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Copper Vapor Laser and Microsclerotherapy of Facial Telangiectases a Patient Questionnaire PAUL KENNETH THIBAULT, MBBS

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Copper Vapor Laser and Microsclerotherapy of Facial Telangiectases a Patient Questionnaire PAUL KENNETH THIBAULT, MBBS FEATURES PHLEBOLOGY Copper Vapor Laser and Microsclerotherapy of Facial Telangiectases A Patient Questionnaire PAUL KENNETH THIBAULT, MBBS BACKGROUND.Facial telangiectasia due to photodamage is a RESULTS. Both treatments were found to be effective but common disfiguring condition in modern society. Over the patients who received the combined treatment gave signifi- past 10 years yellow light laser photocoagulation has be- cantly higher ratings in effectiveness and overall satisfac- come the treatment of choice. tion. There was also non-significant reduction in the inci- OBJECTIVE.To compare the effectiveness of copper vapor dence of adverse effects reported by patients treated by the laser alone with combined microsclerotherapy and copper combined method. vapor laser in the treatment of facial telangiectases. CONCLUSION. Supplementary microsclerotherapy enhances METHODS. Two hundred thirty-nine consecutive patients the effectiveness of copper vapor laser photocoagulation were asked to complete a questionnaire evaluating the two of facial telangiectases. J Dermatol Surg Oncol 1994; different treatments; 180 (75%) patients responded. 20~48-54. elangiectases are ectatic dermal vessels visible age, other common etiological factors for facial telangiec- to the human eye. They usually measure 0.1 to tases are genetic predisposition, rosacea, surgical trauma 1 mm in diameter and may originate from arte- (eg, postrhinoplasty), topical or systemic steroid use, rioles, capillaries, or venules.' Clinically, telan- postmenopausal hormonal supplements, and radiation giectasesT can be classified into four types: linear, arboriz- therapy.' ing, spider and punctiform.2 Punctiform telangiectases The predominant presenting symptom of patients are frequently associated with collagen diseases and ge- with facial telangiectasia is cosmetic disfigurement and netic syndromes such as hereditary hemorrhagic telangi- therefore effective treatment should be relatively free of ectasia.' Although punctiform telangiectases are rela- adverse sequelae. In recent years laser photocoagulation tively uncommon, the other three types are frequently of facial telangiectases using yellow light wavelengths of encountered on the face. 577 to 585 nm has become the treatment of ~hoice,~-'O The most common etiological factor in the occurrence displacing earlier techniques using diathermy and argon of facial telangiectasia is chronic sun exp~sure.',~Invari- laser. Adverse sequelae such as pain, hypo- and hyper- ably, the presence of facial telangiectasia will be asso- pigmentation, hyper- and atrophic scamng which were ciated with other manifestations of photodamage such as frequently reported with diathermy and argon laser irregular pigmentation, dermal elastosis, epidermal atro- therapy7J1-'3 theoretically should occur less frequently phy, and actinic kerat~ses.~-~In actinically damaged skin with laser therapy utilizing wavelengths of 577 to 585 histologic changes can be found in dermal arterioles, cap- nm." These wavelengths result in optimum absorption illaries, and venules, with the postcapillary venules by hemoglobin when treating ectatic dermal blood ves- showing the most obvious effects.6 Spider telangiectases sels. Despite this there have been reports of the occur- arise from a central filling vessel of arteriolar origin' while rence of these adverse sequelae following treatment of facial linear and arborizing telangiectases usually arise facial telangiectases using yellow light lasers.8J0 from the postcapillary venule. Frequently all three types Microinjection of sclerosant solutions to treat telan- will coexist in the same patient. Apart from actinic dam- giectases was first described by Biegelei~en'~in 1934. While this method has become the treatment of choice for lower limb telangiectases,I6there has been only an occa- From Central Vein and Laser, New South Wales, Australia. sional report of successful application of this technique to Address correspondence and reprint requests to: Paul Kenneth Thibault, treat facial telangie~tases.'~Goldman18 has hypothesized MBBS, Suite 1, 41 Belford Street, Broad Meadow NSW 2292, Australia. that there may be theoretical advantages in combining 48 0 1994 by Elseuier Science Inc. 0148-0812/94/$7.00 J Dematol Surg Oncol THIBAULT 49 1994;20:48-54 COPPER VAPOR LASER FOR TELANGIECTASES sclerotherapy with pulsed dye laser when treating leg as well as treatment type (copper vapor laser alone or telangiectases. Similarly, combined microsclerotherapy combined) and whether linear or spider separately. P and laser photocoagulation offers both theoretical and values are presented in the tables, with P 5 .05 being practical advantages over either modality alone when taken as statistically significant. treating facial telangiectases. When treating larger facial The treatment method chosen for each patient was not telangiectases, particularly on the nasolabial folds, laser randomized but resulted from the development of the treatment has often been ineffective or has caused combined technique in July 1990 that was thereafter ap- atrophic scaning10*19~20owing to the high powers required plied to all patients presenting with spider telangiectases to photocoagulate these vessels. It is possible that more and those patients with linear/arborizing telangiectases reliable results with a lower incidence of scarring may be whose vessels were technically possible to inject. The achieved by obliterating or reducing the size of larger number of patients responding to the questionnaire in telangiectases using microsclerotherapy prior to laser each group is shown in Table 1. The response rate com- photocoagulation. pared favorably with Pickering's study in which 59% of The aim of this study was to evaluate the effectiveness patients with facial telangiectases and 66% of spider nevi of copper vapor laser photocoagulation with and without patients returned completed questionnaires. supplementary microsclerotherapy in the treatment of The copper vapor laser used in this study was a Vis- linear, arborizing, and spider telangiectases affecting the Erase 3w (Visiray Pty Limited, Hornsby, N.S.W., Austra- face. As the symptoms of these lesions are usually con- lia). This freestanding mobile unit uses a vaporized me- fined to the patient's perception of disfigurement, the tallic copper discharge tube to produce yellow light at 578 patient's own assessment has become the accepted nm. Laser light is delivered to the patient via a fiber optic method of comparing the effectiveness of various treat- delivery system made up of a 5 m length of 200-pm fiber ment method^.^,^' cable terminated with a lightweight optical delivery handpiece that is fitted with a lens holder. The laser beam could be focused to either a spot size of 150-pm diameter Materials and Methods or 400-pm diameter by a simple interchange of lenses. A questionnaire similar to that of Pickering et all* was The operator used 8X magnifying loupes (Zeiss, Ger- distributed to 239 consecutive patients treated for facial many) with a specific eye protection filter for the wave- telangiectasia. The patients had all completed treatment length of 578 nm. The patients' eyes were protected at all at least 6 months prior to entering the study. There were times with occlusive shields. 13 questions covering the following areas: When treating linear and arborizing telangiectases, the operator traced individual vessels precisely from distal 1. Pain experienced during treatment (thinnest) to proximal (thickest) utilizing the 150-pm spot 2. Effectiveness of treatment size. This ensured that the minimum power necessary to 3. Adverse effects of treatment photocoagulate the vessel was used. The end point was 4. Overall satisfaction with treatment complete disappearance or blanching of the vessel. Most questions were constructed with a bipolar scale Powers ranging between 300 and 500 mW were used. with patient responses being collated on Claris Filemaker When treating spider telangiectases with the copper I1 database (Claris Corporation, Santa Clara, CA) on an vapor laser alone, a similar method was used with the Apple MacIntosh 30SE computer (Apple Computer, Inc., operator tracing the peripheral "arms" fmt using the Cupertino CA). For analysis, patients were categorized 150-pm spot then changing to the 400-pm spot to vapor- into four groups according to type of telangiectasia and ize the central vessel. The end point of this latter proce- treatment method: dure was a visible and audible "popping" of the central feeding arteriole which usually required powers in the 1. Linear and/or arborizing telangiectasia treated with range of 600 to 700 mW impinging on the vessel for less copper vapor labor alone. than one second. 2. Linear and/or arborizing telangiectasia treated with Microsclerotherapy of facial telangiectases requires a combined microsclerotherapy and copper vapor laser. modified technique compared with that used in treating 3. Spider telangiectasia treated with copper vapor laser lower limb telangiectases. Sodium tetradecyl sulphate alone. (STD, STD Pharmaceuticals, Hereford, England) was 4. Spider telangiectasia treated with combined micro- used because of its highly specific sclerosant action, in- sclerotherapy and copper vapor laser. trinsic vasospastic activity, and safety when injected (in- Pearson's xz statistic was used to test for association advertently) extravascularly in concentrations of less between the treatment groups and the outcome variable, than 0.3%.16,22-24Sodium tetradecyl sulphate has
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