By Natasha Mohr
As you know, the arrival of Spring Break is often when patients start to press the “exposed skin” panic button. They want to address the issues that are easier to hide during the bulky sweater, layered up winter months – regrettable tattoos, pesky veins and ancient scars all get more attention.
Whether you’re treating the “dolphin jumping through the hoop of my belly button” tattoo that now looks more like “carp on a plate”, the scar from “that time I tripped over my own feet” or the “old lady veins I inherited from my mother”, we’ve got some tips, tricks and device recommendations that will make a difference in the way you treat your patients!
“Never. Get. Red. I see at least 1 patient a month who is allergic to a tattoo and more than 90% of the time it is to the red part of the tattoo only,” says Dr. Matt Zirwas, in Columbus, OH. If you do see a patient in your practice who is having a reaction, don’t laser the tattoo! “We reported a case in which a patient had a localized allergic reaction to the red dye in her tattoo,” Dr. Zirwas continues. “A physician attempted to remove the red pigment by lasering it with a typical very short pulse laser and she developed a generalized reaction, including reactions to the red dye in her other tattoos.” He suggests that if you want to try something, “either excise the parts they are reacting to or consider using an ablative laser to vaporize the tissue – they’ll be left with scarring on the areas you ablated, but that is better than raised, itchy areas.”
Dr. Joel Schlessinger, in Omaha, NE says, “Typically, tattoos are treated with the stacked method of 4 sessions in succession as detailed in the R20 method with perfluorodecalin spray in between. Generally, this results in approximately 4-5 treatments total (so 16-20 total treatments) and nearly complete clearance in most patients.”
But he also brings up the case that it can be difficult to know which device to purchase. Historically, his older laser was breaking down constantly so he was in the market for a new one. Some trusted colleagues recommended he go with a Fotona device as they are rock-solid dependable, so he has recently purchased a Fotona QX MAX Q-Switched Alexandrite Laser for his practice. He adds, “We can’t wait to see how it performs!”
In Houston, TX, Suneel Chilukuri, MD, is well-known for finding multiple uses for his in-office devices. He shares that for treating tattoos, his “long-standing workhorse” is the Cynosure RevLite. He finds “it is incredibly versatile and also helps resolve melasma and hyperpigmentation. In addition, it can be used for laser tightening with no downtime, even on the day of a special event.”
In the land between tattoos and scars, Michael Gold, MD, in Nashville, TN, is creating a new protocol that is helpful in both arenas. “I use the PicoWay by Syneron-Candela and what we do is not only treat tattoos, but treat pigment. We actually fractionate the pico which allows us to rejuvenate the skin and treat scars. So this one device allows me to treat things so much faster. If I used to treat a tattoo in 10 sessions, now it takes 3 or 4. If I was using an ablative or non-ablative laser which took 3 to 4 treatments, I can do that in 2 or even 1 treatment. Patients love this!”
Joe Niamtu, MD of Richmond, VA, still goes what he calls ‘old school.’ “I still use fully ablative, full coverage CO2. This has to be done in a controlled manner to prevent hypopigmentation. Although many docs advocate fractional treatments for scar improvement, it has been less effective in my hands compared to full coverage, fully ablative treatment.”
Dr. Niamtu is specific about the equipment he uses for burn scars on light or pigmented skin. “I use deep fractional (Lumenis (DEEP) ResurFX or SCAAR FX) on extremely hyperplastic scars. This type of treatment requires many more treatment sessions compared with traditional CO2.”
By way of additional treatment, Dr. Niamtu says, “For hypertrophic scars I also perform intralesional monthly injections of Kenalog or 5FU. For hypoplastic scares I employ subcision permanent fillers, such as silicone oil.”
When it comes to scars, Dr. Chilukuri shares that “our workhorse for scars and facial veins is also our most utilized device, the ICON platform. For scars, I typically start with the Frax 1540 (which has no consumable).” But going deeper than that, what they are doing that has made the biggest impact across his practice, is combination therapy. “Combination Therapy has made a significant impact in our practice. By understanding the pathophysiology of the medical condition being treated, we can combine multiple treatments in one session for synergistic effects. For example, I often combine non-ablative Frax 1540 with Sculptra and microneedling (the Eclipse Micropen at a depth of 2.5 to 1.5 in multiple passes) for significant improvement of acne scars.”
Additionally, he adds that “new technology that has been useful in scars treatment is the radiofrequency microneedling system. I have both the Infini and Fractora and can safely use these for scars all skin types.”
Dr. Schlessinger is also experimenting with new treatments in his practice. “We are experimenting with some additions to our scar repertoire based on information learned at CSF! Drs. Gold, Taub and Taylor were incredible on the podium in sharing their treatments and ideas for scar improvement and I can already see many wins where I would have had ‘meh’ results before with keloids!”
“While we still use kenalog 10-20 mg injections for most, we also use Aldara treatments and IPL to augment the sessions with excellent results,” he adds.
Dr. Schlessinger says, “What’s old is new. We still use sclerotherapy predominantly for the treatment of spider veins, even though most patients expect that the laser is more powerful.”
“When we do sclerotherapy we recommend that individuals wear support hose for 72 hours after the procedure, but until we actually had panty hose that were available to purchase at the clinic we didn’t see great patient compliance,” he explains.
So, he and his team recently began making hose available in the practice. “We brought in Sigvaris compression stockings and sell them for $40. Now that we have them available in our office, our results are much better and patients find our costs are significantly better than when they went to pharmacies for the hose.”
The workhorse Chilukuri recommended for tattoos (Cynosure RevLite), he says, is also great for leg veins. Though, like Schlessinger, he typically does recommend sclerotherapy as the primary treatment.
For facial veins, however, he revisits the aforementioned ICON. “I use the Max G handpiece on the same ICON base to clear 99% of vessels on the face. It is highly versatile due to the ability to change pulse duration and energy, thereby allowing us to treat deep or superficial vessels of diameters up to 2 mm.”
Because Dr. Chilukuri is known for using equipment in new and creative ways, we asked if there was anything that has been surprising in its versatility. It came as no surprise that he had an answer at the ready. “Actually,” said Chilukuri, “I have been surprised by the multiple uses of these RF microneedling devices. I use them for skin tightening, scars and even axillary hyperhidrosis. I will be publishing our results on the successful treatment of axillary hyperhidrosis with RF microneedling in the next few months.”
Well, Dr. Chilukuri, we look forward to hearing about the results in future blogs and at CSF 2017!