Comparative effectiveness among available treatments in difficult-to-treat port-wine stains (PWS): a Network Meta-Analysis of observational evidence

BACKGROUND

Although pulsed dye laser (PDL) is the treatment of choice for port-wine stains (PWS), clinical resistance to PDL has been observed in 20-30% of cases. Several alternative treatment modalities have been introduced; however, there is still a lack of definite recommendations regarding the optimal treatment for difficult-to-treat PWS.

OBJECTIVE

We aimed to systematically review and analyze the comparative effectiveness among treatments for problematic PWS.

METHODS & MATERIALS

We systematically searched for comparative studies assessing treatments for patients with difficult-to-treat PWS through relevant biomedical databases until August 2022. A Network Meta-Analysis (NMA) was conducted to estimate the odds ratio (OR) for all pairwise comparisons. The primary outcome is the improvement of lesions of more than 25%.

RESULTS

Of the 2498 studies identified, six treatments from five studies were available for NMA. Compared with 585 nm short-pulsed dye laser (SPDL), intense pulsed light (IPL) was the most effective in clearing lesions (OR 11.81, 95% CI 2.15 to 64.89, very low confidence rating), followed by 585 nm long-pulsed dye laser (LPDL) (OR 9.95, 95% CI 1.75 to 56.62, very low confidence rating). The 1064 nm NdYAG, 532 nm NdYAG, and LPDL >585 nm exhibited potential superiority over SPDL 585 nm, although statistical significance was not observed.

CONCLUSIONS

IPL and 585 nm LPDL are likely to be more effective than 585 nm SPDL for treating difficult-to-treat PWS. Well-designed clinical trials are warranted to confirm our findings.

A Rare Case of Blastic Plasmacytoid Dendritic Cell Neoplasm in a Child Mimicking Lymphoma/Leukemia Cutis

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare tumor that affects elderly individuals and presents a poor prognosis. Skin is the most common site of involvement, accounting for 89% of the cases. Extracutaneous organs, especially bone marrow, lymph nodes, and peripheral blood, can be involved at the time of diagnosis. We report a case of BPDCN in a child, presenting with a cutaneous lesion mimicking lymphoma or leukemia cutis. The histologic findings revealed a dense diffuse infiltration by monomorphic agranular medium-sized blast cells with sparing of the grenz zone, whose first immunophenotypic profile raised the possibility of diagnosing B lymphoblastic lymphoma or leukemia. However, the absence of CD10 expression and strongly positive expression for CD4, CD56, CD45RA, and the plasmacytoid dendritic cell-associated antigens, including CD123, supported the definite diagnosis of BPDCN. The patient responded well to a systemic combination chemotherapy regimen, modified from the Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP) protocol for anaplastic large cell lymphoma (ALCL), that differed from the established recommendation using ALL protocol. Owing to the patient’s excellent treatment outcome, this regimen could represent an effective alternative regimen for BPDCN in children.

Fluocinolone Acetonide Microemulsion in Combination with a Fractional Laser for the Treatment of Scalp Psoriasis

This study introduces fluocinolone acetonide (FA) microemulsion in combination with ablative fractional lasering as a new effective treatment for scalp psoriasis. A pseudo-ternary phase diagram was constructed using the aqueous titration method. The suitable ratio of surfactant mixture (S_mix):oil mixture (O_mix):water was chosen from the microemulsion region of the diagram. FA was loaded into the selected ratio to prepare FA microemulsion. Ex vivo skin permeation study of the FA microemulsion with fractional laser assistance was performed to determine a proper ablative depth. A pilot clinical study was conducted to evaluate the efficacy of FA microemulsion and FA microemulsion combination with lasering at the optimum ablation depth. The selected microemulsion base contained (in wt%) 77% water, 20% S_mix (Tween 80:ethanol, 2:1), 3% O_mix (10% benzyl benzoate and 1% benzyl alcohol in bergamot oil), and 0.2% sodium carboxymethylcellulose. FA was loaded into this base at a concentration of 0.1%. The skin lasered at an ablation depth of 50 µm was conducted in the pilot clinical study. Scalp psoriasis responded well to the FA microemulsion. Psoriasis scalp severity index (PSSI) scores indicated that the FA microemulsion plus laser treatment provides higher efficacy than the FA microemulsion alone without any topical and systemic side effects. The efficacy of the treatments could be maintained for at least 1 week after treatment discontinuation. FA microemulsion was properly formulated and evaluated. The microemulsion demonstrating the greatest benefits was used in combination with ablative fractional lasering to treat scalp psoriasis.

Treatment of tinea capitis with topical 1% encapsulated terbinafine hydrochloride gel: A pilot study

BACKGROUND/OBJECTIVE

Oral antifungal agents are the mainstay of the therapy of pediatric tinea capitis. No approved topical medications for tinea capitis are found. We evaluated the therapeutic efficacy, safety, and tolerability of topical 1% encapsulated terbinafine hydrochloride gel for the treatment of pediatric tinea capitis.

METHODS

An open-label clinical trial was performed on 10 children with clinical and mycologically confirmed diagnosis of tinea capitis. Each child was prescribed topical 1% encapsulated terbinafine hydrochloride gel to be applied twice daily to the full scalp for 4 weeks. Clinical and mycological examinations were assessed 2 weeks after completion of treatment. Monitoring was performed for associated side effects during the treatment and follow-up periods.

RESULTS

Ten male patients were enrolled with a mean age of 10.3 years. A cure rate of 80% (n = 8) was noted 2 weeks after treatment completion. An additional 20% (n = 2) had mycological cure with incomplete, but significant clinical improvement. No significant side effects were reported.

CONCLUSIONS

This preliminary study demonstrated that topical 1% encapsulated terbinafine hydrochloride gel was an effective treatment for tinea capitis in children.

Comparison of short-pulsed and long-pulsed 532 nm lasers in the removal of freckles

The purpose of this study was to compare the efficacy and safety of the 532 nm long-pulsed laser (10 ms) with that of the 532 nm short-pulsed laser (10 ns) for freckle removal. Currently, the gold standard for treatment is the short-pulsed laser. Recently, several long-pulsed lasers have been introduced for both hair removal and the treatment of freckles. To our investigative team's knowledge, no controlled experiments have been performed to compare the safety and efficacy of long-pulsed versus short-pulsed lasers for the treatment of freckles. This was a 4-week trial, and all patients had three freckles that were randomly allocated to be treated with short-pulse laser, long-pulse laser, or to receive no treatment (control). All patients had three freckles that were randomly selected to be treated with short-pulse 532 nm Medlite IV laser (10 n, 1 J/cm(2)), or long-pulse 532 nm Aura laser (10 ms, 1 J/cm(2)) or to remain as a control (no treatment). The laser treatment was only performed once, followed by a 1-day and a 1-month follow-up visit. Freckle size was determined by a novel surface area measurement technique that was created by our research staff. The study included 17 sets of freckles (three in each set). All of the lesions which received the short-pulsed laser treatment had immediate whitening of the lesions, which turned into dry scabs the next day. None of the freckles treated in the long-pulsed group or control group developed immediate whitening or scabs. No blisters or ulcers developed. The average pain score in the short-pulsed laser group was 2-3 out of 10, while it was 0 out of 10 in the long-pulsed laser group. All scabs that developed in the short-pulsed laser group fell off between days 6 and 12 (average 8 days). The outcome of this study verified the appropriate treatment of freckles. The study confirmed that when the same energy settings, short-pulsed laser is the more effective laser treatment regimen (when compared with the long-pulsed laser), with high tolerability and minimal side effects for patients with skin types I to IV.

Clinical pearl: the evaluation of the surface area of small pigmented lesions

The ability to calculate the surface area of small pigmented lesions is an important assessment tool, especially if one is suspicious for malignancy. Calculation of the surface area can be an arduous task if one does not have a standard technique. This article is in regards to the inexpensive and relatively easy technique of calculating the surface area of small pigmented lesions. This technique is a unique method, not described in the literature before, and may be utilized by any dermatologist at any level of experience. Our method is presented because the calculation of small pigmented lesions is an important tool to utilize, especially in cases of skin carcinoma. This technique can also be modified to calculate the surface area of much larger lesions and therefore may have a broad clinical application in the field of dermatology and cutaneous surgery.