Prospective study of pulsed dye laser in conjunction with cryogen spray cooling for treatment of port wine stains in Chinese patients

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.

Topical Halometasone Reduces Acute Adverse Effects Induced by Pulsed Dye Laser for Treatment of Port Wine Stain Birthmarks

Introduction: Pulsed dye laser (PDL) for treatment of port wine stain (PWS) usually causes some acute adverse effects, including pain, erythema, scabbing and swelling. This study aimed to determine whether topical halometasone can be used to reduce these acute adverse effects for post-PDL care of patients. Methods: A total of 40 PWS subjects were enrolled in this study and randomly assigned into two regimens: PDL alone and PDL + halometasone. All subjects were given a single treatment of PDL with wavelength of 595 nm, fluence of 8.0~13.5 J/cm2, pulse duration of 0.45~20 ms (We mainly used purpuric pulse duration for PWS) and spot size of 7 mm. Subjects in the PDL + halometasone group received topical application of halometasone daily for 3 days. Subjects were followed-up on days 3, 7 and one month post-PDL to evaluate the reduction of adverse effects. Results: Subjects in the PDL + halometasone group had significantly improved erythema and scab scores and had less erythema duration days as compared to those in the PDL alone group. Topical halometasone also showed a decrease in pain index among subjects, but was statistically insignificant. Topical halometasone did not affect the ultimate efficacy of PDL treatment for PWS. Conclusion: Topical halometasone can significantly reduce acute adverse effects induced by PDL for treatment of PWS birthmarks, thus providing a safe and efficacious solution for post-PDL care of PWS patients.

Topical rapamycin suppresses the angiogenesis pathways induced by pulsed dye laser: molecular mechanisms of inhibition of regeneration and revascularization of photocoagulated cutaneous blood vessels

BACKGROUND AND OBJECTIVES

Pulsed dye laser (PDL) is the most effective treatment for port wine stain (PWS) birthmarks. However, regeneration and revascularization of photocoagulated blood vessels may result in poor therapeutic outcome. We have recently shown that rapamycin (RPM), an angiogenesis inhibitor, can reduce the regeneration and revascularization of photocoagulated blood vessels. Herein, we attempt to further elucidate the molecular pathophysiology on the inhibition of the regeneration and revascularization of photocoagulated blood vessels by topical RPM in an animal model.

MATERIALS AND METHODS

Two separate skin areas on each hamster were irradiated by PDL. After PDL exposure, topical RPM was applied daily to one of the randomly selected test sites. PDL, PDL + RPM and normal skin test sites were biopsied on day 3 after PDL exposure. The total ribonucleic acid (RNA) and protein were extracted from biopsied skin samples and quantified. Real-time reverse transcription-polymerase chain reaction (RT-PCR) and immunoblot were subsequently performed to quantify the mRNA and protein levels of hypoxia-inducible factor-1alpha (HIF-1α), vascular endothelial growth factor (VEGF) and ribosomal protein S6 kinase (S6). The phosphorylation levels of S6 and AKT were also evaluated by immunoblot.

RESULTS

The mRNA and protein levels of HIF-1α, VEGF, and S6 significantly increased after PDL exposure as compared to the normal hamster skin. Topical application of 1% RPM suppressed the PDL-induced increase in mRNA and protein levels of those genes on day 3 post-PDL exposure. The phosphorylation levels of S6 and AKT increased after PDL exposure but the increases were suppressed by the topical application of RPM.

CONCLUSION

The increase in expression of HIF-1α, VEGF, and S6 after PDL-exposure suggests that angiogenesis pathways play very active roles in the process of skin blood vessel regeneration and revascularization. Topical application of 1% RPM can suppress the angiogenesis pathways and, therefore, reduce the regeneration and revascularization of photocoagulated blood vessels.

An overview of clinical and experimental treatment modalities for port wine stains

Port wine stains (PWS) are the most common vascular malformation of the skin, occurring in 0.3% to 0.5% of the population. Noninvasive laser irradiation with flashlamp-pumped pulsed dye lasers (selective photothermolysis) currently comprises the gold standard treatment of PWS; however, the majority of PWS fail to clear completely after selective photothermolysis. In this review, the clinically used PWS treatment modalities (pulsed dye lasers, alexandrite lasers, neodymium:yttrium-aluminum-garnet lasers, and intense pulsed light) and techniques (combination approaches, multiple passes, and epidermal cooling) are discussed. Retrospective analysis of clinical studies published between 1990 and 2011 was performed to determine therapeutic efficacies for each clinically used modality/technique. In addition, factors that have resulted in the high degree of therapeutic recalcitrance are identified, and emerging experimental treatment strategies are addressed, including the use of photodynamic therapy, immunomodulators, angiogenesis inhibitors, hypobaric pressure, and site-specific pharmaco-laser therapy.

Optical coherence tomography: a potential tool for unsupervised prediction of treatment response for Port-Wine Stains

BACKGROUND

Treatment of Port-Wine Stains (PWS) suffers from the absence of a reliable real-time tool for monitoring a clinical endpoint. Response to treatment varies substantially according to blood vessel geometry. Even though optical coherence tomography (OCT) has been identified as a modality with potential to suit this need, it has not been introduced as a standard clinical monitoring tool. One reason could be that - although OCT acquires data in real-time - gigabyte data transfer, processing and communication to a clinician may impede the implementation as a clinical tool.

OBJECTIVES

We investigate whether an automated algorithm can address this problem.

METHODS

Based on our understanding of pulsed dye laser treatment, we present the implementation of an unsupervised, real-time classification algorithm which uses principal components data reduction and linear discriminant analysis. We evaluate the algorithm using 96 synthesized test images and 7 clinical images.

RESULTS

The synthesized images are classified correctly in 99.8%. The clinical images are classified correctly in 71.4%.

CONCLUSIONS

Principal components-fed linear discriminant analysis (PC-fed LDA) may be a valuable method to classify clinical images. Larger sampling numbers are required for a better training model. These results justify undertaking a study involving more patients and show that disease can be described as a function of available treatment options.

Does dye laser treatment with higher fluences in combination with cold air cooling improve the results of port-wine stains?

BACKGROUND AND OBJECTIVE

The use of cold air cooling (CAC) and cryogen spray cooling during dye laser treatment of port-wine stains (PWS) has become a standard in recent years. Still unsolved is the question of which fluences are necessary in combination with CAC in order to achieve an optimum clearance and the lowest possible rate of side-effects.

STUDY DESIGN

In a prospective study, we treated 11 patients with PWS with pulsed dye laser (Photogenica V, Cynosure, lambda = 585 nm, iota(p) = 0.5 ms, spot size = 7 mm). Each PWS was partitioned into three areas: (area 1) 6 J/cm(2) without CAC, (area 2) 6 J/cm(2) with CAC (level 4), (area 3) 9 J/cm(2) with CAC (level 4).

RESULTS

Area 3 (mean, 59%) showed a slightly better clearance than area 1 (mean, 57%); in area 2, we observed a reduced clearance (mean, 45%). Compared with area 1, we achieved a reduction of pain through CAC in areas 2 and 3. The healing periods as well as the rate of side-effects were comparable in all areas.

CONCLUSION

We observed a slight but not statistically relevant increase in clearance with the use of higher fluences and CAC compared with lower fluences without CAC. Because pain is lowered significantly when using CAC, and because this makes the treatment more comfortable for the patients, we tend to recommend the use of higher fluences (9 J/cm(2)) with simultaneous CAC for treating PWS.

Efficacy of Pulsed Dye Laser in Facial Port-Wine Stains in Indian Patients

BACKGROUND

Facial port-wine stain (PWS) produces severe cosmetic disfigurement and pulsed dye laser (PDL) has revolutionized the treatment of PWS.

OBJECTIVE

To assess the efficacy of PDL for facial PWS in Indian patients.

MATERIALS AND METHODS

Twenty-seven patients of Fitzpatrick skin types IV and V in the age group of 8 to 34 years (mean 21.6 years), with lesional size 3 x 1.5 to 25 x 19 cm and color from light pink to deep red and violaceous, were recruited. Laser parameters were spot size, 7 mm; fluence, 5 to 7.5 J/cm(2); wavelength, 585 nm, pulse duration, 0.45 ms; along with continuous air cooling. Response at every session was graded from 0 to 5+(0, no improvement; 1+, up to 25%; 2+, 26% to 50%; 3+, 51% to 75%; 4 +, 76% to 99%; 5+, 100% lightening).

RESULTS

In a total of 170 sessions, maximum response of 1+ was observed in 6 patients after mean of 3.5 sessions, 2+ in 8 patients after mean of 5.25 sessions, 3+ in 8 patients after mean of 7 sessions, and 4+ improvement in 5 patients after mean of 4.8 sessions. No patient showed complete clearance. Seven patients developed hyperpigmentation while 1 patient showed hypopigmentation, but none had textural change or scarring.

CONCLUSION

PDL offers significant cosmetic improvement in facial PWS in Indian patients.

Effect of Pulse Width of a 595-nm Flashlamp-Pumped Pulsed Dye Laser on the Treatment Response of Keloidal and Hypertrophic Sternotomy Scars

BACKGROUND

Flashlamp-pumped pulsed dye lasers (PDLs) have successfully treated keloidal and hypertrophic scars.

OBJECTIVE

The objective was to investigate the effect of pulse width of a PDL in treating keloidal and hypertrophic scars.

METHODS

On each of 19 patients, keloidal or hypertrophic median sternotomy scars were divided into two segments. Both segments on all patients were randomly treated with a 595-nm PDL at a fluence of 7 J/cm(2) and pulse widths of 0.45 and 40 ms to both segments, every 4 weeks for a total of three treatments. Scar volume, height, erythema, and pliability were measured at Weeks 0, 4, 8, and 24.

RESULTS

The volume of segments treated with 0.45- and 40-ms pulses decreased significantly after two treatments. Segments treated with a 0.45-ms pulse width showed significantly greater improvement than those treated with 40-ms pulses after three treatments. Elasticity of 0.45-ms segments was significantly higher than those of 40-ms segments, following two treatments. Pulse width had no significant effect in improvement of scar erythema.

CONCLUSIONS

A pulse width of 0.45 ms of PDL was more effective in decreasing scar size and improving scar pliability than that of 40 ms. A 595-nm PDL was safe and effective in treatment of hypertrophic scars and keloids in dark-skinned individuals. This study was supported in part by an educational grant from the Dermatological Society of Thailand.

Evaluation of the treatment of port-wine stains with the 595-nm long pulsed dye laser: a large prospective study in adult Japanese patients

BACKGROUND

Treatments of port-wine stains with conventional pulsed dye laser yield inconsistent results.

OBJECTIVE

We evaluated the efficacy and safety of the longer pulse duration 595-nm dye laser.

METHODS

Sixty-six adult Japanese patients were enrolled in this prospective study. The laser treatment with a cooling device was repeated 4 times at 8-week intervals with a consistent setting of 10-ms pulse duration and an energy fluence of 12 J/cm2, using 7-mm spot size.

RESULTS

Improvement of port-wine stains was observed after multiple treatments, and 67% of the patients achieved either good or excellent response after the fourth treatment. Transient purpura, edema, or both were noted immediately after each treatment (76%-79% and 58%-67%, respectively). Hyperpigmentation (8%-17%) and hypopigmentation (6%-14%) were also mild and their occurrence did not increase by repeating treatments.

LIMITATIONS

Eighty five percent of the patients were classified as having Fitzpatrick skin type IV.

CONCLUSION

Our study indicated that the 595-nm dye laser with 10-ms pulse duration may be effective and well tolerated in the treatment of port-wine stains in adult Asians.

Selected Laser-based Therapies in Otolaryngology

This article has discussed selected applications of laser therapies in otolaryngology. Lasers are the treatment of choice for PWS lesions, but new advances are needed to achieve complete blanching in the majority of cases. Noninvasive in vivo imaging and laser therapy coupled with PDT are two areas showing promise to improve outcome. PDT has the potential to offer new, cost-effective treatment options, and possibly cure, to cancer patients who are not candidates for traditional surgery, chemotherapy, and radiotherapy.

Treatment of Port Wine Stains with Intense Pulsed Light: A Prospective Study

BACKGROUND

Recent studies have shown that intense pulsed light can be useful in treating port wine stains that were resistant to previous pulsed dye laser therapy. Asian persons with high epidermal melanin context can be at a higher risk of complication.

OBJECTIVE

The aim of this study was to conduct a prospective trial to assess the efficacy and complication of intense pulsed light in the treatment of port wine stains in Chinese patients.

METHODS

Twenty-two Chinese patients with port wine stains without previous treatment were recruited to receive intense pulsed light source therapy for five to seven treatments at intervals of 3 to 4 weeks. Patient demographics, skin type, characteristics of port wine stains including color and location, treatment parameters, degree of pain caused by intense pulsed light treatment, percentage of clearing, and treatment complications were recorded and entered into a database. A questionnaire was conducted to assess the influence of treatment on daily activity and the intensity of pain experienced during treatment.

RESULTS

There were 17 female and 5 male patients. Their ages ranged from 6 to 45 years with a mean age of 21.8+/-10.1 years. More than 90% of patients had more than 25% of clearing and the majority of patients (50%) had 25% to 50% of clearing. Although 40% of the patients showed more than 50% clinical clearance, 9% of the patients were able to achieve more than 75% clearing. The only 2 patients with less than 25% clearing had nodular port wine stains and no patient was able to achieve complete clearing. The procedures were well tolerated with a mean pain score of 2.1+/-0.9 and the treatment had no influence on daily activity. One patient developed blisters and 6 patients had swelling for more than 24 hr that all resolved within 1 week without leaving permanent marks. They have been followed up from 12 to 27 months and there was no long-term complication.

CONCLUSION

Intense pulsed light can be effective in treating port wine stains in Asian patients. In experienced hands, complications can be low and should be considered as one of the therapeutic options.