Dermoscopy predicts outcome in hemoporfin-mediated photodynamic therapy of port-wine stains: A prospective observational study

Abstract

To the Editor: Port-wine stain (PWS) is defined as ectasia of the vessels in the dermis, affecting the dermal papillae capillary loops, the horizontal plexus at the dermal-subcutaneous junction, or a combination of these.1Anderson R.R. Levins P.C. Grevelink J.M. Lasers in dermatology.in: Fitzpatrick T.B. Eisen A.Z. Wolff K. Freedberg I.M. Austen K.F. Dermatology in General Medicine. 4th ed. McGraw-Hill, New York1971: 1755-1766Google Scholar Recent studies have identified 2 main dermoscopic patterns of PWS. Type 1 is a superficial pattern composed of red globules and dots that correspond to dilated capillary loops in the papillary dermis. Type 2 is a deep pattern that features red ring structures corresponding to dilated ectatic vessels located deep in the horizontal vascular plexus.2Piccolo V. Russo T. Moscarella E. et al.Dermatoscopy of vascular lesions.Dermatol Clin. 2018; 36: 389-395Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Histopathologic examination is the standard approach to determine the depth of the vascular lesion, but it is invasive. Dermoscopy can preoperatively predict the outcome of treatment and the minimal effective fluence in pulsed dye laser treatment.3Eubanks L.E. McBurney E.I. Videomicroscopy of port-wine stains: correlation of location and depth of lesion.J Am Acad Dermatol. 2001; 44: 948-951Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar,4Shirakawa M. Ozawa T. Wakami S. et al.Utility of dermoscopy before and after laser irradiation in port wine stains.Ann Dermatol. 2012; 24: 7-10Crossref PubMed Scopus (17) Google Scholar PWS in areas that typically respond well to laser treatment were more likely to have a superficial type 1 but those that have a poorer response were more likely to have a deeper type 2. The immediate vessel disappearance after pulsed dye laser treatment observed by dermoscopy can predict the minimal effective fluence and prevent adverse effects. Hemoporfin-mediated photodynamic therapy (HMME-PDT) is considered to be a successful and well-tolerated treatment option for PWS.5Zhao Y. Tu P. Zhou G. et al.Hemoporfin photodynamic therapy for port-wine stain: a randomized controlled trial.PLoS One. 2016; 11: e0156219Crossref PubMed Scopus (38) Google Scholar The response of different depth vessels to HMME-PDT and the relationship between dermoscopic features and the efficacy of HMME-PDT have not been reported to our knowledge. We present a prospective observational study of 16 patients with PWS who received HMME-PDT. The Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (2019S1170) approved this study. All of the detailed methods are in the Supplemental file available on Mendeley at https://doi.org/10.17632/b968gsy7bp.1. Group A consisted of 8 patients with the type 1 pattern, and group B consisted 8 patients with the type 2 pattern (Table I). Dermoscopic images of PWS lesions were taken from each patient using the hand-held dermoscope with 50× polarized light (CH-DSIS-2000 Plus; Guangzhou Chuanghong Medical Technology Co, Ltd, Guangzhou, China). Clinical efficacy was observed after 1 treatment of HMME-PDT.Table IProfile of the patients in the studyPatient No.Age, ySexPWS locationResponse∗No improvement (NI): <20%; some improvement (SI): 20%-59%; great improvement (GI): 60%-89%; nearly completely resolved (CR): 90%.Group A 110FemaleRight cheekCR 231MaleMandible and neckGI 34FemaleMandibleCR 48MaleRight chinGI 56MaleLeft cheekGI 611MaleLeft cheekGI 74FemaleLeft cheek and orbitCR 84FemaleLeft temporalCRGroup B 18MaleRight cheekNI 240FemaleMandible and neckSI 36FemaleRight cheekNI 47MaleRight cheekNI 518MaleLeft cheekNI 69MaleLeft cheekNI 78MaleRight cheekNI 819MaleRight cheekNIPWS, Port wine stain.∗ No improvement (NI): <20%; some improvement (SI): 20%-59%; great improvement (GI): 60%-89%; nearly completely resolved (CR): 90%. Open table in a new tab PWS, Port wine stain. Patients in the 2 groups had markedly different responses after 1 treatment with HMME-PDT. Patients in group A (type 1 pattern) had an excellent response to HMME-PDT, whereas those in group B (type 2 pattern) had a poor response (Fig 1). In HMME-PDT treatment, the 532-nm laser can activate the photosensitizer injected into the blood vessels to produce highly reactive singlet oxygen, which can destroy the endothelial cells.5Zhao Y. Tu P. Zhou G. et al.Hemoporfin photodynamic therapy for port-wine stain: a randomized controlled trial.PLoS One. 2016; 11: e0156219Crossref PubMed Scopus (38) Google Scholar HMME-PDT can more easily destroy or remove deformed vessels that are superficial because of the limited range of wavelength penetration. It is still difficult to penetrate PWS lesions with thicker vessel walls, deeper locations, and larger diameters. Possibility of the need for multiple treatments should be discussed in the initial consultation. Dermoscopy is a simple, noninvasive technique that allows the microvascular patterns in PWS to be assessed and recorded. We have observed that the type 1 pattern is readily treated with HMME-PDT and an excellent response can be expected, whereas the type 2 pattern resists treatment. Further studies will increase the sample size, refine the dermoscopic patterns, and study the relationship between different patterns and HMME-PDT results.