Bullous malignant melanoma: an unusual differential diagnosis of a hemorrhagic friction blister

BACKGROUND

A 66-year-old woman presented to our outpatient clinic with a 3 x 2.5-cm tense, hemorrhagic-appearing bulla on her forefoot. Histopathology and immunohistochemistry confirmed a transtumoral-transepidermal blister formation within an advanced acrolentiginous malignant melanoma (MM).

OBJECTIVE

To study bullous malignant melanoma.

METHODS

Blistering in MMs represents a rare but clinically important pitfall in clinical differential diagnosis. The blisters are typically due to the disruption of the cohesion between neoplastic cells and keratinocytes, but physical friction may also contribute.

RESULTS

Hemorrhagic blistering is, in many cases, a relatively insignificant finding in which frictional forces are imposed.

CONCLUSION

The case reported here underscores that in rare cases MMs, particularly if acrally located, can be complicated by hemorrhagic blistering. Because of the life-threatening consequences, one should be aware of this rare differential diagnosis.

Photodynamic therapy and fluorescence diagnosis of skin cancers

In several countries throughout the world the photosensitizer porfimer-sodium has been approved for systemic photodynamic therapy (PDT) for different oncological indications. However, owing to the prolonged photosensitization entailed, the use of this porphyrin derivative is restricted. Currently, the most promising sensitizers in dermatology that can be applied topically are 5-aminolevulinic acid (ALA) or ester derivatives that are precursors of heme biosynthesis. ALA has shown good clinical and excellent cosmetic results in superficial skin cancer and precancerous conditions, e.g. superficial basal cell carcinoma (BCC), or actinic keratoses (AK): phase III studies have demonstrated its efficacy especially in Bowen's disease and AK. ALA-PDT for AK was therefore approved by the FDA in late 1999, and the corresponding registration process is currently in train in Europe. Besides its usefulness in oncological therapy, ALA also has a unique feature that can be exploited for diagnostic purposes: after topical or systemic application protoporphyrin IX is induced rather selectively in epithelial tumors, with a high tumor-to-surrounding tissue ratio, which can be visualized after excitation with light. By using a CCD camera system together with digital imaging, the contrast of the acquired fluorescence images can be significantly enhanced and allows the determination of a threshold, which can be utilized either for a directed biopsy or for preoperative planning when Mohs' surgery is scheduled. At present, the routine employment of such systems is being assessed in prospective studies.

Eruptive multiple lentigo-maligna-like lesions in a patient undergoing chemotherapy with an oral 5-fluorouracil prodrug for metastasizing colorectal carcinoma: a lesson for the pathogenesis of malignant melanoma?

Induction of multiple eruptive dermal and atypical melanocytic naevi has frequently been reported in children with malignant haematological diseases and chemotherapy-induced immunosuppression. This is the first report of an adult patient to develop multiple eruptive melanocytic skin lesions while undergoing chemotherapy with an oral 5-fluorouracil prodrug for metastasizing cancer. Our observation adds further evidence to the link between systemic (iatrogenic or intrinsic) immunosuppression and the induction of melanocyte proliferation and transformation.

Dead Sea treatment - principle for outpatient use in atopic dermatitis: safety and efficacy of synchronous balneophototherapy using narrowband UVB and bathing in Dead Sea salt solution

Safety and efficacy of this new treatment modality for out-patients were evaluated by an uncontrolled multicenter trial under GCP-conditions. Patients had to undergo 3-5 treatment sessions per week up to 35 in total. SCORAD (SC) was assessed at baseline, after 20 and 35 sessions. For patients with early study withdrawal the last-observation-carry-forward-principle was used. 615 intention-to-treat (itt)- (baseline SC: 59.4) and 143 according-to-protocol (atp)-patients (baseline SC: 60.1) could be analysed. 289 patients (47%) (baseline SC: 59.1) underwent less than 35 sessions. Main reasons were: lack of time (16%), non-compliance (12%), good improvement (7%), lack of efficacy (6%), intercurrent disease (4%) and side effects (3%). Mean number of sessions in atp-group was 35, in itt 26, and in patients with early study withdrawal 15.8. SC decreased in atp-group to 37.5 (itt: 44.5/patients with early study withdrawal: 46.1) after 20 sessions and to 27.1 (35.2/42.6) at end of treatment. Relative SC-improvement was statistically significant in atp- (55%), itt-group (41%), and in patients with early study withdrawal (26%). Most frequent side effects were: erythema in 7.3%, burning of skin due to salt solution in 3.6%. Safety and efficacy could be proven in both atp- and itt-group. A marked difference in efficacy between atp and itt underlines the importance of evaluating itt-data providing a more realistic assessment of a treatment modality in practice. This treatment is especially recommended for patients with chronic type of AD, high compliance and time free for therapy.

Correlations between light penetration into skin and the therapeutic outcome following laser therapy of port-wine stains

For several years the flashlamp-pumped pulsed dye laser (FPDL) has been the favoured method for the treatment of port-wine stains (PWS). The therapeutic outcome of FPDL laser therapy depends on the anatomical location of the PWS and is mainly attributed to morphological parameters such as size and depth of the PWS blood vessels. The aim of this study was to show a correlation between the therapeutic outcome following FPDL therapy and the optical properties of the skin overlying the PWS vessels. For this purpose the therapeutic outcome following FPDL treatment (585 nm; 0.45 ms) of 884 PWS situated on different body sites was evaluated by judging the grade of fading of PWS colour. On the other hand the light penetration into 123 skin samples (thickness 0.10-1.35 mm) was determined between 450 nm and 1030 nm and compared with the PWS laser therapy outcome for equal locations by statistical analysis. PWS on the neck, trunk, arms or legs yielded a higher mean grade of fading as compared to PWS on the head. Within the face, a wide range of fading was evident. The light penetration into skin increased linearly with increasing wavelength and location-dependent differences were found. The attenuation coefficient was 22.8+/-5.3 mm(-1) at 585 nm. No significant or strong correlation was observed between the therapeutic outcome of PWS laser therapy and the light penetration into skin. However, a correlation was obvious by plotting the respective profile plots. Therefore, among other effects, in particular morphological parameters of PWS vessels, the optical properties of the skin contribute to a small extent to the clinical outcome of PWS laser therapy.

IgE-mediated anaphylactic reaction induced by succinate ester of methylprednisolone

BACKGROUND

In systemic administration the prevalence of anaphylactic reactions attributable to corticosteroids is approximately 0.3%. Positive prick tests with different corticosteroids have been reported suggesting an immunoglobulin (Ig)E-mediated mechanism.

OBJECTIVE

A 42-year-old man with multiple sclerosis developed flush, erythema, and itching a few minutes after the begin of an intravenous infusion of methylprednisolone-21-sodium succinate. DIAGNOSTIC AND RESULTS: Prick tests were found to be positive with methylprednisolone-21-sodium succinate and prednisolone-21-sodium succinate, whereas prick tests with prednisolone without ester and betamethasone-21-dihydrogen phosphate showed negative results. Oral challenge with prednisolone without ester and intravenous challenge with betamethasone-21-dihydrogen phosphate were well tolerated. Specific IgE-antibodies against methylprednisolone-21-sodium succinate were found in the serum of the patient. Because of the positive prick test and specific IgE antibodies against methylprednisolone-21-sodium succinate, the diagnosis of IgE-mediated anaphylactic reaction could be proven. Succinate ester was suspected to be immunogenic, as other corticosteroids without this particular ester or with other substitutions at the C21 remained negative both in the prick and the challenge tests.

CONCLUSIONS

This patient showed an adverse reaction caused by methylprednisolone-21-sodium succinate. The uniqueness in this case was the presence of specific IgE antibodies against this esterified corticosteroid in the patient's serum proving that this reaction was based upon a true IgE-mediated mechanism.

[Psoriatic onycho-pachydermo- periostitis]

We report about a patient with a 2 year history of palmo-plantar psoriasis and psoriatic involvement of the nails. Within six months he developed a psoriatic onychodystrophy and painful swellings of the toes and fingers. X-rays revealed acral lamellar periostitis. The case of this patient represents a rare variety of psoriatic arthritis: The psoriatic onycho-pachydermo-periostitis. After a 6 week therapy with methotrexate (15mg per week) the nails began to grow regularly. Therefore, in cases of psoriasis with unusual symptoms of psoriatic arthritis the psoriatic onycho-pachydermo-periostitis should be included in differential diagnosis and therapy.

Multiple, bilateral and painful ear nodules of the anthelices: a variant of chondrodermatitis nodularis?

A case of a distinctive clinicopathologic condition of the ear cartilage is presented, characterized by multiple, bilateral and painful nodules of the anthelices without epidermal involvement. Histologically, there was a peri-chondrial lymphohistiocytic infiltrate and a small focus of degenerate, basophilic cartilage as well as cystic chondromalacia containing an amorphous mass. This condition is both clinically and histopathologically distinct from other causes of ear nodules, although the lesions seen in our patient exhibit features of chondrodermatitis nodularis helices and therefore could well be a variant of the latter.

Hair removal with the long pulsed Nd:YAG laser: a prospective study with one year follow-up

BACKGROUND AND OBJECTIVE

The aim was to investigate the efficacy, side effects, and the long-term results of a long pulsed Nd:YAG-Laser for hair removal in different hair colors and skin types.

STUDY DESIGN/MATERIALS AND METHODS

We performed a prospective clinical study with 29 volunteers. Treatment was performed on the lower leg with a long pulsed Nd:YAG-Laser. Five test areas were treated 1-5 times in monthly intervals; one served as control. Follow-up investigations were performed at each session, and 3, 6, and 12 months after the last therapy. No depilatory treatment except shaving was allowed during the time of follow-up. Percentual hair loss, short- and long-term side effects, and pain during the treatment were evaluated.

RESULTS

After one month, a hair loss of greater than 50% was found in 44.9% of the areas treated once. With up to five treatments, this percentage increased up to 71.5%. One year after therapy, a greater than 50% hair reduction was still present in 40% of the five-treatment-areas and in 0% of the areas treated only once. There were no permanent side effects despite one small scar after a folliculitis.

CONCLUSIONS

The long pulsed Nd:YAG is suitable to remove hair for more than 12 months effectively, although 4-5 sessions are necessary for these results. Blond hair can also be removed, although much less effective. No lasting side effects could be seen. Darker skin types or tanned skin can also be treated without side effects. A cooling may be advisable due to the pain reported by the volunteers.

Non-oncologic indications for ALA-PDT

Topical photodynamic therapy with 5-aminolevulinic acid (ALA-PDT) is a well-established treatment regimen for superficial epithelial skin tumours, but it is evident that inflammatory diseases of the skin and virus-induced lesions can also profit from PDT. Depending on the light dose applied, either cytotoxic effects resulting in tumour destruction or immunomodulatory effects resulting in improvement of inflammatory conditions occur. Patients with localized scleroderma that had been unresponsive to various treatments, including PUVA or bath-PUVA therapy, respond very well to topical ALA-PDT performed repeatedly. In contrast to PUVA therapy, no carcinogenic potential is being discussed for PDT. Also, HPV-induced skin lesions might provide a possible indication for topical ALA-PDT. The rapidly proliferating cells in viral acanthomas accumulate ALA-induced protoporphyrin IX (PPIX) selectively when compared to the surrounding non-infected cells. The efficacy of topical ALA-PDT in the treatment of recalcitrant foot and hand warts has been shown in a placebo-controlled, randomized, double-blind trial. Furthermore, case reports describe a good response of other virus-induced diseases, for example condylomata acuminata and epidermodysplasia verruciformis, to topical PDT with ALA. However, controlled clinical trials are still needed to demonstrate more fully the effectiveness of PDT for inflammatory skin diseases.

Willingness to pay and time trade-off: useful utility indicators for the assessment of quality of life and patient satisfaction in patients with port wine stains

BACKGROUND

For cost utility analyses in health economic research it is necessary to assess quality of life for content validation. Previously, both quality of life questionnaires and utility indicators such as willingness to pay and time trade-off have been used successfully in patients with chronic skin diseases, such as psoriasis vulgaris or atopic eczema.

OBJECTIVE

For the first time to assess willingness to pay and time trade-off in patients with port wine stains, and to study possible correlations between these indicators, patient income, quality of life questionnaires and subjective or objective outcome measures.

METHODS

The results of a survey on 36 patients with facial lesions who had completed laser treatment were used for assessments. The 'Chronic Skin Disease Questionnaire' (CSDQ) and the 'Short Form-36 Health Survey' (SF-36) were used as quality of life questionnaires. Special questions were used as a basis for calculating the utility indicators, willingness to pay and time trade-off.

RESULTS

Completed questionnaires were sent back by 25 patients (69%). Willingness to pay and time trade-off were used as instruments for the assessment of quality of life [questions answered by 23 (92% of respondents)]; patients were willing to pay 11.8% of their monthly income and would offer a mean value of 1.2 h per day for an imaginary therapy leading to complete cure of the skin problem. Statistical correlation analyses were not performed because this pilot study included only a small number of patients. Frequency distributions show no apparent correlation between willingness to pay and patients' profession (used as a surrogate for income). Possible correlations were seen between willingness to pay, time trade-off, the scales 'anxiety/avoidance' and 'helplessness' of the CSDQ as well as 'social function' of SF-36 and subjective or objective efficacy. Twenty-nine patients (80%) were willing to pay for the treatment, a surrogate measure for patients' satisfaction with treatment modality. Overall, patients would pay an average of 16.0 euros per single treatment and 192.0 euros for the whole course of treatments. In contrast with patients who evaluated treatment modality as excellent or very good (willingness to pay for single treatment, euro 22.0; for whole treatment, 270.0 euros), patients who judged treatment good (8.0 euros, 145.0 euros), moderate or bad (12.0 euros, 146 .0 euros) were willing to pay markedly less.

CONCLUSIONS

(i) The questions for willingness to pay and time trade-off were understood by most patients and produced meaningful answers. (ii) There were apparent correlations between the utility indicators, subjective or objective outcome and the scales of the quality of life questionnaires. (iii) The results show that these indicators have a high potential for use in this dermatological condition, especially as a basis for health economic evaluations.

[Cutaneous microdialysis. Use in dermatology]

The determination of concentrations of exogenous or endogenous substances in the dermis, e.g. for pharmacokinetic studies, is technically difficult. Performing skin biopsies or inducing suction blisters results in the disintegration of the tissue and allows only single measurements. Recently, cutaneous microdialysis, a new simple and minimally invasive technique for continuously measuring of substances in the dermis in vivo, has been introduced in dermatological research. According to the principle of dialysis, a semipermeable membrane is inserted in the dermis and due to a concentration gradient between the interstitial space and a perfusate, substances diffuse through the pores of the membrane and can be analyzed in the dialysate. Cutaneous microdialysis represents a useful technique for pharmacokinetic or pharmacodynamic studies as well as for investigations regarding cutaneous physiology and pathophysiology.

The effect of different spot sizes on the efficacy of hair removal using a long-pulsed diode laser

BACKGROUND

In the last years several lasers have proven their efficacy for hair removal. However, little is known about the efficacy of varying the spot size with those lasers.

OBJECTIVE

To evaluate the long-term efficacy of hair removal using a diode laser with different spot sizes.

METHODS

A long-pulsed diode laser (2 x 60 msec) was used. The spot size was 8 mm, 12 mm, or 14 mm. Twenty consenting volunteers were treated three times at regular intervals of 3 weeks. The ratio of the number of hairs in the treated area to an adjacent area left untreated (control) was referred to as regrowth.

RESULTS

One month after laser treatment, regrowth was 23% (8 mm), 12% (12 mm), and 13% (14 mm). After 3 months regrowth was 67% (8 mm), 54% (12 mm), and 55% (14 mm). Fifteen months after treatment 4 of 16 volunteers had a regrowth rate of less than 25%.

CONCLUSION

The results provide evidence for an effective and long-lasting growth delay of hairs using the long-pulsed diode laser. The use of large spot sizes improved the growth delay of hairs measured 1 month after treatment.

Role of lasers and photodynamic therapy in the treatment of cutaneous malignancy

Tumor therapy is not a common indication for the use of lasers, as it is in the treatment of benign vascular skin lesions, since many alternative treatment modalities exist. However, certain patients may benefit from laser therapy of premalignant and malignant skin tumors. Skin tumors can be treated by laser excision, laser coagulation, laser vaporization, or photodynamic therapy (PDT). For these purposes, the carbon dioxide laser, the neodymium:yttrium aluminum garnet laser and the argon laser are particularly suitable. PDT is a therapeutic approach based on the photosensitization of the target tissue by topical or systemic photosensitizers and subsequent irradiation with light from a laser or a lamp inducing cell death via generation of reactive oxygen species. Laser therapy and PDT have shown good results in the curative treatment of actinic keratoses, superficial basal cell carcinoma, Bowen's disease and cheilitis actinica. However, they are not recommended for primary malignant melanoma and invasive squamous cell carcinoma. In some patients, lasers and PDT might also be used effectively for the palliative treatment of cutaneous metastases. In selected patients, lasers and PDT may offer some advantages over routine procedures, e.g. reduction of scarring and better cosmetic results. However, when treating invasive tumors with curative intention, one has to bear in mind the lack of histologic control and the limited depth of tissue penetration of most laser and PDT therapies.

Transient and partial effect of high-dose intravenous immunoglobulin in polyarteritis nodosa

A 57-year-old male patient suffered from polyarteritis nodosa. He presented with articular pain, polyneuropathy, subcutaneous nodules and nodes on the lower legs. After several immunosuppressive agents (methotrexate, mycophenolate mofetil and prednisolone) had proven to be ineffective, 2 g intravenous immunoglobulin (IVIG) per kilogram body weight were administered within 2 days in combination with 10 mg prednisolone per day. Subsequently, 6 cycles of IVIG were applied in increasing intervals from 4 to 6 weeks resulting in a minimum dosage of 0.33 g/kg/week IVIG. The polyarteritis improved within a few days after the first IVIG application. The intensity of polyneuropathy and arthralgia of polyarteritis decreased during the period of IVIG treatment. Finally, a dose reduction of less than 0.25 g/kg/week IVIG resulted in recurring polyarteritis nodosa, which could not be controlled by further administration of IVIG. Therefore, our data indicate that: (1) IVIG is partially effective in cases of polyarteritis nodosa, but the therapeutic effect is only transient; (2) the success of treatment may be correlated with the dose of IVIG per body weight and week; (3) the efficacy/cost ratio of IVIG in polyarteritis nodosa appears to be low.

[How large is the loss of effectiveness of a treatment procedure between "theory" and "practice"? Evaluating health economics basic data within the scope of a trial model of ambulatory synchronous balenophototherapy of atopic eczema]

BACKGROUND AND OBJECTIVE

Before introducing new treatment modalities, efficacy has to be proven in clinical trials. Furthermore, it is of special interest to what extent results of clinical trials can be transferred to daily routine.

PATIENTS/METHODS

In the framework of a trial on out-patient synchronous balneophototherapy, a possible loss in treatment efficacy from "clinical trial" to "daily routine" was examined. Therefore all patients without protocol deviations (representing treatment success available in a "clinical trial") and all patients with at least one treatment session regardless of protocol deviations (model for "daily routine") were analyzed.

RESULTS

257 "daily routine" and 1281 "clinical trial" patients with atopic dermatitis were analyzed. Relative SCORAD-improvements provided a clear loss in treatment efficacy in the "daily routine" group of 14.2%: 55% of patients received less than the planned 3 treatments per week and 48% left the study early because of noncompliance, good improvement, lack of time or lack of efficacy.

CONCLUSIONS

For the first time a loss of efficacy of a treatment modality between "theory" and "practice" can be demonstrated in a representative number of patients suffering from atopic dermatitis. For the optimal use of rare financial resources, the comparison of different treatment modalities under "daily routine" conditions is also necessary in future.

Progression and NSAID-induced apoptosis in malignant melanomas are independent of cyclooxygenase II

Cyclooxygenase-II (Cox-II) overexpression is involved in the progression of various subtypes of cancer. We investigated the significance of Cox-II in the progression of malignant melanomas (MMs). Using immunohistology we determined that Cox-II is not expressed in 70 benign and malignant melanocytic tumours. Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) were also analysed as controls: the BCCs were consistently Cox-II negative (n = 11), whereas the SCCs showed moderate to strong Cox-II expression in 53% (n = 17). Reverse transcription-polymerase chain reaction and Western blotting of MM cell lines and MM tissues confirmed the lack of Cox-II expression in MM. However, in vitro the Cox-inhibiting non-steroidal anti-inflammatory drug (NSAID) sulindac sulphide (SIS) was significantly more effective in inducing apoptosis than sulindac sulphone (SOS), a derivative with a negligible effect on Cox (P < 0.01). The SIS doses needed for the induction of apoptosis were not significantly different in MM cell lines versus a Cox-II-positive colon carcinoma cell line (HT29). Furthermore, add-back experiments with high doses of the prostaglandins PGE2 and PGF2beta, major Cox-II products, did not abrogate this effect. We conclude that Cox-II expression is not involved in the progression of MM, and NSAID-induced apoptosis in MM cell lines seems to follow pathways independent of Cox-II. Nevertheless, Cox-II inhibitors are still candidates for therapy, though they act via an unknown mechanism.

Overexpression of monocyte chemoattractant protein 1 in systemic sclerosis: role of platelet-derived growth factor and effects on monocyte chemotaxis and collagen synthesis

OBJECTIVE

In addition to its chemotactic properties, recent evidence suggests that monocyte chemoattractant protein 1 (MCP-1) might participate in the fibrotic process by inducing the secretion of extracellular matrix (ECM) components. Since the factors that initiate the accumulation of inflammatory infiltrates and ECM deposits in systemic sclerosis (SSc) skin lesions are still unknown, this study was undertaken to examine the role of MCP-1 in SSc.

METHODS

In situ hybridization and immunohistochemistry studies for MCP-1 were performed on skin biopsy specimens from patients with SSc and healthy controls. To identify possible stimulators of MCP-1 overexpression in SSc lesions, cultured dermal fibroblasts were incubated with recombinant platelet-derived growth factor (PDGF) and analyzed by real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay. The chemotactic effects of SSc fibroblasts were examined using a modified Boyden chamber assay. To analyze the fibrotic potential of MCP-1, cultured dermal fibroblasts were incubated with recombinant MCP-1, and type I procollagen was measured by radioimmunoassay and real-time PCR.

RESULTS

MCP-1 was expressed by fibroblasts, keratinocytes, and perivascular infiltrates throughout the skin, in involved as well as uninvolved skin areas, from 10 of 11 SSc patients, whereas no expression of MCP-1 was found in healthy controls. Stimulation with PDGF resulted in a significant increase in MCP-1 messenger RNA and protein, with differences between healthy control fibroblasts and fibroblasts from SSc patients. The chemotactic activity for peripheral blood mononuclear cells of SSc fibroblast supernatants increased in a time-dependent manner. Antibodies blocking MCP-1 decreased the chemotactic activity of SSc fibroblasts by a mean +/- SD of 37 +/- 12%. Despite an increase in type I collagen levels over time, no effect of recombinant MCP-1 on the synthesis of type I collagen was observed.

CONCLUSION

These data indicate that MCP-1 might contribute to the initiation of inflammatory infiltrates in SSc. Possible stimuli of MCP-1 in dermal SSc lesions include PDGF, which is known to be expressed in SSc. In contrast to previous findings in fibrotic lung diseases, no effect of MCP-1 on collagen synthesis was observed in SSc dermal fibroblasts in vitro.

[Treatment of port-wine stains with the flash lamp pumped dye laser. 5 years of clinical experience]

BACKGROUND AND OBJECTIVE

Portwine stains are reported to occur in 2.8% of the newborn. Depending on the location and size, portwine stains can be disfiguring and may lead to psychosocial complications. They can be safely and successfully treated with the flashlamp pumped pulsed dye laser (FPDL). Our objective was to evaluate retrospectively the efficacy of the FPDL (450 microseconds, 585 nm, 5 and 7 mm) after five years of clinical experience with this laser.

PATIENTS/METHODS

Between 1993-1998 in 961 patients with port-wine stains laser treatment was performed in the department of dermatology of the university of Regensburg.

RESULTS

Total clearance of the portwine stain was recorded in 6.9% of the patients. In 40.4% of the patients 75-95% clearance and in 38.5% 50-75% clearance was observed. In 14.2% response was less than 50%. Laser therapy was more effective for lesions of the neck and trunk than for lesions on the head and extremities. Better results were found after laser therapy of light-red or red portwine stains compared to dark red and violaceus portwine stains. In children (less than 3 year old), clearance of more than 75% occurred significantly more often than in older patients.

CONCLUSIONS

Since laser treatment in early childhood is more effective than treatment at a later age, a smaller number of treatment sessions is necessary and lower recurrence rates can be expected, laser treatment should be started in early childhood. Side effects were rare after FPDL treatment. This study underlines that the FPDL is a safe and successful treatment for portwine stains with rare side effects. But total clearance can only be reached in a small number of patients.