▸ Do no harm. This tool can injure, so be cautious. Ulceration will worsen in a subset of patients. Don't re-treat with a laser if the first round made things worse.
▸ Where to laser? Nobody really knows. She lasers open areas in the ulceration and along the rolled edge to try to stimulate cytokine production. Sometimes she'll apply the laser to dark, dusky areas that look like they're about to ulcerate.
▸ Debride. It's not clear how laser treatment helps ulcerated hemangiomas, but it does affect cytokines, and for that living tissue must be treated. Be sure to debride to reach living tissue.
▸ Use sufficient energy. There seems to be a window between 6 and 8 J/cm2 that provides enough energy to have an effect without causing injury, but no one really knows the best setting.
▸ Dry the field. Before the laser is used, dry the field not only to get debris out, but to prevent splattering. Prepare for bleeding during the procedure, especially if the child has been treated with Regranex (becaplermin). Inform parents to expect more bleeding in the operating room and in the postoperative period, especially from ulcerations in the genital area.
▸ Cover the wound. Do this after laser treatment for pain control.
▸ Re-treat? No study has looked at optimal intervals between laser treatments for ulcerated hemangiomas. Dr. Wagner sees patients again in 2 weeks, although she will occasionally see some patients sooner.