Evaluation of the safety and efficacy of the dual wavelength picosecond laser for the treatment of benign pigmented lesions in Asians.

BACKGROUND AND OBJECTIVES: Cutaneous pigmentary disorders are both more common and more difficult to treat in patients with skin color given the higher melanin content in the epidermis. Although Q-switched lasers are widely considered to be the standard treatment for both epidermal and dermal pigmentary conditions, a very high risk of post-inflammatory hyperpigmentation (PIH) of up to 25% is seen in patients with skin of color. Recently, the novel picosecond laser with pulse durations operating at sub-nanosecond domains has been shown to be effective in tattoo removal and in the treatment of acne scars. The objective of this study is to examine the safety and efficacy of the dual wavelength picosecond laser for the treatment of benign pigmented skin lesions in Asian patients. METHODS: Twelve subjects with benign pigmentary disorders and Fitzpatrick skin types III to IV were recruited in a prospective clinical study to examine the safety and efficacy of the dual wavelength picosecond laser. Patients were treated at approximately 2-6 week intervals depending of the type of lesion. The primary efficacy endpoint is the global percent of clearance which was evaluated by blinded observers using post treatment photographs compared to baseline photographs. Safety was evaluated before and after each laser treatment and patients were asked to rate the level of pain according to the Visual Analog Scale after each treatment session. Patient satisfaction was assessed at the completion of treatment with questionnaires. All patients were followed up at 4, 8, and 12 weeks after the last treatment session. RESULTS: The pigmentary conditions treated included melasma, freckles, lentiginies, café au lait macules, and Hori's macules. Three months after treatment, 53.8% of all pigments achieved excellent response (75-94% lightening,) 30.8% of pigments achieved good response (50-74% lightening,) and 7.7% of pigments achieved both fair (25-49% lightening) and poor responses (0-24% lightening), respectively. The average number of treatment sessions required to reach at least 50% clearance was 4.5 for melasma, 1 for freckles, 1.5 for lentigines and 1 for café au lait. The patient with Hori's macules did not reach 50% clearance after a total of six treatments. Sixty three percent of patients reported satisfaction in the subjective assessment, while 27.3% were neutral and 9.1% were very dissatisfied. The post inflammatory hyperpigmentation rate was 4.8% and 6.5% of subjects developed blistering as a side effect of treatment. CONCLUSION: The dual wavelength picosecond laser is a safe and effective treatment of benign pigmentary conditions in patients with skin of color. In particular, superior clinical efficacy is demonstrated for treatment of freckles and lentigines with a low risk of PIH. Lasers Surg. Med. 51:14-22, 2019. © 2018 Wiley Periodicals, Inc.

The efficacy of a combination non-thermal focused ultrasound and radiofrequency device for noninvasive body contouring in Asians.

BACKGROUND AND OBJECTIVE: Several studies have been published on the first generation non-thermal focused ultrasound with an average improvement of 0-3.95 cm reported. We aim to investigate the efficacy of the second-generation non-thermal focused ultrasound device with a combined radiofrequency hand piece. With the addition of radiofrequency energy, the temperature of the adipose tissue is raised before focused ultrasound is applied. This facilitates the mechanical disruption of fat cells by focused ultrasound. STUDY DESIGN AND METHODS: Twenty subjects were recruited and underwent three treatments biweekly. Caliper reading, abdominal circumference, and standardized photographs were taken with the Vectra(®) system at all visits. We aim to have the subjects stand and hold the same position and the photograph taken after exhalation. Caliper and circumference measurements carry uncertainty. It is impossible to eliminate all uncertainties but can be improved by having the same trained physician assistant perform the measurement at the same site and taking an average of three readings. Pain score and satisfaction were recorded by means of the visual analogue scale. The efficacy is defined by a statistically significant improvement in circumferential improvement based on intention-to-treat analysis. RESULTS: Seventeen subjects completed the treatment schedule. Abdominal circumference showed statistically significant improvement at 2 weeks post-second treatment (P = 0.023) and almost all subsequent follow-ups. Caliper readings were statistically significant at 2 weeks post-second treatment (P = 0.013) and almost all follow-ups. The mean pain score reported was 2.3 on the visual analog scale and 6% were unsatisfied with the overall treatments. Six incidents of wheal formation appeared immediately after treatment all of which subsided spontaneously within several hours. CONCLUSION: The combination non-thermal focused ultrasound and radiofrequency device is effective for improving body contour in Asians.

Efficacy of high-intensity focused ultrasonography for noninvasive body sculpting in Chinese patients.

BACKGROUND AND OBJECTIVES: High-intensity focused ultrasound (HIFU) is a noninvasive technology for body contouring. HIFU is focused within the subcutaneous adipose tissue, causing coagulative necrosis and cell death. The objective of this study is to evaluate the effectiveness of a HIFU device for sculpting of the abdomen. MATERIALS AND METHODS: The system has a set focal depth of 1.3 cm. Twelve subjects with adipose thickness no less than 2.5 cm who met the screening criteria were recruited. Each subject received one treatment to the abdomen. The total fluence used per site was 150-165 J/cm(2) with a mean of 161 J/cm(2) . The waist circumference at iliac crest and the point of maximum circumference were recorded at baseline, 4, 8, and 12 weeks post-treatment, as well as their weight and BMI. Subjects' rating on comfort level and satisfaction were collected via questionnaires at every follow-up. Standardized photographs were also taken with the Canfield System® at each visit. RESULTS: Seven out of 12 subjects were satisfied with the outcome and 9 out of 12 would recommend this treatment to their friends and family. There was statistically significant improvement in the waist circumference measured at both the iliac crest (P-value 0.013, 0.002, 0.005) and maximum waistline (P-value 0.003, 0.034, 0.023) at 4, 8, 12 weeks post-treatment. Spearman's rho for correlation of energy level versus improvement showed that at 12 weeks post-treatment follow-up, the improvement significantly correlated with the total fluence per treatment (P-value 0.041). The higher the total fluence delivered, the larger the decrease in waist circumference. CONCLUSIONS: High-intensity focused ultrasound effectively decreases waist circumference in Chinese. The higher the total fluence delivered, the larger the decrease in waist circumference was observed.

Pharmacogenetics of allopurinol--making an old drug safer.

Allopurinol is a drug that has been used for decades to lower serum urate levels in patients with gout or chronic renal failure and in cancer patients undergoing chemotherapy at risk of tumor lysis syndrome. Patients may develop cutaneous hypersensitivity reactions, ranging from mild rashes to potentially fatal severe cutaneous adverse reactions (SCARs) namely drug hypersensitivity syndrome, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). Recent studies have demonstrated the association between human leukocyte antigen (HLA) B*58:01 allele and allopurinol-induced SCARs, which might explain ethnic differences in their incidences. Genotyping is now required before starting abacavir and carbamazepine so as to identify individuals susceptible to SJS. However, no genetic screening is advocated before commencement of allopurinol. The lack of availability of a rapid and inexpensive screening test for the HLA-B*58:01 allele is one of the obstacles to such screening. Development of a test that is quick, accurate, and cost-effective is warranted.

Evaluation of combined fractional radiofrequency and fractional laser treatment for acne scars in Asians.

BACKGROUND AND OBJECTIVES: Fractionated radiofrequency (RF) induces deep dermal heating and leaves the epidermis less affected. We studied the efficacy and safety of bipolar RF and fractional diode laser followed by fractional RF in Asians with acne scars. MATERIALS AND METHODS: Twenty-four patients (skin types III and IV) with acne scars received up to five treatments of combined fractional 915-nm laser and bipolar RF using a Matrix IR applicator (Syneron Medical Ltd, Yokneam, Israel) with fluence ranging from 50 to 70 J/cm(2) , RF at 70-100 J/cm(3) , double passes followed by full-face bipolar fractional RF treatment using Matrix RF at energy ranging from 50 to 62 mJ/pin, at 4-week intervals. Changes in acne scars, skin texture, pore size, pigmentation irregularity, and complications were assessed up to 3 months post-treatment by standardized photographs obtained with Canfield Visia-CR system®. Subjective improvement and patient satisfaction were assessed by questionnaire. RESULTS: Twenty patients (age 27.7 ± 8.4 years) completed the study. Modest but statistically significant improvement was noted in acne scars, with the mean grade decreased by 29% (P < 0.001), and 52% were rated with at least moderate objective global improvement at 3 months. Mean pain score was 2.6 on a scale of 0-4. There were also objective improvements in all secondary endpoints. Post-inflammatory hyperpigmentation (PIH) occurred mainly over bony areas in 6.5% of all treatments. Subjective improvement was moderate to significant for 36.8% of patients, and 63% reported being satisfied with the treatment results at 3 months despite considerable pain level. CONCLUSION: Use of fractional laser with RF followed by fractional RF was shown to be safe and effective for acne scars with modest improvement and low PIH rate comparable to other resurfacing techniques in this Asian case series. Adequate pain control and recduced energy level when treating areas in close proximity to bone are advised. Lasers Surg. Med. 44: 622-630, 2012. © 2012 Wiley Periodicals, Inc.

Safety study of transcutaneous focused ultrasound for non-invasive skin tightening in Asians.

BACKGROUND AND OBJECTIVES: Transcutaneous intense focused ultrasound has emerged as a novel technology for non-invasive skin tightening. The objective of this study was to evaluate the safety profile of a transcutaneous focused ultrasound device for the treatment of facial skin laxity in Asians. MATERIALS AND METHODS: The patients received one to three full-face treatments with the transcutaneous focused ultrasound device. Three transducers (7.0 MHz, 3.0 mm focal depth; 7.0 MHz, 4.5 mm focal depth; 4.0 MHz, 4.5 mm focal depth) were used to deliver a single pass of microthermal coagulation zones without any topical anesthetics. Standardized photos were taken at baseline and at each follow-up with the Canfield Visia CR system® and were assessed by two independent physicians. Adverse effects were assessed up to 6 months post treatment. Subjective assessments in terms of pain and tolerability were also evaluated with patient questionnaires. RESULTS: Forty nine Chinese patients (skin types III-IV, mean age 53.3) completed a total of 68 treatment sessions. Transient erythema and edema were seen in the majority of patients. Focal bruising was present in up to 25% of treatment sessions. Two cases of post-inflammatory hyperpigmentation were seen on the forehead at 1-month post-treatment. One patient experienced focal twitching over the lower eyelid at 1-month follow-up, which was clinically consistent with hemifacial spasm and was unrelated to the ultrasound device. The degree of pain during treatment was recorded as severe in 54.4% of treatment sessions. CONCLUSIONS: Transcutaneous intense focused ultrasound appeared to be safe for non-invasive facial skin tightening in Asians. Adverse events were mild and transient. Pain control during treatment should be optimized. No serious permanent or delayed side effects were noted up to 6 months post treatment.

Liposome-encapsulated 0.5% 5-aminolevulinic acid with intense pulsed light for the treatment of inflammatory facial acne: a pilot study.

BACKGROUND: Liposome used in spray form to encapsulate and deliver 5-aminolevulinic acid (5-ALA) into the pilosebaceous unit lowers the concentration of 5-ALA to 0.5% in photodynamic therapy (PDT) for acne, with low post-treatment photosensitivity. OBJECTIVE: To investigate the clinical outcome and side effects of PDT using intense pulsed light (IPL) and 0.5% 5-ALA spray for inflammatory facial acne in Asian skin. METHODS: Twelve subjects (skin types IV-V) with facial acne received full-face treatment at 3-week intervals with IPL 1 hour after being sprayed with 5-ALA. Lesion counts were assessed using serial standardized photographs taken up to 6 months after treatment. Serial sebum measurement and subjective assessment was conducted. RESULTS: There were mean reductions in inflammatory lesions of 52% at 1 month (p=.02) and 65% at 6 months (p=.04) after treatment. Mean subjective acne score decreased from 6.6 to 4.5 (on a scale from 1 to 10) 1 month after treatment. Significant reduction in sebum production was noted only on the forehead. No significant side effects, including postinflammatory hyperpigmentation and phototoxicity, were observed. CONCLUSION: Use of 0.5% liposome-encapsulated 5-ALA spray with IPL reduced inflammatory facial acne in Asians, with a low risk of persistent phototoxic effects after PDT in this pilot study.

Fractional ablative carbon dioxide laser resurfacing for skin rejuvenation and acne scars in Asians.

BACKGROUND AND OBJECTIVES: Ablative fractional resurfacing (AFR) is a new modality for photorejuvenation and acne scars which combines carbon dioxide (CO2) laser ablation with fractional photothermolysis. The objective is to evaluate the efficacy and side effects of a new fractional CO2 ablative device (Fraxel Re:pair) for skin rejuvenation and acne scars in Asians. MATERIALS AND METHODS: Nine patients underwent one full-face treatment. The energy levels ranged from 30-70 mJ with coverage between 30% and 45%. Improvement in skin texture, laxity, wrinkles, enlarged pores, overall pigmentation irregularity, and adverse effects were assessed up to 6 months post-treatment. Standardized photographs using the Canfield Visia CR system® were assessed by two independent observers. Subjective improvement was assessed by patient questionnaires. RESULTS: Nine Chinese patients (skin types III and IV, mean age 44.8) were included. Statistically significant improvements were seen for skin texture, skin laxity, wrinkles, enlarged pores, and acne scars. The post-inflammatory hyperpigmentation rate was 55.5% and 11.1% at 1 and 6 months post-treatment, respectively. Eighty-six percent of patients were overall satisfied to very satisfied with the treatment. CONCLUSION: Ablative fractional CO2 laser resurfacing was overall safe and effective for skin rejuvenation and acne scars in Asians. However, in view of the high post-inflammatory rate and the statistically significant but only mild to moderate improvement after a single treatment as observed in this study, there is a need to review the current role of fractional ablative CO2 laser treatment as compared to fractional non-ablative for skin rejuvenation and acne scar treatment in Asians.

Hair removal with neodymium-doped yttrium aluminum garnet laser and pneumatic skin flattening in Asians.

BACKGROUND: Based on the "gate theory" of pain transmission, pneumatic skin flattening (PSF) may reduce pain during laser hair removal. OBJECTIVE: To compare the pain, efficacy, and adverse effects after laser hair reduction using PSF with that using a dynamic cooling device (DCD) in Asians. METHODS: Twelve participants (skin types III-IV) received laser hair removal with a PSF device on the right axilla and DCD on the other side. Pain was assessed based on a visual analogue scale. Hair regrowth was rated based on photographs taken before treatment and in follow-up visits at 8 and 36 weeks. RESULTS: Sixty-seven percent of participants felt less pain in the PSF side than the DCD side right after laser treatment. On a scale of 1 to 10, the immediate mean pain score was 5.7±2.0 for the PSF side and 6.5±1.5 for the DCD side (p=.09). Seventy-five percent of the participants preferred treatments with PSF. Efficacy of hair reduction was similar on both sides 8 and 36 weeks after treatment. CONCLUSION: PSF decreases pain sensation during laser hair removal while allowing higher energy densities in Asian patients. The equal efficacy and complication rate of PSF indicates that it is a feasible alternative to DCD at lower cost.

A case series of facial depigmentation associated with low fluence Q-switched 1,064 nm Nd:YAG laser for skin rejuvenation and melasma.

BACKGROUND AND OBJECTIVE: In recent years, "laser toning" using low fluence, large spot size, multiple passed Q-switched 1,064 nm Nd:YAG laser has gained much popularity in Asian countries for non-ablative skin rejuvenation and the treatment of melasma. This case series highlights one of the complications associated with laser toning, which is facial depigmentation. MATERIALS AND METHODS: Fourteen patients with laser toning-associated facial depigmentation were assessed with cross-polarized and ultraviolet (UV) photographic images. The laser toning regimens received by these patients, as well as the treatment given for depigmentation, were analyzed retrospectively. RESULTS: All 14 patients were Chinese females, 9 of whom received laser toning for non-ablative skin rejuvenation and the other 5 for melasma. The treatment regimens received by these patients were highly variable. The total number of treatments received ranged from 6 to 50 (mean 22.07). In all cases, UV photographic images demonstrated facial mottled depigmentation. Laser toning failed to significantly improve melasma in all five patients. Five patients received targeted narrowband UVB for depigmentation with good clinical results. CONCLUSIONS: Laser toning with low fluence Q-switched 1,064 nm Nd:YAG laser for skin rejuvenation and melasma can be associated with mottled depigmentation. With laser toning being frequently performed, this complication may become more commonly encountered in clinical practice. The depigmentation can appear after only a few treatment sessions, and can cause much disfigurement, especially in cases with background melasma. Further studies on laser toning are needed with the view to optimizing efficacy and minimizing side-effects.

The use of non-ablative fractional resurfacing in Asian acne scar patients.

BACKGROUND AND OBJECTIVES: Non-ablative fractional resurfacing (NA FR) has been shown to be effective for photorejuvenation and acne scarring. Previous studies indicated that density, more than pulse energy, was associated with post-inflammatory hyperpigmentation (PIH) in Asians. The objective of this retrospective study was to assess the efficacy and complications of eight passes of NA FR ('full-NA FR') with the 1,550 nm erbium-doped fibre fractional laser (Fraxel SR laser system, Solta Medical, Hayward, CA) versus four passes ('mini-NA FR') with comparable pulse energy and treatment level as 'full-NA FR', but double the number of treatment sessions in Asian acne scar patients. MATERIALS AND METHODS: Forty-seven Asian atrophic facial acne scar patients who received full-face full-NA FR or mini-NA FR treatments between December 2005 and February 2009 were included. All photographic images captured with the Canfield Visia CR system at baseline and follow-ups were assessed for clinical efficacy and complications by an independent, non-treating and blinded physician. RESULTS: The total treatment densities for full-NA FR and mini-NA FR were 442.5 and 210.5 MTZ/cm(2), respectively. For full-NA FR, the PIH risk was 18.2% with cross-polarized images compared to 6.0% for mini-NA FR. This difference was statistically significant (P < 0.001). Improvement in skin texture, acne scarring, enlarged pores and overall pigmentation irregularity all reached statistical significance at last follow-up compared to baseline. There was no statistically significant difference in clinical efficacy between three full-NA FR and six mini-NA FR treatments. CONCLUSIONS: NA FR was effective and safe in Asians. By reducing the number of passes and the total treatment density, the risk of PIH could be reduced. Meanwhile, clinical efficacy could be maintained by increasing the total number of treatment sessions.

Treatment of inflammatory facial acne with 1,450-nm diode laser in type IV to V Asian skin using an optimal combination of laser parameters.

BACKGROUND: The 1,450-nm diode laser is effective for the treatment of inflammatory acne, but there is a significant risk of postinflammatory hyperpigmentation (PIH) in Asian skin. OBJECTIVE: To determine whether lower fluence and shorter cooling duration of the 1,450-nm diode laser improve acne effectively with minimal PIH in darker skin. MATERIALS AND METHODS: Twenty-six subjects (skin phototypes IV-V) with inflammatory facial acne received four treatments using the 1,450-nm diode laser with 6-mm spot size 3 to 4 weeks apart. We used three passes with a fluence of 8 J/cm(2) with dynamic cooling of 25 ms to minimize PIH. Serial blinded assessment of acne lesion counts and sebum measurement were evaluated before and up to 6 months after treatment. RESULTS: Four weeks and 6 months after the last treatment, reduction of mean acne lesions was 29% (p<.01) and 40% (p<.03), respectively, from baseline in the group with moderate acne. Significant improvements of sebum production were noted. Four episodes of temporary PIH (3.8%) were observed out of all treatment sessions. CONCLUSION: Use of multiple passes of a 1,450-nm diode laser with lower fluence and shorter dynamic cooling device retains its therapeutic efficacy with substantial reduction of PIH for moderate acne.

Combined infrared light and bipolar radiofrequency for skin tightening in Asians.

BACKGROUND AND OBJECTIVE: As the demand for non-invasive procedures for skin tightening is increasing, combined optical and radiofrequency (RF) devices have recently emerged. The purpose of this study is to evaluate the safety and efficacy of a device that combined broadband infrared (IR) light (700-2000 nm) and bipolar RF (electro-optical synergy [ELOS]) for non-ablative treatment of facial laxity. DESIGN/MATERIALS AND METHODS: Nineteen Chinese volunteers of skin types III-V, with facial laxity and periorbital rhytides, received three treatments at 3-week intervals with combined IR (700-2000 nm, 10 W/cm(2)) and RF energies (70-120 J/cm(3)). Standardized photographs were taken by the Canfield Visia CR system at baseline and serially for 3 months after the last treatment. Two masked assessors evaluated the photographs to assess the improvement in skin laxity. Patient satisfaction scores were also obtained. RESULTS: At 3 months after the last treatment, 89.5% of the subjects reported moderate to significant subjective improvement in skin laxity of cheek, jowl, periorbital area and upper neck, with a high overall satisfaction rating. Masked observers' assessments were less remarkable. Mild improvement in skin laxity was observed over mid and lower face. There was no serious complication. CONCLUSION: The combination of broadband infrared light and bipolar radiofrequency produces mild improvement of facial laxity in Asians with no serious adverse sequelae. A high patients' satisfaction is achieved. However, further studies are necessary to demonstrate the long-term effects of the procedure and to optimize treatment parameters.

A comparative study of intense pulsed light alone and its combination with photodynamic therapy for the treatment of facial acne in Asian skin.

BACKGROUND AND OBJECTIVES: The reaction to intense pulsed light (IPL) on Asian skin often differs from that on Caucasian skin. The study reported herein evaluated the effect on acne vulgaris of IPL alone and when IPL was combined with photodynamic therapy (PDT) using topical methyl aminolevulinate (MAL) in Asians. STUDY DESIGN/MATERIALS AND METHODS: Thirty Chinese subjects with phototypes IV or V and moderate acne were enrolled for a randomized, half-facial treatment study with IPL alone, IPL with PDT, or as controls. Sixteen percent MAL cream was applied to half of the face 30 minutes before treatment in the PDT group. The IPL was provided by the Ellipse Flex system (Danish Dermatologic Development, Denmark), which emitted wavelengths of 530 to 750 nm. The subjects were treated four times at 3-week intervals. Single passes of double pulses with a 10 milliseconds delay and a pulse duration of 2.5 milliseconds were used. The assessment of inflammatory and non-inflammatory acne lesions by two blinded investigators was based on standardized photographs that were taken before each treatment, and at 4 and 12 weeks after the final treatment. RESULTS: Twenty-three patients completed the study. The mean reduction of the inflammatory lesion count was 53% in the PDT group, 22% in the IPL group, and 72% in the control group at 4 weeks, and 65% in the PDT group, 23% in the IPL group, and 88% in control group at 12 weeks. The mean clearance of non-inflammatory lesions was 52% in the PDT group, 15% in the IPL group, and 14% in the control group at 4 weeks, and 38% in the PDT group and 44% in the IPL group at 12 weeks, when and an increase of 15% was noted in the control group. Most patients experienced a reduction of inflammatory lesions that was not statistically significant on the PDT-treated side (P = 0.06) or the IPL-treated side (P = 0.82) at 12 weeks after treatment. Pretreatment with MAL resulted in a better clearance of inflammatory acne than IPL alone. There were no statistically significant differences between the intervention groups and the control group in the mean reduction of inflammatory lesions. Significant reductions of non-inflammatory lesions were observed in the MAL-PDT group (38%, P = 0.05) and IPL groups (43%, P = 0.00) 12 weeks after treatment. Twenty-five percent of the subjects in the PDT group withdrew because of intolerance to procedure-related discomfort. CONCLUSIONS: MAL-PDT using IPL and MAL in Asians did not lead to significant improvement of moderate inflammatory acne compared with the control group. However, there was a delayed effect on non-inflammatory lesions, with significant reductions in both the PDT and IPL groups. A proportion of patients could not tolerate the discomfort that was related to PDT despite the short MAL incubation.