Recommendation for Laser and Intense Pulsed Light (IPL) Therapy in Dermatology
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1036 Guidelines DOI: 10.1111/j.1610-0387.2007.06513.x
Recommendation
Recommendation for Laser and Intense Pulsed Light
(IPL) Therapy in Dermatology
Friedrich Bahmer, Michael Drosner, Ulrich Hohenleutner, Roland Kaufmann, Gerd Kautz,Wolfgang Kimmig,
Michael Landthaler, Reinhard Neumann, Christian Raulin, Nikolaus Seeber
Section Editor
Prof. Dr. Hans Christian Korting,
München
Recommendations for Medical and different laser systems. Certification 1.2.2 Technical equipment requirements
Aesthetic Treatment of the Skin using should be received from a laser center or All laser systems used must comply with
Laser or Intense Pulsed Light (IPL) equivalent academic institution that is applicable EU directives (i.e., they
Systems operated independently of any equip- should be CE marked); they must also
The following guidelines on the use of ment manufacturer and that has been be regularly serviced and meet the speci-
laser and IPL systems in treating skin approved by the quality assurance com- fications in the accident prevention reg-
conditions and imperfections reflect the mission of the German Society of ulations (BVG B2). Compliance with
state of laser technology and medical Dermatology (DDG), German Society the German law on medical products is
knowledge of its use as of 2006. The rec- for Laser Medicine (DGLM) or German mandatory.
ommendations contained herein are Society of Laser Dermatology (DDL).
based on average requirements for diag- 1.2.3 Hygiene requirements
nosis and treatment which in actual 1.1.2 Certification in dermatologic laser When using laser systems that generate
practice may vary in individual patients. therapy fumes, appropriate measures must be
Recommended dosages and equipment Certification according to dermatologi- taken to minimize associated risks (e.g.,
selection may also vary according to cal standards, including performance of hazards arising from virus particles or
treatment situation. These recommenda- a minimum of 110 laser / IPL treatments burnt-off material) to patients and per-
tions should thus be critically interpret- under the instruction of a specialist. Of sonnel (including the use of protective
ed while keeping in mind individual these, a minimum of 25 treatment ses- wear for the eyes, mouth, and nose, as
patient factors. sions each for vascular (25) and pigmen- well as exhaust systems).
tary (25) skin changes, benign (25) and
1 Requirements premalignant (25) skin tumors, and 10 1.2.4 Personnel requirements
1.1 Requirements for physicians who skin-resurfacing treatments should be In accordance with the accident preven-
perform dermatologic laser / IPL therapy performed. tion regulations, a certified laser safety
Dermatologic laser / IPL therapy should officer must be appointed in writing to
be performed according to dermatologi- 1.2 Specifications for treatment rooms, operate the laser equipment, unless the
cal standards. Therapy must be per- technical equipment, hygiene, physician fulfills this function himself.
formed by or with the assistance of a der- and personnel
matologist; or under his or her direct Compliance with all specifications 2 Performing laser / IPL treatment
supervision and guidance with the contained in the applicable accident 2.1 General treatment procedures
potential for prompt intervention. prevention regulations (in Germany 2.1.1 Consultation and consent
Additionally, the responsible physician “Unfallverhütungsvorschrift” [UVV]) After obtaining the patient history, find-
must meet the following training and under “laser radiation” (BGV B2) is ings, diagnosis, and determining an indi-
certification requirements: required. These regulations should be cation for laser / IPL therapy, the patient
consulted for further details. should be thoroughly informed of meth-
1.1.1 Certification in laser use ods, risks, potential adverse effects,
Successful participation in a one-day long 1.2.1 Specifications concerning treatment chances of success, and alternative treat-
medical laser course on the principles of rooms ment options. The last point also includes
laser technology, laser safety (in accor- The design of treatment areas should other laser / IPL techniques that may not
dance with accident prevention regula- comply with § 7 and § 8 of the accident be available at the present location. The
tions on “laser radiation”), as well as med- prevention regulations on “laser radia- consultation should be tailored to the
ical and specialized dermatological uses of tion” (BGV B2) from 01/01/1993. chosen treatment method (see 2.2).
JDDG | 11˙2007 (Band 5) © Dt. Dermatologische Gesellschaft • Journal compilation © Blackwell Verlag, Berlin • JDDG •1610-0379/2007/0511-1036Guideline 1037
2.1.2 Documentation needed to enhance healing and minimize modified handpiece with a rapidly mov-
The following data should be collected adverse effects. For many procedures, skin ing beam and brief tissue exposure times
and recorded in the patient file: cooling is sufficient follow-up treatment. for ablation of the skin surface. There is
- Preoperative diagnosis In laser ablation and treatment of larger almost no coagulation and only limited
- Indication for treatment areas of the skin or around the eyes, addi- subsequent necrosis. Compared with
- Informed consent tional anti-swelling measures (e.g., conventional (mechanical) dermabra-
- Type of anesthesia NSAID) may be needed. When using sion, this technique is a largely bloodless
- Type of treatment (laser / IPL type) laser ablation, preventive measures against procedure that offers controlled ablation
- Cooling system herpes may also be necessary. Depending density and has advantages, for example,
- Therapy parameters on the treatment method, patients should in difficult-to-treat areas such as the eye-
- Histological findings (if applicable) be advised to avoid UV exposure. lids, neck, and backs of the hands.
- Side effects Patient information and side effects:
- Complications: intraoperative and 2.2 Laser type according to main Ablation of large surface areas (e.g., “skin
postoperative, infections, delayed form of laser-tissue interaction resurfacing”) in particular is associated
complications 2.2.1 Laser-tissue interactions that mainly with a risk of superinfection and postop-
It is advisable to keep records of the fol- produce thermal coagulation erative pigmentary disorders (permanent
lowing: 2.2.1.1 CO2 laser depigmentization). There is a small
- Photo documentation (forensic and The CO2 laser (10600 nm, absorption amount of residual thermal damage and
billing reasons) mainly by tissue water) allows vaporiza- thus, compared with dermabrasion or
- Type of procedure (surgical procedure) tion of superficial layers as well as cut- Er:YAG laser ablation, healing may be
- Result of procedure and long-term ting of the skin surface with a focused somewhat prolonged. The risk of scar-
assessment beam. Tissue ablation is possible at high ring mainly depends on ablation depth.
- Test sites for treatment of large energy densities using pulsed laser or a Other potential side effects are forma-
lesions and alternative procedures scanner system (see 2.2.2.1). tion of milia, hypertrichosis, scarring,
Patient information and side-effect profile: keloids, and persistent erythema.
2.1.3 Anesthesia Depends on the indication and type of pro-
Measures must be taken to prevent pain cedure. Vaporization of deep tissue is asso- 2.2.2.2 Erbium:YAG laser
during various laser / IPL procedures. ciated with scarring and sometimes even The pulsed Er: YAG laser (2940 nm,
Depending on the patient (e.g., chil- keloids. Thermal necrosis in superficial skin maximum absorption in tissue water)
dren) and method (e.g., laser dermabra- layers is advantageous for hemostasis and allows ablation of the skin surface with
sion) various forms of anesthesia may be disadvantageous for wound healing. Long- almost no thermal damage (minimal
required: topical anesthetic (e.g., cold, term erythema, hyperpigmentation, and necrosis due to coagulation) and thus
local anesthetic applied with an occlusive permanent depigmentation can occur. achieves greater precision in ablation
dressing), local anesthesia (infiltration or than CO2 laser (2.2.2.1) or mechanical
conduction anesthesia) intravenous anal- 2.2.1.2 Continuous wave (CW) Nd:YAG dermabrasion (using a diamond fraise).
gesics, or general anesthesia. laser One disadvantage of this technique is
The continuous wave Nd:YAG laser bleeding if capillaries are opened.
2.1.4 Cooling the skin (1064 nm, CW, nonspecific absorption, Advantages are similar to those of CO2
Modern laser systems use different deep penetration of tissue) is suitable for laser (2.2.2.1)
methods for cooling the skin's surface large-volume tissue coagulation (e.g., Patient information and side effects:
(e.g., contact cooling, cooling spray, hemangiomas, vascular malformations). Analogous to other pulsed and scanner
cold-air cooling) to reduce any related Patient information and side effects: lasers. Due to low thermal necrosis,
pain as well as to protect the epidermis Due to the extensive necrosis caused by wound healing is analogous to that in
from thermal damage, thereby allowing thermal coagulation: pain, delayed dermabrasion.
the use of higher energy densities. wound healing, and scarring
2.2.3 Selective photothermolysis
2.1.5 Pretreatment 2.2.2 Laser-tissue interactions with Given their wavelength-related absorp-
In general patients should avoid exposure a predominantly ablative effect tion in certain chromophores (hemoglo-
to UV rays to reduce hyperpigmentation Given predominant absorption in tissue bin, melanin, tattoo pigments), various
of the epidermis. Depending on the water and brief exposure times (pulse pulsed Q-switched lasers enable targeted
planned laser treatment, other pretreat- mode / very short pulses or CW mode destruction of specific structures.
ment measures may be needed to with continuous deflection / scanner),
improve healing and minimize any unde- various laser systems enable ablation of 2.2.3.1 Pulsed dye laser
sired side effects (e.g., superficial removal the surface of the skin with resulting ther- Flashlamp-pumped pulsed dye laser
of body hair for epilation or pigment mal damage that is less than that achieved (FPDL) (577–600 nm, 200–1500 s or
removal or pre-cooling of the epidermis). with CW mode or even virtually absent. up to 40 milliseconds (ms), predomi-
nant absorption in oxyhemoglobin) is
2.1.6 Follow-up care 2.2.2.1 CO2 laser mainly suitable for photothermolysis of
Depending on the method of laser thera- CO2 laser is used in pulsed mode with superficial neovascularizations or vascu-
py, follow-up treatment sessions may be pulse durations in the ms range or with a lar malformations. It is superior to other
JDDG | 11˙2007 (Band 5)1038 Guideline
techniques in treating nevi flammei in is used for photothermolysis of hair fol- Patient information and side effects:
children (and also adults), in particular. licles and treatment of vessels (2.2.4.6). Comparable to argon laser.
Shorter pulse durations of 200–450 s Frequency-doubled (532 nm), millisec-
are generally used for smaller-caliber vessels ond-pulsed lasers are used for vascular 2.2.4.3 Krypton laser
(< 200 m) longer durations (1.5–40 ms) conditions, but are generally less effec- Continuous wave laser that emits either
for larger ones. Performing a test treat- tive than FPDL and have a higher rate of green or yellow light. Hemoglobin
ment is advisable. side effects (pigmentary changes, danger absorption is not much better than that
Patient information and side effects: of epithelial damage with small scars) of the Argon laser. On the whole, limit-
Pain depending on treated area, although Patient information and side effects: ed clinical experience.
generally minimal. Depending on age Pain and inflammatory reaction with Patient information and side effects:
and location or extent of area to be treat- post-therapy formation of crusts and pos- Comparable to argon laser.
ed, general anesthesia may be needed in sibly faint atrophic scars as well as lasting
young children. With short pulse dura- depigmentation depending on intensity 2.2.4.4 fd-Nd: YAG laser (532 nm)
tions there may be blue-black discol- and frequency of retreatment. Unexpected High-frequency, pulsed quasi-continu-
oration of the treated surface immediate- color changes of tattoo dyes are possible ous wave laser. Similar uses as argon
ly after therapy. Low risk of pigmentary and prior testing is advised. There is a risk laser, but due to higher power levels and
disorders and superinfections. Scars are of posttherapeutic hypopigmentation at thus smaller pulse components, treat-
very rare. Treatment of a single area usu- frequencies of 532 nm, which is smaller at ment is less painful with comparable
ally requires several sessions. 1064 nm. Hyperpigmentation is rare. effectiveness.
Possible allergic reactions when treating Patient information and side effects:
2.2.3.2 Ruby and alexandrite lasers tattoos cannot be ruled out. Comparable to argon laser.
The Q-switched ruby laser (694 nm)
and alexandrite laser (755 nm), which 2.2.4 Semi-selective lasers 2.2.4.5 Diode laser
also emits red light, use pulse durations The settings on such lasers (wavelength, The diode laser (810, 940, 980 nm,
in the nanosecond range to destroy pulse duration, etc.) are insufficient for minimal selective absorption in hemo-
melanin as well as for photothermolysis truly selective photothermolysis (or not globin and melanin) is used for thermal
of tattoo dyes. Alexandrite laser is also used for every indication), yet with appropri- coagulation of superficial blood vessels
with longer pulse durations (5-100 ms) ate irradiation parameters they allow rel- and for selective photothermolysis of
for laser epilation. atively selective damage of structures hair follicles.
Patient information and side effects: containing hemoglobin or pigment. Patient information and side effects:
For use in pulsed mode (nanosecond For treating vessels: depending on pulse
pulses): pain and inflammatory reaction 2.2.4.1 Argon laser duration, comparable to argon laser.
with post-therapy formation of crusts The argon laser (488 / 514 nm, moder- For epilation see “Laser and light epilation”
and possibly faint atrophic scars as well ately selective absorption in hemoglobin
as lasting depigmentation depending on and melanin) is primarily used for super- 2.2.4.6 Pulsed Nd: YAG-Laser
intensity and frequency of retreatment, ficial coagulation, especially vascular Pulsed Nd: YAG laser (1064 nm) is used
but as a rule minimal. Relatively fre- changes; it may also be used for vapor- for epilation with selective photother-
quent post-therapeutic (generally tem- ization with a focused beam and high molysis (see “Selective photothermoly-
porary) hypopigmentation due to effect power density. sis”) as well as semi-selective coagulation
on melanin, rarely hyperpigmentation, Patient information and side effects: of superficial vessels, especially with skin
especially with dermal pigmentation. Given thermal interaction with subse- cooling (telangiectases, spider veins,
Unexpected color changes of tattoo dys quent coagulation, inflammatory reac- phlebectasia)
are possible and prior testing is advised. tion, and necrosis, patients must be Patient information and side effects:
Possible allergic reactions when treating informed of the possibility of scarring Depending on location and irradiation
tattoos cannot be ruled out. and pigmentary changes. Depending on parameters, therapy may be quite
For epilation see under “Laser and light the technique used and the treated site, painful. Risk of atrophy, small scars, and
epilation.” therapy can be quite painful. Several pigmentary changes as seen in use of
treatment sessions are generally required. argon laser; side effects may be reduced
2.2.3.3 Nd: YAG laser For multiple skin changes or when treat- by cooling of the treated area.
Quality-switched Nd: YAG lasers (1064 ing larger areas, perform a test treat-
nm) are used with pulses in the nanosec- ment. Possibility of long-term depig- 2.2.5 Intense pulsed light (IPL)
ond range mainly for destruction of mentation and / or hyperpigmentation Intense pulsed light sources are not lasers.
deep, blue-black tattoos. At the same and / or small scars. They produce high-energy flashes of
beam diameter, the depth of penetration light of several milliseconds' duration
at this wavelength is larger than that of 2.2.4.2 Copper vapor laser with a broad wavelength spectrum, rang-
the ruby or alexandrite laser. If the fre- Continuous wave, pseudo-pulsed laser ing from visible light to well into the
quency is doubled (532 nm), this laser is (578 nm, more specific absorption in infrared spectrum. Filters are used to
also suitable for photothermolysis of red hemoglobin than argon laser), relatively cover the light source, eliminating certain
dyes and melanin. 1064 nm Nd:YAG selective vessel coagulation, but, similar wavelengths in order to optimize treatment
laser with pulses in the millisecond range to argon laser, epidermal coagulation. of different conditions. For pigmentary
JDDG | 11˙2007 (Band 5)Guideline 1039
changes, the selected wavelength begins 2.3. Indications in dermatology extensive telangiectases (rubeosis faciei,
at shorter wavelengths (typically about The information presented here is mere- couperosis, erythrosis interfollicularis)
550 nm); for treatment of vascular ly intended to serve as recommenda- and extrafacial telangiectases, pulsed
changes it begins at a longer wavelength tions. Determining indications for treat- laser or intense pulsed light systems
(typically 580–590 nm). Flashlamp sys- ment and choice of laser vary for each have distinct advantages in terms of scar-
tems of the older generation did not fil- patient and according to the experience ring and hypopigmentation compared
ter out infrared light; due to the infrared of the practitioner. Basically, coagulation with continuous-wave techniques. The
portion and imprecise choice of parame- and ablative lasers that target superficial frequency of side effects for treatment of
ters, relatively mild side effects resulted layers of the skin can be used for any facial lesions is very low for all treatment
such as epithelial coagulation with subse- skin change that could also be treated modalities.
quent pigmentary changes and small with other ablative measures (e.g., curet-
scars. Newer flashlamp systems of the tage, surgical snare) (see 2.3.2). 2.3.1.3 Spider nevi
second generation use circulating water Treatment of these skin changes belongs Comparable to telangiectasia. In more
to filter out the infrared portion of longer to standard dermatologic knowledge and pronounced, papular spider nevi laser
wavelengths, significantly reducing asso- thus will not be further discussed in the therapy is usually only moderately suc-
ciated side effects. following. If necessary, results of a test cessful; use of a laser with good coagula-
Intense pulsed light sources operate on patch can help decide the appropriate tion properties (e.g., Argon laser) is pos-
the principle of selective photothermoly- approach. sible. Simultaneously pressing the lesion
sis and, given the relatively flexible set- with a glass spatula, partly emptying the
tings for treatment parameters (wave- 2.3.1 Vascular conditions hemangiomatous component of the
length, pulse durations in milliseconds, 2.3.1.1 Nevi flammei lesion, along with longer irradiation
double and multiple pulses), can be used The use of yellow-light flashlamp- times, is often successful.
in a wide variety of conditions (e.g., vas- pumped pulsed dye laser is currently the
cular changes such as nevi flammei, method of choice given the related effi- 2.3.1.4 Spider veins
telangiectases, spider nevi; superficial cacy and side effect profile. Improved In general, fine red spider veins can be
pigmentary changes; epilation; and results may be achieved using the dou- treated with flashlamp-pumped pulsed
photo rejuvenation). The typically large ble-pulse technique, i.e., treatment with dye laser, argon laser, copper vapor laser,
exposure areas enable rapid and effective variable pulse durations during a single KTP laser, or intense pulsed light
treatment of larger areas. treatment session. In special circum- sources. Especially for treatment of the
Patient information and side effects: stances, high-energy flashlamps or legs, however, consideration should be
Depending on selected treatment argon, continuous wave krypton, copper given to the typical side effects of contin-
parameters, associated discomfort may vapor, or potassium titanyl phosphate uous wave laser. The pulsed dye laser,
be slight or more pronounced. (KTP) lasers may be used in adult which is less problematic in this regard,
Depending on the device used, a clear patients, although, depending on treat- is suitable if longer pulsed (1.5–40 ms)
gel should be applied to skin to aid ment method, side effects may be more laser types are used for thermocoagula-
movement of the handpiece, which can common (pigmentary changes, scar- tion of spider veins with a diameter up
also be cooled to help cool the skin. ring). Laser ablation or coagulation (e.g., to 1 mm. Post-treatment hyperpigmen-
With proper use, side effects are rare, CO2 laser or Nd: YAG-Laser) can also be tations are very common and often
although they are possible and include used on an individual basis in patients remain for several months.
hypopigmentation and hyperpigmenta- with livid nevi flammei or nevi flammei Larger-caliber spider veins can be treated
tion, blisters, crusts, and atrophic scars. related to tuberous sclerosis. using long-pulsed (up to 20 ms) alexan-
These side effects are much more com- It is advisable to test a smaller area of the drite, Nd: YAG (1064 nm) or diode
mon with older, first generation flash- skin prior to treating large areas or in laser; pulsed Nd: YAG lasers are now
lamps which emit a higher proportion of order to assess treatment effects and pos- considered the laser of choice.
infrared light. sible side effects and to determine the Nevertheless, there is a risk of (initial)
best irradiation parameters (beam diam- hyperpigmentation, (later) depigmenta-
eter, power density). In general, multiple tion, and scarring.
2.2.6 Excimer laser sessions are needed to achieve good
This refers to UVB radiation emitted by results. 2.3.1.5 Hemangiomas in pediatric patients
an excimer (excited dimer) laser at a Small, circumscribed initial hemangiomas:
wavelength of 308 nm in quasi-continu- 2.3.1.2 Telangiectasia Flashlamp-pumped pulsed dye laser pro-
ous wave (high-frequency short pulses) Flashlamp-pumped pulsed dye laser, duces good results; other options are
mode. Excimer laser allows circum- argon laser, copper vapor laser, krypton argon laser, copper vapor laster, KTP, laser,
scribed treatment of skin changes that laser, pulsed Nd: YAG laser (frequency- or IPL, usually requiring several sessions.
are accessible to UVB therapy and are doubled at 532 nm or at 1064 nm) and Superficial hemangiomas:
thus UV light therapy devices. Strictly IPL devices are equally effective in treat- Pulsed dye laser or IPL are the methods
speaking, they are therefore not the sub- ing facial telangiectasias. Post-treatment of choice given their efficacy / side effect
ject of this guideline. The reader is blue-black discoloration associated with profiles. The use of more strongly coag-
directed to the guideline on UV light flashlamp-pumped pulsed dye laser is ulating lasers is not advisable given asso-
therapy in dermatology. occasionally bothersome. For more ciated pain and greater risk of side
JDDG | 11˙2007 (Band 5)1040 Guideline
effects. Several sessions are usually tial adverse effects (scarring). In patients patient has been thoroughly informed of
required. with flatter xanthelasmas, resolution can the risks involved. In special situations,
Larger nodular, deep hemangiomas: also be initiated by several sessions with combination therapy with various laser
It is not possible to make general recom- pulsed dye laser. systems may be advisable (e.g., primary
mendations since the use of laser or IPL dermabrasion with CO2 or Er: YAG laser
is mainly determined by individual 2.3.3 Precancerous skin changes followed by Q-switched laser).
patient needs and the experience of the Before initiating laser therapy in patients
practitioner. Depending on the condi- with precancerous skin changes, diagnosis 2.3.5.1 Decorative tattoos
tion, it may be advisable to use various by a dermatologist as well as biopsy con- Q-switched laser is currently the laser of
laser systems (e.g., those specifically for firmation are needed. Documentation of choice for removing decorative tattoos.
vascular lesions, ablation, coagulation) disease course and long-term clinical fol- Ideally, the color of the laser light should
alone or in combination, or possibly in low-up examinations should be ensured. correspond to the absorption spectrum
conjunction with interstitial laser thera- Leukoplakia, cheilitis actinica without of the tattoo dyes. Q-switched ruby,
py. Particularly with coagulation laser infiltrative growth, actinic keratoses, alexandrite, Nd: YAG, or frequency-
therapy, special attention should be Bowen's disease, and erythroplasia of doubled Nd: YAG lasers may be used.
given to the risk of scarring and tissue Queyrat can be managed well with laser Test treatment to evaluate the response
damage (e.g., nerves). Referral of ablation (usually CO2 laser), assuming to therapy is advisable in individual
patients to specialized treatment centers correct evaluation of treatment indica- patients. Treatment generally requires
is advised. tion and technique. The Er: YAG laser is several sessions.
only advisable in very superficial skin
2.3.1.6 Angiomas of the lips (venous lake) changes with minimal infiltration. 2.3.5.2 Traumatic and other accidental tattoos
Laser coagulation (argon, krypton, cop- Test treatment is advisable given the
per vapor, KTP, or pulsed Nd: YAG) or highly variable response to laser therapy
2.3.4 Infectious skin diseases
pulsed dye lasers (usually requiring sev- depending on the type of embedded
Viral papillomas
eral sessions) may be used. For larger material.
There have been reports on successful
lesions, possible careful use of CW Nd:
use of pulsed dye laser and Nd: YAG or
YAG or CO2 laser. Reducing power out- 2.3.6 Scars
CO2 laser hyperthermia for treatment of
put and increasing pulse duration is rec- 2.3.6.1 Hypertrophic scars and keloids
warts. Laser coagulation or ablation is
ommended to achieve deeper coagula- There are reports on successful use of
also possible, but given the considerable
tion. pulsed dye laser, especially in active,
risk of scarring, usually advisable only
highly vascularized hypertrophic scars
after all other conservative methods have
2.3.1.7 Senile angiomas (ruby spots) and keloids as well as on the use of Er:
been exhausted.
Coagulation of lesions in superficial skin YAG laser in “thermal mode” (subabla-
CO2 laser ablation therapy of condylo-
layers can be achieved with argon, kryp- tive Er: YAG laser) to flatten and lighten
mata acuminata is usually a bloodless
ton, copper vapor, KTP, pulsed Nd: hypertrophic scars.
procedure that spares normal tissue.
YAG laser or with pulsed dye laser (usu- The (repeated) use of laser ablation can
Infectious diseases may be transmitted
ally requiring several sessions). In princi- be attempted to smooth hypertrophic
by laser smoke and precautionary meas-
ple, ablative laser is also a possibility. scars. To treat keloids, laser ablation is
ures are required (see 1.2.3). For patients
Risk of adverse effects should be noted usually combined with other treatment
with potentially infectious diseases and
(scarring, permanent depigmentations). forms (e.g., cryotherapy, steroid injec-
those with HIV, electrocoagulation,
tions, pulsed dye laser, compression).
argon plasma coagulation, or coagula-
2.3.1.8 Pyogenic granuloma
tion with Nd: YAG laser are preferable, 2.3.6.2 Atrophic or sunken scars and acne
For small lesions, CW laser coagulation
although these methods are associated scars
of lesions in superficial skin layers (see
with a heightened risk of thermal necro- All scars which are treatable by der-
2.3.1.6) is possible; larger lesions are
sis and subsequent scarring. mabrasion can also be treated by laser
generally treatable with laser ablation
and / or coagulation. Several sessions are methods that involve ablation of superfi-
usually required. Primary surgical proce- 2.3.5 Tattoos cial layers of the skin with minimal ther-
dures are often a better option. CAUTION: Red, reddish, purple, light, mal residual necrosis (i.e., pulsed or
earth-colored, and especially skin-col- scanned CO2 laser or Er: YAG laser).
2.3.2 Nonvascular benign neoplasms (see ored decorative tattoos can change irre- The effect and range of adverse affects
preliminary note in 2.3) versibly to black or dark brown after are generally comparable to those associ-
Xanthelasma, syringomas, sebaceous therapy with Q-switched laser. The pos- ated with dermabrasion.
gland hyperplasia (sebaceous gland sibility of allergic reactions arising from Subablative exposure using Er: YAG
epitheliomas), angiofibromas (Brooke's laser therapy of tattoos cannot be ruled laser (thermal mode) can improve the
disease, Pringle's disease), chondroder- out. appearance of atrophic scars.
matitis nodularis helicis, and others. CO2 laser therapy of tattoos is currently In individual situations, the use of laser
Good results are often achieved in super- considered a last resort given that it nec- coagulation to treat superficial layers of
ficial layers of the skin with laser coagu- essarily leads to scarring; in individual sit- the skin (e.g., argon laser) may also be
lation or ablation, paying heed to poten- uations it may be used, however, after the considered.
JDDG | 11˙2007 (Band 5)Guideline 1041
Several treatment sessions are often studies show that these therapies are far principle, treatment with laser ablation
required; these should be scheduled at less effective than ablation, most of them is possible. Histological confirmation
least six months apart. do not entail any significant risk of side should always be attempted, e.g., by
Acne patients who have received effects. shave biopsy.
isotretinoin should not receive ablation The effectiveness and long-term results
laser treatment over large areas for at of nonablative methods for type 2 skin 2.3.9 Rare indications
least 12 months afterward. rejuvenation cannot yet be reliably deter- Laser therapy is never the method of
mined given lacking data. Further stud- choice for treating malignant or other
2.3.7 Aging skin and wrinkles (skin ies with larger patient numbers and infiltrating skin changes given the lack of
resurfacing) long-term follow-up are needed. histological control. In exceptional cir-
2.3.7.1 Ablation methods cumstances, laser therapy may be chosen
In principle, age-related skin changes 2.3.8 Pigmented skin changes after careful consideration by experi-
may be treated by laser ablation therapy The indication for laser treatment of enced laser therapists. Possible indica-
with minimal thermal residual necrosis. pigmented skin changes should be deter- tions could include multiple skin
Good results can be achieved when pre- mined by the patient's dermatologist changes or palliative use.
cise laser technique is used, in particular and confirmed by biopsy if there is any Good clinical follow-up, with correspon-
when treating skin that has been dam- doubt as to the nature of the lesion, ding patient compliance, is mandatory
aged by acne or for fine or moderate especially if malignant potential is sus- for such interventions. Examples include
facial wrinkles. Long-term results show pected. initial Kaposi's sarcoma (palliative treat-
stable treatment outcomes over several ment with pulsed dye laser), superficial
years. In terms of long-term effects of 2.3.8.1 Lentigines multicentric basal cell carcinoma on the
skin tightening, most experience has Simple removal is possible with Q- trunk (CO2 laser), or initial squamous
been with pulsed or scanned carbon switched laser, the wavelength of which cell carcinoma affecting specific sites on
dioxide laser. Er: YAG laser has a lower has relatively specific for absorption by the body (CO2 laser).
risk of side effects and can produce com- melanin, without significant side effects.
parably good results, although usually IPL is an alternative for thermal treat- 2.3.10 Laser and light epilation
only after several treatment sessions. ment of lentigines. The goal of epilation with laser or light
Given that treatment is for aesthetic pur- Only in exceptional situations should sources is to permanently damage the
poses, special care should be taken to laser ablation of superficial skin layers be hair follicles using selective photother-
inform patients of possible side effects used; the risk of scarring should be noted. molysis. Light absorbed by the pigment
(e.g., provocation of herpes or acne, per- in the hair follicle (root, hair shaft) leads
sistent erythema, irritant dermatitis, 2.3.8.2 Cafe-au-lait spots or nevus spilus to heating of follicle structures which
hyper-depigmentation and persistent See lentigines (2.3.8.1). Recurrence is results in thermal damage and reduces
depigmentation, milia, scarring, and possible after only a relatively short time. hair growth. Lasers with longer wave-
hypertrichosis). There is lacking knowledge of long-term lengths are typically used with pulse
effects. Test treatment is advisable. durations of several milliseconds (alexan-
2.3.7.2 Non-ablative methods drite laser, diode laser, Nd: YAG laser,
Non-ablative skin rejuvenation is aimed 2.3.8.3 Pigmented melanocytic nevi IPL).
at improving the appearance of the skin The treatment of pigmented melanocyt- Multiple studies clearly show the effec-
without removing superficial skin layers. ic nevi with Q-switched laser, the wave- tiveness of treatment, although adequate
Two types are distinguished: type 1, length of which has relatively specific for epilation generally requires several ses-
which involves removal of pigmentary absorption by melanin, is currently out sions. The numbers of hairs as well as
changes (e.g. lentigines) and telangiec- of favor as a routine method. (see also pigmentation and thickness are reduced.
tases to improve the skin's appearance the guidelines on melanocytic nevi). Hair reduction cannot yet be considered
and type 2, which uses thermal induc- Given that the melanocytic cells are permanent as repeated treatments (albeit
tion to shrink collagen, thereby tighten- insufficiently damaged and lacking expe- in larger intervals) are usually needed to
ing the skin and reducing wrinkles. rience or long-term results on reactions maintain a good outcome. Treatment
For type 1 rejuvenation, devices are used of sublethally damaged cells to laser ther- sometimes also leads to re-growth of
which have proven effective in treatment apy, this method of treatment is reserved much thinner hair with decreased pig-
of vascular and pigmentary changes (e.g., for use only in individual situations or mentation. The darker the hair, the more
FPDL, argon, and frequency-doubled clinical studies. The only even partially amenable it is to treatment; the clinical
Nd: YAG laser, Q-switched laser, IPL). certain indication for treatment is cur- effect on light or white hair is thus very
For type 2 rejuvenation, various lasers rently lightening of Ota nevi. limited. For this reason, especially when
are used which either directly or indi- Given the risk of scarring and lacking using laser or IPL for epilation, careful
rectly cause the collagen in the skin to histological control, use of laser ablation attention should be paid to ensuring that
shrink by heating the vessels (these or coagulation should also be reserved the skin is not tanned as this is associat-
include flashlamp-pumped pulsed dye for use on an individual basis and only ed with greater likelihood of side effects
laser below the purpuric threshold, Er: after careful consideration. such as blisters, crusts, pigmentary
YAG and Er: glass laser, various diode Clinically unequivocal, non-pigmented, changes, and scars. The latter does not
lasers, and IPL). Although available papular dermal nevi are an exception; in apply to long-pulsed Nd: YAG laser,
JDDG | 11˙2007 (Band 5)1042 Guideline
which is FDA-approved for treating Subcommission: Physical treatment 3 Dover J S, Arndt K A, Dinehart S M,
darkly pigmented skin. methods in dermatology Fitzpatrick R E, Gonzalez E and the
Leader: Prof. Dr. E. Hölzle Guidelines/Outcomes Committee.
2.3.11 Treatment of acne Board of authors: Prof. Dr. F. Bahmer, Guidelines of care for laser surgery. J
Regarding the treatment of acne with Prof. Dr. M. Drosner, Prof. Dr. U. Am Acad Dermatol 1999; 41: 484–95.
various laser and flashlamp systems, Hohenleutner, Prof. R. Kaufmann, Dr. 4 Greve B, Raulin C. Professional Errors
there are reports on both successful and G. Kautz, Dr. W. Kimmig, Prof. Dr. Caused by Lasers and Intense Pulsed
ineffective outcomes, some of which M.J.E. Landthaler, Prof. Dr. R. Light Technology in Dermatology and
directly contradict each other. The Neumann, Dr. Ch.Raulin, Dr. N. Seeber Aesthetic Medicine: Preventive Strate-
rationale behind treatment is, on the one These recommendations were developed gies and Case Studies. Dermatol Surg
hand, thermal damage of the sebaceous without third party support, financial or 2002; 28 (2): 156–61.
glands and on the other a photodynam- otherwise. 5 Greve B, Raulin C. Laser und IPL-Tech-
Date created: 01/2007 nologie in der Dermatologie. 2. Auflage
ic effect on porphyrin produced by pro-
Planned review date: 12/2009 2003, Schattauer Verlag Stuttgart.
pioni bacteria. This minimally-invasive
6 Drosner M, Adatto M. Photo-epilation:
technique does not involve and risks
Guidelines for care from the European
such as development of resistance or sen-
Society for Laser Dermatology (ESLD).
sitization (as seen with antibiotic use) or
Correspondence to J Cosmet Laser Ther 2005; 7(1):33–8.
teratogenous effects (as seen in
Prof. Dr. med F. Bahmer 7 Landthaler M, Hohenleutner U.
isotretinoin therapy). In addition, it has
Dermatologische Klinik Lasertherapie in der Dermatologie. 2.
a positive effect on inflammatory and Auflage 2006, Springer-Verlag Berlin,
non-inflammatory acne lesions and seb- Zentralkrankenhaus
Heidelberg, New-York.
orrhea. Good results have been reported Sankt Jürgen Str. 1
8 Leitthema Laser. Der Hautarzt 2003;
after 6–8 treatments. D-28205 Bremen
54(7): 573–602.
It is not yet possible to conclusively state Tel.: 04 21-49 75 32 1
9 Raulin C, Kimmig W, Werner S.
whether and which laser or IPL therapy Fax: 04 21-49 73 31 6
Lasertherapie in der Dermatologie und
is definitively effective. E-mail: fbahmer@t-online.de
Ästhetischen Medizin – Nebenwirkungen,
Komplikationen und Behandlungsfehler.
Consensus formation References Der Hautarzt 2000; 51(7): 463–73.
Quality assurance commission of the 1 American Society for Laser Medicine 10 Strahlenschutzkommission des
German Society of Dermatology and Surgery ASLMS. Professional In- Bundesministeriums für Umwelt,
Occupational Association of German formation/ Standards of Practice. Naturschutz und Reaktorsicherheit.
Dermatologists e. V. www.aslms.org Empfehlungen 2000: Gefahren bei
German Society of Laser Dermatology e. 2 Deutsche Dermatologische Laserge- Laseranwendungen an der menschlichen
V. (DDL) sellschaft www.ddl.de Haut. www.ssk.de
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