Efficacy, tolerability, and safety of a long-pulsed ruby laser system in the removal of unwanted hair.

BACKGROUND: Unwanted hair growth is a common, usually physiologic phenomenon. OBJECTIVE: In this study the efficacy and tolerability of a long-pulsed ruby laser system was compared with needle electrolysis and hot wax on three parts of the body. METHODS: Thirty volunteers were treated three times on the forearm (n = 10), on the face (n = 10), or in the pubic area (n = 10) with 25 J/cm2 laser, 40 J/cm2 laser, needle electrolysis, and hot wax therapy. RESULTS: The 25 J/cm2 and 40 J/cm2 laser treated sites showed a statistically significant decrease (38% and 49%, respectively) in the number of hairs at the first visit after the last treatment compared to the pretreatment hair counts. No significant decrease was observed in the needle electrolysis and hot wax treated sites. Laser therapy yielded better results on the forearm than on the face or pubic area and was scored as the least painful. CONCLUSION: The long-pulsed ruby laser is a promising, well-tolerated method of epilation.

Treatment of cutaneous lesions of xanthoma disseminatum with a CO2 laser.

We describe a case of a 15-year-old African American girl with widespread papulonodular lesions of xanthoma disseminatum especially in the periorbital area and on the flexural surfaces of the neck, axillae, arms, and legs. There were no mucosal lesions. An initial trial in the distant past of liquid nitrogen cryotherapy resulted in partial shrinking of cutaneous lesions but was too painful for the patient. She then underwent surgical excision of bilateral eyelid lesions with improvement, but additional procedures were deemed impractical when considering the great number and size of the lesions. Consequently we treated the patient with a carbon dioxide (CO2) laser with excellent results. The relatively great speed at which the CO2 laser procedure can be performed has made the removal of multiple lesions in each session possible. Additional advantages included precise vaporization of lesions, hemostasis during the operative procedure, and minimal postoperative pain and edema.

Complications of aesthetic laser surgery.

Aesthetic laser surgery is not risk free. It behooves the laser surgeon to become intimately familiar with the potential adverse effects of laser use to guard against and to minimize their occurrence. Moreover, patients must be thoroughly, clearly, and honestly educated about the procedure and its risks so that their expectations are realistic and so that any complications that do occur can be recognized early and treated appropriately. This review summarizes basic laser safety and discusses the nature of complications that may occur during continuous-wave, pulsed dye, pigment-specific, hair removal, and resurfacing laser procedures.

Laser treatment of pigmented lesions in children.

A variety of lasers can be used to effectively treat cutaneous pigmentation in children. Furthermore, using the principle of selective photothermolysis, several pigment-specific lasers can be used to achieve significant clinical improvement if not complete removal of pigmented lesions with greatly reduced risks of scarring, textural or pigmentary changes. A summary of laser treatments for pigmented lesions that commonly present in children including café-au-lait macules, nevus of Ota and other dermal melanocytosis, congenital melanocytic nevus, nevus spilus, lentigines, epidermal nevus, Becker's nevus, and tattoos is presented. Overall, laser treatment is a very safe, effective treatment option that could offer distinct advantages compared with other conventional modalities.

Effects of overlap and pass number in CO2 laser skin resurfacing: a study of residual thermal damage, cell death, and wound healing.

BACKGROUND: Newer CO2 laser systems incorporating short pulse and scanning technology have been used effectively to resurface the skin. As the number of resurfacing cases has increased, hypertrophic scarring has been reported more commonly. Previous dermabrasion and continuous wave CO2 studies have suggested that depth of injury and thermal damage are important predictors of scarring for a given anatomic region. To determine whether rapid overlapping of laser pulses/scans significantly altered wound healing, we examined residual thermal damage, cell death, and histologic and clinical wound healing in a farm pig. METHODS AND MATERIALS: Two popular CO2 systems were used, with a range of radiant exposures, degrees of overlap, and numbers of passes. Thermal damage was assessed by histology, and dermal cell viability was measured with nitrotetrazolium blue staining. Presence or absence of clinical scarring was determined by textural change and loss of skin markings. RESULTS: We observed that dermal thermal damage did not increase significantly with pass number when performed as in the normal clinical setting (for 2-4 passes); however, by delivering rapidly overlapping pulses and scans, residual thermal damage and cell death depth were increased as much as 100% over areas without immediate overlap of laser impacts. CONCLUSIONS: Immediate overlapping of CO2 laser pulses and scans is a significant risk factor in increasing thermal damage, cell death, and possibly scarring.

Comparison of erbium:YAG and carbon dioxide lasers in resurfacing of facial rhytides.

OBJECTIVE: To compare the efficacy, adverse effects, and histological findings of erbium:YAG (Er:YAG) and carbon dioxide (CO2) laser treatment in removing facial rhytides. DESIGN: An intervention study of 21 subjects with facial rhytides. All participants were followed up for 6 months. The end points of the study were wrinkle improvement and duration of adverse effects. SETTING: Academic referral center. SUBJECTS: Nineteen female and 2 male volunteers with skin type I to III and wrinkle class I to III participated in the study. INTERVENTION: In all subjects, 1 side of the face was treated with a CO2 laser and other side with an Er:YAG laser. Skin biopsies were performed in 6 subjects before treatment and immediately, 1 day, 2 days, and 6 months after treatment. Observations were recorded by subjects, investigators, and a blinded panel of experts. MAIN OUTCOME MEASURES: Improvement in wrinkles and severity and duration of adverse effects. RESULTS: The CO2 laser-treated side had relatively better wrinkle improvement when evaluating all subjects (P<.03). However, in subjects receiving more than 5 passes of Er:YAG laser, improvement scores were not significantly different from those for 2 to 3 passes of CO2 laser treatment. Posttreatment erythema was noted at 2 weeks in 14 subjects (67%) on the Er:YAG laser-treated side and 20 subjects (95%) on the CO2 laser-treated side. The frequency of erythema was significantly less after Er:YAG laser treatment at 2 (P=.001) and 8 (P=.03) weeks. Hypopigmentation was seen in 1 Er:YAG-treated (5%) and 9 CO2-treated (43%) sides (chi2, P<.05). Histological evaluation showed residual thermal damage of up to 50 microm on the Er:YAG-treated side and up to 200 microm on the CO2-treated side. CONCLUSIONS: Erbium:YAG laser is safe and effective in removing facial rhytides. Subjects treated with Er:YAG laser recover more quickly from the procedure than those receiving CO2 laser treatment.

Treatment of benign and atypical nevi with the normal-mode ruby laser and the Q-switched ruby laser: clinical improvement but failure to completely eliminate nevomelanocytes.

OBJECTIVE: To evaluate the effect of normal-mode and Q-switched ruby laser light (694 nm) on nevomelanocytes of benign, atypical, and congenital nevi. DESIGN: Half of the lesion of each of 31 nevi was treated with either the Q-switched ruby laser or the normal-mode ruby laser or both; the other half of the lesion was covered with aluminum foil and was not treated. SETTING: A university-affiliated, hospital-based laser center. PATIENTS: Sixteen patients with a total of 31 melanocytic nevi were enrolled in the study. INTERVENTIONS: All nevi were evaluated by at least 2 dermatologists to assess the degree of clinical atypia. Photographs were taken before and immediately after treatment and at each follow-up visit. The digital imaging system was used to evaluate the number of melanocytes in a measured length of basement membrane zone. MAIN OUTCOME MEASURE: Three individual readings (number of melanocytes per unit length) were taken on both the control and treated halves and then compared to quantitate treatment effect. All analyses used averages from 3 measurements. A Student paired t test was used to compare the treated and untreated sides. RESULTS: Sixteen (52%) of the nevi showed a clinically visible decrease in pigment on the treatment side at the 4-week follow-up visit. CONCLUSION: No lesions had complete histologic removal of all nevomelanocytes. Therefore, 1 or 2 laser treatments are not sufficient to cause complete removal of a lesion either clinically or histologically.

Comparison of the Q-switched alexandrite, Nd:YAG, and ruby lasers in treating blue-black tattoos.

BACKGROUND: A new generation of highly selective short-pulsed lasers has emerged in recent years for the treatment of tattoos. Several studies (including reports by the present investigators) have proven the efficacy of each of the three commercially available, FDA approved devices; namely, the Q-switched alexandrite, Q-switched Nd:YAG and Q-switched ruby lasers. Considerable differences among the three have been reported in relation to the rate of clearing of the tattoo ink particles, tissue effects, beam profile, wound healing, and side effects. OBJECTIVE: This study was primarily conducted to examine and compare the clinical response of patients with blue-black tattoos simultaneously treated with three different Q-switched lasers (alexandrite, Nd:YAG, ruby) with a focus on the percentage of tattoo lightening/clearance and the occurrence or non-occurrence of pigmentary change as a side effect. METHODS: A total of forty-two blue-black tattoos seen at two laser centers (Massachusetts General Hospital Dermatology Laser Center and Laser and Skin Surgery Center of La Jolla) were simultaneously treated with three types of Q-switched lasers: a Candela Q-switched alexandrite laser (755nm 50-100 nanoseconds, 3.0 mm spot size, 6-8 J/cm2); a Continuum Biomedical Q-switched Nd:YAG laser (1064nm, 10-20 nanoseconds, 3.0 mm spot size, 5-10 J/cm2); and a Spectrum Q-switched ruby laser (694 nm, 25-40 nanoseconds, 5.0 mm spot size, 4-10 J/cm2). Paired t-tests and McNemar tests were used to compare the treatment outcome and pigmentation side effects between sites per tattoo, with each site representative of one of the three lasers. The statistical significance level was set at p < .05. RESULTS: Overall, the Q-switched ruby laser had a significant difference in tattoo lightening versus the Q-switched Nd:YAG and Q-switched alexandrite lasers. An increase in the number of treatments paralleled a statistically significant increase in tattoo clearance for all three Q-switched lasers. CONCLUSION: The Q-switched ruby laser had the highest clearance rate in blue-black tattoos and the highest incidence of long-lasting hypopigmentation. The Nd:YAG had no incidence of hypopigmentation.

The effect of wiping on skin resurfacing in a pig model using a high energy pulsed CO2 laser system.

BACKGROUND: The impact of wiping in laser skin resurfacing has not been systematically studied. METHODS: We examined the effects of wiping during single- and multiple-pass high energy pulsed CO2 laser skin resurfacing in a farm pig. Consequences of wiping were evaluated with regard to depth of residual thermal damage, tissue necrosis, and fibroplasia. Also, the impact of wiping on gross wound healing was observed. Wounds were followed for 21 days and biopsies were obtained on postoperative days 0, 1, and 21. RESULTS: Immediate postoperative biopsies of single-pass wounds showed equivalent residual thermal damage regardless of wiping; in contrast, biopsies from multiple-pass sites without wiping showed more extensive and variable residual thermal damage than wiped sites. On postoperative day one, single pass sites without wiping were grossly less erythematous than wiped sites, and biopsies showed less extensive necrosis and inflammation. In contrast, multiple pass sites without wiping were grossly more erythematous than corresponding wiped sites, and biopsies revealed significantly increased and variable necrosis. After 21 days, multiple pass sites without wiping were grossly more erythematous and showed a thicker band of fibroplasia microscopy. CONCLUSIONS: For single pass wounds, not wiping decreased the level of wounding. In contrast, not wiping in multiple pass wounds significantly increased the depth and variability of residual thermal damage and necrosis, resulting in prolonged healing.

Comparative clinical trial of 2 carbon dioxide resurfacing lasers with varying pulse durations. 100 microseconds vs 1 millisecond.

OBJECTIVES: To compare the clinical and histological effects of 2 carbon dioxide lasers with different pulse durations and to evaluate the effect of carbon dioxide laser pulse duration on postprocedure erythema, wound healing, and efficacy of wrinkle treatment. DESIGN: Prospective, randomized, comparative clinical trial. SETTING: A university-affiliated hospital-based laser center. PATIENTS: Thirty-five patients with facial wrinkles were enrolled in the study. Treatment sites included 15 perioral, 14 periorbital areas, and 6 full face. INTERVENTION: A 2-sided comparison was performed. One side of the study site was treated with the TruPulse laser (Tissue Technologies, Palomar Medical Products Inc, Lexington, Mass). The other side of the study site was treated with the UltraPulse 5000 laser (Coherent Medical Inc, Palo Alto, Calif). The 2 sides were treated to equivalent tissue effects rather than maintaining the number of passes. MAIN OUTCOME MEASURES: Photographs of the treatment areas at baseline, week 1, week 2, month 2, and month 6 were evaluated by a 5-member panel for degree of erythema, amount of edema, and percentage of wrinkle improvement. Silicon skin casts for profilometry measurements before and after the treatment were compared. To evaluate skin shrinkage, surface area before and after treatment of square tattoos on both cheeks of the full-face patients were computed using a digital imaging system. Histological sections before and after the procedure were analyzed. RESULTS: At week 1, 75% of the patients had more erythema on the UltraPulse than TruPulse sides. The difference in erythema (TruPulse less than UltraPulse) between the 2 treatment sides was clinically mild yet statistically significant for weeks 1 (P = .05) and 2 (P = .05). Although observed results favored the UltraPulse over the TruPulse, the difference in efficacy between the 2 lasers did not reach statistical significance. CONCLUSIONS: Compared with the longer pulse-duration carbon dioxide laser, the shorter pulse-duration carbon dioxide laser, used with higher energy and more passes, caused slightly less erythema while maintaining efficacy. The longer pulse-duration laser required lower energy and fewer number of passes to achieve an equivalent depth of ablation, level of residual thermal damage, and degree of efficacy. The shorter TruPulse allows for more superficial tissue damage per pass and therefore is best suited for situations requiring superficial or more controlled ablation. The longer UltraPulse achieves a desirable depth of tissue damage with fewer passes. The data did not support the long-term presence of tissue collagen shrinkage in the treated areas.

Concurrent use of laser skin resurfacing and punch excision in the treatment of facial acne scarring.

BACKGROUND: Laser skin resurfacing has added to the numerous treatment options available for acne scarring. Adjunct modalities such as punch excision should be considered to enhance treatment outcomes. Traditionally, punch excision and grafting have been performed, followed 1-2 months later by dermabrasion. OBJECTIVE: To determine the effectiveness of laser skin resurfacing and the concurrent use of punch excision performed at the same treatment session in the treatment of acne scarring. METHODS: Twenty-one patients with skin types I-III with mild to severe facial acne scarring were treated with a combination of laser skin resurfacing and punch excision of acne scars in the same treatment session. Baseline, postoperative, and follow-up photographs were taken and evaluated by an independent dermatologist and a laser nurse blinded to patient treatment. In addition, subjective patient assessments of improvement were obtained. RESULTS: There was a range of clinical improvement by the independent assessor of 25-50% in skin type I, 50-75% in skin type II, and 50-75% in skin type III. There was a patient subjective improvement of 25-50% for skin type I, 50-75% for skin type II and 75-100% for skin type III. Postoperative hyperpigmentation was noted in five patients and postoperative hypopigmentation was not seen in any patients. There was no wound dehiscence, evidence of infection, or hypertrophic scarring of treated areas noted on follow-up. CONCLUSION: Laser skin resurfacing with the concurrent use of punch excision improves facial acne scarring. This newly described method negates the need to delay additional resurfacing for a future visit.

Care before and after laser skin resurfacing. A survey and review of the literature.

BACKGROUND: The extent of the wound healing period and the final outcome of cutaneous laser resurfacing are influenced not only by the treatment protocol and type of laser used but also on care of the skin before and after the procedure. OBJECTIVE: This project was conducted to determine the pre- and postresurfacing care protocols currently in practice and to research the literature in an effort to clarify which interventions can accelerate wound healing and improve efficacy of the treatment. METHODS: Three hundred thirty-nine questionnaires were mailed to all dermatology and plastic surgery members of the American Society for Laser Medicine and Surgery (ASLMS). Questionnaires were completed anonymously to decrease respondent bias. Statistical analysis included calculation of percentages and means of the data. RESULTS: Survey results are discussed and compared with data from the literature for the following interventions: tretinoin cream, glycolic acid cream, hydroquinone, oral prophylactic antibiotics, oral prophylactic antivirals, hydrogel dressings, semiocclusive ointments, topical antibiotics, topical corticosteroids, oral corticosteroids, and dilute acetic acid soaks. CONCLUSIONS: Many options are appropriate, based on data from past studies, for pre- and postresurfacing skin care. Approximately 73% of the results of the survey correlate with information from the literature. Past studies do provide information to help us select interventions that can improve wound healing and the final cosmetic outcome. Further studies involving resurfacing patients may clarify some of the more complex wound care issues, such as oral prophylactic antibiotics, hydroquinone, and topical vitamins C and E.

Long-term results after CO2 laser skin resurfacing: a comparison of scanned and pulsed systems.

BACKGROUND: New laser technology permits the use of high-energy pulsed and continuous-wave carbon dioxide (CO2) lasers with flashscanners to treat rhytides. OBJECTIVE: We compared the efficacy and side effects of the two leading CO2 lasers used in skin resurfacing. METHODS: A total of 28 patients with facial rhytides were treated with either the UltraPulse or SilkTouch laser systems; in five additional patients, contralateral cosmetic units were treated with one system or the other in a direct comparison of the lasers. RESULTS: We compared photographs taken before and after treatment, and a lessening of facial wrinkling was noted in all subjects. In some subjects improvement was confirmed by optical profilometry methods. Biopsy specimens in representative patients showed that immediate thermal damage was limited to 180 microns. Long-term postoperative specimens showed changes in the papillary dermis consistent with new collagen deposition and reduction of pretreatment solar elastosis. Posttreatment facial erythema was noted in half the patients for up to 2 months; transient hyperpigmentation was observed in one third of the treated areas. CONCLUSION: Although the SilkTouch system produced more immediate thermal damage, there were no significant differences in efficacy or adverse effects between the lasers. Our results suggest that both laser systems, used with appropriate settings, are capable of safely smoothing the skin surface.

Laser hair transplantation.

A review of the present state of the art of laser hair transplantation highlights recommendations for treatment parameters and discusses the studies published in the literature. An evolving field, laser hair transplantation is maturing to find its place in the armentarium for hair restoration surgery.

Pulsed laser treatment in children and the use of anesthesia.

BACKGROUND: The rationale for choosing certain anesthetic options in children when they are being treated with pulsed lasers is unclear. OBJECTIVE: Our purpose was to assess the safety and side effects of general anesthesia in the treatment of vascular lesions and to compare this to treatment outcome in the office setting. METHODS: We carried out a retrospective chart review of 179 patients, with an age range of 5 weeks to 18 years, who received laser treatment and underwent different anesthetic modalities. The age of the patient and the size, location, and severity of the vascular lesion were also noted. RESULTS: The factors determining the type of anesthesia to use included (1) the age of the patient, (2) the number of treatments, and (3) the size and location of the lesion. Our data showed minimal risk and sequelae of general anesthesia in the treatment of vascular lesions in children. CONCLUSION: Proper selection of anesthesia is a key factor in dealing with children. Office surgery can be performed safely when small lesions are treated. The use of general anesthesia in the treatment of port-wine stains in children does not appear to be accompanied by increased risk.

Treatment of nevus spilus with the Q-switched ruby laser.

BACKGROUND: Q-switched lasers have shown to be effective in the removal of unwanted cutaneous pigmentation. Benign cutaneous pigmented lesions represent a heterogeneous group. Nevus spilus is a relatively uncommon pigmented lesion characterized by dark, hyperpigmented dots scattered over a tan-colored macule. OBJECTIVE: A cohort of patients with nevus spilus was studied to determine the effects of Q-switched ruby and Q-switched Nd:YAG laser treatment on clearance of pigment and to evaluate potential side effects. METHODS: Six patients with nevus spilus were treated with the Q-switched ruby laser (QSR). In addition, three lesions received a test treatment with the Q-switched Nd:YAG (QSYAG) laser at 532 or 1064 nm. The results of treatment were documented during follow up visits. RESULTS: Most lesions showed a near-complete or complete response to laser treatment. In one case partial hyperpigmentation occurred after treatment and in one case no follow-up could be obtained. In the three cases that received both QSR and QSYAG laser treatment, the QSR laser was shown to be the most effective in removing pigment. CONCLUSION: Nevus spilus can be treated effectively with the Q-switched ruby laser.

Treatment of small nevomelanocytic nevi with a Q-switched ruby laser.

BACKGROUND: Small nevomelanocytic nevi are common and some are of cosmetic concern. Conventional therapy may cause a scar or permanent hypopigmentation. OBJECTIVE: Our purpose was to determine whether selective photothermolysis of pigmented cells by Q-switched ruby laser treatment removes small nevomelanocytic nevi in a nonscarring fashion. METHODS: Twelve patients with 18 small nevomelanocytic nevi were treated with a Q-switched ruby laser (694 nm, 28 nsec) at fluences of 8 J/cm2. Biopsy specimens were obtained after treatment at varying time intervals. RESULTS: Twelve lesions (67%) showed a complete response and six lesions (33%) had a partial response. The only adverse sequela observed was mild fibrosis of the papillary dermis, without loss of papillary architecture. CONCLUSION: The Q-switched ruby laser is effective in removing small melanocytic nevi. However, some might recur depending on the depth of the nevomelanocytic nests.

Clinical and histological responses of congenital melanocytic nevi after single treatment with Q-switched lasers.

BACKGROUND: Laser irradiation of congenital melanocytic nevi is a controversial treatment. Recurrence of lesions after laser treatment appears to be the rule, and the effects of laser irradiation on cellular biological behavior and the possible mutagenic responses of nevomelanocytes that have received nonlethal doses of irradiation are still unclear. Without treatment, there is an increased potential for malignant degeneration over a life-time. The purpose of this study was to examine the effects of Q-switched lasers on congenital nevi and to explain the mechanism(s) behind the response of the nevi to laser treatment. Five congenital nevi were divided into 3 equal parts: 1 part was treated with the Q-switched ruby laser at a wavelength of 694 nm, 1 part was treated with the Q-switched neodymium: YAG laser at a wavelength of 1064 nm, and 1 part was left untreated to serve as control. At intervals ranging from 3 days to 3 months after laser irradiation, the lesions were excised and evaluated by routine staining. This clinical study was conducted entirely at the Massachusetts General Hospital Dermatology Laser Center, Boston, Mass. OBSERVATIONS: Both the superficial and the deep portions of the congenital melanocytic nevi were affected by the 2 lasers, as evidenced by macroscopic inspection as well as microscopic evaluation. However, the Q-switched laser treatment did not destroy all nevomelanocytes, particularly in the deeper, less pigmented portions of the lesions. CONCLUSIONS: Both the Q-switched ruby laser and the neodymium: YAG laser often removed only the superficial portion of the congenital melanocytic nevi. The Q-switched ruby laser (694 nm) appeared to be more effective in removing nevomelanocytes than the Q-switched neodymium: YAG laser (1064 nm).

Laser treatment of tattoos in darkly pigmented patients: efficacy and side effects.

BACKGROUND: Many modalities for the treatment of tattoos and pigmented lesions produce a greater risk of complications in Fitzpatrick types V and VI skin because of an increased incidence of adverse pigmentary changes and keloidal scarring. In fair-skinned persons Q-switched lasers have proved effective in removing pigmented lesions and tattoos without scarring. OBJECTIVE: This study was conducted to determine the efficacy and effects of Q-switched lasers on a small series of darkly pigmented patients with tattoos. METHODS: Four patients of Ethiopian origin with facial and neck tribal tattoos were treated with both the Q-switched ruby and Nd:YAG lasers. One black woman with a multicolored tattoo on the mid chest was treated with the Q-switched ruby laser. RESULTS: Clearing of all lesions was seen. The treatments did not result in scarring or permanent pigment changes other than the ones intended. CONCLUSION: Our results indicate that in darkly pigmented patients, Q-switched laser treatment of tattoos can be performed successfully. The longer wavelength Q-switched Nd:YAG laser is recommended when removing tattoos in darker complected persons. A test treatment is advised before treatment of large skin areas.