1. Introduction

Vascular lesions on the face or body are widespread and lead to dissatisfaction with appearance and reduced self-esteem in patients and negatively impact their health-related quality of life [1]. Laser have become a significant support and for patients a frequently desired treatment executed by dermatologist all over the world. They are an effective therapy option for small vessels, melasma, telangiectasia and post-inflammatory hyperpigmentation (PIH) with a vascular component, occurring, among others, as a result of acne vulgaris [2].

PDL treatments with wavelengths from 577nm – 595 nm have become a gold standard in the treatment of vascular lesions [3]. As one of the most common and frequently performed laser treatments for superficial, vascular lesions the procedure can lead to purpura, when not performed below the purpuric threshold. In particular, short pulse durations (0.5ms) are associated with a high frequency of purpura, which can persist for several days to a few weeks [4]. This effect is normally not well accepted in aesthetic treatments, where no social downtime is wanted [3]. An additional non-negligible disadvantage of the PDL for operation in practice is the significant maintenance costs, which are due, among other things, to the use of dye.

The aim of reporting these two cases was to show the effective improvement of vascular lesions as melasma, telangiectasia and post-inflammatory hyperpigmentation, resulting from acne vulgaris, using an alternative method to PDL, a 577nm diode laser (QuadroStarPRO YELLOW, Asclepion Laser Technologies GmbH). The used laser is a diode laser with HOPSL (High-power Optically Pumped Semiconductor Laser) technology. The wavelength used falls within the lower end of the standard therapy’s wavelength range, specifically that of the PDL pulsed-dye laser (PDL) spectrum. This wavelength of 577nm has the best absorption in haemoglobin, leading to appropriate occlusion of the vessel by selective photo thermolysis [5, 6].

2. Materials and methods

Treatment data and photos of this case report were collected retrospectively from the routine physician consultation and treatment of the two patients (20 and 34 years old) described in this article. Both female patients suffer(ed) from acne and skin impurities in their early twenties. This resulted in resistant PIH (Post-Inflammatory Hyperpigmentation) with underlying vascular components, telangiectasias in combination with rosacea and hyperplasia of sebaceous glands, acne scars and erythema. After clinical examination and detailed anamnesis both patients were treated using the 577nm emitting diode laser with HOPSL technology. For both patients, pictures were taken directly before and 1 month after the laser treatment for measuring clinical outcomes by subjective assessment of the physician (Figure 1-2). Improvement was rated as excellent (75% – 100%), very good (50% – 74%), good (25% – 49%), and poor (<25%).

The laser has two handpiece options. Treatment can be performed with a single spot focused handpiece to treat small lesions such as angiomas or fine telangiectasias with targeted pulses, or a with a scanner handpiece in scanner mode for larger target regions. For the cases presented in this report, we decided to treat each case with the scanner handpiece, which has an integrated cooling through sapphire glass. The second patient was additionally treated with the single spot focused handpiece (Case 2, first pass).

Case 1

A 20 years old, female patient; Fitzpatrick skin type IV, presented to the practice with acne scars and persistent erythema secondary to an acne vulgaris flare-up. During examination with a dermatoscope, erythema and small telangiectatic vasodilatations were visible. After validating the potential risks for side effects and contraindications and obtaining written informed consent, the area was cleaned with a skin disinfectant, and a thin layer of clear ultrasound gel was applied. The scanner handpiece was used with an energy of 16 J/cm², 60 – 80% coverage and a pulse duration of 26 ms. During application the area was precooled with the scanner tip, to increase the tolerance level for pain. The tip was placed in contact and mild pressure on the treatment area. One pass was performed. The after-treatment procedure consisted of post-cooling and sunscreen. A total of four sessions were performed, with a three-week interval between sessions.

Case 2

A 35 years old, female patient; Fitzpatrick skin type III-IV, presented to the practice with erythematotelangiectatic rosacea and associated hyperplasia of sebaceous glands. This subtype of rosacea is characterized by flushing (transient erythema), persistent, central facial erythema (background erythema), and telangiectasias. Macroscopic, prominent vasodilatations were visible and a pronounced erythema in the background. After validating potential risks for side effects and contraindications and obtaining written informed consent, the area was cleaned with a skin disinfectant, and a thin layer of clear ultrasound gel was applied. Two passes, each with one of the two handpieces were performed. The prominent vessels were treated using the single spot focusing handpiece in basic mode with moderate contact and mild pressure on the treated area with 14 J/cm² and a 2Hz frequency. A single spot-technique was used for the first pass following the course of each vessel continuously without any overlap to reduce potential side effects. No pre-cooling was performed. The second pass was performed to treat the background erythema, using the scanner handpiece with 14J/cm², a pulse duration of 22ms and a coverage of 80%. One session was performed on this patient.

3. Results

Case 1

The procedure was well tolerated by the patient. As a clinical endpoint, vasospasm and a darkening of the erythema was observed. After a few minutes, a slight edema appeared. In Figure 1 it can be seen that acne scars and persistent erythema are strongly reduced. (rated as very good outcome (50% – 74%) by the physician).

Fig: 1: Female patient, 20 years. 4 sessions within 9 weeks, scanner mode Fluence (16 J/cm2, one pass). a) status before treatment, b) status 1 month after treatment.

Case 2

The procedure was well tolerated by the patient. As a clinical endpoint visible clearance of the treated area was observed. After a few minutes, a mild edema appeared. In Figure 2 it can be seen that acne scars and persistent erythema are strongly reduced (rated as very good (50% – 74%), by the physician).

Fig. 2: Female patient, 35 years presenting with a subtype of rosacea with flushing erythema, persistent, central facial erythema, and telangiectasia, 1 session, two passes.  A: status before treatment, B: status 1 month after treatment.

We observed an improvement of over 50%, as estimated by the patients’ subjective perceptions, clearly visible in the before and after treatment photos (Figure 1, Figure 2). Both patients expressed high satisfaction with the treatment, largely due to the visible, positive changes in the treated areas.

During the treatment process, the patients reported a heat sensation and discomfort, rating it as 5/10 on the visual analogue scale (VAS) for pain, which indicates mild to moderate discomfort. Apart from mild redness and slight swelling, no further side effects were observed in either of the patients.