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Chapter
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13
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
354
A
B
Figure 13.24 Appearance of venule 1 mm in diameter stained with
hematoxylin–eosin 48 hours after treatment with the PhotoDerm VL at 26 J/
cm2, delivered in a double pulse 6 and 15 ms long separated by 50 ms.
A, Note size and depth of vessel, which appears collapsed from biopsy
and processing artifacts but devoid of blood; original magnification ×50.
B, Same vessel as in A. Note intravascular margination of mast cell and
lymphocytes with partial destruction of endothelium and vessel wall;
original magnification ×200.
With the theoretical considerations just mentioned, IPL
emitting in the 515- to 1000-nm range was used at varying
energy fluences (5–90 J/cm2) and various pulse durations
(2–25 ms) to treat venectasias 0.4 to 2.0 mm in diameter. This
IPL allows treatment through a quartz crystal of 8 mm ×
35 mm or 8 mm × 15 mm (up to 2.8 cm2) that can be
decreased in size to match the clinical area of treatment. Clinical trials using various parameters with the IPL, including
multiple pulses of variable duration, demonstrated efficacy
ranging from over 90% to total clearance in vessels less than
0.2 mm in diameter, 80% in vessels 0.2 to 0.5 mm in diameter, and 80% in vessels 0.5 to 1 mm in diameter.
87–89
The
incidence of adverse sequelae was minimal, with hypopigmentation occurring in 1% to 3% of patients, but resolving
within 4 to 6 months. Tanned or darkly pigmented Fitzpatrick
type III patients were likely to develop hypopigmentation and
hyperpigmentation in addition to blistering and superficial
erosions. However, these all cleared over a few months. Treat-
ment parameters found to be most successful for vessels less
than 0.2 mm in diameter ranged from a single pulse of 22 J/
cm2 in 3 ms to a double pulse of 35 to 40 J/cm2 given in 2.4
and 4.0 ms with a 10-ms delay. Vessels between 0.2 and
0.5 mm were treated with the same double-pulse parameters
or with a 3.0- to 6.0-ms pulse at 35 to 45 J/cm2 with a 20-ms
delay time. Vessels above 0.5 mm were treated with triple
pulses of 3.5, 3.1, and 2.6 ms with pulse delays of 20 ms at a
fluence of 50 J/cm2 or with triple pulses of 3, 4, and 6 ms with
a pulse delay of 30 ms at a fluence of 55 to 60 J/cm2. The
choice of a cut-off filter was based on skin color, with lightskinned patients using a 550-nm filter and darker-skinned
patients using a 570- or 590-nm filter (Figs 13.25 and 13.26).
Weiss and Weiss
90
have reported increased efficacy by
increasing the pulse durations to a maximum of 10 ms as two
consecutive pulses separated by a 20-ms delay with a 570-nm
cut-off filter and fluences of 70 J/cm2. They have achieved
response rates of 74% with two-treatment sessions, with an
8% incidence of temporary hypopigmentation or hyperpigmentation. By combining a shorter pulse (2.4–3 ms) with a
longer pulse (7–10 ms), it is theoretically possible to ablate
smaller and larger vessels overlying one another in the dermis
(Fig. 13.27).
In a European multicenter study, 40 women with leg
telangi ectasias up to 1 mm in diameter were treated with
various parameters.87 For vessels less than 0.2 mm in diameter,
a 3-ms pulse of 22 J/cm2 was used. A double pulse of 2.4 ms
each, separated by 20 ms, with 35 J/cm2 was given for vessels
0.2 mm to 0.5 mm in diameter. A triple pulse of 3.5, 3.1, and
2.6 ms was used with delays of 20 ms and a fluence of 50 J/
cm2 for vessels 0.5 mm to 1 mm in diameter. A clearance rate
of 92% occurred in vessels less than 0.2 mm in diameter,
80% clearing in vessels less than 0.5 mm in diameter, and
81% clearing in vessels less than 1 mm in diameter. Vessels
did not recur in the 1-year follow-up period. Eleven patients
had temporary hyperpigmentation. One patient had temporary hypopigmentation, and two patients had a nonscarring
blister.
Schroeter and Neumann
91
have reported a similar success
rate in treating 40 patients with leg telangiectasia. They used
a single pulse of 3 to 4 ms with a 550-nm cut-off filter between
22 and 28 J/cm2 for veins less than 0.2 mm in diameter. A
570-nm cut-off filter was used with a double-pulse technique
of 2.4 ms each with a 10- to 20-ms delay between pulses at
24 to 30 J/cm2 for vessels between 0.2 and 2 mm in diameter.
With these parameters they achieved over 80% clearance that
was maximal at 1-month follow-up. Even with these parameters, which are more conservative than those used by Weiss
or Goldman, hyperpigmentation was seen in 20 of the 40
patients, with two of 40 having blistering and three of 40
having hypopigmentation.
Although most authors have reported satisfactory results
with IPL in treating leg telangiectasia, this opinion is not
universal. Green
92
has not seen effective results when he used
the IPL and attributes this to having a different objectivity
in evaluating his patients compared with those authors
previously discussed. He reported low clearance rates with
unacceptable side effects.
93
Treatment of essential telangiectasia, especially on the legs,
is efficiently accomplished with the IPL (see Figs 13.25–13.27).
A variety of parameters have been shown to be effective. We
recommend testing a few different parameters during the first
treatment session and using the most efficient and least
painful parameter on subsequent treatments. One study of 14
patients, one of whom had leg telangiectasia, found that a
single pulse of 30 J/cm2 delivered through a 550-nm cut-off
filter in 5 ms was 100% effective.94 Many other parameters,
such as those in Figure 13.12, are also very effective.
One of the most rewarding conditions to treat is essential
telangiectasia. This condition, described previously, responds
A
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C
Figure 13.25 A, Clinical appearance of a 0.6-mm-diameter vessel on the distal calf before treatment. B, Immediately after treatment with the PhotoDerm
VL with a 590-nm cut-off filter, 41 J/cm2 given as a double pulse of 6.5 and 15 ms with a 10-ms delay time. C, 10 weeks after treatment, with complete
resolution.
disease, St Louis, 1996, Mosby.)
(From: Goldman MP: Laser and noncoherent pulsed light treatment of leg telangiectasia and venules. In Goldman MP, Bergan JJ, editors: Ambulatory treatment of venous
B
Figure 13.26 A, Ankle telangiectasia before
treatment. B, 6 weeks after a single treatment
with the PhotoDerm VL at 40 J/cm2 given as a
double pulse of 2.4- and 4.0-ms duration with a
10-ms delay.
Cutaneous laser surgery: the art and science of selective
photothermolysis, 2nd edn, St Louis, 1998, Mosby.)
(From Goldman MP, Fitzpatrick RE:
High-Intensity Pulsed Light
A
well to PDL, but this can be time consuming and expensive.
With IPL, large areas of involvement can be treated quickly
and effectively with many different parameters
The use of IPL to treat leg veins has produced some encouraging results, but these are far from being easily reproduced.
This technology requires significant experience and surgical
ability to produce good results. Various parameters must be
B
94
(Fig. 13.28).
matched both to the patient’s skin type as well as diameter,
color, and depth of leg vein. With older machines that do not
have integrated cooling through sapphire crystals, a cold gel
must be placed between the IPL crystal and skin surface to
provide optimal elimination of epidermal heat. Many have
likened using the IPL to playing a violin. A 2- to 3-year-old
child playing a violin will make a squeaky noise, but, with
355
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13
Rights were not granted to include this figure
in electronic media.
Please refer to the printed publication.
A C
Figure 13.27 Tanned, skin type III, 63-year-old female with isolated telangiectasias without associated varicosities. Previous attempt with sclerotherapy
yielded no improvement. A, Before treatment. B, 10 minutes after treatment with intense pulsed light. Parameters were a double pulse of 2.4 and 7 ms with
a 10-ms delay using a 570-nm filter, at 44 J/cm2. C, Resolution 2 months after second treatment. (From Goldman MP, Weiss RA, Bergan JJ, editors: Varicose veins and
telangiectasia: diagnosis and treatment, St Louis, 1999, Quality Medical Publishers.)
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
A
B
Rights were not granted to include this figure
B
in electronic media.
Please refer to the printed publication.
C
Figure 13.28 A, Female patient, 55 years old, with large varicose veins on medial aspect of right leg along with telangiectasia at ankle. Varicose veins
originated from reflux at midthigh (Hunterian) perforator eliminated by duplex-guided sclerotherapy. After resolution of the varicose veins, the remaining
ankle telangiectasia was treated with intense pulsed light. Parameters were 5-ms pulse duration, 35 J/cm2, single pulse, 550-nm filter. B, Just after second
treatment. C, Near complete resolution 2 months after second treatment.
treatment, St Louis, 1999, Quality Medical Publishers.)
356
(From Goldman MP, Weiss RA, Bergan JJ, editors: Varicose veins and telangiectasia: diagnosis and
practice, by the time the child is 7 or 8, he or she will make
Absorption (log scale)
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beautiful music. Regarding the IPL, it is the art of medicine
that assumes an equal importance to its science.
Fortunately, for those who do not play musical instruments, there are now dozens of IPLs available from many
different manufacturers (see Table 13.1).
ND:YAG Laser, 1064 nm
532 Nd:YAG
Alexandrite
PDL
Diode
Nd:YAG
The Nd:YAG laser, 1064 nm, is probably the most effective
laser available to treat leg telangiectasia and was first used for
this purpose in 1987.
human skin is 0.75 mm, and reduction to 10% of the incident
power occurs at a depth of 3.7 mm.95 A narrow therapeutic
fluence range, which reduces both its efficacy and safety, is
associated with the 1,064-nm Nd:YAG laser.
range may be largely attributed to the formation of methemoglobin (metHb), an oxidized form of hemoglobin that appears
during laser-induced blood vessel heating.
metHb shows a significantly stronger absorption than either
hemoglobin or oxyhemoglobin. Theoretically, this metHb
formation effect is less pronounced at 755 nm.
Apfelberg et al18 treated leg telangiectasia with the Nd:YAG
laser equipped with a 1.5-mm sapphire contact probe. Treatment complications included linear hypopigmentation and
depressions overlying the skin of the treated vessel. Retreatment was needed at 6-week intervals. In addition, the cost
is high because the disposable sapphire tips are expensive.
The Nd:YAG Q-switched laser modified with filters to treat
vessels at 532, 585, 650, and 1064 nm 7 days after sclerotherapy treatment was reported by Cisneros et al.97 With a
standard Q-switched Nd:YAG laser, disk-shaped colorant
cartridges are inserted into the distal laser arm to produce
emitted wavelength of 585 and 660 nm with the cartridges
lasting about 50,000 pulses before needing replacement. Fifty
percent of the power is lost as the light passes through the
cartridges with the laser being used at 2 Hz, 4 to 12 J/cm2 with
a 1- to 4-mm diameter pulse. The sclerotherapy solution used
was polidocanol (POL) 0.5%.
The 585-nm wavelength was used on the smallest vessels,
532-nm on reticular veins, 1064-nm on deeper blue vessels,
and 650-nm and/or 532-nm wavelengths on post-treatment
hyperpigmentation. With this technique 54 patients were
treated. Two treatment sessions were required to improve 49
patients. Three treatments were required to completely eliminate vessels in 25% of the male patients and 29% of female
patients. Ten percent of men and women had small persistent
telangiectasia remaining after three treatments. Thirty percent
of patients had hyperpigmentation that resolved with treatment. Careful evaluation of this technique fails to disclose the
benefit of using a Nd:YAG laser with sclerotherapy. The
authors did not separate benefits of the two treatments from
each other and, in reality, as described in Chapter 12, sclerotherapy treatment alone was probably responsible for treatment efficacy. Careful review of the photographs indeed shows
linear hypopigmentation over treated areas. This experience
with different laser wavelengths and pulse durations directed
at different color and sized blood vessels has been termed the
‘bimodal or dual wavelength’ approach to treating leg veins.
In an effort to deliver laser energy to the depths of leg veins
(often 1–2 mm beneath the epidermis) with thermocoagulation of vessels 1 to 3 mm in diameter, 1064-nm lasers with
pulse durations of between 1 and 250 ms have been developed. However, because of the poor absorption of Hb and
HbO
with a 1064-nm wavelength, higher fluences must be
2
used. Depending on the amount of energy delivered, the epidermis must be protected to minimize damage to pigment
cells and keratinocytes. Three mechanisms are available to
minimize epidermal damage through heat absorption. First,
18
The average depth of penetration in
70
This narrow
96
At 1064-nm,
Melanin
Oxyhemoglobin
Water
300 1000
Figure 13.29 Oxyhemoglobin, water, and melanin absorption curves as a
function of wavelength. (Adapted from Boulnois JL: Lasers Med Sci 1:47, 1986.)
500 700 2000
Wavelength (nm)
the longer the wavelength, the less energy will be absorbed by
melanocytes or melanosomes (Fig. 13.29). This will allow
darker skin types to be treated with minimum risks to the
epidermis caused by a decrease in melanin interaction. Second,
delivering the energy with a delay in pulses greater than the
thermal relaxation time for the epidermis (1–2 ms) allows the
epidermis to cool conductively between pulses. This cooling
effect is enhanced by the application of cold gel on the skin
surface, which conducts away epidermal heat more efficiently
than air. Finally, the epidermis can be cooled directly to allow
the photons to pass through without generating sufficient heat
to cause damaging effects.
Epidermal cooling can be given in many different ways. The
simplest method is continuous contact cooling with chilled
water, which can be circulated in glass, sapphire, or plastic
housings. The laser impulse is given through the transparent
housing, which should be constructed to ensure that the
laser’s effective fluence is not diminished. The benefit of continuous contact cooling is its simplicity. The disadvantage is
that the cooling effect continues throughout the time that the
device-crystal is in contact on the skin. This results in a vari-
98,99
able degree and depth of cooling determined by the length of
time the cold housing is in contact with the skin. This nonselective and variable depth and temperature of cooling may
necessitate additional treatment energy so that the cooled
vessel will heat up sufficiently to thermocoagulate (Fig. 13.30).
Another method of cooling is contact precooling. In this
approach, the cooling device contacts the epidermis adjacent
to the laser aperture. The epidermis is precooled and then
treated as the handpiece glides along the treatment area.
Because the cooling surface is not in the beam path, no optical
window is required and better thermal contact can be made
ND:YAG Laser, 1064 nm
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13
A
C D
Figure 13.30 Cool laser optics (CLO) device. A, Appearance of device. B, Open unit being filled with ice water. Half-moon-shaped plastic forms to make
ice blocks for lateral compartments of the unit. C, CLO unit attached with Velcro straps to the patient’s left thigh over telangiectasia. D, Close-up of
telangiectasia viewed through the CLO unit before treatment.
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
B
(Courtesy of Cyrus Chess, MD)
A
Figure 13.31 Thermal quenching through the application of dynamic cooling. A, Laser pulse penetrates through the epidermis and dermis to be absorbed
by the vascular target. B, After absorption by the blood vessel, a pulse of cooling selectively protects the epidermis and quenches the heat rising from the
thermocoagulated vessel.
(Courtesy of New Star lasers)
between the cooling device and the epidermis. The drawback
is the nonreproducibility of cooling levels and degrees that are
based on the speed and pressure at which the surgeon uses
the contact cooling device.
Yet another method for cooling the skin is to deliver a cold
spray of refrigerant to the skin that is timed to precool the skin
before laser penetration and also to postcool the skin to minimize thermal back-scattering from the laser-generated heat in
the target vessel. The authors have termed this latter effect
‘thermal quenching’ (Fig. 13.31). This method reproducibly
protects the epidermis and superficial nerve endings. In
addition, it acts to decrease the perception of thermal-laser
epidermal pain by providing another sensation (cold) to the
sensory nerves. Finally, it allows an efficient use of laser energy
because of the relative selectivity of the cooling spray that can
be limited to the epidermis. The millisecond control of the
cryogen spray prevents cooling of the deeper vascular targets
and is given in varying amounts so that epidermal absorption
of heat is counteracted by exposure to cryogen.
Since the target vessel poorly absorbs 1064-nm wavelength
(see Fig. 13.29), a much higher fluence is necessary to cause
358
B
thermocoagulation. Whereas a fluence of 10 to 20 J/cm2 is
sufficient to thermocoagulate blood vessels when delivered at
532 nm or 585 nm, a fluence of 70 to 150 J/cm2 is required
to generate sufficient heat absorption at 1064 nm. Various
1064-nm lasers are currently available that meet the criteria
for selectively thermocoagulating blood vessels, such as
Lumenis One and Vasculite (Lumenis, Santa Clara, Calif.),
Varia (CoolTouch Corp., Roseville, Calif.), Lyra (Laserscope,
San Jose, Calif.), GentleYAG (Candela, Wayland, Mass.),
SmartEpil II (Cynosure, Chelmsford, Mass.), Harmony (Orion
Lasers, Fla.), Profile (Sciton, Palo Alto, Calif.), Mydon (WaveLight, Erlangen, Germany), and CoolGlide (Cutera, Burlingame, Calif.) (see Table 13.1). All long-pulse 1064-nm
Nd:YAG lasers are not the same. Variables include the spot size,
laser output in both fluence as well as how the extended time
of the laser pulse is generated, pulse duration, and epidermal
cooling. In addition, although many claims are made by
the laser manufacturers, few well-controlled peer-reviewed
medical studies are available. Because of the variability
between the 1064-nm Nd:YAG lasers, a review of the clinical
studies with each system will be presented separately.
Vasculite
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The Vasculite was the first long-pulsed, 1064-nm laser to be
approved by the Food and Drug Administration (FDA) for
vascular treatment. The Nd:YAG 1064-nm laser is pulsed with
IPL technology. Individual pulses up to 16 ms in length can
be delivered as single, double, or triple synchronized pulses
with a total maximum fluence of 150 J/cm2. The laser beam
is generated in the handpiece and delivered through a sapphire crystal 6, 9, or 3 ×
Weiss,
100,101
Sadick,
102
and Goldman
results in treating leg telangiectasias from 0.1 to 3 mm in
diameter. Application of a cool gel to the skin (cooling of the
crystal is unnecessary with the most advanced version, Lumenis
1, which is thermokinetically cooled to 4°C) and synchronization of the pulses, allows epidermal cooling and protection.
In addition, synchronized timing between pulses can be tailored to thermal relaxation times of blood vessels.
Weiss and Weiss
101
satisfied with previous leg vein treatments with either sclerotherapy or other laser lights or IPLs. A single 14- to 16-ms
pulse at 110 to 130 J/cm2 was given to treat vessels 1 to 3 mm
in diameter. A double pulse of 7 ms separated by 20 to 30 ms
at a fluence of 90 to 120 J/cm2 was used to treat vessels 0.6 to
1 mm in diameter. A triple synchronized pulse of 3 to 4 ms
at a fluence of 80 to 110 J/cm2 was used to treat vessels 0.3 to
0.6 mm in diameter. Immediate contraction of the vessel was
used as an endpoint of treatment followed by urtication.
Immediate bruising from vessel rupture occurred in 50% of
vessels. At 3 months after treatment the majority of sites had
improved by over 75% (Fig. 13.32). Hyperpigmentation was
noted in 28% of patients at the 3-month follow-up period. In
short, this report demonstrated successful treatment on otherwise difficult vessels and mirrors the authors’ experience.
Weiss and Weiss
104
also reported on 3-year results in the treatment of leg telangiectasias 0.3 to 3 mm in diameter at slightly
higher fluences of 110 to 150 J/cm2. They found an average of
75% improvement in 2.38 treatments. Sixteen percent of
patients developed pigmentation which resolved at 6 months
and 4% developed TM.
Sadick
105
reported on 12-month follow-up in 25 patients
with leg veins, with a fluence of 120 J/cm2 given through a
6-mm diameter spot in a 7-ms double pulse to vessels 0.2 to
2 mm in diameter and as a single pulse of 14 ms and a fluence
of 130 J/cm2 to vessels 2 to 4 mm in diameter. Using these
parameters, 64% of patients could achieve 75% or greater
clearance in three treatments. Two of the 25 treated patients
who had less than 25% vessel clearance developed a recurrence of the veins within 6 to 12 months. Sixteen percent of
patients developed pigmentation which lasted 4 months and
8% developed TM.
Slightly higher fluences were used by Trelles et al
ing 40 patients with leg veins up to 4 mm in diameter: 130 J/
cm2 given as a double pulse of 7 ms and 140 J/cm2 given as a
6 mm in diameter. Weiss and
103
have reported excellent
treated 30 patients who had been dis-
106
in treat-
14-ms triple pulse was used on vessels less than 2 mm and 2
to 4 mm in diameter, respectively. They used a computerized
objective assessment tool to determine efficacy. The percent
improvement was not noted, only that 80% of patients were
satisfied with treatment.
CoolTouch varia
The CoolTouch Varia combines a multiple train of pulses to
generate a pulse width from 10- to 300-ms bursts. Fluences of
up to 150 J/cm2 can be generated. A 3- to 10-mm diameter
beam is delivered through a fiberoptic cable. Dynamic cooling
is given with a cryogen spray that can be delivered before,
during, and/or after the laser pulse. The cooling spray can be
varied from 5 to 200 ms and can be given in 5- to 30-ms bursts
in 5-ms intervals before and/or after the laser pulse. In this
manner, in the treatment of larger or deeper vessels, the postcooling quenching cryogen spray can be given 20 to 30 ms
after the laser pulse to coincide with conduction of heat
absorbed by the vessel propagating back to the epidermis.
More superficial and smaller vessels require a shorter delay in
the postlaser cooling spray of 5 ms. The authors have found
this laser to be therapeutically beneficial in treating leg telangiectasias 0.1 to 2 mm in diameter (Fig. 13.33). A comparative
study of two long-pulsed 1064-nm Nd:YAG lasers was performed on 11 patients with leg telangiectasia without (or with
previously treated) feeding reticular veins. The CoolTouch
Varia was used with a 6-mm diameter spot size at a fluence of
135 J/cm2 with a 25-ms pulse and precooling of 5 ms, with
post cooling of 15 ms. The CoolGlide laser was used with a
5-mm diameter spot, 25-ms pulse at 200 J/cm2 and contact
cooling. Both lasers produced comparable clearing of 75% in
all treated vessels. However, the CoolGlide laser was significantly more painful.
Two papers were published on the same 23 of 30 leg vein
patients (completing the study) treated with the CoolTouch
108,109
Varia.
Greater than 75% improvement was noted at 85%
of treated sites. Transient pigmentation was noted in 6 of 23
patients, with TM in 1 of 23 patients. Fluences of 150 J/cm2
were used for all diameter veins with a 25-ms pulse duration
on veins less than 1.5 mm in diameter and 50 to 100 ms on
veins 1.5 to 3 mm in diameter. Patients received up to two
treatments 4 to 6 weeks apart. One to three passes were
required to blanch the targeted vessels. Laser spot diameters
and the time of pre- and/or postcooling was not noted in
either of the two papers. Patients who had previously had
treatment with non-HS sclerotherapy preferred sclerotherapy
over laser because of increased pain with laser.
A direct comparison of the CoolTouch Varia with sclerotherapy utilizing sodium tetradecyl sulfate (STS) was performed on 20 patients with size-matched superficial leg
telangiectasia 0.5 to 1.5 mm in diameter.
were given through a 5.5-mm diameter spot at 125–150 J/cm2
with a 25-ms pulse duration. Precooling ranged from 0 to
107
110
Laser treatments
ND:YAG Laser, 1064 nm
A
Figure 13.32 Treatment of leg telangiectasia with the Vasculight at parameters specified. A, Before treatment; B, 60 days after treatment. (Courtesy of Robert
Weiss, MD)
B
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13
A
Figure 13.33 A, After sclerotherapy an ulceration occurred that is covered with an occlusive dressing. B, After treatment of a foot telangiectasia with the
CoolTouch Varia at 150 J/cm2 with a 50-ms pulse and 5 ms of precooling 10 ms before the laser pulse, followed by a 10-ms cooling burst 10 ms after the
laser pulse. Note complete clearing 60 days after treatment.
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
A
Figure 13.34 A, Appearance of dilated reticular vein 2 mm in diameter in the lateral canthal and infraorbital region before treatment. B, Appearance 4
weeks after a treatment using the CoolTouch Varia at 210 J/cm2 with a 3.5-mm diameter spot size and a 25-ms pulse duration with 30 ms of cryogen spray
cooling immediately after the laser pulse.
B
B
5 ms and postcooling ranged from 20 to 50 ms with a delay
of 5 to 20 ms. The endpoint of laser treatment was vessel
contraction. Sclerotherapy with STS 0.25% was followed by
48-hours’ wear of 20- to 30-mmHg graduated compression
stockings. Sclerotherapy-treated patients had a significantly
better response in fewer treatments with comparable adverse
effects.
The CoolTouch Varia is especially useful in treating periorbital telangiectasia and reticular veins. Although these veins
may be treated with sclerotherapy (see Chapter 12), we have
had near 100% success without adverse effects in treating
these vessels with the CoolTouch Varia (Fig. 13.34).
CoolGlide
The CoolGlide can deliver fluences up to 100 J/cm2 through
a 10-mm diameter spot. The pulse duration can be varied
continuously from 10 to 100 ms. Unlike the other systems,
which can deliver each burst at a 1-Hz speed, the CoolGlide
can deliver pulses at 2 Hz. Cooling is provided by a contact
system that glides in front of the laser beam so that 2 cm of
skin is precooled before the laser aperture glides over the treatment site. The authors have also found this system to be effective in treating leg telangiectasias 0.1 to 3 mm in diameter
360
(Fig. 13.35).
107
However, the lack of effective, reproducible
cooling can lead to the production of epidermal scars, more
so than with the other 1064-nm laser systems, as well as an
increase in procedural pain (Fig. 13.36).
Fifteen women with 21 sites of leg telangiectasia 0.25 to
4 mm in diameter were treated twice, separated by an interval
of 6 to 8 weeks, with the CoolGlide using a 7-mm spot,
fluence of 90 to 160 J/cm2 and pulse durations of 10 to
111
50 ms.
Significant improvement was seen in 71% of sites
but hyperpigmentation was present in 61% of sites at 3-month
follow-up. A second study on 20 patients with reticular veins
1 to 3 mm in diameter was performed using 100 J/cm2 and a
50-ms pulse without mention of the laser spot diameter.
112
Although 66% of the vessels cleared by more than 75% with
one treatment at 3 months, pain was significant, especially
without the use of EMLA cream applied for 1 hour. Unfortunately, longer follow-up was not reported.
Lyra
The Lyra long-pulse 1064-nm Nd:YAG laser was used to treat
20 patients with leg telangiectasias 0.5 to 5 mm in diameter
with 100 to 200 J/cm2 at 50 to 100 ms with a 3- to 5-mm
diameter spot and one to four treatments.
113
Comparable
A
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Figure 13.35 A, Reticular vein 2 to 3 mm in diameter on the medial thigh feeding into an area of telangiectasia. B, Complete resolution 16 weeks after
treatment with the CoolGlide laser with multiple pulses until vessel spasm occurred at a fluence of 80 J/cm2, 30-ms pulses with epidermal contact cooling.
B
The pulse duration consists of a series of three 3.5-ms pulses
each separated by 250 ms. Sixty percent of the energy is delivered in the first pulse, with 20% in each of the next two pulses.
In an initial study on 11 patients with blue leg veins 1 to
2 mm in diameter, patients had up to three treatments at
6-week intervals. There was 98% clearance after three treatments, with moderate pain with each treatment.
SmartEpil lS
A comparative study of the long-pulsed 1064-nm Nd:YAG
Figure 13.36 A lack of effective, reproducible cooling can lead to an
increase in procedural pain as well as the production of epidermal scars
(seen here), more so than with the other 1064-nm laser systems.
telangiectasias on the same patient received a single sclerotherapy treatment with STS 0.6%. No compression was used.
Even at these parameters with excessive concentration of STS
without compression, and four laser treatments versus one
sclerotherapy treatment, adverse effects and treatment efficacy
were not statistically different between the two treatment
modalities. Patient surveys found that 35% preferred laser and
45% preferred sclerotherapy.
Sadick
114
also evaluated the Lyra with a 30- to 50-ms pulse
duration, 1.5-mm diameter spot, 400 to 600 J/cm2 for red
vessels and a 50- to 60-ms pulse, 1- to 3-mm diameter spot,
250 to 370 J/cm2 for blue vessels through a 4°C cold window
for three treatments. At 6 months, 80% of vessels had greater
than 75% clearance. This was a limited study on 10 patients.
Two of the 10 had pigmentation lasting up to 6 months and
TM occurred in 1 patient. Moderate discomfort was experienced by all patients.
Quantel medical multipulse mode
The most recent development in long-pulse 1064-nm Nd:YAG
technology has been the production of a nonuniform pulse
sequence mode device with contact cooling to 5°C.
device has a fluence of 300 to 360 J/cm2 through a 2-mm
diameter spot. The rationale for multiple pulsing is to convert
HbO
to met-Hb, which will be absorbed better by 1064 nm.
2
115
This
laser with sclerotherapy was performed on 14 patients with
leg telangiectasias 0.5 to 2 mm in diameter.
laser was used at 100 to 125 J/cm2 through a 2.5-mm diameter
spot and a 10-ms pulse without cooling. Sclerotherapy was
performed with POL 0.5% without post-treatment compression. An evaluation of combinations of laser and sclerotherapy was also performed. There was no statistical difference in
efficacy between the four different treatment modalities.
However, the sclerotherapy-treated veins had better resolution.
To summarize, we have found the 1064-nm, long-pulsed
Nd:YAG lasers to be beneficial in the treatment of leg telangiectasia not responsive to sclerotherapy or other lasers. The
benefit in using a 1064-nm laser is that its longer wavelength
can penetrate more deeply, allowing effective thermosclerosis
of vessels up to 3 to 4 mm in diameter. In addition, the
1064-nm wavelength permits treatment of patients of skin
types I to VI with or without a tan, since melanin absorption
is minimal. The 1064-nm, long-pulse laser systems are not
entirely without side effects. Cutaneous burns with resulting
ulcerations, pigmentation, and TM have been observed with
each of these systems as parameters are being tested. The
dynamically cooled 1064-nm Nd:YAG laser appears to produce
the best clinical resolution with the least pain and adverse
effects compared with other long-pulse 1064-nm lasers.
However, sclerotherapy still provides better results in fewer
treatments, is associated with less pain, and has comparable
adverse effects to lasers. Thus, the reader should evaluate the
latest studies to ensure ideal results.
Evaluation of Combined
Laser–Sclerotherapy Treatment
of Leg Telangiectasia
Goldman et al52 hypothesized that the combination of sclerotherapy with laser thermocoagulation may be effective in
the treatment of leg veins as early as 1990. Twenty-seven
patients, with either bilaterally symmetrical telangiectatic
116
The Nd:YAG
Evaluation of Combined Laser–Sclerotherapy Treatment of Leg Telangiectasia
361
Chapter
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13
Figure 13.37 Telangiectatic flare on lateral thigh
divided into two treatment sites. Anterior aspect
treated with flashlamp-pumped pulsed dye laser
(PDL) at 6 J/cm2, 50 pulses, immediately before
sclerotherapy with polidocanol 0.25%, 2 mL. Posterior
aspect treated with pulsed dye laser (PDL) at 7 J/cm2,
34 pulses. A, Immediately before treatment. B, 3
months after treatment. Note complete resolution of
vessels treated with each modality.
A
Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light
A C
Figure 13.38 Telangiectatic matting on medial knee and calf 6 months after sclerotherapy. A, Immediately before treatment. B, Immediately after
treatment with flashlamp-pumped pulsed dye laser (PDL) to anterior aspect at 7.5 J/cm2, 51 pulses; posterior aspect treated with PDL at 7.5 J/cm2, 41 pulses,
followed by sclerotherapy with polidocanol 0.5%, 1 mL. C, 11 months after treatment.
Table 13.3 Results of PDL/SCL treatment of leg telangiectasia (all POL concentrations)
Laser Energy
2
(J/cm
)
No. of Sites
Treated No Change (%) <90% Faded (%) Total Fade (%)
B
B
Ulceration/
Matting (%)
5.5 3 — 100 — —
6.0 10 20 30 40 10
7.0 4 — 25 25 50
7.25 2 — 50 50 —
7.5 7 14 14 72 —
7.75 1 — — 100 —
Total 27 11 33 44 11
PDL, pulsed dye laser; SCL, sclerotherapy; POL, polidocanol.
Modified from Goldman MP, Fitzpatrick RE: J Dermatol Surg Oncol 16:338, 1990.
patches or a large ‘sunburst’ telangiectatic flare that could be
divided into two separate treatment sites, were evaluated.53
Patients were treated at one site with the 0.45-ms, 585-nm
PDL alone, and at the other site with laser fluences 1 to
2 J/cm2 less than those used with PDL alone immediately
362
before injection of the telangiectasia with POL 0.25%, 0.5%,
or 0.75%, with a volume of 0.1 to 0.25 mL per injection
site (Fig. 13.37). Forty-four percent of combination treated
areas completely resolved (Table 13.3 and Fig. 13.38). There
appeared to be little difference in efficacy and adverse sequelae
A
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C
Figure 13.39 Essential telangiectasia on the feet. Distal aspect treated with flashlamp-pumped pulsed dye laser (PDL) at 6 J/cm2, 114 pulses, immediately
followed by sclerotherapy (SCL) with polidocanol 0.25%, 1 mL. Proximal aspect treated with PDL at 7 J/cm2, 100 pulses. A, Immediately before treatment.
B, Immediately after treatment. C, 4 months after treatment. Note superficial ulceration at the PDL/SCL-treated site.
Table 13.4 Results of PDL/SCL treatment with PDL and POL 0.25% and 0.5%
B
Laser Energy (J/cm2) No. of Sites Treated No Change (%) <90% Faded (%) Total Fade (%) Ulceration/Matting (%)
POL 0.25%
5.5 1 — 100 — —
6.0 6 17 33 33 17
7.0 1 — — 100 —
POL 0.5%
5.5 2 — 100 — —
6.0 2 50 — 50 —
7.0 2 50 — 50 —
7.25 2 — 50 — 50
7.5 6 17 — 83 —
7.75 1 — — 100 —
PDL, pulsed dye laser; SCL, sclerotherapy; POL, polidocanol.
Modified from Goldman MP, Fitzpatrick RE: J Dermatol Surg Oncol 16:338, 1990.
Evaluation of Combined Laser–Sclerotherapy Treatment of Leg Telangiectasia
with concentrations of POL between 0.25% and 0.75%. There
did appear to be an increased efficacy of treatment with laser
energies of 7.5 to 7.75 J/cm2. As with the PDL alone, treatment
site did not appear to significantly affect outcome except for
an increased incidence of complications in the ankle and
knee areas.
The most significant difference between the PDL alone and
combination treatment was the incidence of complications.
With combination treatment, post-treatment ulceration and
TM occurred in 11% of treated areas, compared with no
adverse sequelae with PDL alone. Six of 23 nonulcerated treat-
ment sites developed persistent pigmentation beyond 1 year.
Two of 27 sites developed TM that lasted over 1 year. Four of
27 treatment sites developed superficial ulceration. In these
ulcerated patients, laser fluences were equal to or greater than
6.5 J/cm2 and POL concentration was equal to or greater
than 0.5% (Table 13.4 and Figs 13.39 and 13.40).
Theoretically, combining administration of a laser with an
injected sclerosant to treat leg telangiectasias could decrease
the amount of each therapy necessary to yield optimal results,
thus mitigating the individual side effect profiles of each.
Galeckas et al
117
reported the successful treatment of a
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