Laser therapy for refractory discoid lupus erythematosus when everything else has failed.

BACKGROUND: Discoid lupus erythematosus (DLE) is restricted to the skin, mostly the face, often chronic and disfiguring. Standard medical therapies include topical corticosteroids and antimalarials. This is a retrospective long-term follow-up of refractory DLE treated with different lasers and intense pulsed light (IPL). METHODS AND MATERIALS: Sixteen patients with histologically confirmed DLE participated in this study. Two men and fourteen women, aged 28-69 years, mean age 54 years, were treated at the laser units of the Departments of Dermatology at the University Hospital of Örebro from 2001 and at Skåne University Hospital in Malmö, Sweden from 1999. Several therapies, including first- and second-line treatments and even cryotherapy, had been used without response. Many patients had marked scarring. Pulsed dye laser (PDL) and IPL were used with low fluencies. RESULTS: Of 16 patients, 14 were improved regarding itching, erythema, scaling, scarring and pain. There was no scarring as a side effect of laser therapy or IPL. Two patients were not satisfied: one because of long healing time, and the other because of post inflammatory hyper pigmentation. CONCLUSION: IPL and PDL is a safe adjunctive therapy to conventional treatment of DLE. In the effort to prevent severe scarring and disfigurement it should be used as early as possible.

Improvement of microstomia in scleroderma after intense pulsed light: A case series of four patients.

INTRODUCTION: Intense pulsed light (IPL) treatment is well known for, for example, photo rejuvenation, where higher cut-off filters are used. The longer wavelengths penetrate deeper in the dermis leading to damage of the collagen and stimulation of new collagen formation, which lead to more soft and elastic skin. Microstomia in systemic sclerosis is the end result of excessive collagen deposition, which makes the perioral skin firm and tight. The patients have difficulties performing oral self-care, and even professional dental care can be complicated. METHODS: Four patients with systemic sclerosis and microstomia were treated with IPL (Ellipse A/S Flex System, Denmark ) in the perioral region. The patients received 3-5 treatments with 4-week interval. Oral opening was measured before and after treatments. results: The oral opening increased approximately 1 mm per treatment in three patients. One patient had temporomandibular joint symptoms of locking and did not have any increase in mouth opening. All four patients felt softening of the perioral skin, and all four patients described that articulation, eating and tooth brushing had become easier. CONCLUSION: IPL can be a new adjunctive alternative in the non-surgical treatment of microstomia in patients with systemic sclerosis.

Skin fluorescence controlled photodynamic photorejuvenation (wrinkle reduction).

BACKGROUND: Identical skin fluorescence can be obtained after one hour spraying with 0.5% liposome-encapsulated 5-ALA and after 0.5 hour application of 20% 5-ALA in a cream base. In this study the clinical outcome and side effects using the 0.5% 5-ALA in Caucasian skin are investigated and compared to earlier reported non-ablative treatments for wrinkles and improvements of skin texture using 20% ALA photodynamic photorejuvenation. METHODS AND MATERIALS: 37 healthy Caucasian female patients participated in a randomized, prospective split face study. Two different intense pulsed light (IPL) treatment modalities were investigated; both employed a pre-treatment of approximately one hour of spraying with 0.5% liposome encapsulated 5-ALA. One modality combined type I photorejuvenation with wrinkle reduction (C-PDT) using a waveband from 530 to 750 nm and short pulse durations (7 J/cm(2), 2 x 2.5 ms, delay 10 ms). The other modality (PDT alone) emitted a band of wavelengths from 400 to 720 nm, three passes were performed (3.5 J/cm(2), 30 ms pulse duration). RESULTS: After a series of three C-PDT or PDT-alone treatments, the patients obtained statistically significant (P< 5 x 10-5) reductions in periorbital and perioral wrinkles. Using the Fitzpatrick wrinkle scale, periorbital wrinkles were reduced by 1.2 grades (SD: 1.1) and 1.1 (SD: 1.1), respectively and perioral wrinkles were reduced by 0.8 grades (SD: 1.0) and 0.7 (SD: 0.9) respectively. The difference in treatment efficacy between. C-PDT and PDT alone treated sides was not statistically significant (P = 0.224). CONCLUSION: The present study shows that statistically significant improvements in wrinkle reduction and skin texture, equivalent to previously reported results obtained with 20% ALA, can be obtained with 0.5% liposome encapsulated 5-ALA. Only minor and infrequent side effects were registered at the 0.5% 5-ALA treated areas. Skin fluorescence monitoring during pre-treatrnent with 5-ALA may improve clinical efficacy, reduce time consumption and increase safety of the treatment.

Vascular lasers and IPLS: guidelines for care from the European Society for Laser Dermatology (ESLD).

Dermatology and dermatologic surgery have rapidly evolved during the last two decades thanks to the numerous technological and scientific acquisitions focused on improved precision in the diagnosis and treatment of skin alterations. Given the proliferation of new devices for the treatment of vascular lesions, we have considerably changed our treatment approach. Lasers and non-coherent intense pulse light sources (IPLS) are based on the principle of selective photothermolysis and can be used for the treatment of many vascular skin lesions. A variety of lasers has recently been developed for the treatment of congenital and acquired vascular lesions which incorporate these concepts into their design. The list is a long one and includes pulsed dye (FPDL, APDL) lasers (577 nm, 585 nm and 595 nm), KTP lasers (532 nm), long pulsed alexandrite lasers (755 nm), pulsed diode lasers (in the range of 800 to 900 nm), long pulsed 1064 Nd:YAG lasers and intense pulsed light sources (IPLS, also called flash-lights or pulsed light sources). Several vascular lasers (such as argon, tunable dye, copper vapour, krypton lasers) which were used in the past are no longer useful as they pose a higher risk of complications such as dyschromia (hypopigmentation or hyperpigmentation) and scarring. By properly selecting the wavelength which is maximally absorbed by the target--also called the chromophore (haemoglobin in the red blood cells within the vessels)--and a corresponding pulse duration which is shorter than the thermal relaxation time of that target, the target can be preferentially injured without transferring significant amounts of energy to surrounding tissues (epidermis and surrounding dermal tissue). Larger structures require more time for sufficient heat absorption. Therefore, a longer laser-pulse duration has to be used. In addition, more deeply situated vessels require the use of longer laser wavelengths (in the infrared range) which can penetrate deeper into the skin. Although laser and light sources are very popular due to their non-invading nature, caution should be considered by practitioners and patients to avoid permanent side effects. These guidelines focus on patient selection and treatment protocol in order to provide safe and effective treatment. Physicians should always make the indication for the treatment and are responsible for setting the machine for each individual patient and each individual treatment. The type of laser or IPLS and their specific parameters must be adapted to the indication (such as the vessel's characteristics, e.g. diameter, colour and depth, the Fitzpatrick skin type). Treatments should start on a test patch and a treatment grid can improve accuracy. Cooling as well as a reduction of the fluence will prevent adverse effects such as pigment alteration and scar formation. A different number of repeated treatments should be done to achieve complete results of different vascular conditions. Sunscreen use before and after treatment will produce and maintain untanned skin. Individuals with dark skin, and especially tanned patients, are at higher risk for pigmentary changes and scars after the laser or IPLS treatment.

5-ALA for photodynamic photorejuvenation--optimization of treatment regime based on normal-skin fluorescence measurements.

BACKGROUND AND OBJECTIVES: Photodynamic therapy using 20% 5 aminolevulinic acid (5-ALA) has recently been introduced as a new tool in optical skin rejuvenation. The primary objective of this study was to optimize incubation time, the topical delivery mechanism (vehicle) and the concentration of 5-ALA by detecting the dynamic changes of normal skin after 5-ALA application. The secondary objective was to develop a treatment regime which minimizes post-treatment photosensitivity. STUDY DESIGN/MATERIALS AND METHODS: Skin fluorescence distribution patterns after topical application of low concentrations of 5-ALA (0.5% and 1% preparations encapsulated in liposomes), were investigated. Twenty percent 5-ALA in moisturizing cream was used as a control. Ten healthy volunteers participated, and skin fluorescence was documented by fluorescent photography. The fluorescent intensity was measured in % of maximum obtained fluorescence after 3 hours 5-ALA application. RESULTS: Skin fluorescence intensity after topical application of 0.5% and 1% non-occluded liposome-encapsulated 5-ALA application was heterogeneous distributed and reached saturation level after approximate 2 hours. The maximal fluorescence for 0.5% and 1% 5-ALA treated areas was 4.2% (SD: 3.5%) and 2.4% (SD: 2%), respectively, and this difference was statistically significant (P = 0.036). The fluorescence decayed linearly shortly (within 15 minutes) after end of application and was back to baseline within 8 hours. In contrast, the fluorescence of areas treated more than 1 hour with 20% 5-ALA was very uniform and a linear relationship (r2 = 0.998) to the incubation time (0-3 hours) was registered. Furthermore, fluorescence intensity (15.2-57.9%) continued to increase after the end of 5-ALA application. The maximum fluorescence reach a level of 1.6-9 times the fluorescence measured by end of the 5-ALA application and occurred 8:13 hours (SD: 0:49 hours) after the end of 20% 5-ALA application. The average skin surface fluorescence induced by the liposome-encapsulated 0.5% 5-ALA applied for longer than 2 hours, was found to be statistically equal (P = 0.47) to the average measured skin surface fluorescence (4.2%) obtained after 30 minutes exposure to 20% 5-ALA cream (4.3%). CONCLUSION: Changing the 5-ALA vehicle from a moisturizing cream to liposome encapsulation, the 5-ALA concentration can be lowered by a factor of 40, and still induce the same skin fluorescence and at the same time eliminates the need for occlusion. The low post-treatment fluorescence also suggests a significantly reduced risk of post-treatment phototoxicity.

Epilation today: physiology of the hair follicle and clinical photo-epilation.

Despite the variations of length and type of hair (vellus or terminal), the growth of human hair in all body sites is cyclic. Phases of active hair growth, or anagen, are separated by periods of quiescence, or telogen. The duration of both phases varies greatly depending on the body site. Whether hairs are in anagen/telogen at the time of hair removal is important because only anagen hairs are particularly sensible to physical insults. Photo-epilation is a technique for long-term removal of unwanted hair by thermal destruction of the hair follicle and its reproductive system (stems cells). As melanin is the main chromophor existing in hair follicles the corresponding wavelength spectrum would range from ultraviolet up to infrared light. Furthermore longer wavelengths are preferred as the cromophor lies deep in the skin and the penetration of light is increasing with the wavelength. Thus, in the range of 600-1100 nm melanin absorption may be used for selective photothermolysis of hair follicles. Yet to be resolved questions for permanent destruction are the location of the key follicular target and the possible influence of the hair growth cycle on photothermolysis-induced hair removal. An overview on the individual physiology of the hair follicle is given to discuss the latest strategies for photo-epilation.

Facial photo rejuvenation using two different intense pulsed light (IPL) wavelength bands.

BACKGROUND AND OBJECTIVES: Intense pulsed light (IPL) systems are increasingly used for treatment of photo damaged skin. In the present study, we investigated the clinical efficacy and safety of two different wavelength bands generated by the same IPL device. STUDY DESIGN/MATERIALS AND METHODS: An IPL device was equipped with either a 555-950 nm filter (VL), or a 530-750 nm filter (PR). RESULTS: Fair, good or excellent clearance of visible telangiectasias was obtained in 81.8% of the patients (PR) and in 58.8% (VL). In the treatment of diffuse erythema, fair, good or excellent clearance was obtained in 72.7% (PR) and in 35.0% (VL). The PR filter was more efficient (P = 0.025) in reduction of diffuse erythema. The average number of treatments was 1.75 (PR) and 1.82 (VL). For the treatment of irregular pigmentation, fair, good or excellent clearance was obtained in 54.5% (PR) and in 61.9% (VL). Multiple treatments of irregular pigmentation were also evaluated. Using the VL filter more than two treatments did not induce further clinical improvement. The patients also scored their over-all satisfaction. Either fair, good or excellent results were reported by 66.7% (PR) and by 76.2% (VL). No skin atrophy, scarring or pigment disturbances were noted after the treatments. Swelling and erythema were registered by 2/3 (PR) and 1/3 (VL) of the patients. CONCLUSIONS: The two IPL wavelength bands were both found to be effective in the treatment of photo damaged facial skin. The clinical efficacy and safety of the two different treatment procedures were comparable to those reported in earlier studies, and finally treatment with these filter combinations required less than half the fluence, no active cooling and fewer treatments.