[Potential and limitations of dye laser therapy for capillary malformations]. / Möglichkeiten und Grenzen der Farbstofflasertherapie bei kapillären Malformationen.

Capillary malformations (port-wine stains) are observed in less than 1 % of neonates and may occur coincidentally with other vascular and nonvascular malformations. Two thirds of lesions occur in the head and neck area and may have important cosmetic and psychological implications for the patients. Treatment with flashlamp-pumped pulsed dye lasers is still the therapy of choice for capillary malformations and can be applied to infants. If the laser device is used appropriately, the rate of persistent side effects is low. Although laser treatment achieves good clearance in the majority of patients with capillary malformations, complete clearance is rare. New therapeutic options are thus urgently required.

Fractional carbon dioxide laser resurfacing of rhytides and photoageing: a prospective study using profilometric analysis.

BACKGROUND: Results of profilometric skin analyses after fractional ablative skin resurfacing are not only important for evaluating the efficacy of this therapy but are also relevant for physicians practising laser and aesthetic skin therapy. Currently, objective measurements of wrinkle reduction after fractional CO2 laser resurfacing are scarce, and it remains unclear whether the various facial areas respond differently to this therapy. OBJECTIVES: To measure wrinkle parameters, the homogeneity of melanin distribution and skin roughness in four facial areas (periorbital, perioral, forehead, cheeks) before and after three fractional CO2 laser treatments. METHODS: Twenty-five women were analysed with regard to wrinkle parameters and mottled pigmentation on the face. We measured wrinkle size, depth and width and the homogeneity of melanin distribution and skin roughness in four facial areas before and after three fractional CO2 laser treatments. Additionally, the investigators rated clinical improvement using five-point grading scales. RESULTS: Wrinkles were significantly reduced in all facial areas, and the best results for wrinkle size and depth were found for the cheeks (-58·3%, P = 0·018 and -51·3%, P = 0·018) and the periorbital area (-35·1%, P < 0·001 and -31·1%, P = 0·001, respectively). The percentage improvements of rhytides evaluated by the investigators were mostly similar to those found from in vivo measurements. The homogeneity of melanin distribution in the skin was improved by 21·4% on the cheeks (P = 0·012) and by 24·0% in the periorbital area (P < 0·001). Clinical investigators rated the improvement of mottled pigmentation considerably higher (51-75%). CONCLUSIONS: After a serial treatment with the fractional CO2 laser, we measured considerably varying wrinkle reduction depending on the area of the face, and the best results were found for the cheeks.

Indocyanine green-augmented diode laser treatment of port-wine stains: clinical and histological evidence for a new treatment option from a randomized controlled trial.

BACKGROUND: Complete clearance of port-wine stains (PWS) is difficult to achieve, mainly because of the resistance of small blood vessels to laser irradiation. Indocyanine green (ICG)-augmented diode laser treatment (ICG+DL) may overcome this problem. OBJECTIVES: To evaluate the feasibility of ICG+DL therapy of PWS and to compare the safety and efficacy of ICG+DL with the standard treatment, flashlamp-pumped pulsed dye laser (FPDL). METHODS: In a prospective randomized controlled clinical study, 31 patients with PWS were treated with FPDL (λ(em)=585 nm, 6 J cm(-2) , 0.45 ms pulse duration) and ICG+DL (λ(em)=810 nm, 20-50 J cm(-2) , 10-25 ms pulse duration, ICG-concentration: 2 mg kg(-1) body weight) in a split-face modus in one single treatment setting that included histological examination (haematoxylin and eosin, CD34). Two blinded investigators and the patients assessed clearance rate, cosmetic appearance and side-effects up to 3 months after treatment. RESULTS: ICG+DL therapy induced photocoagulation of medium and large blood vessels (>20 µm diameter) but not of small blood vessels. According to the investigators' assessment, clearance rates and cosmetic appearance were better after ICG+DL therapy than after FPDL treatment (P=0.114, P=0.291, respectively), although not up to a statistically significant level, whereas patients considered these parameters superior (P=0.003, P=0.006, respectively). On a 10-point scale indicating pain during treatment, patients rated ICG+DL to be more painful (5.81 ± 2.12) than FPDL treatment (1.61 ± 1.84). CONCLUSION: ICG+DL represents a new and promising treatment modality for PWS, but laser parameters and ICG concentration need to be further optimized.

[Innovations in dermatologic laser therapy]. / Innovationen in der dermatologischen Lasertherapie.

Dermatologic laser therapy is a rapidly-changing field with many new innovations. One of the most important is the introduction of fractional photothermolysis. This method is established for skin rejuvenation and acne scars; both the original non-ablative devices and newer ablative ones are available. While its side effects and the patient's downtime are considerably less than with ablative skin resurfacing, its efficacy is much better than non-ablative laser skin rejuvenation. This approach is also effective for melasma and other forms of hyperpigmentation in some patients. Successful reports exist also for treating other, more infrequent dermatoses. Another new procedure is laser lipolysis. It can be used as an adjunct to classical liposuction or as laser lipolysis alone. Fat lysis is achieved by laser energy via fibers that are inserted in the subcutaneous fat, and the additional heating of dermal tissue may lead to the reduction of side effects such as bleeding and to reduction of skin laxity. Nevertheless, the superiority of laser lipolysis to classical liposuction techniques is not yet established, and the ideal wavelengths and treatment parameters are not yet fully clear. There have been improvements in the therapy of vascular lesions, especially the use of longer, infrared wavelengths. In addition, there is early information on experimental therapeutic approaches for diseases normally not amenable to laser therapy such as onychomycosis, hemorrhoids and allergic rhinitis.

Hereditary haemorrhagic telangiectasia treated by pulsed neodymium:yttrium-aluminium-garnet (Nd:YAG) laser (1,064 nm).

Hereditary haemorrhagic telangiectasia (HHT) is a familial, autosomal, dominant, multi-system, vascular, dysplasia. Besides repetitive epistaxis, cutaneous eruptive macules and nodules lead to recurring bleeding and cosmetic problems. We report on a pilot study of four cases of HHT in which cutaneous lesions were treated with a pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1,064 nm). Pulsed Nd:YAG laser treatment, without anaesthesia, was performed several times on eruptive angiomas on palmar and facial skin. Lesions on fingers and face mostly showed very good, or even complete, clearing after the first laser treatment. Several macules required multiple treatment; only a few lesions showed no effect. Pulsed Nd:YAG laser therapy (1,064 nm) appears to be an effective and safe treatment option for hereditary haemorrhagic telangiectasia on the skin of face and extremities.

Laser therapy of vascular lesions.

Since the first construction of a laser by Maiman in 1960 and the first clinical application of a laser in the therapy of skin lesions by Leon Goldman, laser therapy has become an important therapeutic modality in dermatology. Various lasers can be used for the treatment of different vascular and non-vascular lesions. According to our results, vascular lesions constitute the most important indication for laser therapy in dermatology.

Elastosis perforans serpiginosa-like pseudoxanthoma elasticum in a child with severe Moya Moya disease.

A 2-year-old girl with Moya Moya disease who had relapsing cerebrovascular strokes presented with loose skin folds, 'chicken' skin appearance and perforating elastosis serpiginosa-like lesions in the genitocrural region. Histologically, calcified material perforating the epidermis and adjacent short curled and mineralized elastic fibres suggested a variant of pseudoxanthoma elasticum (PXE). As PXE is known to be caused by various mutations in the transmembrane transporter ABCC6 gene, we hypothesized that a novel ABCC6 mutation may underlie this unique combination of PXE and elastopathic vascular damage. Therefore, the complete ABCC6 coding region of the patient and her parents was screened for genetic alterations. No bona fide disease-causing mutation of ABCC6 could be found in the child and in her parents. However, two novel allelic amino acid substitutions (Arg1273Lys and Glu1293Lys; exon 27) were found in the girl and her father, localized in close proximity to the region that codes for the functionally critical second nucleotide-binding fold of ABCC6. Although a causal involvement of these amino acid substitutions could not be proven based on this study, both heterozygote substitutions may possibly have interacted with other undetected recessive maternal ABCC6 changes in the child. To the best of our knowledge, this is the first report of an association between early-onset PXE and severe Moya Moya syndrome possibly related to ABCC6 changes.

Comparison of the 308-nm excimer laser and a 308-nm excimer lamp with 311-nm narrowband ultraviolet B in the treatment of psoriasis.

BACKGROUND: Psoriasis is a chronic, genetically determined inflammatory disease, characterized by an immunomediated pathogenesis, which affects approximately 1-3% of the population. Various modalities have been used for psoriasis treatment, including ultraviolet (UV) radiation. Narrowband UVB (311 nm) phototherapy is a well-established, widely used and highly efficient treatment for psoriasis, but a big disadvantage is that large areas of unaffected skin are irradiated along with the psoriatic lesions. OBJECTIVES: This investigation evaluates a 308-nm excimer laser and a 308-nm excimer lamp in comparison with 311-nm narrowband UVB in the treatment of patch psoriasis by using two different dose-increase schemes. MATERIALS AND METHODS: Fifteen patients with plaque psoriasis were enrolled in the study (first regime). Three different psoriatic lesions were treated with the 308-nm excimer laser, the 308-nm excimer lamp or 311-nm narrowband UVB three times per week. UVB doses were increased slowly and stepwise (1, 1, 2, 2, 3, 3, ...multiple MEDs). Sixteen patients were enrolled in the second regime. Two plaques were treated with the 308-nm excimer laser or with the 308-nm lamp with an accelerated scheme (2, 2, 4, 4, 6, 6, ...multiple MEDs) three times per week. We increased the UVB doses every second treatment (first and second regime) during the whole treatment. If blistering occurred, the blistered plaque was not treated on the next scheduled treatment. At every third visit and 1, 2 and 4 months after the last treatment a Psoriasis Severity Index (PSI) score was assigned in both regimes. RESULTS: Using Friedman analysis, the PSI scores did not show a statistically significant difference (P > 0.05) comparing 308-nm laser therapy, 308-nm lamp therapy and 311-nm narrowband therapy after 10 weeks in the first regime. The mean number of treatments to achieve clearance was 24. With the accelerated scheme, clearance could be achieved with fewer treatments and with half the cumulative dose of the first regime. Nevertheless, the side-effects such as blistering and crusting were also increased. CONCLUSIONS: Both 308-nm light sources can clear patch psoriasis in a similar manner to standard phototherapy, with the advantage of the ability to treat exclusively the affected skin and with a reduced cumulative dose, thus perhaps reducing the long-term risk of carcinogenicity.

[Dialysis associated skin changes]. / Dialyseassoziierte Hautveränderungen.

Patients with end-stage renal disease often suffer from different dermatologic conditions. Reports indicate that 50-100% of patients with end-stage renal disease have at least one cutaneous disorder. The persisting chronic uremia is responsible for a variety of structural and functional skin changes. Dialysis or even renal transplantation leads to an improvement of some uremia associated skin disorders, others however can persist.

Role of laser therapy in dermatology -- clinical aspects.

BACKGROUND: Laser therapy has become an integral part of therapeutic alternatives in dermatology. Nevertheless, there are only few statistical data on the role of lasers in everyday practice of dermatological clinics. OBJECTIVE: Analysis of laser patients, indications and lasers used. METHODS: We analysed 10244 patients treated with laser therapy in the Department of Dermatology at the University of Regensburg from 1992 to 2000. This figure represents 9.6 % of all patients seen during that period. RESULTS: Vascular lesions (hemangiomas, port-wine stains, telangiectasias) represented the most common indication (more than 70%) followed by infectious disorders (mostly papillomavirus lesions) as well as the removal of hairs and tattoos. Accordingly, the most frequently used laser was the flashlamp-pumped pulsed dye laser (585 nm) followed by the argon ion, the long-pulse tunable flashlamp-pumped pulsed dye laser, the Q-switch ruby laser, and the CO(2)-laser. In recent years, the percentage of indications and lasers used has changed significantly, reflecting the development of new lasers and the introduction of new indications. CONCLUSIONS: The results confirm the important role of laser therapy in dermatology.

Optimizing treatment parameters for hair removal using long-pulsed Nd:YAG-lasers.

Our aim was to determine the most effective treatment parameters for laser-assisted hair removal using long-pulsed Nd:YAG-lasers. 42 volunteers were treated with 1064 nm long-pulsed Nd:YAG-lasers. We used two different laser systems (Lyra XP, Wavelight and Smartepil II Deka-LMS) with various pulse lengths, fluences, and spot sizes. For each parameter, five test areas were treated one to five times at 4-week intervals. Follow-ups were performed 1, 3, 6, and 12 months after the last treatment. Percentual hair loss, side effects, and pain during treatment were evaluated. The average hair reduction 12 months after the last treatment using the Lyra XP was 48%, using the Smartepil II it ranged between 30% and 35%. There were no permanent side effects. Long-pulsed 1064 nm Nd:YAG-lasers are safe and effective for hair reduction. Although the different treatment parameters did not lead to a lot of differing hair reduction 12 months after the last treatment, the laser with the largest spot size and the longest pulse time showed the best results.

Discoid lupus erythematosus and lupus profundus in childhood: a report of two cases.

Discoid lupus erythematosus (DLE) is a rare disorder in childhood, with 22 cases reported in the English-language literature. Less than 2% of patients with DLE have an onset before 10 years of age. We describe two children with DLE and lupus profundus with an onset of the disease at the ages of 11 and 15 years and focus on likely histopathologic differences between DLE in children and in adults. Histopathologic characteristics for childhood DLE might be an intense periadnexal and perivascular infiltrate extending into the interstitium and subcutaneous tissue consisting of lymphocytes, histiocytes, eosinophilic granulocytes, and plasma cells and lacking epidermal atrophy. The diagnosis of DLE in our two patients was established by clinicopathologic correlation based on clinical presentation, histologic and immunofluorescent findings in skin biopsy specimens, and the absence of clinical and laboratory evidence of systemic involvement. Therapy with antimalarials resulted in reduction of the skin lesions, but in one patient severe lipoatrophy occurred.

Correlations between light penetration into skin and the therapeutic outcome following laser therapy of port-wine stains.

For several years the flashlamp-pumped pulsed dye laser (FPDL) has been the favoured method for the treatment of port-wine stains (PWS). The therapeutic outcome of FPDL laser therapy depends on the anatomical location of the PWS and is mainly attributed to morphological parameters such as size and depth of the PWS blood vessels. The aim of this study was to show a correlation between the therapeutic outcome following FPDL therapy and the optical properties of the skin overlying the PWS vessels. For this purpose the therapeutic outcome following FPDL treatment (585 nm; 0.45 ms) of 884 PWS situated on different body sites was evaluated by judging the grade of fading of PWS colour. On the other hand the light penetration into 123 skin samples (thickness 0.10-1.35 mm) was determined between 450 nm and 1030 nm and compared with the PWS laser therapy outcome for equal locations by statistical analysis. PWS on the neck, trunk, arms or legs yielded a higher mean grade of fading as compared to PWS on the head. Within the face, a wide range of fading was evident. The light penetration into skin increased linearly with increasing wavelength and location-dependent differences were found. The attenuation coefficient was 22.8+/-5.3 mm(-1) at 585 nm. No significant or strong correlation was observed between the therapeutic outcome of PWS laser therapy and the light penetration into skin. However, a correlation was obvious by plotting the respective profile plots. Therefore, among other effects, in particular morphological parameters of PWS vessels, the optical properties of the skin contribute to a small extent to the clinical outcome of PWS laser therapy.

Willingness to pay and time trade-off: useful utility indicators for the assessment of quality of life and patient satisfaction in patients with port wine stains.

BACKGROUND: For cost utility analyses in health economic research it is necessary to assess quality of life for content validation. Previously, both quality of life questionnaires and utility indicators such as willingness to pay and time trade-off have been used successfully in patients with chronic skin diseases, such as psoriasis vulgaris or atopic eczema. OBJECTIVE: For the first time to assess willingness to pay and time trade-off in patients with port wine stains, and to study possible correlations between these indicators, patient income, quality of life questionnaires and subjective or objective outcome measures. METHODS: The results of a survey on 36 patients with facial lesions who had completed laser treatment were used for assessments. The 'Chronic Skin Disease Questionnaire' (CSDQ) and the 'Short Form-36 Health Survey' (SF-36) were used as quality of life questionnaires. Special questions were used as a basis for calculating the utility indicators, willingness to pay and time trade-off. RESULTS: Completed questionnaires were sent back by 25 patients (69%). Willingness to pay and time trade-off were used as instruments for the assessment of quality of life [questions answered by 23 (92% of respondents)]; patients were willing to pay 11.8% of their monthly income and would offer a mean value of 1.2 h per day for an imaginary therapy leading to complete cure of the skin problem. Statistical correlation analyses were not performed because this pilot study included only a small number of patients. Frequency distributions show no apparent correlation between willingness to pay and patients' profession (used as a surrogate for income). Possible correlations were seen between willingness to pay, time trade-off, the scales 'anxiety/avoidance' and 'helplessness' of the CSDQ as well as 'social function' of SF-36 and subjective or objective efficacy. Twenty-nine patients (80%) were willing to pay for the treatment, a surrogate measure for patients' satisfaction with treatment modality. Overall, patients would pay an average of 16.0 euros per single treatment and 192.0 euros for the whole course of treatments. In contrast with patients who evaluated treatment modality as excellent or very good (willingness to pay for single treatment, euro 22.0; for whole treatment, 270.0 euros), patients who judged treatment good (8.0 euros, 145.0 euros), moderate or bad (12.0 euros, 146 .0 euros) were willing to pay markedly less. CONCLUSIONS: (i) The questions for willingness to pay and time trade-off were understood by most patients and produced meaningful answers. (ii) There were apparent correlations between the utility indicators, subjective or objective outcome and the scales of the quality of life questionnaires. (iii) The results show that these indicators have a high potential for use in this dermatological condition, especially as a basis for health economic evaluations.

Role of lasers and photodynamic therapy in the treatment of cutaneous malignancy.

Tumor therapy is not a common indication for the use of lasers, as it is in the treatment of benign vascular skin lesions, since many alternative treatment modalities exist. However, certain patients may benefit from laser therapy of premalignant and malignant skin tumors. Skin tumors can be treated by laser excision, laser coagulation, laser vaporization, or photodynamic therapy (PDT). For these purposes, the carbon dioxide laser, the neodymium:yttrium aluminum garnet laser and the argon laser are particularly suitable. PDT is a therapeutic approach based on the photosensitization of the target tissue by topical or systemic photosensitizers and subsequent irradiation with light from a laser or a lamp inducing cell death via generation of reactive oxygen species. Laser therapy and PDT have shown good results in the curative treatment of actinic keratoses, superficial basal cell carcinoma, Bowen's disease and cheilitis actinica. However, they are not recommended for primary malignant melanoma and invasive squamous cell carcinoma. In some patients, lasers and PDT might also be used effectively for the palliative treatment of cutaneous metastases. In selected patients, lasers and PDT may offer some advantages over routine procedures, e.g. reduction of scarring and better cosmetic results. However, when treating invasive tumors with curative intention, one has to bear in mind the lack of histologic control and the limited depth of tissue penetration of most laser and PDT therapies.