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Brief Report
November 2017

Response to Laser Treatment of Café au Lait Macules Based on Morphologic Features

Author Affiliations
  • 1Laser & Skin Surgery Center of New York, New York
  • 2Dermatology & Laser Surgery Center, Houston, Texas
  • 3Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York
JAMA Dermatol. 2017;153(11):1158-1161. doi:10.1001/jamadermatol.2017.2807
Key Points

Question  Can the morphologic characteristics of a café au lait macule help predict response to treatment with pigment lasers?

Findings  In this retrospective case series of 45 patients, irregularly bordered lesions on average achieved a mean visual analog scale score of 3.67 (range, 1-4), corresponding to excellent clearance, while smooth-bordered lesions achieved a mean score of 1.76, corresponding to fair clearance, a significant difference.

Meaning  Pigment lasers are more effective at clearing irregularly bordered lesions than smooth-bordered lesions, a distinction that can be used clinically to help predict response and manage expectations.


Importance  Response to laser treatment for café au lait macules (CALMs) is inconsistent and difficult to predict.

Objective  To test the hypothesis that irregularly bordered CALMs of the “coast of Maine” subtype respond better to treatment than those of the smooth-bordered “coast of California” subtype.

Design, Setting, and Participants  This retrospective case series included patients from 2 multiple-clinician US practices treated from 2005 through 2016. All patients had a clinical diagnosis of CALM and were treated with a Q-switched or picosecond laser. A total of 51 consecutive patients were eligible, 6 of whom were excluded owing to ambiguous lesion subtype. Observers were blinded to final patient groupings.

Exposures  Treatment with 755-nm alexandrite picosecond laser, Q-switched ruby laser, Q-switched alexandrite laser, or Q-switched 1064-nm Nd:YAG laser.

Main Outcomes and Measures  Main outcome was grade in a visual analog scale (VAS) consisting of 4 levels of treatment response: poor (grade 1, 0%-25% improvement), fair (grade 2, 26%-50% improvement), good (grade 3, 51%-75% improvement), and excellent (grade 4, 76%-100% improvement).

Results  Forty-five patients were included in the series, 19 with smooth-bordered lesions and 26 with irregularly bordered lesions. Thirty-four (76%) of the participants were female; 33 (73%) were white; and the mean age at the time of laser treatment was 14.5 years (range, 0-44 years). Smooth-bordered lesions received a mean VAS score of 1.76, corresponding to a fair response on average (26%-50% pigmentary clearance). Irregularly bordered lesions received a mean VAS score of 3.67, corresponding to an excellent response on average (76%-100% clearance) (P < .001).

Conclusions and Relevance  CALMs with jagged or ill-defined borders of the coast of Maine subtype tend to respond well to laser treatment, whereas those with smooth and well-defined borders of the coast of California subtype tend to have poor response. Clinicians using Q-switched or picosecond lasers to treat CALMs can use morphologic characteristics to help predict response and more effectively manage patient expectations.