Laser Therapy: Benign Pigmented Lesions

Benign Pigmented Lesions

Epidermal lesions include lentigo, café-au-lait macules, ephelides, junctional nevus, and seborrheic keratosis. Dermal lesions include blue nevi and Nevus of Ota or Ito. Some lesions have both dermal and epidermal fractions such as melasma. Pigmented lesions with atypical characteristics should never be treated with a laser. They follow the acronym ABCDE. A is for asymmetry, B is for irregular border, C is for multicolored, D is for enlarging diameter, and E is for evolving. These need to be evaluated by a dermatologist. Patients with a family history of melanoma or dysplastic nevi should not get laser treatment.

Lentigines are small irregular patches with sharp borders. Solar lentigo (sun spots) grow in number with aging, is related to the amount of sun exposure, and is not pre malignant. These lesions can be treated with KTP lasers or IPL. Lesions will darken with treatment.

Ephelides (freckles) are tan to dark brown patches or spots with sharp borders, occur on sunexposed areas, and darken with sun light. Appearance decreases with age. Treatment involves sun screen and sun avoidance. Hydroquinone, alpha hydroxyl acids and tretinoin can decrease freckles if used regularly. Q switched, KTP lasers, and IPL are effective treatments. Repeat sun exposure without protection causes recurrences.

Seborrheic keratosis are epidermal growths that progress from yellow smooth patches to irregular papules or plaques. For thicker lesions the longer pulsed Alexandrite laser is more efficacious and need fewer treatments.

Melasma
This is an area of light to dark brown facial discoloration that develops gradually. Its cause may be unknown, or it may be related to pregnancy or birth control pills. It occurs in 50-70% of pregnant women usually in the second and third trimesters. It occurs in 8-29% of women taking birth control pills. Laser therapy has been used when topical therapy fails. Recurrence can be decreased by sun block, abstinence, and regular use of hydroquinone. Treatment with Q switched lasers, IPL, erbium, and CO2 are not that successful with repigmentation being common, as well as post inflammatory hyperpigmentation. A test site is recommended before treating an entire area since some cases are worsened by treatment. Superficial resurfacing with erbium gives the best chance for benefit but is unpredictable and still may recur.

Epidermal nevus before and after treatment with a CO2 laser

Blue Nevi

Before and after treatment of nevi with a diode laser

These are usually single discreet plaques 1-8 mm in diameter that appear in children and young adults. They are mostly benign and are removed for cosmetic reasons. The principle method of removal is surgical excision. However, Q switched alexandrite and Nd:YAG lasers can be used if the lesion has not spread too deeply into the underlying fat. There are rare cases of conversion to malignant melanoma. So new, multinodular or plaque like lesions should be biopsied. Patients should be made aware that not all lesions can be removed completely and significant lightening may need several treatments 6 weeks apart. Side effects include transient hyper or hypopigmentation, scarring, permanent hyperpigmentation, incomplete clearance, or recurrences. To avoid hyperpigmentation after laser treatment, patients should avoid the sun and use sunblock with micronized zinc dioxide. If hyperpigmentation occurs, hydroquinone should be used two times a day until it resolves. If hypopigmentation occurs, it usually resolves with time. If not an excimer laser can be used. For scarring, early treatment with a PDL is used.

BBL vascular Protocol v4.3 110904 Page 1 of 12
PROFILE™ BBL™ PULSED LIGHT MODULE:
NON-ABLATIVE VASCULAR/SKIN TREATMENT
WITH 560 & 590 NM FILTERS
Introduction
Vascular lesions can be treated with the selective absorption of light by blood in the target vessel. This process was described as early as 1968 using ruby (694 nm) and Nd:YAG (1064 nm) lasers (Solomon et al., J Inv Derm, 1968, 50:141-146). The absorption converts light into heat energy, which raises the temperature of blood within vessels. With appropriate selection of fluence and pulse width, the temperature of the blood will be high enough to alter and damage the vessel wall resulting in the elimination of the vessel.
Pigmented lesions are treated by selective destruction of melanin or melanocytes with short high intensity light pulses.
The theory of Selective Photothermolysis explains how wavelength, energy, pulse width and thermal relaxation time all play a part in the destruction of a target and the preservation of surrounding tissue. Because of their large surface area-to-volume ratio, melanin and microvessels rapidly lose absorbed energy (heat) into the surrounding tissue. The thermal relaxation time of very small vessels is less than 1 millisecond, while that of larger vessels and hair can be 20 -100 milliseconds (ms) depending on size, and the thermal relaxation time
of the epidermis is 3 -10 ms.
The PROFILE BBL can deliver enough energy or fluence to effectively target melanin and surface vessels, and has variable pulse widths for treating a range of target sizes. When the BBL is used to treat blood vessels, there is heat build-up in tissue from the absorption of light energy in vessels. The heat dissipates from the vessel into surrounding tissue. Absorption of the BBL light in melanin can be substantial, and epidermal cooling is recommended for darker skin.

Surface Cooling
Although absorption of the BBL light in melanin may be desirable, some epidermal cooling is beneficial to protect the skin. The amount of cooling required will vary depending upon the patient’s skin type. Lighter skin types require less cooling, and darker skin types require more cooling. The BBL contact cooling plate insures that the epidermis is adequately protected from overheating regardless of skin type. When the BBL is used to treat blood vessels, there is heat build-up in tissue from the absorption of light energy in vessels and melanin. The heat dissipates towards the skin surface. Surface cooling before, during and immediately after BBL treatment, or after the light is converted to heat, can quench heat from the surface and protect the epidermis from undesirable heating. For the parameters used in treating microvascular conditions there is
minimal heat build up and less cooling is required.

Classification of Skin Types
The following table offers a broad guidance to identifying skin types based on hair, skin and eye color as well as sun reaction.

Fitzpatrick Scale
Type /Hair Color /Skin Color /Eye Color /Sun Reaction
I /Red /Light /Blue-green /Burn, never tan
II /Blonde /Light /Blue /Burn, may tan
III /Brown /Medium /Brown /Burn, then tan
IV /Brown-black /Moderate brown /Brown-black /Tan
V /Black /Dark brown /Dark /Tan
VI /Black /Black (African) /Dark /Tan

Consultation / Treatment
The consultation or initial visit allows an exchange of views between case provider and patient in an attempt to reach a decision regarding treatment. The patient must understand the procedure, pre and post care instructions, and expectations before the procedure is performed.

Patient Education (Expectations)
The BBL is used to reduce flushing, telangiectasia, redness, dyspigmentation, reduce unwanted hair, and improve skin tone. Patients must understand that results vary with each individual. Multiple treatments may be necessary over a time span (2-4 week intervals) to reduce redness in most areas. Results should be evaluated several weeks post treatment. The BBL light pulse is often described as a wave of heat with the sensation of a pinprick. A topical anesthetic may be necessary.

Patient Documentation Forms

• Consent: the process of accepting and confirming treatment must be reviewed,
understood and signed by the patient prior to treatment. This document must review the topics discussed during consultation. It acknowledges that the patient understands the procedure and that all questions have been answered.
• Review post care instructions and confirm that the patient will adhere to such
instructions throughout the course of their treatment.
• Upon patient's assessment, the case provider must determine the need of medications or creams. These can be given before the procedure and used throughout the treatment.
• Post-treatment appointments are scheduled for: treatment assessment, patient
evaluation and routine therapy.

Photographs
Before and after photographs should be taken throughout the course of the treatment to monitor patient response to therapy. Photographs should be taken prior to treatment, immediately after treatment and during follow-up visits. Camera settings should be the same to maintain photographs of similar quality. Photographs are useful in demonstrating efficacy of treatment to the patient.
Pre Treatment Procedure
• For better results, patients should avoid sun exposure, tanning beds and tanning creams for 2-3 weeks prior to treatment and throughout the course of their BBL treatment. Sunless tanning lotions must also be avoided for 2-3 weeks prior to treatment. However, if sun exposure is not avoidable treatment sessions need to be increased since treatments on sun-exposed skin will require lower fluence settings to protect the epidermis. • Instruct the patient that recent sun exposure may result in cancellation of the treatment.
Post Testing Evaluation
• Evaluation of any tested area(s) usually occurs 1-2 weeks post treatment.
• Verify that any hypo/hyperpigmentation has been transient (to date). If the patient is concerned about the pigmentary changes, further treatments may be delayed. Once the area returns to normal skin tone, treatments may be resumed.
• Further testing may be indicated depending on the results seen from the first tested area(s).
Determination of Clinical Endpoint
Caution: Treating with excess energy levels can result in adverse effects
such as abnormal pigmentation, blistering and scarring.
• Erythema should be noted in the skin. If the treatment area has even the slightest tan, the erythema response may be greater. If blistering occurs, treatment should be stopped immediately. Treatment can resume when the tan has faded.

Treatment Procedures
• The highest energy density determined through test spots should be utilized. An increase in fluence should be tolerated after 2-3 consecutive treatments.
• Double treatment of the same area is not recommended and can increase the chances of post treatment complications.
• Treatments are scheduled at 2 to 4 week intervals for most areas, 6 to 8 weeks for hair removal.
Sun Protection
• A broad spectrum (UVA/UVB) sun block with an SPF of 30 must be applied 15
minutes prior to casual sun exposure.
• Prolonged sun exposure requires repeated applications of sun block every 2 hours (e.g. yard work, beach activities, etc.).
• Sun block must be reapplied after swimming.
Adverse Effects
Complications, though rare, can occur and should be discussed and understood. The patient must understand the importance of the post-care instructions, and that failure to comply may increase the potential for complications.
• Scarring, though rare, can occur following any intense light procedure.
• Histamine/Hives: some patients develop raised urtecaria similar to hives. This irritation usually subsides in a few hours.
• Pigmentary changes: hyperpigmentation or hypopigmentation may occur. There is a higher risk in darker skin types. Sun exposure to the treatment area should be avoided at least 2-3 weeks prior to treatment. A broad spectrum (UVA/UVB) sunscreen SPF 30 or greater should be applied to the area(s)
to be treated whenever exposed to the sun.

Post Treatment Skin Care
Patients should receive post skin care instruction following each BBL treatment. Sample post care instruction sheets are included.
• Application of an ointment or aloe vera:
I. Ointment is applied to the area to prevent drying. Ointment applied following
the BBL treatment can have a soothing effect.
II. An antibiotic ointment should be utilized if there is any blistering or break
in the skin, and the patient should be instructed to contact the office.

PROFILE™ BBL™ PULSED LIGHT MODULE:
NON-ABLATIVE VASCULAR/SKIN TREATMENT
SAFE START PROTOCOL
The following protocol is a safe start guide based upon the clinical observations of
experienced physicians.
IMPORTANT: Treating with too high of a fluence or overlapping pulses may lead to undesirable outcomes, including blisters, depressions and transient
hyperpigmentation, all due to overheating of tissue.

1. PRE-TREATMENT CONSIDERATIONS
1.1. CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment
area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.
1.2. SITE PREP
Cleanse the area with mild soap and water followed by an alcohol swab to
thoroughly remove any residue from lotions, makeup or shaving. Remove the alcohol with a gauze and plain water leaving the surface of the skin slightly moist.
Use caution when treating over beards – fluence should be lowered, and there is a small possibility of alopecia. A small test area is recommended.
1.3. ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or sensitive areas prior to treatment. Remove before treatment with mild soap and water or an alcohol swab, then plain water. Dry the area thoroughly before treatment.
1.4. EYEBROWS AND BEARDED AREAS
Use caution when treating over beards – fluence should be lowered, and there is a small possibility of alopecia. A small test area is recommended.
Eyebrows should be protected as there is a small possibility of alopecia.
1.5. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the treatment room during the treatment.
1.6. PATIENT EXAMINATION
Shave the area to be treated. Veins and telangiectasias, wrinkles, and skin tone
should be classified prior to treatment according to size and depth. A pre-treatment photo should be taken to assist in evaluating the effectiveness of the treatment.
1.7. TREATMENT OF AREAS WITH ARTIFICAL MAKE-UP, TATTOOS AND
DARKENED MOLES.
Areas tattooed with designs or permanent make-up should be avoided. Not only do they create an additional and unwanted target for deposition of heat, but those targets with red or frosty white appearance commonly have iron or titanium in their composition. The red or white pigment will often oxidize and turn black from exposure to high intensity light. If you must treat those areas, a test spot with close monitoring for one to four days is recommended.
CAUTION: Tattooed areas should not be treated. Tattoo ink may absorb
energy resulting in a color change in tattoo ink or a risk of epidermal
damage. Darkened moles should not be treated. Moles may absorb energy
resulting in a color change creating a risk of epidermal damage and the
inability to monitor the lesion under ABCD guidelines.

2. SETTING TREATMENT PARAMETERS
2.1 FLUENCE
Starting fluence will be will depend on the condition and the skin type. The
parameters in Table 1 are safe start parameters. Patient response can vary, so the fluence setting should begin low and be increased gradually after assessing the individual patient response. The desired response is spontaneous erythema (redness).
Fluence and pulse widths may change for a patient during the series of treatments. Be sure to properly evaluate the treatment parameters before each treatment based on previous successes or complications, and the response of the patient to questions about the first 24 hours after the previous treatment. Those who respond with no irritation or without prolonged erythema for the first 24 hours after treatment are within a safe, and possibly low, fluence range.
2.2 COOLING
Cooling is recommended for patient comfort and protecting the surface of dark
skin. Treating with warmer temperatures will require treating with lower FLUENCE settings. The inverse also applies. Most treatments for lighter Fitzpatrick skin types can be performed at the 25°C setting. A thin coating of colorless gel, KY, surgilube or water should be used in conjunction with the system for better heat removal, improved optical coupling, and lubrication for sliding the plate over skin.
2.3 PULSE WIDTH
Select the starting pulse width from the table. It may be necessary to change the
pulse width and fluence to achieve the desired erythema response. Shorter pulse
width and higher fluence settings are more aggressive. Longer pulse width and
lower fluence settings are less aggressive.

3. TECHNIQUE
3.1. PATIENT POSITION
Position is based on the area to be treated. Patient should be in a comfortable
position. The treatment area should be presented to the BBL user at a convenient height and position.
3.2. TEST AREA
Treating a test area before a patient’s first treatment can establish their response
threshold and help establish safe starting parameters. The test area should be
monitored for response for a period of five to ten minutes. Blistering or the
immediate grey or white presentation of the skin is the immediate concern.
TEST AREA should reach the desired response of erythema within a few minutes. Increase fluence in small increments until the desired response is achieved.
CAUTION: Use only enough fluence to achieve the desired endpoint of erythema.
IMPORTANT: Keep fluence conservative for the first treatment session, and monitor
the patient for any evidence of prolonged erythema, swelling, urticaria or blistering.
3.3. HANDPIECE POSITION
Position the patient so the BBL can be held perpendicular to the skin surface. Move the patient if necessary so that the treatment area is easy to reach.
Position the BBL so the cooling plate is in full contact with the skin. For highly
curved regions, use the edge of the cooling plate while pushing the skin upward
with your other hand to insure proper cooling. If you are unable to maintain
contact, then use a white ‘block’ or tongue depressor to protect the non-cooled
tissue.
The BBL must remain in contact with skin long enough before and after the the
light pulse to cool the surface of the skin and reduce the heat sensation. It may
take several seconds for the deeper heat to propagate to the surface after the light pulse. A coating of colorless gel, KY, surgilube or water should be used in
conjunction with the system for better heat removal, improved optical coupling, and lubrication for sliding the plate over skin.
3.4. TREATMENT METHOD
Match the “trailing edge” of the next treatment area to the “leading edge” of the
previous treatment. The BBL will give a uniform treatment with uniform fluence
within the treatment area.
Make certain to maintain complete skin contact with the treatment area before,
during and after the treatment. A coating of colorless gel, KY, surgilube or water
should be used in conjunction with the system for better heat removal, improved
optical coupling, and lubrication for sliding the plate over skin.
Do not overlap or immediately repeat BBL pulses.
For small lesions such as cherry angiomas a mask can be used to protect
surrounding skin. Use a white card and cut out an area corresponding to the size of the lesion. Place the card over the lesion such that only it is exposed to direct light from the BBL. Higher fluences can be used since the surrounding skin is shielded from intense light.

4. TREATMENT GOALS
The immediate goal is light, uniform erythema a few minutes after treatment.
Patients will typically report feeling tighter skin or the sensation of mild sunburn
following treatment.
CAUTION: Presentation of a blister or immediate graying or whitening of tissue indicates immediate complication. Treatment methods and parameters should immediately be reevaluated. The blisters or skin discoloration will commonly resolve without complication.

5. POST-TREATMENT CONSIDERATIONS
5.1. OBSERVATIONS
Erythema or a mild sunburn sensation should be noticed in the treatment area for up to two hours after treatment. Patients should not feel any significant discomfort after treatment.
5.2. INTERVENTION
While not often used, a cold compress can provide some comfort after treatment. If blistering occurs, aggressive wound treatment should be administered ( i.e. Vigilon, Second Skin, silastic sheeting or other intervention).
5.3. INTERVAL
Recommended time interval between treatments is 2-4 weeks. 4 to 6 treatments maybe necessary.

6. CONCURRENT PROCEDURES
COMBINATIONS –treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (Botox, collagen injection) in conjunction with the PROFILE, it is advisable to perform the PROFILE treatment first. There may be increased sensitivity in the treated areas for an hour or two.

7. CONCLUSIONS
Do not be overly aggressive. Begin conservatively and be patient. Results are determined by the physiology of the patient’s skin. Patients will usually notice a change in their erythema after the second treatment for small matting or vessels. It will take longer for larger telangiectasias to resolve.