Transcutaneous laser treatment of leg veins

Abstract

Leg telangiectasias and reticular veins are a common complaint affecting more than 80% of the population to some extent. To date, the gold standard remains sclerotherapy for most patients. However, there may be some specific situations, where sclerotherapy is contraindicated such as needle phobia, allergy to certain sclerosing agents, and the presence of vessels smaller than the diameter of a 30-gauge needle (including telangiectatic matting). In these cases, transcutaneous laser therapy is a valuable alternative. Currently, different laser modalities have been proposed for the management of leg veins. The aim of this article is to present an overview of the basic principles of transcutaneous laser therapy of leg veins and to review the existing literature on this subject, including the most recent developments. The 532-nm potassium titanyl phosphate (KTP) laser, the 585-600-nm pulsed dye laser, the 755-nm alexandrite laser, various 800-983-nm diode lasers, and the 1,064-nm neodymium yttrium-aluminum-garnet (Nd:YAG) laser and various intense pulsed light sources have been investigated for this indication. The KTP and pulsed dye laser are an effective treatment option for small vessels (<1 mm). The side effect profile is usually favorable to that of longer wavelength modalities. For larger veins, the use of a longer wavelength is required. According to the scarce evidence available, the Nd:YAG laser produces better clinical results than the alexandrite and diode laser. Penetration depth is high, whereas absorption by melanin is low, making the Nd:YAG laser suitable for the treatment of larger and deeply located veins and for the treatment of patients with dark skin types. Clinical outcome of Nd:YAG laser therapy approximates that of sclerotherapy, although the latter is associated with less pain. New developments include (1) the use of a nonuniform pulse sequence or a dual-wavelength modality, inducing methemoglobin formation and enhancing the optical absorption properties of the target structure, (2) pulse stacking and multiple pass laser treatment, (3) combination of laser therapy with sclerotherapy or radiofrequency, and (4) indocyanin green enhanced laser therapy. Future studies will have to confirm the role of these developments in the treatment of leg veins. The literature still lacks double-blind controlled clinical trials comparing the different laser modalities with each other and with sclerotherapy. Such trials should be the focus of future research.

Guidelines of care for vascular lasers and intense pulse light sources from the European Society for Laser Dermatology

“…The longer the wavelength, the deeper is its penetration into the skin . For example, Nd:YAG lasers (1064 nm) can penetrate millimetres below the epidermis.…”

“…Thermal energy produced within the red blood cells diffuses through the blood and damages the walls of the vessels, producing thrombosis. Accordingly, different laser pulse lengths must be considered taking into account the blood flow and the different diameters of the vessels . Since large structures require more time for sufficient heat absorption, longer laser‐pulse durations have to be used.…”

“…Large spot sizes are recommended to increase the heated volume of the blood. Furthermore, these tend to have deeper dermal penetration at equal radiant exposure values without increasing epidermal damage …”

“…Spatially selective cooling can be achieved by active cooling using a cryogen spray, cold sapphire contact handpieces or air pre‐cooled and blown onto across the skin surface. These devices promote rapid epidermal cooling to lower temperatures without affecting the target …”

Management of vascular lesions using advanced laser technology

“…The use of this laser device was also proposed by other researchers for the treatment of deeper vascular lesions, who also underlined that to avoid overheating of the skin and textural changes, the use of a cooling devise is necessary [61] . The Nd:YAG laser is also a treatment of choice for telangiectasia of darker skin (Fitzpatrick IV-V), as the long wavelength enables deep penetration but minimum absorbance by melanin [62] . In general, the basic principles for laser application on linear or arborising telangiectasias concern the targeting of the vessel (vessel tracing method), the use of the appropriate beam diameter (seeking to achieve deeper penetration and reduce scattering), and the use of variable pulse range depending on vessels' size.…”