Pulsed dye laser (577 nm) treatment of portwine stains: ultrastructural evidence of neovascularization and mast cell degranulation in healed lesions.

Portwine stains were examined before, immediately after, and 1 yr after successful clearance by a pulsed dye laser (577 nm) using ultrastructural techniques. Dilated vascular channels and mast cell hypoplasia characterized lesional skin before treatment. Immediately after treatment, widespread selective vessel necrosis, similar to changes previously described, was observed. One year after laser irradiation, the abnormally ectatic portwine stain vessels had been replaced by small venules and arterioles, similar in number and diameter to blood vessels in normal skin; the only difference noted was that these new vessels were surrounded by easily identifiable mast cells. Many of these mast cells exhibited evidence of activation and degranulation. We conclude that mast cells may play an important role in the neovascularization of portwine stains treated by 577-nm dye laser irradiation.

Effect of dye laser pulse duration on selective cutaneous vascular injury.

The pulsed dye laser at 577 nm, a wavelength well absorbed by oxyhemoglobin, causes highly selective thermal injury to cutaneous blood vessels. Confinement of thermal damage to microvessels is, in theory, related to the laser exposure time (pulsewidth) on selective vascular injury. This study investigates the effect of 577 nm dye laser pulsewidth on selective vascular injury. Nine Caucasian, normal volunteers received 577 nm dye laser exposures at pulsewidths of 1.5-350 microseconds to their skin. Clinical purpura threshold exposure doses were determined in each volunteer, and biopsies of threshold and suprathreshold doses were examined in each volunteer. The laser exposure dose required to produce purpura increased as pulsewidth increased in all 9 subjects (p less than 0.001). This finding corresponds to laser pulsewidths equal to or exceeding the thermal relaxation times for dermal blood vessels. Histologically, vessel damage was selectively, but qualitatively, different for short vs long pulsewidths. Pulsewidths shorter than 20 microseconds caused vessel wall fragmentation and hemorrhage, whereas longer pulsewidths caused no significant hemorrhage. The purpura noted clinically appears to be due to a coagulum of intralumenal denatured erythrocytes. At 24 h, there was marked vessel wall necrosis at all pulsewidths. The short pulsewidths may cause erythrocyte vaporization, rapid thermal expansion, and mechanical vessel rupture with hemorrhage. Long pulsewidths appear to cause thermal denaturation with less mechanical vessel damage. The selective, nonhemorrhagic, vascular necrosis caused by the long-pulsewidth dye laser may lead to a more desirable clinical outcome in the therapy of blood vessel disease processes.

Myocardial necrosis in a patient with mixed connective tissue disease.

A 23-year-old black woman with mixed connective tissue disease developed acute onset of shortness of breath and evidence of pulmonary edema. Cardiac isoenzymes, electrocardiograms and radionuclide myocardial scintigraphy were consistent with focal myocardial necrosis. The patient has had no further myocardial complication since initiation of therapy with steroids.

Systemic absorption of topical steroids. Metabolic effects as an index of mild hypercortisolism.

This study was undertaken to determine whether the commonly used treatment of psoriasis with potent topical glucocorticoids results in hypercortisolism and whether metabolic changes might provide a means for monitoring pharmacologic effects of excessive systemic absorption of glucocorticoids. Plasma cortisol, glucose, and insulin and circulating polymorphonuclear leukocytes were assessed under controlled conditions in five otherwise healthy patients with psoriasis (40% to 85% involvement) treated with topical desoximetasone, without occlusion. In all patients, there were rapid and sustained suppression of endogenous cortisol production, twofold to threefold increases in fasting insulin levels indicating insulin resistance, and elevated levels of polymorphonuclear leukocytes. Two patients also experienced reduced glucose tolerance. These findings suggest that application of potent corticosteroids to large areas of diseased skin results in sufficient systemic absorption to cause not only adrenal suppression but some degree of hypercortisolism with greater frequency and rapidity than has been suggested. Prospective monitoring of insulin-glucose relationships as a sensitive index of the metabolic effects of glucocorticoids may provide a means of assessing excess systemic absorption that is not predictable on the basis of adrenal suppression or circulating levels of the drug. Such prediction could have particular relevance in anticipating adverse clinical effects in the treatment of chronic skin disorders with potent topical glucocorticoids.

Essential primary cutis verticis gyrata. Treatment with the scalp reduction procedure.

A case of cutis verticis gyrata (CVG) occurred in a patient with no known associated disorders. Under the present classification system, patients with primary CVG are all grouped together. We propose subclassifying patients with primary CVG into two groups: those with associated neurologic and ophthalmologic diseases and those without. Our patient was treated with a scalp reduction procedure.

Hydroa vacciniforme. Diagnosis by repetitive ultraviolet-A phototesting.

Hydroa vacciniforme is a rare disorder manifested in early childhood by recurrent photoinduced vesicles that heal with scarring. We report a case in which repetitive exposures to artificial ultraviolet light in the A range reproduced the clinical findings induced by natural sunlight. Phototesting may be viewed as an important diagnostic aid, as the induction of lesions clinically identical to hydroa vacciniforme can provide a reliable criterion for the diagnosis.

Pruritus in hepatic cholestasis. Pathogenesis and therapy.

Pruritus associated with hepatic cholestasis may cause significant morbidity. Current evidence indicates that bile acids may not be the pruritogenic factor. Rather, the factor may be some other cholephilic anion or anions that bind to cholestyramine resin and are photolabile. Effective treatment modalities used currently include cholestyramine resin and phenobarbital. Phototherapy is a promising modality in which the mechanism and most effective wavelengths remain to be elucidated. Analysis of the possible role of non-steady state bile acid compartmentalization in the pathogenesis of pruritus is presented.

The treatment of port-wine stains by the pulsed dye laser. Analysis of pulse duration and long-term therapy.

A flashlamp-pumped pulsed dye laser at 577 nm was evaluated in the treatment of port-wine stains. The degree of lesional lightening was compared following laser exposure with pulse durations of 20 and 360 microseconds. In addition, lesional therapy using the 360-microseconds pulse duration was evaluated for lightening and side effects following long-term patient observation and after repeated treatments of the same site. A total of 52 patients with port-wine stain were treated; their average age was 29 years, with eight patients less than 18 years, of whom 29 had comparative test site placement for the different pulse durations. Of these 29 patients, 25 demonstrated greater lightening at the 360-microseconds pulse duration test site. All 52 patients proceeded to receive full treatment placement with the 360-microseconds pulse duration, which resulted in an overall lightening of 42% after the initial treatment and 68% after re-treatment sessions. Forty-four percent of the patients had equal to or greater than 75% lesional lightening. Pretreatment anesthesia was unnecessary and only minimum posttreatment care was required. Mild adverse effects of epidermal change, depression, or pigmentary change appeared in only four cases and was limited to less than a 2% area in each of these lesions. These side effects did not recur when the lesions were re-treated at lower energy dosages. No posttreatment sclerosis or scarring appeared, even after multiple retreatment sessions to the same area, regardless of the anatomic location, color of the lesion, or age of the patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Laser treatment of port-wine stains and hemangiomas.

Since their discovery, lasers have truly advanced and broadened our options for the treatment of port-wine stains and hemangiomas. It is a blending of many sciences and much effort that allows us the opportunity today to selectively treat these vascular processes with relative effectiveness and significant safety. Ongoing study and development continue to offer hope on increasing benefit for our patients. Laser systems with variable wavelengths, pulse durations, and delivery methods will help accommodate the diversity of various port-wine stains and hemangiomas that are encountered in medicine.

Laser treatment of pigmented lesions and tattoos.

Benign pigmented lesions and tattoos are often very responsive to laser treatment. The chromophore in most cases is melanin, although other endogenous and exogenous pigments can be targeted. The chromophore and its distribution in the skin, as well as the underlying biological processes, all help determine the best laser, if any, for a given pigmented lesion. Epidermal lesions respond well to shorter wavelengths (up to 755 nm), whereas for deeper lesions, 694 nm or longer are typically used. The 1,064-nm Nd:YAG laser is best for treating darker skinned individuals. Multicolored tattoos may need several wavelengths to best target individual ink colors.

The pulsed dye laser for cutaneous vascular and nonvascular lesions.

The pulsed dye laser was originally developed for the treatment of vascular lesions, especially hemangiomas and port-wine stains. The central concept of pulsed-dye laser is to preserving the epidermis by allowing hemoglobin to be more precisely targeted within lesions. More recently, the pulsed dye laser has also been used in the treatment of a wide spectrum of nonvascular lesions. Because of its safety profile, and its selectivity in targeting lesions, therapists can comfortably treat a wide variety of lesions in all age groups and anatomic sites.

Clinical efficacy of the pulsed dye laser in the treatment of vascular lesions.

BACKGROUND: Increasing the selectivity of laser-induced damage is an ongoing goal for the laser treatment of cutaneous lesions. The flashlamp-pumped pulsed dye laser has significantly participated and advanced this pursuit. This is especially true in its use for the treatment of cutaneous vascular lesions. OBJECTIVE: A review of the development and current use of this laser for the treatment of cutaneous vascular lesions will be presented. METHODS: The laser has been designed to limit laser energy absorption and damage to hemoglobin and the blood vessel. This has been done by setting the wavelength at 577 to 585 nm and the pulse duration at 360 to 450 microseconds. RESULTS: The therapeutic results have been beneficial for almost all types of superficial small vessel vascular lesions regardless of lesional anatomic site or patient age. These lesions include port-wine stains, telangiectasia, capillary hemangioma, and other angiomata and vascular ectasia. Deeper cutaneous vascular processes and lower extremity telangiectases have proven to be less responsive to therapy. The increased vascular selectivity has allowed for a dramatic decrease in adverse effects when compared to previously used laser systems. CONCLUSION: Based on many thousands of treatment sessions and follow-up evaluation, the pulsed dye laser appears to have the greatest margin of safety in the treatment of cutaneous vascular lesions, especially for the pediatric population.

Pearly penile papules: treatment with the carbon dioxide laser.

Pearly penile papules are frequently occurring lesions located over the corona and sulcus of the penis. They are asymptomatic and are considered to be acral angiofibromas. Some individuals, disturbed by their presence, request removal of the lesions. Even after patients are assured of the benign nature of the process and its relatively high incidence, prominent lesional involvement may still cause significant psychological distress. Two patients with pearly penile papules have been successfully treated with the carbon dioxide laser. A review of the literature and description of treated cases are presented.

Dermatologic laser surgery.

The laser is becoming an increasingly important surgical and medical instrument in the field of dermatology. Developments in the areas of laser technology and application have significantly broadened its clinical use over the past several years. These rapid changes and advances in the use of the laser for cutaneous processes may make it difficult for the physician to maintain a current base of knowledge in this area. Relevant laser systems and their clinical applications are presented and discussed, as are investigational laser systems, which may be of importance for the future. This will allow the dermatologic surgeon the opportunity to update concepts and evaluate the various laser systems and their cutaneous applications.

Nodular primary localized cutaneous amyloidosis: immunohistochemical evaluation and treatment with the carbon dioxide laser.

Nodular primary localized cutaneous amyloidosis is an uncommon disorder for which there is no consistently satisfactory treatment. The amyloid fibrils are thought to have an immunoglobulin light chain derivation and systemic involvement must be excluded in all cases. We report a patient with a large scalp lesion of nodular primary localized cutaneous amyloidosis whose immunohistochemical evaluation revealed lambda light chain deposits and who thus far has no apparent systemic involvement. The lesion was treated by the carbon dioxide (CO2) laser with excellent cosmetic results and minimal morbidity.

Cryoglobulinemia and cutaneous leukocytoclastic vasculitis associated with hepatitis C virus infection.

Hepatitis C virus infection is a frequent cause of non-A, non-B hepatitis worldwide. Resultant morbidity is significant; chronic liver disease develops in 50% of infected persons. Since serologic testing has become available there have been several reports of cutaneous findings in association with hepatitis C virus infection, including vasculitis, cryoglobulinemia, urticaria, and lichen planus. We describe a patient with cryoglobulinemia, chronic cutaneous leukocytoclastic vasculitis, and hepatitis C virus infection. Hepatitis C virus infection should be included in the differential diagnosis of the causes of cryoglobulinemia and leukocytoclastic vasculitis.