Lasers in Dermatology

Springer-Verlag London Ltd.

Sean W. Lanigan

Lasers in
Dermatology

Springer
Sean W. Lanigan, MD, FRCP, DCH
Department of Dermatology, Princess of Wales Hospital, City Road, Bridgend, CF31 1RQ, UK

ISBN 978-1-4471-1143-6

British Library Cataloguing in Publicat ion Data

Lanigan, Sean W.
Lasers in dermatology
l.Dermatology 2.Skin - Laser surgery
\.Ti tIe
617.4'77'059

Library of Congress Cataloging-in-Publication Data

Lanigan,Sean,1955-
Lasers of dermatology / Sean Lanigan.
p.em
rncludes index.
ISBN 978-1-4471-1143-6 ISBN 978-1-4471-0437-7 (eBook)
DOI 10.1007/978-1-4471-0437-7
1. Skin-Laser surger. r. Title.
RL120.L37 1342000
617.4'77059-dc21 00-024606

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Originally published by Springer-Verlag London Berlin Heidelberg in 2000
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 To

Hilary, Stuart and Eleanor

 --

Preface

Over the past decade there has been a huge increase in interest in the use of lasers
in dermatology. The number and choice of lasers have increased dramatically. This
has expanded the number of conditions treatable by lasers and also the number
of clinicians now wishing to include dermatological lasers in their therapeutic
armamentarium.
Marketing forces and commercial pressures have led to a situation where lasers are
purchased and used without a broad-based understanding of this important and
developing field. The aim of this textbook is to provide a comprehensive guide to
the theoretical and practical aspects of lasers used in the fields of dermatology and
plastic surgery. I would hope this book would allow the trainee, consultant dermato-
logist or plastic surgeon to gain a full understanding of all aspects of lasers in der-
matology, both from the basic science and safety aspects through to the most
appropriate choice of laser for the treatment of most particular conditions.
This, however, is not a "how to ... cook book"; guidance only on treatment is pro-
vided based on my own experience and published research. Full understanding of
the "whys" and "whens" of treatment are the aim, coupled with an extensive review of
current and "cutting edge" research. This textbook will be an ideal complement to
practical hands-on laser training to provide the clinician with all that is necessary
for safe and competent practice in this field.

vii
 Acknowledgements
·"~i·:r..;

.,~.

It is a pleasure to acknowledge help and support from colleagues and mentors - the
opportunity rarely arises. I would particularly like to acknowledge and thank John
Cotterill, who over the years has been teacher, colleague and friend and has done
most to foster and support my interest in clinical laser work and research.
I also greatly benefited in my clinical training from the time, interest and encour-
agement given to me by Dr Eugene Farber during my time spent with him at the
Psoriasis Research Institute, Palo Alto, California. My current laser practice could
not have been established without the generous continued support of Doreen and
Peter Trust at the Disfigurement Guidance Centre.
I would also like to thank colleagues who took the time to review parts of this
manuscript: John Cotterill, Harry Moseley, Rob Sheehan-Dare, Sunny Varma; and
those who have kindly provided me with clinical slides to illustrate the text: John
Cotterill, Barry Monk, Rob Sheehan-Dare and Sunny Varma. I would also like
to thank those laser companies who have provided me with illustrative material,
in particular Sharplan (UK) also Candela Corporation, Cross Medical, Danish
Dermatological Developments, lriderm and Lynton Lasers. Finally I would like to
thank Maria Pritchard for all the time and effort she has given to the successful
completion of this manuscript.

ix
Preface . . . . . . . Vll

Acknowledgements IX

1 The Basic Science of Laser-Tissue Interactions in Dermatology 1

Introduction 1
Laser Radiation . . . 2
Laser Construction . 2
Laser Light Delivery 3
Terminology 3
Spatial Average Energy Fluence 4
Number of Passes . . . . . 4
Laser-Tissue Interactions .. 4
Photothermal Interactions 5
Selective Photothermolysis 5
Further Reading . . . . . . . 6

2 The Safe Use of Lasers in Dermatology . . ...... 7

Introduction . . . . . . . . . . . . . 7
Classification of Lasers . . . . . . . . . . . 7
Warning Signs for Laser Equipment 8
Environmental Considerations for the Safe Use of Lasers
in Dermatology . . . . . 8
Local Rules . . . . . . . . . . . . . . 9
Laser Controlled Area . . . . . . . . 9
Fire, Ignition and Electrical Hazards 9
Ocular Hazards . . . . . . . 10
Hazards of the Laser Plume 10
Laser Training . . . . . . . . . 11
Core of Knowledge . . . . . 11
Laser Safety Education Program 12
Clinical Training . . . . . . . . 12
References and Further Reading . . 13

3 Laser Treatment of Cutaneous Vascular Lesions . . . . . . . . 15

Treatment of Port Wine Stains . . . . . . . . . . . . . . . . . . 15
Principles of Selective Photothermolysis and the Treatment
of Port Wine Stains . . . . . . .. .......... . . . 15

xi
 xii Contents

Port Wine Stain Treatment with the Flashlamp Pulsed Dye Laser 17
Side Effects from Pulsed Dye Laser Therapy . . . . . 21
Psychological Aspects of Port Wine Stain Treatment . . . . 21
Argon Laser Treatment of Port Wine Stains .. . . . . . . . 22
Continuous Wave Dye Laser Treatment of Port Wine Stains 23
Robotic Scanning Handpieces . . . . . . . . . . . . 24
Copper Vapour Laser Treatment of Port Wine Stains 25
Nd:YAG Laser Treatment of Port Wine Stains 25
Krypton Laser . . . . . . . . . . . . . . . . . . . . . 26
CO 2 Laser Treatment of Port Wine Stains . . . . . . 26
Laser Treatment of Capillary (Strawberry) Haemangiomas 26
Laser Treatment of Leg Veins and Telangiectasias 27
Treatment of Other Cutaneous Vascular Lesions 29
Laser Treatment of Scars and Striae . . . 30
Laser Treatment of Striae Distensae . 31
Pulsed Dye Laser Treatment of Psoriasis 32
Laser Treatment of Viral Warts 33
References and Further Reading . . . . . 33

4 Laser Treatment of Pigmented Lesions 39

Introduction . . . . . . . . . . . . . . 39
Categories of Pigmented Lesions 39
Pulsed Dye Laser (510 nm) Treatment of Pigmented Lesions 40
Q-Switched Ruby Laser Treatment of Pigmented Lesions . . 40
Q-Switched Nd:YAG Laser Treatment of Pigmented Lesions 42
Q-Switched Alexandrite Laser Treatment of Pigmented Lesions 44
Copper Vapour Laser Treatment of Pigmented Lesions 44
Other Lasers for the Treatment of Pigmented Lesions 45
Treatment of Melanocytic Naevi with Lasers 45
References and Further Reading . . . . . . . . . . . . 46

5 Laser Treatment of Tattoos . . . . . . . . . . 49

Introduction . . . . . . . . . . . . . . . . . . 49
Q-Switched Ruby Laser Treatment of Tattoos 49
Q-Switched Nd:YAG Laser Treatment of Tattoos 51
Q-Switched Alexandrite Laser Treatment of Tattoos 52
Pulsed Dye (510 nm) Laser Treatment of Tattoos 53
Comparative Studies of Lasers Used to Remove Decorative Tattoos 53
Laser Treatment of Other Tattoos 54
Cosmetic Tattoos . . . . . . . 54
Traumatic Tattoos . . . . . . 54
References and Further Reading 54

6 The Carbon Dioxide and Erbium:YAG Lasers in Dermatology 57

CO 2 Laser Treatment in Dermatology . . 57
Introduction . . . . . . . . . . . . . . . . 57
Incisional Surgery with the CO 2 Laser .. 58
Wound Healing with CO 2 Laser Excisions 59
Pulsed, Superpulsed and Scanned CO 2 Lasers 59
 Contents xiii

Tissue Ablation with the CO 2 Laser 60

Resurfacing Skin with the CO 2 Laser 62
Mechanism of Action . . . . . . . 63
Preoperative Patient Evaluation and Preparation 64
Treatment Methods 65
General Considerations . . . . . . 65
Coherent UltraPulse . . . . . . . . 66
Sharplan SilkTouch/Feather Touch 66
Other CO 2 Lasers . . . . . . . . . . 67
Postoperative Management . . . . 67
Complications of Resurfacing with the CO 2 Laser 68
Long-Term Results of CO 2 Laser Resurfacing .. 69
Comparison Between CO 2 Laser Resurfacing and Chemical Peels 69
CO 2 Resurfacing of the Acne-Scarred Face . 70
Erbium:YAG Laser Treatment in Dermatology 70
Introduction . . . . . . . . . . . . . . . . . 70
Clinical Studies with the Er:YAG Laser .. . 71
Comparisons and Combinations of the Er:YAG and CO 2 Lasers 75
Conclusions . . . . . . . . . . . . 76
References and Further Reading . . . . . . . . . . . . . . . . . 77

7 Hair Removal by Lasers . . . . . . . . . . . . . . . . 81

Introduction . . . . . . . . . . . . . . . . . . . . . . 81
Laser Removal of Hair by Selective Photothermolysis 82
Ruby Laser Treatment of Hair . . . . 83
Alexandrite Laser Treatment of Hair .. . 84
Diode Laser Treatment of Hair . . . . . . 85
Other Laser Treatments for Hair Removal 85
Intense Pulsed Light Laser Treatment of Hair 85
Treatment Techniques for Selective Photothermolysis of Hair 87
Conclusions . . . . . . . . . . . . . . 88
Laser-Assisted Hair Transplantation 88
References and Further Reading . . . 89

8 Photodynamic Therapy in Dermatology 91

Systemic Photodynamic Therapy . . . 91
Clinical Studies . . . . . . . . . . . . 91
Invasive Squamous Cell Carcinoma 92
Bowen's Disease 92
Malignant Melanoma 92
Kaposi's Sarcoma 92
Topical Photodynamic Therapy 92
Light Sources . . . . . . . . . . 93
Treatment of Cutaneous Malignancies with Topical
Photodynamic Therapy 93
Basal Cell Carcinoma 93
Actinic Keratoses . . . 93
Bowen's Disease 93
Squamous Cell Carcinoma 95
Mycosis Fungoides . . . . . 95
 xiv Contents

Photodynamic Therapy for Benign Skin Disease 95

References and Further Reading . . . . . . . . . . 96

9 New Lasers, Emerging Technology, Experimental and

Developing Applications 99
Diode Lasers . . . . . . . . . . 99
Introduction . . . . . . . . . 99
Clinical Use in Dermatology 99
Excimer Lasers . . . . . . . . . 100
Intense Pulsed Light Source .. 101
Non-Ablative Cutaneous Laser Resurfacing 102
Conclusions . . . . . . . . . . . . 103
References and Further Reading . . . . . . . 103

Appendix: Index of Laser Manufacturers . . . . . . . . . . . . . . . . . . . .. 107

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109
 The Basic Science of
Laser-Tissue Interactions in
Dermatology

Introduction Stimulated absorption of radiation

The word laser is an acronym for light amplification - - - - - - - E2 - - - • - - - E2

by the stimulated emission of radiation. Einstein in
1917 developing quantum theories of light added
- - -.....----E1 --------E1
the concept of stimulated emission to the known
effects of spontaneous emission and stimulated
absorption. In stimulated absorption an electron
absorbs photons of energy and is raised to a higher
~ Light energy

energy level. In spontaneous emission photons of Electron in resting state Electron in excited state
energy are released and the electron returns to a
lower energy level (Fig. 1.1). Photons emitted from
Spontaneous emission of radiation
non-laser light sources occur randomly and are not
correlated in direction or phase.
In stimulated emission an atom or molecule is ~ Light energy
stimulated by an absorbed photon and after excit-
ation emits a photon of the same frequency as the - • - - - E2 - - - - - - - E2
exciting photon. If the released photon collides
with another atom in the excited state another --------E1 - - - - - i l e l - - - - E1
photon identical in phase, frequency and direction
will be released as the atom returns to its stable
Electron in excited state Electron in resting state
state. In a laser it is necessary for there to be a large
number of atoms in the excited state to be present. Fig. 1.1. Stimulated absorption of radiation and spontaneous
This occurs if there is a metastable energy level emission of radiation.
in which excited atoms remain in an excited state
for some time. Once the population of electrons
in a metastable excited state exceeds those in a
stable state a population inversion has occurred. taining the active medium has reflective mirrors at
Photons emitted by electrons in thi& population either end to bounce photons back and forth to
in turn stimulate release of further photons as sustain the interactions. The amplification of light
electrons return from metastable to stable states energy by this process creates an enormous increase
(Fig. 1.2). in light energy in a short period. In a laser one of
All the photons released by these events will be of the reflecting mirrors will allow a small percentage
the same wavelength and in phase. To amplify these of the light though its surface which can then be
events in a laser a resonating or optical cavity con- used as required.

1
 2 lasers in Dermatology
- - - - - - - - - - - - E2
Light energy
Metastable energy level (E 3 ) with population
inversion and light emitted by stimulated emission
Fig.1 .2. Stimulated emission of radiation.
Laser Radiation
The light emitting from a laser has a number of dif-
ferences from light arising from a non-laser source.
Laser light is considered coherent: all the light is of
the same wavelength, travelling in the same direction
and in the same phase. This can be seen in Fig. 1.3.
These unique features of laser radiation have been
responsible for the explosive expansion of laser
developments in medicine. The unique properties of
laser light mean that the light emitted from a laser
is very nearly parallel (collimated). There is very
little divergence of light so high irradiance (power
per unit area irradiated) is maintained over long
distances.
Because laser light is coherent, it can be focused
down to a very small spot maintaining very high
irradiance. The monochromatic wavelength of light
~ Output
=9~~
~ L"" Ugh"o","
Non-coherent
light source
Fig.1.3. Coherent and non-coherent light sources.
emitted from a laser can be utilised in selecting
specific chromophores within the skin: selective
photo thermolysis, e.g. 585 nm light from a pulsed
dye laser targeting oxyhaemoglobin in cutaneous
blood vessels.
The wavelengths of lasers used in dermatology
can range from ultraviolet (100 nm) though the
visible range into the infrared (10,600 nm). With the
exception of ultraviolet lasers that are used prim-
arily as research tools, laser wavelengths used in
dermatology are non-ionising and not considered
carcinogenic. The wavelength of light emitted by a
laser gives it its characteristic colour within the
visible range.
Laser Construction
A laser consists essentially of a power source, a
lasing medium and a resonating cavity (Fig. 1.4). It is
necessary to supply energy into a lasing medium to
elevate electrons to an excited state and produce a
population inversion. The energy source can be elec-
trical, optical or chemicaL Even for optical pumping
an electrical discharge is needed to source the light
energy that is coupled into the lasing medium.
Lasers can be used to pump other lasers, e.g. the
argon laser-pumped dye laser.
The lasing medium will determine the character-
istics of the laser light emitted. The lasing medium
can be solid (e.g. crystals such as ruby), liquid (e.g.
rhodamine dye) or gaseous (e.g. carbon dioxide).
The resonating cavity as discussed above contains
the lasing material and has mirrors at either end to
reflect back released photons. One mirror is only
partially reflecting, allowing some of the radiation
to escape being the laser output.
Resonating cavity beam
DI
Reflective
~edium _I D~ _ ~~~~~~~
Reflective
mirror (100%) mirror «1 00%)
Power source
Fig. 1.4. Basic laser structure.
 The Basic Science of laser-Tissue Interactions 3

Laser Light Delivery wave lasers, e.g. carbon dioxide and argon lasers,
produce a steady beam of radiation although this can
be mechanically shuttered into pulses of light. The
The light emerging from a laser cavity can be deliv-
pulses thus produced are usually tens of milliseconds
ered to tissue either via an optical fibre or using an
or longer. Pulsed lasers, e.g. flashlamp pumped pulsed
articulating arm with mirrors to deflect the beam.
dye lasers, emit a single pulse or a train of pulses.
The handpiece delivers the laser beam on to the
Extremely short pulses of light can be achieved by Q-
skin. The light emerging can be collimated, i.e. non-
switching. A photo-optical shutter is placed within
divergent, or divergent. The spot size of the beam on
the resonating cavity, which allows turning on and off
the skin will determine the area of tissue inter-
of the beam very rapidly to create short pulses in the
action. In divergent beams the energy density deliv-
nanosecond domain, e.g. Q-switched Nd:YAG laser.
ered to tissue is a function of the square of the
Pseudo-continuous beams occur where very short
diameter of the beam. Small changes in beam area
pulses of light are emitted at very high repetition
can result in large changes in energy density. Many
rates so that the gap between individual pulses is also
handpieces therefore have a spacing bar to maintain
very short. These lasers often have a biological effect
the same distance from the laser beam emerging
similar to continuous wave lasers, e.g. copper vapour
from the delivery system and the skin.
laser.
The beam profile of the laser cannot be assumed
to be uniform. Often the intensity varies across the
cross-section of the beam; when this is Gaussian it is
termed "TEMoo". Some lasers may emit small spikes Terminology
of energy within the beam and manufacturers
should provide details of energy intensity across There are three important characteristics of laser
beams of new lasers. light: irradiance, energy density or fluence and expo-
Laser light can be delivered as a continuous, pulsed sure time. Irradiance is the power density or power
or pseudo-continuous beam (Fig. 1.5). Continuous per unit area incident on the skin during a single
pulse and is given by

c~.o
>
r---------
'--_ _ _ _ _ _ _ _ _ _
Continuous wave,
" e.g. argon laser

Time
Irradiance
(W Icm 2 )
Laser power output (W)
Laser beam cross-sectional area (cm 2 )

It can be seen that the irradiance is related to the

inverse of the square of the beam diameter. Thus in
a 50 W power output laser with a beam diameter of
0.4 cm the irradiance is approximately 400 W/cm 2 •

11 (\" /\. <

450 ~s
>
Pulsed,
e.g. pulsed dye laser
By focusing the beam to a diameter of 0.2 cm and
maintaining 50 W output the irradiance increases to
Time 1600 W/cm 2 • This illustrates the importance of
maintaining the same spot size in treatment.

11 ~ ~ ~ ~ ~ ~ ~.
Quasi-continuous,
The fluence is the energy per unit area on the
e.g. copper vapour skin. Energy in joules is power (watts) times time
< > < >
laser (seconds) and so fluence is the product of irradiance
20 ns 60 ~s
Time and exposure time as in
Laser power output (W) x
Exposure time (s)
Fluence (JIcm 2 ) =
.... Laser beam cross-sectional
<l)

~ area (cm 2)
o Q-switched,
c..
e.g. Q-switched Fluence describes the energy per unit area for a
' - - _ _'::-!<>'-_ _ _ _.....l.l._~ Nd:YAG laser
single pulse. For a fixed beam diameter and pulse
10 ns
Time duration fluence can be altered by changing the
power of the laser. When very short pulses of light
Fig.l .S. laser light delivery (not to scale).
are used in Q-switched lasers with nanosecond
 4 l asers in Dermatology

pulse duration, although the fluence may be less

than with a longer pulse the laser delivers very high
Laser-Tissue Interactions
powers in each pulse: megawatts or gigawatts of
Laser light when it interacts with tissue can be re-
power. The fluence with such short pulse durations
flected, scattered, transmitted or absorbed (Fig. 1.6).
may be only 1-10 J/cm2.
The important effect therapeutically is absorption.
In quasi-continuous lasers a mechanically shut-
The absorbing molecule within tissue, which in the
tered pulse of light of perhaps 0.5 s will contain
skin could be haemoglobin, melanin, collagen or
multiple short (ns) pulses of light with a rapid (kHz)
water, is termed the chromophore. The penetration of
repetition rate. It may be useful with these lasers to
light into skin is governed by the combination of
average out the energy fluence for the mechanically
absorption and scattering. In general, as the wave-
shuttered pulse rather than the individual pulses.
length of light increases the penetration into skin also
increases. In the far infrared, where water absorption
Spatial Average Energy Fluence is important, the depth of penetration falls again; this
is used therapeutically with the resurfacing lasers
When covering a treatment area with laser impacts it such as CO 2 and Er:YAG. However, because of the
is important to be aware of the total laser energy strong absorption bands of haemoglobin at 418, 542
delivered to this area. For pulsed lasers this will be and 577 nm depth of penetration of light at these
related to the beam diameter, energy fluence and wavelengths will be attenuated (Fig. 1.7).
placement of laser pulses. If the laser pulses are The outcome of laser-tissue interactions can be
applied exactly adjacent to all their neighbours with- grouped as follows: photothermal, photochemical
out overlapping or spaces the laser beam area x plasma-induced ablation, photo ablation and photo-
number of pulses should approximate to the area
treated. If this product exceeds the treated area it
implies overlapping of spots or multiple pulses to a Incident
unit area. If the product is less than the treated area it light
Scattered light
implies gaps between spots or untreated areas. In
practice, when reporting results researchers may state
that either non-overlapping or overlapping spots were
applied to a treated area. The degree of overlapping
should be specified, e.g. 10% overlap. Laser operators
should endeavour to determine that they actually
deliver their treatments in the manner they describe.
For continuous wave lasers swept continuously Reflected
light
over an area the spatially averaged energy fluence is
given by the product of the laser power and expos- Fig.1.6. Interaction of light with matter (tissue).
ure time divided by the total area irradiated. This
implies movement of the laser beam continuously
over the area at uniform speed without overlapping.
Speeding up and slowing down will decrease and
- - - Hb0 2
increase the energy fluence respectively.
- - - Melanin
c:
Number of Passes o
'e-o
For some treatments, e.g. argon laser treatment of a '"
«
..Q

port wine stain, one impact of the laser is applied to

each unit area. With ablative and resurfacing lasers
successive passes of the laser will produce addi- 350 450 550 650 750
tional ablative effects to the unit area of tissue
treated. It is important to record the number of Wavelength (nm)
treatments or passes of the laser over a unit area as
this will influence outcome and can be used as a Fig. 1.7. Absorption spectrum of oxyhaemoglobin (Hb02) and
guide for subsequent treatments. melanin.

Photodisruption
and photoablation
10- 15
Exposure time (s)
Fig.1.S. Laser-tissue interactions showing influence of exposure
time and power density.
disruption (Fig. 1.8). By far the most important
interaction in dermatology is photothermal. Photo-
chemical interactions are important in photo-
dynamic therapy, which will be discussed later.
Experimentally, excimer lasers produce some of
their effects by photoablation; this is more import-
ant in refractive corneal surgery as a plasma-
induced ablation. Photo disruption mechanisms are
used therapeutically in lithotripsy and lens frag-
mentation with lasers emitting nanosecond pulses
of power densities up to 10 16 W/cm 2 •
Photothermal Interactions
In photothermal laser interactions the absorbed
photons are converted to heat. The local increase in
temperature is the most significant influencing
factor. The effect of heat on biological tissue depends
on the duration and the peak value of the tissue tem-
perature achieved. The effects of heating can be seen
as coagulation, which can proceed to necrosis and
vaporisation, resulting in tissue ablation and carbon-
isation. It should be noted that other biological
effects of heating tissue below levels to induce coagu-
lation are less clearly defined but may be of import-
ance in biostimulation.
As tissue is heated, structural changes occur
in complex molecules such as proteins, DNA and
RNA. These structural changes result in impairment
of function termed denaturation. In addition to
denaturation there is grosser structural disorder
with entanglement of molecules termed coagulation.
Denaturation and coagulation generally proceed as
tissue temperature rises above 60°C. Again the dura-
tion of temperature rise is also important in inducing
tissue damage. Thermal coagulation causes cell necro-
The Basic Science of Laser- Tissue Interactions 5
--.'"---4-- Hyperthermia
'--~"-----+-- Coag u lalio n
__~LJ.,....z::.....----1- Carbon isation
1....-_ _ _ _ _-+_ Vaporisation
Tissue
103
Widths of each zone can
vary with laser parameters
Fig.1.9. Thermal effects of ablative lasers.
sis. Gross thermal necrosis of the dermis is equivalent
to a burn and in many instances laser surgery involves
controlled and limited thermal injury to the skin.
Heating tissue above 100°C causes evaporation of
water and vaporisation of tissue (Fig. 1.9). Tissue
vaporisation is used therapeutically in resurfacing
lasers such as the CO 2 laser. Vaporised tissue is seen
as a plume of steam arising from the treated area
containing water vapour and particulate material. If
the energy from the laser is delivered in a suf-
ficiently short duration all the absorbed energy will
be utilised in vaporising the tissue water in the
superficial layer of tissue irradiated. The treated
layer is rapidly vaporised away so that there is no
heat source applied to the deeper tissue layers. In
this way, by using short pulsed CO 2 or Er:YAG lasers
the residual thermal damage below the vaporised
tissue is only a few micrometres in depth.
In contrast, if the pulse durations employed for
vaporisation are long there is heat conduction to
deeper tissues. The surface layer becomes desiccated
and extreme heat rises occur in excess of 350°C with
charring (carbonisation) of tissue. The tissue bed
below a long pulse (continuous wave) CO 2 laser can
be thermally necrosed to a depth of 1 mm or more.
This is likely to result in visible scarring of healed
tissue. In general, carbonisation is an unwanted out-
come of laser treatment and usually arises from
inappropriate laser parameter selection or faulty
technique.
Selective Photothermolysis
Perhaps the most important concepts in the devel-
opment of lasers in dermatology have been by
 6 Lasers in Dermatology
Anderson and Parrish, elaborated in their paper pub-
lished in Science in 1983. In this paper the authors
discussed the concept of selective photothermolysis.
Utilising the principles of selective photothermolysis
by the appropriate selection of wavelength, pulse
duration and energy fluence a precise biological
target can be thermally damaged by lasers.
In considering the most appropriate wavelength
for the target, the light must penetrate sufficiently to
reach the target and also be absorbed by it to produce
photothermal changes. For example, oxyhaemoglobin
absorbs visible light with absorption peaks at 418, 542
and 577 nm (Fig. 1.7). However, for the therapeutic
thermal damage of cutaneous blood vessels the more
deeply penetrating wavelengths are preferred.
The heat generated within the target can be con-
fined to that target by the appropriate selection of
pulse duration. This is related to the thermal relax-
ation time of the target. The thermal relaxation time
is a measure of the intrinsic cooling time of the
target and is the time taken for the target to dissipate
half of the incident thermal energy. This cooling
time is primarily related to the physical size of the
target: the larger the target the longer the thermal
relaxation time. If the laser pulse duration is equal to
or less than the thermal relaxation time of the target
then unwanted heat diffusion to adjacent tissue will
be reduced. For example, for port wine stain capillar-
ies pulse durations around 1 ms would be appropri-
ate whereas for melanosomes in pigmented lesions
nanosecond pulses would be more appropriate.
Having defined the most appropriate wavelength and
pulse duration it is then important to deliver suf-
ficient fluence to the target to produce the desired
temperature rise. The fluence will be influenced by
attenuation of the beam by competing chromo-
phores, e.g. melanin in the epidermis overlying port
wine stains, depth of penetration and scattering.
In clinical practice many targets have a three-
dimensional structure which includes depth and it
is impossible to achieve complete thermal damage
with one laser impact as superficial components of
the target will absorb light, shadowing deeper
targets. This is why for many structures, e.g. port
wine stains, pigmented naevi and tattoos, multiple
treatments are necessary.
Further Reading
Anderson RR, Parrish JA (1981a) The optics of human skin.
J Invest Dermatol 77: 13-19
Anderson RR, Parrish JA (1981 b) Microvasculature can be select-
ively damaged using dye lasers: a basic theory and experimen-
tal evidence in human skin. Lasers Surg Med 1:263-266
Anderson RR, Parrish JA (1983) Selective photothermolysis:
precise microsurgery by selective absorption of pulsed radi-
ation. Science 220:524-527
Arndt KA, Noe JM, Northam DBC, ltzkan I (1981) Laser therapy.
JAm Acad Dermatol 5:649-654
Maiman T (1960) Stimulated optic radiation in ruby. Nature
187:493-494
 The Safe Use of Lasers in
Dermatology

Table 2.1. Lasers used in dermatology

Introduction
Laser Wavelength(s) Output
Many of the features of lasers that make them of
(nm)
such value in dermatology can also be hazardous to
patients and staff. This chapter will address the Excimer 193- 350 Pulsed
nature of the hazards presented by medical lasers Argon 488,514 Continuous
and the mechanisms and practices to minimise Pigmented lesion dye 500-520 Pulsed
them. Copper vapour 511 ,578 Quasi-continuous
Krypton 530,568 Continuous
Frequency-doubled 532 Q-switched
Nd:YAG
Classification of Lasers KTP 532 Quasi-continuous
Pulsed dye 577,585-600 Pulsed
Lasers are grouped into four classes. The class- Argon dye 585,630 Continuous
ification reflects the hazard potential of each group Gold vapour 628 Quasi-continuous
of lasers. The classification is based upon the beam Ruby 694 Continuous,
output, power or energy emitted by the laser; the Q-switched
higher the class number the greater the potential Alexandrite 755 Pulsed, Q-switched
hazard. Examples of lasers used in dermatology are Diode 795- 830 Continuous
shown in Table 2.1. There are specific safety standard Nd:YAG 1,064 Continuous
Q-switched
requirements relating to each laser class provided by
the American National Standards Institute's (ANSI) Er:YAG 2,940 Pulsed, Q-switched
Zl36.3 1996 "Safe use of lasers in Health Care COl 10,600 Continuous, pulsed
Facilities", and also in Britain by BS EN 60825-2-22
1993: "Particular requirements for the safety of diag-
nostic and therapeutic laser equipment". • Class 3A. Medium-power lasers. Wavelength
A summary of the laser characteristics by each varies from 200 nm to 1 mm. Output power less
class follows: than 5 mW and irradiance less than 25 W/m 2•
Safe for viewing with unaided eye. Blink reflex
• Class 1. Very low-power laser systems. Inherently protects in visible range. Potential ocular hazard
safe. No hazard to vision. if used with focusing optics.
• Class 2. Low-power visible light lasers. Output • Class 3B. Medium-power lasers that are haz-
power less than 1 m W. Blink reflex normally pro- ardous if viewed directly or by reflection. Output
tects. Potential hazard if beam viewed directly power less than 500 mW. Potential for skin injury
for more than 1000 s. as well.

7
 8 lasers in Dermatology
• Class 4. High-power lasers exceeding 500 mW.
Direct beam, specular reflections and diffuse
reflection all ocular hazards. Direct and specular
reflections hazardous to skin. Some Class 4 lasers
are capable of igniting flammable materials.
The maximum permissible exposure (MPE) is a value
for the level of laser radiation to which the eye or skin
may be exposed without suffering adverse effects.
The MPE depends on wavelength, exposure times
and power. MPE values are tabulated for eye and skin.
MPE values for the eye can be used to calculate the
nominal ocular hazard distance (NOHD), providing
the distance from a laser aperture to the point at
which the intensity is reduced to the level of the MPE.
Warning Signs for Laser
Equipment
For each class of laser certain warning signs are
required. For Class 1, a sign "Class 1 laser product"
Fig.2.1. laser warning signs.
~L IN USE
®
EYE PROTECTION
~ MUST BE WORN
Fig. 2.2. Laser warning sign outside laser controlled area.
at the access panel is appropriate. For Class 2, "Class
2 laser product. Laser radiation. Caution, do not
stare directly into beam" is necessary.
For Class 3A lasers warning signs include "Class
3A laser product. Laser radiation. Caution, do not
stare directly into beam". For Class 3B lasers, signs
include "Avoid exposure to beam. Class 3B laser
product. Danger, laser radiation". For Class 3B and
4 lasers there should be a visible "Laser ready"
warning if the laser is capable of emitting laser
radiation when the firing switch is activated. For
Class 4 lasers warning signs include ''Avoid eye or
skin exposure to direct or scattered radiation. Class
4 laser product".
If a laser emits outside the visible range the warn-
ing should include "Invisible laser radiation or
visible and invisible laser radiation". At the beam
aperture should be a label "Laser aperture". Warning
signs should also be provided at every entrance to a
laser controlled area and can be illuminated when
the laser is switched on. Examples of suitable warn-
ing sign are shown in Figs 2.1 and 2.2.
Environmental Considerations
for the Safe Use of Lasers in
Dermatology
As medical lasers have the potential for a variety of
hazards to both patients and staff it is essential that
good safe clinical practice in a laser environment

is maintained at all times. There is a responsibility
by an employer for heath and safety matters and
these include those relating to lasers in the working
environment. There are guidelines in the UK from
the Department of Health: "Guidance on the Safe
Use of Lasers in Medical and Dental Practice", ISBN
1 85839 4880. In the USA the American National
Standards Institute's ANSIZ136.3-1996 offers guid-
ance on safety aspects of laser management. In
office practice there should be clearly documented
safety policies and procedures with an ongoing
quality assurance programme. For hospital-based
laser services there should be written policies on
laser safety. Local rules detailing specific instruc-
tions relevant to particular lasers and their environ-
ment should be drawn up and maintained. In the
UK a laser protection advisor (LPA) is appointed in
installations with Class 3A or greater lasers. The LPA
has a role similar to that of a radiation protection
advisor. The LPA has responsibility for advising on
evaluation and control of laser hazards and draws
up local rules for each installation. To assist the LPA
a laser protection supervisor (LPS) is appointed to
ensure that the local rules are implemented. There
should be a process of training and accreditation of
laser operators and access to lasers would be
restricted to those individuals. LPS in the UK and
laser safety officers (LSO) in the USA should be
designated to ensure local rules are implemented.
Examples of local rules are shown below.
Local Rules
Local rules should include the following:
1. Nature of hazard to persons
2. Controlled and safe access
3. A register of authorised users
4. Nominated keyholders
5. Keyholder's responsibilities
6. Need for as a minimum core of knowledge
training for all persons
7. Laser users' responsibilities
8. Safe working methods
9. Definition of simple pre-use safety checks
10. Personal protective equipment, especially
eyewear
11. Prevention of unauthorised use
12. Normal operating procedures
13. Adverse incident procedures
14. Contact point for LPA
15. The limits of the laser controlled area
The Safe Use of lasers 9
Laser Controlled Area
A laser controlled area will be the area established
around a laser while it is in use where there is a risk
of MPE levels being exceeded: the nominal hazard
zone (NHZ). Within this area the activity of all
persons will be controlled to prevent hazardous
exposure to radiation. The LPA or LSO would advise
on the boundaries of the area. Because of the
hazards of reflected as well as direct irradiation
from Class 3B and 4 lasers potential reflections
within the laser controlled area should be kept to a
minimum. Windows should be covered with mater-
ial opaque to the wavelength(s) of light used. The
orientation of the laser treatment procedure should
be in such a way as to minimise direct or reflected
light pointing towards the door.
Remote interlocks can be applied to doors within
the laser controlled area. These disable the laser if
the door is opened. These are indicated if there is a
reasonable chance that the beam may strike the door
with irradiances exceeding the MPE. Otherwise
interruptions during laser procedures may result in
potentially hazardous delays in the treatment. It is
usually better in these circumstances to adopt safe
working practices.
Fire, Ignition and Electrical Hazards
Most lasers use high-voltage power supplies to gener-
ate coherent light. Lasers should have safety controls
to protect the operator and patient from high-voltage
sources. Only experienced personnel should be
involved in maintenance of lasers using insulated
tools with appropriate precautions. Normally inter-
locking systems within the laser prevent operation
when the cover of the laser is removed.
Because laser light generates heat, lasers should
never be used in the presence of flammable mater-
ials or oxygen-enhanced anaesthetic gas mixtures.
Hair and theatre gauze are readily ignitable in the
presence of 100% oxygen. Fire-retardant fabrics are
available for surgical drapes and towels. Tubes car-
rying anaesthetic gases also need to be protected.
Plastic and Teflon materials can ignite and release
toxic gases. Metal tubes when required are preferred
and should have a matt black finish to reduce
reflection of the laser beam.
The area around the treatment site should be
covered to minimise skin injury and drapes and
dressings should be moistened with water, which is
 10 Lasers in Dermatology

particularly useful when using resurfacing lasers 208 1994. Also see ANSI Z87.1-1989 and ANSI
such as COz and Er:YAG lasers, which both emit Z136.1-1993.
light absorbed by water.
Flammable skin preparations such as alcohol Hazards of the Laser Plume
should be avoided. Fretkin et al (1996) has reviewed
the ignition potential of the pulsed dye laser. The CO z laser as it heats tissue to vaporisation pro-
duces a plume of steam and smoke arising from the
Ocular Hazards treatment area (Fig. 2.3). Substantial concerns have
been raised about the safety of the materials in the
Ocular injuries are the most serious potential haz- plume. The plume contains not only water vapour
ard relating to dermatological laser use. Operator, as steam but also aerosolised tissue particles less
patient and any other personnel in the laser con- than 10 mm in diameter. These particles can be
trolled area are at risk. Visible and near infrared light inhaled and penetrate to the alveoli. In animal
(780-1400 nm) passes through the eye and is focused experiments laser-induced smoke was a potent
on the retina, producing a burn. A burn in the peri- inducer of pulmonary damage. In one study by
pheral retina may only cause a small blind spot that Matthews et al (1985) intact keratinocytes and
the patient may not be aware of; with a foveal burn erythrocytes were found in the plume and splatter
central vision is lost. Blindness can develop after an of COzlaser-irradiated tattoos and epitheliomas.
exposure so short it may not have been visible. With A number of investigators have looked at the
the COz laser emitting at 10,600 nm tissue water transmission of viruses in COz laser plumes. These
absorbs the laser beam. This will occur in the cornea studies have included human and bovine papilloma
and the degree of damage will depend on the dura- virus and human immunodeficiency virus (HIV). In
tion of exposure. experimental conditions it has been possible to
For these reasons all personnel and patients detect all of the above in laser smoke. The actual
within the laser controlled area must wear adequate amount of infectious material in the laser plume is
protective eyewear from the time the laser is activ- very small and certainly in the case of HIV is
ated until it is switched off. For the patient, opaque damaged. Ordinary surgical masks will substantially
lenses can be used to cover the eyes or for COz or protect the operator from exposure to viral and
Er:YAG laser treatments lids closed and covered other infectious agents.
with moistened gauze. For treatments of the eyelids It is essential when using COz and Er:YAG lasers
or lesions close to the eye an intraocular eye shield to use a high-volume smoke evacuation system to
composed of metal or acrylic can be inserted after remove the laser plume as it is generated. This not
anaesthetising the cornea. It is essential that the eye
shield is made of the appropriate material for the
laser used.
The eyewear used by the laser operator and other
personnel must meet certain standards and be
appropriate for the laser used. Protective eyewear
should be marked to indicate the type of laser with
which it is to be used and the optical density of the
filter. The optical density determines how opaque
the eyewear is to a specified wavelength. The glasses
should be capable of reducing the maximum irradi-
ance to below the MPE for 10 s without damage. If
the laser heats the glasses to melting the optical pro-
tection is lost. The thermal capacity records how
much heat the glasses can absorb. For visible light
lasers tinted glasses are used of the complementary
colour. For the COz laser clear plastic lenses will
block the beam but polycarbonate fibres have a
higher thermal capacity. The British Standards
applicable to eyewear are BS EN 2071994 and BS EN Fig.2.3. laser plume after CO/ laser vaporisation of tissue.

only reduces the exposure of the operator to the
potentially hazardous materials but also removes
the vapour away from the patient's skin, where it
may act as a local heat source. With Q-switched
lasers as well as the Er:YAG there is often tissue
splatter in addition to smoke. Appropriate skin and
eye protection should be worn. To minimise splatter
particularly in high-risk patients treatments can be
performed with Q-switched lasers through trans-
parent dressings such as Tegaderm R or Second
Skin R• This will allow transmission of laser light
through the dressing into the tissue but capture
tissue splattering upwards.
Laser Training
The issue of laser training is a vexed one as there are
no national standards or criteria for laser training
either in the UK. or the USA. There is no specific
examination to pass to become certified in laser
surgery. The needs of a dermatologist using lasers will
be very different, for example, from those of a urolo-
gist. A number of national bodies such as the British
Medical Laser Association, the British Association of
Dermatologists and the American Society for Laser
Medicine and Surgery (ASLMS) develop and maintain
standards in clinical laser use and offer training
courses and regular educational meetings for up-
dating information and presentation of research.
The minimum standard of training of anyone
using lasers should be the laser safety requirements
for the safety of both themselves and all other per-
sonnel in the environment. In the UK the Medical
Devices Agency in its "Guidance on the safe use of
lasers in medical and dental practice" outlines a core
of knowledge which should be the minimum syl-
labus necessary for laser courses. In i'nstitutions
with Class 3B or 4 lasers all authorised users should
attend a course which includes the core of knowl-
edge as defined above. The Medical Devices Agency
recommend the following core of knowledge.
(ore of Knowledge
Core of knowledge as to the Protection of the Patient
and all Persons Present During the Use of Class 3A,
3B or 4 Laser in Medical Practice.!
1 Crown copyright. Reproduced with the permission of the
Controller of Her Majesty's Stationery Office.
The Safe Use of Lasers 11
The following core of knowledge is recommended to
training centre as the minimum syllabus necessary
for laser courses. If this is followed, then laser users
will have the necessary training to carry out the
duties required of them under these Guidance
Notes. This syllabus is not sufficiently detailed for
the training of laser protection advisors.
• Characteristic features of laser radiation emitted
from different types of laser.
• Generation of laser radiation and hazards asso-
ciated with device malfunctions.
• Principles of quality assurance.
• Equipment management.
• Laser-tissue interactions
• Effects of exposure of eye and skin to laser
radiation.
• Laser safety management, local rules, the desig-
nation of the laser controlled area, the role of the
laser protection advisor and laser protection
supervisor, and how to deal with a suspected
case of accidental exposure.
• Hazards from reflection or absorption of the
laser beam with respect to instruments and
other substances and hazards associated with
anaesthetic mixtures.
• Precautions to ensure that exposure of unpro-
tected skin and eye of those present is less than
the maximum permissible levels.
• Hazards to the patient associated with laser
treatment procedures and methods of minimis-
ing risks.
• Incidental hazards, such as electrical hazards,
fire and explosion risk, cryogenic liquids, atmo-
spheric contamination and tissue debris.
• Recommendations of relevant standards and
guidelines.
• Principles of risk assessment.
• It may be appropriate to refer to other sources of
intense non-ionising radiation, such as arc dis-
charges and light-emitting diodes.
It is thought that the material could normally be
covered in lectures totalling approximately four
hours.
In the USA a laser safety officer (LSO) is responsi-
ble for monitoring laser safety hazards. The ANSI
recommend that the following topics be included in
a laser safety education course for laser safety.
 12 Lasers in Dermatology
Laser Safety Education Program 2
1. The laser
(a) Physics and biological effects
(b) Components of the laser system, delivery
devices, and instrumentation
(c) Overview of clinical applications
2. Administrative controls
(a) Laser committee
(b) Role of the LSO
(c) Development of policies/procedures
(d) Documentation methods
(e) Regulations, standards, and recommended
professional practices
(f) Certification criteria and skills validation
(g) Medical surveillance
3. Perioperative safety
(a) Controlled access
(b) Eye protection
(c) Reflection hazards
(d) Flammability hazards and draping
(e) Electrical safety
(f) Management of plume
(g) Management of anesthesia in airway surgery
(h) Equipment testing, aligning, and trouble-
shooting
Clinical Training
In the UK the importance of cutaneous laser therapy
as a component of dermatological surgical practice is
acknowledged. Training in this aspect of dermatolo-
gical practice should ideally be addressed at specialist
registrar level. Registrars should have a basic under-
standing of laser physics, laser safety issues and
current regulations relating to the safe use of lasers,
as outlined in the "Guidance on the safe use of lasers
in medical and dental practise" produced by the
Medical Devices Agency. Specialist registrars should
have an understanding of the clinical use of lasers in
the treatment of cutaneous vascular and pigmented
disorders and the use of ablative lasers such as the
Er: YAG and CO 2 lasers. Specialist registrars should
have observed treatment of common vascular dis-
orders such as port wine stains with a pulsed dye
laser and if possible another laser suitable for vascu-
lar disorders. They should have observed the clinical
2Reproduced with permission from the American National
Standard Z136.3 (1996). Copyright Laser Institute of America
Orlando, Florida.
use of ablative lasers and Q-switched lasers in the
treatment of pigmented lesions. Not all dermatology
departments in the UK can offer this training in
lasers and the specialist registrar may need to visit a
dermatological laser centre to gain this experience.
For more advanced training in cutaneous laser
therapy, this can be achieved towards the end of spe-
cialist registrar training. A period of 4-12 months
training would be necessary. At the end of this
period of training the registrar in addition to the
basic-level training would have acquired more
advanced laser skills. These would include an under-
standing of the relative merits and limitations of the
available lasers for cutaneous disorders and the
value of non-laser treatments. They will have under-
taken assessments, counselling, treatment and
follow-up of patients requiring laser treatment with
the following disorders: adult and paediatric port
wine stains, telangiectasia, pigmented skin lesions,
tattoos, hair removal and lesions for ablation or
resurfacing. The advanced trainee should also have
experience of managing the work of laser operators
from allied health care professions and have an
understanding of the issues relating to supervision
and training. It is recommended that the overall
training of a registrar should be by one individual
who would be responsible for monitoring the train-
ing programme. It is likely in the future that the
accredited laser centres and responsible clinicians
will develop training programmes further.
. In ~he ~SA training in cutaneous laser therapy
IS beIng Incorporated into many residency pro-
grammes, with a component of this subject included
in certifying examinations. There are a number of
Continuous Medical Education (CME) courses in
the use of lasers for physicians in practice. It is likely
that speciality boards will standardise the credent-
ialing process in the near future with guidelines on
residency training and CME course contents. In
individual health care institutions the process of
laser credentialing for individual clinicians will
depend on evidence of the individual's abilities and
training as well as his or her board certification. An
LSO or laser safety committee may need to advise
on an individual's suitability. The ASLMS offers
guidance on content of laser education courses,
and standards of training for physicians in the use
of lasers and office-based laser procedures. The
American Academy of Dermatology has produced
~eco.mmendations for credentialing and privileg-
Ing In dermatology which includes dermatological
' surgery and laser surgery.

References and Further Reading
Laser Hazards
Baggish MS, Poesz B, Jorot D, Williamson P, Refai A (1991)
Presence of human immunodeficiency virus DNA in laser
smoke. Lasers Surg Med 11:197-203
Fretkin S, Beeson WH, Hanke CW (1996) Ignition potential of the
585 nm pulsed-dye laser. Dermatol Surg 22:699-702
Garden JM, O'Banion K, Shelnitz LS et al (1988) Papillomavirus in
the vapor of carbon dioxide laser-treated verrucae. JAMA
259:1199-1202
Hughes PSH, Hughes AP (1998) Absence of human papillo-
mavirus DNA in the plume of erbium:YAG laser-treated warts.
JAm Acad DermatoI38:426-428
Kokosa JM (1994) Hazardous chemicals produced by laser mate-
rials processing. j Laser AppI6:195-201
Matthews j, Newsom SWB, Walker NPj (1985) Aerobiology
of irradiation with the carbon dioxide laser. J Hosp Infect
6:230-233
Moseley H (1994) Ultraviolet and laser radiation safety. Phys Med
Bioi 39: 1765-1799
Walker NPj, Matthews j, Newsom SWB (1986) Possible hazards
from irradiation with the carbon dioxide laser. Lasers Surg
Med6:84-86
Wood RL, Sliney DH, Basye RA (1992) Laser reflections from
surgical instruments. Lasers Surg Med 12:675-678
Laser Training
Guidelines for office-based laser procedures (1997) American
Society for Laser Medicine and Surgery, Inc. Lasers Surg Med
21:210-214
The Safe Use of Lasers 13
Pfister JI (1997) Education and credentialing in laser surgery. In:
Arndt KA, Dover jS, Olbricht SM (eds) Lasers in cutaneous and
aesthetic surgery. Lippincott-Raven, Philadelphia, pp 446-471
Recommendations for credentialing and privileging (1998)
American Academy of Dermatology. j Am Acad Dermatol
39:765-786
Standards of training for physicians for the use oflasers in medi-
cine and surgery (1991) American Society for Laser Medicine
and Surgery, Inc.
Reference Documentation and Standards
UK
BS EN 60825-1 1994: Radiation safety of laser products, equip-
ment classification, requirements and user's guide.
BS EN 60601-2-22 1993: Medical electrical equipment. Part 2:
Particular requirement for the safety of diagnostic and thera-
peutic laser equipment.
BS EN 207 1994: Specification for filters and equipment used for
personal eye-protection against laser radiation.
BS EN 208 1994: Specification for personal eye protectors used for
adjustment work on lasers and laser systems.
Guidance on the safe use of lasers in medical and dental practice.
Medical Devices Agency, London SE1 6TQ. Fax: ++(0) 171 972
8105. E-mail: wodowd@doh.gov.uk
USA
American National Standard for Safe Use of Lasers in Health
Care Facilities ANSI Z136.3-1996. American National Standards
Institute, 11 West 42nd Street, New York, NY 10036. Publisher:
Laser Institute of America, 12424 Research Parkway,
Suite 125, Orlando, FL 32826. Fax: (407) 380-5588. E-mail:
LIA@mail.creol.ucf.edu. Home page: www.creol.ucf.edu/zlia/
ANSI Z136.1 Safe use oflasers
 ser Treatment of Cutaneous
scular Lesions
Treatment of Port Wine Stains
Principles of Selective Photothermolysis
and the Treatment of Port Wine Stains
Current successful treatment of port wine stains
(PWS) follows the principles of selective photo-
thermolysis proposed by Anderson and Parrish
(1981,1983) (see Ch.l). The target in PWS is haemo-
globin in cutaneous blood vessels. By the appropriate
selection of wavelength, pulse duration and energy
fluence the chosen chromophore can be selectively
thermally damaged. PWS are benign, vascular naevi
consisting of ectatic dermal capillaries situated pre-
dominantly superficially in the dermis. The colour of
the PWS is related in part to the erythrocyte content
of the ectatic capillaries (Barsky et aI, 1976). Laser
treatment that successfully reduces the number, size
and erythrocyte content of these vessels results in
observable lightening of the PWS.
The absorption spectra of oxyhaemoglobin and
melanin are shown in Fig. 3.1. For selective destruc-
tion of red cells, light preferentially absorbed by
haemoglobin is necessary. It can be seen from the
figure that haemoglobin has three major absorption
peaks at 418, 542 and 577 nm. Although 418 nm is the
strongest absorption peak the penetration of light at
this shortest wavelength is not sufficient to treat the
dermal capillaries. In addition melanin, which is a
competing absorber of light in the visible range, has a
falling absorption capacity with longer wavelengths.
Light at 577 nm is selectively absorbed by haemo-
globin compared to other cutaneous structures and
will penetrate into dermal vessels. When laser light
1S
- - - Melanin
c
o
""8.
....
o(f)
.n
«
350 450 550 650 750
Wavelength (nm)
Fig. 3.1. Absorption spectra of oxyhaemoglobin and melanin.
energy of sufficient fluence is absorbed by haemo-
globin local heating will occur from within the blood
vessel (van Gernert et aI, 1995). Depending on the
duration of the heat application this temperature rise
will diffuse outwards to the vessel wall and beyond
to the perivascular connective tissue. The extent of
heat diffusion can be estimated with reference to the
thermal relaxation time: this is the time it takes for a
heated container, e.g. a cutaneous blood vessel, to
lose half of its maximum heat. The thermal relax-
ation time is related to the diameter of the vessel
(De Boer et aI, 1996). In PWS, vessel diameters can
range from 10 to >100 /Lm. The thermal relaxation
time of vessels in this size range has been measured
as 1-10 ms (Dierickx et aI, 1995). Blood vessel dia-
meter increases with age and pink PWS tend to have
smaller blood vessels than purple PWS. If the pulse
duration of the laser greatly exceeds the thermal
relaxation time of the targeted blood vessel, non-
selective thermal damage will occur to perivascular
 16 Lasers inDermatology

connective tissue and beyond, leading to adverse
clinical events such as scarring. Conversely, if the
pulse dl,lration is very short vessels can be punctured
by the laser beam with haemorrhage but the duration
of heating is insufficient to result in permanent
damage to blood vessels with no resulting lightening
of the PWS (Garden et aI, 1986) (Fig. 3.2).
Other factors to consider in the selective photo-
thermolysis of PWS are:
1. Epidermal melanin (Tan et aI, 1984). As can be
seen from Fig. 3.1, melanin also absorbs visible
light. In patients with darker skin types more of
the laser energy will be absorbed within the pig-
mented epidermis; this can result in insufficient
energy reaching blood vessels and an increased
incidence of unwanted postinflammatory pig-
mentary changes.
2. Beam diameter (Keijzer et aI, 1991). Many of the
observations relating to the interactions of laser
light and skin have been made from mathemat-
ical models. The effects of diffusion losses at the
edges of a laser beam can contribute to loss of
energy in the centre with very small beam diame-
ters. Conversely with wide beams back-scattered
irradiance augments the central beam energy. In
general terms large laser beam diameters have a
deeper penetration than smaller beams when the
same energy fluence is delivered.
3. Shadowing effects (Lucassen et aI, 1996). As dis-
cussed previously, light penetrating skin can be
absorbed and scattered. Coherent laser light pen-
etrates skin from above and penetrates centrally;
the light is attenuated with distance. When
strongly absorbent molecules interact with the
light no further penetration occurs. This explains

1. Laser pulse too short (e.g. Q-switched laser)

Laser pUlse-----t I Light

absorption
Heat
diffusi on
The rma l
injury

@ @® o
2. Laser pulse too long (e.g. continuous wave laser)

Laser pUlse---t I

@
-® @@o
3. Laser pulse appropriate to thermal relaxation time

Laser PUlse-----t I Light

absorption
Heat
diffusion
Therma l
injury

Derma l
c.onnective -
t issue

Endothelium

Red cel ls

Fig. 3.2. Schematic diagram of effect of pulse duration on thermal injury to a dermal blood vessel.
 Laser Treatment of Cutaneous Vascular Lesions 17

the very short penetration depth of the Er:YAG The PDL is activated by the discharge of a high-
laser, which is avidly absorbed by tissue water. In power flashlamp. The active medium is a rhodamine
a PWS there is a three-dimensional matrix of dye selected to produce yellow light at 577 or 585 nm.
blood vessels. If strong absorption of light occurs Most lasers emit the latter and despite the original
in the most superficial capillaries there will be title of tunable dye laser these lasers are not tunable
insufficient penetrating light to effect thermal in clinical situations and the wavelength is fixed. The
damage to deeper vessels. For this reason 585 nm pulse duration is also fixed at 450 /Ls so the main
light has been used in tunable dye lasers instead variables are the spot size and the fluence. Spot sizes
of 577 nm. This longer wavelength light pene- available with modern lasers are 3, 5, 7 and 10 mm.
trates more deeply, is less well absorbed by Five and 7 mm spot sizes are generally preferred as
melanin but also less avidly absorbed by haemo- these will cover larger areas quicker than 3 mm. It
globin in superficial capillaries, so some light is may not be possible to obtain sufficiently high
scattered downwards to deeper blood vessels. Tan fluences at 10 mm but this spot size is valuable when
(1989) demonstrated that by increasing the wave- low energies are used in delicate tissue areas such as
length of the flashlamp pumped pulsed dye laser the neck and eyelid.
from 577 to 585 nm the depth of penetration The energy fluence used can be determined by
increased fn)m 0.5 to 1.2 mm while still retaining performing a test treatment over a range of fluences
selectivity of cutaneous blood vessels. and reviewing the patient 8 weeks later. The lowest
fluence producing lightening of the PWS can be
In fact the interactions of laser light and PWS are
used. As a general rule with a 7 mm spot fluences
extremely complex. Mathematical models of PWS
will be in the range of 4.5-8 J/cm 2• The lower range
make a number of assumptions and can be consid-
of fluences should be used in the paediatric patient
ered only an approximation of a true PWS. Clinical
and at delicate skin sites. As treatment progresses
and histological assessments of PWS-Iaser inter-
with lightening of the PWS it is reasonable to cau-
action have demonstrated the efficacy of laser treat-
tiously increase the fluence by 0.25-0.5 J/cm 2 to
ment but it is acknowledged that PWS are far more
maintain improvement. It should be acknowledged,
heterogeneous than originally assumed.
however, that not all PWS will clear with PDL treat-
ment and repeatedly increasing the fluence in a non-
Port Wine Stain Treatment with the responding PWS will increase the likelihood of an
Flashlamp Pulsed Dye Laser adverse reaction.
Pretreatment assessment of the patient should
The flashlamp pulsed tunable dye laser (PDL) was include a record of previous treatment and its
the first laser specifically designed for the selective effects. Argon laser treatment in particular can
photothermolysis of cutaneous blood vessels. I produce frequent pigmentary disturbances, espe-
consider the PDL the best laser for the treatment cially hypopigmentation, which may not be obvious
overall of a mixed population of patients with PWS in a partially treated PWS but becomes very obvious
although individuals may benefit from other lasers after successful PDL therapy. Scarring from previous
(Table 3.1). treatment should be recorded. The patient should be
advised not to expose their skin to sunlight as a tan
overlying the PWS will interfere with therapy. Good-
Table 3.1. Lasers used for treatment of port wine stains quality standardised colour photographs should be
taken at baseline. It is useful to show the patients a
Laser Wavelength (nm) Pulse duration (ms) portfolio of photographs to illustrate the procedure,
in particular the bruising that will occur after treat-
Pulsed dye 577.585 0.45 ment. In the UK a small illustrated book, Puss Puss
Long pulsed dye 585.590.595.600 1.5 and the Magic Laser (Pod Publications, Companion
Argon 488.514 50- 200
Argon pumped dye 577,585 50- 200 Books, PO Box 7, Cupar, Fife KY15 4PF, UK), helps to
Copper vapour 578 50- 200 inform children of the treatment process. Adults are
KTP 532 2- 20 provided with printed leaflets explaining the treat-
Krypton 568 50-200 ment and its after-effects and care of the skin.
Carbon dioxide 10.600 50- cJw
PDL treatment causes discomfort or pain to the
Clw = continuous. patient. There is a sharp stinging sensation similar
 18 Lasers in Dermatology

to being flicked with an elastic band. The stinging is in infants under 1 month. There are concerns of
replaced by a hot itching sensation. One or two laser absorption of AmetopR from highly vascular surfaces
impacts will be tolerated by most adults but treat- and large areas should not be treated with this
ment of a large surface, especially on the face, can be drug. Skin irritation and allergic rashes can occur.
distressing. Some stoic individuals appear to be able Although AmetopR has vasodilatory properties this
to tolerate large treatments without distress but does not appear to effect outcome after PDL treat-
this should not be assumed. Two per cent of my ment. These creams may not be available in all coun-
own patients surveyed described severe pain after tries. Use of a cryogen spurt to cool the skin (see
treatment despite attempts at adequate analgesia below) can also reduce pain from the laser impacts
(Lanigan, 1995). on the skin. Despite correct techniques sensitive
Topical anaesthetic agents can assist patients. A areas of the face, especially the upper lip and peri-
eutectic mixture of local anaesthetic (EMLAR) cream orbital areas, may not be adequately anaesthetised.
containing lignocaine 2.5% and prilocaine 2.5% has Additional infiltrational and nerve block anaesthesia
been shown effective in reducing PDL-induced pain can be used to supplement the topical agents; this in
(Lanigan and Cotterill, 1987; Sherwood, 1993). The itself can be traumatic for the patient.
cream must be applied thickly under occlusion to the In children these anaesthetic techniques are often
PWS for 90 min to 4 h before treatment. (Fig. 3.3). It not enough and in my experience the majority will
is not indicated for children under 1 year. Although require general anaesthesia as a day case procedure
the cream has vasoconstrictive properties this does (Rabinowitz and Esterly, 1992). Some authors advo-
not appear to interfere with treatment outcome, and cate sedation in combination with other anaesthetic
EMLA R cream is well tolerated. An alternative to techniques without general anaesthesia. The proce-
EMLAR is AmetopR, a 4% amethocaine gel which has dure can cause anxiety in children as well as dis-
the advantage of a more rapid onset of action of comfort as their eyes are covered and the laser emits
30-45 min (Armstrong et aI, 1996). It also should noises as well as light during the treatment.
be applied under occlusion and is not recommended After the test treatment each subsequent procedure
involved placement of laser impacts over the whole
PWS using the lowest fluence to achieve lightening.
This may need to be reduced over the eyelids, upper
lip and neck. Each impact of the laser produces a
visible purpuric discoloration which appears either
immediately or within minutes. This is a sharply
demarcated circle which allows the operator to place
the next spot adjacent to it. Although some authors
advise application of contiguous, non-overlapping
spots the Candela PDL beam energy profile is
Gaussian such that there is reduced fluence at the
perimeter of the beam; this allows overlapping of
spots by up to 10%. This will reduce the tendency in
some patients to a spotty appearance as the PWS
clears. Other PDLs may have different beam profiles
and a decision on whether to overlap spots can only
be made on the basis of knowledge of the beam
energy profile (Dinehart et aI, 1994; Jackson et al,
1996).
After treatment the PWS will show a purple
bruised discoloration for 7-14 days, up to 28 days
in the minority (Fig. 3.4). Small areas may crust
or weep but large areas of blistering suggest reduc-
tion of the fluence at the next treatment. The great-
est reaction after treatment occurs early in the
Fig. 3.3. Use of EMLA cream in laser treatment of a port wine course of therapy or after increasing the fluence.
stain.
After each treatment the PWS should be lighter in

Fig. 3.4. Bruising after pulsed dye laser treatment.
Fig. 3.S. Successful treatment of a facia l port wine stain with the pulsed dye laser.
Laser Treatment of Cutaneous Vascular Lesions 19
appearance. Treatments are repeated at an interval
of about 8 weeks. Gradually through a course of
treatment the lightening after each treatment gets
smaller until no further progress can be seen. The
majority of patients will experience satisfactory
lightening of their PWS in the first 4-10 treatments.
Although improvements can occur beyond 20
treatments the small benefits should be balanced
with the morbidity from treatment (Kauvar and
Geronemus, 1995).
There are a number of studies reporting the
efficacy of the PDL in the treatment of PWS. Results
are generally reported in terms of lightening the
PWS rather than clearance, which only occurs in the
minority. The vast majority of reports use subjective
criteria for improvement compared with baseline
photography. Approximately 40% of patients with
PWS achieve 75% lightening or more after laser
treatment (Fig. 3.5), and more than 80% of PWS
lighten by at least 50%. Several prognostic criteria
have been put forward to assist in predicting the
outcome of treatment. Some authors report best
results in pink lesions (Fitzpatrick et aI, 1994).
Others report better results in red lesions (Taieb
et aI, 1994). In a study of 261 patients treated over a
5-year period by Katugampola and Lanigan (1997)
colour of PWS was not found to be a prognostic
value. Although it is generally considered that
younger children require fewer treatments than
 20 lasers in Dermatology
adults, Alster and Wilson (1994) have reported that
younger children may require more treatments
owing to the rapid growth of residual blood vessels
between treatments. Van der Horst et al (1998)
found no evidence that treatment of PWS in early
childhood was more effective than treatment at a
later stage. Edstrom and Ros (1997) compared the
effects of two PDLs on PWS. Twenty-two patients
were treated at either 585 or 600 nm. At equal
fiuences, lightening was superior with the laser at
585 nm. When using fiuences 1.5 and 2 times higher
at 600 nm than at 585 nm, overall lightening was
similar but in 11 of 22 patients it was superior by at
least 20% at the longer wavelength. Nelson et al
(1995) investigated the effect of dynamic cooling
in combination with PDL treatment. In dynamic
cooling, the epidermis is cooled selectively by a
spurt of cryogen applied to the skin for an appro-
priately short time linked to the PDL exposure
(Fig. 3.6). By using a 20-80 ms cryogen spurt the
authors demonstrated protection of the epidermis
Fig. 3.6. Schematic diagram to illustrate cryogen spurt linked
with pulsed dye laser irradiation to protect the epidermis from
therma l damage by dynamic epidermal cooling. (Courtesy of
Candela Corporation.)
from thermal injury without affecting the temper-
ature of deeper PWS.
The combination of higher fiuences at longer
wavelengths as proposed by Edstrom in combin-
ation with dynamic epidermal cooling may allow
further lightening of some PWS.
Two features that may affect outcome are site of
the PWS and size of the naevus. PWS on the face
and neck respond better than those on the leg and
hand (Lanigan, 1996). On the face PWS on the fore-
head and lateral face respond better than those over
the middle of the face, particularly those involving
the second branch of the trigeminal nerve (Renfro
and Geronemus, 1993). The chest, upper arm and
shoulder generally respond well. PWS less than
20 cm 2 at initial examination cleared more than
those greater than 20 cm 2 irrespective of age
(Morelli et aI, 1995).
However, the clinical appearance of the lesion
cannot always be used as the basis for predicting
outcome. Motley et al (1997) used a video micro-
scope to examine the microvascular patterns of
patients with PWS receiving PDL treatment. Two
major patterns of abnormality were identified. One
type showed ectasia localised to the capillary loops
(type 1) and the other was composed of dilated
ectatic vessels in the superficial horizontal plexus in
a ring pattern (type 2) (Fig. 3.7). The type 1 ectasia
was associated with a good outcome from PDL
treatment, while patients with type 2 abnormalities
had a poor response.
Fiskerstrand et al (1996a) examined pretreatment
biopsies of PWS in 30 patients. In the 16 patients with
a good response to the PDL the vessels were signi-
ficantly more superficially located. Poor responders
had significantly smaller vessels. Moderate respon-
ders had deeper and larger vessels than the poor
responders. Vessel diameter correlated with colour,
with pink lesions having the smallest -diameter
vessels and purple lesions the largest. Red lesions
were significantly more superficially located than
pink or purple lesions. The authors concluded that
red PWS predict a good response due to superficial
location of the PWS but pink PWS predict a poor
response due to the small vessel size and deep loca-
tion. Similar observations were made by this group
in the post-PDL-treated PWS biopsies (Fiskerstrand
et al (1996b). Further research is needed in this field
to develop non-invasive assessments of PWS to
determine likely outcomes from PDL treatment and
also to assist in deciding whether other lasers may be
a more appropriate treatment.

I b
Fig. 3.7. Video microscopic and schematic appearance of vessel ectasia in port wine stains: (a) type 1 ; b( ) type 2. (From Lanigan, 1998,
Courtesy of Dr R. Motley.)
Side Effects from Pulsed Dye Laser
Therapy
Notwithstanding the unpredictable response of PWS
to the PDL the other noteworthy feature of this
treatment is the low incidence of side effects.
Postinfiammatory hyperpigmentation is the com-
monest side effect and occurs in between 10% and
27% (Seukeran et aI, 1997; Fiskerstrand et aI, 1998;
Wlotzke et aI, 1996) of patients. Hyperpigmentation
is more common in treated PWS on the leg and is
reversible. Hypopigmentation occurs in less than 1%
of patients and occupies only a small area of the
treated lesion. Atrophic scarring occurs in 1-5% and
hypertrophic scarring in less than 1%. Atrophic
textural changes often improve spontaneously over
6-12 months. Rarer side effects reported occasion-
ally include atrophie blanche-like scarring (Sommer
and Sheehan-Dare, 1999) eczema (Shahidullah and
Frieden, 1999) and keloid formation during iso-
tretinoin therapy (Bernestein and Geronemus,
1997). These figures should be compared with the
results of argon laser treatment of PWS where the
Laser Treatment of Cutaneous Vascular Lesions 21
majority of patients will experience some degree of
post-treatment hypopigmentation and textural
alteration, and incidence of hypertrophic scarring in
up to 26% of patients. The PDL is a considerably
safer and more efficacious laser than the argon laser
when appropriate fiuences are selected. Paediatric
patients can commence PDL treatment in the first
year of life and have completed their treatment
before starting school (Fig. 3.8).
Psychological Aspects of Port Wine Stain
Treatment
The importance of treating PWS has been explored
by investigating the psychological problems associ-
ated with living with a PWS. There has been con-
siderable research into the stigmatising effects of
disfigurement. In patients with PWS this results in
negative psychological, social and developmental
impacts. However, standard psychological screening
tests for psychiatric illness, depression or anxiety
may fail to detect this (Lanigan and Cotterill, 1989;
Kalick et aI, 1981). More specific enquiries into the
 22 Lasers in Dermatology

Fig. 3.8. Pre-school child with a facial port wine stain before and after pulsed dye laser treatment.

psychosocial disabilities of the patients revealed inantly at 488 and 514.5 nm. This is visible blue-
several areas of morbidity including anxiety, embar- green light. These two wavelengths of light are
rassment and the need to hide the PWS. Troilius et alabsorbed by two chromophores in the skin: oxy-
(1998) reported that 75% of their patients had a haemoglobin and melanin. Although the argon laser
PWS which influenced their lives negatively. There wavelengths do not coincide with the absorption
are very few studies to explore whether successful maxima of oxyhaemoglobin there is sufficient
treatment of a PWS will improve psychological well- absorption to produce thermal damage to red blood
being. In the paper by Troilius questionnaires were cells in cutaneous blood vessels. However, because
sent to patients and their families who were either argon laser light is delivered in a continuous mode
on the waiting list for treatment, undergoing treat- which greatly exceeds the thermal relaxation time
ment or having completed treatment. After laser of cutaneous blood vessels there is non-specific
treatment all of the distress parameters were signi- thermal damage to perivascular connective tissue
ficantly relieved. Kurwa et al (1999) followed a group
and beyond (Finley et al 1984). This resulted clin-
of 53 PWS patients who had completed PDL ically in textural alteration, atrophic and hyper-
therapy: the disability scores measured by question- trophic scarring and pigmentary disturbances.
naire fell significantly from pretreatment levels. Treatment techniques using the argon laser differ
There was a close correlation between better out- from those with the PDL. The continuous wave beam
comes from laser treatment in terms of lightening can be mechanically shuttered to a pulse duration of
the PWS and reduction in disability scores. 200 ms or alternatively the operator moves the beam
There is clearly a need for more research into out-
continuously across the surface of the skin to reduce
comes of laser treatment. There is good evidence the exposure time at each unit area of skin. A spot
that successful PDL treatment of PWS can reduce size of 1 mm is used so treatment areas require far
psychological distress but there appears to be great more laser beam impacts than with the PDL. The
inter-patient variability both in expectations and power of the laser is usually between 0.8 and 2 W.
improvements in distress. The clinical end point is minimal blanching. This
is a just-visible, greyish-white discoloration of the
skin (Fig. 3.9). The operator gradually increases the
Argon Laser Treatment of Port Wine power until this change is observed. Treatment para-
Stains meters are then maintained to treat a larger area
either in stripes or concentric circles, starting at the
Throughout the 1980s the argon laser was the most centre and moving outwards, avoiding overlapping
frequently used laser worldwide for the treatment of of laser impacts. The visible change of minimal
PWS. It has been largely superseded by the PDL, blanching inevitably involves non-selective thermal
which became widely available during the latter half damage as it is the visible sign of thermal coagula-
of that decade. The argon laser emits light predom- tion of tissue protein.

Fig.3.9. Minimal blanching effect of the argon laser on a port
wine stain.
Treatment is far more painful than with the PDL
and generally localised areas within a PWS are
treated after infiltrational anaesthesia rather than
the whole PWS in one session. Because of the small
spot size treatment is tedious and time consuming
for the operator.
After treatment the skin invariably weeps and
crusts with some superficial blistering (Finley et aI,
1981). The blanched appearance reverts to a reddish
purple colour after a few days. Gradually after a
period of 4-8 weeks the treated area will visibly
lighten towards normal skin colour. This lightening
can progress for more than 6 months after the initial
treatment. Because of the high incidence of adverse
reactions with the argon laser it is essential to
perform a small test treatment initially, preferably in
an inconspicuous site such as under the hairline or
behind the ear. The presence of scarring in the test
site would normally indicate cessation of treatment
or change to a different laser (Cosman, 1980).
Results of treating PWS with the argon laser are
generally better in adults with purple PWS (Noe et
aI, 1980). Seventy per cent of adult patients will
obtain good to excellent results (Apfelberg et aI,
1978). The majority of patients, however, will have
some degree of textural abnormality and perma-
nent hypopigmentation which was not always con-
sidered an adverse result (Fig. 3.10). Hypertrophic
scarring ranged from 9% to 26% (Dixon et aI,
1984). Even patients with an excellent patch test can
go on to develop scarring when a large treatment
area was performed. The results in children were
not considered good enough and scarring rates too
high to recommend the argon laser for paediatric
PWS.
LaserTreatment of Cutaneous Vascular Lesions 23
Fig. 3.10. Hypopigmentation after argon laser treatment of a
port wine stain.
Continuous Wave Dye Laser Treatment
of Port Wine Stains
An argon laser can be used to energise a rhodamine
dye to produce coherent light at 577 or 585 nm. As
with the argon laser the light emerging is continuous
but can be mechanically shuttered to produce pulses
of light tens to hundreds of milliseconds in duration.
The longer wavelength was considered advantageous
compared to the argon laser wavelength as discussed
above. Lanigan et al (1989) reported the results of
treating 100 patients with PWS with the continuous
wave dye laser at 577 nm. A minimal blanching tech-
nique was used with a 2 mm spot size, 0.2-2.0 s pulse
duration and fluence of 10-32 J/cm 2• A good or excel-
lent response was seen in 63%, with a fair result in
17%. Twelve per cent of patients had a poor response
(Fig. 3.11). Hypertrophic scarring occurred in 5% and
a similar percentage had postinflammatory hyper-
pigmentation. The best results were seen in older
patients with purple PWS. These results were similar
to those obtained with the argon laser. MaIm et al
(1988) also found similar results with argon and con-
tinuous wave dye lasers. It would appear that any
advantage gained by longer wavelength was offset by
the long pulse durations employed and the use of
minimal blanching as an end point. Scheibner and
Wheeland (1989, 1991) developed a tracing technique
with the continuous wave dye laser to treat PWS. This
involved low powers with magnifying binoculars.
Excellent results were obtained in 44% of adults with
PWS and in 38% of children. This technique, which is
technically difficult, has not been widely utilised.
Dover et al (1995) treated 28 patients with PWS with
 24 Lasers in Dermatology

power meter, 30-990 ms electronic shutter and a

focusing device that provides a 1 mm spot diameter
with uniform energy distribution. The automated
programme places pulses of energy in a precise,
non-adjacent pattern in the shape of a hexagon (see
Fig. 3.12). The number of pulses delivered will deter-
a mine the size of the hexagon, which varies from
3 mm to 13 mm in diameter. Approximately 20 s are
required to create the largest hexagon, which con-
tains 127 pulses. Adjacent hexagons can then be
applied to cover the PWS skin. For anatomically
difficult sites, e.g. around the nose, smaller hexagons
can be utilised to complete coverage (Rotteleur et aI,
1988).
The advantages of automated scanning devices
______ _____
b ~ ~~
are shorter pulse durations, uniformity of energy
placement, faster treatments and reduced operator
Fig. 3. 11. (a) Port wine stain on right cheek before and after fatigue. In a study using scanning devices compared
treatment with the argon pumped continuous wave dye laser.
(From Lanigan et ai, 1989.) (b) Small port wine stain on upper lip
with conventional techniques the rates of scarring
after one (left) and two (right) treatments with the argon pumped were substantially reduced and clinical results
continuous wave dye laser. improved in the scanned patients (Mordon et aI,
1989). Early studies used a minimal blanching tech-
nique with powers of around 3 Wand fiuence of
the PDL and a continuous wave dye laser delivered 16-24 J/cm2. Once the fiuence is chosen the pulse
through a Hexascan R• Results were better in 45% of duration is automatically selected by the laser based
patients treated with the PDL and in 15% of patients on the power currently available from the laser.
treated via the Hexascan R• There was a higher inci-

o u
dence of hyperpigmentation with the continuous
wave laser but no differences in the incidence of scar-
ring or hypopigmentation. The authors used a grey
discoloration of treated skin as their end point with
the Hexascan R•
1 mm spot 5 mm hexagon
Robotic Scanning Handpieces
As has been discussed, the major disadvantage of
continuous wave lasers in the treatment of PWS is
the long pulse duration, which results in non-
specific thermal damage to connective tissue. In 9 mm hexagon 13 mm hexagon
addition, manual movement of a continuous wave
laser beam over the skin is dependent on the oper-
ator's skill not to under- or over-treat the area.
Robotic scanning devices have been developed to
try and address some of these difficulties. These
handpieces can be used in conjunction with contin- Distribution of
uous wave laser such as argon, argon dye, krypton scanned spots to
and frequency-doubled Nd:YAG; and also quasi- avoid thermal injury
continuous lasers such as the copper vapour and Placement of
KTP:YAG lasers. adjacent hexagons
The Hexascan R has been most widely used in to cover large areas
treatment of pws.1t is connected to the laser source
Fig. 3.12. Diagram of Hexascan R robotised scanning system.
by a fibre-optic cable. The handpiece contains a

Patients experience less discomfort with this tech-
nique than with freehand treatment.
(opper Vapour Laser Treatment of Port
Wine Stains
The copper vapour laser (CVL) is one of two heavy
metal vapour lasers (the other being gold vapour)
used clinically. Results of treating PWS with this laser
were reported in the early 1990s (Pickering et aI,
1990). The wavelengths oflight emitted by a CVL are
510 and 578 nm. The longer-wavelength yellow light
is well absorbed by oxyhaemoglobin and useful clin-
ically. In contrast to other yellow light laser the CVL
emits a train of pulses with a duration of 20-25 ns
and 10,000-15,000 pulses per second (10-15 Hz).
Because of the very short gap between each pulse of
light from the CVL (60-120 fLS) the biological effect
of this laser is similar to that of a continuous wave
laser. The CVL is often termed a quasi-continuous
laser for this reason.
In the treatment of PWS the CVL is either used
freehand in a "point-by-point" method with a 1 mm
spot size and mechanical shuttering of light to
50-200 ms. (Neumann et aI, 1993; Dinehart et aI,
1993). This technique is similar to that used with
argon and argon dye lasers. Alternatively the light
can be directed through an automated scanning
device, the most widely reported being the
Hexascan R• The scanner reduces the pulse duration
to 50 ms. Good or excellent results have been
reported in treating PWS with the CVL. Best results
are seen in predominantly purple or red PWS. Pink
or red PWS in children are likely to be better treated
with the PDL.
In comparison with the argon laser, Sheehan-Dare
and Cotterill (1993) found that the CVL produced
superior results using a minimal blanching tech-
nique and a Hexascan R • In a later study (1996) the
same authors comparing the CVL, argon laser and
frequency-doubled Nd:YAG laser with similar pulse
widths through a scanner found only small differ-
ences in the results with the three lasers in the treat-
ment of purple PWS. Jonell and Larko (1994) treated
19 patients previously treated with the argon laser
with the CVL. The latter produced a better effect in
eight and an equal effect to the argon laser in nine
patients.
Adverse reactions with the CVL are infrequent
but most studies have been on small numbers of
patients. Textural changes and pigmentary disturb-
LaserTreatment of Cutaneous Vascular lesions 2S
ances are most commonly reported. Use of minimal
blanching fluences will cause epidermal blistering.
Fluences exceeding 15 Jlcm 2 (Neumann et aI, 1993)
produced non-specific epidermal and dermal coagu-
lation necrosis histologically. Most authors do not
recommend the CVL for paediatric patients because
of the long pulse durations employed.
Nd:YAG Laser Treatment of Port Wine
Stains
The Nd:YAG laser is a solid-state laser containing
a crystal rod of yttrium-aluminium-garnet doped
with neodymium ions (Nd:YAG). The laser is
pumped by a flashlamp and emits light in the
infrared at 1064 nm. It is either delivered as a contin-
uous beam or pulsed in Q-switched mode. Frequency
doubling of the Nd:YAG laser produces green light at
532 nm half the wavelength of the primary laser
light. 1064 nm light is poorly absorbed by the chro-
mophores in the skin and penetrates deeply into
tissue with wide diffusion of the beam. Although this
laser has been used for the treatment of PWS as a
continuous wave laser it has only been of value in
reducing bulky, hypertrophic lesions (Landthaler et
aI, 1986). Because of the non-specific thermal damage
there is a significant risk of scarring.
Although the continuous wave green 532 nm
wavelength light is absorbed by haemoglobin it is
not deeply penetrating and there is little published
information on the efficacy of this wavelength in the
treatment of PWS. As a Q-switched laser at either
wavelength the short pulse duration (5 ns) is in-
appropriate for the thermal relaxation time of PWS
blood vessels. Haemorrhagic rupture of vessels may
occur but the short pulse duration does not cause
full-thickness vessel damage.
There are two interesting laser developments pro-
ducing green light at 532 nm. The first is the KTP
laser (Aura Laserscope). The Nd:YAG wavelength of
1064 nm is frequency doubled with a KTP (potas-
sium titanyl phosphate) crystal to produce green
light at 532 nm. This is a quasi-continuous laser with
individual pulses of 200 ns produced at a frequency
of 25,000 Hz. This train of pulses can be shuttered to
deliver macro pulses of 2-20 ms. High fluences are
available with this laser and the pulse durations may
be more appropriate for some PWS. In a preliminary
investigation comparing a KTP 532 nm laser with an
argon laser (Apfelberg et aI, 1986), in 14 patients
with PWS treated with these lasers the results were
 26 Lasers in Dermatology
Fig. 3.13. Port wine stain on ankle treated with Aura KTP laser
with Smart5(an~.
equivalent in 12 and superior with the KTP laser in
two. There is little published data on this laser but it
does appear clinically effective and does not pro-
duce the purpura seen with the PDL. When deliv-
ered through a robotic scanning device, Smartscan R,
hexagonal patterns can be delivered similar to the
Hexascan R and the treatment is well tolerated by the
patient (Fig. 3.13).
The Versapulse, produced by the Coherent Laser
Company, is another long pulsed Nd:YAG laser at
532 nm. The laser has a spot size of 2-10 mm and a
pulse width of 2-10 ms. The handpiece contains a
water-cooled chilled tip to reduce epidermal heating
and patient discomfort. Multiple passes have been
employed over the same area after compressing the
skin with the handpiece. Like the KTP laser there is
more data concerning the use of these lasers in the
treatment of telangiectasias but the Versapulse has
been shown to lighten PWS (Tanghetti and Adrian,
1998; Dummer et aI, 1998).
Krypton laser
The krypton laser produces green and yellow light at
521, 530 and 568 nm. The two shorter green light
wavelengths can be filtered out to leave the yellow
wavelength for the treatment of vascular lesions. The
krypton laser is a continuous wave laser and the light
can be delivered through robotic scanning devices as
with other continuous and quasi-continuous wave
lasers discussed with pulsed durations of 50 ms.
There has been almost no published data on the use
of this laser in the treatment of PWS.
CO 2 laser Treatment of Port Wine Stains
The CO 2 laser will be discussed in greater detail in
Ch. 6. I consider its use in the treatment of PWS pri-
marily of historical interest although it may have
a role in the removal of haem angiomatous blebs
within PWS resistant to other lasers. The CO 2 laser
emits infrared light at 10,600 nm, which is absorbed
by tissue water. In a continuous mode the laser will
non-selectively vaporise tissue. It was hypothesised
that if the majority of ectatic blood vessels were
localised superficially within the dermis, vaporis-
ation of tissue down to this level but no further
would result in clinical lightening of the PWS
without scarring. Prior to the widespread use of the
PDL the CO 2 laser was considered of potential value
in the treatment of PWS. Lanigan and Cotterill
(1990) reported the results in 51 patients with PWS:
29 of the patients had failed to respond to argon or
continuous wave dye laser; 22 were children with
pink PWS. Good or excellent result were seen in 74%
of adults and 53% of children. Two children (12%)
had a poor result, including a hypertrophic scar on
the neck in one. Histological examination of treated
PWS showed a zone of residual thermal necrosis
with residual ectatic vessels and sparing of cutan-
eous appendages. More recently, Miralles et al (1996)
treated the tuberous component of 30 patients unre-
sponsive to PDL treatment. In all patients the lesions
disappeared but textural changes were seen in 37%,
with one patient developing hypertrophic scarring.
In view of the excellent safety profile of the PDL in
the treatment of PWS the COzlaser cannot be recom-
mended as initial treatment of PWS.
laser Treatment of Capillary
(Strawberry) Haemangiomas
Capillary or strawberry haemangiomas are common
benign tumours of infancy. Most develop during the
first to the fourth week of life and are characterised
by an early proliferative phase which usually last for
6-9 months with a tumorous enlargement of the
lesion. This growth phase slows down and is fol-
lowed by a gradual spontaneous involution which
is complete in the majority by 5-10 years of age.

Deeper (cavernous) haemangiomas often do not
completely regress.
The majority of strawberry haemangiomas are of
cosmetic concern only although the appearance of a
large vascular tumour on the face of a baby is not
without significance. However, some haemangiomas
can cause problems by interference with organ func-
tion, e.g. periocular haemangiomas with vision,
subglottic and intranasal haemangiomas with swal-
lowing and respiration. Bleeding and ulceration can
occur particularly in perineal haemangiomas. Most
complications occur during the proliferative phase
of the haemangiomas and once regression is under
way the majority of complications associated with
the haemangioma will settle. Regression of many
haemangiomas is incomplete, leaving either a fiat
telangiectatic patch or an area of redundant dis-
coloured skin. If ulceration has occurred scarring
may follow.
Laser treatment of strawberry haemangiomas is
performed either to slow or arrest proliferation in
early haemangiomas, correct or minimise complica-
tions, or cosmetically improve residual telangiectatic
lesions. Apfelberg et al (1981) first reported the use
of the argon laser for the treatment of capillary hae-
mangiomas. Treatment with this laser has been
limited by textural and pigmentary alterations. The
continuous wave Nd:YAG laser has also been used;
this laser has a deep penetration, with thermal coag-
ulation of large volumes of tissue. It is useful for
debulking large haemangioma but hypertrophic
scarring frequently occurs (Landthaler et al, 1995).
Intraoral haemangiomas can respond particularly
well to this form of treatment (Dixon et aI, 1986).
Nd:YAG and KTP lasers can also be used intrale-
sionally in the treatment of bulky haemangiomas
(Wimmershoff et ai, 1999; Achauer et ai, 1999). A
bare fibre is inserted into the tumour and irradi-
ation performed as it is withdrawn. Substantial
shrinkage of tumours can occur.
The majority of patients treated currently are with
the PDL. The fist report of a patient treated with the
PDL was by Glassberg et al (1989). The infant was
6 days old and the haemangioma was still macular.
This report and subsequent publications emphasise
the importance of early treatment of proliferative
haemangiomas to obtain most benefit from treat-
ment (Ashinoff et al 1991; Garden et ai, 1992). The
PDL has a penetration depth of just over 1 mm and it
is unrealistic to expect significant alterations in a
large mature capillary haemangioma. Fluences of
5.5-6 J/cm 2 with a 5 mm spot are generally used with
Laser Treatment of Cutaneous Vascular Lesions 27
treatment interval reduced to every few weeks to
achieve clearance of the lesion. Multiple treatments
may be required. In small infants anaesthesia with
amethocaine gel may be adequate; general anaesthe-
sia is sometimes required. The deeper component
of the haem angioma may still develop despite suc-
cessful treatment of the superficial component. For
life-threatening proliferative haem angiomas a com-
bination of laser treatment, systemic steroids and
interferon may be required under supervision in a
specialist paediatric unit.
The complications of bleeding and ulceration
respond very well to PDL treatment. Usually only
one or two treatments are required and there is a
prompt response. Noticeably the pain from an ulcer-
ated haemangioma regresses rapidly after treatment
(Barlow et ai, 1996; Morrelli et aI, 1991). In some
patients the haemangioma will also undergo regres-
sion, but this is not always the case. The whole hae-
mangioma and not just the ulcerated or bleeding
area should be treated.
In the incompletely regressed capillary haeman-
gioma in the older child superficial ectatic blood
vessels can be easily treated with the PDL but scar-
ring or redundant tissue may require surgical repair.
It is important to ascertain the patient's expectations
before embarking on a course of laser therapy as
surgical excision may be preferred.
Laser Treatment of Leg Veins and
Telangiectasias
Visible veins on the leg are a common cosmetic
problem and remain a therapeutic challenge.
Sclerotherapy is currently the gold standard of
therapy but many vessels less than 1 mm in diameter
are difficult to inject. Side effects of sclerotherapy
include scarring, ulceration, hyperpigmentation and
telangiectatic matting. The majority of leg vein
telangiectasias are in the range of 0.1 mm to several
millimetres in diameter - much larger than the
vessels in a port wine stain, which are 0.1 mm or
less. Very small red superficial telangiectasias will
respond readily with most of the lasers already dis-
cussed. Following the principles of selective pho-
tothermolysis, most vessels greater than 0.1 mm will
require pulse durations longer than that delivered
currently by the PDL. The larger the vessel the longer
the desired pulse duration. In addition, longer wave-
lengths of light may be required to penetrate deeply
 28 Lasers in Dermatology

Table 3.2. Lasers used for the treatment of leg veins Massey and Katz (1999) using the same laser with a
50 ms pulse (Versapulse HELP-G) with ftuences of
Laser Wavelength (nm) Pulse duration (ms) 18-20 J/cm 2 treated 46 patients with leg veins. In
patients with veins less than 1 mm in diameter, 80%
KTP 532 1-100 had greater than 50% clearing after two treatments.
Pulsed dye 585 0.45
Long pulsed dye 585,590,595,600 1.5 In patients with veins 1-2 mm in diameter, 67% had
Ultra long pulsed dye 595 4 greater than 50% clearing after two treatments. Side
Alexandrite 755 3-20 effects were minimal and not permanent. Crusting
Nd:YAG 1064 1-100
or blistering occurred if the chill tip was not kept
Diode 800- 915 1- 250
continuously in contact with the skin.
Recently a study of a long pulsed alexandrite laser
(McDaniel et aI, 1999) with a wavelength of 755 nm
into the dermal blood vessels. In recent years a and pulse duration of 5-20 ms in the treatment of
number of new lasers have been developed to try and leg veins has been published. Haemoglobin has a
tackle these therapeutic problems (Table 3.2). small absorption peak in the infrared and the long
The long pulsed dye laser with wavelengths of pulse durations used allow thermal damage of larger
590-600 nm and a pulse duration of 1.5 ms (three vessels. Treatment at 20 J/cm 2 with double pulses
times longer than the conventional PDL) has been produced almost a two-thirds reduction in vessels
developed (Candela Corporation, Natick, MA; 0.4-1 mm in diameter after three treatments.
Cynosure, Chelmsford, MA) (Hsia et aI, 1997; Hypertonic saline sclerotherapy after laser treat-
Reichert, 1998). Hsia et al (1997) treated 18 patients ment produced a reduction in telangiectasia of
with leg veins ranging in diameter from 0.6 mm to nearly 90%. Several long pulsed Nd: YAG lasers with
1 mm; after one treatment at 15 JI cm 2 50% of vessels 1-50 ms pulses at 1064 nm are also being investi-
cleared, and at 18 J/cm 2 67% of the vessels cleared. gated for treatment of leg veins. The Vasculight
Treatments can be delivered using an elliptical Nd:YAG laser (ESC Medical Systems, Needham, MA)
(2 x 7 mm) spot which can be aligned over the uses synchronised double or triple pulses. Weiss and
telangiectasias. Several studies have shown this laser Weiss (1999) treated 30 patients with this laser and
to be efficacious in the treatment of small-vessel at 3 months follow-up 75% improvement was noted.
telangiectasia on the leg. Reichert (1998) treated Further research using millisecond domain lasers
80 patients with the long pulsed dye laser using such as diode lasers around 900 nm are likely to add
ftuences of 16-22 J/cm 2. One hundred per cent clear- to the therapeutic armamentarium of laser treat-
ance was achieved in vessels with diameters up to ment of leg veins. When using long-wavelength
0.5 mm and 80% fading in vessels between 0.5 mm lasers with deep penetration but relatively poor
and 1.0 mm. Hohenleutner et al (1998) also found absorption the combination of higher ftuences and
the 1.5 ms PDL effective in treating vessels smaller cooling devices will reduce epidermal injury. Alora
than 0.5 mm in diameter; 595 nm and 20 J/cm 2 with et al (1999) compared the long pulsed dye laser with
ice cube cooling was preferred. Side effects include an ultra long pulse (4 ms) laser in the treatment of
purpura, pigmentary disturbances and oedema. One leg veins. The authors noted that neither laser regu-
study comparing the long pulsed dye laser with a larly induced satisfactory diminution or disappear-
KTP (532 nm) laser with a pulse duration of 10 ms ance of vessels after one treatment. Although there
(Aura, Laserscope) found results with the long was no significant difference between the test site
pulsed dye superior to the KTP laser when assessed the 4 ms laser with a 3 x 5 mm spot appeared to
both by observer and patient (West and Alster, be more effective. Caution should be exercised,
1998). McMeekin (1999) used a long-pulsed Nd:YAG however, on the short follow-up times of studies to
laser at 532 nm (Versapulse) to treat 10 patients with date and that the underlying cause of the telangiec-
leg veins less than 1 mm in diameter. A chilled tasia is not being addressed.
sapphire tip was used. One to three passes were It would appear that until further work has been
made with ftuences of 12 or 16 J/cm2. Overall 44% of performed sclerotherapy remains the treatment
patients had more than 50% clearance following a of choice for the treatment of a variety of vein dia-
single treatment; 94% of patients had pigmentation meters up to and in excess of 2 mm. Lasers are cur-
which took 6 months to clear. The higher ftuence rently ineffective for vessels greater than 2 mm in
was associated with atrophic scarring in one patient. diameter but may have a role in the treatment of

small vessels in combination with sclerotherapy or at
sites such as the lower leg and ankle area where there
are higher risks of complications from sclerotherapy.
Treatment of Other Cutaneous
Vascular Lesions
Facial telangiectasias respond readily to most lasers
emitting light absorbed by haemoglobin. Of this
group of lasers the PDL has the lowest incidence of
scarring; however, the number of treatments and
fluences required to treat facial telangiectasia fre-
quently allow the safe use of other lasers. The PDL
will cause significant bruising after treatment which
may not be cosmetically acceptable to patients with
relatively mild disease. In a comparison of CVL and
PDL treatment of facial telangiectasia (Waner et aI,
1993) similar improvements were seen with both
lasers but patients preferred the linear crusting pro-
duced by the CVL compared to the purpura of the
PDL. The copper bromide laser, which has similar
parameters to the CVL, has been reported as an
effective treatment for facial telangiectasia by
McCoy (1997), with more than 75% clearance in
70% of patients. In a comparison of argon dye and
PDL (Broska et aI, 1994) the PDL was shown to
produce better results but only 6 of 13 patients pre-
Fig. 3.14. Facial telangiectasia before and after treatment with the KTPlaser. (Courtesy of Dr R. Sheehan-Dare.)
Laser Treatment of Cutaneous Vascular Lesions 29
ferred this laser because of purpura and post-
inflammatory hyperpigmentation. A questionnaire
study (Thibault, 1997) comparing the krypton laser
with the CVL in the treatment of facial telangiec-
tasias found both lasers equally effective but pain
and adverse effects were significantly reduced in
patients treated with the krypton laser. Four differ-
ent frequency-doubled Nd:YAG (532 nm) lasers for
treatment of facial telangiectasias were assessed by
Goldberg and Meine (1999). Using ftuences of
between 8 and 24 J/cm 2 the authors demonstrated
equal efficacy with no evidence of scarring or pig-
mentary change (Figs 3.14 and 3.15).
Areas of persistent erythema as seen in patients
with rosacea and post-rhinoplasty can be treated
with the PDL (Lowe et aI, 1991). More treatments are
required than for individual telangiectasia and
purpura remains a problem for patients. In addition,
the first one or two laser treatments often induce a
rather spotty lightening on a background erythema,
necessitating further treatment.
Poikiloderma of Civatte can respond to PDL
therapy but lower energy densities (4-6 J/cm 2 )
are required as there is a high incidence of post-
treatment hypopigmentation and scarring in this
disorder (Geronemus, 1990). Longer pulse duration
lasers are not recommended for this condition.
Spider naevi are easily treated with lasers and treat-
ment with the PDL is safe and efficacious in children
 30 lasers in Dermatology
Fig.3.15. Facial telangiectasia before (left top and bottom) and after (right top and bottom) pulsed dye laser treatment.
(Fig. 3.16). The majority of spider naevi will clear
with one or two treatments without side effects.
Venous lakes, angiokeratomas, cherry angiomas
and pyogenic granulomas have all been reported to
respond to laser therapy. Tumorous outgrowths
of vascular tissue such as pyogenic granulomas,
nodular haemangiomas and Kaposi's sarcoma are
likely to have only a partial response owing to the
limited dept of penetration of the laser beam.
Other lesions with a vascular component such as
angiolymphoid hyperplasia, adenoma sebaceum,
lymphangiomas (Fig. 3.17) and granuloma faciale
have all been reported as successfully treated with
lasers. Results are variable in adenoma sebaceum; if
the angiofibromas do not have a prominent vascular
component then CO 2 laser vaporisation can be con-
sidered, although this laser has a higher rate of post-
treatment scarring than vascular-specific lasers.
Laser Treatment of Scars and
Striae
Much of the research relating to the effects of the
PDL on scars has been led by Dr Tina Alster in
Washington, DC. She noted (Alster et aI, 1993) that
the PDL was able to alter argon laser-induced scars,
which are often erythematous and hypertrophic.
By using optical profilometry measurements she
demonstrated a trend toward more normal skin
texture as well as reduction in observable erythema.

Fig.3.1 6. Spider naevus on left cheek before and after pulsed dye laser treatment.
Fig. 3.17. Lymphangioma on neck with prominent vascular
component before and after pulsed dye laser.
This work was extended to the treatment of ery-
thematous and hypertrophic scars (Alster and
Williams, 1995) using objective measurements; clin-
ical appearance (colour and height), surface texture,
skin pliability and pruritus could all be improved.
It is not known how the PDL improves the
appearance of hypertrophic and keloidal scars.
Microvascular damage may affect collagen or colla-
genase activity within the scar. Thermal damage to
abnormal collagen within the hypertrophic scar
my allow remodelling, and reduction in endothelial
cell volume can affect type V collagen, which is
increased in hypertrophic scars (Hering et aI, 1983).
Mast cell alterations after laser irradiation may also
be of importance.
Although established hypertrophic scars can
respond to treatment, early treatment of scars
within the first months might prevent hypertrophy
in individuals who are keloid-prone. I have certainly
seen the benefits of early PDL treatment of excised
recurrent keloids (Smith, Lanigan and Murison,
unpublished observations). In a group of 11 patients
treated in this way, none had a recurrent keloidal
Laser Treatment of Cutaneous Vascular Lesions 31
scar. Treatment at 6.5-7.5 J/cm2 with a 5 mm spot or
6-6.75 J/cm2 with a 7 mm spot is usually used.
Treatment is repeated at 6- to 8-weekly intervals
depending on clinical response. Keloidal scars
require multiple treatments and the response is
unpredictable. There may be additional benefits
from using newer PDL with wavelengths of 590 or
595 nm but there is no published work to confirm
this.
Alster's work has been confirmed by Dierickx
et al (1995), who treated 15 patients with erythema-
tous/hypertrophic scars and obtained an average
improvement of 77% after an average of 1.8 treat-
ments. Goldman and Fitzpatrick (1995) also treated
48 patients with similar laser parameters. Scars less
than 1 year old did better than those more than
1 year old and facial scars did better than non-facial
scars. For facial scars less than 1 year old there was
an 88% average improvement, with total resolution
in 20% after 4.4 treatments. Similar results were also
seen in erythematous and hypertrophic facial acne
scars by Alster and McMeekin (1996). Combinations
of CO 2 and PDL treatment of hypertrophic non-
erythematous scars have also shown additional
benefit of the PDL compared to the CO 2 laser alone
(Alster et al, 1998).
For persistent scars combinations of intra-
lesional corticosteroid injections, steroid impreg-
nated tapes and laser therapy may be necessary
(Sawcer et aI, 1998).
Laser Treatment of Striae Distensae
Striae distensae appear as erythematous linear bands
or wrinkled or atrophic skin that later become
 32 Lasers in Dermatology
Fig. 3.18. Striae distensae on back of legs. left leg only treated
with pulsed dye laser.
hypopigmented and somewhat silvery in colour.
They occur in areas of over-stretched skin physiolo-
gically in adolescents and pregnant women. Striae
have been treated with the PDL with an improve-
ment in clinical appearance as well as optical
profilometry (McDaniel et aI, 1996). Relatively low
fluences (3 J/cm 2 ) with large (7 or 10 mm) spot sizes
are advocated (Alster, 1997), one or two treatments
being necessary (Fig. 3.18). The results of laser treat-
ment of striae are unpredictable and further research
in this field is needed to clarify the role of lasers in
the treatment of this disorder.
A recent study by Nehal et al (1999) in which five
patients with mature striae were treated with the
PDL at 2-monthly intervals for 1-2 years showed no
significant photographic, textural or histological
improvement.
Pulsed Dye Laser Treatment of
Psoriasis
The aetiology of psoriasis is still unclear but it
is considered to be a T-cell-mediated disorder.
However, the earliest observable changes in a devel-
oping psoriatic plaque are in the cutaneous blood
vessels. In a psoriatic plaque the capillaries of the
dermal papillae are enlarged, dilated and tortuous. It
is known that the flashlamp-pumped PDL can be
used to treat superficial cutaneous vascular ecstasias
such as PWS following the principles of selective
photothermolysis and it seems logical to investigate
whether this laser has any therapeutic efficacy in
the treatment of plaque psoriasis. Hacker and
Rasmussen (1992) first reported the potential
benefits of the PDL in psoriasis. Subsequent studies
by Katugampola et al (1995), Zelickson et al (1996)
and Ros et al (1996) have confirmed the effective-
ness of this treatment. Katugampola et al (1995)
treated eight patients with chronic plaque psoriasis
using the PDL at 8.5 J/cm 2 with a 5 mm spot three
times over a 6-week period. Five of their eight
patients recorded an improvement of >50%, with
one patient showing complete resolution (Fig. 3.19).
Zelickson et al (1996) performed a clinical and his-
tological evaluation of PDL treatment of psoriasis in
36 patients. There was no difference in response
when using either 450 /-Ls or 1500 /-LS. Responding
patients remained in remission for 13 months. The
authors performed confocal micrographic analysis
of the pretreatment vascular patterns. They con-
cluded that lesions with vertically oriented vessels
with few horizontal vessels were associated with
better clinical results than those with numerous tor-
tuous vessels. Parallels with the vascular patterns of
good and poor responding PWS were noted by
Lanigan and Katugampola (1997).
Ros et al (1996) treated 10 patients between 6.5
and 8 J/cm 2 up to three times. Six of their patients
had a noticeable improvement in the treated plaque
up to 9 weeks after treatment. The results of these
studies should be contrasted with those of Alora
et al (1998) using a CO 2 laser resurfacing technique
in which the majority of their psoriatic patients had
a recurrence within 8 weeks of treatment.
It appears that the PDL can effect an improvement
in psoriasis. Multiple treatments are often necessary
and this is an expensive technological treatment
that is inappropriate for widespread disease. Some
Fig. 3.19. Plaque of psoriasis on knee successfully treated with
the pulsed dye laser. (From Katugampola et ai, 1995.)

patients with localised resistant plaque psoriasis
could benefit from this form of therapy but further
work along the lines of Zelickson et al (1996) is
necessary to determine the most appropriate use of
this laser.
Laser Treatment of Viral Warts
Although not true vascular lesions, warts have been
treated with lasers. COzlaser vaporisation can effect-
ively treat resistant verrucae but the treatment is
painful, with a risk of scarring and recurrence. The
PDL has also been reported as successful for the treat-
ment of resistant viral warts (Tan et aI, 1993). In this
study 28 of 39 patients experienced resolution of the
warts following an average of only 1.68 treatments
with fiuences of 6.5-7.5 J/cmz. Warts need to be pared
aggressively prior to treatment and high fiuences
8.5-9.5 J/cm 2 are necessary. Some clinicians apply
multiple overlapping spots which can be painful for
the patients and is likely to result in non-selective
thermal injury. Although the PDL has been reported
as effective in plantar warts (Jain and Storwick, 1997)
in other centres plantar warts appear relatively resist-
ant to the laser. Not all authors have been as success-
ful as Tan et al (1993) in eradicating warts. Huilgol
et al (1996) treated seven patients (six plantar, one
periungual) with recalcitrant verrucae; although there
was a partial response, none of their patients experi-
enced complete resolution of their lesions. Ross et al
(1999) treated 96 warts with only a 48% complete
clearance over an average of 3.4 treatments.
A recent study using the KTP laser at 532 nm
(Gooptu and James, 1999) showed complete clearing
of warts in 12 of 25 patients with resistant verrucae.
Multiple treatments were necessary. In patients with
a partial response, there was recurrence of the ver-
rucae after cessation of treatment. The use of the
PDL or KTP laser is associated with a low side-effect
profile but it is unclear whether this form of laser
treatment is superior to any other modality.
References and Further Reading
Principles of Selective Photothermolysis
Etc.
Anderson RR, Parrish JA (1981) Microvasculature can be select-
ively damaged using dye lasers: a basic theory and experimen-
tal evidence in human skin. Lasers Surg Med 1:263-266
Laser Treatment of Cutaneous Vascular Lesions 33
Anderson RR, Parrish JA (1983) Selective photothermolysis:
precise microsurgery by selective absorption of pulsed radi-
ation. Science 220:524-527
Barsky SH, Rosen S, Geer DE, Noe JM (1976) The nature and evo-
lution of port wine stains: a computer-assisted study. J Invest
Dermatol 74: 154-157
De Boer JF, Lucassen GW, Verkruysse W, van Gernert MJC (1996)
Thermolysis of port-wine-stain blood vessels: diameter of a
damaged blood vessel depends on the laser pulse length. Lasers
Med Sci 11:177-180
Dierickx CC, Casparian JM, Venugopalan V, Farinelli WA,
Anderson RR (1995) Thermal relaxation of port-wine stain
vessels probed in vivo: the need for 1-10-millisecomd laser
pulse treatment. J Invest Dermatol105:709-714
Garden JM, Tan OT, Kerschmann R et al (1986) Effect of dye laser
pulse duration on selective cutaneous vascular injury. J Invest
DermatoI87:653-657
Keijzer M, Pickering JW, van Gernert MJC (1991) Laser beam
diameter for port wine stain treatment. Lasers Surg Med
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Lucassen GW, Svaasand LO, Verkruysse W, van Gernert MJC
(1995) Laser energy threshold for thermal vascular injury in a
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Lucassen GW, Verkruysse W, Keijzer M, van Gernert MJC (1996)
Light distributions in a port wine stain model containing
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Smithies OJ, Butler PH (1995) Modelling the distribution of laser
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Svaasand LO, Fiskerstrand EJ, Kopstad G et al (1995) Therapeutic
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Tan OT, Kerschmann R, Parrish JA (1984) The effect of epidermal
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Flashlamp Pulsed Dye Laser
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Anderson RR (1995) Thermal relaxation of port-wine stain
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Dinehart SM, Flock S, Waner M (1994) Beam profile of the flash-
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Lasers Surg Med 15:277-280
 34 Lasersin Dermatology
Edstrom DW, Ros AM (1997) The treatment of port-wine stains
with the pulsed dye laser at 600 nm. Br J DermatoI136:360-363
Fiskerstrand EJ, Svassand LO, Kopstad G et al (l996a). Laser treat-
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 _...... r Treatment of Pigmented

melanin absorption exceeds haemoglobin absorp-

Introduction tion and the light penetrates deeply. As the absorp-
tion of melanin falls with increasing wavelength
The principles of selective photothermolysis can also
higher fluences are required at longer wavelengths of
be applied to the laser treatment of pigmented cuta-
light to effect the same damage to melanosomes as
neous lesions. The target chromophore in pigmented
lower fluences at shorter wavelengths. The advantage
lesions is melanin, which is packaged within cells in
of longer wavelengths of light is deeper dermal
melanosomes. These organelles are 0.3-1.0 fLm in
penetration.
length. Melanin absorbs light over a broad spectrum
To effect organelle-specific damage to melano-
from 250 to 1200 nm (Fig. 4.1) so lasers emitting light
somes without thermal damage to adjacent struc-
within this range can be expected to effect cutaneous
tures the pulse duration of the laser should be within
pigmentation to some degree. However, there are
the thermal relaxation time of the melanosome,
other chromophores competing for light particularly
which is estimated at 100-1000 ns. Lasers with pulse
in the visible range, e.g. haemoglobin, and tissue
durations less than 1 fLs can effect selective photo-
water in the ultraviolet. A therapeutic window of
thermolysis of melanosomes. Damage occurs both
wavelengths exists between 630 and 1100 nm where
from thermal effects but also shock waves arising
from rapid thermal-induced expansion of tissue
occurring during the short pulse durations.

Categories of Pigmented
c
o
o§-
Lesions
o
Melanocytic naevi will be considered later in this
'"
.0
<i chapter. Otherwise it is useful to consider whether
the pigment within the lesion is primarily in the
epidermis, the dermis or mixed (see Table 4.1).
200 1000 In general terms epidermal lesions are relatively
easily treated by lasers emitting light absorbed by
Wavelength (nm) melanin. Response is not always predictable and
some lesions may recur.
Fig.4.1. Schematic diagram of absorption of melanin and other Lasers used for the treatment of pigmented lesions
cutaneous chromophores. N( ote"window of opportunity"between are shown in Table 4.2. The CO 2 laser emits infrared
630 and 1100 nm.J
light at 10,600 nm; this light is completely absorbed

39
 40 Lasers in Dermatology

Table 4.1. Classification of cutaneous pigmented lesions The green 510 nm light produces selective photo-
thermolysis of epidermal pigment with a pulse
Epidermal Dermal Both duration of 300 ns. Epidermal pigmented lesions
such as lentigines, cafe au lait macules, freckles and
Lentigines Naevus of Ota Postinflammatory seborrhoeic keratoses will respond well to this laser.
Freckles (ephelides) Naevus of Ito hyperp ig mentatio n
Cafe au lait macules Blue naevi Melasma
Several studies have demonstrated the efficacy of
Becker's naevi Naevus spilus this laser, with 80-90% of lesions clearing from the
Drug-induced face and hands after three treatments. Treatments
are usually performed at 2-3 Jtcm 2 with 5 mm spots.
An immediate ash-white discoloration occurs, fol-
Table 4.2. Lasers for the treatment of cutaneous pigmented lesions lowed by purpura which lasts for 4-7 days before
fading. Transient postinflammatory hyperpigmenta-
tion may follow which can persist for some weeks
Laser Wavelength (nm) Pulse duration
before fading. Cafe au lait macules may respond ini-
Pulsed dye 510 300 ns tially but repigment from follicular reservoirs of
Q-switched ruby 694 25-40 ns melanocytes. One or two treatments are required to
Normal mode ruby 694 0.3- 1 ms eradicate lentigines; the number of treatments to
Q-switched Nd:YAG 1,064 10- 20 ns clear cafe au lait macules may range from 8 to 12.
Frequency-doubled 532 10-20 ns Treatment of dermal melanocytic lesions such as
Q-switched Nd:YAG naevus of Ota, melasma and postinflammatory
Q-switched alexandrite 755 lOOns hyperpigmentation is disappointing with this laser.
Copper vapour 510 200ms
Krypton 521,530 200ms
KTP
COl·
532
10,600
1- 10 ms
0.1 s
Q-Switched Ruby Laser
Erbium:YAG' 2,940 0.1 s Treatment of Pigmented Lesions
a Ablative.
The ruby laser was one of the earliest lasers devel-
oped and one of the first used in medical research.
The ruby laser produces red light at 694 nm which
by water. This laser and the Er:YAG laser at 2.94 /Lm penetrates about 1 mm into skin and is extremely
produce highly selective tissue ablation. Resurfacing well absorbed by melanin, with little absorption by
of photo damaged skin with these lasers can remove haemoglobin. Original work with the continuous
lentigines and other superficial changes of actinic wave long pulsed ruby laser was limited by non-
damage (see Ch. 6). Lower fluences «5 Jtcm 2 ) and specific thermal damage. Q-switching of the laser
short pulse durations of O.ls with the CO 2 laser will allows very high peak powers to be achieved with
limit thermal damage to the epidermis (Dover et aI, pulse durations of 28-40 ns. The Q-switched ruby
1988). Lentigines have been effectively treated in this laser has the advantage therefore of emitting a wave-
way. However, cryotherapy with liquid nitrogen was length of light selectively absorbed by melanin,
found to be four times more likely to produce light- deeply penetrating the skin with a pulse duration
ening of the lentigines compared to low-fluence CO 2 within the thermal relaxation time of the targeted
laser (Stern et aI, 1994). melanosome.
Epidermal pigmented lesions are easily treated
with the Q-switched ruby laser. Lentigines clear after
one to four treatments with fluences of 5-6 Jtcm 2
Pulsed Dye Laser (510 nm) and spot sizes of 5-6.5 mm (Fig. 4.2). Twenty-nine
Treatment of Pigmented Lesions patients with lentigines treated by Taylor et al (1991)
with the Q-switched ruby laser cleared completely
The 510 nm PDL was developed for cutaneous pig- after one treatment. Other epidermal pigmented
mented lesions following the work of Sherwood lesions such as ephelides and labial melanocytic
et al (1989), who investigated the wavelength effect macules respond well to the Q-switched ruby laser
of pulsed laser irradiation of cutaneous pigment. (Gupta et aI, 1999). Although cafe au lait macules,
 Laser Treatment of Pigmented Lesions 41

Fig.4.2. lentigo simplex before and after Q-switched ruby laser treatment. (Courtesy of Dr R. Sheehan-Dare.)

Fig.4.3. Cafe au lait macule before and after treatment with the Q-switched ruby laser. (Courtesy of Mr A.Quaba,lynton Lasers.)

Becker's naevi and naevus spilus can respond, the
results are unpredictable (Fig. 4.3). Failure of light-
ening and recurrence of pigmentation occur in a
variable number of patients. The long-pulsed ruby
laser has been reported recently to be effective for
the treatment of Becker's naevi (Nanni and Alster,
1998).
The ruby laser appears to be particularly useful for
the treatment of dermal melanocytic lesions such as
naevus of Ota (Fig. 4.4) and naevus of Ito. This is in
part due to its deeply penetrating wavelength. Both
of these pigmented lesions are far more common in
Japanese patients, with a prevalence of 0.2-0.8% of
the population. The incidence in white persons is

Fig.4.4. Naevus of Ota before and after Q-switched ruby laser treatment. (Courtesy of Dr J. Cotterill.)
 42 Lasers in Dermatology
significantly lower. In a study of 15 patients with
naevus of Ota (Geronemus and Ashinoff, 1992)
treated with the Q-switched ruby laser up to seven
times, complete clearing was seen in four patients,
with significant lightening in the others. Taylor et al
(1994) treated nine naevi of Ota up to six times with
fluences of 4.5 and/or 7.5 J/cm2 at 3-weekly intervals.
Hypopigmentation occurred for 2-4 weeks after
each exposure, followed by the gradual development
of hyperpigmentation. This hyperpigmentation faded
after 2-3 months back to pretreatment appearances.
Six naevi were available for follow-up 2 years after
treatment and all showed cosmetic improvement.
This improvement generally occurred 1-2 years after
final irradiation as the hyperpigmentation faded. The
largest study of Q-switched ruby laser treatment has
been on over 100 Japanese patients (Watanabe and
Takahshi, 1994). The degree of lightening achieved
was directly proportional to the number of treat-
ments performed. No textural changes after treat-
ment were seen.
Treatments are usually performed after topical
anaesthesia such as EMLA R or infiltrational anaes-
thesia. Pulses can be delivered to the skin though
a transparent occlusive dressing, e.g. TegadermR,
to reduce back-splatter. Immediate tissue whiten-
ing occurs, followed by erythema and oedema. A
wheal and flare reaction also commonly occurs. The
oedema settles after a few hours, with erythema last-
ing a week or more. After treatment an antibacterial
ointment is applied for about 1 week, followed by a
high-factor sunscreen.
Other melanocytic lesions such as chloasma
and postinflammatory hyperpigmentation tend to
respond poorly to Q-switched ruby laser treatment.
Two patients with nasally situated blue naevi res-
ponded well to Q-switched ruby laser treatment.
(Milgraum et aI, 1995). Minocycline is an antibiotic
commonly used for skin disorders. Skin pigment-
Fig.4.5. Minocycline-induced hyperpigmentation after test treatment (left) with Q-switched ruby laser and complete clearance (right).
(Courtesy of Dr J. Cotterill.)
ation induced by this drug can occur in up to 5%
of patients with acne vulgaris. The pigment is due
in part to increased melanin in the basal cell layer
and macrophages, and pigment distributed within
macrophages. Q-switched ruby laser treatment can
remove the pigmentation after one to three treat-
ments without adverse effects (Collins and Cotterill,
1996; Knoell, 1996) (Fig. 4.5).
Q-Switched Nd:VAG laser
Treatment of Pigmented lesions
The Nd:YAG laser emits infrared light at 1064 nm,
when Q-switched high-fluence short pulses
(10-20 ns) are emitted. By insertion of a frequency-
doubling crystal into the laser beam the wavelength
is halved to green light at 532 nm. The infrared
wavelength is deeply penetrating (4-6 mm) into
skin because this wavelength is poorly absorbed by
melanin, haemoglobin and water. The deep pene-
tration is advantageous in the treatment of dermal
pigmented lesions such as naevus of Ota, as there is
relatively preferential absorption at this depth by
melanin. The infrared wavelength is not of value
in the treatment of epidermal pigmented lesions
because of poor absorption. For treatment of
naevus of Ota multiple treatments are required:
often 5-10. Fluences around 8 J/cm2 are used with a
3 mm spot. The response to treatment is related to
the pigment in the skin, with very little observable
change in normal skin. Pinpoint bleeding can often
be seen in lesional skin immediately after treat-
ment. Not all patients will lighten completely even
after an extended course of treatment. In a compar-
ison of patients' tolerance of Q-switched Nd:YAG
and Q-switched alexandrite lasers in the treatment
of naevus of Ota (Chan et aI, 1999) the immediate

pain after treatment was more severe with the
alexandrite laser. However, 1 week after laser therapy
most patients preferred the alexandrite laser to the
Nd:YAG laser in terms of pain, discomfort, swelling
and wound healing. There have been no studies to
compare clinical efficacy of different Q-switched
lasers in the treatment of naevus of Ota to date.
The green 532 nm light from the frequency-
doubled Nd:YAG laser is well absorbed by melanin
and haemoglobin. The short pulses with Q-switching
make this laser appropriate for the selective photo-
thermolysis of epidermal melanosomes (Fig. 4.6).
The pulse duration is too short to effect permanent
thermal damage to cutaneous blood vessels, where
microsecond and millisecond pulses are more appro-
priate. Solar lentigines are readily treated with this
laser (Figs 4.7 and 4.8). Typical ftuences are 2-5 J/cm 2
with 1-3 mm spot sizes. The majority will clear after
one or two treatments. In a small study comparing
Fig.4.6. Speckled lentiginous naevus of right side of face and neck successfully treated with the Q-switched frequency-doubled Nd:YAG
.laser.
Fig. 4.7. Solar lentigo before and after Q-switched frequency-doubled Nd:YAG laser treatment.
Laser Treatment of Pigmented Lesions 43
frequency-doubled Q-switched Nd:YAG laser and
35% trichloroacetic acid in the treatment of facial
lentigines, Li and Yang (1999) found better results
with the laser in Fitzpatrick skin types III-IV. A
prominent purpuric change occurs after treatment
but there is generally less pigmentary alteration. In a
comparison of three lasers, including the Q-switched
Nd:YAG laser at 532 nm with cryotherapy for solar
lentigines, clinical results with the lasers were super-
ior to cryotherapy and the majority of patients pre-
ferred laser treatment (Todd et aI, 1999).
The response of cafe au lait macules to Q-switched
Nd:YAG laser treatment, as with Q-switched ruby
laser treatment, is variable and unpredictable
(Fig. 4.9). Failure to respond, localised darkening and
repigmentation after a variable period can all occur.
Clinicians should always educate their patients
on the potential side effects of treatment as well as
the possibility of recurrence. Mixed epidermal and
 44 Lasers in Dermatology
Fig.4.8. Multiple solar lentigines on arm: before (top), immedi-
ately after (middle) and 2 months after (bottom) Q-switched
frequency-doubled Nd:YAG laser treatment.
dermal lesions such as postinfiammatory hyper-
pigmentation and melasma, as with the Q-switched
ruby laser, respond poorly if at all.
Minocycline-induced hyperpigmentation is easily
treated with the Q-switched Nd:YAG laser at 532 nm
(Wood et aI, 1998) and 1064 nm (Greve et aI, 1998),
with excellent clearance of the pigment without side
effects.
Q-Switched Alexandrite Laser
Treatment of Pigmented Lesions
The Q-switched alexandrite laser emits light at
755 nm, which is a longer wavelength than the ruby
laser and somewhat more penetrating. It has similar
efficacies to the Q-switched ruby laser in the treat-
ment of pigmented lesions. Both lentigines and
cafe au lait macules have been reported to respond
well to this laser (Stafford and Tan, 1995). Fluences
Fig. 4.9. (afe au lait macule on leg before and after Q-switched
frequency-doubled Nd:YAG laser treatment.
of 6-7 J/cm 2 are typically used with a 3 mm spot
size. The Q-switched alexandrite laser can lighten
naevus of Ota after five or six treatments (Alster and
Williams, 1995). Infraorbital hyperpigmentation can
also respond to this laser. Side effects of treatment
include transient hypopigmentation in 50% of
patients and textural changes or scarring in 4%.
Once again melasma and postinfiammatory hyper-
pigmentation respond poorly if at all to treatment.
Copper Vapour Laser Treatment
of Pigmented Lesions
The CVL is a heavy metal vapour laser which emits
two wavelengths of light, at 578.2 nm (yellow) and
510 nm (green). The yellow light, which is preferent-
ially absorbed by haemoglobin, can be filtered out
to leave a green light source for the treatment of
melanocytic lesions. The laser emits a train of very
short pulses lasting 20 ns, with an interval between
pulses of 67-125 f..Ls. Ten thousand to 15,000 pulses
are emitted per second. This very high pulse rate
with short inter-pulse duration has the biological
effect of a continuous wave laser, known as "quasi-
continuous". There is little published data on the use
of the CVL in treating pigmented lesions but lentig-
ines and freckles can be expected to respond well.
The laser beam is mechanically shuttered to 200 ms
pulses or run freehand over the skin with short dwell
times or delivered through an automated scanner.
The pulse duration with all these manoeuvres will
still exceed the thermal relaxation time of melano-

somes and some non-selective thermal injury will
occur which may be therapeutically useful. Results
following treatment of cafe au lait macules with this
laser have been variable, with hypopigmentation,
scarring and recurrence of the lesion being reported.
This laser is not of value in the treatment of dermal
pigmented lesions.
Other lasers for the Treatment
of Pigmented lesions
The krypton laser emits two bands of green light, at
521 and 530 nm. It is a continuous wave laser with
pulses shuttered to 200 ms. Similar results in the
treatment of lentigines to the CVL can be expected.
The KTP laser at 532 nm is a frequency-doubled
YAG laser that produces only green light. The laser is
a quasi-continuous wave laser with 200 ns pulses
delivered at 25,000 Hz. Macropulses of 1-10 ms can
be delivered to the skin through a computerised
scanner. The green wavelength is absorbed both by
haemoglobin and melanin and there is growing
experience in the treatment of vascular lesions with
this laser. There is very little published research on
the use of this laser for pigmented lesions but it is
likely to be useful for treatment of epidermal lesions
such as lentigines and ephilides but not for dermal
lesions such as naevus of Ota or melasma.
Treatment of Melanocytic Naevi
with lasers
Melanocytic naevi can be congenital or acquired.
Large congenital naevi (>20 cm 2 in diameter) have
a reported lifetime risk of 6-12% of developing
melanoma. For small and medium congenital naevi
the increase lifetime risk of developing melanoma is
less clear but may be of the order of 1-2%. Small
congenital naevi probably do not have a significant
increased risk of malignant change.
The treatment of choice for large congenital naevi
to reduce the risk of melanoma is surgical. Some
congenital naevi may be difficult to excise in toto
and there may be naevomelanoctyes in neurovascu-
lar and appendageal structures. Some congenital
naevi occur in cosmetically sensitive areas where a
surgical scar may be undesirable. The ruby laser has
been reported as an alternative to surgical excision.
laser Treatment of Pigmented lesions 4S
The following factors should be considered when
planning laser treatment of congenital naevi:
• Is surgical excision feasible? Will there be a satis-
factory cosmetic result?
• What will the cosmetic result be after laser
treatment?
• Lifetime risk of melanoma in the untreated
naevus.
• Presence of residual naevomelanocytes in lesion
after laser treatment.
• Recurrence rate after laser treatment.
• Does laser treatment increase or decrease the
risk of melanoma in the treated naevus?
Ruby laser treatment of congenital melanocytic
naevi will be for cosmetic purposes primarily where
surgical excision is technically difficult or likely to
leave a prominent scar. Goldberg and Stampien
(1995) treated four children with congenital pig-
mented naevi with a Q-switched ruby laser with a
pulse duration of 40 ns and fluences of 6-9 J/cm 2.
Each naevus was treated two to four times over a
year. Two children had marked improvement; two
naevi were minimally improved. Follow-up at 3 years
of one patient showed minimal repigmentation.
Waldorf et al (1996) treated 18 children with small
or medium (s5 cm 2 diameter) sized congenital pig-
mented naevi with a Q-switched ruby laser (28 ns
pulse duration, 5 mm spot, fluences of 8-10 J/cm2).
By the fourth treatment there was an average of 57%
lightening, with an average maximum clearance of
76% after eight treatments. Five patients had greater
than 90% clearance after an average of 13 treat-
ments. After completing treatment 11 of 12 patients
had partial repigmentation. The average final clear-
ance was almost 50%.
In a histological study of Q-switched laser treat-
ment of congenital naevi which were later excised
(Grevelink et aI, 1997) both Q-switched ruby and
Nd:YAG lasers removed only the superficial portion
of the congenital naevus, with persistence in the
deeper, less pigmented parts. The Q-switched ruby
laser seemed more effective than the Q-switched
Nd:YAG laser in removing naevomelanocytes. Nelson
and Kelly (1999) reported complete removal of a
10 cm diameter histologically confirmed congenital
melanocytic naevus following treatment with a
Q-switched ruby laser. They used a 4 mm spot at
10 J/cm 2 with a pulse duration of 20 ns. The case
report is notable in that the child was followed up for
5 years without recurrence of the naevus.
 46 Lasers in Dermatology
In a study from Japan, Veda and Imayama (1997)
treated three patients with congenital naevi with a
normal-mode (non-Q-switched) ruby laser (pulse
duration 0.3-1 ms, 10-30 J/cm 2fiuence and spot size
10 or 15 mm diameter). Striking improvement was
seen in all their patients after three to four treat-
ments. One patient had a small area of scarring, but
otherwise the treatment was well tolerated. They fol-
lowed up their patients between 6 and 22 months
after completion of treatment. Imayama and Veda
(1999) assessed the long-term histological changes
in eight Japanese patients who had had a good result
following normal-mode ruby laser treatment to
their congenital pigmented naevus. Residual naevus
cells were seen at a mean depth of 1.11 mm below
the skin surface. Above them was a microscopic scar
with preservation of the papillary dermis. The
authors concluded that the microscopic scar masked
underlying residual naevus cells to produce a good
cosmetic result.
Acquired melanocytic naevi have also been
treated with the Q-switched ruby laser (Vibhagool
et aI, 1997). Eighteen small naevi were treated with
a pulse duration of 28 ns and fiuences of 8 J/cm2.
Twelve lesions responded completely after one treat-
ment. In the partial responders residual naevome-
lanocytic nests were seen in the superficial reticular
dermis. Follow-up was 10 weeks after treatment.
In summary it appears the ruby laser both in
normal mode and Q-switched can lighten the
appearance of congenital small and medium sized
naevi. The one study from Japan with the normal-
mode laser has demonstrated the most striking
results but there is a higher risk of scarring with this
laser. Recurrence of pigmentation after treatment is
likely and there are no long-term studies to quantify
this. What cannot be addressed at present is whether
laser treatment of congenital melanocytic naevi
affects the risk of melanoma in these naevi. It can be
argued that reducing the population of available pre-
malignant cells before puberty might decrease the
risk of melanoma. Conversely, effects of laser irrad-
iation on residual naevus cells could increase risk of
melanoma. Alteration of the clinical appearance of
such naevi after laser treatment may reduce the early
warning clinical signs of malignant transformation.
There are, however, no documented instances of
malignant transformation after ruby laser treat-
ment. There are fewer concerns about laser treat-
ment of naevus spilus and naevus of Ota, both of
which have been rarely reported to show malignant
change. Of concern is the demonstration in vitro
(Van Leeuwen et aI, 1996) that Q-switched ruby laser
irradiation induced alteration in adhesion molecule
expression in cultured melanoma cells but not in
benign melanocytes.
Long-term follow-up studies of laser-treated naevi
are required. Until then clinicians intending to treat
patients with melanocytic naevi should make
current information concerning this treatment avail-
able to the patient and their family in a comprehens-
ible way so that they may participate fully in the
decision-making process necessary for treatment.
References and Further Reading
Introduction
Dover jS, Smoller BE, Stern RS et al (1988) Low fluence car-
bon dioxide laser irradiation of lentigines. Arch Dermatol
124:1219-1224
Murphy GF, Shepard RS, Paul BS, Menkes A, Anderson RR, Parrish
jA (1983) Organelle-specific injury to melanin-containing cells
in human skin by pulsed laser irradiation. Lab Invest 49:680-685
Stern RS, Dover jS, Levin j, Arndt KA (1994) Laser therapy versus
cryotherapy of lentigines: a comparative trial. j Am Acad
Dermatol 30:985-987
Pulsed Dye Laser (510 nm) Treatment of
Pigmented Lesions
Alster TS (1995) Complete elimination of large cafe-au-Iait birth-
marks by the 510 nm pulsed dye laser. Plast Reconstr Surg
96: 1660-1664
Fitzpatrick RE, Goldman MP, Ruiz-Esparza j (1993) Laser treat-
ment of benign pigmented epidermal lesions using a 300
nanosecond pulse and 510 nm wavelength. j Dermatol Surg
Oncol 19:341-347
Grekin RC, Shelton RM, Gesse JK, Frieden T (1993) 510 nm pig-
mented lesions dye laser: its characteristics and clinical uses.
J Dermatol Surg Oncol 19:380-387
Sherwood KA, Murray S, Kurban AK, Tan OT (1989) Effect of
wavelength on cutaneous pigment using pulsed irradiation.
J Invest Dermatol92:717-720
Stafford T, Tan 0 (1995) 51O-nm pulsed dye laser and alexandrite
crystal laser for the treatment of pigmented lesions and
tattoos. Clin Dermatol13:69-73
Tan OT, Morelli JG, Kurban AK (1992) Pulsed dye laser treatment
of benign cutaneous pigmented lesions. Lasers Surg Med
12:538-542
Q-Switched Ruby Laser Treatment of
Pigmented Lesions
Ashinoff R, Geronemus RG (1992) Q-switched ruby laser treat-
ment of benign epidermal pigmented lesions. Lasers Surg Med
Supp14:73
Cheng C), Nelson jS, Achauer BA (1996) Q-switched ruby laser
treatment of oculodermal melanosis (nevus of Ota). Plast
Reconstr Surg 98:784-790

Collins P, Cotterill JA (1996) Minocycline-induced pigmentation
resolves after treatment with the Q-switched ruby laser. Br J
Dermatol135:317-319
Depadova-Elder SM, Milgraum SS (1994) Q-switched ruby laser
treatment of labial lentigines in Peutz-Jeghers syndrome. J
Dermatol Surg OncoI20:B30-B32
Geronemus RG (1992) Q-switched ruby laser therapy of nevus of
Ota.Arch DermatoI12B:161B-1622
Geronemus RG, Ashinoff R (1992) Q-switched ruby laser therapy
of nevus of Ota. Lasers Surg Med Supp14:74
Goldberg DJ (1993) Benign pigmented lesions: treatment with the
Q-switched ruby laser. J Dermatol Surg OncoI19:376-379
Grossman MC, Anderson RR, Farnelli W, Flotte TJ, Grevelink JM
(1995) Treatment of cafe-au-lait macules with lasers: a clinico-
pathological correlation. Arch Dermatol 131: 1416-1420
Gupta G, MacKay IR, Mackie RM (1999) Q-switched ruby laser in
the treatment of labial melanotic macules. Lasers Surg Med
25:219-222
Knoell KA (1996) Q-switched ruby laser treatment of minocy-
cline-induced cutaneous hyperpigmentation. Arch Dermatol
132:1251-1253
Lowe NJ, Wieder JM, Sawcer D et al (1993) Nevus of Ota: treat-
ment with high energy fluences of the Q-switched ruby laser. J
Am Acad DermatoI29:997-1001
Lowe NJ, Wieder JM, Shorr N et al (1995) Infra orbital pigmented
skin: preliminary observations of laser therapy. Dermatol Surg
31:767-770
Milgraum S, Cohen M, Auletta M (1995) Treatment of blue nevi
with the Q-switched ruby laser. J Am Acad DermatoI32:307-310
Nanni CA,Alster TS (199B) Treatment of a Becker's nevus using a
694-nm long-pulsed ruby laser. Dermatol Surg 24:1032-1034
Taylor CR, Flotte T, Michaud N, Jimbow K, Anderson RR (1991)
Q-switched ruby laser treatment of benign pigmented lesions:
dermal vs epidermal. Lasers Surg Med Suppl 3:65
Taylor CR, Flotte TJ, Gange RW,Anderson RR (1994) Treatment of
nevus of Ota by Q-switched ruby laser. J Am Acad Dermatol
30:743-751
Watanabe S, Takahashi H (1994) Treatment of nevus of Ota with
the Q-switched ruby laser. N Engl J Med 331:1745-1750
Q-Switched N d: YAG Laser Treatment of
Pigmented Lesions
Chan HHL, King WWK, Chan ESY et al (1999) In vivo trial com-
paring patients tolerance of Q-switched alexandrite (QS Alex)
and Q-switched neodymium:yttrium-aluminium-garnet (QS
Nd:YAG) lasers in treatment of nevus of Ota. Lasers Surg Med
24:24-2B
Greve B, Schonermark MP, Raulin C (199B) Minocin-induced
hyperpigmentation: treatment with the Q-switched Nd:YAG
laser. Lasers Surg Med 22:223-227
Kilmer S, Wheeland RG, Goldberg OJ, Anderson R (1994) Treatment
of epidermal pigmented lesions with the frequency-doubled Q-
switched Nd: YAG laser. Arch Dermatol130:1515-1519
Li Y-T, Yang K-C (1999) Comparison of the frequency-doubled Q-
switched Nd:YAG laser and 35% trichloroacetic acid for the
treatment of face lentigines. Dermatol Surg 25:202-204
Todd M, Rallis T, Hata T (1999) Laser treatment of solar lentig-
ines: a comparison of three lasers and liquid nitrogen. Lasers
Surg Med Supplll :31
Laser Treatment of Pigmented Lesions 47
Tse Y, Levine CJ, Mclain SA, Ashinoff R (1994) The removal
of cutaneous pigmented lesions with the Q-switched
neodymium:yttrium-aluminium-garnet laser. J Dermatol Surg
Oncol 20:795-BOO
Wood B, Munro CS, Bilsland D (1998) Treatment of minocycline-
induced pigmentation with the neodymium-YAG laser. Br J
Dermatol139:562
Q-Switched Alexandrite Laser Treatment
of Pigmented Lesions
Alster TS, Williams CM (1995) Treatment of nevus of Ota by the
Q-switched Alexandrite laser. Dermatol Surg 21:592-596
Stafford T, Tan 0 (1995) 51O-nm pulsed dye laser and alexandrite
crystal laser for the treatment of pigmented lesions and
tattoos. Clin DermatoI13:69-73
Other Lasers for Treatment of Pigmented
Lesions
Dinerhart SM, Waner M, Flock S (1993) The copper vapor laser
for treatment of cutaneous vascular and pigmented lesions.
J Dermatol Surg OncoI19:370-375
Keller GS (1992) Use of the KTP laser in cosmetic surgery. Am J
Cosmetic Surg 9: 177 -lBO
Somyos K, Boonchu K, Somsak K, Panadda L, Leopairut J (1996)
Copper vapour laser treatment of cafe-au-lait macules. Br J
Dermatol135:964-96B
Treatment of Melanocytic Naevi with
Lasers
Goldberg DJ, Stampien T (1995) Q-switched ruby laser treatment
of congenital naevi. Arch Dermatol131:621-623
Grevelink JM, van Leeuwen RL, Anderson RR, Byers HR (1997)
Clinical and histological responses of congenital melanocytic
naevi after single treatment with Q-switched lasers. Arch
Dermatol 133:349-353
Imayama S, Veda S (1999) Long- and short-term histological
observations of congenital nevi treated with the normal mode
ruby laser. Arch Dermatol135:1211-121B
Nelson JS, Kelly KM (1999) Q-switched ruby laser treatment of a
congenital melanocytic nevus. Oermatol Surg 25:274-276
Van Leeuwen RL, Dekker SW, Byers HR, Vermeer BJ, Grevelink JM
(1996) Modulation of a4bl and a5bl integrin expression: het-
erogeneous effects of Q-switched ruby, Nd:YAG, and alex-
andrite lasers on melanoma cells in vitro. Lasers Surg Med
18:63-71
Veda S, Imayama S (1997) Normal-mode ruby laser for treating
congenital nevi. Arch Dermatol133:355-359
Vibhagool C, Byers HR, Grevelink JM (1997) Treatment of small
nevomelanocytic nevi with a Q-switched ruby laser. J Am Acad
DermatoI36:73B-741
Waldorf HA, Kauvar ANB, Geronemus RG (1996) Treatment of
small and medium congenital nevi with the Q-switched ruby
laser. Arch Dermatol132:30 1-304
 Laser Treatment of
Tattoos

Introduction Table 5.1. Lasers used for removal oftattoos

Tattoos consist of insoluble ink particles injected Laser Wavelength Fluence Pulse duration
(nm) (J/cm2) (ns)
intradermally and ingested by phagocytic cells.
These phagocytic cells do not remove the tattoo ink Q-switched ruby 694 6- 8 25-40
away from the skin and remain relatively stable. Q-swi tched Nd:YAG 1064 6- 12 10- 20
Decorative tattoos can be divided into amateur and Frequency doubled 532 2- 3 10- 20
professional. Amateur tattoos contain carbonaceous Q-switched Nd:YAG
material from indian ink or graphite. They are Q-switched alexandrite 755 4-8 50- 100
injected by the patient or a colleague into the skin Pulsed dye laser 510 3 300
and usually take the form of relatively simplistic
linear lettering or designs. There is usually less par-
ticulate matter than in a professional tattoo but the
depth of the tattoos may vary more in an amateur the 510 nm, 300 ns short pulsed dye laser. However,
tattoo. Professional tattoos can consist of a variety the CO 2 laser may still have a role to play in ablation
of inks and colour using insoluble metal salts and of difficult-to-remove multicoloured tattoos in
organic complexes. They may be densely coloured patients who are prepared to accept a scar (Fig. 5.1).
and occupy large areas of the skin.
Prior to laser treatment a number of surgical tech-
niques have been used to remove tattoos, including
surgical excision with grafting, salabrasion, derma-
Q-Switched Ruby Laser
brasion and cryotherapy. All these treatments result Treatment of Tattoos
in scarring to some degree.
Goldman first explored the use of lasers for tattoos From the early work of Goldman et al (1967) it has
in the 1960s with a series of papers investigating the been shown that the light of a ruby laser at 694 nm is
effects of normal mode and Q-switched ruby lasers selectively absorbed by pigmented substances in
on tattoos. Since then a number of lasers have been the skin. However, excessive damage to the skin
developed to treat tattoos either by non-selective could still occur unless the pulse width of the laser
removal of the tattoo containing tissue as with the is limited. The calculated thermal relaxation time
CO 2 laser or by selective photo thermolysis using for 40-100 nm diameter particles characteristically
high-energy Q-switched lasers (Table 5.1). Because found in most amateur and professional tattoos is
the risk of scarring with nanosecond-domain lasers approximately 1-10 ns. However, it is unlikely that
is substantially less than with earlier lasers this photothermal mechanisms alone are responsible
chapter will concentrate on tattoo removal with the for the fragmentation of tattoo particles. This photo-
Q-switched ruby, Nd:YAG and alexandrite lasers and mechanical disruption may be more efficiently

49
 SO Lasers in Dermatology

fiuences up to 10 J/cm2 (Lowe et aI, 1994) revealed

even better results in professional tattoos, with 22 of
28 tattoos lightening by 75% or greater.
Amateur tattoos can be expected to clear after
three or four treatments. In professional tattoos, best
results are seen with blue and black tattoos (Fig. 5.2).
Green tattoos respond variably, with 65% of such
tattoos clearing after six to eight treatments (Goyal
et aI, 1997).
Neither red, yellow nor pale coloured tattoos
will respond to Q-switched ruby laser treatment.
Treatment is performed usually without anaesthesia;
the laser pulses are uncomfortable to painful but due
to the short pulse durations are usually tolerated. The
sensation has been likened to a rubber band being
snapped against the skin or like hot fat splashing on
the skin. If anaesthesia is required infiltration with
lignocaine 1% with adrenaline or topical anaesthesia
with EM LA R cream under occlusion for 90 min can
be performed. Laser treatment is usually performed
through a sheet of clear acetate or transparent dress-
ing such as TegadermR or Second Skin R applied
closely over the skin. These dressings allow transmis-
sion of the laser beam but act as a barrier for any
cutaneous debris that may splatter back during the
treatment. Most lasers will deliver 6-8 J/cm 2 fiuences
with spot sizes of 3-8 mm diameter. Pulses are deliv-
ered every 0.5-3 s to cover the tattoo. Immediately
after laser exposure the skin shows a slightly elevated
Fig. 5.1. Tattoo treated with COl iaser.
white discoloration which is most marked in the
tattoo compared to normal skin. The white discolor-
ation is thought to be due to rapid formation of
achieved with lasers emitting pulses less than 1 ns in steam or gas around pigment particles. There may be
duration. Q-switching of lasers allows concentration some pinpoint bleeding at higher fiuences. The white
of all the laser energy into a single intense nano- discoloration changes over the next 24-48 h and a
second pulse with extremely high peak powers in sloughing crust occurs which may contain some
excess of 10 8 W/cm 2• These powerful pulses are tattoo pigment. The slough separates after about
achieved by the use of a fast electromagnetic switch 2 weeks, with a more normal appearance of the skin
(Pockel's cell) in the laser cavity. and clinical lightening of the tattoo. Treatments can
Early studies by Reid et al (1983, 1990) used a be repeated at 4- to 8-week intervals. Postoperative
Q-switched ruby laser with a 30 ns pulse duration wound care consists of antibacterial ointments and a
to treat both blue-black amateur and some pro- non-occlusive dressing.
fessional tattoos. Best results were obtained with Side effects with the Q-switched ruby laser are
amateur tattoos, which cleared after four to six mainly due to absorption of the 694 nm light by pig-
treatments without scarring. Professional tattoos mented cells in the skin. Up to 50% of treated
were lightened rather than cleared. Subsequent patients show some changes in pigmentation of
studies by Taylor et al (1990) using a Q-switched normal skin, with hypopigmentation most common;
ruby laser with pulses of 40-80 ns revealed complete this can be permanent in up to 10% of patients.
clearance of 78% of 23 amateur and 23% of 13 pro- Scarring occurs in less than 5% of patients, most
fessional tattoos. Persistent post-treatment hypo- commonly after treatment of professional tattoos.
pigmentation was common. Further studies using a Side effects are more common in darker-skinned
Q-switched ruby laser with a 28 ns pulse with higher individuals receiving treatment.
 LaserTreatment ofTattoos S1

was found within membrane-bound intracellular

granules in fibroblasts, macrophages and mast cells.
After treatment the large deposits of pigment were
fragmented into smaller particles. By the 11 th day
all the altered pigmented particles were repackaged
and removed by phagocytosis. Some tattoo pigment
is also removed in the slough. Tattoo pigment re-
maining in the skin after laser treatment may be
altered in such a way as to be less optically apparent.

Q-Switched Nd:YAG Laser

Treatment of Tattoos
The Q-switched Nd:YAG laser is a solid-state laser
containing a crystal of yttrium-aluminium-garnet
(YAG) doped with neodymium (Nd) ions. The
primary wavelength of this laser is in the near
infrared at 1064 nm. With Q-switching, this laser
produced high -fluence infrared light with pulse
durations of 10-20 ns. the laser has faster repetition
rates (10 Hz) than the Q-switched ruby laser. By
placing a doubling crystal in the laser beam's path
the frequency doubling halves the wavelength to
green light at 532 nm.
The long-wavelength infrared light of the Nd:YAG
laser penetrates deeply (4-6 mm) into skin and is
poorly absorbed by melanin and haemoglobin.
Although tattoo pigment absorption is also poor
there is a relatively preferential absorption of the
light sufficient to produce changes due to selective
photothermolysis.
The Q-switched Nd:YAG laser has been shown to
clear amateur blue-black tattoos effectively (Fig. 5.3).
An excellent result in both amateur and professional
black tattoos can be expected after four treatments
(Kilmer et aI, 1993). Even tattoos resistant to prior

Fig. S.2. Series of tattoos treated with the Q-switched ruby laser.
(Courtesy of Lynton Lasers Ltd.)

The mechanisms by which the Q-switched ruby

laser removes dermal tattoo pigment is not entirely
known. Taylor et al (1991) performed light and
electron microscopic analysis of tattoos treated by Fig.S.3. Amateur tattoo on shoulder before and after one treat-
Q-switched ruby laser. Prior to treatment pigment ment with the Q-switched Nd:YAG laser.
 52 lasers in Dermatology
Q-switched ruby laser treatment were responsive.
Brighter colours including green, yellow and white
were resistant to Q-switched Nd:YAG laser treat-
ment. Red tattoo pigment is responsive to the fre-
quency-doubled green light at 532 nm, which is the
laser of choice for this pigment. Red tattoo pigment
faded completely in 75% of patients with three treat-
ments (Kilmer and Anderson, 1993).
Treatment with the Q-switched Nd:YAG laser is
similar to that performed with the Q-switched ruby
laser; however, there is more tissue and blood splat-
ter with the Nd:YAG laser and treatment is usually
performed through clear acetate sheeting. Because
of the fast repetition rate of the laser (10 Hz) more
patients may require local anaesthesia during treat-
ment. The largest spot size available (usually 3 mm)
is used with fluences of 6-12 J/cm 2• Small spot sizes
and higher fluences are more likely to produce
bleeding. The whole tattoo is covered with laser
impacts avoiding gross overlapping of spots.
Immediately after treatment there is a greyish dis-
coloration of the area with fine pinpoint bleeding.
A wheal and flare reaction follows. More reaction
occurs early in a course of treatment because of the
density of pigment and lower fluences for the first
one or two treatments can minimise this. Healing
usually proceeds uneventfully, with discoloration
fading after 7-10 days. There may be some swelling
of the treated area particularly with treatments
near the eyes or on the hands or feet. Postoperative
care with non-adherent dressings and topical anti-
bacterial agents is usually only required for a few
days. When using the frequency-doubled green
wavelength at 532 nm there is much more reaction
with normal cutaneous components, as epidermal
melanin and haemoglobin will react with this
laser. An immediate whitening is seen, rapidly fol-
lowed by a haemorrhagic purpuric appearance with
some swelling. This again heals uneventfully in the
majority.
Treatments are repeated at 4- to 8-week intervals,
with two to four treatments necessary for amateur
tattoos and 4-10 treatments for blue-black profes-
sional tattoos depending on density of tattoo pig-
mentation and patients' expectations. Side effects
with the Q-switched Nd:YAG laser are of a similar
nature to those of the ruby laser. The incidence of
textural change is higher than with the ruby laser
but pigmentary disturbance, particularly hypo-
pigmentation, occurs less often.
Analysis of Q-switched Nd:YAG laser-induced
changed in tattoos has been by both light and elec-
tron microscopy (Kilmer et aI, 1993; Ferguson et aI,
1997). Biopsies immediately after laser treatment
showed vacuolation, with complete clearance of
tattoo particles in the most superficial layers of the
dermis. It has been proposed that the "disappear-
ance" of the tattoo particle arises from the form-
ation of atomic species and gaseous products which
rapidly dissolve in the extracellular fluid. Partially
altered pigment can be see in the mid dermis with
unaltered pigment in the deep dermis even in
patients with clinical clearance of their tattoo. The
majority of patients show no evidence of fibrosis or
granulomatous change.
Recently (Ross et aI, 1998) an investigation has
been performed comparing picosecond and nano-
second Q-switched Nd:YAG lasers. As most carbon
particles from indian ink are about 40 nm in
diameter it was suggested that sub-nanosecond
pulses may be more appropriate for treatment. In 16
patients with black tattoos, 12 tattoos were signi-
ficantly lightened in the picosecond areas compared
with those treated with nanosecond pulses. Low
fluences (0.65 J/cm 2) were employed. High-energy
nanosecond pulsed Nd:YAG lasers were more effec-
tive than the low-fluence picosecond pulses. It
was not possible to deliver high-energy picosecond
pulses without using an unacceptably small spot size.
Q-Switched Alexandrite laser
Treatment of Tattoos
The Q-switched alexandrite laser is a relatively
recently introduced solid-state laser emitting light at
755 nm with a pulse duration of 100 ns. Clinical
research on the use of this laser to remove tattoos in
animals and humans first appeared in the early 1990s
(Fitzpatrick et aI, 1993a; Fitzpatrick and Goldman,
1994). Experiments on tattooed porcine skin demon-
strated that this laser was effective in removing blue-
black tattoos. It has also been shown to remove both
amateur and professional tattoos after a mean
number of treatments of 4.6 and 8.5 respectively
(Alster, 1995). The relatively longer pulse duration of
this laser may be the reason why there is less tissue
splatter after impacts with this laser compared to
the other Q-switched lasers. Typical fluences used are
4-8 J/cm 2 with a 3 mm spot diameter and a repetition
rate of 1 Hz. Fluence is chosen to produce the char-
acteristic grey-white discoloration while avoiding
bleeding and tissue splatter; local anaesthesia is not
 Laser Treatment ofTanoos 53

usually required. Side effects are uncommon, those well as long-term clearance of tattoos with the
with the Q-switched alexandrite laser being transient Q-switched Nd:YAG laser.
hypopigmentation and textural changes. Scarring Zelickson et al (1994) compared the efficacies of
with this laser is considered a rare occurrence. the Q-switched ruby laser, the Q-switched Nd:YAG
The Q-switched alexandrite laser has been shown laser (1064 and 532 nm) and Q-switched alexandrite
to have some benefits in removing tattoo inks other laser in removing 14 commonly used tattoo pig-
than blue and black; in particular, green tattoos can ments injected into guinea-pig skin. The Q-switched
be completely removed after an average of nine ruby laser was most effective in removing blue-
treatments (Stafford et aI, 1995). Other coloured black tattoos; the Q-switched alexandrite laser was
tattoos may also respond to this laser, except yellow most effective in removing blue and green tattoos.
and orange inks. Histological analysis of tattoos at The green wavelength of the Q-switched Nd:YAG
various stages of treatment with this laser revealed laser (532 nm) was most effective in removing red.
fragmentation of tattoo pigment granules followed Levine and Geronemus (1995) compared the Q-
by macrophage engulfment and gradual clearance switched ruby laser with the Q-switched Nd:YAG
from the dermis (Fitzpatrick et aI, 1993b). laser in the treatment of 39 professional and nine
amateur tattoos. They found that after one treatment
the Q-switched ruby laser produced more lighten-
ing in 18 of the black tattoos and the Q-switched
Pulsed Dye (510 nm) Laser Nd:YAG laser more lightening in four (there was no
Treatment of Tattoos difference in 17 tattoos). Overall the ruby laser was
superior in fading black pigment in both amateur
The PDL at 510 nm emits green light with a pulse and professional tattoos and also in removing green
duration of 300 ns. This laser was developed for the pigment. There was no difference in the fading of
treatment of epidermal pigmented lesions but has other colours except that the green (532 nm) wave-
also been used for the treatment of tattoos. The light length Nd:YAG laser was superior in the removal of
is delivered through a flexible fibre-optic system with red ink. Hypopigmentation was seen most frequently
a 5 mm spot size and repetition rate of 1 Hz. with the Q-switched ruby laser and textural changes
Fluences of 3 J/cm 2 are employed. An immediate with the Q-switched Nd:YAG laser.
tissue whitening is seen, followed by some purpuric Goyal et al (1997) compared the Q-switched
changes. This laser has been shown to be effective in Nd:YAG (1064 nm and 532 nm) with the Q-switched
the removal of brightly coloured tattoos such as red, ruby laser in the treatment of 14 professional and
orange and yellow (Fitzpatrick et aI, 1993). Two to six amateur tattoos. Results were assessed after one
four treatments are required to clear these pigments. treatment only. The Q-switched ruby laser produced
the greatest lightening in both professional and
amateur tattoos. The 532 nm Nd:YAG laser was best
for red tattoos.
Comparative Studies of Lasers Leuenberger et al (1999) compared the Q-switched
Used to Remove Decorative alexandrite, Nd:YAG and ruby lasers in the treatment
of 42 blue-black tattoos. The Q-switched ruby laser
Tattoos was shown to have more significant tattoo clearing
than the other lasers. Hypopigmentation was seen in
Several comparative studies have been performed to 38% of ruby laser-treated tattoos compared to 0%
assess the efficacy of lasers for the treatment of and 2% for the Nd:YAG and alexandrite lasers
tattoos. McMeekin and Goodwin (1993) compared respectively. No textural changes were reported. Herd
the Q-switched ruby laser (694 nm, 25 ns, 6 J/cm 2 ) et al (1999) compared a picosecond titanium:-
with the Q-switched alexandrite laser (755 nm, sapphire (795 nm) laser with the Q-switched alexan-
100 ns, 6 J/cm 2 ) in the treatment of 10 amateur black drite (752 nm) laser for removal of black tattoos in
tattoos and found that the Q-switched ruby laser porcine skin. Similar fluences (2.39-6.11 J/cm 2 ) were
was more effective in clearing all tattoos. Kaufmann used for each laser; superior tattoo clearance was
et al (1993) compared the Q-switched Nd:YAG laser seen with the picosecond laser.
(1064 nm) with the Q-switched alexandrite laser in In summary, it is clear that the Q-switched
the treatment of 50 tattoos and saw better initial as ruby, Nd:YAG (1064 nm) and alexandrite lasers are
 S4 Lasers in Dermatology

It is thought that there is a reduction of ferric

oxide (Fe 20 3, "rust") to ferrous oxide (FeO, jet black)
within the tattoo pigment, causing significant dark-
ening which may require surgical excision. Test
treatments should always be performed when treat-
ing cosmetic tattoos. The immediate tissue whiten-
ing will obscure any pigment darkening and a delay
of at least 10 min to let the whitening fade should
occur before examining the patient for pigment
darkening.

Traumatic Tattoos
Fig. 5.4. Example of tattoo perhaps best not tackled with lasers!
Traumatic tattoos result from the mechanical
penetration of the skin by foreign body particles
following explosions, abrasions and punctures. The
effective in removing amateur and professional
e.xplosive tattoo usually involves gunpowder, gaso-
blue-black tattoos. The ruby laser is probably the
hne or other volatile substances. Abrasive tattoos
most effective but has the highest incidence of
arise when skin wounds occur on road surfaces or
hypopigmentation. The 532 nm Nd:YAG laser is
s~il. Abrasive tattoos can contain particles of metal,
most effective in removing red tattoos and the
dIrt, glass and carbonaceous material. Puncture
alexandrite laser most effective in removing green
wounds are often pencil point injuries in children.
tattoos. There is insufficient published data to
The Q-switched ruby, Nd:YAG and alexandrite lasers
compare the efficacy of the PDL (510 nm) with the
have all improved traumatic tattoos without scar-
~ther lasers for tattoo removal. It is clear from pub-
ring; the depth of penetration of the tattoo will
hshed data that although professional tattoos can
i~fluence outcome (Fig. 5.5). There is an explosion
substantially lighten after laser treatment they may
nsk when irradiating explosive and firework tattoos
not clear completely. It is important to assess each
with lasers and great care should be exercised if
tattoo in terms of colour, pigment density and size
performing this procedure; surgical excision is
to give the patient a realistic idea of likely outcomes
preferred (Taylor, 1998).
fr~m treatment (Fig. 5.4). A protracted, costly,
pamful course of laser treatment to result in a 60%
cleared tattoo is less than ideal.

Laser Treatment of Other Tattoos

Two other groups of patients may seek removal of
their tattoos; those with cosmetic tattoos and those
Fig. 5.5. Traumatic tattoo on nose before and after one treat-
with traumatic tattoos. ment with the Q-switched Nd:YAG laser.

Cosmetic Tattoos
Some female patients have elected to have lipliner,
eyeliner and eyebrow tattoos rather than apply
make-up on a regular basis. Should it be necessary
to remove these tattoos black pigment is likely to
respond; however, flesh-coloured, red, tan or white
inks should be approached with extra caution as
darkening of the pigment has been reported with
several lasers (Anderson et aI, 1993).
References and Further Reading
Introduction
Goldman L, Blaney DUJ, Kindel DJ et al (1963) Pathology of the
effect of the laser beam on the skin. Nature 197:912-914
Goldman L, Wilson RG, Hornby P, Meyer RG (1965) Radiation
from a Q-switched ruby laser. J Invest DermatoI44:69-71

Lanigan SW, Sheehan Dare RA, Cotterill JA (1989) The treatment
of decorative tattoos with the carbon dioxide laser. Br J
DermatoI120:819-825
Reid R, Muller S (1980) Tattoo removal by carbon dioxide laser
dermabrasion. Plast Reconstr Surg 65:717-728
Q-switched Ruby Laser Treatment of
Tattoos
Goldman L, Rockwell RJ, Meyer R, Otten R, Wilson RG, Kitzmiller
KW (1967) Laser treatment of tattoos: a preliminary survey of
three years' clinical experience. JAMA 201:841-844
Goyal S, Arndt KA, Stern RS, O'Hare D, Dover JS (1997) Laser
treatment of tattoos: a prospective, paired, comparison study
of the Q-switched Nd:YAG (1064 nm), frequency-doubled
Q-switched Nd:YAG (532 nm) and Q-switched ruby lasers.
JAm Acad Dermatol36: 122-125
Lowe NJ, Luftman D, Sawcer D (1994) Q-switched ruby laser:
further observations on treatment of professional tattoos.
J Dermatol Surg OncoI20:307-311
Reid WH, McLeod PJ, Ritchie A, Ferguson-Pell M (1983) Q-
switched ruby laser treatment of black tattoos. Br J Plast Surg
36:455-459
Reid WH, Miller ID, Murphy MJ, Paul JP and Evans JH (1990)
Q-switched ruby laser. Treatment of tattoos: a 9-year experi-
ence. Br J Plast Surg 43:663-669
Taylor CR, Gange RW, Dover JS et al (1990) Treatment of tattoos by
Q-switched ruby laser: a dose-response study. Arch Dermatol
126:893-899
Taylor CR, Anderson RR, Gange RW, Michaud NA, Flotte TJ
(1991) Light and electron microscopic analysis of tattoos
treated by Q-switched ruby laser. J Invest Dermatol 97: 131-136
Wheeland RG (1991) Q-switched ruby laser treatment of tattoos.
Lasers Surg Med Suppl 3:64
Q-switched Nd:YAG Laser Treatment of
Tattoos
Ferguson JE, Andrew SM, Jones CJP, August PJ (1997) The
Q-switched neodymium:YAG laser and tattoos: a micro-
scopic analysis of laser tattoo interactions. Br J Dermatol
137:405-410
Kilmer SL, Anderson RR (1993) Clinical use of the Q-switched
ruby and the Q-switched Nd:YAG (1064 nm and 532 nm) lasers
for treatment of tattoos. J Dermatol Surg OncoI19:330-338
Kilmer SL, Lee MS, Grevelink JM, Flotte TJ, Anderson RR (1993)
The Q-switched Nd:YAG laser effectively treats tattoos: a con-
trolled dose-response study. Arch DermatoI129:971-978
Ross EV, Naseef G, Lin C et al (1998) Comparison of responses of
tattoos to picosecond and nanosecond Q-switched neodymium:
YAG lasers. Arch Dermatol134: 167-171
Q-switched Alexandrite Laser Treatment
of Tattoos
Alster TS (1995) Q-switched alexandrite (755 nm) laser treatment
of professional and amateur tattoos. J Am Acad Dermatol
33:69-73
Fitzpatrick RE, Goldman MP (1994) Tattoo removal using the
alexandrite laser. Arch Dermatol130:1508-1514
Fitzpatrick RE, Goldman MP, Ruiz-Esparza J (1993a) Use of
the alexandrite laser (755 nm, 100 nsec) for tattoo pigment
removal in an animal model. J Am Acad DermatoI28:745-750
Laser Treatment ofTattoos 55
Fitzpatrick RE, Ruiz-Esparza J, Goldman MP (1993b) Alexandrite
laser treatment of tattoos: a clinical and histological study.
Lasers Surg Med Supp15:54
Stafford TJ, Lizek R, Boll J, Tan OT (1995) Removal of coloured
tattoos with the Q-switched alexandrite laser. Plast Reconstr
Surg 95:313-320
Pulsed Dye (510 nm) Laser Treatment of
Tattoos
Fitzpatrick RE, Goldman MP, Ruiz-Esparza J (1993) Laser treat-
ment of benign pigmented lesions using a 300 nanosecond pulse
and 510 nm wavelength. J Dermatol Surg Oncol 19:341-346
Sherwood KA, Murray S, Kurban AK, Tan OT (1989) Effect of
wavelength of cutaneous pigment using pulsed irradiation.
J Invest DermatoI92:717-720
Comparative Studies of Lasers Used to
Remove Decorative Tattoos
Goyal S, Arndt KA, Stern RS, O'Hare D, Dover JS (1997) Laser
treatment of tattoos: a prospective, paired, comparison study
of the Q-switched Nd:YAG (1064 nm), frequency-doubled Q-
switched Nd:YAG (532 nm) and Q-switched ruby lasers. J Am
Acad DermatoI36:122-125
Herd RM,Alora MB, Smoller B,Arndt KA, Dover JS (1999) A clin-
ical and histologic prospective controlled comparative study of
the picosecond titanium: sapphire (795 nm) laser versus the
Q-switched alexandrite (752 nm) laser for removing tattoo
pigment. J Am Acad DermatoI40:603-606
Kaufmann R, Boehncke WH, Konig K, Hibst R (1993)
Comparative study of the Q-switched Nd:YAG and alexandrite
laser treatment of tattoos. Lasers Surg Med Suppl 5:54
Leuenberger ML, Mulas MW, Hata TR, Goldman MP, Fitzpatrick
RE, Grevelink JM (1999) Comparison of the Q-switched
alexandrite, Nd:YAG, and ruby lasers in treating blue-black
tattoos. Dermatol Surg 25: 10-14
Levine V, Geronemus R (1995) Tattoo removal with the Q-switched
ruby laser and the Q-switched Nd:YAG laser: a comparative
study. Cutis 55:291-296
McMeekin TO, Goodwin DP (1993) A comparison of the alexan-
drite laser (755 nm) with the Q-switched ruby laser (694 nm)
in the treatment of tattoos. Lasers Surg Med Suppl 5:54
Zelickson BD, Mehregan D, Zarrin A et al (1994) Clinical, histo-
logical, and ultrastructural evaluation of tattoos treated with
three laser systems. Lasers Surg Med 15:364-372
Laser Treatment of Other Tattoos
Anderson RR, Geronemus R, Kilmer SL, Fannelli W, Fitzpatrick
RE (1993) Cosmetic tattoo ink darkening: a complication of
Q-switched and pulsed-laser treatment. Arch Dermatol
129:1010-1014
Ashinoff R, Geronemus RG (1993) Rapid response of traumatic
and medical tattoos to treatment with the Q-switched ruby
laser. Plast Reconstr Surg 91:841-845
Chang SE, Choi JH, Moon KC, Koh JK, Sung KJ (1998) Successful
removal of traumatic tattoos in Asian skin with a Q-switched
Alexandrite laser. Dermatol Surg 24: 1308-1311
Taylor CR (1998) Laser ignition of traumatically embedded
firework debris. Lasers Surg Med 22:157-158
Tope W, Tsoukas M, Fanvelli W, Anderson R (1996) Tattoo ink
darkening: the effect of wavelength, flue nee and pulsed dura-
tion. Lasers Surg Med Suppl 8:40
 The Carbon Dioxide and
rbium:YAG Lasers in
Dermatology

(0 2 laser Treatment in laser (Fig. 6.1). The ability of the CO 2 laser to excise
tissue is a function of its irradiance or power
Dermatology density. As can be seen from the formula below,
irradiance is a function of the inverse of the square
Introduction of the spot diameter:

Irradiance Power output (W)

The carbon dioxide (C0 2) laser is currently enjoying = ----------------------------
W/cm l Laser beam cross-sectional area (cml)
a renaissance with the advent of laser skin resurfac-
ing, but from the time it was first introduced in the When the CO 2 laser is used for incisional surgery
mid-1960s it was widely used as a cutting and abla- its beam is focused to very small diameters of
tive laser and was one of the few lasers genuinely 0.1-0.2 mm with a relatively high output of
useful to a number of different surgical specialists. 20-35 w. This results in extremely high irradiances
The CO 2 laser emits far infrared light at 10,600 nm. of between 50,000 and 100,000 W/cm2, which will
The original output from CO 2 lasers was continuous incise tissue.
but it is now possible to develop CO 2 lasers with The response of tissue to CO 2 laser irradiation
pulsed outputs. Because infrared light is invisible, will be heating up to 100°C (the boiling point of
the laser is operated with a coaxial low-powered red
(633 nm) helium-neon laser which allows the oper-
ator to see where the COl laser beam will be incident
on the skin. Because it is not possible to transmit the
10,600 nm wavelength light by optical fibres the beam
is delivered along a series of sealed tubes reflecting
the beam off a series of mirrors within rotational
articulated couplings.
The COl laser light is strongly absorbed by water,
which is the major component of most human soft
tissues. Thus when the CO 2 laser impacts on skin it
will be absorbed by this tissue superficially. Using a
0.2 s pulse with a 1 mm spot size, 90% of the CO 2
laser energy will be absorbed within the first 0.1 mm
of tissue.
Early COl lasers operating in the continuous
mode could be shuttered to deliver 0.1-1 s pulses.
The laser was used either in focused mode as an Fig. 6.1. Focused or defocused COl laser. (Courtesy of ESC
excisionallaser or in defocused mode as an ablative Sharplan.)

57
 58 lasers in Dermatology
water), when vaporisation occurs. When heating is
rapid all targeted tissue water is vaporised as steam.
Tissue structures explode outwards owing to the
rapid thermal expansion of water, shock waves and
cavitation effects. This tissue combined with steam
constitutes the plume of smoke arising from COz
laser-irradiated tissue and there is minimal thermal
damage to adjacent tissue. This is due to heat diffu-
sion from the impact site causing a zone of coagula-
tive necrosis 0.6-1.3 mm away. If the fluence used is
insufficient to vaporise tissue rapidly, coagulation,
desiccation and carbonisation will occur. Carbonis-
ation is an undesired event; carbonised tissue
cannot vaporise owing to its low water content. As
further COz laser energy is delivered to carbonised
tissue temperatures in excess of 600°C can occur,
producing extensive thermal damage to adjacent
tissue; this can extend 5 mm away from the target.
Inappropriate use of the COz laser in this way is
likely to produce scarring.
This high irradiance obtained with focused COz
laser beams allows rapid heating over short time
intervals, so unwanted thermal damage is min-
imised. The dwell time of the laser providing irrad-
iance, is adequate, will influence the volume of tissue
ablated. With continuous or long pulse COz lasers
the surgeon must move the COzlaser beam over the
skin to control the depth of excision.
For ablative COzlaser use the surgeon is attempt-
ing to remove controlled superficial layers of tissue
with minimal thermal damage to surrounding
tissue. The beam is defocused with a spot diameter
of 0.5-5 mm; this larger beam will significantly
reduce the irradiance or power density. The abla-
tion threshold for skin is greater than 5 J/cmz so a
defocused COz laser must have sufficient power
output to deliver sufficient fluences within a short
period of time. For example, using a 2 mm beam
diameter with 5 W of power an irradiance of
160 W/cm z can be achieved. Fluences of 5 J/cmz can
be achieved in 30 ms. The surgeon will need to keep
the COz laser moving over the tissue to control
the depth of vaporisation. With both excisional
and ablative techniques, the width of the zone of
thermal damage of adjacent tissue is directly pro-
portional to the duration of the exposure. Even
with good techniques, when the continuous
wave COz laser is used to vaporise tissue the resid-
ual thermal damage can be between 300 and
600 J-Lm in depth. Short pulsed COz lasers have
significantly reduced the depth of residual thermal
damage.
Incisional Surgery with the CO 2 Laser
With a small focused spot and high irradiances, as
discussed above, skin can be precisely cut with a
COz laser. The advantages of COz laser incisional
surgery are as follows:
• Non-contact surgery
• Haemostasis
• Reduced postoperative pain
• Sealing of lymphatic channels:
- malignancy
- oedema
It is important to maintain a focused beam when
performing surgery and a handpiece with a built-in
focusing lens is employed. The depth of the incision
is a function of the irradiance and the dwell time
(speed) at which the incision is made. Considerable
skill and expertise are required by the operator to
produce controlled uniform excisions. Too slow a
movement of the laser will increase the depth of the
incision; if the fluence falls by defocusing the beam
there is a risk of increasing the zone of thermal
damage around the wound. Of all lasers used in der-
matology, the COzlaser has the greatest potential for
harm when used inappropriately or by an inexperi-
enced operator.
Because the laser is not in contact with the skin
procedures performed through highly infected
tissue such as burns, synergistic gangrene and decu-
bitus ulcers can be performed with the CO 2 laser.
Haemostasis seen with the COz laser is due to seal-
ing of blood vessels 0.5 mm in diameter or less
within the zone of thermal damage adjacent to the
laser incision (Goldman et aI, 1970). This can
produce an almost bloodless operating field, provid-
ing excellent visualisation of tissue for the surgeon.
The haemostasis obtained by the COz laser has
proved valuable in excisional surgery that is likely to
produce excessive blood loss. Thus excision of
highly vascular tumours such as cavernous haeman-
giomas and haemangiosarcomas can be performed
(Apfelberg et aI, 1984). In addition, non-vascular
lesions in highly vascular anatomical locations, e.g.
malignancies in irradiated port wine stains, rhyno-
phyma surgery and surgery within the oral cavity,
can be more easily performed with a COz laser.
Patients with bleeding disorders or on anticoagu-
lants can be treated; also those with cardiac pace-
makers where electrosurgical instruments are
contraindicated. Although, in general, the excision
 The COl and Er:YAG Lasers 59

made with a CO 2 laser is slower than with a scalpel, time of the 30 /Lm layer of tissue absorbing the laser,
the haemostasis achieved with the former can which has been calculated to be less than I ms
shorten operating times. (Walsh et aI, 1998). The width of the zone of residual
The majority of patients who have had identical thermal damage is directly proportional to the pulse
procedures performed with the CO 2 laser and a duration of the laser. For a continuous beam the
scalpel have reported reduced postoperative pain pulse duration on the skin can be reduced by the
after laser surgery. Most surgeons will acknowledge surgeon moving the laser over the skin freehand or
that patients have a reduction in the expected post- mechanically pulsing the light. By using a fan-like
operative pain. The reduction in pain is due prim- device pulses can be mechanically "chopped" to
arily to thermal sealing of nerve endings as the durations of 10-20 ms, which is in excess of the
incision is made (Ascher et aI, 1978). Sealing of lym- thermal relaxation time of the tissue to be ablated.
phatic vessels in a similar fashion will also minimise In addition, high peak powers cannot be generated
oedema and inflammation, again contributing to a in this way. To achieve adequate fluences small spot
reduction in postoperative pain. sizes must be used and there will still be a zone of
The ability to seal blood and lymph vessels may thermal necrosis ranging from 100/Lm to 2 mm
also be advantageous in the treatment of cutaneous beyond the incision (Walsh et aI, 1988; Montgomery
malignant disease. Tissue excised by the CO 2 laser et aI, 1983). Despite good clinical practice surgical
can be examined histologically without difficulty. ablation using continuous wave CO 2 lasers is often
There appears to be no advantage over scalpel sur- associated with unacceptable rates of scarring.
gery for primary excisions except in the circum- Pulsed CO 2 lasers have been developed to try and
stances already outlined (Bailin et aI, 1981). It may address some of the problems associated with the
be possible, however, to reduce local tumour recur- continuous wave CO 2 laser. Superpulsed lasers were
rence by laser excision (Lanzafame et aI, 1986). developed with peak powers 2-10 times the power
Malignant melanoma metastases can be quickly and of continuous wave CO 2 lasers. The laser is pumped
easily vaporised with the CO 2 laser; the rate of electronically to produce pulse durations typically
recurrences for this palliative treatment varies of 0.1-0.9 ms. The pulses are produced rapidly with
(Waters et aI, 1991; Strobbe et aI, 1997). repetitions of 100-5000 Hz. Superpulsing should not
be confused with "Q-switching", where very high
Wound Healing with CO 2 Laser Excisions powers with short (nanosecond) pulse durations are
developed. By using a superpulsed CO 2 laser high
peak powers with short cooling pauses between
The overall cosmetic result following CO 2 laser exci-
each pulse are delivered. This reduces the need for
sion is identical to that following scalpel surgery
the laser surgeon to manually remove the laser
(Norris and Mullarky, 1982). The tensile strength of
beam from the skin to avoid unwanted thermal
the wound early after CO 2 laser surgery may be
damage. With superpulsing, for only a percentage of
reduced compared to scalpel surgery. This occurs in
the first 3 weeks, after which both wounds are equal the time is the laser actually delivering energy: the
duty cycle. The duty cycle is usually 10% but can
in strength. This is thought to be a consequence of
range from 2% to 50%. The duty cycle can be
the haemostasis achieved with the laser. There is
further reduced by pulsing the superpulses so that a
reduction in formation of the fibrin clot and a firm
eschar which impedes epithelial migration. Once the chain of superpulses is delivered, followed by a gap
and then another chain of pulses, and so on. If the
eschar is removed healing precedes rapidly (Moreno
et ai, 1984; Hall, 1971; Carney et aI, 1985). repetition rate becomes too low, however, the quality
of haemostasis will be impaired. Conversely, if the
repetition rate is too high, the cooling time between
Pulsed, Superpulsed and Scanned CO 2 pulses will be insufficient, there will be a build-up of
Lasers heat and thermal damage will mimic that of a con-
tinuous wave CO 2 laser. By appropriate selection of
The main clinical effects of the CO 2 laser on skin are parameters, using a pulsed CO 2 laser it is possible to
ablation and residual thermal damage. To ablate ablate tissue while reducing peripheral thermal
tissue, fluences in excess of 5 J/cm 2 are required. To damage to less than 100 /Lm thickness.
minimise residual thermal damage this energy The development of CO 2 lasers that could del-
should be delivered within the thermal relaxation iver sufficient energy to vaporise tissue within the
 60 lasers in Dermatology
thermal relaxation time (1 ms) in a single pulse sub-
stantially advanced the use of lasers for resurfacing
photo damaged skin, including mild and moderate
wrinkles (Fitzpatrick et aI, 1996; Lowe et aI, 1995;
Waldorf et aI, 1995). Initially two CO 2 lasers were
developed to address this problem. Coherent
Medical Inc., Palo Alto, California, produced the
UltraPulse laser. This was a high-energy pulsed laser
which could deliver up to 500 mJ/pulse with a pulse
duration of 600 p.,s to 1 ms. The beam could be
delivered through a 3 mm collimated handpiece or
through a computerised pattern generator (CPG),
which automatically places an array of 2.25 mm
spots of light on the skin in a preselected pattern
and size, hexagonal and square patterns being most
popular with operators.
An alternative technology was developed by
Sharplan Laser Inc., Allendale, New Jersey, using a
continuous wave CO 2 laser and a flash scanner
which, using rapidly oscillating mirrors in the hand-
piece, scanned the focused laser beam in a spiral
pattern across the tissue: the Sharplan Silk Touch
laser (Fig. 6.2). The scanner is microprocessor-
B r1
Icroproc sso
Con roll (
Irro
Microprocessor
Controlled
irror
Fig.6.2. SilkTouch Flashscan. (Courtesy of ESC Sharplan.)
controlled and moves the beam rapidly across the
skin with a dwell time of less than 1 ms. The beam
size is 0.1-0.25 mm and the scan size is 0.8-16 mm
in diameter and can be round, elliptical or square.
To deliver the scan takes less than 0.5 s (Chernoff
et aI, 1995).
Although the bulk of clinical experience was orig-
inally with these two lasers, other CO 2 lasers have
been developed which meet the criteria for selective
photothermolysis to ablate tissue. The Surgi-Pulse
Xl-ISO, developed by Sharp Ian Lasers Inc., produces
two 600 p.,s pulses with a 3 mm spot size from a col-
limated beam. When delivered together the two
pulses will ablate skin (Cotton et aI, 1996). Tissue
Technologies, Albuquerque, New Mexico, have pro-
duced the Tru-Pulse CO 2 laser, which has a very
short pulse duration of 60-100 p.,s and peak powers
of 10,000 W. This short pulse duration may result in
less ablation per pass although is not likely to result
in significantly different clinical outcomes (Alster
et aI, 1999).
Other CO 2 lasers continue to be developed and
marketed. To reach ablation thresholds, small spot
sizes are often used and these can be scanned to
shorten treatment times.
Tissue Ablation with the CO 2 Laser
Over the past 20 years numerous clinical applica-
tions for tissue ablation with the CO 2 laser have
been reported. Before the development of high-
powered superpulsed CO 2 lasers most treatments
would result in unwanted residual thermal necrosis
to some degree. Treatment using the continuous
wave CO 2 laser was very operator-dependent. The
clinical end point of vaporisation was based on
experience rather than any objective measures:
small variations in spot size, particularly using free-
hand devices, would dramatically alter ftuence. Thus
clinical results varied greatly from surgeon to
surgeon. Despite the wide range of treatments
reported, the CO 2 laser has a distinct advantage over
other treatment modalities in probably only a small
number of conditions. Initial enthusiasm for treat-
ments to disorders such as port wine stains and
warts was tempered by reports of scarring and
adverse outcomes (Van Gernert et aI, 1987; Logan
and Zachary, 1989). Similar treatments using super-
pulsed lasers may minimise adverse results.
Conditions where treatment with the CO 2 lasers may
offer distinct advantages over conventional treat-
ment are shown in Table 6.1.
 The CO 2 and Er:YAG lasers 61

Actinic Cheilitis in reduced pain and scarring when compared with

electrocautery. Despite accurate vaporisation of
Actinic cheilitis is probably the best example of a dis- lesions there is still a significant recurrence rate due
order where CO 2 laser ablation is the treatment of to presence of virus in clinically normal adjacent
choice. The CO 2 laser offers advantages over other skin. Treatment techniques vary but local or general
treatment modalities, including excisional vermil- anaesthesia is usually required. Hyperkeratotic
lionectomy, cryotherapy and 5-fiuorouracil topically, tissue is usually pared down prior to laser treat-
by being less painful with a shorter healing time ment. High-fiuence vaporisation of the wart into the
and reduced risk of scarring. Actinic cheilitis is a dermis is performed. Normal tissue tends to retain
common premalignant disorder of the lower lip dermatoglyphics and contract with laser irradiation.
which can progress to invasive squamous cell carci- Wart tissue does not retain dermatoglyphics and
noma that may metastasise. Because the disorder is tends to bubble when irradiated. Focal ablation of
entirely epidermal it can be easily and rapidly vapor- residual wart tissue using a focused beam can be
ised after regional anaesthesia with usually just one performed based on these end points and clinical
treatment pass with the CO 2 laser. Re-epithelialisation experience. Ablation of a narrow margin of clinically
occurs within 4 weeks with excellent cosmetic results normal adjacent skin may reduce recurrence rates.
(Stanley and Roenigk, 1988; Johnson et aI, 1992). Plantar warts and condyloma acuminata can be
Similarly, superficial neoplastic disorders such as removed in a single procedure in this way.
erythroplasia of Queyrat (Greenbaum et aI, 1989) Post-treatment analgesia will be necessary and the
and vulval Bowen's disease can be treated in a wound dressed with antibacterial ointments and non-
similar fashion with low morbidity and complete adherent dressings. Periungual warts can be treated
clearance of the neoplastic tissue. with the CO 2 laser without avulsion of the nail. The
warts can either be "chased" under the nail with the
Warts focused beam or the overlying portion of the nail
There are a number of reports of the effectiveness vaporised prior to removal of the wart tissue.
of CO 2 laser ablation of viral warts (Fig. 6.3). The As with all CO 2 laser vaporisation procedures, a
vast majority of viral warts will regress sponta- plume of smoke containing water vapour and par-
neously or respond to simple measures such as kera- ticulate matter will develop. Of particular import-
tolytics and cryotherapy. CO 2 laser ablation should ance when removing warts is that this plume will
be reserved for treatment of recalcitrant warts, those contain viral DNA. Plantar warts containing HPV1
causing discomfort, large condylomata acuminata appear to be the richest source of viral particles. To
and at sites where CO 2 laser treatment may be easier, reduce the possible risk of infection following
faster or associated with less morbidity. inhalation of viral material it is mandatory that an
The precise vaporisation that can be achieved adequate smoke evacuator system is used diligently
with the CO 2 laser allows accurate destruction of to extract the smoke as it arises from the wound.
lesional tissue with great accuracy. The reduced Surgical masks have also been shown to effectively
thermal damage with superpulsed CO 2 laser results filter aerosolised viral particles, probably acting as
electrostatic filters to trap the smallest particles.

Fig.6.3. CO 2 laser ablation of warts.
Syringomas
The CO 2 laser has advantages in the vaporisation of
selected benign dermal tumours over other surgical
modalities. Laser treatment allows precise and
speedy ablation of multiple tumours with a minimal
risk of scarring. Multiple syringomas in particular
respond well to this form of treatment. The blood-
less operating field, reduced postoperative pain and
reduced swelling are all distinct advantages. Good
results using the CO 2 laser have been reported for a
number of other dermal tumours such as tricho-
epitheliomas, cylindromas, tricholemmomas of
 62 Lasers in Dermatology

Cowden's disease, neurofibromas and angiofibromas Table 6.1. Conditions reported as treatable By CO 2 laser ablation
in tuberous sclerosis. The last may also respond well
to pulsed tunable dye laser treatment. Epidermal disorders Actinic cheilitis
Erythoplasia of Queyrat
Debridement of Burnt Skin Bowen's disease
Epidermal naevi
Early studies using the continuous wave CO 2 laser Bowenoid papulosis
showed effective vaporisation of necrotic and infec- Dermal disorders Syringomas
tive tissue. Haemostasis was a benefit of this treat- Trichoepitheliomas
ment but the residual thermal damage impeded Cylindromas
Cowden'sdisease
wound healing and graft survival. Research using a
Neurofibromas
pulsed CO 2 laser (Green et aI, 1990) showed that Adenoma sebaceum
vaporisation of burn eschar could be effectively per- Xanthelasma
formed with a narrow (100 /Lm) band of residual Chondrodermatitis nodularis helicis
thermal damage such that the wound could take a Vascular lesions Port wine stains (generally no longer
graft. recommended)
Pyogenic granulomas
Angiokeratomas
Rhinophyma Lymphangioma circumscriptum
A number of surgical approaches to the treatment Angiosarcomas
of rhinophyma have been reported, including der- Tattoos
mabrasion, sculpting with a scalpel and cryosurgery. Debridement of burn
The CO 2 laser has the distinct advantage of greater wound/necrotic tissue
precision and ease of tissue removal, while sculpting Rhinophyma
the nasal tissue haemostatically. The tumorous Keloids
tissue can be excised or debulked by the laser in
focused mode and then resurfaced to finish the pro-
cedure, leaving minimal residual thermal damage.
Q-switched laser treatment of tattoos can require
Epidermal Naevi multiple procedures and not all inks will respond.
Some patients prefer a one-off treatment to com-
Linear and verrucous epidermal naevi can be excised
pletely remove the tattoo at the expense of a scar.
if feasible, otherwise treatment has traditionally
A large proportion of the published literature
been performed by dermabrasion. The inability to
relating to tissue ablation with the CO 2 laser relates
control the depth of tissue removal precisely results
to continuous wave CO 2 lasers with their inherent
almost inevitably in lesion recurrence or scarring
disadvantages. Tissue ablation with superpulsed CO 2
from too deep a treatment. The CO 2 laser can more
lasers is undoubtedly more efficiently and easily
precisely remove epidermal naevi but the ablation
achieved. Conversely developments in other treat-
must extend into the papillary dermis to prevent
ments particularly in lasers such as the pulsed dye
recurrence. Hypopigmentation is likely after this
and Q-switched lasers has altered the balance as to
procedure and the results are dependent on the skill
the most appropriate treatment for the conditions
and experience of the laser operator.
listed in Table 6.1 and elsewhere. The decision to use
the CO 2 laser for tissue ablation is often based on
Tattoos
the surgeon's experience and local facilities.
Tattoos were frequently treated by the continuous
wave CO 2 laser to ablate the tissue containing tattoo
particles. Good clearance of the tattoo could be
achieved but inevitably some degree of scar would
Resurfacing Skin with the (0 2
develop. Patients frequently preferred a scar to the Laser
stigmatisation associated with the tattoo. The devel-
opment of Q-switched lasers such as the Q-switched The development of high-energy short-pulsed CO 2
ruby and Nd:YAG lasers has supplanted the CO 2 lasers, as discussed previously, has led to an exponen-
laser as the main laser for tattoo removal. However, tial increase in interest in resurfacing photo-aged skin

Fig. 6.4. Vaporisation of tissue 30-70 ~m into the papillary dermis with the SilkTouch CO 2 laser. (Courtesy of ESC Sharplan.)
as a cosmetic treatment for reduction of wrinkles and
improvement in appearance. The power densities
of the newer-generation pulsed and scanned CO 2
lasers range from 10,000 to 50,000 W/cm 2• This allows
efficient tissue ablation with minimal (60-120 /Lm)
residual thermal damage (Fig. 6.4).
Photo-aged skin has an atrophic epidermis with
atypical keratinocytes. The dermis is also abnormal,
with decreased amounts of altered collagen and an
increase in elastotic material. Clinically photo-aged
skin shows wrinkles, papular elastosis, yellow discol-
oration and uneven pigmentation. Removal of the
abnormal layers of photo damaged epidermis and
dermis, which may be 100-500 /Lm thick, results in
immediate clinical improvement. Sustained improve-
ments may be achieved through increased deposit-
ion of collagen I and collagen remodelling (Nelson
et aI, 1995). Animal studies using a microsecond
pulsed CO 2 laser have shown that it is possible to
remove these abnormal layers with great precision
(Fitzpatrick et aI, 1996). The earliest clinical studies
on resurfacing of photo-aged skin were published in
the mid-1990s (Waldorf et aI, 1995; Lowe et al, 1995;
Weinstein, 1994; Lask et aI, 1995) The two lasers most
commonly used were the UltraPulse (Coherent) and
the SilkTouch (Sharplan). The earliest results with
these lasers were encouraging, with significant im-
provement in appearance and low risk of adverse
effects. Weinstein (1994) treated 36 patients with
resurfacing of the periorbital skin in association
The COl and Er:YAG lasers 63
with transconjunctivallower lid CO 2 laser blepharo-
plasty. All patients had an excellent result. Waldorf
et al (1995) treated 47 patients with perioral, peri-
orbital and glabellar wrinkles using a SilkTouch laser
with flash scanner. Good to excellent results were
achieved in all anatomical areas treated. All patients
experienced post-treatment erythema lasting up to
6 months. Lowe et al (1995) reported on the results
of resurfacing 100 patients with the UltraPulse
CO 2 laser. All patients had moderate to severely
photodamaged skin. At 1 month after treatment,
five patients achieved a marked improvement, 68 a
moderate improvement and 27 patients minimal
improvement.
A large study by Alster and Garg (1996) reported
the results of resurfacing 259 patients with facial
wrinkles using an UltraPulse CO 2 laser. On average
90% improvement in all areas studied was seen. Best
results were in the periorbital region. Lowest response
rates (86.8%) were seen in the most severe wrinkles
and those associated with excessive muscle move-
ment (i.e. frown lines at the glabella). Post-treatment
erythema persisted for a mean of 2.2 months.
Mechanism of Action
(The reader is advised to read the excellent review by
Ross et aI, 1999, which discussed this subject in detail.)
There are two mechanisms by which resurfacing
lasers can improve photo damaged skin: these are:
 64 Lasers in Dermatology

ablation and residual thermal damage. Photo- and moderately severe photo damaged skin but is
damaged skin is removed during resurfacing; the equally effective in early photodamage. By increas-
whole epidermis and a variable thickness of dermis ing the number of passes with the Er:YAG laser it is
is ablated. However, this level of ablation may not possible to achieve results similar to the CO 2 laser
extend to the depths of wrinkles and yet marked (Khatri et aI, 1999). This may be due to deeper abla-
cosmetic improvement can occur. Fitzpatrick et al tion with the Er:YAG laser. There are no long-term
(1996) noted significant shrinkage of tissue during follow-up studies comparing the results of Er:YAG
resurfacing, particularly after the epidermis had and CO 2 laser resurfacing.
been removed. This shrinkage of tissue, indicating
heat-induced collagen shrinkage, was thought to
account for the smoother, tighter appearance of the Preoperative Patient Evaluation and
skin. The depth of dermal residual thermal damage Preparation
increases with fluence until a threshold is reached
and then remains relatively constant, provided pulse It is essential that thorough evaluation of patients
durations are short. By the correct use of appropri- requesting laser resurfacing is performed. There is
ate CO 2 resurfacing lasers the thickness of residual considerable discomfort following the procedure;
thermal damage is usually kept to a minimum of often a complicated and time-consuming treatment
50-100 /Lm. This minimises the risk of scarring after regimen needs to be adhered to and there may be a
CO 2 laser resurfacing. prolonged healing time particularly with respect to
There has been considerable debate as to the post-treatment erythema. Patient expectations and
importance of residual thermal damage in deter- their understanding of likely outcomes are para-
mining improvement in photo damaged skin after mount to a satisfactory result that is pleasing to the
laser ablation. It has been proposed that the persist- patient.
ing erythema after resurfacing is related to the The best areas to respond to laser resurfacing are
residual thermal damage rather than tissue ablation periorbital and perioral wrinkles. Deep wrinkles
and efforts to minimise thermal damage with lasers and movement associated wrinkles such as forehead
such as short pulsed CO 2 and Er:YAG (see below) creases, glabella folds, crow's feet and nasolabial
have resulted in a reduction in the duration of ery- folds may respond only partially and movement-
thema postoperatively. Skin resurfacing with 90 /LS associated deformities are likely to recur more
pulse duration CO 2 lasers (Tru-Pulse) has been quickly.
reported to have shorter duration of erythema com- Typewritten information explaining the procedure
pared with resurfacing with 900 /LS dwell time CO 2 should be supplied to the patient and photographic
lasers (Bucalo and Moy, 1998). However, in a com- material showing patients before and after treatment
parison of four CO 2 lasers including the Tru-Pulse, are very helpful. A full discussion of potential com-
Alster et al (1999) showed no difference in the dura- plications and likely post-treatment course should be
tion of erythema postoperatively, although it was given to the patient and contact numbers of named
less intense with the Tru-Pulse and FeatherTouch personnel provided for reassurance. Patients should
lasers compared to the UltraPulse and NovaPulse. sign a consent form demonstrating they have
The same authors found no difference in clinical received and understood the necessary information.
results with the four lasers employed. Similar ranges Although most skin tones can be treated with CO 2
of residual thermal damage after multiple passes laser resurfacing, patients with types I and II are the
were seen with each laser (Duke et aI, 1998). best candidates. Darker skin tones have a significant
The Er:YAG laser produces almost all its effects higher incidence of post-treatment hyperpigment-
by skin ablation, with substantially less residual ation. Patients with a personal history of keloid
thermal damage «50 /Lm) than pulsed CO 2 lasers. formation should not undergo laser resurfacing.
Postoperative erythema duration is significantly Patients with reduced adnexal structures or in-
reduced with this laser (Teikemeier and Goldberg, creased tissue fibrosis, which includes patients who
1997) compared to CO 2 laser resurfacing. There are have had prior X-ray treatment, dermabrasion or
few studies, however, to compare the efficacy of the chemical peels, patients with scleroderma and
Er:YAG laser with pulsed CO 2 lasers in resurfacing patients taking isotretinoin, may all experience
photo damaged skin. It is generally considered that increased scarring after resurfacing procedures. It
the Er:YAG laser is less effective for deep rhytides is not clear how long after a course of isotretinoin

patients can safely undergo resurfacing but scarring
can occur after dermabrasion performed more than
a year after a course of isotretinoin (Rubenstein et aI,
1986) and it is wise to defer laser resurfacing until at
least a year after a course of this drug.
A number of therapies given pre- or perioper-
atively have been shown to reduce the incidence of
adverse events after laser resurfacing. Tretinoin used
before dermabrasion has been shown to speed re-
epithelialisation and has a similar effect when used
as a pretreatment before laser resurfacing. Patients
are instructed to use tretinoin cream (Retin A)
0.025% or 0.05% nightly for the 6 weeks prior to
laser therapy. All patients are discouraged from
having a sun tan prior to resurfacing and should
apply a high factor (15 or greater) broad-spectrum
sunscreen daily for a similar duration to the tretin-
oin. Although many authors have recommended
pretreatment with hydroquinone to reduce the
frequency of post-treatment hyperpigmentation,
recent work (West and Alster, 1999) suggest this may
not be necessary.
A further risk to the patient following laser resur-
facing is reactivation of herpes simplex virus infec-
tions. Many patients may not be aware than they are
carrying a latent form of this virus. Early reports of
laser resurfacing showed herpes simplex virus reac-
tivation rates up to 9.4% (Nanni and Alster, 1998;
Sriprachya-Anunt et aI, 1997). As history of recur-
rent cold sores may not accurately predict risk of
viral reactivation, all patients should be treated with
prophylactic antiviral agents: acyclovir, valacyclovir
or famciclovir commencing 24 h before laser resur-
facing and continued for 7-10 days (Lowe et aI, 1995;
Alster and Nanni, 1999).
Patients after skin resurfacing are at high risk of
bacterial contamination of the denuded skin.
Prophylactic antibacterial therapy has substantially
reduced the incidence of impetiginisation of treated
skin postoperatively. Treatment regimens vary:
cephalexin, ciprofloxacin, dicloxacillin and erythro-
mycin have all been recommended by various
authors. A study by Manuskiatti et al (1999) revealed
that 8.2% of patients without antibiotic prophylaxis
had bacterial infections after the procedure, com-
pared with 4.3% of patients taking prophylactic
ciprofloxacin. In all cases this occurred after the
ciprofloxacin had been discontinued. Capizzi et al
(1998) examined the debris in the plume following
CO 2 laser resurfacing. Of l3 patients, five had coagu-
lase-negative staphylococci; in addition one patient
also had a corynebacterium and another also had
The COl and Er:YAG Lasers 65
Neisseria in the debris. It is recommended that
perioperative anti-staphylococcal antibacterial anti-
biotics are given to patients having full-face resur-
facing although this may not be necessary for
localised procedures.
Treatment Methods
The following is a general guide to CO 2 laser
resurfacing techniques for photo damaged skin.
Inappropriate techniques with the CO 2 laser have
great potential for adverse reactions, including scar-
ring, hypopigmentation and unacceptable cosmetic
results. It is essential that practitioners embark on a
structured period of approved training under the
supervision of an experienced laser physician before
considering treating patients unsupervised.
General Considerations
The areas to be resurfaced are marked out with a skin
pencil prior to treatment. It is important to vaporise
the full length of the wrinkles treated and this may
involve extension beyond the normal anatomical unit
for that area. To minimise a sharp border between
treated and untreated skin a "blending" or "feather-
ing" technique can blur the boundaries.
Adequate analgesia/anaesthesia is necessary for
resurfacing of the face and it is unlikely that topical
agents such as EM LA or Ametop will be adequate for
all but the smallest treatments. For localised areas of
resurfacing regional nerve blocks in combination
with infiltrational anaesthesia can provide full anaes-
thesia of the treatment field. For full-face resurfacing
intravenous sedation or general anaesthesia is often
preferred. Prior to treatment the skin is cleansed
with antiseptic and the surrounding tissue and hair
protected with wet gauze. Flammable materials
including oxygen should be excluded from the treat-
ment field and the patient's eyes protected. If both
the perioral and periorbital areas are to be treated it
is preferable to resurface the entire face. Treatment
of the intervening skin improves the other two areas
and the erythema post-treatment is less noticeable if
it is uniformly distributed over the face.
Laser treatment takes place by the delivery of
adjacent or slightly overlapping «10%) spots or pat-
terns over the affected skin. Each treatment is a
"pass" of the laser over the targeted area. Between
each pass the proteinaceous debris is removed from
the area by saline-soaked gauze. This debris contains
 66 Lasers in Dermatology
little water and will interfere with subsequent abla-
tion. After removing the debris the tissue is dried to
remove any surface water before the next pass. The
first pass of the CO 2 laser will completely ablate the
epidermis; subsequent passes will progressively
ablate layers of dermis. The depth of dermal ablation
per pass will decrease after several passes. Tissue
colour changes as ablation proceeds through the
dermis. The papillary dermis is pink, changing to
grey with deeper ablation. The upper reticular
dermis has a yellowish colour and ablation should
not proceed beyond this.
Coherent UltraPulse
The UltraPulse can be used either with a ePG or
with a 3 mm collimated beam handpiece. A variety
of patterns and sizes are available with the ePG and
most operators use square or hexagonal patterns
ranging from 3 to 9 mm. Typical fluences with the
3 mm handpiece range from 350 to 500 mJ per pulse
at 3-7 W. With the ePG, 150-300 mJ is the fluence
range most commonly used with the scan density
set to low to produce non-overlapping or 10% over-
lapping spots. For large areas the scanner will pro-
duce uniform ablation quickly and easily for the
operator. The collimated handpiece is useful for
awkward sites or where precise spot placement is
necessary. Feathering at the edge of treatment zones
is performed by reducing the pulse energy and
density of the pulses to produce a smooth blend
between treated and untreated skin.
Sharplan SilkTouch/FeatherTouch
The Sharp Ian CO 2 laser systems are continuous wave
CO 2 lasers with a focused beam which is delivered
Table 6.2. Depth of ablation per pass of COl laser
Ultra Pulse'
One pass Epidermal vaporisation
+ 20 ~m dermal coagulation necrosis
Two passes Epidermal vaporisation
+ 40 ~m dermal coagulation necrosis
Three passes Epidermal vaporisation
+ 60 ~m dermal coagulation necrosis
a 300mJ, 2.25 mm spot,100W,density 6.
b 200-Hhandpiece,8 mm square, 18 W,28 J/cm 2.
(200-H handpiece, 10 mm square,36 W, 10 J/cml.
From Weinstein (1998).
onto the skin by a flash scanner which moves the
laser beam rapidly in a series of patterns such that
the beam dwell time on any given spot is less than 1
ms. With the FeatherTouch this is 0.3 ms. Powers are
in the 5-20 W range depending on spot size. Typical
powers of 16 W give fluences of 13 Jtcm 2• The scan
duration is usually 0.2 s. Using the SilkTouch mode
the pattern is scanned twice: once inwards and then
outwards (Fig. 6.5).
For the above lasers the first pass will ablate the
epidermis (60 /Lm); by the third pass, ablation will be
down to the reticular dermis (see Table 6.2). A recent
study (Khosh et aI, 1999) using the FeatherTouch
at different fluences showed that single passes of
7-9 Jtcm 2 ablated the epidermis but rarely pene-
trated the dermis. One or two passes at 17 Jtcm 2
caused complete ablation of the epidermis and a
maximum of 140 /Lm of thermal injury to the papil-
lary dermis. The authors performed laser resurfac-
ing of the face (excluding the periorbital region) with
just one pass of the FeatherTouch laser at 17 Jtcm 2
with satisfactory results and reduction in postoper-
ative erythema. Side-by-side comparisons of the
UltraPulse and Sharp Ian FeatherTouch with other
CO 2 lasers have shown no clinical differences in the
results of resurfacing. Neither has there been any dif-
Fig. 6.S. Perioral wrinkles before and 3 months after (0 2 laser
resurfacing. ((ourtesy of ES( Sharplan.)
Silk Touch' Feather Touch'
Epidermal vaporisation Epidermal vaporisation
+ 70 ~m dermal coagulation necrosis + 10 ~m dermal coagulation necrosis
Epidermal vaporisation Epidermal vaporisation
+ 100 ~m dermal coagulation necTosis + 30 ~m dermal coagulation necrosis
Epidermal vaporisation
+ 50 p,m dermal coagulation necrosis

ference in the frequency of adverse reactions (Gross
and Rogers, 1998; Alster et aI, 1999). The choice
between these two lasers for resurfacing will depend
on operator preference, cost and availability.
Other CO 2 Lasers
Two other CO 2 lasers have been investigated for
cutaneous resurfacing of photo damaged skin. The
Luxar Nova Pulse (Luxar Corp., Bothell, WA) is a
superpulsed CO 2 laser. It can deliver fluences of
7 J/cm2, suitable for selective photothermolysis. The
superpulses are clustered together into short bursts
of less than 1 ms and scanned rapidly over the skin
through a CPG. In direct comparisons with the
UltraPulse and FeatherTouch results were similar in
terms of outcome and adverse events (Gross and
Rogers, 1998; Alster et aI, 1999).
The Tru-Pulse (Tissue Technologies,Albuquerque,
NM) has a pulse duration an order of magnitude
less than contemporary CO 2 lasers. It can deliver
10,000 W with a pulse duration of 90 JLS and pulse
energies of 250-500 mJ. A spot size of 3 mm is used.
Several investigations on the effects of the Tru -Pulse
laser in animal skin and human volunteers have
been reported (Smith et aI, 1997a, 1997b; Bucalo and
Moy, 1998). Reduced contraction of tissue occurs
after ablation compared to longer pulsed lasers. It
has been suggested that the duration of erythema
after resurfacing is less with this laser than other
resurfacing CO 2 lasers (Harris et aI, 1999). The depth
of residual thermal damage may also be less than
longer pulse CO 2 lasers. It is not clear whether these
differences are clinically apparent; some researchers
have found the Tru- Pulse less effective than other
CO 2 lasers for deep rhytides, while others have
shown no differences in outcome (Alster et aI, 1999).
It appears that whichever system is used, if used
appropriately roughly equivalent clinical results can
be obtained. There appears to be little clinical
advantage in exceeding three passes of the laser over
the resurfaced skin. Further passes are likely to
increase the risk of unwanted events such as scar-
ring. It is important to avoid pulse stacking where
multiple pulses are delivered to tissue without ade-
quate time for cooling. This can occur with slow
movement of the handpiece with rapid pulse repeti-
tion rates or high percentage overlap of spots with a
scanning device. Fitzpatrick et al (1999) has demon-
strated a linear increase in the depth of thermal
necrosis with the number of pulses stacked.
The CO2 and Er;YAG lasers 67
Postoperative Management
Following a resurfacing procedure the patient is left
with a large exudating wound of all or part of their
face. It is important that equal attention is given to
postoperative care as to other parts of the procedure
to reduce operative morbidity and the incidence of
side effects.
Post-treatment care can be divided up into the
acute exudative phase which usually lasts about
3 days, the intermediate phase while the skin re-
epithelialises, which usually lasts about 7 days, and
then the long-term care of the skin.
Acute Exudative Phase
There are two methods of caring for the skin after
resurfacing: open and closed methods.
The open method involves keeping the skin moist
by the regular application of soothing ointments
such as petrolatum, aquaphor (Xipamide) etc.
Regular ice packs are applied to the skin to reduce
oedema and the patient sleeps with the head ele-
vated. The ointment applications are every couple of
hours and the skin is kept moistened with cool tap
water, saline or weak vinegar solutions. Non-
steroidal anti-inflammatory medication or anal-
gesics will be required and some patients benefit
from night-time sedation.
The advantages of the open method are low cost
and ease of use. The disadvantages are discomfort
for the patient, milia and folliculitis and allergic
contact dermatitis, which is more common when
using antibacterials such as polysporin ointment.
Once the skin has re-epithelialised the skin does
not need to be kept moist.
The closed method involves the application of an
occlusive dressing to the treated skin which is
applied in the operating theatre. The dressing can
either be a hydrogel such as Second Skin or Vigilon,
a polymer film such as Silon or composite foam
such as Flexzan. Dressings such as Vigilon cling to
the skin but do not adhere and need to be held in
place with tape or other supportive dressings such
as Flexinet. Flexan will stick to untreated skin
peripherally and is thus more convenient.
Some operators use the closed method for the
first 24-48 h before switching to the open method.
The dressings can be changed twice daily or daily
depending on the exudation. Re-epithelialisation
under occlusion occurs 3 days earlier than without.
If a dressing falls off and cannot be replaced, the
 68 Lasers in Dermatology
patient is instructed to use ointment as in the open
method. One of the major benefits of occlusive
dressing is minimisation of pain and discomfort.
Patients may be unwilling to use occlusive dressings
for more than 2 or 3 days. Hydrogel and polymer
film dressing reduced pain significantly more than
other dressings (Newman et al, 1998). The disadvan-
tages are cost to the patient of the dressings and
possible follow-up visits for reapplication of the
dressing. Occlusive dressings for the first 48 h after
resurfacing followed by open wound care may be
the most cost-effective post-resurfacing wound
regimen. With both open and closed methods
regular ice pack applications will reduce swelling
and discomfort.
Intermediate Phase
The intermediate phase occurs when the skin
has re-epithelialised. This usually occurs around
6-10 days post-treatment. When re-epithelialisation
is completed the noticeable post-treatment ery-
thema will be present. At this stage the skin will be
very dry and possibly itchy. A regular emollient
should be applied plus a mild corticosteroid such as
1% hydrocortisone ointment to itchy areas. Make-up
to minimise the erythema can be applied from
about 10 days postoperatively. The patient should be
advised to completely avoid sun exposure while the
erythema lasts, which can be from 1 to 4 months,
occasionally much longer. A broad-spectrum high-
factor sunscreen should be used daily. After about 1
month as the skin settles topical retinoids such as
tretinoin can be reintroduced. Although many oper-
ators pretreat patients with hydro quinone to reduce
the incidence of post-treatment hyperpigmentation
there is no published evidence to support this
concept. West and Alster (1999) showed that pre-
treatment with 10% glycolic acid cream, hydro-
quinone 4% cream or tretinoin 0.025% cream made
no significant difference in the incidence of post-
CO 2 laser resurfacing hyperpigmentation. Post-
treatment hyperpigmentation does develop,
however, in the intermediate period after resurfac-
ing and can occur in the majority of patients with
darker skin types. It is reasonable therefore to intro-
duce hydro quinone therapy at the same time as
tretinoin in subjects likely to develop hyperpigmen-
tation or at the first sign of this occurring.
Long-term care of the skin should be aimed at
minimising any adverse effects of the resurfacing
procedure and maintenance of the beneficial effects
to the photo damaged skin. In addition to the
management outlined above the patients should
practise life-long sun reduction to their exposed
skin by avoidance of sun exposure, daily high-factor
sunscreen and appropriate clothing. Long-term
tretinoin use will also slow down the reappearance
of changes of photo damage.
Complications of Resurfacing with the
CO 2 Laser
Although the rate of serious complications with the
CO 2 laser is low with experienced operators, there is
considerable risk from this procedure due to poor
technique, inappropriate patient selection and in-
adequate pre- and postoperative care.
Infections
The de-epithelialised facial skin under a moist
occlusive dressing is prone to infections with bac-
teria, viruses - particularly reactivation of herpes
simplex - and fungi - most commonly Candida.
Disseminated herpes simplex can take 7 days to
become clinically obvious, presenting as malaise,
fever and skin tenderness. The involved lesions
become secondarily infected with Gram-negative
bacteria. A negative history of cold sores is unreli-
able and antiviral prophylaxis in all patients is pre-
ferred for full-face and perioral procedures.
Allergic Contact Dermatitis
Patients can become allergic to the topical prepar-
ations used during the early post-treatment period.
An itchy erythematous vesiculation can develop
which is difficult to diagnose on the background of
re-epithelialising skin. Avoidance of antibacterial
preparations with a higher incidence of allergic
contact dermatitis induction such as polysporin can
reduce the frequency of this complication. Removal
of the offending antigenic agent and application of a
mild to moderate topical corticosteroid is usually
required.
Pigmentary Disturbances
Transient hyperpigmentation is the commonest
reported side effect of CO 2 laser resurfacing, occur-
ring in up to 37% of darker skin types. It is usually
reversible but may persist for several months.
Treatment with hydroquinone with sunscreen can
be started 3 weeks after the procedure in darker

skin types or at the onset of hyperpigmentation.
Hydroquinone should not be used for more than
3 months because of the risk of drug-induced
hypopigmentation. There appears to be no benefit
from pretreating the patient with hydroquinone
(West and Alster, 1999).
Hypopigmentation occurs in up to 16% of
patients (Bernstein et aI, 1997). The onset is often
not until 6 months or longer after treatment and is
permanent. The incidence of hypopigmentation may
increase with longer follow-up times of treated
patients.
MilialAcneform Eruptions
Occasionally milia develop 1-3 months after resur-
facing. This is far less common than with derma-
brasion. Pretreatment with tretinoin reduces this
complication and can also be used to speed their
resolution. Acneform eruptions are uncommon
and more often seen in patients using "open" post-
treatment care. Dressing changes and topical tret-
inoin are usually sufficient to settle the problem.
Scarring and Ectropion
The most severe complications after CO 2 laser resur-
facing are scarring and ectropion. Scarring is more
likely if deeper passes have been performed or with
high spot overlapping or pulse "stacking" (Ross et aI,
1999). Scarring usually develops within 1 month
postoperatively. Intralesional corticosteroids or sili-
cone gel applications may be helpful. Alster (1997)
recommends treatment with the 585 nm pulsed dye
laser at the first sign of scarring.
Ectropion has occurred when upper and lower
eyelids are treated. It is more common in patients
who have had a prior blepharoplasty.
Long-Term Results of CO 2 Laser
Resurfacing
One study (Manuskiatti et aI, 1999) has assessed the
long-term results in over 100 patients followed up for
more than 1 year after UltraPulse CO 2 laser resurfac-
ing. Seventy-five patients had a full-face procedure.
Over 90% of patients reported that the procedure
was considered cosmetically successful and would
recommend it to others. Objective assessments
revealed 30-40 % improvement in periorbital and
perioral wrinkles respectively. Hyperpigmentation
was seen in 2% and hypopigmentation in 19% of
The COzand Er:YAG Lasers 69
patients. Four patients had local scarring; all four
had postoperative infections.
Comparison Between CO 2 Laser
Resurfacing and Chemical Peels
Superficial chemical peels such as alpha-hydroxy-
acids and Jessner's solution remove only a superficial
part of the epidermis and have no effect on wrinkles.
Medium-depth chemical peels such as solid CO 2 and
35% trichloroacetic acid with Jessner's solution can
lessen textural irregularities and very superficial
wrinkles but have minimal effect on clinically visible
wrinkles. This depth of injury can be achieved with
one pass of an UltraPulse or SilkTouch CO 2 laser. The
depth of injury with the laser is relatively constant
from patient to patient and predictable.
The depth of injury with medium-depth peels is
more variable both between patients and in anyone
patient. This is due to a combination of technique,
degree of photo damage, density of adnexal struc-
tures and other unidentified factors. Resurfacing
lasers are thus preferred to medium-depth peels
because of their greater efficacy, predictability and
safety. Reed et al (1997) compared a medium-depth
chemical peel (Jessner's solution and 35% trichloro-
acetic acid) with the SilkTouch CO 2 laser in 24
patients with moderate to severe periorbital wrin-
kles. There was a statistically significant superior
improvement in wrinkle severity after two to four
passes with the laser compared to the peel. Fibrosis
of the lower eyelid was seen in 52% of the laser-
treated patients, particularly if four passes were
made, compared to 12.5% of the peel treatments.
Post-treatment erythema was considerably longer
after laser treatment.
Deep chemical peels using Baker's 50% phenol
solution acts as a keratolytic and causes destruction
towards the mid-reticular dermis. This peel can
significantly reduce even deep wrinkles but there is
a high incidence of post-treatment hypopigment-
ation and a risk of scarring. Deep chemical peeling
is very sensitive to operator experience and tech-
nique. One study comparing the SilkTouch CO 2 laser
with unoccluded Baker's phenol peel was performed
by Chew et al (1999). Upper lip wrinkles were
treated in a side-by-side comparison with three
laser passes and a chemical peel with extra phenol
applied to the deeper wrinkles. The degree of
improvement in wrinkle score was significantly
greater in the phenol-treated side compared to the
 70 lasers in Dermatology
Fig.6.6. Atrophic acne scars before and 8 months after Ultra Pulse CO 2 laser resurfacing. C
laser-treated side. One of the 20 subjects had a
hypertrophic scar on the phenol-treated side. The
authors comment that four passes with the CO 2 laser
would have given superior results. Localised areas
were treated and the authors had substantial experi-
ence in chemical peeling. A histological comparison
of CO 2 laser resurfacing and Baker-Gordon phenol
(Moy et aI, 1999) revealed that after two laser passes
more superficial tissue ablation occurred in the
laser-treated skin compared to the phenol-treated
skin initially. After 3 months the zone of new colla-
gen formation was thicker as a result of the phenol
peel. Clinical comparisons between laser and peel
were not performed. Further studies are needed
to clarify the merits of the two treatments when
compared with each other.
CO 2 Resurfacing of the Acne-Scarred
Face
The traditional surgical treatment of acne scarring
has been dermabrasion. This has the disadvantages
of possible scarring and pigmentary disturbances
and the procedure itself is very bloody, present-
ing risks to the surgeon. With experience in CO 2
laser resurfacing growing, laser surgeons such as
Apfelberg (1997a, 1997b) and Alster and West (1996)
reported improvement of facial acne scars after CO 2
laser resurfacing. Treatment technique is similar to
resurfacing of photo-aged skin. Effacement of the
scars can be seen in the bloodless field as passes
with the laser ablate tissue into the dermis. Alster
( ourtesy of Dr R. Sheehan-Dare.)
and West (1996) reported an 81.4% average clinical
improvement in acne scars following treatment. No
hypertrophic scarring was observed. "Ice-pick" acne
scars which are deeper tend to do less well than
more shallow atrophic scars (Fig. 6.6). Sides of acne
scars can be vaporised using a small spot size. Ice-
pick scars can be excised prior to resurfacing to
improve the cosmetic result (Abergel and Dahlman,
1995). Subcisional techniques to release scars from
their myofascial attachments may also be beneficial
(Orentreich and Orentreich, 1995). For best results it
may be necessary to offer the patient a combination
of all these techniques.
Erbium:YAG Laser Treatment in
Dermatology
Introduction
The erbium:YAG (Er:YAG) laser is a recently intro-
duced laser with a wavelength of 2940 nm, which is in
the mid-infrared invisible light spectrum. This wave-
length corresponds to the main peak of water absorp-
tion. This wavelength has a 10-15 times greater
water absorption than a CO 2 laser at 10,600 nm (see
Fig. 6.7). Thus the penetration depth into tissue of the
Er:YAG laser beam is limited to a small volume of
tissue. The ablation threshold of the Er:YAG laser
for human skin has been calculated at 1.6 J/cm 2
(Hohenleutner et aI, 1997) as compared to 5 J/cm 2 for
 The COzand Er:YAG Lasers 71

2940 Er:YAG laser to produce desired tissue ablation, no collagen

contraction in resurfacing photo damaged skin and
no haemostasis due to the very narrow zone of
residual thermal damage (Fig. 6.9).
Over the past few years several laser companies
Water have developed Er:YAG lasers and there is now a
c: wide choice of such machines commercially avail-
o
.~ able. The laser is a solid-state laser with a YAG
o
(J)
crystal doped with erbium. The crystal is excited
.0
<l: by a pulsed flash lamp. Newer lasers are capable of
20 W power. The 2940 nm beam is delivered through
rigid tubing with mirrored jointed, articulated arms.
A coaxial red aiming beam is required and some
500 1000 5000 machines can deliver the light through scanners.
Wavelength (nm)
Most lasers can deliver light with sufficient fluence
to ablate tissue with spot sixes of 6 mm or more
Fig. 6.7. Schematic diagram of absorption of water and other with frequencies of 10Hz. Focused beams less than
cutaneous chromaphores to show absorption peak at Er:YAG 1 mm in diameter can be used for incisional surgery
wavelength. and are used in other specialities such as dentistry.
Early in vivo and in vitro studies on the effects of
the Er:YAG laser on a variety of tissues including
short pulsed CO 2 lasers. Thus with typical operating skin revealed clean ablation craters and precise cuts
fluences of 5-15 J/cm 2 the Er:YAG laser is operated with only minimal adjacent tissue damage followed
well above ablation threshold which results in greater by excellent healing without scarring (Kaufmann
ablation and less residual thermal damage. Because and Hibst, 1989, 1990). The advantages of this laser
of the short penetration depth of the 2940 nm radi- in precise tissue ablation were clearly demonstrated
ation, the laser-heated layer of tissue is initially 1 J-Lm but the lack of haemostasis with the Er:YAG for
wide with a thermal relaxation time of approximately incisional work suggested no advantage over simple
1 J-Ls. Thus single pulses of the Er:YAG less than 1 J-Ls scalpel surgery for skin (Kaufmann et aI, 1994).
in duration will minimise the zone of thermal
damage. (See Selective Photothermolysis, Ch.l). Clinical Studies with the Er:VAG Laser
The Er:YAG laser can operate in free-running
mode or in Q-switched mode. In the free-running
The Er:YAG laser has been used in clinical studies as
mode typical pulse widths of 200-400 ms are gener- a resurfacing laser for treatment of wrinkles, photo-
ated. Within each single laser pulse a number of
damage and acne scarring or to ablate skin tumours
very short spikes 1 J-LS in duration follow rapidly on (Fig. 6.10).
from each other. The number and height of the
spikes grow with the energy of the flashlamp
Skin Resurfacing of Wrinkles
pumping the laser. When used with pulses of this
duration the laser causes 5-40 J-Lm of tissue ablation Teikemeier and Goldberg (1997) treated 20 patients
with residual thermal damage as little as 5 J-Lm in with an Er:YAG laser (ESC Medical Systems, Israel).
depth and does not exceed 50 J-Lm (Kaufmann and For wrinkles around the eyes and upper lip a 2.5 mm
Hibst, 1996). Using Q-switched pulses of 90 ns spot with single pulses of 400-800 mJ was used. For
thermal damage was consistently 5-10 J-Lm (Walsh thicker-skinned regions such as the forehead a 5 mm
et aI, 1989). These results should be contrasted with spot with energies of 600-800 mJ was employed. All
the typical thermal injury of 75-150 J-Lm induced by treated areas required one to three passes to achieve
pulsed CO 2 lasers (see Fig. 6.8). Thus the Er:YAG visual lessening of the wrinkles. Re-epithelialisation
laser can ablate very narrow layers of tissue with occurred between 4 and 10 days and postoperative
minimal residual thermal damage. Potential advan- erythema resolved in less than 2 weeks (contrast
tages of this laser are extremely precise control of with CO 2 laser resurfacing). Clinical improvement
tissue ablation with reduced thermal damage. assessed by the clinicians was seen in all patients.
Possible disadvantages are multiple passes of the Perez et al (1998) treated 15 patients with an Er:YAG
 72 Lasers in Dermatology

(a) One pass

,Ii
Er;YAG

AbI,lioo
,
Pulsed CO 2

0
Residual
Epiderm is thermal
injury

Cl
<b
"S
60 ::r
Papillary i:
dermis 3

Reticular
dermis
120

(b ) Three passes Er:YAG

~ Ablation
,
Pulsed CO 2

o
Epidermis
I I Residual
thermal
injury

Cl
<b
"S
60 ::r
Papillary -=
dermis 2.

Reticular
120
dermis

Pi npoint haemo rrhage Haemostatic

as papillary dermis thermal
is ablated coagu lation

Fig.6.S. Schematic diagram to illustrate differences in ablation with Er:YAG and pulsed CO 2 laser.

laser (Continuum Biomedical). All patients were
treated with a 5 mm spot and energies of 800 mJ to
1 J at 5 Hz. Number of passes ranged from two to
three for the periorbital area and up to five to seven
for cheeks, chin and forehead. Most passes were
delivered stacked without wiping between passes,
with no more than 10% overlap. Wrinkle removal
was seen clinically in association with blood-tinged
oozing. Average healing time after the procedure was
3.2 days. All evidence of erythema resolved between
3 and 6 weeks. All patients were improved, with
marked improvement seen in eight. Similar results
were obtained by Weiss et al (1999), with moderate
to good improvements in wrinkles in 50 patients

Fig. 6.9. Bleeding during Er:YAG laser resurfacing.
treated with three passes of an Er:YAG laser. Mean
duration of erythema was 15 days.
Alster (1999) compared the clinical and histolo-
gical effects of six erbium:YAG lasers in patients
with mild cutaneous photo damage. Three passes
were used at 5 J/cm2. Histological assessments
showed that three passes were necessary to ablate
the epidermis without measurable residual thermal
damage in the dermis. Re-epithelialisation was
complete in 83% by 0.5 weeks; mean duration of
erythema was 1.2 weeks. There was no significant
difference in the outcomes from the different laser
systems employed. Although erythema duration
appears to be shorter after Er:YAG resurfacing it is
likely to relate to number of passes and depth of
ablation produced (Bass, 1998).
The Er:YAG laser has also been used in patients
and at sites where laser CO 2 resurfacing has been
associated with a higher incidence of adverse events.
Goldberg and Meine (1998) treated 10 patients with
neck wrinkles with a Continuum Biomedical Er:YAG
laser. A 5 mm spot with energies of 600-800 mJ was
used. Four passes with 10% overlap were made, then
three to four passes directly over the involved area
until mild bleeding occurred. No wiping of debris
The C01 and Er:YAG Lasers 73
was performed. All patients showed at least 25%
improvement in their wrinkles. There were no com-
plications following treatment at review 6 months
later. Effective resurfacing of neck skin has been
limited in the past due to the risk of hypertrophic
scarring. This was a small study with promising
results, but a significantly larger number of individu-
als with longer follow-up periods are needed to
determine the complication rates after treatment at
this site with the Er:YAG laser.
CO 2 laser resurfacing in Asian skin is associated
with a high risk of prolonged erythema and post-
inflammatory hyperpigmentation. Polnikorn et al
(1998) treated 50 Asian patients with a variety of
skin disorders, including wrinkles (21 patients),
acne scarring (10 patients) and syringomas (10
patients). Er:YAG laser treatment was performed
with a 2-5 mm spot, 1 J per pulse at 10 Hz with
20-30% overlap. Four to 12 laser passes were per-
formed. All patients showed degrees of improve-
ment, the greatest being in rhinophyma and
chickenpox scarring. There was an 80% improve-
ment in patients with wrinkles. No scarring was
seen; post-treatment erythema lasted 1-8 weeks.
Postinflammatory hyperpigmentation occurred in
 74 lasers in Dermatology

are needed to determine the role of the Er:YAG laser

in the treatment of darker skin types.

Er:YAG Laser Treatment of Acne Scars

The Er:YAG laser also appears to be beneficial in the
treatment of facial acne scars (Fig. 6.11) (Kye, 1997;
Weinstein, 1998). Kye (1997) treated 21 patients with
pitted acne scars using four to six passes with a

Fig. 6.10. Er:YAG laser resurfacing of periocular wrinkles.

Top: pretreatment. Middle: 4 weeks after treatment - note
minimal erythema. Bottom: result 3 months after resurfacing.
(Courtesy of Dr J. Cotterill.)

30%, usually starting in the second week, and

resolved in almost all patients at 4-8 weeks.
One patient had persisting hyperpigmentation at
4 months. The authors conclude that the Er:YAG laser
is safe and effective in Asian skin. Post-treatment Fig.6.11 . Er:YAG laser resurfacing of atrophic acne scars. Top:
complications although present are reduced when pretreatment. Middle: 4 days' treatment. Bottom: result 3 months
compared with CO 2 laser resurfacing. Further studies after resurfacing.

2 mm spot and 500 mJ per pulse. Assessments at
3 months showed an average improvement of 40%.
Weinstein (1998) treated 10 patients with acne scar-
ring out of a patient study group of 141. Various
parameters were used, including two to five passes
with a single spot and then two to three passes with
a scanner. Seven patients experienced 70-90% and
three patients 50-70% improvement. Some authors
prefer the Er:YAG to the CO 2 laser for acne scarring
because of the precision in sculpting acne scars with
good visual control and minimal residual thermal
damage (Dover, 1999).
Small numbers of patients with other cutaneous
disorders treated with the Er:YAG laser have been
reported (see list below and Fig. 6.12). Good results
have been reported by authors, with a low incidence
of side effects. As with the COz laser adequate
suction to remove the plume of smoke generated by
the laser is essential. The Er:YAG laser emits a very
loud cracking sound due to the explosive vaporisa-
tion of tissue and photo acoustic effects. This can be
distracting for the operator and distressing for the
patient, and can exceed recommended safe noise
levels.
The following dermatological disorders have been
treated with the Er: YAG laser:
• Acne scars
• Tattoos
• Epidermal naevi
• Adenoma sebaceum
• Angiofibromas
Fig. 6.12. Rhinophyma on left side of nose before and 1 month
after treatment with Derma™ 20 Er:YAG laser. (Courtesy of
Dr A. Orenstein, Tel-Aviv - ESC Sharplan.)
The CO 2 and Er:YAG lasers 7S
• Syringomas
• Xanthelasma
• Sebaceous hyperplasia
• Osteoma cutis
• Rhinophyma
• Solar lentigines
• Melasma
• Verruca vulgaris
• Darier's disease
• Hailey-Hailey disease
Comparisons and Combinations of the
Er:YAG and CO 2 Lasers
The residual thermal damage after Er:YAG laser
treatment of about 50 fLm compared to typical resid-
ual thermal damage with resurfacing COz lasers
has led to interest in the relative merits of these
two lasers for resurfacing. Er:YAG laser wounds
re-epithelialise earlier than CO 2 laser wounds
(Kaufmann and Hibst, 1990) and it has been sug-
gested that the duration of erythema after Er:YAG
resurfacing is shorter than after conventional CO 2
laser resurfacing. One study (Khatri et ai, 1999) com-
pared the side-by-side effects of the two lasers in 21
patients with wrinkles. An UltraPulse CO 2 laser with
a 3 mm spot using 3.5-6.5 J/cmz was employed. The
CO 2 laser-treated sides received two to three passes.
The Er:YAG laser was from Continuum Biomedical,
having a 5 mm spot with a 300 fLS pulse duration
and fluences of 5-8 J/cm 2• Initially, two to three
passes were also performed with the Er:YAG but
this was inadequate to improve wrinkles. Further
passes were employed until some bleeding occurred.
In subjects receiving more than five passes of the
Er:YAG laser, improvement scores were not signi-
ficantly different from two to three passes with the
CO 2 laser. Frequency of erythema and hypopigment-
ation was significantly less on the Er:YAG laser side.
The authors conclude that if the same total depth of
tissue necrosis - that is, tissue ablated plus residual
thermal damage - is achieved then similar results
can be expected with the two lasers. More passes
with the Er:YAG laser than the CO 2 laser will be
necessary. The depth of residual thermal damage
after Er:YAG ablation was shown to be up to 50 /-tm
compared to up to 200 fLm in the CO 2 laser-ablated
skin. The thinner layer of residual thermal damage
after Er:YAG laser ablation may contribute to the
reduced frequency of adverse events postoperatively.
 76 Lasers in Dermatology
Adrian (1999) compared the pulsed Continuum
Biomedical Er:YAG laser with the UltraPulse CO 2
laser in 20 patients with wrinkles. Parameters for
the Er:YAG laser treatment were a 5 mm spot at
1 J/cm 2 and five to seven passes to the periocular
area and 7-10 passes to the lateral area. Upper lip
wrinkles received 12-15 passes. The CO 2 laser was
superior in the treatment of moderate and deep
wrinkles. Re-epithelialisation occurred slightly
earlier after Er:YAG treatment (8-10 days) com-
pared to CO 2 treatment (10-12 days). There was
little difference between the lasers in postoperative
pain and duration of erythema. The higher number
of passes (7-15) with the Er:YAG laser in this study
produced a deeper ablation (140-300 JLm) com-
pared to four or five passes as used in the studies
above (80-100 JLm).
It has been thought that the Er: YAG laser is effec-
tive in resurfacing of superficial or early wrinkles
with reduced adverse effects compared to the CO 2
laser but less effective for removal of medium to
deep wrinkles because of the narrower depth of abla-
tion. However, after CO 2 laser resurfacing excessive
thermal tissue damage can increase postoperative
pain, delay wound healing, prolong erythema and
contribute to scarring. McDaniel et al in two studies
(1997, 1999) have attempted by the combination of
CO 2 and Er:YAG lasers to minimise the residual
thermal injury after resurfacing to speed healing
while still retaining some subnecrotic thermal effects
to stimulate wound remodelling. In the two studies,
patients received resurfacing to the upper lip region
either with a CO 2 laser alone or followed by three
passes with an Er:YAG laser, or five passes with an
Er:YAG laser. Assessments of improvements were
43% with Er:YAG laser alone, 67% with CO 2 laser
alone and 69% with C0 2 Iaser/Er:YAG laser combin-
ation. The laser combination achieved a 17% reduc-
tion in re-epithelialisation time, a 23% reduction in
pruritus and a 12% decrease in crusting compared
to CO 2 laser alone, presumably due to removal of the
zone of tissue necrosis resulting from CO 2 laser
ablation with the Er:YAG laser. In a similar study
(Utley et aI, 1999) preauricular skin was treated with
CO 2, Er:YAG or Er:YAG and CO 2 lasers. Histological
assessments at 7 days showed reduced collagen
injury and less thermal necrosis in the CO 2 followed
by Er:YAG laser-treated area compared to CO 2 alone
or Er: YAG followed by CO 2 laser.
It is possible to use a combined Er:YAG and CO 2
laser (Derma K, ESC Medical Systems) which can
allow simultaneous or separate irradiation of tissue.
Goldman and Manuskiatti (1999) using this laser
system concluded that treating a patient with the
Er:YAG laser after treatment with the CO 2 laser
decreased the incidence of adverse sequelae without
any noticeable difference in the degree of wrinkle
improvement. The full benefits of this system have
not yet been elucidated.
Conclusions
The Er: YAG laser has excited significant interest
over the past decade as an alternative resurfacing
laser to the CO 2 laser. It has also prompted debate as
to the mechanisms by which wrinkles are ablated.
The two main clinical differences between these
lasers is the depth of ablation per pass and the depth
of residual thermal damage after completing the
resurfacing procedure. It has been argued that the
superficial injury produced by the Er:YAG laser
allows successful treatment of superficial wrinkles
with a reduction in the duration of unwanted post-
operative sequelae such as re-epithelialisation and
erythema. However, similar results can be obtained
by superficial resurfacing with just one pass of the
CO 2 laser.
It has been argued that the Er:YAG laser may not
be appropriate for moderate to severe wrinkles, but
it has been shown that by increasing the number of
passes to say 5-10 similar depths of tissue injury to
three passes with the CO 2 laser can be achieved.
There is no visible shrinkage of tissue with the
Er:YAG laser and yet this laser still improves wrin-
kles. The good results obtained with both lasers
are in part due to the techniques of the operators
who chose end points from their clinical experi-
ence. The exact importance of ablation depth,
thermal injury, clinical improvement and duration
of erythema will hopefully become clearer with
further studies.
The Er:YAG laser has potentially great flexibility
for use in dermatology. With the current high-
powered short pulsed lasers extremely precise tissue
removal with minimal thermal damage can be
achieved. By using long pulses or high repetition
rates it is possible to exceed the thermal relaxation
time of the tissue volume ablated sufficiently to
increase residual thermal damage. This could be
advantageous for haemostasis but could also allow
the Er: YAG laser to act biologically like a CO 2 laser,
considerably enhancing therapeutic options.

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Kye YC (1997) Resurfacing of pitted facial scars with a pulsed
Er:YAG laser. Dermatol Surg 23:880-883
Weinstein C (1998) Computerized scanning erbium:YAG laser for
skin resurfacing. Dermatol Surg 24:83-89
Comparisons and Combinations of CO 2
and Er: YAG Laser
Adrian RM (1999) Pulsed carbon dioxide and erbium-YAG laser
resurfacing: a comparative clinical and histologic study. J Cutan
Laser Ther 1:29-35
Goldman MP, Manuskiatti W (1999) Combined laser resurfacing
with the 950-microsec pulsed CO 2 + Er:YAG lasers. Dermatol
Surg 25:160-163
Kaufmann R, Hibst R (1990) Pulsed 2.94 microm erbium-YAG
laser skin ablation: experimental results and first clinical appli-
cation. Clin Exp Dermatol 15:389-393
Khatri KA, Ross V, Grevelink jM, Magro CM, Anderson RR (1999)
Comparison of erbium:YAG and carbon dioxide laser in resurf-
acing of facial rhytides. Arch Dermatol135:391-397
McDaniel DH, Ash K, Lord j, Newman j, Zukowski M (1997) The
erbium:YAG laser: a review and preliminary report on resurf-
acing of the face, neck and hands. Aesthetic Surg j 17:157-163
McDaniel DH, Lord j, Ash K, Newman j (1999) Combined
CO/erbium:YAG laser resurfacing of peri-oral rhytides and
side-by-side comparison with carbon dioxide laser alone.
Dermatol Surg 25:285-293
Utley DS, Koch Rj, Egbert BM (1999) Histologic analysis of the
thermal effect on epidermal and dermal structures following
treatment with the superpulsed CO 2 laser and the erbium:YAG
laser: an in vivo study. Lasers Surg Med 24:93-102
 Hair Removal by Lasers

Depilatory preparations are generally available as

Introduction creams, pastes and lotions. The most widely used
preparations contain thioglycolates, which disrupt
There has long been desire for effective removal of
disulphide bonds, especially in cystine which is
unwanted body hair. Excessive hair in an androgen-
found in hair keratin. The major problem patients
dependent distribution, e.g. beard area, lower
experience with depilatory preparations is an irrit-
abdomen in females, is termed hirsutism. Non-
ant dermatitis which can severely limit use.
androgen-dependent hair growth, e.g. forearms or
Waxing involves the application of warmed
back, is termed hypertrichosis. Patients with
molten wax applied to hair-bearing skin. When the
hirsutism require a full evaluation to exclude treat-
wax cools the hairs are embedded within the sub-
able causes of androgen excess, including some
strate of the wax and when it is pulled off the skin in
tumours. Many patients with hirsutism can be
brisk stripping motions the trapped hair is pulled
managed by oral anti-androgens such as cypro-
away. The stripping off of the wax is unpleasant
terone acetate.
for the patient. Side effects of waxing include folli-
Other causes of hypertrichosis include drug-
culitis, pseudofolliculitis, hyperpigmentation, scar-
induced, congenital and hair growth from grafted
ring and thermal burns with poor technique. A
donor sites. Men undergoing sex-change operations
delay of 3-4 months before regrowth in axillary or
may request hair removal, as may females in cos-
thigh sites will occur.
metically undesirable (e.g. "bikini line", axillae)
Electrolysis is widely available in the private sector
sites. and is somewhat cheaper than laser treatment.
There are a number of treatments available for
Successful electrolysis can to some degree achieve
hair removal which most women will be aware of.
permanent hair removal. Essentially the electrolysist
These include bleaching, shaving, plucking, depil-
delivers an electric current to the hair via a probe
atory creams, waxing and electrolysis. Although
kept in contact with it. Hairs need to be treated indi-
shaving is an effective method of hair removal
vidually and the process is slow and can be painful.
many women are completely unable to use this
An estimation of the amount of treatment required
form of treatment because of the masculine con-
using one form of electrolysis (Richards et aI, 1986)
notations of the act and the ensuing stubble as
for a female patient with heavy facial hair was 2-3 h
regrowth occurs.
per week of electrolysis for 2 years followed by 30 min
Plucking may lead to delay in the reappearance of
every other week for an undetermined time but a
an anagen hair after removal. There are a number of
total of at least 210 h. Vellous hairs in the treated area
side effects associated with plucking, which include
could still convert to terminal hairs. Side effects of
folliculitis, postinfiammatory hyperpigmentation
electrolysis include pain, scarring, hypo- and hyper-
and scarring.
pigmentation and can be operator-dependent.

81
 82 Lasers in Dermatology

Laser Removal of Hair by
Selective Photothermolysis
To fully appreciate the relevance of laser-hair inter-
actions the reader should be familiar with hair
anatomy, hair growth cycles and the variation in
hair growth cycles in different parts of the body.
Figure 7.1 shows the anatomy of normal hair. The
base of the hair follicle is 2-7 mm below the surface
of skin so only red and near-infrared wavelengths of
light will penetrate to this depth. Active hair growth
occurs during anagen (Fig. 7.2). The dermal papillae
cells enlarge and the lower part of the follicle grows
down, enclosing the dermal papilla. The matrix cells
move more superficially and differentiation occurs
Epiderm is
Arrector pi li
muscle
into the inner and outer root sheaths. The hair
formed is confined within the internal root sheath
until it emerges from the skin surface and continues
to grow until the onset of catagen. In catagen
melanocytes in the tip of the papilla resorb their
dendrites and melanisation ceases. The follicular
bulb moves up superficially in the dermis. The
dermal papillae cells are pulled towards the bottom
of the regressing follicle by connective tissue con-
traction. The terminal portion of the hair becomes
club-shaped and lacks melanin. The club hair moves
upwards as the follicle shortens and moves into
telogen, the resting phase of the hair cycle. The folli-
cle re-enters anagen spontaneously at the end of
telogen or may be induced to do so if the hair is
plucked. The new hair grows up below and then
beside the club hair. The duration of anagen is
dependent on age, sex, season, body site, hormones
and genetic susceptibilities. In regions of the body
other than the scalp anagen is relatively short and
telogen relatively long (see Table 7.1).
Length of hair is related to duration of anagen
and rate of hair growth. Hair growth is fastest for
longest growing hairs (beard, scalp) and slowest for
shortest hairs (eyebrows, thighs).

/II-.'-+~~-- Medul la Table 7.1. Hair growth cycle at different body sites

Inner root ----.I-"" ' - - - -The bu lge Body area % Anagen Telogen duration Follicle depth
sheath (months) (mm)
Hai r bulb
Scalp 85- 90 3- 4 3- 5
Matrix Dermal Beard 65-70 1.5-2.5 2-4
cells papilla cells Axillae 30- 60 3 3.5- 4.5
Thighs 20-35 4-6 2.5-4
Fig. 7.1. Normal hair anatomy. Pubic 20-30 12 3.5-4.5

Telogen Earlyanagen Anagen Catagen

TeIOg,"~
T
club hair

Dermal
papilla New
anagen hair Dermal
papilla
hair
papilla

Fig. 7.2. Normal hair cycle.


Only hairs in anagen are susceptible to injury
from lasers (Lin et aI, 1998) so it is important to be
aware of the percentage of anagen hairs at a body
site when assessing possible outcomes from treat-
ment. Results after treatment should take into
account the naturally occurring duration of telogen.
Clinical follow-up periods should extend beyond the
natural telogen duration before assumptions of fol-
licular death rather than laser-induced telogen can
be assumed.
Several lasers have been developed for selective
photothermolysis of hair follicles (Table 7.2).
Melanin in the hair follicle has been the selected
chromophore. The pulse duration appropriate for
the thermal relaxation time of hair follicles ranges
from several to 100 ms. The site within the hair fol-
licle where stem cells necessary for the regeneration
of the follicle is likely to be in the mid-follicle or
isthmus region (Kim and Choi, 1995). In murine
hair follicles the primary site of stem cells is the
bulge region at the site of attachment of the arrector
pili muscle (Costarelis et aI, 1990). The exact follicu-
lar anatomy with respect to follicular stem cells and
targeted chromophores remains unclear.
The epidermis also contains melanin and selec-
tive photothermolysis of hair follicles can occur
either through differential amounts of the target
chromophore. i.e. high melanin in dark-coloured
hairs and low in pale skin; or through appropriate
selection of pulse duration. The thermal relaxation
time of the epidermis can be considered to be
around 3-10 ms. Therefore pulse widths matched
to the hair follicle are more effective in causing
thermal injury selectively to these structures. For
the first reason outlined, best results with many
lasers for selective thermolysis of hair have been in
patients with white or pale skin and black hair.
Further protection of the epidermis can be obtained
by a variety of intraoperative cooling devices.
Ruby Laser Treatment of Hair
The melanin within a pigmented hair follicle can
be targeted by lasers. As discussed above, to obtain
adequate depth of penetration red or near infrared
light is needed. Using a Q-switched ruby laser Dover
et al (l989) were able to selectively damage pig-
mented cells without interfering with hair shaft pro-
duction. A longer pulse duration with higher fluences
is needed to produce fluence-dependent selective
thermal injury to hair follicles. Grossman et al (l996)
Hair Removal by Lasers 83
in l3 patients was able to produce fluence-dependent
selective thermal injury to hair follicles using a ruby
laser with a pulse duration of 270 fLS, beam diameter
of 6 mm, with fluences of 30-60 J/cm 2 (Epilaser,
Palomar Medical Technologies, Beverly, MA). At
6 months there was significant hair loss in areas
treated at the highest fluence. At 6 months four
patients had less than 50% regrowth of hair.
Histological examination showed thermal injury
confined to the follicular epithelium and dermis
immediately adjacent. The treatment was well toler-
ated with no scarring, with transient erythema and
pigmentary changes. This same group of patients was
followed up 2 years after completing their treatment
(Dierickx et aI, 1998). Four patients still had obvious,
significant hair loss at all laser-treated sites with
no significant change in hair counts 6 months, 1 and
2 years after treatment. Permanent, non-scarring
alopecia was thus induced with miniaturisation of
the terminal hair follicles.
Further studies have been performed with the four
commercially available ruby lasers for epilation. It
should be noted, however, that apart from the study
by Dierickx et al (l998) there has been no long-term
published follow-up studies with any of the lasers
removing hair by selective photo thermolysis and
most studies report hair growth delay rather than
permanent hair removal. Use of the EpiTouch ruby
laser (Sharplan) has been reported by Lask et al
(1997) and Nestor (1998). Multiple treatments are
required for increasing effect. Treating the beard and
moustache area at 25 J/cm2, regrowth 1 month after
three treatments was 25%. On arm hair Lask reported
40-80% regrowth at 12 weeks. A transparent cooling
gel was used to reduce cutaneous side effects.
The Chromos 694 (SLS/Biophile) ruby laser has
been reported by Bjerring et al (l998) on 133
patients. The average number of treatments was 2.2,
fluence was 10-25 J/cm2, with a pulse duration of
0.7-0.8 ms. Follow-up was 90 days after last treat-
ment. Results were reported as greater than 50% hair
removal (59% of patients) and greater than 25% hair
removal (75% of patients). Side effects were tem-
porary hypo pigmentation in 10% with no scarring.
Williams et al (l998) used the EpiLaser on 25
patients with different hair colours at facial and body
sites. Results 16 weeks after the third treatment with
fluences of 10-40 J/cm2 were reported. There was an
average of 35% regrowth in terminal hair counts
regardless of body site or skin type. McCoy et al
(l999) using the same lasers and fluences performed
a histological study of hair follicle responses to the
 84 lasers in Dermatology
EpiLaser. One treatment induced typical changes of
catagen followed by telogen. Two and three treat-
ments resulted in atypical telogen with infundibular
dilatation and plugging. New anagen follicles were
evident even after three treatments 6 weeks after-
wards but no hair extended through the epidermis.
Sommer et al (I998) treated 43 patients with a
ruby laser (Lambda, Photometrics) with a pulse
width of 950 J-LS and mean fluences of 48 J/cm 2• One
site was treated once and another four times at
monthly intervals (Fig. 7.3). After one treatment hair
counts were 60% of baseline at 6 months. Three
months after four treatments the hair count was
44% of baseline. This group has used higher
fluences than other researchers. Fourteen per cent of
patients experienced mild blistering and 33% crust-
ing but there was no scarring.
Alexandrite Laser Treatment of
Hair
The alexandrite laser has a wavelength of 755 nm and
is more deeply penetrating than the ruby laser. There
is also less absorption of this light in the epidermis.
Fig. 7.3. Female patient 9 months after four treatments (right side of chin) and 12 months after one treatment (left side of chin) with a
lambda normal-mode ruby laser. ((ourtesy of Dr R. Sheehan-Dare.)
There are several long pulsed alexandrite lasers
marketed for hair removal with pulse durations of
2-20 ms and spot sizes of 7-10 mm. For the operator
the advantage of a large spot size with rapid repeti-
tion rate (up to 5 Hz) means quicker treatments for
large areas such as the back. A cooling gel is applied
to the skin surface prior to treatment to reduce epi-
dermal thermal injury. Cooling tip handpieces and
dynamic cooling devices are available on newer
models. Finkel et al (1997) treated 126 patients with
fluences of 20-40 J/cm2. Three-month follow-up after
multiple treatments (three to six) showed 75-95%
hair reduction. Similar side effects are seen with
alexandrite and ruby laser treatments. McDaniel et al
(1999) treated different body sites on 22 patients
with an alexandrite laser with a 10 mm spot. Best
results were obtained using a 10 ms pulse at 20 J/cm2.
Treatments were performed through a thin layer of
K-Y Jelly which had been chilled before application
to the skin. Assessments 6 months after one treatment
revealed maximum reductions of 40%, 56%, 50% and
15% for lip, leg, back and bikini areas respectively.
Nanni and Alster (1999) assessed a long pulsed
alexandrite laser in 36 subjects using fluences of
18 J/cm 2 with pulse durations of 5, 10 or 20 ms.
Although hair counts were reduced by 66% at

1 month there was only a 4% reduction at 6 months.
There were no significant differences in clinical
efficacy or side effects with the different pulse dura-
tion used. Goldberg and Ahkami (1999) were also
unable to detect any differences in the clinical effec-
tiveness of the alexandrite laser for hair removal
using two pulse durations of2 ms and 10 ms.
Diode Laser Treatment of Hair
Diode lasers have been marketed commercially for
hair removal (Fig. 7.4). The Light Sheer diode laser
has a wavelength of 800 nm, a pulse duration of
5-30 ms and a 9 mm spot with a cold sapphire tip.
The tip is pressed hard against the skin to optimise
cooling and bring the targeted hair follicle nearer to
the skin surface. To date there has been no research
Fig. 7.4. Diode laser test treatments on right side of male back.
(Courtesy of Dr B. Monk.)
Hair Removal by Lasers 85
paper on the effectiveness of diode lasers but they
appear to have a similar effect on hair reduction to
ruby and alexandrite lasers with a similar side effect
profile. The longer wavelength of the diode laseFs
may make them more useful in darker skin types
because of reduced epidermal absorption.
Other Laser Treatments for Hair
Removal
The Q-switched Nd:YAG laser has been used in
combination with a topical preparation containing
micro-particulate carbon (Goldberg et aI, 1997).
Before treatment the area is waxed or shaved and
the topical preparation massaged into the skin. It is
assumed that the micro-particulate carbon-based
material migrates down the follicle. The skin is then
irradiated using the Q-switched Nd:YAG laser with a
7 mm spot and fluences of 2-3 J/cm2. The infrared
(1064 nm) wavelength of the light is absorbed
by the exogenously applied carbon particles. When
the light is absorbed focal photochemical damage
is caused by the short nanosecond pulse. All hair
types can be treated but the treatment is potentially
very messy and the long-term results are not as
effective as with laser treatment by selective photo-
thermolysis and it is likely that this treatment will
be superseded. Newer preparations with smaller
carbon particles which may penetrate more deeply
into the hair follicle are currently being assessed.
A long pulsed Nd: YAG laser has also been reported
as effective treatment of hair (Bencini et aI, 1999).
Two hundred and eight patients were treated with an
Nd:YAG laser (1064 nm, 3-4 mm spot fluences of
23-56 J/cm2), with all hair colours except white being
receptive. The authors report complete epilation
after three to eight treatments, without significant
side effects. Follow-up ranged from 1 to 6 months. It
is not clear why this particular laser should produce
such good results in this study as the Nd:YAG laser is
poorly absorbed by hair follicle structure, although
the light is deeply penetrating.
Intense Pulsed Light Laser
Treatment of Hair
The intense pulsed light system of ESC Medical
Systems, the EpilightTM, has been marketed for hair
 86 lasers in Dermatology
removal (Figs 7.5,7.6). The Epilight is not a laser but
emits ftashlamp-stimulated non-coherent broadband
light filtered to limit wavelengths from 590 to
1200 nm. This system allows delivery of the light dose
fractionated into a series of millisecond-domain
pulses separated by a variable interpulse delay.
Multiple treatment variables are available to the oper-
ator, including filter-determined bandwidth, pulse
delay, number of pulses and ftuence. A large rectang-
ular light spot is available either lO x 45 mm or 8 x
35 mm. A study by Gold et al (1997) on 37 test sites in
31 patients noted approximately 60% hair removal at
12 weeks following treatment. Treatment parameters
were: filters of 590-690 nm, pulse sequences of two to
five pulses of 1.5 to 3.5 ms separated by 20-50 ms and
ftuences of 34-55 J/cm2. Transient erythema after
treatment is common and hyperpigmentation and
blistering have been seen. A follow-up study of 24 of
these 31 patients (77%) 1 year after one session with
the intense pulsed light source (Gold et aI, 1999)
revealed 75-100% clearance in 75% of the treated
sites. Another long-term follow-up study (Troilius
and Troilius, 1999) of the results of intense pulsed
light (Ellipse Relax Light 1000, Danish Dermatologic
Development, Hoersholm, Denmark) on bikini line
hair revealed an 80% hair reduction 8 months after
the last of four treatments.
Fig. 7.5. Female patient before and after three EpilightTMtreatments within 6 months. (Courtesy of Dr R.Weiss, HuntValley - ESC Sharplan.)
Fig. 7.6. Bikini line hair before and 2 months after Epilight lM treatment. (Courtesy of Dr A.del Giglio, Verona - ESC Sharplan.)
Weiss et al (1999) reported the results in 28 sites
in 23 patients treated once with the Epilight and
followed up for 3 months and 59 sites on 48 patients
treated twice 1 month apart and followed for
6 months. Parameters were 615 or 645 nm cut off
filter depending on skin type, and triple pulses
delivering a total ftuence of 40-42 J/cm 2 using a
refrigerated water-based contact gel. For the single-
treatment protocol there was a 63% reduction in
hair counts at 12 weeks. For the double-treatment
protocol by 6 months hair count reduction was 33%.
Erythema and urticated oedema were common.
Twelve per cent of patients experienced some crust-
ing lasting up to 1 week. There were no long-term
side-effects. Schroeter et al (1999) treated 40 females
with facial hair with the Photoderm VL. A variety of
treatment modalities were used, with an average
ftuence of 38.7 J/cm2. There was a 76.7% removal of
hair within six treatments. There was no correlation
between treatment parameters and amount of hair
removal or between percentage hair reduction and
hair colour. Hyperpigmentation was seen in 20%
and was the only reported side effect. Sadick et al
(1999) treated 67 patients with the Epilight hair
removal system. Various sites were treated. There
was a mean hair loss of 64% after multiple treat-
ments. The authors used cut-off filters of 590 nm for
 Hair Removal by Lasers 87

Fitzpatrick skin type I through to 695 nm for

Fitzpatrick skin type IV. Fluences of 40-42 J/cm 2
were used with 3.0 ms pulses with a 30 ms pulse
delay. Histological assessment after one treatment
revealed photothermal damage confined to hair
follicles and shafts.
The multiplicity of options available to the clin-
ician using the Epilight has meant that the optimal
parameters for hair removal have yet to be defined.
In theory, it may be possible to successfully treat
darker-skinned patients but there is insufficient
published research to confirm this. There have been
no objective studies to compare laser and intense
pulsed light laser treatment of hair. Intense pulsed
light sources are also discussed in Ch. 9. Fig. 7.7. Perifollicular erythema after ruby laser treatment to hair
on right leg.

Treatment Techniques for

Selective Photothermolysis of
Hair
For selective photothermolysis pigmentation in
anagen hair is required. Best results will occur in
dark hair on lighter skin (reduced absorption of
light in the epidermis). Darker skin types are likely
to experience post-treatment pigmentary disturb-
ances. Prior to treatment the patients should have
received written information concerning the likely
benefits from their treatment. They should be
instructed not to wax or pluck their hairs for
1 month prior to the treatment. They should not
shave their hair within 1-2 days of the treatment, so
that a small amount of hair is visible for treatment. If
the laser does not contain a cooling device the skin
should be cooled with a water-based gel or chemical
cool bag. Pretreatment with EMLA cream can reduce
discomfort in patients who tolerate the procedure
poorly. If the laser has a cooled handpiece this
should be applied firmly to the skin; this minimises
epidermal injury and increases beam coupling into
the skin by reducing the skin-air interface.
Fluences selected for the laser can be based on
published work and the patient's tissue response.
Slight perifollicular erythema and urtication can be
seen (Fig. 7.7) but blistering should be avoided. Each
visible hair should be treated with one or two
impacts with the laser. Vaporisation of some hairs
occurs; others remain loosely attached to the skin
but thermally injured. These frequently separate a
few days after treatment. for large body areas it Fig. 7.S. Holes drilled in scalp by SilkTouch COj laser prior to hair
is useful to divide the treated area up into squares transplantation. (Courtesy of ESC Sharplan.)
 88 Lasers in Dermatolo9Y

Table 7.2. Lasers and light sources for hair removal

Laser Wavelength (nm) Pu lse (ms) Spot size (mm) Fluence (J/cm2) Rep. (Hz)

Ruby
EpiLaser (Palomar) 694 3 7,10 10-40 0.5
EpiTouch (Sharplan) 694 1.2 5,7,10 25- 40 2.5
Chromos (515, biophile) 694 0.7- 0.8 7,10 10- 25
lambda 694 0.95 4 10-60

Alexandrite
LPIR (Photogenica) 755 5,10,20 7,10 10- 40
Gentle lase (Candela) 755 3 8,10,12, 15 6-100
EpiTouch (Sharplan) 755 2 5,10 10- 25
Apogee (Cynosure) 755 5,10,20 7,10,12.5 1- 50

Q-switched Nd:YAG
Softlight 1064 10 ns 7 2.5- 3 10'
Long pulsed Nd:YAG 1064 30 3,4 23- 56

Diode
Light sheer 800 5- 30 7, 10 10-40

Intense pulsed light

Epilight Broadband Varies 10 x 45, 8 x.35 30- 65 Varies
Ellipse relax light Broadband Varies 10 x 45,8 x 35 30-65 Varies

a Dynamic cooling device.

b Scanning handpiece.
C With topically applied carbon chromophore.

to ensure complete coverage. For darker-skinned
patients a test treatment should always be per-
formed before embarking on large areas of skin.
After treatment standard wound care instructions
should be offered to the patient, including sun
avoidance, antiseptic ointment if necessary and
avoidance of trauma to the skin. For highest rates of
hair reduction patients will need to reattend for
further treatment as new anagen hairs develop.
Conclusions
It can be seen that a variety of laser and non-laser
systems for the removal of hair have been devel-
oped; all have been reported as efficacious and safe
for the removal of hair. Original reports and claims
by manufacturers of permanent hair removal have
been quite rightly tempered to hair regrowth delay.
It is still not clear how laser-induced injury causes
hair removal or which laser is most successful
in achieving this goal. There is a dearth of well-
controlled objective studies of laser-induced hair
removal and limited follow-up times. Until these
deficits have been corrected it is not possible to
determine the exact role of lasers for removal of
unwanted hair.
Laser-Assisted Hair
Transplantation
By using high-energy, pulsed CO 2 lasers it is possible
to create small holes or slits in the recipient site of the
scalp to accommodate mini grafts harvested from
hair-bearing skin. Incision depth, slit width and
length can be precisely controlled, with very little
residual thermal damage to surrounding skin. Laser-
assisted hair transplantation when successfully per-
formed has many advantages over traditional punch
grafting (Fig. 7.8). Interested readers should consult
textbooks of cosmetic dermatological procedures and
the references at the end of this chapter.

References and Further Reading
Introduction
Costarelis G, Sun T- T, Lavker RM (1990) Label-retaining cells
reside in the bulge area of pilosebaceous unit: implications for
follicular stem cells, hair cycle and skin carcinogenesis. Cell
61:1329-1337
Kim j-C, Choi Y-C (1995) Hair follicle regeneration after horiz-
ontal resectioning: implications for hair transplantation. In:
Stough DB, Haber RS (eds) Hair replacement: surgical and
medical. Mosby-Yearbook, St Louis, pp 358-363
Lin T-YD, Manuskiatti W, Dierickx CC, Farinelli WA et al (1998)
Hair growth cycle affects hair follicle destruction by ruby laser
pulses. j Invest Dermatollll :107- 113
Olsen EA (1999) Methods of hair removal. j Am Acad Oermatol
40:143-155
Richards RN, McKenzie MA, Meharg GE (1986) Electroepilation
(electrolysis) in hirsutism. j Am Acad Dermatol 15:693-697
Ruby Laser
Bjerring P, Zachariae H, Lybecker H, Clement M (1998)
Evaluation of the free-running ruby laser for hair removal: a
retrospective study.
Acta Derm Venereol (Stockh) 78:48-51
Dierickx CC, Grossman MC, Farinelli WA, Anderson RR (1998)
Permanent hair removal by normal-mode ruby laser. Arch
DermatoI134:837-842
Dover jS, Margolis Rj, Polla LL et al (1989) Pigmented guinea pig
skin irradiated with Q-switched ruby laser pulses: morphologic
and histologic findings. Arch DermatoI125:43-49
Grossman MC, Dierickx, Farinelli W, Flotte T, Anderson RR
(1996) Damage to hair follicles by normal-mode ruby laser
pulses. j Am Acad DermatoI35:889-894
Lask G, Elman M, Slatkine M, Waldman A, Rozenberg Z (1997)
Laser-assisted hair removal by selective photo thermolysis.
Dermatol Surg 23:737-739
McCoy S, Evans A, james C (1999) Histological study of hair fol-
licles treated with a 3-msec pulsed ruby laser. Lasers Surg Med
24:142-150
Nestor MS (1998) Laser hair removal: clinical results and practical
applications of selective photothermolysis. Skin Aging 1:34-40
Sommer S, Render C, Burd R, Sheehan-Dare R (1998) Ruby laser
treatment for hirsutism: clinical response and patient toler-
ance. Br j Dermatol138:1009-1014
Williams R, Havoonjian H, Isagholian K, Menaker G, Moy R
(1998) A clinical study of hair removal using the long-pulsed
ruby laser. Dermatol Surg 24:837-842
Other Lasers
Bencini PL, Luci A, Galimberti M, Ferranti G (1999) Long-term
epilation with long-pulsed neodymium:YAG laser. Oermatol
Surg 25:175-178
Hair Removal by Lasers 89
Finkel B, Eliezri YD, Waldman A, Slatkine M (1997) Pulsed alexan-
drite laser technology for non invasive hair removal. j Clin
Laser Med Surg 15:225-229
Goldberg 0), Ahkami R (1999) Evaluation comparing mUltiple
treatments with a 2-msec and 10-msec alexandrite laser for
hair removal. Lasers Surg Med 25:223-228
Goldberg Dj, Littler CM, Wheeland RG (1997) Topical suspension-
assisted Q-switched Nd:YAG laser hair removal. Oermatol Surg
23:741-745
McDaniel DH, Lord j,Ash K, Newman j, Zukowski M (1999) Laser
hair removal: a review and report on the use of the long pulsed
alexandrite laser for hair reduction of the upper lip, leg, back
and bikini region. Dermatol Surg 25:425-430
Nanni CA, Alster TS (1999) Long-pulsed alexandrite laser-
assisted hair removal at 5, 10, and 20 millisecond pulse dura-
tions. Lasers Surg Med 24:332-337
Intense Pulsed Light Laser Treatment
Gold MH, Bell MW, Foster TD, Street S (1997) Long-term epil-
ation using the Epilight broad band, intense pulsed light hair
removal system. Dermatol Surg 23:909-913
Gold MH, Bell MW, Foster TO, Street S (1999) One-year follow-up
using an intense pulsed light source for long-term hair removal.
j Cutan Laser Ther 1:167-171
Sadick NS, Shea CR, Burchette jL, Prieto VG (1999) High-
intensity ftashlamp photo epilation: a clinical, histological,
and mechanistic study in human skin. Arch Dermatol
135:668-676
Schroeter CA, Raulin, Thurlimann W, Reineke T, De Potter C,
Neumann HAM (1999) Hair removal in 40 hirsute women
with an intense laser-like light source. Eur j Dermatol
9:374-379
Troilius A, Troilius C (1999) Hair removal with a second gener-
ation broad spectrum intense pulsed light source: a long-term
follow-up. j Cutan Laser Ther 1:173-178
Weiss RA, Weiss MA, Marwaha S, Harrington AC (1999) Hair
removal with a non-coherent filtered ftashlamp intense pulsed
light source. Lasers Surg Med 24: 128-132
Laser-Assisted Hair Transplantation
Fitzpatrick RE (1995) Laser hair transplantation: tissue effects of
laser parameters. Dermatol Surg 21 :1042-1046
Ho C, Nguyen Q, Lask G, Lowe N (1995) Mini-slit graft hair trans-
plantation using the Ultrapulse carbon dioxide laser hand-
piece. Dermatol Surg 21: 1056-1059
Unger WP, David LM (1994) Laser hair transplantation. j Dermatol
Surg OncoI20:515-521
Unger WP (1995) Laser hair transplantation II. Dermatol Surg
21:759-765
Unger WP (1995) Laser hair transplantation III: computer-
assisted laser transplanting. Dermatol Surg 21:1047-1055
Villnow MM, Feriduni B (1998) Update on laser-assisted hair
transplantation. Dermatol Surg 24:749-754
 todynamic Therapy in
matology
Photodynamic therapy (PDT) involves the ther-
apeutic combination of a photosensitiser adminis-
tered to the patient and its activation by light. This
combination generates the formation of highly reac-
tive oxygen intermediates which cause irreversible
tissue injury and necrosis. Oxygen must be present
in the tissue to effect damage. Van Tappeiner used
this combination with eosin as the photosensitiser
and artificial light for the treatment of skin carcino-
mas as early as 1903 but it was not until the 1970s
that PDT became more widely investigated.
Systemic Photodynamic Therapy
Most early clinical work in PDT was with the systemic
administration of porphyrins. Haematoporphyrin
derivative (HPD), a complex mixture of porphyrin
esters and ethers, was shown to localise in malignant
tumours after systemic administration. This mixture
of porphyrins is photo activated by red light at
630 nm. The combination of photosensitiser and light
was shown in animal studies to completely irradicate
transplanted tumours (Diamond et ai, 1972).
HPD was purified to some degree in an attempt
to concentrate the active ingredient and Photofrin II
was evaluated in clinical trials in the 1980s. The drug
is given intravenously and after 48-72 h there is
selective retention of the drug in tumour micro-
vasculature. The target tissue is then irradiated with
visible red light to produce tumour destruction.
Although most clinic experience has been with
Photofrin this is not an ideal photosensitiser for
PDT. It is only weakly absorbing at 630 nm, which
is the wavelength at which deeper penetration
91
into tissue occurs. A significant disadvantage of
Photofrin after systemic administration is persisting
retention in skin causing prolonged and often severe
photosensitisation.
Because of these disadvantages other photosensi-
tisers have been developed with absorption maxima
at wavelengths longer than 630 nm for deeper tissue
penetration. Benzoporphyrin derivative monoacid
ring A is a pure second-generation reduced por-
phyrin which has a maximum light absorption at
690 nm. In early clinical studies this drug, photo-
activated by an argon pumped dye laser, was shown
to be effective in primary and metastatic skin
tumours with minimal cutaneous phototoxicity (Lui
et ai, 1995).
Phthalocyanines, e.g. chloro-aluminium sulphon-
ated phthalocyanine, have been developed as photo-
sensitisers with absorption wavelengths between
600 and 700 nm. There is extensive experience with
these compounds in PDT of non-cutaneous neo-
plasia and they are able to induce superior tumour
regression compared to Photofrin.
Other new photosensitisers include chlorins
(absorbing at 650-700 nm), which induced a 50%
complete response rate in skin and oropharyngeal
carcinomas (Pass, 1993). Purpurins and verdins are
also being evaluated as potential photosensitisers
for PDT and have the advantage of longer wave-
length absorption than Photofrin.
Clinical Studies
Most clinical studies with systemic PDT have used
HPD or Photofrin in the treatment of cutaneous
malignancies. Basal cell carcinomas (BCC), squamous
 92 Lasers in Dermatology
cell carcinomas (SCC), solar keratoses (AK) and
Bowen's disease have all been treated. Response rates
vary greatly from study to study and this reflects vari-
ations in treatment schedules, light sources, clinical
and histological assessments and follow-up duration.
For basal cell carcinomas complete response rates
after PDT have ranged from 31 % to 100%. Large
phase II trials performed at the Roswell Park Cancer
Institute, Buffalo (Wilson et aI, 1989, 1992) showed
very good results with superficial and nodular BCCs
but poor results with morphoeic BCCs, 80% of the
recurrences being morphoeic. At 16 months follow-
up 18% of the lesions had recurred. Excellent cos-
metic results were reported but 25% of patients
developed photosensitivity reactions. Patients with
basal cell naevus syndrome with multiple BCCs can
be successfully treated with this modality in one
sitting, with a complete response rate of 95% and
generally excellent cosmetic results.
Invasive Squamous Cell Carcinoma
There are few studies of systemic PDT for invasive
squamous cell carcinoma. Disappointing results
were obtained by Pennington et al (1988) with an
initial clearance rate of 81 %, dropping to less than
50% at 6 months. Low light doses (30 J/cm 2 ) were
employed by this group. Keller et al (1989) reported
100% complete responses 4 years after therapy.
Numbers of patients with squamous cell carcinoma
treated in this way are small and insufficient data on
follow-up has been available.
Bowen's Disease
Multiple lesions of Bowen's disease respond particu-
larly well to PDT using Photofrin (Jones et aI, 1992;
Robinson et aI, 1988). In the study by Robinson more
than 500 lesions in two patients were treated success-
fully with complete clearance of the lesions. Cosmetic
results can be considered equal to or superior to
other destructive treatment modalities.
Malignant Melanoma
Pigmented melanomas are uniformly unresponsive
to PDT. The melanin in the tumours interferes with
the phototoxic process probably by a combination
of competitive photon absorption, transference of
excitation energy to melanin instead of cellular
oxygen and by quenching singlet oxygen formed by
the excitation process (Nelson et aI, 1988; Sealy et aI,
1984).
Kaposi's Sarcoma
Lesions of Kaposi's sarcoma which are highly vas-
cular could be considered to respond to PDT. In a
study of five patients with oral Kaposi's sarcoma in
association with HIV (Schweitzer and Visscher,
1990) regression occurred in 60%. Classic Kaposi's
sarcoma has also been successfully treated, showing
early and late complete responses (Dougherty,
1981).
Topical Photodynamic Therapy
The most problematic aspect of systemic PDT with
haematoporphyrins and Photofrin is the slow rate of
clearance of the drug from the skin, resulting in pro-
longed photosensitivity. A novel solution to this
problem was proposed by Kennedy et al (1990).
They used the percutaneous application of the
metabolic precursor to the desired photosensitiser
for clinical effect. They applied 5-aminolaevulinic
acid (ALA) to the skin, which leads to the accumula-
tion of the endogenous photosensitiser protopor-
phyrin IX (PpIX). By administering excess ALA, the
rate-limiting enzyme ALA synthetase in the haem
biosynthetic pathway is bypassed, which results in
excess PpIX. As PpIX metabolism proceeds towards
haem it does not persist in the skin and is elimin-
ated within 24 h.
There are several advantages to topical ALA PDT.
ALA penetrates intact epidermis relatively poorly
but will penetrate abnormal epidermis to result in
selective uptake in disorders such as actinic kerato-
sis, Bowen's disease and superficial neoplasia
(Svanberg et aI, 1994). The localised uptake and
metabolism within 24 h minimises any photosensiti-
sation problems. Application times are usually 3-6
hours and irradiation is then performed. The ALA is
usually applied is an ointment vehicle in concentra-
tions of 10-30% (Jeffes et aI, 1997). The vehicle with
ALA is applied under occlusion to prevent pho-
todegradation of the ALA. Irradiation of the treated
area is associated with pruritus and pain, which can
be severe. Some erythema and discomfort of the
treated area can persist for 1-2 weeks. Crusting of
the treated area, which is common, heals within the
same amount of time.

Light Sources
For both systemic PDT with haematoporphyrin or
Photofrin and topical photodynamic treatment
with ALA light wavelengths in the 630 nm range are
most appropriate. Early clinical studies all relied on
laser light sources. The lasers used were the argon
pumped dye and gold vapour lasers. The gold
vapour laser emits pulsed light with high peak
powers at 628 nm. The effective penetration depth
into tissue at this wavelength is 1-3 mm. The advan-
tages of these laser light sources were the ability to
deliver high-fluence monochromatic light to induce
lethal damage in photosensitised tissue. The dis-
advantages were the cost of the laser, large size of
the machinery, long warm-up times for some lasers
and the need for specialised staff and facilities.
Polychromatic light sources are now more widely
available and cheaper than lasers (Fig. 8.1). These
light sources include short-arc xenon lamps emit-
ting 30 nm bandwidth light around 630 nm, filtered
slide projectors with wavelengths of 400-650 nm
and halogen lamps (600-800 nm). Developments in
laser diode arrays are also likely to replace older
lasers. These lasers are small, powerful and cheaper
than other lasers. They are currently not tunable to
630 nm and are more appropriate for photosensitis-
ers activated at longer wavelengths.
Fluence and fluence rates can significantly in-
fluence the efficacy of PDT in combination with
tissue oxygen tension. There appears to be a wide
range of fluences which can effect tumour destruction
(10-150 J/cm2) (Jeffes et aI, 1997). Treatment times
Fig. 8.1. Patient receiving topical ALA PDT. (Reproduced by
permission of Dr S.Varma.)
Photodynamic Therapy in Dermatology 93
can be shortened by high fluence rates. If these exceed
150 mW/cm 2 hyperthermic effects will also influence
outcome. Mild hyperthermia (41.5-42SC) increases
tumour oxygen tension and enhances PDT. Higher
temperatures will reduce oxygen tension and efficacy
of PDT. (Fuchs and Thiele, 1998). High fluence rates
are limited by patient tolerance. Very low fluence rates
may allow repair of sublethal damage caused by treat-
ment. Fractionating the light dose may enhance the
photodynamic effect (Muller et aI, 1998).
Treatment of Cutaneous
Malignancies with Topical
Photodynamic Therapy
Basal Cell Carcinoma
Several studies are now available reporting the clini-
cal efficacy of topical PDT with ALA in the treat-
ment of BCCs. In the first study by Kennedy et al
(1990) a complete response in 90% of 80 superficial
BCCs was achieved. Results of other studies are
shown in Table 8.1. Best results are in superficial and
small nodular lesions. Morphoeic and deep lesions
respond poorly; this may be in part due to the poor
penetration of the ALA. Follow-up durations after
treatment do not match those for other treatment
modalities such as surgery and curettage so it is
impossible to make valid comparisons as to the
long-term efficacy of this treatment.
Actinic Keratoses
AK respond very well to topical ALA PDT. Several
studies have shown complete response rates of
80-100% (Kennedy et aI, 1990; Wolf et aI, 1993;
Calzavara-Pinton, 1995; Fijan et aI, 1995; Jeffes et aI,
1997). Best results occur in actinic keratoses on the
face and trunk, with more treatment failures in
distal lesions which are often hyperkeratotic.
Concentrations of 10% ALA are sufficient to obtain
high response rates, which reduced the pain experi-
enced by the patient during irradiation of multiple
lesions. Cosmetic results are generally excellent.
Bowen's Disease
The intraepidermal nature of Bowen's disease
would suggest a favourable response to PDT. High
 ID
.,.
r-
~
'"Vl
5'
0

Table 8.1. Treatment of basal cell carcinomas using topical 20% ALA PDT '"3
g'"
0'
IQ
Reference Lesions Disease Adjunct Duration Ughtdose Source Cr % Pr % Assessment Recurrence Follow-up (months) '<
application (h) (J/cml) (months) (%)

cairnduffet al (1994) 16 SUP 3- 6 125- 250 Copper 87.5 12.5 2 43 17 (median)

vapour dye

Rjan et al (1995) 34 SUP 3% om 20 Up to 300 Halogen 88 3- 20 (mean =6)

22 NOD 22

Harth et al (1998) 31 SUP or 3% OESF 12 150 Versalight 84 6-15

small NOD hyperthermia

Ken nedy et al (1990) 80 SUP 3-6 54-540 Tungsten 90 7.5 2- 3

Meijnders et al (1996) 42 3-6 50- 100 Argon dye 81 19 3 1- 39 (mean =13)

Morton and MacKie (1998) 53 4-6 150 Xenon 85 2 6 6-27 (mean =24 and 10)
Svanberg et al (1994) 55 SUP 4-6 60 Nd:YAG 100 0.75 6-14
2S NOD 64 0.75 6- 14

Wolf et al (1993) 37 SUP 4- 8 30 Tungsten 97 290 1- 2 2 3-12 (median =7)

10 NOD 4-8 90 10 1- 2 3- 12 (median =7)
Abbreviations: CR, complete response; DESF, desferrioxamine; NOD, nodular BCC; PR, partial response; SUp, superficial BCC.
 PhotodynamicTherapy in Dermatology 9S

complete response rates have been reported (see

references cited above; Cairnduff et aI, 1994). Other
authors have reported response rates of 50% (Fijan
et aI, 1995; Fritsch et aI, 1998). Even repeated PDT
treatments may not improve complete response
rates. There are very few long-term studies to assess
the efficacy of PDT for Bowen's disease and there are
concerns that recurrences may be higher than previ-
ously reported (Varma et aI, 1999). In patients who
respond, the cosmetic results are excellent and on
the lower limb superior to most other treatment
modalities (Fig. 8.2). Morton et al (1996) compared
topical PDT with cryosurgery for Bowen's disease.
Twenty per cent ALA was applied for 4 h followed by
red light at 125 J/cm2. Cryotherapy was performed
by a single 20 s freeze-thaw cycle. At 12 months, the
complete response rate in the PDT group was 100%
and 90% in the cryosurgery group. Five lesions
ulcerated after cryotherapy and none ulcerated in
the PDT group.

Squamous Cell Carcinoma

There have been some reports of successful treat-
ment of invasive SCCs in small numbers of patients
(Wolf et aI, 1993; Kennedy et aI, 1990; Fritsch et aI,
1998). Repeated treatments may be necessary. Initial
stages of SCCs may be treated by PDT but there is
insufficient published data to widely recommend
this treatment until controlled, prospective, long-
term studies have reported the success rates of this
treatment in comparison with other treatment
modalities.
There are also case reports of successful treat-
ment of erythroplasia of Queyrat (Stables et aI,
1999), actinic cheilitis (Stender and Wolf, 1996) and
oral mucosal SCCs (Nauta et aI, 1996). Less suc-
cessful results have been achieved in the treatment
of cervical and vulval intraepithelial neoplasias b
(Martin-Hirsch et aI, 1998).
Fig. 8.2. a( ) Large Bowen's disease on ankle. (b) Complete clear-
ance after one treatment with ALA PDT. (Both reproduced by
Mycosis Fungoides permission of Dr S. Varma.)

Mycosis fungoides has also been reported as

responding to topical ALA PDT (Wolf et aI, 1994;
Ammann and Hunziker, 1995; Stables et aI, 1997).
Photodynamic Therapy for
Multiple treatment sessions appear to be necessary Benign Skin Disease
in the majority. Clinical response does not always
correlate with histological clearance of the lesion. Cutaneous disorders characterised by hyperprolifer-
More studies are necessary to evaluate tl1is modal- ation or increased vascularity may be amenable to
ity's potential therapeutic efficacy. treatment with PDT.
 96 Lasers in Dermatology
Psoriasis has been treated with both systemic
PDT using haematoporphyrin and Photofrin and
topical ALA PDT (Berns et aI, 1984; Weinstein et aI,
1991; Boehncke et aI, 1994).
Using systemic PDT there is highly selective
uptake of the drug in psoriatic plaques compared to
normal skin; it may therefore be possible to reduce
the dose of sensitiser to reduce photosensitivity of
normal skin. Topical PDT of course avoids the
problem of generalised photosensitisation. Topical
ALA has also been used in combination with ultra-
violet A (UVA) (Nelson et aI, 1997). Multiple treat-
ments were superior to single ones. More than 50%
clearing of the lesion was obtained with 10% ALA
and UVA of 80-120 J/cm2. Further developments in
this area with improved drug penetration and light
sources may produce significant advances in treat-
ment of psoriasis.
Other conditions subject to ongoing clinical trials
include port wine stains (Nelson, 1993) and hir-
sutism (Grossman et aI, 1995). Parallel development
have occurred in laser treatment of these conditions
and the role of PDT in these disorders needs to be
established.
References and Further Reading
Systemic Photodynamic Therapy
Diamond I, Granelli SG, McDough F, Nielson S, Wilson CB,
Jaenicke R (1972) Photodynamic therapy of malignant tumors.
Lancet ii: 1175-1177
Dougherty II (1981) Photo radiation therapy for cutaneous and
subcutaneous malignancies. J Invest Dermatol 77:122-124
Jones CM, Mang T, Cooper M et al (1992) Photodynamic therapy
in the treatment of Bowen's disease. J Am Acad Dermatol
27:1979-1982
Keller GS, Razum NJ, Doiron DR (1989) Photodynamic therapy
for non-melanoma skin cancer. Facial Plast Surg 6:180-184
Lui H, Hruza L, McLean D et al (1995) Photodynamic therapy of
malignant skin tumors with BPD Verteporfin (benzoporphyrin
derivative). Lasers Surg Med Suppl 7:44
Nelson JS, McCullough JL, Berns MW (1988) Photodynamic
therapy of human malignant melanoma xenografts in athymic
nude mice. J Nat! Cancer Inst 80:56-60
Pass HI (1993) Photodynamic therapy in oncology: mechanism
and clinical use. J Natl Cancer Inst 85:443-456
Pennington DG, Waver M, Knox A (1988) Photodynamic therapy
for multiple skin cancers. Plast Reconstr Surg 82:1067-1071
Robinson PI, Carruth JAS, Fairris GM (1988) Photodynamic
therapy: a better treatment for widespread Bowen's disease.
Br J DermatoII19:59-61
Schweitzer VG, Visscher 0 (1990) Photodynamic therapy for
treatment of AIDS-related oral Kaposi's sarcoma. Otolaryngol
Head Neck Surg 102:639-649
Sealy R, Sarn T, Wanner E et al (1984) Photosensitization of
melanin: an electron spin resonance study of sensitized radical
production and oxygen consumption. Photochem Photo bioi
40:453-459
Wilson BD, Mang TS, Cooper RN, Stoll H (1989) Use of photo-
dynamic therapy for the treatment of extensive basal cell carci-
nomas. Facial Plast Surg 6:185-189
Wilson BD, Mang TS, Stoll H, Jones C, Cooper M, Dougherty TJ
(1992) Photodynamic therapy for the treatment of basal cell
carcinoma. Arch DermatoI128:1597-1601
Topical Photodynamic Therapy for
Cutaneous Malignancies
Ammann R, Hunziker T (1995) Photodynamic therapy for mycosis
fungo ides after topical photosensitization with 5-aminolevulinic
acid. J Am Acad Dermatol33:541
Cairn duff F, Stringer MR, Hudson EJ, Ash DV, Brown SB (1994)
Superficial photodynamic therapy with topical 5-aminolae-
vulinic acid for superficial primary and secondary skin cancer.
Br J Cancer 69:605-608
Calzavara-Pinton PG (1995) Repetitive photodynamic therapy with
topical delta -aminolevulinic acid as an appropriate approach to
the routine treatment of superficial non-melanoma skin tumors.
J Photochem Photobiol B 29:53-57
Fijan S, Honigsmann H, Ortel B (1995) Photodynamic therapy of
epithelial skin tumours using delta-aminolevulinic acid and
desferrioxamine. Br J Dermatol133:282-288
Fritsch C, Goerz G, Ruzicka T (1998) Photodynamic therapy in
dermatology. Arch Dermatol 134:207-214
Fuchs J, Thiele J (1998) The role of oxygen in cutaneous photo-
dynamic therapy. Free Rad Bioi Med 24(5):835-847
Harth Y, Hirshowtitz B, Kaplan B (1998) Modified topical photo-
dynamic therapy of superficial skin tumors utilising aminole-
vulinic acid, penetration enhancers, red light and hyperthermia.
Dermatol Surg 24:723-726
Jeffes EW,McCullough JL, Weinstein GO et al (1997) Photodynamic
therapy of actinic keratoses with topical 5-aminolaevulinic acid.
Arch DermatoI133:727-732
Kennedy JC, Pottier RH, Pross DC (1990) Photodynamic therapy
with endogenous protoporphyrin IX: basic principles and
present clinical experience. J Photochem Photobiol B 6: 143-148
Martin-Hirsch PL, Whitehurst C, Buckley CH et al (1998)
Photodynamic treatment for lower genital tract intraepithelial
neoplasia. Lancet 351: 1403
Meijnders PJN, Star WW, De Bruijn RS et al (1996) Clinical results
of photodynamic therapy for superficial skin malignancies or
actinic keratosis using topical 5-aminolaevulinic acid. Laser
Med Sci 11:123-131
Morton CA, MacKie RM (1998) Photodynamic therapy for basal
cell carcinoma: effect of tumour thickness and duration of pho-
tosensitizer application on response. Arch Dermatol134:248-249
Morton CA, Whitehurst C, Moseley H et al (1996) Comparison of
photodynamic therapy with cryotherapy in the treatment of
Bowen's disease. Br J Dermatol135:766-771
Muller S, Walt H, Dobler-Girdziunaite D et al (1998) Enhanced
photodynamic effects using fractionated laser light. J Photochem
Photobiol B 42:67-70
Nauta JM, Van Leengoed HLLM, Star WM et al (1996)
Photodynamic therapy of oral cancer: a review of basic mechan-
isms and clinical applications. Eur J Oral Sci 104:69-81
Stables GI, Stringer MR, Robinson DJ (1997) Treatment of cuta-
neous T-cell lymphoma by topical aminolaevulinic acid photo-
dynamic therapy. Br J Dermatol137 (SuppI50):50
Stables GI, Stringer MR, Robinson OJ, Ash OV (1999)
Erythroplasia of Queyrat treated by topical aminolaevulinic
acid photodynamic therapy. Br J Dermatol 140:514-517
Stender 1M, Wulf HC (1996) Photodynamic therapy with
5-aminolevulinic acid in the treatment of actinic cheilitis. Br J
Oermatol 135:454-456

Svanberg K, Andersson T, Killander D et al (1994) Photodynamic
therapy of non-melanoma malignant tumours of the skin
using topical delta-amino levulinic acid sensitization and laser
irradiation. Br J Dermatol130:743-751
Wolf P, Rieger E, Kerl H (1993) Topical photodynamic therapy
with endogenous porphyrins after application of 5-aminole-
vulinic acid. J Am Acad Dermatol 28: 17 - 21
Wolf P, Fink-Puches R, Cerroni L, Kerl H (1994) Photodynamic
therapy for mycosis fungoides after topical photosensitization
with 5-aminolevulinic acid. J Am Acad DermatoI31:678-680
Photodynamic Therapy for Benign Skin
Disease
Berns MW, Rettenmaier MA, McCullough JL et al (1984) Response
of psoriasis to red light (630 nm) following systemic injection of
hematoporphyrin derivative. Lasers Surg Med 4:73-77
PhotodynamicTherapy in Dermatology 97
Boehncke WH, Sterry W, Kauffman R (1994) Treatment of psor-
iasis by topical photodynamic therapy with polychromatic
light. Lancet 343 :80 1
Grossman M, Wimberely J, Dwyer P et al (1995) PDT for hir-
sutism. Lasers Surg Med Suppl 7:44
Nelson JS (1993) Photodynamic therapy of port wine stains: pre-
liminary clinical studies. SPIE 1876:142-146
Nelson JS, McCullough JL, Berns MW (1997) Principles and appli-
cations of photodynamic therapy in dermatology. In Arndt KA,
Dover JS, Olbricht SM (eds) Lasers in cutaneous and aesthetic
surgery. Lippincott-Raven, Philadelphia, pp 370-372
Varma S, Wilson H, Kurwa HA, Charman C, Gambles B, Anstey A
(1999) One year relapse rates for Bowen's disease, basal cell car-
cinomas and solar keratoses treated by photodynamic therapy:
analysis of 189 lesions. Br J Dermatol141 (SuppI55):114
Weinstein GD, McCullough JL, Nelson JS, Berns MW, McCormick
A (1991) Low dose Photofrin II photodynamic therapy of psor-
iasis. Clin Res 39:509A
 N w Lasers, Emerging
1i chnology, Experimental and
D veloping Applications
Diode Lasers
Introd uction
Diode lasers were originally introduced in the 1980s
with power outputs of only 100 mW. They are semi-
conductor devices which generate light when an
electric current is passed through the diode. This
conversion from electric energy to light energy is
very efficient. More than 50% of the electrical
power is converted into light, which can be con-
trasted with an argon laser where less than 1% of
the electrical power is converted into light. Minimal
heat is generated, so diode lasers can be small,
lightweight, portable and quiet. Multiple diode laser
arrays have now been developed which can be
coupled directly into fibre-optic delivery devices
and outputs have increased to 60 W or more. Diode
lasers can be used to pump solid-state lasers instead
of fiashlamps (Fig. 9.1) or for contact, non-contact
and interstitial applications across a wide range of
medical disciplines.
Fig.9.1. Facial telangiectasia before and after treatment with the Iriderm Diolite™532 diode laser.((ourtesy of Iriderm.)
99
Diode lasers can emit light over a broad range of
wavelengths from 600 to 1020 nm. The wavelength is
determined by the active compound used. Most
medical research has been with diode lasers such as
gallium-arsenide (GaAs) and gallium-aluminium-
arsenide (GaAIAs) emitting light in the 795-830 nm
range. High-powered diode lasers emitting at 805 nm
can be used for contact probe cutting of tissue and
may be superior to the Nd:YAG laser for such pur-
poses. Non-contact cutting of tissue produces several
millimetres of collateral thermal injury which is only
appropriate for debulking of tissue.
Clinical Use in Dermatology
Leg Vein Telangiectasia
Several preliminary clinical studies have reported the
use of diode lasers for leg vein telangiectasia (Adrian
and Griffin, 1999; Campos et aI, 1999; Dierickx et aI,
1998; Garden et aI, 1998; Varma and Lanigan, 1999).
Diode lasers at 800, 810 and 815 nm have been evalu-
ated. Light at these wavelengths is deeply penetrating
 100 lasers in Dermatology
c scanned CO 2 laser. This wavelength is deeply pene-
o
'2-
o
'"
.J:J
« can be treated with a 980 nm diode laser while
Haemoglobin
200
1000
Wavelength (nm)
Fig. 9.2. Absorption spectrum of haemoglobin and melanin to
demonstrate absorption peak of haemoglobin at 915 nm.
with decreased melanin absorption; there is a tertiary
absorption peak of haemoglobin at 915 nm (Fig. 9.2).
Pulse durations of 10-50 ms with varying fluences
have been used. Some response in small vessels
assessed by the researchers could be observed. The
laser was well tolerated, with a low incidence of side
effects. New lasers with contact cooling devices to
cool the epidermis allow higher fluences to be deliv-
ered to the targeted blood vessels. A diode pumped
dye laser (Grossman et aI, 1999) operating at 585-605
nm with aI-50 ms pulse duration has also been used
to treat leg veins up to 2.0 mm in diameter. Vessel
fading in 75% of subjects was noted.
Hair Removal
Diode lasers have been shown to be effective for hair
removal. A diode laser emitting light at 800 nm has
been most commonly reported (Alster, 1999;
Campos et aI, 1999; Dierickx et aI, 1998a; Dierickx
et aI, 1998b; Dierickx et aI, 1999; Grossman et aI,
1998). The laser is operated at 5-30 ms with a 9 mm
square spot and cooling handpiece. Hair reduction
similar to ruby laser treatment without significant
side effects has been achieved. McDaniel et al (1999)
used a 770-840 nm diode laser with a long pulse
duration of 5 s at 35 W/cm 2 to reduce hair counts
without side effects.
Non-Ablative Resurfacing
A 980 nm diode laser has been used to induce
thermal damage in the dermis with epithelial pre-
servation (Muccini et aI, 1998). A spherical optic
handpiece to focus the light into the dermis was
used on breast and facial skin to assess tissue
shrinkage. The diode laser at 8 W induced tissue
shrinkage (16%) similar to that of three passes of a
trating with absorption by haemoglobin, melanin
and water. The authors propose that solar elastosis
preserving the epithelial layer.
Excimer Lasers
The name excimer comes from "excited dimer" and
refers to a group of lasers emitting in the ultraviolet
(UV) and infrared. The lasers are high-powered
pulsed lasers with pulses of 10-15 ns. Excimer lasers
are of considerable importance in sculpting the
surface of the cornea to improve refractive errors.
The major applications of excimer lasers in derma-
tology are in precise tissue ablation and treatment
of pigmented lesions. These lasers currently are
used as research tools rather than widely distributed
for therapeutic use.
The UV wavelengths of the excimer laser are
absorbed by tissue proteins. The ablation achieved
by these lasers is the most precise of any laser. The
argon fluoride (ArF) laser at 193 nm ablated 1 /Lm of
stratum corneum per pulse (Lane et aI, 1985). The
krypton fluoride (KrF) laser at 248 nm ablates tissue
in a fluence-dependent manner with ablations of
0.5-6 /Lm with fiuences of 0.5-1.5 J/cm2. There is a
much wider zone of residual thermal damage after
KrF laser ablation (125-500 /Lm) (Morelli et aI, 1987).
The quality of the incisions produced by the
pulsed UV lasers arises from photchemical mecha-
nisms. The UV photons are more energetic than
infrared and visible photons, producing sufficient
energy to break intramolecular bonds.
The precise sequential ablation of the stratum
corneum (which is 15 /Lm thick) with the ArF may
prove a useful tool in the investigation of the func-
tion of the stratum corneum and its role in the
barrier to percutaneous absorption (Jacques et aI,
1987). The ArF laser was used in comparison with
three other lasers to produce fascial graft bed thermal
damage in an animal model (Green et aI, 1993). The
minimal thermal injury in the graft bed after excimer
laser ablation led the authors to conclude that the ArF
laser may prove a valuable instrument for ablative
removal of necrotic skin, full-thickness skin and skin

Table 9.1. Commercially available excimer lasers
laser Wavelength (nm)
Argon fluoride (AF) 193
Krypton chloride (KrCl) 222
Krypton fluoride (KrF) 248
Xenon chloride (XeCl) 308
Xenon fluoride (XeF) 351
lesions to permit skin graft take approximating that
of conventional surgical techniques.
Although the short pulse width of the xenon
fluoride (XeF) laser at 351 nm has been used for the
selective photothermolysis of melanosomes
(Murphy et aI, 1983), clinical experience with Q-
switched lasers such as the ruby and Nd:YAG in the
treatment of pigmented cutaneous lesions has
somewhat superseded that of the XeF laser. There
are concerns at the potential mutagenicity of UV
excimer lasers (Kochevar, 1989) and further
research is needed to establish the hazards associ-
ated with their use. Similar ablation depths per pulse
can be achieved with a femtosecond pulsed tita-
nium-sapphire laser at 800 nm (Frederickson et aI,
1993) without the mutagenic risks of UV excimer
laser light.
Intense Pulsed Light Source
A high-energy gas discharge lamp has recently been
marketed as a source of non-coherent pulsed broad-
spectrum light (ESC Medical Systems Ltd, Haifa,
Israel). This is not a laser but has similar indications
to many dermatological lasers in the fields of cuta-
neous vascular and pigmented disorders and hair
removal. The light source produces broadband light
from 515 to 1200 nm. Cut-off filters are used to
remove unwanted shorter-wavelength light. For
example, using a 550 nm cut-off filter only light from
550 to 1200 nm will be transmitted. The light source
allows great flexibility in pulse duration, fluence and
application of single, double and triple pulses. Large
rectangular spots 8 x 15 and 8 x 35 mm are available
and the light is applied through a clear coupling gel
applied to the overlying skin.
Because of the many therapeutic options with this
light source it has not been clear in the past which is
the most appropriate treatment parameters for dif-
New lasers, Emerging Technology 101
Fig.9.3. Medium-sized leg telangiectasias before and after ve
treatments with the PhotoDermRVL (Courtesy of Dr J. Hunt, Tampa
- ESC Sharplan.)
ferent disorders. Goldman and Eckhouse (1996) has
attempted by the use of a theoretical model to select
the treatment parameters for a clinical study of the
treatment of telangiectatic and reticular leg veins
(Fig. 9.3). Parameters were determined based on
vessel size; double or triple pulses were used. In
159 patients in a multicentre study the authors
reported a 75-100% clearance in 79% of treated
vessels 0.1-3 mm in diameter. Greater than 50%
clearance was achieved in 94%. In contrast, Green
(1998) treated 72 patients with telangiectases of the
lower limb up to 1 mm in diameter. Complete or
almost complete clearance of telangiectases was
observed in only 10% of patients, with no improve-
ment in 56%. Adverse effects were common, includ-
ing scarring in 21 % of patients. However, Schroeter
and Neumann (1998) treating a number of patients,
including 40 with leg telangiectasias, with the
intense pulsed light source observed clearance rates
in excess of 80% at 1 month for all size of vessels
treated up to 1 mm in diameter.
Other benign cutaneous vascular disorders (Figs 9.4,
9.5) have also been treated with this light source.
Schroeter and Neumann (1998) successfully treated
facial telangiectasias, both red and blue nasal vessels,
using different parameters. Spider naevi and senile
angiomas both cleared in 95%, and 90% clearance of
the vascular component of erythrosis interfollicularis
colli occurred in 15 females. Strempel and Klein
(1996) treated 32 patients with port wine stains with
both the pulsed dye laser and the high-energy gas dis-
charge lamp (PhotoDerm VL). The PhotoDerm para-
meters were 40 J/cm2, wavelength 570-1200 nm, pulse
length 5 ms. In 24 patients results were better with the
 102 Lasers in Dermatology
a ____~__~___________________
b
Fig. 9.4. (a) 42-year-old with port wine stain on neck. (b) Result
after ve treatments with the PhotoDermR VL. (Both courtesy of
Dr P. Bandel, Paris, TX - ESC Sharplan.)
pulsed dye laser; in six patients the PhotoDerm results
were better and the remainder showed equal improve-
ment. Raulin et al (1997a) reported one patient with a
facial port wine stain that had failed to respond to one
treatment with the pulsed dye laser. The patient was
treated with the PhotoDerm VL using a 550 nm cut-
off filter with pulse durations of 5 ms and fluences of
Fig.9.S. Actinic and steroid induced facial telangiectasia before
and 8 months after one treatment with the PhotoDermR VL.
(Courtesy of Dr W. Yourchek, Stockton - ESC Sharplan.)
25-35 J/cm2. After five treatments the port wine stain
had cleared completely.
Two patients with deep-seated venous malform-
ations were successfully treated by Raulin et al
(1997b) using a PhotoDerm VL with a 590 nm cut-
off filter and fluences of 40-77 J/cm2.
The intense pulsed light source has also been
used for hair removal and this is discussed in greater
detail in Ch. 7. The potential advantage of the broad-
band light source is the potential to remove hair
which has minimal colour contrast to the patient's
skin colour. The very large spots sizes used with this
device allow rapid coverage of large areas for hair
removal such as the back or thighs.
The intense pulsed light source has recently been
combined with a pulsed (1-14 ms) laser at 1064 nm
(Vasculight™) for the treatment of deeper and
larger leg veins; complete closure of vessels up to
3 mm in diameter and 5 mm depth have been
reported by the manufacturers but there is no pub-
lished research to confirm the efficacy of this device.
In conclusion, the intense pulsed light source,
because of its versatility, offers a great deal of
promise for the treatment of a number of cutaneous
disorders. The multiplicity of treatment parameters
available to the clinician has resulted in some delay
in establishing optimal parameters for each condi-
tion treated and contradictory published results.
More research is urgently needed in the use of this
source and, as with all clinical laser research, object-
ive assessment of results achieved.
Non-Ablative Cutaneous Laser
Resurfacing
Substantial advances have been made in the treat-
ment of photodamaged skin by precise ablative
 New lasers, Emerging Technology 103

therapy with high-energy, short pulsed or scanned Long pulsed non-coherent intense pulsed light
CO 2 lasers and more recently the Er:YAG laser. Both (Goldberg, 1999b) and an erbium glass laser at 1550
lasers remove the epithelium and superficial dermis. nm with surface cooling (Ross et aI, 1999) have also
The patient is then left with an open facial wound been evaluated in preliminary studies. Goldberg and
that takes 7-14 days to re-epithelialise. The immedi- Metzler (1999) have also reported on the use of low-
ate postoperative period is accompanied by burning fiuence Nd:YAG (1064 nm) laser treatment in com-
discomfort, exudation and oedema and is followed bination with an exogenous carbon suspension
by erythema which can persist for months. New chromophore. Using fiuences of 2.5 J/cm 2 at 8 months
approaches to cutaneous resurfacing have involved the investigators reported improvement in both skin
laser-induced injury to dermal collagen with main- texture and elasticity, with wrinkle reduction.
tenance of the epidermis. Adverse events were limited to mild erythema which
It has been noted that the pulsed dye laser at was present in 54% at 8 weeks following treatment.
585 nm (Kilmer and Chotzen, 1997) the Q-switched Muccini et al (1998) used a 980 nm diode laser
ruby and Q-switched Nd:YAG (Goldberg and with a spherical optical handpiece to focus the light
Whitworth, 1997) lasers have all been shown to into the dermis. They investigated tissue shrinkage
improve facial wrinkles. A solid -state pulsed Nd: YAG and histological changes after diode laser treatment.
laser emitting at 1320 nm has also been evaluated for The diode laser did not ablate the epidermis but
the non-ablative improvement of photo damaged produced equivalent shrinkage (16%) to three
skin (Lask et aI, 1997; Nelson et aI, 1997; Alster 1999; passes of a scanned CO 2 laser. After 21 days tissue
Sriprachya-Anunt et aI, 1999). This laser operates showed new collagen and an abundance of young
with pulse durations around 200 fLs and is used in elastic fibres.
conjunction with a dynamic cooling device in which
a cryogen is spurted on to the skin immediately
before the laser impulse, cooling the epidermis. The
long wavelength of light is deeply penetrating and
Conclusions
thought to act by production of new dermal collagen
Preliminary studies have shown that a variety of
after inducement of a dermal wound, with preserv-
lasers can be used to alter dermal collagen with pre-
ation of the epidermis. Menaker et al (1999) using
servation of the epidermis. The benefits of preserv-
the Nd:YAG laser at 1320 nm with three 300 fLS pulses
ation of the epidermis for the patient are obvious and
delivered at 100 Hz repetition to produce a 20 ms
this represents a very attractive option for the patient
macro pulse treated 10 patients with facial wrinkles.
in preference to current resurfacing lasers. This form
They used fiuences of 32 J/cm 2 with a preset cryogen
of treatment is being marketed heavily but to date the
spray of 20 ms. With this treatment regimen they
clinical results are modest and probably most appro-
found a subtle and statistically insignificant improve-
priate for mild wrinkles.
ment in wrinkle severity and side effects includ-
Further research is needed to precisely define the
ing hyperpigmentation and scarring. In contrast,
most appropriate laser and treatment parameters to
Goldberg (1999a) treated 10 patients four times over
achieve the goal of effective non-ablative resurf-
16 weeks with the Nd:YAG laser at 1320 nm using
acing. In addition, much interesting work on the
28-38 J/cm 2 with cryogen cooling and 30% overlap
nature of wound healing can follow from these new
of spots. Subjective assessments of improvement
technological advances.
were made and eight patients were reported to be
improved 6 months after the final treatment. All eight
patients showed evidence of new upper papillary
dermal collagen formation in skin biopsies per- References and Further Reading
formed 6 months after the final treatment. Kelly et al
(1999) treated 35 patients with periorbital wrinkles
Diode Lasers
with a non-ablative Nd:YAG (1320 nm) laser in com-
bination with cryogen spray cooling.
Introduction
Three treatments were performed at intervals of 2
weeks. Small but statistically significant improve- Amin Z (1995) Diode lasers: experimental and clinical review.
Lasers Med Sci 10:157-163
ments were seen in all severities of wrinkles but only Byer RL (1988) Diode laser-pumped solid state lasers. Science
maintained at 24 weeks in the most severe group. 239:742-747
 104 Lasers in Dermatology
Raven T, Mannonen I, Fernie D (1993) High power diode lasers
and their surgical applications. SPIE Proc 1892:12-16
Leg Vein Telangiectasia
Adrian RM, Griffin L (1999) Long pulsed alexandrite (755 nm)
and diode (800 nm) lasers in the treatment of lower extremity
telangiectasia: a comparative clinical study. Lasers Surg Med
Supplll:20
Campos VB, Lucchina LC, Dierickx CC, Anderson RR (1999)
Treatment of leg telangiectasia by a pulsed, 915 nm infrared
laser system. Lasers Surg Med Sup pi 11:20-21
Dierickx CC, Duque V, Anderson R (1998) Treatment of leg
telangiectasia by a pulsed, infrared laser system. Lasers Surg
Med Supp110:40
Garden JM, Bakus AD, Miller ID (1998) Diode laser treatment of
leg veins. Lasers Surg Med Suppll 0:32
Grossman MC, Kilmer SL, Chotzen VA, Lou WW, Geronemus RG
(1999) Laser treatment of leg veins diode pumped dye laser.
Lasers Surg Med Supplll:20
Varma S, Lanigan SW (1999) A preliminary study of the 810 nm
diode laser in the treatment of telangiectatic leg veins. J Eur
Acad Derm Vener 12(SuppI2):S202
Hair Removal
Alster TS (1999) Prolonged clinical experience with laser-assisted
hair removal: a clinical comparison of systems. Laser Surg Med
Supplll:14
Campos VB, Dierickx CC, Lin T-YD, Farinelli WA, Manuskiatti W,
Anderson RR (1999) Long term efficacy of normal-mode 694
nm ruby laser and 800 nm diode laser for hair removal. Lasers
Surg Med Suppl II :22
Dierickx CC, Grossman MC, Farinelli WA et al (1998a) Hair
removal by a pulsed, infrared laser system. Laser Surg Med
SuppllO:42
Dierickx CC, Grossman MC, Farinelli WA et al (1998b)
Comparison between a long pulsed ruby laser and a pulsed,
infrared laser system for hair removal. Lasers Surg Med Suppl
10:42
Dierickx CC, Campos VB, Lin D, Farinelli W, Anderson RR (1999)
Influence of hair growth cycle on efficacy of laser hair removal.
Lasers Surg Med Supplll:21
Grossman M, Dierickx C, Quintana A, Geronemus R, Anderson R
(1998) Removal of excess body hair with an 800 nm pulsed
diode laser. Lasers Surg Med Supp110:42
Lin T-YD, Dierickx CC, Campos VB, Farinelli WA, Rosenthal J,
Anderson RR (1999) Reduction of regrowing hair shaft size
and pigmentation after ruby and diode laser treatment. Lasers
Surg Med Supplll :22
McDaniel DH, Newman J, Lord J, Ash K, Friskey J (1999) Hair
reduction with a very long pulse infrared diode laser. Lasers
Surg Med Supplll :23
Non-Ablative Resurfacing
Muccini JA, O'Donnell FE, Fuller T, Reinisch L (1998) Laser treat-
ment of solar elastosis with epithelial preservation. Lasers Surg
Med 23: 121-127
Excimer Lasers
Frederickson KS, While WE, Wheeland RG, Slaughter DR (1993)
Precise ablation of skin with reduced collateral damage using
the femtosecond-pulsed terawatt titanium-sapphire laser. Arch
DermatoI129:989-993
Green HA, Burd EE, Nishioka NS, Compton CC (1993) Skin graft
take and healing following 193-nm excimer, continuous-wave
carbon dioxide (C0 2 ), pulsed CO" or pulsed holmium:YAG
laser ablation of the graft bed. Arch Dermatol 129:979-988
Jacques SL, McAuliffe DJ, Blank IH, Parrish JA (1987) Controlled
removal of human stratum corneum by pulsed laser. J Invest
Dermatol 88:88-93
Kochevar IE (1989) Cytotoxicity and mutagenicity of excimer
laser radiation. Lasers Surg Med 9:440-445
Lane RJ, Linsker R, Wynne JJ, Torres A, Geronemus RG (1985)
Ultraviolet-laser ablation of skin. Arch DermatoI121:609-617
Morelli J, Kibbi A-G, Farinelli W, Boll J, Tan OT (1987) Ultraviolet
excimer laser ablation: the effect of wavelength and repetition
rate on in vivo guinea pig skin. J Invest Dermatol 88:769-773
Murphy GF, Shepard RS, Paul BS, Menkes A, Anderson RR,
Parrish JA (1983) Organelle-specific injury to melanin-contain-
ing cells in human skin by pulsed laser irradiation. Lab Invest
49:680-685
Intense Pulsed Light Source
Goldman M, Eckhouse S (1996) Photothermal sclerosis of leg
veins. Dermatol Surg 22:323-330
Green D (1998) Photodermal removal of telangiectasias of the
lower extremities with the Photoderm VL. J Am Acad Dermatol
38:61-68
Raulin C, Hellwig S, Schonermark MP (1997a) Treatment of a
nonresponding port-wine stain with a new pulsed light source
(Photoderm R VL). Lasers Surg Med 21:203-208
Raulin C, Raulin SJ, Hellwig S, Schonermark MP (1997b)
Treatment of benign venous malformations with an intense
light source (PhotoDerm R VL). Eur J Dermatol 7:279-282
Schroeter CA, Neumann HAM (1998) A intense light source: the
photoderm VL-flashlamp as a new treatment possibility for
vascular skin lesions. Dermatol Surg 24:743-748
Strempel H, Klein (1996) Laser therapy without laser: a controlled
trial comparing the flashlamp-pumped dye laser with the pho-
toderm high-energy gas discharge lamp. Lasers Med Sci
11:185-187
Non-Ablative Cutaneous Laser Resurfacing
Alster TS (1999) Nonablative cutaneous laser resurfacing: a clini-
cal and histologic analysis. Lasers Surg Med Supplll :25
Goldberg DJ (1999a) Non-ablative subsurface remodelling: clini-
cal and histologic evaluation of a 1320-nm Nd:YAG laser. J
Cutan Laser Ther 1:153-157
Goldberg DJ (1999b) Non-ablative improvement of superficial
rhytides with long-pulsed, non-coherent, intense pulsed light
treatment. Lasers Surg Med Supplll:25
Goldberg DJ, Metzler C (1999) Skin resurfacing utilizing a low-
fluence Nd:YAG laser. J Cutan Laser Ther 1:23-27
Goldberg DJ, Whitworth J (1997) Laser skin resurfacing with the
Q-switched Nd:YAG laser. Dermatol Surg 23:903-907
Kelly KM, Nelson JS, Lask GP, Geronemus RG, Bernstein LJ (1999)
Cryogen spray cooling in combination with nonablative laser
treatment of facial rhytides. Arch Dermatol135:691-694
Kilmer SL, Chotzen VA (1997) Pulsed dye laser treatment of
rhytids. Laser Surg Med Suppl 9:44
Lask G, Lee P, Seyfeadeh M et al (1997) Non-ablative laser treat-
ment of facial rhytids. SPIE Proc 2970:338-349
Menaker GM, Wrone DA, Williams RM, Moy RL (1999) Treatment
of facial rhytids with a nonablative laser: a clinical and histo-
logic study. Dermatol Surg 25:440-444
Muccini JA, O'Donnell FE, Fuller T, Reinisch L (1998) Laser treat-
ment of solar elastosis with epithelial preservation. Lasers Surg
Med 23:121-127

Nelson JS, Millner TE, Dave 0, Lask GP (1997) Clinical study of
non-ablative laser treatment of facial rhytides. Laser Surg Med
SuppI9:32-33
Ross EV, Sajben FP, McKinlay JR, Miller CH, Barnette OJ, Hsia J
(1999) Non-ablative skin remodelling: selective dermal heating
New Lasers, Emerging Technology lOS
using an IR laser with surface cooling. Lasers Surg Med Suppl
11:25-26
Sriprachya-Anunt S, Fitzpatrick RE, Goldman MP (1999) The
effect of a 1320 nm Nd:YAG laser with dynamic cooling on
human skin. Lasers Surg Med Suppl!! :25
Index of Laser Manufacturers Cross Medical Ltd
1 The Chase Centre, 8 Chase Road, Park Royal,
London NWI0 6QD, UK
Aesculap
Tel. +44 (181) 453 0388
Meditec
Fax +44 (181) 453 0336
Medizinische Laser-Technologie,
E-mail: user@cross-medicaLbdx.co.uk
PO Box D-07739, Jena, Germany
Tel. +49 (3641) 65 32 23 Cynosure, Inc.
Fax +49 (3641) 65 2121 35 Wiggins Avenue, Bedford, MA 01730, USA
http://www.aesculap-meditec.com Tel. (800) 8862966 and (617) 275 5007 (inside MA)
Fax (617) 275 5449
Candela Corporation
530 Boston Post Road DDD
Wayland, MA 01788, USA Danish Dermatologic Development A/S,
Tel. + 1 (508) 358 7637 Dr. Neergaards Vej SF, Danish Science Park,
Fax + 1 (508) 358 5569 DK-2970 Hoersholm, Denmark
http://www.clzr.com Tel. +45 45768888
E-mail: sales@clzrl.com Fax +45 45 76 88 89

Coherent Medical Group DEKA

Global Headquarters, Coherent,
3270 West Bayshore Road, Palo Alto,
CA 94303, USA
Tel. + 1 (415) 852 8221 and (800) 6351313
Fax +1 (415) 8564348 and (800) 505 1133
http://www.coherentmedical.com
Medical Electronics Laser Associated,
DEKA MELA s.r.l., Via Baldanzese 17,
50041 Calenzano (Fl), Italy
Tel. +39 (055) 8874942
Fax +39 (055) 8832884
http://www.dekait-deka@deka.it

Diomed USA
Coherent (UK) Ltd 30-31 Union Wharf, Boston, MA 02109, USA
Cambridge, UK Tel. + 1 (617) 723 6593
Tel. +44 (1223) 424048 Fax + 1 (617) 723 6598
Fax +44 (1223) 425902 E-mail: diomedinc@aol.com

Continuum Biomedical, Inc. DiomedLtd

2456 Armstrong Street, Livermore, Cambridge Research Park, Ely Road,
CA 94550, USA Cambridge CBS 9TE, UK
Tel. + 1 (510) 606 3750 Tel. +44 (1223) 729300
Fax +1 (510) 447 8378 Fax +44 (1223) 729329
E-mail: info@diomed-lasers.com
http://www.diomed-Iasers.com

107
 108 lasers in Dermatology

ESC Medical Systems Ltd Nidek,Inc.

PO Box 240, Yokneam 20692, Israel 47651 Westinghouse Drive, Fremont,
Tel. +972 (4) 959 9000 CA 94539, USA
Fax +972 (4) 959 9050 Tel. + 1 (510) 226 5700 and (800) 223 9044
Fax +1 (510) 2265750
Iridex http://www.nidekeye.com
Iriderm
1212 Terra Bella Avenue, Mountain View, Palomar Medical Products, Inc.
CA 94043-1824, USA 45 Haartwell Avenue, Lexington,
Tel. + 1 (650) 2372288 and (800) 3884747 (toll free, MA 02173, USA
US only) Tel. +1 (888) 876 5400 (toll free) and
Fax + 1 (650) 237 2289 +1 (617) 676 7300 (international)
http://www.iriderm.com Fax +1 (617) 676 7330

Laserscope
Sharplan
Corporate Headquarters, 3052 Orchard Drive,
Corporate and International Headquarters:
San Jose, CA 95134-2011, USA
Tel. +972 (4) 959 9000
Tel. (800) 3567600 and + 1 (408) 9430636
Fax +972 (4) 959 9050
Fax +1 (408) 428 0512 and + 1 (408) 9439630
US Headquarters:
http://www.laserscope.com
Tel. (800) 562 5915
Fax +1 (781) 444 8812
Laserscope (UK) Ltd
Raglan House, Llantarnam Park, Cwmbran,
Gwent NP44 3AX, UK SharpIan Lasers (UK) Ltd
Tel. +44 (1633) 838081 Merit House, Edgware Road, Colin dale,
Fax +44 (1633) 838161 London NW9 5AF, UK
Tel. +44 (18I) 3244200
LuxarCorp. Fax +44 (18I) 3244222
19204 North Creek Parkway, Bothell, E-mail mchurchill@sharplan.com
WA 98011-8009, USA http://www.sharplan.com http://www.escmed.com
Tel. +1 (206) 4834142 and (800) 5481482 (US only)
Fax + 1 (206) 483 6844 SLS (Wales) Ltd
Units 1 and 2, Heol Rhosyn,
Lynton Lasers Ltd Dafen Industrial Estate, Llanelli,
Lindow House, Beech Lane, Wilmslow, Dyfed SA14 8LX, UK
Cheshire SK9 5ER, UK Tel. +44 (554) 755444
Tel. +44 (1625) 536646 Fax +44 (554) 755333
Fax +44 (1625) 530633
Tissue Technologies
Nidek Co. Ltd A Polomar Company
Tokyo Office (International Division), 6th Floor, 4432 Anaheim Avenue NE, Albuquerque,
Takahashi Building, NM 87113, USA
No.2, 3-chrome, Kanda-jinbouchou, Chiyoda-ku, Tel. (800) 658 3185 (toll free) and + 1 (505) 8280508
Tokyo 101,Japan Fax + 1 (505) 828 0525
Tel. +83 (3) 32880571
Fax +81 (3) 3288 0570
E-mail: ask@nidek.co.jp
http://www.nidek.co.jp
A port wine stains 17,26
Ablation 5,57-8,60-2,64 pulsed, superpulsed and scanned 59-60
Acne skin resurfacing 62-70
carbon dioxide laser 70 tattoo removal 50,62
Er:YAG laser 74-5 tissue ablation 60-2
Acneform eruptions 69 wound healing 59
Actinic cheilitis 61,95 Carbonisation 5
Actinic keratosis 93 Cavernous haemangioma 58
Adenoma sebaceum 30,75 Charring see Carbonisation
Alexandrite laser 7 Chemical peels 69-70
hair removal 84-5,88 Cherry angioma 30
leg veins 28 Chloasma 42
long pulsed 28 Chromophore 4
pigmented lesions 40,44 Chromos laser 88
tattoo removal 49,52-3 Classification of lasers 7-8
Allergic contact dermatitis 68 see also individual laser types
Ametop 18,65 Clinical training 12
5-Aminolaevulinic acid 92 Coagulation 5
Angiofibroma 75 Coherent light 2
Angiokeratoma 30 Collimation 2, 3
Angiolymphoid hyperplasia 30 Continuous wave dye laser 23-4
Apogee laser 88 Copper bromide laser see Copper vapour laser
Argon dye laser 7 Copper vapour laser 3,7
Argon fluoride laser 101 facial telangiectasias 29
Argon laser 4,7 pigmented lesions 40,44-5
port wine stains 17,22-3 port wine stains 17,25
Atrophic scarring 21 Core of knowledge 11
Cosmetic tattoos 54
B Cryogen spurt 20
Basal cell carcinoma 92,93,94 Cutaneous vascular lesions 15-37
Beam diameter 16 capillary haemangiomas 26-7
Becker's naevi 40,41 leg veins and telangiectasias 27-9
Blue naevi 40,42 port wine stains see Port wine stains
Bowen's disease 61,92,93,95 viral warts 33
Bruising with pulsed dye laser 19
o
C Darier's disease 75
Cafe au lait macules 40,41,43,44 Debridement 62
Capillary (strawberry) haemangioma 26-7 Defocused carbon dioxide laser 57
Carbon dioxide laser 7,57-70 Denaturation 5
comparison with Er:YAG laser 75-6 Depilatories 81
incisional surgery 58-9 Diode laser 7,99-100
pigmented lesions 40 hair removal 85,88,100

109
110 Lasers in Dermatology

Diode laser - cont. Haemoglobin 4,42,45, 51

leg veins 28, 99-100
skin resurfacing 100
E normal cycle 82
Ectropion 69
Electrical hazards 9-10
Electrolysis 81
Ellipse relax light laser 88
EMLA cream 18,42,65,87
Energy density see Fluence
Environmental considerations 8-9
Epidermal naevi 62,75
Epilight laser 85-6,88
EpiTouch laser 83, 88
Erbium:YAG laser 7,70-6
acne 74-5
comparison with carbon dioxide laser
pigmented lesions 40
skin resurfacing 7l-4
tattoo removal 75
Excimer laser 7,100-1
Excisional surgery 58-9
Exposure time 3
F skin resurfacing 69
FeatherTouch laser 64,66-7
Fire hazards 9-10
Flashlamp pulsed dye laser see pulsed dye laser
Flexinet 67
Flexzan 67
Fluence 3,17,27
spatial average energy 4
Focused carbon dioxide laser 57
Freckles 40
Hailey-Hailey disease 75
Hair
anatomy 82
see also Hair removal; Hair transplantation
Hair removal 81-9
alexandrite laser 84-5
diode laser 85, 100
intense pulsed light source 102
photodynamic therapy 96
ruby laser 83-4
selective photothermolysis 82-3
treatment techniques 87-8
Hair transplantation 87,88
Herpes simplex virus, reactivation 65
Hexascan 24-5
75-6 Hyperpigmentation 21
hair removal 86
infraorbital 44
minocycline-induced 42,44
skin resurfacing 68-9
Hypertrichosis 81
Hypertrophic scarring 21,23,31
Hypopigmentation 21,23,24,42,44, 50
Ignition hazards 9-10
Infection 68
Intense pulsed light source laser 101-2
Intranasal haem angioma 27
Intraoral haem angioma 27
Irradiance 3,57
Isotretinoin 21,65

G K
Gallium-aluminium-arsenide laser 99 Kaposi's sarcoma 30,59,92
see also Diode laser Keloidal scars 21,31
Gallium-arsenide laser 99 Krypton chloride laser 101
see also Diode laser Krypton fluoride laser 101
Gentle lase laser 88 Krypton laser 7
Gold vapour laser 7 pigmented lesions 40,45
Granuloma faciale 30 port wine stains 17,26
KTP laser 7
H facial telangiectasias 29
Haemangioma leg veins 28
capillary (strawberry) 26-7 pigmented lesions 45
cavernous 58 port wine stains 17
intranasal 27 verrucae 33
intraoral 27
nodular 30 L
perineal 27 Lambda laser 88
periocular 27 Laser construction 2
Haemangiosarcoma 58 Laser controlled area 9
Haematoporphyrin derivative 91 Laser light delivery 3

Laser plume, hazards of 10-11
Laser protection advisor 9
Laser protection supervisor 9
Laser radiation 2
Laser safety education program
Laser safety officer 9,11
Laser-tissue interactions 4-5
Lasing media 2
Leg veins 27 -8,99-100
Lentigines 40
Lentigo simplex 41
Light sheer laser 88
Light sources 93
Local rules 9
long pulsed dye laser 28
long pulsed lasers 28
LPIR laser 88
Lymphangioma 30,31
M ruby laser 40-2
Malignant melanoma 59,92
Maximum permissable exposure
Melanin 4, 15,39,42,51
epidermal 16
hair follicles 83
see also Pigmented lesions
Melanocytic naevi 45-6
Melasma 40,45,75
Metastable energy levels
Milia 69
Minimal blanching 22,23
Mycosis fungoides 95
N psychological aspects of treatment 21-2
Naevus of Ito 40,41
Naevus of Ota 40,41,42,45
Naevus spilus 40
Necrosis 5
Neodymium:YAG laser 7
hair removal 85,88
leg veins 28
long pulsed 28
pigmented lesions 40,42-4
port wine stains 25-6
tattoo removal 49,51-2
Nodular haemangioma 30
Nominal hazard zone 9
Nominal ocular hazard distance
Non-coherent light 2
NovaPulse laser 64,67
o hair removal 85-6,88
Ocular hazards 10
Optical density 10
Osteoma cutis 75
Oxyhaemoglobin 6, 15,22
Index 111
p
Passes, number of 4
Perineal haemangioma 27
Periocular haemangioma 27
12 Photodynamic therapy 91-7
benign skin disease 95-6
cutaneous malignancies 93-5
systemic 91-2
topical 92-3
Photofrin 91
Photons 1
Photothermal interactions 5
Pigmented lesions 39-47
alexandrite laser 44
categories of 39-40
copper vapour laser 44-5
melanocytic naevi 45-6
Nd:YAG laser 42-4
pulsed dye laser 40
Pockel's cell 50
8 Poikiloderma of Civatte 29
Population inversion 1
Port wine stains 4,6,15-26
argon laser 22-3
carbon dioxide laser 26
continuous wave dye laser 23-4
copper vapour laser 25
ftashlamp pulsed dye laser 17-21
intense pulsed light source 102
krypton laser 26
Nd:YAG laser 25-6
photodynamic therapy 96
robotic scanning handpieces 24-5
selective photo thermolysis 15-17
side effects of treatment 21
Potassium titanyl phosphate laser see KTP laser
Power sources 2
Protective eyewear 10
Pseudo-continuous lasers 3
Psoriasis 32-3,96
Pulsed carbon dioxide laser 59-62
Pulsed dye laser 7
facial telangiectasias 30
leg veins 28
pigmented lesions 40
8 port wine stains 17-21
psoriasis 32-3
tattoo removal 49,53
Pulsed light laser 3
Pyogenic granulomas 30
Q
Q-switching 59
112 Lasers in Dermatology

Quasi-continuous laser 4,25 Surgi-Pulse XJ-150 laser 60

Queyrat's erythroplasia 61,95 Syringoma 61-2,75

R T
Remote interlocks 9 Tattoos 49-55
Residual thermal damage 64 alexandrite laser 52-3
Resonating cavity 2 carbon dioxide laser 62
Rhinophyma 62,75 colour of 50,51, 52, 53
Robotic scanning handpieces 24-5 comparative studies 53-4
Rosacea 29 cosmetic 54
Ruby laser 7 Er:YAG laser 75
hair removal 83-4,88 Nd:YAG laser 51-2
pigmented lesions 40-2 pulsed dye laser 53
tattoo removal 49-51 ruby laser 49-51
traumatic 54
5 Tegaderm 11, 50
Scanned carbon dioxide laser 59-62 Telangiectasia
Scarring 69 facial 29,102
Scars, treatment of 30-1 leg vein 27-8,99-100,101
Sclerotherapy 27 TEMoo 3
Sebaceous hyperplasia 75 Thermal capacity 10
Second Skin 11,50,67 Thermal relaxation time 6,15
Selective photothermolysis 2, 5-6 Training 11
hair removal 82-3 clinical 12
port wine stains 15-17 Traumatic tattoos 54
Shadowing 16-17 Tru-Pulse laser 60,64,67
Side effects
pulsed dye laser therapy 21
U
see also Hyperpigmentation; Hypopigmentation; Ultra long pulsed dye laser, leg veins 28
Scarring UltraPulse laser 60,63,64,66
SilkTouch laser 60,63,66-7
Silon 67
Skin resurfacing 102-3
v
Vaporisation 5
carbon dioxide laser 62-70
Vasculight laser 102
acne scars 70
Venous lakes 30
coherent Ultra pulse 66
Verrucae 33,75
complications 68-9
Versapulse 26
long-term results 69
Vigilon 67
mechanism of action 63-4
postoperative management 67-8
preoperative patient evaluation 64-5 W
Sharplan SilkTouch/FeatherTouch 66-7 Warning signs 8
treatment methods 65 Warts 33
diode laser 100 carbon dioxide laser 61
Er:YAG laser 7l-4 Waxing 81
Nd:YAG laser 103 Wound healing 59
Softlight laser 88 Wrinkles, skin resurfacing 71-4
Solar lentigo 43,44,75
Spatial average energy flue nee 4 X
Speckled lentiginous naevus 43 Xanthelasma 75
Spider naevus 29-30,31 Xenon chloride laser 101
Squamous cell carcinoma 92,95 Xenon fluoride laser 101
Stimulated emi;sion 1,2
Strawberry (capillary) haemangiomas 26-7 y
Striae 30-2 Yttrium-aluminium-garnet (YAG) laser see Erbium:YAG
Superpulsed carbon dioxide laser 59-62 laser; Neodymium:YAG laser