fig1 offers a schematic illustration of the treatment kit according to the invention . the generation and application part 10 comprises control circuitry 1 that is electronically connected to a laser 2 , wherein the circuitry controls generation of pulses of light in the laser and further allows choosing between the different preprogrammed running modes . the laser 2 also comprises a potentiometer for varying the fluency of the laser light . the laser 2 is optically connected to a dermatology handpiece 3 via a light guide 5 and during the treatment , the laser light pulses are emitted through an application head 4 positioned on one end of the handpiece 3 . the kit 10 also comprises a set of instructions 8 for guiding the user to use the kit in a way according to the invention , e . g . a printed manual or a cd - rom . from the dermatology handpiece 3 of the kit a beam of laser light with a wavelength of e . g . 1064 nm can be emitted through the application head 4 . this wavelength yields a heating effect penetrating several millimeters into the human body , thereby facilitating treatment of the varices below the surface of the skin without any incisive actions . fig2 is a schematic drawing of a varicose vein receiving treatment according to the method of the invention . the valves of a vein 6 have ceased to function correctly so that they no longer prevent the venous blood from returning back down to the limb . this causes the venous blood to collect in the vein leading to dilation , i . e . a varicose vein or varix 7 . by positioning the patient in a substantially upright , standing position during the application of the laser light , as shown in fig2 , the user can apply an increased number of light pulses to the same varix 7 from the application head 4 . since the varix 7 will be distended as a result of the patient standing up , the actual area of the skin overlying the varix is increased thereby allowing more applications of light pulses to the same varix before the skin sustains unpleasant burns . this is particularly important since it typically is the risk of serious burns to the skin that limits the number of pulses . this is also illustrated by schematically depicting different angular positions of the application head 4 . fig3 is a schematic drawing of a typical treatment situation according to the invention . a user applies treatment to a patient positioned in an upright , standing position by use of the kit according to the invention . below a table is shown displaying suggested procedures , settings as well as checking steps in the treatment method . the proposed settings / steps are based on the results of the clinical tests using a lumenis ipl quantum dl . the quantum dl use a nd : yag laser and emits at 1064 nm . during testing the apparatus was running in various preprogrammed modes entitled ‘ program nos . 1 - 3 ’ while manually setting the fluency value to 130 - 150 j / cm 2 . from 30 to 800 pulses were applied per treatment depending on the amount and size of varices . the treatment must of course be thoroughly planned for each person receiving treatment taking into consideration the actual size of the varix to be treated . since individual conditions ( skin pigmentation , skin diseases , response to heat etc .) play a role in the response to the treatment , these condition should be taken into consideration as well . the table is therefore primarily a quick overview of the correlation between important patient variables and the applied treatment . by indicating that varicose veins with a diameter larger than 5 mm can be treated by non - invasive treatment , the table also represents possible content of a set of instructions for inviting a user to apply the method according to the invention in treating large varices . such table can be provided in a manual for a dermatological laser applicable in the present invention . fluency check - signs / program [ j / cm 2 ] things to avoid quality of the skin : soft + pale 1 - 2 150 twisting of the skin tanned 3 150 twisting of the skin increased tightness 3 135 - 140 edema in connective in the tissue of the tissue surrounding treated limb treated vessel . jelly - like appearance of the skin varices located at 3 130 - 140 subcutaneous hematomas knee hollow / ankle white spots twisting of skin surface vessel size 3 - 5 mm 3 110 - 130 subcutaneous hematomas white spots vessel size 5 - 12 mm 2 140 - 150 twisting of skin surface vessel size & gt ; 12 mm 1 150 heating of the skin (+) configuration of varices ; cord ( string ) 1 - 2 150 white spots , twisting . cluster ( circle ) 3 140 - 150 heating of the skin the quality of the skin may differ substantially between patients . a tanned skin should be treated more gently , so should dry and dehydrated skin often seen in elder patients . pale , elastic and smooth kind of skin is the easiest to treat successfully . patients who due to their anamnesis easily get bruises should be treated less aggressively . the increased tightness of the skin surface and the underlying connective tissue , seen in particular in adipose women , represents a special challenge . a certain edema in the connective tissue surrounding the treated vessel , due to a normal inflammatory response to the laser - induced injury of the vessel , may in this kind of tissue cause a critical decrease in blood circulation of the untreated tissue . clinically the condition is recognized by a jelly - like appearance of the skin . the location of the vessel to be treated influences the treatment setting . varicose veins located at the hollow of the knee and the ankle require special precautions . the configuration of varices also requires attention . cords of outpouchings along a vessel can be treated more aggressively while clusters of outpouching vessels in a limited area of the lower limb should be treated repeatedly and less aggressively . the following is a general step - by - step procedure used in the clinical testing of the treatment method of the invention . this procedure thereby also represents a procedure for applying a typical treatment according to the invention , and can be provided in a manual for a dermatological laser applicable for this treatment . 1 . prepare the patient in an upright , standing position as illustrated in fig3 and apply cooling gel to the areas to be treated . 3 . select one of the preprogrammed running modes of the kit . pulse duration in the interval 5 - 15 ms are typical . 4 . enter the desired value for fluency manually . fluencies in the interval 100 - 200 j / cm 2 are applicable , typically a fluency between 140 - 180 j / cm 2 is chosen . 5 . place the application head ( 4 ) of the dermatology handpiece ( 3 ) in touching relationship with a varix to be treated while applying minimal pressure . 6 . shift between triggering a number of laser pulses and constantly surveying the treated vein by touching and feeling with the fingers together with visual inspection in order to establish the effect on the varix and the conditions of the surrounding area , especially changes in coloration or burns to the skin . also , make sure that the laser light is applied from constantly shifting positions and / or angles as illustrated in fig2 in order to prevent such skin burns . change the settings of the kit if detected necessary . 7 . by touching and feeling with the fingers , determine the change in texture of the varix . when the treated protruding vessel visually collapses and an induration can be palpated instead of a fluctuation , the treatment is finished . if further treatment is needed , the skin covering the varicose vein should be allowed to rest for some minutes whereupon step 6 is repeated until a satisfactory texture is obtained or until light pulses cannot be applied anymore without harming the skin . typically , varices of diameter ˜ 10 mm will get around 25 pulses per treatment . 8 . repeat steps 6 and 7 above with respect to the number of varices to be treated and until the treatment is considered adequate for a first time treatment . the patient will experience a certain swelling and slightly increased temperature of the treated areas from day two till day six after the treatment . there will be significant treatment stains lasting for months after the treatment — changing from red just after the treatment , into greyish / almost black after a couple of hours — and finally into a hyperpigmentation which will fade away after some months . depending on the effects of the treatment on the individual varices , the above procedure may be repeated up to three times over a period of six to eight months . the treatment is preferably followed by telephone consultation with the patient 3 - 4 days after and 3 weeks after treatment . a clinical examination of the treated areas is recommended 3 - 4 months after the treatment . the beam profile or spot shape / size of the light emitted from the application head can be adjusted to correspond with the varicose vein . because of the larger treatment area when treating large varices , it is advantageous to have a larger spot size from the dermatological handpiece . a larger spot size provides the possibility of delivering more energy per pulse while keeping the fluency at a level which does not harm the skin . the larger spot size therefore has a number of advantages described in the following . with a constant fluency ( energy / area ) of the pulse , the delivered energy scales with the area of the spot size . typical spot sizes are circular and between 2 - 6 mm ( diameter at full - width - half - maximum ) which is appropriate for treating smaller varices . when treating varices of e . g . 15 mm in diameter , a much larger spot size can be used without irradiating skin outside the varix . as varices are in general elongated , having an irregular spot shape allows for even larger spot sizes to be used without irradiating skin outside the varix . fig4 illustrates an example . here , an application head 4 emits a light pulse resulting in a spot ( 15 , 16 , 17 ) on the skin of a patient ( the application head is held in contact with the skin — not shown ). a circular spot 15 from a pulse with fluency 150 j / cm 2 and spot diameter 6 mm delivers an amount of energy e = 150 j / cm 2 × π ( 0 . 3 cm ) 2 = 42 j in a single pulse . a rectangular spot 16 with size 10 × 20 mm at the same fluency delivers e = 150 j / cm 2 × 1 cm × 2 cm = 300 j in a single pulse . hence , the energy delivered in a single pulse can be increased by a factor of six without increasing the strain on the skin . the higher energy delivered by the larger rectangular spot 16 compares to more than six pulses with the smaller circular spot 15 . but , the effect caused is far from the same : firstly , by applying six pulses , succeeding pulses will typically be overlapped simply because it is not possible exactly to judge the area covered by the preceding pulses . this means that smaller regions of the skin will be burned more than the average , thereby increasing the probability of burns . secondly , six pulses will be applied over a much longer time span . a single 300 j pulse may be applied over tens of milliseconds , whereas six 42 j pulses will typically take at least 12 - 18 seconds . this is because ( a ) the laser must typically charge between pulses , ( b ) security measures in the dermatological handpiece does not allow more than one pulses in a given time period , typically , a warning sound of approximately is sounds before each pulse , and ( c ) the application head must be relocated to another region of the skin covering the varix . during the time span of 12 - 18 seconds , blood circulation in the varix and heat dissipation to surrounding tissue result in a much lower temperature increase in the target blood and tissue . the much shorter application time of a single pulse has the advantage of substantially increasing the heating of the blood and vein caused by a given amount of applied energy hence , a single , high energy ( same fluency but larger area ) pulse provides a much more efficient treatment . it should be noted that the fluency is not constant over the spot size area . typically there is a peak in the center according to e . g . a gaussian beam profile . this means that the above calculations are only approximate . the spot size may be adjusted by including adjustable beam expanding optics in the handpiece 4 as shown in fig5 . this is comparable to the zoom function in a camera , where adjusting the zoom expands / contracts the spot size . in fig5 , the end 20 of the light guide emits radiation which is collimated by lens 21 . collimated beam 22 reaches the beam expander consisting of lenses 23 and 24 . adjusting the distance between lenses 23 and 24 will adjust the spot size from spot 16 to 17 in fig4 , or vice versa . alternatively , the spot size can be adjusted by having several interchangeable application heads , each application head providing for a given spot size depending upon the size of the varix to be treated . this can be enabled by having one or both lenses from the beam expander ( lenses 23 and 24 ) in the application head . for an oval or rectangular spot shape , the lenses 21 , 23 and 24 can be cylindrical or custom made . in both of the above embodiments , it is important that the total pulse energy is adjusted to obtain a selected fluency , a large spot size requiring larger pulse energy to keep the fluency constant . in a preferred embodiment , the user selects a desired fluency at the beginning of the treatment , typically determined by the skin type of the patient . before treating a varix , the user adjusts the spot size to fit the size of the varix , and the dermatological handpiece detects the chosen spot size . based on the current spot size reading from the handpiece , the laser control circuit adjusts the pulse energy , by adjusting the laser power or pulse duration , so that the selected fluency is obtained . if the spot size is adjusted by the user in between pulse applications , the pulse energy is automatically adjusted by the system to give the selected fluency . existing laser systems can already provide different fluencies while having a fixed spot size — hence , when the user selects fluency , it is the laser pulse energy which is adjusted . therefore , the preferred embodiment described above requires only modifications to the control system and not to the laser . the light emitting surface of the application head must increase in size in order to be able to emit larger spot sizes . the outpouching varix creates a skin evagination with a curvature in the range of a radius of the varix . therefore , if the application head is held so that it does not compress the skin ( in accordance with the method of the first aspect ), gaps between the skin and the periphery parts of the light emitting surface of the application head will occur . these gaps decrease the efficiency of the treatment by increasing the reflection in the skin . therefore , in a preferred embodiment , the light emitting surface of the application head is concave , preferably having a curvature radius comparable to the radius of a mid - range sized varix .
the invention is directed to a method , a laser system , and a kit for non - invasive treatment and removal of varices . in particular the invention allows for non - invasive laser treatment of large varices , such as varices having a diameter larger than 5 mm . the method of treatment can apply presently available dermatological lasers . the invention further propose developments and additions to presently available dermatological lasers making these particularly applicable to the treatment method .