Prospective analysis of the port-wine stain patient population in the Netherlands in light of novel treatment modalities

Dermatology Life Quality Index in Thai Patients with Facial Port-Wine Stains

INTRODUCTION

Port-wine stains (PWS) are congenital capillary abnormalities caused by immature, venule-like vasculature that progressively dilates due to poor endothelial cell differentiation. PWS affects between 0.3% and 0.9% of newborns, with 90% of cases occurring on the face. Individuals with facial PWS and their parents had a significant negative impairment on their quality of life (QoL) and also suffered from psychological disabilities.

METHODS

This was a cross-sectional questionnaire-based survey study in Thailand from July 2021 to April 2022. The questionnaires included demographic data, subjective evaluation (SE), and the Dermatology Life Quality Index (DLQI). The questionnaire was performed with a full scale and adjusted scale of validity and reliability test of DLQI using factor analysis and Cronbach's alpha. The study outcome was a subjective evaluation and DLQI in patients who received pulsed dye laser (PDL) treatment.

RESULTS

Of the 54 patients, 35.2% (19) are male, and 64.8% (35) are female. Regarding age groups, 64.8% (35) are below 5 years old, and 35.2% (19) are older than 5 years. SE results showed that males evaluated an improvement of the facial PWS lesion significantly better than females (P < 0.05). The older age group graded the percentage of improvement better than the younger age group (P < 0.01). The result of the DLQI showed no difference in DLQI between gender. Older age result resulted in a significantly different DLQI compared with younger age (P < 0.01). Parent-reported DLQI improvement was less than self-reported DLQI improvement in patients with PWS treated with PDL (P < 0.05). Concerning the instrument of the study, the validity and reliability analysis of the DLQI questionnaire using factor analysis and Cronbach's alpha have been performed. The adjusted scale with the 5-item DLQI questionnaire is more appropriate in terms validity and reliability.

CONCLUSION

This study demonstrates that facial PWS reduces the QoL as measured by DLQI. We discovered that the QoL of patients and parents with PWS was significantly impaired. The main influencing factors were older age, the improved perception between gender, and PDL treatments. In addition, we found only five questions that are reliable for PWS. The adjusted five-item DLQI questionnaires are more appropriate regarding validity and reliability.

TRIAL REGISTRATION NUMBER

TCTR20230210001, COA no. si 1059/2020.

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.

Willingness to Pay and Time Trade-off in Thai Patients with Port-Wine Stains

Background

Port-wine stains are congenital vascular abnormalities that impact children’s and parents’ quality of life (QoL). There are currently no established criteria for assessing the quality of life in PWS patients. Utility measures such as willingness-to-pay (WTP) and time trade-off (TTO) can be used to quantify disease burden, impact on QoL, and assess the cost-effectiveness of interventions.

Methods

This was a cross-sectional questionnaire-based survey study in Thailand from July 2021 to April 2022. The questionnaire included sociodemographic data and preference-based measurement, WTP and TTO. The primary outcome was a WTP and TTO for PWS laser treatment. The subsample analysis for the primary outcome was based on gender (male and female) and age (<5 years and ≥5 years). The household income was measured for time trade-off outcome.

Results

Out of 46 respondents, WTP for the base case at 40% improvement cost 6109.01 baht per visit. Patients were willing to spend their time 9.95 hours per visit for a clinical improvement of 40%. Female was willing to pay and spend more time than male, while those aged≥5 years were willing to pay and spend more time than those aged <5 years. High household income >100k per month willing to spend less time than lower income groups.

Conclusion

There were obvious correlations between WTP and TTO with clinical outcomes. Utility indicators such as WTP and TTO can be used to measure disease burden, impact on QoL, and assess the cost-effectiveness of interventions. WTP and TTO could provide a more personalized approach to improving QoL, considering each patient’s unique treatment plan and priority. This could help with patient uncertainty and long-term planning strategies to increase the QoL cost-effectively.

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.

Therapeutic Strategies for Untreated Capillary Malformations of the Head and Neck Region: A Systematic Review and Meta-Analyses

Background

Capillary malformations of the head and neck region often cause psychological and physical burden. As the effectiveness of modern laser and light therapies is still suboptimal, patients often seek different therapeutic strategies. Other recognized, but not routinely proposed therapies include cosmetic camouflage, surgery, and medical tattooing. Information on therapeutic outcomes is currently lacking for patients to adequately participate in the treatment decision-making process.

Objective

The objective of this systematic review was to review the effectiveness and safety of recognized therapies for untreated capillary malformations of the head and neck: laser and light treatment modalities, photodynamic therapy, cosmetic camouflage, medical tattooing, and surgery.

Methods

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to 16 December, 2020 for observational and experimental studies examining recognized therapies for untreated capillary malformations of the head and neck. Two reviewers independently evaluated the risk of bias of included studies. Predefined treatment and safety outcomes of pooled data were scored using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

We included 48 observational and three randomized studies (totaling 3068 patients), evaluating nine different therapies. No studies on surgery or cosmetic camouflage matched our inclusion criteria. The pooled proportion of patients reaching a ≥75% clearance was 43% (95% confidence interval 24–64%; I² = 55%) for the pulsed dye laser after three to eight treatment sessions (GRADE score: very low). Other therapies were less effective. Hyperpigmentation was most frequently described after the pulsed dye laser (incidences up to 40%). Pain was most common after photodynamic therapy, yet the intensity was unreported. Substantial heterogeneity among studies as to patient characteristics and outcomes limited pooling and data comparisons.

Conclusions

The pulsed dye laser seems preferable for treatment-naive capillary malformations of the head and neck region, yet demonstrates greater hyperpigmentation rates compared with other therapies. Our results are, however, based on low-quality evidence. Future studies using uniform outcome measures and validated metrics are warranted for study comparability. Based on this systematic review, clinicians and patients should be aware of the limited evidence about the available options when making (shared) treatment decisions for capillary malformations.

Trial Registration

Review registration number PROSPERO database: CRD42020199445.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-021-00616-5.

Quality of Life and Psychological Effects of Port-Wine Stain: A Review of Literature

Introduction

Port-wine stain (PWS) is a congenital malformation that does not resolve spontaneously and can cause a physiological or psychological burden to the patients. At present, most of the studies done on PWS are focused on the treatment rather than the quality of life and psychological effects of the disease.

Material and Methods

A comprehensive literature search was done in MEDLINE using PubMed database, Embase^®, and Cochrane. All observational studies were included in this review.

Results

A total of 17 relevant articles with 2,135 PWS patients were included in this review. There were 36 measurement tools used to assess the quality of life and the psychological effects among PWS patients. The results showed that patients with facial PWS had a significant negative effect on their quality of life and had also suffered from psychological disabilities. The PWS lesion tends to worsen with age and may cause further adaptation problems towards the social environment, especially in children.

Conclusion

Early treatment, psychological assistance, and patient support are the key management in improving the quality of life of patients with PWS. Quality of life must be regularly assessed together with the improvement of treatment.

Self-stigma and psychosocial burden of patients with port-wine stain: A systematic review and meta-analysis

BACKGROUND

Port-wine stain (PWS) is a congenital malformation that does not resolve spontaneously and can lead to social and self-stigma. However, little is known about how PWS affects the patients' quality of life (QoL) and psychosocial well-being. In this article, we examine the existing empirical evidence on self-stigma caused by PWS.

METHODS

A systematic review was done using MEDLINE, PubMed, Embase, and Cochrane databases on January 15, 2021 to retrieve all case reports, cohort studies, and clinical trials written in English. The keywords used in this literature search included port-wine stain, quality of life, self-stigma, and social stigma.

RESULTS

From the 74 initial records, eight articles were quantitative studies that assessed the QoL and self-stigma experienced by PWS patients. With regard to perceived stigma or the patients' understanding of how others think and act toward them, we found that the parents of children with facial PWS tend to have more perceived stigma than the children. For anticipated stigma or expectations of future stigma, young patients with PWS have less or no concern about their skin conditions. In terms of enacted stigma or experiences with discriminatory acts, there were significant differences in the QoL score between patients with facial PWS and those with non-facial PWS.

CONCLUSION

This study suggests that self-stigma caused by PWS affects young patients and their parents. The parents in particular tend to suffer more than their children from perceived and anticipated stigma. Psychological support and early treatment can improve the livelihoods of young patients and their parents.

The Cost-Effectiveness of Pulsed-Dye Laser Therapy Among Thai Patients with Facial Port-Wine Stain: A Retrospective Study and Economic Evaluation

Introduction

Port-wine stain (PWS) is a progressive capillary malformation that does not resolve spontaneously without treatment. Pulsed dye laser (PDL) is currently the gold standard treatment for PWS, although it is difficult to attain complete clearance and recurrences are common. This study determined the cost-effectiveness of PDL treatment among Thai patients with facial PWS.

Methods

This was a retrospective chart review of 109 Thai patients with facial PWS and treated with PDL at Siriraj Hospital, Thailand from January 2008 to December 2017. The primary outcome of the study was the cost-effectiveness of PDL treatment in the clinical improvement of facial PWS.

Results

Ten PDL treatment sessions will have an expected clinical improvement of 60%. At the 10th treatment, the marginal incremental improvement with respect to visit is approximately equal to one. The succeeding treatment sessions will only give an additional improvement of 5–10%.

Conclusion

A total of 10 PDL treatment sessions was considered cost-effective as it can achieve 60% clinical improvement among Thai patients with facial PWS.

Treatment Outcome Measurement Instruments for Port Wine Stains: A Systematic Review of Their Measurement Properties

BACKGROUND

A plethora of outcome measurement instruments (OMIs) are being used in port wine stain (PWS) studies. It is currently unclear how valid, responsive, and reliable these are.

OBJECTIVES

The aim of this systematic review was to appraise the content validity and other measurement properties of OMIs for PWS treatment to identify the most appropriate instruments and future research priorities.

METHODS

This study was performed using the updated Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology and adhered to PRISMA guidelines. Comprehensive searches in Medline and Embase were performed. Studies in which an OMI for PWS patients was developed or its measurement properties were evaluated were included. Two investigators independently extracted data and assessed the quality of included studies and instruments to perform qualitative synthesis of the evidence.

RESULTS

In total, 1,034 articles were screened, and 77 full-text articles were reviewed. A total of 8 studies were included that reported on 6 physician-reported OMIs of clinical improvement and 6 parent- or patient-reported OMIs of life impact, of which 3 for health-related quality of life and 1 for perceived stigmatization. Overall, the quality of OMI development was inadequate (63%) or doubtful (37%). Each instrument has undergone a very limited evaluation in PWS patients. No content validity studies were performed. The quality of evidence for content validity was very low (78%), low (15%), or moderate (7%), with sufficient comprehensibility, mostly sufficient comprehensiveness, and mixed relevance. No studies on responsiveness, minimal important change, and cross-cultural validity were retrieved. There was moderate- to very low-quality evidence for sufficient inter-rater reliability for some clinical PWS OMIs. Internal consistency and measurement error were indeterminate in all studies.

CONCLUSIONS

There was insufficient evidence to properly guide outcome selection. Additional assessment of the measurement properties of OMIs is needed, preferentially guided by a core domain set tailored to PWS.

Lasers, Birthmarks, and Sturge-Weber Syndrome: A Pilot Survey

BACKGROUND AND OBJECTIVES

There is limited or no data on the experience of patients with Sturge-Weber Syndrome (SWS) and/or their parents who seek out laser treatments for their port-wine birthmark (PWB). Our study aimed to develop a survey to understand patient perspectives on laser therapy and subsequent behaviors while focusing on three elements of the health belief model: perceived susceptibility, perceived benefits, and perceived barriers.

STUDY DESIGN/MATERIALS AND METHODS

A 31 item survey was developed and sent to 650 members of the Sturge-Weber Foundation. The survey included questions regarding four domains: demographics, disease severity, laser experience, and perceptions and behaviors. Logistic regression models and bivariate analyses were conducted to analyze the results.

RESULTS

Among the 123 respondents, earlier initiation of laser treatments was associated with greater birthmark satisfaction. Overall satisfaction increased up to 20 treatments and then leveled off. Color satisfaction increased up to 100 laser treatments; however, the flatness of the PWB was not associated with the number of laser treatments. The perceived benefits of lasers were not associated with the number of lifetime treatments or with spending. However, the perceived susceptibility was associated with greater spending on travel and medical expenses.

CONCLUSION

The results of our survey provide insight into SWS patient experiences, beliefs, and behaviors regarding laser therapy. Further exploration of these variables may allow for the improvement of the care experience. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

In Vivo Assessment of Thermosensitive Liposomes for the Treatment of Port Wine Stains by Antifibrinolytic Site-Specific Pharmaco-Laser Therapy

Antifibrinolytic site-specific pharmaco-laser therapy (SSPLT) is an experimental treatment modality for refractory port wine stains (PWS). Conceptually, antifibrinolytic drugs encapsulated in thermosensitive liposomes are delivered to thrombi that form in semi-photocoagulated PWS blood vessels after conventional laser treatment. Local release of antifibrinolytics is induced by mild hyperthermia, resulting in hyperthrombosis and complete occlusion of the target blood vessel (clinical endpoint). In this study, 20 thermosensitive liposomal formulations containing tranexamic acid (TA) were assayed for physicochemical properties, TA:lipid ratio, encapsulation efficiency, and endovesicular TA concentration. Two candidate formulations (DPPC:DSPE-PEG, DPPC:MPPC:DSPE-PEG) were selected based on optimal properties and analyzed for heat-induced TA release at body temperature (T), phase transition temperature (T_m), and at T > T_m. The effect of plasma on liposomal stability at 37 °C was determined, and the association of liposomes with platelets was examined by flow cytometry. The accumulation of PEGylated phosphocholine liposomes in laser-induced thrombi was investigated in a hamster dorsal skinfold model and intravital fluorescence microscopy. Both formulations did not release TA at 37 °C. Near-complete TA release was achieved at T_m within 2.0–2.5 min of heating, which was accelerated at T > T_m. Plasma exerted a stabilizing effect on both formulations. Liposomes showed mild association with platelets. Despite positive in vitro results, fluorescently labeled liposomes did not sufficiently accumulate in laser-induced thrombi in hamsters to warrant their use in antifibrinolytic SSPLT, which can be solved by coupling thrombus-targeting ligands to the liposomes.

Port wine stain treatment outcomes have not improved over the past three decades

BACKGROUND

Since the early '80s, the pulsed dye laser has been the standard treatment tool for non-invasive port wine stain (PWS) removal. In the last three decades, a considerable amount of research has been conducted to improve clinical outcomes, given that a fraction of PWS patients proved recalcitrant to laser treatment. Whether this research actually led to increased therapeutic efficacy has not been systematically investigated.

OBJECTIVE

To analyse therapeutic efficacy in PWS patients globally from 1986 to date.

METHODS

PubMed was searched for all available PWS trials. Studies with a quartile percentage improvement scale were included, analysed and plotted chronologically. Treatment and patient characteristics were extracted. A mean clearance per study was calculated and plotted. A 5-study simple moving average was co-plotted to portray the trend in mean clearance over time. The data were separately analysed for multiple treatment sessions in previously untreated patients.

RESULTS

Sixty-five studies were included (24.3% of eligible studies) comprising 6207 PWS patients. Of all patients, 21% achieved 75-100% clearance. Although a few studies reported remarkably good outcomes in a subset of carefully selected patients, there was no upward trend over time in mean clearance.

CONCLUSION

The efficacy of PWS therapy has not improved in the past decades, despite numerous technical innovations and pharmacological interventions. With an unwavering patient demand for better outcomes, the need for development and implementation of novel therapeutic strategies to clear all PWS is as valid today as it was 30 years ago.

Numerical Modeling and Clinical Evaluation of Pulsed Dye Laser and Copper Vapor Laser in Skin Vascular Lesions Treatment

Introduction: Different yellow lasers have been successfully used for the treatment of vascular lesions. This study is aimed to ascertain the role and efficiency of copper vapor lasers (CVLs) and pulsed dye lasers (PDLs) for the treatment of vascular lesions using numerical modeling and to compare results with our clinical experience. In this study we aimed to develop criteria for the choice of more efficient laser exposure mode, investigate more relevant modes of laser irradiation to ensure selective photothermolysis of target vessels, and compare the CVL and PDL efficiency in the course of patients with skin vascular lesions (SVL) treatment. Methods: We performed numerical simulation of the processes of heating a vessel with CVL and PDL to temperatures at which its coagulation could occur. Calculated fluencies were compared with clinical results of laser therapy performed on 1242 patients with skin hemangiomas and vascular malformations (SHVM), including 635 patients treated with CVL and 607 patients treated with PDL. PDL and CVL provided excellent results in 40 and ten days after treatment. The treatment was not painful. Patients did not need anesthesia. Postoperative crusts were greater with PDL than with CVL. Results: Results of computer simulation of a selective vessel heating using PDL and CVL radiation are presented. By results obtained, depth of the location and sizes of vessels that could be selectively heated to more than 75°C are determined. Conclusion: Based on calculated and clinical data, the heating mode for dysplastic vessels using a series of CVL micropulses could be regarded to be safer and more efficient than the mode of a PDL short, powerful pulse.