Case and Research Letter
Congenital Plaque-type Glomuvenous Malformation: 11 Years of Follow-up and Response to Treatment With the Combined Pulsed-Dye and Neodymium:Yttrium-Aluminum-Garnet Laser
Malformación glomovenosa congénita en placas: 11 años de seguimiento y respuesta al tratamiento con láser combinado PDL/Nd: YAG
N. Vargas-Navia
, E. Baselga, F.Z. Muñoz-Garza, L. Puig
Corresponding author
Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Vargas-Navia, E. Baselga, F.Z. Muñoz-Garza, L. Puig" "autores" => array:4 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Vargas-Navia" "email" => array:1 [ 0 => "navana2@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Baselga" ] 2 => array:2 [ "nombre" => "F.Z." "apellidos" => "Muñoz-Garza" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Puig" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Malformación glomovenosa congénita en placas: 11 años de seguimiento y respuesta al tratamiento con láser combinado PDL/Nd: YAG" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1802 "Ancho" => 1500 "Tamanyo" => 289708 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical course of the lesions. A, Newborn: erythematous-violaceous plaques on the back. B, At 6 months of age: plaques with prominent vessels, erythematous borders, and a blue-violaceous center. C, Before laser treatment (7 years of age). D, After 10 sessions of combined pulsed dye and neodymium-doped yttrium aluminium garnet laser treatment (11 years of age).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Glomuvenous malformations (GVM), previously known as glomangiomas, show a familial tendency and are characterized histologically by the presence of vascular channels surrounded by a variable number of glomus cells. There is a rare form that presents as plaques. The treatment of these lesions has still not been standardized.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a newborn boy from a twin pregnancy, born preterm at 34 weeks, with erythematous plaques present on his back since birth. There was no family history of similar lesions. On physical examination, nonpulsatile, depressed erythematous-violaceous plaques were observed on the boy's back (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). We performed skin biopsy to clarify our differential diagnosis of capillary malformation, multiple myofibromas, or subcutaneous fat necrosis. Histopathology showed an increased number of ectatic vessels in the dermis and was interpreted as a capillary malformation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">At 6 months, the plaques had acquired an annular pattern, with an erythematous halo, depressed blue-violaceous center, ectatic vessels, and flaccid skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><p id="par0020" class="elsevierStylePara elsevierViewall">A further biopsy, performed because of the lack of clinical-pathological correlation, revealed a dermis with vascular structures surrounded by several layers of monomorphic round cells with eosinophilic cytoplasm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Immunohistochemistry showed the perivascular glomus cells to be positive for vimentin and α-actin and negative for desmin and S100 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Based on these findings, we made a diagnosis of congenital plaque-type GVM.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Initially we took a wait-and-see approach. Over the following years, the plaques extended to the adjacent skin and took on a more atrophic appearance, with very dilated vessels. No new lesions appeared.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At 7 years of age, the lesions were still asymptomatic, but their appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) negatively affected the patient's self-esteem, leading us to evaluate the treatment options. The size of the lesions limited a possible surgical intervention. It was decided to start treatment with combined pulsed dye (PDL) (595<span class="elsevierStyleHsp" style=""></span>nm) and neodymium-doped yttrium aluminium garnet (Nd:YAG) (1064<span class="elsevierStyleHsp" style=""></span>nm) lasers (Cynergy Multiplex™, Cynosure, Westford, Massachusetts, United States), with a spot size of 10<span class="elsevierStyleHsp" style=""></span>mm, a PDL pulse duration of 0.5<span class="elsevierStyleHsp" style=""></span>ms and fluence of 8.5-9<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>, followed by a pulse of Nd:YAG with a duration of 15<span class="elsevierStyleHsp" style=""></span>ms and fluence of 50<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>. A cooling system was used simultaneously to prevent epidermal damage. The sessions were performed under general anesthesia every 2 or 3 months. The post-treatment recommendations included oral analgesia and photoprotection. At the time of writing, the patient has received 10 sessions of laser therapy, with lightening of the color of the lesions and a reduction in lesion volume and in the caliber of the vessels (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Treatment has been well tolerated and no complications have been detected.</p><p id="par0035" class="elsevierStylePara elsevierViewall">GVMs account for 5% of venous malformations (VM) and are distinct from sporadic VMs and from hereditary mucocutaneous VMs. A familial tendency is detected in 88%, with an autosomal dominant inheritance pattern and incomplete penetrance (90%). Their etiology has been related to mutations in the glomulin gene (<span class="elsevierStyleItalic">GLMN</span>).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> GVMs are usually multiple and tend to appear at an early age. They can present as papular-nodular lesions or as plaques, and may be congenital<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> or acquired.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Congenital plaque-type GVMs present clinically as bluish plaques with a cobblestone surface,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> or as atrophic plaques with telangiectasias,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4–9</span></a> as in our patient. A segmental distribution is often observed.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histology is characterized by a nonencapsulated proliferation of ectatic vascular channels surrounded by 1 or several layers of polygonal glomus cells. Immunohistochemistry is positive for α-smooth muscle actin and vimentin and negative for desmin.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The clinical course of plaque-type GVMs varies. Progressive thickening and darkening of the lesions has been reported, as well as a tendency to spread into adjacent unaffected areas,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> as was seen in our patient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The objectives of treatment of GVMs are to relieve pain and improve function and cosmetic appearance.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7,9</span></a> Surgery is an option for small localized lesions. Treatments such as sclerotherapy and ablative therapy have been used in multiple or extensive GVMs, but results have not been consistent.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> There are also descriptions of cases treated with Nd:YAG laser with good results,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and PDL lasers have been reported to be useful for the more superficial component of the lesions.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The dual laser (PDL/Nd:YAG) allows us to treat different depths of the skin using lower fluences and thus minimize the risk of scars or necrosis. There are 2 previous reports of congenital plaque-type GVM treated successfully with the combined PDL/Nd:YAG laser,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> using higher Nd:YAG fluences than those employed in our patient, with no complications (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, we have presented a case of congenital plaque-type GVM that, in its initial phases, was included in the series by Mallory et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> We draw attention to its uncommon clinical presentation, which was a diagnostic challenge and required histopathological confirmation, the atypical clinical course over 11 years, and the favorable response to combined laser treatment.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vargas-Navia N, Baselga E, Muñoz-Garza FZ, Puig L. Malformación glomovenosa congénita en placas: 11 años de seguimiento y respuesta al tratamiento con láser combinado PDL/Nd: YAG. Actas Dermosifiliogr. 2017;108:72–74.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1802 "Ancho" => 1500 "Tamanyo" => 289708 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical course of the lesions. A, Newborn: erythematous-violaceous plaques on the back. B, At 6 months of age: plaques with prominent vessels, erythematous borders, and a blue-violaceous center. C, Before laser treatment (7 years of age). D, After 10 sessions of combined pulsed dye and neodymium-doped yttrium aluminium garnet laser treatment (11 years of age).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 558 "Ancho" => 1500 "Tamanyo" => 191373 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology. A, Blood vessels of different calibers surrounded by several layers of monomorphic round cells. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×20). B, Positivity for α-smooth muscle actin. Immunohistochemistry, original magnification<span class="elsevierStyleHsp" style=""></span>×20.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age and Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site Affected \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fluence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pulse Duration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spot Size \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Sessions \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up Period \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Response \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 y<br>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDL 8<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span><br>Ns:YAG 70<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDL: 0.5<span class="elsevierStyleHsp" style=""></span>ms<br>Ns:YAG: 15<span class="elsevierStyleHsp" style=""></span>ms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><br>10<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution of the pain, lightening of color and volume reduction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 mo<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scalp, trunk, abdomen, back, right inguinal region and thighs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDL: 6<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span><br>Ns:YAG: 110<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDL: 0.5<span class="elsevierStyleHsp" style=""></span>ms<br>Ns:YAG: 20<span class="elsevierStyleHsp" style=""></span>ms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lightening of color and size reduction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Our patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 y<br>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Back \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDL: 8.5<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">9</span><br>Ns:YAG: 50<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">9</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDL: 0.5<span class="elsevierStyleHsp" style=""></span>ms<br>Ns:YAG: 15<span class="elsevierStyleHsp" style=""></span>ms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lightening of color and reduction of volume and of vessel caliber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1302824.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients With Congenital Plaque-Type Glomuvenous Malformations Treated With Combined Pulsed Dye and Neodymium-Doped Yttrium Aluminium Garnet Laser.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Glomuvenous malformation (glomangioma) and venous malformation: Distinct clinicopathologic and genetic entities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 20 | 8 | 28 |
| 2024 October | 97 | 41 | 138 |
| 2024 September | 96 | 21 | 117 |
| 2024 August | 116 | 53 | 169 |
| 2024 July | 99 | 34 | 133 |
| 2024 June | 104 | 31 | 135 |
| 2024 May | 114 | 23 | 137 |
| 2024 April | 104 | 23 | 127 |
| 2024 March | 108 | 27 | 135 |
| 2024 February | 86 | 25 | 111 |
| 2024 January | 88 | 32 | 120 |
| 2023 December | 100 | 30 | 130 |
| 2023 November | 110 | 25 | 135 |
| 2023 October | 83 | 33 | 116 |
| 2023 September | 70 | 33 | 103 |
| 2023 August | 58 | 21 | 79 |
| 2023 July | 54 | 48 | 102 |
| 2023 June | 58 | 30 | 88 |
| 2023 May | 69 | 23 | 92 |
| 2023 April | 50 | 25 | 75 |
| 2023 March | 75 | 29 | 104 |
| 2023 February | 61 | 31 | 92 |
| 2023 January | 50 | 38 | 88 |
| 2022 December | 95 | 34 | 129 |
| 2022 November | 55 | 32 | 87 |
| 2022 October | 93 | 22 | 115 |
| 2022 September | 40 | 31 | 71 |
| 2022 August | 70 | 35 | 105 |
| 2022 July | 64 | 28 | 92 |
| 2022 June | 32 | 24 | 56 |
| 2022 May | 36 | 27 | 63 |
| 2022 April | 53 | 36 | 89 |
| 2022 March | 58 | 42 | 100 |
| 2022 February | 56 | 38 | 94 |
| 2022 January | 56 | 37 | 93 |
| 2021 December | 40 | 33 | 73 |
| 2021 November | 54 | 53 | 107 |
| 2021 October | 54 | 47 | 101 |
| 2021 September | 43 | 33 | 76 |
| 2021 August | 47 | 33 | 80 |
| 2021 July | 64 | 35 | 99 |
| 2021 June | 53 | 38 | 91 |
| 2021 May | 47 | 56 | 103 |
| 2021 April | 116 | 46 | 162 |
| 2021 March | 70 | 39 | 109 |
| 2021 February | 62 | 37 | 99 |
| 2021 January | 54 | 40 | 94 |
| 2020 December | 51 | 33 | 84 |
| 2020 November | 41 | 22 | 63 |
| 2020 October | 32 | 13 | 45 |
| 2020 September | 43 | 27 | 70 |
| 2020 August | 30 | 23 | 53 |
| 2020 July | 40 | 28 | 68 |
| 2020 June | 40 | 27 | 67 |
| 2020 May | 23 | 11 | 34 |
| 2020 April | 26 | 13 | 39 |
| 2020 March | 26 | 11 | 37 |
| 2020 February | 8 | 0 | 8 |
| 2020 January | 1 | 0 | 1 |
| 2019 December | 5 | 0 | 5 |
| 2019 September | 6 | 0 | 6 |
| 2019 June | 9 | 0 | 9 |
| 2019 May | 2 | 0 | 2 |
| 2019 April | 10 | 7 | 17 |
| 2019 March | 1 | 0 | 1 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 7 | 0 | 7 |
| 2018 December | 12 | 0 | 12 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 6 | 0 | 6 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 22 | 5 | 27 |
| 2018 January | 30 | 3 | 33 |
| 2017 December | 43 | 6 | 49 |
| 2017 November | 24 | 7 | 31 |
| 2017 October | 27 | 9 | 36 |
| 2017 September | 24 | 6 | 30 |
| 2017 August | 33 | 7 | 40 |
| 2017 July | 24 | 6 | 30 |
| 2017 June | 47 | 22 | 69 |
| 2017 May | 27 | 14 | 41 |
| 2017 April | 27 | 14 | 41 |
| 2017 March | 32 | 17 | 49 |
| 2017 February | 53 | 36 | 89 |
| 2017 January | 47 | 28 | 75 |
| 2016 December | 5 | 20 | 25 |
| 2016 November | 0 | 1 | 1 |
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