As part of my laser list I commonly treat portwine birthmark- portwinestains daily. Red birth marks respond much better to laser compared to brown birth marks. Over 90% of red birthmarks can be markedly reduced with laser treatment. Brown birthmarks such as Cafe Au Lait Macules can be reduced with special pico lasers. Congenital moles respond best to surgery, whilst some birthmarks such as Becker’s naevi do not respond to treatment. A diagnosis of what type of birthmark is essentially, as this gives me an idea of how successful treatment can be, and how many treatments maybe needed.
- Red birth marks such as portwine birthmark and vascular lesions are much easier to treat than brown or pigmented birth marks
- Portwine birthmark or Portwine Stains are one of the most common birth marks and occurs in 2-4 out of 1000 births.
- Red birth marks include stork marks, portwine birthmark and mixed vascular lesions
- Brown birth marks include café au lait macules, moles at birth and Becker’s or late onset naevi
- Most red birth marks such as port wine stains are only present just below the skin, however some stains around the eye area maybe associated with ocular problems
- Laser treatment of RED birthmarks can improve lesions by up to 90%
- Depending on the age, size, thickness and location of the portwine birthmark, 5- 10 treatments maybe needed
- I use the V Beam Vascular lesion in most cases of red birthmarks including portwine birthmark- portwine stains
- Brown birth marks are much harder to treat, and usually a Q Switch laser is needed- results are not as predictable as treating red birth marks
- Some brown birthmarks, such as Becker’s Naevi are resistant to laser treatments
The classification of birthmarks can be complicated, however the prognosis and clearance rates can be determined by colour. Red birthmarks are much easier to treat compared to brown birthmarks.
Red birthmarks include portwine birthmark- port wine stains, stork bite birthmarks, and various marks caused by abnormal blood vessels.
Brown birthmarks include congenital naevi or moles at birth, Becker’s naevi, Café au lait macules, and epidermal naevi. Some of these birthmarks are barely visible at birth, but increase in the teenage years.
Identifying the type of birthmark you have is extremely important because this determines the success rate of laser treatment. The only brown birthmark that can reliably be treated with laser is called a CALM or Cafe Au Lait Macule.
PWS or portwine stains are classed as red vascular birthmarks, and are made up of thousands of tiny capillaries lying in different depths of the skin. They can be slightly pink when early, but a deep purple in adult age. PWS most commonly occur in the face and neck area, but can affect any part of the body including the limbs.
PWS do not cause symptoms, but can be psychologically distressing, especially if they occur on the face. Fortunately the majority of PWS respond very well to V Beam vascular laser.
PWS are one the most common vascular birthmarks, affecting 2-4 out of 1000 births in Brisbane. These birthmarks vary in size from a few centimetres, uncommonly they may affect an entire limb.
Portwine birthmark and associations
Yes! PWS surrounding the orbit can affect the eye area. All patients who exhibit this pattern of birthmark should be reviewed by an eye doctor. Very large port wine stains on the limbs can give rise to growth changes. Your GP or Paediatrician will discuss the possibility for further investigations and ongoing monitoring.
There is controversy in regards to when is the best time to have portwine birthmark and other blood vessel lesions treated. I do believe that the very earliest treatment should be commenced ‘ as soon as possible.’ The best centers in the World, including the Royal Children’s Hospital in Melbourne treat vascular lesion early in life, however they can be treated and improved at any age.
Lasers work on the basis of ‘selective thermolysis.’ This means that a specific wavelength is needed to treat blood vessels. Each laser will have an ideal target. In vascular stains such as port wine lesions, the target is haemoglobin, found in blood. Laser targets haemoglobin, and transfers its energy via heat to the vessel walls. This heat destroys the walls, and fades the port wine stain.
Remember, port wine stains and vascular birthmarks lie under your skin. This means that the top layer of your skin must be protected from the laser beam. A very clever trick is to cool the skin’s surface a fraction of a second before the laser is delivered- this is termed Dynamic Cooling Device. This makes treatments more comfortable and safer.
I use 4 different laser and light based machines to treat vascular lesions depending on your skin type, depth of the blood vessels and previous responses. Our centre represents the largest specialist laser center in Queensland – we have the ability and skill level to treat all forms of vascular lesions from port wine stains thru to venous lakes and AV Malformations.
A vascular laser is the most common laser I use to treat a Portwine birthmark. The type of vascular laser will depend on the thickness of the birthmark, and previous treatment success and or failures. My laser of choice is the 595 V Beam laser, as this is considered the Gold Standard for many vascular birthmarks. If the blood vessels are thick or lie deep in the skin I also use a 755 Alex laser or a long pulse 1064 NdYag laser.
Lasers with a special cooling system are best for birthmarks.
All laser treatments are performed in our laser suites at Westside Laser Dermatology, located in Taringa- just 10 minutes from Brisbane’s CBD. On average it takes me 10 minutes to perform a treatment. Small portwine stains may only take 10-20 seconds to treat.
This is very difficult to say, however most patients will require between 5-10 sessions. Sometimes up to 15 sessions are needed. You will see a fading after one or two treatments.
The number of laser sessions will depend on the following factors-
- Age of port wine stain- older lesions will need more sessions are they are thicker
- Thickness of PWS- thick lesions may require me to use another laser that penetrates deeper into the skin.
- The location of your Port Wine Stain- PWS on the face responds best, whilst PWS on the hands and feet take the most treatments
- Size of your PWS- smaller lesions are much easier to remove than larger ones
- Skin colour of the patient- the fairer you are the less treatments needed
- Treatment intervals – should be every 4-10 weeks apart
As a rule over 90% of PWS will respond to laser. Mixed vascular AV birthmarks like the one below can also respond nicely to vascular lasers.
90% of patients can expect improvement with laser treatment.
- 10-20% will be completely removed without scarring
- 80% will have 50% or greater improvement with laser
- 10% will have no response
Fair skin patients will improve faster compared to ethnic skin types.
Yes. (Sorry, but that is the truth). This is because the power setting of the laser has to be very high to achieve bruising. If you bruise, your PWS will improve. The question now arises as to how to decrease the pain.
These are some methods I use to treat PWS and to make this treatment less painful-
- I use a laser with the dynamic cooling system that cools the skin and eases pain. A cold spray both protects your skin, but also distracts you from the laser beam.
- Pre-chill the area with ice before laser.
- Laughing gas before laser
- A strong numbing cream applied 30 minutes before laser can decrease pain by up to 80%
- Sedation prior to laser- especially if I am performing treatment to large areas of port wine stains.
After laser treatment of your portwine birth mark you will be required to ice the area for at least 10 minutes per hour for the remainder of the day. This reduces swelling, pain and bruising.
Much like surgery, laser for your portwine birthmark will need to undergo a healing process over a week to 10 days.
Straight after laser: You will experience swelling and bruising. I bruise all my PWS patients because a ‘prupuric’ or bruising setting has been scientifically shown to be the best. Ice packs to the area will help reduce swelling, and aid in recovery. You should use ice for 10-15 min on per hour for the first 24 hours post laser. Prior to laser you should avoid fish oil, asprin and anti-inflammatory medications. You can recommence these meds after laser.
Day 2-7: Swelling will decrease over 48-72 hours, as well as the intensity of bruising. You should use a bland moisturiser such as aqueous cream during the healing up stage. Blisters should not form (however may occur in ‘thin skin’ areas such as the eyelids). I normally prescribe an antibiotic ointment such as Chlorsig if I expect blistering- I will inform you prior to laser.
Day 7 to week 3: Swelling, and bruising will subside. In some cases bruising may take up to 10 days to completely fade. Your skin should not peel now, and you may notice that your PWS will start to fade (maximal fading maybe seen 2-3 months after the laser). This is the time whereby delayed side effects such as skin colour changes may occur. It is vital you stay out of the sun, wear hats, and sunscreen- especially important if the PWS is located on your face.
Week 4- week 8: Sun protection should be carried out throughout your treatment – towards week 8 you will notice that your birthmark will continue to fade this is called the delayed ‘inflammatory cascade’ that causes the blood vessels to shrink even more.
Expected effects: These can be considered as normal and part of the healing process. Expect a mild degree of post laser pain (controlled with ice and anti-inflammatory tabs/ panandol), also expect bruising. This occurs in 100% of patients that I treat. Bruising subsides within a week.
Uncommon side effects: These occur in less than 10% of patients and include the following-blistering. This occurs in areas such as the eyelids. The use of an antibiotic ointment can aid in healing, and prevent infection. Skin colour changes such as darkening or lightening of the skin can be seen after laser. Most commonly darkening of the top layer of the skin can be seen in ethnic skin types, or if you expose the treated areas to sun. Side effects are rarely seen in portwine birthmark treatments in fair skin types, and more common in ethic and darker skin types.
IPL or intense pulse light can be used to treat portwine birthmark- portwine stains however lasers are better. This is because lasers are much more specific in their target. IPL does not have the energy needed to deliver optimal results. Additionally Medicare does not recognise IPL as a treatment for portwine birthmark, and a rebate does not apply if IPL is used.
IPL can fade red marks such as blood vessels and rosacea, however for red birthmarks such as portwine birthmarks, lasers are by far the best treatment.
IPL should never be used to treat brown birthmarks because the energy pulse delivered by IPL is too long, and the machines do not have enough power to break up pigment. Q Switch lasers are used to treat brown birthmarks. Birthmark treatments should always be conducted by Specialists.
Brown birthmarks are much more complex to explain and to categorise compared to red birthmarks. A diagnosis is essential, as this will give an accurate prognosis as to how well they respond to laser.
The most common brown birth marks are-
- Café au lait macules- this is the most common brown birthmark. They are flat and light brown in colour, and most commonly occur on the trunk and limbs.
- Congenital naevi or moles at birth- these are darker in colour, and maybe present at birth or tardive (present shortly after birth). They are usually slightly raised.
- Epidermal naevi- these are brown bumpy birth marks that appear to have a shape to them, often as line. They are common on the head and face and tend to grow bigger during teenage years.
- Sebaceous naevi – these are yellowish in colour and commonly found on the face and scalp, again growing in size during teenage years.
- Becker’s naevi – very common. More so in males. They appear as slightly raised birthmarks with excess hair. They tend to increase in size during puberty.
- Naevus of Ota- blue to dark brown marks around the eyes. This birth mark lies in the depths of the skin layers.
As I reinforced throughout this page, brown marks are much harder to treat than red birthmarks. A diagnosis is essential as this will give you an accurate probably of success or failure in treating these lesions. My treatment philosophy is that I only treat birthmarks that have a HIGH probability of success, this is purely based on ethics.
The Q Switch laser is the laser of choice for brown birth marks- here are some percentages based upon scientific literature-
- Café au lait macules- just over 50% respond to Q switch laser, 50% recur over time. May need 3-5 treatments. Test spot need.
- Epidermal and sebaceous naevi- I frequently treat these birthmarks. If small, best excised. If large I use a curette with a laser to flatten. I also use vitamin A after the procedure to help with remission. Laser will need to be repeated every 18 to 36 months to re-flatten the lesions as recurrence is the rule.
- Becker’s naevi- very hard to treat. I can reduce the hair growth with a 755 or 1064 laser, but multiple treatments with Q Switch and Fractional lasers will yield only a mild flattening and fading of the patch. I discourage treatment.
- Naevus of Ota- 1064 Nd yag laser- multiple treatments needed, internal eye shields needed with each treatment. Test spots are needed prior to treatment. Good success rate.
The good news is that Medicare subsidises laser treatments for birthmarks. Up to 6 sessions are subsidised per year and most patients will reach the safety net threshold after a few treatments. Once this is reached, Medicare pays for up to 80% of the out of pocket expenses.
The cost of laser will depend on the type of laser used and the area treated. As a guide –
Each treatment costs between $650- $850 dollars, inclusive of anaesthetic and theatre costs*.
*All birthmark laser therapy is conducted in our Specialist Laser and Operating suites at Westside Laser Dermatology, Taringa.
I cannot stress the importance of a diagnosis and careful examination before birthmarks are lasered. The strengths of your success will be determined on the factors discussed- namely the type of birthmark (red vs brown), the location, depth, size and also your skin colour. Birthmarks may fade within 2 treatments conversely some birthmarks may take up to 15 sessions to fade. Hence careful planning and a discussion is needed prior to treatment. Portwine Birthmark can always be improved with lasers, especially on the face.
Consider the following before embarking on birthmark removal –
Motivation for removal: Removing a birthmark such a portwine birthmark may take many treatments, over months, and in some brown birthmarks years. Treatment sessions vary from 2-3 laser sessions for small red birthmarks, to 15 sessions for large birthmarks or brown colours. Rest assured I use the best lasers to achieve results, but you must be motivated to attend appointments and understand the downtime following treatment.
Time off and sick leave: Most laser treatments will be associated with swelling and bruising for a week. In some cases such as birthmark removal on your eyelids, you may not be able to work for a few days. Removing birthmarks is a medical procedure, and sick leave will be granted depending on what to expect after treatment. Each patient will be different.
Preventing pain: Laser treatment is painful, and I do not provide sedation for children under the age of 12. The new Mater Children’s Hospital can provide treatment under sedation. The laser unit will be opened in mid 2015.
Adult and teenage patients can be treated safely with sedation using inhalers making treatment well tolerated. Pain management is thus not an issue for teenage and adult patients.
Costs: costing can be an issue, however the Medicare Safety Net ensure that treatment can be affordable. Up to 6 laser sessions are subsidised per annum for the treatment of portwine birthmark and other brown birthmarks such as Cafe au Lait Macules (CALM).
Portwine birthmark and other birthmarks
Dr Davin S. Lim
Consultant Laser Dermatologist
Along with acne scarring, treating birthmarks is one of my favoured laser procedures. It changes people’s lives. Birthmarks are very common, occurring in up to 30% of the population. Some patients don’t even realise they may have a birthmarks as it can be as subtle as a beige mark on the back, or a feint pink ‘Stork Mark’ on the back of the neck. In the other extreme, birthmarks can be very noticeable- especially port wine stains on the face. The good news is that red birthmarks are responsive to lasers in over 90% of cases, the flip side is that many treatments maybe needed- anywhere between 2-15. I usually space treatments at least 6 weeks apart. As mentioned not all birthmarks can be treated with laser- reds tend to do better than browns, and birthmarks on the face tend to do better than those on the trunks and limbs. An accurate assessment and diagnosis is the very first step.