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Dermatology and Skin Disease Treatment
The first lasers used to treat skin conditions occurred over 40 years ago. diode
lasers were commonly used to treat benign vascular birthmarks such as port-wine stains and haemangiomas. Although these birthmarks could be effectively lightened, a side effect was the unacceptably high rate of scar formation. In the last 20 years major advances in laser technology has revolutionised their use in the treatment of many skin conditions and congenital defects, including vascular and pigmented lesions, and the removal of tattoos, scars and wrinkles. Nowadays there is a wide spectrum of laser and light technologies available for skin resurfacing and rejuvenation.
Properties of laser light
‘Laser’ is an acronym: light amplification by the stimulated emission of radiation.
Lasers are sources of high intensity light with the following properties:
Monochromatic, i.e., the light is of a single wavelength
Coherent, i.e., the light beam waves are in phase
Collimated, i.e., the light beams travel in parallel
Laser light can be accurately focused into small spots with very high energy.
The light is produced within an optical cavity containing a medium, which may be a gas (eg argon, krypton, carbon dioxide), liquid (eg dye) or solid (eg ruby, neodymium:yttrium-aluminium-garnet, alexandrite). The process involves excitation of the molecules of the laser medium, which results in the release of a photon of light as it returns to a stable state. Each medium produces a specific wavelength of light, which may be within the visible spectrum (violet 400 through to red 700nm) or infrared spectrum (more than 700 nm).
Vascular skin lesions contain oxygenated haemoglobin, which strongly absorbs visible light at 418, 542 and 577 nm, whereas pigmented skin lesions contain melanin, which has a broad range of absorption in the visible and infrared wavebands. Infrared lasers are broadly destructive because they are absorbed by water in and between skin cells (these are composed of 70-90% water).
The aim is to destroy the target cells and not to harm the surrounding tissue. Short pulses reduce the amount that the damaged cells heat up, thereby reducing thermal injury that could result in scarring. Automated scanners aim to reduce the chance of overlapping treatment areas
Lasers have been used successfully to treat a variety of vascular lesions including superficial vascular malformations (port-wine stains), facial telangiectases, haemangiomas, pyogenic granulomas, Kaposi sarcoma and poikiloderma of Civatte. Lasers that have been used to treat these conditions include argon, APTD, KTP, krypton, copper vapour, copper bromide, pulsed dye lasers and Nd:YAG. Argon (CW) causes a high degree of non-specific thermal injury and scarring and is now largely replaced by yellow-light quasi-CW and pulsed laser therapies.
The pulsed dye laser is considered the laser of choice for most vascular lesions because of its superior clinical efficacy and low risk profile. It has a large spot size (5 to 10mm) allowing large lesions to be treated quickly. Side effects include postoperative bruising (purpura) that may last 1-2 weeks and transient pigmentary changes. Crusting, textural changes and scarring are rarely seen.
The new V-beam features provide ultra-long pulse duration so greater is energy directed at the target blood vessels over a longer period of time, resulting in more uniform blood vessel damage. This reduces the purpura seen with the earlier pulse dye lasers. The addition of dynamic cooling increases comfort during treatment enabling higher fluencies (energy) to be delivered safely and effectively, so fewer treatments are required.
Vascular malformations associated with smaller more superficial blood vessels respond better to treatment than deeper larger vessels (more often arising in older individuals). It is therefore best to begin treatment early. Fading by 80% occurs after 8 to 10 treatments on average. Further treatment may be necessary if the lesion recurs.
Treatment with quasi-CW lasers also produce effective outcomes but they are may be associated with higher incidences of scarring and textural changes. The most common side effects include mild erythema, oedema, and transient crusting.
Non-laser intense pulsed light devices can also be used for treating vascular lesions.
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