Pain management strategies of photodynamic therapy for nevus flammeus_West China Medical Journal

Authors：

ZHANG Zhidong , ZHU Zhucai ,  LI Qi , LIANG Peng , ZUO Yunxia

Anesthesia & Operation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

LI Qi, Email: liqimd@qq.com

Keywords：

Nevus flammeus; photodynamic therapy; pain management; nerve block

DOI：

10.7507/1002-0179.202211078

Video：

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Nevus flammeus is a skin disease caused by congenital skin capillary malformation. In recent years, photodynamic therapy (PDT) has been proved to be effective and safe for this disease, but significant pain in the treatment process is the biggest obstacle to the implementation of this therapy. This article reviews the current pain management strategies in PDT. The current pain management methods include topical anesthesia, cold air analgesia, nerve block and others. Topical anesthesia has weak analgesic effect and short duration in PDT. Cold air analgesia is simple and feasible, but there is potential risk of affecting the treatment effect. The analgesic effect of nerve block is accurate, but the application scenario is limited. For nevus flammeus patients who need PDT, individualized analgesia should be selected according to the patient’s age and treatment scenario.

Citation： ZHANG Zhidong, ZHU Zhucai, LI Qi, LIANG Peng, ZUO Yunxia. Pain management strategies of photodynamic therapy for nevus flammeus. West China Medical Journal, 2023, 38(2): 300-303. doi: 10.7507/1002-0179.202211078 Copy

1.	Yu L, Qin K, Deng X, et al. Epidemiological study of capillary malformation among 7299 infants under 1 year of age in China. J Eur Acad Dermatol Venereol, 2022: 22.
2.	Liu L, Li X, Zhao Q, et al. Pathogenesis of port-wine stains: directions for future therapies. Int J Mol Sci, 2022, 23(20): 12139.
3.	Jiang F, Shao J, Chen L, et al. Influence of port-wine stains on quality of life of children and their parents. Acta Derm Venereol, 2021, 101(8): adv00516.
4.	van Raath MI, Chohan S, Wolkerstorfer A, et al. Port wine stain treatment outcomes have not improved over the past three decades. J Eur Acad Dermatol Venereol, 2019, 33(7): 1369-1377.
5.	Han Y, Ying H, Zhang X, et al. Retrospective study of photodynamic therapy for pulsed dye laser-resistant port-wine stains. J Dermatol, 2020, 47(4): 348-355.
6.	Zhang LC, Yang J, Huang YB, et al. Efficacy of hemoporfin photodynamic therapy for pulsed dye laser-resistant facial port-wine stains in 107 children: a retrospective study. Indian J Dermatol Venereol Leprol, 2022, 88(2): 275.
7.	Chaves YN, Torezan LA, Niwa AB, et al. Pain in photodynamic therapy: mechanism of action and management strategies. An Bras Dermatol, 2012, 87(4): 521-526, quiz 527-529.
8.	Sandberg C, Stenquist B, Rosdahl I, et al. Important factors for pain during photodynamic therapy for actinic keratosis. Acta Derm Venereol, 2006, 86(5): 404-408.
9.	Arits AH, van de Weert MM, Nelemans PJ, et al. Pain during topical photodynamic therapy: uncomfortable and unpredictable. J Eur Acad Dermatol Venereol, 2010, 24(12): 1452-1457.
10.	Yu W, Wang T, Zhu J, et al. EMLA cream does not influence efficacy and pain reduction during pulsed-dye laser treatment of port-wine stain: a prospective side-by-side comparison. Lasers Med Sci, 2018, 33(3): 573-579.
11.	Langan SM, Collins P. Randomized, double-blind, placebo-controlled prospective study of the efficacy of topical anaesthesia with a eutetic mixture of lignocaine 2.5% and prilocaine 2.5% for topical 5-aminolaevulinic acid-photodynamic therapy for extensive scalp actinic keratoses. Br J Dermatol, 2006, 154(1): 146-149.
12.	Touma D, Yaar M, Whitehead S, et al. A trial of short incubation, broad-area photodynamic therapy for facial actinic keratoses and diffuse photodamage. Arch Dermatol, 2004, 140(1): 33-40.
13.	Pagliaro J, Elliott T, Bulsara M, et al. Cold air analgesia in photodynamic therapy of basal cell carcinomas and Bowen’s disease: an effective addition to treatment: a pilot study. Dermatol Surg, 2004, 30(1): 63-66.
14.	Charkoudian N. Mechanisms and modifiers of reflex induced cutaneous vasodilation and vasoconstriction in humans. J Appl Physiol (1985), 2010, 109(4): 1221-1228.
15.	Leff DR, Nortley M, Dang V, et al. The effect of local cooling on pain perception during infiltration of local anaesthetic agents, a prospective randomised controlled trial. Anaesthesia, 2007, 62(7): 677-682.
16.	Tyrrell J, Paterson C, Curnow A. Regression analysis of protoporphyrin IX measurements obtained during dermatological photodynamic therapy. Cancers (Basel), 2019, 11(1): 72.
17.	Paoli J, Halldin C, Ericson MB, et al. Nerve blocks provide effective pain relief during topical photodynamic therapy for extensive facial actinic keratoses. Clin Exp Dermatol, 2008, 33(5): 559-564.
18.	Halldin CB, Paoli J, Sandberg C, et al. Nerve blocks enable adequate pain relief during topical photodynamic therapy of field cancerization on the forehead and scalp. Br J Dermatol, 2009, 160(4): 795-800.
19.	Klein A, Karrer S, Horner C, et al. Comparing cold-air analgesia, systemically administered analgesia and scalp nerve blocks for pain management during photodynamic therapy for actinic keratosis of the scalp presenting as field cancerization: a randomized controlled trial. Br J Dermatol, 2015, 173(1): 192-200.
20.	Lavand’homme P. Rebound pain after regional anesthesia in the ambulatory patient. Curr Opin Anaesthesiol, 2018, 31(6): 679-684.
21.	Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia, 2021, 76(Suppl 1): 100-109.
22.	Sinha C, Kumar A, Kumari P, et al. Does radial or median nerve blocks affect the area and blood flow of radial artery?. Anaesth Crit Care Pain Med, 2021, 40(2): 100831.
23.	Huang N, Zeng J, Liang J, et al. A randomized, double-blind, placebo-controlled study of oral oxycodone plus acetaminophen for the treatment of pain in photodynamic therapy on port wine stains. Photodiagnosis Photodyn Ther, 2014, 11(2): 134-140.
24.	Chan CS, Chan MTV. Use of nitrous oxide in contemporary anesthesia-an ongoing tug of war. Can J Anaesth, 2021, 68(11): 1597-1600.
25.	Brotzman EA, Sandoval LF, Crane J. Use of nitrous oxide in dermatology: a systematic review. Dermatol Surg, 2018, 44(5): 661-669.
26.	Fink C, Uhlmann L, Enk A, et al. Pain management in photodynamic therapy using a nitrous oxide/oxygen mixture: a prospective, within-patient, controlled clinical trial. J Eur Acad Dermatol Venereol, 2017, 31(1): 70-74.
27.	Paquier-Valette C, Wierzbicka-Hainaut E, Cante V, et al. Evaluation of hypnosis in pain management during photodynamic therapy: a pilot study. Ann Dermatol Venereol, 2014, 141(3): 181-185.
28.	许昉方. 音乐疗法对降低光动力治疗尖锐湿疣疼痛的影响. 微创医学, 2017, 12(5): 712-713.
29.	Zhao Y, Tu P, Zhou G, et al. Hemoporfin photodynamic therapy for port-wine stain: a randomized controlled trial. PLoS One, 2016, 11(5): e0156219.
30.	Troilius A, Wrangsjö B, Ljunggren B. Patients with port-wine stains and their psychosocial reactions after photothermolytic treatment. Dermatol Surg, 2000, 26(3): 190-196.
31.	U.S. Food and Drug Administration. FDA drug safety communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children. (2017-05-09)[2022-11-10]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-label-changes-use-general-anesthetic-and-sedation-drugs.
32.	Reighard C, Junaid S, Jackson WM, et al. Anesthetic exposure during childhood and neurodevelopmental outcomes: a systematic review and meta-analysis. JAMA Netw Open, 2022, 5(6): e2217427.
33.	Mathes EF, Frieden IJ. Early use of laser for port-wine stains: timing, efficacy, and shared decision making. JAMA Dermatol, 2019, 155(4): 421-423.
34.	Stanzel A, Sierau S. Pediatric medical traumatic stress (PMTS) following surgery in childhood and adolescence: a systematic review. J Child Adolesc Trauma, 2021, 15(3): 795-809.
35.	Hildenbrand AK, Kassam-Adams N, Barakat LP, et al. Posttraumatic stress in children after injury: the role of acute pain and opioid medication use. Pediatr Emerg Care, 2020, 36(10): e549-e557.
36.	Jeon H, Bernstein LJ, Belkin DA, et al. Pulsed dye laser treatment of port-wine stains in infancy without the need for general anesthesia. JAMA Dermatol, 2019, 155(4): 435-441.
37.	Chun-Hua T, Li-Qiang G, Hua W, et al. Efficacy and safety of hemoporfin photodynamic therapy for port-wine stains in paediatric patients: a retrospective study of 439 cases at a single centre. Photodiagnosis Photodyn Ther, 2021, 36: 102568.
38.	Ning L, Jiang L, Zhang Q, et al. Effect of scalp nerve block with ropivacaine on postoperative pain in pediatric patients undergoing craniotomy: a randomized controlled trial. Front Med (Lausanne), 2022, 9: 952064.

1. Yu L, Qin K, Deng X, et al. Epidemiological study of capillary malformation among 7299 infants under 1 year of age in China. J Eur Acad Dermatol Venereol, 2022: 22.
2. Liu L, Li X, Zhao Q, et al. Pathogenesis of port-wine stains: directions for future therapies. Int J Mol Sci, 2022, 23(20): 12139.
3. Jiang F, Shao J, Chen L, et al. Influence of port-wine stains on quality of life of children and their parents. Acta Derm Venereol, 2021, 101(8): adv00516.
4. van Raath MI, Chohan S, Wolkerstorfer A, et al. Port wine stain treatment outcomes have not improved over the past three decades. J Eur Acad Dermatol Venereol, 2019, 33(7): 1369-1377.
5. Han Y, Ying H, Zhang X, et al. Retrospective study of photodynamic therapy for pulsed dye laser-resistant port-wine stains. J Dermatol, 2020, 47(4): 348-355.
6. Zhang LC, Yang J, Huang YB, et al. Efficacy of hemoporfin photodynamic therapy for pulsed dye laser-resistant facial port-wine stains in 107 children: a retrospective study. Indian J Dermatol Venereol Leprol, 2022, 88(2): 275.
7. Chaves YN, Torezan LA, Niwa AB, et al. Pain in photodynamic therapy: mechanism of action and management strategies. An Bras Dermatol, 2012, 87(4): 521-526, quiz 527-529.
8. Sandberg C, Stenquist B, Rosdahl I, et al. Important factors for pain during photodynamic therapy for actinic keratosis. Acta Derm Venereol, 2006, 86(5): 404-408.
9. Arits AH, van de Weert MM, Nelemans PJ, et al. Pain during topical photodynamic therapy: uncomfortable and unpredictable. J Eur Acad Dermatol Venereol, 2010, 24(12): 1452-1457.
10. Yu W, Wang T, Zhu J, et al. EMLA cream does not influence efficacy and pain reduction during pulsed-dye laser treatment of port-wine stain: a prospective side-by-side comparison. Lasers Med Sci, 2018, 33(3): 573-579.
11. Langan SM, Collins P. Randomized, double-blind, placebo-controlled prospective study of the efficacy of topical anaesthesia with a eutetic mixture of lignocaine 2.5% and prilocaine 2.5% for topical 5-aminolaevulinic acid-photodynamic therapy for extensive scalp actinic keratoses. Br J Dermatol, 2006, 154(1): 146-149.
12. Touma D, Yaar M, Whitehead S, et al. A trial of short incubation, broad-area photodynamic therapy for facial actinic keratoses and diffuse photodamage. Arch Dermatol, 2004, 140(1): 33-40.
13. Pagliaro J, Elliott T, Bulsara M, et al. Cold air analgesia in photodynamic therapy of basal cell carcinomas and Bowen’s disease: an effective addition to treatment: a pilot study. Dermatol Surg, 2004, 30(1): 63-66.
14. Charkoudian N. Mechanisms and modifiers of reflex induced cutaneous vasodilation and vasoconstriction in humans. J Appl Physiol (1985), 2010, 109(4): 1221-1228.
15. Leff DR, Nortley M, Dang V, et al. The effect of local cooling on pain perception during infiltration of local anaesthetic agents, a prospective randomised controlled trial. Anaesthesia, 2007, 62(7): 677-682.
16. Tyrrell J, Paterson C, Curnow A. Regression analysis of protoporphyrin IX measurements obtained during dermatological photodynamic therapy. Cancers (Basel), 2019, 11(1): 72.
17. Paoli J, Halldin C, Ericson MB, et al. Nerve blocks provide effective pain relief during topical photodynamic therapy for extensive facial actinic keratoses. Clin Exp Dermatol, 2008, 33(5): 559-564.
18. Halldin CB, Paoli J, Sandberg C, et al. Nerve blocks enable adequate pain relief during topical photodynamic therapy of field cancerization on the forehead and scalp. Br J Dermatol, 2009, 160(4): 795-800.
19. Klein A, Karrer S, Horner C, et al. Comparing cold-air analgesia, systemically administered analgesia and scalp nerve blocks for pain management during photodynamic therapy for actinic keratosis of the scalp presenting as field cancerization: a randomized controlled trial. Br J Dermatol, 2015, 173(1): 192-200.
20. Lavand’homme P. Rebound pain after regional anesthesia in the ambulatory patient. Curr Opin Anaesthesiol, 2018, 31(6): 679-684.
21. Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia, 2021, 76(Suppl 1): 100-109.
22. Sinha C, Kumar A, Kumari P, et al. Does radial or median nerve blocks affect the area and blood flow of radial artery?. Anaesth Crit Care Pain Med, 2021, 40(2): 100831.
23. Huang N, Zeng J, Liang J, et al. A randomized, double-blind, placebo-controlled study of oral oxycodone plus acetaminophen for the treatment of pain in photodynamic therapy on port wine stains. Photodiagnosis Photodyn Ther, 2014, 11(2): 134-140.
24. Chan CS, Chan MTV. Use of nitrous oxide in contemporary anesthesia-an ongoing tug of war. Can J Anaesth, 2021, 68(11): 1597-1600.
25. Brotzman EA, Sandoval LF, Crane J. Use of nitrous oxide in dermatology: a systematic review. Dermatol Surg, 2018, 44(5): 661-669.
26. Fink C, Uhlmann L, Enk A, et al. Pain management in photodynamic therapy using a nitrous oxide/oxygen mixture: a prospective, within-patient, controlled clinical trial. J Eur Acad Dermatol Venereol, 2017, 31(1): 70-74.
27. Paquier-Valette C, Wierzbicka-Hainaut E, Cante V, et al. Evaluation of hypnosis in pain management during photodynamic therapy: a pilot study. Ann Dermatol Venereol, 2014, 141(3): 181-185.
28. 许昉方. 音乐疗法对降低光动力治疗尖锐湿疣疼痛的影响. 微创医学, 2017, 12(5): 712-713.
29. Zhao Y, Tu P, Zhou G, et al. Hemoporfin photodynamic therapy for port-wine stain: a randomized controlled trial. PLoS One, 2016, 11(5): e0156219.
30. Troilius A, Wrangsjö B, Ljunggren B. Patients with port-wine stains and their psychosocial reactions after photothermolytic treatment. Dermatol Surg, 2000, 26(3): 190-196.
31. U.S. Food and Drug Administration. FDA drug safety communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children. (2017-05-09)[2022-11-10]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-label-changes-use-general-anesthetic-and-sedation-drugs.
32. Reighard C, Junaid S, Jackson WM, et al. Anesthetic exposure during childhood and neurodevelopmental outcomes: a systematic review and meta-analysis. JAMA Netw Open, 2022, 5(6): e2217427.
33. Mathes EF, Frieden IJ. Early use of laser for port-wine stains: timing, efficacy, and shared decision making. JAMA Dermatol, 2019, 155(4): 421-423.
34. Stanzel A, Sierau S. Pediatric medical traumatic stress (PMTS) following surgery in childhood and adolescence: a systematic review. J Child Adolesc Trauma, 2021, 15(3): 795-809.
35. Hildenbrand AK, Kassam-Adams N, Barakat LP, et al. Posttraumatic stress in children after injury: the role of acute pain and opioid medication use. Pediatr Emerg Care, 2020, 36(10): e549-e557.
36. Jeon H, Bernstein LJ, Belkin DA, et al. Pulsed dye laser treatment of port-wine stains in infancy without the need for general anesthesia. JAMA Dermatol, 2019, 155(4): 435-441.
37. Chun-Hua T, Li-Qiang G, Hua W, et al. Efficacy and safety of hemoporfin photodynamic therapy for port-wine stains in paediatric patients: a retrospective study of 439 cases at a single centre. Photodiagnosis Photodyn Ther, 2021, 36: 102568.
38. Ning L, Jiang L, Zhang Q, et al. Effect of scalp nerve block with ropivacaine on postoperative pain in pediatric patients undergoing craniotomy: a randomized controlled trial. Front Med (Lausanne), 2022, 9: 952064.

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