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Light-Based Treatment of Pigmented Lesions E CosmetiC teChnique Light-Based Treatment of Pigmented Lesions E. Victor Ross, MD Pigmented lesions are common among patients presenting to dermatologists. Fortunately, a large arsenal of light-based technology is available for the reduction and removal of these lesions. By developing a comprehensive understanding of the microanatomy of dyschromia, physicians can optimize protocols based on principles of laser-tissue interactions and reports in the literature. This article will examine the author’s experience and preferences in treating specific types of pigmented lesions with various lasers and light devices. Cosmet Dermatol.COS 2011;24:515-522. DERM ermatologists commonly treat patients laser and nonlaser devices can be employed, sometimes with pigmented lesions. A large arsenal with different wavelengths, spot sizes, and pulse widths, of light-based devices are available for the but still achieve similar results.1 reduction and removal of these lesions. Chemical peels and cryotherapy at one time were wor- The most important factor to consider thy opponents of the laser but can present challenges Dwhen choosing the best light source for the treatment of related to damage confinement. For generalized superfi- pigmentedDo lesions is the microanatomy Not of the dyschro- cial pigmentCopy reduction, chemical peeling in experienced mia. A crucial factor in treatment of excessive pigment hands is quite sufficient. However, in focal destruction, is having an understanding of the pigment distribution the agent often will extend beyond the perimeter of the with the lesion. Lesion microanatomy should be con- lesion, even with careful application. Cryotherapy also is sidered when strategizing for optimal removal. It also notoriously challenging to control. The best success usu- is important to consider certain types of dyschromia, ally is achieved with a cotton swab, copper tip attached such as melasma, postinflammatory hyperpigmenta- to a sprayer, or cone (such as an ear speculum) to con- tion (PIH), and Hori nevus, as inflamed “dynamic” types fine the spray to a particular treatment spot; however, the of pigmented lesions. In contrast, lentigines and freckles chance of temporary PIH and possibly even long-term typically are stable and noninflamed. Multiple types of hypopigmentation still is high. Although an accomplished peeler or cryotherapist might perform admirably and competitively in a laser duel, reaching that level of experi- ence would require much practice, and similar to derm- From Laser and Cosmetic Dermatology, Scripps Clinic, San abrasion, the number of residents being trained to treat Diego, California. pigmented lesions with peels and advanced cryotherapy Dr. Ross has received research support from Alma Lasers, Ltd, is declining. and is a consultant for Lumenis. He also is a consultant for and An exceptional review of laser treatment of pigmented has received research support from Candela Corporation; lesions recently was published in the literature.2 In con- Palomar Medical Technologies, Inc; and Syneron Medical Ltd. trast to that review, this article will examine the author’s Correspondence: E. Victor Ross, MD, Scripps Clinic, 3811 Valley experience and preferences in treating specific types of Centre Dr, San Diego, CA 92130 ([email protected]). pigmented lesions with various lasers and light devices. www.cosderm.com VOL. 24 NO. 11 • NOVEMBER 2011 • Cosmetic Dermatology® 515 Copyright Cosmetic Dermatology 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Light-Based treatment A series of key pearls will be presented as well as practi- duration that is less than or equal to the time necessary cal and realistic approaches for treating pigmented lesions for cooling of the target structures, and sufficient energy that are typically seen in a dermatology practice. to damage the target. The heterogeneity of the skin allows for selective injury in microscopic targets, and the focal PRINCIPLES IN LIGHT-BASED nature of heating decreases the likelihood of widespread PIGMENT REDUCTION thermal damage.5 The basis for pigment reduction in most laser and Thermal relaxation time () is the interval necessary light applications is selective targeting of the 1-µm for a target to cool to a certain percentage of its peak diameter melanosome.1 Melanin absorption scales as temperature. The larger the area, the longer it takes to . It follows that the threshold for epidermal dam- cool. When defining thermal relaxation time, the tar- age in surface pigmented lesions increases by the same get size and geometry are important. Normally, the scale of relative absorption versus . For example, value for is expressed as 2/g, where indicates the a typical ratio for pigment damage threshold flu- diameter of the particle; , the thermal diffusivity (a ence at 504 and 750 nm in pigmented lesions was measure of heat capacity and conductivity [for tissue, shown to be approximately 1 to 1.7, indicating that ~ 1.3 · 1023 cm2/s]); and g, a constant based on the almost twice the fluence is needed to heat a lesion at shape of the target (ie, slab, cylinder, sphere). 750 nm versus 504 nm.1 Therefore, if a lentigo is treated A simple rule for most targets is that the thermal relax- with 10 J/cm2 at 532 nm for immediate graying or darken- ation time in seconds is approximately equal to the square ing, a fluence of 18 J/cm2 would be required at 750 nm for of the target dimension in millimeters. Thus a 0.5-µm the same lesion. These calculations assume similar pulse melanosome (531024 mm) should cool in approximately durations. For shorter pulses with the same wavelength, 2531028 seconds or 250 nanoseconds. Recall that is smaller fluences are required for selective melanosome derived from a solution of a differential equation and does heating; for instance, although a fluence of 8 J/cm2 might not represent an absolute cooling time but rather provides be required to treat a typical lentigo with a Q-switched approximate pulse widths for varying degrees of ther- alexandriteCOS laser, 20 to 35 J/cm2 might be required forDERM a mal confinement.4 3-millisecond pulse. Thus pulse duration and wavelength The geometry and therefore the microscopic character- are the 2 most important factors in selective epidermal istics of the lesion also is important. For example, nevi are heating of pigmented lesions. composed of melanocytes in aggregates; collectively, the Physicians can optimize a particular device for selec- nodules often are several hundred micrometers in diam- tive heating of pigmented lesions versus vascular lesions eter. In contrast, lentigos are comprised of a thin sheet of by manipulating the laser parameters. For example, by melanocytes, some 10-µm thick. When treating a nevus applyingDo a compression handpiece Not without cooling with with a long-pulsedCopy alexandrite laser at a high fluence, the 595 nm, blood is depleted as a target and pigment is pref- thermal relaxation time will approach 1 second. Accord- erentially heated.3 Also, some intense pulsed light (IPL) ing to the previous equation, it follows that thermal con- devices allow the user to increase or decrease the sapphire finement will be high, and the peak temperature will rise window temperature to enhance epidermal versus vascu- accordingly. More importantly, the thick slab of melano- lar heating. cytes will take longer to cool, so there will be consider- When the pulse width is reduced to the nanosecond able heat diffusion away from the target. On the other range, melanosomes are preferentially heated instead hand, the lentigo represents a slab only tens of microns of vessels. Extremely short Q-switched 532-nm pulses thick; there will be heat diffusion during the long pulse will cause fine vessels to rupture, and inadequate heat and rapid cooling after the pulse. Thus, with millisecond- diffusion to the vessel walls precludes long-term vessel domain fluences, the nevus case might result in scarring, destruction.4 On the other hand, melanosomes are suf- whereas a lighter lentigo (so-called low contrast lesion) ficiently heated for single-session lentigo destruction. might not become hot enough for clearance. If nanosec- Nonbulk skin heating is based on selective absorption ond pulses are applied to both types of lesions, the len- by discrete chromophores of relatively low concentra- tigo shows a good response with a possibility for complete tion (ie, melanin, hemoglobin). Anderson and Parrish5 clearing, whereas the nevus will require multiple sessions, described the concept of selective photothermolysis, a as each laser application will result in confinement of heat process that offers a mathematically rigorous rationale to the most superficial part of the lesion. for tissue-selective lasers. They explained that extreme Most pigment-specific lasers rely on selective absorp- localized heating relies on a wavelength that reaches tion of light. In another category, there are devices (ie, CO2 and is preferentially absorbed by the target, an exposure and erbium:YAG [Er:YAG] lasers) in which water is the 516 Cosmetic Dermatology® • NOVEMBER 2011 • VOL. 24 NO. 11 www.cosderm.com Copyright Cosmetic Dermatology 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Light-Based treatment chromophore and the pigment just happens to be in the endpoints are frosty and white (Figure 2). Q-switched way. These lasers require a more skilled operator because, lasers also carry little risk for PIH in lighter-skinned Asian whether in continuous-wave or pulsed mode, the ablation/ and Hispanic patients as well as tanned white patients heating must be confined to the level of the lesion and not with Fitzpatrick skin types II and III.4 proceed deep into the dermis. In darker-skinned Asians and other populations with olive complexions, some persistence of pigmented lesions GENERAL GUIDELINES AND SCENARIOS is observed after Q-switched 532-nm, 755-nm, and In my practice, if a lighter-skinned white patient presents 694-nm laser applications.
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