Transcutaneous laser treatment of leg veins

Treatment of lower limb telangiectasias with Nd: Yag 1064 nm laser with and without tumescent anesthesia - TTL technique

INTRODUCTION

Transdermal laser is an option for varicous veins treatment, yet it may be painful. In this study, we will present a technique for performing tumescent anesthesia associated to transdermal laser (TTL) to reduce pain during treatment.

OBJECTIVE

The study compares pain during treatment of telangiectasias in lower limb with and without tumescent anesthesia to offer a less painful procedure.

METHODS

50 CEAP C1 patients with bilateral telangiectasias on thighs underwent transdermal laser treatment, using tumescent anesthesia on one side and standard technique on the other. Pain was assessed via the Visual Analogue Scale. The outcomes were compared with Student's t-test. Significance was set at p < .05.

RESULTS

Laser treatment without tumescent anesthesia resulted in a VAS pain score of 7.9, versus 0.0 with anesthesia, showing a significant statistical difference.

CONCLUSION

Tumescent anesthesia and transdermal laser (TTL) is capable of reducing pain in laser treatment of telangiectasias and reticular veins.

Energy-Based Skin Rejuvenation: A Review of Mechanisms and Thermal Effects

BACKGROUND

Energy-based photoelectric and ultrasonic devices are essential for skin rejuvenation and resurfacing in the field of plastic surgery and dermatology. Both functionality and appearance are impacted by factors that cause skin to age, and various energy types have variable skin penetration depths and modes of transmission.

AIM

The objective is to advise safe and efficient antiaging treatment while precisely and sensitively controlling and assessing the extent of thermal damage to tissues caused by different kinds of energy-based devices.

METHODS

A literature search was conducted on PubMed to review the mechanisms of action and thermal effects of photoelectric and ultrasonic devices in skin remodeling applications.

RESULTS

This paper reviews the thermal effects of energy-based devices in skin resurfacing applications, including the tissue level and molecular biochemical level. It seeks to summarize the distribution form, depth of action, and influencing factors of thermal effects in combination with the mechanisms of action of various types of devices.

CONCLUSION

Accurate control of thermal damage is crucial for safe and effective skin remodeling treatments. Thorough investigation of molecular biochemical indicators and signaling pathways is needed for real-time monitoring and prevention of severe thermal injury. Ongoing research and technological advancements will improve the accuracy and control of thermal damage during treatments.

Use of a fractional 1570-nm diode laser scanner for nonablative face and neck rejuvenation

BACKGROUND

The use of non-ablative fractionated lasers for skin rejuvenation has been proven to be effective in improving skin texture, and has become popular due to minimal wounding, significantly shorter recovery times and decreased adverse effects.

OBJECTIVE

To retrospectively analyze improvement in skin texture in healthy women aged over 18 years with Fitzpatrick skin type II-IV.

METHODS

Participants received 3 facial and/or neck treatments with the 1570-nm fractional scanning diode laser at one-month intervals. Three months after the last treatment session two blinded evaluators assessed skin improvement using before and after photos. Pain and patient satisfaction were recorded.

RESULTS

Sixteen women with a mean age of 45.4 ± 4.1 years (range 35-50 years) and skin type II-IV were included in the analysis. All 16 participants received facial treatments and seven (43.8%) also received neck treatments. Three months follow-up evaluation showed that the majority of participants had at least a visible change in the treated areas. Mean pain score was low and decreased with each treatment session.

CONCLUSION

Skin treatment using fractional scanning 1570-nm diode laser improves skin laxity in women with skin types II-IV. Larger studies are warranted to further clarify the efficacy and safety of this modality.

Lasers for the treatment of nail psoriasis: a systematic review

This systematic review assesses the evidence concerning laser treatments for nail psoriasis (NP), a prevalent condition among individuals with cutaneous psoriasis that notably affects their quality of life. Traditional treatments have limitations in terms of drug delivery and poor patient adherence, leading to interest in laser therapies for their targeted approach, extended treatment intervals, and the potential to enhance topical medication effectiveness. The MEDLINE, Embase, Web of Science, and Cochrane Library databases were searched. English-language randomized and non-randomized controlled trials with full-text availability were included. Data on the laser type, treatment protocol, Nail Psoriasis Severity Index (NAPSI) outcomes, and adverse events were extracted, and nail bed and matrix features and patient satisfaction were assessed. The primary effect measure was a percentage reduction in NAPSI scores from baseline. Nineteen studies involving the pulse dye laser (PDL), long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser and fractional carbon dioxide laser (FCL) were identified. Lasers, particularly those used in conjunction with topical agents, have shown favorable results. PDL effectively lowered NAPSI scores, and the Nd:YAG laser had comparable effectiveness but more discomfort. FCL also shows promise, particularly for topical drug delivery. PDL and Nd:YAG laser treatment were more effective at reducing nail bed features, whereas FCL was effective at reducing both nail bed and matrix features. Overall, lasers are promising treatment alternatives for NP, with similar NAPSI outcomes to topical therapies and intralesional injections.

A comparative study between cryo-laser cryo-sclerotherapy and sclerotherapy in the treatment of telangiectasia and reticular veins: A randomized controlled trial

OBJECTIVE

Telangiectasias, characterized by dilated venules, are frequently observed in the lower extremities. Sclerotherapy stands out as the predominant treatment of these vascular lesions. The integration of laser therapy with a mild sclerosing agent, serving as an osmotic sclerosant, presents an enhanced cosmetic treatment approach, aiming to optimize outcomes and minimize potential adverse effects. This study sought to evaluate the feasibility, efficacy, and safety of cryo-laser and cryo-sclerotherapy (CLaCS) and compare it with injection sclerotherapy for the treatment of telangiectasia and reticular veins.

METHODS

In this randomized controlled trial, individuals expressing concerns about telangiectasia and reticular veins were recruited for aesthetic treatment. The enrolled patients were prospectively randomized according to the chosen treatment technique. Group A included patients undergoing CLaCS with 70% dextrose, focusing on a single area measuring 20 cm by 20 cm. Group B included patients receiving polidocanol injection sclerotherapy for a single area of the same dimensions.

RESULTS

Group A comprised 195 patients and group B comprised 197 patients. The rates of complete lesion elimination after the first, second, and third treatment sessions were 64.6%, 86.2%, and 100% in group A and 50.3%, 74.1%, and 85.3% in group B, respectively. Group A exhibited a significantly higher complete elimination rate compared with group B at the conclusion of the study (P < .001). Furthermore, group A demonstrated a statistically significant lower incidence of postprocedural pigmentation and other complications compared with group B (P < .001). These findings underscore the enhanced efficacy and safety profile associated with the CLaCS technique using 70% dextrose compared with injection sclerotherapy with polidocanol.

CONCLUSIONS

CLaCS, combining cryo-laser and cryo-sclerotherapy, demonstrated superior efficacy and safety compared with traditional polidocanol sclerotherapy for treating telangiectasia and reticular veins.

Is multiple wavelength diode laser for facial contouring safe?

The multiple wavelength diode laser (MWDL) is a sophisticated device designed to target deeper skin layers by emitting various wavelengths. Its unique feature is the ability to deliver heat to specific depths within the tissue using different wavelengths while simultaneously cooling the skin surface. Recent research by Choi et al. suggests that wavelengths of 755 and 810 nm can induce carbonization in hair follicles, while the 1064 nm wavelength penetrates deeper into tissues. MWDL has been proposed for fat redistribution in aging, but concerns have been raised regarding ocular safety and potential tissue damage, particularly when used near the eyes. Studies have shown ocular injuries during cosmetic laser procedures, emphasizing the need for robust ocular protection and safety protocols. Additionally, there are reports of internal ischemic necrosis and burns, highlighting the importance of precise energy settings and parameter management. While MWDL shows promise, further research and comprehensive guidelines are needed to ensure safe and effective usage in clinical practice.

Use of a fractional 1570-nm diode laser scanner for non-ablative face and neck rejuvenation

BACKGROUND

The use of non-ablative fractionated lasers for skin rejuvenation has been proven to be effective in improving skin texture, and has become popular due to minimal wounding, significantly shorter recovery times and decreased adverse effects.

OBJECTIVE

To retrospectively analyze improvement in skin texture in healthy women aged over 18 years with Fitzpatrick skin types II-IV.

METHODS

Participants received three facial and/or neck treatments with the 1570-nm fractional scanning diode laser at 1-month intervals. Three months after the last treatment session two blinded evaluators assessed skin improvement using before and after photos. Pain and patient satisfaction were recorded.

RESULTS

Sixteen women with a mean age of 45.4 ± 4.1 years (range 35-50 years) and skin type II-IV were included in the analysis. All 16 participants received facial treatments and seven (43.8%) also received neck treatments. Three months follow-up evaluation showed that the majority of participants had a visible change in the treated areas. Mean pain score was low and decreased with each treatment session.

CONCLUSION

Skin treatment using fractional scanning 1570-nm diode laser improves skin laxity in women with skin types II-IV. Larger studies are warranted to further clarify the efficacy and safety of this modality.

Intense Pulsed Light (IPL) for the treatment of vascular and pigmented lesions

BACKGROUND

IPL devices emit a wide range of wavelengths that can be absorbed by different chromophores in the skin. Selective destruction of a specific chromophore with minimal side effects is controlled by wavelength, pulse duration, and fluence.

AIM

This study aims to evaluate the treatment of vascular and pigmented lesions using narrow-band Intense Pulsed Light (IPL) with Advanced Fluorescence Technology (AFT), which offers more efficient energy usage per pulse to increase safety, and improve clinical outcomes.

METHODS

A retrospective analysis of data from 100 patients treated with narrow-band IPL for vascular and pigmented lesions. Efficacy was measured by the Global Aesthetic Improvement Scale (GAIS) and Patient Satisfaction Scale (0-10). Safety was assessed by evaluating pain levels and adverse events.

RESULTS

Mean GAIS scores were 8.02 ± 0.84 for vascular and 8.14 ± 0.9 for pigmented lesions with no significant difference between groups (p=0.49, α=0.05). Patient satisfaction correlated with GAIS scores (correlation coefficient 0.8). No pain was reported and two patients experienced temporary and transient side effects.

CONCLUSION

Overall, the advanced IPL treatments provided favorable outcomes for vascular and pigmented lesions.

Review of laser and energy-based devices to treat rosacea in skin of color

The prevalence of rosacea in skin of color (SOC) populations is estimated to be as high as 10% in some countries. Traditionally, intense pulsed light (IPL) and pulsed dye laser (PDL) have been the laser and energy-based devices (EBDs) used to treat rosacea. However, not all laser and EBDs are safe for SOC (Fitzpatrick skin types IV-VI) due to increased absorption of energy in pigmented skin and increased risk of post-inflammatory hyperpigmentation and scarring. This review summarizes the use of the top seven laser and EBDs for treating rosacea in SOC.

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Effects of long-pulsed 1064-nm Nd:YAG laser on telangiectasias and reticular veins: a human in-vivo histological study

BACKGROUND

Telangiectasias and reticular veins are associated with aesthetic disorders. Sclerotherapy is the gold standard treatment, but long-pulsed 1064-nm Nd:YAG laser (LP1064 laser) is also used. No data on the human histological effects of these lasers are reported. The objective was to test different LP1064 laser parameters and their histological effects on the dermis, collagen, telangiectasias, and reticular veins.

METHODS

This was a single-center, prospective, single-arm, case-control, human study. During surgery (dermolipectomy), the abdominal section of 10 female patients was irradiated with 6 different transdermal LP1064 laser parameters after anesthesia. Ten pieces with areas of varying irradiation were evaluated according to the characteristics of the vessels identified by area. In each piece, two irradiation areas were performed per group, totaling 12 irradiation areas per piece, with 120 regions later analyzed at the end of the ten samples. After removing the surgical product, histological sections were extracted, and the dermis, telangiectasias, and reticular veins were analyzed.

RESULTS

Histological analysis showed that exposition to six different parameters from LP1064 laser led to significant dermal layer separation and collagen alterations. The effects were inconsistent on the loss of endothelial cells, intravascular thrombus formation, and fusion of vascular walls for both telangiectasias and reticular veins. In reticular veins, effects on intravascular thrombus formation and vascular wall fusion were not observed.

CONCLUSIONS

The LP1064 laser in monotherapy with fixed settings did not lead to a consistent vascular lesion to promote immediate occlusion in telangiectasias and reticular veins. This strategy may not work as monotherapy for small vein treatment, but the possible late response to the LP1064 laser cannot be ruled out and require further investigation.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Nd:YAG-photobiomodulation enhanced ADSCs multilineage differentiation and immunomodulation potentials

To investigate the effects of Nd: YAG (1064 nm) photobiomodulation on multilineage differentiation and immunomodulation potentials of adipose tissue-derived stem cells (ADSCs) in vitro and in vivo. For in vitro experiments, cells were divided into the control group (non-irradiated control ADSCs) and photobiomodulation groups. 0.5 J/cm2, 1 J/cm2, 2 J/cm2, and 4 J/cm2 were used for proliferation assays; for ADSCs adipogenic differentiation assays, 0.5 J/cm2, 1 J/cm2 were applied; 1 J/cm2 was used for migration and immunomodulation assays. The differentiation abilities were assessed by qPCR, Oil Red O staining, and Alizarin Red staining. The immunomodulation potential was assessed by qPCR and human cytokine array. DSS-induced colitis model. was used to test the effect of photobiomodulation on ADSCs immunomodulation potentials in vivo. Nd:YAG-based photobiomodulation dose-dependently promoted ADSCs proliferation and migration; 1 J/cm2 showed the best promotion effect on proliferation. Moreover, Nd:YAG photobiomodulation promoted ADSCs osteogenic differentiation and brown adipose adipogenic differentiation. The potential immunomodulation assays showed Nd:YAG photobiomodulation improved Anti-inflammation capacity of ADSCs and photobiomodulation irradiated ADSCs effectively alleviated DSS-induced colitis severity in vivo. Our study suggests Nd:YAG photobiomodulation might enhance the ADSCs multilineage differentiation and immunomodulation potentials. These results might help to enhance ADSCs therapeutic effects for clinical application. However, further studies are needed to explore the mechanisms of Nd:YAG photobiomodulation promoting multilineage differentiation and immunomodulation potentials of ADSCs.

980 nm laser endo-perivenous treatment of lower limb reticular veins and telangiectasias. Technical notes

INTRODUCTION

For several years, the venous aesthetic problem has been tackled mainly with sclerotherapy techniques. In recent years, laser techniques have been added, both surface (transdermal) and endo-perivenous, performed with small optical fibers (100-200 μm) and low intensities in terms of LEED and Watt. The endo-perivenous technique has extended the possibilities of laser treatment also to the nourishing veins, to telangiectasias resistant to therapies with sclerosing agents and/or transdermal lasers and to vessels with larger diameters (1-3 mm) and depths >1.3 mm.

MATERIALS AND METHODS

We report a series of 20 patients affected by reticular veins and telangiectasias of the lower limbs (CEAP C1-2) treated with endo-perivenous technique. The most used setting was: 3 W (range: 2-4 W) with a mean fluence delivered of 11.25 J/cm (range: 6-18) in pulse mode with 980 nm laser, 200 μm fiber after a preventive skin cooling. Scheduled follow-up occurred 20 and 60 days after treatment.

RESULTS

Total technical success, understood as complete obliteration of all treated vessels, was achieved in 70% of cases (14/20) after just one treatment. The most observed early local complications were erythema, vesicles, and small cutaneous eschars that regressed in 3 weeks. At 60-day follow-up, just one complication was observed: a small area of hyperpigmentation (5%). In this case, chemical peel procedures was performed with good clinical results.

CONCLUSIONS

Endoperivenous laser treatment represents an effective and valid tool for the treatment of teleangectasias and reticular varicose veins.

A Review of Laser Therapies for the Treatment of Scarring and Vascular Anomalies

Significance: Laser use has become part of the gold standard of treatment as an effective adjuvant in multimodal therapy for pathologic scarring caused by burns, trauma, acne, and surgery, as well as vascular anomalies. Understanding indications and applications for laser therapy is essential for physicians to improve patient outcomes. Recent Advances: Since the 1980s, the medical use of lasers has continuously evolved with improvements in technology. Novel lasers and fractionated technologies are currently being studied in the hopes to improve treatment efficacy, while reducing complications. Recent advancements include acne treatment with novel picosecond lasers, new hypertrophic scar therapies with simultaneous laser and intense pulsed light use, and novel systems such as lasers with intralesional optical fiber delivery devices. In addition, optimizing the timing of laser therapy and its use in multimodal treatments continue to advance the field of photothermolysis. Critical Issues: Selecting the correct laser for a given indication is the fundamental decision when choosing a laser balancing effective treatment with minimal complications. This article covers the principles of laser therapy, the preferred lasers used for the treatment of scarring and vascular anomalies, and discusses the current evidence behind these laser choices. Future Directions: To optimize laser therapy, larger randomized control trials and split scar studies are needed. Continued advancement through better randomized controlled studies will help to improve patient outcomes on a broader scale.

A randomized split-face comparative study of long-pulsed alexandrite plus low-fluence Nd:YAG laser versus pulsed-dye laser in the treatment of rosacea

OBJECTIVES

To compare the effectiveness of long-pulsed alexandrite laser (LPAL) with that of pulsed-dye laser (PDL) for rosacea.

METHODS

This was a single-blind randomized controlled trial on 27 patients who were clinically diagnosed with rosacea. Randomly assigned split face in each patient received four times monthly treatment of LPAL plus low-fluence Nd:YAG with the contralateral side serving as the control treated with PDL. At every visit, the erythema index (EI) was measured with skin analysis systems, and two independent dermatologists evaluated digital photographs for five-point global aesthetic improvement scale (GAIS).

RESULTS

The EI significantly decreased on both treated sides (LPAL 366.5 ± 101.0 vs. 295.8 ± 90.2, p < 0.001, PDL 369.0 ± 124.3 vs. 302.7 ± 92.1, p < 0.001) 1 month after fourth treatment (visit 5). Also 3 months after the fourth treatment (visit 6), the reduction in the EI was well maintained on both sides (LPAL 360.3 ± 96.8 vs. 282.0 ± 89.2, p < 0.001, PDL 364.3 ± 121.6 vs. 281.6 ± 97.8, p < 0.001). When comparing the improvement in the EI between the two groups, the percentage reduction in the EI on the LPAL-treated side was not inferior to the PDL-treated side (visit 5: LPAL 18.7 ± 15.7% vs. PDL 16.4 ± 12.9%, p = 0.501 and visit 6: LPAL 21.7 ± 13.9% vs. PDL 21.9 ± 15.2%, p = 0.943). The GAIS and patient satisfaction were comparable between the LPAL and PDL sides and did not show any significant difference. No serious adverse events occurred on either of the treated sides.

CONCLUSION

This study showed that the decrease in EI in the treatment of rosacea was comparable between PDL and LPAL. Therefore, LPAL could be a promising alternative treatment option with good merits for rosacea, considering no consumables are required for device maintenance.

Characterization of the Workspace and Limits of Operation of Laser Treatments for Vascular Lesions of the Lower Limbs

The increase of the aging population brings numerous challenges to health and aesthetic segments. Here, the use of laser therapy for dermatology is expected to increase since it allows for non-invasive and infection-free treatments. However, existing laser devices require doctors' manually handling and visually inspecting the skin. As such, the treatment outcome is dependent on the user's expertise, which frequently results in ineffective treatments and side effects. This study aims to determine the workspace and limits of operation of laser treatments for vascular lesions of the lower limbs. The results of this study can be used to develop a robotic-guided technology to help address the aforementioned problems. Specifically, workspace and limits of operation were studied in eight vascular laser treatments. For it, an electromagnetic tracking system was used to collect the real-time positioning of the laser during the treatments. The computed average workspace length, height, and width were 0.84 ± 0.15, 0.41 ± 0.06, and 0.78 ± 0.16 m, respectively. This corresponds to an average volume of treatment of 0.277 ± 0.093 m³. The average treatment time was 23.2 ± 10.2 min, with an average laser orientation of 40.6 ± 5.6 degrees. Additionally, the average velocities of 0.124 ± 0.103 m/s and 31.5 + 25.4 deg/s were measured. This knowledge characterizes the vascular laser treatment workspace and limits of operation, which may ease the understanding for future robotic system development.

Evaluation of the safety and efficacy of long pulsed Nd: YAG laser in the treatment of vascular lesions in vivo

Long-pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers have recently been used for the treatment of vascular lesions refractory to conventional vascular lasers. The aim of this study was to evaluate the clinical efficacy and safety of long-pulsed Nd:YAG laser treatment for vascular disorders. Laser irradiation was performed using two approaches: the 532 nm Nd:YAG laser was used to irradiate the dorsal skin fold in mice and the 1064 nm Nd:YAG laser was used to irradiate the leg of mice without skin incision. The specimens were observed immediately after laser treatment using a laser Doppler perfusion imaging system. Red blood cell (RBC) extravasation and hemorrhage were observed using the hematoxylin and eosin stain. The diameter of blood vessel under 30 μm was disrupted with a laser pulse at a fluence of 12 J/cm² and a wavelength of 532 nm regardless of pulse duration. The veins and arteries of approximately 1 mm in size were ablated with laser pulses at a fluence of 140 J/cm² and above and a wavelength of 1064 nm. Selective photopyrolysis can be achieved with either 532- or 1064 nm Nd:YAG laser pulses in vascular diseases based on the depth and size of the vessel.

Classification of Chronic Venous Disorders using an Ensemble Optimization of Convolutional Neural Networks

Chronic Venous Disorders (CVD) of lower limbs are one of the most prevalent medical conditions, affecting 35% of adults in Europe and North America. The early diagnosis of CVD is critical, however, the diagnosis relies on a visual recognition of the various venous disorders which is time- consuming and dependent on the physician's expertise. Thus, automatic strategies for the classification of the CVD severity are claimed. This paper proposed an automatic ensemble-based strategy of Deep Convolutional Neural Networks (DCNN) for the classification of CVDs severity from medical images. First, a clinical dataset containing 1376 images of patients' legs with CVD of 5 different levels of severity was constructed. Then, the constructed dataset was randomly split into training, testing, and validation datasets. Subsequently, a set of DCNN were individually applied to the images for classification. Finally, instead of a traditional voting ensemble strategy, extracted feature vectors from each DCNN were concatenated and fed into a new ensemble optimization network. Experiments showed that the proposed strategy achieved a classification with 93.8%, 93.4%, 92.4% of accuracy, precision, and recall, respectively. Moreover, compared to the traditional ensemble strategy, improvement in the accuracy of ~2% was registered. The proposed strategy showed to be accurate and robust for the diagnosis of CVD severity from medical images. Nevertheless, further research using an extensive clinical database is required to validate the potential of this strategy. Clinical Relevance- An automatic classification of CVD to reduce the probability of underdiagnoses and promote the treatment of CVD in the early stages.

Treatment of nail psoriasis with pulsed dye laser versus combined pulsed dye and Nd:YAG lasers-An intrapatient left-to-right study

BACKGROUND AND OBJECTIVES

There are limited treatment options for nail psoriasis. It is important to find new therapies and improve existing ones. The aim of this study was to compare the effectiveness of pulsed dye laser (PDL) versus combined PDL and Nd:YAG lasers in patients with nail psoriasis.

METHODS

Fourteen patients (with a total of 126 nails affected by nail psoriasis) were treated with PDL (6 J/cm2, 7 mm, 0.45 milliseconds) on both hands and additionally with Nd:YAG (10 J/cm² , 6 mm, 15 milliseconds) on the right hand. Three treatment sessions were applied at 4-week intervals and patients were followed up for 6 months after the last session. Disease severity was assessed using the Nail Psoriasis Severity Index, both 8- and 32-point variant. Additionally, Dermatology Life Quality Index was assessed before and after treatment.

RESULTS

Overall, there was a statistical difference in 8- and 32-point NAPSI score before and after treatment for both hands. However, there was no statistical difference between the score for the right and left hands based on both scale variants. Some aspects of patients' lives showed improvement due to the treatment.

CONCLUSIONS

Both PDL in monotherapy and combined Nd:Yag+PDL lasers are safe and effective in treatment of nail psoriasis, although combined therapy shows no advantage over the use of a single laser.

Induction of Apoptotic Temperature in Photothermal Therapy under Various Heating Conditions in Multi-Layered Skin Structure

Recently, photothermal therapy has attracted attention as an alternative treatment to conventional surgical techniques because it does not lead to bleeding and patients quickly recover after treatment compared to incisional surgery. Photothermal therapy induces tumor cell death through an increase in the temperature using the photothermal effect, which converts light energy into thermal energy. This study was conducted to perform numerical analysis based on heat transfer to induce apoptosis of tumor tissue under various heating conditions in photothermal therapy. The Monte Carlo method was applied to evaluate a multi-layered skin structure containing squamous cell carcinoma. Tissue-equivalent phantom experiments verified the numerical model. Based on the effective apoptosis retention ratio, the numerical analysis results showed the quantitative correlation for the laser intensity, volume fraction of gold nanorods injected into the tumor, and cooling time. This study reveals optimal conditions for maximizing apoptosis within tumor tissue while minimizing thermal damage to surrounding tissues under various heating conditions. This approach may be useful as a standard treatment when performing photothermal therapy.

Treatment for telangiectasias and reticular veins

BACKGROUND

Telangiectasias (spider veins) and reticular veins on the lower limbs are very common, increase with age, and have been found in 41% of women. The cause is unknown and the patients may be asymptomatic or can report pain, burning or itching. Treatments include sclerotherapy, laser, intense pulsed light, microphlebectomy and thermoablation, but none is established as preferable.

OBJECTIVES

To assess the effects of sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy treatments for telangiectasias and reticular veins.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 16 March 2021. We undertook additional searches in LILACS and IBECS databases, reference checking, and contacted specialists in the field, manufacturers and study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared treatment methods such as sclerotherapy, laser therapy, intensive pulsed light, thermocoagulation, and microphlebectomy for telangiectasias and reticular veins in the lower limb. We included studies that compared individual treatment methods against placebo, or that compared different sclerosing agents, foam or laser treatment, or that used a combination of treatment methods.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, extracted data, assessed risks of bias and assessed the certainty of evidence using GRADE. The outcomes of interest were resolution or improvement (or both) of telangiectasias, adverse events (including hyperpigmentation, matting), pain, recurrence, time to resolution, and quality of life.

MAIN RESULTS

We included 3632 participants from 35 RCTs. Studies compared a variety of sclerosing agents, laser treatment and compression. No studies investigated intensive pulsed light, thermocoagulation or microphlebectomy. None of the included studies assessed recurrence or time to resolution. Overall the risk of bias of the included studies was moderate. We downgraded the certainty of evidence to moderate or low because of clinical heterogeneity and imprecision due to the wide confidence intervals (CIs) and few participants for each comparison. Any sclerosing agent versus placebo There was moderate-certainty evidence that sclerosing agents showed more resolution or improvement of telangiectasias compared to placebo (standard mean difference (SMD) 3.08, 95% CI 2.68 to 3.48; 4 studies, 613 participants/procedures), and more frequent adverse events: hyperpigmentation (risk ratio (RR) 11.88, 95% CI 4.54 to 31.09; 3 studies, 528 participants/procedures); matting (RR 4.06, 95% CI 1.28 to 12.84; 3 studies, 528 participants/procedures). There may be more pain experienced in the sclerosing-agents group compared to placebo (SMD 0.70, 95% CI 0.06 to 1.34; 1 study, 40 participants; low-certainty evidence). Polidocanol versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.01, 95% CI -0.13 to 0.14; 7 studies, 852 participants/procedures), hyperpigmentation (RR 0.94, 95% CI 0.62 to 1.43; 6 studies, 819 participants/procedures), or matting (RR 0.82, 95% CI 0.52 to 1.27; 7 studies, 859 participants/procedures), but there were fewer cases of pain (SMD -0.26, 95% CI -0.44 to -0.08; 5 studies, 480 participants/procedures) in the polidocanol group. All moderate-certainty evidence. Sodium tetradecyl sulphate (STS) versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.07, 95% CI -0.25 to 0.11; 4 studies, 473 participants/procedures). There was more hyperpigmentation (RR 1.71, 95% CI 1.10 to 2.64; 4 studies, 478 participants/procedures), matting (RR 2.10, 95% CI 1.14 to 3.85; 2 studies, 323 participants/procedures) and probably more pain (RR 1.49, 95% CI 0.99 to 2.25; 4 studies, 409 participants/procedures). All moderate-certainty evidence. Foam versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD 0.04, 95% CI -0.26 to 0.34; 2 studies, 187 participants/procedures); hyperpigmentation (RR 2.12, 95% CI 0.44 to 10.23; 2 studies, 187 participants/procedures) or pain (SMD -0.10, 95% CI -0.44 to 0.24; 1 study, 147 participants/procedures). There may be more matting using foam (RR 6.12, 95% CI 1.04 to 35.98; 2 studies, 187 participants/procedures). All low-certainty evidence. Laser versus any sclerosing agent There was no clear difference in resolution or improvement (or both) of telangiectasias (SMD -0.09, 95% CI -0.25 to 0.07; 5 studies, 593 participants/procedures), or matting (RR 1.00, 95% CI 0.46 to 2.19; 2 studies, 162 participants/procedures), and maybe less hyperpigmentation (RR 0.57, 95% CI 0.40 to 0.80; 4 studies, 262 participants/procedures) in the laser group. All moderate-certainty evidence. High heterogeneity of the studies reporting on pain prevented pooling, and results were inconsistent (low-certainty evidence). Laser plus sclerotherapy (polidocanol) versus sclerotherapy (polidocanol) Low-certainty evidence suggests there may be more resolution or improvement (or both) of telangiectasias in the combined group (SMD 5.68, 95% CI 5.14 to 6.23; 2 studies, 710 participants), and no clear difference in hyperpigmentation (RR 0.83, 95% CI 0.35 to 1.99; 2 studies, 656 participants) or matting (RR 0.83, 95% CI 0.21 to 3.28; 2 studies, 656 participants). There may be more pain in the combined group (RR 2.44, 95% CI 1.69 to 3.55; 1 study, 596 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Small numbers of studies and participants in each comparison limited our confidence in the evidence. Sclerosing agents were more effective than placebo for resolution or improvement of telangiectasias but also caused more adverse events (moderate-certainty evidence), and may result in more pain (low-certainty evidence). There was no evidence of a benefit in resolution or improvement for any sclerosant compared to another or to laser. There may be more resolution or improvement of telangiectasias in the combined laser and polidocanol group compared to polidocanol alone (low-certainty evidence). There may be differences between treatments in adverse events and pain. Compared to other sclerosing agents polidocanol probably causes less pain; STS resulted in more hyperpigmentation, matting and probably pain; foam may cause more matting (low-certainty evidence); laser treatment may result in less hyperpigmentation (moderate-certainty evidence). Further well-designed studies are required to provide evidence for other available treatments and important outcomes (such as recurrence, time to resolution and delayed adverse events); and to improve our confidence in the identified comparisons.

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.

Photodynamic therapy using self-assembled nanogels comprising chlorin e6-bearing pullulan

With minimal invasiveness and spatiotemporal therapeutic effects, photodynamic therapy is one of the most promising candidates for cancer treatment. Here, we developed a facile self-assembled nanogel using photosensitizer-grafted polysaccharides called chlorin e6-bearing pullulan. Chlorin e6 is used as a photosensitizer in cancer therapy. The anti-cancer effect of photodynamic therapy with our nanogel system was 780 times higher than that of the commercially available photosensitizer Photofrin. Finally, we demonstrated that actively growing cancer cell spheroids can be completely suppressed after treatment. Our system could efficiently induce tumor regression in tumor xenograft mice.

Endoscopic ultrasound (EUS)-guided cylindrical interstitial laser ablation (CILA) on in vivo porcine pancreas

This study aims to demonstrate the feasibility of cylindrical interstitial laser ablation (CILA) in porcine pancreatic tissue to develop a EUS-guided PC ablation technique with enhanced safety. A diffusing applicator created a uniformly symmetrical laser ablation in pancreatic tissue. Ex vivo tests presented that both ablation thickness and volume increased linearly with the applied power (R² = 0.96 and 0.90, respectively) without carbonization and fiber degradation. The numerical simulations matched well with the experimental results in terms of temperature development and thermal damage (deviation of ≤ 15%). In vivo tests with EUS confirmed easy insertion and high durability of the diffusing applicator. EUS-guided CILA warranted a feasible therapeutic capacity of ablating in vivo pancreatic tissue. The proposed EUS-guided CILA can be a feasible therapeutic approach to treat PC with predictable thermal ablation and enhanced safety.

A pilot study on the effects of transcutaneous and transmucosal laser irradiation on blood pressure, glucose and cholesterol in women

The present pilot study had the objective to determine the effects of transcutaneous and transmucosal laser irradiation on arterial blood pressure (ABP), glucose (Glu) triglycerides (Tg), total cholesterol (Ch), high-density level cholesterol (HDL) and low-density cholesterol (LDL) immediately after treatment (T0) and after 30 (T30) and 60 (T60) days. Patients (n = 36) were selected and randomly distributed into 6 groups (n = 6/group; [G1] negative control, [G2] radial artery transcutaneous laser irradiation [G3] radial artery transcutaneous irradiation, [G4] transmucosal sublingual irradiation, [G5] transmucosal intra-nasal irradiation and [G6] extended radial artery transcutaneous irradiation). Blood exams were performed at T0, T30 and T60. Systolic and diastolic pressure results have indicated that patients' pressures ranged from 90 mmHg (P22, T30, G4) to 189 mmHg (P16, T0, G3) and 54 mmHg (P21, T60, G4) to 175 mmHg (P16, T30, G3). Levels of Glu at T30 and T60 varied from 5.53% (G1) to -5.78% (G6) and 1.21 (G2) to -8.69 (G6), respectively. Data was statistically assessed for normality and homogeneity of variances using the F-statistic and Bartlett's tests. Significant differences were determined using One-Way ANOVA and Fischer post hoc tests. Results indicated that treatments investigated can be safely used as an adjunct method to regulate blood pressure, glucose, triglycerides and cholesterol.

Adjuvant radiofrequency thermocoagulation improves the outcome of liquid sclerotherapy in the treatment of spider veins of the leg: A pilot study

OBJECTIVE

This study evaluated the effect of low-energy radiofrequency thermocoagulation added to standard liquid sclerotherapy on clinical outcomes of patients with venous insufficiency.

PATIENTS AND METHOD

We included 111 patients with spider veins CEAP/C1 stage. The patients were randomized into sclerotherapy (Group 1) and sclerotherapy + sclerotherapy immediately followed by low energy percutaneous RF thermocoagulation (Group 2) groups and followed up with same protocols prospectively.

RESULTS

The study groups did not differ in terms of the mean age, body mass index, the number of spider veins and pre-interventional venous clinical severity scores (VCSS). Patients' self-assessed satisfaction ratings of cosmetic outcomes were found to be higher compared to the baseline (p = 0.001). While both techniques caused a significant decline in VCSS at postprocedural third month, it was observed that the type of applied intervention did not affect the VCSS (p = 0.43 and p = 0.93, respectively). There was a significant difference in hyperpigmentation and trapped blood between the two groups after the procedure (p = 0.009 and p = 0.02, respectively), there was no statistically significant difference in terms of skin necrosis (p = 0.52). A significant difference in the self-assessed cosmetic outcomes was observed in patients treated with sclerotherapy followed by low energy percutaneous RF thermocoagulation compared with patients whom sclerotherapy performed alone (p = 0.001).

DISCUSSION

This study suggests that radiofrequency thermocoagulation added to the sclerotherapy provides better cosmetic outcomes with less treatment sessions and no additional complication rates.

Combination of 1,064-nm Neodymium-doped Yttrium Aluminum Garnet Laser and Steroid Tape Decreases the Total Treatment Time of Hypertrophic Scars: An Analysis of 40 Cases of Cesarean-Section Scars

BACKGROUND

The 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (Cutera, Inc., Brisbane, CA) and steroid tape (fludroxycortide tape) have been used to treat keloids and hypertrophic scars.

OBJECTIVE

To evaluate the efficacy of contact-mode 1,064-nm Nd:YAG laser therapy and steroid tape for hypertrophic cesarean-section scars versus conservative therapy (steroid tape only).

MATERIALS AND METHODS

A medical record review identified 40 consecutive Japanese patients who had hypertrophic scars (total Japan Scar Workshop Scar Scale [JSS] 2015 evaluation scores of 9 to 12) for more than 1 year after a vertical cesarean section and who were treated at our scar-specialist clinic from July 2015 to December 2017. All 40 patients continued treatment until the total JSS score dropped below 3. Recurrence was defined as a ≥1-point increase in the total JSW score 6 months after achieving a total JSS score <3.

RESULTS

The patients had a mean age of 34.2 years. The test (n = 25) and control (n = 15) groups took on average 16.9 and 24.3 months to achieve a total JSS score <3, respectively (p < .01). In the following 6 months, none of the scars recurred.

CONCLUSION

Nd:YAG laser treatment effectively decreased the total treatment time of hypertrophic cesarean-section scars. An algorithm for treating mild and severe hypertrophic cesarean-section scars is proposed.

Assessment of Effects of Laser Light Combining Three Wavelengths (450, 520 and 640 nm) on Temperature Increase and Depth of Tissue Lesions in an Ex Vivo Study

Background: Lasers are widely used in medicine in soft and hard tissue surgeries and biostimulation. Studies found in literature typically compare the effects of single-wavelength lasers on tissues or cell cultures. In our study, we used a diode laser capable of emitting three components of visible light (640 nm, red; 520 nm, green; 450 nm, blue) and combining them in a single beam. The aim of the study was to assess the effects of laser radiation in the visible spectrum on tissue in vitro, depending on the wavelength and pulse width. Methods: All irradiations were performed using the same output power (1.5 W). We used various duty cycles: 10, 50, 80 and 100% with 100 Hz frequency. Maximum superficial temperature, rate of temperature increase and lesion depth were investigated. Results: Maximum superficial temperature was observed for 450 + 520 nm irradiation (100% duty cycle). The highest rate of increase of temperature was noted for 450 + 520 nm (100% duty cycle). Maximum lesion depth was observed in case of three-wavelength irradiation (450 + 520 + 640 nm) for 100, 80 and 50% duty cycles. Conclusions: The synergistic effect of two-wavelength (450 + 520 nm) irradiation was observed in case of maximum temperature measurement. The deepest depth of lesion was noted after three-wavelength irradiation (450 + 520 + 640 nm).

Dermatologic Laser Side Effects and Complications: Prevention and Management

The evolution of modern laser and light-based systems has mirrored the demand for clinically effective treatments and the need for safer technologies with reduced postoperative recovery, side effects, and complications. With each new generation of lasers, more selective tissue destruction can be achieved with reduced unwanted sequelae. Patient selection and preparation, operator technique, and expeditious recognition and management of post-treatment side effects are paramount in avoiding complications and patient dissatisfaction. An overview of important variables to consider for dermatologic laser treatments are presented in order to provide a framework to reduce the severity and duration of possible post-treatment side effects and complications.

Molecular and Cellular Mechanisms of Arthritis in Children and Adults: New Perspectives on Applied Photobiomodulation

Juvenile idiopathic arthritis and adult rheumatoid arthritis are two major groups with chronic joint pain and inflammation, extra-articular manifestations, and high risk of comorbidities, which can cause physical and ocular disability, as well as create great socio-economic pressure worldwide. The pathogenesis of arthritis manifested in childhood and adulthood is multifactorial, unclear, and overly complex, in which immunity plays an important role. Although there are more and more biological agents with different mechanisms of action for the treatment of arthritis, the results are not as expected, because there are partial responses or non-responsive patients to these compounds, high therapeutic costs, side effects, and so on; therefore, we must turn our attention to other therapeutic modalities. Updating knowledge on molecular and cellular mechanisms in the comparative pathogenesis of chronic arthritis in both children and adults is necessary in the early and correct approach to treatment. Photobiomodulation (PBM) represents a good option, offering cost-effective advantages over drug therapy, with a quicker, more positive response to treatment and no side effects. The successful management of PBM in arthritis is based on the clinician's ability to evaluate correctly the inflammatory status of the patient, to seek the optimal solution, to choose the best technology with the best physical parameters, and to select the mode of action to target very precisely the immune system and the molecular signaling pathways at the molecular level with the exact amount of quantum light energy in order to obtain the desired immune modulation and the remission of the disease. Light is a very powerful tool in medicine because it can simultaneously target many cascades of immune system activation in comparison with drugs, so PBM can perform very delicate tasks inside our cells to modulate cellular dysfunctions, helping to initiate self-organization phenomena and finally, healing the disease. Interdisciplinary teams should work diligently to meet these needs by also using single-cell imaging devices for multispectral laser photobiomodulation on immune cells.

A new technique for the treatment of nasal telangiectasia using atmospheric plasma (voltaic arc dermabrasion): Postoperative pain assessment by thermal infrared imaging

BACKGROUND

Nasal telangiectasias are superficial, small vessels in the ala nasi and nasolabial crease with a varying origin. They represent an unaesthetic condition, frustrating patients who frequently request their removal. Microsclerotherapy, electrosurgery, different types of laser therapy, needle-assisted electrocoagulation, and TRASER therapy have been described for treating this condition.

AIMS

The aim of this study is to describe a novel technique that removes nasal telengectiasias using voltaic arc dermabrasion (VAD).

PATIENTS/METHODS

Voltaic arc dermabrasion treatment was used to remove nasal telangiectasia in 23 patients. The post-treatment condition was monitored by means of photographic records and the evaluation of erythema, pain score, patient and surgeon satisfaction, and skin temperature. The timing points were 1, 4, 6 days and 1 year after treatment.

RESULTS

Patients referred a moderate pain during the treatment that ceased at the end of the procedure. Moderate erythema and punctiform fine crusting were present in all patients that lasted until the 6th day after treatment. No other adverse effects were observed. After 1-year, the mean patient and surgeon satisfaction scores were 2.90 and 3.00 ± 0.3, respectively. A single treatment was effective in 85% of the patients and no recurrences were recorded for one year. The skin temperature increased about 18.2 ± 3.2°C during the treatment but returned to basal values in about 20 seconds in most of the patients.

CONCLUSION

Voltaic arc dermabrasion treatment is a viable, easy to use, and inexpensive tool for successful nasal telangiectasia removal, with minimal post-treatment discomfort.

State of the art on cryo-laser cryo-sclerotherapy in lower limb venous aesthetic treatment

Here we describe a combination of neodymium:yttrium-aluminium-garnet 1064-nm laser emission and injection of 75% dextrose solution to treat lower limb reticular veins. The strategy is known as cryo-laser cryo-sclerotherapy. Preliminary outcomes are reported, showing ecchymosis in up to 30% of cases and intravenous thrombus in 14%. A satisfactory vessel elimination is found in 86% of cases. No improvement or worsening was reported in 14% of patients. The paper provides technical details with the aim of promoting homogeneity in future data collection, so fostering publication of long-term effectiveness and related comparative evaluation with sclerotherapy and laser treatment alone.

Utilization of Laser Therapy During Pregnancy: A Systematic Review of the Maternal and Fetal Effects Reported From 1960 to 2017

BACKGROUND

Due to concerns regarding maternal and fetal safety and the absence of evidence to the contrary, laser treatment during pregnancy has traditionally been limited to situations of absolute necessity.

OBJECTIVE

This review seeks to examine the available evidence to determine the safety of laser therapy during pregnancy.

METHODS

Medical databases were searched for relevant reports from all specialties regarding the use of lasers during pregnancy from 1960 to 2017. A legal case review was also performed.

RESULTS

Twenty-two publications in the literature reported the use of various laser wavelengths in 380 pregnant women during all trimesters. Other than 1 case of premature rupture of membranes questionably related to the laser treatment, there were no cases of maternal or fetal morbidity or mortality, premature labor, or identifiable fetal stress.

CONCLUSION

The available evidence, limited to low evidence level case reports and series, indicates cutaneous laser treatment during pregnancy is safe for both mother and fetus. Furthermore, laser physics and optics dictate there should theoretically be no risk of fetal laser exposure from commonly used cutaneous lasers.

Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.

Safety and short-term efficacy of telangiectasia treatment by means of an innovative combination of 532 and 808 nm transdermal diode laser

Objectives

To evaluate the safety and efficacy of an innovative transdermal multiple wavelength diode laser in telangiectasia treatment.

Methods

A total of 94 females underwent treatment by means of a multiple wavelength laser. All the cases were treated by three cycles of 532 nm combined with simultaneous 808 nm pulse. OFF time between the cycles was 10 ms. The handling physician, the patient and a blind assessor scored the aesthetic outcome in a range from 0 (no change) to 10 (100% disappearance). Pain was scored from 0 (no pain) to 10 (most painful experience ever) by the patient.

Results

At 5 ± 1 months, depigmentation was observed in 3/94 cases (3.2%), hyperpigmentation in (4/94 4.2%), transient erythema in 14/94 (14.9%), transient oedema in 11/94 (11.7%), matting in 1/94 (1.1%). Mean aesthetic outcome was scored as 7.9 ± 1.3 by the physician, 7.7 ± 1 by the independent assessor and 7.2 ± 2.4 by the patient. Patients reported a mean peri-procedural pain of 3.4 ± 1.5.

Conclusions

The simultaneous application of 532 nm and 808 nm laser emission is safe and effective in 0.1–1 mm telangiectasia treatment. The present investigation provides data for a deeper insight into the biology of the tissue photo-modulation.

Bi2Se3 nanoplates for contrast-enhanced photoacoustic imaging at 1064 nm

Photoacoustic (PA) imaging is a high-resolution biomedical imaging modality, which can be used to visualize biological tissues located beyond the limited penetration depth of existing optical imaging techniques. An optical wavelength of 1064 nm is of great interest in PA imaging due to low intrinsic absorption at this wavelength. Reduced absorption implies an increased depth of imaging, which enables several new clinical applications such as bladder imaging, gastrointestinal (GI) imaging, and sentinel lymph node (SLN) imaging. In addition, a 1064 nm Nd:YAG laser system enables a high power, cost-effective, and compact laser-based PA imaging system. However, at this wavelength, due to low intrinsic contrast, high absorption exogenous PA contrast agents are necessary for imaging. To this end, we present new Bi2Se3 nanoplates as PA contrast agents at 1064 nm wavelength for PA imaging. We successfully synthesized Bi2Se3 nanoplates and they exhibited relatively strong PA signals at 1064 nm. We confirmed the increased imaging depth of penetration by imaging the Bi2Se3-containing tube located 4.6 cm deep in biological tissues. We present in vivo PA imaging of the bladder, GI tract, and SLN in mice using a Bi2Se3 contrast agent establishing the clinical feasibility of these agents with a clinical photoacoustic/ultrasound imaging system. Our results confirm that Bi2Se3 nanoplates are promising PA contrast agents at 1064 nm that offer a high optical absorbance in the second NIR region providing a high contrast imaging and increased depth of penetration.

Three Hundred Patients Treated with Ultrapulsed 980 nm Diode Laser for Skin Disorders

The use of lasers in skin diseases is quite common. In contrast to other laser types, medical literature about 980 nm ultrapulsed diode laser is sparse in dermatology. Herein, we report the use of ultrapulsed diode 980 nm laser in 300 patients with vascular lesions, cysts and pseudocysts, infectious disease, and malignant tumors. This laser is a versatile tool with excellent safety and efficacy in the hands of the experienced user.

Leg Rejuvenation: A Combination Approach: A Review and Our Experience

BACKGROUND

Patients increasingly seek to enhance the appearance of their legs. Elimination of unwanted leg veins, reduction of epidermal photo-aging changes such as solar lentigines and keratoses, tightening of skin laxity and reduction of adipose tissue are among the most commonly requested goals. Many patients require a combination approach to address their concerns. It is important for dermatologists to be aware of the multitude of procedures that can be performed, often in combination, to rejuvenate the leg.

OBJECTIVE

The purpose of this review article was to discuss procedures for improving the appearance of the leg and to share the authors experience, especially in the combination approach to leg rejuvenation.

METHODS

A literature search was performed to investigate cosmetic procedures being performed on the leg, with an emphasis on controlled or randomized studies. In addition, the authors contributed their personal experience.

RESULTS

Our discussion of the literature review highlights the treatments for leg veins, unwanted fat, cellulite, and photodamage of the legs that are most supported in peer-reviewed publications.

CONCLUSION

A synergistic, combination approach to leg rejuvenation works best. This includes the use of injectable agents, energy-based devices, and more invasive surgical procedures.

The role of lasers and intense pulsed light technology in dermatology

The role of light-based technologies in dermatology has expanded dramatically in recent years. Lasers and intense pulsed light have been used to safely and effectively treat a diverse array of cutaneous conditions, including vascular and pigmented lesions, tattoos, scars, and undesired hair, while also providing extensive therapeutic options for cosmetic rejuvenation and other dermatologic conditions. Dermatologic laser procedures are becoming increasingly popular worldwide, and demand for them has fueled new innovations and clinical applications. These systems continue to evolve and provide enhanced therapeutic outcomes with improved safety profiles. This review highlights the important roles and varied clinical applications that lasers and intense pulsed light play in the dermatologic practice.

Guidelines of care for vascular lasers and intense pulse light sources from the European Society for Laser Dermatology

AIM

Lasers and non-coherent intense pulse light sources (IPLS) are based on the principle of selective photothermolysis and can be used for the treatment of many vascular skin lesions. A variety of lasers has been developed for the treatment of congenital and acquired vascular lesions which incorporate these concepts into their design. Although laser and light sources are very popular due to their non-invasive nature, caution should be considered by practitioners and patients to avoid permanent side-effects. The aim of these guidelines is to give evidence-based recommendations for the use of lasers and IPLS in the treatment of vascular lesions.

METHODS

These guidelines were produced by a Consensus Panel made up of experts in the field of vascular laser surgery under the auspices of the European Society of Laser Dermatology. Recommendations on the use of vascular lasers and IPLS were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

RESULTS

Lasers and IPLS are very useful and sometimes the only available method to treat various vascular lesions. It is of a paramount importance that the type of laser or IPLS and their specific parameters are adapted to the indication but also that the treating physician is familiar with the device to be used. The crucial issue in treating vascular lesions is to recognize the immediate end-point after laser treatment. This is the single most important factor to ensure both the efficacy of the treatment and avoidance of serious side-effects.

[Therapeutic indications for percutaneous laser in patients with vascular malformations and tumors]

Lasers are increasingly used to treat vascular abnormalities. Indeed, this technique is non-invasive and allows a specific treatment. The aim of this review is to present some biophysical principles of the lasers, to describe the different sorts of lasers available for treatment in vascular medicine indications. Three principal lasers exist in vascular medicine: the pulsed-dye laser, for the treatment of superficial pink lesions, the NdYAG-KTP laser for purple and bigger lesions, and the NdYAG long pulse laser for even deeper and bigger vascular lesions. In vascular malformations, port wine stains can also be treated by pulsed-dye laser, KTP or NdYAG when they are old and thick. Telangiectasias are good indications for the three sorts of lasers, depending on their depth, color and size. Microcystic lymphatic malformations can be improved by laser treatment. Arterio-venous malformations constitute a contraindication of laser treatment. In vascular tumors, involuted infantile hemangiomas constitute an excellent indication of pulsed-dye laser treatment. Controlled studies are necessary to evaluate and to compare the efficacy of each laser, in order to determine their optimal indications and optimal parameters for each machine.

Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial

BACKGROUND

Telangiectasias of the lower extremities are very common. There are no blinded, randomized, controlled clinical trials comparing laser modalities with the gold standard sclerotherapy, while the few available studies encompass small patients cohorts.

OBJECTIVE

This prospective, randomized, open-label trial compares the efficacy of sclerotherapy with polidocanol vs. long-pulsed neodymium-doped yttrium aluminium garnet (Nd:YAG) laser in the treatment of leg telangiectasias.

PATIENTS AND METHODS

Fifty-six female patients with primary leg telangiectasias and reticular veins (C1A or SEpAS1PN) were included in the study. One leg was randomly assigned to get treatment with the multiple synchronized long-pulsed Nd:YAG laser, while the other received foam sclerotherapy with polidocanol 0.5%. The patients were treated in two sessions at intervals of 6 weeks. The patients were evaluated by the handling physician after 6 weeks and 6 months. Two investigators assessed blindly at the end of the study the photographs for clearing of the vessels using a six-point scale from 1 (no change) to 6 (100% cleared). Patients reported about pain sensation and outcome satisfaction.

RESULTS

According to the handling dermatologist, at the last follow-up, there was an improvement of 30-40% with a median of 3 (IQR 2) and a good improvement of 50-70% with a median of 4 (IQR 2) after laser treatment and sclerotherapy respectively. In contrast, according to the blinded investigators, there was a median of 5 (IQR 1) with a very good improvement of >70% after both therapies. Improvement was achieved more quickly by sclerotherapy, although at the last follow-up visit there was no difference in clearance between the two groups as assessed by the blinded experts (P-value 0.84). The degree of patient's satisfaction was very good and similar with both therapeutic approaches. There was a significant difference (P-value 0.003) regarding pain perception between the types of therapy. Laser was felt more painful than sclerotherapy.

CONCLUSION

Telangiectasias of the lower extremities can be successfully treated with either synchronized long-pulsed Nd:YAG laser or sclerotherapy. The 1064-nm long-pulsed Nd:YAG laser is associated with more pain and is suitable especially in case of needle phobia, allergy to sclerosants and in presence of small veins with telangiectatic matting, while sclerotherapy can also treat the feeder veins.

Ins and outs of endovenous laser ablation: afterthoughts

Physicists and medical doctors "speak" different languages. Endovenous laser ablation (EVLA) is a good example in which technology is essential to guide the doctor to the final result: optimal treatment. However, for the doctor, it is by far insufficient just to turn on the knobs of the laser. He should understand what is going on in the varicose vein. On the other hand, the physicist is usually not aware what problems the doctor finds on his road towards improving a new technique. We have tried to bring both languages together in the special on Ins and outs of endovenous laser ablation published in this issue of Lasers in Medical Science. The 13 articles include endovenous related clinical (de Roos 2014; Kockaert and Nijsten 2014; van den Bos and Proebstle 2014) and socioeconomical articles (Kelleher et al 2014), the first paper on the molecular pathophysiologic mechanisms (Heger et al 2014), fiber tips (Stokbroekx et al 2014), the future of EVLA (Rabe 2014), a review of EVLA with some important issues for debate (Malskat et al 2014), an excellent paper on transcutaneous laser therapies of spider and small varicose veins (Meesters et al 2014), as well as several scientific modeling articles, varying from a mathematical model of EVLA that includes the carbonized blood layer on the fiber tip (van Ruijven et al 2014) and its application to the simulation of clinical conditions (Poluektova et al 2014) via experimental measurements of temperature profiles in response to EVLA, radiofrequency waves, and steam injections (Malskat et al 2014) to a literature review and novel physics approach of the absorption and particularly scattering properties of whole blood also including the infrared wavelengths used by EVLA (Bosschaart et al 2014). The aim of our afterthoughts, the 14th article in this special, is to try to amalgamate the clinical and physical contents of these contributions, providing the reader with the bridge that overlaps these different backgrounds.