Fractional Photothermolysis: A New Concept Richard Fitzpatrick, M.D. U sually, when we’re treating photodamaged skin, we’re peeling away the whole surface. Whether we’re using chemical peels, dermabrasion or lasers, we’re removing the outermost layers of the most sundamaged areas of skin. But the problem is that this approach creates a fairly significant wound and requires significant downtime for patients. In addition, it creates the potential for adverse reactions, such as pigment changes, infection or scarring. Rox Anderson, M.D., and Dieter Manstein, M.D., at Wellman Laboratories at Harvard, worked with researchers at Reliant Technologies to develop something entirely new — a way to treat many, small spots of skin at the same time while also treating the skin’s surface vertically instead of horizontally. The end effect of this new treatment, called fractional photothermolysis, is that thousands of microthermal zones are created. These treated areas bridge the gap between areas of untreated tissue, resulting in rapid re-epithelialization. Basically, because there’s normal tissue in between the microthermal zones, healing is much faster and without the downtime usually associated with resurfacing procedures. The microthermal zones are close enough together that the wound healing process gradually spreads throughout the skin. Fractional photothermolysis uses a computer-controlled fiber optic laser with an infrared laser that’s a little over 1500 nm (the Fraxel SR) that places about 2,000 of these tiny spots in a square centimeter — you can’t see these spots with the unaided eye. The laser, which interacts with water in the skin, creates the microthermal zones. These zones extend into the skin up to 700 microns, which is a significant amount. No matter how fast or slow you move the laser, the computer control enables precise application of the microthermal zones at the appropriate intervals. Patients undergo a series of treatments, typically about three to five. One of the nice things about this technology is that there’s no downtime associated with it, and most of the risk factors are eliminated that you’d normally associate with peeling away the surface of the skin. This technology has a number of unique features that are potentially very significant in treating photodamaged skin and many other conditions — it’s very exciting. Dr. Fitzpatrick is in private practice in Encinitas, CA, and is also a former President of the American Society for Laser Medicine and Surgery. Utilizing a Larger Spot Size Robert Weiss, M.D. W ith a new laser that has a much larger spot size, the Gemini Laserscope, we’re finding that we can treat conditions such as telangiectasia, photoaging and acne with success. The Gemini has a much larger spot size than any other laser before it. This 532 nm Er:YAG laser, has a 10-mm spot size, whereas before the largest spot size available was 4 mm. The increased size now allows us to do much more than just spot-treat. We can really treat the patient’s entire face, and quickly — each side of the patient’s face can be treated in 90 seconds. Also, we can treat patients more effectively and with fewer overall treatments. The larger spot size gives the laser totally different properties. We used to use the 532 nm as an adjunct to intense pulsed light, but now we use it as the primary treatment for telangiectasia, pigmentation and active acne. Right now, we’re finishing a split-face study with the Gemini with a KTP filter. We’ve been studying 15 patients and treating them for photodamage. Results have been really promising. We’re at the 4-month point now, and we’re seeing some incredible changes. I think this technology is working wonderfully. We need fewer treatments, we have larger treatment areas, and so we can treat conditions much more quickly than before. Dr. Weiss is Assistant Professor of Dermatology at Johns Hopkins University School of Medicine. He’s also Director of the Maryland Laser, Skin and Vein Institute in Baltimore. Greater Outcomes with Optical Clearing J. Stuart Nelson, M.D., Ph.D. O ptical clearing is a very new idea that was presented for the first time this past April at the American Society for Laser Medicine and Surgery annual meeting. This concept involves topically applying chemical agents to the skin’s surface so that we can actually “clear” the skin. Optical clearing makes the skin more transparent, so there’s much less dermal scattering and more absorption of the light being delivered to the targeted chromophores underneath the skin. Then, we’re able to better see what we want to target for treatment because they’re better visualized. Gracie Vargas, a graduate student at the University of Texas, discussed this in her thesis on which she collaborated with her colleagues, Bernard Choi and A. J. Welsh. They injected glycerol into the skin and were able to make the skin more transparent. Based on this thesis, the challenge that I presented to colleagues and others in our lab is that we need to be able to induce optical clearing after agents are applied topically. The really unique thing about this is that all of this is totally reversible. When you re-hydrate the skin with normal saline, the skin returns to its normal opaque appearance. There’s a paper that we published in the December issue of the Journal of Investigative Dermatology looking at the mechanism of how this “clearing” process occurs. With optical clearing of the skin, you actually see a change in the collagen structure. The triple helix molecules seem to unwind in response to these clearing agents and then once you re-hydrate the skin they form again, creating three-dimensional triple helixes. We’ve been looking at a number of these agents, but by far the most promising is a mixture of polypropylene glycol and polyethylene glycol. We apply these to the skin surface, and then 2 hours later we can see much more detail in the skin, such as blood vessels. When using lasers on skin treated with an optical clearing agent, what we’ve found is that the skin has a lower threshold for purpura, and we don’t get the degree of epidermal injury we typically have with skin not treated with an optical clearing agent. So not only do these agents reduce the amount of dermal light scattering, they also allow more light to get to the target. As we reduce the scattering, the epidermal temperature actually drops. This all actually increases the threshold for epidermal damage, allowing us to use much higher light doses than we were able to before. So one can imagine that there is a variety of different therapeutic applications. Moreover, the diagnostic potential of this technology is also huge. Dr. Nelson is Professor of Surgery, Dermatology, and Biomedical Engineering at the University of California at Irvine. He’s also Associate Director of the Beckman Laser Institute and Medical Clinic. Non-Ablative Skin Rejuvenation Works S. Jeffrey Dover, M.D., FRCPC I think that there are some potential misconceptions about the efficacy of non-ablative skin rejuvenation. Non-ablative skin rejuvenation works within expected limitations. As long as the physician and patient understand these limitations, the results are encouraging and patient acceptance is high. The problem is that if patients are misinformed or they have unrealistic expectations, then they’ll be unhappy. I like to think of these devices in four categories: 1. Pulsed infrared devices. These include the CoolTouch (1320 nm), the SmoothBeam (1450 nm), and the Aramis (1540 nm). These devices use cooling to protect the skin surface, and they’re moderately good at improving skin texture and tone in both acne scarring and photoaging. However, these devices aren’t effective in improving skin color. 2. Pulsed dye lasers. These lasers do a great job of eliminating red tones in the skin. They also help improve skin texture, but not as well as the infrared (IR) lasers. 3. Intense pulsed light devices and pulsed 532 nm devices. These devices, which include the IPL Quantum, the MediLux, the Aurora and the PhotoLight, to name a few, and also the new 532 nm, 10-mm spot Gemini, help improve red and brown tones in the skin, and they help improve skin tone and texture, but not as much as the IR lasers. 4. Light-emitting diode photomodulation. The GentleWaves and OmniLux are an example of this type of device. This therapy helps improve tone and texture and may help skin color, but not as much as IPLs do. However, each treatment only takes 1 to 2 minutes — we typically do six treatments every 2 weeks — and there are no adverse effects. In addition, this therapy is totally painless and it’s inexpensive. I use this type of device as an adjunct to all other non-ablative skin rejuvenation procedures. These four groups of devices help to improve a variety of aspects of the aging process. It’s imperative that the physician know in advance what these devices can do for the patient and select the best device for the individual situation. Then, it’s important to convey realistic outcomes to the patient. Dr. Dover is a Director of SkinCare Physicians of Chestnut Hill in Chestnut Hill, MA. He is Associate Clinical Professor of Dermatology at Yale University School of Medicine. He is also Adjunct Professor of Medicine (Dermatology) at Dartmouth Medical School. A New Ripple in the Treatment of Cellulite Tina Alster, M.D. W hoever wins the war on fat — wins the war. And when I’m referring to fat, I specifically mean cellulite. There has never been a viable treatment for cellulite — disappointing, given the fact that 80% of women are affected by it (and the other 20% think they have it). I am now convinced that we have a viable treatment for this condition. I’ve been using the VelaSmooth by Syneron [Dr. Alster disclosed that she’s on the company’s medical advisory board] and have recently completed a controlled study on 20 patients with cellulite. One thigh on each patient was randomly chosen to receive treatment, using the other non-treated thigh as a control. Each patient received eight circumferential thigh treatments over 4 weeks. During the course of treatment, it was clear to the investigators and patients that changes were being made to the cellulite. Thigh circumference measurements and sequential photographs were used to monitor patient progress. In addition, patients’ subjective evaluations of improvement were gauged. The study’s findings will be reported at this year’s meeting of the American Society for Dermatologic Surgeons in early October. By then, data from 3 months post-treatment will be available for presentation. The VelaSmooth system is a medical device that incorporates the revolutionary ELOS technology (combination of bi-polar radiofrequency and infrared light) with tissue mobilization/suction to safely and effectively re-contour the skin’s surface. The mechanical manipulation portion of the device mimics the older Endermologie units, which had mechanical rolling heads, but the VelaSmooth device applies more suction to the tissue. This device works because heat is delivered deep into the tissue, causing dermal collagen contraction and redistribution of tissue water. Also, the technology disrupts the fibrous bands that surround the fat. There may be some mild lipolysis and shifting of water content along with dermal collagen contraction that adds to the overall effect of treatment. It’s great that we can combine these different technologies into one non-invasive apparatus to such a great effect. Dr. Alster is the Director of the Washington Institute of Dermatologic Laser Surgery, which she founded in 1990. She’s also a Clinical Professor of Dermatology at Georgetown University in Washington, D.C. Bruce Katz, M.D. I t’s clear that one of the hottest new areas of dermatology is the treatment of cellulite. We’re also starting a study. Ours is with a new device called Tri-Activ, which is a combination of a laser suction device and a low-energy diode laser. The device has the triple action of producing mechanical massage, localized cooling and deep laser stimulation. We’re in contact with scientists in Italy who are developing this technology. The idea behind how the technology works is that the low energy laser light seems to break up the fibrous bands that are part of the cellulite. Our study will be a controlled study in which we can measure the changes by ultrasound scanning. It’s not 100% clear what the mechanism of action is, but hopefully by next year we will be reporting the results of our study and have a better knowledge of how this technology produces positive outcomes. If we can effectively treat cellulite with this technology, it will be the first time that a laser has been shown to effectively treat this type of tissue. Dr. Katz is Associate Clinical Professor at the Mount Sinai School of Medicine in New York City. He’s also the Director of the Cosmetic Surgery and Laser Clinic at Mount Sinai Hospital. In addition, he’s Director of the JUVA Skin & Laser Center in New York City. The Myriad Uses of ALA/PDT Michael Gold, M.D. I’m completely convinced that the field of photodynamic therapy in combination with 5-aminolevulinic acid (ALA - Levulan and Photocure [not available at present in the United States]) has so much potential to take over a lot of what we do in laser practice. With this type of treatment, we’re adding technology to the machines we already have to make them work better. What we’re trying to figure out now is which of the light devices works better for acne vs. photorejuvenation. We already know that the spectrum of light that is effective is between 400 nm and 650 nm, and we know we must leave the ALA on for 1 hour prior to treatment. Here’s what else we’ve learned using this technology: • We know for actinic keratoses that blue light, intense pulsed light (IPL) and vascular lasers all work well. • The various blue light therapies and IPL work best for acne. In my practice, I’m using this treatment all the time now for acne patients. It just takes a few treatments, and these patients are remarkably better. We’ve haven’t looked at patients’ acne results long term, but we know that 3 or 4 months later they’re still clear. We still recommend maintenance therapy for these patients. I tell them to plan for up to four treatments on average. After I get them better, I bring them back 1 month later. At that point, I may not do anything but keep them on some type of topical treatment. It depends how well they’ve responded to treatment. • It also appears that the vascular systems and IPL systems seem to work better for photodamage. Instead of the five or six treatments needed with a light device alone, we only need to treat patients two or three times with the photodynamic therapy. • We’re treating sebaceous gland hyperplasia and achieving really good results with the IPL and vascular systems. • Patients who have hydradenitis suppurativa are also responding well to this therapy. We’re clearing people for months at a time, and these are recalcitrant cases I’m referring to. We’re seeing incredible results with this. • We’re treating a group of patients with hyperhidrosis. We’re in the process of seeing if photodynamic therapy can work with these patients, and we’re seeing some nice preliminary results. • Dr. Mitchel Goldman and I are about to study psoriasis patients with one of the biologics in conjunction with photodynamic therapy and IPL to see if we can make the biologics work better and faster. We’re finalizing the protocol right now. • We’re also looking at treating light and blond hairs. There’s preliminary evidence that the ALA is absorbed well and can treat this type of hair. We’re working on finalizing details of a multi-center trial for this purpose. Overall, ALA/PDT works well for so many different conditions; it has so much potential. Dr. Gold’s practice, Gold Skin Care Center, is located in Nashville, TN. Radiofrequency: Coming into its Own Kenneth Arndt, M.D. L aser photomedicine has become a lot broader. We have energies of many kinds, and they all meld together and complement one another. Of these newer technologies, I think one that is reaching its maturity is radiofrequency. Before the advent of this technology, we hadn’t been able to induce tissue tightening. Radiofrequency technology can take the form of mono-polar and bi-polar devices. Mono-polar. This is the most interesting of the two types. Radiowave energy is harnessed to apply heat to about 2.5 mm — deeper than heat from a laser. This causes tissue tightening and can be used for many purposes. Originally, the forehead was studied. Now we know that we can lift brows several millimeters, and successfully treat multiple areas to tighten jowls, neck, and nasolabial folds. Radiofrequency doesn’t induce changes as drastic as a facelift, but, then again, it’s not as invasive either. It’s not yet clear how long the results last. We first began talking to Thermage in 1999, so the instruments haven’t been around that long. However, there’s already one report that’s found the results last for at least a year. Bi-polar. If you asked me a year ago, I couldn’t even have told you much about the bi-polar technology because it’s so new. It’s used along with a laser or intense pulsed light. Bi-polar devices produce more superficial energy, producing not a tissue tightening effect but a tissue heating result, which may enhance the effects of the laser or IPL used along with it. This technology may treat photodamage faster or may treat light or white hairs. It will take a study of several years to discover this technology’s best applications. With radiofrequency overall, we’re seeing some really exciting results. Dr. Arndt is a Director of SkinCare Physicians of Chesnut Hill in Chestnut Hill, MA. He’s also Clinical Professor of Dermatology at Yale and Harvard Medical Schools, and Adjunct Professor of Medicine at Dartmouth Medical School.
Exciting Advances in Light & Laser Technologies
Fractional Photothermolysis: A New Concept Richard Fitzpatrick, M.D. U sually, when we’re treating photodamaged skin, we’re peeling away the whole surface. Whether we’re using chemical peels, dermabrasion or lasers, we’re removing the outermost layers of the most sundamaged areas of skin. But the problem is that this approach creates a fairly significant wound and requires significant downtime for patients. In addition, it creates the potential for adverse reactions, such as pigment changes, infection or scarring. Rox Anderson, M.D., and Dieter Manstein, M.D., at Wellman Laboratories at Harvard, worked with researchers at Reliant Technologies to develop something entirely new — a way to treat many, small spots of skin at the same time while also treating the skin’s surface vertically instead of horizontally. The end effect of this new treatment, called fractional photothermolysis, is that thousands of microthermal zones are created. These treated areas bridge the gap between areas of untreated tissue, resulting in rapid re-epithelialization. Basically, because there’s normal tissue in between the microthermal zones, healing is much faster and without the downtime usually associated with resurfacing procedures. The microthermal zones are close enough together that the wound healing process gradually spreads throughout the skin. Fractional photothermolysis uses a computer-controlled fiber optic laser with an infrared laser that’s a little over 1500 nm (the Fraxel SR) that places about 2,000 of these tiny spots in a square centimeter — you can’t see these spots with the unaided eye. The laser, which interacts with water in the skin, creates the microthermal zones. These zones extend into the skin up to 700 microns, which is a significant amount. No matter how fast or slow you move the laser, the computer control enables precise application of the microthermal zones at the appropriate intervals. Patients undergo a series of treatments, typically about three to five. One of the nice things about this technology is that there’s no downtime associated with it, and most of the risk factors are eliminated that you’d normally associate with peeling away the surface of the skin. This technology has a number of unique features that are potentially very significant in treating photodamaged skin and many other conditions — it’s very exciting. Dr. Fitzpatrick is in private practice in Encinitas, CA, and is also a former President of the American Society for Laser Medicine and Surgery. Utilizing a Larger Spot Size Robert Weiss, M.D. W ith a new laser that has a much larger spot size, the Gemini Laserscope, we’re finding that we can treat conditions such as telangiectasia, photoaging and acne with success. The Gemini has a much larger spot size than any other laser before it. This 532 nm Er:YAG laser, has a 10-mm spot size, whereas before the largest spot size available was 4 mm. The increased size now allows us to do much more than just spot-treat. We can really treat the patient’s entire face, and quickly — each side of the patient’s face can be treated in 90 seconds. Also, we can treat patients more effectively and with fewer overall treatments. The larger spot size gives the laser totally different properties. We used to use the 532 nm as an adjunct to intense pulsed light, but now we use it as the primary treatment for telangiectasia, pigmentation and active acne. Right now, we’re finishing a split-face study with the Gemini with a KTP filter. We’ve been studying 15 patients and treating them for photodamage. Results have been really promising. We’re at the 4-month point now, and we’re seeing some incredible changes. I think this technology is working wonderfully. We need fewer treatments, we have larger treatment areas, and so we can treat conditions much more quickly than before. Dr. Weiss is Assistant Professor of Dermatology at Johns Hopkins University School of Medicine. He’s also Director of the Maryland Laser, Skin and Vein Institute in Baltimore. Greater Outcomes with Optical Clearing J. Stuart Nelson, M.D., Ph.D. O ptical clearing is a very new idea that was presented for the first time this past April at the American Society for Laser Medicine and Surgery annual meeting. This concept involves topically applying chemical agents to the skin’s surface so that we can actually “clear” the skin. Optical clearing makes the skin more transparent, so there’s much less dermal scattering and more absorption of the light being delivered to the targeted chromophores underneath the skin. Then, we’re able to better see what we want to target for treatment because they’re better visualized. Gracie Vargas, a graduate student at the University of Texas, discussed this in her thesis on which she collaborated with her colleagues, Bernard Choi and A. J. Welsh. They injected glycerol into the skin and were able to make the skin more transparent. Based on this thesis, the challenge that I presented to colleagues and others in our lab is that we need to be able to induce optical clearing after agents are applied topically. The really unique thing about this is that all of this is totally reversible. When you re-hydrate the skin with normal saline, the skin returns to its normal opaque appearance. There’s a paper that we published in the December issue of the Journal of Investigative Dermatology looking at the mechanism of how this “clearing” process occurs. With optical clearing of the skin, you actually see a change in the collagen structure. The triple helix molecules seem to unwind in response to these clearing agents and then once you re-hydrate the skin they form again, creating three-dimensional triple helixes. We’ve been looking at a number of these agents, but by far the most promising is a mixture of polypropylene glycol and polyethylene glycol. We apply these to the skin surface, and then 2 hours later we can see much more detail in the skin, such as blood vessels. When using lasers on skin treated with an optical clearing agent, what we’ve found is that the skin has a lower threshold for purpura, and we don’t get the degree of epidermal injury we typically have with skin not treated with an optical clearing agent. So not only do these agents reduce the amount of dermal light scattering, they also allow more light to get to the target. As we reduce the scattering, the epidermal temperature actually drops. This all actually increases the threshold for epidermal damage, allowing us to use much higher light doses than we were able to before. So one can imagine that there is a variety of different therapeutic applications. Moreover, the diagnostic potential of this technology is also huge. Dr. Nelson is Professor of Surgery, Dermatology, and Biomedical Engineering at the University of California at Irvine. He’s also Associate Director of the Beckman Laser Institute and Medical Clinic. Non-Ablative Skin Rejuvenation Works S. Jeffrey Dover, M.D., FRCPC I think that there are some potential misconceptions about the efficacy of non-ablative skin rejuvenation. Non-ablative skin rejuvenation works within expected limitations. As long as the physician and patient understand these limitations, the results are encouraging and patient acceptance is high. The problem is that if patients are misinformed or they have unrealistic expectations, then they’ll be unhappy. I like to think of these devices in four categories: 1. Pulsed infrared devices. These include the CoolTouch (1320 nm), the SmoothBeam (1450 nm), and the Aramis (1540 nm). These devices use cooling to protect the skin surface, and they’re moderately good at improving skin texture and tone in both acne scarring and photoaging. However, these devices aren’t effective in improving skin color. 2. Pulsed dye lasers. These lasers do a great job of eliminating red tones in the skin. They also help improve skin texture, but not as well as the infrared (IR) lasers. 3. Intense pulsed light devices and pulsed 532 nm devices. These devices, which include the IPL Quantum, the MediLux, the Aurora and the PhotoLight, to name a few, and also the new 532 nm, 10-mm spot Gemini, help improve red and brown tones in the skin, and they help improve skin tone and texture, but not as much as the IR lasers. 4. Light-emitting diode photomodulation. The GentleWaves and OmniLux are an example of this type of device. This therapy helps improve tone and texture and may help skin color, but not as much as IPLs do. However, each treatment only takes 1 to 2 minutes — we typically do six treatments every 2 weeks — and there are no adverse effects. In addition, this therapy is totally painless and it’s inexpensive. I use this type of device as an adjunct to all other non-ablative skin rejuvenation procedures. These four groups of devices help to improve a variety of aspects of the aging process. It’s imperative that the physician know in advance what these devices can do for the patient and select the best device for the individual situation. Then, it’s important to convey realistic outcomes to the patient. Dr. Dover is a Director of SkinCare Physicians of Chestnut Hill in Chestnut Hill, MA. He is Associate Clinical Professor of Dermatology at Yale University School of Medicine. He is also Adjunct Professor of Medicine (Dermatology) at Dartmouth Medical School. A New Ripple in the Treatment of Cellulite Tina Alster, M.D. W hoever wins the war on fat — wins the war. And when I’m referring to fat, I specifically mean cellulite. There has never been a viable treatment for cellulite — disappointing, given the fact that 80% of women are affected by it (and the other 20% think they have it). I am now convinced that we have a viable treatment for this condition. I’ve been using the VelaSmooth by Syneron [Dr. Alster disclosed that she’s on the company’s medical advisory board] and have recently completed a controlled study on 20 patients with cellulite. One thigh on each patient was randomly chosen to receive treatment, using the other non-treated thigh as a control. Each patient received eight circumferential thigh treatments over 4 weeks. During the course of treatment, it was clear to the investigators and patients that changes were being made to the cellulite. Thigh circumference measurements and sequential photographs were used to monitor patient progress. In addition, patients’ subjective evaluations of improvement were gauged. The study’s findings will be reported at this year’s meeting of the American Society for Dermatologic Surgeons in early October. By then, data from 3 months post-treatment will be available for presentation. The VelaSmooth system is a medical device that incorporates the revolutionary ELOS technology (combination of bi-polar radiofrequency and infrared light) with tissue mobilization/suction to safely and effectively re-contour the skin’s surface. The mechanical manipulation portion of the device mimics the older Endermologie units, which had mechanical rolling heads, but the VelaSmooth device applies more suction to the tissue. This device works because heat is delivered deep into the tissue, causing dermal collagen contraction and redistribution of tissue water. Also, the technology disrupts the fibrous bands that surround the fat. There may be some mild lipolysis and shifting of water content along with dermal collagen contraction that adds to the overall effect of treatment. It’s great that we can combine these different technologies into one non-invasive apparatus to such a great effect. Dr. Alster is the Director of the Washington Institute of Dermatologic Laser Surgery, which she founded in 1990. She’s also a Clinical Professor of Dermatology at Georgetown University in Washington, D.C. Bruce Katz, M.D. I t’s clear that one of the hottest new areas of dermatology is the treatment of cellulite. We’re also starting a study. Ours is with a new device called Tri-Activ, which is a combination of a laser suction device and a low-energy diode laser. The device has the triple action of producing mechanical massage, localized cooling and deep laser stimulation. We’re in contact with scientists in Italy who are developing this technology. The idea behind how the technology works is that the low energy laser light seems to break up the fibrous bands that are part of the cellulite. Our study will be a controlled study in which we can measure the changes by ultrasound scanning. It’s not 100% clear what the mechanism of action is, but hopefully by next year we will be reporting the results of our study and have a better knowledge of how this technology produces positive outcomes. If we can effectively treat cellulite with this technology, it will be the first time that a laser has been shown to effectively treat this type of tissue. Dr. Katz is Associate Clinical Professor at the Mount Sinai School of Medicine in New York City. He’s also the Director of the Cosmetic Surgery and Laser Clinic at Mount Sinai Hospital. In addition, he’s Director of the JUVA Skin & Laser Center in New York City. The Myriad Uses of ALA/PDT Michael Gold, M.D. I’m completely convinced that the field of photodynamic therapy in combination with 5-aminolevulinic acid (ALA - Levulan and Photocure [not available at present in the United States]) has so much potential to take over a lot of what we do in laser practice. With this type of treatment, we’re adding technology to the machines we already have to make them work better. What we’re trying to figure out now is which of the light devices works better for acne vs. photorejuvenation. We already know that the spectrum of light that is effective is between 400 nm and 650 nm, and we know we must leave the ALA on for 1 hour prior to treatment. Here’s what else we’ve learned using this technology: • We know for actinic keratoses that blue light, intense pulsed light (IPL) and vascular lasers all work well. • The various blue light therapies and IPL work best for acne. In my practice, I’m using this treatment all the time now for acne patients. It just takes a few treatments, and these patients are remarkably better. We’ve haven’t looked at patients’ acne results long term, but we know that 3 or 4 months later they’re still clear. We still recommend maintenance therapy for these patients. I tell them to plan for up to four treatments on average. After I get them better, I bring them back 1 month later. At that point, I may not do anything but keep them on some type of topical treatment. It depends how well they’ve responded to treatment. • It also appears that the vascular systems and IPL systems seem to work better for photodamage. Instead of the five or six treatments needed with a light device alone, we only need to treat patients two or three times with the photodynamic therapy. • We’re treating sebaceous gland hyperplasia and achieving really good results with the IPL and vascular systems. • Patients who have hydradenitis suppurativa are also responding well to this therapy. We’re clearing people for months at a time, and these are recalcitrant cases I’m referring to. We’re seeing incredible results with this. • We’re treating a group of patients with hyperhidrosis. We’re in the process of seeing if photodynamic therapy can work with these patients, and we’re seeing some nice preliminary results. • Dr. Mitchel Goldman and I are about to study psoriasis patients with one of the biologics in conjunction with photodynamic therapy and IPL to see if we can make the biologics work better and faster. We’re finalizing the protocol right now. • We’re also looking at treating light and blond hairs. There’s preliminary evidence that the ALA is absorbed well and can treat this type of hair. We’re working on finalizing details of a multi-center trial for this purpose. Overall, ALA/PDT works well for so many different conditions; it has so much potential. Dr. Gold’s practice, Gold Skin Care Center, is located in Nashville, TN. Radiofrequency: Coming into its Own Kenneth Arndt, M.D. L aser photomedicine has become a lot broader. We have energies of many kinds, and they all meld together and complement one another. Of these newer technologies, I think one that is reaching its maturity is radiofrequency. Before the advent of this technology, we hadn’t been able to induce tissue tightening. Radiofrequency technology can take the form of mono-polar and bi-polar devices. Mono-polar. This is the most interesting of the two types. Radiowave energy is harnessed to apply heat to about 2.5 mm — deeper than heat from a laser. This causes tissue tightening and can be used for many purposes. Originally, the forehead was studied. Now we know that we can lift brows several millimeters, and successfully treat multiple areas to tighten jowls, neck, and nasolabial folds. Radiofrequency doesn’t induce changes as drastic as a facelift, but, then again, it’s not as invasive either. It’s not yet clear how long the results last. We first began talking to Thermage in 1999, so the instruments haven’t been around that long. However, there’s already one report that’s found the results last for at least a year. Bi-polar. If you asked me a year ago, I couldn’t even have told you much about the bi-polar technology because it’s so new. It’s used along with a laser or intense pulsed light. Bi-polar devices produce more superficial energy, producing not a tissue tightening effect but a tissue heating result, which may enhance the effects of the laser or IPL used along with it. This technology may treat photodamage faster or may treat light or white hairs. It will take a study of several years to discover this technology’s best applications. With radiofrequency overall, we’re seeing some really exciting results. Dr. Arndt is a Director of SkinCare Physicians of Chesnut Hill in Chestnut Hill, MA. He’s also Clinical Professor of Dermatology at Yale and Harvard Medical Schools, and Adjunct Professor of Medicine at Dartmouth Medical School.
Fractional Photothermolysis: A New Concept Richard Fitzpatrick, M.D. U sually, when we’re treating photodamaged skin, we’re peeling away the whole surface. Whether we’re using chemical peels, dermabrasion or lasers, we’re removing the outermost layers of the most sundamaged areas of skin. But the problem is that this approach creates a fairly significant wound and requires significant downtime for patients. In addition, it creates the potential for adverse reactions, such as pigment changes, infection or scarring. Rox Anderson, M.D., and Dieter Manstein, M.D., at Wellman Laboratories at Harvard, worked with researchers at Reliant Technologies to develop something entirely new — a way to treat many, small spots of skin at the same time while also treating the skin’s surface vertically instead of horizontally. The end effect of this new treatment, called fractional photothermolysis, is that thousands of microthermal zones are created. These treated areas bridge the gap between areas of untreated tissue, resulting in rapid re-epithelialization. Basically, because there’s normal tissue in between the microthermal zones, healing is much faster and without the downtime usually associated with resurfacing procedures. The microthermal zones are close enough together that the wound healing process gradually spreads throughout the skin. Fractional photothermolysis uses a computer-controlled fiber optic laser with an infrared laser that’s a little over 1500 nm (the Fraxel SR) that places about 2,000 of these tiny spots in a square centimeter — you can’t see these spots with the unaided eye. The laser, which interacts with water in the skin, creates the microthermal zones. These zones extend into the skin up to 700 microns, which is a significant amount. No matter how fast or slow you move the laser, the computer control enables precise application of the microthermal zones at the appropriate intervals. Patients undergo a series of treatments, typically about three to five. One of the nice things about this technology is that there’s no downtime associated with it, and most of the risk factors are eliminated that you’d normally associate with peeling away the surface of the skin. This technology has a number of unique features that are potentially very significant in treating photodamaged skin and many other conditions — it’s very exciting. Dr. Fitzpatrick is in private practice in Encinitas, CA, and is also a former President of the American Society for Laser Medicine and Surgery. Utilizing a Larger Spot Size Robert Weiss, M.D. W ith a new laser that has a much larger spot size, the Gemini Laserscope, we’re finding that we can treat conditions such as telangiectasia, photoaging and acne with success. The Gemini has a much larger spot size than any other laser before it. This 532 nm Er:YAG laser, has a 10-mm spot size, whereas before the largest spot size available was 4 mm. The increased size now allows us to do much more than just spot-treat. We can really treat the patient’s entire face, and quickly — each side of the patient’s face can be treated in 90 seconds. Also, we can treat patients more effectively and with fewer overall treatments. The larger spot size gives the laser totally different properties. We used to use the 532 nm as an adjunct to intense pulsed light, but now we use it as the primary treatment for telangiectasia, pigmentation and active acne. Right now, we’re finishing a split-face study with the Gemini with a KTP filter. We’ve been studying 15 patients and treating them for photodamage. Results have been really promising. We’re at the 4-month point now, and we’re seeing some incredible changes. I think this technology is working wonderfully. We need fewer treatments, we have larger treatment areas, and so we can treat conditions much more quickly than before. Dr. Weiss is Assistant Professor of Dermatology at Johns Hopkins University School of Medicine. He’s also Director of the Maryland Laser, Skin and Vein Institute in Baltimore. Greater Outcomes with Optical Clearing J. Stuart Nelson, M.D., Ph.D. O ptical clearing is a very new idea that was presented for the first time this past April at the American Society for Laser Medicine and Surgery annual meeting. This concept involves topically applying chemical agents to the skin’s surface so that we can actually “clear” the skin. Optical clearing makes the skin more transparent, so there’s much less dermal scattering and more absorption of the light being delivered to the targeted chromophores underneath the skin. Then, we’re able to better see what we want to target for treatment because they’re better visualized. Gracie Vargas, a graduate student at the University of Texas, discussed this in her thesis on which she collaborated with her colleagues, Bernard Choi and A. J. Welsh. They injected glycerol into the skin and were able to make the skin more transparent. Based on this thesis, the challenge that I presented to colleagues and others in our lab is that we need to be able to induce optical clearing after agents are applied topically. The really unique thing about this is that all of this is totally reversible. When you re-hydrate the skin with normal saline, the skin returns to its normal opaque appearance. There’s a paper that we published in the December issue of the Journal of Investigative Dermatology looking at the mechanism of how this “clearing” process occurs. With optical clearing of the skin, you actually see a change in the collagen structure. The triple helix molecules seem to unwind in response to these clearing agents and then once you re-hydrate the skin they form again, creating three-dimensional triple helixes. We’ve been looking at a number of these agents, but by far the most promising is a mixture of polypropylene glycol and polyethylene glycol. We apply these to the skin surface, and then 2 hours later we can see much more detail in the skin, such as blood vessels. When using lasers on skin treated with an optical clearing agent, what we’ve found is that the skin has a lower threshold for purpura, and we don’t get the degree of epidermal injury we typically have with skin not treated with an optical clearing agent. So not only do these agents reduce the amount of dermal light scattering, they also allow more light to get to the target. As we reduce the scattering, the epidermal temperature actually drops. This all actually increases the threshold for epidermal damage, allowing us to use much higher light doses than we were able to before. So one can imagine that there is a variety of different therapeutic applications. Moreover, the diagnostic potential of this technology is also huge. Dr. Nelson is Professor of Surgery, Dermatology, and Biomedical Engineering at the University of California at Irvine. He’s also Associate Director of the Beckman Laser Institute and Medical Clinic. Non-Ablative Skin Rejuvenation Works S. Jeffrey Dover, M.D., FRCPC I think that there are some potential misconceptions about the efficacy of non-ablative skin rejuvenation. Non-ablative skin rejuvenation works within expected limitations. As long as the physician and patient understand these limitations, the results are encouraging and patient acceptance is high. The problem is that if patients are misinformed or they have unrealistic expectations, then they’ll be unhappy. I like to think of these devices in four categories: 1. Pulsed infrared devices. These include the CoolTouch (1320 nm), the SmoothBeam (1450 nm), and the Aramis (1540 nm). These devices use cooling to protect the skin surface, and they’re moderately good at improving skin texture and tone in both acne scarring and photoaging. However, these devices aren’t effective in improving skin color. 2. Pulsed dye lasers. These lasers do a great job of eliminating red tones in the skin. They also help improve skin texture, but not as well as the infrared (IR) lasers. 3. Intense pulsed light devices and pulsed 532 nm devices. These devices, which include the IPL Quantum, the MediLux, the Aurora and the PhotoLight, to name a few, and also the new 532 nm, 10-mm spot Gemini, help improve red and brown tones in the skin, and they help improve skin tone and texture, but not as much as the IR lasers. 4. Light-emitting diode photomodulation. The GentleWaves and OmniLux are an example of this type of device. This therapy helps improve tone and texture and may help skin color, but not as much as IPLs do. However, each treatment only takes 1 to 2 minutes — we typically do six treatments every 2 weeks — and there are no adverse effects. In addition, this therapy is totally painless and it’s inexpensive. I use this type of device as an adjunct to all other non-ablative skin rejuvenation procedures. These four groups of devices help to improve a variety of aspects of the aging process. It’s imperative that the physician know in advance what these devices can do for the patient and select the best device for the individual situation. Then, it’s important to convey realistic outcomes to the patient. Dr. Dover is a Director of SkinCare Physicians of Chestnut Hill in Chestnut Hill, MA. He is Associate Clinical Professor of Dermatology at Yale University School of Medicine. He is also Adjunct Professor of Medicine (Dermatology) at Dartmouth Medical School. A New Ripple in the Treatment of Cellulite Tina Alster, M.D. W hoever wins the war on fat — wins the war. And when I’m referring to fat, I specifically mean cellulite. There has never been a viable treatment for cellulite — disappointing, given the fact that 80% of women are affected by it (and the other 20% think they have it). I am now convinced that we have a viable treatment for this condition. I’ve been using the VelaSmooth by Syneron [Dr. Alster disclosed that she’s on the company’s medical advisory board] and have recently completed a controlled study on 20 patients with cellulite. One thigh on each patient was randomly chosen to receive treatment, using the other non-treated thigh as a control. Each patient received eight circumferential thigh treatments over 4 weeks. During the course of treatment, it was clear to the investigators and patients that changes were being made to the cellulite. Thigh circumference measurements and sequential photographs were used to monitor patient progress. In addition, patients’ subjective evaluations of improvement were gauged. The study’s findings will be reported at this year’s meeting of the American Society for Dermatologic Surgeons in early October. By then, data from 3 months post-treatment will be available for presentation. The VelaSmooth system is a medical device that incorporates the revolutionary ELOS technology (combination of bi-polar radiofrequency and infrared light) with tissue mobilization/suction to safely and effectively re-contour the skin’s surface. The mechanical manipulation portion of the device mimics the older Endermologie units, which had mechanical rolling heads, but the VelaSmooth device applies more suction to the tissue. This device works because heat is delivered deep into the tissue, causing dermal collagen contraction and redistribution of tissue water. Also, the technology disrupts the fibrous bands that surround the fat. There may be some mild lipolysis and shifting of water content along with dermal collagen contraction that adds to the overall effect of treatment. It’s great that we can combine these different technologies into one non-invasive apparatus to such a great effect. Dr. Alster is the Director of the Washington Institute of Dermatologic Laser Surgery, which she founded in 1990. She’s also a Clinical Professor of Dermatology at Georgetown University in Washington, D.C. Bruce Katz, M.D. I t’s clear that one of the hottest new areas of dermatology is the treatment of cellulite. We’re also starting a study. Ours is with a new device called Tri-Activ, which is a combination of a laser suction device and a low-energy diode laser. The device has the triple action of producing mechanical massage, localized cooling and deep laser stimulation. We’re in contact with scientists in Italy who are developing this technology. The idea behind how the technology works is that the low energy laser light seems to break up the fibrous bands that are part of the cellulite. Our study will be a controlled study in which we can measure the changes by ultrasound scanning. It’s not 100% clear what the mechanism of action is, but hopefully by next year we will be reporting the results of our study and have a better knowledge of how this technology produces positive outcomes. If we can effectively treat cellulite with this technology, it will be the first time that a laser has been shown to effectively treat this type of tissue. Dr. Katz is Associate Clinical Professor at the Mount Sinai School of Medicine in New York City. He’s also the Director of the Cosmetic Surgery and Laser Clinic at Mount Sinai Hospital. In addition, he’s Director of the JUVA Skin & Laser Center in New York City. The Myriad Uses of ALA/PDT Michael Gold, M.D. I’m completely convinced that the field of photodynamic therapy in combination with 5-aminolevulinic acid (ALA - Levulan and Photocure [not available at present in the United States]) has so much potential to take over a lot of what we do in laser practice. With this type of treatment, we’re adding technology to the machines we already have to make them work better. What we’re trying to figure out now is which of the light devices works better for acne vs. photorejuvenation. We already know that the spectrum of light that is effective is between 400 nm and 650 nm, and we know we must leave the ALA on for 1 hour prior to treatment. Here’s what else we’ve learned using this technology: • We know for actinic keratoses that blue light, intense pulsed light (IPL) and vascular lasers all work well. • The various blue light therapies and IPL work best for acne. In my practice, I’m using this treatment all the time now for acne patients. It just takes a few treatments, and these patients are remarkably better. We’ve haven’t looked at patients’ acne results long term, but we know that 3 or 4 months later they’re still clear. We still recommend maintenance therapy for these patients. I tell them to plan for up to four treatments on average. After I get them better, I bring them back 1 month later. At that point, I may not do anything but keep them on some type of topical treatment. It depends how well they’ve responded to treatment. • It also appears that the vascular systems and IPL systems seem to work better for photodamage. Instead of the five or six treatments needed with a light device alone, we only need to treat patients two or three times with the photodynamic therapy. • We’re treating sebaceous gland hyperplasia and achieving really good results with the IPL and vascular systems. • Patients who have hydradenitis suppurativa are also responding well to this therapy. We’re clearing people for months at a time, and these are recalcitrant cases I’m referring to. We’re seeing incredible results with this. • We’re treating a group of patients with hyperhidrosis. We’re in the process of seeing if photodynamic therapy can work with these patients, and we’re seeing some nice preliminary results. • Dr. Mitchel Goldman and I are about to study psoriasis patients with one of the biologics in conjunction with photodynamic therapy and IPL to see if we can make the biologics work better and faster. We’re finalizing the protocol right now. • We’re also looking at treating light and blond hairs. There’s preliminary evidence that the ALA is absorbed well and can treat this type of hair. We’re working on finalizing details of a multi-center trial for this purpose. Overall, ALA/PDT works well for so many different conditions; it has so much potential. Dr. Gold’s practice, Gold Skin Care Center, is located in Nashville, TN. Radiofrequency: Coming into its Own Kenneth Arndt, M.D. L aser photomedicine has become a lot broader. We have energies of many kinds, and they all meld together and complement one another. Of these newer technologies, I think one that is reaching its maturity is radiofrequency. Before the advent of this technology, we hadn’t been able to induce tissue tightening. Radiofrequency technology can take the form of mono-polar and bi-polar devices. Mono-polar. This is the most interesting of the two types. Radiowave energy is harnessed to apply heat to about 2.5 mm — deeper than heat from a laser. This causes tissue tightening and can be used for many purposes. Originally, the forehead was studied. Now we know that we can lift brows several millimeters, and successfully treat multiple areas to tighten jowls, neck, and nasolabial folds. Radiofrequency doesn’t induce changes as drastic as a facelift, but, then again, it’s not as invasive either. It’s not yet clear how long the results last. We first began talking to Thermage in 1999, so the instruments haven’t been around that long. However, there’s already one report that’s found the results last for at least a year. Bi-polar. If you asked me a year ago, I couldn’t even have told you much about the bi-polar technology because it’s so new. It’s used along with a laser or intense pulsed light. Bi-polar devices produce more superficial energy, producing not a tissue tightening effect but a tissue heating result, which may enhance the effects of the laser or IPL used along with it. This technology may treat photodamage faster or may treat light or white hairs. It will take a study of several years to discover this technology’s best applications. With radiofrequency overall, we’re seeing some really exciting results. Dr. Arndt is a Director of SkinCare Physicians of Chesnut Hill in Chestnut Hill, MA. He’s also Clinical Professor of Dermatology at Yale and Harvard Medical Schools, and Adjunct Professor of Medicine at Dartmouth Medical School.
