Unilateral Nevoid Telangiectasia Treated with Pulsed Dye Laser

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Unilateral Nevoid Telangiectasia Treated with Pulsed Dye Laser: Use of Dermoscopy to Monitor the Response

Unilateral nevoid telangiectasia (UNT) is a rare vascular dermatosis characterized by linear, unilateral patterns of telangiectasia. While its exact etiology remains unclear, elevated estrogen levels—often associated with puberty, pregnancy, oral contraceptive use, or chronic liver disease—are hypothesized to contribute to its development. Patients frequently seek treatment for UNT due to cosmetic concerns. Pulsed dye laser (PDL) therapy, a modality known for its ability to selectively target blood vessels through photothermolysis, has emerged as an effective treatment for vascular lesions such as port-wine stains, hemangiomas, and spider angiomas. This case report highlights the successful use of PDL in treating UNT and underscores the role of dermoscopy in monitoring therapeutic responses.

Clinical Presentation and Diagnostic Evaluation

A 12-year-old girl presented with a four-year history of progressively increasing telangiectasias on her right arm. The lesions appeared as linear, erythematous patches consistent with the clinical features of UNT. Dermoscopic examination (CBS-908; CBS Inc., Wuhan, China) revealed a vascular pattern dominated by small red-dotted and globular vessels against a reddish background [Figure 1B]. Reflectance confocal microscopy (RCM; Vivascope 1500; Lucid Inc., Rochester, NY, USA) further corroborated the diagnosis by showing dilated vessels within the dermal papillae, with visible red and white blood cells circulating in the lumen [Figure 1C]. These findings confirmed the superficial location of the vascular abnormalities, a critical factor in predicting favorable responses to PDL therapy.

Treatment Protocol

The patient underwent three sessions of PDL therapy using a fast-lamp tunable PDL system (Cynosure VLS, Chelmsford, MA, USA). Preoperative preparation included the application of a topical anesthetic cream (2.5% lignocaine and 2.5% prilocaine) for one hour. Laser parameters were standardized as follows:

  • Wavelength: 595 nm (optimized for hemoglobin absorption)
  • Spot size: 7 mm
  • Fluence: 7.5–8.5 J/cm²
  • Pulse duration: 0.5 ms
  • Cooling: Air cooling (Cryo 5, Zimmer, Germany)

Treatments were administered at six-week intervals. Post-procedure care included strict sun protection and daily use of sunscreen (SPF 35).

Immediate and Short-Term Responses

Immediately after the first session, the treated areas exhibited erythema and purpura [Figure 1D], indicative of vascular rupture and erythrocyte extravasation. Dermoscopy at this stage showed persistent red-dotted and globular vessels but with a more pronounced reddish background [Figure 1E]. RCM imaging revealed capillary thrombosis within the dermal papillae [Figure 1F], confirming effective coagulation of oxyhemoglobin and vascular destruction.

After the first treatment, the patient achieved approximately 80% clearance of the telangiectasias. A second session resulted in near-complete resolution, with only minimal residual vessels visible under dermoscopy [Figure 1G, H]. The third session eliminated these remaining vessels, achieving full clinical clearance [Figure 1J]. However, oval-to-round hyperpigmentation was noted at the treatment sites, a known side effect of PDL linked to melanin absorption of laser energy.

Role of Dermoscopy in Monitoring

Dermoscopy played a pivotal role in both pretreatment assessment and post-treatment monitoring. The initial dotted and globular vascular pattern observed in this case is classified as a superficial vascular morphology, which correlates with higher treatment efficacy. In contrast, reticular or deep vascular patterns are associated with poorer outcomes. By tracking changes in vascular structures after each session, dermoscopy provided real-time feedback on treatment progress and helped determine the optimal endpoint for therapy. Post-treatment dermoscopy confirmed the absence of residual vessels [Figure 1K], aligning with clinical outcomes.

Reflectance Confocal Microscopy (RCM) Insights

RCM complemented dermoscopy by offering cross-sectional visualization of vascular changes. Pretreatment RCM images highlighted dilated papillary vessels [Figure 1C], while post-treatment imaging demonstrated thrombosed capillaries [Figure 1F, I], confirming vessel occlusion. Final RCM evaluation after three sessions showed normalization of the papillary dermis architecture [Figure 1L], further validating the treatment’s success.

Discussion

This case illustrates the efficacy of PDL in managing UNT, particularly in patients with superficial vascular patterns identifiable via dermoscopy. The correlation between dermoscopic findings and therapeutic outcomes underscores the utility of this non-invasive tool in guiding laser therapy. The 595 nm wavelength used here selectively targets hemoglobin, ensuring minimal collateral damage to surrounding tissues. The 0.5 ms pulse duration is optimal for coagulating small, superficial vessels while avoiding excessive thermal diffusion.

Hyperpigmentation, a common side effect of PDL, was managed with sun protection measures. The transient nature of this side effect and its resolution over time were discussed with the patient, emphasizing the importance of postoperative care.

Conclusion

The successful treatment of UNT in this case highlights the importance of integrating dermoscopy and RCM into therapeutic protocols. Dermoscopy not only aids in pretreatment prognostication but also enables precise monitoring of vascular changes, ensuring timely intervention and optimal outcomes. PDL remains a gold-standard modality for superficial vascular lesions, with parameters tailored to individual lesion characteristics. Future studies should explore long-term outcomes and the role of estrogen modulation in preventing recurrence.

doi.org/10.1097/CM9.0000000000000397

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