Vascular Lesions

Vascular lesions impact up to 5% of children and range in clinical impact from minor cutaneous aberrations to large masses impacting both form and function. Vascular lesions may be characterized as tumors or malformations. Establishing a clear diagnosis is imperative to understanding the natural history of a vascular lesion and developing a treatment plan. Medical, surgical, intralesional, and laser therapy are all effective and indicated on a case-by-case basis. There are a number of important surgical considerations for operative management of these lesions.

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.

Complication rates and safety of pulsed dye laser treatment for port-wine stain: a systematic review and meta-analysis

Pulsed dye laser (PDL) is the most commonly used method for port-wine stain (PWS); however, no studies have reported the safety of PDL. This review aimed to collect and summarize complications reported in relevant literature, assess complication rates in treating PWS with PDL, and explore the relevant influencing factors. A systematic review and meta-analysis were conducted to search for related studies in PubMed, Embase, and the Cochrane Library until August 2022. Two reviewers independently evaluated the risk of bias of included studies. Stata Software version 17.0 was used for the analysis. All complications reported in the literature are divided into acute phase complications and long-term complications. Overall pooled purpura, edema, crusting, blistering, hyperpigmentation, hypopigmentation, and scarring rates were 98.3%, 97.6%, 21.5%, 8.7%, 12.8%, 0.9%, and 0.2%, respectively. Although the acute adverse reactions were found to be common, the long-term permanent complications clearly have a lower frequency, and the occurrence of scarring is much lower than that initially thought. This indicates that effective protective measures after treatment are very important for preventing scar formation. Overall, PDL treatment for PWS shows a high level of safety and low chances of causing long-term complications.

A review of treatment of port-wine stains with pulsed dye laser in fitzpatrick skin type IV-VI

Port-Wine Stains are a congenital vascular malformation that affect 0.3-0.5% of newborns. It is a benign capillary malformation that commonly occurs on the head and neck. It is formed by progressive dilation of the post-capillary venules, and as the patient ages it may be associated with hypertrophy and nodularity which can lead to cosmetic disfigurement and psychological aggravation. There are many choices of treatment such as cryosurgery, cosmetic tattooing, and dermabrasion, amongst others. The treatment of choice is pulse dye laser (PDL) because it is both effective and safe to use. In darker skin types (Fitzpatrick skin types IV-VI), treatment is more difficult. Caution when treating darker skin types with PDL comes from the fact that there is an inverse correlation between vessel specificity of the PDL and skin pigmentation. In this review, we will be reviewing the literature and discussing the manuscripts that describe the treatment of PWS on patients with fitzpatrick skin type IV-VI. Authors searched the PubMed Medline in the English language from database inception through December 2022 for eligible articles. The keywords searched included "PDL," "pulse dye laser," "skin of color," "Fitzpatrick skin types IV-VI," "fitzpatrick," "pigmented skin," "Port-wine stain," "PWS", and "pulse dye laser." The articles that were included discussed PDL in the treatment of PWS in patients of skin of color. Any additional similar articles that were cited in our search were also included. Articles that were excluded did not discuss Fitzpatrick skin types IV-VI, darker skin type, or PDL. Data collected from each article included the number of participants, Fitzpatrick skin type, age, and laser parameters. There were 120 articles that were reviewed from our search and a total of nine articles met inclusion criteria with 241 patients that were considered Fitzpatrick skin type IV-VI. The patients were of a wide range of ages from 1 month to 74 years old. In our review, patients who are treated at a younger age had better results than when treated at an older age. The results show that darker skin individuals have better results when treated at a younger age compared to adults, they can experience complete resolution. Adults who were treated saw a variation of results, from improvements in the appearance to hyperpigmentation/hypopigmentation or scarring of the treated area. Patients who are Fitzpatrick skin type IV-VI are at higher risk of adverse events when treated with PDL for PWS when compared to patients of other skin types. Studies show that PDL can be beneficial for PWS in patients of skin of color; however, there are risks of hyperpigmentation, hypopigmentation, and scarring that are important to take into consideration when treating these patients. Further research is warranted to improve the understanding of PDL for PWS in patients of skin of color.

Largest comparative analysis: Novel large spot size 595 nm, high-energy, pulsed dye laser reduces number of treatments for improvement of adult and pediatric port wine birthmarks

OBJECTIVE

Port wine birthmarks (PWBs) are vascular malformations affecting 0.3%-0.5% of newborns with the tendency to persist into adulthood without adequate treatment of the heterogenous ectatic vessels. This study compares treatment outcomes and parameters of the prior generation pulsed dye laser (PPDL) and the larger spot novel generation pulsed dye laser (NPDL) to establish whether a larger spot size laser provides greater clearance with fewer treatments.

METHODS

One hundred and sixty patients were treated with either the PPDL (80 patients) and NPDL (80 patients) with retrospective review of age, body site, laser treatment parameters, number of treatments, and improvement following laser therapy.

RESULTS

Patients treated with PPDL were older on average than patients treated with NPDL (mean 24.8 ± 19.7 vs. mean 17.1± 19.3 years, p < 0.05). The majority of lesions treated with PPDL were located on the face and neck, whereas truncal and extremity sites were more frequently treated with the NPDL. Use of NPDL was associated with a mean maximum spot size of 13.1 mm and mean maximum fluence of 7.3 J/cm2 with pulse durations of 0.45-3 ms, whereas use of the PPDL was associated with a mean spot size of 10.8 mm and mean maximum fluence of 8.8 J/cm2 with pulse durations of 0.45-6 ms. Fifty percent improvement was seen with 8.8 PPDL treatments compared to 4.3 NPDL treatments (p ≤ 0.01) with no significant difference in overall mean improvement between both devices at the chosen parameters. Multiple regression analysis showed that device type, not age or lesion location, was the only statistically significant independent variable to affect the endpoint of at least 50% improvement of the lesion.

CONCLUSIONS

Use of the larger spot NPDL is associated with achieving 50% improvement with fewer treatments.

Assessment of the efficacy of 595 nm pulsed dye laser in the management of facial flat angiomas. Results of a case series

BACKGROUND

Studies on pulsed dye laser (PDL) have shown the best efficacy and safety data for treating vascular anomalies among the various lasers used and the 595-nm PDL has been used to treat cutaneous vascular anomalies for about 30 years. The purpose of this study was to assess the efficacy of 595 nm Pulsed Dye Laser in the management of facial flat angiomas present in the form of Port-Wine Stain.

MATERIALS AND METHODS

Seven cases of PWS in Fitzpatrick skin type ranged from I to III and colour ranging from pink to purple, were treated with 595 nm pulse Dye Laser. Patients underwent to 6-8 laser sessions at 20-30 days intervals. Results obtained were judged by dermatologist, by comparing pre-treatment and post-treatment photographs, 6 months after the last session and a quartile scale of lesion clearance (4-point Investigator Global Assessment scale): 1 = no or low results (0%-25% of the lesion area improved), 2 = slight improvement (25%-50% of the lesion area cleared), 3 = moderate-good improvement (50%-75%), and 4 = excellent improvement (75%-100%) was used. Possible side effects such as blisters, hyper/hypopigmentation, and scarring were monitored.

RESULTS

All patients observed global improvements. 71% of patients achieved excellent clearance and 29% patients achieved good-moderate clearance of their angioma. Patients were asked for a subjective evaluation of the results: 57% of patients were very satisfied, 29% were satisfied, and 14% patients were not very satisfied with the results. No patients were dissatisfied. No significant side effects were noted.

CONCLUSION

This research confirms the efficacy of the 595 nm PDL for flat angioma management, without considerable side effects.

Update on lasers in pediatric dermatology: how primary care providers can help patients and families navigate appropriate treatment options and timelines

PURPOSE OF REVIEW

The use of lasers in pediatric dermatology is well established, but recent literature has expanded the evidence for specific timelines of treatment. Additionally, new devices and combinations with medical therapy have improved outcomes and treatment options for various conditions.

RECENT FINDINGS

Pulsed dye laser remains the first-line laser for vascular lesions. Recent guidelines support early initiation of laser treatment in port-wine birthmarks to optimize outcomes. For hemangiomas, laser treatment can offer a meaningful addition to oral propranolol therapy. Lasers with shorter wavelengths offer improved outcomes with decreased downtime for pigmented lesions. General anesthesia in the pediatric population continues to be a controversial topic, and the decision to perform laser under general versus topical anesthesia requires discussion with family of risks and benefits.

SUMMARY

Primary care providers can benefit their patients by prompt referral to dermatology for discussion of laser treatment. Port-wine birthmarks require referral in the first weeks of life so that laser treatment can be initiated if appropriate. Although many dermatologic conditions cannot be completely cleared or cured with laser, treatment can offer meaningful outcomes and benefit for patients and families.

Time interval between pulse dye laser treatments of port-wine stains: 30 years of experience

Port-wine stains (PWS) are frequently refractory to laser treatments. The aim of this study is to evaluate the role of treatment interval time. From 1990, 216 patients underwent Pulsed Dye Laser sessions. The laser sessions were scheduled at a minimum interval of 4 weeks to a maximum of 48 weeks. Clinical outcomes were assessed 8 weeks after the last laser session. Better results were obtained with 8 weeks interval time between therapy session, and high efficacies were also found for intervals of 4, 6 and 10 weeks. For greater interval instead, the effectiveness is significantly lower.

Extended Application of Fractional Carbon Dioxide Laser in the Treatment of Port Wine Stain Birthmarks with Hypertrophy: A Case Report

Background: Conventional treatments of port wine stain birthmarks often do not achieve the desired outcome in patients with hypertrophy. Potential reasons include deeper and larger blood vessels, abnormal arrangement of blood vessels, and darker or thicker epidermis. However, these factors may not significantly limit the efficacy of fractional carbon dioxide (CO2) laser. The aim of this case report was to examine the extended application of fractional CO2 laser in treating patients with hypertrophic port wine stain birthmarks. Methods: Two cases with hypertrophic port wine stain birthmarks treated with fractional CO2 laser for 5 years are described in this case report. Results: When compared with conventional treatment, both cases reported better outcomes, including a reduced risk of infection, pigmentation, and scarring, a decrease of clinical erythema, and much less pain. Conclusions: The findings demonstrate that fractional CO2 laser has the potential to be an effective modality for the treatment of patients with hypertrophic port wine stains.

[Medical tattooing, an unknown treatment option]

Medical tattooing is mostly known as a treatment option after breast reconstructive surgery. Nowadays, medical tattooing has a broader indication and can be used for treating port wine stains, scars, burns and transplanted skin. We present three patients with different indications for medical tattooing: one patient with a facial port wine stain, one patient with a scar after a thoracotomy, and a patient with a skin transplantation. They were all satisfied with the result. We discuss alternative treatment options, the treatment technique, the aftercare, and the follow-up of medical tattooing. Patients with facial port wine stains, scars, burns and skin transplants remain difficult to treat. We therefore recommend to apply medical tattooing in a broader spectrum of patients and to set up a multi-center study investigating the patient reported outcomes measures and the results of this treatment technique.

What do Cochrane systematic reviews say about congenital vascular anomalies and hemangiomas? A narrative review

BACKGROUND

Congenital vascular anomalies and hemangiomas (CVAH) such as infantile hemangiomas, port-wine stains and brain arteriovenous malformations (AVMs) impair patients' lives and may require treatment if complications occur. However, a great variety of treatments for those conditions exist and the best interventions remain under discussion.

OBJECTIVE

To summarize Cochrane systematic review (SR) evidence on treatments for CVAH.

DESIGN AND SETTING

Review of SRs conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo, Brazil.

METHODS

A broad search was conducted on March 9, 2021, in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed treatments for CVAH. The key characteristics and results of all SRs included were summarized and discussed.

RESULTS

A total of three SRs fulfilled the inclusion criteria and were presented as a qualitative synthesis. One SR reported a significant clinical reduction of skin redness by at least 20%, with more pain, among 103 participants with port-wine stains. One SR reported that propranolol improved the likelihood of clearance 13 to 16-fold among 312 children with hemangiomas. One SR reported that the relative risk of death or dependence was 2.53 times greater in the intervention arm than with conservative management, among 218 participants with brain AVMs.

CONCLUSION

Cochrane reviews suggest that treatment of port-wine stains with pulsed-dye laser improves redness; propranolol remains the best option for infantile hemangiomas; and conservative management seems to be superior to surgical intervention for treating brain AVMs.

Wavelength optimization for the laser treatment of port wine stains

Based on the well-known principle of selective photothermolysis, laser has been a promising way for the treatment of port wine stains (PWSs). The laser wavelengths used for PWS's clinical treatment include but are not limited to pulsed dye laser (PDL) in 585-600 nm, long-pulse 755-nm alexandrite, and 1064-nm Nd:YAG lasers. The objective of this study was to investigate the optimal wavelength for PWS's laser treatment. A two-scale mathematic model was constructed to simultaneously quantify macroscale laser energy attenuation in two-layered bulk skin and microscale local energy absorption on target blood vessels within Krogh unit. The effects of morphological parameters, including epidermal melanin content, epidermal thickness, dermal blood content, blood vessel depth, and diameter on laser energy deposition within target blood vessels, were investigated from the visible to near-infrared bands (500-1100 nm). The energy deposition ratio of target blood vessel to epidermal surface was proposed to determine the optimal laser wavelength for PWS with different skin morphological parameters. The bioheat transfer modeling and animal experiment are also conducted to prove our wavelength optimization. The optimal wavelengths for lightly pigmented skin with small and shallow target blood vessels are 580-610 nm in the visible band. This wavelength coincides with commercially used PDL. The optimal wavelength shifts to 940 nm as the epidermal pigmentation increases or the size and blood vessel depth increases. The optimal wavelength changes to 1005 nm as the epidermal pigmentation or the size and burying depth of target blood vessel further increases. Nine hundred forty nanometers can be selected as a general wavelength in PWS treatment to meet the need in most widely morphological structure. Lasers with wavelengths in the 580-610, 940, and 1005 nm regions are effective for treating PWS because of their high optical selectivity in blood over the epidermis.

[Assessment of the Efficacy and Influencing Factors of Treating Facial and Neck Port-Wine Stains with 595 nm Pulsed Dye Laser]

OBJECTIVE

To assess the efficacy of 595 nm pulsed dye laser (PDL) in the treatment of facial and neck port-wine stains (PWSs), and to explore the main factors affecting the efficacy.

METHODS

A total of 259 PWS cases who were treated with 595 nm PDL were retrospectively enrolled and their clinical information was analyzed in the study. Before- and after-treatment comparison of individual patient was done by comparing patient photographs taken before and after PDL treatment of the PWSs in order to assess the treatment efficacy, using mild purpura as the endpoint of the PDL treatment. A total of 82 male and 177 female cases were included, with patient age ranging between 1 month and 63 years. Univariate analysis was done to select factors influencing the treatment efficacy. Then, ordered multivariate logistic regression analysis was performed to evaluate the main factors affecting the efficacy. Statistics of adverse reaction of patients were also collected.

RESULTS

Of the 259 patients covered in the study, 57 (22%) had achieved complete clearing of PWS, 106 (40.9%) showed significant improvement, and 68 (26.3%) showed moderate improvement, amounting to a total of 231 effective treatment cases, indicating a 89.2% overall rate of effective treatment. There were 28 ineffective treatment cases (10.8%). Ordered multivariate logistic regression analysis showed that the color of PWS, the area of PWS, anatomical sites of PWS and the number of treatment sessions were the main factors affecting the therapeutic efficacy, while proliferation did not affect the therapeutic efficacy. Red-type PWS had better treatment efficacy than that of the purple-type PWS (odds ratio [ OR]=2.748, P<0.05). Patients with PWS≤10 cm 2 showed better treatment efficacy than those with PWS>10 cm 2 ( OR=2.094, P<0.05). Treatment efficacy of PWS located in the central section of the face was not as good as those located on the neck ( OR=0.190, P<0.05), and the treatment efficacy of PWS located in the central and lateral section of the face was not as good as those located on the neck ( OR=0.243, P<0.05). Patients who had more than 3 treatment sessions showed better efficacy than those who had 1-3 sessions of treatment ( OR=0.508, P<0.05). No patients incurred any serious adverse reactions.

CONCLUSION

Patients with PWS located on the neck, red-type PWS and area ≤10 cm 2 are suitable for treatment with 595 nm PDL and there should be more than three sessions of treatment. Patient sex, age, or proliferation do not affect the treatment effect.

Recalcitrant Facial Port-Wine Stain Successfully Responding to a Novel 585 nm Diode Laser

Port-wine stains are capillary malformations of the skin that are typically present at birth. As maturity can lead to the development of nodularity and hypertrophy in addition to the risk of bleeding, treatment has been advocated. While the pulsed dye laser has become the standard of care for laser treatment, other lasers have also been used with varying degrees of success for recalcitrant lesions. We demonstrate the safe and effective use of a novel 585 nm diode laser for a recalcitrant facial port-wine stain in a patient.

Glucose in Conjunction with Multiple Laser Pulses on Laser Treatment of Port-wine Stain: An in vivo Study

Port-wine stain (PWS) birthmark is a congenital microvascular malformation of the skin. A 1064-nm Nd:YAG laser can achieve a deeper treatment, but the weak absorption by blood limits its clinical application. Multiple laser pulses (MLPs) are a potential solution to enhance the curative effect of a Nd:YAG laser. To reduce the pulse number (p_n) required for the thermal destruction of the blood vessel, the effect of glucose in conjunction with MLP was investigated. In vivo experiments were performed on a dorsal skin chamber model. Different concentrations (20, 25, 30, and 40%) of glucose were applied to the sub-dermal side of the hamster skin before laser irradiation. Identical vessels with diameters of 200 ± 30 and 110 ± 20 μm were chosen as representatives of typical PWS vessels. Instant thermal responses of the blood vessel were recorded by a high-speed camera. The required p_n for blood vessel damage was compared with that without glucose pretreatment. Results showed that the use of glucose with a concentration of 20% combined with MLP Nd:YAG laser to damage blood vessels is more appropriate because severe hemorrhage or carbonization easily appeared in blood vessels at higher glucose concentration of 25, 30, and 40%. When 20% glycerol is pretreated on the sub-dermal hamster skin, the required p_n for blood vessel damage can be significantly decreased for different power densities. For example, p_n can be reduced by 40% when the power density is 57 J/cm². In addition, generation of cavitation and bubbles in blood vessels is difficult upon pretreatment with glucose. The combination of glucose with MLP Nd:YAG laser could be an effective protocol for reducing the p_n required for blood vessel damage. Randomized controlled trial (RCT) and human trials will be conducted in the future.

Port-Wine Stains: A Focused Review on Their Management

<p>Port-wine stain (PWS) is the second most common congenital vascular malformation characterized as ectatic capillaries and venules in the dermis that clinically appears as a deep red to purple patch on the skin. Typically, PWS progressively darken and may become hypertrophic or nodular without treatment. There are several treatment options available for PWS from topical antiangiogenic agents to laser therapies. Vascular-specific lasers are the gold standard in treating PWS and classically pulsed dye lasers are usually the treatment of choice. However, some patients with PWS are recalcitrant to PDL and may require a combination of treatment methods. Nonetheless, even with the advancements in laser therapies utilized today, it is can be difficult to achieve complete clearance of the PWS. Thus, new innovations for treating recalcitrant PWS are underway in order to improve overall patient treatment outcomes.</p> <p><em>J Drugs Dermatol. 2017;16(11):1145-1151.</em></p>.

Nd:YAG laser-induced morphology change and photothermal conversion of gold nanorods with potential application in the treatment of port-wine stain

Based on the principle of selective photothermolysis, 1064 nm Nd:YAG laser has great potential for the treatment of deeper and larger PWS. However, the clinical effectiveness is limited because of the weak absorption of blood to Nd:YAG laser. The aim of this study is to obtain the optimal irradiation conditions to effectively destroy vascular lesions with the assistance of PEG-modified gold NRs to enhance blood absorption of Nd:YAG laser. In our study, PEG-modified gold NRs were prepared by the seeded growth method. Gold NRs after exposure to Nd:YAG laser were characterized using absorption spectra and transmission electron microscope images. The tissue-like phantom containing a glass capillary with blood was prepared and exposed to Nd:YAG laser to investigate the laser energy density and pulse number required for blood coagulation before and after the addition of gold NRs in blood. The results show that the millisecond Nd:YAG laser irradiation does not result in the shape change of gold NRs. After injection of gold NRs into the bloodstream (4.60 mg/kg), the absorbance of blood at 1064 nm increased 3.9 times. The threshold energy density for the treatment of PWS decreased by 33% (from 30 to 20 J/cm²). Our findings provide an experimental guide for choosing laser parameters and gold NRs concentration for the treatment of deeper and larger PWS with the assistance of PEG-modified gold NRs in vivo in the future.

Intraoperative, real-time monitoring of blood flow dynamics associated with laser surgery of port wine stain birthmarks

BACKGROUND AND OBJECTIVE

Port-wine stain (PWS) birthmarks affect ∼22 million people worldwide. After several treatment sessions, complete disappearance of the PWS occurs in only ∼10% of treated patients. There is a need to develop a new strategy to improve the efficacy of each treatment session and the overall treatment outcome. The study objective was to determine how intraoperative measurements of blood flow correlate with treatment response assessed several weeks post treatment.

STUDY DESIGN/MATERIALS AND METHODS

We employed Laser Speckle Imaging (LSI) to measure intraoperative blood-flow dynamics. We collected data from 24 subjects undergoing laser therapy for facial PWS birthmarks. Photographs were taken before treatment and at a follow-up visit, and analyzed by two expert observers.

RESULTS

Intraoperative LSI enables real-time monitoring of blood-flow dynamics in response to laser treatment and can inform clinicians on the need for focused re-treatment. The degree of PWS blanching achieved is positively correlated with the log-transformed acute blood-flow reduction (P = 0.022).

CONCLUSION

LSI is a simple, intraoperative monitoring tool during laser therapy of PWS birthmarks. LSI provides a single value for blood flow that correlates well with the degree of blanching achieved with laser therapy.

Novel genetic mutations in a sporadic port-wine stain

IMPORTANCE Port-wine stains (PWSs) are common congenital cutaneous capillary malformations. A somatic GNAQ mutation was recently identified in patients with sporadic PWSs and Sturge-Weber syndrome. However, subsequent studies to confirm or extend this observation are lacking.OBSERVATIONS We report a long-standing, unilateral facial PWS of a man in his early 70s confirmed by histopathological analysis. Staged surgical excision of the vascular malformation was performed, and genomic DNA was extracted from the vascular malformation specimen and normal skin. Targeted next-generation sequencing of the coding sequence of 275 known cancer genes including GNAQ was performed in both specimens. A single-nucleotide variant(c.548G>A, p.Arg183Gln) in GNAQ was identified in the PWS-affected tissue but not in the normal skin sample. In addition, this sequencing approach uncovered several additional novel somatic mutations in the genes SMARCA4, EPHA3, MYB, PDGFR-β, and PIK3CA.CONCLUSIONS AND RELEVANCE Our findings confirm the presence of somatic mutations inGNAQ in the affected skin of a patient with congenital PWS, as well as alterations in several other novel genes of possible importance in the pathogenesis of PWS that may also offer substantial therapeutic targets.

Microarray analysis of port wine stains before and after pulsed dye laser treatment

BACKGROUND AND OBJECTIVES

Neither the pathogenesis of port wine stain (PWS) birthmarks nor tissue effects of pulsed dye laser (PDL) treatment of these lesions is fully understood. There are few published reports utilizing gene expression analysis in human PWS skin. We aim to compare gene expression in PWS before and after PDL, using DNA microarrays that represent most, if not all, human genes to obtain comprehensive molecular profiles of PWS lesions and PDL-associated tissue effects.

MATERIALS AND METHODS

Five human subjects had PDL treatment of their PWS. One week later, three biopsies were taken from each subject: normal skin (N); untreated PWS (PWS); PWS post-PDL (PWS + PDL). Samples included two lower extremity lesions, two facial lesions, and one facial nodule. High-quality total RNA isolated from skin biopsies was processed and applied to Affymetrix Human gene 1.0ST microarrays for gene expression analysis. We performed a 16 pair-wise comparison identifying either up- or down-regulated genes between N versus PWS and PWS versus PWS + PDL for four of the donor samples. The PWS nodule (nPWS) was analyzed separately.

RESULTS

There was significant variation in gene expression profiles between individuals. By doing pair-wise comparisons between samples taken from the same donor, we were able to identify genes that may participate in the formation of PWS lesions and PDL tissue effects. Genes associated with immune, epidermal, and lipid metabolism were up-regulated in PWS skin. The nPWS exhibited more profound differences in gene expression than the rest of the samples, with significant differential expression of genes associated with angiogenesis, tumorigenesis, and inflammation.

CONCLUSION

In summary, gene expression profiles from N, PWS, and PWS + PDL demonstrated significant variation within samples from the same donor and between donors. By doing pair-wise comparisons between samples taken from the same donor and comparing these results between donors, we were able to identify genes that may participate in formation of PWS and PDL effects. Our preliminary results indicate changes in gene expression of angiogenesis-related genes, suggesting that dysregulation of angiogenic signals and/or components may contribute to PWS pathology.

Use of reflectance spectrophotometry to predict the response of port wine stains to pulsed dye laser

Reflectance spectroscopy can be used to quantitate subtle differences in color. We applied a portable reflectance spectrometer to determine its utility in the evaluation of pulsed dye laser treatment of port wine stains (PWS) and in prediction of clinical outcome, in a prospective study. Forty-eight patients with PWS underwent one to nine pulsed dye laser treatments. Patient age and skin color as well as PWS surface area, anatomic location, and color were recorded. Pretreatment spectrophotometric measurements were performed. The subjective clinical results of treatment and the quantitative spectrophotometry results were evaluated by two independent teams, and the findings were correlated. The impact of the clinical characteristics on the response to treatment was assessed as well. Patients with excellent to good clinical results of laser treatments had pretreatment spectrophotometric measurements which differed by more than 10%, whereas patients with fair to poor results had spectrophotometric measurements with a difference of of less than 10%. The correlation between the spectrophotometric results and the clinical outcome was 73% (p < 0.01). The impact of the other clinical variables on outcome agreed with the findings in the literature. Spectrophotometry has a higher correlation with clinical outcome and a better predictive value than other nonmeasurable, nonquantitative, dependent variables.

Treatment of port-wine stains with a short pulse width 532-nm Nd:YAG laser

BACKGROUND AND OBJECTIVE

Pulsed dye laser treatment often results in port-wine stain (PWS) improvement; however, results vary. A frequency-doubled neodymium-doped yttrium aluminum garnet (Nd:YAG) laser that allows for shorter pulse widths along with large spot sizes and high fluences has been developed for the treatment of cutaneous vascular lesions.

STUDY DESIGN

A prospective, controlled study was performed in 5 adults with PWS using a frequency-doubled Nd:YAG laser (Excel V; Cutera Inc, Brisbane, CA) in 4 quadrants, using spot sizes of 6 to 10 mm, fluences of 4.8 to 9 J/cm2, and pulse durations of 3 to 6 ms. An adjacent control area was not treated. Each was assessed immediately posttreatment for purpura and edema and at 1 month for PWS color, size, texture, and thickness. Skin biopsies obtained immediately after and at 1 month posttreatment were evaluated.

RESULTS

All treatment quadrants displayed purpura. At 1-month follow-up, all treatment quadrants showed at least 1 grade of color improvement, from a minimum of 1% to 25% to a maximum of 51% to 75% improvement (12/20 quadrants with 1%-25% improvement, 3/20 with 26%-50%, 5/20 with 51%-75%, and 0/20 with 76%-100%). Histologic evaluation of treatment quadrants revealed vascular changes ranging 0.35 to 4 mm in depth. Immediately posttreatment, thrombi and extravasated red blood cells were observed in treatment quadrants. Histology at 1 month revealed decreased number and diameter of vessels in treatment quadrants (superficial vessels decreased by mean 1.1 vessels per section [13%], and diameter by 3.0 μm [47%], midlevel vessels decreased in number by 2.3 [20%], diameter by 2.42 μm [25%], and deep vessels decreased in number by 1.5 [83%], and diameter by 7.44 μm [88%]).

CONCLUSIONS

A single treatment with a short pulse width, frequency-doubled Nd:YAG laser resulted in safe and effective improvement of PWS, with up to 75% improvement in color observed at 1 month. Histologic evaluation demonstrated vascular injury at depths of 0.35 to 4 mm with a reduction in vessel number and size at multiple dermal levels.

New frontiers in laser surgery

The simultaneous advances in engineering, medicine, and molecular biology have accelerated the pace of introductions of new light-based technologies in dermatology. In this review, the authors examine recent advances in laser surgery as well as peer into the future of energy-based cutaneous medicine. The future landscape of dermatology will almost undoubtedly include (1) noninvasive imaging technologies and (2) improved "destructive" modalities based on real-time feedback from the skin surface.

Three-dimensional Monte Carlo model of pulsed-laser treatment of cutaneous vascular lesions

We present a three-dimensional Monte Carlo model of optical transport in skin with a novel approach to treatment of side boundaries of the volume of interest. This represents an effective way to overcome the inherent limitations of "escape" and "mirror" boundary conditions and enables high-resolution modeling of skin inclusions with complex geometries and arbitrary irradiation patterns. The optical model correctly reproduces measured values of diffuse reflectance for normal skin. When coupled with a sophisticated model of thermal transport and tissue coagulation kinetics, it also reproduces realistic values of radiant exposure thresholds for epidermal injury and for photocoagulation of port wine stain blood vessels in various skin phototypes, with or without application of cryogen spray cooling.

[Laser treatment of port wine stains]

OBJECTIVE

To assess the efficiency of the PDL in the treatment of PWS in Chinese patients with skin type III-IV.

METHODS

252 patients with PWS at different anatomical sites were retrospectively studied. A flashlamp-pumped pulsed dye laser was used. The differences in therapeutic effect of laser were analyzed in the following ways: (1) by dermatomal distribution of face and neck; (2) by anatomical subdivision of face; (3) by the size of the lesion. The therapeutic effect was graded as 0 < or = poor < 25%, 25% < or = fair < 50%, 50% < or = good < 75%, 75% < or = excellent < or = 100%.

RESULTS

It revealed that the lesions at neck had the best response. The dermatome II zone showed the least response to PDL. Among the anatomical subdivision of face, the frontal area had the highest clearance, while the zygoma and cheek had the lowest clearance. Patients with PWS on the extremities respond less favorably with the fair lightening effect. Furthermore, the mean lightening was decreased as the size of PWS was increased.

CONCLUSIONS

The response difference of PWS to PDL was not only related to the anatomical region, but also related to the lesion size. It is imperative to give the patients rational treatment suggestion and normal expectation.

Choosing optimal wavelength for photodynamic therapy of port wine stains by mathematic simulation

Many laser wavelengths have been used in photodynamic therapy (PDT) for port wine stains (PWS). However, how these wavelengths result in different PDT outcomes has not been clearly illuminated. This study is designed to analyze which wavelengths would be the most advantageous for use in PDT for PWS. The singlet oxygen yield in PDT-treated PWS skin under different wavelengths at the same photosensitizer dosage was simulated and the following three situations were simulated and compared: 1. PDT efficiency of 488, 532, 510, 578, and 630 nm laser irradiation at clinical dosage (100 mW∕cm(2), 40 min); 2. PDT efficiency of different wavelength for PWS with hyperpigmentation after previous PDT; 3. PDT efficiency of different wavelengths for PWS, in which only deeply located ectatic vessels remained. The results showed that singlet oxygen yield is the highest at 510 nm, it is similar at 532 nm and 488 nm, and very low at 578 nm and 630 nm. This result is identical to the state in clinic. According to this theoretical study, the optimal wavelength for PDT in the treatment of PWS should near the absorption peaks of photosensitizer and where absorption from native chromophores (haemoglobin and melanin) is diminished.

Longitudinal, multimodal functional imaging of microvascular response to photothermal therapy

Although studies have shown that photothermal therapy can coagulate selectively abnormal vasculature, the ability of this method to achieve consistent, complete removal of the vasculature is questionable. We present the use of multimodal, wide-field functional imaging to study, in greater detail, the biological response to selective laser injury. Specifically, a single-platform instrument capable of coregistered fluorescence imaging and laser speckle imaging was utilized to monitor vascular endothelial growth factor gene expression and blood flow, respectively, in a transgenic rodent model. Collectively, the longitudinal, in vivo data collected with our instrument suggest that the biological response to selective laser injury involves early-stage redistribution of blood flow, followed by increased vascular endothelial growth factor promoter activity to stimulate pro-angiogenic events.

The pulsed-dye laser for treatment of cutaneous conditions

The concept of selective photothermolysis simply states that if one heats target tissue with a laser that is selectively absorbed by that tissue, heat should last sufficiently enough to cause damage to the target tissue, but not so long for the heat to spread to the surrounding tissue. The pulsed-dye laser (PDL) was the first laser to utilize the concept of selective photothermolysis to treat dermatologic conditions. The first application of this concept was directed at treating port-wine stain birthmarks (PWSs). A myriad of conditions that were previously only marginally treated by earlier-generation PDLs could be addressed, increasing by a factor of many thousand the number of potential patients for PDL treatment. Rosacea, scars, red striae, some lower-extremity spider veins, and photodamage could now be easily treated in addition to PWSs, nevus araneuses, cherry hemangioma, and verrucae. Finally, the latest advances in PDL technology have maximized the ability to treat linear vessels such as lower-extremity spider veins, and linear facial vessels associated with rosacea, photodamage or simply heredity, as well as improving the ability to treat diffuse erythema such as the facial redness of rosacea, PWSs, scars and striae with less risk of epidermal damage and hyperpigmentation. Final advances aim to reduce side-effects of both types of vascular lasers while potentially increasing benefits by allowing the delivery of higher fluencies. Cooling the surface of the skin protects melanin pigment while allowing the delivery of light to the dermis to remove unwanted blood vessels and potentially stimulate dermal remodeling.

Survey of the practices of laser users in the UK in the treatment of port wine stains

BACKGROUND

Laser treatment for the management of port wine stains (PWS) is well established but there are some variations in practices amongst clinicians in the UK.

OBJECTIVES

To identify areas of consensus and highlight issues where sufficient variation existed to warrant further debate or clinical research using a postal questionnaire survey of clinicians carrying out laser treatments for PWS in the UK.

METHODS

A 29-item questionnaire was constructed regarding the laser treatment of PWS and was sent to 55 members of the British Skin Laser Study Group in 2000. The questions related to the usual clinical practice of the respondents and facilities available.

RESULTS

Completed questionnaires were returned from 45 clinicians (28 dermatologists, 14 plastic surgeons, two maxillofacial surgeons and one ENT surgeon) at 36 laser centres. The following areas of consensus were identified. The majority of centres used a pulsed dye laser (PDL) for the treatment of PWS, either alone or in conjunction with a KTP laser, and medical personnel assessed and treated patients. Written information and consent was obtained in 89% of centres before starting treatment. Test areas were usually performed before embarking on a full treatment by 98% of the clinicians. The majority of respondents (84%) considered 2-3 months as the optimum interval between treatments. All the clinicians were prepared to treat patients with skin types I-IV, but skin type VI was often not treated. The vast majority of laser users treated most PWS affecting the face, neck and upper limb. The majority of clinicians used local or topical anaesthesia frequently or sometimes in the treatment of PWS and 81% of the respondents used general anaesthesia, especially when treating children. When using the PDL, 91% of respondents selected an initial fluence based on experience and/or the appearance of the skin immediately after the laser pulse. Postoperatively, most clinicians advised patients to avoid the sun, avoid injury and use an emollient. Areas of variation in practice included some centres using non-medical in conjunction with medical staff to review and treat patients. The earliest age at which the clinician thought it appropriate to treat PWS varied from newborn to 8 years old; 25% of the clinicians who treat children would treat from the age of 2-3 months old and 34% would only treat patients over 1 year old. There was considerable variation in the initial fluence selected. The usual number of treatments given to each area of the PWS varied from 3 to 16.

CONCLUSIONS

This survey has demonstrated a number of areas where there appears to be a consensus of opinion about laser treatment of PWS. However, issues where there are significant variations in practice have also been identified and require further evaluation to help direct further clinical research.

[Selectivity of photothermolysis in the treatment of port wine stains using multiple pulses with a pulsed dye laser]

BACKGROUND

In 25 % to 50 % of patients with port wine stains treated with pulsed dye laser (even in multiple sessions), only a partial improvement is obtained that is often unsatisfactory for the patient. Various factors have been proposed to explain the resistance to treatment, such as the presence of deep, small-caliber, or very thick vessels that cannot be coagulated with a single laser pulse. Certain mathematical models suggest that multiple pulses would be effective in coagulating those vessels without losing the selectivity of photothermolysis, since more energy could be delivered to the target structures without damaging the surrounding tissue. The aim of this study was to assess the efficacy and selectivity of photothermolysis with multiple laser pulses.

METHODS

Twelve patients with port wine stains were included in the study. Various areas of each lesion were treated with pulsed dye laser (Candela V-beam, 595 nm) using different parameters. Immediately afterwards, the treated areas were biopsied.

RESULTS

The risk of exceeding an appropriate dose was greater with small spot size, long pulse duration, short intervals between pulses, and high fluences. Heat damage was less with spots of 10 mm, short pulses, intervals of 1 minute between pulses, and low fluences. In selected cases, multiple pulses were effective and selective where single pulses did not successfully coagulate the vessels.

CONCLUSIONS

Our results indicate the enormous possibilities of multiple laser pulses for the treatment of refractory vascular lesions. In addition, we have addressed the variables defining the complex thermodynamic interaction between the laser and the cutaneous tissue and indicated the safest parameters. We discuss the possible usefulness of this approach with other lasers and skin diseases.

Capillary malformation associated with angiolipoma: analysis of 127 consecutive clinic patients

BACKGROUND

Capillary malformations (also known as port-wine stains) are low-flow vascular malformations of the skin that occur in 0.3% of neonates. Angiolipomas are subcutaneous, benign, usually multiple, lesions, composed of adipose tissue and blood vessels, which occur in young adults.

OBJECTIVE

The aims of this study were to determine whether there is an association between capillary malformations and angiolipoma, and to describe the characteristics of patients with this association.

METHODS

Prompted by our finding of an accompanying subcutaneous mass in a patient with capillary malformation, we reviewed the entire pool of 127 patients (71 women, 56 men; average age 22.2 years) attending the Rabin Medical Center (Petach Tikva, Israel) for treatment of nonfacial capillary malformations. All patients underwent a detailed history and comprehensive physical examination. Biopsy samples were taken from suspect lesions.

RESULTS

In addition to the index patient, four patients were found to have a subcutaneous mass beneath the capillary formation. Imaging and histologic studies identified the mass as an angiolipoma. All of the lesions were relatively refractory to pulsed dye laser or intense pulsed light treatment.

CONCLUSION

This unique report of an association between capillary malformation and angiolipoma is intended to raise the index of suspicion for underlying angiolipoma in clinicians treating patients with refractory nonfacial capillary malformations.

Efficacy of early treatment of facial port wine stains in newborns: A review of 49 cases

BACKGROUND

Port wine stains (PWS) affect 0.3-0.5% of both sexes of newborns, usually occurring on the face.

OBJECTIVE

To document safety and effectiveness of cryogen spray cooled, pulsed-dye laser at higher fluences than previously used to lighten facial PWS in infants < or =6 months, and establish that frequent treatment early in life yields better clearance than if delayed until later in life.

MATERIALS AND METHODS

Forty-nine infants who had been treated with pulsed-dye laser treatments for facial PWS at < or =6 months were identified by case review of photographs, age, sex, PWS severity score prior to laser treatment, number of treatments, and improvement following laser therapy.

RESULTS

Patients averaged 9.3 (range 2-16) treatments at 4-6 week intervals at 7.75-9.5 J/cm(2). Average surface area treated was 24.0% with 88.6% average clearance after 1 year. Average clearance was 90.7% for lesions covering <20% surface area and 85.6% for lesions > or =20%. Location (V1, V2, V3, eye, and/or scalp), treated surface area, treatment number, and fluence predicted clearance. Average clearance for sole involvement of V1 was highest (at 93.8%), followed by V2 (at 91.1%), V3 (at 84.3%), V1/V2 (at 83.7%), V1/V2/V3 (at 81.0%), periocular (at 88.6%), and scalp (at 89.9%). All patients tolerated the higher treatment fluences without atrophy or scarring.

DISCUSSION/CONCLUSIONS

Frequent, high energy pulsed-dye laser treatments are safe and highly effective in improving facial PWS in infants < or =6 months of age. Patients with PWS should be referred for pulsed-dye laser treatment during early infancy.

Treatment of Resistant Port-Wine Stains with a Variable-Pulse Pulsed Dye Laser

BACKGROUND

The conventional pulsed dye laser (PDL), operating at a wavelength of 585 nm and a pulse duration of 0.45 ms, usually does not achieve complete clearance in the majority of port-wine stains (PWSs).

OBJECTIVE

In this study, we demonstrate the efficacy of a variable-pulse pulsed dye laser (VPPDL) equipped with cryogen spray cooling (CSC) in the treatment of PWS that have become resistant to PDL treatment.

METHODS

Forty Asian patients with Fitzpatrick skin types III to IV were enrolled in this study. All patients had previously been treated by the PDL at least eight times (mean, 12.8+/-5.9) and had reached a treatment plateau. A VPPDL with a wavelength of 595 nm and a spot size of 7 mm was used. The patients were treated with fluences between 9 and 15 J/cm(2) and pulse durations of 1.5 to 10 ms. Four treatments were administered at 8-week intervals for each lesion. Three months after the last treatment, all patients were evaluated for the degree of improvement by two independent clinicians.

RESULTS

Eight patients had excellent improvement, 9 had good improvement, 11 had fair improvement, and 12 had poor improvement. No complications were observed during the course of laser treatment. Vessels larger than 30 microm were not seen in the biopsy specimens obtained after the final treatment.

CONCLUSION

The VPPDL is more effective than the PDL and the VPPDL should be used for treating PDL-resistant PWSs. Nonetheless, vessels less than 30 mum in diameter are resistant to both PDL and VPPDL treatment.

Treatment of pulsed dye laser-resistant port wine stain birthmarks

The concept of selective photothermolysis with the 577-/585-nm pulsed dye laser (PDL) revolutionized treatment of relatively common port wine stain (PWS) birthmarks. The majority of PWS can be significantly lightened with the PDL. However, few PWS are lightened completely with PDL and up to 20% hardly lighten at all. PDL-resistant PWS exist in any large cutaneous laser practice and constitute a difficult management problem. This article discusses the proposed cause, and currently available and emerging options for PDL-resistant PWS. These include higher power, longer wavelength, variable pulse width lasers with selective epidermal cooling such as 595-nm PDL, 755-nm alexandrite, 810-nm diode, 1064-nm neodymium:yttrium-aluminum-garnet, and intense pulse light systems. Other promising modalities include topical and systemic photodynamic therapy, electrical optical synergy technology, pulse stacking of similar or differing wavelengths, use of optical clearing agents in conjunction with laser, and erbium laser epidermal stripping before laser treatment.

[Spectral measurement system and laser therapy experiments for port wine stains]

To measure and analyze the spectrum of a small skin region for laser therapy of port wine stain is very useful for clinical doctor to understand the optical characters of patient's pigmented skin, to adjust the output parameters of lasers and then to improve the therapy effects. Based on the analysis of the forming mechanism of port wine stains and clinical operation of the disease, the present paper presents an automatic spectral measurement and analysis system for port wine stain therapy. It can accomplish the spectral detection in the range from 380 to 780 nm, with a spectral resolution of 1 nm. Experiments were performed for patients with various age and pigment diseases; finally, some influencing factors and relevant solutions are enumerated and discussed.

[Vascular malformations (II). Diagnosis, pathology and treatment]

Diagnosis of vascular malformations is essentially clinical, based on the evolution and morphology of lesions. A biopsy is rarely needed to evaluate the nature of the vessels. Imaging examinations are necessary to assess the extension of malformations as well as the osteomuscular and visceral compromise. New techniques such as 3D angio-CT scan and angio-MRI improve the diagnosis of some vascular malformations, especially the large combined ones such as Klippel-Trénaunay syndrome, thus limiting the need for invasive procedures. On the other hand, the advances in laser technology, particularly pulsed dye laser for port-wine stains and Nd:YAG laser for superficial venous malformations constitute new alternatives for the management of these patients. Other emergent treatments include microfoam sclerotherapy for venous and combined, slow-flow malformations, and new embolizing materials associated to surgery for arterio-venous malformations. The second part of this review is focused on the complementary diagnosis (imaging exams, pathology and accessory tests) and multidisciplinary and specific treatment based on the different groups.