Case 1

A fifteen-year-old female patient with no notable pathological history reported a lesion on the anterior surface of the right elbow present since childhood, which had been biopsied in favor of lymphatic malformation: presence of multiple grouped vesicles with sometimes clear and sometimes hemorrhagic content on the anterior surface of the right elbow (Fig. 1a). The patient underwent soft-tissue ultrasound to exclude a subcutaneous component, which returned normal. She underwent two sessions of Er: YAG laser, handpiece R11, spot 3 mm, fluence 6–8 J/cm², with good improvement and no recurrence in six months (Fig. 1a).

Figure 1: (a) Lymphangioma circumscriptum on the anterior aspect of the elbow. (b) Laser results after six months.

Case 2

A nine-year-old female patient with no notable pathological history reported a lesion on the anterior aspect of the right arm since childhood: presence of multiple grouped vesicles with sometimes clear and sometimes hemorrhagic content on the anterior aspect of the right arm (Fig. 2a). The patient underwent soft-tissue ultrasound to exclude a subcutaneous component, which returned normal, and underwent two Er: YAG laser sessions under sedation, handpiece R11, spot 3 mm and 2 mm for small vesicles, fluence 7 J/cm², with good improvement and no recurrence in six months (Fig. 2b).

Figure 2: (a) Lymphangioma circumscriptum on the anterior aspect of the arm. (b) Erythema immediately after laser treatment.

DISCUSSION

Lymphangiomas circumscriptum may be congenital or secondary to surgery [1]. Its treatment is not codified and depends on the site, size, and presence or absence of an underlying deep component, which must be investigated before considering therapeutic management by ultrasound of the soft tissue and/or MRI, These lymphatic malformations correspond to saccular dilatations of lymphatic vessels, which will appear clinically in the form of vesicles filled with yellowish lymph, sometimes reddish, due to intravesicular bleeding of the vessels, Therapeutic modalities are varied and include cryotherapy, ablative CO₂ laser, sclerotherapy, and pulsed dye laser and surgery, which is the therapeutic modality of choice for this type of vascular malformation, yet whose scar ratio sometimes conditions the indication [2]. Ablative lasers, in particular CO₂, have a dual property: they are simultaneously ablative and coagulant, unlike Er: YAG laser, which is purely ablative. This coagulant property of CO₂ laser gives it a superiority compared with the clinical result, and avoids bleeding that may be a nuisance during medical procedures [3]. Between these tiny impacts, the skin is respected, enabling direct and rapid healing and, consequently, little or no social eviction. The ablative effect is due to photo-vaporization, resulting in the perforation of the epidermis in the form of pits, and an underlying zone of thermal damage [4]. Several articles have demonstrated the efficacy of laser treatment of circumscriptum lymphangioma and other vascular anomaly [5], notably the diode laser with a wavelength of 900 nm and a spectrum of absorption by the blood. It was combined with radiofrequency in a series of six patients [6] and produced an excellent response (75% to 100% disappearance of the lesion) in four of the six children in the series. Indeed, the 900 nm wavelength penetrates the dermis and acts on the deeper or shallower vessels of the dermis. The heat diffused by the laser centrifugally attracts the energy of the radiofrequency used simultaneously and diffuses it centripetally inside the cavity, which potentiates the effect of the diode laser. Pulsed dye laser (PDL) is a type of laser widely indicated for the treatment of vascular lesions with a wavelength of 595 nm. Although it does not penetrate deeply, this laser has a strong affinity with oxyhemoglobin and may, therefore, be indicated in the treatment of superficial lymphatic malformations with hemorrhagic components, as shown by a case in the literature [7] in which a thirteen-year-old patient with lymphangioma circumscriptum with a strong hemorrhagic component of the shoulder was treated with LCP laser under general anesthesia with a spot size of 7 and energy of 7.25 J/cm2. A marked improvement was noted with one recurrence in three years. CO₂ laser is reputed to be the ablative laser of choice with a wavelength of 10600 nm. It penetrates deep into the dermis, exerting a vaporizing action on the vesicles that constitute the malformation and a coagulating action that seals off the deep blood and lymphatic vessels responsible for recurrences, making this laser the option of choice in the treatment of circumscriptum lymphangiomas [8], as indicated in a review of the literature [9] on cases treated with CO₂ laser in the continuous mode. This review also highlighted the rarity of LC treatment with fractional ablative CO₂ laser, which is said to be more effective than fractional ablative Er: YAG laser. Fractional ablative Er: YAG laser treatment is a technique aimed at destroying skin layers with visual control in order to treat pathology of the dermal-epidermal component. The laser wavelength of 2940 nm enables good laser beam penetration and symptomatic improvement [10]. A case report on the use of this type of laser in LC was published [11] on a thirteen-year-old boy who underwent two sessions two months apart, with confocal microscopy in two years after treatment, confirming the disappearance of ectatic lymphatic ducts in the dermis and ectatic lymphatic channels in the superficial dermis yet showed the persistence of deeper lymphatic vessels in the dermis, suggesting that fractional ablative Er: YAG laser treatment of LC is effective, yet that patients should be kept under surveillance for recurrence.

Consent

The examination of the patient was conducted according to the principles of the Declaration of Helsinki.

The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for images and other clinical information to be included in the journal. The patients understand that their names and initials will not be published and due effort will be made to conceal their identity, but that anonymity cannot be guaranteed.