A number of therapies are used to reduce the evidence of the veins — sclerotherapy and surgical methods. Arielle N.B. Kauvar, M.D., specializing in cosmetic dermatology and Mohs micrographic surgery, and a clinical associate professor at New York University, says the treatment of the veins with the Nd:YAG laser (FriendlyLight) does an excellent job of destroying the veins in a painless and safe way — offering several advantages over other options.
"Sclerotherapy injections carry certain risks," she tells Dermatology Times. "Sclerotherapy carries a risk of causing skin ulcerations when the sclerosant diffuses into the skin. When detergent solutions are used at high volumes or concentrations, backflow into the ophthalmic artery carries a risk of retinal changes and blindness. The surgical method of direct cautery and transection can cause scars and the veins have a high recurrence rate."
Dr. Kauvar says the YAG laser can be used safely as long as it is not used within 1 cm of the orbital rim where there would be a risk of light being transmitted to the eye.
She says the procedure is virtually painless and causes no patient down-time.
At the American Society for Dermatologic Surgery meeting in Atlanta, Dr. Kauvar outlined the method she uses for removing the veins.
"We treated veins measuring 1 mm to 3 mm on the temporal region, forehead, nasal dorsum and cheek. No anesthetic was required. We used the Nd:YAG laser (Laserscope Gemini) with a sapphire-chilled tip. The parameters we use are a 3 mm spot size, a 50 ms pulse duration, and a fluence of 150-250 J/cm, depending on the size of the vein. The way we perform the treatment is to apply laser pulses along the length of the vessel with about 1 mm to 3 mm of space between each laser pulse."
Contiguous, non-overlapping pulses must be applied to prevent excessive tissue heating, which can occur with a long pulsed Nd:YAG laser, and a risk of vesiculation and ulceration. The endpoint of treatment is complete vessel blanching.
If any portions of the vein are visible following the first pass of the laser, after about 20 seconds to 30 seconds, Dr. Kauvar goes back for a second and up to a third pass, applying pulses to that portion of blood vessel. Some individuals need more than one pass before there is a complete blanching of the vein.
She says the lack of pain is due to using the chilled laser tip, which is cooled to 5 degrees Celsius and functions to ice the area. It cools the skin immediately, so there is no residual pain.
"We apply a water-based gel to the surface of the skin before treatment to allow the skin to cool more efficiently and enable the laser hand-piece to slide more easily along the tissue."
Dr. Kauvar has treated nine patients with 17 regions of veins. Patients were treated at monthly intervals until complete clearance was achieved. The veins remained closed in all subjects at the six-month to one-year follow-up.
"Immediately after treatment, there may be mild erythema and edema, but no skin wounding, no blistering and no ulcerations — just a very temporary pinkness."
Two patients have experienced the urticarial swelling right over the veins that lasted a day or two, but usually the erythema resolves in a couple of hours.
Other than that, Dr. Kauvar says the only drawback is the need to be extremely careful in treating areas near the eyes. The other danger is actually stacking the pulses because that can result in blistering and an open wound to the skin.