Carbon dioxide laser

The carbon dioxide (CO₂) laser has been used for obliterating venules and telangiectatic vessels.^17–21 One recent case report described the successful treatment of matted telangiectasias with fractional photothermolysis.²² The patient underwent five successive monthly treatments with the 1550 Fraxel SR laser (Solta Medical, Hayward, Calif.), at energies ranging from 10 to 12 mJ, to an area on her medial thigh. At 6 months after the final treatment session, the target areas showed more than 75% improvement. However, since the natural history of matted telangiectasias is usually to spontaneously resolve over the course of a year, it is uncertain how much of the improvement seen in the aforementioned case report was actually due to ‘the tincture of time’ as opposed to the CO₂ laser treatment.

The rationale for using the CO₂ laser in the treatment of telangiectasia is to produce ‘precise’ vaporization without significant damage to tissue structures adjacent to the penetrating laser beam. Also, since the CO₂ laser does not specifically target melanin, it can be used on those of darker skin types, a subgroup of the population that cannot be safely treated with the pulse dye laser. However, with the CO₂ laser, the epidermis and the dermis overlying the blood vessel are destroyed. CO₂ laser disruption of vessels has also been reported to cause occasional brisk bleeding from the vessel, which required pressure bandages for 48 hours.²⁰ Pain during treatment is moderate to severe, but of short duration. Most reported studies demonstrate unsatisfactory cosmetic results. Treated areas show multiple hypopigmented punctate scars with either minimum resolution of the treated vessel or neovascularization adjacent to the treatment site (Fig. 13.4). Because of this nonselective action, the CO₂ laser is of no advantage over the electrodesiccation needle and has not been used successfully in treating leg telangiectasia.

Figure 13.4 Hypopigmented scars with skin textural changes 5 years after treatment of leg telangiectasia with the CO₂ laser.

Argon laser

The argon laser with output at 488 nm and 511 nm has wavelengths somewhat preferentially absorbed by hemoglobin and to a lesser, although significant, extent by water and melanin (Fig. 13.5). Its relatively short wavelength, combined with a spot size of 1 mm, prevents its penetration much beyond 0.5 mm. When the patient is pigmented or tanned, epidermal melanin will selectively absorb the laser energy, preventing penetration below the epidermis. Thus, the argon laser does not have ideal parameters for treating leg veins (Fig. 13.6).

Figure 13.5 Average temperature increase across a cutaneous vessel as a function of wavelength for two cases: a shallow capillary vessel (similar to those found in a port-wine vascular malformation), and a deeper (2 mm) and larger (1 mm) vessel typical of a leg venule. The calculated curves are generated assuming that the main light-absorbing chromophore in the blood is either oxygenated or deoxygenated hemoglobin. The calculation is carried out for a 10-J/cm² fluence and does not take into account cooling by heat conductivity. Note the dramatic shift in the optimal wavelength as a function of vessel depth and diameter. Also note the difference between oxygenated and deoxygenated hemoglobin.

(Courtesy Shimon Eckhouse, PhD, Energy Systems Corporation, Inc, Newton, Mass.; from Goldman MP, Fitzpatrick RE: Cutaneous laser surgery, St Louis, 1994, Mosby.)

Figure 13.6 Biopsy of a port-wine vascular malformation on the cheek of a 40-year-old man immediately after argon laser treatment at 15 J/cm², 1-mm spot diameter, which produced clinical epidermal whitening. Note coagulation of ectatic vessels in the middle and deep dermis with smudging of perivascular collagen. The overlying epidermis shows marked thermal effects with streaming of the epidermal cells and coagulation necrosis of the superficial papillary dermis. (Hematoxylin–eosin, ×200.)

(From Goldman MP, Fitzpatrick RE: Cutaneous laser surgery, St Louis, 1994, Mosby.)

Being continuous in nature, argon lasers do not allow for selective vessel heating, so scarring commonly occurs.²³ Specifically, argon laser treatment of telangiectasia or superficial varicosities of the lower extremities may cause purple or depressed scars. In a report of 38 patients treated by Apfelberg et al,¹⁸ 49% had either poor or no results from treatment, and only 16% had excellent or good results. In addition, almost half of the patients had hemosiderin bruising. In another series, Dixon et al²⁴ noted significant improvement in only 49% of patients. They speculated that after initial improvement, incomplete thrombosis, recanalization, or new vein formation produced reappearance of the vessels after 6 to 12 months.

In an effort to enhance therapeutic success with leg vein sclerotherapy, the argon laser has been used to interrupt the telangiectasia every 2 to 3 cm before injection of a sclerosing agent.²⁵ Eleven of 16 patients completed treatment. Two patients developed punctate depigmented scars, and three patients developed hyperpigmentation. However, 93.7% of patients were reported to have ‘satisfactory’ results.

Cooling the skin simultaneously with argon or tunable dye (577 nm, 585 nm) laser treatment has been demonstrated to produce improvement in 67% of leg telangiectasia 1 mm in diameter.²⁶ This may be caused by temperature-related vasomotor changes in blood flow.²⁷

Overall, argon laser therapy appears to be extremely technique dependent and not only relatively ineffective in treating leg telangiectasia but also associated with an unacceptably high risk of adverse sequelae.

Krypton triphosphate and frequency-doubled Nd:YAG (532 nm)

Modulated krypton triphosphate (KTP) lasers have been reported to be effective at removing leg telangiectasia, using pulse durations between 1 and 50 ms (see Table 13.1). The 532-nm wavelength is one of the hemoglobin absorption peaks (see Fig. 13.5). Although this wavelength does not penetrate deeply into the dermis (about 0.75 mm), relatively specific damage (compared with the argon laser) can occur in the vascular target by selection of an optimal pulse duration, enlargement of the spot size, and addition of epidermal cooling.

Effective results have been achieved by tracing vessels with a 1-mm projected spot. Typically, the laser is moved between adjacent 1-mm spots with vessels traced at 5 to 10 mm/second. Immediately after laser exposure, the epidermis is blanched. Lengthening of the pulse duration to match the diameter of the vessel is attempted to optimize treatment (see Table 13.2). With this method, West and Alster³⁰ utilized this method to treat 12 patients with leg telangiectasia. They used a 10-ms pulse at 15 J/cm² with a 1-mm handpiece at a repetition rate of two pulses per second. The average improvement was 25% to 50% (Fig. 13.7).

Figure 13.7 A, before treatment. B, 3 months after treatment there is hyperpigmentation in the telangiectasia treated with the flashlamp-pumped pulsed dye laser at 15 J/cm². Of note, the side treated with the KTP (532-nm) laser at 15 J/cm² and a 10-ms pulse showed no change.

(From West TB, Alster TS: Dermatol Surg 24:221, 1998.)

Quintana et al³¹ treated 19 leg veins that were less than 1.5 mm in diameter with the Laserscope KTP Dermastat (Laserscope, San Jose, Calif.). They used a 2-mm diameter handpiece at a fluence of 13 to 15 J/cm² given at a rate of 10 to 15 milliseconds. Patients were treated at 4- to 6-week intervals on four separate visits, with results examined 6 months after the last visit. Of the 28% of patients evaluated, 15% percent achieved 100% clearance, 40% had 75% clearance, 35% had 50% clearance, and 10% had 25% clearance. No scarring was reported, and 25% had transient hyperpigmentation. Therefore, this laser is somewhat effective but requires multiple treatments.

We and others have found the long-pulse 532-nm laser (frequency-doubled Nd:YAG) (VersaPulse, Lumenis, Palo Alto, Calif.) to be effective in treating leg veins less than 1 mm in diameter that are not directly connected to a feeding reticular vein.³² When used with a 4°C chilled tip, a fluence of 12 to 15 J/cm² is delivered as a train of pulses in a 3- to 4-mm diameter spot size in order to trace the vessel until spasm or thrombosis occurs. Some overlying epidermal scabbing is noted with hypopigmentation not uncommonly occurring in dark-skinned patients. Individual physicians report considerable variation in results. Usually, more than one treatment is necessary for maximum vessel improvement, with only rare reports of 100% resolution of the leg vein (Fig. 13.8). A summary of important clinical evaluations of this technology follows.

Figure 13.8 A, Before treatment. B, After one treatment with the VersaPulse at 15 J/cm² with a 10-ms pulse through a 3-mm diameter spot with the skin chilled through a 4°C quartz tip. Notice the residual hypopigmentation at the site of the superiormost reticular vein seen in A.

(Courtesy Robert Adrian, M.D.; from Goldman MP, Weiss RA, Bergan JJ, editors: Varicose veins and telangiectasia: diagnosis and treatment, St Louis, 1999, Quality Medical Publishers.)

McMeekin³³ treated 18 sites of leg veins ranging from 0.5 to 1.1 mm in diameter in 10 patients, using a VersaPulse with a 3-mm diameter spot, 5.5°C cooling, at 12 and 16 J/cm² with one to three passes over each vessel at 2 Hz. He followed the patients for 1 year after a single treatment. Overall, 44% of patients had a greater than 50% clearance from a single treatment. Six percent of patients had complete clearance, 88% had partial clearance, and 6% had no change. Of the partial clearance group of patients, more cleared at 16 J/cm² than at 12 J/cm². At 16 J/cm², 37% cleared 25% to 50%, 25% cleared 50% to 75%, and 37% cleared 75% to 100%. Ninety-four percent developed hyperpigmentation that took up to 6 months to resolve. One patient developed blisters and hypopigmented atrophic scars.

Bernstein et al³⁴ achieved similar efficacy in a study of 15 women with leg telangiectasia less than 0.75 mm in diameter at 27 sites, using a 10-ms pulse duration 532-nm laser at 16 J/cm² with a 3-mm diameter spot size at 4 Hz and using a chill tip with three passes over each vein twice, 6 weeks apart. Computer-based image analysis demonstrated more than 75% clearing. Ten of the 27 sites (37%) cleared completely after one treatment. Two of 15 patients (13.3%) reported blistering with minimal hyperpigmentation noted 6 weeks after treatment.

A longer pulse duration of 20 to 50 ms, accompanied by an increase in spot size to 5 mm with a higher total fluence of 20 J/cm² became available, with improvement in efficacy and a reduction in pigment changes. Narukar³⁵ evaluated patients with leg veins less than 1.5 mm in diameter, treated with 2- to 50-ms pulses up to 40 J/cm² with a 3- to 6-mm diameter spot size and a 4°C chill tip. He treated patients at 6- to 8-week intervals two to three times. A 45% clearance was found. Interestingly, a 68% clearance was found in patients whose previous sclerotherapy showed a good response. A 32% clearance occurred in patients whose vessels responded poorly to sclerotherapy. At 2-month follow-up, 2% of patients had TM, 4% had hyperpigmentation, and 2% had hypopigmentation.

Massey and Katz³⁶ bettered Narukar’s results using a spot size of 5 mm, a pulse width of 50 ms, fluences of 18 to 20 J/cm², and a 1.5-Hz repetition rate. A 75%–100% reduction was achieved in 68% of vessels less than 1 mm and in 44% of vessels 1 to 2 mm after two treatments. These results were obtained with multiple passes to achieve vessel clearance. Hypopigmentation and mild hyperpigmentation, lasting 6 to 8 weeks, were noted in 20% of patients. No scarring was observed. Krause³⁷ claimed similar results using a 2-mm diameter spot size. A 2-mm diameter spot size is claimed to produce a narrower band of either hypo- or hyperpigmentation.

A 532-nm KTP laser was also evaluated in a multipulse mode emission (three stacked pulses of 100 ms, 30 ms, 30 ms, and a delay between pulses of 250 ms), a fluence of 60 J/cm², and a 0.75-mm collimated spot without cooling (Virdis Derma, Quantel Medical, France).³⁸ On average, with one treatment, 53% of leg veins 0.5 to 1 mm in diameter were cleared, 78% with two treatments, 85% after three treatments, and 93% 6 weeks after a fourth treatment, all 6 weeks apart. It is suggested that the multipulse mode increases intravascular heating in a manner similar to the multipulse mode of IPL (see below) while allowing cooling of the epidermis. Hypopigmentation lasting ‘a few months’ was observed in 18% of patients and TM occurred in 7% of patients.

In a study by Woo et al,³⁹ a 532-nm Nd:YAG at 20 J/cm² delivered as a 50-ms pulse through a contact cooling and 5-mm diameter spot was compared with a 595-nm PDL at 25 J/cm² with a pulse duration of 40 ms, cryogen spray cooling, and a 3- × 10-mm elliptical spot. After one treatment with the 532-nm Nd:YAG there was 50% to 75% improvement in 2 of 10 patients and more than 75% improvement in 3 of 10 patients. There was better improvement in the PDL-treated patients, with 6 of 10 having 50% to 75% improvement.

In another study, a 532-nm diode laser with a 1-mm diameter spot at fluences of 2 to 32 J/cm² was compared with a 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.⁴¹ Up to three treatments 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.

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.⁴² The 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.⁴³ However, telangiectasia over the lower extremities has not responded as well, with less lightening and more post-therapy hyperpigmentation.⁴⁴ This may be due to the larger diameter of leg telangiectasia as compared with dermal vessels in PWS and larger diameter feeding reticular veins, as described previously.

Vessels that should respond optimally to PDL treatment are 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).

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.)

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.)

(Reprinted from Goldman MP et al: J Am Acad Dermatol 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.)

Figure 13.12 Vessel 2 days after treatment with flashlamp-pumped pulsed 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.)

(Reprinted from Goldman MP 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.)

(Reprinted from Goldman MP et al: J Am Acad Dermatol 23:23, 1990, with permission from American Academy of Dermatology.)

The etiology of TM is unknown but has been thought to be related either to angiogenesis⁴⁵ or to a dilatation of existing subclinical blood vessels by promoting collateral flow through arteriovenous anastomoses.⁴⁶ One or both of these mechanisms 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.⁴⁷ In 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.^48,49 Sclerotherapy by its mechanism of endothelial 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 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 laser-treated 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.⁵² Multiple factors associated with inflammation have been demonstrated to promote both a dilatation of existing blood vessels and angiogenesis.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 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 Fitzpatrick⁵³ 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 laser-induced sensation of heat resolved (5–15 minutes). Thirty-nine 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).

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.

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.

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.

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.

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.

(Courtesy of Richard Fitzpatrick, MD)

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).

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, 1 year after treatment of the entire area with LPDL at 7.25 J/cm², 46 pulses; note complete resolution of prior telangiectatic matting without pigmentary or textural skin changes.

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^44,55 may be 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.

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.

(Courtesy of Richard Fitzpatrick, MD)

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).

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.)

Another study evaluated the use of the 595-nm long-pulse PDL on 35 sites of lower extremity spider veins in 15 subjects.⁵⁹ 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 were pre- or post-treatment, assessed improvement in each case as well. Of note, one subject developed severe post-treatment 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 Lask⁶⁰ treated 25 women with leg telangiectasias less than 1 mm in diameter with the long-pulse PDL (LPDL) (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 Alster³⁰ treated 12 patients with leg telangiectasia 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 telangiectasias 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. Computer-based 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.

Reichert⁵⁷ 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 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% 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 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/cm² pulse, a 4-ms 20-J/cm² pulse, and a 1.5-ms 14- or 16-J/cm² pulse. Little or no 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 veins.⁶³ 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.

Polla⁶⁴ 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 Weiss⁶⁵ 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 long-lasting hyperpigmentation, like Weiss and Weiss⁶⁵ and Kono et al,⁶⁷ we reserve the use of the LPDL for sclerotherapy-resistant, 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.^68,69,70 One study of leg telangiectasia in 28 patients 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)⁶⁹ (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%.

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.

(Courtesy McDaniel DH, MD; from Goldman MP, Weiss RA, Bergan JJ, editors: Varicose veins and telangiectasia: diagnosis and treatment, St Louis, 1999, Quality Medical Publishers.)

Kauvar and Lou⁷¹ treated 20 women with 54 patches of leg 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.

An additional study using an alexandrite laser at 90 J/cm² with a 3-ms pulse through a 3- × 10-mm spot size and dynamic 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:YAG-treated 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 above-mentioned 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. Chess⁸² 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 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 time-consuming to perform.

A stronger endoluminal laser has been used to treat larger diameter veins, including the great saphenous vein (GSV). Bone Salat⁸⁶ 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.

Vasculite

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 × 6 mm in diameter. Weiss and Weiss,^100,101 Sadick,¹⁰² and Goldman¹⁰³ have reported excellent 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 Weiss¹⁰¹ treated 30 patients who had been dissatisfied 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 Weiss¹⁰⁴ 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.

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)

Sadick¹⁰⁵ 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 al¹⁰⁶ in treating 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 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.¹⁰⁷

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.

Two papers were published on the same 23 of 30 leg vein patients (completing the study) treated with the CoolTouch Varia.^108,109 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.¹¹⁰ Laser treatments 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 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).

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.

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 (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).

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.

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.

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 50 ms.¹¹¹ 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 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.

Sadick¹¹⁴ 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.¹¹⁵ This device has a fluence of 300 to 360 J/cm² through a 2-mm diameter spot. The rationale for multiple pulsing is to convert HbO₂ to met-Hb, which will be absorbed better by 1064 nm. 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 laser with sclerotherapy was performed on 14 patients with leg telangiectasias 0.5 to 2 mm in diameter.¹¹⁶ The Nd:YAG 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.