As physicians, you are well aware that patients are consistently seeking diverse treatment options for conditions such as melasma, acne, skin tightening and body contouring. Historically, laser devices have been good tools for physicians to use when treating such concerns. It turns out they are in fact helpful, but in some cases, not in the ways you might expect. Drs. Manjula Jegasothy, Barry Lycka, Neil Sadick and Jill Waibel are back to expand upon their 2019 CSF presentations, offering their expert insight into new technologies and how known technologies can be used in unexpected ways.
Acne is in a constant battle for the title as the number one condition patients seek to improve. Dr. Jill Waibel of Miami, Florida says that more and more, patients sidestep antibiotics or Isotretinoin and instead, want to try a non-pill option for treatment. This, inevitably, includes lasers. Serving as an investigator in multiple trials, Dr. Waibel says there has been significant advancement in treating acne with laser technology.
One new option, named Sebacia, uses selective photothermolysis for the treatment of inflammatory acne by targeting select sebaceous glands with gold nanoparticles. These particles are massaged into the skin for ten minutes and then activated with a Diode 755 Alexandrite or 1064 Nanometer Laser. Already FDA-approved, this treatment protocol includes 2-3 treatments one week apart and the results have been promising. After 3 treatments, Dr. Waibel saw a 63% reduction in inflammatory acne after 2 months and an 85% reduction after 12 months.
In addition, a 1720 Nanometer Laser has been co-invented by Dr. Rox Anderson and Dr. Fernanda Sakamoto, which also targets and destroys specific sebaceous glands, with Emil Tanghetti performing initial clinical work. It’s pending FDA approval but the company offering the device has been named Accure, (as in, a “cure” for acne”) and Christopher Carlton is serving as CEO. Dr. Waibel, who served as an investigator offers these findings, “Natural sebum had absorption peaks near 1,210 nm, 1,728 nm, 1,760 nm, 2,306 nm and 2,346 nm. The laser-induced heating of the sebum was found to be approximately twice that of water at 1,710 nm and 1,720 nm, and approximately one and a half times higher in human sebaceous glands compared to water.”
Developments have also been made in using lasers as fat reduction treatments. The new, precision-controlled, motorized articulated 1064 nm laser delivery arm has been upgraded with advanced jet impingement cooling technology that allows heat to not only remain consistent throughout treatment without discomfort for the patient, but also can potentially be safely increased for more fat reduction in a shorter period of time. The original technology was FDA approved in June of 2019 and one year after the study, Dr. Waibel says that the treatment is still evolving; “(In the last year), there has been an increased energy input to improve (the laser’s) efficacy. In the future, a second laser could be added for epidermal/dermal rejuvenation.”
Physicians know that lasers have incredible uses and offer many anti-aging benefits. However, what are emerging now are devices and techniques which nod to known techniques, but advance them to the next level.
Inspired by both fractional ablative lasers and punch biopsy technology, Dermal Micro Coring removes and suctions tiny micro cores (400 micrometers) of skin, allowing skin to naturally tighten and contract in response. This treatment aims to minimize wrinkles and skin laxity on the face and near the jawline. Dermal Micro Coring results in virtually no scarring and requires minimal to no downtime, making it an attractive treatment to patients who want immediate results. Serving as an investigator for this yet unnamed device, Dr. Waibel adds that as of October 2020, “The final data is in and Cytrellis, the company offering the device, has sent everything to the FDA.”
By way of advancements in known laser technologies, Dr. Barry Lycka of Alberta, Canada says the non-ablative Erbium/YAG laser is also an option for patients who want to tighten the face without using fillers. Since his 2019 CSF presentation, Dr. Lycka expands on that topic and adds, “I believe both ablative and non-ablative work well for skin tightening, as does microneedling and unipolar and bipolar heat sources.”
Additionally, Dr. Lycka notes that in many cases, a combination of lasers is the best option, for example he says, “For rosacea, I find a combination of Pulsed Dye Laser and Excel V Laser can help. For acne scarring (not active acne), a combination of Fraxel and Ultrapulse CO2 lasers are effective. In the case of melasma, I like to use a combination of Fotona and Fraxel lasers.” Dr. Lycka also adds that known technologies can also create more possibilities. He adds, “Picosecond lasers are ideal for more than just tattoo removal. They provide phenomenal results for conditions like acne and acne scarring. In fractional mode, they target melanocytes, making the picosecond effective at targeting pigmentation.”
Dr. Manjula Jegasothy of Coral Gables, Florida finds that by using the lasers she does have in her office in new ways, she is able to achieve improved and unexpected patient outcomes. She says “For patients who have failed radio frequency treatments, I find that trying Ultherapy in place of Kybella just above the trachea tightens and improves the superficial loose skin. However, radio frequency tends to work better than Kybella on the knees, thighs and lower abdomen.” Additionally, she adds that Ultherapy has been helpful in lifting and tightening the buttocks.
Dr. Jegasothy adds that physicians shouldn’t be afraid to try different things for patients who are budget-conscious. Radio frequency can be a good substitute for those who can’t afford specific treatments. For example, she finds that using her BTL Vanquish for back fat instead of on the stomach often yields optimal results for patients in a specific BMI range.
Melasma and Inflammatory Sun Damage
Discoloration in the skin is notoriously difficult to treat and particularly for those who have medium to dark skin tones. One hindrance can be misdiagnoses of melasma, when in fact; the diagnosis is inflammatory sun damage. It is important to note that there are differences in protocols for these two diagnoses. Dr. Jegasothy says, “Inflammatory photo damage is easier to treat long-term with superficial treatments such as fractionated laser or peels, whereas melasma often recurs as early as a month after treatment.”
Dr. Waibel agrees and says it’s important to educate patients on melasma and what kind of expectations they should have. It’s a chronic disease that needs to have ongoing treatment and patients shouldn’t expect a “cure.”
Dr. Jegasothy reminds us that like most other skin conditions, patients are looking for results on discoloration treatments, with minimal downtime. To treat conditions like inflammatory sun damage, she is no longer turning to her Nd:YAG laser and is instead, using a Fraxel laser in combination with directing patients to use a bleaching cream like Cysteamine for 24 hours after treatment. She says, “This yields phenomenal results that really persist.”
Dr. Neil Sadick of New York, New York has found that non-thermal disruption of melanocytes is ideal when treating inflammatory pigmentation. He posits, “This may be a controversial point, but I don’t think heat plays a role in treating inflammatory pigmentation, because the heat can lead to rebound dyschromia and hyperpigmentation. I have found that the PICO Genesis laser works well in my practice.” Dr. Sadick says he gets the best results in treating inflammatory pigmentation by, “Combining the non-thermal lasers in conjunction with 8% hydroquinone compounds, alternating with alpha hydroxy acids.”
Dr. Jegaosothy concurs and says, “I was getting a lot of rebound with higher settings on the laser and noticed once I dialed back the settings, the rebound minimized.”
Dr. Lycka takes a different point of view and adds, “I think fractional resurfacing is still helpful in treating discoloration for two reasons – first, it allows the hydroquinone to go deeper into skin and second, it deposits collagen which pushes the melanocytes further down, making them less noticeable.” Dr. Waibel concurs and explains that she likes heat in treating melasma. She typically starts with low dose IPL and the 1927 laser, plus an oral tranexamic acid prescription.
As for the future of laser technology, all of our experts agree that multiple tools make for the greatest patients outcome. Dr. Lycka further posits that to be successful, dermatologists need not only multiple tools, but to have access to those tools at a cost effective price. Looking ahead he speculates that this will likely be possible through 3D printers. Dr. Lycka says, “3D printing technology is the future of lasers. They are already re-creating lasers with 3D printing, which will allow more physicians entry. The way it is now isn’t the way it will always be!”
Physicians and patients are keeping an eye toward the future for more advanced laser treatments and techniques. Do you have a unique laser technique that you are finding helpful in your practice? Please share with a comment below!