Natural Support for Sexual Performance and Libido For Men and Women James Meschino DC, MS, ND In the normal aging process the decline in sex hormone levels and the declining number of functioning nerve endings in the genitalia region often contribute to a reduction in sex drive, arousal capabilities, climax and intensity of pleasure-full sensations. This can become a source of frustration and disappointment that is a common problem, which affects the quality of life for many men and women over the age of 50. As a result many people turn to hormone replacement therapy and erectile dysfunction medications to help overcome these problems. Unfortunately, hormone replacement therapy can increase risk of breast cancer, endometrial cancer, prostate cancer as well as heart attack and stroke. In addition, erectile dysfunction medication is not suitable for all men, carries risk for sudden death and does not affect libido, only performance. In my view, before resorting to pharmaceutical drugs, individuals should first turn to natural libido and sexual performance-enhancing herbs, which have been shown to be safe and effective in human clinical trials. The following herbal compounds have been used individually for many years by health practitioners in various countries as therapies for low libido and sexual dysfunction. When combined into a single formulation, the synergistic effects of these herbs can exert a potent influence, helping to maximize, restore and prolong sexual desire, arousal and performance in both men and women.
Even if Viagra is not needed, it is possible that the doctor will be able to determine the etiology of erectile dysfunction and prescribe appropriate treatmen viagra australia it doesn't pay to forget about sexual activeness even at the first sings of malfunction.
UntitledLaser Treatment of Cutaneous
Mitchel P. Goldman Laser treatment of cutaneous vascular lesions began with keep the laser energy within the thermal relaxation time Dr Leon Goldman in 1963 at the Children's Hospital of the blood vessel.
Research Foundation in Cincinnati, Ohio, with the treat- The latest advance was the development of the intense ment of port-wine stain (PWS) and cavernous hemangioma pulsed light (IPL) devise in 1993. This therapeutic modal- using ruby, neodymium : yttrium-aluminum-garnet ity did not use a single wavelength of light, but a broad(Nd:YAG), and argon lasers. His initial report of 45 patients spectrum of visible light where the lower portion was treated with these three lasers appeared in 1968 and stim- cut off to limit the wavelength to various band-widths ulated great interest in this new treatment modality.1 between 515 nm and 1000 nm. The output was pulsed in Beginning in 1970, early pioneering work in argon laser single, double or triple pulses of 1.5–20 ms with delays surgery was accomplished at the Palo Alto Medical Clinic between the pulses to allow for epidermal cooling. IPL by Apfelberg, Maser, and Lash2 for treatment of cutaneous technology, which at ﬁrst was stated by the ‘experts' as vascular lesions. By 1984 the argon laser was generally being both dangerous and ineffective is now adopted by accepted as the treatment of choice for PWS.3 Indeed, every laser manufacturer and laser surgeon and is the single before the development of the argon laser, no effective most popular technology for the treatment of vascular form of treatment could be recommended to patients.
lesions word-wide. This chapter reviews current laser and The next major advance was the development of the IPL technologies in the treatment of vascular lesions. Other ﬂashlamp pumped pulse dye laser (PDL) in the mid-1980s chapters speciﬁcally discuss the treatment of leg veins, pig- to treat PWS. This laser was developed to encompass the mented lesions, photorejuvenation and light activation of theory of selective photothermolysis. This theory states photosensitizers: photodynamic therapy.
that a speciﬁc laser wavelength and energy be delivered to vaporize a speciﬁc target. The target was oxygenatedhemoglobin in the red blood cell in the blood vessel of the PWS. The most important factor was to keep the thermaldamage within the blood vessel's 20–50-mm diameter Importance of Pulse Duration
through the use of a pulsed laser output of 350 msec, whichhas been expanded to 450 msec then 1500 msec and now up To limit thermal damage to the intended target, the pulse to 40 ms. The original wavelength chosen was 577 nm, duration must be shorter than the thermal relaxation time which soon changed to 585 nm and then 595 nm to allow of the target tissue (Tables 2.1 and 2.2). The thermal relax- both deeper penetration as well as more efﬁcient use of the ation time of tissue is deﬁned as the time necessary for excitation dye between the ﬂashlamps of the laser. Finally, target tissue to cool down by 50% through transfer of its techniques providing epidermal cooling and copper vapor heat to surrounding tissue through thermal diffusion. If a lasers emitting a wavelength of 577 nm were also devel- targeted tissue can be heated sufﬁciently to affect it oped to target oxygenated hemoglobin. The use of a scan- irreversibly before its surrounding tissue is damaged by ning hand-piece for use with non-pulsed lasers was used to thermal diffusion, selective photocoagulation occurs.4,5 Cutaneous and Cosmetic Laser Surgery Classiﬁcation of Vascular Malformations
Capillary Malformation (CM)
Sturge–Weber syndrome Lymphatic Malformation (LM)
Venous Malformation (VM)
Arterial Malformation (AM)
Temperature distribution achieved during treatment of four different-size vessels with PDL. Two 0.05-mm-diameter vessels are located at 0.4-mm and 0.5-mm depths. A large 1-mm-diametervessel is located at a depth of 1.1 mm; a medium-sized 0.4-mm- diameter vessel is located at a depth of 0.6 mm. Treatment Klippel–Trenaunay syndrome (CLM, VM) conditions: 585-nm wavelength, 6-mm-diameter spot size, 10-J/cm2 Parkes–Weber syndrome (CLM, VM, AM) ﬂuence. (Reprinted with permission from Goldman MP, Eckhouse S et al: Dermatologic Surgery: Ofﬁcial Publication for American Society Maffucci syndrome (LM, VM, enchondromas) for Dermatologic Surgery 22:323, 1996. With permission from Solomon syndrome (CM, VM, intracranial AM, Blackwell Publishing Ltd.) epidermal nevi, osseous defects, tumors) Riley–Smith syndrome (LM, VM, macrocephaly, Table 2.2
Thermal Relaxation Time (Tr) of Laser Targets
Bannayan syndrome (AM, LM, VM, macrocephaly, Diameter (mm, approx)
Proteus syndrome (CM, VM, macrodactyly, hemihypertrophy, lipomas, pigmented nevi, scoliosis) Modiﬁed from Mulliken JB The classiﬁcation of vascular birthmarks. In: Tan OT, ed. Management and treatment of benign cutaneous lesions. Philadelphia: Lea & Febiger; 1992.
than 20 ms result in vessel rupture and hemorrhage sec- Table 2.1
Approximate Thermal Relaxation Time (Tr)
ondary to RBC explosion.6 This will lead to hemosiderin for Vessels of Different Diameters
pigmentation. Therefore, with single laser pulses, the ther- apeutic window is small. This argues for the developmentof a wider single pulse or a multipulsed laser that is able to transfer absorbed heat to the endothelium without causing its rupture (Figs 2.1 and 2.2).
Extension of the pulse duration of the PDL from 0.45 ms to over 1.5 ms limits purpura without decreasing efﬁcacy. The immediate purpuric threshold increases from 6.2 to 8, 10.4, and 13.8 J/cm2 with an increase in the pulseduration from 0.5 to 2.0, 20 and 40 ms.7 Even though a decrease in purpura can be obtained by extending the pulseduration to 10 ms, patients are still erythematous for 3–4 Data from Anderson RR, Parrish JA. Lasers Surg Med 1981; days and posttreatment edema is present to a similar extent.7 Importance of Wavelength
For vascular lesions, the exposure time should be long enough to conduct heat from the red blood cell (RBC)- The theory of selective photothermolysis is the basis for ﬁlled lumen to the entire blood vessel wall. The thermal the development of the PDL with a wavelength of 577, relaxation time of vessels 10 to 50 mm in diameter is 0.1 to 585 or 595 nm to increase penetration into the dermis 10 ms, averaging 1.2 ms.4,5 However, pulse durations less without loss of vascular speciﬁcity.8 Although blood Laser Treatment of Cutaneous Vascular Lesions surface usually cools to about -30°C, whereas the tempera-ture of the epidermal basal layer will not drop below 0°C.13This allows for higher ﬂuences to be given without adverseepidermal effects. The result of epidermal cooling and higher laser ﬂuences increases efﬁcacy, allows deeper laser penetration, and minimizes treatment pain.14,15 One potential problem is the effect on the cryogen spray on laser light. One study on 594 and 785-nm light demon- strated a 3% decrease in light transmission after a 30-ms pulse and a 30-ms delay before the laser pulse.16 Other methods for cooling the epidermis are air cooling, contact cooling through a quartz or sapphire crystal or topical cold gel or ice. The cold air cooling devise com- monly used, SmartCool or Cryo 5 (Zimmer Elektromedi- zin, Ulm, Germany) generates a continual air current of 500–1000 L/min at a minimal temperature of -30°C. Thelevel of airﬂow can be regulated. At a cooling level of 6 Figure 2.2
Temperature distribution achieved during treatment of (1–6 scale), a temperature of -15°C has been measured at four different-size vessels with IPL. Two 0.05-mm-diameter vessels are the skin surface after 8 seconds of cooling.17 In addition, located at 0.4- and 0.5-mm depths. A large 1-mm-diameter vessel is the air transport system can be modiﬁed with an adapter located at a depth of 1.1 mm; a medium-sized 0.4-mm-diameter so that the stream of cold air hits the skin exactly at the vessel is located at a depth of 0.6 mm. Treatment conditions: 590-nmcutoff ﬁlter, double pulse of 5 and 10 ms, 150-ms delay between laser impact site. A study on 166 patients treated with a pulses, irradiance of 55 J/cm2. (Reprinted with permission from variety of lasers for hair removal, tattoo removal and the Goldman MP, Eckhouse S et al: Dermatologic Surgery: Ofﬁcial treatment of vascular abnormalities were treated with air Publication for American Society for Dermatologic Surgery 22:323, cooling or ice pack cooling or chilled tip cooling; 86% of 1996. Blackwell Publishing Ltd.) patients felt that the cold air cooling was better than othercooling methods.18 The analgesic effect was better in 37% absorbs 585-nm light about one-half as efﬁciently as it of patients than ice gel. There was also a reduction in absorbs 577-nm light,9 585-nm light will coagulate larger erythema and purpura of 70% and 83% respectively.
vessels better than 577-nm light at a given depth because However, contact cooling has certain advantages in of deeper penetration of laser energy. In addition, deeper comparison to air cooling. As a physician you can use the vessels absorb laser energy at longer wavelengths.10 contact cooling handpiece to compress the skin up to a The tissue depth to which a given ﬂuence will coagulate certain degree. By doing this, the amount of blood in the the target vessel depends largely on the blood volume of vein to be coagulated can be adjusted and optimized. This vessels above the target vessels. Superﬁcial vessels contain- procedure can reduce pain and result in good coagulation.
ing blood will absorb laser light before it reaches deeper In this connection it is important to have a handpiece target vessels. This explains why multiple treatments are that provides parallel cooling through a cooled sapphire necessary for complete PWS resolution.
window as well as long post cooling through an integrated Because blood also has an absorption peak at 532 nm, cooled metal piece. The handpiece of the long-pulsed the frequency doubled Nd : YAG laser is also effective in Nd : YAG laser MYDON from WaveLight is the only device treating superﬁcial vascular lesions. However, to obtain a that features not only these options but also has a remov- degree of selectivity over the high melanin absorption able cooled sapphire window. The advantage of this possi- at 532 nm and to penetrate to clinically useful depths, bility is remarkable when it comes to treating ﬁne vessels cooling the overlying epidermis is important.
where you need optimal vision at the treatment area. Addi-tionally, it also avoids the blood disappearing completely Effect of Epidermal Cooling
by the pressure of the contact cooling when treating thesevery small veins.
Cooling the epidermis has been shown to increase the The effect of epidermal cooling to enhance clinical efﬁ- depth of penetration of effective thermocoagulation.11,12 cacy has been shared by other therapeutic modalities, par- Addition of the pretreatment epidermal cooling allows ticularly the IPL and long-pulsed Nd : YAG systems described treatment to occur at higher energy ﬂuences (9–10 J/cm2 later in this chapter and hair removal lasers and IPLs.
versus 6–7 J/cm2 without cooling) without increasing theincidence of scarring or pigmentary changes.
The Beckman Laser Institute developed the concept of Lasers Commonly Used to
delivering a cryogen spurt of tetraﬂuorethane (boiling point Treat Vascular Lesions
-26.2°C) just before laser impact. They term this ‘dynamiccooling'. The Candela Laser Corporation and CoolTouch Flashlamp-pumped Pulsed Dye Lasers
Corporation have proprietary rights to this technology. Skinsurface temperature is reduced by as much as 40°C with a Tan et al's successful treatment of children with PWSs 20- to 80-ms cryogen spurt after PDL exposure. The skin established the safety and efﬁcacy of the PDL.19 Garden
Cutaneous and Cosmetic Laser Surgery Figure 2.3
Beam proﬁle of Candela SPTL-1 from laser head. It exhibits Gaussian-like distribution of energy with some irregularities.
Cynosure PhotoGenica V laser from laser head. Like the (Reprinted from Jackson BA, Arndt KA, Dover JS. Journal of the Candela SPTL-1 (see Fig. 2.3), it exhibits Gaussian energy distribution American Academy of Dermatology 34:1000, 1996, with permission with irregularities. (Reprinted from Jackson BA, Arndt KA, Dover JS.
from the American Academy of Dermatology.) Journal of the American Academy of Dermatology 34:1000, 1996,with permission from the American Academy of Dermatology.) and others20–22 further reﬁned the treatment parametersand expanded the use to lesions in adults. This clinical efﬁ- spot size of the two lasers were tested, the Candela laser cacy has been conﬁrmed by other authors,23–29 and the use spot size was up to 35% larger than 5 mm while the Cyno- has been expanded to include the early treatment of cap- sure laser was up to 8% smaller. Therefore it is prudent to illary hemangiomas as well as many different cutaneous check the diameter of the spot with burn paper before lesions that have a vascular component.30–32 switching from one PDL machine to another.
Three manufacturers produce this type of laser. Candela Corporation (Wayland, MA) manufactures the SPTL line of machines, which originally emitted a wavelength of 585 nm and now can emit wavelengths of 590, 595, and 600 nm. The original pulse duration was 450 ms and nowcan be increased to 40,000 ms. The beam proﬁle can be Doubling the frequency and halving the wavelength to circular at 3, 5, 7, 10 and 12 mm in diameter or elliptic 532 nm has made the 1064 nm Nd : YAG laser more poten- at 2 ¥ 7 mm. Maximal energy ﬂuences of 10 or 20 J/cm2 tially useful in the management of vascular lesions. This are available. The Candela machine uses cryogen spray laser is produced by Continuum (CB Diode/532), and other cooling. Another PDL is the PhotoGenica V with a 585 nm laser companies. The 532-nm wavelength is at one of the wavelength and the Photogenica V-Star with a 595 nm hemoglobin peaks for 50-mm superﬁcial blood vessels. wavelength and similar spot sizes and power as the Candela This allows some selectivity in treating vascular lesions.
machine manufactured by Cynosure, Inc. (Chelmsford, However, its shorter wavelength does not allow deep MA). Currently produced Candela systems, according to penetration. A preliminary study using the Con-Bio their website, include the Vbeam (6 J output, 595-nm, 0.45- Laser (Continuum) at ﬂuences ranging from 1 to 6 J/cm2 to 40-ms, with 5-, 7-, 10-, 3 ¥ 10-mm handpieces) and (maximum 10 ns, 150 mJ) in mice and rabbit ear veins Cbeam (6 J output, 585-nm, 0.45-ms, 5-, 7-, 10-mm hand- showed a depth of coagulation of 0.73 ± 0.44 mm and hem- pieces). Cynosure currently produces the PhotoGenica V- orrhage of 0.68 ± 0.41 mm. In addition, edema (blistering) Star (8 J output, 585- or 595-nm, 0.5- to 40-ms, with 7-, 10-, was observed at all ﬂuences tested with mild subcutaneous 12-mm and elliptical handpieces and PhotoGenica V (4 J ﬁbrosis and epidermal hypertrophy. Therefore this laser output, 585-nm, 0.45-ms, with 7- and 10-mm handpieces).
can produce vascular injury, but because of its interaction Currently, no manufacturer produces a multi-wavelength with epidermal melanin, it is relatively nonselective.
dye laser. Both the Candela Sclerolaser and the CynosureVLS multi-wavelength systems have been discontinued, Potassium Titanyl Phosphate (KTP)
although they may be available on the used market. The Cynosure PDL uses cold air cooling. The third company isDEKA (Florence, Italy), which produces the Dermobeam at LaserScope (San Jose, CA) has developed a modulated KTP 595 nm with similar spot sizes and pulse durations as the laser that uses an arc lamp running at a constant current other PDL. DEKA uses an integrated cooling system.
pulsed to a much higher current than the lamp can toler- The PDL beam proﬁles may be different between laser ate under current operation. This produces an average companies. With the Candela PDL a 10% to 20% over- power up to 160 W packaged into a single pulse that can lapping spot provides for an even distribution of energy be adjusted to pulse durations of 1 to 100 ms at pulse rates ﬂuence. This is because of the Gaussian distribution of that are adjustable from one to ten pulses per second. Ten beam output. An 18% overlap has been found to cover the watts of power are available, with peak power of up to largest surface area with the least overlap.33 In contrast, the 60 W for pulse widths of 1 to 50 ms. The ﬂuence is deliv- Cynosure PDL has a ‘top hat' distribution of energy ﬂuence ered through a bare ﬁber 1–5 mm in diameter, which can (Figs 2.3 and 2.4).34 In addition, when the 5-mm-diameter be connected to various scanning delivery systems.
Laser Treatment of Cutaneous Vascular Lesions The KTP lasers are used in three modes when treating directly correlated with the energy ﬂuence, so that if vascular lesions. In one mode the laser is used with the a higher ﬂuence is needed, the pulse duration is longer. Dermastat (LaserScope), which applies a spot size to the The Palomar Palmalite/Prolite features advanced pulse- skin varying in size from 0.1 to 2.0 mm in diameter. forming. The target tissue experiences the pulse burst as The maximum average laser power is 5 W, and the pulse continuous. The ﬁrst third of the pulse train with higher duration can be varied in the range of 0.1 to 1.0 s. The 1- power is said to heat up the target tissue with the lower mm spot size at 5 W with a pulse duration of 0.2 s gener- power last third of the pulse train maintaining the target ates a ﬂuence of 127 J/cm2 on the skin. Higher ﬂuences can tissue temperature.
be selected by using longer pulse durations or smaller spot The ﬂuence is delivered through a quartz or sapphire sizes. These high energies may not be appropriate for treat- light guide with a spot size/surface area of 8 ¥ 15 to 15 ¥ ing PWS in children or pink superﬁcial lesions.
35 mm (Figs 2.6–2.8). This spot size can be further mini-mized by covering the surface area with any opaque covering, such as white paper. All settings are computer Intense Pulsed Noncoherent
controlled to deliver the desired energy to a ﬂashlamp. Theexact wavelength spectral output is proprietary.
The ability to pulse the intense light rapidly within the thermal relaxation time of the target vessel allows an accu- The PhotoDerm VL is the original intense pulsed light mulation of heat to occur within the target vessel with dis- source emitting a continuous light spectrum with most of sipation of heat within the epidermis (Figs 2.9 and 2.10).
its energy ﬂuence between 515 and 1000 nm. Xenon-ﬁlled The use of a cool gel on the skin surface and/or a cooled ﬂashlamps are the primary light source with the lamps crystal that touches the epidermis provides epidermal pro- powered by a capacitor bank. The lamps are cooled by tection to heat generated by the light output (Fig. 2.11).
water which surrounds the lamps and helps in cutting The ability of the epidermis to cool more quickly than the down longer infra-red emissions. The intense pulse light target vessel is a function of the vessel size. When one com- source produces incoherent light whose spectrum can be bines the longer wavelength, longer pulse duration, larger cut off through the use of colored ﬁlters. Filters in standard spot size, and ability to deliver multiple pulses within the use are 515, 550, 560, 570, 595, 610, 645, 695 and 755 nm.
thermal relaxation time of the target vessel, treatment efﬁ- These ﬁlters block out the shorter wavelengths, allowing cacy is enhanced. Multiple sequential pulsing is a propri- the energy ﬂuence to be concentrated up to 1000 nm with etary technology of Lumenis. All other IPL devises use resulting deeper penetration of the high-intensity pulsed variations of increasing ﬂuence with pulse duration and light (Fig. 2.5). Different manufacturers use different various methods of epidermal cooling to selectively heat absorbing ﬁlters to cut-off the lower wavelengths. Palomar blood vessels.
uses a ﬂuorescent ﬁlter to shift the wavelengths to the right The BBLTM intense pulsed light is available as a module preserving the 800–950-nm band (this is said by the for the ScitonProﬁle platform or as a stand-alone system company to help with dermal heating).
(Sciton, Sunnyvale, CA). BBL has the widest single pulse The pulse durations of the Lumenis IPLs can be adjusted width of presently available IPLs and can also deliver from 2 to 25 ms/pulse given as a single, double, or triple double or triple pulses. An integrated thermo-electric pulse with delays between pulses of 2 to 100 ms. The total cooled sapphire crystal cools the treatment area and can energy ﬂuence emitted can range from 3 to 90 J/cm2. Other control skin temperature to within 1°C during an entire IPL devises do not have this degree of variability. Mostsystems have only one or two pulse durations that are Effective penetration (cm)
Application of intense pulsed light (IPL) treatment head Figure 2.5
Light penetration into tissue. (Courtesy ESC Medical, to the skin. Pulsed light passes through quartz crystal light guide and layer of clear coupling gel before going into skin.
Cutaneous and Cosmetic Laser Surgery Figure 2.8
Footprint of elliptic pulsed dye laser (PDL) compared with intense pulsed light (IPL) footprint. (Courtesy ESC Medical, Inc.) External light on the skin Figure 2.7
(A) Footprint of the intense pulsed light. (B) Footprint of 5-mm-diameter pulsed dye laser (PDL). (C) Footprint of typical CVL.
(Courtesy ESC Medical, Inc.) heat penetrationduring the time delaysbetween pulses Figure 2.9
Diagram of effect of repetitive pulses of intense pulsed procedure. The contact cooling system uses a high-power light on 2-mm vessel, 1 mm below epidermis. (Courtesy ESC Medical, quad thermoelectric temperature regulator that can be set from 0°C to 30°C allowing the physician to control thelevel of epidermal cooling.
The vascular network leading to facial ﬂushing, redness and ﬁne telangiectasia is very near the surface as is dys- BBL uses an advanced dual-lamp conﬁguration. The life- pigmentation. Surface cooling systems may affect the time of lamps decreases rapidly as they are driven to higher response of the superﬁcial vascular targets and surface pig- energies. Using dual lamps results in each lamp supplying mentation to the IPL. With the proper temperature control half of the energy for a lifetime that is an order of magni- BBL is able to treat vascular conditions and pigmented tude greater than that of a typical single-lamp system. lesions with only 50% of the ﬂuence of many other sys- As a result, BBL comes with a standard 300,000-shot tems leading to greater comfort, safety, and consistency. For warranty. BBL has the following ﬁlters: 420 nm, 515 nm, deeper targets the high power of the quad-thermoelectric 560 nm, 590 nm, 640 nm, 695 nm, and 755 nm.
system can provide deep regulated cooling for maximum Table 2.3 details the present variety of vascular-speciﬁc patient comfort.
Laser Treatment of Cutaneous Vascular Lesions Temperature (°C) Temperature (°C) Figure 2.10
(A) Vessel size is 0.2 mm in diameter. Double pulse with 550-nm cut-off ﬁlter is used with energy of 35 J/cm2 given in 2.4-ms
pulses. (B) Vessel size is 1 mm in diameter. Double pulse is given with 590-nm cutoff ﬁlter and energy of 40 J/cm2 given in 2.4- and 4.0-mspulses. (Courtesy ESC Medical, Inc.) Figure 2.12
A 48-year-old woman 20 years after radiation therapy for thyroid tumor with development of telangiectasia. Clinicalappearance 6 months after treatment with pulsed dye laser at Figure 2.11
Application of cool gel to skin minimizes thermal 7 J/cm2. Hypopigmented macules took approximately 18 months damage and allows thermocoagulation to occur in vessel. Without for complete resolution.
gel, skin is thermally damaged before the underlying vessel isthermocoagulated.
Adverse Effects of Vascular Lasers
Hypopigmentation can occur in treated areas in dark-skinned patients and was found in 3.2% of patients in onestudy, who were Hispanic or Middle Eastern treated withthe PDL.35 Persistent hypopigmentation is more commonon the neck, legs, and chest (Fig. 2.12). Persistent hyper-pigmentation may also occur with premature sun exposureon facial areas and after treatment of vascular lesions onthe leg. This is especially common and appears as ‘skipped'areas of normal skin on a background of sun-damaged skin.
(Fig. 2.13) Fortunately, most hypopigmented areas resolvespontaneously within 6–12 months. Treating these areaswith an Eximer laser or Relume narrow band UVB Figure 2.13
Patient treated with the intense pulsed light. Each light source (Relume, Lumenis, Santa Clara, CA) can speed impulse is spaced too far apart and areas of ‘skipped' treated skin are Table 2.3
Vascular Speciﬁc Lasers and Intense Pulsed Light
V-StarSmartEpill II 46 ¥ 18; None46 ¥ 10 adjustable crystal adjustable crystal adjustable crystal adjustable crystal Cooled sapphirecrystal Cooled sapphirecrystal 15 ¥ 35, Cooled 10 ¥ 20, None20 ¥ 25 pulsed lightNd : YAG 30 ¥ 30,13 ¥ 15 10–30/2–25 RF Contact or aircooling Laser Treatment of Cutaneous Vascular Lesions Although rare, hypertrophic scarring has been reported (rings)43 (Figs 2.15 and 2.16). Patients with type 1 vascu- with high laser ﬂuences and when treating lesions on the larity have a better response to PDL treatment because type neck, arms, or shoulder with any vascular speciﬁc laser.35–37 2 PWS lesions are more deeply situated and consist of freely Another report described ‘isolated, superﬁcial, depressed anastomosing dilated vessels of the superﬁcial horizontal scars' in 2 of 35 children treated, reportedly in areas trau- vascular plexus. Videomicroscopy may allow the physician matized within 24 hours after PDL treatment.19 Two of 92 to choose the most appropriate laser or pulsed light source adults with facial telangiectasia developed dermal atrophy for treatment of PWS.
with normal skin texture on the nose, nasolabial folds, andmalar regions that lasted at least 6 months. These areaswere treated with a 1-mm spot diameter PDL at a ﬂuence Adverse Medical Effects
of 7 J/cm2.38 Laser ﬂuence, lesion location, and posttreat-ment care are important factors that may contribute to the In addition to their abnormal cosmetic appearance, PWSs risk of scarring.
may be associated with medical problems, the mostcommon and serious being glaucoma and less commonand serious being inﬂammation. Glaucoma occurs inapproximately 45% of patients with a PWS involving Port-wine Stain
both the ophthalmic (V1) and maxillary (V2) divisions of Port-wine stains (PWSs) occur in 0.3% to 0.5% of new- borns39,40 and represent a congenital malformation of the superﬁcial dermal capillaries. They should not be con-fused with the common pink patches known as ‘nevusﬂammeus neonatorum', ‘angel's kiss', ‘stork bite', or‘salmon patch'. These ‘stains' fade within the ﬁrst year oflife in 50% of patients. A midline PWS-appearing lesionmay represent a capillary malformation that clears quicklywith one or two treatments and thus is not typical of themore ectatic and venular PWS (Fig. 2.14). These midlinelesions may represent a maturation delay in autonomicinnervation because up to 60% of lesions resolve spontaneously.41 Most PWSs are superﬁcial, with a mean vessel depth of 0.46 mm.42 The lesion is ﬁrst present as a relatively sharplymarginated pink patch, most often involving the head andneck in 90% of patients, especially in the areas of the ﬁrstand second trigeminal nerves.39,40 Videomicroscopy has demonstrated two patterns of vas- cular abnormality: type 1 consists of tortuous, superﬁcial,dilated capillary loops (blobs); type 2 consists of dilatedectatic vessels in the superﬁcial horizontal vascular plexus Figure 2.15
(A) Results of transcutaneous videomicroscopy of patient with port-wine stain (PWS) showing type 1 blob abnormalities(¥200). (B) Results of transcutaneous videomicroscopy of patient with Figure 2.14
(A) Four-month-old girl with urticaria pigmentosa and PWS showing type 2 ring abnormalities. Note the small, ﬁne capillary midline port-wine stain before treatment. (B) 6 1/ years after single dots that are capillary loops in normal dermal papillae. Dilated vessels treatment with pulsed dye laser at 5.5 J/cm2 using 5-mm-diameter of horizontal plexus lie in a deeper plane (¥200). (Reprinted from spot size, lesions show 100% clearance without adverse sequelae and Arch Dermatol 133:921, 1997. Copyright 1997 American Medical no evidence of recurrence.
Association. All rights reserved.) Cutaneous and Cosmetic Laser Surgery existence of these associated lesions should not cause confusion in diagnosis.
Various support groups are available for children with congenital vascular abnormalities and their families. TheSturge–Weber Foundation (PO Box 460931, Aurora, CO80046, USA) publishes an excellent booklet for childrenthat clearly explains the syndrome as well as multiple treatment options. The Klippel–Trenaunay Support Group(4610 Wooddale Ave, Edina, MN 55424, USA) publishes auseful quarterly newsletter and holds support group andeducational meetings for the public. The National Con-genital Port-Wine Stain Foundation (125 E. 63rd St, NewYork, NY 10021, USA) also provides information andsupport to patients and families of children with PWSs; Figure 2.16
Diagrammatic representations of vascular abnormalities www.birthmarks.com is an excellent website for patient found with videomicroscopy. (Left) Tortuous, dilated papillary tipvessels. (Right) Dilated vessels of superﬁcial horizontal vascular plexus.
information. Patients and parents should be encouraged to Note that type 1 abnormality (left) presents a superﬁcial target with use these resources.
limited blood supply. Type 2 abnormality (right) is more deeply PWSs can also present with an inﬂammatory compo- situated, and vessels anastomose freely. (Reprinted from Arch nent consisting of scaling, excoriations, oozing, and crust- Dermatol 133:921, 1997. Copyright 1997 American Medical ing, resembling a dermatitis.55 PWS with this secondary Association. All rights reserved.) inﬂammation has been reported in lesions on the nuchaland occipital areas. Treatment with topical steroids helps the trigeminal nerve. The most well-known condition is decrease the inﬂammation, but the PDL is curative after Sturge–Weber syndrome, which consists of a PWS involv- one treatment.
ing the ﬁrst branch of the trigeminal nerve, a high inci- The natural history of a PWS is that the vessels become dence of glaucoma of the ipsilateral eye (especially if the progressively ectatic over time.42,56 This results in gradual upper lid is involved), angioma of the lids, choroidal darkening, thickening, and development of nodularity hemangiomas (in up to 40% of patients),44 calciﬁcation (Fig. 2.17). One study found that two-thirds of patients and vascular anomalies of the brain with associated seizure develop hypertrophy and nodularity by age 46, with a disorders, and, in some cases, mental retardation.45–47 In mean age of 37 years for hypertrophy.57 Rarely, sponta- 70% to 80% of patients with glaucoma, Sturge–Weber neous improvement may occur,58 possibly during the ﬁrst syndrome presents as buphthalmos, a grossly enlarged 3 years of life.
eye soon after birth. The remaining patients develop glau- Giant proliferative hemangiomas may also arise in PWSs coma in childhood, with 44% diagnosed after 4 years of and can develop without any prior history of trauma.59 age.48 Therefore repeated intraocular pressures should betaken every 3 to 4 months if glaucoma is not present initially.
The extent of the PWS does not usually correlate with neurologic disease.49 However patients with bilateral PWS In addition to lesion characteristics that may cause have a greater likelihood of neurologic involvement with bleeding and produce physical deformity, a PWS carries a an earlier onset of seizures.46,50 Epileptic seizures occur in deﬁnite risk for lasting detrimental effects on a child's 72% of Sturge–Weber patients with unilateral lesions and psychologic, social, interpersonal, and cognitive develop- 93% of patients with bihemispheric involvement.44,46 ment.60–62 The exact age when psychosocial development Mental retardation occurs in up to 30% of Sturge–Weber is affected is speculative. A psychiatric study of 19 children patients, with a 92% incidence of retardation in patients 3 to 5 years old with face, head, or neck hemangiomas with bilateral lesions.46 Recommended neurologic tests found no association with major problems in psychosocial include electroencephalography and functional testing development.63,64 However, early treatment improves the with positron emission tomography (PET), single-photon responsiveness, decreases the number of treatments, and emission computed tomography (SPECT), computed reduces the likelihood of permanent adverse seque- tomography (CT) of cranium, or magnetic resonance lae.19,26–28,64 Therefore we recommend that treatment be started at the earliest possible age.
Other congenital syndromes include the Klippel– A common misperception regarding PWS in adults is Trenaunay and Klippel–Trenaunay–Weber syndromes that if one has reached adulthood without psychologic (PWS with associated varicose vein and hypertrophy of damage from a cosmetic deformity, one does not require skeletal tissue52 with or without arteriovenous malforma- treatment. Former Soviet president Mikail Gorbachev is an tions [AVMs], respectively) and Cobb syndrome (PWS with example of successful ‘coping' with a cosmetic handicap.
underlying AVM of the spinal cord).53 A PWS may be (Interestingly, the Soviet news agency, Tass, airbrushed out associated with an underlying venous malformation or Gorbachev's PWS from published photographs until pere- occasionally an arterial malformation or AVM,54 so the stroika.) However, such presumptions are often incorrect.
Laser Treatment of Cutaneous Vascular Lesions Figure 2.17
Progressive nodularity of port-wine stain (PWS) is Figure 2.18
(A) Twelve-year-old girl with congenital port-wine stain noted with aging. (A) Patient, age 15, has light-pink PWS on right on her right cheek. (B) After third treatment with pulsed dye laser.
cheek. (B) Patient, age 35, has marked nodularity and darkening of First treatment used a ﬂuence of 7.25 J/cm2 with 213 5-mm pulses, PWS. (C) Clinical appearance after 12 separate treatments with pulsed second treatment 7.5 J/cm2 with 109 5-mm pulses, and third dye laser at average ﬂuence of 7.0 to 7.5 J/cm2. Each treatment treatment 7.5 J/cm2 with 40 5-mm pulses. Patient and parents noted averaged 600 5-mm impacts. (Courtesy of Gerald Goldberg, MD.) 90% resolution of entire lesion. (From Goldman MP, Fitzpatrick RE,Ruiz-Esparza J. J Pediatr 1993; 122:71.) More often, the misperception of treatment complicationsalong with cost considerations are the primary reasons foravoiding treatment. These misconceptions are often used 1989 annual meeting of the American Academy of Der- by insurance companies to deny coverage and save money.
matology dramatically demonstrates this point. A model Unfortunately, cosmetic considerations are not the only had a PWS painted on her face and then feigned an illness reasons PWS should be treated in adults. Hypertrophy, that led to unconsciousness on a public bus. Not one pas- hemorrhage, and infection are the medical reasons for senger came to her aid. When the same model feigned the same illness on a bus without the facial PWS, all those Adult PWS can also have an adverse impact on social present eagerly came to her aid. Pena Clementina Mas- relationships. A questionnaire given to 186 patients who clarelli,66 a senior occupational therapist who also has an sought treatment for their PWS found that 29% thought extensive PWS, wrote a poignant chapter about her inter- the PWS was disadvantageous in forming interpersonal actions with others that should be required reading for all relationships with members of the opposite sex.65 Half rated their PWS as unattractive, although only 33% Multiple studies have demonstrated an improvement thought that other people perceived their PWS to be mod- in psychological health after successful treatment of erately to very unattractive. The true incidence of psycho- PWS.63,67,68 We have noted a change in personal percep- logic problems from PWS may be higher or lower because tions dramatically in our treated patients. A 12-year-old girl this study was obviously skewed to patients who were ﬁrst sought treatment in our practice for a PWS on the actively seeking treatment. Nevertheless, the survey does right cheek. Initially, although of above-average intelli- show that a signiﬁcant number of adults with PWS would gence, she was introverted and interacted sparingly with beneﬁt psychologically from treatment.
her classmates. After three treatment sessions, resulting in Psychologic difﬁculties in interactions with others occur 75% clearance, she began dating, joined the school band, as often in adults as in children. An experiment during the and excelled academically (Fig. 2.18). These are the obser- Cutaneous and Cosmetic Laser Surgery Table 2.4
Childhood Port-wine Stains: Treatment Response by Age
Age 0–4 years
Age 4.5–14 years
Total 0–14 years
From Goldman MP, Fitzpatrick RE, Ruiz-Esparza J. J Pediatr 1993; 122:71.
vations so gratifying to the physician and medical staff children less than 14 years old (mean age 7 years 2 months) involved in laser treatment.
with an average of 6.5 treatments.19 Subsequent clinical Despite the psychologic and medical complications of studies demonstrated notable efﬁcacy and deﬁned more PWS, insurance coverage in the US for laser treatment reasonable expectations. Reyes and Geronemus26 success- of PWS varies from state to state. A study by McClean fully treated 73 patients between age 3 months and 14 and Hanke69 of insurance reimbursement in 18 States years. The overall average lightening after one treatment found that determination for approval of treatment was 53%, and the percentage of lightening increased was made on a case-by-case basis, with the majority with subsequent treatments. More than 75% lightening requiring preauthorization. The percentage of requests was achieved with an average of 2.5 treatments in 33 approved for coverage varied from 50% to 100% without apparent reason. Some insurance carriers would only Morelli and Weston88 advocate beginning treatment as approve treatment if functional impairment existed and early as 7 to 14 days of age so that three treatments can be some only if the patient was less than 1 year of age. done before the infant reaches 6 months of age. They Only Minnesota has a law requiring all health insurance noted a 50% resolution with this protocol by the third to cover the elimination or maximum feasible treatment treatment. In their population of 132 patients, complete clearance was obtained in 25% of PWSs when treatmentwas begun before 18 months of age (average 7.8 treatmentsessions) versus 7% to 10% having total clearance when treatment was begun between ages 11/2 and 18 years(average 7.0 treatment sessions). A follow-up evaluation Many therapeutic methods have been attempted to treat of this patient population conﬁrmed the authors' initial PWSs. These include surgery (excision, grafts, ﬂaps, observations with 83 children: 32% of children who began dermabrasion),45,70,71 radium implants,72 X-ray therapy,45 treatment before 1 year of age had complete clearing of their PWS compared with 18% of children treated after 1 ing,74,75 and cosmetic camouﬂage.76 These methods all have year of age.89 In this later study, 32% of patients with PWS limited and unpredictable results as well as potentially less than 20 cm2 in size completely cleared compared with serious complications.64 In addition to currently recom- an 8% complete clearance rate in patients with larger mended laser treatments, the CO2 laser,77–80 Nd : YAG laser,81 copper vapor laser (CVL),82,83 and argon laser56,84–87 have Our studies on the treatment of 43 children between previously been used to treat PWS in children. As previously ages 2 weeks and 14 years with 49 lesions of capillary mal- discussed, cosmetic results with these lasers have been formation conﬁrm these results.28 Lesions treated in chil- poor in children, with the risk of scarring unacceptably dren under age 4 had greater overall improvement with less treatment sessions compared with those in childrenover age 41/2 years (Table 2.4). In general, improvement and Childhood Port-wine Stains
clearance were gradual and required 5 to 10 treatments.
The PDL was speciﬁcally designed to treat the small vessels However, very superﬁcial lesions cleared more quickly, found in childhood PWSs.19,21 The ﬁrst published reports with four lesions reaching a level of 95% clearing in one noted complete clearing of pink-to-red macular PWSs in 35 or two treatments (Table 2.5).
Laser Treatment of Cutaneous Vascular Lesions Table 2.5
Childhood Port-wine Stains: Response Per Number of Treatments
Improvement of nonclear lesion
From Goldman MP, Fitzpatrick RE, Ruiz-Esparza J. J Pediatr 1993; 122:71.
An additional study of 12 children 6 to 30 weeks of age with the argon laser. Third, treatment is usually painful to conﬁrmed that treatment of infants only a few weeks old can be undertaken safely and with an accelerated response: In our experience, treatment is considerably eased with 45% demonstrated 75% or more lightening of their lesions topical anesthetic creams, cooling the epidermis with after a mean of 3.8 treatments.64 Alster and Wilson90 cryogen spray or ice, or conscious sedation administered reported an 87% clearance rate in patients less than 2 years by a pediatric anesthesiologist, but necessary only in chil- of age, 78% clearance in patients ages 3 to 8, and 73% dren 8 years old or younger. Fortunately, earliest childhood clearance rate in patients 16 years and older. All these memories usually occur after 2 or 3 years of age.93 Thus studies demonstrate a better treatment outcome with treatments given before this time should not have long- younger patients.
term psychologic effects. We have been treating infants Only one study of 23 facial PWS lesions in patients up with the PDL since 1985 and have yet to observe adverse to age 17 showed no difference among different ages in the psychologic effects in our patients with continuing long- average number of treatments to obtain maximum lesion term follow-up. Some of our initial patients, treated in the lightening.91 However, this study only evaluated four ﬁrst few months of life with continued treatment at 4- lesions in children less than 1 year of age and eight lesions to 6-month intervals, are now 8 to 10 years old and con- in those 1 to 7 years of age.
tinue to receive treatment without apparent psychologic Although treatment is efﬁcacious and most laser sur- geons recommend treatment at the earliest sign of a lesion, For children less than age 12 years, we recommend laser photothermolysis of blood vessels does result in the release ﬂuences that generate slight purpura. We like to use a large of free Hb into the circulation. Hemoglobinemia may spot size (10–12 mm in diameter for PDL or the large foot- theoretically lead to renal impairment in a young patient.
print of the IPL) to minimize skipped areas. The initial Therefore a study of 15 patients under age 5 treated with treatment session usually results in an average improve- the PDL tested serum haptoglobin and urine hemosiderin ment of approximately 50%. Each subsequent treatment postoperatively.92 Even though patients had a treatment provides an additional increment of approximately 10% region more than 3% of total body surface area and improvement. After six treatments, 40% of our patients received more than 1500 5-mm-diameter pulses in some completely clear, and those who are not clear have an cases, the authors found no evidence of urine hemoglobin average improvement of approximately 80% (Fig. 2.19).
and reported normal levels of serum haptoglobin We have not had patients with scarring or persistent pig-levels.
mentary changes despite rare episodes of vesiculation and Therefore the advantages of early treatment are: (1) crusting after treatment. Skin type (I–III) also does not quicker resolution requiring fewer treatments; (2) fewer appear to inﬂuence the ultimate treatment outcome, but laser pulses because of smaller size (children triple in size darker skin requires more treatment sessions to achieve the from birth to age 2 and further double in size from ages 2 same degree of clearing as in PWSs of fair-skinned patients to 8); and (3) less need for anesthesia.
as we recommend lower ﬂuences and a higher degree of Unfortunately, pediatricians and family practitioners are epidermal cooling. Lesions on distal limbs respond with reluctant to refer their patients for treatment. This is most less fading than lesions elsewhere, such as on the neck and likely a result of too few reports in all but the most recent torso (Table 2.6). The diminished response of PWS on the pediatric literature and thus lack of knowledge. Second, limbs has been reported by others.94,95 older physicians may remember the failures of the argon Fortunately, treatment of PWS in childhood and infancy laser in treating these lesions and equate all laser treatment not only has been very efﬁcacious with the PDL, but also Cutaneous and Cosmetic Laser Surgery has proved to be safe. Swelling and erythema are fre-quently present immediately after treatment, especiallyaround the eyes, but resolve within 24 to 48 hours. Hyper-pigmentation of the treated site occurs in 25% to 30% ofpatients but is temporary and resolves over 2 to 3 months.
Hypopigmentation occurs infrequently and resolves spon-taneously over 3 to 6 months. Cutaneous depressions oratrophic scars have occurred in isolated laser impact sitesand have been associated with excessive delivery of energy,excessive spot overlap, or posttreatment trauma to the site.
Almost all reported cases have resolved spontaneouslywithin 1 year.21,26,28 Adult Port-wine Stains
The treatment of PWS in adults has been as equally grati-
fying as our experience in children (Figs 2.20 and 2.21).
The PDL is used in the same manner as with children
except that ﬂuences are usually increased depending on
the lesion's color and thickness. A 7- to 12-mm-diameterspot size is preferred because of its deeper penetration. Werecommend beginning with a ﬂuence of 5.0 to 5.5 J/cm2with a 7-mm-diameter spot size and increasing by 0.5 J/cm2with each subsequent treatment at 3- to 4-month intervals.
A mathematical model as well as clinical experience predict a 10% clearance of the PWS with each of the ﬁrstﬁve or six treatments. Additional treatments result in adecreased therapeutic response so that 20 treatments arerequired to produce a 90% clearing.96 The IPL can also be used in a number of different set- tings to effect vascular-speciﬁc thermocoagulation of PWS.
Multiple studies have demonstrated an enhanced efﬁcacyof clearing in comparison to the PDL. This holds true evenfor Asian patients.97–101 Different settings are used with each treatment, which Figure 2.19
(A) Initial appearance of extensive port-wine stain can be given at monthly intervals. We usually increase the (PWS) on a 10-week-old girl. Evaluation by pediatric neurologist was ﬂuence with each subsequent treatment as well as the pulse entirely within normal limits. (B) The same patient 4 months after her duration, cutoff ﬁlter, and number of simultaneous pulses fourth treatment with the pulsed dye laser. First and second (Fig. 2.22). The following settings are effective for initial treatments were performed at an energy of 6 J/cm2 and third and and subsequent treatments (these settings apply for the fourth treatments at 6.25 J/cm2. Total of 400 pulses were given to theentire PWS during each treatment visit. Parents and physician noted Lumenis vasculite system; parameters will vary with other almost 90% resolution of PWS. (From Goldman MP, Fitzpatrick RE, Ruiz-Esparza J. J Pediatr 1993; 122:71.) Table 2.6
Childhood Port-wine Stains: Treatment Response by Location
From Goldman MP, Fitzpatrick RE, Ruiz-Esparza J. J Pediatr 1993; 122:71.
Laser Treatment of Cutaneous Vascular Lesions Figure 2.20
Port-wine stain on left anterior chest of 44-year-old woman. (A) Before treatment. (B) Near 100% resolution after six treatments.
Each treatment used a ﬂuence of 7.25 J/cm2 with PDL. First treatment used 136 5-mm impacts, second treatment 175 5-mm impacts, thirdtreatment 117 5-mm impacts, fourth treatment 87 5-mm impacts, ﬁfth treatment 77 5-mm impacts, and sixth treatment 37 5-mm impacts. Fig.
2.20A and B: Reprinted from Fitzpatrick RE: American Journal of Cosmetic Surgery 9:107, 1992. With permission from American Academy ofCosmetic Surgery. (C) Continued clearance 12 years after original treatment clearance.
in these patients. Ice-cold coupling gel and/or cold contactcrystals are used.
One advantage when using the IPL is the minimization of purpura after treatment (Fig. 2.23). Other advantages aredescribed later.
Complications and Adverse Sequelae
Complications and adverse sequelae when treating vascu-lar lesions with the PDL, IPL or any vascular speciﬁc laseras described previously are rare. Adverse sequelae areusually temporary and limited to purpura and epidermalcrusting. Purpura is more common with the PDL.
The most common long-term adverse sequelae are pigmentary changes. Because melanin competes as anabsorber with Hb in patients with Fitzpatrick type III skinor greater, hypopigmentation (especially in patients withtanned skin) is not uncommon. Alternatively, postinﬂam- Figure 2.21
This 34-year-old patient had a port-wine stain of her matory melanocytic hyperpigmentation may occur. At chin (A). She underwent a series of ﬁve pulsed dye laser treatments times this may appear as a ‘checkerboard' pigmentation with approximately 2 months between sessions. Treatmentparameters were the following: 585-nm wavelength; 7- to 10-mm (Fig. 2.24). When this occurs, additional treatments are spot size; 8–12 J/cm2; cryogen spray cooling spurt duration of 30– usually necessary to even out the skin color. Oftentimes, 50 ms with a 30–50-ms delay. The patient achieved an excellent result switching to the IPL, which with its larger spot size evens (B). (Courtesy Kristen Kelley, MD.) out the dyspigmentation in addition to the nontreatedareas (discussed later). In addition, the use of depigment-ing agents such as hydroxyquinone, alpha-hydroxy acids,azelaic acid, and kojic acid alone or in combination with 515-nm or 550-nm cutoff ﬁlter, single pulse at 2 to 5 ms retinoic acid both before and after treatment is helpful.
with 20 to 25 J/cm2 Fortunately, permanent scars or pigmentary changes are 550-nm cutoff ﬁlter, double-pulsed at 2.4 ms with 10-ms delay, 4.0 ms with 35 to 42 J/cm2 More serious potential adverse events include atrophic 570-nm cutoff ﬁlter, double-pulsed at 3.0 ms with 20-ms and hypertrophic scarring and keloid formation. The for- delay, 6 ms with 40 to 45 J/cm2 mation of keloids may be enhanced when the patient 590-nm cutoff ﬁlter, triple-pulsed at 3 ms with 30-ms is also taking isotretinoin. Multiple case reports of the delay, 4.5 ms with 30-ms delay, 7 ms with 30-ms delay development of keloid formation in patients receiving at 50 to 60 J/cm2 isotretinoin have been reported with argon laser and As with other lesions, patients with more darkly pigmented dermabrasion treatment.102,103 A single case report of this skin are treated with higher cutoff ﬁlters to circumvent occurrence with PDL treatment of a neck PWS has melanin absorption and longer delay times between appeared in the literature.104 Although the mechanism for double and triple pulses because epidermal heat is higher enhancing scarring is speculative and the length of time Cutaneous and Cosmetic Laser Surgery Figure 2.22
(A) Port-wine stain on 24-year-old male before treatment. (B) Immediately after treatment with PhotoDerm VL. Note purpuric response to treated areas (C) One month after treatment. Note resolution at various treatment parameters, all given in single pulses. (Top tobottom) 590-nm cutoff ﬁlter at 50 J/cm2, 570-nm cutoff ﬁlter at 40 J/cm2, 550-nm cutoff ﬁlter at 30 J/cm2.
from cessation of treatment to ‘safety' is unknown, it scarring were treated in the early stages of the PDL would seem prudent to avoid laser treatment within 1 to development, when problems with the dosage meter were 2 years of isotretinoin use.
Numerous retrospective studies have detailed adverse A study of 701 patients who received 3,877 full treat- sequelae. A study of 133 patients (89 females, 44 males) ments with the PDL using a 5- or 7-mm-diameter spot and with PWS who had been treated with the PDL over a 2- ﬂuences of 5.5 to 9.5 J/cm2 with the Candela and the Cyno- year period showed good or excellent results in 84% of the sure systems reported severe blistering in 1.08%, severe PWSs.27 The average number of treatments increased from crusting in 0.13%, hypopigmentation in 0.26%, hyperpig- 1.7 to 2.3 to 3.5 as the clinical results improved from slight mentation in 1.7%, atrophic scarring in 0.7%, and hyper- to good to excellent, accordingly. After a treatment session, trophic scarring in 0.13% of treatments.105 Seven patients discoloration and purpura were seen in all patients, crust- developed atrophic scarring despite uneventful test area ing in 51.9%, and scaling or peeling in 19.6%. Three treatments. Thirty percent of patients with scarring had patients reported swelling, and two reported blisters. Many clinical resolution over 6 to 12 months. Hypertrophic scar- patients reported crusting only after their ﬁrst treatment ring also occurred after an uneventful test and four or ﬁve and not with subsequent treatments. The average duration uneventful treatments. Hypertrophic scarring showed no of these immediate skin changes was reported to be 7 resolution in these patients.
to 14 days. Long-term skin changes with PDL therapy Complaints of discomfort from treatment were rated as included hyperpigmentation in six patients, hypopigmen- moderate in 49.1% of patients, which is higher than pre- tation in ﬁve, and isolated punctate depressions in two.
viously reported.21 However, pain in adults was not a lim- Pigmentation changes in patients who had completed iting factor in treatment. Although patients, in retrospect, therapy lasted an average of 6 months. Atrophic surface have rated treatment pain as moderate, treatment was not changes noted in two patients involved small areas of exco- discontinued because of pain in any patient.
riation. No hypertrophic scarring was noted. This apparentscarring was transient in nature, and both episodesresolved completely within 12 months. No signiﬁcant Variable Treatment Response by Lesion
differences in adverse sequelae were apparent between Location and Size
original lesions that were ﬂat or raised.
An additional study of 500 patients treated with the PDL In addition to an obvious decrease in responsiveness to found an incidence of atrophic scarring of less than 0.1%.
treatment on the extremities compared with the face (see Hyperpigmentation was seen in 1% of patients and tran- the next section), PWSs responded differently even within sient hypopigmentation in 2.6%. Patients with atrophic the same anatomic location. The centrofacial regions Laser Treatment of Cutaneous Vascular Lesions Figure 2.24
(A) Facial telangiectasia in 32-year-old woman 3 years after one treatment with the PDL at 7.0 J/cm2 with 5-mm-diameterspot. Note hypopigmented circles and persistent telangiectasia.
(B) Ten months after three treatments with PhotoDerm VL. Firsttreatment was with 570-nm cutoff ﬁlter at 37 J/cm2 given as a doublepulse of 2.4 and 2.4 ms with a delay time of 10 ms. Second and thirdtreatments given 4 weeks apart, 4 weeks later through a 550-nmcutoff ﬁlter at 40 J/cm2 given as a 2.4- and 4.0-ms double pulse witha 10-ms delay. Note complete resolution of the telangiectasia andhypopigmented circles.
(medial aspect of the cheek, upper cutaneous lip, nose)respond less favorably than the periorbital, forehead,temple, lateral cheek, neck, and chin areas.91,106 Evaluationby dermatomal distribution revealed that V2 lightened onaverage 74%, whereas combined dermatomes V1 and V3 Figure 2.23
(A) Port-wine stain (PWS) on the cheek of 4-year-old lightened on average 82% when treated with the PDL at girl immediately before treatment. (B) Purpuric response immediately 585 nm, 5-mm-diameter spot size, and 5.75 to 8.5 J/cm2 after treatment with PDL at 7.0 J/cm2 delivered through 7-mm- in an average of four treatments. V diameter spot size. (C) Opposite cheek with identical PWS 2 lesions also require immediately after treatment with PhotoDerm VL with 570-nm cutoff more treatments to reach maximal clearance than V1 or V3 ﬁlter at 40 J/cm2 given as a single 8-ms-duration pulse. Note lesions (Fig. 2.25). Lesions in the V3 dermatome have been diminished purpuric response.
found to have more superﬁcially ecstatic blood vessels,whereas lesions in V2 dermatome and on distal extremi-ties have more deeply placed vessels.107 Lesion size may be an independent factor determining lesion response. A study of 74 adult PWSs on various loca- Cutaneous and Cosmetic Laser Surgery Mean lightening, 70.7%; Mean lightening V2, 73.8%; Mean lightening, 82.3%; Mean lightening V1, V3, C2/C3; excellent response 82.3%; excellent response Figure 2.25
(A) Anatomic subdivision of therapeutic response of port-wine stain (PWS) to pulsed dye laser (PDL) treatment. (B) Dermatomal distribution of therapeutic response of PWS to LPDL treatment. (Reprinted from Arch Dermatol 129:182, 1993. Copyright 1993 AmericanMedical Association. All rights reserved.) PDL Treatment of Extremity Lesions
The poor response of lesions located on the distal extrem-ities has been seen in our practice and reported by others.
In one review, 7 of 10 patients with PWS on the extremi- ties responded only slightly or poorly.94 This ﬁnding mightreﬂect an artifact of fewer treatments because the average Rate of clearing
number of treatments was 2.6 (Fig. 2.27). In contrast, thoselesions on the face and neck that responded slightly or poorly had an average of only 1.1 treatments. Twenty-seven patients with lower limb PWS treated with the PDL 10.1-20 20.1-40 40.1-60 60.1-80 80.1-100 at ﬂuences up to a maximum of 8.5 J/cm2 also had a Lesion size (cm2)
poor response.95 In this population, only one patient had greater than 95% clearance, despite these patients Figure 2.26
Facial PWS lesion size affects rate of clearing after PDL treatment in adults. Data are represented as mean ± standard error of having an average of 9.4 treatments. Overall, 26% of these mean for each lesion-size category. Asterisk (*) designates signiﬁcant patients had no response, 22% had a poor response, 33% difference (p < 0.05) in rate of clearing versus size category of greater had less than 50% lightening, 15% had 50% to 75% light- than 100 cm2. (From Yohn JJ, Huff JC, Aeling JL et al. Reprinted with ening, and only one had greater than 95% clearance after permission from Cutis. 1997; 59:267–270. 1997, Quadrant seven treatments. In addition, 18% of patients developed hyperpigmentation, which lasted for an undisclosedperiod.
The effect of decreased response to treatment with lesions located in extremities was also noted by Orten tions found that all lesions responded, with 25% to 90% et al,91 who found only 33% lightening despite a mean of lightening.108 However, only 36.5% achieved 50% clearing approximately six treatments, compared with 80% to 90% despite 4 to 19 treatments, depending on the size of the lightening of PWS lesions in fewer or similar number of lesion. No lesions had greater than 75% clearance despite treatments in other locations. Lanigan109 also reported 6 to 15 treatments when their size was greater than 60 cm2, poor response to treatment in 23 patients with lower and no lesions had greater than 50% clearance despite a limb PWS. Ten patients had no discernible lightening mean of 17 treatments when their size was larger than after one treatment at 7.75 J/cm2. Seventeen patients with 100 cm2 (Fig. 2.26).
a median of seven treatments at a median ﬂuence of Laser Treatment of Cutaneous Vascular Lesions Figure 2.27
Port-wine stain on entire right hand, arm, and chest of 38-year-old woman. Photograph was taken 2 years after treatment ofhand and arm. Right dorsal hand has been treated three times withthe pulsed dye laser at ﬂuences ranging between 7 and 7.5 J/cm2.
Area from wrist to elbow has been treated once at an energy of 7 J/cm2. Area of demarcation from midforearm to lateral aspect of photograph was treated a second time with a ﬂuence of 7.5 J/cm2.
Note signiﬁcant improvement in proximal forearm without noticeableimprovement (by comparison) of distal forearm, dorsal hand, orﬁngers.
7.25 J/cm2 showed median lightening of 40%. Of thoseresponding, only three patients had lightening of 70% orgreater after six, ten, and ﬁve treatments. However, someauthors have reported a similar treatment efﬁcacy despitelesion location with a similar average number of treatments.90 The reason PWSs on the distal limbs respond slowly is Figure 2.28
Extensive port-wine stain (PWS) of left hand, forearm, unknown but may be related to gravitational or deoxy- and chest of 18-month-old boy. (A) Before treatment. (B) Six months genation effects on circulation. Distal vessels have a thicker after two treatments to dorsal hand with pulsed dye laser using a wall, which may require increased thermal effects for irre- ﬂuence of 6.75 J/cm2. Total of 80 5mm impacts were given duringeach treatment session. Note signiﬁcant resolution of PWS.
versible damage (see p. 50). Because distal areas respondmore poorly than more proximal areas, early treatment ofextremity lesions, before ambulation, may be beneﬁcial.
We have found this to be true in the small number ofpatients we have treated at an early age with distal limb density may have been chosen. Generally, three or four PWS (Figs 2.28 and 2.29).
energy ﬂuences are tested and evaluated at approximately As previously mentioned, even treating extremity 6 weeks (Fig. 2.29). The most effective one is then chosen lesions with high-energy ﬂuences has been unsuccessful.
for treatment. If none of the test sites shows improvement, Near-complete resolution in only two treatments has a second series of test energies is chosen. With experience, been reported when ﬂuences of 9 J/cm2 are used. However, the test period may be eliminated and the treatment this degree of laser energy poses a risk of pigmentary and energy chosen by evaluation of the laser's immediate nonspeciﬁc epidermal changes.88 Epidermal cooling may allow these necessary higher ﬂuences to be used.
Treatment of the entire lesion or a portion of the lesion may be accomplished by covering the treatment area withlaser or IPL impacts that overlap 10%. Overlapping can minimize a mottled ‘egg crate' or ‘foot-print' appearance.
However, as previously described, the degree of overlap- The treatment protocol involves ﬁrst performing a test of ping is determined by the type of PDL used, with the Cyno- several different energy densities to determine efﬁcacy.
sure PDL better used without any overlapping, except with Immediately after impact, a dark purple discoloration a ‘fuzzy spot'. Overlapping may also be achieved with the occurs. Conversely, if the site does not discolor, too low an Candela PDL by use of the so-called fuzzy spot.110 With this energy ﬂuence may have been chosen. If edema, blistering, treatment modiﬁcation, the laser handpiece is moved away or blackening of the impact site occurs, too high an energy from the skin beyond the laser's focal point, resulting in a Cutaneous and Cosmetic Laser Surgery Figure 2.29
(A) Immediately after application of test doses with pulsed dye laser at laser energies speciﬁed. (B) Four months after testdoses. Note signiﬁcant clearing in all areas, with maximum clearing atﬂuences of 7.0 and 7.25 J/cm2. Patch treated at 7.5 J/cm2 shows light-brown hyperpigmentation. Treatment will therefore proceed at anenergy of 7.0 J/cm2.
larger, defocused impact spot. This has a lower energydensity than that indicated for the focused spot and alsoa more indistinct or ‘fuzzy' border that blurs the edges ofclearing from a single treatment. Re-treatments are gener-ally done at 11/2- to 4-month intervals.
The use of overlapping pulses should be undertaken with caution, however, because biopsies of PWSs treated Figure 2.30
Congenital port-wine stain on thigh of 66-year-old with single impact and consecutive double-impact therapy man. (A) Before treatment. (B) Immediately after treatment with reveal an additive thermal effect resulting in nonspeciﬁc pulsed dye laser at 7 J/cm2. S, area treated with single pulse; D, area thermal damage to the superﬁcial dermis and epidermis treated with double pulse. Double-pulse area has darker (Figs 2.30 and 2.31). This double-pulsing technique does promote greater resolution of nodular, thicker, and darkerlesions but results in loss of speciﬁcity.
The reason for multiple treatments is the layered nature effective wavelength related to their depth.) However, of ectatic vessels of a PWS. Modeling studies using the purple lesions are not completely or always unresponsive histologically correct layered vessel demonstrate that to treatment. We found that although purple lesions are the more superﬁcial vessels receive most of the delivered graded most often as excellent responders (52%), they also energy. The deeper vessels receive less energy and are there- are the leading group of poorly responsive lesions (21%).27 fore not thermocoagulated because of mutual shadowing This paradox may occur because two distinct populations of the superﬁcial vessels111 (Fig. 2.32).
of purple lesions exist: macular and nodular. Exophyticnodular lesions respond well, whereas purple and macularlesions respond poorly because of deeper and larger dermal Other Factors in Treatment Response
Paradoxically, lesions that respond poorly may appear In addition to size and location of the PWS (lesions on clinically similar to good responders. In these lesions, extremities), other factors may be important in predicting biopsy demonstrates vessel walls that are thicker despite responsiveness to treatment. PWSs that are dark red or a vessel diameter that is smaller than 0.056 to purple may be less responsive to laser treatment. The rela- 0.102 mm.112,113 Such lesions are usually on the trunk or tive difﬁculty in treating these lesions results from the extremities. Alternatively, lesions with deeper vessels presence of deeper, larger vessels that are beyond the laser's respond poorly, because the PDL at 585 nm and 6 to 8 J/cm2 penetration depth19,21 or that are too large to be photo- has been found to coagulate the entire vessel wall only to coagulated completely within treatment parameters of the a maximum depth of 0.65 mm (mean 0.37 mm), even in PDL.10 (As discussed previously, the thermal relaxation vessels not shielded by more superﬁcial vessels.114 Superﬁ- time of target vessels is related to their diameter, with the cial PWS vessels up to 0.15 mm in diameter were found Laser Treatment of Cutaneous Vascular Lesions Figure 2.33
Biopsy of port-wine stain on the face of a 43-year-old female. Lesion is violaceous and thick immediately after treatmentwith pulsed dye laser at 6.5 J/cm2. There is complete coagulation of Figure 2.31
(A) Biopsy specimen immediately after single pulse as red blood cells (RBCs) and vessel wall in a 150-mm vessel (right) and described in Figure 2.47A. Note coagulation of superﬁcial dermal no damage to the lower third of RBCs and vessel wall in a larger ectatic blood vessels without any change in overlying epidermis or vessel. Note the ‘steam bubble' formation in upper half of vessels and perivascular tissue (hematoxylin–eosin; ¥40). (B) Biopsy specimen perivascular dermal coagulation zone. (Reprinted from Hohenleutner immediately after double-pulse technique as described in Figure U, Hilbert M, Wlotzke U et al: Journal of Investigative Dermatology 2–47B. Note nonspeciﬁc thermal damage to overlying epidermis and 104:798, 1995. With permission from Blackwell Publishing Ltd.) perivascular tissue. Ectatic blood vessels in superﬁcial papillary dermisare thrombosed with evidence of perivascular collagenhomogenization (hematoxylin–eosin ¥40).
histologically to coagulate completely without nonspeciﬁcdamage to epidermal or perivascular tissues (Table 2.7 and Therefore both vessel size and vessel depth in addition to vascular wall thickness are important determinants in predicting treatment efﬁcacy. Vessel size has an important effect because the entire vessel (not just the superﬁcialportion) must be thermocoagulated. This assumes that forvessel coagulation, heating the center of the vessel is necessary for thermal radiation to the entire vessel wall.
This requires both an adequate wavelength (for depth of penetration) and an adequate pulse duration (thermal Finally, Waner115 has proposed that autonomic inner- Deposited energy (
vation is an important determinant of treatment efﬁcacy.
In a study of 118 PWSs in 102 patients, recurrence of the PWS depended on the time lapsed since the completion oftreatment. Although only 3% of patients showed evidence of recurrence at 1 year, 20% and 40% showed evidence forrecurrence at 1 to 2 and 2 to 3 years after treatment, respec- tively. Cutaneous venules of the PWS vasculature areinnervated by sympathetic postganglionic neurons as wellas sensory neurons.116–118 The apparent underlying cause Deposited energy (
of a venular malformation is an absolute or relative deﬁ- ciency of autonomic innervation of the cutaneous vascu- Figure 2.32
(A) Geometry with 17 multiple straight vessels in three lar plexus. Smaller and Rosen116 demonstrated a deﬁcit in layers at different depths z of 300, 435, and 570 mm, and lateral the number of perivascular nerves in PWS. Kane et al119 spacing between vessels' centers of 270 mm. Energy deposition in also found a decrease in autonomic innervation in six multi-blood-vessel geometry for (B) wavelength 577 nm, and (C) patients with poorly response PWS despite 5 to 21 treat- wavelength 585 nm. Laser beam diameter is 1 mm. Upper vessels ments with the PDL at ﬂuences up to 10 J/cm2.
receive most of the energy. Deeper vessels receive less energy by Therefore Waner115 postulates and we concur that even decreasing light ﬂuence with depth and also by mutual shadowing ofvessels. (Fig. 2.32A, B and C. Lucassen GW, Verkruysse W, Keijzer M though effective treatment decreases the number of ectatic et al: Lasers in Surgery and Medicine 18:345, 1996. Reprinted with vessels signiﬁcantly, the remaining milieu allows for a con- permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.) tinuing course of progressive ectasia. Recurrence of com- Cutaneous and Cosmetic Laser Surgery Table 2.7
Treatment of Port-wine Stains with Flashlamp-pumped Pulsed Dye Laser (PDL, 6.5 J/cm2): Lightening Per Vessel
Size and Depth
Measurement (mm; mean ± SD)
Poor lightening (n = 8)
Moderate lightening (n = 12)
Good lightening (n = 22)
From Fiskerstrand EJ, Svaasand LO, Kopstad et al. J Invest Dermatol 1996; 107:671.
pletely resolved capillary malformations, however, has not IPL as previously discussed. To enhance the therapeutic been observed by the authors.
effects of the PDL one can use cryogen spray with higherﬂuences, increase the spot size of the PDL, change from a595 to a 585 dye, increase the pulse duration from 0.45 ms to 1.5–20 ms, and perform multiple passes at the samesession with variable pulse durations.
Improvement and clearance are gradual and usually The primary purpose of cryogen cooling is to allow require 5 to 10 treatments, although some lesions may not higher ﬂuences to be used without damage to the epider- fully clear despite more than 20 separate treatments. It is mis. Higher ﬂuences will produce higher temperatures sometimes difﬁcult to determine when a lesion has reached within the dermal ecstatic vessels. Studies have found that a point of maximum improvement, but treatments should the use of cooling with higher ﬂuences enhances the be continued as long as each results in an increment of resolution of PWS.121–123 improvement. We have found the point of diminishing Performing multiple passes with 0.45-ms and 1.5-ms return to occur about the seventh treatment. Finally, pulse durations has been reported to accelerate resolution areas within a PWS that fail to respond to treatment of PWS.124 However, this has not been uniformly con- should be closely examined because we and others have ﬁrmed by our group and others.125 reported the development of basal cell carcinoma within a Increasing the pulse duration from 0.45 ms to 1.5 or even 2.0 ms has been reported to result in further clearing A retrospective photographic analysis was performed on of ‘resistant' PWS.126,127 69 patients who failed to achieve greater than 75% lesional Changing from a 585-nm dye to a 595-nm dye has lightening in nine treatment sessions with the PDL at resulting in enhanced clearing in some PWS. It appears typical treatment parameters.120 Retreatment at similar that pink or red PWS do best with 585 nm whereas blue or parameters with a 5-mm-diameter spot size and ﬂuences of dark red PWS do better with 595-nm dyes.127–131 This is 5.75 to 8.0 J/cm2 resulted in continued improvement in due to the shift of absorption to higher wavelengths with these patients. An additional 25% to 100% lightening was production of methemoglobin, which is formed by a achieved in these patients treated up to 25 separate times.
photoinduced oxidation of hemoglobin with laser Extensive surface area involvement and limb lesions were the slowest to respond.
Finally, other maneuvers, such as increasing the diame- As mentioned previously, the dominant vessel size in ter of the blood vessels by using a proximal tourniquet has childhood PWS is 10 to 50 mm in diameter. The average also enhanced absorption with a 585-nm, 1.5-ms PDL.133 thermal relaxation time of PWS vessels is estimated at 1.2 ms.4 As the child grows to adulthood, progressiveectasia results in larger and deeper vessels up to 300 mm indiameter with a thermal relaxation time of approximately Recurrence of Port-wine Stains
10 ms. It is reasonable to assume that these larger vesselswould be more common in the darker, thicker lesions of The use of the PDL in treating PWS has been widely prac- adults. Although the PDL has been shown to be very effec- ticed for almost 20 years. Recently, we and others have tive in the treatment of adult PWS,22,23,25,27 larger vessels begun to evaluate our patients treated in the early years for in these lesions are not ideally suited for the speciﬁc signs of persistent or recurrent lesions. Although we have parameters of this laser. Therefore other laser or pulsed not seen a signiﬁcant number of patients returning to our light sources or photodynamic therapy may be useful.
practice with progressing lesions, other physicians havereported recurrence after completion of treatment (see Fig. 2.17). Orten et al91 have evaluated a small number of Treatment of ‘Resistant' Lesions
patients who were 2, 3, and 4 years posttreatment. Theyhave reported recurrence (darkening of the lesion) in 5 of Multiple methods are available for treating PWS lesions 24 patients at 2 years, 4 of 10 patients at 3 years, and 2 of that fail to respond to the PDL. The ﬁrst is to switch to the 4 patients at 4 years posttreatment. The most obvious Laser Treatment of Cutaneous Vascular Lesions patient, an adult female whose PWS was on the midlateral pulses at 15 or 20 J/cm2. Posttreatment purpura developed cheek, had near-complete clearance of the PWS only to at all effective treatment sites. No scarring or ulceration have almost total recurrence after 42 months. Whether occurred. Histology showed that selective vessel closure these recurrent lesions would respond more favorably to was achieved without hemorrhage. Perivascular collagen alternative treatment modalities (e.g. IPL) or respond damage was always present at the effective treatment sites.
equally as well to additional treatment is unknown. Recur- These ﬁndings show that a 532-nm laser pulsed in the 1- rence of PWS in a subset of patients may support a to 30-ms domain is capable of inducing selective vessel ‘neuronal' theory of PWS evolution.
Raulin et al134 reported complete resolution of a facial PWS in a 35-year-old male that did not respond to a single 532 nm Nd:YAG Long-pulse Laser
treatment with the PDL at 6.5 J/cm2. They used a 550-nm By extending the pulse duration to within the thermal cutoff ﬁlter with single and double pulses of 25 J/cm2 3 ms relaxation time of the vessel treated, purpura is avoided in duration. Treatments were given every 8 weeks until without loss of efﬁcacy (see earlier). This laser has been clearance occurred after the fourth treatment.
effective in treating PWSs that have sometimes proved tobe recalcitrant to treatment with other laser modalities136 Treatment with Other Lasers
(Fig. 2.35). Our experience in using this modality, bothwith and without epidermal cooling, has been variable but Carbon Dioxide Laser
positive. The 532 nm laser is less effective in Asian patients In our opinion, nodular lesions are best treated with the with a higher risk of complications.137 A dual pulsed 532 UltraPulse CO2 (UPCO2) laser (see Chapter 6) or the IPL.
and 1064 nm laser (Dualis KTP+, Fotana d.d., Ljubljana, With the UPCO2 laser the lesion can be sculpted to reestab- Slovenia) has been found in a pilot study on 10 patients lish a normal facial contour in addition to thermocoagu- to be effective in treating PWS. Cryogen spray cooling as lating the ectatic blood vessels. The advantages of the well as topical anesthesia is necessary but atrophic scars UPCO2 laser are its precise hemostasis and avoidance of still occurred.138 nonspeciﬁc thermal damage (Fig. 2.34). After normal con-tours are obtained, the PDL or IPL can be used to lighten 1064 nm Nd:YAG Long-pulse Laser
the remaining erythema.
Most recently, this longer wavelength laser has been usedin the treatment of PWS. It is thought that the deeper pen- Potassium Titanyl Phosphate Laser
etration of the 1064 nm wavelength would allow further The 532-nm Starpulse KTP laser (LaserScope) has been used improvement especially in blue PWS. Although effective, in conjunction with a scanner to treat adults with PWS.
this laser has a relatively high incidence of hypertrophic Best clearing of the test sites was obtained with 3- or 5-ms and atrophic scarring due to the high energies needed Figure 2.34
(A) Congenital port-wine stain with large hypertrophic Figure 2.35
Port-wine stain on left upper cheek of female patient mass on right lateral distal nose and nodules on right inner canthus treated under general anesthesia with copper bromide laser (CBL); present in 47-year-old Hispanic man. Over last 20 years, lesion has actual treatment required about 15 minutes. (A) Before treatment.
grown progressively darker in appearance as well as developing (B) After treatment with exposure time of 7 ms, 2.5 W, and spot size nodular hypertrophies. (B) Three weeks after treatment with Coherent of 0.7 to 1.0 mm (4.5 J/cm2), with 10 ms (6.5 J/cm2) for darker areas.
Ultra Pulse CO2 Laser (Coherent Laser Corp., Palo Alto, CA) at 250 mJ, (Courtesy Sue McCoy, MD.) pulse width of 794 ms at 20 W, 80 pulses per second, in continuous-wave mode with 2-mm spot.
Cutaneous and Cosmetic Laser Surgery gioma. Other times it is used to (mis)label a noninvolut-ing ‘cavernous hemangioma', which in reality is a venousmalformation with spongy architecture.141 A venous mal-formation may be difﬁcult to differentiate clinically froma deep hemangioma. Failure to evacuate blood with com-pression occurs in hemangiomas, not in venous malfor-mations, and this is a useful maneuver to differentiate thetwo conditions.
Hemangiomas are the most common tumor of infancy;60% occur on the head and neck, 25% on the trunk, and15% on the extremities.142 Eighty percent of hemangiomasare present as a single, well-circumscribed lesion 0.5 to 5.0 cm in diameter, and the remainder occur as multiplecutaneous and visceral lesions.141 The lesions are generally Figure 2.36
Long-standing PWS before and 1 month after 4- absent at birth, but a localized area of pallor or macular monthly treatments with a long-pulse Nd : YAG laser using a 7-mm-diameter handpiece with a ﬂuence of 60–65 J/cm2 at 10–15 ms pulse erythema or telangiectasia may be present. The majority of duration. (Courtesy of Don Groot, MD.) hemangiomas (70%–90%) appear during the ﬁrst monthof life, and by age 12 months the incidence is reported tobe in the 10% to 12% range.39,143,144 Hemangiomas present at birth result from in utero growth. They are difﬁcult to diagnose with routine ultrasonic evaluation, even when associated with to thermocoagulate red blood cells at this wavelength.
Kasabach–Merritt syndrome. They tend not to grow after Although patients prefer the lack of signiﬁcant purpura birth and usually regress by 14 months, leaving atrophic, with the 1064 nm laser, scarring has been noted to occur redundant, or scarred skin.145 even with epidermal cooling after establishing a minimal When lesions have distinct borders, homogeneous purpuric laser ﬂuence.139 This may be related to the differ- color, no overlying telangiectasia they are usually a capil- ent absorption characteristics of the vessels of a PWS in dif- lary malformation. When the borders are indistinct and ferent locations within the same lesion. At this time, this the lesions are variably colored with visible overlying laser modality is only recommended for thick, blue lesions telangiectasia they are true hemangiomas.
recalcitrant to other treatment modalities (see Fig. 2.36).
Congenital hemangiomas of eccrine glands have also been reported.146 These rare lesions usually appear at birthas bluish, slightly elevated tumors. None shows evidenceof hyperhidrosis, and all resolve spontaneously. Diagnosis is made on histologic examination of dilated capillary-likevessels located around sweat glands.
The treatment of hemangiomas remains a challenge. Part The female/male ratio for hemangiomas is estimated to of the problem in evaluating published reports and in be 3 : 1.142,147 Caucasian infants have been reported to have designing rational therapeutic plans resides in the confu- an increased incidence over other racial groups.119,143,144 sion in terminology that still exists.
The clinical appearance is related to the depth of the pro- Hemangiomas are benign vascular tumors composed of liferating lesion. Superﬁcial lesions are raised and bright proliferative, plump, endothelial cells. They can occur in red (Fig. 2.37). Deeper dermal lesions appear as bluish skin, mucous membranes, and other soft tissues. A heman- subcutaneous nodules. The overlying skin may have a ﬁne gioma often begins as a ﬁeld transformation, frequently in network of telangiectasia (Fig. 2.38). With regression, multiple sites simultaneously or over a large area of skin.140 superﬁcial lesions leave a ﬂaccid, pedunculated, waxy, The tumor may begin in subcutaneous tissue or muscle or yellow-colored skin (Fig. 2.39). Deep lesions usually leave may inﬁltrate the skin densely without elevating it, giving a smooth skin surface with overlying telangiectasia. A an appearance similar to that of a PWS.141 However, mottled grayish mantle spreads towards the periphery of whether superﬁcial, deep, or mixed, the lesion is thought the lesion and is less tense to palpation. Parents note that to have the same histologic and biologic behavior pattern deep lesions do not swell as much as superﬁcial lesions throughout.140 Hemangioma typically present with both when the child cries.
a superﬁcial component and a deep cutaneous compo- The hallmark of hemangiomas is a rapid proliferative nent as well as a subcutaneous proliferation of ectatic phase. Immunohistochemical cellular markers that indi- cate proliferation include type IV collagenase, vascular The term ‘cavernous' is confusing. At times this term is endothelial growth factor, basic ﬁbroblast growth factor, used to refer to the deep dermal component of a heman- and other endothelial markers (CD31 and von Willebrand Laser Treatment of Cutaneous Vascular Lesions Figure 2.37
Hemangioma on forehead of infant appeared at 2 Figure 2.38
(A) Clinical appearance of deep hemangioma with weeks of age and gradually enlarged. (A) Appearance at 9 weeks of overlying telangiectasias on lateral trunk of 3-month-old girl. (B) After age. (B) Clinical appearance 4 months after initial laser treatment ﬁve treatments with PDL at a ﬂuence of 7 J/cm2. Note complete and 1 month after ﬁfth treatment with PDL at a ﬂuence of 7 J/cm2.
resolution of hemangioma with only very faint persistence of Treatments were given at 3-week intervals. Although some persistence overlying telangiectatic component. Hypopigmented area was present of the lesion is seen clinically as a faint pink macule, parents elected before any treatment commenced.
to discontinue treatment. (Reprinted from Fitzpatrick RE: AmericanJournal of Cosmetic Surgery 9:107, 1992. With permission fromAmerican Academy of Cosmetic Surgery.) the basement membrane, further thickening the vessel factor).148 Growth is particularly rapid during the ﬁrst 6 wall. Therefore, although response to laser treatment months of life but may continue until 12 months of age.
occurs, it may not be as dramatic as in thinner-walled Gradual spontaneous involution begins between the sixth hemangiomas of infancy.
and tenth month.39,149,150 These stages are not distinct, Studies of the natural history of hemangiomas reveal because proliferation continues while involution slowly that complete resolution occurs in 50% of children by age begins to dominate. The ﬁrst sign of regression is a change 5 and in 70% by age 7, with continued improvement in in color from crimson to dull purple. Clinical studies indi- the remaining children until ages 10 to 12.39,40,143,150–152 cate that involution proceeds on the same time schedule However, 15% to 25% of lesions do not completely invo- for both deep and superﬁcial hemangiomas.142,147 Lesions lute, and lesions that do not show signiﬁcant signs of located on the nose and lips are thought to involute more regression by age 6 to 8 years are not likely to regress com- pletely.152,153 Rate and extent of resolution are unrelated to Adult hemangiomas are composed of mature, capillary- lesion size147 (Fig. 2.40).
sized vessels approximately 100 mm in diameter, resem-bling dermal venules with virtually no endothelialgrowth.151 Basement membrane thickness ranges from 0.6 Complications and Adverse Sequelae
to 14 mm because of multiple superimposed layers of basallamina. At times an ingrowth of dermal collagen ﬁbers is Complications from the proliferative phase include ulcer- seen in the vessel wall. Pericytic cells are also immersed in ation (5% to 11% of patients) and infection, which is more Cutaneous and Cosmetic Laser Surgery Figure 2.40
(A) Hemangioma on left cheek of 15-month-old child.
Extensive hemangioma on right forehead and upper Lesion arose at 3 weeks of age and increased in size over ﬁrst year eyelid of 9-month-old girl. (A) Clinical appearance before any therapy.
before beginning a short resolution. Patient was treated with oral (B) Clinical appearance 7 months after systemic prednisolone therapy prednisolone at 6 weeks of age until 6 months of age without per protocol described in this text, plus six separate treatments with noticeable effect on size of hemangioma. (B) Appearance at 3 years PDL at a ﬂuence of 7 J/cm2. CT scan demonstrated no intracranial of age. Note redundant skin with some superﬁcial atrophic scarring connection with hemangioma. Severe orbital dystopia will be and persistent superﬁcial telangiectasia.
corrected when her bones are more fully developed at age 6. Inaddition, periorbital atrophy and loss of subcutaneous tissue in areaof hemangioma will be corrected with surgical excision after bonycorrection has been achieved. (Reprinted from Fitzpatrick RE: Skeletal distortion is rare but may occur from a mass American Journal of Cosmetic Surgery 9:107, 1992. With permission effect on underlying bone. Lesions of the nasal tip often from the American Academy of Cosmetic Surgery.) distort underlying cartilage (Fig. 2.42). Deviation of facialbones or orbital enlargement may occur.157 Lesions of the upper eyelid may obstruct the visual axis, causing deprivation amblyopia with failure to develop common on the lip and genitoanal areas, where abrasion binocular vision.158 Interruption of vision in infancy for as is common149,154 (Fig. 2.41). Bleeding from trauma is an brieﬂy as 1 to 2 weeks can cause permanent damage, with annoying and relatively common problem that usually longer periods of obstruction being more harmful. Upper responds to pressure. At times, superﬁcial ulcerations eyelid lesions may also distort the growing cornea by appearing on buttock, sacral, or lip skin in infants can direct pressure producing refractive errors (strabismic precede the development of hemangiomas by a few weeks.
amblyopia).159 Large hemangiomas of the lower eyelid may The reason for this evolution in some infants is result in similar problems, but even the smallest heman- gioma within the upper eyelid can cause visual distur- A retrospective analysis of 60 pediatric patients showed bances.160 Therefore all children with hemangiomas that in the 37% of ulcerations that were treated with the involving either the upper or the lower eyelid should be PDL, 50% showed deﬁnite improvement, 18% showed no referred to an ophthalmologist promptly, even if vision response and 5% showed worsening. Other forms of treat- appears normal.
ment included surgical excision (3%), interferon (8%), Other functional problems may occur because of the systemic antibiotics (43%) and systemic corticosteroids sheer bulkiness of lesions in critical locations causing obstruction. Lesions of the nose may interfere with breath- Laser Treatment of Cutaneous Vascular Lesions Figure 2.42
(A) Five-month-old boy with 1.5-cm hemangioma on tip of nose and overlying 4 ¥ 8-mm strawberry-red mark in center oflesion, which is very ﬂuctuant. Hemangioma was present at birth andis continuing to enlarge. (B) Approximately 3 years later, after fourtreatments with pulsed dye laser at a ﬂuence beginning initially at6.75, then 7.5, 8.0, and 8.5 J/cm2. In addition to laser treatment,patient received intralesional injection of triamcinolone, with a total of10 mg given over ﬁve injections Although nose has assumed normalappearance, it is still slightly boggy and increases in size with hotweather and when patient cries. (Reprinted from Fitzpatrick RE:American Journal of Cosmetic Surgery 9:107, 1992. With permissionfrom American Academy of Cosmetic Surgery.) Extensive facial hemangiomas may also be associated with cardiac and abdominal anomalies. Associated anom-alies can be right-sided aortic arch coarctation, a supra-umbilical midabdominal raphe defect, associated laryngeal Figure 2.41
(A) Three-month-old girl with hemangioma on right
and duodenal hemangiomas, and posterior brain fossa lower lip that was ﬂat and pink at birth and slowly enlarged duringﬁrst 2 months before rapid enlargement over last 4 weeks, at which abnormalities such as Dandy–Walker malformations.164–168 point it interfered with eating and was bleeding. (B) Clinical response The constellation of ﬁndings consisting of large facial 2 years later and 1 year after last treatment with PDL. Total of nine hemangiomas, posterior fossa malformations, arterial laser treatments were given at 4- to 6-week intervals with a ﬂuence of anomalies, coarctation of the aorta and cardiac defects, and 7 J/cm2. Within 2 weeks of ﬁrst laser treatment, deﬁnite improvement eye abnormalities has been given the acronym PHACE syn- with rapid resolution of lesion was seen, as well as near-immediate drome.168 This syndrome represents a spectrum of malfor- resolution of pain associated with eating. Slight depression appears in mations of varying degrees of severity caused by a common midportion of lower lip underlying previous hemangioma. However,there is no distortion of the vermilion border. (Reprinted from morphogenetic event or events in utero.167,169 Fitzpatrick RE: American Journal of Cosmetic Surgery 9:107, 1992.
The facial hemangiomas seen in the PHACE syndrome With permission from American Academy of Cosmetic Surgery.) are usually plaque like in quality and cover at least one der-matome; 88% occur in females. Infants who have largefacial hemangiomas should be evaluated with head cir-cumference measurements and neurologic studies, includ-ing brain imaging with cranial ultrasound and MRI scans.
ing. Lesions in the subglottic airway may obstruct the These patients also appear at risk for developing airway larynx, causing life-threatening asphyxiation.161 Lesions abnormalities and should be evaluated closely for cardiac may obstruct the external auditory canal and cause a mild defects as well.
to moderate hearing loss. Lesions in the anogenital area Sacral hemangiomas have also been associated with may cause obstruction, pressure, or tenderness when ulcer- several anomalies, including imperforate anus, genitouri- ated and inﬂamed.
nary abnormalities (absent or hypoplastic kidney, abnor- Medical complications include the Kasabach–Merritt mal genitalia), and tethered spinal cord without neurologic syndrome162: generalized bleeding from profound throm- bocytopenia associated with a large hemangioma or exten- In a study of 175 cases of severe superﬁcial heman- sive hemangiomatosis. Congestive heart failure is a giomas, deﬁned as lesions involving large surface areas, potentially lethal complication in an infant with multiple symptomatic visceral hemangiomas were present in 11.4% cutaneous and visceral hemangiomas.163 and associated malformations in 6.9%.172 The authors Cutaneous and Cosmetic Laser Surgery found that MRI was the best imaging modality to detect ill-advised attempts at treatment that have resulted in the deep growth. Hemangiomas give signals that are dif- excessive scarring.176 ferent from lymphatic or arteriovenous malformations. It Surgical intervention,177 X-ray therapy,72,176,178 sclero- may also indicate the rapidity of blood ﬂow movement.
therapy,176,179 diathermy,180 CO2 snow cryotherapy,181 Color-ﬂow duplex ultrasonography was helpful but could and electrocautery182 have all been attempted, resulting in not accurately distinguish a hemangioma from an AVM signiﬁcant scarring. A basal cell carcinoma (BCC) present- because both may have a high-ﬂow pattern.
ing 58 years after thorium X applications to a birthmark As described later, many hemangiomas resolve sponta- when the patient was 3 years old has been reported.183 neously without any form of treatment. However, even Thorium X, a rich source of alpha radiation, was frequently when resolution is complete, the skin that remains after used for treating hemangiomas until the 1960s.184,185 BCC involution exhibits mild atrophy, has a wrinkled texture developing after thorium X treatment of hemangiomas has with a few telangiectatic vessels, or is paler than the sur- also been reported.186 Angiosarcomas have also occurred rounding skin.141 Resolution that is considered cosmeti- after radiation treatment of hemangiomas, with a review cally acceptable has been said to occur in 70% to 82% of of the literature uncovering 11 such cases.187 The progno- patients.154 However, in an analysis of 298 hemangiomas, sis is poor, with a 10% 5-year survival rate.
80% that had not involuted by age 6 left a signiﬁcant resid- Thus these prior methods of treatment, because of ual cosmetic deformity.173 In addition, 38% of those lesions unacceptable side effects and lack of efﬁcacy, have been that had completely resolved by age 6 left a signiﬁcant replaced with laser therapy as a destructive and antiprolif- residual deformity. Scarring after ulceration generally erative modality and with other antiproliferative medical leaves a white, ﬂat area of ﬁbrosis. When the hemangioma treatments. As discussed later, some patients require has been large, there is often redundant skin and a resid- multiple forms of therapy.
ual subcutaneous ﬁbrofatty tissue mass.141 Therefore, our When the pathogenesis of these lesions is considered, opinion, supported by the clinical studies detailed next, is an antiangiogenic agent that would prevent proliferation to treat lesions at the ﬁrst available opportunity.
and induce involution of the entire lesion is the most In addition to medical complications, including persist- logical therapeutic approach.188 At present, the only ent scarring, the psychologic consequences are real. A child treatment of this type is the use of systemic steroids with develops a sense of self-awareness between 18 and 24 or without interferon-alpha.
months of age. This awareness may be transmitted to psychosocial developmental disorders. Parental guilt,anger, and disappointment as well as over protectiveness Systemic and Intralesional
are common. These feelings may affect the dynamics of the entire family. A study consisting of interviews of the parents of 25 children aged 6 months to 8 years with If a hemangioma is steroid responsive (30%–60% of facial hemangiomas at least 1 cm in diameter reported neg- cases),188,172 the result is often immediate and dramatic.176 ative social stigmatization in the majority of families.174 A treatment schedule of 2 to 3 mg/kg/day of prednisone, For 32% of parents this interfered with outings. Common rapidly tapered, when the tumor has reduced in size, is feelings that the parents expressed were grief, loss, isola- given for a cycle of 4 to 6 weeks, followed by a rest period.
tion and guilt. For the children, social sensitivity occurred Complications have been few.188 In patients who fail to after age 4. This study underscores a family's need for respond, however, increasing the dose of prednisone to 4 more than just medical management of an infant's to 5 mg/kg/day may trigger growth of the lesion.172 Loss of appetite and diminished growth rate have been observedbut resolve quickly when steroids are discontinued.
However, because the proliferative activity of the tumor continues for 6 to 12 months, the need for prolongedsteroid suppression persists, with rebound growth of the Treatment of hemangiomas has been oriented toward hemangioma occurring when treatment is discontinued.
waiting for natural regression to occur since Lister's article This often results in an escalating steroid dosage or aban- in 1938 outlined a predictable course for these lesions.152 donment of this regimen because of concern regarding However, contemporaries of Lister recognized the effec- potential steroid side effects.
tiveness of early treatment before and during the pro- A second steroid schedule has been used throughout liferative stage of growth.175 Therapeutic intervention the entire proliferative phase of the hemangioma. Pred- historically has been reserved for lesions causing recurrent nisolone is given in a dosage of 3 to 5 mg/kg/day for 2 to bleeding, ulceration, infection, or serious distortion of 4 weeks until control of growth of the hemangioma is facial features and lesions that interfere with normal achieved. An alternate-day schedule is then instituted by physiologic functions, such as breathing, hearing, eating, doubling the dose on the ‘on' day and eliminating the vision, and bladder and bowel function. Despite these alternate-day dosage gradually over 2 weeks. Prednisolone therapeutic guidelines, there is tremendous pressure on is then tapered every 2 weeks by 5 mg if the hemangioma anguished, concerned parents observing an enlarging does not enlarge.189 This treatment schedule is maintained hemangioma on their child, particularly when it is a facial for 6 to 10 months. In 43 infants treated, only one infant lesion of any size. Because of this, there have been many had transient side effects. However, it is advisable to use Laser Treatment of Cutaneous Vascular Lesions emphasizes the need for close monitoring of patients whorequire systemic steroids.
Intralesional steroids have been used successfully in the treatment of periorbital hemangiomas.191,192 Soft tissueatrophy is common but seems to be temporary.191 Intra-lesional steroid injection carries a risk of hemorrhage orhematoma in the retrobulbar space, which is a threat tovision.167 It may cause occlusion of the central retinalartery and damage to the optic nerve.193 When the heman-gioma extends posterior into the orbital cone, systemicsteroids should be considered.176 A study of 70 children with 74 hemangiomas treated with intralesional corticosteroids showed more than 75%reduction in volume in 58% of patients, 50% to 75%improvement in 22%, 25% to 50% improvement in 12%,and less than 25% improvement in 8%.194 No patient hadregrowth after treatment with a mean follow-up of 14months. The authors used doses of 10 to 120 mg per injec-tion of triamcinolone and betamethasone acetate (1.5–18 mg/injection) given in a total volume of 0.5 to 6.0 mL, Figure 2.43
(A) Large hemangioma over right side of face of 4- depending on the hemangioma's size. Side effects included week-old girl. This lesion began as a red macule 5 mm in diameter, temporary cushingoid facies and hypopigmentation, each ﬁrst noted over right cheek 2 days after birth. Hemangioma spreadrapidly over left forehead, cheek, neck, and eyelid over only 2 to 3 in two patients. No apparent correlation existed between days. Patient was initially treated with pulsed dye laser (PDL) alone at response and lesion location, size, patient gender, or age.
a ﬂuence of 7.25 J/cm2. However, when seen 2 weeks later, although Enjolras and Mulliken195 advise giving 3 to 5 mg/kg/pro- there was deﬁnite improvement in laser-treated site, hemangioma cedure (either intralesional or systemic) of triamcinolone was continuing to enlarge rapidly, involving entire orbit and right with or without cortisone acetate. They believe that parotid and neck area. Subcutaneous masses were present, and intralesional and systemic corticosteroids have a similar prednisolone was begun at a dosage of 4.5 mg/kg/day. Laser response rate. They advise caution when injecting treatment was continued at a ﬂuence of 7.5 J/cm2 at 2-week intervals. Almost immediately after institution of oral prednisolone, hemangiomas of the upper eyelid because particles in the hemangioma stopped growing and began a resolution phase.
steroid suspension can potentially occlude retinal or Prednisolone dosage was tapered 2 weeks after institution. When it choroidal microvessels or the central retinal artery.
was discontinued totally on pediatrician's advice 6 weeks later,hemangioma again began to enlarge. We therefore restartedprednisolone therapy, increasing it to a dosage of 5 mg/kg/day to initiate resolution of hemangioma. During this time, lesion wascontinually treated at 2- to 3-week intervals with PDL at ﬂuences Interferon is the second-line drug for treating severe, large ranging from 7.0 to 7.5 J/cm2. Interestingly, on alternate-day hemangiomas. Interferon-alpha2a (IFN-a2a) is a potent, prednisolone therapy, patient's parents noticed hemangioma fairly well-tolerated cytokine that requires liver and hema- increasing in size during the day off therapy, with it regressing in size tologic monitoring during therapy. Long-term treatment during the day on prednisolone therapy. Prednisolone therapy was carries the risk of thyroid dysfunction and neurologic com- tapered over 2 years before being discontinued. (B) Patient, now 11 plications. Interferon is known to inhibit angiogenesis, months old, has marked resolution of hemangioma. At this point she probably through inhibition of vascular smooth muscle is continuing to have prednisolone therapy and has had total of ninetreatments with PDL, with last treatment 4 months previous to this cells and capillary endothelial cells.196 photograph. (C) Patient is now 7 years old without recurrence.
In a study of 20 patients with vision-threatening (Reprinted from Fitzpatrick RE: American Journal of Cosmetic Surgery hemangiomas resistant to corticosteroids, 18 patients had 9:107, 1992. With permission from American Academy of Cosmetic more than 50% regression after an average of 8 months of the lowest effective dose of steroid for the shortest period until the hemangioma enters the regression phase (Fig. 2.43).
At times, especially when treating large or extensive Adverse effects of systemic corticosteroids include hemangiomas and conditions such as diffuse neonatal immunosuppression, osteoporosis, hypertension, cushin- hemangiomatosis, multiple modalities may be required. In goid features, hypothalamic–pituitary–adrenal (HPA) axis these patients, systemic prednisone with or without inter- suppression, impaired glucose tolerance, growth suppres- feron, embolization of hemangiomas, surgical debulking sion and ocular complications. One study of 22 patients and excision of the dermal component, and PDL treatment with hemangiomas treated with an average corticosteroid to superﬁcial lesions may all be used198 (Fig. 2.44).
dose of 2.23 mg/kg/day for an average of 28.1 weeks found Although one might believe that the laser is cosmetic, its irritability, fussiness or insomnia in 73%, hypertension use in these patients prevents cutaneous hemorrhage and in 45% and HPA suppression in 87%.190 This review facilitates routine skin care.
Cutaneous and Cosmetic Laser Surgery a hemangioma are its depth of penetration, energy ﬂuence,and pulse duration. Lasers with short wavelengths (<585 nm) can only deliver sufﬁcient energy required forthermocoagulation to a depth less than 1 mm. Pulse dura-tions necessary range from 0.5 to 10 ms, depending on thesize of the ectatic vessels. Energy ﬂuences should be greaterthan 6 J/cm2. With these parameters, many differentpulsed-light modalities have demonstrated efﬁcacy.
The argon laser199–201 has been used effectively to treat
hemangiomas. The potential beneﬁt of the argon laser
is limited by its depth of penetration into the dermis
(<1 mm) and its tendency to cause hypertrophic scarring
through nonspeciﬁc thermal injury, as reported in children
with PWS.25 However, with PWSs thicker than 1 mm, non-
speciﬁc thermal injury may be advantageous with a physi-cian experienced in the laser's use. In addition, onephysician noted atrophic, hypopigmented scarring inthree of ﬁve cases of hemangioma treated with the argonlaser.202 Nd:YAG Laser
The Nd:YAG laser at 1064 nm can penetrate deeply into
tissue (2–8 mm) but produces widespread tissue injury
because of its nonspeciﬁc absorption. This tends to result
in scar formation. The Nd : YAG laser has been successful
in shrinking large symptomatic lesions through non-
speciﬁc thermal injury,203 but the risk of scarring, which
always occurs to some extent,204 must be weighed against
(A) Venous malformation involving lip and mucosa Some physicians believe the Nd : YAG laser should be before treatment. (B) After therapy with Nd:YAG laser delivered as limited to treating mucous membrane lesions (e.g., oral two separate treatments 6 weeks apart. Laser was used with 600-mmﬁlter in noncontact mode and energy ﬂuence of 30 W delivered in mucosa). Treatment technique also makes a difference.
0.2-s pulses to shrink malformation. This was followed 6 weeks later Treatment using 3- to 4-mm-diameter spots with 6- to 8- by surgical resection. This photograph is clinical appearance 6 mm untreated lesion between spots has been advocated as months after surgery. (Courtesy Milton Waner, MD.) a method to decrease scarring while still effectively debulk-ing a lesion.
Early therapeutic intervention with laser photocoagula- In 160 patients treated with the Nd : YAG laser at energy tion of the vessels of a hemangioma when it is in a thin, ﬂuences of 400 to 1600 J/cm2 in a continuous manner with ﬂat stage or on initial presentation as localized telangiec- pulses of 0.5 s, 13% had excellent results, 55% had a reduc- tasia is advocated to minimize enlargement of the tumor, tion in hemangioma size by more than 50%, 35% had a ulceration, bleeding, and obstruction of vital organs.30,32 reduction in lesion size by less than 50%, and 2% had This may be effective theoretically if the laser is capable of negligible results.205 Ten percent of patients had scarring reaching all the vessels present. However, the notion that from superﬁcial necrosis. The incidence of textural or pig- superﬁcial photocoagulation will initiate regression of the mentary changes to the overlying skin was not reported.
entire hemangioma, including adjacent untreated tumor, The authors noted an advantage of surgical resection of does not appear to be true. Our experience, along with that bulky tumors after thermocoagulation was obtained with of several colleagues, is that the deep portion of heman- the Nd : YAG laser.
giomas beyond the depth of laser penetration continues to Dr Berlien in Germany has successfully used the proliferate despite involution of the superﬁcial compo- Nd : YAG laser to coagulate tissue, with its ﬂuence being nents treated by laser.28,30,32 transferred to the bulk of the tumor through a 600-mm bareﬁber at 8 to 10 W on a continuous mode until tumor coag- ulation occurs. The ﬁber is introduced through an 18-gaugeTeﬂon cannula, and the skin is monitored with a thermal The necessary requirements for any laser or pulsed light probe and cooled to minimize thermal injury to the epi- source to thermocoagulate effectively the ectatic vessel of dermis. The ﬁber is slowly extracted at a rate approximat- Laser Treatment of Cutaneous Vascular Lesions ing 0.5 mm/s, and monthly treatments are given to allow with 8% maintaining this reduction at 6 months. To resorption of coagulated tissue. Postoperative edema and achieve these results, 50% required two treatments and some pain occur for about 6 hours. A study of 100 pedi- 8% three treatments; 33% of hemangiomas ulcerated after atric patients treated over 3 years with intralesional 532 nm therapy. Thus this aggressive form of treatment is best KTP and 1064 nm Nd : YAG laser in continuous mode for reserved for large, voluminous hemangiomas that have one to four treatments showed a 90% reduction in size in functional signiﬁcance (e.g. airway obstruction, visual 446 patients and 50–90% reduction in 56 patients of the hemangiomas with no difference between the two lasers The 532 nm Nd:YAG laser can be used on the skin to used.206 Surgical resection was required in 76 patients.
treat superﬁcial hemangiomas. A retrospective study of 50 Thus, the intralesional laser decreased the size of the lesion infants with 62 superﬁcial hemangiomas found that com- to permit a smaller, more cosmetic resection of the plete regression occurred in 41% of lesions with PDL treat- ment versus 30% with the 532 nm Nd : YAG laser.214 The Use of the sapphire-tip contact probe with the Nd : YAG 532 nm Nd : YAG laser was used at 20 J/cm2 with a 50-ms laser allows excision of vascular lesions with control of pulse through a 5-mm-diameter spot. The PDL was a 0.45- bleeding and offers another therapeutic approach in ms, 585 nm laser with a 7-mm spot size.
debulking the lesion.207,208 However, a retrospective analy-sis of 11 patients treated with this technique demonstratedonly three ‘aesthetically acceptable' results despite four Carbon Dioxide Laser
separate treatments.209 In contrast, Afpelberg210 has The CO2 laser is also useful as a scalpel to excise and debulk reported total removal without complications or side vascular tissue with minimal blood loss. It has been used effects in 16 patients treated in this manner. The difference to excise laryngeal lesions causing airway obstruction,30,161 in treatment results may be related to preoperative prepa- oral hemangiomas,215–217 and facial lesions.218 Because this ration of the patient with intralesional corticosteroids or treatment modality has also been associated with a higher waiting until the lesion is in a stable or regressive stage rate of scarring, it is not recommended for cutaneous before proceeding with surgical correction.
lesions and is most efﬁcacious in treating internal and Cryogen spray cooling of the epidermis overlying mucosal hemangiomas.30 In our practice the UPCO2 laser hemangiomas may protect the epidermis and papillary has been used to resurface scarred hemangiomas and dermis while achieving deep tissue photocoagulation tighten those with redundant and stretched tissue with during Nd : YAG laser irradiation.211 A preliminary study on excellent results (Fig. 2.45).
the highly vascularized chicken comb demonstrated 6.1-mm-deep photocoagulation while preserving epidermalintegrity. To be effective, however, surface temperature Pulse Dye Laser
monitoring must occur simultaneously with laser treat- Although initially developed to treat vessels present in ment and cooling to prevent epidermal damage. Therefore PWS, the similar vessel diameter and depth in heman- this technique may allow treatment of thick hemangiomas giomas explains the PDL's clinical efﬁcacy. The depth of with a deep component.
penetration of 585 nm is 0.6 to 1.2 mm, which limits its One study detailing the treatment of 61 deep vascular efﬁcacy to relatively superﬁcial lesions. Its safety and speci- malformations with a contact cooling 1064 nm Nd : YAG ﬁcity are the reasons for its appeal. Early studies have laser showed that 50% of treated lesions demonstrated demonstrated efﬁcacy in hastening resolution of lesions 55% or greater resolution after a single treatment session beyond the proliferative phase,28,32 as well as slowing or with 35% having less than 50% improvement and 20% arresting proliferative growth.28,30,32 The PDL is best uti- having 100% resolution.212 Unfortunately, many of the lized and most effective in eradicating lesions in a macular lesions presented in this paper did not have speciﬁed treat- stage before proliferation.30,32 ment parameters.
The PDL will not affect hemangioma vasculature below 1.5 mm, because proliferation of deeply situated heman-gioma vessels proceeds despite involution of superﬁcial 532 nm Potassium Titanyl Phosphate (KTP) and
Nd : YAG Laser
Of 50 patients (mean age 13 months) treated with The KTP laser used through an intralesional 0.6-mm- the PDL an average of 3.8 times, 53% had signiﬁcant diameter bare ﬁber has been found to shrink heman- improvement in color without an appreciable reduction in giomas.213 With this technique the ﬁber is passed through lesion bulk.219 Four of seven patients with ﬂat lesions com- a 20-gauge needle positioned in the center of the heman- pletely cleared after two treatments, with the remaining gioma. Laser energy is then delivered at 15 J until shrink- three patients achieving satisfactory results requiring no age is seen or the overlying skin begins to feel warm to the further treatment. Eight ﬂat, ulcerated hemangiomas touch. However, this is inaccurate and potentially danger- healed completely with PDL treatment after one to three ous because once the overlying skin is warm, excessive treatments. Ten patients with slightly raised lesions nonspeciﬁc damage has probably occurred. In a series of required a mean of 5.2 treatments to achieve clearance in 12 patients 1 month to 31/2 years of age, 92% had a greater four and a good degree of ﬂattening and improvement than 50% reduction in the hemangioma size at 3 months, in the remaining six patients. Red raised lesions with a Cutaneous and Cosmetic Laser Surgery 2- to 4-week intervals at ﬂuences of 6.0 to 6.5 J/cm2.
Almost 70% healed within 2 weeks after a single laser treatment.
Garden et al222 have reported that the best results occur when the hemangioma is elevated 3 mm or less and advisetreatment in the ﬁrst weeks of life. They studied 33 heman-giomas in 24 patients 2 weeks to 7 months of age in whom a 93.9% lightening occurred in the superﬁcial lesions in4.1 treatment sessions. Seven lesions 4 mm or more inthickness lightened 83.7% in seven treatment sessions.
They found that compressing the hemangioma with a glassslide to bring the deeper vascular component closer to thesurface did not increase efﬁcacy.
A report on treating 68 infants with 100 hemangiomas within 12 weeks of their development further conﬁrmsPDL efﬁcacy.223 Seventy-three lesions required a singletreatment and 27 up to ﬁve treatments; 23% of lesionsshowed complete remission, 55% showed partial remis-sion, and 14% stopped growing. Only 8% of lesions con-tinued to grow despite treatment. This efﬁcacy occurredwith virtually no serious adverse sequelae.
Proliferative hemangiomas causing functional impair- ment in seven patients 8 to 24 weeks of age showed signiﬁcant reduction in size, normalization of color, andresolution of superﬁcial ulceration.224 Lesions were treatedat ﬂuences of 7.0 to 9.25 J/cm2 at 4- to 8-week intervals(two to six times) until the hemangioma completelyregressed or stopped regressing further. As reported in theprevious studies, all patients with ulceration responded totreatment. Four of seven patients had complete resolutionof the hemangioma. No adverse events or complicationswere noted.
Our experience is similar to that of most reports.225 The following is a summary of our experience with a total of34 infants and children. We used the PDL at ﬂuences of6.25 to 8.0 J/cm2 at 2- to 3-week intervals with spots over- Figure 2.45
(A) Appearance of hemangioma in 5-year-old girl. (B) Clinical appearance 30 years later. Note ﬂaccid, wrinkled skin. lapping 10% to 15% to produce an endpoint of homoge- (C) Six months after resurfacing with Coherent Ultra Pulse CO2 Laser.
nous darkening of the entire lesion until one of the Three passes were given at 500 mJ through 3-mm collimated spot size following circumstances: resolution occurred, the treat- ment was judged to be ineffective, or the parents discon-tinued treatment for unrelated reasons. Treatment wasoffered to all parents of children with hemangiomas after signiﬁcant subcutaneous component showed elimination explanation of the natural resolution history of the lesions of the red coloration and any ulcerations without change and the potential beneﬁts and risks of laser therapy and in lesion bulk.
steroid therapy. Some patients had medical reasons for Morelli and Weston220 reported their 2-year experience treatment (visual obstruction, interference with feeding or in treating 55 lesions. Five patients with hemangiomas less breathing, or lesional bleeding), but treatment was also than 3 cm3 treated once or twice with the PDL in the pro- offered to patients with lesions that caused concern liferative phase had a good response with arrest of lesion because of proliferative activity, tissue distortion, or cos- growth. An additional ﬁve patients with large lesions greater than 20 cm3 had an excellent response and resolu- Seventeen hemangiomas had only a superﬁcial compo- tion of lesions in those who continued treatment. Twenty nent, with 13 of these less than 1 cm in diameter, averag- patients with superﬁcial and deep lesions had resolution ing 7 mm. The lesions appeared as a red macule initially, of the superﬁcial component only. Purely nodular older at an average age of 15 days. The lesions typically began lesions resisted treatment. Ulcerated painful heman- to proliferate, causing parental concern. The average age at giomas, when treated, heal and become painless, provid- ﬁrst treatment was 5.5 months. The most common reason ing the best indication for treatment. Morelli et al221 for the delay in treatment was difﬁculty in ﬁnding an reported a total of 37 infants with ulcerated hemangiomas appropriate treatment center. The average patient received treated with the PDL between 2 and 40 weeks of age. 3.6 treatments over 3.3 months. The average ﬂuence used All ulcerations healed with one to three treatments at was 6.8 J/cm2. Nine patients (53%) cleared completely.
Laser Treatment of Cutaneous Vascular Lesions Table 2.8
Superﬁcial Capillary Hemangiomas: PDL Treatment
if not clear
Mixed Superﬁcial/Deep Capillary Hemangioma: Early PDL Treatment
Mixed Superﬁcial/Deep Capillary Hemangioma: Late PDL Treatment
Those lesions not clearing had an average improvement of age of 41 months. These nine lesions received an average 67% (Table 2.8).
of 3.5 treatments, using an average ﬂuence of 7.2 J/cm2 Seventeen infants had hemangiomas classiﬁed as mixed, and a treatment interval averaging 9 weeks. Two patients with both a superﬁcial and a deep component. All these received intralesional steroids in an attempt to shrink lesions were large, some encompassing the entire side of the persistent deep component of the lesion. These nine the face. Eight lesions were treated relatively early, during patients achieved a much more modest degree of improve- the proliferative phase, and nine lesions were treated later, ment than the other eight patients treated early, with the during the involution-dominant phase (Table 2.9).
superﬁcial component improving an average 62% and the Those hemangiomas treated early had appeared at an deep component only 32% (Table 2.10).
earlier age (average age 6 days). Treatment was initiated at Most authors report cessation of the proliferative phase an average age of 4.5 months and continued for an average as a consequence of treatment with the PDL.30,31,222 Con- 7.4 months, during which time 4.5 treatments were troversy has surrounded the question of whether early administered, using an average ﬂuence of 6.8 J/cm2. Four treatment can prevent the proliferative phase and espe- patients (50%) received adjunctive therapy with steroids cially whether it may have an effect on the deep com- during this period, two receiving systemic prednisolone ponent that the PDL cannot reach.226 Indeed, the case and two receiving intralesional steroids. Interestingly, in reported by Glassberg et al30 showed deep proliferation these four patients, treatment with steroids abruptly halted despite cutaneous involution during PDL therapy. Mul- the proliferation of the deep component and resulted in liken176 reported his experience of the same phenomenon.
shrinking this deep portion, but it had no visible effect on This was our experience as well: four patients with super- the superﬁcial component. Likewise, the PDL treatment ﬁcial and deep components showed response of only the abruptly halted proliferation and resulted in clearance of superﬁcial component to treatment with the PD laser, the superﬁcial component without apparent effect on the while the deep component continued to proliferate. Inter- deep component, which continued to proliferate unless estingly, the opposite was true as well; only the deep com- steroids were used. Treatment resulted in near-complete ponent was responsive to steroid therapy, the superﬁcial (96%) clearing of the superﬁcial component in all patients component being unaffected. Glassberg et al30 also have and an average improvement of 73% in the deep compo- mentioned this point.
nent (Table 2.9).
The cases reported by Glassberg et al,30 Sherwood and Lesions treated later in their course appeared at an Tan,31 and us well illustrate that the PDL can rapidly and average age of 40 days but were not treated until an average dramatically halt the proliferative superﬁcial component.
Cutaneous and Cosmetic Laser Surgery In two of these three series, the hemangiomas were very extensive and were responsive throughout the superﬁcialcomponent. Because the depth of penetration is limited, aseries of treatments is usually necessary gradually to reachdeeper layers of vessels. We recommend a treatment sched-ule of every 2 to 3 weeks for three to six treatments, usinga ﬂuence of 5 to 7 J/cm2 for most lesions. Lesions with onlya superﬁcial component are very responsive to treatmentbecause 90% will completely involute (see Fig. 2.37). Thosewith a deep component and a superﬁcial component mayrequire intralesional steroid therapy for the deep compo-nent and laser therapy for the superﬁcial component (seeFigs 2.42 and 2.43). Widespread and deep lesions mayrequire laser therapy and systemic steroids to arrest thegrowth of the deep component. Treatment at the earliestopportunity is critical in determining success in thesecases.
Kauvar227 presented the 1.5-ms pulsed, 595 nm PDL in Figure 2.46
(A) Fifteen-year-old girl with facial hemangioma. the treatment of ten hemangiomas. Two superﬁcial lesions (B) Appearance after 6 treatments with the PDL. (Courtesy Gerald cleared in two or three treatments, and eight lesions with both a superﬁcial and a deep component cleared in two tofour treatments. In the latter group, the superﬁcial com-ponent cleared completely, but with only a 10% to 50% Intense Pulsed-light Treatment
reduction in the deep component. Kauvar recommends thefollowing parameters: In addition to monochromatic light, noncoherent lighthas also been found to be effective in treating heman- infants: 7-mm-diameter spot, 7 J/cm2 giomas when used within an adequate wavelength range adults: 7-mm-diameter spot, 8 J/cm2 and with proper ﬂuence and pulse duration. We have used hypertrophic lesions: 7-mm-diameter spot, 9 J/cm2.
the IPL with a cutoff ﬁlter at 550, 570, or 590 nm to treat A total of 165 children with 225 separate hemangiomas multiple hemangiomas with excellent results (Fig. 2.47).
treated with the PDL with a mean of two treatments were We have used this light source to treat evolving as well as separated out as superﬁcial or mixed hemangiomas.228 Flat long-established tumors. One 66-year-old patient devel- cutaneous hemangiomas had an excellent response in 32% oped a hemangioma after trauma 15 years before treat- and good results in 52%. Of the mixed hemangiomas, 39% ment. One treatment with a 570-nm cutoff ﬁlter at had a response of the superﬁcial component with contin- 80 J/cm2 given as a double pulse of 9 and 13 ms separated ued proliferation in 61% and no change in the dermal by a 50-ms delay resulted in 100% resolution. The lesion component. The authors concluded that early treatment is immediately became purpuric, then crusted before com- only effective for superﬁcial lesions and did not prevent pletely involuting (Fig. 2.48).
progression of deep or mixed lesions. The drawback of this Foster and Gold230 reported 90% involution of a 7.5 ¥ study was that the investigators used an old PDL at 4-cm ulcerated cavernous hemangioma on the abdomen 585 nm, 300-ms pulse and a 5-mm spot beam without epi- of an 11-week-old black infant. They used a 550-nm cutoff dermal cooling allowing for only 5–7 J/cm2 to be delivered.
ﬁlter at a ﬂuence of 38 J/cm2 in a triple-pulse mode (T1 One would suspect that the use of a 595 nm PDL with a 3 ms, T2 2 ms, T3 1.7 ms) with a 10-ms delay between pulses.
7- to 10-mm-diameter spot and epidermal cooling would Two additional treatments at 2-week intervals with a 570- allow deeper therapeutic effects to be obtained.
nm cutoff ﬁlter at ﬂuences of 30 and 38 J/cm2 using a triple The largest study on the treatment of childhood heman- pulse (T1 4 ms, T2 3 ms, T3 2 ms) with a 20-ms delay between giomas evaluated 548 children with 692 hemangiomas pulses resulted in maximal resolution with minimal who were treated with the PDL.229 After 1 to 12 treatments (mean 2.5) further growth was stopped in 96.6% of allhemangiomas; 13.8% achieved a complete remission with a signiﬁcant regression in another 14.9%. Small and super-ﬁcial hemangiomas responded best to treatment. As with Surgical therapy should be considered for certain lesions.
previous studies, the drawback of this study was the use of Hemangiomas of the vermilion border, mucous mem- a ﬁrst-generation PDL with a pulse duration of 0.45 ms and branes, and nasal tip are very slow to involute and may a spot size of 5 to 7 mm. A mean ﬂuence of 8.4 J/cm2 was seriously interfere with a child's self-esteem. In these cases, used. Adverse effects even with this high ﬂuence were rare excision before entering school may be considered.176 with 7% developing temporary pigmentary changes and Microsurgical techniques with hemostatic lasers have been 4% developing small atrophic scars. The age at the start of successful at debulking lesions and coagulating vessels treatment was not important in this study (Fig 2.46).
to allow for easier surgical excision.231 The use of tissue Laser Treatment of Cutaneous Vascular Lesions Figure 2.48
(A) This 66-year-old male had a 15-year history of hemangioma on forehead before treatment. (B) Immediately aftertreatment with PhotoDerm VL (see text). (C) Nine days aftertreatment an eschar developed, which healed without scarring 3 months later. (D) Complete resolution 4 weeks later.
(A) Persistent hemangioma/venous malformation the only antiangiogenic agents currently available are cor- despite four treatments with argon laser (0.5-s pulses at 2 W) and one ticosteroids and that they may afford dramatic beneﬁt treatment with the PDL (8 J/cm2 with 5-mm-diameter spot size). without signiﬁcant risks as one might expect. When this (B) After three treatments with Photoderm VL with 590-nm cutoff therapeutic approach is considered in light of the recent ﬁlter, double pulse of 4.2 and 7.7 ms with 300-ms delay between information available regarding laser responsiveness of the pulses at 65, 71, and 69 J/cm2, respectively.
superﬁcial component, we conclude that the PDL shouldbe used at the earliest sign of a capillary hemangioma andcertainly as soon as active proliferation begins. In con-junction with this treatment, intralesional or systemic expansion further improves excision cosmesis.232 Facial or steroids should be given to halt the proliferation of the neck hemangiomas that have incompletely resolved with deep component when that portion proceeds despite laser sagging skin or excessive ﬁbrofatty residuum may be therapy. The risks of therapy have been demonstrated to Ideally, a team approach should be used in treating Extensive hemangiomas that have not responded to extensive hemangiomas. Multiple specialties, including other treatments have reduced with IPL treatment.235 but not limited to vascular surgeons, radiologists, derma- The recommendations of the American Academy of Der- tologists, plastic surgeons, and pediatricians, may combine matology's Guidelines of Care Committee for treatment of their expertise to optimize patient care. Apfelberg et hemangiomas are summarized as follows236: al207,234 have reported the use of the Nd:YAG laser with sapphire tip in conjunction with intralesional steroids and 1. Prevent or reverse life-threatening or function-
also in a team approach using superselective embolization before resection.
2. Prevent permanent disﬁgurement left by residual skin
3. Minimize psychosocial stress.
4. Avoid scarring procedures.
Mulliken140 correctly calls for a biologic approach to the 5. Prevent or treat ulcerative lesions to minimize scarring,
treatment of hemangiomas of infancy. He points out that infection, and pain.
Cutaneous and Cosmetic Laser Surgery Pyogenic granuloma (PG) is an acquired vascular lesion, a The term ‘telangiectasia' refers to superﬁcial cutaneous true neoplasm distinct from granulation tissue, usually vessels visible to the human eye.248 These vessels measure solitary, 0.5 to 2.0 cm in diameter, bright red, and pedun- 0.1 to 1.0 mm in diameter and represent a dilated venule, culated.237–239 The surface is soft, bleeding easily with capillary, or arteriole. Telangiectasia that are arteriolar in trauma. It may become ulcerated and develop a granulo- origin are small in diameter, bright red in color, and do not matous surface with a brown or black crust. Lesions usually protrude above the skin surface. Those that arise from appear suddenly and may enlarge rapidly. There is no venules are wider, blue in color, and often protrude above history of preceding trauma or infection in most patients the skin surface. Telangiectasia arising at the capillary loop (75%),240 although this typically is assumed.241 These are often initially ﬁne, red lesions but become larger and lesions also frequently occur as a superimposed growth on purple or blue with time because of venous backﬂow from the surface of a PWS.158 Repeated episodes of bleeding and increasing hydrostatic pressure.249 unresponsiveness to electrocautery have been reported in Telangiectasia have been subdivided into four classiﬁca- up to 50% of patients.240 This may be secondary to tions based on clinical appearance: (1) simple or linear, (2) the extension of vascular proliferation deep into the arborizing, (3) spider, and (4) papular250 (Fig. 2.49). Red dermis, often with a unique lobular arrangement of linear and arborizing telangiectasia are very common on the face, especially the nose, midcheeks, and chin. These The argon laser,243 as well as the CO2 laser,244 has been lesions are also seen relatively frequently on the legs. Blue shown to be effective in treating PGs. The PG is photo- linear and arborizing telangiectasia are most often seen on coagulated until the entire lesion blanches and turns a the legs but also may be present on the face. Spider telang- dusty gray color. Treatments are repeated at 3- to 4-week iectasia are described in the next section. Papular telang- intervals as needed.
iectasia are frequently part of genetic syndromes, such as PG lesions have been unpredictably responsive to the Osler–Weber–Rendu disease, and also are seen in collagen PDL.78 They have been shown to respond,38,241,245,246 but in vascular diseases.
most cases lesions are too thick for the laser to penetrate All forms of telangiectasia are thought to occur through throughout the lesion in one treatment. Tan and Kurban245 the release or activation of vasoactive substances under the use a glass slide to compress the superﬁcial ectatic vessels inﬂuence of a variety of factors, such as anoxia, estrogen, and use the laser through the glass to treat the deeper com- corticosteroids (topical or systemic), various chemicals, ponent of this lesion. This maneuver presumably allows multiple types of bacterial or viral infection, and multiple treatment of deep vessels, after which the slide is removed physical factors, with resultant capillary or venular neo- and the treatment is repeated to coagulate more superﬁ- genesis.249 Box 2.2 lists the associated diseases and causes cially located vessels. When effective by itself, the PDL of telangiectasia.
must be used with multiple, 100% overlapping pulses toturn the lesion deep purple. As previously demonstrated,this technique produces nonselective photo-thermolysisand is therefore no different than CW argon, copper vapor,or 577-nm dye lasers.
A study of 18 patients with PG treated with the PDL demonstrated both symptomatic and clinical clearing in16 patients with excellent cosmetic results.247 Seven of thelesions had been previously treated with electrosurgery orexcision. The authors ﬂattened the lesions with a glass slideand used ﬂuences of 6.5 to 9.0 J/cm2 in an overlappingmanner to cover the lesion completely. Treatments wererepeated up to four times to achieve success. Treatmentoutcomes were excellent, but two postoperative photosshowed textural changes that resembled a scar, althoughthis was not noted by the authors.
We have not been able to achieve uniform success in treating PG lesions with or without the diascopy maneu-ver with the PDL. In addition, multiple treatments areimpractical because of the ease with which lesions aretraumatized between sessions. We therefore recommendshave excision of the lesion's papular component if a his-tologic specimen is necessary or CO2 vaporization of thelesion followed by PDL therapy to the remaining ﬂatmacular lesion if necessary.
Four types of telangiectasia. (A) simple; (B) arborized; (C) spider; and (D) popular. (Modiﬁed from Goldman MP, BennettRG. J Am Acad Dermatol 1987; 17:167.) Laser Treatment of Cutaneous Vascular Lesions Causes of Cutaneous Telangiectasia
Telangiectasia macularis eruptiva perstans Carcinoma telangiectasia (metastatic tumors) Ataxia telangiectasia Component of a primary cutaneous disease
Sturge–Weber syndrome Maffucci syndrome Basal cell carcinoma Congenital poikiloderma (Rothmund– Merkel cell tumor Thomson syndrome) Necrobiosis lipoidica diabeticorum Poikiloderma vasculare atrophicans Cockayne syndrome Capillaritis (purpura annularis telangiectodes) Hereditary hemorrhagic telangiectasia Xeroderma pigmentosum Pseudoxanthoma elasticum Essential progressive telangiectasia Generalized essential telangiectasia Superﬁcial epithelium with sebaceous differentiation Familial (autosomal dominant)Acquired (hormonal or infectious stimulation) Unilateral nevoid telangiectatic syndrome Diffuse neonatal hemangiomatosis Corticoid induced Hereditary benign telangiectasia Cushing syndrome/diseaseIatrogenic (from systemic, topical, or intralesional use) Acquired disease with secondary cutaneous
Estrogen therapy (usually with high dose) component: Collagen vascular diseases
Lupus erythematosus (especially periungual)
Actinic dermatitis Progressive systemic sclerosis (especially periungual, and with the calcinosis, Raynaud, esophageal dysmotility, Postsurgical, especially in suture lines under tension and sclerodactyly, and telangiectasia [CREST] syndrome) after rhinoplasty Modiﬁed from Goldman MP, Bennett RG Treatment of telangiectasia: a review. Journal of the American Academy of Dermatology 1987;17:167.
Telangiectasia of the face are most often seen in patients Carbon Dioxide Laser
with fair complexion (Fitzpatrick types I and II skin). These The CO2 laser has been used for treatment of facial telang- lesions are especially common on the nasal alae, nose, and iectasia.251 Because tissue destruction is nonselective with midcheeks and are probably caused by persistent arteriolar this laser, occurring by vaporization of water within cells, vasodilatation resulting from vessel wall weakness. The the skin surface and dermis overlying the telangiectasia are vessels dilate further when damage to the surrounding destroyed as well as the vessel. Because of this nonselective connective and elastic tissue occurs from factors such as action, the CO2 laser has no advantage over electrosurgery chronic sun exposure or use of topical steroids. These in the treatment of telangiectasia.
lesions have a deﬁnite familial or genetic component.
Rosacea may be an accompanying condition.
Telangiectasia: Clinical Variants
The argon laser has often been used for treatment of facialtelangiectasia. Treatment parameters have varied, with laser Linear Facial Telangiectasia
powers of 0.8 to 2.9 W; exposure times of 50 ms, 0.2 s, and These telangiectasia often carry an unjustiﬁed social stigma 0.3 s; and continuous output with spot sizes of 0.1 and implying alcoholism. Thus patients are understandably 1 mm. Although the success rate has been reported to be distressed by this otherwise benign condition. Treatment good to excellent in 65% to 99% of patients treated,2,252 of large vessels on the nasal ala or nasal alar groove is dif- pitted and depressed scars, hypopigmentation, hyperpig- ﬁcult and often leads to noticeable scarring when conven- mentation, and recurrence of veins have been noted.3,253 tional methods are used. We have found the PDL to be a One area of particular concern is the nasal alae and powerful and effective tool in the treatment of these nasolabial creases, where depressed scarring is relatively lesions, virtually without the risk of scarring or other per- common, although resolution gradually occurs over manent skin changes.
Cutaneous and Cosmetic Laser Surgery Adverse healing may occur with the argon laser because painful than the ATDL. Swelling and erythema was similar of nonspeciﬁc thermal damage to perivascular tissue and between the two lasers, but hyperpigmentation was greater the overlying epidermis. This is caused by competition for with the ATDL. Excellent clearance occurred with the LPDL absorption of laser ﬂuence from epidermal melanin and in 78% of patients compared with 28% with the ATDL.
extensive radial diffusion and dissipation of heat from thetarget blood vessels.254 Both these factors result in rela- Copper Vapor/Copper Bromide Laser
tively nonspeciﬁc thermal destruction. To minimize these The CVL or CBL operates at two speciﬁc wavelengths, effects, a small beam size (100 mm) has been advocated to 578 nm (yellow) and 511 nm (green), and delivers a ‘quasi- trace vessels precisely,83,255,256 and a low power or pulsing continuous wave' composed of pulsed laser light energy in with a 50-ms shutter has been recommended.255,257,258 As 20-ns pulses at a frequency of 15,000 pulses per second.
mentioned previously, these parameters must be moni- This train of pulses interacts with tissue in the same tored closely, because the successful treatment of vascular manner as a continuous beam because of the accumula- lesions with the argon laser requires experience and artful tion of heat with the large number of pulses delivered.
expertise. As described previously, the use of a very small Because of resulting thermal diffusion, it may be necessary beam (100 mm) greatly increases the scattering of laser to gate the pulse electronically with 20- to 50-ms second- photons within the dermis and limits treatment to the ary pulses or to use a scanning device.
most superﬁcial of dermal vessels. With these parameters, The ability to pulse the CVL between 20 and 50 ms many physicians ﬁnd the argon laser effective in treating allows this laser to work within the thermal relaxation time facial telangiectasia, with only minimal risk of adverse of many telangiectasia (Fig. 2.50). When the laser is used healing. This application is its most successful use.
To limit heat diffusion with the argon laser, robotized scanning laser handpieces have been used (see earlier section on treatment of PWS in adults). The use of thisdevice has been reported to be successful in the treatmentof facial and leg telangiectasia when the telangiectasiaoccur in densely interlacing mats.259 This technique iseffective and greatly reduces the risk of adverse response,but it is not well suited for individual or widespread isolated telangiectasia.
Argon-Pumped Tunable Dye Laser
The argon-pumped tunable dye laser (ATDL) is a CW laser,
although mechanically shuttered pulses as short as 20 ms
are achievable. Beam size may be varied from 50 mm to
6.0 mm. Yellow light (577–595 nm) is usually chosen for
treatment of vascular lesions. The tracing technique using
a 100-mm beam with this laser has been used extensively
and advocated by Scheibner and Wheeland255 as a tech-
nique that produces good to excellent results with minimal
risk in a variety of cutaneous vascular lesions,83,256 includ-ing facial telangiectasia.260 The proper endpoint of treat-ment is disappearance of the vessel, not blanching,blistering, or charring of the overlying skin. Because thetracing hand motion cannot be accurately quantiﬁed,treatment parameters are difﬁcult to teach except by directmonitoring. In addition, this technique is more tediousand time-consuming than the PDL, even when onebecomes a skilled operator. Multiple treatments are usuallyrequired, with hypopigmentation rarely occurring.261 Thelaser also may be used with a robotized scanning device iflarge areas of matted telangiectasia are to be treated.259,262However, multiple treatments are required, including spotvessel tracing to eliminate the hexagonal appearance.
A prospective, side-by-side comparison of the ATDL with the PDL in 14 patients found better efﬁcacy with the Figure 2.50
This man with telangiectasias was treated for about PDL.263 The ATDL used was a modiﬁed ophthalmic laser at 20 minutes on two occasions with a copper bromide laser. (A) Beforetreatment. (B) After treatment. First treatment was at 2.2 W and 585 nm, focused to a 0.1-mm circular spot with a power of 0.7 mm spot size, with 20-ms pulses (11.4 J/cm2) for smaller vessels 0.7 to 0.8 W at a pulse duration of 0.1 s (Coherent Medical, and 30-ms pulses (17.1 J/cm2) for larger vessels. Second treatment now Lumenis). Treatment times were about three times 2 months later was at 2 W with 20-ms pulses for all remaining vessels longer for the ATDL than the PDL. The PDL was more (10.4 J/cm2). (Courtesy Sue McCoy, MD.) Laser Treatment of Cutaneous Vascular Lesions with these reﬁnements, it is somewhat safer and more pulse duration varied from 7 to 60 ms, the treatment effective than the argon laser for treatment of facial telang- endpoint was vessel spasm without epidermal blanching.
iectasia and has the advantage of leaving only very minor About 45% of patients required one treatment, and 35% of superﬁcial crusts overlying treated vessels, in contrast to patients required two treatments. The remaining 20% of the very visible, dark purpuric impact spots of the PDL.264 patients received three to ﬁve treatments. Treatment ses- A comparison of the CVL with the PDL in 10 adults with sions ranged from 5 to 60 minutes, with the average treat- facial telangiectasia resistant to electrosurgical therapy ment requiring 16.7 minutes. Moderate erythema occurred demonstrated no difference in efﬁcacy or adverse seque- in most patients and lasted 2 to 3 hours. Swelling and lae.265 However, Dinehart et al188 report a 10% incidence crusting were rare. There were no reports of scarring or of transient hyperpigmentation. Whether this represents melanin or hemosiderin is unknown.
McCoy et al270 postulate that the reduced effectiveness Of 33 patients with facial telangiectasia treated with the in treating vessels less than 100 mm results from the CVL, 69% had good to excellent results and 19% had poor thermal relaxation time being much less than the deliv- results.266 Treatment occurred with a 1-mm-diameter spot ered pulse durations. The reduced effectiveness in vessels size at pulse durations of 50 to 200 ms at energy densities greater than 300 mm results from absorption of laser ﬂuence from 8 to 32 J/cm2 or continuous until vessel blanching in the superﬁcial portion of the vessel with ‘protection' to occurred. Best results were seen on the cheeks, with poor the deeper endothelium. McCoy recommends using sclero- results on the nose or nasolabial folds. Atrophic scarring therapy for vessels greater than 300 mm in diameter.
was reported on nasal lesions (7 of 33 patients), and edema When used with the modulating inﬂuence of a second- lasting 1 to 3 days occurred on the cheeks and lower ary shuttered pulse or scanning device, the risk of adverse response is further minimized without signiﬁcant change Thibault267 reported the results of a patient question- in clinical effectiveness. In a comparison of 144 patients naire of 180 patients treated with the CVL with or without treated with the point-by-point technique and 105 sclerotherapy for facial telangiectasia. He used a CVL (Vis- patients treated by the Hexascan, French investigators Erase 3 w, Visiray Pty Ltd., Hornsby, NSW, Australia) with determined that the incidence of hypertrophic scarring a 200-mm ﬁber delivering a spot size of 150 to 400 mm. A was less than 1% in the Hexascan group versus 7% in the clinical endpoint of vessel blanching was used, which point-by-point group. Treatment time was also reduced to required a power of 600 to 700 mW impinging on the 20% of the point-by-point time. Patients treated by Hexa- vessel for less than 1 s delivered continuously. Patients scan also experienced less pain, and local anesthesia was developed blistering 24 to 48 hours after treatment, with rarely required.271 The balance between these two results crusting lasting 7 to 17 days. Edema usually lasted 3 days.
(vessel obliteration and adverse healing) must be weighed Almost half of patients treated with the CVL alone devel- and the treatment technique altered to be consistent with oped hypopigmentation. Good results were seen in 47% of the goals of treatment.
vessels treated with the CVL alone, and these patients weresatisﬁed with treatment, versus 86% of patients who hadcombination treatment with CVL and sclerotherapy being 532 nm KTP Laser
satisﬁed with treatment.
The Starpulse KTP laser (LaserScope) operates at 532 nm Waner et al268 compared the CVL with the PDL in 12 and emits a train of 1-ms Q-switched pulses at 25 kHz.
patients with facial telangiectasia. Treatment times and What distinguishes this system from other frequency- patient satisfaction were equivalent. Postoperative swelling doubled Nd : YAG lasers is that the arc lamp is modulated and prolonged healing occurred with the PDL. The CVL and can provide pulse durations ranging from 1 to 50 ms.
used was the Vasculase (Metalaser), with a spot size of This produces very-high-energy pulses that can be pro- 150 mm at a power of 0.35 to 0.55 W chopped at 0.2-s inter- jected onto the skin in spots ranging in diameter from 0.25 vals. Waner concludes that both lasers have equal efﬁcacy, to 4.0 mm while still maintaining ﬂuences within the 5 with most patients preferring the CVL.
to 10 J/cm2 therapeutic range. The combination of high- McCoy269 has reported her results in treating 570 energy pulses and ability to adjust pulse duration to match patients with facial telangiectasia. Similar results were the thermal relaxation time of blood vessels allows reported in another study of 23 patients evaluated in a modulated KTP lasers to remove vascular lesions with less blinded manner.270 In both studies, greater than 75% clear- purpura than the PDL (Figs 2.51 and 2.52). One study ance was achieved in 70% of patients, 50% to 75% clear- demonstrated a 75–100% improvement in 94% of patients ance in 17%, and less than 50% clearance in 13%. Vessels using 16–22.5 J/cm2 through a 500- to 700-mm spot with on the cheeks cleared much better than nasal telangiecta- pulse durations of 15–30 ms. Telangiectasia were treated sia, which only had an excellent response in 26% of with complete vessel blanching or visible intravascular patients. Vessels less than 100 mm or greater than 300 mm did not respond as well as vessels 100 to 300 mm in diam- A comparison study of the KTP laser (Starpulse) with eter. McCoy used the CBL at 578 nm only (Norseld CuB D- the PDL found less swelling, pain, bruising, and redness 10, Adelaide, South Australia) in a train of 30-ns pulses at with the KTP laser.273 The Starpulse was used with a 2-mm- 16 kHz. The average power through the 600-mm ﬁber was diameter spot size, 17 J/cm2, 10 ms. The PDL was used with 2 W. The ﬁber was used in a slightly defocused mode to a 3-mm-diameter spot size at 6.8 J. No signiﬁcant difference produce a 0.9-mm-diameter spot. Although the chopped in efﬁcacy was found between the two lasers.
Cutaneous and Cosmetic Laser Surgery Figure 2.51
(A) Perinasal telangiectasia before treatment. (B) Two Figure 2.52
(A) Facial telangiectasia before treatment. (B) Three weeks after treatment with Orion potassium titanyl phosphorus (KTP) months after treatment with Orion KTP at 40 W, 4-mm Dermastat at 5 W, tracing vessels once with 250-mm spot Dermastat with 10-ms with 20-ms exposure duration, 1 pps. (Courtesy Burton E Silver, MD.) exposure duration, 5 pulses per second (pps). (Courtesy Burton ESilver, MD.) This laser has been effective in treating facial telangiecta-sia that have sometimes proved to be recalcitrant to Q-switched Nd:YAG laser, 532 nm
treatment with other laser modalities260 (Fig. 2.54). Our Even without consideration for the thermal relaxation experience in using this modality both with and without time of vascular lesions, the 532-nm laser has been shown epidermal cooling has been variable but positive.
to be effective in clearing facial telangiectasia. Ten patients An evaluation of four different 532nm Nd:YAG lasers treated with the Nd:YAG laser at 532 nm in the Q-switched showed improvement with all four lasers without signiﬁ- mode with 5-ns pulses at 1 to 2 and 3 to 4 J/cm2 demon- cantly different adverse effects. One was a Q-switched laser strated clearance.274 Excellent results occurred in 30% of with a train of 5–10 ms pulses producing a pulse duration patients treated at 1 to 2 J/cm2 versus 70% of patients of 10–400 ms; a second machine used a quasi-continuous having excellent results when treated at 3 to 4 J/cm2.
train of pulses delivering pulse durations of 10–25 ms; a However, at 3 to 4 J/cm2, purpura occurred in all patients, third system was a diode-pumped system delivering 1– with hyperpigmentation developing in 20% at 30 days and 100 ms pulses and the fourth laser delivered 2–10 ms 10% at 60 days. The effectiveness and pigmentation were probably caused by the explosive effects to the absorption To decrease pain associated with the use of 532 nm of the laser energy in a very short time (5 ns) with rupture lasers, cold clear gel has been demonstrated under a cooled of the vessel and release of hemosiderin.
sapphire window to decrease pain and erythema. Coolingthe skin did not decrease efﬁcacy.276 Long-pulse Nd:YAG laser, 532 nm
By extending the pulse duration to within the thermal
Pulse Dye Laser
relaxation time of the vessel treated, purpura is avoided The clinical treatment technique involves delivering a without loss of efﬁcacy (see earlier discussion) (Fig. 2.53).
train of pulses overlapping 10% to 20%, tracing the vessels Laser Treatment of Cutaneous Vascular Lesions Depth (mm)
Temperature distribution achieved in treating 0.1-mm- diameter, 0.2-mm deep vessel with 532-nm laser with 2-ms pulseduration, 5-mm-diameter spot size, 15 J/cm2 with epidermal coolingto 4°C. (Courtesy ESC Medical, Inc.) to be treated with a 3-, 5-, 7- or 10-mm delivery spot, andtreating an area of interlacing telangiectasia with overlap-ping spots to cover the involved area. Delivery energiesrange from 5 to 8 J/cm2 with a 0.45-ms pulse and higherwith longer duration pulses as described below and areadjusted according to lesion response and location. Dis- Figure 2.54
(A) Facial telangiectasia on cheek of 60-year-old ruption of blood ﬂow occurs with resultant purpura which woman before treatment. (B) Two months after single treatment with varies with pulse duration and ﬂuence but without exces- Versapulse, 532 nm at 10-ms pulse duration, 3-mm-diameter spot sive swelling or crusting. Treatments of telangiectasia are size, 10 J/cm2 with epidermal cooling to 4°C.
generally done without the use of test spots, althoughthese may be used if the patient or physician is unsure andwants to observe response in a small area. If test spots areused, the entire length of the vessel must be treated to erated by our patient population, who were informed in eliminate the vessel (Fig. 2.55).
advance of its occurrence. They could therefore modify One study reports a 77% response rate to PDL treatment their social and business schedules accordingly. Typically, of adult facial linear telangiectasia.38 Although vessel diam- makeup foundation was used to camouﬂage the purpura eter was not measured, larger blue vessels were less respon- approximately 5 days after treatment. A small number of sive than smaller red vessels. The poorer response to patients experienced other transient skin changes at the treatment of these larger vessels may result from: (1) the treatment site. Even though no anesthesia was used, thermal relaxation time in larger-diameter telangiectasia patients experienced only mild to moderate discomfort in being longer than the pulse duration of the laser; and (2) 93% of the cases. Most patients (62%) underwent only one the deoxygenated Hb absorbing at a lower wavelength of treatment, although further improvement and a better the laser (545 nm.) response were seen in patients with more than one treat- Our published series shows 97.5% of 182 patients ment. The largest percentage of patients had an excellent achieving good to excellent results (14% good, 83.5% response with ﬂuences above 7 J/cm2 (93% versus 78%).
excellent), indicating resolution of more than 50% of the There was a noticeable trend toward increasing effec- treated lesions in one or two treatments277 (Figs 2.56 and tiveness with increasing ﬂuence. Our experience is that 2.57). In 152 of these patients, more than 75% of their vessels larger than 0.2 mm in diameter require multiple telangiectasia was removed. Scarring did not occur in treatments. Vessels larger than 0.4 mm in diameter are any patient, and skin texture remained unchanged. As responsive to PDL treatment when the pulse duration is expected, all patients experienced a transient bluish purple discoloration at the treatment site that resolved sponta- A method for using the PDL without purpura formation neously in 10 to 14 days. This discoloration was well tol- consists of giving two to three pulses over the telangiecta- Cutaneous and Cosmetic Laser Surgery Figure 2.55
(A) Facial rosacea and telangiectasia in 32-year-old woman before treatment. (B) Three years after single treatment with PDL at 7 J/cm2 delivered through 5-mm-diameter spot.
sia at lower ﬂuences (pulse stacking). Typically, with a 595nm PDL, a 10-mm-diameter spot size is used at 4–5 J/cm2. Multiple pulses even with short pulse durations(0.45 ms) allow a gradual increase in intravascular temper-ature to effect selective photothermolysis without vesselrupture. The only drawback is that multiple treatments arerequired. One study demonstrated a good effect using theabove-mentioned parameters with a 1.5-ms pulse. Patientsrequired 7.4 ± 2.3 weekly treatments for vessel resolutionto occur. A second study compared the PDL used atpurpura-free parameters (595 nm, 10-ms pulse, 10-mm spotsize dynamic cooling with a 30-ms spray and 20-ms delay Figure 2.56
(A), Bright-red linear telangiectasia 0.1 mm in diameter at 7.5 J/cm2) as a single pulse on one side of the face with over nasal alar crease in 46-year-old man. (B) Three months after three or four pulses on the other side. Although side effects PDL treatment at 7 J/cm2. Note complete resolution of nasal alar were similar with both single and stacked pulses, vessel telangiectasia. (C) One year after laser treatment. Note persistent clearance was 74.3% in the pulse stacked side and 58.5% resolution of nasal telangiectasia.
in the single pulse side.278 Another method of achieving purpura-free resolution of telangiectasia with the PDL is to increase the pulse 9 J/cm2. This study divided the face so that one side was duration. One study used a 7-mm-diameter spot at 10-ms treated with purpura-free settings and the other side pulse duration with a dynamic cooling device delivering with purpuric settings. The study demonstrated that in a 30-ms spray with a 20-ms delay. One pass was used at a 82% of the patients, the purpuric side had better ﬂuence 1 J/cm2 lower than a purpuric ﬂuence, typically Laser Treatment of Cutaneous Vascular Lesions Figure 2.57
(A) Extensive telangiectasia bilaterally on cheeks of 56- year-old woman. (B) Six months after one treatment with pulsed dyelaser at 7.25 J/cm2. Total of 40 5-mm impact pulses were given toentire left cheek.
940 nm Diode-Pumped Laser
This laser (Medilas D SkinPulse; Dornier MedizinLaser
GmbH, Germering, Germany) has been reported to be
effective at clearing 1- to 3-mm-diameter periocular vessels
in 86% of patients when used at 141 J/cm2, 20-ms pulse
through a 3-mm-diameter spot size.280
1064 nm Long Pulse Nd:YAG Laser
In an effort to treat deeper, larger and bluer vessels, a longer
wavelength system has been developed. Using this wave-
length requires ﬂuences over ten times that used with 532
(A) Nasal telangiectasia 1–2 mm in diameter. nm to 595 nm lasers since the absorption of Hb and HbO2 (B) Complete resolution after 1 treatment with the LP 1064nm at 1064 nm is ten times less. These higher ﬂuences neces- CoolTouch Varia. A 3.5-mm-diameter spot size was used at 200 J/cm2 sitate epidermal cooling. One laser uses dynamic cryogen with a 25-ms pulse duration and 25 ms of cryogen cooling given cooling to achieve epidermal protection. A study using the immediately after the laser pulse. A total of 22 laser pulses were CoolTouch laser (New Star Lasers, Rosemont, CA) found greater than 75% improvement in 97% of treated sites witha 125–150 J/cm2 ﬂuence through a 6-mm-diameter spotand 25-ms pulse duration for small diameter vessels and Another long-pulse 1064 nm laser using precooling 75- to 100-ms pulse durations for reticular veins (Fig. 2.58).
through a copper contact probe demonstrated moderate to All treated reticular veins including periorbital and tem- signiﬁcant vessel improvement in 80% of patients.282 This poral veins resolved 100%. One or two passes were required laser (CoolGlide Excell, Cutera, Burlingame, CA) is used to achieve vessel spasm or coagulation.281 at 120–170 J/cm2 with a 3-mm-diameter spot size and 5– Cutaneous and Cosmetic Laser Surgery with this IPL may be due to the lower ﬂuence used (13 and 22 J/cm2) and single pulse durations of 10, 15 or 30 ms.
Spider telangiectasia represents telangiectasia with a
central feeding arteriole. They typically appear in pre-
school and school-age children. The peak incidence
appears to be between ages 7 and 10,285 and as many as
40% of girls and 32% of boys less than 15 years old have
at least one lesion.286,287 The incidence in healthy adults
is about 15%.288 The difference between these stated
incidences implies that 50% to 75% of childhood lesions
regress. However, this is not easily observable because most
lesions seem to persist without change and become a
source of cosmetic concern when present on the face.
Treatment in the past included electrocautery and the argon laser. Both modalities have the disadvantages ofbeing painful and prone to causing punctate scarring. Inaddition, recurrence is common if treatment is done lightlyto avoid scarring. The PDL has proved to be a very effec-tive treatment for these benign lesions.289,290 Figure 2.59
Multiple depressed 3mm scars at the point of treatment with the CoolGlide (now Cutera) 1064-nm long pulse laser(see arrows).
Pulse Dye Laser
Geronemus289 reported 100% success without any adverse
sequelae in 12 children treated with the PDL for facial
40-ms pulses until vessel blanching or coagulation occurs.
spider telangiectasia. We retrospectively evaluated the These patients received two treatments 4 weeks apart to response to treatment with the PDL in 23 children with 55 achieve therapeutic efﬁcacy. Cutaneous blistering and scar- spider telangiectasia.290 Lesions were treated at energy ring with 2- to 3-mm depressions and/or hypopigmenta- ﬂuences of 6.5 to 7.5 J/cm2 (mean 6.9 J/cm2). One or two tion was reported in this study and is not uncommonly pulses were given to the central punctum of the ‘spider', seen by this author with the use of this laser (Fig. 2.59). It with additional pulses with a 10% overlap given to the is presumed that pre- and postcontact cooling can be insuf- radiating ‘arms' of the lesion if the lesion was greater than ﬁcient in some patients.
5 mm in diameter. Local anesthesia was not used. Seventypercent of lesions resolved completely with one treatment.
Intense Pulsed Light
Twelve lesions required a second treatment for complete This high-energy pulsed light source described previously resolution. The remaining ﬁve lesions not treated a second is very effective in treating facial telangiectasia. Advantages time had an average clearance of 78% (Fig. 2.62). The three are the almost complete lack of purpura and adverse seque- patients with ﬁve lesions who did not have a second treat- lae. Energy ﬂuences of 25 to 45 J/cm2 are required for vessel ment were either satisﬁed with the degree of resolution ablation given as a double pulse of 2.4 to 6.0 ms each with from their ﬁrst treatment or were unavailable for further a 10–30-ms delay between pulses. A 550 nm, 560 nm or 570 nm cutoff ﬁlter works best. Lesions usually clear in one Spider telangiectasia respond equally as well in adults, treatment in 90% of patients.283 Lesions are treated with with 93% of patients having total resolution with one one or two pulses until initial vessel spasm or slight treatment between 6.5 and 7.0 J/cm238 (Fig. 2.63).
purpura occurs (Figs 2.60 and 2.61). The only potential side With the PDL, lesions become purpuric immediately effects are slight purpura, which lasts 2 to 4 days, or epi- after laser treatment. Purpura resolves within 7 to 10 days.
dermal desquamation when treatment is performed on We have not seen permanent pigmentary changes or tanned or type III or IV skin. Epidermal desquamation in scarring. Although adverse effects from treating spider pigmented patients can be avoided by changing the ﬁlter telangiectasia are extremely rare, one case of granuloma to a longer wavelength or increasing the delay time telangiectaticum (pyogenic granuloma) after argon laser between double or triple pulses (see Chapter 8).
therapy has been reported.291 This complication occurred A dual-mode ﬁltering IPL (Ellipse Flex, Danish Derma- 3 months after the central vessel was treated at 5 W, 50 ms, tologic Development, Hoersholm, Denmark) that restricts with a 0.5-mm-diameter spot size. The authors speculated the ﬁltered light to between 555 and 950 nm (median that laser trauma, in addition to the lack of complete wavelength of 705 nm) has been show to provide more destruction of the spider telangiectasia endothelium, led than 50% reduction in facial telangiectasia in 79% of to a focal capillary proliferation. This effect has also been patients after one to four treatments; 37.5% of patients had reported with laser treatment of PWS, with development greater than 75% improvement.284 The decreased efﬁcacy of ‘hemangiomas' within the treated areas.
Laser Treatment of Cutaneous Vascular Lesions Figure 2.60
(A) Extensive facial telangiectasia on 55-year-old woman after automobile airbag impacted her face. (B) Eight weeks after treatment with PhotoDerm VL, 550-nm cutoff ﬁlter, 40 J/cm2, double pulse of 2.4 and 4.0 ms with 10-ms delay. Note 50% improvement.
(C) Four weeks after second PhotoDerm VL treatment with 570-nm cutoff ﬁlter, 44 J/cm2 delivered in two pulses of 2.4 and 4.0 ms with 10-msdelay. (D) Complete resolution 8 weeks after third and fourth treatments, with parameters similar to those in (C).
(A) Facial telangiectasia before treatment. (B) After two treatments with PhotoDerm VL with 570- or 550-nm cutoff ﬁlters, 37 J/cm2 given as double pulse of 3 and 4 ms with 10-ms delay between pulses. (Courtesy Beverly Kemsley, MD, Calgary, Canada.) Cutaneous and Cosmetic Laser Surgery Figure 2.62
(A) Two spider telangiectasia on left inner canthal area Figure 2.63
(A) This 44-year-old man had an 18-month history of and outer canthal area of 10-year-old girl for 6 months. (B) Four enlarging spider telangiectasia on right cheek. (B) Six months after weeks after single treatment with PDL at 7 J/cm2. Note complete single treatment with PDL at 7 J/cm2. A total of six 5-mm pulses were resolution of telangiectasia without any evidence of cutaneous given, with complete resolution of telangiectasia.
changes. (Reprinted from Fitzpatrick RE: American Journal of CosmeticSurgery 9:107, 1992. With permission from American Academy ofCosmetic Surgery.) 532 nm KTP or Nd:YAG Laser
An additional nearly painless treatment modality is the
long-pulse 532 nm laser. Parameters found to be efﬁcacious
in treating spider telangiectasia are a 3- to 4-mm-diameter
spot with an energy ﬂuence of 12 to 14 J/cm2 delivered in
a 10-ms pulse. The treatment is almost painless because the
laser beam is delivered through a double-chambered clear
quartz crystal cooled in its center to 4°C with water (Fig.
2.64). The quartz cooling device is placed over the lesion
on the skin surface, and the laser ﬂuence is delivered one
to three times until the lesion blanches. This laser has an
efﬁcacy of almost 100% for this treatment in our practice.
The KTP laser (Orion/Aura, Laserscope, Palo Alto, CA) Figure 2.64
Cooling head is attached to handpiece of Versapulse has been found to be effective when used with a 1- to 532-nm laser and placed on skin over target vascular lesion. Laser 2-mm diameter spot size, at 13–10 J/cm2 respectively with energy is then given through this cooling device.
a 5–8 ms pulse duration.
paper to match the lesion's diameter. A simple sheet of Intense Pulsed Light
white paper, cardboard, or self-sticking label is sufﬁcient The IPL has also been useful in treating these lesions.
to block out the light delivered through the quartz or sap- Because one needs only to treat the lesion, we use a hole phire light guide. Fluences of 35 to 40 J/cm2 delivered in a punch or scissors to cut out an open area in a sheet of white double pulse of 2.4 and 4.0 ms with a 10-ms delay through Laser Treatment of Cutaneous Vascular Lesions Rosacea
Rosacea is essentially a cutaneous vascular disorder. It is
best thought of not as a disease but as a typology of a
cluster of patients with a characteristic combination of
cutaneous stigmata consisting of telangiectasia, papules,
pustules, and rhinophyma.293 A comprehensive review of
the literature ﬁnds that of the 18 histologic studies on
rosacea, 14 showed an increase in Demodex mites.294 It is
hypothesized that these mites may play a role in the
inﬂammation of rosacea.295 Studies have demonstrated
thermal destruction of these mites after IPL therapy,
which may contribute to the therapeutic effects of
IPL.295,296 Telangiectasia represents the later phase of
vascularization and probably results from a reduction in
mechanical integrity of the upper dermal connective
tissue, allowing a passive dilatation of capillaries. Inﬂam-
mation and associated angiogenesis may contribute to
the telangiectasia. Interestingly, facial temperature ishigher in rosacea and this has been associated with a dif-ference in the nature and behavior of skin bacteria, par-ticularly coagulase-negative staphylococci.297 Therefore,the elimination of excessive blood vessels may not onlydecrease the erythematous appearance of rosacea but alsomodify the bacterial ﬂora further decreasing the cutaneouserythema.
Pulse Dye Laser
Rosacea-associated telangiectasia and erythema respond
well to treatment with the PDL. We have reported good to
excellent results in 24 of 27 patients (89%).298,299 In addi-
tion to the cosmetic improvement resulting from elimina-
Extensive vascular ectasia on both feet of 54-year-old tion of the vascular component of this disorder, PDL woman. (A) Before treatment. (B) Six months after initial treatment treatment also appears to alter the pathophysiology of this and 3 months after second treatment with PDL at 7.25 J/cm2 using condition because a decrease in papule and pustule activ- 84 and 115 pulses, respectively. (From Goldman MP. Sclerotherapy: ity occurs in up to 59% of patients (Fig. 2.67). After PDL treatment of varicose and telangiectatic leg veins, 2nd edn. St Louis: treatment, patients who responded to treatment with elim- ination of the vascular component required less or notopical or systemic antibiotic therapy to maintain disease a 550-nm cutoff ﬁlter usually gives near 100% efﬁcacy with resolution.299 Anecdotal reports from Tan and Kurban245 almost no pain. Even small children and male adults tol- conﬁrm our more formal evaluations. An additional study erate the treatment without complaint. Lesions are rarely of 12 patients with rosacea treated with the PDL to one purpuric and usually without adverse sequelae, making cheek with the other as a control at purpuric settings of this modality a treatment of choice.
5-mm diameter, 5.5–6.5 J/cm2, 0.45-ms pulse withoutcooling also demonstrated a 75% reduction in telangiecta-sia is 11 of 12 patients and a decrease in erythema of 50% Generalized Essential Telangiectasia
after three treatments.300 This telangiectasia generally occurs on the legs but may The efﬁcacy of the ﬁrst-generation PDL was reproduced also involve other cutaneous surfaces. Various treatments in a study of a 6 ms PDL at 595 nm with ﬂuence between have been proposed, with variable efﬁcacy.249 Tan and 7 and 9 J/cm2 and cryogen spray cooling.301 Here, two of Kurban245 reported successful treatment with the PDL at 12 patients had over 75% improvement with one treat- ﬂuences of 6 J/cm2. We also treated four patients with the ment. Another two had 50–75% improvement; ﬁve had PDL at ﬂuences ranging from 6.0 to 7.5 J/cm2. Two patients 25–50% improvement. These parameters did not produce responded with total resolution, but two patients had almost no improvement in their appearance (Fig. 2.65).
A questionnaire rating of Dermatology Life Quality Therefore we believe that intrinsic factors in these patients Index and symptoms of ﬂushing, burning, itching, may preclude predictable results. We recommend per- dryness, swelling and skin sensitivity was performed on forming a patch test for such patients.
16 patients treated with a PDL for their rosacea.302 PDL IPL treatment has also been found to be effective parameters of treatment were 10 J/cm2, 7-mm-diameter spot, 1.5-ms pulse duration with cryogen skin cooling Cutaneous and Cosmetic Laser Surgery Figure 2.66
(A) Essential telangiectasia before treatment in a 38-year-old women. (B) After one treatment with the Lumenis Vasculite IPL at 32 J/cm2 with a 570 cut-off ﬁlter and a double pulse of 2.4 and 4.0 ms with a 10-ms delay. (Reprodued with permission from Goldman MP,Bergan JB: Sclerotherapy treatment of varicose and telangiectatic leg veins, 3rd Ed. Mosby, 52 Louis, 2001.) treatment. Seven patients had less symptoms and only onepatient was unchanged. Superﬁcial nerve ﬁber density andnumber of substance P immunoreactive nerve ﬁbers weredecreased.
In assessing the overall success and potential risk of each laser used in the treatment of facial telangiectasia withrosacea, we believe that the PDL provides effective and relatively risk-free results. However, purpura resulting aftertreatment is an inconvenience that must be recognized inadvance in scheduling treatment. In addition, one studyof ten patients showed that only 50% had less papulopus-tular lesions after an average of 2.4 treatments with param-eters of the PDL previously described above.304 However,even in this ‘negative' paper, two of the ten treated pa-tients had excellent results when evaluated 5 years aftertreatment.
(A) 24-year-old women with rosacea on the cheeks.
532 nm KTP Laser
(B) One month after the second of two treatments with the PDL.
A study of 47 patients treated with the KTP 532 nm laserwith variable-sized handpieces depending on the type of of 40–50-ms spray after a 20-ms delay. Two treatments telangiectasia showed good results.305 Matted telangiecta- were performed. The Dermatology Quality of Life Index sia were treated with a 4-mm-diameter spot and 20-ms improved in each patient from an average score of 7.8 pulse width at an average energy of 0.7 W. Vessels 0.1 to before treatment to 3 after the ﬁrst treatment and 1.9 after 0.3 mm in diameter were treated with a 0.25-mm-diameter the second treatment (75.6%). Symptoms of burning, spot size and 20-ms pulse width at an average energy of ﬂushing, stinging and itching improved by at least 57% 0.12 W. Vessels greater than 0.3 mm in diameter were after treatment. Therefore, a cosmetic improvement is not treated with a 1-mm-diameter spot and 10-ms pulse width the only beneﬁt of laser treatment of rosacea.
at an average energy of 0.2 W. Vessels were treated by The improvement in symptoms was reproduced in tracing them with the laser until they disappeared. This another study of 32 patients with rosacea treated with required one to several tracings. Of the 47 patients, 38% the ﬁrst-generation 0.45-ms, 5-mm-diameter PDL with had more than 70% resolution of their telangiectasia, and purpura lasting 5–14 days.303 These patients all had a posi- 32% required a second treatment to achieve the same tive lactic acid (Stinger) test indicating skin sensitivity. 24 result. The only adverse effect consisted of linear crusting of the 32 patients became stinger negative after one PDL along the path of the telangiectasia.
Laser Treatment of Cutaneous Vascular Lesions Figure 2.68
(A) Erythematous cheeks of 66-year-old woman before treatment. (B) After three treatments with PhotoDerm VL using 570-nm cutoff ﬁlter and 12-ms pulse at 52 J/cm2; followed 4 weeks laterby 590-nm cutoff ﬁlter and 12-ms pulse at 55 J/cm2; then followed 4weeks later by 550-nm cutoff ﬁlter at 44 J/cm2 given as double pulseof 4.2 and 7.7 ms with 20-ms delay.
Intense Pulsed Light
The IPL has also been found to be effective in treating
rosacea. As described previously, this light source has the
advantage of relatively quick vessel elimination without
(A) Diffusely red telangiectatic nose of 58-year-old signiﬁcant purpura or crusting (Figs 2.68 and 2.69). Scan- male. (B) After one treatment with Lumenis 1 intense pulsed lightusing 560-nm cutoff ﬁlter at 20 J/cm2 given as double pulse of 3, 5 ning Doppler evaluation demonstrated a 30% decrease in and 3.5 ms with a 10-ms delay.
blood ﬂow after ﬁve IPL treatments.306 In addition, a 21%decrease in erythema intensity as well as a 29% decreasein the actual size of the cheek with telangiectasia was noted 2.4 ms and 4.0 ms with a 10-ms delay and an energy in this study of four patients. A larger study of 60 patients density of 30 J/cm2 (26J/cm2 with the QuantumSR) and were treated with the IPL with pulse durations of 4.3 to 3.0 ms and 3.0 ms at 18 J/cm2 with the Lumenis One).
6.5 ms and energy density of 25–35 J/cm2.307 A mean clear- Patients are retreated every 3–4 weeks until clear. We have ance of 77.8% was achieved and maintained for a follow- found that most patients clear in two or three treatments.
up period averaging 51.6 months. An additional study of A certain percentage of patients (20%) do not respond to 32 consecutive patients treated with an average of 3.6 IPL the IPL and need to be treated with the PDL. Most of treatments similar to the above-mentioned parameters our patients need to return for retreatment every year showed that 83% of patients had reduced redness, 75% experienced reduced ﬂushing and 64% noted fewer acnebreakouts.308 Poikiloderma of Civatte
Poikiloderma of Civatte is a variant of telangiectasia
involving the neck and upper chest and occurring We treat the entire facial area affected by the erythematous from accumulated ultraviolet exposure and associated rosacea. Short pulses appear to be most effective. We typi- photosensitization of various chemicals, most notably cally use a 550 or 560 cutoff ﬁlter with a double pulse of fragrances.309 Poikiloderma consists of a combination Cutaneous and Cosmetic Laser Surgery of telangiectasia, irregular pigmentation, and atrophic changes of the skin. Histologic changes on biopsy conﬁrmthis clinical combination. These changes are best treatedby addressing the telangiectatic and pigmentary compo-nents simultaneously.
In the past, poikiloderma treatment focused on the telangiectatic component and solely on various lasermodalities. Fair efﬁcacy was reported, but treatments werelengthy because of the large surface areas involved andmultiple sessions required. The argon laser is only partiallysuccessful and frequently results in areas of hypopigmen-tation with a low incidence of scarring. The 532 nm KTPlaser has also been reported to be successful in a onepatient case report.310 Pulse Dye Laser
The PDL, as reported by Tan and Kuran,245 Wheeland and
Applebaum,311 and us, has good efﬁcacy at ﬂuences of 6 to
7 J/cm2 with a 5-mm-diameter spot size. Our recommendedﬂuence at a 7-mm-diameter is 5 to 6 J/cm2. Problems withthe PDL include extensive purpura, multiple treatmentsbecause of large surface area, and mottled response withcircular imprints (Figure 2.70). In addition, by mainly tar-geting the vascular component, these treatments often dolittle to change the hyperpigmentation. Scarring has alsobeen reported when the PDL was used at ﬂuences greaterthan 6 J/cm2.312 We recommend that if the PDL is used to treat poikilo- derma of Civatte, it be used with a 10-mm-diameter spotsize, 0.45- to 0.5-ms pulse duration if pigmentation isprominent and 1.5- to 2-ms pulse duration if erythema isprominent. Fluence should be just strong enough to give aminimal purpuric response and epidermal cooling shouldbe performed. Patients must be told that three to ﬁve Figure 2.70
(A) Extensive poikilodermic changes from sun damage treatments will be necessary and that the treated area on central chest of 36-year-old woman. (B) After three treatmentswith FLPDL at a ﬂuence of 7 J/cm2 during each treatment session.
may appear to be polka-dotted until all treatments are given.
Between 200 and 300 5-mm impact pulses were given at eachsession. Note excellent clearing of poikilodermic changes. Somewhat Intense Pulsed Light
mottled pigmentation remains between laser impact sites and on Our results using an IPL have been very favorable. With peripheral aspect of poikiloderma.
this pulsed light system, the target is both vascular and epidermal and dermal melanin. Multiple wavelengths are second expanded study of 135 patients randomly selected used, usually with a 515-nm ﬁlter ﬁrst. This ﬁlter is used with typical changes of poikiloderma of Civatte on the with a single pulse of 3 ms at a ﬂuence of 22 to 25 J/cm2.
neck and/or upper chest were treated one to ﬁve times These treatment parameters are effective in removing every 4 weeks with the IPL. Clearance of over 75% of epidermal melanin and very superﬁcial telangiectasia. A telangiectasias and hyperpigmentation comprising second or third treatment spaced at least 4 weeks apart is poikiloderma was observed. Incidence of side effects was usually necessary and typically uses a 550-nm cutoff ﬁlter 5% including pigment changes. In many cases, improved with a double pulse of 2.4 and 4 ms with a 10-ms delay.
skin texture was noted both by physician and patient This is helpful in treating slightly larger or deeper telang- (Figs 2.71 and 2.72).315,316 iectasia. A total ﬂuence from 35 to 42 J/cm2 is usually Approximately 75% improvement occurs after one treat- necessary to achieve an optimal clinical result. With these ment. Side effects include transitory erythema from 24 to parameters, few or no side effects have been noted in 72 hours. Purpura occurs only 10% of the time and only our patients (Fig. 2.71). This experience has been detailed with some pulses in variable locations. This purpura is dif- in a study in which 66 patients with typical changes of ferent from that seen with the PDL in that it is intravas- poikiloderma of Civatte on the neck were treated with IPL cular and resolution occurs within 3 to 5 days. A slight at various settings every 4 weeks until desired improve- stinging pain during treatment is easily tolerated for up to ment occurred. A 50%–75% improvement in the extent of 60 pulses per session. No anesthesia is required, and the telangiectasias and hyperpigmentation comprising entire neck and chest area can be treated during one treat-poikiloderma was observed in an average of 2.8 treat- ment session. Patients must be informed that ‘foot-prints' ments. Incidence of hypopigmentation was 5%.313,314 A representing the shape of the contact crystal may be Laser Treatment of Cutaneous Vascular Lesions Figure 2.71
(A) Poikiloderma of Civatte in 44-year-old male before treatment. (B) One month after a second treatment with IPL using a550-nm cutoff ﬁlter at 40 J/cm2 given as a double pulse of 2.4 and4.0 msec separated by a 10 msec delay.
(A) Progressively enlarging venous lake on lower lip of a 78-year-old women for 2 years. (B) Three months after single treatment with PDL at 7.5J/cm2 with a total of four 4-mm impacts.
present after the ﬁrst and even second treatment and is anormal response.
Venous lakes are dilated ‘lake-like' venules in the upperdermis typically seen on the lips or ears of elderly patients.
These lesions are dark-blue to purple, soft, raised nodules,usually 2 to 10 mm in diameter.317 Patients generallyrequest treatment because of concern over possible medicalconsequences and recurrent bleeding with trauma or forcosmetic improvement.
Treatment of venous lakes of the lips and ears has been effective with the argon laser, requiring from one to four Figure 2.72
(A) Poikiloderma of Civatte in 52-year-old male before treatment sessions.318,319 Use of laser spot size less than treatment. (B) Six months after third treatment with PhotoDerm VL 1 mm in diameter may promote excessive bleeding.320 using 550-nm cutoff ﬁlter at 37 to 40.5 and 43.5 J/cm2 given over Lesions less than 5 mm in diameter almost always heal three treatments as a double pulse of 2.4 and 2.4 ms with 10-ms without scarring, whereas those larger than 5 mm healed delay between pulses.
with scarring in 21% of patients treated in one study.321Treatment of venous lakes with electrocautery has beenunsatisfactory.322 The PDL has been reported to be suc-cessful in treating venous lake lesions (Fig. 2.73).245,269 Cutaneous and Cosmetic Laser Surgery Figure 2.74
(A) Venous lake present for more than 20 years on the lower lip. (B) Four weeks after second treatment with intense pulsedlight at 590-nm cutoff ﬁlter, 38J/cm2 given as a double pulse of 3 msand 2 ms with a 10-ms delay.
When using the PDL, selective photothermolysis is not thegoal. Multiple pulses over the same area with or withoutdiascopy are usually required for efﬁcacy. This has resultedin epidermal and perivascular thermal damage as previ-ously described. A tunable dye laser at 577 nm used withdiascopy in a continuous wave at 1 W also gives excellent Figure 2.75
(A) A 32-year-old woman who had a venous lake on cosmetic results.323 the lower lip for 18 years and requested removal for cosmeticreasons. One treatment was given with a long-pulse Nd:YAG laser The IPL has also been found to be effective in resolving with a 7-mm diameter spot size, a pulse duration of 45 ms and a venous lakes in one or two treatments. Treatment param- ﬂuence of 120 J/cm2. Six pulses were given. (B) Complete resolution eters are similar to those used for treating hemangiomas 4 months after treatment. (Courtesy of Don Groot, MD.) (Fig. 2.74). The long-pulse Nd:YAG is also suitable for treat-ing this vascular lesion. Figure 2.75A shows a 32-year-oldwoman who had had a venous lake on the lower lip for 18 from epidermal hyperproliferation in response to viral years and requested removal for cosmetic reasons. One genome incorporation into epidermal cellular DNA. To treatment was given with a long-pulse Nd:YAG laser with maintain a proliferative growth, neovascularization is stim- a 7-mm-diameter spot size, a pulse duration of 45 ms and ulated. This is reﬂected histologically in prominent, dilated a ﬂuence of 120 J/cm2; six pulses were given. Figure 2.75B blood vessels in dermal papillae.325 Theoretically, vapor- shows complete resolution 4 months after treatment.
ization and coagulation of the new capillaries should haltviral replication and promote verrucae resolution. Toproduce vascular coagulation, the CVL has been reported to treat genital warts effectively.326 Nemeth and Reyes326 postulated that using epidermal Verrucae represent benign tumors of epidermal cells melanin as the ‘surrogate' target produces epidermal- induced by the human papillomavirus (HPV). They occur dermal separation with removal of the wart. In a population in about 10% of adults and children.324 Verrucae develop of resistant warts, only 12 of 137 patients failed to respond Laser Treatment of Cutaneous Vascular Lesions to treatment with a CVL. However, one-third of patients higher clearance rate because they were usually treated up developed recurrent lesions at the 6-month follow-up.
to three times, whereas never-treated were usually only In an effort to coagulate deeper vessels, using a laser with treated once or twice. These patients generally preferred a longer wavelength should be effective. Therefore we have PDL treatment to cryosurgery, with only 2 of 32 patients used the PDL to treat common verrucae. Lesions are treated having residual pain lasting 1.5 days to 1.5 weeks.
at a ﬂuence of 7.0 to 7.5 J/cm2 with single pulses to ﬂat warts Increasing the ﬂuence of the PDL to 8.1 to 8.4 J/cm2 has and two to four pulses to hypertrophic verrucae. Paring increased clearance. Of 97 verrucae treated at this higher down the warts is recommended but not to the point of ﬂuence, 70% had 100% clearance.331 bleeding, which would cause the laser light to be absorbed A prospective randomized study of PDL vs. conventional by surface blood. Lesions are treated until they appear gray.
treatment on 40 adults with 194 warts showed a 70% They then become black after 24 hours. Patients are response with conventional and 66% response with PDL retreated every 1 to 2 weeks until resolution. We combined treatment. Conventional treatment was LN2 with 2, 15 a limited series of patients with those of Webster et al327 at second freeze thaw time. PDL treatment was with a 5-mm- Jefferson Medical College and found that ﬂat warts were diameter spot, 9–9.5 J/cm2 given in two pulses. Both groups most responsive to treatment, with 71% resolving com- also performed 17% salicylic acid treatments daily to their pletely in an average of 2.4 treatments. Palmar and plantar warts. A mean number of two treatments was necessary in warts had a 65% total resolution response in 2.3 treatments, both groups to achieve clearance. There appeared to be a and periungual warts only cleared completely in 33% of slight advantage of the PDL in the treatment of recalcitrant patients despite an average of 3.3 treatments. Some warts cleared after one treatment, and some required several Unfortunately, not all studies report the same degree of treatments. There was no signiﬁcant difference in the signiﬁcant efﬁcacy with PDL therapy.332 A study of 27 number of treatments or ﬂuence used. Very few warts failed patients with 79 recalcitrant palmoplantar, digital, periun- to show some response to treatment, with smaller warts gual, and body lesion warts found that 36% of the patients responding more quickly than larger warts. None of our had complete resolution of their warts and 59% partially patients developed postprocedural debility.
responded. Of the total number of warts treated, only 21% Tan et al328 treated 39 patients with verrucae recalcitrant completely resolved.333 Of those warts that cleared, 40% to multiple treatment modalities with the PDL after paring recurred within 4 months with a mean follow-up of 7 the warts at ﬂuences ranging from 6.25 to 7.5 J/cm2. As months. Exact treatment parameters and techniques were with our patients, excellent resolution occurred, warts not noted in this abstract, but this study from a major totally clearing in 72% of patients after an average of laser center casts doubt on the absolute efﬁcacy of PDL 1.68 treatments. The more rapid response was most likely related to enhanced efﬁcacy by allowing deeper vascular Reasons for the difference in therapeutic response is coagulation through paring the surface of the verrucae.
unknown. Because of a wart's tendency toward sponta- Only one of the patients had a recurrence in the 5- to neous resolution, however, a blinded controlled study of 6-month follow-up period. The authors examined 15 PDL versus sham laser is necessary. Nevertheless, the efﬁ- patients histologically and found marked agglutination cacy of this treatment, in addition to its ease and lack of of RBCs accompanied by vessel wall necrosis. Necrotic scarring, is encouraging. In addition to the proposed mech- keratinocytes surrounded these vessels.
anism of vascular coagulation for wart destruction, direct Kauvar et al329 have reported the highest efﬁcacy with thermal effects from treatment may be signiﬁcant.
PDL treatment: 93% overall efﬁcacy in treating 142 Nonlaser-induced hyperthermia has been demonstrated patients with 703 verrucae that had been recalcitrant to result in regression of warts in a high percentage of to previous treatment with various modalities, including patients.334 The mechanism of action for heat may be related liquid nitrogen and CO2 laser vaporization. Warts were to direct epidermal protein coagulation or coagulation of pared and hemostasis obtained with aluminum chloride 3 nutritive blood vessels or to the subsequent inﬂammatory weeks before treatment. When warts cleared, they did so response to thermal injury. Other lasers have been used to in an average of 2.5 treatments (range 2–5). In addition to produce local hyperthermia, and the term ‘laserthermia' has an enhanced therapeutic response from therapy, 60% of been used speciﬁcally with Nd:YAG laser therapy.335,336 As patients reported adverse effects that were minimal enough with PDL treatment, Nd:YAG laserthermia has advantages to prevent a change in their daily activities, and 70% over CO2 laser treatment because the skin remains intact and thought PDL treatment was less painful than liquid nitro- bleeding usually does not occur. Thirty-one patients with gen cryosurgery. Interestingly, the study found no differ- recalcitrant warts (previous unsuccessful cryosurgery, kera- ence in efﬁcacy among 7, 8, 9, or 10 J/cm2 ﬂuences, as well tolytic treatment, antimitotic therapy, and excision alone or as no apparent difference between two to ﬁve pulses and in combination) were treated with the Nd:YAG at 10 W with six to ten pulses. The authors concluded that each wart 8-mm-diameter spot size and irradiation time of 20 s. These should receive two or three pulses at a ﬂuence of 6 to parameters resulted in heating of wart tissue to 40°C for 7 J/cm2 at 3-week intervals.
30 s. Patients were treated up to three times at 3-week inter- An additional study of 156 warts in 32 individuals vals. At 9-month follow-up, 77% of patients cleared com- treated with the PDL at 8 J/cm2 showed resolution of 68% pletely without scarring or recurrence.337 Local anesthesia of recalcitrant warts and 47% of never-treated warts with was not necessary because patients felt only a slight burning an average of 1.78 treatments.330 Recalcitrant warts had a sensation during and after treatment.
Cutaneous and Cosmetic Laser Surgery The frequency doubled Nd:YAG laser has also been found 6. Garden JM, Tan OT, Kerschmann R et al. Effect of dye laser to be effective in the treatment of ﬂat warts.338 This laser was pulse duration on selective cutaneous vascular injury. J used with a 3-mm-diameter spot size at 2.5 J/cm2 with mul- Invest Dermatol 1986; 87:653.
tiple 10 ns pulses. Lesions were treated until whitening 7. Tanghetti E, Sierra RA, Sherr EA, Mirkov M. Evaluation of occurred and all lesions turned into eschars after a few days.
pulse-duration on purpuric threshold using extended pulsepulsed dye laser (Cynosure V-Star). Lasers Surg Med 2002; In the seven patients treated, hyperpigmentation developed but all lesions resolved without adverse effects.
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