Comparison study of a Q‐switched alexandrite laser delivered with versus without compression in the treatment of dermal pigmented lesions

Background: The Q‐switched laser is the treatment of choice when attempting to improve dermal pigmented lesions. However, purpura and dyspigmentation are frequently observed after treatment. Objective: To compare the efficacy and complications of the Q‐switched alexandrite laser when delivered with versus without compression in the treatment of dermal pigmented lesions. Methods: Ten patients with dermal lesions were enrolled in the study. Each patient had a lesion treated with the Q‐switched alexandrite laser delivered with compression. Each patient also had a lesion treated with the Q‐switched alexandrite laser delivered without compression with the same fluence and spot size. The patients were evaluated for efficacy and treatment‐related side effects. Results: There was no significant difference in efficacy, but purpura and dyspigmentation were more likely when pigmented lesions were treated without compression. Conclusion: Purpura from Q‐switched laser treatment in darkly pigmented skin is due to mechanical injury of blood vessels. It is well known that pressure ‘diascopy’ eliminates blood from cutaneous vessels by coapting the vessel lumen. In this study, we used pressure applied by a glass window on the Q‐switched laser handpiece to remove cutaneous blood during laser exposure, making it possible to reduce purpura and dyspigmentation.     

Facial scars after a road accident: Combined treatment with PDL and Q‐switched ND:YAG laser

We report the case of a woman who presented with several facial scars following a road accident. Treatment was carried out using combined laser treatment with pulsed dye laser (PDL) and the Q‐switched neodymium:yttrium‐aluminum‐garnet laser (QS Nd:YAG laser). No side effects or complications from treatment were noted or reported. The patient had very good cosmetic results with this combined technique. A variety of facial scars – erythematous, pigmented, atrophic and hypertrophic – may occur as a result of trauma, surgery, burns and skin disease. Surgery with other adjunctive methods including radiotherapy, intralesional steroids and pressure therapy has shown variable results. Laser treatment has been attempted for scar revision since the 1980s. The PDL is the optimal treatment for reducing scar bulk and symptoms. It also decreases the erythema and telangiectasia associated with scars, normalizes the skin surface texture and improves scar pliability. The QS Nd:YAG laser (1064?nm) is highly effective for traumatic tattoo removal, resulting in complete clearance in the majority of cases.     

Ultrapulse carbon dioxide laser treatment for bilateral facial nevus comedonicus: A case report

Nevus comedonicus (NC), a rare skin ailment with an aggregation of dilated follicular orifices filled with keratinous material, is difficult to treat. Several drugs have been assessed for the treatment of NC, but with limited success. Surgery requires much experience and the recurrence rate is high. Various types of laser have been tried, with promising outcomes. A 54‐year‐old male patient with bilateral facial NC was admitted on July 8, 2014. A coin‐sized area was first treated successfully with ultrapulse CO₂ laser. The remaining lesions were treated during three subsequent sessions at 2‐week intervals. There were no complications. There was no recurrence after 2 years. This case suggests that ultrapulse CO₂ laser could efficiently alleviate NC. Ultrapulse CO₂ laser treatment should be further studied for its application in the treatment of NC.     

Outcomes of treatment of nine cases of recalcitrant severe hidradenitis suppurativa with carbon dioxide laser

Background Hidradenitis suppurativa (HS) is a chronic and often a recalcitrant inflammatory skin condition. Objectives To present the results of carbon dioxide (CO₂) laser treatment of recalcitrant HS in nine patients who had failed to improve on medical and other surgical treatments. Methods HS lesions consisting of abscesses, sinuses and granulation tissue were completely excised using the cutting mode of a CO₂ laser, leaving only healthy residual subcutaneous fat. The wounds were closed by primary intention where possible and left to granulate otherwise. Outcomes were determined by clinical review and questionnaire. Results Twenty‐seven sites were treated in 19 sessions on nine patients. Seven procedures were performed under general anaesthesia and 12 under local. All patients rated their postoperative discomfort as less or equal to their preoperative state. Seven of the nine patients had complete remission for 12 months or longer after their last laser treatment and ceased all medications. High levels of patient satisfaction were reported with CO₂ laser treatment. The main complication was axillary scar contracture in two patients but this was insufficient to limit limb movement. Conclusions CO₂ laser treatment should be considered as a treatment option in recalcitrant HS, where multiple medical treatments have been ineffective.     

Cutaneous photoaging treated with a combined 595/1064 nm laser

Background and objectives: The pulsed dye laser (PDL) has been used for a variety of vascular changes associated with photoaging. The Nd:YAG laser has been shown to be effective in the treatment of deeper facial vessels, as well as to stimulate new dermal collagen deposition. This study was undertaken to evaluate the safety and efficacy of sequential dual‐wavelength PDL and Nd:YAG laser treatment of photoaged facial skin. Methods: Fifteen individuals, between the ages of 38 and 66 years old, with various stigmata of facial photoaging, were entered into the study. Five sequential combined PDL/Nd:YAG (Cynergy, Cynosure Inc., Westford, MA, USA) treatments were performed using a 10‐mm handpiece at monthly intervals. PDL parameters included a 10‐ms pulse duration and a fluence set at 1?J/cm² below the purpura threshold. Nd:YAG parameters were set at a 50‐ms pulse duration with fluences varying between 35 and 50?J/cm², depending on patient comfort. Improvement was determined by evaluation of photographs taken before the first treatment and at 1 and 3 months following the last treatment, as well as the individual's self‐assessment. Results: Individuals tolerated treatments well with no serious, long‐term, or permanent adverse effects. Improvement was most pronounced in telangiectasias and diffuse erythema, followed by epidermal dyspigmentation and lentigines. Some individuals were also noted to have improved smoothness, radiance, or pore size. The improvement was generally maintained at the 3‐month follow‐up. In addition, the average self‐reported improvement was 1.7 (on a 0–4 scale) at 1 month and 2.4 at 3 months following the last treatment. Conclusion: A novel combined sequential PDL/Nd:YAG laser can be used to treat a variety of cutaneous changes associated with photoaging. Further studies may determine the relative impact of each laser and whether the total effect is simply additive or synergistic.     

Efficacy of platelet‐rich plasma plus fractional carbon dioxide laser in treating posttraumatic scars

The management of posttraumatic scars is a great challenge. Autologous platelet‐rich plasma (APRP) and fractional carbon dioxide (CO2) laser can be applied as innovative treatments for posttraumatic scars. The aim of this study was to evaluate the efficacy, safety and complications of fractional CO2 laser exposure plus APRP injection in treating traumatic scars versus CO2 laser applied as a monotherapy. Twenty participants were treated 3 times at a 4‐week interval with a follow‐up visit. The scars were divided into an upper and lower half‐treated with fractional CO2 laser exposure plus APRP injection and CO2 laser alone, respectively. The scar was evaluated using the Vancouver scar scale (VSS), along with patient satisfaction. Twenty patients completed the 3 month treatment course. The mean VSS score improved significantly from 7.0 ± 3.97 to 3.25 ± 1.55 and 6.75 ± 1.77 to 3.85 ± 1.59 with fractional CO2 laser exposure plus APRP injection and CO2 laser exposure, respectively (p < .001). However, CO2 laser plus APRP was significantly superior to CO2 laser alone (p = .001), with fewer adverse effects. Our study shows that combined treatment with CO2 laser exposure plus APRP injection is safer and more effective for posttraumatic scar management than CO2 laser exposure alone.     

Treatment of inflammatory facial acne vulgaris: Comparison of the 1450‐nm diode laser and conventional physical treatment

The efficacy of the 1450‐nm diode laser in the treatment of inflammatory facial acne was evaluated by comparing it with conventional physical treatment. Seventeen patients received laser treatment on the right side of the face and conventional physical treatment on the other side. The two modalities were compared through photographs, inflammatory acne lesion counts, and a patient questionnaire. Clinical response was evaluated in 16 patients. Evaluation of baseline and follow‐up photographs indicated that more improvement was obtained after laser treatment than by physical treatment in six patients. In two patients, physical treatment yielded better results than laser treatment. Equal effect was obtained in eight patients. All patients had a reduction in the inflammatory acne lesion count on the laser‐treated side, which was statistically significantly greater on the laser‐treated side compared with the side treated physically (p = 0.039, Wilcoxon signed ranks test). By the assessment of patient satisfaction, seven patients preferred laser treatment, two patients preferred physical treatment and three patients found laser treatment equal to physical treatment. Questionnaire details could not be obtained in 4 patients. This study indicates that the 1450‐nm diode laser is a new option for local treatment of acne.     

Treatment of gingival pigmentation with a 755-nm alexandrite picosecond laser

ABSTRACT

Hyperpigmentation of the gums can be associated to several etiological factors. Although it is physiological in most cases it can cause esthetic concerns in some patients. The objective of our study was to evaluate the clinical efficacy and patient satisfaction with the treatment of gingival hyperpigmentation with picosecond alexandrite laser of 755 nm. We selected two patients with gingival hyperpigmentation on the anterior face of the upper and lower gums of years of evolution. Malignancy, drug ingestion, exposure to tobacco and underlying genetic and endocrine alterations were ruled out. Clinical photographs were taken before treatment and 2 weeks after the procedure. In both cases, anterior gingival areas were depigmented with satisfaction. The patients did not complain of severe pain or discomfort. Two weeks after the procedure the gingiva showed almost complete depigmentation. In conclusion, the 755-nm alexandrite picosecond laser seems to be safe and effective for the esthetic treatment of gingival hyperpigmentation.     

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.     

Evaluation of a combined laser‐radio frequency device (Polaris WR) for the nonablative treatment of facial wrinkles

Nonablative wrinkle reduction or skin tightening is desired by individuals who, ideally, hope to have the skin improvement associated with chemical or laser ablative techniques but without the undesirable recovery process. Electro‐optical synergy (ELOS) technology that combines radio frequency (RF) and diode laser energy (900?nm) was used to treat 15 patients in this IRB sanctioned study. Energy settings were based on the depth of wrinkles (the greater the depth and concentration of wrinkles, the higher the RF setting) and ranged from 50–100?J/cm² RF and 15?J/cm² for the optical, laser component. Patients received three full‐face treatments, and results were evaluated by comparison of standardized photographs and patient questionnaire given prior to each treatment and one month after the third treatment. The primary investigator and three other “blinded” physicians evaluated these photographs using Fitzpatrick's wrinkle classification to assess the improvement, if any, between the initial and final visit. Eight patients completed the study. Explanation for the exclusion of the remaining six patients were: one decided to have surgery, two felt the treatment was too painful, and three moved out of the area. Following treatment, all patients had mild swelling (resolved <48?hours) and skin hyperemia (resolved <24?hours). Results observed one month after the last treatment in eight patients demonstrated an average of 25% reduction in skin wrinkles (range 14%–32%). There were no adverse side effects. The major concern of the patients was the discomfort associated with the treatment. As part of an FDA investigation to assess efficacy, long‐term follow‐up was not a part of this study protocol.     

Cutaneous effects compared between higher fluence with fewer treatments and lower fluence with more treatments in a combined IR laser/radio frequency system

Background and aims: A combined infrared (IR) laser/radio frequency (RF) system has recently been reported to create rejuvenation‐related cutaneous effects, but was associated with high levels of pain and some complications. The present study was designed to evaluate the cutaneous effects of the same system with a lower fluence and more treatments. Methods: Twenty patients were randomly assigned into two groups of 10 individuals each: Group A was treated at 50 J/cm² / 100 J/cm³ (laser/RF), respectively, two passes, three treatment sessions 30 days apart; Group B at 30 J/cm² / 50 J/cm³, three passes, five treatment sessions 15 days apart. Objective comparisons were made at the same time points with a computer program based on the clinical photography. Results: Group A noted more improvement in wrinkles than Group B at the first assessment, but both groups showed slight and progressive deterioration at the 2‐ and 6‐month assessments. Improved skin appearance was maintained throughout in both groups. The authors recognize that the comparatively small number of subjects possibly limits the statistical power of the study. Conclusions: Lower fluences and more treatment sessions with the combined 900 nm laser/RF system were complication‐free, produced improvements in the overall skin condition and less pain during sessions, suggesting that this combination may produce better patient compliance. Further treatment sessions may improve the results with implications in skin rejuvenation.     

Treatment of molluscum contagiosum with a pulsed dye laser: Pilot study with 19 children

Background: Molluscum contagiosum is a common, self‐limiting viral disease of childhood caused by a poxvirus. Often the children themselves and their parents desire treatment for cosmetic reasons or because of pruritus. Laser therapy offers another option to the traditional methods of treatment. Methods: 19 children aged between 2 and 13 years (median:6) with molluscum contagiosum were treated in a prospective, non‐randomized pilot study with the flashlamp pumped pulsed dye laser (wave length:585 nm, pulse duration 0,45 ms, spot size 7 mm, energy density 6–7 J/cm²). Results: All patients tolerated the laser treatment well. In 84.3% one laser treatment led to total remission. In 10.5% a further laser session was necessary and one patient was treated three times to achieve total remission. Conclusions: Treatment of molluscum contagiosum with the flashlamp pulsed dye laser is a safe and efficient treatment modality.     

A case of solitary angiokeratoma successfully treated with a 1064-nm long-pulsed Nd:YAG laser

Angiokeratomas are vascular malformations that are clinically or histologically verrucous, with superficial vessels just beneath the epidermis. Solitary angiokeratomas occur most commonly as a small, warty, black papule on the lower extremities. Various therapeutic methods, including laser, electrocoagulation, excision, and cryotherapy, may be used for their treatment. A 13-year-old girl presented to the laser clinic for the treatment of her lesions that were present for two months. A 1064-nm long-pulsed Nd:YAG (yttrium aluminium garnet) laser was used to treat the patient's lesions. We performed two laser treatment sessions at a 4-week interval. We saw the patient 1 month after the last treatment session and obtained successful cosmetically acceptable results. No recurrence was observed over a follow-up period of 3 months. Long-pulsed Nd:YAG laser is more effective for the treatment of hyperkeratotic angiokeratomas due to deeper skin penetration of laser. Long-pulsed Nd:YAG laser is an effective and safe therapeutic option for the treatment of solitary angiokeratomas.     

Pulsed alexandrite laser for treatment of melasma in Asian patients

Background: Melasma is a common acquired facial hypermelanosis with irregular brownish macules and patches. The clinical course is often fluctuated and refractory to treatment. The present study was conducted to evaluate the efficacy and safety of pulsed alexandrite laser for the treatment of melasma. Materials and methods: In the present study, we enrolled Asian patients with melasma. All the patients received four monthly treatments with a pulsed alexandrite laser. The severity of melasma was evaluated by a blinded dermatologist, using the Modified Melasma Area and Severity Index (MMASI), and by patient assessment, using a visual analogue scale, at baseline, before each treatment, and at the 1-month and 3-month follow-up visits after the last treatment. Results: Twenty-three patients completed all treatments and follow-up visits. The MMASI scores decreased significantly from 8.71 ± 5.83 at baseline to 6.07 ± 4.65 after four sessions of treatment (P < 0.05) and 6.91 ± 4.97 at 3 months after the last laser treatment (P < 0.05). After 4 sessions of treatment, 10 patients (43.5%) described their improvement as marked and excellent (>60% improvement). The treatments were well tolerated with only mild skin reaction. Conclusion: In the present study, we demonstrated that the pulsed alexandrite laser is safe and effective to treat melasma in Asian skin.     

A comparative study on the use of fractional CO2 laser with tacrolimus or calcipotriol or narrow band ultraviolet‐B in treatment of stable nonsegmental vitiligo

Conventional methods of treatment for vitiligo are often unsatisfactory to the patients and time consuming, new treatment modalities are needed. This study was conducted to evaluate the efficacy and safety of fractional carbon dioxide (CO₂) laser therapy followed by narrow band ultraviolet‐B (NB‐UVB) phototherapy, topical tacrolimus or topical calcipotriol on stable nonsegmental vitiligo. Thirty patients with stable nonsegmental vitiligo were evaluated. All patients were subjected to three sessions of fractional CO₂ laser 1 month apart. Patients were divided into three groups (each group 10 patients). Group (A) treated with tacrolimus ointment twice daily for 3 months, group (B) treated with calcipotriol ointment twice daily for 3 months, and group (C) treated with NB‐UVB twice weekly for 3 months. Outcomes were evaluated by calculating vitiligo area scoring index (VASI) score change, percentage of repigmentation, patient satisfaction, and adverse effects. There was a statistical significant decrease in VASI score after treatment in the three groups. The VASI change and % of regimentation was higher in group (C) treated by laser and NB‐UVB and this was significantly higher than group (B) treated with laser and calcipotriol. Otherwise, there was no statistical significant difference between other treatment groups. In concluion, NB‐UVB phototherapy, topical tacrolimus, or topical calcipotriol in combination with fractional CO₂ laser could be used effectively and safely as an alternative modality for treatment of vitiligo. The combination of fractional CO₂ laser and NB‐UVB was found to be more effective.     

Lasers and laser‐like devices: Part two

Part two of this review series evaluates the use of lasers and laser‐like devices in dermatology based on published evidence and the collective experience of the senior authors. Dermatologists can laser‐treat a wide range of dermatoses, including vascular, pigmentary, textural, benign proliferative and premalignant conditions. Some of these conditions include vascular malformation, haemangioma, facial telangiectases, café‐au‐lait macules, naevi of Ota, lentigines, acne scarring, rhytides, rhinophyma and miscellaneous skin lesions. Photodynamic therapy with lasers and intense pulsed light is addressed, with particular reference to actinic keratosis and actinic cheilitis. A treatment algorithm for acne scarring based on scar morphology and severity is comprehensively outlined. Following from part one, the various devices are matched to the corresponding dermatological conditions with representative pictorial case vignettes illustrating likely clinical outcomes as well as limitations and potential complications of the various laser and light therapies.     

Laser treatment for pigmented lesions: a review

Background Just a few decades ago, before lasers were introduced into dermatologic practice, many cutaneous lesions were untreatable. Since the introduction of lasers in dermatology in the 1960s and its revolution by Anderson and Parrish in the 1980s based on the selective photothermolysis theory, lasers have become a main component of many dermatology practices. With the advent of these selective lasers and their constant technological advancements, many lesions can now be easily removed with a low incidence of complications, creating a high demand for laser surgery. Aims This paper will review current laser systems used for pigmented lesions. Methods An English‐language literature search and review through Medline from January 1994 to October 2004. Review of the latest techniques and lasers used in treating pigmentary disorders and possible future applications and treatment options. Conclusions Laser technique and technology has greatly advanced producing more effacious treatment with minimal complications.     

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.     

Medical devices for the treatment of onychomycosis

Device‐based therapies are the most rapidly expanding area of onychomycosis treatment. Traditional pharmacotherapy of onychomycosis has a low to moderate efficacy and is associated with adverse reactions and drug interactions that limit its use in many patients. These new therapies include laser systems, photodynamic therapy, iontophoresis, and ultrasound. Device‐based therapies are procedures conducted in the clinic by a trained professional, which mitigates the requirement for long‐term patient compliance. In addition, the drug component of these therapies is topical, preventing the adverse events associated with systemic antifungal administration, and potentially allowing for the treatment of individuals who were previously excluded due to drug interactions. Device‐based therapy is a nascent field, so clinical data is still in an emergent stage; however, preliminary clinical trials of laser, photodynamic therapy, and iontophoresis suggest that some devices may have a degree of efficacy. More studies are required to better determine their ability to treat onychomycosis.     

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.