With the wide range of lasers available today, dermatologists are challenged to find the right devices to fit their individual practices. In this article, Gerald Goldberg, M.D., a dermatologist in private practice in Tucson, AZ, Clinical Associate Professor at the University of Arizona and an expert on the dermatological application of laser technologies, will take a look at the latest developments in this exciting and important field.
“Clinical lasers can be used to effectively treat a wide variety of skin conditions, including birthmarks and rosacea, to rejuvenate the skin, to resurface wrinkles, to correct scars and to remove tattoos and unwanted hair,” says Dr. Goldberg. “The key is to find the workhorse devices that will allow you to cost-effectively deliver the broadest range of services to your patients. In addition, you might also need to find devices that will address the particular needs of your specific patient population.”
Vascular Lesions
Vascular lesions range from common conditions such as rosacea, facial telangiectasia and, hemangioma to more rare anomalies such as port wine stains associated with Sturge Weber syndrome.
Today, most of these conditions can be effectively treated with laser therapy producing excellent results. According to Dr. Goldberg, since many of these conditions manifest at or soon after birth, the key to effectively treating them may be in beginning treatment as early as possible.
“The sooner you can begin treatment on some of these conditions, for example, hemangioma, the better the results will be,” he explains. “In many cases, we can significantly alter the rapid growth pattern and reduce the impact of the growing hemangioma on important structures if we start treatments when patients are very young or before rapid growth begins. There is a critical window before more serious consequences occur. However, pediatricians have traditionally held off on treatments since most hemangioma resolve on their own. Unfortunately, many do not resolve and it is critical to quickly identify those that need intervention so that treatment can begin as soon as possible.”
Even those lesions that resolve over time can cause emotional distress for the afflicted children and their families. Being able to trigger involution of a hemangioma for a child who would have otherwise had to live with it for the first several years of his or her life can make a tremendous difference in the quality of that child’s life.
“We have a small window of opportunity to address these conditions and, unfortunately, we often don’t see them from the pediatrician until it’s already been through its rapid growth phase when there’s not much we can do,” says Dr. Goldberg. “We need to focus on developing good relationships with local pediatricians to consult early in the first weeks of life, so that we can make a difference.”
When significant superficial and deep hemangiomata cannot be effectively ablated by laser alone, Dr. Goldberg uses a pulsed dye laser in conjunction with injection therapy with interlesional steroids. When hemangiomata have fully involuted, they often leave residual telangiectatic vessels that can respond to laser treatment. “These are discrete vessels and you can use any of the 532 nm KTP or pulsed dye lasers,” he says. “This therapy works great for residual vessels in youngsters approaching school age. It’s a great indication for some of the laser devices. You can also use these devices to speed the healing of hemangiomas.”
Port wine stains are the other major birthmarks that are fairly common vascular birthmarks seen in children. The gold standard of treatment is the pulsed dye laser. Very gratifying results are seen when treatment with a pulsed dye laser is performed early, particularly in the first year of life. After a series of treatments, most lesions can be very effectively lightened and improved. Small lesions in infants and young children can often be done in the office under little or no anesthesia. When treating larger lesions, we often need sedation or, on occasion, general anesthesia. The goal of treatment is to significantly lighten these lesions before school age.
Among the most troublesome of cases that Dr. Goldberg treats are those involving resistant vascular lesions. The challenge with these lesions is knowing when you have gone as far with treatment as you can go.
“How many treatments are enough when you’re treating port wine stains with a pulsed dye laser? This can be difficult to determine, but once it is clear that you have reached a plateau, you have to suspend treatment. You might want to resume treatment in about 6 months or after waiting several years in selected cases.” Dr. Goldberg warns that many vascular lesions recur so you might find yourself seeing these patients for several years as they come back for additional series of treatments, when there are additional vessels present to treat.
Combination Therapy for Resistant Lesions
Dr. Goldberg has had some success treating resistant lesions with combination therapies.
“I’ve been trying the 1064 nm lasers to get deeper penetrations and when combined with the pulsed dye laser, we can get a bit faster response,” he says. “However, you have to be very careful with the 1064 nm devices — you can deliver a lot of energy when using larger spot sizes. You can have some problems if you’re not careful, so be a little cautious when you’re using additional wave lengths.”
Many resistant lesions can be effectively managed by treating them with a number of different modalities. “I’ll use a C02 or radiofrequency device to shave certain areas and then go to the pulsed dye laser. I’ll use sclerotherapy along with a pulsed dye laser for blebs, I’ll use steroid and a pulsed dye laser for hemangiomas,” he explains. “I’ll do stack pulses of different lasers or different spot sizes, different fluences, different pulse durations in the same session. I’ll do multiple passes using different wavelengths, superimposed over one another as another way to treat resistant lesions.”
For lymphangioma, Dr. Goldberg recommends using a C02 laser or a radiofrequency device to cauterize the lesion to seal the vessels and to stop any bleeding. The lesion can then be treated with a pulsed dye laser. These lesions can not really be cured, but at least you can control the bleeding. You might have to see these patients every 3 to 4 months for an extend period of time.
One key to successfully treating vascular lesions is to be absolutely certain of what you are treating.
“I have sent patients back to referring physicians because they were not correctly diagnosed and needed a completely different treatment,” warns Dr. Goldberg. “For example, I had a patient sent to me with what was supposed to be a hemangioma of the eyelid, but what she really had was a arterial venous malformation, which was effectively treated with complex vascular ophthalmologic and plastic surgery.”
If you’d rather just use one workhorse, rather than combination therapy, Dr. Goldberg recommends that you use a pulsed dye laser. “If you learn how to use your device, learn the machine and its capabilities, then you’ll be able to deliver reliable reproducible results,” he says. “I like the pulsed dye laser. It’s safe, if you know your machine and what it can deliver.”
Other Skin Targets
There are a variety of additional skin conditions that can be treated with one of the many lasers available today, including scars, warts, poikiloderma, psoriasis,and others. “These treatments are not magic, but for many of these patients, even a modest improvement is welcome,” says Dr. Goldberg. “For many of these conditions, especially for profound cases, combination therapies that involve many different treatments and lasers can yield the best results. However, you must proceed carefully with modest fluences and be sure that you know exactly what you are treating.”
According to Dr. Goldberg, when treating burn scars use a combination of steroid injections and a pulsed dye laser using low fluences.
“You’re not getting purpura necessarily. You just want to stimulate a little collagen remodeling,” he explains. “I don’t think the pulse duration in this particular situation is that critical. The whole idea is that it’s been shown that lower fluences and non-purpura are probably appropriate.”
Dr. Goldberg is currently treating a number of patients with recalcitrant warts using ALA and a pulsed dye laser. “For plantar surface or palm, I’ll soak the area with acetone to break the barrier a little bit, typically an hour and a half,” he explains. “I then leave it on under occlusion for an hour and a half, and then hit it with all the energy I can get. Topical or injection anesthetic is essential. ”
Choosing the Right Device
When treating facial veins, Dr. Goldberg prefers the 532 nm devices, though he says some of the 1064 nm devices can be used. A pulsed dye laser can also be used, either with purpura or non-purpura fluences,” he says.
For rosacea or diffuse facial redness, Dr. Goldberg uses the pulsed dye laser. Poikiloderma can be treated in a manner similar to rosacea with a non-purpuric end point. With port wine stains and hemangiomata, I still like the pulsed dye lasers. However, with hemangiomata he recommends using larger spot sizes for deeper penetration or a combination of an infrared (1064 nm) with or without interlesional steroids. Finally, for spider veins, any number of lasers are effective, particularly 1064 nm devices or a pulsed dye laser or a 532 nm laser, according to Dr. Goldberg.
Non-Ablative Skin Rejuvenation
Many laser rejuvenation patients are looking to turn back the hands of time, but while laser skin rejuvenation can significantly improve the look and texture of skin, it is not a fountain of youth in a light beam. You need to set patient expectations accordingly. Whether you are treating fine wrinkles or irregular skin color or tackling a tougher problem like deeper wrinkles, your patients must understand the limitations of the devices or they will never be happy with the results. Many patients prefer the non-ablative treatments because of the reduced side effects and limited downtime.
Non-ablative skin remodeling (“toning”) can be used to correct wrinkles, atrophy, laxity, actinic keratosis, lentigines and telangiectasia. There is an ever-growing list of devices that can be used, some of with are not lasers, but are instead intense light sources or radio frequency devices. Among the devices commonly used for non-ablative rejuvenation are infrared sources in the 1064 nm, 1320 nm and 1450 nm ranges, intense pulsed light, radiofrequency devices such as Thermage, Syneron, Polaris, and others. Superficial lasers that can be used for minimally invasive resurfacing are the Er:YAG and the Fraxel Laser.
Ablative Resurfacing
According to Dr. Goldberg, there is still a role for ablative skin resurfacing, primarily because it is still a very effective way to rejuvenate and there are patients who are willing to tolerate the down time and side effects to achieve better results. Ablative lasers, especially the Er:YAG, can be used safely on darker skin types. Ablative therapies are very effective for treating acne scarring and can be used to rejuvenate the neck.
The scanning CO2 laser remains the gold standard for ablative therapies, but the Er:YAG device is a very precise device allowing for ablation in areas where you may not want to risk using the CO2 device. “The Erbium is great for perioral, periorbital and for neck texture. I find it’s still excellent, better than chemical peels in my hands,” says Dr. Goldberg. “I just find the Er:YAG laser more controllable in my hands.”
Pigment Targets
A variety of pigmented targets can be removed using laser therapies. Very good results can be achieved when treating Nevus, café au lait macules, tattoos and other pigmented targets.
Lentigos can be treated with many devices, some in the millisecond domain, but usually they are best treated with the Q-switched lasers (nanosecond domain). For light skinned patients, lasers in the 532 nm range such as the Nd:YAG, KTP, or ruby laser (695 nm) are effective, while dark skinned individuals may respond better to a Q-switched alexandrite laser ( 755 nm). “Patients are usually very happy with this treatment. However, with a 532 nm laser, because of hemoglobin competition, you’re going to get some purpura and more crusting,” warns Dr. Goldberg. “I always warn patients that they may look a little sketchy for a bit before they get better. I use photographs all the time for educating patients about what they’ll look like immediately after treatment and after a few days, so people really understand what they’re getting into.”
According to Dr. Goldberg, tattoos can be removed using selective lasers that create a photoacoustic effect on tattoos that disperses and miniaturizes the pigments. The lasers work best on single color amateur tattoos and older tattoos. If treating darker skin, you should use longer wavelengths (755 nm or 1064 nm) to minimize epidermal melanin competition. Non-selective Lasers such as the CO2 or Er:YAG are rarely used for tattoo removal because of increased potential scarring.
Different tattoo colors respond better to different laser wavelengths. Dr. Goldberg recommends that black or dark blue pigments be treated with a Q-switched Nd:YAG (1064 nm), and that green be treated with a Q-switched ruby (694 nm) or alexandrite (755 nm). Red pigments can be treated with either a Q-switched Nd:YAG (532 nm) or a pulsed dye laser (510 nm). He usually treats traumatic particles with a Q-switched Nd:YAG (1064 nm).
“Traumatic tattooing does nicely, but multi-color tattoos can be very challenging; especially green, yellow or orange pigments. I use Erbium laser to remove the epidermis and then I use a selective laser, so I can really minimize injury and scarring,” says Dr. Goldberg. “Sometimes when treating a cosmetic tattoo, you will get immediate pigment darkening, but patients might be alright with that to remove the tattoo. Your best approach is to do a test spot and let the patient decide. In some cosmetic tattoos, which are typically flesh colored, I know I’ll get pigment darkening and I often recommend using the Er:YAG laser to carefully ablate the pigment. You can achieve excellent results without scarring.”
Lasers and Hair Removal
According to Dr. Goldberg, there are a number of very effective hair removal lasers at a variety of wavelengths. You must match the device to the hair type and the skin type; shorter wavelengths work best for light-skinned patients while the longer wave length lasers are more effective for darker skin types. Similarly, the pulse duration has to match the target; fine, wispy hairs respond to shorter pulse widths, while thicker, coarser hairs need more energy and therefore longer pulse durations.
“Photothermal hair removal is not perfect. Even with multiple treatments, a patient may not achieve the hair removal that he or she wanted,” Dr. Goldberg explains. “You must prepare your patients for a realistic expectation. You can reduce hair counts, delay the hair cycle, thin the hair shaft, and you get some permanent hair removal.”
Lasers and Acne
The infrared 1450 nm diode laser is the first laser to show significant documented effects for acne and acne scarring. Optimal results are obtained after multiple treatments at 4 to 6 months. The advantage of the 1450 nm diode laser is that it targets the sebaceous gland.
A promising approach to acne treatment with lasers is the use of aminolevulinic acid (ALA) in combination with a laser to achieve impressive, long-lasting results. ALA is applied to the skin and allowed to absorb for at least an hour. The ALA is taken up by cells preferentially, primarily the rapidly growing sebaceous cells and the Propionibacterium acnes. The ALA is converted to porphyrin, which, when activated with light, triggers production of activated singlet oxygen and subsequent cell death. Many different wave lengths can activate the porphyrin.
“To obtain greater depth of penetration, I tend to use the pulsed dye laser. In addition, intense pulsed light devices are good as well as the blue light devices, however the effect of intense pulsed light device is superficial as it targets the porphyrins in P. acnes bacteria, which, in my estimation does not give the same lasting results as when we target the sebaceous gland.”
Know your Capabilities and your Limitations
Medical laser technology has advanced at a rapid pace and will continue to evolve, offering new, more effective ways to treat a wide variety of skin conditions. The challenge for all physicians doing laser therapies is to keep pace with the changes. Find devices that you are comfortable using, sharpen your skills so that you are an expert at the devices that you use and move cautiously in the early stages with new devices.
In addition, it is essential that all physicians understand not only what these devices can do, but also what they cannot do. Realistic patient expectations must be set prior to treatment. Exaggerated promises of clear skin and permanent changes will simply lead to unhappy patients and frustrated doctors.
“We’re harnessing lasers and we are doing wonderful things. But, we are not miracle workers and there are still limits to the technologies,” says Dr. Goldberg. “A lot of what we have to do as responsible dermatologists is to properly set our patients’ expectations. In short, we need to under-promise and over-deliver what we do. If we do that, our patients will always walk away happy.”
Dr. Goldberg is an internationally recognized dermatologist with unique experience in laser surgery spanning more than two decades. Dr. Goldberg is an Associate Clinical Professor of Dermatology and Pediatrics at the University of Arizona Health Sciences Center in Tucson.
With the wide range of lasers available today, dermatologists are challenged to find the right devices to fit their individual practices. In this article, Gerald Goldberg, M.D., a dermatologist in private practice in Tucson, AZ, Clinical Associate Professor at the University of Arizona and an expert on the dermatological application of laser technologies, will take a look at the latest developments in this exciting and important field.
“Clinical lasers can be used to effectively treat a wide variety of skin conditions, including birthmarks and rosacea, to rejuvenate the skin, to resurface wrinkles, to correct scars and to remove tattoos and unwanted hair,” says Dr. Goldberg. “The key is to find the workhorse devices that will allow you to cost-effectively deliver the broadest range of services to your patients. In addition, you might also need to find devices that will address the particular needs of your specific patient population.”
Vascular Lesions
Vascular lesions range from common conditions such as rosacea, facial telangiectasia and, hemangioma to more rare anomalies such as port wine stains associated with Sturge Weber syndrome.
Today, most of these conditions can be effectively treated with laser therapy producing excellent results. According to Dr. Goldberg, since many of these conditions manifest at or soon after birth, the key to effectively treating them may be in beginning treatment as early as possible.
“The sooner you can begin treatment on some of these conditions, for example, hemangioma, the better the results will be,” he explains. “In many cases, we can significantly alter the rapid growth pattern and reduce the impact of the growing hemangioma on important structures if we start treatments when patients are very young or before rapid growth begins. There is a critical window before more serious consequences occur. However, pediatricians have traditionally held off on treatments since most hemangioma resolve on their own. Unfortunately, many do not resolve and it is critical to quickly identify those that need intervention so that treatment can begin as soon as possible.”
Even those lesions that resolve over time can cause emotional distress for the afflicted children and their families. Being able to trigger involution of a hemangioma for a child who would have otherwise had to live with it for the first several years of his or her life can make a tremendous difference in the quality of that child’s life.
“We have a small window of opportunity to address these conditions and, unfortunately, we often don’t see them from the pediatrician until it’s already been through its rapid growth phase when there’s not much we can do,” says Dr. Goldberg. “We need to focus on developing good relationships with local pediatricians to consult early in the first weeks of life, so that we can make a difference.”
When significant superficial and deep hemangiomata cannot be effectively ablated by laser alone, Dr. Goldberg uses a pulsed dye laser in conjunction with injection therapy with interlesional steroids. When hemangiomata have fully involuted, they often leave residual telangiectatic vessels that can respond to laser treatment. “These are discrete vessels and you can use any of the 532 nm KTP or pulsed dye lasers,” he says. “This therapy works great for residual vessels in youngsters approaching school age. It’s a great indication for some of the laser devices. You can also use these devices to speed the healing of hemangiomas.”
Port wine stains are the other major birthmarks that are fairly common vascular birthmarks seen in children. The gold standard of treatment is the pulsed dye laser. Very gratifying results are seen when treatment with a pulsed dye laser is performed early, particularly in the first year of life. After a series of treatments, most lesions can be very effectively lightened and improved. Small lesions in infants and young children can often be done in the office under little or no anesthesia. When treating larger lesions, we often need sedation or, on occasion, general anesthesia. The goal of treatment is to significantly lighten these lesions before school age.
Among the most troublesome of cases that Dr. Goldberg treats are those involving resistant vascular lesions. The challenge with these lesions is knowing when you have gone as far with treatment as you can go.
“How many treatments are enough when you’re treating port wine stains with a pulsed dye laser? This can be difficult to determine, but once it is clear that you have reached a plateau, you have to suspend treatment. You might want to resume treatment in about 6 months or after waiting several years in selected cases.” Dr. Goldberg warns that many vascular lesions recur so you might find yourself seeing these patients for several years as they come back for additional series of treatments, when there are additional vessels present to treat.
Combination Therapy for Resistant Lesions
Dr. Goldberg has had some success treating resistant lesions with combination therapies.
“I’ve been trying the 1064 nm lasers to get deeper penetrations and when combined with the pulsed dye laser, we can get a bit faster response,” he says. “However, you have to be very careful with the 1064 nm devices — you can deliver a lot of energy when using larger spot sizes. You can have some problems if you’re not careful, so be a little cautious when you’re using additional wave lengths.”
Many resistant lesions can be effectively managed by treating them with a number of different modalities. “I’ll use a C02 or radiofrequency device to shave certain areas and then go to the pulsed dye laser. I’ll use sclerotherapy along with a pulsed dye laser for blebs, I’ll use steroid and a pulsed dye laser for hemangiomas,” he explains. “I’ll do stack pulses of different lasers or different spot sizes, different fluences, different pulse durations in the same session. I’ll do multiple passes using different wavelengths, superimposed over one another as another way to treat resistant lesions.”
For lymphangioma, Dr. Goldberg recommends using a C02 laser or a radiofrequency device to cauterize the lesion to seal the vessels and to stop any bleeding. The lesion can then be treated with a pulsed dye laser. These lesions can not really be cured, but at least you can control the bleeding. You might have to see these patients every 3 to 4 months for an extend period of time.
One key to successfully treating vascular lesions is to be absolutely certain of what you are treating.
“I have sent patients back to referring physicians because they were not correctly diagnosed and needed a completely different treatment,” warns Dr. Goldberg. “For example, I had a patient sent to me with what was supposed to be a hemangioma of the eyelid, but what she really had was a arterial venous malformation, which was effectively treated with complex vascular ophthalmologic and plastic surgery.”
If you’d rather just use one workhorse, rather than combination therapy, Dr. Goldberg recommends that you use a pulsed dye laser. “If you learn how to use your device, learn the machine and its capabilities, then you’ll be able to deliver reliable reproducible results,” he says. “I like the pulsed dye laser. It’s safe, if you know your machine and what it can deliver.”
Other Skin Targets
There are a variety of additional skin conditions that can be treated with one of the many lasers available today, including scars, warts, poikiloderma, psoriasis,and others. “These treatments are not magic, but for many of these patients, even a modest improvement is welcome,” says Dr. Goldberg. “For many of these conditions, especially for profound cases, combination therapies that involve many different treatments and lasers can yield the best results. However, you must proceed carefully with modest fluences and be sure that you know exactly what you are treating.”
According to Dr. Goldberg, when treating burn scars use a combination of steroid injections and a pulsed dye laser using low fluences.
“You’re not getting purpura necessarily. You just want to stimulate a little collagen remodeling,” he explains. “I don’t think the pulse duration in this particular situation is that critical. The whole idea is that it’s been shown that lower fluences and non-purpura are probably appropriate.”
Dr. Goldberg is currently treating a number of patients with recalcitrant warts using ALA and a pulsed dye laser. “For plantar surface or palm, I’ll soak the area with acetone to break the barrier a little bit, typically an hour and a half,” he explains. “I then leave it on under occlusion for an hour and a half, and then hit it with all the energy I can get. Topical or injection anesthetic is essential. ”
Choosing the Right Device
When treating facial veins, Dr. Goldberg prefers the 532 nm devices, though he says some of the 1064 nm devices can be used. A pulsed dye laser can also be used, either with purpura or non-purpura fluences,” he says.
For rosacea or diffuse facial redness, Dr. Goldberg uses the pulsed dye laser. Poikiloderma can be treated in a manner similar to rosacea with a non-purpuric end point. With port wine stains and hemangiomata, I still like the pulsed dye lasers. However, with hemangiomata he recommends using larger spot sizes for deeper penetration or a combination of an infrared (1064 nm) with or without interlesional steroids. Finally, for spider veins, any number of lasers are effective, particularly 1064 nm devices or a pulsed dye laser or a 532 nm laser, according to Dr. Goldberg.
Non-Ablative Skin Rejuvenation
Many laser rejuvenation patients are looking to turn back the hands of time, but while laser skin rejuvenation can significantly improve the look and texture of skin, it is not a fountain of youth in a light beam. You need to set patient expectations accordingly. Whether you are treating fine wrinkles or irregular skin color or tackling a tougher problem like deeper wrinkles, your patients must understand the limitations of the devices or they will never be happy with the results. Many patients prefer the non-ablative treatments because of the reduced side effects and limited downtime.
Non-ablative skin remodeling (“toning”) can be used to correct wrinkles, atrophy, laxity, actinic keratosis, lentigines and telangiectasia. There is an ever-growing list of devices that can be used, some of with are not lasers, but are instead intense light sources or radio frequency devices. Among the devices commonly used for non-ablative rejuvenation are infrared sources in the 1064 nm, 1320 nm and 1450 nm ranges, intense pulsed light, radiofrequency devices such as Thermage, Syneron, Polaris, and others. Superficial lasers that can be used for minimally invasive resurfacing are the Er:YAG and the Fraxel Laser.
Ablative Resurfacing
According to Dr. Goldberg, there is still a role for ablative skin resurfacing, primarily because it is still a very effective way to rejuvenate and there are patients who are willing to tolerate the down time and side effects to achieve better results. Ablative lasers, especially the Er:YAG, can be used safely on darker skin types. Ablative therapies are very effective for treating acne scarring and can be used to rejuvenate the neck.
The scanning CO2 laser remains the gold standard for ablative therapies, but the Er:YAG device is a very precise device allowing for ablation in areas where you may not want to risk using the CO2 device. “The Erbium is great for perioral, periorbital and for neck texture. I find it’s still excellent, better than chemical peels in my hands,” says Dr. Goldberg. “I just find the Er:YAG laser more controllable in my hands.”
Pigment Targets
A variety of pigmented targets can be removed using laser therapies. Very good results can be achieved when treating Nevus, café au lait macules, tattoos and other pigmented targets.
Lentigos can be treated with many devices, some in the millisecond domain, but usually they are best treated with the Q-switched lasers (nanosecond domain). For light skinned patients, lasers in the 532 nm range such as the Nd:YAG, KTP, or ruby laser (695 nm) are effective, while dark skinned individuals may respond better to a Q-switched alexandrite laser ( 755 nm). “Patients are usually very happy with this treatment. However, with a 532 nm laser, because of hemoglobin competition, you’re going to get some purpura and more crusting,” warns Dr. Goldberg. “I always warn patients that they may look a little sketchy for a bit before they get better. I use photographs all the time for educating patients about what they’ll look like immediately after treatment and after a few days, so people really understand what they’re getting into.”
According to Dr. Goldberg, tattoos can be removed using selective lasers that create a photoacoustic effect on tattoos that disperses and miniaturizes the pigments. The lasers work best on single color amateur tattoos and older tattoos. If treating darker skin, you should use longer wavelengths (755 nm or 1064 nm) to minimize epidermal melanin competition. Non-selective Lasers such as the CO2 or Er:YAG are rarely used for tattoo removal because of increased potential scarring.
Different tattoo colors respond better to different laser wavelengths. Dr. Goldberg recommends that black or dark blue pigments be treated with a Q-switched Nd:YAG (1064 nm), and that green be treated with a Q-switched ruby (694 nm) or alexandrite (755 nm). Red pigments can be treated with either a Q-switched Nd:YAG (532 nm) or a pulsed dye laser (510 nm). He usually treats traumatic particles with a Q-switched Nd:YAG (1064 nm).
“Traumatic tattooing does nicely, but multi-color tattoos can be very challenging; especially green, yellow or orange pigments. I use Erbium laser to remove the epidermis and then I use a selective laser, so I can really minimize injury and scarring,” says Dr. Goldberg. “Sometimes when treating a cosmetic tattoo, you will get immediate pigment darkening, but patients might be alright with that to remove the tattoo. Your best approach is to do a test spot and let the patient decide. In some cosmetic tattoos, which are typically flesh colored, I know I’ll get pigment darkening and I often recommend using the Er:YAG laser to carefully ablate the pigment. You can achieve excellent results without scarring.”
Lasers and Hair Removal
According to Dr. Goldberg, there are a number of very effective hair removal lasers at a variety of wavelengths. You must match the device to the hair type and the skin type; shorter wavelengths work best for light-skinned patients while the longer wave length lasers are more effective for darker skin types. Similarly, the pulse duration has to match the target; fine, wispy hairs respond to shorter pulse widths, while thicker, coarser hairs need more energy and therefore longer pulse durations.
“Photothermal hair removal is not perfect. Even with multiple treatments, a patient may not achieve the hair removal that he or she wanted,” Dr. Goldberg explains. “You must prepare your patients for a realistic expectation. You can reduce hair counts, delay the hair cycle, thin the hair shaft, and you get some permanent hair removal.”
Lasers and Acne
The infrared 1450 nm diode laser is the first laser to show significant documented effects for acne and acne scarring. Optimal results are obtained after multiple treatments at 4 to 6 months. The advantage of the 1450 nm diode laser is that it targets the sebaceous gland.
A promising approach to acne treatment with lasers is the use of aminolevulinic acid (ALA) in combination with a laser to achieve impressive, long-lasting results. ALA is applied to the skin and allowed to absorb for at least an hour. The ALA is taken up by cells preferentially, primarily the rapidly growing sebaceous cells and the Propionibacterium acnes. The ALA is converted to porphyrin, which, when activated with light, triggers production of activated singlet oxygen and subsequent cell death. Many different wave lengths can activate the porphyrin.
“To obtain greater depth of penetration, I tend to use the pulsed dye laser. In addition, intense pulsed light devices are good as well as the blue light devices, however the effect of intense pulsed light device is superficial as it targets the porphyrins in P. acnes bacteria, which, in my estimation does not give the same lasting results as when we target the sebaceous gland.”
Know your Capabilities and your Limitations
Medical laser technology has advanced at a rapid pace and will continue to evolve, offering new, more effective ways to treat a wide variety of skin conditions. The challenge for all physicians doing laser therapies is to keep pace with the changes. Find devices that you are comfortable using, sharpen your skills so that you are an expert at the devices that you use and move cautiously in the early stages with new devices.
In addition, it is essential that all physicians understand not only what these devices can do, but also what they cannot do. Realistic patient expectations must be set prior to treatment. Exaggerated promises of clear skin and permanent changes will simply lead to unhappy patients and frustrated doctors.
“We’re harnessing lasers and we are doing wonderful things. But, we are not miracle workers and there are still limits to the technologies,” says Dr. Goldberg. “A lot of what we have to do as responsible dermatologists is to properly set our patients’ expectations. In short, we need to under-promise and over-deliver what we do. If we do that, our patients will always walk away happy.”
Dr. Goldberg is an internationally recognized dermatologist with unique experience in laser surgery spanning more than two decades. Dr. Goldberg is an Associate Clinical Professor of Dermatology and Pediatrics at the University of Arizona Health Sciences Center in Tucson.
With the wide range of lasers available today, dermatologists are challenged to find the right devices to fit their individual practices. In this article, Gerald Goldberg, M.D., a dermatologist in private practice in Tucson, AZ, Clinical Associate Professor at the University of Arizona and an expert on the dermatological application of laser technologies, will take a look at the latest developments in this exciting and important field.
“Clinical lasers can be used to effectively treat a wide variety of skin conditions, including birthmarks and rosacea, to rejuvenate the skin, to resurface wrinkles, to correct scars and to remove tattoos and unwanted hair,” says Dr. Goldberg. “The key is to find the workhorse devices that will allow you to cost-effectively deliver the broadest range of services to your patients. In addition, you might also need to find devices that will address the particular needs of your specific patient population.”
Vascular Lesions
Vascular lesions range from common conditions such as rosacea, facial telangiectasia and, hemangioma to more rare anomalies such as port wine stains associated with Sturge Weber syndrome.
Today, most of these conditions can be effectively treated with laser therapy producing excellent results. According to Dr. Goldberg, since many of these conditions manifest at or soon after birth, the key to effectively treating them may be in beginning treatment as early as possible.
“The sooner you can begin treatment on some of these conditions, for example, hemangioma, the better the results will be,” he explains. “In many cases, we can significantly alter the rapid growth pattern and reduce the impact of the growing hemangioma on important structures if we start treatments when patients are very young or before rapid growth begins. There is a critical window before more serious consequences occur. However, pediatricians have traditionally held off on treatments since most hemangioma resolve on their own. Unfortunately, many do not resolve and it is critical to quickly identify those that need intervention so that treatment can begin as soon as possible.”
Even those lesions that resolve over time can cause emotional distress for the afflicted children and their families. Being able to trigger involution of a hemangioma for a child who would have otherwise had to live with it for the first several years of his or her life can make a tremendous difference in the quality of that child’s life.
“We have a small window of opportunity to address these conditions and, unfortunately, we often don’t see them from the pediatrician until it’s already been through its rapid growth phase when there’s not much we can do,” says Dr. Goldberg. “We need to focus on developing good relationships with local pediatricians to consult early in the first weeks of life, so that we can make a difference.”
When significant superficial and deep hemangiomata cannot be effectively ablated by laser alone, Dr. Goldberg uses a pulsed dye laser in conjunction with injection therapy with interlesional steroids. When hemangiomata have fully involuted, they often leave residual telangiectatic vessels that can respond to laser treatment. “These are discrete vessels and you can use any of the 532 nm KTP or pulsed dye lasers,” he says. “This therapy works great for residual vessels in youngsters approaching school age. It’s a great indication for some of the laser devices. You can also use these devices to speed the healing of hemangiomas.”
Port wine stains are the other major birthmarks that are fairly common vascular birthmarks seen in children. The gold standard of treatment is the pulsed dye laser. Very gratifying results are seen when treatment with a pulsed dye laser is performed early, particularly in the first year of life. After a series of treatments, most lesions can be very effectively lightened and improved. Small lesions in infants and young children can often be done in the office under little or no anesthesia. When treating larger lesions, we often need sedation or, on occasion, general anesthesia. The goal of treatment is to significantly lighten these lesions before school age.
Among the most troublesome of cases that Dr. Goldberg treats are those involving resistant vascular lesions. The challenge with these lesions is knowing when you have gone as far with treatment as you can go.
“How many treatments are enough when you’re treating port wine stains with a pulsed dye laser? This can be difficult to determine, but once it is clear that you have reached a plateau, you have to suspend treatment. You might want to resume treatment in about 6 months or after waiting several years in selected cases.” Dr. Goldberg warns that many vascular lesions recur so you might find yourself seeing these patients for several years as they come back for additional series of treatments, when there are additional vessels present to treat.
Combination Therapy for Resistant Lesions
Dr. Goldberg has had some success treating resistant lesions with combination therapies.
“I’ve been trying the 1064 nm lasers to get deeper penetrations and when combined with the pulsed dye laser, we can get a bit faster response,” he says. “However, you have to be very careful with the 1064 nm devices — you can deliver a lot of energy when using larger spot sizes. You can have some problems if you’re not careful, so be a little cautious when you’re using additional wave lengths.”
Many resistant lesions can be effectively managed by treating them with a number of different modalities. “I’ll use a C02 or radiofrequency device to shave certain areas and then go to the pulsed dye laser. I’ll use sclerotherapy along with a pulsed dye laser for blebs, I’ll use steroid and a pulsed dye laser for hemangiomas,” he explains. “I’ll do stack pulses of different lasers or different spot sizes, different fluences, different pulse durations in the same session. I’ll do multiple passes using different wavelengths, superimposed over one another as another way to treat resistant lesions.”
For lymphangioma, Dr. Goldberg recommends using a C02 laser or a radiofrequency device to cauterize the lesion to seal the vessels and to stop any bleeding. The lesion can then be treated with a pulsed dye laser. These lesions can not really be cured, but at least you can control the bleeding. You might have to see these patients every 3 to 4 months for an extend period of time.
One key to successfully treating vascular lesions is to be absolutely certain of what you are treating.
“I have sent patients back to referring physicians because they were not correctly diagnosed and needed a completely different treatment,” warns Dr. Goldberg. “For example, I had a patient sent to me with what was supposed to be a hemangioma of the eyelid, but what she really had was a arterial venous malformation, which was effectively treated with complex vascular ophthalmologic and plastic surgery.”
If you’d rather just use one workhorse, rather than combination therapy, Dr. Goldberg recommends that you use a pulsed dye laser. “If you learn how to use your device, learn the machine and its capabilities, then you’ll be able to deliver reliable reproducible results,” he says. “I like the pulsed dye laser. It’s safe, if you know your machine and what it can deliver.”
Other Skin Targets
There are a variety of additional skin conditions that can be treated with one of the many lasers available today, including scars, warts, poikiloderma, psoriasis,and others. “These treatments are not magic, but for many of these patients, even a modest improvement is welcome,” says Dr. Goldberg. “For many of these conditions, especially for profound cases, combination therapies that involve many different treatments and lasers can yield the best results. However, you must proceed carefully with modest fluences and be sure that you know exactly what you are treating.”
According to Dr. Goldberg, when treating burn scars use a combination of steroid injections and a pulsed dye laser using low fluences.
“You’re not getting purpura necessarily. You just want to stimulate a little collagen remodeling,” he explains. “I don’t think the pulse duration in this particular situation is that critical. The whole idea is that it’s been shown that lower fluences and non-purpura are probably appropriate.”
Dr. Goldberg is currently treating a number of patients with recalcitrant warts using ALA and a pulsed dye laser. “For plantar surface or palm, I’ll soak the area with acetone to break the barrier a little bit, typically an hour and a half,” he explains. “I then leave it on under occlusion for an hour and a half, and then hit it with all the energy I can get. Topical or injection anesthetic is essential. ”
Choosing the Right Device
When treating facial veins, Dr. Goldberg prefers the 532 nm devices, though he says some of the 1064 nm devices can be used. A pulsed dye laser can also be used, either with purpura or non-purpura fluences,” he says.
For rosacea or diffuse facial redness, Dr. Goldberg uses the pulsed dye laser. Poikiloderma can be treated in a manner similar to rosacea with a non-purpuric end point. With port wine stains and hemangiomata, I still like the pulsed dye lasers. However, with hemangiomata he recommends using larger spot sizes for deeper penetration or a combination of an infrared (1064 nm) with or without interlesional steroids. Finally, for spider veins, any number of lasers are effective, particularly 1064 nm devices or a pulsed dye laser or a 532 nm laser, according to Dr. Goldberg.
Non-Ablative Skin Rejuvenation
Many laser rejuvenation patients are looking to turn back the hands of time, but while laser skin rejuvenation can significantly improve the look and texture of skin, it is not a fountain of youth in a light beam. You need to set patient expectations accordingly. Whether you are treating fine wrinkles or irregular skin color or tackling a tougher problem like deeper wrinkles, your patients must understand the limitations of the devices or they will never be happy with the results. Many patients prefer the non-ablative treatments because of the reduced side effects and limited downtime.
Non-ablative skin remodeling (“toning”) can be used to correct wrinkles, atrophy, laxity, actinic keratosis, lentigines and telangiectasia. There is an ever-growing list of devices that can be used, some of with are not lasers, but are instead intense light sources or radio frequency devices. Among the devices commonly used for non-ablative rejuvenation are infrared sources in the 1064 nm, 1320 nm and 1450 nm ranges, intense pulsed light, radiofrequency devices such as Thermage, Syneron, Polaris, and others. Superficial lasers that can be used for minimally invasive resurfacing are the Er:YAG and the Fraxel Laser.
Ablative Resurfacing
According to Dr. Goldberg, there is still a role for ablative skin resurfacing, primarily because it is still a very effective way to rejuvenate and there are patients who are willing to tolerate the down time and side effects to achieve better results. Ablative lasers, especially the Er:YAG, can be used safely on darker skin types. Ablative therapies are very effective for treating acne scarring and can be used to rejuvenate the neck.
The scanning CO2 laser remains the gold standard for ablative therapies, but the Er:YAG device is a very precise device allowing for ablation in areas where you may not want to risk using the CO2 device. “The Erbium is great for perioral, periorbital and for neck texture. I find it’s still excellent, better than chemical peels in my hands,” says Dr. Goldberg. “I just find the Er:YAG laser more controllable in my hands.”
Pigment Targets
A variety of pigmented targets can be removed using laser therapies. Very good results can be achieved when treating Nevus, café au lait macules, tattoos and other pigmented targets.
Lentigos can be treated with many devices, some in the millisecond domain, but usually they are best treated with the Q-switched lasers (nanosecond domain). For light skinned patients, lasers in the 532 nm range such as the Nd:YAG, KTP, or ruby laser (695 nm) are effective, while dark skinned individuals may respond better to a Q-switched alexandrite laser ( 755 nm). “Patients are usually very happy with this treatment. However, with a 532 nm laser, because of hemoglobin competition, you’re going to get some purpura and more crusting,” warns Dr. Goldberg. “I always warn patients that they may look a little sketchy for a bit before they get better. I use photographs all the time for educating patients about what they’ll look like immediately after treatment and after a few days, so people really understand what they’re getting into.”
According to Dr. Goldberg, tattoos can be removed using selective lasers that create a photoacoustic effect on tattoos that disperses and miniaturizes the pigments. The lasers work best on single color amateur tattoos and older tattoos. If treating darker skin, you should use longer wavelengths (755 nm or 1064 nm) to minimize epidermal melanin competition. Non-selective Lasers such as the CO2 or Er:YAG are rarely used for tattoo removal because of increased potential scarring.
Different tattoo colors respond better to different laser wavelengths. Dr. Goldberg recommends that black or dark blue pigments be treated with a Q-switched Nd:YAG (1064 nm), and that green be treated with a Q-switched ruby (694 nm) or alexandrite (755 nm). Red pigments can be treated with either a Q-switched Nd:YAG (532 nm) or a pulsed dye laser (510 nm). He usually treats traumatic particles with a Q-switched Nd:YAG (1064 nm).
“Traumatic tattooing does nicely, but multi-color tattoos can be very challenging; especially green, yellow or orange pigments. I use Erbium laser to remove the epidermis and then I use a selective laser, so I can really minimize injury and scarring,” says Dr. Goldberg. “Sometimes when treating a cosmetic tattoo, you will get immediate pigment darkening, but patients might be alright with that to remove the tattoo. Your best approach is to do a test spot and let the patient decide. In some cosmetic tattoos, which are typically flesh colored, I know I’ll get pigment darkening and I often recommend using the Er:YAG laser to carefully ablate the pigment. You can achieve excellent results without scarring.”
Lasers and Hair Removal
According to Dr. Goldberg, there are a number of very effective hair removal lasers at a variety of wavelengths. You must match the device to the hair type and the skin type; shorter wavelengths work best for light-skinned patients while the longer wave length lasers are more effective for darker skin types. Similarly, the pulse duration has to match the target; fine, wispy hairs respond to shorter pulse widths, while thicker, coarser hairs need more energy and therefore longer pulse durations.
“Photothermal hair removal is not perfect. Even with multiple treatments, a patient may not achieve the hair removal that he or she wanted,” Dr. Goldberg explains. “You must prepare your patients for a realistic expectation. You can reduce hair counts, delay the hair cycle, thin the hair shaft, and you get some permanent hair removal.”
Lasers and Acne
The infrared 1450 nm diode laser is the first laser to show significant documented effects for acne and acne scarring. Optimal results are obtained after multiple treatments at 4 to 6 months. The advantage of the 1450 nm diode laser is that it targets the sebaceous gland.
A promising approach to acne treatment with lasers is the use of aminolevulinic acid (ALA) in combination with a laser to achieve impressive, long-lasting results. ALA is applied to the skin and allowed to absorb for at least an hour. The ALA is taken up by cells preferentially, primarily the rapidly growing sebaceous cells and the Propionibacterium acnes. The ALA is converted to porphyrin, which, when activated with light, triggers production of activated singlet oxygen and subsequent cell death. Many different wave lengths can activate the porphyrin.
“To obtain greater depth of penetration, I tend to use the pulsed dye laser. In addition, intense pulsed light devices are good as well as the blue light devices, however the effect of intense pulsed light device is superficial as it targets the porphyrins in P. acnes bacteria, which, in my estimation does not give the same lasting results as when we target the sebaceous gland.”
Know your Capabilities and your Limitations
Medical laser technology has advanced at a rapid pace and will continue to evolve, offering new, more effective ways to treat a wide variety of skin conditions. The challenge for all physicians doing laser therapies is to keep pace with the changes. Find devices that you are comfortable using, sharpen your skills so that you are an expert at the devices that you use and move cautiously in the early stages with new devices.
In addition, it is essential that all physicians understand not only what these devices can do, but also what they cannot do. Realistic patient expectations must be set prior to treatment. Exaggerated promises of clear skin and permanent changes will simply lead to unhappy patients and frustrated doctors.
“We’re harnessing lasers and we are doing wonderful things. But, we are not miracle workers and there are still limits to the technologies,” says Dr. Goldberg. “A lot of what we have to do as responsible dermatologists is to properly set our patients’ expectations. In short, we need to under-promise and over-deliver what we do. If we do that, our patients will always walk away happy.”
Dr. Goldberg is an internationally recognized dermatologist with unique experience in laser surgery spanning more than two decades. Dr. Goldberg is an Associate Clinical Professor of Dermatology and Pediatrics at the University of Arizona Health Sciences Center in Tucson.
