Redness and Pigment in Skin of Color: Insights Into Laser Surgery

During his presentation, “Laser Surgery: What You Need to Know,” at Fall Dermatology Week 2022, Vincent Richer, MD, FRCPC, discussed treating redness, pigment in skin of color, resurfacing, and choosing the best laser devices for physician practices.

He started with redness, emphasizing that it’s important for physicians to confirm diagnoses and responsiveness to lasers before they proceed to treat to biological endpoint. In fact, he encouraged physicians to consider if there’s something in their toolbox that can do a better job than lasers. One of the lasers he emphasized was vascular laser, which can typically cause scars. He shared that these lasers are commonly used to treat telangiectasias, spider/cherry angiomas, and venous lakes within 1 to 2 treatments. They are also used in multiple treatments for background erythema/flushing, poikiloderma, and red scars. However, he noted there is also a potential for the unpredictable or unusual use of vascular laser to treat keratosis pilaris rubra faceii, dermatosis papulosa nigra/seborrheic keratosis, and nevi. Dr Richer shared the following complications that could follow treatment:

• Postinflammatory pigmentary alteration
• Footprinting/honeycombing
• Crust/ulceration
• Scar

Next, Dr Richer discussed laser use for treating pigment, especially in patients with skin of color. He opened by presenting Hori’s nevus, which is a subset of dermal melanocytosis most common in Asian skin. He noted that it is less well-demarcated than solar lentigo and melasma, with a grayish appearance. This condition is highly responsive to a series of Q-switched or picosecond pigment lasers. These pigment lasers are commonly used to treat solar lentigines and macular seborrheic keratosis within 1 to 2 treatments. Additionally, they are utilized in multiple treatments for dermal melanocytosis, with unpredictable or combination use for melasma, postinflammatory hyperpigmentation, Becker’s nevus, and café-au-lait macule.

One of the pigment lasers that Dr Richer focused on was the picosecond laser, which was originally used for the tattoo removal process; however, it has been found to have increased treatment safety in patients with skin of color. Picosecond lasers have a photoacoustic mechanism of action, a shorter recovery time, and a potential for less postinflammatory hyperpigmentation. He added that the diffractive lens array, holographic lens, and pico genesis technologies provide textural improvements. Following the procedure, the “recovery” process includes:

• Pain upon laser exposure
• Heat/sunburn sensation
• Erythema/edema
• Temporary pigment darkening
• Scale/crust

Potential complications that could also follow the procedure are postinflammatory pigmentary alteration, scarring, paradoxical pigment darkening, and chrysiasis.

Dr Richer also shared the common issues when using devices to treat patients with skin of color, such as undertreatment where treatment is either not offered or there is physician reservation and gaps in knowledge when treating skin of color. There’s also the issue with overtreatment where patients with skin of color are exposed to procedure risks, particularly pigmentary risks.

In fact, Dr Richer stressed that preventing postinflammatory hyperpigmentation using lasers and devices in patients with skin of color depends on and consists of the following:

• Patient characteristics
• Treatment/devices selection
• Choosing treatment settings
• Pretreatment prophylaxis
• Posttreatment prophylaxis

“We’re very lucky when we treat pigment because we have a lot of options and a lot of devices,” Dr Richer concluded.

Reference
Richer V. Laser surgery: what you need to know. Presented at: Dermatology Week 2022; September 14-17, 2022; Virtual.