Fractional resurfacing: Lower density = fewer side effects

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.