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The Combined Continuous-Wave/Pulsed Carbon Dioxide Laser for Treatment of Pyogenic Granuloma
Christian Raulin, MD;
Baerbel Greve, MD;
Stefan Hammes, MD
Arch Dermatol. 2002;138:33-37.
ABSTRACT
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Background Pyogenic granuloma is a frequently diagnosed, benign vascular lesion.
Objectives To present the use of the combined continuous-wave/pulsed carbon dioxide
(CO2) laser as an innovative therapeutic method, to compare it
with established methods, and to assess its results.
Design Prospective observational study between March 1998 and July 2000, comprising
1 treatment session with 6-week and 6-month follow-up examinations and evaluations.
Setting Private or institutional practices as well as ambulatory or hospitalized
care.
Patients One hundred patients with pyogenic granuloma selected from a population-based
sample.
Interventions Treatment with CO2 laser. The laser was first used in continuous
mode (power, 15 W) and then in pulsed mode (pulse length, 0.6-0.9 milliseconds;
energy fluence, 500 mJ/pulse).
Main Outcome Measure Complete resolution of treated granuloma pyogenicum.
Results Pyogenic granuloma was removed completely in 1 treatment session in
98 patients without recurrence. In 88 cases there were no visible scars; in
10 cases slight textural changes of the skin were observed. Hypertrophic scars
or keloids did not occur. Sixty-three patients were very satisfied with the
result of the treatment, 37 were satisfied (ie, 100% patient satisfaction),
and none indicated that they were not satisfied. No permanent hypopigmentation,
hyperpigmentation, or erythema was observed.
Conclusions The combined continuous-wave/pulsed CO2 laser is our treatment
of choice for pyogenic granuloma because this kind of laser is widely available,
produces excellent results with few adverse effects, is easy to use, yields
low recurrence rates, and is well tolerated by most patients.
INTRODUCTION
PYOGENIC GRANULOMA is a frequently diagnosed, benign vascular lesion.
Possible treatment methods are excision, curettage, cryotherapy, chemical
and electric cauterization, and the use of lasers.1-5
The argon laser has long been used to treat pyogenic granuloma, but its use
may be associated with an increased risk of scarring.6
In one case, a large gingival pyogenic granuloma was removed with a continuous-wave
(CW) Nd:YAG laser.5 There are several reports
about the use of the pulsed dye laser,3, 7-8
although it has only been successfully used in removing very small granulomas;
several treatment sessions were necessary in most cases.8-9
In the past few years, the CW carbon dioxide (CO2) laser has proved
to be an effective treatment option.10 Its
use permits rapid, minimally invasive surgical treatment, but the nonspecific
coagulation may lead to scars.
In 1997, we first reported the successful combined use of CW and pulsed
CO2 lasers in a retrospective pilot study10
that involved 13 patients. The CW laser was used to coagulate the lesion,
and the pulsed CO2 laser to treat the base carefully; the correct
use of the latter permits the skin to heal with minimal scarring. These positive
results and the simplicity of the method encouraged us to evaluate it further
and carry out the present prospective study with 100 patients.
PATIENTS AND METHODS
In a prospective study conducted between March 1998 and July 2000, we
used the CO2 laser (10 600 nm) (UltraPulse 5000 C; Coherent
Inc, Palo Alto, Calif) to treat 100 patients (57 female and 43 male) with
pyogenic granuloma (Table 1).
Their age ranged between 6 months and 84 years (mean, 26.8 years; median,
24.9 years). The laser was first used in continuous mode (power, 15 W; focused
handpiece with variable spot size of 1.5-3.0 mm) and then in pulsed mode (pulse
length, 0.6-0.9 milliseconds; fluence, 500 mJ/pulse), with the same handpiece.
Prior to laser therapy, intracutaneous local anesthetic (1% lidocaine [1%
Xylocaine; AstraZeneca GmbH, Wedel, Germany]) was administered in 98 cases;
a brief general anesthesia was selected for the treatment of 2 children. Postoperative
erosions and the crusting that occurred after some days were treated with
iodine ointment.
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Table 1. Demographic Data
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In 58 cases, the granulomas were localized on the face (cheek, 18; lips,
12; tongue, 1; and other, 27); in 17 cases, on the fingers; and in 25 cases,
elsewhere on the integument. The diameter of the lesions measured less than
0.3 cm in 23 cases, 0.3 to 0.6 cm in 64 cases, and greater than 0.6 cm in
13 cases. In 5 cases the granulomas had occurred as an adverse effect of a
prior laser treatment of port-wine stains (4 after treatment with pulsed dye
laser, 1 after argon laser treatment). In 4 cases the granulomas were recurrences
after excisions carried out in other surgeries. A summary of the demographic
data is given in Table 1.
The study design comprised a 1-treatment session with 6-week and 6-month
follow-up examinations and evaluations conducted by 3 independent physicians
who were not involved in the study as well as by the patients (or their parents).
In this context, the following data and scales were used by the patients:
satisfaction with the result (0, very satisfied; 1, satisfied; 2, not satisfied),
healing process (0, very satisfied; 1, satisfied; 2, not satisfied). The evaluating
physicians used the following data and scales: duration of healing (data given
in weeks), recurrence (Boolean value), hypopigmentation or hyperpigmentation
(0, none; 1, transient hypopigmentation or hyperpigmentation; 2, permanent
hypopigmentation or hyperpigmentation), scars (0, no visible scars; 1, slight
textural changes of the skin; 2, atrophic scars; 3, hypertrophic scars; 4,
keloids), erythema (0, none; 1, transient; 2, permanent), duration of erythema
(weeks). Photographic documentation was done at the beginning and at the end
of the study (EOS100 [Canon USA, Inc, Lake Success, NY] with Agfachrome CTx
100 film [Agfa Corp, Ridgefield Park, NJ]).
RESULTS
The pyogenic granuloma was removed completely in 1 session without recurrence
in 98 patients; recurrence was observed in only 2 patients. There were no
visible scars in 88 cases, and slight textural changes were observed in 10.
Small atrophic scars were documented in 2 cases, and hypertrophic scars or
keloids did not occur at all.
Sixty-three patients found the treatment results very satisfactory;
37, satisfactory; and none said that it was unsatisfactory. In terms of patient
response to the healing process, the reactions were quite similar: 41 found
it very satisfactory; 59%, satisfactory; and none, unsatisfactory. In our
evaluation, the answers "satisfied" and "very satisfied" were taken as an
indication that the operation was successful and appreciated by the patient.
Therefore, we had 100% patient satisfaction. The difference between "satisfied"
and "very satisfied" was only gradual and perhaps based on different patient
expectations.
The healing process (defined as re-formation of the epidermal integrity
after disappearance of the crusts) lasted up to 1 week in 52 patients, up
to 2 weeks in 41, and up to 3 weeks in 7. No hypopigmentation or hyperpigmentation
was observed in 88 cases; transient hypopigmentation or hyperpigmentation
occurred in 12 (lasting up to 6 months). No permanent hypopigmentation or
hyperpigmentation occurred. In 62 cases, the erythema had disappeared after
6 weeks. For the remaining 38, the erythema had resolved before the second
follow-up examination (total duration under 6 months). On average, the erythema
persisted for 3.5 weeks. Permanent erythema was not observed. A summary of
the results is given in Table 2. Figure 1, Figure 2, and Figure 3,
show pretreatment and posttreatment status for 3 typical patients.
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Table 2. Results of Treatment With the Combined Continuous-Wave/Pulsed
Carbon Dioxide Laser*
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Figure 1. A, Patient with pyogenic granuloma
on the finger. B, Status 6 weeks after a single therapy session with the continuous-wave/pulsed
carbon dioxide laser. The lesion has healed completely without scars.
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Figure 2. A, Patient with pyogenic granuloma
on the upper lip. B, Status 5 weeks after a single therapy session with the
continuous-wave/pulsed carbon dioxide laser. The lesion has healed completely
without scars.
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Figure 3. A, Patient with pyogenic granuloma
on the lower lip. B, Status immediately after operation. C, Status 7 weeks
after a single therapy session with the continuous-wave/pulsed carbon dioxide
laser. The lesion has healed completely with only slight textural changes.
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COMMENT
So far, surgical excision or electrocoagulation has been considered
the standard treatment of pyogenic granuloma.2
However, because of the remaining scars, excision is a suboptimal form of
therapy, especially since the lesions often occur in exposed places such as
the face or fingers. Bleeding can also complicate the operation process, especially
in huge granulomas or if the excision is close to the lesion.
The use of the pulsed dye laser can yield excellent cosmetic results,
although several treatment sessions are necessary.1, 9, 11
Owing to its limited penetration depth, this kind of laser can only be used
to treat small granulomas. Tay et al9 showed
that a successful treatment is possible only with granulomas of a diameter
smaller than 5 mm. Using the pulsed dye laser, we could remove only lesions
with a maximum diameter of 2.5 mm successfully. There are reports about the
induction of pyogenic granuloma due to the use of the dye laser, potassium-titanyl-phosphate–Nd:YAG
laser, and argon laser, as well as by cryosurgery.12-18
The etiological data of our study confirms this observation for the dye and
argon lasers. Any laser therapy should only be done if it is certain that
the lesion is benign. If there is any doubt, conventional surgical methods
or laser treatment should be used only with histological confirmation.
The CO2 laser emits radiation with a wavelength of 10 600
nm, which is absorbed by the water in biological structures. The laser energy
destroys the integrity of the cellular structure by quickly heating and vaporizing
the intracellular liquid. Target structures such as pigmentation or vascularization
are of no importance for the CO2 laser,19-20
which is unlike other kinds of lasers such as the Q-switched ruby laser or
the pulsed dye laser. There is a certain risk of scars due to the unspecific
coagulation in the continuous mode.
In case reports21 and in our pilot study,10 the use of the CW CO2 laser has proved
to be an effective method to treat pyogenic granuloma. Kirschner and Low22 described the combined use of shaving and photocoagulation
with pulsed dye laser. Here, the advantage of the histological confirmation
must be balanced against the increased risk of bleeding, which, in our experience,
may not be well controlled by dye laser irradiation, especially in deep or
large granulomas.
For some years now, pulsed (<1 millisecond) CO2 lasers
have been used in addition to the CW CO2 laser in dermatology and
plastic surgery. The pulse length of these lasers is 600 to 900 µs and
is shorter than the thermal relaxation time of the epidermal cells (695 to
950 microseconds); thus, thermal damage in the surrounding tissue can be neglected.
When used correctly, the pulsed CO2 laser makes it possible to
remove very thin skin layers without leaving scars.4, 19-20,23
The risk of scarring cannot be ruled out entirely because the basement membrane
can be destroyed when several treatment passes are used.24
In the present study, pyogenic granulomas were removed successfully
with low rates of concomitant reactions or adverse effects; this was due to
the combined use of continuous and pulsed mode of the CO2 laser.
The continuous mode leads to rapid and minimally invasive coagulation of the
vascular lesion. This is, in principle, also possible with other coagulating
lasers (eg, argon and CW Nd:YAG), but when it comes to the delicate task of
removing the basis of the lesion, vaporization in pulsed mode has proved to
be advantageous. Extremely thin skin layers can be removed, thus allowing
differences in skin levels to be gently evened out. This can only be achieved
with pulsed CO2 lasers.
In contrast to the pulsed dye laser, only 1 treatment session with the
CO2 laser was necessary in 98% of the cases. It is indeed a problem
to find the correct point to switch from continuous to pulsed mode. We used
the continuous mode until the lesion was flattened down to its ground and
there were only capillary bleedings left. Then we switched to pulsed mode.
It is critical to go deep enough to remove the granuloma entirely; the 2 recurrences
that occurred in our study were probably due to an incomplete or overcautious
removal, and they disappeared permanently after another treatment session.
The CO2 laser has advantages over common operative methods:
treatment and convalescence take considerably less time. An experienced physician
needs a maximum of 5 minutes for the operation, even for big granulomas. There
is no wound to close and no suture material to trigger allergic or foreign
body reactions. With the CO2 laser, it is no problem to treat the
sites of predilection, which are usually difficult to access and are located
on exposed parts of the body such as the eyelids, fingers, or toe phalanges.
The method can accommodate large lesions, and it is equally suitable for patients
who tend to bleed heavily. We see the use of the combined CW/pulsed CO2 laser as the treatment of choice for pyogenic granuloma because this
kind of laser is widely available, produces excellent results with few adverse
effects, is easy to use, yields low recurrence rates, and is well tolerated
by most patients.
AUTHOR INFORMATION
Accepted for publication May 2, 2001.
We dedicate this article to Detlef Petzoldt, professor of dermatology
and venereology, head of the department of dermatology of the University of
Heidelberg, Heidelberg, Germany, on the occasion of his 65th birthday. He
has always been an extraordinary teacher for us and an excellent physician
for his patients, and he has always focused on scientific innovation. We would
like to thank Alexandra Sitzmann, MA, and Laura Russel, MA, for help with
the translation of the text.
Corresponding author and reprints: Christian Raulin, MD, Laserklinik
Karlsruhe, Kaiserstr 104, D-76133 Karlsruhe, Germany (e-mail: info{at}laserklinik.de).
From the Laserklinik Karlsruhe, Karlsruhe, Germany.
REFERENCES
| |
1. Goldberg DJ, Sciales CW. Pyogenic granuloma in children: treatment with the flashlamp-pumped
pulsed dye laser. J Dermatol Surg Oncol. 1991;17:960-962.
ISI
| PUBMED
2. Fitzpatrick TB, ed, Eisen AZ, ed, Wolff K, ed, Freedberg IN, ed, Austen KF, ed. Dermatology in General Medicine. New York, NY: McGraw-Hill Co; 1987:661.
3. Glass AT, Milgraum S. Flashlamp-pumped pulsed dye laser treatment for pyogenic granuloma. Cutis. 1992;49:351-353.
ISI
| PUBMED
4. Goldman MP, Fitzpatrick RE. Cutaneous Laser Surgery. St Louis, Mo: Mosby–Year Book Inc; 1994:64.
5. Powell JL, Bailey CL, Coopland AT, Otis CN, Frank JL, Meyer I. Nd:YAG laser excision of giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med. 1994;14:178-183.
ISI
| PUBMED
6. Apfelberg DB, Maser MR, Lash H, Rivers JL. Progress report on extended clinical use of the argon laser for cutaneous
lesions. Lasers Surg Med. 1980;1:71-83.
PUBMED
7. Gonzalez E, Gange RW, Momtaz KT. Treatment of telangiectases and other benign vascular lesions with
the 577 pulsed dye laser. J Am Acad Dermatol. 1992;27:220-226.
ISI
| PUBMED
8. Meffert JJ, Cagna DR, Meffert RM. Treatment of oral granulation tissue with the flashlamp pulsed dye
laser. Dermatol Surg. 1998;24:845-848.
FULL TEXT
|
ISI
| PUBMED
9. Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granuloma in children with the flashlamp-pumped
pulsed dye laser. Pediatrics. 1997;99:368-370.
FREE FULL TEXT
10. Raulin C, Petzoldt D, Werner S. Granuloma pyogenicum: Entfernung mit dem CO2-Laser. Hautarzt. 1997;48:402-405.
FULL TEXT
|
ISI
| PUBMED
11. Gonzalez S, Vibhagool C, Falo LD Jr, Momtaz KT, Grevelink J, Gonzalez E. Treatment of pyogenic granulomas with the 585-nm pulsed dye laser. J Am Acad Dermatol. 1996;35:428-431.
FULL TEXT
|
ISI
| PUBMED
12. Abd-el-Raheen TA, Hohenleutner U, Landthaler M. Granuloma pyogenicum as a complication of flashlamp-pumped pulsed dye
laser. Dermatology. 1994;189:283-285.
ISI
| PUBMED
13. Wlotzke U, Hohenleutner U, Abd-El-Raheem TA, Baumler W, Landthaler M. Side-effects and complications of flashlamp-pumped pulsed dye laser
therapy of port-wine stains: a prospective study. Br J Dermatol. 1996;134:475-480.
FULL TEXT
|
ISI
| PUBMED
14. De Rooij MJ, Neumann HA. Granuloma telangiectaticum after argon laser therapy of a spider nevus. Dermatol Surg. 1995;21:356-357.
FULL TEXT
|
ISI
| PUBMED
15. Beers BB, Rustad OJ, Vance JC. Pyogenic granuloma following laser treatment of a port-wine stain. Cutis. 1988;41:266-268.
ISI
| PUBMED
16. Dejonckere PH, Franceschi D, Scholtes JL. Extensive granuloma pyogenicum as a complication of endolaryngeal argon
laser surgery. Lasers Surg Med. 1985;5:41-45.
ISI
| PUBMED
17. Cecchi R, Giomi A. Pyogenic granuloma as a complication of cryosurgery for venous lake. Br J Dermatol. 1999;140:373-374.
FULL TEXT
|
ISI
| PUBMED
18. Raulin C, ed, Greve B, ed. Laser und IPL-Technologie in der Dermatologie und
Ästhetischen Medizin. Stuttgart, Germany: Schattauer; 2001.
19. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch Dermatol. 1996;132:395-402.
FREE FULL TEXT
20. Lowe NJ, Lask G, Griffin ME, Maxwell A, Lowe P, Quilada F. Skin resurfacing with the ultrapulse carbon dioxide laser. Dermatol Surg. 1995;21:1025-1029.
FULL TEXT
|
ISI
| PUBMED
21. Modica LA. Pyogenic granuloma of the tongue treated by carbon dioxide laser. J Am Geriatr Soc. 1988;36:1036-1038.
ISI
| PUBMED
22. Kirschner RE, Low DW. Treatment of pyogenic granuloma by shave excision and laser photocoagulation. Plast Reconstr Surg. 1999;104:1346-1349.
ISI
| PUBMED
23. Reid R. Physical and surgical principles governing carbon dioxide laser surgery
on the skin. Dermatol Clin. 1991;9:297-316.
ISI
| PUBMED
24. Raulin C, Kimmig W, Werner S. Lasertherapie in der Dermatologie und Ästhetischen Medizin: Nebenwirkungen,
Komplikationen und Behandlungsfehler. Hautarzt. 2000;51:463-473.
FULL TEXT
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ISI
| PUBMED
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