LASERS: CAN THEY TREAT SPIDER VEINS? Steven E. Zimmet, MD

LASERS: CAN THEY TREAT SPIDER VEINS? Steven E. Zimmet, MD

No conflicts of interest DISCLOSURES

YES!

WHY USE LASERS FOR LEG VEINS? Patient s Perception Less Painful Newer technology Must be better Needle phobic Don t need compression Patient s Experience Previous sclero painful (HS) Poor results Physician May not offer sclerotherapy/poor technique May own lasers Marketing reasons Sclero-resistance Unable to cannulate

ADVANCES IN TECHNOLOGY Multiple wavelengths/devices available Deeper penetrating wavelengths Longer pulse durations Better cooling methods

LASER-TISSUE INTERACTION Skin type Wavelength Pulse duration Spot size Fluence Cooling Knowledge of laser physics, proper patient selection, patient safety, familiarity with laser device are important

WAVELENGTH Target absorption Wavelength that is better absorbed by the target (hemoglobin) than surrounding chromophores (melanin, water) Target location/depth Penetration to the full depth of the target blood vessel Longer wavelengths penetrate deeper and enable treatment of darker skin types 532 nm ~0.5 mm 1064 nm ~several mms

Target absorption Wavelength that is better absorbed by the target than surrounding chromophores (melanin, water) Target location/depth Penetration to the full depth of the target Longer wavelengths penetrate deeper and enable treatment of darker skin types 532 nm ~0.5 mm 1064 nm ~several mms WAVELENGTH

PULSE DURATION Select pulse duration that yields significant injury to the targeted vasculature without damaging surrounding tissue Thermal relaxation time Time for 50% of heat to be dissipated to surrounding tissue If pulse width equal to or less than TRT of target, thermal damage confined to target If pulse width > TRT, thermal damage outside target Depends on target size

EXTENDED THEORY OF SELECTIVE PHOTOTHERMOLYSIS Non-uniform targets may require longers PD Vessels have stronger and weaker absorbing targets (blood, vessel wall) May require PD longer than expected TRT to achieve successful closure Altshuler et al. Lasers in surgery and medicine. 29. 416-32, 2001

SPOT SIZE Small spot size- more light scattering, less penetration Large spot size maximizes depth of penetration Reduced sideways scattering Large spot size important for treating deeper lesions Need increased laser power output to maintain same energy fluence Match to target

LASER PARAMETERS Veins < 1 mm 585-1064 nm 1-25 msec Small spot size Veins 1-3 mm 755-1064 nm 20-100 msec Larger spot size

FLUENCE Amount of energy (J/cm2)needs to adequately heat entire vein without damaging collateral tissue Higher the absorption by target the lower the required energy 585 nm- high absorption in blood and may require 4-6 J/cm2 1064 nm- much lower absorption coefficient in blood with treatment ranges from 100-150 J/cm 2

COOLING Cooling is essential Reduces pain and risk of injury Enables higher fluences Cooling may be pre, parallel, or post Cooling methods Cryogen spray Chilled air Contact cooling Combination

LASER: CONTRAINDICATIONS Tanned skin (fake or real) Collagen vascular disease (lupus, etc) Photosensitizing medications Accutane within 6 months History of true keloid Pregnancy Ever been treated with gold Difficult personality/unreasonable expectations

LASER SAFET Y & COMPLICATIONS Cutaneous complications Hyperpigmentation or hypopigmentation Scarring HSV Matting Ocular Direct or Indirect Inappropriate use of goggles Fire Electrical shock

LASER SAFET Y Know how to skin type your patient Always use cooling (contact, Zimmer) Eye protection for all Sign on door Know and check settings Know your clinical endpoints Vessel darkening followed by urtication Vessel spasm Test spots When Where How

LASER TREATMENT OF LEG VEINS Initial reports about new technologies tend to report high levels of success and low complication rates Long-pulsed alexandrite lasers have recently been applied to the treatment of leg telangiectasia and reticular veins with excellent results 1 Initially very encouraging results utilizing pulsed light to treat leg veins; almost 80% of patients achieved 75-100% clearance. 2 However, with more experience, they stated sclerotherapy is more efficacious and less painful than laser. 3 1. AAD Annual Meeting Syllabus, 2001 2.Goldman & Eckhouse. Dermatol Surg Oncol. 1996;22:323-30. 3.Goldman. Derm Surg 2002:10:969.

WHY LASERS AREN T GREAT FOR LEG VEINS Veins are at variable depths Veins tend to be deeper Difficult to deliver adequate photons to deeper aspect of leg veins We probably generally don t treat all visible veins with laser modalities Doesn t address underlying veins at all Lasers are more painful than sclerotherapy

LASER: CONCLUSIONS Treat underlying reflux based on evaluation Treat proximal-distal, large-small Sclerotherapy is gold standard Laser is more expensive, more painful, less effective Laser treatment of facial veins is more effective than leg veins Vein size, depth and lack of underlying reflux Consider primarily in small telangiectasias Veins resistant to sclerotherapy Veins too small to be injected Patient is allergic to available sclerosants