Overview of Laser Therapy for Common Vascular Lesions Naomi Travers

FEATURE ARTICLE 2.5 Contact Hours Overview of Laser Therapy for Common Vascular Lesions Naomi Travers ABSTRACT: Vascular irregularities, especially on the face, Rosacea can be a source of great cosmetic concern and, as such, Rosacea is a common and challenging condition to treat as constitute a significant portion of complaints presenting it is dynamic and progressive. Different classification sys- to dermatology clinics. Vascular lasers are an important tems have been used to categorize the multifactorial presen- tool in the treatment of these presentations, either as the tation of this complex condition. The discussion of vascular singular modality or as an adjunct to systemic therapies. laser treatment is most relevant to the most predominant Nurses and nurse practitioners play a crucial role in de- subtype, erythematotelangiectatic rosacea. Characterized livering vascular laser treatments, either independently by episodes of facial flushing, it involves primarily the cen- or under physician supervision. It is therefore incumbent tral faceVcheeks, nose, chin, and to a lesser extent, fore- upon them to understand appropriate clinical assess- head. Triggers may include heat, temperature changes, ment of the most common vascular issues and to have a alcohol, stress, strong emotion, and spicy foods (Crawford, firm grasp of the technical concepts that govern optimal Pelle, & James, 2004). Over time, select vessels become per- treatment of each class of lesion. The purpose of this article manently dilated so the individual has a persistent ‘‘ruddy’’ is to provide an overview of the anatomical composition complexion. Patients present with a spectrum of vessel of common vascular conditions, to outline the major tech- sizesVfrom small vessels that coalesce to create a gener- nical concepts of how vascular lasers function, and to alized pinkness to large telangiectasias that are visible to highlight how the laser nurse or nurse practitioner can the naked eye. At its worst, the condition presents as a fla- integrate both clinical assessment and technical theory grant network of visible blood vessels in some or all areas to effectively plan and/or execute a course of vascular of the central face on a background of erythema. Some pa- laser treatment. tients note an unpleasant burning or tingling sensation Key words: Cherry Angiomas, Port Wine Stains, Pulsed during a flare. Dye Laser, Rosacea, Spider Nevi, Vascular Laser It is important to inform patients that laser therapy has no impact on the underlying and still not fully understood ANATOMY OF VASCULAR LESIONS mechanism of flushing. Laser therapy is meant to reduce The vascular concerns that the dermatology nurse or nurse redness and visible vessels. The physical destruction of practitioner are most likely to see range considerably in size vessels not only improves appearance but also can im- and construct. Each class of lesion varies in the diameter, prove symptoms to the extent that it lessens the number configuration, and density of vessels involved. Location and of vessels dilating in response to flushing triggers. This severity also varies from patient to patient, and all of these provides only temporary relief of the condition, however, factors must be included in the treatment assessment. The and over a period of years, patients will likely require following is a summary of lesions commonly considered maintenance treatment. For many patients with the amenable to treatment with a vascular laser, either solely condition, the prospect of any type of treatment that will or in combination with medical treatment, the latter of minimize their facial redness is worth pursuing (Figure 1). which is beyond the scope of this article. Spider Nevi Naomi Travers, MSN, GNP Skin & Cancer Foundation, Westmead, These are focal clusters of dilated vessels that radiate out- NSW, Australia. ward from a central, larger arteriole. They generally appear The author declares no conflicts of interest. on the face, neck, and sometimes, the chest. Their presence Correspondence concerning this article should be addressed to Naomi Travers, MSN, GNP 28 Wandella Avenue, Northmead, may be associated with cirrhosis, especially alcoholic cir- NSW 2152, Australia. rhosis, or excessive estrogen levels but also occurs in approx- E-mail: [email protected] imately 15% of patients, including children, who have no DOI: 10.1097/JDN.0b013e3182a52609 underlying health issues. Although harmless, their red 280 Journal of the Dermatology Nurses’ Association Copyright © 2013 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. can reduce the conspicuous redness of these conditions, it is invaluable. BASIC LASER CONCEPTS Familiarity with the above lesions is essential for the nurse practitioner ordering treatment and for the nurse follow- FIGURE 1. (Left) Patient with rosacea before treatment with ing prescribed parameters. This becomes evident after a re- intense pulsed light (IPL) and after two treatments with IPL. view of the basic technical components of laser mechanics. Each treatment had two parameter sets: visible telangiectasias were treated with a 560-nm filter at a pulse width of The cornerstone concept of vascular laser technology is 20 ms and fluence of 25 J/cm2; generalized erythema was that of ‘‘selective photothermolysis,’’ which Kim, Roher, treated with the 560-nm filter, a pulse width of 10 ms, and and Geronemus (2005) succinctly define as ‘‘the ability to 2 fluence of 16 J/cm . Copyright Dr. Shawn Richards, Sydney, target a specific chromophore in the skin without damag- Australia. All permission requests for this image should be ing surrounding structures through the selection of proper made to the copyright holder. wavelength, pulse duration and fluence’’ (p. 11). Oxyhemoglobin is the operative chromophore in all color and solitary presence on the face make them a con- vascular lesions (Kim et al., 2005). Science has shown that spicuous cosmetic annoyance to many patients (Goldsmith, hemoglobin preferentially absorbs light energy to a max- Katz, Gilchrest, Leffell, & Wolff, 2012). imum degree at the wavelengths, in nanometers (nm), of 418, 542, and 577 nm and has a smaller peak between 700 Venous Lakes and 1100 nm. Lasers relevant to vascular treatments are de- These small, elevated lesions with a dark-purple, almost signed to emit wavelengths within the range of these peaks. blue color are found predominantly on the lips and, some- When hemoglobin absorbs light energy, the resulting heat times, the ears or face of older adults (see Figure 2). They is transmitted to the encasing vessel, causing intravascular are composed of dilated veins, either singularly or in a cluster coagulation and contraction of collagen (Wall, 2007). of such vessels, that appear as one papule on gross exam- ination (Kelly & Baker, 2012). Port Wine Stains (PWS) Also known as nevus flammeus, PWS are congenital cap- illary malformations that occur in approximately 0.3% of all newborn infants (Jasim & Handley, 2007). They come in virtually all shapes, sizes, and densities. They can occur anywhere on the body but are most common on the head and neck, where they are of particular cosmetic concern to parents and the socially aware patient. These pink to dark-red macules consist of a dense network of dilated capillaries in the superficial papillary and upper reticular dermis (Figure 3). If not treated, the involved skin can become thickened and even form nodules (Wall, 2007). Cherry Angiomas Cherry angiomas are round papules that may grow to sev- eral millimeters in size and are predominantly found on the trunk and extremities with increasing age. They are benign and generally asymptomatic, although larger ones may bleed with trauma (North & Kincannon, 2012). Other Lesions With Vascular Involvement Lasers may play an adjunct role in many other conditions FIGURE 2. Venous lake before and after treatment with that have a vascular component such as keratosis pilaris 595-nm PDL. First treatment was with a 7-mm spot at a pulse 2 rubra, poikiloderma of Civatte, acne scars, striae, and sur- width of 20 ms and fluence of 15 J/cm . A second treatment with a 7-mm spot, 10-ms pulse width, and 12-J/cm2 fluence gical scars. These presentations all have unique textural was required to clear some remaining lesion. Copyright Dr. issues that may be addressed by methods beyond the scope Shawn Richards, Sydney, Australia. All permission requests for of this article. However, to the extent that laser treatment this image should be made to the copyright holder. VOLUME 5 | NUMBER 5 | SEPTEMBER/OCTOBER 2013 281 Copyright © 2013 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. peaks mentioned (Kim et al., 2005). Although the 1064 nm is less absorptive than those emitted by the PDL, the en- hanced depth of penetration can play a role in treating deeper, recalcitrant vessels that may comprise a component of many common presentations such as PWS, telangiectasias, and hemangiomas. Similarly, the alexandrite laser, which emits light at 755 nm, is not the first choice for most vascular lesions because hemoglobin suboptimally absorbs light at this wavelength. However, it may play a role for deeper vessels that are better reached by this relatively long wavelength (Srinivas & Kumaresan, 2011; Wall, 2007). Finally, intense pulsed light (IPL), which is technically not a laser, can be an important tool in treating vascular lesions. IPL functions per the principles of selective photo- FIGURE 3. PWS before treatment and after three treatments thermolysis, but in a less precise way. Rather than emitting of PDL. Copyright Dr. Shawn Richards. All permission requests for this image should be made to the copyright holder. a solitary wavelength, IPL systems produce a spectrum of wavelengths from 500 to 1200 nm and come with a series of filters to manipulate exposure of wavelengths based on Macrophages gradually dispose of the nonviable tissue so skin type and lesion characteristics (Srinivas & Kumaresan, the vessels no longer fill with blood. 2011). Unlike laser systems, the IPL delivery device is placed As light waves pass through the skin, some are scat- directly onto the skin.

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