Treatment of Purpura With Lasers and Light Sources

November 2013 | Volume 12 | Issue 11 | Original Article | 1219 | Copyright © 2013

Laurel M. Morton MD,a Kevin C. Smith MD FRCPC,b Jeffrey S. Dover MD FRCPC,a,c,d,e Kenneth A. Arndt MDa,d,e,f

aSkinCare Physicians, Chestnut Hill, MA
bNiagara Dermatology and Skin Care Centre cSection of Dermatologic Surgery and Oncology, Department of Dermatology, Yale University School of Medicine, New Haven, CT
dDepartment of Dermatology, Geisel School of Medicine at Dartmouth, Hanover, NH
eDepartment of Dermatology, Brown Medical School, Providence, RI
fDepartment of Dermatology, Harvard Medical School, Boston, MA

Abstract

The potential for bruising is a frequent concern for patients undergoing minimally invasive procedures, particularly injection-based soft tissue fillers and botulinum toxin type A. Decreasing the risk of this side effect with good technique and careful patient selection is key, but interventions that quicken the resolution of bruising are also helpful. Many practitioners have employed the theory of selective photothermolysis, using laser and light devices, to target hemoglobin and its breakdown products to speed time to bruise resolution. 585-595nm pulsed dye, pulsed 532nm and 1064 nm long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and intense pulsed light may be utilized with best results achieved when treatment is performed 1-2 days after the appearance of purpura. Specific therapy recommendations, side effects and contraindications will be addressed in this review.

J Drugs Dermatol. 2013;12(11):1219-1222.

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INTRODUCTION

In 2012, 13 million minimally invasive cosmetic procedures were performed in the U.S., an increase of 6% compared to 2011. The most popular interventions are injection-based, particularly use of soft tissue fillers and botulinum toxin type A.1 In comparison, the number of invasive cosmetic surgical procedures decreased by 2% in 2012.1 The reasons patients prefer minimally invasive methods to surgery include their convenience and ease, decreased risks and side effects and significant but sometimes elusive effects. The private nature of these treatments and patient satisfaction with them is significantly impaired when bruises result. One of the most frequent concerns for new and return patients undergoing injection-based cosmetic procedures is the potential for bruising. Bruises are one of the most common complications associated with botulinum toxin2,3 and soft tissue filler injections3,4. While bruises have no long-term negative health effects, they can be emotionally distressing for patients and can interfere with work and social obligations. Patients usually do not want others to realize they have undergone a cosmetic procedure and all individuals wish to avoid bruising.

An experienced practitioner is often able to reduce the risk of bruising by avoiding visible superficial vessels and injecting into the superficial subcutis, which contains fewer vessels. It should be noted that hyaluronic acid fillers are at times purposely placed in the superficial reticular dermis, which has been verified by ultrasound analysis.5 Using side lighting and cleansing the skin with alcohol may make it easier to see superficial dermal vessels. The fanning and cross hatching techniques have been shown to increase bruising risk in at least one study and ought to be avoided where possible.6 Also helpful is careful patient selection and screening for medications associated with decreased ability of the blood to clot such as aspirin, other non-steroidal anti-inflammatory drugs, warfarin, clopidogrel and alcohol consumption. Certain herbal supplements including, but not limited to garlic, ginger, ginkgo, ginseng, omega-3 fatty acids, St. John’s wort and Vitamin E may also increase risk of bleeding and subsequent bruising. Post-treatment pressure to injected areas will often prevent or minimize bruising. Yet, even with every precaution, bruising can happen.

When bruises do occur there are several interventions to decrease the amount of time to their resolution. Multiple medical therapies have been reported including application of hydrogen peroxide 15% carbamide gel under occlusion,7 perioperative oral and topical Arnica Montana,8,9 topical Vitamin K9 and bromelain3. However, their effect is unpredictable and minimal in some cases. More marked improvement is achieved by employing laser and light-based procedures that target the chromophores present in bruises. These include the 585-595nm pulsed dye laser (PDL), pulsed 532nm light, 1064 nm longpulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and intense pulsed light (IPL). (Figure 1)

Scientific Theory

Bruising is the clinical representation of extravasated red blood cells resulting from compromise of the skin’s vasculature. Red blood cells contain hemoglobin, an oxygen-transporting, tetrameric protein. Oxy-hemoglobin is red and absorbs a broad spectrum of wavelengths. Absorption peaks for oxy-hemoglobin include 418nm, 542nm and 577nm.10 (Figure 2).

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