Long-pulsed 1064nm Nd:YAG laser in the treatment of leg veins: Systematic review

Abstract

Objective

Long-pulsed 1064 nm Nd:YAG laser can damage vessels with higher diameters and penetrate to a deeper level than other laser therapies. We aim to analyze outcomes of the treatment of leg veins with long-pulsed 1064 nm Nd:YAG laser regarding intervention protocol, technical success, clinical success, and side effects.

Methods

A research of the published literature was conducted, using PubMed and Embase databases, in April 2022. The key words used were telangiectasia, reticular veins, neodymium YAG laser, clearance, satisfaction, and treatment. PRISMA guidelines were followed.

Results

We included twenty-six articles, twenty-three prospective and three retrospective studies, with a total of 1991 patients. The articles were organized in different sections according to the control group. The four outcomes were analyzed in each section. These studies showed that the long-pulsed 1064 nm Nd:YAG laser is a safe and very good option for the treatment of leg veins measuring up to 3 mm in diameter. Studies comparing long-pulsed 1064 nm Nd:YAG laser therapy and sclerotherapy showed similar clearance rates with no significant differences. However, sclerotherapy seemed to be less painful and to have faster clinical improvements. In two articles, Nd:YAG laser had better outcomes in the treatment of smaller vessels with less than 1 mm in diameter, than sclerotherapy alone. Treatment with polidocanol microfoam and Nd:YAG laser had better clearance rates than Nd:YAG laser alone in three studies. In the comparison of 1064 nm Nd:YAG laser therapy with other lasers and light sources, the studies had contradictory results.

Conclusion

Long-pulsed 1064 nm Nd:YAG laser is a valid therapeutic option for leg telangiectasia and reticular veins with great aesthetic outcomes and minor side effects. Nd:YAG laser therapy could be combined with sclerotherapy or other laser therapies or IPL in order to achieve better results. Serious side effects are rare, but the procedure is almost always accompanied by moderate tolerable pain.

Keywords

Neodymium YAG laser telangiectasia reticular veins efficacy satisfaction

Introduction

Leg telangiectasias and reticular veins are a very common and prevalent unaesthetic problem. Their etiology is not well understood and may or may not be concurrent with venous hypertension. The result is an unaesthetic appearance of the legs, and some of these patients can become symptomatic over time. Furthermore, it can be responsible for psychological side effects that distress self-confidence and mental health. For all these reasons, this is a significant concern nowadays with an increasing demand for cosmetic treatment.

Sclerotherapy remains a gold standard in the treatment of leg telangiectasias and reticular veins. However, a continuous technological development in laser devices has been noticed and laser therapy is now a noninvasive and efficiently proven option for the treatment of leg veins. It could be an option to consider in many patients, but it has a clear application in patients with needle phobia, resistance or contraindications for sclerotherapy, and vessels too small for the needle diameter.¹

In laser therapy, there is a conversion of the absorbed light energy into thermal energy. This energy will heat the target chromophore, which is the hemoglobin present in the treated vessels, resulting in vascular coagulation.² Cooling of the skin is crucial to minimize side effects such as burned skin and post-inflammatory hyperpigmentation. Pulse durations, wavelength, and fluence will determine the selectivity for the target vessels, depth level of penetration, and potency of the laser device, respectively.³

Despite the technological evolution, leg veins remain a difficult pathology to treat with laser devices, especially deeper and larger vessels. Long-pulsed 1064 nm Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser can damage vessels with higher diameters and penetrate to a deeper level into the dermis avoiding absorption by the epidermal melanin. In fact, it can be used to treat deeper and larger varicose veins and has less side effects in the skin surface, compared to other laser techniques. On the other hand, some patients have been describing laser therapy as more painful than sclerotherapy.^4–8

In this systematic review, we aim to gather and analyze the information published so far related to different outcomes of long-pulsed 1064 nm Nd:YAG laser in the treatment of leg veins (intervention protocol, technical success, clinical success, and side effects).

Methods

We performed an electronic search of the literature published about this matter, in the PubMed and Embase databases. The search was conducted in April 2022. The key words used in the search engines advanced tool followed the PICO scheme: ((telangiectasia* OR reticular veins*) AND (neodymium yag laser OR Nd:YAG) AND (clearance* OR satisfaction* OR treatment*)). We included only retrospective or prospective studies, in English. Backwards citation tracking was performed by manual review of the lists of references of each included article. PRISMA guidelines for systematic review were followed. Risk of bias was evaluated using ROB2 crossover bias assessment (Figure 1).

Figure 1.

ROB2 crossover bias assessment.

The inclusion criteria were studies published since January 2000 until April 2022; only articles in English; studies with information about treatment of telangiectasia or reticular veins in the lower extremities; and retrospective or prospective studies. There were no exclusion criteria related to gender, ethnicity, or socioeconomic level. Commentary, letter, expert opinion, or review articles were excluded. Animal studies or studies with a pregnant population were also excluded.

The primary outcomes of this systematic review were technical success, clinical success, and side effects. Secondary outcomes were the features of the intervention protocol.

Results

First, we screened the titles of 174 articles retrieved in our search after excluded those that were duplicated. Then, we excluded 136 articles after scanning the titles and abstracts. After fully read 38 reports, we end up with 20 articles that we could use to discuss in this systematic review. Finally, we searched the selected articles’ references and found six more suitable articles, giving a total of twenty-six studies included in our review (Figure 2).

Figure 2.

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only.

We included twenty-six studies, twenty-three prospective and three retrospective, with a total of 1991 included patients. The articles were organized in different sections according to the control group: (I) case series of long-pulsed 1064 nm Nd:YAG laser without a control group; (II) long-pulsed 1064 nm Nd:YAG laser versus sclerotherapy; (III) long-pulsed 1064 nm Nd:YAG laser versus other laser therapies; and (IV) combined treatments. Then, we analyzed the outcomes we aimed to study in each section (intervention protocol, technical success, clinical success, and side effects).

The intervention protocol refers to the laser settings (spot size, pulse duration, and fluency), the number of sessions, and the control group. The evaluation of the results was based on the comparison of pretreatment and posttreatment pictures of the treated areas. The technical success was described by the clearance rate assessed by one or more experienced physicians that graded the results according to a selected scale that varied across the studies, but that was mostly divided in relation with the percentage of clearance. The clinical success corresponded to the patients’ satisfaction with the results, patients’ subjective clearance rate, and painful sensation. To measure the clinical success, some studies had the participants answering a self-evaluation questionnaire at the follow-up to quantify their satisfaction and subjective clearance according to a selected scale and their pain with a visual analogue scale. Finally, the side effects were assessed and compared between different treatment groups.

Case series of long-pulsed 1064 nm Nd:YAG laser

Nine studies were case series of patients treated with long-pulsed 1064nm Nd:YAG laser without a control group. In general, these studies showed that the long-pulsed 1064 nm Nd:YAG laser is a safe and very good option for the treatment of leg veins measuring up to 3 mm in diameter (Table 1).^4,5,9–15

Table 1.

Long-pulsed 1064 nm Nd:YAG laser efficacy.

Authors	Type of study	No. of patients	Patients characteristics	Follow-up	Exclusion criteria	Intervention	Technical success	Clinical success	Side effects
Eremia et al.⁹	Prospective study	30	Females, 32–67 years, skin types I to V	1 week, 1, 2, and 3 months	Previous history of deep vein thrombosis, pregnancy, poor wound healing diseases (diabetes), connective tissue disease, hypercoagulability, keloid formation, and large varicose veins	Up to two sessions with 4–6 weeks apart; laser parameters varied according to the size of the treated veins	Improvement of >75% was seen at 85% of the vessels treated sites; improvement of >50% was seen at 95% of the treated sites; improvement of <25% was seen at 5% of the treated sites^a	-	Transient post-inflammatory hyperpigmentation (n = 6), burns with blisters (n = 3), and telangiectatic matting (n = 1); all these complications healed without scarring
Ianosi et al.¹⁰	Prospective study	446	21 males and 425 females, >18 years, skin types II to IV	1 month	Infection or inflammation of the cutaneous treated area, deep venous thrombosis, pregnancy, intake of non-steroidal anti-inflammatory drugs, isotretinoin, recent exposure to ultraviolet radiations, photosensitization or allergies, vitiligo, psoriasis, immunosuppressive diseases, hypertrophic scars, or hyperpigmented areas	Laser spot 1.5–6 mm, pulse duration 10–30 ms, and fluency 350–500 J/cm²; vessels <2 mm	Doctor’s satisfaction increased from 6.116 at the initial phase of the treatment to 9.000 in the end (p < .001)^b	Patients’ satisfaction increased from 6.029 at the initial phase of the treatment to 8.703 in the end (p < .001).^b Sensitivity was assessed with a scale from 1 (most intensive pain) to 10 (no pain). The average sensitivity was 6.33 for men and 7.077 for women
Major et al.¹¹	Prospective study	32	29 females and 3 males, 24–58 years, skin types II to III	-	Inflammatory disorders of cutaneous circulation, hypercoagulability, large tortuous veins, pregnancy or lactation, systemic diseases, systemic drugs, photosensitivity, history of poor healing, or keloid formation	1–5 sessions at 8 weeks intervals; pulse duration 10–30 ms, fluency 125–200 J/cm², 10–30 ms and 2 Hz repetition rate	29/32 (90.6%) patients showed 50%–100% clearing of the lower extremity vessels after three to five sessions^a	The treatment was well tolerated	Transitory hypopigmentation (n = 2), which resolved in 2–3 months
Omura et al.³³	Prospective study	20	Females, 23–69 years, skin types I to IV	1 and 3 months	<18 years old, pregnancy, scarring or infection in the treatment areas, use of iron supplements or an anticoagulant, history of a photosensitivity disorder, keloids/hypertrophic, scarring and herpes simplex in the treatment area	One treatment session; fluence of 100 J/cm² and pulse duration 50 ms; vessels 1.0–3.0 mm	There was greater than 50% clearance in 21 of 24 vessels and greater than 75% clearance in 16 of 24 vessels.^a Larger vessels (2.0–3.0 mm) had a more significant improvement than smaller vessels (1.0–1.5 mm)		Matting (n = 4), transient hyperpigmentation (n = 2), transient bruising (n = 5), and superficial thrombosis (n = 8, one requiring needle aspiration)
Ozyurt et al.¹²	Prospective study	99	Females and males, 7–65 years, skin types II to V	1 month after the first, third, and fifth sessions	Diabetes mellitus, cardiovascular diseases, and anticoagulant drugs	Five sessions with 4 weeks apart, in a 5 year period; fluence increased up to 500 J/cm² with 1.5 mm spot size in veins <0.5 mm; fluence 260–320 J/cm² with 3 mm spot size, in larger leg veins	80.8% of the leg veins showed a significant clearance after five sessions, but only 21.2% had this improvement after three sessions^c		Pain and erythema 80.8%, focal thrombosis 7.1%, bulla formation 2.1%, erosion and crusting 6.1%, and transient post-inflammatory hyperpigmentation 14.1%
Parlette et al.¹⁶	Prospective study	18	Females, 27–82 years, skin types I to IV	1, 7, and 21 days	Scarring or infection in the treated area, photosensitivity, medications in the previous 3 months known to induce photosensitivity, isotretinoin within the last 6 months, iron supplements or anticoagulants, thromboembolic condition or hypercoagulability, immunocompromised state, systemic disease, pregnancy or lactation, poor wound healing or keloidal scarring, and skin type V or VI	Single session with different pulse durations (20 ms, 40 ms, and 60 ms); vessels of 0.1–1.6 mm	Complete clearance in 71% of the vessels.^a Longer pulse durations (40–60 milliseconds) were associated with higher clearance rates. For smaller vessels, it is necessary lager fluences to achieve immediate vessel changes	Patients were satisfied (mean score of 4.2) with a mean subjective improvement of 3.8 out of 5^d	Longer pulse durations (40–60 milliseconds) were associated with less side effects
Rogachefsky et al.¹³	Prospective study	21	Females 22–69 years, skin types I to IV	3 months	Pregnant, predisposition for hypertrophic scars or keloids, history of laser irradiation or sclerotherapy in the past year, and immunocompromised	Two sessions with 4–6 weeks interval; pulse durations 10–50 msec, and fluences 90–187 J/cm2; vessels 0.25–4 mm in diameter	Significant improvement was observed in 71% of the patients.^e The results were better in blue vessels with larger diameter (2.1–4 mm), but these were also the vessels with higher rates of hyperpigmentation		Hyperpigmentation (62% of the patients at 3 months)
Sadick et al.⁵	Prospective study	13	Females, 32–58 years, skin types II to V	4 weeks		One session; spot size 6 mm, pulse duration 14 msec, fluence and 130 J/cm²; vessels 0.5–4 mm	Significant clearance (75%–100%) was observed in 62% of the patients^a		Transitory hyperpigmentation (23%) and telangiectatic matting (8%)
Sadick et al.¹⁴	Prospective study	10	Females, 26–57 years, skin types I to IV	3 and 6 months	<18 years, pregnancy, scarring or infection in the treatment zones, suntan, iron supplements or an anticoagulant, history of photosensitivity disorder, keloid/hypertrophic scarring, and Herpes simplex in the treatment area	Up to three sessions; spot size 1.5 mm, fluence 400 to 600 J/cm², and pulse duration 30–50 ms for red vessels 0.2–1 mm; and spot size 3 mm, fluence 250–370 J/cm², and pulse duration 50–60 ms for blue vessels 1–3 mm)	Significant clearance (>75%) was observed in 80% of the patients at 6 months after treatment.^a The results were similar in red smaller vessels and in blue larger vessels	90% of the patients were highly satisfied with the results^f	Transitory hyperpigmentation 2 (20%), bruising 2 (20%), superficial focal blistering and crusting one (10%) and had telangiectatic matting one (10%)
Sadick et al.⁴	Prospective study	25	Females, 21–56 years, skin types II to V	6 and 12 months	Pregnancy, oral contraceptive therapy in the last 3 months, and history of thrombophlebitis or sclerotherapy in the last 6 months	Up to three sessions at 6-week intervals; single 14 ms pulse, fluence 130 J/cm², spot size 6 mm for 2.0–4.0 mm vessels; and double synchronized pulse of 7 ms separated by a 20 msec delay, fluence 120 J/cm², and spot size 6 mm for 0.2–2.0 mm vessels	Significant clearance (>75%) was observed in 64% of the patients after a maximum of three sessions, and 72% had at least 50% clearance^a	64% reported to be highly satisfied with the results, 16% were moderately satisfied, 8% minimally satisfied, and 8% were disappointed^g	Four patients (16%) had temporary hyperpigmentation and two patients (8%) had telangiectatic matting
Trelles et al.¹⁵	Retrospective study	100	Females, 25–60 years, skin types II to IV	6 months	Pregnancy, history of scarring, and history of previous laser and/or sclerotherapy	Up to two sessions at a 2 months interval; pulse length of 20 ms and 130 J/cm² for the 1 mm veins; 30 ms and 120 J/cm² for the 2 mm veins; 40 ms and 110 J/cm² for the 3 mm veins; and 50 ms and 100 J/cm² for the 4 mm veins	Clinical and computer assessment considered the treatment “Good” or “Very good” in 64% and 71% of the patients, respectively.^a There was no significant difference in results regarding different skin types	Patients’ satisfaction was assessed through a questionnaire. Only 57% of the patients considered the treatment “Good” or “Very good”	The side effects were discomfort during treatment and matting. The presence of side effects was similar in all skin types

y: years-old.

^aObserver(s) judged the outcome and graded the improvement in five percentage groups (0%; 0%–25%; 25%–50%; 50%–75%; 75%–100%).

^bPatients rated their satisfaction and subjective improvement in five groups: 1 (no satisfaction/improvement), 2 (little satisfaction/improvement), 3 (somewhat satisfied/some improvement), 4 (satisfied/significant improvement), and 5 (very satisfied/complete improvement).

^cClearance was graded in subgroups: clear (I), marked improvement (II), partial response (III), poor response (IV), and no change or worsening.

^dEfficacy scale from 1 (totally unsatisfied) to 10 (totally satisfied) was used by the doctor and each patient to assess the results.

^eObserver(s) rated the clearance rate in four subgroups: none; mild; moderate; significant.

^fPatients’ satisfaction was evaluated in a posttreatment questionnaire and graded in three groups (not satisfied; somewhat satisfied; highly satisfied).

^gPatients’ satisfaction was assessed by a self-evaluation scale (not at all satisfied; minimally satisfied; moderately satisfied; greatly satisfied).

The number of sessions in the treatment of leg veins can possibly play an important role in the outcomes. In these studies, the number of sessions varied between one and five. Ozyurt et al. found that 80.8% of the leg veins treated with Nd:YAG laser showed a significant clearance after five sessions with 4 weeks interval, but only 21.2% had this magnitude of improvement after three sessions.¹² On the other hand, the studies in our search with the best clearance results needed up to three sessions.^9,14 There was also a discrepancy between laser settings across the reports (laser spot size 1.5–6.0 mm, pulse duration 10–60 ms, and fluency 90–600 J/cm²) that could have influenced the results.

Patient satisfaction is crucial when assessing laser therapy outcomes. Studies using self-evaluation scales found high satisfaction rates (64% to 90%) after treatment with long-pulsed 1064 nm Nd:YAG laser for leg veins under 2 mm in diameter.^10,14–16

The side effects were assessed with the most common ones being transient post-inflammatory hypo or hyperpigmentation, burns with blisters, telangiectatic matting, bruising, and superficial thrombosis. Transitory hyperpigmentation appears to be the most common side effect with a prevalence varying between 10% and 62%. Parlette et al. stated that longer pulse durations (40–60 milliseconds) were associated with less side effects.¹⁶ Moderate tolerable discomfort was mentioned across all studies. In a report of Ianosi et al., sensitivity was assessed with a scale from 1 (most intensive pain) to 10 (no pain) and the average sensitivity was 6.33 for men and 7.077 for women.¹⁰

Long-pulsed 1064 nm Nd:YAG laser versus sclerotherapy

Five articles compared the long-pulsed 1064 nm Nd:YAG laser versus sclerotherapy, and all were randomized trials (Table 2).

Table 2.

Long-pulsed 1064 nm Nd:YAG laser versus sclerotherapy.

Authors	Type of study	No. of patients	Patients characteristics	Follow-up	Exclusion criteria	Intervention	Technical success	Clinical success	Side effects
Ianosi et al.¹⁷	Prospective study	132 (264 lower limbs in total, divided in three groups of 88)	Females >18 years	60 and 120 days	Symptomatic telangiectasia. Superficial venous reflux on Doppler ultrasound. Deep venous thrombosis or post-thrombotic syndrome. Pregnancy or breastfeeding. Patients with cancers or significant health problems	One group was treated with sclerotherapy with 0.5% polidocanol (POL-0.5), other with sclerotherapy with 1% polidocanol (POL-1), and the third with Nd:YAG laser. There were two treatment sessions with a 60-day interval. The laser settings were 3 mm spot size, pulse duration of 30 ms, and fluency between 290 and 350 J/cm². Vessels <2 mm	Leg veins <1 mm led to good (51%–75%) and very good (75%–100%) results in 100% of the cases treated with Nd:YAG laser, in 33% of the subjects treated with POL-0.5 and 47.81% of patients treated with POL-1, respectively.^a In leg veins > 1 mm diameter, good (51%–75%) and very good (75%–100%) results occurred in 86.36% of patients treated with LAS and in 100% of the cases treated with POL-0.5 and POL-1^a	-	Minor burns (n = 14 limbs with seven treated with laser, three with POL-0.5, and four with POL-1) and hyperpigmentations (n = 3 limbs with two from the laser group and one from the POL-1 group); no statistically significant differences between the groups
Ianosi et al.¹⁸	Prospective study	285	Females >18 years	2 months after each session	Symptomatic telangiectasias. Patients with superficial venous reflux assessed with Doppler ultrasound of the lower limbs. Previous deep venous thrombosis or post-thrombotic syndrome. Pregnant or breastfeeding patients. Patients with neoplasms or other systemic conditions or under chronic treatment for any other disease	One leg was treated with long-pulsed Nd:YAG laser, hypertonic 20% saline/2% lignocaine, or polidocanol 0.5%. The other leg received randomly other of these treatments, with a total of 190 legs treated with each method. There were two sessions with an interval of 2 months. The laser settings were 3 mm spot size, pulse duration of 30 ms, and fluency between 290 and 350 J/cm²	Long-pulsed Nd:YAG laser was significantly better than the other two treatments only for leg veins under 1 mm diameter (RR = 9.72, p < .0001). For leg veins over 1 mm, Nd:YAG and polidocanol 0.5% were equally effective, but both were superior to hypertonic 20% saline/2% lignocaine^a		Cutaneous burns (n = 14) and hyperpigmentation (n = 31), no statistic correlation with intervention
Lupton et al.²⁰	Prospective study	20	Females, 27–68 years, skin types I to III	1 month after the first session and 1 and 3 months after the second session	Previous history of lower extremity leg veins treatment. Clinical evidence of severe vascular incompetence. Anticoagulant treatment. Pregnant or breastfeeding	Long-pulsed 1064 nm Nd:YAG in one leg and sodium tetradecyl sulfate sclerotherapy in the other leg. Laser parameters were 5.5 mm spot size, fluences of 125–150 J/cm², and pulse duration of 50 ms for vessels >0.5 mm in diameter and 25 ms for smaller vessels	Significant clinical results were seen in all sites treated with sclerotherapy and laser therapy.^b However, leg veins seemed to respond faster and have a better outcome with sclerotherapy rather than with long-pulsed 1064 nm Nd:YAG laser irradiation, but these differences were not proven to be statistically significant		Mild pain (70%) with both treatments and transient post-inflammatory hyperpigmentation (10% of the patients on the leg treated with sclerotherapy)
Munia et al.⁸	Prospective study	30	Females, 25–65 years, skin types I to IV	1 week after treatment	Signs of chronic venous insufficiency or varices (CEAP grades ≥C2). Pregnant or breastfeeding. Anticoagulant therapy	One leg of each patient was treated with sclerotherapy with 75% glucose solution and the other leg with Nd:YAG laser; spot size of 3 mm at 1 Hz, fluence of 100–120 J/cm², and pulse duration of 15 ms (on smaller vessels) or 30 ms (on larger vessels); vessels of 0.5–1.5 mm	There was no significant difference in clearing rates between the two treatments^c	The clearance results were perceived to be good to excellent by 12 (40%) and 16 (53%) patients in the laser groups and sclerotherapy groups, respectively. These differences were not significant. Level of pain was significantly higher in the legs treated with long-pulsed Nd:YAG laser, than sclerotherapy	Transient post-inflammatory hyperpigmentation (n = 1) and a scar (n = 1) on a laser therapy site
Parlar et al.¹⁹	Prospective study	51	Females, 23–66 years	6 weeks and 6 months	Varicose veins greater than C1. Arterial occlusive disease. Pregnancy. Veins not symmetrically distributed in both legs	Patients were randomly treated with long-pulsed Nd:YAG laser in one leg and sclerotherapy with polidocanol injection in the other leg. The treatment consisted in two sessions with 4 weeks interval. Laser parameters were fluences 100–200 J/cm², spot size of 3–7 mm, and pulse duration of 10–50 ms	There was no difference in clearance rates between Nd:YAG laser and sclerotherapy, but the effects of sclerotherapy were faster. In a handling physicians’ evaluation, the results of sclerotherapy were significantly better (p < .001) and a quicker effect was also noted	The level of satisfaction was similar between both groups, but laser therapy was significantly more painful (p = .003)	Transient post-inflammatory hyperpigmentation was seen in 22 (39.3%) and 38 (67.9%) patients treated with laser and with sclerotherapy, respectively. This difference was statistically significant (p < .001). Matting occurred in 20% of the patients in both treatment groups

y: years-old.

^aResults were analyzed using a clearance scale with 5°: 0 (no change), 1 (1%–25%), 2 (25%–50%), 3 (51%–75%), and 4 (75%–100%).

^bThe physicians graded the improvement in four-point groups: 1 (<25%); 2 (26%–50%); 3 (51%–75%); 4 (76%–100%).

^cThe physician and two independent observers graded the improvement in a scale from 0 (no improvement) to 10 (complete clearing).

In these five articles, the number of sessions was two in four studies and three in one study. A significant variation between laser setting was also present across the reports (laser spot size 3.0–7.0 mm, pulse duration 10–50 ms, and fluency 100–350 J/cm²).

In studies comparing long-pulsed 1064 nm Nd:YAG laser and sclerotherapy, results varied based on factors such as vessel diameter. Laser therapy was more effective for telangiectasias under 1 mm, while sclerotherapy showed better results for vessels between 1 and 2 mm.^17,18

Some studies indicated quicker effects with fewer sessions for sclerotherapy.^19,20

Laser therapy was generally found to be more painful, and there were no severe complications reported.^8,19,20 Differences in side effects were observed, with laser therapy causing more transient post-inflammatory hyperpigmentation than sclerotherapy.¹⁹ Overall, the choice between laser therapy and sclerotherapy depends on factors such as vessel size and patient preferences, with each method having its advantages and considerations.

Long-pulsed 1064 nm Nd:YAG laser versus other laser therapies

Four articles compared the long-pulsed 1064 nm Nd:YAG laser versus other laser therapies, two were randomized and two were nonrandomized trials (Table 3).

Table 3.

Long-pulsed 1064 nm Nd:YAG laser versus other laser therapies.

Authors	Type of study	No. of patients	Patients characteristics	Follow-up	Exclusion criteria	Intervention	Technical success	Clinical success	Side effects
Eremia et al.²¹	Prospective study	22	Females, 32–67 years, skin types I to V	1 week, 1, 2 and 3 months	Previous history of deep vein thrombosis. Pregnancy. Poor wound healing diseases. Connective tissue disease.Hypercoagulability.Keloid formation.Large varicose veins	The patients were treated with Nd:YAG laser and other laser (diode, Alexandrite, or both), in a total of two sessions 4–6 weeks apart.Nd: YAG laser parameters were a fluence of 150 J/cm², spot size of 6 mm, and a pulse duration from 25 to 100 ms according to vessel size	Improvement of >75% was seen in 88% of the vessels treated with 1064 nm Nd:YAG laser, 29% with 810 nm diode laser, and 33% with 755 nm Alexandrite laser^a		Transient post-inflammatory hyperpigmentation (n = 6), burns with blisters (n = 3), and telangiectatic matting (n = 11; ten occurred on 755 nm Alexandrite laser-treated sites and one on a 1064 nm Nd:YAG laser-treated site and the one caused by 755 nm Alexandrite laser was more severe and persistent)
Klein et al.²³	Prospective study	29	White females, skin types I to III	6 weeks and 12 weeks after treatment	<18 years old.Pregnancy or breastfeeding.Suntan. Risk of noncompliance.Venous insufficiency.Skin type IV–VI.Any treatment in the study area in the 3 months prior to the screening visit	The patients were treated with 1064 nm Nd:YAG laser and indocyanine green-augmented diode laser (ICG+DL) with a single session. Nd:YAG laser parameters were 160–240 J/cm², 5 mm spot size, and 65 ms pulse duration	Clearance rates were 3.4 after ICG+DL therapy and 2.2 after Nd:YAG laser therapy, 3 months after treatment. Clearance rates were significantly better with ICG+DL than Nd:YAG laser (p < .001)^b	Subjective clearance rates by the patients were 3.4 after ICG+DL therapy and 2.3 after Nd:YAG laser therapy, 3 months after treatment (p < .001).ICG+DL therapy was more painful^c	Burning (Nd:YAG 76%; ICG+DL 90%), blistering (Nd:YAG 10%; ICG+DL 10%, both mild), and edema (Nd:YAG 90%; ICG+DL 93%). At 3-month, hyperpigmentation (Nd:YAG 21% and ICG+DL 41%), hypopigmentation (2 with ICG+DL), and matting (1 with ICG+DL). Slight scarring (3 with Nd:YAG)
Nguyen et al.²⁴	Prospective study	22	Three males and nineteen females, >18 years, skin type IV	1 month and 3 months after treatment	Pregnancy and lactation.Anticoagulation.Active skin infection. History of herpes simplex infection. Thrombosis or hypercoagulability. Diabetes. Hypertrophic/keloid scar. Cardiovascular, renal, and liver diseases	Laser therapy with long-pulsed lasers with 755 nm vs 1064 nm in a single session.The long-pulsed 1064 nm therapy used a single pass with 5 mm spot size, pulse duration of 20 ms for telangiectasias and 30 ms for reticular veins, and fluences of 120–220 J/cm²	At 1-month follow-up, the clearances with long-pulsed laser were 71.87% and 71.69% with the 1064 nm laser and 755 nm laser, respectively (p = .99). In the vessels treated with 1064 nm laser, the clearance of the ones with 1–3 mm diameter was significantly higher than of those with <1 mm	1064 nm Nd:YAG laser therapy was associated with significantly more pain with a median of 7 than 755 nm laser with a median of 5 (p = .00)^d	Hyperpigmentation (>63.64% and 50% for 1064 nm laser and 755 nm laser, respectively; p = .36); hypopigmentation (one patient with 755 nm laser therapy); vesicles (five patients with 755 nm laser therapy); purpura (two patients treated with 1064 nm laser)
Ozden et al.²²	Prospective study	16	Caucasian females, 20–60 years, skin types I to III	4 weeks after each session and at 12 weeks	Prior history of deep vein thrombosis.Previous treatment of leg veins.Pregnancy. Poor wound healing diseases.Hypercoagulability.Large varicose veins. Severe vascular incompetence	Patients had a three-session treatment with long-pulsed 1064 nm Nd:YAG laser in one leg and 532 nm KTP laser in the other leg	An improvement of more than 75% in vessels with <1 mm diameter was observed in 44% of the sites treated with Nd:YAG laser and 44% of the sites treated with KTP laser.^aAn improvement of more than 75% in vessels with >1 mm diameter was observed in 50% of the sites treated with Nd:YAG laser and 25% of the sites treated with KTP laser^a		Transient urticaria (62.5% and 37.5% of patients on the side treated with 1064 nm Nd:YAG laser and with 532 KTP laser, respectively), transient crusting, and post-inflammatory hyperpigmentation (four patients on the Nd:YAG leg)

y: years-old.

^aTwo physicians judged the outcome and graded the improvement in 5% groups (0%; 0%–25%; 25%–50%; 50%–75%; 75%–100%).

^bTwo physicians judged the outcome and graded the improvement in a scale from 0 (no clearance) to 4 (excellent clearance).

^cPatients also rated the subjective clearing and reported pain sensation in a visual analogue scale from 0 to 10.

^dPain sensation was measured in a visual analogue scale from 0 to 10.

In these four articles, the number of sessions varied from one to three sessions. A variation between laser settings was still seen across the reports (laser spot size 5.0–6.0 mm, pulse duration 20–100 ms, and fluency 120–240 J/cm²).

In studies comparing long-pulsed 1064 nm Nd:YAG laser with other laser therapies, results varied based on vessel diameter. Nd:YAG laser showed better technical success rates for vessels >1 mm in two studies,^21,22 but diode laser therapy was more successful in another study.²³ The fourth study reports no differences between treatments.²⁴

Patient satisfaction and pain levels were assessed in some studies. Diode laser therapy resulted in better subjective clearance and less pain than Nd:YAG laser therapy.^23,24

Common side effects included transient post-inflammatory hyperpigmentation, burns, telangiectatic matting, and transient urticaria. Notably, 755 nm Alexandrite laser caused more severe and persistent telangiectatic matting than 1064 nm Nd:YAG laser.²¹ No serious complications were reported.

Results of combined treatments

Some combined or sequential treatments have been studied in order to optimize the results when treating leg veins problems (Table 4). These include the use of sclerotherapy and Nd:YAG laser in three articles^6,7,25 and use of Nd:YAG laser with other lasers in the same session in three articles.^26–28

Table 4.

Combined treatments.

Authors	Type of study	No of patients	Patients characteristics	Follow-up	Exclusion criteria	Intervention	Technical success	Clinical success	Side effects
Levy et al.²⁵	Prospective study	14	Females, 27–68 years, skin types I to IV	3 months after the last treatment	Severe vascular incompetence.Reflux detected by Doppler. Pregnancy and lactation. Previous sclerotherapy 6 months before the study. Deep or superficial vein thrombosis	Four comparable sites were selected in each patient. One site was treated with long-pulsed Nd:YAG alone, the second sclerotherapy alone, the third laser followed by sclerotherapy, and the last one sclerotherapy followed by laser.Vessels 0.5–2 mm	The clearance rate was described in a scale: 1 (0%–25%); 2 (25%–50%); 3 (50%–75%); 4 (75%–100%). Although sclerotherapy followed by laser therapy did appear to be more effective, there were no statistically significant differences between the four treatments		Side effects were minimal and showed no statistically significant difference between treatments (p = .1762)
Moreno-Moraga et al.⁷	Prospective study	298	Females, 19–72, skin types II to IV	3 years after the treatment	Reflux in the deep system confirmed by Doppler. Organic or psychological conditions which advised against the treatment, or which could alter the assessment of results	The patients were randomly selected for treatment with polidocanol microfoam injection only (79 legs) or polidocanol microfoam + Nd:YAG laser (517 legs)	The combined treatment with polidocanol microfoam and Nd:YAG laser had better clearance rates in vessels with a diameter under 4 mm (p < .001). At 3 years follow-up, the clearance rates were 89% for <0.5 mm veins, 94% for 0.5–1.5 mm veins, and 95% for 1.5–4.0 mm veins, in comparison to 15%, 18%, and 17%, respectively, in the subgroup treated only with microfoam	86% of patients were Satisfied or Very Satisfied
Moreno-Moraga et al.⁶	Prospective study	90	Females, skin type IV	16 weeks after the second session	<18 years old.Pregnancy or breastfeeding.Scarring or infection at the treatment site.Use of iron supplements or anticoagulants.History of photosensitivity or scarring	Patients were divided in three treatment groups: A (polidocanol microfoam); B (Nd:YAG laser); C (polidocanol microfoam + Nd:YAG laser). The treatment consisted in two sessions, 8 weeks apart.Vessels <1.5 mm in diameter	The clearance rates were significantly higher in the group C, with the combined treatment of polidocanol microfoam injection and long-pulsed 1064 nm Nd:YAG laser	Patients’ satisfaction index was also significantly higher in the group C
Sadick et al.²⁶	Prospective study	50	Females, 20–42 years, skin types II to IV	Follow-up at 3 and 6 months after treatment	Oral contraceptive use. Pregnancy.Sclerotherapy.History of thrombophlebitis in the last 6 months	Patients were treated with 550 nm intense pulsed light for telangiectasias <1 mm and 1064 nm Nd:YAG laser for vessels with 1–4 mm.Vessels 0.1–4 mm in diameter	Significant clearance (75%–100%) was observed in 80% of the patients with a mean of two and a half sessions	76% of the patients were satisfied with the treatment
Trelles et al.²⁷	Retrospective study	60	Females, 24–62 years, skin types II to IV			A sequential treatment with 585 nm long-pulsed dye laser and 1064 nm long-pulsed Nd:YAG laser (pulse duration 30 ms; fluence 80 J/cm²), in a maximum of two sessions with a 2 months interval	Clinical and computer assessment considered the treatment “Good” or “Very good” in 78% and 82% of the patients, respectively. There was no significant difference in results regarding different skin types	78% of the patients considered the treatment “Good” or “Very good.”	The side effects were discomfort during treatment and matting. The presence of side effects was similar in all skin types
Zerbinati et al.²⁸	Retrospective study	58	A 8–69 years, skin types I to IV		Pregnancy.Photosensitive or anti-coagulant medications.Suntan. Diabetes mellitus. Cardiovascular diseases. Prior treatment with laser. Retinoids or isotretinoin in the last 6 months. Wounded skin.Epilepsy/seizures ineligible	The patients were treated with a sequential emission of 755 nm Alexandrite followed by 1064 nm long-pulsed Nd:YAG laser	A median of four sessions were needed to reach clearance. Significant clearance (>75%) was observed in 65.6% of the patients at the follow-up

y: years-old.

Moreno-Moraga et al. conducted three studies on combined sclerotherapy and 1064 nm Nd:YAG laser therapy. In a prospective study, the combined treatment showed superior clearance rates in vessels <3 mm (p < .001) at 3 years follow-up.⁷ A retrospective analysis of 202 patients revealed high clearance rates at 5 years (85% for class I, 89% for class II, and 92% for class III varicose veins).²⁹ In another study, combined therapy resulted in significantly higher clearance rates and patient satisfaction (p < .0001).⁶ Levy et al. studied a small population of fourteen patients that were treated in four sites (one site with 1064 nm Nd:YAG laser alone, the second one with sclerotherapy alone, the third with laser followed by sclerotherapy, and the last one with sclerotherapy and then laser). Although sclerotherapy followed by laser therapy did appear to be more effective, there were no statistically significant differences between the four treatments, likely due to the small sample size.²⁵

Combining 1064 nm Nd:YAG laser with other therapies also showed promising outcomes. Sadick et al. achieved significant clearance (>75%) in 80% of patients using IPL for vessels <1 mm and 1064 nm Nd:YAG laser for larger vessels.²⁶ Trelles et al.’s sequential protocol with 585 nm long-pulsed dye laser and 1064 nm Nd:YAG laser resulted in positive patient and clinical assessments (78%–82% with “Good” or “Very good” results).²⁷ Zerbinati et al. reported significant clearance (>75%) in 65.6% of patients with a combination of 755 nm Alexandrite laser followed by 1064 nm Nd:YAG laser.²⁸

Discussion

This review summarizes the main features of the protocols that use long-pulsed 1064 nm Nd:YAG laser to treat telangiectasia and reticular veins as a single intervention, or as part of a treatment that combines long-pulsed 1064 nm Nd:YAG with sclerotherapy or with other lasers.

Sclerotherapy has been the “gold-standard” for treatment of legs’ telangiectasia and reticular veins. More recently, with new technological advances in laser and intense pulse light devices, laser therapy has become increasingly popular for the treatment of these pathologies.³⁰

Long-pulsed 1064 nm Nd:YAG laser has a longer wavelength and a larger pulse, which can be responsible for better results in the treatment of deeper and larger veins, with less side effects on the skin.³¹ The longer wavelength contributes for less absorption of the energy by the skin’s melanin, making it also an important advantage when treating patients with higher phototypes, because there is a significant lower risk of dyschromia.³² Studies have been shown promising results for Nd:YAG laser in the treatment of vessels up to 3 mm in diameter,^4,5,9–15 and some found better outcomes in blue vessels with diameters above 2 mm.^13,33 Numerous studies showed not only good clearance rates but also a great percentage of patients highly satisfied with the outcomes.^10,14 However, Trelles et al. stated that only 57% of the patients in their retrospective study considered the treatment “Good” or “Very good,” whereas the clinical and computer assessment considered the treatment “Good” or “Very good” in 64% and 71% of the patients, respectively.¹⁵ These differences could probably be explained by high unrealistic expectations that are often encountered in these patients and should be assessed and clarified previously to the treatment. Thus, long-pulsed 1064 nm Nd:YAG laser is a valid therapeutic option for the treatment of leg veins with 3 mm or less in diameter, deeper blue veins and veins in patients with darker skin, with good clearance rates and patients’ satisfaction. Serious side effects are rare, but the procedure is almost always accompanied by moderate pain level.³³

Even though long-pulsed 1064 nm Nd:YAG laser has been showing great results in the treatment of vessels with up to 3 mm diameter, it is interesting to note that laser parameters such as spot size, pulse duration, and fluence vary in the different studies and the consequences of these variations on the outcomes aren’t yet fully understood.³⁴ Sadick et al. used different parameters in the Nd:YAG laser device for vessels with less than 1 mm and vessels with 1 to 3 mm (spot size 1.5 mm, fluence 400 to 600 J/cm², and pulse duration 30 to 50 ms for red vessels <1 mm; and spot size 3 mm, fluence 250–370 J/cm², and pulse duration 50–60 ms for blue vessels 1–3 mm). In this study, they concluded that for the treatment of red vessels with <1 mm, long-pulsed 1064 nm Nd:YAG should be used with a smaller spot size, higher fluence, and shorter duration. Whereas in the treatment of blue vessels with 1–3 mm, it should be used a large spot size, moderate fluence, and long pulse duration.¹⁴

In the comparison of 1064 nm Nd:YAG laser therapy with other lasers and light sources, the studies we found in the literature have some contradictory outcomes. These discrepancies can possibly be explained by a limitation present in all four articles, which is a very small population size, along with the great heterogeneity of laser therapies being used as the control group.

Studies comparing sclerotherapy and long-pulsed 1064 nm Nd:YAG laser therapy in the treatment of leg veins showed similar clearance rates with no significant differences. However, sclerotherapy seemed to be less painful and had faster clinical improvements.^8,19,20 In two articles conducted by Ianosi et al. (one with a population of 132 female patients and the other with 285), Nd:YAG laser had better outcomes in the treatment of smaller vessels with less than 1 mm in diameter, than sclerotherapy alone.^17,18

Sclerotherapy consists in injecting a chemical agent able to provoke sclerosis of the blood vessels and damage to the endothelium. It has great results in the treatment of leg veins, but there are many disadvantages (allergic reactions, need for multiple injections, ulceration, or telangiectatic matting), that can make it not the ideal option for all patients.³⁵ There isn’t still enough evidence that supports the use of Nd:YAG laser above sclerotherapy and both can be used to treat effectively leg telangiectasia and reticular veins. Nonetheless, Nd:YAG laser is an excellent option for patients with needle phobia, resistance or contraindications for sclerotherapy, known allergy to sclerosant solutions, with vessels too small for the needle diameter, or patients who developed post-sclerotherapy telangiectatic matting.²⁰

Moreno-Moraga et al. wrote three articles about a combined treatment with 1064 nm Nd:YAG laser and sclerotherapy in comparison with both treatments alone and found statistically significant higher clearance and patients’ satisfaction percentages.^6,7,29 Sclerotherapy and laser therapy should be used as complementary treatments because small vessels could be very difficult to needle catheterization in sclerotherapy and 1064 nm Nd:YAG laser results are still limited for vessels larger than 3–4 mm.³⁶

Conclusion

Long-pulsed 1064 nm Nd:YAG laser is a valid therapeutic option for leg telangiectasia and reticular veins with growing evidence and popularity. It has been showing great aesthetic outcomes with minor side effects. Nd:YAG laser therapy could be combined with sclerotherapy or other laser therapies or IPL in order to achieve better results. Giving the limited level of evidence, more powered studies should be conducted to further understand which laser device parameters should be used to obtain the best clinical improvements.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Leonor Baldaia

References

Alora

Anderson

. Recent developments in cutaneous lasers. Lasers Surg Med 2000; 26(2): 108–118.

Anderson

Parrish

. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science (New York, NY) 1983; 220(4596): 524–527.

Bäumler

Ulrich

Hartl

, et al. Optimal parameters for the treatment of leg veins using Nd:YAG lasers at 1064 nm. Br J Dermatol 2006; 155(2): 364–371.

Sadick

. Long-term results with a multiple synchronized-pulse 1064 nm Nd:YAG laser for the treatment of leg venulectasias and reticular veins. Dermatol Surg 2001;27(4):365–369.

Sadick

Prieto

Shea

, et al. Clinical and pathophysiologic correlates of 1064-nm Nd:Yag laser treatment of reticular veins and venulectasias. Arch Dermatol 2001; 137(5): 613–617.

Moreno-Moraga

Hernández

Royo

, et al. Optimal and safe treatment of spider leg veins measuring less than 1.5 mm on skin type IV patients, using repeated low-fluence Nd:YAG laser pulses after polidocanol injection. Lasers Med Sci 2013; 28(3): 925–933.

Moreno-Moraga

Smarandache

Pascu

, et al. 1064 nm Nd:YAG long pulse laser after polidocanol microfoam injection dramatically improves the result of leg vein treatment: a randomized controlled trial on 517 legs with a three-year follow-up. Phlebology 2014; 29(10): 658–666.

Munia

Wolosker

Munia

, et al. Comparison of laser versus sclerotherapy in the treatment of lower extremity telangiectases: a prospective study. Dermatol Surg 2012; 38(4): 635–639.

Eremia

. Treatment of leg and face veins with a cryogen spray variable pulse width 1064-nm Nd:YAG laser--a prospective study of 47 patients. J Cosmet Laser Ther 2001; 3(3): 147–153.

10.

Ianosi

Calbureanu-Popescu

Dragusin

, et al. Treatment of lower limbs telangiectasias with Nd: yag laser-prospective study on 446 patients. Curr Health Sci J 2018; 44(3): 235–242.

11.

Major

Brazzini

Campolmi

, et al. Nd:YAG 1064 nm laser in the treatment of facial and leg telangiectasias. J Eur Acad Dermatol Venereol 2001; 15(6): 559–565.

12.

Ozyurt

Colgecen

Baykan

, et al. Treatment of superficial cutaneous vascular lesions: experience with the long-pulsed 1064 nm Nd:YAG laser. Sci World J 2012; 2012: 197139.

13.

Rogachefsky

Silapunt

Goldberg

. Nd:YAG laser (1064 nm) irradiation for lower extremity telangiectases and small reticular veins: efficacy as measured by vessel color and size. Dermatol Surg 2002; 28(3): 220–223.

14.

Sadick

. Laser treatment with a 1064-nm laser for lower extremity class I-III veins employing variable spots and pulse width parameters. Dermatol Surg 2003;29(9):916–919.

15.

Trelles

Allones

Álvarez

, et al. Long-pulsed Nd:YAG 1064 nm in the treatment of leg veins: check up of results at 6 months in 100 patients. Med Laser Appl 2005; 20(4): 255–266.

16.

Parlette

Groff

Kinshella

, et al. Optimal pulse durations for the treatment of leg telangiectasias with a neodymium YAG laser. Lasers Surg Med 2006; 38(2): 98–105.

17.

IanoȘi

Neagoe

Tutunaru

, et al. Single blind, randomised study regarding the treatment of the telangiectasia of the lower limbs (C1EAP) using polidocanol 0.5%, 1%, and Nd:YAG laser. Curr Health Sci J 2020; 46(2): 141–149.

18.

Ianosi

Calbureanu-Popescu

, et al. Comparative study in leg telangiectasias treatment with Nd:YAG laser and sclerotherapy. Exp Ther Med 2019; 17(2): 1106–1112.

19.

Parlar

Blazek

Cazzaniga

, et al. Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial. J Eur Acad Dermatol Venereol 2015; 29(3): 549–554.

20.

Lupton

Alster

Romero

. Clinical comparison of sclerotherapy versus long-pulsed Nd:YAG laser treatment for lower extremity telangiectases. Dermatol Surg 2002; 28(8): 694–697.

21.

Eremia

Umar

. A side-by-side comparative study of 1064 nm Nd:YAG, 810 nm diode and 755 nm alexandrite lasers for treatment of 0.3-3 mm leg veins. Dermatol Surg 2002; 28(3): 224–230.

22.

Ozden

Bahçivan

Aydin

, et al. Clinical comparison of potassium-titanyl-phosphate (KTP) versus neodymium:YAG (Nd:YAG) laser treatment for lower extremity telangiectases. J Dermatolog Treat 2011; 22(3): 162–166.

23.

Klein

Buschmann

Babilas

, et al. Indocyanine green-augmented diode laser therapy vs. long-pulsed Nd:YAG (1064 nm) laser treatment of telangiectatic leg veins: a randomized controlled trial. Br J Dermatol 2013; 169(2): 365–373.

24.

Nguyen

HTN

Firas

Van

. Long-pulsed 1064-nm and 755-nm lasers for C1 leg veins on skin type IV patients: a side-by-side comparison. Lasers Med Sci 2021; 36(4): 829–835.

25.

Levy

Elbahr

Jouve

, et al. Comparison and sequential study of long pulsed Nd:YAG 1,064 nm laser and sclerotherapy in leg telangiectasias treatment. Lasers Surg Med 2004; 34(3): 273–276.

26.

Sadick

. A dual wavelength approach for laser/intense pulsed light source treatment of lower extremity veins. J Am Acad Dermatol 2002; 46(1): 66–72.

27.

Trelles

Weiss

Moreno-Moragas

, et al. Treatment of leg veins with combined pulsed dye and Nd:YAG lasers: 60 patients assessed at 6 months. Lasers Surg Med 2010; 42(9): 609–614.

28.

Zerbinati

Protasoni

D'Este

, et al. Skin vascular lesions: a new therapeutic option with sequential laser-assisted technique. Dermatol Ther 2021; 34(1): e14573.

29.

Moreno-Moraga

Pascu

Alcolea

, et al. Effects of 1064-nm Nd:YAG long-pulse laser on polidocanol microfoam injected for varicose vein treatment: a controlled observational study of 404 legs, after 5-year-long treatment. Lasers Med Sci 2019; 34(7): 1325–1332.

30.

Rabe

Breu

Cavezzi

, et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014; 29(6): 338–354.

31.

Dudelzak

Hussain

Goldberg

. Vascular-specific laser wavelength for the treatment of facial telangiectasias. J Drugs Dermatol 2009; 8(3): 227–229.

32.

Weiss

. Early clinical results with a multiple synchronized pulse 1064 NM laser for leg telangiectasias and reticular veins. Dermatol Surg 1999; 25(5): 399–402.

33.

Omura

Dover

Arndt

, et al. Treatment of reticular leg veins with a 1064 nm long-pulsed Nd:YAG laser. J Am Acad Dermatol 2003; 48(1): 76–81.

34.

Christiansen

Drosner

Bjerring

. Optimized settings for Nd:YAG laser treatments of leg telangiectasias. J Cosmet Laser Ther 2015; 17(2): 69–76.

35.

Worthington-Kirsch

. Injection sclerotherapy. Semin Intervent Radiol 2005; 22(3): 209–217.

36.

Nael

Rathbun

. Treatment of varicose veins. Curr Treat Options Cardiovasc Med 2009; 11(2): 91–103.