70 MODERN AESTHETICS® | SEPTEMBER/OCTOBER 2019

L asers are one of the top nonsurgical cosmetic pro-cedures in the country, touted for their ability to remove dark spots, address blotchiness and rosacea, tighten skin, and smooth scars. Whether scars are pit-ted or raised, cosmetic surgeons have been able to

use lasers to help even out the skin’s surface and tone—at least, as long as patients were light-skinned. In the past, we couldn’t often recommend these therapies for people of color because the risk of hyperpigmentation was higher. Recent advances, however, are making laser therapies a much more viable option for all people with scarring, and physicians should feel more comfortable exploring this option for their patients.

THE PROBLEM WITH LASER THERAPIES OF THE PASTWhen scarring traumatizes the skin, dermatologists and

aesthetic physicians assess which of the three main types of acne scars a patient may have—ice pick, rolling, and box car scars—to generate an effective treatment option that depends on the type of scarring, its depth and shape. Narrow and deep ice-pick scars,1 for example, respond to treatments like surgery or resurfacing procedures, which impact the der-mis layers.

Not long ago, however, patients with darker skin tones were limited in the ways they could be treated for scarring.2 Available options included chemical peels, microdermabra-sion, fillers, and surgical subcision techniques.3 Such treat-

ments are helpful, yet the results are arguably not as attrac-tive as those from lasers.

Unfortunately, laser treatments were basically off the table. After receiving such a treatment, patients with skin of color were at a greater risk4 for post-inflammatory hyper-pigmentation, and/or loss of pigment due to laser effects on melanin production. Their skin cells were at risk of inju-ry, either due to melanin heat absorption and overheating, or heat diffusion into the surrounding skin, or both.

The result was often uneven pigmentation or post-inflam-matory hyperpigmentation, a consequence that could last for months or become permanent. Patients with darker skin tones in years past had to be willing to possibly trade scars for discol-oration or, in some cases, blisters, burns, and additional scarring.

LASER THERAPIES EVOLVEThankfully, lasers (and the physicians wielding them)

have come a long way. We’ve developed better technol-ogy and have also learned smarter ways to use existing lasers. While ablative and intense pulsed lasers (IPL) still carry increased risks for skin of color, their non-ablative counterparts, such as the 1064 Nd:YAG, fare much bet-ter for darker complexions.5 Of course, we will want to choose the non-ablative laser option that best addresses the scarring present, and so far we know that ice-pick scars respond better to pulse dye lasers (PDL), and boxcar scars do best with Nd:YAG lasers.6 Pico lasers—Rohrer PicoLaze,

LASER THERAPY ADVANCEMENTS: ACNE SCARRING FOR SKIN OF COLOR

A review of the latest laser therapy options that are safer for dark complexions.CAMILLE VEROVIC, DO AND SOURAB CHOUDHURY, DO

SEPTEMBER/OCTOBER 2019 | MODERN AESTHETICS® 71

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PicoSure, PicoWay, and Pico Genesis—have also improved considerably7 in the last five years, proving a safe and effec-tive option for most scarring in darker skin tones.

Whereas before, non-ablative lasers had difficulty target-ing specific problems in darker skin, today’s long pulsed lasers produce less damaging heat and cool skin down more effectively thanks to efficient cooling systems (a sap-phire cooled tip, cryogen spray, or cold air flow). The new generation of lasers employ longer wavelengths and cooling technology that enable dermatologists to confidently pro-tect darker skin while effectively treating scars.

While patients may feel anxious to reduce their acne scar-ring as quickly and cost-effectively as possible, we believe in championing a less aggressive approach, at least to start. For that reason, we recommend that laser procedures be performed with conservative treatment settings, such as low treatment densities, which result in fewer cases of hyper-pigmentation in skin of color.8 Non-ablative lasers may not achieve the same dramatic results as their ablative counter-parts—improvements are accomplished more slowly over several sessions—but patients will nevertheless enjoy a high-er degree of safety and less post-procedure downtime.

Providers must also stress that patients only receive therapy from skilled, licensed practitioners who specialize in treating patients of color, as there are subtle nuances in laser treatment modalities which can impact the treatment outcomes. An ideal treatment plan may combine lasers with peels or other procedures to ensure the best results. It’s also imperative to communicate the importance of avoiding sun exposure and wearing a broad-spectrum sunscreen before and after receiving laser treatments. This step is just as essen-tial for darker complexions as it is for lighter ones.

When determining whether laser therapies are right for individual patients, physicians will want to weigh factors such as skin tone and condition, time, cost and potential risks prior to choosing the perfect laser therapy. Results are also largely dependent on the type of device used, the treatment settings, technique and the individual’s unique response to treatment. Given these nuances, it’s often helpful to test a laser on a small patch of skin first to ensure positive results.

If it’s determined that laser therapies should be avoided, chemical peels and microneedling are typically the most effective alternatives. Chemical peels work well for super-ficial scars, but may involve prolonged recovery times or the risk of complications. Microneedling, however, which encourages collagen production by making small punctures to the skin, is a relatively safe option with a shorter down-time and lower risk of pigment alteration.9 Patients should know, however, that both peels and microneedling should not be attempted at home. These treatments are best per-formed in a physician’s office.

IN THE CLEAR: THE FUTURE OF LASER THERAPY Laser therapy options that address acne scarring on darker

complexions are more popular and effective than ever before and, looking forward, we will certainly see improvements in ablative lasers, as well. These lasers provide deeper collagen induction for better results, and in the not-so-distant future the technology will accomplish this without the adverse effects of pigmentary alteration or hypertrophic scarring.

The latest research has focused on the role of platelet-rich plasma in laser ablation.10 It’s been found that acti-vated, leukocyte- and platelet-rich plasma used in combina-tion with fractional ablative laser treatments improves the appearance of scars and results in higher patient satisfac-tion and decreased downtime.

Ultimately, physicians need to determine which treat-ments are best for each indivual patient. Thankfully, the latest dermatological innovations have made laser therapy for darker skin tones a much more feasible option, one that should not be dismissed as readily as it had been in the past. The technology and results are only improving further over time, meaning that the most upsetting skin concerns are finally becoming readily fixable—for everyone. n

1. https://www.healthline.com/health/beauty-skin-care/ice-pick-scars2. Rivera AE. Acne scarring: a review and current treatment modalities. J Am Acad Dermatol. 2008 Oct;59(4):659-76.3. Aalami Harandi S, Balighi K, Lajevardi V, Akbari E. Subcision-suction method: a new successful combination therapy in treatment of atrophic acne scars and other depressed scars. J Eur Acad Dermatol Venereol. 2011 Jan;25(1):92-9. 4. Carniol PJ, Woolery-Lloyd H, Zhao AS, Murray K. Laser treatment for ethnic skin. Facial Plast Surg Clin North Am. 2010 Feb;18(1):105-10. 5. Lee DH, Choi YS, Min SU, Yoon MY, Suh DH. Comparison of a 585-nm pulsed dye laser and a 1064-nm Nd:YAG laser for the treatment of acne scars: A randomized split-face clinical study. J Am Acad Dermatol. 2009 May;60(5):801-7.6. Keller R, Junior W, Valente N, Rodrigues C. Nonablative 1,064-nm Nd:YAG Laser for Treating Atrophic Facial Acne Scars: Histologic and Clinical Analysis. Dermatologic surgery: official publication for American Society for Dermatologic Surgery. 33.1470-6. 10.1111/j.1524-4725.2007.33318.x.7. https://www.allure.com/story/best-laser-treatments-for-dark-skin-at-dermatologist8. Alexis AF, Coley MK, Nijhawan RI, Luke JD, Shah SK, Argobi YA, Nodzenski M, Veledar E, Alam M. Nonablative Fractional Laser Resurfacing for Acne Scarring in Patients With Fitzpatrick Skin Phototypes IV-VI. Dermatol Surg. 2016 Mar;42(3):392-402. 9. Cohen BE, Elbuluk N. Microneedling in skin of color: A review of uses and efficacy. J Am Acad Dermatol. 2016 Feb;74(2):348-55. 10. Hesseler MJ, Shyam N. Platelet-rich plasma and its utility in the treatment of acne scars: A systematic review. J Am Acad Dermatol. 2019 Jun;80(6):1730-1745.

SOURAB CHOUDHURY, DO n Board-certified dermatologist and the Chief Medical Officer at The Dermatology

Specialists, a full-service dermatology practice with 10 locations across New York City.

n Clinical Instructor in the Department of Dermatology at The Mount Sinai School of Medicine.

n Attended medical school at Michigan State University and completed his fellowship at NYU Medical Center.

CAMILLE VEROVIC, DOn Fourth year dermatology resident.n Founder of GIRL+HAIR, an innovative multicultural hair care brand sold in

Target, Harmon Face Values and Sally Beauty.