Microvascular Effects of Pulsed Dye Laser in Combination With Oxymetazoline

Does Topical Anesthesia Alter the Outcomes of Vascular Laser Procedures? Review of Vasodynamic Effects and Clinical Outcomes Data

BACKGROUND

Topical anesthesia has vasodynamic effects within the skin and therefore has the potential to change the presence of hemoglobin as a chromophore before intense pulsed light (IPL) and vascular laser treatments. It is unclear whether this is clinically relevant. Global consensus on the use of topical anesthetics in this context is lacking.

OBJECTIVE

Review the effects of topical anesthetics on the skin microvasculature and the clinical implications of such effects on vascular treatments.

METHODS

PubMed and Medline searches were performed to identify studies examining the vasodynamic effects of topical anesthesia on skin and evaluating differences in efficacy of IPL and vascular laser treatments with or without topical anesthetic use.

RESULTS

Published studies reveal variable effects of different topical anesthetic agents on skin microvasculature. Only 3 controlled studies that directly examined the effect of topical anesthesia on clinical outcomes for pulsed dye laser (PDL) treatment of vascular conditions were identified. They did not support a difference in clinical outcomes with or without the use of topical anesthesia before PDL treatment.

CONCLUSION

Although topical anesthetic agents have vasodynamic effects within the skin, there is currently insufficient evidence to advise against their use before light and laser-based vascular treatments.

GNAQ mutations drive port wine birthmark-associated Sturge-Weber syndrome: A review of pathobiology, therapies, and current models

Port-wine birthmarks (PWBs) are caused by somatic, mosaic mutations in the G protein guanine nucleotide binding protein alpha subunit q (GNAQ) and are characterized by the formation of dilated, dysfunctional blood vessels in the dermis, eyes, and/or brain. Cutaneous PWBs can be treated by current dermatologic therapy, like laser intervention, to lighten the lesions and diminish nodules that occur in the lesion. Involvement of the eyes and/or brain can result in serious complications and this variation is termed Sturge-Weber syndrome (SWS). Some of the biggest hurdles preventing development of new therapeutics are unanswered questions regarding disease biology and lack of models for drug screening. In this review, we discuss the current understanding of GNAQ signaling, the standard of care for patients, overlap with other GNAQ-associated or phenotypically similar diseases, as well as deficiencies in current in vivo and in vitro vascular malformation models.

Transmissive-detected laser speckle contrast imaging for blood flow monitoring in thick tissue: from Monte Carlo simulation to experimental demonstration

Laser speckle contrast imaging (LSCI) is a powerful tool to monitor blood flow distribution and has been widely used in studies of microcirculation, both for animal and clinical applications. Conventionally, LSCI usually works on reflective-detected mode. However, it could provide promising temporal and spatial resolution for in vivo applications only with the assistance of various tissue windows, otherwise, the overlarge superficial static speckle would extremely limit its contrast and resolution. Here, we systematically investigated the capability of transmissive-detected LSCI (TR-LSCI) for blood flow monitoring in thick tissue. Using Monte Carlo simulation, we theoretically compared the performance of transmissive and reflective detection. It was found that the reflective-detected mode was better when the target layer was at the very surface, but the imaging quality would rapidly decrease with imaging depth, while the transmissive-detected mode could obtain a much stronger signal-to-background ratio (SBR) for thick tissue. We further proved by tissue phantom, animal, and human experiments that in a certain thickness of tissue, TR-LSCI showed remarkably better performance for thick-tissue imaging, and the imaging quality would be further improved if the use of longer wavelengths of near-infrared light. Therefore, both theoretical and experimental results demonstrate that TR-LSCI is capable of obtaining thick-tissue blood flow information and holds great potential in the field of microcirculation research.

Light-Based Devices for the Treatment of Facial Erythema and Telangiectasia

Facial erythema is one of the most common outpatient complaints in dermatology. There are various causes of facial erythema and several devices are available for its treatment. Pulsed dye laser (PDL) and intense pulsed light (IPL) are the two common light devices used for these conditions. In this review, we evaluated the literature to assess efficacy of IPL versus PDL in facial erythema and telangiectasia. We searched published articles including clinical trials or reviews articles, case series, and case reports. Electronic databases (MEDLINE and PubMed) were searched to retrieve the articles. Reference lists of selected articles were also considered for the review. Articles published in English language until June 2021 were considered for this review.

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.

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.

Segmental branches emanating from saphenous nerve morphing into sympathetic trunks for innervation of saphenous artery and its clinical implication for arterial sympathectomy

Sympathectomy of arteries has been adopted for the treatment of peripheral arterial disease and Raynaud's disease. However, the exact route for sympathetic axons to reach peripheral arteries awaits further investigation that could pave the way for development of new surgical strategies. In this study, saphenous neurovascular bundles from 10 neonatal Sprague-Dawley rats first were harvested for whole-mount immunostaining to show sympathetic innervation pattern of the artery. Secondly, 40 Sprague-Dawley male rats weighing 350 to 400 g were assigned to five groups, receiving either sham, perivascular sympathectomy, nerve-artery separation, nerve transection in the saphenous neurovascular bundle, or lumbar sympathectomy surgery that removes the lumbar sympathetic trunks. Immediately after surgery, the arterial perfusion and diameter were measured using laser speckling contrast imaging, and 1 week later the saphenous neurovascular bundles were harvested for immunostaining using antibodies against TH, neuron-specific β-tubulin (Tuj 1), and α-SMA to show the presence or absence of the TH-immuopositive staining in the adventitia. The differences among the five groups were determined using one-way analysis of variance (ANOVA). We found that an average of 2.8 ± 0.8 branches with a diameter of 4.8 ± 1.2 μm derived from the saphenous nerve that morphed into a primary and a secondary sympathetic trunk for innervation of the saphenous artery. Nerve-artery separation, nerve transection, and lumbar sympathectomy could eradicate TH-immunopositive staining of the artery, resulting, respectively, in a 12%, 36%, and 59% increase in diameter (P < .05), and a 52%, 63%, and 201% increase in perfusion compared with sham surgery (P < .01). In contrast, perivascular sympathectomy did not have a significant impact on the TH-immunopositive staining, the diameter, and perfusion of the distal part of the artery (P > .05). We conclude that the sympathetic innervation of an artery derives from segmental branches given off from its accompanying nerve. Nerve-artery disconnection is a theoretic option in sympathectomy of an artery.

Topical Oxymetazoline Hydrochloride Cream 1% for the Treatment of Persistent Facial Erythema of Rosacea in Adults: A Comprehensive Review of Current Evidence

BACKGROUND: Rosacea is a chronic, multisymptom, inflammatory condition that affects the centrofacial skin. Facial erythema associated with rosacea can negatively impact a patient's quality of life and is often hard to treat. OBJECTIVE: We sought to review the literature on the role of alpha-adrenergic receptors (α-adrenoceptors) in the context of persistent facial erythema in patients with rosacea and the use of oxymetazoline hydrochloride cream 1% as a topical treatment. METHODS: PubMed was searched; search terms included "alpha adrenoceptor," "oxymetazoline," and "rosacea." Additional articles were identified from the reference lists of the results. RESULTS: Some α-adrenoceptor agonists have vasoconstrictive properties and may be used topically to treat persistent facial erythema in rosacea. Oxymetazoline hydrochloride cream 1% is an α_1A-adrenoceptor agonist approved for the treatment of persistent facial erythema associated with rosacea. Based on our review, we discuss the role of the α-adrenoceptor in persistent facial erythema; provide an overview of the mechanism of action of α-adrenoceptor agonists, such as oxymetazoline, in the treatment of persistent facial erythema; and summarize the clinical development and data to date demonstrating the efficacy and safety of oxymetazoline in the treatment of persistent facial erythema associated with rosacea. CONCLUSION: The review of available literature suggests that oxymetazoline cream is well-tolerated, safe, and effective for the treatment of persistent facial erythema in rosacea and is an important component of combination treatment regimens, which are likely to become the standard of treatment for rosacea in the future.

Mechanically Induced Vasospasm-Evaluation of Spasmolytic Efficacy of 10 Pharmaceutical Agents Using Laser Speckle Contrast Imaging

BACKGROUND AND OBJECTIVES

Vasospasm is a thorny problem often encountered in microvascular surgery that seriously threatens the survival of vascularized tissue transfers. This investigation is dedicated to establishing a model of vasospasm and to evaluating the antispasmodic efficacy of 10 pharmacologic agents.

STUDY DESIGN/MATERIALS AND METHODS

Eighty Sprague-Dawley rats were used. After anesthesia and depilation, the femoral neurovascular bundle was exposed, and a pair of microsurgical forceps were used to trigger vasospasm of the femoral vessels by blunt dissection. Then, 10 pharmacological agents, namely, prostaglandin E1, sodium nitroprusside, magnesium sulfate, papaverine, normal saline, phentolamine, verapamil, 2% lidocaine hydrochloride, amrinone, and 12% lidocaine hydrochloride, were dripped to the femoral vessels, after which laser speckle contrast imaging was used to collect perfusion images, acquiring the perfusion and the inner caliber of the femoral vessels at multiple timepoints. Furthermore, blood perfusion and the time consumed to escape vasospasm and reach hyperperfusion in each group were calculated. The difference of spasmolytic efficacy among the agents was statistically analyzed by one-way analysis of variance.

RESULTS

There was a significant difference in antispasmodic ability among the 10 agents (P < 0.001). 10% magnesium sulfate and 12% lidocaine were distinguished among the 10 agents in resolving the vasospasm. 10% magnesium sulfate demonstrated the best antispasmodic potency, which enabled the shortest time consumed for vessels to escape spasm and reach hyperperfusion. 12% lidocaine ranked second in efficacy, demonstrating a similar effect except that it could not propel the femoral vein to a state of hyperperfusion. For the remaining agents, the time consumed for the artery to escape spasm was all significantly shortened when compared with normal saline (P < 0.001). For the venous spasm, all agents except prostaglandin E1 could significantly shorten the time consumed for the vein to escape spasm (P < 0.001).

CONCLUSIONS

In terms of resolving mechanically induced vasospasm, 10% magnesium sulfate is the best antispasmodic, followed by 12% lidocaine. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Quantitative analysis of collagen and capillaries of 3.8-μm laser-induced cutaneous thermal injury and wound healing

The biological effects of cutaneous thermal injury and wound healing after 3.8-μm laser radiation were investigated by observing the effects of different radiation doses on in vivo cutaneous tissue. A 3.8-μm laser with a radiation dose that changes from small (5.07) to large (15.74 J/cm²) was used to irradiate mouse skin with the 2 × 4 grid array method. The healing progress of laser-injured spots, pathological morphology (H&E staining), and collagen structure changes (Sirius Red staining) were dynamically observed from one hour to 21 days after laser radiation, and the capillary count and collagen content were quantitatively and comparatively analyzed. When the radiation doses were 5.07, 6.77, 8.21, and 9.42 J/cm², a white coagulation spot predominantly occurred, and when the radiation doses were 11.09 12.23, 14.13, 15.74 J/cm², a small injured spot predominantly occurred. One hour after radiation, the collagen structure was obviously damaged. Three to fourteen days after radiation, the hyperplasia and morphology of the collagen in the 5.07 J/cm² group were significantly better than those in the other dose groups. The number of capillaries in the 5.07 J/cm² and 6.77 J/cm² groups was significantly higher than that in the normal group (P < 0.01 or P < 0.05). Twenty-one days after radiation, only the collagen in the 5.07 J/cm² group was densely arranged, and it was basically close to the normal group level. The collagen content in the 5.07 J/cm² group was approximately 10.7%, but it was still lower than that in the normal group (with a collagen content of approximately 14.1%). The collagen in the other dose groups was diminished and had not returned to the normal group level. As the dose of the 3.8-μm laser increased, skin thermal injury gradually increased, the full-thickness skin increased, and the collagen content decreased, showing better dose-dependent and time-dependent effect relationships. The increase in capillaries in the early stage of laser radiation and the significant increase in collagen content in the middle and late stages of laser radiation were two important factors that promoted wound healing.

Oxymetazoline and Energy-Based Therapy in Patients with Rosacea: Evaluation of the Safety and Tolerability in an Open-Label, Interventional Study

Background and Objectives

The objectives of this study were to evaluate the safety, tolerability, and efficacy of oxymetazoline hydrochloride cream, 1% (oxymetazoline) when used as an adjunctive treatment with energy‐based therapy for patients with moderate to severe facial erythema associated with rosacea.

Study Design/Materials and Methods

In this Phase 4, multicenter, interventional, open‐label study, eligible patients received one of four energy‐based therapies (potassium titanyl phosphate laser, intense pulsed light therapy, pulsed‐dye laser Vbeam Perfecta, or pulsed‐dye laser Cynergy) on day 1 and day 29 and once‐daily application of oxymetazoline on days 3 through 27 and days 31 through 56. Improvement from baseline in Clinician Erythema Assessment (CEA) score, patient satisfaction measures, incidence of treatment‐emergent adverse events (TEAEs), and worsening from baseline on dermal tolerability assessments and the Clinician Telangiectasia Assessment (CTA) were assessed. Data were summarized using descriptive statistics.

Results

A total of 46 patients (mean age, 51.1 years; 78.3% female) enrolled in this study. Similar numbers of patients received each of the energy‐based therapies in addition to oxymetazoline. All patients demonstrated an improvement from baseline in CEA during the study with 39 of 43 evaluable patients (90.7%) demonstrating an improvement 6 hours posttreatment on day 56. Most patients were satisfied or very satisfied with treatment at the end of the study. All TEAEs were mild or moderate in severity. Some patients experienced worsening in dermal tolerability assessment symptoms (range: 4–21 patients; 8.7–45.7%). Worsening in CEA and CTA were each reported by three patients (6.5%) at any time during the study.

Conclusions

Treatment with oxymetazoline as adjunctive therapy with energy‐based therapy was safe, well tolerated, and reduced facial erythema in patients with moderate to severe persistent facial erythema associated with rosacea. Lasers Surg. Med. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC