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Lasers give leg up on leg veins, but sclerotherapy still called 'gold standard'


National report - Laser companies continue to forge ahead with new techniques to stake their claim among leg vein treatments; however, sclerotherapy currently remains the treatment of choice for most cases, according to Mich?l Gold, M.D.

"If doctors want to try to use their lasers or IPL, that's fine, but I always remind people that sclerotherapy is the gold standard for treatment of leg veins," says Dr. Gold, assistant clinical professor at the Vanderbilt University School of Medicine in Nashville, Tenn.

Sclerotherapy's needle injections aren't for everyone, however, and lasers continue to evolve, with a goal of eventually treating leg veins with the same success that has been seen with facial veins.

Leg veins tend to be more problematic that facial veins, however, due to factors including increased hydrostatic pressure, a deeper location and different cytokine pattern injuries that occur with injured lower leg veins.

To try to address the challenges, laser companies have concentrated on longer wavelengths, longer pulse durations and larger spot sizes. Lasers that are showing some of the best success are those with a 1064 wavelength, such as the Cutera CoolGlide or the CoolTouch Varia, which uses Nd:YAG technology.

"1064 may be the ideal wavelength for this, and a lot of focus is in that area right now," Dr. Gold says.

Wavelengths, cooling, variations

As wavelengths reach deeper, the importance of cooling to avoid epidermal damage has become a greater issue, but most devices have evolved to address the problem.

"Nearly every machine now has really good contact cooling," Dr. Gold says.

In conjunction with contact or cryogen cooling, air-cooling such as a Zimmer device may be helpful, he adds.

One of the newest variations on 1064 lasers is the Cynergy Multiplex, from Cynosure, which combines a high-powered pulsed dye laser with an Nd:YAG unit. Dr. Gold is involved in clinical trials for the product, which he says shows promise in using 585 and 1064 wavelengths sequentially.

"The idea is to actually do sequential pulsing to improve treatment outcomes," he explains.

A variety of other pulsed dye lasers have also been tried for leg veins, but studies have had inconsistent results, with some showing little to no improvement and problems with hyperpigmentation.

And while the 532 long-pulse Nd:YAG has a good absorption technique that works well on facial vessels, results have also been inconsistent for leg vessels.

"I find the 532 works well on very small vessels, such as ankle vessels," Dr. Gold notes.

Intense pulsed light

Some studies have reported good results with intense pulsed light for lower leg veins, but the technique can present the risk of hyperpigmentation.

"I love IPL, but it is very technique-sensitive for this use," Dr. Gold says. "But I always tell people to be extremely careful if you ever use IPL for lower leg veins."

Improving treatment

Ultimately, as companies experiment with wavelengths, pulse durations and spot sizes, the goal should be to improve treatment.

"We need to prevent inadequate treatment by ensuring complete thermal coagulation and protection of the epidermis so there aren't further problems - that's the key," Dr. Gold says.

And until an optimal use of lasers for leg veins is established, it's a good idea keep sclerotherapy as a backup.

"We all want to use these lasers and light sources, but my advice is, if you're not proficient in sclerotherapy, don't use the lasers," Dr. Gold says.

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