Experts' top device picks

Dermatologists with established laser practices agree on their picks for the best workhorse lasers. These are the lasers, dermatologists say, they use day after day, regardless of where they practice in the United States.

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Pulsed Dye, Nonablative Fractionated

Tina S. Alster, M.D., who started the Washington Institute of Dermatologic Laser Surgery in 1990, says there are a few devices she can’t live without at her Washington, D.C., laser practice.

Dr. Alster“One is the pulsed dye laser, which is a vascular-specific laser that I use for birthmarks, port wine stains, hemangiomas, hypertrophic scars (and) for a variety of other vascular conditions,” she says. “It is a workhorse laser for me. It also happens to be my oldest laser. Of course, the system has received several upgrades over the years, but it’s the laser system that is my longest-standing and most used.”

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Dr. Alster’s second pick is her nonablative fractionated laser, the Fraxel Dual (Solta Medical).

“I like it because you can treat atrophic acne and traumatic or surgical scars, as well as wrinkles, dyspigmentation, large pores and stretch marks. Unlike prior resurfacing lasers, it is useful for treatment of photodamaged and scarred skin in nonfacial areas, as well,” she says.

Dr. Alster says she could start a new laser practice with the pulsed dye and nonablative fractionated devices, alone, along with fillers and injectables.

Dr. KeaneyTerrence Keaney, M.D., clinical professor of dermatology and urology at George Washington University Medical Center, and director of Men’s Cosmetic Center at the Washington Institute of Dermatologic Laser Surgery, says the two most popular lasers for his male patients are the pulsed dye and nonablative fractionated resurfacing lasers.

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“There are a lot of men coming in for the treatment of rosacea, which is common in men, as well as a lot of male patients coming in for treatment of acne scarring or traumatic scarring,” Dr. Keaney says. “I found that both those lasers can be used for scarring. The pulsed dye laser is indicated for hypertrophic, erythematous traumatic scars; whereas the fractionated nonablative resurfacing laser is great for atrophic acne scarring or older atrophic scars.”

NEXT: Scar treatment 

Scar treatment

elizabeth L. Tanzi, M.D.Elizabeth L. Tanzi, M.D., clinical professor of dermatology at George Washington University Medical Center, also a co-director at the Washington Institute of Dermatologic Laser Surgery, says the two things she does most often at her laser practice happen to be the procedures she enjoys the most. The first is the treatment of scars with pulsed dye or fractionated lasers.

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“I love to treat scars because of the high level of satisfaction, not only for the patient but also for the physician. The laser treatment of scars has really blossomed in the past two decades,” Dr. Tanzi says.

Another top pick for Dr. Tanzi is fractionated lasers because of their versatility.

“[Fractionated lasers] treat scars well, but they can also treat other indications, such as photodamaged skin, wrinkles, and they treat old acne scars. So, fractional lasers are high on the list as one of the first lasers in which to invest if you’re thinking about starting a laser practice,” she says.

NEXT: Intense pulsed light

Intense Pulsed Light

Michael H. Gold, M.D., whose laser practice in Nashville, Tenn., features more than 40 devices, says the workhorse in any laser practice is Intense pulsed light (IPL) or the Harmony AFT (Advanced Fluorescence Technology, Alma Lasers), which is needed for treating red and brown lesions.

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“It is a must for pigment and vascular lesions and rejuvenating the skin. The AFT 540 and 570 nm with contact cooling is a technology we use every day,” Dr. Gold says. “IPLs of today are far more sophisticated than IPLs of yesterday - better in every way. Devices like the Harmony, the M22 (Lumenis), and the BBL (BroadBand Light; Sciton) are used all the time and we find patients requesting these kinds of treatments daily.”

IPL is a proven technology and works to rejuvenate the skin, according to Dr. Gold.

“Fractional lasers can be used to rejuvenate the skin and also to treat acne scars. One can also use fractional bipolar RF in these cases that has proven to work very nicely here,” he says.

NEXT: Other go-to devices

Other Go-To Devices

Photodynamic therapy for acne is among the sound device options for dermatologists who don’t do cosmetic work, according to Bruce Katz, M.D., director of the Juva Skin and Laser Center in midtown Manhattan, N.Y.

“Today we have lasers that will treat psoriasis, vitiligo - we have lasers just for medical conditions. These include 308 nm lasers,” Dr. Katz says.

Dr. Katz, who has more than 50 lasers at his laser practice, says his go-to devices include a fractional laser for wrinkles, the alexandrite laser for brown spots, a pulsed dye laser for broken blood vessels and redness, and a radiofrequency type device for skin-tightening.

“There’s a new one that is called vShape (Alma Lasers), which we use for skin tightening. That’s good for… around the neck, jowls (and for) loose abdomens.” Dr. Katz says. “If you want to do liposuction… then I would say laser lipolysis, called Smartlipo (Cynosure). Cellulite is a very popular problem, so a laser to treat that is called Cellulaze (Cynosure).”

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If she were to add a third dimension to a new laser practice, Dr. Alster says she most likely would have body contouring devices, including Coolsculpting and Ultherapy (Ulthera), and ultrasound device for skin lifting and tightening.

A hair removal device is one to consider, according to Dr. Katz.

“That’s very popular. I would definitely put that in the bucket,” says Dr. Katz who also points out that the hair removal laser you choose depends on your patient population’s skin type - whether you have patients with lighter or darker skin. “There are about three different types of lasers just for hair removal that we use,” Dr. Katz says.

Dr. Gold also gives the thumbs-up to hair removal lasers.

“There are many great devices, and now they are fast and painless. Hair removal is our domain and a source for referral for other procedures we do,” Dr. Gold says.

Depending on where a practice is, tattoo removal could be a lucrative addition to a dermatologist’s menu of services. Estimates are that nearly 10 percent of Americans have some sort of tattoo, and as many as half of those will eventually want them removed.

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One laser that’s creating a buzz for tattoo removal is the PicoSure (Cynosure), according to Dr. Katz. The laser delivers ultra-short pulse bursts of energy to the skin in trillionths of a second and the device’s pulse width is 100 times shorter than nanosecond technology. These features, according to company literature, result in better clearance with fewer treatments and less fluence.

NEXT: Approach with caution

Approach With Caution

Some skin issues are better left to treatments outside the realm of lasers and light sources, and melasma is a prime example says Dr. Tanzi.

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“Oftentimes, laser treatments are not effective for melasma or may even worsen it due to the heat imparted by the laser. Chemical peels are just as effective if not better than laser for melasma,” she says. “If you’re talking about things like psoriasis, lasers can be helpful for… psoriasis in small areas, but if a patient has widespread psoriasis, lasers will only have a supportive role.”

It’s also important that dermatologists use the best laser for any given indication, rather than use a subpar technology when other better options exist. For example, says Dr. Katz, avoid using a nonablative fractional laser to tighten skin when there are other technologies - such as ultrasound or radiofrequency, which work better to tighten the skin.

Disclosures

Dr. Tanzi is on the medical advisory boards at Zeltiq, Marimar and Clarisonic. Dr. Alster has relevant financial interests with Cynosure, Home Skinovations, Palomar and Syneron. Dr. Katz is on the clinical advisory boards of Allergan, Alma, Valeant and Merz. He is a consultant for Pacific Biosciences and El-En Engineering, and is a Cynosure stockholder. Dr. Gold is compensated for research initiatives and speaking engagements when sponsored by laser companies. He works with Alma, Lumenia, Syneron, Ellman, Ulthera and Venus. Dr. Keaney reports no relevant financial interests.