LASER FOR PIGMENTATIONs melasma, freckles, sunburn

explain on types of pigmentation and treatment with laser

1. INTRODUCTION TO LASERS IN
PIGMENTATION &
TATTOO REMOVAL
DrChin Shih Choon
Medical Director, AessenceClinic.
President, Malaysian Society of Aesthetic Medicine.
Medical Aesthetic Certification (MAC) Program

2. Overview
Medical Aesthetic Certification (MAC) Program
•The acronym ‘LASER’ stands for light amplification by
stimulated emission of radiation.
•A laser works by emitting a wavelength of high energy
light, which when focused on a certain skin condition
creates heat and destroys diseased cells. Wavelength is
measured in nanometres (nm).

3. Overview
Medical Aesthetic Certification (MAC) Program
•Various kinds of lasers are available; they are differentiated
by the medium that produces the laser beam.
•Each of the different types of lasers has a specific range of
utility, depending on its wavelength and penetration.

4. History & Evolution:
Medical Aesthetic Certification (MAC) Program
•In the 1950s, based on the theory of stimulating radiant
energy published by Albert Einstein in 1916, the collaboration
of physicists and electrical engineers, searching
for monochromatic radiation to study the spectra of
molecules, led to the invention of the first laser in 1960.
•Ophthalmologists and dermatologists were the first to
study the biological effects and therapeutic possibilities
of laser beams.

5. History & Evolution:
Medical Aesthetic Certification (MAC) Program
•The construction of new laser systems emitting energy at
different wavelengths or with different durations, as well as
the development of new concepts of the biomedical effects,
led to its broad use in surgery in the treatment of vascular
and pigmented lesions as well as cosmetic applications.

6. History & Evolution:
Medical Aesthetic Certification (MAC) Program
•In 1963, Goldman and his co-workers published the first
study on the effects of lasers on skin describing the selective
destruction of pigmented structuresof the skin including
hair follicles with the beam of the ruby laser.
•They noted highly selective injury of pigmented structures
(black hair) with no evident change in the white skin
underneath [21, 22].

7. By the early 1980s, R. RoxAnderson and John A.
Parrish from the Department of Dermatology at
the Harvard Medical School in Boston developed
the theory of selective photothermolysisthat revolutionized
the practice of cutaneous laser surgery[28].
The authors recognized that the collateral thermal damage
in the surrounding tissue of the target chromophoreresulted
from prolonged exposure to the laser’s energy.
History & Evolution:

8. By the appropriate manipulation of wavelength and pulse
duration, and in dependence upon the chromophore’s
relaxation time, therapeutic destruction could be maximized
while minimizing thermal damage to the surrounding tissue
[29].
History & Evolution:
Medical Aesthetic Certification (MAC) Program

9. The new theoretical understanding of the advantages of
pulsed lasers led to a revival of the Q-switched lasers
(ruby[30], alexandrite[31], Nd:YAG[32]) for the
treatment of benign pigmented cutaneous lesions, especially
for tattoo and hair removal [33].
History & Evolution:
Medical Aesthetic Certification (MAC) Program

10. More than 3 decades later, a nearly identical ruby laser to
the one used by Goldman in 1963 became the first device
approved by the FDA in 1989 for permanent removal of
pigmented hair
And the Q-Switched Nd:YAGreceived FDA approval as a
treatment modality of tattoo removal in 1991
History & Evolution:
Medical Aesthetic Certification (MAC) Program

11. Nd:YAG(neodymium-doped yttrium aluminium garnet) is a
crystal that is used as a laser medium for solid-state lasers.
The triply ionised neodymium [Nd(III)] dopant (iea substance
added in minute amounts to another pure substance to alter its
conductivity), typically replaces a small fraction of the yttrium
ions in the host crystal structure, since the two ions are of similar
size.
The neodymium ion provides the laser activity in the crystal.
What is Nd: YAG Laser:
Medical Aesthetic Certification (MAC) Program

13. Nd:YAGlaser has a
wave length of 1064
nm and has the
capability to reach
deeper layers of skin
tissue than other
types of lasers.
What is Nd: YAG Laser:
Medical Aesthetic Certification (MAC) Program

14. In Q-switched mode, Nd:YAGproduces 2 wavelengths,
one in the infrared range (1064 nm) and a second beam of
532 nm wavelength which is useful for superficial skin
lesions.
Q-switching refers to the technique of making the laser
produce a high intensity beam in very short pulses
What is Nd: YAG Laser:
Medical Aesthetic Certification (MAC) Program

15. Lasers work by emitting
a wavelength of high
energy light, which when
focused on a certain skin
condition will create heat
and destroy diseased
cells.
How Does NdYAG Work?:
Medical Aesthetic Certification (MAC) Program

16. The enzyme responsible for melanin production is
tyrosinase, a copper-containing oxygenaseenzyme, which
mediates melanin production through the intermediate, L-
dopa [27].
Tyrosinaseactivity may be regulated by many factors. For
example, incubation of human melanocytes with 1,25-
dihydroxy vitamin D3, α-MSH, and β-estradiolcaused
an increase in tyrosinaseactivity [30].
Nevertheless, no specific receptors have yet been
demonstrated on the melanocyte [27].
Pigmentation:

17. Hyperpigmentation in pregnancy is attributed by some
investigators to an increased output of some combination
of placental, pituitary, and ovarian hormones[40].
An increased amount of MSH of the pituitary was
postulated in the past to be the cause of hyperpigmentation.
It was even believed that the demonstration of MSH in
urine could be used as a pregnancy test [4].
Pigmentation:

18. Other factors which were suggested to
be related to hyperpigmentation in
pregnancy are progesteroneand
estrogen, the levels of both of which
are increased during pregnancy
Pigmentation:
Medical Aesthetic Certification (MAC) Program

19. Hyperpigmentation of the face occurs in women taking
oral contraceptivesor during the menstrual cycle,
supporting the idea that estrogenand progesterone are
involved
[27]. In addition, hyperpigmentation of the face is
associated with disorders involving the function of the
uterus and ovaries, a condition termed “chloasma
uterinum” [24].
Pigmentation:
Medical Aesthetic Certification (MAC) Program

20. The FDA has approved a range of Nd:YAGlaser machines for
various skin disorders.
These include Cutera® Nd:YAGlaser (Cutera, California, USA),
RevLite® Q-Switched Nd:YAGlaser (Cynosure, Massachusetts,
USA) and Fotona® Nd:YAGlaser(Aesthetic Lasers Inc. MN,
USA).
Individual machines are designed to treat specific skin
problems.
Indication:
Medical Aesthetic Certification (MAC) Program

21. Vascular lesions
ND:YAG can be used to removespider and thread veinsin the
face (cheek, temporal region, nasal dorsum, forehead) and
legs.
Some vascular birthmarks (capillaryvascular malformations)
Varicose veinsin the leg
Facial veins(telangiectasis)
Haemangiomas(vascular tumours) in the face and around the
mouth
Indication:
Medical Aesthetic Certification (MAC) Program

22. Vascular lesions
The laser light pulses target red pigment (haemoglobin).
Typical settings employed for the treatment of facial veins include
a 50 milliseconds pulse duration, and fluence(ieoutput energy) of
150¬250 J/cm
2
(measured in Joules per centimetre squared).
Indication:
Medical Aesthetic Certification (MAC) Program

23. Pigmented lesions
1.Solar lentigines
2.Freckles,
3.Naevusof Ota,Naevusof Ito,Mongolian spots, Hori naevus
4.Café-au-lait-macules.
5.Melasma
6.Light pulses target melanin at variable depth on or in the skin.
Indication:
Medical Aesthetic Certification (MAC) Program

24. Hair removal (Long Pulse)
Nd:YAGlaser may be used forhair removalin any location
including underarms, bikini line, face, neck, back, chest and legs.
Nd:YAGlaser is generally ineffective for light-coloured
(blonde/grey) hair, but effective for treating dark (brown/black)
hair in patients ofFitzpatrick typesI to III, and perhaps light-
coloured type IV skin.
Indication:
Medical Aesthetic Certification (MAC) Program

25. Hair removal
Extreme caution is
recommended in tanned or
darker-skinned patients, as
the laser can also destroy
melanin, resulting in white
patches of skin
(leukoderma).
Indication:
Medical Aesthetic Certification (MAC) Program

26. Hair Removal
The longer-pulse (millisecond)1064-nm Nd:YAGlaser system
has been shown to be more effective in safely removing hair than
has the Q-switched (nanosecond) Nd:YAGsystem.
Light pulses target the hair follicle, which causes the hair to fall
out and minimises further growth. Typical settings employed
include pulse durations of 2 to 20 milliseconds and fluencesof
10¬40 J/cm
2
.
Indication:
Medical Aesthetic Certification (MAC) Program

27. Tattoo Removal
Blue, grey and black tattoos can be removed with a Q-switched
Nd:YAGlaser (1064 nm wavelength).
Red tattoos is removed by 532nm
The colour of the tattoo and the depth of the pigment influence the
duration and the outcome of the laser treatment.
Green tattoos are removed by PDL (pulsed-dye laser), picosecond
755/532nm alexandrite (PicoSure)
Indication:
Medical Aesthetic Certification (MAC) Program

28. Tattoo Removal
Laser treatment involves the selective destruction of ink molecules
that are then absorbed by macrophages and eliminated.
Typical settings are pulse duration: 10 nanoseconds, output energy:
300¬500mJ.
Indication:
Medical Aesthetic Certification (MAC) Program

29. Onychomycosis
Onychomycosisis a common nail disorder caused by fungal
pathogens.
There are significant barriers to treatment withoralandtopical
antifungals.
Successful treatment of onychomycosis requires antifungal drugs
to penetrate the nail plate and nail bed, but this is often incomplete
with oral and topical agents.
Indication:
Medical Aesthetic Certification (MAC) Program

30. Onychomycosis
Several laser devices have been granted FDA marketing approval for the
treatment of onychomycosis.
The first two lasers that were sanctioned by the FDA for the treatment of
onychomycosis(PinPointe™ FootLaser™[Cynosure, Massachusetts,
USA ] and CuteraGenesisPlus™[Cutera, California, USA]) are both
flashlamppumped short-pulse Nd:YAG1064 nm lasers.
These lasers emit 100–3000 microsecond pulses with an energy fluence
of 25.5 J/cm
2
for a 1 mm spot size.
Indication:
Medical Aesthetic Certification (MAC) Program

31. Nd:YAGlasers have
also be used to
improvewrinklesin
photo-aged skin.
Indication:
Medical Aesthetic Certification (MAC) Program

32. It is important that the correct diagnosis has been made by the
clinician prior to treatment, particularly when pigmented lesions
are targeted, to avoid mistreatment ofskin cancersuch
asmelanoma.
Refer when in doubt.
Laser procedure
Medical Aesthetic Certification (MAC) Program

33. The patient must wear eye protection(an opaque covering or
goggles) throughout the treatment session.
Treatment consists of placing a hand piece against the surface of
the skin and activating the laser. Many patients describe each pulse
feeling like the snapping of a rubber bandagainst the skin.
Laser procedure
Medical Aesthetic Certification (MAC) Program

34. Topicalanaestheticmay be applied to the area but is not usually
necessary.
Skin surface coolingis applied during all hair removal
procedures. Some lasers have built-in cooling devices.
Immediately following treatment, an ice packmay be applied to
soothe the treated area.
Laser procedure
Medical Aesthetic Certification (MAC) Program

35. Care should be taken in the first few days following treatment to
avoid scrubbing the area, and/or use of abrasive skin cleansers.
A bandage or patch may help to prevent abrasion of the treated
area.
During the course of treatment patients shouldprotect the area
from sun exposureto reduce the risk ofpostinflammatory
pigmentation.
Laser procedure
Medical Aesthetic Certification (MAC) Program

36. Isotretinoinuse within 6 months
Cutaneous infections: Bacterial or viral
Keloid or hypertrophied scarring
Ongoing ultraviolet exposure
Prior radiation therapy to the area
Collagen vascular disease
Chemical peel (strong)
Dermabrasion
Contraindication:
Medical Aesthetic Certification (MAC) Program

37. Side effects from Nd:YAGlaser treatment are usually
minor and may include:
Painduring treatment (reduced by contact cooling and if
necessary, topical anaesthetic)
Redness, swelling and itchingimmediately after the
procedure that may last a few days after treatment
Adverse Effects & Complications:
Medical Aesthetic Certification (MAC) Program

38. Rarely, skin pigment may absorb too much light energy and
blisteringcan occur (this settles by itself)
Changes in skin pigmentation. Sometimes the pigment cells
(melanocytes) can be damaged, leaving darker
(hyperpigmentation) or paler (hypopigmentation) patches
of skin.
Generally, cosmetic lasers will work better on people with
lighter rather than darker skin tones
Adverse Effects & Complications:
Medical Aesthetic Certification (MAC) Program

39. Bruisingaffects up to 10% of patients. It usually fades on its
own
Bacterial infection.Antibioticsmay be prescribed to treat or
to prevent wound infection.
Adverse Effects & Complications:
Medical Aesthetic Certification (MAC) Program

40. Postinflammatorypigmentation–
occurs more commonly in patients with
a history of melasmaor
postinflammatoryhyperpigmentation
(more common in patients of darker
skin types)
Side Effects & Complications:
Medical Aesthetic Certification (MAC) Program

41. 1.Long Pulse NdYAG
2.Q Switched NdYAG
3.Fractional Q Switched NdYAG
Types of Nd:YAGLasers Available:
Medical Aesthetic Certification (MAC) Program

42. In addition to their categorization by wavelength, lasers
can be divided into continuous wave (CW) or pulsed.
A CW laser delivers a steady stream of light that is
measured as average power in watts or kilowatts.
A pulsed laser delivers a very short but intense light
emission followed by a period of no light.
What is Q Switching?
Medical Aesthetic Certification (MAC) Program

43. If the laser is repetitively pulsed, the pulse repeats
itself on a regular basis.
The time between the pulses is referred to as the
interpulseperiodand the length of each pulse is called
the pulse duration.
The number of hertz (Hz)represents the number of
pulses emitted per second.
What is Q Switching?
Medical Aesthetic Certification (MAC) Program

44. The length of the pulse duration is an important
characteristic of any pulsed laser/light device.
Pulses lasting a few milliseconds (10
-3
)are generally
characterized as long pulses.
Nanosecond (10
-9
)pulses are considered short. Q-
switched NdYAG laser pulses are typically 3-7
nanoseconds in length.
[2]
Picosecond(one trillionth of a second)
What is Q Switching?
Medical Aesthetic Certification (MAC) Program

45. The principal laser-skin interactions observed in dermal
melanocytosisby Q-switched Nd:YAGlaser treatment is
based on photothermaland photomechanical
interactions induced by selective photothermolysis
Advantages of Q Switching:
Medical Aesthetic Certification (MAC) Program

46. The 1,064 nm Q-switched
Nd:YAGlaser can cause
dermal and epidermal
melanosomerupture,
melanosomerupture in
melanocytes and destruction
of dermal melanophages
11,12
.
Advantages of Q Switching:

47. Anderson et al.
12
conducted a study examining
selective photothermolysisof cutaneous pigmentation in
guinea pigs using a Q-switched Nd:YAGlaser with
single-pulse exposures at 1,064, 532 and 355 nm that
resulted in melanosomerupture within melanocytes
and keratinocytes.
Advantages of Q Switching:
Medical Aesthetic Certification (MAC) Program

48. Rosenbachet al.
13
reported the reduction of epidermal
melanocytesand the number of functional and dermal
melanocytic nestsafter treatment of benign acquired
melanocytic nevi with Q-switched lasers.
Therefore, it is postulated that the Q-switched Nd:YAGlaser
could be an effective treatment modality to remove
melanocytic nevi, which have histological features similar to
dermal melanocytosis, as long as bleeding could be
controlled.
Advantages of Q Switching:
Medical Aesthetic Certification (MAC) Program

49. The treatment with the fractional, nonablativeQ-switched 1,064-
nm Nd:YAGlaser device significantly improves superficial
rhytides.
With its outstanding safety, it seems to be particularly suitable
for the treatment of sensitive areas, such as the periorbital
region, lips, neck, and chest.
The Q-switched Nd:YAGlaser is a facile, safe, and fast
treatment for aesthetic skin rejuvenation.
J Drugs Dermatol.2012;11(11):1300-1304.
Fractional Q Switched ND YAG:

50. Principle of Picolasers: SPT (photothermal) & SRT (photoacoustic)
concepts
Shift from Selective Photothermolysistowards Stress Relaxation
Time concept and LIOB (Light Induced Optical Breakdowns):
meant a shift from photothermal based heating of melanin/ink to a
photomechanical (photoacoustic) effect based on the action of a
pressure wave causing cavitating lesions within the dermis
Pulse duration in the sub nanosecond range aka picosecs and
hence closer to TRT of melanin and ink
Ultrashort high peak pulses produced by mode locking.
Pico Lasers:

51. Pigment shattered into smaller particles and hence better
results
As picolasers work primarily via shock waves that occur
below the upper epidermis, there is reduced risk of thermal
damage to adjacent tissue eghypopigmentation and avoid
unnecessary damage to the upper epidermis
Fractionation of the energy beam by using a focus lens array
produces treatment zones of high and low energy and allows
a form of non ablative fractional photothermal acoustic
treatment especially for scars
Pico Lasers:

52. When a particle is heated up, there is thermal expansion
which manifests as vibrations. Vibrations can diffuse from the
particles to the adjacent tissue. If the heating up time is short,
then this stress remains in the particles and if this stress is
high enough, this will cause the particles to fracture.
Stress Relaxation Time is the time in which Stress Lock in
occurs. This is shorter than TRT egSRT for ink pigments < 1ns.
Nanosecond lasers cannot achieve Stress Lock in as the pulse
duration is > SRT but in Picosecond lasers, the pulse duration
is less than SRT
Stress Relaxation Time (SRT)Theory:

53. Stress Relaxation Time (SRT)Theory:

54. Light Induced Optical
Breakdown(LIOB)
This novel description of skin rejuvenation was first described
by Habbemaet al in 2011.
This was observed using a fractionated non ablative Nd:YAG
laser with pulse duration in sub nanosecond range. ie
Picolasers
LIOB caused microscopic damage below the epidermis and
caused a resultant healing response with new collagen
formation and hence skin remodellingwithout epidermal
damage.
LIOB is independent of the endogenous chromophobe and
the treatment position in the skin is dependent on the
focusing optics.

55. Light Induced Optical
Breakdown(LIOB)
Using a tightly focused near
infrared laser pulse in a grid
pattern to produce LIOB

56. LIOB vs Selective Photothermolysis
Source: Adapted from “Interac3on Mechanisms”, p128. In: Laser-Tissue Interac3ons. M.H. Niemz. Springer VerslagBerlinHeidelberg,
1996 B.A. Rockwell, R.J. Thomas and A. Vogel. Med Las Appl2010 25:84-9

57. Light Induced Optical
Breakdown(LIOB)
Laser energy created is high enough to create a plasma state
which causes micro-explosions in the tissue within the
fractional grid pattern.
Within 10 mins, changes in the affected dermal tissue show
differing levels of cavitation
Within 1 hr, inflammatory response with accumulation of
erythrocytes and later macrophages are seen.
Adjacent epidermis was intact.
New collagen type 3 as part of the extracellular remodellingin
3 days
Significant new collagen noted after 30 days

58. Uses of Pico Lasers
Tattoo removal
Pigment disorders
Acne scarring
Photoageing
Medical Aesthetic Certification (MAC) Program

59. Copper Bromide Lasers:
At 511 or 578nm: melanin
and Hb (511 more for
melanin)
Particularly good for
epidermal pigmentation
Also effective in vascular
melasma, port-wine stains
and acne
Dual Yellow: 578nm & 511nm

60. Informed consent should be obtained before the
procedure according to guidelines.
The consent form should specifically state the possible
postoperative appearance of the treated area, possible
pigmentation changes and need for post-treatment care.
Consent-Salient Highlights:
Medical Aesthetic Certification (MAC) Program

73. Be conservative, know your limits
Know your device well
Learn from expert peers, network with them
Rule out the contraindications
Anticipate and know how to treat complications
Emphasize on post laser care
Think of combination treatment modalities
Tips:
Medical Aesthetic Certification (MAC) Program

74. Nd :YAG Lasers and Picolasersare versatile laser systems
used widely aesthetic dermatology
It has a wide range of indications in pigmentation and tattoo
removal
We need to differentiate the different type of Nd YAG and
picolasers and their use
Each laser is also unique in its parameters and usage
Summary:
Medical Aesthetic Certification (MAC) Program

75. Reference:
1.Stratigos AJ, Dover JS, Arndt KA. Laser treatment of pigmented lesions--2000: how far have we gone?Arch Dermatol.2000;136:915–921.[PubMed]
2.AlsterTS, Lupton JR. Laser therapy for cutaneous hyperpigmentation and pigmented lesions.DermatolTher.2001;14:46–54.
3.Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation.Science.1983;220:524–
527.[PubMed]
4.Chan HH, AlamM, KonoT, Dover JS. Clinical application of lasers in Asians.DermatolSurg.2002;28:556–563.[PubMed]
5.Chan HH, Ying SY, HoWS, KonoT, King WW. An in vivo trial comparing the clinical efficacy and complications of Q-switched 755 nm alexandrite and Q-
switched 1064 nm Nd:YAGlasers in the treatment of nevus of Ota.DermatolSurg.2000;26:919–922.[PubMed]
6.PolnikornN, TanrattanakornS, Goldberg DJ. Treatment of Hori's nevus with the Q-switched Nd:YAGlaser.DermatolSurg.2000;26:477–480.[PubMed]
7.Cho SB, Kim JS, Kim MJ. Melasmatreatment in Korean women using a 1064-nm Q-switched Nd:YAGlaser with low pulse energy.ClinExp
Dermatol.2009;34:e847–e850.[PubMed]
8.Cho SB, Park SJ, Kim MJ, Bu TS. Treatment of acquired bilateral nevus of Ota-like macules (Hori's nevus) using 1064-nm Q-switched Nd:YAGlaser with
low fluence.IntJ Dermatol.2009;48:1308–1312.[PubMed]
9.Cho SB, Park SJ, Kim JS, Kim MJ, Bu TS. Treatment of post-inflammatory hyperpigmentation using 1064-nm Q-switched Nd:YAGlaser with low fluence:
report of three cases.J EurAcadDermatolVenereol.2009;23:1206–1207.[PubMed]
10.Kim SD, Kim SW, Huh CH, SuhDH, EunHC. Changes of biophysical properties of the skin measured by non-invasive techniques after Q-switched Nd-
YAG laser therapy in patients with nevus of Ota.Skin Res Technol.2001;7:262–271.[PubMed]
11.Anderson RR. Laser-tissue interactions in dermatology. In: Arndt KA, Dover JS, OlbrichtSM, editors.Lasers in cutaneous and aesthetic
surgery.Philadelphia: Lippincott-Raven; 1997. pp. 25–32.
12.Anderson RR, Margolis RJ, WatenabeS, FlotteT, HruzaGJ, Dover JS. Selective photothermolysisof cutaneous pigmentation by Q-switched Nd:YAGlaser
pulses at 1064, 532, and 355 nm.J Invest Dermatol.1989;93:28–32.[PubMed]
13.RosenbachA, Williams CM, AlsterTS. Comparison of the Q-switched alexandrite (755 nm) and Q-switched Nd:YAG(1064 nm) lasers in the treatment of
benign melanocytic nevi.DermatolSurg.1997;23:239–244.[PubMed]
1.Gupta AK, Simpson F. Device-based therapies for onychomycosistreatment. Skin Therapy Letter. 2012; 17(9).
2.Noguchi H, Miyata K, Sugita T, HirumaM. Treatment of OnychomycosisUsing a 1064nm Nd: YAG Laser. Med MycolJ. 2013; 54(4):333-9.
3.MeestersAA, PitassiLH, Campos V, WolkerstorferA, DierickxCC. Transcutaneous laser treatment of leg veins. Lasers Med Sci. 2013 Nov 13. [Epub
ahead of print].
4.Alexis AF. Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI. Br J Dermatol.
2013 Oct;169 Suppl3:91-7. doi: 10.1111/bjd.12526.

76. Thank you

77. [email protected]
Thank You