Comparative efficacy and safety of six photoelectric therapies for the atrophic acne scars: A network meta-analysis.

Objectives This network meta-analysis assessed the relative efficacy and safety of six common photoelectric therapies including 1064-nm neodymium-doped yttrium aluminum garnet (Nd: YAG), fractional carbon dioxide laser(FSCO2), fractional micro-plasma radiofrequency(Plasma), micro-needling fractional radiofrequency (MRF), 1550nm or 1540nm erbium-glass non-ablative fractional laser (NAFL) fractional erbium-doped yttrium aluminum garnet (Er: YAG). Methods A comprehensive search to identify relevant studies was conducted using four electronic databases. Outcome measures were extracted based on subjective and objective indexes, including the dermatologists' evaluation(DE), the patients' overall satisfaction(PS), VAS score, and Postinflammatory hyperpigmentation (PIH). Results Eleven published clinical research studies, involving 405 patients were included in this study. Ranking of DE from large to small is as follows: Nd: YAG, FSCO2, Er: YAG, Plasma, NAFL, MRF. In terms of PS, the rand from high to low can be described as follows: Er: YAG, Nd: YAG, FSCO2, Plasma, NAFL, MRF. In connection with the sequencing of adverse events, pain severity from slight to severe as follows: Er:YAG, Nd:YAG, FSCO2, NAFL, MRF, Plasma. The probability of having PIH are presented in order from lowest to highest as follows: MRF, Plasma, Nd: YAG, NAFL, Er: YAG, FSCO2. Conclusion FSCO2 remains the mainstream of potentially curative treatment, then again Nd: YAG and Er: YAG require greater efforts to prove their superior effectiveness. NAFL might be appropriate for mild and moderate improvement with its strengths of good tolerance while Plasma fits into patients with higher pain thresholds but an expectation of higher results. MRF has not given expression on absolute predominance for the present. Registration PROSPERO CRD42021242160 (available from https://www.crd.york.ac.uk/prospero).

Optimizing Q-switched lasers for melasma and acquired dermal melanoses.

The Q-switched Nd:YAG laser is an established modality of treatment for epidermal and dermal pigmented lesions. The dual wavelengths of 1064nm and 532nm are suited for the darker skin tones encountered in India. Though this laser has become the one of choice for conditions such as nevus of Ota, Hori's nevus and tattoos, its role in the management of melasma and other acquired dermal melanoses is not clear. Despite several studies having been done on the Q-switched Nd:YAG laser in melasma, there is no consensus on the protocol or number of sessions required. Acquired dermal melanoses are heterogenous entities with the common features of pigment incontinence and dermal melanophages resulting in greyish macular hyperpigmentation. This article reviews the current literature on laser toning in melasma and the role of the Q-switched Nd:YAG laser in stubborn pigmentary disorders such as lichen planus pigmentosus. As the pathology is primarily dermal or mixed epidermal-dermal in these conditions, the longer wavelength of 1064nm is preferred due to its deeper penetration. Generally multiple sessions are needed for successful outcomes. Low fluence Q-switched Nd:YAG laser at 1064nm utilizing the multi-pass technique with a large spot size has been suggested as a modality to treat melasma. Varying degrees of success have been reported but recurrences are common on discontinuing laser therapy. Adverse effects such as mottled hypopigmentation have been reported following laser toning; these can be minimized by using larger spot sizes of 8 to 10mm with longer intervals (2 weeks) between sessions.

Autologous noncultured melanocyte-keratinocyte transplantation in stable vitiligo: A randomized comparative study of recipient site preparation by two techniques.

BACKGROUND: Accurate preparation of recipient area is a critical step in melanocyte-keratinocyte transplantation procedure for vitiligo. It is an important potential step for adaptation in the quest to achieve better results and ablative lasers potentially offer excellent precision over margin and depth control in achieving that. OBJECTIVE: To compare between the two techniques used for recipient site preparation: Er:YAG laser ablation and mechanical dermabrasion for melanocyte-keratinocyte transplantation procedure in terms of re-pigmentation achieved and adverse effects seen. METHODS: A randomized comparative trial was performed among 32 patients of stable vitiligo undergoing melanocyte-keratinocyte transplantation procedure. In Group A (n = 15), recipient site preparation was done with Er:YAG laser, and in Group B (n = 17), it was done with a motorized dermabrader. Patients of both groups were objectively assessed for re-pigmentation at 1, 3 and 6 months. RESULTS: A total of 253.696 cm2 of depigmented surface was operated upon and re-pigmentation of 125.359 cm2 (49.4%) was achieved. On comparison between two groups, no statistical difference was found with respect to total re-pigmentation achieved (Group A: 54.67% vs Group B: 48.841%, P = 0.663) and grades of re-pigmentation achieved (P = 0.796). Occurrence of adverse events was also statistically similar in both the groups. CONCLUSION: This study did not reveal any statistically different outcome (in terms of re-pigmentation and adverse effects) between the two methods of recipient site preparation - motorized dermabrasion and Er:YAG ablation. LIMITATIONS: This study is small and larger studies are needed to ascertain the benefit of Er:YAG for recipient site preparation. Future studies may also ascertain variables such as time taken to prepare the recipient area, nature of bleeding, postoperative healing, difficulties in specific area, cost of the procedure, patient comfort and ease of the surgeon, rather than comparing the re-pigmentation alone.

Combined vitamin C sonophoresis and neodymium-doped yttrium aluminum garnet (NdYAG) laser for facial hyperpigmentation: An outcome observation study in Asian patients.

BACKGROUND: The neodymium-doped yttrium aluminum garnet (NdYAG) laser therapy has been a popular technique for facial rejuvenation but certain adverse effects like post-inflammatory hyperpigmentation are issues of concern to Asian patients. AIMS: To assess the outcome following combined treatment with vitamin C sonophoresis and NdYAG laser, in selected cases of facial hyperpigmentation. METHODS: Twenty three women with dyschromia or melasma who had undergone five sessions of Q-switched NdYAG laser therapy followed by transdermal delivery of vitamin C via sonophoresis were selected after a retrospective review of case records. The objective and subjective clinical outcomes and the side effects, including erythema, scaling, pruritus, dryness and post-inflammatory hyperpigmentation were evaluated. RESULTS: In both objective or subjective outcomes, 91.3% (21/23) of the patients showed an excellent or better outcome, while 8.7% (2/23) showed no change. A majority of the patients (73.9%, 17/23) experienced no post-inflammatory hyperpigmentation or had slight post-inflammatory hyperpigmentation which quickly resolved within 1 week. Only one (4.3%) patient had extreme post-inflammatory hyperpigmentation which lasted for over a month. LIMITATIONS: This was a retrospective study without a control group; a comparative study with a control group (patients treated with the laser alone, without vitamin C sonopheresis) is needed to determine the difference in the outcome. CONCLUSION: The use of vitamin C sonophoresis along with NdYAG laser may reduce the incidence of adverse effects in Asian patients. Patients experienced obvious improvement in hyperpigmentation and had lower chances of experiencing extreme or severe post-inflammatory hyperpigmentation.

Evaluation of an ablative and non-ablative laser procedure in the treatment of striae distensae.

BACKGROUND: Striae distensae or stretch marks are atrophic linear dermal scars with epidermal atrophy. There are many therapeutic options for management, but no consistently effective modality is available yet. OBJECTIVE: We compared the efficacy of 1064 nm long pulse (LP) Nd: YAG laser and 2940 nm variable square pulse (VSP) erbium: YAG laser in the treatment of striae distensae. METHODS: Twenty female volunteers (Fitzpatrick skin types II-V) aged between 20 and 40 years with striae (3 patients with the rubra type and 17 with the alba type) were enrolled in the study. The duration of striae ranged from 4 months to 12 years. Lesions were located on the abdomen in all patients except one patient who had striae on the arms and two patients with striae in the lumbar region. Treatments were randomly allocated to both sides of the body in each patient, one side being treated with VSP erbium: YAG laser and the opposite side with LP Nd: YAG laser. All subjects were treated monthly for a total of three treatments. Two 3-mm punch biopsies were obtained from six subjects, both of the same striae, one before the first treatment and one 4 weeks after the last session. RESULTS: Response was evaluated clinically by photographic comparison and was found to be poor in 17 subjects, both on the LP Nd: YAG laser treated side and VSP erbium YAG laser treated side. All these patients had mature lesions (striae distensae alba). Three subjects had a moderate response on both sides; these patients' striae were immature (striae distensae rubra). Histologically, elastic fibers were slightly increased in post-treatment samples compared with pretreatment skin biopsies. CONCLUSION: We observed no satisfactory clinical improvement in striae distensae alba lesions although histopathological changes were seen. We suggest that variable square pulse Er: YAG and long pulse Nd: YAG lasers are not useful in the treatment of striae distensae alba.

Efficacy and safety of erbium-doped yttrium aluminium garnet fractional resurfacing laser for treatment of facial acne scars.

BACKGROUND: Treatment of acne scars with ablative fractional laser resurfacing has given good improvement. But, data on Indian skin are limited. A study comparing qualitative, quantitative, and subjective assessments is also lacking. AIM: Our aim was to assess the improvement of facial acne scars with Erbium-doped Yttrium Aluminium Garnet (Er:YAG) 2940 nm fractional laser resurfacing and its adverse effects in 25 patients at a tertiary care teaching hospital. METHODS: All 25 patients received four treatment sessions with Er:YAG fractional laser at 1-month interval. The laser parameters were kept constant for each of the four sittings in all patients. Qualitative and quantitative assessments were done using Goodman and Barron grading. Subjective assessment in percentage of improvement was also documented 1 month after each session. Photographs were taken before each treatment session and 1 month after the final session. Two unbiased dermatologists performed independent clinical assessments by comparing the photographs. The kappa statistics was used to monitor the agreement between the dermatologists and patients. RESULTS: Most patients (96%) showed atleast fair improvement. Rolling and superficial box scars showed higher significant improvement when compared with ice pick and deep box scars. Patient's satisfaction of improvement was higher when compared to physician's observations. No serious adverse effects were noted with exacerbation of acne lesions forming the majority. CONCLUSION: Ablative fractional photothermolysis is both effective and safe treatment for atrophic acne scars in Indian skin.Precise evaluation of acne scar treatment can be done by taking consistent digital photographs.

Newer and upcoming therapies for melasma.

Melasma is one of the most common and distressing pigmentary disorders presenting to dermatology clinics. The precise cause of melasma remains unknown; however, there are many possible contributing factors. It is notably difficult to treat and has a tendency to relapse. The existing and most tried topical therapy is hydroquinone and the triple combination with tretinoin and corticosteroids, which is considered the gold standard for melasma. Besides that, azelaic acid, kojic acid, arbutin, ascorbic acid, glycolic acid and salicylic peels have also been tried with limited success. However, multiple novel topical agents are being investigated for their potential as hypopigmenting agents with unique mode of action. But, further trials are required to study their efficacy and safety before they can be further recommended. The article highlights these newer formulations and also briefly mentions about the newer chemical peels and the much hyped lasers in treating this difficult and frustrating condition.

A comparative study on efficacy of high and low fluence Q-switched Nd:YAG laser and glycolic acid peel in melasma.

BACKGROUND: Melasma is acquired symmetric hypermelanosis characterized by light-to-deep brown pigmentation over cheeks, forehead, upper lip, and nose. Treatment of this condition is difficult and associated with high recurrence rates. With the advent of newer therapies, there is interest in the use of glycolic acid peels and Q-switched Nd:YAG laser (QSNYL) in high and low fluence for this disorder. AIMS: To compare the therapeutic efficacy of low fluence QSNYL, high fluence QSNYL, and glycolic acid peel in melasma in three study groups of 25 patients each. METHODS: Seventy-five Indian patients diagnosed as melasma were included. These patients were randomly divided in three groups (Group A = 25 patients of melasma treated with low-fluence QSNYL at weekly intervals, Group B = 25 patients of melasma treated with glycolic acid peel at 2 weeks intervals, Group C = 25 patients of melasma treated with high-fluence QSNYL at 2 weeks intervals). Study period and follow-up period was of 12 weeks each. Out of the 75 patients included, 21 patients in Group A, 19 patients in Group B, and 20 patients in Group C completed the study. Response to treatment was assessed using melasma area and severity index score. RESULTS: Significant improvement was recorded in all the three groups. The improvement was statistically highly significant in Group A as compared to Group C (P<0.005), significant in Group A as compared to Group B (P<0.05), and also in Group B when compared to Group C (P<0.05). Low-fluence QSNYL was associated with least side effects. CONCLUSIONS: This study shows the efficacy of low-fluence QSNYL and glycolic acid peel in melasma. These could be an effective treatment options compared to conventional methods for the treatment of melasma.

1064 nm Q switched Nd: YAG laser treatment of nevus of Ota: an Indian open label prospective study of 50 patients.

BACKGROUND: Nevus of Ota is very common in Asians. Estimated male to female ratio is 1:4.8. Patients seek treatment early in life due to psychological trauma and cosmetic disfigurement. The creation of high power, short pulse Q switched lasers has recently provided tools for considerable therapeutic advances in the treatment of dermal pigmented lesions. AIMS: To determine the efficacy and side-effect profile of Q switched Nd:YAG Laser (QSNYL) in fifty Indian patients. METHODS: Fifty patients of nevus of Ota underwent multiple treatments (average 5 sessions) at monthly intervals carried out over a period of 2 years with QSNYL (Med-lite C6). Of the 50 patients, 2 were males; and the rest were females. Skin types treated included phototype IV and V. The response after subsequent treatments was documented through serial photographs that were taken before and after every treatment session. Response to the treatment was graded based on quartile grading scale. RESULTS: Near total improvement was seen in 8%, marked improvement in 22%, moderate improvement in 38% and 32% patients reported less than 25% clearing of the lesion. All patients reported some improvement. Transient postinflammatory hyperpigmentation was observed in 4 (8%) patients, which cleared with use of sunscreens and bleaching agents within 2 months. No textural change or scarring was observed in any patient. CONCLUSIONS: QSNYL is an easy-to-perform and effective treatment in cases of nevus of Ota in Indian patients with few side effects.

Long pulsed Nd:YAG laser with inbuilt cool sapphire tip for long term hair reduction on type- IV and V skin: a prospective analysis of 200 patients.

BACKGROUND: Laser hair reduction has become a very popular means to get rid of unwanted hair. AIMS: We conducted the current study to evaluate the safety and efficacy of Nd: YAG laser on dark skin. We also evaluated the effect of increasing the gap between sessions on the long term efficacy of hair reduction achieved with long pulsed Nd: YAG laser. METHODS: A prospective study was conducted on 200 consecutive female patients who underwent laser hair reduction for unwanted hair over the face, at Kaya skin clinic Delhi, with long pulsed Nd: YAG laser, from May 2006 to May 2009. The gap between sessions was increased from 2 nd session itself. RESULTS were evaluated 6 months after 6 sessions. Also a note was made of worsening of hair growth or any side effects experienced the patient during any of the sessions. RESULTS: A total of 200 female patients (160 skin type IV and 40 skin type V) were followed up. Of these, 64 enrolled for lower face, 88 for chin or upper neck and 48 for upper lip. 6 months after 6 sessions, more than 50% improvement was seen in 68.7% of lower face, 89.69% cases of chin and 59% of upper lip cases. None of the patients had any worsening. CONCLUSIONS: The current study shows that long pulsed Nd: YAG is a very safe and effective means of hair reduction in skin types IV and V. Adequate fluences and increasing the gap between sessions from the 2 nd session could be the key to achieving long term hair reduction with Nd: YAG laser. Adequate cooling and proper shaving are the key factors determining the safety.