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Chapter
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13
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
1064-nm Nd:YAG laser at 1- to 20-ms pulses through a 3-mm
diameter spot at 130 to 160 J/cm2 in the treatment of TM
vessels less than 0.3 mm in diameter that did not respond to
sclerotherapy.40 Two to three passes were needed to close the
vessels with each laser. Overall, 39% of vessels treated with
the 532-nm laser and 55% of those treated with the 1064-nm
laser had better than 50% lightening.
In short, the 532-nm, long-pulsed, cutaneous, chilled
Nd:YAG laser is effective in treating leg telangiectasia. As summarized previously, efficacy is technique dependent, with
excellent results achievable. Patients need to be informed of
the possibility of prolonged pigmentation at an incidence
similar to that with sclerotherapy, as well as temporary blistering and hypopigmentation that is predominantly caused by
epidermal damage in pigmented skin (type III or above, especially when tanned).
Copper bromide 578 nm
Forty-six women with red leg telangiectasias less than 1.5 mm
in diameter were treated with 1 minute of precooling to the
skin followed by laser pulses at 50 to 55 J/cm2 through a
1.5-mm diameter spot size generated with a 300-ms pulse,
with a 75-ms delay between pulses.
were given at 6-week intervals. An average of 1.7 treatments
produced greater than 75% improvement in 72% of patients.
Treatments were given through a circulating cooling window
at 1 to 4°C. Problems with this new technology are the long
warm-up time of the laser (15–20 minutes) and the long time
required to treat the vessels with a 1.5-mm diameter spot size.
41
Up to three treatments
Figure 13.9 Vessel 1 hour after treatment with flashlamp-pumped pulsed
dye laser alone at 8 J/cm2. Endothelium is vacuolated. (Hematoxylin–eosin,
original magnification ×200.)
Flashlamp-pulsed dye laser, 585 or 595 nm
The PDL has been demonstrated to be highly effective in treating cutaneous vascular lesions consisting of very small vessels,
including PWSs, hemangiomas, and facial telangiectasia.
depth of vascular damage is estimated to be 1.5 mm at 585 nm
and 15 to 20 µm deeper at 595 nm. Therefore, penetration to
the typical depth of superficial leg telangiectasia may be
achieved.
has not responded as well, with less lightening and more posttherapy hyperpigmentation.
diameter of leg telangiectasia as compared with dermal vessels
in PWS and larger diameter feeding reticular veins, as described
previously.
predicted to be red telangiectasia less than 0.2 mm in diameter, particularly those vessels arising as post-sclerotherapy
TM. This is based on the time of thermocoagulation produced
by this relatively short pulse laser system (see Table 13.2). The
PDL produces vascular injury in a histologic pattern that is
different than that produced by sclerotherapy. In the rabbit
ear vein, approximately 50% of vessels treated with an effective concentration of sclerosant demonstrated extravasated
RBCs, whereas with PDL treatment, extravasated RBCs were
apparent in only 30% of vessels treated (unpublished observations). Thus, the PDL may produce less post-therapy pigmentation because of a decreased incidence of extravasated RBCs
(Figs 13.9–13.13).
related either to angiogenesis
subclinical blood vessels by promoting collateral flow through
arteriovenous anastomoses.
nisms may occur. Obstruction of outflow from a vessel
(which is the end result of successful sclerotherapy) is one of
the most important factors contributing to angiogenesis.
addition, endothelial damage leads to the release of histamine
and other mast cell factors and vasokines, which promote
both the dilatation of existing blood vessels and angiogenesis.
344
43
However, telangiectasia over the lower extremities
44
This may be due to the larger
Vessels that should respond optimally to PDL treatment are
The etiology of TM is unknown but has been thought to be
48,49
Sclerotherapy by its mechanism of endothelial
45
or to a dilatation of existing
46
One or both of these mecha-
42
47
The
In
Figure 13.10 Vessel 1 hour after treatment with flashlamp-pumped pulsed
dye laser alone at 9.5 J/cm2. There is focal endothelial necrosis with
adherence of platelets to damaged endothelium. (Hematoxylin–eosin,
original magnification ×400.)
23:23, 1990, with permission from American Academy of Dermatology.)
Figure 13.11 Vessel 1 hour after treatment with flashlamp-pumped pulsed
dye laser alone at 10 J/cm2. Perivascular heat denaturization of collagen is
apparent. There is also extensive homogenization of red blood cells with
intravascular fibrin deposition. (Hematoxylin–eosin, original magnification
×200.)
(Reprinted from Goldman MP et al: J Am Acad Dermatol 23:23, 1990, with
permission from American Academy of Dermatology.)
(Reprinted from Goldman MP et al: J Am Acad Dermatol
destruction provides the means for new blood vessel formation to occur. Indeed, it is remarkable that physicians do not
see a higher incidence of post-treatment TM associated with
sclerotherapy.
TM has not been reported to be a side effect of argon, PDL,
or other laser treatment of any other vascular disorders. This
may be due to the production of intravascular fibrin that
occurs during laser treatment.
50–52
Fibrin develops through
Figure 13.12 Vessel 2 days after treatment with flashlamp-pumped pulsed
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dye laser alone at 9.5 J/cm2. Focal endothelial necrosis and thrombus
formation are present along with margination of white blood cells.
(Hematoxylin–eosin, original magnification ×200.)
et
al: J Am Acad Dermatol 23:23, 1990, with permission from American Academy of
Dermatology.)
Figure 13.13 Vessel shown 10 days after treatment with flashlamp-
pumped pulsed dye laser alone at 10 J/cm2. Advanced endosclerosis is
present within organizing thrombosis. (Hematoxylin–eosin, original
magnification ×200.)
1990, with permission from American Academy of Dermatology.)
(Reprinted from Goldman MP et al: J Am Acad Dermatol 23:23,
(Reprinted from Goldman MP
thermal alteration of fibrin complexes or proteolytic cleavage
of fibrinogen. Fibrin deposition has been demonstrated to
promote angiogenesis.
48
Sclerotherapy-induced vascular injury
has not been associated with the appearance of fibrin strands
(unpublished observations). This is explained by limitation of
angiogenesis by factors other than those associated with the
absence of fibrin deposition, or by intravascular consumption
of fibrin-promoting factors in laser treatment of cutaneous
vascular disease.
Another possible mechanism for absence of TM in lasertreated blood vessels is a decrease in perivascular inflammation. Rabbit ear vein treatment with the PDL relatively
decreases perivascular inflammation compared with vessels
treated with sclerotherapy alone.
with inflammation have been demonstrated to promote both
a dilatation of existing blood vessels and angiogenesis.
52
Multiple factors associated
49
The pulse duration of the first generation of PDL was 450 µ
seconds, optimal for the 50- to 100-µm diameter of PWS
vessels. This pulse duration is most effective for treating leg
telangiectasias that are less than 1 mm in diameter. Unfortunately, many studies failed to demonstrate satisfactory efficacy
with the PDL at these parameters. We believe this is a result
of failure to recognize the importance of high-pressure vascular flow from feeding reticular and varicose veins and treatment of these before treating the distal telangiectasia.
Polla et al44 treated 35 superficial leg telangiectasias with
the PDL. The exact laser parameters were not given, except that
Figure 13.14 Temporary hypopigmentation, lasting for 6 months in this
32-year-old woman with type III tan skin treated on the anterior thigh with
the flashlamp-pumped pulsed dye laser at 7.5 J/cm2.
vessels were treated an average of 2.1 times with a maximum
of four separate treatments. These vessels were described as
being either red–purple and raised, or blue and flat. No
mention was made regarding the association of reticular or
varicose veins or vessel diameter. Fifteen percent of treated
vessels had greater than 75% clearing, with 73% of treated
areas showing little response to treatment. The only lesions
that responded at all were red–pink tiny telangiectasia. Almost
50% of the treated patients developed persistent hypopigmentation or hyperpigmentation.
Goldman and Fitzpatrick
53
treated 30 female patients with
red leg telangiectasias of less than 0.2 mm in diameter. Thirteen of 101 telangiectatic patches were noted to have an associated reticular ‘feeding’ vein between 2 and 3 mm in diameter
that was not treated. Seven patients with 25 patches of TM
after previous sclerotherapy were also treated.
PDL 5-mm diameter spots were overlapped slightly with
every effort made to treat the entire vessel. After treatment, a
chemical ice pack (Kwik Kold, American Pharmaseal Co.,
Valencia, Calif.) was applied to the treated area until the laserinduced sensation of heat resolved (5–15 minutes). Thirtynine telangiectatic patches, chosen randomly, were treated
with laser energies between 7.0 and 8.0 J/cm2 and compressed
with a rubber ‘E’ compression pad (STD Vascular Products Ltd,
Bristol, England) fixed in place with Microfoam 100-mm tape
(3 M Medical-Surgical Division, St Paul, Minn.). A 30- to
40-mmHg graduated compression stocking was then worn
over this dressing continuously for approximately 72 hours.
As hypothesized, TM and persistent pigmentation did not
occur with PDL treatment of leg telangiectasia. Post-PDL
hyperpigmentation completely resolved within 4 months.
There were no episodes of cutaneous ulceration, thrombophlebitis, or other complications. However, hypopigmentation occurred in some patients with tanned skin (Fig. 13.14).
The laser impact sites usually remained hypopigmented for
years and in many cases were thought to be permanent. With
PDL treatment, the most effective fluence appears to be
between 7.0 and 8.0 J/cm2. With these parameters, approximately 67% of telangiectatic patches completely faded within
4 months (Figs 13.15–13.18).
Laser Treatment of Leg Telangiectasia
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Chapter
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13
A
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
C
Figure 13.15 Photographic record of false resolution of flashlamp-pumped pulsed dye laser (PDL)-treated leg veins. A, Treatment site at medial distal thigh
with parameters of experimental treatment marked. B, Immediately after PDL treatment; note extent of purpura. C, Same treatment site immediately before
marking the skin with laser parameters (taken at different F-stop exposure). Note ‘false’ clearing of vessels.
There appears to be no difference in the response to PDL
treatment between linear leg telangiectasias and TM vessels.
In the seven patients with 25 sites treated (mentioned earlier
in this section), 72% of the treated sites completely faded at
laser fluences between 6.5 and 7.5 J/cm2. Matted vessels did
not respond to treatment in only one patient with four areas
of TM. Less than 100% resolution occurred in 16% of treated
areas (Fig. 13.19).
Like TM vessels, essential telangiectasia represents a network
of fine red telangiectasia usually less than 0.2 mm in diameter.
This condition responds well to the PDL at fluences of 7 to
7.25 J/cm2.54 Treatment, however, is tedious, with more than
2000 5-mm diameter pulses sometimes necessary to cover the
entire affected area.
The reason for greater efficacy of treatment in Goldman
and Fitzpatrick’s report in comparison with others
due to the rigid criteria by which patients were selected for
treatment. Patients who responded well to treatment had red
telangiectasia less than 0.2 mm in diameter without associated ‘feeding’ reticular veins.
Many physicians have found that vessel location may affect
treatment outcome, with vessels on the medial thigh being the
most difficult to completely eradicate. However, with the PDL,
vessel location appears to be unrelated to treatment outcome
if telangiectatic patches with untreated associated reticular
veins are excluded. In addition, there appears to be no obvious
difference in efficacy between telangiectatic patches that are
treated with compression and those that are not (Fig. 13.20).
Sadick et al56 conducted a study which further supported the
notion that graduated compression stocking use for 7 days
starting immediately after treatment of class I-II venulectasia
with PDL yielded no additional therapeutic efficacy.
346
44,55
may be
B
In conclusion, laser treatment of leg veins is most efficacious if all vessels larger than 0.2 mm in diameter, especially varicose and reticular feeding veins, are treated first
with sclerotherapy or another modality. Results are not
affected by vessel location. Post-treatment compression
appears unnecessary. Combination treatment appears to offer
no advantage to sclerotherapy alone and appears to have a
significant degree of complications when treatment is limited
to red telangiectasia less than 0.2 mm in diameter. For treatment of larger vessels, increasing the pulse duration, the wavelength, and the fluence with epidermal cooling through either
a contact or dynamic cooling system allows increased
efficacy.
Long-pulse flashlamp-pumped pulsed
dye laser
In an effort to thermocoagulate larger diameter blood vessels,
a second generation of PDLs with a longer pulse duration,
lengthened to 1.5 to 40 ms, and longer wavelength, increased
to 595 to 600 nm, was released in 19966 (see Table 13.1). This
theoretically permits more thorough heating of a larger vessel
at a greater depth. Specifically, this new-generation PDL is able
to treat vessels 1 mm in width and 1 mm in depth.57One study
using a 595-nm PDL at 1.5 ms found more than 50% clearance of leg veins at a fluence of 15 J/cm2 and approximately
65% clearance using a fluence of 18 J/cm2.58 In this limited
study of 18 patients, vessels ranging in diameter from 0.6 to
1 mm were treated with an elliptical spot size of 2 mm ×
7 mm through a transparent hydrogel-based wound dressing.
No adverse sequelae were noted at the 5-month follow-up
visit (Fig. 13.21).
A
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B
Laser Treatment of Leg Telangiectasia
C
E
Figure 13.16 Photographic follow-up of telangiectatic patch on the medial thigh treated with the flashlamp-pumped pulsed dye laser at 7.5 J/cm2, 15
pulses. A, Immediately before treatment. B, Immediately after treatment. C, 2 days after treatment. Note some nonspecific vesiculation of the skin. D, Vessel
shown 11 days after treatment. Note some hypopigmentation and fading of the telangiectasia; purpura is no longer present. E, 11 months after treatment,
showing complete vessel elimination without pigmentary or textural skin changes.
Another study evaluated the use of the 595-nm long-pulse
PDL on 35 sites of lower extremity spider veins in 15 sub-
59
jects.
This new laser utilized 8 pulselets spread over the
selected pulse duration, up to 40 ms. Treatments were administered three times, at 6-week intervals, using a 3- × 10-mm
spot size, an average fluence of 20.4 J/cm2, and a dynamic
cooling device. At 8 weeks following the final treatment, clearance rates ranged from 65% to 75% when measured by the
treating physician, and approximately 40% to 50% when
assessed by blinded observers. Thus, results were strengthened
by the fact that not only did the treating physician determine
subject improvement scores but also an additional three separate physicians, who were blinded as to which photographs
D
were pre- or post-treatment, assessed improvement in each
case as well. Of note, one subject developed severe posttreatment hyperpigmentation, which persisted long enough to
delay subsequent treatment by 6 weeks. At 8 weeks following
the final treatment, 9 of 28 sites receiving three treatments
showed residual hyperpigmentation as assessed by the treating physician; blinded observers using digital photographic
assessment noted a 25% incidence of hyperpigmenation at
this same time point. From our experience, it is highly likely
that this hyperpigmentation would continue to resolve completely over the ensuing weeks to months.
Lee and Lask
60
treated 25 women with leg telangiectasias
less than 1 mm in diameter with the long-pulse PDL (LPDL)
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13
A C
Figure 13.17 Photographic follow-up of telangiectatic flare on the lateral thigh treated with flashlamp-pumped pulsed dye laser at 7 J/cm2, 125 pulses.
A, Immediately before treatment. B, Immediately after treatment; note the characteristic, localized urticarial response. C, 6 weeks after treatment; note slight
hyperpigmentation and total resolution of telangiectasia. Pigmentation resolved over the subsequent 2 to 4 weeks.
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
A
Figure 13.18 Photographic follow-up of extensive pedal telangiectasia treated on two occasions with the flashlamp-pumped pulsed dye laser at 7.25 J/cm2,
84 pulses and 115 pulses. A, Before treatment. B, 6 months after initial treatment; 3 months after second treatment.
B
B
(Courtesy of Richard Fitzpatrick, MD)
(Sclerolaser, Candela Corp., Wayland, Mass.). Each patient
had four areas treated; two at a wavelength of 595 nm with
fluences of 15 or 20 J/cm2, with two additional areas treated
with a 600-nm wavelength at 15 or 20 J/cm2, respectively. A
maximum of three treatments were performed at 6-week intervals. All patients had improvement. The 595-nm wavelength
at 20 J/cm2 gave the best results. Treatment response was variable and unpredictable, with some patients having complete
resolution and some having only slight improvement. Three
patients had superficial scabbing that resolved without apparent scarring. Most patients experienced purpura and hyperpigmentation that resolved after several weeks. Reasons for the
variable efficacy were not reported.
West and Alster
with a 590- or 595-nm pulse at 15 J/cm2. An average improvement of 75% occurred in their patients. Hyperpigmentation
persisted at the 12-week follow-up period in 71% of patients.
Bernstein et al61 demonstrated similar results in their study
of 10 women with skin type I and II and having leg telangi-
348
30
treated 12 patients with leg telangiectasia
ectasias less than 1.5 mm in diameter treated with a 1.5-ms,
595-nm LPDL at fluences of 15 and 20 J/cm2 three times at
each site at 6-week intervals. Patients were treated through a
hydrogel dressing that resulted in a 9% energy loss. Computerbased image analysis demonstrated at least 50% clearing in
80% of treated areas. Twenty percent of treated sites had hypopigmentation, and 40% had hyperpigmentation 6 weeks after
the final treatment.
Reichert
57
performed the largest study on the use of the
LPDL by evaluating 80 patients with more than 250 treatment
sites of telangiectasia not associated with feeding reticular
veins. Treatment parameters were a 1.5-ms pulse at 16 to 22 J/
cm2 with a 2 mm × 7 mm or a 7-mm diameter spot at a
590-nm wavelength for red telangiectasias than 0.5 mm in
diameter and a 595- to 600-nm wavelength for larger vessels.
Ice cooling of the skin was performed both before and after
treatment. A hydrogel was used during treatment and was
cooled to 8°C when fluences exceeded 20 J/cm2. A clearance
rate of almost 100% was achieved at the 4- to 6-month
A
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C D
Figure 13.19 Telangiectatic matting 9 months after sclerotherapy treatment of leg telangiectasia on the medial thigh. A, Immediately before treatment.
B, Immediately after patch tests were performed with the flashlamp-pumped pulsed dye laser (PDL), 9 pulses to each site. C, 2 months after patch test
treatment; note complete vessel resolution in areas treated at laser parameters of 7.25 and 7.5 J/cm2. Only partial resolution occurred at 7.0 J/cm2. Some
hyperpigmentation is noted. D,
matting without pigmentary or textural skin changes.
1 year after treatment of the entire area with LPDL at 7.25 J/cm2, 46 pulses; note complete resolution of prior telangiectatic
B
Laser Treatment of Leg Telangiectasia
A
C
B
Figure 13.20 Telangiectatic patches with a feeding reticular vein 2 mm in
diameter on the lateral thigh. A, Immediately before treatment. B, Immediately
after treatment with the flashlamp-pumped pulsed dye laser, 20 pulses to each
patch: 7.25 J/cm2, superior patch; 7.5 J/cm2, medial patch; 7.75 J/cm2, inferior
patch. C, 9 months after treatment. Note only partial resolution of the treated
areas with persistence of the untreated reticular vein.
MD)
(Courtesy of Richard Fitzpatrick,
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13
A
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
C
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
B
D
E
Figure 13.21 Treatment of leg telangiectasia with the long-pulse flashlamp-pumped pulsed dye laser. A, Before treatment. B, Immediately after treatment
at 595 nm, 25 J/cm2. C, 8 weeks after treatment. D, 8 weeks after second treatment at identical parameters. E, 6 months after second treatment. (Courtesy of CS
Burton III, MD; from Goldman MP, Weiss RA, Bergan JJ, editors: Varicose veins and telangiectasia: diagnosis and treatment, St Louis, 1999, Quality Medical Publishers.)
follow-up time after one to two treatments in 95% of vessels
up to 0.5 mm in diameter. Eighty percent of telangiectasias
0.5 to 1 mm in diameter faded in about 80% of sites after four
treatments. Hyperpigmentation was present for ‘months’ in
40% of treated sites, with 10% having hypopigmentation.
‘Frequent epidermal sloughing followed by crusting and
gradual re-epithelization over 2 to 3 weeks’ was reported when
high fluences were used. Although this study had poor statistical and evaluation analysis, it does indicate that with optimal
technique, specific types of leg telangiectasia will respond to
the LPDL.
Hohenleutner et al62 treated 87 patients with telangiectasias that were less than 1 mm in diameter with the LPDL using
either ice cube or gel cooling. They did not treat feeding reticular veins when they were of ‘no hemodynamic significance’.
Vessels greater than 1 mm in diameter did not respond to
treatment parameters and were excluded from study. They
found that cooled Vigilon gel decreases fluence by 35% in
addition to decreasing skin temperature by 5°C for 1 minute.
Ice cube cooling produced a 15°C decrease in skin temperature for 1 minute. With ice cube cooling, greater than 95%
350
clearance occurred in 20% of patients with veins that were less
than 0.5 mm in diameter, and no veins between 0.5 and
1 mm in diameter treated at 600 nm with 18 J/cm2 achieved
greater than 95% clearing. A 50% to 95% clearance occurred
in 82% of veins that were less than 0.5 mm in diameter and
in 50% of veins between 0.5 and 1 mm in diameter at a
fluence of 20 J/cm2. Hyperpigmentation and/or hypopigmentation occurred in 32% of treated areas and resolved within 6
months. When fluence was increased to 20 J/cm2, hyperpigmentation occurred in 48% of treated areas. Thus, cooling
with ice cubes enhances clinical efficacy of this laser; multiple
treatments may enhance efficacy even further. This has led to
the development of the dynamic cooling LPDL discussed
below.
Ultralong pulse PDLs have been developed with pulse
widths of 2 to 40 ms at a wavelength of 595 nm (Cynosure,
Chelmsford, Mass. and Candela, Wayland, Mass.). The 2- to
40-ms pulse durations are created by using two separate laser
beams each emitting a 2.4-ms pulse. These lasers operate at
595 nm with an adjustable pulse duration from 0.5 to 40 ms
delivered through a 5-, 7-, or 10-mm diameter spot size or a
3- × 10-mm or 5- × 8-mm elliptical spot. Dynamic cooling
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with a cryogen spray is also available, with the cooling spray
adjustable from 0 to 100 ms, given 10 to 40 ms after the laser
pulse, or as continuous 4°C air-cooling at a variable speed. A
fluence of 10 to 25 J/cm2 can be delivered through a 3- ×
10-mm or a 5- × 8-mm elliptical spot.
Twenty-seven women with leg telangiectasias that were less
than 1 mm in diameter were evaluated in one clinical study.
Each patient had three areas treated. There was no difference
in vessel response between a 4-ms 16-J/cm
2
cm
pulse, and a 1.5-ms 14- or 16-J/cm2 pulse. Little or no
2
pulse, a 4-ms 20-J/
improvement was seen in 50% and 33% of patients, respectively, after one treatment. Hyperpigmentation lasting about
12 weeks was seen in 40% to 67% of treated veins. Hypopigmentation lasting about 12 weeks occurred in 20% to 27% of
63
veins.
It is unclear why this specific study proved much less
effective than previous studies on similar telangiectasia. The
authors of this study were particularly objective in their treatment evaluation, with subtle improvements being less noticeable in photographic analysis by independent evaluators.
64
Polla
evaluated the Candela LPDL on 40 patients with leg
veins 0.05 to 1.5 mm in diameter. He used a 6- or 20-ms pulse
with a 7- or 10-mm diameter spot at 10 to 13 J/cm2 and 6 to
7 J/cm2, respectively, with a dynamic cooling device (DCD)
setting of 30 ms, 10 ms delay. One to seven treatments were
performed at 3-week intervals. Optimal results were obtained
after two sessions, with 8% having total clearance and 67%
having clearance above 40%. All patients had purpura for 7
to 10 days; 33% had pigmentation for less than 2 months and
15% for over 2 months.
Weiss and Weiss
65
had similar results using the Cynosure
LPDL on 20 patients with sclerotherapy-resistant TM. They
performed a single treatment with a 20-ms pulse and a 7-mm
diameter spot at 7 J/cm2 for a total of three stacked pulses with
simultaneous cold air cooling. Eighteen of 20 patients had at
least 50% improvement at 3 months post-treatment. Purpura
occurred in only 25% of patients and lasted 10 days.
A longer pulse duration of 40 ms was used on 10 patients
with leg telangiectasia up to 1 mm in diameter at 595 nm with
DCD cooling at 25 J/cm2.66 Six patients had 50% to 75%
improvement and 2 of 10 had hyperpigmentation which
lasted over 3 months.
Finally, a study using the DCD LPDL was performed on 14
Asian patients with 38 leg veins, distinguishing between veins
less than 0.2 mm in diameter, 0.2 to 1 mm in diameter, and
1 to 2 mm in diameter.67 Vessels less than 0.2 mm in diameter
were treated twice at 8-week intervals with 1.5- or 3-ms pulses
through a 3- ×
10-mm elliptical spot at 4 to 25 J/cm2. These
vessels demonstrated total resolution. Vessels between 0.2 and
1 mm in diameter were treated with a pulse duration of 3 to
10 ms, with 91% having greater than 75% improvement.
Vessels between 1 and 2 mm in diameter were treated with a
pulse duration of 10 to 20 ms, with 55% of veins having better
than 50% clearing. All treatments were performed with DCD.
Mild hyperpigmentation was present in nearly 50% of treated
areas at 3-month follow-up.
Our experience is similar to that reported above. We utilize
the LPDL at pulse durations matching the thermal relaxation
time of the leg veins as detailed by Kono et al.67 The energy
fluence used is just enough to produce vessel purpura and/or
spasm. Like Weiss and Weiss,
65
we use stacked pulses to
achieve this clinical endpoint. We have used both LPDL
systems and find them comparable. Because of the necessity
for multiple treatments and the significant occurrence of longlasting hyperpigmentation, like Weiss and Weiss
65
and Kono
et al,67 we reserve the use of the LPDL for sclerotherapyresistant, red telangiectasias that are less than 0.2 mm in
diameter.
Long-pulse alexandrite (755 nm)
A long-pulse alexandrite laser was developed to treat hair. It
soon became apparent that the wavelength, fluence, and pulse
duration could also be used for telangiectasia (see Table 13.1).
The 755-nm wavelength should penetrate 2 to 3 mm beneath
the epidermis. This laser has been reported to be effective in
thermocoagulating blood vessels in clinical and histologic
studies.
treated three times every 4 weeks at fluences ranging from 15
to 30 J/cm2 found that a single-pulse technique with 20 J/cm2,
5-ms pulse duration yielded the best resolution when combined with sclerotherapy using 23.4% hypertonic saline (HS)
(Fig. 13.22). When this technique was used without epidermal
cooling with a chill tip at 4°C, focal crusting and scabbing was
noted. With laser treatment alone, telangiectasias smaller than
0.2 mm in diameter improved by 23%, vessels between 0.4
and 1 mm improved by 48%, and telangiectasias of 1 to
3 mm improved by 32%.
veins measuring 0.3 to 2 mm in diameter with a single treatment of a 3-ms alexandrite laser at 60 to 80 J/cm2 through an
8-mm diameter spot with dynamic epidermal cooling. Multiple passes were given until vessel clearance (averaging 1.9
passes). At 12-week follow-up, 65% of 51 treated areas showed
greater than 75% clearance. Hyperpigmentation was observed
in 35% of treated areas.
with a 3-ms pulse through a 3- × 10-mm spot size and dynamic
68,69,70
One study of leg telangiectasia in 28 patients
69
Kauvar and Lou71 treated 20 women with 54 patches of leg
An additional study using an alexandrite laser at 90 J/cm2
Laser Treatment of Leg Telangiectasia
A
Figure 13.22 Treatment of leg telangiectasia with the long-pulse alexandrite laser. A, Before treatment. B, 7 weeks after treatment. Note the post-
inflammatory hyperpigmentation remaining at treatment sites. This likely cleared over the ensuing weeks to months.
Weiss RA, Bergan JJ, editors: Varicose veins and telangiectasia: diagnosis and treatment, St Louis, 1999, Quality Medical Publishers.)
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
B
(Courtesy McDaniel DH, MD; from Goldman MP,
351
Chapter
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13
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
352
cooling with an 80-ms cryogen spray was performed on leg
telangiectasia 0.3 to 1.3 mm in diameter.72 The pain of treatment ranged from mild to severe. Almost all treated areas had
purpura, edema, and erythema. Most vessels showed clearance
of 50% to 75%, with hyperpigmentation in 15 of 20 subjects
at 12 weeks. The authors speculated that the high pigmentation rate, three times that of Kauvar and Lou’s study,
71
was due
to the increased fluence used.
Ross et al73 set out to determine the optimal fluence and
pulse width for the treatment of leg telangiectasias with the
long pulse 755 nm alexandrite laser. Fifteen patients with leg
telangiectasias ranging in diameter from 0.2 to 1.0 mm were
treated with pulse durations ranging from 3 to 100 milliseconds. For each pulse duration, test spots were performed to
determine optimal radiant exposures which ellicited persistent
bluing and/or immediate stenosis as clinical endpoints. The
optimal settings for each patient were then used to treat larger
areas of similar-sized vessels. Follow-up evaluations were performed 12 weeks after the treatment. Overall, the optimal
pulse duration was 60 ms for most patients, with a clearance
of approximately 65% after the single treatment session. Furthermore, the average radiant exposure necessary for vessel
closure was 89 J/cm2. Using these optimal long pulse alexandrite settings not only achieved satisfactory vessel clearance
but also resulted in minimal side effects. A study by Eremia
et al,74 comparing the alexandrite laser to the 810-nm diode
laser and the 1064-nm Nd:YAG laser in the treatment of leg
telangiectasia 0.3 to 3 mm in diameter on 30 women, did not
show as promising results as those previously mentioned.
These authors found that the 3- ×
10-mm spot size was difficult to use and the study was performed with an 8-mm
diameter spot with 60 to 70 J/cm2, a 3-ms pulse, and an 80–
100-ms cryogen spray after an 80-ms delay. With the alexandrite laser, greater than 75% improvement occurred in only
33% of sites and greater than 50% improvement in 58% of
sites after two treatments. Ten of 22 patients developed TM,
pain was a significant problem, and almost all patients demonstrated marked post-treatment inflammation for 1 to 2
weeks. The 1064-nm Nd:YAG and 810-nm diode lasers were
better tolerated, having little to no adverse effects, with greater
than 75% improvement occurring in 88% of the Nd:YAGtreated veins and 29% of the diode-treated veins. The 1064-nm
Nd:YAG was used with a 6-mm diameter spot size, 150 J/cm2,
with a 25-ms pulse duration for small vessels and a 100-ms
pulse for larger vessels, with a 30-ms post-contact cryogen spray.
The bottom line is that the alexandrite laser is more painful,
no more effective, and probably produces more adverse effects
than other lasers at the parameters stated by the abovementioned studies.
Diode lasers
Multiple diode-pumped lasers are now available, including a
532-nm, an 800-nm, and an 810-nm (gallium-arsenide) laser
(see Table 13.1). Diode lasers generate coherent monochromatic light through excitation of small diodes. These devices
are therefore lightweight and portable, with a relatively small
desktop footprint. Dierickx et al75 evaluated an 800-nm diode
laser (LightSheer, Lumenis, Santa Clara, Calif.) on eight areas
of leg veins. The laser was used at 15 to 40 J/cm2 given in 5- to
30-ms pulses as double or triple pulses separated by a delay
of 2 seconds. Veins were treated every 4 weeks for three sessions and evaluated 2 months after the last treatment. Optimal
parameters were 30-ms pulses at 40 J/cm2. At these parameters, vessels 0.4 to 1 mm in diameter showed 100% clearing
in 22%, 75% clearing in 42%, and 50% clearing in 32%.
Trelles et al76 evaluated both the subjective as well as the
objective efficacy of an 800-nm diode laser for leg vein clearance in 10 women of various ages and skin types. Investigators
used a sequence of five to eight stacked pulses with a pulse
duration of 50 ms, a delay of 50 ms, and a 3-mm spot size.
Treatments were administered at 2 month intervals until complete clearance occurred, and final efficacy was assessed 6
months following each patient’s final treatment. To reach
complete clearance, 50% of patients needed three treatment
sessions and the remaining 50% needed less than three.
Although treated leg veins varied from 1 to 4 mm in diameter,
the best results were ultimately seen in those vessels that had
initially measured 3 to 4 mm. Treatment of vessels located on
the thigh as well as those in patients with Fitzpatrick skin type
III also yielded superior efficacy. Of note, no correlation was
found between patient age and efficacy of treatment.
Garden et al77 used an 810-nm diode laser with a 750-µm
spot size at 40 W and 50-ms pulses for a total of 453 J/cm2 of
fluence delivered. Twelve patients with 58 vessels 0.2 to
0.5 mm in diameter were treated with three to four passes
until vessel spasm occurred. Patients were retreated every 2 to
4 weeks. There was a mean clearance of 60% after 2.2 treatments. Eighteen vessels had greater than 70% clearance after
three treatments. When a scanner was incorporated into the
diode laser so that 15- to 20-mm-long passes could be given,
efficacy increased. In 11 patients treated with the scanner
diode in two sessions 2 to 4 weeks apart, 18% of vessels had
75% to 90% clearance, 21% had 50% to 75% clearance, 18%
had 25% to 50% clearance, and 36% had up to 25%
clearance.
In another study, 35 patients with spider leg veins were
treated with an 810-nm diode laser with a 12-mm diameter
spot, 60-ms pulse duration and 80 to 100 J/cm2 with a cooled
handpiece.
78
Fifteen of the 35 patients had complete disappearance of the spider veins. Six months after the second laser
treatment, 12 patients with partial or no response had dropped
out of the study and 7 patients had had a relapse in their leg
veins, with an additional patient having a relapse at 1-year
follow-up. Two of the 35 patients had scarring. EMLA cream
was applied to treatment sites 1 hour prior to the procedure
to limit perioperative pain.
A 940-nm diode laser has also been used in the treatment
of blue leg telangiectasias less than 1 mm in diameter without
Doppler evidence of refluxing feeding veins.79 Twenty-six
patients were treated with 300 to 350 J/cm2 with a 40 to 70-ms
pulse and 1-mm diameter spot, with a clearance of greater
than 50% in 20 patients and greater than 75% in 12 patients.
Slight textural changes were seen in five patients and pigmentation taking several months to resolve in four patients. No
cooling was provided except for ice packs after treatment. In
a follow-up of these patients 1 year later, 75% of patients had
greater than 75% clearance.
80
These outstanding long-term results were not seen in a
separate study using the same laser but with a variety of pulse
durations (10–100 ms) and fluences (200–1000 J/cm2)
through a 0.5-mm diameter spot for vessels less than 0.4 mm
in diameter, a 1-mm diameter spot for vessels 0.4 to 0.8 mm
in diameter, and a 1.5-mm diameter spot for vessels 0.8 to
1.4 mm in diameter.81 Fluences were adapted to have complete vessel clearance without epidermal blanching. No
cooling device was used and patients were evaluated at 1 year.
The largest diameter vessels had the highest clearance rates,
with only 13% of vessels that were less than 0.4 mm in diameter clearing by more than 75% as opposed to 88% of vessels
that were 0.8 to 1.4 mm in diameter. Laser therapy was more
painful than sclerotherapy in 31 of 46 patients, with equal
efficacy noted by the patients who had had both forms of
treatment.
Finally, a combination diode laser with radiofrequency
(RF) delivered at levels up to 100 J/cm3 has been used to treat
leg telangiectasia. Chess
82
treated 25 patients with 35 leg veins
0.3 to 5 mm in diameter with a 915-nm diode laser at fluences
ranging between 60 and 80 J/cm2 as well as RF energy at 100 J/
cm3 through a 5- × 8-mm elliptical spot size, with 5°C contact
cooling, in up to three sessions every 4 to10 weeks. He found
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77% of treated sites exhibited greater than 75% improvement
at 6 months. The average discomfort rating was 7 out of 10.
Three sites on three different patients developed eschar formation without permanent scarring. In another study, leg telangiectasia 1 to 4 mm in diameter was treated with 60 to 80 J/
cm2 fluence and 100 J/cm3 RF energy through a 5- × 8-mm
elliptical spot size with 5°C contact cooling in three separate
sessions at 2- to 4-week intervals.
83
Overall, 75% of vessels
had greater than 50% improvement and 30% had greater than
75% improvement at 2-month follow-up. Almost no complications were noted to occur. Another study evaluated the efficacy of a combined 900-nm diode laser with a bipolar RF
device in the treatment of 1 to 4 mm leg veins in 40 patients
with skin types II-IV.84 At the beginning of the study, each
patient was examined to ensure the saphenous vein and its
collaterals were competent, without perforating or reticular
vessels. Treatments were administered at 2 week intervals, for
a maximum of three treatments. The diode laser reached an
average fluence of 60 J/cm2 and had a 250 ms exposure time.
Radiofrequency energy was delivered at 100 J/cm3, with 5°C
contact cooling. The majority of patients required one or two
treatment sessions. Clinical photography coupled with computer generated data minimized subjectivity in follow-up
improvement assessments. During 6-month post-treatment
assessments, 82.5% of subjects achieved over a 50% clearance
in target vessels. Interestingly, treatments on thicker vessels
(>
2 mm) and those performed on patients of darker skin types
showed the greatest efficacy. However, even in those patients
with lighter, Type II, skin, a vessel clearance rate of greater than
50% was seen in 66%. The post-treatment telangiectatic
matting that developed in less than 10% of patients had completely or almost completely resolved in each by the 6-month
assessment. Overall, very few side effects were noted.
Finally, a more recent study evaluated the dermal histologic
and immunohistochemical changes induced by exposure of
leg telangiectasias to either a combination 915-nm diode laser
and RF device or to a 1064-nm Nd:YAG laser.
85
Three patients
with 0.1 to 2.0-mm telangiectasias each had one leg treated
with the combination diode and RF device, and the opposite
leg treated with the Nd:YAG laser. Punch biopsies from treated
areas were taken 7 days after laser/RF exposure. Tissue from
each treatment type showed intermediate-sized vessels with
complete thrombosis and hemorrhage within the dermis as
well as the subcutis; focal full-thickeness necrosis was seen in
the overlying epidermis. In a single treatment session of both
the combination diode and RF device as well as the Nd:YAG,
each yielded an average of 50% to 75% clinical clearing. Thus,
when comparing results from both treatment modalities, the
similar degree of improvement in the clinical appearance of
the telangiectasias was supported by histologic examination
of tissue specimens.
In summary, although relatively efficacious in the treatment of leg telangiectasia, diode laser use is limited by treatment pain and adverse effects. Of note is that when feeding
reticular veins are not treated, distal treated telangiectasias
tend to recur at 6 to 12 months post-treatment. Some authors
appear to be able to achieve better results than others using
similar parameters. Though most apparent in target vessels
larger than 1 to 2 mm in diameter, the addition of RF to the
diode appears to yield vessel clearance at lower diode fluences
than would be necessary to achieve the same results if the
diode was used alone.
Fiber-guided laser coagulation
Trelles et al reported another method for treating leg veins
with fiberoptic transmission of argon or tunable dye laser into
the vessel (International Society of Cosmetic Laser Surgeons,
Palm Desert, Calif., February 1993). With this technique, a
vessel is cannulated with a 0.840-mm hypodermic needle, and
a 200-mm optical fiber is passed through the needle into the
vein. Two to four pulses of laser light (514, 570, 585, and
620 nm) are delivered with a pulse duration of 100 to 300 ms
at 1.5 to 5 W. The pulse duration and energy are adjusted
to coagulate the vessel. Because of nonspecific thermal
heating related to long pulse durations, the skin is cooled with
ethyl chloride. Out of 175 patients, 111 were satisfied with
treatment. However, 9 of the 175 developing a depressed or
pigmented scar, and this technique is tedious as well as timeconsuming to perform.
A stronger endoluminal laser has been used to treat larger
diameter veins, including the great saphenous vein (GSV).
Bone Salat
86
treated 44 patients, 38 with incompetent GSVs,
with endoluminal laser thermocoagulation. The fiber is
inserted through either a phlebectomy or a percutaneous
approach into the GSV. The first laser used in this treatment
was the 810-nm LaserLite A100 diode laser (Diomed, Andover,
Mass.) with energy emission powers of 0.5 to 30 W. Using an
optical fiber of 300 to 600 µm in diameter, the practitioner
used 5 to 10 W with 3- to 4-second pulses to thermocoagulate
the vessel. Vessels ranged from 7 to 22.5 mm in diameter.
Treated limbs were then compressed with bandages or graduated compression stockings and evaluated at 1 and 2 weeks
and at 3 to 6 months with duplex. No adverse effects were
reported. All but one patient had resolution of reflux.
High-Intensity Pulsed Light
The high-intensity pulsed light (IPL) source was developed as
an alternative to lasers to maximize efficacy in treating leg
veins (PhotoDerm VL, ESC/Sharplan now Lumenis, Santa
Clara, Calif.). This device permits sequential rapid pulsing,
longer duration pulses, and penetrating longer wavelengths
compared with other laser systems (Fig. 13.23).
Theoretically, a phototherapy device that produces a noncoherent light as a continuous spectrum longer than 550 nm
should have multiple advantages over a single-wavelength
laser system. First, both oxygenated and deoxygenated hemoglobin absorb at these wavelengths. Second, blood vessels
located deeper in the dermis are affected. Third, thermal
absorption by the exposed blood vessels should occur
with less overlying epidermal absorption, since the longer
wavelengths penetrate deeper and are absorbed less by the
epidermis, including melanin (Fig. 13.24).
Depth of thermal penetration
vs pulse width
External light on the skin
Heated
area
Depth of
heat penetration
during the time delays
between pulses
Figure 13.23 Diagram of the effect of repetitive pulses of the PhotoDerm
light source on a 2-mm vessel 1 mm below the epidermis. (Courtesy Shimon
Eckhouse, PhD, Energy Systems Corporation, Inc, Newton, Mass.)
High-Intensity Pulsed Light
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