lasers laser like 2

REVIEW ARTICLE

Lasers and laser-like devices: Part two

Deshan F Sebaratnam,1,2 Adrian C Lim,3 Patricia M Lowe,1,2 Greg J Goodman,4 Philip Bekhor5

and Shawn Richards6

1Department of Dermatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2University ofSydney, Camperdown, New South Wales, 3Department of Dermatology, Royal North Shore Hospital, St

Leonards, New South Wales, 4Skin and Cancer Foundation Inc, Carlton, Victoria, 5Department ofDermatology, Royal Childrens Hospital, Melbourne, Victoria, and 6Skin and Cancer Foundation Australia,

Westmead, New South Wales, Australia

ABSTRACT

Part two of this review series evaluates the use oflasers and laser-like devices in dermatology basedon published evidence and the collective experienceof the senior authors. Dermatologists can laser-treata wide range of dermatoses, including vascular,pigmentary, textural, benign proliferative andpremalignant conditions. Some of these conditionsinclude vascular malformation, haemangioma, facialtelangiectases, caf-au-lait macules, naevi of Ota,lentigines, acne scarring, rhytides, rhinophyma andmiscellaneous skin lesions. Photodynamic therapywith lasers and intense pulsed light is addressed, withparticular reference to actinic keratosis and actiniccheilitis. A treatment algorithm for acne scarringbased on scar morphology and severity is comprehen-sively outlined. Following from part one, the variousdevices are matched to the corresponding dermato-logical conditions with representative pictorial casevignettes illustrating likely clinical outcomes as wellas limitations and potential complications of thevarious laser and light therapies.

Key words: acne, CO2 laser, Er:YAG laser, KTPlaser, Nd:YAG laser, pigment, QS laser, rhytides,ruby laser, vascular.

INTRODUCTION

The broad principles of dermatological laser therapy havebeen covered in Part one of this review series.1 Part twoexplores the use of lasers in procedural and cosmetic der-matology with a particular focus on conditions that areclinically relevant to dermatologists. We discuss likely clini-cal outcomes as well as the limitations of laser therapy,including its use in darker Fitzpatrick skin types, based onthe literature review and the senior authors collectiveexperience.

Vascular conditions

Vascular malformation The most recent CochraneReview2 of laser treatments for capillary malformations(CM) (port-wine stains) included five randomised con-trolled trials (RCT) totalling 103 patients. A pulsed dye laser(PDL) (585 or 595 nm) was employed in all five trials and,depending on the regimen employed, resulted in a

Correspondence: Dr Deshan F Sebaratnam, Department ofDermatology, Royal Prince Alfred Hospital, Missenden Road,Camperdown, NSW 2050, Australia. Email: [email protected]

Deshan F Sebaratnam, MBBS (Hons). Adrian C Lim, FACD.Patricia M Lowe, FACD. Greg Goodman, FACD. Philip Bekhor,FACD. Shawn Richards, FACD.

Conflict of interest: noneSubmitted 28 June 2013; accepted 11 August 2013.

Abbreviations:

AK actinic keratosisALA aminolevulinic acidCM capillary malformationCMN congenital melanocytic naevusCO2 carbon dioxideDST darker skin typeEr erbiumEVLA endovenous laser ablationHHT hereditary haemorrhagic telangiectasiaHQ hydroquinoneHOI haemangioma of infancyIPL intense pulsed lightKTP potassium tritanyl phosphateNd:YAG neodymium-doped yttrium aluminium garnetPDL pulsed dye laserPIH post-inflammatory hyperpigmentationPDT photodynamic therapyQS quality switchedRCT randomised controlled trialTCA trichloracetic acidTTT triple topical therapy

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Australasian Journal of Dermatology (2014) 55, 114 doi: 10.1111/ajd.12111

2013 The Australasian College of Dermatologists

minimum of 25% reduction in redness. Both the pulsedneodymium-doped yttrium aluminium garnet (Nd:YAG)(1064 nm) laser and intense pulsed light (IPL) were effec-tive, but the PDL results were superior and therefore, con-sidered the laser of choice for CM (Fig. 1).3

Head and neck CM respond better than trunk and distalextremity lesions. Nodular, hypertrophic or recalcitrant CMmay not respond to PDL and may be better suited to treat-ment with a pulsed Nd:YAG laser, a PDL and pulsed Nd:YAGlaser combination, a pulsed alexandrite laser (755 nm) orIPL.4 Children under the age of 1 year seem to have the bestresponse and should be treated as early as possible.4 It isimportant to inform patients or parents that gradual recur-rence is likely but tends to be less cosmetically conspicuous.Recently topical rapamycin has been used as an adjuvant tovascular laser to accelerate the clearance of CM with PDL.5

Haemangioma of infancy Laser treatment of haeman-gioma of infancy (HOI) remains controversial. Early studiesusing obsolete, non-cooled lasers and employing excessivefluence and severe purpuric end-points have complicatedthe pursuit of an evidence-based approach to the manage-ment of HOI.6 It has been our experience that the PDL at 67J/cm2, 10 mm spot, 1.5 ms pulse width, achieving a transientto minimally purpuric end-point will effectively treat earlyflat HOI present in the superficial dermis. This treatmentprotocol is often used for focal, facial and superficial hae-mangioma in conjunction with timolol; a topical beta-blocker. In general, lasers do not have a major role in raisedor subcutaneous haemangiomas because PDL can pen-etrate to a depth of only 1.2 mm. PDL is useful in selectedcases of involuting and ulcerated haemangiomas. Somecentres use more deeply penetrating wavelengths (IPL andNd:YAG) to treat thicker and deeper lesions. The role oflasers in patients with haemangiomas is set to diminish

further with the advent of systemic beta-blockers as a dra-matically effective medical treatment option.7,8 However,many lesions treated with beta-blockers will leave a super-ficial telangiectatic component that is amenable to PDL.

Facial telangiectases The most commonly used devicesfor facial telangiectases are PDL, potassium tritanyl phos-phate (KTP) (532 nm) lasers and IPL. The role of lasers inreducing telangiectases is well established, with severalstudies demonstrating their treatment efficacy with copper-bromide (578 nm), krypton (520, 530 or 568 nm), KTP andPDL (Fig. 2).9 The 532 nm and 1064 nm tracing lasers areideally suited for targeting discrete facial telangiectases; thelatter being useful for larger calibre blood vessels andvenules. PDL can be used on a range of vascular lesionswith either purpuric (pulse duration < 3ms) or non-purpuric (pulse duration 3ms) end-points. It has beensuggested that fine telangiectases can be adequately treatedwith non-purpuric parameters while purpuric parametersare more effective at clearing thicker telangiectases.However, thicker lesions can be effectively treated (withoutpurpura) through pulse stacking and multiple passes usingnon-purpuric parameters. Perialar telangiectases can berecalcitrant to laser treatment, thus requiring more ses-sions, and are also more prone to recurrence.10 IPL has alsobeen shown to improve facial telangiectases. Although laseris considered to be superior,11,12 a study comparing PDL andIPL showed no significant clinical difference between thetwo modalities.13 Facial telangiectases frequently occur inthe setting of rosacea. Anecdotally, it has been found thatsome patients will demonstrate a clinical amelioration ofthe rosacea itself but few studies have actually investigatedthis phenomenon.

Hereditary haemorrhagic telangiectasia Hereditary haem-orrhagic telangiectasia (HHT) or OslerWeberRendu syn-drome is an autosomal dominant disorder characterised bycutaneous and visceral telangiectases that require systemicinvestigation. Smaller HHT vascular lesions respond to PDLand KTP lasers while larger and often bleeding lesions

Figure 1 Caucasian male, 3-years old, Fitzpatrick phototype IIwith capillary malformation right cheek and upper lip treated withpulsed dye laser (Candela Vbeam; Candela, Irvine, CA, USA)(595 nm): 7 mm spot, 9 J/cm2 fluence, 1.5 ms pulse duration (mildpurpuric end-point), 30 ms spray 30 ms delay cryogen cooling,single pass with minimal overlap. Showing: (a) baseline and (b) 18months after third treatment undertaken at 612 monthly intervals.

Figure 2 Caucasian woman, 57-years old, Fitzpatrick phototypeIII with rosacea erythema and telangiectases treated with pulseddye laser (Candela Perfecta; Candela, Irvine, CA, USA) (595 nm): 3 10 mm spot, 13.5 J/cm2 fluence, 20 ms pulse duration, 30 ms spray20 ms delay cryogen cooling, 12 passes followed by intense pulsedlight (Sciton BBL Palo Alto, CA, USA): 560 nm filter, 16 J/cm2

fluence, 1520 ms pulse duration, 15C, single pass. Showing: (a)baseline and (b) 6 weeks after second treatment.

2 DF Sebaratnam et al.


require treatment with a Nd:YAG laser. Use of the Nd:YAGlaser within the oral cavity needs to be undertaken withcare as the laser beam can damage natural dentition anddental crowns. Oral mucosal lesions may bleed profusely ifthe treatment power is inadequate and may require over-sewing for adequate haemostasis.

Venous lakes and other vascular lesions Venous lakes arecharacterised by ectatic thin-walled venules in the superfi-cial papillary dermis and, depending on size, can be effec-tively treated with a variety of vascular lasers: Nd:YAG ordiode laser for larger lesions14 and PDL for smaller lesions.15

Nd:YAG laser is the laser of choice with a 94% clearancerate in one case series of 35 patients.16 Other vascularlesions such as cherry angiomas, spider angiomas andangiokeratomas respond satisfactorily to any of the vascularlasers listed above if the laser is selected according to thelesion size and the lasers depth of penetration.

Leg veins Sclerotherapy remains the gold standard forsmall diameter vessels such as venules and capillaries.However, in the last decade, endovenous laser ablation(EVLA) has replaced surgical stripping as the preferredtreatment option for varicose veins. EVLA consists of a fibre-optic thread inserted into the vein with wavelengths rangingfrom 8101500 nm. A meta-analysis of 64 clinical studiesevaluating 12 320 limbs concluded that EVLA of lower limbvaricosities was superior to surgical intervention17 and isoften performed in conjunction with ultrasound-guidedsclerotherapy. External beam lasers play a very limited rolein lower limb vessels unless all the larger refluxing veins(both clinical and subclinical) have been adequatelytreated.18 Nevertheless, external beam lasers may on occa-sion be useful for small vessels that are difficult to cannulate,telangiectatic matting not due to underlying venous refluxand for needle-phobic patients. Lasers with longer wave-lengths offer deeper penetration and epidermal sparing,with the most commonly employed lasers being Nd:YAG,KTP, PDL, alexandrite, diode (810 nm) and IPL. The choicewill again be determined by the size and depth of the vascu-lar target.19 Generalised essential telangiectasia is anothercause of telangiectases on the legs and is responsive to lowfluence vascular lasers (PDL and KTP) and IPL.

Pigment-related conditions

Epidermal lesions Lesions such as solar lentigines, lentigosimplex and ephelides consist of epidermal pigment origi-nating from basal layer melanocytes. Any laser that selec-tively targets the melanin chromophore or ablates theepidermis can potentially ameliorate such lesions, typicallyin 12 sessions. The mainstay lasers include quality switched(QS) alexandrite, QS ruby (694 nm) and QS frequencydoubled Nd:YAG (532 nm).20 Long-pulsed counterpartsare also effective, less likely to cause post-inflammatoryhyperpigmentation (PIH) and generally preferred forpatients of dark skin types (DST). IPL (filter 500600 nm) canalso be very effective for this indication, while concurrently

improving telangiectases. Superficial and fractional resur-facing lasers (density > 50%) also treat epidermal pigmenta-tion and ameliorate mild textural photodamage but have arecovery time of approximately 57 days.

Caf-au-lait macule In our experience, QS lasers yieldthe best results with QS frequency doubled Nd:YAG, QSalexandrite and QS ruby as the modalities of choice. Recur-rences are common and multiple treatment sessions may berequired, but some patients will obtain excellent outcomeswith a long-term significant reduction in colour of themacule if they sun-protect the area.

Beckers naevus Patients with Beckers naevus may ask fortreatment for lesional hyperpigmentation and hyper-trichosis. Recurrence and incomplete response arecommon and are believed to be due in part to the sparing ofsanctuary sites of pigmented keratinocytes and melanocytesin the deeper hair follicle.21 At this time there is no reliabletreatment for Beckers naevus. Different approaches totreatment have been described in the literature but there isno consensus on their safety or effectiveness.21,22 Until betteroutcomes are achieved these patients are usually bestadvised to avoid treatment.

Congenital melanocytic naevus Many different lasershave been employed in the management of congenitalmelanocytic naevus (CMN),23 with the largest series of 52patients with 314 lesions treated with combined ultrapulsedcarbon dioxide (CO2) laser and frequency doubled QSNd:YAG (532 nm), with mean follow up of 8 years.24 Approxi-mately 95% of these lesions had a reduction in pigment,with five patients failing treatment, five experiencing recur-rence and one developing melanoma. While there is someevidence for the role of lasers in the treatment of CMN,surgery remains the gold standard.

Acquired naevus Definitive surgical excision also remainsthe mainstay of treatment for acquired naevi. Shave exci-sion of skin-coloured dermal nevi is accepted practice dueto their low risk of malignant transformation, along withablative laser re-contouring of these lesions. However, flat,pigmented naevi should be excised rather than treated withlaser. Asian patients with a very low risk of melanoma aresometimes considered for QS laser treatment of benignnaevi on the face.25 Laser treatment of pigmented naevi maycomplicate an accurate diagnosis of subsequently re-pigmenting lesions and is not ideal in the setting of mela-noma surveillance.

Naevus of Ota Pigment-selective lasers have largely super-seded other treatments in the management of naevi of Ota.As the melanocytosis in the naevus of Ota is primarilydermal, longer wavelength QS lasers (694 nm, 755 nm and1064 nm) are generally preferred (Fig. 3). Published caseseries support the use of QS ruby,26 QS alexandrite27,28 and

Clinical use of lasers in dermatology 3


QS Nd:YAG for this condition.29 A study of 602 Chinesepatients treated by QS alexandrite laser reported a cure rateof 92% after 9 treatments, with success significantly relatedto the number of treatment sessions (P < 0.001).27

Naevus of Hori Given the histopathological and clinicalsimilarities between the naevus of Ota and Horis naevus(bilateral mid-face macular pigmentation with ocularsparing), QS lasers have been used to treat the latter since itwas first described in 1984. In a case series of 131 Thaifemale patients treated with QS ruby laser there was com-plete clearance of lesions after an average of 2.3 sessions ata mean follow-up period of 2.5 years.30 In contrast, in a studyof 66 patients treated by QS Nd:YAG only 26% of themdemonstrated a 50% improvement after 12 treatments,although the authors noted that this may have improvedwith further sessions.31

Melasma Topical treatments such as superficial chemicalpeels, hydroquinone (HQ), kojic acid, tranexamic acid andtriple topical therapy (TTT) (consisting of a mixture of HQ,retinoid and corticosteroid) remain first-line management,with mixed evidence for the effectiveness of lasers (Fig. 4).A RCT of 20 patients with predominantly epidermalmelasma compared TTT with fractional erbium:glass(Er:glass) non-ablative laser (1,550 nm) and demonstratedsimilar efficacy and safety,32 but at 6 month follow up mostof the patients had recurrence. In contrast, a split-face RCTof 29 patients comparing combined TTT and fractionalEr:glass non-ablative laser with TTT monotherapy demon-strated poorer outcomes with laser due to a high frequencyof PIH.33

Topical agents remain the mainstay of treatment formelasma with the benefits offered by laser seeminglyreduced by the risk of PIH and rebound hyperpigmentation.At best, lasers play an adjuvant and supporting role totopical therapy for melasma. Trials comparing TTTmonotherapy with combination TTT and fractional CO2laser34 and combination TTT and PDL (to treat finetelangiectases commonly accompanying melasma)35 havedemonstrated a beneficial synergistic effect of combining

topical and laser modalities. This finding was also observedin a RCT comparing HQ monotherapy with low fluence QSNd:YAG plus HQ.36 The fractionated thulium (1927 nm)laser, a relative newcomer, has shown early promise in thissetting.37 Ablative lasers may facilitate the delivery of drugsthrough the skin, such as HQ, with a multimodal approachpotentially improving patient outcomes. Laser-assisteddrug delivery may have a role in melasma management aswell as in the broader dermatological arena.38

Post-inflammatory hyperpigmentation As with melasma,PIH can be disappointing to treat and general measuresalong with realistic patient expectations are paramount.There is a paucity of clinical trials investigating the role oflasers in the management of PIH and accordingly it is dif-ficult to provide an evidence-based evaluation of their effi-cacy in this setting. Selected cases of persistent PIH (> 12months) may respond to QS lasers39 but this is fraught withpotential problems and is not routinely recommended.Variable responses of PIH to laser therapy have beenobserved and generally there is incomplete clearance ofpigmentation, along with a risk of the PIH worsening.

Hair removal Permanent hair reduction refers to stable,long-term decreased hair regrowth following laser treat-ment rather than the total elimination of all hairs in thetreatment area.40 A systematic review concluded that epila-tion with lasers resulted in partial short-term hair reductionbeyond 6 months following treatment with alexandrite anddiode lasers, and probably after ruby and Nd:YAG lasertreatment.41 Efficacy was improved with repeated treat-ment, superior to conventional epilation treatments andIPL, with a low frequency of adverse effects being observedacross all laser types. More recent studies have further vali-dated the utility of the diode4244 alexandrite45,46 and Nd:YAG47

lasers, with hair reduction achieved beyond 12 months in

Figure 3 Asian woman, 33-years old, Fitzpatrick phototype IV withnaevus of Ota, treated with quality switched neodymium-dopedyttrium aluminium garnet laser (Revlite C3; Cynosure, Westford,MA, USA) (1064 nm): 4 mm spot, 6.57.5 J/cm2 fluence at 10 Hz.Showing: (a) baseline and (b) after 12 treatments. Figure 4 African woman, 45-years old, Fitzpatrick phototype VVI

with prominent periorbital melasma effectively controlled withfirst-line topical therapy with 4% hydroquinone, 4% kojic acid, 1%hydrocortisone and 0.05% tazarotene (prescribed separately). Thepigmentation worsened with prior attempted low-fluence qualityswitched neodymium-doped yttrium aluminium garnet laser.Showing: (a) baseline and (b) after 12-months topical therapy.



some studies,4850 and this is preferred over the ruby laser.IPL produced a comparable degree of hair reduction tolasers, especially in fair-skinned individuals, but was lesseffective and more likely to cause burns in tanned or darkskin types.41 There is increasing awareness of the problemof paradoxical hypertrichosis (especially in women withpolycystic ovarian syndrome) that can compromise thetreatment of fine facial hair.

Tattoo removal QS lasers are the treatment of choice fortattoo removal and the most commonly employed are theQS ruby, QS Nd:YAG and QS alexandrite.51 The QS Nd:YAGcan treat most colours but blue or green responds best to QSalexandrite, purple or violet responds best to QS ruby andred responds best to QS 532 nm. All lasers perform equallywell at removing black tattoo pigment52 and amateur blacktattoos are the easiest to remove. A recent report advocatedundertaking four treatment sessions in the same day sepa-rated by a 20-min interval for accelerated tattoo clearance.53

However, we have not been able to replicate these impres-sive results with this method of tattoo removal.

Important adverse effects observed with laser treatmentinclude pigmentary changes and irreversible darkening ofcosmetic (e.g., skin-coloured) tattoos. Accordingly, testspots are an important consideration when using lasers forthis indication. Multiple treatments (often > 5 sessions andsometimes between 1020 sessions) are required to achievethe greatest clearance. However, if a particular laser failsto adequately remove a tattoo, another device can beemployed as multi-modal and multi-wavelength treatmentoften has a synergistic effect on clearance.

Lasers in Darker Skin Types (DST)

Patients with Fitzpatrick phototypes IIIVI have greaterquantities of melanin in the stratum basale and thus havean increased risk of non-specific light absorption, leadingto a higher risk of adverse effects including burns,dyspigmentation, textural changes, atrophy and scarring.Concomitantly, competitive absorption by melanindecreases the total amount of energy reaching targettissues, rendering it more of a challenge to obtain desiredclinical outcomes.54 Given the predilection for absorption ofenergy by the epidermal melanin, it is essential to use con-servative power settings and employ effective coolingdevices to counteract the effects of accumulated thermalenergy within the stratum basale in DST patients.

Despite these challenges, patients with DST can be suc-cessfully treated with a variety of lasers using appropriatemodification of laser parameters. The peak absorption ofmelanin lies within the UV range and decreases as wave-length increases. Accordingly, lasers generating longerwavelengths, which are less avidly absorbed by endogenousmelanin, provide improved safety profiles and clinical effi-cacy for DST patients such as the diode, Nd:YAG or IPL withfilter cut-offs at longer wavelengths.55 Devices with longerinfrared wavelengths become colour blind as they have alow affinity to melanin but a high affinity to water, and are

characterised by resurfacing lasers (1550 nm and beyond).Resurfacing lasers (ablative or non-ablative) in DSTpatients have increased potential for PIH and thus peri-procedural bleaching and sun protection is important.

Textural or benign proliferative conditions

Acne scarring Fractional non-ablative Er:glass (1540 nm,56

1550 nm), fractional ablative CO2 laser57 and ablativeEr:YAG58 have all been shown to ameliorate the appearanceof acne scars. Based on qualitative findings from a RCT of 20patients with DST, combination treatment with fractionalablative CO2 plus non-ablative Nd:YAG laser treatmentyielded superior cosmetic results compared with a frac-tional CO2 laser alone.59 While the outcome measuresemployed in the various studies have been diverse, a sys-tematic review of fractional laser for acne scars concludedthat ablative fractional lasers offered an improvement rangeof 2683% compared to 2650% with non-ablative fractionalresurfacing.60 It is reasonable to say that of all the conditionsthat fractional lasers can improve, it is acne scarring thatshows the most consistent and remarkable benefits and theprocedure is not only safer than fully ablative lasers butappear to be at least as effective (Fig. 5).

A treatment algorithm has been developed by a seniorauthor stratifying patients according to the grade of acne

Figure 5 Caucasian man, 39-years old, Fitzpatrick phototype IIIwith Grade 3 acne scarring. The patient received treatment withfractionated CO2 laser (Deka Smartxide; Deka, Via Baldanzese,Italy) and fractionated non-ablative erbium: glass laser (1550 nm)(Fraxel Restore; Fraxel, Hayward, CA, USA), as well as hyaluronicacid injections, punch grafting and scar excision. Showing: (a) base-line and (b) after combination treatment.



scarring and burden of disease, which has been reportedpreviously.61 Briefly, the scarring is first graded according tothe morphology of the lesions (Table 1), with treatmentdetermined accordingly (Tables 25). In grade 1 scarring,where pathology is mainly flat but dyschromic the emphasisis to even out these discolourations. As the severity ofcontour abnormality increases, preparatory (pre-laser)work is necessary for contour correction before lasertherapy, whose role is to treat the more superficial contourand texture issues. For hypertrophic scarring, lasers mayhave a minor ancillary role in settling the contour but againonly after a preparatory injection and medical therapy.Quite often the preparatory medical and procedural treat-ment will make laser treatment unnecessary. Our manage-ment algorithm is outlined in Tables 25.

Rhytides The role of lasers in facial rejuvenation is wellestablished and a range of lasers has been utilised in thetreatment of rhytides. For the past 20 years fully ablativelaser resurfacing with the continuous wave CO2 laser orEr:YAG has been the mainstay of therapy. The popularity ofthese methods of full ablation has waned, in view of longhealing times and the very high incidence of CO2-inducedhypopigmentation. However, advances such as fractionatedlasers and novel technologies (erbium: yttrium scandiumgallium garnet [2790 nm] and plasma skin resurfacing)have further expanded our therapeutic armamentarium.62

Three RCT comparing CO2 lasers with Er:YAG lasers havedemonstrated comparable clinical results.6365 It has beenproposed that Er:YAG laser is best employed for fine tomedium rhytides and due to its superior safety profile it isbetter suited to DST patients. In comparison CO2 laser issuperior for deep lines and more intensive tissue tighten-ing. In terms of combination therapy, the administration ofbotulinum toxin enhanced cosmetic outcomes in patientsundergoing laser resurfacing,66,67 the application of topical

retinaldehyde increased dermal thickness in patientstreated with the Er:glass laser68 and adjunctive CO2 laserresurfacing improved the overall cosmetic effect forpatients undergoing surgical blepharoplasty.69 Fractionalablative lasers (CO2 and erbium) have an established rolein the management of rhytides and can complement othermodalities ranging from non-ablative IPL to full resurfac-ing (Fig. 6).70,71

Rhinophyma Ablative resurfacing lasers can effectivelyre-contour the rhinophymatous nose.72 CO2 is preferredover erbium lasers because of the bloodless field thataccompanies the coagulation of blood vessels from residualthermal energy (Fig. 7). There have been several small caseseries comparing laser resurfacing to electrosurgery orscalpel excision, all yielding similar patient outcomes.9

Rhinophyma can also be de-bulked and sculpted with aradiofrequency electrosurgery wire loop. It has been rec-ommended that isotretinoin be discontinued 6 12 monthsprior to resurfacing of rhinophyma to mitigate the risk ofdelayed wound healing or keloid formation.9 There is alsoan increasing trend to employ high-density fractional abla-tive lasers for mild rhinophyma followed by a secondtouch-up treatment if required.

Epidermal naevus Pigmented epidermal naevi can be tar-geted by long pulsed 532 nm lasers. Verrucal epidermalnaevi and related benign proliferative skin disorders can beeffectively controlled with ablative lasers. Depending uponthe type of epidermal naevus, long-term remission can beachieved with a single treatment session. In general, super-ficial seborrhoeic keratosis and acrochordon-like lesions dobest whereas lesions with deep appendageal involvementwill tend to recur unless deep ablative procedures are per-formed, which carry the risk of incomplete ablation, scar-ring and dyspigmentation. Although there are morepublished data on CO2 ablation of epidermal naevi than onablative erbium, the latter is also effective.73 Debulkingcurettage of the lesion immediately prior to ablative laserhastens the procedure and provides a specimen for ahistopathological review.

Other benign skin pathologies Seborrhoeic keratosis andits related variant dermatosis papulosa nigra commonlypresent for cosmetic treatment. Many of these are amena-ble to cryotherapy, shave excision, curettage and cautery;all of which are reasonable first-line therapies. However,for cosmetically sensitive locations such as the eyelids,nose and lips, lasers offer superior control and finesse.These growths can be treated with 23 mm spot ablativelasers, as well as long pulsed 532nm lasers (Table 6).Common skin-derived tumours such as dermal naevi,fibrous papules angiofibromas and sebaceous hyperplasiaare amenable to ablative laser removal, as areappendageal tumours such as syringomas and depositssuch as xanthelasma. However, many of these tumours,particularly syringomas and angiofibromas, will recur over

Table 1 Grading algorithm for acne scarring according to lesionmorphology

Grade Description

1 Abnormally coloured macular disease: erythematous,hyperpigmented or hypopigmented flat marks visibleat any distance.

2 Mild but abnormally contoured scarring: mild atrophyor hypertrophy that may not be obvious at socialdistances of 50 cm or greater and may be adequatelycamouflaged with makeup, the normal shadow of ashaved beard in men or normal body hair ifextra-facial.

3 Moderately abnormally contoured disease: moderateatrophic or hypertrophic scarring that is obvious atsocial distances of 50 cm or greater and is notcovered easily but flattens substantially by manualstretching of the skin.

4 Severely abnormally contoured disease: severe atrophicor hypertrophic scarring that is obvious at socialdistances greater than 50 cm, is not covered easily.Manual skin stretching cannot flatten it.



time due to their deep location in the skin. Laser (Er:YAG)is also better suited for patients of DST where excessivetissue injury from non-laser methods can increase the riskof PIH. It is important to acknowledge that the use of

topical rapamycin is a major breakthrough in the manage-ment of angiofibromas associated with tuberous sclerosis.Rapamycin has the potential to significantly reduce therole of laser in this condition.74

Table 2 Treatment algorithm for acne scarring grade 1: macular coloured marks

Scar type Pre-laser treatment plan Appropriate laser treatment

Erythematous flat marks Surface SurfaceSkin care Vascular lasers (long-pulsed 532 nm or 595 nm)

Fractional non-ablative lasersHyper-pigmented flat marks

(post-inflammatory marks)Skin care

Optimised home care (bleaching agents, sunprotection etc.) and light-strengthpeels microdermabrasion

Possibly fractional 1927 nm laserPigment lasers or intense pulsed light if required

Hypo-pigmented macular scars Skin care, sunscreens and occasionallybleaching preparations to limit contrast

Occasionally melanocyte transfer procedures

Fractional non-ablative resurfacing

Retinoids, topical anti-inflammatories and silicon dressings.

Table 3 Treatment algorithm for acne scarring grade 2: minor atrophic or hypertrophic disease


Mild rolling atrophic scars Surface SurfaceMultiple treatments of one or more of the following:Skin needling or rollingMicrodermabrasion

Non-ablative fractional resurfacingMid-infrared, non-ablative non-fractional

resurfacing (not as effective as fractional lasers)Volume (to increase)Dermal fillers and superficial dermal fillers

Small soft papular scars andmild hypertrophic disease

Volume (to decrease) Volume (to decrease)Fine wire diathermyIntralesional fluorouracil, intralesional

corticosteroids

Fractional ablative lasers

Table 4 Treatment algorithm for acne scarring grade 3: moderately abnormally contoured disease moderate atrophic or hypertrophicscarring


Moderate rolling,shallow boxcar

Surface SurfaceMedical skin rolling, dermabrasion, chemical peeling, plasma

skin resurfacingThese may be replacement for lasers rather than preparatory

treatment (medical skin rolling is the only currently popularalternative technique)

Fractional resurfacing (ablative ornon-ablative); ablative lasers (CO2 orerbium). All are excellent for this scar typeafter appropriate preparation

Volume (to increase)Focal dermal fillers if localisedConsider volumetric, deeply placed hyaluronic acid, calcium

hydroxylapatite or other stimulatory agents such aspoly-L-lactic acid if more generalised

Volume (to decrease) Volume (to decrease)Intralesional corticosteroids or intralesional fluorouracil Fractional ablative and non-ablative

occasionally usefulPulsed dye laser for residual erythema

MovementBotulinum toxin to muscles in lower face in affected areas (chin,

marionettes) or in sites (glabella, forehead) of maximal musclemovement

SurgerySubcision



Premalignant conditions

Solar radiation is implicated in the pathophysiology ofphotoaging, actinic dysplasia and cutaneous malignancy.In Australia these conditions commonly overlap and lasersare well placed to treat these conditions synchronously.

Actinic keratosis Historically, ablative lasers such as fullCO2 and erbium resurfacing have been used to treat actinickeratosis (AK) and compare favourably with field fluorour-acil (5-FU) and trichloroacetic acid (TCA) (30%) peels.75,76

Fractional resurfacing lasers are currently being evaluatedfor their efficacy in treating AK, with thulium (1927 nm)showing the most promise.77 Amelioration of photoagingwas noted in a RCT comparing photodynamic therapy(PDT) monotherapy with combination fractional CO2 laserand PDT treatment. Combination treatment also resulted ina lower rate of AK recurrence.78 PDT using aminolevulinicacid (ALA) in combination with either PDL (575595 nm) orIPL can significantly clear AK.79,80 Pretreating the skin withshort contact (1 h) ALA prior to vascular laser or IPL

therapy is a useful strategy to reduce any dysplastic lesionsthat may accompany the pigmentary and vascular photo-damage (Fig. 8). For patients seeking treatment of prema-lignant skin lesions as well as photorejuvenation, eitherPDT with non-ablative laser or light devices or fractionalresurfacing lasers (thulium or CO2) may offer a practicaltherapeutic solution.

Actinic cheilitis Ablative laser therapy of actinic cheilitis isan important tool in the dermatologists armamentarium,which includes topical therapy, PDT, cryotherapy, curettageand cautery, and surgical vermillionectomy. A prospectivecohort study of 40 patients compared CO2 laser withvermillionectomy, 5-FU or TCA peels in the management ofactinic cheilitis, followed up for 4 years.81 None of thepatients treated with laser or surgical vermillionectomydeveloped clinical recurrence, compared with 50% recur-rence rates with the other modalities. ALA PDT activated byPDL has also shown promise as an effective intervention forpatients with actinic cheilitis recalcitrant to conventionaltherapies,82 as has fractional thulium laser.83 An important

Table 5 Treatment algorithm for acne scarring grade 4: severely abnormally contoured disease severe atrophic or hypertrophic scarring


Punched outatrophic (deepboxcar), ice pick

Surface SurfaceTrichloroacetic acid (Chemical Reconstruction of

Skin Scars [CROSS] technique if numerous, deepand small)

Fractional resurfacing may be combined with CROSSIf few and broad but still < 4 mm in diameter,

consider punch techniques (float, elevation,excision or grafting) see surgery, with or withoutsubsequent fractional or ablative resurfacingtechniques

Fractional resurfacing (ablative or non-ablative)All are good for this atrophic scar type but only after

preparatory treatmentAblative lasers (CO2 or erbium) is generally not as

useful as fractional lasers

Marked atrophy Volume (to increase) Volume (to increase)Fat transferVolumetric filling with hyaluronic acid or calcium

hydroxylapatite or stimulatory fillers such asdiluted poly-L-lactic acid

Fractional resurfacing (ablative or non-ablative)All are good for this atrophic scar type but only after

preparatory treatmentAblative lasers (CO2 or erbium) is generally not as

useful as fractional lasers but is better than it iswith punched out scars due to its tightening effecton the skin surface

Significanthypertrophy orkeloid

Intralesional corticosteroids or fluorouracil maybesupplemented with vascular laser

Fractional lasers and vascular lasers may be usefulbut again, preparation must be undertaken foruseful results

Atrophic orhypertrophicdisease

MovementBotulinum toxin often combined with fillers

especially in lower face for atrophic diseaseAs supplement to excision of atrophic or

hypertrophic scars

Fractional lasers are more useful if movement andtension on scars are settled prior to laser therapyeven if only in the few months following treatment

Bridges andtunnels,dystrophic scars

SurgeryExcision Fractional ablative and non-ablative and

non-fractional full ablative lasers are all useful todisguise scars after excision

Punched out scars(deep boxcar)

Punch elevation if scar base suitablePunch excision, punch grafting if scar base poor

Laser use is the same as for bridges and tunnels

Marked saggingand apparentredundancy

Occasionally rhytidectomy Lasers have limited role

CO2, carbon dioxide.



consideration in treating actinic cheilitis with laser, as withany other ablative modality, is that no tissue specimen isobtained, precluding a histopathological review. In an anec-dotal report on approximately 100 patients with actiniccheilitis treated with CO2 ablation only one case developeda squamous cell carcinoma in the treatment field,84

although rates of up to 5% have been reported. Ongoingsurveillance in this group is essential.

Inflammatory dermatoses

Lasers have been used as a nonfirst-line therapy forvarious common dermatological conditions such as acneand psoriasis (Table 6). The generic mechanism of action ismost likely related to laser effects on lesion vasculature andthe modulation of underlying cytokines and inflammatorymediators. Due to community concern over the systemictherapy of active acne, laser and light-based treatmentalternatives have gained popularity in recent years. Thesetherapies are thought to ameliorate acne through the inhi-bition of sebum production, the modulation of inflammationand keratinisation, and the conversion of porphyrins natu-rally synthesised by Propionibacterium acnes to bactericidalreactive oxygen species.85 PDL has been shown to reduceacne severity, with the most rapid improvements observedwithin 4 weeks of commencing treatment.86 PDL has beenshown to be as effective as IPL and light-emitting diodephototherapy in the treatment of acne.87 PDL effects wereenhanced in the setting of methyl-aminolevulinate-PDT,88

but conferred no additional benefit when combinedwith clindamycin-benzoyl peroxide topical therapy.89 Theresults for Nd:YAG, KTP and diode (1450 nm) were lessconclusive.9094 The studies described have employed a widerange of outcome measures, using pooled results for meta-analysis. However, a protocol recently submitted for aCochrane Review on light therapies for acne may yield anevidence-based approach for the use of lasers in thissetting.95 Nevertheless, given that well-established, effectiveand less costly medications are available, consideration forlaser therapy should be reserved for those who fail or havecontraindications to medical therapies.

LASER COMPLICATIONS

The safety of laser therapy is well established although, aswith any intervention, adverse effects are possible. A preop-erative clinical review should include an evaluation ofFitzpatrick phototype, recent or planned sun exposure,recent artificial tan application, immunological or inflam-matory comorbidities, history of herpes simplex, allergy,scarring, previous cosmetic or surgical procedures and amedication history for risk stratification. Pre-procedure andpost-procedure photo-documentation should be mandatory.Common transient side effects include pain, pruritus, ery-thema, purpura, oedema, acne, vesiculation, crusting andpigmentary change. Bacterial, viral and candidal infectionscan complicate resurfacing procedures and prophylacticantimicrobials are often considered. Depending on the laseremployed, potential long-term sequelae include permanent

Figure 6 Caucasian woman, 50-years old, Fitzpatrick phototype IIIwith photodamage and periorificial rhytides. Resurfacing param-eters for: (i) upper eyelids: superficial fractional CO2 (LumenisAcupulse, San Jose, CA, USA) 100 mJ, 60% density, single pass,(ii) perioral region: deep fractional CO2 25 mJ 15%, two passeswith third pass superficial CO2 100 mJ 60% (Lumenis Acupulse),(iii) rest of face: superficial erbium peel 30 microns with 30microns coagulation (Sciton Profile, Palo Alto, CA, USA) withonabotulinumtoxinA (Botox; Allergan, Irvine, CA, USA) injections tofrontalis, corrugator supercilii, procerus and lateral orbicularisoculi (30 units in total). Showing: (a) baseline and (b) 2 months aftertreatment.

Figure 7 Caucasian man, 72-years old, Fitzpatrick phototype IIwith severe rhinophyma. Treated with the Sharplan CO2 (nowLumenis Acupulse; Lumenis, San Jose, CA, USA) laser with com-puterised flash-scanner at 30 w, 3 mm spot, on continuous setting infeather mode. Treatment carried out under nerve block local anaes-thesia. Showing: (a) baseline and (b) after treatment.



Tab

le6

Com

mon

derm

atol

ogic

alco

ndi

tion

sam

enab

leto

lase

rth

erap

y

Der

mat

olog

ical

con

diti

onPa

thol

ogy

Non

-las

erth

erap

yL

aser

ther

apy

Com

men

t

Acn

evu

lgar

isC

omed

ones

,pa

pule

s,pu

stu

les

from

incr

ease

dse

bum

and

Pro

pion

iba

cter

ium

acn

esac

tivi

ty

T

opic

als

(ben

zoyl

pero

xide

,an

tibi

otic

s,re

tin

oids

)

Ch

emic

alpe

els

Sy

stem

ic(a

nti

biot

ics,

reti

noi

ds,

anti

-an

drog

ens)

L

ED

(blu

e,re

d)

PDL

/IPL

PDT

wit

hab

ove

Con

ven

tion

alth

erap

yle

ssco

stly

than

lase

r

An

giofi

brom

aPa

pule

sw

ith

incr

ease

dva

scu

latu

rean

dfi

brou

sti

ssu

e

Ele

ctro

surg

ery

(cau

tery

orh

yfre

cati

on)

shav

eex

cisi

on

Abl

ativ

ela

ser

(spo

tC

O2

orer

biu

m)

H

otK

TP

Pote

nti

altu

bero

us

scle

rosi

sli

nk

(con

side

rto

pica

lra

pam

ycin

)PD

Lu

sefu

lon

lyfo

rle

sion

eryt

hem

aD

erm

aln

evu

sSm

ooth

skin

-col

oure

ddo

me-

shap

edn

ests

ofn

aevo

mel

anoc

ytic

cell

s

Shav

eex

cisi

on;

elec

tros

urg

ery;

cure

tte

E

xcis

ion

A

blat

ive

lase

r(s

pot)

Las

eru

sefu

lfo

rfa

cial

lesi

ons

Sebo

rrh

oeic

kera

tosi

sor

derm

atos

ispa

pulo

san

igra

Ben

ign

epid

erm

alh

yper

kera

tosi

san

dac

anth

osis

C

yrot

her

apy

Sh

ave

exci

sion

orel

ectr

osu

rger

yor

cure

tte

A

blat

ive

lase

r(s

pot)

K

TP

(532

nm

)So

lar

len

tigi

nes

may

bepr

ecu

rsor

lesi

on(t

reat

wit

hn

on-a

blat

ive

devi

ces)

Fla

tle

sion

sm

ayre

spon

dto

pigm

ent

lase

rsor

IPL

Ker

atos

ispi

lari

sru

bra

Fol

licu

lar

kera

tosi

sw

ith

peri

foll

icu

lar

eryt

hem

aon

face

,la

tera

lar

ms

and

thig

hs

T

opic

alke

rato

lyti

cs

Gen

tle

mec

han

ical

exfo

liat

ion

PD

Lor

IPL

L

aser

hai

rre

mov

alE

ryth

ema

resp

onds

bett

erth

ante

xtu

rero

ugh

nes

s

Pseu

dofo

llic

uli

tis

Infl

amm

ator

yfo

llic

ula

rpa

pule

s,an

dpu

stu

les

from

curl

yh

air

re-e

nte

rin

gth

esk

in

T

opic

al(b

enzo

ylpe

roxi

de,

anti

biot

ics,

eflor

nit

hin

e)

Stop

shav

ing

L

aser

hai

rre

mov

alL

ong

puls

edN

d:YA

Gpr

efer

red

for

pati

ents

wit

hda

rksk

inph

otot

ypes

Psor

iasi

sT

-cel

ldr

iven

hyp

erpr

olif

erat

ive

skin

diso

rder

T

opic

al

Phot

oth

erap

y

Syst

emic

orbi

olog

ics

30

8n

mex

cim

erla

ser

PD

LL

aser

opti

onn

otbe

enw

idel

yad

opte

d

Seba

ceou

sh

yper

plas

iaV

isib

leye

llow

enla

rgem

ent

ofse

bace

ous

glan

ds

Ele

ctro

surg

ery

PD

L(

PDT

)

Dio

de(1

450

nm

)

Abl

ativ

ela

ser

(spo

t)

KT

P(5

32n

m)

Rec

urr

ence

com

mon

Syri

ngo

ma

Ben

ign

prol

ifer

atio

nof

swea

tdu

cts

pres

enti

ng

aspe

rioc

ula

rpa

pule

s

Ele

ctro

surg

ery

Sn

ipex

cisi

on(f

ew)

A

blat

ive

lase

r(s

pot)

F

ract

ion

alab

lati

vela

ser

O

ccas

ion

ally

KT

Pla

ser

Rec

urr

ence

expe

cted

Vit

ilig

oF

ocal

orge

ner

alis

edlo

ssof

skin

mel

anoc

ytes

and

pigm

ent

T

opic

alim

mu

nos

upp

ress

ion

Ph

otot

her

apy

A

uto

logo

us

graf

ts

30

8n

mex

cim

erla

ser

A

blat

ive

wit

hpi

gmen

ttr

ansf

erte

chn

iqu

es

Las

erop

tion

not

been

wid

ely

adop

ted

War

t(v

erru

cae)

Hu

man

papi

llom

avi

rus

indu

ced

epid

erm

alh

yper

kera

tosi

s

Cry

oth

erap

y

Ele

ctro

surg

ery

T

opic

alch

emoc

aute

ry

Imm

un

oth

erap

y

PD

L(

PDT

)

Lon

g-pu

lse

Nd:

YAG

(106

4n

m)

A

blat

ive

lase

r(s

pot

CO

2)

Non

-sca

rrin

gm

eth

ods

pref

erre

d

Xan

thel

asm

aC

hol

este

rol

depo

siti

onar

oun

dth

em

edia

lca

nth

us

T

rich

loro

acet

icac

id(3

050

%)

E

lect

rosu

rger

y

Exc

isio

n

A

blat

ive

lase

r(s

pot)

F

ract

ion

alab

lati

vela

ser

Ch

eck

seru

mli

pids

CO

2,ca

rbon

diox

ide;

IPL

,in

ten

sepu

lsed

ligh

t;K

TP,

pota

ssiu

mtr

itan

ylph

osph

ate;

LE

D,l

igh

t-em

itti

ng

diod

e;N

d:YA

G,n

eody

miu

m-d

oped

yttr

ium

alu

min

ium

garn

et;P

DL

,pu

lsed

dye

lase

r;PD

T,

phot

odyn

amic

ther

apy.



hypopigmentation or hyperpigmentation, paradoxicalhypertrichosis (from laser hair removal) and scarring.96

WHATS NEW AND WHATS IMPORTANT?

Over the past 50 years technological advances have led to thedevelopment of light-based modalities, such that laser nowoffers a valuable therapeutic option for a wide range ofdermatoses. As this technology evolves it is likely that therange of conditions amenable to light treatment will con-tinue to expand. Confocal microscopy, optical coherencetomography and spectral approaches are all poised to bolsterthe impact of lasers in dermatology.97 Newer lasers are beingdeveloped with pulse durations in femtoseconds, with somealready finding clinical applications such as the femtosecondinfrared titanium sapphire laser for onychomycosis.98 Recentwork on platelet-rich plasma,99 neonatal cell suspensions100

and cultured epithelial autografts101 in concert with lasershow promising results in improving postoperative healing.Adjuvant photosensitisers such as the use of intravenousindocyanine green to augment lasertissue interaction whentreating vascular lesions are currently being trialled.102

Combination therapy is another important consideration,with research now directed at multimodal treatments utilis-ing different lasers, or lasers in combination with medicaltherapies.

As more lasers and laser-like devices enter the market,patients and doctors may feel overwhelmed by the informa-tion and hype surrounding these devices; information thatmay be unsubstantiated, misleading or at times erroneous.Even published studies relating to a particular device orprocedure may be subject to various biases and methodo-logical flaws, such as insufficient power calculation, inad-equate follow up and the misrepresentation of statisticalsignificance as clinical significance. It is only with thebenefit of time and shared experience that a particulardevice or treatment algorithm can be adequately assessed.The practitioners experience and familiarity with theirdevice(s) has a bearing on treatment outcomes. This isparticularly relevant for multimodal or combinationtherapy favoured by some experienced practitioners atreatment paradigm that is not well represented in conven-tional RCT. Furthermore, there is a significant learningcurve in using many devices prior to gaining competency. Inthe rush to embrace the new, one should not lose sight ofthe fact that it is the practitioner, not the device, that isdriving the treatment and ultimately, the end results.

CONCLUSION

Since the first applications of lasers in dermatology 50 yearsago, we are now able to treat a myriad of conditions includ-ing vascular, pigmentary, inflammatory and cosmetic con-cerns. With ongoing research and clinical application,existing laser and laser-like therapies will continue toevolve and serve us well. We can expect a steady introduc-tion of new technologies the good, the bad, and the medio-cre that will be subjected to ongoing evaluation. To get themost out of each new wave of technology, the practitionershould take time to evaluate the available clinical evidence,strive to develop personal experience with worthwhiledevices in order to find new ways to assist our patients.Practitioner experience in turn should be matched withsound clinical judgement to ensure that useful devices areused appropriately and ethically for optimum patient care.

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