Pre- and post-laser treatment in cosmetic dermatology.

Abstract

Laser therapy gains a lot of interest from the medical and non-medical community, although not all of the goals of laser treatment in dermatology can be fulfilled. Laser therapy is currently used in four major fields: vascular lesions, hair removal, pigmented lesions and laser ablation of tissue. Newer applications of lasers for medical indications such as psoriasis, vitiligo, acne or wound healing will not be considered in this article, although some of the pre-and post-laser procedures might be useful in these areas as well. To ensure the optimal outcome of any laser treatment, there are three general rules that should be followed: • Carry out a critical evaluation of the patient regarding his or her diagnosis and expectations of the treatment. An unsuitable diagnosis and/or unrealistic expectations are the major causes of dissatisfaction with laser treatment. • Choose the right laser and the best technical parameters to meet the treatment goal. In the case of vascular lesions, their depth, diameter and colour (or oxygenation of the blood) are the most important issues for the selection of specific laser equipment. In the case of acquired telangiectasias there is more than one laser that can be applied. Adverse effects, pain and the number of treatments necessary differ between the available laser types. • Prepare the skin before laser treatment in the best possible way to avoid adverse effects, and advise the patient on post-laser skin care to ensure optimum results. This article will concentrate on the third rule of laser therapy for the four major fields of laser application in dermatology.

Full text

Laser therapy gains a lot of interest from the medical and non-
medical community, although not all of the goals of laser treatment in
dermatology can be fulfilled. Laser therapy is currently used in four
major fields: vascular lesions, hair removal, pigmented lesions and
laser ablation of tissue. Newer applications of lasers for medical
indications such as psoriasis, vitiligo, acne or wound healing will not
be considered in this article, although some of the pre- and post-laser
procedures might be useful in these areas as well. To ensure the
optimal outcome of any laser treatment, there are three general rules
that should be followed:
• Carry out a critical evaluation of the patient regarding his or
her diagnosis and expectations of the treatment. An unsuitable
diagnosis and/or unrealistic expectations are the major causes of
dissatisfaction with laser treatment.
• Choose the right laser and the best technical parameters to meet
the treatment goal. In the case of vascular lesions, their depth,
diameter and colour (or oxygenation of the blood) are the most
important issues for the selection of specific laser equipment. In
the case of acquired telangiectasias there is more than one laser
that can be applied. Adverse effects, pain and the number of
treatments necessary differ between the available laser types.
• Prepare the skin before laser treatment in the best possible way to
avoid adverse effects, and advise the patient on post-laser skin
care to ensure optimum results.
This article will concentrate on the third rule of laser therapy for the
four major fields of laser application in dermatology.
General Measures
There are general measures that can be taken to reduce the risks and
side effects of laser treatment that are independent of the indication
and laser type used. One piece of advice that applies to all laser
therapy indications is to exclude infected areas from treatment.
Another is to take a careful history of current medications and dietary
supplements that might increase photosensitivity or interfere with
wound healing. The third piece of advice is to keep away from
recently tanned skin, as laser therapy in such areas may result in
permanent pigmentary changes.
Smoking is a significant risk factor for side effects, since it interferes
not only with clotting but also with ultraviolet (UV)-induced extrinsic
ageing. Smoking increases the formation of oxygen radicals during UV
light exposure and thereby increases inflammation. Smoking should
be avoided during any laser treatment and laser therapy may be
unsuitable for heavy smokers, depending on the individual case.
A general recommendation post-laser therapy is sun protection. Sun
protection is even more important in patients with a Fitzpatrick skin type
3 or higher. Sun protection consists of avoidance of exposure to the
midday sun, avoidance of tanning beds, use of appropriate clothing and
topical sun blockers. In the future, systemic compounds may become
available that will reduce acute and chronic adverse UV effects.1
Vascular Laser Therapy
Vascular laser therapy can be divided into two main categories. The first
is endovascular, which uses a bare fibre inserted into the vessel by
either puncture or small incision; most often diode lasers are applied for
this purpose. Endovenous laser therapy has to be performed with
tumescent anaesthesia to avoid skin burning. The second is exovascular,
where the laser light has to penetrate the cutaneous tissue to reach
vascular structures. The former is applied to vascular malformations and
varicose veins, while the latter is used for acquired telangiectasias,
spider leg veins and most vascular birthmarks.
47
© TOUCH BRIEFINGS 2010
Aesthetic Dermatology
Uwe Wollina
Professor of Dermatology and Venerology, and Head, Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt
Pre- and Post-laser Treatment in Cosmetic Dermatology
Abstract
Laser therapy is the cornerstone of both medical and aesthetic dermatology. Optimal results can be obtained only when indications and
contraindications are respected. The right laser for the specific skin problem has to be chosen, and the skinmay need preparation before
treatment. In this article, these objectives are discussed for vascular, pigmentary and ablative laser use. The best outcome will be obtained when
post-laser-treatment skin care, including sun protection, is used.
Keywords
Laser therapy, sun protection, retinoids, wound healing
Disclosure:
The author has no conflicts of interest to declare.
Received:
7 January 2010
Accepted:
19 April 2010
Citation:
European Dermatology, 2010;5:47–9
Correspondence:
Uwe Wollina, Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Friedrichstrasse 41, 01067 Dresden,
Germany. E: wollina-uw@khdf.de
Wollina_EU Dermatology 01/06/2010 13:02 Page 47

The major target in both types of vascular laser therapy is the
endothelium, which is damaged by intravascular blood heating. To
avoid collateral damage of the adjacent tissue during treatment,
pre-treatment cooling by contact cooling, cryogen spray or air is
used.2Cooling cannot be achieved in the same way with
endovascular laser application. Here, perivascular tumescent
anaesthesia serves to numb pain and prevent the heating of adjacent
tissue. When treating larger areas with a relatively high density of
laser shots, such as in naevus flammeus, the use of a moisturising
cream will reduce possible discomfort. By these means, the risk of
skin ulceration and post-inflammatory hyperpigmentation can be
reduced. After vascular laser therapy, the treated area consequently
needs sun protection.
Laser Hair Removal
The target hair removal depends on the laser wavelength and other
laser parameters. Melanin, the epithelium of hair root sheets and
hair bulb vessels are the major targets for inducing permanent hair
removal. Regardless of the laser used,the major pre-treatment task is
to shave the hair two to three days before treatment. This avoids
burning the hair on the skin surface, which might harm the patient’s
epidermis and the laser optics.
Cooling the skin immediately before and/or during laser shots can
reduce the risk of pigmentary changes.3After treatment, a cooling body
lotion applied to the treated areas may increase comfort. The upper lip
in particular is very sensitive to pain and hyperpigmentation due to
laser hair removal. Here, the use of low-molecular-weight hyaluronic
acid may help in the prevention and treatment of such adverse effects.4
Laser Therapy of Pigmentary Lesions
Tattoos are a common indication for laser therapy. The more colours
a tattoo is composed of, the more challenging the treatment. Since
tattoo colours can cause allergic and non-allergic adverse effects, a
careful medical history is necessary before starting any treatment. In
the case of allergic reactions to tattoo colours in the past, the patient
might experience a relapse of this allergic reaction during laser
treatment. In severe cases, treatment with antihistamines starting the
day before the first laser application might be useful. However, there
have been no systematic studies of such treatment yet.
In any case of laser treatment, all medications that either stimulate
laser-induced inflammation or increase pigmentation have to be
stopped before the first treatment. Such medications include
oestrogens, drugs or supplements known to cause photosensitivity.
Chinese patients have a high risk of scarring after laser-assisted
tattoo removal. About 25% of these patients develop scarring. The
repeated application of a gel containing onion extract, heparin and
allantoin resulted in a significant reduction in scarring after laser-
assisted tattoo removal in a prospective randomised, controlled trial
covering a total of 120 patients with 144 professional tattoos.5
Acquired dermal hypermelanosis (ADH) is commonly seen in Oriental
and Asian patients. Laser treatment in this indication is far from being
ideal, with a significant number of cases where there is incomplete
clearing of lesions. Various pre- and post-laser treatments have been
used over the years. Recently, a protocol for Asian patients with ADH
was studied in 62 subjects. It consisted of repeated bleaching (up to
three times) with tretinoin gel 0.1–0.4% and 5% hydrochinon
combined with a Q-switched ruby laser. The topical treatment was
performed for eight weeks as pre-laser therapy followed by laser
treatment and a break for two weeks. After that, the course was
repeated up to two times, with six-week intervals of topical bleaching
and a single laser treatment followed by a final topical course for
another six weeks. After the complete treatment, 85% of cases were
considered to be excellent.6
To reduce post-inflammatory hyperpigmentation of Asian skin, skin
vessels were compressed by the attachment of a flat glass lens to
the tip of a 595nm long-pulsed dye laser. In a prospective study, facial
lentigines were treated (n=18) without skin cooling. The clearing
was 13% better than that achieved with a Q-switched ruby laser and
there were fewer adverse effects. In particular, there was no scarring
or hypopigmentation.7
After treatment of pigmentary lesions the use of sun block is
necessary, since the skin temporarily becomes more sensitive to UV
irradiation resulting in either relapse or hypopigmentation.
Ablative Laser Therapy
Ablative laser therapy is used for a number of benign skin lesions,
such as seborrhoeic keratosis, human-papillomavirus-induced warts,
benign skin tumours and actinic keratoses. The treatment can also be
helpful for hypertrophic/hypotrophic scars and for laser peeling/
rejuvenation of aged skin.
Since in many situations larger areas have to be treated, a pre-laser
antibiotic shot is often used in patients with a higher risk of skin
infections, such as those with diabetes. If there is a history of
recurrent herpes infection, prophylactic antiviral therapy is advisable.
The use of moist balanced wound care can reduce pain and burning
sensations as well as the rate of infection after treatment.
Furthermore, re-epithelialisation is improved and contributes to an
optimal outcome.
Various types of wound dressing have been investigated, including
polymer films, hydrogels, hydrocolloids, composite foam dressings
and silicone sheets. There is not much difference in general clinical
efficacy between the different dressing types, but ease of application,
leakage of fluid, risk of contact allergies to adhesives and price may
vary considerably. The major benefit is gained when these dressings
are applied immediately after laser ablation and kept on for at least
24 hours, or ideally for up to four days. Further application does not
result in more improvement.8–11
There is some evidence that silicone sheets and silicone gels may
reduce the risk of scarring if used for a longer period of weeks to
months.12–14 Specially shaped sheets of silicone are marketed for post-
laser treatment, particularly for facial areas. They may not only reduce
the risk of scarring, but also decrease discomfort. A side-by-side
evaluation among three patients with facial laser resurfacing oxygen
mist therapy for five days resulted in less crusting after five days
compared with occlusive dressing for four days.15
The disadvantages of dressings for the face and neck area are
problems with fixing and fluid leakage. The use of a moisture-retentive
ointment was therefore evaluated when applied every four to six
hours on laser-treated areas. The procedure is considered to be
Aesthetic Dermatology
EUROPEAN DERMATOLOGY
48
Wollina_EU Dermatology 01/06/2010 13:08 Page 48

safe and effective and a valid alternative for occlusive dressings.16
Even those groups who used the occlusive dressing in the first days
completed their post-laser care with a moisturising ointment.9
In vitro studies suggest a positive effect on superficial wound healing
with the use of hyaluronic acid and collagen substrate, but not with
gelatine or collagen hydrolysate.16,17
In a comparative trial, a moisturising ointment was compared with
a mucopolysaccharide–cartilage complex for topical use. The latter
was found to be superior in the sense of signs of inflammation and
re-epithelialisation.18 Dexpanthenol is another interesting and safe
compound for superficial wound healing. Dexpanthenol-containing
ointments have been shown to improve wound healing after ablative
laser procedures.19
In a small study, hormone replacement therapy in post-menopausal
women who underwent full-face laser resurfacing did not improve
post-laser wound healing.20 Whether topical hormone therapy has an
effect has not been studied so far.
Carbon dioxide laser therapy for aged skin sometimes results in
skin hypersensitivity. Atopic patients are at risk of developing
hypersensitivity in the laser- and non-laser-treated areas, often lasting
for weeks or months after the original treatment. In these cases
topical steroids are often necessary to control the symptoms.21 Strict
avoidance of intense UV light exposure is particularly important after
ablative laser therapy to the face and neck region.
Conclusion
Although randomised, prospective, controlled trials for a standardised
pre- and post-laser treatment have in most cases not been carried
out, there is consensus about the importance of such measures.
Using a specified pre- and post-laser treatment reduces the risk of
adverse side effects and discomfort, and the outcome is at least
ensured if not improved in many cases. There is a need for higher
levels of evidence-based medicine in this area. n
Pre- and Post-laser Treatment in Cosmetic Dermatology
EUROPEAN DERMATOLOGY
49
1. Pillai S, Oresajo C, Hayward J, Ultraviolet radiation and
skin aging: roles of reactive oxygen species,
inflammation and protease activation, and strategies for
prevention of inflammation-induced matrix degeneration,
Int J Cosmet Sci
, 2005;27:17–34.
2. Torres JH, Tunnell JW, Pikkula BM, et al., An analysis of
heat removal during cryogen spray cooling and effects of
simultaneous airflow application,
Lasers Surg Med
,
2001;28:477–86.
3. Lapidoth M, Shafirstein G, Ben Amitai D, et al., Reticulate
erythema following diode laser-assisted hair removal: a
new side effect of a common procedure,
J Am Acad
Dermatol
, 2004;51:774–7.
4. Wollina U, Hyaluronsäure in der ästhetischen Dermatologie.
Praktische Erfahrungen mit einem topischen
Hyaluronsäure-Serum,
Kosmet Med
, 2006;27:16–18.
5. Ho WS, Ying SY, Chan PC, et al., Use of onion extract,
heparin, allantoin gel in prevention of scarring in Chinese
patients having laser removal of tattoos: a prospective
randomized controlled trial,
Dermatol Surg
, 2006;32:891–6.
6. Yoshimura K, Sato K, Aiba-Kojima E, et al., Repeated
treatment protocols for melasma and acquired dermal
melanocytosis,
Dermatol Surg
, 2006;32:365–71.
7. Kono T, Manstein D, Chan HH, et al., Q-switched ruby
versus long-pulsed dye laser delivered with compression
for treatment of facial lentigines in Asians,
Lasers Surg
Med
, 2006;38:94–7.
8. Newman JP, Koch RJ, Goode RL, Closed dressings after
laser skin resurfacing,
Arch Otolaryngol Head Neck Surg
,
1998;124:751–7.
9. Newman JP, Fitzgerald P, Koch RJ, Review of closed
dressings after laser surgery,
Dermatol Surg
, 2000;26:
562–71.
10. Khatri KA, Margolis RJ, Bhatty RS, et al., Comparison
of two wound dressings after laser skin resurfacing,
J Cosmet Laser Ther
, 2005;7:206–12.
11. Batra RS, Ort RJ, Jacob C, et al., Evaluation of a silicone
occlusive dressing after laser skin resurfacing,
Arch
Dermatol
, 2001;137:1317–21.
12. Michelow BJ, Varghai A, Movassaghi K, et al., A new
dressing for laser-treated areas,
Plast Reconstr Surg
,
2002;110:1150–57.
13. O’Brien L, Pandit A, Silicon gel sheeting for preventing
and treating hypertrophic and keloid scars,
Cochrane
Database Syst Rev
, 2006;(1):CD003826.
14. Onouye T, Menaker G, Christian M, et al., Occlusive
dressing versus oxygen mist therapy following CO2 laser
resurfacing,
Dermatol Surg
, 2000;26:572–6.
15. Atiyeh BS, Dham R, Costagliola M, et al., Moist exposed
therapy: an effective and valid alternative to occlusive
dressings for postlaser resurfacing wound care,
Dermatol
Surg
, 2004;30:18–25.
16. Laube F, Hyaluronsäure-Rezeptoren,
Trends Clin Exp
Dermatol
, 2004;3:152–200.
17. Li GY, Fukunaga S, Takenouchi K, et al., Comparative
study of the physiological properties of collagen, gelatine
and collagen hydrolysate as cosmetic materials,
Int J
Cosmet Sci
, 2005;27:101–6.
18. Tanzi EL, Perez M, The effect of a mucopolysaccharide-
cartilage complex healing ointment on Er:YAG laser
resurfaced facial skin,
Dermatol Surg
, 2002;28:305–8.
19. Wollina U, Kubicki J, Dexpanthenol supports healing of
superficial wounds and injuries,
Kosmet Med
, 2006;27:
240–49.
20. Batra RS, Dover JS, Hobbs L, et al., Evaluation of the role
of exogenous estrogen in postoperative progress after
laser skin resurfacing,
Dermatol Surg
, 2003;29:43–8.
21. Widgerow AD, Braun SA, Post-laser hypersensitivity and
the atopic patient,
Plast Reconstr Surg
, 2000;106:155–9.
Uwe Wollina is a Professor of Dermatology and Venerology and Head of the
Department of Dermatologyand Allergology at the Academic Teaching Hospital
Dresden-Friedrichstadt in Germany. He is President of the Saxonian Society of
Dermatology, Vice President and Chair of the regional offices of the International
Society of Dermatology, Vice President of the European Academy of Aesthetic and
Cosmetic Dermatology, Secretary General of the Winter Academy of Dermatology and
an honorary member of the Czech Society of Dermatology, the Jordanian Society of
Dermatology and the Cosmetic Dermatology Society of India.He is an active member
of theEuropean Academy of Dermatology and Venereology,the European Society for
Laser Dermatology, the International Academy of Cosmetic Dermatology, the German
Society of Dermatology and the German Cancer Society, among others.
Wollina_EU Dermatology 01/06/2010 13:09 Page 49