Laser resurfacing of the skin for the improvement of facial acne scarring: a systematic review of the evidence

This review presents and evaluates the evidence of the effectiveness of laser resurfacing for facial acne scars. Primary studies of all types of design in any language were identified from MEDLINE, EMBASE, the Cochrane database, Science Citation Index and various internet sites. Studies were accepted if they included patients treated by any laser for atrophic or ice-pick acne scars. The quality of the studies was assessed and data extracted by two independent researchers. There were no controlled trials but 14 case series were found which reported the effects of either the carbon dioxide or erbium:YAG laser. All of the studies were of poor quality. The types and severity of scarring were poorly described and there was no standard scale used to measure scar improvement. There was no reliable or validated measure of patient satisfaction; most improvement was based on visual clinical judgement, in many cases without blinded assessment. The inaccurate use of ordinal scales meant that any improvement was impossible to quantify with any validity, although the evidence suggested that laser treatment had some efficacy (a range in individual patients of 25-90% for both the carbon dioxide laser and the erbium:YAG laser). Changes in pigmentation as a side-effect were common (in up to 44% of patients), although lasting only a few weeks. Laser resurfacing technology is increasingly used in clinical practice to treat acne scars. Despite the poor quality evidence, it is plausible that there is some improvement of acne scarring; there is insufficient information, however, for patients to make informed decisions on whether to opt for treatment and there is not enough evidence to compare the two types of laser. There is a particular lack of information about the psychological effects of acne scar improvement. Good quality randomized controlled trials are needed with standardized scarring scales and validated patient outcome measures in order to assess the effectiveness of laser resurfacing in this group of patients.     

Laser treatment for facial acne scars: A review

Background and Objectives: Acne scarring is a widely prevalent condition that can have a negative impact on a patient’s quality of life and is often worsened by aging. A number of options are available for the treatment of acne scarring, including retinoids, microdermabrasion, dermal fillers, and surgical techniques such as subcision. The aim of this review is to evaluate the different laser modalities that have been used in peer-reviewed clinical studies for treatment of atrophic acne scars, and summarize current clinical approaches.

Materials and Methods: A Medline search spanning from 1990 to 2016 was performed on acne scarring. Search terms included “atrophic acne scars,” “ablative’’, “nonablative,” “fractional,” “nonfractional,” “neodymium,” “alexandrite,” “pulsed dye” lasers, and results are summarized.

Results: Various types of lasers have been evaluated for the treatment of atrophic acne scars. While they are efficacious overall, they differ in terms of side effects and clinical outcomes, depending on patients skin and acne scar type. A new emerging trend is to combine lasers with other energy-based devices and/or topicals.

Conclusion: Evaluation of the literature examining acne scar treatment with lasers, revealed that clinical outcomes are dependent on various patient factors, including atrophic acne scar subtype, patient skin type, treatment modality, and side-effect profile.     

Treatment of acne scarring

Background Post‐acne scarring remains a common entity despite advances in the treatment of acne. This represents limitations in our quality of therapy and a failure of public education. The level of severe scarring remains as much an ongoing challenge to prevent as well as manage. Methods This review will concentrate on the methods by which acne scarring may be improved and the available evidence for their utility. It will also rely on a grading scale of disease burden to classify patients and their ideal therapy. New therapies allowing treatment of scarring in areas other than the face will also be highlighted. Results Tabulated treatment planning will present algorithms summarizing best practice in the treatment of post‐acne scarring. Conclusion Post‐acne scarring is being better managed. Grade 1 scars with flat red, white, or brown marks are best treated with topical therapies, fractionated and pigment or vascular‐specific lasers and, occasionally, pigment transfer techniques. Grade 2 mild scarring as seen primarily in the mirror is now the territory of non‐ablative fractionated and non‐fractionated lasers as well as skin rolling techniques. Grade 3 scarring, visible at conversational distance but distensible, is best managed by traditional resurfacing techniques or with fractional non‐ablative or ablative devices, sometimes including preparatory surgical procedures. Grade 4 scarring, where the scarring is at its most severe and non‐distensible, is most in need of a combined approach.     

Update dermatologic laser therapy

New trends in dermatological laser therapy during the last years are based on new wavelengths, concepts and treatment combinations resulting in a variety of new dermatologic indications. Fractional laser therapy of chronic actinic damage of the skin has been introduced and already represents a standard technique. The concept of fractional non‐ablative and ablative laser treatment has been shown to be safe and effective. Also pigmented and vascular skin changes can be treated by this method. New, very promising concepts for laser epilation include linear scanned as well as low fluence laser systems. The first enable very short treatment times for large areas; the latter are the basis for the growing market of laser epilation devices for home use. Nevertheless, the potential of low fluence laser devices for long‐term hair reduction has not been tested so far. Furthermore, no data exist on side effects resulting from repetitive application of laser light to melanocytic lesions. Laser lipolysis has been introduced as the latest, minimally invasive way of removing small localised fat deposits. The new procedure may have a great potential for liposculpture; its further development should be thoughtfully observed. The latest innovations for precise ablation are ultra‐short pulsed laser systems. Femtosecond lasers avoid thermal damage at the border areas of ablation zones.     

Energy-based devices in the treatment of acne scars in skin of color

Background

Acne scarring is disfiguring and psychologically taxing on patients. Many energy-based modalities have emerged and been studied for the treatment of acne scarring; however, there is a paucity of these studies in skin phototypes IV–VI.

Objective

To review the medical literature and discuss the most significant studies regarding safety and efficacy of energy-based devices (ablative lasers, non-ablative lasers, and radiofrequency microneedling) in the treatment of ethnic skin (skin phototypes IV–VI).

Methods

A literature search was conducted using the PubMed database and bibliographies of relevant articles.

Results

Ablative and non-ablative lasers have proven to be effective for treatment of acne scars in ethnic skin. The risk of developing adverse effects such as post-inflammatory hyperpigmentation is contingent upon several factors including skin phototype, laser device, fluence, and moreso density settings. Non-ablative fractional lasers have been considered first line for the treatment of acne scars in skin of color due to their better safety profile; however, they are less efficacious and require more treatments compared to ablative lasers. Studies regarding efficacy and safety of radiofrequency microneedling for treatment of acne scarring in skin of color are limited, but are promising.

Conclusion

Ablative lasers, non-ablative lasers, and radiofrequency microneedling are all useful treatments for acne scarring in ethnic skin when appropriate settings are used. Further head-to-head studies are needed to evaluate their efficacy and safety in darker skin phototypes V–VI.     

Evidence for laser- and light-based treatment of acne vulgaris

Acne is a very prevalent skin disorder, affecting more than 85% of adolescents and often continuing into adulthood. Active acne and its sequelae, especially permanent scarring, may cause longstanding psychological or emotional harm in patients. Novel and promising treatments with laser/light devices (such as blue light, red light, pulsed dye laser, infrared lasers, light-emitting diodes, and pulsed light) have been reported to have varying degrees of efficacy for treatment. The authors compiled a summary of evidence-based literature on laser/light treatment for acne to assist clinicians to more appropriately identify treatment options, should they choose to supplement current medical antiacne therapies.     

Q开关Nd:YAG激光和585nm脉冲染料激光治疗色素性、血管性皮肤病1686例

目的评估Q开关Nd:YAG激光和585nm脉冲染料激光治疗色素性皮肤病和血管性皮肤病的疗效。方法分别采用Q开关Nd:YAG激光治疗色素性皮肤病400例、585nm脉冲染料激光治疗血管性皮肤病1177例,并采用二者治疗病毒疣109例,观察疗效。结果Q开关Nd:YAG激光对色素性皮肤病的有效率由高到低依次为:雀斑(100%)、文身(87.50%)、脂溢性角化(84.60%)、斑痣(46.70%)、咖啡斑(40.40%);585nm脉冲染料激光对血管性皮肤病的有效率由高到低为:蜘蛛痣(98.30%)、草莓状血管瘤(91.40%)、红斑期酒渣鼻(83.30%)及颜面毛细血管扩张(80.00%);二者对病毒疣的有效率分别为:寻常疣90.10%、尖锐湿疣66.70%、扁平疣52.60%。结论Q开关Nd:YAG激光治疗色素性皮肤病、585nm脉冲染料激光治疗血管性皮肤病及二者治疗病毒疣疗效较好。     

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.     

Vascular lasers and IPLS: Guidelines for care from the European Society for Laser Dermatology (ESLD)

Dermatology and dermatologic surgery have rapidly evolved during the last two decades thanks to the numerous technological and scientific acquisitions focused on improved precision in the diagnosis and treatment of skin alterations. Given the proliferation of new devices for the treatment of vascular lesions, we have considerably changed our treatment approach. Lasers and non‐coherent intense pulse light sources (IPLS) are based on the principle of selective photothermolysis and can be used for the treatment of many vascular skin lesions. A variety of lasers has recently been developed for the treatment of congenital and acquired vascular lesions which incorporate these concepts into their design. The list is a long one and includes pulsed dye (FPDL, APDL) lasers (577?nm, 585?nm and 595?nm), KTP lasers (532?nm), long pulsed alexandrite lasers (755?nm), pulsed diode lasers (in the range of 800 to 900?nm), long pulsed 1064 Nd:YAG lasers and intense pulsed light sources (IPLS, also called flash‐lights or pulsed light sources). Several vascular lasers (such as argon, tunable dye, copper vapour, krypton lasers) which were used in the past are no longer useful as they pose a higher risk of complications such as dyschromia (hypopigmentation or hyperpigmentation) and scarring. By properly selecting the wavelength which is maximally absorbed by the target – also called the chromophore (haemoglobin in the red blood cells within the vessels) – and a corresponding pulse duration which is shorter than the thermal relaxation time of that target, the target can be preferentially injured without transferring significant amounts of energy to surrounding tissues (epidermis and surrounding dermal tissue). Larger structures require more time for sufficient heat absorption. Therefore, a longer laser‐pulse duration has to be used. In addition, more deeply situated vessels require the use of longer laser wavelengths (in the infrared range) which can penetrate deeper into the skin. Although laser and light sources are very popular due to their non‐invading nature, caution should be considered by practitioners and patients to avoid permanent side effects. These guidelines focus on patient selection and treatment protocol in order to provide safe and effective treatment. Physicians should always make the indication for the treatment and are responsible for setting the machine for each individual patient and each individual treatment. The type of laser or IPLS and their specific parameters must be adapted to the indication (such as the vessel's characteristics, e.g. diameter, colour and depth, the Fitzpatrick skin type). Treatments should start on a test patch and a treatment grid can improve accuracy. Cooling as well as a reduction of the fluence will prevent adverse effects such as pigment alteration and scar formation. A different number of repeated treatments should be done to achieve complete results of different vascular conditions. Sunscreen use before and after treatment will produce and maintain untanned skin. Individuals with dark skin, and especially tanned patients, are at higher risk for pigmentary changes and scars after the laser or IPLS treatment.     

Efficacy of laser treatment of tattoos using lasers emitting wavelengths of 532 nm, 755 nm and 1064 nm

BACKGROUND: Multifunctional laser devices can be used to treat tattoos successfully. OBJECTIVES: To report the efficacy of laser treatment in professional, amateur, accidental and permanent make-up tattoos from our own experience and to compare it with the literature. METHODS: We retrospectively studied 74 consecutive patients with professional, amateur, make-up and accidental tattoos between June 1998 and November 2000. Patients were treated with a Q-switched Nd:YAG laser (wavelengths of 532 nm and 1064 nm), a Q-switched alexandrite laser (755 nm) and a variable pulse Nd:YAG laser (532 nm). RESULTS: Fourteen patients (19%) achieved a complete response (>95% lightening of treated tattoos), 23 (31%) an excellent response (76-95% lightening) and 21 (28%) a good response (51-75% lightening). Sixteen patients (22%) showed only a slight improvement (< or =50% lightening). Make-up tattoos and blue-black professional tattoos were most successfully treated. Multicoloured professional tattoos needed more treatments (mean +/- SD 5.7 +/- 5.4) in comparison with single-colour tattoos (3.5 +/- 2.0). The amateur tattoos needed fewer treatments (2.8 +/- 1.1) in comparison with professional tattoos. With accidental tattoos the results depended on the particles which had penetrated the skin. In contrast to literature reports, newer tattoos showed a trend to better treatment results than older tattoos. CONCLUSIONS: Using modern Q-switched lasers, tattoos are removed successfully with minimal risk of scarring and permanent pigmentary alterations. Even multicoloured tattoos can be treated successfully and with a low rate of side-effects.     

Lasers and laser‐like devices: Part one

Lasers have been used in dermatology for nearly 50 years. Through their selective targeting of skin chromophores they have become the preferred treatment for many skin conditions, including vascular malformations, photorejuvenation and acne scars. The technology and design of lasers continue to evolve, allowing greater control of laser parameters and resulting in increased safety and efficacy for patients. Innovations have allowed the range of conditions and the skin types amenable to treatment, in both general and cosmetic dermatology, to expand over the last decade. Integrated skin cooling and laser beam fractionation, for example, have improved safety, patient tolerance and decreased downtime. Furthermore, the availability and affordability of quality devices continues to increase, allowing clinicians not only to access laser therapies more readily but also to develop their personal experience in this field. As a result, most Australian dermatologists now have access to laser therapies, either in their own practice or within referable proximity, and practical knowledge of these technologies is increasingly required and expected by patients. Non‐laser energy devices utilising intense pulsed light, plasma, radiofrequency, ultrasound and cryolipolysis contribute to the modern laser practitioners' armamentarium and will also be discussed.     

Reversing precancerous actinic damage by mixing wavelengths (1064 nm, 532 nm)

Abstract

Background: Premalignancies resulting from photodamage, such as actinic keratosis and carcinoma in situ, can be treated with various modalities. Most of these treatments may reverse or treat these conditions although they often involve considerable skin irritation over a long period of time, are very uncomfortable for the patients or they need many office visits and sometimes are very expensive, such as photodynamic therapy (PDT). Objective: To study the effectiveness of a mixed session of Q-switched KTP 532 nm and Nd:YAG 1064 nm laser treatment on precancerous lesions resulting from solar damage. Methods: Ten patients with long-standing actinic damage/keratosis or carcinoma in situ were subjected to only one session of mixed Q-switched KTP 532 nm and Nd:YAG 1064 nm laser treatment. Lesions were evenly and repeatedly scanned with both wavelengths until light pain or purpura presented. Results: All patients responded extremely well within a period of 20 days, with just one session, with virtually no pain, minimum irritation, no down time at all and excellent cosmetic outcome. Conclusion: The use of a mixed Q-switched 532 nm and Nd:YAG 1064 nm laser session seems to be ideal for treating precancerous lesions resulting from photodamage since it can be a fast, painless and simple office procedure with no down time and minimum discomfort for the patient. This method proves to be much more selective than traditional intense pulse light (IPL) photorejuvenation.     

Epilation with Nd:YAG laser: a brief analysis of the technical application methods,results and pre‐ and post‐treatment procedures

With the use of the so‐called “selective” lasers, it is possible to operate specifically on the melanin as the absorbing target of undesirable hair. The optimal pulse duration for laser epilation should be found between the TRT of the epidermis (1–2?msec) and the TRT of the follicle (10–50?msec). For the thermal destruction of the follicle containing melanin, the ideal laser energy should (1) be absorbed in a selective manner with respect to other chromophores; (2) have a wavelength capable of penetrating in depth and reaching the target to be treated; and (3) be sufficient to destroy tissue targets (in the hair the papilla, the follicular epithelium, the so‐called “bulge” and also the vascular support). With this method the melanin and the follicular structures are “heated” in a preferential manner while still safeguarding the adjacent skin structures. Numerous laser systems are employed in the treatment of undesirable hair with varying results according to the source, procedures, phototype, and pigmentation of the hair to be treated. The most frequent side effects may be discomfort or a slight burning sensation and un‐aesthetic pigment changes or scarring.

We report here our experience based on the treatment of 94 subjects over a 12 month period using the Nd:YAG laser (SMARTEPIL 2, Deka M.E.L.A., Italy). Our results indicate that a wavelength of 1064?nm is efficacious in obtaining a greater penetration and reaching the deeper follicles, with a greater respect for the skin due to the lower absorption by the melanin, and consequently a lower incidence of side effects.     

Nonablative skin rejuvenation

Laser resurfacing of photodamaged or scarred skin has traditionally involved the use of ablative lasers with their associated limitations and side effects. Nonablative skin rejuvenation is a relatively new concept in facial rejuvenation, which aims to induce dermal remodeling without visible epidermal disruption. A number of laser devices and light sources, emitting at various wavelengths, have been shown to effectively enhance the appearance of facial skin through nonablative mechanisms. Among the conditions that can be treated with this novel modality are erythema, telangiectasia, pigmentation, lentigines, and textural imperfections ranging from fine and moderate rhytides to other surface irregularities such as acne scarring. A major attraction of nonablative laser therapy is the very limited downtime after each treatment, making it an ideal method for patients seeking a minimally invasive procedure with an excellent safety profile.     

Nonvascular uses of pulsed dye laser in clinical dermatology

Lasers are fast becoming the vogue of dermatology ranging from ablative, nonablative, fractional photothermolysis to vascular lasers. There are a range of vascular lasers including potassium titanyl phosphate (KTP 532 nm), pulsed dye laser (PDL ?595 nm), diode (810 nm), and Nd:YAG (1064 nm). PDL is a laser that emits yellow light using Rhodamine dye as it is lasing medium. Typical vascular lesions which are treated by PDL include port wine stain, hemangioma, telangiectasia, spider angioma, and rosacea. This article focuses on the use of PDL beyond primary vascular conditions. We review the evidence, or lack thereof, of the use of PDL in acne vulgaris, scars, striae, warts, molluscum, psoriasis, rejuvenation, basal cell carcinoma (BCC), and miscellaneous dermatological sequelae.     

The Treatment of Acne Scars,a 30-Year Journey

Over the past 30 years, the treatment of acne scars has undergone changes that have been significantly influenced by the concurrent development of new devices. The advent of fractional resurfacing lasers was a watershed moment for acne scarring therapy. The author recounts a career history of considerations of acne scarring treatments as well as the literature supporting the experiences causing changes in practice. Fractional ablative and nonablative lasers, sublative radiofrequency, picosecond lasers, microneedling with and without radiofrequency and fillers are the bulk of the treatments covered, along with a discussion of combination therapy. A practical algorithm for acne scarring for selection of treatment modalities is presented.

     

Laser surgery: an approach to the pediatric patient

Revolutionary advances in laser research and technology have led to expanded dermatologic laser applications. With the wide range of lasers now available, a large spectrum of skin conditions in the pediatric population can be successfully treated or, in some cases, completely eradicated. Laser treatment of the pediatric population poses a unique challenge for the clinician on a variety of levels. Physically, the composition of many vascular and pigmented lesions changes as children age making them more resistant to laser therapy. Thus, in many cases, treating lesions at an early age has resulted in clearing in fewer sessions and with decreased complications. Mechanically, lasers and laser settings used for the treatment of adult lesions may have to be adjusted for the smaller vessels and the unpredictable nature of scarring with children's skin. For vascular lesions, the pulsed dye laser is considered the laser of choice for its efficacy and low-risk profile, whereas the Q-switched, pigment-specific lasers are ideal for most childhood pigmented lesions, allowing for single pigment cell destruction. Other conditions such as acne and acne scars, psoriasis, keloids, warts and hypertrichosis that traditionally have been treated with a variety of modalities are now being managed safely with laser surgery. Other issues specific to the pediatric population include the determination of suitable anesthesia, the provision of size-appropriate safety equipment, and the assessment and management of patient and parent anxiety. The use of lasers specifically designed for structural differences in pediatric lesions and the recognition of emotional issues surrounding a young patient during laser surgery are critical components of successful treatment. Learning objective: At the conclusion of this learning activity, participants should be familiar with the mechanism of laser technology, current trends in the use of lasers for skin lesions in the pediatric population, and the issues specific to treating a patient with laser surgery.     

532-nm and 1064-nm Q-switched Nd:YAG laser therapy for reduction of pigmentation in macular amyloidosis patches

Background Macular amyloidosis is a primary form of skin amyloidosis with deposition of small to moderate amyloid material in the upper dermis and mild pigmentary incontinence with resultant clinical hyperpigmentation. Objectives To determine the efficiency of Q‐switched Nd:YAG laser (532 and 1064 nm) in reducing the pigmentations due to skin macular amyloidosis. Methods A prospective, side by side, controlled, clinical trial study was designed. Twenty subjects with clinical diagnosis and pathology confirmation of macular amyloidosis were treated with Q‐switched Nd:YAG laser: 532 nm in a part of their plaques and with 1064 nm in another part of their plaques. Assessment of efficiency was done by colorimetric scores based on Mexameter measurement and also digital photographs before laser therapy and 8 weeks after treatment. Results Mexameter‐based data analysis showed that the two lasers (Q‐switched 532 and 1064 Nd:YAG) are effective in reducing the degree of macular amyloidosis patches pigmentation, and 532 nm is meaningfully more effective than 1064 nm in this matter. Photograph‐based analysis showed that 90% of cases treated by 532 nm had good or very good response, and for the 1064 nm–treated patches, 60% of cases had the good or very good response. Conclusions The results of study showed the net positive effect of Q‐switched Nd:YAG laser, either 532 nm or 1064 nm, in pigment reduction of macular amyloidosis patches, but the 532‐nm laser was more effective than 1064 laser.     

Post acne scarring: a review

Historically, post acne scarring has not been well treated. New techniques have been added and older ones modified to manage this hitherto refractory problem. The patient, his or her expectations and overall appearance as well as the morphology of each scar must be assessed and treatment designed accordingly. Upon reaching an understanding of what the pathology of the scar is and where it resides in the skin, the most pertinent treatment for that scar may be devised. Post acne scars are polymorphous and include superficial macules, dermal troughs, ice picks, multi‐channelled fistulous tracts and subcutaneous atrophy. The wide variety of new methods includes the latest resurfacing tools such as CO₂ and erbium infrared lasers, dermasanding and possibly some future techniques such as non‐ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous (including fat and blood transfer) and non‐autologous tissue augmentation and the advent of tissue undermining has greatly improved the treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser and intralesional cytotoxics are interesting developments. Most often occurring extra‐facially and in males, these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.     

Patient compliance as a major determinant of laser tattoo removal success rates: A 10-year retrospective study

Abstract

The use and success of high-energy, short-pulse, Q-switched lasers for tattoo removal has been well demonstrated. Three types of lasers are currently commercially available for tattoo removal: the Q-switched ruby laser (694 nm), the Q-switched alexandrite laser (755 nm) and the Q-switched Nd:YAG laser (532 nm and 1064 nm). Multiple parameters such as tattoo type, color, location, and patient skin type dictate which laser is optimal in each patient. Despite the demonstrated efficacy of these modalities, there are few papers that address some of the long-term issues of tattoo removal, such as patient compliance, and how these issues impact on the success rates of optimal tattoo removal treatments. In this retrospective study, 10-year data from a single center are presented. Our data include parameters such as clearance rates, number of treatments, wavelength of the utilized laser, and fluence and spot-size setting. In addition, potential complications such as scarring, hypopigmentation, and pain were analyzed. Finally, we examine the patient compliance that accompanied tattoo removal and the reasons behind the typically low success rates for total tattoo clearance.