Chapter: Capillary malformations
Article: 10 of 14
Update: Mar 30, 2021
Author(s): Ott, Hagen
As a decisive basis for all further treatment steps, the parents and the patient (if possible, given the patient’s age) should be informed about the possible clinical course and therapy options and, as far as possible, about etiology and pathogenesis. This should be done in generally understandable language and, ideally, with illustrated information material. Very often, no intervention is required for capillary malformation (CM) located outside the facial region. However, if the cervicofacial region is involved, further treatment steps should be carefully considered together with the affected family.
If there is evidence of severe psychosocial distress to the patient or the parents, psychological care should be offered at an early stage. It is also strongly advisable to inform affected families about patient support groups, which can offer numerous support options.
Cosmetics with a high pigment content can be used to cover a psychologically stressful capillary malformation. This treatment, known as cosmetic camouflage, has been shown to have a positive effect on the quality of life of children with vascular anomalies. It depends on the type and location of the underlying malformation, the patient's skin type and numerous other factors, and it can be very challenging. Therefore, it should be practiced by affected children and their parents with an appropriately trained professional.
Together with the attending physician and the cosmetic specialist, suitable products are selected, which should have the following properties (selection):
Commercial preparations are available which differ in water and fat content. Selection of products should take into account concomitant skin diseases (e.g. acne, eczema). Economic aspects should also be taken into consideration, as complex, long-term camouflage treatment can prove costly. In these cases, it may be advisable to contact the relevant health insurance program to clarify whether the costs could be covered.
Unfortunately, medical therapy of capillary malformations is still not possible today.
Pulsed dye laser (PDL) is today considered the treatment of choice for capillary malformations, even though no sizeable prospective, controlled studies on large patient groups over prolonged periods have yet been published. Nevertheless, it is consistent with clinical experience that PDL acts specifically on the dilated vessels of capillary malformations through selective photothermolysis and can result in significant fading of these lesions. However, parents and, if they are old enough, patients should be educated early on about important limitations of this treatment (selection):
In centers with sufficiently high numbers of patients and appropriate therapeutic experience, PDL therapy is a safe treatment that is very rarely associated with significant side effects. The main problems after laser therapy relate to localized skin atrophy after excessively high laser intensity has been used. Therefore it is recommended that use of PDL is confined to experienced hands.
Immediately after laser therapy, the desired disruption of the small superfluous, dilated capillaries of the skin can cause the formation of purpura, i.e., a punctiform hemorrhage in the skin due to therapy-induced extravascular leakage of erythrocytes. This laser-induced purpura usually disappears spontaneously within 7−21 days, and patients and parents should be told about this.
Whether a therapeutic improvement can be achieved by other treatment methods such as photodynamic therapy, or the combination of PDL with drug treatment (e.g., mTOR antagonists) needs to be investigated in further studies.
Other laser techniques are also used for laser therapy such as Nd:YAG laser, sequential dye laser (2 wavelengths) or Intense Pulsed Light (IPL) laser. However, there is so far a lack of prospective studies for direct comparison.