Dermatologic Laser Therapy Advances on Many Fronts

PRAGUE – It has been a big year for dermatologic laser therapy.

Among the major advances in the field seen during 2012 has been introduction of novel techniques for remodeling mature burn scars and removing tattoos, as well as welcome, albeit preliminary, data supporting laser therapy of onychomycosis, and – finally – some long-overdue first persuasive evidence of the effectiveness of a home-use, light-based device for unwanted hair removal, Dr. Merete Haedersdal said in a keynote year-in-review laser lecture at the annual congress of the European Academy of Dermatology and Venereology.

• Tattoos. Based upon the concept of selective photothermolysis coupled with recognition that tattoo pigment particles are really tiny – a mere 40-300 nm in size – dermatologists at SkinCare Physicians in Chestnut Hill (Mass.) treated 12 patients using a novel picosecond 755-nm alexandrite laser.

After an average of 4.2 treatment sessions spaced roughly 6 weeks apart, all 12 patients showed greater than 75% clearance upon blinded physician assessment. All 12 declared themselves either satisfied or extremely satisfied with their results (Arch. Dermatol. 2012;17:1-4).

This picosecond alexandrite laser delivers pulses 100 times shorter than the familiar nanosecond lasers. It’s not yet commercially available, but is expected to be quite soon, according to Dr. Haedersdal of the University of Copenhagen.

Meanwhile, Greek dermatologists have pioneered a laser technique for tattoo removal that entails four treatment passes separated by 20-minute intervals, all delivered in a single lengthy session. The underlying concept is that the downtime between passes allows the treated skin to relax and shed treatment-induced air bubbles. In an 18-patient study, the clinical results were demonstrably better with the four-pass technique than with conventional single-treatment sessions (J. Am. Acad. Dermatol. 2012;66:271-7).

Dr. Haedersdal said that she’s heard some colleagues who’ve tried the four-pass-in-a-session technique say they’re not convinced it really does work better than the standard approach. She has tweaked the technique somewhat to good effect in her own practice: She starts out removing a tattoo using the standard single-treatment-per-session method and sticks with it until there is no further improvement. Then she switches to the four-pass-per-session technique.

"I would say it works very nicely when we add it on," the dermatologist commented.

• Home-use hair-removal device effectiveness. The home-device market has been on fire in the United States for more than 5 years and in Europe for the last couple. It is a field that’s been long on claims and short on evidence of meaningful efficacy and safety – until 2012. Just in September, Dr. Ronald G. Wheeland, professor of dermatology and chief of dermatologic surgery at the University of Missouri, Columbia, published a case-controlled study that Dr. Haedersdal considers most welcome.

Thirteen patients underwent eight hair removal treatment sessions at monthly intervals using an 810-nm home-use diode laser marketed as the Tria Hair Removal Laser. Untreated areas of unwanted hair growth served as controls. At 1 year of follow-up after completing the eighth and final treatment, the mean hair count reduction was 44%, 49%, and 65%, respectively, in areas treated at fluences of 7, 12, and 20 J/cm² compared with controls (Lasers Surg. Med. 2012;44:550-7).

In addition, Dr. Haedersdal coauthored a systematic literature review of the two approved diode laser devices and nine intense pulsed light devices marketed for home use for hair removal. The cumulative supporting evidence isn’t super strong: six prospective uncontrolled studies and one controlled study (J. Eur. Acad. Dermatol. Venereol. 2012;26:545-53).

"Clearly, there is something to this home therapy based on the Wheeland study and our systematic review. We really need some randomized comparative trials, though," she said.

• Home-device safety. This is an area of such great concern that she and her colleagues in the European Society for Laser Dermatology recently published hair-removal home-device safety guidelines (J. Eur. Acad. Dermatol. Venereol. 2012;26: 799-811).

"People just aren’t being trained in the safe use of these devices," she cautioned.

The risks associated with improper use include ocular injury, skin burns, and paradoxical hair growth, as is the case with devices used in physicians’ offices.

The paradoxical hair growth risk in untreated areas close by treated skin is an issue that has been largely beneath dermatologists’ radar prior to the European guidelines. The reported risk with professional devices used by dermatologists is 0.6%-10%. With home devices, who knows?

"It’s a real matter of concern these days. When you lower the fluences, the incidence of paradoxical hair growth may be even higher. There’s nothing in the literature yet, but I’m sure there will be in the next few years," Dr. Haedersdal said.

Patients at increased risk for paradoxical hair regrowth are women with darker skin types, typically with polycystic ovarian syndrome, who are undergoing facial treatment. The mechanism of paradoxical hair regrowth is unknown. Two leading possibilities are light-driven triggering of inflammatory mediators or stimulation of the hair cycle secondary to subtherapeutic thermal injury, she continued.

• Burn scars. A solid body of evidence has accrued regarding the efficacy and safety of both ablative and nonablative fractional lasers to remodel mature burn scars.

Particularly noteworthy was a recent prospective, single-arm, blinded-evaluator study in which a 1,550-nm nonablative fractional erbium laser was employed to treat burn scars in 10 patients. Ninety percent of patients showed improved skin texture and 80% demonstrated improvement in dyschromia, something that hasn’t previously been reported with laser therapy (Lasers Surg. Med. 2012;44:441-6).

The 13 published studies of nonablative fractional laser therapy for burn scars show 26%-50% improvement. That’s slightly less than the 26%-83% improvement reported in the 13 studies of ablative fractional lasers. On the other hand, nonablative fractional laser therapy entails fewer side effects: 1-3 days of erythema and a postinflammatory hyperpigmentation rate of up to 13%, compared with 3-14 days of erythema with ablative fractional laser therapy and a postinflammatory hyperpigmentation rate of up to 92%. As yet, though, there have been no head-to-head comparative studies of the two types of devices.

• Onychomycosis. This is a brand-new area for laser therapy. A recent review noted that, while the Food and Drug Administration has approved four YAG lasers for treatment of onychomycosis, the regulatory standards for device approval don’t require persuasive evidence of efficacy, unlike for drugs (J. Am. Podiatr. Med. Assoc. 2012;102:428-30). Although it’s a promising technology, the authors stated that there are as yet no data showing how laser therapy stacks up against existing standard treatments for onychomycosis in terms of efficacy.

Nevertheless, Dr. Haedersdal noted, attention-getting cure rates were seen in a recent Chinese study involving 154 laser-treated nails in 33 patients. The week-24 complete cure rate, both mycologic and clinical, was 51% after eight weekly treatments and 53% after four weekly treatments (Chin. Med. J. 2012;125:3288-91).

Dr. Haedersdal reported serving on the scientific advisory boards for Galderma, LEO Pharma, and Procter & Gamble.

PRAGUE – It has been a big year for dermatologic laser therapy.

Among the major advances in the field seen during 2012 has been introduction of novel techniques for remodeling mature burn scars and removing tattoos, as well as welcome, albeit preliminary, data supporting laser therapy of onychomycosis, and – finally – some long-overdue first persuasive evidence of the effectiveness of a home-use, light-based device for unwanted hair removal, Dr. Merete Haedersdal said in a keynote year-in-review laser lecture at the annual congress of the European Academy of Dermatology and Venereology.

• Tattoos. Based upon the concept of selective photothermolysis coupled with recognition that tattoo pigment particles are really tiny – a mere 40-300 nm in size – dermatologists at SkinCare Physicians in Chestnut Hill (Mass.) treated 12 patients using a novel picosecond 755-nm alexandrite laser.

After an average of 4.2 treatment sessions spaced roughly 6 weeks apart, all 12 patients showed greater than 75% clearance upon blinded physician assessment. All 12 declared themselves either satisfied or extremely satisfied with their results (Arch. Dermatol. 2012;17:1-4).

This picosecond alexandrite laser delivers pulses 100 times shorter than the familiar nanosecond lasers. It’s not yet commercially available, but is expected to be quite soon, according to Dr. Haedersdal of the University of Copenhagen.

Meanwhile, Greek dermatologists have pioneered a laser technique for tattoo removal that entails four treatment passes separated by 20-minute intervals, all delivered in a single lengthy session. The underlying concept is that the downtime between passes allows the treated skin to relax and shed treatment-induced air bubbles. In an 18-patient study, the clinical results were demonstrably better with the four-pass technique than with conventional single-treatment sessions (J. Am. Acad. Dermatol. 2012;66:271-7).

Dr. Haedersdal said that she’s heard some colleagues who’ve tried the four-pass-in-a-session technique say they’re not convinced it really does work better than the standard approach. She has tweaked the technique somewhat to good effect in her own practice: She starts out removing a tattoo using the standard single-treatment-per-session method and sticks with it until there is no further improvement. Then she switches to the four-pass-per-session technique.

"I would say it works very nicely when we add it on," the dermatologist commented.

• Home-use hair-removal device effectiveness. The home-device market has been on fire in the United States for more than 5 years and in Europe for the last couple. It is a field that’s been long on claims and short on evidence of meaningful efficacy and safety – until 2012. Just in September, Dr. Ronald G. Wheeland, professor of dermatology and chief of dermatologic surgery at the University of Missouri, Columbia, published a case-controlled study that Dr. Haedersdal considers most welcome.

Thirteen patients underwent eight hair removal treatment sessions at monthly intervals using an 810-nm home-use diode laser marketed as the Tria Hair Removal Laser. Untreated areas of unwanted hair growth served as controls. At 1 year of follow-up after completing the eighth and final treatment, the mean hair count reduction was 44%, 49%, and 65%, respectively, in areas treated at fluences of 7, 12, and 20 J/cm² compared with controls (Lasers Surg. Med. 2012;44:550-7).

In addition, Dr. Haedersdal coauthored a systematic literature review of the two approved diode laser devices and nine intense pulsed light devices marketed for home use for hair removal. The cumulative supporting evidence isn’t super strong: six prospective uncontrolled studies and one controlled study (J. Eur. Acad. Dermatol. Venereol. 2012;26:545-53).

"Clearly, there is something to this home therapy based on the Wheeland study and our systematic review. We really need some randomized comparative trials, though," she said.

• Home-device safety. This is an area of such great concern that she and her colleagues in the European Society for Laser Dermatology recently published hair-removal home-device safety guidelines (J. Eur. Acad. Dermatol. Venereol. 2012;26: 799-811).

"People just aren’t being trained in the safe use of these devices," she cautioned.

The risks associated with improper use include ocular injury, skin burns, and paradoxical hair growth, as is the case with devices used in physicians’ offices.

The paradoxical hair growth risk in untreated areas close by treated skin is an issue that has been largely beneath dermatologists’ radar prior to the European guidelines. The reported risk with professional devices used by dermatologists is 0.6%-10%. With home devices, who knows?

"It’s a real matter of concern these days. When you lower the fluences, the incidence of paradoxical hair growth may be even higher. There’s nothing in the literature yet, but I’m sure there will be in the next few years," Dr. Haedersdal said.

Patients at increased risk for paradoxical hair regrowth are women with darker skin types, typically with polycystic ovarian syndrome, who are undergoing facial treatment. The mechanism of paradoxical hair regrowth is unknown. Two leading possibilities are light-driven triggering of inflammatory mediators or stimulation of the hair cycle secondary to subtherapeutic thermal injury, she continued.

• Burn scars. A solid body of evidence has accrued regarding the efficacy and safety of both ablative and nonablative fractional lasers to remodel mature burn scars.

Particularly noteworthy was a recent prospective, single-arm, blinded-evaluator study in which a 1,550-nm nonablative fractional erbium laser was employed to treat burn scars in 10 patients. Ninety percent of patients showed improved skin texture and 80% demonstrated improvement in dyschromia, something that hasn’t previously been reported with laser therapy (Lasers Surg. Med. 2012;44:441-6).

The 13 published studies of nonablative fractional laser therapy for burn scars show 26%-50% improvement. That’s slightly less than the 26%-83% improvement reported in the 13 studies of ablative fractional lasers. On the other hand, nonablative fractional laser therapy entails fewer side effects: 1-3 days of erythema and a postinflammatory hyperpigmentation rate of up to 13%, compared with 3-14 days of erythema with ablative fractional laser therapy and a postinflammatory hyperpigmentation rate of up to 92%. As yet, though, there have been no head-to-head comparative studies of the two types of devices.

• Onychomycosis. This is a brand-new area for laser therapy. A recent review noted that, while the Food and Drug Administration has approved four YAG lasers for treatment of onychomycosis, the regulatory standards for device approval don’t require persuasive evidence of efficacy, unlike for drugs (J. Am. Podiatr. Med. Assoc. 2012;102:428-30). Although it’s a promising technology, the authors stated that there are as yet no data showing how laser therapy stacks up against existing standard treatments for onychomycosis in terms of efficacy.

Nevertheless, Dr. Haedersdal noted, attention-getting cure rates were seen in a recent Chinese study involving 154 laser-treated nails in 33 patients. The week-24 complete cure rate, both mycologic and clinical, was 51% after eight weekly treatments and 53% after four weekly treatments (Chin. Med. J. 2012;125:3288-91).

Dr. Haedersdal reported serving on the scientific advisory boards for Galderma, LEO Pharma, and Procter & Gamble.

PRAGUE – It has been a big year for dermatologic laser therapy.

Among the major advances in the field seen during 2012 has been introduction of novel techniques for remodeling mature burn scars and removing tattoos, as well as welcome, albeit preliminary, data supporting laser therapy of onychomycosis, and – finally – some long-overdue first persuasive evidence of the effectiveness of a home-use, light-based device for unwanted hair removal, Dr. Merete Haedersdal said in a keynote year-in-review laser lecture at the annual congress of the European Academy of Dermatology and Venereology.

• Tattoos. Based upon the concept of selective photothermolysis coupled with recognition that tattoo pigment particles are really tiny – a mere 40-300 nm in size – dermatologists at SkinCare Physicians in Chestnut Hill (Mass.) treated 12 patients using a novel picosecond 755-nm alexandrite laser.

After an average of 4.2 treatment sessions spaced roughly 6 weeks apart, all 12 patients showed greater than 75% clearance upon blinded physician assessment. All 12 declared themselves either satisfied or extremely satisfied with their results (Arch. Dermatol. 2012;17:1-4).

This picosecond alexandrite laser delivers pulses 100 times shorter than the familiar nanosecond lasers. It’s not yet commercially available, but is expected to be quite soon, according to Dr. Haedersdal of the University of Copenhagen.

Meanwhile, Greek dermatologists have pioneered a laser technique for tattoo removal that entails four treatment passes separated by 20-minute intervals, all delivered in a single lengthy session. The underlying concept is that the downtime between passes allows the treated skin to relax and shed treatment-induced air bubbles. In an 18-patient study, the clinical results were demonstrably better with the four-pass technique than with conventional single-treatment sessions (J. Am. Acad. Dermatol. 2012;66:271-7).

Dr. Haedersdal said that she’s heard some colleagues who’ve tried the four-pass-in-a-session technique say they’re not convinced it really does work better than the standard approach. She has tweaked the technique somewhat to good effect in her own practice: She starts out removing a tattoo using the standard single-treatment-per-session method and sticks with it until there is no further improvement. Then she switches to the four-pass-per-session technique.

"I would say it works very nicely when we add it on," the dermatologist commented.

• Home-use hair-removal device effectiveness. The home-device market has been on fire in the United States for more than 5 years and in Europe for the last couple. It is a field that’s been long on claims and short on evidence of meaningful efficacy and safety – until 2012. Just in September, Dr. Ronald G. Wheeland, professor of dermatology and chief of dermatologic surgery at the University of Missouri, Columbia, published a case-controlled study that Dr. Haedersdal considers most welcome.

Thirteen patients underwent eight hair removal treatment sessions at monthly intervals using an 810-nm home-use diode laser marketed as the Tria Hair Removal Laser. Untreated areas of unwanted hair growth served as controls. At 1 year of follow-up after completing the eighth and final treatment, the mean hair count reduction was 44%, 49%, and 65%, respectively, in areas treated at fluences of 7, 12, and 20 J/cm² compared with controls (Lasers Surg. Med. 2012;44:550-7).

In addition, Dr. Haedersdal coauthored a systematic literature review of the two approved diode laser devices and nine intense pulsed light devices marketed for home use for hair removal. The cumulative supporting evidence isn’t super strong: six prospective uncontrolled studies and one controlled study (J. Eur. Acad. Dermatol. Venereol. 2012;26:545-53).

"Clearly, there is something to this home therapy based on the Wheeland study and our systematic review. We really need some randomized comparative trials, though," she said.

• Home-device safety. This is an area of such great concern that she and her colleagues in the European Society for Laser Dermatology recently published hair-removal home-device safety guidelines (J. Eur. Acad. Dermatol. Venereol. 2012;26: 799-811).

"People just aren’t being trained in the safe use of these devices," she cautioned.

The risks associated with improper use include ocular injury, skin burns, and paradoxical hair growth, as is the case with devices used in physicians’ offices.

The paradoxical hair growth risk in untreated areas close by treated skin is an issue that has been largely beneath dermatologists’ radar prior to the European guidelines. The reported risk with professional devices used by dermatologists is 0.6%-10%. With home devices, who knows?

"It’s a real matter of concern these days. When you lower the fluences, the incidence of paradoxical hair growth may be even higher. There’s nothing in the literature yet, but I’m sure there will be in the next few years," Dr. Haedersdal said.

Patients at increased risk for paradoxical hair regrowth are women with darker skin types, typically with polycystic ovarian syndrome, who are undergoing facial treatment. The mechanism of paradoxical hair regrowth is unknown. Two leading possibilities are light-driven triggering of inflammatory mediators or stimulation of the hair cycle secondary to subtherapeutic thermal injury, she continued.

• Burn scars. A solid body of evidence has accrued regarding the efficacy and safety of both ablative and nonablative fractional lasers to remodel mature burn scars.

Particularly noteworthy was a recent prospective, single-arm, blinded-evaluator study in which a 1,550-nm nonablative fractional erbium laser was employed to treat burn scars in 10 patients. Ninety percent of patients showed improved skin texture and 80% demonstrated improvement in dyschromia, something that hasn’t previously been reported with laser therapy (Lasers Surg. Med. 2012;44:441-6).

The 13 published studies of nonablative fractional laser therapy for burn scars show 26%-50% improvement. That’s slightly less than the 26%-83% improvement reported in the 13 studies of ablative fractional lasers. On the other hand, nonablative fractional laser therapy entails fewer side effects: 1-3 days of erythema and a postinflammatory hyperpigmentation rate of up to 13%, compared with 3-14 days of erythema with ablative fractional laser therapy and a postinflammatory hyperpigmentation rate of up to 92%. As yet, though, there have been no head-to-head comparative studies of the two types of devices.

• Onychomycosis. This is a brand-new area for laser therapy. A recent review noted that, while the Food and Drug Administration has approved four YAG lasers for treatment of onychomycosis, the regulatory standards for device approval don’t require persuasive evidence of efficacy, unlike for drugs (J. Am. Podiatr. Med. Assoc. 2012;102:428-30). Although it’s a promising technology, the authors stated that there are as yet no data showing how laser therapy stacks up against existing standard treatments for onychomycosis in terms of efficacy.

Nevertheless, Dr. Haedersdal noted, attention-getting cure rates were seen in a recent Chinese study involving 154 laser-treated nails in 33 patients. The week-24 complete cure rate, both mycologic and clinical, was 51% after eight weekly treatments and 53% after four weekly treatments (Chin. Med. J. 2012;125:3288-91).

Dr. Haedersdal reported serving on the scientific advisory boards for Galderma, LEO Pharma, and Procter & Gamble.