Linear Scarring Following Treatment With a 595-nm Pulsed Dye Laser
Pulsed dye laser (PDL) treatment is well established and has been reported to be safe and effective in the management of superficial hemangiomas, port-wine stains, and other vascular lesions. Although hyperpigmentation is quite common, other side effects such as hypopigmentation, ulceration, hemorrhaging, atrophic scarring, and hypertrophic scarring are rare. We report the case of a 42-year-old woman who developed atrophic scarring of the nasal alae following cosmetic PDL treatment. Patients receiving PDL treatment should be warned about the risk for the development of scarring.
Practice Points
- Lasers should be used by experienced operators and treatments should be tailored to individual patient needs.
- Multiple passes at subpurpuric settings with the pulsed dye laser may lead to safer results with fewer adverse events and at the same time more tolerable treatments for the patient by minimizing downtime associated with purpura.
- Although scarring is rare, it can occur and should be part of the patient’s informed consent prior to treatment.
Alternative laser treatment protocols have been proposed in the literature. Rohrer et al15 recommended multiple passes at subpurpuric doses for treatment of facial telangiectases with the PDL. It has been suggested that multiple stacked pulses at lower fluences may have similar effects on targets as a single pulse at a higher fluence, thereby minimizing thermal injury and leading to decreased risk for adverse events such as scarring. When treating vascular lesions such as telangiectases, increasing the fluence will increase the risk for purpura due to the constant pulse duration. Stacking pulses of lower fluence may have the advantage of heating vessels to a critical temperature without creating purpura, leading to similar clearance rates with decreased adverse risk profiles.15
It may be better to err on the side of safety by performing a greater number of treatment sessions with increased pulse width and decreased fluence (subpurpuric treatment settings) to minimize the risk for atrophic scarring from treatment with the PDL. Treating superficial facial telangiectases with a pulse-stacking technique may improve clinical results without a remarkable increase in adverse effects. It may be wrongfully intuitive to try to maximize results by using high fluences and purpuric narrow pulse durations; this case report reiterates the danger of using these settings in an attempt to rapidly achieve clearance of telangiectases. Lastly, this case underscores the value of verbal and written postoperative instructions that should be given to every patient prior to undergoing laser therapy. Specifically, with regard to our case, the laser operator must be aware at all times of potential adverse events, which may be foreseen during treatment if persistent or prolonged blanching and/or blistering occurs. The physician operator and patient must be prepared to rapidly respond to adverse reactions such as skin necrosis or blistering. Meticulous wound care is necessary if skin breakdown occurs. We recommend using a hydrating petrolatum ointment or a topical emulsion to minimize the risks for scarring, if possible.
