Treatment of Resistant Port-Wine Stains with a Pulsed Dual Wavelength 595 and 1064 nm Laser: A Histochemical Evaluation of the Vessel Wall Destruction and Selectivity

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.

Combination Therapy for the Treatment of Complex Vascular Lesions

BACKGROUND AND OBJECTIVES

Combination treatment with debulking surgical procedures, vascular and ablative lasers, and topical and intralesional vascular therapies may improve outcomes in nodular hypertrophic and mixed complex vascular malformations; however, there is a paucity of data reporting specific combinations of these treatments. We report 15 cases of complex vascular malformations, which were successfully treated with novel combinations of these modalities.

STUDY DESIGN/MATERIALS AND METHODS

We performed a review of 15 patients treated with combination vascular laser therapy, electrosurgery, ablative laser technologies, and topical and intralesional vascular therapies from May 2000 to October 2020. Photographs were taken at intervals with attempts made for consistent lighting and positioning.

RESULTS

All 15 patients achieved an excellent clinical response to combination therapy with visible improvement of the hypertrophic, textural, and vascular components of their lesions. No major complications or adverse events were encountered during any of the treatments.

CONCLUSION

Combination multimodality therapy with surgical debulking, laser technologies, and topical and injection therapies can be highly effective and efficient in treating complex vascular malformations. © 2021 Wiley Periodicals LLC.

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.

Effectiveness of Dual Sequential Wavelength Laser in the Treatment of Portwine Stains - A Retrospective Study

Background

Port Wine Stain (PWS) is only partially and superficially treated with the Pulsed dye laser (PDL) because of its limited depth of penetration. The 1064-nm long pulsed Nd:YAG laser has greater depth of penetration and is used to treat deeper vessels. The dual sequential wavelength laser (DSWL) which combines PDL/Nd:YAG (595/1064 nm) can be more effective for the treatment of deeper, nodular portwine stains due to its synergistic effect. The purpose of this study is to evaluate the efficacy and safety of DSWL in the treatment of portwine stains after five treatment sessions.

Materials and Methods

A total of 11 patients with PWS lesions on the head and neck, who were treated with DSWL for at least five sittings at monthly interval were included in this study. The assessment of the therapeutic response and grading of improvement was done with a scale of 0 to 4 by comparing the photographs taken before treatment and after 5 sittings of laser treatment.

Results

Out of the 11 patients, 5 patients (45.45%) had more than 70% improvement. Six out of eleven patients (54.54%) had 40 to 70% improvement at the end of five sittings with no adverse effects including purpura.

Conclusion

Dual Sequential Wavelength Laser is a good modality of treatment for portwine stains. It has enhanced penetration and effective clearance of thicker, nodular, recalcitrant lesions of PWS. DSWL is safe and efficacious and it can be recommended as a therapeutic modality for portwine stains.

Capillary Malformations Treated With Sequential Pulsed Dye and Nd:YAG Laser Therapy: A Retrospective Study

INTRODUCTION AND OBJECTIVE

Capillary malformations are the most common vascular malformations in childhood. The current treatment of choice is pulsed dye laser (PDL) therapy, but this frequently does not result in complete resolution. The search for alternative treatment strategies thus continues. In this study we describe our experience with the use of sequential dual-wavelength PDL and Nd:YAG laser therapy in patients with capillary malformations.

MATERIAL AND METHODS

We conducted a retrospective, descriptive study of patients with capillary malformations treated with dual-wavelength PDL and Nd:YAG laser therapy between 2006 and 2011. Four dermatologists rated the effectiveness of treatment on a scale of 10 to 0. We also investigated the potential value of the following factors as predictors of better treatment response: sex, malformation size and color, and presence of associated hypertrophy. Adverse effects were also analyzed.

RESULTS

We studied 71 patients and most of them experienced a statistically significant improvement after treatment. More favorable responses were observed for violaceous malformations, lesions with associated hypertrophy, and smaller lesions. Adverse effects were reported for 26.76% of patients, and the most common effect was the appearance of isolated areas of skin atrophy.

CONCLUSIONS

We consider that sequential dual-wavelength PDL and ND:YAG laser therapy is an effective alternative for treating capillary malformations in selected patients.

Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.

Treatment of sporadic port-wine stains: a retrospective review of 17 cases consecutively treated by pulsed sequential dual wavelength 595 and 1064 nm laser

BACKGROUND

Port-wine stains (PWS) are relatively common and often cause cosmetic and psychological concerns. The pulsed dye laser is currently the treatment of choice for PWS.

OBJECTIVE

To assess the effectiveness of the pulsed sequential dual wavelength 595 and 1064 nm laser as first-line treatment for PWS and to identify prognostic factors for treatment outcome in a retrospective series of 17 consecutive previously untreated patients.

METHODS

The response to treatment was evaluated 2 months after treatment utilizing comparative photographs and a standard physician global assessment (PGA) grading system. Furthermore, measurement of the normalized erythema index (NEI) reduction (ΔNEI%) was carried out using an image analysis system. The subjective improvement was assessed using a patient's satisfaction questionnaire. Multiple linear regression models were finally used to identify factors associated with ΔNEI% and patients' satisfaction.

RESULTS

Seventeen patients, with PWS, including 12 children were included. The average PGA assessment was 2.5 ± 1.3 corresponding to an amelioration of 50% with a high intraclass correlation coefficient among the experts. The before-after NEI showed a statistically significant mean reduction of 3.5 ± 2.6 units, corresponding to a relative reduction of 31%. Questionnaires showed that the satisfaction was very good with an average score of 6.1 points on a scale ranging from -10 to 10 points. Multiple regression analysis revealed that location in the frontotemporal area was associated with a significant reduction in ΔNEI% (38.4%; 95% CI 4.3, 72.6). Presence of PWS on the neck was associated with a lower patient satisfaction (-3.7 points; 95% CI -6.5, -0.9). There were no significant side-effects, except for transient discomfort and purpura.

CONCLUSIONS

Based on the results obtained in the largest reported series so far, the pulsed sequential dual wavelength 595 and 1064 nm laser represents an effective and safe first-line therapeutic option for the treatment of PWS.

Histochemical Evaluation of the Vessel Wall Destruction and Selectivity After Treatment with Intense Pulsed Light in Capillary Malformations

BACKGROUND

Among the different approaches for improving the effectiveness in the treatment of Capillary Malformations type Port Wine Stain (CM type PWS) are the intense pulsed light sources. There are few clinical studies prove useful in the treatment of CM. Furthermore, no studies have been published yet demonstrating the histological effects of IPL in CM.

OBJECTIVES

To assess the histological effects of pulsed light in capillary malformations type port wine stain. We wanted to compare epidermal, dermal and vessel wall damage after treatment with different combinations of IPL parameters.

MATERIAL AND METHODS

Fifty-five post-treatment biopsies were performed in 15 consenting patients with CM and stained with nitroblue-tetrazolium chloride (NBTC). Patients had not been treated previously.

RESULTS

Fifteen patients with CM, with a median age of 39 years-old were enrolled in this study. In this series, the patients with the most severe epidermal damage were those with a darker phototype. Pink CM were especially resistant to treatment, even using high fluences, short pulse durations and stacking pulses. Longer intra- and interpulse delays were effective in purple CM, achieving adequate vessel destruction.

CONCLUSIONS

IPL devices provide a vast amount of treatment possibilities and further studies are necessary to optimize therapeutic approaches to CM. In this study we have observed the histological effects of different pulses on the MC type PWS.

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.

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.

Comparative effectiveness of nonpurpuragenic 595-nm pulsed dye laser and microsecond 1064-nm neodymium:yttrium-aluminum-garnet laser for treatment of diffuse facial erythema: A double-blind randomized controlled trial

BACKGROUND

Facial erythema is a common symptom that responds to vascular laser treatment, but there are few comparative studies.

OBJECTIVE

We sought to compare the effectiveness of microsecond 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with nonpurpuragenic 595-nm pulsed dye laser (PDL) for diffuse facial erythema.

METHODS

This was a split-face, double-blind randomized controlled trial. Bilateral cheeks received 4 treatments each at one month intervals with PDL or Nd:YAG. Spectrophotometer measurements, digital photographs, pain scores, and patient preferences were recorded.

RESULTS

Sixteen patients enrolled and 2 dropped out. Fourteen patients, all skin types I to III, 57% women, mean age 42 years, completed the study and were analyzed. Spectrophotometer readings changed after both PDL (8.9%) and Nd:YAG (2.5%), but varied by treatment type, with PDL reducing facial redness 6.4% more from baseline than Nd:YAG (P = .0199; 95% confidence interval -11.6 to -1.2). Pain varied (P = .0028), with Nd:YAG associated with less pain, at 3.07, than PDL at 3.87. Subjects rated redness as improved by 52% as a result of PDL, and 34% as a result of Nd:YAG (P = .031; 95% confidence interval -34.6 to -1.94). No serious adverse events were observed.

LIMITATIONS

Lasers settings are not standardized across devices.

CONCLUSION

Facial erythema is safely and effectively treated with PDL and Nd:YAG. Nonpupuragenic PDL may be more effective for lighter-skinned patients, but microsecond Nd:YAG may be less painful.

Infantile hemangiomas treated by sequential application of pulsed dye laser and Nd:YAG laser radiation: a retrospective study

BACKGROUND AND OBJECTIVES

Infantile hemangiomas are the most common benign tumor in children. They have 3 phases of development: a proliferative phase, an involuting phase, and involution. Although active treatment is often not required, it is necessary in some cases. Of the possible treatments for hemangiomas, lasers have been shown to be effective in all phases of development. We report our experience with dual-wavelength sequential pulses from a pulsed dye laser and an Nd:YAG laser.

MATERIAL AND METHODS

This was a retrospective, descriptive study of patients with infantile hemangioma in different phases of development treated with pulsed dye laser pulses followed by Nd:YAG laser pulses. Four dermatologists assessed the effectiveness of treatment on a scale of 10 to 0. Adverse effects and incidents related to treatment were recorded. The median and interquartile range were calculated as descriptive statistics. Pretreatment and posttreatment comparisons were performed using the Wilcoxon test.

RESULTS

Twenty-two patients with hemangiomas in different phases of development were included. A statistically significant improvement was obtained both for the entire group and for different subgroups. Posttreatment events were reported in 4 patients, and included edema and ulceration, skin atrophy, and hyperpigmentation.

CONCLUSIONS

We believe that treatment with dual-wavelength light from a pulsed dye laser and a Nd:YAG laser is a viable treatment option for infantile hemangiomas when first-line therapies are ineffective or contraindicated.

Long-pulsed 1064 nm Nd:YAG laser improves hypertrophic port-wine stains

BACKGROUND

Hypertrophic port-wine stains (PWS) usually respond poorly to pulsed dye laser treatment. The long-pulsed 1064 nm Nd:YAG laser can target deeper situated vessels and may therefore be more effective.

OBJECTIVE

To evaluate the efficacy and safety of the Nd:YAG laser for the treatment of hypertrophic PWS.

METHODS

In a retrospective cohort study, all hypertrophic PWS patients treated with the Nd:YAG laser between 2005 and 2011 were invited for follow-up. Clinical improvement was assessed using Physician Global Assessment (PhGA) and Patient Global Assessment (PGA).

RESULTS

Assessment was obtained in 32 of 44 eligible patients (mean age 51.4 years), after a mean of 2.8 (SD ± 2.1) Nd:YAG laser treatments. Good or excellent improvement of hypertrophy was found in a majority of patients, both by PhGA (91%) and PGA (93%). Good or excellent improvement of colour was found in 63% of patients by PhGA, and in 87% by PGA. Recurrence of hypertrophy was seen in three patients. All but two patients would recommend Nd:YAG treatment to other patients. Mild to moderate scars were seen in seven patients, hypopigmentation in 14 patients.

CONCLUSION

The 1064 nm Nd:YAG laser is highly effective in the treatment of hypertrophic PWS with only a few treatments needed. Mostly mild side effects were seen in half of all patients. Hypertrophy seems to respond better than colour. To further improve colour, a combination with pulsed dye laser treatment is advisory. Observation of immediate clinical endpoints is important when using the Nd:YAG laser, to optimize outcomes and reduce side effects.

An overview of clinical and experimental treatment modalities for port wine stains

Port wine stains (PWS) are the most common vascular malformation of the skin, occurring in 0.3% to 0.5% of the population. Noninvasive laser irradiation with flashlamp-pumped pulsed dye lasers (selective photothermolysis) currently comprises the gold standard treatment of PWS; however, the majority of PWS fail to clear completely after selective photothermolysis. In this review, the clinically used PWS treatment modalities (pulsed dye lasers, alexandrite lasers, neodymium:yttrium-aluminum-garnet lasers, and intense pulsed light) and techniques (combination approaches, multiple passes, and epidermal cooling) are discussed. Retrospective analysis of clinical studies published between 1990 and 2011 was performed to determine therapeutic efficacies for each clinically used modality/technique. In addition, factors that have resulted in the high degree of therapeutic recalcitrance are identified, and emerging experimental treatment strategies are addressed, including the use of photodynamic therapy, immunomodulators, angiogenesis inhibitors, hypobaric pressure, and site-specific pharmaco-laser therapy.

Treatment using a long pulsed nd:yag laser with a pulsed dye laser for four cases of blebbed port wine stains

Port wine stains (PWS) are congenital capillary malformations consisting of ectasia of capillaries and venules. At birth,lesions are flat and relatively uniform in color, but evolve with age to become raised, thickened, irregularly surfaced, and deeply colored. Therefore, it is considered optimal to begin treatment of patients at an early age. Conventional treatment modalities, such as electrocautery or excision, require considerable effort and may be cosmetically unsatisfactory. We have performed treatment of blebbed PWS of four patients using a 1,064 nm long pulsed Nd:YAG laser with a contact cooling device. According to their size, most blebs required three or fewer treatment sessions at 8-week intervals. Treatments were well tolerated by all subjects and patients showed moderate to good improvement of blebs. A 1,064 nm long pulsed Nd:YAG laser with contact cooling may be considered as a promising therapeutic option for treatment of blebbed PWS.