Advances in lasers, light sources

Dr. WaibelDermatology has been at the forefront of the laser and light development-an area in aesthetic and medical dermatology that has surged in recent years, according to Jill S. Waibel, M.D., Miami Dermatology and Laser Institute, assistant professor at the Miller School of Medicine, University of Miami (Voluntary), and chief of dermatology at Baptist Hospital, Miami, Fla.

“From the development of picosecond laser, devices created for lipolysis, scar treatments, to laser-assisted drug delivery, the recent expansion in laser dermatology is both promising and exciting as lasers continue to have a significant positive impact in medicine,” says Dr. Waibel, who directed the March presentation “Advances in Lasers and Light Sources: What's the Truth?” at the 2017 American Academy of Dermatology (AAD) Annual Meeting in Orlando, Fla.

Indications

Laser and light source treatments target many of the most common skin conditions that dermatologists encounter.

“The initial indication for the medical use of laser was to treat cutaneous vascular lesions, specifically vascular birthmarks on the skin of children. Recent innovations in laser have placed this modality at the forefront of treating a variety of vascular lesions. Several vascular lesions that can be treated are port wine stains (PWS), hemangiomas, venous malformations, facial telangiectasias, rosacea, cherry angiomas and spider angiomas,” she says.

Aging skin is prone to develop harmless brown lesions. Lasers and intense pulsed light sources are an excellent choice and frequently used for the cosmetic treatment of pigmented lesions, according to the dermatologist.

“Over-activity of the melanocytes may result in blotchy pigmentation,” she says. “Superficial pigmented lesions including ephelides, solar lentigines, and flat pigmented seborrheic keratosis, Nevus of Ota, Nevus of Ito, melasma and post inflammatory hyperpigmentation (PIH) can be effectively treated with most of the pigment-specific lasers.”

One word of caution: Clinical diagnoses need to be made prior to the lasing of any pigmented lesions so that dermatologists never treat a potentially premalignant or malignant lesion with a laser, Dr. Waibel says.

Permanent reduction of unwanted hair by lasers and light sources has been established in the last 20 years as a quick, safe and reliable option over all earlier, temporary hair removal modalities. Excess, unwanted hair affects both genders, and treating it with lasers has been found to improve quality of life for many patients, according to Dr. Waibel.

“Setting realistic expectations is important in laser hair reduction,” she says. “In general, the purpose of treatment is to decrease the amount of hair and thickness of hair in the treated areas. As we age, we continue to grow ‘new’ hairs over many decades. In some cases, such as faces of females and backs of males, the hair are genetically programmed to continue to activate new hair follicles over time, so periodic re-treatments are often needed for hair reductions patients.”

Tattoo removal is a big and still growing use for lasers.

“Recent studies have estimated that approximately one in four American adults have tattoos. Furthermore, approximately 40% of individuals between the ages of 26 and 40 have a tattoo. Of that subset, approximately one in five will consider removal of their tattoo,” Dr. Waibel says.

Perhaps the greatest breakthrough with lasers has been to treat wrinkles, texture and scars.

“The best devices that have been developed for such conditions are the fractional lasers,” Dr. Waibel says. “The first commercially available device for fractional non-ablative resurfacing was introduced in 2004. This device showed complete re-epithelization in 24 hours and collagen denaturation from papillary dermis to mid reticular dependent on treatment energy. The healing process response occurs from the zones of spared tissue by activating the epidermal stem cells. These lasers can be effective in treating photodamage, fine rhytids, mild dyschromia, melisma, scars, striae, and [much] more.”

Fractional ablative lasers continue to evolve with new second-generation devices.

“These fractional devices create fractional grooves and generate a directional injury and cross linear patterns that can be customized by the physician. These lasers can be used for the treatment of moderate to severe rhytides, moderate dyschromia, eyelid tightening, etc.,” Dr. Waibel says.

Photodynamic Therapy (PDT) effectively treats superficial non-melanoma skin cancers, actinic keratosis and acne. The treatment combines use of a photosensitizer, a light source within the absorption spectrum of the photosensitizer and molecular oxygen, which when stimulated will destroy a specific target tissue. Laser and light sources are currently being used for PDT to stimulate the photosensitizer and molecular oxygen to target the tissue, as well as create an aesthetically pleasing outcome, according to Dr. Waibel.

Lasers are leading the way in scar rehabilitation, or the restoration of form and function in scar patients. While there are multiple therapeutic scar rehabilitation approaches, lasers are a scientifically precise and effective treatment modality to rehabilitate and improve scars.

“Laser has added a powerful tool to improve scar symptoms and deformities. The kind of scars that laser can treat are atrophic, acne, surgical, burn and trauma scars,” Dr. Waibel says.

Next: Future applications

Future applications

“It is an exciting time for device innovation,” Dr. Waibel says.

The military is evaluating plasma-induced ablation as a source of plasma energy for wound healing, infection, skin treatments and aesthetic purposes.

Vaginal laser rejuvenation can tighten and tone sagging, loose or excess tissues in the vaginal and labial area. It also helps with urinary incontinence.

“These laser techniques are non-invasive, without the need for surgical incisions and sutures. There are still more clinical trials being conducted and the jury is out on the efficacy, timing and side effect profile for this procedure,” Dr. Waibel says.

The indocyanine green augmented laser diode is an IV infusion of the indocyanine green (throughout the process of PDT), which is activated with a laser. European researchers are studying the use of the indocyanine green augmented laser diode port wine stain treatment and other vascular applications, according to Dr. Waibel.

Researchers also are studying the free electron laser

“In lasers, electrons go through an accelerator and give up energy in order to be able to control the electromagnetic spectrum. This is how the beam of a laser is simulated and how there are different lasers with different wavelengths to treat different indications,” Dr. Waibel says. “This new device that is being studied will have one device that will have all of the different wavelengths to be able to treat all of the indications.”

Smarter devices are on the horizon, such as Optimal Coherence Tomography. This imaging device helps visualize skin structure in in-vivo high definition. Advantages are that it might provide additional valuable information to physicians in real-time. It’s non-invasive, rapid and painless for the patient and offers views in less than one second.

Dr. Waibel is involved in a clinical trial looking at using novel epidermal harvesting technology for treatment of hypopigmented skin conditions. CelluTome (Acelity) is a scarless and painless epidermal grafting procedure of fibroblasts and melanocytes by creating micro suction blisters with a combination of suction and warmth. This device is currently FDA approved as a therapy for diabetic ulcers.

“This tool allows for epidermal skin grafting in the outpatient setting without donor site morbidities, like scarring,” Dr. Waibel says.

Dr. Waibel offers Dermatology Times’ readers these laser and light source use practice pearls:

·    Always take photographs of your patients, regardless of which procedure they’re having.

·    Show patients photos of the healing process for each procedure. This will help them to look realistically at their options and choose the best for their lives.

·    Don’t treat patients with unrealistic expectations or patients that are rude to you or your staff. This will only lead to unnecessary problems.

Dr. Waibel is a speaker, investigator or researcher for Acelity, Alma Lasers, Candela/Syneron, Cutera, Lumenis, Lutronics, Michelson Diagnostics, Kythera, Sebacia and Sciton.