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Absorption Spectrum

Fig. 2.8. Schematic absorption spectrum of hemoglobin (Hb), Oxyhemoglobin (Hbo2) and melanin (Me) to show absorption peak of Hb at 755 nm (courtesy of Cynosure Lasers)

These lasers have been used in the treatment of superficial and deep small-to-medium size leg telangiectasia. Diode lasers emit light that closely matches a tertiary hemoglobin absorption peak at 915 nm. Investigators (Varma and Lanigan 2000) have evaluated an 810-nm diode laser for the treatment of telangiectatic veins on the leg. Vessels measuring 0.5-1.5 mm in diameter were treated using fluences of 12-18 J/cm2 with a 5-mm spot. Improvements were modest but patient acceptance was high. There were no significant side effects. Others also investigated a 940-nm diode laser in 60 patients with vessels of varying size. Best results were seen in vessels between 0.8 and 1.44 mm in diameter where 88% of patients obtained more than 75% vessel clearance. Vessels smaller than this responded poorly.

■ Long-Pulsed Nd:YAG Lasers

Several long-pulsed Nd:YAG lasers are available with pulse durations in the tens of milliseconds. These pulse widths are more appropriate in targeting large leg veins than the previous Q-switched Nd:YAG nanosecond lasers used in the treatment of tattoos. The 1064-nm infrared light is deeply penetrating with minimal absorption by melanin. When using long wavelength lasers with deeper penetration but relatively poor absorption, the combination of higher fluences and cooling devices will reduce epidermal injury.

In one study, 50 sites were evaluated with this laser. Number of pulses and fluence were altered based on vessel size. At 3-months follow-up a 75% improvement was noted. There was no epidermal injury with this laser although hyperpigmentation was common. Several studies have now demonstrated the effectiveness of the millisecond-pulsed Nd:YAG laser for lower extremity telangiectasia (Rogachefsky et al. 2002; Omura et al. 2003). Studies have focused on methemoglobin production following laser-induced heating. This methemoglobin formation leads to an increase in the absorption of the 1064-nm infrared light, adding to the effect of the Nd:YAG laser. Others (Eremia et al. 2002) compared the long-pulsed 1064-nm Nd:YAG, 810-nm diode, and 755-nm alexandrite lasers in the treatment of leg vein telangiectasia.

Vessels were 0.3-3 mm in diameter. At follow-up greater than 75% improvement was observed at 88% of the Nd:YAG laser-treated sites, 29% of the diode laser-treated sites, and 33% of the alexandrite laser-treated sites.

Despite these developments, sclerotherapy may well remain the treatment of choice for a variety of leg vein telangiectasia. A comparative study of sclerotherapy and long-pulsed Nd:YAG laser treatment (Lupton et al. 2002) showed that leg telangiectasia responded best to sclerother-apy, in fewer treatment sessions, as compared to the long-pulsed YAG laser. The incidence of adverse sequelae was equal. Laser treatment of leg vein telangiectasia appears to be of particular value in patients with telangiectatic matting and needle phobia, and for small superficial vessels too small to be treated with a needle.

Facial Telangiectasia

Facial telangiectasias are one of the commonest vascular disorders presenting for treatment. They respond readily to most lasers emitting light absorbed by hemoglobin. The two main groups of lasers used for facial telangiectasia are the pulsed dye and KTP lasers. The PDL has the lowest incidence of scarring, but may cause significant bruising after treatment (Fig. 2.9). This may not be cosmetically acceptable to patients with relatively mild disease. In a comparison of the older copper vapor laser and PDL treatment of facial telangiectasia similar improvements were seen with both lasers. However, patients preferred the linear crusting produced by the copper vapor laser compared to the purpura induced by the PDL. In a comparison study of the argon, dye, and pulsed dye lasers, the PDL was shown to produce better results. However, only 6 of 13 patients preferred this laser because of laser-induced purpura and postinflammatory hyperpigmentation. Four different frequency-doubled Nd:YAG lasers for the treatment of facial telangiectasia were assessed (Goldberg et al. 1999), using fluences of between 8 and 24/Jcm2. The authors demonstrated equal efficacy with all such lasers and no evidence of scarring or pigmentary changes (Figs. 2.10,2.11)

Photo Purpura Laser
Fig. 2.9. Bruising after pulsed dye laser
Pdl Laser Treatment

Fig. 2.10. a Facial telangiectasia pretreatment (courtesy of Lasercare Clinics Ltd). b Complete clearance after KTP laser treatment (courtesy of Lasercare Clinics Ltd)

Fig. 2.10. a Facial telangiectasia pretreatment (courtesy of Lasercare Clinics Ltd). b Complete clearance after KTP laser treatment (courtesy of Lasercare Clinics Ltd)

With the development of long PDL with epidermal cooling, it may be possible to produce satisfactory improvement in facial telangiecta-sia while minimizing the purpura seen with the earlier PDL. Some investigators (Alam et al. 2003) have treated patients with facial telangiectasia using the PDL at fluences 1 J/cm2 below and 0.5 J/cm2 above the purpura threshold. There was a small reduction in observed telan-giectasia with the purpura-free treatment. This was seen most commonly with finer telang-iectatic vessels. A more significant reduction in telangiectasia was seen in those with laser-induced purpura. Similar work has been reported using a PDL with refrigerated air cooling and extended pulse widths of 40 ms-at fluences at or below the purpuric threshold. In all cases vessel clearance was associated with transient purpura lasting less than 7 days. The authors did not feel that it was possible, in a single treatment, to produce vessel clearance without the presence of purpura.

The addition of contact cooling when treating facial telangiectasia with the KTP laser has also been assessed. The combination of an aqueous gel with a water-cooled hand piece significantly reduced the incidence of side effects from this procedure. Yet, there was no alteration in the efficacy of clearance of telangiectasia.

Fig. 2.11. a Steroid induced facial telangiectasia (courtesy of Lasercare Clinics Ltd). b Post-KTP laser treatment (courtesy of Lasercare Clinics Ltd)

Ktp Laser Treatment

Fig. 2.11. a Steroid induced facial telangiectasia (courtesy of Lasercare Clinics Ltd). b Post-KTP laser treatment (courtesy of Lasercare Clinics Ltd)

Psoriasis

In a psoriatic plaque the capillaries of the dermal papillae are enlarged, dilated, and tortuous. A variety of lasers can be used for the treatment of psoriasis (see Chap. 6). Since the PDL can be used to treat superficial cutaneous vascular ectasias, it seemed logical to investigate whether this laser had any therapeutic efficacy in the treatment of plaque-type psoriasis. Over a decade ago there were reports of the potential benefits of the PDL in psoriasis. Subsequent studies (Katugampola et al. 1995) have confirmed the effectiveness of this treatment. Katugampola et al. treated 8 patients with chronic plaque psoriasis using the PDL at 8.5 J/cm2 with a 5-mm spot, 3 times, over a 6-week period. Five of their 8 patients recorded an improvement of >50%, with one patient showing complete resolution. Some have performed a clinical and histological evaluation of the PDL treatment of psoriasis in 36 patients. There was no difference in response when using either a 450-^s or 1500-^s pulse duration.

Others have looked at psoriatic plaques 1 year after PDL treatment. Of nine areas completely cleared after treatment, six remained clear up to 15 months after therapy

It appears that PDL treatment can lead to improvement in psoriasis. Multiple treatments are often necessary and this technology may be inappropriate for widespread disease. Some patients with localized, resistant plaque psoriasis may benefit from this form of therapy. Further studies are required to determine the most appropriate use of this laser in the treatment of psoriasis.

Scars

PDL treatment is able to alter argon laser-induced scars, which are often erythematous and hypertrophic. By using optical profilometry measurements, researchers have shown a trend toward more normal skin texture as well as reduction in observed erythema. This work was extended to the treatment of other erythema-tous and hypertrophic scars using objective measurements. Investigators have noted that clinical appearance (color and height), surface texture, skin pliability, and pruritus could all be improved.

Dierickx, Goldman and Fitzpatrick (Die-rickx et al. 1995; Goldman and Fitzpatrick 1995), treated 15 patients with erythematous/hyper-trophic scars and obtained an average improvement of 77% after an average of 1.8 treatments. In another study 48 patients were treated with the PDL. Scars less than 1 year old responded better than those more than 1 year old. Facial scars also showed greater improvement, with an

88% average improvement with total resolution in 20% of scars after 4.4 treatments.

For persistent scars, combinations of intra-lesional corticosteroid injections, steroid impregnated tapes, and laser therapy may be necessary. Two studies have compared the effects of PDL treatment with other treatment modalities, particularly intralesional steroids. One study compared PDL treatment alone with laser therapy combined with intralesional corticosteroid treatment. Both treatment arms produced improvement in scars; there was no significant difference between the two treatments. Another study compared scar treatment with intrale-sional corticosteroids alone, combined steroids and 5-fluorouracil, 5-fluorouracil alone, or PDL treatment using fluences of 5 J/cm2. All treatment areas were improved compared to baseline. The highest risk of adverse sequelae occurred in the corticosteroid intralesional group.

Other studies, however, have failed to demonstrate substantial effects of the PDL on scars. In one study, laser-treated scars were assessed using remittance spectroscopy. Although a discrete decrease in redness of the scars was reported clinically, this was not confirmed by objective data. Another prospective single blind randomized controlled study, compared laser treatment with silicon gel sheeting and controls. Although there was an overall reduction in blood volume, flow and scar pruritis over time, there were no differences detected between the treatment and control groups. Finally investigators in another study treating old and new scars with the PDL with fluences of 5-6 J/cm2, were unable to demonstrate any statistical differences between treatment and control sites by photographic assessments or surface profile measurements. However, they did notice a significant improvement in scar pruritis in the laser-treated group as compared to the control group.

There are now multiple studies assessing the effects of the PDL in the treatment of scars. Although results are conflicting, particularly when controlled studies are performed, it would appear that in some cases laser therapy can be beneficial in the treatment of such scars. It is likely that vascular-induced erythema and pruri-

tis are the two parameters that are most likely to significantly improve with this treatment.

Verrucae

Verrucae, although not truly vascular lesions, have been treated with lasers. The PDL may have potential benefits in the treatment of warts. The laser light can selectively obliterate blood vessels within the verrucae; it may also destroy the most rapidly replicating cells carrying the virus. The ability to focus the energy of the light directly on to the lesional vasculature minimizes injury to healthy skin. The PDL has been reported as successful for the treatment of resistant viral warts. In one study, 28 of 39 patients experienced resolution of the warts following an average of only 1.68 treatments with fluences of 6.5-7.5 J/cm2. Warts need to be pared aggressively prior to treatment; higher fluences of 8.5-9.5 J/cm2 may be necessary.

Although the PDL has been reported to be effective in the treatment of plantar warts, plantar warts appear relatively resistant to the laser treatment. In another study, 7 patients (6 plantar, 1 periungual) with recalcitrant verrucae were treated. Although there was a partial response, none of their patients experienced complete resolution of their lesions. Others treated 96 warts with only a 48% complete clearance over an average of 3.4 treatments. A study using the KTP laser at 532 nm showed complete clearing of warts in 12 of 25 patients with resistant verrucae.

There has been only one prospective randomized controlled trial comparing PDL therapy with conventional therapy in the treatment of verrucae. Forty adult patients were randomized to receive either PDL therapy (585 nm) or conventional therapy. Up to four treatments were provided at monthly intervals. One hundred and ninety four warts were evaluated. Complete response was seen in 70% of the warts treated with conventional therapy and in 66% of those in the PDL group. Thus, there was no significant difference in the treatment responses.

It should be noted that although PDL treatment is widely used in the treatment of viral warts, there are no randomized controlled studies to demonstrate the superiority of this treatment over conventional methods. While undoubtedly effective in selected patients, it is important to note that there is a significant spontaneous remission rate in viral warts. More studies with controlled trials are required.

Treatment of Other Cutaneous Vascular Lesions

Spider angiomas are easily, and successfully, treated with lasers (Table 2.3). In addition, both the pulsed dye and KTP lasers have been shown to be safe and efficacious in children. The majority of spider angiomas will clear with one or two treatments without significant complications.

Venous lakes, angiokeratomas, and cherry angiomas have all been reported to respond well to laser therapy. Tumorous outgrowths of vascular tissue such as pyogenic granulomas, nodular hemangiomas, and Kaposi's sarcoma are likely to have only a partial response owing to the limited depth of penetration of the emitted laser beam.

Areas of persistent erythema, as seen in patients with rosacea and postrhinoplasty, can be treated with the PDL (Fig. 2.12). More treatments are required than for individual telan-giectasias. Purpura can be a problem when the PDL is utilized. Purpura can be diminished by using PDL-emitted longer pulse durations. In addition, the first one or two laser treatments often induces a rather spotty lightening on a background erythema, necessitating further treatment.

Matt telangiectasia seen in CREST syndrome (calcinosis, .Raynaud's phenomenon, esophageal motility disorders, sclerodactyly, and Telangiectasia) can respond well to treatment (Fig. 2.13). Poikiloderma of Civatte, with its combination of pigmentation and telangiecta-sia seen on the lateral neck, can respond to PDL therapy. Low fluences (approximately 4 J/cm2) should be used because of the high incidence of posttreatment hypopigmentation and possible scarring seen in this disorder. Telangiectasia

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