diode, and Nd:YAG have been recognized to be most effective for deeper veins.4
In terms of PDL, the 595-nm laser has traditionally been viewed as superior in treating leg veins than the original 585-nm laser.3 Studies also suggest a preference for treatments with longer pulse durations (typically 10 ms-100 ms) to target larger vessels and avoid common side effects, such as purpura, postinflammatory hyperpigmentation, and hemosiderin deposition (Meesters et al).7 Additionally, most studies with PDL used fluences in the 10 J/cm2 to 20 J/cm2 range, and demonstrated that higher fluences are associated with an increased incidence of hyperpigmentation.8
This case is unique in that, despite using the previously discredited lower wavelength PDL (585-nm) with a short pulse duration (0.5 ms) and a relatively low energy density (5.5 J/cm2), near 100% clearance was achieved with only a single treatment. In fact, the results prove to be more efficacious compared with previous reports that are more in line with the existing parameter consensus. The study by Garden reported perhaps the most favorable outcome, with 585-nm PDL at 1.5 ms and 16-20 J/cm2, having achieved 69±8% clearance after a single treatment.9 In comparison, our case achieved a higher clearance (nearly 100%) at a lower fluence (5.5 J/cm2).
Positive reports using the 595-nm PDL date back to 1997, when Hsia et al reported achievement of over 75% clearance in 64.7% of sites treated at 18 J/cm2 and in 52.9% of sites treated at 15 J/ cm2 after a single treatment with the 595-nm PDL with a pulse duration of 1.5 ms.6 Buscher et al reported similar results with an average 67.5% clearance rate using the same laser and pulse duration with fluences of 20 J/cm2 and 24 J/cm2; but with 2 treatments needed to achieve this level of clearance.10 In 2003, Tanghetti reported even better results, with over 75% clearance in 80% of treated lesions at 16 J/cm2 with a 40 ms pulse duration after a single treatment.11 However, there was an increase in the incidence of temporary purpura, likely secondary to the use of higher fluences. Compared with the collective results using the 595-nm PDL, our case was able to achieve a greater clearance rate with a much lower fluence and pulse duration, with no notable side effects.
Another unique aspect of this case is the employment of OCT. The use of OCT in dermatology is still novel but has already shown great promise. Recent studies have recommended OCT-based microangiography as a modality to provide high-resolution vascular maps, as well as direct visualization and quantitation of in vivo microvascular changes.12 Particularly in the treatment of telangiectasia, OCT has been reported to provide visualization of coagulation following intense pulsed light treatment, making OCT an attractive adjunct tool both before and after treatment.13 In this case, OCT imaging was useful in identifying treatment
In terms of PDL, the 595-nm laser has traditionally been viewed as superior in treating leg veins than the original 585-nm laser.3 Studies also suggest a preference for treatments with longer pulse durations (typically 10 ms-100 ms) to target larger vessels and avoid common side effects, such as purpura, postinflammatory hyperpigmentation, and hemosiderin deposition (Meesters et al).7 Additionally, most studies with PDL used fluences in the 10 J/cm2 to 20 J/cm2 range, and demonstrated that higher fluences are associated with an increased incidence of hyperpigmentation.8
This case is unique in that, despite using the previously discredited lower wavelength PDL (585-nm) with a short pulse duration (0.5 ms) and a relatively low energy density (5.5 J/cm2), near 100% clearance was achieved with only a single treatment. In fact, the results prove to be more efficacious compared with previous reports that are more in line with the existing parameter consensus. The study by Garden reported perhaps the most favorable outcome, with 585-nm PDL at 1.5 ms and 16-20 J/cm2, having achieved 69±8% clearance after a single treatment.9 In comparison, our case achieved a higher clearance (nearly 100%) at a lower fluence (5.5 J/cm2).
Positive reports using the 595-nm PDL date back to 1997, when Hsia et al reported achievement of over 75% clearance in 64.7% of sites treated at 18 J/cm2 and in 52.9% of sites treated at 15 J/ cm2 after a single treatment with the 595-nm PDL with a pulse duration of 1.5 ms.6 Buscher et al reported similar results with an average 67.5% clearance rate using the same laser and pulse duration with fluences of 20 J/cm2 and 24 J/cm2; but with 2 treatments needed to achieve this level of clearance.10 In 2003, Tanghetti reported even better results, with over 75% clearance in 80% of treated lesions at 16 J/cm2 with a 40 ms pulse duration after a single treatment.11 However, there was an increase in the incidence of temporary purpura, likely secondary to the use of higher fluences. Compared with the collective results using the 595-nm PDL, our case was able to achieve a greater clearance rate with a much lower fluence and pulse duration, with no notable side effects.
Another unique aspect of this case is the employment of OCT. The use of OCT in dermatology is still novel but has already shown great promise. Recent studies have recommended OCT-based microangiography as a modality to provide high-resolution vascular maps, as well as direct visualization and quantitation of in vivo microvascular changes.12 Particularly in the treatment of telangiectasia, OCT has been reported to provide visualization of coagulation following intense pulsed light treatment, making OCT an attractive adjunct tool both before and after treatment.13 In this case, OCT imaging was useful in identifying treatment
spots as well as monitoring changes with treatment. OCT was also helpful in identifying small interconnecting vessels surrounding the treatment spots that were otherwise invisible to the naked eye and dermoscopy. Identification and treatment of these accessory vessels are speculated to have greatly reduced the need for multiple treatment sessions. Our results suggest there is still much to learn about the use of PDL in treating telangiectasias of the lower extremities, and that the ideal parameters warrant further investigation. The excellent outcome achieved in this case was beyond expectation and, as such, necessitates more research in the application of low fluence, shorter wavelength PDL in the treatment of telangiectasia. Furthermore, the novel use of OCT in auxiliary imaging for identification of treatment spots as well as monitoring response at a microvascular level holds great potential for wider application.
DISCLOSURE
The authors have no conflicts of interest.
REFERENCES
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- Goldman MP, Fitzpatrick RF. Pulsed-dye laser treatment of leg telangiectasia: with and without simultaneous sclerotherapy. J Dermatol Surg Oncol. 1990. 16(4):338-44.
- Hsia JAL, Zelickson B. Treatment of leg telangiectasia using a long-pulse dye laser at 595 nm. Lasers Surg Med. 1997. 20(1):1-5.
- Meesters AA, Pitassi LH, Campos V, Wolkerstorfer A, Dierickx CC. Transcutaneous laser treatment of leg veins. Lasers Med Sci. 2014;29(2):481-492.
- Bernstein EF. The new-generation, high-energy, 595 nm, long pulse-duration, pulsed-dye laser effectively removes spider veins of the lower extremity. Lasers Surg Med. 2007;39(3):218-24.
- Garden AB. Treatment of leg veins with high energy pulsed dye laser. Lasers Surg Med. 1996;8:34.
- Buscher BA, McMeekin TO, Goodwin D. Treatment of leg telangiectasia by using a long-pulse dye laser at 595 nm with and without dynamic cooling device. Lasers Surg Med. 2000;27(2):171-175.
- Tanghetti E, Sherr E. Treatment of telangiectasia using the multi-pass technique with the extended pulse width, pulsed dye laser (Cynosure V-Star). J Cosmet Laser Ther. 2003;5(1):71-75.
- Baran U, Choi WJ, Wang RK. Potential use of OCT-based microangiography in clinical dermatology. Skin Res Technol. 2016;22(2):238-246.
- Ulrich M, Themstrup L, de Carvalho N, Manfredi M, Grana C, Ciardo S, Kästle R, Holmes J, Whitehead R, Jemec GB, Pellacani G, Welzel J. Dynamic optical coherence tomography in dermatology. Dermatology. 2016;232(3):298-311.
AUTHOR CORRESPONDENCE
Ali Rajabi-Estarabadi MD arajabi@med.miami.edu
