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.