T elangiectasia is one of the most common conditions that dermatologist treat, and the pulsed dye laser is generally considered the treatment of choice for this condition. However, recent developments in laser technologies offer alternatives to the pulsed dye laser and hold the promise of allowing physicians to treat difficult cases that they had, until recently, been unable to address. In addition, new techniques and methodologies for using lasers and other light sources, sometimes in tandem, have also shown promise for treating difficult cases and even improving the results for more treatable cases. Now, dermatologists have a wide range of devices and approaches to choose from, and the challenge is to understand how to apply the new developments in the appropriate way to achieve the maximum benefit for patients. The most common treatment for telangiectasia is the traditional pulsed dye laser. In the hands of a skilled operator, the pulsed dye laser would very effectively treat the target vessels with little or no damage to the surrounding tissue. The results of the treatment were often dramatic with most patients enjoying almost total clearing after only a few treatments with little or no scarring or change in pigmentation. Unfortunately, effective treatment with a 450-microsecond pulsed dye laser results in a significant degree of purpura. Although the purpura is transient, lasting only a week or so, most telangiectasia patients will not tolerate it. In addition to patient concerns about purpura, dermatologists treating telangiectasia face other issues that, until recently, could not be effectively resolved. Perhaps the most critical of these is the fact that certain vessel types could not be treated with traditional laser treatments. Moreover, certain areas of the face, especially on and around the nose, are difficult to effectively treat. Considering the number of patients seeking relief from telangiectasia, finding more effective laser treatments that reduce the level of purpura is essential. Recently, a number of new lasers, methodologies and techniques have been developed that promise to deliver effective treatments while reducing side effects such as purpura, recurrence and scarring. According to Brian D. Zelickson, M.D., a dermatologist with a practice in Minneapolis, MN, the treatment options available to dermatologists are rapidly expanding. “Early on, there was essentially one laser, an argon laser, and little information about other effective treatments,” says Dr. Zelickson. “Now, there is a wide range of devices and treatment approaches that can deliver amazing results with little or no purpura or pain to the patient.” Telangiectasia and Erythema With more options available to treat telangiectasia and similar conditions, such as erythema, a treating physician must carefully analyze a patient’s condition to determine the most effective treatment regimen. Better results can be obtained by carefully matching the treatment approach, including the choice of laser, with the condition being treated. In addition, since certain conditions cannot be effectively treated with lasers without risking scarring or other side effects, it’s especially important to be aware of all conditions that the patient might have. “There are a lot of causative factors that we can see in our patients that may be aggravating their condition,” explains Dr. Zelickson. “We need to make sure that we’re not treating something that we shouldn’t be treating with lasers.” When developing treatment for a patient with erythema, it’s essential to determine if the condition is persistent or transient. Transient erythema is often untreatable and those patients should be discouraged. Patients with persistent erythema or telangiectasia or both can be effectively treated using a number of techniques. However, care should be taken to ensure that the patient is not suffering from other conditions, such as an angiosarcoma, sarcoidosis or a lupus purnia. If the patient has red vessels, a long-pulse KTP laser or long-pulse pulsed dye laser at lower fluences to avoid purpura offers an effective treatment. Darker blue, purple or burgundy vessels or large, deeper vessels respond well to a diode laser at 810 nm with a small spot or to a small spot Nd:YAG laser. These devices deliver the appropriate energy absorption and deeper penetration required to treat these types of vessels. If treating patients with both diffuse erythema and telangiectasia, the telangiectasia should be addressed first using the device appropriate for the type of vessel for the telangiectasia. The treating physician can then treat the erythema at the same session with intense pulsed light or a pulsed dye laser using cooling, being careful to keep contact with the skin with the cooling device. Avoiding Purpura With most telangiectasia patients wanting to avoid purpura, even if that means additional treatments or less clearing, dermatologists are seeking alternative treatments to the pulsed dye laser traditionally used to treat telangiectasia. Studies suggest that longer pulse duration would work better because the vessel could be slowly heated causing it to collapse and not rupture, even if dealing with larger vessels. Purpura is caused when the vessel ruptures and blood is released into the surrounding tissue. “With the classic pulsed dye laser at 450 microseconds, the purpura was quite profound and lasted as long as 2 weeks,” says Jeffrey S. Dover, M.D., a dermatologist practicing in Massa-chusetts. “If you have a cosmetically concerned patient with facial telangiectasia, there’s no way they will tolerate that sort of purpura.” A Wide Range of Available Laser and IPL Treatments Another methodology that has the promise to deliver effective treatment with lower incidence of purpura is the use of longer wavelength devices. Because of the significant hemoglobin absorption peaks at 541 nm or 577 nm, manufacturers and physicians focused on those wavelengths. However, substantial absorption occurs at 800 nm and again at above 1000 nm. This is important because the energy penetration is deeper at the higher wavelength. Thus, a longer wavelength can be used to effectively target deeper vessels or facial deep blue veins. “We now treat facial blue veins with nice results between one and three treatments with any one of the long-pulse Nd:YAG lasers,” says Dr. Dover. “However, be very careful around the eye because these lasers penetrate deeply.” With longer wavelengths to treat deeper vessels and longer pulse durations that allow for targeting larger vessels, physicians can now treat larger and deeper vessels without purpura. The dermatologist now has an array of devices from the pulsed dye laser at 595 nm to the long-pulse 1064 nm devices. “Physicians can now target a greater range of vessels and provide effective treatments without significant purpura,” says Dr. Dover. “Not only can we provide treatments for more of our patients, we can offer improved results with treatments that our patients are happy with.” Despite the drawbacks of the original 450 millisecond pulsed dye lasers, these devices still provide an effective treatment for telangiectasia, as well as erythema. The newer 1.5 microsecond pulsed dye laser with cryogen spray to protect the epidermis also offers an effective treatment device and can significantly lower the occurrence of purpura. By using both laser devices, effective clearing of vessels can be achieved with very low levels of purpura. “By stretching the pulse duration even further by stacking or combining short pulses one right after the other, a very effective treatment was developed without purpura for improving facial redness,” explains Dr. Dover. “And, it turns out it also works for many facial vessels without purpura.” Pulsed 532 nm lasers can be used to effectively clear individual vessels by allowing the operator to literally move the laser along the vessels. In many cases, physicians can achieve virtually 100% clearing of these vessels in an average of three treatments with no bruising or crusting. Intense pulsed light devices can be used to treat individual facial telangiectasia and pigmentation in the same treatment session. IPL has been used for years to treat facial redness without purpura, but many laser users found the IPL devices difficult to use. Now, many of the laser manufacturers also offer IPL units, with several that have an IPL unit built right into their laser boxes. Manufacturers have streamlined the operation of these devices and physicians are finding them a valuable tool. “When treating with IPL, we usually do four to six treatments,” says Dr. Dover. “We can achieve very impressive improvement with no purpura.” Physicians should, however, avoid aggressive settings to treat poikiloderma of Civatte with either the pulsed dye or IPL because they can cause hypopigmented bars in the case of IPL or hypopigmented circles in the case of the pulsed dye laser. Cooling Gels Perhaps the simplest technique to improve results is the use of gels. In addition to providing some direct cooling on its own, a gel can also help a cooling device remain in good contact with the skin, particularly around the eye or the nose. Cooling gels can decrease patient pain and discomfort and can help decrease the edema and crusting of the treatments without significantly impacting treatment efficacy. “I always use a gel, not only for a passive cooler, but if you’re using a contact cooling device it allows you to keep in contact with the skin, especially in difficult areas such as around the nose,” explains Dr. Zelickson. “I find that when I use cooling gel, I can increase my energy a bit and get additional clearing with each treatment.” Getting Visual When treating telangiectasia, it’s critical to be able to see the vessels being cleared, and a number of products exist to help physicians see vessels not completely visible to the naked eye. Syris Scientific produces several visualization products designed to make vessels clearer when viewed using their system. “With the Syris products, you see a lot more of the vessels that you need to target,” explains Dr. Zelickson. “You can really get a lot better effect when you’re doing a tracing-out pattern with a small spot size in these vessels.” Longer Wavelengths Longer wavelengths, like those generated by a Nd:YAG laser, can be very effective when treating dark blue or burgundy vessels or very large vessels. Simply tracing the vessels with the laser can treat these vessels. However, care must be taken when treating on the nose as it is quite easy for atrophic scarring to occur. Stacking Laser Pulses Another way to improve results is the use of multiple pulse passes, or stacking. With stacking, the physician uses multiple pulses at the same time, one pulse right on top of the other or makes multiple passes over the same area. While better results can be obtained than those possible with a single pulse treatment, physicians need to be very careful not to damage or destroy the tissue. When stacking laser pulses, physicians must use lower power levels with each pulse. One downside to stacking laser pulses is the possibility of purpura, which is generally medically insignificant, but which many patients wish to avoid. With stacking, purpura may develop a day or so later, so inform patients of that possibility. Combined Wavelengths Many physicians and researchers are looking at the results that can be obtained by attacking targets with various devices set at different wavelengths. Some physicians are getting encouraging results by treating vessels using a conventional laser treatment, then immediately re-treating the areas using a V-beam. The second treatment appears to improve the overall results. One of the more exciting developments that may soon be available for treatment is a technique that uses a low-energy green light KTP laser that changes the hemoglobin in the target vessel from oxy-hemoglobin to met-hemoglobin, significantly enhancing the absorption at 1064 nm. The vessel is immediately treated with a long-pulse Nd:YAG laser. The net result is that the vessels can be treated with lower energy pulses, producing effective results at less risk to the patient. Treating the Nose The most difficult cases involve telangiectasia of the nose. Vessels on and around the nose are extremely resistant to treatment and tend to recur even after aggressive treatment. In addition, the area is very prone to atrophic scarring. A promising approach is to combine wavelengths and pulse durations from two devices. “What we have found to be effective is to address the vessels with a tracing technique using a KTP laser with a 2-mm spot, a 20 msec pulse, and anywhere from 13 to 14 J/cm2,” explains Dr. Zelickson. “We follow that immediately with a long-pulse pulsed dye laser to avoid purpura. Each pulse produces a bluish hue that dissipates in a matter of seconds.” When using the pulsed dye laser, physicians can opt for a single pass, multiple passes, or stack pulsing, depending on each case. However, even with pulse stacking, you may only achieve a 50% improvement and the vessels may recur. Improving your success rates Not all facial vessels respond to currently available laser therapies, and not all patients will be happy with the results. But, by skillfully using the latest laser technologies and by carefully applying newly developed techniques, you can significantly improve your success rate with laser treatments. “As physicians, we have a responsibility to not only bring safe care but also the best available care to our to our patients,” says Dr. Zelickson. “We need to be aware of new technologies and methodologies and be creative in their use to maximize the benefits to our patients.”
ADVERTISEMENT
Getting the Red Out
T elangiectasia is one of the most common conditions that dermatologist treat, and the pulsed dye laser is generally considered the treatment of choice for this condition. However, recent developments in laser technologies offer alternatives to the pulsed dye laser and hold the promise of allowing physicians to treat difficult cases that they had, until recently, been unable to address. In addition, new techniques and methodologies for using lasers and other light sources, sometimes in tandem, have also shown promise for treating difficult cases and even improving the results for more treatable cases. Now, dermatologists have a wide range of devices and approaches to choose from, and the challenge is to understand how to apply the new developments in the appropriate way to achieve the maximum benefit for patients. The most common treatment for telangiectasia is the traditional pulsed dye laser. In the hands of a skilled operator, the pulsed dye laser would very effectively treat the target vessels with little or no damage to the surrounding tissue. The results of the treatment were often dramatic with most patients enjoying almost total clearing after only a few treatments with little or no scarring or change in pigmentation. Unfortunately, effective treatment with a 450-microsecond pulsed dye laser results in a significant degree of purpura. Although the purpura is transient, lasting only a week or so, most telangiectasia patients will not tolerate it. In addition to patient concerns about purpura, dermatologists treating telangiectasia face other issues that, until recently, could not be effectively resolved. Perhaps the most critical of these is the fact that certain vessel types could not be treated with traditional laser treatments. Moreover, certain areas of the face, especially on and around the nose, are difficult to effectively treat. Considering the number of patients seeking relief from telangiectasia, finding more effective laser treatments that reduce the level of purpura is essential. Recently, a number of new lasers, methodologies and techniques have been developed that promise to deliver effective treatments while reducing side effects such as purpura, recurrence and scarring. According to Brian D. Zelickson, M.D., a dermatologist with a practice in Minneapolis, MN, the treatment options available to dermatologists are rapidly expanding. “Early on, there was essentially one laser, an argon laser, and little information about other effective treatments,” says Dr. Zelickson. “Now, there is a wide range of devices and treatment approaches that can deliver amazing results with little or no purpura or pain to the patient.” Telangiectasia and Erythema With more options available to treat telangiectasia and similar conditions, such as erythema, a treating physician must carefully analyze a patient’s condition to determine the most effective treatment regimen. Better results can be obtained by carefully matching the treatment approach, including the choice of laser, with the condition being treated. In addition, since certain conditions cannot be effectively treated with lasers without risking scarring or other side effects, it’s especially important to be aware of all conditions that the patient might have. “There are a lot of causative factors that we can see in our patients that may be aggravating their condition,” explains Dr. Zelickson. “We need to make sure that we’re not treating something that we shouldn’t be treating with lasers.” When developing treatment for a patient with erythema, it’s essential to determine if the condition is persistent or transient. Transient erythema is often untreatable and those patients should be discouraged. Patients with persistent erythema or telangiectasia or both can be effectively treated using a number of techniques. However, care should be taken to ensure that the patient is not suffering from other conditions, such as an angiosarcoma, sarcoidosis or a lupus purnia. If the patient has red vessels, a long-pulse KTP laser or long-pulse pulsed dye laser at lower fluences to avoid purpura offers an effective treatment. Darker blue, purple or burgundy vessels or large, deeper vessels respond well to a diode laser at 810 nm with a small spot or to a small spot Nd:YAG laser. These devices deliver the appropriate energy absorption and deeper penetration required to treat these types of vessels. If treating patients with both diffuse erythema and telangiectasia, the telangiectasia should be addressed first using the device appropriate for the type of vessel for the telangiectasia. The treating physician can then treat the erythema at the same session with intense pulsed light or a pulsed dye laser using cooling, being careful to keep contact with the skin with the cooling device. Avoiding Purpura With most telangiectasia patients wanting to avoid purpura, even if that means additional treatments or less clearing, dermatologists are seeking alternative treatments to the pulsed dye laser traditionally used to treat telangiectasia. Studies suggest that longer pulse duration would work better because the vessel could be slowly heated causing it to collapse and not rupture, even if dealing with larger vessels. Purpura is caused when the vessel ruptures and blood is released into the surrounding tissue. “With the classic pulsed dye laser at 450 microseconds, the purpura was quite profound and lasted as long as 2 weeks,” says Jeffrey S. Dover, M.D., a dermatologist practicing in Massa-chusetts. “If you have a cosmetically concerned patient with facial telangiectasia, there’s no way they will tolerate that sort of purpura.” A Wide Range of Available Laser and IPL Treatments Another methodology that has the promise to deliver effective treatment with lower incidence of purpura is the use of longer wavelength devices. Because of the significant hemoglobin absorption peaks at 541 nm or 577 nm, manufacturers and physicians focused on those wavelengths. However, substantial absorption occurs at 800 nm and again at above 1000 nm. This is important because the energy penetration is deeper at the higher wavelength. Thus, a longer wavelength can be used to effectively target deeper vessels or facial deep blue veins. “We now treat facial blue veins with nice results between one and three treatments with any one of the long-pulse Nd:YAG lasers,” says Dr. Dover. “However, be very careful around the eye because these lasers penetrate deeply.” With longer wavelengths to treat deeper vessels and longer pulse durations that allow for targeting larger vessels, physicians can now treat larger and deeper vessels without purpura. The dermatologist now has an array of devices from the pulsed dye laser at 595 nm to the long-pulse 1064 nm devices. “Physicians can now target a greater range of vessels and provide effective treatments without significant purpura,” says Dr. Dover. “Not only can we provide treatments for more of our patients, we can offer improved results with treatments that our patients are happy with.” Despite the drawbacks of the original 450 millisecond pulsed dye lasers, these devices still provide an effective treatment for telangiectasia, as well as erythema. The newer 1.5 microsecond pulsed dye laser with cryogen spray to protect the epidermis also offers an effective treatment device and can significantly lower the occurrence of purpura. By using both laser devices, effective clearing of vessels can be achieved with very low levels of purpura. “By stretching the pulse duration even further by stacking or combining short pulses one right after the other, a very effective treatment was developed without purpura for improving facial redness,” explains Dr. Dover. “And, it turns out it also works for many facial vessels without purpura.” Pulsed 532 nm lasers can be used to effectively clear individual vessels by allowing the operator to literally move the laser along the vessels. In many cases, physicians can achieve virtually 100% clearing of these vessels in an average of three treatments with no bruising or crusting. Intense pulsed light devices can be used to treat individual facial telangiectasia and pigmentation in the same treatment session. IPL has been used for years to treat facial redness without purpura, but many laser users found the IPL devices difficult to use. Now, many of the laser manufacturers also offer IPL units, with several that have an IPL unit built right into their laser boxes. Manufacturers have streamlined the operation of these devices and physicians are finding them a valuable tool. “When treating with IPL, we usually do four to six treatments,” says Dr. Dover. “We can achieve very impressive improvement with no purpura.” Physicians should, however, avoid aggressive settings to treat poikiloderma of Civatte with either the pulsed dye or IPL because they can cause hypopigmented bars in the case of IPL or hypopigmented circles in the case of the pulsed dye laser. Cooling Gels Perhaps the simplest technique to improve results is the use of gels. In addition to providing some direct cooling on its own, a gel can also help a cooling device remain in good contact with the skin, particularly around the eye or the nose. Cooling gels can decrease patient pain and discomfort and can help decrease the edema and crusting of the treatments without significantly impacting treatment efficacy. “I always use a gel, not only for a passive cooler, but if you’re using a contact cooling device it allows you to keep in contact with the skin, especially in difficult areas such as around the nose,” explains Dr. Zelickson. “I find that when I use cooling gel, I can increase my energy a bit and get additional clearing with each treatment.” Getting Visual When treating telangiectasia, it’s critical to be able to see the vessels being cleared, and a number of products exist to help physicians see vessels not completely visible to the naked eye. Syris Scientific produces several visualization products designed to make vessels clearer when viewed using their system. “With the Syris products, you see a lot more of the vessels that you need to target,” explains Dr. Zelickson. “You can really get a lot better effect when you’re doing a tracing-out pattern with a small spot size in these vessels.” Longer Wavelengths Longer wavelengths, like those generated by a Nd:YAG laser, can be very effective when treating dark blue or burgundy vessels or very large vessels. Simply tracing the vessels with the laser can treat these vessels. However, care must be taken when treating on the nose as it is quite easy for atrophic scarring to occur. Stacking Laser Pulses Another way to improve results is the use of multiple pulse passes, or stacking. With stacking, the physician uses multiple pulses at the same time, one pulse right on top of the other or makes multiple passes over the same area. While better results can be obtained than those possible with a single pulse treatment, physicians need to be very careful not to damage or destroy the tissue. When stacking laser pulses, physicians must use lower power levels with each pulse. One downside to stacking laser pulses is the possibility of purpura, which is generally medically insignificant, but which many patients wish to avoid. With stacking, purpura may develop a day or so later, so inform patients of that possibility. Combined Wavelengths Many physicians and researchers are looking at the results that can be obtained by attacking targets with various devices set at different wavelengths. Some physicians are getting encouraging results by treating vessels using a conventional laser treatment, then immediately re-treating the areas using a V-beam. The second treatment appears to improve the overall results. One of the more exciting developments that may soon be available for treatment is a technique that uses a low-energy green light KTP laser that changes the hemoglobin in the target vessel from oxy-hemoglobin to met-hemoglobin, significantly enhancing the absorption at 1064 nm. The vessel is immediately treated with a long-pulse Nd:YAG laser. The net result is that the vessels can be treated with lower energy pulses, producing effective results at less risk to the patient. Treating the Nose The most difficult cases involve telangiectasia of the nose. Vessels on and around the nose are extremely resistant to treatment and tend to recur even after aggressive treatment. In addition, the area is very prone to atrophic scarring. A promising approach is to combine wavelengths and pulse durations from two devices. “What we have found to be effective is to address the vessels with a tracing technique using a KTP laser with a 2-mm spot, a 20 msec pulse, and anywhere from 13 to 14 J/cm2,” explains Dr. Zelickson. “We follow that immediately with a long-pulse pulsed dye laser to avoid purpura. Each pulse produces a bluish hue that dissipates in a matter of seconds.” When using the pulsed dye laser, physicians can opt for a single pass, multiple passes, or stack pulsing, depending on each case. However, even with pulse stacking, you may only achieve a 50% improvement and the vessels may recur. Improving your success rates Not all facial vessels respond to currently available laser therapies, and not all patients will be happy with the results. But, by skillfully using the latest laser technologies and by carefully applying newly developed techniques, you can significantly improve your success rate with laser treatments. “As physicians, we have a responsibility to not only bring safe care but also the best available care to our to our patients,” says Dr. Zelickson. “We need to be aware of new technologies and methodologies and be creative in their use to maximize the benefits to our patients.”
T elangiectasia is one of the most common conditions that dermatologist treat, and the pulsed dye laser is generally considered the treatment of choice for this condition. However, recent developments in laser technologies offer alternatives to the pulsed dye laser and hold the promise of allowing physicians to treat difficult cases that they had, until recently, been unable to address. In addition, new techniques and methodologies for using lasers and other light sources, sometimes in tandem, have also shown promise for treating difficult cases and even improving the results for more treatable cases. Now, dermatologists have a wide range of devices and approaches to choose from, and the challenge is to understand how to apply the new developments in the appropriate way to achieve the maximum benefit for patients. The most common treatment for telangiectasia is the traditional pulsed dye laser. In the hands of a skilled operator, the pulsed dye laser would very effectively treat the target vessels with little or no damage to the surrounding tissue. The results of the treatment were often dramatic with most patients enjoying almost total clearing after only a few treatments with little or no scarring or change in pigmentation. Unfortunately, effective treatment with a 450-microsecond pulsed dye laser results in a significant degree of purpura. Although the purpura is transient, lasting only a week or so, most telangiectasia patients will not tolerate it. In addition to patient concerns about purpura, dermatologists treating telangiectasia face other issues that, until recently, could not be effectively resolved. Perhaps the most critical of these is the fact that certain vessel types could not be treated with traditional laser treatments. Moreover, certain areas of the face, especially on and around the nose, are difficult to effectively treat. Considering the number of patients seeking relief from telangiectasia, finding more effective laser treatments that reduce the level of purpura is essential. Recently, a number of new lasers, methodologies and techniques have been developed that promise to deliver effective treatments while reducing side effects such as purpura, recurrence and scarring. According to Brian D. Zelickson, M.D., a dermatologist with a practice in Minneapolis, MN, the treatment options available to dermatologists are rapidly expanding. “Early on, there was essentially one laser, an argon laser, and little information about other effective treatments,” says Dr. Zelickson. “Now, there is a wide range of devices and treatment approaches that can deliver amazing results with little or no purpura or pain to the patient.” Telangiectasia and Erythema With more options available to treat telangiectasia and similar conditions, such as erythema, a treating physician must carefully analyze a patient’s condition to determine the most effective treatment regimen. Better results can be obtained by carefully matching the treatment approach, including the choice of laser, with the condition being treated. In addition, since certain conditions cannot be effectively treated with lasers without risking scarring or other side effects, it’s especially important to be aware of all conditions that the patient might have. “There are a lot of causative factors that we can see in our patients that may be aggravating their condition,” explains Dr. Zelickson. “We need to make sure that we’re not treating something that we shouldn’t be treating with lasers.” When developing treatment for a patient with erythema, it’s essential to determine if the condition is persistent or transient. Transient erythema is often untreatable and those patients should be discouraged. Patients with persistent erythema or telangiectasia or both can be effectively treated using a number of techniques. However, care should be taken to ensure that the patient is not suffering from other conditions, such as an angiosarcoma, sarcoidosis or a lupus purnia. If the patient has red vessels, a long-pulse KTP laser or long-pulse pulsed dye laser at lower fluences to avoid purpura offers an effective treatment. Darker blue, purple or burgundy vessels or large, deeper vessels respond well to a diode laser at 810 nm with a small spot or to a small spot Nd:YAG laser. These devices deliver the appropriate energy absorption and deeper penetration required to treat these types of vessels. If treating patients with both diffuse erythema and telangiectasia, the telangiectasia should be addressed first using the device appropriate for the type of vessel for the telangiectasia. The treating physician can then treat the erythema at the same session with intense pulsed light or a pulsed dye laser using cooling, being careful to keep contact with the skin with the cooling device. Avoiding Purpura With most telangiectasia patients wanting to avoid purpura, even if that means additional treatments or less clearing, dermatologists are seeking alternative treatments to the pulsed dye laser traditionally used to treat telangiectasia. Studies suggest that longer pulse duration would work better because the vessel could be slowly heated causing it to collapse and not rupture, even if dealing with larger vessels. Purpura is caused when the vessel ruptures and blood is released into the surrounding tissue. “With the classic pulsed dye laser at 450 microseconds, the purpura was quite profound and lasted as long as 2 weeks,” says Jeffrey S. Dover, M.D., a dermatologist practicing in Massa-chusetts. “If you have a cosmetically concerned patient with facial telangiectasia, there’s no way they will tolerate that sort of purpura.” A Wide Range of Available Laser and IPL Treatments Another methodology that has the promise to deliver effective treatment with lower incidence of purpura is the use of longer wavelength devices. Because of the significant hemoglobin absorption peaks at 541 nm or 577 nm, manufacturers and physicians focused on those wavelengths. However, substantial absorption occurs at 800 nm and again at above 1000 nm. This is important because the energy penetration is deeper at the higher wavelength. Thus, a longer wavelength can be used to effectively target deeper vessels or facial deep blue veins. “We now treat facial blue veins with nice results between one and three treatments with any one of the long-pulse Nd:YAG lasers,” says Dr. Dover. “However, be very careful around the eye because these lasers penetrate deeply.” With longer wavelengths to treat deeper vessels and longer pulse durations that allow for targeting larger vessels, physicians can now treat larger and deeper vessels without purpura. The dermatologist now has an array of devices from the pulsed dye laser at 595 nm to the long-pulse 1064 nm devices. “Physicians can now target a greater range of vessels and provide effective treatments without significant purpura,” says Dr. Dover. “Not only can we provide treatments for more of our patients, we can offer improved results with treatments that our patients are happy with.” Despite the drawbacks of the original 450 millisecond pulsed dye lasers, these devices still provide an effective treatment for telangiectasia, as well as erythema. The newer 1.5 microsecond pulsed dye laser with cryogen spray to protect the epidermis also offers an effective treatment device and can significantly lower the occurrence of purpura. By using both laser devices, effective clearing of vessels can be achieved with very low levels of purpura. “By stretching the pulse duration even further by stacking or combining short pulses one right after the other, a very effective treatment was developed without purpura for improving facial redness,” explains Dr. Dover. “And, it turns out it also works for many facial vessels without purpura.” Pulsed 532 nm lasers can be used to effectively clear individual vessels by allowing the operator to literally move the laser along the vessels. In many cases, physicians can achieve virtually 100% clearing of these vessels in an average of three treatments with no bruising or crusting. Intense pulsed light devices can be used to treat individual facial telangiectasia and pigmentation in the same treatment session. IPL has been used for years to treat facial redness without purpura, but many laser users found the IPL devices difficult to use. Now, many of the laser manufacturers also offer IPL units, with several that have an IPL unit built right into their laser boxes. Manufacturers have streamlined the operation of these devices and physicians are finding them a valuable tool. “When treating with IPL, we usually do four to six treatments,” says Dr. Dover. “We can achieve very impressive improvement with no purpura.” Physicians should, however, avoid aggressive settings to treat poikiloderma of Civatte with either the pulsed dye or IPL because they can cause hypopigmented bars in the case of IPL or hypopigmented circles in the case of the pulsed dye laser. Cooling Gels Perhaps the simplest technique to improve results is the use of gels. In addition to providing some direct cooling on its own, a gel can also help a cooling device remain in good contact with the skin, particularly around the eye or the nose. Cooling gels can decrease patient pain and discomfort and can help decrease the edema and crusting of the treatments without significantly impacting treatment efficacy. “I always use a gel, not only for a passive cooler, but if you’re using a contact cooling device it allows you to keep in contact with the skin, especially in difficult areas such as around the nose,” explains Dr. Zelickson. “I find that when I use cooling gel, I can increase my energy a bit and get additional clearing with each treatment.” Getting Visual When treating telangiectasia, it’s critical to be able to see the vessels being cleared, and a number of products exist to help physicians see vessels not completely visible to the naked eye. Syris Scientific produces several visualization products designed to make vessels clearer when viewed using their system. “With the Syris products, you see a lot more of the vessels that you need to target,” explains Dr. Zelickson. “You can really get a lot better effect when you’re doing a tracing-out pattern with a small spot size in these vessels.” Longer Wavelengths Longer wavelengths, like those generated by a Nd:YAG laser, can be very effective when treating dark blue or burgundy vessels or very large vessels. Simply tracing the vessels with the laser can treat these vessels. However, care must be taken when treating on the nose as it is quite easy for atrophic scarring to occur. Stacking Laser Pulses Another way to improve results is the use of multiple pulse passes, or stacking. With stacking, the physician uses multiple pulses at the same time, one pulse right on top of the other or makes multiple passes over the same area. While better results can be obtained than those possible with a single pulse treatment, physicians need to be very careful not to damage or destroy the tissue. When stacking laser pulses, physicians must use lower power levels with each pulse. One downside to stacking laser pulses is the possibility of purpura, which is generally medically insignificant, but which many patients wish to avoid. With stacking, purpura may develop a day or so later, so inform patients of that possibility. Combined Wavelengths Many physicians and researchers are looking at the results that can be obtained by attacking targets with various devices set at different wavelengths. Some physicians are getting encouraging results by treating vessels using a conventional laser treatment, then immediately re-treating the areas using a V-beam. The second treatment appears to improve the overall results. One of the more exciting developments that may soon be available for treatment is a technique that uses a low-energy green light KTP laser that changes the hemoglobin in the target vessel from oxy-hemoglobin to met-hemoglobin, significantly enhancing the absorption at 1064 nm. The vessel is immediately treated with a long-pulse Nd:YAG laser. The net result is that the vessels can be treated with lower energy pulses, producing effective results at less risk to the patient. Treating the Nose The most difficult cases involve telangiectasia of the nose. Vessels on and around the nose are extremely resistant to treatment and tend to recur even after aggressive treatment. In addition, the area is very prone to atrophic scarring. A promising approach is to combine wavelengths and pulse durations from two devices. “What we have found to be effective is to address the vessels with a tracing technique using a KTP laser with a 2-mm spot, a 20 msec pulse, and anywhere from 13 to 14 J/cm2,” explains Dr. Zelickson. “We follow that immediately with a long-pulse pulsed dye laser to avoid purpura. Each pulse produces a bluish hue that dissipates in a matter of seconds.” When using the pulsed dye laser, physicians can opt for a single pass, multiple passes, or stack pulsing, depending on each case. However, even with pulse stacking, you may only achieve a 50% improvement and the vessels may recur. Improving your success rates Not all facial vessels respond to currently available laser therapies, and not all patients will be happy with the results. But, by skillfully using the latest laser technologies and by carefully applying newly developed techniques, you can significantly improve your success rate with laser treatments. “As physicians, we have a responsibility to not only bring safe care but also the best available care to our to our patients,” says Dr. Zelickson. “We need to be aware of new technologies and methodologies and be creative in their use to maximize the benefits to our patients.”
