Effectively treating vascular and pigmented lesions — from common facial telangiectasias to more challenging hemangiomas — relies on identifying the appropriate tools and then honing one’s technique to achieve the best results. However, more often than not, patients want to make the most of their sessions by undergoing concomitant facial resurfacing to improve wrinkles and texture changes related to repeated sun exposure, according to William F. Groff, D.O., who practices alongside aesthetic laser pioneer, Richard Fitzpatrick, M.D., at the La Jolla Cosmetic Surgery Centre, in La Jolla, Calif. In these cases, Dr. Groff tells Cosmetic Surgery Times, a combination of two or more lasers is often the best approach. Here, Dr. Groff offers tips and perspective on wrinkle and vascular and pigmented lesion treatment strategies that result in patients whose post-procedure appearance is ultimately the best form of marketing.
RESULTS DELIVERED The most common facial lesions that patients request treatment for are wrinkles, telangiectasias and solar lentigines according to Dr. Groff, who adds that these are followed in frequency by rosacea, melasma, cherry angiomas and spider angiomas.
“Facial telangiectasias, cherry angiomas and spider angiomas are fairly easy to treat if you have the right tools,” says Dr. Groff. They can all be treated very safely and effectively with pulsed dye lasers (PDLs) in just one or two sessions. “PDL has a long track record and is certainly considered the gold standard, so if the practitioner wants to treat both vascular and pigmented lesions, the PDL is one unit that can be counted on to deliver reliable, predictable and safe results. We have about 20 lasers in our practice and the PDL is probably the safest. The chance of having a problem or complication is extremely rare.”
Dr. Groff’s technique for facial telangiectasias comprises the use of a Candela V-beam Perfecta PDL, using the 10 mm spot size with 7.5 to 10 J/cm2. “I would usually use a 6, 10 or 20 ms pulse duration [depending on the size of the vessels], and it could take anywhere from one to three sessions at the most,” he explains. Larger vessels require treatment with longer pulse durations. David J. Goldberg, M.D., J.D., adds that, “A variety of other lasers and light sources can also be successfully and safely used to treat such vascular lesions. Among the more popular wavelengths besides the 595 PDL are the 532, 940, 980 and 1064 nm wavelengths.” Dr. Goldberg is director of Skin Laser & Surgery Specialists of NY/NJ, and clinical professor of dermatology/director of laser research at the Mount Sinai School of Medicine in NYC.
There is a high demand for facial laser resurfacing in Dr. Groff’s practice and almost every person who comes in for resurfacing has brown spots and telangiectasias. “But no matter what kind of fractional resurfacing device you use, most telangiectasias and some brown spots remain.” To get the best results, Dr. Groff recommends using a combination of lasers. “There’s not one box that does it all and does it all the best,” he says.
For a patient who has facial telangiectasias, solar lentigines and wrinkles, Dr. Groff recommends using the PDL to remove the capillaries, the PDL or Q-switched alexandrite to remove the lentigines, then immediately treating with fractional CO2 resurfacing all in one session. “The results are much better than if you use any of these technologies alone,” he says. “Dr. Fitzpatrick and I have been doing these combination treatments for years, and we’ve never had any complications from combining lasers in one session. Our results are excellent and patients appreciate not having to come back for separate treatments, which would incur more social downtime. There’s a synergistic effect where the results are much better when these treatments are done at the same time, in comparison to doing them separately,” he adds.
Taking the synergistic effect one step further, Dr. Groff recommends pretreating with BOTOX around the glabella, the forehead and the crow’s feet area one to two weeks before performing fractional resurfacing. “If you do this, those muscles are relaxed so they’re not contracting and etching lines into freshly resurfaced skin,” he explains.
STACKING TREATMENTS In the majority of these cases, patients who are seeking resurfacing and treatment for telangiectasias also want to be rid of the vertical upper lip “smokers’ lines” that are commonplace among women over the age of 40. “The gold standard for erasing these lines is still traditional multiple pass CO2 laser resurfacing in combination with erbium laser resurfacing. So even though fractionated CO2 will soften the lines, if the patient wants those lines to be gone you still need multiple pass CO2 and erbium laser resurfacing,” he explains. “In our practice, if we’re going to resurface a woman’s facial skin, we’ll use a fractional CO2 over the entire face with the exception of the upper lip where we’ll perform traditional multiple pass CO2 and erbium resurfacing in addition to using the PDL and the Q-switched alexandrite laser to address the telangiectasias and brown spots, respectively. We use these lasers back to back in the same treatment session. That’s really the way to get the best results,” Dr. Groff says. With regard to these challenging upper lip lines, Dr. Goldberg adds that, “Although fractional nonablative lasers do not typically lead to improvement of upper lip lines, many clinicians have also seen great results from ablative fractional lasers emitting 2790, 2940 and 10,600 nm wavelengths.”
For pigmented lesions, Dr. Groff opts for Candela’s TriVantage, a Q-switched alexandrite laser, which delivers energy through a fiber optic cable, giving it a homogeneous result with less variation from pulse to pulse. “We consider this laser the workhorse of our practice. It’s fast and extremely effective,” he says. The TriVantage offers Q-switched 1064 nm and 532 nm wavelengths, as well as a 755 nm wavelength, so, in addition to treating pigmented lesions, it is also effective for tattoo removal of many colors. “Previously removing multicolor tattoos meant using multiple lasers, but with the TRiVantage we’re able to remove all colors except for white, yellow and fluorescents,” he says.
Treatment of pigmentation is a complex subject. Determining the type of lesion will help to establish which laser or light device to use and what parameters to set.
Hyperpigmentation is a broad descriptive term, offering us little information about etiology or pathophysiology of the lesion. Dividing this expansive category into primary versus secondary helps with treatment decision-making and predicting outcome.
Moreover, hyperpigmentation can stem from epidermal, dermal or a combination of these locations. Discrete lesions, such as lentigines, ephelides (primarily epidermal lesions) and nevus of Ito or Ota and decorative tattoos (primarily dermal lesions), show the most favorable response to laser and light-based therapies.
Postinflammatory hyperpigmentation would be the main component of the secondary hyperpigmentations. Melasma can also be considered in this category, as it generally behaves similarly to postinflammatory hyperpigmentation after laser treatments, showing the most unpredictable response to laser and light-based therapies.
Primary pigmented lesions are generally easier to treat than secondary lesions. For localized lesions on the trunk and face, the Q-switched lasers are very successful at removing pigmentation. These include Q-switched ruby (694 nm), Q-switched alexandrite (755 nm) and Q-switched Nd:YAG (both 1,064 nm and 532 nm). For darker skin types, choose the longer-wavelength Q-switched lasers, as their emissions have less absorption by melanin and hence less competition/absorption from normally pigmented skin.
To learn more about the use of IPLs, long-pulsed dye laser (LPDL) and Q-switched lasers for the treatment of solar lentigines, photoaging and flat seborrheic keratosis read The right tool: Lesion type determines which laser, light device is best choice, opinions of Joely Kaufman, M.D., assistant professor of clinical dermatology at the University of Miami Miller School of Medicine and director of lasers for the University of Miami Cosmetic Group, and Vic Narurkar, M.D., the chair of dermatology at California Pacific Medical Center and director and founder, Bay Area Laser Institute, and associate clinical professor of dermatology at University of California Davis School Of Medicine.
Just like Dr. Kaufman and Dr. Narurkar, I believe that there is a potential of further development of “do it at home” lasers:
“It remains to be seen what type of contribution the at-home devices will play in the treatment of pigmentation. The newer devices coming to the market look very promising as both preventive and adjuvant therapeutic options.”
Laser lasers and light-based devices for home use cannot be considered as a replacement of medical office treatment, but some of the products in the laser industry pipeline can be used as ancillary tools to enhance the effectiveness of a medical treatment plan.
Pulsed dye laser (PDL, 595 nm) is the current treatment of choice for port-wine stains (PWS), but 25–50% of treated lesions do not demonstrate a significant improvement.
Combination of laser may improve treatment efficacy, especially those using the synergies between PDL and Nd:YAG 1064nm laser. There is a growing body of research and anecdotal evidence that the dual wavelength approach shows efficacy with less discomfort for the patient.
What do brown spots, liver spots, sun spots, age spots, pigmented spots, sun burns, melasma, chloasma, hiperpigmentation and skin cancer have in common? The sun damage.
Watch the Sun Damaged Skin Slideshow of alarming pictures of skin damage and take action to prevent skin problems and reduce your skin care costs.
This is our most recent (constantly updated) collection of video materials demonstrating laser treatments of pigmented skin lesions, such as liver spots, brown spots, cafe au lait spots, sunspots (lentigines) and age spots.
Expanding on Fiona’s post about pigmented spots, melasma (aka chloasma) or the “mask of pregnancy” as it is also called, is a skin condition when tan or brown spots and small areas discolor the skin. It is most commonly found among woman, especially pregnant women or those taking hormone replacement therapy medications.
Generally the symptoms include dark patches and spots on the cheeks, nose, temples and forehead. “Melasma upper lip” is also very common. They may develop and worsen over time. Melasma is a purely cosmetic concern, though any unusual spotting should be diagnosed by a qualified dermatologist to determine if it is skin cancer.
Genetics, hormones such as estrogen and progesterone, and extrinsic factors such as sun exposure are thought to be the cause of Melasma. Hormones stimulate the production of melanocytes, the pigment-producing cells in our skin, as they become exposed by the sun. The increased melanin production causes the spotting we see with Melasma. Avoiding the sun is key and wearing sunscreen with both UVA and UVB protection will help protect the skin and diminish the factors contributing to a worsening of melasma.
There are a number of treatments available for melasma. Some include:
Lasers are ideal for age spot removal. Because the melanin pigment is designed to absorb light, almost any color of laser light can be used to take away brown spots. There are a number of lasers which may be used for this. For example, the Q-switched lasers are very safe to treat the surface of the skin. Many doctors use the 532nm Nd:YAG laser, which is a green light laser, a 1064 Nd:YAG laser which is an invisible, infrared laser. You can use the 755nm Alexandrite Q-switched laser or the 694 Ruby Q-switched laser.
Laser resurfacing melasma is a relatively new but very effective treatment that can be done with ablative lasers, such as Erbium or Erbium fractionated lasers.
Your doctor will make the recommendation based on your skin type and his armamentarium.
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We have received a few questions about liver spots, liver spots cancer and its causes, as well as about laser treatment of liver and other pigmented spots.
Liver spot, brown spot, sun spot are all synonyms for age spot. Liver spots have nothing to do with or caused by the liver. Pigmented lesions (spots) often appear on the face, the top of the hand, arms, neck and decolletage. These areas are the most common because they are the most exposed to the sun.
These spots are the main signs of aging from the sun, i.e. they are caused not by the passage of time and chronological aging, but from the sun. The pigment spots you see appearing on your face are not a function of age, but of sun exposure. Sun spots are another common phrase for “age spots”, “liver spots” or “brown spots”. They are also called lentigos or solar lentigines.
Our skin has melanin pigment which absorbs sunlight and helps naturally protect our skin from UV rays. However as we age, our skin’s natural ability to fend off UV rays from the sun begins to deteriorate, and we see the development of age spots.
There are a couple different types of liver spots that people get on their skin. There are solar lentigos (age spots) and freckles (known as ephiledes). These come from the sun and that’s because the sun damages the melanocytes, which are the cells in the epidermis (the skin’s surface layer) that produce melanin pigment. Most of the cells in our epidermis are skin cells that form the dead skin layer as well as keratin that protects us from the outside world, but one in every tenth or twentieth cell is a melanocyte which produces melanin pigment and transfers this brown pigment to our skin cells to help protect us against the sun.
People with very light skin have almost no melanin pigment and that type of skin cannot do a good job of protecting them from the sun, causing abnormal melanin pigment in the form of freckles and brown spots. Dark-skinned people do a much better job of protecting themselves from the sun.
Tan skin is not healthy skin. A tan is our body’s way of telling us our skin has been damaged, and its attempt to protect itself from further damage. As we undergo UVA and UVB light exposure from the sun’s rays or from tanning beds, we are damaging our skin, which will lead to age spots (solar lentigines), sun spots, liver spots, poikiloderma (reddish–brown areas of discoloration) and melasma (mottled brownish areas). Tanning beds have been shown to have a much more damaging effect on the skin than the sun.
Health experts are fighting back against the aggressive campaign by the indoor tanning industry to portray sunbathing and the use of indoor tanning beds as safe and beneficial for you. There are many research papers linking tanning beds to melanoma, the most dangerous kind of skin cancer.
Preventing age spots requires sun avoidance and sun protection. Most of the sun damage we receive occurs while we are driving. Car window glass protects us from 100% of the UVA light (the light which causes a burn) but none of the UVB, the light responsible for sun damage and aging skin. Installing a tinted or clear UVB-protecting film on the car window is a very good idea to help prevent much of the sun damage which causes age, liver, or brown spots.
The second recommendation is to wear sunscreen all day, every day, all the time. Even if you already have sun damaged skin, it’s never too late to start. This will help prevent further damage and age spotting.
Rarely, but if you see any pigmented lesion on your skin do not assume that it’s benign. If you notice a lesion on your skin, especially if it has any changes in color, size or shape, you should see a dermatologist to determine if they are cancerous.
You may need to have a biopsy performed to determine if the lesion is benign or not. Once the doctor has determined that it is benign, there are a variety of lasers that can be used to improve or remove it. Most of pigmented lesions are very effectively removed with laser treatments.
In general laser treatment of pigmented lesions is very effective and permanent. New spots may appear as your sun exposure increases. These are new spots, not a recurrence of the old, removed spots. Good sun-avoidance is key if you wish to see your skin free of sun spots for a long time.
Since there is a chance that some of the age spots could be a sign of skin cancer, laser treatments should be initiated or cleared by a dermatologist. Laser treatments typically last 20-30 minutes, can be paindfull depending on the laser modality available to your provider, and should be repeated 2-4 times.
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