Dr Ahmed El Houssieny details the presentation of telangiectasia and outlines considerations for treatment
Smooth, even-toned skin is something most aesthetic patients aspire to achieve from treatment in our clinics. As a first-base approach, we should be recommending that patients invest in medical-grade skincare products and advising them of a suitable regimen to follow. Sometimes, however, certain skin concerns call for more targeted treatment. This is the case for vascular lesions such as telangiectases.
Also known as spider veins or facial thread veins, telangiectases are tiny blood vessels that cause thread-like red lines on the skin. They generally form gradually and appear in clusters in different areas across the face. Telangiectases’ vessel diameter is usually between 0.2-0.5mm and the distribution is defined by linear, matted and combined patterns, with a depth of 200-250 microns.1 Some patients suffering from telangiectasia may experience pain or itching, but most concerns relate to how it looks.1
Research suggests that patients with skin types I-III, a history of significant sun exposure and/or long-standing rosacea are predisposed to presenting with telangiectasia.1,2 Additionally, telangiectasia can be associated with hypertension, or as part of the clinical manifestations of connective tissue disorders such as scleroderma. Alcoholism, because blood flow is affected; pregnancy, due to increased pressure on venules; and ageing in general, as blood vessels begin to weaken, have also been linked to the condition.1,2
Practitioners should take care to diagnose telangiectasia appropriately, as there are certain underlying disorders associated with it such as Sturge-Weber disease and xeroderma pigmentosum. One in particular to be cautious of is hereditary haemorrhagic telangiectasia (HHT), which is an inherited disorder of the blood vessels in skin and internal organs that can cause excessive bleeding. Symptoms include frequent nosebleeds, red or dark black blood in stools, shortness of breath, seizures, small strokes and a port-wine stain birthmark.2
There are various options available to treat telangiectasia. If it is caused by a medical condition, such as HTT mentioned above, then it’s important that you identify and treat this, which should then resolve the telangiectases. If aesthetic-based, then you can consider:
Laser – uses a single wavelength of light, which is absorbed by molecules (chromophores) that can convert the light energy to heat energy, which then destroys the abnormal blood vessels.3
Intense pulsed light (IPL) – like laser, IPL targets chromophores to heat and destroy the telangiectases, but instead uses several wavelengths of light in the same beam.3
Sclerotherapy – injection of a chemical solution into the veins that causes the lining of the blood vessel to collapse and clot. This then turns into scar tissue which eventually fades from view.4
Electrosurgery – a small cautery tip is applied on the skin along the lengths of the telangiectases or at the route of the vessel and allows an electric current to coagulate the lesions which, as above, will lead them to disappear.4
Microphlebectomy – performed using hooks which allow the practitioner to extract veins through minimal skin incisions or needle punctures.5
Thermocoagulation – uses radiofrequency energy to cause thermal damage to destroy and fade the veins.5
Your treatment choice will depend on your skillset and, most importantly, the best option for the patient. Here, I will focus on the evidence behind light and laser-based approaches, as this is the most common treatment approach that I use and is proven to be effective.
As described above, laser and light-based treatments work on the principle of selective photothermolysis, whereby light energy – from the laser or IPL device – targets specific chromophores that can convert the light into heat and destroy them, without damaging surrounding tissue.3
McCoppin et al. explain that the intended target, or chromophore, of telangiectasia is largely intravascular oxyhaemoglobin, although deoxyhaemoglobin and met-haemoglobin are targeted as well.6
The principal absorption peaks of oxyhaemoglobin are in the blue-green-yellow portion of the visible range at 418, 542 and 577 nm. The authors highlight that there is also absorption between 700 and 1100 nm, although this is less.6
This means that there are a number of types of lasers that can be used to treat telangiectasia, with research indicating that pulsed dye laser (PDL), potassium-titanyl-phosphate (KTP) and IPL sources are the most standard options.6
KTP laser light is created by passing the near-infrared light of 1064 nm Nd:YAG through a KTP crystal, which doubles the frequency and halves the wavelength to emit a 532 nm green light.7
The small spot sizes available of 1mm or less can be useful for tracing out individual telangiectases. According to McCoppin et al., the range of longer pulse durations (1-100 ms) allows the KTP pulses to expand the intravascular ‘steam bubble’ gradually without vessel wall rupture. One of the benefits of KTP is that patients do not experience purpura (small flat spots on the skin) following treatment.6
A large-scale study of 647 patients with vascular lesions was conducted in 2014. It found that 77.6% of those treated with KTP laser had complete clearance or marked improvement after six weeks. Only 5.8% of participants experienced adverse events, all of which were minor and the main one being swelling which reduced after a couple of days.8
Other research has cited 90% clearance or marked improvement in telangiectasia following KTP treatment (49 patients),9 66.1% clearance or marked improvement (146 patients)10 and 75-100% clearance of telangiectases in 93.9% of 66 participants.6
One of the main disadvantages of KTP laser is that its use is limited to patients with skin types I-III. This is because, along with the targeted oxyhaemoglobin chromophores, the green light is also absorbed by melanin chromophores, which can therefore lead to dyspigmentation.6 Another downside, in my opinion, is that while the small spot sizes are good for linear telangiectases, more diffuse or widespread vascular conditions such as rosacea or port wine stains can be difficult to treat. Other side effects are that it can produce erythema and oedema lasting six to 12 hours after treatment, while blistering, scabbing and bruising can occur.8 As with all aesthetic treatments, the risk of severe side effects is reduced with appropriate use.
PDLs use an organic dye mixed in a solvent as the lasing medium. PDLs have wavelengths of 585 or 595 nm, with pulse durations of 0.45-40 ms.11
The larger spot sizes, which range from 2-10mm, deliver a fluence averaging 5-10 J/cm2, which allow for deeper dermal penetration and destruction of larger blood vessels.11 It has been advised that treatment areas should not overlap by more than 30%, to prevent excessive thermal damage that could result in blistering or scarring.6
A review of 326 articles on treating rosacea (one of the most commonly associated conditions of telangiectasia) with PDL was conducted in 2022. Results suggested that clinical improvements of more than 50% clearance were noted in 68.6% of participants treated with PDL.12
Another study of 30 patients found that telangiectases were resolved in 93% of participants after a single treatment,13 while a further suggested that the average improvement in 19 patients was 53.9%.14
Post-treatment purpura is one of the most undesired effects of PDL – often increasing patient dissatisfaction and elongating downtime.15 Some devices have non-purpuric settings, however it has been reported that improvement may be greater when purpura is induced in thicker telangiectases.16
Other side effects associated with PDL treatment include redness, swelling and itching that may last for a few days post treatment, changes in skin pigment and blistering – although this is rare when used in safe hands.11
While the laser options discussed are proven to produce positive results for the treatment of telangiectasia, IPL also offers an effective solution.17 With wavelengths ranging from 500 to 1200 nm, most IPL devices will use filters to refine the energy output for the intended treatment.18 Studies indicate positive results with IPL use. One, comprising 140 patients with linear and spider facial telangiectases, reported excellent results in 67.1% of participants, good in 30.7% and poor in 2.1% out of those who took part.19 Another demonstrated that 95.3% of 107 patients showed improvement in their telangiectases six months post-treatment.20 An additional study found that 90% of 30 patients with facial telangiectases had more than 50% clearance post-treatment. Significantly, 27% had more than 75% clearance.19
Adverse events include blisters, dyspigmentation and scar formation; as with other treatments, these can be limited with appropriate patient selection and proper use.19 A disadvantage of IPL treatment is that there are many variations between systems, and low power IPLs may give unsatisfactory results. To avoid this, it’s essential to choose IPLs that can deliver high fluences in short pulse train durations.
In my experience, deeper vessels will need treatment with an Nd:YAG laser rather than IPL (or PDL/KTP laser) to induce the most effective results. My device of choice is the Lynton Lumina, which is a multi-platform system that includes IPL and Nd:YAG laser, allowing me to tailor treatment to individual patients.
There have been numerous studies undertaken that compare the various devices available for the treatment of telangiectases.16,19,21 In those analysing PDL vs. IPL, most found equal efficacy and safety results. One study (p=19) suggested while both effective, PDL had a better outcome in terms of appearance, but IPL was preferred by patients because there were fewer side effects.21 Likewise, in a study comparing IPL with KTP by analysing literature, both were found to achieve marked improvement after one session. It was, however, highlighted that the KTP caused slightly more discomfort and oedema than the IPL, yet it was described as faster and more ergonomically flexible.16
It should be noted that larger study groups are required for more informative data.16
A laser or IPL device is an expensive investment, so it’s important to carefully consider your options before purchasing. I would recommend evaluating your current patient demographic and thinking about whether you want to grow this or expand into different areas. Don’t be afraid to ask the distributor or manufacturer lots of questions, read plenty of clinical studies (not just the ones conducted by the company), and seek advice from your peers.
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