Treatment of Leg Vein Telangiectases: 1-Year Results With a New 940 nm Diode Laser

Peter Kaudewitz, MD,* Winfried Klvekorn, MD, and Werner Rother, PhD
*Department of Dermatology, Ludwig Maximilians-University Munich, Munich, Germany, Laser Center Gilching, Gilching, Germany, and Dornier MedizinLaser GmbH, Germering, Germany

background. Short-term results obtained with a 940 nm diode laser indicate that this laser is effective in the treatment of leg vein telangiectasia. Long-term studies are needed to evaluate the definitive clinical end results. objective. To evaluate long-term results in the treatment of leg vein telangiectasia with a 940 nm diode laser and to compare these with short-term results. methods. Twenty patients were treated with 940 nm diode laser, 300350 J/cm2, 4070 msec, 1 mm spot, single pass. Pho-

tographs for evaluation of clearance were taken before treatment and 4 weeks and 12 months after the last treatment. results. At 12 months follow-up, clearing rates were greater than 75% in 15 patients (75%) and 5075% in 5 patients. In 7 patients (35%) the clearing rate had improved considerably during follow-up. conclusion. Definitive results with the 940 nm laser occur only after prolonged follow-up. They are considerably better than the short-term results.

P. KAUDEWITZ, MD, W. KLVEKORN, MD, AND W. ROTHER, PhD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

RECENT EFFORTS to more effectively treat leg veins with lasers have focused on the use of longer wavelengths and more prolonged pulse durations.1,2 Lasers operating at wavelengths between 810 and 1064 nm can target deeper and larger vessels by their deeper penetration into the skin and blood vessels and provide longer pulses to deposit adequate energy for vessel heating and destruction.3,4 A new 940 nm diode laser designed according to this rationale has been reported as effective and safe for the treatment of leg vein telangiectasia.5 These reports are based on shortterm clinical assessments performed 4 weeks after the last of three treatment sessions. Clinical experience with sclerotherapy of leg vein telangiectasia suggests that longer follow-up periods are needed to fully assess the definite clinical end results in terms of vessel clearance. As a sequel to our first report we investigated the long-term effects of the new 940 nm diode laser in 20 patients with leg vein telangiectasia evaluated 12 months after the last treatment session. These results were compared with those obtained after 4 weeks and with long-term results reported for other laser systems in use to treat leg veins.

Materials and Methods

The design of the study, the patients characteristics, and the laser parameters used have been described previously.5 In brief, 20 female patients were available for the present longterm follow-up study. They all had leg vein telangiectases on various locations on their calves and shins with a vessel diameter of less than 1 mm. Both blue and red telangiectases were included with a preponderance of the blue variant. No further differential evaluation was performed due to the relatively small number of patients participating in this first controlled study of long-term follow-up. Venous insufficiency was excluded by Doppler sonography and duplex ultrasound investigation. Six patients treated in our first study were not available for follow-up. These patients had varying short-term rates of vessel clearance including more than 75% clearance, but could not complete the study for personal reasons. Patients were treated using a new diode laser. The laser emits radiation at a wavelength of 940 nm. A fluence of 300350 J/cm2, pulse duration of 4070 msec, and a spot size of 1 mm were used. Vessels were treated with a single pass without cooling prior to treatment. Patients received three treatments at intervals of 4 weeks. The laser parameters and the treatment schedule were suggested as likely to be effective in previous preliminary tests performed prior to this first controlled study. After marking the treatment area, pretreatment photographs were taken. Postoperative photographs were obtained after each session, and 4 weeks and 12 months after

Address correspondence and reprint requests to: Peter Kaudewitz, MD, Department of Dermatology, Ludwig-Maximilians-University Munich, Frauenlobstr 9-11, D-80337 Muenchen, Germany.

2002 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing, Inc. ISSN: 1076-0512/02/$15.00/0 Dermatol Surg 2002;28:10311034

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Figure 1. Clearing of leg telangiectasia 4 weeks after the last treatment (dark columns) and 1 year after the last treatment (light gray columns).

the last treatment. Color slides were projected over a grid with 16 squares, then corresponding squares were evaluated by two independent blinded physicians. This method both allowed for the detection of new vessels or recanalization of treated vessels and the assessment of degree of clearing rates for individual vessels. Clearing of treated vessels within the individual squares of the grid was graded as less than 25%, 2550%, 5075%, and greater than 75%. The results of all grids were added to determine the patients overall clearing rate.

Results
At 12 months follow-up a clearing rate of greater than 75% was achieved in 15 patients (75%) and 5 patients (25%) had clearing rates of 5075%. In seven patients, considerable further improvement was found after 1 year (Figures 2 and 3); recanalization was not observed in any patient. The degree of additional improvement could not be predicted from the responses observed 4 weeks after the last treatment A comparison of short-term (4 weeks after the last treatment) and long-term results (1 year after the last treatment) is given in Figure 1. New vessel formation close to treated vessels was observed in two patients, most likely in conjunction with persisting reticular veins. Side effects such as hypo- and hyperpigmentation observed in the location of the treated vessel 4 weeks after the last treatment session in one patient and three patients, respectively, had resolved after 1 year. In particular, no persistent disturbances of pigmentation were noted. Superficial textural changes were seen in five patients 1 week after the last treatment. After 1 year they were only detectable by very close examination and were not regarded as cosmetically relevant by the patient.

Figure 2. A) Isolated telangiectatic vessels before treatment. B) Incomplete clearance with residual vessels 4 weeks after the last treatment. C) Complete clearance of vessels after 12 months without additional treatment.

Discussion
There is accumulating evidence for the effectiveness of lasers in treating telangiectases of the lower extremities. Depending on the laser systems and protocols applied, mean clearing rates of 6070% (range 100% to

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Figure 3. A) Larger superficial arborizing telangiectases before treatment. B) Reduction of vessels 4 weeks after the last treatment. C) Complete clearance of vessels after 12 months without additional treatment.

less than 25%) have been reported.6 The large majority of these studies have assessed the clinical results a few weeks after the last treatment session. When longterm results are reported, the focus is on documenting a long-lasting effect and the safety of the procedure as

evidenced by the absence or progressive disappearance of side effects. In such a study using a Nd:YAG laser, 64% of the patients after a maximum of three treatments achieved a 75% or greater clearance of vessels after 12 months.7 No explicit comparison of these results with those obtained several weeks after treatment is reported. Short-term clearing rates for a new 940 nm diode laser were greater than 75% in 46% of the patients. The clinical observation of continuing further vessel clearance after cessation of treatment, similar experiences in sclerotherapy, and the availability of follow-up long-term results for other laser systems have prompted this study of follow-up long-term results in our patients to compare these with short-term clearance rates for the same laser system. Without further treatment, considerable further improvement as evident from a clearance of greater than 75% in three-fourths of the patients was noted. This clinical course indicates that the short-term results previously reported do not represent the true clinical end results for the 940 nm diode laser. These can only be assessed after a longer time period. In the present study we compared the process of posttreatment vessel clearance at two generally accepted intervals1 and 12 months. The kinetics of this process, as well as its morphologic and molecular correlates, as yet are largely unknown. Studies performed with a Nd:YAG laser suggest both an immediate effect of laser impact on vessels evident from intravascular hemorrhage and changes in elastic fibers and a long-lasting initiation of tissue remodeling by the induction of key factors controlling wound repair and fibrosis such as transforming growth factor (TGF)-. Since our lasers wavelength of 940 nm is very close to the 1064 nm of Nd: YAG laser, similar mechanisms may be effective. More detailed studies on the laser-induced process of vessel clearance and tissue remodeling now in progress may reveal a complex picture of mediator interaction as known from general studies on wound healing. Our study demonstrates a lasting efficacy of the new 940 nm diode laser for the treatment of leg veins without major side effects. The present long-term clearance rates are equal to those reported for the Nd:YAG laser and compare well with those achieved with other laser systems. The number of treatments and the treatment parameters to obtain these results may differ and are subject to ongoing comparative studies. The fact that definitive results with this laser system are seen only after prolonged follow-up is of practical interest to both the patient and the physician using this system. The patient should be informed that less favorable immediate results will improve considerably over time and the physician should be prepared to avoid unnecessary additional treatments with an increasing risk of side effects.

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References
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treatment of leg venulectasias and reticular veins. Arch Dermatol 2001;137:6137. 5. Kaudewitz P, Klvekorn W, Rother W. Effective treatment of leg vein telangiectasia with a new 940 nm diode laser. Dermatol Surg 2001;27:1016. 6. Dover JS, Sadick NS, Goldman MP. The role of lasers and light sources in the treatment of leg veins. Dermatol Surg 1999;25:32836. 7. Sadick N. Long term results with a multiple synchronized-pulse 1064 nm Nd:YAG laser for the treatment of leg venulectasias and reticular veins. Dermatol Surg 2001;27:3659.