Outcomes of 52 patients with congenital

melanocytic naevi treated with UltraPulse Carbon

Dioxide and Frequency Doubled Q-Switched Nd-Yag
laser
Nada Al-Hadithy*, Khalil Al-Nakib, Awf Quaba
St Johns Hospital, Plastic and Reconstructive Surgery, Livingston, Howden, EH54 6PP, United Kingdom
Received 24 October 2011; accepted 1 March 2012
KEYWORDS
Congenital
melanocytic naevus;
Ultrapulsed CO
2
laser
treatment;
Frequency Doubled
Q-Switched Nd-Yag
Summary Background: A variety of treatment options exist for the management of congen-
ital melanocytic naevi (CMN). Surgical treatment has been the traditional approach. Recently,
lasers have been introduced to treat CMN. This study assesses the effectiveness of UltraPulse
Carbon Dioxide (UCO
2
) and Frequency Doubled Q-Switched (FDQS) Nd-Yag laser up to a 15 year
period which is the longest follow-up period of any study, as far as we are aware.
Materials & methods: We performed a retrospective review of 52 patients with 314 CMN,
treated with UCO
2
laser and FDQS Nd-Yag laser. The reduction in visible pigmentation, signs
of recurrence and any adverse skin changes were evaluated clinically by two clinicians inde-
pendent to the laser operator.
Results: There was minimal visible pigmentation after completion of treatment in 40
patients. Treatment failure occurred in 5 patients, recurrence in 5 and partial success in
2. 5 patients developed hypertrophic scarring, 1 developed hyperpigmentation and 1 patient
developed an intracranial melanoma. 87% of patients were satised with their treatment and
in hindsight would not have chosen surgery. Mean follow-up period was 8 years (interquartile
range 3e11years).
Conclusion: UCO
2
and FDQS Nd-Yag lasers are clinically useful treatment options for patients
with CMN and have minimal complications. This combined laser regime is particularly effec-
tive for the treatment of CMN in cosmetically sensitive and anatomically critical areas, espe-
cially when surgical excision may not be straight forward and/or leave unacceptable scars.
2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: 44 (0) 7958041497.
E-mail addresses: nadaucl@yahoo.com, n.alhadithy@doctors.org.uk (N. Al-Hadithy).
1748-6815/$- seefront matter 2012BritishAssociationof Plastic, ReconstructiveandAestheticSurgeons. PublishedbyElsevier Ltd. All rightsreserved.
doi:10.1016/j.bjps.2012.03.003
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1019e1028
Introduction
Congenital melanocytic naevi (CMN) are benign prolifera-
tions of cutaneous melanocytes which are apparent at birth
or become so within the rst postnatal weeks. CMN are
classied by their projected adult size (PAS).
1
They are
further characterised by their varying shape, surface
texture and hairiness. Incidence ranges from 1 to 2% for any
size of CMN to around 0.005% for giant lesions.
2,3
The CMN
is similar to acquired naevi except for larger size, more
varied architecture and cellular morphology with greater
cellularity,
4
and the ability to penetrate beyond the layers
of the reticular dermis into the subcutaneous tissues. As
melanocytes are of neural crest origin they can be found in
any tissue which develops from the mesectoderm including
craniofacial cartilage and bone, parafollicular cells of the
thyroid, smooth muscle, peripheral and enteric neurons,
glia, iris pigment cells and pia mater. Early research indi-
cates that CMN is part of a complex syndrome rather than
simply neurocutaneous lesions.
5
CMN may have considerable cosmetic and psychosocial
effects
6
alongside an increased risk of malignant trans-
formation.
7,8
The management of CMN remains controver-
sial with the mainstay of treatment being surgical
excision.
9,10
Complications from surgery include infection,
the requirement for further skin grafting and scars, which
may mask melanoma detection.
23
There have been various treatment options for CMN.
Curettage has been used successfully,
11
however it requires
a natural cleavage plane thought only to be present in the
rst few weeks of life
10
and is associated with scarring.
Dermabrasion reduces pigmentation by removing the
epidermis and part of the dermis,
12
however causes
thinner, friable skin with a reduced hair density.
13
The most
commonly used laser in the treatment of CMN is the Q-
switched ruby laser and operators have enjoyed some
degree of success where surgical excision was not
possible.
14
However the possibility of recurrence can be as
high as 50%.
15
In 1998, for the rst time, a giant CMN was successfully
treated with a high energy pulsed CO
2
laser.
16
There have
since been several further studies, which have shown
promising results of CO
2
laser therapy, although these
have had small patient numbers and short follow-up
periods.
17e19
We present our experience of CMN treated with Ultra-
Pulsed Carbon Dioxide (UCO
2
) laser with or without
Frequency Double Q-Switched (FDQS) Nd-Yag laser therapy
of 314 CMN lesions in 52 patients.
Method
Between 1996 and 2011, 65 patients were treated with
UltraPulsed Carbon Dioxide (UCO
2
) laser, with or without
Frequency Double Q-Switched (FDQS) Nd-Yag laser
therapy in our institution, 13 were lost to follow-up
leaving 52 patients available for follow-up. Patients
were treated at 3 monthly intervals until the lesions were
no longer visible or laser operators felt no further
improvement could be achieved. There were 43 females
and 9 males with a mean entry and exit age of 12 and
21 years respectively. All patients had prior histological
conrmation.
Laser treatment
Patients and guardians were counselled regarding the risks
and benets of laser treatment and informed consent was
obtained prior to all treatments. The number of lesions
were counted and photographed pre-treatment. All
procedures in children were performed under general
anaesthesia. Treatment was administered from a UCO
2
laser machine through a computer pattern generator (CPG)
hand-piece. Laser power was set between 25 and 100 W and
the energy density ranged between 175 and 400 mJ. The
CPG pattern was a hexagon, and the size between 3 and
7 mm, depending on the size of the CMN. There was an
overlap of 30%. There was a minimum of 1 pass with
a maximum of 5 passes, removing as much of the pigment as
possible to the reticular dermis. When necessary, a 1 mm
collimated beam with the same energy density was used to
target scattered residual pigment (power 5e10 W). The
ablative laser was never used beyond the reticular dermis.
When used, the FDQS Nd-Yag laser used had a spot beam
diameter between 2 and 3 mm, the energy varied between
5 and 7 J/cm
2
and the repetition rate between 5 and 10 Hz.
Patients with large naevi were treated in stages. Young
children with large areas treated were admitted to HDU
overnight for analgesia and monitoring and had an inpatient
stay of 4 days with 3 days of intravenous antibiotics.
Follow-up
All lesions were reviewed at 3, 6 weeks and 6 months post
laser therapy until the patient and clinician were satised
with the results or treatment deemed complete. Patients
were further reviewed at 1 and 2 years for recurrence in
most cases. At each visit the treated areas were evaluated
for healing status, pigmentation, recurrence and any
complications. Patients were photographed by the clinical
photography department.
Reduction in pigmentation was measured by two inde-
pendent third party clinicians on review of the clinical
photographs. Patient satisfaction was documented in the
notes at the time of clinical assessment on completion of
treatment. With young children, parental satisfaction was
recorded. Recurrence was dened as the re-appearance of
residual pigmentation after completion of treatment in the
same area of skin.
Results
65 patients with CMN were included in this study. 13
patients were lost to follow-up. 52 patients with 314 lesions
underwent 142 treatments of CMN (Figure 1) with a mean
follow-up of 8 years (interquartile range 3e11 years).40
patients were treated with UCO
2
laser in combination with
FDQS Nd-Yag laser; 9 with UCO
2
alone and 3 with FDQS Nd-
Yag alone. Details of size, site, numbers, and number of
laser therapies and duration of treatment are shown in
Tables 1 & 2.
1020 N. Al-Hadithy et al.
Clinical
Of the 314 lesions, 297 (94.6%) had a reduction in pigment,
and had no complications or recurrence (Figure 2).
Reduction in pigmentation in the peripheries of non-
hairy naevi with recurrence only centrally occurred in 3
(<1%) lesions. Two were on the chest wall (one of which
was near the nipple) and the third case was a periorbital
CMN. Successful peripheral vaporisation rendered a smaller
residual lesion, and therefore reduced the size of subse-
quent scars from excision and skin grafts.
No reduction in pigmentation occurred in 5 (1.6%) lesions
after a mean of 1 treatment of laser therapy. They were
followed-up over a period of 8.8 months; 4 had surgical
excision successfully and 1 declined further treatment.
Giant congenital melanocytic naevi
The giant CMN responded to laser treatment in the same
way as smaller lesions, irrespective of the age of the
patient at the time of treatment (Figure 3). Table 3
summarises the treatment regimens and outcomes for
each of our giant lesions.1 patient required uids.1 patient
developed an intracranial primary melanoma. She died 1
year after diagnosis. In order to ensure no patients were
Figure 1 Flow chart of patients with congenital melanocytic naevi seen in the laser clinic.
Outcomes of 52 patients with congenital melanocytic naevi treated with UCO
2
and FDQS 1021
lost to follow-up all patients were cross checked with The
Scottish Melanoma Group and SCAN database. This was the
only case of malignancy in 314 lesions or 52 patients over
a mean of 8 years.
One patient had surgical excision of a giant lesion on her
back with multiple, large hypertrophic scars, previously
attempted elsewhere. Following UCO
2
, FDQS Nd-Yag and
triamcinolone injections the scar attened out consider-
ably and the background pigment was resolved; rendering
the scar less prominent (Figure 4).
Satisfaction
Forty-ve patients (87%) were satised with their treat-
ment and would not have chosen surgery in retrospect. Of
the satised patients, 10 (22%) had some residual CMN or
other complication. 5 of those patients had hairy CMN
which are deeper and no attempt was made at targeting
the hair, as hypertrichosis cannot be treated with UCO
2
.
The other 5 patients had lesions in critical areas so were not
able to be treated as aggressively. Of the 7 (13%) patients
who were dissatised, all had lesions in cosmetically crit-
ical areas (face and neck) and had recurrence of at least
one of their treated naevi.
Complications
Five (1.6%) treated lesions developed hypertrophic scars in
the interscapular area (n Z 3), philtrum (n Z 1) and
glabella region (n Z 1). In all cases, hypertrophic scarring
occurred following treatment with UCO
2
laser at high
energy density (200 mJ), in paint mode. In all cases of
hypertrophic scarring, the scars settled within 6 months.
Hypertrophic scars were treated with silicon dressings and
in some cases, triamcinolone as well. In all areas, except
the glabella, there was no recurrence of pigment. In
the glabella, residual pigment was only present around
the hair follicles. All patients (or guardians of patients)
with hypertrophic scarring reported that they were satis-
ed with their nal outcome despite this complication
(Table 4).
Five (1.6%) CMN lesions recurred. 4 were peri-follicular,
and 1 was simple. Recurrences were located in the anterior
neck (n Z 1) (Figure 5), glabella (n Z 2), anterior thigh
(n Z 2) and had 2 mean laser treatments. Recurrences
occurred at a mean of 10 months. 3 patients declined
further surgical excision, and 2 underwent excision with full
thickness skin grafting.
One (0.3%) lesion on the right malar exhibited hyperpig-
mentation after 1 treatment with UCO
2
250 mJ and 10 Wand
three treatments with FDQS Nd-Yag: 8.2 J/cm
2
. The hyper-
pigmentation settled with hydroquinone cream and the nal
outcome was complete resolution of pigment with patient
satisfaction. There were no cases of hypopigmentation.
Discussion
Successful treatment of CMN will require consideration of
size, location, depth and hypertrichosis to offer a treat-
ment which addresses the needs of the patient. Malignant
melanoma is approximately 70 times more likely in children
and adolescents with large CMN
6,20
than in the general
population,
21
especially in large axial naevi
8
with satel-
litosis.
7
Quaba and Wallace
22
suggested that early prophy-
lactic excision should be the mainstay treatment to reduce
the risk of malignant transformation. This may require total
melanocyte reduction with complete excision.
23,24
However, others suggest reduction of melanocytic load
with laser may adequately reduce risk of malignant trans-
formation to an acceptable level.
25
There has been concern
Table 1 Size and details of number of Laser Treatments
(LT) for CMN lesions.
Size of
CMN
No. of
patients
No. of
lesions
Total no.
of lesions
No. of
LT
Mean no.
of LT
<5 cm 29 1 37 61 1.6
4 2
5e10 cm 6 1 13 33 2.5
2 2
1 3
>10 cm 2 1 2 5 2.5
Giant 1 1 262 43 5.4
1 6
1 16
1 31
4 >50
Total 52 314
Table 2 Location and number of Laser Treatments (LT).
Location No. of
lesions
Average no. of LT
for this site
Time until treatment concluded
UCO
2
& FDQS Nd-Yag UCO
2
FDQS Nd-Yag
Head & Neck 26 1.6 236 161
Chest 5 3 995 405 42
Back 2 1.5 67
Upper limbs 7 2.6 28 197
Lower limbs 12 2.7 330 42 264
GCMN 8 5.6 1388
Satellites associated
with GCMN
254 5.6 1388
Total 314
1022 N. Al-Hadithy et al.
that abrasive treatments may accelerate malignant trans-
formation, and although this theory has been largely dis-
credited
26
; to date there have been no studies large enough
to reliably demonstrate this. Some authors state that CMN
should not be treated at all due to spontaneous resolu-
tion.
27
In any case, total surgical removal of cutaneous
melanocytes in CMN does not prevent the development of
melanoma as this can always manifest in extra cutaneous
sites.
28
From our data there was 1 case of malignancy, an
intracranial melanoma, in 52 patients over 8 years in
a cohort treated with laser.
In our institution treatment has only been for aesthetic
improvement at the wishes of the patients, parents or
guardians. The majority of small CMN are excised and
closed directly. When considering excision of larger lesions
necessary serial excisions and/or tissue expansion increase
the risk of scarring, haematoma and infection.
29,30
There-
fore laser treatment is reserved for lesions too large to
excise and close directly or in cosmetically critical
22
areas.
We treated 297 CMN lesions with reduction in pigment
with fewer treatments compared with other laser treat-
ment regimes.
31
The use of UCO
2
laser is attractive because
it offers the possibility of precise vaporization of the
supercial component of the CMN down to the reticular
dermis.
15
The FDQS Nd-Yag laser is an established method
for the selective treatment of supercial pigmented
lesions
32
by selectively targeting melanosomes in melano-
cytes and keratinocytes
33
with negligible risk of scarring.
Our results demonstrate that this combined laser tech-
nique of UCO
2
and FDQS Nd-Yag is an effective method for
treatment of CMN.
34
Treatment could be realized for any
size of naevus; in any age of patient; and companion naevi
Figure 2 Large CMN on anterior neck and chin treated with UCO
2
and FDQS ND-Yag Laser. Follow-up image 5 years on demon-
strate minimal residual pigmentation but no recurrence compared with previous treatments.
Figure 3 Treatment of giant CMN, in stages. Left trunk treated with UCO
2
and FDQS ND-Yag laser with signicant reduction in
pigmentation.
Outcomes of 52 patients with congenital melanocytic naevi treated with UCO
2
and FDQS 1023
Table 3 Treatment Regime and Outcomes of Patients with Giant Naevi.
Age & Year
of Referral
Treated Lesions
Size &Location
Treatment Results Follow
up
Complications
8 years
1995
10% TBSA
Mid thoracic
region to knees
1. Test patch: UCO
2
laser 175 mJ 35 W
2. Buttock & back: UCO
2
175 mJ 35 W
3. Chest: UCO
2
laser 225 mJ, 100 W
4. Legs & buttock UCO
2
, 225 mJ, 100 W
5. Legs: UCO
2
laser 250 mJ, 100 W
6. FDQS Nd-YAg: areas of residual pigment
on buttock and thigh: FDQS Nd-YAG 532
8.0 J, 2 mm, rep rate 10.0, shots 1085
Complete
resolution
after 1 year
15
years
None
4 years
1996
20 20 cm
Left thigh
1. Left thigh: UCO
2
laser 175 mJ,
50 W &FDQS Nd-Yag 532 8.0 J, 2 mm,
rep rate 10.0, shots 1085
2. FDQS Nd-Yag 532 8.0 J, 2 mm,
rep rate 10.0, shots 1085
Complete
resolution
within 1 year
15
years
None
9 days
1996
50% of TBSA
Hairy Bathing trunk
naevus: buttocks,
left upper back,
anterior & posterior
upper thighs,
anterior chest.
Satellite lesions:
thighs, legs and arms
1. Buttock & back: UCO
2
200 mJ 35 W
2. Buttock & back: UCO
2
200 mJ 35 W
3. Back: UCO
2
225 mJ, 100 W
4. Legs & buttock: UCO
2
225 mJ, 100 W
5. Legs & buttock: UCO
2
225 mJ, 100 W
6. Back: UCO
2
225 mJ, 100 W
7. Back & interscapular area: UCO
2
225 mJ, 100 W
8. Areas of residual pigment on
buttock & thigh: FDQS Nd-Yag 532
8.0 J, 2 mm rep rate 10.0, shots 1085
9. Areas of residual pigment on thigh:
FDQS Nd-YAG 532 8.0 J, 2 mm rep
rate 10.0, shots 1085
Complete
resolution
within 1 year
15
years
None
6 days
1996
10% TBSA
Back and left
side of chest
1. Test UCO
2
: 400 mJ, power 60 W
2. 10% TBSA & HDU: UCO
2
400 mJ, power 60 W
3. 10% TBSA & HDU: UCO
2
400 mJ, power 50 W
4. Ant chest wall: UCO
2
:
200e250 mJ, 30e35 W
5. L upper abdo wall: UCO
2
laser 250e300 mJ 30e40 W
Complete
resolution
after 5 years
15
years
None
3 days
2001
70% TBSA
Buttocks, anterior
chest and left
upper back and upper
thighs anteriorly
and posterioly. Satellite
lesions to hand and
foot and tip of nose
1. Left upper back nose tip:
UCO
2
250 mJ, power 25 W
2. 5e7% TBSA UCO
2
laser: 250 mg, 30 W
3. 5e7% TBSA UCO
2
250 mg, 30 W
4. Whole lower back: UCO
2
300 mg, 30 W, & 100 localised
satellite lesions, energy 225 mJ,
power 30 W.
5. Ant abdo wall, nose tip
RMF UCO
2
: energy 250 mg, power 35 W
6. L Foot, lower leg, rt lower leg,
rt thigh, left hand nger: UCO
2
:
175 mJ, 35 W
Successful
treatment
of targeted
lesions
10
years
Primary
intracranial
melanoma e RIP
4 days
2003
60% of TBSA
Hairy bathing trunk
Whole of back
and swimming
trunk distribution
1. Test patch: UCO
2
laser 200 mJ 35 W
2. Buttock & back: UCO
2
200 mJ 35 W
3. Buttock & back: UCO
2
200 mJ 35 W
4. Back: UCO
2
laser 225 mJ, 100 W
5. Back: UCO
2
laser 225 mJ, 100 W
6. Leg & buttock UCO
2
, 225 mJ, 100 W
7. Back & interscapular area: UCO
2
laser 250 mJ, 100 W
Complete
resolution
after 4.5 years
8
years
Hypertrophic
scar which
resolved with
steroid injections
1024 N. Al-Hadithy et al.
were treated at the same time. In our giant lesions, we did
not see any difference in results due to the age at time of
treatment. This reduces the pressure to make use of the
natural cleavage plane that Moss stipulated to exist only in
the neonatal period; allowing more time to treat the lesion
in stages and start treatment at a later age, therefore
reducing the risk of anaesthesia and post-operative care.
10
In younger patients with larger lesions, the minimal blood
loss during the procedure was an important advantage;
supplemental intravenous uid therapy was required in
only 1 patient with a giant CMN, for 1 of her treatments.
The need for blood transfusion was avoided. In older
patients, in contrast to other authors who state that
treatment with UCO
2
is less successful in this group; our
patients rarely displayed melanocytic repopulation of the
initially depleted layers of CMN, with a recurrence rate of
1.6%.
The lake theory states that the deepest point of pigment
is usually in the centre, with pigment shallower in the periph-
eries. Laser treatment can target the shallower, peripheral
aspects of the lesion, to shrink a large lesion to a smaller one.
This makes the lesion more amenable to excision and direct
closure with a smaller scar or reduced requirement for skin
grafts. Targeted pigmentation, supercial to the reticular
Figure 4 Patient with hypertrophic scars secondary to previous attempted surgical excision of a giant lesion on her back. 6 years
following UCO
2
, FDQS Nd-Yag and triamcinolone injections the scar attened out considerably and the background pigment was
resolved.
Table 3 (continued)
Age & Year
of Referral
Treated Lesions
Size &Location Treatment Results
Follow
up Complications
8. Leg: UCO
2
laser 250 mJ, 100 W
9. Back: UCO
2
laser 250 mJ, 100 W
10. FDQS Nd-YAG: areas of residual
pigment on buttock and thigh: 8.0 J,
2 mm, rep rate 10.0, shots 1085
11. FDQS Nd-YAG: areas of residual
pigment on buttock: 8.0 J, 2 mm,
rep rate 10.0, shots 1085
9 years
2004
20% of TBSA
Upper 2/3 back and
anterior chest and
bathing trunk naevus
1. Test patch UCO
2
200 mJ, 35 W
2. Interscapular area: UCO
2
200 mJ, 35 W
3. Back: UCO
2
225 mJ, 100 W
4. Back of neck & shoulders: UCO
2
175 mJ,
35 W
Complete
Resolution
after 3 years
7
years
Hypertrophic
scare which
resolved with
steroids
1 day
2006
10 10 cm
periorbital CMN
1. Periorbital lesion: UCO
2
, 225 mJ, 30 W
2. Periorbital lesion: UCO
2
, 200 mJ, 30 W
Partial
Success
to peripheries
5 years Residual pigment
excised & FTSG
Outcomes of 52 patients with congenital melanocytic naevi treated with UCO
2
and FDQS 1025
Table 4 Hypertophic Scar Treatment Regimes.
Location of
Lesion Age
at Referral
Laser Treatment Hypertrophic
Scar Location
Age at time
of Scar
Treatment
of Scar
Interscapular area
16 year old
1. UCO
2
laser: 250 mJ, 35 W
2. FDQS Nd-YAG 532, 8.2 J, 1.4 mm
3. FDQS Nd-YAG 532, 8.0 J, 2.0 mm
4. FDQS Nd-YAG 532, 8.1 J, 1.5 mm
5. FDQS Nd-YAG 532, 10 J, 2.0 mm
6. FDQS Nd-YAG 532, 8.1 J, 1.4 mm
Interscapular area
following rst
treatment
17 years Mepitel 1x
triamcinolone
injection
10% of TBSA
Bathing Trunk
Naevus
4 days old
1. Test patch: UCO
2
laser 200 mJ 35 W
2. Buttock & back: UCO
2
200 mJ 35 W
3. Buttock & back: UCO
2
200 mJ 35 W
4. Back: UCO
2
laser 225 mJ, 100 W
5. Back: UCO
2
laser 225 mJ, 100 W
6. Leg & buttock UCO
2
, 225 mJ, 100 W
7. Back & interscapular: UCO
2
laser 250 mJ, 100 W
8. Leg: UCO
2
laser 250 mJ, 100 W
9. Back: UCO
2
laser 250 mJ, 100 W
10. FDQS Nd-YAG: areas of
residual pigment on buttock &
thigh: 8.0 J, 2 mm, rep rate 10.0,
shots 1085
11. FDQS Nd-YAG: areas of residual
pigment on buttock: 8.0 J, 2 mm,
rep rate 10.0, shots 1085
Interscapular area
following ninth
treatment on back
10 weeeks Mepitel 1x
triamcinolone
injection
8% of TBSA
Bathing Trunk
Naevus
9 years old
1. Test patch UCO
2
200 mJ, 35 W
2. Interscapular area: UCO
2
200 mJ, 35 W
3. Back: UCO
2
225 mJ, 100 W
4. Back of neck & shoulders:
UCO
2
175 mJ, 35 W
Interscapular area
following fourth
treatment
9 years old Mepitel 1x
triamcinolone
injection
Upper Lip Philtrun
9 years old
1. UCO
2
laser 200 mJ, 35 W Philtrum 9 years Mepitel
Glabella Region
3 years old
1. UCO
2
laser 200 mJ, 30 W and
FDQS Nd-YAG 8.2 J, 1.4 mm
Glabella region 3 years old Mepitel
Figure 5 Simple recurrence of CMN on anterior neck.
1026 N. Al-Hadithy et al.
dermis and within the penetration depth was treated
successfully, with no recurrence in the peripheries. This was
the case in the periorbital CMN where skin grafts were only
required for the eyelids, thereby reducing risk of ectropion.
Theanterior chest wall lesion, closetothenipple, was similarly
reduced in size which led to a smaller scar on subsequent
excision and less nipple distortion. Consideration should be
given to a combined laser and surgical approach for the
management of lesions in critical areas.
Our results contrasted with August et al.
17
who reviewed 55
patients with 55 CMN treated with combined UCO
2
and FDQS
Nd-Yag laser and had satisfaction rates of 46% due to partial or
complete repigmentation, which occurred in 6% macular and
21% of mammilated CMN. We had recurrence in only 5 patients
(10%) and 87% of patients were satised. August et al. graded
their outcomes subjectively by the treating physician as poor,
good or excellent. Although we are unable to compare directly
as both outcomes are subjective, we had 42 patients (81%) and
94.6% of all lesions having complete resolution of pigment, this
compares with half their patients having excellent
outcomes. This may be attributed to self-report bias; differing
denitions of outcome; different patient selection and
different power settings used on the laser: August et al. used
12e27 W compared with our 25e100 W.
The disadvantages of UCO
2
laser include the fact that it
is non-selective and will target any tissue containing water
so its application must be carried out by experienced
operators. In addition, there are considerable administra-
tive and safety factors.
In our experience, complications of laser CO
2
treat-
ment include pain, recurrence of deeper lesions and
scarring. Five lesions developed hypertrophic scar,
amounting to 1.6%. In contrast, Horner found 50% of 12
patients treated with CO
2
laser developed hypertrophic
scars following completion of laser treatment.
35
The
power used was 18 W: 200 mJ. The median number of
passes was 4 and although he did not comment on the
penetration depth specically, he did infer that in areas
where there was greater hypertrophic scarring the laser
was more likely to have caused full thickness skin
vaporization. Following early experience of hypertrophic
scarring secondary to laser treatment, we used prophy-
lactic silicon dressings and lower energy density settings
in high risk areas, such as the interscapular area. We
postulate that this and the depth to which the laser was
used as the differentiating factors.
Our overall complication rate of 5.4% may also be lower
than August et al., as we deemed treatment unsuccessful
after 1 or 2 laser procedures compared with their regime of
5e6 treatments. A recent British Medical Laser Association
Meeting
36
revealed most senior and experienced laser
surgeons will attempt to treat CMN many more times than
this, several quoting up to 9 times before they deemed
treatment unsuccessful.
19
Further evaluation of the number
of treatments and the likelihood of treatment failure or
recurrence may be of interest. Our experience is that if there
is no response at all within the rst 2 treatments, then there
will be nothing to gain by offering further treatments.
We did not experience any additional complications
cited in the literature, including pseudomelanoma.
37

Historically, the term pseudomelanoma has been used to

describe recurrent naevi which closely resembles
supercial spreading malignant melanoma both clinically
and histologically. To date, we have not observed this
effect nor had histo-pathological conrmation of pseudo-
melanoma in recurrences. We believe that the term pseu-
domelanoma has the potential to cause confusion.
38,39
In order to obtain informed consent and patient satis-
faction we recommend careful patient selection and thor-
ough pre-treatment counselling. Patients should be made
aware of the potential benets of laser treatment of CMN
as well as the limitations and risks. All patients were
informed that 100% eradication of pigmentation may not
always be possible and is unlikely in the presence of hairy
lesions. Patients were also informed that hair is not eradi-
cated by UCO
2
laser. Further counselling regarding the
course of treatment; the need for repeated treatments;
wound healing time; inpatient stay and the possibilities of
recurrence, hypertrophic scar, infection, and of course,
malignant transformation is essential.
Limitations of this study include the facts that:
the study was not blinded and there was no objective
standardised assessment tool of clinical images for
pigment reduction. Standardised assessment of pigment
distribution within melanocytic lesions has been devel-
oped for diagnostic accuracy in malignant melanoma.
40
However, there is no validated technique for pigment
reduction in benign lesions. The Physicians Global
Assessment scale was not used as it is subjective
41
and
has not been evaluated in terms of its validity and reli-
ability.
42
13 patients were lost to follow-up; this was
accounted for by the fact that the older notes had been
stored in an offsite archive and the lack of audit
department in our institution.
In conclusion, UCO
2
with or without FDQS Nd-Yag laser
treatment of CMN is relatively quick and simple to perform,
producing reduction in visible pigmentation, with minimal
complications. Our goal of cosmetic improvement was met
for the majority of lesions. The clinician must select the
patient carefully and we would suggest to only treat those
lesions in cosmetically sensitive areas or lesions too large to
excise and close directly. Pre-treatment patient and
parental counselling is essential. Whether any malignant
potential has been reduced or not can only be commented
on after a very long term follow-up.
Funding
None.
Conict of interest
None.
References
1. Kopf AW, Bart RS, Hennessey P. Congenital nevocyticnaevi and
malignant melanomas. AmAcadDermatol 1979;1:123e30.
2. Walton RG, Jacobs AH, Cox AJ. Pigmented lesions in newborn
infants. Br J Dermatol 1976;95:389.
3. Castilla EE, Da Graca Dutra M, Oriolo-Parreiras IM. Epidemi-
ology of congenital pigmented naevi; incidence rates and
relative frequencies. Br J Dermatol 1981;104:307e15.
Outcomes of 52 patients with congenital melanocytic naevi treated with UCO
2
and FDQS 1027
4. Nickoloff BJ, Walton R, Pregerson-Rodan K. Immuno-histologic
patterns of congenital nevocellular naevi. Arch Dermatol 1986;
122:1263e8.
5. Kinsler V. Congenital melanocytic naevus syndrome: clinical and
genetic aspects. Oral Communication. International Pigment
Cell Conference, Bordeaux, France September 2011. 21e24.
6. Koot HM, de Waard-van der Spek F, Peer CD, et al. Psychosocial
sequelae in 29 children with giant congenital melanocytic
naevi. ClinExpDermatol 2000;25:589e93.
7. Egan CL, OliveriaSA, Elenitsas R, et al. Cutaneous melanomarisk
and phenotypic change in large congenital melanocytic naevi:
a follow-up of 46 patients. J Am Acad Dermatol 1998;39:923.
8. Bittencourt FV, Marghoob AA, Kopf AW, et al. Large congenital
melanocytic naevi and the risk for development of malignant
melanoma and neurocutaneous melanocytosis. Pediatrics
2000;106:736.
9. Kopp J, Magnus NE, Rubben A, et al. Radical resection of giant
congenital melanocytic nevus and reconstruction with meek-graft
covered integra dermal template. Dermatol Surg 2003;29:653e7.
10. Moss Al. Congenital Giant Naevus: a preliminary report of
a new surgical approach. Br J Plast Surg 1987;40:410e9.
11. Deraeve LE, Roseeuw DI. Curettage of giant congenital mela-
nocytic naevi in neonates. A decade later. Arch Dermatol 2002;
138:943e7.
12. Rompel R, Moster M, Petres J. Dermabrasion of congenital
nevocellularnaevi: experience in 215 patients. Dermatol 1997;
194:261e7.
13. Bohn J, Svensson H, Aberg M. Dermabrasion of large congenital
melanocytic naevi in neonates. Scand J Plast Reconstr Surg
Hand Surg 2000;34:321e6.
14. Nelson JS, Kelly KM. Q-switched ruby laser treatment of
acongenital melanocytic nevus. Dematol Surg 1999;25(4):274e6.
15. Waldorf HA, Kauvar ANB, Geronemus RG. Treatment of small
and medium congenital naevi with the Q-switched ruby laser.
Arch Dermatol 1996;132:301e4.
16. Kay AR, Kenealy J, Mercer NS. Successful treatment of a giant
congenital melanocytic naevus with the high energy pulsed CO
2
laser. Br J Plast Surg 1998;51(1):22e4.
17. August PJ, Ferguson JE, Madan V. A study of the efcacy of
carbon dioxide and pigment-specic lasers in the treatment of
medium-sized congenital melanocytic naevi. Br J Dermatol
2011;164(5):1037e42.
18. Reynolds N, Kenealy J, Mercer N. Carbon dioxide laser derm-
abrasion for giant congenital melanoyctic naevi. Plast Reconstr
Surg 2003;111(7):2209e14.
19. Chong SJ, Jeong E, Park HJ, et al. Treatment of congenital
nevomelanocytic naevi with the CO
2
and Q-switched alexan-
drite lasers. Dermatol Surg 2005;31(5):518e21.
20. DeDavid M, Orlow S, Provost N, et al. A study of large
congenital melanocytic naevi and associated malignant mela-
nomas: review of cases in New York university registry and the
world literature. J Am Acad Dermatol 1997;36:409e16.
21. Hamre MR, Chuba P, Bakhshi S, et al. Cutaneous melanoma in
childhood and adolescence. Paediatr Haematol Oncol 2002;19:
309e17.
22. Quaba AA, Wallace AF. The incidence of malignant melanoma
(0 to 15 years of age) arising in large congenital nevocellu-
larnaevi. Plast Reconstr Surg 1986;78(2):174e81.
23. Dellon AL, Edelson RL, Chretien PB. Dening the malignant
potential of the giant pigmented naevus. Plast Reconstr Surg
1976;57:611e8.
24. Arons MS, Hurwitz S. Congenital nevocellular nevus: a review
of the treatment controversy and a report of 46 cases. Plast-
Reconstr Hand Surg 1993;27:223e32.
25. Sandsmark M, Eskeland G, Ogaard Ar, et al. Treatment of large
congenital naevi. Scand J Plast Reconstr Surg Hand Surg 1993;
27:223e32.
26. Goldberg DJ, Zeichner JA, Hodulik SG, et al. Q-switched laser
irradiation of pigmented naevi: analysis of markers for malig-
nant transformation. Lasers Med Sci 2006;18:53.
27. Kinsler VA, Birley J, Atherton DJ. CMN, a 19-year prospective
study; Part 1. Br J Dermatol 2009 Jan;160(1):143e50.
28. Krengel S, Hauschild A, Schafer T. Melanoma risk in CMN:
a systematic review. Br J Dermatol 2006;155:1e8.
29. Marghoob AA, Borrego JP, Halpern AC. Congenital melanocytic
naevi: treatment modalities and management options. Semi-
nCutan Med Surg 2003;22:21e32.
30. Lawrence CM. Treatment options for giant congenital naevi.
Clin Exp Dermatol 2000;25:7e11.
31. Kishi K, Okabe K, Ninomiya R, et al. Early serial Q-switched
ruby laser therapy for medium-sized to giant congenital mel-
anocytic naevi. Br J Dermatol 2009;161:345e52.
32. Anderson R, Margolis R, Watanabe S, et al. Selective photo-
thermolysis of cutaneous pigmentation by Q-switched Nd:Yag laser
pulses At 1064, 532, and355Nm. JInvest Dermatol 1989;93:28e32.
33. Ara G, Anderson Rr, Mandel Kg, et al. Irradiation of pigmented
melanoma cell with high intensity pulsed radiation generates
acoustic wave and kills cells. Laser Surg Med 1990;10:52e9.
34. Cisnerios JL, Del Rio R. Laser treatment of congenital nevus.
International master courses of laser dermatology. Marseille
2001 2e3 November.
35. Horner BM, El-Muttardi NS, Mayou BJ. Treatment of congenital
melanocytic naevi with CO
2
laser. Ann Plast Surg 2005;55(3):
276e80.
36. Annual Scientic meeting of the British Medical Laser Associ-
ation, Woburn 2011.
37. Kornberg R, Ackerman AB. Pseudomelanoma: recurrent mela-
nocytic nevus following partial surgical removal. Arch Derma-
tol 1975;111(12):1588e90.
38. Michel JL. Is laser therapy an adequate treatment for giant
congenital melanocytic naevi? Med Laser Appl 2004;19:6e18.
39. Fox JC, Reed JA, Shea CR. The recurrent nevus phenomenon:
a history of challenge, controversy, and discovery. Arch Pathol
Lab Med 2011;135(7):842e6.
40. Seidenari S, Pellacani G, Grana C. Pigment distribution in mela-
nocytic lesion images: a digital parameter to be employed for
computer-aided diagnosis. Skin Res Technol 2005;11:236e41.
41. Berth-Jones J, Grotzinger K, Rainville C, et al. A study exam-
ining inter- and intrarater reliability of three scales for
measuring severity of psoriasis: psoriasis area and severity
index, physicians global assessment and lattice system physi-
cians global assessment. Br J Dermatol 2006;155(4):707e13.
42. Langley RGB, Ellis CN. Evaluating psoriasis with psoriasis area
and severity index, psoriasis global assessment, and lattice
system physicians global assessment. J Am Acad Dermatol
2004;51:563e9.
1028 N. Al-Hadithy et al.