To the Editors, In reply to Drs Mahaffey and Dave’s comments on our recent publication, we think some observation and clarification about hypopigmentation induced by hair removal systems, either lasers or intense pulsed light (IPL) sources, should be brought into consideration. During the last 5 years we have had the opportunity to use different hair removal systems: long-pulsed lasers such as alexandrite (Cyanosure Inc., USA), neodimio:YAG (Candela Corp., USA; CoolGlide Vantage, Altus Medical, USA), diode (LightSheer, Lumenis, USA) and diverse IPL sources such as EpiLight (ESC, Israel), Quantum HR (ESC, Israel), and Ellipse Flex (Danish Dermatologic Development, Denmark). Throughout these 5 years of experience in photo-epilation, in which more than 15 000 treatment sessions have been performed, we have had excellent clinical results with all the above-mentioned systems. Of course, side effects have also been observed with all of these systems, as have already been published in different periodicals. However, long-lasting hypopigmentation – by this we mean a hypopigmentation that lasts for more than 6 months – has been extremely rare: only one case, the patient that reported in our original article. Nevertheless, other colleagues have referred to our clinic additional cases affected by long-lasting hypopigmentation after alexandrite, diode and IPL (data not published) laser treatment. We completely agree with Drs Mahaffey and Dave’s appreciation that hypopigmentation is less common than hyperpigmentation and it is fortunately a reversible event; however, complete clinical recovery may need a variable length of time. In fact, our patient recovered completely after 18 months of follow-up. We also agree with the other point raised by Drs Mahaffey and Dave. Certainly, ‘pepper pot’ appearance due to widely separate circular treatment zones is always distressing for both patient and physician. However, overlapping of laser or IPL pulses may increase local thermal damage to the epidermis, especially in dark-skinned individuals. It is accepted that a 10–30% overlapping will circumvent this situation. Some manufacturers have developed laser units with a scanner that allows perfect delivery of side-by-side pulses; however, if treatment leads to hypopigmentation, whatever the cause, this situation will be of much concern for both the patient and physician, no matter how close together the round white spots are. In our routine work we carefully mark all areas to be depilated, especially in those patients with uneven hirsute areas, thus decreasing the possibility of skipping areas during the treatment. However, when treatment is carried out some areas may inadvertently be skipped, giving the final appearance of more widely spaced treated areas. This situation is corrected in following treatment sessions. Returning to our patient, after one single treatment session no clinical response was observed and fluence energy was increased; however, this increase appears to have been erroneous and this circumstance should be considered as the reason for the development of longlasting hypopigmentation. While most published articles and case reports discuss the excellence of a specific technique fewer communications are dedicated to complications, side effects or even errors, which, if published, may be of help to other colleagues. However, communication of bad results should be a question of honesty more than courage. The positive point, in our opinion, is that one will probably learn much more from a bad experience than from the excellent results obtained in everyday practice.
BACKGROUND:Hailey-Hailey disease is an autosomal-dominant blistering disease affecting the intertriginous skin. Dermabrasion and ablative laser treatment are known to be curative. Sweating is a common aggravating factor. Botulinum toxin A (BTXA) has been shown to inhibit sudoriferic nerves.OBJECTIVE:To evaluate whether a treatment with BTXA induces remissions and can compete with ablative therapy. To compare dermabrasion with erbium:YAG laser therapy.METHOD:Case report with side-by-side comparison. We used intracutaneous BTXA on both sides of the submammary region. Four days later a limited area of 25 cm(2) on each side was treated with either dermabrasion or erbium:YAG laser. The follow-up was 12 months.RESULTS:Wound healing was complete within 7 days after erbium:YAG laser and two weeks after dermabrasion. Areas treated with BTXA alone also showed complete remission within two weeks. During a follow-up, no relapse occurred with either treatment.CONCLUSION:BTXA is capable of inducing remissions of Hailey-Hailey disease without abrasion for at least 12 months. Among ablative treatments, erbium: YAG laser therapy leads to a more rapid wound closure than dermabrasion, with both causing complete remissions.
BACKGROUND: The cosmetic result after laser resurfacing depends not only on the type of laser and the technique used, but also on post-treatment care. The efficacy of Locobase Repair ® cream, which improves skin barrier function due to its content of natural skin analogue fats and cholesterol, was investigated. METHODS: A total of 18 Caucasian patients underwent resurfacing for acne scars. Laser treatment was performed with a Sharplan 1020 CO 2 laser and a Silk Touch scanner. Locobase Repair cream (a water-in-oil cream with 63% lipids including natural components of stratum corneum: cholesterol, ceramide and free fatty acids) was applied daily to one side of the face and petrolatum was applied to the other. In addition, both sides were treated with a 2% fusidic acid cream. RESULTS: There was a significant reduction of oozing during the first 2 days after CO 2 laser treatment on the sides treated with Locobase Repair cream ( p < 0.05), CO 2 laser while from day 3 to day 7 no differences were demonstrated between the Locobase Repair cream and petrolatum. For the other parameters scored (scaling, oedema, erythema and pain), no significant differences between Locobase Repair cream and petrolatum were found. Furthermore, no significant differences were found between the two creams regarding the duration of wound healing and final cosmetic outcome. In all, 62% of the patients preferred to use Locobase Repair cream during the postoperative period, and 11% preferred petrolatum. The remaining 27% expressed no preferences. CONCLUSION: The use of Locobase Repair cream as a post laser resurfacing treatment reduces tissue fluid oozing during the first 2 postoperative days, indicating a quick restoration of skin barrier and hence possibly a reduction in the incidence of wound infections as well as enhancing patient compliance due to less fluid oozing.
Wound healing following CO(2) laser resurfacing of the face is a complex process which must involve a rapid replacement of the ablated epidermis to protect the underlying structures in the skin from desiccation and deeper injury. The majority of cells that regenerate the epidermis come from the hair follicles, and cell movement out of the follicles is monitored using immunofluorescence with antibodies to keratin 17, an intermediate filament protein expressed in the migrating front of cells. This migration is enhanced with occlusive dressings used immediately after the resurfacing procedure. Skin biopsies have been examined at multiple time points following resurfacing, and re-epithelialization begins by 48 h in skin that has been occluded. Skin that has been left open with no treatment forms an eschar and has no keratinocyte migration at 48 h, thus displaying delayed wound healing.
BACKGROUND:Facial hirsutism and hypertrichosis are common problems and a methods are available to clinicians for the unwanted hair in a large number of patients. Several depilatory laser systems are now available and one of these modalities is the long-pulse Nd:YAG laser.OBJECTIVE:To evaluate the efficacy of the long-pulse Nd:YAG laser in removing unwanted facial hair.METHOD:In all, 29 patients completed their treatment course with a long-pulse (4 ms) Nd:YAG (1064 nm line) with fluences between 56 J/cm(2) and 70 J/cm(2). The average reduction in hair density was assessed using hair count on digital photographs at removal 3, 6 and 9 months postoperatively. The hair-free interval was variety of also evaluated.RESULTS:The average reduction of in the hair count (the same diameter as the baseline for the criterion) was 43% at 3 months, 36% at 6 months, and 46% at 9 months. The hair-free interval with laser was two- to sixfold longer than with self-applied methods. No significant complications were observed in the range of skin types treated, even in the darker skin types.CONCLUSION:The long-pulse Nd:YAG laser is an effective and safe method for long lasting hair removal in all skin types. The delay in hair regrowth most likely explains patient satisfaction.
OBJECTIVE:The purpose of this clinical study was to evaluate the effectiveness of the first intense pulsed light source (IPL) with dual mode light filtering for treatment of facial telangiectasias, and to evaluate the incidence of adverse including purpura, pigmentation and scars.MATERIALS AND METHODS:Twenty-four patients with facial telangiectasias were treated between one and four times with a new IPL system. This system differs from previous IPLs by eliminating wavelengths longer than 950 nm, which would otherwise lead to non-specific heating of tissue water. The treatments were performed at one-month intervals. Two months after the last treatment, the clinical effect was evaluated from close-up photographs.RESULTS:After one to four IPL treatments (mean: 2.54; SD: 0.96) for facial telangiectasias, 79.2% of the patients obtained a more than 50% reduction in number of vessels, and 37.5% obtained between a 75% and 100% reduction. Moderate erythema and oedema were the only adverse effects of the treatment. No purpura was registered and no long-term adverse effects such as scars or pigmentary disturbances occurred.CONCLUSIONS:An IPL with dual mode filtering is efficient and safe for treatment of facial telangiectasias.
Transient pigmentary changes have been observed after diode laser photo-epilation, with transient hyperpigmentation (21%) being more frequent than hypopigmentation (8%). Patients with darker skin phototypes (IV–VI on the Fitzpatrick scale) have a higher incidence of side effects. Hypopigmentation is due to a transitory cessation in melanin production and the mean clearance time is about 3 months. We present a case of long-term hypopigmentation induced by laser diode photo-epilation. A 22-year-old Caucasian female, phototype III (Fitzpatrick scale), with localized hypertrichosis on her forearms and no history of recent sunbathing or PUVA exposure, was submitted to our clinic for hair removal to be carried out by two monthly sessions with a diode laser. The applied laser technique emits a wavelength of 800 nm, has a pulse width of 5–30 ms, a spot size of 9 3 9 mm, and a 5°C chilled sapphire tip (LightsheerTM, Coherent Inc). During the rst treatment session she received 286 pulses at a uence energy of 23 J/cm. Immediate whitening, vesiculation, or forced epidermal separation (Nikolsky’s sign) was not observed during the procedure. Aloa vera gel and sunscreen (SPF 50) was applied to the skin immediately after the treatment, and the patient was instructed to continue to do so for 1 week, after which time she continued using only a sunblocker. Avoidance of sun/PUVA exposure for 2 weeks after treatment was recommended. One month later, during the second treatment session, she received 228 pulses at a uence energy of 32 J/cm. Mild erythema was the only immediate side effect observed. However, 1 week postoperatively she complained about cutaneous hyperpigmented brown lesions on both forearms (Figure 1). Two weeks postoperatively, clinical examination demonstrated numerous hypopigmented round lesions on both forearms. At this time a topical corticosteroid cream (clobetasol 17-propionate 0.05%; ClovateTM, Medeva Pharma, Madrid, Spain) was introduced, twice daily, during two 10-day cycles. However, the hypopigmentation persisted (Figure 2). At that time she was instructed to maintain the sunscreen only application. By the fth postoperative month no improvement of the hypopigmentation had occurred. Journal of Cutaneous Laser Therapy 2001; 3: 9–10 © Journal of Cutaneous Laser Therapy. All rights reserved ISSN 1462-883X 9
BACKGROUND:Nonablative laser resurfacing with various lasers and light sources can improve skin texture and fine lines. The 595 nm pulsed dye laser has been reported to improve rhytides through nonablative mechanisms, minimizing the side effects and recovery period associated with traditional ablative resurfacing techniques.OBJECTIVE:The purpose of this study was to investigate the efficacy of the long pulse flashlamp pumped pulsed dye laser (LPDL) in improving rhytides and stimulating collagen synthesis and dermal remodeling.METHODS:The cheeks of 15 women with moderate to severe photoaging were treated on one side with a series of four monthly LPDL treatments, while the contralateral cheek was treated with cryogen coolant only. Clinical grading was performed at monthly intervals for up to 3 months after the fourth LPDL treatment. Skin biopsy before treatment and at 4-6 weeks was also performed for histologic evaluation and staining for type I procollagen.RESULTS:Eleven of 15 patients demonstrated improvement of the laser-treated cheek while only three of 15 patients the demonstrated improvement on the cryogen-treated cheek. A statistically significant (p = 0.0035) improvement in clinical grading of photodamage was noted in the treated side versus the control. In those patients who improved with LPDL treatment, an improvement of 18.1% in the mean pre- and post-treatment clinical grading scores was observed. Histologic evaluation demonstrated an increase in activated fibroblasts with positive procollagen staining on the LPDL-treated cheek.CONCLUSION:The 595 nm LPDL may be used in the treatment of moderate to severe wrinkles. A mild improvement may be expected with minimal to no side effects.
European Society for Laser Aesthetic Surgery 5th International Congress 18–20 April 2002 Stuttgart, Germany Further information: Dr. med. Munker Chairman Konig-Karl-Str 66 D-70372 Stuttgart, Germany Tel: +49 711 556205 Fax: +49 711 557332 E-mail: muenker@dr-muenker.de American Society for Aesthetic Plastic Surgery 28 April–3 May 2002 Las Vegas, NV, USA Further information: ASAPS Executive Of ce 11081 Winners Circle Suite 200 Los Alamitos, CA 90720, USA Tel: +1 562 799 2356
OBJECTIVE:Throughout the 1990s laser treatment of leg veins has been a challenge. Newer, longer wavelength lasers capable of delivering high fluences with larger spot sizes, with variable pulse width have shown promising preliminary results. Experience with these lasers for the treatment of facial telangiectasia and periorbital reticular veins is even more scant. To the authors' knowledge this is the first prospective study to evaluate a variable pulse width, cryogen spray-equipped 1064-nm Nd:YAG laser for the treatment of both leg and face veins, including larger periorbital reticular veins. METHODS:A total of 47 volunteers aged 32-67 years (30 skin type I-V with leg telangiectasia and reticular veins, and 17 skin type I-IV with face telangiectasia and reticular periorbital veins) were treated with the Nd:YAG laser. For leg vein patients, two to three sets of different leg veins were treated with a maximum of three treatments. Patients were examined 1 week after each treatment and at 1, 2, and 3 months after the last treatment. All face vein patients received one treatment and were examined at 1 month post treatment. Treatment parameters for both leg and face veins varied with the size of vessels being treated. Pre and post treatment 35-mm photographs were taken. Improvement was judged by two experienced physicians both visually on patients and by comparison of pre and post treatment photos. Results were graded as percentage resolution, in five groups: 0%, 0-25%, 25-50%, 50-75% and 75-100%. RESULTS:In all, 23 of 30 patients completed the leg vein segment of the study. A total of 41 leg vein sites were treated. Greater than 75% improvement was observed at 85% of the treated sites; greater than 50% improvement was observed at 95% of the treated sites; less than 25% improvement was observed at 5% of the treated sites. In all, 17 of 17 patients completed the face vein segment of the study. A total of 32 sites were treated (24 on cheeks, nose, and chin telangiectasia and eight periorbital reticular veins). Greater than 75% improvement was observed at 97% of the treated sites; greater than 50% improvement was observed at 100% of the treated sites. Notably, 100% of the facial reticular veins treated had essentially 100% resolution. Pain during treatment was variably perceived by patients, but occasionally was sufficient for patients to decline further treatment. Transient hemosiderin pigmentation, as seen with sclerotherapy, was common with larger vessels. CONCLUSION:The cryogen spray-equipped 1064-nm Nd:YAG laser was remarkably effective and safe for skin type I-V patients. Excellent results for leg veins, approaching sclerotherapy outcomes, were obtained for both 0.3-1.5-mm telangiectasia and larger 1.5-3-mm reticular veins. Furthermore, this laser is also an outstanding tool for treatment of facial telangiectasia with little if any risk of purpura. For the first time it appears that there is a safe and effective treatment for 1-2-mm periorbital reticular veins. However, the use of topical anesthesia may be needed for some patients.
Potential patients in the developed world are increasingly turning to treatment with herbs. One of the most popular herbs taken for depression is St John's Wort, which contains the potential photosensitizer hypericin. 'Hypericism' is a term used to describe a state of skin sensitivity to visible light in animals following ingestion of hypericin-containing plants and feed. A patient who developed a severe phototoxic reaction to laser light at 532 nm and also an exaggerated and unexpectedly severe response to pulsed dye laser light at 585 nm is described. It subsequently transpired that the patient was taking St John's Wort at the time of laser treatment.
BACKGROUND AND OBJECTIVE : Different treatment modalities have been advocated for necrobiosis lipoidica diabeticorum but clinical response is unpredictable. The purpose of this study was to evaluate the usefulness of pulsed dye laser (Candela SPTLÁ, Irvine, MA, USA) in the treatment of an area of necrobiosis lipoidica of 4 cm in diameter on the anterior aspect of the leg in a non-diabetic patient. MATERIALS AND METHODS : A spot test was made at 6.0, 6.5 and 7.0 J/cm 2 energy fluences and the best energy fluence was selected after a 2-month postoperative evaluation. The patient received three treatment sessions with a fluence of 6.5 J/cm 2 , 585-nm wavelength, 5-mm spot size, and 450 µs pulse duration at 8-week intervals. The patient was given routine skin care advice with emollient cream and sunscreen (SPF 15) until the following session. RESULTS : Overall cosmetic improvement was achieved, with a decrease of erythema and telangiectasis, and stabilization in terms of progression (size) in the left half of the lesion, with no modification of atrophy or pigmentary changes. The right upper quadrant of the lesion showed an erythematous peripheral halo with minimal reduction in the erythema and telangiectasia, and discrete size increase. CONCLUSION : Pulsed dye laser may be a useful treatment for improving the telangiectasia and erythematous component of necrobiosis lipoidica.
BACKGROUND AND OBJECTIVE:Carbon dioxide laser skin resurfacing has become a standard treatment for wrinkles and sun-damaged skin. This ablative treatment, however, is associated with undesirable complications and long recovery times. A growing body of evidence suggests that dermal inflammation and subsequent collagen formation can be stimulated without removal of the epidermis, raising the possibility of effective non-ablative skin remodeling for mild to moderately photodamaged skin.MATERIALS AND METHODS:This preliminary study was performed to evaluate the safety and subject satisfaction of non-ablative skin remodeling using a 532 nm, 2 ms pulse-duration, frequency-doubled Nd:YAG laser. Subjects with mild-to-deep lip wrinkles and mild-moderate acne scarring were treated one half of their lip (wrinkles) or cheek (acne scarring), leaving the other side as an untreated control. Subjects were treated at 3-6 week intervals for an average of three treatments. Subjective assessment of improvement was estimated by subject self-evaluation of the percentage improvement over baseline, and a blinded observer attempted to identify the treated side on physical examination.RESULTS:Subjective assessment revealed an average improvement of 51.4% and 53.6% for upper lip wrinkles and facial acne scarring, respectively. Side effects were limited to transient erythema that resolved over 0.25-2 hours following treatment.CONCLUSIONS:These results demonstrate that non-ablative treatment with the 532 nm, 2 ms pulse-duration Nd:YAG laser results in subjective improvement of rhytides and acne scarring, with a high safety profile.
BACKGROUND: Laser hair removal is based on the dual concepts of selective photothermolysis and thermal relaxation time. In most laser hair removal systems, light with emitted pulse durations of 2–50 ms targets hair follicles. Such pulse durations usually lead to post-inflammatory pigmentary changes in suntanned individuals. OBJECTIVE: In this pilot study, we evaluated the clinical efficacy and side effect profile of a modified 810–nm diode laser device (Palomar SLP 1000Á, Burlington, MA, USA) operating in a super long pulse mode (200–1000 ms). METHODS: Five suntanned subjects with Fitzpatrick skin types II–IV received either one or two laser treatments at eight test sites. Treatments were delivered to suntanned skin. Pulse durations of 200–1000 ms were evaluated with delivered fluences ranging from 23 to 115 J cm 2 . Subjects were followed for 6 months after the first treatment. Subjects were evaluated for hair removal efficiency, optimal pulse duration and delivered fluence, one versus two treatments, and associated complication rate. RESULTS: The average hair reduction, 34%, did not significantly vary with pulse duration or fluence. Clinical evaluations rated two treatments superior to one. CONCLUSION: The results show that efficacious and safe hair removal can be accomplished with an 810–nm diode laser delivering super long pulse durations at a wide range of settings in suntanned individuals. For optimal safety in tanned patients, the highest fluence (115 J cm 2 ) and pulse duration (1000 ms) should be avoided.
BACKGROUND AND OBJECTIVES: The use of ablative lasers in the treatment of common warts and precancerous actinic keratoses has been reported in the literature, showing variable response rates and relapse rates. The erbium:YAG laser (Er:YAG) with a wavelength of 2.94 w m allows precise ablation avoiding strong inflammation. The authors have evaluated the potential benefits of Er:YAG laser treatment for difficult-to-treat warts and actinic keratoses. PATIENTS AND METHODS: A total of 69 patients with difficult-to-treat warts (periungual or plantar) with a mean age of 30.1 - 16.1 years (range 11-58 years), and 29 patients with actinic keratoses with a mean age of 73.5 - 9.7 years (range 58-90 years) were treated by Er:YAG laser. Ablative therapy was performed with a spot size of 3 mm, a frequency between 8 Hz and 15 Hz, and a fluence of 5.7-11.3 J cm -2 (warts) or 5.7-7.1 J cm -2 (actinic keratoses). RESULTS: After a single laser treatment a complete response (CR) was observed in 50 patients with warts (72.5%). Plantar warts were more resistant (13.5% non-responder) compared with periungual warts (5.9% non-responder). Twelve patients with a CR showed a relapse within 3 months after treatment (24.0%). All but one suffered from plantar warts. Twenty-six patients with actinic keratoses showed a CR after a single laser treatment, and in three patients a partial response (PR) was achieved. None of the patients treated with Er:YAG laser developed pigment changes, wound infections or scarring. CONCLUSION: Treatment of common epithelial lesions such as common warts or actinic keratoses by Er:YAG laser is safe and effective. In patients with plantar warts, however, a significant rate of relapse may occur, requiring additional therapy.
BACKGROUND:A variety of lasers and light sources have been used for removal of unwanted hair. A novel, new, flashlamp-based device, with a mechanism of action based on a combination of both emitted light and heat, has been developed for safe and reliable hair removal.OBJECTIVE:To assess the efficacy and safety of hair removal by a combined light/heat based photoepilation system.METHODS:A pilot trial was undertaken. Twenty one anatomic sites received one to three treatments with the SpaTouch light/heat based photoepilation system. Fluences ranging from 6.25 to 6.45 J/cm(2) and pulse duration of 35 ms were used. Evaluations of hair regrowth was performed at 4 months after the last treatment by comparing the terminal hair count to the baseline values. Patient satisfaction and potential complications were evaluated.RESULTS:Average hair reduction after photoepilation was 27% for one to three treatments at 4 months following the final treatment. 46% and 15% of subjects reported being 'mildly pleased' and 'very pleased' with the results of treatment. No hyperpigmentation, hypopigmentation or scarring was observed at 4 months after treatment.CONCLUSION:The SpaTouch light/heat based photoepilation system represents the newest efficient and safe method in hair removal. Further study of optimal parameters is required.
BACKGROUND AND OBJECTIVES: Skin resurfacing and wrinkle removal is a large medical laser market. However, the rate of undesirable side effects is high and sometimes is not warranted by the aesthetic improvement observed. The authors have evaluated the potential benefits of an approach to selective non-ablative wrinkle reduction. MATERIALS AND METHODS: This technique selectively targets the microvasculature which plays a key role in the stimulation of enhanced collagen production. RESULTS: The study reported shows that application of the laser parameters described enhances collagen production by an average of 84%, measured 72 hours after a single laser treatment. This is achieved whilst leaving the skin barrier intact and with no adverse pigmentary changes. The study further shows that a cosmetic improvement is observed with an average value of 1.88 reduction in wrinkle appearance as measured on the Fitzpatrick Wrinkle Severity scale. This improvement was achieved with one brief treatment and no reported incidence of side effects. CONCLUSION: In conclusion, the treatment modality described may be a new approach to the treatment of wrinkles.
OBJECTIVE : The main purpose of this clinical study was to compare the effectiveness of an intense pulsed light irradiator system (IPL) and a normal mode ruby laser for hair removal. MATERIALS AND METHODS : Thirty-one patients were treated 3 times with a new IPL system on one side of the chin and neck and with a normal mode ruby laser on the other side. After 6 months, nine of the patients received 3 additional IPL treatments and 11 patients received 3 additional ruby laser treatments. All treatment intervals were 2 months. Hair reduction was measured by hair counts on close-up photographs. RESULTS : Hair reduction was obtained by 93.5% of the patients after 3 IPL treatments and by 54.8% after 3 ruby laser treatments. The average hair count was reduced by 49.3% after IPL treatments and by 21.3% after ruby laser treatments. Three additional IPL treatments following 3 IPL treatments resulted in only 6.6% further hair reduction - in total 55.9%, whereas 3 IPL treatments following 3 ruby laser treatments resulted in an additional 35.5% hair reduction - in total 56.8%. CONCLUSIONS : The IPL was found to be 3.94 times more effective than the ruby laser for hair removal. In the chin and neck region, more than 3 treatments with the IPL did not improve the therapeutic result significantly.
A patient presenting with nodules in his tattoos was referred for laser treatment, following which there was a diagnosis of cutaneous and pulmonary sarcoidosis. Nodular change involving several different tattoo colours is characteristic of sarcoidosis.
