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(BQ) Part 1 book Lasers in dermatological practice presentation of content: The history of dermatology, skin structure, function and development, approach towards a dermatological patient, bacterial infections, fungal infections, viral infections, parasitic infestation, diseases caused by arthropods and other venomous animals.
LASERS in Dermatological Practice LASERS in Dermatological Practice Editors Kabir Sardana MD DNB MNAMS Professor Department of Dermatology and STD Maulana Azad Medical College New Delhi, India Vijay K Garg MD MNAMS Director–Professor and Head Department of Dermatology and STD Maulana Azad Medical College New Delhi, India Forewords Ganesh S Pai B Krishna Rau JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • London • Philadelphia • Panama Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +44 (0)20 3008 6180 Email: info@jpmedpub.com Jaypee Medical Inc The Bourse 111 South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: +1 267-519-9789 Email: jpmed.us@gmail.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +1 507-301-0496 Fax: +1 507-301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu Nepal Phone: +977-9741283608 Email: kathmandu@jaypeebrothers.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2014, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and not necessarily represent those of editor(s) of the book All rights reserved No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book Medical knowledge and practice change constantly This book is designed to provide accurate, authoritative information about the subject matter in question However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications It is the responsibility of the practitioner to take all appropriate safety precautions Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book This book is sold on the understanding that the publisher is not engaged in providing professional medical services If such advice or services are required, the services of a competent medical professional should be sought Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Lasers in Dermatological Practice First Edition: 2014 ISBN 978-93-5152-300-0 Printed at Dedicated to My colleagues, friends and foes, the last of which goad us to better ourselves constantly…… My wife Dr Supriya, who helps me to keep the balance between family and academics My daughter Zoya, who is the ‘zing’ in my life My parents, Mrs Amba Sardana and Major General Sardana who have instilled discipline in my life and Lastly, the Department where over the years we have honed the skills in laser intervention —Kabir Sardana My family and friends My wife Mrs Manju Garg, who has stood by me through times of strife My son Devansh, who is pursuing his MBBS and My daughter Dr Ekta, who is a dentist —Vijay K Garg Contributors Anil Aggrawal MD Forensic Medicine (AIIMS) Director-Professor Forensic Medicine Maulana Azad Medical College New Delhi, India Anil Ganjoo MBBS MD Senior Consultant Dermatologist and Head of Dermatology Sunderlal Jain Hospital Saroj Hospital and INMAS New Delhi, India Anjali Madan MD Senior Resident Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Anuj Tenani MBBS PGY-II Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Anusha H Pai MD Consultant Dermatologist Derma-Care Skin and Cosmetology Center Mangalore, Karnataka, India Atul M Kochhar MD DNB MNAMS FAAD Senior Specialist–Grade I Department of Dermatology and STD Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Banwari Jangid MD Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India Dharmendra Karn MD Dermatologist Dhulikhel Hospital Kathmandu University Teaching Hospital Kavre, Nepal Ganesh S Pai MD DVD Senior Consultant Dermatologist Derma-Care Skin and Cosmetology Center Mangalore, Karnataka, India Inder Raj S Makin MBBS (India) Dipl-Ing (Germany) RDMS PhD (USA) Associate Professor AT Still University School of Osteopathic Medicine in Arizona (SOMA) Arizona School of Dentistry and Oral Health (ASDOH) Mesa, USA Jaspriya Sandhu MBBS PGY-I Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Kabir Sardana MD DNB MNAMS Professor Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Khushbu Goel MD Pool Officer Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India viii Lasers in Dermatological Practice Narendra Kamath MD DVD Consultant Dermatologist Cutis Skin Care Center Mangalore, Karnataka, India Pavithra S Bhat MD Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India Payal Chakravarty MD Senior Resident Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Rashmi Ranjan MD Senior Resident Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Rashmi Sarkar MD MNAMS Professor Department of Dermatology Maulana Azad Medical College and LN Hospital New Delhi, India Chief Founder and Honorary Secretary Pigmentary Disorders Society New Delhi, India Shahin S Nooreyezdan MBBS MS MCh (Plastic Surgery) PGIMER Chandigarh Senior Consultant Department of Plastic, Cosmetic and Reconstructive Surgery Indraprastha Apollo Hospitals New Delhi, India Shikha Bansal MD DNB MNAMS Specialist Department of Dermatology Safdarjung Hospital New Delhi, India Shivani Bansal MD Senior Resident Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Simal Soin PG Dermatology (St Johns Institute of Dermatology) London MPhil Cambridge University UK Medical Director and Chief Cosmetic Dermatologist Three Graces New Delhi, India Soni Nanda MD (Dermatology) Shine and Smile Skin Clinic Max Super Specialty Hospital New Delhi, India Sujay Khandpur MD DNB MNAMS Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India Twinkle Daulaguphu MBBS PGY-I Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Vanya Narayan MBBS PGY-III Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Vijay K Garg MD MNAMS Director-Professor and Head Department of Dermatology Maulana Azad Medical College and Lok Nayak Hospital New Delhi, India Vivek Nair MBBS MD Consultant Dermatologist Dr Nair’s Skin Clinic (Palam Vihar) Clinic Dermatech (Vasant Vihar and Gurgaon) Metro Hospital (Palam Vihar) New Delhi, India Foreword Lasers have moved from the fringe of dermatology to a more centrist path over the past decade Fifteen years ago, when lasers trickled into our country, they were considered to be exotic and perhaps accessible to a select few Cosmetic dermatology and lasers have grown by leaps and bounds and that necessitates that they are absorbed in the mainstream With close to half of the dermatologists now owning or having access to lasers, it is important that our younger generation of dermatologists have access to good practical textbooks as well as high quality equipment This book, Lasers in Dermatological Practice is best suited to educate our specialty about the perils and pitfalls of using lasers Indian skin is unique since it comes commonly in types—IV, V, VI Parameters will therefore vary depending on the skin types, a dilemma that western books not address Postinflammatory hyperpigmentation will vary in each skin type and even show variation among patients in a single skin type Such unpredictability and perplexing results are a cause of anxiety in a cosmetologist at an inflexion point in his career A comforting thought is that our patients, except for a miniscule minority, are forgiving and compliant Most cases of tissue damage by laser will heal over time, nature coming to our rescue Our patience and reassurance will comfort patients in the interim period In clinical dermatology, we have a chance to assess, judge and treat patients If there is an error of management, we can apply a midcourse correction and modify therapy Unfortunately, this is not true of lasers A mistake made, a poor assessment, using more or less power than required can lead to laser burns and scarring If it is on the face, as it is most of the time, the consequences are not difficult to portend Since there is no second chance to repair damage, it is important to understand the basics of lasers and the specifics of equipment much like reading a car manual before driving your new car This book does both and will hopefully lead to confident cosmetologists and happy patients Ganesh S Pai MD DVD FAAD Medical Director Derma-Care Skin and Cosmetology Center, The Trade Center Director-Professor, Department of Dermatology KS Hegde Medical College, Deralakatte Mangalore, Karnataka, India Nonablative and Subsurface Rejuvenation 279 laxity by heating deeper skin and subcutaneous tissue, causing skin and tissue tightening These devices have been discussed previously A new RF tool, the ‘Portrait’ plasma skin regeneration (PSR 3) device, has been shown to improve skin texture, tone, fine lines, dyschromia, and rhytides The plasma is emitted in millisecond pulses to deliver energy to the desired tissue without reliance on a skin chromophore, and energy settings on the device can be varied for different depths One disadvantage of this technology is that there is about a 1-week period of required downtime Vascular Lasers Studies have shown that KTP lasers have better collagen formation results when compared to 1,064 nm lasers in the treatment of skin photorejuvenation Pulsed dye lasers (PDL) function best in the treatment of vascular lesions (i.e port wine stains and hemangiomas) with significant production of procollagen type I and type III Increased activity of dermal fibroblasts and mucin, as well as the thickening of the stratum spinosum in the dermis, has been noticed in the restoration of degenerated skin The use of modern PDL systems for skin rejuvenation provides nonablative results by minimizing sideeffects and reducing purpura Study Results Zelickson and Kilmer determined that purpurogenic doses of the PDL also induced fibroblast proliferation and the production of the Grenz zone of new collagen in the papillary dermis, beneficial for resurfacing Though early studies, showed a good histological response, there was little patient satisfaction In 2004, Trelles et al compared the effects of the 595 nm PDL to a 1,450 nm diode laser and to a combination treatment with both lasers The combination protocol was found to be better It has been proposed that the logic of combination is that following the removal of the vascular-associated pigment from the superficial dermis by the PDL, enables deeper penetration of the following pulse with the 1,450 nm diode, helping to amplify the woundhealing response This has led to a combination approach of PDL with other laser systems (595/1,064 nm) Many other wavelengths that target hemoglobin in blood vessels have been used, which include the long-pulsed 755 nm alexandrite laser, 810 nm diode, and the 1,064 Nd:YAG lasers The 1,064 nm Nd:YAG laser induces deeper remodeling than the 532 nm laser due to its lower degree of dermal scattering and chromophore absorption at 1,064 nm Thus, the logic of combining 532 nm laser to treat dyschromia and telangiectasia and following it with the 1,064 nm laser to obtain some deeper remodeling in the same treatment session 280 Lasers in Dermatological Practice Intense Pulsed Light Intense pulsed light (IPL) devices emit polychromatic light in broad ranges of wavelengths, selectively filtered to target specific chromophores, between 500 and 1,200 nm IPLs treat vascular lesions, pigmentation, and have shown to have an effect in the production of collagen and elastic fibers in the dermis Studies have shown that IPL photorejuvenation treatments using cooling apparatuses considerably increase epidermal thickness, and improve skin texture This necessitates a proper cooling to avoid the adverse effects relating to skin damaged The addition of radiofrequency has been utilized to supplement and improve outcomes with use of IPL devices (Elos, Syneron) Bipolar radio frequency exhibits a preference for warmer tissue This technology considers this property by utilizing the IPL system to heat the target chromophore and then using the radiofrequency technology to target the now ‘warmer’ tissue target Study Results Bitter et al studied the effect of a series of treatments with the IPL (photorejuvenation) in 49 patients After 4–6 IPL sessions every weeks, more than 90% of patients had improvement in all aspects of photoaging: 50% or greater improvement was noted by 46% of patients for fine wrinkles, 72% for skin smoothness, 70% for telangiectasias, 67% for decreased pore size, 59% for facial erythema, and 50% for flushing In a multicenter study of 93 patients (skin phototypes I–III, Fitzpatrick Wrinkle Classes I–II, and Elastosis Scores 1–6), Sadick et al gave treatments at monthly intervals with the 560 or 640 nm cutoff filter The markedly favorable results at 4- and 6-month follow-up visits confirmed its long lasting results Further studies (Negishi et al.) have used a longer pulse durations with a cutoff filter at 590 nm, to treat photoaging in skin type IV Long-term followup results have confirmed sustained improvement of the face, neck, and chest up to years after treatment Summary Even though newer systems have improved user friendly pre-programmed settings, one should become comfortable with one or two IPL systems as each has different interfaces, wavelength spectrums, filters, power outputs, pulse profiles, cooling systems, and spot sizes In fact, the variations make it impossible to compare the different IPL devices This is as some IPL devices that calculate fluences based partly on theoretical modeling and photon Nonablative and Subsurface Rejuvenation 281 recycling whereas others determine fluence based solely on an actual output at the sapphire or quartz window on the handpiece tip Our own experience with this modality in Indian skin has been less enthusiastic and we feel that the fluencies recommended can cause side effects and a lower dose can have little objective benefit Light-emitting Diodes Light-emitting diodes (LED) provide “athermal and atraumatic” photo activation of mitochondria, epidermis and fibroblasts The singular advantage of LED devices is that they are well tolerated by patients Typically, LED devices emit a range of wavelengths The interaction of LED devices with the skin is unclear, though photomodulation of cell receptors, cell organelles, or existing protein products is the possible mechanisom Unlike many of the devices discussed above, non-thermal interactions with the extracellular matrix and fibroblasts remodel existing collagen, increase collagen production by fibroblasts, inhibit collagenase activity, and result in rhytid reduction Combination of various LED wavelengths is the key to clinical efficacy One wavelength will not target all chromophores optimally Based on the published peer-reviewed literature, a combination of wavelengths is necessary for effective LED phototherapies are given in Table 7.2 The wavelengths used for LED skin rejuvenation have been near IR at 830 nm applied first, followed by 633 nm 72 hours later, repeated over weeks The reasons for these wavelengths and the order in which they are applied are photobiologically based on the precepts of the wound healing cycle Both of these wavelengths involve the basal keratinocytes and also target dermal cells, with beneficial effects to both the cellularity and organization of the epidermis (Table 7.2) Study Results Lee and colleagues, in the first controlled study in the peer-reviewed literature, compared LED skin rejuvenation in a total of 76 patients randomly assigned to four groups: 830 nm LED therapy on its own, 633 nm LED therapy on its own, the combination therapy with 830 nm and 633 nm and a sham irradiated group All patients were treated hemifacially, so there were intrapatient Table 7.2 A summary of the LED wavelengths and clinical utility Wavelength Indications 633 nm + ALA PDT Non-melanoma skin cancers Blue 415 nm endogenous PDT + red 633 nm Acne vulgaris Near infrared 833 nm + 633 nm Skin rejuvenation, wound healing 595 nm yellow light Rosacea, skin rejuvenation 282 Lasers in Dermatological Practice as well as intergroup controls In addition, to clinical photography and subjective patient assessment, Dr Lee tested the results with profilometry and instrumental measurement of skin melanin and elasticity She also carried out histological, immunohistochemical and biochemical assays She found that wrinkles and skin elasticity were best improved in the 830 nm-treated groups, skin lightening was best in the 633 nm group, so the combination of the two wavelengths was able to achieve the best overall efficacy and high patient satisfaction with the results, with statistical significance seen between all treated groups and the sham-irradiated controls, and a statistically significant improvement between the treated and occluded sides in all of the experimental groups, but not in the sham irradiated group The clinical photography was backed up by the histological findings for both collagenesis and elastinogenesis, which was proved to take place in all dermal layers down to the deep reticular dermis A 90-subject prospective study by Weiss et al (2005) using a 590 nm nonthermal full-face LED (eight treatments over weeks with a minimum of 48 hours between treatments) showed a global improvement of more than 85% and a self-assessment improvement of 84% in patients at months With digital imaging, there was a 90% reduction in the signs of photoaging: Smoother texture, and reduced periorbital wrinkles, erythema, and pigmentation However, profilometry results only showed a 10% improvement by surface measurements In a prospective study using the OmniluxTM LED system, a combination of IR (633 nm) and near-IR (830 nm) light with fluences of 126 and 66 J/ cm2, respectively, 31 patients underwent treatments: 830 nm light on days 1, 3, 5, 15, 22, and 29, and 633 nm light on days 8, 10, and 12 (Russel BA) Patient satisfaction scores, photos, and profilometry were used to assess improvement at and 12 weeks A clinically significant reduction in surface roughness, maximum profile peak height, and maximum height of the profile was demonstrated Fifty-two percent of the subjects had a 25–50% improvement in photoaging scores at 12 weeks, and 81% displayed a signifi cant improvement in periorbital rhytides at the end of the study The Gentle Waves device (Light BioScience, LLC, Virginia Beach, VA), which generates a 588 nm yellow light pulses with an on-time of 250 ms and off-times of 10 ms for a total of 100 pulses resulting in a total light dose of 0.1 J/cm2 Boulos found that there was a strong placebo effect with the 588 nm Gentle Waves system, and that little objective improvement was observed by blinded raters Despite the subjective improvement in two trials, objective improvement in blinded studies is unproven But as stated above a combination approach is better than the use of a single wavelength Consequently, LED combination therapy is a safe and effective method of skin resurfacing, but in order to optimize treatment parameters, further studies are necessary Nonablative and Subsurface Rejuvenation 283 Infrared Laser The 1,320 nm Nd : YAG laser was the first commonly used nonablative midinfrared laser to rejuvenate skin The Q-switched 1,064 nm laser systems that stimulate deep dermal collagen stimulation had revealed faster healing than carbon dioxide systems Further, studies have shown that Q-switched 1,064 nm laser devices significantly decrease solar elastosis and thicken upper papillary dermal zones of collagen The 1,064 nm Nd: YAG laser devices have useful skin lightening mechanisms for skin rejuvenation With the use of epidermal cooling devices, such as cryogen, 1,319/1,320 nm laser devices have provided optimal results in the formation of new collagen, reduction of lines and wrinkles These nonablative laser systems leave the epidermis intact and provide great results in all skin rejuvenating procedures The 1,450 nm mid-infrared diode laser systems have functioned successfully in the treatment of active inflammatory acne vulgaris, acne scars on the face, fine lines and wrinkles This laser system targets dermal water, creates a wound in the dermis and triggers the regeneration process of collagen The 1,540 nm Erbium:Glass laser devices have also clinically shown to help in dermal remodeling by treating fine lines and wrinkles, acne vulgaris and acne scars, and atrophic scars on the face These lasers use a sapphire lens cooling device throughout the treatment process One issue with these devices is the side effects that range from dyschromia, purpura, and blistering to scarring Epidermal cooling techniques are imperative in patients with Fitzpatrick IV–VI type skin The 1,320 nm Nd : YAG uses either a pre- or post-laser spray, while the 1,450 nm diode laser applies cryogen before, during, and after the laser pulse These are ideal for Fitzpatrick IV, V, and VI skin types As in the case of the 1,450 nm system, the total spray time is delivered over a long period (up to 220 ms), there is a risk of cryoinjury Thus, the shorter spray times with the 1320 nm laser and the 5°C sapphire lens incorporated into the 1,540 nm erbium : glass laser are a better option Study Results Infrared laser-1,064 nm Nd:YAG: The LP Nd:YAG laser, like the PDL, is a vasculature-selective device and works best for red pigment and vascular lesions This has also been used for treatment of photodamaged skin, improving dyspigmentation, skin tone, and texture Studies by Goldberg DJ, 1997 and Cisneros JL,1998 have shown that the QS laser can be considered as a modestly effective treatment for wrinkles, lentigines, and acne scarring In 2006, a short-pulsed 1,064 nm Nd:YAG laser was developed for more effective acne scar reduction This pilot study in patients with moderate-to-severe 284 Lasers in Dermatological Practice facial acne scars used this laser with a low fluence (14 J/cm2) and after eight sequential treatments (Lipper GM) there was marked improvement in acne scarring Infrared laser-1,320 nm Nd:YAG: The CoolTouch laser (CoolTouch, Roseville, CA) was the first device specifically designed for nonablative resurfacing and improving skin texture It has been tried both in acne and photodamaged skin Chan et al studied this laser’s effect on wrinkle reduction and the treatment of acne scarring in 27 Asian females The protocol was a monthly treatment for months with passes per session and objectively only a mild improvement or no change was seen in most cases In 2006, Bhatia et al performed a study utilizing structured interviews of 34 patients months after undergoing a series of monthly treatments with the CoolTouch laser for the treatment of acne scarring or photodamage This study noticed that patient satisfaction was high and textural improvement were seen These studies suggest that although the 1,320 nm Nd:YAG shows a mildto-moderate benefit for wrinkling and acne scarring, but patients are more than satisfied with the results than the clinician Infrared 1,450 nm diode: Similar to the CoolTouch laser, the 1,450 nm diode (SmoothBeam, Candela, Wayland, MA) uses a cryogen cooling device to protect the epidermis during treatment and delivers energy via a 4- or 6-mm spot In addition to its thermal effects on the dermis, it also damages sebaceous glands, thereby making it a useful treatment option for acne Mild-to-moderate improvement was seen in 12 of the 16 patients on the treated side in a split face study (Ross EV, 2000) Another study in patients with mild-to-moderate perioral or periorbital wrinkles, Tanzi et al (2003) demonstrated mild-to-moderate improvement of wrinkles An increase in dermal collagen was seen at months after the last treatment, and patient satisfaction scores reflected the histological and photographic changes Tanzi and Alster later compared this laser to the 1,320 nm Nd:YAG for the treatment of atrophic facial scars in 20 patients receiving three successive treatments with a LP 1,320 nm Nd:YAG laser on one side of the face and with a LP 1,450 nm diode laser on the other side Both lasers improved atrophic scarring but the 1,450 nm diode laser showed a greater clinical scar response Some authors have suggested that if passes with the 1,320 nm Nd:YAG had been performed improved results can be achieved As a result, using the pass protocol with the Nd:YAG laser may yield similar or greater results to the 1,450 nm diode laser Infrared laser-1,540 nm Erbium: Glass (NAFR): The 1,540 nm Erbium:glass laser (Aramis, Quantel Medical, Clermont-Ferrand, France), like the SmoothBeam and CoolTouch, also uses contact cooling for epidermal protection Unlike these lasers, it has a smaller spot size (4 mm), and therefore treatments are relatively comfortable and require no topical anesthesia The 1540 nm erbium:glass laser penetrates to a depth intermediate between Nonablative and Subsurface Rejuvenation 285 1320 nm (deepest) and 1450 nm (shallowest) and also induces tissue water heating, thermal injury, and neocollagenesis Fournier et al determined that the erbium:glass laser results in progressive improvement of perioral and periorbital rhytids at and 14 months New collagen formation was also noted at the papillary dermis from biopsy specimens Infrared laser-1,550 nm erbium-doped fiber (NAFR): Manstein et al performed the first study of the fractional laser by treating 15 subjects with varying densities on the distal forearm Biopsies taken from the treated sites at 48 hours, week, month, and months were used to help describe the wound-healing process Results from this study eventually led to FDA approval for the use of the fractional laser for soft tissue coagulation in 2003 Since then, the laser has been sanctioned for the following indications: periorbital rhytides, pigmented lesions, melasma, skin resurfacing, and scarring This device has been discussed previously in detail and has been the “game changer” as it has managed to optimize results and side effects “In Motion Devices “ Near-infrared lasers have been used in a motion technique for skin rejuvenation The procedure (Laser Genesis, Cutera, Brisbane, CA) is easy to perform and results in only mild erythema postoperatively This 1,064 nm laser, which has a 5: 7 mm spot size is used in a rapid back-and-forth fashion at Hz and 12–15 J/cm2 The device is moved from region to region based on the surface temperature or patients comfort Obviously, the lack of anesthetic is imperative in this approach, as excessive pain must be reported by the patient and should alert the operator to move and prevent epidermal injury Plasma Resurfacing Plasma resurfacing is a relatively new technology that has been in clinical use for over years, with years of ongoing trials assessing its efficacy for facial and non-facial skin rejuvenation The Portrait PSR system is currently the only commercially available plasma resurfacing system to date (Kilmer S, Bentkover SH) Mode of Action Plasma skin regeneration (PSR) utilizes energy derived from nitrogen gas to create heat that is delivered onto the skin surface resulting in zones of thermal damage and thermal modification PSR is not chromophore dependent and does not result in vaporization of the epidermis, as is seen with ablative lasers, but leaves a layer of intact, desiccated epidermis that acts as a biologic dressing and promotes rapid healing 286 Lasers in Dermatological Practice The histological depth of cleavage is directly related to the pulse energy of the treatment At settings of J, the line of cleavage extends only to the superficial most portions of the epidermis and at J, the line of cleavage is within the papillary dermis (Fig 7.1) Dose Seven treatment protocols are available to treat the full spectrum of patient conditions These range from a low pulse energy (0.5 J) “lunch hour” procedure with effects and recovery times similar to those of fractional lasers to high energy (4 J) double pass procedures with more dramatic improvements and recovery times of 7–10 days Protocols are comprised of either single or multiple treatments that can be matched to the patient’s condition Indications The PSR has received FDA 510(k) clearance for treatment of rhytides of the body, superficial skin lesions, actinic keratoses, viral papillomata, and seborrheic keratosis As only one manufacturer for this device is there in the World, there are issues in procuring spare parts for this device The PSR has beneficial effects in the treatment of dyschromias and photoaged skin, and has been utilized for the treatment of acne scars, eyelid laxity, Hailey-Hailey disease, and linear porokeratosis Contraindications Patients with keloid prone skin, active infection, breaks in skin or any cutaneous inflammatory condition, patients who are pregnant or nursing, those who would be deemed ineligible for general surgery, patients with Fitzpatrick skin types V and VI, and those patients who have taken oral isotretinoin within the past months Fig 7.1: Diagrammatic depiction of the depth of the plasma resurfacing device at various doses Note that at J, the ablation is superficial, while at J the ablation zone is till the dermis Nonablative and Subsurface Rejuvenation 287 Results Published reports assessing high energy (3–4 J) single pass PSR for facial rejuvenation have demonstrated a mean 50% improvement in skin tone 30 days after treatment Other reports have shown attenuated clinical improvement over time, e.g a mean 39% reduction in depth of fine facial lines at 10 days after treatment that decreased to 23% months after treatment The PSR has been also used for acne scars with a 23% reduction in scar depth at months Published reports assessing PSR in the treatment of non-facial skin using low energy settings have demonstrated mean clinical improvements of 57%, 48%, and 41% in chest, hands, and neck sites, respectively, and significant reductions in wrinkle severity, dyschromia, and increased skin smoothness were achieved (Alster TS, Konda S) Conclusion Do We have the Ideal Device for Skin Rejuvenation ? Skin rejuvenation and antiaging have become ‘hot’ topics with almost all the major laser companies jumping on to the bandwagon Excessive skin exposure to solar UVA and UVB brings about damaging morphological and metabolic changes in the epidermis and dermal extracellular matrix (ECM), combining with and accelerating the effects of chronological aging and resulting in the lax, dull and wrinkled appearance of ‘old’ skin Oxidative stressors such as singlet oxygen, which are generated following absorption of UV radiation damage the matrix causes elevation of matrix metalloproteinases (MMPs) and and leads to elastotic damage to the underlying connective tissue As this damage is cause by light, an elegant concept to use the power of light to reverse the damage led to the application of lasers, usually the CO2 or/and the Er:YAG, in what became known as ablative laser resurfacing Although still regarded as the ‘gold standard’ in the rejuvenation of severely photoaged skin in general and wrinkles in particular, the possibly severe side effects and a prolonged patient downtime of up to several months associated with this approach drastically reduced its popularity To attempt to overcome these problems, so-called nonablative resurfacing was developed using specially adapted laser or intense pulse light sources The theory was to deliver a controlled zone of deliberate photothermal damage beneath an intact epidermis, so that the wound-healing processes, including collagenesis and remodeling, could occur under the undamaged epidermis, thereby obtaining rejuvenation of the skin without any patient downtime and was popularized as the ‘lunch-break rejuvenation’ The theory was good, but in clinical practice patient satisfaction was very low, (Trelles MA 2001, Nikolaou VA,2005) because the good dermal neocollagenesis 288 Lasers in Dermatological Practice seen in post-treatment histological analysis was not reflected in a ‘younger’ epidermis (Orringer JS) In an attempt to bridge this gap between ablative and pure nonablative rejuvenation, so-called fractionated or fractional technology was developed whereby many spots of almost grossly invisible epidermal and dermal ‘microdamage’ were delivered via a scanner or ‘stamp-type’ head, all surrounded by normal epidermis and dermis to obtain swift re epithelialization and dermal wound healing Unfortunately, once again the clinical results were not satisfactory to the majority of patients, with good dermal neocollagenesis not being echoed in the epidermis In both, the nonablative laser/IPL and the first generation of fractional technologies, the big problem was that what the patient first sees when looking in a mirror is the epidermis, not the dermis It does not matter to the patient (or her friends) that her dermis is wonderfully better organized if her epidermis remains unchanged, what Dr Glen Calderhead refers to as the SOE syndrome—‘same old epidermis’ Recognizing this, manufacturers of the more recent second generation of fractional systems have returned to the orginal ablative wavelengths, the CO2 and the Er:YAG, in addition to newer media such as Er-doped fiber, to deliver fractionated microbeams that visibly damage the skin, with a recognizable amount of erythema and some edema post-treatment Thus, we have “reinvented the wheel” so as to speak and gone back to our gold standard of ablative resurfacing This approach has been much more successful from the patient satisfaction criterion, although at the cost of a little downtime, because it is involving the epidermis more than the previous nonablative and fractional approaches How to Choose the Right Device ? The first rule to remember is that no single device can tackle all the problems of a photodamaged skin and secondly dramatic responses are hard to come by and should not be promised to the patient When selecting a thermal photorejuvenation system, it is therefore critical to understand the physics behind the wavelength and the method of delivery rather than “exaggerated” manufacturer’s claims Having knowledge of the output of a device, understanding whether the target is hemoglobin, melanin or water (or all three) and understanding spot size and method of delivery, the physician may be better able to choose the correct system for the correct application For example, photorejuvenation of pigmented lesions would not be possible with a unit emitting 1,450 nm, for which the target is water and not melanin This knowledge is also vital if the clinician is to minimize possible adverse clinical events in darker ethnic skin types Visible light, more strongly absorbed by melanin, must therefore be used with greater caution in darker Nonablative and Subsurface Rejuvenation 289 skin A patient concerned about excessive telangiectasia, would be better served by the 532 nm potassium titanyl phosphate (KTP), a PDL, or an IPL device If the goal is to obtain deeper dermal remodeling, one of the many infrared devices may be needed An approach to specific patient problems with specific treatments is outlined in Box 7.2 Thus, in clinical practice a combination of laser devices is needed for optimal results (Box 7.2) As the relative benefits of individual devices within in each indications have not compared to determine the ideal device, this leaves this field open to research Numerous other issues have to be considered some of which are given in Box 7.3 Clinical evaluations of nonablative and minimally ablative therapy generally rely on patient and physician (blinded and nonblinded) assessments of before and after photographs Additional objective methods of skin texture measurement include profilometry and ultrasound, among others Differences in before and after results can be subtle, even with the use of digital photography Though most of the studies in literature have used these parameters some clinicians are not satisfied by the end results But these therapeutic interventions remain popular among both patients and physicians, suggesting that although differences may not always be clear, results are real Determining which patients are suitable for skin resurfacing depends in part on the patients’ desires and expectations with treatment Box 7.2 A summary of the use of laser/light for treating photodamaged skin Morphology Devices used Telangiectasias IPL PDL LP Nd:YAG (LP 532 nm) Diffuse-redness (nonvisible telangiectasia) IPL LED photomodulation Mottled pigmentation IPL Nd:YAG (LP) 532 nm LED Mild rhytides LED photomodulation IPL PDL Nonablative infrared lasers Moderate rhytides Infrared lasers Deeper rhytides 1,320 nm,1,450 nm, 1,540 nm RF Acne scars Erythematous: IPL, PDL, LED Nonerythematous: 1,320 nm, 1,450 nm, 1,540 nm IPL, LED Texture 532 nm, PDL, Qs Nd:YAG IR laser, LED 290 Lasers in Dermatological Practice Box 7.3 Miscellaneous aspects relevant to nonablative lasers Ideal patient Glogau grade II or III with mild to moderate photodamage Dark skin type Mid-infrared lasers, Avoid light based devices Fillers and botox Should precede subsurface laser procedure by hours Pain More with IR devices Edema More PDL, IPL, or Nd:YAG Contraindications Active dermatitis or infection History of keloid / hypertrophic scar formation History of koebnerizing dermatitis (psoriasis, vitiligo) History of photosensitive dermatitis History of oral retinoid use (12 month) Recent medium or deep chemical peel Nonablative and Subsurface Rejuvenation 291 Step By Step Approach Patient selection is important here as this is one indication where the expectation-outcome is crucial Thus, it is better to give less expectation to the patient so that the end results achieved are satisfactory! Patient Selection The ideal patient is a relatively young patient (25–65 years of age), with minimal facial skin sagging, and should be made aware that skin texture and fine lines will improve, but will not be eliminated Furthermore, since the effects of treatment are cumulative, it is important to reiterate that multiple treatments will be more beneficial than a single treatment Pre-procedure The physician should always obtain pre-treatment photographs The patient should be placed and draped in a position that allows full access to the treatment area This is typically achieved by placing the patient in the supine position to treat photodamaged areas, such as the face, neck, chest, and forearms Appropriate goggles or eye shields (internal or external depending on the treatment area) are then applied to assure proper ocular protection It is helpful to inform the patient who has appropriate eye protection about the likelihood of seeing a flash of light during the procedure Many patients become anxious regarding the dangers of lasers when they see a flash of light even when they have goggles or shields over their eyes Informing them that they are adequately protected, even when they see a flash of light adjacent to the shields, puts them at ease Procedure It is difficult to detail the various settings required to operate the devices given in Box 7.3 Thus, an individulized approach is needed But for pigmented skin, it is our view that most of the light based devices should be used with care and the infrared and RF help the patients more than vascular, IPL and PDL devices Bibliography Alam M, Dover JS Nonablative laser and light therapy: an approach to patient and device selection Skin Therapy Lett 2003;8(4):4-7 Calderhead RG Light-emitting diode phototherapy in dermatological practice K Nouri (ed.), Lasers in Dermatology and Medicine, DOI: 10.1007/978-0-85729281-0_19, © Springer-Verlag London Limited, 2011 292 Lasers in Dermatological Practice DeHoratius DM, Dover JS Nonablative tissue remodeling and photorejuvenation Clin Dermatol 2007;25:474-9 Journals Alster TS, Konda S Plasma skin resurfacing for regeneration of neck, chest and hands: investigation of a novel device Dermatol Surg 2007;33(11):1315-21 Bentkover SH Plasma skin resurfacing: personal experience and long-term results Facial Plast Surg Clin North Am 2012;20(2):145-62 Bhatia AC, Dover JS, Arndt KA, Stewart B, Alam M Patient satisfaction and reported long-term therapeutic efficacy associated with 1,320 nm Nd:YAG laser treatment of acne scarring and photoaging Dermatol Surg 2006;32:346-52 Bitter PH Non-invasive rejuvenation of photodamaged skin using serial, full face intense pulsed light treatments Dermatol Surg 2000;26:835-43 Boulos PR, Kelley JM, Falcao MF, et al In the eye of the beholder – skin rejuvenation using a light-emitting diode photomodulation device Dermatol Surge 2009;35(2):229-39 Chan HHL, Lam L, Wong DYS, et al Use of 1,320 nm Nd:YAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians Lasers Surg Med 2004;34:98-103 Cisneros JL, Rio R, Palou J The Q-switched neodymium (Nd):YAG laser with quadruple frequency Clinical histological evaluation of facial resurfacing using different wavelengths Dermatol Surg 1998;23:345-50 Fournier N, Dean S, Barneon G, et al Nonablative remodeling: clinical, histologic, ultrasound imaging and profilometric evaluation of a 1540 nm Er:glass laser Dermatol Surg 2001;27:799-806 Goldberg DJ, Whitworth J Laser skin resurfacing with the Q-switched Nd:AYG laser Dermatol Surg 1997;23:903–7 10 Kilmer S, Semchyshyn N, Shah G, Fitzpatrick R A pilot study on the use of a plasma skin regeneration device (Portrait PSR3) in full facial rejuvenation procedures Lasers Med Sci 2007 11 Lee SY, Park KH, Choi JW, Kwon JK, et al A prospective, randomized, placebocontrolled, double-blinded, and split-face clinical study on LED phototherapy for skin rejuvenation: clinical, profilometric, histologic, ultrastructural, and biochemical evaluations and comparison of three different treatment settings J Photochem Photobiol B 2007;88:51-67 12 Lipper GM, Perez M Nonablative acne scare reduc-tion after a series of treatments with a short-pulsed 1,064-nm neodymium:YAG laser Dermatol Surg 2006;32:998-1006 13 Manstein D, Herron GS, Sink RK, et al Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury Lasers Surg Med 2004;34(5):426-38 14 Negishi K, Kushikata N, Takeuchi K, et al Photorejuvenation by intense pulsed light with objective measurement of skin color in Japanese patients Dermatol Surg 2006;32:1380-7 15 Nikolaou VA, Stratigos AJ, Dover JS Nonablative skin rejuvenation J Cosmet Dermatol 2005;4:301-7 Nonablative and Subsurface Rejuvenation 293 16 Orringer JS, Voorhees JJ, Hamilton T, Hammerberg C, et al Dermal matrix remodeling after nonablative laser therapy J Am Acad Dermatol 2005;53:77582 17 Ross EV, Sajben FP, Hsia J, et al Non ablative skin remodeling: selective dermal heating with mid-infrared laser and contact cooling combination Lasers Surg Med 2000;26:186-95 18 Sadick NS, Weiss R, Kilmer S, Bitter P Photorejuvenation with intense pulsed light: results of a multicenter study J Drugs Dermatol 2004;3(1):41-9 19 Tanzi EL, Alster TS Comparison of a 1450-nm diode laser and a 1320-nm Nd:YAG laser in the treatment of atrophic facial scars: a prospective clinical and histologic study Dermatol Surg 2004;30:152-7 20 Tanzi EL, Williams CM, Alster TS Treatment of facial rhytides with a nonablative 1,450-nm diode laser: a controlled clinical and histological study Dermatol Surg 2003;29:124-8 21 Trelles MA, Allones I, Levy JL, et al Combined nonablative skin rejuvenation with the 595- and 1450-nm lasers Dermatol Surg 2004;30:1292-8 22 Trelles MA, Allones I, Luna R Facial rejuvenation with a nonablative 1320 nm Nd:YAG laser: a reliminary clinical and histologic evaluation Dermatol Surg 2001;27:111-6 ... Pearls in Lasers Medicolegal Aspects of Lasers in Dermatological Practice Complications and their Management New Aspects and Controversies in Lasers 379 416 4 21 432 4 41 455 4 71 xviii Lasers in. .. Delhi 11 0 002, India Phone: + 91- 11- 43574357 Fax: + 91- 11- 43574 314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44-20 317 08 910 ... plotted in Figure 1. 1 while the penetration is shown in Figure 1. 5 Chromophores Blood, water and melanin are the main absorbing components in the tissue (Fig 1. 1) Therefore, dye lasers and diode lasers