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

Current clinical evidence is insufficient to support HMME-PDT as the first choice of treatment for young children with port wine birthmarks

BACKGROUND

Port wine birthmark (PWB) is a congenital vascular malformation of the skin. Pulsed dye laser (PDL) is the "gold standard" for the treatment of PWB globally. Hematoporphyrin monomethyl ether (HMME or hemoporfin)-mediated photodynamic therapy (HMME-PDT) has emerged as the first choice for PWB treatment, particularly for young children, in many major hospitals in China during the past several decades.

AIM

To evaluate whether HMME-PDT is superior to PDL by comparing the clinical efficacies of both modalities.

METHOD

PubMed records were searched for all relevant studies of PWB treatment using PDL (1988-2023) or HMME-PDT (2007-2023). Patient characteristics and clinical efficacies were extracted. Studies with a quartile percentage clearance or similar scale were included. A mean color clearance index (CI) per study was calculated and compared among groups. An overall CI (C0), with data weighted by cohort size, was used to evaluate the final efficacy for each modality.

RESULT

A total of 18 HMME-PDT studies with 3910 patients in China were eligible for inclusion in this analysis. Similarly, 40 PDL studies with 5094 patients from nine different countries were eligible for inclusion in this analysis. Over 58% of patients in the HMME-PDT studies were minors (<18 years old). A significant portion (21.3%) were young children (<3 years old). Similarly, 33.2% of patients in the PDL studies were minors. A small proportion (9.3%) was young children. The overall clearance rates for PDL were slightly, but not significantly, higher than those for HMME-PDT in cohorts with patients of all ages (C0, 0.54 vs. 0.48, p = 0.733), subpopulations with only minors (C0, 0.54 vs. 0.46, p = 0.714), and young children (C0, 0.67 vs. 0.50, p = 0.081). Regrettably, there was a lack of long-term data on follow-up evaluations for efficacy and impact of HMME-PDT on young children in general, and central nervous system development in particular, because their blood-brain barriers have a greater permeability as compared to adults.

CONCLUSION

PDL shows overall albeit insignificantly higher clearance rates than HMME-PDT in patients of all ages; particularly statistical significance is nearly achieved in young children. Collectively, current evidence is insufficient to support HMME-PDT as the first choice of treatment of PWBs in young children given: (1) overall inferior efficacy as compared to PDL; (2) risk of off-target exposure to meningeal vasculature during the procedure; (3) administration of steriods for mitigation of side effects; -and (4) lack of long-term data on the potential impact of HMME on central nervous system development in young children.

Efficacy and influential factors of hematoporphyrin monomethyl ether mediated photodynamic therapy in the treatment for port-wine stains

BACKGROUNDS

Hematoporphyrin monomethyl ether mediated photodynamic therapy (HMME-PDT) has emerged as an alternative approach for port-wine stain (PWS), which was primarily treated with pulsed dye laser (PDL). This study was aimed to evaluate the efficacy and safety of HMME-PDT for PWS and to explore influential factors on the efficacy.

METHODS

A total of 254 patients were enrolled. Patients received an intravenous injection of HMME at 5 mg/kg. Lesion areas were irradiated with 532-nm light for 20-25 min. Efficacy was assessed according to fading of lesions and graded as excellent (≥90 %), good (60 %-89 %), fair (20 %-59 %), or poor (<20 %). Adverse events were recorded. Clinical data were analyzed including gender, age, lesion sub-type, lesion location and number of treatments.

RESULTS

Overall, 72.4 % of patients achieved an effective response, with 27.6% showing excellent efficacy, 24.8 % showing good efficacy and 20.1 % showing fair efficacy. Only 27.6 % showed poor efficacy. Patients under the age of 18 obtained a better efficacy than adults. Lesions in face showed a better therapeutic outcome than those in neck or trunk and extremities. A more effective response was seen in pink type compared with nodular thickening type. Multiple HMME-PDT treatments could improve the clinical response. Lesion location, lesion sub-type, number of treatments were independent influential factors on efficacy. Adverse events included edema, blister, crust, hypopigmentation, hyperpigmentation, pain, itch and burning sensation. No severe systemic side events were observed.

CONCLUSIONS

HMME-PDT was effective for treating PWS and was safe and well-tolerated by patients. It is worth further investigation in efficacy and safety involving more patients from medical institutions in different regions in China. The optimal treatment parameters and treatment protocols are still being explored in the clinical treatment for PWS.

Lasers and Nonsurgical Modalities

Head and neck vascular pathology is routinely encountered by the maxillofacial surgeon. Although these anomalies have been traditionally managed by surgical means, adjunctive therapies have been popularized in recent years. The use of laser therapy has gained attention for its ability to better access and to provide more predictable outcomes in the highly intricate and vascular areas of the head and neck. Laser therapy allows for the selective targeting of diseased tissue while maintaining the integrity of surrounding healthy tissue.

Pulsed dye laser and adjuvant topical therapies for the treatment of port-wine stains: A systematic review

OBJECTIVES

The current gold standard treatment for port-wine stains (PWS) is pulsed dye laser (PDL). However, multiple treatment sessions may be necessary and complete resolution is often not achieved. Neoangiogenesis can occur soon after treatment and is thought to be a major factor contributing to treatment failure. Adjuvant antiangiogenic topical therapies may therefore improve the efficacy of pulsed dye laser treatment of port-wine stains.

MATERIAL AND METHODS

Following PRISMA guidelines, we searched PubMed, Embase, Web of Science, and clinicaltrials.gov using "port-wine stain," "nevus flammeus," "capillary malformation," "sturge weber," and "pulsed dye laser" as keywords and medical subject heading (MeSH) terms. Articles were included if they (1) were a randomized controlled trial (RCT); (2) studied patients with PWS; and (3) investigated topical adjuvant therapies with PDL. Bias was assessed using the Critical Appraisal Skills Programme (CASP) Randomized Controlled Trial Standard Checklist.

RESULTS

1835 studies were identified, with six studies meeting inclusion criteria. The total number of patients studied was 103 (range: 9-23), with 8-36 week follow-up. The average age ranged from 11 to 33.5 years old. Three studies examined adjuvant topical sirolimus (n = 52), two examined timolol (n = 29), and one studied imiquimod (n = 22). Two of three RCTs reported no improvement through colorimetric analysis with topical sirolimus; however, one of these studies did show a significant improvement through Investigator Global Assessment (IGA) score. The last sirolimus study showed significant improvement through digital photographic image scoring (DPIA). Studies examining topical timolol reported no change in PWS appearance compared to placebo. The addition of 5% adjuvant imiquimod cream did lead to significant improvement. A variety of outcome measures were used. Imiquimod and sirolimus led to mild cutaneous adverse events, while timolol caused no side effects. None of the adverse events led to treatment discontinuation. Study quality was moderate in three, high in two, and low in one.

CONCLUSION

The efficacy of adjuvant topical therapy was unclear. Limitations included variation in concentration and duration of adjuvant therapies, differences in follow-up time, and inconsistent outcome measure reporting. Given their potential clinical promise, larger prospective studies examining topical adjuvant therapies should be considered.

Efficacy of hemoporfin-PDT on port-wine stains: A retrospective analysis of 2952 cases

OBJECTIVE

To conduct a retrospective analysis of Hemoporfin photodynamic therapy (HMME-PDT) in the treatment of port-wine stains (PWS).

METHOD

A retrospective analysis was conducted based on the clinical data from March 2017 to December 2022, so as to summarize the demographic characteristics, clinical efficacy and adverse reactions. The effectiveness of HMME-PDT was examined with respect to treatment times, age, gender, subtype, and location of PWS lesions.

RESULT

The age of the 2952 cases ranged from 8 months to 56 years old (median, 2.8 years), with 1419 males (48.07 %), and 1533 females (51.93 %). There were 669 cases of pink type (22.66 %), 2184 cases of purplish red type (73.98 %), and 99 cases of nodular thickening type (3.35 %). The prevalence location was face (88.04 %), neck (14.94 %), limbs and trunk. 1602 cases (54.27 %) had never received treatment, 661 cases (22.39 %) had been treated by pulse dye laser (PDL), 229 cases (7.76 %) had previously been treated by PDT, 296 cases (10.03 %) had received both the modalities. The 2952 cases completed totally 7996 HMME-PDT times. Cure rate and effective rate increased continuously with the number of treatments. The pink type has the highest cure rate and effective rate, followed by the purplish red type and the last was the nodular thickening type. The therapeutic effects are considerably influenced by age, subtype, and treatment site (P < 0.05). However, there was no significant difference in the effectiveness of HMME-PDT between both genders. The local adverse reactions after the first treatment included edema (97.73 %), itching (82.62 %), purpura-like change (79.51 %), crusts (24.59 %), infection (4.07 %), scars (1.08 %), hyperpigmentation (0.61 %), and depigmentation (0.41 %). Nausea and vomiting occurred in 2 juveniles and 1 young adult (5, 6 and 22 years old respectively) immediately after treatment, and did not interfere with the administration of the treatment. Patients aged 21-30 were found to have a 3.4-fold higher likelihood of undergoing HMME-PDT under general anesthesia compared to those aged 15 or younger. There was no distinct systemic adverse reaction, such as allergic responses, cardiovascular effects, neurological symptoms, hematological abnormalities, respiratory symptoms, or musculoskeletal issues.

CONCLUSION

HMME-PDT is preferred in treating PWS, with relatively high effective rate and cure rate, mild local reactions and no distinct systemic adverse reaction.

Cutaneous Hypervascularization Treatment Using Photo-Mediated Ultrasound Therapy

Photo-mediated ultrasound therapy (PUT) is a cavitation-based, highly selective antivascular technique. In this study, the effectiveness and safety of PUT on cutaneous vascular malformation was examined through in vivo experiments in a clinically relevant chicken wattle model, whose microanatomy is similar to that of port-wine stain and other hypervascular dermal diseases in humans. Assessed by optical coherence tomography angiography, the blood vessel density in the chicken wattle decreased by 73.23% after one session of PUT treatment in which 0.707 J/cm2 fluence laser pulses were applied concurrently with ultrasound bursts (n = 7, P < .01). The effectiveness of removing blood vessels in the skin at depth up to 1 mm was further assessed by H&E-stained histology at multiple time points, which included days 1, 3, 7, 14, and 21 after treatment. Additional immunohistochemical analyses with CD31, caspase-3, and Masson's trichrome stains were performed on day 3 after treatment. The results show that the PUT-induced therapeutic effect was confined and specific to blood vessels only, whereas unwanted collateral damage in other skin tissues such as collagen was avoided. The findings from this study demonstrate that PUT can efficiently and safely remove hypervascular dermal capillaries using laser fluence at a level that is orders of magnitude smaller than that used in conventional laser treatment of vascular lesions, thus offering a safer alternative technique for clinical management of cutaneous vascular malformations.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clinical efficacy and safety of two different hematoporphyrin monomethyl ether-mediated photodynamic therapy regimen in Chinese children with port-wine stain

Hematoporphyrin monomethyl ether-photodynamic therapy (HMME-PDT) has achieved encouraging clinical outcomes in adult port-wine stain (PWS). Optimal treatment option for children with PWS was minimal. To compare whether the clinical effectiveness of HMME-PDT with the 5-min (fast) administration treatment regimen (FATR) was better than the 20-min (slow) administration treatment regimen (SATR) for PWS of children in vivo and in vitro. Thirty-four children with PWS were divided into two groups including FATR and SATR. The two groups received three times HMME-PDT, respectively. Treatment efficacy and safety were evaluated in vivo and in vitro. Erythema index (EI) was used to evaluate the clinical outcomes. Both FATR and SATR were effective and safe in children with PWS after HMME-PDT. There were significance differences between the two groups in reductions of EI after the second treatment (p < 0.001) and the third treatment (p < 0.001) with HMME-PDT. The serum HMME concentration reach the peak level at short time compare with SATR group. A significance increased superoxide levels were observed in FATR group compare to SATR groups in vitro (p < 0.05). Our study suggested that HMME-PDT was effective and safe for children with PWS, the therapy regimen with FATR was better in clinical efficacy than that of the SATR.

Perturbations of Glutathione and Sphingosine Metabolites in Port Wine Birthmark Patient-Derived Induced Pluripotent Stem Cells

Port Wine Birthmarks (PWBs) are a congenital vascular malformation on the skin, occurring in 1-3 per 1000 live births. We have recently generated PWB-derived induced pluripotent stem cells (iPSCs) as clinically relevant disease models. The metabolites associated with the pathological phenotypes of PWB-derived iPSCs are unknown, and so we aim to explore them in this study. Metabolites were separated by ultra-performance liquid chromatography and screened with electrospray ionization mass spectrometry. Orthogonal partial least-squares discriminant, multivariate, and univariate analyses were used to identify differential metabolites (DMs). KEGG analysis was used to determine the enrichment of metabolic pathways. A total of 339 metabolites was identified. There were 22 DMs, among which nine were downregulated-including sphingosine-and 13 were upregulated, including glutathione in PWB iPSCs, as compared to controls. Pathway enrichment analysis confirmed the upregulation of glutathione and the downregulation of sphingolipid metabolism in PWB-derived iPSCs as compared to normal ones. We next examined the expression patterns of the key molecules associated with glutathione metabolism in PWB lesions. We found that hypoxia-inducible factor 1α (HIF1α), glutathione S-transferase Pi 1 (GSTP1), γ-glutamyl transferase 7 (GGT7), and glutamate cysteine ligase modulatory subunit (GCLM) were upregulated in PWB vasculatures as compared to blood vessels in normal skin. Other significantly affected metabolic pathways in PWB iPSCs included pentose and glucuronate interconversions; amino sugar and nucleotide sugars; alanine, aspartate, and glutamate; arginine, purine, D-glutamine, and D-glutamate; arachidonic acid, glyoxylate, and dicarboxylate; nitrogen, aminoacyl-tRNA biosynthesis, pyrimidine, galactose, ascorbate, and aldarate; and starch and sucrose. Our data demonstrated that there were perturbations in sphingolipid and cellular redox homeostasis in PWB vasculatures, which could facilitate cell survival and pathological progression. Our data implied that the upregulation of glutathione could contribute to laser-resistant phenotypes in some PWB vasculatures.

The combined application of bleomycin with triamcinolone acetonide in port wine stains: inhibiting proliferation and recurrence of port wine stains

BACKGROUND

Port wine stains slowly grow thicker over time, nodules appear on the surface, and the color slowly deepens from pink to purple. Even after laser treatment, some port wine stains will recur and slowly grow, and the erythema appears again. The purpose of this study was to investigate the effectiveness of bleomycin in combination with triamcinolone acetonide in the treatment of inhibiting the proliferation and recurrence of port wine stains.

RESULTS

Histopathological change: Before treatment, dense capillaries were distributed within the lesion, and blood fills the lumen. Lack of normal skin structure: After bleomycin and triamcinolone acetonide injection, the number of capillaries was significantly reduced, and fibrosis occurred in tissues. Changes in facial morphology: After treatment, the port wine stains became thinner, the asymmetry of the face was effectively improved, and the appearance have been significantly improved. After 5 years of follow-up, there were no recurrent cases.

CONCLUSION

Bleomycin and triamcinolone acetonide injection can effectively inhibit the proliferation of port wine stains and prevent port wine stains from recurring after treatment.

Supporting materials: Endothelial cells differentiated from patient dermal fibroblast-derived induced pluripotent stem cells resemble vascular malformations of Port Wine Birthmark

Background

Port wine birthmark (PWB) is a congenital vascular malformation resulting from developmentally defective endothelial cells (ECs). Developing clinically relevant disease models for PWB studies is currently an unmet need.

Objective

Our study aims to generate PWB-derived induced pluripotent stem cells (iPSCs) and iPSC-derived ECs that preserve disease-related phenotypes.

Methods

PWB iPSCs were generated by reprogramming lesional dermal fibroblasts and differentiated into ECs. RNA-seq was performed to identify differentially expressed genes (DEGs) and enriched pathways. The functional phenotypes of iPSC-derived ECs were characterized by capillary-like structure (CLS) formation in vitro and Geltrex plug-in assay in vivo .

Results

Human PWB and control iPSC lines were generated through reprogramming of dermal fibroblasts by introducing the "Yamanaka factors" (Oct3/4, Sox2, Klf4, c-Myc) into them; the iPSCs were successfully differentiated into ECs. These iPSCs and their derived ECs were validated by expression of a series of stem cell and EC biomarkers, respectively. PWB iPSC-derived ECs showed impaired CLS in vitro with larger perimeters and thicker branches as compared to control iPSC-derived ECs. In the plug-in assay, perfused human vasculature formed by PWB iPSC- derived ECs showed bigger perimeters and greater densities than those formed by control iPSC- derived ECs in severe combined immune deficient (SCID) mice. The transcriptome analysis showed that dysregulated pathways of stem cell differentiation, Hippo, Wnt, and focal adhesion persisted through differentiation of PWB iPSCs to ECs. Functional enrichment analysis showed that Hippo and Wnt pathway-related PWB DEGs are enriched for vasculature development, tube morphology, endothelium development, and EC differentiation. Further, members of the zinc finger (ZNF) gene family were overrepresented among the DEGs in PWB iPSCs. ZNF DEGs confer significant functions in transcriptional regulation, chromatin remodeling, protein ubiquitination, and retinoic acid receptor signaling. Furthermore, NF-kappa B, TNF, MAPK, and cholesterol metabolism pathways were dysregulated in PWB ECs as readouts of impaired differentiation.

Conclusions

PWB iPSC-derived ECs render a novel and clinically-relevant disease model by retaining pathological phenotypes. Our data demonstrate multiple pathways, such as Hippo and Wnt, NF-kappa B, TNF, MAPK, and cholesterol metabolism, are dysregulated, which may contribute to the development of differentiation-defective ECs in PWB.

Bulleted statements

What is already known about this topic?: Port Wine Birthmark (PWB) is a congenital vascular malformation with an incidence rate of 0.1 - 0.3 % per live births.PWB results from developmental defects in the dermal vasculature; PWB endothelial cells (ECs) have differentiational impairments.Pulse dye laser (PDL) is currently the preferred treatment for PWB; unfortunately, the efficacy of PDL treatment of PWB has not improved over the past three decades.What does this study add?: Induced pluripotent stem cells (iPSCs) were generated from PWB skin fibroblasts and differentiated into ECs.PWB ECs recapitulated their pathological phenotypes such as forming enlarged blood vessels in vitro and in vivo.Hippo and Wnt pathways were dysregulated in PWB iPSCs and ECs.Zinc-finger family genes were overrepresented among the differentially expressed genes in PWB iPSCs.Dysregulated NF-kappa B, TNF, MAPK, and cholesterol metabolism pathways were enriched in PWB ECs.What is the translational message?: Targeting Hippo and Wnt pathways and Zinc-finger family genes could restore the physiological differentiation of ECs.Targeting NF-kappa B, TNF, MAPK, and cholesterol metabolism pathways could mitigate the pathological progression of PWB.These mechanisms may lead to the development of paradigm-shifting therapeutic interventions for PWB.

M-CSAFN: Multi-Color Space Adaptive Fusion Network for Automated Port-Wine Stains Segmentation

Automatic segmentation of port-wine stains (PWS) from clinical images is critical for accurate diagnosis and objective assessment of PWS. However, this is a challenging task due to the color heterogeneity, low contrast, and indistinguishable appearance of PWS lesions. To address such challenges, we propose a novel multi-color space adaptive fusion network (M-CSAFN) for PWS segmentation. First, a multi-branch detection model is constructed based on six typical color spaces, which utilizes rich color texture information to highlight the difference between lesions and surrounding tissues. Second, an adaptive fusion strategy is used to fuse complementary predictions, which address the significant differences within the lesions caused by color heterogeneity. Third, a structural similarity loss with color information is proposed to measure the detail error between predicted lesions and truth lesions. Additionally, a PWS clinical dataset consisting of 1413 image pairs was established for the development and evaluation of PWS segmentation algorithms. To verify the effectiveness and superiority of the proposed method, we compared it with other state-of-the-art methods on our collected dataset and four publicly available skin lesion datasets (ISIC 2016, ISIC 2017, ISIC 2018, and PH2). The experimental results show that our method achieves remarkable performance in comparison with other state-of-the-art methods on our collected dataset, achieving 92.29% and 86.14% on Dice and Jaccard metrics, respectively. Comparative experiments on other datasets also confirmed the reliability and potential capability of M-CSAFN in skin lesion segmentation.

Perturbations of glutathione and sphingosine metabolites in Port Wine Birthmark patient-derived induced pluripotent stem cells

Port Wine Birthmark (PWB) is a congenital vascular malformation in the skin, occurring in 1-3 per 1,000 live births. We recently generated PWB-derived induced pluripotent stem cells (iPSCs) as clinically relevant disease models. The metabolites associated with the pathological phenotypes of PWB-derived iPSCs are unknown, which we aimed to explore in this study. Metabolites were separated by ultra-performance liquid chromatography and were screened with electrospray ionization mass spectrometry. Orthogonal partial least-squares discriminant analysis, multivariate and univariate analysis were used to identify differential metabolites (DMs). KEGG analysis was used for the enrichment of metabolic pathways. A total of 339 metabolites were identified. There were 22 DMs confirmed with 9 downregulated DMs including sphingosine and 13 upregulated DMs including glutathione in PWB iPSCs as compared to controls. Pathway enrichment analysis confirmed the upregulation of glutathione and downregulation of sphingolipid metabolism in PWB-derived iPSCs as compared to normal ones. We next examined the expression patterns of the key factors associated with glutathione metabolism in PWB lesions. We found that hypoxia-inducible factor 1α (HIF1α), glutathione S-transferase Pi 1 (GSTP1), γ-glutamyl transferase 7 (GGT7), and glutamate cysteine ligase modulatory subunit (GCLM) were upregulated in PWB vasculatures as compared to blood vessels in normal skins. Our data demonstrate that there are perturbations in sphingolipid and cellular redox homeostasis in the PWB vasculature, which may facilitate cell survival and pathological progression. Our data imply that upregulation of glutathione may contribute to laser-resistant phenotypes in the PWB vasculature.

Influential Factors in the Efficacy of Hemoporfin-Mediated Photodynamic Therapy for Port-wine Stains

Hemoporfin-mediated photodynamic therapy (HMME-PDT) is commonly used in the treatment of port-wine stains (PWS). However, the influential factors for the efficacy of the treatment are not well defined. This study intends to observe the influential factors for the efficacy of HMME-PDT in the treatment of port-wine stains (PWS). A total of 551 patients with PWS of head and neck was enrolled in this retrospective study. Further screening the patients of facial PWS, 484 patients were chosen. Patients were treated with HMME-PDT. All patients received 1~3 sessions of treatment with 2~3-month intervals. We photographed the lesions before each session and 2~3 months after the last session. Ages, sessions, lesion subtypes, and previous treatment history were related to the response of HMME-PDT (P =0.032, P<0.001, P=0.012, P=0.003 respectively). Treatment sessions were the independent factor correlated with efficacy after 3 sessions of treatment. Patients with no treatment history targeting PWS showed higher efficacy than those were treated with laser or other photodynamic treatment (P<0.05). The efficacy was higher by increasing the sessions of treatment. The efficacy was higher for lesion on maxillary prominence area and mandibular prominence area that on frontonasal prominence area and optic vesicle area (P<0.05). HMME-PDT is an effective in the treatment of PWS. Patients received no previous treatment for PWS, total treatment sessions and lesion on maxillary prominence area and mandibular prominence area are positive factors.

Hemoporfin-mediated photodynamic therapy with general anesthesia showed superior efficacy in the treatment of port-wine stains: a retrospective evaluation

Background

Hemoporfin-mediated photodynamic therapy (PDT) is an effective treatment for port-wine stains (PWS), and pain is the main adverse effect of this therapy. General anesthesia is commonly used for pain management during PDT, but the effect of general anesthetics on the subsequent treatment efficacy of PDT in PWS has not been reported.

Objectives

To assess the use of general anesthesia combined with PDT compared with PDT alone in 207 PWS patients, and to provide further safety and efficacy data on this combined therapy.

Methods

Propensity score matching (PSM) was used at a 2:1 ratio to create a general anesthetic group (n = 138) and a highly comparable nonanesthetic group (n = 69). The clinical outcomes were evaluated, and the treatment reactions and adverse effects were recorded after one treatment with PDT.

Results

After matching, there was no significant difference in the demographic data of the patients in the two groups (p > 0.05), while the treatment efficacy was significantly higher in the general anesthetic group than in the nonanesthetic group (76.81 vs. 56.52%, p < 0.05). Moreover, logistic regression analysis confirmed that patients receiving general anesthesia showed an association with a good response to PDT (OR = 3.06; 95% CI, 1.57-6.00; p = 0.0011). Purpura lasted longer in the general anesthetic group, but the other treatment reactions and adverse effects were similar in the two groups (p > 0.05). No serious systemic adverse reactions were observed.

Conclusion

We recommend this combined therapy, which is associated with painless, as a high efficacy treatment option for PWS patients, especially for patients with a poor response to multiple PDT alone treatments.

A review on photo-mediated ultrasound therapy

Photo-mediated ultrasound therapy (PUT) is a novel therapeutic technique based on the combination of ultrasound and laser. The underlying mechanism of PUT is the enhanced cavitation effect inside blood vessels. The enhanced cavitation activity can result in bio-effects such as reduced perfusion in microvessels. The reduced perfusion effect in microvessels in the eye has the potential to control the progression of eye diseases such as diabetic retinopathy and age-related macular degeneration. Several in vivo studies have demonstrated the feasibility of PUT in removing microvasculature in the eye using rabbit eye model and vasculature in the skin using rabbit ear model. Numerical studies using a bubble dynamics model found that cavitation is enhanced during PUT due to the dramatic increase in size of air/vapor nuclei in blood. In addition, the study conducted to model cavitation dynamics inside a blood vessel during PUT found stresses induced on the vessel wall during PUT are higher than that at normal physiological levels, which may be responsible for bio-effects. The concentration of vasodilators such as nitric oxide and prostacyclin were also found to be affected during PUT in an in vitro study, which may limit blood perfusion in vessels. The main advantage of PUT over conventional techniques is non-invasive, precise, and selective removal of microvessels with high efficiency at relatively low energy levels of ultrasound and laser, without affecting the nearby structures. However, the main limitation of vessel rupture/hemorrhage needs to be overcome through the development of real-time monitoring of treatment effects during PUT. In addition to the application in removing microvessels, PUT-based techniques were also explored in treating other diseases. Studies have found a combination of ultrasound and laser to be effective in removing blood clots inside veins, which has the potential to treat deep-vein thrombosis. The disruption of atherosclerotic plaque using combined ultrasound and laser was also tested, and the feasibility was demonstrated.

Does Topical Anesthesia Alter the Outcomes of Vascular Laser Procedures? Review of Vasodynamic Effects and Clinical Outcomes Data

BACKGROUND

Topical anesthesia has vasodynamic effects within the skin and therefore has the potential to change the presence of hemoglobin as a chromophore before intense pulsed light (IPL) and vascular laser treatments. It is unclear whether this is clinically relevant. Global consensus on the use of topical anesthetics in this context is lacking.

OBJECTIVE

Review the effects of topical anesthetics on the skin microvasculature and the clinical implications of such effects on vascular treatments.

METHODS

PubMed and Medline searches were performed to identify studies examining the vasodynamic effects of topical anesthesia on skin and evaluating differences in efficacy of IPL and vascular laser treatments with or without topical anesthetic use.

RESULTS

Published studies reveal variable effects of different topical anesthetic agents on skin microvasculature. Only 3 controlled studies that directly examined the effect of topical anesthesia on clinical outcomes for pulsed dye laser (PDL) treatment of vascular conditions were identified. They did not support a difference in clinical outcomes with or without the use of topical anesthesia before PDL treatment.

CONCLUSION

Although topical anesthetic agents have vasodynamic effects within the skin, there is currently insufficient evidence to advise against their use before light and laser-based vascular treatments.

Sturge-Weber Syndrome: A Review of Pathophysiology, Genetics, Clinical Features, and Current Management Approache

Sturge-Weber syndrome (SWS) is a congenital, sporadic, and rare neurocutaneous disorder, characterized by the presence of a facial port-wine birthmark (PWB), glaucoma, and neurological manifestations including leptomeningeal angiomatosis and seizures. It is caused by a postzygotic, somatic, gain-of-function variant of the GNAQ gene, and more recently, the GNA11 gene in association with distinctive clinical features. Neuroimaging can help identify and stratify patients at risk for significant complications allowing closer follow-up; although no presymptomatic treatment has been demonstrated to be effective to date, these patients could benefit from early treatment and/or supportive interventions. Choroid plexus (CP) thickness measurements in brain magnetic resonance imaging (MRI) have a high sensitivity and specificity for early and incipient changes in SWS. In contrast, the absence of pathologic findings makes it possible to rule out associated neurological involvement and leads to periodical observation, with new imaging studies only in cases of new clinical signs/symptoms. Periodic ophthalmological examination is also recommended every 3 months during the first year and yearly afterwards to monitor for glaucoma and choroidal hemangiomas. Treatment for SWS depends on the extent and areas that are affected. These include laser surgery for PWB, anticonvulsants in the case of brain involvement, with either seizures or abnormal EEG, and medical treatment or surgery for glaucoma. Sirolimus has been used in a limited number of patients and appears to be a safe and potentially effective treatment for cutaneous and extra-cutaneous features, however controlled clinical studies have not been carried out. Better knowledge of GNAQ/GNA11 molecular pathways will help to develop future targeted treatments.

High speed photo-mediated ultrasound therapy integrated with OCTA

Photo-mediated Ultrasound Therapy (PUT), as a new anti-vascular technique, can promote cavitation activity to selectively destruct blood vessels with a significantly lower amount of energy when compared to energy level required by other laser and ultrasound treatment therapies individually. Here, we report the development of a high speed PUT system based on a 50-kHz pulsed laser to achieve faster treatment, decreasing the treatment time by a factor of 20. Furthermore, we integrated it with optical coherence tomography angiography (OCTA) for real time monitoring. The feasibility of the proposed OCTA-guided PUT was validated through in vivo rabbit experiments. The addition of OCTA to PUT allows for quantitative prescreening and real time monitoring of treatment response, thereby enabling implementation of individualized treatment strategies.

Pathogenesis of Port-Wine Stains: Directions for Future Therapies

Port-wine stains (PWSs) are congenital vascular malformations that involve the skin and mucosa. To date, the mechanisms underlying the pathogenesis and progression of PWSs are yet to be clearly elucidated. The potential reasons for dilated vessels are as follows: (1) somatic GNAQ (R183Q) mutations that form enlarged capillary malformation-like vessels through angiopoietin-2, (2) decreased perivascular nerve elements, (3) the coexistence of Eph receptor B1 and ephrin B2, and (4) the deficiency of αSMA expression in pericytes. In addition, ERK, c-JNK, P70S6K, AKT, PI3K, and PKC are assumed to be involved in PWS development. Although pulsed-dye laser (PDL) remains the gold standard for treating PWSs, the recurrence rate is high. Topical drugs, including imiquimod, axitinib, and rapamycin, combined with PDL treatments, are expected to alter the recurrence rate and reduce the number of PDL sessions for PWSs. For the deep vascular plexus, photosensitizers or photothermal transduction agents encapsulated by nanocarriers conjugated to surface markers (CD133/CD166/VEGFR-2) possess a promising therapeutic potential in photodynamic therapy or photothermal therapy for PWSs. The pathogenesis, progression, and treatment of PWSs should be extensively investigated.

Efficacy and influential factors analysis in hemoporfin-mediated photodynamic therapy in the treatment of port-wine stains: a retrospective analysis

BACKGROUND

Hemoporfin-mediated photodynamic therapy (Hemoporfin-PDT) is a safe and effective treatment modality for port-wine stain (PWS). However, there is still no consensus about the influential factors for the efficacy of the treatment. This study investigated the influential factors associated with the efficacy of Hemoporfin-PDT.

METHODS

We retrospectively analyzed 321 PWS patients who underwent Hemoporfin-PDT at our center from August 2017 to July 2021. The correlation between efficacy versus sex, age, location, type of PWS, treatment numbers, and the lesion size were analyzed.

RESULTS

The numbers of treatment sessions undertaken were associated with the response to therapy, and compared with patients who received one session, patients who received two or more sessions showed a better response (ORadj=2.46, 95%CI, 1.49-4.07; ORadj=6.01, 95%CI, 3.38-10.70, P<0.001). The effect on central face, peripheral face, and neck was superior to the extremity and trunk, respectively (P<0.001). The lesion size smaller than and equal to 25 cm² showed a better effect than those whose lesion size was larger than 64 cm² (ORadj=1.92, 95%CI, 1.03-3.57, P=0.040). However, other variables, including sex and age, were not associated with the efficacy of the treatment.

CONCLUSIONS

Hemoporfin-PDT is an effective and safe treatment for PWS. The number of treatments was a favorable factor for Hemoporfin-PDT, smaller lesion sizes showed a better effect than the larger one, and the location of extremity and trunk was a negative factor.

Multimodality Treatment of Vascular Anomalies of The Head And Neck

Vascular anomalies affect up to 5% of children with the majority affecting the head and neck. They present at different ages as a wide variety of lesions. Careful evaluation with history, physcial examination and imaging assist in the proper diagnosis. Depending on the condition, treatment options for vascular anomalies include topical therapy, selective photothermolysis, sclerotherapy, embolization, surgical excision and targeted systemic therapy. Staged multimodal therapeutic regimens have proven to best control disease and allow for preservation of function and aesthetics. The timing, sequence and combination of therapies is best determined by a multidisciplinary vascular anomalies team. Patients and families need to be counseled on anticipated positive outcomes following a protracted course of treatment for the majority of vascular anomalies.

Histological analysis of different types of port-wine stains to guide clinical decision making: A retrospective study

Background and objectives Port-wine stains are defined as congenital benign vascular lesions. The treatment of port-wine stains remains a challenge, worldwide. This study aimed to analyze the histological characteristics in different types of port-wine stains and provide guidance for clinical decision-making. Methods and materials Biopsies were from the hospital from 2015 to 2021. H&E staining, Immunofluorescence staining, Masson's trichrome staining and Weigert staining were performed on the tissues. Results A total of 35 port-wine stains patients were included in the study of four distinct types, namely red port-wine stains (11 cases), purple port-wine stains (seven cases), hypertrophic port-wine stains (nine cases) and nodular port-wine stains (eight cases). The mean vessel diameter of the different types was 38.7 ± 5.9 μm, 93.5 ± 9.7 μm, 155.6 ± 21.8 μm and 155.6 ± 29.54 μm, respectively. Mean vessel depth was 396.4 ± 31 μm, 944.2 ± 105.4 μm, 2,971 ± 161.3 μm and 3,594 ± 364.6 μm, respectively. The vessels in red port-wine stains, purple port-wine stains and hypertrophic port-wine stains were mainly composed of capillary and venous malformations, whereas those in nodular port-wine stains were venous or arteriovenous malformations. Limitation The main limitation of the current study was the small number of patients. Conclusion As the disease progresses, vessel diameters become larger, the vessel wall becomes thicker and vessels were found in a greater depth. A treatment plan should be scientifically formulated keeping in mind the histological characteristics of port-wine stains.

Histological Characteristics of Port-Wine Stains with Complete Regression After Photodynamic Therapy Treatment: A 7-Year Follow-Up

Background: Vascular-targeted photodynamic therapy (PDT) is an effective alternative treatment choice for port-wine stains (PWSs). The histological characteristics of PWSs after PDT treatment have not yet been reported. Objective: To investigate the morphological features of PWSs treated by PDT and define the histopathological characteristics of PWS that achieve clinical cure. Methods: Thirteen patients with facial PWSs, who presented with complete regressive PWS lesions after a mean of 4.38 (standard deviation = 4.907) sessions of PDT. Post-treatment biopsy samples were obtained from each patient. The number of blood vessels, vascular diameter, and depth were measured and compared in all samples of PDT-regressive sites, PDT-resistant sites, and normal skin. Results: Within the 7-year follow-up after PDT, there was no recurrence in the regression area of PDT. In the PDT-regressive sites, within 800 μm of the dermal-epidermal junction, the dilated vessels were occluded and remained fissure-like after PDT. Conclusions: When the vascular lesions within 800 μm of the dermal-epidermal junction were closed after PDT, a stable clinical cure (no recurrence) was achieved.

Hemoporfin-Mediated Photodynamic Therapy for Port-Wine Stains: Multivariate Analysis of Clinical Efficacy and Optical Coherence Tomography Appearance

Background

Hemoporfin-mediated photodynamic therapy (HMME-PDT) is reported to be effective and safe for port-wine stains (PWS). However, its efficacy is influenced by several factors and there is no appropriate method to evaluate efficacy so far. Therefore, this study explored the clinical efficacy of HMME-PDT for PWS on the face and neck and the feasibility of evaluating treatment potency with optical coherence tomography (OCT).

Methods

A total of 211 PWS patients subjected to HMME-PDT were recruited for study and correlations of therapeutic effect with treatment sessions, age, gender, lesion distribution and treatment history analyzed. OCT was utilized for quantitative analysis of PWS lesions of 36 selected patients before and after HMME-PDT.

Results

The efficacy of two consecutive treatments was significantly higher than that of single treatment (P < 0.05). In multivariate analysis, after the first treatment, age, lesion distribution and treatment history were correlative factors affecting treatment efficacy (P < 0.05). The improvement effect on central facial lesions was lower than that on lateral facial lesions (P < 0.05). The efficacy of therapy on the group with no history of pulsed dye laser (PDL) treatment was greater than that on effective and ineffective treatment groups (P < 0.05). After the second session, age remained the only factor correlated with efficacy (P < 0.05). Dilated vessel diameter and depth before and after treatment were significantly different (P < 0.05). With increasing treatment times, age was the most significant factor influencing treatment efficacy.

Conclusions

Our collective findings indicate that HMME-PDT therapy is effective and safe for PWS and support the utility of OCT in objective assessment of the efficacy of HMME-PDT.

Analysis of port-wine birthmark vascular characteristics by location: Utility of optical coherence tomography mapping

INTRODUCTION

Port-wine birthmarks (PWBs) are congenital capillary malformations that can be located on any area of the body. Vascular features include vessel size, depth, and density, which can greatly differ between patients, individual lesions, and even sites within the same lesion. Previous studies have determined that the location of PWB lesions has impacted their clinical response to laser treatment.

OBJECTIVE

We utilized dynamic optical coherence tomography (D-OCT) to measure in vivo vessel diameter, density, and superficial plexus depth in patients of all ages with PWB on various sites of the body. We hypothesized that these vascular characteristics would differ according to body location.

MATERIALS AND METHODS

Patients who had a PWB and presented to clinic at three sites for treatment with the pulsed dye laser (PDL) were enrolled into the study. A D-OCT scanner was utilized for noninvasive, in vivo imaging of PWB lesions. The depth of the top portion of the superficial vascular plexus was estimated as the depth at which the vessel density reaches 50% of the maximum. Vessel diameter and density were calculated by incorporated software algorithm.

RESULTS

A total of 108 patients were enrolled into the study. There was a total of 204 measurements of PWB lesions. Of all patients, 56.5% (n = 61) reported having a previous treatment with PDL. Of all D-OCT scans, 62.3% (n = 127) were located on the head, 14.2% (n = 29) the upper extremities, 8.3% (n = 17) the lower extremities, 7.8% (n = 16) the trunk, and 7.8% (n = 15) the neck. All locations were compared for each vascular characteristic. For superficial plexus depth, lesions on the head were significantly shallower than those on the upper extremities (217 vs. 284 µm; p < 0.001) and lower extremities (217 vs. 309 µm; p < 0.001). For vessel diameter, lesions on the head had significantly larger vessels than those on the upper extremities (100 vs. 72 µm; p = 0.001). For vessel density, lesions on the head had significantly denser vessels than those on the trunk (19% vs. 9.6%; p = 0.039) and upper extremities (19% vs. 9.3%; p < 0.001) CONCLUSIONS: PWB lesions have distinct vascular characteristics, which can be associated with their body location. This includes superficial vascular plexus depth as well as vessel diameter and density.

Efficacy of hemoporfin photodynamic therapy for pulsed dye laser-resistant facial port-wine stains in 107 children: A retrospective study

BACKGROUND

Port-wine stains occur in 0.3-0.5% newborns, mainly on the face and neck. Pulsed dye laser is recognized as the gold standard treatment; nevertheless, it is associated with a low cure rate and a high recurrence rate.

AIMS

This study aims to evaluate the efficacy of hemoporfin photodynamic therapy for pulsed dye laser-resistant port-wine stains in children.

METHODS

We studied 107 children who received hemoporfin photodynamic therapy for port-wine stains on the face and neck that were resistant to pulsed dye laser. After intravenous injection of 5 mg/kg hemoporfin, the local lesion was irradiated with 532 nm LED green light for 20 min with a power density of 80-100 mW/cm2. A total of 65 patients were given a second treatment after eight weeks. The efficacy and therapeutic responses were recorded at four days and eight weeks after each treatment.

RESULTS

The efficacy was positively correlated with the number of treatments received; two treatment sessions yielded significantly better results compared to a single treatment with a response rate of 96.9%, a significant response rate of 50.8% and a cure rate of 21.5%, respectively (P < 0.001). After two treatment sessions, the efficacy was negatively correlated with age (P = 0.04). The efficacy for port-wine stains located on the lateral part was better than that of the central face (P = 0.04). The efficacy for the pink type was better than that for the red and purple types (P = 0.03). No allergic or systematic adverse reactions were reported.

LIMITATIONS

No objective measurement data were available.

CONCLUSION

Hemoporfin photodynamic therapy is effective and safe for pulsed dye laser-resistant facial port-wine stains in children.

Efficacy and safety of hemoporfin photodynamic therapy for port-wine stains in paediatric patients: A retrospective study of 439 cases at a single centre

BACKGROUND

Although hemoporfin photodynamic therapy is a promising treatment approach for port-wine stains, its efficacy in children has not been sufficiently assessed. We aimed to evaluate the efficacy and safety of this approach in a paediatric population.

METHODS

We retrospectively analysed the medical records of 439 children with port-wine stains receiving hemoporfin photodynamic therapy at our institution from July 2017 to January 2020. They received intravenous hemoporfin (hematoporphyrin monomethyl ether, 5 mg/kg), followed by lesion irradiation with a 532-nm green LED light for 20-25 min. The stains' blanching degree and occurrence of adverse events were registered.

RESULTS

Overall, 95.2% of patients showed an 'effective response' (>20% fading) and 74.3% showed almost-complete resolution and great improvement (≥60% fading). Red and pink lesions showed better response than purple lesions (P < 0.05). Neck and facial lesions showed better response than the trunk and extremity lesions (P < 0.05). The response of the patients to the PDT showed a cumulative effect of the treatment session. No photosensitivity or systemic adverse reactions were observed. Transient local adverse effects included swelling, purpura, crusts, and pigmentation, which resolved without treatment. Only 2% of children had permanent scars, likely related to scratching crusts.

CONCLUSIONS

Hemoporfin photodynamic therapy was well tolerated and effective in paediatric Chinese patients with port-wine stains. It could be recommended as the first choice, over pulsed-dye laser therapy, for treating port-wine stains, particularly for large lesions. This should be evaluated in direct clinical trials.

Efficacy of influential factors in hemoporfin-mediated photodynamic therapy for facial port-wine stains

Hemoporfin-mediated photodynamic therapy (HMME-PDT) is a vascular-targeted treatment for port-wine stains (PWS). However, the efficacy of this has varied and is difficult to predict. The objective of this study was to evaluate the efficacy of influential factors associated with HMME-PDT and provide a suitable method for predicting the efficacy. Patients with facial PWS who underwent HMME-PDT were retrospective analyzed. A total of 212 patients (93 males) with mean age of 13.01 ± 12.67 years (range, 1-51) years were included. There were 143 cases with red, 56 cases with purple, and 13 cases with hypertrophic-type PWS. The number of HMME-PDT sessions ranged 1-6. The excellent response rate after 1-4 PDT sessions was 9.4%, 17.6%, 32.7%, and 42.9%, respectively. The number of PDT treatments is associated with efficacy, and patients who underwent treatment with more than three sessions had response better than those who underwent treatment with less than three sessions (p = 0.003). Response to HMME-PDT in patients of different ages, previous treatment history, lip involvement, and vessels morphology showed significant differences after two treatment sessions (p = 0.001, 0.03, 0.014, and 0.001, respectively), while patients of different sex, subtype, lesion size, location (medial, lateral, or mixed), or non-vascular morphology showed no significant differences. Logistic regression analysis confirmed that the patients with lip hypertrophy (p = 0.002), history of more than five times prior treatment (p = 0.003), fewer PDT sessions (<3) (p = 0.000002), linear vessels (p = 0.007), and reticular vessels (p = 0.0003) showed association with poor response of HMME-PDT. In conclusion, HMME-PDT is an effective treatment for PWS. Patients who had underwent treatment for more than five times prior, lip hypertrophy, and linear vessels or reticular vessels under dermoscope showed association with poor efficacy.

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.

Noninvasive diagnostic techniques of port wine stain

Port-wine stain (PWS) is a benign capillary malformation that most commonly occurs in the head and neck. It is present at birth and progresses over time. It is formed by progressive dilatation of post-capillary venules and is associated with hypertrophy and nodularity with increasing age, leading to cosmetic disfigurement and psychological aggravation. It is caused by genetic mosaicism in GNAQ and GNA11 genes. Histopathology is the gold standard for assessment of PWS but it is invasive and may cause scarring. Inadequate characterization of the lesions may predispose to inadequate treatment protocols as well as higher treatment dosages. Clinical evaluation of treatment efficacy is subjective and may not be a representative of actual results. Therefore, an objective visualization modality is required. With evolving technology, numerous optical instruments have been developed for objective evaluation and visualization of subsurface structures. These include VISIA-CR™ system, videodermoscopy, high-frequency ultrasound (HFUS), laser speckle contrast imaging (LSCI), reflectance spectrophotometers and tristimulus colorimeter, laser Doppler flowmetry (LDF), cross-polarized diffuse reflectance imaging system (CDR), reflectance confocal microscopy (RCM), optical coherence tomography (OCT), and spatial frequency domain imaging (SFDI). These semi-quantitative modes of diagnosis are complementary to each other. Some can be used in the clinical setting while others, due to high instrument cost, are limited to the research settings. In this review, we bring to you a brief overview of noninvasive diagnostic modalities in 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.

Monitoring perfusion and oxygen saturation in port-wine stains during vascular targeted photodynamic therapy

Background

Vascular targeted photodynamic therapy (V-PDT) is a safe and effective therapeutic modality for port-wine stains (PWS) by targetedly damaging the dilated and malformed blood vessels. This study aims to monitor and quantify the changes in oxygen saturation (StO₂), blood volume fraction (BVF) and perfusion in PWS lesions before and during V-PDT.

Methods

Microvascular parameters (i.e., StO₂ and BVF) and skin perfusion were measured noninvasively by using diffuse reflectance spectroscopy (DRS) and laser Doppler imaging (LDI), respectively. The change in StO₂, BVF and perfusion that occurred in the PWS lesions of 26 patients were monitored and investigated before and during V-PDT in vivo with the systematic administration of the porphyrin-based photosensitizer HiPorfin.

Results

The mean StO₂ (P<0.05), BVF (P<0.05), and perfusion (P<0.001) in PWS lesions of all subjects significantly increased by 6%, 34%, and 113%, respectively, 3 min after the initiation of V-PDT. The StO₂ increased first and fluctuated during V-PDT. The overall trend of BVF change was consistent with the perfusion change. The BVF and the perfusion of PWS lesions increased after the initiation of V-PDT, and then gradually decreased.

Conclusions

V-PDT is an effective therapeutic modality in treating PWS. Results showed that LDI and DRS permitted the noninvasive monitoring of the changes in StO₂, BVF, and perfusion in PWS lesions during V-PDT, and these methods can be useful in facilitating our understanding of the basic physiological mechanisms during V-PDT.

Crosstalk between oxidative stress, autophagy and apoptosis in hemoporfin photodynamic therapy treated human umbilical vein endothelial cells

BACKGROUND

Photodynamic therapy (PDT) provides a treatment for port-wine stain (PWS) using hemoporfin (hematoporphyrin monomethyl ether, HMME), a novel photosensitizer, reporting better efficacy and lower recurrence rate. This study investigated the effects of HMME-PDT on human umbilical vein endothelial cells (HUVECs) as well as underlying mechanisms.

METHODS

Cell proliferation ability was measured by CCK8 assay and cell apoptosis was determined by TUNEL assay and Western blot analysis. Confocal fluorescence microscopy monitoring RFP-GFP-LC3 transfected HUVECs and Western blot analysis were used to evaluate autophagy. 3-Methyladenine (3-MA), Z-VAD-FMK, N-acetylcysteine (NAC) were used for inhibitor studies.

RESULTS

HMME-PDT decreased cell proliferation ability in an HMME concentration and light dose-dependent manner. Oxidative stress played an important role in HMME-PDT induced cell apoptosis and autophagy in HUVECs. Pretreatment with Z-VAD-FMK, the inhibitor of apoptosis, enhanced HMME-PDT induced autophagy. 3-MA, the suppressor of autophagy, significantly increased HMME-PDT induced apoptosis rates.

CONCLUSIONS

Our study demonstrated that HMME-PDT induced both apoptosis and autophagy in HUVECs via oxidative stress. Our data suggested that HMME-PDT- induced autophagy was able to prevent apoptotic cell death of HUVECs and rendered them more resistant to HMME-PDT induced toxicity.

Photodynamic Therapy Using HMME for Port-Wine Stains: Clinical Effectiveness and Sonographic Appearance

This study aims at exploring the clinical efficacy and sonographic changes of photodynamic therapy (PDT) using Hematoporphyrin Monomethyl Ether (HMME) for the treatment of port-wine stains (PWS). Forty-five patients with PWS were recruited between March 2017 and June 2018 from the Department of Dermatology of The Third Affiliated Hospital of Soochow University. Five cases were of the pink type, thirty-nine cases were of the purple-red type, and one case was of the thickened type. All patients received three treatment sessions of PDT. After covering normal skin outside the treated area, patients received an intravenous injection of 5 mg/kg HMME within 20 minutes. The affected areas were exposed to a 532 nm LED light and were kept vertically at a distance of 10 cm. The irradiation energy density was set between 80 and 110 J/cm² in 15-minute sessions. Intermittent power density adjustment was performed at a rate of 5 mW/cm², and the treatment was withheld when the endpoint reaction appeared. Three follow-ups were performed before and after treatment, respectively, and the efficacy, thickness, and density of skin before and after treatment were evaluated with high-frequency ultrasound. The overall efficacy rate was 97.78% in forty-five cases after treatment for three sessions. Efficacy was related to age (P = 0.029) and lesion severity (P < 0.001). There were significant differences in the efficacy between the groups of <18 years old, 18-29 years old, and >29 years old (P = 0.029). A marked decrease in the numbers of distorted enlarged blood vessels per unit of the lesion was observed under high-frequency ultrasound. There were significant differences in skin thickness and skin density before and after treatment (F = 14.528, 5.428, P < 0.001). The swelling was reported to varying degrees in the treated areas in 23 patients with cheek lesion and in 6 frontal lesions. Hyperpigmentation after inflammation was observed in four patients that faded spontaneously after two months. In conclusion, photodynamic therapy for the treatment of PWS using HMME is effective and safe with few adverse reactions. Moreover, monitoring the changes in skin thickness and density of lesion tissue using high-frequency ultrasound can objectively evaluate the clinical efficacy of HMME photodynamic therapy and provide the basis for the formulation of individualized photodynamic therapy.

Correlation between the hemoporfin-mediated photodynamic treatment response and the dermoscopy vascular pattern in patients with a port-wine stain: a prospective study

BACKGROUND

Vascular targeted photodynamic therapy (PDT) is a novel and promising therapy for the treatment of port-wine stains (PWS). There has been little prior exploration to our knowledge of how the dermatological vascular pattern may predict the response to PDT.

OBJECTIVES

To analyse whether the vascular pattern classifications of PWS by dermoscopy can predict the efficacy of PDT.

METHODS

This prospective cohort study included 163 patients with a clinical diagnosis of PWS who were treated twice with hemoporfin-mediated photodynamic therapy (HMME-PDT) at two-month intervals and followed up for 6 months. The vascular manifestations of dermoscopy with PWS were independently classified into 8 categories by 3 dermatologists. Images of the lesions were taken using VISIA, and the vascular patterns were imaged by dermoscopy by the same investigator. Images were captured before and after each treatment. The efficacy was evaluated with pre- and post-treatment VISIA images, and correlations between efficacy and vascular patterns were analysed by four dermatologists in a blinded and independent manner, between 10 January 2019 and 11 December 2019.

RESULTS

In the dermoscopy images for the whole cohort, dotted and globular vessels (15.3%), short clubbed vessels (18.4%) and curved vessels (12.9%) were highly associated with cure and beneficial treatment effects. Pale halos surrounding brown dots (8.0%) and arborizing vessels (9.8%) were mainly correlated with skin lesion alleviation. Mixed vessels (12.9%), a grey-whitish veil (11.7%) and reticular patterns (11.0%) were mainly associated with no effect. The differences between each subgroup were statistically significant (P = 0.000).

CONCLUSIONS

There is a clear correlation between the efficacy of PDT and the dermoscopy pattern in patients with PWS. Dermoscopy may therefore provide very useful clinical information prior to treatment in these cases. In addition, the vascular manifestations of PWS determined by dermoscopy help to predict response to PDT and manage patient expectations.

Hematoporphyrin monomethyl ether photodynamic therapy for the treatment of facial port-wine stains resistant to pulsed dye laser

BACKGROUND

Pulsed dye laser is the first treatment choice for port-wine stains. However, as some facial port-wine stains are resistant to this modality, we evaluated the efficacy and safety of hematoporphyrin monomethyl ether (hemoporfin) photodynamic therapy for the treatment of such resistant port-wine stains.

METHODS

Patients were treated with two sessions of hemoporfin photodynamic therapy in our department. Patients received an intravenous injection of hematoporphyrin monomethyl ether (5 mg/kg) followed by 532 nm LED green light therapy. Three physicians graded the improvement in the port-wine stain, using a 4-level scale. Patients' satisfaction, reaction to treatment, and adverse effects were evaluated.

RESULTS

Thirty-one patients (mean age, 23.9 ± 11.9 years, range, 3-48 years) were enrolled in this study. Hypertrophic lesions accounted for 48.4% of port-wine stain, with 80.6% of lesions being larger than 40 cm². With regard to location, 41.9% were located on the central face and 32.3% involved a mix of the central and peripheral face. After one session, a treatment response was identified in 87.1% of cases, with the response deemed 'significant' in 29.0%. After two sessions, these rates increased to 100.0% and 61.3%, respectively. The clinical effect after two sessions was significantly greater than that after one session. Treatment reactions and adverse effects were well tolerated, and included pruritus, burning sensation, pain, edema, purpura-like change, blister, crust, and hyperpigmentation.

CONCLUSIONS

Hemoporfin photodynamic therapy is a promising treatment for port-wine stains resistant to pulsed dye laser therapy.

Effect of 532nm photodynamic therapy with hemoporfin on the expression of vascular endothelial growth factor in cultured human vascular endothelial cells

BACKGROUND

Photodynamic therapy (PDT) with hemoporfin (hematoporphyrinmonomethyl ether, HMME) and 532 nm continuous-wave lasers is effective for port-wine stains (PWS) and is considered as a promising treatment modality. The vascular endothelial growth factor (VEGF) is involved in the development of PWS. This study aimed to investigate the effect of 532 nm-HMME-PDT on the in vitro expression of VEGF in human umbilical vein endothelial cells (HUVECs) exposed to different power levels of 532 nm laser and different concentrations of HMME.

METHOD

The CCK-8 assay was performed to assess cell viability. Enzyme-linked immunosorbent assay (ELISA) was performed to measure VEGF secretion. VEGF and VEGF receptor (VEGFR) mRNA expression levels were detected by quantitative reverse transcription-polymerase chain reaction (qRT-PCR).

RESULTS

Within 72 h after HMME-PDT, cell viability was inhibited, secretion and expression of VEGF was decreased, and expression of VEGFR mRNA was significantly decreased with the increase of HMME concentration.

CONCLUSION

532 nm-HMME-PDT can downregulate the expression of VEGF and VEGFR mRNA. Future studies are necessary to examine the HMME doses to achieve better efficacy with fewer adverse effects.

Retrospective study of the treatment of port-wine stains with 595-nm pulsed dye laser in 261 Chinese patients

Pulsed dye laser (PDL) at the wavelength of 595 nm is the common choice for the treatment of port-wine stains (PWSs). In this study, the efficacy of 595-nm PDL in treatment of PWSs in Chinese patients was investigated. A follow-up visit was performed on 261 Fitzpatrick skin type II-III Chinese patients with PWS who received more than two treatments with 595-nm PDL. Based on cosmetic improvement, treatment response was graded as follows: complete, if color blanching was > 90%; significant, if color blanching was 60-90%; moderate, if color blanching was 30-60%; and poor, if color blanching was < 30%. The efficacy of laser treatment on patients of different treatment numbers, ages, lesion locations, lesion colors, extents of hypertrophy, and laser pulse durations was evaluated. All patients improved following an average of almost 4 to 5 laser treatments. The earlier the intervention, the better the efficacy was. Lesions on cheek, neck, and forehead were better than that those on oral, eye periorbital, and nose areas. The purple group had a more excellent clearance, i.e., complete and significant clearance rate (53.6%), than the red group (36.1%). Treatment effect became worse as the extent of lesion hypertrophy increased. PWS lesions treated with short pulse durations of 0.45, 1.5, and 3 ms had better clearance (complete and significant clearance) rate of 56.5% than those treated with pulse durations of 6 ms or longer (34.8%). Pulsed dye laser with 595-nm laser equipped with dynamic cooling device is an effective option for the treatment of PWS in Chinese patients. Younger patients with lateral face position, larger vessel size (deeper color), and lesser hypertrophy received better clinical effect than the others. Treatment with short pulse duration of less than 3 ms for 4 to 5 times was recommended to treat PWS.

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.

The Pathogenesis of Port Wine Stain and Sturge Weber Syndrome: Complex Interactions between Genetic Alterations and Aberrant MAPK and PI3K Activation

Port wine stain (PWS) is a congenital vascular malformation involving human skin. Approximately 15-20% of children a facial PWS involving the ophthalmic (V1) trigeminal dermatome are at risk for Sturge Weber syndrome (SWS), a neurocutaneous disorder with vascular malformations in the cerebral cortex on the same side of the facial PWS lesions. Recently, evidence has surfaced that advanced our understanding of the pathogenesis of PWS/SWS, including discoveries of somatic genetic mutations (GNAQ, PI3K), MAPK and PI3K aberrant activations, and molecular phenotypes of PWS endothelial cells. In this review, we summarize current knowledge on the etiology and pathology of PWS/SWS based on evidence that the activation of MAPK and/or PI3K contributes to the malformations, as well as potential futuristic treatment approaches targeting these aberrantly dysregulated signaling pathways. Current data support that: (1) PWS is a multifactorial malformation involving the entire physiological structure of human skin; (2) PWS should be pathoanatomically re-defined as "a malformation resulting from differentiation-impaired endothelial cells with a progressive dilatation of immature venule-like vasculatures"; (3) dysregulation of vascular MAPK and/or PI3K signaling during human embryonic development plays a part in the pathogenesis and progression of PWS/SWS; and (4) sporadic low frequency somatic mutations, such as GNAQ, PI3K, work as team players but not as a lone wolf, contributing to the development of vascular phenotypes. We also address many crucial questions yet to be answered in the future research investigations.

Treatment of Previously Treated Facial Capillary Malformations: Results of Single-Center Retrospective Objective 3-Dimensional Analysis of the Efficacy of Large Spot 532 nm Lasers

BACKGROUND

Current treatment of facial capillary malformations (CM) has limited efficacy.

OBJECTIVE

To assess the efficacy of large spot 532 nm lasers for the treatment of previously treated facial CM with the use of 3-dimensional (3D) image analysis.

PATIENTS AND METHODS

Forty-three white patients aged 6 to 59 were included in this study. Patients had 3D photography performed before and after treatment with a 532 nm Nd:YAG laser with large spot and contact cooling. Objective analysis of percentage improvement based on 3D digital assessment of combined color and area improvement (global clearance effect [GCE]) were performed.

RESULTS

The median maximal improvement achieved during the treatment (GCE) was 59.1%. The mean number of laser procedures required to achieve this improvement was 6.2 (range 1-16). Improvement of minimum 25% (GCE25) was achieved by 88.4% of patients, a minimum of 50% (GCE50) by 61.1%, a minimum of 75% (GCE75) by 25.6%, and a minimum of 90% (GCE90) by 4.6%. Patients previously treated with pulsed dye lasers had a significantly less response than those treated with other modalities (GCE 37.3% vs 61.8%, respectively).

CONCLUSION

A large spot 532 nm laser is effective in previously treated patients with facial CM.

Determination of Optical and Microvascular Parameters of Port Wine Stains Using Diffuse Reflectance Spectroscopy

Characterizing port wine stains (PWS) with its optical parameters [i.e. absorption coefficient (μ a) and reduced scattering coefficient (μ s')] and microvascular parameters [i.e. blood volume fraction (BVF), mean vessel diameter (MVD), and oxygen saturation (StO2)] is extremely important for elucidating the mechanisms for its light-based treatments, such as pulsed dye laser and photodynamic therapy. In this study, a customized diffuse reflectance spectroscopy (DRS) probe with an appropriate source-detector distance was used to measure the diffuse reflectance spectra of PWS lesions in clinical practice. The results demonstrate that optical parameters of different types of PWS lesions can be accurately extracted by fitting the DRS with diffusion equation. Since the sampling depth of the probe coincides with the depth distribution of abnormal vasculature in PWS, the obtained microvascular parameters of PWS lesions that changed from pink to purple are in agreement with the corresponding physiological conditions. This study suggests that DRS can be utilized to quantitatively determine the optical and microvascular parameters of PWS lesions, which have the potential for planning the protocol and predicting the efficiency for light-based PWS treatments.