BJD

D ER M A T O L O G I C A L S U R GE RY AN D L A S E R S British Journal of Dermatology

A study of the efficacy of carbon dioxide and

pigment-specific lasers in the treatment of medium-sized
congenital melanocytic naevi
P.J. August, J.E. Ferguson and V. Madan
Laser Division, The Dermatology Centre, Salford Royal Hospital NHS Foundation Trust, Manchester M6 8HD, U.K.

Summary

Correspondence Background Treatment of medium-sized congenital melanocytic naevi (CMN) can

Vishal Madan. be challenging.
E-mail: vishalmadan@doctors.org.uk Objectives To present the results of treatment of 55 CMN with the carbon dioxide
(CO2) and pigment-specific lasers.
Accepted for publication
24 November 2010 Methods CO2 and Q-switched lasers (frequency-doubled Nd:YAG, Nd:YAG and
alexandrite) were used to treat 55 CMN. Patients were treated at 3-month inter-
Funding sources vals until maximum clearance. Clinical response at 3–6 months after final treat-
None. ment was graded as poor (< 50%), good (50–75%) or excellent (> 75%).
Outcomes were evaluated on case note review and questionnaire.
Conflicts of interest
Results Thirty-six of the 55 CMN were macular and 19 were mammillated. Twenty-
None declared.
seven CMN were present on the head and neck. For macular CMN, outcomes were
This study was presented at the British Society of better for truncal CMN. Scarring and pallor were seen in three lower limb macular
Dermatological Surgery session of the 90th Annual CMN treated with a CO2 laser. Mammillated CMN on the head and neck showed
Meeting of the British Association of most improvement. Pigment-specific lasers were of no additional benefit.
Dermatologists, Manchester, July 2010.
Repigmentation occurred in 6% of macular and 21% of mammillated CMN. Partial
DOI 10.1111/j.1365-2133.2011.10236.x
or complete regimentation of CMN was reported by 46% of patients.
Conclusions Compared with macular CMN, mammillated CMN show a marginally
better response to laser treatment. CMN on the limbs respond poorly. Pigment-
specific lasers do not lighten mammillated CMN. Adverse effects can occur with
CO2 laser treatment of macular CMN on lower limbs.

Medium-sized congenital melanocytic naevi (CMN) measure
between 1Æ5 and 19Æ9 cm.1 Alternatively, they have been clas-
sified as naevi which, once excised, the resulting surgical
defect cannot be closed primarily and would necessitate use
of flaps, grafts or tissue expanders.2 Unlike their ‘giant’ coun-
terparts, CMN carry a low risk of malignancy which is high-
est after puberty.3 Although the psychosocial implications of
giant naevi are well established, the psychological impact of
CMN is often underestimated.4 Patients often seek treatment
for cosmetic reasons especially for CMN on visually exposed
sites.
Treatment options for CMN have been extensively
reviewed.3 In sum, these include full- or partial-thickness
excision, dermabrasion, curettage, chemical peels, laser treat-
ment or a combination of these techniques. Where possible,
the treatment of choice for CMN should be full-thickness sur-
gical excision. However, this option is often not suitable for
large CMN located on sites which would otherwise be con-
sidered inoperable. Additionally, surgical excision may be
declined by some patients. In such circumstances laser treat-
ment of CMN is considered a suitable alternative.
Both pigment-specific [Q-switched alexandrite (755 nm, Qs
AL), Q-switched neodymium: yttrium-aluminium-garnet
(1064 nm, Qs Nd:YAG), frequency-doubled Q-switched
Nd:YAG laser (532 nm, Qs fd Nd:YAG) and Q-switched ⁄nor-
mal mode ruby (694 nm)] and resurfacing lasers [erbium:
YAG and carbon dioxide (CO2)] and more recently, a combin-
ation of pigment-specific and resurfacing lasers, have been
found to be effective in the treatment of CMN. Whether
combination lasers are better than resurfacing or pigment-
specific lasers alone has thus far not been assessed. Further,
the efficacy of lasers in the treatment of macular and mammil-
lated CMN has not been studied.
Patients and methods
Between 2002 and 2008, we treated 55 CMN with the CO2,
Qs fd Nd:YAG, Qs Nd:YAG and Qs AL lasers. CO2 and

 2011 The Authors

BJD  2011 British Association of Dermatologists 2011 164, pp1037–1042 1037
1038 Laser treatment of CMN, P.J. August et al.
pigment-specific lasers were used alone or in combination.
Patients were treated at 3-monthly intervals until maximum
improvement or until the laser operator felt that no further
improvement could be obtained. Outcomes were determined
on retrospective case note review and prospective satisfaction
questionnaire.
Laser treatment
Informed consent and photographs were obtained. CO2 laser
treatment was carried out under local anaesthesia using 1% or
2% lignocaine solution containing 1 : 200 000 adrenaline
(maximum dose 7 mg kg)1, Xylocaine; AstraZeneca UK Ltd,
Luton, U.K.). Patients treated with pigment-specific lasers
alone received topical anaesthesia (EMLA cream 5%; Astra-
Zeneca UK Ltd). Test patches were carried out to determine
the best combination of lasers for the CMN.
The Sharplan 40C CO2 laser (Sharplan, London, U.K.) is
used in silk touch mode using a scanner device (200 mm
handpiece, 4–7 mm spot size, 12–37 W in repetition mode).
Multiple passes result in ablation of the superficial layers of
CMN, which are wiped using saline-soaked gauze. Further
passes are delivered after the excess saline is wiped until the
macular CMN are sufficiently lighter and mammillated CMN
flat and lighter. The Qs fd Nd:YAG (2–3 mm, 2–4 J cm)2),
Qs Nd:YAG (2–3 mm, 5–10 J cm)2) or Qs AL (2–3 mm,
6–10 J cm)2) lasers are then used alone or following CO2
laser treatment.
Post-treatment, for CO2 laser-treated CMN, topical mupiro-
cin ointment (Bactroban; GlaxoSmithKline, Uxbridge, U.K.) is
applied under hydrocolloid dressing (Aquacel; ConvaTec,
Uxbridge, U.K.). Topical antibiotics are not required for CMN
treated with pigment-specific lasers alone. Written wound care
instructions are provided. Post-treatment analgesia is not usu-
ally required. Patients are reviewed in outpatients 3–6 months
after final treatment. The clinical response is graded by the
treating physician as poor (< 50%), good (50–75%) or excel-
lent (> 75%) depending upon presence or absence of
side-effects and the cosmetic outcome.
Satisfaction questionnaire
All patients were sent a satisfaction questionnaire in March
2010 and asked the following questions. On a scale of 1–10
(with 10 being the best), how satisfied were you with the
treatment? Are the beneficial results of laser treatment still
Table 1 Laser treatment of congenital melanocytic naevi (CMN)
CMN CO2 CO2 + Qs AL CO2 + fd Nd:YAG
Mammillated 8 7 2 2
Macular 2 7 1 2
CO2, carbon dioxide laser; Qs AL, Q-switched alexandrite laser; fd Nd:YAG, Q-switched frequency-doubled Nd:YAG laser; Nd:YAG, Q-
switched Nd:YAG laser.
BJD  2011 British Association of Dermatologists 2011 164, pp1037–1042
maintained? Did you have any side-effects from the treat-
ment? Would you rather have surgery (cutting the mole out)
if this were an option? Would you recommend this treat-
ment to other patients with a similar birthmark? Patients
were welcomed to enter any additional comments in a free
text box.
Results
Thirty-six of the 55 CMN were macular and 19 were mamm-
illated. Forty-seven CMN were coffee or tan coloured and
eight were dark brown. Mean size of CMN was 5Æ45 cm
(range 2–19) and mean age of the patients at presentation
was 18 years (range 9–43), 45 were females. Head and neck
were the most commonly involved sites (n = 27; 18 macular
and nine mammillated) followed by the limbs (n = 22; six
arms and 16 legs; 16 macular and six mammillated) and the
trunk (n = 6; two macular and four mammillated).
Mammillated CMN underwent treatment with the CO2 laser
alone (n = 8) or in combination with pigment-specific lasers
(n = 11). None of the mammillated CMN was treated with
pigment-specific lasers alone. Macular CMN were treated with
the pigment-specific lasers either alone (n = 24) or in com-
bination with the CO2 laser (n = 10). Two of the 36 macular
CMN were treated with the CO2 laser alone (Table 1).
Macular and mammillated congenital melanocytic naevi
As shown in Table 2, the mean number of treatments (males
4Æ1; females 5Æ4) and overall responses were similar for males
and females. Truncal CMN improved the most while those
CMN on limbs showed least improvement. Side-effects of scar-
ring and hypopigmentation were seen in two female patients
each of whom had CO2 laser and combination laser treatment
of CMN on the lower limbs. Repigmentation occurred in 11%
of patients.
Macular congenital melanocytic naevi
As shown in Table 3, for macular CMN the mean number of
treatments (males 5Æ4; females 6Æ5) and overall response was
similar in males and females. Truncal CMN showed better
improvement with laser treatment than those on the limbs or
head and neck (Figs 1 and 2). Post-treatment scarring (n = 2)
and hypopigmentation (n = 1) were seen in three female
patients who had their lower limb CMN treated with the CO2
CO2 + Nd:YAG fd Nd:YAG Qs AL Nd:YAG
0 0 0
16 7 1
 2011 The Authors
 Laser treatment of CMN, P.J. August et al. 1039

Table 2 Laser treatment of macular and mammillated congenital melanocytic naevi (n = 55)

Improvement (%)
Mean no. Adverse Repigmentation,
treatments Total < 50, n (%) 50–75, n (%) > 75, n (%) effects, n (%) n (%)
Females 5Æ4 45 3 (7) (2 DNA) 10 (22) 24 (53) 4 (9) (2 4 (9)
hypertrophy,
2 pale)
Males 4Æ1 10 0 2 (20) (1 DNA) 6 (60) 0 2 (20)
Head and neck 4Æ15 27 1 (4) (DNA) 6 (22) 17 (63) 0 3 (11)
Limbs 6Æ35 22 2 (9) (DNA) 5 (23) 8 (36) 4 (18) 3 (14)
Trunk 4Æ6 6 0 1 (17) 5 (83) 0 0
CO2 3Æ1 10 1 (10) 2 (20) 5 (50) 1 (10) 1 (10)
CO2 + Qs AL 4Æ25 14 0 4 (29) 7 (50) 2 (14) 1 (7)
fd Nd:YAG 7 16 1 (6) (DNA) 5 (31) 9 (56) 0 1 (6)
Nd:YAG 3 1 0 1 (100) 0 0 0
CO2 + fd Nd:YAG 4 3 0 0 2 (67) 0 1 (33)
Qs AL 4Æ5 7 1 (14) (DNA) 1 (14) 4 (57) 0 1 (14)
CO2 + Nd:YAG 7Æ5 4 0 0 2 (50) 1 (25) 1 (25)

CO2, carbon dioxide laser; Qs AL, Q-switched alexandrite laser; fd Nd:YAG, Q-switched frequency-doubled Nd:YAG laser; Nd:YAG,
Q-switched Nd:YAG laser; DNA, did not attend.

Table 3 Laser treatment of macular congenital melanocytic naevi (n = 36)

Improvement (%)
Mean no. Adverse Repigmentation,
treatments Total < 50, n (%) 50–75, n (%) > 75, n (%) effects, n (%) n (%)
Females 6Æ5 29 3 (10) (2 DNA) 7 (24) 15 (51) 3 (10) 1 (3)
(2 hypertrophy,
1 pale)
Males 5Æ4 7 0 2 (29) (1 DNA) 4 (57) 0 1 (14)
Head and neck 4Æ8 18 1 (6) (DNA) 6 (33) 10 (56) 0 1 (5)
Limbs 6Æ5 16 2 (12) (1 DNA) 3 (19) 7 (44) 3 (19) 1 (6)
Trunk 6 2 0 0 2 (100) 0 0
CO2 3Æ5 2 1 (50) 0 0 1 (50) 0
CO2 + Qs AL 3Æ5 7 0 3 (43) 3 (43) 1 (14) 0
fd Nd:YAG 7 16 1 (6) (DNA) 5 (31) 9 (56) 0 1 (6)
Nd:YAG 3 1 0 1 (100) 0 0 0
CO2 + fd Nd:YAG 3 1 0 0 1 (100) 0 0
Qs AL 4Æ5 7 1 (14) (DNA) 1 (14) 4 (57) 0 1 (14)
CO2 + Nd:YAG 8Æ5 2 0 0 1 (50) 1 (50) 0

CO2, carbon dioxide laser; Qs AL, Q-switched alexandrite laser; fd Nd:YAG, Q-switched frequency-doubled Nd:YAG laser; Nd:YAG,
Q-switched Nd:YAG laser; DNA, did not attend.

laser either alone or in combination with the pigment-specific additional benefit over that achieved with the CO2 laser alone.
lasers. Repigmentation occurred in 6% of patients. Repigmentation was observed in 21% of CMN.

Mammillated congenital melanocytic naevi Satisfaction survey

As shown in Table 4, compared with macular CMN, mammil-
lated CMN showed better response with fewer treatments.
Mammillated CMN on the head and neck and trunk showed
more improvement than those on the limbs (Figs 3 and 4).
Hypertrophic scar was seen in one patient’s lower limb CMN.
Treatment with a pigment-specific laser did not bring about
As shown in Table 5, 28 patients (51%) responded to the
postal survey. Of those, 16 had their treatment between 2 and
5 years and 12 more than 5 years ago. Most patients were
either satisfied (n = 14, 50%) or very satisfied with the results
(n = 8, 28%). However, results were maintained in only 15
patients (54%), with partial or complete repigmentation

 2011 The Authors

BJD  2011 British Association of Dermatologists 2011 164, pp1037–1042
1040 Laser treatment of CMN, P.J. August et al.

(a) (a)

(b)
(b)

Fig 2. Macular congenital melanocytic naevus. (a) Before and (b)

Fig 1. Macular congenital melanocytic naevus. (a) Before and 6 months after treatment with frequency-doubled Q-switched Nd:YAG
(b) 6 months after treatment with Q-switched alexandrite laser. laser.

Table 4 Laser treatment of mammillated congenital melanocytic naevi (n = 19)

Improvement (%)
Mean no. Adverse Repigmentation,
treatments Total < 50, n (%) 50–75, n (%) > 75, n (%) effects, n (%) n (%)
Females 4Æ3 16 0 3 (19) 9 (56) 1 (6) 3 (19)
Males 2Æ8 3 0 0 2 (67) 0 1 (33)
Head and neck 3Æ5 9 0 0 7 (78) 0 2 (22)
Limbs 6Æ2 6 0 2 (33) 1 (17) 1 (17) 2 (33)
Trunk 3Æ25 4 0 1 (25) 3 (75) 0 0
CO2 2Æ7 8 0 2 (25) 5 (62) 0 1 (12)
CO2 + Qs AL 5 7 0 1 (14) 4 (57) 1 (14) 1 (14)
CO2 + fd Nd:YAG 5 2 0 0 1 (50) 0 1 (50)
CO2 + Nd:YAG 6Æ5 2 0 0 1 (50) 0 1 (50)

CO2, carbon dioxide laser; Qs AL, Q-switched alexandrite laser; fd Nd:YAG, Q-switched frequency-doubled Nd:YAG laser; Nd:YAG,
Q-switched Nd:YAG laser.

occurring in four (14%) and nine (32%) patients, respec-
tively. Despite this, most patients preferred laser treatment of
CMN to surgery (24 vs. 4) and a similar number would rec-
ommend this procedure to other patients. The number of laser
treatments was an inconvenience for some of the patients
(data from free text box).
Discussion
Besides the choice of laser and selected parameters, treatment
of CMN also depends on the characteristics of the CMN,
including the histological depth of naevomelanocytes. Success-
ful treatment of CMN can be anticipated if the naevus cells are
predominant in the lower epidermis and higher dermis, as
compared with the deep dermis. Both ablative and nonablative
lasers have been used for the treatment of CMN. Ablation of
epidermis and superficial dermis results in mechanical clear-
ance of naevomelanocytes and formation of subtle scar. In
contrast, the pigment-specific lasers induce a relatively targeted
treatment of pigment cells through photoacoustic and selective
photothermolysis effects.
Despite multiple Q-switched laser treatments of CMN, resid-
ual naevomelanocytic nests may remain unaffected in the
deeper sections of the treated CMN as demonstrated by the

 2011 The Authors

BJD  2011 British Association of Dermatologists 2011 164, pp1037–1042
 Laser treatment of CMN, P.J. August et al. 1041

(a) (b) Table 5 Results of patient satisfaction survey

Question Response, n (%)

Satisfaction
0–4 6 (21)
5–8 14 (50)
8–10 8 (28)
Effects maintained
Yes 15 (54)
Partial repigmentation 4 (14)
Complete repigmentation but lighter 9 (32)
Complete repigmentation 0
Side-effects
Fig 3. Mammillated congenital melanocytic naevus. (a) Before and (b) None 26 (93)
6 months after treatment with carbon dioxide laser. Scarring 2 (7)
Preference
Surgery 4 (14)
presence of naevus cells in the upper reticular dermis below a
Laser 24 (86)
microscopic subtle scar.5 This may also explain the partial
Recommend
improvement in pigmentation and a high risk of repigmenta- Yes 24 (86)
tion seen after treatment of CMN with pigment-specific lasers No 4 (14)
alone.5,6
The precise and controlled ablation of tissue achieved with
the CO2 laser makes it an attractive treatment option for CMN. unlikely to bring about a sustained therapeutic response as the
The bloodless field achieved with this laser is an added advan- deeper naevus cells remain unaffected and are likely to
tage, which allows the operator to identify the depth of abla- repopulate the treated area.
tion. The risk of thermal damage to reticular dermis and In the last decade several authors have used combination
consequent scarring can be minimized by restricting the num- lasers to treat CMN. These combinations have included normal
ber of passes to superficial–midpapillary dermis. However, for mode and Q-switched ruby laser,7 CO2 and Qs AL,8 CO2 and Qs
aforementioned reasons, such a superficial treatment alone is fd Nd:YAG laser9 and CO2 and Q-switched ruby laser.10 The
rationale of using the CO2 laser prior to pigment-specific lasers
in CMN is to expose the otherwise unaffected, deep-sited naevo-
(a) melanocytes to the pigment-specific laser. Naevus cells in the
superficial dermis are additionally removed by the CO2 laser.
The present study provides answers to several hitherto un-
answered questions. By classifying the CMN into macular and
mammillated subtypes it is now possible to predict certain
outcomes. Irrespective of the subtype, CMN on the limbs have
the worst outcomes in terms of clearance and side-effects of
scarring and hypopigmentation. Macular CMN on the trunk
and mammillated CMN on the head and neck and trunk show
a better response to laser treatment than their counterparts on
the limbs. As there are few patients, comparing the outcomes
(b) for each laser subgroup is difficult. For the combined macular
and mammillated group, none of the laser combinations was
superior to the other or to the CO2 laser alone. On the con-
trary, it would appear that pretreatment of macular CMN with
the CO2 laser prior to treatment with pigment-specific lasers
only increases the risk of side-effects and not efficacy. Addi-
tionally, pigment-specific laser treatment of mammillated
CMN offers no advantage over treatment with the CO2 laser
alone.
Chong et al. used the CO2 and Qs AL combination to treat
11 CMN, achieving excellent results, no scarring or hypo-
pigmentation and no recurrence at 2-year follow-up.8 This is
Fig 4. Mammillated congenital melanocytic naevus. (a) Before and in contrast to our results, as using this combination we
(b) 6 months after treatment with carbon dioxide laser and obtained excellent improvement in only 50% of patients and
Q-switched alexandrite laser. scarring occurred in two patients.

 2011 The Authors

BJD  2011 British Association of Dermatologists 2011 164, pp1037–1042
1042 Laser treatment of CMN, P.J. August et al.
Except surgical excision, all available treatment options for
CMN are associated with a high risk of partial or complete re-
pigmentation. High repigmentation after laser treatment of
CMN has also been reported by other authors.6,11
Although overall results were better after fewer treatments,
repigmentation was substantially higher for mammillated as
compared with macular CMN (6% vs. 21%). Despite high in-
cidence of repigmentation of CMN following laser treatment,
79% of our patients were satisfied or very satisfied with the
treatment. This could be attributed to the substantial initial
lightening of the CMN with laser treatment, following which
partial or complete repigmentation is still perceived to be an
improvement over baseline. It is rare for the CMN to repig-
ment to its original colour intensity. All adverse effects of
scarring and hypopigmentation seen in our patients can be at-
tributed to the CO2 laser treatment of CMN on lower limbs.
Therefore CO2 laser should be used with caution when treat-
ing CMN on lower limbs and should be avoided for macular
CMN. The need for repeat laser treatments should also be
discussed with the patients as this can be an inconvenience.
More aggressive CO2 laser treatments may reduce the need for
multiple treatments, but at the expense of increased risk of
scarring. Cost implications of repeat laser treatments should
also be considered when choosing treatment options for
CMN. Our study limitations include low patient numbers in
each laser subgroup, making comparison difficult, and a short
follow-up duration.
Finally, laser-induced malignant transformation of naevus
cells remains a theoretical concern but such concerns have not
been found to be true in clinical practice.12
Based on our results, we can conclude that pretreatment of
CMN with CO2 laser appears no more effective than pigment-
specific laser alone in the treatment of macular CMN and may
increase the incidence of adverse effects especially for macular
CMN on the lower limbs. Additional treatment of mammillat-
ed CMN following CO2 laser treatment does not increase effi-
cacy. Despite multiple treatments and initial clearance, there is
a high risk of repigmentation with laser treatment of CMN.
Despite this limitation, laser treatment of CMN remains an
attractive alternative for inoperable CMN or when cold steel
surgery is declined.
What’s already known about this topic?
• Medium-sized congenital melanocytic naevi (CMN)
have been treated with ablative and pigment-specific
lasers.
• Combination lasers may be useful in the treatment of
CMN.
BJD  2011 British Association of Dermatologists 2011 164, pp1037–1042
What does this study add?
• Compared with macular CMN, mammillated CMN show
a marginally better response to laser treatment.
• CMN on the limbs respond poorly.
• Pigment-specific lasers do not lighten mammillated
CMN.
• Adverse effects can occur with CO2 laser treatment of
macular CMN on lower limbs.
References
1 Kopf AW, Bart RS, Hennessey P. Congenital nevocytic nevi and
malignant melanomas. J Am Acad Dermatol 1979; 1:123–30.
2 Lanier VC, Pickrell KL, Georgiade NG. Congenital giant nevi: clini-
cal and pathological considerations. Plast Reconstr Surg 1976; 58:48–
54.
3 Marghoob AA, Borrego JP, Halpern AC. Congenital melanocytic
nevi: treatment modalities and management options. Semin Cutan
Med Surg 2007; 26:231–40.
4 Koot HM, de Waard-van der Spek F, Peer CD et al. Psychosocial
sequelae in 29 children with giant congenital melanocytic naevi.
Clin Exp Dermatol 2000; 25:589–93.
5 Imayama S, Ueda S. Long- and short-term histological observations
of congenital nevi treated with the normal-mode ruby laser. Arch
Dermatol 1999; 135:1211–18.
6 Kim S, Kang WH. Treatment of congenital nevi with the
Q-switched alexandrite laser. Eur J Dermatol 2005; 15:92–6.
7 Kono T, Erçöçen AR, Nozaki M. Treatment of congenital melano-
cytic nevi using the combined (normal-mode plus Q-switched)
ruby laser in Asians: clinical response in relation to histological
type. Ann Plast Surg 2005; 54:494–501.
8 Chong SJ, Jeong E, Park HJ et al. Treatment of congenital nevo-
melanocytic nevi with the CO2 and Q-switched alexandrite lasers.
Dermatol Surg 2005; 31:518–21.
9 Dave R, Mahaffey PJ. Combined early treatment of congenital mel-
anocytic naevus with carbon dioxide and NdYag lasers. Br J Plast
Surg 2004; 57:720–4.
10 Park SH, Koo SH, Choi EO. Combined laser therapy for difficult
dermal pigmentation: resurfacing and selective photothermolysis.
Ann Plast Surg 2001; 47:31–6.
11 Waldorf HA, Kauvar ANB, Geronemus RG. Treatment of small and
medium congenital nevi with the Q-switched ruby laser. Arch
Dermatol 1996; 132:301–4.
12 Goldberg DJ, Zeichner JA, Hodulik SG et al. Q-switched laser irradi-
ation of pigmented nevi: analysis of markers for malignant trans-
formation. Lasers Med Sci 2006; 18 (Suppl.):53 (Abstract).
 2011 The Authors