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Nordic Course on Laser Dermatology
Programme & Presentations
www.nordicdermatologycourses.org
16 - 17 November 2018Bispebjerg Hospital
Copenhagen, Denmark
Nordic Course on Laser Dermatology is initiated by the Nordic Dermatology Association
Index
Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
General information . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Faculty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Nordic Course on Laser Dermatology
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Welcome
Dear ParticipantIt is a great pleasure to welcome you to the
1st Nordic Course on Laser Dermatology in Copenhagen.
The 2 day course will offer 12 lectures, given by internationally recognized speakers, hands-on exercises and case-based interaction . You will achieve up-to-date theoreti-cal knowledge on lasers and energy based devices in dermatology and gain clinically relevant skills about practical procedures, tips and tricks .
We look forward to provide you with the theoretical and practical skills, required to practice laser dermatology in your own setting .
A warm welcome to Copenhagen, enjoy the course!
On behalf of the entire faculty,
Merete Haedersdal, MD, Ph .D, DMSc
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Programme
Friday 16th November
9:00 Registration and coffee
9:50 Welcome and introduction to scientific faculty
Part 1: Basics
10:00 Lecture 1 Devices overview, Laser-tissue interactionsImmediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
11:00 Lecture 2 Laser safety
Merete Haedersdal
11:30 Lecture 3 Side effects – and how to avoid them
Christine Dierickx
12:00 - 12:45 Lunch
Part 2: Clinical Indications I
12:45 Lecture 4 Vascular lesions – How to optimize treatment outcomes
Merete Haedersdal
13:15 Lecture 5 Hair removal – Procedures and different patient groups
Christine Dierickx
13:45 Lecture 6 Surgical procedures with ablative lasers . Fractional and full ablative
Albert Wolkerstorfer
14:15 Questions and Catch up
14:30 – 15:00 Coffee break Walk to Derm Department, Laser Unit, Entrance 4, 1st floor
Part 3: Hands on
15:30 – 17:30 Clinical exercises, Laser unit, Derm Department, Bispebjerg Hospital
Katrine Karmisholt
17:30 – 19:00 Welcome reception: Wine and snacks
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Saturday 17th November
Part 4: Clinical indications II
9:00 Lecture 7 Lasers for the treatment of skin (pre)-malignancies
Merete Haedersdal
9:30 Lecture 8 Pigmented lesions and tattoos
Albert Wolkerstorfer
10:00 Lecture 9 Treatment of the ageing face and neck
Christine Dierickx
10:30 Coffee break
11:00 Lecture 10 Scar treatment - different approaches to different types of scars
Merete Haedersdal
11:30 Lecture 11 Hyperhidrosis
Christine Dierickx
12:00 Lecture 12 Cutting edge – New treatments in the pipeline
Merete Haedersdal
12:30 - 13:15 Lunch
Part 5: Clinical Cases
13:15 Case-based interaction with participants Albert Wolkerstorfer,
Christine Dierickx,
Katrine Karmisholt,
Merete Haedersdal
15:00 Test, self-assessment Katrine Karmisholt
15:30 Evaluation, thank you and good bye
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General information
Certificates of AttendanceCertificates of attendance will be available for download after the course . A link will be sent to you shortly after the end of the course .
Conference venueBispebjerg HospitalEsther Ammundsens vejUddannelsescenter, building 502400 CopenhagenDenmark
ContactCourse Secretariatc/o CAP Partner Nordre Fasanvej 113, 2nd floor 2000 Frederiksberg C Denmark T: +45 70 20 03 05 info@cap-partner .eu or ks@cap-partner .eu
Language The language of the course is English .
EntitlementsThe registration fee includes:
4 Admission to the full course programme
4 All course materials
4 Lunches and break refreshments
4 Welcome reception on November 16 2018
4 Certificate of attendance
Lost and Found Found items should be returned to the registration desk . If you lose something, please report to this desk for assistance .
Mobile phones All mobile phones must be on silent mode during the sessions .
Wi-FiFree Wi-Fi is provided throughout the venue . Connect to BBH guest net and follow the steps provided .
Social Event
Welcome receptionFriday 16th November Auditorium hallway
Join your colleagues for snacks and wine/soft drinks . Included in the registration fee . Please note that the reception is not a dinner .
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Faculty Information
Christine C. Dierickx, MD
Christine C. Dierickx finished her dermatology residency in Belgium . Subsequently, she completed a fellowship in phlebology in the Netherlands, a clinical laser fellowship with Dr . R . Fitzpatrick in San Diego, CA and a Mohs fellow-ship with Dr . F . Mohs in Madison, Wi .
During a 2-year laser fellowship with Dr . R . Anderson at Massachusetts General Hospital of Harvard University, she developed research laser expertise in various fields. For her work on the thermal relaxation time of ectatic blood vessels, she received the Best Basic Science Award of the American Society for Laser Medicine and Surgery . Subsequently, she became a full-time staff member of the Wellman Laboratories at Harvard . During this time, she conducted the research projects with long pulsed ruby and diode lasers for hair removal that led to approval for permanent hair reduction .
She returned to Europe in 2000 where she is in private practice in Luxembourg .
In 2006, Dr . Dierickx was vice-president of the “American Society of Laser Medicine and Surgery, Inc” and afterwards a board member of the International Committee . In 2013 she was the recipient of the Vasant Orwal Oration van de British Medical Laser Society . In April 2016, she was granted the Leon Goldman memoriam award . This award recognizes a practicing physician whose career demonstrates excellence in clinical research, patient care, or education, related to medical lasers .
Dr . Dierickx remains actively involved in research on various energy based devices and its applications . She has published and lectured nationally and internationally in the field of la-ser surgery, energy based devices and photodynamic therapy .
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Merete Hædersdal, MD, Ph.D, DMSc
Dr . Merete Haedersdal, MD, PhD, DMSc, is clinical professor of dermatology at University of Copenhagen, senior consult-ant at Dept of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark .
Dr . Haedersdal directs the Laser Dermatology Clinic at Bispebjerg University Hospital, and she is affiliated visiting scientist at Wellman Center for Photomedicine, Massachu-setts General Hospital, Harvard Medical School, pioneering “laser-assisted drug delivery” together with Dr . R . Rox Ander-son and his team .
Professor Haedersdal has published > 150 scientific papers and lectures internationally . Her research team focuses on translational medicine in the field of laser dermatology, frac-tional laser-assisted drug delivery, photodynamic therapy, and treatment of skin cancer with light-based devices .
Katrine Elisabeth Karmisholt, MD, Ph.D
Dr. Karmisholt is a Danish board-certified specialist in dermatology at Bispebjerg Hospital . Since Dr . Karmisholt specialized in dermatology, almost 6 years ago, she has worked with a wide range of laser devices .
On a regular base, Dr . Karmisholt treats vascular lesions, acne scars, burn scars, rhinophyma as well as performs minor surgery with lasers .
Dr . Karmisholt has received expert training with the Miami-based international laser expert in scar treatments Dr . J . Waibel . Furthermore, Dr . Karmisholt’s research com- prises laser treatment of scars with her Ph .D . thesis focusing on laser treatment in early wound healing and the clinical effect on scar formation .
Additionally, Dr . Karmisholt speaks at and attends interna-tional and national laser conferences and laser meetings .
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Faculty Information
Albert Wolkerstorfer, MD, Ph.D
Albert Wolkerstorfer works as dermatologist at the Department of Dermatology/Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centre in the Netherlands .
His academic fields of interest are laser dermatology and pigmented disorders. In both fields, he combines experi- mental and clinical research with clinical activities at the outpatient department .
Nordic Course on Laser Dermatology
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Albert WolkerstorferNetherlands Institute for Pigment Disorders
Dept DermatologyAmsterdam University Medical Centre
Devices - Tissue interaction - Immediate skin responses
Lasers – The Basics1
• Disclosures– Research grant: AvitaMedical
Devices - Tissue interaction - Immediate skin responses2
• Introduction• Devices• Laser – tissue interaction• Immediate skin responses
Lasers – The Basics3
1960 –First Laser
Laserdermatology - history4
November 1916 ‘A splendid light has fallen on me
about the absorption and emission of radiation’.
L ightA mplification byS timulatedE mission of R adiation
Laser History5
November 1916 ‘A splendid light has fallen on me
about the absorption and emission of radiation’.
L ightA mplification byS timulatedE mission of R adiation
Laser History6
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November 1916 ‘A splendid light has fallen on me
about the absorption and emission of radiation’.
First laser - 1960“A solution looking for a problem"
Laser History7
• 1961: laser for retinatumor by Charles Campbell• 1961: laser for melanoma by Leon Goldman• 1966: 1e operation without bleeding
• Patent jurisdiction 30 years
Laser History8
Laserdermatology Today
• Innovative• Technical refinements• New devices
9
Laserdermatology Today
But….• Fake news• Glamour & Glitter• Many claims – few proof• Personal experience• Cosmetic• Desinformation
10
Desinformation
Company
Distributor
Expert
Congresses
Practitioner
Approval• FDA approval– Pre Market Approval– 510(k) Pre Market Notification
• ...demonstrate substantialequivalence to a legally marketeddevice.
11
SolidLiquid Gas
L ightA mplification byS timulatedE mission of R adiation
Laserdermatology - basics12
14
Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Laserdermatology - basics13
Laserdermatology - basics14
Laserdermatology - basics15
Laser light is different!
Normal light Laser light
16
•monochromatic
•coherent
•parallel
Laserdermatologie SNIP
Laser light is different!
Laser
17
Electromagnetic Radiation
Ultraviolet
X-Ray
Visible Light Nanometers Invisible Light
AM Radio
Microwave
NdY
AG(1
064n
m)
Alex
andr
iet
lase
r (75
5nm
)
CO
2 la
ser
(106
00nm
)
Vbea
m(5
95)
TV and FM Radio
Cosmic
400 500 600 700 1,000 10,000
Laserdermatologie SNIP
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Laserdermatology - Future
More wavelengths
19
Laser – Tissue Interaction20
• Absorption• Energy of photons
transfered to tissue
Lasers – tissue interaction21
(A)thermal Processes
>43°C Enzyme induction>60°C Protein denaturation and
coagulation>100°C Dehydration and vacuolization>150°C Carbonization und Pyrolysis>300°C Vaporization, Ablation>1000°C Ionization, Disruption
22
Unselective heating
Thermal damage
23
Selective Photothermolysis
Tattoos
Vascular
Melanin
Hair
Sucutaneous tissue
24
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Anderson & Parish – 1983
• Different chromophores absorb different wavelengths of light
• Use laser with wavelength of light preferentially absorbed by target
Selective Photothermolysis25
Absorption curve
Absorption of light
Different chromophores absorb different wavelengths
26
514 nmArgon
Absorption of light
Vascular Lasers
532 nmKTP
595 nmPDL
27
1064 nm
Absorption of light
Alexandrite Nd:YagRuby
694 nm
755 nm
28
High water absorption
Absorption of light29
Absorptiespectra
0,00010,0010,010,1
110
1001000
10000100000
1000000
0,1 1 10Golflengte [µm]
Abso
rptie
coëf
ficie
nt [1
/cm
]
bloed met O2
bloed zonder O2
watermelanosoomeiwit
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Anderson & Parish – 1983
• Different chromophores absorb different wavelengths of light
• Use laser with wavelength of light preferentially absorbed by target
Selective Photothermolysis31
Anderson & Parish – 1983
• Different chromophores absorb different wavelengths of light
• Use laser with wavelength of light preferentially absorbed by target
• Selectively heat target• Keep the pulse short – only to heat target
Selective Photothermolysis32
• Pulse duration is critical
Lasers – The Basics
Target Target Target
Pulse duration optimal Pulse duration too long
Short pulse duration
33
Selective Photothermolysis
Parish & Anderson (1983)
Concept of selective destruction of tissue, sparing surroundingstructures through light with a specific wavelenght.
Pulse duration must match thethermal relaxation time.
34
Pulse duration is critical
Hair removalTRT 100ms
Pigmented lesions TRT 250ns
Alexandriet 755nm 2-40ms 50-100nsNdYAG 1064nm 10-100ms 5-7nsRuby 694nm 1-3ms 25-40ns
35
Pulse duration36
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Many devices
Tattoos
Vascular
Melanin
Hair
Sucutaneous tissue
• …in order to match• Target absorption• Size of target• Depth of target• Spare the skin surface• Surrounding heat
37
Many devices
Tattoos
Vascular
Melanin
Hair
Sucutaneous tissue
• Vascular lasers• Pigment lasers• Hair reduction lasers• Ablative lasers• Fractional lasers • Lasers for subcutis
38
Absorption curve
Intense Pulsed Light (IPL)39
400 600 800 1000 1200 1400 1600 1800 2000
5
4
3
2
1
0
Dep
th (m
m)
Wavelength (nm)
Penetration of light in skin40
Absorption curve
Absorption of light41
Lasers – The Basics
Farkas et al. Aesthetic Surg J. 2013.
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Laser – Tissue Interaction43
(A)thermal Processes
>43°C Enzyme induction>60°C Protein denaturation and
coagulation>100°C Dehydration and vacuolization>150°C Carbonization und Pyrolysis>300°C Vaporization, Ablation>1000°C Ionization, Disruption
44
• Photobiomodulation• Gen expression
• Photothermal• Light energy transformed to heat
• Photomechanical / Photoacoustic• Light energy creates shockwave
• Photochemical• Light starts chemical reaction (PDT)
• Photoablation• Removal of tissue
Lasers – Tissue Interaction45
1. Light enters skin
2. Absorptie in melanine(koelen met spray)
3. Absorptie in bloed waardoorbloedvaten kapot gaan
Photothermal Interaction46
Completely occluded
Incompletely occluded
Voorbeeld:behandeling van wijnvlekken
Photothermal Interaction47
Photodynamic Therapy (PDT)
Application Occlusion Photo-activativation Selectievedestruction
Photochemical Interaction48
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Photablative Interaction49
Cataract reoccurrence
Stone pulverization
Tattooremoval
Phototmechanical Interaction50
• Wavelength• Pulse duration• Spotsize• Cooling• Fluence (J/cm2)
Five parameters for optimal results51
Spot size - Penetration52
Cooling Devices
Cryogen
Contact Cooling
Air Cooling
53
Large-diameter vessels Small-diameter vesselsHigher vascular volume Lower vascular volume
Pink or red vessels Purple or blue vesselsSmall-diameter vessels Large-diameter vessels
Deep vessels Superficial vesselsSmall spot sizes Large spot sizes
High-pressure vessels Flaccid vessels
Deep vessels Superficial vesselsLarge-diameter vessels Small-diameter vessels
Pulse Duration
Spot Size
Fluence
Parameters Pulsed Dye Laser
Laserdermatologie SNIP
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Laser - complications55
…can help to achieveoptimal outcomes
Immediate Skin Responses56
WHAT ARE IMMEDIATE SKIN RESPONSES
• Tissue responses based on laser-tissue interaction
• Directly after laser• Bio-endpoints, biological endpoints,
immediate skin responses, clinicalendpoints………
Immediate Skin Responses57
WHY SHOULD WE USE THEM• Improve outcomes• Choosing settings is complex
Immediate Skin Responses58
Port Wine Stains59
Settings for telangiectasia
Nymann et al. Britsh J Dermatol 2009
60
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
WHY• Improve outcomes• Choosing settings is complex• Laser manuals + knowledge + algorithms
can not stand alone• Tailor-made settings• Prevent side effects
Immediate Skin Responses61
Subpurpuric PDL - telangiectasia
Immediate Skin Responses62
Temporary darkening
595nm PDL10mm6ms DCD 30-20
7.25J/cm2 sec
4 sec
63
Temporary darkening
595nm PDL10mm6ms DCD 30-20
7.25J/cm2 sec
7.5J/cm2 sec
4 sec
6 sec4 sec
64
Izikson L, Anderson RR. Journal of Cosmetic and Laser Therapy. 2009; 11: 52–55
755 nm alexandrite:
Watchful waiting
Transient grey colorthat evolves intodeep purpura
Immediate Skin Responses65
1064 nm NdYAG - FEEL & SEE & HEAR
Immediate Skin Responses66
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1064 nm Nd:YAG – subtle purpura, no greying
Immediate Skin Responses67
Q-switched 694 nm ruby - lentigo
Immediate Skin Responses68
Q-switched 694 nm ruby - lentigo
Immediate Skin Responses69
Immediate Skin Responses70
Q-switched 694 nm ruby – Hori’s nevus
Immediate Skin Responses71
Immediate Skin Responses72
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Intense Pulsed Light (IPL)
On-site biological endpoints73
Immediate Skin Responses74
Immediate Skin Responses75
Immediate Skin Responses76
CO2 laser - endpoint77
Erb:YAG laser - endpoint78
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Ablative laser endpoint
Erb:YAG laser CO2 laser
79
Immediate Skin Responses80
Basic knowledge• Knowledge of skin• Knowledge of laser devices• Knowledge of laser – tissue interaction• Laser manuals + laser algorithms
Experience• Tailor-made settings• Prevent side effects
Optimal outcomes81
Epidermis Dermis Total ThicknessChin 149 1375 1524Forehead 202 969 1171Upper lip 156 1061 1217Lower lip 113 973 1068Nasal tip 111 918 1029Neck 115 138 253Cheek 141 909 1050Glabella 144 324 468Eyelids 130 215 351
Facial skin thickness
Freeman SM. Plast Surg Clinics North AM: 425-42; 1996
82
Cosmetic Unit83
Immediate Skin Responses84
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Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs
Albert Wolkerstorfer
Albert WolkerstorferNetherlands Institute for Pigment Disorders
Dept DermatologyAmsterdam University Medical Centre
Devices - Tissue interaction - Immediate skin responses
Lasers – The Basics85
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Lecture 2 Laser Safety
Merete Haedersdal
Laser Safety
NDA Laser Course 2018
Department of Dermatology, Bispebjerg Hospital
Merete HaedersdalProfessor, PhD, DMSc
Bispebjerg HospitalUniversity of Copenhagen Denmark
Wellman Center for PhotomedicineMGH, Harvard Medical SchoolBoston, USA
1
1. Laser Classification
2. Beam hazards - Ocular injuries
- Skin damage
3. Non-beam hazards
4. Practical safety guidelines
Agenda
Department of Dermatology, Bispebjerg Hospital
2
1: Laser Classification
Class 1 laser: Low power
Considered safe
Class 2 laser: Visible and continuous lasers only (<1 mW)
Eye protection afforded by the eye blink response
Class 3 laser: Medium power
3R & 3B Hazard to the eye from direct exposure
3R: 1-5mW
3B: <0.5W
Class 4 laser: High power (>0.5 W)
Hazard to eye and skin from direct and reflected exposure
Fire hazard
3
1: Laser Classification
Wavelength
Absorption
Penetration
4
1: Laser Classification
Skin Cornea Lens Retina<300 nm yes yes no no
300-400 yes yes yes no
400-600 yes no no yes
600-1400 yes no no yes
1400-10600 yes yes no no
All devicesUV
CO2 laser UV
IPL systems
IPL systems
Pulsed dye laser
Near IR: Alex, Nd:YAG
5
Ocular injuries
2: Beam Hazards
Direct and reflected light
Inappropriate use of glasses and goggles
- Wavelength dependent
- Removal of glasses, blinking
Never treat within orbital rim with Near IR wavelengths, incl. IPLs
- Retinal injury
- Iris defect, coloboma,
Use shields inside orbital rim: PDL, CO2, YAG lasers
6
28
Protective Eyewear
Alexandrite
CO2 Er:YAG
CO2 Er:Glass Q-switched
Ruby Nd:YAG
Dye laser
Wear appropriate
protective eye wear!
7
Glasses, glasses, and glasses……
Wavelength-specific eyewear
Wavelength(s) & optical density (OD) should be clearly written
OD > 4-6
Check OD yourself !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Attenuation is given in Optical Density “OD” An OD of 4 means that the irradiance of the beam passing through
the eyewear is attenuated by 104 = 10,000 times
8
Risk of Ocular Hazards – Professional devices
9
Eye Injury
Nd:YAG (1064 nm) - Permanent damage
Individual saw a white flash, heard a click, then immediately a dark spot
in visual field
(www.ucl.ac.uk/uro-neph/ppt/lm221102.ppt)
10
11 12
Lecture 2 Laser Safety
Merete Haedersdal
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Skin injuries
2: Beam Hazards
Visible and IR lasers can cause mild to severe erythema,
blisters and scarring.
Depigmentation, ulceration and scarring may be permanent
Usually caused by high powered lasers
14
Do Your Homework….
JAAD, 2016
CME papers
15
Standard Settings, but….
do better than cook-book approach
16
Biological End-Point = Immediate Skin Reaction
17
Cooling
2: Beam Hazards
Air cooling
Contact cooling
Cryo spurt
18
Lecture 2 Laser Safety
Merete Haedersdal
30
3: Non-Beam Hazards
Electrical hazards
High voltage.
Laser capacitors can retain high energy charges even when the power is off
Know where the kill switch is!!!!
Know Your Kill switch
3: Non-Beam Hazards
Fire
Ignition of materials can occur from direct,intense reflected or scattered beams- Hair, paper, textiles- Make sure hitting right foot pedal
- Always go to standby when not using laser
Protect flammable areas with wet drapes- Endotracheal tube- Perianal region / methane
Electrical equipment fire extinguisher should be conveniently located in case of fire
3: Non-Beam Hazards
Plume - contaminants
Bacterial sporesBacterial spores survive low CO2 irradiances
Papilloma VirusHPV cultured from plume after CO2 tx of warts
HIVHIV not cultured
3: Non-Beam Hazards
Plume - avoidance
Special laser mask
Filter to 0.3 – 0.1 microns
Smoke evacuator
Held close to surgical field
Flow rate
Best if filters out particles > 0.1 microns
(HIV 0.18 microns)
4: Practical Guidelines for Daily Use
Room - Warning sign
- Smoke evacuator
Staff - Protective eyewear
- Masks
- Education
Patients - Information
- Cooling
- Protective eyewear
Device - Check device before starting out
- Off patient test – optical alignment
Lecture 2 Laser Safety
Merete Haedersdal
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4: Trouble shooting
Log books
Nurse
Medicotech ingeneer
Support service
We’re Prepared – Ready to Shoot…..
Thank youfor listening & wearing glasses.
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32
Lecture 3 Side effects and how to avoid them
Christine Dierickx
Side effects and how to avoid them
Dr. Christine Dierickx | 2018 Nordic laser course, Copenhagen
1
Side effects
1. Expected side effects: based on proper TX parameters
2. Complications that occur : based on inappropriate TX parametersbut can be avoided based on inproper pre & post-TX measurements
based on device failurebased on inproper medical history
3. Complications that occur: despite proper TX parameters
can not be avoided
4. Side effects specific for laser procedure
2
1. Expected Side Effects
- Based on mechanism of action the following adverse events may be expected after :
EBD Hair removal:- Vaporization of hair shaft
- Perifollicular Erythema- Perifollicular Edema
- Sunburn feeling
Pigment/ tattoo removal:
- Whitening- Wheal and flare
- Pinpoint bleeding- Sunburn feeling
3
2. Side effects that can be avoided
• Based on inappropriate Tx parameters for patient’s skin color– Epidermal damage (erosions/ crusting)
– Pigment changes (hypo/hyperpigmentation)– Scarring
• Based on device failure:– Failure of cooling modality– Accumulated debris on contact tip– Non uniform spatial beam profile
• Based on lack of taking a proper history, proper aftercare, proper clinical examination:– Infections: herpes flare up– Koebner: vitiligo, psoriasis, perforating collagenosis– Presence of a tattoo in tx area: scarring
4
3. Complications that occur despite appropriate TX parameters
1. Paradoxical hair growth2. Livedo reticularis3. Urticaria4. Darkening of pigment5. Paradoxical hyperplasia
Induced by laser procedure itself
5
Pearls
1. 1064 nm Nd-YAG laser2. Eye Protection3. Local anesthesia
Things to know when you start using EBD
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Importance of good eye protection
1. Wrong gogglesPlastic internal eyeshields
1. Wrong indication2. Patient related eye disease
Even with eye protection
Eye injury can occur
Take care of good eye protection!for the patient and for yourself
7
No plastic intra-ocular
Eyeprotection
8
“Nothing worthwhile is ever without complications.”
Nora Roberts
9 10
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Lecture 4 Vascular lesions – How to optimize treatment outcomes
Merete Haedersdal
Vascular Lesions
How to Optimize Treatment Outcomes
Department of Dermatology, Bispebjerg Hospital
Dr. Merete HaedersdalProfessor, PhD, DMSc
University of Copenhagen, Bispebjerg Hospital, Denmark
Wellman Center for Photomedicine,MGH, Harvard Medical School, Boston, USA
NDA Laser Course 2018
1
Classification of Vascular Anomalies
The International Society for the Study of Vascular Anomalies (ISSVA)
Diagosis is
important
Lasers and energy-
based devices are
not the only options
2
Common Vascular Lesions, referred to Tx with Laser
Telangiectatic lesions
Venous malformations / Venous lake
Capillary malformations / Port-wine stains
Angiomas / angiokeratomas
Hemangiomas
Erythematous scars
3
Selective Photothermolysis
1. Wavelength
• Strong absorption by blood and good
penetration
2. Pulse duration
• Confines thermal damage to vessels
3. Energy
• Sufficient energy for irreversible
damage
Ref: Anderson, Parish, Science 1983
4
1. Wavelength
2. Pulse duration
3. Spot size
4. Pulse energy
5. Skin coolingVascular network: Bolognia Dermatology:
Ex literature reviews:
Valdebran M, Martin B, Kelly KM. State-of-the-art-lasers and light treatments for vascular
lesions: From red faces to vascular malformations. Semin Cutan Med Surg 2017; 36 (4):
207-12.
Garden BC, Garden JM, Goldberg DJ. Light-based devices in the treatment of cutaneous
vascular lesions: An updated review. J Cosmet Dermatol 2017; 16 (3): 296-302.
Parameters to consider
5
Wavelength
KTP: 532 nm
Pulsed dye: 595 nm
IPL: ~500-1200 nm
Alexandrite: 755 nm
Nd:YAG: 1064 nmIPL
Absorption Spectra for Skin Chromophores
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Wavelength Depth of Penetration
FH Sakamoto, Wellman Center MGH, Boston
Uwe Paasch, Leipzig
7
Pulse duration
Confine thermal damage to vessels
Tr = d2/16k d=diameter, K=thermal diffusivity
Tr is the time it takes a laser-heated object to cool by half its value
Pulse duration must be shorter than Tr
Vessel diameter (µm)
Thermal relaxation time (msec)
30 0.86
50 2.40
150 21.6
300 86.2
Ref: Dierickx C, J Invest Dermatol 1995
8
Spot size
Advantages of larger spot size
Increase depth of photon penetration
Increase effective fluence
Avoids reticulation
Ref: Dierickx C, J Invest Dermatol 1995
9
Fluence and Cooling
Fluence must be high enough to cause irreversible vessel damage
Cooling helps avoid melanin-related epidermal injury
Contact cooling Cryogen Air cooling
10
Telangiectasia
Pulsed dye (585/595 nm)
KTP (532 nm)
IPL (filtered)
Alexandrite (755 nm)
Nd:YAG (1064 nm)
Penetration to 2.0 mm
Pulse durations 6 – 20 ms
Trace linear or arborizing vessels with
small spot
Cover entire area with large spot
IPLs have large foot prints
Deeper penetration
Weaker absorption
Best for large purple vessels (nose)
11
Biological end point:
Immediate vessel clearance
Transient purpura
Ellipse IPL: PR applicator 14 ms, 12 J/cm2
Telangiectasia - Rosacea
12
36
Phlebectasia
Pulsed dye laser, 595 nm: 3x10 mm elliptical spot, 40 ms, 16 J/cm2
13
Nyman et al.
British J Dermatol 2009; 160: 1237-41.
Telangiectasia – Individualised Tx settings
3 IPL Txs vs 3 PDL Txs
14
Alexandrite
755 nm
8 mm spot, 3 ms, 45 J/cm2
DCD 60/40
Nd:YAG laser
1064 nm
5 mm spot, 55 ms, 140 J/cm2
Continuous steam of air cooling
Venous malformations – Venous lake
15
Venous malformations – Venous lake
Mucosa
responds very
well
Don’t do
gingiva!
16
Port Wine Stains
1st choice Tx = Pulsed Dye Laser
Post-capillary venular malformation
Faurschou A, Olesen AB, Leonardi-Bee J, Haedersdal M. Lasers or light sources for port wine staind.
Cochrane Database Syst Rev 2011; 11: CD007152
Ortiz AE, Nelson JS. PWS laser treatments and novel approaches. Facial Plast Surg 2012; 28 (6): 611-20
Brightman LA, Geronemus RG et al. Laser treatment of PWS. Clin Cosmet Investig Dermatol 2015; 8: 27-33
17
PDL J/cm2Pulse Cooling EndpointPasses
18
Lecture 4 Vascular lesions – How to optimize treatment outcomes
Merete Haedersdal
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Bulk heating – watch out!
Near IR lasers
• Avoiding going over the same area twice.
• Give the skin time to cool down.
• Respect timing between shots.
Use cautiously !
Settings: 8 mm, 3 ms, 30-40 J/cm2,
no overlap
Cooling important (60-40 ms with cryo spray)
19
Before After 2 Tx
Alexandrite, 755 nm, GentleLase
8 mm, 50 J/cm2, DCD 30ms-20ms
Venous malformation
Christine Dierickx, MD
20
PDL 595 nm
5 & 7mm spot; 1.5ms; 14J/cm, DCD 30/20
Angiokeratoma of Fordyce
21
Haemangiomas
Vascular lasers / devices
Residual telangiectatic component Propanolol
Systemic treatment
Treatment of choice
hemangiomas in proliferative phase
22
Erythematous Scars
Vascular lasers standard treatment to relieve erythematous component
23
Tips and Tricks
Increase amount of chromophore
- Heat blankets
- Briskly pat the skin before treatment
- Posture – take advantage of gravity
Reduce postop erythema and swelling
- Air cooling
- Cold packets
- Consider topical Brimonidine
24
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Facial teleangiectasias
Spider angiomas
Cherry angiomas
Venous lakes
Pyogenic granulomas
Angiokeratomas
Rosacea
Poikiloderma of Civatte
Radiation induced telangiectasia
CREST syndroma
Adenoma sebaceum
Hemangiomas
Port Wine Stains
Lasers and IPL devices are the Tx of choice
for a large number of vascular lesions
Thank You!
25
Lecture 4 Vascular lesions – How to optimize treatment outcomes
Merete Haedersdal
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Lecture 5 Hair removal – Procedures and different patient groups
Christine Dierickx
HAIR REMOVAL BY LIGHT
Christine C. DierickxNordic Laser course 2018
Copenhagen
1
Different Techniques
• Photomechanical
� Photochemical
� Photothermal
2
Q‐switched pigment lasers produce
short, very high energy laser pulses causing
photoacustic disruption of hair follicle
1. Photomechanical
3
pre post
photoacustic disruption of hair follicle
1. Photomechanical
4
Q‐switched 1064nm Nd‐YAG Lasers
� Advantage: All Skin types
� Disadvantage: No long term hair lossOnly temporary hair removal
5
Different Techniques
• Photomechanical
� Photochemical
� Photothermal
6
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2. Photochemical
Photochemical destruction of hair follicle
630 nm
Photosensitizer and Light
Excited oxygen species
ALA PPIX
7
ADVANTAGE
� All skin colors� All hair colors
PHOTODYNAMIC THERAPY
DISADVANTAGE
� Side effects�Mild to moderate pain�Transient hyperpigmentation
�Time consuming procedure�Limiting factor: conversion ALA to PPIX �High Dose required: long exposure time
8
Different Techniques
• Photomechanical
� Photochemical
� Photothermal
9
3. Photothermal
chromophore
2. Diffusion of heat1. Absorption by chromophore
Photons
3. Destruction of stemcells in bulge/bulb
stem cells
target
Melanin in Hair shaft
10
•Wavelength
• Spotsize
• Pulse Duration
•Cooling method
LASER HAIR REMOVAL
11
Hair RemovalDevices
• 694 nm Ruby Lasers
• 755 nm Alexandrite Lasers
• 800 nm Diode Lasers
• 1064 nm Nd‐YAG Lasers
• Pulsed, Non‐Coherent Flashlamps
12
Lecture 5 Hair removal – Procedures and different patient groups
Christine Dierickx
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Wavelength (nm)
103
102
101
100
10‐1
10‐2200 300 500 1000700
Abso
rption Coefficient
Laser Wavelength
600 1100
rubyalexandrite
diode
Nd‐YAG
flashlamp
13
•Wavelength
• Spotsize
• Pulse Duration
•Cooling method
LASER HAIR REMOVAL
14
Size of Spotsize
For dermal targets, larger spots are better
improved radiation distribution
deeper depth of penetration
15 16
•Wavelength
• Spotsize
• Pulse Duration
•Cooling method
LASER HAIR REMOVAL
17
Evolution of Pulse Duration
L A S E R P U L S E
D U R A T I O N
( M S E C )
Q S - N d : Y A G
T h e r m o l a s e1 0 - 5
R u b y
P a l o m a r. 3
L P - R u b y
P a l o m a r3
L P - A l e x a n d r i t e
C y n o s u r e2 0
L i g h t S h e e r
P a l o m a r / S t a r / C o h e r e n t3 0
L P - N d : Y A G
L a s e r S c o p e / A l t u s5 0 / 1 0 0
L i g h t S h e e r X C
C o h e r e n t1 0 0
S L P 1 0 0 0 1 0 0 0
18
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Shaft
Stem Cells
Motivation for Long PulseChromophore and target are separated
Heat needs to diffuse from chromophore to target
Long PulseHeat
Diffusion
19
� 10 ‐ 100 ms
� based on TRT of hair follicle
� 100 ‐ 500 ms
� based on TDT of hair follicle
Modified Selective Photothermolysis
“Thermal Damage Time”
Pulse Duration > Thermal Relaxation Time
20
•Wavelength
• Spotsize
• Pulse Duration
• Cooling method
LASER HAIR REMOVAL
21
Laser Hair Removal
� Chromophore:
melanin in hair shaft and/or follicle� Epidermis:
contains the same pigment as hair
need for protecting epidermis
HOW?
22
Skin CoolingMethod: ice
gel
cold liquid (cryogen)
cold air flow
glass chamber
sapphire window
23
Patient Assessment
24
Lecture 5 Hair removal – Procedures and different patient groups
Christine Dierickx
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History
• Endocrine historyHormonal check‐up
•History of herpes simplex
Antiviral medication day before Tx
•History of recent UV exposure
DELAY TREATMENT
•History of hair removal methods
Shave or chemical depilatory
Don’t bleach, pluck or wax
25
Physical Examination•Hair:
Hair ColorHair TypeHair Density
� Skin:
Skin TypeSkin Color
26
Procedure
27
Pre‐Operative
•Anesthesia (optional)Emla creamLidocaine injection
� Shave
�Optional: gel , oil
28
How do I set the
treatment fluence ?
29
Test Sites• Single pulses
•Within or near treatment area
• In small J/cm2 increments
• Signs of epidermal damage
30
44
• Ablation
• Blistering
• Immediate whitening
• Positive Nikolsky sign
Signs of epidermal damage
31
Treatment Fluence• Epidermal injury
5 J/cm2 less than threshold
fluence for epidermal damage
•No epidermal injuryhighest fluence
32
• Sliding Technique
• Firm Pressure
•Adjacent pulses
• Look for responses
Treatment Techniques
33
Immediate Skin Response
• Expectedvaporization of hair shaftserythema
perifollicular edema
34
• Sunburn Feeling: 1‐2 hours
• Swelling & erythema: few hours
Cold compresses/steroid crème
• “Shedding” of hair casts
Follow ‐Up
35
•Antiseptic Ointment
•Make‐up is ok
•Avoid sun exposure
•Call if problems
Post ‐Treatment Care
36
Lecture 5 Hair removal – Procedures and different patient groups
Christine Dierickx
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Side Effects
� Desired side effect:Erythema, edema = 100%
� Inappropriate pulse duration and fluence for patient’s skin color:
Epidermal damage
Transient pigment changeScarring
37
Safety Considerations•High Risk for Eye hazard:
Wear goggles Don’t treat in bony orbit
• Plume: irritatingWear mask
Smoke evacuator system• Infectious risk:
Clean handpiece
38
• Return for treatment:
when hairs start to grow back
• If treating sooner:
no additional benefit
Re ‐Treatment
39
Suggested Tx intervalsArea
� Face
� Axilla
� Inguinal
� Back
� Legs
Tx Interval
� 4‐6 wks
� 4‐8 wks
� 4‐8 wks
� 8‐12 wks
� 8‐12 wks
40
Summary of Clinical Results•Temporary hair loss:
100% and lasts for 1 ‐ 3 months
• Significant Permanent hair loss with 1 Tx:20 ‐ 40 %
•Additional hair loss with each treatment:20 ‐ 40 %
� Regrowing hairs:thinner and lighter
• # Tx for complete, permanent hair loss:usually 52 ‐ 7 or more
41
Ideal Hair Removal Laser ?
� Safe on Dark Skin
� Effective on Light Hair
� Effective on Thin Hair
� Effective on Coarse Hair
� Safe on Tanned Skin
Ruby Alexandrite SP‐Diode LP‐Diode SLP‐Diode Nd:YAG
42
46
Laser Hair Removal
Good alternative for hair removal:
•Minimally invasive
• Shorter treatment time
•Proven efficacy and safety
43
Lecture 5 Hair removal – Procedures and different patient groups
Christine Dierickx
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Lecture 6 Surgical procedures with ablative lasers. Fractional and full ablative
Albert Wolkerstorfer
Albert WolkerstorferDept. of Dermatology
Academic Medical Center, Amsterdam
Surgical Procedures with AblativeLasersFractional and Full Ablative
1
• Conflict of interest:
Research grant AvitaMedical
Ablative lasers
2
Ablation ‐ Ablatio• Ablatio (lat): To remove
• Ablative lasers
• Surgical lasers
• Vaporizing lasers
3
• Two ablative lasers in dermatology
• CO2 laser (10600 nm)
• Erbium:YAG laser (2940 nm)
Surgical procedures with ablative lasers
4
Surgical procedures ‐ ablative lasersKey points
• Two ablative lasers in dermatology
• CO2 laser (10600 nm)
• Erbium:YAG laser (2940 nm)
5
Surgical procedures ‐ ablative lasers
Key points
• Ablative lasers cause:
• Ablation
• Necrosis
• Surrounding thermal damage
• Risk of scarring depends on:
• Mainly the depth of ablation/necrosis & location
• Many other risk factors: skin type, medication, wound care, age, medical history, constitutional…
6
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Surgical lasers ‐ absorption
0,0001
0,001
0,01
0,1
1
10
100
1000
10000
100000
1000000
0,1 1 10Golflengte [m]
Absorp
tion c
oëffic
ient[1
/cm
]
blood + O2
blood - O2
water
melanin
proteins
2940 nm
Erb:YAG laser
10600 nm
CO2 laser
7
Necrosis in different surgical procedures
• Standard electrocautery: 270 m
• Microneedle electrocautery: 180 m
• CO2 laser: 150 m
• ErbYAG laser: 15 m
8
CO2 vs Erb:YAG ‐ Neocollagenesis
Baseline CO2 laser ErbYAG laser
9
Techniques with ablative lasers
• Superficial ablation
• Deep ablation
• Drilling ablation
• Fractional ablation
• Laser excision
10
Fractional laser
Fractional Photothermolysis
A New Concept for Cutaneous
Remodeling Using Microscopic Patterns of
Thermal InjuryDieter Manstein, Scott Herron, R. Kehl Sink, Heather
Tanner and R. Rox Anderson.
Lasers Surg Med. 2004;34(5):426-38.
11
Fractional laser
Fractional Photothermolysis
A New Concept for Cutaneous
Remodeling Using Microscopic Patterns of
Thermal InjuryDieter Manstein, Scott Herron, R. Kehl Sink, Heather
Tanner and R. Rox Anderson.
Lasers Surg Med. 2004;34(5):426-38.
12
Lecture 6 Surgical procedures with ablative lasers. Fractional and full ablative
Albert Wolkerstorfer
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Fractional lasers – wavelength (nm)
915
294010600
2790
15501064
1440
1410
1064
13
Nonablative Fractional laser
14
30W CO2 laser
10600nm
A. 9.2mJB. 13.8mJ
C. 18mJ
D. 23.3mJ
Hantash et al.LSM 2007
Ablative Fractional laser
15
40m 400 m
CO2 laser
10600nm 18J
Ablative Fractional Laser
Ex Vivo Histological Characterization of a
Novel Ablative Fractional Resurfacing Device
Hantash et al.Lasers in Surgery and Medicine 39:87–95 (2007)
16
17
2 days 1 month 3 month
Ablative Fractional Laser – Healing response
18
50
Fractional laser ‐ settings• Type ablative laser• Density Channels
• Depth channels
19
Fractional laser ‐ settings• Type ablative laser
• Density Channels• Depth channels
20
Fractional laser ‐ settings• Type ablative laser
• Density Channels
• Depth channels
21
Avram MM et al. (2009)
Hypertrophic scarring of the neck following
ablative fractional carbon dioxide laser
resurfacing.
Lasers in Surgery and Medicine. 2009;
41: 185–188.
Fife DJ et al. (2009)
Complications of fractional
CO2 laser resurfacing: Four
cases.
Lasers in Surgery and
Medicine. 2009; 41: 179–184.
Complications
Cave:
• ↑energy & ↑density
• Off the face
22
• Remove
• Regenerate
• Deliver
Ablative Fractional Laser - mechanisms
23
Fractional Lasers for scars24
Lecture 6 Surgical procedures with ablative lasers. Fractional and full ablative
Albert Wolkerstorfer
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Take Home Message
• Ablative lasers: ablative + thermal damage
• Two types:
• CO2 laser (10600 nm)
• Erb:YAG laser (2940 nm)
• Indication for various skin disorders
• Fractional ablative lasers
• ↑ safety, ↓ down�me
• Rejuvenation, scars
25
Albert WolkerstorferDept. of Dermatology
Academic Medical Center, Amsterdam
Surgical Procedures with AblativeLasersFractional and Full Ablative
26
52
Lecture 7 Lasers for the treatment of skin (pre)-malignancies
Merete Haedersdal
Lasers for the Treatment of Skin (Pre)-Malignancies
Department of Dermatology, Bispebjerg Hospital
Dr. Merete HaedersdalProfessor, PhD, DMSc
University of Copenhagen, Bispebjerg Hospital, Denmark
Wellman Center for Photomedicine,MGH, Harvard Medical School, Boston, USA
NDA Laser Course 2018
1
Disclosures
Cynosure-Hologic Loan of equipment
Galderma Research grant
Leo Pharma Research grant
Lutronic Research grant, Loan of equipment
Novoxel Research grant, Loan of equipment
PerfAction technologies Research grant, Loan of equipment
Procter & Gamble Research grant
Sebacia Research grant
2
3 4
LADD – Potentials for Dermatology
Bridging medicine with technology
o Str. Corneum major barrier
o Low cutaneous bioavailability
~ 1-5% of applied drug
o Large, hydrophilic drugs
not suited for topical delivery
o Enhanced drug penetration
o Enhanced bioavailability
o Empower topical Tx regimens
o New available drugs
5 6
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Actinic keratoses
CIS
Basal cell carcinoma
Photodynamic therapy
5-FU
Ingenol mebutate
Combination chemotherapy
LADD – Potentials for Dermatology
Bridging medicine with technology
7
ACKNOWLEDGEMENTS
Bispebjerg Hospital
Derm. Research Unit
Copenhagen University
Wellman Center of Photomedicine,
Massachusetts general Hospital,
Harvard Medical School
8
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Lecture 8 Pigmented lesions and tattoos
Albert Wolkerstorfer
Pigmented Lesions and Tattoos
Albert Wolkerstorfer
Netherlands Institute for Pigment Disorders
Dept Dermatology
Amsterdam University Medical Centre
1
• Conflict of interest:
No potential conflict of interest
Pigment lasers2
Lasers & Pigment
Q switched lasers
• 694 nm Robijn laser
• 755 nm Alexandriet laser
• 1064 nm Nd:YAG laser
• 532 nm Nd:YAG laser
Melanin – a broad absorption spectrum
3
• Q-switched lasers result in
fragmentation of pigment granules
• Subsequent elimination via
– Vascular system
– Lymphatic system
– Rephagocytosis
Q-switched lasers4
Lasers & Pigment
Q-switched lasers - short pulse duration
Photoacoustic effect
Steam formation (whitening)
Banging sound
Pinpoint bleeding
Erosions
5
Epidermal- Melasma
+ Lentigo
+ Dermatosis pap. nigra
± Cafe au lait macula
± Nevus spilus
- Becker nevus
Mixed- Melasma
± Nevus
± Postinflamm. hyperpigment
- Congenital
nevus
Dermal+ Hori nevus
+ Ota nevus
± Blue nevus
- Postinflamm.
hyperpigment.
+ Tattoo
+ Good result± Variable result- Poor result
Indications Lasers & Pigment
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Melasma - Consensusus
• 1st choice: topical– triple therapy
– Hydroquinon, tretinoin, azelaic acid
• 2nd choice: peelings (glycol)– Eventually combination topicals
• 3rd choice : lasers, IPL
Exacerbation!
Pigmentary Disorders Academy
Rendon et al. J Am Acad Dermatol. 2006; 54: S272-81.
7
Laser & Bleaching regimens
Momosawa et al. in Asians.Plast Reconstr Surg. 2008 Jan;121(1):282-8.
Yoshimura et al.
Dermatol Surgery. 2006 Mar;32(3):365-71
Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for dermal hyperpigmentation
Repeated treatment protocols for melasma and acquired dermal melanocytosis
8
Tattoos• Types: cosmetic, traumatic, iatrogenic,
decorative– Professional versus amateur tattoos
• Depth, density, composition
• Cave compounds: ferric oxide, titanium dioxide
• Color– Green, blue, black: 694 nm, 755nm, 1064 nm
– Red: 532 nm
– Yellow, orange: pico lasers
9
Lasers & Pigment
Indications
• Lentigines always improve
• Melasma can improve, however temporary
• Lasers in congenital nevi are controversial
• Becker nevus does not improve
• Cafe au lait macules: effect highly variable
• Tattoos: effect depends on many variables
10
Recent trends
• Picosecond and femtosecond lasers
• Low fluence Q-switched laser
• Optical clearing agents
• Repeated exposures at single session
• Fractional mode
• Combination with fractional lasers
11
Pigmented lesions and tattoos
Key points
• Not all brown patches (hyperpigmentations) improve by
lasertherapy
• Epidermal pigmented lesions can be treated with lasers and
Intense Pulsed Light
• Dermal pigmented lesions & tattoos can only be treated with Q-
switched lasers
• Laser induced whitening is an important biological endpoint for Q-
switched lasers
12
56
Lecture 9 Treatment of the ageing face and neck
Christine Dierickx
TREATMENT OF AGING FACE AND NECK
WITH ENERGY BASED DEVICES
Dr. Christine Dierickx | 2018 Nordic laser course, Copenhagen
1
Treatment of Skin Aging
Many different aspects to consider
Each aspect has its specific treatment modality
2
Fillers
Toxins
Plastic Surgery
Treatment of Skin Aging
Cosmeceuticals
Peelings
Energy Based Devices
3
Energy Based Rejuvenation
Highly selective treatment modalitySpecific energy – based devices to treat:
• Solar lentigines & telangiectasia:pigment & vascular lasers / IPL
4
IPL
TELANGIECTASIA
Rosacea
Broken vesselsBerloque dermatitis
The redIRREGULAR PIGMENTATION
Lentigines
Freckles
Melasma
Berloque dermatitis
The brown
Treatment of uneven skin tone
Pigment lasers
694 nm755 nm1064 nm
Vascular lasers
532 nm585 nm1064 nm
5
Specific energy – based devices to treat:
• Solar lentigines & telangiectasia:pigment & vascular lasers / IPL
• Epidermal and Dermal rejuvenation: non‐ablative fractional lasers
Highly selective treatment modality
Energy Based Rejuvenation
6
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• New concept for cutaneous remodeling:
Fractionated laser beam creates thousandsof microscopic wounds surrounded by viable
tissue for rapid healing
• Non‐ablative Tissue is coagulated, not vaporized
• Induces a unique biological wound healing response
Manstein DD, Anderson RRLasers Surg Med 2004; 34:426‐438
Fractional Photothermolysis
7
Results:
• MicroThermal Zone(MTZ) formation
• Clear collagen denaturation from papillary dermis into mid reticular dermis Controlled Zones of
Denatured Collagen in the Dermis
Photo Courtesy of D. Manstein, MD
Fractional Photothermolysis
8
Dermal collagen remodeling & neovascularisation
Strong staining with procollagen III around the MTZ.
9
Laser Wavelength (nm)
Non‐ablative
Fractional Photothermolysis
(NAFX)
Thulium
Erbium doped fiber
Nd:YAG
Er:glass rod
Er:glass fiber
1927
1410
1440
1540
1550
Non‐ablative Fractional Technologies
10
• No severe side effects
• Rapid healing
• No long lasting down time
Unique aspects of treatment
11
1. Epidermal and dermal rejuvenation
2. All anatomical areas can be treated
Indications
12
58
1. Epidermal and dermal rejuvenation
• 30‐40 year old patientPhotodamage
Fine wrinkles
• 3‐5 Tx are requiredWith minimal side effectsWith little downtime
13
1. Epidermal and dermal rejuvenation
2. All anatomical areas can be treated
Indications
14
Advances in non‐ablative fractional
Fractionated picosecond lasers
15
Fractionated Picosecond Lasers
� ‐Tattoo removal� Nanosecond v. Picosecond� Photoacustic rupture� Faster clearance
‐ Skin remodeling � Focus optic
10‐9 sec = nanosec= one billionth of a second10‐12 sec = picosec= one trillionth of a second
Advances in non‐ablative fractional
16
Fractionated Pico second
Focus Lens Array
Fluence distribution created on the skin surface
Holographic Fractional Technology
Uniform Top Hat ProfileAll peaks have the same energy.
No energy is lost as background energy.
Focus lens Array
Comprised of hundreds of microlenses per cm2
that redistribute the Picosecond pulse : highly concentrated beams & lower fluence background
17
Fractionated Picosecond pulses
LIOB
Controlled high intensity injuries limited to the epidermis cause a LASER INDUCED OPTICAL BREAKDOWN (LIOB) generating
significant pressure waves which propagates through the tissueand induces optimal cell signaling
18
Lecture 9 Treatment of the ageing face and neck
Christine Dierickx
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FOCUS Lens Array
H&E 100X H & E 400X
• Pockets of intra‐epidermal necrosis with prominent pigment
• Junctional melanocytes are undamaged
• Resolves in normal epidermal turn over cycle• Contributes to no downtime
Vacuoles caused by Laser induced Optical Breakdown (LIOB)
Immediate Post Treatment
Dr. Emil Tanghetti
19
H & E Inflammation 100X H & E Inflammation 400X• Superficial perivascular lymphocytic inflammatory process• No vasculitis• Sustained dermal inflammation = new collagen and elastin
Dr. Emil Tanghetti
24 hours Post Treatment
“Elegant Injury” caused by PicoSure with the Optic
FOCUS Lens Array
20
Collagen: increased collagen production
Elastin: more dense elastin fibersDr. D. Mc Daniel
Effect on dermal compartmentincrease in collagen and elastin
Before
After
21
• Fractionated Picosecond• Revitalization:
‐ With little discomfort/ downtime
‐ On face and off‐ face‐ Safe to use on darker skin types ( IV‐VI)
• Indications:
‐ Acne Scars ‐ FDA Cleared‐ Wrinkle reduction – FDA Cleared‐ Photorejuvenation: Pico toning
Diversified Applications
22
Treatment of Wrinkles with PicoSecond 755nm and Focus
Safety and Efficacy of a Novel Diffractive Lens Array Using a Picosecond 755 nm Alexandrite Laser for
Treatment of Wrinkles
Robert A.Q3 Weiss, MD, FAAD,1 David H. McDaniel, MD, FAAD,2 Margaret A. Weiss, MD, FAAD,1Anne Marie Mahoney, MD, FAAD,1 Karen L. Beasley, MD, FAAD,1 and Christian Halvorson, MD, FAAD
• Statistically significant improvement of wrinkles
• 1.97 change in Fitzpatrick Wrinkle Score• Pigment improvement was rated as high‐moderate
• Post treatment erythema lasted only for hours on average• Histology demonstrated increase of collagen and elastin
23
Coagulation zoneAblation zone
From “Bulk Ablation”
to “Localized Ablation”
Ablative (Fractional) Resurfacing
24
60
Device Wavelength (nm)
Ablative
Fractional Photothermolysis
(AFX)
YSCG
Erbium
CO2
2790
2940 10,600
Device Company
Fractional Bipolar RF E‐matrix
Venus VivaLegato
Syneron/candela
Venus ConceptAlma
Ablative Fractional Technologies
25
Fractional Ablative Resurfacing
• 40‐60 year old patientPhotodamage
Fine wrinkles
• Single Treatment
With minimal side effectsWith reduced downtime
26
Ablative resurfacing
• > 60 year old patientPhotodamage
Deep wrinkles
• Single Treatment
With side effectsWith downtime
27
Specific energy – based devices to treat:
• Solar lentigines & telangiectasia:pigment & vascular lasers / IPL
• Epidermal and Dermal rejuvenation: non‐ablative fractional lasers
• Wrinkles:ablative (fractional) lasers
• Sagging: High Intensity Focussed UltrasoundIn situ bipolar RF
Highly selective treatment modality
Energy Based Rejuvenation
28
UltheraTM System Components
CONTROL UNIT HANDPIECE/TRANSDUCER
• One handpiece
• Multi‐patient transducers
• Region specific
‐ Forehead: 7MHz at 4.5 mm depth
‐Cheeks/preauricular: 4MHz at 4.5 mm depth
‐Temple/infraorbital: 7MHz at 3.0 mm depth
‐ Periorbital: 10 MHz AT 1.5 mm depth
29
Deposition of Micro‐Focused Ultrasound at Precise Depth
Lines of discrete thermal
coagulation points
form a consistent matrix
on the targeted plane
30
Lecture 9 Treatment of the ageing face and neck
Christine Dierickx
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Discrete Thermal Coagulation Points
Approximately 10,000 discrete coagulation points are placed at dual depths,causing immediate tissue contraction and initiating neocollagenisis
31
Specific energy – based devices to treat:
• Solar lentigines & telangiectasia:pigment & vascular lasers / IPL
• Epidermal and Dermal rejuvenation: non‐ablative fractional lasers
• Wrinkles:ablative (fractional) lasers
• Sagging: High Intensity Focussed UltrasoundIn situ bipolar RF
Highly selective treatment modality
Energy Based Rejuvenation
32
Needles are inserted in the skin
with in situ
delivery of bipolar radiofrequency
In situ Fractional Resurfacing
33
RF fractional microneedle devices
Device Technology Needles Length
Profound
Syneron Candela
In situ bipolar RF 5 pairs of electrically‐ isolated 32 Gauge needles
6 mm length
Infiny
Lutronic
In situ bipolar RF Unique 7x7 array of insulated microneedles
Only the needle tip (300 µm) is the active electrode
Intensif RF microneedle handpiece
Endymed
In situ bipolar RF 25 gold plated microneedles
fractionated pulse mode deliveryGold Plated Microneedle
(300 microns )
Fractora
Invasix
In situ bipolar RF Variable pin configurations ( 20,24,60 & 126)
Variable TX depths
34
• Multilayer Approach• Multiple Passes• Selectable Depths: 0.5‐3.5 mm
1st Pass2nd Pass3rd Pass
MicroFractional RF
35
Fractional RF Thermal Zones (65°C, 4 sec)
Pilot clinical study of a novel minimally invasive bipolar microneedle radiofrequency device.
Hantash BM, Renton B, Berkowitz L, Stridde BC, Newman J. Lasers Surg Med. 2009;41:87‐95
36
62
Full Dermal Structure
• Collagen, hyaluronic acid, and elastin content increased
• Unique wound healing response ‐ Low catabolic activity
‐ Increased anabolic activity adding new dermal volume
Old Collagen
Mixed
New Collagen
New Elastin
New Hyaluronic AcidHistology courtesy ofBasil Hantash,
37
• Study of 33 Patients, – 26 F , 7 M – Age 37‐74
• Three Infini Treatment – 1 Tx per Month, 3 passes each
• Photos and Grading at 6 Months Post– Independent Graders gave 81% Moderate to Excellent Results– Patient satisfaction at 87% at 12 Months
Laser Surg Med, 2016;48(5):461‐70
38
Specific energy – based devices to treat:
• Solar lentigines & telangiectasia:pigment & vascular lasers / IPL
• Epidermal and Dermal rejuvenation: non‐ablative fractional lasers
• Wrinkles:ablative (fractional) lasers
• Sagging: High Intensity Focussed UltrasoundIn situ bipolar RF
• Submental fat: Cryolipolysis
Highly selective treatment modality
Energy Based Rejuvenation
39
Introducing the CoolMini Applicator
• Designed for submental fat
• Optimized for smaller bulges
• Treat new areas of undesirable fat
40
Submental Studies
• Submental Area
– IDE Pilot – 15 subjects– Mexico Feasibility Study – 32 Subjects– US Pivotal Study – 60 Subjects– European Pilot – 125+ Subjects
41
CONCLUSION
WHAT WE CAN LEARN FROM THIS SESSION
‐Treatment of ageing, is the same as ageing itself:
It‘s a stepwise process
‐A combination of different treatments
‐Try to get a rejuvenated face which matches patients‘ expectations
“ NO TRACE FACE “
42
Lecture 9 Treatment of the ageing face and neck
Christine Dierickx
WelcomeInformationFaculty informationPresentationsNotes Programme
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Thank yo
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Before
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Lecture 10 Scar treatment - different approaches to different types of scars
Merete Haedersdal
Scar Treatment - Different Approaches
to Different Types of Scars
Department of Dermatology, Bispebjerg Hospital
Dr. Merete HaedersdalProfessor, PhD, DMSc
University of Copenhagen, Bispebjerg Hospital, Denmark
Wellman Center for Photomedicine,MGH, Harvard Medical School, Boston, USA
NDA Laser Course 2018
1
Each year 100 million scars are caused…
55 million from elective surgery
25 million from trauma
11 million keloids
4 million burn scars
70% in children
Hot
topic
2
Guidelines
Select refs:Anderson RR et al. JAMA Dermatol. 2014;150(2):187-93.
Monstrey S et al. J Plast Reconstr Aesthet Surg. 2014;67(8):1017-25.
Gold MH et al. Dermatol Surg. 2014;40(8):817-2.
Gold MH et al. Dermatol Surg. 2014;40(8):825-31.
Karmisholt K et al. Ugeskr Laeger 2016;178(32).
3
Several players
o Pulsed dye laser
o Nonablative fractional lasers - NAFXL
o Ablative fractional lasers - AFXL
o Microneedle RF
o Laser-assisted drug delivery
o Early intervention
Established > 20 years
~ 10 years
~ 10 years
New technique
Evolving technique
- // -
Lasers are part of standard care for scar management
4
Management Algorithms
Ref Karmisholt K et al. Ugeskr Laeger 2016;178(32).
5
Erythematous Scars
Department of Dermatology, Bispebjerg Hospital
Select refs: Anderson RR, Parrish J. Science 1983; 220: 429-7Alster TS. Ann Plast Surg 1994; 32(2): 186-90Nouri K et al. Derm Surg 2003; 29(1): 65-73
and …… many, many more refs
PDL and vascular lasers, IPL are the treatment of choice
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Shoot profile characteristics
o Controlled zones of denatured collagen / ablation zones
o Induces a unique biological wound healing response
DERMAL COLLAGEN REMODELING
HSP, MMPs, collagenases, fibroblasts
Strong staining with procollagen III
around the MTZ.
8
Needles are inserted in the skin
with in situ delivery of bipolar radiofrequency
Microneedle RF
In situ Fractional Resurfacing
• Multilayer Approach
• 1 – 3 passes
• Select depths: 0.5-3.5 mm
1st Pass2nd Pass3rd Pass
Ref: Cohen J et al. J Drugs in Dermatology 2016; 15 (11): 1308-12
9
© Palomar Medical Technologies 2008. All rights reserved.| www.palomarmedical.com
Fractional Photothermolysis
o Game changer for cutaneous remodeling
o Fractionated laser beam creates microscopic wounds surrounded by viable tissue for rapid healing
o Induces a unique biological wound healing response
Manstein DD, Anderson RRLasers Surg Med 2004; 34:426-438
7
Fractional RF Thermal Zones (65°C, 4 sec)
Pilot clinical study of a novel minimally invasive bipolar microneedle radiofrequency device.
Hantash BM, Renton B, Berkowitz L, Stridde BC, Newman J. Lasers Surg Med. 2009;41:87‐95
10
Burn Scars Which Lasers to Use?
Multi-modal approach
o What type of scar are you treating?
o Is there a color problem?
o Is there a collagen problem?
Courtesy to Jill Waibell
11
Laser repairs BURN ScarsBurn Scar – 12 years after injury
Jill Waibel
Combo: Thulium 1.927 nm
PDL 595 nm
AFL 10.600 nm
12
66
Significant response:
o More even and smooth textur
o Improvement
7 to 2 (1540 nm) vs 7 to 7 (no tx)
Pre
12 w postop
Patients with meshed skin responded more favourably
Ref. Haedersdal et al.Las Surg Med 2009; 41: 189-95
8/17 patients evaluated
moderate or significant
improvements
13
Improved range of motion
Chef at 5 star hotel Photocourtesy Jill Waibel
14
CONCEPT
©Courtesy of Uwe Paasch, University of Leipzig
Drug Delivery Through Fractional Holes
15
Laser Assisted Drug Delivery for Burn Scars
Post-op topically applied substances into fractional tunnels Triamcinolone injectable suspension 5FU
Waibel J, MD
16
Laser Assisted Drug Delivery for Burn Scars
Post-op topically applied substances into fractional tunnels
Triamcinolone injectable suspension, 40 mg/ml
5FU 50 mg/ml
17
Baseline
3 mth
8 mth
6/9 cleared 9/9 visible
- Tx+ Tx
Appetizer for Early Scar Treatment
18
Lecture 10 Scar treatment - different approaches to different types of scars
Merete Haedersdal
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Lecture 11 Hyperhidrosis
Christine Dierickx
Dr. Christine Dierickx
Nordic laser courseCopenhagen
Microwave technology in the treatment of
unwanted sweat, hair and odor
1
Sweating is a Real Problem Wide range of sweat‐bothered patients
Patients with excessive sweating
Patients who sweat normally, but are bothered by their sweatYoung Adult ‐ sweating is affecting her confidence
Professional ‐ sweating projects the wrong image
Organically Minded ‐ hate the chemicals applied daily
Wardrobe ‐ too many yellowed whites, can’t wear silks
2
Most Embarrassing ?
Source: 2008 Harris Interactive US rep pop survey 2897 adults 18+ conducted for International Hyperhidrosis Society
60% Underarm Sweat
58% Overweight
47% Acne
43% Cold Sore
38% Dandruff
3
CE and FDA‐cleared microwave energy procedure for lasting underarm sweat reduction
4
Microwave energy: Mechanism of Action
CoolingCooling
HeatingHeating
Tx applies:• Suction
• Cooling
• Microwave (heat)
heat at dermal/hypodermal interface where sweat glands reside, results in thermolysis of sweat glands
5
MiraDry ProcedureThree Easy Steps
Mark customized treatment area
Administer
local anesthesiaTreat with
miraDry System
• Patients require as little as one treatment
• Each appointment typically lasts 60–75 minutes, depending on the size of treatment area
• Able to delegate to PA, NP or RN where local laws allow
Pre‐ProcedurePreparation Procedure
6
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Microwave technology
1. Sweat Reduction
2. Hair Reduction
3. Odor reduction
Long term Efficacy for
7
miraDry® Long‐term Efficacy Study 1,2
� 2 sites in Canada: Drs. Chih‐ho Hong and Mark Lupin� Single‐group, open‐label study, n = 31� Follow‐up for 24 months
� Multiple efficacy measures – HDSS
– Gravimetric assessment
– Patient Satisfaction– Dermatology Life Quality Index (DLQI)
1. H. Chih‐Ho Hong, MD, Mark Lupin, MD et al;
Dermatol Surgery 2012; 38:728‐735
2. Lupin MS and Hong C‐H. OʼShaughnessy KF
Dermatol Surg. 2014 ;40: 805‐807
12 month data published May 2012
24 month data published July 2014
8
1. Gravimetric % sweat reduction only obtained at in‐office visits through 12 months
93%97% 96% 100% 100% 100% 100% 100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 mon… 3 mon… 6 mon… 12 mon… 15 mon… 18 mon… 21 mon… 24 mon…
% with HDSS1 or 2
82%Sweat Reduction
At 12 mos
100% No longer
bothered by sweat at 24 mos
LupinM, Hong HC‐H, O’Shaughnessy KF. Long‐term Efficacy and Quality of Life Assessment for Treatment of Axillary HyperhidrosisWith a Microwave Device. Dermatol Surg 2014; 40: 805‐807.
Long‐Term Results HDSS Improvement and Gravimetric Sweat Reduction
9
Dermatology Life Quality Index (DLQI)
• Highly validated
• 10 questions that cover all aspects of quality of life
• Scores range from 0 (no problem) to 30 (huge problem)
• Used for many dermatologic conditions
Psoriasis = 10.5, Severe acne vulgaris = 7.5
10
DLQI Results
Clinically meaningful change is 5 points*
DLQI = Dermatology Life Quality Index; ranges from 0 (no problem) to 30 (worst) *Kowalski et al. JAAD 2007; 53: AB52. Poster at AAD2006.
0
2
4
6
8
10
12
14
Baseline 1 mon(n=30)
3 mon(n=29)
6 mon(n=27)
12 mon(n=26)
15 mon(n=18)
18 mon(n=18)
21 mon(n=18)
24 mon(n=17)
Dermatology Life Quality Index (DLQI)
11
Gravimetric
Efficacy
82%average
DLQI Satisfaction
90%
HDSS Efficacy
90%
12 Month Results Summary
12
Lecture 11 Hyperhidrosis
Christine Dierickx
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Microwave technology
1. Sweat Reduction
2. Hair Reduction
3. Odor reduction
Long term Efficacy for
13
FDA and CE Mark cleared microwave energy procedure for lasting underarm sweat reduction.
FDA Cleared for permanent reduction of underarm hair of all colors.
14
• Multi‐center study, n=56 subjects enrolled for hair reduction
− 80% female, average age 32, 38% had light hair, Fitz I ‐V
• 43 patients received 2 treatments, 13 received 1 treatment
− treatment parameters same as used for sweat reduction
� Quantified & Qualified axillary hair reduction :
− FU at 3,6,9 and 12 months
− blinded hair counts & blinded side by side
− Subgroup analysis of patients with light‐colored axillary hair
A Prospective Study of Axillary Hair Reduction in Patients Treated With Microwave Technology.Brauer JA, Neckman JP, Zelickson B, Vasily DB, Geronemus RG.
Dermatol Surg. 2017 43(4):558‐565.
15
Average Hair Reduction from Quantitative Assessment
0%
20%
40%
60%
80%
100%
3 mon
n=42
6 mon
n=40
9 mon
n=38
12 mon
n=44
Average % Reduction
"All"
"Light"
"Dark"
Average reduction was approx. 70% independent of hair color
16
0%
20%
40%
60%
80%
100%
3 mon
(n=85)
6 mon
(n=83)
9 mon
(n=85)
12 mon
(n=93)
Side‐by‐Side Qualitative Analysis per Axilla
% axilla blindedreviewer correctly chose the baseline photo
% where assessor rated the reduction as being at least 50%
17
Baseline 12 month follow‐up;94% reduction
Results – dark hair
18
70
Results – light hair
Baseline 12 month follow‐up; 84% reduction
19
Baseline
Results – dark hair
12 month follow‐up; categorized as 76‐100 % reduction
20
Baseline 12 month follow‐up; categorized as 76‐100 % reduction
Results – light hair
21
Side‐by‐side Analysis
>50% reduction
70%approximately
Hair
Reduction at 12 months
74.9%average
Results Summary
Quantitative Qualitative
22
Microwave technology and Hair
1. Long term efficacy for hair reduction
2. Potential for 90‐100 % hair reduction in a single Tx
3. Colorblind Technology
23
Microwave technology
1. Sweat Reduction
2. Hair Reduction
3. Odor reduction
Long term Efficacy for
24
Lecture 11 Hyperhidrosis
Christine Dierickx
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Odor Reduction Peer Reviewed Publications
� Long‐term Efficacy and Quality of Life Assessment for Treatment of Axillary Hyperhydrosis With a Microwave Device‐ Lupin et al. Derm Surg 2014; 40: 805‐807 ‐ 2 year data from Commercial device study
� The efficacy of a microwave device for treating axillary hyperhidrosis and osmidrosis
in Asians: a preliminary study‐ Lee et al. J Cosmet and Laser Ther 2013; 15(5):255‐9
� A prospective clinical and histologic study of axillary osmidrosis treated with the microwave‐ based device‐ Chang YY, et al. Dermatologica Sinica 2015 ;33:134‐141
25
Long‐Term Results Odor Reduction
16%
80% 83% 81%88%
83%89% 89% 89%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline(n=31)
1 mos(n=30)
3 mos(n=29)
6 mos(n=27)
12 mos(n=26)
15 mos(n=18)
18 mos(n=18)
21 mos(n=18)
24 mos(n=19)
% of subjects without problematic odor
89%Patients without
Problematic odor
at 2 years
LupinM, Hong HC‐H, O’Shaughnessy KF. Long‐term Efficacy and Quality of Life Assessment for Treatment of Axillary Hyperhidrosis With a Microwave Device. Dermatol Surg
2014; 40: 805‐807.
26
Chang et al Study Overview
� Prospective, Single Center Study� Population: n=7 (2 male;5 female)/ 22‐53 y.o./ axillary osmidrosis
� Primary Objective: To investigate the efficacy, safety, and histological changes of microwave‐based devices in treating axillary osmidrosis.
� Endpoints at 90 day FU visit:� Reduction of at least 3 points on the odor‐10 point score
� 10‐point scale (1 stands for completely no odor and 10 for severe odor)� HSSD score of 1 or 2 � Biopsy
27
Chang et al Study Results� Results:
‐ 6/7 patients (85.7%) met the primary endpoint of sweat and odor reduction‐ Mean percentage of reduction in odor‐10 scale was 76.4% and 61.8% at 30‐day and 90‐day visits
respectively
28
Chang et al Study Results ‐ Biopsy
� Immunohistochemistry staining using CAM5.2 to highlight apocrine sweat glands (A, C, E, G) were from Patients 6, 7, 2, and 5, respectively, preoperatively. (B, D, F, H) from Patients 6, 7, 2, and 5, respectively, postoperatively.
� Method used: Immunohistochemically, apocrine glands react strongly to CAM5.2 with heavy staining of the nucleus and cytoplasm whereas eccrine glands showed only little reactivity
Skin biopsies specimens revealed 93% reduction in apocrine glands
29
� A non‐invasive solution for underarm sweat and odor
‐ Side effects mild and transient
‐ A significant reduction of underarm sweat ‐ 82%average reduction*
� Permanent results in as little as 1 treatment
‐ Sweat glands are destroyed and do not regenerate� Reduction in underarm hair� High patient satisfaction procedure
* Hong et al. Dermatol Surg 2012; 38: 728‐735
What Patients Can Expect
30
Lecture 11 Hyperhidrosis
Christine Dierickx
72
Thank you!
31
Lecture 11 Hyperhidrosis
Christine Dierickx
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Lecture 12 Cutting edge – New treatments in the pipeline
Merete Haedersdal
Cutting Edge
New Treatments in the Pipeline
Department of Dermatology, Bispebjerg Hospital
Dr. Merete HaedersdalProfessor, PhD, DMSc
University of Copenhagen, Bispebjerg Hospital, Denmark
Wellman Center for Photomedicine,MGH, Harvard Medical School, Boston, USA
NDA Laser Course 2018
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Disclosures
Cynosure-Hologic Loan of equipment
Galderma Research grant
Leo Pharma Research grant
Lutronic Research grant, Loan of equipment
Novoxel Research grant, Loan of equipment
PerfAction technologies Research grant, Loan of equipment
Procter & Gamble Research grant
Sebacia Research grant
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1: Laser-assisted drug delivery – New indications
2: Gold-coated Microparticles and Laser
in Treatment of Facial Acne
3: Early scar treatment
Agenda
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LADD – Potentials for Dermatology
Bridging medicine with technology
o Str. Corneum major barrier
o Low cutaneous bioavailability
~ 1-5% of applied drug
o Large, hydrophilic drugs
not suited for topical delivery
o Enhanced drug penetration
o Enhanced bioavailability
o Empower topical Tx regimens
o New available drugs
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CONCEPT
©Courtesy of Uwe Paasch, University of Leipzig
Combo of Laser and Drug
Drug Delivery Through Fractional Holes
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Department of Dermatology, Bispebjerg Hospital
LADD – Status
Evidence evolving
PubMed > 100 publications
PhotosensitizersPDT
Corticosteroids
5FU
PLLA
Botulinum toxin
Vit C and E
Amorolfine
Terbinafin
Finasteride
Without exception,
Ablative Fractional Laser
enhanced
drug accumulation
in the skinof any drug or substance
applied to the skin
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AFXL assisted drug delivery
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Acne is still the #1 reason to see a dermatologist
Inflammatory disease of
the pilosebaceous unit
Follicular hyperkeratosis and occlusion
Increased sebum production
Proliferation of P. acnes
Inflammation
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GOLD MICROPARTICLES:
Silica core, gold shell 0.150 micron diameter Efficient near-IR absorber
Selective Targeting of Sebaceous Glands with Externally Added Gold Chromophore
Refs: Paithankar DY et al. J Invest Dermatol. 2015;135(7):1727-34Paithankar DY et al. J Contr Release. 2015; 206: 30-36
Approval status: EU, CE mark, CE 612960, received 07 March 2016US, Investigational Use Only
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Efficacy to treat acne with selective photothermolysis using gold microparticles
a 3-center European trial
Study Design Uncontrolled trial
3 EU centres
Good Clinical Practice, EC approved
ClinicalTrials.gov Id: NCT02758041
3 Tx sessions at 1-week intervals
Primary outcome:
> 40% improvement at 12 week FU
810 nm diode laser
Mean fluence 32 J/cm2
Pulse duration 30 ms
Spot size: 9x9mm,12x12mm
Integrated contact cooling
23 patients per protocol
IGA 3, IGA 4
Wash out period prior to study
Tx Period
Isotretinoin 6 months
Systemic medication 4 weeks
Topical retinoids,
antibiotics
2 weeks
OTC 1 week
Light based Txs 8 weeks
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% Change Weighted Lesion Count (WLC) at 12w No other acne interventions
Responder> 40% improvement
n = 18/23 (78%)
Sub-responder < 40% improvementn = 5 (22%)
Median reduction62%
Rank ordered graph for each individual per protocol patient
Scale adapted from Hongcharu,
Anderson, et al., JID 2000
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Hypothesis: Pre-conditioning the skin makes pores more accessible
Delivering more chromophore to target anatomy, sebaceous gland, may boost clinical effect
Hypothesis:
Daily application of a topical retinoid and BPO will “empty” the pores and increase the delivery of particles to the follicles
+
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Lecture 12 Cutting edge – New treatments in the pipeline
Merete Haedersdal
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Morphological changes in skin after tretinoin treatment, case study: RCM imaging
Reduced content within follicles after topical tretinoin application
Week 0
Hair follicles with sebum and keratinous content
1st week tretinoin
Hairfollicles with less content
2nd week tretinoin
Hairfollicles with less content
Mette
MogensenChristine
Fuchs
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Real World Preconditioning Data (Interim Results) vs. Historical Gold Microparticle Treatment w/o Preconditioning
Preconditioning Period
Tx x3
% C
han
ge I
LC
Historical Monotherapy Data: Paithankar, et al., JID 2015
N=26
0.0%
N=26
-44.0% N=25
-49.0%
N=23
-65.0%
N=71
-12%
N=67
-63.2% N=58
-66.1%N=38
-78.5%-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
BL1 (~-1m) BL2 2m 3m 6m
No preconditioning, monothe rapy (historical)
Preconditioning, polytherapy
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Gold Microparticles with Preconditioning Results
3 months
Lesion Count: 1
∆Lesions: -93%
IGA: 0
OS23-0021(Age 17)
Baseline
Lesion Count: 15
IGA: 2
3
MO
BL
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Gold Microparticles with Preconditioning Results
3 months
Lesion Count: 0
∆Lesions: -100%
IGA: 0
OS23-0103(Age 19)
Baseline
Lesion Count: 25
IGA: 3
3
MO
BL
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Thank you!
• England– Skin 55
– The Skincare Network
– London Dermatology Centre
– Kosmesis
• France– CLIPP
• Poland– Novaderm
– Miracki Clinic
– Murano Clinic
– Dermedicus
Mette Mogensen
Christine Fuchs
MauriceAdatto
HansLomholt
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Early scar treatment
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Lecture 12 Cutting edge – New treatments in the pipeline
Merete Haedersdal
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Paradigm Shift towards Scar Prevention
Laser tx of mature scars established
Early intervention emerging procedure
Literature heterogeneous
No standard protocols
Upregulated cytokine environment may benefit skin healing
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Department of Dermatology, Bispebjerg Hospital
WOUND HEALING PHASES
Inflammation < 3 days- Cascade of cytokines
Proliferation 4-21 days- Granulation tissue
Remodeling > 21 days- New collagen
Katrine Karmisholt
Ref: Karmisholt K et al. JEADV. In press
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o PubMed 1997 -2017
o Interventions < 3 months after wounding
o 22 of 25 studies were controlled
o 17 of 25 studies compared intervention versus untreated control
Body of Evidence
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o Inflammation phase: 3 of 4 studies
o Proliferation phase: 6 of 16 studies
o Maturation phase: 2 of 5 studies
Studies with Significant Improvement on
Laser Tx Scar Side vs Untx Control Side
Early laser intervention has the potential to reduce scar formation
No consensus
We need standard protocols
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o Split-scar design
o Three NAFL exposures vs no Tx
o Target all 3 separate wound healing phases
o 30/32 patients completed study
o Benign, premalignant, NMSC lesions
o 3 mth FU
Real Life Setting
Ref: BJD In press
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Study procedures:Target all 3 wound healing phases with NAFL 1540 nm Er:glassDeep Fx: 50 mJ/mB, 3 stacks / 2 passes Superficial: 40 mJ/mB, 50% overlap, 1 pass
# 1 Immediately before excision Inflammation phase
# 2 At suture removal Proliferation phase
#3 6 weeks after excisionRemodelling phase
ControlNAFL-Tx
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Lecture 12 Cutting edge – New treatments in the pipeline
Merete Haedersdal
WelcomeInformationFaculty informationPresentationsNotes Programme
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No Tx
No Tx
Three Txs
Three Txs
Good Responders
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Clinical evaluations Observer part of Patient Observer Scar Assessment Scale (POSAS) Vancouver Scar Scale
(VSS) at 3 months follow-up.
POSAS VSSTreated scar Control scar P* Treated scar Control scar P*
Vascularity
3 month 2 (1-3) 2.5 (2-4) 0.005 1 (0-1) 1 (1-1) 0.031
Pigmentation
3 month 1 (1-1) 1(1-1) 0.125 0 (0-0) 0 (0-0) 0.219
Thickness /height
3 month
1 (1-1) 1 (1-2) 0.125 0 (0-0) 0 (0-0.25) 0.250
Relief
3 month 2 (2-3) 3 (2-3) 0.023 NA NA NA
Pliability
3 month 2 (1-2) 2 (2-3) 0.037 1 (0-1) 1 (1-1) 0.344
Surface Area
3 month 2 (2-3) 2 (2-3) 0.016 NA NA NA
Overall Opinion
3 month 2 (2-3) 3 (2-4) 0.003 NA NA NA
Total Score
3 month 11 (9-12) 12 (10-16) < 0.001 2 (1-2.25) 2 (1.75-3) 0.007
Treatment Effects - Statistics
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Variation in Treatment Efficacy
Poor Responder1 point difference,favouring untreated control
Average Responder3 point difference,favouring NAFL
Good Responder11 point difference,favouring NAFL
NAFL superior 63% of patients
No difference 26% -//-
NAFL worse 10% -//-
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ACKNOWLEDGEMENTS
Bispebjerg Hospital
Derm. Research Unit
Copenhagen University
Wellman Center of Photomedicine,
Massachusetts general Hospital,
Harvard Medical School
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Lecture 12 Cutting edge – New treatments in the pipeline
Merete Haedersdal
WelcomeInformationFaculty informationPresentationsNotes Programme
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Notes
Nordic Course on Laser Dermatology is initiated by the Nordic Dermatology Association, which was founded in 1910 in Copenhagen, Denmark . The aim of the association is to promote Nordic cooperation in scientific, educational and clinical aspects of dermatology and venereology, mainly by arranging congresses in the Nordic countries .
More information about the Association is available on www .nordicdermatology .com
Nordic Course on Laser Dermatology