies for IH and share our experience in the
field of laser treatment of IH. Treatment strategies for IH include both pharmacological, laser, and surgical interventions
depending on the stage and severity of the lesion. Various laser beams have been attemptedwith varying effects and
effectiveness. The 595nm pulsed dye laser therapy has been most widely utilized owing to its great efficacy but minimal
adverse effects. It works by targeting oxyhemoglobin chromophore in blood vessels located within the dermis, causing
photothermal damage of these target vessels stimulating quick involution without damaging surrounding healthy skin. It
is especially useful in treating ulcerated superficial facial hemangiomas that necessitate rapid healing to avoid unsightly
scarring. It has a good safety profile but small risk of epidermal burn, blistering, postinflammatory pigment changes, and
scarring remains in those with darker skin types treated with higher fluences and shortpulsed duration. Combination
treatment with 1064nm neodymiumdoped yttrium aluminum garnet laser, oral propranolol, and even corticosteroids remains
an option, especially in treatment of deep, large, and functionally threatening IH. Careful consideration in consultation with
the childs parents given the complexities and potential complications surrounding treatment should always be considered.
Laser treatment remains an appropriate treatment for rapidly growing IH in exposed locations at early presentation.

Key words: Infantile hemangioma, laser, neodymiumdoped yttrium aluminum garnet, pulsed dye laser, treatment

INTRODUCTION as ulceration, infection, vision obstruction, feeding,

and breathing difficulties as well as facial lesions.

I nfantile hemangiomas(IHs) are the most common

benign soft tissue tumor seen in infancy and
childhood; ulceration is the most frequent complication
Treatment options include topical timolol, oral
propranolol, corticosteroids, and laser therapy.

during the rapid growth phase when the hemangioma
outgrows its blood supply.[1] Many patients seek
treatment early to inhibit growth, to accelerate
regression, and to achieve the best possible cosmesis.
Given that most hemangiomas regress without sequelae,
the management of IH remains controversial. Some
authorities advocate early intervention to ameliorate
the impact of larger and more severe hemangiomas,
while others favor a more conservative approach as
intervention occasionally worsens outcome. However,
treatment is necessary for complicated lesions such
The goal of laser therapy is to maximize vascular
destruction while minimizing injury to the
surrounding healthy epidermis and dermal tissues.
Several types of lasers including pulsed dye laser
(PDL), neodymiumdoped yttrium aluminum garnet
(Nd:YAG) laser, carbon dioxide laser, argon laser, and
fractional photothermolysis have been attempted
with varying effects.[24] Of these lasers, PDL is most
ADDRESS FOR CORRESPONDENCE:
Dr.Michelle Si Ying Ng,
Blk 43 Sims Drive, #04209, S380043, Singapore.
Email:michellengsiying@gmail.com

Access this article online This is an open access article distributed under the terms of the Creative
Commons AttributionNonCommercialShareAlike 3.0 License, which allows
Quick Response Code others to remix, tweak, and build upon the work noncommercially, as long as the
Website:
author is credited and the new creations are licensed under the identical terms.
www.ijpd.in
For reprints contact: reprints@medknow.com

DOI:
How to cite this article: Ng MS, Tay YK. Laser treatment of infantile
10.4103/ijpd.IJPD_108_16
hemangiomas. Indian J Paediatr Dermatol 2017;18:160-5.

160 2017 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.ijpd.in on Tuesday, November 21, 2017, IP: 180.246.76.43]
Ng and Tay: The use of laser in the treatment of infantile hemangiomas in Asian children
widely utilized owing to its high efficacy and good
safety profile.[5,6]
This review article seeks to review the literature
regarding the use of PDL in the treatment of IH. Our
experiences in utilizing laser therapy in the treatment
of IH will also be discussed.
DATA SOURCES AND SELECTION
We searched MEDLINE database through PubMed
from 2005 to December 2015 using a combination
of controlled vocabulary and key terms related to
treatment for IH (e.g.,IH, laser, PDL, Nd:YAG,
timolol, propranolol, corticosteroid). We also
handsearched the reference lists of included articles
and recent reviews of interventions for IH to identify
potentially relevant articles.
DATA EXTRACTION AND SYNTHESIS
We initially extracted relevant articles in English
with appropriate and comparable study population,
characteristic, intervention characteristics, and
baseline and outcome data of interests from eligible
studies. This is followed by a thorough review of the
extracted data for accuracy and completeness.
HOW DO LASERS WORK?
The major chromophores in the skin include
oxyhemoglobin, melanin, and water, each with a
different absorption spectrum. In vascular lesions
such as hemangiomas, the major chromophore is the
oxyhemoglobin found in blood vessels.
Figure1: The absorption spectrum of the major chromophores in the skin
as a function of wavelength
Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
Intravascular oxyhemoglobin has an absorption
coefficient curve with peaks at 418, 524, 577, and
1064nm[Figure1]. At the first and second peaks,
the melanin absorption is equally high, and therefore,
these wavelengths should not be used. The spectrum
between 580 and 590nm is most useful clinically.
Thus, PDL with a wavelength of 595nm is at present
considered to be the gold standard laser used for the
treatment of vascular lesions.[6]
Flashlamppumped PDL has a wavelength of 585
or 595nm, allowing the selective destruction of the
blood vessels while keeping the overlying skin intact.
Laser devices emit wavelengths near the target
peaks to induce photomechanical and photothermal
damage of the target tissue. PDL works through the
same principle. The basic principle is the preferential
absorption of laser light by hemoglobin and its
subsequent conversion into thermal energy leading to
coagulation of blood vessels. When the 595nm PDL
is absorbed by its target chromophore, oxyhemoglobin,
the heat that is generated coagulates the target vessels
while keeping the overlying skin intact.[7] With
successive treatments, the blood vessels progressively
shrink, gradually decreasing in size till they eventually
diminish.
Multiple clinical studies have demonstrated success
rates as high as 93% with the use of PDL for treatment
of proliferating hemangiomas, with few associated
complications.[8]
OUR LASER EXPERIENCE
Choice of Laser
Laser therapy is recognized as the gold standard
treatment in the treatment of ulcerated IH owing
to its high success rates.[9,10] In our practice, PDL is
used as firstline therapy in the treatment of ulcerated
or superficial facial hemangiomas. It is also used as
an adjunct when firstline topical timolol or oral
propranolol treatment does not achieve satisfactory
results. We use 595nm PDL as the laser of choice as it
is effective in treating superficial hemangiomas, with
high success rates and good cosmetic outcomes. PDL
stimulates vessel involution and accelerates healing of
ulcerated hemangiomas to good effect. Pain control
can be achieved in 23days and rapid healing of
ulcerations(as much as 75%) occurs in the short span
of 2weeks.[5] PDL has also been shown to stimulate
the production of dermal collagen and elastic fibers
in the superficial dermis, preventing the atrophy of
lasertreated skin.[11,12]
161
[Downloaded free from http://www.ijpd.in on Tuesday, November 21, 2017, IP: 180.246.76.43]

Ng and Tay: The use of laser in the treatment of infantile hemangiomas in Asian children

a b c
Figure2: Treatment response achieved with treatment using pulsed dye laser(a), timolol topical solution(b), and oral propranolol(c). (a) Before and after
treatment of a left preauricular mixed infantile hemangioma with pulsed dye laser at settings: 595nm pulsed dye laser: 7mm, 1012J/cm, 1.5 ms, 50/30,
with a total of seven treatment sessions. The bulk of the superficial tumor has resolved leaving minimal deeper subcutaneous component. (b) Before and
after treatment of a left dorsum of foot superficial infantile hemangioma with timolol maleate 0.5% eye drops solution. The bulk of the tumor has resolved
but some hemangioma can still be seen at the toes. The treatment duration was 6months. (c) Before and after treatment of a right wrist superficial infantile
hemangioma with oral propranolol. The bulk of the tumor has resolved leaving minimal vascularity seen at the edges. The treatment duration was 5months

Although therapeutic efficacy has been demonstrated
with the use of PDL therapy in ulcerated hemangiomas,
we emphasize that PDL therapy should be targeted at
the entire hemangioma and not merely the ulcerated
area. This is to reduce the likelihood of recurrence in
the surrounding residual vessels.[13] PDL treatment
of residual vessel telangiectasia after hemangioma
involution has also been shown to result in excellent
treatment outcomes. This goes a long way toward
improving cosmetic outcomes for patients.
From our experiences [Figure 2], using the 595nm PDL
at moderately high fluences of 10.514.5J/cm2 with a
short pulse duration of 1.53 ms is as equally effective as
compared to a longer pulse duration of 10 ms.[14] We use
a spot size of 7mm with dynamic cooling device(DCD)
spray duration of 50 ms with a delay of 30 ms for short
pulse settings, and DCD spray duration of 40 ms with
a delay of 20 ms for the longer pulse settings. Ahigher
cooling setting was used with the shorter pulse durations
to provide more epidermal protection at higher fluences.
This is particularly pertinent for our Asian patients who
have darker skin, allowing us to mitigate complications
such as blisters, ulceration, and scarring.
How long we maintain our patients on laser therapy
is highly dependent on the growth stage of the
hemangiomas. The treatment is repeated every fortnight
for actively proliferating lesions and every 12months
for stable lesions. An average of eight laser sessions(range
314) is required to achieve optimal cutaneous healing
and hemangioma involution with the shorter pulse
settings, with a mean of nine sessions(range 414) when
the longer pulse settings are used. Treatment duration
also differs depending on hemangioma depth. Owing
to its more deeply seated location, mixed hemangiomas
require more treatment sessions(45 on average) for
involution compared to its more superficial counterparts.
Limitations
The use of PDL, however, is limited to superficial
IH due to its maximum depth of only 1.2mm
penetration into the skin. More deeply seated
hemangiomas necessitate the use of longer
wavelengths which have greater penetration
depth. Longpulse 1064nm Nd:YAG lasers have
been used to treat deeper hemangiomas with good
outcomes.[15] Notably, adverse effects such as
ulceration, infection, bleeding, and scarring are not
entirely uncommon if these lasers are delivered too
intensely and extensively. [16,17]
Therefore, in the treatment of mixed and deeper
hemangiomas, combined use of 595nm PDL and
1064nm Nd:YAG lasers yield better results compared
to single laser treatments.[18] It allows for laser
intensity to be modulated, with the higher intensity
Nd:YAG used for targeting deeper lesions, and PDL
for the more superficial ones. Acombined sequential
dual wavelength laser has been tried successfully for
the treatment of IH with good effect.[19]
Our efforts to treat mixed hemangiomas with PDL
alone showed poorer treatment results although
combination therapy with other treatment modalities
has been shown to improve outcomes. The combination
of PDL with oral propranolol has shown to result in a
synergistic therapeutic effect, resulting in a more rapid
and enhanced clearance of lesions.[20,21]
Side Effect Profile
The more common side effects experienced with PDL
include erythema, edema, and purpura. These lasted
for about 1week in the shortpulsed duration group
but many shorter (only 23) days in the longpulsed
duration group. We did not observe any blistering,
ulceration, or hypertrophic scarring with any of our
lasertreated patients.
In patients with darker skin phototypes, i.e.,Fitzpatrick
typeIV and above, a slightly higher incidence of
side effects was seen when shorter pulse durations
were used. Thus, appropriate counseling and greater
caution would need to be exercised, especially when

162 Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017

[Downloaded free from http://www.ijpd.in on Tuesday, November 21, 2017, IP: 180.246.76.43]
Ng and Tay: The use of laser in the treatment of infantile hemangiomas in Asian children
shorter pulse durations need to be employed in this
specific subgroup of darker skin patients.
TREATMENT ALTERNATIVES
Specific disease characteristics such as lesion size,
location, type, rate of growth as well as age, functional
impact, and IH subtype influence the ultimate
treatment choice.
In cases of rapidly proliferating deep or mixed IH,
or hemangiomas that compromise critical bodily
functions (vision/airway), treatment adjuncts on top
of laser therapy should always be considered. These
include topical application of timolol, systemic medical
therapy such as oral propranolol, corticosteroids,
surgical excision or debulking procedures, intraarterial
embolization, or intralesional corticosteroid injections.
Topical preparations such as timolol maleate(TM), a
nonselective adrenergic antagonist, are now widely
accepted as an effective therapy for uncomplicated
superficial and mixed IH due to its excellent efficacy
and good safety profile.[22,23]
Betaadrenergic antagonists, such as oral propranolol,
have been one of the most commonly employed
treatment modalities for IHs.[24] It is often used
as firstline treatment for large, segmental, and
complicated hemangiomas. However, it can be
associated with hypoglycemia, cardiac, and respiratory
side effects.[25]
Oral corticosteroids are effective and quick in reducing
the size of IH, but potential side effects include
cataracts, gastritis, growth retardation, and adrenal
suppression can occur.[26] Owing to these serious
systemic side effects and the variable response rates,
it is no longer used as firstline treatment but as an
adjunctive therapy if the use of oral propranolol is
contraindicated.
Intralesional corticosteroid therapy effectively
shrinks the lesion but carries a risk of atrophy and
depigmentation of treated skin, adrenal suppression,
failure to thrive, and arterial occlusion.[26]
Overall, the risks of intralesional therapies and
systemic medical/surgical treatment are higher than
that of laser therapy. Hence, such adjunct therapies
are primarily indicated in complicated hemangiomas
and should not be employed as firstline therapy for
proliferating superficial IH. The clinical characteristics
Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
of each and every IH would thus need to be carefully
evaluated before the institution of any form of
treatment for the best results with minimal adverse
effects.
COMBINATION TREATMENT
Because of the limitations of laser therapy and the
potential permanent complications of unarrested
HI growth, complicated hemangiomas are often
treated with combination therapy for maximum
therapeutic efficacy. This includes a betaadrenergic
antagonist(topical TM/oral propranolol) together
with PDL treatment. Combination treatments may
have potential benefits, including greater efficacy,
synergistic effects, and lower toxicity. However,
owing to a lack of sufficient comparative studies, the
consensus on the safest and most effective modality
of treatment still remains highly controversial and
strongly contested.
Timolol Maleate 0.5% + Pulsed Dye Laser
Asilian et al. conducted a doubleblind study on
thirty infants aged 112months old comparing
the effectiveness of PDL treatment alone versus
a combination therapy of PDL with 0.5% topical
timolol gel treatment. The author reported a
statistically significant reduction in the mean size of
the hemangiomas as well as an improvement in the
visual analog scores of the hemangiomas. The adverse
effects reported were the same in both groups and were
mostly changes in texture and/or pigmentation.[27]
In another study, Park etal. performed a retrospective
3year review of 140 IH patients treated with topical
TM 0.5% solution alone compared with combination
therapy of both TM and PDL. The author reported
significantly improved outcomes(P=0.018) in
the group with combination therapy compared to
topical treatment alone. From their data, it is also
suggested that the combination treatment response
was increased considerably in the first 13months of
life. This also suggests the necessity of early treatment
of IH for better treatment outcomes.[28]
Propranolol+Pulsed Dye Laser
Reddy etal. conducted a retrospective review of a group
of IH infants comparing the treatment responses of oral
propranolol alone(n=8) with combination therapy
of both oral propranolol and PDL(n=17, of whom
12 were treated with the two therapies concurrently
and 5 were treated with propranolol treatment
followed by PDL). IH treated with combination
163
[Downloaded free from http://www.ijpd.in on Tuesday, November 21, 2017, IP: 180.246.76.43]
Ng and Tay: The use of laser in the treatment of infantile hemangiomas in Asian children
therapy of oral propranolol and PDL showed a
greater clearance than those treated with propranolol
alone. 100% of IH treated with combination therapy
achieved complete or nearcomplete clearance
compared to 38% in the oral propranolol arm. This
clearly reflects the more favorable response of IH
toward combination compared to monotherapy.
Sequence of treatment in combination therapy is also
of utmost importance. Patients treated concurrently
with both oral propranolol and PDL responded more
completely and quickly compared to those treated
sequentially, first with oral propranolol followed by
PDL. Nonetheless, sequential treatment still proved
to be more efficacious compared to monotherapy with
oral propranolol alone.[20]
CONCLUSION AND
RECOMMENDATIONS
The treatment of IH should be considered carefully
in consultation with the childs parents given the
complexities and potential complications surrounding
treatment.[20] Laser therapy remains to be one of
the most effective modalities of treatment. Early
laser treatment can safely and effectively reduce the
proliferation of superficial hemangiomas, promote
involution, and improve cosmesis. Therefore, laser
therapy may be an appropriate treatment modality
for rapidly growing IH in exposed locations at early
presentation.
595nm PDL is one good modality to consider for
early management of superficial proliferative and
ulcerative hemangiomas. It can also be considered as
an adjunctive therapy to oral propranolol to improve
treatment outcomes while shortening treatment
duration.
Till date, the optimal parameters for the treatment
of IH using PDL are still highly contested. In our
experience, however, we found that operating PDL at
a setting of moderately high fluences with either short
or long pulse durations has shown similar rates of
clearing although the incidence of adverse outcomes
was slightly higher when shorter pulse durations were
used. Kono et al.[29] shared a similar experience with
the same settings and also proved it to be safer and
more effective in the treatment of early childhood
hemangiomas in Asian patients. In situations where
lesions continue to enlarge despite laser therapy,
supplementary pharmacotherapy such as topical
timolol or oral propranolol should be considered.
164 Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
REFERENCES
1. KimHJ, ColomboM, FriedenIJ. Ulcerated hemangiomas:
Clinical characteristics and response to therapy. JAm Acad
Dermatol 2001;44:96272.
2. GladstoneGJ, BeckmanH. Argon laser treatment of an
eyelid margin capillary hemangioma. Ophthalmic Surg
1983;14:9446.
3. Al BuainianH, VerhaegheE, DierckxsensL, NaeyaertJM. Early
treatment of hemangiomas with lasers. Areview. Dermatology
2003;206:3703.
4. LaubachHJ, AndersonRR, LugerT, MansteinD. Fractional
photothermolysis for involuted infantile hemangioma. Arch
Dermatol 2009;145:74850.
5. MorelliJG, TanOT, WestonWL. Treatment of ulcerated
hemangiomas with the pulsed tunable dye laser. Am J Dis Child
1991;145:10624.
6. PatilUA, DhamiLD. Overview of lasers. Indian J Plast Surg
2008;41 Suppl S1:101-13.
7. AndersonRR, ParrishJA. Microvasculature can be selectively
damaged using dye lasers: A basic theory and experimental
evidence in human skin. Lasers Surg Med 1981;1:26376.
8. HohenleutnerS, BadurGanterE, LandthalerM,
HohenleutnerU. Longterm results in the treatment of
childhood hemangioma with the flashlamppumped pulsed
dye laser: An evaluation of 617cases. Lasers Surg Med
2001;28:2737.
9. SmitJM, BaulandCG, WijnbergDS, SpauwenPH. Pulsed dye
laser treatment, a review of indications and outcome based on
published trials. Br J Plast Surg 2005;58:9817.
10. DavidLR, MalekMM, ArgentaLC. Efficacy of pulse dye laser
therapy for the treatment of ulcerated haemangiomas: A review
of 78patients. Br J Plast Surg 2003;56:31727.
11. ZelicksonBD, KilmerSL, BernsteinE, ChotzenVA, DockJ,
MehreganD, etal. Pulsed dye laser therapy for sun damaged
skin. Lasers Surg Med 1999;25:22936.
12. MoodyBR, McCarthyJE, HruzaGJ. Collagen remodeling
after 585nm pulsed dye laser irradiation: An ultrasonographic
analysis. Dermatol Surg 2003;29:9979.
13. LacourM, SyedS, LinwardJ, HarperJI. Role of the pulsed dye
laser in the management of ulcerated capillary haemangiomas.
Arch Dis Child 1996;74:1613.
14. TayYK, TanSK. Treatment of infantile hemangiomas with
the 595nm pulsed dye laser using different pulse widths in an
Asian population. Lasers Surg Med 2012;44:936.
15. LandthalerM, HainaD, BrunnerR, WaidelichW,
BraunFalcoO. NeodymiumYAG laser therapy for vascular
lesions. JAm Acad Dermatol 1986;14:10717.
16. ChangCJ. Long term followup of intralesional laser
photocoagulation(ILP) for hemangioma patients. Laser Ther
2011;20:2557.
17. VlachakisI, GardikisS, MichailoudiE, CharissisG. Treatment
of hemangiomas in children using a Nd:YAG laser in conjunction
with ice cooling of the epidermis: Techniques and results. BMC
[Downloaded free from http://www.ijpd.in on Tuesday, November 21, 2017, IP: 180.246.76.43]

Ng and Tay: The use of laser in the treatment of infantile hemangiomas in Asian children

Pediatr 2003;3:2. of propranolol in treating infantile haemangiomas: A

18. ZhengJW, ZhangL, ZhouQ, MaiHM, WangYA, FanXD, etal.
Apractical guide to treatment of infantile hemangiomas of the
head and neck. Int J Clin Exp Med 2013;6:85160.
19. PoetkeM, PhilippC, BerlienHP. Flashlamppumped pulsed
dye laser for hemangiomas in infancy: Treatment of superficial
vs. mixed hemangiomas. Arch Dermatol 2000;136:62832.
20. ReddyKK, BleiF, BrauerJA, WanerM, AnolikR, BernsteinL,
etal. Retrospective study of the treatment of infantile
hemangiomas using a combination of propranolol and pulsed
dye laser. Dermatol Surg 2013;39:92333.
21. EhsaniAH, NoormohammadpoorP, AbdolrezaM, BalighiK,
ArianianZ, DaklanS. Combination therapy of infantile
hemangioma with pulsed dye laser with topical propranolol: A
randomized clinical trial. Arch Iran Med 2014;17:65760.
22. SemkovaK, KazandjievaJ. Topical timolol maleate for
treatment of infantile haemangiomas: Preliminary results of a
prospective study. Clin Exp Dermatol 2013;38:1436.
23. YuL, LiS, SuB, LiuZ, FangJ, ZhuL, etal. Treatment of
superficial infantile hemangiomas with timolol: Evaluation
of shortterm efficacy and safety in infants. Exp Ther Med
2013;6:38890.
24. LouY, PengWJ, CaoY, CaoDS, XieJ, LiHH. The effectiveness
metaanalysis including 35 studies. Br J Clin Pharmacol
2014;78:4457.
25. PriceCJ, LattoufC, BaumB, McLeodM, SchachnerLA,
DuarteAM, etal. Propranolol vs. corticosteroids for infantile
hemangiomas: A multicenter retrospective analysis. Arch
Dermatol 2011;147:13716.
26. CeislerE, BleiF. Ophthalmic issues in hemangiomas of infancy.
Lymphat Res Biol 2003;1:32130.
27. AsilianA, MokhtariF, KamaliAS, AbtahiNaeiniB,
NilforoushzadehMA, MostafaieS. Pulsed dye laser and topical
timolol gel versus pulse dye laser in treatment of infantile
hemangioma: Adoubleblind randomized controlled trial. Adv
Biomed Res 2015;4:257.
28. ParkKH, JangYH, ChungHY, LeeWJ, KimDW, LeeSJ.
Topical timolol maleate 0.5% for infantile hemangioma;
its effectiveness and/or adjunctive pulsed dye laserSingle
center experience of 102cases in Korea. JDermatolog Treat
2015;26:38991.
29. KonoT, SakuraiH, GroffWF, ChanHH, TakeuchiM, YamakiT,
etal. Comparison study of a traditional pulsed dye laser versus
a longpulsed dye laser in the treatment of early childhood
hemangiomas. Lasers Surg Med 2006;38:1125.

Indian Journal of Paediatric Dermatology | Volume 18 | Issue 3 | July-September 2017 165