Couperose skin, spider angioma stellaire and other telangiectasias

Dilations of the superficial dermal vessels or telangiectasias are “isolated” in the vast majority of cases and constitute an aesthetic concern, but they can sometimes be part of a general illness or even be the symptom that reveals a condition. The significance and management of telangiectasias is therefore completely different depending on whether they are isolated, or on the other hand whether they are associated with other cutaneous or general signs, which will then lead to a cause being identified and a treatment of aetiology being possible. They can be congenital or acquired and table I illustrates the great diversity of forms.

1 - DIAGNOSIS

There are multiple factors involved in clinical diagnosis.

The clinical appearance consists of:

— The pattern of the thread-like capillaries (a linear or lacelike pattern in couperose skin with symptomatic large vessels or lower limb telangiectasias seen in chronic venous insufficiency, homogenous macules in erythrosis)

— Variable colouring, from purplish red (such as a spider angioma) to purplish blue (such as the harmless telangiectasias of the lower limbs in chronic venous insufficiency) 

— The basic lesion type: 1) star-shaped vascular lesion (or spider angioma), in which the telangiectasia has a central red dot that is more or less raised with an arborising pattern radiating from it; 2) telangiectasia macules, in which the flat mark is uniform in colour, from pink to purplish red, with no arborisation visible to the naked eye. These can be localised with clear quadrangular borders, as in telangiectasia in scleroderma, or diffuse and widespread as in erythrosis, with even less distinct borders if there is an associated flush; 3) telangiectasia papules, in which the vascular lesion is palpable (such as cherry angiomas), which are sometimes associated with a pustule (such as in papulopustular episodes of Rosacea) or hyperkeratosis (as in angiokeratoma).

Aside from the clinical appearance, diagnosis is determined by

— Whether the lesion is isolated or, by contrast, associated with extracutaneous signs

— Whether it is acquired or congenital (hereditary or not).

2 - TREATMENT STRATEGY

We will detail below the action to be taken and the treatment for so-called essential telangiectasia according to the type of signs presented. Treatments may be adapted for telangiectasias with the same types of signs whether associated with a general illness or particular circumstances.

This treatment combines measures designed ideally to remove visible vascular dilations without scarring and preventive measures intended to reduce the severity and frequency of recurrence.

2.1 - TECHNIQUES FOR REMOVAL

Techniques for removal have for a long time consisted only of electrocoagulation and the oldest approaches like cryotherapy, scarification etc., which have produced only temporary or imperfect results (or indeed scars). These have now been overtaken by the development of laser treatments, which is undeniably progress even though the results remain inconsistent depending on the type of telangiectasia and the equipment used.

Punctate telangiectasias, linear telangiectasias, and thread-like capillaries, because of their localised distribution and their visibility to the naked eye, lend themselves to point-by-point treatment techniques. The continuous lasers (CO₂, then argon, krypton, YAG) that offer this approach remain worthwhile when used with good judgment; indeed, the use of a moderate fluence and, even more importantly, moderate exposure time, allows for accurate and meticulous treatment of the separate points of a linear lesion, with a result that is totally operator dependent. The advantages that this approach has over electrocoagulation are that it is fast, there is no bleeding during treatment, the patient often deems it to be less painful, and the result lasts longer.

However, only punctate and linear telangiectasias that are very red and superficial will benefit from this treatment. The individual telangiectasias on the face in couperose skin or clusters of cherry angiomas are therefore the main indication. Treatment of telangiectasias producing a “red sock” effect on the lower third of the leg is a less common indication. The possible side effects are for the linear pattern of the telangiectasia to turn white or scar if the power or exposure time is too great, and skin pigmentation connected to sun exposure too soon after treatment. The patient will almost always experience recurrence affecting the purplish vessels of the sides of the nose. In spite of the efforts of manufacturers to convince us otherwise, it has to be acknowledged that lower limb telangiectasias in chronic venous insufficiency are at present a poor indication for treatment with lasers of any type. Immediate recurrence, scarring along the vessels and delayed or even permanent residual pigmentation are usual.

In telangiectasia macules, which produce erythrosis in their diffuse form, there is a good indication for so-called pulsed dye lasers or continuous lasers that are operated with a computerised handset, allowing treatment to be administered by juxtaposing hexagonal geometric units. The disadvantages of the first generation pulsed dye lasers are: transient purpura inherent to this technique, a residual lattice pattern between the circular points that often means that a second pass is required, and an increased financial burden due to the cost of the equipment and the cartridges. Improvements have recently been made in this technique with the use of second and then third generation pulsed dye lasers:

— Adjustable wavelengths (585, 590 and 595 nm)

— Handsets with wider impacts from 7 to 10 mm in diameter

— The resultant purpura does not last as long and is less severe

— Less painful with the use of a cryopump system with each impact.

Continuous lasers delivered with a computerised handset do not produce temporary purpura after the session, but efficacy appears to be relative, even when treating the face.

Erythrosis or erythrosis and couperose skin (Rosacea) are very often accompanied by flushing on which the effect of lasers of any type is less consistent. Recently an alternative to laser treatment of erythrosis was put forward that involves the use of brimonidine tartrate. This alpha2-adrenergic receptor agonist leads to a reduction in facial erythema in rosacea due to vasoconstriction, a temporary phenomenon with a duration that varies from 3 to 12 hours. The true role for this treatment remains to be seen both in terms of efficacy and safety.

Pulsed dye lasers are recommended for treating children, in accordance with guidelines from ANAES in France (National Agency for Health Accreditation and Evaluation). Before large surface areas are treated, a patch test is often useful to check what result can be expected. Finally, before any treatment of somewhat atypical patches of telangiectasia, it is sensible to check that that there is no underlying arteriovenous malformation; if there is any increase in heat locally, or any sensation of pulsating or thrill then at the very least an echo-Doppler ultrasound investigation is called for and laser treatment of any kind is contraindicated.

Spider angioma, while very small in size, is especially subject to recurrence even in children after one or two laser treatment sessions. It is often pulsed dye laser that is offered and this can be completed by usage of one or two spots targeted at the centre with continuous laser, if it happens that both types of equipment are available at the same time.

• Among other good indications for laser treatment are telangiectasia in radiodermatitis and flat angiomas.

2.2 - PREVENTIVE MEASURES

The purpose of these is to reduce the severity and frequency of recurrence depending on the aetiology, and they consist of:

— Addressing the cause when this is possible (discontinuing unnecessary corticosteroid therapy) or natural (end of a pregnancy or of exposure to dietary or environmental factors that encourage symptoms)

— Specific treatment for a condition such as for telangiectasia papules or acne rosacea. A disease-modifying treatment is needed for pustular outbreaks (oral tetracycline and topical metronidazole) and laser treatment for residual telangiectasia must be scheduled to take place outside of these episodes. In a number of cases, this has been suggested to a have a positive impact on pustular recurrence

— Classic additional treatments such as thermal spas (Saint-Gervais, Avène, Uriage, La Roche-Posay), photoprotection and cosmetics, which often benefit the patient by masking symptoms (ranges that offer correction of complexion) rather than treating them.

The current limitation on the expansion of laser treatment to address purely aesthetic concerns in essential telangiectasias is cost, and that fact that, in France, this treatment is not covered by Social Security (except for the indication of flat angioma).