Rufus R. Noble The treatment of telangiectatic matting, which occurs in up to 30% of these patients, is difficult. Sclerotherapy can be used to treat telangiectatics in women.
The pulse dye laser can be used to treat telangiectasia in both the upper and lower extremities. However, when the same laser parameters are applied, the treatment results are less effective. This is because the vessels in the lower extremities have thicker adventitial tissues and a larger basal lamina, and they are also under greater intravascular hydrostatic tension.
This study reports on the use (1) of a 532 nm solid state pulse diode (ConBio Co. Dublin, CA) for the treatment of facial and lower extremity telangiectasia and (2) of a water-filled, dynamic cooling device from Cool Laser Optics in Westborough, MA to protect the skin when treating with long pulse duration.
Materials and Methods
Patient Selection
The study included patients who had not received cosmetic treatment before and had facial telangiectasia or lower-extremity vessels smaller than 1 mm. ( Table 1.). Lower-extremity patients were treated bilaterally. Fitzpatrick classifies skin types from I to III. The mean Fitzpatrick rating was 1.9. All patients were required to give informed consent.
Table 1
Summary of patient and results
Categories Telangiectasia of the lower extremity Facial telangiectasia
Patients
Number of patients of patients 36 41
Mean Fitzpatrick classification 2 1.6
Age (y) 47 41
Treatments
Treatments: Total number Total number of treatments 51 41
No. Mean no. 1.5 1
No. No. 38 32
No. No protocol Treatments 13 9
Results
Mean Protocol Clearance 2.3 2.94
Mean non-protocol clearance 1.5 2.56
95% CI 2.49-1.05 NA
P value <.005 <.15
During their initial consultations, patients were advised to limit sun exposure prior to laser treatment. It was also recommended that patients avoid sun exposure after laser treatment for a month. Strict adherence to sun exposure guidelines, however, was not possible due to the intense sun exposure that is a constant part of South Carolina’s living conditions. Sun exposure was not the sole reason for excluding a patient from treatment. The patients were asked to refrain from prolonged standing, aspirin, and nonsteroidal anti-inflammatory drugs for one week before treatment and after.
Treatment
The laser used was a 4W diode solid-state laser with a wavelength of 532 nm. Initial fluences (nonprotocols) were applied based on the manufacturer’s recommendations. We learned that higher fluences were safe to use with experience. The spot size in our protocol was 400 mm. The pulse duration was 40 or 100ms. And the repetition rate was 5 Hz. ( Table 2). The resulting energy densities are 140 J/cm 2 and 35 J/cm 2. The peak power was 1000W, as the pulse duration of 100 ms is actually made up of 2500 mini-pulses.
Table 2
Current treatment protocol
Condition Spot size Pulse duration Dynamic cooling device used
Facial telangiectasia 400 mm 40 ms No,
Facial angioma 400 mm 40-60 ms Yes,
Lower-extremity 400 mm 100 ms Yes,
telangiectasia* 40 ms No,
*The first pass was done using the 100-ms pulse length and dynamic cooling device. The second pass was made without using the cooling device.
The dynamic cooling tip was required for all 100-ms pulse treatments to protect the epidermis while applying higher fluence. The cooling device is a transparent quartz sphere that can reduce skin temperature to 1.5degC on contact but still allow the laser to pass through without losing fluence. The cooling device is moved along the treatment path to cool the skin. Manually checking the clinical temperature was done. Manually checking the clinical correlation was done. The condensate was manually removed from the cooling plate when necessary. The treatment was carried out directly through the quartz device on the most constrained area and the one that had been subjected to the longest cooling period. The dynamic cooling tip wasn’t used for the treatments with a pulse duration of 40 ms because previous experience showed that it was unnecessary in this setting.
The first five days following treatment, all patients treated for lower-extremity vessels had to wear class 1, 20 to 30 mm Hg venous stockings from Carolon Co. in Rural Hall, NC. The correct size of compression stockings was determined by measuring the diameter of the patient’s leg and selecting the appropriate size. The patient was told to remove their socks when bathing so that they could be cleaned. Three patients refused to comply but were included in the analysis for selection bias.
Data collection
The treatment team took photographs of the final results six weeks after treatment, immediately after posttreatment, and under identical lighting conditions. The treatment parameters were adjusted based on the minimal sequelae of the telangiectasia and the degree of clearance. After six weeks, the telangiectasia had resolved. Each patient was asked to rate the degree of resolution using a scale of support. ( Table 1). We also reviewed each patient’s photographs and examined them to determine their percentage of support. The clearance recorded is the lower score. To minimize quantification errors and reduce variations between investigators, the degree of consent is measured using broad categories.
Results
In 98% of cases, facial telangiectasia cleared up after one treatment. After 38 treatments, patients with lower extremity telangiectasia had a greater than 50% clearance rate after just one session. Patient satisfaction was high, with minimal untoward consequences. Figures 1, 2, and 3 show some representative results.
A Preoperative view showing a woman aged 56 with telangiectasia on the chin. A Postoperative view four months after treatment shows complete obliteration.
A Preoperative view of a 56-year older woman with right cheek telangiectasia. A Postoperative view four months after treatment showing complete ablation.
A Preoperative view showing a 44-year-old man with telangiectasia in the left medial knee and upper leg. A Postoperative view six months after treatment showed obliteration of left knee and upper leg vessels.
After the first treatment, a patient receiving tamoxifen for breast cancer experienced a less-than-optimal outcome. The second treatment, using the same laser settings, resulted in a better-than-expected clearance. There was no change in the patient’s behavior.
Table 3
Clearance Rating Scale
1 = <50%
2 = 51% to 95%
3 = >90%
You can also find out more about Pain.
Pain is subjective by nature. All patients tolerated treatments well. All patients reported that, although some discomfort after treatment was expected, as with thermal injury, the discomfort stopped when the light was removed. The majority of patients said that they felt less Pain after using the cooling device. A placebo effect is possible, however, as patients could observe the treatment.
Skin pigmentation
A permanent change in the skin pigmentation was not observed. Transient color changes were observed in patients with lower extremity telangiectasia. Initial perivascular edema transformed into intraluminal darkly-colored spots. This color change occurred in small superficial telangiectasias. The epidermis crusted over where the blood vessel was. The treated areas showed a near-complete clearing, patency, or slow, purple-hued blood flow four weeks after surgery. The authors and patients felt that the diameters remained telangiectasias had shrunk compared to before treatment.
