Combination Therapy for the Treatment of Complex Vascular Lesions.

BACKGROUND AND OBJECTIVES: Combination treatment with debulking surgical procedures, vascular and ablative lasers, and topical and intralesional vascular therapies may improve outcomes in nodular hypertrophic and mixed complex vascular malformations; however, there is a paucity of data reporting specific combinations of these treatments. We report 15 cases of complex vascular malformations, which were successfully treated with novel combinations of these modalities. STUDY DESIGN/MATERIALS AND METHODS: We performed a review of 15 patients treated with combination vascular laser therapy, electrosurgery, ablative laser technologies, and topical and intralesional vascular therapies from May 2000 to October 2020. Photographs were taken at intervals with attempts made for consistent lighting and positioning. RESULTS: All 15 patients achieved an excellent clinical response to combination therapy with visible improvement of the hypertrophic, textural, and vascular components of their lesions. No major complications or adverse events were encountered during any of the treatments. CONCLUSION: Combination multimodality therapy with surgical debulking, laser technologies, and topical and injection therapies can be highly effective and efficient in treating complex vascular malformations. © 2021 Wiley Periodicals LLC.

Current Practices in Pediatric Dermatology Laser Therapy: An International Survey.

BACKGROUND AND OBJECTIVES: To date, there are no well-established guidelines regarding laser therapy for the treatment of cutaneous lesions in pediatric patients. We aim to ascertain the types of lasers commonly used, types of lesions treated, and factors that affect the selection of specific laser modalities in pediatric patients. STUDY DESIGN/MATERIALS AND METHODS: An anonymous online survey was distributed to healthcare providers who treat children with lasers through listservs of four major national and international dermatology and laser organizations. RESULTS: Outpatient office-based procedure rooms are the most common clinical setting for laser procedures (74.4%), and pulsed dye laser is the most commonly used laser (95.4%). Conditions routinely treated with lasers included port wine stains (95.4%), infantile hemangiomas (81.5%), other vascular lesions (81.5%), scars (77.7%), and hair (60.8%). 84.4% of respondents expressed concern about general anesthesia in patients <2 years old. Nevi of Ota is treated with laser more frequently (52.3%) than other pigmented lesions. LIMITATIONS: Limited generalizability of case examples to general conditions. CONCLUSIONS: Vascular lesions are the most common lesions treated with lasers in pediatric dermatology patients, and most providers are using these devices in the outpatient setting. Many providers are concerned about the effects of repeated general anesthesia in infants, and there appears to be a trend toward providing laser therapy in the outpatient setting without general anesthesia. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Analysis of lesional color to differentiate infantile hemangiomas from port-wine birthmarks in infants less than 3 months old: A pilot study.

BACKGROUND: In their early phase, infantile hemangiomas (IH) can sometimes be difficult to differentiate from port-wine birthmarks (PWB). Until recently, inexpensive diagnostic tools have not been readily available. OBJECTIVE: To determine the diagnostic utility of widely available colorimetric technology when differentiating PWB from IH in photographs of infants less than 3 months old. METHODS: Multi-center, retrospective analysis of RGB (red, green, and blue) and HSL (hue, saturation, lightness) values collected using electronic colorimeters from images of clinically confirmed untreated IH or PWB. Subgroup analysis of flat vascular birthmarks was subsequently performed. RESULTS: Images of 119 IH (specifically, 45 flat IH) and 59 PWB were identified. PWB had significantly (P < .001) higher RGB values of all primary colors, most notably for blue and green (mean difference: >50), irrespective of thickness. RGB or RGB with HSL values had an excellent accuracy (90%), sensitivity (92%), specificity (98%), and positive predictive value (98%) when discriminating PWB from flat IH. IH could be distinctly clustered from PWB when combining their RGB with HSL values. CONCLUSION: Electronic colorimeters with emphasis on blue and green values, are able to differentiate PWB from IH, irrespective of thickness, with a high degree of accuracy. A larger scale evaluation is now required.

Evolution of congenital melanocytic nevi toward benignity: A case series.

We report on four children born with medium to large congenital melanocytic nevi (CMN) with color heterogeneity and irregular surface rugosity. As these patients aged, their nevi evolved to become more homogeneous and lighter in color, and developed a smoother, more even texture. We propose that given this evolution toward benignity, conservative monitoring and management may be appropriate even in the context of atypical-appearing features at birth. Such knowledge regarding the evolution of these CMN can more accurately guide parents and clinicians in determining whether to biopsy or remove an atypical-looking lesion early in life for medical or cosmetic reasons.

Keratosis pilaris rubra: a common but underrecognized condition.

BACKGROUND: Keratosis pilaris is a common skin disorder of childhood that often improves with age. Less common variants of keratosis pilaris include keratosis pilaris atrophicans and atrophodermia vermiculata. OBSERVATIONS: In this case series from dermatology practices in the United States, Canada, Israel, and Australia, the clinical characteristics of 27 patients with keratosis pilaris rubra are described. Marked erythema with follicular prominence was noted in all patients, most commonly affecting the lateral aspects of the cheeks and the proximal arms and legs, with both more marked erythema and widespread extent of disease than in keratosis pilaris. The mean age at onset was 5 years (range, birth to 12 years). Sixty-three percent of patients were male. No patients had atrophy or scarring from their lesions. Various treatments were used, with minimal or no improvement in most cases. CONCLUSIONS: Keratosis pilaris rubra is a variant of keratosis pilaris, with more prominent erythema and with more widespread areas of skin involvement in some cases, but without the atrophy or hyperpigmentation noted in certain keratosis pilaris variants. It seems to be a relatively common but uncommonly reported condition.

Exposure to human tragedy, empathy, and trauma in ambulance paramedics.

Paramedics are exposed to events involving human pain and suffering on a daily basis, many of which are the result of violence perpetrated by 1 individual on another. For the most part, these emergency workers have learned to deal with such events and take them in stride. At times, however, certain circumstances lead workers to develop an emotional connection with the victim or his or her family. When this occurs, paramedics report increased symptoms of traumatic stress. Aspects that can trigger this connection include the victim's alienation from others, profound loss, or the abuse of an innocent child. One of the coping strategies described in these circumstances is to manage the events on a cognitive and technical level while maintaining an emotional distance. Although such a strategy may be protective, it may also have long-term negative effects in terms of interpersonal relationships. This mixed-methods study attempts to better understand factors that lead to higher levels of distress among paramedics within the theoretical framework of emotional and cognitive empathy.

Posttraumatic symptoms and disability in paramedics.

OBJECTIVE: The concern that secondary gain may result in an overreporting of trauma symptoms in those seeking compensation or taking stress leave from work has raised questions about the relation between posttraumatic stress and disability. This study attempts to examines the relation between traumatic stress symptoms and the use of work leave in an anonymous sample of emergency-service workers who are not currently seeking compensation. METHOD: A total of 86 paramedics completed questionnaires that addressed exposure to traumatic events, use of mental health stress leave, social support, current level of distress, and personality patterns. Comparisons were made between groups who had used mental health stress (MHS) leave and those who had not. Logistic regression was used to determine the best predictors of using leaves. RESULTS: Current levels of social support were associated with previous use of mental health stress leave. In addition, significantly more individuals who had taken MHS leave in the past reported posttraumatic stress symptoms in the high or severe range. People with personality patterns characterized by suspiciousness, hostility, and isolation and having a tendency toward demanding, controlling, and manipulative behaviour in relationships were also more likely to have taken an MHS leave. CONCLUSION: Although social support and trauma symptoms were associated with the use of MHS leave, in this study, personality style was the strongest factor differentiating those individuals who took MHS leave from those who did not.

Tuberous sclerosis-associated lesions of the kidney, brain, and skin are angiogenic neoplasms.

BACKGROUND: Tuberous sclerosis is an autosomal dominant condition characterized by the development of benign neoplasms of the brain, kidney, and skin. Progressive growth and malignant transformation of brain and kidney lesions constitute the major cause of morbidity and mortality in adults with tuberous sclerosis. In addition, growth of skin lesions may be disfiguring to patients. OBJECTIVE: The purpose of this study was to determine whether benign tumors in patients with tuberous sclerosis are angiogenic. METHODS: Brain, kidney, and skin tumors from patients with tuberous sclerosis were stained with CD31, a specific marker of vascular endothelium. In addition, we used Northern blot analysis to demonstrate that renal angiomyolipoma cells express the potent angiogenesis stimulator vascular endothelial growth factor (VEGF). RESULTS: Brain, kidney, and skin neoplasms from patients with tuberous sclerosis are highly angiogenic. Renal angiomyolipoma cells produce the potent angiogenic factor VEGF. CONCLUSION: Benign neoplasms of patients with tuberous sclerosis are highly vascular. Our results provide a rationale for antiangiogenic therapy in the treatment and prevention of tuberous sclerosis-associated neoplasms.