Mark the Difference

By: Dr Neil Walker
Created on 05th October 2010

Consultant dermatologist Dr Neil Walker answers our questions on birth marks and how to treat them

What different types of birthmarks exist and what causes them?

It depends on how you define a birthmark. As far as the skin is concerned there are a lot of developmental abnormalities that can occur.

One of the most common of these is a malformation of the capillaries, known as a port wine stain.This can be anything from a small mark on the surface of the skin to very extensive abnormal development of the whole blood vessel architecture.

Then there are abnormalities of the pigment system, which are called congenital melanocytic nevi. These can be quite small individual lesions – smaller than the tip of a pencil even – or they can be really quite extensive and disfiguring.

Finally, there are abnormalities of the other cellular structures of the skin, from the sebaceous glands to the normal, ‘horny’ layer of the skin, which are called epidermal nevi.

The cause is not always known – in certain instances there are identified genetic problems, but very often it just seems to be a developmental glitch, as the tissues are developing in utero.

What methods exist to treat them?

It all depends on the severity of the birthmark. Sometimes, if it’s a very disfiguring or disabling mark, formal plastic and reconstructive surgery is appropriate.

Some people have a problem with extensive thickening and overgrowth of the horny layers of the skin and have to manage a very strict care routine to look after their skin and stop it getting thickened, chaffed or infected.

Then there are various lasers available to deal with birthmarks. One of the ones I use is Cynosure’s Cynergy laser, which is basically a vascular pulse dye laser with a long pulse YAG laser attached, so you can use it as a standalone vascular laser, or as a standalone long pulse YAG laser, which is primarily used to treat deeper vessels or to remove hair on darker skin tones.

I use the two lasers synergistically – which is howit is meant to be used, hence the name – to treat some of the more difficult port wine stains. Although Cynergy is not the first machine to deliver both these lasers in the same package, it is the first that can employ both lasers together.

How does the Cynergy treatment work?

The pulses of laser light are delivered as circles, which are about seven millimetres across. These need to be abutted, but you can’t overlap them, so you need to do a series of treatment sessions, usually spaced about two months apart.

What the laser is doing is delivering pulses of light into the tissues and damaging the vessels, which produces a tissue reaction that settles down over a period of a week to ten days each time.

So each time you go back and pick up the gaps in between the circles and you do that working your way down through the depth of the port wine stain until you get no further improvement.

How much of an improvement can you expect at the end of treatment?

Again, that’s very variable. The Cynergy is one of the best treatments available for this and offers a far greater improvement than any other laser I have worked with, however there are some vessels that are so deep even a machine like the Cynergy can’t reach them without scarring.

A small proportion of patients – around ten to 15 per cent – will get such an improvement that you can’t see the mark at normal social distances. The vast majority get a significant improvement, which means that the mark is much easier to disguise with make-up.

What sort of downtime can I expect?

The main side effect is local inflammation and bruising – what’s called a purpuric reaction. That’s actually reduced with the Cynergy, compared to the conventional pulse dye laser, but you would still expect an average of about a week’s downtime post-treatment.

A lot of patients use aloe products or soothing creams to calm the inflammation, and some will just cover it with make-up so they can get out and about sooner rather than later. It is all up to the individual patient, but I usually recommend a week of rest and avoidance of social activity.

Can the treatment be performed on children?

You can perform it on children, and you often get a very nice improvement with a child. With lasers I used in the past, however, you would often see that child go through to adulthood and the mark beginning to come back.

There are patients who I treated 15 or 20 years ago who are now coming back for further treatment as the mark has darkened up. We don’t quite know why this happens, but I think it is a degenerative thing – basically, these are vessels which, as we understand it, haven’t got their proper nerve controls. They’re not as tight as they should be and therefore they expand over time and carry more blood.

What one doesn’t know yet with the Cynergy, as it’s only been in use in the UK for four years, is whether that relapse rate is going to reduce because we’re getting a more complete improvement.

When is the best time to have the treatment?

As with any laser treatment, it cannot be performed if you have a tan – the tanning layer of the skin is between the surface and the blood vessels, so your patients need to be in a programme of very careful sun protection and, where possible, sun avoidance. So autumn or winter is probably the best time to begin treatment.