Short-Term Side Effects of Fractional Photothermolysis

A faster CO2 fractional scanner system mode for skin rejuvenation. A clinical study

BACKGROUND

The market requires ever-faster techniques, in particular for pre-rejuvenation condition.

AIM

The purpose of this study was to assess if a fractional CO2 scanner modality (called moveo) results in a faster full-face rejuvenation treatment in comparison to the standard mode, currently existing in the scanner system.

MATERIALS AND METHODS

A total of 12 female patients affected by fine lines participated in a split-face clinical investigation and underwent to two sessions with a fractional CO2 laser system equipped with an existing and a faster dedicated scanner units. Pain was assessed using VAS. Three-dimensional clinical photographs were captured before, immediately after, 3 days, 14 days after the first treatment and immediately after the second treatment and 1 months after the last one. The uniformity and aesthetic coverage of treatments were assessed using dermatoscopy. Global aesthetic improvement scale (GAIS) was used. The time taken to treat the two sides of the face and all possible side effects were monitored.

RESULTS

Following only two treatment session with both scanner modes, the patient's skin texture improved significantly, with fine lines reduction. There is no statistically significant difference in perceived pain between patients. The GAIS score showed satisfactory results following both modalities. The time parameters indicated that with the faster scanner mode the full-face treatment time was reduced by 30% compared to the standard one. No adverse effects were observed.

CONCLUSIONS

The moveo modality provide faster treatment and a better final dermal aesthetic outcome than the standard procedure while maintaining the same safety profile.

Evidence-based management of cutaneous scarring in dermatology part 2: atrophic acne scarring

Atrophic acne scars are the most common type of acne scars and are classified into three main types: icepick, boxcar, and rolling scars. Various procedures and techniques for atrophic acne scarring are discussed in detail, with stronger evidence-based support for lasers (non-fractional, fractional, ablative, and non-ablative), platelet-rich plasma as adjunctive treatment, chemical peels (glycolic acid, trichloroacetic acid, and Jessner's solution), dermal fillers such as hyaluronic acid, and microneedling, and lesser quality evidence for microdermabrasion, subcision, and lipoaspirate grafting. Further research is needed to optimize treatment protocols, assess the efficacy of monotherapies, and establish standardized guidelines for clinicians. This paper will provide a comprehensive review of the evidence-based management of atrophic acne scars, including currently commonly utilized therapies as well as more innovative treatment options.

The Efficacy and Safety of Radiofrequency Microneedling Versus a Nonablative Fractional 1,550-nm Erbium:Glass Laser for the Rejuvenation of the Neck

BACKGROUND

Radiofrequency microneedling (RFMN) and nonablative fractional 1,550-nm erbium:glass lasers (NAFLs) have been reported to be used with success in neck rejuvenation. There are no head-to-head trials to compare these modalities.

OBJECTIVE

The purpose of the study was to compare the efficacy and safety of radiofrequency microneedling and nonablative fractional 1,550-nm erbium:glass lasers for the rejuvenation of the neck.

METHODS

This was a single-center, randomized, investigator-blinded clinical trial. A total of 21 subjects were randomized into 2 groups, NAFL and RFMN; subjects received 3 treatments 4 weeks apart and were followed up 12 weeks after last treatment.

RESULTS

Subjects in NAFL and RFMN groups showed 42.1% and 8.6% improvement in the Fitzpatrick-Goldman Wrinkling Score, respectively, 41.3% and 16.3% improvement in the elastosis score, respectively. Subjects in the NAFL 1,550-nm erbium:glass group showed significantly better blinded investigator Fitzpatrick-Goldman Wrinkling and Elastosis scores; subjects in the RFMN groups showed a more significant reduction in the Horizontal Neck Wrinkle Severity Score. There was a trend for higher patient satisfaction with the NAFL.

CONCLUSION

This study showed that both treatments resulted in significant improvement in wrinkling and elastosis scores; the NAFL treatment was associated with significantly better blinded investigator Fitzpatrick-Goldman Wrinkling and Elastosis scores and better subject satisfaction.

1,550 nm Erbium-Doped and 1,927 nm Thulium Nonablative Fractional Laser System: Best Practices and Treatment Setting Recommendations

BACKGROUND

The Fraxel Dual laser system (Solta Medical, Inc., Bothell, WA) contains a 1,550 and 1,927 nm wavelength single handpiece with different indications for each wavelength.

OBJECTIVE

To discuss treatment setting recommendations and best practices for select on-label and investigational applications of the 1,550 and 1,927 nm dual laser system.

MATERIALS AND METHODS

Eight board-certified dermatologists with 10 or more years of experience with the 1,550 and 1,927 nm laser system completed an online survey about their clinical experience with the system and then participated in a roundtable to share clinical perspectives and best practices for using the laser system.

RESULTS

For all Fitzpatrick skin types, treatment recommendations were described for selected approved indications for the 1,550 and 1,927 nm laser system, including both lasers in combination. Treatment recommendations were also reached for investigational applications with the 1,550 nm laser and 1,927 nm laser. Best practices for using the lasers during the treatment session to achieve optimal outcomes and decrease the post-treatment recovery time were compiled.

CONCLUSION

The 1,550 and 1,927 nm dual laser system is effective for a wide range of aesthetic and therapeutic applications, on and off the face and across all Fitzpatrick skin types.

Transdermal Delivery of Therapeutic Compounds With Nanotechnological Approaches in Psoriasis

Psoriasis is a chronic, immune-mediated skin disorder involving hyperproliferation of the keratinocytes in the epidermis. As complex as its pathophysiology, the optimal treatment for psoriasis remains unsatisfactorily addressed. Though systemic administration of biological agents has made an impressive stride in moderate-to-severe psoriasis, a considerable portion of psoriatic conditions were left unresolved, mainly due to adverse effects from systemic drug administration or insufficient drug delivery across a highly packed stratum corneum via topical therapies. Along with the advances in nanotechnologies, the incorporation of nanomaterials as topical drug carriers opens an obvious prospect for the development of antipsoriatic topicals. Hence, this review aims to distinguish the benefits and weaknesses of individual nanostructures when applied as topical antipsoriatics in preclinical psoriatic models. In view of specific features of each nanostructure, we propose that a proper combination of distinctive nanomaterials according to the physicochemical properties of loaded drugs and clinical features of psoriatic patients is becoming a promising option that potentially drives the translation of nanomaterials from bench to bedside with improved transdermal drug delivery and consequently therapeutic effects.

Dependence of laser-induced optical breakdown on skin type during 1064 nm picosecond laser treatment

The current study aims to evaluate the dependence of laser-induced optical breakdown (LIOB) on skin types by using 1064 nm picosecond laser with micro-lens arrays (MLA) and diffractive optical elements (DOE). Both black and white skin tissues were examined to comparatively assess the LIOB effects in the skin in terms of laser-induced vacuolization. The black skin irradiated at 3.0 J/cm² demonstrated that MLA yielded a deeper distribution (180-400 μm) of laser-induced vacuoles with a size of 67 μm, compared to DOE (180-280 μm; 40 μm in size). However, the white skin presented that MLA created larger vacuoles (134 μm in size) in a smaller number at deeper distributions (125-700 μm) than MLA with the black skin. DOE generated no laser-induced vacuolization in the white skin. The white skin tissue with inherent higher scattering could be responsible for deeper vacuolization after the picosecond laser treatment. Further investigations are expected to determine the optimal treatment conditions for various skin types.

Paradigms in Complex Facial Scar Management

The process of scar formation is a sequela of the healing following soft tissue injury extending to, or through, the reticular dermis. Scars, within the head and neck in particular, may be physically disfiguring with resultant psychosocial implications. Mitigation of excessive scar formation during the healing process following surgery, or in the setting of trauma, begins with meticulous soft tissue handling and reconstructive technique. The reconstructive surgeon's armamentarium must therefore include techniques that minimize initial scar formation and revision techniques that address unfavorable outcomes. With this in mind, this article reviews both conservative nonsurgical and surgical treatment modalities that mitigate scar formation or address mature scar formation.

Laser-induced optical breakdown effects of micro-lens arrays and diffractive optical elements on ex vivo porcine skin after 1064 nm picosecond laser irradiation

The current study aims to investigate the effects of micro-lens arrays (MLA) and diffractive optical elements (DOE) on skin tissue via intra-dermal laser-induced optical breakdown (LIOB) after irradiation of 1064-nm picosecond laser light at high energy settings. Irradiation with MLA and DOE was tested on dimming paper, tissue-mimicking phantom, and dark pigmented porcine skin to quantitatively compare distributions of micro-beams, micro-bubbles, and laser-induced vacuoles in the skin. DOE yielded more uniform distributions of the micro-beams on the paper and laser-induced micro-bubbles in the phantom, compared to MLA. The ex vivo skin test confirmed that the DOE-assisted irradiation accompanied more homogeneous generation of the micro-beams on the tissue surface (deviation of ≤ 3%) and a high density of small laser-induced vacuoles (∼78 µm) in the dermis than the MLA-assisted irradiation (deviation of ∼26% and ∼163 µm). The DOE-assisted picosecond laser irradiation may help to achieve deep and uniformly-generated vacuolization under the basal membrane after intra-dermal LIOB for effective fractional skin treatment.

Dermatologic Laser Side Effects and Complications: Prevention and Management

The evolution of modern laser and light-based systems has mirrored the demand for clinically effective treatments and the need for safer technologies with reduced postoperative recovery, side effects, and complications. With each new generation of lasers, more selective tissue destruction can be achieved with reduced unwanted sequelae. Patient selection and preparation, operator technique, and expeditious recognition and management of post-treatment side effects are paramount in avoiding complications and patient dissatisfaction. An overview of important variables to consider for dermatologic laser treatments are presented in order to provide a framework to reduce the severity and duration of possible post-treatment side effects and complications.

Resurfacing of Facial Acne Scars With a New Variable-Pulsed Er:YAG Laser in Fitzpatrick Skin Types IV and V

Introduction:

The Er:YAG laser, considered to be less effective than CO₂ laser in its traditional form, in its new modulated version has variable pulse technology that is claimed to be superior to the earlier versions of the laser.

Aim:

The aim of the study was to check efficacy and safety of the new variable square pulse (VSP) Er:YAG laser in the management of acne scar in patients with Fitzpatrick skin types IV and V.

Materials and Methods:

This retrospective study consisted of 80 patients (Fitzpatrick skin types IV and V) with atrophic and hypertrophic facial acne scars. Records of the patients who had undergone four treatment sessions with VSP technology equipped with Er:YAG laser were extracted. Each patient had undergone a minimum of four sessions. Fractional mode at medium laser pulse (SP) and long pulse (LP) was employed for the depressed center of the scars to stimulate neocollagenogenesis. Short laser pulse (MSP) in nonfractionated mode was used for ablating the raised scar border and hypertrophic scars. Goodman and Baron global scarring grading system was used for qualitative and quantitative assessments. Patient’s satisfaction to the treatment and observer’s assessment of improvement (based on photographs) was graded as poor (<25% improvement), fair (25–50% improvement), good (51–75% improvement), and excellent (>75% improvement).

Results:

At the end of the four sessions, the number of patients in grade IV postacne scarring reduced from 16 to 2 and that in grade III from 47 to 29. The mean score significantly dropped from 36.94 to 27.5. Subjective assessment revealed that 78 of 80 patients had noticed more than 25% improvement, with 50 of them showing more than 50% improvement at the end of four sessions. Eight patients perceived an excellent response and 42 reported a good response. This is notably higher than the observer’s grading, which showed an excellent response in only 2 patients and a good response in 35. Adverse effects were limited to prolonged erythema (two patients), prolonged crusting (one patient), and postinflammatory hyperpigmentation (one patient).

Conclusion:

Ninety-seven percent of the subjects in our study perceived at least a fair improvement. We also saw a significant change in the objective score with a fall of the mean quantitative score from 36.94 to 27.15. This underscores the new variable-pulsed Er:YAG laser’s effectiveness in the treatment of acne scars. It also has the added advantage of lesser adverse events and faster healing.

Treatment of facial photodamage and rhytides using a novel 1,565 nm non-ablative fractional erbium-doped fiber laser

BACKGROUND AND OBJECTIVE

Non-ablative fractional lasers (NAFL) generate microscopic non-contiguous columns of thermal injury in the dermis, resulting in collagen remodeling. This manuscript details our experience with a novel 1,565 nm scanned, erbium-doped fiber NAFL for the treatment of facial photodamage.

STUDY DESIGN/MATERIALS AND METHODS

A prospective, open-label clinical trial was conducted at two clinical sites in the United States on 16 female subjects with a mean age of 49.6 years, Fitzpatrick skin types II to IV, and a baseline Fitzpatrick-Goldman Wrinkle and Elastosis Score (FGWES) of 3-6. Each subject received three treatments at 4-5 week intervals with follow-up assessments at 1, 3, and 6 months after the last treatment.

RESULTS

The mean FGWES demonstrated a statistically significant decrease from baseline both at 3 months (-0.58 ± 0.23, P = 0.02) and 6 months (-0.66 ± 0.22, P = 0.008) after the last treatment. Fifty percent (95%CI [24.21%, 68.49%]) of subjects showed a significant (at least 1 grade) improvement in FGWES from baseline at 3-month follow-up. At least 72% of subjects perceived the results as "moderate" to "very good" at 3 months post-treatment, with comparable satisfaction rates. Treatments were not associated with a high level of pain or discomfort and typical downtime was less than 2 days. No unexpected adverse events or serious adverse events were reported.

CONCLUSION

The 1,565 nm erbium-doped scanned NAFL is an effective treatment for facial wrinkles with a favorable recovery and side effect profile.

Laser and energy-based devices' complications in dermatology

Laser dermatology is an ever-expanding part of the specialty used extensively for both aesthetic and medical conditions. Advances in laser technology have led to an expansion in the number of devices available, with as a consequence an increase in the total number of complications. Fortunately, the current technology has improved greatly which adds to the safety profile of such devices; nevertheless, thorough knowledge of laser complications and how to avoid them is paramount for any practitioner who uses such technology.

Laser resurfacing pearls

Ablative skin resurfacing using the carbon dioxide laser was long considered the gold standard for treatment of photoaging, acne scars, and rhytids. However, conventional full-face carbon dioxide resurfacing is associated with significant risk of side effects and a prolonged postoperative recovery period. Fractional resurfacing has recently revolutionized laser surgery by offering close to comparable results with minimal side effects and a more rapid recovery. Although fractional devices have grown in popularity, and have essentially replaced traditional resurfacing, fractional resurfacing can still be a challenging modality to control precisely due to hardware variations across comparable devices, the range of settings that can be used, and patient-specific considerations. Certain precautions and rules of thumb can reduce the risk associated with fractional resurfacing, and increase the likelihood of a good outcome.

Non-ablative fractional resurfacing in combination with topical tretinoin cream as a field treatment modality for multiple actinic keratosis: a pilot study and a review of other field treatment modalities

BACKGROUND

Actinic keratoses (AK) are premalignant lesions occurring mainly in sun-damaged skin. Current topical treatment options for AK and photo-damaged skin such as liquid nitrogen and electrosurgery are not suitable for field treatment. Otherwise, therapies suitable for field treatment bring along considerable patient discomfort. Non-ablative fractional resurfacing has emerged as a logical treatment option especially for field treatment of AK.

OBJECTIVES

To evaluate the clinical efficacy of fractional laser therapy for clearing AK and improving skin quality. To compare patient friendliness of the "fractional" therapy with those reported for other field treatment modalities.

MATERIALS & METHODS

Ten patients with Fitzpatrick skin type I to III with multiple AK and extensive sun-damaged skin, received 5-10 sessions with a 4-week interval using a 1550 nm Erbium-Glass Fractionated laser (Sellas, Korea). Four weeks and 24 weeks after the last treatment the clinical results were evaluated by an independent physician.

RESULTS

The mean degree of improvement, in terms of reduction in the number of AK and improvement of skin texture, was 54% on a 4 point PGA scale, and persisted for approximately 6 months. The biggest advantage of fractional laser treatment, besides the eradication of AK and a clear rejuvenation effect, is the absence of "downtime".

CONCLUSION

Fractional non-ablative resurfacing induces significant reduction in the number of AK and improves the skin quality. Also all patients preferred fractional laser therapy above other AK treatment modalities.

Hand rejuvenation: a review and our experience

BACKGROUND

The aged hand is characterized by cutaneous and dermal atrophy, with deep intermetacarpal spaces, prominent bones and tendons, and bulging reticular veins. Epidermal changes include solar lentigines, seborrheic keratoses, actinic keratoses, skin laxity, rhytides, tactile roughness, and telangiectasia.

STUDY DESIGN

A Medline search was performed on hand rejuvenation from 1989 to 2011, and results are summarized. Practical applications of these procedures are also discussed.

RESULTS

Reports of injectable hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, autologous fat transfer, vein treatment, and chemical peels, along with lasers and light sources such as Q-switched laser, intense pulsed light, photodynamic therapy, nonablative resurfacing lasers, and ablative resurfacing lasers, in the rejuvenation of hands were found.

CONCLUSION

Review of the literature revealed options for minimally invasive treatment for rejuvenation of the skin and volume restoration of the dorsal hand. These treatments include injectables and fat transfer for volume restoration; sclerotherapy or vein ablation for dorsal hand vein treatment; and chemical peels, lasers, light, and energies for the treatment of epidermal and dermal changes.

TUNEL assay to characterize acute histopathological injury following treatment with the active and deep FX fractional short-pulse CO2 devices

BACKGROUND

This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo.

METHODS

The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation.

RESULTS

The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column.

CONCLUSIONS

The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.

Fractionated laser skin resurfacing treatment complications: a review

BACKGROUND

Fractional photothermolysis represents a new modality of laser skin resurfacing that was developed to provide a successful clinical response while minimizing postoperative recovery and limiting treatment complications.

OBJECTIVES

To review all of the reported complications that develop as a result of fractional ablative and nonablative laser skin resurfacing.

METHODS

A literature review was based on a MEDLINE search (1998-2009) for English-language articles related to laser treatment complications and fractional skin resurfacing. Articles presenting the highest level of evidence and the most recent reports were preferentially selected.

RESULTS

Complications with fractional laser skin resurfacing represent a full spectrum of severity and can be longlasting. In general, a greater likelihood of developing post-treatment complications is seen in sensitive cutaneous areas and in patients with intrinsically darker skin phototypes or predisposing medical risk factors.

CONCLUSIONS

Although the overall rate of complications associated with fractional laser skin resurfacing is much lower than with traditional ablative techniques, recent reports suggest that serious complications can develop. An appreciation of all of the complications associated with fractional laser skin resurfacing is important, especially given that many of them can be potentially prevented. The authors have indicated no significant interest with commercial supporters.

Fractional laser photothermolysis for treatment of facial wrinkles in Asians

Purpose

To evaluate the safety and efficacy of fractional photothermolysis (FP) in the treatment of facial wrinkles in Asians.

Methods

A total of 27 Korean patients (Fitzpatrick type III or IV) received 2-3 FP treatment sessions (Sellas; Dinona Inc., Seoul, Korea) spaced two weeks apart. Treatments were performed at settings of 7 to 9 mJ/microthermal treatment zone (MTZ) and a density of 1000 MTZ/cm². Standardized digital photographs were obtained before each treatment and three months after the final treatment. The evaluations of clinical photographs were performed by three physicians blinded to the study subjects using a five-point grading scale. In addition, the patients' perceived degree of improvement was assessed three months after the final treatment using a five-point grading scale. Side effects were monitored at each follow-up visit.

Results

The physicians' assessed degrees of improvement were excellent in three patients (12%), significant in ten (40%), and moderate in seven (28%). The patients' self-assessed degrees of improvement were excellent in five patients (20%), significant in 11 (44%), and moderate in six (24%). Adverse events were limited to transient pain, erythema and edema, except in one case of transient postinflammatory hyperpigmentation.

Conclusions

FP is an effective treatment modality for reducing facial wrinkles with minimal side effects in Asian patients.

Optimal treatments for hyperpigmentation

The current treatment of hyperpigmentation relies on multiple modalities to achieve satisfactory cosmetic results. Patients are savvy consumers who often present to physicians asking about the latest treatments and breakthroughs. By combining topical bleaching agents, chemical peels, laser therapy, and adequate photo-protection, many pigmentary disorders can be successfully treated. A review of recent trials and new technologies will be discussed.

Fractional photothermolysis for the treatment of telangiectatic matting: A case report

BACKGROUND

Recent reports have demonstrated clinical and histologic evidence of the potential benefit of fractional photothermolysis (1550 nm Fraxel SR laser) for the treatment of dermal vascular lesions. This report evaluated the potential efficacy of fractional photothermolysis for the treatment of matted telangiectasias.

METHODS

A 62-year-old female, Fitzpatrick skin type III, with matted telangiectasias on her right medial thigh underwent five successive treatments at monthly intervals with the 1550 nm Fraxel SR laser. Digital photographs were taken prior to each treatment and at 6 months after the last treatment. Clinical assessments were performed by a non-treating physician.

RESULTS

Clinical assessment 6 months after the last treatment with the Fraxel SR laser revealed marked improvement in the clinical appearance of the matted telangiectasias. The patient's degree of satisfaction paralleled the physician's assessment of improvement. Side effects were limited to mild pain during treatment and mild, transient post-treatment erythema and edema.

CONCLUSION

Fractional photothermolysis is a potentially effective modality for the treatment of matted telangiectasias and warrants further studies. No long-term adverse events were noted and the safety profile appears to be fairly broad.

Fractionated mid-infrared resurfacing

Fractional resurfacing devices thermally alter microscopic treatment columns in the skin, leaving intervening areas between the columns untouched. Because only a fraction of the skin is being modified, untreated areas are able to rapidly repopulate the treatment columns to greatly reduce recovery time and adverse events. Mid-infrared fractional systems have shown improvement in treating photoaging, scars, rhytides, dyschromia, and textural disorders. An additional advantage is that they are safe and effective for the treatment of nonfacial areas such as the neck, chest, and extremities.

Low density, non-ablative fractional CO2 laser rejuvenation

BACKGROUND AND OBJECTIVES

Fractional skin rejuvenation has gained increased interest since its introduction in 2003. Both non-ablative and ablative lasers as well as different treatment techniques have been devised. Recent clinical studies indicate that a paradigm of low spot density combined with high fluences tend to produce better clinical results and less risk of post-inflammatory hyperpigmentation in darker skin types. The present study is focused on investigations of the clinical outcome by non-ablative fractional CO(2) treatments with a single pass with low spot density.

METHODS AND MATERIALS

A CO(2) laser was equipped with a scanner enabling it to perform fractional treatments with 36, 64 or 100 microthermal zones (MTZ)/cm(2). Twelve patients participated in the study. The perioral area was treated three times with 1-month intervals using a spot density of 64 MTZ/cm(2), a spot diameter of 0.5 mm, a micro-beam energy of 36-60 mJ, and a pulse duration of 3-5 milliseconds. Follow-up was performed 3 months after the last treatment.

RESULTS

At the 3-month follow-up 72.7% of the volunteers had obtained improvement in ultrasonographically determined dermal density, and the average improvement was 40.2% (SD: 48.0%). This improvement was statistically significant (P<0.006). Eighty percent of the volunteers rated the reduction in visible perioral wrinkles to be fair, good or excellent. For reduction of irregular pigmentation, fair, good or excellent clearance was reported by 62.5% of the volunteers.

CONCLUSIONS

The present study demonstrates subjective improvements in wrinkles, skin texture and mottled pigmentation as well as statistically significant objectively measured improvements in ultrasonographical dermal density after three non-ablative fractional CO(2) laser treatments.