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Lasers in Dermatology: a Review Ralph A Lasers in Dermatology: A Review Ralph A. Massey, MD, New York, New York Gina Marrero, MD, New York, New York Mimi Goel-Bansal, MD, New York, New York Robyn Gmyrek, MD, New York, New York Bruce E. Katz, MD, New York, New York The revolution in laser technology has had a lasers have resulted in their successful application to significant impact on medicine in general and a wide variety of conditions. These include vascular dermatology in particular and has piqued the inter- and pigmented lesions, acne scarring, wrinkled and est of physicians, the lay public, and the media. sun-damaged skin, tattoos, hypertrophic scars, warts, Advances in laser therapy have dramatically stretch marks, excessive hair, and skin cancer. improved the clinicians’ ability to treat cosmetic Although many practitioners are not directly and noncosmetic skin lesions safely and effec- involved in laser therapy, a basic knowledge of its tively. The number and variety of skin problems applications is vital given the considerable public amenable to laser treatment continues to grow. We interest in this field. This review will describe the will provide a review of the major cosmetic and types of conditions treated and the appropriate therapeutic applications of laser therapy. lasers used. t is not often in medicine that the advances in a Vascular Lesions particular technology simultaneously capture the Vascular lesions such as port-wine stains were among I imagination and immense curiosity of physicians, the first to be treated effectively with lasers, and the lay public, and the media. This has been the case much of our understanding of laser tissue interac- with laser applications in dermatology. The great tions stems from this work. Today, a wide variety of interest in this subject is primarily because of the lasers are used to treat both congenital and acquired enhanced specificity of laser interactions with skin vascular lesions, including port-wine stains, heman- and the significant advances of laser applications in giomas, facial telangiectasias, poikiloderma, cherry cosmetic surgery. angiomas, venous lakes, and spider leg veins. Many The great proliferation in laser technology is due variables may affect the efficacy of lasers in treating in large part to the concept of selective photother- these lesions, for example: the depth and caliber of molysis. In other words, if a targeted tissue (chro- the target vessels; the level of pigmentation of the mophore) strongly absorbs a selected wavelength, overlying epidermis; and the emission wavelength, and the pulse duration is shorter than the thermal pulse duration, spot size, and fluence (energy output) relaxation time (cooling time) of the tissue, then of the laser. only selective thermal injury will occur. By limiting When treating vascular lesions, the chromophore thermal damage to the target chromophore, less targeted is hemoglobin. The efficiency of energy injury occurs to the surrounding tissue, with a transfer to the chromophore will depend on the reduced risk for scarring. wavelength of the laser. Hemoglobin has absorption Lasers that were developed based on the principle peaks at 418 nm, 542 nm, and 577 nm. Energy of selective photothermolysis include the pulsed dye, absorption by this chromophore results in local ther- Q-switched ruby, neodymium:yttrium aluminum gar- mal damage. Limiting the spread of this damage is net (Nd:YAG), alexandrite, carbon dioxide (CO2), achieved best with a pulse duration that is less than and erbium:yttrium aluminum garnet (Er:YAG). The the thermal relaxation time of the target vessels.1 precise, controlled, and reproducible effects of these The first laser used in dermatology was the argon laser, with emission bands at 488 and 514 nm. Drs. Massey, Marrero, Goel-Bansal, Gmyrek, and Katz are from Although this did not coincide directly with one of the Department of Dermatology, Columbia University, College of Physicians and Surgeons, New York, New York. the absorption peaks of hemoglobin, it was suffi- Reprints: Bruce E. Katz, MD, JUVA Skin & Laser Center, ciently well-absorbed to have a selective effect on 60 E 56th St, New York, NY 10022. vascular lesions. The relatively long pulse duration of VOLUME 67, JUNE 2001 477 LASERS IN DERMATOLOGY A B Figure 1. Spider leg veins before (A) and 3 months after (B) VersaPulse laser treatment. this laser was associated, however, with a significant “chill tip” that is placed on the skin overlying the risk for fibrosis and scarring. vessel to be treated5 or a dynamic cooling device that The first pulsed-dye laser had an emission wave- sprays a brief spurt of cryogen before the laser pulse.6 length of 577 nm to coincide with one of the absorp- The benefits of these methods include decreased pain tion peaks of hemoglobin. The more recently and limited epidermal heating and damage. developed pulsed-dye lasers of 585 nm have a greater Any of the following lasers can be used to treat a depth of penetration at this longer wavelength. variety of vascular lesions: the argon at 488 to 514 nm; These new lasers have a pulse duration of 450 ␮s, the frequency-doubled Nd:YAG at 532 nm; the kryp- which is less than the thermal relaxation time of the ton at 568 nm; the argon dye at 577 to 600 nm; the target vessels. This gives good results and a better copper vapor at 578 nm; and the pulsed dye at 585, safety profile than the argon laser. However, purpura 595, and 600 nm. In principle, any cutaneous vascular resulting from rupture of the target vessels, probably lesion may be helped by laser therapy, and lasers are as a result of the short pulse duration, is a significant recognized as the treatment of choice for many of cosmetic problem. these lesions (Figure 1). However, no one laser is The frequency-doubled, 532-nm Nd:YAG laser ideal for all types of vascular lesions. Lasers with does not coincide with one of the absorption peaks of longer wavelengths penetrate more deeply, thus hav- hemoglobin but, nevertheless, has shown great utility ing an advantage for the treatment of deeper lesions. for the treatment of vascular lesions such as facial Target vessels, as opposed to epidermal melanin, will telangiectasias2,3 and leg veins.4 The pulse duration of absorb lasers with wavelengths at or close to one of this laser (1–50 ms) may allow for intravascular coag- the absorption peaks of hemoglobin more selectively. ulation without vessel rupture or significant periph- A longer pulse duration may be advantageous in eral thermal damage, causing slower heat transfer to treating larger caliber vessels. Epidermal cooling the target vessel. Presently, this means that the post- devices may limit some of the more common side operative purpura seen with the pulsed-dye laser can effects. As investigators try different combinations of be avoided, without an increased risk for scarring. these and other laser parameters, more will be learned Even longer pulse durations, up to 50 ms, are being about which lasers and what settings are appropriate evaluated for the treatment of larger vascular lesions, for any given vascular lesion. such as leg veins. Despite efforts to match the laser wavelength to Pigmented Lesions one of the absorption peaks of hemoglobin, some Treatment of benign pigmented lesions, including energy will be absorbed by epidermal melanin. Thus, solar lentigines, ephelides, melasma, and Ota’s there is always a risk for epidermal damage, with nevus, as well as red, blue, black, and green tattoos, resultant hypopigmentation, hyperpigmentation, or has been revolutionized by the advent of the even scarring. One method of limiting damage is the Q-switched lasers. “Q-switching” refers to lasers that use of simultaneous epidermal cooling. This can be produce very high power and extremely short pulses achieved with either a transparent, water-cooled of light. The Q-switched lasers approved for use in 478 CUTIS® LASERS IN DERMATOLOGY A B Figure 2. Tattoo before (A) and after (B) 4 treatments with the 1064-nm Nd:YAG laser. the United States are the ruby, which emits a red component, such as lentigines and ephelides, may be light at 695-nm wavelength; the Nd:YAG, at 1064 nm treated by all of these lasers, with lightening usually in the near-infrared spectrum and 532 nm in the occurring in 3 to 6 weeks (Figure 3). Café au lait green light spectrum; and the alexandrite, which maculae, Becker’s nevi, and melasma have a variable emits a red light at 755 nm.7,8 The predominant response to these lasers.11 Melasma may recur, even chromophores for these lasers are melanin and after successful treatment, especially if patients are exogenously placed tattoo pigment, and the wave- not diligent with their use of sunscreens. Infraorbital lengths of these lasers are long enough to penetrate hyperpigmentation associated with dermal melanin into the dermis where there is tattoo ink or dermal pigment also shows improvement with the ruby, pigment.8 Therefore, considerable gains have been alexandrite, and 532-nm Nd:YAG lasers, as well as made with these lasers for the treatment of decora- with the nonpigment-specific, high-energy, pulsed 12,13 tive, traumatic, and cosmetic tattoos, as well as CO2 laser. benign pigmented lesions and congenital nevi. Lesions with a deeper dermal pigmented compo- All of these lasers are effective in treating tattoos. nent, including Ota’s nevi and congenital nevi, It is believed that the destruction of tattoos occurs respond better to the longer wavelength Q-switched through energy transfer, as well as through photo- lasers such as the ruby, 1064-nm Nd:YAG, and acoustic waves occurring secondary to the ultrashort alexandrite. However, deeper dermal melanocytes pulse duration of these lasers. This breaks the tattoo may persist. particles into smaller pieces.
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