S2k guideline: Laser therapy of the skin.

This guideline aims to improve the efficiency and safety of lasers and optical radiation sources with similar effects (especially IPL). Laser therapy of skin lesions with an increased amount of melanocytes should be performed with caution. Laser treatment of pigmented melanocytic nevi is not recommended. The guideline contains recommendations regarding the treatment of lentigines and café-au-lait spots, non-pigmented dermal nevi, Becker nevus, nevus of Ota/Hori/Ito and melasma. Further recommendations focus on the treatment of skin lesions without an increased amount of melanocytes (ephelides, postinflammatory hyperpigmentation including berloque dermatitis, seborrheic keratoses, traumatic/decorative tattoos and metallic deposits), hypopigmentation (vitiligo), benign non-pigmented neoplasms (fibrous papule of the nose, nevus sebaceus, epidermal nevus, neurofibroma, sebaceous gland hyperplasia, syringoma, xanthelasma palpebrarum), inflammatory dermatoses (acne papulopustulosa/conglobata, acne inversa, granuloma faciale, lichen sclerosus, lupus erythematosus, psoriasis vulgaris, rosacea, rhinophyma), wrinkles/dermatochalasis/striae, hypertrichosis, scars (atrophic, hypertrophic; keloids, burn/scald scars), laser-assisted skin healing, onychomycosis, precancerous lesions and malignant tumors (actinic keratoses/field cancerization, cheilitis actinica, basal cell carcinoma), vascular skin lesions (angiokeratoma, angioma, hemangioma, malformation, spider veins, granuloma telangiectaticum (pyogenic granuloma), rubeosis (erythrosis interfollicularis colli, ulerythema ophryogenes), nevus flammeus, telangiectasias and Osler's disease (hereditary hemorrhagic telangiectasia) and viral skin lesions (condylomata acuminata, mollusca contagiosa, verrucae planae juveniles/vulgares/ verrucae palmares et plantares).

Optimized settings for Nd:YAG laser treatments of leg telangiectasias.

BACKGROUND AND OBJECTIVES: Telangiectasias of the lower extremities are very common. The objective of this study was to investigate whether the visual control of clinical signs for coagulation is needed to obtain an efficient treatment. STUDY DESIGN/MATERIALS AND METHODS: A total of 28 pairs of close-to-identical telangiectasias located on their lower extremities of 14 Caucasian females were included in the study. One of the paired vessels was randomly treated with a theoretically optimized and clinically verified fixed fluence (FF). The fluence on the other vessel was manually adjusted to the lowest level that resulted in visual coagulation or obstruction of blood flow (judged fluence [JF]). One or two treatments were made. RESULTS: By the four-month follow-up the same high degree of clinically evaluated vessel clearance of 2.6 (0-4 scale) was obtained for both the FF- and JF-treated vessels (P > 0.95, power = 0.60). The JF-treated group showed a significant higher incidence of hyperpigmentation 39.3% versus 28.6% (P = 0.05). CONCLUSIONS: As the vessel clearance was equal in both groups, these results strongly indicate that the use of fixed, clinically proven standard device laser settings lead to fewer side effects and should be recommended as the most safe Nd:YAG laser treatment for leg telangiectasias.

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.

Minimally invasive skin rejuvenation with Erbium: YAG laser used in thermal mode.

BACKGROUND AND OBJECTIVES: To evaluate the efficacy and safety of a thermal mode Erbium:YAG laser several in-vivo morphological as well as clinical changes were monitored in a multi-center investigation. STUDY DESIGN/MATERIALS AND METHODS: An Erbium:YAG laser was used at a thermal mode with sub-ablative fluences of 2.1 and 3.1 J/cm(2) with parallel air cooling to treat either periorbital, perioral rhytides or patients with post-traumatic or acne scars. Two treatments were applied 2 months apart, with follow-up at 1, 3, 6, and 12 months post-treatment. Photographs were taken before and at each follow-up visit and evaluated by three blinded independent reviewers. Histology and immunohistochemistry for pro-collagen expression were investigated. Optical coherence tomography (OCT) was performed before, and at 4, 14, and 28 days after single pass treatment with Erbium:YAG thermal pulses. RESULTS: The improvement of rhytides at 1-3 months follow-up was graded as excellent in 19%, good in 19%, fair in 31%, and no improvement in 31%. At the 6- to 12-month follow-up, the improvement was excellent in 40%, good in 40%, fair in 20%, and no improvement in 0%. The improvement of scars at 3-6 months follow-up was graded as excellent in 50%, good in 25%, fair in 25%, and no improvement in 0%. Intra- and post-operative discomfort was described as mild by the patients. OCT, histological sections and immunohistochemistry demonstrated production of new collagen bundles. CONCLUSIONS: Thermal Erbium:YAG pulses can induce collagen neogenesis, as proved by temperature elevation and morphological changes in the upper dermis. This leads clinically to visible and long lasting reduction of wrinkles and scars after applying multiple passes with minimal side-effects.

Photo-epilation: guidelines for care from the European Society for Laser Dermatology (ESLD).

Laser- or flashlamp- (also called intense pulsed light source or IPLS) assisted hair removal is a well tolerated and effective technique for patients who desire permanent reduction of hair growth. Although laser and light sources are very popular because of their non-invasive nature and the speed at which they operate, practitioners and patients have to be cautious to avoid permanent side effects instead of permanent hair reduction. These guidelines focus on patient selection and treatment protocol in order to provide safe and effective treatment. The ideal patient for laser hair removal is light skin with black coarse hair. Blond, grey and white hair does not respond to treatment. Individuals with dark skin, and especially tanned patients, are at higher risk for pigmentary changes. Sunscreen before and after treatment will produce and maintain untanned skin. The type of laser or IPLS and their specific parameters must be adapted to the patient (hair thickness, pigment concentration, Fitzpatrick skin type). Treatments should start on a test patch and a treatment grid can improve accuracy. Pre-, parallel and post-cooling, as well as a reduction of the fluence, will prevent adverse effects such as pigment alteration and scar formation. Average rates of long-term hair reduction are reported at between 70% and 90% at 6 months follow-up. At least three repeated treatments should be done to achieve partly permanent epilation.

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.