激光治疗：血管病变患者的新选择

拉斯维加斯——在美国美容外科学会(AACS)年会上，加州索拉纳海滩的皮肤科医生Melanie Palm博士表示，可应用8个微脉冲(而非1个)的595-nm脉冲染料激光器是治疗血管病变的首选装置。

Melanie Palm博士

与该激光器的前几代相比，目前这一代在使用较高注量时不会产生茄子紫变色或紫癜。例如，在治疗鼻毛细血管扩张时，将新一代595 nm脉冲染料激光器的参数设为注量13~15 J/cm2、脉冲宽度40毫秒和光斑大小7 mm，不会发生使用老式585 nm脉冲染料激光器时观察到的紫癜。

Palm 博士还使用595 nm脉冲染料激光器治疗酒渣鼻、樱桃血管瘤、静脉湖、血管畸形、炎症后红斑、膨胀纹、疤痕和紫癜。她经常使用联合治疗方案。对于瘢痕，她可能会联合使用5 -氟尿嘧啶和病变内注射康宁克通(曲安奈德)，并立即使用595 nm脉冲染料激光器，参数设为注量8 j/cm2、脉冲宽度10毫秒和光斑大小7 mm。对于顽固疣，治疗方案是病变内注射博来霉素，并使用595 nm脉冲染料激光器，参数设为1~15 J/cm2、脉冲宽度1.5毫秒和光斑大小7 mm。使用595 nm脉冲染料激光器治疗晒斑和其他色素性皮肤病也具有一定效果。她还经常使用该激光器处理治疗后瘀伤。

强脉冲光是Palm博士用来治疗血管病变的另一种技术。使用该技术时需要多次治疗，因为在治疗后血管会发生痉挛、消失然后又出现，通常需要数周时间才能够观察到改善。在进行强脉冲光治疗前，Palm博士通常使用利多卡因乳膏作为麻醉剂来缓解患者不适。如果患者需要更强的麻醉剂，Palm博士会联合使用利多卡因和丁卡因，后者可导致潮红。在治疗前，还可使用吹风机来刺激面部的红斑。Palm博士通常使用515 nm滤光片和三脉冲的强脉冲光治疗面部红斑。对于面部毛细血管扩张，她通常使用560 nm滤光片和双脉冲的强脉冲光治疗。对于顽固斑点，她改用较小的治疗机头，这样可产生较高注量。

Palm博士建议临床医生积极治疗术后瘢痕。对于发红，她通常在术后1个月就尽早使用脉冲染料激光或强脉冲光治疗。如果使用脉冲染料激光器，参数设为注量7~10 J/cm2、脉冲宽度10毫秒和光斑大小7 mm。如果使用强脉冲光，她会使用560 nm滤光片，并将装置的参数设为注量16~18 J/cm2和脉冲宽度4毫秒。对于术后瘀伤，如果使用脉冲染料激光器，参数设为注量6 J/cm2、脉冲宽度6毫秒和光斑大小10 mm；如果使用强脉冲光，则使用560 nm滤光片，装置的参数设为13~15 J/cm2和脉冲宽度4毫秒，采用双脉冲模式。注量与瘀伤程度成反比。如果瘀伤严重，则减少注量。如果瘀伤轻微，则使用较高注量。Palm博士通常使用单脉冲，这可避免加重瘀伤。Palm博士不仅治疗瘀伤部位，而且对其周围1 cm内的区域也进行治疗。

Palm博士在会上也讨论了其使用Q-转换Nd:YAG双频532 nm激光器治疗面部发红的经验。使用双频1,064 Nd:YAG平台通常治疗1次即可。她一般使用8 mm机头，参数设为注量3.5~5 J/cm2。治疗一两次通常即可见效。

Palm博士声明是Valeant、Medicis和Lumenis公司的讲师，并且是Lutronic公司的顾问。

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By: DOUG BRUNK, Internal Medicine News Digital Network

LAS VEGAS – The 595-nm pulsed dye laser, which allows for the application of 8 micropulses instead of a single pulse is one go-to device for treating vascular lesions, according to Dr. Melanie Palm.

"This allows me to use higher fluences without some of that eggplant purple discoloration or purpura that I would get if I used higher fluences in earlier generations of this laser," Dr. Palm said at the annual meeting of the American Academy of Cosmetic Surgery.
 
For example, when treating nasal telangiectasias, Dr. Palm said she sets the parameters to a fluence of 13-15 J/cm2, a pulse width of 40 milliseconds, and a spot size of 7 mm. "Using this new platform, I don’t get any of the purpura that you would expect with the more traditional 585-nm pulsed dye laser," said Dr. Palm, a dermatologist in Solana Beach, Calif.

Dr. Palm said she also has used the 595-nm pulsed dye laser (PDL) to treat rosacea, cherry angiomas, venous lakes, vascular malformations, postinflammatory erythema, striae distensae, scars, and purpura. "I will often combine treatments," she continued. For scars, she may combine 5-fluorouracil and intralesional Kenalog (triamcinolone), and immediately treat with the 595-nm PDL set to a fluence of 8 J/cm2, a pulse width of 10 milliseconds, and a spot size of 7 mm. For recalcitrant warts, she will often try intralesional bleomycin combined with the 595-nm PDL set to a fluence of 1-15 J/cm2, a pulse width of 1.5 milliseconds, and a spot size of 7 mm. "If the 595-nm PDL is the only laser in your office, you can use it to treat solar lentigines and other pigmentary disorders with some success," Dr. Palm said. "I also use it a lot for posttreatment bruising."

Intense pulsed light (IPL) is another technology Dr. Palm said she uses to treat vascular lesions. When discussing this technology with her patients, "I set the expectation that this is going to involve multiple treatments," Dr. Palm said. "I’ll often show them right after treatment that the vessels have gone into vasospasm. They have disappeared, but they will come back, and it will be several weeks before they see improvement."

Dr. Palm said she typically uses lidocaine cream as a numbing agent to improve patient comfort prior to IPL procedures. "But if patients want a stronger numbing agent, I mix lidocaine with tetracaine, which has a tendency to cause flushing," she said. "You can also use a hair dryer to aggravate erythema on the face prior to treatment."

Dr. Palm said she often uses the 515-nm filter with IPL energy applied in triple pulses to treat facial erythema. For facial telangiectasias, she typically uses the 560-nm filter with IPL energy applied in double pulses. "For stubborn spots, I switch to a smaller treatment hand piece, which creates higher fluence," she said.

Dr. Palm said she advises clinicians to be aggressive in treating postoperative scars. "If I see some redness, I’ll often treat as early as 1 month after treatment, using either a PDL or an IPL," she said. If she uses a PDL, she sets it to a fluence of 7-10 J/cm2, a pulse width of 10 milliseconds, and a spot size of 7 mm. If she uses an IPL, she employs a 560-nm filter, and sets the device to a fluence of 16-18 J/cm2 and a pulse width of 4 milliseconds.

To treat postprocedural bruising, Dr. Palm said she may use a PDL set to a fluence of 6 J/cm2, a pulse width of 6 milliseconds, and a spot size of 10 mm. If she opts to treat the bruising with an IPL, she employs a 560-nm filter and sets the device to a fluence of 13-15 J/cm2 and a pulse width of 4 milliseconds, and applies it in a double-pulse fashion. "You want to titrate the fluence inversely to the degree of bruising," Dr. Palm advised. "If you have an intense bruise, you want to decrease the fluence. If it’s a light bruise, you want to use higher fluences," she said. "I typically use a single pulse. You want to avoid pulse stacking because you can make the bruising worse. I don’t just treat where the bruise is. I treat within a centimeter around the bruised area as well."

Dr. Palm also discussed her experience using the Q-switched Nd:YAG double-frequency 532-nm laser as "a peel" to treat facial redness. "It’s usually a single-pass treatment that uses a double-frequency 1,064 Nd:YAG platform," she said. "I typically use an 8-mm hand piece set to a fluence of 3.5-5 J/cm2. Results are usually apparent within one to two treatments," she noted.

Dr. Palm disclosed that she is a speaker for Valeant, Medicis, and Lumenis. She is also a consultant for Lutronic.