REVIEW ARTICLE Low Level Laser Therapy in Dermatology Fatma Abd Al Salam, MD, Wafaa Afify, MD Al-Azhar University , Cairo, Egypt BACKGROUND Low-level laser therapy (LLLT) refers to the use of a red-beam or near-infrared laser with a wave-length between 600 and 1000 nanometers and power from 5 to 500 millwatts. Other names for the therapy include low-power laser, soft laser, cold laser, biostimulation laser and therapeutic laser. As high-power lasers ablate tissue, low-power lasers stimulate it, en- couraging the cells to function. The laser photons are absorbed by mitochondrial chromophores. (cytochrome-c oxidase) stimulating oxidative phosphorylation to increase ATP production and reduce oxidative stress. This effects lead to improved tissue repair, reduces inflammation and reduces pain. LLLT has beneficial effects on many dermatologic disorders including wound healing, hypertrophic scars and burns, herpes simplex, acne and acne scars; wrinkles, vitiligo and psoriasis. LLLT is safe, simple, non invasive, painless, drugless therapy, easy to apply, with no reported side effect. Laser is an acronym for Light Amplification by 3- Optical Resonator: Stimulated Emission of Radiation. Consists of 2 specially designed mirrors, dia- gramatically opposed to each other. The high re- LASER COMPONENTS flectance mirror reflects 100% of the light which All lasers contain 3 primary components to oper- strikes it, while the other mirror (partially trans- ate: missive mirror) reflects less than 100% of the light 1-Active medium which strikes it. The small fraction of light which 2- Excitation mechanism and passes through the partially transmissive mirror is 3- The optical resonator the beam output.1 The therapeutic action of laser energy is based on 1- Active medium: the unique properties of laser light and laser tissue It is a collection of atoms, molecules, or ions interaction. which absorb energy from an outside source and generate laser light through atomic processes. The LASER PROPERTIES active medium may be solid, liquid or gas. 1. Monochromatic: The emitted light is of sin- gle, discrete wavelength that can be absorbed 2- Excitation Mechanism: by specific targets or chromophores. It is the input energy device, which could be an 2. Coherence: Laser light traveling in phase intense light source, an electrical current through with respect to both time and space. an active gas, or in the case of dye lasers, light 3. Collimation: Emission of a narrow, intense from another laser. beam of light in parallel fashion to achieve Correspondence: Dr. Fatma Abd Al Salam, Al-Azhar University , Cairo, Egypt E-mail: [email protected] The Gulf Journal of Dermatology and Venereology Volume 21, No.2, Oct. 2014 1 Low Level Laser Therapy in Dermatology Fig. 1 Primary laser components. its propagation across long distances without a specific wavelength of light, it may be endog- light divergence → so it can be focused into a enous as hemoglobin, melanin and water or exog- small spot size.2 enous as tattoo ink.4 Once laser energy is absorbed in the skin the possible, effects are: • Photothermal effects; occur when chromophore absorbs the specific wavelength of energy and destruction of the target results from the conversion of absorbed energy into heat. • Photochemical effects; derive from native Fig. 2 Characteristics of laser beam. or photo sensitizer effects, are related reac- Laser tissue interaction tion that serves as the basis of photo dynamic When lasers are used on the skin, the light may therapy. be absorbed, reflected, transmitted or scattered. • Photomechanical effects; the extremely rapid The light must be absorbed by tissue for a clini- thermal expansion can lead to acoustic waves cal effect to take place whereas transmitted or re- and subsequent photomechanical destruction flected light has no effect.3 The energy absorbed of the absorbing tissue. is measured in joules per square centimeter and • Photoablative causes photodissociation or is known as the energy density or fluence. The breaking of the molecular bonds in tissue.2 amount of absorption is determined by the chro- mophore present in the skin. The laser tissue interaction depends on the theory Chromophores are substances in tissue that absorb of selective photothermolysis. This theory de- The Gulf Journal of Dermatology and Venereology Volume 21, No.2, Oct. 2014 2 Fatma Abd Al Salam et al. scribes how controlled destruction of targeted le- Classification by active medium sion is possible without significant thermal dam- Table 1 Common Laser classification by wavelength 5 age to surrounding normal tissue. Type Wavelength To limit the amount of thermal energy deposited Nanometer Micron Ultraviolet (180 to 400mm) within the skin, the exposure duration of the tissue (nm) (µm) to light (pulse duration) must be shorter than the • Argon fluoride (ArF) 193 0.193 chromophores’ thermal relaxation time (the time required for the targeted site to cool to one half of • Krypton Chloride (KrCl) 222 0.222 its peak temperature immediately.5 • Krypton fluoride (KrF) 249 0.249 Optical properties of tissue and action spectra • Xenon-chloride (XeCl2) 308 0.308 Both the absorption and scattering of the light in the tissue are wavelength dependent (both much • Nitrogen (N2) 337 0.337 higher in the blue region of the spectrum than the • Helium- Cacmium 325 0.325 red). The principle tissue chromophores (hemo- (HeCd) globin and melanin) have high absorption bands Visible (400 to 700 rm) at wave lengths shorter than 600 nm. Water begins 0.543, to absorb infrared wavelength greater than 1150 543, 594, 0.594, • Helium- Neon (HeNe) nm wavelength. For this reasons there is so called 612, 633 0.612, 0.633 optical window in tissue covering the red and NIR • Krypton (Kr) 647 0.647 wavelengths where the effective tissue penetration of light is maximized. This optical window runs • Ruby 694 0.694 approximately from 650 nm to 1200 nm.3 (Fig. 3) 0.488 to • Argon (Ar) 488 to 515 0.515 • Nd: YAG (2 harmony) 532 0.532 Infrared (700nm to 1mm) • Gallium Arsenide (diode) 850 0.85 • Carbon Dioxide (Co2) 10.600 10.6 • Nd: YAG 1064 1.064 Fig. 3 Optical window in tissue. LASER CATEGORIES • Ho: YAG 2100 2.1 Lasers are classified either by their active medi- • Semi-conductor materials (diode): e.g. gal- um, their wavelength or maximum output power. lium/arsenide; gallium / aluminum / arsenide • Common Laser Solid crystalline materials: • Liquid dyes: utilize a flowing dye pumped by e.g. Ruby, Neodymium: YAG flash lamp of other lasers The Gulf Journal of Dermatology and Venereology Volume 21, No.2, Oct. 2014 3 Low Level Laser Therapy in Dermatology • Gaseous materials: e.g. Helium-Neon, CO2, 3. Relief of neurogenic pain and some neuro- Argon, Krypton logical problems. Common classification by maximum output power: I. High power lasers (Thermal lasers) They are used to cut, coagulate and evaporate tis- sues. These lasers are often called surgical lasers because they can replace the scalpel of the sur- geon as CO2, KTP (potassium- titanyl-phosphate) and argon pumped tunable dye (APTD). II. Low level lasers (Therapeutic lasers) Fig. 4 Schematic representation of the main areas of They can be used for the stimulation of cell func- application of LLLT. tion. Their biological effect is not thermal. Mechanisms of low level laser therapy: LLLT is the application of light (usually a low It was suggested in 1989 that the mechanism of power laser or light emitting diode (LED) in the LLLT at the cellular level was based on the absorp- range of 10 mw- 500 mw) to the tissue to promote tion of monochromatic visible and NIR radiation tissue regeneration, reduce inflammation and re- by components of the cellular respiratory chain. lieve pain. The light is typically of narrow spectral The inner mitochondrial membrane contains 5 width in the red or near infrared (NIR) spectrum. complexes of integral membrane proteins: NADH The reason why the technique is termed low level dehydrogenase (Complex I), succinate dehydro- is that optimum levels of energy density delivered genase (Complex II), cytochrome c reductase are low when compared to other forms of laser (Complex III), cytochrome c oxidase (Complex therapy as practiced for ablation, cutting, and IV), ATP synthetase (Complex V) and two freely thermal coagulation of tissue.6 LLLT also know diffusible molecules ubiquinone and cytochrome as cold laser, soft laser, biostimulation laser or c that shuttle electrons from one complex to the photobiomodulation laser, and therapeutic laser.7 next (Fig. 5). The respiratory chain accomplishes Biomodulations defined as changing the natural the stepwise transfer of electrons from NADH and biochemical response of cells or tissue within the FADH2 (produced in the citric acid or Krebs cy- normal range of its function. cle) to oxygen molecules to form (with the aid of The three main areas of medicine practice where protons) water molecules. The energy released by LLLT has a major role to play are as follows: this process of active transport forms a miniature (Fig. 4). battery.8 (Fig. 5). 1. Wound healing, tissue repair and prevention of tissue death; Cytochrome C oxidase (COX) hypothesis: 2. Relief of inflammation in chronic diseases and Cox is a subunit in the mitochondrial electron injuries with its associated pain and edema; transport chain. It is the primary photoacceptor of The Gulf Journal of Dermatology and Venereology Volume 21, No.2, Oct. 2014 4 Fatma Abd Al Salam et al. 2. Reverses the partial inhibition of the catalytic centre by nitric oxide, so increase O2 binding and respiration.13 • Nitric oxide (NO) hypothesis Mitochondria produce an enzyme that synthesizes NO that was identified as neuronal isoforms of NO synthase.14 Nitric oxide produced in the mitochondria can bind to Cox leading to inhibition of respiration which is explained by direct competition between Fig.