Summary

Removal of vascular skin lesions without scarring was unthinkable a few decades ago. In the past thirty years, advances in laser technology have revolutionized the treatment of cutaneous vascular disorders and expanded the dermatologist’s therapeutic armamentarium. Based on many thousands of treatment sessions and follow-up evaluations, these vascular lesions can now safely and effectively be treated in infancy, early childhood, or as adults, with virtually little or no pain, textural changes, pigment changes, or scarring, and minimal postoperative wound care. Birthmarks such as port-wine stains (PWS) hemangiomas, lymphangioma, venous lake, cherry hemangioma, pyogenic granuloma, and warts are successful treatments. Furthermore, acne rosacea, facial erythema, facial telangiectasia, spider veins, red scars, and red stretch marks are markedly improved. Condition. We use selective lasers, fractional lasers, fractional radiofrequency, and elos light technology. We mix and match different technologies to give the best possible results.

The red blemishes appearing on the skin are due to abnormal blood vessels located directly under the skin’s surface, creating reddish color and vascular lesions. Port-wine stains, strawberry hemangiomas, and spider veins (telangiectasias) are all forms of vascular lesions. They can vary in color from red to purple, and in size, from a small spot to those covering large body areas. Sometimes present at birth, but may also be acquired from overexposure to the sun, contraceptive use, hormonal therapy, or natural aging.

Why Do Skin Red Spots Require Treatment?

Patients with various types of vascular lesions present to dermatologists for treatment, primarily due to cosmetic concerns. However, disfiguring birthmarks can cause severe psychological disability for both the patient and their family. Pain may be present, and complications such as ulceration, infection, bleeding. Functional impairment of the sensory organs like the nose, ear, or eyes can occur with hemangiomas or port-wine stains. Serious medical problems like a high-output cardiac failure and generalized bleeding may accompany large, multiple hemangiomas and /or visceral involvement.

What Treatment Options are Currently Available to Treat Skin Red Spots?

Removal of vascular skin lesions without scarring was unthinkable a few decades ago. In the past twenty years, advances in laser technology have revolutionized the treatment of cutaneous vascular disorders and expanded the dermatologist’s therapeutic armamentarium. Based on many thousands of treatment sessions and follow-up evaluations, these vascular lesions can now safely and effectively be treated in infancy, early childhood, or as adults, with virtually little or no pain, textural changes, pigment changes or scarring, and minimal postoperative wound care. The laser is simply a unique light source. When perfect parameters are used, laser light behaves like magic bullets, clearing the thousands of superficial, superficial cutaneous blood vessels without adverse effects on the surrounding tissue. This allows laser surgeons to target visible cutaneous blood vessels and invisible superficial dilated dermal capillaries.

Lasers differ in colors (wavelength) and the amount and time the laser energy is delivered to the skin. Non-selective lasers can destroy unwanted blood vessels, but at the same time, can destroy surrounding normal skin. In simple terms, lasers work precisely as a cautery machine applied to the skin with the same possibilities of scarring and pigment changes. Improved current understanding of the effects of laser and tissue interaction has led to the design of new generation laser systems (selective vascular lasers) that deliver the right color in the right amount at the right time, allowing for extreme precision in destroying unwanted blood vessels, and at the same time providing a high safety profile.

Selective lasers (yellow, red, and infra-red) offer adjustable laser parameters that help the surgeon determine the perfect wavelength, pulse duration, spot size, and cooling time for each patient. Over the years, laser treatment has become safer and virtually painless. It is now the standard treatment for various cutaneous vascular lesions in patients as young as six months to adults.

How do MSI Treat Patients Suffering from Skin Red Spots?

The MSI team of medical professionals will thoroughly assess your condition before determining which laser(s) is best to treat your condition. We use selective lasers to remove vascular lesions, and occasionally we mix and match selective lasers or different laser parameters, enabling us to give the best possible results. We are proud to have the most advanced laser technology around.

Oxyhemoglobin and reduced hemoglobin have comprehensive absorption characteristics, with relevant peaks in the near-IR range (700-1200 nm). MSI we have the latest Lasers in the red and near-IR range used to treat vascular lesions, including the diode (810nm) and short and long-pulsed Nd: YAG (1064 nm). These wavelengths have been used successfully in treating reticular veins, mature port-wine stains, and bulky vascular malformations, which tend to be challenging to treat because of the presence of large deep vessels containing deoxygenated hemoglobin. While we use e the green 532nm KTP for treating superficial vascular lesions, the fractional CO2laser is used successfully to treat nodules and hypertrophy in PWS lesions in combination. Furthermore, the elos technology which combines IPL and bipolar radiofrequency offers a promising alternative.

Port-wine Stains: usually unilateral. They frequently occur on the face but also appear elsewhere. They represent a congenital birthmark occurring in 0.3 to 0.5% of newborns. They may be a few millimeters in diameter or may cover an entire limb. However, the size remains stable throughout life. Although port-wine stains are flat and relatively faint, they are uniform in color at birth but evolve into thick, irregularly surfaced (blebs) deeply colored lesions by the fifth decade. Early treatment will achieve the best results with fewer laser treatments. Factors such as the anatomical location, color of the lesion, skin type, and patient’s age are essential in determining the degree of the clearing. Dramatic changes occur in the first six sessions. Although it is common to have less than 100% clearing after five sessions, more treatment can lead to more clearing.

Salmon patches (stork bite, angel’s kiss) are variants of nevus flammeus; they are present in approximately 40% to 70% of newborns. They are red, irregular, macular patches resulting from the dilation of dermal capillaries. The most common site is on the nape, where the lesion is referred to as a stork bite. Salmon patches on the face fade within a year, but those on the nape may persist for life. Treated the same as above if needed

Hemangiomas: most common tumor in infancy. Most of these lesions appear during the first month of life, starting as pink patches commonly found on the head and neck. Superficial lesions are raised and are bright red. Deep hemangiomas appear as bluish subcutaneous nodules. Unlike port-wine stains, hemangiomas begin as a proliferating phase for a period of up to one year, followed by a prolonged phase of involution. Regressed lesions may leave residual scars or discoloration, and around 15-20% do not know completely involute. Cosmetic surgery is often necessary to correct residual lesions. As in port-wine stains, it’s recommended to treat all superficial hemangiomas appearing during the first weeks of life for the best results. In the proliferative phase, lasers are used successfully to retard growth and heal ulcerations.

Pyogenic granuloma is an acquired vascular lesion, usually solitary, 0.5-2.0 cm in diameter, bright red, and pedunculated. The surface is soft, bleeding easily with trauma. It may become ulcerated and develop a granulomatous surface with a brown or black crust. Lesions usually appear suddenly and may enlarge rapidly. These lesions typically occur as a superimposed growth on the surface of a PWS. The pyogenic granuloma may clear after 1-3 laser treatments.

Venous lakes are dilated lake-like venules in the upper dermis commonly seen on the lips or ears of elderly patients. These lesions are dark blue to purple, soft, raised nodules, usually 2- 10 mm in diameter. Patients generally request treatment because of concern over possible medical consequences, recurrent bleeding with trauma, or cosmetic improvement.

The term telangiectasia refers to superficial cutaneous vessels visible to the human eye. Vessels measure 0.1-1.0mm in diameter and represent a dilated venule, capillary, or arteriole. It may be linear, arborizing, spider, or papular. Red linear and arborizing telangiectasias are very common on the face, especially on the nose, mid cheeks, and chin. These lesions are also seen relatively frequently on the legs. Blue linear and arborizing telangiectasias are most commonly seen on the legs and may be found on the face. Spider telangiectasias typically appear in preschool and school-age children. All forms of telangiectasia are thought to occur through the release or activation of vasoactive substances under the influence of various factors, such as anoxia, hormones, or chemicals. At MSI, Selective lasers (yellow, red, infrared) are used to safely and effectively clear telangiectatic vessels up to several millimeters in diameter. It is common to do sclerotherapy with legs to clear “feeding” leg vessels before laser surgery.

Cherry angiomas are small, well-circumscribed, bright-red vascular proliferations that initially appear in early adulthood and increase in number with age. These benign growths can be easily treated with cryosurgery, radiofrequency, and vascular-specific lasers to improve cosmesis.

Poikiloderma of Civatte clinically appears as a reticulated brown pigmentation of the neck, anterior chest, and lower face with prominent telangiectasias caused by chronic sun exposure. The ectatic vessels present in the papillary dermis are usually 0.1 mm in diameter. Poikiloderma treatment using selective thermolysis requires wavelengths absorbed concurrently by melanin and hemoglobin. The intense pulsed light (IPL)has been used to treat this condition successfully. The intense pulsed light source may prove more helpful in eliminating associated hyperpigmentation because of its additional effect on epidermal melanin.

Lymphangiomas are slow-growing lymphatic malformations acquired after lymphatic drainage obstruction, chronic inflammation, infections, trauma, or surgical procedures. However, most are congenital and likely arise from a combination of abnormal budding of lymphatic structures, failure of venous vasculature to unite with the lymphatics, and atypical lymphatic tissue sequestration during embryogenic development.

Most of these lesions are diagnosed by age 2years, with nearly half diagnosed at birth. Lymphangiomas are typically found as soft tissue masses in the axillae or neck regions, but they can occur in other locations such as the tongue, esophagus, and upper airways. These lesions can be classified as either superficial or deep. A superficial lesion is the lymphangioma circumscriptum, whereas cystic hygroma is a deep lymphatic malformation typically found in the neck. Lymphangiomas can be found in patients with specific chromosomal abnormalities, such as Turner syndrome.

A lymphangioma may not require treatment; up to 15% of cystic hygromas may spontaneously regress. Surgical excision is typically the preferred treatment modality; however, complete excision may not always be possible because of vital structures’ location and possible involvement. Other options include sclerosing agents and laser therapy. Successful treatment with lasers (i.e., Nd: YAG, PDL, carbon dioxide) has been reported. They have been used for ablation, debulking, and complete excision. However, scarring after laser treatment, recurrence, and multiple treatment sessions should be of concern. Successful treatment for lymphangiomas, especially those in the oral cavity, has been reported using Nd: YAG lasers. Carbon dioxide lasers work by vaporizing the tissues (non-selectively) and sealing the lymphatic channels. The main disadvantage of this treatment modality is the need for local or general anesthesia and subsequent scarring. PDL has been used to treat vascular abnormalities, but it is not the choice treatment for lymphangiomas due to the laser’s selectivity and superficial absorption.

Acne Rosacea is a frequent disease in women with dry skin and rarely in men with oily skin. In women, rosacea is heralded around twenty years by intermittent facial erythema and sensitivity to cosmetics. This is followed by the gradual development of permanent erythema with telangiectasia. Around age forty, very unsightly papule-pustules (papular rosacea, improperly called acne rosacea) appear. Eyes may also become involved; fifty percent of patients experience burning and a grittiness sensation. Dermatologists recommend a combination of treatments tailored individually. Treatment rests on hygienic and dietary rules. The mainstay of treatment may contain topical agents as well as oral antibiotics or systemic retinoids.

At MSI, the combination approach of using green, red, and infra-red long pulse lasers as well as IPL and also provides excellent results in eliminating red and telangiectasia as well as diminishing papules or pustules.

Erythematous Hypertrophic/Atrophic Scars: resulting from skin-repairing wounds caused by trauma, surgery, or a skin disease like acne. The more severe the damage, the longer it takes for the skin to heal, and the greater the chance of noticeable scars. When selective lasers are used as early as possible, there is an improvement in the itchiness, redness, and skin surface texture. The scar height is reduced, and the overall scar appearance approaches those of normal surrounding skin. Prof Moawad strongly believes in using non-ablative lasers targeting micro-vascular and the non-ablative acne-specific laser long-pulsed 1320nm Nd: YAG that MSI uniquely owns is the first step in an integrated program to improve acne scars, especially in darkly pigmented skin.

Stretch Marks: dermal scars with overlying epidermal changes. Mechanical stress and hormonal changes are generally believed to be the principal factors that trigger most stretch marks, occurring most in healthy adult women, most often during pregnancy, or in association with excessive weight gain. Sometimes they appear after a chronic illness or excessive use of topical steroids. Whatever the cause, destruction of the elastin and collagen is the result. Clinically, striae first appear as flattened, thinned skin with a pinkish hue and occasionally itchy. The lesions pass through an early phase of inflammation (striae rubra) when they enlarge in length and width and take on a vivid reddish-purplish color. Over time, they assume a white, sunken appearance (striae alba) parallel to skin tension lines. Stretch marks occur most frequently in areas of mechanical stress such as breasts, abdomen, thighs, groin, or buttocks.

Adopting a combination approach at MSI that includes; topical cosmeceuticals, diamond peel, non-ablative vascular, and water targeted lasers as well IPL and fractional CO2 laser had led to a successful outcome in treating both red and white striae.

Warts (Verrucae): are caused by a viral infection of the cells found in the top layer of the ski. They are caused by one or more members of the human papillomavirus (60 viruses). Each of the HPV types is associated with a different type of wart. Several different warts include common hand warts, foot warts, flat warts, and genital warts. Warts commonly occur in children and young adults but may appear at any age. Their course is highly variable. Most resolve spontaneously in weeks or months; others may last years or a lifetime. Warts are transmitted simply by touch. And commonly appear at sites of trauma, on the hands, in peri-ungual regions from nail-biting, and on plantar surfaces. Warts are skin-colored and feel rough to the touch. Histologically there are prominent, dilated blood vessels in dermal papillae that are thought to provide nutrients to infected epidermal cells. Although commonly more of cosmetic or nuisance significance, warts can be painful and even disabling in sub-ungular or plantar locations. Recent evidence showed that selective destruction of prominent blood vessels in warts using a specific vascular laser would prevent virus-infected cells’ nutritional blood and growth. The red and infra-red long pulse is used on all types of warts, including recalcitrant warts. Lesions appear gray to purpuric becoming black after twenty-four hours. Patients treat everyone for two weeks until resolution. Efficacy of the treatment, in addition to ease and lack of pain or scarring, makes laser a superior tool in fighting recalcitrant warts compared with other traditional modalities. Wart regression after vascular laser surgery presumably results from vascular-specific injury inflicted on their prominent dermal blood supply, thought to provide nutrients to infected epidermal cells. Over the past few years, the carbon dioxide laser (CO2) has become a relatively common modality in treating warts, particularly in those lesions that have proven recalcitrant to other traditional therapies. The ability to operate in a bloodless field offers well-documented advantages.

Treatment sessions consist of three phases; pretreatment preparation, treatment, and post-treatment healing phase: You are advised to avoid aspirin or any non-steroidal anti-inflammatory agent such as ibuprofen to prevent the occurrence of bruising after treatment. Topical Vitamin K may be applied two weeks before your session and continued for another two weeks to decrease any incidence of bruising. Most patients benefit from topical anesthetic cream (EMLA) applied under an occlusive dressing one to two hours before laser treatment and removed just before the surgery. During the procedure, I will cover my eyes with protective eyewear. The skin is kept cool with a cold gel or another cooling device for the patient’s comfort. The procedure itself is relatively quick, but the duration is variable depending on the site treated. Following the procedure, a topical antibiotic and dressing may be applied to the treated area. You will be provided detailed instructions for the care of the treated area by a medical staff member.

The treated area may develop a crust and/or a scab that should be handled gently to minimize the potential for alterations in the skin’s texture. Generally, the treated area should heal throughout one to two weeks, with gradual fading over time. Any subsequent treatment sessions should be scheduled two to six weeks apart.

Conclusion

• Vascular lesions are one of the most common indications for laser treatment.
• Pulsed dye laser remains the standard gold treatment for port-wine stains, and while most improve, the minority clear entirely.
• Early laser treatment improves port-wine stain response
• Indications for laser treatment of hemangiomas include ulcerated lesions and involuted lesions with residual telangiectasias and/or textural change
• The role of laser treatment for proliferating hemangiomas remains less clear and may be most beneficial for superficial hemangiomas
• I may implement Deeper-penetrating near-infrared lasers to treat select venous malformations
• Vascular lasers and intense pulsed light are the treatment of choice for the background erythema and telangiectasias associated with rosacea
• Poikiloderma of Civatte can be successfully treated with intense pulsed light, or a combination of vascular and pigment selective lasers