The patient was treated with 3 sessions of pulsed dye laser (PDL) and followed up 3 months after the final treatment. The laser setting of PDL was 595 nm, 12 J/cm2 with 1.5 ms (black arrowheads), and 11 J/cm2 with 0.45 ms (white arrowheads); spot size of 7 mm; cryogen spray cooling for 40 ms with a delay of 20 ms. Better efficacy can be observed on the chest (A) and the upper arm (B) compared with the forearm (C) and the hand (D).
The histologic vascular features show that the ectatic vessels (white arrowheads) were much more superficial on the chest and upper arm compared with vessels on the forearm and hand. The thickness of the epidermis and stratum corneum (black arrowheads) was also much thinner in the chest and upper arm port-wine stain (PWS) compared with PWS on the forearm and hand. Presented here are biopsy samples from a PWS on the chest (A), upper arm (B), forearm (C), and hand (D). Tissue preparations were stained with hematoxylin-eosin and viewed at ×40 magnification light microscopy.
eFigure 1. Clinical treatment efficacy and histologic features.
eFigure 2. The histopathological characteristics of each patient.
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Yu W, Zhu J, Han Y, et al. Assessment of Outcomes With Pulsed Dye Laser Treatment of Port-Wine Stains Located Proximally vs Distally on Extremities. JAMA Dermatol. 2020;156(6):702–704. doi:10.1001/jamadermatol.2020.0363
Port-wine stains (PWSs) positioned proximally on the limb often respond better to pulsed dye laser (PDL) treatment compared with those positioned distally on the limb.1 To our knowledge, self-controlled case series aimed to evaluate the localization-based efficacy and anatomic features of PWSs in response to PDL treatment have not previously been reported. Here, we investigate the morphological and anatomical features of PWSs treated by PDL based on their location on the limb and suggest a possible explanation for the difference in PDL treatment efficacy.
Fifteen patients with previously untreated limb PWSs received 3 sessions of 595-nm PDL treatment (Vbeam, Candela Corporation) using radiant exposure of 11 to 12 J/cm2, pulse duration of 0.45 to 1.5 milliseconds, 7-mm spot size, and cryogen spray cooling of treated sites for 40 milliseconds with a 20-millisecond delay from August 2016 to January 2018. Clinical efficacy was evaluated by a CR-400 Chroma Meter (Minolta) using the International Commission on Illumination L*a*b* color system2 3 months after the last treatment. Values of ΔE (expressed color change), Δa* (change in vascular erythema), and blanching rates were monitored. Furthermore, pretreatment biopsy samples of PWSs located on the proximal, middle, and distal part of the limbs were obtained from each patient. Vascular diameter, depth, vessel wall thickness, and epidermal and stratum corneum thickness were measured in all PWS biopsy samples using a medical image analysis software program (Image-Pro Plus, Media Cybernetics, Inc).3 The therapeutic effects (Δa*, ΔE, and blanching rate) and the histological features of the PWS were compared using the paired t test (2-tailed). The therapeutic results and the histological parameters of the PWS were compared using Pearson’s correlation coefficients. P values ≤ .05 were considered statistically significant (eFigures 1 and 2 in the Supplement).
This study (Chinese Clinical Trial Registry identifier: ChiCTR1800014656) was approved by the investigational review board of the Shanghai Ninth People’s Hospital. All patients provided written and verbal informed consent to participate in this study.
Following 3 PDL treatments, lesions located on the proximal part of the limb showed significantly better clearance than those located on the middle and distal parts of the limb, as indicated by higher Δa* (6.21, 2.87, and 1.86, respectively; P < .001), ΔE (12.2, 7.0, and 5.7; P < .001), and blanching rate (52.9%, 20.0%, and 8.6%; P < .001) (Figure 1). Blood vessels in PWS lesions located on the proximal part of the limb were significantly more superficial when compared with lesions on the middle and distal parts of the limb (0.17, 0.21, and 0.26 mm, respectively; P < .001). Furthermore, the epidermis and stratum corneum in PWS sites located proximally on the limb were thinner than those on the middle and distal parts of the limb (epidermis: 0.018, 0.021, and 0.029 mm, respectively; P < .001; stratum corneum: 0.011, 0.015, and 0.031 mm; P < .001). Negative correlations between clinical efficacy and vascular depth (r = −0.509; P = .02), epidermal thickness (r = −0.534; P = .01), and stratum corneum thickness (r = −0.705; P = .001) were found (Figure 2).
Our study findings suggest that the superior efficacy of PDL treatment of PWSs located proximally on the limb might be associated with the more superficial distribution of blood vessels as a result of the thinner epidermis and stratum corneum in this aspect of the limb. These results are consistent with earlier studies4 suggesting that it is easier to coagulate more superficially distributed vessels. A correlation between laser therapy outcome and the rate of light penetration into the skin was reported.1 Theoretically, the thicker epidermis and stratum corneum may cause higher scattering and absorption of laser light, resulting in lower efficacy in PWSs located distally on the limb. Thus, therapeutic outcome may be improved by the use of skin thickness–reducing techniques, such as ablative laser treatment,5 or longer-wavelength laser (eg, 755 nm or 1064 nm) when treating PWSs located distally on the limb, even though such approaches may increase the risk of scarring.6 A limitation of our study is its small sample size.
In conclusion, histological assessment of PWSs and their association with the efficacy of PDL treatment between lesions located proximally vs distally on the limb suggests that the differences in blood vessel depth and thickness of the epidermis and stratum corneum might be associated with the variation in therapeutic outcomes in the same patient.
Accepted for Publication: January 31, 2020.
Corresponding Authors: Xiaoxi Lin, MD, PhD (firstname.lastname@example.org), and Gang Ma, MD, PhD (email@example.com), Shanghai Ninth People’s Hospital, Department of Plastic and Reconstructive Surgery, Department of Laser and Aesthetic Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China.
Published Online: April 29, 2020. doi:10.1001/jamadermatol.2020.0363
Author Contributions: Dr Yu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Yu, Zhu, and Han (co–first authors) contributed equally to this work. Drs Ma and Lin contributed equally to this work.
Study concept and design: Yu, Han, Ma, Lin.
Acquisition, analysis, or interpretation of data: Zhu, Han, Chang, Shang, Ma, Lin.
Drafting of the manuscript: Yu, Zhu, Han, Shang, Ma.
Critical revision of the manuscript for important intellectual content: Yu, Zhu, Han, Chang, Ma, Lin.
Statistical analysis: Zhu, Han, Shang, Ma.
Obtained funding: Yu, Ma.
Administrative, technical, or material support: Zhu, Chang, Ma, Lin.
Study supervision: Chang.
Conflict of Interest Disclosures: Drs Yu, Zhu, Han, and Shang reported receiving grants from the National Natural Science Foundation of China during the conduct of the study. No other disclosures were reported.
Funding/Support: This study was supported by grants from the National Natural Science Foundation of China (No. 81602777) and Clinical Research Project of Multi-Disciplinary Team, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine (No. 201701001).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Trial Registration: Chinese Clinical Trial Registry Identifier: ChiCTR1800014656
Additional Contributions: We thank the patient for granting permission to publish this information.
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