Long-pulsed Nd : YAG laser: does it give clinical benefit on the treatment of resistant telangiectasia?

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1 DOI: /j x JEADV ORIGINAL ARTICLE Long-pulsed Nd : YAG laser: does it give clinical benefit on the treatment of resistant telangiectasia? J.H. Lee,* S.Y. Na, M. Choi, H.S. Park, S. Cho Department of Dermatology, Seoul National University Boramae Hospital, Seoul, Korea *Correspondence: J.H. Lee. bell711@hanmail.net Abstract Background Long-pulsed Nd : YAG laser has been used in treating larger and deep-seated leg veins. Objective This study investigated the effectiveness and safety of long-pulsed Nd : YAG laser to treat alae nasae and nasal tip telangiectasia. Methods Twelve patients were evaluated in a prospective IRB approved study. They had a history of previous unsatisfactory treatments with pulsed dye laser and or intense pulsed light for their telangiectases on alae nasae and tip (4 12 times, average 5.8 times). All patients underwent a single treatment session using long-pulsed Nd : YAG laser. Photographic images were taken. At 12-week follow-up, two independent physicians evaluated the percentage of vessels cleared, and patients were asked to rate their satisfaction with the procedure. Results Five men and seven women were enrolled (aged 43 ± 5.8 years). Total clearance of vessels was 78.3%. The number of vessels in diameter of 0.1 mm was reduced by 61.1% and that of vessels in diameter of mm decreased by 92.2% on the average at 12-week follow-up. Eleven of 12 patients were very satisfied with the clinical results. One patient rated as satisfied due to hyperpigmentation after the treatment, which improved at 12-week follow-up. Conclusion Long-pulsed Nd : YAG laser can be considered as another effective and safe treatment modality for stubborn telangeictasia even on face, if applied cautiously. Received: 17 April 2011; Accepted: 30 August 2011 Conflict of interest None declared. Funding source None. Introduction Lasers emitting green and yellow range of light spectrum have been considered as a criterion standard in the treatment of various vascular disorders, taking advantage of high oxyhaemoglobin absorption peaks at their wavelengths. 1 3 However, these lasers can penetrate skin only 1 2 mm deep and this property has been a major drawback for eliminating deeper vascular lesion effectively. 4,5 Long-pulsed Nd : YAG laser has been proven effective mainly in the treatment of leg veins for its deeper penetration into skin (6 10 mm) and homogeneous heating of large vessel walls. 6 8 Recently, several studies have paid their attention to the treatment of various vascular disorders other than leg vein using long-pulsed Nd : YAG laser such as portwine stain, haemangioma, angiokeratomaandvenouslake,andtheyreportedpromisingresults Facial telangiectasia is one of very annoying clinical manifestations and sometimes frustrates many patients. 1,8 It appears as small dilated vessels and these vessels are not located deep in the dermis. Therefore, most of facial telangiectasia can be treated very successfully by conventional light-based therapies such as pulsed dye laser or intense pulsed light. However, telangiectasia on alae nasae and nasal tip might be a different issue. 12 This study investigated clinical effectiveness and safety of longpulsed Nd : YAG laser to treat telangiectasia on alae nasae and tip. Materials and methods Patients Twelve patients (aged 43 ± 5.8 years, M F = 5 : 7) with telangiectasia on alae nasae and tip were evaluated in a prospective IRB approvedstudy.allpatientshadbeentreatedwithpulseddyelaser and or intense pulsed light several times (4 12 times, 5.8 ± 1.2 times) for their telangiectasia on alae nasae and tip, with unsatisfactory results (Table 1). Patients with pregnancy or lactation, a history of deep vein thrombosis, connective tissue disease,

2 2 Lee et al. Table 1 Summary of previous treatments which patients had received before the enrollment in this study. All patients had received several treatment sessions with pulsed dye laser (PDL) and or intense pulsed light (IPL) for their telangiectasia Patient no. Previous treatment PDL IPL Total Tx no Average SD predisposition to hypertrophic scars and keloids, oral isotretinoin treatment in the previous 2 months or immunosuppression were excluded. Treatment methods All patients underwent a single treatment session using longpulsed Nd : YAG (MultiFlex, Ellipse A S Ò, Denmark). Surface cooling was supplied by a focused stream of cool air (SoftCoolÔ) to reduce pain during treatments and minimize the risk of possible epidermal damage. Before applying laser on the treatment site, dilated vessel diameters were measured with a transparent vein gauge provided with the laser machine. For vessel diameter of 0.1 mm, the treatment parameter was set as followed: 8.0 ms of pulse width and J cm 2 of fluence with 1.5 mm spot. The larger dilated vessels of mm in diameter were treated with 12.0 ms pulse width and J cm 2 of fluence using 1.5 mm spot. Before laser irradiation, refrigerated optical coupling gel was applied evenly on the treated site. When the vessel was treated with the laser, the immediate vessel responses were meticulously tracked down. If the vessel immediately vanished, the next laser shot was applied at the point where the vanishing point stopped. If the vessel did not show any response at the first shot, the fluence was raised to the next level (10 20 J cm 2 higher in general) and the laser firing point was moved up by about 1 2 mm from the initial spot to avoid stacking laser pulses. Patients were examined at 1 and 12 weeks after the treatment. Evaluation Pain score was checked using visual analogue scale (VAS : no pain; 10: unbearable pain) right after the treatment. At 1 week follow-up, possible adverse responses were checked. Photographic images were taken, and two independent physicians counted the vessels depending on vessel size at the initial visit and at 12-week follow-up. At 12-week follow-up, the patients were asked to rate their satisfaction with the results (1 = not satisfied, 2 = little satisfied, 3 = somewhat satisfied, 4 = satisfied, 5 = very satisfied). Results All 12 patients completed this study. Pain score during the procedurewasmarkedas2 6(datanow shown). A total of treated vessels were 162, and overall, 78.3% clearance was observed at 12-week follow-up. Vessels in diameter of 0.1 mm counted 72 at the initial visit and they went down to 28 at 12-week follow-up (mean reduction 61.1%). The number of vessels in diameter of mm was reduced from 90 to 7 (mean reduction 92.2%) (Table 2, Fig. 1). Eleven patients did not report any discomfort and side effects at 1-week follow-up. One patient complained of vesicles 1 day after the treatment and she was treated with topical steroid (hydrocortisone 1% cream) for 1 week. At the final follow-up, postinflammatory hyperpigmentation on the site of previous vesicles was observed, although it faded a little bit (Fig. 2). For patients satisfaction with the treatment, eleven patients rated very satisfied and the box of satisfied was checked by the patient who had experienced vesicles (Table 3). Table 2 Results at 12 weeks after laser treatment. Total % reduction of all treated vessels was 78.3%, which was much higher than other previous reports. The clearance of larger vessels in diameter of mm was measured by more than 90%. Smaller vessels in diameter of 0.1 mm appeared less responsive than larger ones Patient no. Before Tx 12 weeks after Tx 0.1 mm mm 0.1 mm mm Average SD SUM % Reduction 61.1% 92.2% Total % reduction 78.3%

3 Long-pulsed Nd : YAG laser for facial telangiectasia 3 (a) (a) (b) (b) Figure 1 Patient no. 8. A long arrow shows a pigmented nevus on cheek. Dilated vessels (small arrows) did not recur at 12-week follow-up after the treatment. The telangiectasia on alar base was not treated. (a) Before treatment and (b) 12 weeks after the laser treatment. Discussion This study showed excellent clinical outcomes after only one session of laser treatment on telangiectases on alae nasae and nasal tips. Especially, the patient (No. 10 in Table 1) had been treated at our own department for her facial telangiectasia before she was enrolled in this study. After three times of pulsed dye laser and one time of intense pulsed light treatment, her bothering telangiectasia on the cheeks and forehead were almost gone. However, telangiectasia on her alae nasae and tip was not treated satisfactorily enough. She was enrolled in this study, and long-pulsed Nd : YAG laser was applied on her obstinate telangiectasia. The result was outstanding, except unwanted vesicles on one site of alar bases. The rest of 11 patients enrolled in this study had been treated at other local clinic and visited our department for the resisting vessels on alae nasae and tip. They were all content with the treatment result. Facial telangiectasia is usually treated at ease with the help of vascular lasers, 4,13 but telangiectasia on alae nasae and nasal tip seemed different problems. McCoy 14 mentioned that telangiectasia on the alae nasae and tip was less efficacious after his 5-year experiences of treatments in 570 patients with facial telangiectasia, which was the same finding as this study. The reason why these dilated vessels do not response well like others on the face may be speculated in their anatomical specificities. Dilated vessels of most Figure 2 Patient no. 10. She had a very troublesome telangiectasia on her nasal alae. She was treated with long-pulsed Nd : YAG laser and she experienced vesicles on alar bases. She was instructed to put on topical steroid for 1 week and vesicles subsided. At 12-week follow-up, hyperpigmentation on the site of previous vesicles (small arrows) was observed. However, thick vessels on other site (long arrows) improved. (a) Before treatment and (b) 12 weeks after the laser treatment. telangiectases are venules, which are easily collapsed. 2,8 Meanwhile, those on alae nasae and tip are mostly composed of arterioles directly branched from lateral nasal artery. 15,16 Arterioles are more resistant to be obliterated than venules by the same insult. 15,17 Therefore, telangiectasia on alae nasae and tip appears to be less responsive, and tends to be recanalized within a couple of weeks after laser treatment. Long-pulsed Nd : YAG laser can heat up Table 3 Patient satisfaction with the laser treatment. Eleven of 12 enrolled patients rated as very satisfied Satisfaction Patient (12 total) Not satisfied 0 Little satisfied 0 Somewhat satisfied 0 Satisfied 1 Very satisfied 11

4 4 Lee et al. entire vessel walls and coagulate them with high fluence unlike pulsed dye laser and intense pulsed light, 17 and this might lead satisfactory clearance of telangiectases in this study. As the results demonstrated, the clearance of larger vessels was higher (more than 90%) than smaller ones (about 60%). This finding correlates with other reports regarding leg veins. 5 7,9 Very high fluence of more than 150 J cm 2 must be applied due to low absorption coefficient in blood at 1064 nm. 6 Water is a competing chromophore of light at the wavelength of 1064 nm, although this wavelength is absorbed in oxyhaemoglobin, still abouttentimeshigherthaninwater. 8,12 Therefore, higher risk of potential collateral damage around vessels (such as burns) and pain during the procedure should be kept in mind when using this laser for vessels. No unbearable pain was marked in this study, and all patients were well tolerated. Before and after each laser shot, we held a handpiece for several seconds, so that cold air stream fully cooled down the treated field and carefully checked the vessel response, like described above. This waiting-and-see technique might help lessen severe pain during the laser exposure and prevent unexpected epidermal damage as well. One patient experienced postinflammatory hyperpigmentation on the site of vesicles and this epidermal damage may be related with the pulse stacking. As described in the Materials and methods section, if there is no response at the laser exposed site, the next laser shot should not be repeated at the same spot. During the procedure, unexpected pulse stacking happened in this patient. The sites on which the patient experienced vesicles were alar bases, and we did take the trouble when shooting the laser there. When using long-pulsed Nd : YAG laser, the pulse stacking might be extremely dangerous, because this laser is set at very high fluence. 12 Recently, the laser machine emitting dual wavelength (595 and 1064 nm) was introduced. Pulsed dye laser works first on haemoglobin and it turned laser irradiated oxyhaemoglobin into methemoglobin, which absorbs following Nd : YAG laser much effectively. The sequential delivery of 595 and 1064 nm wavelength was expected to bring synergistic effects on vessel treatment, reducing the required fluence of following Nd : YAG laser. 18,19 The split face study was conducted to compare the treatment efficacy of dual laser and pulsed dye laser or long-pulsed Nd : YAG laser alone on facial telangiectasia. 18 The diameter of targeted vessels was <0.6 mm, and the skin type of enrolled patients was I III according to Fitzpatrick. 18 Pulse dye laser was irradiated first using a fluence of 10 J cm 2, a pulse duration of 10 ms and a 7 mm spot size handpiece and after 100 ms of delay, Nd : YAG laser was irradiated at 70 J cm 2 of fluence of 15 ms duration. Pulse dye laser or long-pulsed Nd : YAG laser alone was applied with the same parameter like above, and dual laser treatment yielded much better results. 18 Combining pulsed dye and Nd : YAG laser was shown to treat leg veins well by other researchers too. 19 The idea of dual laser treatment is acceptable and agreeable. However, pulse dye laser with a fluence of 10 J cm 2, 10 ms pulse duration and a 7 mm spot can treat most of facial telangiectaisa effectively. 12,14 The combination of long-pulsed Nd : YAG with lower fluence might give additional benefits on telangiectasia, but the optimal parameter of this new dual laser application on vascular lesion needs to be further evaluated. This study has its limitation that it was not a randomized controlled study and we did not perform direct comparison between pulsed dye laser intense pulsed light and long-pulsed Nd : YAG. However, all enrolled patients got through unsatisfactory results after prior several treatment sessions of pulsed dye laser and or intense pulsed light, and long-pulsed Nd : YAG laser produced excellent results. From this point of view, it can be said that long-pulsed Nd : YAG laser provides encouraging results in unmanageable facial telangiectasia with minimal side effects, if applied cautiously. This study has its own value over other previous reports 8,9,12,20,21 in that it was performed on the patients with telangiectasia unresponsive to previous multiple treatments of pulsed dye laser and or intense pulsed light. Long-pulsed Nd : YAG laser is not the first choice of treatment for facial telangiectasia. However, it can be considered as another treatment modality for stubborn telangeictasia even on face. References 1 Cassuto DA, Ancona DM, Emanuelli G. Treatment of facial telangiectasias with a diode-pumped Nd:YAG laser at 532 nm. 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5 Long-pulsed Nd : YAG laser for facial telangiectasia 5 13 Ross EV, Meehan KJ, Domankevit Y, Trafeli JP, Annadono J, Jacoby M. Use of a variable long-pulse Alexandrite laser in the treatment of facial telangiectasia. Dermatol Surg 2010; 36: McCoy SE. Copper bromide laser treatment of facial telangiectasia: results of patient treatment over five years. Lasers Surg Med 1997; 21: Eivazi B, Cremer HJ, Mnagold C, Teymoortash A, Wiegand S, Werner JA. Hemangiomas of the nasal tip: an approach to a therapeutic challenge. Int J Ped Otorhinolaryn 2011; 70: Nakajima H, Imanishi N, Aiso S. Facial artery in the upper lip and nose: anatomy and a clinical application. Plast Reconstr Surg 2002; 109: Kauvar ANB, Khrom T. Laser treatment of leg veins. Semin Cutan Med Surg 2005; 24: Karsai S, Roos S, Raulin C. Treatment of facial telangiectasia using a dual wavelength laser system (595 nm and 1,064 nm): a randomized controlled trial with blinded response evaluation. Derm Surg 2008; 34: Trelles MA, Weiss R, Moreno-Moragas J, Romero C, Velez M, Alvarez X. Treatment of leg veins with combined pulsed dye and Nd:YAG lasers: 60 patients assessed at 6 months. Laser Surg Med 2010; 42: Sarradet DM, Hussain M, Goldberg DJ. Millisecond 1,064-nm neodymium:yag laser treatment of facial telangiectases. Dermatol Surg 2003; 29: Eremia S, Li CY. Treatment of face veins with a cryogen spray variable pulse width 1064 nm Nd:YAG laser: a prospective study of 17 patients. Dermatol Surg 2002; 28: