Long-Pulsed Nd:YAG Laser
The long-pulsed Nd:YAG laser also can be used to treat deep vascular lesions and remove unwanted hair. Because of its low window of safety in the treatment of vascular lesions, the alexandrite laser usually is preferred. However, it is the preferred laser for treatment of unwanted hair and hidradenitis suppurativa in darker skin types. It often provides a 50% reduction in hair density after 9 treatments.20
Quality-Switched Lasers
Pigment granules in melanosomes and tattoo particles are targeted with quality-switched (QS) lasers. Typically, a device will contain a combination of QS 532-nm potassium-titanyl-phosphate (KTP) lasers, QS 1064-nm Nd:YAG lasers, and QS 755-nm alexandrite lasers in 1 machine. In general, shorter wavelengths are used to treat epidermal lesions such as ephelides, lentigines, and café-au-lait macules. Longer wavelengths are used to treat deeper lesions such as nevus of Ota. A 2017 review suggested that café-au-lait macules with ragged borders (so-called coast of Maine borders) may respond well to QS lasers.21
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Ablative Lasers
The 10,600-nm CO2 laser and 2940-nm erbium:YAG laser can be used to debulk superficial tumors such as lymphangiomas, syringomas, angiofibromas, and xanthomas.22 These treatments have a higher risk for scarring than other lasers, so it is important to have a good understanding of desired clinical end points before using these devices.
Fractionated Lasers
Fractionated lasers can be nonablative (several devices are available in the 1410- to 1927-nm range) or ablative (CO2 or erbium:YAG). In pediatrics, they are usually used to treat burn scars, traumatic scars, and mild to moderate acne scarring.22 The most common side effects from fractionated lasers are prolonged erythema or hyperpigmentation. In addition, it typically takes at least 3 treatments to notice improvements.
Excisions
Pediatric procedural dermatologists remove a variety of unique lesions through excision. A few tips are provided for some of the more common lesions that may be excised in children.
Accessory Tragi
Prior to excising an accessory tragus, the surgeon should consider documenting a facial nerve examination, as accessory tragi can be associated with complete or partial facial nerve dysfunction. Additionally, there usually is an underlying cartilage structure present within the tragus. The cartilage stalk also should be addressed during the excision to avoid a continued palpable deformity after excision.
Dermoid Cysts
Dermoid cysts are the most commonly diagnosed benign orbital lesion in children.23 Exophytic periorbital lesions, which extend outside the orbital rim, can be removed through an infrabrow incision. Endophytic periorbital lesions, which are inside the orbital rim, should be removed through a crease incision. Midline lesions may have an intracranial extension and should be imaged through MRI and/or a computed tomography.24 Because dermoid cysts usually are located below the orbicularis oculi muscle, the muscle should be fixed with a suture prior to closing with skin sutures.
Pilomatricomas
Typically, a linear incision is made overlying the lesion, and then the underlying tumor is removed with sharp or blunt dissection. However, if the overlying skin has been stretched thin, a lenticular excision that includes the thinned skin may improve cosmesis.
Congenital Nevi
Large congenital nevi typically are removed through staged excisions. Lower extremity lesions are best removed before 10 months of age or before walking begins to minimize wound tension. However, if the procedure is not performed in infancy, it is best to wait until walking becomes stable.25 In older children, it is advisable to splint the affected lower extremity for 2 weeks to prevent dehiscence. The interval between excisions typically is 4 to 6 weeks for small lesions and 3 months for larger nevi.
Conclusion
Procedural pediatric dermatology is a broad and emerging field. As this article highlights, children are not small versions of adults and have unique biology, diseases, therapies, social situations, and ethical challenges from adults. This article provides a superficial overview of some of the more common issues faced by pediatric dermatologists and providers who perform procedures on infants, children, and teenagers. Readers who are interested in obtaining a more in-depth understanding of procedural pediatric dermatology should look at Procedural Pediatric Dermatology,1 the first textbook to provide expert opinion and evidence-based information on procedural management of pediatric skin conditions.