|Year : 2020 | Volume
| Issue : 3 | Page : 233-240
A novel use of dermoscope in the evaluation of chronic leg ulcer healing progress using low-level laser therapy
Manar N Fayed1, Fatma M.A Al-Salam1, Abeer M Kamel1, Maisa A Abdel Wahab2
1 Department of Dermatology and Venereology, Faculty of Medicine (for Girls), Al Azhar University, Cairo, Egypt
2 Department of Vascular Surgery, Faculty of Medicine (for Girls), Al Azhar University, Cairo, Egypt
|Date of Submission||11-Jun-2019|
|Date of Decision||02-Jan-2020|
|Date of Acceptance||30-Jan-2020|
|Date of Web Publication||30-Oct-2020|
Maisa A Abdel Wahab
Source of Support: None, Conflict of Interest: None
Objective Chronic leg ulcers (CLUs) present an economic burden to health care system and significant reductions in quality of life for those affected. Low-level laser therapies (LLLTs) can play a useful role in healing of CLUs. This study aimed to evaluate the efficacy of using LLLT in CLU healing, and we focused on the use of dermoscopy in healing progress follow-up of different types of CLUs regarding some features.
Patients and methods This was a case–control study. It included 60 patients recruited from dermatological and vascular outpatient clinics and divided equally into two groups: study group and control group; in each group, there were 10 patients who had arterial ulcer, 10 patients who had diabetic ulcer, and 10 patients who had venous ulcer. The ulcers in the study group were treated by LLLT and the control group received conventional treatment. Pressure ulcer scale for healing and dermoscopic evaluation before and after treatment was done.
Results There was a statistically significant difference before and after LLLT, which indicates the progress of healing. The pressure ulcer scale for healing score is decreased in patients who were treated with LLLT compared with patients treated with conventional treatment (P=0.002). Good improvement (≥75%) was seen regarding push healing ratio in the arterial group.
Conclusion LLLT is safe, inexpensive, and effective and increases the healing progress of CLUs, which were detected with push score ratio and a novel use of dermoscope.
Keywords: chronic leg ulcers, dermoscopy, low-level laser therapy
|How to cite this article:|
Fayed MN, Al-Salam FM, Kamel AM, Abdel Wahab MA. A novel use of dermoscope in the evaluation of chronic leg ulcer healing progress using low-level laser therapy. Al-Azhar Assiut Med J 2020;18:233-40
|How to cite this URL:|
Fayed MN, Al-Salam FM, Kamel AM, Abdel Wahab MA. A novel use of dermoscope in the evaluation of chronic leg ulcer healing progress using low-level laser therapy. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Nov 25];18:233-40. Available from: http://www.azmj.eg.net/text.asp?2020/18/3/233/299584
| Introduction|| |
Chronic leg ulcer (CLU) is a break of the epidermis and dermis below the level of the knee for more than6weeks. There are three common types of CLU: venous, diabetic, and arterial ulcers .
Patients with chronic venous ulcer have impaired healing because of decreased skin perfusion as a result of elevated venous pressures in the capillaries and diminished oxygen and glucose delivery to tissues .
The narrowing of the arterial lumen by atherosclerosis, resulting in ischemia, and if perfusion is not regained, tissue loss will occur leading to arterial ulcers .
The major causes of diabetic foot ulcers are peripheral neuropathy, ischemia from peripheral vascular disease, and hyperglycemia, which impair leukocyte function and alter glucose uptake in cells, thereby weakening the patient’s immune defenses and ability to repair wounds .
Successful management of leg ulcers needs clear diagnosis, treatment of precipitating cause, promotion of circulation, and improvement of venous return .
Low-level laser therapy (LLLT) is a noninvasive, painless technique with minor adverse effects for the treatment of CLUs .
LLLT is the application of light to a biologic structure to stimulate tissue regeneration, decrease inflammation, and relieve pain. It does not have an ablative or thermal mechanism, but the light is absorbed and causes a chemical change .
When suitable concentration, strength, and times are used for treatment, LLLT has a photochemical effect that reduces oxidative stress and increase ATP production. This improves cell metabolism and reduce inflammation .
Laser irradiation can promote proliferation of myofibroblasts in cutaneous ulcers by stimulating mitochondrial activity and maintaining viability without causing more injury to the wound .
The mechanisms by which LLLT accelerates wound healing is through the release of growth factors, increased mitochondrial ATP production, increased proliferation of fibroblasts, and increased skin microcirculation .
Dermoscopy has been shown to be a useful tool in supporting the noninvasive diagnosis of various dermatological diseases.
| Patient and methods|| |
This case–control study enrolled 30 patients who attended the outpatient clinic for Vascular Surgery and Dermatology Clinics in Al-Zahraa University Hospital between March 2017 and February 2018 and had CLUs (10 arterial, 10 venous, and 10 diabetic). Another 30 patients with CLUs were used as controls (10 arterial, 10 venous, and 10 diabetic). Informed written consent was obtained from all patients. The approval from the Research Ethics Committee of the Faculty of Medicine for Girls, Al-Azhar University, was also obtained.
The following were the inclusion criteria:
- Patients above 18 years old.
- Duration: more than 6 weeks.
- Size: less than 8×8 cm.
- Superficial ulcer not involving tendons, ligaments, and joints.
- Types of ulcer included diabetic (10), venous (10), and arterial (10).
The following were the exclusion criteria:
- History of photosensitivity.
All patients were subjected to a detailed medical history, clinical examination of CLU, and the size of the ulcer according to pressure ulcer scale ([Table 1]).
Dermoscopic examination of the ulcer was done using DermLite Hud Smart Skin (3Gen, Inc., 31521 Rancho Viejo Road, Suite 104 San Juan Capistrano, CA, USA), which has contact polarized and nonpolarized light to allow visualization of deeper skin structures and provide information about the superficial skin, respectively.
Dermoscopic findings of the ulcers before and after the sessions were analyzed to evaluate the progress of healing.
The patients were divided into two groups:
It include 30 patients who were treated with 12 sessions of low-level laser device (650 nm, 50 mw; OMEGA, Omega Laser Systems Ltd., Great Britain) during 1 month, comprising three sessions per week in alternated days. The device has two probes: the shower with 808 nm and the pen with 650 nm. The ulcer floor was irradiated by the shower for 3 min, whereas the edges were irradiated by the pen for 1 min at each point. Pen and shower were held perpendicular to the wound, with approximate distance of 1 cm from skin surface. Lastly, protective eye glasses for the doctor and the patient are necessary to prevent damage to their eyes.
It included 30 patients who receive conventional treatment in the form of daily saline dressings for 1 month and compression bandage in cases with venous ulcer.
At every session, the ulcer area was calculated and photographs were taken by a digital camera (20 megapixels), and dermoscopy was done for all patients before and after 1-month treatment.
Then patients in the two groups were compared regarding the response to the management plan, which was assessed by reduction in the size of ulcer area and improvement of symptoms.
| Results|| |
This study was conducted on 60 patients with CLU. They were divided into 2 groups:
- Group A (cases): it included 30 patients with CLUs who were divided into 10 diabetic, 10 venous, and 10 arterial patients. They were treated with LLLT for 12 sessions during 1 month (three sessions weekly).
- Group B (control): it included 30 patients with CLU who received conventional treatment during 1 month.
The two groups were sex and age matched, with no statistically significant difference between them.
There were no significant difference between case group and control group regarding the types of ulcers and their size. Moreover, there were no significant differences between case group and control group regarding pressure ulcer scale for healing (PUSH) score ([Table 2]).
|Table 2 Comparison of pressure ulcer scale for healing score before and after treatment among all cases and control groups|
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The PUSH score was decreased by 6.3±2.8 in patients who were treated with LLLT compared with patients who were treated with conventional treatment (by 4.4±1.7), with statistically significant difference (P=0.002) ([Table 2]).
Regarding subgroups, there was a statistically significant decrease in PUSH score (P=0.009) in arterial case group that was treated with LLLT compared with the control group, whereas there was no statically significant decrease in both diabetic and venous groups that were treated either by laser or ordinary treatment (P=0.079 and 0.234, respectively) ([Table 3] and [Figure 1],[Figure 2],[Figure 3]).
|Table 3 Comparison of pressure ulcer scale for healing score before and after treatment among case and control groups in different types of ulcers|
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|Figure 1 (A) The ulcer at the first visit, it measured 8×7 cm, PUSH score is 15. Arterial ulcer of a 65-year-old male patient in his right leg; (b) the ulcer after sixth session measured 7×5.5 cm, with a PUSH score of 13; (c) the ulcer after 12 sessions of low-level laser therapy measured 6×4.5 cm, with a PUSH score of 11. PUSH, pressure ulcer scale for healing.|
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|Figure 2 Diabetic ulcer of a 63-year-old male patient, with the ulcer in his left sole. (a) The ulcer at the first visit measured 1×1.5 cm, with a PUSH score of 7; (b) the ulcer after sixth sessions measured 0.9× 0.5 cm, with a PUSH score of 4; (c) the ulcer after 12th sessions of low-level laser therapy healed, with a PUSH score of 0. PUSH, pressure ulcer scale for healing.|
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|Figure 3 Venous ulcer of a 56-year-old male patient who had an ulcer in his right leg. (a) The ulcer at the first visit measured 4×2.5 cm, with a PUSH score of 12; (b) the ulcer after sixth sessions measured 3×2 cm, with a PUSH score of 11; (c) the ulcer after 12th sessions of low-level laser therapy measured 2.5×1 cm, with a PUSH score of 8. PUSH, pressure ulcer scale for healing.|
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Comparison of treatment ratio outcome after 1 month among cases and controls in different types of ulcers revealed that good improvement (≥75%) in 60% of arterial, 50% in the diabetic, and 20% in venous groups in the group treated with LLLT regarding push healing ratio. However, in control patients, the healing ratio in all types of ulcer was lower ([Table 4]).
|Table 4 Outcome of treatment ratio after 1 month among case and control groups in different types of ulcers|
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Dermoscopic evaluation was done before and after treatment in patients who were treated with LLLT to detect the healing process. We focused on the use of dermoscopy regarding some features including the morphology and arrangement of vascular structures, in addition to color and content of ulcer background.
- Color of background:
- Pink background.
- Red background.
- White structures (fibrous tissue):
- Thick white reticular lines.
- Thick white lines.
- Diffuse white patches.
- Morphology of the blood vessels:
- Large dotted.
We found positive changes in 15 cases regarding pink background, hairpin or no blood vessels, no white components, and appearance of keratin, scales, and yellow-orange area, which indicated the healing, as pink backgrounds increased by 53% and red backgrounds decreased by ∼53%, 60% of ulcers had no blood vessels and decreased the other types of blood vessels, as hairpin, large dotted and serpiginous blood vessels disappeared. Moreover, there was decrease in all white components and other findings appeared such as keratin, scales and yellow-orange area, indicating complete healing and intact skin ([Table 5] and [Figure 4]).
|Table 5 Summary of different dermoscope parameters before and after laser therapy|
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|Figure 4 Dermoscopic evaluation of chronic leg ulcer before and after LLTT treatment. (a) Dermoscope before low-level laser therapy shows red background, large dotted blood vessel, and thick white lines; (b) dermoscope after 12 sessions low-level laser therapy shows pink background, no white component, and no blood vessels.|
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| Discussion|| |
Research studies have shown that LLLT can play a useful role in progress of CLUs healing versus conventional treatment .
This study was conducted on 60 patients with chronic lower leg ulcers. They were divided into two equal groups (study and control) to evaluate the efficacy of using low-level laser therapy (LLLT) in CLU healing. Examination of ulcer was done according to pressure ulcer scale. PUSH tool is the most frequently referenced instrument of wound healing, with lower scores indicating better wound condition. Dermoscopic evaluation was done before and after treatment as a new indicator for healing of the ulcers.
The first group (study group) included 30 patients with CLUs (subdivided into arterial, venous and diabetic ulcers) who were treated with LLLT and then covered with sterile dressing for 12 sessions during 1 month.
The second group (control group) included another 30 patients with CLUs who were instructed to use only sodium chloride (saline solution 0.9%) regarding the daily asepsis of the ulcer.
Results of the present work showed that laser treatment decreased the PUSH score by 6.3±2.8 compared with 4.4±11.7 in the control group. This was statistically significant (P=0.002). Moreover, among the type of ulcers, laser treatment is superior in decreasing the PUSH score by 7.3±1.8 in arterial group compared with 5.2±1.3 in control group, with statistically significant difference (P=0.009). However, in diabetic and venous groups, P value was 0.079 and 0.234, respectively.
Aguirre and other colleagues treated 34 diabetic leg ulcers with LLLT and showed significant reduction in percentage wound area, that is, 40.24±6.30 mm2 compared with 11.87±4.28 mm2 in control groups (P<0.001). These results showed significant benefit following the use of LLLT, which indicates that LLLT is an effective modality to facilitate wound contraction in patients experiencing leg ulcer and can be used as an adjunct to conventional mode of treatment (dressings and debridement) for healing .
There was a study that demonstrated a significantly greater reduction (P<0.002) in the surface area of leg ulcers treated with red light and infrared light than in controls. The leg ulcers were given three sessions per week for 10 weeks. Treated ulcers showed an average reduction in surface area of 193.0 mm2, whereas in controls, it was only 14.7 mm2 .
A study by Lenifa et al.  has treated 34 diabetic leg ulcers with LLLT and showed significant reduction in percentage wound area, that is, 40.24±6.30 mm2 compared with 11.87±4.28 mm2 in control groups (P<0.001). These results show significant benefit following the use of LLLT.
Another study has reported, the wounds in subjects treated with LLLT contracted significantly more than the wounds in the nontreated group (40.24 vs 11.87%; P<0.001), which indicates that LLLT is an effective modality to facilitate wound contraction in patients with diabetes and can be used as an adjunct to conventional mode of treatment (dressings and debridement) for healing of diabetic wounds .
Dermoscopic examination of ulcers before and after LLLT showed statistically significant improvement in 15 cases in the form of pink background, hairpin or no blood vessels, no white components, and appearance of keratin, scales, and yellow-orange area, which indicates the progress of healing.
The color of the background indicates the blood vessel supply, as more blood vessels give the background red color. When the ulcer healed or about to heal, the blood vessels are small in size, few in number, and the background takes pink color.
The white components indicate fibrosis, indicating delayed healing. White reticular lines and white diffuse patches decreased after LLLT treatment, indicating that LLLT facilitated healing.
Other findings after LLLT included keratin, scales, and yellow-orange area appearance.
Up to our knowledge, this is the first study to evaluate the healing process in CLUs using dermoscope.
In this study, there were no adverse effects associated with application of LLLT in patients with CLU.
| Conclusion|| |
LLLT is safe, simple, painless, and inexpensive and is effective with no adverse effect. So it is important to motivate both patients and clinicians to use LLLT as a recent adjuvant treatment modality in CLUs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]