Excel V Roundtable

November 2013 | Volume 12 | Issue 11 | Features | 1231 | Copyright © November 2013

Macrene Alexiades-Armenakas MD PhD

Dermatology and Laser Surgery Center, New York, NY

I don’t ever encounter purpura with this laser because of the smooth pulse. After three treatments we had very nice clearing
Dover: This is a fantastic result done at 7Jcm2, 10mm, 10ms, and 10°C. Those are my favorite settings that Jeremy Green helped develop and have turned into my universal go to settings. This setting is very well tolerated and delivers a beautiful result. The pulse dye laser delivers a long pulse, which is a series of pulses stuck together. Theoretically the skin sees one broad pulse but it’s micro spikes where this is truly a top hat square pulse, which means its much smoother and delivers the energy more smoothly to the skin. You get less ruptured vessels at the same settings.
Alexiades: I tend to be a little bit more aggressive with matted telangiectasia and rosacea. In this case I would probably use a little bit higher settings (between 8 - 9Jcm2, 10mm, 10ms, and 10°C) but the problem is that universally the patient will get a hive live reaction and they will be very swollen – the advantage is that I can potentially clear the patient in one treatment as opposed to having to do more than one. I do adequately prepare the patients that they will be swollen, pre- and post, medicate them with antihistamines, and provide them with a topical corticosteroid.
Dover: What percentage of your patients, (Dr. Green), are swollen afterwards and what is your post care regiment?
Green:There is some edema with this or with pulse dye lasers but it is rare for me to see those results. My Miami patients prefer to come in for additional treatments than have welts or be swollen. I tell my patients to ice as often as they can and to use an extra pillow. If you are treating intra orbital that elevation while sleeping might save you a call back because they might get some edema in the morning. It hasn’t been studied but I tell my patients not to use a sauna or exercise during that day or the next day after treatment because theoretically anything that increases your heart rate and blood pressure will push blood through these vessels and could mitigate the effectiveness of the treatment.

Resistant Port Wine Stain

Alexiades: This is a fascinating case. This woman has a long standing PWS and she was one of the first patients treated at Mass General in the 1980’s with argon and other early technologies. As you can see, there is a veil of hypo pigmented scarring there. Subsequent to that time, she was in some of the original pulse dye laser sessions with purpura and has received hundreds of treatments in her lifetime. After having a very large number of long pulse dye laser therapeutic sessions, she stopped responding and remained in remission for a number of years. Recently, she noted a sudden worsening of her PWS. Having treated her for many years with PDL, I decided to use the Excel V with 7Jcm2, 7mm, 6ms, and 5°C. The intriguing aspect regarding her PWS is the faint blue dermal patch underlying the pink reticulated overlying vascular lesion.
This blue patch correlated with the distribution of her baseline PWS, which was something she hasn’t seen in about 20 years, demonstrating a deep-seated recrudescence of the PWS. After treating, you can see (I only treated the bright pink-red areas that you can see) you could see a hive like reaction that the patient attests exactly outlines her original PWS. The hive like reaction clearly demarcated the territory of the underlying blue vasculature, which is still present. After one treatment, this was by far (in the patients’ opinion) the best result she has ever seen in 30 years of treatments from any of the vascular lasers with which she has been treated. This was a phenomenal level of efficacy after a single treatment. Interestingly she continued to improve two months out and she will continue to come in for follow up photos until she no longer observes a benefit.
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