The effect of autophagy on hemoporfin-mediated photodynamic therapy in human umbilical vein endothelial cells

SIGNIFICANCE

Hemoporfin-mediated photodynamic therapy (HMME-PDT) has been recognized as a safe and effective treatment for port wine stain (PWS). However, some patients show limited improvement even after multiple treatments. Herein, we aim to explore the effect of autophagy on HMME-PDT in human umbilical vein endothelial cells (HUVECs), so as to provide theoretical basis and treatment strategies to enhance clinical effectiveness.

METHODS

Establish the in vitro HMME-PDT system by HUVECs. Apoptosis and necrosis were identified by Annexin Ⅴ-FITC/PI flow cytometry, and autophagy flux was detected by monitoring RFP-GFP-LC3 under the fluorescence microscope. Hydroxychloroquine and rapamycin were employed in the mechanism study. Specifically, the certain genes and proteins were qualified by qPCR and Western Blot, respectively. The cytotoxicity was measured by CCK-8, VEGF-A secretion was determined by ELISA, and the tube formation of HUVECs was observed by angiogenesis assay.

RESULTS

In vitro experiments revealed that autophagy and apoptosis coexisted in HUVECs treated by HMME-PDT. Apoptosis was dominant in early stage, while autophagy gradually increased in the middle and late stage. AMPK, AKT and mTOR participated in the regulation of autophagy induced by HMME-PDT, in which AMPK was positive regulation, while AKT and mTOR were negative regulation. Hydroxychloroquine could not inhibit HMME-PDT-induced autophagy, but capable of blocking the fusion of autophagosomes with lysosome. Rapamycin might cooperate with HMME-PDT to enhance autophagy in HUVECs, leading to increased cytotoxicity, reduced VEGF-A secretion, and weakened angiogenesis ability.

CONCLUSIONS

Both autophagy and apoptosis contribute to HMME-PDT-induced HUVECs death. Pretreatment of HUVECs with rapamycin to induce autophagy might enhance the photodynamic killing effect of HMME-PDT on HUVECs. The combination of Rapamycin and HMME-PDT is expected to further improve the clinical efficacy.

Evaluating the clinical efficacy of pulsed dye laser with sirolimus for treatment of capillary malformations: A systematic review

Port-wine stains (PWS) are capillary vascular anomalies that are often treated with pulsed-dye laser (PDL). Revascularization limits persistent clearance; however, the anti-angiogenic effects of sirolimus (SIRO) may inhibit revascularization. This review aims to determine differences in PWS outcomes when treated with PDL monotherapy or in combination with SIRO. A systematic review was conducted using PubMed, Cochrane, and Embase databases. The following search terms were used: 'port wine stain PDL SIRO', 'port wine stain PDL', and 'port wine stain PDL and topical treatment' with (MeSH) and (Title/Abstract) limits. The search was limited to the English language and human-subject studies conducted between 1 January 2000 and 1 June 2023. Inclusion criteria included studies evaluating SIRO as an adjunct to PDL in patients with PWS. Data extraction and quality assessment were performed by two independent reviewers. A total of nine studies met the inclusion criteria, which included randomized controlled trials (3), case series (2), case reports (3), and a prospective intrapatient study (1), which represented a total of 58 patients. Five studies showed improvement of a measured post-treatment PDL parameter including shortening treatment time and less frequent dosing. A subset of studies (4/9) which did not demonstrate significant clinical improvements exhibited significant photographic evidence of improvement. Heterogeneity among the studies highlights the need for further research and standardization. While adjunctive SIRO shows promise, larger studies and comprehensive evaluation methods are required to establish conclusive safety and efficacy guidelines to shape clinical decision-making.

Delayed ulceration following combination pulse dye laser and topical sirolimus treatment for port wine birthmarks: A case series

Port wine birthmarks (PWB) are capillary vascular malformations within the papillary and reticular dermis, most commonly occurring on the head and neck and may darken and thicken with age. Pulsed dye laser (PDL) is the gold standard of treatment for PWB as it selectively targets involved vessels. Sirolimus is a macrolide antibiotic that selectively inhibits mammalian target of rapamycin, thereby suppressing the angiogenesis pathways that can be activated by PDL. Sirolimus and PDL may be used together to treat PWB. We present a case series describing three cases of delayed ulceration and systemic sirolimus absorption following combination therapy, highlighting a potential complication and patient safety concern.

High speed photo-mediated ultrasound therapy integrated with OCTA

Photo-mediated Ultrasound Therapy (PUT), as a new anti-vascular technique, can promote cavitation activity to selectively destruct blood vessels with a significantly lower amount of energy when compared to energy level required by other laser and ultrasound treatment therapies individually. Here, we report the development of a high speed PUT system based on a 50-kHz pulsed laser to achieve faster treatment, decreasing the treatment time by a factor of 20. Furthermore, we integrated it with optical coherence tomography angiography (OCTA) for real time monitoring. The feasibility of the proposed OCTA-guided PUT was validated through in vivo rabbit experiments. The addition of OCTA to PUT allows for quantitative prescreening and real time monitoring of treatment response, thereby enabling implementation of individualized treatment strategies.

A core outcome domain set for clinical research on capillary malformations (the COSCAM project): an e-Delphi process and consensus meeting

BACKGROUND

There is limited evidence on the best available treatment options for capillary malformations (CMs), mainly due to the absence of uniform outcome measures in trials on therapies. A core outcome set (COS) enables standard reporting of trial outcomes, which facilitates comparison of treatment results.

OBJECTIVES

To develop a core outcome domain set (CDS), as part of a core outcome set (COS), for clinical research on CMs.

METHODS

Sixty-seven potentially relevant outcome subdomains were recognized based on the literature, focus group sessions, and input from the COSCAM working group. These outcome subdomains were presented in an online Delphi study to CM experts (medical specialists and authors of relevant literature) and (parents of) patients with CM (international patient associations). During three e-Delphi study rounds, the participants repeatedly scored the importance of these outcome subdomains on a seven-point Likert scale. Participants could also propose other relevant outcome subdomains. Consensus was defined as ≥ 80% agreement as to the importance of an outcome subdomain among both stakeholder groups. The CDS was finalized during an online consensus meeting.

RESULTS

In total 269 participants from 45 countries participated in the first e-Delphi study round. Of these, 106 were CM experts from 32 countries, made up predominantly of dermatologists (59%) and plastic surgeons (18%). Moreover, 163 (parents of) patients with CM from 28 countries participated, of whom 58% had Sturge-Weber syndrome. During the two subsequent e-Delphi study rounds, 189 and 148 participants participated, respectively. After the entire consensus process, consensus was reached on 11 outcome subdomains: colour/redness, thickness, noticeability, distortion of anatomical structures, glaucoma, overall health-related quality of life, emotional functioning, social functioning, tolerability of intervention, patient satisfaction with treatment results, and recurrence.

CONCLUSIONS

We recommend the CDS to be used as a minimum reporting standard in all future trials of CM therapy. Our next step will be to select suitable outcome measurement instruments to score the core outcome subdomains. What is already known about this topic? Besides physical and functional sequelae, capillary malformations (CMs) often cause emotional and social burden. The lack of uniform outcome measures obstructs proper evaluation and comparison of treatment strategies. As a result, there is limited evidence on the best available treatment options. The development of a core outcome set (COS) may improve standardized reporting of trial outcomes. What does this study add? A core outcome domain set (CDS), as part of a COS, was developed for clinical research on CMs. International consensus was reached on the recommended core outcome subdomains to be measured in CM trials: colour/redness, thickness, noticeability, distortion of anatomical structures, glaucoma, overall health-related quality of life, emotional functioning, social functioning, tolerability of intervention, patient satisfaction with treatment results, and recurrence. This CDS enables the next step in the development of a COS, namely to reach consensus on the core outcome measurement instruments to score the core outcome subdomains. What are the clinical implications of this work? The obtained CDS will facilitate standardized reporting of treatment outcomes, thereby enabling proper comparison of treatment results. This comparison is likely to provide more reliable information for patients about the best available treatment options.

Pathogenesis of Port-Wine Stains: Directions for Future Therapies

Port-wine stains (PWSs) are congenital vascular malformations that involve the skin and mucosa. To date, the mechanisms underlying the pathogenesis and progression of PWSs are yet to be clearly elucidated. The potential reasons for dilated vessels are as follows: (1) somatic GNAQ (R183Q) mutations that form enlarged capillary malformation-like vessels through angiopoietin-2, (2) decreased perivascular nerve elements, (3) the coexistence of Eph receptor B1 and ephrin B2, and (4) the deficiency of αSMA expression in pericytes. In addition, ERK, c-JNK, P70S6K, AKT, PI3K, and PKC are assumed to be involved in PWS development. Although pulsed-dye laser (PDL) remains the gold standard for treating PWSs, the recurrence rate is high. Topical drugs, including imiquimod, axitinib, and rapamycin, combined with PDL treatments, are expected to alter the recurrence rate and reduce the number of PDL sessions for PWSs. For the deep vascular plexus, photosensitizers or photothermal transduction agents encapsulated by nanocarriers conjugated to surface markers (CD133/CD166/VEGFR-2) possess a promising therapeutic potential in photodynamic therapy or photothermal therapy for PWSs. The pathogenesis, progression, and treatment of PWSs should be extensively investigated.

Theoretical and in vivo experimental investigation of laser hyperthermia for vascular dermatology mediated by liposome@Au core-shell nanoparticles

The 1064 nm Nd:YAG laser shows a good prospect for the treatment of port-wine stain (PWS), but it is necessary to enhance the blood absorption to laser energy by exogenous chromophore. Owing to the conjunction effect of local surface plasmon resonance (LSPR) by gold nanoparticle and drug delivery as well as lumen blockage abilities by liposome, liposome@Au core-shell nanoparticles are used as exogenous chromophore, and the efficiency of photothermal therapy is studied systematically. In this work, theoretical simulations were conducted to investigate the electric field and solid heat conduction of liposome@Au core-shell nanoparticles with various size and particles distance, aiming to achieve maximum photothermal conversion efficiency during the laser irradiation. Thereafter, liposome@Au core-shell nanoparticles with optimal size and structure were prepared, and in vivo experiments were conducted to evaluate the thermal damage of blood vessels enhanced by liposome@Au core-shell nanoparticles. Theoretical results imply that maximum temperature rise (167 K) is obtained when radius is 45 nm and shell thickness is 5 nm with distance of 4 nm. Liposome@Au core-shell nanoparticles were prepared with diameter of 101 nm and shell thickness of 5 nm according to the finite element simulation of electric field and solid heat conduction. When the molar ratio of chloroauric acid to phospholipid is 2.25, the LSPR absorption peak is about 981 nm, which is close to the wavelength of Nd:YAG laser. In vivo experiments show that injecting liposome@Au core-shell nanoparticles into the blood vessels can effectively reduce the number of laser pulses and the corresponding energy density required for obvious vasoconstriction.

[Complex treatment of children with vascular head and neck malformations]

AIM

The article analyzes the results of treatment of children affected with lesions of blood vessels of the head and neck. The research is aimed at developing and implementing minimally invasive techniques to treat such children.

MATERIAL AND METHODS

The study group comprised 4416 patients with hyperplasia of blood vessels (the so-called infantile and congenital hemangiomas) and 397 patients with blood vessel malformations, examined and treated from 1991 to 2020.

RESULTS

The paper summarizes developed indications and the results of implementation of effective minimally invasive methods for the treatment of children with vascular lesions: radiofrequency thermal ablation and pulsed dye laser treatment of children with severe forms of arterio-venous malformation in their maxillofacial area and. The treatment is currently the golden standard that provides stable aesthetic results.

CONCLUSION

The most optimal and preferred methods of vascular lesions treatment proved to be minimally invasive techniques that include: radiofrequency thermal ablation, interstitial laser coagulation, pulse phototherapy, sclerotherapy and systemic treatment of beta-blockers.

Triple pass laser therapy for recalcitrant facial port wine stains

Patients with recalcitrant facial port wine stains (rfPWS) can be challenging to manage, often leaving the clinician with difficult decisions for treatment options. 'Triple therapy' consists of using three different laser wavelengths at each treatment setting. The evidence on outcomes is limited as this treatment approach has not been previously reported to the best of our knowledge. Children who received triple therapy at least once for rfPWS, and for whom SIAscopy readings had been taken, were retrospectively identified. SIAscope readings were compared before the first triple therapy treatment and at final the most recent clinical follow-up. The clinical appearance was also assessed using a Visual Analogue Scale comparing clinical photographs taken before triple therapy to those taken at the most recent clinical follow-up. A total of 47 children were identified and included in our review. The SIAscope readings showed an overall significant (p < 0.001) lightening with 39 (83%) showing lightening and 8 (17%) patients showing a darkening. Scores using the VAS also showed improvement with 55% experiencing an improvement in their clinical appearance, 38% showing no visible change and 6% appearing to have worsened. Triple therapy can offer improvement of rfPWS which have failed to respond to single wavelength laser therapy. SIAscopy and VAS scores correlate well in assessing clinical response; however, the added clinical benefit of SIAscopy in vascular laser clinics remains uncertain.

A Randomized Controlled Pilot Study: Combined 595-nm Pulsed Dye Laser Treatment and Oxymetazoline Hydrochloride Topical Cream Superior to Oxymetazoline Hydrochloride Cream for Erythematotelangiectatic Rosacea

Background and Objectives

We evaluated if oxymetazoline therapy combined with 595‐nm pulsed dye laser (PDL) will be more beneficial than topical oxymetazoline alone for the improvement of erythematotelangiectatic rosacea.

Study Design/Materials and Methods

This was a randomized, controlled, prospective clinical trial approved by an independent Institutional Review Board, which enrolled 34 patients with moderate to severe clinical erythema (CEA) into a two‐arm study of PDL with concomitant oxymetazoline cream (Arm 1) and oxymetazoline cream alone (Arm 2). Patients in Arm 1 were treated with 3 monthly laser sessions, which were started after 1 month of topical oxymetazoline cream. Thirty subjects continued with the study, and 25 subjects (Arm 1: 14, Arm 2: 11) completed the 6‐month follow‐up. With photographic comparison to baseline images, efficacy endpoints were based on clinical on‐site grading by both the investigator and the patient, using the grading tools for CEA, Global Aesthetic Improvement (GAI) assessment, vessel size improvement, and subject self‐assessment. These scales were assessed at baseline and/or at each clinical follow‐up at 1, 2, 3, and 6 months. Subject satisfaction as well as post‐treatment immediate response and treatment‐associated pain scores were also evaluated.

Results

Statistically significant improvement in CEA was seen in both arms at the 1‐, 2‐, and 3‐month post‐baseline visits (P < 0.01). Only Arm 1 presented statistically significant improvement in CEA (P < 0.001) at 6 months post baseline with a mean score of 1.6 (almost clear‐mild) compared with 3.2 at baseline. Arm 1 showed significantly greater mean vessel size improvement at 3 months (P < 0.01) and 6 months (P < 0.05) post baseline compared to Arm 2. Significantly greater improvement (P < 0.05) in the investigator GAI score was reported at the 2‐ and 6‐month follow‐ups compared with Arm 2. Subject GAI scores showed statistically significant greater improvement in Arm 1 compared with Arm 2 at both the 3‐ and 6‐month follow‐ups (P < 0.01). There were no complications or long‐term effects associated with PDL or topical oxymetazoline treatments.

Conclusion

The prospective trial verifies a safe, enhanced clinical outcome with the combination of PDL therapy and topical oxymetazoline for the treatment of erythematotelangiectatic rosacea patients. Lasers Surg. Med. © 2021 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

Genetic Basis and Therapies for Vascular Anomalies

Vascular and lymphatic malformations represent a challenge for clinicians. The identification of inherited and somatic mutations in important signaling pathways, including the PI3K (phosphoinositide 3-kinase)/AKT (protein kinase B)/mTOR (mammalian target of rapamycin), RAS (rat sarcoma)/RAF (rapidly accelerated fibrosarcoma)/MEK (mitogen-activated protein kinase kinase)/ERK (extracellular signal-regulated kinases), HGF (hepatocyte growth factor)/c-Met (hepatocyte growth factor receptor), and VEGF (vascular endothelial growth factor) A/VEGFR (vascular endothelial growth factor receptor) 2 cascades has led to the evaluation of tailored strategies with preexisting cancer drugs that interfere with these signaling pathways. The era of theranostics has started for the treatment of vascular anomalies. Registration: URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2015-001703-32.

Combination Therapy for the Treatment of Complex Vascular Lesions

BACKGROUND AND OBJECTIVES

Combination treatment with debulking surgical procedures, vascular and ablative lasers, and topical and intralesional vascular therapies may improve outcomes in nodular hypertrophic and mixed complex vascular malformations; however, there is a paucity of data reporting specific combinations of these treatments. We report 15 cases of complex vascular malformations, which were successfully treated with novel combinations of these modalities.

STUDY DESIGN/MATERIALS AND METHODS

We performed a review of 15 patients treated with combination vascular laser therapy, electrosurgery, ablative laser technologies, and topical and intralesional vascular therapies from May 2000 to October 2020. Photographs were taken at intervals with attempts made for consistent lighting and positioning.

RESULTS

All 15 patients achieved an excellent clinical response to combination therapy with visible improvement of the hypertrophic, textural, and vascular components of their lesions. No major complications or adverse events were encountered during any of the treatments.

CONCLUSION

Combination multimodality therapy with surgical debulking, laser technologies, and topical and injection therapies can be highly effective and efficient in treating complex vascular malformations. © 2021 Wiley Periodicals LLC.

A narrative review of the role of sirolimus in the treatment of congenital vascular malformations

OBJECTIVE

Vascular malformations arise from defects in the morphologic development of the vascular system and can have an impact on quality of life and/or lead to severe complications. To date, vascular malformations are frequently managed by invasive techniques, after which recurrence is common. Sirolimus, a downstream inhibitor of the phosphatidylinositol 3 kinase/AKT pathway and best known for its immunosuppressive effect, has been used off-label for lesions for which approved therapies were associated with unsatisfactory results or recurrence. The aim of this study was to review the available data on the effect of sirolimus on the size and symptoms of different types of malformations and to summarize the main safety issues.

METHODS

A literature search in Pubmed, Embase, Web of Science, and SCOPUS was performed. Case reports, case series, and clinical trials evaluating the effect of sirolimus in vascular malformations were eligible for this review. Fully terminated studies published between January 2010 and May 2019 reporting an evaluable response on size and/or symptoms were included. Relevant data on lesion size, symptoms, side effects and duration of treatment were extracted as reported in the study. Additionally, we reported 10 unpublished cases who were treated in UZ Leuven.

RESULTS

The literature review included 68 articles, describing 324 patients. The median duration of therapy was 12 months (range, 1-60 months). After 6 months of treatment, the size of the malformation had at least decreased in 67% of patients with common venous malformations (VM), in 93% of patients with blue rubber bleb nevus syndrome and in all patients with verrucous VM. The size of lymphatic malformations improved in more than 80% of the patients, even in the case of extensive involvement such as in Gorham-Stout disease and generalized lymphatic anomaly. In addition, the majority of patients with syndromic vascular malformations experienced a decrease in size and reported symptoms improved in almost all patients, regardless of the type of malformation. Side effects were common (53%) but usually mild; mucositis and bone marrow suppression were the most common. Regrowth or recurrence of symptoms occurred in 49% of patients who discontinued treatment. Comparable effects were seen in our own patients.

CONCLUSIONS

This review shows that sirolimus is effective in decreasing the size and/or symptoms of particularly lymphatic malformations as well as VMs. Although common, side effects were usually mild. Nevertheless, clinical trials are needed to confirm the safety and effectivity of sirolimus and to identify the required serum levels and duration of treatment.

Recent Progress in Lymphangioma

Lymphangioma is a common type of congenital vascular disease in children with a broad spectrum of clinical manifestations. The current classification of lymphangioma by International Society for the Study of Vascular Anomalies is largely based on the clinical manifestations and complications and is not sufficient for selection of therapeutic strategies and prognosis prediction. The clinical management and outcome of lymphangioma largely depend on the clinical classification and the location of the disease, ranging from spontaneous regression with no treatment to severe sequelae even with comprehensive treatment. Recently, rapid progression has been made toward elucidating the molecular pathology of lymphangioma and the development of treatments. Several signaling pathways have been revealed to be involved in the progression and development of lymphangioma, and specific inhibitors targeting these pathways have been investigated for clinical applications and clinical trials. Some drugs already currently in clinical use for other diseases were found to be effective for lymphangioma, although the mechanisms underlying the anti-tumor effects remain unclear. Molecular classification based on molecular pathology and investigation of the molecular mechanisms of current clinical drugs is the next step toward developing more effective individualized treatment of children with lymphangioma with reduced side effects.

Evaluating the efficacy and safety of topical sirolimus 0.2% cream as adjuvant therapy with pulsed dye laser for the treatment of port wine stain: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Port Wine Stain (PWS) is a congenital capillary malformation. Although multiple treatments are required, the gold standard treatment for PWS is Pulsed Dye Laser (PDL). Given its anti-angiogenic effects, sirolimus can be considered as an adjuvant to PDL in PWS.

AIM

To evaluate the efficacy and safety of topical sirolimus (Rapamycin) 0.2% cream as adjuvant therapy for PDL for PWS.

METHODS

In this randomized double-blind placebo-controlled trial, 15 patients with PWS were enrolled. Each lesion was divided into upper and lower parts, and each part was assigned randomly to receive PDL (4 sessions, 2 months apart) plus sirolimus vs PDL and placebo. The response was evaluated using colorimetry, investigator global assessment (IGA), and patient global assessment (PGA) every two months for eight continuous months.

RESULTS

According to the colorimetric analysis, medial and lateral sides of the treatment and placebo parts did not differ significantly (both P-value > .05). However, according to PGA and IGA, there was a significant difference in favor of sirolimus (P-values = .041 and .039, respectively). Itching and dryness (86.7%), contact dermatitis (20%) were the most common adverse effects in the sirolimus group, while none of them were observed in placebo.

CONCLUSION

Although the improvement was significant subjectively, topical sirolimus 0.2% as an adjuvant to PDL does not appear to improve PWS erythema using calorimetric assessment.

Removing Subcutaneous Microvessels Using Photo-Mediated Ultrasound Therapy

BACKGROUND AND OBJECTIVES

We have developed a novel anti-vascular technique, termed photo-mediated ultrasound therapy (PUT), which utilizes nanosecond duration laser pulses synchronized with ultrasound bursts to remove the microvasculature through cavitation. The objective of the current study is to explore the potential of PUT in removing subcutaneous microvessels.

STUDY DESIGN/MATERIALS AND METHODS

The auricular blood vessels of two New Zealand white rabbits were treated by PUT with a peak negative ultrasound pressure of 0.45 MPa at 0.5 MHz, and a laser fluence of 0.056 J/cm2 at 1064 nm for 10 minutes. Blood perfusion in the treated area was measured by a commercial laser speckle imaging (LSI) system before and immediately after treatment, as well as at 1 hour, 3 days, 2 weeks, and 4 weeks post-treatment. Perfusion rates of 38 individual vessels from four rabbit ears were tracked during this time period for longitudinal assessment.

RESULTS

The measured perfusion rates of the vessels in the treated areas, as quantified by the relative change in perfusion rate, showed a statistically significant decrease for all time points post-treatment (P < 0.001). The mean decrease in perfusion is 50.79% immediately after treatment and is 32.14% at 4 weeks post-treatment. Immediately after treatment, the perfusion rate decreased rapidly. Following this, there was a partial recovery in perfusion rate up to 3 days post-treatment, followed by a plateau in the perfusion from 3 days to 4 weeks.

CONCLUSIONS

This study demonstrated that a single PUT treatment could significantly reduce blood perfusion by 32.14% in the skin for up to 4 weeks. With unique advantages such as low laser fluence as compared with photothermolysis and agent-free treatment as compared with photodynamic therapy, PUT holds the potential to be developed into a new tool for the treatment of cutaneous vascular lesions. Lasers Surg. Med. © 2020 Wiley Periodicals, LLC.

Current Practices in Pediatric Dermatology Laser Therapy: An International Survey

BACKGROUND AND OBJECTIVES

To date, there are no well-established guidelines regarding laser therapy for the treatment of cutaneous lesions in pediatric patients. We aim to ascertain the types of lasers commonly used, types of lesions treated, and factors that affect the selection of specific laser modalities in pediatric patients.

STUDY DESIGN/MATERIALS AND METHODS

An anonymous online survey was distributed to healthcare providers who treat children with lasers through listservs of four major national and international dermatology and laser organizations.

RESULTS

Outpatient office-based procedure rooms are the most common clinical setting for laser procedures (74.4%), and pulsed dye laser is the most commonly used laser (95.4%). Conditions routinely treated with lasers included port wine stains (95.4%), infantile hemangiomas (81.5%), other vascular lesions (81.5%), scars (77.7%), and hair (60.8%). 84.4% of respondents expressed concern about general anesthesia in patients <2 years old. Nevi of Ota is treated with laser more frequently (52.3%) than other pigmented lesions.

LIMITATIONS

Limited generalizability of case examples to general conditions.

CONCLUSIONS

Vascular lesions are the most common lesions treated with lasers in pediatric dermatology patients, and most providers are using these devices in the outpatient setting. Many providers are concerned about the effects of repeated general anesthesia in infants, and there appears to be a trend toward providing laser therapy in the outpatient setting without general anesthesia. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Laser for vascular anomalies: successful outcomes in children

Vascular anomalies can cause both emotional and physical distress to patients, particularly children. The paediatric laser service at Great Ormond Street Hospital (GOSH) treats a range of dermatological conditions including a variety of vascular anomalies, excess hair growth and disfiguring scars. The laser team at GOSH has 25 years of experience in treating a wide variety of paediatric dermatological conditions using various laser therapies. With over 600 new referrals for laser therapy and over 1000 laser procedures each year the GOSH laser team has vast amounts of experience with both common and rare conditions. Excellent clinical outcomes continue to be delivered, and new treatment therapies are constantly being developed to treat more recalcitrant lesions. The adverse effect rates experienced by the GOSH laser patients have been decreasing over the past two decades, reaching the low rate of 0.8% per treated patients per year. This remarkable achievement has been continuously improved by integrating specific and standardized laser protocols for each patient treated, to ensure efficacious and safe laser treatment delivery. Treating vascular anomalies with laser therapy creates significant positive results among the paediatric population, thus laser therapy at GOSH makes a significant impact upon children's lives with both rare and common vascular anomalies.

The Pathogenesis of Port Wine Stain and Sturge Weber Syndrome: Complex Interactions between Genetic Alterations and Aberrant MAPK and PI3K Activation

Port wine stain (PWS) is a congenital vascular malformation involving human skin. Approximately 15-20% of children a facial PWS involving the ophthalmic (V1) trigeminal dermatome are at risk for Sturge Weber syndrome (SWS), a neurocutaneous disorder with vascular malformations in the cerebral cortex on the same side of the facial PWS lesions. Recently, evidence has surfaced that advanced our understanding of the pathogenesis of PWS/SWS, including discoveries of somatic genetic mutations (GNAQ, PI3K), MAPK and PI3K aberrant activations, and molecular phenotypes of PWS endothelial cells. In this review, we summarize current knowledge on the etiology and pathology of PWS/SWS based on evidence that the activation of MAPK and/or PI3K contributes to the malformations, as well as potential futuristic treatment approaches targeting these aberrantly dysregulated signaling pathways. Current data support that: (1) PWS is a multifactorial malformation involving the entire physiological structure of human skin; (2) PWS should be pathoanatomically re-defined as "a malformation resulting from differentiation-impaired endothelial cells with a progressive dilatation of immature venule-like vasculatures"; (3) dysregulation of vascular MAPK and/or PI3K signaling during human embryonic development plays a part in the pathogenesis and progression of PWS/SWS; and (4) sporadic low frequency somatic mutations, such as GNAQ, PI3K, work as team players but not as a lone wolf, contributing to the development of vascular phenotypes. We also address many crucial questions yet to be answered in the future research investigations.

Use of topical rapamycin in the treatment of superficial lymphatic malformations

BACKGROUND

The superficial lymphatic component of vascular malformations poses a significant treatment challenge. It is responsible for the majority of symptoms presented, and to date, there is no consensus regarding treatment.

OBJECTIVE

To evaluate the effectiveness of topical rapamycin in treating superficial lymphatic malformations (LM).

METHODS

A case series study was performed of patients with superficial LM, treated with topical rapamycin. The clinical characteristics of patients and the concentration and application mode of the drug were recorded. The changes in the signs and symptoms observed and associated adverse effects were noted and analyzed.

RESULTS

The study population consisted of 11 patients of an average age of 10.5 years. All were treated with topical rapamycin: 6 patients with a 1% concentration, 1 with a 0.8% concentration, and 4 with a 0.4% concentration. Changes in the clinical appearance of the lesions were observed in all patients. The associated symptoms, present in 9 of 11 patients, improved in every case. The mean follow-up time was 16.1 months.

LIMITATIONS

This study is retrospective, with a small sample size and considerable heterogeneity of lesions and treatment approaches.

CONCLUSION

Treatment with topical rapamycin modifies the clinical appearance and alleviates symptoms of superficial LM.

Topical Adjuncts to Pulsed Dye Laser for Treatment of Port Wine Stains: Review of the Literature

BACKGROUND

Port wine stains (PWS) pose a therapeutic challenge. Pulsed dye laser (PDL) is the treatment of choice; however, treatment is often ineffective and recurrences are common.

OBJECTIVE

This article provides a review of topical therapies that have been investigated to improve efficacy of PDL for the treatment of PWS.

MATERIALS AND METHODS

A literature search was performed through PubMed, EMBASE, Web of Science, and CINAHL, using the search terms "port wine stain," "pulsed dye laser," and "topical."

RESULTS

Clinical trials have investigated the topical agents, timolol, imiquimod, and rapamycin (RPM) in combination with PDL for the treatment of PWS. Topical timolol with PDL failed to show improved efficacy compared with PDL alone. Two clinical trials using imiquimod and PDL showed enhanced blanching of PWS compared with controls. Rapamycin and PDL were more effective than controls for facial PWS, but not for nonfacial PWS.

CONCLUSION

Topical imiquimod and RPM have shown some efficacy in treating PWS with PDL, but to date there is no topical adjuvant to PDL that reliably improves results for PWS.

Effect of laser therapy on quality of life in patients with radiation-induced breast telangiectasias

OBJECTIVE

To evaluate the effects of laser monotherapy on quality of life in breast cancer patients with chronic radiation dermatitis.

STUDY DESIGN

A prospective, IRB-approved study was conducted at Memorial Sloan Kettering Cancer Center. Breast cancer patients with chronic radiation dermatitis completed health-related quality of life (HR-QOL) questionnaires before and after laser monotherapy for radiation-induced breast telangiectasias (RIBT).

METHODS

After informed consent, all patients were issued the Skindex-16 and Breast-Q Adverse Effects of Radiation HR-QOL questionnaires prior to receiving laser treatment. Patients were treated with a 595 nm pulsed dye laser at 4- to 6-week intervals, with percent telangiectasia clearance and adverse events recorded at each visit. Post-treatment HR-QOL questionnaires were collected after clinician-assessed telangiectasia clearance of >50%. Median HR-QOL scores before and after therapy were reported for individual HR-QOL domains (Skindex-16) and HR-QOL totals (Skindex-16 and Breast-Q Adverse Effects of Radiation). Before- and after-differences were calculated using the Wilcoxon Signed-Rank Test.

RESULTS

Twenty-two female patients (average age 56 years) enrolled in this study. A majority (13/22, 59%) exhibited telangiectasias across the décolletage and axilla in addition to the breast. Sixteen patients reached the 50% RIBT clearance threshold during the study period, and 11 of these patients (69%) completed follow-up HR-QOL questionnaires. Patients showed statistically significant improvements in emotional and functional Skindex-16 HR-QOL domains and in overall Skindex-16 HR-QOL score. Breast-Q scores also improved significantly, illustrating a decrease in specific physical and cosmetic concerns common to radiated breast skin. Common adverse events were transient post-treatment pain and redness.

CONCLUSION

Breast cancer patients with RIBT presented with substantial deficits in several HR-QOL arenas. Laser monotherapy effectively treated the appearance of radiation dermatitis in these patients and also significantly improved HR-QOL. Lasers Surg. Med. 50:284-290, 2018. © 2017 Wiley Periodicals, Inc.

Advances in the Medical Management of Vascular Anomalies

Vascular anomalies comprise a spectrum of diseases that are broadly classified as tumors and malformations. Diagnosis is often challenging, given a wide range of clinical presentations with overlapping signs and symptoms. Accurate diagnosis is critical to determine prognosis and to generate a management plan, which frequently involves multiple subspecialists during different phases of treatment. An updated classification system provides structure and clear, consistent terminology, allowing for improved diagnosis, provider communication, and collaboration. Historically, treatment of vascular anomalies was primarily surgical and medical therapies were limited or ineffective. Recent discoveries of pharmacologic agents effective in treating vascular anomalies have broadened our medical therapeutic options, limiting the need for unnecessary or high-risk procedures and improving patients' quality of life.

Correction of Facial Deformity in Sturge-Weber Syndrome

Background:

Although previous studies have reported soft-tissue management in surgical treatment of Sturge–Weber syndrome (SWS), there are few reports describing facial bone surgery in this patient group. The purpose of this study is to examine the validity of our multidisciplinary algorithm for correcting facial deformities associated with SWS. To the best of our knowledge, this is the first study on orthognathic surgery for SWS patients.

Methods:

A retrospective chart review included 2 SWS patients who completed the surgical treatment algorithm. Radiographic and clinical data were recorded, and a treatment algorithm was derived.

Results:

According to the Roach classification, the first patient was classified as type I presenting with both facial and leptomeningeal vascular anomalies without glaucoma and the second patient as type II presenting only with a hemifacial capillary malformation. Considering positive findings in seizure history and intracranial vascular anomalies in the first case, the anesthetic management was modified to omit hypotensive anesthesia because of the potential risk of intracranial pressure elevation. Primarily, both patients underwent 2-jaw orthognathic surgery and facial bone contouring including genioplasty, zygomatic reduction, buccal fat pad removal, and masseter reduction without major complications. In the second step, the volume and distribution of facial soft tissues were altered by surgical resection and reposition. Both patients were satisfied with the surgical result.

Conclusions:

Our multidisciplinary algorithm can systematically detect potential risk factors. Correction of the asymmetric face by successive bone and soft-tissue surgery enables the patients to reduce their psychosocial burden and increase their quality of life.