Updates On Lasers in Dermatology

Updates on Laser s i n
Dermatology
Ashaki D. Patel, MDa,b,*, Rishi Chopra, MDa,b, Mathew Avram, MD, JDa,b,
Fernanda H. Sakamoto, MD, PhDa,b, Suzanne Kilmer, MDb,c, Richard Rox Anderson, MDa,b,
Omar A. Ibrahimi, MD, PhDb,d,1
KEYWORDS
Lasers Dermatology Updates Vascular Hair removal Tattoo Acne
Selective photothermolysis
KEY POINTS
Lasers can cause ablative or non-ablative tissue damage. When a laser is used to destroy only a
single tissue target (or chromophore), it uses selective photothermolysis.
Since the advent of selective photothermolysis, lasers have played a large role in expanding the ca-
pabilities of the procedural dermatologist.
Selective photothermolysis allows for the precise and targeted treatment of many skin conditions.
Fractional photothermolysis further expands the ability of procedural dermatologists to improve a
variety of medical and cosmetic conditions.
This review highlights how lasers have evolved since their introduction in the treatment of a variety
of dermatologic applications.
INTRODUCTION AND HISTORY had high rates of scarring and complications due
to the non-selective nature in which the laser en-
The history of laser medicine starts with Albert Ein- ergy was absorbed in the skin. The theory of selec-
stein’s theory of stimulated emission, introduced tive photothermolysis, as elucidated by Drs. John
in 1916. He postulated that when excited mole- Parrish and Rox Anderson, propelled the use of la-
cules/atoms interact with each other, they are sers and forever changed the field of dermatology,
able to stimulate emission of new photons that and other medical specialties.2 The concept of se-
are of a similar frequency, phase, and direction lective photothermolysis refers to localized, “se-
as the original atoms/molecules. This concept lective,” destruction of the desired target by
was used by early physicists, including Theodore combining a selective wavelength that is absorbed
Maiman, to develop the earliest lasers. In 1963, by the target chromophore and a pulse duration
Dr. Leon Goldman, a pioneer in laser medicine, that is equal or shorter than the thermal relaxation
first used a laser on human skin to treat melanoma. time of the target chromophore. The combination
Dr. Goldman also used the continuous wave CO2 of these 2 notions allows for more precise control
and argon lasers to treat port wine stains.1 of thermal energy and allows for more focused
Although the lesions he treated lightened, they destruction. With the advent of selective
a
Department of Dermatology, Massachusetts General Hospital Laser and Cosmetic Center, 50 Staniford Street,
Suite 250, Boston, MA 02114, USA; b Wellman Center for Photomedicine, Massachusetts General Hospital, 15
Parkman Street, Wang Ambulatory Care Center - Suite 435, Boston, MA 02114, USA; c Laser & Skin Surgery
derm.theclinics.com
Center of Northern California, 3837 J Street, Sacramento, CA 95816, USA; d Connecticut Skin Institute, Stam-
ford, CT, USA
1
Present address: 2 Hampton Road, Darien, CT 06820.
* Corresponding author. 3 Omni Drive, Schaumburg, IL 60193.
E-mail address: Apatel105@mgh.harvard.edu
Dermatol Clin 42 (2024) 33–44

https://doi.org/10.1016/j.det.2023.07.004
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34 Patel et al
photothermolysis, the treatment of unwanted delivery of a maximum of 8 J with a maximum

pigment, tattoos, and hair became possible. We spot size of 12 mm. The newer pulsed dye laser
went from non-selective lasers to early versions has a larger spot size of 15 mm, allowing a
of both ablative and non-ablative lasers. Additional maximum delivery of 12 J, an almost 50% increase
applications became possible with the advent of as compared to the previous generation. This is
fractional photothermolysis.3 The laser beam can important, as larger beam sizes allow for greater
be applied fully to the tissue, or it can be delivered photon densities to be delivered at a greater
in a pixilated pattern, called fractional photother- depth, thus allowing more energy delivery to
molysis (FP). FP can use both ablative and non- larger, deeper vessels in the skin. Additionally,
ablative wavelengths of light. This fractional injury the deeper penetration of energy allows bypass
is seen in the form of microscopic treatment zones of epidermal melanin, reducing the risk of postin-
(MTZ) that often form a grid pattern of injury on the flammatory hyperpigmentation (PIH). The larger
skin. This allows for the sparing of normal tissue spot size also allows for broader surface area
between each MTZ, and a shorter treatment re- coverage and perhaps quicker treatment time. In
covery time. Interestingly, up to 50% of the tissue 2021, Sodha and colleagues found that the larger
can be destroyed during FP without causing scar- spot size and safe delivery of increased energy
ring or necrosis. By creating multiple laser holes in allowed for shorter and fewer treatments to clear
the skin, FP has been also used as a new method a port wine stain in 7 patients aged 10 to 38 years.8
for drug delivery. This expansion continues with Even though the pulsed dye laser is considered the
advances in technology and technique. Herein, gold standard in PWB treatment, other various
we provide a review of updates in lasers as they wavelengths of light have also been demonstrated
are used in dermatology to treat a variety of med- to be useful in treating PWBs, especially those that
ical and aesthetic conditions. are resistant to 577 to 595 nm wavelengths (Fig. 1).
One reason lasers in the 577 to 595 nm wavelength
may not be able to clear or even lighten a PWB is
Vascular Lasers
due to the depth of the penetration. PWBs are
One of the first applications of selective photother- made of vessels of various depths. To reach
molysis in dermatology was to help treat port wine deeper dermal vessels, longer wavelength lasers
stains.4–6 Initially, the argon laser was introduced have been used such as the 755-nm alexandrite,
in the 1970s and was one of the first lasers used 810-nm diode, and 1064-nm neodymium (Nd):yt-
to treat port wine birthmarks (PWBs). These lasers trium-aluminum-garnet (YAG) lasers.9 Additionally,
functioned at a wavelength of 488 to 514 nm and in 2001, Barton and colleagues described how the
although this wavelength is absorbed by hemoglo- combined effects of both green visible light and
bin in red blood cells, the thermal damage was not infrared wavelength light worked better to coagu-
confined to the blood vessels but spread to adja- late cutaneous blood vessels.10 They described a
cent tissue structures. Argon laser treatments synergistic phenomenon in which green light
caused significant scarring and were not an ideal changes the constituents of blood to form methe-
treatment option for PWBs.7 The pulsed deliver moglobin, which then is better absorbed by
of the same wavelengths addressed these short- infrared wavelengths. This led to the development
falls and had fewer side effects, by allowing heat of several laser systems that combined both
to diffuse strictly on the vessels. Earlier versions wavelengths including a 595/1064 combination
of the pulsed dye laser were 577 nm and worked device, a 532/1064 device, and more recently, a
well to selectively target blood vessels in port 532/1064 device with variable sequential pulsing
wine stains without significant thermal damage to and cryogen spray cooling. Eichenfield and col-
the surrounding structures of the skin. However, leagues demonstrated the clinical effects of
as our understanding of laser-tissue interactions combining the 532 nm with 1064 nm wavelengths
improved, so did technology. More recently, in treating vascular malformations in a cohort of 23
newer versions of the pulsed dye laser have larger patients. They showed that combining these 2
spot sizes and a variety of pulse durations. This al- wavelengths, 532-nm potassium titanyl phosphate
lows the dermatologic surgeon to treat lesions in to target superficial components and long-pulse
purpuric and non-purpuric approaches. Having 1064-nm Nd:YAG for deeper components, can
the option of larger spots sizes and more precise safely and effectively treat both capillary venous
variation in pulse durations is advantageous and venous malformations.11 However, the au-
because it allows for the treatment of certain thors do not recommend treating capillary malfor-
vascular conditions, such as rosacea, with less mations and arterial vascular entities with
purpura and downtime. The most recent previous 1064 nm, as the wavelength can often penetrate
version of the pulsed dye laser allowed for the deeper and inadvertently select for deeper arterial
Updates on Lasers in Dermatology 35
Fig. 1. Before and after 4 treatments of a port wine stain in an adult patient with a 595-nm pulsed dye laser.
(Courtesy of Dr. Omar Ibrahimi.)
branches, leading to complications. Additionally, Hair Removal

caution is also advised when treating venous en-
The most popular cutaneous application of laser
tities with the 1064 nm wavelength as well, as
energy is hair removal.12 Laser hair removal
the 1064 nm wavelength is more selective for
(LHR) was first reported using a normal mode
oxyhemoglobin than it is for deoxyhemoglobin;
ruby laser and histologically showed selective
therefore, sticking to the 755 nm wavelength is
destruction of the follicular shaft and epithe-
advised when treating older, more hypertrophic
lium.13 The mechanism of action for LHR is
PWBs. Lastly, PWBs may be made of vessels of
unique in that the chromophore in LHR is the
various diameters, requiring various pulse widths.
melanin found in the hair shaft, however, the
A recent 532 nm/1064 nm combination device
intended target are the follicular stem cells found
includes variable sequential pulsing with both
in the “bulge” and “bulb” of the hair shaft.
sub-milli and sub-micro pulse modes, allowing
Because of the small distance between where
for absorption by a broader size range of vessels.
the melanocytes and stem cells are located, the
In addition to revolutionizing how we treat
extended theory of selective photothermolysis is
vascular birthmarks, vascular lasers have also
used to fully describe the mechanism of action
become standard of therapy for several other ap-
of laser hair removal. This theory suggests that
plications including angiomas, venous lakes,
there is some degree of diffusion of heat from
erythematous scars, and rosacea (Fig. 2).
the chromophore (melanin) and the desired target
(stem cells).14
CLINICS CARE POINTS It is important to note that all devices for LHR
target melanin as a chromophore and melanin is
also present in the dermal–epidermal junction.
Thus, some laser energy is absorbed into the
Port wine stains typically take numerous epidermis and poses risk for adverse events
treatments to lighten and complete removal such as burns, scarring, and postinflammatory
is often challenging. Treatment should be dyspigmentation. A variety of methods for skin
initiated as early as possible as infants tend
cooling have been developed to cool and protect
to respond better than adults.
the epidermal melanin and is a critical element in
Treating within the bony orbit required the safely performing LHR procedures, especially
use of eye shields to protect the retina. While when performed on darker Fitzpatrick phototypes.
hemoglobin is the target chromophore,
Cooling of the skin helps efface epidermal damage
melanin is present in the retina and it also ab-
while also allowing treatment at higher fluences.15
sorbs energy from most vascular lasers.
Most laser hair removal systems have built in cool-
Conditions such as rosacea can be treated ing systems that act as heat sinks and help remove
with non-purpric settings and typically entail
heat from the surface, either in the form of contact
minimal downtime but require a series of
cooling with a cold sapphire or dynamic cooling
treatments to bring about improvement.
with cryogen spray.
36 Patel et al
Fig. 2. Before and after 4 treatments for rosacea with a 595-nm pulsed dye laser. (Courtesy of Dr. Omar Ibrahimi.)
In addition to cooling, spot size is an important at about 76% to 84% at the 18-month mark for
parameter in laser hair removal. Larger spot sizes the Alex laser and 84% hair reduction at the 12-
allow more photons to be delivered to the target month mark for the Diode laser.18,19 Although
due to less scatter. Smaller spot sizes allow long-term hair reduction data are less convincing
more scattering of photons. With less scatter and for the long-pulsed Nd:YAG laser at 1064 nm than
larger surface area covered, also minimizes the other devices, this is thought to be the best wave-
number of pulses required to cover a treatment length for Fitzpatrick skin phototype V and VI.20 A
area, thereby reducing treatment time. In one 1060-nm diode laser has also been recently re-
double-blinded, randomized controlled study, ported to be safe and effective for LHR of all
when all other treatment parameters are kept iden- skin types, including darkly pigmented individ-
tical, an 18 mm spot size, as compared to a 12 mm uals.21 The 1060 and 1064 nm wavelengths
spot size, led to 10% more reduction in hair have much lower peak absorbance by melanin,
counts.16 making it less likely for epidermal melanin to be
Today, there are multiple wavelengths available heated, and thus decreasing the risk of complica-
for LHR including 755 nm, 800 to 810 nm, and tions (see Fig. 3). Although intense pulsed light
1060 to 1064 nm (Figs. 3 and 4). Although long- (IPL) is sometimes used for hair removal, IPL
pulsed ruby lasers are not commercially available uses a flashlamp with broad band cutoff filter at
in the United States, in one study, a majority of different wavelengths that may not be as selec-
nearly 200 patients had >75% hair loss at the 6- tive and deliver as much fluence as LHR. There-
month follow-up after 4 treatments.17 Alexandrite fore, one has to be careful, especially in treating
and diode lasers, which are commercially avail- darker skin types. Two studies that provide
able in the United States, showed similar results head-to-head comparison between the long-
Fig. 3. Before and 15 months after 3 laser hair removal treatments in the axillae of a patient with a 1060-nm de-
vice. (Courtesy of Dr. Omar Ibrahimi.)
Fig. 4. Before and after 3 treatments of laser hair removal of the upper lip with a 755-nm device. (Courtesy of Dr.
Omar Ibrahimi.)
pulsed Alexandrite and Nd-YAG found results that cold sapphire skin cooling suppressed plume
from an IPL to be inferior.22,23 from laser hair removal as compared to cryogen
Prior to any treatments, it is important that clear spray cooling, possibly eliminating the need for
expectations are set for the patient, and it should smoke evacuators, ventilation, and respiratory pro-
be communicated that LHR does not provide tection if using this method of cooling that required
100% permanent hair removal. Instead, there will contact with a gel.30 Nowadays, several newer la-
be a significant permanent reduction in the growth sers have built in smoke-evacuators to enhance
of hair but there will be a few hairs which persist, user and patient safety.
though they are on average, 19% thinner and
10% lighter in color.24 To help combat this problem,
CLINICS CARE POINTS
newer hair removal laser devices have the ability to
deliver several long duration pulses in rapid succes-
sion such that the hair does not have the time to
disperse the heat between pulses. The short delay Patients should be counseled that on average
between pulses is shorter than the thermal relaxa- 15% of hairs will be removed with each laser
tion time of the melanin in the hair follicle being treatment and treatments should be spaced
treated, and thus the hair does not cool off between about 6 to 8 weeks apart to allow hairs to
properly cycle through the various growth
the pulses, allowing for more damage to the hair fol-
phases.
licle (patent). Although lasers in the 694 to 1064 nm
range became the most effective way to achieve Avoid treating within the bony orbit,
long-term hair removal, recently there have been including the glabella, due to the high risk
of retinal damage (the retina contains
devices that combine all 3 wavelengths for laser
melanin dense tissues).
hair removal. In 2020 and 2021, 2 retrospective
cohort studies showed that a simultaneous triple Be careful to keep the handpiece perpendic-
wavelength laser device is safe and effective.25,26 ular over convex and concave surfaces to
ensure that the laser energy and any skin
The simultaneous triple-wavelength devices were
cooling methods are being delivered uni-
shown to be safe in skin types III toV as well.27,28 formly and will help avoid complications.
There are several devices that not only blend
various wavelengths but also help deliver pulses
at a programmed percent overlap. Lastly, along
with advances in the technology itself, there have
Tattoos
also been advances in procedure safety. In 2016,
a group out of Massachusetts General Hospital An important parameter within the theory of selec-
used gas chromatography–mass spectrometry to tive photothermolysis is laser pulse duration. Un-
analyze plume after laser hair removal and found like the lasers used for vessels and hair removal,
several carcinogenic compounds within the plume which are on the order of milliseconds, lasers
and thus concluded that the plume should be designed for tattoo removal have optimal pulse
considered a biohazard, warranting the use of duration in the order of picoseconds (Figs. 5 and
smoke evacuators, ventilation, and respiratory pro- 6). This is because the chromophore that is tar-
tection.29 In 2018, Ross and colleagues showed geted in tattoo removal is tattoo ink, which is 10^-
38 Patel et al
Fig. 5. Before and after 22 laser tattoo removal treatments with a 1064-nm picosecond device. (Courtesy of Dr.
Omar Ibrahimi.)
4 to 10^-3 mm wide. Based on this size, the pulse visible light in the range of their complementary
duration should be on the order of picoseconds. color. Based on this complementary matching of
In 1998, Ross and colleagues tested this theory colors, green ink, for example, will be best
by comparing nanosecond domain pulses with removed by a laser that emits red light (694 nm).
picosecond domain pulses to remove black ink Some colors such as yellow and orange are
tattoos.31 There was significantly more lightning more difficult to remove because there are few to
with the picosecond laser pulses than the nano- no lasers on the market that operate in their com-
second laser pulses. In vitro studies show that plementary color ranges (400–520 nm).
picosecond lasers can remove smaller tattoo ink However, tattoo removal remains a challenge
particles using lower fluences, and fewer number even when using a picosecond laser in the correct
of treatments.32 More recent human studies have wavelength range. There have been newer
corroborated this data and showed that, at methods and technological developments that
matched fluences, picosecond lasers have been can be combined with picosecond.35 A fractional
able to remove tattoos statistically more signifi- ablative laser will allow extrusion of ink through
cantly than nanosecond lasers.33,34 Today, pico- the micro-columns that the laser creates.35 Gas
second lasers are considered the gold standard bubbles that are created during treatment with a
in tattoo removal. Conversely, long-pulse lasers picosecond laser can also escape faster through
and particularly IPLs, which also run in the milli- the micro-columns and thus allow for repeat
second domain, should not be used for tattoo passes. A recent study showed that the micro-
removal, with a potential to cause severe scars. focused arrays of a fractional nanosecond or pico-
In addition to pulse duration, successful tattoo second laser allow for fewer treatments and more
removal depends on correct selection of wave- passes within 1 treatment session.36 Alternatively,
length. Colors in tattoo inks absorb the most one can also do the fractional picosecond laser
Fig. 6. Before and after 22 laser tattoo removal treatments with a 1064-nm picosecond device. (Courtesy of Dr.
Omar Ibrahimi.)
after doing picosecond tattoo removal. Sirithana- Pigmentation/Pigmented Lesions

badeekul and colleagues showed that this method
Another way selective photothermolysis of
allowed 84.6% of tattoos to be 50% cleared after
melanin can be used in dermatology is for treating
multiple treatments versus 69.2% with pico-
pigmented lesions. There are a wide variety of pig-
second laser alone.36 Another shortcoming of
mented lesions in dermatology, and they vary in
tattoo removal has been that multiple treatments
the amount of melanin deposition and/or
are required, even with picosecond lasers, to suc-
increased density of active melanocytes. Common
cessfully lighten or clear a tattoo. In 2012, Kossida
pigmented conditions that may be treated by la-
and colleagues reported that 4 passes of a
sers in dermatology include PIH, melasma, lenti-
Q-switched laser, separated by 20 minutes, was
gines, café au lait macules, and nevus of Ota.
superior to a single pass treatment.37 A waiting
There are occasional reports of lasers being used
period of 20 minutes was necessary to allow the
to treat more diffuse disorders of hyperpigmenta-
gas bubbles formed during picosecond laser treat-
tion, including erythema dyschromium perstans,
ment to fully dissipate before another pass of pico-
lichen planus pigmentosus, and drug-induced
second laser energy can be absorbed. This
hyperpigmentation.39–41
method of repeating treatments 20 minutes apart
Laser technologies have been extensively used
was dubbed the “R20 method.” Given that the
to treat these benign epidermal and dermal pig-
R20 method showed more clearance with a single
mented lesions over the past 20 years since
pass, but took more time, the perfluorodecalin
Anderson and colleagues first described the use
(PFD) patch was re-purposed for use in tattoo
of the Q-switched (QS) Nd: YAG laser to treat
removal. PFD patches are silicon patches that
cutaneous pigmentation.42 Although Q-switched
contain fluorocarbon in them, a potent gas
lasers did provide some improvement in pig-
dissolver. Using this patch allowed for multiple
mented lesions, they produced high rates of PIH
laser passes in 1 treatment session without having
in certain skin types.43,44 Picosecond pulses,
to wait 20 minutes between sessions. PFD
however, are able to generate higher peak tem-
patches were shown to have other benefits as
peratures in a short amount of time, allowing for
well, including limits in the increase of skin temper-
less unwanted heat diffusion. With picosecond
ature during laser treatment.38
pulses, lower fluences could be used for effective
treatments, reducing the chances of PIH. Thus,
CLINICS CARE POINTS more recently, picosecond lasers have played a
huge role in our ability to treat individual pig-
mented lesions.45 Many different wavelengths in
the picosecond pulse duration range have been
Laser tattoo removal requires matching an reported to safely treat pigmented lesions,
unwanted tattoo ink color to its complemen- ranging from 532 to 1064 nm.46–49 Although pico-
tary laser wavelength. second lasers work well for individual lentigines,
Picosecond lasers are an improvement that there have been several advances in near infrared
has led to faster and better clearing of tattoos wavelength resurfacing devices, which have
but most tattoos still fall short of complete allowed us to improve larger areas of pigmenta-
clearance. tion, including photodamage and even melasma.
Be cautious when treating a multicolored Since the introduction of the dual 1550/1927 nm
tattoo in the skin of color patient as melanin fractional non-ablative laser, several variations in
is targeted by many of the laser wavelengths non-ablative technology have been released
used and can result in significant depigmen- including the dual 1440/1927 low power diode
tation and hypopigmentation.
laser, and the 1927 thulium laser. Each of these
Newer, professional, and single ink color tat- varies in power and downtime but can be paired
toos (ideally black) are easier to fade with with picosecond lasers for synergistic effects in
laser treatments. treating pigmentation.
The use of fractional ablative, repeat treat-
ments, PFD patches, and rapid acoustic pulses
may enhance and speed up laser tattoo CLINICS CARE POINTS
removal.
Never use a long pulse laser or an intense
pulsed light (IPL) for tattoo removal, even if
the device has the right wavelength for the A proper evaluation of the pigmented lesion
color of the tattoo. is needed prior to any laser treatments,
ideally with dermoscopy.
40 Patel et al
Lasers are not a first-line treatment for mel- drug-delivery””(LADD). Ablative fractional lasers
asma. Melasma should be carefully evaluated are a landmark treatment for hypertrophic scars
and treated with first-line standard of care in the last 10 to 15 years. In one consensus paper,
treatments to help stabilize pigment forma- 75% of the respondents use both a vascular and
tion. ablative fractional laser with or without LADD for
thickened and/or contracted scars.52 These lasers
have been noted to allow improvement of texture,
Scars color, pliability, thickness, and quality of life.53–56
Lasers have also revolutionized how we treat scars Non-ablative fractional lasers have also shown to
in the past decade. In brief, injury to the skin trig- improve texture, specifically in hypertrophic and
gers a multiphase healing process categorized atrophic burn scars.57,58 (Fig. 7).
into 3 main phases: inflammatory, proliferative,
and remodeling. The proliferative phase occurs CLINICS CARE POINTS
about 1 week post injury and is characterized by
new vessel formation, fibroblast growth, and the
creation of new extracellular matrix. During the
Vascular lasers and fractional lasers (ablative
remodeling phase, new collagen is being laid
and non-ablative) can treat a variety of scars
down, all while the scar is slowly decreasing its with success.
cellularity and vascularity to eventually build a
mature scar.50 In this long and tightly orchestrated Be careful about laser parameters when treat-
ing scars. Treating at lower densities and
chain of events, much can go wrong. Prolonged
higher pulse energies (depth) is safer for
erythema, for example, can be an early sign of a scars.
pathologic scar. Vascular devices are often used
to treat erythematous scars. Although we do not It is never too late to initiate laser treatment
for scars, though earlier treatment is better.
know the exact mechanism by which vascular de-
Lasers can be implemented as early as right
vices are thought to help, there is some thought after wound formation. Complete epithelial-
that the laser tissue interaction sets forth a cyto- ization is not necessary to initiate laser treat-
kine cascade that triggers scar remodeling rather ment of scars.
than simple vascular destruction.51 Besides ery-
Although ablative fractional lasers can be
thema, scar texture and thickness are also treat- used in darker skin types, one must tread
able via lasers. Fractional lasers, both ablative with caution. In some circumstances, such as
and non-ablative, are crucial in treating the spec- non-hypertrophic scars, non-ablative frac-
trum of scars from atrophic to hypertrophic—the tional lasers may be preferred over ablative
fractionated injury allows for remodeling of the to decrease the risk of PIH.
scar without delivering too much thermal heat.
Additionally, fractional lasers create microscopic
treatment zones with cuffs of thermal coagulation.
Acne
These channels are held open, due to the cuff of
coagulation, and allow for subdermal delivery of One of the newest applications of selective photo-
topicals via a concept termed “laser-assisted thermolysis is for acne. Acne is one of the most
Fig. 7. Before and 6 weeks after a single fractional ablative CO2 laser treatment for a scar. Note the improved
texture, color, and thickness in certain areas. (Courtesy of Dr. Omar Ibrahimi.)
Fig. 8. Before and 24 months after a series of 4 monthly treatments with a 1726-nm device. (Courtesy of Dr. Emil
Tanghetti & Accure Acne, Inc.)
common skin conditions worldwide, dispropor- CLINICS CARE POINTS

tionately affecting younger individuals. Although
it is a very common condition, cure is difficult. Iso-
tretinoin is an excellent oral option, but poses
several side effects, compliance issues, and a Acne is the most common dermatologic
minimum 6 months course on average. Addition- complaint and complete cure remains elusive.
ally, many patients or parents are resistant to the
Sebaceous glands are lipid rich and the devel-
use of isotretinoin. In the last decade, excellent de-
opment of a lipid-selective 1726 nm wave-
velopments have been made on targeting the length offers the ability to selectively
sebaceous glands with selective photothermolysis damage sebaceous glands.
as a hope to cure acne without the use of oral
medications. In 2011, Sakamoto and colleagues
described that both natural and artificial sebum
New Devices
had an absorption peak near 1,210, 1,726, 1,760,
2306, and 2,346 nm; however, laser-induced heat- Although there have been so many recent ad-
ing of sebum was approximately twice that of wa- vances and updates in laser technology and its ap-
ter at 1710 nm and 1720 nm.59 Histologic skin plications, there are continually new devices and
samples exposed to w1700 nm, with 100 to applications in the pipeline. One promising devel-
125 milliseconds pulses, showed evidence of se- opment is a newer 3-dimensional (3D) laser that
lective thermal damage to sebaceous glands.59 has been FDA cleared and will be commercially
At 1726 nm, the peak of absorption of acne sebum available in the United States soon. This 3D laser
is about 30% higher than that of the surrounding is highly focusable allowing laser energy to be tar-
tissue, making it possible to create a new acne- geted at precise depths in the dermis with reduced
targeting laser by delivering high power (w40 W) fluences at the epidermis. The reduced energy at
with robust cooling (Fig. 8). Two new devices the epidermis will make this a safer device for
have been approved by the Food and Drug Admin- the skin of color patients. Additionally, there will
istration (FDA) in 2022 to treat mild to severe acne be a high-resolution, high-speed imaging system
and will likely forever change the way we approach that will be paired and integrated with the laser.
the management of this common skin condition. In This imaging system will not only allow mapping
the FDA white papers, about 80% of inflammatory and guidance during treatment but also pretreat-
lesions were reduced in a multicenter study for ment and post-treatment skin changes to be
both devices after 12 weeks of treatment, with archived, making way for a more personalized
sustained clearance for up to 2 years after 4 laser treatment for every patient.
monthly treatment sessions. Even though both de- Other devices modifications that may be on the
vices use the same wavelength, there are differ- horizon in the future include the integration of ro-
ences that might affect the overall efficacy and bots into dermatology. These laser “robots” may
safety, but there are no comparative studies pub- be programmed by humans, however, the action
lished to date. itself will be executed by robot software. Such a
42 Patel et al
laser “robot” may be useful in skin cancer surgery, 10. Goldberg GN. Commentary on Efficacy and Safety
where we can perform image-guided laser abla- of the 532-nm KTP and Long-Pulsed 1,064-nm Nd:
tion. Another way to integrate robots into lasers YAG Laser for Treatment of Vascular Malformations.
may be fractional-laser robots. These laser robots Dermatol Surg 2020;46(12):1540–1. PMID:
may be able to penetrate the skin at any precise 32604229.
depth and target several imageable structures 11. Eichenfield, Dawn Z, Ortiz AE. Efficacy and Safety of
such as sweat glands, nerves, cells, tumors, etc. the 532-nm KTP and Long-Pulsed 1064-nm
These ablative fractional robot lasers may even Neodymium-doped Yttrium Aluminum Garnet Laser
be used for very precise drug delivery. The future for Treatment of Vascular Malformations. Dermatol
remains very bright when it comes to the emer- Surg 2020;46(12):1535–9.
gence of new technology that will advance our 12. Ibrahimi OA, Avram MM, Hanke CW, et al. Laser hair
ability to treat a variety of medical and cosmetic removal. Dermatol Ther 2011;24(1):94–107.
dermatologic conditions. 13. Grossman MC, Dierickx C, Farinelli W, et al. Damage
to hair follicles by normal-mode ruby laser pulses.
J Am Acad Dermatol 1996;35(6):889–94.
DISCLOSURE
14. Altshuler GB, Anderson RR, Manstein D, et al.
The authors have no disclosures to share (the au- Extended theory of selective photothermolysis. La-
thors need to look at disclosure criteria, certainly sers Surg Med 2001;29(5):416–32.
Rox, Fernanda, Mat, Suzy, and OI may need to 15. Zenzie HH, Altshuler GB, Smirnov MZ, et al. Evalua-
make disclosures). F.H. Sakamoto, science advisor tion of cooling methods for laser dermatology. La-
for Accure Acne, Beiersdorf: receives portions of sers Surg Med 2000;26(2):130–44.
patent royalties from Massachusetts General 16. Nouri K, Chen H, Saghari S, et al. Comparing 18- vs.
Hospital. 12-mm spot size in hair removal using a gentlease
755-nm alexandrite laser. Dermatol Surg 2004;30(4
Pt 1):494–7.
REFERENCES
17. Anderson RR, Burns AJ, Garden J, et al. Multicenter
1. Goldman L, Dreffer R, Rockwell RJ Jr, et al. Treat- study of long-pulse ruby laser hair removal. Lasers
ment of portwine marks by an argon laser. Surg Med 1999;11(Suppl):11.
J Dermatol Surg 1976;2(5):385–8. 18. Davoudi SM, Behnia F, Gorouhi F, et al. Comparison
2. Anderson RR, Parrish JA. Selective photothermoly- of long-pulsed alexandrite and Nd : YAG lasers, indi-
sis: precise microsurgery by selective absorption vidually and in combination, for leg hair reduction:
of pulsed radiation. Science 1983;220(4596):524–7. an assessorblinded, randomized trial with 18
3. Manstein D, Herron GS, Sink RK, et al. Fractional months of follow-up. Arch Dermatol 2008;144(10):
photothermolysis: a new concept for cutaneous re- 1323–7.
modeling using microscopic patterns of thermal 19. Eremia S, Li C, Newman N. Laser hair removal with
injury. Lasers Surg Med 2004;34(5):426–38. alexandrite versus diode laser using four treatment
4. Kauvar AN, Geronemus RG. Treatment of port-wine sessions: 1-year results. Dermatol Surg 2001;
stains. N Engl J Med 1998;339(9):635–6. 27(11):925–9. discussion 929–930.
5. Goldman MP, Fitzpatrick RE, Ruiz-Esparza J. Treat- 20. Alster TS, Bryan H, Williams CM. Long-pulsed Nd:
ment of portwine stains (capillary malformation) YAG laser-assisted hair removal in pigmented skin:
with the flashlamp-pumped pulsed dye laser. a clinical and histological evaluation. Arch Dermatol
J Pediatr 1993;122:71–77 15. 2001;137(7):885–9. PMID: 11453807.
6. Anderson RR, Parrish JA. Microvasculature can be 21. Ross EV, Ibrahimi OA, Kilmer S. Long-term clinical
selectively damaged using dye lasers: a basic the- evaluation of hair clearance in darkly pigmented in-
ory and experimental evidence in human skin. La- dividuals using a novel diode1060 nm wavelength
sers Surg Med 1981;1:263–76. with multiple treatment handpieces: A prospective
7. Cosman B. Experience in the argon laser therapy of analysis with modeling and histological findings. La-
port wine stains. Plast Reconstr Surg 1980;65(2): sers Surg Med 2018;50(9):893–901. Epub 2018 May
119–29. 30. PMID: 29845623.
8. Sodha P, Richmond H, Friedman PM. Safe and Effec- 22. McGill DJ, Hutchison C, McKenzie E, et al.
tive Use of a Novel Large Spot Size 595-nm Pulsed A randomised, split-face comparison of facial hair
Dye Laser With High Energies for Rapid Improvement removal with the alexandrite laser and intense
of Adult and Pediatric Port-Wine Birthmarks. Dermatol pulsed light system. Lasers Surg Med 2007;39(10):
Surg 2021;47(8):1147–9. PMID: 33867471. 767–72.
9. Izikson L, Anderson RR. Treatment endpoints for 23. Goh CL. Comparative study on a single treatment
resistant port wine stains with a 755 nm laser. response to long pulse Nd : YAG lasers and intense
J Cosmet Laser Ther 2009 Mar;11(1):52–5. pulse light therapy for hair removal on skin type IV to
VI – is longer wavelengths lasers preferred over Treatment of Professional Tattoos in Asians. Laser
shorter wavelengths lights for assisted hair removal. Ther 2020;29(1):47–52. PMID: 32903983; PMCID:
J Dermatolog Treat 2003;14(4):243–7. PMC7447827.
24. Ibrahimi OA, Kilmer SL. Long-term clinical evalua- 35. Ibrahimi OA, Syed Z, Sakamoto FH, et al. Treatment
tion of a 800-nm long-pulsed diode laser with a large of tattoo allergy with ablative fractional resurfacing:
spot size and vacuum-assisted suction for hair a novel paradigm for tattoo removal. J Am Acad Der-
removal. Dermatol Surg 2012;38(6):912–7. PMID: matol 2011;64(6):1111–4. PMID: 21571169.
22455549. 36. Sirithanabadeekul P, Vongchansathapat P,
25. Lehavit A, Eran G, Moshe L, et al. A Combined Sutthipisal N, et al. Outcomes of 1064-nm pico-
Triple-Wavelength (755nm, 810nm, and 1064nm) second laser alone and in combination with frac-
Laser Device for Hair Removal: Efficacy and Safety tional 1064-nm picosecond laser in tattoo removal.
Study. J Drugs Dermatol 2020;19(5):515–8. PMID: J Cosmet Dermatol 2022;21(7):2832–9. PMID:
32484620. 35488471.
26. Noyman Y, Levi A, Reiter O, et al. Using blend wave- 37. Kossida T, Rigopoulos D, Katsambas A, et al.
lengths in order to improve the safety and efficacy of Optimal tattoo removal in a single laser session
laser hair removal. J Cosmet Dermatol 2021;20(12): based on the method of repeated exposures. J Am
3913–6. Epub 2021 Oct 25. PMID: 34694683. Acad Dermatol 2012;66(2):271–7. Epub 2011 Oct
27. Gold MH, Biron J, Wilson A, et al. Safety and efficacy 27. PMID: 22036610.
for hair removal in dark skin types III and IV with a 38. Danysz W, Becker B, Begnier M, et al. The effect of
high-powered, combined wavelength (810, 940 the perfluorodecalin patch on particle emission and
and 1060 nm) diode laser: A single-site pilot study. skin temperature during laser-induced tattoo
J Cosmet Dermatol 2022;21(5):1979–85. Epub removal. J Cosmet Laser Ther 2020;22(3):150–8.
2022 Apr 6. PMID: 35306725. PMID: 32516063.
28. Raj Kirit EP, Sivuni A, Ponugupati S, et al. Efficacy 39. Wolfshohl JA, Geddes ER, Stout AB, et al. Improve-
and safety of triple wavelength laser hair reduction ment of erythema dyschromicum perstans using a
in skin types IV to V. J Cosmet Dermatol 2021; combination of the 1,550-nm erbium-doped fraction-
20(4):1117–23. Epub 2021 Feb 22. PMID: ated laser and topical tacrolimus ointment. Lasers
33567152. Surg Med 2017;49(1):60–2. Epub 2016 Aug 23.
29. Chuang GS, Farinelli W, Christiani DC, et al. PMID: 27552666.
Gaseous and Particulate Content of Laser Hair 40. Shah DSD, Aurangabadkar DS, Nikam DB. An open-
Removal Plume. JAMA Dermatol 2016;152(12): label non-randomized prospective pilot study of the
1320–6. efficacy of Q-switched Nd-YAG laser in manage-
30. Ross EV, Chuang GS, Ortiz AE, et al. Airborne par- ment of facial lichen planus pigmentosus.
ticulate concentration during laser hair removal: A J Cosmet Laser Ther 2019;21(2):108–15. PMID:
comparison between cold sapphire with aqueous 29768073.
gel and cryogen skin cooling. Lasers Surg Med 41. Barrett T, de Zwaan S. Picosecond alexandrite laser
2018;50(4):280–3. Epub 2017 Dec 7. PMID: is superior to Q-switched Nd:YAG laser in treatment
29214662. of minocycline-induced hyperpigmentation: A case
31. Ross V, Naseef G, Lin G, et al. Comparison of re- study and review of the literature. J Cosmet Laser
sponses of tattoos to picosecond and nanosecond Ther 2018;20(7–8):387–90. Epub 2018 Feb 5.
Q-switched neodymium: YAG lasers. Arch Dermatol PMID: 29400580.
1998;134(2):167–71. 42. Anderson RR, Margolis RJ, Watenabe S. Selective
32. Jang WH, Yoon Y, Kim W, et al. Erratum: Visualization photothermolysis of cutaneous pigmentation by
of laser tattoo removal treatment effects in a mouse Q-switched Nd:YAG laser pulses at1064, 532 and
model by two-photon microscopy: publisher’s note. 355 nm. J Invest Dermatol 1989;93:28–32.
Biomed Opt Express 2018;9(9):4162. Erratum for: 43. Wang CC, Sue YM, Yang CH, et al. A comparison of
Biomed Opt Express. 2017 Jul 20;8(8):3735-3748. Q-switched alexandrite laser and intense pulsed
PMID: 30615732; PMCID: PMC6157788. light for the treatment of freckles and lentigines in
33. Lorgeou A, Perrillat Y, Gral N, et al. Comparison of Asian persons: A randomized, physician-blinded,
two picosecond lasers to a nanosecond laser for split-face comparative trial. J Am Acad Dermatol
treating tattoos: a prospective randomized study 2006;54:804–10.
on 49 patients. J Eur Acad Dermatol Venereol 44. Chan HHH, Fung WKK, Ying SY, et al. An in vivo trial
2018;32(2):265–70. Epub 2017 Aug 21. PMID: comparing the use of different types of 532nm Nd:
28758261. YAG lasers in the treatment of facial lentigines in ori-
34. Kono T, Chan HHL, Groff WF, et al. Prospective ental patients. Derm Surg 2000;26:743–9.
Comparison Study of 532/1064 nm Picosecond 45. Wu DC, Goldman MP, Wat H, et al. A systematic re-
Laser vs 532/1064 nm Nanosecond Laser in the view of picosecond laser in dermatology: Evidence
44 Patel et al
and recommendations [published online ahead of 2020 International Consensus Recommendations.

print April 13, 2020]. Lasers Surg Med 2020. Lasers Surg Med 2020 Feb;52(2):96–116. Epub
https://doi.org/10.1002/lsm.23244. 2019 Dec 9. PMID: 31820478.
46. Guss L, Goldman MP, Wu DC. Picosecond 532 nm 53. Blome-Eberwein S, Gogal C, Weiss MJ, et al. Pro-
neodymium-doped yttrium aluminium garnet laser spective evaluation of fractional CO2 laser treatment
for the treatment of solar lentigines in darker skin of mature burn scars. J Burn Care Res 2016;37(6):
types: Safety and efficacy. Dermatol Surg 2017; 379–87.
43(3):456–9. 54. Issler-Fisher AC, Fisher OM, Smialkowski AO, et al.
47. Chan JC, Shek SY, Kono T, et al. A retrospective Ablative fractional CO2 laser for burn scar recon-
analysis on the management of pigmented lesions struction: An extensive subjective and objective
using a picosecond 755-nm alexandrite laser in short-term outcome analysis of a prospective treat-
Asians. Lasers Surg Med 2016;48(1):23–9. ment cohort. Burns 2017;43(3):573–82.
48. Alegre-Sanchez A, Jiménez-Gómez N, Moreno-
55. Anderson RR, Donelan MB, Hivnor C, et al. Laser
Arrones ÓM, et al. Treatment of flat and elevated
treatment of traumatic scars with an emphasis on
pigmented disorders with a 755-nm alexandrite
ablative fractional laser resurfacing: consensus
picosecond laser: Clinical and histological evalua-
report. JAMA Dermatol 2014;150(2):187–93.
tion. Lasers Med Sci 2018;33(8):1827–31.
56. Miletta N, Siwy K, Hivnor C, et al. Fractional ablative
49. Vachiramon V, Iamsumang W, Triyangkulsri K.
laser therapy is an effective treatment for hypertro-
Q-switched double frequency Nd:YAG 532-nm
phic burn scars: A prospective study of objective
nanosecond laser vs. double frequency Nd:YAG
and subjective outcomes. Ann Surg 2019;274(6):
532-nm picosecond laser for the treatment of solar
e574–80.
lentigines in Asians. Lasers Med Sci 2018;33(9):
1941–7. 57. Haedersdal M, Moreau KE, Beyer DM, et al. Frac-
50. Tredget E, Ding J. The cellular and molecular basis tional nonablative 1540 nm laser resurfacing for ther-
of scarring: the paradigm of hypertrophic scarring mal burn scars: A randomized controlled trial.
after thermal injury. In: Krakowski A, Shumaker P, ed- Lasers Surg Med 2009;41(3):189–95.
itors. The scar book. Philadelphia: Wolters Kluwer; 58. Waibel J, Wulkan AJ, Lupo M, et al. Treatment of
2017. p. 104–8. burn scars with the 1,550 nm nonablative fractional
51. Kuo YR, Jeng SF, Wang FS, et al. Flashlamp pulsed Erbium Laser. Lasers Surg Med 2012;44(6):441–6.
dye laser (PDL) suppression of keloid proliferation 59. Sakamoto FH, Doukas AG, Farinelli WA, et al. Selec-
through down- regulation of TGF-beta1 expression tive photothermolysis to target sebaceous glands:
and extracellular matrix expression. Lasers Surg theoretical estimation of parameters and preliminary
Med 2004;34(2):104–8. results using a free electron laser. Lasers Surg Med
52. Seago M, Shumaker PR, Spring LK, et al. Laser 2012 Feb;44(2):175–83. Epub 2011 Dec 13. PMID:
Treatment of Traumatic Scars and Contractures: 22170298.

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Dermatol Clin 42 (2024) 33–44

photothermolysis, the treatment of unwanted delivery of a maximum of 8 J with a maximum

branches, leading to complications. Additionally, Hair Removal

after doing picosecond tattoo removal. Sirithana- Pigmentation/Pigmented Lesions

common skin conditions worldwide, dispropor- CLINICS CARE POINTS

and recommendations [published online ahead of 2020 International Consensus Recommendations.

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