Superficial erbium:YAG laser resurfacing of photodamaged skin

Background: Light chemical peels and microdermabrasion have enjoyed recent popularity for the treatment of mild photoaging. However, clinical improvement from these modalities is often minimal from both a patient's and physician's perspective. Erbium:YAG lasers have been effective in treating mild to moderate photoaging, but the need for either regional or general anesthesia, as well as the significant post‐treatment recovery period has limited its use.

Objective: We sought to utilize a very low fluence approach to erbium:YAG laser resurfacing, with topical anesthesia, to ascertain its efficacy in treating mild to moderate photoaging.

Methods: A total of 250 subjects aged 28–80 years with skin types 1–4 and mild to moderate facial rhytids were treated with topical anesthesia and subsequently one pass of a 2940?nm erbium:YAG laser, using between 5 and 17.5?J/cm². In addition, 58 of the treated facial subjects underwent neck resurfacing with fluences between 5 and 15?J/cm² and eight treated facial subjects underwent upper chest resurfacing at fluences of 5–7?J/cm². A single treatment was received by 246 subjects; four subjects were treated a second time after a 1‐month interval.

Results: Most subjects completely re‐epithelialized by 3–4 days; healing time was depth dependent. Most subjects were able to start skin care regimens within 1–2 weeks after the procedure. Results were judged to be excellent in individuals with thin skin and good in subjects with thicker skin.

Conclusions: One pass of low fluence erbium:YAG resurfacing, under topical anesthesia, was effective for the treatment of mild to moderate photoaging.     

Laser skin resurfacing with a novel portable erbium:YAG laser.

BACKGROUND AND OBJECTIVE: The erbium:YAG laser is a popular modality for laser skin resurfacing (LSR). This study was performed to evaluate the safety and efficacy of a new portable Er:YAG laser in the treatment of photo-damaged skin. METHODS: Nine patients with skin types I-III were treated for rhytides, large pores, pigmented lesions, lentigines and photo-damage. Small facial areas such as the periorbital area, nose, cheeks, and upper lip were treated with one to six passes at 5-6 J/cm2 with a new portable Er:YAG laser. Topical and local anesthesia was used. RESULTS: All treated areas showed improvement and, depending upon the number of passes, re-epithelialization was complete within 2-7 days. The intense erythema resolved within 7 days and there was blending of treated and untreated areas within 2 weeks. CONCLUSION: The technique of applying a tailored number of 5-6 J/cm2, 300 micros pulses of a new portable Er:YAG laser to small areas appears to be safe and effective. There was minimal discomfort and a high level of patient satisfaction after a relatively short recovery time.     

Laser skin resurfacing with a novel portable erbium:YAG laser

Background and objective. The erbium:YAG laser is a popular modality for laser skin resurfacing (LSR). This study was performed to evaluate the safety and efficacy of a new portable Er:YAG laser in the treatment of photo‐damaged skin.

Methods. Nine patients with skin types I–III were treated for rhytides, large pores, pigmented lesions, lentigines and photo‐damage. Small facial areas such as the periorbital area, nose, cheeks, and upper lip were treated with one to six passes at 5–6 J/cm² with a new portable Er:YAG laser. Topical and local anesthesia was used.

Results. All treated areas showed improvement and, depending upon the number of passes, re‐epithelialization was complete within 2–7 days. The intense erythema resolved within 7 days and there was blending of treated and untreated areas within 2 weeks.

Conclusion. The technique of applying a tailored number of 5–6 J/cm², 300 µs pulses of a new portable Er:YAG laser to small areas appears to be safe and effective. There was minimal discomfort and a high level of patient satisfaction after a relatively short recovery time.     

Er:YAG laser skin resurfacing

Recent advances in Er:YAG laser technology have dramatically enhanced the ability to resurface the skin safely. Selection of precise ablation and coagulation levels allows laser surgeons to modify these variables to fit the esthetic concerns of individual patients. These systems truly represent a viable alternative to conventional CO2 laser resurfacing.     

Erbium:YAG laser skin resurfacing: a Pakistani experience

BACKGROUND AND OBJECTIVES: To evaluate the use of the erbium:YAG laser for resurfacing in type IV skin patients in Pakistan.

STUDY DESIGN/MATERIALS AND METHODS: Ten patients with skin type IV underwent laser skin resurfacing with an erbium:YAG laser to treat wrinkles, acne/chickenpox scars and hyperpigmentation. An evaluation was done by the treating physician and a photographic evaluation and grading was done by a blinded observer.

RESULTS: The treating physician's records show no erythema, pigmentary alteration, infection or scarring at the 3‐month follow‐up. The blinded observer's evaluation of the 3‐month photographs showed moderate to excellent improvement in 80% of patients in their respective underlying condition.

CONCLUSION: The erbium:YAG laser is safe and effective in treating wrinkles, acne/chickenpox scars and hyperpigmentation in skin type IV patients.     

High-fluence fractional treatment of photodamaged facial skin using a 2940 nm erbium:yttrium-aluminum-garnet laser

Abstract

Introduction: Fractional resurfacing with an Erbium:yttrium-aluminum-garnet (Er:YAG) 2940 nm laser is an increasingly popular option for the treatment of the signs of facial photoaging, which include wrinkles as well as pigmentation issues and unwanted textural changes. Fractional treatment has produced favorable clinical responses, but with less complications and shorter recovery times than traditional laser resurfacing. This study was conducted to evaluate a fractionated Er:YAG treatment regimen of 1–2 higher fluence sessions with a multiple-pass technique. Materials and methods: Eight subjects with moderate to severely photodamaged facial skin received one to two full-face laser treatments. Multiple-pass (MP) treatment results were evaluated in terms of procedure time, discomfort, social downtime and effectiveness. A photographic evaluation, subject improvement assessments and a subject satisfaction assessment were performed. Results: An investigator's photographic review showed a 26–75% improvement in the signs of overall photoaging. Subjects treated with the MP technique exhibited a relatively short 3–4 day downtime and ratings of mostly moderate discomfort with the use of topical anesthetic cream only. Subjects treated with higher fluences demonstrated the highest average improvement in specific features of photoaging. Two laser treatments resulted in substantially higher improvement scores than those received just one laser treatment.     

Basic physics of erbium laser resurfacing

The rapid growth in erbium laser resurfacing gives rise to a need for clinicians to become familiar with some new terminology and concepts. The design of erbium laser machines used for these procedures is described giving clinicians a basis for machine selection. The basic concepts of energy, fluence and overlap will allow the clinician to manipulate the laser parameters so as to achieve the desired clinical results.     

Effect of carbon dioxide laser resurfacing on epidermal p53 immunostaining in photodamaged skin

OBJECTIVE: To quantitatively examine changes in p53 tumor suppressor gene immunostaining after carbon dioxide (CO(2)) laser resurfacing of photodamaged skin to assess the potential value of this treatment in reducing the risk of progression to cutaneous carcinoma. DESIGN: Serial in vivo immunohistochemical analyses after laser therapy. SETTING: Academic referral center, Department of Dermatology, University of Michigan, Ann Arbor.Other PARTICIPANTS: Volunteer sample of 11 adults, 51 to 76 years old, with clinically evident photodamage of the forearms. INTERVENTION: Focal CO(2) laser resurfacing of photodamaged forearms and serial biopsies at baseline, 3 weeks, and 6 months after treatment. MAIN OUTCOME MEASURES: Because keratinocytes with mutations in p53 or altered p53 expression stain via immunohistochemical techniques, image analysis of immunohistochemically stained sections was used to quantify p53 expression. RESULTS: Positive immunostaining for p53 in the interfollicular epidermis was noted in 8 of 11 subjects at baseline, with an average staining density of 250 cells/mm(2). Average staining decreased to 3 cells/mm(2) 3 weeks after treatment. This decrease was sustained at 5 cells/mm(2) 6 months after resurfacing. CONCLUSIONS: There was a consistent decrease in p53 immunostaining in the interfollicular epidermis lasting for at least 6 moths after CO(2) laser resurfacing of photodamaged skin. Since p53 mutation or overexpression is observed in a majority of cases of cutaneous carcinoma, the posttreatment repopulation of the epidermis with p53-negative keratinocytes should theoretically decrease the risk of malignant progression. Further study of laser resurfacing as a prophylactic procedure in patients at high risk for skin cancer development appears warranted.     

Erbium:YAG cutaneous laser resurfacing

The short-pulsed Er:YAG laser system is an excellent ablative tool for cutaneous resurfacing. This system is most efficacious for patients with milder cutaneous involvement, including mild photoinduced facial rhytides, mildly atrophic scars, and textural changes caused by fibrosis and dermatochalasis. The Er:YAG laser cannot achieve the same dramatic clinical and histologic improvements produced with the CO2 laser but does offer some distinct advantages that make it a valuable addition to the laser surgeon's armamentarium. The Er:YAG laser, because of its higher affinity for water-containing tissues, effects a much finer level of tissue ablation. Although erbium laser resurfacing results in decreased postoperative morbidity with a shorter recovery period, it cannot effect the same degree of improvement in photodamaged skin as can the CO2 laser. Excellent results, however, can be achieved with this laser, up to 50% or more overall clinical improvement, in patients with milder photodamage and scarring (Glogau classes I and II). In darker-skinned patients, the Er:YAG laser is often the preferred treatment modality. Continued research in the field has already led to the development of longer-pulsed Er:YAG lasers, which offer a compromise between the CO2 laser and the short-pulsed Er:YAG lasers in terms of clinical benefits while maintaining the safety profile of the traditional short-pulsed system. In addition, many surgeons now use a combination approach with the CO2 and Er:YAG lasers in an effort to maximize collagen contraction in certain areas and limit postoperative morbidity. As more research is conducted within the field of cutaneous resurfacing, newer systems will be developed in the continuing effort to create the ideal laser system--one which ameliorates the signs of photoaging without risk of major side effects or significant postoperative recovery.     

Controversies in skin resurfacing: the role of erbium

Carbon dioxide laser resurfacing has been a valuable procedure for facial skin rejuvenation since the early 1990s, largely replacing medium and deep chemical peels and dermabrasion. The introduction of the erbium:YAG laser for resurfacing has caused confusion about its role. Because of its ability to resurface very superficially it has been limited by many laser surgeons to treating only superficial rhytides and sun damage. However, it is the equal of CO2 in improving deep rhytides but with quicker healing and fewer side-effects.     

Acrokeratoelastoidosis treated with the erbium:YAG laser

Acrokeratoelastoidosis is a rare skin disorder characterized by grouped, small, firm, translucent papules distributed on the margins of the hands and feet. We report a 21-year-old white patient with acrokeratoelastoidosis in whom Er:YAG laser surgery was carried out, resulting in a slight post-treatment improvement of the disease with slight flattening of the lesions. No clinical recurrence of the lesions developed during the 6 months of follow-up. We suggest that Er:YAG laser surgery of acrokeratoelastoidosis may be considered as a treatment option for this rare disease; however, patients should be informed of the limited clinical improvement obtained with this treatment.     

One-pass resurfacing with a combined-mode erbium: YAG/CO2 laser system: a study in 102 patients

BACKGROUND: The CO2 and erbium: YAG (Er: YAG) lasers have been used for skin resurfacing. A recently developed system combines pulsed ablative Er: YAG and continuous wave subablative CO2 wavelengths in one console. OBJECTIVES: To assess the potential benefits of this system. METHODS: The study follows 102 women, skin types I-V, with 26 full face, 48 perioral and 28 periocular resurfacing procedures. The ablative Er: YAG pulse (350 micros, 29 J cm(-2)) is followed immediately by a non-ablative CO2 laser shot (4-6 W, 50 ms) through the same collimated handpiece (3-mm diameter spot), 50% overlapping, repetition rate 10 Hz, giving two-pass equivalence with one single pass. RESULTS: Patients scored the results as very good (n = 67), good (n = 25) and fair (n = 10). Mild but successfully resolved side-effects occurred in only four patients. The 2-month histology showed a good band of new collagen tightening the overlying healthy epidermis. Follow-up periods ranged from 1.5 to 2 years (mean +/- SD 1.76 +/- 0.33). CONCLUSIONS: This device at the above settings offers speedy resurfacing without compromising the quality of the procedure for the patient, and may well satisfy the basic requirements of laser skin resurfacing.     

Comparison of erbium:YAG and carbon dioxide lasers in resurfacing of facial rhytides

OBJECTIVE: To compare the efficacy, adverse effects, and histological findings of erbium:YAG (Er:YAG) and carbon dioxide (CO2) laser treatment in removing facial rhytides. DESIGN: An intervention study of 21 subjects with facial rhytides. All participants were followed up for 6 months. The end points of the study were wrinkle improvement and duration of adverse effects. SETTING: Academic referral center. SUBJECTS: Nineteen female and 2 male volunteers with skin type I to III and wrinkle class I to III participated in the study. INTERVENTION: In all subjects, 1 side of the face was treated with a CO2 laser and other side with an Er:YAG laser. Skin biopsies were performed in 6 subjects before treatment and immediately, 1 day, 2 days, and 6 months after treatment. Observations were recorded by subjects, investigators, and a blinded panel of experts. MAIN OUTCOME MEASURES: Improvement in wrinkles and severity and duration of adverse effects. RESULTS: The CO2 laser-treated side had relatively better wrinkle improvement when evaluating all subjects (P<.03). However, in subjects receiving more than 5 passes of Er:YAG laser, improvement scores were not significantly different from those for 2 to 3 passes of CO2 laser treatment. Posttreatment erythema was noted at 2 weeks in 14 subjects (67%) on the Er:YAG laser-treated side and 20 subjects (95%) on the CO2 laser-treated side. The frequency of erythema was significantly less after Er:YAG laser treatment at 2 (P=.001) and 8 (P=.03) weeks. Hypopigmentation was seen in 1 Er:YAG-treated (5%) and 9 CO2-treated (43%) sides (chi2, P<.05). Histological evaluation showed residual thermal damage of up to 50 microm on the Er:YAG-treated side and up to 200 microm on the CO2-treated side. CONCLUSIONS: Erbium:YAG laser is safe and effective in removing facial rhytides. Subjects treated with Er:YAG laser recover more quickly from the procedure than those receiving CO2 laser treatment.     

Epidermal naevi treated with pulsed erbium:YAG laser

Epidermal naevi are common and can cause marked cosmetic disability. Ablative laser treatment may be successful in their removal, but may result in significant scarring. Surprisingly the erbium:YAG laser is rarely reported for this indication even though it produces minimal tissue damage. We report our experience using this laser to treat six patients with epidermal naevi. Patients (five female, one male; aged 4-41 years) underwent treatment with pulsed 2940 nm erbium:YAG laser at 0.4-0.45 J/cm(2), 2 mm spot size at 4 pulses/s. All six patients had excellent cosmetic results at follow up ranging from 6 to 60 months. The favourable results were dependent on selection of cases with superficial or small, discrete lesions which could be ablated accurately. The erbium:YAG laser is therefore an effective treatment for relatively nonverrucous or papular epidermal naevi.     

Ablative laser resurfacing: high-energy pulsed carbon dioxide and erbium:yttrium-aluminum-garnet

The development of the short-pulsed high-energy carbon dioxide laser in the mid 1990's led to the emergence of laser skin resurfacing. Used in the continuous mode, the CO(2) laser can cut and coagulate simultaneously. Used in the pulsed mode, the CO(2) laser is a powerful tool for epidermal ablation in many different contexts both therapeutic and cosmetic. Both the CO(2) and Erbium YAG lasers emit light in the infrared spectrum. Energy is preferentially absorbed by intracellular water creating rapid heating and vaporization of tissue. Because of the wavelength of the Er:YAG laser (2940 nm) more closely approximates the absorption peak of water (3000 nm) the target chromophore than the CO(2) laser (10,600 nm) nearly all of the energy is absorbed in the epidermis and papillary dermis yielding superficial ablation and less underlying thermal damage. The advantages, disadvantages, and applications of each type of laser resurfacing will be discussed. Despite proven efficacy, the public acceptance of laser resurfacing has declined with the emergence of new laser systems that cause dermal remodeling without ablating the overlying epidermis dramatically reducing recovery time. In the absence of blinded comparison studies, it remains unclear whether the clinical results of the newer 'nonablative' laser systems compare with their ablative predecessors.     

Ablation of cutaneous lesions using an erbium:YAG laser

BACKGROUND AND OBJECTIVE: This study was performed to evaluate the effectiveness and safety of erbium:YAG laser in removal of cutaneous lesions.

STUDY DESIGN: Data were collected after removing 363 benign, pre‐malignant and malignant lesions in 27 patients at a dermatology and cosmetic laser surgery center.

RESULTS: All lesions were completely removed. Eight of 363 lesions recurred and the histological analysis showed complete removal of one malignant lesion with erbium:YAG laser ablation. There were no long term or permanent complications.

CONCLUSION: Erbium:YAG laser is safe and effective in removal of cutaneous lesions.     

The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing

The drive to attain cosmetic facial enhancement with minimal risk and rapid recovery has inspired the field of nonsurgical skin rejuvenation. Laser resurfacing was introduced in the 1980s with continuous wave carbon dioxide (CO(2)) lasers; however, because of a high rate of side effects, including scarring, short-pulse, high-peak power, and rapidly scanned, focused-beam CO(2) lasers and normal-mode erbium-doped yttrium aluminium garnet lasers were developed, which remove skin in a precisely controlled manner. The prolonged 2-week recovery time and small but significant complication risk prompted the development of non-ablative and, more recently, fractional resurfacing in order to minimize risk and shorten recovery times. Nonablative resurfacing produces dermal thermal injury to improve rhytides and photodamage while preserving the epidermis. Fractional resurfacing thermally ablates microscopic columns of epidermal and dermal tissue in regularly spaced arrays over a fraction of the skin surface. This intermediate approach increases efficacy as compared to nonablative resurfacing, but with faster recovery as compared to ablative resurfacing. Neither nonablative nor fractional resurfacing produces results comparable to ablative laser skin resurfacing, but both have become much more popular than the latter because the risks of treatment are limited in the face of acceptable improvement. LEARNING OBJECTIVES: At the completion of this learning activity, participants should be familiar with the spectrum of lasers and light technologies available for skin resurfacing, published studies of safety and efficacy, indications, methodologies, side effects, complications, and management.