New approaches to the treatment of vascular lesions

Rosacea: Practical Guidance and Challenges for Clinical Management

Rosacea is a common chronic dermatosis. Clinically, rosacea can present with flushing, erythema, papules, pustules, telangiectasias, phymatous changes, pruritus, burning, and stinging. In 2017, the National Rosacea Society Expert Committee recommended a phenotype-based classification for therapy. In this review, we identify monotherapies and multimodal treatment approaches for the clinical management of rosacea including topical, systemic, laser and light, alternative, and combination therapies.

A randomized split-face comparative study of long-pulsed alexandrite plus low-fluence Nd:YAG laser versus pulsed-dye laser in the treatment of rosacea

OBJECTIVES

To compare the effectiveness of long-pulsed alexandrite laser (LPAL) with that of pulsed-dye laser (PDL) for rosacea.

METHODS

This was a single-blind randomized controlled trial on 27 patients who were clinically diagnosed with rosacea. Randomly assigned split face in each patient received four times monthly treatment of LPAL plus low-fluence Nd:YAG with the contralateral side serving as the control treated with PDL. At every visit, the erythema index (EI) was measured with skin analysis systems, and two independent dermatologists evaluated digital photographs for five-point global aesthetic improvement scale (GAIS).

RESULTS

The EI significantly decreased on both treated sides (LPAL 366.5 ± 101.0 vs. 295.8 ± 90.2, p < 0.001, PDL 369.0 ± 124.3 vs. 302.7 ± 92.1, p < 0.001) 1 month after fourth treatment (visit 5). Also 3 months after the fourth treatment (visit 6), the reduction in the EI was well maintained on both sides (LPAL 360.3 ± 96.8 vs. 282.0 ± 89.2, p < 0.001, PDL 364.3 ± 121.6 vs. 281.6 ± 97.8, p < 0.001). When comparing the improvement in the EI between the two groups, the percentage reduction in the EI on the LPAL-treated side was not inferior to the PDL-treated side (visit 5: LPAL 18.7 ± 15.7% vs. PDL 16.4 ± 12.9%, p = 0.501 and visit 6: LPAL 21.7 ± 13.9% vs. PDL 21.9 ± 15.2%, p = 0.943). The GAIS and patient satisfaction were comparable between the LPAL and PDL sides and did not show any significant difference. No serious adverse events occurred on either of the treated sides.

CONCLUSION

This study showed that the decrease in EI in the treatment of rosacea was comparable between PDL and LPAL. Therefore, LPAL could be a promising alternative treatment option with good merits for rosacea, considering no consumables are required for device maintenance.

Light-based therapies in the management of rosacea: a systematic review with meta-analysis

BACKGROUND

The current scenario and position of laser and light-based therapies (LLBT) in the therapeutic rosacea scheme are lacking evidence-based recommendations and comparisons on efficacy and tolerability among different devices. This article aimed to systematically compare the efficacy, acceptability, and tolerability of the pulsed dye laser (PDL) versus other devices.

METHOD

A literature search was conducted in March 2020. Four domains were analyzed throughout the following six outcomes: Spectrophotometer erythema index and percentage of reduction for background erythema, telangiectasia grading scale for telangiectasias, visual analog scale for pain, and physician's assessment and patient's satisfaction for treatment success.

RESULTS

Our search yielded 423 potentially relevant studies. After removing the excluded and duplicated records, 12 records were assessed for eligibility in the meta-analysis. Erythema (RR:0.38 95%CI: -0.20-0.95), telangiectasias (RR:0.54 95%CI: -0.87-1.94), and the treatment success throughout the physician's assessment (RR:1.23 95%CI: 0.74-2.04) and the patient's satisfaction (RR:1.15 95%CI: 0.73-1.82) were not significantly different between pulsed dye laser and other LLBT. In the pain domain, PDL was as painful as other LLBT (RR:-0.23 95%CI: -0.96-0.49) but more painful than neodymium: yttrium-aluminum-garnet laser (RR:0.84 95%CI: 0.53-1.14) and less than intense pulsed light (RR:-1.18 95%CI: -1.56-0.80).

CONCLUSION

This work based on previously published literature demonstrates that the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence, although in the meta-analysis the effectiveness was comparable to other LLBT, such as neodymium: yttrium-aluminum-garnet laser (Nd-YAG) or IPL.

Combination of 1,064-nm Neodymium-doped Yttrium Aluminum Garnet Laser and Steroid Tape Decreases the Total Treatment Time of Hypertrophic Scars: An Analysis of 40 Cases of Cesarean-Section Scars

BACKGROUND

The 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (Cutera, Inc., Brisbane, CA) and steroid tape (fludroxycortide tape) have been used to treat keloids and hypertrophic scars.

OBJECTIVE

To evaluate the efficacy of contact-mode 1,064-nm Nd:YAG laser therapy and steroid tape for hypertrophic cesarean-section scars versus conservative therapy (steroid tape only).

MATERIALS AND METHODS

A medical record review identified 40 consecutive Japanese patients who had hypertrophic scars (total Japan Scar Workshop Scar Scale [JSS] 2015 evaluation scores of 9 to 12) for more than 1 year after a vertical cesarean section and who were treated at our scar-specialist clinic from July 2015 to December 2017. All 40 patients continued treatment until the total JSS score dropped below 3. Recurrence was defined as a ≥1-point increase in the total JSW score 6 months after achieving a total JSS score <3.

RESULTS

The patients had a mean age of 34.2 years. The test (n = 25) and control (n = 15) groups took on average 16.9 and 24.3 months to achieve a total JSS score <3, respectively (p < .01). In the following 6 months, none of the scars recurred.

CONCLUSION

Nd:YAG laser treatment effectively decreased the total treatment time of hypertrophic cesarean-section scars. An algorithm for treating mild and severe hypertrophic cesarean-section scars is proposed.

Laser and light-based therapies in the management of rosacea: an updated systematic review

Unlike other rosacea therapies which need daily takings or applications over long periods, the edge of lasers and light-based therapies (LLBT) is the limited number of sessions to achieve improvement. The proper selection of the adequate physical device in accordance with the patients' skin features and rosacea-related signs and symptoms should be considered and the management with physical sources should be updated as new data become available. This article reviews and discusses the current use of lasers and light-based therapies in rosacea with reference to all the available literature.This systematic review demonstrates the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence. Treatments options should be tailored for each specific clinical scenario as it is unlike that single modality results in complete resolution. Platforms that include two or more devices and combined therapies with topical agents are suitable and they warrant further investigations.

Aesthetic Treatment Outcomes of Capillary Hemangioma, Venous Lake, and Venous Malformation of the Lip Using Different Surgical Procedures and Laser Wavelengths (Nd:YAG, Er,Cr:YSGG, CO2, and Diode 980 nm)

Different approaches with different clinical outcomes have been found in treating capillary hemangioma (CH), venous lake (VL), or venous malformations (VM) of the lips. This retrospective study aims to assess scar quality, recurrence rate, and patient satisfaction after different surgeries with different laser wavelengths. A total of 143 patients with CH or VM were included. Nd:YAG laser was used for 47 patients, diode 980 nm laser was used for 32 patients (treatments by transmucosal photo-thermo-coagulation), Er,Cr:YSSG laser was used for 12 patients (treatments by excision), and CO₂ laser was used for 52 patients (treatments by photo-vaporization). The Manchester scar scale was used by practitioners to assess the scar quality. The recurrence rate and patients' satisfaction were noted at different follow-ups during 12 months. Our retrospective study showed that laser-assisted aesthetic treatment of vascular lesions (CH, VL, and VM) of the lips can be considered effective regardless of the wavelength used (Er,Cr:YSGG, CO₂, Nd:YAG, and diode 980 nm) or the treatment procedure (transmucosal photo-thermo-coagulation, photo-vaporization, and surgical excision). There was no significant difference in patient and practitioner satisfaction with aesthetic outcome at 6 months follow-up. Furthermore, the treatments of lip vascular lesions performed using Er,Cr:YSGG and CO₂ lasers did not show any recurrence during the 12 months of follow-up, while recurrence rates of 11% ± 1.4% and 8% ± 0.9% were seen in the diode and Nd:YAG groups, respectively.

Enhanced Pulsed Dye Laser for Facial Rejuvenation

BACKGROUND AND OBJECTIVES

To evaluate the efficacy of an enhanced pulsed dye laser (PDL) for treatment of facial-dyschromia.

STUDY DESIGN/MATERIALS AND METHODS

Thirteen patients were enrolled in the study. Nine patients were female, four were male, with a mean age of 61 years. All patients presented with either facial telangiectasia, rosacea, pigment, or a combination thereof. At the initial evaluation, test spots were performed to determine the subject's response to selected treatment parameters. In the study, the enhanced 595 nm PDL deployed a spot size range of 5-12 mm with fluences ranging from 8 to 18 J/cm² . Pulse duration was 10 milliseconds. Enhancements in this device included the option for contact or cryogen spray cooling, increased maximum pulse energy, increased repetition rate, option for addition of radiofrequency (RF), an option for a 15 mm spot size, and longer dye life. The smaller spots were used only for focal low contrast pigmented lesions that persisted after overall facial treatment with the larger spot. Smaller fluences were applied for general rejuvenation with the 12 mm spot (mean ~9 J/cm² ). Sapphire contact cooling was applied at 10°C. A smaller area of the skin was reserved (typically pre-auricular area) for addition of RF energy just before the pulse (40-70 J/cm³ ) over 100 milliseconds with a 20 milliseconds delay between the end of the RF pulse and beginning of the laser pulse. The minimum fluence that achieved vessel closure/vessel bluing and/or slight immediate pigment darkening was applied based on test spots performed just before treatment to the entire face. Determinations of improvement were made by evaluation of photographs with standard settings using polarized and nonpolarized images. Up to three treatments were performed approximately 1 month apart with follow-up visits 1 and 3 months after the final treatment.

RESULTS

Evaluation by a panel of blind observers determined a mean clearance of at least 50% in all lesions, while 77% of lesions had 50-75% clearance, and 23% of lesions had 76-100% clearance. Pain was approximately 4/10. Subjective lesion improvement and satisfaction rates were 3 out of 4 and 3.6 out 4, respectively.

CONCLUSION

An enhanced PDL is effective in one pass treatments for facial rejuvenation with considerably less operative time than previous commercially available systems. A second pass applied to focal challenging lesions results in even more improvement, in a single treatment session. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

An Overview of Laser in Dermatology: The Past, the Present and … the Future (?)

The authors discuss a brief history of lasers and their use in dermatology. Although the excellent results achieved by the use of laser in dermatology, this special treatment modality is in continuous evolution. At present, new devices have been under development for the therapy of different kind of diseases, while lasers, already in use, has been changing, in order to be more secure, effective and be useful in many others disorders.

Efficacy of a Novel Optimized Pulsed Light Source (MaxG) for the Treatment of Facial Vascular Lesions

BACKGROUND AND OBJECTIVE

Facial vascular malformations can cause a number of functional problems, including difficulties in breathing, eating, speech, and mobility. Psychological problems can also arise due to the possible unpleasant appearance of such lesions. Further, these lesions can lead to a number of complications, including pain, ulceration, infection, and significant bleeding. Many treatments have been proposed in the literature. Laser therapy (and its related treatments by non-coherent light sources) is now considered the gold standard in the treatment of the majority of vascular lesions.

METHODS

Here, we present our experience with a novel optimized pulsed light source for the treatment of vascular anomalies. In this prospective study, we evaluate the clinical outcomes of 30 patients treated with this method.

RESULTS

Our results confirm the efficacy and safety of this treatment for facial vascular lesions.

CONCLUSIONS

Based on our experience and results, we believe this device could be considered as both an alternative monotherapy and a useful adjunctive to the already existing laser instruments.

Nd:YAG Laser Treatment for Keloids and Hypertrophic Scars: An Analysis of 102 Cases

Background:

The present retrospective cohort study was performed to determine the efficacy of contact-mode 1064 nm neodymium-yttrium-aluminum-garnet (Nd:YAG) laser laser for keloids and hypertrophic scars. The indication and limitations of this modality are discussed.

Methods:

The cohort consisted of 102 consecutive Japanese patients (23 males and 79 females) with keloids and hypertrophic scars for more than 1 year. They were treated every 3–4 weeks for 1 year with a long-pulsed 1064 nm Nd:YAG laser (Cutera, Brisbane, Calif.) in contact mode. Thirty-eight patients had hypertrophic scars and 64 had keloids. The scars were evaluated before the treatment commenced and 1 month after the last session by using the Japan Scar Workshop Scar Scale 2011. Recurrence was assessed at 6 months after the termination of treatment.

Results:

The average total Japan Scar Workshop score of the keloid and hypertrophic scar region groups dropped significantly after 1 year of treatment compared with before treatment (all P < 0.05). None of the hypertrophic scars or keloids deteriorated. However, 3 of the 34 anterior chest keloids (8.8%) did not respond. The following recurrence rates were observed 6 months after stopping laser treatment: 1 of the abdomen hypertrophic scars (4%), 18 of the anterior chest keloids (52.9%), 5 of the upper arm keloids (35.7%), and 4 of the scapula keloids (25%).

Conclusions:

Hypertrophic scars responded significantly better to 1064 nm Nd:YAG laser treatment than keloids. However, keloid recurrence occurred when there was remaining redness and induration, even if only a small part of the scar was affected.

Treatment of port-wine stains with flash lamp pumped pulsed dye laser on Indian skin: a six year study

Context:

Port-wine stain (PWS) is one of the commonly encountered congenital cutaneous vascular lesions, with an equal sex distribution. Pulsed dye lasers (PDL) have revolutionized the treatment of both congential and acquired cutaneous vascular lesions. The pulsed dye lasers owing to its superior efficacy and safety profile have become the gold standard for the management of port-wine stains.

Aims:

To evaluate the efficacy and side effects of pulsed dye laser for the management of Port-wine stain on Indian skin.

Materials and Methods:

Seventy five patients of Fitzpatrick skin types IV&V with PWS underwent multiple treatments with PDL (V beam-Candela) over a period of six years at monthly intervals. Laser parameters were wavelength 595nm, spot sizes 7-10mm, fluence 6-12 j/cm2, pulse duration 0.45-10ms, along with cryogen cooling. Serial photographs were taken before and after every session. Clinical improvement scores of comparable photographs using a quartile grading (o=<20%, 1=21-40%, 2=41-60%, 3=61-80%, 4=>80%) were judged independently by two dermatologists after the series of treatment. Minimum number of treatments was 6 and maximum 17. They were followed up at six monthly intervals to observe re darkening of PWS.

Results:

No patient showed total clearance.Grade3 improvement was observed in 70 % of children and 50% of adults after 8-10 sessions. Children showed better and faster response than adults. Thirty percent of patients developed post inflammatory hyper pigmentation which resolved over a period of six to eight weeks. Two patients had superficial scarring due to stacking of pulses. None of the patients showed re darkening of PWS till now.

Conclusion:

Pulsed dye laser is an effective and safe treatment for port-wine stain in Indian skin.

Pulsed dye laser-resistant port-wine stains: mechanisms of resistance and implications for treatment

Port-wine stains (PWS) are among the most common congenital vascular malformations. Unlike capillary haemangiomas, these lesions do not involute spontaneously but rather become progressively more disfiguring as the patient ages. While benign in nature, the cosmetic deformity and attendant psychological and emotional distress prompt the majority of those afflicted to seek treatment. The pulsed dye laser (PDL) has long been considered the treatment of choice for these vascular lesions; however, very few patients achieve total clearance with PDL therapy and a significant number of lesions fail to respond at all. In order to address these recalcitrant cases, the mechanisms that contribute to treatment resistance must be understood and novel laser and light therapies must be employed. This review will address what is currently known about lesion-specific characteristics of PDL-resistant PWS as well as discuss current and future treatment options.

Current status of surgery in dermatology

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Diagnosis and management of extensive vascular malformations of the lower limb: part II. Systemic repercussions [corrected], diagnosis, and treatment

At least nine types of vascular malformations with specific clinical and radiologic characteristics must be distinguished in the lower limbs: Klippel-Trénaunay syndrome, port-wine stain with or without hypertrophy, cutis marmorata telangiectatica congenita, macrocephaly-capillary malformation, Parkes Weber syndrome, Stewart-Bluefarb syndrome, venous malformation, glomuvenous malformation, and lymphatic malformation. Extensive vascular malformations are often more complex than they appear and require a multidisciplinary therapeutic approach. Vascular malformations may be associated with underlying disease or systemic anomalies. Part II of this two-part series on the diagnosis and management of extensive vascular malformations of the lower limb highlights the systemic repercussions [corrected] (bone, articular, visceral, and hematologic involvement), diagnosis, and treatment of these lesions.

Laser treatment of dark skin: an updated review

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements. Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults. Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.

Laser transport through thin scattering layers

Many modern applications of lasers involve understanding the transport of radiation through thin layers. The interactions of continuous wave and pulsed lasers with skin in dermatological use related to surgery and cosmetic procedures are examples of such. These highly scattering thin layers in skin are best modeled by the Monte Carlo method. However, most traditional Monte Carlo models may inaccurately account for the presence of thin layers. As an example, the very thin epidermis, with its highly absorbing melanin, is known to influence the laser penetration significantly. If the Monte Carlo model is implemented without special features, then the results of the simulation will show incorrect effects of thin layers because the path length of most photons would be significantly larger than the layer thickness. As a result, the computed photon travel path length would simply not feel the presence of the layer. In this paper, we present numerical and algorithmic features for computation of radiation transport through thin layers. It is noted that, while Monte Carlo without special features smears the radiative effect of the layers, the refined technique indicates that layers have a great impact on the absorption of energy, especially if the layer properties are distinctly different from those of the adjacent layers. The results have significant implications in the study of diagnostic and therapeutic applications of lasers in biomedicine and surgery.

[Vascular lasers]

After reviewing the main technical features of the lasers and flashlamps currently available, the indications for these devices are detailed, mainly port wine stains, facial telangiectasia, hemangiomas, and lower-limb varicosities. Respecting the principles of treatment (briefly reviewed herein), contributes to preventing complications, which are consequently becoming rare.

The use of the pulse dye laser in the treatment of vocal fold scar: a preliminary study

OBJECTIVES/HYPOTHESIS

Dysphonia due to vocal fold scarring is a challenging problem to the laryngologist. Vocal fold scarring after radiation, phonosurgery, and laser cordectomy causes moderate to severe dysphonia. Surgical attempts at scar removal and voice restoration have limited success. Pulsed dye laser (PDL) treatment has been shown to be effective in softening scarred skin by serial office treatments. The objective of this preliminary study was to evaluate the use of the PDL in the management of patients with established vocal fold scar.

STUDY DESIGN

This is an Institutional Review Board-approved prospective study involving 11 patients. The causes of scarring were phonosurgery (n = 7), radiation (n = 2), and partial laryngectomy (n = 2). The subjects were evaluated pre- and postprocedure using the voice handicap index (VHI), laryngeal stroboscopy rating, voice recordings with acoustic and aerodynamic analysis, and self-evaluation.

METHODS

The PDL was applied with the fiberoptic delivery system by three treatments at 1-month intervals in the office setting. Each treatment endpoint was blanching of the treatment site.

RESULTS

: There were three women and eight men in our study group. Ten of 11 patients subjectively improved by self-rating. No patients were worse. VHI improved from 48.44 pretreatment to 35.55 at 6 months posttreatment (P < .05). The jitter at 6 months improved from 2.230% to 1.654% (P = NS) and shimmer improved from 3.679% to 3.196% (P = NS). The noise to harmonic ration improved from 0.1428 to 0.1316 (P = NS). The mean phonotory flow went from 0.177 to 0.254 L/S (P < .05). Three raters blinded to treatment sequence rated the posttreatment stroboscopy findings as better than pretreatment in a forced choice comparison, kappa score 0.903.

CONCLUSION

PDL is a safe and potentially promising treatment for established vocal fold scar. Subjectively, no patients were worse and 10 of 11 patients reported improved voice. There was improvement in the VHI, acoustic measures of shimmer and jitter, and stroboscopy findings. Further study using this approach in a larger cohort seems to be warranted.

[Vascular lasers]

After reviewing the main technical features of the lasers and flashlamps currently available, the indications for these devices are detailed, mainly port wine stains, facial telangiectasia, hemangiomas, and lower-limb varicosities. Respecting the principles of treatment (briefly reviewed herein), contributes to preventing complications, which are consequently becoming rare.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of side effects. Although the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.

Selektive Retinatherapie

Selective retina therapy (SRT) is currently under evaluation, as a new and very subtle laser method, for the treatment of retinal disorders associated with a degradation of the retinal pigmentary epithelium (RPE). SRT makes it possible to selectively effect the RPE, sparing the adjacent neural retina with the photoreceptors and also the choroid below the RPE. In the best case, the therapy leads to regeneration of the RPE and a long-term metabolic increase at the chorio-retinal junction. In contrast to conventional laser photocoagulation, which is associated with complete thermal necrosis of and around the treated site, absolutely no scotoma occurs in SRT. This paper reviews the methods and mechanisms behind the selective effects of the RPE. In vitro and preclinical results are used to describe the bandwidth of selective effects with respect to different irradiation settings. An optoacoustic technique is introduced to visualize effects that cannot be seen by ophthalmoscopy and to facilitate dosimetry control without recourse to angiography completes the report.

Outcomes of 532 nm frequency-doubled Nd:YAG laser use in the treatment of port-wine stains

BACKGROUND

Port-wine stains (PWSs) are congenital dermal malformations involving venules, capillaries, and, probably, perivascular nerves. The primary morbidities of PWS are psychological disturbances that adversely affect the development of personality. Lasers have been the treatment of choice for PWS. However, only one type of laser is not a panacea for all PWS malformations. For the treatment of PWSs, carbon dioxide, argon, krypton, copper bromide, frequency-doubled neodymium:yttrium-aluminum-garnet (Nd:YAG), flashlamp pumped pulsed dye laser, and also intense pulsed light sources can be used.

OBJECTIVE

To determine the efficacy and the frequency of side effects of the frequency-doubled Nd:YAG laser for the treatment of PWSs.

PATIENTS AND METHODS

In this study, 532 nm frequency-doubled Nd:YAG laser with a 2 to 6 mm spot size, 15- to 50-millisecond pulse width, and a 9.5 to 20 J/cm2 fluence was applied for 89 patients (62 female, 27 male; age range 3-49 years) with PWSs on the face and/or neck for 1 to 12 sessions, with 2-month treatment-free intervals. Improvement rates were considered a failure (< 25%), mild (25-49%), moderate (50-74%), good (75-94%), and excellent (> 95%).

RESULTS

Excellent (n = 12; 13%), good (n = 34; 38%), moderate (n = 39; 44%), and mild (n = 4; 5%) improvement of lesions was obtained after an average of 5.6, 5.5, 4.4, and 3.8 therapy sessions, respectively. No treatment failure was observed for any patient. As adverse effects, transient hyperpigmentation (n = 2; 2.25%), hypopigmentation (n = 1; 1.12%), and hypotrophic scarring (n = 1; 1.12%) were noted.

CONCLUSIONS

The results obtained asserted that the frequency-doubled Nd:YAG laser is a quick, safe, and effective treatment modality for PWS malformations and can be appreciated as a useful alternative therapy that can raise the rates of success in cases with PWSs refractory to other laser therapies.

Evaluation of different temperatures in cold air cooling with pulsed-dye laser treatment of facial telangiectasia

BACKGROUND AND OBJECTIVES

Cold air cooling is widely used in dermatological laser therapy. We investigated the influence of cold air cooling at different skin temperatures on therapeutic outcome and side effects of pulsed dye laser treatment of facial telangiectasia.

STUDY DESIGN/MATERIALS AND METHODS

From September 2002 to February 2003, 17 patients with previously untreated facial telangiectasia underwent a single treatment session with flash-lamp pulsed dye laser (3.5 J/cm(2), 585 nm, 0.45 milliseconds pulse length, 10 mm beam diameter, Cynosure V). The treatment area was divided into three sub-areas: no cooling, cold air cooling to 20 degrees C and to 17 degrees C skin temperature. The skin temperature was monitored by a prototype infrared sensor system which controlled the temperature of the cold air stream (Cryo5). In a prospective study, we collected data on purpura, pain, clearance, and patient satisfaction on numerical analog scales (NAS) from 0 (meaning "no") to 3 (meaning "high").

RESULTS

Without cooling, purpura (2.53), pain (2.41), and clearance (2.35) were rated medium to high. Cooling to 20 degrees C reduced purpura (1.12) and pain (1.06), whereas the clearance (2.12) was only slightly affected. Cooling to 17 degrees C reduced purpura (0.88) and pain (0.76) even more, the clearance (2.06) was lowered marginally. Most patients preferred cooling to 20 degrees C skin temperature.

CONCLUSION

In dermatological laser therapy of facial telangiectasia, the use of cold air cooling can significantly reduce side effects and increase patient satisfaction while only slightly affecting clearance. Cooling to 20 degrees C skin temperature proved to be a well-balanced middle course. For the practical use of cold air cooling, we thus recommend cooling to a level which the patient can tolerate without problems and to try to increase the energy densities.

Epidermal and vascular damage analysis of in vivo human skin in response to 595 nm pulsed laser irradiation

BACKGROUND AND OBJECTIVES

Laser irradiation is the current modality for treatment of cutaneous hypervascular malformations such as port wine stains and telangiectasia. Although cryogen spray cooling (CSC) is used to protect the epidermis from non-specific laser-induced thermal damage in moderately-pigmented skin types, individuals with high melanin content are still at risk for epidermal damage using the current laser irradiation and CSC parameters. The objective of this study was to investigate the influence of the spray Weber number (1,100 or 5,100) on epidermal protection and examine vascular coagulation in response to pulsed dye laser irradiation.

STUDY DESIGN/MATERIALS AND METHODS

Normal, in vivo human skin from eight subjects of Fitzpatrick skin types I-V were precooled with either low or high Weber number cryogen sprays and subsequently irradiated with a pulsed dye laser at 595 nm. Analysis of gross purpura, morphological vascular damage, and apoptosis of the vascular walls were performed.

RESULTS

Results demonstrated a high Weber number spray of 5,100 decreased the level of epidermal damage in darker and moderate pigmented individuals compared to a Weber number spray of 1,100. This study also established a positive correlation between gross purpura and the level of vessel wall apoptosis.

CONCLUSIONS

This study has demonstrated that CSC with a high Weber number spray can decrease nonspecific thermal damage to the epidermis in response to laser irradiation in vivo. We have also established a positive correlation between gross purpura and the level of vessel wall apoptosis. Lasers Surg. Med. (c) 2005 Wiley-Liss, Inc.

Efficacy of the 1.5 millisecond pulse-duration, 585 nm, pulsed-dye laser for treating port-wine stains

BACKGROUND AND OBJECTIVES

Some reports have suggested that 1.5-millisecond pulse-duration pulsed-dye lasers (PDLs) may have increased efficacy in treating port-wine stains (PWSs) as compared to previous generation lasers. We study the efficacy of the 1.5-millisecond pulse-duration PDL for treating PWSs.

STUDY DESIGN/MATERIALS AND METHODS

We treated 104 areas of involvement by PWSs in 95 subjects with the 1.5-millisecond pulse-duration PDL. Subjective and objective measures of improvement were utilized. Twenty-one of these PWSs had failed treatment with earlier generation PDLs.

RESULTS

PWSs previously refractory to the shorter pulse duration lasers responded well to treatment, as did PWSs not previously treated with any laser.

CONCLUSIONS

The 1.5-millisecond pulse-duration PDL is effective for treating PWSs and may offer improved efficacy over shorter pulse-duration lasers.

Thermal response of human skin epidermis to 595-nm laser irradiation at high incident dosages and long pulse durations in conjunction with cryogen spray cooling: an ex-vivo study

BACKGROUND AND OBJECTIVES

Improved laser treatment of cutaneous hypervascular lesions is expected by utilizing higher incident dosages, longer pulse durations and longer wavelengths than those currently used in clinical settings. However, simply increasing the incident dosage will also increase the risk of nonspecific thermal injury to the epidermis due to light absorption by melanin. In this study, we investigated the thermal response of human skin epidermis to 595-nm wavelength laser irradiation at high incident dosages (up to 20 J/cm(2)) and long pulse durations (up to 40 milliseconds) in conjunction with cryogen spray cooling (CSC) using ex-vivo human skin samples.

STUDY DESIGN/MATERIALS AND METHODS

The Candela V-beam trade mark laser (595-nm wavelength) was used in the experiments. Ex-vivo human skin samples (Fitzpatrick types I-VI) were irradiated at the incident dosages D(0) = 4, 6, 10, 15, and 20 J/cm(2), laser pulse durations tau(laser) = 1.5, 10, and 40 milliseconds, without and with CSC (refrigerant-134A, spurt duration tau(CSC) = 100 milliseconds). Thermal injury to the epidermis was evaluated by histological observations.

RESULTS

Under the same incident dosage, longer pulse durations led to reduced thermal injury to the epidermis. Without CSC, no demonstrable thermal injury to the epidermis was observed in skin types I-II irradiated at the incident dosage as high as 15 J/cm(2), and in skin types III-IV at 10 J/cm(2). When CSC was applied, no evidence of thermal injury to the epidermis was present in skin types I-II even when irradiated at the maximum available incident dosage of the laser system (20 J/cm(2)). In skin types III-IV, no demonstrable thermal injury to the epidermis was observed when using incident dosage as high as 15 J/cm(2) in conjunction with CSC. In skin type VI, thermal injury to the epidermis could not be avoided even at the setting D(0) = 4 J/cm(2), tau(laser) = 40 milliseconds in conjunction with CSC.

CONCLUSIONS

For a given incident dosage, longer pulse durations help reduce thermal injury to the epidermis. When a 100-millisecond cryogen spurt is applied, thermal injury to the epidermis can be prevented in ex-vivo skin types I-IV when irradiated at higher incident dosages (15-20 J/cm(2)) than those currently used in clinical settings. Further studies on optimizing the CSC parameters in conjunction with the laser irradiation parameters are needed to protect skin types V-VI from thermal injury to the epidermis.

Multicenter study of noninvasive radiofrequency for periorbital tissue tightening

BACKGROUND AND OBJECTIVES

This 6-month study evaluated the efficacy and safety of treatment with a nonablative radiofrequency (RF) device.

STUDY DESIGN/MATERIALS AND METHODS

Eighty-six subjects received a single treatment with the ThermaCool TC System (Thermage, Inc., Hayward, CA) and were evaluated for 6 months after treatment.

RESULTS

Independent scoring of blinded photographs resulted in Fitzpatrick wrinkle score improvements of at least 1 point in 83.2% (99/119) of treated periorbital areas. Treating physicians, without reference to pre-treatment photographs, noted improvements in 28.9% (48/166) of treatment areas. Fifty percent (41/82) of subjects reported being satisfied or very satisfied with periorbital wrinkle reductions. Objective photographic analysis showed that 61.5% (40/65) of eyebrows were lifted by at least 0.5 mm. Rates and duration of edema/erythema were very low (e.g., vs. ablative procedures). Overall 2nd-degree burn incidence was 0.36% (21 per 5,858 RF applications). Three patients had small areas of residual scarring at 6 months.

CONCLUSIONS

A single treatment with this RF tissue tightening (RFTT) device produces objective and subjective reductions in periorbital wrinkles, measurable changes in brow position, and acceptable epidermal safety. These changes were indicative of a thermally induced early tissue-tightening effect followed by additional tightening over a time course consistent with a thermal wound healing response.

Intense pulsed light for the treatment of lentigines in LEOPARD syndrome

A 28-year-old female patient suffering from LEOPARD syndrome presented, asking for the removal of lentigines (covering her face and most of her body) for aesthetic reasons. Intense pulsed light technology has been already used successfully for the removal of various benign pigmented lesions and it proved effective in this very rare case as well.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

The new 940-nanometer diode laser: an effective treatment for leg venulectasia

BACKGROUND

The 940-nm diode laser has been shown to be an effective treatment for leg veins.

OBJECTIVE

We sought to evaluate the effectiveness of the 940-nm diode laser on leg veins, depending on the size and morphologic aspect of the treated vessels.

METHODS

A total of 60 patients (mean age: 44.4 years, Fitzpatrick skin types I-IV) underwent up to 3 treatment sessions at 4-week intervals using the 940-nm diode laser. Treatment parameters were: vessels < 0.4 mm in diameter, 0.5-mm spot, pulse duration of 10 milliseconds, fluence 306 J/cm(2); 0.4 to 0.8 mm in diameter, 1-mm spot, pulse duration of 30 milliseconds, fluence 306 J/cm(2); and 0.8 to 1.4 mm in diameter, 1.5-mm spot, pulse duration of 70 milliseconds, fluence 317 J/cm(2). Repetition rate was 2.5 Hz. Success rate was evaluated through double-blind observation.

RESULTS

Only 13.33% of patients with telangiectases less than 0.4 mm in diameter had a percentage of vessel clearance superior to 75%. However, 88.24% of patients with vessels between 0.8 and 1.44 mm in diameter obtained more than 75% vessel clearance.

CONCLUSION

The treatment of leg veins by the 940-nm diode laser strongly depends on the size of the target vessel. Better results were obtained with 0.8- to 1.4-mm leg venulectases.

Evaluation of the long pulsed high fluence alexandrite laser therapy of leg telangiectasia

BACKGROUND AND OBJECTIVES

The treatment of larger leg veins with laser or intense pulsed light often shows varying degrees of success and inconsistent clinical response rates. Aim of this study was to evaluate the effectiveness and safety of the 755 nm long pulsed high fluence alexandrite laser in the treatment of larger leg veins.

STUDY DESIGN/MATERIALS AND METHODS

Twenty female volunteers aged 25-51 years (mean 39) with 0.3-1.3 mm leg telangiectasias received laser treatment, 10 of them with an additional pass done right after the first pass. Their skin type ranged from 1 to 3 (five type 1, seven type 2, eight type 3). After test spots with increasing fluences (40-90 J/cm(2)) to determine the individual safe fluence, the maximum fluence of 90 J/cm(2) could be used in all 20 subjects. The spot size was 3 x 10 mm, a spray cooling system was used with 80 milliseconds spray and delay time, respectively. The number of pulses administered ranged from 30 to 467 per subject (mean 139). The treated area was controlled 1 day, 1 month, and 3 months post-treatment and the side effects were quantified. At each visit, the treatment area was photographed. The percent clearance in the treated areas was scored by two observers. Subject satisfaction was evaluated at the 3 months post-treatment visit.

RESULTS

After 3 months, in all 20 test subjects some clearance was visible. It ranged from low-grade to complete clearance. Most subjects (15 of 20) had a clearance between 26 and 75%. Hyperpigmentation was observed in 15 subjects. Hypopigmentation was seen in two subjects. No edema, no purpura, no erythema, no scarring, no blistering, and no crusts were observed. Mean subject satisfaction score was assessed and all volunteers reported to be "satisfied."

CONCLUSIONS

The long pulsed high fluence alexandrite laser is effective and safe in the treatment of leg veins 0.3-1.3 mm in diameter.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of untoward side effects. While the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.

Transvaginal radio frequency treatment of the endopelvic fascia: a prospective evaluation for the treatment of genuine stress urinary incontinence

PURPOSE

We evaluate the safety and efficacy of a new treatment modality for genuine stress urinary incontinence which was a transvaginal radio frequency applicator to deliver radio frequency energy to the endopelvic fascia. The purported mechanism of effect for this therapy is shrinkage of the collagenated tissue which composes the endopelvic fascia that supports the bladder neck and proximal urethra, thus stabilizing the proximal urethra and bladder neck. In prior animal trials and early pilot studies this therapy was shown to cause a reproducible thermal effect manifested by fascial shrinkage. Preliminary human trials indicated a therapeutic benefit of this therapy for women with genuine stress urinary incontinence.

MATERIALS AND METHODS

To our knowledge this is the first multicenter study of a transvaginal approach for radio frequency of the endopelvic fascia for treatment of genuine stress incontinence. Between June 1999 and June 2000, 120 consecutive women (mean age 49.9 years) at 10 sites underwent transvaginal radio frequency treatment in a prospective trial to evaluate the overall efficacy and safety profile of this therapy. All patients had preoperative urethral hypermobility (average cotton swab change 38 degrees). Detrusor instability was excluded by cystometry. In all procedures precisely controlled radio frequency energy was applied to the endopelvic fascia to heat and shrink the tissue. The patients were evaluated postoperatively at 1 week and at 1, 3, 6 and 12 months using objective and subjective measures. Primary end points consisted of physician assessment of continence, patient reported pad use and the number of patient reported episodes. Safety was determined for acute (immediate postoperative) and chronic time frames.

RESULTS

Of the 120 patients 96 completed 1-year evaluation. Average operative time was less than 30 minutes, and all patients were treated as outpatients. Preoperatively 101 patients (84%) averaged 1 or more episodes of urinary incontinence per day. At 3, 6 and 12 months 57%, 66% and 59% of patients, respectively, averaged 1 or no daily episodes of urinary incontinence. At 12-month followup 79 of 109 patients (73%) reported being continent or improved. Preoperatively, 43% of patients reported using 1 or no pads daily. At 3, 6 and 12 months 69%, 70% and 72% of patients, respectively, required 1 or no pads daily. On urodynamic evaluation at 12-month followup 76.0% of the patients did not leak with a Valsalva maneuver. A total of 30 cases were classified as failures and 11 women were lost to followup. There were no intraoperative complications, 3 (4%) minor postoperative complications which resolved, and no device related complications.

CONCLUSIONS

The transvaginal radio frequency applicator demonstrated good efficacy and excellent safety at 1-year followup. Ongoing analysis of the data has indicated opportunities for improvement of this new surgical technique that could result in higher efficacy rates without compromising safety. Further long-term evaluation is being conducted to assess chronic durability of the procedure.

Radiofrequency bladder neck suspension for the treatment of genuine stress urinary incontinence

Radiofrequency energy has been used for numerous medical applications including orthopedic, oncologic, and ophthalmologic indications. Characteristics of this energy source also allow it to be used for precisely controlled thermal therapy directed at soft tissues so as to induce such changes as collagen deposition and tissue shrinkage. These soft tissue effects have recently been used for the treatment of genuine stress urinary incontinence in women. As experience with this modality has matured, improved and less invasive methods of energy application have been developed. Large-scale clinical trials using this energy modality via laparoscopic and transvaginal approaches have either recently been completed or are near completion. A completely noninvasive approach is presently undergoing early clinical trials. The efficacy and safety profiles of this therapy support radiofrequency treatment of the endopelvic fascia as an option for the management of stress urinary incontinence in women.

Clinical testing of a photoacoustic probe for port wine stain depth determination

BACKGROUND AND OBJECTIVE

Successful laser treatment of port wine stain (PWS) birthmarks requires knowledge of lesion geometry. Laser parameters, such as pulse duration, wavelength, and radiant exposure, and other treatment parameters, such as cryogen spurt duration, need to be optimized according to epidermal melanin content and lesion depth. We designed, constructed, and clinically tested a photoacoustic probe for PWS depth determination.

STUDY DESIGN/MATERIALS AND METHODS

Energy from a frequency-doubled, Nd:YAG laser (lambda=532 nm, tau(p)=4 nanoseconds) was coupled into two 1,500 mum optical fibers fitted into an acrylic handpiece containing a piezoelectric acoustic detector. Laser light induced photoacoustic waves in tissue phantoms and a patient's PWS. The photoacoustic propagation time was used to calculate the depth of the embedded absorbers and PWS lesion.

RESULTS

Calculated chromophore depths in tissue phantoms were within 10% of the actual depths of the phantoms. PWS depths were calculated as the sum of the epidermal thickness, determined by optical coherence tomography (OCT), and the epidermal-to-PWS thickness, determined photoacoustically. PWS depths were all in the range of 310-570 microm. The experimentally determined PWS depths were within 20% of those measured by optical Doppler tomography (ODT).

CONCLUSIONS

PWS lesion depth can be determined by a photoacoustic method that utilizes acoustic propagation time.

Extended theory of selective photothermolysis

BACKGROUND AND OBJECTIVE

We present a new theory of selective thermal damage of non-uniformly pigmented structures in biological tissues. Spatial separation of the heavily pigmented areas and the target requires limitation of the pigment temperature and heat diffusion from the pigmented to the targeted areas.

STUDY DESIGNS/MATERIALS AND METHODS

A concept of selective target damage by heat diffusion is presented for three target geometries: planar, cylindrical, and spherical. An in vitro experiment is described in which the dependence of thermal damage on pulsewidth at constant fluence was evaluated.

RESULTS

The in vitro experiment showed that the size of the damage zone for similar hair follicles was pulsewidth-independent over a very broad range of pulsewidths (30-400 ms). We formulated a new theory (extended theory of photothermolysis) to interpret the experimental results.

CONCLUSIONS

Based on this new theory, the treatment pulsewidth for non-uniformly pigmented targets is significantly longer than the target thermal relaxation time (TRT). The theory provides new recommendations for photoepilation and photosclerotherapy parameters.