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Picosecond lasers emerging as a go-to for tattoo removal
SAN DIEGO – When counseling patients about laser tattoo removal, resist the temptation to promise clearance in a certain number of treatments.
“You will regret it,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “If you say, ‘This looks like this is going to take 6-8 treatments, this looks very simple to me,’ you’ll find that you’ll have someone who requires 15-18 treatments. Further, partial clearing may be cosmetically inferior than nontreatment.”
“These target the microscopic tattoo particles located inside dermal phagocytic cells and scattered extracellularly throughout the dermis,” Dr. Avram explained. The Q-switched laser heats particles to more than 1,000º C within nanoseconds, or billionths of a second. “It produces extreme heat, cavitation, and cell rupture,” he said. “The clinical endpoint is immediate epidermal whitening of tattooed skin.” The process causes transdermal elimination; some of it flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.
Picosecond lasers are even faster than their Q-switched counterparts, delivering high energies in trillionths of a second. “A picosecond is to a second as 1 second is to 37,000 years,” Dr. Avram said. Commercially available picosecond (ps) lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 ps. The Nd:YAG lasers work best for red and black ink, while Alexandrite lasers work best for green and blue ink.
In Dr. Avram’s experience, ps lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There’s some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos,” he said. “Combining nanosecond and picosecond devices provides enhanced results, but picosecond lasers are more expensive.”
The clinical endpoint for ps lasers is the same as for nanosecond lasers: epidermal whitening. He said he schedules about 8 weeks between treatments. “If you don’t inform patients of the expectations, they’re going to be very disappointed with you,” Dr. Avram said. “You need to tell them that it’s going to take a lot of treatments and that it may not clear completely. You may be working with them for a year or 2.”
The checklist prior to the first treatment with any laser involves assessing the type of tattoo (amateur or professional), the color of the tattoo, patient skin type, and the duration of the tattoo. “You also want to palpate for an existing scar,” he said. “A lot of times, patients don’t recognize they have a scar on the treatment site. You don’t want to own a complication that has nothing to do with your treatments. Photographing the scar is also important.”
Hyperpigmentation or hypopigmentation is a greater concern in darker skin types or tanned individuals, compared with fairer-skinned patients. “The 1,064-nm Q-switched Nd:YAG laser is the least likely to affect skin pigment,” said Dr. Avram, who is codirector of the Massachusetts General Hospital/Wellman Laser and Cosmetic Fellowship. “It’s safest for Fitzpatrick skin types IV-VI but it’s not very effective for green, blue, and red tattoo ink colors. Some degree of dyspigmentation occurs in most patients regardless of skin type. Much of this is temporary and improves with time, but it may take months to years.”
Professional tattoos are the most difficult to treat because they often feature dense and deeply placed tattoo ink and require 6-20 or more treatments to improve, he said. On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos improve more rapidly and generally require fewer treatment to yield improvement.
“Color is key,” Dr. Avram said. “If you have different colors in one tattoo, it is going to be more difficult to clear.” Black and dark-blue tattoos respond best to laser, while light blue and green also respond well. Red responds well, but purple can be challenging. “Yellow and orange do not respond well, but they respond partially,” he said.
Researchers who conducted a large cohort trial of variables influencing the outcome of tattoos treated by Q-switched lasers found that 47% of tattoos were cleared after 10 treatment sessions, while 75% were cleared after 15 sessions (Arch Dermatol. 2012;148[12]:1364-9). Predictors of poor response included smoking, the presence of colors other than black and red, tattoo size larger than 30 cm2, location on the feet or legs, duration greater than 36 months, high color density, and treatment intervals of 8 weeks or less.
Dr. Avram cautioned against taking a “cookbook” approach to treating tattoos and underscored the importance of decreasing the fluence if tissue “splatter” occurs, as this may produce scarring. “The treating clinician should follow the treatment endpoint, not the laser fluences,” he said. “Do not use IPL [intense pulsed light therapy] for tattoos; that’s inappropriate and you may end up scarring your patient.”
Common adverse effects include erythema, blistering, hyper- and hypopigmentation, and scarring. Less common adverse effects include an allergic reaction, darkening of the cosmetic tattoo, an immune reaction, and chrysiasis, a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold-salt ingestion. “Any history of gold ingestion will produce this finding, even if they ingested 40 years ago,” he said. “This is very difficult to correct.”
The optimal interval between treatments continues to be explored. For example, the R20 method consists of four treatments separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol. 2012;66[2]:271-7). A companion technology that is playing a role in such repeat treatments is a Food and Drug Administration–approved transparent silicone patch infused with perfluorodecalin that helps reduce scattering and improves efficacy.
“It also allows for performing consecutive repeat laser treatments at the same visit,” Dr. Avram said. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side that was treated without the patch (Laser Surg Med. 2015;47[8]:613-8).
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.
[email protected]
SAN DIEGO – When counseling patients about laser tattoo removal, resist the temptation to promise clearance in a certain number of treatments.
“You will regret it,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “If you say, ‘This looks like this is going to take 6-8 treatments, this looks very simple to me,’ you’ll find that you’ll have someone who requires 15-18 treatments. Further, partial clearing may be cosmetically inferior than nontreatment.”
“These target the microscopic tattoo particles located inside dermal phagocytic cells and scattered extracellularly throughout the dermis,” Dr. Avram explained. The Q-switched laser heats particles to more than 1,000º C within nanoseconds, or billionths of a second. “It produces extreme heat, cavitation, and cell rupture,” he said. “The clinical endpoint is immediate epidermal whitening of tattooed skin.” The process causes transdermal elimination; some of it flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.
Picosecond lasers are even faster than their Q-switched counterparts, delivering high energies in trillionths of a second. “A picosecond is to a second as 1 second is to 37,000 years,” Dr. Avram said. Commercially available picosecond (ps) lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 ps. The Nd:YAG lasers work best for red and black ink, while Alexandrite lasers work best for green and blue ink.
In Dr. Avram’s experience, ps lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There’s some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos,” he said. “Combining nanosecond and picosecond devices provides enhanced results, but picosecond lasers are more expensive.”
The clinical endpoint for ps lasers is the same as for nanosecond lasers: epidermal whitening. He said he schedules about 8 weeks between treatments. “If you don’t inform patients of the expectations, they’re going to be very disappointed with you,” Dr. Avram said. “You need to tell them that it’s going to take a lot of treatments and that it may not clear completely. You may be working with them for a year or 2.”
The checklist prior to the first treatment with any laser involves assessing the type of tattoo (amateur or professional), the color of the tattoo, patient skin type, and the duration of the tattoo. “You also want to palpate for an existing scar,” he said. “A lot of times, patients don’t recognize they have a scar on the treatment site. You don’t want to own a complication that has nothing to do with your treatments. Photographing the scar is also important.”
Hyperpigmentation or hypopigmentation is a greater concern in darker skin types or tanned individuals, compared with fairer-skinned patients. “The 1,064-nm Q-switched Nd:YAG laser is the least likely to affect skin pigment,” said Dr. Avram, who is codirector of the Massachusetts General Hospital/Wellman Laser and Cosmetic Fellowship. “It’s safest for Fitzpatrick skin types IV-VI but it’s not very effective for green, blue, and red tattoo ink colors. Some degree of dyspigmentation occurs in most patients regardless of skin type. Much of this is temporary and improves with time, but it may take months to years.”
Professional tattoos are the most difficult to treat because they often feature dense and deeply placed tattoo ink and require 6-20 or more treatments to improve, he said. On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos improve more rapidly and generally require fewer treatment to yield improvement.
“Color is key,” Dr. Avram said. “If you have different colors in one tattoo, it is going to be more difficult to clear.” Black and dark-blue tattoos respond best to laser, while light blue and green also respond well. Red responds well, but purple can be challenging. “Yellow and orange do not respond well, but they respond partially,” he said.
Researchers who conducted a large cohort trial of variables influencing the outcome of tattoos treated by Q-switched lasers found that 47% of tattoos were cleared after 10 treatment sessions, while 75% were cleared after 15 sessions (Arch Dermatol. 2012;148[12]:1364-9). Predictors of poor response included smoking, the presence of colors other than black and red, tattoo size larger than 30 cm2, location on the feet or legs, duration greater than 36 months, high color density, and treatment intervals of 8 weeks or less.
Dr. Avram cautioned against taking a “cookbook” approach to treating tattoos and underscored the importance of decreasing the fluence if tissue “splatter” occurs, as this may produce scarring. “The treating clinician should follow the treatment endpoint, not the laser fluences,” he said. “Do not use IPL [intense pulsed light therapy] for tattoos; that’s inappropriate and you may end up scarring your patient.”
Common adverse effects include erythema, blistering, hyper- and hypopigmentation, and scarring. Less common adverse effects include an allergic reaction, darkening of the cosmetic tattoo, an immune reaction, and chrysiasis, a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold-salt ingestion. “Any history of gold ingestion will produce this finding, even if they ingested 40 years ago,” he said. “This is very difficult to correct.”
The optimal interval between treatments continues to be explored. For example, the R20 method consists of four treatments separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol. 2012;66[2]:271-7). A companion technology that is playing a role in such repeat treatments is a Food and Drug Administration–approved transparent silicone patch infused with perfluorodecalin that helps reduce scattering and improves efficacy.
“It also allows for performing consecutive repeat laser treatments at the same visit,” Dr. Avram said. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side that was treated without the patch (Laser Surg Med. 2015;47[8]:613-8).
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.
[email protected]
SAN DIEGO – When counseling patients about laser tattoo removal, resist the temptation to promise clearance in a certain number of treatments.
“You will regret it,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “If you say, ‘This looks like this is going to take 6-8 treatments, this looks very simple to me,’ you’ll find that you’ll have someone who requires 15-18 treatments. Further, partial clearing may be cosmetically inferior than nontreatment.”
“These target the microscopic tattoo particles located inside dermal phagocytic cells and scattered extracellularly throughout the dermis,” Dr. Avram explained. The Q-switched laser heats particles to more than 1,000º C within nanoseconds, or billionths of a second. “It produces extreme heat, cavitation, and cell rupture,” he said. “The clinical endpoint is immediate epidermal whitening of tattooed skin.” The process causes transdermal elimination; some of it flows into the lymphatic system, while the rest undergoes rephagocytosis by dermal scavenger cells.
Picosecond lasers are even faster than their Q-switched counterparts, delivering high energies in trillionths of a second. “A picosecond is to a second as 1 second is to 37,000 years,” Dr. Avram said. Commercially available picosecond (ps) lasers include devices with wavelengths of 532 nm, 755 nm, and 1,064 nm that deliver energy in a range of 300-750 ps. The Nd:YAG lasers work best for red and black ink, while Alexandrite lasers work best for green and blue ink.
In Dr. Avram’s experience, ps lasers are generally more effective for tattoo removal, compared with nanosecond lasers. “There’s some nonselective targeting of other pigments, and they’re particularly effective for faded tattoos,” he said. “Combining nanosecond and picosecond devices provides enhanced results, but picosecond lasers are more expensive.”
The clinical endpoint for ps lasers is the same as for nanosecond lasers: epidermal whitening. He said he schedules about 8 weeks between treatments. “If you don’t inform patients of the expectations, they’re going to be very disappointed with you,” Dr. Avram said. “You need to tell them that it’s going to take a lot of treatments and that it may not clear completely. You may be working with them for a year or 2.”
The checklist prior to the first treatment with any laser involves assessing the type of tattoo (amateur or professional), the color of the tattoo, patient skin type, and the duration of the tattoo. “You also want to palpate for an existing scar,” he said. “A lot of times, patients don’t recognize they have a scar on the treatment site. You don’t want to own a complication that has nothing to do with your treatments. Photographing the scar is also important.”
Hyperpigmentation or hypopigmentation is a greater concern in darker skin types or tanned individuals, compared with fairer-skinned patients. “The 1,064-nm Q-switched Nd:YAG laser is the least likely to affect skin pigment,” said Dr. Avram, who is codirector of the Massachusetts General Hospital/Wellman Laser and Cosmetic Fellowship. “It’s safest for Fitzpatrick skin types IV-VI but it’s not very effective for green, blue, and red tattoo ink colors. Some degree of dyspigmentation occurs in most patients regardless of skin type. Much of this is temporary and improves with time, but it may take months to years.”
Professional tattoos are the most difficult to treat because they often feature dense and deeply placed tattoo ink and require 6-20 or more treatments to improve, he said. On the other hand, amateur tattoos, traumatic tattoos, and radiation tattoos improve more rapidly and generally require fewer treatment to yield improvement.
“Color is key,” Dr. Avram said. “If you have different colors in one tattoo, it is going to be more difficult to clear.” Black and dark-blue tattoos respond best to laser, while light blue and green also respond well. Red responds well, but purple can be challenging. “Yellow and orange do not respond well, but they respond partially,” he said.
Researchers who conducted a large cohort trial of variables influencing the outcome of tattoos treated by Q-switched lasers found that 47% of tattoos were cleared after 10 treatment sessions, while 75% were cleared after 15 sessions (Arch Dermatol. 2012;148[12]:1364-9). Predictors of poor response included smoking, the presence of colors other than black and red, tattoo size larger than 30 cm2, location on the feet or legs, duration greater than 36 months, high color density, and treatment intervals of 8 weeks or less.
Dr. Avram cautioned against taking a “cookbook” approach to treating tattoos and underscored the importance of decreasing the fluence if tissue “splatter” occurs, as this may produce scarring. “The treating clinician should follow the treatment endpoint, not the laser fluences,” he said. “Do not use IPL [intense pulsed light therapy] for tattoos; that’s inappropriate and you may end up scarring your patient.”
Common adverse effects include erythema, blistering, hyper- and hypopigmentation, and scarring. Less common adverse effects include an allergic reaction, darkening of the cosmetic tattoo, an immune reaction, and chrysiasis, a dark-blue pigmentation caused by Q-switched laser treatment in patients with a history of gold-salt ingestion. “Any history of gold ingestion will produce this finding, even if they ingested 40 years ago,” he said. “This is very difficult to correct.”
The optimal interval between treatments continues to be explored. For example, the R20 method consists of four treatments separated by 20 minutes. The initial study found that this approach led to better outcomes, compared with conventional, single-pass laser treatment (J Am Acad Dermatol. 2012;66[2]:271-7). A companion technology that is playing a role in such repeat treatments is a Food and Drug Administration–approved transparent silicone patch infused with perfluorodecalin that helps reduce scattering and improves efficacy.
“It also allows for performing consecutive repeat laser treatments at the same visit,” Dr. Avram said. In one study, 11 of 17 patients had more rapid clearance on the side treated with the perfluorodecalin patch, compared with the side that was treated without the patch (Laser Surg Med. 2015;47[8]:613-8).
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.
[email protected]
AT MOAS 2017
Platelet-rich plasma treatment for hair loss continues to be refined
SAN DIEGO – There is currently no standard protocol for injecting autologous platelet-rich plasma to stimulate hair growth, but the technique appears to be about 50% effective, according to Marc R. Avram, MD.
“I tell patients that this is not FDA [Food and Drug Administration] approved, but we think it to be safe,” said Dr. Avram, clinical professor of dermatology at the Cornell University, New York, said at the annual Masters of Aesthetics Symposium. “We don’t know how well it’s going to work. There are a lot of published data on it, but none of [them are] randomized or controlled long-term.”
In Dr. Avram’s experience, he has found that PRP is a good option for patients with difficult hair loss, such as those who had extensive hair loss after chemotherapy but the hair never grew back in the same fashion, or patients who have failed treatment with finasteride and minoxidil.
Currently, there is no standard protocol for using PRP to stimulate hair growth, but the approach Dr. Avram follows is modeled on his experience of injecting thousands of patients with triamcinolone acetonide (Kenalog) for hair loss every 4-6 weeks. After drawing 20 ccs-30 ccs of blood from the patient, the vial is placed in a centrifuge for 10 minutes, a process that separates PRP from red blood cells. Next, the clinician injects PRP into the deep dermis/superficial subcutaneous tissue of the desired treatment area. An average of 4 ccs-8 ccs is injected during each session.
After three monthly treatments, patients follow up at 3 and 6 months after the last treatment to evaluate efficacy. “All patients are told if there is regrowth or thickening of terminal hair, maintenance treatments will be needed every 6-9 months,” he said.
Published clinical trials of PRP include a follow-up period of 3-12 months and most demonstrate an efficacy in the range of 50%-70%. “It seems to be more effective for earlier stages of hair loss, and there are no known side effects to date,” said Dr. Avram, who has authored five textbooks on hair and cosmetic dermatology. “I had one patient call up to say he thought he had an increase in hair loss 2-3 weeks after treatment, but that’s one patient in a couple hundred. This may be similar to the effect minoxidil has on some patients. I’ve had no other issues with side effects.”
In his opinion, future challenges in the use of PRP for restoring hair loss include better defining optimal candidates for the procedure and establishing a better treatment protocol. “How often should maintenance be done?” he asked. “Is this going to be helpful for alopecia areata and scarring alopecia? Also, we need to determine if finasteride, minoxidil, low-level light laser therapy, or any other medications can enhance PRP efficacy in combination. What’s the optimal combination for patients? We don’t know yet. But I think in the future we will.”
Dr. Avram disclosed that he is a consultant for Restoration Robotics.
SAN DIEGO – There is currently no standard protocol for injecting autologous platelet-rich plasma to stimulate hair growth, but the technique appears to be about 50% effective, according to Marc R. Avram, MD.
“I tell patients that this is not FDA [Food and Drug Administration] approved, but we think it to be safe,” said Dr. Avram, clinical professor of dermatology at the Cornell University, New York, said at the annual Masters of Aesthetics Symposium. “We don’t know how well it’s going to work. There are a lot of published data on it, but none of [them are] randomized or controlled long-term.”
In Dr. Avram’s experience, he has found that PRP is a good option for patients with difficult hair loss, such as those who had extensive hair loss after chemotherapy but the hair never grew back in the same fashion, or patients who have failed treatment with finasteride and minoxidil.
Currently, there is no standard protocol for using PRP to stimulate hair growth, but the approach Dr. Avram follows is modeled on his experience of injecting thousands of patients with triamcinolone acetonide (Kenalog) for hair loss every 4-6 weeks. After drawing 20 ccs-30 ccs of blood from the patient, the vial is placed in a centrifuge for 10 minutes, a process that separates PRP from red blood cells. Next, the clinician injects PRP into the deep dermis/superficial subcutaneous tissue of the desired treatment area. An average of 4 ccs-8 ccs is injected during each session.
After three monthly treatments, patients follow up at 3 and 6 months after the last treatment to evaluate efficacy. “All patients are told if there is regrowth or thickening of terminal hair, maintenance treatments will be needed every 6-9 months,” he said.
Published clinical trials of PRP include a follow-up period of 3-12 months and most demonstrate an efficacy in the range of 50%-70%. “It seems to be more effective for earlier stages of hair loss, and there are no known side effects to date,” said Dr. Avram, who has authored five textbooks on hair and cosmetic dermatology. “I had one patient call up to say he thought he had an increase in hair loss 2-3 weeks after treatment, but that’s one patient in a couple hundred. This may be similar to the effect minoxidil has on some patients. I’ve had no other issues with side effects.”
In his opinion, future challenges in the use of PRP for restoring hair loss include better defining optimal candidates for the procedure and establishing a better treatment protocol. “How often should maintenance be done?” he asked. “Is this going to be helpful for alopecia areata and scarring alopecia? Also, we need to determine if finasteride, minoxidil, low-level light laser therapy, or any other medications can enhance PRP efficacy in combination. What’s the optimal combination for patients? We don’t know yet. But I think in the future we will.”
Dr. Avram disclosed that he is a consultant for Restoration Robotics.
SAN DIEGO – There is currently no standard protocol for injecting autologous platelet-rich plasma to stimulate hair growth, but the technique appears to be about 50% effective, according to Marc R. Avram, MD.
“I tell patients that this is not FDA [Food and Drug Administration] approved, but we think it to be safe,” said Dr. Avram, clinical professor of dermatology at the Cornell University, New York, said at the annual Masters of Aesthetics Symposium. “We don’t know how well it’s going to work. There are a lot of published data on it, but none of [them are] randomized or controlled long-term.”
In Dr. Avram’s experience, he has found that PRP is a good option for patients with difficult hair loss, such as those who had extensive hair loss after chemotherapy but the hair never grew back in the same fashion, or patients who have failed treatment with finasteride and minoxidil.
Currently, there is no standard protocol for using PRP to stimulate hair growth, but the approach Dr. Avram follows is modeled on his experience of injecting thousands of patients with triamcinolone acetonide (Kenalog) for hair loss every 4-6 weeks. After drawing 20 ccs-30 ccs of blood from the patient, the vial is placed in a centrifuge for 10 minutes, a process that separates PRP from red blood cells. Next, the clinician injects PRP into the deep dermis/superficial subcutaneous tissue of the desired treatment area. An average of 4 ccs-8 ccs is injected during each session.
After three monthly treatments, patients follow up at 3 and 6 months after the last treatment to evaluate efficacy. “All patients are told if there is regrowth or thickening of terminal hair, maintenance treatments will be needed every 6-9 months,” he said.
Published clinical trials of PRP include a follow-up period of 3-12 months and most demonstrate an efficacy in the range of 50%-70%. “It seems to be more effective for earlier stages of hair loss, and there are no known side effects to date,” said Dr. Avram, who has authored five textbooks on hair and cosmetic dermatology. “I had one patient call up to say he thought he had an increase in hair loss 2-3 weeks after treatment, but that’s one patient in a couple hundred. This may be similar to the effect minoxidil has on some patients. I’ve had no other issues with side effects.”
In his opinion, future challenges in the use of PRP for restoring hair loss include better defining optimal candidates for the procedure and establishing a better treatment protocol. “How often should maintenance be done?” he asked. “Is this going to be helpful for alopecia areata and scarring alopecia? Also, we need to determine if finasteride, minoxidil, low-level light laser therapy, or any other medications can enhance PRP efficacy in combination. What’s the optimal combination for patients? We don’t know yet. But I think in the future we will.”
Dr. Avram disclosed that he is a consultant for Restoration Robotics.
AT MOAS 2017
Radiofrequency devices appear to reduce vaginal laxity
SAN DIEGO – The first randomized, sham-controlled study of a radiofrequency energy-based device for vaginal laxity showed a significant and sustained effect, and likely raises the bar on vaginal rejuvenation options, Suzanne L. Kilmer, MD, said during a presentation at the annual Masters of Aesthetics Symposium.
“There are a lot of women who have vaginal laxity, vaginal atrophy, and other issues, and this is something that seems to help,” she said. No devices have yet received female rejuvenation/vaginal function indications from the Food and Drug Administration.
Current in-office procedures involve the delivery of radiofrequency (RF) energy, which appears to stimulate collagen production, and the use of fractionated lasers to target the epithelium. “RF devices tend to be easier to use,” said Dr. Kilmer, director of the Laser and Skin Surgery of Northern California, Sacramento. “They’re smaller devices, do not require as much laser training, and they tend to be less expensive. There’s no plume or odor with any of the RF devices.”
She discussed the results of the Viveve Treatment of the Vaginal Introitus to Evaluate Effectiveness (Viveve I) study, conducted at nine sites in four countries, which examined the Viveve monopolar RF device in 155 premenopausal women. The study subjects were randomized to one of two groups: the treatment group received 90 J/cm2 for five passes and the sham group received 1 J/cm2 for five passes (J Sex Med 2017;14[2]:215-25).
The researchers used the Vaginal Laxity Questionnaire (VSQ), which grades vaginal tone on a 7-point scale that ranges from very loose (0) to very tight (7), and the Female Sexual Function Index (FSFI) to collect patient-reported outcomes at one, three, and six months. Subjects had to have a VSQ score of 3 or less to participate in the study.
At 6 months, patients in the treatment group were more than 3 times as likely to have no vaginal laxity, compared with their counterparts in the sham group (P less than or equal to 0.006). In addition, more than half of patients in the treatment group moved at least 2 points on the VSQ scale toward a “tighter” vagina.
“Even a one-point increase in tightness will be significant for women,” said Dr. Kilmer, who has used the Viveve device in her practice but was not part of this study.
Based on responses to the FSFI questionnaire, the researchers observed a significant and sustained improvement in sexual function after a single treatment among patients in the treatment group, compared with those in the sham group. The placebo effect didn’t rise above “dysfunctional” at six months, and rate of treatment emergent adverse events was similar between the treatment and sham groups (11.1% vs. 12.3%, respectively), she said.
The researchers also reported the following patient tolerability variables: warmth during the procedure (96% in the treatment group vs. 19% in the sham group, respectively); cool sensation during the procedure (42% vs. 75%), and stopped procedure due to discomfort (1% in each group).
Dr. Kilmer explained that RF heating of the skin and mucosa provides immediate contraction of collagen, long-term stimulation of new collagen production, as well as increased blood flow and restoration of nerve signaling, which results in normal vaginal lubrication. “The critical RF temperature is in the 35 to 47 degree range,” she said. “Very few people can tolerate above 42 degrees.”
Similarly, good results were noted in a pilot study of the ThermiVa radiofrequency product manufactured by ThermoGen in 23 patients who underwent three treatments one month apart (Int J Laser Aesthet Med. July 2015:16-21). All patients experienced significant change with about a 50% reduction in symptoms.
“Patients are very happy with this treatment,” said Dr. Kilmer, who is also a professor of dermatology at the University of California, Davis Medical Center. “It may not be the absolute home run, but I think it’s very safe ... Most people say it lasts about six months then they’ll start to see some of their symptoms coming back.”
Dr. Kilmer reported that she is a member of the medical advisory board for Allergan, Cytrellis, Lumenis, Merz, Miramar, Sienna Labs, Syneron/Candela, Zarin, Zeltiq, and Zift. She has also received research support from those companies as well as from Cutera, Cynosure, Lutronic, R2 Derm, Solta/Valeant, and Ulthera.
SAN DIEGO – The first randomized, sham-controlled study of a radiofrequency energy-based device for vaginal laxity showed a significant and sustained effect, and likely raises the bar on vaginal rejuvenation options, Suzanne L. Kilmer, MD, said during a presentation at the annual Masters of Aesthetics Symposium.
“There are a lot of women who have vaginal laxity, vaginal atrophy, and other issues, and this is something that seems to help,” she said. No devices have yet received female rejuvenation/vaginal function indications from the Food and Drug Administration.
Current in-office procedures involve the delivery of radiofrequency (RF) energy, which appears to stimulate collagen production, and the use of fractionated lasers to target the epithelium. “RF devices tend to be easier to use,” said Dr. Kilmer, director of the Laser and Skin Surgery of Northern California, Sacramento. “They’re smaller devices, do not require as much laser training, and they tend to be less expensive. There’s no plume or odor with any of the RF devices.”
She discussed the results of the Viveve Treatment of the Vaginal Introitus to Evaluate Effectiveness (Viveve I) study, conducted at nine sites in four countries, which examined the Viveve monopolar RF device in 155 premenopausal women. The study subjects were randomized to one of two groups: the treatment group received 90 J/cm2 for five passes and the sham group received 1 J/cm2 for five passes (J Sex Med 2017;14[2]:215-25).
The researchers used the Vaginal Laxity Questionnaire (VSQ), which grades vaginal tone on a 7-point scale that ranges from very loose (0) to very tight (7), and the Female Sexual Function Index (FSFI) to collect patient-reported outcomes at one, three, and six months. Subjects had to have a VSQ score of 3 or less to participate in the study.
At 6 months, patients in the treatment group were more than 3 times as likely to have no vaginal laxity, compared with their counterparts in the sham group (P less than or equal to 0.006). In addition, more than half of patients in the treatment group moved at least 2 points on the VSQ scale toward a “tighter” vagina.
“Even a one-point increase in tightness will be significant for women,” said Dr. Kilmer, who has used the Viveve device in her practice but was not part of this study.
Based on responses to the FSFI questionnaire, the researchers observed a significant and sustained improvement in sexual function after a single treatment among patients in the treatment group, compared with those in the sham group. The placebo effect didn’t rise above “dysfunctional” at six months, and rate of treatment emergent adverse events was similar between the treatment and sham groups (11.1% vs. 12.3%, respectively), she said.
The researchers also reported the following patient tolerability variables: warmth during the procedure (96% in the treatment group vs. 19% in the sham group, respectively); cool sensation during the procedure (42% vs. 75%), and stopped procedure due to discomfort (1% in each group).
Dr. Kilmer explained that RF heating of the skin and mucosa provides immediate contraction of collagen, long-term stimulation of new collagen production, as well as increased blood flow and restoration of nerve signaling, which results in normal vaginal lubrication. “The critical RF temperature is in the 35 to 47 degree range,” she said. “Very few people can tolerate above 42 degrees.”
Similarly, good results were noted in a pilot study of the ThermiVa radiofrequency product manufactured by ThermoGen in 23 patients who underwent three treatments one month apart (Int J Laser Aesthet Med. July 2015:16-21). All patients experienced significant change with about a 50% reduction in symptoms.
“Patients are very happy with this treatment,” said Dr. Kilmer, who is also a professor of dermatology at the University of California, Davis Medical Center. “It may not be the absolute home run, but I think it’s very safe ... Most people say it lasts about six months then they’ll start to see some of their symptoms coming back.”
Dr. Kilmer reported that she is a member of the medical advisory board for Allergan, Cytrellis, Lumenis, Merz, Miramar, Sienna Labs, Syneron/Candela, Zarin, Zeltiq, and Zift. She has also received research support from those companies as well as from Cutera, Cynosure, Lutronic, R2 Derm, Solta/Valeant, and Ulthera.
SAN DIEGO – The first randomized, sham-controlled study of a radiofrequency energy-based device for vaginal laxity showed a significant and sustained effect, and likely raises the bar on vaginal rejuvenation options, Suzanne L. Kilmer, MD, said during a presentation at the annual Masters of Aesthetics Symposium.
“There are a lot of women who have vaginal laxity, vaginal atrophy, and other issues, and this is something that seems to help,” she said. No devices have yet received female rejuvenation/vaginal function indications from the Food and Drug Administration.
Current in-office procedures involve the delivery of radiofrequency (RF) energy, which appears to stimulate collagen production, and the use of fractionated lasers to target the epithelium. “RF devices tend to be easier to use,” said Dr. Kilmer, director of the Laser and Skin Surgery of Northern California, Sacramento. “They’re smaller devices, do not require as much laser training, and they tend to be less expensive. There’s no plume or odor with any of the RF devices.”
She discussed the results of the Viveve Treatment of the Vaginal Introitus to Evaluate Effectiveness (Viveve I) study, conducted at nine sites in four countries, which examined the Viveve monopolar RF device in 155 premenopausal women. The study subjects were randomized to one of two groups: the treatment group received 90 J/cm2 for five passes and the sham group received 1 J/cm2 for five passes (J Sex Med 2017;14[2]:215-25).
The researchers used the Vaginal Laxity Questionnaire (VSQ), which grades vaginal tone on a 7-point scale that ranges from very loose (0) to very tight (7), and the Female Sexual Function Index (FSFI) to collect patient-reported outcomes at one, three, and six months. Subjects had to have a VSQ score of 3 or less to participate in the study.
At 6 months, patients in the treatment group were more than 3 times as likely to have no vaginal laxity, compared with their counterparts in the sham group (P less than or equal to 0.006). In addition, more than half of patients in the treatment group moved at least 2 points on the VSQ scale toward a “tighter” vagina.
“Even a one-point increase in tightness will be significant for women,” said Dr. Kilmer, who has used the Viveve device in her practice but was not part of this study.
Based on responses to the FSFI questionnaire, the researchers observed a significant and sustained improvement in sexual function after a single treatment among patients in the treatment group, compared with those in the sham group. The placebo effect didn’t rise above “dysfunctional” at six months, and rate of treatment emergent adverse events was similar between the treatment and sham groups (11.1% vs. 12.3%, respectively), she said.
The researchers also reported the following patient tolerability variables: warmth during the procedure (96% in the treatment group vs. 19% in the sham group, respectively); cool sensation during the procedure (42% vs. 75%), and stopped procedure due to discomfort (1% in each group).
Dr. Kilmer explained that RF heating of the skin and mucosa provides immediate contraction of collagen, long-term stimulation of new collagen production, as well as increased blood flow and restoration of nerve signaling, which results in normal vaginal lubrication. “The critical RF temperature is in the 35 to 47 degree range,” she said. “Very few people can tolerate above 42 degrees.”
Similarly, good results were noted in a pilot study of the ThermiVa radiofrequency product manufactured by ThermoGen in 23 patients who underwent three treatments one month apart (Int J Laser Aesthet Med. July 2015:16-21). All patients experienced significant change with about a 50% reduction in symptoms.
“Patients are very happy with this treatment,” said Dr. Kilmer, who is also a professor of dermatology at the University of California, Davis Medical Center. “It may not be the absolute home run, but I think it’s very safe ... Most people say it lasts about six months then they’ll start to see some of their symptoms coming back.”
Dr. Kilmer reported that she is a member of the medical advisory board for Allergan, Cytrellis, Lumenis, Merz, Miramar, Sienna Labs, Syneron/Candela, Zarin, Zeltiq, and Zift. She has also received research support from those companies as well as from Cutera, Cynosure, Lutronic, R2 Derm, Solta/Valeant, and Ulthera.
REPORTING FROM MOAS 2017
Maintenance therapy typically required after laser hair removal
REPORTING FROM MOAS 2017
SAN DIEGO – Hair removal ranks as the most popular laser procedure performed in the United States, but patients with blond, red, or gray hairs are out of luck, since those threadlike strands lack a chromophore for the laser to respond to.
“For now, I recommend that these patients get electrolysis or use eflornithine cream,” Arisa Ortiz, MD, said at the annual Masters of Aesthetics Symposium.
Future treatment options for patients with light-colored hair look promising, however. One emerging technology combines laser hair removal with the insertion of a silver nanoparticle into the unpigmented hair follicle. “These are currently in pivotal trials, so we should be seeing them on the market very soon,” she said.
According to Dr. Ortiz, director of laser and cosmetic dermatology in the department of dermatology at the University of California, San Diego, there is still a place for nonlaser hair removal, including shaving, waxing, threading, and electrolysis, but laser hair removal is safe, effective in skilled hands, and permanent. Key factors in optimizing treatment include understanding laser safety and laser-tissue interaction, proper patient selection, preoperative preparation, parameter selection, and recognizing complications.
The first-degree target in laser hair removal is eumelanin contained in the bulb of hair follicles, she said, but the heat must diffuse to a secondary target – follicular stem cells in the bulge of the outer root sheath. “Pulse duration is important,” she said. “The thermal relaxation time of a terminal hair follicle is roughly 100 milliseconds. Longer pulse widths are going to be safer for darker skin types, and you want shorter pulse durations for fine hair, and longer pulse durations for thicker hair. Spot size is also important. Larger spot sizes are faster and create less pain and less epidermal damage.”
Indications include unwanted hair, hypertrichosis, and hirsutism/polycystic ovary syndrome (PCOS). “You want to counsel patients with PCOS properly, because they will require multiple treatments as they tend to make new hair follicles,” she said. Other indications include ingrown hairs, pseudofolliculitis barbae, and pilonidal cysts.
The best candidates for laser hair removal are patients who have a light skin color and dark hair, and those who have thick, coarse hair. “Be cautious when treating tanned patients, and adjust your setting to a longer pulse duration and a lower fluence,” she continued. “I tell (patients) they’ll likely need at least six treatments. You want to treat them every 6 to 8 weeks. If you do treatments sooner than that, it’s probably not cost effective for the patient, because of the way hair follicles cycle. It’s also important that they avoid the sun.”
Clinicians can achieve temporary hair removal with Q-switched lasers, which may be suitable for patients with pseudofolliculitis barbae but who may not want permanent hair removal. “This will just vaporize the actual hair follicle, but that heat is not extending to the stem cells, so it’s temporary hair removal, because the hair follicle transitions into the telogen phase,” Dr. Ortiz explained. “The hair will then grow back after a few months.”
Endpoints are the most important factor for laser hair removal. You want to see perifollicular erythema, perifollicular edema, or hair singeing. “Then you know you have an effective treatment setting,” she said. “Sometimes, however, it takes time for this erythema or edema to develop, so you don’t want to keep increasing your fluences to see this end point. If you’re not comfortable with the laser you’re using, I recommend waiting a few minutes after treatment, and looking for the end point. You could always go higher during the next treatment, if you need to.”
Higher fluences have been correlated with greater permanent hair removal, but also with more side effects. “The recommended treatment settings are going to be the highest possible tolerated fluence that yields the desired endpoint without any adverse effects,” Dr. Ortiz said.
The first hair removal laser to hit the market was the Ruby 694-nm laser, which is safe for Fitzpatrick skin types I-III. A long-term follow-up of the seminal study showed permanent posttreatment efficacy of up to 2 years (Arch Dermatol. 1998;134[7]:837-42). The Alexandrite 755-nm laser, meanwhile, penetrates deeper because it’s a longer wavelength, so there’s less melanin absorption, and it’s safer for darker skin types. “With a device like this, you want to make sure that you’re always holding the laser perpendicular to the skin surface so that your cryogen spray is firing at the same area as the laser. [That way] you don’t get a burn injury,” she said.
The diode at 800 nm and 810 nm penetrates even deeper, which results in less melanin absorption. “Originally these devices had smaller spot sizes, but now some of the newer devices have larger hand pieces and use contact cooling,” she said. “Some of the diode lasers cause singeing and char. The carbon actually sticks onto the sapphire window of the device, so you want to make sure you swipe the window after every few pulses so that you’re not putting the char onto the epidermis and causing an epidermal burn,” Dr. Ortiz advised.
She described the Nd:YAG 1,064-nm laser as the safest for skin types V and VI. It has the deepest penetration but the least melanin absorption. Intense pulsed light (IPL) can also be used for hair removal. IPLs “have a larger spot size, and you can use various cutoff filters to make them safer for darker skin types,” she said. “However, in head-to-head studies, usually laser hair removal does better than IPL.”
Potential complications from laser hair removal include paradoxical hypertrichosis; pigmentary alterations such as hyperpigmentation or hypopigmentation; infections/folliculitis, scarring, and eye injury. Dr. Ortiz underscored the importance of counseling patients about the need for maintenance treatments prior to initiating their first hair removal session. Laser hair removal removes about 85-90% of hairs permanently “so that leaves a significant number that remain, and new hairs may grow over time,” she said.
Authors of a recent study found that the plume release during laser hair removal should be considered a potential biohazard that warrants the use of smoke evacuators and good room ventilation (JAMA Dermatol. 2016;152[12]:1320-26). “We are learning that we should be more careful to evacuate the plume from laser hair removal or wear laser protective masks as the plume may contain harmful chemicals that we breathe in on a daily basis,” said Dr. Ortiz, who was not affiliated with the analysis.
She disclosed serving as a consultant to, receiving equipment from, and/or being a member of the scientific board of several device companies, including Alastin, Allergan, BTL, Cutera, InMode, Merz, Revance, Rodan and Fields, Sciton, and Sienna Biopharmaceuticals.
-[email protected]
REPORTING FROM MOAS 2017
SAN DIEGO – Hair removal ranks as the most popular laser procedure performed in the United States, but patients with blond, red, or gray hairs are out of luck, since those threadlike strands lack a chromophore for the laser to respond to.
“For now, I recommend that these patients get electrolysis or use eflornithine cream,” Arisa Ortiz, MD, said at the annual Masters of Aesthetics Symposium.
Future treatment options for patients with light-colored hair look promising, however. One emerging technology combines laser hair removal with the insertion of a silver nanoparticle into the unpigmented hair follicle. “These are currently in pivotal trials, so we should be seeing them on the market very soon,” she said.
According to Dr. Ortiz, director of laser and cosmetic dermatology in the department of dermatology at the University of California, San Diego, there is still a place for nonlaser hair removal, including shaving, waxing, threading, and electrolysis, but laser hair removal is safe, effective in skilled hands, and permanent. Key factors in optimizing treatment include understanding laser safety and laser-tissue interaction, proper patient selection, preoperative preparation, parameter selection, and recognizing complications.
The first-degree target in laser hair removal is eumelanin contained in the bulb of hair follicles, she said, but the heat must diffuse to a secondary target – follicular stem cells in the bulge of the outer root sheath. “Pulse duration is important,” she said. “The thermal relaxation time of a terminal hair follicle is roughly 100 milliseconds. Longer pulse widths are going to be safer for darker skin types, and you want shorter pulse durations for fine hair, and longer pulse durations for thicker hair. Spot size is also important. Larger spot sizes are faster and create less pain and less epidermal damage.”
Indications include unwanted hair, hypertrichosis, and hirsutism/polycystic ovary syndrome (PCOS). “You want to counsel patients with PCOS properly, because they will require multiple treatments as they tend to make new hair follicles,” she said. Other indications include ingrown hairs, pseudofolliculitis barbae, and pilonidal cysts.
The best candidates for laser hair removal are patients who have a light skin color and dark hair, and those who have thick, coarse hair. “Be cautious when treating tanned patients, and adjust your setting to a longer pulse duration and a lower fluence,” she continued. “I tell (patients) they’ll likely need at least six treatments. You want to treat them every 6 to 8 weeks. If you do treatments sooner than that, it’s probably not cost effective for the patient, because of the way hair follicles cycle. It’s also important that they avoid the sun.”
Clinicians can achieve temporary hair removal with Q-switched lasers, which may be suitable for patients with pseudofolliculitis barbae but who may not want permanent hair removal. “This will just vaporize the actual hair follicle, but that heat is not extending to the stem cells, so it’s temporary hair removal, because the hair follicle transitions into the telogen phase,” Dr. Ortiz explained. “The hair will then grow back after a few months.”
Endpoints are the most important factor for laser hair removal. You want to see perifollicular erythema, perifollicular edema, or hair singeing. “Then you know you have an effective treatment setting,” she said. “Sometimes, however, it takes time for this erythema or edema to develop, so you don’t want to keep increasing your fluences to see this end point. If you’re not comfortable with the laser you’re using, I recommend waiting a few minutes after treatment, and looking for the end point. You could always go higher during the next treatment, if you need to.”
Higher fluences have been correlated with greater permanent hair removal, but also with more side effects. “The recommended treatment settings are going to be the highest possible tolerated fluence that yields the desired endpoint without any adverse effects,” Dr. Ortiz said.
The first hair removal laser to hit the market was the Ruby 694-nm laser, which is safe for Fitzpatrick skin types I-III. A long-term follow-up of the seminal study showed permanent posttreatment efficacy of up to 2 years (Arch Dermatol. 1998;134[7]:837-42). The Alexandrite 755-nm laser, meanwhile, penetrates deeper because it’s a longer wavelength, so there’s less melanin absorption, and it’s safer for darker skin types. “With a device like this, you want to make sure that you’re always holding the laser perpendicular to the skin surface so that your cryogen spray is firing at the same area as the laser. [That way] you don’t get a burn injury,” she said.
The diode at 800 nm and 810 nm penetrates even deeper, which results in less melanin absorption. “Originally these devices had smaller spot sizes, but now some of the newer devices have larger hand pieces and use contact cooling,” she said. “Some of the diode lasers cause singeing and char. The carbon actually sticks onto the sapphire window of the device, so you want to make sure you swipe the window after every few pulses so that you’re not putting the char onto the epidermis and causing an epidermal burn,” Dr. Ortiz advised.
She described the Nd:YAG 1,064-nm laser as the safest for skin types V and VI. It has the deepest penetration but the least melanin absorption. Intense pulsed light (IPL) can also be used for hair removal. IPLs “have a larger spot size, and you can use various cutoff filters to make them safer for darker skin types,” she said. “However, in head-to-head studies, usually laser hair removal does better than IPL.”
Potential complications from laser hair removal include paradoxical hypertrichosis; pigmentary alterations such as hyperpigmentation or hypopigmentation; infections/folliculitis, scarring, and eye injury. Dr. Ortiz underscored the importance of counseling patients about the need for maintenance treatments prior to initiating their first hair removal session. Laser hair removal removes about 85-90% of hairs permanently “so that leaves a significant number that remain, and new hairs may grow over time,” she said.
Authors of a recent study found that the plume release during laser hair removal should be considered a potential biohazard that warrants the use of smoke evacuators and good room ventilation (JAMA Dermatol. 2016;152[12]:1320-26). “We are learning that we should be more careful to evacuate the plume from laser hair removal or wear laser protective masks as the plume may contain harmful chemicals that we breathe in on a daily basis,” said Dr. Ortiz, who was not affiliated with the analysis.
She disclosed serving as a consultant to, receiving equipment from, and/or being a member of the scientific board of several device companies, including Alastin, Allergan, BTL, Cutera, InMode, Merz, Revance, Rodan and Fields, Sciton, and Sienna Biopharmaceuticals.
-[email protected]
REPORTING FROM MOAS 2017
SAN DIEGO – Hair removal ranks as the most popular laser procedure performed in the United States, but patients with blond, red, or gray hairs are out of luck, since those threadlike strands lack a chromophore for the laser to respond to.
“For now, I recommend that these patients get electrolysis or use eflornithine cream,” Arisa Ortiz, MD, said at the annual Masters of Aesthetics Symposium.
Future treatment options for patients with light-colored hair look promising, however. One emerging technology combines laser hair removal with the insertion of a silver nanoparticle into the unpigmented hair follicle. “These are currently in pivotal trials, so we should be seeing them on the market very soon,” she said.
According to Dr. Ortiz, director of laser and cosmetic dermatology in the department of dermatology at the University of California, San Diego, there is still a place for nonlaser hair removal, including shaving, waxing, threading, and electrolysis, but laser hair removal is safe, effective in skilled hands, and permanent. Key factors in optimizing treatment include understanding laser safety and laser-tissue interaction, proper patient selection, preoperative preparation, parameter selection, and recognizing complications.
The first-degree target in laser hair removal is eumelanin contained in the bulb of hair follicles, she said, but the heat must diffuse to a secondary target – follicular stem cells in the bulge of the outer root sheath. “Pulse duration is important,” she said. “The thermal relaxation time of a terminal hair follicle is roughly 100 milliseconds. Longer pulse widths are going to be safer for darker skin types, and you want shorter pulse durations for fine hair, and longer pulse durations for thicker hair. Spot size is also important. Larger spot sizes are faster and create less pain and less epidermal damage.”
Indications include unwanted hair, hypertrichosis, and hirsutism/polycystic ovary syndrome (PCOS). “You want to counsel patients with PCOS properly, because they will require multiple treatments as they tend to make new hair follicles,” she said. Other indications include ingrown hairs, pseudofolliculitis barbae, and pilonidal cysts.
The best candidates for laser hair removal are patients who have a light skin color and dark hair, and those who have thick, coarse hair. “Be cautious when treating tanned patients, and adjust your setting to a longer pulse duration and a lower fluence,” she continued. “I tell (patients) they’ll likely need at least six treatments. You want to treat them every 6 to 8 weeks. If you do treatments sooner than that, it’s probably not cost effective for the patient, because of the way hair follicles cycle. It’s also important that they avoid the sun.”
Clinicians can achieve temporary hair removal with Q-switched lasers, which may be suitable for patients with pseudofolliculitis barbae but who may not want permanent hair removal. “This will just vaporize the actual hair follicle, but that heat is not extending to the stem cells, so it’s temporary hair removal, because the hair follicle transitions into the telogen phase,” Dr. Ortiz explained. “The hair will then grow back after a few months.”
Endpoints are the most important factor for laser hair removal. You want to see perifollicular erythema, perifollicular edema, or hair singeing. “Then you know you have an effective treatment setting,” she said. “Sometimes, however, it takes time for this erythema or edema to develop, so you don’t want to keep increasing your fluences to see this end point. If you’re not comfortable with the laser you’re using, I recommend waiting a few minutes after treatment, and looking for the end point. You could always go higher during the next treatment, if you need to.”
Higher fluences have been correlated with greater permanent hair removal, but also with more side effects. “The recommended treatment settings are going to be the highest possible tolerated fluence that yields the desired endpoint without any adverse effects,” Dr. Ortiz said.
The first hair removal laser to hit the market was the Ruby 694-nm laser, which is safe for Fitzpatrick skin types I-III. A long-term follow-up of the seminal study showed permanent posttreatment efficacy of up to 2 years (Arch Dermatol. 1998;134[7]:837-42). The Alexandrite 755-nm laser, meanwhile, penetrates deeper because it’s a longer wavelength, so there’s less melanin absorption, and it’s safer for darker skin types. “With a device like this, you want to make sure that you’re always holding the laser perpendicular to the skin surface so that your cryogen spray is firing at the same area as the laser. [That way] you don’t get a burn injury,” she said.
The diode at 800 nm and 810 nm penetrates even deeper, which results in less melanin absorption. “Originally these devices had smaller spot sizes, but now some of the newer devices have larger hand pieces and use contact cooling,” she said. “Some of the diode lasers cause singeing and char. The carbon actually sticks onto the sapphire window of the device, so you want to make sure you swipe the window after every few pulses so that you’re not putting the char onto the epidermis and causing an epidermal burn,” Dr. Ortiz advised.
She described the Nd:YAG 1,064-nm laser as the safest for skin types V and VI. It has the deepest penetration but the least melanin absorption. Intense pulsed light (IPL) can also be used for hair removal. IPLs “have a larger spot size, and you can use various cutoff filters to make them safer for darker skin types,” she said. “However, in head-to-head studies, usually laser hair removal does better than IPL.”
Potential complications from laser hair removal include paradoxical hypertrichosis; pigmentary alterations such as hyperpigmentation or hypopigmentation; infections/folliculitis, scarring, and eye injury. Dr. Ortiz underscored the importance of counseling patients about the need for maintenance treatments prior to initiating their first hair removal session. Laser hair removal removes about 85-90% of hairs permanently “so that leaves a significant number that remain, and new hairs may grow over time,” she said.
Authors of a recent study found that the plume release during laser hair removal should be considered a potential biohazard that warrants the use of smoke evacuators and good room ventilation (JAMA Dermatol. 2016;152[12]:1320-26). “We are learning that we should be more careful to evacuate the plume from laser hair removal or wear laser protective masks as the plume may contain harmful chemicals that we breathe in on a daily basis,” said Dr. Ortiz, who was not affiliated with the analysis.
She disclosed serving as a consultant to, receiving equipment from, and/or being a member of the scientific board of several device companies, including Alastin, Allergan, BTL, Cutera, InMode, Merz, Revance, Rodan and Fields, Sciton, and Sienna Biopharmaceuticals.
-[email protected]
How to tackle telangiectasias with light
AT MOAS 2017
SAN DIEGO – Multiple light-based devices can be used to treat telangiectasias, often with little or no down time.
During a presentation at the annual Masters of Aesthetics Symposium, Kristen M. Kelly, MD, listed her preferred light-based treatment options for telangiectasias as the pulsed dye laser (PDL), the 532 nm Nd:YAG laser, and the diode laser. The PDL has been around the longest and “is one of the greatest devices for treating vasculature, because it’s very specific,” she said. Purpura can result, but for cosmetic indications, pulse durations of 6 milliseconds or more work well. “Keep in mind, though, that when you’re using longer pulse durations, patients will often require more than one treatment,” she said. “Most people are okay with that, knowing that they’re going to have minimal to no down time with these procedures.”
Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, noted that erythematotelangiectatic rosacea generally responds well to light-based devices, while papulopustular/inflammatory forms of the condition are best treated with anti-inflammatory agents or antibiotics. Multiple passes or judicious pulse stacking can be used with PDL for treating telangiectases, “but always know what your endpoint is,” Dr. Kelly advised. “You generally don’t want to pulse over purpura when treating telangiectasias; that just increases the risk of adverse effects.”
Settings to consider vary, depending on the patient and the area to be treated. The desired endpoints for telangiectasia are vessel blanching or diminution, or a darker red/purple change to the vessel. “You should not see graying or whitening of the skin; that’s when you’re getting epidermal damage, so you want to watch for that,” she said. For a first pass, Dr. Kelly will often treat with a spot size of 10 mm or 12 mm with a 6-millisecond pulse duration with cryogen spray cooling set at 30 milliseconds with a 30-millisecond delay. If a second pass is required, she will often treat with a spot size of 7 mm and a 6-millisecond pulse duration and slightly higher fluence, again using cryogen spray cooling. “It is important to know your specific device to determine settings,” she said.
The frequency-doubled Nd:YAG laser features a wavelength of 532 nm but requires cautious use in patients with darker skin types or photodamaged skin. The desired endpoint is a darkening of the vessel or vessel disappearance. “Many of these devices have contact cooling, which is an excellent method of cooling, but you have to make sure you keep the contact,” she said. Other cooling options include cryogen spray and the application of cold air. “When you’re doing cold-air cooling, you want to be careful not to point it toward someone’s nose,” she said. “It sounds funny, but this is uncomfortable for the patient.”
Diode lasers with wavelengths of 800-980 nm allow the user to treat larger blood vessels, such as nasal telangiectasias. “Some devices with small spot sizes allow you to trace along the vessel, and you can see it disappear before your eyes, and when the patient leaves, they’re generally very happy,” she said.
Intense pulsed light works well in patients with both pigmentary and vascular changes, especially for poikiloderma with brown and red pigment. “Multiple treatments are required, and there is significant melanin absorption, so you don’t want to treat people with tanned skin,” she said.
Dr. Kelly emphasized the importance of being familiar with the device you use and knowing the desired tissue endpoint. Decisions depend on the patient’s skin type, their tolerance for down time and multiple treatments, and the devices at your disposal. “Patients should be aware of all options, even if you may not have a certain device in your office,” she said. “You can refer them.”
She disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Syneron Candela, ThermiRF, and Novartis. She is also a consultant for MundiPharma, Allergan, and Syneron Candela.
[email protected]
AT MOAS 2017
SAN DIEGO – Multiple light-based devices can be used to treat telangiectasias, often with little or no down time.
During a presentation at the annual Masters of Aesthetics Symposium, Kristen M. Kelly, MD, listed her preferred light-based treatment options for telangiectasias as the pulsed dye laser (PDL), the 532 nm Nd:YAG laser, and the diode laser. The PDL has been around the longest and “is one of the greatest devices for treating vasculature, because it’s very specific,” she said. Purpura can result, but for cosmetic indications, pulse durations of 6 milliseconds or more work well. “Keep in mind, though, that when you’re using longer pulse durations, patients will often require more than one treatment,” she said. “Most people are okay with that, knowing that they’re going to have minimal to no down time with these procedures.”
Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, noted that erythematotelangiectatic rosacea generally responds well to light-based devices, while papulopustular/inflammatory forms of the condition are best treated with anti-inflammatory agents or antibiotics. Multiple passes or judicious pulse stacking can be used with PDL for treating telangiectases, “but always know what your endpoint is,” Dr. Kelly advised. “You generally don’t want to pulse over purpura when treating telangiectasias; that just increases the risk of adverse effects.”
Settings to consider vary, depending on the patient and the area to be treated. The desired endpoints for telangiectasia are vessel blanching or diminution, or a darker red/purple change to the vessel. “You should not see graying or whitening of the skin; that’s when you’re getting epidermal damage, so you want to watch for that,” she said. For a first pass, Dr. Kelly will often treat with a spot size of 10 mm or 12 mm with a 6-millisecond pulse duration with cryogen spray cooling set at 30 milliseconds with a 30-millisecond delay. If a second pass is required, she will often treat with a spot size of 7 mm and a 6-millisecond pulse duration and slightly higher fluence, again using cryogen spray cooling. “It is important to know your specific device to determine settings,” she said.
The frequency-doubled Nd:YAG laser features a wavelength of 532 nm but requires cautious use in patients with darker skin types or photodamaged skin. The desired endpoint is a darkening of the vessel or vessel disappearance. “Many of these devices have contact cooling, which is an excellent method of cooling, but you have to make sure you keep the contact,” she said. Other cooling options include cryogen spray and the application of cold air. “When you’re doing cold-air cooling, you want to be careful not to point it toward someone’s nose,” she said. “It sounds funny, but this is uncomfortable for the patient.”
Diode lasers with wavelengths of 800-980 nm allow the user to treat larger blood vessels, such as nasal telangiectasias. “Some devices with small spot sizes allow you to trace along the vessel, and you can see it disappear before your eyes, and when the patient leaves, they’re generally very happy,” she said.
Intense pulsed light works well in patients with both pigmentary and vascular changes, especially for poikiloderma with brown and red pigment. “Multiple treatments are required, and there is significant melanin absorption, so you don’t want to treat people with tanned skin,” she said.
Dr. Kelly emphasized the importance of being familiar with the device you use and knowing the desired tissue endpoint. Decisions depend on the patient’s skin type, their tolerance for down time and multiple treatments, and the devices at your disposal. “Patients should be aware of all options, even if you may not have a certain device in your office,” she said. “You can refer them.”
She disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Syneron Candela, ThermiRF, and Novartis. She is also a consultant for MundiPharma, Allergan, and Syneron Candela.
[email protected]
AT MOAS 2017
SAN DIEGO – Multiple light-based devices can be used to treat telangiectasias, often with little or no down time.
During a presentation at the annual Masters of Aesthetics Symposium, Kristen M. Kelly, MD, listed her preferred light-based treatment options for telangiectasias as the pulsed dye laser (PDL), the 532 nm Nd:YAG laser, and the diode laser. The PDL has been around the longest and “is one of the greatest devices for treating vasculature, because it’s very specific,” she said. Purpura can result, but for cosmetic indications, pulse durations of 6 milliseconds or more work well. “Keep in mind, though, that when you’re using longer pulse durations, patients will often require more than one treatment,” she said. “Most people are okay with that, knowing that they’re going to have minimal to no down time with these procedures.”
Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, noted that erythematotelangiectatic rosacea generally responds well to light-based devices, while papulopustular/inflammatory forms of the condition are best treated with anti-inflammatory agents or antibiotics. Multiple passes or judicious pulse stacking can be used with PDL for treating telangiectases, “but always know what your endpoint is,” Dr. Kelly advised. “You generally don’t want to pulse over purpura when treating telangiectasias; that just increases the risk of adverse effects.”
Settings to consider vary, depending on the patient and the area to be treated. The desired endpoints for telangiectasia are vessel blanching or diminution, or a darker red/purple change to the vessel. “You should not see graying or whitening of the skin; that’s when you’re getting epidermal damage, so you want to watch for that,” she said. For a first pass, Dr. Kelly will often treat with a spot size of 10 mm or 12 mm with a 6-millisecond pulse duration with cryogen spray cooling set at 30 milliseconds with a 30-millisecond delay. If a second pass is required, she will often treat with a spot size of 7 mm and a 6-millisecond pulse duration and slightly higher fluence, again using cryogen spray cooling. “It is important to know your specific device to determine settings,” she said.
The frequency-doubled Nd:YAG laser features a wavelength of 532 nm but requires cautious use in patients with darker skin types or photodamaged skin. The desired endpoint is a darkening of the vessel or vessel disappearance. “Many of these devices have contact cooling, which is an excellent method of cooling, but you have to make sure you keep the contact,” she said. Other cooling options include cryogen spray and the application of cold air. “When you’re doing cold-air cooling, you want to be careful not to point it toward someone’s nose,” she said. “It sounds funny, but this is uncomfortable for the patient.”
Diode lasers with wavelengths of 800-980 nm allow the user to treat larger blood vessels, such as nasal telangiectasias. “Some devices with small spot sizes allow you to trace along the vessel, and you can see it disappear before your eyes, and when the patient leaves, they’re generally very happy,” she said.
Intense pulsed light works well in patients with both pigmentary and vascular changes, especially for poikiloderma with brown and red pigment. “Multiple treatments are required, and there is significant melanin absorption, so you don’t want to treat people with tanned skin,” she said.
Dr. Kelly emphasized the importance of being familiar with the device you use and knowing the desired tissue endpoint. Decisions depend on the patient’s skin type, their tolerance for down time and multiple treatments, and the devices at your disposal. “Patients should be aware of all options, even if you may not have a certain device in your office,” she said. “You can refer them.”
She disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Syneron Candela, ThermiRF, and Novartis. She is also a consultant for MundiPharma, Allergan, and Syneron Candela.
[email protected]
Tips for avoiding laser treatment complications
SAN DIEGO – The way Mathew M. Avram, MD, JD, sees it, the best way to avoid complications from using lasers for aesthetic procedures is to trust your own eyes, not the laser device itself.
“Lasers are never perfect,” he said at the annual Masters of Aesthetics Symposium. “The same device made by the same manufacturer may produce highly different outputs at the same setting. Moreover, lasers produce much different energies after they’ve been serviced. So, if you have two devices sitting right next to each other, don’t assume that the energy output on one device is exactly the same as the other device.”
He also warned clinicians against taking a “cookbook approach” to using lasers, such as memorizing settings or using ones recommended by a colleague or a device manufacturer. “Some lasers are not externally calibrated,” said Dr. Avram, who is codirector of the Massachusetts General Hospital/Wellman Laser and Cosmetic Fellowship. “Safe and unsafe laser endpoints and close clinical observation are the best means to avoiding complications. Learn your endpoints. This is true with the selective photothermolysis lasers: the pigment lasers, vascular lasers, and laser hair removal. Unfortunately, when you use nonablative fractional lasers, there really isn’t an endpoint, so it’s going to be more difficult to discern in that case. The key clinical finding is the endpoint, not the energy setting.”
When treating pigmented lesions and tattoos, for example, immediate whitening is the desired endpoint, not tissue splatter. “So, if you see the epidermis fly off with your first pulse, dial it down,” Dr. Avram said. “It sounds obvious, but sometimes, if you’re working quickly, you figure it will be all right. Just stop and make sure you’re seeing what you’re supposed to be seeing.”
The desired endpoints for vascular lasers, meanwhile, include purpura, transient purpura, or vessel clearance. “What you don’t want to see is gray,” he said. Desired endpoints for hair removal include perifollicular edema and erythema. “What you don’t want to see is epidermal change or dermal tightening,” he added. “Observe the skin and the patient. If the skin is reacting strangely, stop and check all of your settings. If the patient is having an inordinate amount of pain, stop and check all of your settings. These are often the clues that can help you avoid harming a patient.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.
SAN DIEGO – The way Mathew M. Avram, MD, JD, sees it, the best way to avoid complications from using lasers for aesthetic procedures is to trust your own eyes, not the laser device itself.
“Lasers are never perfect,” he said at the annual Masters of Aesthetics Symposium. “The same device made by the same manufacturer may produce highly different outputs at the same setting. Moreover, lasers produce much different energies after they’ve been serviced. So, if you have two devices sitting right next to each other, don’t assume that the energy output on one device is exactly the same as the other device.”
He also warned clinicians against taking a “cookbook approach” to using lasers, such as memorizing settings or using ones recommended by a colleague or a device manufacturer. “Some lasers are not externally calibrated,” said Dr. Avram, who is codirector of the Massachusetts General Hospital/Wellman Laser and Cosmetic Fellowship. “Safe and unsafe laser endpoints and close clinical observation are the best means to avoiding complications. Learn your endpoints. This is true with the selective photothermolysis lasers: the pigment lasers, vascular lasers, and laser hair removal. Unfortunately, when you use nonablative fractional lasers, there really isn’t an endpoint, so it’s going to be more difficult to discern in that case. The key clinical finding is the endpoint, not the energy setting.”
When treating pigmented lesions and tattoos, for example, immediate whitening is the desired endpoint, not tissue splatter. “So, if you see the epidermis fly off with your first pulse, dial it down,” Dr. Avram said. “It sounds obvious, but sometimes, if you’re working quickly, you figure it will be all right. Just stop and make sure you’re seeing what you’re supposed to be seeing.”
The desired endpoints for vascular lasers, meanwhile, include purpura, transient purpura, or vessel clearance. “What you don’t want to see is gray,” he said. Desired endpoints for hair removal include perifollicular edema and erythema. “What you don’t want to see is epidermal change or dermal tightening,” he added. “Observe the skin and the patient. If the skin is reacting strangely, stop and check all of your settings. If the patient is having an inordinate amount of pain, stop and check all of your settings. These are often the clues that can help you avoid harming a patient.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.
SAN DIEGO – The way Mathew M. Avram, MD, JD, sees it, the best way to avoid complications from using lasers for aesthetic procedures is to trust your own eyes, not the laser device itself.
“Lasers are never perfect,” he said at the annual Masters of Aesthetics Symposium. “The same device made by the same manufacturer may produce highly different outputs at the same setting. Moreover, lasers produce much different energies after they’ve been serviced. So, if you have two devices sitting right next to each other, don’t assume that the energy output on one device is exactly the same as the other device.”
He also warned clinicians against taking a “cookbook approach” to using lasers, such as memorizing settings or using ones recommended by a colleague or a device manufacturer. “Some lasers are not externally calibrated,” said Dr. Avram, who is codirector of the Massachusetts General Hospital/Wellman Laser and Cosmetic Fellowship. “Safe and unsafe laser endpoints and close clinical observation are the best means to avoiding complications. Learn your endpoints. This is true with the selective photothermolysis lasers: the pigment lasers, vascular lasers, and laser hair removal. Unfortunately, when you use nonablative fractional lasers, there really isn’t an endpoint, so it’s going to be more difficult to discern in that case. The key clinical finding is the endpoint, not the energy setting.”
When treating pigmented lesions and tattoos, for example, immediate whitening is the desired endpoint, not tissue splatter. “So, if you see the epidermis fly off with your first pulse, dial it down,” Dr. Avram said. “It sounds obvious, but sometimes, if you’re working quickly, you figure it will be all right. Just stop and make sure you’re seeing what you’re supposed to be seeing.”
The desired endpoints for vascular lasers, meanwhile, include purpura, transient purpura, or vessel clearance. “What you don’t want to see is gray,” he said. Desired endpoints for hair removal include perifollicular edema and erythema. “What you don’t want to see is epidermal change or dermal tightening,” he added. “Observe the skin and the patient. If the skin is reacting strangely, stop and check all of your settings. If the patient is having an inordinate amount of pain, stop and check all of your settings. These are often the clues that can help you avoid harming a patient.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea.
FROM MOAS 2017
Does microneedling have a role in aesthetics?
AT MOAS 2017
SAN DIEGO – When Jill S. Waibel, MD, first saw a dermal roller microneedling device around 2004, it reminded her of a weapon that might be conjured up by the character Dr. Kaufman, a professional assassin who appeared in the 1997 James Bond film, “Tomorrow Never Dies.”
“I’m thinking, that thing looks super painful,” Dr. Waibel said at the annual Masters of Aesthetics Symposium.
Patients seek microneedling treatments to rejuvenate skin; to treat acne scarring, other scars, striae, and rhytides; and to improve pigmentation. Its mechanism of action remains elusive. The hypothesis for microneedling’s effects on superficial rhytides, the wound that it creates induces production of new collagen and that multiple tiny wounds in the skin stimulate the release of various growth factors that play a role in collagen synthesis. When used on atrophic scars, the hypothesis is that microneedling breaks apart collagen bundles in the superficial layer of the dermis while inducing production of collagen. Authors of a recent systematic review on the topic found that the procedure showed noteworthy results on its own, particularly when combined with radio-frequency features (J Plast Reconstr Aesthet Surg. 2017 Jun 17. pii: S1748-6815[17]30250-4. doi: 10.1016/j.bjps.2017.06.006).
“However, there were shortcomings with most of the research: There were small numbers of patients, studies that were not randomized, not controlled, and further research is needed to see if microneedling truly works,” said Dr. Waibel, who was not involved with the analysis.
Microneedling devices come in many forms, including manual rollers, fixed-needle rollers, electric-powered pens, and devices with a new light-emitting microneedling technology. Of the five devices currently cleared by the Food and Drug Administration, four feature bipolar radio frequency and insulated needles, while one is a bipolar radio-frequency device (Infini) that contains noninsulated needles. Dr. Waibel favors the electric-powered pens, such as the StrataPen and the Eclipse MicroPen, that enable the user to adjust operating speed and penetration depths from 0.5 mm-3.0 mm, as well as feature disposable needle tips and disposable needles. These devices allow the depth of penetration to be changed according to what part of the face is being treated: “So on thinner areas of the face, like the forehead and the nose, you’re going to treat with a depth of 0.5 mm-1.0 mm, whereas in thicker areas, like the cheeks, you go up to 3.0 mm,” she said. “Typically, we do vertical and horizontal passes, repeating three to six times. When you see pinpoint bleeding, that’s the sign to stop. You can stop prior to that as well.”
One split-face study compared microneedling with nonablative fractional laser in 30 patients with atrophic scars, who underwent five sessions 1 month apart. (Dermatol Surg 2017; 43:S47-56). At 3 months, the side of the face treated with the laser showed a 70% improvement, compared with 30% for the side treated with microneedling (P less than .001). The researchers observed significantly lower pain scores with the laser procedure, but microneedling had a significantly shorter down time. A separate study of 12 healthy adults found that pretreatment with an ablative fractional laser significantly intensifies protoporphyrin IX fluorescence to a larger extent than curettage, microdermabrasion, microneedling, and nonablative fractional laser (JAMA Derm. 2017;153[4]:270-8). “So the message is that lasers are still superior, but there may be a role for microneedling,” Dr. Waibel said.
Since she began dabbling with microneedling in her practice over the past year, Dr. Waibel has found it is a good option for younger patients and for patients who desire little to no recovery time. “These are not expensive procedures for someone who doesn’t have a lot of skin damage,” she said. “It’s also good for difficult indications to improve, like striae. If I charge patients a few hundred dollars for a laser treatment, maybe I can do two or three follow-ups with the microneedle to stimulate collagen. This has become one of my go-tos with the radio-frequency device. I’ll do one fractional ablative laser treatment, then I’ll do two of the radiofrequency microneedle devices 1 and 2 months later. Then I’ll reassess to see what they need next. Or you might tweak [the course of treatment] after isolated laser treatments.”
Using a microneedle device requires meticulous cleaning of the intended treatment area prior to the procedure to avoid introducing bacteria or makeup into the skin. Dr. Waibel uses topical anesthesia for 20-30 minutes and then applies hyaluronic acid gel on the treatment surface to facilitate the gliding action of the device. “The technique involves perpendicular device placement with manual skin traction for smooth delivery of microneedles, going in vertical, horizontal, and oblique motions,” she explained. “Pinpoint bleeding is your guide for the pens. You don’t get pinpoint bleeding with some of the actual devices. Use manual pressure with ice and water to stop the bleeding.”
Contraindications for microneedling include patients with an active infection (such as herpes labialis), acne, and a predisposition for keloid scarring. Caution is advised with concomitant use of topical products of any type during a microneedling procedure because of the risk of granuloma formation. In 2014, researchers published a case series of three patients who developed biopsy-proven foreign body granulomas after the application of topical products during microneedling, including two cases that involved topical vitamin C (JAMA Dermatol 2014;150[1]:68-72).
“These are new devices, and we have new questions,” Dr. Waibel concluded. “I think they have a role, but we don’t fully understand the mechanism of action, and we have to be very careful about putting pharmacology down these channels. We don’t know the best treatment intervals, and we don’t know the best devices,” she added, pointing out that many of the devices have no indications cleared by the FDA yet.
She also noted that the FDA has put a hold on many microneedling devices from being sold in the United States until appropriate safety and efficacy data are collected.
Dr. Waibel disclosed that she has conducted clinical research for Strata Sciences, Aquavit, and Lutronic. She is also a member of the advisory board for Lutronic.
AT MOAS 2017
SAN DIEGO – When Jill S. Waibel, MD, first saw a dermal roller microneedling device around 2004, it reminded her of a weapon that might be conjured up by the character Dr. Kaufman, a professional assassin who appeared in the 1997 James Bond film, “Tomorrow Never Dies.”
“I’m thinking, that thing looks super painful,” Dr. Waibel said at the annual Masters of Aesthetics Symposium.
Patients seek microneedling treatments to rejuvenate skin; to treat acne scarring, other scars, striae, and rhytides; and to improve pigmentation. Its mechanism of action remains elusive. The hypothesis for microneedling’s effects on superficial rhytides, the wound that it creates induces production of new collagen and that multiple tiny wounds in the skin stimulate the release of various growth factors that play a role in collagen synthesis. When used on atrophic scars, the hypothesis is that microneedling breaks apart collagen bundles in the superficial layer of the dermis while inducing production of collagen. Authors of a recent systematic review on the topic found that the procedure showed noteworthy results on its own, particularly when combined with radio-frequency features (J Plast Reconstr Aesthet Surg. 2017 Jun 17. pii: S1748-6815[17]30250-4. doi: 10.1016/j.bjps.2017.06.006).
“However, there were shortcomings with most of the research: There were small numbers of patients, studies that were not randomized, not controlled, and further research is needed to see if microneedling truly works,” said Dr. Waibel, who was not involved with the analysis.
Microneedling devices come in many forms, including manual rollers, fixed-needle rollers, electric-powered pens, and devices with a new light-emitting microneedling technology. Of the five devices currently cleared by the Food and Drug Administration, four feature bipolar radio frequency and insulated needles, while one is a bipolar radio-frequency device (Infini) that contains noninsulated needles. Dr. Waibel favors the electric-powered pens, such as the StrataPen and the Eclipse MicroPen, that enable the user to adjust operating speed and penetration depths from 0.5 mm-3.0 mm, as well as feature disposable needle tips and disposable needles. These devices allow the depth of penetration to be changed according to what part of the face is being treated: “So on thinner areas of the face, like the forehead and the nose, you’re going to treat with a depth of 0.5 mm-1.0 mm, whereas in thicker areas, like the cheeks, you go up to 3.0 mm,” she said. “Typically, we do vertical and horizontal passes, repeating three to six times. When you see pinpoint bleeding, that’s the sign to stop. You can stop prior to that as well.”
One split-face study compared microneedling with nonablative fractional laser in 30 patients with atrophic scars, who underwent five sessions 1 month apart. (Dermatol Surg 2017; 43:S47-56). At 3 months, the side of the face treated with the laser showed a 70% improvement, compared with 30% for the side treated with microneedling (P less than .001). The researchers observed significantly lower pain scores with the laser procedure, but microneedling had a significantly shorter down time. A separate study of 12 healthy adults found that pretreatment with an ablative fractional laser significantly intensifies protoporphyrin IX fluorescence to a larger extent than curettage, microdermabrasion, microneedling, and nonablative fractional laser (JAMA Derm. 2017;153[4]:270-8). “So the message is that lasers are still superior, but there may be a role for microneedling,” Dr. Waibel said.
Since she began dabbling with microneedling in her practice over the past year, Dr. Waibel has found it is a good option for younger patients and for patients who desire little to no recovery time. “These are not expensive procedures for someone who doesn’t have a lot of skin damage,” she said. “It’s also good for difficult indications to improve, like striae. If I charge patients a few hundred dollars for a laser treatment, maybe I can do two or three follow-ups with the microneedle to stimulate collagen. This has become one of my go-tos with the radio-frequency device. I’ll do one fractional ablative laser treatment, then I’ll do two of the radiofrequency microneedle devices 1 and 2 months later. Then I’ll reassess to see what they need next. Or you might tweak [the course of treatment] after isolated laser treatments.”
Using a microneedle device requires meticulous cleaning of the intended treatment area prior to the procedure to avoid introducing bacteria or makeup into the skin. Dr. Waibel uses topical anesthesia for 20-30 minutes and then applies hyaluronic acid gel on the treatment surface to facilitate the gliding action of the device. “The technique involves perpendicular device placement with manual skin traction for smooth delivery of microneedles, going in vertical, horizontal, and oblique motions,” she explained. “Pinpoint bleeding is your guide for the pens. You don’t get pinpoint bleeding with some of the actual devices. Use manual pressure with ice and water to stop the bleeding.”
Contraindications for microneedling include patients with an active infection (such as herpes labialis), acne, and a predisposition for keloid scarring. Caution is advised with concomitant use of topical products of any type during a microneedling procedure because of the risk of granuloma formation. In 2014, researchers published a case series of three patients who developed biopsy-proven foreign body granulomas after the application of topical products during microneedling, including two cases that involved topical vitamin C (JAMA Dermatol 2014;150[1]:68-72).
“These are new devices, and we have new questions,” Dr. Waibel concluded. “I think they have a role, but we don’t fully understand the mechanism of action, and we have to be very careful about putting pharmacology down these channels. We don’t know the best treatment intervals, and we don’t know the best devices,” she added, pointing out that many of the devices have no indications cleared by the FDA yet.
She also noted that the FDA has put a hold on many microneedling devices from being sold in the United States until appropriate safety and efficacy data are collected.
Dr. Waibel disclosed that she has conducted clinical research for Strata Sciences, Aquavit, and Lutronic. She is also a member of the advisory board for Lutronic.
AT MOAS 2017
SAN DIEGO – When Jill S. Waibel, MD, first saw a dermal roller microneedling device around 2004, it reminded her of a weapon that might be conjured up by the character Dr. Kaufman, a professional assassin who appeared in the 1997 James Bond film, “Tomorrow Never Dies.”
“I’m thinking, that thing looks super painful,” Dr. Waibel said at the annual Masters of Aesthetics Symposium.
Patients seek microneedling treatments to rejuvenate skin; to treat acne scarring, other scars, striae, and rhytides; and to improve pigmentation. Its mechanism of action remains elusive. The hypothesis for microneedling’s effects on superficial rhytides, the wound that it creates induces production of new collagen and that multiple tiny wounds in the skin stimulate the release of various growth factors that play a role in collagen synthesis. When used on atrophic scars, the hypothesis is that microneedling breaks apart collagen bundles in the superficial layer of the dermis while inducing production of collagen. Authors of a recent systematic review on the topic found that the procedure showed noteworthy results on its own, particularly when combined with radio-frequency features (J Plast Reconstr Aesthet Surg. 2017 Jun 17. pii: S1748-6815[17]30250-4. doi: 10.1016/j.bjps.2017.06.006).
“However, there were shortcomings with most of the research: There were small numbers of patients, studies that were not randomized, not controlled, and further research is needed to see if microneedling truly works,” said Dr. Waibel, who was not involved with the analysis.
Microneedling devices come in many forms, including manual rollers, fixed-needle rollers, electric-powered pens, and devices with a new light-emitting microneedling technology. Of the five devices currently cleared by the Food and Drug Administration, four feature bipolar radio frequency and insulated needles, while one is a bipolar radio-frequency device (Infini) that contains noninsulated needles. Dr. Waibel favors the electric-powered pens, such as the StrataPen and the Eclipse MicroPen, that enable the user to adjust operating speed and penetration depths from 0.5 mm-3.0 mm, as well as feature disposable needle tips and disposable needles. These devices allow the depth of penetration to be changed according to what part of the face is being treated: “So on thinner areas of the face, like the forehead and the nose, you’re going to treat with a depth of 0.5 mm-1.0 mm, whereas in thicker areas, like the cheeks, you go up to 3.0 mm,” she said. “Typically, we do vertical and horizontal passes, repeating three to six times. When you see pinpoint bleeding, that’s the sign to stop. You can stop prior to that as well.”
One split-face study compared microneedling with nonablative fractional laser in 30 patients with atrophic scars, who underwent five sessions 1 month apart. (Dermatol Surg 2017; 43:S47-56). At 3 months, the side of the face treated with the laser showed a 70% improvement, compared with 30% for the side treated with microneedling (P less than .001). The researchers observed significantly lower pain scores with the laser procedure, but microneedling had a significantly shorter down time. A separate study of 12 healthy adults found that pretreatment with an ablative fractional laser significantly intensifies protoporphyrin IX fluorescence to a larger extent than curettage, microdermabrasion, microneedling, and nonablative fractional laser (JAMA Derm. 2017;153[4]:270-8). “So the message is that lasers are still superior, but there may be a role for microneedling,” Dr. Waibel said.
Since she began dabbling with microneedling in her practice over the past year, Dr. Waibel has found it is a good option for younger patients and for patients who desire little to no recovery time. “These are not expensive procedures for someone who doesn’t have a lot of skin damage,” she said. “It’s also good for difficult indications to improve, like striae. If I charge patients a few hundred dollars for a laser treatment, maybe I can do two or three follow-ups with the microneedle to stimulate collagen. This has become one of my go-tos with the radio-frequency device. I’ll do one fractional ablative laser treatment, then I’ll do two of the radiofrequency microneedle devices 1 and 2 months later. Then I’ll reassess to see what they need next. Or you might tweak [the course of treatment] after isolated laser treatments.”
Using a microneedle device requires meticulous cleaning of the intended treatment area prior to the procedure to avoid introducing bacteria or makeup into the skin. Dr. Waibel uses topical anesthesia for 20-30 minutes and then applies hyaluronic acid gel on the treatment surface to facilitate the gliding action of the device. “The technique involves perpendicular device placement with manual skin traction for smooth delivery of microneedles, going in vertical, horizontal, and oblique motions,” she explained. “Pinpoint bleeding is your guide for the pens. You don’t get pinpoint bleeding with some of the actual devices. Use manual pressure with ice and water to stop the bleeding.”
Contraindications for microneedling include patients with an active infection (such as herpes labialis), acne, and a predisposition for keloid scarring. Caution is advised with concomitant use of topical products of any type during a microneedling procedure because of the risk of granuloma formation. In 2014, researchers published a case series of three patients who developed biopsy-proven foreign body granulomas after the application of topical products during microneedling, including two cases that involved topical vitamin C (JAMA Dermatol 2014;150[1]:68-72).
“These are new devices, and we have new questions,” Dr. Waibel concluded. “I think they have a role, but we don’t fully understand the mechanism of action, and we have to be very careful about putting pharmacology down these channels. We don’t know the best treatment intervals, and we don’t know the best devices,” she added, pointing out that many of the devices have no indications cleared by the FDA yet.
She also noted that the FDA has put a hold on many microneedling devices from being sold in the United States until appropriate safety and efficacy data are collected.
Dr. Waibel disclosed that she has conducted clinical research for Strata Sciences, Aquavit, and Lutronic. She is also a member of the advisory board for Lutronic.