LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.

For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm², a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm², a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm², a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm²and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm², a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm² and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm². Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.

d.brunk@elsevier.com

Lasers expand options for vascular lesion treatment