Clinical Exploration Of Laser Treatment Based On Vascular Heterogeneity Of Port-wine Stain

Part 1 The Clinical Study of Prospective Side by Side Comparison Treatment for Port-Wine Stain1.1Prospective Comparison Treatment of 595 nm Pulsed Dye Lasers(PDL) for Port-Wine Stain(PWS)Background: The arrival of pulsed dye laser(PDL) were become the gold standard for port-wine stain(PWS). However, the complete lesion removal were hard to reached of most patients.Vbeam? and Cynergy? are 595 nm pulsed dye laser(PDL)equipment options, both extensively used in clinical treatment of port-wine stain(PWS).However, there has been no study conducted of the differences in PWS therapeutic outcomes across both devices.Objective: To compare of the efficacy and safety of Vbeam and Cynergy equipment in the treatment of PWS.Method: Twenty-two PWS patients were included this study and were treated with both Vbeam and Cynergy. Patients underwent three treatment sessions. Treatment parameters used were as follows:(1) Cynergy?, Cynosure Corp, 595 nm wavelength,radiant exposure of 11 J/cm2, 2 ms pulse duration, 7 mm spot size, cold-air cooling system of level three.(2) Vbeam?, Candela Corp, 595 nm wavelength, radiant exposure of 11 J/cm2, 1.5 ms pulse duration, 7 mm spot size, cryogen spray cooling(30 ms of cooling with a 20 ms delay). Clinical efficacy outcomes were evaluated by chromameter and visual assessment two months posttreatment.Results: All patients were treated by both Vbeam and Cynergy on adjacent sites.Chromameter evaluation showed that the average blanching rate was 21.24% for Cynergy sites and 36.42% for Vbeam sites. This difference was statisticallysignificant(p = 0.05), which suggests that PWS respond better to Vbeam compared with Cynergy at the settings used in this study. No patients developed scarring or permanent pigmentation change.Conclusion: Compared with Cynergy, Vbeam may be more effective in PWS treatment. Despite using supposedly equivalent fluences in 595 nm PDLs, one cannot guarantee equivalent clinical results.1.2 Does The Efficacy of Port-Wine Stains Treatment with Pulsed Dye Laser Increases by Shortening The Treatment Intervals?Background: It has been shown that shorter treatment intervals with pulsed dye laser(PDL) may provide more effective treatment, however, it is uncertain whether treatment of port-wine stain(PWS) is more effective with shorter time intervals.Objective: To compare the treatment of PWS with PDL at a 3 and a 6 weeks interval.Methods: Thirty-nine patients with untreated PWS were included, all patients were treated three times by PDL, on adjacent areas in each patient, at a 3 and a 6 weeks interval, respectively. The efficacy outcome was assessed, 2 months post-treatment,by visual examination and chromameter evaluation.Results: Chromameter assessment showed that the average blanching rate at the sites treated with PDL at a 3 weeks interval was 40.27% and 44.17% at the sites treated at a6 weeks interval(p ? 0.05), suggesting that the efficacy of both PDL treatment courses was comparable in all PWS patients in this study. No patients developed scarring or permanent pigmentation change.Conclusion: The treatment interval of 3 weeks resulted in similar lightening of the PWS compared with the standard 6-week interval. Additionally, it is well tolerated by patients,which indicates its safety, and also has the potential to significantly reduce the total duration of a course of treatment.Part 2 The Exploration of Vascular Heterogeneity of Port-Wine Stain2.1 Histopathological Basis of Different Anatomic Subunit of Facial Port-Wine Stain Treated by Pulsed Dye LaserObjective To explore the histopathological basis of different anatomic subunit of facial port-wine stain(PWS) treated by pulsed dye laser(PDL) and to illustrate the possible explanation for the discrepancy of therapeutic efficacy.Methods Thirteen PWS patients had biopsies and underwent PDL treatments in different anatomic subunit of facial PWS(central and lateral facial area). The diameter and depth of PWS vessels were analyzed and the clinical efficacy were evaluated by chromameter assessment 2 months after treatment.Results All patients were treated on both sites, according to the chromameter evaluation, average Δa* and average ΔE were 4.63 and 8.81 for lateral facial area,while-0.19 and 3.55 for central facial area respectively(P<0.05). Histopthological observation showed that ectatic vessels in lateral facial area were primarily distributed in super dermis, while the ectatic vessels in central facial area were distributed extensively from capillaries to the reticular dermis, and even deep into the subcutaneous tissue. The Pearson correlation coefficient suggested that the depth and diameter of PWS vessels were negatively related to efficacy outcomes of PDL treatment.Conclusion Better results can be obtained in lateral facial PWS compared to central facial PWS on the same patient. The differences in histopathological manifestation,especially the depth of vessels, may be responsible for the discrepancy of therapeutic efficacy.2.2 The Histological Manifestation of Upper Extremity Port-Wine Stain.Objective: It has been widely known that PWS response variously to pulsed dye laser(PDL) among different anatomy sites of port-wine stain(PWS). PWS in extremity response poor to PDL compared with facial PWS. The objective of this study is tocompare the histological manifestation of PWS in face with PWS in extremity and to find the explanation for this clinical phenomenon.Methods:11 patients with upper limb PWS and 11 normal skin specimens were included in this study. Biopsies were performed in hand, forearm and upper arm in each patient. Mean diameter, mean depth and maximum depth of blood vessels were measured.Results: The mean blood vessel diameter of normal skin, hand, forearm, upper arm PWS was 18.75 mm, 22.49 mm, 20.48 mm and 35.15 mm, respectively. PWS in upper arm had larger blood vessel diameter than other groups(P < 0.05). The maximum blood vessel depth of normal skin, hand, forearm, upper arm PWS was0.335 mm,0.572 mm,0.447 mm and 0.448 mm, respectively. PWS in hand had larger maximum blood vessel depth than other groups(P < 0.05). The mean blood vessel depth of normal skin, hand, forearm, upper arm PWS was 0.172 mm,0.312 mm,0.256 mm and 0.224 mm, respectively. PWS in hand had larger mean blood vessel depth than that in normal skin and upper arm(P < 0.05). PWS in forearm had larger mean blood vessel depth than that in normal skin(P < 0.05).Conclusion: As the anatomical location is more remote, the blood vessel diameter of PWS in extremity became smaller. PWS in the hand had small and deep blood vessels depth, which may play an important role for the poor laser therapeutic effect in hand.3.The Expression of VEGF, MMP-9, ANG-2 and FGF-2 in Port-Wine Stains.Objective: To observe the expression of VEGF, MMP-9, ANG-2 and FGF-2 in port-wine stains.Methods:62 untreated PWS were biopsied and 11 normal skin specimens were taken.All specimens stained with routine immunohistochemistry(IHC) by using polyclonal anti-VEGF, MMP-9, ANG-2 and FGF-2 antibodies and which were evaluated.Results: 62 untreated PWS and 11 normal skin were included this study, which were grouped by location and thickening: 47 from face and 16 from extremities. 29 lesions were flat PWS, 21 were hypertrophic PWS and 12 nodular PWS. All hypertrophic and nodular PWS were in facial area. Pathologic manifestation in nodular PWS wasdifferent from the other two types. A large number of newborn blood vessels were clustered in the nodular PWS. VEGF, MMP-9, ANG-2 and FGF-2 in PWS blood vessels were consecutively activated. PWS specimens showed statistically significant overexpression of VEGF, MMP-9, ANG-2 and FGF-2 molecules when compared with control specimens, and which were showed strong activation in nodular PWS blood vessels(P≤0.05).Conclusion: Angiogenesismay play an important role in the pathogenesis of the PWS progress. It is possible that PWS may progress by hyperplasia in addition to hypertrophy. It may have a potential role as a targeted approach in the treatment of this disfiguring condition in the future.