By Richard Mark Kirkner, Medscape
Children can benefit from a variety of dermatologic laser procedures, from hair removal to treatment of scars and vascular anomalies. However, the data on the safety and effectiveness of lasers for treating skin conditions in pediatric patients are lacking, as are clinical guidelines.
Lasers have been widely used in pediatric dermatology, with the earliest reports of laser treatment of port-wine stains going back 30 years or more. The steady evolution of devices has improved clinical results, but the use of lasers in children for dermatologic conditions carries unique challenges, pediatric dermatologists who specialize in laser treatments have reported.
A multitude of indications for ablative fractional lasers (AFLs) for pediatric patients exist. However, “performing laser surgery on kids tends to be a very different experience than working with adult patients,” Andrew C. Krakowski, MD, network chair of dermatology at St. Luke’s University Health Network in Easton, Pennsylvania, told Medscape Medical News. “First off, adult patients want to be there, usually to have something being made to look better. Kids, on the other hand, want to be anywhere other than the doctor’s office.”
Lasers can be useful for patients of all ages, “from newborns to people over 100 years old, depending on what you’re trying to treat,” Kristen M. Kelly, MD, professor and chair of dermatology at UC Irvine School of Medicine, told Medscape Medical News. “Just like any therapeutic modality, you want to make sure that you know how to use it, that you’re using it for the correct indications, you’re using it in the correct way for that particular indication.”
Indications for Lasers in Pediatric Dermatology
Pediatric patients can undergo laser procedures for many of the same indications as adults, including hair removal. Anna Yasmine Kirkorian, MD, chief of dermatology at Children’s National Hospital, Washington, DC, and colleagues reviewed the ethical and clinical considerations of lasers and other hair removal modalities in pediatric patients in a 2024 review. “All methods of hair removal appear to be safe and generally well tolerated in children, and there are no age restrictions to any modality,” Kirkorian and her coauthors wrote. Regarding lasers specifically, they added, “In the pediatric population, lasers have the most extensive data supporting their use for hair removal, and their safety profile in treating other dermatologic conditions adds to the existing body of evidence.”
AFL can be used for a host of scarring indications in pediatric patients, including hypertrophic scarring, keloid scarring, acne scarring, and surgical scarring. At the Society for Pediatric Dermatology annual meeting held the day before the American Academy of Dermatology meeting in March, Krakowski said the treatment of self-cutting scars is another indication.
“A big focus of mine is treating kids’ scars, not just the appearance of scars but, perhaps even more importantly, any deficit in function the scar may be causing,” Krakowski told Medscape Medical News.
Other pediatric indications Krakowski enumerated include collagen nodules and contracture, repigmentation of pulse dye laser hypopigmentation, porokeratotic eccrine ostial and dermal duct nevus, Dowling-Degos disease, angiofibromas in tuberous sclerosis, recessive dystrophic epidermolysis bullosa, Goltz syndrome, and infantile hemangiomas and birthmarks.
Psychosocial Issues in Children
“Scars can also be associated with posttraumatic stress disorder and depression,” Krakowski said. Burn scars are a typical example of the latter. And disfiguring scars can also be associated with increased anxiety and feelings of social isolation in adolescents and teenagers.
“These scar-related comorbidities are often under-investigated and underreported, so you really have to make the deliberate point to ask your patients and then be prepared to address what they share,” he said.
Children with chronic skin conditions deal with a host of psychosocial issues, such as bullying and stigmatization, different from those that adults deal with, a multisite cross-sectional study of 1671 children published last year in JAMA Dermatology reported.
The study concluded that this is an area that requires further study and one that dermatologists need to take more seriously. While skin disorders “are often regarded as less serious” than other groups of diseases, “a child or adolescent with a chronic skin disorder risks becoming the target for bullying, alienation, and feelings of reduced self-worth, leading to stigma,” the authors wrote.
“There are both physical and emotional scars,” Kelly said. “Sometimes, that’s something that people need an opportunity to be able to deal with.” In some cases, other resources, such as counseling or group therapy, may be in order, she said.
Informed Consent for Pediatric Patients
Obtaining informed consent for a dermatologic laser procedure for a child is far different from the process for adults, Kirkorian told Medscape Medical News. “Children cannot consent to procedures, but as often as is possible, they should be able to assent,” she said. The dermatologist must be able to explain the procedure to the child in an age-appropriate manner.
“For procedures, such as laser hair removal, which are elective and not medically necessary, the child should both want to participate in the procedure and be able to comply with safety requirements,” such as having the ability to wear eye protection and stay still during the procedure, she said.
Parents play an integral role in the informed consent process because they are the ones ultimately giving the informed consent for their child, Kirkorian said. But the child must also cooperate. “It’s important that we do not force children to undergo procedures that are not medically necessary or the only option if they are unwilling participants,” she said.
Two examples Kirkorian offered where the child’s cooperation is vital are cryotherapy for the treatment of verruca and intralesional steroid injections for the treatment of alopecia areata. She only performs these procedures on children if they “are willing and able to participate because these procedures can be painful and do not lead to resolution of the condition in all cases,” she said. “If a child cannot or will not participate with such procedures, then alternative medical treatments would be indicated.”
Medically necessary procedures, such as biopsy of a changing nevus, require a different approach, she said. “If a child cannot comply, then we consider a sedated procedure as an alternative,” Kirkorian said.
Informing parents and children of procedures requires different approaches for each, Kelly said. “Obviously, the language you might use for the parents and the children could be somewhat different because certainly, you want everyone to understand.”
In addition, “you want to work with the parents to find the best way to approach the information with the child,” she added. “You want them to be informed. You also don’t want to create unnecessary fear, and so you need to find the right approach to let them know what will be happening but not scare them.”
Pain Management in Children
Children also have different pain management needs. “Obviously, it’s not a totally painless procedure,” Lisa Arkin, MD, director of Pediatric Dermatology and co-director of the Birthmarks and Vascular Anomalies Program at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin, said of laser ablation. “Most kids of an appropriately selected age and maturity can tolerate these procedures in the office.”
Here, the dermatologist may need to take a nuanced approach based on the type of injury or condition being treated, she said. “There’s always sort of a select patient population, particularly the kids who’ve had extensive burns, where there’s just too much trauma, and you just need to leverage general anesthesia to keep them comfortable.”
In children, the same principles apply as in adults: mitigating anxiety, pain, and fear, Arkin said. Techniques include topical anesthetic cream, cooling of the epidermis, and use of the Buzzy handheld device that combines a reusable ice pack and vibration near the treatment area.
“Control is a big thing for kids,” Arkin said. “They want to know how much it’s going to hurt and how many pulses it will take so that they can mentally wrap their head around expectations.”
Another strategy in small children that Kirkorian has found useful is having the parent hold the child during the laser treatment. “There are many positions or embraces that can be taught, especially by collaborating with child-life teams,” she said. “The parent’s job is to provide comfort, not to ‘hold the child down.’”
Besides topical anesthetics, vibratory devices, and cold sprays, other approaches include distraction with videos, music, or virtual reality, Kirkorian said.
“Lastly, dermatologists who perform procedures on children should feel very comfortable doing so and be able to perform the procedures quickly and effectively on a moving patient,” she added. Otherwise, the child should be referred to a board-certified pediatric dermatologist.
Managing Expectations
Preparing parents and children for the eventual outcome also requires some skill and nuance. “Dermatologists should explain the procedure plan in detail with parents in advance of the procedure while being mindful that this discussion might be best performed without the child present in case it will increase the child’s anxiety if it is a small child,” Kirkorian said.
“For older children or adolescents, it’s important to include them in the discussion because they cannot be ‘held down’ or restrained safely, so they need to be able to understand and assent,” she added.
Kelly gave an example of how that conversation can go with a child. “If I’m treating a scar — and I would say the same thing to adults — I never promise that I’m going to completely remove the scar,” she said. “I’m not going to be able to make it go away like it had never happened, but we can dramatically improve it.”
A Word About Teenagers
In Krakowski’s experience, “teenagers are awesome” and have often been the most motivated of patients “because they want nothing more than to fit in with their peers,” whereas adults “tend to want to stand out from the people around them.”
However, teenagers can also present unique challenges compared with younger children, he said.
“The trouble with teenagers, though, is that they are old enough and strong enough to be able to get off the exam table and walk out of the procedure room,” Krakowski said. “You can be halfway through a procedure, and if they decide they are finished, there is not much you can do about it.”
His advice: Plan ahead so that the treatment can be completed. For example, to treat atrophic scars from chronically inflamed acne, which is the most common condition he treats with lasers in teenagers, he’s switched from AFL to a fractional nonablative device because patients tolerate it better. Referring to AFL, he said, “I know this device hurts and is associated with significant downtime.”
With the nonablative device, “I can finish the treatments, and I know the patients will notice some significant improvement by the end of our third or fourth treatment session,” Krakowski said.
That, he said, improves the chances that these potentially difficult pediatric patients will complete their treatment.
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