JAMA Facial Plastic Surgery Journal Club Slides: PDL for Pediatric Cutaneous Vascular Anomalies Sajan JA, Tibesar R, Jabbour N, Lander T, Hilger P, Sidman J. Assessment of pulsed-dye laser therapy for pediatric cutaneous vascular anomalies. JAMA Facial Plast Surg. Published online September 5, 2013. doi:10.1001/jamafacial.2013.257.

Introduction Hemangiomas of infancy (HOIs) and port-wine stains affect 5% to 10% of children. 20% may cause pain, bleeding, ulceration, infection, or functional impairment (ie, impairment with vision, feeding, or breathing) necessitating medical or surgical intervention. Significant complications may occur from untreated lesions. Early treatment of these vascular lesions can improve outcomes. Inconsistent results with pulsed-dye laser (PDL) have been reported in the literature. To date, no validated assessment tools exist to analyze results from PDL therapy.

Purpose To create and evaluate a valid assessment tool to efficiently consider results from PDL therapy for HOIs and port-wine stains in the clinical setting.

Description of Evidence Retrospective medical chart review performed at a tertiary care hospital. The records of all consecutive patients treated with the cool-tip PDL from January 2005 to March 2011 were screened. Inclusion required the treatment of an HOI or port-wine stain with the 595-nm cool-tip PDL. Photographs were assessed independently by 3 pediatric otolaryngologists and facial plastic surgeons. The reviewers were nontreating surgeons for these patients. Standardized lighting and specialized photography were not performed. All images were obtained from our electronic medical records.

The Tool

Patients 22 patients, average age of 10 months at start of treatment, for a total of 79 treatments. PDL therapy was applied to the upper lip, lower lip, nasal tip, nasal ala, upper eyelid, cheek, forehead, and the temple. 8 patients with HOIs chose surgery after PDL therapy. These lesions were in the upper lip (2 lesions), lower lip and cheek (2 lesions in each location), and nasal tip, upper eyelid, and forehead (1 lesion in each of these locations).

Analysis Average values for each question. Nonparametric Mann-Whitney test for questions 1 through 3. Fisher exact test for questions 4 through 6. Intraclass correlation was reported for the interrater reliability between 3 raters with the assumption of a 2-way mixed model.

Interpretation of the Interrater Reliability Resultsa Analysis Interpretation of the Interrater Reliability Resultsa a LeBreton JM, Senter JL. Answers to 20 questions about interrater reliability and interrater agreement. Organ Res Methods. 2008;11:815-853. doi:10.1177/1094428106296642.

Results Interrater reliability by question: Color: 0.92 Thickness: 0.92 Size: 0.93 Scarring: 0.91 Atrophy: 0.70 Hypopigmentation: 0.10

Results Average Values of Reviewer Answers for Questions 1 to 6

Comment The assessment tool has excellent interrater reliability to detect changes in color, thickness, size, and scarring after laser therapy to HOIs and port-wine stains. There is acceptable interrater reliability to detect changes in atrophy. The tool was not reliable in assessing hypopigmentation amongst the raters. Port-wine stains had a significantly greater change in color than HOIs. HOIs had a significantly greater change in thickness than port-wine stains. There was no significant difference seen in scarring or atrophy between HOIs and port-wine stains with PDL therapy.

Patient Case After treatment with the cool-tip PDL, raters noted 76% to 99% change in color, 1% to 24% improvement in thickness, and 1% to 24% improvement in size.

Conclusions Currently, no standardized or validated methods exist to evaluate results of HOIs and port-wine stains after intervention with PDL. This assessment tool is a consistent rating system that shows agreement among raters to detect change in color, size, thickness, scarring, and atrophy in HOIs and port-wine stains treated with PDL.

Conflict of Interest Disclosures Contact Information If you have questions, please contact the corresponding author: Javad A. Sajan, MD, Department of Otolaryngology-Head and Neck Surgery, Unversity of Minnesota, 500 E Grant St, Ste 1006, Minneapolis, MN 55404 (javad.sajan@gmail.com). Conflict of Interest Disclosures None reported.