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.

Price decomposition of laser treatment for port-wine stain using the hedonic pricing model.

BACKGROUND: Port-wine stain (PWS) is a congenital capillary malformation associated with negative effects on the quality of life and psychological health of the patients. Pulsed dye laser (PDL) is the current treatment of choice for PWS; however, there is little information on the factors determining the treatment price of PWS. We aim to explore the factors determining the treatment price of PWS. METHODS: Data were collected through telephone surveys and self-reported questionnaires from hospitals, chain clinics, and doctor's offices that offered PWS treatment from February 1 to March 30, 2021. Data were analyzed by descriptive statistics and multivariate analysis using a log-linear regression model. RESULTS: A total of 104 observations were gathered. The estimated base price of the treatment without any additional features is 98.34 USD. Treatment by dermatologists has an additional charge of 28.41 USD or 28.9%. Some private clinics offer a lower price of 28.7% (or 28.27 USD) by illegally having non-medical doctors perform the treatment. Treatment with 595-nm PDL and 585-nm PDL and 1064-nm Nd:YAG lasers has an additional charge of 34% (or 33.45 USD) and 38% (or 37.41 USD), respectively. The location and type of medical facility can also affect the price of the treatment. CONCLUSION: Many factors determine the base price and shadow price of PWS treatment. Factors determining a higher cost of laser fee includes non-government facilities, location within the capital city, and shopping complexes (high-cost location). Lastly, the type of laser and medical personnel provider can also affect the price of the treatment.

[Assessment of the Efficacy and Influencing Factors of Treating Facial and Neck Port-Wine Stains with 595 nm Pulsed Dye Laser].

OBJECTIVE: To assess the efficacy of 595 nm pulsed dye laser (PDL) in the treatment of facial and neck port-wine stains (PWSs), and to explore the main factors affecting the efficacy. METHODS: A total of 259 PWS cases who were treated with 595 nm PDL were retrospectively enrolled and their clinical information was analyzed in the study. Before- and after-treatment comparison of individual patient was done by comparing patient photographs taken before and after PDL treatment of the PWSs in order to assess the treatment efficacy, using mild purpura as the endpoint of the PDL treatment. A total of 82 male and 177 female cases were included, with patient age ranging between 1 month and 63 years. Univariate analysis was done to select factors influencing the treatment efficacy. Then, ordered multivariate logistic regression analysis was performed to evaluate the main factors affecting the efficacy. Statistics of adverse reaction of patients were also collected. RESULTS: Of the 259 patients covered in the study, 57 (22%) had achieved complete clearing of PWS, 106 (40.9%) showed significant improvement, and 68 (26.3%) showed moderate improvement, amounting to a total of 231 effective treatment cases, indicating a 89.2% overall rate of effective treatment. There were 28 ineffective treatment cases (10.8%). Ordered multivariate logistic regression analysis showed that the color of PWS, the area of PWS, anatomical sites of PWS and the number of treatment sessions were the main factors affecting the therapeutic efficacy, while proliferation did not affect the therapeutic efficacy. Red-type PWS had better treatment efficacy than that of the purple-type PWS (odds ratio [ OR]=2.748, P<0.05). Patients with PWS≤10 cm 2 showed better treatment efficacy than those with PWS>10 cm 2 ( OR=2.094, P<0.05). Treatment efficacy of PWS located in the central section of the face was not as good as those located on the neck ( OR=0.190, P<0.05), and the treatment efficacy of PWS located in the central and lateral section of the face was not as good as those located on the neck ( OR=0.243, P<0.05). Patients who had more than 3 treatment sessions showed better efficacy than those who had 1-3 sessions of treatment ( OR=0.508, P<0.05). No patients incurred any serious adverse reactions. CONCLUSION: Patients with PWS located on the neck, red-type PWS and area ≤10 cm 2 are suitable for treatment with 595 nm PDL and there should be more than three sessions of treatment. Patient sex, age, or proliferation do not affect the treatment effect.

Anesthetic techniques used for pulsed dye laser (PDL) in the treatment of port-wine birthmarks: An exploratory assessment of current attitudes and practice patterns among pediatric dermatologists in the United States.

BACKGROUND/OBJECTIVES: Pulsed dye laser (PDL) is the gold standard for treating port-wine birthmarks (PWBs), but no consensus exists regarding anesthetic techniques when performing PDL for PWB. Given potential adverse neurocognitive effects from general anesthesia (GA) exposure in early childhood, we sought to establish current attitudes and practice patterns regarding anesthesia when treating PWB with PDL. METHODS: An electronic REDCap survey was distributed to members of the Pediatric Dermatology Research Alliance (PeDRA) and the Society for Pediatric Dermatology (SPD) via email. Aggregate, anonymized results were reported. RESULTS: Among 47 respondents, the majority (83%) identified as board-certified pediatric dermatologists. When treating children <4 years old, 70% endorsed some use of topical anesthesia. Although 87% reported concerns about long-term side effects on development and school performance affecting their pursuit of GA, 61% reported use of GA for PDL in children <4 years old. All 4 (100%) respondents whose PDL was located in the operating room (OR) setting reported use of GA, compared to 6 of 17 (35%) respondents whose PDL machine was not located in the OR. Providers were more likely to use GA in patients between 1 and 4 years old (70%) compared to those <1 year old (2%). CONCLUSIONS: Diverse practice patterns reiterate the need for a standardized anesthetic approach for PDL in young children and continued research on other factors (ie, location/accessibility of PDL, lesion size) impacting anesthesia choices. Given potential neurodevelopmental risks associated with GA, specific guidance to effectively minimize its use in favor of topical anesthetics should be provided.

The assessment of pulsed dye laser treatment of port-wine stains with reflectance confocal microscopy.

BACKGROUND: Reflectance confocal microscopy (RCM) is a noninvasive technique for evaluating cutaneous lesions with cellular level resolution close to conventional histopathology. The aim of this study is to observe the vascular changes in Port-wine (PWS) lesions and assess the clinical efficacy of Pulsed Dye Laser (PDL) treatment by examining vessel diameter and density with RCM. MATERIALS AND METHODS: Eleven adult patients with PWS, each had four test patches carried out with different pulse durations (1.5, 3, 6, and 10 ms), respectively; fluences of 9-12 J/cm²; and a spot size of 7 mm. The PDL treatment was repeated 3-5 times at a 2-month interval. Photographs and measurements with RCM were taken before each treatment and 2 months after the last treatment. RESULTS: The PDL treatment exhibited increasing clearance with reducing pulse durations. Vessel diameters and densities were significantly decreased in the same pulse-duration groups after treatment. There was significant difference between 1.5 ms pulse-duration group and other pulse-duration groups in reducing blood vessel diameter at the depth of 150 µm. CONCLUSIONS: RCM can be used to assess the clinical efficacy of PDL treatment.

Quantitative three-dimensional assessment of port-wine stain clearance after laser treatments.

BACKGROUND AND OBJECTIVE: Outcomes analysis of laser treatment for port-wine stains has been hampered by the lack of an objective measure of surface area and volume; moreover, treatment success is often gauged by clinician subjective assessment. Three-dimensional (3D) surface imaging has been applied in several medical disciplines to quantify surface changes, with promising results. We hypothesized that 3D surface imaging could be used to objectively measure changes in area and volume of port-wine stains following laser treatment. STUDY DESIGN/MATERIALS AND METHODS: We performed a retrospective review of consecutive patients with port-wine stains treated over a 20-month time period. Area and volume of the lesions were measured using 3dMD photogrammetric software (3dMD, Atlanta, GA) before and after a series of sequential pulsed dye laser and/or alexandrite laser treatments. RESULTS: Fifty-five patients with 59 port-wine stains were included in the study. The initial average measured area was 44.3 cm(2) ; final average measured area decreased to 36.9 cm(2) (P < 0.001). The average volume change was 1.20 cc for all PWS included in the study and 1.90 cc for lesions that received at least 5 laser treatments within the study period. CONCLUSION: Three-dimensional photography demonstrated area and volume changes in patients with port-wine stains after laser treatments. Future studies to determine if statistically significant changes correlate with clinically appreciable changes are warranted.

Quantitative three-dimensional assessment of port-wine stain clearance after laser treatments.

BACKGROUND AND OBJECTIVES: Outcomes analysis of laser treatment for port-wine stains (PWS) has been hampered by the lack of an objective measure of surface area and volume; moreover, treatment success is often gauged by clinician subjective assessment. Three-dimensional (3D) surface imaging has been applied in several medical disciplines to quantify surface changes, with promising results. We hypothesized that 3D surface imaging could be used to objectively measure changes in area and volume of PWS following laser treatment. STUDY DESIGN/MATERIALS AND METHODS: We performed a retrospective review of consecutive patients with PWS treated over a 20-month time period. Area and volume of the lesions were measured using 3dMD photogrammetric software (3dMD; Atlanta, GA) before and after a series of sequential pulsed dye laser and/or alexandrite laser treatments. RESULTS: Fifty-five patients with 59 PWS were included in the study. The initial average measured area was 45.6 cm(2) ; final average measured area decreased to 34.6 cm(2) (P < 0.001). The average volume change was 1.20 ml for all PWS included in the study and 1.90 ml for lesions that received at least five laser treatments within the study period. CONCLUSION: Three-dimensional photography demonstrated area and volume changes in patients with PWS after laser treatments. Future studies to determine if statistically significant changes correlate with clinically appreciable changes are warranted.

Assessment of pulsed-dye laser therapy for pediatric cutaneous vascular anomalies.

IMPORTANCE: Although facial vascular malformations are often treated by facial plastic surgeons, no reliable validated assessment tool exists for surgeons to assess results. OBJECTIVES: To use our assessment tool to analyze results from pulsed-dye laser therapy used for pediatric facial vascular malformations, and to determine interrater reliability of our assessment tool in a standard clinical environment without the use of professional photography. DESIGN: A blinded retrospective review of pediatric patients who underwent pulsed-dye laser therapy for treatment of hemangiomas of infancy (HOIs) and port-wine stains. Three pediatric otolaryngologists and facial plastic surgeons independently rated all of the pictures using our assessment tool. SETTING: Tertiary care pediatric hospital. RESULTS: Pulsed-dye laser therapy was performed in 22 patients, 17 with HOIs and 5 with port-wine stains. Patients with HOIs treated only by pulsed-dye laser showed, on average, a 50% to 75% improvement in color, 1% to 24%, improvement in thickness, and 1% to 24% improvement in size of the lesion. Eight patients with HOIs underwent surgery after laser therapy, and of these, 100% saw improvement in color, thickness, and size. Port-wine stains showed a 1% to 24% improvement in color and no improvement in thickness or size. Interrater reliability for questions 1 to 6 was 0.92, 0.92, 0.93, 0.91, 0.70, and 0.10, respectively. CONCLUSIONS AND RELEVANCE: Currently, no standardized or validated methods exist to evaluate results from intervention of pediatric facial HOIs and port-wine stains. Our assessment tool is reliable to assess patients with HOIs and port-wine stains who undergo pulsed-dye laser therapy and surgical reconstruction. LEVEL OF EVIDENCE: 3.

Noninvasive clinical assessment of port-wine stain birthmarks using current and future optical imaging technology: a review.

Port-wine stain (PWS) birthmarks are one class of benign congenital vascular malformation. Laser therapy is the most successful treatment modality of PWS. Unfortunately, this approach has limited efficacy, with only 10% of patients experiencing complete blanching of the PWS. To address this problem, several research groups have developed technologies and methods designed to study treatment outcome and improve treatment efficacy. This article reviews seven optical imaging techniques currently in use or under development to assess treatment efficacy, focusing on: reflectance spectrophotometers/tristimulus colorimeters; laser Doppler flowmetry and laser Doppler imaging; cross-polarized diffuse reflectance colour imaging system; reflectance confocal microscopy; optical coherence tomography; spatial frequency domain imaging; and laser speckle imaging.

Three-dimensional Monte Carlo model of pulsed-laser treatment of cutaneous vascular lesions.

We present a three-dimensional Monte Carlo model of optical transport in skin with a novel approach to treatment of side boundaries of the volume of interest. This represents an effective way to overcome the inherent limitations of "escape" and "mirror" boundary conditions and enables high-resolution modeling of skin inclusions with complex geometries and arbitrary irradiation patterns. The optical model correctly reproduces measured values of diffuse reflectance for normal skin. When coupled with a sophisticated model of thermal transport and tissue coagulation kinetics, it also reproduces realistic values of radiant exposure thresholds for epidermal injury and for photocoagulation of port wine stain blood vessels in various skin phototypes, with or without application of cryogen spray cooling.

Choosing optimal wavelength for photodynamic therapy of port wine stains by mathematic simulation.

Many laser wavelengths have been used in photodynamic therapy (PDT) for port wine stains (PWS). However, how these wavelengths result in different PDT outcomes has not been clearly illuminated. This study is designed to analyze which wavelengths would be the most advantageous for use in PDT for PWS. The singlet oxygen yield in PDT-treated PWS skin under different wavelengths at the same photosensitizer dosage was simulated and the following three situations were simulated and compared: 1. PDT efficiency of 488, 532, 510, 578, and 630 nm laser irradiation at clinical dosage (100 mW∕cm(2), 40 min); 2. PDT efficiency of different wavelength for PWS with hyperpigmentation after previous PDT; 3. PDT efficiency of different wavelengths for PWS, in which only deeply located ectatic vessels remained. The results showed that singlet oxygen yield is the highest at 510 nm, it is similar at 532 nm and 488 nm, and very low at 578 nm and 630 nm. This result is identical to the state in clinic. According to this theoretical study, the optimal wavelength for PDT in the treatment of PWS should near the absorption peaks of photosensitizer and where absorption from native chromophores (haemoglobin and melanin) is diminished.

Numerical optimization of sequential cryogen spray cooling and laser irradiation for improved therapy of port wine stain.

BACKGROUND AND OBJECTIVE: Despite application of cryogen spray (CS) precooling, customary treatment of port wine stain (PWS) birthmarks with a single laser pulse does not result in complete lesion blanching for a majority of patients. One obvious reason is nonselective absorption by epidermal melanin, which limits the maximal safe radiant exposure. Another possible reason for treatment failure is screening of laser light within large PWS vessels, which prevents uniform heating of the entire vessel lumen. Our aim is to identify the parameters of sequential CS cooling and laser irradiation that will allow optimal photocoagulation of various PWS blood vessels with minimal risk of epidermal thermal damage. STUDY DESIGN AND METHODS: Light and heat transport in laser treatment of PWS are simulated using a custom 3D Monte Carlo model and 2D finite element method, respectively. Protein denaturation in blood and skin are calculated using the Arrhenius kinetic model with tissue-specific coefficients. Simulated PWS vessels with diameters of 30-150 µm are located at depths of 200-600 µm, and shading by nearby vessels is accounted for according to PWS histology data from the literature. For moderately pigmented and dark skin phototypes, PWS blood vessel coagulation and epidermal thermal damage are assessed for various parameters of sequential CS cooling and 532-nm laser irradiation, i.e. the number of pulses in a sequence (1-5), repetition rate (7-30 Hz), and radiant exposure. RESULTS: Simulations of PWS treatment in darker skin phototypes indicate specific cooling/irradiation sequences that provide significantly higher efficacy and safety as compared to the customary single-pulse approach across a wide range of PWS blood vessel diameters and depths. The optimal sequences involve three to five laser pulses at repetition rates of 10-15 Hz. CONCLUSIONS: Application of the identified cooling/irradiation sequences may offer improved therapeutic outcome for patients with resistant PWS, especially in darker skin phototypes.

The assessment of port wine stains in children following multiple pulsed-dye laser treatments.

The purpose of this study was to compare 3 methods of assessment of pediatric port wine stains (PWSs) following multiple pulsed-dye laser (PDL) treatments; (i) parental evaluation, (ii) objective evaluation utilizing L*a*b* color measurement, and (iii) the visual inspection of serial photographs by blinded observers. Twenty-one children who had received at least 4 prior PDL treatments were prospectively enrolled. Following additional PDL treatment, 72.5% of the parental responses indicated a lighter PWS; 85% said that they would continue with further treatment. According to the assessments by 3 observers, only 33.3% to 61.9% (correlation coefficients: 0.41 and 0.54; P < 0.01) of the PDL treatments resulted in a perceived lightening. L*a*b* measurements were not significantly correlated with the observers' perceptions. L*a*b* assessment is not a clinically useful method to evaluate PDL response in the PWS previously treated. Relying solely on parental assessment may lead to overtreatment without a demonstrable benefit.

Improvement of port wine stain laser therapy by skin preheating prior to cryogen spray cooling: a numerical simulation.

BACKGROUND AND OBJECTIVES: Although cryogen spray cooling (CSC) in conjunction with laser therapy has become the clinical standard for treatment of port wine stain (PWS) birthmarks, the current approach does not produce complete lesion blanching in the vast majority of patients. The objectives of this study are to: (1) experimentally determine the dynamic CSC heat flux when a skin phantom is preheated, and (2) numerically study the feasibility of using skin preheating prior to CSC to improve PWS laser therapeutic outcome. STUDY DESIGN/MATERIALS AND METHODS: A fast-response thin-foil thermocouple was used to measure the surface temperature and thus heat flux of an epoxy skin phantom during CSC. Using the heat flux as a boundary condition, PWS laser therapy was simulated with finite element heat diffusion and Monte Carlo light distribution models. Epidermal and PWS blood vessel thermal damage were calculated with an Arrhenius-type kinetic model. RESULTS: Experimental results show that the skin phantom surface can be cooled to a similar minimum temperature regardless of the initial temperature. Numerical simulation indicates that upon laser irradiation, the epidermal temperature increase is virtually unaffected by preheating, while higher PWS blood vessel temperatures can be achieved. Based on the damage criterion we assumed, the depth and maximum diameter of PWS vessels that can be destroyed irreversibly with skin preheating are greater than those without. CONCLUSIONS: Skin preheating prior to CSC can maintain epidermal cooling while increasing PWS blood vessel temperature before laser irradiation. Numerical models have been developed to show that patients may benefit from the skin preheating approach, depending on PWS vessel diameter and depth.

Introduction of the flash-lamp pulsed-dye laser treatment of facial port-wine stains in childhood: A case of health care technology assessment.

BACKGROUND AND OBJECTIVE: Lasers have been used in the treatment of port-wine stains (PWS) for more than 30 years. With the introduction of the flash-lamp pulsed-dye laser (FPDL) it was assumed that infants could be treated safely, effectively, and probably more efficiently. Nowadays, FPDL treatment is an established form of treatment of PWS in childhood. STUDY DESIGN/MATERIALS AND METHODS: On the basis of the iterative Health Care Technology Assessment (HCTA) loop, we examined whether sufficient evidence from evaluations has been present to support the introduction of FPDL treatment for facial PWS at an early age. Such an assessment requires an interdisciplinary approach focusing on aspects of safety, efficacy, effectiveness, quality of life, costs, and the ethical issues of treatment. RESULTS: Assessment of the FPDL in PWS treatment of children did not follow the model of medical innovation and evaluation. Most assessments have been focused on laser applications that were already in clinical use. Efficacy and effectiveness of laser treatment have been the major concern in most assessments. Only a few studies have looked at costs and ethical aspects of treating children. CONCLUSIONS: The introduction and diffusion of the use of the FPDL in the treatment of PWS in childhood were uncontrolled, and the field was not prepared to use this technique properly. We believe that this nonadherence to the iterative HCTA model reflects the gradual way by which innovations find their way into clinical practice.

Temperature distributions in laser-heated biological tissue with application to birthmark removal.

The time-dependent temperature distributions produced within thermally homogeneous media heated by a moving laser beam with Gaussian and uniform power density profiles are examined using a time-domain method based on Green's functions. Regions of finite length, width, and depth within the medium having exponential power absorption are considered. The temperature distribution is written as a single integral with respect to time of simple functions and the resulting expressions have been used to model the heating of blood vessels for birthmark (port-wine stain) removal. The temperature distributions obtained are in good agreement with those produced using Monte Carlo optical and finite difference thermal models.

Assessment of clinical outcome after flashlamp pumped pulsed dye laser treatment of portwine stains: a comprehensive questionnaire.

A generally accepted method to assess the clinical outcome of laser treatment of portwine stains is not available. This paper describes the development and evaluation of a comprehensive questionnaire for the assessment of the following portwine stain characteristics: color (hue and lightness), sharpness of boundary, pigmentation, size, shape, skin surface-structure, and hypertrophy of underlying tissue. The questionnaire was applied to photographs of 70 patients with previously untreated portwine stains in the head/neck area. Photographs were taken before treatment and after five treatments of the entire portwine stain with a flashlamp pumped pulsed dye laser. Each photograph was evaluated separately by a panel of five professionals: the treating physician, two plastic surgeons, a dermatologist, and a clinical photographer. Treatment results were assessed by comparing ratings before and after treatment. Agreement among raters was acceptable for all portwine stain characteristics, as was shown by weighted kappa analysis. The reliability of the answers was further improved by taking the average rating of the five panel members. The scores thus obtained were very reliable, with Cronbach alpha coefficients of 0.8 on average. After five treatments of the entire portwine stain, the most considerable changes were measured in the ratings for color (lightening of the stain by 33 percent), boundary (sharpness reduced by 38 percent), and size (13-percent decrease). Using the questionnaire can be helpful in the design of comparative clinical trials on portwine stain treatment and may facilitate comparison of treatment results between different treatment centers and/or different lasers.

The medical necessity for treatment of port-wine stains.

BACKGROUND: Port-wine stains are congenital vascular malformations that can be disfiguring and may lead to psychosocial as well as medical complications. The 585-nm pulsed dye laser is very effective in treating port-wine stains. Laser treatment is often viewed by insurance companies as a "cosmetic procedure" and not "medically necessary". Consequently many patients are denied coverage for treatment of their disfiguring birthmarks. OBJECTIVE: To determine variability of insurance coverage for laser treatment of port-wine stains from state to state. Natural history, progression, and potential complications of port-wine stains are reviewed and rationale for consistent insurance coverage for laser treatment of port-wine stains is given. METHODS: A questionnaire was mailed to 40 dermatologic surgeons in 22 states and the District of Columbia. We reviewed the literature regarding port-wine stains and their potential complications, and health care policy guidelines regarding "medical necessity" and "cosmetic procedures". RESULTS: Insurance coverage for laser treatment of port-wine stains varies from state to state. CONCLUSION: Based on current health care policy guidelines, laser treatment of port-wine stains should be regarded, and covered, as a medical necessity by all insurance providers.