ArticlePDF Available

Pre- and post-laser treatment in cosmetic dermatology.

Authors:
  • Städtisches Klinikum Dresden

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.
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
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cartilage complex healing ointment on Er:YAG laser
resurfaced facial skin,
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19. Wollina U, Kubicki J, Dexpanthenol supports healing of
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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
... Satisfying esthetic results can be achieved, as illustrated by our clinical cases. We recommend UV protection in combination with skincare as maintenance therapy in pigmented and mixedtype POH [42]. ...
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Cryogen spray cooling (CSC) is a method used to protect the epidermis from non-specific thermal injury that may occur as a result of various dermatological laser procedures. However, better understanding of cryogen deposition and skin thermal response to CSC is needed to optimize the technique. Temperature measurements and video imaging were carried out on an epoxy phantom as well as human skin during CSC with and without simultaneous application of airflow which was intended to accelerate cryogen evaporation from the substrate surface. An inverse thermal conduction model was used to estimate heat flux and total heat removed. Lifetime of the cryogen film deposited on the surface of skin and epoxy phantom lasted several hundred milliseconds beyond the spurt, but could be reduced to the spurt duration by application of airflow. Values over 100 J/cm(3) were estimated for volumetric heat removed from the epidermis using CSC. "Film cooling" instead of "evaporative cooling" appears to be the dominant mode of CSC on skin. Estimated values of heat removed from the epidermis suggest that a cryogen spurt as long as 200 milliseconds is required to counteract heat generated by high laser fluences (e.g., in treatment of port wine stains) in patients with high concentration of epidermal melanin. Additional cooling beyond spurt termination can be avoided by simultaneous application of airflow, although it is unclear at the moment if avoiding the additional cooling would be beneficial in the actual clinical situation.
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Closed dressings are thought to promote postoperative wound healing after laser skin resurfacing; however, quantitative data are lacking. To compare postoperative healing after combination carbon dioxide and erbium:YAG full-face laser skin resurfacing in patients who were treated with a silicone occlusive dressing (Silon-TSR; Bio Med Sciences, Inc, Bethlehem, Pa) vs open-wound care consisting of soaks and ointment application. Thirty-five patients with closed dressings compared retrospectively with 35 control subjects with open-wound care. In a prospective evaluation, 27 patients with closed dressings were then compared with 27 historical controls matched by age, sex, skin type, and treatment technique. Erythema, crusting, swelling, pain, pruritus, purpura, long-term complications, and dressing comfort were evaluated. Referral-based academic practice. Prospectively, closed-dressing and open-wound care groups differed significantly in maximum erythema severity (1.8 vs 2.0 on a scale of 0-3; P =.03), noticeable erythema duration (15.4 vs 31.1 days; P =.04), and time until complete erythema resolution (41.8 vs 96.1 days; P =.02). Swelling resolution was more rapid in the dressing group (12.1 vs 29.5 days; P =.02). Crusting was limited to uncovered areas in the dressing group, and crusting duration was shorter (5.0 vs 9.1 days; P<.001). Pain was more likely to be reported prospectively, but severity was mild, in the closed-dressing group. Other short- and long-term complications did not differ significantly. Subjective patient attitudes toward the dressing were positive. Occlusive silicone dressing application decreases immediate postoperative morbidity with significantly reduced severity and duration of erythema and decreased duration of swelling and crusting. Long-term results and complication rates remain unchanged.
Article
There are several types of dressings which may be utilized after facial laser resurfacing. Laser surgeons favoring the open type of dressing have used the Aquaphor original formula to reduce the loss of moisture from laser resurfaced skin. The objective of this study was to compare the effectiveness of a mucopolysaccharide-cartilage complex (MCC) containing healing ointment with the standard therapy of Aquaphor ointment in treating erythema, edema, and skin erosion caused by Er:YAG laser resurfacing of facial skin. To compare healing time after Er:YAG laser resurfacing treated side-by-side with MCC as compared with Aquaphor. Nineteen patients completing Er:YAG laser resurfacing were randomly assigned to receive MCC healing ointment on one side of their face and standard therapy with Aquaphor on the other for eight consecutive treatment days. Immediately after surgery and again on days 1, 2, 3, 4, 7, and 8, the severity of erythema, edema, and erosion was scored on a 0-3 scale (0 = no observable effect, 1 = mild, 2 = moderate, 3 = severe). Photographs were taken at each follow-up visit. Following scoring on study day 0, the day of resurfacing, treatment was applied according to the left or right assignment code of the randomization schedule. Mean severity ratings for all variables (erythema, edema, and erosion) were consistently lower for MCC healing ointment as compared to Aquaphor ointment. Based on the calculated overall efficacy index, MCC ointment was statistically superior to Aquaphor for all three variables: erythema, P <.001; edema, P =.017; erosion, P <.001. The results of our study demonstrate that MCC healing ointment may provide an advantage over the standard therapy of Aquaphor ointment in the treatment of edema, erosion, and erythema caused by laser resurfacing of facial skin. Mean daily severity scores were consistently lower and improvement tended to occur earlier with MCC healing ointment.
Article
Contemporary studies and observations have left no doubt that occlusive dressings are superior to open treatment after laser resurfacing. The currently available occlusive dressings, however, are time-consuming to apply, often dislodge shortly after application, and most require reapplication. The authors report a cross-sectional observational study of patients who were treated with a new dual silicone-based dressing (DiamondSeal) after full-face laser resurfacing, with or without rhytidectomy. Patients who previously underwent similar surgeries and who were treated with a popular occlusive tape dressing (Flexzan) acted as historic controls. A combination of two silicones produced a gel-like silicone admixture that was spread evenly over the laser-treated areas. The silicone gel solidified into a flexible membrane and remained on the patient's face for 5 days. Questionnaires were sent to patients who were treated with the silicone dressing and those who were treated with a currently popular occlusive dressing. When the attributes of these dressings were compared, the superiority of the silicone dressing approached statistical significance ( = 0.08). The majority of patients treated with the silicone dressing (71 percent) had a positive experience with this dressing, stating they would repeat the experience if necessary. Only 54 percent of patients with a tape dressing were willing to repeat their experience ( = 0.18). The major advantages of this dressing, noted from the surgeon's perspective, were the speed with which the mask was applied; the ease of application, without the need for templates; the acceptable cure duration, allowing spontaneous contouring of the silicone along facial contours; the simple tailoring of the dressing; the reduced need for and minimal time for reapplication; and the paucity of complications.