Laser dermatology

David J. Goldberg (Ed.)

Laser Dermatology

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David J. Goldberg (Ed.)

Laser Dermatology

With 108 Figures and 15 Tables

1 3

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Dr. David J. GoldbergSkin Laser & Surgery Specialistsof New York and New Jersey20 Prospect AvenueSuite 702Hackensack, NJ 07601USA

ISBN 3-540-21277-9 Springer Berlin Heidelberg New York

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The continual array of laser technologythroughout the world has been nothing short ofmiraculous. Over the last fifteen years, this fieldhas continued to grow and expand with theappearance of new technology. This book re-presents the most up-to-date description of thelatest in laser and light-source technology. Allthe chapters are written by leading experts fromboth North America and Europe. After a chap-ter describing our latest understanding of laserphysics, which also covers safety aspects, chap-ters are dedicated to laser treatment of vascularlesions, pigmented lesions and tattoos, un-wanted hair, and ablative and non-ablativeresurfacing and treatment for medical pur-poses. Each chapter begins with the coreconcepts. These basic points are followed by ahistory of the use of lasers for the cutaneousproblem under discussion, currently availabletechnology, and indications and contraindica-tions. Each author then provides an example ofhis/her consent form and approaches to per-sonal treatment.

What has become clear is that a significantunderstanding of lasers and light sources isrequired for optimum use of this technology. Abasic understanding of laser physics is also fun-damental to good laser treatment. Laser safetyand minimizing risk to patients is at least asimportant as an understanding of laser physics.When these concepts, so clearly described inChap. 1, are understood cutaneous laser tech-nology can be safely and successfully used for avariety of purposes.

A wide variety of cutaneous vascular disor-ders can be successfully treated with modernlasers. The pulsed dye laser has enabled treat-ment of cutaneous vessels by following theprinciple of selective photothermolysis, a sim-ple physics concept seen throughout laser der-

matology. The pulsed dye laser is the mosteffective laser for treatment of port wine stainsbut purpura limits its acceptability by patientsfor more cosmetic indications. Both facial andleg vein telangiectasia can also be treated withlasers. Other cutaneous disorders such as pso-riasis, warts and scars can be improved by tar-geting the lesion’s cutaneous vessels with appro-priate lasers. Chapter 2 describes our latestunderstanding of the laser treatment of vascu-lar lesions.

When considering treatment of pigmentedlesions, accurate diagnosis of the pigmentedlesion is mandatory before laser treatment. Forsome pigmented lesions, laser treatment mayeven be the only treatment option. Tattoosrespond well to Q-switched lasers. Amateur andtraumatic tattoos respond more readily to treat-ment than do professional tattoos. Cosmetictattoos should be approached with caution.Treatment of melanocytic nevi remains contro-versial, but worth pursuing. Chapter 3 describesour latest understanding of the laser treatmentof pigmented lesions and tattoos.

A wide variety of lasers can now induce per-manent changes in unwanted hair. Hair-removal lasers are distinguished not only bytheir emitted wavelengths, but also by theirdelivered pulse duration, peak fluence, spot sizedelivery system and associated cooling. Nd:YAGlasers, with effective cooling, are the safestapproach for treatment of darker skin. Despitethis, complications arising from laser hair re-moval are more common in darker skin types.Laser treatment of non-pigmented hair remainsa challenge. Chapter 4 describes our latest un-derstanding of the laser treatment of unwantedhair

Ablative and non-ablative laser resurfacinglead to improvement of photodamaged skin.

Preface

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Ablative laser resurfacing produces a significantwound, but long lasting clinical results.

Non-ablative resurfacing is cosmetically ele-gant, but generally leads to subtle improvementonly. Visible light non-ablative devices lead to alessening of erythema and superficial pigment-ary skin changes. Mid-infrared laser devicespromote better skin quality and skin toning.Chapter 5 describes our latest understanding ofablative and non-ablative laser resurfacing.

Lasers and light sources have become morecommonplace in the treatment of dermatolo-gical medical diseases. Topical ALA and adjunctlight-source therapy (ALA-PDT) is a provenphotodynamic therapy for actinic keratoses

and superficial non-melanoma skin cancers.ALA-PDT, using a variety of vascular lasers,blue-light sources, and intense pulsed lightsources, is also now being used to treat the signsof photoaging. PDT can also be useful therapyfor acne vulgaris. Newer lasers and lightsources are also now being used to treat psoria-sis vulgaris, vitiligo, other disorders of pigmen-tation, and hypopigmented stretch marks.Chapter 6 describes our latest understanding ofphotodynamic therapy and the treatment ofmedical dermatological conditions.

January 2005David J. Goldberg

VI Preface

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Chapter 1Basic Laser Physics and Safety. . . . . . 1Ronald G. Wheeland

History . . . . . . . . . . . . . . . . . . . 1What Is Light? . . . . . . . . . . . . . . . 1What Is a Laser? . . . . . . . . . . . . . . 2Currently Available Technology . . . . . . 5How Does Laser Light Interact with Tissue? . . . . . . . . . . . . . . . . 5What Is a Q-Switched Laser? . . . . . . . . 6Indications . . . . . . . . . . . . . . . . . 7Vascular Lesions . . . . . . . . . . . . . . 7Pigmented Lesions and Tattoos . . . . . . 7Unwanted Hair . . . . . . . . . . . . . . . 8Ablative and Nonablative Facial Resurfacing . . . . . . . . . . . . . . . . 8Safety . . . . . . . . . . . . . . . . . . . . 8Training . . . . . . . . . . . . . . . . . . 8Signage . . . . . . . . . . . . . . . . . . . 8Eye Protection . . . . . . . . . . . . . . . 9Laser Plume . . . . . . . . . . . . . . . . 10Laser Splatter . . . . . . . . . . . . . . . 10Fire . . . . . . . . . . . . . . . . . . . . . 10Future. . . . . . . . . . . . . . . . . . . . 10References . . . . . . . . . . . . . . . . . 10

Chapter 2Laser Treatment of Vascular Lesions . . 13Sean W. Lanigan

History . . . . . . . . . . . . . . . . . . . 13Port Wine Stain Treatment . . . . . . . . . 13Currently Available Lasers for Vascular Lesions . . . . . . . . . . . . 16Indications . . . . . . . . . . . . . . . . . 16Port Wine Stains . . . . . . . . . . . . . . 17Capillary (Strawberry) Hemangiomas . . . 20Leg Veins and Telangiectasia . . . . . . . . 21

Facial Telangiectasia . . . . . . . . . . . . 24Psoriasis . . . . . . . . . . . . . . . . . . 26Scars . . . . . . . . . . . . . . . . . . . . 26Verrucae . . . . . . . . . . . . . . . . . . 27Treatment of Other Cutaneous Vascular Lesions . . . . . . . . . . . . . . 28Disadvantages . . . . . . . . . . . . . . . 28Contraindications . . . . . . . . . . . . . 29Personal Laser Technique . . . . . . . . . 30Facial Telangiectasia . . . . . . . . . . . . 30Port Wine Stains . . . . . . . . . . . . . . 32Postoperative Care . . . . . . . . . . . . . 33Complications . . . . . . . . . . . . . . . 33The Future . . . . . . . . . . . . . . . . . 34References . . . . . . . . . . . . . . . . . 34

Chapter 3Laser Treatment of Pigmented Lesions . 37Christine C. Dierickx

History . . . . . . . . . . . . . . . . . . . 37Selective Photothermolysis . . . . . . . . 37Pigmented Lesion Removal by Selective Photothermolysis . . . . . . . 37Currently Available Technology . . . . . . 38Lasers and Intense Pulsed Light Sources Used to Treat Pigmented Lesions and Tattoos . . . . . . . . . . . . . . . . 38Indications . . . . . . . . . . . . . . . . . 44Epidermal Pigmented Lesions . . . . . . . 44Dermal-Epidermal Pigmented Lesions . . 46Dermal Pigmented Lesions . . . . . . . . 47Tattoos . . . . . . . . . . . . . . . . . . . 48Consent . . . . . . . . . . . . . . . . . . . 49Personal Laser Technique . . . . . . . . . 49Q-Switched Ruby Laser (694 nm) . . . . . 50Q-Switched Nd:YAG Laser (532–1064 nm) . 51Q-Switched Alexandrite Laser (755 nm) . . 55Pulsed Dye Laser (510 nm) . . . . . . . . . 55

Contents

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Continuous Wave (CW) Lasers . . . . . . 55CO2 and Erbium Lasers . . . . . . . . . . 55Intense Pulsed Light (IPL) Sources . . . . 55Further Treatment Pearls . . . . . . . . . 56Complications . . . . . . . . . . . . . . . 58Future Developments. . . . . . . . . . . . 59References . . . . . . . . . . . . . . . . . 59

Chapter 4Laser Treatment of Unwanted Hair . . . 61David J. Goldberg, Mussarrat Hussain

History . . . . . . . . . . . . . . . . . . . 61Selective Photohermolysis . . . . . . . . . 62Extended Theory of Selective Photothermolysis. . . . . . . . . . . . . . 62Physical Basis of Laser Hair Removal . . . 62Pulse Duration . . . . . . . . . . . . . . . 63Spot Size . . . . . . . . . . . . . . . . . . 63Fluence . . . . . . . . . . . . . . . . . . . 63Factors Affecting Efficacy/Results . . . . . 63Hair Color . . . . . . . . . . . . . . . . . 63Growth Centers of Hairs . . . . . . . . . . 64Hair Cycle . . . . . . . . . . . . . . . . . 64Cooling . . . . . . . . . . . . . . . . . . . 65Age . . . . . . . . . . . . . . . . . . . . . 65Hormones . . . . . . . . . . . . . . . . . 65Currently Available Lasers and Light Sources Used for Hair Removal . . . . . . 66Ruby Lasers . . . . . . . . . . . . . . . . 66Alexandrite Lasers . . . . . . . . . . . . . 67Diode Lasers . . . . . . . . . . . . . . . . 68Nd:YAG Lasers . . . . . . . . . . . . . . . 68Q-Switched Nd:YAG Laser . . . . . . . . . 69Intense Pulsed Light Systems . . . . . . . 69Advantages . . . . . . . . . . . . . . . . . 70Disadvantages . . . . . . . . . . . . . . . 70Indications . . . . . . . . . . . . . . . . . 70Contraindications . . . . . . . . . . . . . 71Consent . . . . . . . . . . . . . . . . . . . 71Personal Laser Approach . . . . . . . . . . 71Alexandrite Laser . . . . . . . . . . . . . 71Diode Laser . . . . . . . . . . . . . . . . 73Nd:YAG Laser . . . . . . . . . . . . . . . 73IPL . . . . . . . . . . . . . . . . . . . . . 77Treatment Approach . . . . . . . . . . . . 78Postoperative Considerations . . . . . . . 79Complications . . . . . . . . . . . . . . . 79Pigmentary Changes . . . . . . . . . . . . 79

Hypopigmentation . . . . . . . . . . . . . 79Hyperpigmentation . . . . . . . . . . . . 79Pain . . . . . . . . . . . . . . . . . . . . 80Scarring and Textural Changes . . . . . . 80Effects on Tattoos and Freckles . . . . . . 80Infections . . . . . . . . . . . . . . . . . 80Plume . . . . . . . . . . . . . . . . . . . 80The Future . . . . . . . . . . . . . . . . . 80References . . . . . . . . . . . . . . . . . 80

Chapter 5Ablative and Nonablative Facial Resurfacing . . . . . . . . . . . . 83Suzanne L. Kilmer, Natalie Semchyshyn

History . . . . . . . . . . . . . . . . . . . 83Ablative Resurfacing . . . . . . . . . . . . 84Currently Available Technology . . . . . . 84Advantages . . . . . . . . . . . . . . . . . 84Disadvantages . . . . . . . . . . . . . . . 85Indications . . . . . . . . . . . . . . . . . 85Contraindications . . . . . . . . . . . . . 85Consent . . . . . . . . . . . . . . . . . . 85Personal Laser Technique . . . . . . . . . 88Postoperative Care and Complications . . 89Results . . . . . . . . . . . . . . . . . . . 90The Future . . . . . . . . . . . . . . . . . 90Nonablative Resurfacing . . . . . . . . . . 90Currently Available Technology . . . . . . 90Advantages . . . . . . . . . . . . . . . . . 92Disadvantages . . . . . . . . . . . . . . . 93Indications . . . . . . . . . . . . . . . . . 93Contraindications . . . . . . . . . . . . . 93Consent . . . . . . . . . . . . . . . . . . 93Personal Laser Technique . . . . . . . . . 93Postoperative Care and Complications . . 95Results . . . . . . . . . . . . . . . . . . . 95The Future . . . . . . . . . . . . . . . . . 95References . . . . . . . . . . . . . . . . . 98

Chapter 6Lasers, Photodynamic Therapy, and the Treatment of Medical DermatologicConditions . . . . . . . . . . . . . . . . . 99Michael H. Gold

History of Photodynamic Therapy . . . . . 99Currently Available Technology . . . . . . 101

VIII Contents

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Photodynamic Therapy:The Experience with Actinic Keratoses in the United States . . . . . . . . . . . . 101Photodynamic Therapy:New Indications for Photodynamic Photo-rejuvenation in the United States . . . . . 103Photodynamic Therapy: The (Primarily) European Experience with Actinic Keratoses and Skin Cancers . . . . . . . . 106Photodynamic Therapy – Other Indications . . . . . . . . . . . . . 107Advantages . . . . . . . . . . . . . . . . . 112Psoriasis and Disorders of Hypopigmentation . . . . . . . . . . . 113

Disadvantages . . . . . . . . . . . . . . . 118Contraindications . . . . . . . . . . . . . 118Personal Laser Technique . . . . . . . . . 119ALA-PDT Technique . . . . . . . . . . . . 119Postoperative Care . . . . . . . . . . . . . 119Postoperative Care Following ALA-PDT . . 119Postoperative Care for Psoriasis and Disorders of Hypopigmentations . . . 120The Future . . . . . . . . . . . . . . . . . 120References . . . . . . . . . . . . . . . . . 120

Subject Index . . . . . . . . . . . . . . . 123

IXContents

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Christine C. Dierickx, MD Director Skin and Laser Surgery CenterBeukenlaan 522850 BoomBelgiume-mail: [email protected]

Michael H. Gold, MDGold Skin Care Center2000 Richard Jones RoadSuite 220NashvilleTN 37215USAe-mail: [email protected]

David J. Goldberg, MDClinical ProfessorDirector of Laser ResearchDepartment of DermatologyMount Sinai School of MedicineDirector of Dermatologic SurgeryUMDNJ-New Jersey Medical SchoolDirector. Skin Laser & Surgery Specialists of NY/NJe-mail: [email protected]

Mussarrat Hussain, MDResearch AssistantSkin Laser & Surgery Specialists of NY/NJ

Suzanne L. Kilmer, MD3835 J StreetSacramentoCA 95816USAe-mail: [email protected]

Sean W. Lanigan, MD, FRCP, DCHConsultant DermatologistLasercare ClinicsCity HospitalDudley RoadBirminghamB18 7QHUKe-mail: [email protected]

Natalie Semchyshyn, MD3835 J StreetSacramentoCA 95816USAe-mail: [email protected]

Ronald G. Wheeland, MD, FACP Professor and ChiefSection of DermatologyUniversity of Arizonae-mail: wheeland@email. arizona.edu

List of Contributors

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History

What Is Light?

Light is a very complex system of radiant energythat is composed of waves and energy packetsknown as photons. It is arranged into the electro-magnetic spectrum (EMS) according to thelength of those waves. The distance between twosuccessive troughs or crests of these waves, mea-sured in meters, determines the wavelength. Forthe visible portion of the EMS, the wavelengthdetermines the color of the laser light. The num-ber of wave crests (or troughs) that pass a givenpoint in a second determines the frequency foreach source of EMS energy. The wavelength andfrequency of light are inversely related to oneanother. Thus, shorter wavelengths of light havehigher frequencies and more energetic photonsthan longer wavelengths of light which havelower frequencies and less energetic photons.

■ When Was Light First Used for Medical Purposes?

One must go back to about 4000 B.C. in ancientEgypt to find the earliest recorded use of light.It was at that time that sunlight coupled with atopical photosensitizer, like parsley or otherherbs containing psoralen, to help repigmentindividuals suffering from vitiligo, where theskin becomes depigmented through a pre-sumed autoimmune reaction. In Europe in the19th century, sunlight was used as a treatmentfor cutaneous tuberculosis. However, it wasn’tuntil 1961 that Dr. Leon Goldman, a dermatolo-gist at the University of Cincinnati, firstemployed a ruby laser for the removal of tattoosand other pigmented cutaneous lesions. For hiscontinuous efforts in promoting the use oflasers for medical purposes and for co-foundingthe American Society for Laser Medicine andSurgery, Dr. Goldman (Goldman et al. 1963) hasbeen called the “Father of Lasers in Medicineand Surgery.” Since those earliest days, manyphysicians in different specialties have playedkey roles in the advancement of the use of lasersin medicine such that today most specialties uselasers in either diagnosing or treating a numberof different disorders and diseases (Wheeland1995).

■ Who Invented the Laser?

Professor Albert Einstein (Einstein 1917) pub-lished all of the necessary formulas and theo-retical concepts to build a laser in his 1917 trea-tise called The Quantum Theory of Radiation.In this treatise, he described the interaction ofatoms and molecules with electromagneticenergy in terms of the spontaneous absorptionand emission of energy. By applying principles

Basic Laser Physics and SafetyRonald G. Wheeland

1

▲

Core Messages A significant understanding of lasers

and light sources is required for opti-mal use of these technologies

A basic understanding of laserphysics is at the core of good lasertreatments

Laser safety and minimizing patientrisk is at least as important as anunderstanding of laser physics.

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of thermodynamics he concluded that stimu-lated emission of energy was also possible.However, it wasn’t until 1959 that Drs. CharlesH. Townes and Arthur L. Schalow (Schalow andTownes 1958) developed the first instrumentbased on those concepts, known as the MASER(Microwave Amplification through the Stimu-lated Emission of Radiation). Then, in 1960, thefirst true laser, a ruby laser, was operated by Dr.Theodore H. Maiman (Maiman 1960). Thedevelopment of additional lasers occurredrapidly, with the helium-neon laser appearingin 1961, the argon laser in 1962, the carbon diox-ide and Nd:YAG laser in 1964, the dye laser in1966, the excimer laser in 1975, the copper vaporlaser in 1981, and the gold vapor laser in 1982.

What Is a Laser?

The word “LASER” is an acronym that standsfor Light Amplification by the Stimulated Emis-sion of Radiation. For this reason, a laser is not just an instrument but also a physical pro-cess of amplification (Table 1.1). The last word inthe acronym, “radiation,” is a common source ofpatient anxiety since it is associated with thehigh energy ionizing radiation often associatedwith cancer radiotherapy. However, in the caseof lasers, the word is employed to describe howthe laser light is propagated through space as“radiant” waves. Patients should be assured thatall currently approved medical lasers are in-capable of ionizing tissue and have none of therisks associated with the radiation used in can-cer therapy.

All lasers are composed of the same four pri-mary components. These include the lasermedium (usually a solid, liquid, or gas), theoptical cavity or resonator which surrounds thelaser medium and contains the amplificationprocess, the power supply or “pump” that excitesthe atoms and creates population inversion, anda delivery system (usually a fiber optic or articu-lating arm with mirrored joints) to preciselydeliver the light to the target.

Lasers are usually named for the mediumcontained within their optical cavity (Table 1.2).The gas lasers consist of the argon, excimers,copper vapor, helium-neon, krypton, and car-

bon dioxide devices. One of the most commonliquid lasers contains a fluid with rhodaminedye and is used in the pulsed dye laser. The solidlasers are represented by the ruby, neo-dymium:yttrium-aluminum-garnet (Nd:YAG),alexandrite, erbium, and diode lasers. All ofthese devices are used to clinically treat a widevariety of conditions and disorders based ontheir wavelength, nature of their pulse, andenergy.

The excitation mechanism, i. e., power supp-ly or “pump,” is a necessary component of everylaser in order to generate excited electrons andcreate population inversion (Arndt and Noe1982). This can be accomplished by direct elec-trical current, optical stimulation by anotherlaser (argon), radiofrequency excitation, whitelight from a flashlamp, or even (rarely) chemi-cal reactions that either make or break chemicalbonds to release energy, as in the hydrogen-flu-oride laser.

To understand stand how laser light is createdit is important to recall the structure of an atom.All atoms are composed of a central nucleus sur-rounded by electrons that occupy discrete energylevels or orbits around the nucleus and give theatom a stable configuration (Fig. 1.1). When anatom spontaneously absorbs a photon of light,the outer orbital electrons briefly move to ahigher energy orbit, which is an unstable con-figuration (Fig. 1.2). This configuration is veryevanescent and the atom quickly releases a pho-ton of light spontaneously so the electrons canreturn to their normal, lower energy, but stableinner orbital configuration (Fig. 1.3). Undernormal circumstances, this spontaneous ab-sorption and release of light occurs in a disor-ganized and random fashion and results in theproduction of incoherent light.

When an external source of energy is sup-plied to a laser cavity containing the lasermedium, usually in the form of electricity, light,microwaves, or even a chemical reaction, theresting atoms are stimulated to drive their elec-trons to unstable, higher energy, outer orbits.When more atoms exist in this unstable highenergy configuration than in their usual restingconfiguration, a condition known as populationinversion is created, which is necessary for thesubsequent step in light amplification (Fig. 1.4).

1

2 Chapter 1 Basic Laser Physics and Safety


3History

Table 1.1. Laser terminology

Absorption The transformation of radiant energy to another form of energy (usuallyheat) by interacting with matter

Coherence All waves are in phase with one another in both time and space

Collimation All waves are parallel to one another with little divergence or convergence

Electromagnetic radiation A complex system of radiant energy composed of waves and energy bundlesthat is organized according to the length of the propagating wave

Energy The product of power (watts) and pulse duration (seconds) which isexpressed in joules

Extinction length The thickness of a material necessary to absorb 98% of the incident energy

Focus The exact point at which the laser energy is at peak power

Irradiance (power density) The quotient of incident laser power on a unit surface area, expressed aswatts/cm2

Joule A unit of energy which equals one watt-second

Laser An instrument that generates a beam of light of a single wavelength or colorthat is both highly collimated and coherent; an acronym that stands for lightamplification by the stimulated emission of radiation

Laser medium A material or substance of solid, liquid, or gaseous nature that is capable ofproducing laser light due to stimulated electron transition from an unstablehigh energy orbit to a lower one with release of collimated, coherent,monochromatic light

Meter A unit length based on the spectrum of krypton-86; frequently subdividedinto millimeters (10–3 m), micrometers (10–6 m), and nanometers (10–9 m)

Monochromatic Light energy emitted from a laser optical cavity of only a single wavelength

Optically pumped laser A laser where electrons are excited by the absorption of light energy froman external source

Photoacoustic effect The ability of Q-switched laser light to generate a rapidly moving wavewithin living tissue that destroys melanin pigment and tattoo ink particles

Population inversion The state present within the laser optical cavity (resonator) where more atomsexist in unstable high energy levels than their normal resting energy levels

Power The rate at which energy is emitted from a laser

Power density (irradiance) The quotient of incident laser power on a unit surface area, expressed aswatts/cm2

Pump The electrical, optical, radiofrequency or chemical excitation that providesenergy to the laser medium

Q-switch An optical device (Pockels cell) that controls the storage or release of laserenergy from a laser optical cavity

Reflectance The ratio of incident power to absorbed power by a given medium

Scattering Imprecise absorption of laser energy by a biologic system resulting in a dif-fuse effect on tissue

Selective photothermolysis A concept used to localize thermal injury to a specific target based on itsabsorption characteristics, the wavelength of light used, the duration of thepulse, and the amount of energy delivered

Thermomodulation The ability of low energy light to upregulate certain cellular biologic activi-ties without producing an injury

Transmission The passage of laser energy through a biologic tissue without producing anyeffect


1


Fig. 1.2. Absorption of energy has briefly stimulatedthe outer electron into an unstable, but higher energyorbit.

Fig. 1.3. The stimulated electron rapidly drops backto its normal orbit and assumes a stable configura-tion

Table 1.2. Types of lasers

Name Type Wavelength

ArFl Excimer 193 nmKrCl Excimer 222 nmKrFl Excimer 248 nmXeCl Excimer 308 nmXeFl Excimer 351 nmArgon Gas 488 and 514 nmCopper vapor Gas 511 and 578 nmKrypton Gas 521–530 nmFrequency-

Doubled:YAG Solid state 532 nmPulsed dye Liquid 577–595 nmHelium-Neon Gas 632 nmRuby Solid state 694 nmAlexandrite Solid state 755 nmDiode Solid state 800 nmNd:YAG Solid state 1,064 and

1,320 nmDiode Solid state 1,450 nmErbium:Glass Solid state 1,540 nmErbium:YAG Solid state 2,940 nmCarbon dioxide Gas 10,600 nm

Fig. 1.1. Normal configuration of an atom with cen-tral nucleus and surrounding electrons in stableorbits

Amplification of light occurs in the opticalcavity or resonator of the laser. The resonatortypically consists of an enclosed cavity thatallows the emitted photons of light to reflectback and forth from one mirrored end of thechamber to the other many times until a suffi-cient intensity has been developed for completeamplification to occur. Through a complex pro-cess of absorption and emission of photons ofenergy, the prerequisite for the development ofa laser beam of light has been met and amplifi-cation occurs. The photons are then allowed toescape through a small perforation in the par-tially reflective mirror. The emerging beam oflight has three unique characteristics that allowit to be delivered to the appropriate target byfiber optics or an articulated arm.

■ What Are the Unique Characteristics of Laser Light?

By stimulating the emission of light from alaser, laser light has three unique characteristicsthat differentiate it from nonlaser light. The firstof these characteristics is that laser light is


EF = laser output (watts) × exposure time (secs)

.pi × radius2 (of the laser beam)

In the case of irradiance and energy fluence, thehigher the number the greater the effect. Forexample, high irradiances are needed to incisetissue, while only low irradiances are needed tocoagulate tissue.

Currently Available Technology

How Does Laser Light Interact with Tissue?

In order to understand how to select the ideallaser from the myriad of currently availabledevices for the treatment of any cutaneous con-dition it is important to first understand howlight produces a biologic effect in skin. The inter-action of laser light with living tissue is generallya function of the wavelength of the laser system.In order for laser energy to produce any effect inskin it must first be absorbed. Absorption is the transformation of radiant energy (light) to adifferent form of energy (usually heat) by thespecific interaction with tissue. If the light isreflected from the surface of the skin or trans-mitted completely through it without any ab-sorption, then there will be no biologic effect. Ifthe light is imprecisely absorbed by any target orchromophore in skin then the effect will also beimprecise. It is only when the light is highlyabsorbed by a specific component of skin thatthere will be a precise biologic effect. While thisreaction may seem difficult to accurately antici-pate, in fact, there are really only three main com-ponents of skin that absorb laser light: melanin,hemoglobin, and intracellular or extracellularwater, and their absorption spectra have beenwell established. Manufacturers of lasers havetaken this information and designed currentlyavailable technological devices that producelight which is the right color or wavelength to beprecisely absorbed by one of these componentsof skin. This minimizes collateral injury to thesurrounding normal skin.

In 1983, Drs. R. Rox Anderson and John A.Parrish (Anderson and Parrish 1983) of the Har-

5Currently Available Technology

Fig. 1.4. With the stimulated emission of energy, twophotons are released in phase with one another as theelectron drops back to its normal, stable configura-tion

monochromatic or composed of a single wave-length or color. The second unique characteris-tic is a property known as coherence, where allthe waves of light move together temporally andspatially as they travel together in phase withone another. The third characteristic is collima-tion, where the transmission of light occurs inparallel fashion without significant divergence,even over long distances.

■ What Is Irradiance and Energy Fluence?

In order to use a laser to treat any skin condi-tion, it is necessary to understand how the lasercan be adjusted to obtain the most desired bio-logic effects in tissue (Fuller 1980). Two of thefactors that are important in this process areirradiance and energy fluence. Irradiance, alsocalled power density, determines the ability of alaser to incise, vaporize, or coagulate tissue andis expressed in watts/cm2. It can be calculatedbased on the formula:

IR =laser output (watts) × 100 .

pi × radius2 (of the laser beam)

The energy fluence determines the amount oflaser energy delivered in a single pulse and isexpressed in joules/cm2. It can be calculatedbased on the formula:


vard Wellman Laboratories of Photomedicinepublished in the journal Science their newlydeveloped concept of selective photothermolysis(SPTL). This original concept explained how tosafely and effectively treat the microvessels inchildren with port wine stains using laser light.It also led to the first “ground up” developmentof a specific laser, the pulsed dye laser, to treat aspecific condition–port wine stains in children.This concept has now also been used to developmore effective treatments of many other cuta-neous problems including the treatment of tat-toos, benign pigmented lesions, and theremoval of unwanted or excessive hair. The con-cept of SPTL defines the way to localize thermalinjury to the tissue being treated and minimizecollateral thermal damage to the surroundingnontargeted tissue. This is done by choosing theproper wavelength of light that will be absorbedby the specific targeted chromophore and deliv-ering the right amount of energy with theproper pulse duration, known as the thermalrelaxation time (TRT), which is based on thephysical size of the target.

What Is a Q-Switched Laser?

The laser cavity “Q” is a measure of the opticalloss per pass of a photon within the optical cav-ity (Goldman et al. 1965). Thus, the “Q” of a sys-tem is a way to characterize the quality of thephotons being released so that a high “Q”implies low loss and low “Q” implies high loss.A Q-switch is a physical method to createextremely short (5–20 ns) pulses of high inten-sity (5–10 MW) laser light with peak power of 4 joules. In addition to the normal compo-nents (Fig. 1.5) of a laser that were previouslydescribed, this system utilizes a shutter which isconstructed of a polarizer and a pockels cellwithin the optical cavity. A pockels cell is anoptically transparent crystal that rotates theplane of polarization of light when voltage isapplied to it. Together, the polarizer and pockelscell act as the “Q”-switch. Light energy isallowed to build (Fig. 1.6) within the optical cav-ity when voltage is applied to the pockels cell.Once the voltage is turned off, the light energyis released (Fig. 1.7) in one extremely powerful

short pulse. Currently available Q-switchedlasers include the ruby, Nd:YAG and alexandritelasers.

The Q-switched lasers and the photons oflight released from them have unique character-istics that allow them to be effectively used totreat tattoos (Goldman et al. 1967) and benignpigmented lesions. This is due to the mecha-nism of action whereby photoacoustic wavesare generated within the skin by the releasedphotons of light which heats the small tattoo

1


Fig. 1.5. Classic appearance of a solid state laser withcentral rod that could be a ruby, Nd:YAG or alexandritecrystal surrounded by a flashlamp with emission oflight from only one end of the optical cavity

Fig. 1.6. The Q-switched lasers contain a Pockels cellthat can be made opaque by the application of voltageand thus allow energy to build within the optical cav-ity


pigment particles or the melanosomes. Thisheating causes cavitation within the cells con-taining the ink particles or pigment, followedby rupture and eventual phagocytosis bymacrophages and removal of the debris fromthe site. Clinically, this process produces grad-ual fading of the tattoos with a series of 4–8treatments at 6–8-week intervals and removal ofthe benign pigmented lesion with only 1–2treatments, again at 6–8-week intervals. Theprecise targeting of subcellular organelles andpigment particles by the Q-switched lasersreduces collateral damage and minimizes therisk of scarring or textural changes. The treat-ment of tattoos and benign pigmented lesionsrepresent additional examples of how selectivephotothermolysis can be effectively applied tomore accurately treat conditions other than themicrovessels of port wine stains that this con-cept was originally developed to treat.

Indications

Vascular Lesions

The most common laser used today for thetreatment of many different vascular conditionsis the pulsed dye laser (Garden and Geronemus1990). While initially designed for the treatment

of microvessels in port wine stains of infantsand children, the initial parameters have beenmodified to provide longer pulses and wave-lengths of light to treat deeper and larger bloodvessels and also to do this with epidermal cool-ing. Cryogen spray or contact cryogen coolingprior to the laser pulse reduces pain while alsodecreasing the potential for epidermal injury asthe light passes through it to reach the deeperblood vessels. Thermal quenching from post-pulse cooling further reduces the risk of collat-eral thermal injury following delivery of thepulse of light. Cooling devices are now routinelyused for port wine stains in children and adults,leg veins, solar telangiectasia, and other smallblood vessels diseases. Long pulses of light fromthe Nd:YAG laser and the nonlaser IntensePulsed Light (IPL) devices have also been usedto treat larger and deeper blood vessels. Thesmall beam diameter of the krypton lasermakes it a useful tool in the treatment of limitedareas of involvement with small caliber, linearblood vessels on the nose or cheeks.

Pigmented Lesions and Tattoos

To treat cosmetically important, but benign,pigmented lesions and tattoos it is imperativethat the risk of scarring and other complica-tions be minimized as much as possible. This ismade possible today with the use of short pulsesof light from the Q-switched lasers, ruby,Nd:YAG, and alexandrite, that deliver pulses oflight which approximate the thermal relaxationtime of melanosomes and tattoo ink particles,and through their photoacoustic effects canproduce destruction of melanin pigment or tat-too pigment particles for subsequent removalby macrophages. The most common benign,pigmented lesions treated with these conditionsare solar lentigines, nevus of Ota/Ito, café-au-lait macules, Becker’s nevus, postinflammatoryhyperpigmentation, mucosal lentigines ofPeutz-Jeghers syndrome, and melasma. Thevariability of the response in congenital oracquired nevocellular nevi makes treatmentwith Q-switched lasers less desirable. Decora-tive, traumatic, and cosmetic tattoos can all beeffectively treated with the Q-switched lasers.

7Indications

Fig. 1.7. Once the voltage is turned off, the Pockelscell becomes optically transparent and the accumu-lated energy is allowed to be released in a single,short, powerful pulse


However, multiple treatments are required, andcertain colors may not respond at all. In addi-tion, there is a risk of darkening of some tattoocolors that occurs as a result of a chemical reac-tion following laser treatment, making removalexceedingly difficult.

Unwanted Hair

A number of devices, including the long-pulseruby, long-pulse Nd:YAG, long-pulse diode, andIPL, have been used to permanently reduce thenumbers of darkly pigmented hair (Wheeland1997). This is done by targeting the melaninwithin the hair shaft and bulb with light energywhich thermally damages the cells and eitherslows or destroys their ability to regrow. At pre-sent, treatment of blonde or gray hair with laserlight is poor, even with the application of anexogenously applied synthetic melanin solution.

Ablative and Nonablative Facial Resurfacing

Over the past decade the short-pulsed carbondioxide and erbium:YAG lasers have been usedto perform ablative laser skin resurfacing.These devices thermally destroy the epidermisand superficial dermis with minimal collateraldamage. Long healing times and even longerperiods of persistent erythema and possiblypermanent hypopigmentation have reduced theuse of these devices. Since many patients areunwilling to accept any downtime from a cos-metic procedure, a number of noninvasivedevices have been developed, including theNd:YAG at 1,320 nm, the diode at 1,450 nm, thepulsed dye laser, and the IPL, to help restore theyouthful condition of the skin noninvasivelywithout producing a wound or other visibleinjury that would keep patients from followingtheir normal activities. The most recent nonin-vasive technique for rejuvenation is using lightfrom the light emitting diodes (LED) to stimu-late the skin. This device delivers intense, non-laser, red- or blue-colored light that can stimu-late fibroblasts to produce collagen, elastin, andglycosaminoglycans to help rejuvenate the skinwith a series of treatments. Sometimes the topi-

cal application of a photosensitizer like a5%–20% cream of aminolevulinic acid (ALA)prior to exposure to red light from the LED willincrease the response with only minimal crust-ing and erythema (Walker et al. 1986).

Safety

Safety is the most important aspect of properlyoperating a laser or other optical device sincethere is always some associated risk to thepatient, the laser surgeon, and the operatingroom personnel whenever a laser is being uti-lized for treatment. In the outpatient arena, thesafe operation of lasers is not generally deter-mined by the manufacturer, medical licensingboard, or other regulatory body. Thus, it isimportant for the laser operator to understandthe risks involved in using lasers and thendevelop an appropriate group of standards toensure that the equipment is being used in thesafest fashion possible.

Training

The safe use of any laser begins with appropri-ate training and familiarization in the indica-tions and uses of each device. This allows thedevelopment of the necessary proficiency thatwill also result in the concomitant maximal safeuse of each device.

Signage

The greatest risk when operating a laser is thatof eye injury. To help prevent eye injury, appro-priate signage on the laser operating room doorshould describe the nature of the laser beingused, its wavelength, and energy. Plus, a pair ofprotective glasses or goggles appropriate for thedevice being used should always be placed onthe door outside of the laser operating room incase emergency entrance is required. The doorto the laser operating room should be locked, ifpossible, and all exterior windows closed andcovered.

1



Eye Protection

Inside the operating room, care must also betaken to protect the eyes. If not appropriatelyprotected, the cornea may be injured by eitherdirect or reflected light from the carbon dioxideand erbium:YAG lasers. A more serious injuryto the retina can be caused by any of the visibleor near-infrared lasers. For the laser surgeonand operating room personnel there are specialoptically coated glasses and goggles that matchthe emission spectrum of the laser being used.To check whether the correct eye protection isbeing used the manufacturer has stamped onthe arm of the glasses or the face of the gogglesthe wavelengths of light for which protection isprovided and the amount of the protection pro-vided in terms of optical density (O.D.). Formost laser devices, the current recommenda-tions are to use eye protection with at least anO.D. of 4.0. For the patient, there are severalways to provide appropriate eye protection. Ifthe procedure is being performed in the imme-diate vicinity of the orbit, it is probably best touse metal scleral eye shields (Figs. 1.8, 1.9),which are placed directly on the corneal surfaceafter first using anesthetic eye drops (Nelson etal. 1990). However, if the procedure is beingdone on the lower part of the face, trunk, orextremities, burnished stainless steel eye cups(Figs. 1.10, 1.11) that fit over the eyelids and pro-tect the entire periorbital area are probably best.

9Safety

Fig. 1.8. The appearance of the concave surfaces ofvarious sizes of corneal eye shields used to protectthe eye during laser surgery in the periorbital area

Fig. 1.9. The appearance of the convex surfaces ofvarious sizes of corneal eye shields used to protectthe eye during laser surgery in the periorbital area

Fig. 1.10. The appearance of the Wheeland-Stefa-novsky eye goggles worn over the eyelids for lasersurgery not being performed in the immediate peri-orbital area

Fig. 1.11. The appearance of the externally appliedDurette Oculo-Plastik eye cups worn over the eyelidsduring laser surgery performed closed to periorbitalarea


The same eye glasses or goggles used by thelaser surgeon and operating room personnel arenot recommended for patients since these mayleave gaps on the lower edge near the cheek thatpermit the passage of light under them andcause injury to the patient.

Laser Plume

Any of the lasers that ablate tissue and createa plume of smoke can potentially harm thelaser surgeon, patient, and operating room per-sonnel. Various bacterial spores and humanpapilloma viral (HPV) particles (Garden et al.1988) have been recovered from carbon dioxidelaser plumes. The two best methods to preventthis inhalation injury are to use laser-specificsurgical masks and a laser-specific plume/smoke evacuator held close to the operativesite. There is no evidence that HIV or hepati-tis C viral particles are transmitted in the laserplume.

Laser Splatter

When treating tattoos or benign pigmentedlesions with a Q-switched laser the impact ofthe pulses of light can disrupt the surface of theskin, sending an explosion of blood and skinfragments flying away from the operative site ata very high speed. The speed of these particlesis so fast that it cannot be removed by a smokeor plume evacuator. As a result, most the manu-facturers will supply the device with a nozzle ortip that can contain these particles at the skinsurface and thus prevent dissemination of thesematerials into the air. Another technique thathas also been used successfully when treatingtattoos to prevent tissue splattering from theoperative site is to apply a sheet of hydrogel sur-gical dressing on the surface of the treatmentsite and discharge the laser through this mate-rial to the target. Any extrusion of tissue thatoccurs with the Q-switched laser pulses will betrapped within the hydrogel and not be allowedto splatter from the operative field.

Fire

Most of the medical lasers used in the treatment of skin diseases do not share the risk of olderdevices, like the continuous emitting carbondioxide laser, of igniting a fire. Despite this, it isstill recommended that any flammable mate-rial, including acetone cleansers, alcohol-basedprep solutions, or gas anesthetics be restrictedfrom the laser operating room. By followingthese simple guidelines and using commonsense and skill, the risk of using a laser shouldbe no greater than that associated with usingolder, traditional, nonlaser devices to performthe same procedure.

Future

As new concepts emerge to help explain howlight can be used to more precisely interact withtissue, it is certain that the development of addi-tional devices based on those concepts willfollow soon after. Nonthermal photoablativedecomposition using the femtosecond titan-tium:sapphire laser is but one area of recentinvestigation that could significantly change theway laser light can be used to ablate tissue withminimal collateral injury. Exciting new researchideas initiating photochemical reactions withlaser light with either topically or parenterallyadministered drugs or other photosensitizerscould further expand our knowledge of howlasers can be used to effectively treat a numberof conditions, like inflammatory, premalignant,and malignant conditions, that currently areeither poorly treated or untreatable today.

References

Anderson RR, Parrish JA (1983) Selective photo-thermolysis: Precise microsurgery by selectiveabsorption of pulsed radiation. Science 220:524–527

Arndt KA, Noe JM (1982) Lasers in dermatology.Arch Dermatol 118:293–295

Einstein A (1917) Zur Quanten Theorie der Strahlung.Phys Zeit 18:121–128

Fuller TA (1980) The physics of surgical lasers. LasersSurg Med 1:5–14

1



Garden JM, O’Banion MK, Shelnitz LS, et al (1988)Papillomavirus in the vapor of carbon dioxidelaser-treated verrucae. J Am Med Assoc 259:1199–1202

Garden JM, Geronemus RG (1990) Dermatologiclaser surgery. J Dermatol Surg Oncol 16:156–168

Goldman L, Blaney DJ, Kindel DJ, et al (1963) Effect ofthe laser beam on the skin: Preliminary report. JInvest Dermatol 40:121–122

Goldman L, Wilson RG, Hornby P, et al (1965) Radia-tion from a Q-switched ruby laser. J Invest Der-matol 44:69–71

Goldman L, Rockwell RJ, Meyer R, et al (1967) Lasertreatment of tattoos:A preliminary survey of threeyears’ clinical experience. J Am Med Assoc201:841–844

Maiman T (1960) Stimulated optical radiation inruby masers. Nature 187:493–494

Nelson CC, Pasyk KA, Dootz GL (1990) Eye shield forpatients undergoing laser treatment. Am J Oph-thalmol 110:39–43

Schalow AL, Townes CH (1958) Infrared and opticalmasers. Phys Rev 112:1940

Walker NPJ, Matthews J, Newsom SW (1986) Possiblehazards from irradiation with the carbon dioxidelaser. Lasers Surg Med 6:84–86

Wheeland RG ( 1995) Clinical uses of lasers in derma-tology. Lasers Med Surg 16:2

Wheeland RG (1997) Laser-assisted hair removalDermatol Clin 15:469

11References


History

Port Wine Stain Treatment

■ Argon Laser

The earliest studies on the laser treatment ofvascular disorders were on port wine stains(PWS) and published in the 1970s using boththe argon and ruby lasers (Table 2.1). Most workwas undertaken with the argon laser. In the1980s this was the most frequently used laserworldwide for the treatment of PWS. The argonlaser emits light at six different wavelengths inthe blue green portion of the visible spectrum.

Laser Treatment of Vascular LesionsSean W. Lanigan

2

▲

Core Messages A wide variety of cutaneous vascular

disorders can be successfully treatedwith current lasers.

The pulsed dye laser (PDL) enabledtreatment of cutaneous vessels follow-ing principles of selective photother-molysis.

The PDL is the most effective laserfor the treatment of port wine stainsbut purpura limits its acceptability topatients for more cosmetic indica-tions.

Leg vein telangiectasia can also betreated with lasers but sclerotherapyremains the gold standard.

Other cutaneous disorders such aspsoriasis, warts, and scars can beimproved by targeting the lesions’cutaneous vessels with appropriatelasers.

Table 2.1. Lasers used for treatment of port winestains

Laser Wavelength Pulse duration (nm) (ms)

Argon 488, 514 50–200Continuous 577, 585 50–200

wave dyeCopper vapor 578 50–200Krypton 568 50–200Carbon dioxide 10,600 50–c/w

(limitations see text)

Pulsed dye 577, 585 0.45Long pulsed dye 585, 590, 1.5–40

595, 600KTP 532 2–50Alexandrite 755 3Nd:YAG 1064 50(limitations see text)

Eighty per cent of the total emissions occur at488 and 514 nm. These two wavelengths of lightare absorbed by two chromophores in the skin:oxyhemoglobin and melanin (Fig. 2.1).

Although the argon laser wavelengths donot coincide with the absorption maxima ofoxyhemoglobin, there is sufficient absorptionto produce thermal damage to red blood cells incutaneous blood vessels situated superficiallywithin the first millimeter of the skin. Becausethe argon laser light is delivered in pulses last-ing many tens of milliseconds (ms) there is non-specific thermal damage to perivascular con-nective tissue and beyond. The unfortunateclinical consequence has been textural alter-ation, scarring, and pigmentary changes(Fig. 2.2)

The continuous wave argon laser beam canbe mechanically shuttered to pulses of 50–


100 ms or longer. Alternatively, the operatormoves the beam continuously across the surfaceof the skin to reduce the exposure time at eachunit area. The clinical end point is minimalblanching. This is a just visible grayish whitediscoloration of the skin (Fig. 2.3). The operatorgradually increases the power until this changeis observed. The visible change of minimalblanching inevitably involves nonselective ther-mal damage, as it is a sign of thermal coagula-tion of tissue protein. Treatment is far morepainful than with current lasers, and generallylocalized areas within a PWS are treated afterinfiltrational anesthesia. After treatment theskin invariably weeps and crusts with somesuperficial blistering. The blanched appearancereverts to a reddish purple color after a fewdays. Gradually after a period of 4–8 weeks thetreated area visibly lightens towards normalskin color. This lightening progresses for morethan 6 months after treatment. Because of thehigh instance of adverse reactions with theargon laser, it is essential to initially perform asmall test treatment. The presence of scarringin the test site would normally indicate cessa-tion of treatment or a change to a different laser.

Results of treating PWS with the argon laserare generally better in adults with purple PWS.Seventy per cent of adult patients will obtaingood to excellent results. Hypertrophic scarringafter argon laser treatment of PWS ranges from9 to 26%. The results in children were not con-sidered good enough and scarring rates toohigh to recommend the argon laser for pediatricPWS. The argon laser is rarely used now forPWS.

■ Continuous Wave Dye Laser

It was recognized early on that longer wave-lengths of light absorbed by hemoglobin, par-ticularly at 577 nm which coincides with thebeta absorption peak of hemoglobin, would bemore appropriate for treatment of vascularlesions (Fig. 2.1). An argon laser can be used toenergize a rhodamine dye to produce coherentlight at 577 or 585 nm. As with the argon laser,the light emerging is continuous but can bemechanically shuttered to produce pulses oflight 10s to 100s of milliseconds in duration.

2

14 Chapter 2 Laser Treatment of Vascular Lesions

Fig. 2.1. Schematic absorption spectrum of oxyhemo-globin (Hb02) and melanin

Fig. 2.2. Adverse effects of argon laser treatment[from S.W. Lanigan (2000) Lasers in Dermatology,Springer Verlag, London]

Fig. 2.3. Immediate blanching with argon laser [fromS.W. Lanigan (2000) Lasers in Dermatology, SpringerVerlag, London]


13 mm in diameter. Adjacent hexagons can thenbe applied to cover the PWS skin. The advan-tages of automated scanning devices are shorterpulse durations, uniformity of energy place-ment, faster treatments, and reduced operatorfatigue. In a study using scanning devices com-pared with conventional techniques the rates ofscarring were substantially reduced after scan-ner-assisted laser treatment. Clinical resultswere also improved in the scanned patients.

■ Copper Vapor Laser

The copper vapor laser (CVL) is one of twoheavy metal vapor lasers used clinically. Resultsof treating PWS with this laser were reported inthe early 1990s. The wavelengths of light emit-ted by a CVL are 510 and 578 nm. The longerwavelength yellow light is well absorbed by oxy-hemoglobin. In contrast to other yellow lightlasers, the CVL emits a train of pulses with aduration of 20–25 ns and 10,000–15,000 pulsesper second. Because of the very short gapbetween each pulse of light from the CVL, thebiological effect of this laser is similar to that ofa continuous wave laser. The CVL is oftentermed a quasi-continuous laser for this reason.

Good or excellent results have been reportedin treating PWS with the CVL. Best results areseen in predominantly purple or red PWS. In

15History

Lanigan et al. (1989) reported the results oftreating one hundred patients with PWS with acontinuous wave dye laser at 577 nm. A good orexcellent response was seen in 63%, with a fairresult in 17%; 12% of patients had a poorresponse. Hypertrophic scarring occurred in5% and a similar percentage had postinflamma-tory hyperpigmentation. The best results wereseen in older patients with purple PWS. Theseresults were similar to those obtained with theargon laser.

Others have also found similar results withargon and continuous wave dye lasers. It islikely that any advantage gained by the longerwavelength of light is offset by the long-pulsedurations employed and the use of minimalblanching as an end point. Another study evalu-ated 28 patients with PWS with the PDL and acontinuous wave dye laser delivered through ascanning device. Results were better in 45% ofpatients treated with the PDL and in 15% ofpatients treated by the laser with scanner. Therewas a higher incidence of hyperpigmentationwith a continuous wave laser but no differencesin the instance of scarring or hypopigmenta-tion.

■ Robotic Scanning Hand Pieces

The major disadvantage of continuous wavelasers in the treatment of PWS is the long-pulseduration resulting in nonspecific thermal dam-age. In addition, manual movement of a contin-uous wave laser beam over the skin is depen-dent on the operator’s skill not to under- orovertreat an area. Robotic scanning deviceshave been developed to try and address some ofthese difficulties. These hand pieces can be usedin conjunction with continuous wave laserssuch as the argon laser, and also quasi-continu-ous systems, such as the copper vapor andpotassium titanyl phosphate (KTP) lasers.

Robotic scanning laser devices have beenmost widely used in the treatment of PWS. Thescanner is connected to the laser output by afiber optic cable. The automated programplaces pulses of energy in a precise nonadjacentpattern in the shape of a hexagon (Fig. 2.4). Thenumber of pulses delivered will determine thesize of the hexagon, which varies from 3 to

Fig. 2.4. Hexagonal clearance of a port wine staintreated with the KTP laser and robotic scanning handpiece (Hexascan) [from S.W. Lanigan (2000) Lasersin Dermatology, Springer Verlag, London]


comparison with the argon laser, the CVL pro-duced superior results when used with a mini-mal blanching technique and a laser-associatedcomputerized scanner. In another study (1996),comparing the CVL, argon laser, and frequencydoubled Nd:YAG laser, all used with similarpulse widths and a scanner, investigators foundonly small differences in the results with thethree lasers in the treatment of purple PWS.Adverse reactions with the CVL are infrequent,but most studies have been on small numbers ofpatients. Textural changes and pigmentary dis-turbances are most commonly reported.

■ Carbon Dioxide Laser

The use of the carbon dioxide laser for treat-ment of PWS is primarily of historical interest.Yet this laser may still have a role in the removalof hemangiomatous blebs within PWS whichare resistant to other lasers. The carbon dioxidelaser emits infrared light at 10,600 nm, which isabsorbed by tissue water. In a continuous modethe laser will nonselectively vaporize tissue. It ishypothesized that if the majority of ectaticblood vessels are located superficially withinthe dermis, vaporization of tissue down to thislevel, but no further, could result in clinicallightening of the PWS without scarring. Prior to the widespread use of the PDL, the carbondioxide laser was considered of potential valuein the treatment of PWS. Lanigan and Cotterill(1990) reported their results using this laser in 51 patients with PWS. Twenty-nine of thepatients had failed to respond to argon or con-tinuous wave dye laser treatment. Twenty-twowere children with pink PWS. Good or excellentresults were seen in 74% of adults and 53% ofchildren. Two children (12%) had a poor result,including a hypertrophic scar on the neck inone child. In another study the tuberous com-ponent of 30 patients with PWS was found to beunresponsive to PDL treatment. In all patientsthe lesions disappeared, but textural changeswere seen in 37%, with one patient developinghypertrophic scarring. In view of the excellentsafety profile for the PDL in the treatment ofPWS, the carbon dioxide laser cannot be recom-mended as initial treatment of this vascularbirthmark.

Currently Available Lasers for Vascular Lesions

Currently the main lasers used for the treatmentof vascular lesions including PWS are PDLs andthe KTP laser. Recent work has also demon-strated that long-pulsed 755-nm alexandrite and1064-nm Nd:YAG lasers may be of value intreatment of both PWS, bulky vascular anoma-lies, and leg vein telangiectasia.

Indications

Lasers currently available for treating vasculardisorders have a wide range of applications.Cutaneous ectatic disorders either acquired orcongenital can be treated. Particular attentionin this chapter will be given to the treatment ofPWS, capillary (strawberry) hemangiomas, legvein telangiectasia (Table 2.2), and facial telangi-ectasia. A number of other disorders of cuta-neous vasculature can be treated (Table 2.3).Cutaneous disorders not primarily of vascularorigin, e. g., angiolymphoid hyperplasia, ade-noma sebaceum, etc., (Table 2.4) can also betreated. Particular emphasis will be given ontreating psoriasis, scars, and viral warts in thisway.

2


Table 2.2. Lasers used for treatment of leg veintelangiectasia

Laser Wavelength Pulse duration (nm) (ms)

KTP 532 1–200Pulsed dye 585 0.45Long pulsed dye 585, 590, 0.5–40

595, 600Alexandrite 755 3–40Diode 800, 810, 930 1–250Nd:YAG 1064 0.3–100


Port Wine Stains

■ Port Wine Stain Treatment with the FlashLamp Pulsed Dye Laser

The flash lamp PDL was the first laser specifi-cally designed for the selective photo thermoly-sis of cutaneous blood vessels. It is consideredthe best laser for the overall treatment of amixed population of patients with port winestains (PWS), although some individuals maybenefit from other lasers. The laser’s activemedium is a rhodamine dye selected to produceyellow light at 577–595 nm. Most lasers emit thelonger wavelength as this has been shown tohave a deeper depth of penetration while alsoretaining vascular selectivity. The pulse dura-tion is generally fixed at 450 ms. The main vari-ables are the spot size and fluence. The spotsizes available with today’s PDL are generallybetween 3 and 10 mm. Five- to ten-millimeterspot sizes are generally preferred as these willcover larger areas.

There are a number of studies reporting theefficacy of the PDL in the treatment of PWS(Figs. 2.5, 2.6). Results are generally reported interms of lightening the PWS rather than theclearance, as complete clearance only occurs inthe minority of patients. The vast majority ofresearch papers use subjective criteria forimprovement compared with baseline photo-

17Indications

Table 2.4. Other disorders treated by vascular spe-cific lasers

Angiolymphoid hyperplasiaLymphangiomaAdenoma sebaceumGranuloma facialeScarsPsoriasisWarts

Table 2.3. Other cutaneous vascular lesions treatedwith lasers

Spider angiomaCherry angiomaVenous lakeAngiokeratomaPyogenic granulomaKaposi’s sarcomaRosaceaPoikiloderma of Civatte (caution see the Sect.

titled “Treatment of Other Cutaneous VascularLesions”)

Radiation induced telangiectasiaCREST syndrome

Fig. 2.5. a Extensive port wine stain on face (courtesyof Lasercare Clinics Ltd). b Near total clearance ofport wine stain after course of pulsed dye laser treat-ment (courtesy of Lasercare Clinics Ltd)

b

a


graphy. Approximately 40% of patients withPWS achieved 75% lightening or more afterlaser treatment and more than 80% of PWSlightened by at least 50%. Several prognosticcriteria had been put forward to assist in pre-

dicting the outcome of treatment. Some authorsreported best results in pink lesions; othersreport better results in red lesions. In a study of261 patients treated over a 5-year period(Katugampola and Lanigan 1997) color of PWSwas not found to be of prognostic value.Although it is generally considered that youngerchildren will require fewer treatments thanadults, some (Alster and Wilson 1994) havereported that younger children may requiremore treatments owing to the rapid growth ofresidual blood vessels between treatments. Yetothers found no evidence that treatment of PWSin early childhood was more effective thantreatment at later stage.

Two features that will affect outcome are siteof the PWS and size of the birthmark. PWS onthe face and neck respond better than those onthe leg and hand (Lanigan et al. 1996). On theface, PWS on the forehead and lateral facerespond better than those over the middle ofthe face, particularly those involving the secondbranch of the trigeminal nerve. The chest,upper arm, and shoulder generally respondwell. PWS less than 20 cm2 at initial examina-tion cleared more than those larger than 20 cm2

irrespective of age.

■ Second Generation Pulsed Dye Lasers

The pulsed dye laser (PDL) has become thetreatment of choice for PWS. Several investiga-tors established the efficacy, and low incidenceof side effects, of first generation PDLs operat-ing at either 577-nm or 585-nm wavelengths and0.45-ms pulse width. However, in the majorityof cases complete clearance was not achieved,and a significant proportion of lesions wereresistant to treatment. In recent years, increasedunderstanding of the interaction between lasersand PWS has led to modification of the originalPDL design and has given rise to a number ofsecond generation lasers. The most importantchanges include longer pulse widths, longerwavelengths, higher delivered fluences and useof dynamic cooling devices. Many of theselasers have proven to be useful in the treatmentof PWS (Geronemus et al. 2000).

Geronemus used the a 595-nm wavelengthPDL, 1.5-ms pulse width and fluences up to

2


Fig. 2.6. a Port wine stain on face (courtesy of Laser-care Clinics Ltd). b Complete clearance followingcourse of pulsed dye laser treatment (courtesy ofLasercare Clinics Ltd)

a

b


11–12 Jcm–2 with a dynamic cooling spray. Theyobtained greater than 75% clearing of PWS in 10out of 16 (63%) patients after four treatments.All patients were children under 12 months ofage. In another study comparing a 585-nm,7-mm spot, 0.45-ms pulse width PDL with a sec-ond generation long-pulsed dye laser (LPDL)with 1.5-ms pulse width, 5-mm spot and wave-length settings ranging from 585 to 600 nm,optimal fading in 30 out of 62 patients was seenwith the LPDL compared to only 12 patientswith the shorter pulse width laser. In 20 patientsthere was no difference with respect to wave-length for the LPTDL; 13 patients showed bestfading at 585 nm, 3 at 590 nm, 8 at 595 nm, and6 patients at 600 nm. The authors compensatedby increasing the fluence for the reduced lightabsorption at longer wavelengths.

In another study using a PDL with a 600-nmwavelength, superior lightening of PWS wasseen in 11 out of 22 patients compared to treat-ment with 585 nm when compensatory fluences1.5–2 times higher were used. At equal fluences,585 nm produces significantly greater lighteningthan did the longer wavelength.

The rationale for the aforementioned alter-ation in treatment parameters is in part basedon an increasing understanding of laser-PWSinteractions from noninvasive imaging, mathe-matical modeling, and animal models. Longerpulse widths, as opposed to the 0.45-ms dura-tion delivered by first generation PDLs, may bemore appropriate for larger caliber PWS vessels,based on ideal thermal relaxation times of1–10 ms (Anderson and Parish 1981; Dierickx etal. 1995). Longer wavelengths penetrate deeper,allowing targeting of deeper vessels. Higher flu-ences are needed in part because the newer,longer wavelength is further from the peakabsorption peak of oxyhemoglobin at 577 nm(Fig. 2.1). Unfortunately, higher fluences alsoincrease the potential for epidermal heating due to competitive absorption by epidermalmelanin. This necessitates the use of coolingdevices to minimize epidermal damage (andconsequent side effects). Recent cooling meth-ods include liquid cryogen sprays (Geronemuset al. 2000), cold air cooling, and contact cool-ing. The cooling device can be synchronizedwith laser pulses, or alternatively operated a few

milliseconds before or after the pulse. Studiesusing such epidermal cooling show a reductionin pain and prevention of pigmentary sideeffects during PWS treatment, even at higherfluences.

Overall, the findings of various studies indi-cate an improvement over the results with firstgeneration PDLs, where greater than 75% clear-ing was noted in only about 40% of patients.However, with so many variables uncontrolledin the plethora of small studies, it is often diffi-cult to clarify which modification contributedto improved outcomes.

■ Treatment of Resistant PWS

Further evidence of improved efficacy of sec-ond generation PDLs comes from responses inPWS which have proven to be resistant to firstgeneration PDLs. In a case report, PDL treat-ment with a longer pulse width of 1.5 ms waseffective in treating a PWS previously resistantto a 0.5-ms PDL(Bernstein 2000). Recent workusing high fluence LPDL with cryogen cooling(V beam) in treatment of resistant PWS hasdemonstrated that further lightening can beobtained, though this may be at the expense ofan increased incidence of side effects.

■ KTP Laser Treatment

The Nd:YAG laser is a solid state laser contain-ing a crystal rod of yttrium-aluminum-garnetdoped with Neodymium ions (Nd:YAG). Theprimary wavelength of this laser is in the in-frared at 1064 nm. A frequency-doubling crystalmade of KTP can be placed in the beam path toemit green light at 532 nm. This results in aquasi-continuous laser with individual pulses of200 ns produced at a frequency of 25,000 Hz.This train of pulses can be shuttered to delivermacro pulses of 2–20 ms. High fluences areavailable with this laser and the pulse durationsmay be more appropriate for some PWS. In a preliminary investigation comparing a KTP532 nm laser with an argon laser, 14 PWSpatients were treated with both of these lasers.The results were equivalent in 12 patients andsuperior results were noted in 2 individualstreated with the KTP laser alone.

19Indications


The KTP laser has been shown to producefurther lightening in 30 PDL-resistant PWSlesions. KTP laser fluences ranged from 18 to24 J/cm2 with pulse widths of 9–14 ms. Five (17%)patients showed greater than 50% response. Ingeneral, patients preferred the KTP laser becauseit induced less discomfort and purpura. How-ever, two (7%) patients developed scarring.

A study comparing the PDL with a fre-quency-doubled Nd:YAG laser showed similarresponse rates among the 43 patients; however,a substantially higher scarring rate with the 532-nm Nd:YAG laser was noted. Another study ofChinese patients showed rather modest benefitsusing the 532-nm Nd:YAG laser with only 13.6%of patients showing more than 50% improve-ment (Chan et al. 2000).

It would appear that the KTP laser has a roleto play in the treatment of resistant PWS. How-ever, the long pulses employed with this laser,and the significant epidermal injury induced bythe shorter wavelength of light, may increasethe incidence of laser-induced adverse effectswhen this laser is compared with today’s PDL.

■ Infrared Lasers

Longer wavelength lasers such as the alexan-drite (755 nm) and Nd:YAG (1064 nm) may havea role in PWS treatment. In the millisecondmode these lasers have been widely used forhair removal and leg vein telangiectasia. Theselasers may be of value in the treatment of bulkymalformations and mature PWSs. Such lesionsare typically more resistant to PDL due to thepredominance of larger and deeper vessels andhigher content of deoxygenated hemoglobin. Inone study investigators used a 3-ms alexandritelaser with dynamic cooling to treat 3 patientswith hypertrophic PWS, using fluences rangingfrom 30 to 85 J/cm2. All lesions significantlylightened without side effects. In another study18 patients with PWS were treated, comparing a595-nm PDL to a long-pulsed Nd:YAG laser withcontact cooling. Similar clearance rates wereachieved, and scarring was only noted in onepatient where fluences exceeded the minimumpurpura dose. Patients preferred the Nd:YAGlaser because of the shorter recovery periodbetween treatments.

■ Noncoherent Light Sources

Intense pulsed light (IPL) has also been used totreat PWS. Unlike laser systems, these nonlaserflashlamps produce noncoherent broad bandlight with wavelengths in the range 515 to1200 nm and permit various pulse widths. Fil-ters are used to remove unwanted wavelengths.The first report of thermocoagulation of PWSby polychromatic light was in 1976. In anotherstudy, a PDL-resistant PWS completely resolvedafter treatment with an IPL device. Anotherstudy of 37 patients treated with IPL showed aclearance of pink and red PWS, and lighteningin purple PWS (Raulin et al. 1999). Direct com-parison of an IPL with a PDL source in a studyof 32 patients showed that overall the responserate was better with the PDL. However, it wasnoteworthy that 6 out of the 32 patients had abetter response with the IPL. The potential roleof IPL for treating PDL-resistant PWS is con-firmed by a recent study showing responses in 7 out of 15 patients previously resistant to PDL,with 6 patients showing between 75% and 100%improvement (Bjerring et al. 2003). There is amultiplicity of choices of treatment parameterswith noncoherent light sources. Further work isnecessary to determine optimum settings.

Capillary (Strawberry) Hemangiomas

Capillary or strawberry hemangiomas are com-mon benign tumors of infancy. Most developduring the first to the fourth week of life. Thereis an early proliferative phase which usuallylasts for 6–9 months. This growth phase is fol-lowed by a gradual spontaneous involutionwhich is complete in 50% by 5 years and 70% by7 years of age.

The majority of strawberry hemangiomasare of cosmetic concern. However, the appear-ance of a large vascular tumor on the face of ababy is not without significance. Some heman-giomas cause problems by interference withorgan function, e.g., periocular hemangiomasthat lead to problems with vision. Subglotticand intranasal hemangiomas may cause prob-lems with swallowing and respiration. Bleedingand ulceration can occur, particularly in

2



perineal hemangiomas. Most complicationsoccurred during the proliferative phase of thehemangiomas. Once regression is underway the majority of complications associated withthe hemangioma will resolve. Unfortunately,regression of many hemangiomas is incom-plete, leaving either a flat telangiectatic patch oran area of redundant discolored skin. If ulcera-tion has occurred, scarring may follow.

Laser treatment of strawberry heman-giomas is performed either to slow or arrestproliferation in early hemangiomas, to corrector minimize complications, or cosmetically toimprove residual telangiectatic lesions. Initially,the argon laser was used for the treatment ofcapillary hemangiomas. Treatment with thislaser, however, was limited because of laser-induced textural and pigmentary changes. Acontinuous wave Nd:YAG laser has also beenused; this laser’s longer wavelength leads todeep penetration, with thermal coagulation oflarge volumes of tissue. It is useful for debulk-ing large hemangiomas, but hypertrophic scar-ring occurs frequently. Intraoral hemangiomascan respond particularly well to this form oftreatment. Lasers can also be used intralesion-ally in the treatment of bulky hemangiomaswith both the Nd:YAG and KTP lasers. In thissituation, a laser-connected fiber is inserted inthe tumor and irradiation is performed as thefiber is withdrawn.

The majority of strawberry hemangiomasare currently treated with PDL. In the firstreport of a patient treated with PDL, a macularhemangioma was treated in a 6-day-old infant.This report and other subsequent publicationsemphasized the importance of early treatmentof proliferative hemangiomas to obtain mostbenefit from treatment (Ashinoff et al. 1991).Because of the limited penetration depth of thePDL (just over 1 mm) it is unrealistic to expectsignificant alterations in a large, mature capil-lary hemangioma. Fluences of 5.5–6 J/cm2 witha 5 mm spot are generally used with the 1.5 msPDL. Treatment intervals have been reduced toevery few weeks to achieve optimal benefitwhen treating hemangiomas. Multiple treat-ments may be required in small infants.

There is some controversy over the merits ofearly PDL treatment in uncomplicated child-

hood hemangiomas. In a randomized con-trolled study of early PDL treatment of uncom-plicated childhood hemangiomas investigatorshave found there was no significant differencein the number of children in terms of 1-yearcomplete clearances in the treated vs. theuntreated control group. They suggested thattreatment in uncomplicated hemangiomas is nobetter than a wait-and-see policy. This is con-tested by others who recommend early lasertreatment especially in superficial and smallchildhood hemangiomas.

The deeper component of the hemangiomamay still develop despite successful treatment ofthe superficial component. For life threateningproliferative hemangiomas, a combination oflaser therapy, systemic steroids, and otheragents may be required.

Of note, the complications of bleeding andulceration respond very well to PDL therapy.Usually only one or two treatments are requiredand often there is a prompt response. The painfrom an ulcerated hemangioma regresses notice-ably and rapidly after treatment (Barlow et al.1996). In some patients the hemangioma willalso undergo regression, but this is not always thecase. The entire hemangioma, not just the ulcer-ated or bleeding area, is generally treated.

In the incompletely regressed capillary hem-angioma of the older child, superficial ectaticblood vessels can be easily treated with the PDL(Fig. 2.7), but scarring or redundant tissue mayrequire surgical repair.

Leg Veins and Telangiectasia

Visible veins on the leg are a common cosme-tic problem affecting approximately 40% ofwomen in the United States; they remain a ther-apeutic challenge. Sclerotherapy is currently thegold standard of treatment, but many vesselsless than 1 mm in diameter may be difficult toinject. Work over the last 5 years with vascular-specific, longer-wavelength, longer-pulsed la-sers, has produced very promising results withsome outcomes similar to those seen after scle-rotherapy (Table 2.2).

It is important to remember in advance oflaser treatment of leg vein telangiectasia to

21Indications


examine the patient carefully to determinewhether visible telangiectatic areas are sec-ondary to venous pressure from deeper varicoseveins. In the uncomplicated case, laser therapyor sclerotherapy can be considered. The major-ity of leg vein telangiectasia are in the range of0.1 mm to several millimeters in diameter, muchlarger than the vessels in a PWS, which are0.1 mm or less. Following the principals ofselective photothermolysis, most vessels greaterthan 0.1 mm will require pulse durations longerthan the 0.45 ms short-pulsed dye laser used for PWS. The larger the vessel, the longer thedesired pulse duration. In addition, longerwavelengths of light will be required to pene-trate more deeply into these deeper dermalblood vessels.

■ KTP Laser

The KTP laser produces green light at 532 nm,which is well absorbed by hemoglobin but pene-trates relatively superficially. This laser doesproduce millisecond domain pulses, whichshould be appropriate for leg vein telangiecta-sia. However, early results with this laser in thetreatment of leg veins using small spots andpulse durations of 10 ms or less were disap-pointing and inferior to those of the LPDL(West and Alster 1998). McMeekin (McMeekinet al. 1999) used a long-pulsed Nd:YAG laser at532 nm to treat 10 patients with leg veins lessthan 1 mm in diameter. A 4 °C-chilled sapphiretip was used. One to three passes were madewith fluences of 12 or 16 J/cm2. The spot sizeswere 3–5 mm in diameter. Overall, 44% ofpatients had more than 50% clearance follow-ing a single treatment; 94% of patients hadpostinflammatory hyperpigmentation, whichtook 6 months to clear. The required higher flu-ence was associated with atrophic scarring inone patient.

Others have used the same laser with a 50-ms pulse and fluences of 18–20 J/cm2 in thetreatment of 46 patients with leg veins. Inpatients with veins less than 1 mm in diameter,80% had greater than 50% clearance after twotreatments. In patients with veins 1–2 mm indiameter, 67% had greater than 50% clearanceafter two treatments. Side effects were minimaland temporary. Crusting or blistering occurredif the chill tip was not kept continuously in con-tact with the skin. The KTP laser seems mostappropriate for superficial red telangiectasia upto 1 mm in diameter. Because there is significantabsorption by melanin at 532 nm, patients withdarker skin types or tanned skin will have anincreased risk of side effects, including hypo-and hyperpigmentation. Contact cooling doeshelp to reduce this side effect and allow higherfluences.

■ Long-Pulsed Dye Lasers

Based on the theory of selective photothermoly-sis, the predicted pulse duration ideally suitedfor thermal destruction of leg veins (0.1 to sev-eral millimeters in diameter) is in the 1–50-ms

2


Fig. 2.7. a Telangiectatic residual strawberry heman-gioma. b After pulsed dye laser treatment

a

b


domain (Dierickx et al. 1995). Long PDL withwavelengths of 585–600 nm with pulse dura-tions of 1.5 ms or longer are now available.Other investigators have treated 18 patients withleg veins ranging in diameter from 0.6 mm to1 mm. After one treatment at 15 J/cm2 50% ofvessels cleared, and at 18 J/cm2 67% of the ves-sels cleared. Treatments were delivered using an elliptical (2 × 7 mm) spot, which could bealigned over the telangiectasia. Several studieshave shown this laser to be efficacious in thetreatment of small vessel telangiectasia on theleg.

In another study, 80 patients with 250 legtelangiectasias were treated with the LPDLusing fluences of 16–22 J/cm2; ice packs wereused to cool the skin before treatment. Onehundred per cent clearance was achieved in ves-sels with diameters up to 0.5 mm and 80% fad-ing in vessels between 0.5 and 1.0 mm. Therewas no incidence of scarring, thrombophlebitis,and/or telangiectatic matting. Transient hyper-pigmentation occurred in 50% of cases andhypopigmentation in 50%. Other investigatorsalso found the 1.5-ms PDL effective in treat-ing vessels smaller than 0.5 mm in diameter;595 nm and 20 J/cm2 with ice cube cooling werethe preferred parameters. Side effects includedpurpura, pigmentary disturbances, and edema.Others (Weiss and Dover 2002) have alsoobserved encouraging preliminary results usinga 20-ms pulse duration 595-nm PDL.

■ Long-Pulsed Alexandrite Laser

There is a small peak of hemoglobin absorptionin the 700–900 nm (Fig. 2.8) range of wave-lengths. This has encouraged the use of longerwavelength lasers such as the alexandrite,diode, and Nd:YAG lasers in the treatment ofmore deeply situated, larger-caliber leg veintelangiectasia. The long-pulsed alexandritelaser emits light in the near infrared spectrumat 755 nm. The laser, when used with pulse dura-tions of 3–20 ms theoretically penetrates 2–3 mm in depth into the skin.

Studies have evaluated the long-pulse alexan-drite laser in patients with leg vein telangiectasia.By using a variety of different treatment para-meters they concluded that optimal results were

achieved with 20 J/cm2 and double pulses. Theseparameters produced almost a two-thirds reduc-tion in vessels 0.4–1 mm in diameter after threetreatments. Small vessels respond poorly if at all. Others have treated leg veins measuring0.3–2 mm in diameter in patients with Fitz-patrick skin types I–III with a 3-ms-pulsed alex-andrite laser, 8-mm spot, fluences of 60–80 J/cm2, and associated dynamic epidermalcryogen cooling. Four weeks after a single treat-ment, 48 sites were evaluated; 35% of the treatedsites had cleared by more than 75%, another 33%had cleared by more than 50%. By 12 weeks 65%of treated areas showed greater than 75% clear-ance. Hyperpigmentation was seen in 35% oftreated areas and treatment was noted to beuncomfortable.

■ Diode Lasers

Diode lasers were originally introduced in the1980s with power outputs of only 100 mW. Mul-tiple diode laser arrays have now been devel-oped which can be coupled directly into fiberoptic delivery devices. Laser outputs have nowincreased to 60 W or more. Diode lasers canemit light over a broad range of wavelengthsfrom 600 to 1020 nm. Most medical researchhas been with diode lasers such as gallium-arsenide (GaAs) and gallium-aluminum-arse-nide (GaAlAs) emitting light in this 795- to 830-nm range.

23Indications

Fig. 2.8. Schematic absorption spectrum of hemo-globin (Hb), Oxyhemoglobin (Hb02) and melanin(Me) to show absorption peak of Hb at 755 nm (cour-tesy of Cynosure Lasers)


These lasers have been used in the treatmentof superficial and deep small-to-medium size leg telangiectasia. Diode lasers emit light thatclosely matches a tertiary hemoglobin absorp-tion peak at 915 nm. Investigators (Varma andLanigan 2000) have evaluated an 810-nm diodelaser for the treatment of telangiectatic veins onthe leg. Vessels measuring 0.5–1.5 mm in diame-ter were treated using fluences of 12–18 J/cm2

with a 5-mm spot. Improvements were modestbut patient acceptance was high. There were nosignificant side effects. Others also investigated a940-nm diode laser in 60 patients with vessels ofvarying size. Best results were seen in vesselsbetween 0.8 and 1.44 mm in diameter where 88%of patients obtained more than 75% vessel clear-ance.Vessels smaller than this responded poorly.

■ Long-Pulsed Nd:YAG Lasers

Several long-pulsed Nd:YAG lasers are availablewith pulse durations in the tens of milliseconds.These pulse widths are more appropriate in tar-geting large leg veins than the previous Q-switched Nd:YAG nanosecond lasers used in thetreatment of tattoos. The 1064-nm infrared lightis deeply penetrating with minimal absorptionby melanin. When using long wavelength laserswith deeper penetration but relatively poorabsorption, the combination of higher fluencesand cooling devices will reduce epidermalinjury.

In one study, 50 sites were evaluated withthis laser. Number of pulses and fluence werealtered based on vessel size. At 3-months follow-up a 75% improvement was noted. There was no epidermal injury with this laser althoughhyperpigmentation was common. Several stud-ies have now demonstrated the effectiveness of the millisecond-pulsed Nd:YAG laser forlower extremity telangiectasia (Rogachefsky etal. 2002; Omura et al. 2003). Studies havefocused on methemoglobin production follow-ing laser-induced heating. This methemoglobinformation leads to an increase in the absorptionof the 1064-nm infrared light, adding to theeffect of the Nd:YAG laser. Others (Eremia et al.2002) compared the long-pulsed 1064-nmNd:YAG, 810-nm diode, and 755-nm alexandritelasers in the treatment of leg vein telangiectasia.

Vessels were 0.3–3 mm in diameter. At follow-upgreater than 75% improvement was observed at88% of the Nd:YAG laser-treated sites, 29% ofthe diode laser-treated sites, and 33% of thealexandrite laser-treated sites.

Despite these developments, sclerotherapymay well remain the treatment of choice for avariety of leg vein telangiectasia. A comparativestudy of sclerotherapy and long-pulsed Nd:YAGlaser treatment (Lupton et al. 2002) showed thatleg telangiectasia responded best to sclerother-apy, in fewer treatment sessions, as compared tothe long-pulsed YAG laser. The incidence ofadverse sequelae was equal. Laser treatment ofleg vein telangiectasia appears to be of particu-lar value in patients with telangiectatic mattingand needle phobia, and for small superficialvessels too small to be treated with a needle.

Facial Telangiectasia

Facial telangiectasias are one of the commonestvascular disorders presenting for treatment.They respond readily to most lasers emittinglight absorbed by hemoglobin. The two maingroups of lasers used for facial telangiectasiaare the pulsed dye and KTP lasers. The PDL hasthe lowest incidence of scarring, but may causesignificant bruising after treatment (Fig. 2.9).This may not be cosmetically acceptable topatients with relatively mild disease. In a com-parison of the older copper vapor laser and PDL treatment of facial telangiectasia similarimprovements were seen with both lasers. How-ever, patients preferred the linear crusting pro-duced by the copper vapor laser compared tothe purpura induced by the PDL. In a compari-son study of the argon, dye, and pulsed dyelasers, the PDL was shown to produce betterresults. However, only 6 of 13 patients preferredthis laser because of laser-induced purpura andpostinflammatory hyperpigmentation. Fourdifferent frequency-doubled Nd:YAG lasers forthe treatment of facial telangiectasia wereassessed (Goldberg et al. 1999), using fluencesof between 8 and 24/Jcm2. The authors demon-strated equal efficacy with all such lasers and noevidence of scarring or pigmentary changes(Figs. 2.10, 2.11)

2



With the development of long PDL with epi-dermal cooling, it may be possible to producesatisfactory improvement in facial telangiecta-sia while minimizing the purpura seen with theearlier PDL. Some investigators (Alam et al.2003) have treated patients with facial telangi-ectasia using the PDL at fluences 1 J/cm2 belowand 0.5 J/cm2 above the purpura threshold.There was a small reduction in observed telan-giectasia with the purpura-free treatment. Thiswas seen most commonly with finer telang-iectatic vessels. A more significant reduction intelangiectasia was seen in those with laser-induced purpura. Similar work has beenreported using a PDL with refrigerated air cool-ing and extended pulse widths of 40 ms–at flu-ences at or below the purpuric threshold. In allcases vessel clearance was associated with tran-sient purpura lasting less than 7 days. Theauthors did not feel that it was possible, in asingle treatment, to produce vessel clearancewithout the presence of purpura.

The addition of contact cooling when treat-ing facial telangiectasia with the KTP laser hasalso been assessed. The combination of anaqueous gel with a water-cooled hand piece sig-nificantly reduced the incidence of side effectsfrom this procedure. Yet, there was no alterationin the efficacy of clearance of telangiectasia.

25Indications

Fig. 2.9. Bruising after pulsed dye laser

Fig. 2.10. a Facial telangiectasia pretreatment (cour-tesy of Lasercare Clinics Ltd). b Complete clearanceafter KTP laser treatment (courtesy of LasercareClinics Ltd)

b

a


Psoriasis

In a psoriatic plaque the capillaries of the der-mal papillae are enlarged, dilated, and tortuous.A variety of lasers can be used for the treatmentof psoriasis (see Chap. 6). Since the PDL can be used to treat superficial cutaneous vascu-lar ectasias, it seemed logical to investigatewhether this laser had any therapeutic efficacyin the treatment of plaque-type psoriasis. Overa decade ago there were reports of the potentialbenefits of the PDL in psoriasis. Subsequentstudies (Katugampola et al. 1995) have con-firmed the effectiveness of this treatment.Katugampola et al. treated 8 patients withchronic plaque psoriasis using the PDL at8.5 J/cm2 with a 5-mm spot, 3 times, over a 6-week period. Five of their 8 patients recorded animprovement of >50%, with one patient show-ing complete resolution. Some have performeda clinical and histological evaluation of the PDLtreatment of psoriasis in 36 patients. There wasno difference in response when using either a450-µs or 1500-µs pulse duration.

Others have looked at psoriatic plaques1 year after PDL treatment. Of nine areas com-pletely cleared after treatment, six remainedclear up to 15 months after therapy

It appears that PDL treatment can lead toimprovement in psoriasis. Multiple treatmentsare often necessary and this technology may be

inappropriate for widespread disease. Somepatients with localized, resistant plaque psoria-sis may benefit from this form of therapy. Fur-ther studies are required to determine the mostappropriate use of this laser in the treatment ofpsoriasis.

Scars

PDL treatment is able to alter argon laser-induced scars, which are often erythematousand hypertrophic. By using optical profilometrymeasurements, researchers have shown a trendtoward more normal skin texture as well asreduction in observed erythema. This work wasextended to the treatment of other erythema-tous and hypertrophic scars using objectivemeasurements. Investigators have noted thatclinical appearance (color and height), surfacetexture, skin pliability, and pruritus could all beimproved.

Dierickx, Goldman and Fitzpatrick (Die-rickx et al. 1995; Goldman and Fitzpatrick 1995),treated 15 patients with erythematous/hyper-trophic scars and obtained an average improve-ment of 77% after an average of 1.8 treatments.In another study 48 patients were treated withthe PDL. Scars less than 1 year old respondedbetter than those more than 1 year old. Facialscars also showed greater improvement, with an

2


Fig. 2.11. a Steroid induced facial telangiectasia (courtesy of Lasercare Clinics Ltd). b Post-KTP laser treat-ment (courtesy of Lasercare Clinics Ltd)

a b


88% average improvement with total resolutionin 20% of scars after 4.4 treatments.

For persistent scars, combinations of intra-lesional corticosteroid injections, steroid im-pregnated tapes, and laser therapy may be nec-essary. Two studies have compared the effects ofPDL treatment with other treatment modalities,particularly intralesional steroids. One studycompared PDL treatment alone with laser ther-apy combined with intralesional corticosteroidtreatment. Both treatment arms produced im-provement in scars; there was no significant dif-ference between the two treatments. Anotherstudy compared scar treatment with intrale-sional corticosteroids alone, combined steroidsand 5-fluorouracil, 5-fluorouracil alone, or PDLtreatment using fluences of 5 J/cm2. All treat-ment areas were improved compared to base-line. The highest risk of adverse sequelaeoccurred in the corticosteroid intralesionalgroup.

Other studies, however, have failed todemonstrate substantial effects of the PDL onscars. In one study, laser-treated scars were as-sessed using remittance spectroscopy. Althougha discrete decrease in redness of the scars wasreported clinically, this was not confirmed byobjective data. Another prospective single blindrandomized controlled study, compared lasertreatment with silicon gel sheeting and controls.Although there was an overall reduction inblood volume, flow and scar pruritis over time,there were no differences detected between thetreatment and control groups. Finally investiga-tors in another study treating old and new scarswith the PDL with fluences of 5–6 J/cm2, wereunable to demonstrate any statistical differ-ences between treatment and control sites byphotographic assessments or surface profilemeasurements. However, they did notice a sig-nificant improvement in scar pruritis in thelaser-treated group as compared to the controlgroup.

There are now multiple studies assessing theeffects of the PDL in the treatment of scars.Although results are conflicting, particularlywhen controlled studies are performed, it wouldappear that in some cases laser therapy can bebeneficial in the treatment of such scars. It islikely that vascular-induced erythema and pruri-

tis are the two parameters that are most likely tosignificantly improve with this treatment.

Verrucae

Verrucae, although not truly vascular lesions,have been treated with lasers. The PDL mayhave potential benefits in the treatment ofwarts. The laser light can selectively obliterateblood vessels within the verrucae; it may alsodestroy the most rapidly replicating cells carry-ing the virus. The ability to focus the energy ofthe light directly on to the lesional vasculatureminimizes injury to healthy skin. The PDL hasbeen reported as successful for the treatment of resistant viral warts. In one study, 28 of 39patients experienced resolution of the warts fol-lowing an average of only 1.68 treatments withfluences of 6.5–7.5 J/cm2. Warts need to be paredaggressively prior to treatment; higher fluencesof 8.5–9.5 J/cm2 may be necessary.

Although the PDL has been reported to beeffective in the treatment of plantar warts, plan-tar warts appear relatively resistant to the lasertreatment. In another study, 7 patients (6 plan-tar, 1 periungual) with recalcitrant verrucaewere treated. Although there was a partialresponse, none of their patients experiencedcomplete resolution of their lesions. Otherstreated 96 warts with only a 48% completeclearance over an average of 3.4 treatments. Astudy using the KTP laser at 532 nm showedcomplete clearing of warts in 12 of 25 patientswith resistant verrucae.

There has been only one prospective ran-domized controlled trial comparing PDL ther-apy with conventional therapy in the treatmentof verrucae. Forty adult patients were random-ized to receive either PDL therapy (585 nm) orconventional therapy. Up to four treatmentswere provided at monthly intervals. One hun-dred and ninety four warts were evaluated.Complete response was seen in 70% of thewarts treated with conventional therapy and in66% of those in the PDL group. Thus, there wasno significant difference in the treatmentresponses.

It should be noted that although PDL treat-ment is widely used in the treatment of viral

27Indications


warts, there are no randomized controlled stud-ies to demonstrate the superiority of this treat-ment over conventional methods. While un-doubtedly effective in selected patients, it isimportant to note that there is a significantspontaneous remission rate in viral warts. Morestudies with controlled trials are required.

Treatment of Other CutaneousVascular Lesions

Spider angiomas are easily, and successfully,treated with lasers (Table 2.3). In addition, boththe pulsed dye and KTP lasers have been shownto be safe and efficacious in children. Themajority of spider angiomas will clear with oneor two treatments without significant compli-cations.

Venous lakes, angiokeratomas, and cherryangiomas have all been reported to respondwell to laser therapy. Tumorous outgrowths ofvascular tissue such as pyogenic granulomas,nodular hemangiomas, and Kaposi’s sarcomaare likely to have only a partial response owingto the limited depth of penetration of the emit-ted laser beam.

Areas of persistent erythema, as seen inpatients with rosacea and postrhinoplasty, canbe treated with the PDL (Fig. 2.12). More treat-ments are required than for individual telan-giectasias. Purpura can be a problem when thePDL is utilized. Purpura can be diminished byusing PDL-emitted longer pulse durations. Inaddition, the first one or two laser treatmentsoften induces a rather spotty lightening on abackground erythema, necessitating furthertreatment.

Matt telangiectasia seen in CREST syndrome(calcinosis, Raynaud’s phenomenon, esopha-geal motility disorders, sclerodactyly, andtelangiectasia) can respond well to treatment(Fig. 2.13). Poikiloderma of Civatte, with itscombination of pigmentation and telangiecta-sia seen on the lateral neck, can respond to PDLtherapy. Low fluences (approximately 4 J/cm2)should be used because of the high incidence ofposttreatment hypopigmentation and possiblescarring seen in this disorder. Telangiectasia

after radiotherapy is also easily treated(Fig. 2.14).

Other lesions with a vascular component,such as angio-lymphoid hyperplasia, adenomasebaceum, lymphangiomas (Fig. 2.15), andgranuloma faciale have all been reported assuccessfully treated with vascular lasers. Themajority of reports of these disorders have beencase studies rather than controlled trials. Inadenoma sebaceum, if the angio fibromas donot have a prominent vascular component, thenCO2 laser vaporization should be considered.

Disadvantages

The lasers used currently in the treatment ofvascular disease have a low incidence of sideeffects. Risk of complications is substantiallyless than that seen with previously used contin-uous wave lasers such as the argon laser. Themajor disadvantage of the PDL is the develop-ment of profound purpura. Using the short-pulsed dye laser this occurred in 61 or 62patients and lasted a mean of 10.2 days (1–21days) (Lanigan 1995). In this same study 70% ofpatients reported swelling of the treated areawhich lasted 1–10 days; weeping and crustingoccurred in 48%. Forty five per cent of patientsdid not go out of their home for a mean of

2


Fig. 2.12. Erythematous telangiectatic rosacea treatedwith pulsed dye laser (only right cheek treated)


5.6 days (2–14 days). Longer-pulsed PDL treat-ment leads to less purpura.

Contraindications

There are very few, if any, absolute contraindi-cations in the use of vascular specific lasers.

There are a number of relative contraindica-tions that the laser clinician should considerbefore embarking on treatment. The clinicianshould ascertain that the patient has realisticexpectations from the laser treatment. Intreating PWS, only the minority of cases willcompletely clear, although the majority willsubstantially lighten. Patients with facial telan-

29Contraindications

Fig. 2.13. a Mat telangiectasia in CREST syndrome. b After course of pulsed dye laser treatment

a b

Fig. 2.14. a Postirradiation telangiectasia on chest wall [from S.W. Lanigan, T. Joannides (2003) Brit J Derma-tol 48(1):77–79]. b Near total clearance after one pulsed dye laser treatment [from S.W. Lanigan, T. Joannides(2003) Brit J Dermatol 48(1):77–79]

a b


giectasia may develop a dysmorphophobiawhereby the patient is significantly disturbed bywhat they perceive as abnormal disfiguringchanges–which are not visible to the casualobserver. In general, these patients do poorlywith laser treatment.

Patients who have had previous treatmentsto their vascular lesion, including continuouswave lasers, radiation treatment, and electro-desiccation often have some degree of scarringand hypopigmentation. This may not be obvi-ous until the overlying vasculature has beencleared. It is important to document suchchanges prior to treatment. In general, patientswho have had prior treatment which hasresulted in scarring do not respond as well tosubsequent PDL therapy.

Patients taking aspirin, nonsteroidal anti-inflammatories, and anticoagulants will showmore PDL-induced purpura. There have beenreports of PDL-induced hypertrophic scarringin patients who have recently taken isotretinoin.

A true cause-and-effect relationship has yet tobe proven.

Although laser treatment in itself is inher-ently safe in pregnancy, the treatment doescause pain and can be distressing. It most situa-tions, laser may be best deferred until afterdelivery.

Personal Laser Technique

Facial Telangiectasia

It is extremely important when assessingpatients for treatment of their facial telangiecta-sia that they are made fully aware of the avail-able procedures and the likely outcomes andside effects (Fig. 2.16). In general, patients withsmall, fine, relatively superficial telangiectasiacan be treated with most available lasers. Mostpatients will prefer the KTP laser because of thereduced associated purpura. Also, when treat-ing extensive areas where there is significantbackground erythema, the PDL is likely to pro-duce a superior result. Generally, I perform atest patch in this group of patients.

When using the PDL, although it may bepossible to clear the problem without purpura,it is my experience that such an approach gen-erally requires multiple treatments. I attempt to produce vessel damage with fluences as closeto the purpura threshold as possible. Mostpatients do not require local anesthesia for thisprocedure. A disadvantage of topical anesthe-tics is the vasoconstriction that occurs, whichmay make it difficult to see all the vessels. Thecombination of concurrent epidermal coolingand longer pulse durations will reduce the PDL-induced purpura. Patients should avoid trau-matizing the area after treatment and usepotent sunscreens. Treatments are generallyrepeated at 4- to 6-week intervals until vesselclearance has occurred. In general, mostpatients need between two and four treatments.

When using the KTP laser, the object is toheat seal the vessels under direct observation.This treatment requires more skill and trainingthan when using the PDL. The target vessel istraced with the laser beam using relatively smallspot sizes and repetition rates of 3–8 Hz. This

2


Fig. 2.15. a Lymphangioma on neck with prominenthemoglobin content (from S.W. Lanigan, Lasers inDermatology, Springer Verlag, London 2000). b Goodclearance of redness after pulsed dye laser treatment[from S.W. Lanigan (2000) Lasers in Dermatology,Springer Verlag, London]

a

b


31Personal Laser Technique

AGREEMENT/CONSENT FOR VASCULAR LASER TREATMENT

This agreement is between . . . . . . . . . . . . . Clinics and Doctor/Nurse . . . . . . . . . . . . . . . . . .

and (Mr, Mrs, Miss, Ms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Full name of patient) hereafter known as the patient.

1. Please read this form and the notes very carefully.2. If there is anything you do not understand about the explanation, or if you want more

information, please ask the clinician.3. Please check that all the information on the form is correct. If it is, and you feel happy with

all the explanations given please sign the form.

I the patient understand:1. The efficacy of the treatment with lasers varies from individual to individual and I understand that

a small percentage of patients may fail to respond to treatment and I as an individual may notrespond.

2. The treatment that I receive will be appropriate for my specific needs and will be given by anappropriately trained member of the clinic.

3. I understand I must give staff all the relevant medical details prior to treatment.4. A test patch may be necessary before commencing treatment with lasers.5. Following treatment the skin will be red, and if the Pulsed Dye laser has been used there will be

bruising. Swelling, blistering or crusting can occur and may take several days to resolve, the bruis-ing will take longer (as with any normal bruise).

6. Following treatment I will be given an aftercare sheet, which I should follow. Treated areas shouldnot be picked, scratched or traumatized and should be kept well moisturized.

7. Following treatment there may be hypopigmentation or hyperpigmentation (marked lighteningor darkening of the skin). While these reactions are not common there is a possibility that they canoccur. However, in time, these will usually fade away, although hypopigmentation may be perma-nent, I have been advised to use a total sunblock cream. I understand that following my course oftreatment I must wear sunblock for a minimum of six weeks to avoid possible postinflammatoryhyperpigmentation.

8. There is a 1%–5% risk of scarring with laser treatment of this kind.9. I understand that photographs will be taken before and during my treatment and that these pho-

tographs remain the property of the clinic although I may have access to them at any time.10. I understand that it is my responsibility prior to each treatment undertaken that I inform the

doctor or nurse of any changes in medical status, including medication or herbal remedies Iam taking.

11. I understand that if I have a suntan I may not be offered treatment; during treatment I have beenadvised not to use sunbeds.

The patient acknowledges that he/she has read and fully understood this agreement before signing itand has also read and understood any information sheets that they have been given.

I understand and agree to ………… terms of business and understand that I can request an additionalcopy of these terms at any time.

Patient’s signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fig. 2.16. Consent form


procedure is made easier using illuminatedmagnification. The aim is to see disappearance ofthe vessel without obvious epidermal changes,particularly white lines. A few small test areas are performed altering the fluence, pulse width,or repetition rate to achieve this. Starting para-meters could be 6–12 J/cm2, 3–6 ms with a 1- or 2-mm beam diameter. It may be helpful to useconcurrent cooling during the procedure. Imme-diately afterwards the patients will experiencequite marked reactive erythema. This can bereduced with cool dressings and topical aloevera. The erythema usually clears within24 hours, but some crusting may occur. Largeareas of crusting, blistering, or erosion suggestthat treatment has been too aggressive.

Port Wine Stains

Pretreatment assessment of the patient shouldinclude a record of previous treatment and itseffects. Argon laser treatment in particular canproduce frequent pigmentary disturbances,especially hypopigmentation, which may not beobvious in a partially treated PWS. It willbecome very obvious after successful PDL ther-apy. Scarring from previous treatment shouldbe recorded. The patient should be advised notto expose their skin to sunlight, as a tan overly-ing the PWS will interfere with therapy. Goodquality, standardized color photographs shouldbe taken at baseline and throughout the treat-ment course. It is useful to show the patients aportfolio of photographs to illustrate the proce-dure, in particular the bruising that will occurafter treatment.

The fluence to be used can be determined byperforming a test treatment over a range of flu-ences and reviewing the patients 6–8 weekslater. The lowest fluence producing lightening ofthe PWS can be used. As a general rule, with a 7-mm spot, fluences are in the range of4.5–8 J/cm2. The lower range of fluences shouldbe used in both the pediatric patient and moresensitive anatomic areas. As treatment pro-gresses with lightening of the PWS, it is reason-able to cautiously increase the fluence by0.25–0.5 J/cm2 to maintain improvement. It hasbeen shown, however, that not all PWS will clear

with PDL treatment. Repeatedly increasing thefluence in the nonresponding PWS will unfortu-nately increase the likelihood of an adversereaction, such as scarring.

PDL treatment causes discomfort or pain tothe patient described as a sharp stinging sensa-tion similar to being flicked with an elasticband. This stinging is replaced immediately by a hot pruritic sensation. Some individualsappear to be able to tolerate large treatmentswithout distress, but this should not beassumed. Two percent of patients surveyeddescribed severe pain after treatment despiteattempts at adequate analgesia (Lanigan 1995).

Topical anesthetic agents can assist patients.A eutectic mixture of local anesthetic (EMLA)cream containing lidocaine 2.5% and prilocaine2.5% has been shown effective in reducing PDL-induced pain (Lanigan and Cotterill 1989). Thecream must be applied thickly under occlusion tothe PWS for 90 min to 4 h before treatment. It isnot indicated for children under 1 year. An alter-native to EMLA is Ametop, a 4% amethocaine gelwhich has the advantage of a more rapid onset ofaction of 30–45 min. It also should be appliedunder occlusion and is not recommended ininfants under 1 month. There are concerns ofexcessive absorption of Ametop on highly vas-cular surfaces. Large areas should not be treatedwith this drug. Skin irritation and allergic rashescan occur from these creams. Despite correcttechniques, sensitive areas of the face, especiallythe upper lip and periorbital areas, may not beadequately anesthetized with topical creams.Additional infiltrational and nerve block anes-thesia can be used to supplement the topicalagents; unfortunately this in itself can be trau-matic for the patient.

In children these topical anesthetic tech-niques are often not enough. In my experiencethe majority will require general anesthesia.Some authors advocate sedation in combinationwith other anesthetic techniques without gen-eral anesthesia. The procedure can cause an-xiety in children as well as discomfort, as theireyes are covered while the laser emits noises aswell as light during the treatment. After the testtreatment, each further laser procedure involvesplacement of laser impacts over the whole PWSusing the lowest fluence to achieve lightening.

2



This needs to be reduced over the eyelids, upperlip, and neck. Each impact of the laser producesa visible purpuric discoloration, which appearseither immediately or within minutes. This is asharply demarcated circle, which allows theoperator to place the next spot adjacent to it.For PDL with gaussian beam profiles, spotsshould be overlapped by approximately 10%.This will reduce the tendency in some patientsto a spotty appearance as the PWS clears. OtherPDLs may have different beam profiles and adecision on whether to overlap spots can onlybe made on the basis of knowledge of the beamenergy profile.

After treatment of the PWS, most patientswill note purpura for 7–14 days. A minority willhave purpura up to 28 days. Small areas maycrust or weep, but large areas of blistering sug-gest reduction of the fluence at the next treat-ment. The greatest reaction after treatmentoccurs early in the course of therapy or afterincreasing the fluence. After each treatment thePWS should be lighter in appearance. Treat-ments are repeated at an interval of about8 weeks. Gradually through a course of treat-ment the lightening after each treatment getsless until no further progress between visits canbe seen. The majority of patients who experi-enced satisfactory lightening of their PWS do soin their first four to ten treatments. Althoughimprovements can occur beyond 20 treatments,the small benefits should be balanced againstthe morbidity produced by treatment (Kauvarand Geronemus 1995).

Postoperative Care

There is minimal postoperative care requiredafter treatment with today’s vascular lasers. Inmost cases the epidermis will be intact, but in asignificant minority there will be some blister-ing. The first consideration after treatment is todeal with discomfort. This pain can be lessenedby cooling the skin either with refrigerated airblowing, cold compresses, spraying with water,or aloe vera. With the PDL this cooling can berepeated until pain and discomfort has eased.The area can then be kept moisturized with anemollient. If treatment has been performed

close to or around the eye there will be a risk ofperiocular edema. Patients should be instructedto sleep with an extra pillow to encourage gravi-tational removal of leaked edema fluid. The areacan be washed gently with soap and water. Nomake-up can be applied until after any crustinghas settled.

With the KTP laser and other continuouswave lasers there may be some blistering andcrusting. The operator may consider use oftopical antibiotics. There is little evidence tosuggest this is required. Patients can also beinstructed to take analgesia as needed. Allpatients should be instructed on the absoluteimportance of not picking or scratching attreated areas. They will also need to use a totalsunblock preparation to lessen postinflamma-tory hyperpigmentation. Inability to complywith this will significantly reduce the effective-ness of the procedure.

Complications

All persistent side effects are generally due topigmentary changes and/or scarring. Postin-flammatory hyperpigmentation is the common-est side effect and has been reported to occurbetween 10% and 27% of the time in treatedpatients. Hyperpigmentation is most commonin treated PWS on the leg and is reversible.Hypopigmentation occurs in up to 2.6% ofpatients and generally occupies only a smallarea of the treated lesion. Atrophic scarringoccurs in 1%–5%; hypertrophic scarring in lessthan 1% of PDL-treated patients. Atrophic tex-tural changes often improve spontaneously over6–12 months.

Rarer side effects occasionally reported in-clude atrophie blanche-like scarring, dermati-tis, and keloid formation during Isotretinointherapy. A case has been reported of leg ulcera-tion after PDL treatment of a vascular malfor-mation.

Even when using long PDL to lessen pur-pura, significant facial edema can develop.Alam (Alam et al. 2003) reported postoperativeedema in 87% of 15 patients with purpuric-freelaser parameters. This included 27% of patientswith symptomatic eye swelling.

33Complications


The KTP laser, which has longer pulse dura-tions and a wavelength which is also absorbedby melanin, has a higher incidence of mild sideeffects due to epidermal injury. These may bepain, redness, vesiculation, and crusting. Theseside effects are transient, and in the treatmentof facial telangiectasia are not generally associ-ated with long-term problems. There is a risk ofatrophic scarring with this laser. This will occurmore commonly when treating paranasal areas,as these vessels frequently require more aggres-sive treatment parameters. Concurrent epider-mal cooling will significantly reduce the inci-dence of side effects after treatment with thislaser.

The Future

Significant advances have been made in recentyears in the technological development of lasersthat can target cutaneous vascular disorders byselective photothermolysis. However, results inPWS in particular can still be disappointing.

A number of investigators are pursuing agreater understanding of the vascular responsesof PWS to lasers through noninvasive imagingand mathematical modeling. The eventual goalis to tailor laser therapy to individual PWS char-acteristics by altering both laser type andparameter settings. For example, some havedesigned a photoacoustic probe which allows invivo determination of PWS depth. Others havedemonstrated that videomicroscopy can beused to assess treatment response in relation tovessel depth. Still others have used opticalDoppler tomography to perform real-timeimaging of blood flow within PWS. Partialrestoration of blood flow occurring immedi-ately or shortly after laser exposure was indica-tive of reperfusion due to inadequate vesselinjury. By using this imaging method, they pro-posed that PWS could be retreated with higherfluences in a step-wise manner, until a perma-nent reduction in blood flow occurs. This wouldbe indicative of irreversible vessel damage andexpected clinical lightening.

Despite the recent advances made, itremains difficult to fully eradicate PWS withour current armamentarium of lasers and non-

coherent light sources. Alternative therapiesincluding photodynamic therapy are being con-sidered. The considerable work in this fieldreinforces the notion that PWS display consid-erable clinical and histological heterogeneity.This is likely to mean that a number of ap-proaches will be needed to optimize treatmentof PWS. There is a clear need for further trials,particularly to establish the role of noncoherentlight sources and lasers, other than the PDL. Toensure comparability of future studies, com-mon objective clinical outcome measures needto be employed, together with, where possible,noninvasive imaging techniques which canincrease our understanding of laser-PWS inter-actions. However, we should also recognize the importance of incorporating measures ofpatient satisfaction into study design, sinceafter all, it is patients’ own assessments whichultimately reflect treatment outcomes.

References

Alam M, Dover JS, Arndt KA (2003) Treatment of facialtelangiectasia with variable-pulse high-fluencepulsed-dye laser: comparison of efficacy with flu-ences immediately above and below the purpurathreshold. Dermatol Surg 29(7):681–684

Alster TS, Wilson F (1994) Treatment of port-wine stainswith the flashlamp-pumped PDL: extended clinicalexperience in children and adults. Ann Plast Surg32(5):478–484

Anderson RR, Parish JA (1981) Microvasculature can beselectively damaged using dye lasers: a basic theoryand experimental evidence in human skin. LasersSurg Med 1:263–276

Ashinoff R, Geronemus RG (1991) Capillary heman-giomas and treatment with the flash lamp-pumpedpulsed dye laser. Arch Dermatol 127(2):202–205

Barlow RJ, Walker NP, Markey AC (1996) Treatment ofproliferative hemangiomas with the 585 nm pulseddye laser. Br J Dermatol 134(4):700–704

Batta K, Goodyear HM, Moss C, Williams HC, Hiller L,Waters R (2002) Randomized controlled study ofearly pulsed dye laser treatment of uncomplicatedchildhood hemangiomas: results of a 1-year analy-sis. Lancet 360(9332):521–527

Bernstein EF (2000) Treatment of a resistant port-winestain with the 1.5-msec pulse duration, tunable,pulsed dye laser. Dermatol Surg 26(11):1007–1009

Bjerring P, Christiansen K, Troilius A (2003) Intensepulsed light source for the treatment of dye laser

2



resistant port-wine stains. J Cosmet Laser Ther5:7–13

Chan HH, Chan E, Kono T, Ying SY, Wai-Sun H (2000)The use of variable pulse width frequency doubledNd:YAG 532 nm laser in the treatment of port-winestain in Chinese patients. Dermatol Surg 26(7):657–661

Dierickx CC, Casparian JM, Venugopalan V, FarinelliWA, Anderson RR (1995) Thermal relaxation of portwine stain vessels probed in vivo: the need for 1–10millisecond laser pulse treatment. J Invest Dermatol105:709–714

Eremia S, Li C, Umar SH (2002) A side-by-side compara-tive study of 1064 nm Nd:YAG, 810 nm diode and755 nm alexandrite lasers for treatment of 0.3–3 mmleg veins. Dermatol Surg 28(3):224–230

Fitzpatrick RE, Lowe NJ, Goldman MP, Borden H,Behr KL, Ruiz-Esparza J (1994) Flashlamp-pumpedpulsed dye laser treatment of port-wine stains. JDermatol Surg Oncol 20(11):743–748

Geronemus RG, Quintana AT, Lou WW, Kauvar AN(2000) High-fluence modified pulsed dye laser pho-tocoagulation with dynamic cooling of port winestains in infancy. Arch Dermatol 136:942–943

Goldberg DJ, Meine JG (1999) A comparison of four fre-quency-doubled Nd:YAG (532 nm) laser systems fortreatment of facial telangiectases. Dermatol Surg25(6):463–467

Katugampola GA, Lanigan SW (1997) Five years’ experi-ence of treating port wine stains with the flashlamp-pumped pulsed dye laser. Br J Dermatol 137:750–754

Kauvar AN, Geronemus RG (1995) Repetitive pulsed dyelaser treatments improve persistent port-winestains. Dermatol Surg 21(6):515–521

Lanigan SW (1996) Port wine stains on the lower limb:response to pulsed dye laser therapy. Clin Exp Der-matol 21(2):88–92

Lanigan SW, Cartwright P, Cotterill JA (1989) Continu-ous wave dye laser therapy of port wine stains. Br JDermatol 121(3):345–352

Lupton JR, Alster TS, Romero P (2002) Clinical compar-ison of sclerotherapy versus long-pulsed Nd:YAGlaser treatment for lower extremity telangiectasias.Dermatol Surg 28(8):694–697

McMeekin TO (1999) Treatment of spider veins of the legusing a long-pulsed Nd:YAG laser (Versapulse) at532 nm. J Cutan Laser Ther 1(3):179–180

Omura NE, Dover JS, Arndt KA, Kauvar AN (2003)Treatment of reticular leg veins with a 1064 nm long-pulsed Nd:YAG laser. J Am Acad Dermatol 48(1):76–81

Raulin C, Schroeter CA, Weiss RA, Keiner M, Werner S(1999) Treatment of port wine stains with a nonco-herent pulsed light source: a retrospective study.Arch Dermatol 135:679–683

Rogachefsky AS, Silapunt S, Goldberg DJ (2002) Nd:YAGlaser (1064 nm) irradiation for lower extremitytelangiectasias and small reticular veins: efficacy asmeasured by vessel color and size. Dermatol Surg28(3):220–223

Varma S, Lanigan SW (2000) Laser therapy of telan-giectatic leg veins: clinical evaluation of the 810 nmdiode laser. Clin Exp Dermatol 25(5):419–422

Weiss RA, Dover JS (2002) Laser surgery of leg veins.Dermatol Clin 20(1):19–36

West TB, Alster TS (1998) Comparison of the long-pulsedye (590–595 nm) and KTP (532 nm) lasers in thetreatment of facial and leg telangiectasias. DermatolSurg 24(2):221–226

35References


History

Selective Photothermolysis

The idea of treating cutaneous pigmentedlesions with lasers was first tested in the early1960s with the use of a normal mode ruby laser.This research indicated that the target was themelanosome. Unfortunately, due to laboratorydifficulties, further research was halted.

In the past 15 years selective photothermo-lysis has largely transformed dermatologic lasersurgery. The term selective photothermolysisdescribes site-specific, thermally mediated in-jury of microscopic tissue targets by selectivelyabsorbed pulses of radiation (Anderson 1983).Three basic elements are necessary to achieveselective photothermolysis: (1) a wavelengththat reaches and is preferentially absorbed bythe desired target structures, (2) an exposure

duration less than or equal to the time neces-sary for cooling of the target structures, and (3)sufficient fluence to reach a damaging tempera-ture in the targets. When these criteria are met,selective injury occurs in thousands of micro-scopic targets, without the need to aim the laserat each one.

At wavelengths that are preferentially ab-sorbed by chromophoric structures such asmelanin-containing cells or tattoo-ink particles,heat is created in these targets. As soon as heatis created, however, it begins to dissipate byconduction. The most selective target heating isachieved when the energy is deposited at a ratefaster than the rate for cooling of the targetstructures. In contrast to diffuse coagulationinjury, selective photothermolysis can achievehigh temperatures in structures or individualcells with little risk of scarring because grossdermal heating is minimized.

Pigmented Lesion Removal by Selective Photothermolysis

Because melanin absorbs light at a wide rangeof wavelengths – from 250 to 1200 nm – severallasers or intense pulsed light sources can effec-tively treat pigmented lesions. For tattoos, lightabsorption depends on the ink color, but thepredominant color (blue-black) also absorbswell throughout the 532–1064-nm range. Almostany laser with sufficient power can be used toremove benign pigmented lesions of the epider-mis. The selective rupture of skin melanosomeswas first noted by electron microscopy in 1983,after 351-nm, submicrosecond excimer laserpulses of only about 1 J/cm2. At fluences damag-ing melanocytes and pigmented keratinocytes,epidermal Langerhans cells apparently escapeinjury.

Laser Treatment of Pigmented LesionsChristine C. Dierickx

3

▲

Core Messages Accurate diagnosis of pigmented

lesions is mandatory before lasertreatment.

For some pigmented lesions, lasertreatment may be the only treatmentoption.

Tattoos respond well to Q-switchedlasers.

Amateur and traumatic tattoosrespond more readily to treatmentthan do professional tattoos.

Cosmetic tattoos should be ap-proached with caution.

Treatment of melanocytic nevi remainscontroversial, but worth pursuing.


With regard to wavelength, absorption bymelanin extends from the deep UV through vis-ible and well into the near-IR spectrum. Acrossthis broad spectrum, optical penetration intoskin increases from several micrometers to sev-eral millimeters. One would therefore expectmelanosomes and the pigmented cells contain-ing them to be affected at different depthsacross this broad spectrum.

A variety of thermally mediated damagemechanisms are possible in selective photo-thermolysis, including thermal denaturation,mechanical damage from rapid thermal expan-sion or phase changes (cavitation), and pyroly-sis (changes in primary chemical structure).Mechanical damage plays an important role inselective photothermolysis with high-energy,submicrosecond lasers for tattoo and pigmentedlesion removal. The rate of local heating andrapid material expansion can be so severe thatstructures are torn apart by shock waves, cavi-tation, or rapid thermal expansion.

Grossly, the immediate effect of submi-crosecond near-UV, visible, or near-IR laserpulses in pigmented skin is immediate whiten-ing. This response correlates very well with themelanosome rupture seen by electron micro-scopy and is therefore presumably a direct con-sequence of melanosome rupture. A nearlyidentical but deeper whitening occurs with Q-switched laser exposure of tattoos, which likemelanosomes consist of insoluble, submicrom-eter intracellular pigments. Although the exactcause of immediate whitening is unknown, it isalmost certainly related to the formation of gasbubbles that intensely scatter light. Over severalto tens of minutes, these bubbles dissolve, caus-ing the skin color to return to normal or nearlynormal. In addition, pyrolysis may occur at theextreme temperatures reached within melano-somes or tattoo ink particles, directly releasinggases locally. Regardless of its cause, immediatewhitening offers a clinically useful immediateendpoint that apparently relates directly tomelanosome or tattoo ink rupture (Fig. 3.1).

Melanin in both the epidermis (as in cafe-au-lait macules and lentigines) and the dermis(as in nevus of Ota), as well as dermal tattooparticles, is an important target chromophorefor laser selective photothermolysis. Clinically,

selective photothermolysis is highly useful forepidermal and dermal lesions in which cellularpigmentation itself is a cause. These includelentigines, cafe-au-lait macules (which display ahigh rate of recurrence), nevus spilus, Beckernevi, blue nevi, and nevus of Ota. However,selective thermolysis has only been variablyeffective for dermal melasma, postinflamma-tory hyperpigmentation, or drug-induced hyper-pigmentation.


Lasers and Intense Pulsed Light SourcesUsed to Treat Pigmented Lesions and Tattoos

■ Continuous-Wave Lasers (CW Lasers)

Although Q-switched lasers are now the modal-ity of choice for most pigmented lesions, conti-nuous-wave and quasi-continuous lasers, whenused properly, can also be effective (Tables 3.1,3.2, 3.3). The lasers include the CW argon laser(488 and 514 nm), a CW dye laser (577 and585 nm), a CW krypton (521–530 nm), a quasi-CW copper vapor laser (510 and 578 nm), anerbium (2940 nm) and CO2 (10,600 nm) laser.

The CW and quasi-CW visible light laserscan be used to selectively remove pigmentedlesions. However, because of the shorter wave-lengths of these lasers, they penetrate onlysuperficially. Thus, they are effective only for

3

38 Chapter 3 Laser Treatment of Pigmented Lesions

Fig. 3.1. Immediate whitening after laser treatment


39Currently Available TechnologyTa

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3

40 Chapter 3 Laser Treatment of Pigmented LesionsTa

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41Currently Available TechnologyTa

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3

42 Chapter 3 Laser Treatment of Pigmented LesionsTa

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3


epidermal pigmented lesions. Furthermore, inthe absence of reproducible spatial thermalinjury confinement, the risk of scarring andpigmentary changes is significant in the handsof inexperienced operators.

The pigment-nonselective erbium and CO2lasers can be used to remove epidermal pig-ment effectively because of the ability to targetH2O in the epidermis. The nonspecific thermaldamage leads to destruction of the lesion withdenuding of the epidermis. Pigment is thusdamaged as a secondary event. This destructionis followed by healing that may have some ery-thema and possible pigmentary and texturalchanges.

■ Q-Switched Lasers

The fundamental principle behind laser treat-ment of cutaneous pigment and tattoos is selec-tive destruction of undesired pigment withminimal collateral damage. This destruction isachieved by the delivery of energy at theabsorptive wavelength of the selected chro-mophore. The exposure time must also be lim-ited so that the heat generated by the laser–tis-sue interaction is confined to the target.

The target chromophore of pigmentedlesions is the melanosome and that of tattoos, isthe insoluble, submicrometer intracellular pig-ments. Q-switched lasers produce pulses in thenanosecond range. These high peak powerlasers deliver light with a pulse width shorterthan the approximately 1-ms thermal relaxationtime of the melanosomes or the tattoo ink par-ticles. Various Q-switched lasers (532-nm fre-quency-doubled Q-switched Nd:YAG, 694-nmruby, 755-nm alexandrite, 1064-nm Nd:YAG) aretherefore used for the treatment of various epi-dermal, dermal, and mixed epidermal and der-mal pigmented lesions and tattoos (Table 3.2).

To date, Q-switched lasers have been shownto treat both epidermal and dermal pigmentedlesions effectively in a safe, reproducible fash-ion. Q-switched lasers used for the treatment of superficial pigmented lesions include the 532-nm frequency-doubled Q-switched Nd:YAG,the 694-nm ruby, and the 755-nm alexandritelasers. Strong absorption of light at these wave-lengths by melanin makes these lasers an excel-

lent treatment modality for superficial pig-mented lesions. The Q-switched 694-nm ruby,755-nm alexandrite and 1064-nm Nd:YAG lasersare useful for treating deeper pigmented lesionssuch as nevus of Ota and tattoos. The Q-switched 1064 nm laser should be used whentreating patients with darker skin, because itreduces the risk of epidermal injury and pig-mentary alteration.

■ Pulsed-Dye Laser

The short wavelength (510 nm) and 300-ns pig-ment lesion dye laser (PLDL) is highly effectivein the treatment of superficial, pigmentedlesions and red tattoos, but is no longer com-mercially available.

■ Long-Pulsed Lasers

To target large, pigmented lesions, such as hairfollicles or nevocellular nevi, lasers with longer(millisecond- as opposed to nanosecond-range)pulse durations are more suitable (Table 3.1).These include the long-pulsed 694-nm ruby,755-nm alexandrite, 810-nm diode and 1064-nmNd:YAG lasers. The millisecond pulse widthmore closely matches the thermal relaxationtime of the hair follicles or the nested melano-cytes. Collateral thermal damage results ininjury to the stem cells located in the outer rootsheath or the melanocytes adjacent to the targetarea that may actually not contain melanin.However, it is unlikely that every nevus cell isdestroyed. Cautious follow-up of nevi treatedwith laser light is necessary.

■ Intense Pulsed Light Sources

Intense pulsed light (IPL) systems are high-intensity light sources, which emit polychro-matic light (Table 3.3). Unlike lasers, these flash-lamps work with noncoherent light over a broadwavelength spectrum of 515–1200 nm. Because ofthe wide spectrum of potential combinations ofwavelengths, pulse durations, pulse intervals,and fluences, IPLs have proven to very efficientlytreat photodamaged pigmented lesions like solarlentigines and generalized dyschromia.



Indications

There are many types of pigmented lesions.Each varies in the amount, depth, and density of melanin or tattoo ink distribution. Theapproach to the treatment of cutaneous pig-mentation depends on the location of the pig-ment (epidermal, dermal, or mixed), the way itis packaged (intracellular, extracellular) and thenature of the pigment (melanin or tattoo parti-cles). The benign pigmented lesions which dorespond well to laser treatment include: len-tigines, ephelides (freckles), nevus of Ota,nevus of Ito, and “blue” nevus. Varying resultsare obtained in café-au-lait maculae, nevusspilus, and nevus of Becker. Treatment of con-genital and acquired nevi is still controversialbecause of the risk of incomplete destruction of deeper-situated nevus cells. Hyperpigmen-tation, like melasma and postinflammatoryhyperpigmentation, only shows a moderateresponse. Finally, laser treatment in itself canresult in postinflammatory hyperpigmentation.

Epidermal Pigmented Lesions

In general, epidermal pigment is easier to erad-icate than dermal pigment because of its prox-imity to the skin’s surface. Several lasers caneffectively treat epidermal lesions. These in-clude the Q-switched laser systems, pulsed visi-ble light lasers and flashlamps, CW lasers, and

CO2 or erbium lasers. The goal is to removeunwanted epidermal pigmentation, and as longas the injury is above the dermal-epidermaljunction, it will heal without scarring.

■ Lentigo Simplex, Solar Lentigo

Lentigines are benign macular epidermallesions caused by ultraviolet light, They containmelanin within keratinocytes and melanocytes.The superficial nature of lentigines allows theuse of several lasers, including frequency-doubled Q-switched Nd:YAG, Q-switched ruby,alexandrite, Nd:YAG, pulsed 510 nm, CW argon,CO2 or erbium, and other pulsed visible-lightlasers. Labial melanocytic macules are similarlesions found on the mucosal surface andrespond well to treatment with Q-switchedlasers (Fig. 3.2).

Lentigines frequently clear with 1–3 treat-ments. The argon laser (488 nm, 514 nm), the510-nm pigment laser, and the 532-nm greenlight lasers treat lentigines with superior effi-cacy, especially lightly pigmented lesions inwhich less chromophore is present. Theseshorter wavelength lasers are better absorbedby melanin but have less penetration. Use of abroadband sunscreen helps prevent new lentig-ines from occurring as well as the recurrence oftreated lesions.

Correct diagnosis is a primary concernwhen treating lentigines. Lentigo malignashould not be treated with laser. Although ini-tially one can obtain excellent cosmetic results,

3


Fig. 3.2. Labial lentigo. Complete clearing after single treatment with a Q-switched alexandrite laser

a b


benign finding or associated with certain geno-dermatoses (e. g., neurofibromatosis). Histolog-ically, hypermelanosis is present within the epi-dermis and giant melanosomes may be presentin both basal melanocytes and keratinocytes.Although café-au-lait macules are thin, super-ficial lesions, they are notoriously difficult totreat, and multiple treatments are required foreven the possibility of complete eradication.There is probably a cellular influence in the der-mis that triggers the pigmentation in the moresuperficial cells. This underlying biology mayalso explain why pigment recurrences are oftenobserved. Lesions may remain clear for up to ayear with spontaneous or UV-induced recur-rences in more than 50% of cases. Patient edu-cation is important so that the possibility ofrecurrence is understood. However, given thesignificant disfigurement associated with manyof these larger facial lesions, laser treatment isan excellent treatment option. Q-switchedlasers with wavelengths of 532 nm or the pulsed510-nm (Alster 1995) laser can adequately treatthe café-au-lait macules (Fig. 3.3). Erbium lasersuperficial abrasion of the epidermis of a “Q-switched laser-resistant” cafe-au-lait maculehas also been reported to be a successful treat-ment modality.

■ Nevus Spilus

When darker-pigmented macules or papules(junctional or compound melanocytic nevi) liewithin the café-au-lait macule, the lesion iscalled nevus spilus. The lasers used for café-au-lait macules have also been used for nevusspilus (Carpo et 1999). The darker lesions tendto respond better than the lighter café-au-lait

recurrences are frequently seen. Lentigomaligna frequently has an amelanotic portion,which is not susceptible to laser treatment andwill allow for recurrence. These cases empha-size the importance of careful clinical assess-ment before any laser surgery and the need toadvise patients to return for evaluation if pig-mentation does return.

■ Seborrheic Keratosis

Seborrheic keratoses are benign epidermallesions that have melanin distribution similar tolentigines and a thickened, hyperkeratotic epi-dermis. Liquid nitrogen cryotherapy and othersurgical methods like CO2 or erbium laser areuseful in treating these lesions, but are not prac-tical modalities to tolerate in patients who havelarge numbers of lesions. Using pulsed green orQ-switched lasers offer the possibility toquickly and efficiently destroy hundreds of flatpigment seborrheic keratoses.

■ Ephelides

Ephelides or freckles are responsive to Q-switched laser treatment. Patients who tend tofreckle are likely to refreckle with any sun expo-sure. At a follow-up of 24 months after lasertreatment, 40% of patients showed partialrecurrence. However, all the patients main-tained >50% improvement. The use of a broadband sunscreen is therefore indicated.

■ Café-au-Lait Macules

Café-au-lait macules are light to dark brown flathypermelanotic lesions and may be a solitary

45Indications

Fig. 3.3. Café-au-lait macule. Complete clearing after four treatments

a b c


macule. There can be complete removal of thejunctional or compound nevus portion but noimprovement in the cafe-au-lait portion. Casesof nevus spilus transformation into melanomahave been reported in the literature. These casesemphasize the need for careful clinical assess-ment before any laser surgery, and continuedevaluation after laser treatment.

Dermal-Epidermal Pigmented Lesions

■ Becker’s Nevus

Becker’s nevus is an uncommon pigmentedhamartoma that develops during adolescenceand occurs primarily in young men. The nevusis characterized by hypertrichosis and hyper-pigmentation and is usually located unilaterallyover the shoulder, upper arm, scapula, or trunk.These lesions often require the use of millisec-ond pigment-specific lasers for treatment ofthe hair, but the pigment lightening is variable.Test sites with a variety a pigment-specific Q-switched and millisecond lasers or flashlamps isrecommended to determine which one (or com-bination) will be the best treatment option(Fig. 3.4). More recently, ablation of the epider-mis and superficial dermis with an erbium laser

has been shown to result in occasional completepigment clearance with a single treatment.

■ Postinflammatory Hyperpigmentation

Treatment of postinflammatory hyperpigmen-tation with laser is unpredictable and oftenunsatisfactory. Furthermore, patients withhyperpigmentation following trauma are likelyto respond to laser irradiation with an exacer-bation of their pigment. The use of test sites istherefore recommended before an entire area istreated.

■ Postsclerotherapy Hyperpigmentation

Cutaneous pigmentation commonly occurs fol-lowing sclerotherapy of varicose veins. Pigmen-tation most likely reflects hemosiderin deposi-tion, which is secondary to extravasation of redblood cells through the damaged endothelium(Goldman et al. 1987). Hemosiderin has anabsorption spectrum that peaks at 410–415 nmfollowed by a gradually sloping curve through-out the remainder of the visible spectrum. Sev-eral Q-switched or pulsed lasers have thereforebeen reported to result in significant resolutionof hemosiderin pigmentation (Goldman 1987;Sanchez et al. 1981).

■ Melasma

Melasma is an acquired, usually symmetriclight to dark brown facial hypermelanosis. It isassociated with multiple etiologic factors (preg-nancy, racial, and endocrine), and one of theprimary causes of its exacerbation appears to beexposure to sunlight. Although the results afterQ-switched laser treatment are usually initiallyencouraging, repigmentation frequently occurs.

Destruction of the abnormal melanocyteswith erbium:YAG or CO2 laser resurfacing has been attempted. It effectively improvesmelasma, however, there is almost universalappearance of transient postinflammatoryhyperpigmentation which necessitates promptand persistent intervention. A combination of pulsed CO2 laser followed by Q-switchedalexandrite laser (QSAL) treatment to selec-tively eliminate the dermal melanin with the

3


Fig. 3.4. Beckers nevus. Good clearing in test spotwith long-pulsed alexandrite laser (round spots) andin test spot with IPL (rectangles)


alexandrite laser has also been examined. Com-bined pulsed CO2 laser and QSAL showed abetter result than CO2 or QSAL alone, but wasassociated with more frequent adverse effects.Long-term follow-up and a larger number ofcases are required to determine its efficacy andsafety for refractory melasma.

■ Nevocellular Nevi

Although laser treatment of many pigmentedlesions is accepted, treatment of nevocellularnevi is an evolving field with much controversy.It has yet to be determined if laser treatmentincreases the risk of malignant transformationby irritating melanocytes or decreases it bydecreasing the melanocytic load. For this rea-son, laser treatment of nevi should be under-taken cautiously.

■ Congenital Melanocytic Nevi

The management of giant congenital melano-cytic nevi (GCMN) remains difficult. It hasbeen well proved that there is an increased riskof malignant changes among patients withthese lesions, although the amount of increasedrisk for each individual patient is not clear.There is also a balance to be achieved betweenlimiting the risk of malignant change and mini-mizing the disfiguring appearance of theselesions. Sometimes GCMN are too large to beremoved by multiple surgical excisions or use ofosmotic tissue expanders. Removal of superfi-cial nevus cells is possible by dermabrasion,curettage, shave excision, or laser. High energyCO2 laser therapy is less traumatic and can pro-duce acceptable cosmetic results. Erbium lasertreatment can also be used because it causes lessthermal damage and faster wound healing.These techniques, although improving the cos-metic appearance, do not remove all nevus cellnests. Therefore they do not completely elimi-nate the risk of malignant transformation.

Treatment of giant, congenital nevi with along-pulsed ruby laser has been reported. Thesesystems show promise with follow-up for atleast 8 years after laser treatment. There hasbeen no evidence of malignant change in thetreated areas. However, the longer laser-emitted

pulse widths can lead to thermal damage of sur-rounding collagen with resultant scar forma-tion. This is especially true with darker, thickerlesions with a deep dermal component, whichare often the ones whose removal is mostdesired. Combination therapy is thereforeunder investigation where Q-switched or resur-facing lasers may be used first to reduce thesuperficial component, followed by one of themillisecond pigment-specific lasers.

■ Congenital and Acquired Small Melanocytic Nevi

The Q-switched ruby, alexandrite, and Nd:YAGlasers have been studied for treatment of mela-nocytic nevi (Goldberg 1995). Although clear-ing rates as high as 80% have been reported,short-pulsed lasers are not recommended fornevi because of the high postlaser treatmentrecurrence rates. Melanocytic nevi often havenested melanocytes with significant amounts ofmelanin and therefore may act more as a largerbody than as individual melanosomes. It hastherefore been suggested that longer pulsedruby, alexandrite, or diode lasers or Q-switchedlasers in combination with longer-pulsed lasersmay provide a more effective treatment withfewer recurrences. All laser systems have beenpartially beneficial. No lesions have had com-plete histologic removal of all nevomelanocytes(Duke et al. 1999).

Dermal Pigmented Lesions

The development of Q-switched lasers has revo-lutionized the treatment of dermal melanocyto-sis. The dendritic cells found deep in the dermisare particularly sensitive to short-pulsed laserlight, frequently resulting in complete lesionalclearing without unwanted textural changes.

■ Nevus of Ota, Nevus of Ito

Nevus of Ota is a form of dermal melanocytichamartoma that appears as a bluish discolor-ation in the trigeminal region. Histologic exam-ination shows long, dermal melanocytes widelyscattered in the upper half of the dermis. Nevus

47Indications


of Ito is a persistent grayish-blue discolorationwith the same histologic characteristics ofnevus of Ota, but is generally present on theshoulder or upper arm, in the area innervatedby the posterior supraclavicular and lateralbrachial cutaneous nerves.

The dermal melanocytes found within theselesions contain melanin and are highlyamenable to treatment with Q-switched ruby(Geronemus 1992; Goldberg 1992), alexandrite(Alster 1995), or Nd:YAG lasers. Four to eighttreatment sessions are typically required totreat these lesions. Possible side effects likepostinflammatory hyperpigmentation, hypo-pigmentation or scarring, and recurrences areinfrequent. Although there have been noreports of successful treatment of nevus of Ito,treatment with Q-switched lasers should be effi-cacious.

■ Blue Nevi

Blue nevi are benign melanocytic lesions thatarise spontaneously in children or young adults.The melanocytes are deep within the dermisand the blue-black color results from the Tyn-dall light scattering effect of the overlying tis-sues. Although extremely rare, malignant bluenevi have been reported. Because of theirbenign nature, blue nevi are usually removedfor cosmetic reasons. The deep dermalmelanocytes respond well to Q-switched lasertreatment, as long as the lesion does not extendinto the deep subcutaneous tissue.

■ Acquired Bilateral Nevus of Ota-Like Macules (ABNOMs)

Acquired bilateral nevus of Ota-like macules(ABNOM), also called nevus fuscoceruleuszygomaticus or nevus of Hori, is a commonAsian condition that is characterized by bluishhyperpigmentation in the bilateral malarregions. Unlike nevus of Ota, ABNOM is anacquired condition that often develops after20 years of age, involves both sides of the face,and has no mucosal involvement. Histologi-cally, active melanin-synthesizing dermalmelanocytes are dispersed in the papillary andmiddle portions of the dermis. Since these

lesions are histologically a form of dermalmelanocytosis like nevus of Ota, melanin-tar-geting lasers should be effective in the treat-ment. Although promising results in the treat-ment of Hori’s nevus with Q-switched ruby,alexandrite, and Nd:YAG lasers have beenreported, the treatment responses have beennoted to be less effective than that of nevus ofOta. Multiple laser sessions are necessary toobtain cosmetically desired improvement. Ahigher rate of postinflammatory hyperpigmen-tation is often present after laser treatments.

Tattoos

The popularity of tattoos is burgeoning with20–30 million tattooed individuals in theWestern world. Requests for removal can beexpected to rise concurrently with increasedapplications. Despite their relatively easy acqui-sition, the removal of tattoos has long been areal problem. Laser removal of tattoos is poten-tially a more cosmetically acceptable method ofremoving tattoos than surgical excision or der-mabrasion.

■ Tattoo Pigments

Tattoos, a form of exogenous pigment, are usu-ally composed of multiple colors and variousdyes. In contrast to drugs and cosmetics, tattoopigments have never been controlled or regu-lated in any way, and the exact composition ofa given tattoo pigment is often kept a “tradesecret” by the manufacturer. In most cases,neither the tattoo artist nor the tattooed patienthas any idea of the composition of the tattoopigment.

Until recently, most coloring agents in tattoopigment were inorganic heavy metal salts andoxides, like aluminum, titanium, cadmium,chromium, cobalt, copper, iron, lead, and mer-cury. There has been a shift in recent years awayfrom these agents toward organic pigments,especially azo- and polycyclic compounds.These pigments are considered safer and welltolerated by the skin, although allergic reactionsand phototoxicity occur.

3



■ Laser Removal of Tattoos

For Q-Switched laser tattoo treatment to beeffective, the absorption peak of the pigmentmust match the wavelength of the laser energy.Similar colors may contain different pigments,with different responses to a given laser wave-length, and not all pigments absorb the wave-lengths of currently available medical lasers.

Tattoos absorb maximally in the followingranges: red tattoos, from 505 to 560 nm (greenspectrum); green tattoos, from 630 to 730 nm(red spectrum); and a blue-green tattoo, in tworanges from 400 to 450 nm and from 505 to560 nm (blue-purple and green spectrums,respectively).Yellow tattoos absorbed maximallyfrom 450 to 510 nm (blue-green spectrum),purple tattoos-absorbed maximally from 550 to 640 nm (green-yellow-orange-red spectrum),blue tattoos absorbed maximally from 620 to730 nm (red spectrum), and orange tattoos ab-sorbed maximally from 500 to 525 nm (greenspectrum). Black and gray absorbed broadly inthe visible spectrum, but these colors most effec-tively absorb 600- to 800-nm laser irradiation.

Three types of lasers are currently used fortattoo removal: Q-switched ruby laser (694 nm),Q-switched Nd:YAG laser (532 nm, 1064 nm),and Q-switched alexandrite (755 nm) laser(Adrian 2000). The Q-switched ruby andalexandrite lasers are useful for removing black,blue, and green pigment (Alster 1995). The Q-switched 532-nm Nd:YAG laser can be used toremove red pigments, and the 1064-nm Nd:YAGlaser is used for removal of black and blue pig-ments (Kilmer et al. 1993). Since many wave-lengths are needed to treat multicolored tattoos,not one laser system can be used alone toremove all the available inks (Kilmer 1993;Levine 1995).

There is still much to be learned aboutremoving tattoo pigment. Once ink is im-planted into the dermis, the particles are foundpredominantly within fibroblasts, macro-phages, and occasionally as membrane-boundpigment granules.

Exposure to Q-switched lasers producesselective fragmentation of these pigment-con-taining cells. The pigment particles are reducedin size and found extracellularly. A brisk inflam-

matory response occurs within 24 h. Two weekslater, the laser-altered tattoo ink particles arefound repackaged in the same type of dermalcells.

It is not yet clear how the liberated ink par-ticles are cleared from the skin after lasertreatment. Possible mechanisms for tattoo light-ening include: (1) systemic elimination byphagocytosis and transport of ink particles byinflammatory cells, (2) external elimination via ascale-crust that is shed, or (3) alteration of theoptical properties of the tattoo to make it lessapparent. The first of these appears clinically andhistologically to be the dominant mechanism.

There are five types of tattoos: professional,amateur, traumatic, cosmetic, and medicinal. Ingeneral, amateur tattoos require fewer treat-ment sessions than professional multicoloredtattoos. Densely pigmented or decorative pro-fessional tattoos are composed of a variety ofcolored pigments and may be particularly diffi-cult to remove, requiring 10 or more treatmentsessions in some cases (Fig. 3.5). A 100% clear-ing rate is not always obtained and, in someinstances, tattoos can be resistant to furthertreatment. Amateur tattoos are typically lessdense, and are often made up of carbon-basedink that responds more readily to Q-switchedlaser treatment (Fig. 3.6). Traumatic tattoosusually have minimal pigment deposited super-ficially and often clear with a few treatments(Ashinoff 1993) (Fig. 3.7). Caution should beused when treating gunpowder or firework tat-toos, because the implanted material has thepotential to ignite and cause pox-like scars.

Consent

After obtaining informed consent (Fig. 3.8), thefollowing options are considered.


The approach to treatment will vary with thechosen laser and whether the pigmented lesionto be treated is epidermal, dermal, or mixed.Tattoos may show a different response(Tables 3.4–3.6).



Q-Switched Ruby Laser (694 nm)

The first Q-switched laser developed was a rubylaser. Current models employ a mirrored artic-ulated arm with a variable spot size of 5 or6.5 mm, a pulse width of 28–40 ns and a maxi-mum fluence of up to 10 J/cm2. The 694-nmwavelength is most well absorbed by melanin.

Because hemoglobin absorbs 694-nm lightpoorly, the ruby laser treats pigmented lesionsvery efficiently.

Most lentigines and ephelides clear after oneto three treatments with the Q-switched rubylaser (QSRL). Café-au-lait macules, nevusspilus, and Becker’s nevus respond moderatelywell. Recurrences are frequent with these

3


Fig. 3.5. Professional tattoo. Partial clearing after four treatments

Fig. 3.6. Amateur tattoo. Complete clearing after two treatments


lesions, especially when incomplete clearing isobtained. The QSRL has become the treatmentof choice for dermal pigmented lesions likenevus of Ota or Ito. The long wavelength, thebig spot size and the high delivered energy perpulse generates a high fluence deep in the tis-sue. This all leads to efficient targeting of deepmelanocytes. As effective as other Q-switchedlasers are for removing black tattoo ink, theQSRL is one of the better lasers for removingdark blue or green ink. Removal of red tattooink is problematic given that the QSRL is a redlight source and is not well absorbed by the redink particles. Yellow ink does not respond toQSRL treatment because the absorption of yel-low inks is very low in this laser’s red to near-infrared spectrum of delivered light.

When selecting the energy level for treat-ment with the QSRL, immediate tissue whiten-ing with no or minimal tissue bleeding shouldbe observed. The required energy level is deter-mined by the degree of pigmentation or theamount and color of the tattoo ink. The 6.5-mmspot is recommended for most lesions, with aninitial fluence of 3–5 J/cm2. The excellent QSRLmelanin absorption frequently leads to tran-sient hypopigmentation, which may takemonths to resolve. Rarely (in 1%–5% of cases),one sees permanent depigmentation.

Q-Switched Nd:YAG Laser (532–1064 nm)

The Q-switched Nd:YAG laser (QSNd:YL) emitstwo wavelengths, 532 and 1064 nm, with a pulseduration of 5–10 ns, delivered through a mir-rored, articulated arm. Current models havespot sizes of 2–8 mm and can operate at up to10 Hz.

The long QSNd:YL 1064-nm wavelength hasthe least absorption by melanin and the deepestpenetration. It is therefore potentially effectivefor both epidermal and dermal pigmentedlesions. Use of a frequency-doubling crystalallows emission of a 532-nm wavelength (green).This wavelength is well absorbed by both mela-nin and hemoglobin. Because of the superficialpenetration, this 532-nm laser is limited to treat-ing epidermal pigmented lesions.

Epidermal lesions such as lentigines orephelides treated with the QSNd:YL respond aswell to treatment as they do after QSRL treat-ment. Café-au-lait macules, nevus spilus, andBecker’s nevus do not respond as well toQSNd:YL treatment. The Q-switched 1064-nmlaser is highly effective for removing deep der-mal pigment such as nevus of Ota and Ito.Because this wavelength is less absorbed bymelanin, higher energy is required than withthe QSRL. Newly available Q-switched Nd:YAGlasers which generate high fluences at large spotsizes, have optimized treatment results. In aneffort to treat tattoos without interference ofmelanin absorption, the 1064-nm Q- switched


Fig. 3.7. Traumatic tattoo. Clearing after three treatments


3


CONSENT FORM FOR TREATMENT BY PIGMENT LASER

The undersigned:

Patient: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Born on: . . . . . . / . . . . . . / . . . .

Resident of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physician: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. INTRODUCTIONThe contents of this form give a brief overview of the information exchanged and explained during thepreceding oral conversations between both parties.The patient is considered to be well informed before consenting to receiving pigment laser treatment.

It is obvious that the treating physician is prepared to answer all your possible questions regardingthis operation.

2. NATURE AND COURSE OF THE TREATMENTThe pigment laser is a device producing highly energetic light. During the treatment, a laser beam ispointed at the skin. The laser beam selectively destroys the melanin pigment or tattoo particles in theskin, while the surrounding tissues are left untouched. In general, local anesthesia is not needed. In caseit should be necessary for one or another reason, the treating physician will discuss the modalitiesthereof in detail. During laser treatment, the patient, the physician and the personnel are to wear specialglasses to protect the eyes against the laser light.

3. AIM OF THE TREATMENTThe aim of the treatment is to clear up a lesion caused by melanin pigment or tattoo particles. The num-ber of treatments depends on the extent, the nature, the age and the intensity of the pigmentation ofthe skin lesion. A complete disappearance of the treated lesion is aimed at, but can never be guaranteedin advance.

The physician thus agrees with the patient to operate according to the rules of art, but cannotpromise any well-defined result (= commitment to make every possible effort).

4. RISKSPotential complications of the treatment are:– Wound infection: occurs very rarely and heals when treated appropriately.– Formation of scar tissue: highly exceptional.– Increased or decreased pigmentation:In some cases, the wound heals with increased pigmentation (hyperpigmentation). This usually happensamong patients with darker skin tones or as a result of sun exposure. Other patients are predestined tohave this kind of reaction and may have experienced this before, during the healing of other wounds. Inorder to minimize the risk of hyperpigmentation, post-operational protection of the skin against sunexposure is of the utmost importance. Among some patients, this hyperpigmentation can even occurdespite good sun protection. Hyperpigmentation is usually only temporary, but needs a few months toclear. Seldom does the hyperpigmentation persist nevertheless.Among some patients, the treated area may show decreased pigmentation (hypopigmentation) andthus obtain a lighter color than the surrounding skin tissue. This is usually only a temporary reaction,after which the skin will gradually pigment again. In some cases, however, the depigmentation may bepermanent.The physician has informed the patient how to take care of the treated skin area. Not following thesepostoperative instructions may cause complications.



Nd:YAG laser was developed. It is most effectivefor treating black ink tattoos, especially indarker skin types. The 532-nm wavelength is thetreatment of choice for red tattoo pigment.

When treating epidermal pigmented lesionswith the 532-nm wavelength, nonspecific vascu-lar injury will occur, leading to purpura, whichtakes 5–10 days to resolve. Because of the ultra-short pulse duration, the Q-switched Nd:YAG

laser produces the greatest amount of epider-mal debris. This can be minimized by the use oflarger spot sizes. Recent studies have shownthat larger spot sizes and lower fluences are aseffective in removing tattoo pigment as smallerspot sizes at higher fluences, and have fewerside effects. Therefore, when using the 1064-nmwavelength, treatment should begin with a 4- to8-mm spot size at 3–6 J/cm2.


5. EFFECTSImmediately after being treated, the skin will turn whitish gray. Exceptionally, erosion (superficialwound) and/or pinpoint bleeding may occur. A bluish red discoloration as a consequence of bleedingmay also appear and may last up to 2 weeks before disappearing.

6. ALTERNATIVE TREATMENTSCryotherapy, excisional surgery and dermabrasion are possible alternatives.

7. PHOTOGRAPHSIn order to have a better view on the results of the operation, and for educational and scientific pur-poses, such as presentations and scientific publications, photographs may possibly be taken. The patientwill be turned unrecognizable on these pictures. The patient is well informed about this and agrees to it.

8. REVOCATION OF CONSENTThe patient deliberately consents to the treatment and can at any moment decide to stop further treat-ment.

9. OBSERVATIONSObservations of the physician: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Observations of the patient: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Each of the consenting parties declares to have received a copy of this consent form. The signatureis preceded by the self-written formula ‘read and approved’.The patient declares that all his/her questions have been answered.

Date: . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient’s signature Physician’s signature

Fig. 3.8. Consent form (continued)


3


Table 3.6. Response of pigmented lesions and tattoos to various lasers and light sources

Pigmented Lesions TattoosEpidermal Mixed Dermal Amateur Professional

510-nm pigment lesion pulsed dye laser +++ + + ++ +++ (red colors)

532-nm Q-switched Nd:YAG laser +++ + + ++ +++ (red colors)

694-nm Q-switched ruby laser +++ + +++ +++ +++ (green colors)

755-nm Q-switched alexandrite laser +++ + ++ +++ +++ (green colors)

1064-nm Q-switched Nd:YAG laser ++ + +++ +++ +++Intense pulsed Light source +++ + +

+++ = excellent, ++ = good, + = fair

Table 3.5. Most effective Q-switched lasers for different tattoo ink colors

Tattoo ink color Laser

Blue/black Q-switched ruby, Q-switched alexandrite, Q-switched 1064-nm Nd:YAGGreen Q-switched ruby, Q-switched alexandriteRed/orange/purple Q-switched frequency-doubled 532-nm Nd:YAG laser, 510-nm pigment

lesion pulsed dye laser

Table 3.4. Suggested treatment parameters for pigmented lesions

Indication Laser Spot size(mm) Fluence (J/cm2)

Lentigines 510-nm PLPD 3 2.5QS 532-nm Nd:YAG 4 3QS 694-nm ruby 6.5 3–5QS 755-nm alexandrite 4 3.4

Café-au-lait macules 510-nm PLPD 5 2–3.5QS 532-nm Nd:YAG 3 1–1.5QS 694-nm ruby 6.5 3–4.5QS 755-nm alexandrite 3 4–5

Becker’s nevus QS 532-nm Nd:YAG 3 1.5–2QS 694-nm ruby 6.5 4.5QS 755-nm alexandrite 3 6QS 1064-nm Nd:YAG 3 4–5

Nevus Spilus QS 532-nm Nd:YAG 3 1.5–2QS 694-nm ruby 6.5 4.5QS 755-nm alexandrite 3 6QS 1064-nm Nd:YAG 3 4–5

Tattoo 510-nm PLPD 5 2–3.5QS 532-nm Nd:YAG 3 2–3.5QS 694-nm ruby 6.5 5–8QS 755-nm alexandrite 3 6–6.5QS 1064-nm Nd:YAG 3 5–8

Nevus of Ota QS 694-nm ruby 6.5 5–6QS 755-nm alexandrite 3 6.5QS 1064-nm Nd:YAG 3 5.0


Q-Switched Alexandrite Laser (755 nm)

The alexandrite laser has a wavelength of755 nm, a pulse duration of 50–100 ns, a spotsize of 2–4 mm and is delivered by a fiberopticarm. Fiberoptic delivery allows a more evenbeam profile with fewer hot spots.

The wavelength of the Q-switched alexan-drite laser (QSAL) is similar enough to that ofthe QSRL to obtain comparable results for thetreatment of epidermal and dermal pigmentedlesions, perhaps with the added advantage of aslightly deeper penetration. Similar to theQSRL, this laser is effective at removing black,blue, and most green tattoo inks, and less profi-cient at removing red or orange inks.

Depending on the spot size, a starting flu-ence of 5–6 J/cm2 is usually employed. Immedi-ately after treatment, gray-whitening of the skinoccurs, followed by erythema and edema. Thereis a lower risk of tissue splatter because of thelonger pulse duration and the more even beamprofile. There is also a lower risk of transienthypopigmentation because of slightly less QSALmelanin absorption as compared to the QSRL.

Pulsed Dye Laser (510 nm)

The short wavelength of the pulsed dye laser(PDL) makes it optimal for treatment of super-ficial pigmented lesions. Epidermal lesions suchas lentigines, ephelides, and flat, pigmentedseborrheic keratoses respond extremely well tothe 510-nm pulsed dye laser. Its shallow depth ofpenetration into the skin makes it less thanideal for treating dermal pigmented lesions.However, like the frequency-doubled 532-nmNd:YAG laser, the 510-nm PDL laser effectivelyremoves bright tattoo colors like red, purple,and orange.

Continuous Wave (CW) Lasers

The CW argon (488 and 514 nm), CW dye (577and 585 nm), CW krypton (521–530 nm), and thepulse train quasi-CW copper vapor lasers (510and 578 nm) all have been used to treat pig-mented lesions. However, when these lasers are

used in freehand mode, reproducibility is lack-ing and the thermal damage is somewhatunpredictable. The risk of scarring and pig-mentary changes is therefore significant in thehands of inexperienced operators. In general,these CW lasers, when used by skilled opera-tors, are effective in the treatment of epidermalpigmented lesions.

CO2 and Erbium Lasers

The CO2 and erbium lasers are sources that emitinfrared (IR) light at a wavelength of 10,600 nmand 2940 nm, respectively. These wavelengthsare well absorbed by water. The lasers destroy thesuperficial skin layers nonselectively and can beused to remove superficial epidermal pigment,especially seborrheic keratoses. Superficial er-bium laser epidermal abrasion of a “Q-switchedlaser-resistant”cafe-au-lait macule has also beenreported. Theses ablative lasers can also be help-ful in treating resistant tattoos by removing theepidermis immediately before Q-switched lasertreatment. This will lead to facilitated transepi-dermal tattoo particle elimination.

Intense Pulsed Light (IPL) Sources

Melanin pigmentation, as part of photo aging,can be epidermal or dermal. It is often a combi-nation of both. In early solar damage, melasmais a regular constituent; often with both dermaland epidermal pigment deposition. In laterstages of solar degeneration the solar lentigo,which is mainly located in the epidermis, is aprominent feature. Recently, intense pulsedlight sources (IPL) have shown to be highlyeffective in the treatment of photodamagedpigmented lesions like solar lentigines, andgeneralized dyschromia (Fig. 3.9). Unfortu-nately, light spectra, pulse duration, and num-ber of pulses as well as delivered fluence and theuse of skin cooling vary considerably among thepublished investigations, making direct com-parisons of IPL devices quite difficult.



Further Treatment Pearls

When treating pigmented lesions and tattoos,the laser handpiece should be held perpendicu-lar over the area to be treated. Pulses should bedelivered with 0–10% overlap until the entirelesion is treated.

The desired laser tissue interaction pro-duces immediate whitening of the treated areawith minimal or no epidermal damage or pin-point bleeding. It is best to use the largest spotsize to minimize epidermal damage. If epi-dermal debris is significant, the fluence shouldbe lowered. Higher fluences may be neededwith subsequent treatments when less pigmentor tattoo ink particles are still present in theskin.

IPL treatment or Q-switched laser treatmentof epidermal pigmented lesions rarely requiresanesthesia. When needed, a topical anestheticcream can be applied 1–2 hours before the pro-cedure to reduce the discomfort. For morecomplete anesthesia, local anesthetic infiltra-tion or regional nerve block can be used.

Treatment parameters are determined bythe type of lesion and the patient’s skin type. Asdiscussed above, the ideal response is immedi-ate whitening of the skin with little or no epi-dermal disruption. If the fluence is too low, thewhitening will be minimal, whereas if the flu-ence is too high, the epidermis is ruptured andbleeding might occur. Following treatment witha 510-nm PDL or a QS 532-nm laser, pinpoint

bleeding usually appears and lasts for 7–10 days.This occurs because of vessel rupture afterhemoglobin absorption.

The whitening of the treated area lasts about15 minutes and an urticarial reaction appearsaround the treated area. In the following days,the treated area usually becomes darker anddevelops a crust that falls off in 7–10 days(Fig. 3.10). The postoperative care consists ofapplication of a healing ointment, and avoidanceof sun exposure, in an effort to reduce the risk of postinflammatory hyperpigmentation.

Patients with darker skin types should betreated at lower fluences. Their threshold re-sponse will occur at lower fluences than is seenwith patients with lighter skin types. Treatmentof suntanned individuals should be avoidedbecause of the high risk of laser-inducedhypopigmentation.

While one to three treatments are sufficientto treat most lentigines, multiple treatmentswill be necessary for pigmented birthmarks likecafé-au-lait macules.

Anesthesia is rarely required for dermal pig-mented lesions. When treating larger areas,topical or intralesional anesthesia may be neces-sary. When treating nevus of Ota, regional nerveblocks usually provide adequate anesthesia.

Treatment parameters are again determinedby the type of lesion and the patient’s skin type.In general, higher fluences are necessary thanthose required for the treatment of epidermallesions. The threshold response should be

3


Fig. 3.9. Actinic bronzing. Sloughing of pigment 2 days after treatment. Complete clearance 1 month aftertreatment


immediate whitening of the skin with little orno epidermal disruption. The same postopera-tive aftercare and precautions apply as for epi-dermal pigmented lesions. Dermal melano-cytosis require multiple treatment sessions,usually performed at 6-week intervals or longer.Lesions as nevus of Ota continue to lighten forseveral months after each treatment.

Anesthesia is usually not required for smalltattoos. For certain individuals or for larger tat-toos, topical or intralesional anesthesia mightbe necessary.

If adequate fluences are available, it is best to use the largest laser spot size. This will reducebackward scattering and therefore minimizeepidermal rupture. Following treatment, woundcare is required to help healing and preventinfection. An antibiotic ointment should be

applied. A dressing should be worn for severaldays until healing has been completed.

Tattoo treatment usually requires multipletreatments to obtain adequate clearing. Ama-teur tattoos respond more quickly than do mul-ticolored professional tattoos. Complete clear-ing of tattoos is not always possible. During theinitial consultation, the patient should be in-formed about this. However, dramatic lighten-ing can be expected.

Cosmetic tattoos should be approached with caution. When treating tattoos with colorsthat may darken (white, light pink, tan, or some brown colors), a single test spot should be performed to assess immediate darkening(Fig. 3.11, 3.12). If darkening occurs, the same testsite should be retreated to be sure the ink can belightened before proceeding further. Although


Fig. 3.10.Crusting 1 week after lasertreatment of tattoo

Fig. 3.11. Cosmetic tattoo. Darkening of pigment after first treatment. Partial clearing after 6 treatments withQ-switched alexandrite laser


the darkened pigment may clear easily, it cansometimes be very recalcitrant to treatment.In this case, CO2 or erbium:YAG laser vaporiza-tion can be used, as an adjunctive treatmentmodality, by removing the epidermis immedi-ately before Q-switched laser treatment and/orby facilitating transepidermal tattoo particleelimination.

Treatment sessions are performed at inter-vals of 6 weeks or greater. Waiting longerbetween treatment sessions might be even morebeneficial as tattoos may continue to clear forseveral months following each treatment.

Complications

Unlike previous treatment modalities for pig-mented lesions, Q-switched lasers induce mini-mal side effects. These include pigmentarychanges, partial removal, infection, bleeding,textural changes, and tattoo ink darkening.

Pigmentary changes following laser treat-ment of pigmented lesions are not uncommon.Transient hypopigmentation is most commonafter treatment with the 694- or 755-nm wave-lengths because absorption by melanin is sostrong. Permanent hypopigmentation can beseen with repetitive treatment sessions, particu-larly at higher fluences. The 1064-nm wave-

length is the least injurious to melanocytes andis therefore the treatment of choice for dark-skinned individuals undergoing laser tattootreatment. Transient hyperpigmentation, whichhas been reported in up to 15% of cases, is morecommon in darker skin types or following sunexposure (Kilmer et al. 1993). The incidence ofscarring is less than 5%. It is associated with theuse of excessive fluences. It is also more com-mon when certain areas like the chest and ankleare treated. This complication has also beenobserved in areas with dense deposition of ink,such as in double tattoos. Larger laser spot sizestend to minimize epidermal damage and areassociated with fewer textural changes.

Pigment darkening of cosmetic skin colortattoos can occur after exposure to any Q-switched laser. The darkening occurs immedi-ately and is most often seen with the red, white,or flesh-toned ink colors that are frequentlyused in cosmetic tattoos. These colors oftencontain ferric oxide and titanium dioxide thatcan change to a blue-black color after Q-switched laser treatment. The mechanism prob-ably involves, at least for some tattoos, reduc-tion of ferric oxide (Fe2O3, “rust”) to ferrousoxide (FeO, jet black). Recently, multiple colorchanges following laser therapy of cosmetic tat-toos has been reported (Fig. 3.11). Performingsmall test areas before complete treatment and

3


Fig. 3.12.Color shift to green after laser test with Q-switchedalexandrite laser


using several laser wavelengths throughout thecourse of therapy are essential to the successfultreatment of cosmetic tattoos.

Localized allergic reactions can occur withalmost any treated tattoo color. It can result inan immediate hypersensitivity reaction such asurticaria (Ashinoff 1993). In the alternative, adelayed hypersensitivity reaction such as granu-loma formation may occur. The most seriouscomplication reported after Q-switched lasertattoo removal was a systemic allergic reaction.The Q-switched laser targets intracellular tattoopigment, causing rapid thermal expansion thatfragments pigment-containing cells and causesthe pigment to become extracellular. This extra-cellular pigment may then be recognized by theimmune system as foreign, potentially trigger-ing an allergic reaction. Therefore, if a patientexhibits a local immediate hypersensitivity re-action, prophylaxis before subsequent lasertreatments with systemic antihistamines andsteroids should be considered. Pulsed CO2 anderbium lasers do not seem to trigger this reac-tion, since the particle size does not change.These lasers may be used to enhance transepi-dermal elimination of ink.

Future Developments

Noninvasive, real-time optical diagnostic tools(like optical coherence tomography, confocalmicroscopy, multispectral digital imaging,polarized multispectral imaging) are beingstudied for their role in the accurate prelaserdiagnosis of pigmented lesions as well as a toolfor determining efficacy and safety followingtreatment.

Current tattoo laser research is focused onnewer picosecond lasers. The systems may bemore successful than the Q-switched lasers in theremoval of tattoo inks (Ross 1998). Such lasers,because they emit picosecond pulse widths,cause optimal photomechanical disruption ofthe tattoo ink particles. Another tattoo approachwould be the development of laser-responsiveinks. In this case, tattoo removal might be feasi-ble with only one or two treatment sessions.

It is also possible that a laser that emitstrains of low-fluence, submicrosecond pulses

might cause even more selective injury to pig-mented cells by limiting mechanical damagemodes. The use of pulse trains, specificallydesigned to selectively affect pigmented cells inskin, has not yet been tested.

Since the clearing of tattoo pigment follow-ing laser surgery is influenced by the presenceof macrophages at the site of treatment, it hasalso been suggested that the adjuvant use ofcytokines like macrophage colony-stimulatingfactor, other chemotactic factors such as topicalleukotrienes, or the use of a topical immuno-modulators like imiquimod might recruit addi-tional macrophages to the treatment site. Thiscould expedite the removal of tattoo pigmentfollowing laser surgery.

The extraction of magnetite ink tattoos by a magnetic field has been investigated after Q-switched laser treatment. When epidermalinjury was present, a magnetic field, appliedimmediately after Q-switched ruby laser treat-ment, did extract some ink. Magnetically-extractable tattoos may therefore become feasi-ble one day. Delivery of intradermally-focused,small energy nanosecond laser pulses mightbecome another approach for more efficientand safer tattoo removal. Finally, optical clear-ing of skin with hyperosmotic chemical agentsis currently under investigation. This approachreduces optical scattering in the skin, therebyenhancing the effective light dose that reachesthe tattoo particles.

References

Adrian RM, Griffin L (2000) Laser tattoo removal. ClinPlast Surg 27(2):181–192

Alster TS (1995) Q-switched alexandrite laser treatment(755 nm) of professional and amateur tattoos. J AmAcad Dermatol 33(1):69–73

Anderson R, Parrish J (1983) Selective photothermolysis:precise microsurgery by selective absorption ofpulsed radiation. Science 220:524–526

Ashinoff R, Levine VJ, Soter NA (1995) Allergic reactionsto tattoo pigment after laser treatment. DermatolSurg 21(4):291–294

Carpo BG, Grevelink JM, Grevelink SV (1999) Lasertreatment of pigmented lesions in children. SeminCutan Med Surg 18(3):233–243

59References


Duke D, Byers HR, Sober AJ, Anderson RR, Grevelink JM(1999) Treatment of benign and atypical nevi withthe normal-mode ruby laser and the Q-switchedruby laser: clinical improvement but failure to com-pletely eliminate nevomelanocytes. Arch Dermatol135(3):290–296

Geronemus RG (1992) Q-switched ruby laser therapy ofnevus of Ota. Arch Dermatol 128(12):1618–1622

Goldberg DJ, Nychay S (1992) Q-switched ruby lasertreatment of nevus of Ota. J Dermatol Surg Oncol18(9):817–821

Goldberg DJ, Stampien T (1995) Q-switched ruby lasertreatment of congenital nevi. Arch Dermatol131(5):621–623

Goldman MP, Kaplan RP, Duffy DM (1987) Postscle-rotherapy hyperpigmentation: a histologic evalua-tion. J Dermatol Surg Oncol 13(5):547–550

Kilmer SL (2002) Laser eradication of pigmented lesionsand tattoos. Dermatol Clin 20(1):37–53

Kilmer Sl, Casparian JM, Wimberly JM et al (1993) Haz-ards of Q-switched lasers. Lasers Surg Med S5:56

Levine VJ, Geronemus RG (1995) Tattoo removal withthe Q-switched ruby laser and the Q-switchedNd:YAGlaser: a comparative study. Cutis 55(5):291–296

Ross V, Naseef G, Lin G, Kelly M, Michaud N, Flotte TJ,Raythen J, Anderson RR (1998) Comparison ofresponses of tattoos to picosecond and nanosecondsQ-switched neodymium: YAG lasers. Arch Dermatol134(2):167–171

Sanchez NP, Pathak MA, Sato S, Fitzpatrick TB, SanchezJL, Mihm MC Jr (1981) Melasma: a clinical, lightmicroscopic, ultrastructural, and immunofluores-cence study. J Am Acad Dermatol 4(6):698–710

3



History

Human hair, its amount and distribution, playsan important role in defining appearance incontemporary society. Hair also functions inmany mammals as a sensory organ, reducesfriction in certain anatomic sites, protectsagainst the environment by providing thermalinsulation and thermoregulation, aids inpheromone dissemination, and plays bothsocial and sexual roles (Wheeland 1997).

Individuals, seeking consultation for theremoval of unwanted body hair, generally haveincreased hair in undesirable locations sec-

ondary to genetics or medical conditions. Theseindividuals may be classified as having hir-sutism or hypertrichosis. More commonly,those seeking hair removal have hair that wouldbe considered normal in distribution and den-sity. However, these individuals, for emotional,social, cultural, cosmetic, or other reasons,want the hair to be removed.

There has always been the need for an idealmethod of hair removal that is both practicaland effective. Traditional hair removal tech-niques have included shaving, waxing, tweez-ing, chemical depilation, and electrolysis.

In the early twentieth century, radiographmachines were widely used for removal of facialhair in women. Unfortunately, these treatmentswere associated with a high risk of complica-tions and the potential for subsequent treat-ment-induced carcinogenesis.

Maiman, using a ruby crystal in 1960, devel-oped stimulated laser emission of a 694-nm redlight. This was the first working laser, and it isfrom this prototype that today’s lasers arederived. Since 1960, research and technicaladvances have led to modern day lasers. LeonGoldman, the father of laser surgery, publishedpreliminary results on the effects of a ruby laserfor the treatment of skin diseases. Ohshiro et al.noted hair loss from nevi after treatment with aruby laser (Ohshiro et al. 1983).

Early reports described the use of a CO2laser to eliminate unwanted hair on flaps usedfor pharyngoesophageal procedures. A continu-ous-wave Nd:YAG laser has also been shown toremove hair in urethral grafts All of this earlywork described lasers using ablative techniqueswith the effect of nonspecific vaporization ofskin cells. These methods are not commonlyused for hair removal today because of theirlimited effectiveness as well as their commonly

Laser Treatment of Unwanted HairDavid J. Goldberg, Mussarrat Hussain

4

▲

Core Messages A wide variety of lasers can now

induce permanent changes in un-wanted hair.

Hair removal lasers are distinguishednot only by their emitted wave-lengths, but also by their deliveredpulse durations, peak fluences, spotsize delivery systems, and associatedcooling.

Nd:YAG lasers with effective coolingrepresent the safest approach for thetreatment of darker skin.

Complications from laser hair re-moval are more common in darkerskin types.

Pain during laser hair removal is gen-erally a heat-related phenomenonand is multifactorial.

Laser treatment of nonpigmentedhairs remains a challenge.


induced permanent pigmentary changes andscarring.

Selective Photothermolysis

A detailed understanding of laser-tissue inter-action emerged in 1983 as the theory of selectivephotothermolysis was conceived for the lasertreatment of pediatric port wine stains (Ander-son et al. 1983)

The theory of selective photothermolysis ledto the concept of a laser-induced injury con-fined to microscopic sites of selective lightabsorption in the skin, such as blood vessels,pigmented cells, and unwanted hair with mini-mal damage to the adjacent tissues. To achievethis selective effect, lasers would need to fulfillthree requirements:1. They should emit a wavelength that is highly

absorbed by the targeted structure.2. They should produce sufficiently high ener-

gies to inflict thermal damage to the target.3. The time of tissue exposure to the laser

should be short enough to limit the damageto the target without heat diffusion to thesurrounding tissues. This is known as thethermal relaxation time (TRT).

These concepts revolutionized cutaneous lasertreatment and led to the development of success-ful laser and light-based hair removal devices.

Extended Theory of Selective Photothermolysis

The concept of selective photothermolysis (An-derson et al. 1983) emphasizes both the selectivedamage and minimum light energy require-ments seen with current laser technology. How-ever, the use of such a short pulse width lasersystem may become inapplicable when the tar-get absorption is nonuniform over a treatmentarea. This may be seen when the actual targetexhibits weak or no absorption, yet other sur-rounding portions of the target exhibit signifi-cant absorption. If this is the case, the weaklyabsorbing part of the target chromophore has

to be damaged by heat diffusion from the highlypigmented/strongly absorbing portion of thechromophore (the heater or absorber). Suchnonspecific thermal damage evokes the conceptof thermal damage time (TDT). The TDT of atarget is the time required for irreversible targetdamage with sparing of the surrounding tissue.For a nonuniformly absorbing target structure,the TDT is the time it takes for the outermostpart of the target to reach a target damage tem-perature through heat diffusion from the heatedchromophore.

According to the concept of extended selec-tive photothermolysis, target damage can stillbe selective even though the TDT is many timesas long as the thermal relaxation time (TRT) ofthe actual target.

This new extended theory of selective ther-mal damage of nonuniformly pigmented struc-tures in biological tissue postulates that the tar-get is destroyed by heat diffusion from theabsorbing chromophore to the target but not bydirect heating from laser irradiation, as is seenwith selective photothermolysis. This theoryhas now been applied to the treatment ofunwanted hair. Ultimately, the use of hairremoval lasers expanded rapidly with the sub-sequent development of appropriate coolingdevices that minimized epidermal injury.

Physical Basis of Laser Hair Removal

Successful treatment of unwanted hair is depen-dent on an understanding of the optical proper-ties of the skin. It is these properties that deter-mine the behavior of light within the hair shaftand bulb, including the relative amount ofabsorption of incoming photons.

Different physical factors including deliv-ered fluence, wavelength, pulse duration, andspot size diameter play an important role inmaximizing the efficacy and safety of laser-assisted hair removal.

For optimal laser hair removal, one needs touse an optimal set of laser parameters based onanatomic and physical principles. This is deter-mined by a time–temperature combinationwith the ultimate effect being transfolliculardenaturation.

4

62 Chapter 4 Laser Treatment of Unwanted Hair


Pulse Duration

Laser pulse width seems to play an importantrole in laser-assisted hair removal. Thermalconduction during the laser pulse heats a regionaround each microscopic site of optical energyabsorption. The spatial scale of thermal con-finement and resultant thermal or thermome-chanical damage is therefore strongly related to the laser pulse width. Q-switched lasernanosecond pulses effectively damage individ-ual pigment cells within a hair follicle by con-finement of heat at the spatial level of melano-somes (Zenzie et al. 2000). They can induceleukotrichia and cause a temporary hair growthdelay, but do not inactivate the follicle itself.

On the other hand, lasers with longer pulsedurations not only allow gentle heating of themelanosomes, but also target the entire follicu-lar epithelium by allowing thermal conductionfrom the pigmented hair shaft and pigmentedepithelial cells to the entire follicular structure.

Therefore, lasers emitting longer pulsedurations can achieve two goals: (1) Epidermalmelanosomes are preserved. This then helps topreserve the epidermis. (2) Adequate heat diffu-sion occurs to the surrounding follicle from thelight-absorbing melanized bulb and shaft.

The use of a longer laser-emitted pulsewidth may necessitate the use of higher fluencesbecause the longer pulse now heats a larger vol-ume of tissue. This may be of some benefit inallowing higher fluences to be used on darkskin types with both less risk of epidermalinjury and increased chances of transfolliculardamage.

Spot Size

Large diameter laser exposure spots (e.g.,>10 mm) are associated with substantially lessloss of energy intensity with depth of dermalpenetration as compared to small-diameterexposure spots. This is because optical scatter-ing by dermal collagen causes light to diffuse asit penetrates into the dermis. The larger thespot, the less is the associated scattering.

Fluence

In general, higher-delivered laser fluences leadto better laser hair removal results. However,the higher the utilized fluence, the greater thediscomfort and risk of complications. The effec-tive fluence for any one area of hair is deter-mined mainly by hair color, whereas the toler-ated fluence is determined mainly by skin color.

The tolerance fluence can be increased sub-stantially by various means, such as cooling theskin surface before, during, and/or after theoptical pulse.

Factors Affecting Efficacy/Results

Hair Color

Hair color is genetically determined, and is aresult of both the type and amount of melaninwithin the hair shaft. Melanin production occursonly during the anagen phase, by melanocytes inthe bulb that transfer melanin granules to hairkeratinocytes. Distinct types of melanosomesexist in hair of different colors. Dark hair con-tains large numbers of eumelanin granules,whereas light hair contains mostly pheomelanin.Red hair contains erythromelanin granules thatare rich in pheomelanin. In gray hair, melano-cytes show degenerative changes such as vacu-oles and poorly melanized melanosomes,whereas in white hair melanocytes are greatlyreduced in number or are absent.

Most individuals demonstrate greatermelanin density in their hair as compared totheir skin epidermis such that the absorptioncoefficient of the hair shaft and bulb is roughly2–6 times that of the epidermis. Thus, hair willgenerally absorb more of the melanin-absorb-ing wavelengths emitted from today’s laser andlight source hair removal systems.

Thus, color contrast between the epidermisand the hair shaft are paramount in determin-ing the optimal wavelengths and pulse durationfor successful treatment. For high contrast(dark hair and light skin) high fluences, shorterwavelengths, and relatively short pulse dura-tions can be used without risking epidermalinjury. Conversely, low contrast areas (dark hair

63Factors Affecting Efficacy/Results


and dark skin) require lower fluences, longerwavelengths, and longer pulse durations for safetreatment.

Growth Centers of Hairs

The hair follicle is a self-regenerating structureand contains a population of stem cells capableof reproducing themselves. It has been noted, atleast in animal models, that a complete hair fol-licle can be regenerated even after the matrix-containing hair follicle is surgically removed.Although the dermal papilla is not technicallypart of the actual hair, it remains a very impor-tant site for future hair induction, and melaninproduction in terminal hairs.

Long-term hair removal has been tradition-ally thought to require that a laser or lightsource impact on one or more growth centers ofhair. The major growth centers have alwaysbeen thought to be in the hair matrix. However,research evaluating growth of new hair hasrevealed that the matrix is not the only growthcenter. New hairs may evolve from the dermalpapilla, follicular matrix, or the “bulge.” Thesestem cells are usually found in a well-protected,highly vascularized and innervated area, oftenin close proximity to a population of rapidlyproliferating cells. They always remain intactand, in fact, are left behind after hair plucking.Stem cells are relatively undifferentiated bothultrastructurally and biochemically. They havea large proliferative potential, and are responsi-ble for the long-term maintenance and regener-ation of the hair-generating tissue. They can bestimulated to proliferate in response to wound-ing and certain growth stimuli.

Hair Cycle

All human hairs show various stages of hairgrowth. The hair cycle is divided into threestages: anagen, the period of activity or growthphase; catagen, the period of regression orregression phase; and telogen, the period ofquiescence or resting phase.

Anagen growth phase varies greatly (andcan last up to 6 years) depending on age, sea-

son, anatomic region, sex, hormonal levels, andcertain genetic predispositions. It is these varia-tions that have led to the tremendous disparityin hair cycles reported by various investigators.

The catagen stage is relatively constant andis generally of 3 weeks duration, whereas thetelogen phase usually lasts approximately3 months.

The overall length of the hair is determinedprimarily by the duration of the anagen phase.Human hair appears to grow continuously,because the growth cycles of different hair folli-cles are in dysynchrony with each other.

The histologic appearance of a hair folliclealso differs dramatically with the stages ofgrowth. The anagen follicle penetrates deepestin the skin, typically to the level of subcuta-neous fat. Catagen is characterized by pyknoticchanges in the nuclei of the kerotinocytes, fol-lowed by apoptosis of the transient portion ofthe follicle. The entire transient portion (whichbegins at the level of the insertion of arrectorpili muscle and extends to the deepest portion)is absorbed, except for the basement mem-brane. As the new anagen progresses, the sec-ondary hair germ descends, enlarges, and beginto produce a hair shaft.

Although reports of anagen duration, telo-gen duration, and the percentage of telogenhairs represent an inexact science, most discus-sions of laser hair removal take into account dif-ferent anatomic areas in terms of anagen andtelogen cycles.

It is the sensitivity of the anagen hair to a vari-ety of destructive processes, including laser andlight source damage, that leads to a metabolicdisturbance of the mitotically active anagenmatrix cells. The response pattern is dependentboth on the duration and intensity of the insult.

Lin et al. (Lin et al. 1998) postulate that folli-cles treated in the telogen phase show only agrowth delay for weeks, whereas, when thosefollicles are treated in the anagen phase theymay be susceptible to lethal damage, may have agrowth delay, or may simply switch into telogenphase. This could partly explain the growthdynamics of the hair cycle. Repeated treatmentscould lead to a synchronization of the anagenphase by induction and/or shortening of thetelogen phase, which could increase the effec-

4



tiveness of hair removal with each consecutivetreatment. Another explanation might be thatthe follicle is not destroyed immediately, butshows a growth arrest after only one (short-ened) anagen cycle. Some have questioned theassumption that effective laser hair removal isdetermined solely by treating hairs in the ana-gen cycle. These investigators suggest thatmelanin within a hair follicle may be moreimportant than the actual time of treatment.

Cooling

Laser hair removal-associated epidermal cool-ing can be achieved by various means, includingice, a cooled gel layer, a cooled glass chamber, acooled sapphire or copper window, a pulsedcryogen spray, or solid air flow.

Epidermal melanin and melanized hairspresent competing sites for absorption of lightenergy. Selective cooling is essential to effec-tively minimize photothermal-induced epider-mal adverse effects. In addition, epidermalcooling also permits higher fluences to be deliv-ered to the treated follicular structures. Ideally,the epidermal temperature should be signifi-cantly but harmlessly decreased by the coolingprocedure, while the target follicular tempera-ture should remain unchanged or changedinsignificantly. If this condition is not met, thelaser fluences must be increased to compensatefor the lower target temperature.

Age

In an isolated study a significant negative corre-lation was noted between successful hairremoval and the age of the patients, suggestingthat hair removal was more effective in youngerpatients. However, other studies on hair re-moval have not found age to be a factor in deter-mining efficacy.

Hormones

A number of hormones affect hair growth, withthyroid and growth hormones producing a gen-

eralized increased growth in hair. Estrogenshave only minimal effects on hair growth.Androgens are the most important determinantof the type of hair distributed throughout thebody. The principal circulating androgen,testosterone, is converted in the hair follicle by 5-alpha reductase to dihydrotestosterone(DHT), which stimulate the dermal papilla toproduce a terminal melanized hair. The effect ofandrogens on hair growth is skin area-specific,due to local variations in androgen receptor and5-alpha reductase content). While the effect ofandrogens on hairs (i. e., terminalization of vel-lus hairs) will be more readily apparent in skinareas with a greater numbers of hair follicles,hair follicle density does not correlate with fol-licular sensitivity to androgens. Some areas ofthe body, termed nonsexual skin (e. g., that ofthe eyelashes, eyebrows, and lateral and occipi-tal aspects of the scalp), are relatively indepen-dent of the effect of androgens.

Other areas are quite sensitive to androgens.In these locations hair follicles are terminalizedeven in the presence of relatively low levels ofandrogens. Such areas include the pubic areaand the axilla, which begin to develop terminalhair even in early puberty when only minimallyincreased amounts of androgens are observed.Finally, some areas of skin respond only to highlevels of androgens. These sites include thechest, abdomen, back, thighs, upper arms, andface. The presence of terminal hairs in theseareas is characteristically masculine, and if pres-ent in women is considered pathological, i.e.,hirsutism.

Hirsutism is defined as the presence inwomen of terminal hairs in a male-like pattern.This affects between 5% and 10% of surveyedwomen. Hirsutism above all else should beprincipally considered a sign of an underlyingendocrine or metabolic disorder, and thesepatients should undergo a thorough evaluation.The hormonal therapy of hirsutism consists ofmedications that either suppress androgen pro-duction, or block androgen action.

The main purpose of hormonal therapy is tostop new hairs from growing and potentiallyslow the growth of terminal hairs already pre-sent. Although hormonal therapy alone willsometimes produce a thinning and loss of pig-

65Factors Affecting Efficacy/Results


mentation of terminal hairs, it generally will notreverse the terminalization of hairs.

Currently Available Lasers and LightSources Used for Hair Removal

In the USA, the Food and Drug Administration(FDA) has traditionally used electrolysis resultsas a benchmark to evaluate laser treatment effi-cacy, despite the near lack of significant scien-tific data about electrolysis. In the initially sub-mitted studies, all hair removal devices wererequired to show a 30% decrease in hair growthat 3 months after a single treatment (Tope et al.1998).

This criterion clearly does not equate withpermanent hair loss, as a delay in hair growth,which usually lasts for 1–3 months, is simplyconsistent with the induction of the telogenstage. Permanent hair reduction results shouldbe based on the cyclic growth phases for hairfollicles, and should refer to a significant reduc-tion in the number of terminal hairs after agiven treatment. There must be a reduction thatis stable for a period of time longer than thecomplete growth cycle of hair follicles at anygiven body site.

Multiple laser systems are currently avail-able and approved by the FDA for hair removal.The lists below include the more popular sys-tems. They are not meant to be all-inclusive.

Ruby Lasers

Ruby lasers (694 nm), used for hair removalincludes: Epilaser/E2000 (Palomar, Lexington, MA) EpiPulse Ruby (Lumenis, Santa Clara, CA) RubyStar (Aesculap Meditec., Irvine, CA)

Epilaser/E2000 (Palomar). With this laser,light is delivered through a fiber, and two differ-ent spot sizes (10 mm and 20 mm) are available.A retroreflector is built into the hand piece,allowing photon recycling and therefore higherenergy delivery (Anderson et al. 1999; Ross et al.1996). Depending on skin type or hair thick-

ness, a single pulse of 3 ms or twin pulses (i. e.,two 3-ms pulses delivered with a delay of100 ms) can be chosen. The E2000 uses a sap-phire-cooled handpiece (Epiwand) to protectthe epidermis during laser irradiation. The sap-phire lens is actively cooled to 0° or –10°C andput in direct contact with the skin.

The long-pulsed EpiPulse Ruby laser (Lume-nis) employs triple-pulse technology with 10-ms intervals between pulses. This train ofpulses keeps the follicle temperature sufficientlyhigh to cause destruction. Epidermal cooling isachieved by applying a thick layer of cooledtransparent gel on the skin.

The RubyStar (Aesculap-Meditec) is a dual-mode ruby laser that uses a contact skin coolingmethod. It can operate in the nanosecond Q-switched mode for the treatment of tattoos andpigmented lesions and in the normal millisec-ond mode for hair removal. Its integrated cool-ing device consists of a cooled contact hand-piece which precools the skin before laser pulsedelivery.

Although the mechanism of ruby laserinduction of follicular injury is likely to be ther-mal, the precise contributions of photomechan-ical damage or thermal denaturation to follicu-lar injury are unknown. It is possible that afterabsorption of radiant energy, the large temper-ature differences between the absorbing mela-nosomes and their surroundings produce alocalized rapid volume expansion. This wouldthen lead to microvaporization or “shockwaves,” which cause structural damage to thehairs (Anderson et al. 1983). On the other hand,thermal denaturation leading to melanosomaldamage is also possible. Histologic evaluationof laser-treated mouse skin has revealed evi-dence of thermal coagulation and asymmetricfocal rupture of the follicular epithelium (Lin et al. 1998). Secondary damage to adjacentorganelles could theoretically result either fromthermal diffusion or from propagation of shockwaves.

Because of its comparatively short rubylaser wavelength, this hair removal system isbest suited for the treatment of dark hair inlight skin. It also may be more efficacious thanlonger wavelength devices for the treatment oflight hair or red to red-brown hair (Ross et al.

4



1999). Because of the high melanin absorptioncoefficient at 694 nm, the ruby laser must beused with caution in darkly pigmented or tanpatients.

A number of reports have documented theefficacy of ruby laser hair removal in varyingtypes of skin using different laser parameters.The published hair reduction rates have rangedfrom a 37% to 72% reduction 3 months after oneto three treatments to a 38%–49% hair reduc-tion 1 year after three treatment sessions(Williams et al. 1998). As would be expected,multiple treatments at 3- to 5-week intervalsproduce a greater degree of hair reduction thanis seen after a single session. In general, higherdelivered fluences do lead to better hair removalsuccess, although complications also increase.

Studies with larger numbers of patients haveconfirmed that hair counts are reduced byapproximately 30% after a single treatmentwith ruby laser (Williams et al. 1998). Theeffects of multiple treatments sessions are addi-tive, as hair counts are reduced by approxi-mately 60% after three or four treatment ses-sions. Whether 100% permanent hair removalcan be achieved remains open to debate.

Alexandrite Lasers

Several long-pulsed alexandrite lasers (755 nm)are being used for hair removal, including: Apogee series (Cynosure, Chelmsford, MA) Epitouch ALEX (Lumenis, Santa Clara, CA) GentleLase (Candela, Wayland, MA)

The Apogee system (Cynosure) provides pulsedurations between 5 and 40 ms and fluences upto 50 J/cm2. A cooling handpiece (SmartCool)blows a continuous flow of chilled air into the treatment area. The scanner option(SmartScan) enables treatment of large areaswith an unobstructed view, speedy treatment,and ease of use with minimal operator fatigue.

The Epitouch ALEX (Lumenis) delivers a 2-ms pulse duration, spot sizes of 5–10 mm, andfluences of 10–25 J/cm2. A cooling gel is appliedto the skin before treatment, and a scanningdevice can be used to treat larger body-surfaceareas.

The GentleLase (Candela) delivers a 3-mspulse duration, spot sizes of 8–18 mm, and flu-ences ranging from 10 to 100 J/cm2. It employs adynamic cooling device (DCD) to protect theepidermis. The DCD cooling method uses short(5–100 ms) cryogen spurts, delivered to the skinsurface through an electronically controlledsolenoid valve; the quantity of cryogen deliv-ered is proportional to the spurt duration.

There are a number of advantages in usinglong-pulsed alexandrite lasers for hair removal.Some of the long-pulsed alexandrite laser sys-tems are compact and can be used in smallrooms if adequate ventilation is available. Theirflexible fiberoptic arm is easy to manipulate andprovides access to hard-to-reach body areas.The large spot sizes and frequency (1–5 Hz)improves the possibility of rapidly treatinglarge body areas.

The alexandrite laser wave length of 755 nmis absorbed about 20% less strongly by melanincompared with the ruby laser wavelength of694 nm. Its absorption by the competing chro-mophore, oxyhemoglobin, is substantially in-creased as compared to the 694-nm wavelength.However, the longer wavelength of 755 nm pene-trates more deeply into the dermis and is lessabsorbed by epidermal melanin. This theoreti-cally decreases the risk of epidermal damage,especially in individuals with darker skin types.

Because dermal scattering decreases withincreasingly longer wavelengths, 755-nm lightpenetrates deeper into tissue than does shorterwavelengths. In theory, the use of longer wave-lengths should increase the ratio of energydeposited in the dermis relative to the epider-mis. This would result in relatively increasedbulb heating while at the same time promotingepidermal sparing (Ross et al. 1999).

The reported hair removal success rateusing an alexandrite laser has ranged from 40%to 80% at 6 months after several treatments(Gorgu et al. 2000) In a controlled randomizedstudy using a single 20 J/cm2, 5- to 20-msalexandrite laser on various anatomic sites,investigators reported a 40% reduction in hair growth 6 months after treatment. Thisincreased to >50% (on the upper lip) if a sec-ond treatment was performed after 8 weeks. Inanother study, one treatment with a variable

67Currently Available Lasers and Light Sources


pulsed alexandrite laser produced maximumhair growth reduction at 6 months of 40%–56%for the lip, leg, and back. Finally, one study hasnoted a mean 74% bikini hair reduction 1 yearafter five alexandrite laser treatments.

Diode Lasers

Diode lasers (800 nm) used for hair removalinclude: LightSheer (Lumenis, Santa Clara, CA) Apex-800, (Iriderm, Mountain View, CA) LaserLite, (Diomed, Boston, MA) SLP 1000 (Palomar Medical Technologies,

Lexington, MA) MeDioStar (Aesculap-Meditec, Irvine, CA) EpiStar (Nidek, Freemont, CA)

Although the myriad diode lasers vary in theirdelivered energies, spot sizes, pulse duration,and associated cooling devices, they all set apopular standard for efficiency, reliability, andportability.

Because of reduced scattering at the longer810-nm diode wavelengths, light from the diodelaser penetrates more deeply into the skin. At800 nm, 24% of incident fluence reaches adepth of 3 mm, whereas only 5% reaches thesame depth with 700-nm light (Ross et al. 1999).Also, 800-nm energy is 30% less absorbed bymelanin than that of the ruby laser, yet the 800-nm wavelength leads to better optical penetra-tion.

In general, the diode laser system has beenfound to be better tolerated by patients withdarker skin types (V–VI) as compared to theruby laser (Adrian et al. 2000). This is likely dueto its longer wavelength, longer pulse width,and associated active cooling.

In a prospective controlled trial, the 810-nmdiode laser demonstrated a significant reduc-tion in hair growth (Lou et al. 2000). Overall,clinical studies with the diode laser system havereported variable success rates ranging from65–75% hair reduction at 3 months after one totwo treatments with fluences of 10–40 J/cm2.This was increased to >75% hair reduction in91% of subjects 8 months after three to fourtreatments at 40 J/cm2 (Williams et al. 1999). As

expected, repeated treatments, generally at 4-week intervals, appears to improve results (Louet al. 2000).

Nd:YAG Lasers

Millisecond Nd:YAG lasers (1064 nm) used forhair removal include: Lyra (Laserscope, San Jose, CA) CoolGlide (Cutera, Brisbane, CA) Yaglase (Depilase, Irvine, CA) Image (Sciton, Palo Alto, CA) VascuLight (Lumenis, Santa Clara, CA)

The longer Nd:YAG laser wavelength providesdeeper penetration, a necessary factor in theattempt to achieve optimal laser hair removalresults. In addition, the 1064-nm wavelength isrelatively less absorbed by epidermal melaninthan are the 694- to 810-nm wavelengths. It isthis decreased melanin absorption that leads tothe greater pigmented epidermal safety seenwith these systems.

Although the 1064-nm wavelength is lesswell absorbed by melanin than shorter wave-lengths, the absorption appears to be enough toachieve the selective photothermolysis of thepigmented hair follicle (Lin et al. 1998). The useof appropriate fluences and effective epidermalcooling devices leads to an effective hairremoval device with little risk of complicationswhen such lasers are used correctly. Althoughthe relatively low melanin absorption wouldappear to be a disadvantage in the treatment ofpigmented hair, the Nd:YAG laser’s advantage isits ability to reduce the thermal damage of thelaser-treated melanin containing epidermis.Thus, side effects are decreased in darker-skinned patients).

Although Nd:YAG laser treatment usuallyleads to less dramatic results when compared toother laser systems available for hair reduction,its 1064-nm wavelength decreased absorptionby melanin may also cause a lesser incidence ofepidermal side effects, including blistering andabnormal pigmentation (Nanni et al. 1999).Short-term hair reduction in the range of20%–60% has been obtained with the longpulsed Nd:YAG lasers.

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Early clinical studies have demonstrated lesshair reduction/laser session with Nd:YAG lasersas compared to the published results with eitherruby or alexandrite lasers

However, preliminary studies suggest thatnewer, high powered long-pulsed Nd:YAG lasersmay provide hair loss comparable to that seenwith other devices. The long-term efficacy andprecise role of the long-pulsed Nd:YAG lasersremains to be established.

Q-Switched Nd:YAG Laser

Q-switched Nd:YAG lasers have been used totarget topically applied carbon particles thathave previously been applied to the hair follicle.This method was one of the first available laserhair removal techniques. This short term hairremoval technique has also been used withoutthe prior application of carbon.

Immediately after Q-switched 1064-nmlaser irradiation of carbon coated hairs, the car-bon is heated to its vaporization temperature ofabout 3,700 °C. Vaporization leads to a huge vol-ume expansion with resultant supersonic prolif-eration of high pressure waves. These shockwaves, in turn, produce mechanical damage, aswell as the development of heat. It is not clearhow much mechanical and/or heat energy pro-duced by this mechanism is required fordestruction of a hair follicle. However, histo-logic evidence of follicular damage is seen aftersuch a laser exposure. This results in a clinicaldelay of hair growth.

Depending on the position and amount ofthe topically applied chromophore, as well asthe energy administered, it may be possible tooccasionally irreversibly damage a hair follicleeven with a Q-switched laser.

Histologic studies have documented thepresence of carbon in the follicle after low flu-ence Nd:YAG lasing. This carbon appears topenetrate superficially in a large number of fol-licles with and without a hair shaft in place;deep follicular penetration is rare. The disad-vantages of this technique, therefore, appear torelate to the fact that that the carbon granulesmay not consistently reach the requisite hairbulge or bulb.

Different studies have compared the effec-tiveness of Q-switched Nd:YAG laser hairremoval with ruby and alexandrite laser treat-ments. Millisecond pulse ruby and alexandritelasers showed greater hair reduction than wasseen with Q-switched Nd:YAG lasers. Relativelyweak absorption by the innate target chro-mophore melanin of Q-switched Nd:YAG laserenergy translates into less energy available todamage the follicle. Therefore, a lesser hairremoval effect is seen.

Several studies have examined the 1064-nmQ-switched Nd:YAG laser with and without atopically applied chromophore. However, in onecontrolled study (Nanni et al. 1997), using a sin-gle Q-switched Nd:YAG laser treatment, 100%hair regrowth was observed at 6 months irre-spective of the treatment. Although capable ofinducing delayed regrowth, Q-switched Nd:YAGlaser treatment appears to be ineffective at pro-ducing long-term hair removal.

Intense Pulsed Light Systems

Intense pulsed light (IPL) systems are highintensity pulsed light sources which emit poly-chromatic light in a broad wavelength spectrumof 515–1200 nm. The emitted wavelengths deter-mine not only the absorption pattern of theemitted light but also the penetration depth ofthe light. With the aid of different cut-off filters(515–755 nm), which only allow a defined wave-length emission spectrum, the optimal wave-length spectrum can be filtered to correspondto the depth of the target structure (i.e., hair fol-licles). Similarly, the emitted wavelengths canbe adopted to the patient’s individual skin type.Higher cutoff filters reduce the emission ofmelanin-absorbing wavelengths; thus beingsafer for darker skin types.

The pulse duration of IPL systems can be setto a wide range of parameters. The use of singlepulses is possible. In the alternative, high flu-ences can be divided into multiple pulses. Theintervals between individual pulses can be set atvalues between 1 and 300 ms. This delay, in the-ory, allows the epidermis and smaller vessels tocool down between pulses while the heat isretained in the larger target (hair follicles). This

69Currently Available Lasers and Light Sources


results in selective thermal damage. The extentof maximum delivered fluences and the spotsize vary, depending on utilized IPL.

When an IPL is used, a transparent refriger-ated gel is placed on the skin to cool the epider-mis and to improve light delivery to the skinduring treatment. The large rectangular spotsizes associated with most IPL hand piecesallows a large number of hairs to be treatedsimultaneously.

The IPL delivery of a broad range of wave-lengths has some advantages. The presence oflonger wavelengths provides better penetrationdepth into the dermis, while shorter wave-lengths can be filtered out to protect the epider-mis in darker-skinned individuals. Shorteremitted wavelengths may also be useful to treatred-brown hair (Ross et al. 1999).

One of the greatest technical advantages ofIPL systems is the large exposure area that isused. This improves the resultant damage ofdeep follicles. A disadvantage is that the rectan-gular spot size prevents treatment of hair-bear-ing areas on marked convexities or concavities(Ross et al. 1999).

Several studies have demonstrated the long-term efficacy of IPL hair removal devices (Goldet al. 1997; Weiss et al. 1999). In one study of 67subjects of Fitzpatrick skin phototypes I-IV,mean hair loss was 48% at 6 months or moreafter a single treatment. In another study, after a single treatment, hair reduction ranging from 33% to 60% was observed at 6 monthsafter treatment. Further studies of 14 subjectstreated with this technology and followed for>12 months after their last treatment showed amean of 83% hair reduction was obtained aftertwo to six treatments. As would be expected,repeated treatments appear to improve out-come. Despite this, some have suggested thatmore than three IPL treatments do not appearto increase the success rate. Not all would agreewith this. Finally, treatment with IPL, with andwithout bipolar radiofrequency, has been saidto be useful for the treatment of light-coloredhair. Generally, more treatments are requiredand the results are not expected to be as good asthose seen when treating darker-colored hairs.

Advantages

Laser-assisted hair removal is now an acceptedsuccessful treatment for the removal of un-wanted hair. It has been proven to be moreeffective than electrolysis and clearly representsthe best method for removing large areas ofhair in a relatively short period of time.

Disadvantages

The theoretical explanations behind laser-assisted hair removal seem logical. However,questions do remain. It is very difficult to pre-dict the ideal patient and ideal treatmentparameters for each patient. Even the samepatient may respond differently to the sameparameters on two different treatment sessions.

It is impossible to estimate the exact amountof energy absorbed by each hair follicle afterlaser irradiation owing to skin nonhomogene-ity, multilayering, and anisotrophic physicalproperties of hair growing at different angles in relation to the laser impact. In addition,because growing hair depths vary between 2and 7 mm depending on the body location, laserabsorption characteristics will vary dependingon the anatomic site. Finally, the percentage ofanagen and telogen hairs varies from site to site,from person to person, and from season to sea-son. It is not even clear whether the treatment ofanagen as compared to catagen or telogen hairseven matters.

Many studies now show the hair follicle tobe an incredibly resilient structure, regrowingafter a seemingly lethal injury. It is the deliveryof adequate fluences, optimizing wavelengths,and pulse durations, while reducing unwantedepidermal injuries that leads to the optimaltreatments of pigmented hair. Unfortunately,the treatment of unwanted light or white hairsremains a challenge.

Indications

Individuals may seek laser hair removal becauseof excess hair induced by genetics or associated

4



medical conditions. More commonly, laser hairremoval patients simply have unwanted hairthat would be considered normal in distri-bution and density. Yet, these individuals foremotional, social, cultural, cosmetic, or otherreasons want the hair to be removed. Also, indi-viduals with pseudofolliculitis barbae, a rela-tively common disorder seen with coarse, curlyhairs that occurs in glabrous skin, often seeklaser hair removal.

The ideal candidate for laser hair removal isa dark-haired, fair-skinned individual with littlemelanin within the overlying epidermis. Suchpatients tolerate the use of more effective higherfluences and relatively shorter wavelengths. Indarker-skinned individuals it may be preferableto utilize a longer wavelength laser device. Epi-dermal protection is also afforded by utilizinglonger pulse durations and active cooling.

Contraindications

There are a number of relative contraindica-tions that the laser physician should considerbefore treatment. The physician should ascer-tain that the patient has realistic expectationsfrom the laser treatment. Patients with a historyof hypertrophic or keloidal scarring should betreated more conservatively, using test spotsand lower fluences. Likewise, patients with ahistory of recent isotretinoin use should betreated less aggressively.

Any patient with a history of herpes simplexinfections should be given prophylactic antivi-ral therapy prior to any laser treatment at thatanatomic site. Patients who regularly takeaspirin or anticoagulant therapy should discon-tinue taking these medications at least 10 daysprior to treatment, if possible. If these medica-tions are not discontinued, patients may havemore bruising, as these medications can predis-pose to vessel extravasation after treatment. It isrecommended that patients having a history ofpersistent postinflammatory hyperpigmenta-tion, darkly tanned skin, or skin types greaterthan Fitzpatrick phototype III, not be treatedwith lasers having shorter wavelengths, as suchindividuals are at a greater risk of postinflam-matory hyperpigmentation.

Patients having photosensitivity disorders,or using systemic medications known to bephotosensitizing, should be carefully screened.

Although laser treatment in itself is inher-ently safe in pregnancy, the treatment doescause pain and can be distressing, and is bestdeferred in some patients until after delivery.

All patients should be instructed to postop-eratively avoid sun exposure and wear a broadspectrum sunscreen of SPF 30 or higher ontreated exposed areas.

Consent

Informed consent is mandatory and shouldinclude treatment options, potential reasonablerisks and benefits. One should avoid any guar-antees. Figure 4.1 is a suggested consent forlaser/light source hair removal.

Personal Laser Approach

Alexandrite Laser

Most individuals are no longer using rubylasers. However, the same general approach toalexandrite laser treatments would apply if theruby laser was used for hair removal in lighterskin types. We have found the alexandrite lasersto be very helpful in treating Fitzpatrick I–IIIskin phenotypes (Figs. 4.2–4.14). Although ithas been suggested that alexandrite lasers, withtheir longer 755-nm wavelength, are safer intreating darker complexions than are rubylasers, we have not consistently found this to bethe case. It would appear that the ability to treatdarker complexions with alexandrite lasers maybe more related to the longer pulse durationsemitted by some of these systems. It should benoted that unless appropriate cooling is uti-lized, some Fitzpatrick skin phenotype III andeven sun-tanned type II complexioned indivi-duals tend to have postinflammatory pigmen-tary changes after laser treatment.

71Personal Laser Approach


4


OPERATIVE CONSENT: LASER/LIGHT SOURCE HAIR REMOVAL

Patient . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . .

I am aware that laser/light source hair removal is a relatively new procedure. My doctor has explained tome that much of what has been written about these methods in newspapers, magazines, television, etc.has been sensationalized. I understand the nature, goals, limitations, and possible complications of thisprocedure, and I have discussed alternative forms of treatment. I have had the opportunity to ask ques-tions about the procedure, its limitations and possible complications (see below).

I clearly understand and accept the following:1. The goal of these surgeries, as in any cosmetic procedure, is improvement, not perfection.2. The final result may not be apparent for months postoperatively.3. In order to achieve the best possible result, more than one procedure will be required. There will be a

charge for any further operations performed.4. Strict adherence to the postoperative regimen (i.e., appropriate wound care and sun avoidance) is

necessary in order to achieve the best possible result.5. The surgical fee is paid for the operation itself and subsequent postoperative office visits. There is no

guarantee that the expected or anticipated results will be achieved.

Although complications following laser/light source hair removal are infrequent, I understand that thefollowing may occur:1. Bleeding, which in rare instances could require hospitalization.2. Infection is rare, but should it occur, treatment with antibiotics may be required.3. Objectionable scarring is rare, but various kinds of scars are possible.4. Alterations of skin pigmentation may occur in the areas of laser surgery. These are usually temporary,

but rarely can be permanent.5. A paradoxical increased hair growth may occur at or near treated sites. This generally responds to

further treatments.

This authorization is given for the purpose of facilitating my care and shall supersede all previous autho-rizations and/or agreements executed by me. My signature certifies that I understand the goals, limita-tions and possible complications of laser surgery, and that I wish to proceed with the operation.

. . . . . . . . . . . . . . . . . . . . . . . . . . Patient

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Witness Date



Diode Laser

We have found the 810-nm diode lasers veryuseful in treating Fitzpatrick I–IV skin pheno-types (Figs. 4.15–4.18). The laser should alwaysbe used with a cooling device. When used withthe longer emitted 30-ms pulse durations, somedarker Fitzpatrick skin phenotypes can betreated with a lessening of postinflammatorypigmentary changes. Diode systems are small,portable and very user-friendly.

As a general rule, somewhat lower fluencesare required for effective hair removal than arerequired with the ruby lasers. This may berelated to the deeper penetration of the 800-nmwavelength.

Nd:YAG Laser

We have found the nanosecond Q-switchedNd:YAG lasers to be highly effective in inducing


Fig. 4.2. Before alexandrite laser hair removal Fig. 4.3. Six months after five alexandrite hairremoval sessions

Fig. 4.4. Before alexandrite laser hair removal Fig. 4.5. Six months after five alexandrite hairremoval sessions


4


Fig. 4.6. Before alexandrite laser hair removal Fig. 4.7. Six months after three alexandrite hairremoval sessions

Fig. 4.8. Nine months after three alexandrite hairremoval sessions

Fig. 4.9. Before alexandrite laser hair removal



Fig. 4.10. Six months after three alexandrite hairremoval sessions


Fig. 4.12. Before alexandrite laser hair removal Fig. 4.13. Six months after three alexandrite hairremoval sessions


4



Fig. 4.15. Before diode laser hair removal Fig. 4.16. Six months after two diode hair removalsessions

Fig. 4.17. Before diode laser hair removal Fig. 4.18. Six months after five diode hair removalsessions

temporary short-term hair removal. Skin cool-ing is not required when a nanosecond laser isused. This contrasts with the requisite need forsome form of epidermal cooling with virtuallyall millisecond hair removal lasers.

When the Q-switched Nd:YAG laser tech-nique is utilized with a topical carbon suspen-sion, there is often a greenish hue to the areabeing treated when visualized through goggles.This is presumably due to the interactionbetween the 1064-nm wavelength and thecarbon chromophore. When the 1064-nm Q-switched Nd:YAG laser is used without topicalcarbon chromophore, dark terminal hairs oftenturn white on laser impact. Usually no post-


treatment crusting is noted. Erythema may varyfrom nonexistent to significant in its extent. It isquite safe to treat individuals who have darkercomplexions with nanosecond Q-switchedNd:YAG laser.

Millisecond Nd:YAG laser systems are thesafest laser hair removal systems for Fitzpatrickskin types V–VI (Figs. 4.19, 4.20). Although theycan also be used for lighter skin types, we havenot found the same degree of success whenthese lasers are compared to the shorter wave-length systems. Although postinflammatorypigmentary changes from this laser are rare,such changes can be occasionally expected insome individuals with dark complexions.

IPL

We have found intense pulsed light sources to beuseful in treating Fitzpatrick I and IV skin phe-notypes (Figs. 4.21–4.24). Although some IPLsources are FDA cleared in the USA for Fitz-patrick skin phenotypes V, we have found thatthe incidence of postinflammatory changes maybe too high for practical use in some of theseindividuals. In choosing emitted pulse dura-tions, we have noted that shorter pulse durationsare more helpful for finer hairs, while longerpulse durations appear to have greater efficacy intreating thicker hairs. In addition, longer pulsedurations, because of their epidermal pigmentsparing capacity, are chosen for darker skin phe-notypes. The choice of pulsing mode and inter-


Fig. 4.19. Before Nd:YAG laser hair removal Fig. 4.20. Six months after five Nd:YAG laser hairremoval sessions. Note not only decreased hair butalso improvement in pseudofolliculitis barbae

Fig. 4.21. Before IPL hair removal Fig. 4.22. Six months after three IPL hair removalsessions


pulse times are also dictated by complexion.Darker complexions are usually treated with adouble/triple pulse and longer interpulse times,in comparison with the parameters chosen withlighter skin complexions. As is true for all lasersused for hair removal, the higher the fluences, thebetter the results. The fluence chosen should beas high as can be tolerated without creating anepidermal blister.

Intense pulsed light sources have shown thegreatest safety when used with optimal skincooling.

Treatment Approach

The hair removal treatment technique with alllasers and intense pulsed light sources com-mences with preoperative shaving of the treat-ment site. This reduces treatment-inducedodor, prevents long pigmented hairs that lie onthe skin surface from conducting thermalenergy to the adjacent epidermis, and promotestransmission of laser energy down the hair fol-licle. A small amount of posttreatment crustingand erythema is to be expected. In darkly pig-mented or heavily tanned individuals, it may bebeneficial to use topical hydroquinones andmeticulous sunscreen protection for severalweeks prior to treatment in order to reduceinadvertent injury to epidermal pigment. Indi-viduals with recent suntans should not betreated until pretreatment hydroquinones havebeen used for at least 1 month. Postinflamma-

tory pigmentary changes are still to be expectedin individuals who have darker complexions.

All of the lasers and intense pulsed lightsources described in this chapter, when usedwith almost all fluences, can lead to temporaryhair loss at all treated areas. However, choosingappropriate anatomic locations and using higherfluences will increase the likelihood of perma-nent hair reduction after multiple treatments.Even though permanent hair loss is not to beexpected in all individuals, lessening of hairdensity and thickness is an expected finding.

The ideal treatment parameters must beindividualized for each patient, based on clini-cal experience and professional judgment. Forindividuals who have darker complexions, thenovice might consider delivering the laserenergy in several individual test pulses at aninconspicuous site with lower energy fluences.The delivered energies are then slowly in-creased. Undesirable epidermal changes such aswhitening and blistering are to be avoided.

Prolonged and permanent hair loss mayoccur following the use of all the aforemen-tioned described millisecond systems. However,great variation in treatment results is oftenseen. Most patients with brown or black hairobtain a 2- to 6-month growing delay after asingle treatment. There is usually only mild dis-comfort at the time of treatment. Pain may bediminished by the use of topical or injectedanesthetics.

Transient erythema and edema are alsooccasionally seen and irregular pigmentation of

4


Fig. 4.23. Before IPL hair removal Fig. 4.24. Six months after three IPL hair removalsessions


1- to 3-months duration is often noted. Thesechanges are far less common after treatmentwith an Nd:YAG laser. Permanent skin changes,depigmentation, or scarring is rare.

Finally, it is true for all hair removal lasersthat the higher the delivered fluences, the betterthe results. The fluence chosen should be ashigh as can be tolerated without creating an epi-dermal blister.

Postoperative Considerations

The use of ice packs may reduce postoperativepain and minimize swelling. Analgesics are usu-ally not required unless extensive areas aretreated. Prophylactic courses of antiviral agentsshould be considered in patients with a historyof herpes simplex infections in the to-be-treated area. Topical antibiotic ointment appliedtwice daily is indicated if posttreatment epider-mal injury occurred. Mild topical steroidcreams may be prescribed to reduce swellingand erythema. Any trauma, such as picking orscratching of the area, should be avoided. Dur-ing the first week of healing, sun exposureshould be avoided or sunblocks used. Make-upmay be applied on the next day unless blisteringor crusts have developed. The damaged hair isoften shed during or after the first week of thetreatment. Patients should be reassured thatthis not a sign of hair regrowth.

Complications

The incidence of cutaneous adverse effects afterlaser hair removal is both patient and laserparameter related. Patients with darker-coloredskin, especially skin types V and VI, are morelikely to experience cutaneous adverse effects,related to the abundance of melanin in theirepidermis. However, such complications are notlimited to patients with genetically determineddark skin. This may also be seen in patientswith darker skin due to other reasons, such assun-tanning and lentiginous photoaging. Theincidence of adverse effects will be modified byutilized wavelength, fluence, pulse duration,and associated cooling.

Pigmentary Changes

There is a remarkable variation in the reportedincidence of postoperative pigmentary changesafter laser hair removal. Unfortunately moststudies have not been carried out under stan-dardized conditions. In different studies, variedlaser parameters have been used, follow-upperiods have varied from 90 days to 2 years, andthe preoperative skin characteristics were notstandardized (hair color, skin pigmentation,anatomical region). Finally, the majority ofstudies estimate the incidence of side effects bysubjective clinical evaluation.

In general, laser-induced pigmentarychanges depend on the degree of preoperativepigmentation. Lighter skin types potentiallyexperience more postoperative hyperpigmenta-tion. Darker skin types experience more sub-clinical hypopigmentation. This finding is inaccordance with the fact that laser light in dark-skinned types is strongly absorbed by the epi-dermal melanin, leading to potential mela-nocytic damage (Anderson 1994). Conversely,thermal effects in lighter skin may provokepostinflammatory hyperpigmentation.

Hypopigmentation

Transient posttreatment hypopigmentationoccurs in 10%–17% of patients (Grossman et al.1996; Bjerring et al. 1998; Williams et al. 1998).The exact etiology of postlaser hair removal-induced hypopigmentation is unclear, but maybe related to the destruction of melanocytes,suppression of melanogenesis, or the redistri-bution of melanin in the keratinocytes.

Hyperpigmentation

Transient posttreatment hyperpigmentationoccurs in 14%–25% of patients (Grossman et al.1996; Bjerring et al. 1998; Williams et al. 1998),and is normally related to melanocytic-inducedstimulation. The causes of this hyperpigmenta-tion include delayed tanning, epidermal injury,or an immediate pigment darkening phe-nomenon resulting from photo-oxidation of

79Complications


pre-existing melanin. The darkening is usuallytransient, lasting only 3–4 weeks and resolveswithout sequelae in most individuals (McDaniel1993).

A potentially more serious hyperpigmenta-tion resulting from epidermolysis and blister-ing can occur at energy thresholds higher thanthose associated with immediate pigment dark-ening. This can be associated with permanentdyschromia.

Pain

Laser and light source heat-induced destructionof hair follicles is not pain free, as the hair folli-cle is well endowed with pain fibers arranged ina well-organized neovascular bundle. Theintensity of pain varies with the delivered flu-ence, utilized wave length, pulse duration, spotsize, repetition rate, laser interpulse spacing,and skin pigmentation. Regional body areassuch as the lip and groin, and chronically sun-exposed and tanned areas, also have been asso-ciated with greater amounts of pain perception.In addition, with increasing pulse duration,heat diffusion is likely to raise the temperaturearound the follicle and increase the level ofpain. Finally, pain can be perceived differentlyat different times of the month. During men-struation, the skin appears to be more sensitiveto pain and laser hair removal can be moreuncomfortable.

Scarring and Textural Changes

Despite the presence of severe macroscopiccutaneous damage, collagen and elastin net-works in the dermis are found to be normal inthe majority of the laser hair removal-treatedpatients. Scarring can occur, but is rare.

Effects on Tattoos and Freckles

Lightening of tattoos and loss of freckles or pig-mented lesions after laser-assisted hair removalare common. Patients should be made aware ofthis possibility.

Infections

Herpes simplex infections are uncommon afterlaser and light source treatment of hairremoval, but may occur, especially in patientswith strong prior history of outbreaks. Erup-tions most commonly are seen on or around thelip. Although the risk of bacterial infection isextremely low, it may occur if there is laser-induced epidermal damage.

Plume

The plume generated by the vaporized hairshaft has a sulphur smell and in large quantitiescan be irritating to the respiratory tract. Asmoke evacuator is advised.

The Future

The incredible amount of attention attracted bylaser and light source hair removal techniquesreflects a demand for more practical, tolerable,effective, and safer epilation techniques. At thistime, effective light and white hair removaltechniques do not exist. Research into tech-niques that light activate hair may be a part ofthe future treatment of nonpigmented hairs.

References

Adrian RM, Shay KP (2000) 800 nanometer diode laserhair removal in African American patients: a clini-cal and histologic study. J Cutan Laser Ther 2:183–190

Altshuler GB, Anderson RR, Smirnove MZ, et al (2001)Extended theory of selective photothermolysis.Lasers Surg Med 29:416–432

Anderson RR (1994) Laser-tissue interactions. In: Bax-ter SH (ed) Cutaneous laser surgery. The art andscience of selective photothermolysis. Mosby, StLouis, p 1–19

Anderson RR, Parrish JA (1983) Selective photothermo-lysis: Precise microsurgery by selective absorptionof pulsed radiation. Science 220:524–527

Anderson RR, Dierickx CC, Altshuler GB, et al (1999)Photon recycling. A new method of enhancing hairremoval Lasers Surg Med 11 Suppl:190

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Bjerring P, Zachariae H, Lybecker H, et al (1998) Evalua-tion of free-running ruby laser for hair removal ActaDerm Venereol 78:48–51

Gold MH, Bell MW, Foster TD, et al (1997) Long-termepilation using the EpiLight broad band, intense-pulsed light hair removal system. Dermatol Surg23:909–913

Gorgu M, Aslan G, Akoz T, et al (2000) Comparison ofalexandrite laser and electrolysis for hair removalDermatol Surg 26:37–41

Grossman MC, Dierickx CC, Farnelli W, et al (1996)Damage to hair follicles by normal-mode ruby laserpulses. J Am Acad Dermatol 35:889–894

Lin TD, Manuskiatti W, Dierickx CC, et al (1998) Hairgrowth cycle affects hair follicle destruction by rubylaser pulses. J Invest Dermatol 111:107–113

Lou WW, Quintana AT, Geranemus RG, et al (2000)Prospective study of hair reduction by diode laser(800 nm) with long-term follow-up. Dermatol Surg26:428–432

McDaniel DH (1993) Clinical usefulness of the hexascan.J Dermatol Surg Oncol 19:312

Nanni CA, Alster TS (1997) Optimizing treatmentparameters for hair removal using a topical carbon-based solution and 1064 nm Q-switched neody-mium:YAG laser energy. Arch Dermatol 133:1546–1549

Nanni CA, Alster TS (1999) Laser-assisted hair removal:side effects of Q-switched Nd:YAG, long-pulsed

ruby, and alexandrite lasers. J Am Acad Dermatol41:165–171

Ohshiro T, Maruyama Y (1983) The ruby and argonlasers in the treatment of nevi. Ann Acad Med Sin-gapore 12(2):388

Ross EV, Rathyen JS, Gandet T, et al (1996) Recyclingwasted photons: A device to increase laser energyused in surgery. Lasers Surg Med 8(Suppl):87

Ross EV, Ladin Z, Kreidel M, et al (1999) Theoreticalconsiderations in laser hair removal Dermatol Clin17:333–355

Tope WD, Hordinsky MK (1998) A hair’s breath closer?Arch Dermatol 134:867–869

Weiss RA, Weiss MA, Marwaha S, et al (1999) Hairremoval with a noncoherent filtered flashlampintense-pulsed light source. Lasers Surg Med 24:128–132

Wheeland RG (1997) Laser-assisted hair removal Der-matol Clin 15(3):469–477

Williams R, Havoonjian H, Isagholian K, et al (1998) Aclinical study of hair removal using the long-pulsedruby laser. Dermatol Surg 24:837–842

Williams RM, Gladstone HB, Moy RL (1999) Hairremoval using an 810 nm gallium aluminumarsenide semiconductor diode laser: a preliminarystudy. Dermatol Surg 25:935–937

Zenzie HH, Altshuler GB, Anderson RR, et al (2000)Evaluation of cooling for laser dermatology. LasersSurg Med 26:130–144

81References


History

Ablative resurfacing was first introduced in themid 1990s. Technological advancements withcarbon dioxide (CO2) lasers had emerged tominimize their thermal impact on tissue and,subsequently, possible clinical uses wereexplored. Two types of CO2 lasers were devel-oped. The first utilized ultrashort pulse dura-tions to minimize heat deposition in the tissue.The other utilized the laser beam in a continu-ous wave (CW) mode, in conjunction with ascanning device, to shorten the laser dwell timeand, thereby, minimize thermal damage (Lasket al. 1995). These lasers were first used for thetreatment of rhytides and acne scars; however,investigators soon discovered that superficial

sun damage changes, including lentigines, aswell as actinic keratoses, fine lines, and othersuperficial imperfections also improved. Addi-tionally, the deposition of heat was noted tocause a tissue-tightening effect, which softeneddeeper wrinkles (Fitzpatrick et al. 2000). TheCO2 laser proved to be very effective; however,as the technology expanded into the dermato-logic and plastic surgeon’s armamentarium, itwas found to have significant side effects, espe-cially in inexperienced hands. Many patientsexperienced erythema that lasted for weeks tomonths as well as temporary hyperpigmenta-tion, acne, and contact sensitivity to topicalproducts. Yeast, bacterial, and viral infectionswere a potential problem. Prolonged hypopig-mentation and scarring, although infrequent,were also of great concern.

In an effort to decrease the risk/side effectprofile, the use of erbium lasers was explored(Zachary 2000) These short-pulsed lasers, withstronger water absorption at 2.94 µm were lessinjurious to deeper tissues; they ablated tissuebut left little residual thermal damage. Unfortu-nately it became apparent that this laser,although good for smoothing out the surface,did not lead to the same tightening effect as wasnoted with the CO2 lasers. The next level ofadvancement entailed increasing the pulsewidth of the erbium lasers to include somedeposition of heat, which would allow tighten-ing (Pozner and Goldberg 2000). In addition,lasers were developed that combined botherbium and CO2 lasers to allow heat depositionby the CO2 component as well as pure ablationby the erbium component. The potential benefitwas great; however, side effects continued to bepresent (Tanzi and Alster 2003). A recent papershowed that utilizing a topical anesthetic, whichhydrated the skin, minimized side effects even

Ablative and Nonablative Facial ResurfacingSuzanne L. Kilmer, Natalie Semchyshyn

5

▲

Core Messages Ablative and non-ablative laser re-

surfacing lead to an improvement inphotodamaged skin.

Ablative laser resurfacing produces asignificant wound, but long-lastingclinical results.

Nonablative resurfacing is cosmeti-cally elegant, but generally only leadsto subtle results.

Visible light nonablative devices leadto a lessening of erythema and super-ficial pigmentary skin changes

Midinfrared infrared laser devicespromote better skin quality and skintoning.

The role of newer plasmakinetic andfractional resurfacing devices has yetto be determined.


with pure CO2 lasers. In this study, a decreasedincidence of prolonged erythema, pigmentarychanges, and scarring were noted (Kilmer2003).

Despite these advances, the significantamount of downtime associated with ablativeresurfacing has led to the development of non-ablative lasers to improve solar damage, includ-ing rhytides, telangiectases, and pigmentation.Nonablative technology evolved beginning withthe use of early-pulsed dye lasers (Zelickson1999) It had been noted that using the pulseddye laser for the treatment of port wine stainsthat had been scarred from previous argon lasertreatment improved not only the port winestain, but the scars as well. In addition, patientswith facial telangiectases or poikiloderma ofCivatte commented on their improved appear-ance.

These early studies showed that the pulseddye laser not only improved rhytides but alsocaused histological changes in the dermis con-sistent with improvement of sun-damaged col-lagen. Similarly, the Q-switched Nd:YAG laserused in combination with a topical carbon sus-pension for laser hair removal was noted todiminish fine lines, most likely due to a pho-tomechanical effect. Lasers with an affinity forwater absorption were then investigated fortheir effects on wrinkle improvement. Theselasers, which include the 1320-nm and 1450-nmsystems, deliver heat into the dermis to trigger a wound-healing response. In these cases, epi-dermal damage was avoided by a concomitantcooling mechanism. Laser-induced histologicalchanges showed increased fibroblast activityand new collagen deposition. These changeswere similar to those seen with both the pulsedye and Q-switched Nd:YAG lasers. Over time,there has been an ever-increasing surge inpatients demanding a “no downtime” wrinkletreatment and, consequently, the field of nonab-lative facial rejuvenation has expanded tremen-dously. Because ablative and nonablative lasersand their indications, benefits, risks, and treat-ment techniques vary so greatly they are sepa-rated in the discussion below. Ablative laserresurfacing will be discussed first, followed bythe various nonablative technologies.

Ablative Resurfacing


After a decade of ablative resurfacing, the main-stays remain both the CO2 and erbium lasers. Asnoted above, the CO2 lasers are available in one oftwo forms: the ultrashort pulsed and the rapidlyscanned versions. The UltraPulse is the oldestand most well known of the pulsed versions. TheSilkTouch and FeatherTouch were the more pop-ular of the scanned versions. The TruePulse hadan ultrashort pulse width and caused the leastthermal damage of any CO2 lasers.

The available erbium lasers include short-pulse and variable-pulsed lasers (with a pulserange typically in the microsecond to 10-msrange). Increasing the pulse width correlatesdirectly with an increase in residual thermaldamage, providing possible additional benefitas well as potential side effects. Of note, how-ever, the short-pulse erbium lasers are not risk-free. Since the ablation depth of injury is animportant factor, and erbium lasers can ablateto significant depths, the risk of scarring can besignificant if these lasers are used incorrectly.

Advantages

Ablative resurfacing’s biggest advantage is itsefficacy. With one procedure, a significantreduction in wrinkles, solar lentigines, kera-toses, surface irregularities, and skin laxity isnoted. Five to ten years can be removed from aperson’s perceived age. The effect is immediate,in contrast to nonablative methods whereresults improve slowly over time. The effect isalso predictable and, in most cases, at least 50%improvement is noted.

Most epidermal irregularities can beremoved with a single pass. Subsequent passesallow for more tightening or further sculpting.The improvement in pigmentary changes,superficial growths, scars, fine lines, and skinlaxity is dramatic. Skin tones are evened outand returned to normal nonsun-exposed color.Often, pores are diminished and solar elastoticchanges are removed. Nevi, sebaceous hyper-

5

84 Chapter 5 Ablative and Nonablative Facial Resurfacing


plasia, and other dermal tumors can be flat-tened. Actinic keratoses are removed and anysuperficial basal cell carcinomas (BCC) can betreated at the same session. In fact, severalpatients with a long history of BCCs occurringon both facial and body areas have not experi-enced new tumors on the face subsequent toCO2 facial resurfacing – even though they con-tinue to produce tumors on their nonfacialareas (S.L. Kilmer, personal observation).

Disadvantages

The disadvantage of ablative resurfacing is thesignificant downtime required during the recov-ery period. During the first week, erythema andedema are significant, wound care is necessary,and social activities come to a halt. Postoperativeedema decreases after the first 3–4 days, whereasthe erythema is prominent for the first week untilre-epithelialization occurs and slowly diminishesover the next few weeks. The risk of infection,pigmentary changes and scarring is higher in theimmediate postoperative period, as it is in anyprocedure where de-epithelialization occurs.Makeup is necessary for several weeks to monthsuntil any residual erythema and postinflamma-tory hyperpigmentation diminishes. Contactdermatitis may be more easily triggered in thepostlaser disrupted epidermis, leading to pruri-tis and erythema. Acne, activated by the occlu-sive effect of the petrolatum or other dressings, ismore common in the treated area and may takeseveral weeks to clear. Relative hypopigmenta-tion can be seen as removal of the acquired sundamage or “actinic bronzing” returns the skin to its normal nonsun-exposed color; this under-scores the need for careful blending (feathering)into any surrounding areas of untreated sun-damaged skin during the procedure. Of greaterconcern is the development of either permanentdelayed hypopigmentation or scarring.

Indications

The most common indications for ablativeresurfacing include wrinkles and acne scars.This procedure is especially helpful when pho-

todamage is a significant component as actinickeratoses and lentigines are easily ablated. Epi-dermal lesions such as seborrheic keratoses and even some dermal lesions such as seba-ceous hyperplasia, nevi, trichoepitheliomas,and syringomas can be smoothed out. Superfi-cial basal cell carcinomas can be treated withCO2 laser resurfacing in a manner similar todesiccation and curettage. It appears that thismodality also decreases the risk for the develop-ment of future actinic keratoses and basal cellcarcinomas (S.L. Kilmer, personal observation).

Contraindications

There are few true contraindications. A per-sonal or family history of vitiligo should be con-sidered a relative contraindication. Theoreti-cally, a Koebner phenomenon could occur andbring out vitiligo in the laser-treated areas. Scle-roderma patients should be counseled thatablative resurfacing could exacerbate their dis-ease, although reports of successful treatmentexist (T. Alster, personal communication).Darker-skinned patients need to understandthe likelihood of hyperpigmentation, which isusually temporary but may be long-lasting. Theuse of hydroquinone preparations with vitaminA derivatives, glycolic acid and/or topical corti-costeroids, and good sunscreen minimized thisproblem. Patients with very fair and fine-poredskin appear to be at greatest risk for delayedhypopigmentation, which can be permanent.Unrealistic expectations and inability or unwill-ingness to perform wound care are contraindi-cations for ablative skin resurfacing.

Consent

Informed consent is mandatory and shouldinclude treatment options, potential risks, andbenefits. No guarantees should be made. A care-fully written, detailed consent that explains theabove is suggested (Fig. 5.1).

85Ablative Resurfacing


5


CO2 & ERBIUM LASER RESURFACING PATIENT INFORMATION AND CONSENTWHAT IS LASER SKIN RESURFACING?The carbon dioxide (CO2) laser has been used for more than 25 years for treating the skin. An intensebeam of light is emitted, which heats and vaporizes skin tissue instantly. Recently developed CarbonDioxide and Erbium Lasers are able to perform highly specific vaporization of tissue using powerfullyfocused light to precisely remove the layers of skin, vaporizing the ridges of scars and wrinkles andsmoothing out the surface of the skin. In addition, the skin often tightens and collagen remodelingoccurs with layers of new collagen replacing sun-damaged collagen. The CO2 laser tightens the skinmore while the erbium laser is used more for sculpting. We may use both of these lasers to maximizebenefit depending on each individuals’ needs.

BENEFITSLaser resurfacing may significantly reduce facial wrinkle lines and acne scarring. The length of time thesebenefits will last is unknown. Sun spots and brown spots are often removed as well.

RISKS AND DISCOMFORTSThe most common side effects and complications are explained below.

ERYTHEMA (redness of skin)The laser-treated areas have a distinctive redness which is much more vivid than the areas not treated.This redness generally will last one to four months beyond the time required to heal the skin surface(usually 7 to 10 days). This redness represents increased blood flow from healing as well as new growthof the superficial tissue and fades gradually week to week.

INFLAMMATION (swelling)This is common and varies from person to person. Most patients swell moderately, but in some patients,swelling is severe. Your skin may feel tight in the initial weeks following treatment.

HYPERPIGMENTATION (increased skin color)This is common in those with dark complexions, and almost always is temporary.It responds to the use of hydroquinone, UVA protective sunscreens, and topical retinoids postoperatively.

HYPOPIGMENTATION (decreased skin color)This has been uncommon and although is usually related to the depth of the peel, can occur forunknown reasons even when the procedure has been performed properly. In addition, removing sundamaged skin can return you to your natural lighter color similar to areas on your body that have nothad long term sun exposure (i.e., underarms). Delayed hypopigmentation can occur months – yearsafter the procedure is performed and can be permanent.

SCARRING OR KELOIDSScarring is not anticipated as a consequence of this procedure, but any procedure in which the surfaceof the skin is removed can heal with scarring. This usually occurs because of some secondary factorwhich interferes with healing, such as infection, irritation, scratching, or poor wound care. Scarring frominfection, irritation or scratching, does blend and ordinarily disappears in a few months, but some scar-ring may be permanent if it occurs. Hypertrophic scars or keloids in susceptible people may suddenlyappear. Most of these respond to injections or special creams. Some scarring could be permanent.Notify your physician if you have ever used Accutane as this can increase your risk for scarring.

ALLERGIC REACTIONSAllergic reactions or irritations to some of the medications or creams may develop. An increased sensi-tivity to wind and sun may occur, but is temporary and clears as the skin heals.If you have had a cold sore or herpes outbreak in or around the area to be treated, let us know astreatment can reactivate it.

DRUG SIDE EFFECTSThe drugs that may be administered can have the following general side effects: Retin-A, Renova, (or other topical Vitamin A creams)Sensitivity to sunlight, including sunlamps, mild skin irritation or dryness.Melanex, Soloquin Forte, Lustra, (Hydroquinones or bleaching creams)Mild skin irritation, itching, burning sensation.

Fig. 5.1. Informed consent for ablative resurfacing



Zovirax and Valtrex (antivirals)Headaches, nauseaKeflex and Zithromax (antibiotics)Dizziness, headache, nausea, rashDiflucan (antiyeast)Headache, nauseaToradol, (nonsteroidal ant-inflammatory)Actinic ulcers, bleeding, asthmaVicodin, Maxidone, Darvocet, and Percocet (pain medication)Lightheadedness, dizziness, sedation, nausea and vomiting.ValiumDizziness, lightheadedness, sedation, and respiratory depression

EXPLANATION OF THE PROCEDUREA personal interview and clinical examination will be conducted to obtain relevant facts about yourmedical history, dermatologic history, and any medications you are currently taking or have taken in therecent past. Preoperative vitamin A and C creams may be started prior to the procedure. A sunscreenwith UVB and UVA protection should be applied every morning. If you have a dark complexion, you mayalso need to apply a bleaching gel. You will begin taking an antiviral medication the night before or themorning of the procedure. On the day of the procedure, you will begin taking an antibiotic by mouth fora minimum of 5 days. A topical anesthetic cream will be applied for 2 hours before the procedure todecrease pain. Valium, Vicodin, Toradol or similar pain medication may be given as needed for pain.Injections to block the facial nerve endings may be performed just prior to the procedure. Please plan tohave someone drive you home after the procedure.

AFTER CAREAn aftercare sheet will be given to you on your surgery day. You will be required to soak the treated areafor 10 minutes, every few hours, using 1 teaspoon of vinegar (white) per 2 cups of water. Aquaphor orVaseline is to be kept on your face continuously for 6 to 8 days. Any scabs should be gently soaked off.After soaking, pat the skin dry with a towel and apply more ointment over the treated area. Oozing ofclear fluids, mild to moderate swelling, and a mild burning sensation may occur. Redness is expected for1 to 2 weeks after the procedure and will fade gradually over 4 to 12 weeks.

NO GUARANTEESIt is possible that you may derive no benefits from the above-described procedure. While this procedureis effective in most cases, no guarantees can be made that a specific patient will benefit from treatment.Do not sign this form unless you have had a chance to ask questions and have received satisfactoryanswers to all of your questions.

WAIVER OF LIABILITYAll insurance companies, including Medicare, only pay for services that they determine to be ‘reasonable’and necessary. If your insurance company determines that a particular service is not reasonable and nec-essary under their program standards, they will deny payment for that service. I believe that your insur-ance, or Medicare, will deny payment for Laser Resurfacing, for the following reason: Insurancesusually do not pay for cosmetic procedures.

CONSENTMY SIGNATURE INDICATES THE FOLLOWING: 1) I HAVE READ AND I UNDERSTAND THE INFORMATIONOUTLINED ABOVE; 2) I HAVE DISCUSSED MY QUESTIONS WITH THE DOCTOR OR HER STAFF. 3) I AMAWARE THAT PAYMENT IS DUE 2 WEEKS PRIOR TO MY SURGERY DATE.I AUTHORIZE THE RELEASE OF MY PHOTOGRAPHS.

DATE . . . . . . . . . . NAME OF PATIENT . . . . . . . . . . . . . . SIGNATURE OF PATIENT . . . . . . . . . . .

DATE . . . . . . . . . . NAME OF WITNESS . . . . . . . . . . . . . . SIGNATURE OF WITNESS. . . . . . . . . . .

DATE . . . . . . . . . . NAME OF PHYSICIAN . . . . . . . . . . . . SIGNATURE OF PHYSICIAN . . . . . . . . .

Fig. 5.1. Informed consent for ablative resurfacing (continued)



A successful ablative resurfacing procedurebegins with a thorough preoperative evaluation.This evaluation should pay careful attention topatient expectations, preoperative photographs,and counseling about the perioperative period.Medications are prescribed to minimize poten-tial infection and include a prophylactic anti-biotic (typically a first-generation cephalospo-rin), antiviral (acyclovir or valcyclovir), andantiyeast (fluconazole) medications. A non-steroidal anti-inflammatory agent and an an-algesic are also prescribed to control postopera-tive discomfort. Patients are educated as to whatto expect during the healing period; appropriatewound care for the first week is reviewed. Pre-operatively, patients apply topical anestheticcream EMLA (eutectic mixture of lidocaine and prilocaine) with occlusion 2.5 h prior to the procedure time (Fig. 5.2). Forty-five minu-tes before the procedure, EMLA is reappliedwith occlusion. The following medications arealso provided by mouth: diazepam, hydroco-done or similar analgesic, and intramuscularketorolac.

The first CO2 ablative laser pass is per-formed mainly to remove the epidermis andfeather peripherally to minimize any demarca-tion with surrounding nontreated skin. The sec-ond laser pass, and, if used, a third pass is forheat deposition to promote tightening. Finally,the erbium laser (in the ablation mode) can beused to remove superficial thermal necrosis forfurther sculpting of deeper rhytides and/oracne scars.

When the UltraPulse CO2 laser specifically isused, the first pass is usually performed at adensity of 7 for the main treatment areas. Thepreviously described preoperative topical anes-thetic technique leads to increased skin hydra-tion and, consequently, allows the use of ahigher density setting to more efficientlyremove the epidermis. If no hydration is used,the first pass is performed at a density of 6.Hydration is mandatory, however, for treatmentof the neck. When moving towards the jawlineand hairline, the density is decreased to 6 andpossibly 5 for higher risk patients. Progressingdown the neck, density settings are decreasedby one per row until the lowest setting of 1 isreached, allowing skip areas in the final row.The epidermis is then wiped free on the centralface and other areas where a second pass is to beperformed. The peripheral edges are usuallyleft intact and the neck is never wiped.

The second CO2 laser pass is performed at adensity of 4–5 depending on the tighteningneeded and the risk for the area. The upper eye-lids and the central face are typically treated atdensities of 5, whereas mid cheeks and somelower eyelids may be treated with densities of 4.Delivered energies are also decreased towardsthe periphery. A second pass is rarely done onthe lateral cheeks unless acne scarring is pre-sent. A third pass may be done on acne scarsand in perioral and glabellar regions to deliveradditional heat to enhance tightening. Whenusing the EMLA topical anesthetic technique,the face is typically treated in sections (Fig. 5.3).All passes in a given area are performed beforemoving on to the next section.

In cases where deep rhytides or acne scarspersist, the erbium laser in the ablative(shorter-pulsed) mode is helpful to sculpt theedges or to remove the superficial coagulative

5


Fig. 5.2. EMLA with occlusion, preoperative


necrotic layer, which can hinder healing. Theutilized erbium laser energy, and spot size,depends on the area to be treated, with a 3.5- to5.0-mm spot size set at 1–2 J/cm2 most com-monly used. Bleeding can occur in these areasas the thermal effect is insufficient to providehemostasis.

When the erbium laser is the sole utilizedsystem, the first pass is performed to most effi-ciently debride the epidermis. This is under-taken typically at 100 µm of ablation with nocoagulation. The ablation depth is decreased atthe periphery to minimize the final demarca-tion between treated and untreated areas. Forthe second pass, erbium laser coagulative pulsesor, alternatively, ablation with concomitantcoagulation is used to provide the heat neededfor the tightening effect. Finally, the third passutilizes the ablation mode to remove superficialnecrosis but can also include additional coagu-lation to enhance the thermal effect. To treat theneck, pure ablation is used with a graduateddrop in setting to feather while proceedinglower and laterally on the neck. As with thepulsed CO2 laser, careful feathering to blend thetreated and untreated areas is critical to ensurea natural and cosmetically pleasing result.

Postoperative Care and Complications

Both occlusive and nonocclusive types of dress-ings are available. Occlusive dressings entail acovering that occludes the skin and may pro-vide more postoperative comfort. These aretypically left in place for 1–3 days beforeremoval followed by soaking of the treated area.The patient may then continue wound care withan open dressing. The downside to this methodis that the occlusion can mask an infection andmay, in fact, promote infection by harboringbacteria in the occluded area (Christian 2000).Open dressings are usually petrolatum-basedointments that provide an occlusive-like effectand allow for easy visualization and monitoringof the healing skin. Frequent soaking withdilute acetic acid promotes healing and inhibitsbacterial growth. A variety of petrolatum-basedproducts have been used. Regular vegetable oil-based shortening is also an excellent choice. It isthe product with the least likelihood of trigger-ing a topical allergic or irritant dermatitis. Veg-etable oil-based shortening is usually not thefirst line product, because of its lack of ele-gance. However, if an allergic or irritant reac-tion occurs while using another open dressing,it is our first choice substitute.

Complications of ablative resurfacing caninclude prolonged erythema, contact dermati-tis, acne, infection, pigmentary changes, andscarring (Lewis and Alster 1996; Nanni andAlster 1998; Sriprachya-Anunt 1997). Postopera-tive erythema typically improves with time; it ismost pronounced during the first week andsteadily subsides over the next few weeks. Pro-longed erythema and/or pruritus result fromcontact dermatitis, infection, or thermal dam-age. Allergic and irritant contact dermatitisoccurs more commonly in newly resurfacedskin and likely relates to the increased densityof Langerhans cells, which is noted in areas ofperturbed epidermis. Thus, anything thatcomes into contact with the skin can trigger areaction as the disrupted epidermis more read-ily attracts the dendritic cells to potential sitesof antigen invasion. The most likely contactantsare sources of perfumes or dyes such as thosefound in fabric softener dryer sheets or deter-gents. Patients should be forewarned to elimi-


Fig. 5.3. EMLA with occlusion; the face is treatedwith the CO2 laser in sections, as shown


nate these potential allergens. A reaction to atopical petrolatum-based dressing may occurduring the first postoperative week and is besttreated by switching to vegetable shortening.Oral antihistamines and topical steroids areinvaluable for treating more severe reactions.

Acne can be activated by the occlusive effectof the dressings. It can take up to 6 weeks toclear. This acneform eruption usually respondsto removal of the occlusive factor and a topical,or even oral, antibiotic may be needed in moresevere cases. After a few weeks, comedolyticssuch as topical benzoyl peroxide, retinoids, andalpha- or beta-hydroxy acids may be added asneeded.

Infection from either a viral, bacterial, oryeast/fungal source can also prolong erythema.Infections need to be treated promptly with achange in oral agents based on culture identi-fication and sensitivity results or based onempiric observation. If herpes simplex viralinfection (HSV) is suspected, the antiviralmedication should be increased to a herpeszoster dose. Valcyclovir is the antiviral agent ofchoice, recommended for its ability to attainhigher blood levels in comparison to other anti-HSV drugs (Data on file, GlaxoSmithKline). Forsuspected yeast infections, additional doses offluconazole or spectazole are recommended.

Relative hypopigmentation can occur whenremoval of acquired sun damage has returnedthe skin to its normal nonsun-exposed color.A careful technique of feathering into theuntreated, sun-damaged areas will minimizethis demarcation. If it is still prominent, a touchup at the line of demarcation can help. Addi-tionally, chemical peeling agents, hydroquinonepreparations, or lasers which target melanincan be utilized to minimize the solar lentiginesin the untreated area. Delayed hypopigmen-tation can arise in areas of significant erythemawhich may mask its earlier appearance.Although this hypopigmentation can be perma-nent, treatment with the excimer and othersimilar 308-nm light devices has been shown toimprove this leukoderma (Friedman andGeronemus 2001)

Of greatest concern is scarring, which canbe atrophic or hypertrophic in nature. Scarsshould be treated immediately, once they

become apparent, as earlier treatment is morebeneficial. Topical steroids should be appliedand intralesional steroid injection is recom-mended for any hypertrophic scars. The pulseddye laser can provide significant benefit butseveral treatments may be needed to obtain thedesired result. The laser settings are similar tothose used in other scar treatments and aregenerally performed at 3- to 6-week intervals,depending on severity, until the scarring pro-cess is abated.

Results

Ablative resurfacing leads to dramatic improve-ment in the overall quality of the skin includingfine lines, deeper rhytides, solar lentigos, andelastotic changes. It is also very effective insmoothing other superficial irregularities suchas keratoses, nevi, benign tumors, and acnescars (Figs. 5.4–5.6).

The Future

The field of ablative resurfacing has remainedstable with relatively few advances over the past5 years. A notable exception to this has recentlyarisen with the advent of both plasmakineticand fractional resurfacing. Although in theirinfancy, these novel resurfacing techniquesshow promise as we await the completion oflong-term studies.

Nonablative Resurfacing


Currently, the devices which are available in thefield of nonablative resurfacing can be dividedinto two main types: those with a vascular tar-get that initiate a cascade of events by woundingdermal microvasculature and those that targetwater to deposit heat into the dermis. The firstgroup includes pulsed dye lasers (PDL) andintense pulsed light (IPL) sources, as well as oneIPL device used in conjunction with radiofre-quency (RF) energy. The pulsed dye lasers are

5



in the 585- to 595-nm range and have pulsewidths which vary from 350–450 ms to 1.5, 3, 6,10, 20, and 40 ms. IPL sources utilize a broadband of light with cutoff filters in the 550- to690-nm range which are used to eliminate theshorter, undesirable wavelengths. A recently

developed device uses a combination of IPL andRF and has a similar cutoff filter-IPL systemwith the addition of up to 25 J/cm3 RF energy.The 1064-nm laser in the millisecond andmicrosecond domain has been used for nonab-lative rejuvenation as well. Finally, a combina-

91Nonablative Resurfacing

Fig. 5.4. 73-year-old woman with severe dermatoheliosis, pre (a) and 6 weeks post (b) CO2 and erbium laserresurfacing

a b

Fig. 5.5. 64-year-old woman with photodamage, pre (a) and post (b) CO2 laser resurfacing

a b


tion treatment with 1064-nm and 532-nm lasershas proven beneficial for fine lines and pigmen-tary and vascular changes.

There are several mid-infrared lasers thattarget water to effect dermal heat deposition.The 1320-nm Nd:YAG laser was the original sys-tem to use this approach in nonablative resur-facing in conjunction with a spray coolingdevice to protect the epidermis. Subsequently,the 1450-nm diode laser was shown to have evengreater water absorption resulting in moresuperficial heat deposition. Most recently, the1540-nm erbium:glass laser system, which hasbeen more widely available in Europe, hasemerged as an effective nonablative laser. Thesedevices do not improve vascular or pigmentarychanges. However, their histological and clinicalimprovement of wrinkles is well documented(Fournier et al. 2001; Goldberg et al. 2002; Hard-away 2002; Lupton 2002).

A unique high-powered monopolar RFdevice has recently been shown to deposit heatdeeper in the dermis and possibly into subcuta-neous tissue including fascia and fat. This effectcan lead to more dramatic tissue tightening aswell as traditional nonablative benefits. Addi-tionally, acne scars as well as fine lines andsurface changes have been noted to improve(Zelickson 2004).

Advantages

The main advantage of nonablative wrinkletreatment is the relative lack of patient downtime in contrast to the obligatory 7–10 days ofrecovery time for ablative resurfacing. Thedevices that target dermal vasculature will helpminimize, if not eliminate, the telangiectasesfrequently noted in patients with a history of

5


Fig. 5.6. 48-year-old man with dermatosis papulosa nigra, photodamage and acne scarring, pre (a) and post(b) CO2 resurfacing

a b


significant sun exposure. Patients with diffuseerythema, resulting either from sun damage orrosacea, also note improvement. Devices whichcan target melanin as a potential chromophore,such as those with an IPL component, can alsotreat any concomitant pigmentary changes.Lentigines, melasma, and poikilodermatouschanges can be improved if not completelyeradicated.

Disadvantages

The degree of wrinkle reduction is not as signif-icant as that seen with the ablative devices andthus, patient dissatisfaction can be an issue. Theimprovement is often referred to as skin “ton-ing” or “plumping up of the skin,” in contrast tothe “tightening” often seen with ablative resur-facing. Appropriate patient education about thedegree and unpredictability of enhancement isthe key to success for these procedures. Goodquality preoperative photography is helpful todocument these changes as they can be subtleand improvement occurs over time, making thechange less apparent.

Indications

Nonablative resurfacing is best for patients with fine lines, and, if the appropriate device isused, erythema, telangiectasia, or pigmentarychanges. Patients with a vascular componentare best treated with the longer-pulsed PDLs(VBeam/VStar), IPL, and IPL + RF. IPL is best at targeting pigment and can also targethemoglobin, although multiple treatments areoften necessary to eradicate the vascular com-ponent. If telangiectases are the more predomi-nant characteristic, the longer-pulsed PDLs areour laser of choice, as they more effectively tar-get vessels in a single treatment and are at leastequivalent to IPL devices for wrinkle reduction.For those patients prone to acne or with en-larged pores or sebaceous hyperplasia, the mid-infrared systems offer the greatest ability to tar-get the sebaceous gland.

Contraindications

Photosensitivity to the wavelength of light used,recent tan (if using a wavelength absorbed bymelanin), and unrealistic expectations are thethree main contraindications. In addition,active herpes simplex or other infections orlesions of concern in the treatment field shouldbe avoided.

Consent

Informed consent is mandatory and shouldinclude treatment options, potential risks, andbenefits. No guarantees should be made. A care-fully written, detailed consent that explains theabove is suggested (Fig. 5.7).


The wide array of nonablative rejuvenationdevices allows us to individualize treatmentbased on patients’ specific concerns. If vesselsand pigment are the main issues, we start by tar-geting the chromophore most bothersome to thepatient. Subsequently, we use the system whichwould best treat the most prominent residualchromophore. For the pulsed dye lasers, usingthe largest spot size with the highest fluence at apulse width that is just subpurpuric provides thebest results. Typical PDL settings include a 10-mm spot size with 7–7.5 J/cm2 and a 6-mspulse width. Occasionally, we will increase thepulse width to 10 ms to avoid purpura if thepatient is on some form of anticoagulant therapy.One pass is performed for nonablative rejuvena-tion, whereas additional pulses may be needed to treat discrete vessels, if present.

For mild, diffuse erythema, especially whenlentigines are also present, we start with an IPLdevice, as it will target both melanin andhemoglobin. IPL sources vary depending on theflash lamp and the cut-off filters used. The spotsize is usually set, but the pulse width can bevaried by time per pulse and spacing between1 and 3 pulses.

Although a 585-nm, 350-ms PDL is used forwrinkle reduction, the low utilized fluences of



5


Consent for Nonablative Resurfacing/Collagen Stimulation

These lasers use a light to selectively heat up the collagen in the dermis to stimulate collagen remodel-ing. The superficial part of the skin is spared; therefore, there is no injury to the outer layers of skin. Thismeans that there will be no break in the surface of the skin and you can apply makeup immediately afterlaser treatment. There is little or no downtime associated with this laser treatment. Because there is noimprovement in the superficial part of the skin, patients often do microdermabrasion in conjunctionwith laser treatment to help smooth out some of the fine lines and pigmentary changes that can beseen. Microdermabrasion also helps by removing outer most layers of skin, which allows better penetra-tion of any topical treatment that you are using.

Other alternatives include microdermabrasion alone, chemical peels or laser resurfacing. Ablativelaser resurfacing differs from nonablative resurfacing in that it physically removes the outer portions ofthe skin, and usually causes immediate tightening of the skin. With laser resurfacing you have moreimprovement in the outer layers with removal of sun damage changes and more tightening, but anadditional 1 week period of down time. Both ablative and nonablative techniques lead to new collagenformation which continues for at least 6 months. Microdermabrasion alone will improve some of the finelines on the surface of the skin and some of the pigmentary changes, but will not produce significantcollagen remodeling or skin tightening.

Although rare, potential complications of laser treatment include pigmentary changes or scarring. Aswith any injury to the skin, there is a potential for poor healing.

Typically 2–5 treatments are performed at one month intervals and the resulting increase in collagenformation will continue for six months so that maximum benefits may not be noted for six to eightmonths after this procedure.

NO GUARANTEESIt is possible that you may derive no benefits from the above described procedure. While this procedureis effective in most cases, no guarantees can be made that a specific patient will benefit from treatment.Do not sign this form unless you have had a chance to ask questions and have received satisfactoryanswers to all of your questions.

WAIVER OF LIABILITYAll insurance companies, including Medicare, only pay for services that they determine to be ‘reasonable’and necessary. If your insurance company determines that a particular service is not reasonable and nec-essary under their program standards, they will deny payment for that service. I believe that your insur-ance, or Medicare, will deny payment for the following reason: Insurances usually do not pay forcosmetic procedures.

CONSENTMY SIGNATURE INDICATES THE FOLLOWING: 1) I HAVE READ AND I UNDERSTAND THE INFORMATIONOUTLINED ABOVE; 2) I HAVE DISCUSSED MY QUESTIONS WITH THE DOCTOR OR HER STAFF.

I AUTHORIZE THE RELEASE OF MY PHOTOGRAPHS.

DATE . . . . . . . . . . NAME OF PATIENT . . . . . . . . . . . . . . SIGNATURE OF PATIENT . . . . . . . . . . .

DATE . . . . . . . . . . NAME OF STAFF . . . . . . . . . . . . . . . . SIGNATURE OF STAFF . . . . . . . . . . . .

Fig. 5.7. Informed consent for nonablative resurfacing


3 J/cm2 with a 7-mm spot size does not effec-tively target vasculature. When the laser is usedwith a 5-mm spot size and higher fluences, vas-culature can also be treated.

The most commonly used 1320-nm Nd:YAGlaser is used with a spray cooling device thatprovides not only pre-, but also mid- and post-cooling of the epidermis to allow for a moresuperficial level of skin treatment. A tempera-ture sensor reads the surface heat generated bya test pulse and the goal is to keep it in the 40°Cto 45°C range. Energy settings are then setaccordingly. Although originally done with asingle pass, three passes are now recommendedutilizing a precooling pass, a midcooling pass,and a postcooling pass. The precooling pass isperformed at 30 ms cooling duration with a flu-ence range of 14–18 J/cm2, which is based ontemperature sensor readings. The midcoolingpass is used in combination with pre- and post-cooling at the following settings: 5-ms precool,5-ms midcool, and 20-ms postcool at 17 J/cm2.The postcooling pass fluences are adjustedbased on temperature sensor readings andrange from 13 to 17 J/cm2 with a 30-ms postcoolduration.

The 1450-nm midinfrared laser has greaterwater absorption so changes noted are moresuperficial. This may be more advantageous intargeting dermal solar damage, which typicallyinvolves the superficial dermis. It is used with asimilar dynamic cooling device that protectsthe epidermis while depositing the heat in thedermis. When used for nonablative rejuvena-tion, the larger 6-mm hand piece is used typi-cally at 10–16 J/cm2 with cooling at 25–35 ms. Totarget a specific lesion, as in sebaceous hyper-plasia, the 4-mm spot is used and the fluence is increased to 17–18 J/cm2 and cooling isdecreased to 30 ms. Larger lesions can even bedouble pulsed.

Postoperative Care and Complications

Minimal postoperative care is needed as theepidermis remains intact. Mild burning, ery-thema, and edema can occur, and the applica-tion of aloe vera gel and/or ice packs is helpful.Bruising may occur when pulsed dye lasers are

used at the shorter pulse widths; this can usu-ally be covered with makeup.

Complications are unusual and much lesslikely than with ablative techniques where epi-dermal disruption leaves an entryway for bacte-ria and other contactants. Tanned skin will bemore susceptible to injury due to the increasedmelanin absorption if wavelengths absorbed bymelanin are used and the epidermis is insuffi-ciently cooled. Use of too high an energy settingcan lead to hyperpigmentation or burning andblistering. Hypopigmentation, and even scar-ring, has been reported (Gaston and Clark 1998;Hardaway 2002; Menaker 1999; Moreno-Arias2002; Wlotzke 1996).

Results

Results vary among individuals. Nearly allpatients who have undergone biopsies afternonablative resurfacing have shown histologicalimprovement with increased number of fibro-blasts, increased collagen deposition, and nor-malization of the papillary dermis (Fitzpatricket al. 2000; Goldberg 1999). Clinical improve-ment, however, can be more subtle and does notappear to correlate with histological improve-ment. Although results are relatively inconspic-uous and occur slowly over time, most patientsconcur that the skin feels “tighter,”“firmer,” andmore “toned” (Figs. 5.8–5.11).

The Future

The field of nonablative resurfacing has ex-panded dramatically over the past 8 years. Stud-ies are underway to elucidate the best treatmentintervals, compare the above techniques, andexpand the energy potential of the givendevices. In addition, a new 900-nm laser in con-junction with RF shows promise.



5


Fig. 5.8. 50-year-old woman with deepened nasolabial groove, pre (a) and 4 months post (b) a single full-faceunipolar radiofrequency nonablative treatment

a b

Fig. 5.9. 69-year-old woman with acne scarring, telangiectases, and wrinkles, pre (a) and 4 months post (b)PDL treatment

a b



Fig. 5.10. 44-year-old man with acne scarring and sebaceous hyperplasia, pre (a) and 4 months post (b) 1450-nmdiode laser treatment

a b

Fig. 5.11. 36-year-old woman with telangiectases and fine rhytides, pre (a) and 4 months post (b) IPL treat-ment

a b


References

Christian MM, Behroozan DS, Moy RL (2000) Delayedinfections following full-face CO2 laser resurfacing andocclusive dressing use. Dermatol Surg 26(1):32–36

Fitzpatrick RE, Rostan EF, Marchell N (2000) Collagentightening induced by carbon dioxide laser versuserbium: YAG laser. Lasers Surg Med 27(5):395–403

Fournier N, Dahan S, Barneon G, Diridollou S, LagardeJM, Gall Y, Mordon S (2001) Nonablative remodel-ing: clinical, histologic, ultrasound imaging, andprofilometric evaluation of a 1540-nm Er:glass laser.Dermatol Surg 27(9):799–806

Friedman PM, Geronemus RG (2001) Use of the 308-nmexcimer laser for postresurfacing leukoderma. ArchDermatol 137(6):824–825

Gaston DA, Clark DP (1998) Facial hypertrophic scar-ring from pulsed dye laser. Dermatol Surg 24(5):523–525

Goldberg DJ (1999) Non-ablative subsurface remodel-ing: clinical and histologic evaluation of a 1320-nmNd:YAG laser. J Cutan Laser Ther 1(3):153–157

Goldberg DJ (2000) New collagen formation after der-mal remodeling with an intense pulsed light source.J Cutan Laser Ther 2(2):59–61

Goldberg DJ, Silapunt S (2001) Histologic evaluation of aQ-switched Nd:YAG laser in the nonablative treat-ment of wrinkles. Dermatol Surg 27(8):744–746

Goldberg DJ, Rogachefsky AS, Silapunt S (2002) Non-ablative laser treatment of facial rhytides: a compar-ison of 1450-nm diode laser treatment with dynamiccooling as opposed to treatment with dynamic cool-ing alone. Lasers Surg Med 30(2):79–81

Hardaway CA, Ross EV, Paithankar DY (2002) Non-abla-tive cutaneous remodeling with a 1.45 microM mid-infrared diode laser: phase II. J Cosmet Laser Ther4(1):9–14

Kilmer SL, Chotzen V, Zelickson BD, McClaren M, SilvaS, Calkin J, No D (2003) Full-face laser resurfacingusing a supplemented topical anesthesia protocol.Arch Dermatol 139(10):1279–1283

Lask G, Keller G, Lowe N, Gormley D (1995) Laser skinresurfacing with the SilkTouch flashscanner forfacial rhytides. Dermatol Surg 21(12):1021–1024

Lewis AB, Alster TS (1996) Laser resurfacing: Persistenterythema and postinflammatory hyperpigmenta-tion. J Geriatr Dermatol 4:75–76

Lupton JR, Williams CM, Alster TS (2002) Nonablativelaser skin resurfacing using a 1540-nm erbium glasslaser: a clinical and histologic analysis. DermatolSurg 28(9):833–835

Menaker GM, Wrone DA, Williams RM, Moy RL (1999)Treatment of facial rhytides with a nonablativelaser: a clinical and histologic study. Dermatol Surg25(6):440–444

Nanni CA, Alster TS (1998) Complications of carbondioxide laser resurfacing: An evaluation of 500patients. Dermatol Surg 24:209–219

Pozner JM, Goldberg DJ (2000) Histologic effect of avariable pulsed Er:YAG laser. Dermatol Surg 26(8):733–736

Sriprachya-Anunt S, Goldman MP, Fitzpatrick RE, Gold-man MP, et al. (1997) Infections complicating pulsedcarbon dioxide laser resurfacing for photoagedfacial skin. Dermatol Surg 23:527–536

Sriprachya-Anunt S, Marchell NL, Fitzpatrick RE, Gold-man MP, Rostan EF (2002) Facial resurfacing inpatients with Fitzpatrick skin type IV. Lasers SurgMed 30(2):86–92

Tanzi EL, Alster TS (2003) Side effects and complicationsof variable-pulsed erbium:yttrium-aluminum-gar-net laser skin resurfacing: extended experience with50 patients. Plast Reconstr Surg 111(4):1524–1529;discussion 1530–1532

Wlotzke U, Hohenleutner U, Abd-El-Raheem TA, Baum-ler W, Landthaler M (1996) Side-effects and compli-cations of flashlamp-pumped pulsed dye laser ther-apy of port-wine stains. A prospective study. Br JDermatol 134(3):475–480

Zachary CB (2000) Modulating the Er:YAG laser. LasersSurg Med 26(2):223–226

Zelickson BD, Kilmer SL, Bernstein E, Chotzen VA, DockJ, Mehregan D, Coles C (1999) Pulsed dye laser ther-apy for sun damaged skin. Lasers Surg Med25(3):229–236

Zelickson BD, Kist D, Bernstein E, Brown DB, Ksen-zenko S, Burns J, Kilmer S, Mehregan D, Pope K(2004) Histological and ultrastructural evaluationof the effects of a radiofrequency-based nonablativedermal remodeling device: a pilot study. Arch Der-matol 140(2):204–209

5



History of Photodynamic Therapy

The treatment of superficial nonmelanoma skincancers and actinic keratoses (AKs) with lasersand light sources has recently entered a new erain dermatology with the advent of 20% 5-aminolevulinic acid (ALA), a potent photosen-sitizer. This photosensitizer has demonstratedan effective ability to interact with lasers andlight sources of appropriate wavelengths toselectively destroy the lesions in question. The

term photodynamic therapy, or PDT, is now aphrase which is not foreign to laser physiciansand has, over the past several years, become anintegral part of their therapeutic armamentar-ium. A review of what PDT is, its history andhow it is being incorporated into dermatolo-gist’s offices today will follow.

PDT is a treatment modality which involvesthe use of a photosensitizer, a light sourcewhich fits the absorption spectrum of the pho-tosensitizer, and molecular oxygen, which whenstimulated will destroy a specific target tissue.To be effective in the process, the photosensi-tizer must be able to preferentially penetratemore into the targeted tissue than the sur-rounding skin. ALA has been shown to beabsorbed very well by actinically damaged skin,skin cancer cells, and by the pilosebaceousglands of the skin. The photosensitizer may begiven exogenously or formed endogenouslyduring normal biochemical pathways foundwithin certain disease state pathways. An appro-priate light source must be employed to activatethe photosensitizer and the wavelength of thatlight must be within the appropriate absorptionspectrum of the photosensitizer. Various lasersand light are being utilized by dermatologistsfor PDT. These devices have different wave-lengths of light and thus different penetrationdepths into tissues.

5-ALA, the most common drug used in der-matology for PDT, occurs naturally in cells as anintermediate product formed during theendogenous porphyrin synthesis process. 5-ALA acts as a “prodrug” and has been demon-strated to effectively penetrate the stratumcorneum and to localize in the target tissuesalready mentioned. Once localized into theappropriate cells within the target tissues, the 5-ALA is transformed into a highly photoactive

Lasers, Photodynamic Therapy, and the Treatment of Medical Dermatologic ConditionsMichael H. Gold

6

▲

Core Messages Lasers and light sources have become

more commonplace in the treatmentof dermatologic medical diseases.

ALA-PDT is a proven therapy foractinic keratoses and superficial non-melanoma skin cancers.

ALA-PDT is being used to treat thesigns of photorejuvenation with avariety of vascular lasers, blue lightsources, and the intense pulsed lightsource.

ALA-PDT, with blue light, is a usefultherapy for acne vulgaris.

ALA-PDT is being used to treat mod-erate to severe acne vulgaris, andother sebaceous gland disorders witha variety of vascular lasers, blue lightsources, and the intense pulsed lightsource.

New lasers and light sources arebeing used to treat psoriasis vulgaris,vitiligo, other disorders of pigmenta-tion, and hypopigmented stretchmarks.


endogenous porphyrin derivative, protopor-phyrin IX (PpIX), which has an absorptionspectrum of light in the 415- to 630-nm range(Fig. 6.1).

The history of PDT can trace its routes backto 1900 when Raab (Kalka 2000) found thatParamecium caudatum cells died quickly whenexposed to light in the presence of acridineorange. In 1904, this process was first describedas the “photodynamic effect.” This workinvolved the study of protozoa and describedoxygen-consuming chemical reactions andfluorescence patterns after the applications ofanaline dyes. In 1905 5% eosin was first utilizedas a skin photosensitizer. Artificial light wasused to successfully treat human nonmelanomaskin cancer, condylomata lata, and lupus vul-garis. The next forty-odd years found very fewsubstantial studies being described using PDT.

In 1948, hematoporphyrin was found to beselectively absorbed in neoplastic tissues,embryonic tissues, and traumatized tissues.This work led to the development of a purifiedsynthetic compound, a hematoporphyrin deri-vative, which then became the standard for PDTresearch and treatment in that time. Doughertyet al. (Dougherty et al. 1978) reported in 1978the use of this hematoporphyrin derivative andits photoactivation with a red light source. Thisgroup described its effectiveness in treating avariety of cutaneous malignancies and othercancers as well. PDT has been studied and con-tinues to be investigated for its role in treating a

variety of malignancies including lung, colon,esophagus, peritoneum, pleura, gastrointestinaltract, brain, eye, and skin (Rowe 1988). A varietyof nononcologic applications utilizing PDT in-cludes atherosclerosis, infectious diseases, andrheumatologic diseases, as well as skin concernswhere the pilosebaceous units are involved.Svaasand (Svassand et al. 1996) described adosimetry model for PDT which further de-lineated the necessary three steps for the PDTprocess to occur: (1) ALA diffusion through thestratum corneum and ability to penetrate theepidermis and dermis, (2) synthesis and pro-duction of the photosensitive PpIX from theexogenous ALA applied to the skin, and (3) theproduction of singlet oxygen when PpIX isproperly irradiated with a wavelength of lightwhich is absorbed by PpIX.

In the United States, PDT therapy emergedin the late 1990s as a treatment for nonhyper-keratotic AKs of the face and scalp. AKs are aproblem which dermatologists encounter on adaily basis in their clinical practices. TheActinic Keratosis Consensus Conference of 2001reported that AKs serve as a marker for photo-damage and that their principle etiology isultraviolet light, specifically ultraviolet B light.They found that AKs are associated with alter-ations of DNA that are associated with squa-mous cell carcinomas (SCCs), specifically muta-tions in the tumor-suppressing gene p53.

The conference reported that AKs are a car-cinoma in situ and some of them will naturally

6

100 Chapter 6 Lasers, Photodynamic Therapy, and the Treatment

Fig. 6.1.Protoporphyrin absorptionspectrum


regress, some will remain stable, or some willprogress to the formation of SCCs. Which willregress or which will progress cannot as yet bedetermined. The natural history of AKs isunpredictable, and therefore all AKs should betreated in some fashion to prevent the potentialonset of cutaneous malignancies. Conversionrates to SCCs have been reported from 0.1% to20%. Additionally, 97% of SCCs are associatedwith a nearby AK. Nearby AKs have been foundin 44% of cutaneous SCCs which had metasta-sized. These findings also support the conceptthat all AKs should be treated to prevent furtherpotential conversion to SCCs.

A variety of treatment options are currentlyavailable for the treatment of AKs. These in-clude both medical and surgical options(Table 6.1). Most contend that the principletreatment for AKs involve a destructive process.ALA-PDT fits nicely into this destructive cate-gory for the treatment of AKs and has received agreat deal of recent attention for its role in thetreatment of AKs and other cutaneous con-cerns.

In Europe, ALA research has focused on itsuse in treating not only AKs but also for the treat-ment of superficial cutaneous malignancies.These malignancies include squamous cell carci-noma in situ (Bowen’s Disease) basal (BCCs) andsquamous cell carcinomas. Numerous clinicalreports have now described this role for PDT (Luiand Anderson 1993). A variety of lasers and lightsources have been used to treat AKs, Bowen’s Dis-

ease, BCCs, and SCCs. For AKs, response ratesfrom 80% to 100% are routinely reported. ForBowen’s Disease, response rates from 90% to100% are reported with PDT. For BCCs andSCCs, 67%–100% of treated lesions respond toPDT. A variety of treatment protocols have beenutilized but most have used multiple treatmentapplications with sufficient follow-up to docu-ment the effectiveness of ALA-PDT in the treat-ment of cutaneous malignancies.


The two main photosensitizers being utilized inthis time frame are 20% 5-ALA, known as Levu-lan, manufactured by Dusa Pharmaceuticals,Wilmington, MA, and the methyl-ester deriva-tive of 5-ALA, Metvix, made by PhotoCure ASA,Norway. Both of these compounds havereceived extensive study over the last severalyears and will be summarized below.

Photodynamic Therapy: The Experience with Actinic Keratoses in the United States

In the United States, the 20% 5-ALA product iscurrently the only commercial product avail-able for use by physicians. It is a 20% weight/volume ALA solution with 48% ethanol. It isproduced in the form of a kerastick (Fig. 6.2).The kerastick has a dermatologic applicator atone of its ends for accurate application of theALA medicine. The applicator tip is attached toflexible plastic tubing which contains two glassvials. One of the vials contains the ALA in apowder form and the other glass vial containsthe ethanol solvent. The vials on the kerastickare broken by light manual pressure to the tub-ing and then the contents are mixed by rotatingthe contents of the kerastick back and forth forseveral minutes, with 3 min being the recom-mended time frame for proper mixing of themedicine. Once fully mixed together, the ALA isready for patient application. Preparation of thepatient includes washing of the skin with a mildcleanser followed by one or two applications ofthe ALA. Some clinicians advocate the use of anacetone scrub or a microdermabrasion proce-


Table 6.1. Treatment options for actinic keratoses

Surgical options for AK treatmentCryosurgeryCurettageExcisional surgeryDiffuse superficial destructive processes

Chemical peelsDermabrasionLaser resurfacing

ALA-PDT photodynamic therapyMedical treatments for AKs

5-FluorouracilImiquimodRetinoids – tretinoin, adapalene, tazaroteneDicofenac


(wavelengths of 410–430 nm) for 16 min and40 sec. The blue light source provided a dose of10 J/cm2 to the affected lesions. The results ofthe trial showed that nonhyperkeratotic AKswere effectively treated with the ALA-PDT plusthe blue light source. Specifically, 66% of thetreated AKs responded to the therapy after onetreatment. For those AKs which did not respond(n=16), retreatment was undertaken after8 weeks. This improved the efficacy rate to 85%at the 16-week follow-up period. The treatmentswere well tolerated by the participants in thistrial. All patients noted burning and stingingduring their light therapy, and facial erythemawas reported in 96% of the participants; allresolved by the first 4-week follow-up.

This aforementioned study led to the PhaseIII clinical trial, which was a placebo-controlledmulticenter analysis looking at a larger numberof individuals (n=243) using a similar protocolas reported in the Phase II trial. Two applica-tions of either the ALA solution (L) or a vehicleplacebo (V) were applied to the individual AKlesions, incubation times for the drug remainedat 14–18 h, and the patients received 16 min, 40 sof blue light therapy. Results of the clinical trialsshowed significant differences between theactive ALA and the placebo (Fig. 6.3); more than70% of the lesions were resolved at 12 weeks.Lesions which were not clear were retreated at 8weeks. At the conclusion of the study, 88% ofthe patients with active medicine had a ≥ 75%response rate compared to 20% in the vehicle/placebo group of patients. (Fig. 6.4). The treat-ments were well tolerated by the study partici-

6


Fig. 6.2. 20% topical ALA

Fig. 6.3.Levulan PDT system Phase III studies: efficacyresults. p <0.001.From Dusa Pharmaceuticals

dure to allow an even deeper penetration of theALA. Once the drug has been incubated for thetime period chosen, the ALA is washed off theskin and the patient is then ready for the appro-priate light therapy.

The first clinical trial with 20% 5-ALA was aPhase II clinical trial reported in 2001. In thisclinical trial, 36 individuals with nonhyperkera-totic AKs of the face and scalp were evaluatedfor its safety and efficacy. The patients had theALA applied to individual AK lesions. The drugwas allowed to incubate on the individuallesions for 14–18 h without occlusion and thepatient was then subjected to a blue light source


pants. Patients noted that during their lighttherapy, there was stinging and burning. Someof the patients did have associated erythemaand edema from the therapy. These symptomsresolved at 1 week after the light treatment. Nononcutaneous adverse effects were seen in thePhase III trials. An important outcome of thistrial was patient and physician assessment ofimprovement in the cosmetic appearance of theskin as a result of the ALA therapies. Ninetyfour percent of the patients and 92% of theinvestigators rated the cosmetic improvementas good to excellent.

Recently, a long-term clinical trial haslooked at both efficacy and recurrence ratesassociated with ALA therapy. This studyshowed that 69% of 32 AKs studied in four indi-viduals remained clear at the end of 4 years; 9%were found to be recurrent; 22% were describedas “uncertain” as to whether the lesions wereactually recurrent or whether new lesions devel-oped in the same area.

Photodynamic Therapy: New Indications for PhotodynamicPhotorejuvenation in the United States

We have also studied the use of 20% 5-ALA for AKs with the blue light source. This studylooked at the role of ALA-PDT for photoaging(Figs. 6.5, 6.6). Recently, others have begun to explore new ways to revise our current mind-


Fig. 6.4. a Pretreatment. b One week after ALA-PDTtreatment. c One month after ALA-PDT treatment

a

b

c

Fig. 6.5. a Immediately after blue light treatment.b One month after treatment

b

a


set on the proper use of this therapy for pho-toaging and photorejuvenation. Such studieshave included the use of broad application ofthe ALA over the entire area which will betreated, and the use of a variety of lasers andlight sources which fit the absorption spectrumof protoporphyrin IX (Fig. 6.1). The lightsources which are being studied include a vari-ety of blue light sources, the pulsed dye vascularlasers, and myriad different intense pulsed light(IPL) devices (Table 6.2). In addition, shorterdrug incubation times, with the average being1 h, are now routinely being employed to helpmake the procedures more accessible to thepatients being treated. This means that thepatients need only to have therapy on one day

6


Fig. 6.6.a Before ALA-PDT blue lighttherapy. b Patient undergoing4th ALA-PDT blue light therapysession

a

b

Table 6.2. Lasers/light sources currently being usedfor photorejuvenation with 20% 5-ALA

Blue light sourcesBlue U (Dusa Pharmaceuticals)ClearLight (CureLight, Lumenis)

Pulsed dye vascular lasersV-Star (Cynosure)V-Beam (Candela)

Intense pulsed light sourcesQuantum, Vasculight (Lumenis)Aurora (Syneron)ClearTouch, SkinStation (Radiancy)Estelux, Medilux (Palomar)

versus two consecutive days. In addition, withnewer light sources, therapy becomes more tol-erable to the patients by potentially lesseningthe adverse effect profile seen with the originalPhase II and Phase III trial patients.

To support the notion of full-face, short-con-tact ALA therapy, a number of clinical investiga-tors have recently reported their successes withALA for photorejuvenation. Photorejuvenationutilizing lasers and light sources has been suc-cessfully utilized over the past several years tononinvasively rejuvenate the skin, improvingfacial telangiectasias, pigmentary dyschromias,and overall skin texture. Ruiz-Rodriquez et al.(Ruiz-Rodriquez et al. 2002) found that after 4 hof drug incubation, patients responded well to


ALA therapy. In addition, skin quality improve-ment and a decrease in AKs were noted. Seven-teen individuals were studied in this trial with 38 AKs being assessed. Two IPL sessions withALA applied for 4 h yielded excellent cosmeticresults and an 87% improvement in the para-meters of photorejuvenation (wrinkling, skintexture, pigmentary changes, and telangiec-tasias). He called this new therapeutic approach“photodynamic photorejuvenation,” a termwhich fully describes the use of ALA-PDT andlasers and light sources. Another study utilizedIPL therapy with ALA in 18 individuals with full-face, short-contact therapy. In this study incuba-tion of the ALA was undertaken for 1, 2, and 3 hfollowed by exposure to a blue light source. Theinvestigators found that 1-h drug incubation wasas efficacious as the original 14- to 18-h drugincubation time periods. The patients showedimprovement in skin sallowness, fine wrinkling,and mottled hyperpigmentation with this ther-apy. Gold (Gold 2003) reported his experiencewith full-face, short-contact ALA therapy withIPL in ten patients. IPL settings included the useof a 550-nm cut-off filter, double pulsing with a3.5-ms pulse delay, and fluence ranges from 20 to34 J/cm2. The patients in this clinical trialreceived 3 monthly IPL treatments and had fol-low-up visits at 1 and 3 months following the lastIPL therapy. Results from this clinical trialshowed that over 85% of the targeted AKsresponded to the therapy. In addition, there wasa global skin quality improvement score ofgreater than 75% compared to the baseline visits.

Furthermore, there was a 90% improvement incrow’s feet, 100% improvement in tactile skinroughness, 90% improvement in mottled hyper-pigmentation, and a 70% improvement in facialerythema. No adverse effects were reported; 30%did have facial erythema and edema reportedimmediately after therapy which abated within24–48 h. No patient in this clinical investigationreported any downtime from their day-to-dayactivities as a result of their therapies. (Figs. 6.7,6.8). Other investigators (Goldman et al. 2002)evaluated 32 patients with moderate photodam-age and multiple AKs, again using full-face,short-contact therapy and the blue light source.At the end of this clinical trial there was a 90%clearance of AKs, a 72% improvement in skintexture, and a 59% improvement in skin pigmen-tation. Of note, 62.5% of the patients in this trialfound this therapy less painful than cryotherapy.Avram and Goldman (Avram and Goldman2004) reported on 17 individuals using full-face, short-contact ALA therapy and one IPLtreatment. They used 1-h drug incubation andfound that 68% of the AKs treated respondedafter the one IPL treatment. In addition, theyfound that there was a 55% improvement in facial telangiectasias, 48% improvement in pig-mentary irregularities, and 25% improvement in skin texture, all with just one PDT treatment.

The pulse dye laser has also been shown tobe useful in the photorejuvenation of the skin.By utilizing ALA, Alexiades-Armenakas et al.(Alexiades-Armenakas and Geronemus 2003),evaluated both 3-h and 14- to 18-h drug incuba-


Fig. 6.7. a AK before ALA-PDT/IPL therapy. b AK area 1 month after ALA-PDT/IPL therapy

a b


tions. They found both incubation periods suc-cessful in treating AKs and in improving theparameters of photorejuvenation. This grouputilized a pulsed dye laser at 595 nm, with flu-ence ranges of 4–7.5 J/cm2, 10-ms pulse dura-tions, 10-mm spot size and 30-ms cryogensprays. They evaluated 2,561 face and scalp AKswith clearances of 99.9% at 10 days, 94.8% at2 months, and 90.1% at 4 months. Trunk lesionswere also evaluated; 54.5% responded at 10 daysand 74.4% at 2 months.

Finally, another study has looked at the safetyand efficacy of large-surface application of ALAin hairless mice. In this study investigatorslooked at blue light therapy alone, ALA therapyalone, and the combination of ALA and blue lightwith weekly applications being performed for10 months. No tumors were formed during thistrial period; therefore ALA-PDT should bedeemed not only efficacious but safe as well.

Photodynamic Therapy: The (Primarily) European Experience with Actinic Keratoses and Skin Cancers

The methyl ester derivative of ALA, known asMetvix, is available in Europe and several othercountries, and is currently undergoing clinicalevaluations in the United States. Many trialsevaluating the methyl ester of ALA have beenperformed utilizing a red laser light source at630 nm (Fig. 6.1). This approach led to Euro-

pean Union approval for the treatment of non-hyperkeratotic AKs of the face and scalp as wellas BCCs which are unsuitable for conventionaltherapy. Recommendations for the use of themethyl-ALA include the gentle scraping orcurettage of the effected lesion prior to theapplication of the methyl-ALA cream. This isthen occluded for 3 h before the cream isremoved and the area is subjected to the redlaser light source. Several recent clinical trialssupport the use of the methyl-ALA in the treat-ment of AKs. In one study, investigators studied204 individuals treated with the methyl-ALAcream as compared to cryotherapy and placebo.The methyl-ALA technique was found to havebetter response rates and cosmetic improve-ment compared to both cryotherapy andplacebo. In another study, investigators studiedthe methyl-ALA cream in 80 individuals withAKs. They found an 89% improvement in theAKs and a 90% improvement in the cosmeticappearance. In their group of patients, 72% ofthem preferred PDT over both cryotherapy and5-FU therapy. Others recently completed aprospective randomized study of BCCs treatedwith either methyl-ALA or surgery in 101patients. After 3 months of follow-up, there wasa 98% complete response rate with surgery ver-sus a 91% response rate with the methyl-ALA.After 12 months, there was a 96% response ratewith surgery and an 83% response seen in themethyl-ALA group. At 24 months, there was onerecurrence noted in the surgery group and 5 in

6


Fig. 6.8. a Crows feet immediately after ALA-PDT/IPL therapy. b Crows feet 1 month after ALA-PDT/IPLtherapy

a b


the methyl-ALA group. The authors concludedthat the cosmetic appearance was better in themethyl-ALA group compared to the surgicalgroup.

ALA-PDT is a new therapeutic modality toenhance previously accepted lasers and lightsource technologies. With short-contact, topicalALA full-face treatments, it appears that allparameters of photorejuvenation and associ-ated AKs can be successfully treated with areduced number of treatments. The exact num-ber of required therapeutic sessions has yet tobe determined. Most clinicians perform one tothree sessions at 1-month intervals. Adverseevents are kept to a minimum. Patients rou-tinely report no downtime from day-to-dayactivities utilizing ALA-PDT in this manner.Further research is required to further validateand define this new therapy for photorejuvena-tion and associated AKs.

Photodynamic Therapy – Other Indications

The use of ALA-PDT is not limited to the treat-ment of AKs, BCCs, and SCCs. PDT therapy haslong been recognized as an important treat-ment in acne vulgaris and other disorders of thepilosebaceous glands. Recent advances havemade the use of a variety of lasers and lightsources combined with ALA practical for thosesuffering from acne vulgaris and other pilose-baceous entities.

■ Acne Vulgaris

Acne vulgaris accounts for over 30% of all der-matology visits. It has been estimated thatbetween 70% and 96% of all individuals willsuffer from acne vulgaris at some point in theirlifetime. Recent evidence suggests that over 40million American adolescents and 25 millionAmerican adults are affected by acne vulgaris.

In its simplest form, acne vulgaris is a disor-der of the sebaceous glands. Obstruction of thesebaceous glands leads to the production andproliferation of bacterial growth within thesebaceous glands. The bacteria most commonlyassociated with the formation of acne vulgarisis Propionobacterium acnes (P. acnes). Inflam-

matory acne presents with papules, pustules,and cysts.

There are a variety of effective medicationsto treat those individuals suffering from acnevulgaris. These include topical and systemicantibiotics, topical benzoyl peroxide, topicalsalicylic acid derivatives, and a variety of topicalsulfa preparations. Topical and systemic reti-noids round out the successful medications for the treatment of acne vulgaris. Despite con-tinuing advances, there are drawbacks to eachgroup of therapies. Some of the topical medica-tions are irritating to the skin and may causeclothes to stain. Most topical therapies are slowto achieve an acceptable onset of action, somerequiring several months to become successful.Systemic antibiotics, the mainstay for inflam-matory acne for many years, have recently beenreported to show up to a 40% drug resistancewith the commonly used oral tetracyclines, ery-thromycins, and sulfa derivatives. A recentreport has even suggested that the long-termuse of systemic antibiotics in women may beassociated with a higher incidence of breastcancer (Velicer et al. 2004).

Exposure to natural and artificial UV lighthas been reported to be successful in the treat-ment of acne vulgaris (Sigurdsson et al. 1997).The exact mechanism for this response of acne-form lesions to UV light is not fully understoodbut is felt to be due, in part to, destruction of P.acnes bacteria in the sebaceous unit. This natu-ral endogenous PDT reaction works well in thetreatment of acne vulgaris; however, the dam-aging effects of UV light with regard to pho-toaging and the development of skin cancersprecludes its regular use in today’s medicalenvironment.

The photodynamic reaction seen in thedestruction of the P. acnes bacteria involves thenatural production of porphyrins seen duringthe growth of the P. acnes during the inflamma-tory phase of the acne cycle. The porphyrins pro-duced are principally PpIX and CoproporphyrinIII, which have absorption spectra in the nearultraviolet range of light, in the blue light range,with peak absorption seen at 415 nm. The PDTreaction leads to photoactivation of the P. acnes’porphyrins after exposure to the appropriatelight source. This causes the formation of singlet



oxygen within the bacteria. Ultimately, destruc-tion of the P.acnes bacteria will occur, with resul-tant destruction of the acne lesion, leaving sur-rounding tissues and structures fully intact.

A variety of light sources have been used overthe past century to treat acne vulgaris. Thesehave included halogen, xenon, and tungsten lightsources. More recently, investigations havefocused predominantly on blue light and ALA,blue light alone, vascular lasers, and a variety oflight sources. These lasers and light sources allutilize the concept of PDT and the destruction ofthe P. acnes. Still other lasers focus on destruc-tion of the sebaceous gland and sebaceous glandactivity output. Both groups will be reviewed.

The treatment of inflammatory acne vul-garis with blue light sources has been exten-sively reviewed over the past several years.Papageorgiou (Papageorgiou et al. 2000) re-ported his findings with a blue light source. Heshowed that 63% of inflammatory lesionsresponded to blue light and 45% of comedonallesions also responded. Other investigatorsshowed that 65% of inflammatory acne lesions

responded to blue light therapy. A new high-intensity blue light source has also recently beenevaluated for its effectiveness in the treatmentof inflammatory acne vulgaris (Elman et al.2003). Investigators have shown between 60%and 75% improvement with this high-intensityblue light source. Most of the clinical trials haveevaluated two treatments per week for 4 weekswith appropriate 1- and 3-month follow-ups.These clinical trials had, on average, a 20% non-responder rate. Gold (Gold 2003) reported hisfindings with this blue light source in 40 indivi-duals with mild to moderate inflammatory acnevulgaris. Treatments were conducted two timesper week for 4 weeks, with follow-up at 1 and4 months. The results of this trial showed a 43%improvement in inflammatory acne (Figs. 6.9,6.10). A different blue light source has also beenshown to be more effective than topical 1% clin-damycin solution in treating inflammatory acnevulgaris during a 4-week treatment period witha 1-month follow-up time period (Gold 2004b).

A variety of IPLs are also being used for thetreatment of acne vulgaris. The mechanism of

6


Fig. 6.9. a Acne before blue light therapy. b Acne after blue light therapy

a b


action for IPL is similar to that seen with bluelight therapy; that is, destruction of the P. acnesleading to a PDT effect. In one IPL study, 85% ofpatients showed greater than 50% improvementin their acne lesions. Unfortunately, 15%–20%of the patients were nonresponders.

Other investigators have looked at otherlaser systems whose primary effect may be thedestruction of the sebaceous glands themselves.Lloyd and Mirkov (Lloyd and Mirkov 2002)evaluated the use of a 810-nm diode laser withapplication of indocyanin green. The indo-cyanin green is selectively absorbed into seba-ceous glands and can be destroyed with expo-sure to the 810-nm diode laser. Paithanker et al.(Paithankar et al. 2002) have studied the 1450-nm laser for the treatment of inflammatoryacne lesions. Their clinical evaluations haveshown significant destructions of the sebaceousglands with this therapy and long-lasting reso-lution of the acne lesions.

Recently, a group of investigators has begunto evaluate the use of ALA as an enhancer for thelaser and light therapies. Hongcharu et al.

(Hongcharu et al. 2000) looked at broadbandlight (500–700 nm) using ALA with a 3-h drugincubation period in 22 individuals. They notedsignificant clinical clearance 4 weeks after treat-ment which persisted up to 20 weeks. Adverseeffects included an acneform folliculitis, post-inflammatory hyperpigmentation, superficialpeeling, and crusting. Itoh et al. (Itoh et al. 2000)reported on the use of ALA and a 635-nm pulsedexcimer-dye laser in an intractable case of acnevulgaris on the face. The ALA was incubated for4 h under occlusion. The treated area remainedclear of acneform lesions during the 8-monthfollow-up period. A classic PDT reaction (ery-thema, edema, and crusting) was seen followingthe therapy.A second trial from Itoh et al. (Itoh etal. 2001) looked at a single ALA treatment in 13individuals. Polychromatic visible light was usedwith a wavelength of 600–700 nm, 17 mW/cm2,and 13 J/cm2. The facial appearance of all thepatients improved; new acne lesions werereduced at 1, 3, and 6 months after treatment.During the subsequent 6 months, acne lesionsdid reappear and seborrhea, reduced during


Fig. 6.10. a Acne before blue light therapy. b Acne after blue light therapy

a b


therapy, also returned.Again, a classic PDT reac-tion occurred following the therapy with ery-thema, edema, and crusting noted in the patientsfollowing treatments.

Goldman (Goldman 2003) reported on theuse of short-contact ALA-PDT with either IPLor a blue light device for the treatment of acnevulgaris and sebaceous gland hyperplasia.Treatments were noted to be pain free and with-out adverse effects. Relative clearing of the acnelesions were seen after 2–4 weekly treatments.Gold (Gold 2003) evaluated ten patients withmoderate to severe acne vulgaris utilizing full-face, short-contact ALA-PDT and a high-inten-sity blue light source. Four weekly treatmentsshowed a response of approximately 60% (ver-sus 43% with the blue light source alone). Ses-sions were well tolerated with no noted adverseeffects. Goldman and Boyce (Goldman 2003)also studied acne vulgaris with a blue lightsource with and without ALA in 22 individuals.Blue light therapy was performed alone twiceper week for 2 weeks with a follow-up at2 weeks; blue light plus ALA was performed two

times at 2-week intervals with a follow-up at2 weeks after the final treatment. There was agreater response in the ALA-PDT/blue lightgroup than blue light alone with no significantadverse effects seen in either group of patients.Gold (Gold 2004a) has now been evaluating anew IPL for moderate to severe acne vulgariswith ALA-PDT. Twenty patients were evaluatedand results show significant improvement ininflammatory acne lesions; similar to previousstudies performed by the author with blue lightand ALA (Figs. 6.11, 6.12).

The combination of full-face, short-contactALA-PDT treatments with blue light sources,IPLs, and other lasers and light sources appearsto provide a synergistic effect to effectively treatpatients suffering from moderate to severeinflammatory acne vulgaris. The combinationtherapy has been shown to be safe; it appears towork at a faster rate than lasers or light therapyalone, with fewer required treatments. Thiscombination therapy may eliminate the needfor more intensive systemic therapies in someof our patients.

6


Fig. 6.11. a Acne before ALA-PDT/IPL therapy. b Acne after ALA-PDT/IPL therapy

a b


■ Hidradenitis Suppurativa

Several other medical conditions are also beingtreated with ALA-PDT. Our group has recentlyreported on the successful use of ALA-PDT and ahigh-intensity blue light source in the treatmentof hidradenitis suppurativa (HS). Four individu-

als with recalcitrant HS were treated with short-contact ALA and between three and four sessionsof the blue light source. The treatments weregiven at 1- to 2-week intervals. Seventy-five to onehundred percent of the HS lesions responded tothis therapy and remained clear during a 3-month follow-up period. (Fig. 6.13).


Fig. 6.12. a Acne before ALA-PDT/IPL therapy. b Acne after ALA-PDT/IPL therapy

a b

Fig. 6.13. a Hidradenitis suppurativa (HS) before ALA-PDT blue light therapy. b HS 3 months after ALA-PDTblue light therapy

a b


■ Sebaceous Gland Hyperplasia

Sebaceous gland hyperplasia is an entity whichhas been treated with numerous therapeuticmodalities. These have included cryotherapy,excision, electrodessication, laser vaporization,and oral isotretinoin use. These therapies areoften associated with lesional recurrences orundesirable adverse side effects. Recently, Alsterand Tanzi (Alster and Tanzi 2003) reported onthe use of ALA and the 595-nm pulsed dye laserin the treatment of sebaceous gland hyperplasialesions. Ten patients received short-contactALA drug incubation (1 h) and one or two treat-ments at 6-week intervals. Results showed thatseven individuals had clearing of the targetedsebaceous gland hyperplasia lesions with oneALA-pulsed dye laser treatment, and threepatients required two treatments for lesionclearing. Follow-up in this group of patientswas for 3 months. Matched lesions on the samepatient served as controls; some were treatedwith pulsed dye laser and some not treated at all. The treatments were well tolerated by the study participants. Others have evaluatedten patients with short-contact ALA-PDT andthe blue light source. Patients were given3–6 weekly treatments and were followed for6 months. Seventy percent of all lesionsresponded to therapy. Recurrence rates of up to

10–20% of lesions were seen within 3–4 monthsof the final treatment. Our group has also exam-ined short-contact ALA-PDT in a group ofpatients who received either IPL therapy or ahigh-intensity blue light source. Results from4 weekly treatments show both therapies usefulin the treatment of sebaceous gland hyperpla-sia, with 50% of lesions responding during thetreatment and a follow-up period of 3 months.(Fig. 6.14).

Advantages

ALA-PDT therapy is an important new treat-ment modality which enhances already provenand successful laser and light source treat-ments. It must be remembered that, at the timeof this writing, the only FDA-approved indica-tion for ALA-PDT is for the treatment of nonhy-perkeratotic AKs on the face and scalp andtreated with the blue light source after a 14- to18-h drug incubation period. The clinical trialspresented for photorejuvenation, acne vulgaris,HS, and sebaceous gland hyperplasia, and themethodology used by the investigators are allbeing performed as off-label clinical trials. Clin-icians can use medicines in an off-label format;patients should be made aware of the off-label

6


a b

Fig. 6.14.a Sebaceous gland hyperplasia (SGH) before ALA-PDT/IPL therapy.b SGH after ALA-PDT/IPLtherapy


use of these treatments and proper informedconsents should be made prior to the actualtreatments (Figs. 6.15, 6.16). Research into enti-ties being treated with ALA-PDT is growing andmore investigations will follow in the monthsand years to come.

Psoriasis and Disorders of Hypopigmentation

■ Psoriasis Vulgaris

Psoriasis vulgaris is dermatologic disease whichhas recently been successfully treated with a newgeneration of lasers and light sources. Psoriasis isa chronic, noncontagious skin disease whichaffects between 1% and 3% of the population, orabout 7 million people in the United States. It isthe seventh most common reason patients seek

113Advantages

CONSENT FOR LEVULAN PHOTODYNAMIC TREATMENT

Levulan (Aminolevulinic acid 20%) is a naturally occurring photosensitizing compound which has beenapproved by the FDA and Health and Welfare Canada to treat pre-cancerous skin lesions called actinickeratosis. Levulan is applied to the skin and subsequently “activated” by specific wavelengths of light.This process of activating Levulan with light is termed Photodynamic Therapy. The purpose of activatingthe Levulan is to improve the appearance and reduce acne rosacea, acne vulgaris, sebaceous hyperpla-sia, decrease oiliness of the skin, and improve texture and smoothness by minimizing pore size. Any pre-cancerous lesions are also simultaneously treated. The improvement of these skin conditions (other thanactinic keratosis) is considered an “off-label” use of Levulan.

I understand that Levulan will be applied to my skin for 30–60 minutes. Subsequently, the area will betreated with a specific wavelength of light to activate the Levulan. Following my treatment, I must washoff any Levulan on my skin. I understand that I should avoid direct sunlight for 24 hours following thetreatment due to photosensitivity. I understand that I am not pregnant.

Anticipated side effects of Levulan treatment include discomfort, burning, swelling, blistering, scar-ring, redness and possible skin peeling, especially in any areas of sun damaged skin and pre-cancers ofthe skin, as well as lightening or darkening of skin tone and spots, and possible hair removal. The peelingmay last many days, and the redness for several weeks if I have an exuberant response to treatment.

I consent to the taking of photographs of my face before each treatment session. I understand that Imay require several treatment sessions spaced 1–6 weeks apart to achieve optimal results. I understandthat I am responsible for payment of this procedure, as it is not covered by health insurance.

I understand that medicine is not an exact science, and that there can be no guarantees of my results.I am aware that while some individuals have fabulous results, it is possible that these treatments will notwork for me. I understand that alternative treatments include topical medications, oral medications,cryosurgery, excisional surgery, and doing nothing.

I have read the above information and understand it. My questions have been answered satisfactorilyby the doctor and his staff. I accept the risks and complications of the procedure. By signing this consentform I agree to have one or more Levulan treatments.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name Signature

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date Witness

Fig. 6.15. Informed consent for ALA-PDT


dermatologic care. Numerous studies have notedsignificant quality of life issues in patients withpsoriasis. Psoriasis varies in severity from mildto moderate to severe disease. Mild psoriasis vul-garis involves disease activity of less than 2%body surface area, moderate disease between 2%and 10%, and severe psoriasis generally involvesgreater than 10% body surface area. Genetics,biochemical pathways, and the immune systemare known to be involved in the pathogenesis ofpsoriasis. In psoriasis, faulty immune signals arethought to accelerate the skin growth cycles. Thisleads to an increase in the amount of skin cells,which pile up on the skin surface faster than thebody can shed them – in 3–4 days instead of thenormal 28 days. Much of the recent evidence intothe pathogenesis of psoriasis suggests that psori-asis is a T-cell-mediated disease.

A variety of treatment options exist forpatients suffering from psoriasis. Most of thetreatments are safe and effective. These treat-ments improve the psoriatic skin and reduce thesymptoms associated with psoriasis, mainlyswelling, erythema, flaking, and pruritis. Thesetherapies (Table 6.3) often lead to a remission inthe skin condition. A step-ladder approach topsoriasis therapy is commonly used by mostclinicians. (Table 6.3). With this approach to the

6


Table 6.3. Treatment options for psoriasis vulgaris

Step 1: Topical TherapyTopical corticosteroidsTopical coal tarTopical calcepotriene (Vitamin D)Topical vitamin A derivativesTopical anthralinTopical salicylic acidNatural sunlight

Step 2: Phototherapy/lasersUltraviolet B (UVB) lightNarrowband UVBB Clear (Lumenis)Xtrac (PhotoMedex) excimer laserPUVA (psoralen plus ultraviolet A light)

Step 3: Systemic medicationsMethotrexateOral retinoidsCyclosporineBiologic drugs – alefacept (Amevive)Efalizumal (Raptiva) Etanercept (Enbrel)Infliximal (Remicade)

CONSENT FOR ULTRAVIOLET LIGHT TYPE B-PHOTOTHERAPY

Phototherapy involves the exposure of the involved skin to a short-wave ultraviolet light known as UVB.UVB occurs naturally in sunlight; it is the part of the sunlight, which causes sunburns.

The dosage of UVB will be determined on many factors such as type of skin, disease, age, and type ofequipment. The time is gradually increased until the desired result is achieved. At all times, while insidethe phototherapy light box, special protective eyewear must be worn. Men will also protect their scro-tum area.

The side effects to ultra-phototherapy B are, during treatment the psoriasis can sometimes get tem-porarily worse before getting better. The skin may itch and get red due to overexposure (sunburn). Thelong-term risk in developing skin cancer(s) from long-term exposure to UVB is unknown. Also, long-termexposure can cause freckling and loss of skin elasticity.

During the course of therapy, your skin will be evaluated.

***Also, I agree that any pictures taken of me can be used for either teaching or publication unless Inotify the staff in writing that they are not to use my pictures.***

Fig. 6.16. Informed consent for laser/light therapy for psoriasis and disorders of hypopigmentation


use of phototherapy, a variety of new lasers andlight sources are being evaluated.

The major light sources being used for thetreatment of psoriasis are the BClear (Lumenis)and the Xtrac (PhotoMedix). Clinical trials withthe XTrac, a 308-nm excimer laser, have shownsignificant clearing of psoriatic plaques. Feld-man et al. (Feldman et al. 2002) reported on amulticenter analysis with 124 patients at fivecenters. Seventy-two percent of patients demon-strated 75% or greater clearance in 6.2 treat-ments or less. Eighty-four percent achievedimprovement of 75% or better after ten treat-ments. Other investigators also showed signifi-cant clearance using the excimer laser in 11patients after 1 month of therapy; five patientsremained disease free at a 4-month follow-up(Figs. 6.17, 6.18). The BClear is a narrowbandUVB device which delivers the UVB in afocused, fiber-optic delivery system. This allowsthe UVB to be delivered only to diseased tissue,leaving healthy tissue alone. Such an approachleads to the potential for less treatment sessions.Potential adverse effects and the developmentof skin cancers may also be lessened. Thisdevice produces UVB light in the 290- to 320-nmrange with most emitted wavelengths between311 and 314 nm. The device may deliver lighteither in a single pulse mode or continuouspulse mode. Pulse widths of 0.5, 1.0, 1.5, and2.0 s exist. Fluences range from 50 to 800 mJand spot sizes up to 16 × 16 mm exist for thedevice. Several clinical trials have shown signif-icant clearances with this targeted UVB system.(Figs. 6.19, 6.20).

■ Vitiligo

A variety of leukodermas of the skin have alsobeen treated with both the excimer laser andtargeted UVB systems. Leukodermas of the skinare defined as loss of skin pigment from a dis-ease process (i. e., vitiligo) or secondary to aninjury pattern to the skin (including loss of pig-ment from burns, surgical procedures, and fol-lowing laser resurfacing procedures). Other skinconcerns, such as idiopathic guttate hypome-lanosis and hypopigmented stretch marks arealso being evaluated with these technologies.Vitiligo is a pigmentation disorder in which

115Advantages

Fig. 6.17. a Psoriasis before excimer laser treatment.b Psoriasis after three excimer laser treatments. c Pso-riasis after six excimer laser treatments

a

b

c


6


Fig. 6.18. a Psoriasis before excimer laser treatment. b Psoriasis after ten excimer laser treatments

a b

Fig. 6.19. a Psoriasis before narrowband UVB targeted therapy. b Psoriasis after ten narrowband UVB tar-geted therapy treatments

a b

Fig. 6.20. a Psoriasis before narrowband UVB targeted therapy. b Psoriasis after ten narrowband UVB tar-geted therapy treatments

a b


melanocytes in the skin, mucous membranes,and the retina of the eye may be destroyed. As aresult, white patches of skin can appear on dif-ferent parts of the body. The cause of vitiligo isunknown; genetics may play a role and vitiligois often associated with autoimmune diseases.Vitiligo affects between 1 and 2% of the worldpopulation, or between 40 and 50 million peo-ple worldwide. All races and both sexes areequally affected. A variety of therapies are avail-able in an attempt to repigment those affectedwith vitiligo. The 308-nm excimer laser hasshown promising results in the treatment ofvitiligo. Spencer et al. (Spencer et al. 2002) eval-uated 18 patients with vitiligo. Twenty threepatches of vitiligo, in 12 patients, received atleast six treatments with the excimer laser. Aresponse rate of 57% was noted. Eleven patches,in six patients, received 12 treatments and had

an 82% response rate. (Fig. 6.21). A targetednarrowband UVB device can also be used forrepigmentation. Initial clinical reports supportits usefulness in the treatment of vitiligo(Fig. 6.22).

■ Hypopigmented Stretch Marks

Hypopigmented stretch marks (striae) are oftenseen in dermatologic and cosmetic clinics. Vas-cular stretch marks are easy to treat with a vari-ety of vascular lasers and IPLs. Hypopigmentedstretch marks are more difficult to treat. Gold-berg and his group (Sarradet et al. 2002) treatedten patients with mature hypopigmented striaeusing the 308 nm excimer laser. Repigmentationwas noted in all study participants; acceptableresults were seen in 70% of the individuals. Thetargeted UVB device may improve this loss of

117Advantages

Fig. 6.21. a Vitiligo before excimer laser. b Vitiligo after ten excimer laser treatments

a b

Fig. 6.22. a Vitiligo before narrowband UVB targeted therapy. b Vitiligo after four narrowband UVB targetedtherapy treatments

a b


pigmentation. We also have evaluated 50 indi-viduals who after ten treatments were noted tohave between 30 and 40% repigmentation.(Figs. 6.23, 6.24).

Disadvantages

The lasers and light sources used in the treat-ment of medical dermatologic skin concernshave a low incidence of adverse effects. The useof ALA-PDT can show a “PDT effect” generallydescribed after prolonged drug incubation andexposure to light sources. This PDT effect oferythema, edema, and crusting has been shownto last up to 1 week after light exposure. It is lesslikely to occur with the use of full-face, short-

contact therapy. Lasers and light sources cancause erythema, blisters, burns and, on occa-sion, scarring. No procedure is without an occa-sional complication.

The lasers and light sources being utilizedfor psoriasis vulgaris and disorders of hypopig-mentation have shown themselves to be verysafe and devoid of major complications.

Contraindications

Contraindications are rare when utilizing lasersand light sources for the treatment of medicaldermatologic conditions with or without ALA-PDT. As with all laser and light treatments,patient expectations must be carefully ad-

6


Fig. 6.23. a Hypopigmented stretch marks before narrowband UVB targeted therapy. b Hypopigmentedstretch marks after four narrowband UVB targeted therapy treatments

Fig. 6.24. a Hypopigmented stretch marks before narrowband UVB targeted therapy. b Hypopigmentedstretch marks after four narrowband UVB targeted therapy treatments

a

a b

b


dressed. Multiple treatments are often requiredto produce optimal results. Maintenance thera-pies will also be required in most instances.

Most laser physicians would not recom-mend the use of oral isotretinoin when per-forming laser and light treatments. Whetherthis is an absolute contraindication is open fordebate, but caution should be used if oralisotretinoin is used during these laser or lightprocedures.


ALA-PDT Technique

The technique which we use varies dependingupon the condition which is being treated. Thetwo most common uses of ALA-PDT in ouroffice setting are: (1) for photodynamic pho-torejuvenation, and (2) for the treatment ofmoderated to severe acne vulgaris. Both tech-niques are described below.

ALA-PDT for photodynamic photorejuve-nation utilizes the Levulan Kerastick, and thefollowing light sources: blue light, the intensepulsed light source, and/or the pulsed dye laser.The preparation prior to the procedure is thesame for each device. The areas to be treated arecleansed with a mild facial cleanser. Forincreased penetration of the ALA, in those withmoderate to severe actinic damage, a vigorousacetone scrub or a microdermabrasion proce-dure is performed prior to application of theALA. The ALA is prepared as described above.ALA is applied to the entire area being treatedin an even distribution and allowed to incubatefor approximately 1-h prior to laser/light ther-apy. Before the procedure is performed, theALA is washed off the face with a mild cleanser.The choice of light source is up to each practi-tioner – head to head clinical trials have notbeen performed to determine if one light sourceis superior to another; in my experience, allwork well and deliver the desired results. Weexplain to our patients that treatments are per-formed once a month for up to four treatments,with the actual number determined by thepatient’s response to the therapy.

For the treatment of moderate to severeacne vulgaris, the procedures previously out-lined are once again utilized. For our acnepatients, we typically treat patients every otherweek for up to four visits, all dependent on thepatient’s response to the therapy.

■ Psoriasis Vulgaris and Disorders of Pigmentation Techniques

The two main light sources we currently utilizefor psoriasis vulgaris and disorders of hypopig-mentation are the narrowband UVB source andthe excimer laser. Multiple therapies with eachmodality are required and maintenance thera-pies will be needed.

Postoperative Care

Postoperative Care Following ALA-PDT

Here are some care instructions for patients fol-lowing ALA-PDT photodynamic skin rejuvena-tion.

■ On the Day of Treatment

1. If you have any discomfort, begin applyingice packs to the treated areas. This will helpkeep the area cool and alleviate any discom-fort, as well as help keep down any swelling.Swelling will be most evident around theeyes and is usually more prominent in themorning.

2. Remain indoors and avoid direct sunlight.3. Spray on Avene Thermal Spring Water often.4. Apply Cetaphil moisturizing cream.5. Take analgesics such as Advil if necessary.6. If given any topical medications, apply twice

daily to the treated area.

■ Days 2–7

1. You may begin applying make-up once anycrusting has healed. The area may beslightly red for 1–2 weeks. If make-up is im-portant to you, please see one of our aesthe-ticians for a complimentary consultation.

119Postoperative Care


2. The skin will feel dry and tightened. Ceta-phil moisturizer should be used daily.

3. Try to avoid direct sunlight for 1 week. Use atotal block Zinc Oxide based sunscreen witha minimum SPF 30.

Postoperative Care for Psoriasis and Disorders of Hypopigmentations

You have been treated with a UVB light source.Therefore, some redness may occur to thetreated areas.1. If redness occurs, you may use ice packs or

aloe vera gel to the treated areas.2. Avoid sunlight for the first couple of days

after treatment. You may use sunscreen ifyou must be outdoors.

The Future

A variety of medical concerns are now beingtreated with lasers and light sources. The adventof ALA-PDT has heralded a potentially new erafor dermatologists and laser surgeons farbeyond the treatment of AKs, BCCs, and SCCs.Now “photodynamic photorejuvenation” is acommon term and photorejuvenation treat-ments are being enhanced with the use of ALA-PDT. Other entities, including acne vulgaris,hidradenitis suppurativa, and sebaceous glandhyperplasia are being treated with lasers, lightsources, and ALA-PDT. Lasers and light sourcesare also being used to treat psoriasis vulgaris,vitiligo, and other hypopigmented disorders,including hypopigmented stretch marks. Lasersand light sources can now be used to treat both medical and cosmetic dermatologic condi-tions.

References

Alexiades-Armenakas M, Geronemus R. (2003) Lasermediated photodynamic therapy of actinic kera-toses. Arch Dermatol 139:1313–1320

Alster TS, Tanzi EL (2003) Photodynamic therapy withtopical aminolevulinic acid and pulsed dye laserirradiation for sebaceous hyperplasia. J Drugs Der-matol 2(5):501–504

Avram D, Goldman MP (2004) Effectiveness and safetyof ALA-IPL in treating actinic keratoses and photo-damage. J Drugs Dermatol 3(5):36–39

Dougherty TJ, Kaufman JE (1978) Goldfarb A, et al. Pho-toradiation therapy for the treatment of malignanttumors. Cancer Res 38:2628–2635

Elman M, Slatkine M, Harth Y (2003) The effective treat-ment of acne vulgaris by a high-intensity, narrowband 405–420 nm light source. J Cosmet Laser Ther5:111–117

Feldman SR, et al. (2002) Efficacy of 308 nm excimerlaser for treatment of psoriasis: results of a multi-center study. J Am Acad Dermatol 46(6):900–906

Gold MH (2003) Intense pulsed light therapy for pho-torejuvenation enhanced with 20% aminolevulinicacid photodynamic therapy. J Laser Med Surg15(Suppl):47

Gold, MH (2004a) A multi-center study of photody-namic therapy in the treatment of moderate tosevere inflammatory acne vulgaris with topical 20%5-aminolevulinic acid and a new intense pulsed lightsource. J Am Acad Derm 50(Suppl):54

Gold MH (2004b) A multi-center investigatory study ofthe treatment of mild to moderate inflammatoryacne vulgaris of the face with visible blue light incomparison to topical 1% clindamycin antibioticsolution. J Am Acad Derm 50(Suppl):56

Gold MH, Bridges T, Bradshaw V, et al. (2004) ALA-PDTand blue light therapy for hidradenitis suppurativa.J Drugs Dermatol 3(Suppl):32–39

Goldman MP (2003) Using 5-aminolevulinic acid totreat acne and sebaceous hyperplasia. Cosmet Der-matol 16:57–58

Goldman MP, Atkin D, Kincad S (2002) PDT/ALA in thetreatment of actinic damage: real world experience.J Laser Med Surg 14(Suppl):24

Goldman MP, Boyce S (2003) A single-center study ofaminolevulinic acid and 417 nm photodynamictherapy in the treatment of moderate to severe acnevulgaris. J Drugs Dermatol 2:393–396

Hongcharu W, Taylor CR, Chang Y, et al. (2000) TopicalALA-photodynamic therapy for the treatment ofacne vulgaris. J Invest Dermatol 115(2):183–192

Itoh Y, Ninomiya Y, Tajima S, Ishibashi A (2000) Photody-namic therapy for acne vulgaris with topical 5-ami-nolevulinic acid. Arch Dermatol 136(9):1093–1095

Itoh Y, Ninomiya Y, Tajima S, et al. (2001) Photodynamictherapy of acne vulgaris with topical delta aminole-vulinic acid and incoherent light in Japanesepatients. Br J Dermatol 144:575–579

Kalka K, et al. (2000) Photodynamic therapy in derma-tology. J Am Acad Dermatol 42:389–413

Lloyd JR, Mirkov M (2002) Selective photothermolysisof the sebaceous glands for acne treatment. LasersSurg Med 31:115–120

6



Lui H, Anderson RR (1993) Photodynamic therapy indermatology: recent developments. Dermatol Clin11:1–13

Paithankar DY, Ross EV, Saleh BA, Blair MA, Graham BS(2002) Acne treatment with a 1,450 nm wavelengthlaser and cryogen spray cooling. Lasers Surg Med31:106–114

Papageorgiou P, et al. (2000) Phototherapy with blue(415 nm) and red (660 nm) light in the treatment ofacne vulgaris. Br J Dermatol 142:973–978

Rowe PM (1988) Photodynamic therapy begins to shine.Lancet 351:1496

Ruiz-Rodriquez R, Sanz-Sanchez T, Cordobo S (2002)Photodynamic photorejuvenation. Dermatol Surg28:742–744

Sarradet D, Hussein M, Solana LG, Goldberg DJ (2002)Repigmentation of striae with a 308 nm excimerlaser. Lasers Med Surg 14(Suppl):44–45

Sigurdsson V, et al. (1997) Phototherapy of acne vulgariswith visible light. Dermatology 194:256–260

Spencer JM, Nossa R, Ajmeri J (2002) Treatment ofvitiligo with the 308 nm excimer laser: a pilot study.J Am Acad Dermatol 40:727–731

Svassand LO, et al. (1996) Light and drug distributionwith topically administered photosensitizers. LasersMed Surg 11:261–265

Velicer CM, et al. (2004) Antibiotic use in relation to therisk of breast cancer. JAMA 291:827–835

121References


Aablative facial laser resur-

facing 8, 83–98– informed consent 86acne 85, 93– ALA-PDT/IPL therapy 111– blue light therapy 108– inflammatory 107, 108– scarring 85, 92, 96, 97– vulgaris 107, 108, 110, 119acquired bilateral nevus

of Ota-like macules (ABNOM)48

actinic– bronzing 56, 85– keratoses 83, 99acyclovir 88alexandrite laser 55, 67, 71– hair removal 67allergic dermatitis 89amethocaine 32aminolevulinic acid (ALA) 99– PDT 119– – blue light therapy 111– PDT/IPL therapy 105, 110androgen 65angiokeratoma 28argon laser 13, 21atom 2, 4

Bbacterial infection 80basal cell carcinoma (BCC) 85,

101, 106Becker’s nevus 46bipolar radiofrequency 70blanching 14blue light treatment 103, 108blue nevus 48Bowen’s disease 101

Ccafé-au-lait macules 45, 56capillary hemangioma 20

carbon 69– chromophore 76– dioxide laser 16cavitation 38cellular pigmentation 38cherry angioma 28CO2 laser 83, 84coherence 5collagen 80collimation 5continuous wave (CW) laser 14,

37, 55, 83cooling 95copper vapor laser (CVL) 15,

24cosmetic tattoo 57CREST syndrome 28, 29crows feet 106cutaneous pigmented lesion 37cytokine 59

Ddermal– melanocytosis 57– papilla 64dermatoheliosis 91dermatosis papulosa nigra 92diode laser 23, 73– hair removal 68disorders of hypopigmen-

tation 119– laser/light therapy 114dynamic cooling device

(DCD) 67dyschromia 80dysmorphophobia 30

Eedema 78, 85elastin 80electromagnetic spectrum

(EMS)– frequency 1– wavelength 1

electron 4EMLA 88energy fluence 5ephelides 45epidermal– cooling 65– lesion 85– pigmented lesion 44epilaser 66erbium laser 83, 84erythema 32, 77, 85erythromelanin granules 63estrogen 65eumelanin granules 63excimer laser treatment 115eye– injury 8– protection 9

Ffacial– scars 26– teleangiectasia 24, 30FeatherTouch 84ferric oxide 58flash lamp pulsed dye laser 175-fluorouracil 27freckles 45, 80

Ggallium-aluminium-arsenide

(GaAlAs) 23gallium-arsenide (GaAs) 23gas laser 2giant congenital melanocytic

nevus (GCMN) 47goggles 10granuloma formation 59

Hhair– color 63– cycle 64– follicle 64, 69

Subject Index

Goldberg Index 18.01.2005 16:44 Uhr Seite 123

– growth– – anagen phase 64– – catagen phase 64– – hormones 65– – telogen phase 64, 66– removal 20, 37– – age 65– – alexandrite laser 67– – consent form 72– – diode laser 68, 73– – hyperpigmentation 79– – hypopigmentation 79– – Nd:YAG laser 68, 73– – pigmentary change 58– – ruby laser 66– – treatment approach 78hemangioma 21hematoporphyrin 100hemoglobin 14, 23, 93herpes simplex infection 71, 80,

90hidradenitis suppurativa

(HS) 111– ALA-PDT blue light

therapy 111hirsutism 61, 65hydration 88hydrogel 10hypermelanosis 45, 46hyperpigmentation 95– hair removal 79– postinflammatory 15, 33, 46,

56– postsclerotherapy 46– transient 58hypersensitivity reaction 59hypertrichosis 61hypertrophic scarring 14, 71hypopigmentation 33, 51, 90, 95– hair removal 79– permanent 58– transient 58hypopigmented stretch marks

117, 118

Iincoherent light 2indocyanin green 109inflammatory acne 107infrared laser 20intense pulsed light (IPL) 20,

69, 70, 90– sources 43, 55intralesional corticosteroid

injection 27

irradiance (see also powerdensity) 5

irritant contact dermatitis 89isotretinoin 30, 71

Kkeloidal scarring 71kerastick 101Koebner phenomenon 85KTP laser 22

Llabial lentigo 44laser– argon laser 13, 21– carbon dioxide laser 16– continuous wave dye laser 14– copper vapor laser (CVL) 15,

24– definition 2– delivery systems 2– diode laser 23– flash lamp pulsed dye laser 17– fluence 63– hair removal 62– infrared 20– KTP 22– medium 2– Nd:YAG laser 19– optical cavity 2– picosecon laser 59– plume 10, 80– power supply 2– pulsed dye laser (PDL) 18– splatter 10– tattoo removal 49– terminology 3– types 4leg vein teleangiectasia 16, 20, 21lentigines 83lentiginous photoaging 79lentigo– maligna 44– simplex 44leukoderma 90, 115leukotrichia 63Levulan 101– informed consent 113– kerastick 119– PDT system 102lidocaine 32light emitting diodes (LED) 8liquid cryogen spray 19long pulsed laser 38, 43– alexandrite laser 23

– dye laser 22– Nd:YAG laser 24lymphangioma 30

Mmacrophage colony-stimulating

factor 59MASER 2mat teleangiectasia 29melanin 8, 13, 14, 38, 44, 63, 93– pigmentation 55melanocytes 63melanocytic nevus 47melanosome 43melasma 46methemoglobin 24methyl-ALA cream 106Metvix 101, 106molecular oxygen 99

Nnarrowband UVB targeted

therapy 116, 117nasolabial groove 96Nd:YAG laser 19, 68nevocellular nevus 47nevomelanocytes 47nevus– fuscoceruleus zygomaticus 48– of Hori 48– of Ito 48– of Ota 47, 56– spilus 45nonablative– facial rejuvenation 84– resurfacing 90– – informed consent 94noncoherent light source 20nonhyperkeratotic actinic

keratoses 106

Oocclusive dressing 89open dressing 89optical– cavity 2– density 9oxyhemoglobin 13, 14, 19, 23, 67

PPDT effect 109, 118permanent hypopigmen-

tation 58petrolatum-based ointment 89,

90

124 Subject Index


pheomelanin 63photoablative decomposition 10photoaging 104photodamage 91, 92photodynamic– photorejuvenation 105– rejuvenation 120– therapy 34, 99photon 5photorejuvenation 104photosensitivity 93, 99photothermolysis 22picosecon laser 59pigmentary change 58– hair removal 79pigmented lesion 7, 37–59– consent form 52– removal 37pilosebaceous gland 107pocket cell 6poikiloderma 28population inversion 2porphyrin 107port wine stain (PWS) 17, 18, 32– flash lamp pulsed dye laser 17– resistant type 19– treatment 13postinflammatory hyperpigmen-

tation 15, 33, 46, 56postirridation teleangiectasia 29postrhinoplasty 28postsclerotherapy hyperpigmen-

tation 46power– density 5– supply 2prilocaine 32Propionobacterium acnes 107protoporphyrin IX (PpIX) 100,

104pseudofolliculitis barbae 71, 77psoriasis 26, 115, 116– excimer laser treatment 115– laser/light therapy 114– vulgaris 113, 119

pulsed dye laser (PDL) 7, 18, 43,55, 90

purpura 25, 27, 93pyrolysis 38

QQ-switched laser 6, 38, 41, 43– alexandrite laser (QSAL) 55– Nd:YAG laser 69– ruby laser (QSRL) 50

Rradiofrequency (RF) energy 90resonator 4rhytide 97robotic scanning 15rosacea 28ruby laser 50– hair removal 66

Sscar 26, 90– pruritis 27scleroderma 85sclerotherapy 21, 24sebaceous gland 109– hyperplasia 93, 95, 97, 110, 112seborrheic keratoses 45selective photothermolysis

(SPTL) 6, 37, 62, 68signage 8SilkTouch 84solar lentigo 44spider angioma 28squamous cell carcinoma

(SCC) 100, 101strawberry hemangioma 20, 21striae 117superficial– basal cell carcinoma 85– nonmelanoma skin cancer 99

Ttattoo 7, 43, 48, 80– amateur tattoo 50

– cosmetic tattoo 57– laser removal 49– particles 44– pigments 48– professional tattoo 50– traumatic tattoo 51teleangiectasia 23, 96, 97thermal– damage time (TDT) 62– denaturation 38– relaxation time (TRT) 6, 62titanium dioxide 58transfollicular damage 63transient– erythema 78– hyperpigmentation 58– hypopigmentation 58traumatic tattoo 51TruePulse 84tuberculosis 1

UUltraPulse laser 84unwanted hair 8, 61–80urticaria 59

Vvalcyclovir 88, 90vaporization 69vascular– laser treatment– – consent form 31– – postoperative care 33– lesion 17venous lake 28verrucae 27vitiligo 1, 85, 115– excimer laser treatment 117

Wwrinkle 85, 92, 96– reduction 93

125


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