Analysis of port-wine birthmark vascular characteristics by location: Utility of optical coherence tomography mapping.

INTRODUCTION: Port-wine birthmarks (PWBs) are congenital capillary malformations that can be located on any area of the body. Vascular features include vessel size, depth, and density, which can greatly differ between patients, individual lesions, and even sites within the same lesion. Previous studies have determined that the location of PWB lesions has impacted their clinical response to laser treatment. OBJECTIVE: We utilized dynamic optical coherence tomography (D-OCT) to measure in vivo vessel diameter, density, and superficial plexus depth in patients of all ages with PWB on various sites of the body. We hypothesized that these vascular characteristics would differ according to body location. MATERIALS AND METHODS: Patients who had a PWB and presented to clinic at three sites for treatment with the pulsed dye laser (PDL) were enrolled into the study. A D-OCT scanner was utilized for noninvasive, in vivo imaging of PWB lesions. The depth of the top portion of the superficial vascular plexus was estimated as the depth at which the vessel density reaches 50% of the maximum. Vessel diameter and density were calculated by incorporated software algorithm. RESULTS: A total of 108 patients were enrolled into the study. There was a total of 204 measurements of PWB lesions. Of all patients, 56.5% (n = 61) reported having a previous treatment with PDL. Of all D-OCT scans, 62.3% (n = 127) were located on the head, 14.2% (n = 29) the upper extremities, 8.3% (n = 17) the lower extremities, 7.8% (n = 16) the trunk, and 7.8% (n = 15) the neck. All locations were compared for each vascular characteristic. For superficial plexus depth, lesions on the head were significantly shallower than those on the upper extremities (217 vs. 284 µm; p < 0.001) and lower extremities (217 vs. 309 µm; p < 0.001). For vessel diameter, lesions on the head had significantly larger vessels than those on the upper extremities (100 vs. 72 µm; p = 0.001). For vessel density, lesions on the head had significantly denser vessels than those on the trunk (19% vs. 9.6%; p = 0.039) and upper extremities (19% vs. 9.3%; p < 0.001) CONCLUSIONS: PWB lesions have distinct vascular characteristics, which can be associated with their body location. This includes superficial vascular plexus depth as well as vessel diameter and density.

Vascular characteristics of port wine birthmarks as measured by dynamic optical coherence tomography.

BACKGROUND: Port wine birthmarks (PWBs) are congenital capillary malformations. Vessel characteristics, such as diameter and depth, may impact presentation and outcomes. They can be imaged using dynamic optical coherence tomography, a high-resolution, noninvasive imaging method. PURPOSE: We conducted a cross-sectional observational study to measure in vivo vascular characteristics as a function of PWB color. METHODS: Patients undergoing treatment for PWB were recruited from 3 sites. PWBs were classified by color. Dynamic optical coherence tomography images with calculations were obtained. RESULTS: One hundred eight patients were enrolled. Mean age correlated with PWB color, with birthmarks being lighter in younger patients and darker in older patients (P < .01). Mean superficial plexus depth was significantly shallower in purple PWBs than in pink PWBs. Color was not associated with significant differences in mean superficial vessel density or diameter. Among pink PWBs, each 10-year increase in age was associated with a 10.6-µm increase in superficial plexus depth. Among purple PWBs, each 10-year increase in age was associated with a 16.2-µm reduction in superficial plexus depth. In lesions without prior treatment, vessel density was 12.7% lower in purple PWBs than in pink PWBs. CONCLUSION: Superficial vessels of purple PWBs were significantly closer to the epidermis than those of pink PWBs, which might impact optimal laser parameters.

Case Series of Fractional Ablative Laser Resurfacing of Pediatric Facial Traumatic and Surgical Scars.

BACKGROUND AND OBJECTIVES: Fractional ablative 10,600-nm carbon dioxide (CO2 ) laser has well-demonstrated safety and efficacy in resurfacing treatment of scars in the adult population and in the treatment of pediatric burn scars. However, there is a paucity of literature regarding laser resurfacing of traumatic and surgical scars for cosmetic benefit in the pediatric population, and in majority of cases previously reported, this was done under general anesthesia. STUDY DESIGN/MATERIALS AND METHODS: This was a retrospective chart review of pediatric patients under the age of 18 who underwent fractional ablative CO2 laser resurfacing (FALR) of traumatic or surgical scars at a single center between 2018 and 2019, inclusive. Primary endpoints included safety and tolerance. RESULTS: A total of 31 FALR treatments were performed in 10 patients with traumatic and surgical scars located on the face (age 4-14 years, Fitzpatrick skin type [FST] I-IV, 60% female). Settings ranged from total energy per session 0.02-0.33 kJ, with a 7-mm tip and 30-50% coverage. Nine patients had two or more treatments (average 3, maximum 8) spaced at least 4 weeks apart. All resurfacing treatments were well-tolerated with local infiltration of 1% lidocaine with epinephrine (1:100,000). Six (67%) patients were treated with additional measures including pulsed dye laser, 1927-nm fractional non-ablative low-energy, low-density laser, or intralesional agents (5-fluorouracil, triamcinolone, botulinum toxin). At follow-up (of varied intervals), short-term erythema, as expected, was seen in six patients, and hyperpigmentation in one case (FST IV), both treated with aforementioned alternate devices. Although gradual, improvement in scar appearance and texture was seen with FALR treatments. No additional scarring, infection, or hypopigmentation was seen. CONCLUSIONS: Treatment with fractional ablative laser resurfacing is safe and well-tolerated in the pediatric population in an outpatient setting with local anesthesia. Traumatic scars may cause significant distress to children and parents alike. Multimodal therapy may lead to optimal cosmesis. Given the excellent tolerability, the authors recommend consideration of laser resurfacing in pediatric patients with traumatic or surgical scars when bothersome, either cosmetically or psychologically. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Dynamic Optical Coherence Tomography of Cutaneous Blood Vessels in Melasma and Vessel Response to Oral Tranexamic Acid.

BACKGROUND AND OBJECTIVES: Melasma may be related to aberrant blood vessels, but there has been no report on the utility of dynamic optical coherence tomography (D-OCT) in studying vessel characteristics in melasma. We studied the characteristics of cutaneous blood vessels in melasma and the effects of oral tranexamic acid (TXA) with D-OCT. STUDY DESIGN/MATERIALS AND METHODS: Six patients with moderate to severe melasma had a D-OCT scanning of the areas on the face affected by melasma and not affected by it. Three of them had scans within 3 months after starting oral TXA and at a follow-up visit. Blood flow at different depths of the skin and vessel diameter were compared between the melasma and normal skin. For those taking oral TXA, we compared the percent change of blood flow and diameter between the melasma and normal skin. RESULTS: Dermal blood flow and vessel diameter were greater in the melasma skin than in the normal skin. Oral TXA reduced dermal blood flow in both the melasma and normal skin, but the reduction was more dramatic in the lesional melasma skin. CONCLUSIONS: D-OCT findings that (i) dermal blood vessels in melasma are increased in size and flow and (ii) oral TXA reduced the vessel size and flow, providing evidence supporting the relationship between melasma and cutaneous blood vessels. D-OCT may be utilized in measuring response to treatments targeting melasma. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Safety Profile of Combined Same-Day Treatment for Botulinum Toxin With Full Face Nonablative Fractionated Laser Resurfacing.

BACKGROUND: Spread of botulinum toxin outside the treated muscle is a concern, when energy-based device treatment is performed on the same day as toxin injection. OBJECTIVE: We assessed the frequency of eyelid ptosis after the glabella/periorbital botulinum toxin injection and nonablative fractionated laser performed at the same session. METHODS AND MATERIALS: This single-center, retrospective study identified treatments consisting of glabella and/or periorbital botulinum toxin injection and nonablative fractionated laser treatment to full face from 2017 to 2019 and eyelid ptosis determined by documentation of the complication at a follow-up encounter, or prescription of apraclonidine. RESULTS: Six hundred sixteen treatments of glabella/periorbital botulinum toxin injection and full-face nonablative fractionated laser on the same day on 393 individuals were identified. Five hundred eighty treatments (94%) included botulinum toxin injected in the glabella, 541 (88%) in the periorbital areas, and 508 (82%) in the forehead. Nonablative fractionated lasers used to treat the cohort were a 1,927-nm thulium and a 1,550-nm er:glass laser. Eyelid ptosis complication was documented in one case (0.2%) following the combined laser and toxin treatment. CONCLUSION: The risk of spread of glabella/periorbital botulinum toxin to an unintended muscle was minimal in the setting of the concomitant full-face nonablative fractionated laser.

Peculiar vegetative tumor-like genital herpes simplex nodules with brisk tissue eosinophilia in patients with human immunodeficiency virus infection.

Genital herpes simplex virus (HSV) infection in a human immunodeficiency virus (HIV) patient can present as a vegetative nodule. Clinical differential diagnoses of the nodule include condyloma latum, condyloma acuminatum, viral or fungal infection, and cutaneous neoplasms. Histological examination of herpetic nodules has been reported to show thick pseudoepitheliomatous hyperplasia with dense dermal lymphoplasmacytic infiltrate and multifocal multinucleated cells with herpetic viral cytopathic changes. We report two patients with HIV presenting with vegetative tumor-like HSV nodules with distinctive histopathologic pattern of inflammation that has not been described in the literature before. All samples displayed slightly acanthotic epidermis with focal ulceration, dense dermal sclerosis, scattered plasma cells, and a brisk lymphoeosinophilic infiltrate found dissecting between dense collagen bundles. This pattern of inflammation is an important clue that can guide the pathologist to look for focal herpetic viral changes in the epidermis, as patients with HIV possibly tend to amount a predominantly eosinophilic immune response in inflammatory skin conditions.

Melanoma arising in a nevus of Ito: novel genetic mutations and a review of the literature on cutaneous malignant transformation of dermal melanocytosis.

Dermal melanocytosis refers to a spectrum of benign melanocytic proliferations that includes Mongolian spot, nevus of Ota and nevus of Ito. These lesions most commonly occur in persons of Asian or African descent and are often present at birth or develop during childhood. Very rarely, dermal melanocytoses undergo malignant transformation. There have been only 13 reports in the literature of primary cutaneous melanoma arising in dermal melanocytoses. We report a case of a Chinese woman with melanoma arising in a congenital nevus of Ito. We performed targeted next-generation sequencing of the tumor which revealed mutations of GNAQ and BAP1, suggesting that alterations in these two genes led to malignant transformation of the nevus of Ito. We also provide a summary of reports in the literature regarding primary cutaneous melanoma arising in the context of dermal melanocytosis.

Costs of Keratinocyte Carcinoma (Nonmelanoma Skin Cancer) and Actinic Keratosis Treatment in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) provides health care to large numbers of veterans afflicted with keratinocyte carcinoma (KC). OBJECTIVE: To estimate the number of veterans treated for KCs and the related diagnosis, actinic keratosis (AK) and the costs of treating these conditions over a 1-year period. MATERIALS AND METHODS: The authors conducted a cross-sectional analysis of veterans diagnosed with KC or AK during fiscal year 2012 using administrative data on outpatient encounters and prescription drugs provided or paid by VHA. Marginal costs of each condition were estimated from a regression model. The authors estimated counts of outpatient encounters, procedures, and costs related to KC and AK care. RESULTS: In 2012, there were 49,229 veterans with basal cell carcinoma, 26,310 veterans with squamous cell carcinoma, and 8,050 veterans with unspecified invasive KC. There were also 197,041 veterans with AK and 6,388 veterans with KC-related diagnoses. The VHA spent $356 million on KC and AK outpatient treatment for procedures, prescription drugs, and other dermatologic care during FY2012. CONCLUSION: There was high prevalence of KC and AK and considerable spending to treat these conditions in VHA. Treatment costs are not generalizable to care provided by non-VHA providers where a facility fee was not incurred.

Validation of Photograph-Based Toxicity Score for Topical 5-Fluorouracil Cream Application.

BACKGROUND: An objective tool quantifying the toxicity of 5-fluorouracil (5-FU) from photographs was recently reported, and its reliability was confirmed. OBJECTIVE: The aim of this study was to validate the photograph-based toxicity score. METHODS: Photograph-based toxicity scores of participants assigned to the 5-FU arm of a randomized placebo-controlled trial were tested for correlations with their patient-reported symptom scores and baseline characteristics. RESULTS: Each pair of individual and overall scores of patient-reported symptoms and photograph-based toxicity was correlated at 2 and 4 weeks (correlation coefficient range, 0.34-0.95; P < .001 for all). Older age, more actinic keratoses, previous topical 5-FU use, and more keratinocyte carcinomas on the face and ears in the previous 5 years were correlated with increased 5-FU toxicity at 2 weeks (P < .05). An increase in the total number of 5-FU applications during the trial was correlated with less severe toxicity at 2 weeks (P < .001), but with increased toxicity at 4 weeks (P < .001). CONCLUSION: This study provides evidence for construct validity of the photograph-based 5-FU toxicity score. The tool can be used to objectively measure 5-FU toxicity in clinical or research setting, and it can be a prototype for toxicity measurements of other topical medications.

Risk of subsequent melanoma after melanoma in situ and invasive melanoma: a population-based study from 1973 to 2011.

BACKGROUND: Patients with melanoma in situ are at an increased risk of subsequent melanoma compared with the general population, but the risk of subsequent melanoma after initial melanoma in situ versus after initial invasive melanoma is not known. OBJECTIVE: We sought to compare the risk of subsequent melanoma in the cohort whose first cancer was melanoma in situ to the risk in the cohort whose first cancer was invasive melanoma. METHODS: In this cohort study, we identified individuals whose first cancer was either melanoma in situ or invasive melanoma from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2011 and used Cox proportional hazards models for comparison. RESULTS: Compared with the invasive melanoma cohort, the melanoma in situ cohort was more likely to develop subsequent melanoma of any stage after 2 years, subsequent invasive melanoma after 10 years, and subsequent melanoma in situ at all the time points (P < .001, P = .003, P < .001, respectively). LIMITATIONS: Underreporting of melanomas, particularly melanoma in situ cases, and missing cases of subsequent melanomas as a result of patient migration from the SEER registry areas could affect results. CONCLUSION: Given the increased long-term risk of subsequent melanoma in the melanoma in situ cohort, the patients with melanoma in situ diagnosis may benefit from a long-term surveillance for subsequent melanomas.

Treating pediatric port-wine stains in aesthetics.

A port-wine stain (PWS) is a vascular birthmark present in 0.3% to 0.5% of newborns. If untreated, this erythematous patch will grow proportionally with the child to thicken and darken with age. PWSs have implications for the child's quality of life for many years, with cosmetic, medical, and psychosocial disability. Controversy exists in many aspects surrounding laser treatment of these birthmarks in the pediatric population. We have reviewed the clinical features as well as the historic and current laser treatment of PWS. We have also examined the current hot topics of debate surrounding the treatment of PWS in the pediatric population. These controversies include the patient age of treatment initiation, the long-term psychologic impact, the use of general anesthesia, the application of eye shields, and alternative treatments for recalcitrant PWS. We have concluded with a discussion on the future directions of management and treatment.

Paired facial treatment with 755nm picosecond laser with diffractive lens array and 1060nm laser lipolysis of the submentum: An open-label prospective trial.

BACKGROUND: Performing multiple cosmetic treatments in a single session to target different aspects of facial rejuvenation is an effective regimen. Picosecond lasers with a fractionated handpiece can target fine lines, which can supplement submental fat reduction procedures. However, limited data exist on the safety and efficacy of single-session treatment strategies. AIMS: To assess the safety and utility of paired facial treatment with 755 nm picosecond laser with diffractive lens array (DLA) and 1060 nm laser lipolysis of the submentum. PATIENTS/METHODS: A prospective clinical study investigated the utility of paired facial treatment with 755 nm picosecond laser with DLA and 1060 nm diode laser lipolysis of the submentum. Subjects received treatments during the same session. Subjects were enrolled to receive up to 3 picosecond laser and 2 lipolysis treatments at 2-8-week intervals. RESULTS: Eleven subjects completed the study. Mean age was 52.1 years, and 81.8% were female. Fitzpatrick skin types II-VI were represented. For investigator global aesthetics improvement scores (GAIS), 63.6%, 81.8%, and 85.7% had improvement from baseline at 30-, 90-, and 180-day follow-up, respectively. At 180-day follow-up, 100% maintained improvement from 90-day follow-up. At 90-day follow-up, calculations for neck laxity showed a significant improvement of 11.7% from baseline (p < 0.001) with a mean amount of lift of 42.7 mm2 , which was above the predetermined threshold (20 mm2 ). No serious or unexpected treatment effects were observed. CONCLUSION: Paired facial treatment with 755 nm picosecond laser with DLA and 1060 nm laser lipolysis of the submentum improved clinical aesthetic outcomes. This treatment regimen was demonstrated to be safe, well-tolerated, and well-liked by subjects.

Long-term Efficacy of Topical Fluorouracil Cream, 5%, for Treating Actinic Keratosis: A Randomized Clinical Trial.

IMPORTANCE: Topical fluorouracil was demonstrated to be effective in reducing the number of actinic keratoses (AKs) for up to 6 months, but no randomized trials studied its long-term efficacy. OBJECTIVE: To evaluate the long-term efficacy of a single course of fluorouracil cream, 5%, for AK treatment. DESIGN, SETTING, AND PARTICIPANTS: The Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) trial was a randomized, double-blinded, placebo-controlled trial with patients from dermatology clinics at 12 VA medical centers recruited from 2009 to 2011 and followed up until 2013. Our study population comprised 932 veterans with 2 or more keratinocyte carcinomas in the 5 years prior to enrollment. The mean follow-up duration was 2.6 years in both treatment and control groups. INTERVENTIONS: Participants applied either topical fluorouracil cream, 5% (n = 468), or vehicle control cream (n = 464) to the face and ears twice daily for up to 4 weeks. MAIN OUTCOMES AND MEASURES: This study reports on AK counts and treatments, which were secondary outcomes of the VAKCC trial. Actinic keratoses on the face and ears were counted by study dermatologists at enrollment and at study visits every 6 months. The number of spot treatments for AKs on the face and ears at semiannual study visits and in between study visits was recorded. RESULTS: The number of AKs on the face and ears per participant was not different between the fluorouracil and control groups at randomization (11.1 vs 10.6, P > .10). After randomization, the fluorouracil group had fewer AKs compared with the control group at 6 months (3.0 vs 8.1, P < .001) and for the overall study duration (P < .001). The fluorouracil group also had higher complete AK clearance rates (38% vs 17% at 6 months) and fewer spot treatments at 6-month intervals, at study visits, and in between study visits during the trial (P < .01 for all). The fluorouracil group took longer to require the first spot AK treatment (6.2 months) compared with the control group (6.0 months) (hazard ratio, 0.69; 95% CI, 0.60-0.79). The number of hypertrophic AKs was not different between the 2 groups overall (P = .60), although there were fewer hypertrophic AKs in the fluorouracil group at 6 months (0.23 vs 0.41) (P = .05). CONCLUSIONS AND RELEVANCE: Our results indicate that a single course of fluorouracil cream, 5%, effectively reduces AK counts and the need for spot treatments for longer than 2 years. TRIAL REGISTRATION: clinicaltrials.gov Identifier:NCT00847912.