TBD Meeting (2961-22)

SAN DIEGO – The risk of laser or intense-pulsed light–induced vitiligo from treating vitiligo with either modality appears to be low, but caution is recommended until further studies are carried out.

Those are the preliminary conclusions from a systematic review and survey of experts that Albert Wolkerstorfer, MD, presented during a clinical abstract session at the annual conference of the American Society for Laser Medicine and Surgery.

According to Dr. Wolkerstorfer, a dermatologist at Amsterdam University Medical Center, clinicians are reluctant to perform laser/intense pulsed light (IPL) treatments in patients with vitiligo because of the absence of clear guidelines, so he and his colleagues set out to investigate the risks of laser/IPL-induced vitiligo in patients with vitiligo and to seek out international consensus on recommendations from experts. “There is hardly any literature about it and certainly no guidelines,” he pointed out.

Dr. Wolkerstorfer and his colleagues designed three consecutive studies: A systematic review of laser/IPL-induced vitiligo; an international survey among 14 vitiligo experts from 10 countries about the occurrence of laser‐induced vitiligo, and a Delphi technique aimed at establishing a broad consensus about recommendations for safe use of lasers in vitiligo patients. At the time of the meeting, the Delphi process was still being carried out, so he did not discuss that study.

For the systematic review, the researchers found 11,073 unique hits on PubMed, Embase, and CINAHL using the terms “vitiligo,” “depigmentation,” “hypopigmentation,” and “leukoderma.” Only six case reports of laser/IPL-induced vitiligo were included in the final analysis. Of these, three had de novo vitiligo and three had vitiligo/halo nevi. These cases included two that occurred following treatment of port wine stains with the 585-nm laser; one that occurred following treatment of dyspigmentation with IPL; one that occurred following treatment of hypertrichosis with the 1,064-nm laser, one that occurred following treatment of hypertrichosis with the 755-nm laser, and one case that occurred following treatment of melasma with the ablative laser.

For the international survey of 14 experts from 10 countries, respondents said they had 10,670 new face-to-face vitiligo consultations in the past year. They reported that 30 of the vitiligo cases (0.3%) were likely caused by laser/IPL. Of these 30 cases, 18 (60%) had de novo vitiligo.

Of these cases, vitiligo occurred most frequently after laser hair reduction (47%), followed by use of the fractional laser (17%), and the ablative laser (13%). The interval between laser/IPL treatment and onset of vitiligo was 0-4 weeks in 27% of cases and 4-12 weeks in 57% of cases. Direct complications such as blistering, crusting, and erosions occurred in 57% of cases.

“Our conclusion is that laser and IPL-induced vitiligo is a rare phenomenon, and it often affects patients without prior vitiligo, which was really a surprise to us,” Dr. Wolkerstorfer said. “Complications seem to increase the risk,” he added.

“Despite the apparently low risk, we recommend caution [in patients with vitiligo], especially with aggressive laser procedures,” he said. “We recommend using conservative settings, not to treat active vitiligo patients ... and to perform test spots prior to treating large areas.” But he characterized this recommendation as “totally preliminary” pending results of the Delphi technique aimed at building consensus about laser/IPL treatments in vitiligo.

In an interview at the meeting, one of the session moderators, Oge Onwudiwe, MD, a dermatologist who practices in Alexandria, Va., said that as clinicians await results of the study’s Delphi consensus, current use of lasers and IPL in patients with vitiligo “is based on your clinical judgment and whether the vitiligo is active or inactive. If the patient has vitiligo and you’re doing laser hair removal in the armpit, they may get active lesions in that area, but they can cover it. So, they may take that as a ‘win’ with the risk. But if it can erupt in other areas, that’s a risk they must be willing to take.”

Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical. He is an advisory board member for Incyte. Dr. Onwudiwe reported having no disclosures.

SAN DIEGO – The risk of laser or intense-pulsed light–induced vitiligo from treating vitiligo with either modality appears to be low, but caution is recommended until further studies are carried out.

Those are the preliminary conclusions from a systematic review and survey of experts that Albert Wolkerstorfer, MD, presented during a clinical abstract session at the annual conference of the American Society for Laser Medicine and Surgery.

According to Dr. Wolkerstorfer, a dermatologist at Amsterdam University Medical Center, clinicians are reluctant to perform laser/intense pulsed light (IPL) treatments in patients with vitiligo because of the absence of clear guidelines, so he and his colleagues set out to investigate the risks of laser/IPL-induced vitiligo in patients with vitiligo and to seek out international consensus on recommendations from experts. “There is hardly any literature about it and certainly no guidelines,” he pointed out.

Dr. Wolkerstorfer and his colleagues designed three consecutive studies: A systematic review of laser/IPL-induced vitiligo; an international survey among 14 vitiligo experts from 10 countries about the occurrence of laser‐induced vitiligo, and a Delphi technique aimed at establishing a broad consensus about recommendations for safe use of lasers in vitiligo patients. At the time of the meeting, the Delphi process was still being carried out, so he did not discuss that study.

For the systematic review, the researchers found 11,073 unique hits on PubMed, Embase, and CINAHL using the terms “vitiligo,” “depigmentation,” “hypopigmentation,” and “leukoderma.” Only six case reports of laser/IPL-induced vitiligo were included in the final analysis. Of these, three had de novo vitiligo and three had vitiligo/halo nevi. These cases included two that occurred following treatment of port wine stains with the 585-nm laser; one that occurred following treatment of dyspigmentation with IPL; one that occurred following treatment of hypertrichosis with the 1,064-nm laser, one that occurred following treatment of hypertrichosis with the 755-nm laser, and one case that occurred following treatment of melasma with the ablative laser.

For the international survey of 14 experts from 10 countries, respondents said they had 10,670 new face-to-face vitiligo consultations in the past year. They reported that 30 of the vitiligo cases (0.3%) were likely caused by laser/IPL. Of these 30 cases, 18 (60%) had de novo vitiligo.

Of these cases, vitiligo occurred most frequently after laser hair reduction (47%), followed by use of the fractional laser (17%), and the ablative laser (13%). The interval between laser/IPL treatment and onset of vitiligo was 0-4 weeks in 27% of cases and 4-12 weeks in 57% of cases. Direct complications such as blistering, crusting, and erosions occurred in 57% of cases.

“Our conclusion is that laser and IPL-induced vitiligo is a rare phenomenon, and it often affects patients without prior vitiligo, which was really a surprise to us,” Dr. Wolkerstorfer said. “Complications seem to increase the risk,” he added.

“Despite the apparently low risk, we recommend caution [in patients with vitiligo], especially with aggressive laser procedures,” he said. “We recommend using conservative settings, not to treat active vitiligo patients ... and to perform test spots prior to treating large areas.” But he characterized this recommendation as “totally preliminary” pending results of the Delphi technique aimed at building consensus about laser/IPL treatments in vitiligo.

In an interview at the meeting, one of the session moderators, Oge Onwudiwe, MD, a dermatologist who practices in Alexandria, Va., said that as clinicians await results of the study’s Delphi consensus, current use of lasers and IPL in patients with vitiligo “is based on your clinical judgment and whether the vitiligo is active or inactive. If the patient has vitiligo and you’re doing laser hair removal in the armpit, they may get active lesions in that area, but they can cover it. So, they may take that as a ‘win’ with the risk. But if it can erupt in other areas, that’s a risk they must be willing to take.”

Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical. He is an advisory board member for Incyte. Dr. Onwudiwe reported having no disclosures.

SAN DIEGO – The risk of laser or intense-pulsed light–induced vitiligo from treating vitiligo with either modality appears to be low, but caution is recommended until further studies are carried out.

Those are the preliminary conclusions from a systematic review and survey of experts that Albert Wolkerstorfer, MD, presented during a clinical abstract session at the annual conference of the American Society for Laser Medicine and Surgery.

According to Dr. Wolkerstorfer, a dermatologist at Amsterdam University Medical Center, clinicians are reluctant to perform laser/intense pulsed light (IPL) treatments in patients with vitiligo because of the absence of clear guidelines, so he and his colleagues set out to investigate the risks of laser/IPL-induced vitiligo in patients with vitiligo and to seek out international consensus on recommendations from experts. “There is hardly any literature about it and certainly no guidelines,” he pointed out.

Dr. Wolkerstorfer and his colleagues designed three consecutive studies: A systematic review of laser/IPL-induced vitiligo; an international survey among 14 vitiligo experts from 10 countries about the occurrence of laser‐induced vitiligo, and a Delphi technique aimed at establishing a broad consensus about recommendations for safe use of lasers in vitiligo patients. At the time of the meeting, the Delphi process was still being carried out, so he did not discuss that study.

For the systematic review, the researchers found 11,073 unique hits on PubMed, Embase, and CINAHL using the terms “vitiligo,” “depigmentation,” “hypopigmentation,” and “leukoderma.” Only six case reports of laser/IPL-induced vitiligo were included in the final analysis. Of these, three had de novo vitiligo and three had vitiligo/halo nevi. These cases included two that occurred following treatment of port wine stains with the 585-nm laser; one that occurred following treatment of dyspigmentation with IPL; one that occurred following treatment of hypertrichosis with the 1,064-nm laser, one that occurred following treatment of hypertrichosis with the 755-nm laser, and one case that occurred following treatment of melasma with the ablative laser.

For the international survey of 14 experts from 10 countries, respondents said they had 10,670 new face-to-face vitiligo consultations in the past year. They reported that 30 of the vitiligo cases (0.3%) were likely caused by laser/IPL. Of these 30 cases, 18 (60%) had de novo vitiligo.

Of these cases, vitiligo occurred most frequently after laser hair reduction (47%), followed by use of the fractional laser (17%), and the ablative laser (13%). The interval between laser/IPL treatment and onset of vitiligo was 0-4 weeks in 27% of cases and 4-12 weeks in 57% of cases. Direct complications such as blistering, crusting, and erosions occurred in 57% of cases.

“Our conclusion is that laser and IPL-induced vitiligo is a rare phenomenon, and it often affects patients without prior vitiligo, which was really a surprise to us,” Dr. Wolkerstorfer said. “Complications seem to increase the risk,” he added.

“Despite the apparently low risk, we recommend caution [in patients with vitiligo], especially with aggressive laser procedures,” he said. “We recommend using conservative settings, not to treat active vitiligo patients ... and to perform test spots prior to treating large areas.” But he characterized this recommendation as “totally preliminary” pending results of the Delphi technique aimed at building consensus about laser/IPL treatments in vitiligo.

In an interview at the meeting, one of the session moderators, Oge Onwudiwe, MD, a dermatologist who practices in Alexandria, Va., said that as clinicians await results of the study’s Delphi consensus, current use of lasers and IPL in patients with vitiligo “is based on your clinical judgment and whether the vitiligo is active or inactive. If the patient has vitiligo and you’re doing laser hair removal in the armpit, they may get active lesions in that area, but they can cover it. So, they may take that as a ‘win’ with the risk. But if it can erupt in other areas, that’s a risk they must be willing to take.”

Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical. He is an advisory board member for Incyte. Dr. Onwudiwe reported having no disclosures.

SAN DIEGO – Twelve years ago, Merete Haedersdal, MD, PhD, and colleagues published data from a swine study, which showed for the first time that the ablative fractional laser can be used to boost the uptake of drugs into the skin.

That discovery paved the way for what are now well-established clinical applications of laser-assisted drug delivery for treating actinic keratoses and scars. According to Dr. Haedersdal, professor of dermatology at the University of Copenhagen, evolving clinical indications for laser-assisted drug delivery include rejuvenation, local anesthesia, melasma, onychomycosis, hyperhidrosis, alopecia, and vitiligo, while emerging indications include treatment of skin cancer with PD-1 inhibitors and combination chemotherapy regimens, and vaccinations.

During a presentation at the annual conference of the American Society for Laser Medicine and Surgery, she said that researchers have much to learn about laser-assisted drug delivery, including biodistribution of the drug being delivered. Pointing out that so far, “what we have been dealing with is primarily looking at the skin as a black box,” she asked, “what happens when we drill the holes and drugs are applied on top of the skin and swim through the tiny channels?”

By using high-performance liquid chromatography (HPLC) and HPLC mass spectrometry to measure drug concentration in the skin, she and her colleagues have observed enhanced uptake of drugs – 4-fold to 40-fold greater – primarily in ex vivo pig skin. “We do know from ex vivo models that it’s much easier to boost the uptake in the skin” when compared with in vivo human use, where much lower drug concentrations are detected, said Dr. Haedersdal, who, along with Emily Wenande, MD, PhD, and R. Rox Anderson, MD, at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston, authored a clinical review, published in 2020, on the basics of laser-assisted drug delivery.

“What we are working on now is visualizing what’s taking place when we apply the holes and the drugs in the skin. This is the key to tailoring laser-assisted uptake to specific dermatologic diseases being treated,” she said. To date, she and her colleagues have examined the interaction with tissue using different devices, including ex vivo confocal microscopy, to view the thermal response to ablative fractional laser and radiofrequency. “We want to take that to the next level and look at the drug biodistribution.”

Efforts are underway to compare the pattern of drug distribution with different modes of delivery, such as comparing ablative fractional laser to intradermal needle injection. “We are also working on pneumatic jet injection, which creates a focal drug distribution,” said Dr. Haedersdal, who is a visiting scientist at the Wellman Center. “In the future, we may take advantage of device-tailored biodistribution, depending on which clinical indication we are treating.”

Another important aspect to consider is drug retention in the skin. In a study presented as an abstract at the meeting, led by Dr. Wenande, she, Dr. Haedersdal, and colleagues used a pig model to evaluate the effect of three vasoregulative interventions on ablative fractional laser-assisted 5-fluororacil concentrations in in vivo skin. The three interventions were brimonidine 0.33% solution, epinephrine 10 mcg/mL gel, and a 595-nm pulsed dye laser (PDL) in designated treatment areas.

“What we learned from that was in the short term – 1-4 hours – the ablative fractional laser enhanced the uptake of 5-FU, but it was very transient,” with a twofold increased concentration of 5-FU, Dr. Haedersdal said. Over 48-72 hours, after PDL, there was “sustained enhancement of drug in the skin by three to four times,” she noted.

The synergy of systemic drugs with ablative fractional laser therapy is also being evaluated. In a mouse study led by Dr. Haedersdal’s colleague, senior researcher Uffe H. Olesen, PhD, the treatment of advanced squamous cell carcinoma tumors with a combination of ablative fractional laser and systemic treatment with PD-1 inhibitors resulted in the clearance of more tumors than with either treatment as monotherapy. “What we want to explore is the laser-induced tumor immune response in keratinocyte cancers,” she added.

“When you shine the laser on the skin, there is a robust increase of neutrophilic granulocytes.” Combining this topical immune-boosting response with systemic delivery of PD-1 inhibitors in a mouse model with basal cell carcinoma, she said, “we learned that, when we compare systemic PD-1 inhibitors alone to the laser alone and then with combination therapy, there was an increased tumor clearance of basal cell carcinomas and also enhanced survival of the mice” with the combination, she said. There were also “enhanced neutrophilic counts and both CD4- and CD8-positive cells were increased,” she added.

Dr. Haedersdal disclosed that she has received grants or research funding from Lutronic, Venus Concept, Leo Pharma, and Mirai Medical.

SAN DIEGO – Twelve years ago, Merete Haedersdal, MD, PhD, and colleagues published data from a swine study, which showed for the first time that the ablative fractional laser can be used to boost the uptake of drugs into the skin.

That discovery paved the way for what are now well-established clinical applications of laser-assisted drug delivery for treating actinic keratoses and scars. According to Dr. Haedersdal, professor of dermatology at the University of Copenhagen, evolving clinical indications for laser-assisted drug delivery include rejuvenation, local anesthesia, melasma, onychomycosis, hyperhidrosis, alopecia, and vitiligo, while emerging indications include treatment of skin cancer with PD-1 inhibitors and combination chemotherapy regimens, and vaccinations.

During a presentation at the annual conference of the American Society for Laser Medicine and Surgery, she said that researchers have much to learn about laser-assisted drug delivery, including biodistribution of the drug being delivered. Pointing out that so far, “what we have been dealing with is primarily looking at the skin as a black box,” she asked, “what happens when we drill the holes and drugs are applied on top of the skin and swim through the tiny channels?”

By using high-performance liquid chromatography (HPLC) and HPLC mass spectrometry to measure drug concentration in the skin, she and her colleagues have observed enhanced uptake of drugs – 4-fold to 40-fold greater – primarily in ex vivo pig skin. “We do know from ex vivo models that it’s much easier to boost the uptake in the skin” when compared with in vivo human use, where much lower drug concentrations are detected, said Dr. Haedersdal, who, along with Emily Wenande, MD, PhD, and R. Rox Anderson, MD, at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston, authored a clinical review, published in 2020, on the basics of laser-assisted drug delivery.

“What we are working on now is visualizing what’s taking place when we apply the holes and the drugs in the skin. This is the key to tailoring laser-assisted uptake to specific dermatologic diseases being treated,” she said. To date, she and her colleagues have examined the interaction with tissue using different devices, including ex vivo confocal microscopy, to view the thermal response to ablative fractional laser and radiofrequency. “We want to take that to the next level and look at the drug biodistribution.”

Efforts are underway to compare the pattern of drug distribution with different modes of delivery, such as comparing ablative fractional laser to intradermal needle injection. “We are also working on pneumatic jet injection, which creates a focal drug distribution,” said Dr. Haedersdal, who is a visiting scientist at the Wellman Center. “In the future, we may take advantage of device-tailored biodistribution, depending on which clinical indication we are treating.”

Another important aspect to consider is drug retention in the skin. In a study presented as an abstract at the meeting, led by Dr. Wenande, she, Dr. Haedersdal, and colleagues used a pig model to evaluate the effect of three vasoregulative interventions on ablative fractional laser-assisted 5-fluororacil concentrations in in vivo skin. The three interventions were brimonidine 0.33% solution, epinephrine 10 mcg/mL gel, and a 595-nm pulsed dye laser (PDL) in designated treatment areas.

“What we learned from that was in the short term – 1-4 hours – the ablative fractional laser enhanced the uptake of 5-FU, but it was very transient,” with a twofold increased concentration of 5-FU, Dr. Haedersdal said. Over 48-72 hours, after PDL, there was “sustained enhancement of drug in the skin by three to four times,” she noted.

The synergy of systemic drugs with ablative fractional laser therapy is also being evaluated. In a mouse study led by Dr. Haedersdal’s colleague, senior researcher Uffe H. Olesen, PhD, the treatment of advanced squamous cell carcinoma tumors with a combination of ablative fractional laser and systemic treatment with PD-1 inhibitors resulted in the clearance of more tumors than with either treatment as monotherapy. “What we want to explore is the laser-induced tumor immune response in keratinocyte cancers,” she added.

“When you shine the laser on the skin, there is a robust increase of neutrophilic granulocytes.” Combining this topical immune-boosting response with systemic delivery of PD-1 inhibitors in a mouse model with basal cell carcinoma, she said, “we learned that, when we compare systemic PD-1 inhibitors alone to the laser alone and then with combination therapy, there was an increased tumor clearance of basal cell carcinomas and also enhanced survival of the mice” with the combination, she said. There were also “enhanced neutrophilic counts and both CD4- and CD8-positive cells were increased,” she added.

Dr. Haedersdal disclosed that she has received grants or research funding from Lutronic, Venus Concept, Leo Pharma, and Mirai Medical.

SAN DIEGO – Twelve years ago, Merete Haedersdal, MD, PhD, and colleagues published data from a swine study, which showed for the first time that the ablative fractional laser can be used to boost the uptake of drugs into the skin.

That discovery paved the way for what are now well-established clinical applications of laser-assisted drug delivery for treating actinic keratoses and scars. According to Dr. Haedersdal, professor of dermatology at the University of Copenhagen, evolving clinical indications for laser-assisted drug delivery include rejuvenation, local anesthesia, melasma, onychomycosis, hyperhidrosis, alopecia, and vitiligo, while emerging indications include treatment of skin cancer with PD-1 inhibitors and combination chemotherapy regimens, and vaccinations.

During a presentation at the annual conference of the American Society for Laser Medicine and Surgery, she said that researchers have much to learn about laser-assisted drug delivery, including biodistribution of the drug being delivered. Pointing out that so far, “what we have been dealing with is primarily looking at the skin as a black box,” she asked, “what happens when we drill the holes and drugs are applied on top of the skin and swim through the tiny channels?”

By using high-performance liquid chromatography (HPLC) and HPLC mass spectrometry to measure drug concentration in the skin, she and her colleagues have observed enhanced uptake of drugs – 4-fold to 40-fold greater – primarily in ex vivo pig skin. “We do know from ex vivo models that it’s much easier to boost the uptake in the skin” when compared with in vivo human use, where much lower drug concentrations are detected, said Dr. Haedersdal, who, along with Emily Wenande, MD, PhD, and R. Rox Anderson, MD, at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston, authored a clinical review, published in 2020, on the basics of laser-assisted drug delivery.

“What we are working on now is visualizing what’s taking place when we apply the holes and the drugs in the skin. This is the key to tailoring laser-assisted uptake to specific dermatologic diseases being treated,” she said. To date, she and her colleagues have examined the interaction with tissue using different devices, including ex vivo confocal microscopy, to view the thermal response to ablative fractional laser and radiofrequency. “We want to take that to the next level and look at the drug biodistribution.”

Efforts are underway to compare the pattern of drug distribution with different modes of delivery, such as comparing ablative fractional laser to intradermal needle injection. “We are also working on pneumatic jet injection, which creates a focal drug distribution,” said Dr. Haedersdal, who is a visiting scientist at the Wellman Center. “In the future, we may take advantage of device-tailored biodistribution, depending on which clinical indication we are treating.”

Another important aspect to consider is drug retention in the skin. In a study presented as an abstract at the meeting, led by Dr. Wenande, she, Dr. Haedersdal, and colleagues used a pig model to evaluate the effect of three vasoregulative interventions on ablative fractional laser-assisted 5-fluororacil concentrations in in vivo skin. The three interventions were brimonidine 0.33% solution, epinephrine 10 mcg/mL gel, and a 595-nm pulsed dye laser (PDL) in designated treatment areas.

“What we learned from that was in the short term – 1-4 hours – the ablative fractional laser enhanced the uptake of 5-FU, but it was very transient,” with a twofold increased concentration of 5-FU, Dr. Haedersdal said. Over 48-72 hours, after PDL, there was “sustained enhancement of drug in the skin by three to four times,” she noted.

The synergy of systemic drugs with ablative fractional laser therapy is also being evaluated. In a mouse study led by Dr. Haedersdal’s colleague, senior researcher Uffe H. Olesen, PhD, the treatment of advanced squamous cell carcinoma tumors with a combination of ablative fractional laser and systemic treatment with PD-1 inhibitors resulted in the clearance of more tumors than with either treatment as monotherapy. “What we want to explore is the laser-induced tumor immune response in keratinocyte cancers,” she added.

“When you shine the laser on the skin, there is a robust increase of neutrophilic granulocytes.” Combining this topical immune-boosting response with systemic delivery of PD-1 inhibitors in a mouse model with basal cell carcinoma, she said, “we learned that, when we compare systemic PD-1 inhibitors alone to the laser alone and then with combination therapy, there was an increased tumor clearance of basal cell carcinomas and also enhanced survival of the mice” with the combination, she said. There were also “enhanced neutrophilic counts and both CD4- and CD8-positive cells were increased,” she added.

Dr. Haedersdal disclosed that she has received grants or research funding from Lutronic, Venus Concept, Leo Pharma, and Mirai Medical.

SAN DIEGO – In a 2006 report of complications from laser dermatologic surgery, one of the authors, Dieter Manstein, MD, PhD, who had subjected his forearm to treatment with a fractional laser skin resurfacing prototype device, was included as 1 of the 19 featured cases.

Dr. Manstein, of the Cutaneous Biology Research Center in the department of dermatology at Massachusetts General Hospital, Boston, was exposed to three test spots in the evaluation of the effects of different microscopic thermal zone densities for the prototype device, emitting at 1,450 nm and an energy per MTZ of 3 mJ.

Two years later, hypopigmentation persisted at the test site treated with the highest MTZ density, while two other sites treated with the lower MTZ densities did not show any dyspigmentation. But he noticed something else during the experiment: He felt minimal to no pain as each test site was being treated.

“It took 7 minutes without any cooling or anesthesia,” Dr. Manstein recalled at the annual meeting of the American Society for Laser Medicine and Surgery. “It was not completely painless, but each time the laser was applied, sometimes I felt a little prick, sometimes I felt nothing.” Essentially, he added, “we created cell injury with a focused laser beam without anesthesia,” but this could also indicate that if skin is treated with a fractional laser very slowly, anesthesia is not needed. “Current devices are meant to treat very quickly, but if we [treat] slowly, maybe you could remove lesions painlessly without anesthesia.”

The observation from that experiment also led Dr. Manstein and colleagues to wonder: Could a focused laser beam pattern be used to assess cutaneous innervation? If so, they postulated, perhaps it could be used to not only assess nerve sensitivity of candidates for dermatologic surgery, but as a tool to help diagnose small fiber neuropathies such as diabetic neuropathy, and neuropathies in patients with HIV and sarcoidosis.

The current gold standard for making these diagnoses involves a skin biopsy, immunohistochemical analysis, and nerve fiber quantification, which is not widely available. It also requires strict histologic processing and nerve counting rules. Confocal microscopy of nerve fibers in the cornea is another approach, but is very difficult to perform, “so it would be nice if there was a simple way” to determine nerve fiber density in the skin using a focused laser beam, Dr. Manstein said.

With help from Payal Patel, MD, a dermatology research fellow at MGH, Dr. Manstein and colleagues have developed an intraepidermal nerve fiber density diagnostic device prototype that uses an erbium laser to conduct in vivo exposures, records each subject’s perception of a stimulus, and maps the areas of stimulus response. Current diameters being studied range from 0.076-1.15 mm and depths less than 0.71 mm. “We can focus the laser beam, preset the beam diameter, and very slowly, in a controlled manner, make a rectangular pattern, and after each time, inquire if the subject felt the pulse or not,” Dr. Manstein explained.

“This laser could become a new method for diagnosing nerve fiber neuropathies. If this works well, I think we can miniaturize the device,” he added.

Dr. Manstein disclosed that he is a consultant for Blossom Innovations, R2 Dermatology, and AVAVA. He is also a member of the advisory board for Blossom Innovations.

SAN DIEGO – In a 2006 report of complications from laser dermatologic surgery, one of the authors, Dieter Manstein, MD, PhD, who had subjected his forearm to treatment with a fractional laser skin resurfacing prototype device, was included as 1 of the 19 featured cases.

Dr. Manstein, of the Cutaneous Biology Research Center in the department of dermatology at Massachusetts General Hospital, Boston, was exposed to three test spots in the evaluation of the effects of different microscopic thermal zone densities for the prototype device, emitting at 1,450 nm and an energy per MTZ of 3 mJ.

Two years later, hypopigmentation persisted at the test site treated with the highest MTZ density, while two other sites treated with the lower MTZ densities did not show any dyspigmentation. But he noticed something else during the experiment: He felt minimal to no pain as each test site was being treated.

“It took 7 minutes without any cooling or anesthesia,” Dr. Manstein recalled at the annual meeting of the American Society for Laser Medicine and Surgery. “It was not completely painless, but each time the laser was applied, sometimes I felt a little prick, sometimes I felt nothing.” Essentially, he added, “we created cell injury with a focused laser beam without anesthesia,” but this could also indicate that if skin is treated with a fractional laser very slowly, anesthesia is not needed. “Current devices are meant to treat very quickly, but if we [treat] slowly, maybe you could remove lesions painlessly without anesthesia.”

The observation from that experiment also led Dr. Manstein and colleagues to wonder: Could a focused laser beam pattern be used to assess cutaneous innervation? If so, they postulated, perhaps it could be used to not only assess nerve sensitivity of candidates for dermatologic surgery, but as a tool to help diagnose small fiber neuropathies such as diabetic neuropathy, and neuropathies in patients with HIV and sarcoidosis.

The current gold standard for making these diagnoses involves a skin biopsy, immunohistochemical analysis, and nerve fiber quantification, which is not widely available. It also requires strict histologic processing and nerve counting rules. Confocal microscopy of nerve fibers in the cornea is another approach, but is very difficult to perform, “so it would be nice if there was a simple way” to determine nerve fiber density in the skin using a focused laser beam, Dr. Manstein said.

With help from Payal Patel, MD, a dermatology research fellow at MGH, Dr. Manstein and colleagues have developed an intraepidermal nerve fiber density diagnostic device prototype that uses an erbium laser to conduct in vivo exposures, records each subject’s perception of a stimulus, and maps the areas of stimulus response. Current diameters being studied range from 0.076-1.15 mm and depths less than 0.71 mm. “We can focus the laser beam, preset the beam diameter, and very slowly, in a controlled manner, make a rectangular pattern, and after each time, inquire if the subject felt the pulse or not,” Dr. Manstein explained.

“This laser could become a new method for diagnosing nerve fiber neuropathies. If this works well, I think we can miniaturize the device,” he added.

Dr. Manstein disclosed that he is a consultant for Blossom Innovations, R2 Dermatology, and AVAVA. He is also a member of the advisory board for Blossom Innovations.

SAN DIEGO – In a 2006 report of complications from laser dermatologic surgery, one of the authors, Dieter Manstein, MD, PhD, who had subjected his forearm to treatment with a fractional laser skin resurfacing prototype device, was included as 1 of the 19 featured cases.

Dr. Manstein, of the Cutaneous Biology Research Center in the department of dermatology at Massachusetts General Hospital, Boston, was exposed to three test spots in the evaluation of the effects of different microscopic thermal zone densities for the prototype device, emitting at 1,450 nm and an energy per MTZ of 3 mJ.

Two years later, hypopigmentation persisted at the test site treated with the highest MTZ density, while two other sites treated with the lower MTZ densities did not show any dyspigmentation. But he noticed something else during the experiment: He felt minimal to no pain as each test site was being treated.

“It took 7 minutes without any cooling or anesthesia,” Dr. Manstein recalled at the annual meeting of the American Society for Laser Medicine and Surgery. “It was not completely painless, but each time the laser was applied, sometimes I felt a little prick, sometimes I felt nothing.” Essentially, he added, “we created cell injury with a focused laser beam without anesthesia,” but this could also indicate that if skin is treated with a fractional laser very slowly, anesthesia is not needed. “Current devices are meant to treat very quickly, but if we [treat] slowly, maybe you could remove lesions painlessly without anesthesia.”

The observation from that experiment also led Dr. Manstein and colleagues to wonder: Could a focused laser beam pattern be used to assess cutaneous innervation? If so, they postulated, perhaps it could be used to not only assess nerve sensitivity of candidates for dermatologic surgery, but as a tool to help diagnose small fiber neuropathies such as diabetic neuropathy, and neuropathies in patients with HIV and sarcoidosis.

The current gold standard for making these diagnoses involves a skin biopsy, immunohistochemical analysis, and nerve fiber quantification, which is not widely available. It also requires strict histologic processing and nerve counting rules. Confocal microscopy of nerve fibers in the cornea is another approach, but is very difficult to perform, “so it would be nice if there was a simple way” to determine nerve fiber density in the skin using a focused laser beam, Dr. Manstein said.

With help from Payal Patel, MD, a dermatology research fellow at MGH, Dr. Manstein and colleagues have developed an intraepidermal nerve fiber density diagnostic device prototype that uses an erbium laser to conduct in vivo exposures, records each subject’s perception of a stimulus, and maps the areas of stimulus response. Current diameters being studied range from 0.076-1.15 mm and depths less than 0.71 mm. “We can focus the laser beam, preset the beam diameter, and very slowly, in a controlled manner, make a rectangular pattern, and after each time, inquire if the subject felt the pulse or not,” Dr. Manstein explained.

“This laser could become a new method for diagnosing nerve fiber neuropathies. If this works well, I think we can miniaturize the device,” he added.

Dr. Manstein disclosed that he is a consultant for Blossom Innovations, R2 Dermatology, and AVAVA. He is also a member of the advisory board for Blossom Innovations.

SAN DIEGO – Pilonidal disease – a chronic inflammatory condition that can trigger the formation of cysts and sinuses in the superior portion of the intragluteal cleft or the sacrococcygeal area – remains challenging to manage, but mounting evidence supports the use of lasers to enhance treatment success.

“Draining sinuses or acute abscesses are usually associated with an underlying cyst and associated granulation tissue, fibrosis, and tufts of hair,” Catherine M. DiGiorgio, MD, said at the annual conference of the American Society for Laser Medicine and Surgery. “This is why laser hair removal can help with the treatment of these patients.”

The suspected etiology is a foreign body reaction to the entrapped hairs, which are found in the sinuses in about 75% of cases. “The treatment for that is surgery,” said Dr. DiGiorgio, a laser and cosmetic dermatologist in Boston. Laser hair reduction decreases the recurrence of cyst formation and drainage, and is usually covered by insurance, she noted.
 

Supportive evidence

In a comparative study, French researchers retrospectively reviewed the efficacy of laser hair removal after surgery in reducing recurrence rate of pilonidal cysts, versus surgery alone. Of the 41 study participants, 12 had laser hair removal plus surgery and 29 had surgery alone. The rate of cyst recurrence was significantly lower in the laser hair removal plus surgery group, compared with the surgery only group (8.3% vs. 51.7%, respectively; P < .001).

In another study, researchers from the United Kingdom and The Johns Hopkins Hospital, Baltimore, evaluated the use of the long-pulsed Alexandrite laser in 19 patients with recurrent pilonidal disease who had undergone multiple surgeries.They were treated with the laser for hair removal in the sinus area, requiring 4-12 sessions. The researchers found that 84.2% of patients had a reduction of hair density to less than 5 hairs/cm², while 15.8% had a reduction of hair density to 5-10 hairs/cm^2. They also noted a statistically significant increase in disease-free time in the laser-treated group compared with those treated with surgical management only (P < .01).
 

Lasers for pseudofolliculitis barbae, HS

Lasers also play a significant role in the treatment of pseudofolliculitis barbae, a chronic, inflammatory disease that primarily affects the bearded area of men with thick hairs, usually those with a darker Fitzpatrick skin type. This can also occur in women, particularly those with polycystic ovary syndrome, Dr. DiGiorgio said.

In people with pseudofolliculitis barbae, the hair follicle is positioned at an acute angle to the skin surface and the sharp end of shaved hair reenters the skin, which results in the formation of pustules, papules, secondary infection, and keloids. Treatment involves a variety of medical therapies including retinoids, benzoyl peroxide, antibiotics, and keratolytics, “but laser hair removal is the best way to get rid of this issue, and results in permanent reduction,” she said. “When treating male patients with laser hair removal in the bearded area, you have to tell them that they won’t be able to grow a beard going forward. Most of them are okay with that.”

A 2002 study, led by E. Victor Ross, MD, of the Naval Medical Center, San Diego, evaluated treatment of pseudofolliculitis barbae in patients with skin types IV, V, and VI with a long-pulsed Nd:YAG laser. For the first phase of the study, the investigators tested epidermal tolerance on the thighs of 37 patients and determined that the laser was safe and effective. For the second phase 2 weeks later, they treated a 15x15-mm submental area with the highest fluence tolerated in phase 1 of the trial and used an adjacent site as the control.

After 90 days, the mean papule count was 6.95 for the control site compared with 1 for the laser-treated site. The researchers observed that miniaturization and elimination of hair shafts resulted in decreased inflamed papules. “We know that this works,” Dr. DiGiorgio said.

In another study from investigators at the Naval Medical Center, San Diego, 22 patients with skin types IV, V, and VI who had pseudofolliculitis barbae underwent 5 weekly treatments with a 1,064 nm Nd:YAG laser. Topical anesthesia was not used, and 10 evaluators used a Global Assessment Scale (GAS) to assess treatment success from photos taken at baseline and at 4 weeks. At 4 weeks, 11 patients demonstrated 83% improvement on the GAS (P < .01), the investigators reported.

Laser and energy-based treatments can also be used to treat hidradenitis suppurativa (HS), a chronic condition that affects apocrine gland–bearing skin. “The hypothesized pathogenesis is that it’s an inflammatory disorder of the hair follicle, where the follicle rupture introduces its contents into the surrounding dermis,” Dr. DiGiorgio said. “The skin reacts with a chemotactic response and abscess formation. This results in inflammatory nodules and sterile abscesses, which can lead to sinus tracts and hypertrophic scars and chronic drainage, which can be foul-smelling. This frequently leads to depression and psychological distress for the patients.”

Possible laser and energy-based treatments for HS include follicular destruction with the Nd:YAG laser, the diode laser, the Alexandrite laser, microwave technology, or intense pulsed light, she said. Microwave technology or radiofrequency can be used for sweat gland destruction, while CO₂ lasers can be used to debulk tissue, and the ablative fractional CO₂ laser can be used to reduce scarring and improve range of motion.

In a prospective, randomized, intraindividual comparative trial conducted at eight centers in France, researchers evaluated the use of a long-pulsed Nd:YAG laser to treat 36 patients with mild to moderate HS; 27 had inguinal disease and 9 had axillary disease. They received four laser treatments at 6-week intervals; laser settings varied depending on the patient skin type.

At 1 month, there was a significant reduction in the number of inflammatory lesions on the areas treated with lasers, compared to the untreated areas, but the difference was not significant at 3 months. There was no significant difference in the number of flares between the treated and untreated sites at 1 or 3 months.

In a separate study, researchers found that the Nd:YAG laser in combination with topical benzoyl peroxide and clindamycin was significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS in 22 patients with Hurley stage II disease. The patients received monthly treatments for 4 months and were followed up 2 months after the last treatment; the Hidradenitis Suppurativa Area and Severity Index was used to measure treatment response.

Statistically significant improvements were observed in the inguinal and axillary areas but not in the inframammary areas. Most patients (90%) reported less frequent breakouts while 10% reported no change. “In addition, 92% of subjects felt that the use of laser was more effective than other treatments they had tried but 8% stated it was equal to the other treatments they had tried,” said Dr. DiGiorgio, who was not affiliated with the study. “The researchers noted continued improvement with subsequent laser sessions,” she added.

According to 2019 guidelines from the United States and Canadian HS Foundations on the management of HS – in the section on light, laser, and energy sources – an Nd:YAG laser is recommended in patients with Hurley stage II or III disease on the basis of randomized, controlled trials and case series data, and in patients with Hurley stage I disease based on expert consensus. “Other wavelengths that are used for follicular destruction are recommended on the basis of lower-quality evidence,” the recommendations state.

The guidelines also state that CO₂ laser excision “is recommended in patients with Hurley stage II or III disease with fibrotic sinus tracts” while “external beam radiation and PDT have a limited role in the management of patients with HS.”

Dr. DiGiorgio reported having no relevant disclosures.

SAN DIEGO – Pilonidal disease – a chronic inflammatory condition that can trigger the formation of cysts and sinuses in the superior portion of the intragluteal cleft or the sacrococcygeal area – remains challenging to manage, but mounting evidence supports the use of lasers to enhance treatment success.

“Draining sinuses or acute abscesses are usually associated with an underlying cyst and associated granulation tissue, fibrosis, and tufts of hair,” Catherine M. DiGiorgio, MD, said at the annual conference of the American Society for Laser Medicine and Surgery. “This is why laser hair removal can help with the treatment of these patients.”

The suspected etiology is a foreign body reaction to the entrapped hairs, which are found in the sinuses in about 75% of cases. “The treatment for that is surgery,” said Dr. DiGiorgio, a laser and cosmetic dermatologist in Boston. Laser hair reduction decreases the recurrence of cyst formation and drainage, and is usually covered by insurance, she noted.
 

Supportive evidence

In a comparative study, French researchers retrospectively reviewed the efficacy of laser hair removal after surgery in reducing recurrence rate of pilonidal cysts, versus surgery alone. Of the 41 study participants, 12 had laser hair removal plus surgery and 29 had surgery alone. The rate of cyst recurrence was significantly lower in the laser hair removal plus surgery group, compared with the surgery only group (8.3% vs. 51.7%, respectively; P < .001).

In another study, researchers from the United Kingdom and The Johns Hopkins Hospital, Baltimore, evaluated the use of the long-pulsed Alexandrite laser in 19 patients with recurrent pilonidal disease who had undergone multiple surgeries.They were treated with the laser for hair removal in the sinus area, requiring 4-12 sessions. The researchers found that 84.2% of patients had a reduction of hair density to less than 5 hairs/cm², while 15.8% had a reduction of hair density to 5-10 hairs/cm^2. They also noted a statistically significant increase in disease-free time in the laser-treated group compared with those treated with surgical management only (P < .01).
 

Lasers for pseudofolliculitis barbae, HS

Lasers also play a significant role in the treatment of pseudofolliculitis barbae, a chronic, inflammatory disease that primarily affects the bearded area of men with thick hairs, usually those with a darker Fitzpatrick skin type. This can also occur in women, particularly those with polycystic ovary syndrome, Dr. DiGiorgio said.

In people with pseudofolliculitis barbae, the hair follicle is positioned at an acute angle to the skin surface and the sharp end of shaved hair reenters the skin, which results in the formation of pustules, papules, secondary infection, and keloids. Treatment involves a variety of medical therapies including retinoids, benzoyl peroxide, antibiotics, and keratolytics, “but laser hair removal is the best way to get rid of this issue, and results in permanent reduction,” she said. “When treating male patients with laser hair removal in the bearded area, you have to tell them that they won’t be able to grow a beard going forward. Most of them are okay with that.”

A 2002 study, led by E. Victor Ross, MD, of the Naval Medical Center, San Diego, evaluated treatment of pseudofolliculitis barbae in patients with skin types IV, V, and VI with a long-pulsed Nd:YAG laser. For the first phase of the study, the investigators tested epidermal tolerance on the thighs of 37 patients and determined that the laser was safe and effective. For the second phase 2 weeks later, they treated a 15x15-mm submental area with the highest fluence tolerated in phase 1 of the trial and used an adjacent site as the control.

After 90 days, the mean papule count was 6.95 for the control site compared with 1 for the laser-treated site. The researchers observed that miniaturization and elimination of hair shafts resulted in decreased inflamed papules. “We know that this works,” Dr. DiGiorgio said.

In another study from investigators at the Naval Medical Center, San Diego, 22 patients with skin types IV, V, and VI who had pseudofolliculitis barbae underwent 5 weekly treatments with a 1,064 nm Nd:YAG laser. Topical anesthesia was not used, and 10 evaluators used a Global Assessment Scale (GAS) to assess treatment success from photos taken at baseline and at 4 weeks. At 4 weeks, 11 patients demonstrated 83% improvement on the GAS (P < .01), the investigators reported.

Laser and energy-based treatments can also be used to treat hidradenitis suppurativa (HS), a chronic condition that affects apocrine gland–bearing skin. “The hypothesized pathogenesis is that it’s an inflammatory disorder of the hair follicle, where the follicle rupture introduces its contents into the surrounding dermis,” Dr. DiGiorgio said. “The skin reacts with a chemotactic response and abscess formation. This results in inflammatory nodules and sterile abscesses, which can lead to sinus tracts and hypertrophic scars and chronic drainage, which can be foul-smelling. This frequently leads to depression and psychological distress for the patients.”

Possible laser and energy-based treatments for HS include follicular destruction with the Nd:YAG laser, the diode laser, the Alexandrite laser, microwave technology, or intense pulsed light, she said. Microwave technology or radiofrequency can be used for sweat gland destruction, while CO₂ lasers can be used to debulk tissue, and the ablative fractional CO₂ laser can be used to reduce scarring and improve range of motion.

In a prospective, randomized, intraindividual comparative trial conducted at eight centers in France, researchers evaluated the use of a long-pulsed Nd:YAG laser to treat 36 patients with mild to moderate HS; 27 had inguinal disease and 9 had axillary disease. They received four laser treatments at 6-week intervals; laser settings varied depending on the patient skin type.

At 1 month, there was a significant reduction in the number of inflammatory lesions on the areas treated with lasers, compared to the untreated areas, but the difference was not significant at 3 months. There was no significant difference in the number of flares between the treated and untreated sites at 1 or 3 months.

In a separate study, researchers found that the Nd:YAG laser in combination with topical benzoyl peroxide and clindamycin was significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS in 22 patients with Hurley stage II disease. The patients received monthly treatments for 4 months and were followed up 2 months after the last treatment; the Hidradenitis Suppurativa Area and Severity Index was used to measure treatment response.

Statistically significant improvements were observed in the inguinal and axillary areas but not in the inframammary areas. Most patients (90%) reported less frequent breakouts while 10% reported no change. “In addition, 92% of subjects felt that the use of laser was more effective than other treatments they had tried but 8% stated it was equal to the other treatments they had tried,” said Dr. DiGiorgio, who was not affiliated with the study. “The researchers noted continued improvement with subsequent laser sessions,” she added.

According to 2019 guidelines from the United States and Canadian HS Foundations on the management of HS – in the section on light, laser, and energy sources – an Nd:YAG laser is recommended in patients with Hurley stage II or III disease on the basis of randomized, controlled trials and case series data, and in patients with Hurley stage I disease based on expert consensus. “Other wavelengths that are used for follicular destruction are recommended on the basis of lower-quality evidence,” the recommendations state.

The guidelines also state that CO₂ laser excision “is recommended in patients with Hurley stage II or III disease with fibrotic sinus tracts” while “external beam radiation and PDT have a limited role in the management of patients with HS.”

Dr. DiGiorgio reported having no relevant disclosures.

SAN DIEGO – Pilonidal disease – a chronic inflammatory condition that can trigger the formation of cysts and sinuses in the superior portion of the intragluteal cleft or the sacrococcygeal area – remains challenging to manage, but mounting evidence supports the use of lasers to enhance treatment success.

“Draining sinuses or acute abscesses are usually associated with an underlying cyst and associated granulation tissue, fibrosis, and tufts of hair,” Catherine M. DiGiorgio, MD, said at the annual conference of the American Society for Laser Medicine and Surgery. “This is why laser hair removal can help with the treatment of these patients.”

The suspected etiology is a foreign body reaction to the entrapped hairs, which are found in the sinuses in about 75% of cases. “The treatment for that is surgery,” said Dr. DiGiorgio, a laser and cosmetic dermatologist in Boston. Laser hair reduction decreases the recurrence of cyst formation and drainage, and is usually covered by insurance, she noted.
 

Supportive evidence

In a comparative study, French researchers retrospectively reviewed the efficacy of laser hair removal after surgery in reducing recurrence rate of pilonidal cysts, versus surgery alone. Of the 41 study participants, 12 had laser hair removal plus surgery and 29 had surgery alone. The rate of cyst recurrence was significantly lower in the laser hair removal plus surgery group, compared with the surgery only group (8.3% vs. 51.7%, respectively; P < .001).

In another study, researchers from the United Kingdom and The Johns Hopkins Hospital, Baltimore, evaluated the use of the long-pulsed Alexandrite laser in 19 patients with recurrent pilonidal disease who had undergone multiple surgeries.They were treated with the laser for hair removal in the sinus area, requiring 4-12 sessions. The researchers found that 84.2% of patients had a reduction of hair density to less than 5 hairs/cm², while 15.8% had a reduction of hair density to 5-10 hairs/cm^2. They also noted a statistically significant increase in disease-free time in the laser-treated group compared with those treated with surgical management only (P < .01).
 

Lasers for pseudofolliculitis barbae, HS

Lasers also play a significant role in the treatment of pseudofolliculitis barbae, a chronic, inflammatory disease that primarily affects the bearded area of men with thick hairs, usually those with a darker Fitzpatrick skin type. This can also occur in women, particularly those with polycystic ovary syndrome, Dr. DiGiorgio said.

In people with pseudofolliculitis barbae, the hair follicle is positioned at an acute angle to the skin surface and the sharp end of shaved hair reenters the skin, which results in the formation of pustules, papules, secondary infection, and keloids. Treatment involves a variety of medical therapies including retinoids, benzoyl peroxide, antibiotics, and keratolytics, “but laser hair removal is the best way to get rid of this issue, and results in permanent reduction,” she said. “When treating male patients with laser hair removal in the bearded area, you have to tell them that they won’t be able to grow a beard going forward. Most of them are okay with that.”

A 2002 study, led by E. Victor Ross, MD, of the Naval Medical Center, San Diego, evaluated treatment of pseudofolliculitis barbae in patients with skin types IV, V, and VI with a long-pulsed Nd:YAG laser. For the first phase of the study, the investigators tested epidermal tolerance on the thighs of 37 patients and determined that the laser was safe and effective. For the second phase 2 weeks later, they treated a 15x15-mm submental area with the highest fluence tolerated in phase 1 of the trial and used an adjacent site as the control.

After 90 days, the mean papule count was 6.95 for the control site compared with 1 for the laser-treated site. The researchers observed that miniaturization and elimination of hair shafts resulted in decreased inflamed papules. “We know that this works,” Dr. DiGiorgio said.

In another study from investigators at the Naval Medical Center, San Diego, 22 patients with skin types IV, V, and VI who had pseudofolliculitis barbae underwent 5 weekly treatments with a 1,064 nm Nd:YAG laser. Topical anesthesia was not used, and 10 evaluators used a Global Assessment Scale (GAS) to assess treatment success from photos taken at baseline and at 4 weeks. At 4 weeks, 11 patients demonstrated 83% improvement on the GAS (P < .01), the investigators reported.

Laser and energy-based treatments can also be used to treat hidradenitis suppurativa (HS), a chronic condition that affects apocrine gland–bearing skin. “The hypothesized pathogenesis is that it’s an inflammatory disorder of the hair follicle, where the follicle rupture introduces its contents into the surrounding dermis,” Dr. DiGiorgio said. “The skin reacts with a chemotactic response and abscess formation. This results in inflammatory nodules and sterile abscesses, which can lead to sinus tracts and hypertrophic scars and chronic drainage, which can be foul-smelling. This frequently leads to depression and psychological distress for the patients.”

Possible laser and energy-based treatments for HS include follicular destruction with the Nd:YAG laser, the diode laser, the Alexandrite laser, microwave technology, or intense pulsed light, she said. Microwave technology or radiofrequency can be used for sweat gland destruction, while CO₂ lasers can be used to debulk tissue, and the ablative fractional CO₂ laser can be used to reduce scarring and improve range of motion.

In a prospective, randomized, intraindividual comparative trial conducted at eight centers in France, researchers evaluated the use of a long-pulsed Nd:YAG laser to treat 36 patients with mild to moderate HS; 27 had inguinal disease and 9 had axillary disease. They received four laser treatments at 6-week intervals; laser settings varied depending on the patient skin type.

At 1 month, there was a significant reduction in the number of inflammatory lesions on the areas treated with lasers, compared to the untreated areas, but the difference was not significant at 3 months. There was no significant difference in the number of flares between the treated and untreated sites at 1 or 3 months.

In a separate study, researchers found that the Nd:YAG laser in combination with topical benzoyl peroxide and clindamycin was significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS in 22 patients with Hurley stage II disease. The patients received monthly treatments for 4 months and were followed up 2 months after the last treatment; the Hidradenitis Suppurativa Area and Severity Index was used to measure treatment response.

Statistically significant improvements were observed in the inguinal and axillary areas but not in the inframammary areas. Most patients (90%) reported less frequent breakouts while 10% reported no change. “In addition, 92% of subjects felt that the use of laser was more effective than other treatments they had tried but 8% stated it was equal to the other treatments they had tried,” said Dr. DiGiorgio, who was not affiliated with the study. “The researchers noted continued improvement with subsequent laser sessions,” she added.

According to 2019 guidelines from the United States and Canadian HS Foundations on the management of HS – in the section on light, laser, and energy sources – an Nd:YAG laser is recommended in patients with Hurley stage II or III disease on the basis of randomized, controlled trials and case series data, and in patients with Hurley stage I disease based on expert consensus. “Other wavelengths that are used for follicular destruction are recommended on the basis of lower-quality evidence,” the recommendations state.

The guidelines also state that CO₂ laser excision “is recommended in patients with Hurley stage II or III disease with fibrotic sinus tracts” while “external beam radiation and PDT have a limited role in the management of patients with HS.”

Dr. DiGiorgio reported having no relevant disclosures.

SAN DIEGO – Using the ablative fractional laser and other wounding therapies to destroy actinic keratoses (AKs) as a way to prevent skin cancer appears to spark other beneficial effects on skin biology, according to Molly Wanner, MD, MBA.

As a case in point, Dr. Wanner discussed the results of a trial of 48 people over aged 60 years with actinic damage, who received ablative fractional laser treatment on one arm and no treatment on the other arm, which served as the control. At 24 months, only two nonmelanoma skin cancers (NMSCs) developed on the treated arms, compared with 26 on the treated arms.

“What I find interesting is that the treated arm did not develop basal cell carcinoma, only squamous cell carcinoma,” she said at the annual meeting of the American Society for Laser Medicine and Surgery. “It appears that this is working through more than just treatment of the AK precursor lesions, for which fractional lasers are cleared for use. It appears to impact both types of NMSCs.”

The ablative fractional laser and other wounding therapies can modulate a response to UV light – a process that naturally diminishes with age, according to Dr. Wanner, a dermatologist at Massachusetts General Hospital’s Dermatology Laser and Cosmetic Center in Boston. “This ability to repair DNA is actually modulated by insulin-like growth factor 1,” she said. “IGF-1 is produced by papillary dermal fibroblasts and communicates with keratinocytes. If keratinocytes are exposed to UV light and there is no IGF-1 around, you get a mutated cell, and that keeps spreading, and you could potentially get a skin cancer.”

On the other hand, she continued, if IGF-1 is injected around the keratinocytes, they are able to respond. “Keratinocytes, which are the most superficial layer of the skin, are really active,” noted Dr. Wanner, who is also an assistant professor of dermatology at Harvard Medical School, Boston. “They’re dividing and replicating, whereas fibroblasts are more non-proliferative and more long-lived. They stick around for a long time. I think of them as the adults in the room, giving these new keratinocytes direction.”

In a review of wounding therapies for the prevention of photocarcinogenesis, she and her coauthors noted that IGF-1 increases nucleotide excision repair of damaged DNA, promotes checkpoint signaling and suppression of DNA synthesis, favors specialized polymerases that are better able to repair DNA damage, and enhances p53-dependent transcriptional responses to DNA damage.

“Older fibroblasts produce less IGF-1 and lead to a situation where keratinocytes can grow unchecked,” she said. “We can use fractional laser to help with this. Fractional laser increases fibroblast production and decreases senescent fibroblasts.”

In a 2017 review on the impact of age and IGF-1 on DNA damage responses in UV-irradiated skin, the authors noted the high levels of IGF-1 in the skin of younger individuals and lower levels in the skin of their older counterparts.

“But once older skin has been treated with either dermabrasion or fractional laser, the levels of IGF-1 are restored to that of a young adult,” Dr. Wanner said. “The restoration of IGF-1 then restores that level of appropriate response to UV light. So, what’s interesting is that fractional lasers treat more than a fraction [of skin]. Fractional lasers were developed to have an easier way to improve wound healing by leaving the skin intact around these columns [of treated skin]. It turns out that treatment of these columns of skin does not just impact the cells in that area. There is a true global effect that’s allowing us to almost normalize skin.”

Dr. Wanner now thinks of fractional lasers as stimulating a laser-cell biology interaction, not just a laser-tissue interaction. “It’s incredible that we can use these photons to not only impact the tissue itself but how the cells actually respond,” she said. “What’s going to be interesting for us in the next few years is to look at how lasers impact our cellular biology. How can we harness it to help our patients?”

She and her colleagues are conducting a trial of different wounding modalities to assess their impact on IGF-1. “Does depth matter? Does density matter? Does the wavelength matter?” she asked. “The bottom line is, it turns out that when the skin looks healthier, it is healthier. Cosmetic treatments can impact medical outcomes.”

Dr. Wanner disclosed that she is a consultant and advisor to Nu Skin. She has also received research funding and equipment from Solta.

SAN DIEGO – Using the ablative fractional laser and other wounding therapies to destroy actinic keratoses (AKs) as a way to prevent skin cancer appears to spark other beneficial effects on skin biology, according to Molly Wanner, MD, MBA.

As a case in point, Dr. Wanner discussed the results of a trial of 48 people over aged 60 years with actinic damage, who received ablative fractional laser treatment on one arm and no treatment on the other arm, which served as the control. At 24 months, only two nonmelanoma skin cancers (NMSCs) developed on the treated arms, compared with 26 on the treated arms.

“What I find interesting is that the treated arm did not develop basal cell carcinoma, only squamous cell carcinoma,” she said at the annual meeting of the American Society for Laser Medicine and Surgery. “It appears that this is working through more than just treatment of the AK precursor lesions, for which fractional lasers are cleared for use. It appears to impact both types of NMSCs.”

The ablative fractional laser and other wounding therapies can modulate a response to UV light – a process that naturally diminishes with age, according to Dr. Wanner, a dermatologist at Massachusetts General Hospital’s Dermatology Laser and Cosmetic Center in Boston. “This ability to repair DNA is actually modulated by insulin-like growth factor 1,” she said. “IGF-1 is produced by papillary dermal fibroblasts and communicates with keratinocytes. If keratinocytes are exposed to UV light and there is no IGF-1 around, you get a mutated cell, and that keeps spreading, and you could potentially get a skin cancer.”

On the other hand, she continued, if IGF-1 is injected around the keratinocytes, they are able to respond. “Keratinocytes, which are the most superficial layer of the skin, are really active,” noted Dr. Wanner, who is also an assistant professor of dermatology at Harvard Medical School, Boston. “They’re dividing and replicating, whereas fibroblasts are more non-proliferative and more long-lived. They stick around for a long time. I think of them as the adults in the room, giving these new keratinocytes direction.”

In a review of wounding therapies for the prevention of photocarcinogenesis, she and her coauthors noted that IGF-1 increases nucleotide excision repair of damaged DNA, promotes checkpoint signaling and suppression of DNA synthesis, favors specialized polymerases that are better able to repair DNA damage, and enhances p53-dependent transcriptional responses to DNA damage.

“Older fibroblasts produce less IGF-1 and lead to a situation where keratinocytes can grow unchecked,” she said. “We can use fractional laser to help with this. Fractional laser increases fibroblast production and decreases senescent fibroblasts.”

In a 2017 review on the impact of age and IGF-1 on DNA damage responses in UV-irradiated skin, the authors noted the high levels of IGF-1 in the skin of younger individuals and lower levels in the skin of their older counterparts.

“But once older skin has been treated with either dermabrasion or fractional laser, the levels of IGF-1 are restored to that of a young adult,” Dr. Wanner said. “The restoration of IGF-1 then restores that level of appropriate response to UV light. So, what’s interesting is that fractional lasers treat more than a fraction [of skin]. Fractional lasers were developed to have an easier way to improve wound healing by leaving the skin intact around these columns [of treated skin]. It turns out that treatment of these columns of skin does not just impact the cells in that area. There is a true global effect that’s allowing us to almost normalize skin.”

Dr. Wanner now thinks of fractional lasers as stimulating a laser-cell biology interaction, not just a laser-tissue interaction. “It’s incredible that we can use these photons to not only impact the tissue itself but how the cells actually respond,” she said. “What’s going to be interesting for us in the next few years is to look at how lasers impact our cellular biology. How can we harness it to help our patients?”

She and her colleagues are conducting a trial of different wounding modalities to assess their impact on IGF-1. “Does depth matter? Does density matter? Does the wavelength matter?” she asked. “The bottom line is, it turns out that when the skin looks healthier, it is healthier. Cosmetic treatments can impact medical outcomes.”

Dr. Wanner disclosed that she is a consultant and advisor to Nu Skin. She has also received research funding and equipment from Solta.

SAN DIEGO – Using the ablative fractional laser and other wounding therapies to destroy actinic keratoses (AKs) as a way to prevent skin cancer appears to spark other beneficial effects on skin biology, according to Molly Wanner, MD, MBA.

As a case in point, Dr. Wanner discussed the results of a trial of 48 people over aged 60 years with actinic damage, who received ablative fractional laser treatment on one arm and no treatment on the other arm, which served as the control. At 24 months, only two nonmelanoma skin cancers (NMSCs) developed on the treated arms, compared with 26 on the treated arms.

“What I find interesting is that the treated arm did not develop basal cell carcinoma, only squamous cell carcinoma,” she said at the annual meeting of the American Society for Laser Medicine and Surgery. “It appears that this is working through more than just treatment of the AK precursor lesions, for which fractional lasers are cleared for use. It appears to impact both types of NMSCs.”

The ablative fractional laser and other wounding therapies can modulate a response to UV light – a process that naturally diminishes with age, according to Dr. Wanner, a dermatologist at Massachusetts General Hospital’s Dermatology Laser and Cosmetic Center in Boston. “This ability to repair DNA is actually modulated by insulin-like growth factor 1,” she said. “IGF-1 is produced by papillary dermal fibroblasts and communicates with keratinocytes. If keratinocytes are exposed to UV light and there is no IGF-1 around, you get a mutated cell, and that keeps spreading, and you could potentially get a skin cancer.”

On the other hand, she continued, if IGF-1 is injected around the keratinocytes, they are able to respond. “Keratinocytes, which are the most superficial layer of the skin, are really active,” noted Dr. Wanner, who is also an assistant professor of dermatology at Harvard Medical School, Boston. “They’re dividing and replicating, whereas fibroblasts are more non-proliferative and more long-lived. They stick around for a long time. I think of them as the adults in the room, giving these new keratinocytes direction.”

In a review of wounding therapies for the prevention of photocarcinogenesis, she and her coauthors noted that IGF-1 increases nucleotide excision repair of damaged DNA, promotes checkpoint signaling and suppression of DNA synthesis, favors specialized polymerases that are better able to repair DNA damage, and enhances p53-dependent transcriptional responses to DNA damage.

“Older fibroblasts produce less IGF-1 and lead to a situation where keratinocytes can grow unchecked,” she said. “We can use fractional laser to help with this. Fractional laser increases fibroblast production and decreases senescent fibroblasts.”

In a 2017 review on the impact of age and IGF-1 on DNA damage responses in UV-irradiated skin, the authors noted the high levels of IGF-1 in the skin of younger individuals and lower levels in the skin of their older counterparts.

“But once older skin has been treated with either dermabrasion or fractional laser, the levels of IGF-1 are restored to that of a young adult,” Dr. Wanner said. “The restoration of IGF-1 then restores that level of appropriate response to UV light. So, what’s interesting is that fractional lasers treat more than a fraction [of skin]. Fractional lasers were developed to have an easier way to improve wound healing by leaving the skin intact around these columns [of treated skin]. It turns out that treatment of these columns of skin does not just impact the cells in that area. There is a true global effect that’s allowing us to almost normalize skin.”

Dr. Wanner now thinks of fractional lasers as stimulating a laser-cell biology interaction, not just a laser-tissue interaction. “It’s incredible that we can use these photons to not only impact the tissue itself but how the cells actually respond,” she said. “What’s going to be interesting for us in the next few years is to look at how lasers impact our cellular biology. How can we harness it to help our patients?”

She and her colleagues are conducting a trial of different wounding modalities to assess their impact on IGF-1. “Does depth matter? Does density matter? Does the wavelength matter?” she asked. “The bottom line is, it turns out that when the skin looks healthier, it is healthier. Cosmetic treatments can impact medical outcomes.”

Dr. Wanner disclosed that she is a consultant and advisor to Nu Skin. She has also received research funding and equipment from Solta.

SAN DIEGO – During her third year in the combined Harvard/Massachusetts General Hospital dermatology residency program in 2011, Lilit Garibyan, MD, PhD, attended a lecture presented by R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at MGH. He described the concept of selective cryolipolysis – the method of removing fat by topical cooling that eventually led to the development of the CoolSculpting device.

“He was saying that this is such a great noninvasive technology for fat removal and that patients love it,” Dr. Garibyan recalled at the annual meeting of the American Society for Laser Medicine and Surgery. “But one of the most common side effects after cryolipolysis that is long-lasting, but completely reversible, is hypoesthesia. I was intrigued by this because even as a dermatology resident, I had seen how pain and itch symptoms are present in many dermatologic diseases, and we don’t have great treatments for them. I thought to myself, if we can figure out the mechanism of how this topical cooling is affecting the nerves for such a long time, then maybe we could develop therapies where we could selectively target just the nerves,” not the fat.

courtesy Dr. Lilit Garibyan

Following Dr. Anderson’s lecture, Dr. Garibyan asked him if anyone knew the mechanism of action or if anyone was working to find out. He did not, but Dr. Anderson invited her to join his lab to investigate. “I didn’t have a background in lasers or energy devices, but I thought this was such a great opportunity” and addressed an unmet need, she said at the meeting.

Dr. Garibyan then led a clinical trial to characterize the effect of a single cryolipolysis treatment in 11 healthy people and to quantitatively analyze what sensory functions change with treatment over a period of 56 days. Skin biopsies revealed that cryolipolysis mainly decreased myelinated dermal nerve fiber density, which persisted throughout the study.

“The conclusion was that yes, controlled topical cooling does lead to significant and long-lasting but reversible reduction of sensory function, including pain,” said Dr. Garibyan, who is now an assistant professor of dermatology at Harvard Medical School, Boston, and director of the Magic Wand Initiative at the Wellman Center.

Ice slurry injections

Enter ice slurry, a chilly mix of ice, saline, and glycol that can be directly injected into adipose tissue. In a swine study published online in January 2020, Dr. Garibyan and colleagues at the Wellman Center injected ice slurry into the flanks of swine and followed them for up to 8 weeks, using ultrasound imaging to quantify and show the location of fat loss. The researchers observed about 40%-50% loss of fat in the treated area, compared with a 60% increase of fat in controls. “On histology, this was very selective,” she said. “Only adipose tissue was affected. There was no damage to the underlying muscle or to the dermis or epidermis.”

In 2021, researchers tested the injection of ice slurry in 12 humans for the first time, injected into tissue, and followed them for 12 weeks. As observed by thermal imaging, ultrasound, and tissue histology, they concluded that ice slurry injection was feasible and safe as a way of inducing cryolipolysis, and was well tolerated by patients.

“This can become a promising treatment for a precise, effective, and customizable way of removing unwanted fat for aesthetic application,” Dr. Garibyan said. However, she added, it is not approved by the Food and Drug Administration and more studies are needed, “but it’s promising and encouraging to see this move forward in patients.”
 

Potential nonaesthetic uses

The potential applications of injectable ice slurry extend well beyond cosmetic dermatology, she continued, noting that it is being explored as a treatment for many medical conditions including obstructive sleep apnea (OSA). At the University of Pennsylvania, Philadelphia, researchers used MRI to image the tongue fat in a case-control study of 31 obese patients without OSA and 90 obese patients with OSA. They found that patients with OSA had increased deposition of fat at the base of their tongue, which can lead to airway obstruction in this subset of patients with OSA, pointed out Dr. Garibyan, who was not involved with the study. “This also gave us a hint. If we can remove that tongue fat, we could potentially help reduce severity or even cure OSA in this population of patients. This points to tongue fat as a therapeutic target.”

With help from researchers at Uniformed Services University of the Health Sciences, Bethesda, Md., she and her Wellman Center colleagues recently completed a swine study that showed the safety and feasibility of injecting the base of the tongue with ice slurry, targeting adipose tissue. The work has been submitted for publication in a journal, but at the meeting, she said that, 8 weeks after injecting the ice slurry, there were no changes to any tongue tissue other than fat.

“On histology, we only see selective damage to the adipose tissue,” she said. “It is very promising that it’s safe in animal models and we’re hoping to conduct a human trial later this year to test the ability of this injectable ice slurry to remove fat at the base of the tongue with the hope that this will treat OSA.”

Another potential application of this technology is in the cardiology field. Dr. Garibyan is part of a multidisciplinary team at MGH that includes cardiac surgeons, cardiologists, and imaging experts who plan to investigate whether injecting ice slurry into fat around the heart can modify heart disease in humans. “Visceral fat around the heart – pericardial fat and epicardial fat – is involved in cardiovascular disease, arrhythmias, and many other unwanted effects on the heart,” she said. “Imagine if you could inject this around the heart, ablate the fat, and halt cardiovascular disease?”

She led a study that examined the effect of injecting ice slurry into swine with significant amounts of adipose tissue around their hearts, based on baseline CT scans. She and her coinvestigators observed a significant loss of that fat tissue on follow-up CT scans 8 weeks later. “On average, there was about a 30% reduction of this pericardial adipose tissue after a single injection,” and the procedure “was safe and well tolerated by the animals,” she added.

Ice slurry could also play a role in managing pain by targeting peripheral nerves. Peripheral nerves are composed of 75%-80% lipids, such as the myelin sheaths around the nerves, she noted. “That’s lipid-rich tissue. We think that by targeting that we’re able to block pain.”

She led a study that showed that a single injection of ice slurry around the sciatic nerve in rats served as a sustained anesthetic by blocking mechanical pain sensation for up to 56 days. They imaged the peripheral nerves in the rats and showed that the mechanism involved was loss of the lipid-rich myelin tissue around the nerves, which blocks the signaling of the nerve, she said.

Dr. Garibyan disclosed that she is a member of the advisory board for Brixton Biosciences, Vyome Therapeutics, and Aegle Therapeutics. She is also a consultant for Aegle Therapeutics and Blossom Innovations and holds equity in Brixton Biosciences and EyeCool Therapeutics.

SAN DIEGO – During her third year in the combined Harvard/Massachusetts General Hospital dermatology residency program in 2011, Lilit Garibyan, MD, PhD, attended a lecture presented by R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at MGH. He described the concept of selective cryolipolysis – the method of removing fat by topical cooling that eventually led to the development of the CoolSculpting device.

“He was saying that this is such a great noninvasive technology for fat removal and that patients love it,” Dr. Garibyan recalled at the annual meeting of the American Society for Laser Medicine and Surgery. “But one of the most common side effects after cryolipolysis that is long-lasting, but completely reversible, is hypoesthesia. I was intrigued by this because even as a dermatology resident, I had seen how pain and itch symptoms are present in many dermatologic diseases, and we don’t have great treatments for them. I thought to myself, if we can figure out the mechanism of how this topical cooling is affecting the nerves for such a long time, then maybe we could develop therapies where we could selectively target just the nerves,” not the fat.

courtesy Dr. Lilit Garibyan

Following Dr. Anderson’s lecture, Dr. Garibyan asked him if anyone knew the mechanism of action or if anyone was working to find out. He did not, but Dr. Anderson invited her to join his lab to investigate. “I didn’t have a background in lasers or energy devices, but I thought this was such a great opportunity” and addressed an unmet need, she said at the meeting.

Dr. Garibyan then led a clinical trial to characterize the effect of a single cryolipolysis treatment in 11 healthy people and to quantitatively analyze what sensory functions change with treatment over a period of 56 days. Skin biopsies revealed that cryolipolysis mainly decreased myelinated dermal nerve fiber density, which persisted throughout the study.

“The conclusion was that yes, controlled topical cooling does lead to significant and long-lasting but reversible reduction of sensory function, including pain,” said Dr. Garibyan, who is now an assistant professor of dermatology at Harvard Medical School, Boston, and director of the Magic Wand Initiative at the Wellman Center.

Ice slurry injections

Enter ice slurry, a chilly mix of ice, saline, and glycol that can be directly injected into adipose tissue. In a swine study published online in January 2020, Dr. Garibyan and colleagues at the Wellman Center injected ice slurry into the flanks of swine and followed them for up to 8 weeks, using ultrasound imaging to quantify and show the location of fat loss. The researchers observed about 40%-50% loss of fat in the treated area, compared with a 60% increase of fat in controls. “On histology, this was very selective,” she said. “Only adipose tissue was affected. There was no damage to the underlying muscle or to the dermis or epidermis.”

In 2021, researchers tested the injection of ice slurry in 12 humans for the first time, injected into tissue, and followed them for 12 weeks. As observed by thermal imaging, ultrasound, and tissue histology, they concluded that ice slurry injection was feasible and safe as a way of inducing cryolipolysis, and was well tolerated by patients.

“This can become a promising treatment for a precise, effective, and customizable way of removing unwanted fat for aesthetic application,” Dr. Garibyan said. However, she added, it is not approved by the Food and Drug Administration and more studies are needed, “but it’s promising and encouraging to see this move forward in patients.”
 

Potential nonaesthetic uses

The potential applications of injectable ice slurry extend well beyond cosmetic dermatology, she continued, noting that it is being explored as a treatment for many medical conditions including obstructive sleep apnea (OSA). At the University of Pennsylvania, Philadelphia, researchers used MRI to image the tongue fat in a case-control study of 31 obese patients without OSA and 90 obese patients with OSA. They found that patients with OSA had increased deposition of fat at the base of their tongue, which can lead to airway obstruction in this subset of patients with OSA, pointed out Dr. Garibyan, who was not involved with the study. “This also gave us a hint. If we can remove that tongue fat, we could potentially help reduce severity or even cure OSA in this population of patients. This points to tongue fat as a therapeutic target.”

With help from researchers at Uniformed Services University of the Health Sciences, Bethesda, Md., she and her Wellman Center colleagues recently completed a swine study that showed the safety and feasibility of injecting the base of the tongue with ice slurry, targeting adipose tissue. The work has been submitted for publication in a journal, but at the meeting, she said that, 8 weeks after injecting the ice slurry, there were no changes to any tongue tissue other than fat.

“On histology, we only see selective damage to the adipose tissue,” she said. “It is very promising that it’s safe in animal models and we’re hoping to conduct a human trial later this year to test the ability of this injectable ice slurry to remove fat at the base of the tongue with the hope that this will treat OSA.”

Another potential application of this technology is in the cardiology field. Dr. Garibyan is part of a multidisciplinary team at MGH that includes cardiac surgeons, cardiologists, and imaging experts who plan to investigate whether injecting ice slurry into fat around the heart can modify heart disease in humans. “Visceral fat around the heart – pericardial fat and epicardial fat – is involved in cardiovascular disease, arrhythmias, and many other unwanted effects on the heart,” she said. “Imagine if you could inject this around the heart, ablate the fat, and halt cardiovascular disease?”

She led a study that examined the effect of injecting ice slurry into swine with significant amounts of adipose tissue around their hearts, based on baseline CT scans. She and her coinvestigators observed a significant loss of that fat tissue on follow-up CT scans 8 weeks later. “On average, there was about a 30% reduction of this pericardial adipose tissue after a single injection,” and the procedure “was safe and well tolerated by the animals,” she added.

Ice slurry could also play a role in managing pain by targeting peripheral nerves. Peripheral nerves are composed of 75%-80% lipids, such as the myelin sheaths around the nerves, she noted. “That’s lipid-rich tissue. We think that by targeting that we’re able to block pain.”

She led a study that showed that a single injection of ice slurry around the sciatic nerve in rats served as a sustained anesthetic by blocking mechanical pain sensation for up to 56 days. They imaged the peripheral nerves in the rats and showed that the mechanism involved was loss of the lipid-rich myelin tissue around the nerves, which blocks the signaling of the nerve, she said.

Dr. Garibyan disclosed that she is a member of the advisory board for Brixton Biosciences, Vyome Therapeutics, and Aegle Therapeutics. She is also a consultant for Aegle Therapeutics and Blossom Innovations and holds equity in Brixton Biosciences and EyeCool Therapeutics.

SAN DIEGO – During her third year in the combined Harvard/Massachusetts General Hospital dermatology residency program in 2011, Lilit Garibyan, MD, PhD, attended a lecture presented by R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at MGH. He described the concept of selective cryolipolysis – the method of removing fat by topical cooling that eventually led to the development of the CoolSculpting device.

“He was saying that this is such a great noninvasive technology for fat removal and that patients love it,” Dr. Garibyan recalled at the annual meeting of the American Society for Laser Medicine and Surgery. “But one of the most common side effects after cryolipolysis that is long-lasting, but completely reversible, is hypoesthesia. I was intrigued by this because even as a dermatology resident, I had seen how pain and itch symptoms are present in many dermatologic diseases, and we don’t have great treatments for them. I thought to myself, if we can figure out the mechanism of how this topical cooling is affecting the nerves for such a long time, then maybe we could develop therapies where we could selectively target just the nerves,” not the fat.

courtesy Dr. Lilit Garibyan

Following Dr. Anderson’s lecture, Dr. Garibyan asked him if anyone knew the mechanism of action or if anyone was working to find out. He did not, but Dr. Anderson invited her to join his lab to investigate. “I didn’t have a background in lasers or energy devices, but I thought this was such a great opportunity” and addressed an unmet need, she said at the meeting.

Dr. Garibyan then led a clinical trial to characterize the effect of a single cryolipolysis treatment in 11 healthy people and to quantitatively analyze what sensory functions change with treatment over a period of 56 days. Skin biopsies revealed that cryolipolysis mainly decreased myelinated dermal nerve fiber density, which persisted throughout the study.

“The conclusion was that yes, controlled topical cooling does lead to significant and long-lasting but reversible reduction of sensory function, including pain,” said Dr. Garibyan, who is now an assistant professor of dermatology at Harvard Medical School, Boston, and director of the Magic Wand Initiative at the Wellman Center.

Ice slurry injections

Enter ice slurry, a chilly mix of ice, saline, and glycol that can be directly injected into adipose tissue. In a swine study published online in January 2020, Dr. Garibyan and colleagues at the Wellman Center injected ice slurry into the flanks of swine and followed them for up to 8 weeks, using ultrasound imaging to quantify and show the location of fat loss. The researchers observed about 40%-50% loss of fat in the treated area, compared with a 60% increase of fat in controls. “On histology, this was very selective,” she said. “Only adipose tissue was affected. There was no damage to the underlying muscle or to the dermis or epidermis.”

In 2021, researchers tested the injection of ice slurry in 12 humans for the first time, injected into tissue, and followed them for 12 weeks. As observed by thermal imaging, ultrasound, and tissue histology, they concluded that ice slurry injection was feasible and safe as a way of inducing cryolipolysis, and was well tolerated by patients.

“This can become a promising treatment for a precise, effective, and customizable way of removing unwanted fat for aesthetic application,” Dr. Garibyan said. However, she added, it is not approved by the Food and Drug Administration and more studies are needed, “but it’s promising and encouraging to see this move forward in patients.”
 

Potential nonaesthetic uses

The potential applications of injectable ice slurry extend well beyond cosmetic dermatology, she continued, noting that it is being explored as a treatment for many medical conditions including obstructive sleep apnea (OSA). At the University of Pennsylvania, Philadelphia, researchers used MRI to image the tongue fat in a case-control study of 31 obese patients without OSA and 90 obese patients with OSA. They found that patients with OSA had increased deposition of fat at the base of their tongue, which can lead to airway obstruction in this subset of patients with OSA, pointed out Dr. Garibyan, who was not involved with the study. “This also gave us a hint. If we can remove that tongue fat, we could potentially help reduce severity or even cure OSA in this population of patients. This points to tongue fat as a therapeutic target.”

With help from researchers at Uniformed Services University of the Health Sciences, Bethesda, Md., she and her Wellman Center colleagues recently completed a swine study that showed the safety and feasibility of injecting the base of the tongue with ice slurry, targeting adipose tissue. The work has been submitted for publication in a journal, but at the meeting, she said that, 8 weeks after injecting the ice slurry, there were no changes to any tongue tissue other than fat.

“On histology, we only see selective damage to the adipose tissue,” she said. “It is very promising that it’s safe in animal models and we’re hoping to conduct a human trial later this year to test the ability of this injectable ice slurry to remove fat at the base of the tongue with the hope that this will treat OSA.”

Another potential application of this technology is in the cardiology field. Dr. Garibyan is part of a multidisciplinary team at MGH that includes cardiac surgeons, cardiologists, and imaging experts who plan to investigate whether injecting ice slurry into fat around the heart can modify heart disease in humans. “Visceral fat around the heart – pericardial fat and epicardial fat – is involved in cardiovascular disease, arrhythmias, and many other unwanted effects on the heart,” she said. “Imagine if you could inject this around the heart, ablate the fat, and halt cardiovascular disease?”

She led a study that examined the effect of injecting ice slurry into swine with significant amounts of adipose tissue around their hearts, based on baseline CT scans. She and her coinvestigators observed a significant loss of that fat tissue on follow-up CT scans 8 weeks later. “On average, there was about a 30% reduction of this pericardial adipose tissue after a single injection,” and the procedure “was safe and well tolerated by the animals,” she added.

Ice slurry could also play a role in managing pain by targeting peripheral nerves. Peripheral nerves are composed of 75%-80% lipids, such as the myelin sheaths around the nerves, she noted. “That’s lipid-rich tissue. We think that by targeting that we’re able to block pain.”

She led a study that showed that a single injection of ice slurry around the sciatic nerve in rats served as a sustained anesthetic by blocking mechanical pain sensation for up to 56 days. They imaged the peripheral nerves in the rats and showed that the mechanism involved was loss of the lipid-rich myelin tissue around the nerves, which blocks the signaling of the nerve, she said.

Dr. Garibyan disclosed that she is a member of the advisory board for Brixton Biosciences, Vyome Therapeutics, and Aegle Therapeutics. She is also a consultant for Aegle Therapeutics and Blossom Innovations and holds equity in Brixton Biosciences and EyeCool Therapeutics.

SAN DIEGO – When the Food and Drug Administration gave the nod to a first-in-class tissue removal device in July of 2021, clearance was limited to the treatment of moderate to severe wrinkles in the mid to lower face.

But once the device – Ellacor– becomes available in late 2022, potential applications are likely to be wide-ranging, Jill S. Waibel, MD, a dermatologist with the Miami Dermatology and Laser Institute, predicted at the annual conference of the American Society for Laser Medicine and Surgery. “I’m using it in my practice more for laxity and jowls,” she said. Eventually, “I think it’s going to be preventative for 30- to 50-year-olds but that hasn’t been studied. I think it’s going to have a pre- and postrhytidectomy role, so I think the plastic surgeons are going to love this in their practice.”

Developed by Cytrellis, and based on research conducted by William G. Austen Jr., MD, chief of plastic and reconstructive surgery at Massachusetts General Hospital (MGH), Boston, and R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at MGH, the company’s scientific founders, the device uses hollow needles contained in a handpiece to create thousands of microexcisions to physically remove small cores of skin – a process known as microcoring. Dr. Austin and Dr. Anderson were the senior authors, respectively, of seminal trials of the device in swine, published in 2013 and 2015.

This can result in immediate physical hole closures (mechanical closure), which may lead to skin tightening.

“We’re removing dermis and epidermis,” said Dr. Waibel, who noted that the technology has been studied mostly for skin laxity and rhytids. “There are no other devices that are doing this.”

The immediate closure of tiny holes in the skin results in a quantitative and directional reduction in the treated area of skin, she said, which leads to wrinkle improvement, tightening, and smoothing of lax skin. The device contains three 22-guage needles that are less than 500 micrometers in diameter. “Based on optical coherence tomography work we did, these channels of treated skin stay open for about 1.5 minutes,” she added, noting that the tunable depth of the device ranges from 0 to 4 mm. “I tend to treat only with the 4-mm depth,” said Dr. Waibel, who is subsection chief of dermatology at Baptist Hospital of Miami.

The device features a disposable tip that can remove up to 24,000 cores of skin, and the amount of skin removed in a treated area can be 1%, 3%, 5%, 7%, and 8%. “The more cores you do, the more wrinkle improvement we saw in pivotal trials,” she said. “A minimal core count of 12,000 per treatment is recommended for the mid and lower face. Interestingly, higher core counts do not result in more patient downtime.” In her office, she said that the treatment takes about 20 minutes. Recommended postoperative care involves application of petrolatum or Aquaphor over the treated area for 24 hours, or until the holes have closed. “There is very low postoperative downtime,” she noted.

According to pivotal clinical data from Cytrellis on 51 patients treated with Ellacor, patients experienced a mean 1.3-grade improvement on the Lemperle Rating Scale, 86% said that they were satisfied with the procedure, and investigators rated their Global Aesthetic Improvement as 90%.

To date, Dr. Waibel and her colleagues in Miami have treated 102 patients with Ellacor, mostly for wrinkles and skin laxity. In these patients, the minimal downtime experienced was 3.8 days, 75% of patients did not miss any work, and 46% did not miss any social activities. The worst part for patients is the preprocedure numbing, she said. “We do lidocaine injections. Some people do nerve blocks. Once you do the lidocaine injection, the average pain is about 0.36 on a scale of 1-10 during treatment and 0 for all subsequent time points.”

At the meeting, she presented a set of before and after photos that showed improvement of moderate facial wrinkles in a female patient 90 days after one treatment with Ellacor, which removed about 5% of skin in the area of the jowls. “It’s pretty incredible,” Dr. Waibel remarked.

“I don’t have anything in my practice that can help with that kind of laxity other than sending them to a plastic surgeon, and I have about 80 devices.”

Images courtesy Dr. Jill S. Waibel

At the 2019 meeting of the American Society for Dermatologic Surgery, Dr. Waibel and Roy G. Geronemus, MD, director of the Laser & Skin Surgery Center of New York, presented a small pilot study on the successful use of Ellacor for acne scars and striae. Dr. Waibel said that she and her colleagues in Miami have been using the device to treat skin laxity in several anatomical areas, including the neck, nose, inner thigh, above the knee, elbow, and the axillary region. They have used the device to treat tattoos, rhytidectomy scars, abdominal striae, acne and surgical scars, and idiopathic guttate hypomelanosis, she added.

“We do a lot of combinations with other devices on the same day, and I think this list will increase over the next few years,” she said. “Probably my favorite use in the past 5 months has been doing microcoring and, separated by a month, doing resurfacing.”

Clinical trials of Ellacor were conducted in patients with types I-IV skin, but she has treated several patients with types V-VI skin “with absolutely no safety issues,” which includes treatment of epidermal nevi.

Which variables are the most important for patient selection and procedural success remain unclear, she continued, including patient age, elastic recoil, body mass index, history of a prior procedure (such as radiofrequency or ultrasound), the amount of laxity and rhytids, and overall health, which have not been studied, Dr. Waibel said.

“We have patients that don’t have the same response as others. For the modest improvement seen in some patients, is that their elastic recoil or are we choosing the wrong patients? Do they need more treatments? We are also still learning about the ideal treatment for scars and other indications.”

The device is expected to launch in fourth quarter of 2022.

Dr. Waibel disclosed that she is an advisory board member for Cytrellis. She has conducted clinical trials for and is a consultant to many pharmaceutical and device companies.

SAN DIEGO – When the Food and Drug Administration gave the nod to a first-in-class tissue removal device in July of 2021, clearance was limited to the treatment of moderate to severe wrinkles in the mid to lower face.

But once the device – Ellacor– becomes available in late 2022, potential applications are likely to be wide-ranging, Jill S. Waibel, MD, a dermatologist with the Miami Dermatology and Laser Institute, predicted at the annual conference of the American Society for Laser Medicine and Surgery. “I’m using it in my practice more for laxity and jowls,” she said. Eventually, “I think it’s going to be preventative for 30- to 50-year-olds but that hasn’t been studied. I think it’s going to have a pre- and postrhytidectomy role, so I think the plastic surgeons are going to love this in their practice.”

Developed by Cytrellis, and based on research conducted by William G. Austen Jr., MD, chief of plastic and reconstructive surgery at Massachusetts General Hospital (MGH), Boston, and R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at MGH, the company’s scientific founders, the device uses hollow needles contained in a handpiece to create thousands of microexcisions to physically remove small cores of skin – a process known as microcoring. Dr. Austin and Dr. Anderson were the senior authors, respectively, of seminal trials of the device in swine, published in 2013 and 2015.

This can result in immediate physical hole closures (mechanical closure), which may lead to skin tightening.

“We’re removing dermis and epidermis,” said Dr. Waibel, who noted that the technology has been studied mostly for skin laxity and rhytids. “There are no other devices that are doing this.”

The immediate closure of tiny holes in the skin results in a quantitative and directional reduction in the treated area of skin, she said, which leads to wrinkle improvement, tightening, and smoothing of lax skin. The device contains three 22-guage needles that are less than 500 micrometers in diameter. “Based on optical coherence tomography work we did, these channels of treated skin stay open for about 1.5 minutes,” she added, noting that the tunable depth of the device ranges from 0 to 4 mm. “I tend to treat only with the 4-mm depth,” said Dr. Waibel, who is subsection chief of dermatology at Baptist Hospital of Miami.

The device features a disposable tip that can remove up to 24,000 cores of skin, and the amount of skin removed in a treated area can be 1%, 3%, 5%, 7%, and 8%. “The more cores you do, the more wrinkle improvement we saw in pivotal trials,” she said. “A minimal core count of 12,000 per treatment is recommended for the mid and lower face. Interestingly, higher core counts do not result in more patient downtime.” In her office, she said that the treatment takes about 20 minutes. Recommended postoperative care involves application of petrolatum or Aquaphor over the treated area for 24 hours, or until the holes have closed. “There is very low postoperative downtime,” she noted.

According to pivotal clinical data from Cytrellis on 51 patients treated with Ellacor, patients experienced a mean 1.3-grade improvement on the Lemperle Rating Scale, 86% said that they were satisfied with the procedure, and investigators rated their Global Aesthetic Improvement as 90%.

To date, Dr. Waibel and her colleagues in Miami have treated 102 patients with Ellacor, mostly for wrinkles and skin laxity. In these patients, the minimal downtime experienced was 3.8 days, 75% of patients did not miss any work, and 46% did not miss any social activities. The worst part for patients is the preprocedure numbing, she said. “We do lidocaine injections. Some people do nerve blocks. Once you do the lidocaine injection, the average pain is about 0.36 on a scale of 1-10 during treatment and 0 for all subsequent time points.”

At the meeting, she presented a set of before and after photos that showed improvement of moderate facial wrinkles in a female patient 90 days after one treatment with Ellacor, which removed about 5% of skin in the area of the jowls. “It’s pretty incredible,” Dr. Waibel remarked.

“I don’t have anything in my practice that can help with that kind of laxity other than sending them to a plastic surgeon, and I have about 80 devices.”

Images courtesy Dr. Jill S. Waibel

At the 2019 meeting of the American Society for Dermatologic Surgery, Dr. Waibel and Roy G. Geronemus, MD, director of the Laser & Skin Surgery Center of New York, presented a small pilot study on the successful use of Ellacor for acne scars and striae. Dr. Waibel said that she and her colleagues in Miami have been using the device to treat skin laxity in several anatomical areas, including the neck, nose, inner thigh, above the knee, elbow, and the axillary region. They have used the device to treat tattoos, rhytidectomy scars, abdominal striae, acne and surgical scars, and idiopathic guttate hypomelanosis, she added.

“We do a lot of combinations with other devices on the same day, and I think this list will increase over the next few years,” she said. “Probably my favorite use in the past 5 months has been doing microcoring and, separated by a month, doing resurfacing.”

Clinical trials of Ellacor were conducted in patients with types I-IV skin, but she has treated several patients with types V-VI skin “with absolutely no safety issues,” which includes treatment of epidermal nevi.

Which variables are the most important for patient selection and procedural success remain unclear, she continued, including patient age, elastic recoil, body mass index, history of a prior procedure (such as radiofrequency or ultrasound), the amount of laxity and rhytids, and overall health, which have not been studied, Dr. Waibel said.

“We have patients that don’t have the same response as others. For the modest improvement seen in some patients, is that their elastic recoil or are we choosing the wrong patients? Do they need more treatments? We are also still learning about the ideal treatment for scars and other indications.”

The device is expected to launch in fourth quarter of 2022.

Dr. Waibel disclosed that she is an advisory board member for Cytrellis. She has conducted clinical trials for and is a consultant to many pharmaceutical and device companies.

SAN DIEGO – When the Food and Drug Administration gave the nod to a first-in-class tissue removal device in July of 2021, clearance was limited to the treatment of moderate to severe wrinkles in the mid to lower face.

But once the device – Ellacor– becomes available in late 2022, potential applications are likely to be wide-ranging, Jill S. Waibel, MD, a dermatologist with the Miami Dermatology and Laser Institute, predicted at the annual conference of the American Society for Laser Medicine and Surgery. “I’m using it in my practice more for laxity and jowls,” she said. Eventually, “I think it’s going to be preventative for 30- to 50-year-olds but that hasn’t been studied. I think it’s going to have a pre- and postrhytidectomy role, so I think the plastic surgeons are going to love this in their practice.”

Developed by Cytrellis, and based on research conducted by William G. Austen Jr., MD, chief of plastic and reconstructive surgery at Massachusetts General Hospital (MGH), Boston, and R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at MGH, the company’s scientific founders, the device uses hollow needles contained in a handpiece to create thousands of microexcisions to physically remove small cores of skin – a process known as microcoring. Dr. Austin and Dr. Anderson were the senior authors, respectively, of seminal trials of the device in swine, published in 2013 and 2015.

This can result in immediate physical hole closures (mechanical closure), which may lead to skin tightening.

“We’re removing dermis and epidermis,” said Dr. Waibel, who noted that the technology has been studied mostly for skin laxity and rhytids. “There are no other devices that are doing this.”

The immediate closure of tiny holes in the skin results in a quantitative and directional reduction in the treated area of skin, she said, which leads to wrinkle improvement, tightening, and smoothing of lax skin. The device contains three 22-guage needles that are less than 500 micrometers in diameter. “Based on optical coherence tomography work we did, these channels of treated skin stay open for about 1.5 minutes,” she added, noting that the tunable depth of the device ranges from 0 to 4 mm. “I tend to treat only with the 4-mm depth,” said Dr. Waibel, who is subsection chief of dermatology at Baptist Hospital of Miami.

The device features a disposable tip that can remove up to 24,000 cores of skin, and the amount of skin removed in a treated area can be 1%, 3%, 5%, 7%, and 8%. “The more cores you do, the more wrinkle improvement we saw in pivotal trials,” she said. “A minimal core count of 12,000 per treatment is recommended for the mid and lower face. Interestingly, higher core counts do not result in more patient downtime.” In her office, she said that the treatment takes about 20 minutes. Recommended postoperative care involves application of petrolatum or Aquaphor over the treated area for 24 hours, or until the holes have closed. “There is very low postoperative downtime,” she noted.

According to pivotal clinical data from Cytrellis on 51 patients treated with Ellacor, patients experienced a mean 1.3-grade improvement on the Lemperle Rating Scale, 86% said that they were satisfied with the procedure, and investigators rated their Global Aesthetic Improvement as 90%.

To date, Dr. Waibel and her colleagues in Miami have treated 102 patients with Ellacor, mostly for wrinkles and skin laxity. In these patients, the minimal downtime experienced was 3.8 days, 75% of patients did not miss any work, and 46% did not miss any social activities. The worst part for patients is the preprocedure numbing, she said. “We do lidocaine injections. Some people do nerve blocks. Once you do the lidocaine injection, the average pain is about 0.36 on a scale of 1-10 during treatment and 0 for all subsequent time points.”

At the meeting, she presented a set of before and after photos that showed improvement of moderate facial wrinkles in a female patient 90 days after one treatment with Ellacor, which removed about 5% of skin in the area of the jowls. “It’s pretty incredible,” Dr. Waibel remarked.

“I don’t have anything in my practice that can help with that kind of laxity other than sending them to a plastic surgeon, and I have about 80 devices.”

Images courtesy Dr. Jill S. Waibel

At the 2019 meeting of the American Society for Dermatologic Surgery, Dr. Waibel and Roy G. Geronemus, MD, director of the Laser & Skin Surgery Center of New York, presented a small pilot study on the successful use of Ellacor for acne scars and striae. Dr. Waibel said that she and her colleagues in Miami have been using the device to treat skin laxity in several anatomical areas, including the neck, nose, inner thigh, above the knee, elbow, and the axillary region. They have used the device to treat tattoos, rhytidectomy scars, abdominal striae, acne and surgical scars, and idiopathic guttate hypomelanosis, she added.

“We do a lot of combinations with other devices on the same day, and I think this list will increase over the next few years,” she said. “Probably my favorite use in the past 5 months has been doing microcoring and, separated by a month, doing resurfacing.”

Clinical trials of Ellacor were conducted in patients with types I-IV skin, but she has treated several patients with types V-VI skin “with absolutely no safety issues,” which includes treatment of epidermal nevi.

Which variables are the most important for patient selection and procedural success remain unclear, she continued, including patient age, elastic recoil, body mass index, history of a prior procedure (such as radiofrequency or ultrasound), the amount of laxity and rhytids, and overall health, which have not been studied, Dr. Waibel said.

“We have patients that don’t have the same response as others. For the modest improvement seen in some patients, is that their elastic recoil or are we choosing the wrong patients? Do they need more treatments? We are also still learning about the ideal treatment for scars and other indications.”

The device is expected to launch in fourth quarter of 2022.

Dr. Waibel disclosed that she is an advisory board member for Cytrellis. She has conducted clinical trials for and is a consultant to many pharmaceutical and device companies.

SAN DIEGO – At least 1,200 sex trafficking survivors per year in the United States would benefit from pro bono laser removal of branding tattoos during their recovery – although that number is likely far greater, according to the results of an online survey evaluating the need for and impact of tattoo removal in this population.

Sex trafficking involves the use of force, fraud, or coercion to compel another person to engage in commercial sex acts, and traffickers often brand their victims with tattoos that convey ownership, including tattoos of names, symbols, and barcodes. According to data from Polaris, a nonprofit organization that works to combat and prevent sex and labor trafficking in the United States, 16,658 sex trafficking victims were identified in the country in 2020, but tens of thousands go unreported.

coldsnowstorm/E+/Getty Images

“Given the inherently covert nature of this crime, it is difficult to determine exact statistics,” Emily L. Guo, MD, a cosmetic dermatologic surgery fellow at the Dermatology and Laser Surgery Center in Houston, said during a clinical abstract session at the annual meeting of the American Society for Laser Medicine and Surgery. “We have been working with sex trafficking survivors local to our practice in Houston providing pro bono tattoo removal, and we’ve observed how impactful that is in their recovery. We wanted to see if there was a national need for support of these survivors, allowing them to reclaim their lives.”

In collaboration with Elizabeth Kream, MD, a dermatology resident at the University of Illinois at Chicago, and Paul M. Friedman, MD, director of the Dermatology and Laser Surgery Center and the current ASLMS president, Dr. Guo conducted an online needs and impact survey regarding laser removal of branding tattoos. With assistance from the National Trafficking Sheltered Alliance, the researchers distributed the survey to U.S. organizations that support sex trafficking survivors. Representatives from 40 organizations responded to the survey. Most were based in the South (45%), followed by the West (20%) and Midwest (20%), and the Northeast (15%).

“On average, these programs support 81 survivors per year, which translates into 3,240 victims per year,” Dr. Guo said. Survey respondents estimated that 47% of sex trafficking survivors had branding tattoos. Of those, 67% were in a stable situation that would make it possible to undergo tattoo removal.

On a scale of 1 to 10 with 10 being the highest, “pro bono removal of branding tattoos received a survivor impact recovery score of 9.2 by these respondents,” Dr. Guo said. “Breaking down these numbers, there are at least 1,200 survivors per year who would benefit from tattoo removal during recovery. Qualitative responses to our survey echoed the same messages: There is a great need and a large impact for pro bono tattoo removal.”

For example, one survey respondent wrote, “Thank you for being willing to remove tattoos, allowing them to feel as though they are no longer owned by their trafficker.” Another wrote, “Erasing or revising the mark of her trafficker is a critical part of every survivor’s recovery journey.”

Sometimes branding tattoos are placed in highly visible locations. One sex trafficking survivor presented to Dr. Guo with a large dark blue tattoo above an eyebrow. “She shared with me that because the tattoo was so highly visible, nobody would offer her a job,” Dr. Guo said. Another survivor had her trafficker’s initial tattooed on her left ring finger. Yet another had a large tattoo on her forearm branded with her trafficker’s name as well as the word cash, “indicating that she is source of money for him,” she said, noting that on average, one sex trafficking victim generates about $100,000 per year for their trafficker.

Although there has been work published on recognition of branding tattoos in the medical community, including the difficulty in differentiating branding tattoos from voluntary tattoos, Dr. Friedman said that there have not been any studies evaluating the need and impact of laser branding tattoo removal in the recovery of sex trafficking survivors. Findings from the current survey “illuminate that the removal of branding tattoos is highly impactful on recovery and may be preferred over tattoo cover-ups,” Dr. Friedman told this news organization.

SAN DIEGO – At least 1,200 sex trafficking survivors per year in the United States would benefit from pro bono laser removal of branding tattoos during their recovery – although that number is likely far greater, according to the results of an online survey evaluating the need for and impact of tattoo removal in this population.

Sex trafficking involves the use of force, fraud, or coercion to compel another person to engage in commercial sex acts, and traffickers often brand their victims with tattoos that convey ownership, including tattoos of names, symbols, and barcodes. According to data from Polaris, a nonprofit organization that works to combat and prevent sex and labor trafficking in the United States, 16,658 sex trafficking victims were identified in the country in 2020, but tens of thousands go unreported.

coldsnowstorm/E+/Getty Images

“Given the inherently covert nature of this crime, it is difficult to determine exact statistics,” Emily L. Guo, MD, a cosmetic dermatologic surgery fellow at the Dermatology and Laser Surgery Center in Houston, said during a clinical abstract session at the annual meeting of the American Society for Laser Medicine and Surgery. “We have been working with sex trafficking survivors local to our practice in Houston providing pro bono tattoo removal, and we’ve observed how impactful that is in their recovery. We wanted to see if there was a national need for support of these survivors, allowing them to reclaim their lives.”

In collaboration with Elizabeth Kream, MD, a dermatology resident at the University of Illinois at Chicago, and Paul M. Friedman, MD, director of the Dermatology and Laser Surgery Center and the current ASLMS president, Dr. Guo conducted an online needs and impact survey regarding laser removal of branding tattoos. With assistance from the National Trafficking Sheltered Alliance, the researchers distributed the survey to U.S. organizations that support sex trafficking survivors. Representatives from 40 organizations responded to the survey. Most were based in the South (45%), followed by the West (20%) and Midwest (20%), and the Northeast (15%).

“On average, these programs support 81 survivors per year, which translates into 3,240 victims per year,” Dr. Guo said. Survey respondents estimated that 47% of sex trafficking survivors had branding tattoos. Of those, 67% were in a stable situation that would make it possible to undergo tattoo removal.

On a scale of 1 to 10 with 10 being the highest, “pro bono removal of branding tattoos received a survivor impact recovery score of 9.2 by these respondents,” Dr. Guo said. “Breaking down these numbers, there are at least 1,200 survivors per year who would benefit from tattoo removal during recovery. Qualitative responses to our survey echoed the same messages: There is a great need and a large impact for pro bono tattoo removal.”

For example, one survey respondent wrote, “Thank you for being willing to remove tattoos, allowing them to feel as though they are no longer owned by their trafficker.” Another wrote, “Erasing or revising the mark of her trafficker is a critical part of every survivor’s recovery journey.”

Sometimes branding tattoos are placed in highly visible locations. One sex trafficking survivor presented to Dr. Guo with a large dark blue tattoo above an eyebrow. “She shared with me that because the tattoo was so highly visible, nobody would offer her a job,” Dr. Guo said. Another survivor had her trafficker’s initial tattooed on her left ring finger. Yet another had a large tattoo on her forearm branded with her trafficker’s name as well as the word cash, “indicating that she is source of money for him,” she said, noting that on average, one sex trafficking victim generates about $100,000 per year for their trafficker.

Although there has been work published on recognition of branding tattoos in the medical community, including the difficulty in differentiating branding tattoos from voluntary tattoos, Dr. Friedman said that there have not been any studies evaluating the need and impact of laser branding tattoo removal in the recovery of sex trafficking survivors. Findings from the current survey “illuminate that the removal of branding tattoos is highly impactful on recovery and may be preferred over tattoo cover-ups,” Dr. Friedman told this news organization.

SAN DIEGO – At least 1,200 sex trafficking survivors per year in the United States would benefit from pro bono laser removal of branding tattoos during their recovery – although that number is likely far greater, according to the results of an online survey evaluating the need for and impact of tattoo removal in this population.

Sex trafficking involves the use of force, fraud, or coercion to compel another person to engage in commercial sex acts, and traffickers often brand their victims with tattoos that convey ownership, including tattoos of names, symbols, and barcodes. According to data from Polaris, a nonprofit organization that works to combat and prevent sex and labor trafficking in the United States, 16,658 sex trafficking victims were identified in the country in 2020, but tens of thousands go unreported.

coldsnowstorm/E+/Getty Images

“Given the inherently covert nature of this crime, it is difficult to determine exact statistics,” Emily L. Guo, MD, a cosmetic dermatologic surgery fellow at the Dermatology and Laser Surgery Center in Houston, said during a clinical abstract session at the annual meeting of the American Society for Laser Medicine and Surgery. “We have been working with sex trafficking survivors local to our practice in Houston providing pro bono tattoo removal, and we’ve observed how impactful that is in their recovery. We wanted to see if there was a national need for support of these survivors, allowing them to reclaim their lives.”

In collaboration with Elizabeth Kream, MD, a dermatology resident at the University of Illinois at Chicago, and Paul M. Friedman, MD, director of the Dermatology and Laser Surgery Center and the current ASLMS president, Dr. Guo conducted an online needs and impact survey regarding laser removal of branding tattoos. With assistance from the National Trafficking Sheltered Alliance, the researchers distributed the survey to U.S. organizations that support sex trafficking survivors. Representatives from 40 organizations responded to the survey. Most were based in the South (45%), followed by the West (20%) and Midwest (20%), and the Northeast (15%).

“On average, these programs support 81 survivors per year, which translates into 3,240 victims per year,” Dr. Guo said. Survey respondents estimated that 47% of sex trafficking survivors had branding tattoos. Of those, 67% were in a stable situation that would make it possible to undergo tattoo removal.

On a scale of 1 to 10 with 10 being the highest, “pro bono removal of branding tattoos received a survivor impact recovery score of 9.2 by these respondents,” Dr. Guo said. “Breaking down these numbers, there are at least 1,200 survivors per year who would benefit from tattoo removal during recovery. Qualitative responses to our survey echoed the same messages: There is a great need and a large impact for pro bono tattoo removal.”

For example, one survey respondent wrote, “Thank you for being willing to remove tattoos, allowing them to feel as though they are no longer owned by their trafficker.” Another wrote, “Erasing or revising the mark of her trafficker is a critical part of every survivor’s recovery journey.”

Sometimes branding tattoos are placed in highly visible locations. One sex trafficking survivor presented to Dr. Guo with a large dark blue tattoo above an eyebrow. “She shared with me that because the tattoo was so highly visible, nobody would offer her a job,” Dr. Guo said. Another survivor had her trafficker’s initial tattooed on her left ring finger. Yet another had a large tattoo on her forearm branded with her trafficker’s name as well as the word cash, “indicating that she is source of money for him,” she said, noting that on average, one sex trafficking victim generates about $100,000 per year for their trafficker.

Although there has been work published on recognition of branding tattoos in the medical community, including the difficulty in differentiating branding tattoos from voluntary tattoos, Dr. Friedman said that there have not been any studies evaluating the need and impact of laser branding tattoo removal in the recovery of sex trafficking survivors. Findings from the current survey “illuminate that the removal of branding tattoos is highly impactful on recovery and may be preferred over tattoo cover-ups,” Dr. Friedman told this news organization.

SAN DIEGO – Lasers can be used to safely and effectively remove permanent eyebrow and eyelid tattoos in patients with Fitzpatrick skin types I–V, results from a single-center retrospective study showed.

There is a market for these types of cosmetic tattoos today, “and a need for removal,” David Orbuch, MD, MBA, said during a clinical abstract session at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Orbuch, a fellow at the Laser & Skin Surgery Center of New York, and his colleagues retrospectively reviewed the charts of 57 adults who underwent laser tattoo removal of eyebrow and eyelid tattoos at the center from January 2018 to December 2021. Data recorded included demographics, site location, initial parameters, colors treated, and clinical safety and efficacy. The mean age of the patients was 46 years, 98.8% were female, 50.9% were Fitzpatrick skin type I-II, and the remainder were types III-V.

Among the most common sites treated were the bilateral eyebrows (35%). Other common sites were the upper eyelids (21.1%), the lower eyelids (10.5%), and both the upper and lower eyelids (12%). Each patient underwent an average of 2.5 treatments (range, 1-11). The most common lasers used were a 755-nm picosecond laser (79%), a high‐power 1,064-nm picosecond laser (12.3%), a high‐power 532-nm picosecond laser (3.5%), and a 10,600-nm carbon dioxide laser (1.7%). The most common tattoo colors were black (94.7%), the far most common, followed by red (3.5%), and yellow (1.7%).

For removal of black tattoos, the most common treatment parameters for the 755 picosecond laser were a 2.5-mm spot size and a fluence of 3.36 J/cm². For the 1,064-nm picosecond laser, the most common treatment parameters were a 2-mm spot size and a fluence of 4 J/cm².

For removal of red tattoos, the most common treatment parameters for the 532-nm picosecond laser were a 3.3-mm spot size and a fluence of 2 J/cm². For the 10,600-nm CO₂ laser, the most common treatment parameters were a spot size of 7 mm and a fluence of 28.2 J/cm².

As for removal of yellow tattoos, the most common treatment parameters with the 532-nm picosecond laser were a 3.3-mm spot size and a fluence of 0.5 J/cm².

There were no documented cases of scarring, eyelash/eyebrow loss, necrosis, burns, prolonged erythema, prolonged swelling, or prolonged dyspigmentation noted.

“With all of these treatments, you can get a great effect, but you have to do it safely,” Dr. Orbuch said. “With all of these wavelengths, the 1,064 nm especially, there can be serious eye damage if done improperly,” he added. “As such, placement of the metallic eye shields is important. If they’re not properly placed, they can fall out. Make sure you are comfortable using these shields before doing these treatments.”

Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, who was asked to comment on the study, said that cosmetic tattoos pose treatment challenges for several reasons. First, “there can be variability in the composition of the pigments since they are often tailored to fit the location and complexion of the patient,” she said. “Second, there can be placement of multiple layers of tattoo pigment to provide the final effect. Third, the pigment may contain two metal oxides (titanium dioxide and ferric oxide), which are often used to calibrate skin tone colors.”

Unfortunately, she noted, “these metal oxides are prone to reduction reactions with laser exposure, causing paradoxical darkening of tattoo pigment. In the past, these darker colors were treated with continued laser therapy and even fractional or fully ablative CO2/Er:YAG resurfacing.”

Dr. Sodha noted that prior studies have shown picosecond lasers to be effective cosmetic lasers, “and this study further supports this with a larger cohort of patients who were treated with the array of picosecond wavelengths (532, 755, and 1,064 nm) without long-term sequelae. Interestingly, there did not appear to be long-term sequelae with dyspigmentation or paradoxical darkening, with fewer than 2% necessitating treatment with a carbon dioxide laser.”

Neither Dr. Orbuch nor Dr. Sodha reported having financial disclosures.

SAN DIEGO – Lasers can be used to safely and effectively remove permanent eyebrow and eyelid tattoos in patients with Fitzpatrick skin types I–V, results from a single-center retrospective study showed.

There is a market for these types of cosmetic tattoos today, “and a need for removal,” David Orbuch, MD, MBA, said during a clinical abstract session at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Orbuch, a fellow at the Laser & Skin Surgery Center of New York, and his colleagues retrospectively reviewed the charts of 57 adults who underwent laser tattoo removal of eyebrow and eyelid tattoos at the center from January 2018 to December 2021. Data recorded included demographics, site location, initial parameters, colors treated, and clinical safety and efficacy. The mean age of the patients was 46 years, 98.8% were female, 50.9% were Fitzpatrick skin type I-II, and the remainder were types III-V.

Among the most common sites treated were the bilateral eyebrows (35%). Other common sites were the upper eyelids (21.1%), the lower eyelids (10.5%), and both the upper and lower eyelids (12%). Each patient underwent an average of 2.5 treatments (range, 1-11). The most common lasers used were a 755-nm picosecond laser (79%), a high‐power 1,064-nm picosecond laser (12.3%), a high‐power 532-nm picosecond laser (3.5%), and a 10,600-nm carbon dioxide laser (1.7%). The most common tattoo colors were black (94.7%), the far most common, followed by red (3.5%), and yellow (1.7%).

For removal of black tattoos, the most common treatment parameters for the 755 picosecond laser were a 2.5-mm spot size and a fluence of 3.36 J/cm². For the 1,064-nm picosecond laser, the most common treatment parameters were a 2-mm spot size and a fluence of 4 J/cm².

For removal of red tattoos, the most common treatment parameters for the 532-nm picosecond laser were a 3.3-mm spot size and a fluence of 2 J/cm². For the 10,600-nm CO₂ laser, the most common treatment parameters were a spot size of 7 mm and a fluence of 28.2 J/cm².

As for removal of yellow tattoos, the most common treatment parameters with the 532-nm picosecond laser were a 3.3-mm spot size and a fluence of 0.5 J/cm².

There were no documented cases of scarring, eyelash/eyebrow loss, necrosis, burns, prolonged erythema, prolonged swelling, or prolonged dyspigmentation noted.

“With all of these treatments, you can get a great effect, but you have to do it safely,” Dr. Orbuch said. “With all of these wavelengths, the 1,064 nm especially, there can be serious eye damage if done improperly,” he added. “As such, placement of the metallic eye shields is important. If they’re not properly placed, they can fall out. Make sure you are comfortable using these shields before doing these treatments.”

Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, who was asked to comment on the study, said that cosmetic tattoos pose treatment challenges for several reasons. First, “there can be variability in the composition of the pigments since they are often tailored to fit the location and complexion of the patient,” she said. “Second, there can be placement of multiple layers of tattoo pigment to provide the final effect. Third, the pigment may contain two metal oxides (titanium dioxide and ferric oxide), which are often used to calibrate skin tone colors.”

Unfortunately, she noted, “these metal oxides are prone to reduction reactions with laser exposure, causing paradoxical darkening of tattoo pigment. In the past, these darker colors were treated with continued laser therapy and even fractional or fully ablative CO2/Er:YAG resurfacing.”

Dr. Sodha noted that prior studies have shown picosecond lasers to be effective cosmetic lasers, “and this study further supports this with a larger cohort of patients who were treated with the array of picosecond wavelengths (532, 755, and 1,064 nm) without long-term sequelae. Interestingly, there did not appear to be long-term sequelae with dyspigmentation or paradoxical darkening, with fewer than 2% necessitating treatment with a carbon dioxide laser.”

Neither Dr. Orbuch nor Dr. Sodha reported having financial disclosures.

SAN DIEGO – Lasers can be used to safely and effectively remove permanent eyebrow and eyelid tattoos in patients with Fitzpatrick skin types I–V, results from a single-center retrospective study showed.

There is a market for these types of cosmetic tattoos today, “and a need for removal,” David Orbuch, MD, MBA, said during a clinical abstract session at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Orbuch, a fellow at the Laser & Skin Surgery Center of New York, and his colleagues retrospectively reviewed the charts of 57 adults who underwent laser tattoo removal of eyebrow and eyelid tattoos at the center from January 2018 to December 2021. Data recorded included demographics, site location, initial parameters, colors treated, and clinical safety and efficacy. The mean age of the patients was 46 years, 98.8% were female, 50.9% were Fitzpatrick skin type I-II, and the remainder were types III-V.

Among the most common sites treated were the bilateral eyebrows (35%). Other common sites were the upper eyelids (21.1%), the lower eyelids (10.5%), and both the upper and lower eyelids (12%). Each patient underwent an average of 2.5 treatments (range, 1-11). The most common lasers used were a 755-nm picosecond laser (79%), a high‐power 1,064-nm picosecond laser (12.3%), a high‐power 532-nm picosecond laser (3.5%), and a 10,600-nm carbon dioxide laser (1.7%). The most common tattoo colors were black (94.7%), the far most common, followed by red (3.5%), and yellow (1.7%).

For removal of black tattoos, the most common treatment parameters for the 755 picosecond laser were a 2.5-mm spot size and a fluence of 3.36 J/cm². For the 1,064-nm picosecond laser, the most common treatment parameters were a 2-mm spot size and a fluence of 4 J/cm².

For removal of red tattoos, the most common treatment parameters for the 532-nm picosecond laser were a 3.3-mm spot size and a fluence of 2 J/cm². For the 10,600-nm CO₂ laser, the most common treatment parameters were a spot size of 7 mm and a fluence of 28.2 J/cm².

As for removal of yellow tattoos, the most common treatment parameters with the 532-nm picosecond laser were a 3.3-mm spot size and a fluence of 0.5 J/cm².

There were no documented cases of scarring, eyelash/eyebrow loss, necrosis, burns, prolonged erythema, prolonged swelling, or prolonged dyspigmentation noted.

“With all of these treatments, you can get a great effect, but you have to do it safely,” Dr. Orbuch said. “With all of these wavelengths, the 1,064 nm especially, there can be serious eye damage if done improperly,” he added. “As such, placement of the metallic eye shields is important. If they’re not properly placed, they can fall out. Make sure you are comfortable using these shields before doing these treatments.”

Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, who was asked to comment on the study, said that cosmetic tattoos pose treatment challenges for several reasons. First, “there can be variability in the composition of the pigments since they are often tailored to fit the location and complexion of the patient,” she said. “Second, there can be placement of multiple layers of tattoo pigment to provide the final effect. Third, the pigment may contain two metal oxides (titanium dioxide and ferric oxide), which are often used to calibrate skin tone colors.”

Unfortunately, she noted, “these metal oxides are prone to reduction reactions with laser exposure, causing paradoxical darkening of tattoo pigment. In the past, these darker colors were treated with continued laser therapy and even fractional or fully ablative CO2/Er:YAG resurfacing.”

Dr. Sodha noted that prior studies have shown picosecond lasers to be effective cosmetic lasers, “and this study further supports this with a larger cohort of patients who were treated with the array of picosecond wavelengths (532, 755, and 1,064 nm) without long-term sequelae. Interestingly, there did not appear to be long-term sequelae with dyspigmentation or paradoxical darkening, with fewer than 2% necessitating treatment with a carbon dioxide laser.”

Neither Dr. Orbuch nor Dr. Sodha reported having financial disclosures.

SAN DIEGO – Combining topical tyrosinase inhibitors with either a nonablative fractional laser or a fractional picosecond laser was safe and effective for treating postinflammatory hyperpigmentation (PIH) in patients with Fitzpatrick skin phototypes V and VI, results from a small retrospective case series suggest.

“Postinflammatory hyperpigmentation is a leading chief of complaint of many skin of color persons seeking a dermatologist,” Elizabeth J. Kream, MD, told this news organization in advance of the annual conference of American Society for Laser Medicine and Surgery. “I describe PIH to patients as the ‘ashes after a fire is extinguished.’ It’s the stubborn brown to gray/black spots that persist after conditions like acne and folliculitis, but it can be caused by any insult to the skin including external injury. In fact, there’s a risk of inciting PIH with lasers and energy-based devices and this risk is greater in skin of color given the greater melanin content. Unfortunately, we see patients present after visiting a med spa who were treated with the wrong devices and/or the wrong settings and they have disfiguring scarring and/or dyspigmentation.”

During an abstract session at the meeting, Dr. Kream, a dermatology resident at the University of Illinois at Chicago, discussed three patients with recalcitrant PIH and Fitzpatrick skin phototype V and VI who were treated in San Diego with a combination of topical and laser therapies. She presented the case series on behalf of coauthors Monica Boen, MD and Douglas C. Wu, MD, dermatologists who practice in San Diego.

The first patient was a 37-year-old Black female who presented for evaluation of longstanding hyperpigmentation on the face and neck determined to be PIH secondary to folliculitis on the chin and neck. She was started on 8% hydroquinone with kojic acid daily and received four treatments spaced 4-8 weeks apart with the 1,927-nm fractional nonablative diode laser. Laser settings were 5 mJ pulse energy and 5% coverage after eight passes. Triamcinolone 0.1% ointment was applied immediately after treatment and for 3 days following treatment, and the “patient experienced near complete resolution of PIH with no unexpected adverse events,” Dr. Kream said.

The second patient was a 20-year-old Black male who presented with a 3-month history of facial hyperpigmentation after suffering a laser-induced injury. He was started on a non-hydroquinone topical lightening agent and received five treatments spaced 2 weeks apart with a 1,927-nm fractional nonablative diode laser. The laser settings were 5 mJ pulse energy and 5% coverage after eight passes. The patient experienced 80%-90% resolution of his PIH with no unexpected adverse reactions.

The third patient in the series was a 39-year-old Black male who presented with a 6-month history of hyperpigmentation on his right shin and calf, secondary to minor occupational-related trauma. Treatment was initiated with a fractional 1,064-nm picosecond laser. The laser settings were 2.1 mJ per microbeam microwave pulse energy and a 450 picosecond pulse duration delivered at 2 Hz through a holographic beam splitter with a 6 x 6–mm spot size containing 101 microbeams, for an estimated coverage of 4% per pulse. Four passes were performed for each area. The endpoint was a mild erythema to several treated areas a few minutes following laser treatment. Postoperative care consisted of applying a non-hydroquinone topical lightening agent twice daily to the affected area for 1 month. Near-complete resolution of the PIH was achieved, with no unexpected adverse reactions.

“In our clinical experience, PIH can be treated with the combination of topical skin lighteners and low density, low fluence laser therapy in almost all skin types,” Dr. Kream said. “The rationale behind this combination is to treat and remove existing pigment with the laser therapy while minimizing and preventing any pigmentary recurrence with diligent topical therapy and photoprotection.”

It is important to identify the cause of PIH “because some cases are trickier than others,” such as a lichenoid process that deposits pigment “a little bit deeper into the dermis,” she said. “When selecting an appropriate laser modality for the treatment of PIH in skin types V and VI, it’s especially important to consider the mechanism of action, depth of penetration, degree of tissue damage, and the extent of disruption to the dermal-epidermal junction.”

Following the presentation, one of the session moderators, Albert Wolkerstorfer, MD, PhD, a dermatologist at Amsterdam University Medical Center, the Netherlands, emphasized the importance of proper patient selection for laser treatment of PIH. “Not every patient with PIH is adapted to treatment with the laser,” Dr. Wolkerstorfer said. “I think it’s also important to choose stable PIH, meaning you often see patients with an underlying disorder who want to get rid of the pigment. They often believe that the laser is the solution, but it often isn’t.”

During a question-and-answer session, a meeting attendee pointed out that the study lacked a control area to compare the treatment results to. “This was a retrospective case series,” Dr. Kream replied. “I’d like to see more elegant studies in the future, with a control [area],” she said.

Dr. Kream reported having no financial disclosures, Dr. Boen has no disclosures, and Dr. Wu has conducted research for many pharmaceutical and device companies. Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical, and is an advisory board member for Incyte.

SAN DIEGO – Combining topical tyrosinase inhibitors with either a nonablative fractional laser or a fractional picosecond laser was safe and effective for treating postinflammatory hyperpigmentation (PIH) in patients with Fitzpatrick skin phototypes V and VI, results from a small retrospective case series suggest.

“Postinflammatory hyperpigmentation is a leading chief of complaint of many skin of color persons seeking a dermatologist,” Elizabeth J. Kream, MD, told this news organization in advance of the annual conference of American Society for Laser Medicine and Surgery. “I describe PIH to patients as the ‘ashes after a fire is extinguished.’ It’s the stubborn brown to gray/black spots that persist after conditions like acne and folliculitis, but it can be caused by any insult to the skin including external injury. In fact, there’s a risk of inciting PIH with lasers and energy-based devices and this risk is greater in skin of color given the greater melanin content. Unfortunately, we see patients present after visiting a med spa who were treated with the wrong devices and/or the wrong settings and they have disfiguring scarring and/or dyspigmentation.”

During an abstract session at the meeting, Dr. Kream, a dermatology resident at the University of Illinois at Chicago, discussed three patients with recalcitrant PIH and Fitzpatrick skin phototype V and VI who were treated in San Diego with a combination of topical and laser therapies. She presented the case series on behalf of coauthors Monica Boen, MD and Douglas C. Wu, MD, dermatologists who practice in San Diego.

The first patient was a 37-year-old Black female who presented for evaluation of longstanding hyperpigmentation on the face and neck determined to be PIH secondary to folliculitis on the chin and neck. She was started on 8% hydroquinone with kojic acid daily and received four treatments spaced 4-8 weeks apart with the 1,927-nm fractional nonablative diode laser. Laser settings were 5 mJ pulse energy and 5% coverage after eight passes. Triamcinolone 0.1% ointment was applied immediately after treatment and for 3 days following treatment, and the “patient experienced near complete resolution of PIH with no unexpected adverse events,” Dr. Kream said.

The second patient was a 20-year-old Black male who presented with a 3-month history of facial hyperpigmentation after suffering a laser-induced injury. He was started on a non-hydroquinone topical lightening agent and received five treatments spaced 2 weeks apart with a 1,927-nm fractional nonablative diode laser. The laser settings were 5 mJ pulse energy and 5% coverage after eight passes. The patient experienced 80%-90% resolution of his PIH with no unexpected adverse reactions.

The third patient in the series was a 39-year-old Black male who presented with a 6-month history of hyperpigmentation on his right shin and calf, secondary to minor occupational-related trauma. Treatment was initiated with a fractional 1,064-nm picosecond laser. The laser settings were 2.1 mJ per microbeam microwave pulse energy and a 450 picosecond pulse duration delivered at 2 Hz through a holographic beam splitter with a 6 x 6–mm spot size containing 101 microbeams, for an estimated coverage of 4% per pulse. Four passes were performed for each area. The endpoint was a mild erythema to several treated areas a few minutes following laser treatment. Postoperative care consisted of applying a non-hydroquinone topical lightening agent twice daily to the affected area for 1 month. Near-complete resolution of the PIH was achieved, with no unexpected adverse reactions.

“In our clinical experience, PIH can be treated with the combination of topical skin lighteners and low density, low fluence laser therapy in almost all skin types,” Dr. Kream said. “The rationale behind this combination is to treat and remove existing pigment with the laser therapy while minimizing and preventing any pigmentary recurrence with diligent topical therapy and photoprotection.”

It is important to identify the cause of PIH “because some cases are trickier than others,” such as a lichenoid process that deposits pigment “a little bit deeper into the dermis,” she said. “When selecting an appropriate laser modality for the treatment of PIH in skin types V and VI, it’s especially important to consider the mechanism of action, depth of penetration, degree of tissue damage, and the extent of disruption to the dermal-epidermal junction.”

Following the presentation, one of the session moderators, Albert Wolkerstorfer, MD, PhD, a dermatologist at Amsterdam University Medical Center, the Netherlands, emphasized the importance of proper patient selection for laser treatment of PIH. “Not every patient with PIH is adapted to treatment with the laser,” Dr. Wolkerstorfer said. “I think it’s also important to choose stable PIH, meaning you often see patients with an underlying disorder who want to get rid of the pigment. They often believe that the laser is the solution, but it often isn’t.”

During a question-and-answer session, a meeting attendee pointed out that the study lacked a control area to compare the treatment results to. “This was a retrospective case series,” Dr. Kream replied. “I’d like to see more elegant studies in the future, with a control [area],” she said.

Dr. Kream reported having no financial disclosures, Dr. Boen has no disclosures, and Dr. Wu has conducted research for many pharmaceutical and device companies. Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical, and is an advisory board member for Incyte.

SAN DIEGO – Combining topical tyrosinase inhibitors with either a nonablative fractional laser or a fractional picosecond laser was safe and effective for treating postinflammatory hyperpigmentation (PIH) in patients with Fitzpatrick skin phototypes V and VI, results from a small retrospective case series suggest.

“Postinflammatory hyperpigmentation is a leading chief of complaint of many skin of color persons seeking a dermatologist,” Elizabeth J. Kream, MD, told this news organization in advance of the annual conference of American Society for Laser Medicine and Surgery. “I describe PIH to patients as the ‘ashes after a fire is extinguished.’ It’s the stubborn brown to gray/black spots that persist after conditions like acne and folliculitis, but it can be caused by any insult to the skin including external injury. In fact, there’s a risk of inciting PIH with lasers and energy-based devices and this risk is greater in skin of color given the greater melanin content. Unfortunately, we see patients present after visiting a med spa who were treated with the wrong devices and/or the wrong settings and they have disfiguring scarring and/or dyspigmentation.”

During an abstract session at the meeting, Dr. Kream, a dermatology resident at the University of Illinois at Chicago, discussed three patients with recalcitrant PIH and Fitzpatrick skin phototype V and VI who were treated in San Diego with a combination of topical and laser therapies. She presented the case series on behalf of coauthors Monica Boen, MD and Douglas C. Wu, MD, dermatologists who practice in San Diego.

The first patient was a 37-year-old Black female who presented for evaluation of longstanding hyperpigmentation on the face and neck determined to be PIH secondary to folliculitis on the chin and neck. She was started on 8% hydroquinone with kojic acid daily and received four treatments spaced 4-8 weeks apart with the 1,927-nm fractional nonablative diode laser. Laser settings were 5 mJ pulse energy and 5% coverage after eight passes. Triamcinolone 0.1% ointment was applied immediately after treatment and for 3 days following treatment, and the “patient experienced near complete resolution of PIH with no unexpected adverse events,” Dr. Kream said.

The second patient was a 20-year-old Black male who presented with a 3-month history of facial hyperpigmentation after suffering a laser-induced injury. He was started on a non-hydroquinone topical lightening agent and received five treatments spaced 2 weeks apart with a 1,927-nm fractional nonablative diode laser. The laser settings were 5 mJ pulse energy and 5% coverage after eight passes. The patient experienced 80%-90% resolution of his PIH with no unexpected adverse reactions.

The third patient in the series was a 39-year-old Black male who presented with a 6-month history of hyperpigmentation on his right shin and calf, secondary to minor occupational-related trauma. Treatment was initiated with a fractional 1,064-nm picosecond laser. The laser settings were 2.1 mJ per microbeam microwave pulse energy and a 450 picosecond pulse duration delivered at 2 Hz through a holographic beam splitter with a 6 x 6–mm spot size containing 101 microbeams, for an estimated coverage of 4% per pulse. Four passes were performed for each area. The endpoint was a mild erythema to several treated areas a few minutes following laser treatment. Postoperative care consisted of applying a non-hydroquinone topical lightening agent twice daily to the affected area for 1 month. Near-complete resolution of the PIH was achieved, with no unexpected adverse reactions.

“In our clinical experience, PIH can be treated with the combination of topical skin lighteners and low density, low fluence laser therapy in almost all skin types,” Dr. Kream said. “The rationale behind this combination is to treat and remove existing pigment with the laser therapy while minimizing and preventing any pigmentary recurrence with diligent topical therapy and photoprotection.”

It is important to identify the cause of PIH “because some cases are trickier than others,” such as a lichenoid process that deposits pigment “a little bit deeper into the dermis,” she said. “When selecting an appropriate laser modality for the treatment of PIH in skin types V and VI, it’s especially important to consider the mechanism of action, depth of penetration, degree of tissue damage, and the extent of disruption to the dermal-epidermal junction.”

Following the presentation, one of the session moderators, Albert Wolkerstorfer, MD, PhD, a dermatologist at Amsterdam University Medical Center, the Netherlands, emphasized the importance of proper patient selection for laser treatment of PIH. “Not every patient with PIH is adapted to treatment with the laser,” Dr. Wolkerstorfer said. “I think it’s also important to choose stable PIH, meaning you often see patients with an underlying disorder who want to get rid of the pigment. They often believe that the laser is the solution, but it often isn’t.”

During a question-and-answer session, a meeting attendee pointed out that the study lacked a control area to compare the treatment results to. “This was a retrospective case series,” Dr. Kream replied. “I’d like to see more elegant studies in the future, with a control [area],” she said.

Dr. Kream reported having no financial disclosures, Dr. Boen has no disclosures, and Dr. Wu has conducted research for many pharmaceutical and device companies. Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical, and is an advisory board member for Incyte.