Dermatology Times By Karen Appold
A laser is a suitable mode of treatment for certain dermatologic conditions in pediatric patients; however, there are certain procedural aspects that physicians should consider when treating younger children.
“Indications for children are typically different than those for adults,” notes E. Victor Ross, M.D., dermatologist, Scripps Clinic Carmel Valley, San Diego, Calif. “Most children I treat with lasers have had their conditions since birth, such as birthmarks, whereas adults have conditions brought on by the sun.”
Lawrence F. Eichenfield, M.D., chief of pediatric and adolescent dermatology at Rady Children’s Hospital—San Diego; vice chair of the department of dermatology, and professor of dermatology and pediatrics at the University of California, San Diego School of Medicine, uses lasers to treat children for vascular lesions, including hemangiomas and port-wine stains, pigmented lesions, hamartomas, scars, and laser hair removal.
Considerations: If a child is scared about having a laser procedure — whether they are needle phobic, procedure phobic, or pain phobic, a physician may need to take steps to ensure a successful experience.
“We use techniques to minimize pain and anxiety to make it as pain-free and stress-free as possible, including applying topical numbing agents and oral analgesics, and using general anesthesia for larger treatment areas,” Dr. Eichenfield says.
When using numbing cream, Dr. Ross cautions to not use too much, as it can be toxic for children aged one to three.
“Their skin surface ratio compared to the volume of their body is very high, so only use around 15 grams of numbing cream,” he advises.
Dr. Ross says the child sets the tone for a procedure.
“I can usually tell within the first 30 seconds after entering the exam room if a child will require a lot of reassurance and possibly holding or holding down,” he says. “The key is for the physician to begin the procedure as soon as possible upon entering the room, so the child has less time to think about backing out of it. Therefore, staff should complete preparations for a procedure prior to a physician’s entrance.”
If a dermatologist is performing a treatment on a child’s face, and the child has been equipped with goggles, have a staff person watch the child and make sure the child doesn’t remove them. Likewise, when placing shields over their eyes, expect some children to be apprehensive.
“Sometimes we have to talk to the child throughout the procedure’s duration to reassure them that we are still here,” Dr. Ross says. “Parents have different roles in these encounters — they may hold their child’s hand or even hold a smaller child. But we have to make sure the parent doesn’t get in the way of a procedure,” he adds.
“A goal is to not have a child, parent, physician, or staff member become traumatized,” Dr. Ross continues. “Sometimes, if a child becomes too overwhelmed, they will have to come back another time.”
If using general anesthesia, which would typically be done for larger lesions requiring lengthier procedures, make sure family members are aware of what is known and not known about the potential risks of using it.
“Balance the appropriateness of employing laser therapy with its potential risks,” Dr. Eichenfield says.
Typically, the physician will apply the laser in the same way for children as for adults. However, their approach might change, such as they may administer treatment more slowly.
“I might do a few pulses and then stop, so the child can acclimate themselves to the situation and become more comfortable,” Dr. Ross says.
When lasers aren’t appropriate: When a child has a skin condition with minimal cosmetic impact, a physician may want to recommend laser treatment at a later time if there’s no significant benefit from early treatment.
“For certain port wine stains, there may be advantages to treating them during an infant’s first year,” he says. “But for other conditions, it might be appropriate to wait for a child to get older to determine if laser treatment is truly warranted.”
Also, consider whether the child’s condition might improve with time before treating it with a laser, Dr. Ross says. For example, if a six-year-old child has a prominent spider angioma on his face, discuss the likelihood of it getting better, or rarely getting worse. Or, if a parent or child’s expectation for a procedure isn’t realistic, then forgo treatment.
“Lasers are one of the most challenging and rewarding aspects of my practice,” Dr. Eichenfield concludes. “Although it sometimes requires extra work to get children through procedures, it is worth it, given the significant impact the surgeries can make for the rest of their lives. Observable and functional deformities have lifetime influences. I have seen tremendous psychological effects from birthmarks that haven’t been treated, as well as tremendous satisfaction from intervention with laser technology — which is generally safe and effective.”