Vascular Skin Lesions and Their Treatment with Laser Radiation

The dissertation is devoted to the development and substantiation of effective methods for the treatment of vascular skin lesions — angiodysplasias — using laser radiation generated by modern laser systems. The work includes a comparative evaluation of treatment outcomes for angiodysplasias using traditional methods (diathermocoagulation) and the application of selective laser technologies, including the КТР-Ш:УАО laser and the diode laser «Lazermed». Indications, parameters, and modes of laser exposure were investigated, and a methodology for the complex application of various types of lasers depending on the clinical form and degree of expression of the disease was developed. Data were obtained on the possibility of combined use of high-energy laser actions, which made it possible to substantially improve cosmetic treatment outcomes. The scientific novelty consists in the first-time comparative evaluation of various types of laser radiation in the treatment of vascular skin lesions in Russia and the substantiation of a differentiated approach to the selection of laser exposure parameters.

Relevance of the Topic. Vascular dysplasias of the skin constitute the most frequent cause of patient referrals to plastic surgeons and cosmetologists. Despite substantial advances in general and cosmetic surgery, the problem of treating skin angiodysplasias remains one of the most complex and urgent issues in modern clinical medicine.

The constant and natural increase in patient demands for the quality of the final cosmetic result of treatment of the considered pathology necessitates the urgent refinement of existing treatment methods, since the available capabilities often fail to fully satisfy either specialists or patients themselves.

Since ancient times, it has been known that capillary hemangiomas and angiodysplasias, telangiectasias, port-wine stains, and venous malformations are vascular pathologies encountered quite frequently. In the present century, specialists detect them in approximately 2–12% of newborns and 0.3–1.0% of the adult population (109; 117; 129; 130).

According to current statistical data, among all existing vascular pathology, the considered nosology is encountered in 60% of cases. There is no need to prove today that the treatment of vascular dysplasias is not only an important medical but also a social problem.

Analysis of the modern literature indicates that the complexity of the pathogenesis, dissatisfaction of patients and physicians with the results of both conservative and traditional surgical treatment methods, primarily cosmetic ones, as well as the existing high risk of forming a more pronounced cosmetic defect after treatment, constitute the fact that the problem of adequate treatment of the considered pathology is undoubtedly relevant and, unfortunately, far from a final resolution (16; 25; 52; 74; 88).

It should be noted that to date there exists no single generally accepted clinical classification of the disease. In the various classifications currently available, this pathology is attributed either to "false hemangiomas" or to angiodysplasias, since they do not possess the typical characteristics of a tumor. It is often considered as one of the types of hemangioma, which leads to the selection of an incorrect treatment strategy and consequently to unsatisfactory treatment outcomes.

According to prevailing concepts, angiodysplasias of the skin, as a rule, are of a congenital nature (6; 13; 40; 97; 175). Clinically, the considered pathology manifests as bright red spots of various shades depending on the degree of expression and predominance of the vascular component. Under normal conditions, it causes patients only cosmetic inconvenience, without affecting the state of health or the function of other organs. According to statistical data, the peak of patient referrals falls in the age range from 1 to 20 years, with women more frequently seeking medical attention. The frequency of angiodysplasia occurrence, according to various authors, ranges from 47.8% to 80% of all vascular pathologies of the skin (30; 54), and the most typical localization is the soft tissues of the head and neck.

High morbidity, the characteristic localization of angiodysplasias (on the face), determining the "acute" social significance of the disease, and the insufficient effectiveness of existing treatment methods determine the relevance and great practical importance of developing new approaches to treatment that optimize cosmetic results.

Analysis of the literature indicates (6; 13; 54; 83; 148) that the following treatment methods are currently widely used for the considered pathology:

• operative method,

• endovascular occlusion,

• cryodestruction,

• diathermocoagulation,

• hormone therapy,

• bugi therapy,

• sclerotherapy,

• ultrasound treatment

• laser coagulation

The wide range of existing treatment methods is evidence of the unresolved nature of many questions regarding the treatment of angiodysplasias. Precisely because none of the indicated methods, applied in practice, ensures achievement of a result fully satisfying patient demands, this compels specialists to refine treatment methods. In addition, the improvement of the general level of well-being of modern Russian society in recent decades has naturally substantially increased the demands on medical specialists, which necessitates the search for and creation of new modern techniques ensuring guarantees of achieving quality treatment results.

The widespread introduction of achievements of scientific and technological progress observed since the last century led in the 21st century to the active application of various types of laser radiation (16; 25; 74) initially in surgical practice and subsequently in other clinical areas of medicine, including cosmetology.

In our view, the development and creation of a laser generating a wavelength of 0.532 µm in the green visible spectrum allowed specialists to approach the problem of treating vascular dysplasias in a new way. If previously used methods were based on exploiting the coagulation effect (chemical, thermal, or electrocoagulation) of all tissues on which radiation is exerted, i.e., both pathological and healthy tissues subjected to exposure, then the application of a "vascular" selective laser made it possible to precisely affect only the pathological vascular tissue. The indicated effect is associated with the selective absorption of hemoglobin and oxyhemoglobin of electromagnetic radiation in the green-yellow spectrum of visible light, leading to their coagulation. In this case, the epidermis and surrounding tissues remain "transparent" for this spectrum (104).

At present, the only factor impeding the introduction of laser technologies into everyday practice, in our opinion, is the high cost of equipment. However, such properties of laser radiation as reliable hemostasis, the ability to selectively and clearly regulate depth of effect on pathologically altered tissues, the capability to perform operations in outpatient conditions, and rapid patient rehabilitation should in the near future contribute to the spread of laser technologies in patient treatment (16; 32; 82; 83).

Thanks to the use of the principle of selective photothermolysis (selective absorption of the yellow-green spectrum of oxy- and deoxyhemoglobin by blood) and infrared radiation, it has become possible to create laser systems ensuring the ability to coagulate skin vessels with minimal damage to the skin itself. At present, the literature, primarily foreign, contains a sufficient number of works attesting to the effectiveness of laser action in the treatment of vascular skin pathology (109; 117; 129; 130), including when using, for example, the laser КТР-Мс1:УАО (Russia) and diode lasers («Lazermed», Russia) (117; 130). The literature devotes considerable attention to studying the possibilities of applying various laser sources with different spectral and energy characteristics in vascular surgery and cosmetology (104; 148). However, in no work have we encountered data dedicated to the consideration of indications for the use of selective and non-selective high-energy lasers.

In connection with the above, the determination of the effectiveness of various types of laser action based on the application of modern generations of laser generators, and the development of "gentle" methods of their use in the treatment of skin angiodysplasias, is, in the opinion of many researchers and from our point of view, undoubtedly important and relevant for modern surgical cosmetology (104; 148).

The aim of the study: to develop and substantiate effective methods for the treatment of vascular skin lesions using laser radiation generated by modern lasers ensuring precise impact. The tasks of the study:

1. To conduct a comparative evaluation of the effectiveness of treatment of angiodysplasias using traditional (diathermocoagulation) methods and the proposed method based on the use of the newest generations of medical laser installations.

2. To substantiate the use of the КТР-Ш:УАО laser (Russia) and the diode laser «Lazermed» (Russia) in the treatment of skin angiodysplasias.

3. To determine the possibility of combined application of various types of laser action.

4. To clarify indications and develop a methodology for the complex application of various lasers in the treatment of skin angiodysplasias depending on the clinical form of the disease and the degree of their expression.

5. To study the clinical results of the application of high-energy lasers in the treatment of skin angiodysplasias.

Scientific novelty of the work:

For the first time in Russia, a comparative evaluation of the results of the action of various types of laser radiation on vascular skin lesions was conducted; indications and advantages of the use of the КТР-ШгУАО laser (Russia) and the diode laser «Lazermed» (Russia) in the treatment of skin angiodysplasias were determined.

Based on clinical observations, results were obtained and differentiated approaches to the selection of laser radiation exposure parameters in the treatment of skin angiodysplasias were substantiated, ensuring the best cosmetic and functional results.

The study also investigated the possibility of and developed a methodology for the combined use of various types of high-energy laser actions in the treatment of skin angiodysplasias.

Practical significance:

1. Methodologies for the application of selective laser action in the treatment of skin angiodysplasias have been developed and introduced into clinical practice.

2. Indications for the use of selective and non-selective laser action have been determined.

3. Based on the use of laser radiation with a wavelength of 0.532 µm, optimal parameters and modes of laser action in the treatment of skin angiodysplasias have been studied and substantiated.

4. Cosmetic results of treatment of patients with skin angiodysplasias have been substantially improved.

Implementation into practice:

The developed laser treatment methodologies have been introduced into the practice of treating patients with skin angiodysplasias in the polyclinic department of FSU "GNC Laser Medicine of Roszdrav".

Validation of the work:

The materials of the dissertation were reported at the scientific-practical conference "Modern Achievements of Laser Medicine and Their Application in Practical Healthcare" Moscow, October 5-6, 2006; the scientific-practical conference "Actual Questions of Laser Medicine", Saint Petersburg, May 25-26, 2006; and at a meeting of the Academic Council of FSU "GNC JIM Roszdrav" on June 26, 2007.

Publications:

On the topic of this work, 3 publications have been issued (one in the periodic medical press, two in collections of scientific conferences).

Structure and Volume of the Dissertation:

The dissertation is presented in 99 pages of typed manuscript. It consists of an introduction, a literature review, chapters: Materials and Methods of Investigation, Results of Own Investigations, conclusion, conclusions, and practical recommendations. The work is illustrated with 14 tables and 25 figures. The bibliography includes references to 185 sources, of which 102 are domestic and 83 are foreign authors.