Videomicroscopy of venular malformations (port-wine stain type): prediction of response to pulsed dye laser

Hemoporfin-Mediated Photodynamic Therapy for Port-Wine Stains on Extremities

INTRODUCTION

Pulsed dye laser (PDL) is currently considered to be the first-line treatment for port-wine stains (PWSs) on the extremities despite its less than satisfactory therapeutic efficacy. Hemoporfin-mediated photodynamic therapy (HMME-PDT) is a vascular-targeted therapy that has rarely been used to treat PWSs on the extremities. Here, we evaluate the clinical efficacy and safety of HMME-PDT for the treatment of PWSs on the extremities.

METHODS

Clinical data and dermoscopic images of PWSs on the extremities were obtained from 65 patients who underwent HMME-PDT between February 2019 and December 2022. The clinical efficacy of HMME-PDT was analyzed by comparing the pre- and post-treatment images. The safety of HMME-PDT was evaluated through observation during the treatment period and post-treatment follow-up.

RESULTS

The efficacy rate of a single HMME-PDT session was 63.0% and that of two and three to six sessions was 86.7% and 91.3%, respectively. A positive correlation was found between therapeutic efficacy and the number of HMME-PDT sessions. The therapeutic efficacy of HMME-PDT was better on the proximal extremities than on other parts of the extremities (P = 0.038), and the efficacy of treating PWSs in each site was relatively improved with an increase of treatment time. The clinical efficacy of HMME-PDT differed across four PWS vascular patterns identified by dermoscopy (P = 0.019). However, there was no statistical difference in the therapeutic efficacy based on age, sex, type of PWS, and treatment history (P > 0.05), which may be partly attributed to the relatively small sample size or poor cooperation of infant patients. No obvious adverse reactions were observed during the follow-up period.

CONCLUSIONS

HMME-PDT is a very safe and effective treatment for PWSs on the extremities. Multiple HMME-PDT treatments, lesions located in proximal limbs, and PWSs with type I and IV vascular patterns under dermoscopy were associated with higher efficacy of HMME-PDT. Dermoscopy may help predict the clinical efficacy of HMME-PDT.

TRIAL REGISTRATION NO

2020KJT085.

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.

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.

Dermoscopic features of port-wine stains: A study of 264 cases

BACKGROUND

Port-wine stains (PWS) occur in 0.3-0.5% of the population. However, the dermoscopic features of PWS have not been systematically studied.

METHODS

Dermoscopic images of 264 cases with PWS were retrospectively analysed.

RESULTS

Linear vessels were the most frequent dermoscopic features of PWS (42.0%). Other dermoscopic features were reticular vessels (28.0%), sausage-like vessels (13.6%), dots or globules vessels (9.1%) and mixed vessels (7.2%). Nonvascular morphology comprised white circles (13.6%) and whitish veil (38.3%). Sausage-like vessels and whitish veil were mainly present in the thickened type and in those with PWS aged ≥18 years; mixed vessels were mainly present in purple type of PWS. Dermoscopic features showed no significant difference between lesions located on different facial areas (V1, V2 and V3). Dots or globular vessels were more common in non-facial lesions (P < 0.0001). White circles were only found in the facial lesions, and the frequency of white circles and whitish veil was higher in the treated group than in the untreated group (P = 0.004 and P = 0.04, respectively). The frequency of white circles was significantly higher in the prior treated group than in the untreated group (P < 0.0001).

CONCLUSION

There are various of dermoscopic features of PWS. The dermoscopic features of patients with PWS may correlate with age, subtype, location, prior treatment history and pulsed dye laser (PDL) resistance.

A new clinical and dermoscopic monitoring of infantile hemangiomas treated with oral propranolol

Oral propranolol (OP) demonstrated high efficacy and safety profile for treatment of critical infantile hemangiomas (IHs). Our aim was to assess the morphologic changes of IHs with standard and high-resolution video dermoscopy (HRVD) from baseline to 18 months either in presence or absence of OP therapy; to investigate if extended anamnestic perinatal data and clinical-dermoscopic characteristics of the IHs can correlate with therapeutic outcome. We enrolled 94 patients (112 IHs): 58 were treated with OP, 35 (42 IHs) for 6 months (group 1), and 23 (25 IHs) for 12-months (group 2); 36 (45 IHs) were followed-up. Clinical-dermoscopic examinations were performed every 3 months during therapy and follow-up. Among 67 treated IHs, superficial and deep IHs with homogenous clinical-dermoscopic aspect developed after the 2 weeks of life achieved the better outcome, stable at 9-month follow-up, independently form treatment duration. Under HRVD, glomerular vessels were prevalent at baseline; corckscrew, comma, and linear-irregular vessels were the prevalent pattern at 1, 3, and 6 months of therapy, respectively. At 12-month follow-up, adequate healing was achieved by 96% of IHs in group 2 and by 78% in group 1, showing dotted vessels. Persistent IHs displayed a reticulated aspect and linear irregular vessels, while arborizing vessels characterized relapsed IHs. A 12-month OP therapy can be considered for newborns presenting with nonhomogenous mixed IHs >3 cm on the perineal area/lower extremities. In conclusion, HRVD allows a real time monitoring of vascular changes in IHs treated with OP and can support physicians in identifying relapses before they become clinically evident.

A practical review of dermoscopy for pediatric dermatology part II: Vascular tumors, infections, and inflammatory dermatoses

In addition to the evaluation of melanocytic growths (Part I), dermoscopy is helpful in the identification and management of vascular tumors, skin infections, and inflammatory conditions. In this practical review, we present the classic dermoscopic findings of the following: vascular tumors, infectious conditions (molluscum contagiosum, scabies, verruca vulgaris), inflammatory conditions (psoriasis, atopic dermatitis), juvenile xanthogranuloma, and nevus sebaceus.

Application of different noninvasive diagnostic techniques used in HMME-PDT in the treatment of port wine stains

BACKGROUND

Hematoporphyrin monomethyl ether photodynamic therapy (HMME-PDT) is an effective method for treating port wine stains (PWS). However, methods to evaluate the treatment of HMME-PDT for PWS effectively and objectively are lacking.

OBJECTIVE

This study aimed to describe the different noninvasive diagnostic techniques used in the evaluation of treatment response to HMME-PDT for PWS.

METHODS

Thirty-one lesions of 22 patients with PWS were treated with HMME-PDT. Four noninvasive diagnostic techniques including VISIA-CR™ system, dermoscopy, high-frequency ultrasound (HFUS), and laser speckle contrast imaging (LSCI) were used to obtain standard radiographic data on skin color, skin thickness, blood vessel morphology, blood vessel distribution, and blood perfusion from lesions and surrounding normal skin before and after HMME-PDT.

RESULTS

The standard image pattern of VISIA-CR™ system showed color change in the lesions of PWS after HMME-PDT. RBX red image of VISIA-CR™ system showed that erythema was highly aggregated even in invisible lesions at baseline but decreased after HMME-PDT. The erythema index reduced value d was related to the efficacy rating (γ = 0.631, P < 0.05). Dermoscopy showed that the number of spot-like and irregular linear vessels increased, which was correlated with the increase in clinical classification. After HMME-PDT, vascular rupture was observed by dermoscopy. The response rate of lesions with vascular rupture was 100.00% (20/20). Moreover, the response rate of lesions without vascular rupture was 63.64% (7/11). Vascular rupture sign was correlated with better efficacy (P < 0.05). HFUS showed that the dermis of PWS thickened and was arranged loosely with scattered linear hypoechoic signal. After HMME-PDT, the dermal layer of the lesions became thinner with a decreased linear hypoechoic signal. The response rate of the lesions with linear hypoechoic signal was 76.92% (10/13), and that without linear hypoechoic signal was 94.44% (17/18). The lesions without linear hypoechoic signal in the dermis showed better efficacy (P < 0.05). In some lesions, LSCI showed high blood perfusion signal in PWS lesions and blood perfusion reduction after HMME-PDT.

CONCLUSION

VISIA-CR™ system can be used to observe not only visible but also invisible lesions of PWS. Moreover, lesions fading after HMME-PDT can be described objectively by VISIA-CR™ system. Dermoscopy played an important role in the clinical classification of PWS, including assessing vascular injury after HMME-PDT, guiding the adjustment of therapeutic dose, and selecting the end point of treatment. Both HFUS and LSCI can be used to assist treatment response evaluation of HMME-PDT.

Rhodamine intense pulsed light versus conventional intense pulsed light for facial telangiectasias

Facial telangiectasias represent the major aesthetic alterations of several chronic inflammatory disorders arising on facial skin. We herein report on relevant clinical results of a new subtype of intense pulsed light treatments, the so-called rhodamine intense pulsed light (r-IPL), in comparison with conventional IPL (c-IPL) treatments on forty-five patients affected by facial telangiectasias. The aim of this study is to determinate whether r-IPL represents an effective and safe treatment for the most common superficial vascular alterations and could be advised as a first choice therapy for facial telangiectasias.

Unconventional use of intense pulsed light

According to the literature, intense pulsed light (IPL) represents a versatile tool in the treatment of some dermatological conditions (i.e., pigmentation disorders, hair removal, and acne), due to its wide range of wavelengths. The authors herein report on 58 unconventional but effective uses of IPL in several cutaneous diseases, such as rosacea (10 cases), port-wine stain (PWS) (10 cases), disseminated porokeratosis (10 cases), pilonidal cyst (3 cases), seborrheic keratosis (10 cases), hypertrophic scar (5 cases) and keloid scar (5 cases), Becker's nevus (2 cases), hidradenitis suppurativa (2 cases), and sarcoidosis (1 case). Our results should suggest that IPL could represent a valid therapeutic support and option by providing excellent outcomes and low side effects, even though it should be underlined that the use and the effectiveness of IPL are strongly related to the operator's experience (acquired by attempting at least one specific course on the use of IPL and one-year experience in a specialized centre). Moreover, the daily use of these devices will surely increase clinical experience and provide new information, thus enhancing long-term results and improving IPL effectiveness.

Use of reflectance spectrophotometry to predict the response of port wine stains to pulsed dye laser

Reflectance spectroscopy can be used to quantitate subtle differences in color. We applied a portable reflectance spectrometer to determine its utility in the evaluation of pulsed dye laser treatment of port wine stains (PWS) and in prediction of clinical outcome, in a prospective study. Forty-eight patients with PWS underwent one to nine pulsed dye laser treatments. Patient age and skin color as well as PWS surface area, anatomic location, and color were recorded. Pretreatment spectrophotometric measurements were performed. The subjective clinical results of treatment and the quantitative spectrophotometry results were evaluated by two independent teams, and the findings were correlated. The impact of the clinical characteristics on the response to treatment was assessed as well. Patients with excellent to good clinical results of laser treatments had pretreatment spectrophotometric measurements which differed by more than 10%, whereas patients with fair to poor results had spectrophotometric measurements with a difference of of less than 10%. The correlation between the spectrophotometric results and the clinical outcome was 73% (p < 0.01). The impact of the other clinical variables on outcome agreed with the findings in the literature. Spectrophotometry has a higher correlation with clinical outcome and a better predictive value than other nonmeasurable, nonquantitative, dependent variables.

Dermoscopy for the pediatric dermatologist, part ii: dermoscopy of genetic syndromes with cutaneous manifestations and pediatric vascular lesions

Genetic syndromes including basal cell nevus syndrome (BSNS), xeroderma pigmentosum (XP), and epidermodysplasia verruciformis (EV) predispose the individual to skin cancer. Basal cell carcinomas (BCCs) often develop in patients with BCNS and XP. One of the aims of surveillance examination in these patients is to detect BCC while the tumors are still small and easy to manage. Dermoscopy, by allowing the visualization of arborizing vessels, ovoid nests, nonaggregated blue-gray globules, and spoke-wheel and leaf-like structures, can facilitate in the early detection of BCC. Patients with XP are also at risk for developing squamous cell carcinoma (SCC). Dermoscopy can assist in the early detection of these cancers by allowing the observer to visualize focal glomerular vessels, which is a common feature seen in SCC. This feature can also assist in detecting SCC developing in other syndromes such as EV and epidermolysis bullosa (EB). In addition to helping in the detection of BCC and SCC, dermoscopy can also help detect melanoma in individuals with XP and evaluate nevi developing in those with EB. This review will discuss how dermoscopy can be used in the management of patients with BSNS, XP, EV, and EB and will discuss the dermoscopic findings of vascular lesions, including pyogenic granuloma, hemangioma, port-wine stain, and lymphangioma circumscriptum.

The expression of vascular endothelial growth factor and its receptors in port-wine stains

OBJECTIVE

To investigate the expression of vascular endothelial growth factor (VEGF) and its receptor (VEGF-R2) in port-wine stains (PWSs).

DESIGN

An immunohistochemistry (IHC) study on formalin-fixed, paraffin-embedded specimens.

METHODS

Representative sections from surgical resection specimens of 12 PWS patients and 12 control specimens stained with routine IHC by using polyclonal anti-VEGF and anti-VEGF-R2 antibodies. Slides were evaluated semiquantitatively for the intensity of staining for VEGF and VEGF-R2 by using a scoring system varying from 0 to 3+.

RESULTS

PWS specimens showed statistically significant overexpression of both VEGF and VEGF-R2 molecules when compared with control specimens (P < 0.005).

CONCLUSIONS

VEGF and its receptor may play an important role in the pathogenesis of PWS. It is possible that PWS may progress by hyperplasia in addition to hypertrophy. VEGF-R blockade may have a potential role as a targeted approach in the treatment of this disfiguring condition in the future.

Dermoscopic features in Bean (blue rubber bleb nevus) syndrome

Dermoscopy has become an important tool for evaluating skin lesions in children. We report the dermoscopic findings in a case of Bean syndrome and emphasize the utility of this technique in vascular lesions.

Treatment of pulsed dye laser-resistant port wine stain birthmarks

The concept of selective photothermolysis with the 577-/585-nm pulsed dye laser (PDL) revolutionized treatment of relatively common port wine stain (PWS) birthmarks. The majority of PWS can be significantly lightened with the PDL. However, few PWS are lightened completely with PDL and up to 20% hardly lighten at all. PDL-resistant PWS exist in any large cutaneous laser practice and constitute a difficult management problem. This article discusses the proposed cause, and currently available and emerging options for PDL-resistant PWS. These include higher power, longer wavelength, variable pulse width lasers with selective epidermal cooling such as 595-nm PDL, 755-nm alexandrite, 810-nm diode, 1064-nm neodymium:yttrium-aluminum-garnet, and intense pulse light systems. Other promising modalities include topical and systemic photodynamic therapy, electrical optical synergy technology, pulse stacking of similar or differing wavelengths, use of optical clearing agents in conjunction with laser, and erbium laser epidermal stripping before laser treatment.

Láser y otras fuentes de luz en el tratamiento de manchas en vino de Oporto

Laser treatment of vascular skin lesions is rapidly improving. Port wine stain (PWS) is one of the first lesions successfully treated with laser. The pulsed dye laser (PDL) has been developed on the concept of selective photothermolysis and has revolutionized PWS treatment. Even though the response is variable, substantial blanching can be obtained after several sessions. Greater selectivity and better response have been achieved by modifying PDL parameters such as longer pulse width, longer wavelength, or higher energy fluencies with cooling skin devices. It is known that thick, deep or raised lesions present poor response to conventional treatments. The aim of this study is to review the different lasers and other light sources which are developing for the treatment of PWS and other vascular lesions.

Thickness of Healthy and Affected Skin of Children with Port Wine Stains: Potential Repercussions on Response to Pulsed Dye Laser Treatment

BACKGROUND

Response of port wine stain to pulsed dye laser therapy is variable and dependent on treatment settings used and anatomic site as well as on size and depth of ectatic vessels.

OBJECTIVE

Our purpose was to evaluate skin thickness in different anatomic areas and in port wine stain to thus assess its possible role in the response to pulsed dye laser.

MATERIALS AND METHODS

Twenty-one children with port wine stain underwent high-frequency ultrasound evaluation (20 MHz). Eighteen unaffected areas were considered in each patient and an additional measure was taken from the symmetric affected skin when present (50 areas).

RESULTS

Skin was thicker in the centrofacial area, dermatome V1 (followed by dermatome V2, dermatome V3, and dermatomes C1-2), and with increasing age. No substantial difference between affected and symmetric nonaffected skin was found.

CONCLUSION

Thicker cutaneous areas fit with those that typically respond worse to pulsed dye laser. Differences in skin thickness related to age support the fact that better responses are achieved in younger patients.