Treatment of Leg Telangiectasias with Laser and High-Intensity Pulsed Light

Carbon Dioxide Laser

The carbon dioxide (CO ₂ ) laser has been used for obliterating venules and telangiectatic vessels. One case report described the successful treatment of matted telangiectasias with fractional photothermolysis. The patient underwent five successive monthly treatments with the 1550 Fraxel SR laser (Solta Medical, Hayward, CA), 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, because 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 a result of ‘the tincture of time’ as opposed to the CO ₂ laser treatment.

The rationale for using the CO ₂ laser in the treatment of telangiectasias is to produce ‘precise’ vaporization without significant damage to tissue structures adjacent to the penetrating laser beam; however, most reported studies demonstrate unsatisfactory cosmetic results. Since the CO ₂ laser does not specifically target melanin, it can theoretically be used on those of darker skin types, a subgroup of the population that cannot be safely treated with the PDL. However, with the CO ₂ laser, the epidermis and the dermis overlying the blood vessel are destroyed and CO ₂ laser disruption of vessels has also been reported to cause occasional brisk bleeding from the vessel, which in one report required pressure bandages for 48 hours. Treated areas have also been described to produce multiple hypopigmented punctate scars with either minimum resolution of the treated vessel or neovascularization adjacent to the treatment site ( Fig. 13.4 ). Pain during treatment is also moderate to severe, but of short duration. Because of this nonselective action, the CO ₂ laser is of no advantage over the electrodessication needle and has not been used successfully in treating leg telangiectasias.

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 and increasing risk of adverse effects. Thus, the argon laser does not have ideal parameters for treating leg veins ( Fig. 13.6 ).

Further, as argon lasers are continuous in nature, they do not allow for selective vessel heating, so scarring commonly occurs. Specifically, argon laser treatment of telangiectasias or superficial varicosities of the lower extremities may cause purple or depressed scars. In a report of 38 patients treated by Apfelberg et al, 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 al noted significant improvement in 49% of patients. The authors 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 also been used in a combinational approach to interrupt the telangiectasias similar to a ‘spot weld’ every 2 to 3 cm before injection of a sclerosing agent. In this study, 11 of 16 patients completed treatment. Two patients developed punctate depigmented scars, and three developed hyperpigmentation. Despite this, 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 telangiectasias 1 mm in diameter. This may be caused by temperature-related vasomotor changes in blood flow.

Krypton Triphosphate and Frequency-Doubled Nd:YAG (532 nm)

Modulated krypton triphosphate (KTP) lasers have been reported to be effective at removing leg telangiectasias, 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 more superficial 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 size. Typically, the laser is moved between adjacent 1-mm spots with vessels traced at 5 to 10 mm/s resulting in immediate epidermal blanching. Lengthening the pulse duration to match the diameter of the vessel is attempted to optimize treatment (see Table 13.2 ). West and Alster employed this method in 12 patients with leg telangiectasias using a 1-mm spot size, with a 10-ms pulse (2 pulses per second) at 15 J/cm ² and found an average improvement of 25% to 50% ( Fig. 13.7 ).

Quintana et al similarly treated 19 leg veins less than 1.5 mm in diameter with the Laserscope KTP Dermastat (Laserscope, San Jose, CA) using a 2-mm diameter handpiece at a fluence of 13 to 15 J/cm ² and 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% achieved 100% clearance, 40% had 75% clearance, 35% had 50% clearance and 10% had 25% clearance. No scarring was reported; however, 25% had transient hyperpigmentation. Therefore, this laser appears to be 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, CA) to be effective in treating leg veins less than 1 mm in diameter that are not directly connected to a feeding reticular vein. When used with a 4°C chilled tip, a fluence of 12 to 15 J/cm ² is delivered as a train of pulses in a 3- to 4-mm diameter spot size to trace the vessel until spasm or thrombosis occurs. Notably, some overlying epidermal scabbing is expected with hypopigmentation not uncommonly occurring in dark-skinned patients. While we have found this treatment effective, individual physicians report considerable variation in results described subsequently. Usually, more than one treatment is necessary for maximum vessel improvement, with only rare reports of 100% resolution ( Fig. 13.8 ). A summary of important clinical evaluations of this technology follows.

McMeekin treated 10 patients with 18 sites of leg veins ranging from 0.5 to 1.1 mm in diameter using a VersaPulse with a 3-mm diameter spot, 5.5°C cooling, at 12 and 16 J/cm ² with one to three passes over each vessel at 2 Hz. The patients were followed for 1 year after a single treatment. Overall, 44% experienced 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 more cleared at 16 J/cm ² than at 12 J/cm ² . At 16 J/cm ² , 37% cleared 25% to 50%, 25% cleared 50% to 75% and 37% cleared 75% to 100%. Importantly, 94% developed hyperpigmentation that took up to 6 months to resolve and one patient developed blisters and hypopigmented atrophic scars.

Bernstein et al achieved similar efficacy in a study of 15 women (27 treatment sites) with leg telangiectasias less than 0.75 mm in diameter, using a 3-mm spot size, 10-ms pulse duration at 16 J/cm ² and 4 Hz. Patients were treated with three passes over each vein a total of two times, 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.

Using a longer pulse duration and larger spot size, Narukar evaluated patients with leg veins less than 1.5 mm in diameter, using 20- to 50-ms pulses up to 40 J/cm ² with a 3- to 6-mm diameter spot size. Patients were treated at 6- to 8-week intervals two to three times with an overall clearance of 45%. Interestingly, a 68% clearance was found in patients whose previous sclerotherapy showed a good response and 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 Katz bettered Narukar's results using a spot size of 5 mm, a pulse width of 50 ms, fluences of 18 to 20 J/cm ² and a 1.5-Hz repetition rate. A 75% to 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; however, no scarring was observed. Krause also described similar results using a 2-mm diameter spot size, which was reported to produce a narrower band of either hypo- or hyperpigmentation.

A 532-nm KTP laser has also been evaluated in a multipulse mode emission (three stacked pulses of 100, 30 and 30 ms and a delay between pulses of 250 ms), a fluence of 60 J/cm ² and a 0.75-mm collimated spot without cooling (Virdis Derma, Quantel Medical, France). The authors reported a clearance rates of leg veins 0.5 to 1 mm in diameter treated at 6-week intervals of 53% with one treatment, 78% with two treatments, 85% with three treatments and 93% at 6 weeks following a fourth treatment. It is suggested that the multipulse mode increases intravascular heating in a manner similar to the multipulse mode of IPL (see later) while allowing cooling of the epidermis; however, hypopigmentation lasting ‘a few months’ was observed in 18% of patients and TM occurred in 7% of patients.

Woo et al, directly compared a 532-nm Nd:YAG at 20 J/cm ² delivered as a 50-ms pulse through a contact cooling and 5-mm diameter spot to a 595-nm PDL at 25 J/cm ² with a pulse duration of 40 ms, cryogen spray cooling and a 3 × 10–mm elliptical spot. After one treatment there was 50% to 75% improvement in 2 of 10 patients and greater than 75% improvement in 3 of 10 patients in the 532-nm Nd:YAG group, and 50% to 75% improvement (6 of 10 patients) in the PDL group, which overall performed better.

In another study, a 532-nm diode laser with a 1-mm diameter spot at fluences of 2 to 32 J/cm ² 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/cm ² in the treatment of TM vessels less than 0.3 mm in diameter that did not respond to sclerotherapy. 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.

More recently, Ozden et al compared the 532 KTP laser with the 1064-nm Nd:YAG laser in 16 patients with sized-matched superficial leg veins in three consecutive monthly treatments evaluating a total of 64 leg vein sites. Fluence and pulse width treatment parameters for treated vessels less than 1 mm in diameter were 15 to 25 J/cm ² and 15 to 20 ms for the KTP 532 laser and 300 to 500 J/cm ² and 20 to 50 ms for the 1064-nm Nd:YAG laser, respectively. Fluence and pulse width treatment parameters for treated vessels 1 to 3 mm in diameter were 15 to 22 J/cm ² and 10 to 20 ms for the KTP 532 nm laser and 250 to 350 J/cm ² and 50 to 60 ms in the 1064-nm Nd:YAG laser group, respectively. Response to treatment was graded on a quartile system: 0 = no clearing; 1 = 1–24% clearing; 2 = 25–49% clearing; 3 = 50–74% clearing; 4 = 75–94% clearing; and 5 = 95–100% clearing. Average clinical improvement scores in the thin (<1 mm) and thicker (1–3 mm) treatment sites were 1.94 and 1.25 for the KTP and 3.38 and 3.50 for the Nd:YAG lasers, respectively. Following the third treatment session, average improvement scores improved to 2.44 and 1.31 in the KTP group and 3.75 and 3.23 in the Nd:YAG groups, respectively. Although no adverse effects were reported, pain was significantly higher in the Nd:YAG treated group. This study further elucidates that although both the KTP and Nd:YAG lasers demonstrate reasonable efficacy in smaller more superficial vessels, as would be anticipated by its shorter wavelength and more superficial tissue penetration, the KTP laser has very low efficacy with vessels larger than 1 mm.

Bernstein et al subsequently evaluated the effectiveness of a novel dual-wavelength 532/1064 laser (Excel V, Cutera, Brisbane CA) for the treatment of lower extremity telangiectasias. Twenty female subjects (Fitzpatrick skin types I–III) were treated in 79 sites using the 532-nm wavelength with fluences ranging from 13 to 15 J/cm ² , pulse duration of 40 ms and a 5-mm-diameter spot size. Two treatments were performed at 12-week intervals resulting in an average 2.5/5 point improvement. All patients tolerated the procedure well (mean pain sore 2.9/10) with no serious adverse effects reported. Postinflammatory hyperpigmentation was seen in 2% (1/64 patients).

In short, the 532-nm, long-pulsed, cutaneous, chilled Nd:YAG laser is effective in treating more superficial leg telangiectasias but has overall poor efficacy in deeper vessels because of limited penetration. 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) ( Fig 13.9 ).

Copper Bromide 578 nm

In a single study evaluating the efficacy of the 578-nm copper bromide laser, 46 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/cm ² through a 1.5-mm diameter spot size generated with a 300-ms pulse, with a 75-ms delay between pulses. Treatments were given through a circulating cooling window at 1° to 4°C. 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. While relatively effective this devise is limited by its long warm-up time (15–20 minutes) and small 1.5-mm diameter spot size leading to longer treatment time and overall reduced efficiency limiting use in clinical practice.

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 telangiectasias. 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 telangiectasias may be achieved, but not the deeper larger veins. In comparison with PWS, hemangiomas and facial telangiectasias, lower extremities telangiectasias in general have not responded as well, with less lightening and more posttherapy hyperpigmentation. This may be caused by the larger diameter of leg telangiectasias 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 telangiectasias less than 0.2 mm in diameter, particularly those vessels arising as post­sclerotherapy 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 posttherapy pigmentation because of a decreased incidence of extravasated RBCs ( Figs 13.10–13.14 ).

The etiology of TM is unknown but has been thought to be related either to angiogenesis or to a dilation of existing subclinical blood vessels by promoting collateral flow through arteriovenous anastomoses. 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. In addition, endothelial damage leads to the release of histamine and other mast cell factors and vasokines, which promote both the dilation of existing blood vessels and angiogenesis. Sclerotherapy by its mechanism of endothelial destruction thereby provides the means for new blood vessel formation to occur. Indeed, it is remarkable that physicians do not see a higher incidence of posttreatment TM associated with sclerotherapy.

TM has not been reported to be a side effect of argon or PDL, in the treatment of vascular disorders. This may be caused by the production of intravascular fibrin that occurs during laser treatment. Fibrin develops through thermal alteration of fibrin complexes or proteolytic cleavage of fibrinogen. Unlike laser, sclerotherapy-induced vascular injury has not been associated with the appearance of fibrin strands (unpublished observations M Goldman). 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.

Multiple factors associated with inflammation have been demonstrated to promote both a dilation of existing blood vessels and angiogenesis. Rabbit ear vein treatment with the PDL decreases perivascular inflammation compared with vessels treated with sclerotherapy alone. Thus, another possible mechanism for absence of TM in laser-treated blood vessels is a decrease in perivascular inflammation.

The pulse duration of the first generation of PDL was 450 µs, optimal for the 50- to 100-µm diameter of PWS vessels. This pulse duration, similar to the KTP discussed earlier 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, which may be 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 telangiectasias. A summary of the literature detailing investigations of the flashlamp-pumped PDL (585/595) follows.

Polla et al 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 telangiectasias and almost 50% of the treated patients developed persistent hypopigmentation or hyperpigmentation.

Goldman and Fitzpatrick subsequently 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, Valencia, CA) 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/cm ² and compressed with a rubber ‘E’ compression pad (STD Vascular Products, Bristol, UK) fixed in place with Microfoam 100 mm tape (3 M Medical-Surgical Division, St Paul, MN). A 30- to 40-mmHg graduated compression stocking was then worn over this dressing continuously for approximately 72 hours. The most effective fluence appeared to be between 7.0 and 8.0 J/cm ² . With these parameters, approximately 67% of telangiectatic patches completely faded within 4 months ( Figs 13.15–13.18 ). As hypothesized, TM and persistent pigmentation did not occur with PDL treatment of leg telangiectasias and 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. 13.19 ). The laser impact sites usually remained hypopigmented for years and in many cases were thought to be permanent.

Interestingly, 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/cm ² . Matted vessels did not respond to treatment in only one patient with four areas of TM, and less than 100% resolution occurred in 16% of treated areas ( Fig. 13.20 ).

Like TM vessels, essential telangiectasias represent a network of fine red telangiectasias usually less than 0.2 mm in diameter. This condition responds well to the PDL at fluences of 7 to 7.25 J/cm ² . 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 may be a result of the rigid criteria by which patients were selected for treatment. Patients who responded well to treatment had red telangiectasias 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. 13.21 ). Sadick et al conducted a study that 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.

Long-Pulse Flashlamp-Pumped Pulsed Dye Laser

In an effort to thermocoagulate larger diameter blood vessels, a second generation of PDL with a longer pulse duration, lengthened to 1.5 to 40 ms, and longer wavelength, increased to 595 600 nm, was released in 1996 (see Table 13.1 ). The longer wavelength theoretically permits more thorough heating of larger vessels at greater depths allowing effective treatment of vessels 1 mm in width and 1 mm in depth. A summary of the literature detailing the study of long pulsed flashlamp-pumped PDL is detailed later.

Using a 595-nm PDL at 1.5 ms, Hsai et al found more than 50% clearance of leg veins at a fluence of 15 J/cm ² and approximately 65% clearance using a fluence of 18 J/cm ² . 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 × 7 mm through a transparent hydrogel-based wound dressing. No adverse sequelae were noted at the 5-month follow-up visit ( Fig. 13.22 ).

Another study evaluated the use of the 595-nm long-pulse PDL on 35 sites of lower extremity spider veins in 15 subjects. This laser used 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/cm ² 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. Of note, one subject developed severe posttreatment hyperpigmentation, which persisted long enough to delay subsequent treatment by 6 weeks. At 8 weeks following the final treatment, 9 of 28 sites receiving three treatments showed residual hyperpigmentation as assessed by the treating physician; and blinded observers using digital photographic assessment noted a 25% incidence of hyperpigmentation at this same time point.

Lee and Lask treated 25 women with leg telangiectasias less than 1 mm in diameter with the long-pulse PDL (LPDL) (Sclerolaser, Candela, Wayland, MA). Each patient had four areas treated; two at a wavelength of 595 nm with fluences of 15 or 20 J/cm ² , with two additional areas treated with a 600-nm wavelength at 15 or 20 J/cm ² , respectively. A maximum of three treatments were performed at 6-week intervals. All patients had improvement, although the 595-nm wavelength at 20 J/cm ² gave the best results. Treatment response was variable and unpredictable, with some patients having complete resolution and some having only slight improvement. Most patients experienced purpura and hyperpigmentation that resolved after several weeks and three patients had superficial scabbing that resolved without apparent scarring.

West and Alster treated 12 patients with leg telangiectasias with a 590- or 595-nm pulse at 15 J/cm ² citing an average improvement of 75%. However, persistent hyperpigmentation was noted in 71% of patients at the 12-week follow-up period.

Bernstein et al demonstrated similar results in their study of 10 women (Fitzpatrick skin type I and II) with 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/cm ² . Patients were treated through a hydrogel dressing that resulted in a 9% energy loss, three times at each site at 6-week intervals. 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.

Reichert performed the largest study on the use of the LPDL by evaluating 80 patients with more than 250 treatment sites of telangiectasias not associated with feeding reticular veins. Treatment parameters were a 1.5-ms pulse at 16 to 22 J/cm ² with a 2 × 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/cm ² . 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 telangiectasias will respond to the LPDL.

Hohenleutner et al 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, 20% of patients with veins less than or equal to 0.5 mm in diameter and 0% of patients with veins between 0.5 and 1 mm in diameter achieved greater than 95% clearing treated at 600 nm with 18 J/cm ² . A 50% to 95% clearance occurred in 82% of veins 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/cm ² . Hyperpigmentation and/or hypopigmentation occurred in 32% of treated areas and resolved within 6 months. When fluence was increased to 20 J/cm ² , however, hyperpigmentation occurred in 48% of treated areas. Thus, cooling with ice cubes enhances clinical efficacy and improves safety of this laser.

Ultralong pulse PDLs have been developed with pulse widths of 2 to 40 ms at a wavelength of 595 nm (Cynosure, Chelmsford, MA and Candela, Wayland, MA). 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/cm ² can be delivered through a 3 × 10–mm or a 5 × 8–mm elliptical spot.

Twenty-seven women with leg telangiectasias that were less than 1 mm in diameter were evaluated in one clinical study. Each patient had three areas treated. There was no difference in vessel response between a 4-ms 16-J/cm ² pulse, a 4-ms 20-J/cm ² pulse and a 1.5-ms 14- or 16-J/cm ² pulse. Little or no improvement was seen in 50% and 33% of patients, respectively, after one treatment. Hyperpigmentation and hypopigmentation lasting about 12 weeks was seen in 40% to 67% and 20% to 27% of veins, respectively. It is unclear why this specific study proved much less effective than previous studies on similar telangiectasias. The authors of this study were particularly objective in their treatment evaluation, with subtle improvements being less noticeable in photographic analysis by independent evaluators.

Polla also evaluated the Candela LPDL on 40 patients with leg veins 0.05 to 1.5 mm in diameter using a 6- or 20-ms pulse with a 7- or 10-mm diameter spot at 10 to 13 J/cm ² and 6 to 7 J/cm ² , 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% total clearance and 67% experiencing clearance above 40%. All patients had purpura for 7 to 10 days; 33% had pigmentation for less than 2 months and 15% for over 2 months.

Weiss and Weiss 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/cm ² for a total of three stacked pulses with simultaneous cold air-cooling. Eighteen of 20 patients had at least 50% improvement at 3 months posttreatment. 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 telangiectasias up to 1 mm in diameter at 595 nm with DCD cooling at 25 J/cm ² . In this study, six patients had 50% to 75% improvement and 2 of 10 had hyperpigmentation lasting over 3 months.

Finally, Kono et al studied the DCD LPDL in a population of 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. 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/cm ² and 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. Mild hyperpigmentation was present in nearly 50% of treated areas at 3-month follow-up.

Our experience is similar to that reported earlier. We use the LPDL at pulse durations matching the thermal relaxation time of the leg veins as detailed by Kono et al. The energy fluence used is just enough to produce vessel purpura and/or spasm. Like Weiss and Weiss, 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 Weiss and Kono et al, 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)

The long-pulse alexandrite laser was initially developed to treat hair; however, it soon became apparent that the wavelength, fluence and pulse duration could also be used for telangiectasias (see Table 13.1 ). The 755-nm wavelength penetrates 2 to 3 mm beneath the epidermis and is effective in thermocoagulating blood vessels in clinical and histologic studies as summarized in the following.

One study of leg telangiectasias in 28 patients treated three times every 4 weeks at fluences ranging from 15 to 30 J/cm ² found that a single-pulse technique with 20 J/cm ² , 5-ms pulse duration yielded the best resolution when combined with sclerotherapy using 23.4% hypertonic saline (HS) ( Fig. 13.23 ). 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%.

Kauvar and Lou 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/cm ² 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; however, hyperpigmentation was observed in 35% of treated areas.

An additional study using an alexandrite laser at 90 J/cm ² 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 telangiectasias 0.3 to 1.3 mm in diameter. 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, was a result of the increased fluence used.

Ross et al 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 ms. For each pulse duration, test spots were performed to determine optimal radiant exposures, which elicited 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/cm ² . 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, comparing the alexandrite laser to the 810-nm diode laser and the 1064-nm Nd:YAG laser in the treatment of leg telangiectasias 0.3- to 3-mm in diameter on 30 women, however, 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/cm ² , a 3-ms pulse and an 80- to 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 posttreatment 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/cm ² , with a 25-ms pulse duration for small vessels and a 100-ms pulse for larger vessels, with a 30-ms postcontact 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 studies mentioned earlier.