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Dermatologic laser procedures are becoming increasingly popular worldwide, and demand for them has fueled new innovations and clinical applications. These systems continue to evolve and provide enhanced therapeutic outcomes with improved safety profiles. This review highlights the important roles and varied clinical applications that lasers and intense pulsed light play in the dermatologic practice.
Keywords: laser, intense pulsed light, treatment, dermatology, technology. Laser is an acronym, which represents light amplification by the stimulated emission of radiation. An understanding of the fundamental properties of laser light is essential to appreciate its clinical effects on the skin.
This is determined by the medium of the laser system through which the light passes. Second, laser light is coherent — traveling in phase spatially and temporally. Third, laser light is collimated — emitted in a parallel manner with minimal divergence. Laser light may be absorbed, reflected, transmitted, or scattered when applied to the skin. In order for a clinical effect to occur, light must be absorbed by tissue. Absorption of laser light is determined by chromophores — the target molecules found in the skin, which have specific wavelength absorption profiles.
The three primary endogenous cutaneous chromophores are water, melanin, and hemoglobin; whereas tattoo ink represents an exogenous chromophore.
Upon absorption of laser energy by the skin, photothermal, photochemical, or photomechanical effects may occur. The cutaneous depth of penetration of laser energy is dependent upon absorption and scattering. In the epidermis, there is minimal light scattering, whereas in the dermis there is significant scatter due to the high concentration of collagen fibers. The amount of scattering of laser energy is inversely proportional to the wavelength of light.
The depth of laser energy increases with wavelength until the mid-infrared region of the electromagnetic spectrum, at which point dermal penetration becomes more superficial due to increased absorption within tissue water. The theory of selective photothermolysis proposed by Anderson and Parrish 3 in has been pivotal in the advancement of laser surgery.
It explains the mechanism by which controlled destruction of a cutaneous target can be achieved without significant injury to surrounding tissue. Three principles are crucial to the process.
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First, an appropriate wavelength should be employed that can be absorbed preferentially by the targeted tissue chromophore. Third, the fluence or energy must be sufficient to achieve destruction of the target within the appropriate time interval. These factors guide the selection of lasers and intense pulsed light IPL appropriate for a specific skin target or lesion. Lasers can be further classified by their mode of light emission.
Continuous wave CW lasers produce a continuous beam of light with long exposure durations that can cause nonselective tissue damage. Quasi-CW mode produces interrupted emissions of constant laser energy by shuttering the CW beam into short intervals. Pulsed laser systems emit high-energy laser light in ultrashort pulse durations with relatively long interpulse time intervals.
They can be long pulsed LP or very short pulsed such as the quality-switched QS nanosecond and picosecond laser systems. IPL is a nonlaser filtered flash lamp device. Unlike lasers, IPL devices emit polychromatic, noncoherent, and noncollimated light —1, nm with varying pulse durations. The wider range of light can be absorbed by a variety of chromophores, making IPL less selective than lasers. As such, cutoff filters are often used to narrow the spectrum of emitted wavelengths and render the device more specific.
This endogenous chromophore has three primary absorption peaks within the visible light spectrum: , , and nm. Oxyhemoglobin absorbs the laser light, which is subsequently converted to heat and transferred to the vessel wall causing coagulation and vessel closure. Treatment with vascular-specific lasers causes inhomogeneous heating within dermal blood vessels due to their varying sizes, but results in effective and efficient treatment of small- and large-diameter blood vessels.
The most commonly used vascular lasers in current clinical practice are the potassium titanyl phosphate KTP, nm , pulsed dye laser PDL, — nm , alexandrite nm , diode —, nm , and neodymium-doped yttrium aluminum garnet Nd:YAG, and 1, nm. In addition, IPL with appropriate filters can be used to treat certain vascular lesions. The KTP laser is effective in the treatment of numerous superficial vascular lesions, particularly facial telangiectasias.
One of the advantages of the KTP laser is that postoperative purpura and erythema are minimized. Its shorter wavelength results in decreased tissue penetration and limited absorption by hemoglobin in deeper vessels.
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Given that there is considerable absorption of nm energy by melanin, caution must be exercised when treating patients with darker skin. The PDL is a highly effective laser for the treatment of a wide range of vascular lesions and is considered the workhorse vascular laser in many practices due to its favorable clinical efficacy and low risk profile.
Adverse effects include postoperative purpura, transient dyspigmentation, and rarely vesiculation, crusting, and scarring. Newer PDLs with longer wavelengths and extended pulse durations have enabled deeper tissue penetration and improved clinical outcomes Figure 1A and B.
Figure 1 Facial erythema and prominent telangiectasias in a patient with rosacea before A and after two nm pulsed dye laser PDL treatments B. IPL has also been used to effectively treat a variety of vascular lesions, including facial telangiectasias, capillary malformations, poikiloderma of Civatte, venous malformations, and infantile hemangiomas. Filters are used to limit the wavelengths emitted by the device in order to improve dermal penetration and minimize absorption of energy by other chromophores.
IPL energy is delivered as a series of single, double, or triple pulse sequences with pulse durations of 2—25 milliseconds and interpulse delays of 10— milliseconds. Longer pulse durations are used to more effectively heat deeper vessels, thereby reducing the risk of purpura and hyperpigmentation. Prominent leg veins are a common cosmetic concern and can be challenging to treat. Sclerotherapy is highly effective for leg veins and is considered the gold standard treatment; however, it can be associated with significant adverse effects such as ulceration, allergic reactions, and telangiectatic matting.
The LP alexandrite nm , diode nm , and Nd:YAG 1, nm lasers have each been successful in eradicating small- to medium-sized veins.
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Hypertrophic scars and keloids are abnormal wound responses to cutaneous injury and are marked by excessive collagen formation. They are difficult to treat and have high recurrence rates following conventional treatments such as surgical excision, dermabrasion, radiation, and intralesional therapy. More recently, ablative fractional lasers have been shown to improve hypertrophic scars and are often combined with topical delivery of corticosteroids for improved efficacy. Striae distensae are common atrophic lesions that are often associated with obesity, pregnancy, puberty, and exogenous steroid use.
They initially present as slightly erythematous to pink atrophic bands, termed striae rubra. They gradually become hypopigmented and fibrotic and are referred to as striae alba.
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Striae have been treated successfully with low-fluence PDL, with stria rubra showing greater clinical response to treatment than mature striae alba. Cutaneous pigmented lesions are frequent targets of laser and IPL treatment. These same lasers have also been used to treat amateur, professional, and traumatic tattoos. The red and infrared wavelengths of the QS lasers target melanin within melanosomes as is the case with pigmented lesions and various carbon-based material or organometallic dyes as is the case with tattoos , with limited injury to adjacent normal tissue. The QS ruby was the first system developed to treat pigmented lesions and tattoos and was widely and successfully used; 75 — 82 however, its nm wavelength required caution in patients with darker skin tones due to its energy being so strongly absorbed by melanin with a greater risk of hypopigmentation.
Effective tattoo removal necessitates the use of an appropriate wavelength that is preferentially absorbed by the specific ink color within the tattoo. The QS ruby or alexandrite lasers can safely target blue and green inks since these pigments absorb in the — nm range, whereas only the nm QS Nd:YAG laser can clear red, orange, and yellow inks.
Cosmetic tattoo inks that are typically tan, white, or rust colored are difficult to treat because they frequently contain iron oxide and titanium dioxide compounds that undergo a chemical reaction upon laser irradiation to a black and insoluble form ferric oxide to ferrous oxide. Adverse effects of laser tattoo removal include transient pigmentary alteration hypo- and hyperpigmentation , systemic allergic or localized granulomatous tissue reactions, ignition of explosive particles in traumatic tattoos, and atrophic scars.
IPL devices have also been used to treat benign pigmented lesions including ephelides and solar lentigines, with significant lesional improvement observed after a series of monthly treatments. Safe and long-lasting hair reduction in cosmetically undesirable locations can be achieved with a variety of lasers and IPL devices. These systems emit red and infrared light with wavelengths ranging —1, nm, which are capable of targeting melanin in the hair shaft, follicular epithelium, and hair matrix.
Concomitant epidermal cooling sources help to minimize unwanted thermal injury particularly in patients with darker skin during treatment. While pulse durations of 10— milliseconds are typically used in keeping with the thermal relaxation time of most hair follicles , the biological target in laser hair removal is the follicular stem cell, which is located in the bulge region or dermal papilla of the hair follicle.
Since these stem cells do not always contain significant amounts of melanin and may not be directly adjacent to the targeted pigmented structures, longer pulse durations than those outlined are often necessary for heat diffusion from the follicular shaft to the desired end-target. LP ruby nm , alexandrite nm , diode nm , and Nd:YAG 1, nm lasers as well as IPL —1, nm have been shown, through numerous published studies, to achieve long-lasting hair reduction with a low incidence of adverse effects.
The LP ruby laser is best used in pale-skinned patients with Fitzpatrick skin phototypes I—III, whereas the LP alexandrite and diode lasers can be safely used in individuals with slightly darker skin Fitzpatrick skin phototypes I—IV.
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