1. Aetna considers pulsed dye laser treatment medically necessary for any of the following conditions:
   
   
   1. Verrucae (warts) when conventional therapies such as topical chemotherapy, curettage, electrodesiccation and cryotherapy have failed; or
   2. Port wine stains and other hemangiomas when lesions are located on the face and neck (see CPB 031 - Cosmetic Surgery); or
   3. Keloids or other hypertrophic scars which are secondary to an injury or surgical procedure and either criterion below is met (see CPB 031 - Cosmetic Surgery):
      
      
      1. Results in significant functional impairment; or 
      2. Causes significant pain requiring chronic analgesic medication; or
         
         
   4. Multiple, superficially located glomangiomas in the face and neck, where surgical excision is not practical; or
   5. Pyogenic granuloma in the face and neck; or
   6. Mild to moderate localized plaque psoriasis when criteria are met in CPB 577 - Psoriasis: Laser Treatment; or
   7. Genital warts when home therapy with either podophyllotoxin or imiquimod has failed.

2. Aetna considers the use of the pulsed dye laser cosmetic for any of the following conditions (see CPB 031 - Cosmetic Surgery):
   
   
   1. Removal of telangiectasias; or
   2. Removal of spider angiomata; or
   3. Removal of hair for pseudofolliculitis barbae or follicular cysts; or
   4. Rosacea (see CPB 547 - Rosacea).
      
      
3. Aetna considers the use of the pulsed dye laser experimental and investigational for all other indications, including any of the following conditions:
   
   
   1. Active acne; or
   2. Morphea (scleroderma of the skin); or
   3. Hidradenitis suppurativa; or
   4. Pilonidal disease; or
   5. Balanitis xerotica obliterans; or
   6. Granulation tissue; or
   7. Pityriasis rubra pilaris.

The pulsed dye laser delivers energy at a wavelength and duration that has been optimized for the selective treatment of vascular lesions.  It has been used in the treatment of warts, port wine stains, hemangiomas, hypertrophic scars, and telangiectasias.  Pulsed dye lasers have been used as an alternative to surgical excision or carbon dioxide lasers.

The Food and Drug Administration (FDA) has cleared the pulsed-dye laser for use in treatment of warts, port-wine stains, hemangiomas, hypertrophic scars, and telangiectasias.  The pulsed-dye laser has been shown to be effective in treating glomangiomas in the face and neck, as surgical excision may not be practical in these cosmetically sensitive areas.  The pulsed-dye laser has also shown to be effective in removing pyogenic granulomas in cosmetically sensitive areas of the face and neck.

Charakida and colleagues (2004) reported that low-energy pulsed dye laser therapy has been used, and seems to be a promising alternative that would allow the simultaneous treatment of active acne and acne scarring.  However, the authors concluded that further studies are needed to clarify the role of phototherapy as a monotherapy or an adjuvant treatment in the current management of acne vulgaris. 

Goldberg (2005) stated that pharmacological agents remain the mainstay for initial and maintenance treatment of rosacea. However, monochromatic (i.e., laser) and polychromatic light-based therapies are increasingly being used for the treatment of certain signs of rosacea. The author noted that despite the increased use of lasers and other light-based therapies, few well-controlled studies have been conducted on their use for the treatment of rosacea. Furthermore, a Cochrane review on interventions for rosacea (van Zuuren, et al., 2005) concluded that the quality of studies evaluating rosacea treatments was generally poor. The assessment found that there is evidence that topical metronidazole and azelaic acid are effective (van Zuuren, et al., 2005). The assessment found some evidence that oral metronidazole and tetracycline are effective. The assessment stated that there is insufficient evidence concerning the effectiveness of other treatments. The assessment concluded that good randomized controlled trials looking at these treatments are urgently needed.

Maw (2004) stated that a variety of treatment options are available for the treatment of genital warts; but few have been assessed in large-scale, randomized, placebo-controlled trials. Provider-applied surgical and non-surgical treatments have traditionally been the therapies of choice. Surgical therapies, including cryotherapy, electrotherapy, laser surgery and surgical excision, are generally equivalent in terms of wart clearance rates, but are associated with high rates of wart recurrence. Trichloroacetic acid is a widely used non-surgical therapy, but little is known about its efficacy, and it is associated with unpleasant side-effects. The patient-applied treatments imiquimod and podophyllotoxin are newer therapy choices which are more acceptable to both patients and practitioners. The wart clearance rates for these two treatments are similar, although imiquimod is associated with lower recurrence rates. In the face of increasing pressures on genitourinary clinic services, patient-applied home therapy represents an attractive option for the treatment of genital warts.

O'Mahony (2005) noted that commonly used physical treatment methods for genital warts include cryotherapy, trichloroacetic acid, laser, and electrocautery. However, many patients respond extremely well to home therapies with either podophyllotoxin or imiquimod. Patients prefer the comfort and dignity of home treatment, and this should be the first-line of treatment for the majority of patients. A routine screen for sexually transmitted infections is appropriate in most cases. Detailed explanation and reassurance are of paramount importance in reducing the psychological distress associated with this unpleasant genital condition.

Komericki et al (2006) stated that flashlamp-pumped pulsed dye laser (FPDL) represents one of many treatment options for the management of viral warts (verrucae vulgares), its effectiveness being comparable with that of conventional therapies. These researchers evaluated the effectiveness of FPDL light for the treatment of genital warts (n = 22). All patients showed complete remission after 1.59 (1 to 5) laser sessions and no scarring was observed. The authors concluded that the findings of this study demonstrate that FPDL is a simple and safe, cost- and time-saving alternative treatment option for genital warts and should be listed in genital warts treatment guidelines. Ockenfels and Hammes (2008) explained that FPDL had advantages over carbon dioxide laser in that the former is a nonablative approach to treatment of genital warts that appears to be associated with fewer side effects than the latter.

Scheinfeld and Lehman (2006) stated that genital human papillomavirus (HPV) infection is the most common sexually transmitted disease. Each year 1 million new cases of genital warts are diagnosed, two-thirds of which are in women. The estimated prevalence rate in the U.S. population is 15 %. Human papillomavirus infects keratinocytes. Such infection can manifest clinically as warts. Treatment options for genital warts are numerous, well-established, and effective. Topical treatments include podophyllin resin, imiquimod, trichloroacetic acid, and podophyllotoxin. Surgical or destructive therapies include carbon dioxide laser, surgical excision, loop excision, cryotherapy, and electrodessication. Interferon can be injected locally or administered systemically to treat genital warts. Evidence of efficacy in the treatment of genital warts is drawn from randomized blind-controlled trials, prospective studies, and retrospective cohort studies. Evidence of efficacy appears to be good, but more head-to-head studies and comparisons of combination therapies versus monotherapy need to be done. Treatment of choice depends on the number, size, and location of lesions. There is little certainty that any approach is more effective than another, however costs differ. It would seem that the first line destructive treatment is cryotherapy, but surgery and electrodesiccation are more effective. The first line topical treatments appear to be podophyllotoxin and imiquimod. Interferon is too expensive and trichloracetic acid is too inconsistent to be recommended as primary treatment. It is unclear if combinations of therapies are more effective than monotherapy. Side effect profile, cost, effectiveness and convenience (ability to attend physician's office or to undertake protracted home treatment) define the choice of therapy.