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Treating Vascular Lesions

Treating Vascular Lesions

Vascular LesionsFrom pulsed dye lasers to IPL devices to Nd:YAG lasers, physicians have numerous potential treatment options, but not all devices treat all disorders equally.

There are almost as many types of vascular lesions as there are potential treatments, but the most commonly used lasers include pulsed dye laser, long-pulsed Nd:YAG laser, long-pulsed 32-nm green light laser and intense pulsed light (IPL), with wavelengths ranging from 500 nm to 1200 nm, depending on the type and location of the lesion.

Hands and feet may be the hardest regions to treat, owing, probably, to a combination of factors, including gravity, hydrostatic pressure and thickness of the vessel wall. Leg veins may include an element of hormonal changes, says Jeffrey S. Dover, MD, FRCPC, associate clinical professor of dermatology, Yale University School of Medicine; adjunct professor of medicine (dermatology), Dartmouth Medical School; and director, SkinCare Physicians (Chestnut Hill, MA).

“[Skin] types 5 and 6 never get poikiloderma, but they do get port wine stains, and these are much more difficult to treat than in fair skin individuals because of the competition between the pigment and the blood vessels,” he explains.

Defining the target should be the first step in any treatment regimen, says Christopher B. Zachary, MD, professor and chair of the department of dermatology at the University of California-Irvine School of Medicine.

Having more than one laser readily available “can be a big advantage, since different vascular lesions are located at various depths in the skin,” notes Joely Kaufman, MD, assistant professor of dermatology at the University of Miami Miller School of Medicine and associate at Brandt Dermatology (Coral Gables, FL). Superficial lesions are typically treated with a 595-nm pulsed dye laser or a 532-nm KTP laser, but, for deeper lesions, Dr. Kaufman recommends using an S-wavelength with deeper penetration, such as a 1064-nm Nd:YAG.

“Whatever vascular lesion you’re targeting, consider the photothermal dynamics,” Dr. Zachary says. “You need to consider the best wavelength, pulse duration and fluence.”

The pulsed dye laser has been available for longer than the other treatments, and “it dramatically changed how we treat port wine stains, hemangiomas and even facial vessels,” says Emil A. Tanghetti, MD, clinical professor of dermatology at the University of California, Davis.

In particular, “skin type and location of the body are the two main variables that should dictate how you treat,” explains Lori Brightman, MD, of the New York Eye and Ear Infirmary.

Commonly Treated Disorders

Most dermatologists see and treat facial telangiectasia more than other vascular disorders; port wine stains and patients with hemagiomas are often referred to colleagues who treat these conditions frequently, Dr. Dover explains. Facial telangiectasia is much more common in people with English, Irish or Scottish heritage, “and it’s very common if there is a family history of rosacea or redness.” It’s the one disorder he treats with equal frequency in men and women.
“We can improve the condition — I tell my patients we typically get an 80%-90% improvement in over 90% of individuals,” Dr. Dover says.

The Palomar MaxG handpiece is one of the more powerful IPL devices for vascular disorders, which allows physicians to treat patients at shorter pulse durations, Dr. Tanghetti says. Peak power and shorter pulse duration make it a viable alternative for vascular disorders.

“That makes it a good device for the treatment of facial telangiectasia,” he says, but “our experience with pulsed dye laser is more extensive, making it hard to supplant with other devices.”

Part of treating vascular lesions is learning how the lesion will respond with an optimal treatment, Dr. Kaufman says.

“With the pulsed dye laser and the KTP, you’ll see a slight purpura of the lesion itself without purpura of the surrounding tissue,” she says. With the KTP, “you can see the vessel collapse.”
It’s difficult to judge the depth of a vessel by sight, but it’s easy to determine if the vessel saw the laser light by the way the lesion responds, she adds.

“That’s not necessarily the case with other types of lesions,” Dr. Kaufman explains. “So whichever laser you use for vascular lesions, you need to know what the correct response will look like on the skin.”

For instance, if she’s fired the KTP and the vessel doesn’t blanch or collapse, or there is no purpura, “I know I’m not going to have an effective treatment and I need to change the pulse width or the spot size to get a little more penetration.”

Port wine stains are best treated at an early age when the lesions will be their smallest and thinnest. Dr. Dover recommends treating in the first year of life, because infants don’t usually require sedation, or anesthesia, and the pain is manageable. Dr. Brightman has treated patients as young as 11 days with pulsed dye lasers. In her opinion, earlier treatment also helps the patient avoid future medical concerns if the port wine stain thickens and cobblestones over time. She usually starts with a 595-nm laser but moves to a 755-nm if there are recalcitrant stains.

“Treating port wine stains is not simply cosmetic,” she said. “It really is a medical indication in my eyes.”

Vascular Figure 1Vascular Figure 2Figure 1 (left):  One treatment with the Cynergy laser for facial telangiectasia [before (left) and after (right)].

FIgure 2 (right): One treatment with the Cynergy laser for this blebbed port wine stain [before (left) and after (right)].

Editor's Note: Please click on the image to see the full-size picture in a new window.

Roy G. Geronemus, MD, Director of the Laser & Skin Surgery Center of New York and Clinical Professor of Dermatology at New York University Medical Center, recently presented new evidence suggesting a much shorter treatment spacing where physicians “treat right on top of each other,” Dr. Kaufman says. “He got much better results with port wine than we’re used to seeing.”

Nodular port wine stains can be successfully treated with a long-pulsed Alexandrite 755-nm laser or a long-pulsed 1064-nm Nd:YAG, “but they have a higher risk for scarring,” Dr. Dover warns.

Poikiloderma is actually “very common, and is beautifully treated with either the pulsed dye laser, pulsed 532, or IPL. The red vessel components are treatable with the pulsed dye laser, pulsed 532 or with IPL, and the brown component is treated with pulsed 532, IPL or a Q-switched Alexandrite, Nd:YAG or Ruby laser,” Dr. Dover says. The newer Excel V laser (532 nm) “works beautifully for both the red and the brown component of poikiloderma on the neck and chest,” he adds.

Dr. Kaufman recently completed a study using the Excel V laser on 12 patients with poikiloderma on their necks and chests — a difficult condition that usually takes “several different treatments and doesn’t always respond.” With the Excel, she says “everyone had excellent results with major improvements.”

If there is “a lot of atrophy,” Dr. Kaufman uses a nonablative fractional laser as well.

“The beauty of the IPL device is that it works well for pigmentation,” Dr. Tanghetti explains. “With that device, we use conservative settings with cooling, and we treat poikiloderma of Civatte typically in the winter because we are dealing with a little less pigment.”

Dr. R. Rox Anderson, of Harvard Medical School and Massachusetts General Hospital in Boston, MA, and his group recently found that treating vascular lesions can be done more effectively by understanding the arterial or venous nature of a target. They suggest that port wine stains and other vascular lesions with a substantial venous nature be treated with wavelengths in the 600- to 700-nm range.

Pulsed Dye Lasers

“On average, most patients with port wine stains need at least 12 treatments, some need 18, and we’ve treated many patients with more than 25 treatments,” Dr. Dover says. “The younger the child, the faster the stain clears and the better the result.” He also notes it is rare to completely clear the stain.

Earlier versions of pulsed dye lasers produced “very short little pulses,” Dr. Zachary explains, which resulted in immediate bruising. Once the pulse was extended to 6 or 10 milliseconds, physicians were able to provide pulse stacking without scarring, as long as they employed cooling to protect the skin.

“I have a lot of trouble clearing perinasal telangiectasia with a pulsed dye laser, even with long pulses,” Dr. Kaufman notes. “I have had better luck with the pulsed dye for hypertrophic scars.”

Different Wavelengths For Different Disorders

For facial lesions, Dr. Kaufman says the lesion will dictate which laser to use.

“For rosacea, telangiectasias and other vascular lesions on the face, I use the Excel V KTP laser; for hypertrophic or keloid scars I tend to use the pulsed dye laser,” she says. The IPL is excellent for pigmentation, but for vascular lesions it does have its downside because of the wider range of wavelengths and melanin as the competing chromophore.”

Figure 3 and 4 (left to right):

Vascular Figure 3Vascular Figure 4Figure 3: Palomar Max G was used for one treatment of facial telangiectasia [before (left) and after (right)].

 

Cutera’s KTP “is very powerful, compact and challenges the pulsed dye laser for treating port wine stains,” Dr. Zachary says. “It really shows the 532 is an important wavelength for treating these vascular problems.” That wavelength, he explains, delivers “a large amount of energy in a short amount of time, is in a position to induce purpura, and can be extended over a much longer pulse duration.”

Dr. Zachary does note that one caveat with the long-pulsed 1064-nm Nd:YAG is the eventual scarring, although it is minimally absorbed by melanin.

“In appropriate hands, the 1064 can be useful, but physicians have to be careful because it will cause scarring,” Dr. Zachary explains.

Dr. Brightman believes each patient has to be treated individually and treated “until the point of diminishing returns, which may be a couple of treatments in one patient and 6 or more in someone else.” Physicians need to have “a keen understanding of the wavelengths used and how changing those parameters will produce the desired effect,” she adds.

Intense Pulsed Light Devices

The IPL plays “second fiddle” in treating port wine stains, Dr. Dover says, who reserves IPL in port wine stains “only in cases where pulsed dye laser has failed.” He finds the IPL highly effective in treating facial redness and vessels as well as facial sun-induced pigmentation, such as lentigines.

Dr. Tanghetti says both the pulsed dye laser and the IPL are “very effective” in treating facial telangiectasia, but, for some perinasal resistant vessels, he uses a 595/1064 Cynergy Q-wave device.

Dr. Zachary says European physicians are more likely to use IPLs than their American counterparts, probably because it was developed in Europe.

“Red blood cells don’t react differently to these devices — they’re being cooked appropriately,” he explains. “But not all IPLs are made equally.”

Traser

Dr. Zachary and Morgan Gustavsson, MD, have introduced the Total Reflections Amplifications of Spontaneous Admission of Radiation (or “Traser”) concept.

Dr. Zachary explains that the Traser is “probably 2 to 3 times more efficient than a laser from an electrical-optical point of view. It puts out a huge amount of energy, can be delivered through a large spot, and has a high repetition rate.” The variable pulse width can range from a low of 4-5 msec up to 100 msec.1

“This device can not only replace the KTP and pulsed dye laser, but frankly, the ruby laser for hair removal as well,” Dr. Zachary predicts. “The spot size is very big — something like 25 x 25.”

Mixing And Matching Treatments

Dr. Kaufman advocates mixing and matching treatments, especially in cases where the vessels are not located at the same uniform depth (ie, rosacea). She begins treating with a KTP, but, if after a session or two the patient has plateaued, she will switch to an IPL or Nd:YAG for some of the bigger vessels.

Vascular Figure 5Figure 5: This patient underwent one treatment for her poikiloderma with Cutera’s Excel V [before (left) and after (right)].

“Poikiloderma is a great example where you can treat the pigment, erythema with IPL or with a KTP, but when you get to the point where the skin, the texture, has a lot of atrophy, you need to switch over,” she says. “I treat striae with a KTP or pulsed dye laser when it’s red, but, once it turns white, I’ll switch to something like a Fraxel or Palomar’s fractional XD laser.”

Dr. Tanghetti bases pulse durations on the nature of the lesions being treated. Superficial lesions are treated with shorter pulse durations, from 0.5 to 10 milliseconds, while nodular lesions are generally treated with longer durations of 20 milliseconds. For more nodular lesions, he often uses the combination 595/1064 available in the Cynergy device from Cynosure.

Combining devices “is a great idea,” Dr. Zachary says. “Combining a pulsed dye laser or an IPL with a Fraxel device can be very helpful” for photodamaged skin, and, for pigmentation, he may add a Q-switch laser.

Importance of Cooling

Dr. Kaufman sometimes uses ice packs to cool darker skin even before treatment begins. She stresses that, whichever laser is used, the most important aspect is cooling.

“Move slowly. Make sure your coolants are working. Make sure the patient isn’t too tan,” she explains. “You really cannot treat tanned skin because you’ll remove the tan and end up leaving the patient striped.” She recommends using a melanin meter since most people are embarrassed to admit they are tan, or that they actively tan.

“Never, ever treat tan patients. Ever. Period,” Dr. Dover says. “We tell patients we see in consultation in the summer to come back after Halloween once their tan has faded.”

Final Notes

Whichever laser is used, it is important to learn the specifics of that laser.

“If you’ve introduced blistering or scabbing, you’ve overtreated,” Dr. Dover says. He suggests asking patients about upcoming social events and rescheduling telangiectasia treatments until after the occasion.

“Swelling is quite common after facial treatment, and rigorous use of ice and keeping the head elevated is the best way to help it to subside,” Dr. Dover says. Also alert the patient that most conditions need three or four courses to achieve the best results.

Editor’s note: Dr. Brightman has received research support from Syneron, Cutera and Candela. Dr. Dover is a consultant for Palomar, Cutera and Cynosure. Dr. Kaufman is a consultant for Cutera and Palomar. Dr. Tanghetti performs research for Palomar and Cynosure. Dr. Zachary is a consultant to Cutera, Solta, Zeltiq, Cynosure, Zimmer and Alma.

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