Evidence-Based Clinical Practice Guidelines for Laser-Assisted Drug Delivery

Importance

Laser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD.

Objective

To develop recommendations for the safe and effective use of LADD.

Evidence Review

A systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved.

Findings

Of the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline's 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections.

Conclusions and Relevance

This systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.

Energy-based devices for the treatment of acne scars: 2021 international consensus recommendations

BACKGROUND AND OBJECTIVES

Acne scars are one of the most distressing and long-term consequences of acne vulgaris, with damaging effect on a person's physical, mental, and social well-being. Numerous treatment options are available including surgical and nonsurgical techniques, depending on the clinical presentation. Although considerable advances in the development of new treatment technologies and applications have been made in the last decade, international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the potential utility of energy-based devices (EBDs) for acne scarring, offer recommendations for safe and efficacious treatment, and provide consensus-based EBD treatment options based on varying presentations demonstrated in a series of real-life clinical photographs.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 24 dermatologists and plastic surgeons from 12 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the treatment of acne scars. A two-step modified Delphi method took place between March 2020 and February 2021 consisting of two rounds of emailed questionnaires. The panel members approved the final manuscript via email correspondence.

RESULTS

The manuscript includes a comprehensive discussion and panel recommendations regarding the following topics: 1. the role of EBD in mitigating and treating acne scars in a patient with active acne, 2. the use of various EBDs for the treatment of different acne scar types with special focus on commonly used laser platform such as vascular lasers, ablative fractional lasers (AFLs) and non-AFLs (NAFLs), 3. treatment combinations, and 4. acne scar treatments in skin of color. The last part comprised of 10 photos of real-life clinical cases with the panel recommendation treatment plan to achieve best aesthetic outcome.

CONCLUSION

Panel members were unanimous in their view that EBDs have a role in the management of acne scars, with AFLs, NAFLs, vascular lasers, and RF devices preferentially selected by most of the panel experts. EBDs are considered a first-line treatment for a variety of acne scar types and patients without access to these treatments may not be receiving the best available care for optimal cosmetic results. Future high-quality research and updated international treatment guidelines and reimbursement schemes should reflect this status.

Safety and Efficacy of Nano-Pulse Stimulation Treatment of Non-Genital, Cutaneous Warts (Verrucae)

BACKGROUND AND OBJECTIVES

This study describes the effects of nano-pulse stimulation (NPS) technology on the common verruca with the objectives of demonstrating efficacy and safety. NPS technology applies nanosecond pulses of non-thermal electrical energy to induce highly localized regulated cell death in the cellular structures of the targeted zone with negligible effects on surrounding non-cellular structures. Previous clinical studies applying NPS to common, benign skin lesions have demonstrated safety and efficacy in clearing seborrheic keratoses and sebaceous hyperplasia.

STUDY DESIGN/MATERIALS AND METHODS

Sixty-two subjects were enrolled at a total of five sites. One hundred and ninety-five study verrucae up to 10 mm wide were treated with NPS delivered by a console-based handheld applicator (CellFX® System; Pulse Biosciences) and follow-ups occurred every 30 days with the option to retreat at 30, 60, and 90 days. There were 62 untreated controls and 46% of the treated verrucae were recalcitrant.

RESULTS

Overall, 75.3% (70/93) of the common verrucae, 72.7% (8/11) of the flat verrucae, and 43.8% (14/32) of the plantar verrucae treated with NPS were completely clear by 60 days following the last treatment and did not recur within the 120-day observation period. The majority (54%) of verrucae cleared with a single NPS procedure. The most common treatment site reactions were erythema (50.5%) and eschar formation (23.4%) on Day 30 and on Day 120 mild erythema was present in 14% of the cases and hyperpigmentation in 18.5%. No serious adverse events were reported. A particle counter was used during 11 NPS procedures on verrucae and no significant plume generation was detected during these procedures.

CONCLUSIONS

NPS is a safe and effective procedure for removing non-genital, cutaneous verrucae. Lasers Surg. Med. © 2021 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

Short pulse intense pulsed light versus pulsed dye laser for the treatment of facial redness

Treating diffuse facial redness with an intense pulsed light (IPL) source usually requires multiple sessions and may not achieve complete clearance. The 595 nm pulsed dye laser (PDL) enjoys a good reputation for reducing facial redness with non-purpuric settings. The objective of this study was to compare facial redness reduction using these two devices. After establishing the lowest light dose able to achieve transient purpura for the same pulse width of 1,5 ms with each technology, right and left sides of the face were randomly assigned for each type of treatment. There were two treatment sessions 4 weeks apart and the final evaluation was performed 8 weeks after thesecond treatment. Four blinded experienced dermatologists analyzed pre and post-treatment photographs, which demonstrated an average of 60% improvement on the segment treated with the IPL as opposed to 45% on the other segment. Pain level was described as mild and the procedure was well tolerated for both types of treatment. In this study we showed that short-pulsed intense pulsed light and PDL are similar in decreasing facial redness when non-purpuric low fluence settings are used. The IPL was faster and did not have consumables.

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations

BACKGROUND AND OBJECTIVES

There is currently intense multidisciplinary interest and a maturing body of literature regarding laser treatments for traumatic scars, but international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the tremendous potential of laser techniques, offer recommendations for safe and efficacious treatment, and promote wider patient access guided by future high-quality research.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the laser treatment of traumatic scars. A three-step modified Delphi method took place between March 2018 and March 2019 consisting of two rounds of emailed questionnaires and supplementary face-to-face meetings. The panel members approved the final manuscript via email correspondence, and the threshold for consensus was at least 80% concurrence among the panel members.

RESULTS

The manuscript includes extensive detailed discussion regarding a variety of laser platforms commonly used for traumatic scar management such as vascular lasers and ablative and non-ablative fractional lasers, special considerations such as coding and laser treatments in skin of color, and 25 summary consensus recommendations.

CONCLUSIONS

Lasers are a first-line therapy in the management of traumatic scars and contractures, and patients without access to these treatments may not be receiving the best available care after injury. Updated international treatment guidelines and reimbursement schemes, additional high-quality research, and patient access should reflect this status. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Clinical evaluation and in-vivo analysis of the performance of a fractional infrared 1550 nm laser system for skin rejuvenation

Background: This study was done to demonstrate the safety and efficacy of a novel fractional 1550 nm laser device with a rolling mechanism (FRAX1550 Ellipse Medical, Horsholm, Denmark). Objectives: To evaluated the effectiveness of the 1550 nm device for improvement in wrinkles, pigmentation, and texture on a six point (-1 to 4) global improvement scale. Methods: Five female subjects between the ages of 44 and 71 years, with visible wrinkles and/or dyspigmentation were enrolled in the study. Two full face treatments were performed four weeks apart Follow-up visits at 1 and 3 months posttreatment were scheduled for photographic assessments. Assessment of improvement were performed by the investigators and two blinded evaluators through use of a six-point scale. Results: All subjects demonstrated improvement in all monitored parameters. The mean improvement scores were: wrinkles 1.6, skin texture 1.8, and pigmentation 1.7. All score improvements were statistically significant. Biopsy was performed on one patient immediately post-treatment and showed 800 μ penetration depth at a treatment level of 88 mJ and 400 μ at 44 mJ. Conclusions: The new rolling fractional 1550 nm laser device from this study offers improvement of aging facial skin with short downtime and minimal side effects.

Multi-Center Pilot Study to Evaluate the Safety Profile of High Energy Fractionated Radiofrequency With Insulated Microneedles to Multiple Levels of the Dermis

In this multi-center pilot study, the safety pro le of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for safety in the treatment of the aging neck and face. A newly designed insulated microneedle system delivers a signi cant coagulative thermal injury into the dermis while sparing the epidermis from RF injury. Thirty- ve healthy subjects from seven aesthetic practices were evaluated, and data from each were incorporated in this case report. The subjects received a single treatment using settings that delivered the highest RF energies suggested from the new recommended protocols. The depth of thermal delivery was adjusted before each pass and all subjects received a minimum of two to three passes to the treated areas. Before and after photographs along with adverse effects were recorded. This case report demonstrates the ability to deliver significant RF thermal injury to several layers of the dermis with insulated microneedles safely with little injury to the epidermis and minimum downtime.

Defining the Absorption Spectrum of the Skin After Application of a Popular Sunless Tanner, Dihydroxyacetone, Using Re ectance Photospectrometry

Dihydroxyacetone (DHA) is a popular ingredient in sunless tanner and lotions. We sought to measure the absorption spectrum of hu- man skin after application of DHA. A male in his 30's applied DHA to one underarm once daily for seven days. Re ectance spectropho- tometry was performed on the treated and untreated side. The area treated with DHA revealed increased absorption in the 400-700 nm range. Compared to normal skin, the absorption spectrum of human skin after application of DHA is altered from 400-700 nm. Care should be taking with using lasers in these wavelengths on skin treated with DHA. <em>J Drugs Dermatol. 2016;15(11):1459-1460.</em>.

Objective Melanin Measurements: Review of Novel Dosimetry Guidance Device for Intense Pulsed Light in Aesthetic Treatments

A melanin meter has been created to assess real time skin pigmentation to optimize settings for visible light aesthetic applications.

METHODS

A handheld meter was applied to non sun-damaged skin on the back of volunteers to measure skin pigmentation prior to treatment with IPL light sources over a range of pulse widths and ascending fluences. Curves for maximum epidermal tolerances as a function of pigmentation were determined. These curves were then tabulated for each pulse width in device software to provide guidance in the selection of fluences. Based on these findings, the device was applied in over 300 patients at a comprehensive laser and cosmetic dermatology center.

RESULTS

A pigment meter evaluation led to treatment parameter guidance in intense pulsed light applications. These suggested ranges for settings based on the melanin index score proved useful, accurate, and safe in applications over a broad range of skin colors and across various anatomic units of the skin.

CONCLUSION

A pigment meter can be used to identify appropriate settings with IPL treatments in order to enhance safety and efficacy when treating epidermal pigmented lesions, vessels, general photodamage and excessive hair (where the principles of selective photothermolysis are applied).

Role of Beam Spot Size in Heating Targets at Depth

BACKGROUND AND OBJECTIVE

Wavelength, fluence and pulse width are primary device parameters for the treatment of skin and hair conditions. Wavelength selection is based on tissue scatter and target chromophores. Pulse width is chosen to optimize target heating. Energy absorbed by a target is determined by fluence and spot size of the light source as well as the depth of the target. We conducted an in vitro skin study and simulations to compare heating of a target at a particular depth versus spot size.

STUDY DESIGN/MATERIALS AND METHODS

Porcine skin and fat tissue were prepared and separated to form a 2mm skin layer above a 1 cm thick fat layer. A 50 μm thermocouple was placed between the layers and centered beneath a 23 x 38 mm treatment window of an 805 nm diode laser device (Vectus, Cynosure, Westford, MA). Apertures provided various incident beam spot sizes and the temperature rise of the thermocouple was measured for a fixed fluence.

RESULTS

The 2mm deep target's temperature rise versus treatment area showed two regimes with different positive slopes. The first regime up to approximately 1 cm(2) area has a greater temperature rise versus area than that for the regime greater than 1 cm(2). The slope in the second regime is nonetheless appreciable and provides a fluence reduction factor for skin safety. The same temperature rise in a target at 2 mm depth (typical hair bulb depth in some areas) is realized by increasing the area from 1 to 4 cm(2) while reducing the fluence by half.

CONCLUSIONS

The role of spot size and in situ beam divergence is an important consideration to determine optimum fluence settings that increase skin safety when treating deeper targets.

Analysis of Depth of Ablation,Thermal Damage, Wound Healing, and Wound Contraction With Erbium YAG Laser in a Yorkshire Pig Model

BACKGROUND AND OBJECTIVES

The erbium YAG laser is commonly used for skin resurfacing. It is known that varying the pulse duration can influence residual thermal damage and wound healing. Our study used a porcine model to evaluate a broad range of settings in a comparison of depth of ablation, depth of residual thermal damage (RTD), and wound contraction employing both a full coverage and fractional hand piece with an erbium YAG laser.

MATERIALS AND METHODS

The laser delivered an ablative pulse followed by a heating pulse of variable duration using either the full coverage or fractional hand piece. Pulse durations for specific coagulation depths were selected based on existing heat transfer models. The bilateral flanks of a single Yorkshire pig were irradiated. There were 14 treatment groups. 3 sites were treated per group for a total of 42 sites. Two of the 3 sites were for observational assessments and the 3rd site served as a reservoir for biopsies. Biopsy specimens were collected on days 0, 1, 3, 7, 14, and 28. Bleeding, erythema, wound healing, and wound contraction (in the fractional hand piece groups) were assessed.

CONCLUSION

Wound healing is faster for fractional laser skin resurfacing compared with traditional contiguous resurfacing as demonstrated by textural changes and degree of erythema. The laser operator can be confident that the depth of ablation displayed on this system accurately reflects what is occurring in vivo for both confluent and fractional modes. Likewise, the measured degree of coagulation was consistent with panel display settings for the confluent mode. However, the degree of coagulation, as measured by the thickness of residual thermal damage, did not vary significantly between the fractional groups. In other words, the pulse duration of the second (heating) pulse did not impact the degree of coagulation in the fractional mode. There was a 2.3% wound contraction between some groups and a 6.5% wound contraction between other groups. A two way analysis of variance found a statistically significant difference in wound contraction based on ablation depth ( P = 0.012) but the degree of coagulation did not prove to be statistically significant for wound contraction (P = 0.66).

The Use of a Fractional Ablative Micro-Plasma Radiofrequency Device in Treatment of Striae

OBJECTIVE

To evaluate the efficacy of a fractional ablative micro-plasma radiofrequency (RF) device in the reduction of the appearance of abdominal striae.

METHODS

Five female patients (age range, 30-60) with abdomen striae alba (n=4) and striae rubra (n=1) were enrolled in the study. Skin type distribution among the 5 patients was two type II, one type III, and two type IVs. The device (Accent XL, Alma Lasers Inc.) is a radiofrequency fractional platform (40.68 MhZ) that deploys multiple conical pin electrodes on a moving handheld 6 cogs roller. Four treatments were performed every two weeks with settings based on test spots performed two weeks prior to a full treatment session. Assessment of striae was based on clinical severity of the lesions on a 1-4 scale, with "4" being the most severe. A questionnaire was administered to patients with possible subjective responses ranging from 0-4, with 0 being no improvement and quartiles from 1-4 (1= mild improvement, 2= fair improvement, 3= moderate improvement, and 4= marked improvement, respectively).

RESULTS

Three months after 4 treatments, a mean improvement of 20% was achieved (mean severity score changed from 2.9 to 2.5). Micro-wounds were approximately 200 μm wide on the surface, initially presenting as small gray "dots" and evolving into black dots lasting about 2 weeks. Mean pain was 2/10. Erythema and edema persisted for about one day. No pigmentation abnormalities were observed at the final evaluation. The results from the patient questionnaire revealed a mean score of 2.4/4, thus falling in the range of good to very good.

CONCLUSION

A fractional ablative micro-plasma RF roller device can improve improvement in the appearance of abdomen striae.

Treatment of Acne Scars With High Intensity Focused Radio Frequency

In this multi-site case series, the efficacy of high intensity focused radiofrequency (RF) delivered to the dermis was evaluated for treating acne scars. A novel delivery system that uses insulated microneedles to deliver a desired thermal effect to multiple depths of the dermis while sparing the epidermis from RF injury was used. Four (4) healthy subjects from four different practices were evaluated and used in this case report. The subjects were treated between 3 or 4 times depending on the severity of the acne scars presented. The depth of thermal delivery was adjusted before each pass and all subjects received at a minimum, three passes to the treated area. Before and after photographs along with adverse effects were recorded. The theory behind the use of insulated needles with the active RF delivery at the distal tip is to allow for significant thermal injury to several layers of the dermis while avoiding thermal injury to the epidermis. This case report demonstrates significant improvement on acne scars and that all skin types should be safely treatable with minimum downtime realized.

Q-Switched Alexandrite Laser-induced Chrysiasis

BACKGROUND

Chyriasis is an uncommon side effect that occurs in patients who are receiving prolonged treatment with either intravenous or intramuscular gold as a distinctive blue-gray pigmentation of light-exposed skin. Laser-induced chrysiasis is a rarely described phenomenon in individuals who have received systemic gold and are subsequently treated with a Q-switched laser.

PURPOSE

To describe the characteristics of patients with laser-induced chrysiasis.

METHODS

The authors describe a 60-year-old woman who developed chrysiasis at Q-switched alexandrite laser treatment sites. They also reviewed the medical literature using PubMed, searching the terms chrysiasis, gold, and laser-induced. Patient reports and previous reviews of these subjects were critically assessed and the salient features are presented.

RESULTS

Including the authors' patient, laser-induced chrysiasis has been described in five Caucasian arthritis patients (4 women and 1 man); most of the patients had received more than 8g of systemic gold therapy during a period of 3 to 13 years. Gold therapy was still occurring or had been discontinued as long as 26 years prior to laser treatment. All of the patients immediately developed blue macules at the Q-switched laser treatment site. Resolution of the dyschromia occurred in a 70-year-old woman after two treatment sessions with a long-pulsed ruby laser and the authors' patient after a sequential series of laser sessions using a long-pulsed alexandrite laser, followed by a nonablative fractional laser and an ablative carbon dioxide laser.

CONCLUSION

Laser-induced chrysiasis has been observed following treatment with Q-switched lasers in patients who are receiving or have previously been treated with systemic gold. It can occur decades after treatment with gold has been discontinued. Therefore, inquiry regarding a prior history of treatment with gold-particularly in older patients with arthritis-should be considered prior to treatment with a Q-switched laser. Also, treatment with a long-pulsed laser should be entertained in patients with either idiopathic or laser-induced chrysiasis. (JClinAesthetDermatol. 2015;8(9):48-53.) Chrysiasis is a distinctive blue-gray pigmentation of light exposed skin occurring in individuals who are receiving parenteral gold therapy.1 The 755nm Q-switched alexandrite laser is effective for the treatment of facial lentigines since the melanin granules absorb a high proportion of the laser energy and other chromophores offer little competitive absorption.2 The authors describe a woman who developed chrysiasis at Q-switched alexandrite laser treatment sites and whose dyschromia was successfully treated with a sequential series of laser sessions using a long-pulsed alexandrite laser, followed by a nonablative fractional laser and an ablative carbon dioxide laser.

Bacterial infections following non-ablative fractional laser treatment: a case series and discussion

Non-ablative fractional laser procedures have become increasingly popular since their introduction in 2004. The fractional 1,927 nm thulium laser is a non-ablative device that penetrates up to 300 μm in the skin and the 1,550 nm erbium:glass laser penetrates up to 1,400 μm. These procedures are considered minimally invasive with a high safety profile; therefore, infectious complications are exceedingly rare. However, we report five recent cases of bacterial infection with both gram-positive and gram-negative organisms following treatment with the fractional 1550/1927 nm laser approximately 1 day to 1 week post-procedure. One patient had a rapidly progressing pustular eruption with symptoms of sepsis. These patients were seen immediately, cultures were obtained and empiric antibiotic therapy was initiated. They recovered without long-term complications. Rapid-onset bacterial infections following non-ablative laser resurfacing with the 1550/1927 nm laser have not been previously reported in the literature. The infections can progress quickly and lead to serious sequelae, including systemic illness and severe scarring, if not identified and appropriately treated. We present these cases to highlight the importance of close surveillance and when appropriate, rapid intervention, following non-ablative fractional procedures, especially when patients present with atypical symptoms and signs.

A split face study to document the safety and efficacy of clearance of melasma with a 5 ns q switched Nd YAG laser versus a 50 ns q switched Nd YAG laser

BACKGROUND AND OBJECTIVES

To determine the safety and efficacy of a 50 ns Q switched Nd YAG laser vs. a 5 ns Q switched Nd YAG laser for clearance of melasma. To compare subject satisfaction, efficacy, and comfort level between the two lasers.

STUDY DESIGN/MATERIALS AND METHODS

This is a prospective, randomized split face clinical study. The study was approved by the Scripps IRB. Ten healthy female subjects with moderate to severe melasma were enrolled. Each subject had three laser treatments one month apart. Patients were followed up approximately 1 month, 3 months, and 6 months after the final laser treatment. A treatment session consisted of a microdermabrasion, 1064 nm QS laser, and topicals. Subjects were asked to rate treatment pain based on a numerical scale range 0-10 (0 = no pain and 10 = worst pain). A melasma area and severity index (MASI) grading system was applied. Also, melanin measurements were acquired by a reflectance spectrophotometer. Side effects were documented during the study including post treatment erythema.

RESULTS

Eight patients completed the study. Subjects showed improvement on both sides of the face. From baseline to 1 month post the final laser treatment, the average MASI scores showed a 16% reduction for the 50 ns QS 1064 nm laser vs. a 27% reduction for the 5 ns QS 1064 nm laser (both significant versus baseline pigment, P < 0.05). This difference in MASI scores between the two lasers was not statistically significant (P = 0.87930). Laser treatments displayed mild erythema that resolved after one day. The melanin meter measurements showed a reduction in pigment readings on both sides. Three months after the final treatment there was some relapse in the melasma, as the mean pigment reduction fell to 12% for the 50 ns laser and 11% for the 5 ns laser. By 3 months pigment reduction was not statistically significant for either laser, and no significant differences in pigment reduction were noted between the two pulse durations. There was a statistically significant difference (P < 0.05) in pain scores reported by the subjects (scale 0-10), the mean pain score for 50 ns QS 1064 nm laser was 1.2 and for the 5 ns QS 2.9 the score was 2.9.

CONCLUSIONS

In this study, we showed that a combination of microdermabrasion, QS1064 nm laser, and topicals decreased the MASI and meter scores without clinically significant side effects. Moreover, the longer pulsed Q switched 1064 nm laser i.e. (50 ns) was associated with less pain than its shorter pulse width counterpart.

Clinical evaluation of a non-ablative 1940 nm fractional laser

BACKGROUND AND OBJECTIVES

Non-ablative fractional lasers cause little down-time, however, some patients want more noticeable results with fewer treatments. The 1940 nm wavelength matches one of the water absorption peaks in the mid infrared band of electromagnetic energy. The skin absorption is much stronger than other non-ablative wavelengths (1410-1550 nm) and weaker than ablative wavelengths (Er:YAG or CO2). The objective of this study was to characterize clinical efficacy using this technology to treat photodamaged skin in human subjects.

MATERIALS AND METHODS

Under an IRB approved study, eleven subjects with facial photodamage (1 male and 10 female) were enrolled and completed the study. The fractional 1940 nm laser was comprised of a thulium rod pumped by a pulsed alexandrite laser. The fractional patterns were generated by four separate handpieces (two dot (0.48mm and 0.76mm dot-to-dot distance or pitch) and two grid geometries) whereby a larger beam was broken up into smaller microbeams by a microlens system or reflective square grids. The low -pitch circular dot array handpiece, which is used most frequently, has a macro-spot size of 12 mm and a total applied energy of approximately 2-5 J (~ 4-10 mJ per beamlet). Contact skin cooling (5-20degC) was provided via a sapphire window at the distal end of handpiece. Pulses from the dot handpieces were applied with 20% overlap. The microspot size for the dot handpieces was ~ 0.2-0.3 mm. The two grid pattern handpieces included 0.4 mm wide lines with 45% and 0.7 mm wide lines with 65% coverage. Each subject received 3 full-face treatments 4-6 weeks apart. Anesthesia was achieved by 5% lidocaine cream and a cold air chiller. Typical treatments were carried out with two passes. Outcome assessments included changes in pigment, rhytides, laxity, elastosis, and texture, using a diffuse pigmentation scale and the Alexiades-Armenakas Comprehensive Grading Scale of Rhytides, Laxity, and Photodamage. Photographs of each patient from prior to treatment, and 3 months after treatment were analyzed by 3 blinded physician raters. A paired t-test was applied for each category comparing the pre treatment and 3-month post treatment results.

RESULTS

Three months after the final treatment, (a) mean pigment improvement was 21.1%, (b) rhytides were reduced by 14.3%, (c) laxity was reduced by 8.9%, elastosis was reduced by 22.3%, and (e) texture scores were unchanged. Reductions in pigmentation, rhytides, and elastosis were statistically significant (P≤ 0.05). Clinical downtime was 3-5 days. Pain was variable (mean of 2.8/10) and side effects included two cases of mild focal vesiculation. No long-term side effects were noted. Histological analysis showed focal damage that extended about 200 μm deep to the surface.

CONCLUSION

The 1940nm thulium laser is safe, well tolerated, and results in reduced downtime compared to traditional resurfacing. The study demonstrated that the 1940 nm thulium laser could achieve injury patterns capable of skin rejuvenation.

Abbreviations for device names: a proposed methodology with specific examples

BACKGROUND

Many devices used in dermatology lack generic names. If investigators use commercial device names, they risk the appearance of bias. Alternatively, reliance on ad-hoc names and abbreviations may confuse readers who do not recognize these.

OBJECTIVE

To develop a system for assigning abbreviations to denote devices commonly used in dermatology. Secondarily, to use this system to create abbreviations for FDA-approved neurotoxins and prepackaged injectable soft-tissue augmentation materials.

METHODS

The American Society for Dermatologic Surgery convened a Lexicon Task Force in March 2012. One charge of this Task Force was to develop criteria for assigning abbreviations to medical devices. A modified consensus process was used.

RESULTS

Abbreviations to denote devices were to be: based on a standardized approach; transparent to the casual reader; markedly brief; and in all cases, different than the commercial names. Three-letter all caps abbreviations, some with subscripts, were assigned to denote each of the approved neurotoxins and fillers.

CONCLUSION

A common system of abbreviations for medical devices in dermatology may avoid the appearance of bias while ensuring effective communication. The proposed system may be expanded to name other devices, and the ensuing abbreviations may be suitable for journal articles, continuing medical education lectures, or other academic or clinical purposes.

Combined fractional ablative and nonablative laser resurfacing treatment: a split-face comparative study

BACKGROUND

Fractional ablative and nonablative lasers are useful tools for facial rejuvenation; however, ablative lasers require a period of downtime during reepthelialization. A procedure that combines both ablative and nonablative lasers may deliver good cosmetic results and reduce downtime or other side effects of treatment.

OBJECTIVE

The purpose of this study was to compare a combined fractional ablative and nonablative laser procedure to ablative-only procedures for facial rejuvenation.

METHODS

A total of 8 subjects in 2 study groups received a single, split-face, facial rejuvenation procedure in this study. In group A, we compared a combined procedure using a fractional nonablative 1,440-nm neodymium-doped yttrium aluminum garnet (YAG) laser and a fractional ablative 2,940-nm erbium (Er)-doped YAG laser on one side of the face, and a combined confluent/fractional ablative Er:YAG laser on the other. In group B, we compared the same 1,440/2,940 treatment as group A on one side of the face, and a fractional ablative CO2 laser on the other. Subjects were followed for 3 months to assess side effects and improvement in Fitzpatrick Wrinkle Score and pigmentation.

RESULTS

Improvement in wrinkles and pigment were seen with all techniques in both groups, and results were equivalent. Areas treated with combined fractional nonablative and ablative technique demonstrated fewer immediate side effects.

CONCLUSION

Facial rejuvenation using a combination treatment of fractional ablative 2,940 and nonablative 1,440 lasers provides improvement in wrinkles and pigment similar to conservative purely ablative approaches. These purely ablative approaches include the Er:YAG laser used in a sequential confluent fractional manner, or fractional CO2 laser alone. Reduced side effects make the combined procedure an attractive option for facial rejuvenation.

Treatment of benign pigmented lesions using a long-pulse alexandrite laser

BACKGROUND

To evaluate the efficacy of a novel long-pulse alexandrite laser with contact cooling in the treatment of benign pigmented lesions.

METHODS

Five patients were enrolled in the study. All patients presented with epidermal pigmented lesions on the arms, hands, chest, or legs. Patients were all female with a mean age of 59 years. At the initial evaluation, baseline pigment readings were determined with a pigment meter. Test spots were performed with escalating doses of alexandrite laser (ClearScan ALX, Sciton, Palo Alto, CA) deployed by a 7-mm spot equipped with a 30 mm x 30 mm scanner and a 10-ms pulse duration. Contact cooling was used, and temperature was maintained at 18°C to 20°C. Patients returned 4 to 7 days after test spots for evaluation for the purpose of optimizing settings. The highest settings that allowed for epidermal preservation and crusting of the hyperpigmented lesions were applied for the remainder of the treatment zones. Determinations of improvement were made by evaluation of photographs with standard settings using polarized and nonpolarized images. At each appointment, baseline pigment measurements were made to ensure there were no significant changes between treatment sessions. Two treatment sessions were performed approximately 4 weeks apart, and the final evaluation was 3 months after the final treatment.

RESULTS

Evaluation by a panel of blind observers determined a mean improvement of approximately 30%. Darker lesions responded better than lighter lesions. So-called low-contrast lesions performed the poorest. Pain was approximately 2/10 with the use of 5% lidocaine numbing cream applied approximately 45 minutes before each procedure. Pain was most severe where there was underlying hair.

CONCLUSION

A long-pulse alexandrite laser equipped with contact cooling can achieve significant pigmentation improvement.

Treatment of sebaceous hyperplasia with a novel 1,720-nm laser

BACKGROUND

Sebaceous hyperplasia is a common benign proliferation of sebaceous glands. Multiple treatment methods have been applied in the past, including electrodessication, ablative and visible light lasers, applications of acids, and photodynamic therapy. Often, however, only the superficial component of the lesion is treated, leading to rapid recurrence. It has been shown that human fat has absorption peaks at 1,210 nm and 1,720 nm. We report the first use of a novel 1,720-nm laser in the treatment of sebaceous hyperplasia in human subjects.

METHODS

Four patients with sebaceous hyperplasia underwent a test spot treatment followed by 2 full treatment sessions using the 1,720-nm laser. Photos were taken before treatment, at each treatment session, and 3 months following the last treatment. Pretreatment photographs and 3-month follow-up photographs were compared to assess efficacy.

RESULTS

Four weeks after the final treatment, 3 dermatologists blinded to the date of the photographs and uninvolved with the study evaluated the photos and scored them based on a global assessment comprised of: 1) lesion diameter, 2) lesion height, and 3) lesion color. Many of the lesions resolved almost completely after a single treatment, and no additional treatment was required. Overall, there was a reduction in the color, diameter, and height of the lesions. Crusts were noted by all patients and resolved within 10 days.

CONCLUSION

The use of this novel device that exploits the intrinsic selectivity of 1,720 nm achieved nearly complete clearance of sebaceous hyperplasia lesions without depressions or scarring. Complete heating of the sebaceous gland and sparing of the surrounding skin offered by this device resulted in clinically apparent improvement with a minimum of adverse effects.

Characterization of an optimized light source and comparison to pulsed dye laser for superficial and deep vessel clearance

BACKGROUND AND OBJECTIVE

An arc lamp-based device providing optimized spectrum and pulse shape was characterized and compared with two pulsed dye laser (PDL) systems using a vascular phantom. Safety and effectiveness for facial telangiectasia are presented in clinical case studies.

STUDY DESIGN/MATERIALS AND METHODS

An optimized pulsed light source's (OPL) spectral and power output were characterized and compared with two 595 nm PDL devices. Purpuric threshold fluences were determined for the OPL and PDLs on Fitzpatrick type II normal skin. A vascular phantom comprising blood-filled quartz capillaries beneath porcine skin was treated by the devices at their respective purpuric threshold fluences for 3 ms pulse widths, while vessel temperatures were monitored with an infrared (IR) camera. Patients with Fitzpatrick skin types II-III received a split-face treatment with the OPL and a 595 nm PDL.

RESULTS

The OPL provided a dual-band output spectrum from 500 to 670 nm and 850-1,200 nm, pulse widths from 3 to 100 ms, and fluences to 80 J/cm(2). The smooth output power measured during all pulse widths provides unambiguous vessel size selectivity. Percent energy in the near infra-red increased with decreasing output power from 45% to 60% and contributed 15-26% to heating of deep vessels, respectively. At purpuric threshold fluences the ratio of OPL to PDL vessel temperature rise was 1.7-2.8. OPL treatments of facial telangiectasia were well-tolerated by patients demonstrating significant improvements comparable to PDL with no downtime.

CONCLUSIONS

Intense pulsed light (IPL) and PDL output pulse and spectral profiles are important for selective treatment of vessels in vascular lesions. The OPL's margin between purpuric threshold fluence and treatment fluence for deeper, larger vessels was greater than the corresponding margin with PDLs. The results warrant further comparison studies with IPLs and other PDLs.

Blood flow dynamics after laser therapy of port wine stain birthmarks

BACKGROUND AND OBJECTIVE

During laser therapy of port wine stain (PWS) birthmarks, regions of perfusion may persist. We hypothesize that such regions are not readily observable even when laser surgery is performed by highly experienced clinicians. The objective of this study was to use objective feedback to assess the acute vascular response to laser therapy.

STUDY DESIGN/MATERIALS AND METHODS

A clinic-friendly laser speckle imaging (LSI) instrument was developed to provide the clinician with real-time images of blood flow during laser therapy. Images were acquired from patients undergoing laser therapy of PWS birthmarks at Scripps Clinic and the Beckman Laser Institute and Medical Clinic. Blood flow maps were extracted from the acquired imaging data. Histogram-based analysis was applied in grading the degree of heterogeneity present in the blood flow maps after laser therapy.

RESULTS

Collectively, two types of patient responses were observed in response to laser exposure: (1) an immediate increase in perfusion within minutes after laser therapy; and (2) an overall decrease in blood perfusion approximately 1 hour after laser therapy, with distinct regions of persistent perfusion apparent in the majority of post-treatment blood-flow images. A comparison of blood flow in PWS and adjacent normal skin demonstrated that PWS blood flow can be greater than, or sometimes equivalent to, that of normal skin.

CONCLUSION

In general, a decrease in skin perfusion is observed during pulsed laser therapy of PWS birthmarks. However, a heterogeneous perfusion map was frequently observed. These regions of persistent perfusion may be due to incomplete photocoagulation of the targeted vessels. We hypothesize that immediate retreatment of these regions identified with LSI, will result in enhanced removal of the PWS vasculature. Lasers Surg. Med. 41:563-571, 2009. (c) 2009 Wiley-Liss, Inc.

Blood flow dynamics after laser therapy of port wine stain birthmarks

BACKGROUND AND OBJECTIVE

During laser therapy of port wine stain (PWS) birthmarks, regions of perfusion may persist. We hypothesize that such regions are not readily observable even when laser surgery is performed by highly experienced clinicians. The objective of this study was to use objective feedback to assess the acute vascular response to laser therapy.

STUDY DESIGN/MATERIALS AND METHODS

A clinic-friendly laser speckle imaging (LSI) instrument was developed to provide the clinician with real-time images of blood flow during laser therapy. Images were acquired from patients undergoing laser therapy of PWS birthmarks at Scripps Clinic and the Beckman Laser Institute and Medical Clinic. Blood flow maps were extracted from the acquired imaging data. Histogram-based analysis was applied in grading the degree of heterogeneity present in the blood flow maps after laser therapy.

RESULTS

Collectively, two types of patient responses were observed in response to laser exposure: (1) an immediate increase in perfusion within minutes after laser therapy; and (2) an overall decrease in blood perfusion approximately 1 hour after laser therapy, with distinct regions of persistent perfusion apparent in the majority of post-treatment blood-flow images. A comparison of blood flow in PWS and adjacent normal skin demonstrated that PWS blood flow can be greater than, or sometimes equivalent to, that of normal skin.

CONCLUSION

In general, a decrease in skin perfusion is observed during pulsed laser therapy of PWS birthmarks. However, a heterogeneous perfusion map was frequently observed. These regions of persistent perfusion may be due to incomplete photocoagulation of the targeted vessels. We hypothesize that immediate retreatment of these regions identified with LSI, will result in enhanced removal of the PWS vasculature. Lasers Surg. Med. 41:563-571, 2009. (c) 2009 Wiley-Liss, Inc.

Full-face treatments with the 2790-nm erbium:YSGG laser system

BACKGROUND

Traditional full-face resurfacing has been limited to erbium-doped yttrium aluminium garnet (Er:YAG) and carbon dioxide (CO2) lasers. These devices offer wavelength-specific advantages and disadvantages.

METHODS

Nine patients were enrolled in a pilot study of a resurfacing system using a 2790-nm erbium:yttrium-scandium-gallium-garnet (Er:YSGG) laser system. Two treatments were carried out 1 month apart over the entire face. Test spots were performed prior to the full-face sessions to determine the optimal fluence for 1-pass laser resurfacing. Biopsies were performed at the time of treatment and at the final follow-up visit one month after the second treatment. Clinical endpoints included changes in pigment dyschromias, wrinkles, and skin tone. All outcomes were graded by blinded observers.

RESULTS

Eight patients completed the 2 treatments. Biopsies showed thermal damage extending as deep as 80 microm below the stratum corneum. Reepithelialization was complete within 4 days. No scarring, post inflammatory hyperpigmentation (PIH), or infections were observed.

CONCLUSION

A 2790-nm laser can be used for skin rejuvenation with a 4 day recovery window.

Low-fluence 1,064-nm laser hair reduction for pseudofolliculitis barbae in skin types IV, V, and VI

PURPOSE

To evaluate the efficacy of a 1,064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser using lower than traditional fluences (22-40 J/cm(2)) for treatment of pseudofolliculitis barbae (PFB).

METHODS

Twenty-two patients with PFB refractory to conservative therapy received five weekly treatments over the anterior neck using a 1,064-nm Nd:YAG laser at 12 J/cm(2). Pulse duration was 20 ms with 10 mm spot size. Topical anesthesia was not used. Treatments were completed 15 minutes after patient arrival. Patients presented for 2- and 4-week follow-up. Ten evaluators used a Global Assessment Scale (GAS) to assess dyspigmentation, papule counts, and cobblestoning by comparing baseline to 4-week follow-up visit photographs. Hair and papule counts were performed on five patients and compared with the GAS. Investigators recorded adverse effects using a visual analog and side effects scale.

RESULTS

Eleven patients demonstrated 83% improvement on the GAS (p<.01). There was a mean reduction of 59.5% in dyspigmentation (p<.03), 91.2% in papule count (p<.01), and 75.6% in cobblestoning (p<.02). Patients reported 1 out of 10 on both adverse effects scales.

CONCLUSION

Low-fluence 1,064-nm laser treatment achieved significant temporary reduction in PFB. Subjects noted minimal pain without topical anesthesia.

Laser versus intense pulsed light: Competing technologies in dermatology

Lasers have been competing with non-laser intense pulsed light (IPL) sources in the cosmetic arena over the past 10 years. Initially IPLs were somewhat cumbersome and accepted by a minority of "serious" practitioners. Recently, however, the popularity of full-face visible light skin rejuvenation, enhanced engineering of IPLs, and favorable cost versus many lasers, have lead to a proliferation of IPL devices. No longer a stepchild in the rejuvenation market, IPLs may overtake lasers as the devices of choice among most physicians. We review the pros and cons of lasers and IPLs within the context of design, cost, and other practical concerns for a typical office-based practice.

Effect of monopolar radiofrequency treatment over soft-tissue fillers in an animal model: part 2

BACKGROUND AND OBJECTIVE

Monopolar radiofrequency (RF) treatment is used by physicians to heat skin and promote tissue tightening and contouring. Cosmetic fillers are used to soften deep facial lines and wrinkles. Patients who have had dermal fillers implanted may also benefit from or are candidates for monopolar RF skin tightening. This study examined the effect of RF treatment on various dermal filler substances. This is the second part of a two-part study.

STUDY DESIGN/MATERIALS AND METHODS

A juvenile farm pig was injected with dermal fillers including cross-linked human collagen (Cosmoplast), polylactic acid (PLA) (Sculptra), liquid injectable silicone (Silikon 1000), calcium hydroxylapatite (CaHA) (Radiesse), and hyaluronic acid (Restylane). Skin injected with dermal fillers was RF-treated using a 1.5-cm2 treatment tip and treatment levels typically used in the clinical setting. Fillers were examined histologically 5 days, 2 weeks, or 1 month after treatment. Histological specimens were scored for inflammatory response, foreign body response, and fibrosis in order to assess the effect of treatment on early filler processes, such as inflammation and encapsulation.

RESULTS

Each filler substance produced a characteristic inflammatory response. No immediate thermal effect of RF treatment was observed histologically. RF treatment resulted in statistically significant increases in the inflammatory, foreign body, and fibrotic responses associated with the filler substances.

CONCLUSIONS

Monopolar RF treatment levels that are typically used in the clinical setting were employed in this animal study. RF treatment resulted in measurable and statistically significant histological changes associated with the various filler materials. Additional clinical and histological studies are required to determine the optimal timing of monopolar RF treatment and filler placement for maximal potential aesthetic outcome.

Variable-pulse Nd:YAG laser in the treatment of facial telangiectasias

BACKGROUND

Variable-pulse 1,064 nm wavelength lasers have been used with good effectiveness on leg telangiectasias and reticular veins and have shown promising results on facial telangiectasias as well.

OBJECTIVE

To investigate the effectiveness of a variable-pulse neodymium:yttrium-aluminum-garnet (Nd:YAG) laser using a small spot size in the treatment of facial telangiectasias.

METHODS

Eight male patients (mean age 75 years) underwent a single treatment session using a variable-pulse 1.5 mm spot size Nd:YAG laser with epidermal cooling. Telangiectasia diameters were 0.3 to 2.0 mm. Test sites were performed using three pulse widths (3, 20, and 60 ms), with fluences varying depending on vessel size and response. Full treatments were performed using test parameters giving the best response. Thirteen weeks later, the patients returned for final evaluation and satisfaction rating.

RESULTS

Fluences ranged from 226 to 425 J/cm2, with smaller vessels requiring larger energies. Pulse duration was equally divided between the 20 and 60 ms settings. The shortest pulse width (3 ms) was inferior in all patients. Longer pulse durations achieved superior vessel elimination with minimal immediate purpura and no postinflammatory hyperpigmentation. The average mean vessel clearance was 26 to 50% in half of the patients and 51 to 75% in the other half as evaluated by three unbiased dermatologists with extensive laser experience.

CONCLUSION

A small-spot size Nd:YAG laser using a pulse width of 20 ms or higher appears to be effective in clearing a significant percentage of facial telangectasias with a single pass. The side effects were minimal.

Intense Pulsed Light and Laser Treatment of Facial Telangiectasias and Dyspigmentation: Some Theoretical and Practical Comparisons

BACKGROUND AND OBJECTIVE

A comparative overview is presented, both theoretical and clinical, for intense pulsed light (IPL) and laser treatment of facial telangiectasias and pigmented lesions.

MATERIALS AND METHODS

A narrative approach describes light penetration into the epidermis, dermis, dermal-epidermal junction, and facial ectasias. Based on mathematical models, we examine some temperature profiles for monochromatic and broadband light sources. Specifically, temperature elevations of representative vascular targets are discussed. Also, clinical scenarios are reviewed for both IPL and laser. Although multiple monochromatic devices are reviewed, only the 532 and 595 nm wavelengths are emphasized.

RESULTS

In theory, an IPL can be filtered to simulate 532 and 595 nm laser light in the treatment of telangiectasias and dyschromias. In comparing our experiences with the different devices, all three (IPL, 532 nm laser, and 595 nm laser) are capable of achieving a reduction in ectasias and hyperpigmented macules.

CONCLUSIONS

With an optimal set of parameters, IPLs and lasers are comparable in the treatment of vascular and pigmented lesions with respect to treatment efficiency and safety.

Optical treatments for acne

Light-based treatments for acne are becoming increasingly commonplace in dermatology. This article reviews various light approaches in acne therapy. Methods are discussed from an anatomical and a functional perspective. The emphasis is on the practicality of treatment as well as the pros and cons of various devices. Also, a review of the recent literature is presented. The article is intended to give the reader a panoramic view of this still-young and developing area. Most likely, light-based acne treatment will receive more popularity as dermatologists learn how to integrate this type of therapy within the context of more established drug agents.

Optimal pulse durations for the treatment of leg telangiectasias with a neodymium YAG laser

BACKGROUND

Leg veins can be effectively treated with lasers. However, the optimal pulse duration for small leg veins has not been established in human studies with a Nd:YAG laser.

OBJECTIVES

The purpose of this study was to investigate a range of pulse durations to determine an optimal pulse duration for clearance of leg veins.

STUDY DESIGN/MATERIALS AND METHODS

After mapping and photo documentation of the leg veins to be treated, a variable pulse duration Neodymium:Yttrium Aluminum Garnet (Nd:YAG) laser (3-100 milliseconds) was used in a single test site session. Pulse durations of 3, 20, 40, 60, 80, and 100 milliseconds were used. At the 3-week follow-up, the optimal pulse duration was defined as that pulse duration which resulted in the most complete clearance of vessels with the least side effects. Up to 20 vessels were then treated using the established "optimal" pulse duration. Final evaluation was at 16 weeks after the initial visit. Three blinded observers rated the percent of vessels completely cleared based on initial and final photographs.

RESULTS

Eighteen patients completed the study. Fluence thresholds for immediate vessel changes varied depending on spot size and vessel diameter, with larger fluences required for smaller spot sizes and smaller vessels. Shorter pulse durations (< or =20 milliseconds) were associated with occasional spot sized purpura and spot sized post-inflammatory hyperpigmentation. Longer pulse durations (40-60 milliseconds) achieved superior vessel elimination with less post-inflammatory hyperpigmentation. With a single laser treatment, 71% of the treated vessels cleared.

CONCLUSIONS

Compared to shorter pulses (<20 milliseconds), longer pulses may provide gentler heating of the vessel and a greater ratio of contraction to thrombosis.

Complications of laser dermatologic surgery

BACKGROUND AND OBJECTIVE

Innovations in lasers, light and radiofrequency devices have allowed for improved therapeutic efficacy and safety and the ability to treat patients with an ever-increasing number of medical and aesthetic indications. Safety remains a primary concern and the timely communication of complications and their management is vital to insure that treatments be as safe as possible. The purpose of this report on the Proceedings of the First International Laser Surgery Morbidity Meeting is to provide laser experts the opportunity to present and discuss complications that their patients have experienced and how they were successfully managed.

METHODS

Laser experts were invited to present complications of laser, light, and radiofrequency treatments that their patients have experienced and to discuss the potential mechanisms leading to the complications their management and final outcomes.

RESULTS

Nineteen unique cases are presented and the clinical management of each case discussed. Eighteen sets of pre- and post-operative photos are presented.

CONCLUSION

This report shows that even experts, with extensive experience using light-based therapies, can and do have patients who develop complications. Sound clinical judgment, and knowing how to avoid complications and their timely post-operative management, is essential to insure optimal therapeutic outcome.

Split treatment of photodamaged skin with KTP 532 nm laser with 10 mm handpiece versus IPL: A cheek-to-cheek comparison

BACKGROUND AND OBJECTIVES

The treatment of photodamaged skin with potassium-titanyl-phosphate (KTP) laser and intense pulsed light (IPL) has been reported in several studies. Each device has strengths and weaknesses; however, patient and device variability have made it difficult to ascertain the optimal device for photorejuvenation. The objective of this study was to obtain a head-to-head comparison of IPL and KTP laser for photorejuvenation. Each patient received one KTP laser treatment on one side of the face and one IPL treatment on the other side.

STUDY DESIGN/MATERIALS AND METHODS

Seventeen patients with skin types I-IV were accepted into the study based on existence of dyschromias (pigmented and vascular) and/or discrete telangiectases. After performance of test spots on each patient to determine optimal settings for both devices, patients were treated with both devices in a split face manner. Evaluations and photographs were performed 1 week and 1 month after treatment. Patient and observer evaluations of results were recorded, as well as time to perform each treatment, and patient feedback with regard to pain and edema. No anesthesia was used in these treatments. Photographs were reviewed by a panel of blinded observers to assess changes in red and brown dyschromias.

RESULTS

One month average improvement (evaluator) for IPL side was (mean) 38.16%/35.08% for vascular/pigment lesions versus 41.99%/30.21% for KTP side. Patient self-evaluated global improvement at 1 month was (mean) 65.59% for IPL side versus 60.88% for KTP side. A majority of patients found the KTP to be slightly more painful with a mean pain rating of 5.27 of 10 versus 4.4 of 10 for IPL. A majority of patients experienced subjectively greater post-procedure swelling on the KTP side. Time to conduct treatment was an average of 10.0 minutes for IPL, 8.7 minutes for KTP.

CONCLUSIONS

Both large spot KTP and IPL achieved marked improvement in vascular and pigmented lesions in one session. The KTP laser caused slightly more discomfort and edema than the IPL. On the other hand, the KTP laser was faster, and more ergonomically flexible.

Modified superlong pulse 810 nm diode laser in the treatment of pseudofolliculitis barbae in skin types V and VI

BACKGROUND

Laser hair removal is a well-established therapy for pseudofolliculitis barbae, but there have been few studies on the use of a very-long-pulse 810 nm diode laser for this condition.

OBJECTIVE

To determine the efficacy and tolerability of a modified 810 nm superlong-pulse diode laser (Palomar Medical, Burlington, MA, USA) in the treatment of pseudofolliculitis barbae (PFB) in subjects with type V and VI skin.

METHODS

Thirteen patients were treated three times at 2-week intervals on one side of their neck with varying fluences. They were evaluated for (1) reduction of shaving bumps and (2) pain tolerance on the treated versus the untreated side.

RESULTS

There was a statistically significant improvement in shaving bumps. The treatment side showed a baseline PFB lesion count of 22.5 (+/- 20 SD), which decreased to a mean of 5 (+/- 5 SD) (p<.05). The control baseline mean count was 27.6 (+/- 22 SD) and at the end of the study was 15 (+/- 12 SD) (p = .13). Pain was rated at 2.5 of 10 for subjects treated both with and without anesthetic. The margin of safety was greater in type V compared with type VI skin.

CONCLUSION

A modified 810 nm superlong-pulse diode laser is both effective and well tolerated in the reduction of shaving bumps, especially in patients with type V skin.

Evaluation of a novel flash lamp system (FLS) incorporating optimal spectral filtration for the treatment of photoaging

BACKGROUND AND OBJECTIVES

Improvement in photoaging using laser and Intense Pulsed Light (IPL) modalities is well documented in the literature. We report a prospective study evaluating the safety and efficacy of a novel flash lamp IPL system incorporating a spectral filtration system designed to maximize improvement of facial dyschromias, telangiectases, and skin texture. The device was a prototype xenon flashlamp pulsed light. The novel features of this IPL device are the extended pulse duration and smooth temporal pulse profile.

STUDY DESIGN/MATERIALS AND METHODS

We enrolled 23 patients (22 female, 1 male) of Fitzpatrick skin type I-IV with evidence of photoaging (lentigenes, ephelides, telangiectases, rhytides). Each patient underwent test sites on their back to establish safe treatment parameters. Using treatment fluences of 20-37 J/cm(2), each patient was given 2-4 full-face treatments separated by 3-4 weeks.

RESULTS

Test sites revealed that shorter wavelength filters and shorter pulse durations increased the risk of epidermal injury. Objective assessment by evaluation of pre and post treatment photographs of the face showed an average improvement of 53% in hyperpigmentation, 39% in telangiectases, and 8% in wrinkles. There were no significant adverse effects.

CONCLUSIONS

The novel flash lamp IPL system in this study was safe and effective in reducing vascular and pigment dyschromias in patients with skin types I through IV.

Nd:YAG Laser Treatment of Recalcitrant Folliculitis Decalvans

BACKGROUND

The scarring follicular disorders pose challenging therapeutic dilemmas.

OBJECTIVE

Hair removal lasers have recently been shown to be efficacious in the management of these disorders.

METHODS

We present a young, Fitzpatrick skin type VI African-American patient with recalcitrant folliculitis decalvans, whom we treated with the neodymium:yttrium aluminum garnet (Nd:YAG) laser.

RESULTS

A remission of folliculitis decalvans was successfully achieved using the Nd:YAG for laser depilation.

CONCLUSION

Based on the optical properties of light in skin, the Nd:YAG laser is the best for laser depilation in dark individuals.