Autologous Nanofat Injection Combined with Fractional CO2 Laser in the Treatment of Atrophic Acne Scars

Background

Atrophic acne scarring is a widely prevalent condition and one of the most distressing complications of acne vulgaris. Numerous options with variable outcomes are available for the treatment of acne scarring. Laser is considered a first-line therapy for acne scars, and recently there has been a growing interest in using stem cells and their derivatives for treating acne scars. In addition, combined therapeutic modalities often achieve more satisfactory results than a single treatment.

Objective

We tried to evaluate the role of nanofat and fractional CO2 laser as a combined treatment approach for atrophic acne scarring.

Methods

Twenty-five patients with atrophic acne scarring were enrolled. They received a single session of intradermal nanofat injection, at different points 1 cm apart, for acne scars. Two weeks later, they were treated with three sessions of fractional CO2 laser at monthly intervals. Patients were evaluated three months after the last session using the quantitative Goodman and Baron scoring system. Pain, side effects, and patients' satisfaction were also evaluated.

Results

There were two males and 23 females with a mean age of 25.96 years. Their skin type ranged between Fitzpatrick skin type III, IV, and V. Boxcar scars were the most common scar type in 13 patients (52%). After treatment, there was a significant reduction (p <0.05) in the quantitative Goodman and Baron scores. The improvement was more evident in rolling scars. Seven patients reported significant improvement, and 12 reported marked improvement.

Conclusion

This study showed that combining nanofat and fractional CO2 laser is a safe and effective treatment modality for atrophic acne scars.

Fractional CO2 Laser for Vulvar Tissue Rejuvenation: A Prospective Study

Objective: Aging and changes in hormone levels influence the appearance of the vulva, including the texture, pigmentation, and other manifestations, all of which may largely affect the physical and mental health of women. This study aimed to evaluate the efficacy and safety of fractional carbon dioxide (CO2) laser treatment for vulvar rejuvenation in Chinese women. Background: The limited options currently available for vulvar rejuvenation raise concerns. There is insufficient evidence to determine whether the fractional CO2 laser can safely and effectively rejuvenate the vulvar area for women of various ages and races. Methods: The study included 17 patients (mean age = 36.4 years) treated three times by continuous fractional CO2 laser with an interval of 1 month between each session. The primary outcomes were changes in vulva texture and pigmentation. Treatment was evaluated using images of the patients. Baseline and posttreatment images were collected and evaluated using a scoring system from 0 to 3 to grade the vulvar texture and pigmentation changes. In addition, patients rated their degree of vaginal rejuvenation after the treatment using a scoring system from 0 to 3. Results: Fractional CO2 laser treatment effectively and significantly increased vulvar texture and decreased vulvar pigmentation after three sessions (p < 0.05). Patients also self-reported noticeable improvement. There were no adverse reactions during the treatment and follow-up. Conclusions: Fractional CO2 laser treatment is a safe and effective method for vulvar rejuvenation in women.

Novel 40 µm spot size 3050/3200 nm DFG laser versus CO2 laser for laser-assisted drug delivery

BACKGROUND AND OBJECTIVES

The use of ablative fractional lasers to enhance the delivery of topical drugs through the skin is known as laser-assisted drug delivery. Here, we compare a novel 3050/3200 nm difference frequency generation (DFG) fiber laser (spot size: 40 µm) to a commercially used CO2 laser (spot size: 120 µm). The objective is to determine whether differences in spot size and coagulation zone (CZ) thickness influence drug uptake.

MATERIALS AND METHODS

Fractional ablation was performed on ex-vivo human abdominal skin with the DFG (5 mJ) and CO2 (12 mJ) lasers to generate 680 µm deep lesions. To evaluate drug delivery, 30 kDa encapsulated fluorescent dye was topically applied to the skin and histologically analyzed at skin depths of 100, 140, 200, 400, and 600 µm. Additionally, transcutaneous permeation of encapsulated and 350 Da nonencapsulated dye was assessed using Franz Cells.

RESULTS

The DFG laser generated smaller channels (diameter: 56.5 µm) with thinner CZs (thickness: 22.4 µm) than the CO2 laser (diameter: 75.9 µm, thickness: 66.8 µm). The DFG laser treated group exhibited significantly higher encapsulated dye total fluorescence intensities after 3 h compared to the CO2 laser treated group across all skin depths (p < 0.001). Permeation of nonencapsulated dye was also higher in the DFG laser treated group vs the CO2 laser treated group after 48 h (p < 0.0001), while encapsulated dye was not detected in any group.

CONCLUSION

The DFG laser treated skin exhibited significantly higher total fluorescence uptake compared to the CO2 laser. Additionally, the smaller spot size and thinner CZ of the DFG laser could result in faster wound healing and reduced adverse effects while delivering similar or greater amount of topically applied drugs.

Management of the refractory vitiligo patient: current therapeutic strategies and future options

Vitiligo is an autoimmune disease that leads to disfiguring depigmented lesions of skin and mucosa. Although effective treatments are available for vitiligo, there are still some patients with poor responses to conventional treatment. Refractory vitiligo lesions are mostly located on exposed sites such as acral sites and lips, leading to significant life stress. Understanding the causes of refractory vitiligo and developing targeted treatments are essential to enhance vitiligo outcomes. In this review, we summarized recent treatment approaches and some potential methods for refractory vitiligo. Janus kinase inhibitors have shown efficacy in refractory vitiligo. A variety of surgical interventions and fractional carbon dioxide laser have been widely applied to combination therapies. Furthermore, melanocyte regeneration and activation therapies are potentially effective strategies. Patients with refractory vitiligo should be referred to psychological monitoring and interventions to reduce the potential pathogenic effects of chronic stress. Finally, methods for depigmentation and camouflage may be beneficial in achieving uniform skin color and improved quality of life. Our ultimate focus is to provide alternative options for refractory vitiligo and to bring inspiration to future research.

Split-face study to evaluate efficacy of global cryomodulation for reduction of pain and inflammation after nonablative fractional resurfacing

OBJECTIVES

Cryomodulation, or the delivery of controlled cooling to downregulate inflammatory processes in the skin, has been proposed to mitigate acute side effects following various dermatologic treatments. A new controlled cooling device has been developed to deliver cryomodulation for a range of different indications. In this clinical study, we evaluate the device for the reduction of pain, erythema, and edema following nonablative fractional resurfacing (NAFR).

METHODS

A single-blind, prospective, randomized, split-face study was conducted to assess the efficacy of the controlled dermal cooling device for the reduction of pain, edema, and erythema following nonablative fractional resurfacing with the dual 1550 nm erbium-doped fiber and 1927 nm thulium fiber laser. Subjects were randomized to receive a 10-min controlled cooling treatment to either the left or right side of the face immediately following full face NAFR. Pain ratings were recorded immediately postlaser treatment and immediately postcryomodulation treatment. At follow-up, subjects were surveyed for reduction of side effects and treatment satisfaction. Blinded review of photographs by two physicians was conducted to assess efficacy.

RESULTS

The average pain score for subjects immediately post-NAFR was 5.15. Following cryomodulation, the average pain score on the treatment side was reduced by 69%, to an average of 1.6. The untreated side of the face was reduced by 19%, to an average of 4.2. Overall, 90% of subjects endorsed reduced discomfort. At follow-up, 70% of subjects reported a noticeable improvement in edema and 50% reported a noticeable improvement in erythema between the treatment and control sides. The average subject satisfaction score for the cryomodulation treatment was 4.2. All subjects (100%) indicated that they would elect to undergo the cryomodulation treatment again. Both blinded physician reviewers were successful in identifying the cryomodulation-treated side of the face in 70% of subjects' posttreatment photographs.

CONCLUSIONS

The results of this split-face study support the efficacy of a global cryomodulation device for the reduction of pain, edema, and erythema following NAFR treatment. Cryomodulation was delivered in a simple 10 min procedure and yielded high patient satisfaction.

Single-center real-world treatment outcomes of ablative fractional laser-assisted photodynamic therapy for actinic keratosis

BACKGROUND

Among various treatment modalities of actinic keratosis (AK), ablative fractional laser-assisted photodynamic therapy (fractional PDT) has shown higher efficacy despite shorter incubation time. However, there are lack of real-world studies on the therapeutic response of ablative PDT for AK and the factors that can predict the therapeutic response.

PURPOSE

The aim of this study was to analyze the association between clinical characteristics and treatment outcomes of fractional PDT.

METHODS

One hundred fifty-six patients who were histologically diagnosed with AK and treated with fractional PDT were retrospectively reviewed. The Kruskal-Wallis test was used to compare treatment session differences according to grades.

RESULTS

In multivariate analysis, the grade 2 category tended to be more clinically nonresponders than the grade 1 (OR, 5.17; 95% CI, 1.011-26.439; p = .048) and the group treated four or more times with ablative fractional laser-assisted PDT were more likely to show no response compared with the single treatment session group (OR, 8.78; 95% CI, 1.355-56.874; p = .023). Treatment sessions were significantly lower in grade 1 (1.72 ± 0.63, mean ± SD) when compared to grades 2 and 3, respectively (2.17 ± 0.76; 2.60 ± 1.60, mean ± SD). Recurrence was highest in grade 2, and most of them occurred after 1 year.

CONCLUSION

On average, two treatment sessions are sufficient for AK lesions, but the thicker the lesion, the more treatment sessions may be required. Although there are relatively smaller number of grade 3 patients were included, recurrence was more frequent in higher grade of AK category, which needs special attention to thicker lesions.

The comparison of the efficacy and safety of fractional 1064 nm Nd:YAG picosecond laser and nonablative fractional 1565 nm laser in the treatment of enlarged pores: A prospective split-face study

BACKGROUND AND OBJECTIVES

To compare the efficacy and safety of fractional 1064 nm Nd:YAG picosecond laser and nonablative fractional 1565 nm laser in the treatment of enlarged pores.

STUDY DESIGN/MATERIALS AND METHODS

Twenty patients received five monthly treatments at months 0, 1, 2, 3, and 4 and were followed up at months 5, 6, and 7. All patients were treated by fractional 1064 nm Nd:YAG picosecond laser (FxPico) on the left face, and nonablative fractional 1565 nm laser (ResurFx) on the right face as a control.

RESULTS

For the 19 patients who completed the study, both sides demonstrated significant improvement on pore counts (p < 0.01), while there was no significant difference between the two sides 3 months after the final treatment (p = 0.092). Excellence rate on the FxPico side (57.9%) was significantly better than the ResurFx side (36.8%) (p < 0.05). Sebum secretion and porphyrin value significantly decreased on both sides after five treatments and there was a higher reduction of sebum level on the ResurFx side. There was no difference between the two therapies in terms of overall satisfaction. Pain of treatment for the ResurFx side (average VAS 4.45 ± 1.60) is significantly higher than that for the FxPico side (average visual analog scale [VAS] 1.48 ± 1.36) (p < 0.001). Erythema, edema, and petechiae were common adverse effects and were mild to moderate. There was significantly higher incidence of hyperpigmentation for the ResurFx side (52.6%) compared with that for the FxPico side (5.3%) (p < 0.001).

CONCLUSION

Fractional 1064 nm Nd:YAG picosecond laser and nonablative fractional 1565 nm laser both are effective, efficient, and safe treatment regimens for enlarged pores, while fractional 1064 nm Nd:YAG picosecond laser has better clinical response with less treatment pain, shorter recovery period and much lower induction of hyperpigmentation.

Effect of fractional laser alone or in combination on alopecia areata: A systematic review and meta-analysis

BACKGROUND

Alopecia areata (AA) is characterized by limited non-scarring patchy alopecia, which appears as round or oval patches and is prone to recurrence, causing severe psychological burdens to patients. No specific device has been approved by the FDA for the treatment of baldness, but new treatments are being investigated and treatments such as the excimer laser, He- Ne laser, and excimer lamp have been proposed. A growing number of studies have found that fractional lasers also have great potential in the treatment of AA.

METHODS

A literature search and meta-analysis using Review Manager 5.4 software to investigate the efficacy of fractional laser treatment for AA.

RESULTS

Fractional laser combined with minoxidil (RR 1.32, 95% CI 1.17-1.49, p < 0.00001) or cortisol (RR 1.39, 95% CI 1.15-1.67, p = 0.00006) was more effective than either drug alone in the treatment of AA. Of course, the fractional laser alone was also effective in the treatment of AA (RR 10.33, 95% CI 2.07-51.36, p = 0.004) and more effective than cortisol alone (RR 1.86, 95% CI 1.36-2.52, p < 0.00001), and there was no effect on the occurrence of adverse effects (p = 0.49 > 0.05). When compared to other physical treatments of a comparable kind, fractional laser therapy's effectiveness was not significantly different (p = 0.15 > 0.05).

CONCLUSION

Our results show that the use of fractional lasers can effectively treat alopecia areata.

Fetal Fibroblast Transplantation via Ablative Fractional Laser Irradiation Reduces Scarring

Scar treatments include fractional laser treatment, cell transplantation, surgery, skin needling, and dermal fillers. Fractional laser treatments are used to reduce scarring and blurring. Cell transplantation is promising, with mature fibroblasts and adipose-derived stem cells being used clinically, while embryonic fibroblasts are used experimentally. Herein, we developed a combination of ablative CO₂ (carbon dioxide) fractional laser and cell transplantation for the treatment of scars. Eight-week-old male C57Bl/6 mice were used to create a full-layer skin defect in the back skin and create scars. The scar was then irradiated using a CO₂ fractional laser. The cells were then transplanted onto the scar surface and sealed with a film agent. The transplanted cells were GFP-positive murine fetal fibroblasts (FB), fetal fibroblasts with a long-term sphere-forming culture (LS), and fetal skin with a short-term sphere-forming culture (SS). After transplantation, green fluorescent protein (GFP)-positive cells were scattered in the dermal papillary layer and subcutis in all the groups. LS significantly reduced the degree of scarring, which was closest to normal skin. In conclusion, the combination of ablative fractional laser irradiation and fetal fibroblast transplantation allowed us to develop new methods for scar treatment.

Evaluation of the safety and efficacy of a fractional picosecond 1064 nm laser for post-acne erythema in adult Chinese patients

OBJECTIVE

To evaluate the efficacy and safety of fractional 1064 nm picosecond Nd:YAG laser (FPNYL) in the treatment of post-acne erythema (PAE) of adult Chinese.

MATERIALS AND METHODS

A total of 22 patients received 1 session of treatment and were followed up at the eighth week. Primary outcomes were measured by the Clinician erythema assessment scale (CEAS). Secondary outcomes included a global aesthetic improvement scale (GAIS) and patients' assessment of satisfaction on a five-point scale. Pain scores and adverse effects were also evaluated.

RESULTS

Twenty-two patients with Fitzpatrick skin types III and IV were enrolled in the study and completed all treatments and follow-up visits. The mean CEAS scores fell from 2.74 ± 0.80 to 1.95 ± 0.75 (p < 0.05). The mean GAIS of PAE improvement was 2.46 ± 0.68. Erythema percentile scores by VISIA increased from 32.63 ± 7.0 to 45.75 ± 11.45 (t = 5.442, p = 0). The patient satisfaction score was 1.86 ± 1.17. The pain scores were 3.27 ± 1.17 for the FPNYL treatment (varied from 2 to 6). There were moderate erythema and oedema, which last for 3.84 ± 0.78 days. There were overall 68.18% (15/22) patients who felt pruritus in different degrees and 27.27% patients who encountered acne eruptions (white head type). No scar, hyperpigmentation or hypopigmentation was found.

CONCLUSION

Treatment with fractional 1064 nm picosecond Nd:YAG laser is effective and safe for PAE of Chinese patients.

Comparative study between topical application of triamcinolone acetonide after fractional carbon dioxide laser versus microneedling in the treatment of resistant alopecia areata

Alopecia areata (AA) is a disease that affects the psychological well-being of the affected individuals. Laser-assisted drug delivery and microneedling (MN) are promising methods for the treatment of different dermatological diseases. The aim of the study was to compare the efficacy of topical application of triamcinolone acetonide after fractional carbon dioxide laser versus MN in the treatment of resistant AA from a clinical and dermoscopic perspective. Thirty patients were randomly divided into two groups of 15 patients each: the Laser group received fractional CO₂ laser treatment followed by topical application of triamcinolone acetonide, and the MN group received dermapen treatment followed by topical application of triamcinolone acetonide. In our study, we found no statistically significant difference between the studied groups before and after treatment, except for black dot, which is higher in the MN group than in the laser group (46.7% vs. 13.3%). There is a statistically significant difference between the studied groups in terms of treatment response at the first follow-up, with 13.3% of the laser group seeing terminal hair regrowth compared to 0 in the MN group after 12 weeks. Regarding the degree of improvement, there was no statistically significant difference between the laser group and the MN group. The use of fractional CO₂ laser and MN for transepidermal drug delivery (TED) allowed for more uniform drug distribution. There was no significant difference between the two treatment methods in terms of their high effectiveness in the treatment of resistant AA.

The efficacy and safety of fractional lasers for alopecia in mono and adjunctive therapy: A systematic review and meta-analysis

BACKGROUND

Hair loss is affecting over half of the population worldwide, leading to noticeable psychotic disorders in a considerable proportion of patients. The current treatments remain unpredictable and disappointing.

OBJECTIVE

This study aimed to evaluate the efficacy and safety of fractional lasers compared with other conventional treatments as either mono or combined therapy in the treatment of alopecia.

METHODS

We have conducted a thorough literature search in PubMed, Web of Science, Embase, Cochrane library, and China national knowledge infrastructure databases (from inception to February 9, 2022). Relevant clinical trials, mainly randomized controlled trials, were included, regardless of their comparisons. The Cochrane risk of bias assessment was used for quality appraisal. Outcomes were evaluated by efficiency rate, hair density, etc. RESULTS: Thirteen controlled clinical trials, including nine randomized controlled trials, with 606 patients were retrieved. As an individual therapy, the fractional laser is superior to any other therapy in total efficiency (RR = 1.58, 95% CI: 1.16-2.14, p = 0.003). When the fractional laser was applied in combined treatments, the result showed a significant difference (RR = 1.23, 95%CI: 1.02 to 1.49, P = 0.03) compared with other treatments. Although both mono and adjunctive groups were confirmed to be efficient, there were no statistical differences between the two of them (RR = 1.24, 95% CI: 0.87-1.77, p = 0.24).

CONCLUSION

Our results showed that the fractional laser has a significant efficacy as either mono or adjuvant therapy. Further research and exploration of fractional lasers with larger sample sizes are required to confirm the efficiency and safety of this treatment.

Non-ablative laser treatment improves lip volume, texture, and color

Lips undergo several changes with age, decreased volume, elasticity, turgor, and collagen content. Q-switched Nd:YAG laser are known to increase the production of procollagen and elastin and can promote the generation of collagen, which visibly improves facial imperfections. We aimed to determine the efficacy of a 1064 nm Q-switched Nd:YAG fractional laser on improving lip definition, color, and volume. 32 female patients were treated every 2-3 weeks for a total of 3-5 treatments. Improvement was measured in a follow-up visit a month after the final treatment (29.9 ± 1.4 days) by patients' self-satisfaction questionnaire and physicians blinded evaluations (Likert scale). Patients achieved meaningful aesthetic improvement in in lip color (94% of patients), volume (72%), texture (91%), and overall lip appearance (82%). Furthermore, 91% were satisfied with treatment results and 100% from the overall experience. There were no associated side effects, and the associated pain level (on a 0-10 scale) was rated as 0 in 84% of individuals and 16% as 1. Therefore, laser treatment using a 1064 nm Q-switched Nd:YAG fractional laser on lips is a safe, noninvasive treatment that increases the color and volume of lips, with results that are maintained for at least one month following treatments.

Factors affecting the outcome of fractional carbon dioxide laser resurfacing of various types of scars in skin of color

BACKGROUND

Fractional laser resurfacing has been used widely in management of scars. However, data for post-traumatic and post-burn scar are limited in skin of color.

AIMS

This retrospective study assessed the efficacy of fractional ablative carbon dioxide laser in treatment of various types of scars other than acne scars. We also tried to find out the effect of different factors like skin type, duration, shape, location, and color of the scars on the outcome.

MATERIALS AND METHODS

Forty-two patients with 67 scars including post-traumatic (43), post-burn (15), post-surgical (5), and post-folliculitis (5) scars treated during 2019-2020 were analyzed. The improvement was graded according to investigator and patient global assessment (IGA & PGA) through percentage improvement and quartile scale.

RESULTS

Overall, there was 45.4% and 32.7% of improvement according to PGA and IGA, respectively. Scars with >50% improvement were recorded in 13.43% of the scars with IGA and 41.78% with PGA. Early scars, scars without hyperpigmentation, lighter skin type, post-traumatic scars had better results. There was no significant difference for other parameters like atrophic versus hypertrophic, facial versus extra facial, linear versus non-linear, or the number of sessions.

CONCLUSION

Fractional carbon dioxide laser efficacious for non-acne facial and extra facial scars in the skin of color. Early intervention could yield more satisfactory results.

From the Cochrane Library: Interventions for Acne Scars

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Assessment of a 3050/3200 nm fiber laser system for ablative fractional laser treatments in dermatology

Background and Objectives

Mid‐infrared (IR) ablative fractional laser treatments are highly efficacious for improving the appearance of a variety of dermatological conditions such as photo‐aged skin. However, articulated arms are necessary to transmit the mid‐IR light to the skin, which restricts practicality and clinical use. Here, we have assessed and characterized a novel fiber laser‐pumped difference frequency generation (DFG) system that generates ablative fractional lesions and compared it to clinically and commercially available thulium fiber, Erbium:YAG (Er:YAG), and CO₂ lasers.

Materials and Methods

An investigational 20 W, 3050/3200 nm fiber laser pumped DFG system with a focused spot size of 91 µm was used to generate microscopic ablation arrays in ex vivo human skin. Several pulse energies (10–70 mJ) and pulse durations (2–14 ms) were applied and lesion dimensions were assessed histologically using nitro‐blue tetrazolium chloride stain. Ablation depths and coagulative thermal damage zones were analyzed across three additional laser systems.

Results

The investigational DFG system‐generated deep (>2 mm depth) and narrow (<100 µm diameter) ablative lesions surrounded by thermal coagulative zones of at least 20 µm thickness compared to 13, 40, and 320 µm by the Er:YAG, CO₂, and Thulium laser, respectively.

Conclusion

The DFG system is a small footprint device that offers a flexible fiber delivery system for ablative fractional laser treatments, thereby overcoming the requirement of an articulated arm in current commercially available ablative lasers. The depth and width of the ablated microcolumns and the extent of surrounding coagulation can be controlled; this concept can be used to design new treatment procedures for specific indications. Clinical improvements and safety are not the subject of this study and need to be explored with in vivo clinical studies.

A Combination of Non-ablative Laser and Hyaluronic Acid Injectable for Postacne Scars: A Novel Treatment Protocol

BACKGROUND

Postacne facial scars are often associated with significant patient distress. Energy-based devices, including non-ablative lasers, are commonly used for the treatment of postacne scarring. There is relatively limited data regarding the combination of non-ablative lasers with hyaluronic acid injections for postacne scarring.

OBJECTIVE

We aimed to evaluate the efficacy of a non-ablative 1,540-nm erbium:glass laser combined with a hyaluronic acid injectable for the treatment of postacne scars.

METHODS

This was a retrospective analysis of 12 patients who underwent the full treatment protocol. A before and after blinded clinical evaluation was performed independently by two dermatologists and graded on a scale from 0 (indicating a worsening of scarring) to 4 (indicating a 76-100% improvement in scarring). Pain perception, adverse effects, and patient satisfaction were evaluated.

RESULTS

A mean correct blinded before and after evaluation by two dermatologists was 96 percent. Patients demonstrated mild to moderate improvement as assessed by a quartile scale of improvement (25-50%). Mild transient pain was reported by most patients. The satisfaction level of the patients was high (4 out of 5).

LIMITATIONS

The limitations of our study include the small cohort, retrospective design, and lack of a histological correlation.

CONCLUSION

Our results suggest that this combination treatment using 1,540-nm fractional erbium:glass laser and hyaluronic acid injections is both safe and effective for patients with postacne facial scars.

Fractional laser-assisted administration of human umbilical cord mesenchymal stem cells to reduce hypertrophic scars in rabbit ears

BACKGROUND

The formation of hypertrophic scar is due to the abnormal accumulation and remodeling of the extracellular matrix, especially collagen tissue. Our research was designed to investigate the treatment effect of different administrations of human umbilical cord-derived stem cells and to hypertrophic scars on rabbit ears.

METHODS

Thirty New Zealand female white rabbits were treated as hypertrophic scar models. PBS was injected into the scars on the right ear of each group as control, while human umbilical cord-derived stem cells or condition medium of human umbilical cord-derived stem cells were administrated into the left ear through subcutaneous injection or fractional laser-assisted administration. Gross examination, scar elevation index (SEI) calculation and sampling were executed 5 weeks after administration. Then H&E and Masson staining analysis and the expression levels detections of α-SMA, Collagen I, TGF-β1, IL-1β, and IL-6 were performed.

RESULTS

Our results demonstrated that the severity of hyperplasia was lower than the model group after stem cells and conditioned medium treatment. H&E and Masson staining results showed that the inflammation in scars was greatly alleviated and the degree of fibrosis was reduced after treatment. There was no significant difference in the therapeutic effect between subcutaneous injection or fractional laser-assisted administration. Both stem cells and conditioned medium can down-regulate SEI and factors expression levels in all groups. However, compared with the stem cells, the therapeutic effects of the conditioned medium were lower.

CONCLUSIONS

The results confirmed that stem cells had an available treatment effect on hypertrophic scars of rabbit ears. In addition to the paracrine pathway, stem cells may have other ways to treat hypertrophic scars. Fractional laser-assisted administration may become a potential administration of stem cell clinical application in the future.

Clinical efficacy of different therapeutic modes of CO2 fractional laser for treatment of static periocular wrinkles in Asian skin

BACKGROUND

Periocular fine lines and wrinkles usually appear as a first visible sign of facial aging. Fractional ablative laser has been used to treat periorbital wrinkles.

OBJECTIVE

To compare the efficacy on treatment of static periorbital wrinkles using different emission modes of CO₂ fractional laser.

METHODS

A total of 30 patients with static periorbital wrinkles were enrolled. The subjects were randomly assigned into two split-face groups: One side was treated with a deep (n = 15) or mid-mode of CO₂  superficial laser (n = 15), and the other side of periocular region was treated by a fusion mode in combination of both modes (n = 30).

RESULTS

The patients in three groups showed significant improvements on indexes of periocular wrinkles, skin textures, and elasticity at three-month follow-up as compared with baseline (p < 0.05). Fusion mode resulted in a significantly progressive improvement on periocular wrinkles at three-month follow-up as compared with one-month follow-up (p < 0.05), which were not observed in other modes. Fusion mode delivered better improvements of periocular wrinkles and skin textures as compared to deep and mid-modes at three-month follow-up (p < 0.05). Fusion mode also resulted in better scores of global esthetic improvement scale and patient satisfaction as compared to other modes at both follow-ups.

CONCLUSION

The fusion mode has a synergistic effect in periorbital static wrinkle treatment, which is worthy of further evaluation and investigation.

Fractional carbon dioxide laser versus carbon-assisted Q-switched Nd: YAG laser in the treatment of dilated facial pores

BACKGROUND

The treatment of dilated facial pores is difficult, and the ideal modality is not established yet. Different ablative and nonablative lasers have been used in the treatment of dilated pores with variable outcomes.

AIM

To evaluate and compare the efficacy of fractional CO2 laser versus carbon-assisted Q-switched Nd: YAG laser in dilated facial pores.

METHODS

The study included 80 patients with dilated pores divided into two groups each containing 40 patients. Group (A) had fractional CO2 laser treatment, and group (B) received Q-switched Nd: YAG laser treatment after the application of a carbon solution on the face. The treatment was repeated monthly for a total of 3 sessions. Objective and subjective assessments of the clinical outcome were performed.

RESULTS

Both modalities significantly improved the dilated pores; however, the clinical response was statistically higher and the improvement was maintained for a longer duration of time in the factional laser group compared with the carbon-assisted Q-switched Nd: YAG laser group (p = 0.01). The downtime was significantly lower in the Q-switched Nd: YAG laser group, and the patients' satisfaction rates were comparable in both groups.

CONCLUSION

The two laser systems appear to be effective, safe, and well-tolerated in the treatment of dilated pores. The fractional CO2 laser was associated with a significantly higher and more prolonged clinical response.

The Efficacy and Safety of Fractional 1064 nm Nd:YAG Picosecond Laser Combined With Intense Pulsed Light in the Treatment of Atrophic Acne Scar: A Split-Face Study

BACKGROUND AND OBJECTIVES

To evaluate the efficacy and safety of fractional 1064 nm Nd:YAG picosecond laser combined with intense pulsed light (IPL) in the treatment of atrophic acne scar with post-inflammatory erythema (PIE). © 2021 Wiley Periodicals LLC.

STUDY DESIGN/MATERIALS AND METHODS

Seventeen patients received five sessions of treatment at weeks 0, 4, 8, 12, 16 and were followed up at week 28. One half of the face was randomly treated by fractional 1064 nm Nd:YAG picosecond laser combined with IPL (FxPico + IPL), and the other by IPL alone as a control.

RESULTS

For the 15 patients who completed the study, the FxPico + IPL side demonstrated significant median Échelle D'évaluation clinique des cicatrices D'acné (ECCA) score improvement (P < 0.01), while IPL alone side did not (P = 0.1250). The pore counts for both sides decreased but more pore count reduction was seen on the FxPico + IPL side (P < 0.05). Better scar improvement was observed on the FxPico + IPL-treated side (P < 0.05) while no difference in erythema improvement was seen between the two sides. There was no difference between the two treatments in terms of overall satisfaction. Pain, erythema, edema, petechiae, crusting, reactive acneiform eruptions, and pruritus were common adverse effects and were mild to moderate.

CONCLUSION

FxPico + IPL is an effective, efficient, and safe treatment regimen for atrophic acne scars complicated by PIE.

Fractional 1064 nm picosecond laser and skin photoaging: in vivo evaluation of treatment effects with reflectance confocal microscopy

Few studies showed the role of picosecond laser (PLS) in the treatment of skin photoaging signs. However, no studies have explored the microscopic effects of PSL in photoaging. The aim of this study is to preliminarily identify clinical variations induced by a 1,064 nm Nd:YAG PSL on the décolleté area, then to apply the treatment protocol to treat facial photoaging and estimate the clinical and microscopic outcomes. A total of 10 consecutive patients with cutaneous photoaging were enrolled. Patients were treated 3 times at monthly intervals with the fractionated 1,064 nm Nd:YAG PSL. In a preliminary phase, PSL treatment was performed on the décolleté to establish its efficacy and safety. Then, the same treatment protocol was applied to all the face and clinical and reflectance confocal microscopy (RCM) were analyzed, comparing baseline (T0) pictures and 4 months after the treatment (T1) ones. On the face, a reduction of dyschromia and wrinkles was observed at T1. Furthermore, the underlying RCM variations were revealed at different skin levels. Our results show the clinical and microscopic effectiveness and safety of the 1,064-nm Nd:YAG PSL in the treatment of skin photoaging signs.

Fractional Carbon Dioxide Laser Versus Carboxytherapy in Treatment of Striae Distensae

BACKGROUND AND OBJECTIVES

The aim of this study was to compare the efficacy and safety of fractional carbon dioxide (CO₂ ) laser versus carboxytherapy in treatment of striae distensae.

STUDY DESIGN/MATERIALS AND METHODS

This study was conducted on forty female patients with striae distensae on the abdomen. Patients were selected and divided randomly into two matched groups; group I was treated with fractional CO₂ laser resurfacing and group II with carboxytherapy. Assessment and evaluation of the results were done by comparing photographs and the Global Aesthetic Improvement Scale (GAIS).

RESULTS

Pregnancy, obesity, and long-term steroid use were the most common causes of striae in both groups. Both groups showed a statistically significant improvement in both the width and length of striae with no statistically significant difference between them. Patients' satisfaction was comparable in both groups. Pain and post-inflammatory hyperpigmentation were the two most common side effects in group I while bruising at the injection site was the most common in group II.

CONCLUSIONS

Both modalities could be effective in management of striae distensae. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Self-limited acne agminate-like granulomatous reaction to facial laser rejuvenation in a patient with comedonal acne vulgaris

Minimally invasive fractional rejuvenation was developed to overcome the drawbacks of the traditional ablative laser. The Fotona 4D laser is one of these lasers used for face lifting. This laser uses two wavelengths such as Nd-YAG 1064 and Er-YAG 2940 nm in four different modes of non-ablative and ablative fractional laser to induce bulk heating in different tissue layers of facial skin. Although the overall rate of fractional laser complications is much lower than that of traditional techniques, recent studies have shown that fractional lasers can cause complications such as acne, milia, prolonged erythema, infections, and pigmentary alterations.In this report, we present a very unique case of a 41-year-old female patient with mild comedonal acne who developed severe acne agminate-like granulomatous reaction following fractional rejuvenation laser therapy that resolved spontaneously within 2 months after laser therapy. To the best of our knowledge, this is the first case of acne agminate as a side effect of rejuvenation laser therapy.As ruptured hair follicles are proposed as a pathogenic factor in both acne agminate and developing acne following fractional laser therapies, it is recommended to cautiously use resurfacing fractional lasers or to thoroughly treat acne before laser therapy due to the risk of developing a granulomatous reaction.

Low-power Fractional Carbon Dioxide Laser Followed by Jessner's Peel versus Jessner's Peel Alone for the Treatment of Melasma

BACKGROUND: A number of treatments have been used to treat melasma, with varying degrees of success and side effects. OBJECTIVE: We sought to compare the efficacy of a single session of low-power fractional CO₂ (10,600 nm) laser followed by Jessner's solution peeling against that of Jessner's solution peeling alone for the treatment of melasma by way of a prospective cohort comparative study performed at Alexandria Main University Hospital in Alexandria, Egypt. This study included 40 Egyptian female patients diagnosed with melasma. Group A received a single session of low-power fractional CO₂ laser followed by Jessner's solution peeling for up to six sessions, while Group B received up to six sessions of Jessner's solution peeling alone. Responses were evaluated using the modified Melasma Area and Severity Index (mMASI) score. RESULTS: There was a statistically significant (p≤0.001) difference between mMASI score between before and after treatment in both groups. There was no intergroup significant difference in mMASI score improvements. CONCLUSION: Both low-power fractional CO₂ laser combined with Jessner's solution and Jessner's solution peeling alone were safe and effective for the treatment of melasma in patients with different skin types, especially in dark skin types (Fitzpatrick Skin Types III and IV).

A combination of 1064 nm Q-switched fractional ND-YAG laser with a nonfractional microsecond pulsed technology has a synergistic effect for nonablative facial rejuvenation

BACKGROUND

Non-ablative fractionated lasers for facial rejuvenation are increasingly preferred over ablative lasers due to their minimal downtime and fewer adverse events. The synergistic effect of the Q-switched fractional (QSF) 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, in combination with the non-fractional microsecond pulsed technology has yet to be fully evaluated.

AIM

Our objective was to determine the safety and efficacy of this combination treatment for skin rejuvenation.

METHODS

Patients who underwent treatment using the QSF-Nd:YAG laser, followed by the non-fractional microsecond pulsed Nd:YAG were evaluated retrospectively using a novel 3D imaging modality for degree of facial erythema, wrinkles surface area, and wrinkle depth. Pain perception, adverse effects, and patient satisfaction were assessed at the 2-month post-treatment follow-up visit, graded on a scale of 1- 5 (1 = not satisfied, 5 = very satisfied).

RESULTS

Ten female patients' ages 44-67 (mean 55 years) completed both treatment and follow-up period, with an overall mild improvement in facial erythema and wrinkle surface area (mean improvement of 18% and 19.5% accordingly), as well as a mild improvement in overall wrinkle depth. Pain and adverse effects were mild and transient. Patients' satisfaction was high.

CONCLUSION

The combination of the QSF-Nd:YAG laser and non-fractional microsecond pulsed technology, using a single Nd:YAG 1064 nm laser platform, was found safe and effective as a non-ablative modality for facial rejuvenation, as demonstrated by a novel 3D imaging modality.

Nonablative laser skin resurfacing for periorbital wrinkling-A case series of 16 patients

BACKGROUND

Many modalities have been described for the treatment of periorbital wrinkling.

AIMS

The purpose of this study is to quantify the improvement of periorbital wrinkling achieved by current nonablative modalities, using a fractional 1565 nm Er:glass fiber laser.

METHODS

Our study is a retrospective two-center case series including 16 patients treated with nonablative laser for periorbital wrinkling at the Tel-Aviv Sourasky Medical Center in Israel and Laserplast Aesthetic Medicine Center in Italy between 2017 and 2019. Patients were assessed for objective and subjective improvement, patient satisfaction, side effect profile, and downtime.

RESULTS

Improvement in average Fitzpatrick Wrinkle Scale scores (from 4.3 to 2.7 by ranking physician 1 and 3.8 to 2.4 by ranking physician 2, P < .001) was observed after 8 weeks. Global Assessment Improvement Scale scores were 2.6 (physician 1) and 2.2 (physician 2) on average. This correlated to mild-moderate subjective sense of improvement by patients. Side effects and downtime were minimal.

CONCLUSION

Our study suggests that current nonablative laser skin resurfacing technology offers a mild-moderate improvement in periorbital wrinkling.

Administration of skin care regimens containing β-glucan for skin recovery after fractional laser therapy: A split-face, double-blinded, vehicle-controlled study

BACKGROUND

Laser therapies have brought dawn to refractory skin diseases, but also were accompanied by postlaser inflammation and skin barrier dysfunction. To recover skin function quickly, the research and development of active ingredients including β-glucan for postlaser repair have attracted much attention.

AIMS

To evaluate the efficacy and tolerance of skin care regimens containing β-glucan (Dermdoc®;Songyang Biotech) in repairing postlaser inflammation and skin barrier dysfunction after fractional laser therapy.

METHODS

A total of 20 patients with facial atrophic acne scars who accepted fractional laser therapy were recruited: 10 patients treated with ablative fractional CO2 laser and 10 patients treated with 1565nm nonablative fractional laser. Using the method of split-face vehicle-control study, the left half of the face was served as the treatment side and accepted skin care regimens, and the right half was control side accepted vehicle. Noninvasive bioinstrumentation of skin hydration index, transepidermal water loss (TEWL), and hemoglobin index (E value) was detected in the study. Standard digital photographs were taken at each visit. The skin tolerance and adverse effect were also evaluated by subject questionnaire.

RESULTS

Compared with the control side, the Hemoglobin index (E value) of the treatment side was improved more significantly on the 7th day (P < .05). The skin hydration index of the treatment side was better than that of the control side on the 7th and 14th day (P < .05). After treatment, the TEWL of the treatment side on the 7th day was statistically significantly lower than that of the control side (P < .05). In the subject self-assessment questionnaires, 63.2% thought the repair effect of β-glucan regimens was better than that of vehicle. The skin care regimens were well tolerated without obvious side reactions.

CONCLUSION

The skin care regimens containing β-glucan may play a positive role in accelerating the recovery of skin inflammation and barrier function after fractional laser therapy.

The early and late efficacy of single-pass fractional carbondioxide laser, fractional radiofrequency, and their combination in acne scars: A prospective, split-face, single-blinded, controlled clinical study

We investigated the effectiveness of fractional carbon dioxide laser (FCO₂ ) vs fractional radiofrequency (FRF) and FCO₂ vs FRF plus FCO₂ combination in the treatment of acne scars. Twenty-seven patients were included. Scar severity was scored with "Echelle d'évaluation clinique des cicatrices d'acné" (ECCA) by a dermatologist blinded to treatment. FCO₂ and FRF were administered to the right and left halves of the patients' faces, respectively, at the first three visits, once a month. At the fourth visit, FCO₂ was administered to both sides. Last evaluation was performed 6 months after the last treatment. Mean ECCA scores for both face halves decreased gradually at each visit compared with Visit-1; however, the effect size of decrease was higher in the right half of the face and in terms of gender differences was higher in women for both sides that the difference was more pronounced for the FRF side. There was no statistically significant change in the mean VAS patient satisfaction scores in the following visits compared with Visit-2 on both halves (P > .05). Side effects were similar; but lasted longer in the FCO₂ side. Both FCO₂ and FRF are effective treatment methods in the treatment of atrophic acne scars. Combining FCO₂ to FRF improves patient satisfaction. FRF may achieve better results in women compared with men. To our knowledge the study is unique prospective, controlled clinical study comparing the efficacy of FCO₂ and FRF plus FCO₂ combination treatments.

Potential of Naftifine Application for Transungual Delivery

Naftifine is used to treat fungal skin infections as it inhibits dermatophytes, which are the cause of onychomycosis. However, naftifine's ability to permeate the human nail barrier has not been investigated, thus, the antimycotic potential is not clearly established. This work aims to evaluate the effect of penetration enhancing factors on the accumulation of naftifine hydrochloride through human nail clippings. Naftifine polymeric nail lacquers with Eudragit RL100 were developed as a suitable delivery system. Low penetration of naftifine into nail has been determined as less than 10% of applied drug dose accumulated in the nail layers. Incorporation of thioglycolic acid into formulations resulted in increased accumulation of antifungal agent in the nail layers by 100% compared with a control group. Salicylic acid did not effect naftifine accumulation in the human nail. The permeation of naftifine through the nail increased by threefold when the thioglycolic acid-containing formulation was applied and the nail was pretreated with a fractional CO2 laser. Structural changes of the nail barrier, induced by fractional CO2 laser, were visualized by microscopy. The results suggest, that naftifine nail penetration could be significantly increased when physical and chemical enhancing factors are applied.

Laser-assisted topical steroid application versus steroid injection for treating keloids: A split side study

BACKGROUND

Approaches to improve keloid scars include intralesional corticosteroid injections and fractional lasers exclusively. The combinative use of ablative fractional laser therapy and occluded topical corticosteroid as a drug delivery method enhances therapeutic outcome of two efficient scar therapy modules into one simple synergistic module.

AIM

To compare the therapeutic effect of combining two modalities of scar treatment, the first is fractional ablative laser treatment and the other is occluded topical corticosteroid to the standard use of intralesional steroid injection.

METHODS

Keloids from thirty suffering patients were split faced into two identical parts; one part received an intralesional corticosteroid injection while the other part was treated first with fractional ablative 2940 nm Er: YAG laser followed by occluded topical application of steroid cream. Four treatment sessions were performed with 4-week interval between sessions. Every session was assessed photographically and using the Vancouver Scar Scale (VSS).

RESULTS

The mean keloid VSS before treatment was 6.9 ± 1.9. After treatment, the mean keloid VSS of the injection side became 2.63 ± 2.09, and mean keloid VSS of the laser-treated side became 2.07 ± 2.02. Each of the treated halves showed a statistically significant improvement in their VSS. However, no statistically significant differences were observed for either of the treated halves over the other one.

CONCLUSION

Although intralesional steroids injection is the standard procedure for treatment of keloid scars, the use of ablative fractional laser-assisted delivery of topical steroid can offer a safer and a better aesthetic treatment option.

Comparative study between fractional carbon dioxide laser vs intralesional steroid injection in treatment of alopecia areata

Few studies have reported Fractional Carbon Dioxide (FCO2) laser use in treating alopecia areata (AA), yet, effectiveness of this therapy has not been comparatively analyzed. To assess efficacy and safety of FCO2 laser in comparison to traditional intralesional corticosteroids injection (ILCs) in treatment of AA. This study included 20 patients with at least two patches of AA. Patients were subjected to history taking, general, dermatological and folliscopic examination. One patch was treated by FCO2 laser every 2 weeks for 3 to 6 sessions, while the other treated with intradermal injection of Triamcinolone Acetonide monthly for three sessions maximally. Evaluation of treatment response was done by physician clinical assessment using Mean Improvement Score (MISP), patient satisfaction and folliscopic examination measuring hair density (hair/cm² ) before each session, 1 month and 3 months after end of sessions. The obtained data were tabulated and statistically analyzed. There was a highly significant improvement with FCO2 laser rather than ILCs 3 months after last session according to MISP, patient satisfaction and hair density without serious side effects or relapse. FCO2 laser could be a better therapeutic alternative for treating AA in comparison to traditional ILCs.

Clinical and histopathological comparison of microneedling combined with platelets rich plasma versus fractional erbium-doped yttrium aluminum garnet (Er: YAG) laser 2940 nm in treatment of atrophic post traumatic scar: a randomized controlled study

Background: Different modalities have been tried for treating atrophic post traumatic scars.Objective: To compare the efficacy of microneedling combined with PRP with that of fractional erbium-doped yttrium aluminum garnet (Er: YAG) laser in treating post-traumatic atrophic scars.Methods: Forty-five patients with atrophic post traumatic scars were subdivided into three groups. Group I was subjected to four sessions of skin microneedling followed by topical application of platelet-rich plasma (PRP) immediately after each session. Group II was subjected to the same protocol of treatment but for six sessions. Group III was subjected to four sessions of fractional Er: YAG laser at 4 weeks intervals for four sessions. Response to treatment was assessed clinically using the Quartile Grading Scale and histopathologically using H&E stain, trichrome and Orcein special stains.Results: All patients showed significant clinical improvement regardless of the treatment. There was a significant difference in clinical and histopathological improvement between groups I and III, but there was no significant difference in improvement neither between groups I and II nor between groups II and III.Conclusion: microneedling could be as effective as a fractional laser when combined with PRP and when used for more sessions.

Fractional laser-assisted topical delivery of bleomycin quantified by LC-MS and visualized by MALDI mass spectrometry imaging

Bleomycin exhibits antiproliferative effects desirable for use in dermato-oncology but topical use is limited by its 1415 Da molar mass. Ablative fractional laser (AFL)-assisted drug delivery has been shown to enhance drug uptake in skin. The aim of this study was with AFL to deliver bleomycin into skin, quantify uptake, and visualize biodistribution with mass spectrometry. In a Franz diffusion cell study, pig skin samples (n = 66) were treated with AFL (λ = 10,600 nm), 5% density, and 0, 5, 20, or 80 mJ/microbeam (mb) pulse energies before exposure to bleomycin for 0.5, 4, or 24 h. Bleomycin was quantified in biopsy cryosections at depths of 100, 500, and 1500 µm using high-performance liquid chromatography-mass spectrometry (LC-MS), and drug biodistribution was visualized for 80 mJ/mb samples by matrix assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI). The pulse energies 5, 20, and 80 mJ/mb resulted in microscopic ablation zones (MAZs) reaching superficial, mid, and deep dermis respectively. Bleomycin was successfully delivered into the skin and deeper MAZs and longer exposure time resulted in higher skin concentrations. After 24 h, AFL exposure resulted in significant amounts of bleomycin throughout all skin layers (≥510 µg/cm3, p ≤ .002). In comparison, concentrations in intact skin exposed to bleomycin remained below limit of quantification. MALDI-MSI supported the quantitative LC-MS results by visualizing bleomycin biodistribution and revealing high uptake around MAZs with delivery into surrounding skin tissue. In conclusion, topical drug delivery of the large and hydrophilic molecule bleomycin is feasible, promising, and should be explored in an in vivo setting.

Fractional Laser-Mediated siRNA Delivery for Mitigating Psoriasis-like Lesions via IL-6 Silencing

The poor permeability of topically applied macromolecules such as small interfering RNA (siRNA) has inhibited the translation to clinical application. In this study, the fractional CO₂ laser-assisted approach was developed to describe siRNA permeation enhancement mediated by the created microchannels for silencing the gene to treat psoriasiform lesions. In vitro permeation using Franz cell and in vivo interleukin (IL)-6 silencing using psoriasis-like plaque in mice were evaluated to verify the impact of the laser irradiation. Low-fluence laser exposure enabled a significant increase in skin transport of siRNA, peptide, and 5-fluorouracil (5-FU). The laser treatment resulted in the enhancement of siRNA flux by 33- and 14-fold as compared to the control in nude mouse and pig skin, respectively. The laser exposure also promoted siRNA penetration across psoriatic and photoaging skins with the deficient barrier, although the enhancement level was minor compared to that of intact skin. The 3D images of confocal microscopy revealed a diffusion of macromolecules into the laser-created microchannels; the radial and vertical distribution to the surrounding and deep tissues followed this. A single laser treatment and the following topical siRNA administration were able to reduce IL-6 expression by 64% in the psoriatic skin model. Laser assistance led to the marked improvement in the plaque and the reduction of specific cytokine expression, keratinocyte proliferation, and neutrophil infiltration. Our data support the use of the fractional laser for delivery of functional nucleic acid into the skin and the target cells.

Evaluation of the Safety and Efficacy of a Picosecond Alexandrite Laser With DLA for Acne Scars in Chinese Patients

BACKGROUND AND OBJECTIVES

Recently, picosecond laser treatment has been used as an effective treatment for acne scars. To evaluate the efficacy and safety of a picosecond alexandrite laser with a diffractive lens array in the treatment of acne scars in Chinese patients.

STUDY DESIGN/MATERIALS AND METHODS

Patients with facial acne scars were treated with a picosecond alexandrite laser in three sessions at 4- to 6-week intervals and followed up for 2 months. Primary outcomes were measured by physicians' blinded evaluation of the acne scar using the ECCA (échelle d'éva physicians'luation clinique des cicatrices d'acné) grading scale. The secondary outcomes included the investigator global assessment (IGA) on the improvement of post-inflammatory erythema (PIE), patients' assessment of improvement on a 4-point scale and of satisfaction on a 5-point scale. Pain scores and adverse effects were also evaluated.

RESULT

Twenty patients with Fitzpatrick skin types III and IV were enrolled in the study and completed all treatment and follow-up visits. The mean ECCA scores fell from 197.75 ± 35.26 to 142.00 ± 35.92 (a 28% improvement), and the change was significant (P = 0.000). The mean IGA score of PIE improvement was 3.03 ± 0.75 (0 = no improvement and 4 = 76-100% improvement). On the basis of the patients' self-assessment, the average improvement scores were 2.30 ± 0.98 (0 indicating 0-25% improvement and 3 indicating >75% improvement). In total, 50% and 30% of the patients were "satisfied" and "very satisfied," respectively, with the treatment. The mean pain score was 3.20 ± 0.50 (0 = no pain, 10 = maximum pain) with topical anesthesia. The adverse effects included transient and mild erythema, edema, and scabbing.

CONCLUSIONS

Treatment with a picosecond alexandrite laser with a diffractive lens array is effective and safe for acne scars in Chinese patients. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Potential of Chemical and Physical Enhancers for Transungual Delivery of Amorolfine Hydrochloride

Topical monotherapy of nail infection is limited by poor drug permeability into the human nail plate. Numerous substances and methods are applied to improve the antifungal agent delivery across the nail plate. This work aimed to evaluate the effect of chemical and physical enhancers on the accumulation and permeation of amorolfine hydrochloride through human nail clippings. Polymeric nail lacquers with Eudragit E100 were developed as a potentially suitable delivery system for amorolfine hydrochloride. Incorporating thioglycolic acid and urea into formulations provided increased accumulation of antifungal agent in nail layers of up to 100% and 57%, respectively. Structural changes of nail barrier, induced by fractional CO₂ laser, were visualized by microscopy. The permeation of amorolfine hydrochloride through the nail increased twofold when thioglycolic acid-containing formulation was applied and the nail was pretreated with a fractional CO₂ laser. The results suggest that this novel combination of enhancers has the potential to be an effective option for topical drug delivery through the nail, and increased the efficacy of treatment.

Drug penetration enhancement techniques in ablative fractional laser assisted cutaneous delivery of indocyanine green

Background and Objectives

Topical drug delivery can be increased by pretreatment of the skin with ablative fractional laser (AFXL). Several physical penetration enhancement techniques have been investigated to further improve AFXL‐assisted drug delivery. This study investigated the influence of three of these techniques, namely massage, acoustic pressure wave treatment, and pressure vacuum alterations (PVP) on the distribution of the fluorescent drug indocyanine green (ICG) at different depths in the skin after topical application on AFXL pretreated skin.

Materials and Methods

In ex vivo human skin, test regions were pretreated with AFXL (10,600 nm, channel depth 300 μm, channel width 120 μm, density 15%). Subsequently, ICG was applied, followed by massage, acoustic pressure wave treatment or PVP. ICG fluorescence intensity (FI) was assessed after 1, 3, and 24 hours at several depths using fluorescence photography.

Results

FI was higher when using enhancement techniques compared to control (AFXL‐only) up to 3 hours application time (P < 0.05). After 3 hours, mean surface FI was highest after acoustic pressure wave treatment (61.5 arbitrary units; AU), followed by massage (57.5AU) and PVP (46.9AU), respectively (for comparison: AFXL‐only 31.6AU, no pretreatment 14.9AU). Comparable or higher FI was achieved already after 1 hour with enhancement techniques compared to 3–24 hours application time without. After 24 hours, no significant differences between enhancement techniques and AFXL‐only were observed (P = 0.31).

Conclusion

Penetration enhancement techniques, especially acoustic pressure wave treatment and massage, result in improved drug accumulation in AFXL‐pretreated skin and reduce the application time needed. Lasers Surg. Med. © 2019 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Effectiveness of subcision using carboxytherapy plus fractional carbon dioxide laser resurfacing in the treatment of atrophic acne scars: comparative split face study

Introduction: Fractional carbon dioxide laser resurfacing is the gold standard treatment for atrophic acne scars but when combined with subcision to the depressed scars it provides rapid improvement. Carboxytherapy is considered a tool for subcision via injecting the gas under pressure plus its well-known effect in rejuvenating scars.Aim: Main objective of the work is to evaluate the effectiveness of combined subcision using carboxytherapy plus fractional carbon dioxide laser resurfacing in the treatment of atrophic acne scars.Patients and method: Twenty patients with atrophic acne scars undergone three sessions of fractional carbon dioxide laser resurfacing for both sides of the face and subcision by CO₂ gas for the right side scars only. Standardized photographs were taken before and three months after the last session and evaluated by two independent blinded dermatologists for the degree of improvement.Result: The right side of the face improved better than the left side and showed excellent improvement in 10% of cases that was statistically significant (p value=.003).Conclusion: Subcision via carboxytherapy accelerate the improvement of atrophic acne scars when combined with fractional carbon dioxide laser resurfacing.

Is the Fractional Laser Still Effective in Assisting Cutaneous Macromolecule Delivery in Barrier-Deficient Skin? Psoriasis and Atopic Dermatitis as the Disease Models

PURPOSE

Most of the investigations into laser-assisted skin permeation have used the intact skin as the permeation barrier. Whether the laser is effective in improving cutaneous delivery via barrier-defective skin is still unclear.

METHODS

In this study, ablative (Er:YAG) and non-ablative (Er:glass) lasers were examined for the penetration of peptide and siRNA upon topical application on in vitro skin with a healthy or disrupted barrier.

RESULTS

An enhanced peptide flux (6.9 fold) was detected after tape stripping of the pig stratum corneum (SC). A further increase of flux to 11.7 fold was obtained after Er:YAG laser irradiation of the SC-stripped skin. However, the application of Er:glass modality did not further raise the flux via the SC-stripped skin. A similar trend was observed in the case of psoriasiform skin. Conversely, the flux was enhanced 3.7 and 2.6 fold after treatment with the Er:YAG and the Er:glass laser on the atopic dermatitis (AD)-like skin. The 3-D skin structure captured by confocal microscopy proved the distribution of peptide and siRNA through the microchannels and into the surrounding tissue.

CONCLUSIONS

The fractional laser was valid for ameliorating macromolecule permeation into barrier-disrupted skin although the enhancement level was lower than that of normal skin.

Novel methotrexate soft nanocarrier/fractional erbium YAG laser combination for clinical treatment of plaque psoriasis

Psoriasis is a commonly encountered chronic dermatological disease, presenting with inflammatory symptoms in patients. Systemic treatment of psoriasis is associated with several adverse effects, therefore the development of a customized topical treatment modality for psoriasis would be an interesting alternative to systemic delivery. The therapeutic modality explored in this article was the comparative treatment of psoriatic patients using nanoparticulated methotrexate in the form of jojoba oil-based microemulsion with or without fractional erbium YAG laser. Assessment parameters included follow-up photography for up to 8 weeks of treatment, estimation of the psoriasis severity [TES (thickness, erythema, scales)] score, and histopathological skin evaluation. The prepared methotrexate microemulsion was clinically beneficial and safe in treatment of psoriasis vulgaris. The concomitant use of the fractional laser provided improvement in the psoriatic plaques within shorter time duration (3 weeks compared to 8 weeks of treatment), presenting an alternative topical treatment modality for psoriasis vulgaris.

Assessment of the efficacy and tolerance of an innovative regenerative serum on cutaneous regeneration, following fractional laser procedure using Erbium:YAG

INTRODUCTION

Cutaneous regeneration, fractional laser, medical device, cellular proliferation cutaneous changes linked to photoaging are currently treated with physical treatments, such as fractional laser, which may induce epidermal alteration.

OBJECTIVE

To determine the efficacy and safety of a regenerative serum (Matricium^® , Laboratoire Bioderma, France) after laser procedure.

METHODS

Prospective, double-blind, controlled, and randomized study in subjects with photoaged skin. The regenerative serum of treatment was used after a fractional laser session twice daily for 2 months on 1 side of the face and the placebo on the other side. The main variable to determine efficacy was the improvement of clinical signs and histological and immunological results.

RESULTS

A superior quality of epidermal regeneration on the treated side compared to the placebo side was observed. Likewise, a superior and faster clinical improvement on static wrinkles was observed on the hemiface on which the regenerative serum was used. After 60 days, the investigator and the subjects observed a moderate to significant improvement of the skin on the treated side and a mild to moderate improvement on the placebo side. Histological examinations showed a superior thickness of epidermis and higher cellular proliferation rate (Ki67 markers) as well as a superior thickness of dermis with higher increase in elastin density with the regenerative serum compared to placebo.

CONCLUSION

The use of the regenerative serum after fractional laser on the face accelerated and improved the cutaneous regeneration on both the clinical and histological level and maximized the benefits of the laser procedure.

Ablative fractional carbon dioxide laser combined with intense pulsed light for the treatment of photoaging skin in Chinese population: A split-face study

Intense pulsed light (IPL) is effective for the treatment of lentigines, telangiectasia, and generalized erythema, but is less effective in the removal of skin wrinkles. Fractional laser is effective on skin wrinkles and textural irregularities, but can induce postinflammatory hyperpigmentation (PIH), especially in Asians. This study evaluated the safety and efficacy of ablative fractional laser (AFL) in combination with IPL in the treatment of photoaging skin in Asians.This study included 28 Chinese women with Fitzpatrick skin type III and IV. The side of the face to be treated with IPL alone (3 times) or AFL in combination with IPL (2 IPL treatments and 1 AFL treatment) was randomly selected. Skin conditions including hydration, transepidermal water loss, elasticity, spots, ultraviolet spots, brown spots, wrinkle, texture, pore size and red areas, as well as adverse effects were evaluated before the treatment and at 30 days after the treatment.Compared with IPL treatment alone, AFL in combination with IPL significantly increased elasticity, decreased pore size, reduced skin wrinkles, and improved skin texture (P = .004, P = .039, P = .015, and P = .035, respectively). Both treatment protocols produced similar effects in relation to the improvement of photoaging-induced pigmentation. The combined therapy did not impair epidermal barrier function. No postoperative infection, hypopigmentation, or scarring occurred after IPL and AFL treatments. PIH occurred at 1 month after AFL treatment and disappeared at 30 days after completion of the combined therapy.AFL in combination with IPL is safe and effective for photoaging skin in Asians.

Fractional Carbon Dioxide Laser in Combination with Topical Corticosteroid Application in Resistant Alopecia Areata: A Case Series

Introduction:

Intradermal steroid injections are used as treatment option in resistant alopecia areata. However, it is difficult and quite painful to treat large areas of alopecia with this modality.

Objective:

To assess the efficacy and safety profile of a combination of fractional carbon dioxide (CO₂) treatment followed by topical corticosteroid application in resistant alopecia areata.

Materials and Methods:

Ten cases of resistant alopecia areata who had not responded to multiple treatment modalities were treated with fractional CO₂ laser followed by topical application of triamcinolone spray (10mg/mL) on the resistant lesions. Patients received 4–8 sessions that were repeated at an interval of 3–4 weeks. Response to treatment was assessed on a quartile physician assessment scale and labeled as excellent (>75% regrowth), good (50%–75% regrowth), fair (26%–50% response), and poor (<25% regrowth).

Results:

Eight of these ten cases completed the treatment process. Seven of these eight patients had complete recovery of the area treated. One patient however did not show good response even after four sessions. No significant adverse effects were noted in any of the patients.

Conclusion:

Fractional CO₂ laser in combination with topical triamcinolone can prove to be an effective treatment option in resistant alopecia areata.

Fractional laser-assisted percutaneous drug delivery via temperature-responsive liposomes

Liposomes are used for transdermal delivery of drugs and vaccines. Our objective was to develop temperature-responsive (TR) liposomes to achieve temperature-dependent, controlled release of an encapsulated drug, and use fractional laser irradiation to enhance transdermal permeability of these liposomes. TR-liposomes prepared using a thermosensitive polymer derived from poly-N-isopropylacrylamide, N,N-dimethylacrylamide, egg phosphatidylcholine, and dioleoylphosphatidylethanolamine, delivered fluorescein isothiocyanate-conjugated ovalbumin (OVA-FITC) as a model drug. Effect of temperature on liposome size and drug release rate was estimated at two temperatures. Transdermal permeation through hairless mouse skin, with and without CO₂ fractional laser irradiation, and penetration into Yucatan micro-pig skin were investigated using Franz cell and fluorescence microscopy. Dynamic light scattering showed that mean liposome diameter nearly doubled from 190 to 325 nm between 37 and 50 °C. The rate and amount of OVA-FITC released from TR-liposomes were higher at 45 °C that those at 37 °C. Transdermal permeation of OVA-FITC across non-irradiated skin from both TR- and unmodified liposomes was minimal at 37 °C, but increased at 45 °C. Laser irradiation significantly increased transdermal permeation of both liposome groups at both temperatures. Fluorescence microscopy of frozen biopsy specimens showed deeper penetration of FITC from unmodified liposomes compared to that from polymer-modified liposomes. Rhodamine accumulation was not observed with polymer-modified liposomes at either temperature. Temperature-dependent controlled release of an encapsulated drug was achieved using the TR-liposomes. However, TR-liposomes showed lower skin permeability despite higher hydrophobicity. Fractional laser irradiation significantly increased the transdermal permeation. Additional studies are required to control liposome size and optimize transdermal permeation properties.

Evaluation of Laser-Assisted Trans-Nail Drug Delivery with Optical Coherence Tomography

The nail provides a functional protection to the fingertips and surrounding tissue from external injuries. The nail plate consists of three layers including dorsal, intermediate, and ventral layers. The dorsal layer consists of compact, hard keratins, limiting topical drug delivery through the nail. In this study, we investigate the application of fractional CO₂ laser that produces arrays of microthermal ablation zones (MAZs) to facilitate drug delivery in the nails. We utilized optical coherence tomography (OCT) for real-time monitoring of the laser–skin tissue interaction, sparing the patient from an invasive surgical sampling procedure. The time-dependent OCT intensity variance was used to observe drug diffusion through an induced MAZ array. Subsequently, nails were treated with cream and liquid topical drugs to investigate the feasibility and diffusion efficacy of laser-assisted drug delivery. Our results show that fractional CO₂ laser improves the effectiveness of topical drug delivery in the nail plate and that OCT could potentially be used for in vivo monitoring of the depth of laser penetration as well as real-time observations of drug delivery.

Skin pre-ablation and laser assisted microjet injection for deep tissue penetration

BACKGROUND AND AIMS

For conventional needless injection, there still remain many unresolved issues such as the potential for cross-contamination, poor reliability of targeted delivery dose, and significantly painstaking procedures. As an alternative, the use of microjets generated with Er:YAG laser for delivering small doses with controlled penetration depths has been reported. In this study, a new system with two stages is evaluated for effective transdermal drug delivery. First, the skin is pre-ablated to eliminate the hard outer layer and second, laser-driven microjet penetrates the relatively weaker and freshly exposed epidermis. Each stage of operation shares a single Er:YAG laser that is suitable for skin ablation as well as for the generation of a microjet.

METHODS

In this study, pig skin is selected for quantification of the injection depth based on the two-stage procedure, namely pre-ablation and microjet injection. The three types of pre-ablation devised here consists of bulk ablation, fractional ablation, and fractional-rotational ablation. The number of laser pulses are 12, 18, and 24 for each ablation type. For fractional-rotational ablation, the fractional beams are rotated by 11.25° at each pulse. The drug permeation in the skin is evaluated using tissue marking dyes. The depth of penetration is quantified by a cross sectional view of the single spot injections. Multi-spot injections are also carried out to control the dose and spread of the drug.

RESULTS

The benefits of a pre-ablation procedure prior to the actual microjet injection to the penetration is verified. The four possible combinations of injection are (a) microjet only; (b) bulk ablation and microjet injection; (c) fractional ablation and microjet injection; and (d) fractional-rotational ablation and microjet injection. Accordingly, the total depth increases with injection time for all cases. In particular, the total depth of penetration attained via fractional pre-ablation increased by 8 ∼ 11% and that of fractional-rotational pre-ablation increased by 13 ∼ 33%, when compared with the no pre-ablation or microjet only cases. A noticeable point is that the fraction-rotational pre-ablation and microjet result is comparable to the bulk ablation and microjet result of 11 ∼ 42%. The penetration depth underneath ablated stratum corneum (SC) is also measured in order to verify the pre-ablation effect. The penetration depths for each case are (a) 443 ± 104 µm; (b) 625 ± 98 µm; (c) 523 ± 95 µm; and (d) 595 ± 141 µm for microjet only, bulk ablation and microjet, fractional ablation and microjet, and fractional-rotational ablation and microjet, respectively. This is quite beneficial since any healing time associated with ablation is significantly reduced by avoiding hard-core bulk ablation. Thus the bulk pre-ablation and microjet may well be superseded by the less invasive fractiona-rotational ablation followed by the microjet injection. The density of micro-holes is 1.27 number/mm² for fractional ablation and 4.84 number/mm² for fractional-rotational ablation. The penetration depths measured underneath the ablated SC are 581 µm (fractional ablation and microjet) and 691 µm (fractional-rotational ablation and microjet).

CONCLUSIONS

Fractional-rotational ablation increases number of micro-holes in a unit area, enabling fast reepithelialization and high drug delivery efficiency. Optimization of system parameters such as ablation time, number of ablations, and injection time will eventually ensure a macromolecule delivery technique with the potential to include vaccines, insulins, and growth hormones, all of which require deeper penetration into the skin. Lasers Surg. Med. 49:387-394, 2017. © 2016 Wiley Periodicals, Inc.

Fractional resurfacing in the Asian patient: Current state of the art

BACKGROUND AND OBJECTIVE

Fractionated photothermolysis (FP) has revolutionized modern laser technology. By creating selective columns of microthermal damage, fractionated devices allows for greater treatment depths to be achieved without the prolonged downtime and risk of complications seen in traditional fully ablative laser resurfacing. Fractional resurfacing is a proven method to treat a variety of cutaneous conditions. In the Caucasian patient, a wide range of devices and treatment settings can be utilized safely and effectively. However, ethnic skin requires special consideration due to its unique pigmentary characteristics and clinical presentations. In this review article, we detail the current indications and strategies to optimize results and mitigate complications when utilizing fractional resurfacing for the Asian patient.

METHODS

A review of the MEDLINE English literature was conducted on fractionated laser devices studied in the Asian population. Articles included describe non-ablative devices including fractionated erbium glass, thulium fiber, diode, and radiofrequency devices; and ablative devices including fractionated carbon dioxide (CO₂ ) laser, erbium yttrium aluminum garnet and yttrium scandium gallium garnet (YSGG) laser. These data were integrated with the expert opinion of the authors.

CONCLUSION

Taking into account the unique characteristics and cosmetic concerns of the Asian population, fractional resurfacing can be considered a safe and effective option for the treatment of atrophic and hypertrophic scarring, and photorejuvenation in ethnic skin types. Select cases of melasma may be treated with fractionated non-ablative devices, but utilized with caution. The predominant complication associated with fractional resurfacing for these conditions is post-inflammatory hyperpigmentation (PIH) and rebound worsening of melasma. A greater number of treatments at lower density settings and wider treatment intervals typically produce the lowest risks of PIH without compromising treatment efficacy. Lasers Surg. Med. 49:45-59, 2017. © 2016 Wiley Periodicals, Inc.

The efficacy and safety of subcision using CO2 gas combined with fractional laser for acne scars: Clinical and microscopic evaluation

BACKGROUND

Various modalities have been used to treat acne scars. CO₂ fractional laser is an effective and commonly used treatment. CO₂ gas injection into the dermis by needle with high pressure can cause fibrotic collagen breakage, producing the effects of subcision. CO₂ also stimulates collagen synthesis by increasing neovascularization and releasing oxygen.

OBJECTIVE

This study evaluated the efficacy and the safety of the combined treatment with CO₂ gas subcision and CO₂ fractional laser for acne scars.

METHODS AND MATERIALS

Fourteen patients with acne scars were treated with three sessions of CO₂ gas subcision at 2-week intervals and two sessions of fractional laser at 4-week interval. The clinical improvement was assessed using a 4-point scale. For histologic analysis, punch biopsy was performed before and after treatment in 10 patients.

RESULTS

All patients experienced clinical improvements. Excellent, marked, moderate, and mild response was achieved in 1 (7%), 8 (57%), 4 (29%), and 1 patient (7%), respectively. Histologic evaluation of the biopsy specimens showed increased dermal collagen with dermal thickening and elastic fiber straightening in the reticular dermis after the treatment.

CONCLUSION

The combination therapy with CO₂ gas subcision and fractional laser was satisfactory and safe for treating acne scars. Abbreviation and acronym: CO₂: Carbon dioxide GAS: Global assessment scale H&E: hematoxylin and eosin; SD: standard deviation.