Treating Facial Telangiectasia

09/04/2008

There seem to be nearly as many different approaches to treating facial telangiectasia as there are patients seeking treatment for any one of its multiple presentations.
Facial vascular lesions differ greatly, both in terms of the size and depth of the vessels causing them and in terms of their response to treatment.
An ever-increasing range of options — especially next-generation intense pulsed light (IPL) devices and pulsed dye lasers (PDL) — have continually been refined since the days when vessels around the nose were painfully zapped with electrocautery devices and port wine stains were tattooed.

Physicians generally vary their approaches according to the type of vessels targeted, which include distinct individual veins 1/2 mm to 1 mm in size, larger and/or deeper veins typically around the nose, near the mouth or lateral cheeks, and more diffuse
areas of redness where veins are difficult to differentiate individually, as with the pink blush classically associated with rosacea.

Technology — IPL or Lasers

Murad Alam, M.D., Chief of the Section of Cutaneous and Aesthetic Surgery, Department of Dermatology, Northwestern University in Chicago, notes that there are “two schools of thought,” with physicians generally falling on one side of the IPL-laser divide much like Mac and PC users.

“They’re different enough that when you’re comfortable with one, the other may seem somewhat awkward, but each has its pluses and minuses.”

In recent years, these advantages and disadvantages have traditionally given the edge to lasers for distinct veins that can be individually “tracked out” and IPL for diffuse areas of redness — especially when these are combined with brown areas that IPL can treat simultaneously. Minuses include the purpura that may accompany high-fluence, narrow pulse-width PDL treatment, and IPLs can be somewhat less efficacious for rapid treatment of larger individual vessels and more intense lesions.

But new-generation technology has blurred some of these differences. This includes an IPL device with laser-like handpieces for individual veins and 595-nm long-pulsed PDLs that prevent purpura by permitting the stacking of pulses that separately have lower energy and longer pulse durations but those that collectively target vessels without bruising.

Now falling squarely on the IPL side of the divide is Vic Narurkar, M.D., Associate Professor of Dermatology at the University of California, in Davis, CA, who recently conducted what he termed a “side-by-side study” comparing a new-generation IPL (StarLux LuxG [Palomar Medical]) with lasers (532 nm KTP and 595 nm PDL) and traditional IPL (Quantum SR [Lumenis] 560 nm and 590 nm).

Although he considers them to be highly effective, Dr. Narurkar did not include the older-generation PDLs in this study. “We found that when pulsed dye lasers created purpura, they were more effective in treating the blood vessels in the non-purpuric range, but patients didn’t like the down time associated with having bruises for up to 10 days.”

The new-generation IPLs, however, definitively changed his allegiance.

“The problem with pulsed light before was that it was not good at treating blood vessels. But with the new generation’s photon recycling, light is being delivered more efficiently to the target, while sapphire contact cooling makes it possible to apply the pulsed light directly to the skin. In addition, each handpiece on the device is like a laser; the Lux green handpiece has characteristics of two different lasers — 532-nm and 910-nm laser.”

His study, which wasn’t sponsored by Palomar, found results on isolated telangiectasia to be equal to the Vbeam and KTP and better than Quantum. For diffuse vessels, such as in rosacea, he says the StarLux Lux G was superior.

Brian Zelickson, M.D., an Associate Professor of Dermatology at the University of Minnesota in Minneapolis, finds himself leaning more toward the laser side of the divide, especially since using the VBeam Perfecta (Candela), a new 595-nm long-pulsed pulsed dye laser with a 12-mm spot size for treating large areas.

The eight-micropulse technology, he says, resembles a single continuous pulse while delivering the required fluence for vessel coagulation without purpura. “The original Vbeam’s 150-microsecond macropulse was made up of four micropulses, energy that is now evenly divided into eight micropulses. This enables us to use more energy without purpura.”

Explaining his approach to different types of vessels using this technology, he asserts, “Generally, we use longer pulse durations and a little higher fluence for larger vessels and shorter pulse durations and lower fluence for larger spots in diffuse areas, using a multiple-pass technique. For individual veins, we use an elliptical spot, a 10-ms to 40-ms pulse and a fluence of 9 to 15 J/cm2. For the diffuse erythema of rosacea, we use a 10-mm spot, 6-ms pulse and a fluence of 6.5 to 8.5 J/cm2. The number of treatments vary from one to four, spaced typically 4 to 6 weeks apart.

Although there is no purpura, he maintains, patients experience some redness and swelling for up to 2 days.

 

 

 

 

Diagnosis and Treatment Selection

Dr. Christopher Zachary, Professor and Chair of the Department of Dermatology at the University of California at Irvine, stresses the importance of first evaluating patients medically to rule out underlying conditions such as lupus erythematosus or dermatomyositis that can be associated with facial telangiectasia. Toward this point, he recalls a patient whose post-pregnancy complaints of telangiectasia and hair loss were in fact symptoms of metastatic carcinoma of the uterus, not the alopecia areata diagnosed by another physician.

Beyond that, Dr. Zachary says listening to the patient can help the physician better match the patient with an appropriate treatment.
“Once you’ve established the cause, then weigh factors such as the patient’s budget, time frame, even his or her job. You can achieve the same results with many different systems, so it’s important to choose the right one for the individual patient. For example, I can’t send out a bride-to-be or television broadcaster with a bruised face, as might be the case after treatment with a pulsed dye laser, when the KTP 532-nm laser or current-generation IPL device may leave patients with just a little erythema and swelling for a day.”
There are many different approaches to different types of telangiectasia.

Rosacea and Diffuse Redness

Dr. Alam eschews the term “rosacea,” which he considers to be over-diagnosed.

“Pimples, flushing, and redness, plus fine individual blood vessels must all be present for rosacea, which requires a multimodal treatment approach. Pimples may be improved by oral antibiotics or an acne laser, and flushing with prophylactic medication or avoiding triggers — although if you treat vessels, it could reduce flushing because the blood has fewer places to go.”

As for the diffuse area that appears more as a network than individual vessels, he favors treating the entire area of redness with a pulsed dye laser with a method designed to avoid purpura.

“If using a standard VBeam laser, I would use 7.5 J/cm2, 6-ms and 10-mm spot setting, which I would double pulse before continuing. I zap these areas with these small very fine vessels until there’s a faint bluish blush — two or three stacked passes before moving on to another one. The larger 12-mm spot size and higher peak fluence of the new VBeam Perfecta permits even more rapid and effective treatment of such areas.”

 

Treating Background Redness of Rosacea

Dr. Taub, Director of Advanced Dermatology, Skinfo and SKINQRI and Clinical Instructor, Northwestern University Medical School in Chicago, describes two approaches to background redness associated with rosacea.

One choice is the “Genesis procedure” for the 1064 nm Cool Glide Xeo (Cutera).

“Instead of using a high-intensity focus beam, I use a defocused low-intensity, very short-pulsed duration beam — 5-mm spot size, 15 J/cm2 with a 0.3-ms pulse duration, with the handpiece floating 1 cm to 2 cm over the skin, at a speed of 10 Hz. I ‘paint’ over the face with long strokes, covering the entire face multiple times, completing 8 to 10,000 pulses for a full face.”

She also uses the Aurora SR (Syneron), a combination pulsed light 580 nm to 980 nm and bipolar radiofrequency. She is currently conducting a study, for which she is receiving a research fee from Syneron, using a newer handpiece, the SRA, with wavelengths of 420 nm to 980 nm with radiofrequency for rosacea.

“I use this a lot for rosacea because it is highly effective and offers better objective measurements of safety and efficacy. The bipolar radiofrequency allows you to monitor the change in the tissue temperature from the beginning of the pulse to the end. In my experience using it for the last 3 and a half years, the impedance safety measurement (ISM) number corresponds quite accurately to the ‘sweet spot,’ the most aggressive yet safe parameters. This avoids complications and also makes the treatments much more consistent, leading to better outcomes and fewer treatments.”

As a member of the speaking boards of both Syneron and Cutera, Dr. Taub discloses that she receives an honorarium when she speaks on their behalf; she has also received their equipment at reduced fees.

The Need for Cooling

For all indications, Dr. Taub stresses the importance of adequate cooling, the purpose of which is to prevent injury of the epidermis and dermis.

“Cooling is absolutely mandatory for every laser procedure. Every device has a different kind of cooling, but except for those equipped with cryogen spray cooling, we usually feel using an additional method helps to alleviate discomfort as well as increase the safety profile of the procedure. We chose a cold air method, the Zimmer, because unlike contact cooling, you don’t need to conform it to any shape or size.”

Although some physicians use icing, she abandoned the practice after her own experience while treating leg veins led to a urticaria in one case and cold-induced vasculitis in another.

Treating Capillaries

For individually resolvable capillaries, Dr. Alam describes his method using conservative settings — “perhaps 15 J/cm2 at 3 pulses per second” — on the Aura, a KTP laser (Laserscope).

“I’m a big fan of a 1-mm spot. It doesn’t really matter what settings you use, but I recommend being on the conservative end of whatever device you’re using in terms of both fluence and the rate at which the pulses are fired. Be sure to fire the pulses relatively slowly so that you don’t stack up too much energy in any one area.”

Moving slowly, at a rate of 2 mm to 3 mm per second, also provides adequate time to trace the individual vessels.

“Beginners often make the mistake of moving quickly because the device is pulsing, not understanding that they’re only pulsing a 1-mm spot, which can mean they are missing linear stretches of untreated area,” he warns.

This procedure, which can be repeated during a given session is his first-line treatment for all individual vessels, including nasal dorsal vessels, which may not be ultimately responsive.

Dr. Taub considers the 1064 nm laser highly effective for individual facial veins. She uses a 3-mm spot size with fluences of 180 to 195 J/cm2 and pulse durations of 10 ms to 20 ms for individual telangiectasia.

Treating Larger, Deeper Veins

Dr. Zachary describes several approaches to what he calls larger and/or deeper “high-flow blood vessels” that can often elude first-line treatment with the 532 KTP.

“My first approach would be the 595 pulsed dye laser, taking care to provide for adequate cooling, which enables the doctor to deliver the energy much deeper into the skin. If you pre-chill the skin, you can stack pulses, extending the pulse from typical 1.5 ms to 6 or 10 ms.”

The next method he recommends — particularly for larger, deeper vessels — uses the 940-nm wavelength of the Varilite (Iridex) dual wavelength (532 nm and 940 nm) laser system. This wavelength, he says, does not absorb as well, but the longer wavelength allows for deeper penetration, which diffuses the heat more.

Dr. Zachary says he uses a “spot welding technique” instead of simply tracing along the vessel. “I treat a spot then leave gap, then weld approximately every 2 mm.”

His last approach is the technology he reserves for “big, nodular, vascular lesions” using the long-pulsed 1064 laser. Warning that “this is not for novices” and that even experts can cause scarring, he usually limits its facial application to port wine stains and
vascular malformations inside the mouth.

As for Dr. Alam, when his first-line treatment for individual veins fails after repeated attempts, he turns to old technology, electrocautery by epilating needle — attached to a Hyfrecator 2000 on very low setting.

“Because scarring is a risk, I want to minimize the use of the epilating needle to a limited number of vessels,” he says.

Calling this technique “very operator dependent,” he warns against delegation to physician extenders or residents citing the ease with which it can result in “a nice hole in someone’s nose.”

“I insert one of the very sharp tiny needles ever so slightly into thicker vessels, using the shortest possible burst of energy on a low setting — 3 or 4 — to cauterize the vessel, before moving 4 to 5 mm to zap again a little downstream. If you get it right, it works like a charm. You’ll see a whole bunch of vessels sort of blanch and disappear.”

Treatment of large dark blue veins using the Nd:YAG around the eyes and mouth is effective but can be painful and/or dangerous.
“The Nd:YAG laser needs to penetrate through several skin layers to reach the targeted vessel. Really good cooling is important. It must be effective, appropriate and sufficient to protect the epidermis while directing energy deeper down,” says Dr. Alam. “For small reticular veins around the eye, be cognizant of the fact that you can’t treat within the bony orbit of the eye. The Nd:YAG light can penetrate very deeply and is known to cause retinal injury — even if the eye is closed. If you are within the orbit, there’s no bone to prevent transmission of light through the soft tissue.”

With that said, Dr. Alam describes his approach: “First, give patients occlusive goggles to be safe. Pull the skin so that the vessel is down over bone, and then treat downward toward the jaw.”

“The ideal patient receiving treatment of facial reticular veins is well-informed and non-anxious. In some instances it might also be appropriate to advise against this treatment or try a thermal destructive modality such as an epilating needle.”

Combination Therapy

“People normally have a mixed defect including some redness, finer vessels, and larger vessels of the nose,” says Dr. Alam. This typically entails using two or more different approaches within a single session.

“I start with the KTP, tracing veins that are large enough but not too large, and then I treat the area wall-to-wall with the pulsed dye laser. For the vessels that remain, I use my epilating needle.”

Dr. Taub’s combination approach to individual veins with background redness involves both the two different XEO Coolglide 1064 and the Aurora SRA described earlier for rosacea.

There are many options for treating facial telangiectasia. It’s important to evaluate patients medically to rule out underlying conditions that can be associated with facial telangiectasia, determine the cause and consider the patient’s lifestyle in order to choose the best option.