[Low-level laser therapy in the treatment of diabetic ulcers: an evidence problem]

INTRODUCTION

Diabetes Mellitus is the leading cause of lower limb amputation, representing a significant economic cost for health services. The development of diabetic ulcers is a main risk factor for amputations, which have a high mortality rate at five years. The ischemia caused by macrovascular disease is a key pathophysiological factor in the development of ischemic ulcers. Existing treatments are prolonged and associated with high rates of failure and relapse, requiring the combination of multiple therapeutic modalities. Lowlevel laser therapy has been used as an adjuvant therapy for diabetic foot ulcers, since the 1960's, due to its hypothetical stimulating effects over microcirculation and tissue repair.

MATERIAL AND METHODS

Identification of published scientific studies through a literature search on PubMed, The Cochrane Library and Cochrane Controlled Trials Register.

DISCUSSION AND CONCLUSIONS

Existing evidence is favourable for in vitro cell models, but conflicting in animal models and human populations. There is significant methodological heterogeneity, which may be responsible for discordant results. Guidelines are proposed for future studies in this area, including the detailed characterization of ulcers and the parameters of laser treatment. Well-controlled studies, randomized and double-blind are needed. Accordingly to the primum non nocere, laser therapy can and should be used as adjunctive therapy in the treatment of diabetic foot, because it isn't invasive, has low costs and is a fast therapy without significant adverse effects.

Further discussion on dermatological radiotherapy

Dermatological radiotherapy has used for decades in the treatment of skin diseases with very good results. The Florentine school has always played a fundamental role in the development of this technique, this is where a phototherapy institute, which was going, in the future, to be 1st one in Italy to perform contact radiotherapy regularly, started. As time went by and with the development to new therapeutical modalities, the roentgentherapy met with a decreasing consent. So far, it is still proposed as an effective therapeutically modality in dermatological oncology, if even in selected cases. Basal cell carcinomas can reach big dimensions mainly for recurrence or because the tumor was overlooked for a long time. We bring to attention the case of a 65-year-old man presenting an ulcerated, sharp-bordered, infiltrating and bleeding lesion, occupying most of the left wing of the nose, with a diameter of about 3 cm. The man hadn't received any previous treatment. The lesion was subjected to a biopsy and the istopathological analysis diagnosed an ulcus rodens. The man refused the complete surgical removal, and was thus treated with roentgentherapy, with satisfying results and without any complications in the irradiated area. The patient didn't show any relapse after one year of follow-up. Radiotherapy can still be considered as an effective therapeutical alternative both for lesion requiring a surgical approach and for those developing in patients that couldn't be subjected to any other therapies.

Use of flashlamp-pumped pulsed dye laser in the treatment of superficial vascular malformations and ulcerated hemangiomas

A retrospective study of 502 patients treated with tunable flashlamp pulsed dye laser for superficial vascular malformations (433), ulcerated hemangiomas (65) and postinvolutional redness (4) is presented. Patients were treated in the period from June 1997 to March 2006, with follow-up ranging from six months to four years. The age of the patients ranged from three months to 80 years. Correlation between clinical response and patients' age, location of lesion and number of treatments were evaluated in groups of superficial vascular malformations, whereas healing rates of the ulceration were assessed in a series of hemangiomas. The result were judged to be excellent in 51%, good in 39%, fair in 7% and poor in 3% of patients with vascular malformations. Excellent ultimate outcome confirmed the clinical efficacy of the use of the pulsed dye laser in the treatment of dermal vascular malformations, which also appears to have good prospects in the management of hemangioma complication.

Hemophilic pseudotumor--is there a role of radiotherapy? Literature review and a case report

We share the literature and management of an adult with moderate hemophilia a presented with a calcaneal pseudotumor and non healing ulcer by radiation therapy, factor VIII and cryoprecipitate supplement. Numerous literatures so far have quoted the satisfactory role of radiotherapy in hemophilic pseudotumor. We found it to be of great help as our case responded with radiotherapy, factor VIII and cryoprecipitate supplement and has a satisfactory 2 years follow up.

Defocused diode laser therapy (830 nm) in the treatment of unresponsive skin ulcers: a preliminary trial

BACKGROUND

Skin ulcers with compromised healing remain a major problem for plastic and dermatological surgeons. Low incident levels of laser energy have been shown to increase the blood flow rate and volume and to accelerate the wound healing process, thus raising the possibility in augmenting treatment for skin ulcers.

METHODS

Preliminary controlled experiments with a 830 nm GaAlAs diode laser in axial pattern flap survival in the rat model showed statistically significant improvement in survival for the irradiated versus unirradiated control animals. In the present study, a newly developed defocused GaAlAs diode laser (830 nm, continuous wave, 669 mW/cm(2)) was applied once or twice per week in an uncontrolled study of five patients (aged between 5 and 81 years old, average 46.6 years old, doses from 6.3 J/cm(2) to 21 J/cm(2)) with previously unresponsive ulcers of various aetiologies.

RESULTS

In all five patients, the ulcers healed completely between 3 weeks and 7 months (22.8 +/- 19.3 weeks), without recurrence during a minimum 12-month follow-up.

CONCLUSIONS

Defocused 830 nm diode laser therapy was well tolerated, and was very effective in the treatment of this small number of compromised skin ulcers of different aetiologies and in a large range of patient ages. Further controlled studies in larger populations are required. Defocused diode laser therapy nonetheless appears to be a very useful adjunctive method in the treatment of slow-to-heal and non-healing skin ulcers.

Is surgery an effective and adequate treatment in advanced Marjolin's ulcer?

Malignancies in scars are generally known as Marjolin's ulcers. Between 1999 and 2004, 15 patients with Marjolin's ulcer were treated in our clinic. All lesions were secondary to burns of various causes. We perform a combined approach and aggressive surgery for treatment of Marjolin's ulcer; excision with safe margin, lymphatic dissection, postoperative radiotherapy, chemotherapy and amputation if needed. We think that the scar tissue acts as a barrier for the tumors, which will enlarge. We believe that, if we release this barrier like scar tissue, the virulent the spread of the tumor will be permitted. In this article, we consider whether or not surgical excision alone as recommended in the treatment of Marjolin's ulcers is adequate and effective. An aggressive combined approach is essential for treatment in early stages with high success rate. But there is no consensus for the treatment of advanced disease and results are generally unsuccessful.

Ultraviolet light C in the treatment of chronic wounds with MRSA: a case study

The prevalence of antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus is rapidly increasing in healthcare facilities and spreading to the community. Methicillin-resistant S. aureus colonize the skin and open wounds and can interfere with wound healing. Recent studies have shown that ultraviolet light C can kill antibiotic-resistant strains of bacteria such as methicillin-resistant S. aureus in both laboratory cultures and animal tissue. This clinical report describes the effects of ultraviolet light C on wound bioburden and closure in three people with chronic ulcers infected with methicillin-resistant S. aureus. In all three patients, ultraviolet light C treatment reduced wound bioburden and facilitated wound healing. Two patients had complete wound closure following 1 week of ultraviolet light C treatment. This case study suggests that ultraviolet light C is a promising adjunctive therapy for chronic wounds containing antibiotic-resistant bacteria such as methicillin-resistant S. aureus.

[Combined local use of miliacil and laser in the combined therapy of trophic ulcer]

The efficacy of local use of a new drug miliacil in combination with laser radiation was studied in 44 patients with trophic ulcer of different origin. It is established by clinical, histological and microbiological examinations that healing of trophic ulcers is better in combined use of miliacil and laser radiation. Mean hospital stay reduced 1.3 times after this treatment. Miliacil and laser radiation were applied for preparation of trophic ulcer for autodermoplasty. Mean time of preparation of trophic ulcer for final closure was 1.5 times less than in isolated use of miliacil. Mean hospital stay of patients who underwent autodermoplasty was 1.3 times shorter.

Low intensity laser irradiation in the treatment of recalcitrant radiation ulcers in patients with breast cancer--long-term results of 3 cases

Radiotherapy can be followed by recalcitrant skin ulcers. As low intensity laser irradiation has been demonstrated to have a beneficial effect on impaired wound healing, we investigated its efficacy and safety in three patients with chronic radiation ulcers. The three patients, previously mastectomized due to breast cancer, with recalcitrant radiation ulcers of the skin were treated with a 30 mW helium-neon laser (wavelength: 632.8 nm, intensity: 3 mW/cm2, dose: 30 J/ cm2) three times weekly. In all patients, complete wound closure was achieved within a period of 7, 5, and 8 weeks. One patient died 6 weeks after laser treatment due to tumor cachexia. Neither of the other patients showed recurrence of radiation ulcers or neoplasm during a follow-up of 36 months. Low intensity helium-neon laser irradiation has been shown to be effective in the induction of wound healing in radiotherapy-induced ulcers in three patients with breast cancer.

Increased dermal angiogenesis after low-intensity laser therapy for a chronic radiation ulcer determined by a video measuring system

Acute and chronic radiation-induced dermatitis can occur after high doses of ionizing radiation of the skin. We describe a patient with a long-lasting radiotherapy-induced ulcer that healed after low-intensity laser therapy. A video measuring system was used to determine the number of dermal vessels in the ulcer before and after laser treatment. We found a statistically significant increase in the number of dermal vessels after low-intensity laser therapy in both the central and marginal parts of the ulcer compared with its pretreatment status.

Induction of complete wound healing in recalcitrant ulcers by low-intensity laser irradiation depends on ulcer cause and size

Chronic skin ulcers still represent a therapeutic challenge in dermatology. Among the various non-invasive treatment modalities used for the improvement of impaired wound healing, low-intensity laser irradiations are gaining an increasing body of interest. We used low-intensity laser irradiations delivered by a 30 mW helium-neon laser at an energy density of 30 J/cm2 three times weekly for the induction of wound healing in ulcers of diverse causes. Twenty patients with the same number of ulcers, which had previously been treated by conventional wound care for a median period of 34 weeks (range: 3-120 weeks) without any significant evidence of healing, were included in the study. Concerning the underlying disorders, patients were divided into four groups: diabetes, arterial insufficiency, radio damage and autoimmune vasculitis. In all ulcers, complete epithelization could be induced by laser therapy. No amputation or any other surgical intervention was necessary and no adverse effects of any kind were noted during low-intensity laser treatment. Regarding the different diagnoses, a statistically significant difference was noted (P = 0.008): ulcers due to radio damage healed significantly faster than those caused by diabetes (6 weeks [range: 3-10 weeks] vs. 16 weeks [range: 9-45 weeks], P = 0.005). Wound healing in autoimmune vasculitis (24 weeks [range: 20-35 weeks]) required longer than in radiodermitis, although the difference was not significant. In addition to the diagnosis, wound size was found to be an important factor influencing the duration of wound closure (P = 0.028), whereas duration of previous conventional treatment (P = 0.24) and depth (P = 0.14) showed no effect. Our results indicate that low-intensity laser irradiation could be a valuable non-invasive tool for the induction of wound healing in recalcitrant ulcers, and that healing time is correlated with the ulcer cause and size.

[The helium-neon laser in the treatment of suppurative wounds]

Comparative results of the treatment of purulent wounds of soft tissues of different genesis by traditional methods of drug therapy in combination with the low intensity laser radiation of the red part of the optical spectrum in 274 patients are described. A reliably accelerated cleansing of the wound was achieved with a simultaneous growth of the granulation tissue and epithelization. No complications were noted.

[Radiotherapy of ulcerated hemangioma]

A method of close-focus x-ray therapy for extensive ulcerated hemangiomas was worked out and used in combination with ointment treatment with a good clinical effect in 230 patients. The summary focal dose was 0.5-1.0 Gy. A study of the results of radiotherapy over the period of 3-10 yrs. has shown that such changes as skin atrophy, scars and cosmetic defects result from the ulceration of a tumor at its early stage of development because during irradiation at doses that do not cause local radiation reactions, changes of the skin and soft tissues are not observed.