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Birthmarks

TOP 5 THINGS ABOUT BIRTHMARKS

  1. Advances in laser technology have revolutionised the treatment of birthmarks with far superior results than before lasers were available
  2. Birthmarks fall into 2 main categories of either Vascular (comprised of blood vessels) or Pigmented (comprised of pigment cells)
  3. Different types of Birthmarks require different types of lasers so for the most effective treatment of Birthmarks a range of medical grade lasers are required.
  4. Vascular Birthmarks are best treated by either a pulse dye laser such as the V Beam or a long pulse dual wavelength laser such as the Excel V.
  5. The choice of laser to treat pigmented Birthmarks depends on the depth of the melanin pigment. Shorter wavelength lasers (eg 532 nm) are used to treat superficial (epidermal pigment) and longer wavelength lasers (eg 1064 nm) are used to treat deeper (dermal) pigment.

WHAT CAUSES BIRTHMARKS?

It is not certain exactly why Birthmarks form and whilst they can be inherited they usually are not. Birthmarks do not appear to be caused by trauma during childbirth. Vascular Birthmarks form when blood vessels don’t form correctly. Pigmented Birthmarks form when there are an excessive number of pigment cells (melanocytes).

WHAT ARE THE COMMON VASCULAR BIRTHMARKS?

Macular Stains are small flat patches of pink or faint red skin with poorly defined margins that are very common (40% of newborns). Also called Salmon patches, Stork bites and Angel kisses. Most commonly occur on nape of neck, forehead or eyelids and become more noticeable when a child is crying. These birthmarks typically resolve in the first few years of life.

Strawberry Naevi are benign tumours of newly formed blood vessels clustered together (Haemangiomas) that may be present at birth or develop in the first few weeks of life. Occur in 5-10% of Caucasian background, more in females and most commonly on head or neck. Usually start as a small flat red area that become raised and dimpled (strawberry like). Typically grow in first 3-4 years and can vary greatly in size. Then spontaneously disappear over next few years ( 90% gone by 9 years of age) usually without any scarring.

Port Wine Stains occur in about 3 in 1000 children and can occur anywhere on the skin but most commonly occur on the face. Port Wine Stains get their name because they resemble dark wine split on a tablecloth. They generally appear on one side of the body and have a well defined border. Typically at birth they are flat and a dark red or purple colour and most remain unchanged or become darker and bumpy over time (called Cobblestone effect).

HOW ARE VASCULAR BIRTHMARKS BEST TREATED?

Macular Stains require no treatment as they disappear spontaneously. Strawberry Naevi also do not usually need treatment unless they cause disturbance of vision or breathing. Strawberry Naevi can be treated with medication (Beta blockers such as Propranolol or Timolol) that can result in rapid shrinkage. Very occasionally laser treatment is used on these birthmarks if there is some persistence into later life.

Port Wine Stains can be very effectively treated by Vascular lasers. One of the first uses of medical lasers was to treat Port Wine Stains as prior to lasers the treatment options were limited to cover make up or surgical excision. The treatment of choice for most Port Wine Stains is the Pulse Dye Laser ( V BEAM or CYNERGY). Very good results can also be obtained with advanced vascular lasers such as the EXCEL V. On occasion resistant areas are treated with other lasers such as the Alexandrite laser. Whilst we still see adults presenting with Port Wine Stains most Port Wine Stains are now treated at a very young age in paediatric hospitals such as the Royal Childrens Hospital.

WHAT ARE COMMON PIGMENTED BIRTHMARKS?

Café au Lait: The term is French for ‘coffee with milk’ and refers to their typical light brown colour. These are flat brown birthmarks which may be present at birth or become apparent during infancy after exposure to sunlight. Are usually solitary and occur in 3 in 1000 Caucasians, 4 in 1000 Chinese but are much more common in African Americans. Vary in size but pigment is evenly distributed with a well demarcated border and a round or oval shape. If someone has multiple Café au lait birthmarks there may be an associated genetic syndrome such as Neurofibromatosis.

Dermal Melanocytosis: These are a group of conditions that consist of extra pigment cells in the dermal layer of the skin. Colour may vary from slate brown to blue and even grey. They can slowly grow and darken from childhood to adulthood. Naevus of Ota is on the face and forehead around the eye, whilst Naevus of Hori is on both sides of the face and Naevus of Ito is on the shoulder and upper arm. These birthmarks are more common in Asian background and more common in women.

Congenital Naevi: This group of pigmented birthmarks consist of a proliferation of pigment cells that are present at birth or develop soon after. They vary greatly in size ranging from small (< 1.5 cm), medium (1.5-10cm), large (11-20cm) and giant (>20cm). There is an increased risk for melanoma developing in larger and giant size (5-10% lifetime risk). Congenital naevi occur in all races and equally effect males and females.

HOW ARE PIGMENTED BIRTHMARKS BEST TREATED?

Laser treatment can be very effective in treating pigmented birthmarks. However it is important to remember that lasers are not used to treat melanomas. Hence before any laser treatment of pigmented lesions, any possibility of skin cancer needs to be considered and if necessary a biopsy might be required.

Treating pigmented birthmarks in darker skinned patients is more difficult than in lighter skinned patients and requires caution as if too much pigment is removed then the skin can have areas of no pigment (hypopigmentation) and this can be permanent.

Café au lait birthmarks can respond well to laser treatment but results are variable and a series of treatments are needed. To treat these pigmented birthmarks short pulse lasers are used such as the Q Switch nanosecond or picosecond systems. Short pulse lasers confine their laser energy more inside the pigment cells for better results in shattering the melanin pigment. As these birthmarks consist mainly of superficial (epidermal) pigment, shorter wavelength lasers tend to give the best results, such as the NdYAG, Ruby or Alexandrite lasers.

Dermal Melanocytosis can be treated by laser and because in this group of conditions the pigment is deeper in the dermis layer of the skin, longer wavelength lasers are used such as the 1064 nm laser as it can penetrate deeper. Newer picosecond lasers may be more effective however multiple treatments are needed. Unfortunately it is known that recurrence can occur after laser treatment in some patients.

The laser treatment of Congenital Naevi is controversial as these lesions have a small recognised chance of malignant change. There is no evidence that laser treatment promotes melanoma formation but some experts are concerned that partial laser treatment might mask melanoma formation and delay diagnosis. Large and Giant Congenital Naevi need regular follow up and surveillance in a specialised dermatology clinic.