Laser Treatment of Burn Scars. / Tratamiento láser de cicatrices por quemaduras.

Burn scars cause high morbidity in the form of contractures, body disfigurement, and itching, and they also have a high emotional impact that adversely affects patient quality of life. Laser therapy has proven effective in this setting. It is superior to topical treatments and can be used in conjunction with surgery, helping to reduce morbidity. The use of lasers in hospital dermatology departments, however, is still limited. Carbon dioxide laser resurfacing is the most widely used modality for reducing scar thickness, improving textural abnormalities, and treating contractures. Treatments improve mobility for patients with constrictions. Pulsed dye laser treatments are particularly useful for reducing erythema in recent burn scars and preventing subsequent hypertrophy. Pigment laser treatments with short pulse durations (nanoseconds or picoseconds) can improve hyperpigmentation. In this article, we review the evidence for the use of laser therapy for burn scars and propose a treatment algorithm.

Capillary Malformation in CLAPO Syndrome Successfully Treated with Pulsed Dye Laser. / Malformación capilar del síndrome CLAPO exitosamente tratado con láser de colorante pulsado.

CLAPO syndrome (Capillary vascular malformation of the lower lip, Lymphatic malformations of the head and neck, Asymmetry and Partial/generalized Overgrowth) is a recently described entity, with very few published cases in the literature, and no standardized treatment. The objective of our study was to assess the efficacy and safety of PDL in patients with this syndrome. Seven patients were treated with two to four sessions of PDL at 595-nm wavelength. Laser therapy was performed using a spot size of 7 to 10 mm, a pulse duration of 0,5 to 1,5 ms and a fluence from 6 to 8 J/cm2. Clinical photographs were taken before treatment and 3 weeks after procedure. Clearance of the erythema was > 75% in 4 patients. Transient purpura was present in all patients for about 2 weeks and 1 patient presented post inflammatory hypopigmentation. In conclusion we consider that PDL seems to be a safe and effective treatment for capillary malformations of the CLAPO syndrome. A marked reduction in erythema was achieved in all patients with a low incidence of side effects.

Development of a core outcome domain set for clinical research on capillary malformations (the COSCAM project).

BACKGROUND: Due to a large variety in treatment outcomes reported in therapeutic trials and lacking patient-relevant outcomes, it is hard to adequately compare and improve current therapies for patients with capillary malformations (CMs). The Core Outcome Set for Capillary Malformations (COSCAM) project aims to develop a core outcome set (COS) for use in future CM trials, in which we will first develop a core outcome (sub)domain set (CDS). Here, we describe the methods for the development of a CDS and present the results of the first development stage. METHODS: The COSCAM project is carried out according to the recommendations of the Cochrane Skin Core OUtcomes Set INitiative (CS-COUSIN) and the Core Outcome Measures in Effectiveness Trials (COMET) initiative. During the first stage, we identified all potentially relevant outcome subdomains based on a systematic review, two focus group sessions and input from patient representatives of Dutch patient organizations and the COSCAM-founding group. In stage two, we will present the subdomains in a three-round e-Delphi study and online consensus meeting, in which CM patients, parents/caregivers and CM experts worldwide rate the importance of the proposed subdomains, hereby finalizing the core outcome (sub)domains of the CDS. RESULTS: A total of 67 potential outcome subdomains were included; sixteen were previously used in the literature, 20 were proposed by Dutch patients and their parents/caregivers (n = 13) in focus group sessions and 38 were suggested by the experts of the COSCAM-founding group. Seven were excluded because of overlap. CONCLUSION: The final CDS may serve as a minimum standard in future CM trials, thereby facilitating adequate comparison of treatment outcomes. After this CDS development, we will select appropriate outcome measurement instruments to measure the core outcome subdomains.

Videodermoscopy and doppler-ultrasound in spider naevi: towards a new classification?

INTRODUCTION: Spider naevi (SN) are considered a subtype of telangiectasias, currently classified as low-flow vascular malformations. OBJECTIVE: To describe the videodermoscopy and Doppler-ultrasound (US) features of a large group of SN. MATERIAL AND METHODS: A retrospective study of cases of SN collected at our Dermatology department during the period between June 2015 and June 2017 was performed. Clinical images, dermoscopic, videodermoscopic and Doppler-US files were reviewed. For each case, the age of the patient, time since onset, size and dermoscopic pattern of the lesions were recorded. The presence of pulsatility was also evaluated visually on the videodermoscopy. RESULTS: Two hundred and thirty-three SN in 189 patients were included. The mean age was 39.5 years (range: 10-76 years). Mean size of the lesions was 4.1 ± 2.0 mm. We described three dermoscopic patterns: network, star and looping. Older age, longer time since onset and larger size were found associated with higher frequency of the looping and star patterns compared to that of network pattern (P < 0.01). Pulsatility during videodermoscopy was found in 88 patients (37%). This pulsatility phenomenon was more commonly associated with the looping pattern (64.7%) than star- (40.3%) or network-like patterns (29.9%) (P < 0.001). In Doppler-US studies, a high-flow with arterial biphasic waveform was found. CONCLUSIONS: In the light of the results, we support that SN could be reconsidered in upcoming classifications as lesions closer to the group of high-flow arteriovenous malformations.

Alexandrite Laser for the Treatment of Resistant and Hypertrophic Port Wine Stains: A Clinical, Histological and Histochemical Study.

BACKGROUND: Port wine stains (PWSs) are commonly treated by the pulsed dye laser. However, treatment of hypertrophic or resistant PWSs is a major therapeutic challenge. The long-pulsed Alexandrite laser could be a safe and effective treatment for resistant PWSs, due to an increase depth of penetration of 50-75% over PDL. OBJECTIVE: The aim of this study was to assess the efficacy and safety of a long-pulsed Alexandrite laser in patients with hypertrophic, dark and/or resistant PWSs. Pink pale resistant PWS were excluded from the study. METHODS: Twenty-one patients (age 20-75 years), phototypes I-IV on the Fitzpatrick scale, with PDL dark resistant PWSs were treated with long-pulsed Alexandrite laser. We excluded high phototypes and PDL pink resistant PWSs. All patients were treated with 3 laser sessions at settings of 3-ms pulse duration, 10-mm spot, 35-55J/cm(2), with cooling (Dynamic Cooling Device 50ms with delay 30ms). Laser sessions were repeated approximately every 2 months. Three dermatologists evaluated treatment effectiveness by means of photographs of the patients before and after laser treatment (scale from 0 to 4). Adverse events were registered. Patient satisfaction was also assessed (scale from 0 to 10). RESULTS: Mean global improvement was rated as 2.28. Long-lasting side effects included minimal scarring after blistering in 1 patient. Mean patient satisfaction was 8.5. CONCLUSIONS: Our study concludes that long-pulsed Alexandrite laser was effective for treatment of resistant PWSs, although the therapeutical window is narrow with this treatment.

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

BACKGROUND: Among the different approaches for improving the effectiveness in the treatment of Capillary Malformations type Port Wine Stain (CM type PWS) are the intense pulsed light sources. There are few clinical studies prove useful in the treatment of CM. Furthermore, no studies have been published yet demonstrating the histological effects of IPL in CM. OBJECTIVES: To assess the histological effects of pulsed light in capillary malformations type port wine stain. We wanted to compare epidermal, dermal and vessel wall damage after treatment with different combinations of IPL parameters. MATERIAL AND METHODS: Fifty-five post-treatment biopsies were performed in 15 consenting patients with CM and stained with nitroblue-tetrazolium chloride (NBTC). Patients had not been treated previously. RESULTS: Fifteen patients with CM, with a median age of 39 years-old were enrolled in this study. In this series, the patients with the most severe epidermal damage were those with a darker phototype. Pink CM were especially resistant to treatment, even using high fluences, short pulse durations and stacking pulses. Longer intra- and interpulse delays were effective in purple CM, achieving adequate vessel destruction. CONCLUSIONS: IPL devices provide a vast amount of treatment possibilities and further studies are necessary to optimize therapeutic approaches to CM. In this study we have observed the histological effects of different pulses on the MC type PWS.

Guidelines of care for vascular lasers and intense pulse light sources from the European Society for Laser Dermatology.

AIM: Lasers and non-coherent intense pulse light sources (IPLS) are based on the principle of selective photothermolysis and can be used for the treatment of many vascular skin lesions. A variety of lasers has been developed for the treatment of congenital and acquired vascular lesions which incorporate these concepts into their design. Although laser and light sources are very popular due to their non-invasive nature, caution should be considered by practitioners and patients to avoid permanent side-effects. The aim of these guidelines is to give evidence-based recommendations for the use of lasers and IPLS in the treatment of vascular lesions. METHODS: These guidelines were produced by a Consensus Panel made up of experts in the field of vascular laser surgery under the auspices of the European Society of Laser Dermatology. Recommendations on the use of vascular lasers and IPLS were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. RESULTS: Lasers and IPLS are very useful and sometimes the only available method to treat various vascular lesions. It is of a paramount importance that the type of laser or IPLS and their specific parameters are adapted to the indication but also that the treating physician is familiar with the device to be used. The crucial issue in treating vascular lesions is to recognize the immediate end-point after laser treatment. This is the single most important factor to ensure both the efficacy of the treatment and avoidance of serious side-effects.

Future prospects in dermatologic applications of lasers, nanotechnology, and other new technologies.

We review novel technologies with diagnostic and therapeutic applications in dermatology. Among the diagnostic techniques that promise to become part of dermatologic practice in the future are optical coherence tomography, multiphoton laser scanning microscopy, Raman spectroscopy, thermography, and 7-T magnetic resonance imaging. Advances in therapy include novel light-based treatments, such as those applying lasers to new targets and in new wavelengths. Devices for home therapy are also appearing. We comment on the therapeutic uses of plasma, ultrasound, radiofrequency energy, total reflection amplification of spontaneous emission of radiation, light stimulation, and transepidermal drug delivery. Finally, we mention some basic developments in nanotechnology with prospects for future application in dermatology.

Pulsed dye laser treatment for facial flat warts.

The facial flat wart is not only a contagious viral disease, but also a cause of a distressing cosmetic problem. Although there are many therapeutic options, including salicylic acid, imiquimod, cryotherapy, retinoids, intralesional immunotherapy, and topical 5-aminolevulinic acid photodynamic therapy among others, no monotherapy has been proved to achieve complete remission in every case. Treatment with pulsed dye laser (PDL) seems to be a promising therapeutic option. To assess the efficacy and safety of PDL in a series of patients with viral flat warts on the face, in this prospective study, 32 patients were treated with PDL at 595-nm wavelength, a laser energy density of 9 or 14 J/cm(2) with a spot size of 7 or 5 mm, respectively, with air cooling and a pulse duration of 0.5 millisecond. A complete response was noted in 14 patients (44%), and an excellent response was observed in 18 patients (56%) with 1-year follow-up, with only four recurrences. No significant side effects were reported except intense transitory purpuric response. We consider that PDL is a good option of treatment for flat warts on the face due to its good clinical results, fast response, and low incidence of side effects.

Acquired digital arteriovenous malformations: laser treatment of an uncommon vascular abnormality.

Acquired digital arteriovenous malformations (ADAVM) are uncommon acral vascular lesions most often affecting the finger. Treatment usually requires complete excision of the lesion with complex advancement flap or skin graft reconstruction. However, in recent years, some authors have reported satisfactory outcomes with laser treatment. We describe a series of 6 patients with ADAVM, 5 of whom received laser treatment and obtained a good response. The other patient was treated surgically. After an in-depth review of this type of lesion, we conclude that laser treatment is a safe and effective alternative for these malformations, provided the patients are appropriately diagnosed and have Schöbinger stage i lesions.

Arteriovenous malformations: a diagnostic and therapeutic challenge.

Many dermatologists are largely unfamiliar with arteriovenous malformations (AVMs). This is partly due to the low prevalence of these lesions and to the fact that they are generally managed by other specialists, in particular, interventional radiologists and pediatric, maxillofacial, and plastic surgeons. In this article, we review the recommended nomenclature for AVMs and look at their clinical manifestations and diagnosis, as well as the ideal type and time of treatment. AVMs should be managed from a multidisciplinary approach, and the dermatologist's primary goal should be to make a proper diagnosis and thereby avoid unnecessary treatments.

Venous malformations treated with dual wavelength 595 and 1064 nm laser system.

BACKGROUND & OBJECTIVE: Venous malformations (VM) represent a localized error in the embryological development of the venous branch of the circulation. The management of VM is complex and challenging. The aim of this study was to assess the efficacy and safety of combined sequential pulsed dye laser (PDL)-Nd:YAG laser in patients with cutaneous or mucosal VM. METHODS: Thirty patients (age from 8 to 65 years) with cutaneous or mucosal VM treated with dual wavelength PDL-Nd:YAG laser were retrospectively analyzed. Laser parameters were 10 mm spot size with 10 ms pulse and 8-10 J/cm(2) of PDL, followed with a second delay by Nd:YAG with 15 or 20 ms at 35-70 J/cm(2); or 7 mm spot size with 10 ms pulse and 5-10.5 J/cm(2) of PDL, followed with a second delay by Nd:YAG with 15 or 20 ms at 50-100 J/cm(2). Laser sessions were repeated approximately every 2-6 months. Air cooling was applied during treatment. Three dermatologists evaluated treatment effectiveness by means of photographs of the patients before and after laser treatment (scale from 0 to 4). Differences in the degree of clinical improvement between patients with cutaneous or mucosal VM were also assessed. Adverse events were registered. Patient satisfaction was also assessed in 19 cases (scale from 0 to 10). RESULTS: Mean global improvement was rated as 3.37. Mean improvement in patients with cutaneous VM was 3.35 and 3.38 in patients with mucosal VM. No significant difference between both groups was observed (P = 0.53). Long-lasting side effects included partial epilation of the eyelashes in one patient, ulceration in two patients and permanent scarring in three patients. Mean patient satisfaction was 8.55. CONCLUSIONS: Our study concludes that dual wavelength PDL-Nd:YAG laser was effective for treatment of the superficial component of cutaneous and mucosal VM.

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

BACKGROUND AND OBJECTIVES: Infantile hemangiomas are the most common benign tumor in children. They have 3 phases of development: a proliferative phase, an involuting phase, and involution. Although active treatment is often not required, it is necessary in some cases. Of the possible treatments for hemangiomas, lasers have been shown to be effective in all phases of development. We report our experience with dual-wavelength sequential pulses from a pulsed dye laser and an Nd:YAG laser. MATERIAL AND METHODS: This was a retrospective, descriptive study of patients with infantile hemangioma in different phases of development treated with pulsed dye laser pulses followed by Nd:YAG laser pulses. Four dermatologists assessed the effectiveness of treatment on a scale of 10 to 0. Adverse effects and incidents related to treatment were recorded. The median and interquartile range were calculated as descriptive statistics. Pretreatment and posttreatment comparisons were performed using the Wilcoxon test. RESULTS: Twenty-two patients with hemangiomas in different phases of development were included. A statistically significant improvement was obtained both for the entire group and for different subgroups. Posttreatment events were reported in 4 patients, and included edema and ulceration, skin atrophy, and hyperpigmentation. CONCLUSIONS: We believe that treatment with dual-wavelength light from a pulsed dye laser and a Nd:YAG laser is a viable treatment option for infantile hemangiomas when first-line therapies are ineffective or contraindicated.

Ablative fractional yttrium-scandium-gallium-garnet laser for scarring residual haemangiomas and scars secondary to their surgical treatment.

BACKGROUND: Infantile haemangiomas are benign self-involuting tumours. They have a characteristic clinical course marked by early proliferation and followed by spontaneous involution. However, residual evidence with scar formation, fibrofatty residua, atrophic wrinkling, yellowish discoloration and telangiectasias is usually seen after involution. OBJECTIVE: The aim of this study was to assess the efficacy and safety of ablative fractional yttrium-scandium-gallium-garnet (YSGG) laser in patients with residual haemangiomas or with scarring after their surgery. METHODS: Twelve patients with atrophic scar or fibrofatty tissue secondary to residual hemangiomas or with scarring after surgery of haemangioma were treated with one or two sessions of ablative fractional YSGG laser at 2.790-nm wavelength. Laser therapy was performed using a spot size of 300 µm, a pulse width of 600 ms, a fluence range between 120 and 200 mJ per microspot and a density level of 3. Treatment with PDL at 595-nm or with combined sequential 595 nm PDL and 1064 nm Nd:YAG was applied if telangiectasias or a residual vascular component were present. Three dermatologists evaluated treatment effectiveness by means of photographs of the patients before starting and 3 months after finishing the therapy; the degree of improvement was rated from 0 to 4. Parents' satisfaction was also assessed (scale from 0 to 10). RESULTS: Improvement was rated as 3 in two patients, 2 in four patients, 1 in five patients and no improvement in only one patient. Mean improvement was 1.58. Degree of parents' satisfaction ranged from 0 to 10. Mean satisfaction was 6.75. A discrete punctuate pattern was seen in three patients as the only long-lasting side-effect. CONCLUSION: We consider that ablative fractional YSGG laser could be an interesting option for the treatment of selected patients with atrophic wrinkling or scarring residual haemangiomas and scars secondary to their surgical treatment.

Pulsed dye laser as an excellent choice of treatment for lupus tumidus: a prospective study.

BACKGROUND: Clinical manifestations of cutaneous lupus erythematosus (CLE) vary widely, and different subtypes of this autoimmune disease exist. Tumidus subtype (LT) has been recently separated from the chronic subtypes and is now considered an independent entity due to its particular clinical and histological features. Different treatments are usually prescribed for CLE. Our group has experience of CLE effectively treated with pulsed dye laser (PDL). It was our impression that better responses were achieved in the LT subtype, but no controlled prospective studies with PDL have been specifically performed. MATERIALS AND METHODS: A prospective study was performed on 10 patients with histologically confirmed LT treated with PDL. All patients were treated with 595 nm PDL using the 10 mm spot size at 0.5 ms pulse width and a fluence of 8 J/cm(2). Biopsies were taken before and 4 weeks after treatment and were stained with haematoxylin-eosin. RESULTS: Evaluation after PDL treatment showed clinical improvement in all of them without side-effects and reduction of the dermal lymphocytic infiltrate in 9/10 of the patients. Epidermal changes were absent in all patients. Mucin deposition persisted only in one patient. However, 50% of the patients developed new lesions nearby or distant to the treated zones. CONCLUSIONS: PDL therapy is an effective and fast treatment option for acute flares of LT; however, it does not prevent recurrences. A histological improvement has been confirmed in this study. Purpura seems to be necessary to achieve a good response.

Dermatofibromas treated with pulsed dye laser: Clinical and dermoscopic outcomes.

Dermatofibroma (DF), a common benign skin tumour, sometimes requires treatment either because of cosmetic concern or for associated symptoms. However, no effective treatment with optimal cosmetic outcomes has been reported. An effective and safe therapeutic option could be treatment with pulsed dye laser (PDL). Twenty-two DFs in 15 patients were treated with PDL at 595-nm wavelength, using a spot size of 7 mm, a pulse duration of 2 ms and a fluence of 11 J/cm(2) with 2 or 3 stacked pulses. Clinical and dermoscopic photographs were taken before and after therapy. Global clinical improvement was higher than 50% in 12 lesions. Patient satisfaction assessment showed 73% of patients as satisfied or very satisfied. All lesions showed changes from the previous dermoscopic pattern. We consider that PDL could be a safe, palliative treatment as it is well accepted by patients and has a better cosmetic outcome than surgical excision.