Long-pulsed neodymium:yttrium-aluminum-garnet laser treatment for port-wine stains

532-nm potassium titanyl-phosphate laser versus 595-nm pulsed dye laser for port-wine birthmarks: A prospective, randomized, split-side study

BACKGROUND

Pulsed dye lasers (PDL) are currently the first-line treatment of port-wine birthmarks (PWB). Due to high maintenance costs and instable technology, alternative methods are needed.

OBJECTIVES

To compare clinical outcomes of a variable-sequenced, long-pulsed 532-nm potassium titanyl-phosphate (KTP) laser and PDL on treating PWB.

METHODS

A prospective, randomized, split-side study. Patients were treated with a KTP laser and PDL with 1 to 5 sessions at intervals of 6-8 weeks. A follow-up visit was scheduled 6 weeks post-treatment. Efficacy was evaluated through colorimetric analysis, area reduction measurements and clinical evaluations by two blinded investigators based on photo documentation. Subjects provided rating of pain intensity during treatment, post-treatment reactions and satisfaction. Safety was measured by adverse events. Maintenance issues of the laser systems were documented.

RESULTS

A total of 35 patients (mean age 42.1 years) were enrolled. 63% were female. Patients received 2.4 (SD 1.4; 1-5) treatment sessions. Colorimetric analysis indicated a comparable clearance effect in PWB of both KTP laser and PDL. Independent investigators rated clinical appearance to be significantly improved compared to baseline. No significant difference was observed between both laser systems. Regarding post-treatment reactions, the KTP laser caused less swelling, purpura and crusts. 96% would recommend both treatment modalities. Patients were satisfied with both laser systems. During the study, PDL systems malfunctioned for 6.6 months in total. For the KTP laser, we did not observe any system failures.

CONCLUSION

Our data indicate that the KTP laser of the latest generation with large-spot sizes, subpulse technology and cryogen cooling has a comparable efficacy to the PDL in treating PWB. In addition, KTP laser is associated with greater tolerability, fewer technical failures and lower repair costs. Further prospective studies are required to determine the true effectiveness of the KTP laser in PWB treatment. This study was preregistered in Clinicaltrials.gov (NCT05771298).

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.

Experimental study of combined photodynamic and photothermal therapy in the treatment of port wine stain

Laser therapy has become the golden standard of port wine stain (PWS), but complete clearance of resistant PWSs is still difficult. The application of photodynamic therapy (PDT) in the treatment of PWS shows potential in clinical practice, especially for large-area and deep lesions. In this work, in vivo animal experimental investigation on the coupling effect of PDT with multi-pulse laser (MPL) irradiation on the treatment of PWS was conducted by using a dorsal skin window chamber model. Through visualization of the thermal response of blood vessels and damage evaluation, it is found that the combination of PDT with MPL results in 96.2% more vascular injury than PDT alone and 90% more than MPL alone, thus reducing side effects such as purpura after treatment. The combined therapy also has the benefit of large treatment area, uniform fading effect, shortened light duration, and reduced photosensitizer admit.

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.

Efficacy Evaluation of 755-nm Long-Pulse Alexandrite Laser Combined with 0.5% Timolol Maleate Eye Drops in the Treatment of Thicker Infantile Hemangioma

Purpose

Assessment of the clinical effectiveness and safety of 755-nm long-pulse alexandrite laser combined with 0.5% timolol maleate eye drops in treating thicker infantile hemangioma (IH).

Materials and Methods

Retrospective analysis of IH treated with 755-nm long-pulse alexandrite laser and topical timolol in the Second Affiliated Hospital of Wenzhou Medical University from October 2019 to October 2020. Seventy-eight cases were included, with a five-week laser treatment interval. Treatment status was documented during the 35 weeks before each treatment, the effect was assessed at the visual analog scale (VAS), and side effects were recorded. During the 6-month follow-up period, the recurrence and residual skin lesions were monitored. The relationship between IH thickness, treatment duration and VAS was analyzed.

Results

Among the 78 children with hemangioma, 4 children were treated with a combination of propranolol, fractional laser and cinnamyl alcohol injection due to poor curative effect. Finally, the lesions were effectively alleviated. At the 5th, 15th, 25th, and 35th weeks of treatment, the average VAS of 74 children were 3.56 ± 1.20, 4.61 ± 1.43, 5.63 ± 1.60, and 6.63 ± 1.72, respectively. We analyzed VAS in different thickness groups with Repeated Measures Analysis of Variance(RMANOVA). The results show that the VAS of the thickness 2–3 mm and 3–5mm groups were higher than the 5–7mm and 7–8mm groups (F _group = 440.54, P <0.05, F _time = 448.31, P <0.05). During the 6-month follow-up period, none of the 74 children relapsed and the residual skin lesions gradually vanished.

Conclusion

Combined treatment of IHs with a 755-nm long-pulse alexandrite laser and 0.5% timolol maleate eye drops which has apparent clinical efficacy and safety reduce residual skin lesions and decrease the IH recurrence rate.

Vascular damage mechanism and parameter optimization under alexandrite laser irradiation: a theoretical study

The 755-nm Alexandrite Laser has a good clinical effect in treating resistant port wine stain, without causing thermal damage of normal tissue and side effects such as purpura. However, little is known about the mechanism of vascular damage induced by 755-nm laser irradiation, which restricts the optimization of laser parameters. In this work, the thermal damage model and the pressure damage model were used to study the damage mechanism of 755-nm laser irradiation on vessels, and the incident energy density and pulse width required for vascular damage were determined according to the damage mode. Under the irradiation of 755-nm laser, the vascular injury pattern was the co-occurrence of vessel rupture and vessel constriction, and the energy density required for the treatment of vessels with a diameter of 200 μm to reach the damage threshold was the lowest.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

Review registration number PROSPERO database: CRD42020199445.

Supplementary Information

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

Does Double-Pass Pulsed-Dye Laser With Long and Short Pulse Duration Increase Treatment Efficacy of Port-Wine Stain? A Randomized Clinical Trial

BACKGROUND

Although pulsed-dye laser (PDL) 595 nm is known as the gold standard for treatment of port-wine stains (PWS), complete clearance of lesions occurs in a minority of cases.

OBJECTIVE

To compare the efficacy and safety of double-pass pulsed-dye laser (DPL), long pulse duration (20 m/s) followed by short pulse duration (1.5 m/s) within 20 minutes interval, with single-pass pulsed-dye laser (SPL) for (1.5 m/s) in the treatment of PWS.

METHODS

Twenty-four patients with PWS underwent 3 sessions of PDL. Each lesion was randomly divided into 2 portions to receive DPL or SPL. Colorimetric and dermoscopic evaluations were used to determine the response objectively. In addition, improvement was scored subjectively using the visual analog scale (VAS).

RESULTS

According to colorimetric analysis, the mean blanching rates for DPL and SPL treated sites were 48% (SD = 0.215) and 37% (SD = 0.213), respectively (p = .001). With VAS, 3.79 (SD = 0.93) and 3.33 (SD = 0.91) improvement scores were reported in the DPL and SPL treated areas, respectively (p = .008). Dermoscopic images showed that larger deep vessels were the most common remnant vessels in both treatment areas.

CONCLUSION

Compared with SPL, DPL with 20 minutes interval seems to be a more effective and safe method for the treatment of PWS.

Blue Laser (450 nm) in the Treatment of Port Wine Stains and Telangiectasia

This study aimed to test a blue light source for the treatment of port wine stains (PWS) and telangiectasia and to compare this with the application of green and yellow lasers based on data in the literature. A total of 22 patients with PWS were treated with radiation from a novel, high-power 450 nm blue laser that was created for this project. The group contained 15 patients with red PWS and 7 with pink PWS. The best results were achieved for red PWS, using 15–20 ms light pulses and 47 W power. For patients with pink malformations, the results were unsatisfactory. The group with telangiectasia consisted of six patients with facial lesions and three with leg lesions. The recovery was completed for all patients with facial telangiectasia, while the blue laser therapy was ineffective for patients with leg telangiectasia. This study shows that, in some cases, the use of a blue laser may be an alternative to the use of green and yellow lasers.

Light-based treatment of pediatric port-wine birthmarks

Port-wine birthmarks (PWBs) are progressive vascular malformations with significant disfigurement and psychosocial morbidity; early light-based treatment has shown improved outcomes in the pediatric population. Somatic mosaic mutations underly the progressive nature of PWBs and explain the significant differences in response and heterogeneity of vessel architecture in the pediatric population when compared to the adult cohort. Here, we summarize a review of pediatric specific literature on the various light-based treatment modalities, including pulsed dye laser, near-infrared lasers, and intense pulsed light, providing the various indications, tips, advantages, and disadvantages for the pediatric dermatologist.

Combination therapy of oral propranolol and combined Nd:YAG/pulsed dye laser therapy in infantile hemangiomas: a retrospective analysis of 48 treated hemangiomas in 30 children

BACKGROUND AND AIMS

Infantile hemangiomas can be successfully treated by both systemic propranolol and neodymium:YAG (Nd:YAG)-dye laser combination therapy. In this retrospective study, the efficacy and safety of sequential and parallel therapy of complicated hemangiomas treated with both methods were evaluated.

PATIENTS AND METHODS

30 children with 48 complicated hemangiomas were treated with propranolol and Nd:YAG-dye laser combination therapy. Using photo comparison, the percentage remission rate was evaluated by three investigators on a four-step scale (I: 0-25 %, II: 26-50 %, III: 51-75 % and IV: 76-100 %).

RESULTS

Eleven children received propranolol and laser therapy in parallel (A), twelve children received laser therapy after propranolol (B) and seven children received propranolol after laser therapy (C). Due to emigration abroad, one child was lost to follow-up. A strong improvement (IV) was observed in 23/29 (79.3 %) of all treated children (A: 90.9 %, B 75 %, C 66.7 %). The mean duration of propranolol therapy in all children was 8.6 months (A: 8.9 months, B: 8.2 months, C: 8.9 months). On average, 2.33 laser treatments were performed per hemangioma (A: 1.95, B: 3.2, C: 1.91). Serious side effects caused by propranolol and laser therapy were not observed.

CONCLUSIONS

Propranolol and Nd:YAG-dye laser combination therapy can be used sequentially or in parallel safely and effectively. They complement each other in a meaningful manner.

Clinical outcome measures and scoring systems used in prospective studies of port wine stains: A systematic review

BACKGROUND

Valid and reliable outcome measures are needed to determine and compare treatment results of port wine stain (PWS) studies. Besides, uniformity in outcome measures is crucial to enable inter-study comparisons and meta-analyses. This study aimed to assess the heterogeneity in reported PWS outcome measures by mapping the (clinical) outcome measures currently used in prospective PWS studies.

METHODS

OVID MEDLINE, OVID Embase, and CENTRAL were searched for prospective PWS studies published from 2005 to May 2020. Interventional studies with a clinical efficacy assessment were included. Two reviewers independently evaluated methodological quality using a modified Downs and Black checklist.

RESULTS

In total, 85 studies comprising 3,310 patients were included in which 94 clinician/observer-reported clinical efficacy assessments had been performed using 46 different scoring systems. Eighty-one- studies employed a global assessment of PWS appearance/improvement, of which -82% was expressed as percentage improvement and categorized in 26 different scoring systems. A wide variety of other global and multi-item scoring systems was identified. As a result of outcome heterogeneity and insufficient data reporting, only 44% of studies could be directly compared. A minority of studies included patient-reported or objective outcomes. Thirteen studies of good quality were found.

CONCLUSION

Clinical PWS outcomes are highly heterogeneous, which hampers study comparisons and meta-analyses. Consensus-based development of a core outcome-set would benefit future research and clinical practice, especially considering the lack of high-quality trials.

Thermal coagulum formation and hemostasis during repeated multipulse Nd:YAG laser treatment of cutaneous vascular lesions: animal experiment study

Laser therapy has been widely used to treat port-wine stain (PWS) and other cutaneous vascular lesions via selective photothermolysis. High incident laser fluence is always prohibited in clinic to prevent the thermal damage in normal skin tissue, leading to insufficient energy deposition on the target blood vessel and incomplete clearance of PWS lesion. In this study, repeated multipulse laser (RMPL) irradiation was proposed to induce acute thermal damage to target blood vessels with low incident fluence (40 J/cm² for 1064-nm Nd:YAG laser). The feasibility of the method was investigated using animal models. Repeated multipulse irradiation cycles with 10-min intervals were performed in RMPL. A hamster dorsal skin chamber model with a visualization system was constructed to investigate the instant generation of thermal coagulum and relevant hemostasis by thrombus formation during and after irradiation under 1064 nm Nd:YAG single multipulse laser (SMPL) and RMPL irradiation. The diameter of the target blood vessel and the size of thermal coagula were measured before and after laser irradiation. The reflectance spectra of the dorsal skin were measured by a reflectance spectrometer during RMPL. Stasis thermal coagula that clogged the vessel lumen were generated during SMPL irradiation with low incident fluence. However, there was no acute thermal damage of blood vessels. Reflectance spectra measurement showed that the generation of thermal coagula and subsequent thrombus formation increases blood absorption by more than 10% within the first 10 min after laser irradiation. Acute vessel thermal damage could be induced in the target blood vessel by RMPL with low incident fluence of 40 J/cm². Compared with our previous SMPL study, nearly 30% reduction in incident laser fluence was achieved by RMPL. Low fluence RMPL may be a promising approach to improve the therapeutic outcome for patients with cutaneous vascular lesions by improving energy deposition on the target blood vessel.

Experimental investigations on thermal effects of a long-pulse alexandrite laser on blood vessels and its comparison with pulsed dye and Nd:YAG lasers

Laser has been widely used in the treatment of vascular skin diseases, such as port wine stain, due to the effect of selective photothermolysis in laser on biological tissue. The 755 nm alexandrite laser was expected to achieve better curative effect than the commonly used 585 or 595 nm pulsed dye laser (PDL) because of its deeper tissue penetration. In this study, the dorsal chamber model and microscopic visualization system were used to observe morphology changes on 42 blood vessels before and after irradiation with the 755 nm laser. Results showed that thermal effects of blood vessels intensified with the increase in energy, and high energy was required to produce the same thermal effect as the extension of pulse width. Different from 595 and 1064 nm lasers, partial vessel contraction was dominant thermal effect caused by the 755 nm laser. The bleeding injury rate and thermal effect of the 755 nm laser were between those of 595 nm PDL and 1064 nm Nd:YAG laser. The simulation results proved that 595 nm PDLs were effective for small and shallow target blood vessels. The 755 nm alexandrite lasers were effective in the treatment of hypertrophic and resistant blood vessels to PDL in the skin with low or moderate melanin concentration. The 1064 nm Nd:YAG laser was effective in the treatment of deeply buried and enlarged target blood vessels in the skin with high melanin concentration. The simulation results were supported by published clinical observations.

Retrospective study of photodynamic therapy for pulsed dye laser-resistant port-wine stains

Pulsed dye laser-resistant port-wine stains present a therapeutic challenge. The aim of this study was to evaluate the efficacy and safety of photodynamic therapy for treating these lesions. A total of 67 patients with pulsed dye laser-resistant cervicofacial port-wine stains were retrospectively assessed after undergoing photodynamic therapy mediated with a combination of hemoporfin and 532-nm light. For objective evaluation of photodynamic therapy efficacy, first, the colorimetric changes in the port-wine stain lesions were evaluated according to the L*a*b* color coordinate system, then the values of color changes (ΔE) and blanching rate were calculated. For subjective evaluation of improvement, photographs taken before and after photodynamic therapy were evaluated by three independent assessors blindly. Patient satisfaction was also used as a factor in the subjective evaluation. Adverse events were recorded after treatment. The median ΔE decreased significantly from the pretreatment value of 13.42 to 9.90 at the 2-month follow up (P < 0.001). The median blanching rate of port-wine stains was 28.04% after an average of 1.21 sessions of photodynamic therapy. Based on the overall visual assessment, 46.2% patients showed excellent or good levels of improvement (>50% color blanching). Adverse events were minimal, transient and self-limiting. In conclusion, photodynamic therapy serves as an alternative means to treat pulsed dye laser-resistant port-wine stains.

Combination of Sclerotherapy and Dual-Wavelength Laser in the Management of Infantile Hemangiomas in Chinese Infants

OBJECTIVE

To evaluate the efficacy and safety of combination therapy with sclerotherapy and dual-wavelength pulsed dye laser (PDL) & Nd:YAG for infantile hemangiomas (IHs).

PATIENTS AND METHODS

Fifty-nine patients with IH received treatment with sclerotherapy and dual-wavelength PDL & Nd:YAG treatment at 4-week intervals. Observers assessed the size and color of IH using a size rating scale and color rating scale before and after treatments.

RESULTS

The study showed that IH improved significantly after several sessions of treatment. Sclerotherapy reduced the size of IH, whereas dual-wavelength laser lightened the color of IH. No serious adverse effects occurred.

CONCLUSION

Combined sclerotherapy and dual-wavelength laser treatment is an effective and safe option for IH.

Current treatment and management of infantile hemangiomas

Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.

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.

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.

Nd:YAG and pulsed dye laser therapy in infantile haemangiomas: a retrospective analysis of 271 treated haemangiomas in 149 children

BACKGROUND

Infantile haemangiomas (IH) are common benign tumours in infancy. Most IH resolve spontaneously, but some require treatment due to ulceration, functional impairment or cosmetic disfiguration. While systemic propranolol is effective in many cases, laser therapy may be a safe topical alternative.

OBJECTIVE

To assess the efficacy of combined Nd:YAG/pulsed dye laser (PDL) or PDL alone for therapy of IH.

PATIENTS AND METHODS

A total of 271 IH in 149 infants were treated with combined Nd:YAG/PDL or PDL alone. Based on photographs before and 4-6 weeks after the last treatment, the results were evaluated independently by three physicians. Remissions were categorized as 0-25% (I), 26-50% (II), 51-75% (III) and 76-100% (IV).

RESULTS

In total, 472 laser treatments were performed. In 137 of 149 infants (91.9%) laser therapy was performed during a short sevoflurane mask anaesthesia, while 12 of 149 infants (8.1%) received topical anaesthetic gel. Combined Nd:YAG/PDL was applied in 187 of 271 IH (69.0%), while PDL alone in 84 of 271 IH (31.0%). On average, 1.74 treatments per IH were necessary (Nd:YAG/PDL: 1.95, PDL: 1.26). Moderate or strong (III/IV) improvement was observed in 92.4% of all IH treated. No serious adverse effects were observed.

CONCLUSION

Combined Nd:YAG/PDL therapy is an effective and well-tolerated local treatment option for IH of any classification, in any phase of development and at any age. With regard to the systemic use of propranolol, combined Nd:YAG/PDL therapy seems a safe and promising alternative in many cases.

Split lesion randomized comparative study between long pulsed Nd:YAG laser 532 and 1,064 nm in treatment of facial port-wine stain

BACKGROUND

Lasers have been the treatment of choice for Port-wine stain (PWS). However, only one type of laser is not a panacea for all PWS malformations. This is may be due to the great heterogeneity of phenotypic presentation of this congenital anomaly as color, depth, and the site of the lesion. For the treatment of PWS, flash lamp-pumped pulsed dye laser, carbon dioxide, argon, krypton, copper bromide, frequency-doubled neodymium:yttrium-aluminum-garnet (Nd:YAG), and also intense pulsed light sources can be used.

OBJECTIVES

To assess and compare the effectiveness of wavelength 532 and 1,064 nanometers (nm) long pulse Nd:YAG laser in the treatment of facial port-wine stain.

PATIENTS AND METHODS

This was a comparative therapeutic study for the treatment of facial port-wine stain. We divided the lesion into two halves, medial and lateral, and then each half was treated by 532 or 1,064 nm Nd:YAG. The sessions were done every 4 weeks for six sessions and follow-up after 3 months, then assess the response before and after the sessions and at the end follow-up period objectively (degree of improvement, Photo comparison) and subjectively (Patient satisfaction).

RESULTS

Fourteen out of nineteen patients completed all sessions of the treatment, and the other five patients were defaulted from the study due to different causes, including marriage, poor compliance for treatment, and for unknown causes. They were 13 (92.85%) females and 1 (7.15%) male. The mean age of patients was 22.07 ± 9.003 years (range 8-44 years). Three patients (21.4%) were Fitzpatrick's skin type III and four patients (78.6%) were typed IV. There was no hypertrophy in any of the lesions. All facial PWSs lie along the distribution of the trigeminal nerve. Four patients (28.6%) have V1 (ophthalmic), 12 patients (85.7%) have V2 (maxillary), and 9 (64.3%) have V3 (mandibular). The color of PWSs was pink-red in eight patients (57.1%), dark-red in four patients (28.6%), and purple-dark two patients (14.3%). The improvement score for the halves of the PWS treated with long pulsed Nd:YAG 532 nm were: failure = 0%, mild = 14.3%, moderate = 28.6%, good = 28.6%, excellent = 28.6%, while the score for long pulsed Nd:YAG 1,064 nm were: failure = 7.1%, mild = 85.7%, moderate = 7.1%, good = 0%, excellent = 0%. There are highly significant differences between the two parameters (P-value = <0.001). The visual analog scale regarding the halves of PWS treated by long pulsed Nd:YAG 532 nm before the treatment was 5.00 ± 0.96 and after treatment was 2.28 ± 1.43. There is a highly significant difference between the two scores (P-value <0.001). The visual analog scale for the halves of PWS before the use of long pulsed Nd:YAG 1,064 nm was 5.14 ± 0.77 and after treatment was 3.71 ± 0.82. There is a highly significant difference between the two scores (P-value <0.001). At the end of follow-up period, mean score ± SD for 532 nm was 2.28 ± 1.43 and for 1,064 nm was 3.71 ± 0.82. There is a highly significant difference in both wavelengths, when compared with scores for each before the treatment. In comparison, between 532 and 1,064 nm, the difference in the visual analog scale for 532 nm before and at the end of the follow-up period was 2.7143 ± 1.069, while for 1,064 nm was 1.4286 ± 0.513. There is a highly significant difference between the two wavelengths (P-value <0.001). The mean score for the satisfaction of long pulsed Nd:YAG 532 nm was 76 ± 23, while for 1,064 nm was 33 ± 8, so there is a highly significant difference between the two parameters (P-value = <0.001). None of the patients showed recurrence, scar, or hyperpigmentation after 3 months of the last treatment session. One patient developed hyperpigmentation that resolved with hydroquinone cream 4% and no scarring was seen at the end of follow-up period.

CONCLUSIONS

The long pulsed Nd:YAG laser 532 nm is more effective in the treatment of superficial bright red facial PWSs than the long pulse Nd:YAG 1,064 nm. More treatment sessions may lead to better clearance of the lesions. The use of non-invasive imaging technique such as dermoscopy, skin analyzer likes spatial frequency domain imaging (SFDI) device, or confocal microscopy to assess the level of malformations and the changes before and after the treatment with each type can give a clearer view of tissue response to laser irradiation. Lasers Surg. Med. 48:852-858, 2016. © 2016 Wiley Periodicals, Inc.

Efficacy of a Novel Optimized Pulsed Light Source (MaxG) for the Treatment of Facial Vascular Lesions

BACKGROUND AND OBJECTIVE

Facial vascular malformations can cause a number of functional problems, including difficulties in breathing, eating, speech, and mobility. Psychological problems can also arise due to the possible unpleasant appearance of such lesions. Further, these lesions can lead to a number of complications, including pain, ulceration, infection, and significant bleeding. Many treatments have been proposed in the literature. Laser therapy (and its related treatments by non-coherent light sources) is now considered the gold standard in the treatment of the majority of vascular lesions.

METHODS

Here, we present our experience with a novel optimized pulsed light source for the treatment of vascular anomalies. In this prospective study, we evaluate the clinical outcomes of 30 patients treated with this method.

RESULTS

Our results confirm the efficacy and safety of this treatment for facial vascular lesions.

CONCLUSIONS

Based on our experience and results, we believe this device could be considered as both an alternative monotherapy and a useful adjunctive to the already existing laser instruments.

Why do port-wine stains (PWS) on the lateral face respond better to pulsed dye laser (PDL) than those located on the central face?

BACKGROUND

After pulsed dye laser (PDL) treatment, facial lateral port-wine stains (PWS) clear quicker and more completely than central PWS do.

OBJECTIVE

We sought to investigate whether the difference in the efficacy of the treatment between central and lateral facial PWS was related to different histologic manifestations.

METHOD

Thirteen patients with PWS had biopsies and underwent PDL treatments in both central and lateral areas of the face. The hypothesis was tested by correlating the PWS response to PDL with the depth and diameter of the PWS vessels. The clinical efficacy was assessed by chromameter 2 months after the final PDL treatment, whereas diameter and depth of PWS vessels were measured in biopsy specimens.

RESULTS

All patients were treated on central and lateral facial sites. The chromameter evaluation showed that the average blanching rate was 34.01% and 8.68% for lateral and central facial sites, respectively (P < .05), which suggests a better response to PDL treatment in the lateral than in the central area. Histologic manifestations showed that vessels in the lateral regions were primarily located in the papillary dermis, whereas in the central regions they were extensively distributed from the dermis into the subcutaneous tissue.

LIMITATIONS

The small number of cases included in this study and the lack of follow-up longer than 2 months constitute limitations.

CONCLUSION

Lateral facial PWS respond better to PDL than PWS located in the central face. Differences in vessel location and diameter may be responsible for the variations in PWS response to PDL.

Angiokeratoma of Fordyce response to long pulsed Nd:YAG laser treatment

Angiokeratoma of Fordyce can be easily diagnosed by their typical erythra and cured by varied therapeutic methods including surgery, electrocoagulation, cryotherapy, or various laser systems. Which are the optimal therapeutic methods? There are no consentaneous opinions in the reported articles. We present our characteristic treatment with the application of long pulsed neodymium-dopedyttrium-aluminum-garne (lpNd:YAG) laser in the treatment of angiokeratoma of Fordyce. A 1064 nm lpNd:YAG laser (spot size: 5 mm/7 mm, energy:90-130 J/cm(2) , and pulse duration: 10-20 ms.) was used to treat the patient's lesions. The desirable clinical endpoint of the treatment was lesions shrunk and turned pallor immediately after the irradiation. The treatment interval was at least 8 weeks. Of the 11 patients, 9 of them were cured and 2 of them were improved. The mean treatment sessions were 2.2 times. None of them had a scar formation and any other side effects. All of them were satisfied with the treatment results. We conclude that angiokeratoma of Fordyce responded well to lpNd:YAG laser treatment. It provided a simple, rapid, and no bleeding treatment in treating Angiokeratoma of Fordyce.

The Dermatologist's Approach to Onychomycosis

Onychomycosis is a fungal infection of the toenails or fingernails that can involve any component of the nail unit, including the matrix, bed, and plate. It is a common disorder that may be a reservoir for infection resulting in significant medical problems. Moreover, onychomycosis can have a substantial influence on one's quality of life. An understanding of the disorder and updated management is important for all health care professionals. Aside from reducing quality of life, sequelae of the disease may include pain and disfigurement, possibly leading to more serious physical and occupational limitations. Dermatologists, Podiatrists, and other clinicians who treat onychomycosis are now entering a new era when considering treatment options-topical modalities are proving more effective than those of the past. The once sought after concept of viable, effective, well-tolerated, and still easy-to-use monotherapy alternatives to oral therapy treatments for onychomycosis is now within reach given recent study data. In addition, these therapies may also find a role in combination and maintenance therapy; in order to treat the entire disease the practitioner needs to optimize these topical agents as sustained therapy after initial clearance to reduce recurrence or re-infection given the nature of the disease.

Infantile Hemangioma: Clinical Characteristics and Efficacy of Treatment with the Long-Pulsed 1,064-nm Neodymium-Doped Yttrium Aluminum Garnet Laser in 794 Chinese Patients

OBJECTIVE

This study aimed to evaluate the clinical characteristics of infantile hemangiomas (IHs) and the safety and efficacy of the long-pulse 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for definitive treatment of IHs in 794 Chinese patients.

METHODS

Infants with hemangiomas who had received long-pulse 1,064-nm Nd:YAG laser treatment in our department in the last 5 years were recruited. Demographic and clinical characteristics were recorded and outcomes of long-pulse 1,064-nm Nd:YAG laser treatment were assessed. Statistical analyses were performed to identify factors that affected the efficacy of treatment.

RESULTS

The efficacy of long-pulse 1,064-nm Nd:YAG laser for the treatment of IHs in all patients in our study was 87.57%. Efficacy did not depend on sex or the location of the lesion. Older age and superficial hemangioma were the primary factors contributing to greater efficacy of long-pulse 1,064-nm Nd:YAG laser treatment for IHs. The most common side effects were pigment changes, skin atrophy, and wrinkled redundant skin, which usually resolved spontaneously within 1 to 3 years.

CONCLUSIONS

Long-pulse 1,064-nm Nd:YAG laser is a safe and efficacious treatment for IHs.

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.

Treatment of port wine stains with pulsed dye laser: a retrospective study of 848 cases in Shandong Province, People's Republic of China

Background

Currently, 595 nm pulsed dye laser (PDL) therapy is offered as one of the effective treatments of port wine stains (PWSs). However, the efficacy of PDL differs in different populations.

Objective

The purpose of the study was to investigate the efficacy, and related factors, of 595 nm PDL in the treatment of PWSs in Chinese patients with skin type III to IV.

Methods

A total of 848 cases that were treated with PDL were enrolled and analyzed in this study. An independent dermatologist evaluated these lesions according to the before and after photographs.

Results

The response rate (RR) of all the 848 PWS patients was 69.9%, within which the cure rate was 6.3%. The patients aged ≤1 year had the highest RR (93.9%), whereas those treated after age 50 reacted the worst (RR =25%). We analyzed the anatomical distribution of the lesion and found that the temporal region had the highest lesion clearance (RR =75.3%), while the extremities had the lowest clearance (RR =44.5%). Compared with the patients whose lesion size was larger than 80 cm², the patients with small lesion size, of 0–20 cm², had better clinical effect (RR =73.8% vs 53.2%). The reactions of the patients with hyperplastic lesion were worse than those with red patches (RR =36.4% vs 71.7%). As well, increasing treatment numbers could achieve higher clearance rates (P=0.005).

Conclusion

The PDL had a relatively high RR but a low clearance rate in Chinese patients with PWS, although the earlier the intervention, the better was the efficacy. The response of PDL was, not only related to the anatomical area, but also, to the lesion size, type of lesion (ie, the presence of existing hyperplastic lesions), and the number of treatment, all of which are essential for the evaluation of therapeutic effect and acquisition of patients consent before treatment.

Clinical analysis of port-wine stain in 130 Chinese patients treated by long-pulsed 1064-nm Nd: YAG laser

BACKGROUND

The long-pulsed 1064-nm Nd: YAG laser is effective for treating port-wine stain (PWS). This study evaluated the efficacy and safety of Nd: YAG laser in treating PWS in Chinese patients.

METHODS

A retrospective study of 130 PWS patients treated with long-pulsed 1064-nm Nd: YAG laser from 2009 to 2011.

RESULTS

After treatment, 2, 15, 64, and 19 percent of patients experienced < 25%, 25-49%, 50-75%, and > 75% lesion clearance, respectively. Purple lesions showed more significant improvement than pink lesions. The initial response was blistering, dark gray coloration, or light gray coloration, the best improvement occurred in 100% (27/27), 82.5% (52/63), and 72.5% (29/40), respectively. Patients older than 20 years showed the best improvement (37/38, 97.4%), followed by those 10-20 years old (20/24, 83.3%), 1-9 years old (23/29, 79.3%) and less than 1 year old (28/39, 71.8%). Patients with neck lesions had the best outcome (47/48, 97.9%), followed by those with lesions on the face (43/53, 81.2%), extremities (13/18, 72.2%), and trunk (5/11, 45.5%). The common adverse side effects were blistering and pigment changes.

CONCLUSIONS

1064-nm Nd: YAG laser is effective and safe for the treatment of PWS. The efficacy is affected by the age of the patient, the color and location of the lesions, and immediate responses to the laser.

A comparison of microvascular responses to visible and near-infrared lasers

BACKGROUND AND OBJECTIVE

Pulsed dye laser (PDL) is a commonly used treatment for Port Wine Stain birthmarks (PWS). However, deeper components of PWS are often resistant to PDL. Deeper penetrating lasers, including the long pulsed Neodymium:Yttrium Aluminum Garnet (Nd:YAG) laser have been used, but carry greater risk. This study evaluates the distinct blood vessel thermal responses to visible (595 nm) and near infrared (1,064 nm) lasers using animal and numerical models.

STUDY DESIGN/MATERIALS AND METHODS

Blood vessels in the rodent dorsal skin chamber (DSC) were irradiated by a 595 nm PDL and a long-pulsed 1,064 nm Nd:YAG laser. Laser-induced immediate and 1-hour post-structural and functional changes in the vessels were documented. Numerical simulations were conducted using a 1,000 µm depth SD mouse skin fold to simulate experimental conditions.

RESULTS

PDL irradiation produced immediate blood vessel hemorrhage. Modeling indicated this occurs due to preferential heating of the superior parts of large blood vessels. Nd:YAG irradiation resulted in blood vessel constriction; modeling indicated more uniform heating of vessel walls.

CONCLUSION

PDL and Nd:YAG lasers result in distinct tissue responses. This supports different observable clinical treatment end points when using these devices. Vessel constriction associated with the Nd:YAG may be more difficult to observe and is one reason this device may carry greater risk.

Variables affecting clinical response to treatment of facial port-wine stains by flash lamp-pumped pulsed dye laser: the importance of looking beyond the skin

The response of port-wine stains (PWS) to conventional laser treatment in adults is difficult to predict. To assess the influence of local or systemic hemodynamic variables on the clearance of PWS by using flash lamp-pumped pulsed (FLPP) dye laser. All consecutive patients ages 18 years or older undergoing laser treatment for a facial PWS were eligible. Laser sessions were scheduled every 8 weeks. All patients were evaluated based on a standard scale with four evaluation categories, from no or minimal improvement to total or almost total clearance. Clearance was achieved by 50.1 % (95 % confidence interval 35.6-64.7) of patients after a maximum of 15 treatment sessions. In multivariate analysis, increased age, a newly described Type III capillaroscopic pattern, and presence of lesions in dermatome V2 were all associated with a reduced clinical response to treatment. In a model restricted to demographic pattern and patient characteristics, arterial hypertension was also associated with a lower clinical response. A strong association was found between arterial hypertension and the Type III capillaroscopic pattern. Age, arterial hypertension, capillaroscopic pattern, and body location should be considered when planning laser treatment of PWS.

Beneficial effects of early treatment of infantile hemangiomas with a long-pulse Alexandrite laser

BACKGROUND AND OBJECTIVE

There is an increasing interest in treating vascular lesions with a long-pulse Alexandrite laser. However, it is difficult to search information in the literature about infantile hemangiomas (IH) treated with long-pulse Alexandrite laser. This article aims to determine whether 755 nm long-pulse Alexandrite laser is effective and safe for early intervention of IH and provides some new data on this issue.

MATERIALS AND METHODS

This is a retrospective study of 48 infants with IH treated with long-pulse Alexandrite laser during a 1.5-year period. Patients received a series of 1-7 treatment sessions with long-pulse Alexandrite laser at settings of 3 milliseconds pulse duration, 6-8 mm spot, 45-70 J/cm(2) fluences, and with dynamic cooling device (DCD) spray duration of 90 milliseconds and delay of 80 milliseconds, given at 4- to 6-week intervals.

RESULTS

This study demonstrated that IH responded favorably to the treatment of a long-pulse Alexandrite laser while accompany with relatively few complications. The difference between the original untreated and post-treatment scores of all IH and two subgroups were statistically significant, respectively (P < 0.01). The difference of the degree of improvement between the two subgroups was not significant (P > 0.05). It was observed that IH on the trunk and extremities improved more effectively and more quickly than those on the face, neck, and perineum. Besides, age at the first treatment, the sex of the patients and the presence of proliferation were not significantly correlated with the degree of improvement. Adverse effects were seen in 11 patients (22.91%): blistering (n = 9), marked edema and erosion without subsequent residual scarring (n = 1), and hypopigmentation (n = 1), which improved gradually with time. Fortunately, there was no incidence of scarring or ulceration in this case series of IH.

CONCLUSIONS

It was clinically effective and safe for early treatment of IH, including the thick/deep ones, with a long-pulse Alexandrite laser, which indicated be able to reduce the possibility that the IH will reach its full size. In this way it can prevent several complications connected to the rapid proliferation of IH.

Pulsed dye laser-resistant port-wine stains: mechanisms of resistance and implications for treatment

Port-wine stains (PWS) are among the most common congenital vascular malformations. Unlike capillary haemangiomas, these lesions do not involute spontaneously but rather become progressively more disfiguring as the patient ages. While benign in nature, the cosmetic deformity and attendant psychological and emotional distress prompt the majority of those afflicted to seek treatment. The pulsed dye laser (PDL) has long been considered the treatment of choice for these vascular lesions; however, very few patients achieve total clearance with PDL therapy and a significant number of lesions fail to respond at all. In order to address these recalcitrant cases, the mechanisms that contribute to treatment resistance must be understood and novel laser and light therapies must be employed. This review will address what is currently known about lesion-specific characteristics of PDL-resistant PWS as well as discuss current and future treatment options.

Laser treatment in the management of infantile hemangiomas and capillary vascular malformations

Vascular lesions encountered in dermatology can be divided into vascular malformations and vascular tumors, namely infantile hemangiomas (IH). Vascular malformations can further be subdivided by their flow characteristics and vessel type. Slow, or low-flow lesions are either capillary vascular malformations (CVMs), venous malformations, or lymphatic malformations. Fast, or high-flow lesions include an arterial component, and are categorized as arteriovenous malformations. IH and CVMs are among the most common benign vascular lesions seen and treated in dermatology. CVMs are present at birth and grow as the individual does, whereas IH usually appear days to weeks later and may rapidly enlarge for a period of months to a year before gradually involuting. As the technology has evolved, early and often laser treatment with the pulsed dye 595-nm laser has become our standard therapy of choice. More recently, we have started more patients on combination therapy for IH with the topical beta blocker timolol. If left untreated, CVMs darken and thicken, making them increasingly difficult to successfully treat with lasers. IH involute, sometimes resulting in fibrofatty, atrophic plaques. These individuals can undergo ablative fractional resurfacing with a fractional CO2 laser to improve the texture and appearance of these lesions.