STUDY

Flashlamp-Pumped Pulsed Dye Laser

for Hemangiomas in Infancy
Treatment of Superficial vs Mixed Hemangiomas
Margitta Poetke, MD; Carsten Philipp, MD; Hans Peter Berlien, MD

Objective: To study in a compared manner the effi-
cacy of flashlamp-pumped pulsed dye laser (FPDL)
therapy for superficial and mixed hemangiomas.
Design: Nonrandomized control trial.
Setting: Department of Lasermedicine, General Hospi-
tal Neukölln, Berlin, Germany.
Patients: To investigate variation in response to treat-
ment, a prospective study of 165 children with 225
separate hemangiomas treated with the FPDL was un-
dertaken. Patients were aged 2 days to 7 years; mean
follow-up was 5 months.
Results: In the first group of 100 patients with 153 flat
cutaneous hemangiomas, 52 hemangiomas (34%) had ex-
cellent results; 80 (52%) had good results; and 21 (14%)
showed proliferation of the subcutaneous component, al-
though these lesions were flat at first presentation. Of the
54 mixed hemangiomas, 33 (61%) had continued prolif-
eration of the subcutaneous component. The cutaneous
component responded to therapy in 21 hemangiomas
(39%), whereas the subcutaneous component of the mixed
hemangiomas remained unchanged. No lesions in this group
involuted completely, and therapy was discontinued be-
cause of relatively poor response. Twelve (67%) of 18 pa-
tients with superficial hemangiomas in the involution phase
had excellent results and 6 (33%) had good results.

Interventions: During a 21⁄2-year period, we adminis-
tered 332 treatments, for a mean ± SD of 2.0 ± 1.1 treat-
ments per patient.
Main Outcome Measure: Patients received therapy
until the lesion was almost clear or until the lesion
did not respond to treatment. Evaluation was per-
formed by comparing pretreatment and posttreatment
photographs. In addition, pathologic flow of vessels
and thickness were determined before, during, and
after completion of therapy with color-coded duplex
sonography.
Conclusions: Treatment with the FPDL is effective and
may be the treatment of choice for superficial cutane-
ous hemangiomas at sites of potential functional impair-
ment and on the face. Hemangiomas with a deep com-
ponent do not benefit from FPDL treatment because the
efficacy of the FPDL is limited by its depth of vascular
injury. Furthermore, early therapeutic intervention with
the FPDL may not prevent proliferative growth of the
deeper or subcutaneous component of the hemangioma
despite early intervention.
Arch Dermatol. 2000;136:628-632

From the Department of
Lasermedicine, General
Hospital Neukölln, Berlin,
Germany.
H
EMANGIOMAS ARE com-
mon benign vascular tu-
mors that are present at
birth in 2% to 3% of new-
borns1 and in up to 22%
of preterm infants weighing less than 1000
g.2 Hemangioma has a female-male pre-
ponderance of 3:1.3 Lesions initially ap-
pear as a white or pink macule, a port-
wine stain–like lesion, or a telangiectasia
with surrounding vasoconstriction (pro-
dromal or initial phase). Some stay flat, el-
evating only slightly above the precursor
stage, whereas others grow (proliferation
phase) to become truly gigantic. Heman-
giomas have been classified as cutane-
ous, subcutaneous, or mixed. Their color
intensity essentially depends on their depth
and spread and the lumina of the vessels
involved, but there may be fluctuation due
to localization, state of excitement, and
temperature.
Although all regions of the body can
be affected by hemangiomas, 60% to 70%
are localized on the head. The most com-
mon complications of hemangiomas are
ulceration and secondary infection, bleed-
ing, disfigurement (especially with facial
lesions), and ophthalmic problems re-
lated to periorbital lesions; furthermore,
an airway hemangioma might produce
obstruction and respiratory failure.

ARCH DERMATOL / VOL 136, MAY 2000 WWW.ARCHDERMATOL.COM

628

©2000 American Medical Association. All rights reserved.

Downloaded From: http://archderm.jamanetwork.com/ by a University of Alabama-Birmingham User on 01/14/2013
 PATIENTS AND METHODS
A total of 165 children aged 2 days to 7 years with 225 hem-
angiomas were treated with the FPDL at the Department
of Lasermedicine, General Hospital Neukölln, Berlin, Ger-
many, between July 1996 and December 1998: 113 girls
(68%) and 52 boys (32%). Forty-one patients were pre-
term infants; we started treatment when the children
weighed more than 1800 g. Six patients were twins and 1
was a triplet.
Although most lesions (n=87) were localized to the
face and neck, 60 patients had a lesion on the extremities,
59 had a lesion on the trunk, and 19 had a lesion on the
anogenital region. Eight lesions were ulcerated at presen-
tation.
The 165 patients were divided into 3 groups: 100 pa-
tients with 153 flat cutaneous hemangiomas, 47 with 54
mixed cutaneous-subcutaneous lesions, and 18 with 18 su-
perficial hemangiomas in the involution phase.
Of 153 flat hemangiomas, 74 were clinically early hem-
angiomas (48%) in the initial phase that looked like a faint
macular pink patch, with a patient age range of 2 days to 8
weeks; 48 (31%) were actively proliferative hemangio-
mas; and only 31 (20%) were matured hemangiomas in the
more well-developed phase, that do not develop beyond
this flat stage. They usually looked bright red and nodu-
lar. In the group with actively proliferative flat hemangio-
mas, the average patient age was approximately 14 weeks
(range, 10 weeks to 7 months). Those with matured hem-
angiomas were aged 11 weeks to 9 months.
In the group with mixed hemangiomas, patients
were aged 4 weeks to 10 months. Patients with superfi-
cial hemangiomas in the involution phase were aged 10
months to 7 years. Four were younger than 1 year and
only 2 were older than 7 years. All these lesions were
slow in regressing and occurred in a cosmetically or
functionally prominent area. Mean follow-up for each
group was 5 months.
Pathologic flow of vessels and thickness were deter-
mined before, during, and after completion of therapy with
a color-coded duplex sonography system with a linear ar-
ray applicator of 7.5 to 9.0 MHz (Sonoline Elegra; Siemens
Aktiengesellschaft, Erlangen, Germany). Furthermore, pho-
tographs were taken of all patients before and after each
treatment.
Informed consent was obtained before the proce-
dure, and risks and benefits were explained to the pa-
tients’ parents.
We used the FPDL (Carl Baasel-Lasertechnik GmbH,
Starnberg, Germany) with the following settings: a wavelength
Hemangiomas are characterized by a proliferation
growth phase followed by slow, inevitable regression (in-
volution phase) between 1 and 10 years of age. Al-
though hemangiomas resolve, lesions persist in 35% to
50% of children who begin school. Even after spontane-
ous involution of the lesions, 15% of children have re-
sidual skin changes, including depigmentation or hyper-
pigmentation, telangiectasia, atrophy and wrinkling of
the skin, and cutaneous depression. If skin changes oc-
cur, remaining changes of the skin may correspond to
the largest size of the hemangioma.4 However, sponta-
ARCH DERMATOL / VOL 136, MAY 2000
629
©2000 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Alabama-Birmingham User on 01/14/2013
of 585 nm and a pulse duration of 300 microseconds. The
laser beam was transmitted down at 1-mm fiber with the
use of a convex lens and was focused directly on the skin
surface with a 5-mm spot beam. Energy fluences ranged
from 5 to 7 J/cm2, and its use varied according to the age
of the patient and the anatomical location and thickness
of the lesion. Energy fluency was frequently reduced over
the eyelids, hands, scrotum, and gluteal region. Treat-
ments are performed with a maximum spot overlap of
20% to 30%.
The high pulse peak power of the FPDL disrupts the
vessels. Immediately after treatment, the treated area turned
blue-lilac (purpuric), with surrounding erythematous flare;
this took 7 to 14 days to resolve. Some edema, especially
in the periorbital area, was possible. If blanching or gray-
ing of the epidermis occurred during application, energy
fluences were reduced to avoid blistering of the epider-
mis. After treatment, the treated areas were covered with
panthenol ointment. In case of blistering or crusting, pa-
tients’ parents were instructed to cleanse the area with po-
vidone-iodine solution. Furthermore, we instructed par-
ents to keep their children’s fingernails short or to have the
children wear gloves to avoid trauma to the treated areas.
Patients were then evaluated at 2 to 4 weeks, and, depend-
ing on the degree of response, the entire lesion was then
treated again, usually 4 weeks after the first session.
Because these lesions are usually small in diameter and
few in number, 122 children (74%) generally tolerated the
treatment well without anesthesia. Infants older than 1 year
(8% of patients) had topical anesthetic cream (Eutectic Mix-
ture Topical Anesthetics; Astra Pharmaceutical, Oslow, Swe-
den) applied for 11⁄2 hours under occlusion before laser treat-
ment. General anesthesia was helpful for children with
extensive hemangiomas over a large dermatome and hem-
angiomas of the periorbital area, especially if the eyelids
were treated. Therefore, an eye shield was used to protect
the globe. Thirty patients (18%) required general anesthe-
sia.
Results were considered to be “excellent” when the
hemangioma had completely cleared, “good” when invo-
lution of the tumor was slower or lightening was not com-
plete, and a “failure” when the hemangioma remained rela-
tively unchanged or the lesion showed further enlargement.
Patients with treatment failure received further therapy with
the Nd:YAG laser at 1064 nm with the following settings:
a power of 25 to 46 W, a spot size of 5 mm, and applica-
tion in continuous mode. Highly sufficient protection of
the skin was provided by clear ice cubes placed directly on
the skin, whereby the laser beam was applied directly
through these ice cubes and the coagulation depth could
be increased up to 10 mm.
neous regression is no guarantee of a satisfactory cos-
metic result, as is often presumed.
Because these lesions may involute spontaneously,
allowing for spontaneous regression remains a viable
therapeutic option. Alternative treatments have in-
cluded radiation therapy, electrosurgery, cryosurgery, sur-
gical excision, sclerotherapy, embolization, and drug
therapy. In view of the potential adverse effects, these treat-
ments have not generally been advised for patients with
cutaneous hemangiomas. The quest for a therapy that
eliminates hemangiomas before development of compli-
WWW.ARCHDERMATOL.COM
 Comparison of Flashlamp-Pumped Pulsed Dye Laser A
Treatment of Cutaneous vs Mixed Hemangiomas

Treatment Results, No. (%)

Excellent Good Failure

Superficial hemangiomas (n = 153) 52 (34) 80 (52) 21 (14)
Mixed cutaneous-subcutaneous 0 21 (39) 33 (61)
hemangiomas (n = 54)
Cutaneous hemangiomas in the 12 (67) 6 (33) 0
involution phase (n = 18)
Total (N = 225) 64 (28) 107 (48) 54 (24)

cations and without systemic or cutaneous adverse

effects has been difficult. The flashlamp-pumped B

pulsed dye laser (FPDL) has been demonstrated to

effectively and safely treat cutaneous vascular lesions
like port-wine stains and telangiectases in children
while significantly minimizing any cutaneous adverse
effects. Several clinical trials5-9 with the FPDL have
been reported. Using the FPDL, an early and careful
therapy of hemangiomas has become possible so that
hemangiomas can be treated in the initial or prodro-
mal stage to avoid enlargement. The response of cuta-
neous hemangiomas to FPDL treatment has recently
been described.10,11 We studied in a compared manner
the efficacy of FPDL therapy for superficial cutaneous
and mixed hemangiomas.
C

RESULTS

We administered 332 treatments, for a mean ± SD of

2.0±1.1 treatments per patient. Responses were consid-
ered to be excellent in 64 hemangiomas (28%), good in
107 (48%), and failures in 54 (24%) (Table).
Of 153 flat hemangiomas in 100 patients, 52 (34%)
had excellent results and 80 (52%) had good results. Of
54 mixed hemangiomas in 47 patients who received FPDL
treatment, 21 (39%) had good response to treatment and
33 (61%) failed. Of 18 superficial hemangiomas in the
involution phase in 18 patients, 12 (67%) had excellent
results and 6 (33%) had good results.
The 153 flat hemangiomas showed no pathologic
flow into the subcutis in color-coded duplex sonogra-
phy before FPDL treatment. Thus, patients with flat cu-
taneous hemangiomas were more likely to have an ex-
cellent response (34%). These lesions showed total
lightening. The mean±SD number of treatments needed Figure 1. A, Preterm twin with an erythematous plaque on the neck. B, Same
to achieve complete involution was 1.6±1.1 (range, 1-5); lesion as in panel A after 1 flashlamp-pumped pulsed dye laser treatment.
52% of hemangiomas had good results after 1.4±0.7 treat- The superficial component resolved, whereas the subcutaneous component
proliferated. There was also a transient hypopigmentation of the area. C,
ments. Greater degrees of regression were seen with in- Color-coded duplex sonography showing the deep component and the
creased numbers of treatments. extension of the whole hemangioma. The various colors characterize the
Early or initial hemangiomas lightened 41% com- low-flow vessels of the hemangioma in the subcutis.
pared with 21% for actively proliferative hemangiomas
and 52% for the flat matured hemangiomas and needed with proliferation of the deep component, coloration by
2.1±0.9 treatments compared with 1.4 ± 0.9 treatments perfusion in the color-coded duplex sonography was ob-
for actively proliferative hemangiomas. Of 74 initial hem- served (Figure 1).
angiomas, only 13 (18%) showed no limitation of pro- Of 54 mixed hemangiomas, all showed capillariza-
liferation into the subcutis compared with 8 (17%) of the tion and hyperfusion in the subcutis up to a depth of ap-
48 actively proliferative hemangiomas, and further therapy proximately 4 mm in color-coded duplex sonography at
with the Nd:YAG laser was desired. In all of these cases presentation.

ARCH DERMATOL / VOL 136, MAY 2000 WWW.ARCHDERMATOL.COM

630

©2000 American Medical Association. All rights reserved.

Downloaded From: http://archderm.jamanetwork.com/ by a University of Alabama-Birmingham User on 01/14/2013
 A COMMENT
B proportional to the wavelength of the light. For the FPDL
Figure 2. A, An 8-week-old male infant with a cutaneous hemangioma of the
scrotum. B, The same patient after 1 treatment with the flashlamp-pumped
pulsed dye laser.
None of the mixed hemangiomas completely cleared;
33 (61%) had continued proliferation of the subcutane-
ous component. The cutaneous component responded
to therapy in 21 hemangiomas (39%), and the subcuta-
neous component of these mixed hemangiomas re-
mained unchanged. This was confirmed by color-coded
duplex sonography. The number of treatments in these
lesions was 1.6±0.8 (range, 1-5). Compression of thicker
lesions with a glass slide to assist in laser penetration did
not increase the effectiveness of therapy. In 61% of the
thicker lesions, further therapy with the Nd:YAG laser
was performed with good results.
The greatest degree of effectiveness was noted in
superficial hemangiomas in the involution phase: 12
(67%) of 18 patients had complete involution and
clearing of their lesion after 1.9±1.2 treatments (range,
1-4). In 6 patients (33%), lightening was not complete
after 1.6 ± 0.6 FPDL treatments. Greater degrees of
regression were seen with increased numbers of treat-
ments.
No textural changes after treatment were seen in
treated skin in 206 hemangiomas (92%), whereas 8
(4%) had small, isolated, scars in areas ulcerated
before laser treatment. Hyperpigmentation occurred in
2 hemangiomas (1%) but resolved spontaneously in 7
weeks; hypopigmentation occurred in 9 hemangiomas
(4%). Normal skin color returned spontaneously
within 8 weeks in all patients; there were no perma-
nent complications.
ARCH DERMATOL / VOL 136, MAY 2000
631
©2000 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Alabama-Birmingham User on 01/14/2013
The FPDL is the first laser specially designed to treat cu-
taneous vascular lesions and the first laser to eliminate
these lesions predictably without producing a scar. It is
characterized by a selective destruction of blood vessels
by matching the wavelength of light absorbed by hemo-
globin into the vessels and by using an exposure time less
than the calculated thermal relaxation time (1-10 milli-
seconds) for the blood vessels.12 An exposure time of 1
millisecond or less was advocated to confine that heat
to the vessel to decrease the risk of heat diffusion, which
can cause scarring.
The depth to which light penetrates tissue is also a
critical limiting factor in laser treatment and is directly
adjusted to 585 nm, the depth of penetration for 50% of
the energy is calculated to be 0.8 mm,12 a prediction con-
firmed histologically in laser-treated skin.13 Because the
dermis of facial skin is approximately 0.6 mm deep in
children14 and approximately 0.9 mm deep in adults,15
the FPDL provides adequate penetration for cutaneous
vascular lesions.
The FPDL has proved to be a safe and effective treat-
ment modality for port-wine stains,5,8,9,16 especially in treat-
ing small vessels found in childhood port-wine stains.
Since the study by Sherwood and Tan10 of the suc-
cessful treatment of a hemangioma of the finger with the
FPDL, several authors have reported equally successful
results.11,17 Hohenleutner and Landthaler18 treated 198 pa-
tients with hemangiomas, and 74% of these patients with
initial hemangiomas had a 75% or greater lightening of their
lesions with no evidence of permanent scarring. Good to
excellent results (complete regression or .75% lighten-
ing) have been noted in 61% of these patients with cuta-
neous hemangiomas and 42% with mixed hemangiomas.
Landthaler et al19 described 28 patients with a total of 37
hemangiomas treated with the FPDL. In that study, 29 hem-
angiomas were classified as cutaneous and 8 as mixed. Of
these patients, a good or excellent response with com-
plete regression of the hemangiomas was achieved in 60%,
and in deep-seated or mixed hemangiomas regression was
seen in 40%. All 4 patients with mixed hemangiomas were
considered treatment failures; further therapy with the
Nd:YAG laser was performed.
An earlier study by Garden et al20 involved 24 pa-
tients with 33 hemangiomas. Patients were aged 2 weeks
to 7 months. In 18 of 25 lesions that were 3 mm or less
in elevation lightened in therapy and flattened in thick-
ness in 93.9%, and mixed hemangiomas that were 4 mm
or more in thickness lightened in 85.7% but showed less
diminution in thickness.
This study of 225 hemangiomas compared the re-
sponse of flat cutaneous hemangiomas with that of mixed
cutaneous-subcutaneous hemangiomas: flat hemangio-
mas (Figure 2) responded much better to the FPDL treat-
ment and involuted more completely than did mixed hem-
angiomas. We saw a greater percentage of regression if early
or initial cutaneous hemangiomas were treated than in ac-
tively proliferative cutaneous hemangiomas. Also, ac-
tively proliferative cutaneous hemangiomas did not re-
gress as much as some of the matured cutaneous
WWW.ARCHDERMATOL.COM
 hemangiomas. On the other hand, 13 (18%) of 74 initial
hemangiomas showed proliferation of the subcutaneous
component, although these lesions were flat at first pre-
sentation and no pathologic vessels were found in color-
coded duplex sonography before FPDL treatment. So, in
our experience, FPDL treatment could not always pre-
vent proliferation of the deep component, even in initial
flat hemangiomas.
Even mixed hemangiomas lightened, although they
persisted. The subcutaneous component of mixed hem-
angiomas did not appear to respond, and further therapy
with the Nd:YAG laser with continuous surface cooling
with ice cubes was performed with good results.
All these studies demonstrated a better treatment out-
come in flat cutaneous hemangiomas. Treatment of mixed
hemangiomas has been the source of some controversy in
the literature. Garden et al20 suggested that early treat-
ment of hemangiomas may prevent proliferation of the deep
component and hasten involution of superficial heman-
giomas. Conversely, Ashinoff and Geronemus21 reported
4 cases in which the deep component of the hemangioma
continued to proliferate after treatment with the FPDL,
whereas the superficial component resolved. Ashinoff and
Geronemus11 showed that the thicker the lesion at pre-
sentation, the less effective was FPDL treatment, which
was not surprising given the limited degree of vascular in-
jury caused by this laser. Berlien et al22-24 reported better
results in deep hemangiomas with the Nd:YAG laser (1064
nm) when a coagulation depth of 10 mm can be reached
and highly sufficient protection of the epidermis is pro-
vided by continuous ice cube cooling.
Sometimes it is difficult to predict whether there will
be a superficial and deep component of the heman-
gioma or only a superficial component. In our experi-
ence, a color-coded duplex sonography is helpful. It al-
lows precise measurement of the diameter of single vessels,
the thickness, and the extension of the whole heman-
gioma. Those reproducible flow measurements may be
performed and compared during follow-up together with
the B-scan imaging.
Because of results we have seen from FPDL treat-
ment, we recommend that FPDL for the treatment of hem-
angiomas be reserved for use in carefully selected pa-
tients, ie, those with cutaneous and flat hemangiomas at
sites of potential functional impairment (hands, feet, or
anogenital region) and especially on the face. Further-
more, hemangiomas should be treated with the FPDL as
soon as possible, even in the initial or early phase, before
the lesions reach an exponential growth phase, and the
limited depth of vascular injury of the FPDL is unlikely
to effect any improvement in decreasing the size of the le-
sion. Because flat hemangiomas in the superficial cutane-
ous and involutionary groups responded best, we believe
it is only a factor of whether the FPDL can sufficiently pen-
etrate the total hemangioma. So, the depth of the heman-
gioma is relevent. Subcutaneous or mixed hemangiomas
do not benefit from FPDL treatment because the efficacy
of the FPDL is limited by its depth of vascular injury (1-2
mm), and mixed hemangiomas might extend far beyond
this depth into the subcutaneous tissue.
Also, cutaneous hemangiomas during the involu-
tion phase benefit from FPDL treatment. Many of these
ARCH DERMATOL / VOL 136, MAY 2000
632
©2000 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a University of Alabama-Birmingham User on 01/14/2013
lesions are slow to resolve and can be present in a cos-
metically or functionally prominent area.
As with the treatment of port-wine stains, the inci-
dence of adverse effects from FPDL treatment of hem-
angiomas is small, thus making the benefit-risk ratio high.
Accepted for publication December 14, 1999.
Reprints: Margitta Poetke, MD, Abteilung für Laser-
medizin, Krankenhaus Neukölln, Rudower Strasse 48,
D-12351 Berlin, Germany.
REFERENCES
1. Jacobs AH, Walton RG. The incidence of birthmarks in the neonate. Pediatrics.
1976;58:218-222.
2. Amir J, Metzker A, Krikler R, Reisner SH. Strawberry hemangiomas in preterm
infants. Pediatr Dermatol. 1986;3:331-332.
3. Finn MC, Glowacki J, Mulliken JB. Congenital vascular lesions: clinical applica-
tion of a new classification. J Pediatr Surg. 1983;18:894-899.
4. Poetke M, Philipp C, Berlien HP. Clinical features and classification of congenital
vascular disorders. In: Berlien HP, Schmittenbecher PP, eds. Laser Surgery in
Children. Berlin, Germany: Springer-Verlag; 1997:72-81.
5. Ashinoff R, Geronemus RG. Flashlamp-pumped pulsed dye laser for port-wine
stains in infancy: earlier versus later treatment. J Am Acad Dermatol. 1991;24:
467-472.
6. Geronemus RG. Pulsed dye laser treatment of vascular lesions in children. J Der-
matol Surg Oncol. 1993;19:303-310.
7. Goldman MP, Fitzpatrick RE, Ruiz-Esparaza J. Treatment of port-wine stains (cap-
illary malformation) with the flashlamp-pumped pulsed dye laser. J Pediatr. 1993;
122:71-77.
8. Reyes BA, Geronemus RG. Treatment of port-wine stains during childhood with the
flashlamp-pumped pulsed dye laser. J Am Acad Dermatol. 1990;23:1142-1148.
9. Tan OT, Sherwood K, Gilchrest BA. Treatment of children with port-wine stains
using the flashlamp-pulsed tunable dye laser. N Engl J Med. 1989;320:416-421.
10. Sherwood KA, Tan OT. Treatment of a capillary hemangioma with the flashlamp
pumped-dye laser. J Am Acad Dermatol. 1990;22:136-137.
11. Ashinoff R, Geronemus RG. Capillary hemangiomas and treatment with the
flashlamp-pumped pulsed dye laser. Arch Dermatol. 1991;127:202-205.
12. Anderson RR, Parish JA. The optics of human skin. J Invest Dermatol. 1981;77:
9-13.
13. Nakagawa H, Tan OT, Parrish JA. Ultrastructural changes in human skin after
exposure to a pulsed laser. J Invest Dermatol. 1985;84:396-400.
14. Tong AKF, Tan OT, Boll J, Parrish JA, Murphy GF. Ultrastructure: effects of mela-
nin pigment on target specificity using a pulsed dye laser (577 nm). J Invest Der-
matol. 1987;88:747-752.
15. Tan CY, Statham B, Marks R, Payne PA. Skin thickness measurement by pulsed
ultrasound: its reproducibility, validation and variability. Br J Dermatol. 1982;
106:657-667.
16. Levine VJ, Geronemus RG. Adverse effects associated with the 577- and 585-
nanometer pulsed dye laser in the treatment of cutaneous vascular lesions: a
study of 500 patients. J Am Acad Dermatol. 1995;32:613-617.
17. Ricci RM, Finley EM, Grimwood RE. Treatment of cutaneous hemangiomas in
preterm neonatal twins with the flashlamp-pumped pulsed dye laser. Lasers Surg
Med. 1998;22:10-13.
18. Hohenleutner U, Landthaler M. Die Behandlung der Säuglingshämangiome. Der
Kinderarzt. 1997;28:989-1000.
19. Landthaler M, Hohenleutner U, el-Raheem TA. Laser therapy of childhood hem-
angiomas. Br J Dermatol. 1995;133:275-281.
20. Garden JM, Bakus AD, Paller AS. Treatment of cutaneous hemangiomas by the
flashlamp-pumped pulsed dye laser: prospective analysis. J Pediatr. 1992;120:
555-560.
21. Ashinoff R, Geronemus RG. Failure of the flashlamp-pumped pulsed dye laser
to prevent progression to deep hemangioma. Pediatr Dermatol. 1993;10:77-80.
22. Berlien HP, Waldschmidt J, Müller G. Laser treatment of cutaneous and deep
vessel anomalies. In: Waidelich W, ed. Laser Optoelectronics in Medicine. Ber-
lin, Germany: Springer-Verlag; 1988:526-528.
23. Berlien HP, Müller G, Waldschmidt J. Lasers in pediatric surgery. In: Angerpointer
X, ed. Progress in Pediatric Surgery. Berlin, Germany: Springer-Verlag; 1990:5-22.
24. Poetke M, Philipp C, Berlien HP. Ten years of laser treatment of hemangiomas
and vascular malformations: techniques and results. In: Berlien HP, Schmitten-
becher PP, eds. Laser Surgery in Children. Berlin, Germany: Springer-Verlag; 1997:
82-91.
WWW.ARCHDERMATOL.COM