Complication rates and safety of pulsed dye laser treatment for port-wine stain: a systematic review and meta-analysis

Pulsed dye laser (PDL) is the most commonly used method for port-wine stain (PWS); however, no studies have reported the safety of PDL. This review aimed to collect and summarize complications reported in relevant literature, assess complication rates in treating PWS with PDL, and explore the relevant influencing factors. A systematic review and meta-analysis were conducted to search for related studies in PubMed, Embase, and the Cochrane Library until August 2022. Two reviewers independently evaluated the risk of bias of included studies. Stata Software version 17.0 was used for the analysis. All complications reported in the literature are divided into acute phase complications and long-term complications. Overall pooled purpura, edema, crusting, blistering, hyperpigmentation, hypopigmentation, and scarring rates were 98.3%, 97.6%, 21.5%, 8.7%, 12.8%, 0.9%, and 0.2%, respectively. Although the acute adverse reactions were found to be common, the long-term permanent complications clearly have a lower frequency, and the occurrence of scarring is much lower than that initially thought. This indicates that effective protective measures after treatment are very important for preventing scar formation. Overall, PDL treatment for PWS shows a high level of safety and low chances of causing long-term complications.

Largest comparative analysis: Novel large spot size 595 nm, high-energy, pulsed dye laser reduces number of treatments for improvement of adult and pediatric port wine birthmarks

OBJECTIVE

Port wine birthmarks (PWBs) are vascular malformations affecting 0.3%-0.5% of newborns with the tendency to persist into adulthood without adequate treatment of the heterogenous ectatic vessels. This study compares treatment outcomes and parameters of the prior generation pulsed dye laser (PPDL) and the larger spot novel generation pulsed dye laser (NPDL) to establish whether a larger spot size laser provides greater clearance with fewer treatments.

METHODS

One hundred and sixty patients were treated with either the PPDL (80 patients) and NPDL (80 patients) with retrospective review of age, body site, laser treatment parameters, number of treatments, and improvement following laser therapy.

RESULTS

Patients treated with PPDL were older on average than patients treated with NPDL (mean 24.8 ± 19.7 vs. mean 17.1± 19.3 years, p < 0.05). The majority of lesions treated with PPDL were located on the face and neck, whereas truncal and extremity sites were more frequently treated with the NPDL. Use of NPDL was associated with a mean maximum spot size of 13.1 mm and mean maximum fluence of 7.3 J/cm2 with pulse durations of 0.45-3 ms, whereas use of the PPDL was associated with a mean spot size of 10.8 mm and mean maximum fluence of 8.8 J/cm2 with pulse durations of 0.45-6 ms. Fifty percent improvement was seen with 8.8 PPDL treatments compared to 4.3 NPDL treatments (p ≤ 0.01) with no significant difference in overall mean improvement between both devices at the chosen parameters. Multiple regression analysis showed that device type, not age or lesion location, was the only statistically significant independent variable to affect the endpoint of at least 50% improvement of the lesion.

CONCLUSIONS

Use of the larger spot NPDL is associated with achieving 50% improvement with fewer treatments.

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.

Time interval between pulse dye laser treatments of port-wine stains: 30 years of experience

Port-wine stains (PWS) are frequently refractory to laser treatments. The aim of this study is to evaluate the role of treatment interval time. From 1990, 216 patients underwent Pulsed Dye Laser sessions. The laser sessions were scheduled at a minimum interval of 4 weeks to a maximum of 48 weeks. Clinical outcomes were assessed 8 weeks after the last laser session. Better results were obtained with 8 weeks interval time between therapy session, and high efficacies were also found for intervals of 4, 6 and 10 weeks. For greater interval instead, the effectiveness is significantly lower.

Extended Application of Fractional Carbon Dioxide Laser in the Treatment of Port Wine Stain Birthmarks with Hypertrophy: A Case Report

Background: Conventional treatments of port wine stain birthmarks often do not achieve the desired outcome in patients with hypertrophy. Potential reasons include deeper and larger blood vessels, abnormal arrangement of blood vessels, and darker or thicker epidermis. However, these factors may not significantly limit the efficacy of fractional carbon dioxide (CO2) laser. The aim of this case report was to examine the extended application of fractional CO2 laser in treating patients with hypertrophic port wine stain birthmarks. Methods: Two cases with hypertrophic port wine stain birthmarks treated with fractional CO2 laser for 5 years are described in this case report. Results: When compared with conventional treatment, both cases reported better outcomes, including a reduced risk of infection, pigmentation, and scarring, a decrease of clinical erythema, and much less pain. Conclusions: The findings demonstrate that fractional CO2 laser has the potential to be an effective modality for the treatment of patients with hypertrophic port wine stains.

Wavelength optimization for the laser treatment of port wine stains

Based on the well-known principle of selective photothermolysis, laser has been a promising way for the treatment of port wine stains (PWSs). The laser wavelengths used for PWS's clinical treatment include but are not limited to pulsed dye laser (PDL) in 585-600 nm, long-pulse 755-nm alexandrite, and 1064-nm Nd:YAG lasers. The objective of this study was to investigate the optimal wavelength for PWS's laser treatment. A two-scale mathematic model was constructed to simultaneously quantify macroscale laser energy attenuation in two-layered bulk skin and microscale local energy absorption on target blood vessels within Krogh unit. The effects of morphological parameters, including epidermal melanin content, epidermal thickness, dermal blood content, blood vessel depth, and diameter on laser energy deposition within target blood vessels, were investigated from the visible to near-infrared bands (500-1100 nm). The energy deposition ratio of target blood vessel to epidermal surface was proposed to determine the optimal laser wavelength for PWS with different skin morphological parameters. The bioheat transfer modeling and animal experiment are also conducted to prove our wavelength optimization. The optimal wavelengths for lightly pigmented skin with small and shallow target blood vessels are 580-610 nm in the visible band. This wavelength coincides with commercially used PDL. The optimal wavelength shifts to 940 nm as the epidermal pigmentation increases or the size and blood vessel depth increases. The optimal wavelength changes to 1005 nm as the epidermal pigmentation or the size and burying depth of target blood vessel further increases. Nine hundred forty nanometers can be selected as a general wavelength in PWS treatment to meet the need in most widely morphological structure. Lasers with wavelengths in the 580-610, 940, and 1005 nm regions are effective for treating PWS because of their high optical selectivity in blood over the epidermis.

Port-Wine Stains: A Focused Review on Their Management

<p>Port-wine stain (PWS) is the second most common congenital vascular malformation characterized as ectatic capillaries and venules in the dermis that clinically appears as a deep red to purple patch on the skin. Typically, PWS progressively darken and may become hypertrophic or nodular without treatment. There are several treatment options available for PWS from topical antiangiogenic agents to laser therapies. Vascular-specific lasers are the gold standard in treating PWS and classically pulsed dye lasers are usually the treatment of choice. However, some patients with PWS are recalcitrant to PDL and may require a combination of treatment methods. Nonetheless, even with the advancements in laser therapies utilized today, it is can be difficult to achieve complete clearance of the PWS. Thus, new innovations for treating recalcitrant PWS are underway in order to improve overall patient treatment outcomes.</p> <p><em>J Drugs Dermatol. 2017;16(11):1145-1151.</em></p>.

Double phase treatment with flashlamp-pumped pulsed-dye laser and long pulsed Nd:YAG laser for resistant port wine stains in adults. Preliminary reports

BACKGROUND

Flashlamp-pumped pulsed (FLPP) dye laser still represents the standard treatment for the majority of port wine stains (PWSs), but the results on thick PWSs remain unpredictable, and many of these lesions fail to completely respond. Our aim was to report on the results obtained on unresponsive PWSs to standard laser treatments, by using a double phase laser treatment strategy using two laser passes in the same session.

METHODS

Eleven adult patients with facial PWS resistant to dye laser were enrolled. Laser sessions were scheduled every 8 weeks, and each of them consisting of two laser passes. In phase one, two different laser wavelengths (595 nm and 1064 nm) were delivered consecutively to each affected area. In the second phase, the PWS was treated using a pulse stacking technique with the 1064 nm Nd:YAG.

RESULTS

One patient was lost to follow-up. Among the remaining ten, 5 (50%) patients showed an excellent improvement (>75%), 3 (30%) patients showed a good improvement (51-75%), and 2 (20%) patients had no or minimal improvement (0-25%).

CONCLUSIONS

Our results suggest that the combination of different wavelengths in the same session can be helpful for PWSs resistant to standard laser treatments. However, in most patients two treatment phases were necessary.

A Split-Face Study of Dual-Wavelength Laser on Neck and Facial Port-Wine Stains in Chinese Patients

BACKGROUND

Although pulsed dye laser (PDL) has long been regarded as the gold standard in treating port-wine stain (PWS), advanced PWS with deeper coloration may display resistance because of limited penetration depth of 585 or 595-nm light. Recently, a dual-wavelength laser system has been reported to achieve pronounced fading in many patients.

OBJECTIVE

The objective was to evaluate the efficacy and safety of a dual-wavelength laser device in treatment of neck and facial PWS in a direct side-by-side comparison.

METHODS

Sixteen Chinese patients with neck and/or facial PWSs were enrolled in the study. All lesions were randomly divided into two area, treated area and adjacent untreated area. Five successive treatments using a dual-wavelength laser system (595-nm PDL combined with 1,064-nm Nd:YAG laser) were delivered on treated areas at 4- to 6-week intervals. The adjacent area was not treated as self control. Two blinded dermatologists evaluated the clinical changes by comparing the before and after photos. Erythema index (EI) values were measured with a non-invasive instrument.

RESULTS

After five sessions of treatment, over 62.5% (10/16) patients achieved more than 50% (moderate or significant) improvement. The efficacy maintained at the 3-month follow-up visit. The values of EI on treated area showed a significant decrease. Adverse effects of treated area were limited.

CONCLUSION

Using this split-face module, the dual-wavelength laser system is proved to be effective and well tolerated in treating neck and facial PWSs in Chinese patients. Adverse effects were minimal and acceptable.

[Potential and limitations of dye laser therapy for capillary malformations]

Capillary malformations (port-wine stains) are observed in less than 1 % of neonates and may occur coincidentally with other vascular and nonvascular malformations. Two thirds of lesions occur in the head and neck area and may have important cosmetic and psychological implications for the patients. Treatment with flashlamp-pumped pulsed dye lasers is still the therapy of choice for capillary malformations and can be applied to infants. If the laser device is used appropriately, the rate of persistent side effects is low. Although laser treatment achieves good clearance in the majority of patients with capillary malformations, complete clearance is rare. New therapeutic options are thus urgently required.

Multiple Basal Cell Carcinomas Arising in a Port-Wine Stain with a Remote History of Therapeutic Irradiation

The coexistence of a basal cell carcinoma and a port-wine stain is a very rare condition that may be associated with previous treatments. We present a case of multiple basal cell carcinomas developing within the boundaries of a port-wine stain, which had been treated with a tholium X and argon laser. Our case suggests that port-wine stains which were previously treated with irradiation or argon laser should be examined carefully and regularly by both physician and patient, because they may hide basal cell carcinomas.

Simulating light transport through skin for color prediction of port wine stain lesions: a review

A survey of the literature is presented regarding the simulation of port wine stain (PWS) skin color. Knowledge of PWS features, such as the depths and diameters of affected vessels, is essential for informing laser treatment. These may be determined through the inverse application of a skin model. The techniques which have been applied to achieve this are analyzed in detail. Radiative transfer (RT) is found to be the preferred method of simulation. By far the most common approximations to RT are the diffusion approximations, which have been applied successfully in the past and Monte Carlo techniques, which are now the methods of choice. As the requirements for improvement of laser treatment on an individual basis continues, the needs for further work towards accurate estimations of individual optical coefficients and robust, flexible simulation techniques are identified.

New optional photodynamic therapy laser wavelength for infantile port wine stains: 457 nm

To expand the optional laser wavelengths of photodynamic therapy (PDT) for port wine stain (PWS), the feasibility of applying a 457 nm laser to the PDT for infantile PWS was analyzed by mathematical simulation and was validated by clinical experiment. Singlet oxygen yield of 457 nm PDT or 532 nm PDT in an infantile PWS model and an adult PWS model was theoretically simulated. Fifteen PWS patients (14 infants and 1 adult) with 40 spots were treated with 457 nm (20 spots) and 532 nm (20 spots), respectively, in two PDT courses. Simulation results showed that under the same power density and irradiation time, singlet oxygen yield of 457 nm PDT and 532 nm PDT are similar in infantile PWS vessels. Yet, in adult PWS vessels, singlet oxygen yield of 457 nm PDT is lower than 532 nm PDT. Clinical outcomes showed that no statistic difference existed between 457 nm PDT and 532 nm PDT for infantile PWS. The result of this study suggested that 457 nm wavelength laser has the potential to be applied in PDT for infantile PWS.

Laser treatment of dark skin: an updated review

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements. Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults. Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.

Fast and robust extraction of optical and morphological properties of human skin using a hybrid stochastic-deterministic algorithm: Monte-Carlo simulation study

A hybrid deterministic-stochastic algorithm combining the simplex method (SM) and a genetic algorithm (GA) was applied to the problem of extracting the optical and morphological properties of human skin (HSOMPs) from visual reflectance spectroscopy data. The results using the GA-SM hybrid algorithm adopting tournament selection and selecting new sets of HSOMPs were compared with those using other conventional optimization algorithms that have generally been used for the extraction of HSOMPs. Monte-Carlo simulation showed that the suggested GA-SM hybrid algorithm enhanced the stability of the inverse solutions and computational efficiency.

Blood flow dynamics after laser therapy of port wine stain birthmarks

BACKGROUND AND OBJECTIVE

During laser therapy of port wine stain (PWS) birthmarks, regions of perfusion may persist. We hypothesize that such regions are not readily observable even when laser surgery is performed by highly experienced clinicians. The objective of this study was to use objective feedback to assess the acute vascular response to laser therapy.

STUDY DESIGN/MATERIALS AND METHODS

A clinic-friendly laser speckle imaging (LSI) instrument was developed to provide the clinician with real-time images of blood flow during laser therapy. Images were acquired from patients undergoing laser therapy of PWS birthmarks at Scripps Clinic and the Beckman Laser Institute and Medical Clinic. Blood flow maps were extracted from the acquired imaging data. Histogram-based analysis was applied in grading the degree of heterogeneity present in the blood flow maps after laser therapy.

RESULTS

Collectively, two types of patient responses were observed in response to laser exposure: (1) an immediate increase in perfusion within minutes after laser therapy; and (2) an overall decrease in blood perfusion approximately 1 hour after laser therapy, with distinct regions of persistent perfusion apparent in the majority of post-treatment blood-flow images. A comparison of blood flow in PWS and adjacent normal skin demonstrated that PWS blood flow can be greater than, or sometimes equivalent to, that of normal skin.

CONCLUSION

In general, a decrease in skin perfusion is observed during pulsed laser therapy of PWS birthmarks. However, a heterogeneous perfusion map was frequently observed. These regions of persistent perfusion may be due to incomplete photocoagulation of the targeted vessels. We hypothesize that immediate retreatment of these regions identified with LSI, will result in enhanced removal of the PWS vasculature. Lasers Surg. Med. 41:563-571, 2009. (c) 2009 Wiley-Liss, Inc.

Hair ignition by dye laser for port-wine stain: risk factors evaluated

Flashlamp-pumped pulsed dye laser is the preferred treatment for port-wine stain. Vascular hemoglobin and epidermal melanin are competing sites for dye laser absorption and damage. The case presented illustrates the potential hazard of ignition induced by dye laser treatment on the face of a patient receiving inhalation anesthesia. A 6-year-old girl with almost black hair was treated for a port-wine stain covering most of the right half of her face. She was treated with dye laser under general anesthesia administered by mask. A laser pulse close to the upper part of the eyebrow induced a blaze and the eyebrow was instantly destroyed by the fire. Regrowth of the eyebrow was complete after a few months. Hair specimens of various colors were exposed experimentally to dye laser irradiation in room and oxygen-saturated atmospheres. Risk factors of ignition are high laser dosage, a high oxygen level, repeated pulses and dark colored hair.

Treatment of nodules associated with port wine stains with CO2 laser: case series and review of the literature

BACKGROUND

Port wine stains (PWS) are congenital malformations of capillaries, where with progression, blood vessels become ectatic and result in disfiguring nodules.

OBJECTIVE

To search the MEDLINE database and review literature on the treatment of PWS and present 2 cases of adults with PWS, complicated by hypertrophic and nodular lesions, treated successfully with CO2 laser.

RESULTS

Two patients with PWS, with nodular and hypertrophic areas, were treated with CO2 laser. With the first patient, improvement of 90% or greater was noted in the 14 discrete nodules present within the PWS in a V2 distribution. At baseline, ectropion of the lower eyelid was noted which resolved completely after CO2 laser. With the second patient, improvement was noted as 90% or greater in the 40 of 51 discrete nodules present within the PWS extending across the right V1-V2 distribution.

CONCLUSION

Carbon dioxide ablative laser resurfacing is safe and highly effective in the treatment of the nodular and hypertrophic components of PWS. Future treatment of PWS will likely involve a hybrid approach of utilizing nonablative lasers of varying wavelengths and pulse durations and treatment with novel laser devices, with the goal of early treatment to prevent progression of PWS to disfiguring lesions.

Patient perceptions of 595 nm pulsed dye laser through glass compression in the treatment of thick port wine stains and superficial venous malformations

In treating thickened port wine stains and superficial venous malformations with the 595 nm pulse dye laser, we have sometimes compressed the lesion with a glass slide to enable the laser beam to penetrate more deeply. In order to evaluate the patients' perception of this modality, 54 subjects were treated with glass compression using ice applications to cool the skin surface and without glass compression using a cryospray to cool the surface. The subjects were asked to rate the difference in 2 questionnaires after the first and second treatments as to effectiveness, pain of procedure, and overall preference. Of those subjects who perceived a difference between modalities, a significant number perceived treatments with glass compression to be more effective than without (p=0.0002 and p=0.0006), but more painful (p<0.0001). There was no significant difference in overall preference. Blistering occurred in 5 subjects when the glass slide was left on the skin more than 1 minute between ice applications.

Treatment of Vascular Skin Lesions with the Variable Pulse 595 nm Pulsed Dye Laser

BACKGROUND

In the dermatology field, variable-pulse 595 nm pulsed dye lasers (PDLs) are now being widely used to treat vascular skin lesions. However, there is little information available on variable-pulse 595 nm PDL treatment of dark-skinned patients.

OBJECTIVE

The objective of this study was to evaluate the outcome of variable-pulse 595 nm PDL treatment on Korean patients.

METHOD

Two hundred thirty-nine patients (Fitzpatrick skin phototypes III to V) with vascular skin lesions, such as nevus flammeus, telangiectasia, or hemangioma, were included in this study. All patients were treated with a variable-pulse 595 nm PDL, and the outcomes were assessed by comparing preoperative and postoperative photographs.

RESULTS

The average number of treatments per patient was 4.29, and 51.9% of patients showed a good (51-75% clearance) to excellent (76-100% clearance) response. For nevus flammeus, 48.0% of the patients achieved good to excellent results. The gender and age of the patients did not influence the clinical response; however, lesions of the head and neck were found to respond more favorably to treatment. For telangiectasia, 78.0% of patients showed good to excellent results, and, again, the gender and age of the patients did not alter the treatment outcome. For hemangioma, the male to female ratio of patients was 1.0:3.1 and 54.1% of the patients achieved a good to excellent response. Superficial hemangioma showed a better clinical response than deep hemangioma, and the lesions of younger patients responded more favorably than those of older patients.

CONCLUSION

The variable-pulse 595 nm PDL was found to be effective for treating several vascular skin lesions in dark-skinned patients. However, there were differences in treatment outcome owing to disease, age, and the location of the lesions.

Does dye laser treatment with higher fluences in combination with cold air cooling improve the results of port-wine stains?

BACKGROUND AND OBJECTIVE

The use of cold air cooling (CAC) and cryogen spray cooling during dye laser treatment of port-wine stains (PWS) has become a standard in recent years. Still unsolved is the question of which fluences are necessary in combination with CAC in order to achieve an optimum clearance and the lowest possible rate of side-effects.

STUDY DESIGN

In a prospective study, we treated 11 patients with PWS with pulsed dye laser (Photogenica V, Cynosure, lambda = 585 nm, iota(p) = 0.5 ms, spot size = 7 mm). Each PWS was partitioned into three areas: (area 1) 6 J/cm(2) without CAC, (area 2) 6 J/cm(2) with CAC (level 4), (area 3) 9 J/cm(2) with CAC (level 4).

RESULTS

Area 3 (mean, 59%) showed a slightly better clearance than area 1 (mean, 57%); in area 2, we observed a reduced clearance (mean, 45%). Compared with area 1, we achieved a reduction of pain through CAC in areas 2 and 3. The healing periods as well as the rate of side-effects were comparable in all areas.

CONCLUSION

We observed a slight but not statistically relevant increase in clearance with the use of higher fluences and CAC compared with lower fluences without CAC. Because pain is lowered significantly when using CAC, and because this makes the treatment more comfortable for the patients, we tend to recommend the use of higher fluences (9 J/cm(2)) with simultaneous CAC for treating PWS.

Port-wine-stain-associated dermatitis: implications for cutaneous vascular laser therapy

Port-wine stains are congenital vascular malformations affecting 0.3% to 0.5% of infants. Dermatitis occurring exclusively or most severely within port-wine stains has been described in the literature. Traditionally, topical corticosteroid therapy has been used for the treatment of dermatitis, while pulseddye laser treatment is considered a safe and effective means of lightening the appearance of congenital port-wine stains. To describe the development of port-wine stain-associated dermatitis as well as a rational treatment approach to these patients, we studied three children with facial, limb, or truncal port-wine stains who developed dermatitis within the congenital vascular malformation either prior to or during treatment with pulseddye laser. Laser therapy of dermatitis-affected areas was subsequently deferred pending resolution of the dermatitis with topical corticosteroid or topical calcineurin inhibitor treatment. While pulseddye laser therapy is an effective means of lightening port-wine stains and achieving lasting resolution of any associated dermatitis, this therapy to dermatitis-affected areas should be postponed until the inflammation resolves to minimize the risk of laser-associated adverse effects.

Laser surgery of port wine stains using local vacuum [corrected] pressure: changes in calculated energy deposition (Part II)

BACKGROUND AND OBJECTIVES

Application of local vacuum pressure to human skin during laser irradiation results in less absorption in the epidermis and more light delivered to targeted vessels with an increased blood volume. The objective of the present numerical study is to assess the effect of applying local vacuum pressure on the temperatures of the epidermis and small vessels during port wine stain (PWS) laser treatment. STUDY DESIGN/ MATERIALS AND METHODS: Mathematical models of light deposition and heat diffusion are used to compute absorbed energy and temperature distributions of skin and blood vessels with different diameters (10-60 microm) at various depths (200-800 microm) exposed to laser irradiation under atmospheric and vacuum pressures.

RESULTS

Under 50 kPa (15 in Hg) vacuum pressure, peak temperatures at the inner walls of small diameter vessels (10-30 microm) located 200-300 microm below the skin surface are approximately 10 degrees C higher than those under atmospheric pressure, and peak temperatures in the epidermis of patients with skin phototype II are approximately 5 degrees C lower. In patients with darker skin phototype (IV), the peak temperature at the inner wall of a 10 microm diameter vessel located 200 microm below the skin surface is approximately 5 degrees C higher than that under atmospheric pressure, and the peak temperature in the epidermis is approximately 10 degrees C lower.

CONCLUSIONS

Additional energy deposition in a larger blood volume permits higher temperatures to be achieved at vessel walls in response to laser irradiation. While more energy is deposited in every vessel, temperature gains in small diameter vessels (10-30 microm) are greater, increasing the likelihood of irreversible thermal damage to such vessels. In addition, temperatures in the epidermis decrease because less energy is absorbed therein due to reduced epidermal thickness and concentration of melanin per unit area.

Efficacy of Pulsed Dye Laser in Facial Port-Wine Stains in Indian Patients

BACKGROUND

Facial port-wine stain (PWS) produces severe cosmetic disfigurement and pulsed dye laser (PDL) has revolutionized the treatment of PWS.

OBJECTIVE

To assess the efficacy of PDL for facial PWS in Indian patients.

MATERIALS AND METHODS

Twenty-seven patients of Fitzpatrick skin types IV and V in the age group of 8 to 34 years (mean 21.6 years), with lesional size 3 x 1.5 to 25 x 19 cm and color from light pink to deep red and violaceous, were recruited. Laser parameters were spot size, 7 mm; fluence, 5 to 7.5 J/cm(2); wavelength, 585 nm, pulse duration, 0.45 ms; along with continuous air cooling. Response at every session was graded from 0 to 5+(0, no improvement; 1+, up to 25%; 2+, 26% to 50%; 3+, 51% to 75%; 4 +, 76% to 99%; 5+, 100% lightening).

RESULTS

In a total of 170 sessions, maximum response of 1+ was observed in 6 patients after mean of 3.5 sessions, 2+ in 8 patients after mean of 5.25 sessions, 3+ in 8 patients after mean of 7 sessions, and 4+ improvement in 5 patients after mean of 4.8 sessions. No patient showed complete clearance. Seven patients developed hyperpigmentation while 1 patient showed hypopigmentation, but none had textural change or scarring.

CONCLUSION

PDL offers significant cosmetic improvement in facial PWS in Indian patients.

Redarkening of port-wine stains 10 years after pulsed-dye-laser treatment

BACKGROUND

Although pulsed-dye-laser therapy is currently the gold standard for the treatment of port-wine stains, few objective data are available on its long-term efficacy. Using objective color measurements, we performed a 10-year follow-up of a previously conducted prospective clinical study of the treatment of port-wine stains with a pulsed-dye laser.

METHODS

We invited the patients to undergo repeated color measurements performed by the same procedures as in the previous study. The results at long-term follow-up were compared with color measurements obtained before treatment and after completion of an average of five laser treatments of the complete port-wine stain. A questionnaire was used to investigate patients' satisfaction with the treatment and their perception of long-term changes in the stain.

RESULTS

Of the 89 patients from whom color measurements were obtained in the previous study, 51 were included in this study. The patients had received a median of seven additional treatment sessions since the last color measurement, which had been made after an average of five treatments. The median length of follow-up was 9.5 years. On average, the stain when measured at follow-up was significantly darker than it was when measured after the last of the initial five laser treatments (P=0.001), but it was still significantly lighter than it was when measured before treatment (P<0.001). Fifty-nine percent of patients were satisfied with the overall treatment result. Six percent of patients reported that the stain had become lighter since their last treatment, 59% that it was unchanged, and 35% that it had become darker.

CONCLUSIONS

Using objective color measurements, we observed significant redarkening of port-wine stains at long-term follow-up after pulsed-dye-laser therapy. Patients should be informed about the possibility of redarkening before beginning treatment.

Pupil damage after periorbital laser treatment of a port-wine stain

BACKGROUND

The increase in the number of laser treatments has led to an increase in the number of therapy-related adverse effects. Herein we report a case in which long-term adverse effects occurred after periorbital laser treatment of a treatment-resistant port-wine stain using a long-pulsed alexandrite laser without protective eyewear.

OBSERVATIONS

A 33-year-old woman with a therapy-resistant port-wine stain was treated periorbitally with a 755-nm long-pulsed alexandrite laser after several treatment sessions with the pulsed-dye laser; she was not given protective eye shields. Within a few days of the session, she reported disorders in the motility of her left pupil and a painful sensitivity to light, which was not completely resolved after 12 months of follow-up.

CONCLUSIONS

We recommend that both patients and operators use protective eyewear with every laser procedure. When treatment is administered near the eye, eye shields should be placed behind the eyelid or a safe distance should be maintained between the laser and the eyeball by treating up to the orbital rim only.

Laser surgery of port wine stains using local vacuum pressure: Changes in skin morphology and optical properties (Part I)

BACKGROUND AND OBJECTIVES

In a recent case study, the use of a suction device to aid in port wine stain (PWS) laser treatments showed favorable results. It is our objective to further understand the mechanisms of vacuum-assisted laser therapy by analyzing the mechanical and optical changes of the skin and musculoskeletal tissues during the application of mild vacuum pressure from a suction cup.

STUDY DESIGN/MATERIALS AND METHODS

A mathematical model of tissue deformation was used to determine the changes in tissue morphology that affect the underlying laser-tissue interactions, such as epidermal stretching and thinning, blood vessel dilation, and change in blood vessel depth. Video imaging experiments were used to verify the bulk tissue deformation and skin surface stretching computed by the mathematical model. Additionally, visible reflectance spectroscopy was used to determine the changes in the optical characteristics of tissue, including blood vessel dilation and epidermal absorption coefficient.

RESULTS

At a vacuum pressure of 50 kP(a), the epidermis at the center of the suction cup was measured to stretch 4% and was calculated to be thinned approximately 6%. Blood vessels embedded in the dermis were measured to dilate up to two times their original size. However, these vessels were calculated to be displaced toward the skin surface by a very small amount, approximately 1-3 microm. The absorption coefficient of the epidermis was also measured to be reduced significantly by approximately 25% at a wavelength of 585 nm.

CONCLUSIONS

Mild vacuum pressure applied to the skin surface causes considerable changes in the morphology and optical properties of the tissue. These changes may be used for more efficient photothermolysis of small PWS blood vessels.

Laser therapy of vascular lesions

Since the first construction of a laser by Maiman in 1960 and the first clinical application of a laser in the therapy of skin lesions by Leon Goldman, laser therapy has become an important therapeutic modality in dermatology. Various lasers can be used for the treatment of different vascular and non-vascular lesions. According to our results, vascular lesions constitute the most important indication for laser therapy in dermatology.

Re-emergence of Port Wine Stains Following Treatment With Flashlamp-Pumped Dye Laser 585 nm

Despite the advances in laser treatment of port wine stains (PWS), re-emergence of these lesions still occurs. We carried out a retrospective audit of all children that received laser treatment of PWS between 1997 and 2000 using the flashlamp-pumped dye laser with a 585-nm wavelength. Out of 110 patients treated, 15 re-emerged. The age ranged between 7 months and 15 years. Fourteen had lesions in the head and neck. Before re-emergence, a child had, on average, 6.2 sessions every 4.8 months. Lesions re-emerged on average 31.1 months following discontinuation of treatment. The natural history of an untreated PWS is to darken as the vessels become more ectatic. Therefore, it is not surprising that any residual vessels not affected by laser will continue to progress in this way, causing re-emergence of the lesion. Perhaps we should expect most or all of treated PWS to eventually re-emerge.

The effect of ambient temperature on capillary vascular malformations

BACKGROUND

Following pulsed dye laser (PDL) treatment of capillary vascular malformations (CMs), the capillaries left behind tend to be smaller and deeper. The PDL is most effective against capillaries over 50 microm, suggesting that clearance of CM could be improved by inducing capillary vasodilation of the smaller remaining capillaries. However, there are reduced perivascular nerves within CMs, implying that autonomic innervation to these capillaries may be abnormal.

OBJECTIVES

To investigate whether CM capillaries will vasodilate in response to autonomic stimulation by raising ambient temperature.

METHODS

Ten patients with untreated CMs and nine with previously laser-treated CMs were studied as ambient temperature was increased from 20 degrees C to 28 degrees C. The following measurements were taken at 2 degrees C intervals: skin blood flow (SBF); capillary diameter and depth; CM colour; and skin and core temperatures.

RESULTS

All the subjects studied demonstrated superficial capillary vasodilation and increased SBF as the ambient temperature was raised from 20 degrees C to 28 degrees C. Mean+/-SEM capillary diameter increased from 66+/-7 microm to 110+/-13 microm (P<0.001) in the untreated group, compared with an increase from 28+/-5 microm to 70+/-14 microm (P<0.001) in the treated group. Mean+/-SEM SBF increased from 427.2+/-98.2 perfusion units (PU) to 580.9+/-92.7 PU (P<0.01) in the untreated group, compared with an increase from 201.3+/-28.4 PU to 458.1+/-53.7 PU (P<0.05) in the treated group.

CONCLUSIONS

Superficial capillary vasodilation within CM is achievable by raising ambient temperature, including in those patients resistant to PDL treatment, potentially allowing further clearance of these lesions.

Evaluation of fluence and pulse-duration on purpuric threshold using an extended pulse pulsed-dye laser in the treatment of port wine stains

Laser therapy of port-wine stains (PWS) using the extended pulse pulsed-dye laser (EPPDL) is accepted as the optimal approach because the thermal relaxation time for the vessels in PWS is actually 1-10 msec. The purpose of this study is to elucidate the purpuric threshold using the EPPDL for treatment of PWS. One hundred and seventy-seven Japanese patients with PWS were recruited for this study. All the patients were dark-skinned with skin phototype III (n = 103) and IV (n = 74). PWS were treated with the EPPDL with a pulse duration ranging 1.5-10 msec, fluence ranging 9-15 J/cm(2), and a spot size of 7 mm. Cryogen spray cooling (CSC) was fixed to 30 msec of delay and 30 msec of spray duration. Patients returned to our clinic within 1 week after their initial laser therapy and the treatment sites were examined for the evidence of purpura formation. Of the 177 patients, 108 developed purpura. The lowest fluences that caused purpura and were seen in more than 50% of patients were 10 J/cm(2) with a pulse duration of 1.5 msec, 12 J/cm(2) with a pulse duration of 3 msec, 13 J/cm(2) with a pulse duration of 6 msec, and 13 J/cm(2) with a pulse duration of 10 msec. The fluence and pulse duration thresholds were 12.5 J/cm(2) and 1.65 msec, respectively. Because purpura is one of the treatment endpoints when using a pulsed-dye laser for PWS, higher fluences are necessary when using a long pulse duration.

Laser- und Lichttherapie von vaskulären Hautveränderungen

The use of lasers to treat vascular lesions began in the late 1960s with the introduction of argon laser. More recently pulsed laser and intense pulsed light techniques have further improved results and reduced side effects. Their function is based on the principle of selective photothermolysis. Simultaneous application of cooling methods (contact cooling, cold air, cryogen spray) has become standard procedure for these types of therapy, whose most important indications are port-wine stain, hemangioma, and telangiectasia. A persistent difficulty is their limited penetration, resulting in limited or no effect on deeper dermal layers. New approaches therefore include combinations with bipolar radio frequency or the use of two different laser systems, e.g., dye and Nd:YAG lasers. The different lasers are described along with their effectivity, limitations and indications.

High-energy 595 nm pulsed dye laser improves refractory port-wine stains

BACKGROUND

Port-wine stains respond quite well to 585 nm pulsed dye laser treatment, but often clearance is not complete. We investigated a prototype, a high-energy 595 nm pulsed dye laser capable of delivering up to 9.5 J/cm2 using a 10 mm circular spot, with a 1.5 ms pulse duration.

OBJECTIVE

This study was undertaken to determine if the high-energy, 595 nm, variable-pulse duration pulsed dye laser could improve port-wine stains that had become refractory to conventional treatment.

METHODS

Twenty patients were entered into the study and treated with the high-energy, 595 nm, variable-pulse duration pulsed dye laser using fluences ranging from 7.5 to 9.5 J/cm2, a 1.5 ms pulse duration, and a 10 mm spot size.

RESULTS

Average improvement was rated as 40% prior to the initiation of the study after an average of 8.8 treatments at an average energy of 7.9 J/cm2 with the 585 nm pulsed dye laser and 76% following an average of 3.1 treatments with the high-energy 595 nm pulsed dye laser using an average fluence of 7.9 J/cm2. Dermal spectrometer erythema measurements improved from 2.2-fold that of normal skin to 1.5-fold that of unaffected skin.

CONCLUSIONS

The high-energy 595 nm pulsed dye laser improves port-wine stains that have become refractory to the conventional 585 nm pulsed dye laser.

[Flashlamp-pumped pulsed dye laser (585 nm) in the treatment of port-wine stains--a retrospective study of 2317 Chinese patients]

OBJECTIVE

To evaluate the efficacy and safety of 585 nm flashlamp-pumped pulsed dye lasers (PDL) in the treatment of port-wine stains (PWS).

METHODS

A retrospective review was performed in 2 317 patients with PWS who visited the Dermatology Laser Centre of PUMC Hospital and accepted treatment with 585 nm PDL. The correlation between the treatment efficacy and the treatment sessions, lesion types, and usage of other therapies were analyzed. The adverse effects were also observed.

RESULTS

All the 2 317 patients with PWS received 1-13 consecutive treatments with PDL at 2-3-month intervals. The median number of treatment was 4.93 and the median energy density was 8.29 J/cm2. The response rate after 8 treatments sessions were 84%. The response rate in patients whose lesions are characterized as purple plaques with proliferation and treated with isotope, CO2, cryotherapy, and other treatments was significantly lower than the total response rate (P < 0.05). Superficial scar, hyperpigmentation, and hypopigmentation were found in 5.2%, 2.5%, and 4.0% of these patients, respectively.

CONCLUSION

585 nm PDL is effective and safe in treating PWS.

The treatment of port-wine stains with the pulsed-dye laser at 2-week and 6-week intervals: a comparative study

BACKGROUND

The pulsed-dye laser (PDL) is the treatment of choice for port-wine stains (PWS). Multiple treatments are usually necessary, with standard treatment intervals ranging between 6 and 12 weeks. However, there are no studies on the effect of treating PWS at different time intervals, and the ideal time interval between treatments has not yet been agreed. It is uncertain whether treatment is more effective if administered at shorter time intervals.

OBJECTIVES

To establish whether the treatment of PWS with the variable pulse width 595-nm (V-beam) PDL at 2-week intervals achieves better results, with no difference in the complication rate, than treatment given at 6-week intervals.

METHODS

We prospectively investigated 15 patients with PWS. Each patient had the whole PWS treated at initial visit. Half of the PWS was randomly allocated to be treated at 2 weeks and the other half at 6 weeks from initial visit. Both halves of the PWS thus were treated twice in total, once at the initial visit and the second treatment either at 2 weeks or 6 weeks from initial visit. At 12 weeks an observer blinded to treatment allocation clinically evaluated the results. The outcome measure was lightening of the PWS as measured with a reflectance spectrophotometer. Complications were recorded throughout the study period.

RESULTS

Of the 15 patients, 13 completed the study. Three patients had two PWS each treated separately, giving a total of 16 treated PWS sites. In 11 sites (69%), the 2-week interval treatment resulted in greater reduction in reflectance than the 6-week interval treatment. Using the nonparametric Wilcoxon matched-pair signed rank test, the 2-week treatment interval site resulted in greater reduction in reflectance measurements compared with the 6-week treatment interval site (P < 0.01). This agreed closely with independent observer assessment judging that the 2-week treatment interval resulted in better lightening of the PWS than the 6-week treatment interval (P = 0.003). There were no adverse reactions from the treatments.

CONCLUSIONS

Preliminary data suggest that a treatment interval of 2 weeks is well tolerated by patients and resulted in greater lightening of the PWS in the majority, compared with a standard 6-week interval. It also has the potential to reduce the total duration of a course of treatment significantly.

The use of lasers in the pediatric population

Over the past 2 decades, there have been numerous advances in laser therapy of birth-marks in the pediatric population. Concerns regarding efficacy, overall benefit, and side-effects linger. We present our opinion, based upon decades of clinical experience, on the role of lasers to treat port wine stains, superficial hemangiomas, and café au lait macules in children.

Pulsed dye laser treatment, a review of indications and outcome based on published trials

INTRODUCTION

Pulsed dye laser (PDL) treatment is based on the principle of selective photothermolysis and is widely considered to be the treatment of choice for a variety of cutaneous vascular lesions.

OBJECTIVE

To review the indications and outcome of PDL treatment and summarise new developments.

METHOD

A literature-based study has been conducted entailing the review of publications over the period January 1993-December 2003 using the databases Medline and Cochrane CENTRAL.

RESULTS

The PDL was found to be effective in port wine stain, facial telangiectasia, leg telangiectasia <0.5 mm, scars, hypertrophic scars and ulcerated haemangioma.

DISCUSSION

Essential characteristics of lesions suitable for PDL treatment are discussed and guidelines are presented for future research.

Description and Analysis of Treatments for Port-wine Stain Birthmarks

Port-wine stain (PWS) birthmarks are congenital, low-flow vascular malformations of the skin. Lasers are the modality of choice for the treatment of PWS birthmarks, and for most patients the pulsed-dye laser in conjunction with epidermal cooling offers the greatest efficacy and safety. Other light devices, including the 532-nm frequency-doubled Nd:YAG laser, intense pulsed light, 1064-nm Nd:YAG laser, and combined 1064/532-nm system, may be useful during a treatment course for resistant PWS. Laser treatment results in blanching of most lesions, although complete resolution may not occur and some resistant PWS birthmarks respond minimally, if at all. Factors limiting laser treatment include variable vascular geometry, inadequate damage of some vessels, and lesional posttreatment recurrence as a result of neovascularization. Alternative or adjunct treatment options that address these limitations should be explored, including noninvasive real-time imaging to optimize the selection of treatment settings, photodynamic therapy, and perioperative use of antiangiogenic compounds.

A comparative study of a 595-nm with a 585-nm pulsed dye laser in refractory port wine stains

BACKGROUND

The pulsed dye laser (PDL) is the treatment of choice for port wine stains (PWS); however, some patients' PWS become refractory to further treatments. Technological advances have enabled new machines with the advent of surface cooling devices to deliver longer wavelengths and higher fluence more safely. These advances have the potential to achieve improved response rates in refractory PWS. There are few studies comparing the efficacy of standard PDL treatments for refractory PWS with the wider choice of treatment variables available from newer PDL machines.

OBJECTIVES

To determine if there is any advantage of using a longer wavelength (595 nm) and pulse widths (1.5 ms, 6 ms and 20 ms) over conventional PDL settings (wavelength 585 nm, pulse width 1.5 ms) in refractory PWS.

METHODS

Eighteen consecutive consenting patients with Fitzpatrick skin types 1-4 with a mean age 35 years (range 17-59 years) with refractory PWS were treated routinely with three separate test areas using 595-nm PDL (using three different pulse width settings of 1.5 ms, 6 ms and 20 ms), compared with test areas treated with 585-nm PDL (pulse width 1.5 ms). All test areas were treated with an identical fluence (15 J cm(-2)), spot size (7 mm) and cooling setting (dynamic cooling 60 ms, delay 60 ms).

RESULTS

We found a statistically significant advantage of 595-nm PDL (pulse width 1.5 ms) over 595-nm PDL (pulse width 6 ms) (P < 0.05) in the treatment of refractory PWS; however, we found no significant advantage using longer pulse widths of 20 ms compared with 1.5 ms with the 595-nm PDL. There was no statistically significant advantage in using a 595-nm PDL over a 585-nm PDL using identical pulse widths of 1.5 ms, spot size, fluence and cryogen cooling settings; however, the number of directly comparable test areas was smaller. Some individual patients in our study obtained a better response with certain 595-nm PDL settings (pulse width 1.5 ms and 6 ms) compared with 585-nm PDL (pulse width 1.5 ms).

CONCLUSIONS

Our experience of high fluence PDL in the treatment of refractory PWS suggests patients treated with 585 nm (pulse width 1.5 ms) improve to a similar degree as patients treated with 595-nm PDL (pulse width 1.5 ms). However, the use of the 595-nm PDL with longer pulse widths yields no extra advantage. For those patients who have failed to improve with high-fluence 585-nm PDL (pulse width 1.5 ms), test areas using 595-nm PDL (pulse width 1.5 ms and 6 ms) should be undertaken to ascertain if individual patients may benefit from the longer pulse width 595-nm PDL.

Study of patient-reported morbidity following V-beam pulsed-dye laser treatment of port wine stains

The V-beam pulsed-dye laser (PDL) (595 nm) has gained popularity in the treatment of port wine stains (PWS). It uses longer pulse durations than the standard flashlamp-pumped pulsed-dye laser (FPDL) (585 nm) and has an in-built cooling system to protect the epidermis. This should, theoretically, reduce the treatment-associated side effects, including discomfort. The aim of this questionnaire-based study was to confirm the clinical impression that V-beam PDL is well tolerated. The results were compared with a historical group of 62 PWS patients treated with FPDL. Fifty-one patients took part in the current study. Only 35.7% (vs. 81% in the historical comparison group) required topical anaesthetic prior to laser treatment. A shortening in the duration of bruising (8 vs. 10 days) and of symptoms such as burning and tightness (3 vs. 10 days) was recorded. Lifestyle change after treatment was recorded by fewer patients (39 vs. 57%). We conclude that V-beam PDL is better tolerated than FPDL when used at therapeutic levels in patients with PWS.