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LASER Ablative in DERMATOLOGY

Abraham Arimuko

Presidential Hospital – Gatot Soebroto, Jakarta


The Indonesia Society Laser Medicine (IKLASI)

Jakarta, 4 Maret 2018


HISTORY

• 1960 : Maiman, Ruby rod, 694 nm


• 1961 : Nd : Yag
• 1962 : Argon
• 1964 : CO2
• 1965 : Leon Goldman.
• 1983 : Selective photothermolysis.
History

• 1995 Scanner, Skin resurfacing


• 1997 Broad band light ( IPL )
• 1999 Nonablative rejuveantion
• 2000 Fractional
• Nowadays there is a wide spectrum of laser, light
technologies, RF, ultrasound available for skin
rejuvenation.
Laser Ablative in Dermatology, Application

• Pigmented and tattoo


• Vascular
• Skin rejuvenation
• Hair removal
• Epidermal – Dermal lesion
PIGMENTED LASER
Pigmented laser

• Accurate diagnosis of pigmented lesions is


mandatory before laser treatment.

• For some pigmented lesions, laser treatment may


be the only treatment option.
Pigmented laser, mechanism

• Selective photothermolysis.
• Non Specific chromophore removal.
Pigmented laser, indication

• Epidermal : Lentigo, seb keratosis, ephelides, café au lait,


nevus spilus.

• Epidermal-Dermal : Becker’s n, melanocytic n, PIH,


Melasma.

• Dermal : n Ota, n Hori (ABNOMs)


Patient Selection for pigmented lesion

• Correct diagnosis.
• Realistic expectation.
• Caution in darker skin.
Education / communication

• Laser Indication
• Procedure
• Limitation of the laser
Treatment Algorithm

• Anasthesia.
• Eye protection / laser safety
• Determine parameter
• Handpiece position : perpendicular / distance.
• Overlap
• Post op care
• Follow up
QS 1064-nm Nd:YAG 3 5–8
Nevus of Ota QS 694-nm ruby 6.5 5–6
QS 755-nm alexandrite 3 6.5
QS 1064-nm Nd:YAG 3 5.0

Table 3.5. Most effective Q-switched lasers for different tattoo ink colors

Pigmented laser, suggested parameter


Tattoo ink color Laser
Blue/black Q-switched ruby, Q-switched alexandrite, Q-switched 1064-nm Nd:YAG
Green Q-switched ruby, Q-switched alexandrite
Red/orange/purple Q-switched frequency-doubled 532-nm Nd:YAG laser, 510-nm pigment
lesion pulsed dye laser

Table 3.6. Response of pigmented lesions and tattoos to various lasers and light sources
Pigmented Lesions Tattoos
Epidermal Mixed Dermal Amateur Professional
510-nm pigment lesion pulsed dye laser +++ + + ++ +++
(red colors)
532-nm Q-switched Nd:YAG laser +++ + + ++ +++
(red colors)
694-nm Q-switched ruby laser +++ + +++ +++ +++
(green color
755-nm Q-switched alexandrite laser +++ + ++ +++ +++
(green color
1064-nm Q-switched Nd:YAG laser ++ + +++ +++ +++
Intense pulsed Light source +++ + +

+++ = excellent, ++ = good, + = fair


UNCOMFORTABLE PROCESS

• Painfull
• Repeated procedures
• Transient side effect
• Post laser care
• Downtime
Pigmented laser, Melasma

• Melasma : very common in daily practice.


• Laser treatment : relaps easily.
• Laser treatment should be combined
• Education
• Topical treatment and Sunscreen
• Special parameter setting
Tattoo removal

• Selective photothermolysis concept, laser option :


depend on the color of the ink. (eg, Nd Yag, 1064 nm for
blue/black ink )

• Mechanism of tattoo removal :


• Destruction of ink particle by laser
• Phagocytosis of smaller ink particle by macrophages,
Patient selection for tattoo removal

• Professional tattoo more difficult to remove than


amateur.
• Realistic expectation.
• Caution in darker skin.
• Older tattoo : better result
Q Switched Nd : Yag
1064 nm – 532 nm

Black/Blue 1064 excellent

Green 1064 fair

Red 532 fair

532
Yellow poor
1064
Table 3.6. Response of pigmented lesions and tattoos to various lasers and light sources
Pigmented Lesions Tattoos
Epidermal Mixed Dermal Amateur Professional
Pigmented andlesion
510-nm pigment tattoo
pulsed dye laser,
laser response
+++ + + ++ +++
(red colors)
532-nm Q-switched Nd:YAG laser +++ + + ++ +++
(red colors)
694-nm Q-switched ruby laser +++ + +++ +++ +++
(green colors
755-nm Q-switched alexandrite laser +++ + ++ +++ +++
(green colors
1064-nm Q-switched Nd:YAG laser ++ + +++ +++ +++
Intense pulsed Light source +++ + +

+++ = excellent, ++ = good, + = fair


Side Effect and Complication

• Pain
• Alteration in pigmentation : Hyper / hypo
• Thermal injury
• Scarring
• Darkening of tattoo pigment.
VASCULAR LASER
Vascular laser

•  Principles of selective photothermolysis.


•  Indication :
•  Congenital : PWS, capillary (strawberry)
hemangiomas,
•  Non congenital : telangiectasia, spider angioma,
cherry angioma, venous lake, angiokeratoma,
pyogenic granuloma, Kaposi’s sarcoma, rosacea
Poikiloderma of Civatte, Radiation induced
telangiectasia.
•  Non vascular : scars, viral warts
lasers.

History
Vascular laser
Port Wine Stain Treatment

■ Argon Laser

The earliest studies on the la


vascular disorders were on p
(PWS) and published in the 1
the argon and ruby lasers (Tabl
was undertaken with the arg
1980s this was the most frequ
worldwide for the treatment of
laser emits light at six differen
the blue green portion of the v
Vascular laser

• The pulsed dye laser 577, 585 nm (PDL) : Consider


as gold standard for treating vascular lesion.

• Leg vein telangiectasia can also be treated with


lasers but sclerotherapy remains the gold
standard.
HAIR REMOVAL
Hair removal

• Current used : Ng Yag 1064nm, Ruby 694nm,


Alexandrite 755nm, diode 800nm, IPL 515-1200nm

• Goals :
• Adequate heat diffusion, from light absorbing
melanizied hair bulb to surrounding follicle.
• Preserve the epidermis
Hair removal

•  Operation Setting :
•  Wave lengths : chromophore à pigment of hair
•  pulse durations : longer than Q Switched
•  Fluences : higher better, caution surrouding tissue heating
•  spot size. : preference lager
•  Cooling. : protect epidermal layer.
SKIN REJUVENATION
Rejuvenation,

• Classification : Ablative and nonablative rejuvenation,


lead to an improvement in photodamaged skin.

• Ablative resurfacing : gold standard for wrinkle.


• Midinfrared infrared laser : skin quality and skin toning.
• Visible light nonablative : lessening of erythema and
superficial pigmentary skin changes
Rejuvenation, ablative

•  Current device : CO2 ultrapulse, Erbium.


•  Advantages :
•  immediate result
•  a significant reduction ( at least 50%) in wrinkles, lentigines,
keratoses, surface irregularities, skin laxity
•  Single session.
•  Disadvantages
•  Prolonged Downtime : edema, scab, erythema
•  Risk of infection, Hyperpigmentation, scar
Rejuvenation, nonablative

•  Current device : PDL, Nd Yag 1320nm 1064nm, IPL, RF, Ulrasound.


•  Advantage :
•  Lack of patient down time.
•  Minimizing erythema, vascular, pigmented lesion
•  Disadvantage : The degree of wrinkle reduction is not as
significant
CO2 LASER
Epidermal and Dermal lesion, CO2 Laser

• CO2 Laser : useful in the successful treatment of many


epidermal and dermal skin lesions where there is no
specific target chromophore other than water.

• Beam :
• Cutting : focused
• Ablate : unfocused, lower power
Epidermal Dermal
Actinic keratosis Adenoma sebaceum
Condyloma acuminatum Angiofibromas
Epidermal nevus Granuloma faciale
Keratosis follicularis Hidradenitis suppurativa
Neurofibroma
Lichen sclerosis
Pearly penile papules
Porokeratosis
Pyogenic granuloma
Verruca plantaris
Syringoma
Verruca vulgaris
Trichoepithelioma
Xanthelasma
Take home message

• Important :
• Education
• Patient expectation
• Pre / post treatment
• Best result : combined therapy.
• Each laser has the advantage and limitation.
Terimakasih