Laser Dermatology David J. Goldberg Editor Laser Dermatology Second Edition Editor David J. Goldberg, M.D. Division of New York & New Jersey Skin Laser & Surgery Specialists Hackensack , NY USA ISBN 978-3-642-32005-7 ISBN 978-3-642-32006-4 (eBook) DOI 10.1007/978-3-642-32006-4 Springer Heidelberg New York Dordrecht London Library of Congress Control Number: 2012954390 © Springer-Verlag Berlin Heidelberg 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Preface of Second Edition The continuing development of cosmetic energy-based technologies over the last 25 years has been nothing short of incredible. It is almost a decade since the publication of the 1st edition of Laser Dermatology. Over the last decade, this fi eld has continued to grow and expand with the appearance of new tech- nology. This book represents the most up-to-date description of the latest in laser and light-source technology. All the initial chapters have been re-written and updated by leading experts from both North America and Europe. After a chapter describing our latest understanding of laser physics, which also covers safety aspects, chapters are dedicated to laser treatment of vascular lesions, pigmented lesions and tattoos, unwanted hair, fractional ablative and non-ablative resurfacing and energy-based treatments for medical purposes. Each chapter begins with core concepts. These basic points are followed by a history of the use of energy-based technologies for the cutaneous problem under discussion, currently available technology, and indications and contraindications. The chapter authors then provide an example of his/ her consent form and approaches to personal treatment. What has become clear is that a signi fi cant understanding of lasers and light sources is required for optimum use of these devices. A basic under- standing of laser physics is also fundamental to good laser treatment. Laser safety and minimizing risk to patients is at least as important as an under- standing of laser physics. When these concepts, so clearly described in Chap. 1 , are understood, cutaneous laser technology can be safely and successfully used for a variety of purposes. A wide variety of cutaneous vascular disorders can be successfully treated with modern lasers. The pulsed dye laser has enabled treatment of cutaneous vessels by following the principle of selective photothermolysis, a simple physics concept seen throughout laser dermatology. The pulsed dye laser is the most effective laser for treatment of port wine stains but purpura historically limited its acceptability by patients for more cosmetic indications. Both facial and leg vein telangiectasia can also be treated with lasers. Other cutaneous disorders such as psoriasis, warts and scars can be improved by targeting the lesion’s cutaneous vessels with appropriate lasers. Chapter 2 describes our latest understanding of the laser treatment of vascular lesions. When considering treatment of pigmented lesions, accurate diagnosis of the pigmented lesion is mandatory before laser treatment. For some pigmented lesions, laser treatment may even be the only treatment option. Tattoos respond well to Q-switched lasers. Amateur and traumatic tattoos respond v vi Preface of Second Edition more readily to treatment than do professional tattoos. Cosmetic tattoos should be approached with caution. Treatment of melanocytic nevi remains controversial, but worth pursuing. Chapter 3 describes our latest understanding of the laser treatment of pigmented lesions and tattoos. A wide variety of lasers can now induce permanent changes in unwanted hair. Hair removal lasers are distinguished not only by their emitted wave- lengths but also by their delivered pulse duration, peak fl uence, spot size delivery system and associated cooling. Nd:YAG lasers, with effective cooling, are the safest approach for treatment of darker skin. Despite this, complica- tions arising from laser hair removal are more common in darker skin types. Laser treatment of non-pigmented hair remains a challenge. Chapter 4 describes our latest understanding of the laser treatment of unwanted hair. Ablative and non-ablative fractional laser resurfacing lead to improvement of photodamaged skin. Fractional ablative laser resurfacing produces a more signi fi cant wound, but lasting clinical results. Non-ablative fractional resur- facing is cosmetically more elegant, but generally requires more treatment sessions. Visible light non-ablative devices lead to a lessening of erythema and super fi cial pigmentary skin changes. Mid-infrared laser devices promote better skin quality and skin toning. Chapter 5 describes our latest understanding of ablative and non-ablative fractional laser resurfacing. Lasers and light sources have become more commonplace in the treatment of dermatological medical diseases. Topical ALA and adjunct light-source therapy (ALA-PDT) is a proven photodynamic therapy for actinic keratoses and superfi cial non-melanoma skin cancers. ALA-PDT, using a variety of vascular lasers, red/-light sources, and intense pulsed light sources, is also now being used to treat the signs of photoaging. PDT can also be useful therapy for acne vulgaris. Newer lasers and light sources are also now being used to treat psoriasis vulgaris, vitiligo, other disorders of pigmentation, and hypopig- mented stretch marks. Chapter 6 describes our latest understanding of photo- dynamic therapy and the treatment of medical dermatological conditions. January 2013 David J. Goldberg, M.D. Contents 1 Basic Laser: Physics and Safety . 1 Holly H. Hare and Ronald G. Wheeland 2 Laser Treatment of Vascular Lesions. 13 Sean W. Lanigan 3 Laser Treatment of Pigmented Lesions . 41 Zeena Al-Dujaili and Christine C. Dierickx 4 Laser Treatment of Unwanted Hair. 65 Jeremy Man and David J. Goldberg 5 Ablative and Non-ablative Fractional Resurfacing . 89 David H. Ciocon, Yoon Soo Bae, and Suzanne L. Kilmer 6 Lasers and Light Sources for Medical Dermatologic Conditions. 107 Michael H. Gold Index . 139 vii Basic Laser: Physics and Safety 1 Holly H. Hare and Ronald G. Wheeland meters, determines the wavelength . For the visible Core Messages portion of the EMS, the wavelength determines • A signi fi cant understanding of lasers the color of the laser light. The number of wave and light sources is required for optimal crests (or troughs) that pass a given point in a use of these technologies. second determines the frequency for each source • A basic understanding of laser physics of EMS energy. The wavelength and frequency of is at the core of safe and ef fi cacious laser light are inversely related to one another. Thus, treatments. shorter wavelengths of light have higher frequen- • Laser safety and minimizing patient cies and more energenic photons than longer risks is at least as important as an under- wavelengths of light which have lower frequen- standing of laser physics. cies and less energenic photons. When Was Light First Used for Medical History Purposes? What Is Light? One must go back to about 4000 B.C. in ancient Egypt to fi nd the earliest recorded use of light. At Light is a very complex system of radiant energy that time sunlight was coupled with a topical pho- that is composed of waves and energy packets tosensitizer, like parsley or other herbs containing known as photons. It is arranged into the electro- psoralen, to help repigment the skin of individuals magnetic spectrum (EMS) according to the length suffering from vitiligo, a disorder in which the of those waves. The distance between two succes- skin becomes depigmented through a presumed sive troughs or crests of these waves, measured in autoimmune reaction. In Europe in the nineteenth century, sunlight was used as a treatment for cuta- neous tuberculosis. However, it wasn’t until 1961 H. H. Hare , M.D., FAAD (*) Department of Dermatology, Mohs and Dermatologic that Dr. Leon Goldman, a dermatologist at the Surgery at College Park Family Care Specialty Center , University of Cincinnati, fi rst employed a ruby University of Kansas Medical Center , Overland Park , laser for the removal of tattoos and other pig- KS , USA mented cutaneous lesions. For his continuous e-mail: [email protected] efforts in promoting the use of lasers for medical R. G. Wheeland , M.D., FAAD purposes and for co-founding the American Consultant in Mohs and Laser Surgery , Tuscon , AZ , USA Society for Laser Medicine and Surgery, Dr.