Keloid scar as a complication of triple therapy laser treatment of a recalcitrant facial port wine stain

Abstract

Laser therapy is an established treatment to improve the cosmetic appearance of port wine stains (PWSs) by lightening and improving their colour. For recalcitrant facial PWSs, use of either pulsed dye laser (PDL) or Perfecta (VBeam ; Candela Laser Corporation, Wayland, MA, USA) may not suffice to adequately improve their appearance. Combination laser therapy, also referred to as triple therapy, can be offered, which involves using the Cynergy Multiplex laser (Cynosure UK, Cookham, Berkshire, UK), which is a combination of neodymium:yttrium–aluminium–garnet (Nd: YAG) + PDL, then following this by a superimposed second pass with the Perfecta laser. A 9-year-old girl presented with a red, flat, irregular lesion, which had been present on her right upper lip since birth (Fig. 1a). Soon after, she underwent two initial laser sessions with Perfecta laser, during which SIAscopy showed response to pulses of 8 J/cm; therefore, shots of 6.5 J/cm were superimposed as a second pass, using a 12-mm probe, but the PWS remained unresponsive after two of these sessions a few months apart. After discussion with the family, the patient was offered triple laser therapy to improve the colour of the birthmark. At the age of 10 years, the patient underwent her first triple therapy laser treatment, consisting of a first pass using Cynergy Multiplex, followed by a second superimposed pass with Perfecta laser. This resulted in an improved cosmetic outcome with clear lightening around the edges of the birthmark (Fig. 1b). Immediately following the second triple therapy session, a small grey macule was noted in the centre of the treatment area (Fig. 1c). However, this area was no longer noticeable when the ward round was conducted 2 h later; therefore, the patient was discharged with routine aftercare advice, including contacting the team immediately if any changes were noticed. Two weeks later, the parents contacted the team stating that a ‘cyst’ had developed in the treated area. Upon clinical examination, there was a marked improvement in the appearance of her recalcitrant PWS; however, a keloid scar was present at the previously noticed site of greying (Fig. 2a). The patient is currently undergoing treatment for keloid scarring using steroid injections with the plastic surgery department, which has improved the cosmetic outcome (Fig. 2b). The details of all the patient’s laser treatments and parameters are reported in Table 1. This case describes a previously unreported laser side effect, keloid scarring, which occurred after a triple therapy laser procedure. The pathophysiology behind keloids remains poorly understood; however, it is known that they are commoner in darker skin types and in areas of skin free from hair growth. Our patient had Fitzpatrick skin type IV, due to her father and mother having skin types V and II, respectively. We are aware that this may have been a contributing factor towards the development of this laser complication. The clinical significance of this and its correlation with the laser parameters used is yet to be established. The skin type is important in laser therapy, as melanin in the basal layer of the epidermis can intensify thermal injury from laser and lead to an increased incidence of side effects such as scarring, atrophy and pigmentary changes. Currently, there is a general consensus that long-pulsed lasers such as Nd:YAG are safe to reduce complications in darker skin types as they reduce the absorption of laser from melanin Correspondence: Dr Samira Batul Syed, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK E-mail: [email protected]