With patients paying significant amounts of monies and committing time and effort for treatments, the challenge for dermatologists is to select the approach and technology that will deliver the most desirable results and offer the most satisfaction to patients. However, matching the growing number of technologies and treatments with the needs of patients is becoming an increasing challenge for dermatologists. While many effective non-ablative technologies are available, the effectiveness of each can vary from patient to patient and from condition to condition. Speaking during this year’s annual meeting of the American Society for Laser Medicine and Surgery, a panel of experts offered their insight regarding the latest treatment pearls for the best outcomes in skin rejuvenation techniques. “To get the most effective results for a patient, a dermatologist must match the appropriate technology to the patient and the condition,” says Neil S. Sadick, M.D., a dermatologist and laser surgeon practicing in New York City. “Beyond merely selecting a technology, dermatologists must also decide the frequency and length of treatment, consider side effects and possible complications, and determine when other treatment options such as surgery are appropriate.” Finding the Right Treatment According to Suzanne L. Kilmer, M.D., Director of the Laser and Skin Surgery Center of Northern California and Assistant Clinical Professor at the University of California, Davis, it’s difficult to say that one specific device produces the best results for every patient. “Which device I use really depends on the patient. If a patient’s main complaint is wrinkles, but he or she has a vascular component, I usually start with the Vbeam vascular lesion laser from Candela. If the patient has brown spots and some redness, I’ll start with an IPL device. If a patient has neither and he or she just wants the most improvement, we use the Smoothbeam laser, also from Candela, or the CoolTouch Nd:YAG laser to treat the fine lines.” Dr. Kilmer says that if her patients want general skin tightening, she may use the Thermage ThermaCool radiofrequency system, but warns that the Thermage system is more involved and there is a certain degree of pain. “Patients may balk at the Thermage system because it can’t typically be done on the first visit because you must set up for it,” says Dr. Kilmer. While not specifically identifying any single device as being the most effective, Dr. Kilmer singles out the Vbeam as being the one device that can be effectively used to treat a wide range of patients with the fewest number of treatments. Jeffrey S. Dover, M.D., FRCPC, a laser surgeon with the SkinCare Physicians of Chestnut Hill in Massachusetts agrees that the Vbeam is an effective tool, but primarily for treating superficial redness. “We use The Vbeam extensively to treat redness and it is very effective, but, it doesn’t help texture that much. For patients with mild to moderate epidermal photodamage with dispigmentation, telangiectasia, a bit of redness, and a bit of textural imperfection, you see the most overall improvement with IPL treatments.” Dr. Dover recommends treatments five or six times about once a month to improve both colors and texture, to some extent. “We often do combination therapies when somebody has a lot of superficial wrinkling and other moderate photodamage. We might do a series of IPL treatments and either six CoolTouch treatments or six SmoothBeam treatments, either concurrently or as separate series.” Maintaining the Results A question that the physician and the patient need to consider when doing non-ablative treatments is the expectation of the patient as to how long the results will last and whether or not the patient needs to return for additional maintenance treatments. “Your patient will not suddenly stop aging just because they’ve had treatments,” says Dr. Dover. “Regardless of the technology, maintenance makes sense, and in our experience it works. However, the level of maintenance depends on the patient, his or her desires, and his or her budget because these are expensive treatments.” Maintenance treatments are dependent on the desires of the patient, but patients who are concerned enough about their appearance to seek initial treatments are often willing to accept a long-term maintenance program, as long as the program is effective or can be combined with other treatments to address other issues. “Many patients are accustomed to returning for multiple visits, especially those who are very concerned with their appearance,” says Joop M. Grevelink, M.D., Ph.D., Director of the Boston Dermatology Laser Center, and affiliated with Massachusetts General Hospital. “After an initial treatment regimen, many patients come back once or twice a year. In many cases, I add other treatments that are more immediately pleasing to them, such as freckle removal or removal of other lesions.” Satisfying Your Patients Regardless of the technology employed, the satisfaction level of patients appears to be a function of two separate factors: 1. the expectations of the patient 2. the effectiveness of the treatment. However, it can be said that many of these technologies are extremely effective in addressing specific conditions, and patients appear to be generally very pleased with the results of treatment. Dr. Dover explains, “In a recent study of 40 patients treated with CoolTouch, we found a satisfaction level after 6 months of about a five or six out of nine among patients with acne scarring and photodamage, with the acne patients slightly more satisfied. “What was interesting was that the patient satisfaction rate didn’t change from 6 months after their last treatment to a year after their last treatment, which suggests that the results are actually maintained. Overall, we found that 60% of our patients were very pleased with their results.” Satisfaction levels appear to be as high for other conditions and technologies. “The happiest patients are those with static pigmented and vascular lesions who either have IPL or KTP laser,” says E. Victor Ross, M.D., Clinical Professor, Department of Dermatology, Naval Medical Center, San Diego. “I use the KTP laser actually as much or more than the pulsed dye laser, and certainly as much as the IPL. If I opt for a large-spot, KTP laser, I’ll use either the new Gemini or even the older VersaPulse from Lumenis, which is still a good choice. Large-spot KTP should be on that list because it’s as good as those other therapies.” The mid-IR technologies when used for wrinkles produced much more modest improvement with a corresponding drop in overall patient satisfaction. Patients with active rosacea and associated telangiectasia appear to need more maintenance and may need maintenance therapy every 2 to 3 months. For radiofrequency technologies, patient satisfaction seems to be on a par with other non-ablative technologies. “If treating with the Thermage system, 20% of the people are not going to feel like they got improvement. On the other hand, 20% are thrilled with the improvement,” says Dr. Kilmer. “Sixty percent of patients will be in the middle but out of those 60%, almost every of them is happy and feels tightening.” Most dermatologists will see a small number of patients who don’t benefit from non-ablative therapies. Other patients may have photodamage that requires surgical intervention. Patients with severe dystrophy will likely be happier with a surgical approach. Multiple Modalities During a Single Treatment Session Many dermatologist combine treatment modalities to obtain more satisfying results for their patients. “It really depends on the patient, but multiple modality approach using combinations of Q-Switched, Nd:YAG laser, 1064 nm, sometimes combined with a pigment peel with the 532 nm mode, combining microdermabrasion, salicylic acid peels — all those sort of combinations — are very commonly done and can produce effective results,” says Dr. Grevelink. However, cautions Emil Tanghetti, M.D., dermatologist and laser surgeon at the Center for Dermatology and Laser Surgery, Sacramento, CA, physicians should move carefully when combining modalities and be certain that they understand the technologies and use them very carefully. “We must remember that photodamage is a form of wounding and our treatments are further wounding, so we must proceed very carefully.” Higher or Lower Energies? One issue that remains unresolved is the question of the most effective energy levels to use for these treatments. “There’s always a tendency to believe that if you treat more aggressively you will get better results. But at least two examples in this arena suggest that’s not the case,” says Dr. Dover. “The first example is the pulsed dye laser, which has been shown repeatedly to produce better results in scar treatment with lower fluences than with higher fluences. For IPL devices, studies suggest that doing five or six treatments over 6 months can achieve great results with fewer side effects — many more patients were satisfied. High fluences for most of these devices are not essential.” Dr. Kilmer has experienced the opposite. “In our initial pulsed dye laser study, our results from one treatment at higher fluences were much better than anything I’ve had with our current treatment parameters. A single treatment gave us 25% to 50% improvement in wrinkles. But, you get swelling and purpura.” However, data suggest that the histological processes in photoaging are from chronic inflammation. With repeat treatments over a long time, non-ablative therapies might induce inflammatory responses that could have serious implications for the patient, even at very low energy levels. Looking at the Safety Record An important factor in non-ablative therapies is the relative safety of the technologies. The low incidence of long-term side effects and complications coupled with relatively high patient satisfaction make these technologies an extremely important tool for cosmetic dermatology. According to Dr. Tanghetti, serious side effects and complications are very uncommon. “The incidence of serious complications is very small with typically nothing permanent. With a device like the KTP laser, you might have a couple of pitted scars, though usually because something went wrong, such as the practitioner used the wrong energy levels or something like that. In the hands of a good practitioner, you shouldn’t have any problems.” Dr. Ross agrees that in his experience the technologies are extremely safe. “I’ve seen a handful of pitted scars with KTP laser, and occasional crust with PDL,” Dr. Ross says. “If using the IPL, the critical thing is to see the subtleties and the changes in color, especially along the face. In addition, it’s important to be extra conservative with either IPL or KTP — any laser that targets melanin — so that you don’t add too much too fast.” According to Dr. Dover, the safest technology is the pulsed dye laser, with some minor circular scarring as the worst possible long-term side effect. He cautions, however, that the infrared sources can cause significant scarring if the cooling fails even slightly. He also warns against IPL-induced permanent hypopigmentation with atrophy, especially on the neck and chest, which is irreparable. “When using these devices, you need to have skill and talent in using them. And, you must be a bit cautious when doing them.” Dr. Sadick takes Dr. Dover’s concerns a step further. “Many dermatologists hand off these procedures to other members of staff in their office. It’s extremely important that your staff is well trained and that these technologies stay in the physician’s office, rather than out of the hands of professionals.” Using Non-Ablative Technologies with Other Therapies Many dermatologists are combining non-ablative technologies with other therapies, including photosensitizing drugs, Botox and fillers in the hopes of achieving greater success with their therapies. It is unclear whether or not these combinations produce the desired results, and many practitioners caution that there are many unknowns and that dermatologists need to move carefully. “We’ve been using 5-aminolevulinic acid (Levulan) for a while, and the drug seems effective if it’s left on for at least 30 to 45 minutes,” says Dr. Ross. “What I’ve also noticed is that it seems as if there’s always a bit of sunlight that’s part of the equation. I get far better results on the face or other sun-exposed areas than I do treating non-exposed areas.” Some dermatologists have used non-ablative therapies in conjunction with Botox. However, as with other combinations, the results vary greatly and many feel that using Botox with these therapies may not change the results. “We looked at six non-ablative lasers and Thermage, and treated patients immediately after they received Botox. We also treated patients symmetrically,” says Dr Kilmer. “One side we treated immediately after Botox; the other we used the laser on one side and then used Botox. In one case, 19 out of 19 patients had no change, and they each received Botox symmetrically. However, according to Dr. Dover, IPL treatments may benefit when combined with Botox injections. “Studies by Drs. Alastair and Jean Carruthers show that performing Botox treatments in conjunction with IPL treatments produced better results from IPL photo- rejuvenation. There was no question that the patients who had the combination did better than the patients who had IPL treatments alone.” Dermatologists are divided on the use of fillers with non-ablative technologies. “If I use a filler, then I always do it after the laser treatment,” says Dr. Kilmer. “I don’t perform Thermage over an area that I just used a filler.” Dr. Tanghetti is also as cautious when using fillers. “I don’t do filling and laser therapies at the same time because I’m just not sure what happens when you use these together.” Dr. Dover is also concerned about combining fillers with non-ablative technologies. “I’m not sure it’s a great idea to irradiate the skin with infrared radiation, which penetrates relatively deeply into skin — at least to the depth of collagen — right after you inject it.” However, Dr. Grevelink explains that the two therapies can be effectively combined as long as the physician is careful. “Most of the time, the areas that I have injected with fillers are really not the areas that I target with the non-ablative devices.” Most dermatologists agree that all the photorejuvenation treatments must be accompanied by home treatment regimens that include some combination of sunscreens and retinoids. “The next generation of topicals — other than the retinoids — that will gain increased popularity are going to be a lot of the natural antioxidants such as idebenone from Allergan,” says Dr. Sadick. “We’ve also been researching genestine, a soy derivative. You’ll see the next generation of these high-potency antioxidants as self-protectants, and they will begin to play a major role.” Making It Work for Your Patients There are no secrets to the effective use of non-ablative technologies. If applied properly, the results of treatment can be dramatic — even life-changing. The key to achieving the goals of treatment is to match the treatment to the patient and the condition. Although many of the therapies are effective in a variety of applications, some simply work better for certain patients, and applying the appropriate treatment can make the difference between marginal results and dramatic improvement. With so much at stake, it’s important to understand the proper applications and limitations of each therapy. “It behooves all of us to make certain we know what each of these therapies can do, when they can and should be applied, and that the patient knows what to expect, both in terms of the course of treatment and the results,” says Dr. Sadick. “With the non-ablative therapies available today, there’s little reason why a dermatologist can’t achieve the results that his or her patients want.”
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Non-Ablative Skin Rejuvenation
With patients paying significant amounts of monies and committing time and effort for treatments, the challenge for dermatologists is to select the approach and technology that will deliver the most desirable results and offer the most satisfaction to patients. However, matching the growing number of technologies and treatments with the needs of patients is becoming an increasing challenge for dermatologists. While many effective non-ablative technologies are available, the effectiveness of each can vary from patient to patient and from condition to condition. Speaking during this year’s annual meeting of the American Society for Laser Medicine and Surgery, a panel of experts offered their insight regarding the latest treatment pearls for the best outcomes in skin rejuvenation techniques. “To get the most effective results for a patient, a dermatologist must match the appropriate technology to the patient and the condition,” says Neil S. Sadick, M.D., a dermatologist and laser surgeon practicing in New York City. “Beyond merely selecting a technology, dermatologists must also decide the frequency and length of treatment, consider side effects and possible complications, and determine when other treatment options such as surgery are appropriate.” Finding the Right Treatment According to Suzanne L. Kilmer, M.D., Director of the Laser and Skin Surgery Center of Northern California and Assistant Clinical Professor at the University of California, Davis, it’s difficult to say that one specific device produces the best results for every patient. “Which device I use really depends on the patient. If a patient’s main complaint is wrinkles, but he or she has a vascular component, I usually start with the Vbeam vascular lesion laser from Candela. If the patient has brown spots and some redness, I’ll start with an IPL device. If a patient has neither and he or she just wants the most improvement, we use the Smoothbeam laser, also from Candela, or the CoolTouch Nd:YAG laser to treat the fine lines.” Dr. Kilmer says that if her patients want general skin tightening, she may use the Thermage ThermaCool radiofrequency system, but warns that the Thermage system is more involved and there is a certain degree of pain. “Patients may balk at the Thermage system because it can’t typically be done on the first visit because you must set up for it,” says Dr. Kilmer. While not specifically identifying any single device as being the most effective, Dr. Kilmer singles out the Vbeam as being the one device that can be effectively used to treat a wide range of patients with the fewest number of treatments. Jeffrey S. Dover, M.D., FRCPC, a laser surgeon with the SkinCare Physicians of Chestnut Hill in Massachusetts agrees that the Vbeam is an effective tool, but primarily for treating superficial redness. “We use The Vbeam extensively to treat redness and it is very effective, but, it doesn’t help texture that much. For patients with mild to moderate epidermal photodamage with dispigmentation, telangiectasia, a bit of redness, and a bit of textural imperfection, you see the most overall improvement with IPL treatments.” Dr. Dover recommends treatments five or six times about once a month to improve both colors and texture, to some extent. “We often do combination therapies when somebody has a lot of superficial wrinkling and other moderate photodamage. We might do a series of IPL treatments and either six CoolTouch treatments or six SmoothBeam treatments, either concurrently or as separate series.” Maintaining the Results A question that the physician and the patient need to consider when doing non-ablative treatments is the expectation of the patient as to how long the results will last and whether or not the patient needs to return for additional maintenance treatments. “Your patient will not suddenly stop aging just because they’ve had treatments,” says Dr. Dover. “Regardless of the technology, maintenance makes sense, and in our experience it works. However, the level of maintenance depends on the patient, his or her desires, and his or her budget because these are expensive treatments.” Maintenance treatments are dependent on the desires of the patient, but patients who are concerned enough about their appearance to seek initial treatments are often willing to accept a long-term maintenance program, as long as the program is effective or can be combined with other treatments to address other issues. “Many patients are accustomed to returning for multiple visits, especially those who are very concerned with their appearance,” says Joop M. Grevelink, M.D., Ph.D., Director of the Boston Dermatology Laser Center, and affiliated with Massachusetts General Hospital. “After an initial treatment regimen, many patients come back once or twice a year. In many cases, I add other treatments that are more immediately pleasing to them, such as freckle removal or removal of other lesions.” Satisfying Your Patients Regardless of the technology employed, the satisfaction level of patients appears to be a function of two separate factors: 1. the expectations of the patient 2. the effectiveness of the treatment. However, it can be said that many of these technologies are extremely effective in addressing specific conditions, and patients appear to be generally very pleased with the results of treatment. Dr. Dover explains, “In a recent study of 40 patients treated with CoolTouch, we found a satisfaction level after 6 months of about a five or six out of nine among patients with acne scarring and photodamage, with the acne patients slightly more satisfied. “What was interesting was that the patient satisfaction rate didn’t change from 6 months after their last treatment to a year after their last treatment, which suggests that the results are actually maintained. Overall, we found that 60% of our patients were very pleased with their results.” Satisfaction levels appear to be as high for other conditions and technologies. “The happiest patients are those with static pigmented and vascular lesions who either have IPL or KTP laser,” says E. Victor Ross, M.D., Clinical Professor, Department of Dermatology, Naval Medical Center, San Diego. “I use the KTP laser actually as much or more than the pulsed dye laser, and certainly as much as the IPL. If I opt for a large-spot, KTP laser, I’ll use either the new Gemini or even the older VersaPulse from Lumenis, which is still a good choice. Large-spot KTP should be on that list because it’s as good as those other therapies.” The mid-IR technologies when used for wrinkles produced much more modest improvement with a corresponding drop in overall patient satisfaction. Patients with active rosacea and associated telangiectasia appear to need more maintenance and may need maintenance therapy every 2 to 3 months. For radiofrequency technologies, patient satisfaction seems to be on a par with other non-ablative technologies. “If treating with the Thermage system, 20% of the people are not going to feel like they got improvement. On the other hand, 20% are thrilled with the improvement,” says Dr. Kilmer. “Sixty percent of patients will be in the middle but out of those 60%, almost every of them is happy and feels tightening.” Most dermatologists will see a small number of patients who don’t benefit from non-ablative therapies. Other patients may have photodamage that requires surgical intervention. Patients with severe dystrophy will likely be happier with a surgical approach. Multiple Modalities During a Single Treatment Session Many dermatologist combine treatment modalities to obtain more satisfying results for their patients. “It really depends on the patient, but multiple modality approach using combinations of Q-Switched, Nd:YAG laser, 1064 nm, sometimes combined with a pigment peel with the 532 nm mode, combining microdermabrasion, salicylic acid peels — all those sort of combinations — are very commonly done and can produce effective results,” says Dr. Grevelink. However, cautions Emil Tanghetti, M.D., dermatologist and laser surgeon at the Center for Dermatology and Laser Surgery, Sacramento, CA, physicians should move carefully when combining modalities and be certain that they understand the technologies and use them very carefully. “We must remember that photodamage is a form of wounding and our treatments are further wounding, so we must proceed very carefully.” Higher or Lower Energies? One issue that remains unresolved is the question of the most effective energy levels to use for these treatments. “There’s always a tendency to believe that if you treat more aggressively you will get better results. But at least two examples in this arena suggest that’s not the case,” says Dr. Dover. “The first example is the pulsed dye laser, which has been shown repeatedly to produce better results in scar treatment with lower fluences than with higher fluences. For IPL devices, studies suggest that doing five or six treatments over 6 months can achieve great results with fewer side effects — many more patients were satisfied. High fluences for most of these devices are not essential.” Dr. Kilmer has experienced the opposite. “In our initial pulsed dye laser study, our results from one treatment at higher fluences were much better than anything I’ve had with our current treatment parameters. A single treatment gave us 25% to 50% improvement in wrinkles. But, you get swelling and purpura.” However, data suggest that the histological processes in photoaging are from chronic inflammation. With repeat treatments over a long time, non-ablative therapies might induce inflammatory responses that could have serious implications for the patient, even at very low energy levels. Looking at the Safety Record An important factor in non-ablative therapies is the relative safety of the technologies. The low incidence of long-term side effects and complications coupled with relatively high patient satisfaction make these technologies an extremely important tool for cosmetic dermatology. According to Dr. Tanghetti, serious side effects and complications are very uncommon. “The incidence of serious complications is very small with typically nothing permanent. With a device like the KTP laser, you might have a couple of pitted scars, though usually because something went wrong, such as the practitioner used the wrong energy levels or something like that. In the hands of a good practitioner, you shouldn’t have any problems.” Dr. Ross agrees that in his experience the technologies are extremely safe. “I’ve seen a handful of pitted scars with KTP laser, and occasional crust with PDL,” Dr. Ross says. “If using the IPL, the critical thing is to see the subtleties and the changes in color, especially along the face. In addition, it’s important to be extra conservative with either IPL or KTP — any laser that targets melanin — so that you don’t add too much too fast.” According to Dr. Dover, the safest technology is the pulsed dye laser, with some minor circular scarring as the worst possible long-term side effect. He cautions, however, that the infrared sources can cause significant scarring if the cooling fails even slightly. He also warns against IPL-induced permanent hypopigmentation with atrophy, especially on the neck and chest, which is irreparable. “When using these devices, you need to have skill and talent in using them. And, you must be a bit cautious when doing them.” Dr. Sadick takes Dr. Dover’s concerns a step further. “Many dermatologists hand off these procedures to other members of staff in their office. It’s extremely important that your staff is well trained and that these technologies stay in the physician’s office, rather than out of the hands of professionals.” Using Non-Ablative Technologies with Other Therapies Many dermatologists are combining non-ablative technologies with other therapies, including photosensitizing drugs, Botox and fillers in the hopes of achieving greater success with their therapies. It is unclear whether or not these combinations produce the desired results, and many practitioners caution that there are many unknowns and that dermatologists need to move carefully. “We’ve been using 5-aminolevulinic acid (Levulan) for a while, and the drug seems effective if it’s left on for at least 30 to 45 minutes,” says Dr. Ross. “What I’ve also noticed is that it seems as if there’s always a bit of sunlight that’s part of the equation. I get far better results on the face or other sun-exposed areas than I do treating non-exposed areas.” Some dermatologists have used non-ablative therapies in conjunction with Botox. However, as with other combinations, the results vary greatly and many feel that using Botox with these therapies may not change the results. “We looked at six non-ablative lasers and Thermage, and treated patients immediately after they received Botox. We also treated patients symmetrically,” says Dr Kilmer. “One side we treated immediately after Botox; the other we used the laser on one side and then used Botox. In one case, 19 out of 19 patients had no change, and they each received Botox symmetrically. However, according to Dr. Dover, IPL treatments may benefit when combined with Botox injections. “Studies by Drs. Alastair and Jean Carruthers show that performing Botox treatments in conjunction with IPL treatments produced better results from IPL photo- rejuvenation. There was no question that the patients who had the combination did better than the patients who had IPL treatments alone.” Dermatologists are divided on the use of fillers with non-ablative technologies. “If I use a filler, then I always do it after the laser treatment,” says Dr. Kilmer. “I don’t perform Thermage over an area that I just used a filler.” Dr. Tanghetti is also as cautious when using fillers. “I don’t do filling and laser therapies at the same time because I’m just not sure what happens when you use these together.” Dr. Dover is also concerned about combining fillers with non-ablative technologies. “I’m not sure it’s a great idea to irradiate the skin with infrared radiation, which penetrates relatively deeply into skin — at least to the depth of collagen — right after you inject it.” However, Dr. Grevelink explains that the two therapies can be effectively combined as long as the physician is careful. “Most of the time, the areas that I have injected with fillers are really not the areas that I target with the non-ablative devices.” Most dermatologists agree that all the photorejuvenation treatments must be accompanied by home treatment regimens that include some combination of sunscreens and retinoids. “The next generation of topicals — other than the retinoids — that will gain increased popularity are going to be a lot of the natural antioxidants such as idebenone from Allergan,” says Dr. Sadick. “We’ve also been researching genestine, a soy derivative. You’ll see the next generation of these high-potency antioxidants as self-protectants, and they will begin to play a major role.” Making It Work for Your Patients There are no secrets to the effective use of non-ablative technologies. If applied properly, the results of treatment can be dramatic — even life-changing. The key to achieving the goals of treatment is to match the treatment to the patient and the condition. Although many of the therapies are effective in a variety of applications, some simply work better for certain patients, and applying the appropriate treatment can make the difference between marginal results and dramatic improvement. With so much at stake, it’s important to understand the proper applications and limitations of each therapy. “It behooves all of us to make certain we know what each of these therapies can do, when they can and should be applied, and that the patient knows what to expect, both in terms of the course of treatment and the results,” says Dr. Sadick. “With the non-ablative therapies available today, there’s little reason why a dermatologist can’t achieve the results that his or her patients want.”
With patients paying significant amounts of monies and committing time and effort for treatments, the challenge for dermatologists is to select the approach and technology that will deliver the most desirable results and offer the most satisfaction to patients. However, matching the growing number of technologies and treatments with the needs of patients is becoming an increasing challenge for dermatologists. While many effective non-ablative technologies are available, the effectiveness of each can vary from patient to patient and from condition to condition. Speaking during this year’s annual meeting of the American Society for Laser Medicine and Surgery, a panel of experts offered their insight regarding the latest treatment pearls for the best outcomes in skin rejuvenation techniques. “To get the most effective results for a patient, a dermatologist must match the appropriate technology to the patient and the condition,” says Neil S. Sadick, M.D., a dermatologist and laser surgeon practicing in New York City. “Beyond merely selecting a technology, dermatologists must also decide the frequency and length of treatment, consider side effects and possible complications, and determine when other treatment options such as surgery are appropriate.” Finding the Right Treatment According to Suzanne L. Kilmer, M.D., Director of the Laser and Skin Surgery Center of Northern California and Assistant Clinical Professor at the University of California, Davis, it’s difficult to say that one specific device produces the best results for every patient. “Which device I use really depends on the patient. If a patient’s main complaint is wrinkles, but he or she has a vascular component, I usually start with the Vbeam vascular lesion laser from Candela. If the patient has brown spots and some redness, I’ll start with an IPL device. If a patient has neither and he or she just wants the most improvement, we use the Smoothbeam laser, also from Candela, or the CoolTouch Nd:YAG laser to treat the fine lines.” Dr. Kilmer says that if her patients want general skin tightening, she may use the Thermage ThermaCool radiofrequency system, but warns that the Thermage system is more involved and there is a certain degree of pain. “Patients may balk at the Thermage system because it can’t typically be done on the first visit because you must set up for it,” says Dr. Kilmer. While not specifically identifying any single device as being the most effective, Dr. Kilmer singles out the Vbeam as being the one device that can be effectively used to treat a wide range of patients with the fewest number of treatments. Jeffrey S. Dover, M.D., FRCPC, a laser surgeon with the SkinCare Physicians of Chestnut Hill in Massachusetts agrees that the Vbeam is an effective tool, but primarily for treating superficial redness. “We use The Vbeam extensively to treat redness and it is very effective, but, it doesn’t help texture that much. For patients with mild to moderate epidermal photodamage with dispigmentation, telangiectasia, a bit of redness, and a bit of textural imperfection, you see the most overall improvement with IPL treatments.” Dr. Dover recommends treatments five or six times about once a month to improve both colors and texture, to some extent. “We often do combination therapies when somebody has a lot of superficial wrinkling and other moderate photodamage. We might do a series of IPL treatments and either six CoolTouch treatments or six SmoothBeam treatments, either concurrently or as separate series.” Maintaining the Results A question that the physician and the patient need to consider when doing non-ablative treatments is the expectation of the patient as to how long the results will last and whether or not the patient needs to return for additional maintenance treatments. “Your patient will not suddenly stop aging just because they’ve had treatments,” says Dr. Dover. “Regardless of the technology, maintenance makes sense, and in our experience it works. However, the level of maintenance depends on the patient, his or her desires, and his or her budget because these are expensive treatments.” Maintenance treatments are dependent on the desires of the patient, but patients who are concerned enough about their appearance to seek initial treatments are often willing to accept a long-term maintenance program, as long as the program is effective or can be combined with other treatments to address other issues. “Many patients are accustomed to returning for multiple visits, especially those who are very concerned with their appearance,” says Joop M. Grevelink, M.D., Ph.D., Director of the Boston Dermatology Laser Center, and affiliated with Massachusetts General Hospital. “After an initial treatment regimen, many patients come back once or twice a year. In many cases, I add other treatments that are more immediately pleasing to them, such as freckle removal or removal of other lesions.” Satisfying Your Patients Regardless of the technology employed, the satisfaction level of patients appears to be a function of two separate factors: 1. the expectations of the patient 2. the effectiveness of the treatment. However, it can be said that many of these technologies are extremely effective in addressing specific conditions, and patients appear to be generally very pleased with the results of treatment. Dr. Dover explains, “In a recent study of 40 patients treated with CoolTouch, we found a satisfaction level after 6 months of about a five or six out of nine among patients with acne scarring and photodamage, with the acne patients slightly more satisfied. “What was interesting was that the patient satisfaction rate didn’t change from 6 months after their last treatment to a year after their last treatment, which suggests that the results are actually maintained. Overall, we found that 60% of our patients were very pleased with their results.” Satisfaction levels appear to be as high for other conditions and technologies. “The happiest patients are those with static pigmented and vascular lesions who either have IPL or KTP laser,” says E. Victor Ross, M.D., Clinical Professor, Department of Dermatology, Naval Medical Center, San Diego. “I use the KTP laser actually as much or more than the pulsed dye laser, and certainly as much as the IPL. If I opt for a large-spot, KTP laser, I’ll use either the new Gemini or even the older VersaPulse from Lumenis, which is still a good choice. Large-spot KTP should be on that list because it’s as good as those other therapies.” The mid-IR technologies when used for wrinkles produced much more modest improvement with a corresponding drop in overall patient satisfaction. Patients with active rosacea and associated telangiectasia appear to need more maintenance and may need maintenance therapy every 2 to 3 months. For radiofrequency technologies, patient satisfaction seems to be on a par with other non-ablative technologies. “If treating with the Thermage system, 20% of the people are not going to feel like they got improvement. On the other hand, 20% are thrilled with the improvement,” says Dr. Kilmer. “Sixty percent of patients will be in the middle but out of those 60%, almost every of them is happy and feels tightening.” Most dermatologists will see a small number of patients who don’t benefit from non-ablative therapies. Other patients may have photodamage that requires surgical intervention. Patients with severe dystrophy will likely be happier with a surgical approach. Multiple Modalities During a Single Treatment Session Many dermatologist combine treatment modalities to obtain more satisfying results for their patients. “It really depends on the patient, but multiple modality approach using combinations of Q-Switched, Nd:YAG laser, 1064 nm, sometimes combined with a pigment peel with the 532 nm mode, combining microdermabrasion, salicylic acid peels — all those sort of combinations — are very commonly done and can produce effective results,” says Dr. Grevelink. However, cautions Emil Tanghetti, M.D., dermatologist and laser surgeon at the Center for Dermatology and Laser Surgery, Sacramento, CA, physicians should move carefully when combining modalities and be certain that they understand the technologies and use them very carefully. “We must remember that photodamage is a form of wounding and our treatments are further wounding, so we must proceed very carefully.” Higher or Lower Energies? One issue that remains unresolved is the question of the most effective energy levels to use for these treatments. “There’s always a tendency to believe that if you treat more aggressively you will get better results. But at least two examples in this arena suggest that’s not the case,” says Dr. Dover. “The first example is the pulsed dye laser, which has been shown repeatedly to produce better results in scar treatment with lower fluences than with higher fluences. For IPL devices, studies suggest that doing five or six treatments over 6 months can achieve great results with fewer side effects — many more patients were satisfied. High fluences for most of these devices are not essential.” Dr. Kilmer has experienced the opposite. “In our initial pulsed dye laser study, our results from one treatment at higher fluences were much better than anything I’ve had with our current treatment parameters. A single treatment gave us 25% to 50% improvement in wrinkles. But, you get swelling and purpura.” However, data suggest that the histological processes in photoaging are from chronic inflammation. With repeat treatments over a long time, non-ablative therapies might induce inflammatory responses that could have serious implications for the patient, even at very low energy levels. Looking at the Safety Record An important factor in non-ablative therapies is the relative safety of the technologies. The low incidence of long-term side effects and complications coupled with relatively high patient satisfaction make these technologies an extremely important tool for cosmetic dermatology. According to Dr. Tanghetti, serious side effects and complications are very uncommon. “The incidence of serious complications is very small with typically nothing permanent. With a device like the KTP laser, you might have a couple of pitted scars, though usually because something went wrong, such as the practitioner used the wrong energy levels or something like that. In the hands of a good practitioner, you shouldn’t have any problems.” Dr. Ross agrees that in his experience the technologies are extremely safe. “I’ve seen a handful of pitted scars with KTP laser, and occasional crust with PDL,” Dr. Ross says. “If using the IPL, the critical thing is to see the subtleties and the changes in color, especially along the face. In addition, it’s important to be extra conservative with either IPL or KTP — any laser that targets melanin — so that you don’t add too much too fast.” According to Dr. Dover, the safest technology is the pulsed dye laser, with some minor circular scarring as the worst possible long-term side effect. He cautions, however, that the infrared sources can cause significant scarring if the cooling fails even slightly. He also warns against IPL-induced permanent hypopigmentation with atrophy, especially on the neck and chest, which is irreparable. “When using these devices, you need to have skill and talent in using them. And, you must be a bit cautious when doing them.” Dr. Sadick takes Dr. Dover’s concerns a step further. “Many dermatologists hand off these procedures to other members of staff in their office. It’s extremely important that your staff is well trained and that these technologies stay in the physician’s office, rather than out of the hands of professionals.” Using Non-Ablative Technologies with Other Therapies Many dermatologists are combining non-ablative technologies with other therapies, including photosensitizing drugs, Botox and fillers in the hopes of achieving greater success with their therapies. It is unclear whether or not these combinations produce the desired results, and many practitioners caution that there are many unknowns and that dermatologists need to move carefully. “We’ve been using 5-aminolevulinic acid (Levulan) for a while, and the drug seems effective if it’s left on for at least 30 to 45 minutes,” says Dr. Ross. “What I’ve also noticed is that it seems as if there’s always a bit of sunlight that’s part of the equation. I get far better results on the face or other sun-exposed areas than I do treating non-exposed areas.” Some dermatologists have used non-ablative therapies in conjunction with Botox. However, as with other combinations, the results vary greatly and many feel that using Botox with these therapies may not change the results. “We looked at six non-ablative lasers and Thermage, and treated patients immediately after they received Botox. We also treated patients symmetrically,” says Dr Kilmer. “One side we treated immediately after Botox; the other we used the laser on one side and then used Botox. In one case, 19 out of 19 patients had no change, and they each received Botox symmetrically. However, according to Dr. Dover, IPL treatments may benefit when combined with Botox injections. “Studies by Drs. Alastair and Jean Carruthers show that performing Botox treatments in conjunction with IPL treatments produced better results from IPL photo- rejuvenation. There was no question that the patients who had the combination did better than the patients who had IPL treatments alone.” Dermatologists are divided on the use of fillers with non-ablative technologies. “If I use a filler, then I always do it after the laser treatment,” says Dr. Kilmer. “I don’t perform Thermage over an area that I just used a filler.” Dr. Tanghetti is also as cautious when using fillers. “I don’t do filling and laser therapies at the same time because I’m just not sure what happens when you use these together.” Dr. Dover is also concerned about combining fillers with non-ablative technologies. “I’m not sure it’s a great idea to irradiate the skin with infrared radiation, which penetrates relatively deeply into skin — at least to the depth of collagen — right after you inject it.” However, Dr. Grevelink explains that the two therapies can be effectively combined as long as the physician is careful. “Most of the time, the areas that I have injected with fillers are really not the areas that I target with the non-ablative devices.” Most dermatologists agree that all the photorejuvenation treatments must be accompanied by home treatment regimens that include some combination of sunscreens and retinoids. “The next generation of topicals — other than the retinoids — that will gain increased popularity are going to be a lot of the natural antioxidants such as idebenone from Allergan,” says Dr. Sadick. “We’ve also been researching genestine, a soy derivative. You’ll see the next generation of these high-potency antioxidants as self-protectants, and they will begin to play a major role.” Making It Work for Your Patients There are no secrets to the effective use of non-ablative technologies. If applied properly, the results of treatment can be dramatic — even life-changing. The key to achieving the goals of treatment is to match the treatment to the patient and the condition. Although many of the therapies are effective in a variety of applications, some simply work better for certain patients, and applying the appropriate treatment can make the difference between marginal results and dramatic improvement. With so much at stake, it’s important to understand the proper applications and limitations of each therapy. “It behooves all of us to make certain we know what each of these therapies can do, when they can and should be applied, and that the patient knows what to expect, both in terms of the course of treatment and the results,” says Dr. Sadick. “With the non-ablative therapies available today, there’s little reason why a dermatologist can’t achieve the results that his or her patients want.”
