after radiotherapy is also easily treated (Fig. 2.14).
Other lesions with a vascular component, such as angio-lymphoid hyperplasia, adenoma sebaceum, lymphangiomas (Fig. 2.15), and granuloma faciale have all been reported as successfully treated with vascular lasers. The majority of reports of these disorders have been case studies rather than controlled trials. In adenoma sebaceum, if the angio fibromas do not have a prominent vascular component, then CO2 laser vaporization should be considered.
The lasers used currently in the treatment of vascular disease have a low incidence of side effects. Risk of complications is substantially less than that seen with previously used continuous wave lasers such as the argon laser. The major disadvantage of the PDL is the development of profound purpura. Using the short-pulsed dye laser this occurred in 61 or 62 patients and lasted a mean of 10.2 days (1-21 days) (Lanigan 1995). In this same study 70% of patients reported swelling of the treated area which lasted 1-10 days; weeping and crusting occurred in 48%. Forty five per cent of patients did not go out of their home for a mean of
Fig. 2.14. a Postirradiation telangiectasia on chest wall [from S.W. Lanigan, T. Joannides (2003) Brit J Dermatol 48(i):77-79]. b Near total clearance after one pulsed dye laser treatment [from S.W. Lanigan, T. Joannides (2003) Brit J Dermatol 48(0:77-79]
5.6 days (2-14 days). Longer-pulsed PDL treatment leads to less purpura.
There are very few, if any, absolute contraindications in the use of vascular specific lasers.
There are a number of relative contraindications that the laser clinician should consider before embarking on treatment. The clinician should ascertain that the patient has realistic expectations from the laser treatment. In treating PWS, only the minority of cases will completely clear, although the majority will substantially lighten. Patients with facial telan-
giectasia may develop a dysmorphophobia whereby the patient is significantly disturbed by what they perceive as abnormal disfiguring changes-which are not visible to the casual observer. In general, these patients do poorly with laser treatment.
Patients who have had previous treatments to their vascular lesion, including continuous wave lasers, radiation treatment, and electro-desiccation often have some degree of scarring and hypopigmentation. This may not be obvious until the overlying vasculature has been cleared. It is important to document such changes prior to treatment. In general, patients who have had prior treatment which has resulted in scarring do not respond as well to subsequent PDL therapy.
Patients taking aspirin, nonsteroidal anti-inflammatories, and anticoagulants will show more PDL-induced purpura. There have been reports of PDL-induced hypertrophic scarring in patients who have recently taken isotretinoin.
A true cause-and-effect relationship has yet to be proven.
Although laser treatment in itself is inherently safe in pregnancy, the treatment does cause pain and can be distressing. It most situations, laser may be best deferred until after delivery.
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It is extremely important when assessing patients for treatment of their facial telangiectasia that they are made fully aware of the available procedures and the likely outcomes and side effects (Fig. 2.16). In general, patients with small, fine, relatively superficial telangiectasia can be treated with most available lasers. Most patients will prefer the KTP laser because of the reduced associated purpura. Also, when treating extensive areas where there is significant background erythema, the PDL is likely to produce a superior result. Generally, I perform a test patch in this group of patients.
When using the PDL, although it may be possible to clear the problem without purpura, it is my experience that such an approach generally requires multiple treatments. I attempt to produce vessel damage with fluences as close to the purpura threshold as possible. Most patients do not require local anesthesia for this procedure. A disadvantage of topical anesthetics is the vasoconstriction that occurs, which may make it difficult to see all the vessels. The combination of concurrent epidermal cooling and longer pulse durations will reduce the PDL-induced purpura. Patients should avoid traumatizing the area after treatment and use potent sunscreens. Treatments are generally repeated at 4- to 6-week intervals until vessel clearance has occurred. In general, most patients need between two and four treatments.
When using the KTP laser, the object is to heat seal the vessels under direct observation. This treatment requires more skill and training than when using the PDL. The target vessel is traced with the laser beam using relatively small spot sizes and repetition rates of 3-8 Hz. This
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