Treatment of chrono and photoageing with combined light sources

March 31st

Skin ageing depends on various intrinsic (chronological) and extrinsic (ambiental) factors: chrono and photoageing changes include wrinkles, abnormal pigmentation, skin laxity and telangiectasia.

The Nordlys™ system is a multi-platform device that incorporates dual-filtering Selective Waveband Technology (SWT®) and two fractional, non-ablative laser resurfacing technologies – addressing both shallow (Frax 1940™) and deeper (Frax 1550™) resurfacing needs, as well as Nd:YAG 1064. The Candela SWT is a unique technology, defined by a patented dual filter, as well as sub-millisecond pulses. The pioneering SWT delivers a more precisely filtered narrowband of wavelengths, using only those that have a beneficial treatment effect while filtering out other potentially harmful wavelengths [1].

Non-ablative fractional laser therapy is a new concept of treatment, in which arrays of microscopic treatment zones (MTZ) are produced in the dermis, stimulating a therapeutic response around them. Surrounding normal intact epidermis enables accelerated healing after treatments. Many studies have proven that this treatment modality can achieve desirable clinical results without serious adverse effects or longer downtime, which was the major limitation of ablative laser resurfacing [2].

Non-ablative fractional laser therapy at 1550nm is CE-marked for clinical conditions that require dermal remodelling, like skin resurfacing, stretch marks, acne and surgical scars [3].

With the Nordlys system, it is possible to manage chrono and photoaging using the Light and Bright protocol; combining the narrowband, dual filter SWT, 530 or 555 filters, and the Frax 1550 fractional non-ablative handpiece to treat vascular and pigmented lesions and textural irregularities at the same time [3,4].

Case 1
A 46-year-old Caucasian female presented with severe chrono and photoageing, manifesting in hyperpigmentation, vascular lesions and wrinkles (Figures 1 and 2).

She was treated with the Nordlys SWT using a 555nm filter and a double-pulse technique with 4.5ms pulse duration, 10ms delay, and a fluence of 12J/cm2. Immediately post SWT session, the patient was also treated by Frax 1550 (three passes, 40mJ, 25%). No topical anaesthetic cream was applied.

One month after the first session, a second combined treatment was performed, using the same sources and parameters.

She was examined 30 days after the second treatment: clinical improvement was clearly demonstrated and the patient was very satisfied (Figure 3 and 4).

Case 2
A 57-year-old Caucasian female, presented with severe photoageing, revealing intense hyperpigmentation, skin irregularities and wrinkles (Figure 5).

She underwent two sessions, one month apart, each using the Nordlys SWT (555nm filter, double-pulse technique with 4.5ms pulse duration, 10ms delay, and a fluence of 12J/cm2) combined with Frax 1550nm (three passes, 40mJ, 25%) at the same time. No topical anaesthetic cream was applied.

Thirty days after the last combined session skin quality had significantly improved and hyperpigmentation had almost disappeared (Figure 6), revealing a brighter, smoother-looking skin. The patient is in follow-up care, using daily topical treatment.

Conclusion
Non-ablative fractionated laser facial resurfacing treatments are increasingly preferred to treat skin ageing. With this approach, selective dermal insult is caused by infrared light, leading to the production of new collagen, while the overlying epidermis remains intact.

In the clinical cases presented above, both patients were treated using the Light and Bright protocol. Combined treatments with SWT (555nm or 530nm filters) and Frax 1550, both available on the Nordlys platform, can lead to impressive results on all components of skin ageing, with reduced downtime and a lower incidence of complications.

References

1. Bjerring P, Christiansen K, Troilius A, Dierickx C. Facial photo rejuvenation using two different intense pulsed light (IPL) wavelength bands. Lasers Surg Med 2004;34:120-6.
2. Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a nonablative approach to photoaging. Dermatol Surg 2005;31(9 Pt 2):1179-87.
3. Tidwell WJ, Green C, Jensen D, Ross EV. Clinical evaluation and in-vivo analysis of the performance of a fractional infrared 1550 nm laser system for skin rejuvenation. J Cosmet Laser Ther 2018;24:1-4.
4. Lee YJ, Chung JY, Lee JH, et al. Clinical benefit of combination treatment with 1550 nm fractional laser and a new wavelength at 1927 nm on photorejuvenation in Asian patients. Med Laser 2014;3(1):11-6.

Declaration of competing interests: The author has worked with Candela Italy as a Key Opinion Leader on Nordlys, Velashape and PicoWay since 2019. She is also managing one of the Candela Centers of Excellence in Italy.

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Early treatment of scars with laser therapy

March 31st

Wound healing is a complex process, made up of three phases that overlap with each other: inflammation, proliferation and remodelling [1]. The last phase is the remodelling of the extracellular matrix resulting in a mature scar; it lasts from three weeks up to one year [2].

Any disturbance in these phases results in a variety of outcomes, including hypertrophic, keloid or atrophic scarring, pigmentation disturbances and aesthetic concerns [3]. There are numerous treatment options, such as intralesional corticosteroids, topical creams, ointments, patches, cryotherapy, surgery, pressure therapy, and lasers, among others [1]. Laser therapy has great potential to become one of the most important and available treatments for wound healing abnormalities. A laser can produce three types of reaction: photothermal, photochemical or photomechanical. When treating scarring, the photothermal effect is the main interaction [4].

The indications for laser therapy are based on clinical presentation of the scar regarding: erythema, hypo / hyperpigmentation, atrophy / hypertrophy, epithelization, pliability, restriction together with pain and pruritus [2]. Erythema is normal in the first weeks of wound healing but should progressively start to resolve. The three major mechanisms that contribute to erythema in scars are: inflammation, vascularisation and epidermal defects [5].

It has been shown that erythematous scars are more often associated with pain and pruritus, due to the inflammatory stimulation. Due to all of the above, erythema is a highly targeted aspect when treating scars. Lasers, especially vascular devices, are one of the most widely used methods to treat erythema. Laser therapy decreases the redness and controls symptoms like pruritus and pain, and, even after months or years, can manage hypertrophy [4,5].

Vascular lasers emit wavelengths that are absorbed by oxyhaemoglobin and were one of the first types of lasers used to treat scars. The Vbeam® is a flash-lamp excited pulsed dye laser that delivers laser pulses at a wavelength of 595 nanometers, causing coagulation in the targeted vessels. The optimal endpoint is with purpura and darkening of the treated area.

Case report
A 36-year-old female patient with Fitzpatrick Skin Type III, presented after a serious car crash with consequent avulsion of a significant area of facial skin, predominantly on her forehead. As the patient lived some distance from the clinic, she only received two sessions with the Vbeam system over her remaining scar, which was predominantly erythematous, but with a great cosmetic effect on the patient. The sessions took place eight weeks apart. Both treatments were performed with the following laser parameters: 7mm, 8J/cm2, 1.5msec. Post-laser recommendations included repairing creams containing zinc oxide and SPF in the morning. She was also advised to stay away from direct sunlight. She had not received previous treatments. Even though only two sessions were performed, and with a greater lapse between sessions than usual, a significant decrease in erythema was achieved, and the patient was greatly satisfied with the results.

Conclusion
Multiple treatments have been studied and approved for the treatment of scars, including laser therapy. The indications for which type of laser to use are based on erythema, hypo / hyperpigmentation, atrophy / hypertrophy, epithelization, pliability and restriction; also, on symptoms reported by the patient such as pain and pruritus. Symptomatic scars have been widely associated with erythema.

Erythema is a normal finding in the early wound healing process, and it is an indirect marker of vascularity, making it a perfect target for vascular lasers.

Candela’s flashlamp-excited pulsed dye laser, Vbeam, delivers laser pulses at a wavelength of 595 nanometers. It exerts a phototermal effect over oxyhaemoglobin in the blood vessels, causing coagulation in the targeted vessels. It has a very effective impact on erythematous, and even hypertrophic scars, decreasing redness and visibility of the scars.

We have noticed an important factor in end results when treating with the Vbeam system, which is the early application of the treatment. When used from the inflammatory stage, the number of sessions is reduced, and the results are most noticeable. Patient expectations are better met. We greatly encourage this type of treatment to be started as soon as possible.

The device’s specifications were determined based on the patient’s skin type, type of scar and pain threshold. More studies are required to clarify which specific molecules in atrophic scars are targeted by these lasers, in order to produce a ‘filling effect’ and skin levelling.

Laser therapy is a great alternative for scar treatment, and has significant potential to become a first-line treatment for wound healing abnormalities.

References

1. Al-Mohamady Ael-S, Ibrahim SM, Muhammad MM. Pulsed dye laser versus long pulsed Nd:YAG laser in the treatment of hypertrophic scars and keloid: a comparative randomized splitscar trial. J Cosmet Laser Ther 2016;18(4):208-12.
2. Seago M, Shumaker PR, Spring LK, et al. Laser treatment of traumatic scars and contractures: 2020 International Consensus Recommendations. LasersSurg Med 2020;52(2):96-116.
3. Khetarpal S, Dover JS, Arndt K. Surgical Scars. In: Alam M (Ed.). Evidence-Based Procedural Dermatology Switzerland; Springer Nature; 2019.
4. Khatri KA, Mahoney DL, McCartney MJ. Laser scar revision: a review. J Cosmet Laser Ther 2011;13(2):54-62.
5. Yang Y, Wu X, Liu W. (2020). Scar symptom: erythema and thickness. In: Téot L, Mustoe TA, Middelkoop E, Gauglitz GG. Textbook on Scar Management Switzerland; Springer Nature; 2020:103-8.

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Use of the Novel Frax 1940 Non-Ablative Fractional Laser Handpiece in Clinical Practice

April 21st
PATIENTS DESIRE TREATMENTS FOR THE SKIN TO IMPROVE A range of vascular, pigmentary, and textural irregularities that produce an overall rejuvenated appearance with minimal time away from their normal activities. Laser-based devices, specifically non-ablative lasers in the mid-infrared (IR) spectrum, that are selectively absorbed in water are capable of delivering heat sufficient to coagulate and resurface skin in the epidermal and dermal layers of the skin by stimulating collagen production1. Nonablative fractional lasers deliver energy to the skin in arrays that create microscopic treatment zones (MTZ’s) of treated skin with micro-epidermal necrotic debris (MENDS) located at the margins of the MTZ’s. Zones of healthy tissue between these areas contribute to the more rapid wound-healing response and the epidermal stratum corneum is preserved as compared to ablative therapies or full-beam laser treatments2–3. The 1940 nm wavelength is highly absorbed in water and can create focal damage to approximately 200 microns in depth. The peak absorption of water in this region is at 1935 nm. As such, the 1940 wavelength is a useful tool for treating the more superficial layers of the skin, including treating abnormalities in the epidermis and superficial dermis. It can be used independently and also in combination with the 1550 nm wavelength to create a layered approach to treatment. The 1550 nm wavelength penetrates more deeply to at least 800 microns and is also less highly absorbed in water, creating a different pattern of thermal coagulation than the 1940 nm wavelength. The 1550 nm wavelength remodels skin on a deeper level and can be used for treating deeper tissue or scarring. The 1940 nm wavelength is a useful tool for resurfacing the superficial layers to yield clinical improvements in overall texture and pigmentation and also an improved appearance of fine, smooth skin. Other combination treatments can include treatment of redness with VBeam 595 nm pulsed dye laser or IPL, such as the PR 530 or VL 555 handpieces.Additionally, the treatment of blue vessels with the NdYag wavelength can also be used as required for an overall rejuvenation treatment approach. The Handpiece The Frax 1940 handpiece is equipped with a replaceable roller tip and motion sensor, which allows control of the rate at which the laser delivers the MTZ arrays to the skin. Scan widths range from 4–12 mm and energy per MTZ and percent coverage are adjusted based upon the desired effect. For larger and more generalized resurfacing, the 10–12 mm scan width is preferred in multiple passes depending upon the skin type and skin condition to be treated. The Frax 1940 has the ability to digitally control the scan width without replacing the treatment tip. The scan width can be minimized to 4 mm, allowing for the treatment of epidermal skin abnormalities such as small, linear scars or benign epidermal pigmented lesions for which the clinician may wish to spare the surrounding tissue. The laser only operates in motion, providing a safeguard to overlapping energy deposition. Integrated air cooling improves patient comfort. Treatments Patients well-suited to treatment with the Frax 1940 handpiece are those who desire improvement of overall tone and texture due to photoaging. The face, decollete and hands area ideally suitable locations for treatment. The wavelength is also being studied for its use in the treatment of pigmented lesions and is also being shown to have an effect on the treatment of hyperpigmented skin. As with any laser treatment, protection from the sun, both pre- and post-treatment is important. There should be no active infection or irritation of the skin in the area being treated and there should be no significant medical abnormality that would impair wound healing. Prior to treatment, a topical anaesthetic is typically applied (lidocaine 23%/tetracaine 7%) for 30 minutes under occlusion and then completely removed. The skin is thoroughly cleaned and dried prior to treatment. Initial parameters for full area treatment of the face in skin types I–III generally begin with 3–4 passes at scan width of 10–12 mm, 14–18 MJ per MTZ and densities of 35–45%. Scan width is then reduced to 4 mm to treat individual lesions with 2–3 additional passes using increased densities up to 50%. Treatments off the face may require fewer passes or decreased fractional coverage. In darker skin types, the fractional coverage and number of passes are reduced to 20% or below and 2–4 passes, respectively. Treatments are performed monthly at approximately 4-week intervals for a total of 3 sessions. Post-treatment patients will experience erythema, oedema and possibly crusting depending upon the number of passes and density of treatment. In general, 2–3 days of redness and downtime are visible for mild to moderate treatments with an increasing number of days for more intensive, multipass, higher energy and higher density treatments. Post care involves strict sun protection and ample barrier moisturization. The Frax 1940 treatment provides a high degree of patient satisfaction when performed alone. It can also be performed in combination with the Frax 1550 and/or intense pulsed light (IPL) to further treat pigment, redness or for coagulation of tissue at increased depths.
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Treatment of pigmentation and melasma

April 21st
Uneven tone and pigmentation disorders are frequent problems that motivate patients to seek help. The gold standard for treating the majority of these hyperpigmentation changes is the use of a picosecond laser, as the effect is predominantly photomechanical and photochemical, thus we can achieve optimal results with almost no downtime and side effects. Medical Management The first step, as with any other medical condition, is to diagnose properly the pigmentation disorder presented by the patient. Dermoscopy and standardized photos with UV analysis should be performed. The most common diagnosis cover senile and solar lentigos, ephelides and melasma. On patients with diffuse patterns of pigmentation, the skin should be preconditioned for at least 3 weeks with soft depigmentation agents (e.g. kojic acid 4% 2id), chemoexfoliant actives (e.g. AHA 10%) and sunscreen. In the case of melasma, the patient education and medical care is the cornerstone of the treatment. Beside the behavioral intervention, a full topical regimen should be prescribed, and the laser treatment should only be initiated after 4-8 weeks of patient compliance. This regimen comprehends photoprotection (UVA/UVB/IR/HEV) and depigmentation, antioxidant, anti-inflammatory and chemoexfoliating agents and tranexamic acid. One should consider adding oral tranexamic acid and P. Leucotomos when suitable. Isolated pigmented lesions For lentigos, our way to go is the new 730nm Picoway handpiece. The precise balance of the PicoWay 730 nm handpiece efficiently targets pigment while minimizing risk of hypo- or hyperpigmentation and impact on surrounding tissues 1,2 The handpiece has the shortest pulse duration – only 250 picoseconds* - to reduce thermal impact and boost photoacoustic effect3. After thoroughly cleansing the area to be treated, we use the 4mm spot, with fluences ranging between 0.8-1.0J/cm2, covering all lesions. The endpoint is the darkening of the lesion and a perilesional erythema. Sometimes one may have a slight frosting effect, but it is not mandatory. For a complete clearance of the lentigo, 1-2 sessions, minimum 4 weeks apart are needed. As aftercare, we recommend topical hydrocortisone 3id for 5 days and sunscreen. The usual evolution is the lesion fading in 10-14 days. Diffuse pigmentation For diffuse pigmentation, we start treating the bigger lesions as we’ve described before. Afterwards, we use the 532nm Resolve Fusion fractional handpiece to cover all the area, doing 2 passes crosshatch. This handpiece is a proven picosecond know-how that builds new collagen and elastin4-6 - now integrates blended light technology, reaching more skin surface area. And, with a short pulse duration (375 ps) creates more photoacoustic and less thermal effect.3 The usual energy setup is 0.35-0.50mj/px at 7Hz, needing about 3500-4000 shots to cover the whole face. After the laser treatment, we apply a soothing mask to improve patient comfort. The aftercare is similar as described before. The typical post procedure is a mild redness that lasts up to 5 days. The pigmented lesions will darken, form a very thin crust and scab after about 7 days. For a complete treatment, 2-3 sessions are needed, at a minimum interval of 4 weeks. Melasma Laser therapy is an important adjunctive resource to deal with dermal pigmentation deposits and vascular component and to perform laser drug delivery. The first step is to control the vascular component, using Vbeam Prima at 595nm (15mm, 4.00-4.50J/cm2, 3ms, DCD 30/20). After, we perform a melanocyte dendridectomy, using the Picoway Zoom handpiece, 8mm spotsize, 0.60-0.75J/cm2, doing two general passes and an extra double pass on the pigmented area. Then, we target again the melanosome and perform a fibroblast stimulation using the 1064 Resolve handpiece, with energy 1.3-1.5mj/px, full face double pass with an extra double pass on the pigmented areas. This also increases the skin permeability, allowing to perform laser drug delivery with tranexamic acid. The typical post is a mild erythema lasting up to 48h. As aftercare, we recommend topical hydrocortisone 3id for 5 days and sunscreen. The number of sessions is variable from patient, but the average is 4. The recommended minimum interval between them is 4 weeks. Conclusions The Picoway and its picosecond technology is the front end for treating pigmentation disorders efficiently. The use of holographic fractionated handpieces expands the traditional use of these types of lasers, with its regenerative (and, thus, rejuvenation) capabilities. References *Based on published manufacturer specifications at the date of publication. Candela - data on file, 2020 1. Artzi O et al. Lasers Med Sci. 2018;33(4):693-697. 2. Serup J, Bäumler W (eds): Diagnosis and Therapy of Tattoo Complications. With Atlas of Illustrative Cases. Curr Probl Dermatol. Basel, Karger, 2017, vol 52, pp 113 -123 (DOI: 10.1159/000450812). 3. Kung KY, Shek SY, Yeung CK, Chan HH. Lasers Surg Med. 2019 Jan;51(1):14-22. doi: 10.1002/lsm.23028. Epub 2018 Oct 25 4. Brauer JA, Kazlouskaya V, Alabdulrazzaq H, et al. Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring. JAMA Dermatol. 2015;151(3):278-284. 5. Tanghetti EA, Tartar DM. Comparison of the cutaneous thermal signatures over twenty-four hours with a picosecond alexandrite laser using a flat or fractional optic. J Drugs Dermatol. 2016;15(11):1347-1352. 6. Tanghetti EA. The histology of skin treated with a picosecond alexandrite laser and a fractional lens array. Lasers Surg Med. 2016. Sep;48(7):646-52. doi: 10.1002/lsm.22540. Epub 2016 Jun 1.
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Novel picosecond handpieces for the treatment of pigmentation

April 21st
Introduction: Pigmentary disorders are common with several treatment modalities available ranging from topical therapy to chemical peels and lasers. The advent of ultrashort pulsed picosecond lasers (PSL) transformed the way tattoos and benign pigmented lesions are treated. Unlike long-pulsed lasers (milli to microsecond domain) and Q-switched lasers (nano second domain), the PSL deliver very short pulse durations in one trillionth of a second ( range) giving a predominantly photomechanical effect rather than a photothermal one. This in turn has increased safety on the tissue with less complications, particularly in the higher skin types1. Several PSL exist with different pulse durations and wavelengths. In this article I will explain the way I use two new handpieces of the Candela PSL called Picoway™. The Picoway™ system is a PSL with a total of 6 handpieces spanning across 4 wavelengths (532, 730, 785 and 1064 nm). The non-fractional handpieces are called zoom (532 and 1064nm) or full beam (730 an 785nm), the fractional handpieces called Resolve (532 and 1064nm), and the newer Resolve Fusion handpiece (532nm) merges in one pass one the benefits of fractional and full beam treatments. There are 2 new handpieces for which I was the first doctor in Europe to work on; namely the unique 730 nm titanium sapphire generated wavelength and the 532 Resolve Fusion fractional handpiece. Below are 2 cases detailing how I integrate these handpieces in the treatment of pigmentation. Cases report: In the first case I have a 53-year old woman with skin type 3 and photodamage with benign lentigines and freckles on the face. The novel 730 nm handpiece was used first as a spot treatment for the individual benign lesions. The spot size of 4 mm was used with a fluence of around 1 J/cm2 adjusted down to the use of 2 mm between 2.6 and 3 J/cm2 depending on the achievement of the clinical endpoint which is light whitening of the lesions preserving the surrounding tissue. In the light-coloured lesions an additional pass was performed. Subsequently, the 532 nm Resolve Fusion handpiece was used with a fluence of 0.5 mJ in 2 passes over the entire face with erythema as a clinical endpoint. Post care moisturizer and sunblock were advised. Marked improvement in the pigmentation was noted during her second visit in 4 weeks follow-up (figure 1). In the second case a 45-year old Chinese woman with skin type 4 presented with discrete lentigines on the zygomatic area of her right cheek which she was keen to get rid of. The 730 nm handpiece was used with both the 2 and 3 mm spot with fluences ranging between 1.6 to 2.6 J/cm2 until the desired endpoint of mild whitening was achieved. A potent topical corticosteroid cream was prescribed to use twice daily for 3 days together with meticulous sun protection. Clearance of the lesions was achieved with no adverse effects (figure 2). Conclusion: The treatment of benign pigmented lesion with lasers require the selection of the right wavelength and parameters to ensure a high clinical clearance with low complications, particularly in higher skin types. The novel 730 nm wavelength is unique in that it is highly absorbed by melanin (more than both 755 and 785 nm) with very low haemoglobin (less than both 755 and 785 nm) absorption. It also has the shortest pulse duration of any PSL wavelength available at 250 ps2. This is important as it is shorter than the stress relaxation time of the melanosomes leading to a predominantly photoacoustic method of pigment clearance with little collateral damage. The 532 nm Resolve Fusion provides an array of microbeams which combines a high fluence central beam with a low fluence peripheral rim allowing for greater coverage per pass with less impact in the central beam leading to less side-effects such as petechiae in higher skin types3. This fractionated beam gives a distinct microscopic injury termed light-induced optical breakdown with cell-signalling for rejuvenation and a mechanical destruction of melanosomes leading to enhanced clearance of diffuse pigmentation with little downtime. References: 1. Wu DC, Goldman MP, Wat H, Chan HHL. A Systematic Review of Picosecond Laser in Dermatology: Evidence and Recommendations. Lasers Surg Med. 2020 Apr 13. doi: 10.1002/lsm.23244. Epub ahead of print. PMID: 32282094. 2. Lipp MB, Angra K, Wu DC. Safety and Efficacy of a Novel 730?nm Picosecond Titanium Sapphire Laser for the Treatment of Benign Pigmented Lesions. Lasers Surg Med. 2020 Sep 1. doi: 10.1002/lsm.23314. Epub ahead of print. PMID: 32869883. 3. Miyata N. Picoway clinical insights: innovative picosecond laser with 4 wavelengths. Candela corporate white paper 2020.
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