Anesthesia and/or sedation for pulsed dye laser therapy

Evaluation of the S-Caine Peel for Induction of Local Anesthesia for Laser-Assisted Tattoo Removal: Randomized, Double-Blind, Placebo-Controlled, Multicenter Study

BACKGROUND

Topical anesthetics are important tools for many dermatologic procedures. The S-Caine Peel is composed of a 1:1 (w:w) eutectic mixture composed of lidocaine base 7%, USP, and tetracaine base 7%, USP. It is applied as a cream, dries on exposure to air, and forms a flexible membrane, which can be easily peeled off.

OBJECTIVE

To evaluate the effectiveness of the S-Caine Peel in providing clinically useful local dermal anesthesia for laser-assisted tattoo removal and to monitor the nature and frequency of adverse events associated with the safety of the S-Caine Peel.

METHODS

Thirty adult patients undergoing laser-assisted tattoo removal were enrolled in this multicentered, randomized, double-blind, placebo-controlled study. Each subject received both the S-Caine Peel and placebo simultaneously for 60 minutes. The primary efficacy parameter was a 100 mm visual analog scale (VAS) for patient self-assessment of pain. Secondary efficacy parameters included both the investigator's and an independent observer's evaluation of subject pain (4-point categorical scale: no pain through severe pain) and the patient's and the investigator's overall impression of the local anesthetic.

RESULTS

Mean VAS scores were 42 mm for the S-Caine Peel and 66 mm for placebo treatment sites (p=.001). Patients received adequate pain relief in 50% of S-Caine Peel sites versus 7% of placebo sites (p=.002). The percentage of those who would like to use the S-Caine Peel again were 43% for the S-Caine Peel compared with 7% for placebo (p=.005). Investigators' evaluations revealed that 70% of patients had less pain at S-Caine Peel treatment sites compared with 10% with less pain at placebo sites (p<.001), and 70% of the S-Caine Peel-treated sites achieved adequate anesthesia versus 10% of placebo sites (p<.001). The independent witness assessed less pain in 67% of S-Caine Peel-treated sites versus 10% of the placebo sites (p=.002). One occurrence of moderate to severe erythema was noted at both an S-Caine Peel and a placebo treatment site on removal of the S-Caine Peel after 60 minutes, which self-resolved quickly. There was no statistical difference between the two groups. Other side effects were limited to local mild, transient erythema at the application sites.

CONCLUSION

Administration of the S-Caine Peel for 60 minutes prior to laser-assisted tattoo removal was effective in significantly reducing pain levels associated with the procedure.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

The S-Caine peel: a novel topical anesthetic for cutaneous laser surgery

BACKGROUND

The S-Caine peel (Zars, Inc., Salt Lake City, UT) is a novel eutectic lidocaine/tetracaine mixture that is applied as a cream, drying upon exposure to air to form a flexible film that can be peeled off easily. The patented formulation can be used to anesthetize the skin prior to a variety of cutaneous procedures.

OBJECTIVE

To examine the clinical efficacy of the S-Caine peel as a topical anesthetic for pulsed dye laser (PDL) treatment and to determine the optimal application time for adequate cutaneous anesthesia.

METHODS

Sixty patients were enrolled in one of three separate double-blind, placebo-controlled protocols in which the active product or a placebo was applied to the skin and left intact for 20, 30, or 60 minutes prior to laser treatment. A 585 nm or 595 nm PDL was used to treat facial telangiectases or port-wine stains in each protocol. Patients rated the level of pain experienced during laser treatment on a visual analog scale (VAS). Independent assessments of observed discomfort and side effects were recorded.

RESULTS

All patients experienced significant pain reduction with the S-Caine peel as their sole topical anesthetic. An application time of 20 or 30 minutes was as effective as 60 minutes in achieving anesthesia. Side effects of the peel application were limited to transient mild erythema.

CONCLUSION

The S-Caine peel is a rapid, safe, and effective method of topical anesthesia for cutaneous PDL treatment.

Laser treatment of congenital and acquired vascular lesions. A review

Several quasi-continuous-wave and pulsed lasers can effectively treat a variety of vascular lesions. The pulsed dye laser and its newer variants were specifically designed to target hemoglobin and, by increasing their wavelengths slightly, have successfully achieved greater depths of penetration. When used in to compliance with the theory of selective photothermolysis, these systems have been shown to be safe and to have a low incidence of adverse sequelae. With the concomitant use of epidermal cooling systems, side-effect profiles have been further reduced. Although great progress has been made in the laser treatment of leg telangiectasias, even the newest laser systems have failed to meet patient expectations. Continuing advances in laser technology, however, will probably lead to enhanced clinical results, decreased side-effect profiles, improved hardware, and reduced costs.

Introduction of the flash-lamp pulsed-dye laser treatment of facial port-wine stains in childhood: A case of health care technology assessment

BACKGROUND AND OBJECTIVE

Lasers have been used in the treatment of port-wine stains (PWS) for more than 30 years. With the introduction of the flash-lamp pulsed-dye laser (FPDL) it was assumed that infants could be treated safely, effectively, and probably more efficiently. Nowadays, FPDL treatment is an established form of treatment of PWS in childhood.

STUDY DESIGN/MATERIALS AND METHODS

On the basis of the iterative Health Care Technology Assessment (HCTA) loop, we examined whether sufficient evidence from evaluations has been present to support the introduction of FPDL treatment for facial PWS at an early age. Such an assessment requires an interdisciplinary approach focusing on aspects of safety, efficacy, effectiveness, quality of life, costs, and the ethical issues of treatment.

RESULTS

Assessment of the FPDL in PWS treatment of children did not follow the model of medical innovation and evaluation. Most assessments have been focused on laser applications that were already in clinical use. Efficacy and effectiveness of laser treatment have been the major concern in most assessments. Only a few studies have looked at costs and ethical aspects of treating children.

CONCLUSIONS

The introduction and diffusion of the use of the FPDL in the treatment of PWS in childhood were uncontrolled, and the field was not prepared to use this technique properly. We believe that this nonadherence to the iterative HCTA model reflects the gradual way by which innovations find their way into clinical practice.

Treatment of vascular naevi in children

This article will summarize the treatment options available for the two commonest vascular birthmarks of childhood: port wine stains and capillary haemangiomas. The treatment of port wine stains is primarily cosmetic and performed with lasers. The treatment of capillary haemangiomas is needed for both cosmetic and medical reasons and can include lasers, corticosteroids, interferons and surgery.

Flashlamp-pumped pulsed dye laser treatment of vascular birthmarks

Before the availability of the flashlamp-pumped pulsed dye laser (FPDL), patients with vascular birthmarks were treated with lasers that had a significant risk of scarring. For more than a decade, such patients have had the choice of being treated with the FPDL, which is safe, effective, and has a low risk of scarring; however, not all vascular birthmarks are amenable to treatment with the FPDL. The laser surgeon must understand the classification and natural history of the various vascular birthmarks to select the most appropriate therapy for a given patient. This article reviews FPDL treatment of port wine stains and hemangiomas, as well as the nursing care required for the laser procedure.

Iontophoresis for anesthesia during pulsed dye laser treatment of port-wine stains

Port-wine stains (PWS) are benign, congenital vascular malformations found in approximately 0.3% of newborns. PWS may be effectively treated with the flashlamp pulsed dye laser (FPDL) at 585 nm. However, laser therapy of vascular lesions often produces pain. We performed a prospective double-blind, placebo-controlled evaluation of the iontophoresis of lidocaine 5% with epinephrine 1:50,000 and mepivacaine 2% with epinephrine 1:50,000. Thirty-six patients with facial PWS were included in the study; 13 of them were treated with lidocaine 5% with epinephrine, another 13 were treated with mepivacaine 2% with epinephrine, and the other 13 were treated with preservative-free 0.9% NaCl. The pain was graded by the patient on a visual analog scale from 0 to 10, comparing the iontophoretically treated area with an adjacent area treated without anesthesia. Pain evaluation by patients demonstrated a significant decrease in the pain of pulsed dye laser impulses using the iontophoresis of lidocaine 5% with epinephrine. No change in the efficacy of pulsed dye laser treatment of PWS or important side effects were observed in our patients. Iontophoresis of lidocaine 5% with epinephrine is a safe and effective method of local anesthesia for pulsed dye laser and it is more effective than the iontophoresis of mepivacaine 2% with epinephrine.

Laser treatment of port-wine stains and hemangiomas

Since their discovery, lasers have truly advanced and broadened our options for the treatment of port-wine stains and hemangiomas. It is a blending of many sciences and much effort that allows us the opportunity today to selectively treat these vascular processes with relative effectiveness and significant safety. Ongoing study and development continue to offer hope on increasing benefit for our patients. Laser systems with variable wavelengths, pulse durations, and delivery methods will help accommodate the diversity of various port-wine stains and hemangiomas that are encountered in medicine.

Pulsed laser treatment in children and the use of anesthesia

BACKGROUND

The rationale for choosing certain anesthetic options in children when they are being treated with pulsed lasers is unclear.

OBJECTIVE

Our purpose was to assess the safety and side effects of general anesthesia in the treatment of vascular lesions and to compare this to treatment outcome in the office setting.

METHODS

We carried out a retrospective chart review of 179 patients, with an age range of 5 weeks to 18 years, who received laser treatment and underwent different anesthetic modalities. The age of the patient and the size, location, and severity of the vascular lesion were also noted.

RESULTS

The factors determining the type of anesthesia to use included (1) the age of the patient, (2) the number of treatments, and (3) the size and location of the lesion. Our data showed minimal risk and sequelae of general anesthesia in the treatment of vascular lesions in children.

CONCLUSION

Proper selection of anesthesia is a key factor in dealing with children. Office surgery can be performed safely when small lesions are treated. The use of general anesthesia in the treatment of port-wine stains in children does not appear to be accompanied by increased risk.

Pulsed dye laser treatment of port-wine stains: a review of patients treated in Western Australia

OBJECTIVE

To assess the effectiveness of the flashlamp-pumped pulsed dye laser in the treatment of port-wine stains.

DESIGN

A retrospective review of medical records and patients.

SETTING

Royal Perth Hospital (a tertiary referral hospital), August 1989 to December 1992.

SUBJECTS

186 consecutive patients with port-wine stains treated with a flashlamp-pumped pulsed dye laser.

OUTCOME MEASURES

Degree of lesion fading; adverse reactions.

RESULTS

Of 131 patients who completed treatment, 78% had better than 50% fading of the lesion and only 9% had less than 25% fading. An average 3.4 treatments were needed to achieve more than 50% fading. The response was better in children than in adults, although the difference was not significant. Anaesthesia was needed for 44% of patients. Pigmentary change (usually transient) occurred in 6.1% of patients and permanent and signficiant adverse effects in only 4.6%.

CONCLUSION

This study confirms the efficacy of the flashlamp-pumped pulsed dye laser in the treatment of port-wine stains in children and adults. Early treatment of port-wine stains should be encouraged to reduce the physical and psychological morbidity of disfiguring lesions.

Lasers in dermatology

The use of dermatologic laser therapy is rapidly expanding. Thirty years of experience has produced advances in the technology, techniques, and therapeutic efficacy of dermatologic lasers. The original lasers have been improved and modified, and new types of lasers have expanded the dermatologist's therapeutic repertoire. Extensive research has provided a greater understanding of the skin's clinical and histologic response to laser treatment. This has allowed dermatologists to expand their therapeutic options and techniques and to improve clinical outcome.

Pulsed dye laser therapy for infants and children

Pulsed dye laser therapy has revolutionized the treatment of benign vascular neoplasms of the skin. Treatment is safe and generally effective in children of all ages. Because of the pain associated with the treatment, special techniques are discussed that may minimize the physical and psychological traumas associated with treatment.

Propofol for pulsed dye laser treatments in paediatric outpatients

Pulsed dye laser is a new treatment for port-wine stains, congenital lesions in the cutaneous vascular plexus. We report our anesthetic experience with paediatric outpatients treated in the dermatology clinic. From April to November 1993, 48 ASA 1 children were anaesthetised for a total of 105 consecutive laser treatments. The youngest was eight months old, the oldest was 12 yrs old and most of the sessions (43%) were done for children aged from two to four years. Each received acetaminophen (10 mg.kg-1 p.o.) before treatment. A propofol infusion was chosen for anaesthesia to achieve early discharge and to reduce the incidence of postoperative emesis. The infusion was adjusted to maintain blood pressure within 20% of baseline and to keep the child immobile. The dose was progressively reduced during the procedure from 400 micrograms.kg-1.min-1 to 100 micrograms.kg-1.min-1. Fentanyl (2 micrograms.kg-1 i.v.) was added for analgesia. Respiration was spontaneous through a nasopharyngeal airway (air in oxygen 40%). Anaesthesia proceeded uneventfully in all cases and lasted for 15-30 min (63% of treatments), 30-45 min (28%) or 45-60 min (9%) according to the size of the lesion. The mean stay in the recovery room was 25.1 min and none of the patients experienced emesis. Our experience shows that general anaesthesia with propofol supplemented with fentanyl offers a rapid onset and awakening, a painless treatment and an immobile child. It is a safe solution to alleviate pain from repeated painful procedures even in small children under two years of age.

Pulsed dye laser treatment of vascular lesions in children

BACKGROUND

The flashlamp-pumped pulsed dye laser (577,585 nm) with 300 to 450 microseconds pulsewidths has been demonstrated to effectively and safely treat port-wine stains, telangiectases, and superficial hemangiomas in children.

OBJECTIVE

The objective of this manuscript is to review the indications of the pulsed dye laser in the treatment of vascular lesions in children.

CONCLUSION

Pulsed dye laser treatment of port-wine stains can remove or lighten the lesions with multiple treatment sessions. Spider telangiectases respond with complete resolution, usually within one to two treatment sessions. Superficial hemangiomas respond quite easily and effectively with the pulsed dye laser, while a more variable response is noted in deeper hemangiomas, early proliferative lesions, and ulcerated hemangiomas. This procedure is safe with a low incidence of scarring and pigmentary alteration.

Pulsed dye laser therapy for port-wine stains in children: psychosocial and ethical issues

The port-wine stain is a disfiguring vascular birthmark that commonly occurs on the face. Amelioration of this condition in children was difficult or impossible until the introduction of the flashlamp-pumped pulsed dye laser in the late 1980s. This article provides an interdisciplinary social and ethical examination of pulsed dye laser therapy for port-wine stain in childhood. Specific issues raised relate to the management of pain during therapy, rationale for care, expectations of treatment, the high costs of care, equity, marketing pressures, and therapeutic activism. Laser therapy in the dermatologic care of children is an exciting innovation that has transformed clinical practice and raised important social, ethical, and health policy issues.

Treatment of port-wine stains (capillary malformation) with the flashlamp-pumped pulsed dye laser

Forty-three children with 49 separate port-wine stain vascular malformations were treated with the flashlamp-pumped pulsed dye laser at 585 nm. The patients ranged in age from 2 weeks to 14 years. Overall, 16% of patients had more than 95% resolution of their port-wine stains after an average of 4.8 (1 to 11) treatments. There was an average improvement of 69% in those lesions not clearing completely (average of 3.7 treatments). Lesions in patients less than 4 years of age were almost twice as likely to clear than were those in older children (20% vs 12%), and in fewer treatments (3.8 vs 6.5). An approximate 50% clearing was obtained with one treatment. Subsequent treatments resulted in an additional 10% clearing. There were no episodes of scarring or persistent pigmentary changes in any of the patients. Lesions on the hand and arm responded less well than lesions on the face, neck, and torso. The flashlamp-pumped pulsed dye laser has proved to be a safe and effective treatment modality for port-wine stain capillary malformations in infants and children.