Understanding Vascular Lesions and Treatment Options

What are vascular lesions?

Vascular lesions are a broad category of skin conditions involving abnormal blood vessels. They range from common, benign concerns such as spider veins and broken capillaries to more complex conditions like port wine stains and haemangiomas. In aesthetic medicine, vascular lesions are one of the most common reasons patients seek treatment, as they can significantly affect skin appearance and self-confidence.

Practitioners are experienced in identifying and treating a wide range of vascular lesions using evidence-based technologies. Accurate diagnosis is the essential first step, not all red marks on the skin are created equal, and treatment approaches differ significantly based on the specific type of vascular lesion.

Types of vascular lesions

Telangiectasia (thread Veins/Broken capillaries)

Telangiectasias are permanently dilated small blood vessels (arterioles, venules, or capillaries) visible through the skin as fine red, blue, or purple lines. They are extremely common, affecting approximately 40% of the UK population. Common locations include the face (cheeks, nose, chin, often associated with rosacea), the legs (particularly the lateral thigh and behind the knee), and the chest and decolletage.

Causes include genetic predisposition, chronic sun exposure, hormonal changes (pregnancy, HRT), rosacea, trauma, and prolonged standing (for leg telangiectasias). Research published in Phlebology (2023) identified female sex, family history, and chronic UV exposure as the three strongest independent risk factors.

Spider Naevi

A spider naevus consists of a central arteriole (the “body”) with radiating dilated capillaries (the “legs”). When the central point is compressed, the entire lesion blanches and then refills from the centre outward, a diagnostic sign. Spider naevi are common in children and pregnant women and may indicate liver disease if multiple and clustered on the upper body.

Cherry angiomas (campbell de morgan spots)

These are benign proliferations of capillary endothelial cells, appearing as bright red, dome-shaped papules typically 1–5mm in diameter. They increase in number with age, affecting over 75% of adults over 75. While harmless, they are a common aesthetic concern.

Port wine stains (naevus flammeus)

Present from birth, port wine stains are caused by capillary malformations in the dermis. They typically appear as flat, pink-to-purple patches that darken with age and may thicken in adulthood. Treatment is most effective when initiated early. These lesions may be associated with Sturge-Weber syndrome when located in the ophthalmic trigeminal distribution and require medical assessment.

Haemangiomas

Haemangiomas are benign tumours of vascular endothelial cells. Infantile haemangiomas (which appear in the first weeks of life, grow rapidly, then involute over years) are the most common. Adult haemangiomas are less common but may be treated for cosmetic reasons.

Rosacea-associated vascular changes

The persistent background erythema and telangiectasia of rosacea represent chronic neurovascular dysregulation. While related to telangiectasia, rosacea-associated vascular changes require a broader treatment approach that addresses the underlying inflammatory condition alongside the visible vessels.

Diagnostic Assessment

Proper assessment before treatment should include visual inspection under good lighting with and without magnification, dermoscopy (a handheld magnifying device with polarised light) to assess vessel morphology, blanching test (compression with a glass slide, the diascopy test, to differentiate vascular from pigmented lesions), medical history review (to exclude underlying causes such as liver disease, connective tissue disorders, or medication effects), and photographic documentation for treatment planning and outcome assessment.

Evidence-based treatment options

Intense pulsed light (IPL)

IPL is one of the most versatile and widely used treatments for vascular lesions. It emits a broad spectrum of light (500–1200nm) filtered to target oxyhaemoglobin, the primary chromophore in blood vessels.

A systematic review in Lasers in Surgery and Medicine (2023) reported that IPL achieved 70–85% clearance of facial telangiectasia after 2–4 sessions, 60–75% reduction in diffuse rosacea-related erythema, and 80–90% clearance of spider naevi after 1–3 sessions. IPL is particularly effective for diffuse redness and multiple small vessels, as it treats larger areas per pulse than laser devices.

Pulsed dye laser (PDL)

The PDL (585nm or 595nm) is considered the gold standard for vascular lesion treatment. Its wavelength is specifically absorbed by oxyhaemoglobin. This provides selective photothermolysis of blood vessels with minimal damage to surrounding tissue.

• For telangiectasia: 80–95% clearance rates after 1–3 sessions.
• For port wine stains: The first-line treatment, typically requiring 6–12 sessions. A multicentre study in JAMA Dermatology (2023) reported 50–70% lightening after a course of treatment, with earlier treatment (childhood) producing better outcomes.
• For cherry angiomas: Single-session clearance rates of 90–95%.

The main limitation of PDL is post-treatment purpura (bruising), which can last 7–14 days and may be socially limiting. Newer long-pulse PDL settings can reduce purpura while maintaining efficacy, though some purpura may still occur.

Nd:YAG Laser (1064nm)

The Nd:YAG laser penetrates deeper into the skin than PDL and is particularly effective for deeper, larger-calibre vessels that do not respond to shorter wavelengths. It is the treatment of choice for blue or purple reticular veins on the legs (1–3mm diameter), deeper telangiectasias on the face, and periorbital veins. The Nd:YAG laser generally causes less purpura than PDL but may be associated with more discomfort and a slightly higher risk of thermal injury to surrounding tissue.

Electrocautery and Diathermy

For small, isolated telangiectasias and spider naevi, fine-needle electrocautery or diathermy provides precise, targeted treatment. A fine probe delivers electrical current directly into the vessel, causing coagulation. This technique is particularly useful for individual thread veins on the nose and central face, small cherry angiomas, and spider naevi (targeting the central feeding arteriole).

Sclerotherapy (for leg veins)

While technically an injectable rather than energy-based treatment, sclerotherapy remains the gold standard for leg telangiectasias and small reticular veins. A sclerosing solution (typically sodium tetradecyl sulphate or polidocanol in the UK) is injected directly into the vessel, causing endothelial damage and subsequent vessel closure.

A Cochrane review (2023) confirmed that sclerotherapy is significantly more effective than laser for leg veins larger than 1mm in diameter. For smaller spider veins (less than 1mm), both sclerotherapy and transcutaneous laser are effective, and the choice depends on patient preference and practitioner experience.

Treatment planning and expectations

What to expect during treatment

Most vascular laser and IPL treatments involve a sensation described as a “hot snap” or “rubber band flick” against the skin. Treatment sessions typically last 15–45 minutes depending on the area being treated. Topical anaesthesia is not usually required for facial treatments but may be used for sensitive areas or patients with low pain tolerance.

Post-treatment course

After IPL or laser treatment for vascular lesions, patients should expect immediate redness and mild swelling (resolving within hours to days), possible purpura with PDL treatment (7–14 days), gradual fading of treated vessels over 2–6 weeks, and possible temporary darkening before resolution. Most patients require 2–4 sessions spaced 4–6 weeks apart for optimal results.

Maintenance

Vascular lesions can recur, particularly in patients with rosacea, genetic predisposition, or ongoing UV exposure. Maintenance treatments every 6–12 months and consistent sun protection help preserve results.

Key Takeaways

• Vascular lesions encompass a wide range of conditions requiring accurate diagnosis before treatment
• IPL and pulsed dye laser are the most evidence-based treatments for facial vascular lesions
• Sclerotherapy remains the gold standard for leg veins larger than 1mm
• Multiple treatment sessions are typically required for optimal clearance
• Ongoing sun protection and maintenance treatments help prevent recurrence