Patient-reported outcomes in lasers and light therapy

As the prevalence of lasers and light devices to treat dermatologic conditions increases, patient reported outcomes (PROs) will be an essential component of evaluating clinical efficacy and patient satisfaction. PROs may be used to identify patients' values, weigh risks and benefits of various therapies, identify barriers to treatment and help guide the development of new therapies. Utilizing patient and physician assessments may help determine if a new treatment is objectively better than currently available therapies. In creating a patient-centered treatment plan using laser and light modalities, it is critical to evaluate side effects using PROs. Determining and resolving barriers to treatment has benefits at the individual level and the population level. Many PRO measures (PROMs) are available to use for general and specific dermatologic conditions. The Dermatologic Life Quality Index, Skindex, and FACE-Q are PROMs that have been used in laser and light therapy studies. Selecting the proper instrument should be based on study aims to yield high quality data. Herein, we assess PROs use in laser and light treatment protocols to improve patient care, increase patient satisfaction and reduce barriers to care, and review dermatology PRO measures (PROMs) used in published laser and light clinical studies.

An In Vitro Approach to Photodynamic Therapy

Photodynamic therapy (PDT) is a medical procedure that involves incubation of an exogenously applied photosensitizer (PS) followed by visible light photoactivation to induce cell apoptosis. The Federal Drug Administration has approved PDT for the treatment of actinic keratosis, and clinical guidelines recommend PDT as a treatment for certain non-melanoma skin cancers and acne vulgaris. PDT is an advantageous therapeutic modality as it is low cost, non-invasive, and associated with minimal adverse events and scaring. In the first step of PDT, a PS is applied and allowed to accumulate intracellularly. Subsequent light irradiation induces reactive oxygen species formation, which may ultimately lead to cell apoptosis, membrane disruption, mitochondrial damage, immune modulation, keratinocyte proliferation, and collagen turnover. Herein, we present an in vitro method to study PDT in an adherent cell line. This treatment protocol is designed to simulate PDT and may be adjusted to studying the use of PDT with various cell lines, photosensitizers, incubation temperatures, or photoactivation wavelengths. Squamous cell carcinoma cells were incubated with 0, 0.5, 1.0, and 2 mM 5-aminolevulinic acid (5-ALA) for 30 min and photoactivated with 417 nm blue light for 1,000 s. The primary outcome measure was apoptosis and necrosis, as measured by annexin-V and 7-aminoactinomycin D flow cytometry. There was a dose-dependent increase in cell apoptosis following thirty-minute incubation of 5-ALA. To achieve high inter-test validity, it is important to maintain consistent incubation and light parameters when performing in vitro PDT experiments. PDT is a useful clinical procedure and in vitro research may allow for the development of novel PSs, optimization of protocols, and new indications for PDT.

Combined Hyperthermic 1060nm Diode Laser Lipolysis With Topical Skin Tightening Treatment: Case Series

BACKGROUND

As body contouring procedures have become more popular, post-procedural skin laxity is a concern. Non-invasive body contouring technologies may effectively reduce body fat, but modestly affect skin tightening.

OBJECTIVE

To assess the efficacy and safety of a topical skin tightening agent in combination with hyperthermic diode laser lipolysis.

METHODS

Herein, we describe five patients in which a skin tightening concentrate of 5% yeast extract, 2% hydrolyzed rice protein content, and 2.5% tripeptide was used after 1500-2100 J/cm2 of hyperthermic 1060 nm diode laser.

RESULTS

Overall, all patients had a subjective positive response and high satisfaction with the combined treatment results of improvement in skin laxity and fat reduction. In all five cases, patients demonstrated visible fat reduction and skin improvement on photographs taken between weeks 6-18 compared to baseline. Blinded investigators correctly predicted the order of the photographs based on treatment results. No adverse events were reported.

CONCLUSION

This case series demonstrated that a combined topical skin tightening concentrate with a hyperthermic laser lipolysis device may achieve improved aesthetic outcomes without adverse events. J Drugs Dermatol. 2018;17(7):780-785.

Psoriasiform Pemphigus Foliaceus in an African American Female: An Important Clinical Manifestation

A 50-year-old African-American woman presented to the dermatology clinic with a pruritic eruption of 3 years' duration. On clinical examination, the patient had well-demarcated, pink, atrophic plaques and superficial erosions over the inframammary folds and mid-chest. She also had well-demarcated, hyperpigmented, hyperkeratotic scaly plaques over the abdomen, suprapubic region, elbows, knees, and back with sporadic small superficial blisters. A punch biopsy of the right abdomen was performed and revealed psoriasiform epidermal hyperplasia, focal parakeratosis, and acantholysis throughout the superficial spinous and granular layers. Only a sparse inflammatory infiltrate was present in the underlying dermis. Clinical and histological findings supported the diagnosis of pemphigus foliaceus (PF), but psoriasis was included in the differential diagnosis due to the presence of discrete plaques with an erythematous border. We hypothesize that patients with psoriasiform presentations of PF may be misdiagnosed with plaque psoriasis. It is important to distinguish between PF and psoriasis as there is evidence that ultraviolet light, a common treatment for psoriasis, may exacerbate PF. We document and highlight this atypical psoriasiform presentation of PF in a patient with skin of color to raise awareness and improve diagnosis and outcomes. <p><em>J Drugs Dermatol. 2018;17(4):471-473.</em></p>.

Electronic device generated light increases reactive oxygen species in human fibroblasts

OBJECTIVES

Our skin is constantly exposed to light from solar radiation and electronic devices, which impact skin physiology and aging. The biological altering properties of ultraviolet (UV) solar radiation on skin have been well established. There is significant scientific and public interest on the effects of electronic device generated light (EDGL) on skin. Currently, the effects of EDGL on skin are largely unknown. EDGL includes UV, visible, and infrared light from consumer electronics such as smartphones, computers, and televisions. In this study, we measured the wavelength specific irradiance from electronic devices, and irradiated fibroblasts with white EDGL to determine changes in reactive oxygen species generation, apoptosis, and necrosis.

METHODS

To determine the EDGL output of commonly used consumer electronic devices, we measured the irradiance from electronic devices at the manufacturers' recommended reading distances and at 1 cm. To determine the effect of EDGL on human skin cells, we irradiated AG13145 fibroblasts with EDGL for 1 hour at a distance of 1 cm and measured changes in reactive oxygen species generation, apoptosis, and necrosis.

RESULTS

ROS increased significantly by 81.71%, 85.79%, and 92.98% relative to control following 1 hour of white EDGL from iPhone 8+, iPhone 6, and iPad (first generation), respectively. There was a non-significant change in apoptosis following irradiation with an iPhone 8+, iPhone 6, and iPad. Total necrosis was less than 2% for all treatment and control groups.

CONCLUSIONS

Our results suggest that short exposures of EDGL increase ROS generation, but the long-term effects associated with repeated exposures of EDGL are unknown. As electronic devices become more widely used and integrated into society globally, we anticipate greater scientific research and general public interest on the effects of visible EDGL on skin. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

Light-emitting diodes in dermatology: A systematic review of randomized controlled trials

OBJECTIVE

In dermatology, patient and physician adoption of light-emitting diode (LED) medical technology continues to grow as research indicates that LEDs may be used to treat skin conditions. The goal of this systematic review is to critically analyze published randomized controlled trials (RCTs) and provide evidence-based recommendations on the therapeutic uses of LEDs in dermatology based on published efficacy and safety data.

METHODS

A systematic review of the published literature on the use of LED treatments for skin conditions was performed on September 13th 2017.

RESULTS

Thirty-one original RCTs were suitable for review.

CONCLUSIONS

LEDs represent an emerging modality to alter skin biology and change the paradigm of managing skin conditions. Acne vulgaris, herpes simplex and zoster, and acute wound healing received grade of recommendation B. Other skin conditions received grade of recommendation C or D. Limitations of some studies include small patient sample sizes (n < 20), absent blinding, no sham placebo, and varied treatment parameters. Due to few incidences of adverse events, affordability, and encouraging clinical results, we recommend that physicians use LEDs in clinical practice and researchers continue to explore the use of LEDs to treat skin conditions. Lasers Surg. Med. 9999:1-16, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Laser and light-based therapy for cutaneous and soft-tissue metastases of malignant melanoma: a systematic review

Invasive cutaneous melanoma is a growing health concern. Although surgical excision can effectively treat in situ tumors, use for metastatic melanoma is limited. Laser and light-based therapies may be a valuable palliative treatment option for patients with stage III and stage IV cutaneous metastatic melanoma. Our goal is to review the published literature and provide evidence-based recommendations on laser and light-based palliative therapies for metastatic melanoma. A search of the databases Pubmed, EMBASE, Web of Science, and CINAHL was performed on March 10, 2016. Key search terms were related to melanoma, laser, and light-based modalities. Our search initially identified 13,923 articles and 27 original articles met inclusion criteria for our review. Grade of recommendation: C for non-fractionated carbon dioxide laser, Grade of recommendation: D for fractionated carbon dioxide laser, ruby laser, neodymium laser, near-infrared diode laser, and photodynamic therapy. Non-fractionated carbon dioxide laser had the best palliative efficacy of the reviewed laser and light-based therapies, while other treatment modalities may have potential as adjunctive therapy to standard of care.

Efficacy of ultra short sub-30 minute incubation of 5-aminolevulinic acid photodynamic therapy in vitro

BACKGROUND AND OBJECTIVE

The estimated incidence of cutaneous squamous cell carcinoma (SCC) is 700,000 cases per year. In the US, SCC incidence is highest among fair skinned adults older than 50 years of age. Thus, as the population ages, the reported number of SCCs will likely increase in the future. Photodynamic therapy (PDT) is an FDA approved therapy for treatment of actinic keratoses (AKs), a precursor to cutaneous SCC lesions. The FDA approved incubation time of the photosensitizing agent 5-aminolevulinic acid (ALA) is 14-18 hours. Recent studies have investigated short ALA incubation times of 1-3 hours with ALA and PDT demonstrating treatment success. Therefore, the question exists whether ALA incubation periods of less than 30 minutes are efficacious. Herein, we evaluate the efficacy of short ALA incubation periods by measuring apoptosis after 10, 15, and 20 minutes of ALA incubation.

STUDY DESIGN/MATERIALS AND METHODS

AG13145 normal human dermal fibroblasts HDFs were incubated with 10, 15, or 20 minute of ALA at various concentrations (0, 0.05, 0.075, 0.1, 0.25, 0.375, 0.5, 1, and 2 mM). After ALA incubation, samples were treated with 1,000 seconds (16 minutes 40 seconds) of Blu-U fluorescent blue light (417 ± 5 nm) for a fluence of 10 J/cm² . Immediately following treatment with blue light, samples were collected and stained for apoptosis and necrosis with annexin-V and 7-aminoactinomycin D (7-AAD), and then analyzed by flow cytometry.

RESULTS

HDFs incubated with ALA for 10 minute at 36 °C followed by 10 J/cm² of blue light had no statistically significant changes in apoptosis. HDFs incubated with ALA for 15 or 20 minutes at 36 °C followed by 10 J/cm² of blue light had statistically significant increases in the percentages of cells positive for apoptosis in the 0.5, 1.0, and 2.0 mM ALA doses (P < 0.05).

CONCLUSIONS

We found that incubation of ALA for at least 15 minutes followed by 10 J/cm² of blue light resulted in a statistically significant increase in apoptosis. Lasers Surg. Med. 49:592-598, 2017. © 2017 Wiley Periodicals, Inc.

De novo deletions and duplications of 17q25.3 cause susceptibility to cardiovascular malformations

Background

Genomic disorders resulting from deletion or duplication of genomic segments are known to be an important cause of cardiovascular malformations (CVMs). In our previous study, we identified a unique individual with a de novo 17q25.3 deletion from a study of 714 individuals with CVM.

Methods

To understand the contribution of this locus to cardiac malformations, we reviewed the data on 60,000 samples submitted for array comparative genomic hybridization (CGH) studies to Medical Genetics Laboratories at Baylor College of Medicine, and ascertained seven individuals with segmental aneusomy of 17q25. We validated our findings by studying another individual with a de novo submicroscopic deletion of this region from Cytogenetics Laboratory at Cincinnati Children’s Hospital. Using bioinformatic analyses including protein-protein interaction network, human tissue expression patterns, haploinsufficiency scores, and other annotation systems, including a training set of 251 genes known to be linked to human cardiac disease, we constructed a pathogenicity score for cardiac phenotype for each of the 57 genes within the terminal 2.0 Mb of 17q25.3.

Results

We found relatively high penetrance of cardiovascular defects (~60 %) with five deletions and three duplications, observed in eight unrelated individuals. Distinct cardiac phenotypes were present in four of these subjects with non-recurrent de novo deletions (range 0.08 Mb–1.4 Mb) in the subtelomeric region of 17q25.3. These included coarctation of the aorta (CoA), total anomalous pulmonary venous return (TAPVR), ventricular septal defect (VSD) and atrial septal defect (ASD). Amongst the three individuals with variable size duplications of this region, one had patent ductus arteriosus (PDA) at 8 months of age.

Conclusion

The distinct cardiac lesions observed in the affected patients and the bioinformatics analyses suggest that multiple genes may be plausible drivers of the cardiac phenotype within this gene-rich critical interval of 17q25.3.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-015-0291-0) contains supplementary material, which is available to authorized users.

Transcripts from a novel BMPR2 termination mutation escape nonsense mediated decay by downstream translation re-initiation: implications for treating pulmonary hypertension

Bone morphogenetic protein receptor type 2 (BMPR2) gene mutations are a major risk factor for heritable pulmonary arterial hypertension (HPAH), an autosomal dominant fatal disease. We have previously shown that BMPR2 transcripts that contain premature termination codon (PTC) mutations are rapidly and nearly completely degraded through nonsense mediated decay (NMD). Here we report a unique PTC mutation (W13X) that did not behave in the predicted manner. We found that patient-derived cultured lymphocytes (CLs) contained readily detectable levels of the PTC-containing transcript. Further analysis suggested that this transcript escaped NMD by translational re-initiation at a downstream Kozak sequence, resulting in the omission of 173 amino acids. Treatment of CLs containing the PTC with an aminoglycoside decreased the truncated protein levels, with a reciprocal increase in full-length BMPR2 protein and, importantly, BMPR-II signaling. This is the first demonstration of aminoglycoside-mediated 'repair' of a BMPR2 mutation at the protein level in patient-derived cells and has obvious implications for treatment of HPAH where no disease-specific treatment options are available. Our data also suggest the need for a more thorough characterization of mutations prior to labeling them as haploinsufficient or dominant negative based simply on sequencing data.