Emily P. Tierney

Review of fractional photothermolysis: treatment indications and efficacy.

BACKGROUND Fractional photothermolysis (FP) is one of the most significant milestones in laser technology and resurfacing. METHODS Review of the Medline English literature and recent international conferences regarding FP technology, applications, and indications. RESULTS Successful conditions treated with nonablative FP reported in the literature include acne scarring; dyschromia and fine wrinkling of photoaging on the face, chest, neck, and hands; melasma; poikiloderma of Civatte; nevus of Ota; scars; minocycline hyperpigmentation; telangiectatic matting; residual hemangioma; granuloma annulare; colloid milium; and disseminated superficial actinic porokeratosis. An advance in 2007 was the introduction of ablative FP (AFP), which results in significantly greater improvement in skin laxity and textural abnormalities. Most recently, AFP has demonstrated significantly greater improvement than nonablative FP in reducing acne scarring and skin redundancy and laxity associated with photoaging. CONCLUSIONS Through the induction of microthermal zones of injury, FP technology stimulates a robust and rapid wound healing response resulting in improvement in a diversity of aesthetic, inflammatory, and preneoplastic skin disorders. Further investigation into the technology and diverse array of cutaneous conditions that can benefit from FP is highly needed.

Treatment of Surgical Scars with Nonablative Fractional Laser Versus Pulsed Dye Laser: A Randomized Controlled Trial

OBJECTIVE Comparison of the efficacy of nonablative fractional laser (NAFL) and the V‐beam pulsed dye laser (PDL) for improvement of surgical scars. METHODS A randomized blinded split‐scar study. Fifteen scars in 12 patients were treated a minimum of 2 months after Mohs surgery. Patients were treated on half of the scar with a 1,550‐nm NAFL and on the contralateral half with the 595 nm PDL. MAIN OUTCOME MEASURE(S) A nontreating physician investigator evaluated the outcome of the scar in terms of scar dyspigmentation, thickness, texture, and overall cosmetic appearance (5‐point grading scale). RESULTS After a series of four treatments at 2‐week intervals, greater improvements were noted in the portion of surgical scars treated with NAFL (overall mean improvement 75.6%, range 60–100%, vs. PDL, 53.9%, range 20–80%; p<.001). CONCLUSION These data support the use of NAFL as a highly effective treatment modality for surgical scars, with greater improvement in scar appearance than with PDL. It is likely that the greater depth of penetration and focal microthermal zones of injury with NAFL, inducing neocollagenesis and collagenolysis, account for its greater improvement in scar remodeling. These encouraging results lead us to recommend that NAFL be added to the current treatment armamentarium for surgical scars. This project was supported by a grant from the Cosmetic Surgery Foundation.

Randomized Control Trial for the Treatment of Hidradenitis Suppurativa with a Neodymium‐Doped Yttrium Aluminium Garnet Laser

BACKGROUND Hidradenitis suppurativa (HS) is a chronic suppurative condition for which there is limited efficacy of medical and surgical treatments. OBJECTIVE To assess whether the 1,064‐nm neodymium‐doped yttrium aluminium garnet (Nd:YAG) laser is an effective treatment for HS. MATERIALS AND METHODS Prospective, randomized, controlled study for patients with stage II to III HS disease (n=22). A series of 3 monthly laser sessions were performed. Treatment response was measured before each laser session and 1 month after the completion of laser treatment (HS Lesion, Area, and Severity Index (HS‐LASI) scale). A modification was made to include symptoms (erythema, edema, pain, and purulent discharge; modified HS‐LASI, 0‐3 scale). RESULTS The percentage change in HS severity after 3 months of treatment was –65.3% over all anatomic sites, −73.4% inguinal, −62.0% axillary, and −53.1% inframammary. For all anatomic sites combined and each individual anatomic site, the change in HS severity from baseline to month 3 was statistically significant at the treated sites (p<.02 for modified HS‐LASI and HS‐LASI) but not at the control sites (p>.05 for modified HS‐LASI and HS‐LASI). CONCLUSIONS The long‐pulse Nd:YAG laser is effective for treatment of HS. The effectiveness of Nd:YAG laser, a hair epilation device, supports the primary follicular pathogenesis of the condition. The authors have indicated no significant interest with commercial supporters.

Fractionated CO2 laser skin rejuvenation

Fractional photothermolysis has been reported in the literature to improve both the pigmentary and textural changes associated with photoaging. The objective of the study was to review the literature of non‐ablative fractional laser (NAFL) and ablative fractional laser (AFL) resurfacing for the treatment of photoaging. This is a review of the Medline literature evaluating NAFL and AFL for photoaging. Review of the literature supports the use of NAFL and AFL as safe and effective treatments for photoaging. It is likely that the controlled, limited dermal heating of fractional resurfacing initiates a cascade of events in which normalization of the collagenesis/collagenolysis cycle occurs. The advent of fractionated resurfacing for the treatment of photoaging is a significant advance over ablative laser resurfacing treatments, which were complicated by prolonged erythema, delayed onset hypopigmentation, and scarring.

Fractionated Carbon Dioxide Laser Treatment of Photoaging: Prospective Study in 45 Patients and Review of the Literature

BACKGROUND Ablative fractional photothermolysis (AFP) has been reported to be effective for photoaging. OBJECTIVE To perform a clinical trial in 45 patients with moderate to severe skin photoaging to quantify improvement with AFP. MATERIALS AND METHODS A prospective, single‐blind study in 45 patients who presented for desired treatment of photoaging. Patients received a series of two to three treatments with AFP. RESULTS Thirty‐nine women (86.7%) and six men (13.3%) were enrolled. Patients received two or three treatment sessions (mean 2.4). There were no incidence of adverse events of scarring, prolonged erythema (lasting more than 7 days), postinflammatory hyper‐ or hypopigmentation, or infection in the 108 treatment sessions given during this study. Mean improvement was 48.5% (95% confidence interval (CI)=44.6–52.4%) for skin texture, 50.3% (95% CI=46.1–54.5%) for skin laxity, 53.9% (95% CI=49.5–58.5%) for dyschromia, and 52.4% (95% CI=47.9–56.9%) for overall cosmetic outcome (all p<.05). CONCLUSIONS Significant improvement in photoaging of the face can be achieved using an AFP device with skin types I to III after a series of two to three treatments. The authors have indicated no significant interest with commercial supporters.

Photodynamic Therapy for the Treatment of Cutaneous Neoplasia, Inflammatory Disorders, and Photoaging

BACKGROUND Photodynamic therapy (PDT) has demonstrated high efficacy, minimal side effects, and improved cosmetic outcome when used for the treatment of actinic keratoses (AK), basal cell carcinoma (BCC), squamous cell carcinoma, and photoaging. METHODS To review the literature on the use of PDT in dermatologic surgery using MEDLINE. RESULTS Published clinical studies using PDT in the treatment of AKs yield overall efficacy rates ranging from 50% to 71% with one treatment to as high as 88% to 90% with two or more treatments. For superficial BCC, initial clearance rates were 76% to 97%, and for Bowens disease, initial clearance rates ranged from 72% to 94% overall. The use of PDT for photorejuvenation is a relatively new application of this technology, which has shown promise in improving the appearance of fine lines, pigmentary variation, and telangiectasias. CONCLUSIONS The advantages of photodynamic therapy include the capacity for noninvasive targeted therapy through topical application of aminolevulinic acid and methyl aminolevulinic acid, with outstanding cosmetic results. Although the theory behind the use of chemical photosensitizers and ultraviolet light to treat a wide variety of skin disorders is straightforward, the practical application of this technology is evolving. Additional research into the precise mechanisms of action for specific photosensitizers and optimal light sources will be highly beneficial to the advancement of this technology. The authors have indicated no significant interest with commercial supporters.

Review of the Literature: Treatment of Dyspigmentation with Fractionated Resurfacing

BACKGROUND Traditional ablative laser resurfacing is associated with adverse side effects, including prolonged erythema, edema, burning, milia, acne, crusting, and hypo‐ and hyperpigmentation. Fractional photothermolysis (FP) has been introduced to overcome the disadvantages of traditional ablative and nonablative resurfacing. With FP, the microscopic, pixilated pattern of wounding in the dermis results in significant skin pigmentary and textural improvements without the adverse effects of prolonged wound healing and risks of dyspigmentation associated with traditional ablative resurfacing. FP has been reported to improve hypo‐ and hyperpigmentation in a variety of cutaneous conditions. OBJECTIVE To review the dermatologic literature on the use of FP for treatment of dyspigmentation. RESULTS Review of the Medline literature identified 35 studies on treatment of cutaneous conditions associated with dyspigmentation with ablative FP (AFP) and nonablative FP (NAFP). Specifically, we found treatment of melasma, postinflammatory hyperpigmentation, nevus of Ota, hypo‐ and hyperpigmented scars, poikiloderma of Civatte, laser‐induced hypo‐ and hyperpigmentation, and dyschromia associated with photoaging. CONCLUSIONS AFP and NAFP are potentially effective modalities for the treatment of dyspigmentation of the face and neck. The authors have indicated no significant interest with commercial supporters.

Photodynamic therapy for actinic keratoses: Survey of patient perceptions of treatment satisfaction and outcomes

Background: While there are many available treatments for actinic keratoses (AKs), patient‐preferred treatment options remain undefined. Objective: To quantify patient perceptions and preferences in the management of AKs, including comparison of photodynamic therapy (PDT) with other therapies. Methods: A self‐administered questionnaire was mailed to 45 patients who had received PDT for AKs in 2005–2006 in the Henry Ford Health System. A series of indicators for each treatment were surveyed, including: recovery time, cosmetic appearance, patient cost, effectiveness, patient satisfaction, treatment option preference, and perceived burden of treatment. Results: A total of 39 of the 45 patients participated (86.7%). A patients reported recovery time was significantly more likely to be 1 week or less for PDT when compared with cryotherapy (p = 0.02) and surgical excision (p = 0.02). Borderline significance was found for the improved cosmetic outcome in PDT vs. surgical excision (p = 0.058) and for patient satisfaction with PDT compared with 5‐fluorouracil (p = 0.058). Patients significantly preferred PDT to 5‐fluorouracil (p<0.001) or imiquimod (p = 0.031). Conclusion: While the effectiveness of lesion clearance with PDT for AKs has been well proven in the literature, this is the first study to evaluate patient perception of the effectiveness, side‐effect profile and benefits of PDT relative to several standard treatment approaches for AKs. PDT was found to have equivalent or improved recovery times, cosmetic outcomes, patient satisfaction and preference as a treatment for AKs by patients compared with other options.

Ablative fractionated CO2 laser treatment of photoaging: a clinical and histologic study.

BACKGROUND Ablative fractional photothermolysis (AFP) has been reported to be effective for changes in skin pigmentation and texture associated with photoaging. METHODS A prospective study for the treatment of photoaging using a fractionated ablative carbon dioxide laser in 10 subjects. Assessment of laser efficacy was made using two modalities: histologic examination of skin biopsies and blinded physician clinical photographic assessment. For the histologic portion of the study, patients were randomized to treatment with the device at settings of pulse durations of 500, 1,000, 1,500, and 1,800 &mgr;s. Depth of injury was assessed based on histologic evaluation of depth of thermal coagulation. For the clinical portion of the study, treatment was administered to the face using a carbon dioxide laser at settings of 30 W, 500‐&mgr;m pitch (density of treatment equivalent to ablation of 25% of the skin), and variable pulse duration of 1,000 to 1,500 &mgr;s. RESULTS The mean score for dyschromia had improved 47.5% (95% confidence interval (CI) = 44.1–50.9%), for skin texture 56.0% (95% CI = 51.9–60.1%), for skin laxity 56.0% (95% CI = 51.3–60.7%), for rhytides 52.5% (95% CI = 48.3–56.7%) and for overall cosmetic outcome 61.5% (95% CI = 56.4%,66.6%) 6 months after treatment. Histologic data revealed a proportional increase in depth of thermal coagulation at each pulse duration. The mean ablation depth was 283 &mgr;m for a pulse duration of 500 &mgr;s, 375 &mgr;m for 1,000 &mgr;s, 767 &mgr;m for 1,500 &mgr;s, and 1.05 mm for 1,800 &mgr;s. CONCLUSIONS We present a histologic analysis documenting the correlation between longer pulse duration and ablation depth using an AFP device. We identified that pulse duration settings up to 1,800 &mgr;s could be used safely with an ablation depth up to 1.1 mm, correlating with injury into the deep reticular dermis.

Treatment of lower eyelid rhytids and laxity with ablative fractionated carbon-dioxide laser resurfacing: Case series and review of the literature.

BACKGROUND An increasing array of minimally invasive treatment modalities have evolved for periorbital rhytids. Nonablative fractional photothermolysis has been demonstrated to be effective for periorbital rhytids. OBJECTIVE We sought to prospectively evaluate eyelid tightening with an ablative fractional photothermolysis laser. METHODS We conducted a prospective, single blinded study for lower eyelid laxity in 25 subjects with a series of 2 to 3 treatment sessions. RESULTS The number of treatment sessions required for significant improvement of eyelid laxity ranged from 2 to 3, with an average of 2.44 sessions. For skin texture, the mean score decreased from 3.6 to a mean of 1.2 at 6 months posttreatment (P < .05) for a 62.6% mean improvement. For skin laxity, the mean score decreased from 3.3 to 1.3 at 6 months posttreatment (P < .05) for a 65.3% mean improvement. For rhytids, the mean score decreased from 3.5 to 1.3 at 6 months posttreatment (P < .05) for a 62.1% mean improvement. For overall cosmetic outcome, mean score decreased from 3.6 to 1.2 at 6 months posttreatment (P < .05) for a 65.7% mean improvement. Patients noted moderate postoperative erythema and edema that resolved by the 1-week posttreatment visit. Patients reported minor crusting and oozing that resolved within 48 to 72 hours. LIMITATIONS This is a prospective, single blinded study in 25 patients with varying degrees of laxity and photoaging affecting eyelid skin. Additional studies assessing degree of improvement for patients with varying degrees of laxity and photoaging at variable parameters are needed. CONCLUSION Eyelids can achieve significant improvement in skin texture and laxity with ablative fractional photothermolysis.