Laser Therapy: Treatment of Acne

Acne vulgaris treated with Levulan and IPL

Photodynamic therapy

The principal of photodynamic therapy involves smearing a photosensitizing substance on the skin. The substance accumulates in target cells. Light exposure is used to activate the substance. The activated substance destroys the target cells.

Aminolevulinic acid (Levulan) is used and can be activated by several light sources. BLU clearlight, IPL, LED light, and PDL can be used with Levulan for photorejuvenation. It can help clear pigmented and vascular lesions, early skin cancer, fine wrinkles, abnormal pore size, and acne. PDT offers a good alternative to Accutane and its potential for systemic toxicity. With PDT, patients dissatisfied with photorejuvenation can get an enhanced treatment without having to resort to more aggressive ablative therapies like erbium or CO2. It can provide a brighter, clearer complexion, decrease pore size, and give pan facial skin cancer treatment. PDT with Levulan treats acne vulgaris as effectively, with out topical or systemic antibiotics. Levulan targets both the acne bacteria and the sebaceous glands they reside in. When Levulan is applied, the acne bacteria converts it to a photosensitive porphyrin. The sebaceous glands also accumulate the porphyrin. When activated by light, the porphyrin becomes toxic and kills the bacteria and gland cells. For acne, a short term application of 15-60 minutes is effective without causing skin darkening or redness. Effective light sources include BLU-U, PDL, IPL (intense pulsed light), and LED.

To perform PDT, the skin is prepped with an acetone scrub, isopropyl alcohol scrub, glycolic acid pads, or even microdermabrasion. The Levulan comes in a powder and solvent that are separated within a glass stick. When the glass is cracked, the Levulan and solvent are mixed to create the active liquid. This is spread on any lesions and over the entire face. Most patients should leave the solution on for 30-60 minutes to get a good result. In dry climates 15-30 minutes may suffice. The treatments cause redness and peeling. For nonfacial areas, the solution should incubate for 2-3 hours. Patients can at least hide the redness with clothing. Of the light sources, IPL seems to work the best.

After treatments patients should avoid sun light for 24 hours. The skin should be kept moist with Vaseline, Aquaphor, or HC 1% ointment. If uncomfortable, white vinegar soaks can be used. Mix 1 tsp of vinegar with 8 ounces of ice water. Mineral base make up can hide the redness. Sunscreen should be used to protect the new skin.

Exuberant reactions occur in 5-10% of patients with lots of peeling and redness for 1 week. However, no scarring has ever been reported. Some patients get this from sun exposure with in 24 hours of treatment. Therefore, a complete sun block SPF 65 is recommended. PDT may be combined with other acne therapies like doxycycline and retinoids between visits.

PROFILE™ THERMASCANTM 1.319-μM LASER MODULE:
ACNE TREATMENT SAFE START PROTOCOL
Introduction
The proper combination of cooling with laser treatment can create a beneficial rise in
temperature at a desirable point below the skin surface. Cooling the surface of skin will alter its subsurface temperature gradient. The temperature of the PROFILE cooling plate and the fluence delivered from the laser will determine the temperature profile beneath the surface of treated skin. The following guide is a safe starting protocol for the use of the PROFILE ThermaScan Module for the treatment of active acne. The treatment works by heating the sebaceous glands in the dermis of the skin leading to a reduction of oil production. Repeated treatments lead to an observable reduction in active acne in 2 to 4 weeks. Results of acne treatment by sebaceous gland heating have been reported to last up to 6 months.
The PROFILE has a computer guided scanning device that allows the user to provide a very uniform treatment at high speeds. The scanner is a significant advance, providing treatment consistency and reproducibility unachievable by hand placed laser treatments.

Laser Skin Heating
The epidermis is a robust and resilient structure at the surface. It functions as a physical
barrier to protect the deeper dermis, and retain the skin’s hydration. It is less hydrated than the dermis resulting in less absorption of energy at 1319 nm than in the dermis, since energy at a wavelength of 1319 nm is preferentially absorbed in water and collagen. The highest absorption, and thus the highest temperature, will occur below the epidermis in the more hydrated papillary dermis. In addition, a high degree of scattering prevents photons at 1319 nm from penetrating deep into tissue. Instead, they are absorbed before penetrating deeper into the dermis. The result is a peak temperature near the region of the papillary dermis. By clamping the outer skin surface at a fixed temperature with the PROFILE cooling plate, the peak temperature from laser treatment can be biased toward shallower or deeper regions of the skin.

Surface Cooling
The thermal profile in the skin will have a maximum temperature below the epidermis at a depth determined by the surface temperature and the absorption characteristics of the 1319 nm laser energy in tissue. It is thought that brief heating of sebaceous glands heated to above 60°C causes a reduction in the production of oil. Contact surface cooling clamps the skin surface at a predetermined temperature so that treatments will be consistent regardless of the patient’s nominal skin temperature. The thermodynamic properties of skin are very similar for all patients and a reproducible thermal
response will be achieved by setting surface cooling temperature, laser fluence, and laser
pulse width. Adjusting these settings will allow you to adjust the treatment to different skin areas and different patients with reproducible treatment temperatures.

IMPORTANT: Treating with dirty lenses, high fluence or overlapping laser 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. 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.
1.3. HANDPIECE CLEANING
Prior to each treatment, clean the cooling plate with an alcohol swab. Check the
lenses and cooling plate during long procedures and clean as necessary.

1.4. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the laser
treatment room during the treatment.

1.5. TREATING AREAS WHERE SCARS ARE PRESENT:
1.5.1. FIBROTIC SCARS
Dense fibrotic tissue has been seen to blister at a lower temperature than
normal tissue.
1.5.2. ATROPHIC SCARS
Depressions can be treated less aggressively and possibly more frequently.
Using a lower FLUENCE may help avoid injury to the thinner epidermis of
atrophic tissue.
CAUTION: Tattooed areas should not be treated. Tattoo ink may absorb
laser energy resulting in a color change in tattoo ink or a risk of epidermal
damage.

2. SETTING TREATMENT PARAMETERS
2.1. COOLING
2.1.1. COOLING TEMPERATURE
12°C is recommended for maximum patient comfort. Treating with higher
COOLING temperatures will require treating with lower FLUENCE settings.
The cooling temperature is set on the separate chilling device and not on the
laser panel. A coating of colorless gel, KY, surgilube or water may be used in
conjunction with the system for better heat removal, improved optical
coupling, and lubrication for sliding the plate over skin. The gel should be
used as a very thin film on the bottom surface of the cooling plate.

2.2. FLUENCE
The FLUENCE required depends on the starting surface temperature of the area being
treated. Reduce fluence by 20% over bony areas.
Patient response can vary, so fluences should begin low and be increased gradually after
assessing the individual patient response. The desired response is erythema within a few
minutes of laser application.
Excessive fluence or poor contact with skin can lead to dermal injury or blisters.
Caution: In a patient with an infection, overtreatment that results in
devitalized subcutaneous tissue may set up conditions for aneorbic
cellulitis.

2.3. PULSE WIDTH
Set the starting pulse width to 50 milliseconds.
Cooling Temperature Typical Starting Fluence Pulse Width
5-12°C 12 J/cm2 50 - 200 ms
3. TECHNIQUE
3.1. TEST AREA
Treating a test area before a patient’s first treatment can establish their response
threshold and help establish safe starting parameters. For example: Begin by
testing a small area; treatment requires lower fluence when treating over bony
prominences.
Set the scanner to single spot or a small 2 by 2 array. TEST AREA should reach
the desired response of erythema within a few minutes.
A coating of colorless gel, KY, surgilube or water may be used in conjunction with
the system for better heat removal, improved optical coupling, and lubrication for
sliding the plate over skin. The gel should be used as a very thin film on the bottom
surface of the cooling plate. Gel will insure contact in highly areas with highly
irregular surfaces.
Increase fluence in 2 J/cm2 increments until the desired response is achieved.
CAUTION: Use only enough fluence to achieve the desired endpoint of
erythema.
IMPORTANT: Keep fluence below 18 J/cm2 for the first treatment session, and
monitor the patient for any evidence of prolonged erythema, swelling, urticaria or
blistering.

3.2. HANDPIECE POSITION
Position the patient so the HANDPIECE can be held perpendicular to the skin
surface.
3.3. TREATMENT METHOD
Match the “trailing edge” of the next scan to the “leading edge” of the previous
scan. The computer-guided scanner will give a uniform treatment with selected
beam placement within the scan.
Use the offset function for the scanner to place the scan pattern near the edge of
the cooling plate for convenience in treating small areas or near the boundary of
cosmetic regions.
Two passes are recommended. Wait at least five minutes between passes to
observe the immediate response from the first pass.
IMPORTANT: Blistering is an indication of over treatment due to excessive temperatures, which can be caused by improper handpiece placement, overlapping pulses, repeated scans, improper cooling temperatures, or excessive fluence.

4. TREATMENT GOALS
The immediate goal is light, uniform erythema developing a few minutes after
treatment. The longer-term treatment goal, after a series of treatments, is reduction
of active acne for periods of 6 months or more. Patients will typically report feeling
tighter skin in the days following treatment.
More aggressive treatment may lead to slight bumps that may take an hour to a
couple of days to resolve. Often red, raised and palpable, these are not blisters and
usually will resolve spontaneously.

5. POST-TREATMENT CONSIDERATIONS
5.1. OBSERVATIONS
Erythema and a moderate sunburn sensation should be noticed in the treatment area
for up to two hours after treatment. Patients should not feel any significant discomfort
after PROFILE Rejuvenation treatment.
5.2. INTERVENTION
While not often used, 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 treatment interval is 3 to 4 weeks. Results should become noticeable
within 2 or 3 treatments. Dermal changes from fibroblast activity leading to improved
skin texture may also begin to be observed between 3 to 6 months after treatment.
Incremental improvement may progress for six months or longer along with the
reduction in active acne. Tightness of the treated area may be noticed immediately
after treatment.
6. CONCURRENT PROCEDURES
COMBINATIONS – PROFILE Rejuvenation treatments may be given in combination with
other minimally invasive therapies. If a patient is to receive another treatment (light
chemical peel, microdermabrasion, 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. This is not a surgical process; collagen remodeling
takes time. You should help your patient understand that the results are long term.


PROFILE™ THERMASCANTM 1.319-μM LASER MODULE:
SKIN REJUVENATION & ACNE SCAR TREATMENT
SAFE START PROTOCOL
The following protocol is a safe start guide based upon the clinical observations of
experienced physicians.
Introduction
The proper combination of cooling with laser treatment can create a beneficial rise in
temperature at a desirable point below the skin surface. Cooling the surface of skin will alter its subsurface temperature gradient. The temperature of the THERMASCAN cooling plate and the fluence delivered from the laser will determine the temperature profile beneath the surface of treated skin. The following guide is a safe starting protocol for the use of the THERMASCAN Module for the reduction of fine lines and wrinkles, and remodeled collagen. The PROFILE ThermaScan has a computer guided scanning device, the LAPG™-6 Integrated Scanner, that allows the user to provide a very uniform treatment at high speeds. The scanner is a significant advance, providing treatment consistency and reproducibility unachievable by hand placed laser treatments.

Laser Skin Heating
The epidermis is a robust and resilient structure at the surface. It functions as a physical
barrier to protect the deeper dermis, and retain the skin’s hydration. It is less hydrated than the dermis resulting in less absorption of energy at 1319 nm than in the dermis, since energy at a wavelength of 1319 nm is preferentially absorbed in water and collagen. The highest absorption, and thus the highest temperature, will occur just below the epidermis in the more hydrated papillary dermis. In addition, a high degree of scattering prevents photons at 1319 nm from penetrating deep into tissue. Instead, they are absorbed before penetrating deeper into the dermis. The result is a peak temperature near the region of the papillary dermis. By clamping the outer skin surface at a fixed temperature with the PROFILE cooling plate, the peak temperature from laser treatment can be biased toward shallower or deeper regions of the skin.

Surface Cooling
An examination of the dermal anatomy will show that the papillary dermis is in contact and protrudes into the epidermis. It is therefore impossible to cool the epidermis without some cooling of the papillary dermis. Attempts to selectively pre-cool the epidermis by pulsed cooling followed by laser are equivalent to contact surface cooling with simultaneous laser treatment at the depths and times of interest for collagen remodeling.
The thermal profile in the skin will have a maximum temperature just below the epidermis at a depth determined by the surface temperature and the absorption characteristics of the 1319 nm laser energy in tissue. It is thought that fibroblasts are activated in an inflammatory response to a brief temperature rise above 60°C. Ideally, the peak temperature is just above the threshold for initiating collagen remodeling.
Contact surface cooling clamps the skin surface at a predetermined temperature so that
treatments will be consistent regardless of the patient’s nominal skin temperature. The
thermodynamic properties of skin are very similar for all patients and a reproducible thermal response will be achieved by setting surface cooling temperature, laser fluence, and laser pulse width. Adjusting these settings will allow you to adjust the treatment to different skin conditions with reproducible treatment temperatures.

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. 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.
1.3. HANDPIECE CLEANING
Prior to each treatment, clean the cooling plate with an alcohol swab. Check the
lenses and cooling plate during long procedures and clean as necessary.
1.4. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the laser
treatment room during the treatment.
1.5. TREATING AREAS WHERE SCARS ARE PRESENT:
1.5.1. FIBROTIC SCARS
Dense fibrotic tissue has been seen to blister at a lower temperature than
normal tissue.
1.5.2. ATROPHIC SCARS
Depressions can be treated less aggressively and possibly more frequently.
Using a lower FLUENCE may help avoid injury to the thinner epidermis of
atrophic tissue.

2. SETTING TREATMENT PARAMETERS
2.1. COOLING
2.1.1. COOLING TEMPERATURE
12°C is recommended for maximum patient comfort. Treating with higher
COOLING temperatures will require treating with lower FLUENCE settings.
The cooling temperature is set on the separate chilling device and not on the
laser panel. A coating of colorless gel, KY, surgilube or water may be used in
conjunction with the system for better heat removal, improved optical
coupling, and lubrication for sliding the plate over skin. The gel should be
used as a very thin film on the bottom surface of the cooling plate.
2.2. FLUENCE
Use the LAPG-6 Integrated Scanner or the 6-mm single-spot handpiece. The
FLUENCE required depends on the starting surface temperature of the area
being treated. Reduce fluence by 20% over bony areas such as forehead.
NOTE: The 8-mm single-spot handpiece may require lower fluence than the
6-mm handpiece for the same clinical response.
Patient response can vary, so fluences should begin low and be increased
gradually after assessing the individual patient response. The desired
response is erythema within a few minutes of laser application.
CAUTION: Excessive fluence or poor contact with skin can lead to dermal
injury or blisters.
2.3. PULSE WIDTH
Set the starting pulse width to 50 milliseconds.

3. TECHNIQUE
3.1. PATIENT POSITION
It is usually easiest to lay the patient horizontally and stand directly behind the
patient’s head. Elevate the table so the patient’s head is as high as the top of the
laser console.
Position the patient’s head so the treatment area faces upward. Treat the area
completely with one pass. Next, position the opposite side to face upward and
complete one pass. For example: Treat the right temple completely with one pass.
Reposition the patient’s face. Treat the left temple.
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. For example: Begin by
testing the patient’s forehead; then increase the fluence when progressing to the
cheeks. Treatment requires lower fluence when treating over bony prominences.
Set the scanner to single spot or a small 2 by 2 array, or use the single-spot
handpiece. TEST AREA should reach the desired response of erythema within a
few minutes.
A coating of colorless gel, KY, surgilube or water may be used in conjunction with
the system for better heat removal, improved optical coupling, and lubrication for
sliding the plate over skin. The gel should be used as a very thin film on the bottom
surface of the cooling plate. Gel will insure contact in highly areas with highly
irregular surfaces.
Increase fluence in 2 J/cm2 increments until the desired response is achieved.
3.3. HANDPIECE POSITION
Position the patient so the HANDPIECE can be held perpendicular to the skin
surface. Move the patient’s head if necessary so that the treatment area is easy to
reach.
The HANDPIECE must remain in contact with skin long enough (several seconds)
to cool the surface of the skin. It will take several seconds for the deeper heat to
propagate to the surface. A coating of 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. The gel should be used as a very thin film
on the bottom surface of the cooling plate.
3.4. TREATMENT METHOD
Match the “trailing edge” of the next scan to the “leading edge” of the previous
scan. The computer-guided scanner will give a uniform treatment with selected
beam placement within the scan.
Use the offset function for the scanner to place the scan pattern near the edge of
the cooling plate for convenience in treating small areas or near the boundary of
cosmetic regions.
If using the single-spot handpiece than do not overlap treatment spots. Leave a
gap of at least 50% of the beam width between treatment spots.
Make certain to maintain complete skin contact below the treatment area before,
during and after the treatment . Adjust the scan size or shape to fit only the area
where chill plate is in good skin contact. A coating of colorless gel, KY, surgilube or
water may be used in conjunction with the system for better heat removal,
improved optical coupling, and lubrication for sliding the plate over skin. The gel
should be used as a very thin film on the bottom surface of the cooling plate. Gel
will insure contact in areas with highly irregular surfaces.
Use a slower rep rate (1.5 Hz) if a scan pattern is 2x2 or 2x3.
Treating with higher COOLING temperatures will require treating with lower
FLUENCE settings.
CAUTION: Do not stack pulses or overlap consecutive scans. Repeated
pulses in the same location may lead to a build up of subsurface heat and
a subsequent blister or burn.
IMPORTANT: Blistering is an indication of over treatment due to excessive temperatures, which can be caused by improper handpiece placement, overlapping pulses, repeated scans, improper cooling temperatures, or excessive fluence.

4. TREATMENT GOALS
The immediate goal is light, uniform erythema developing a few minutes after
treatment. The longer-term treatment goal, after 3 to 6 months, is collagen
remodeling resulting in subsequent rhytid improvement, followed by continued or
maintained improvement with a maintenance program. Patients will typically report
feeling tighter skin in the days following treatment.
More aggressive treatment may lead to slight bumps that may take an hour to a
couple of days to resolve. Often red, raised and palpable, these are not blisters and
usually will resolve spontaneously.

5. POST-TREATMENT CONSIDERATIONS
5.1. OBSERVATIONS
Erythema and a moderate sunburn sensation should be noticed in the treatment area
for up to two hours after treatment. Patients should not feel any significant discomfort
after PROFILE Rejuvenation treatment.
5.2. INTERVENTION
While not often used, 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 4 - 6 weeks. Dermal changes
from fibroblast activity may begin to be observed between 3 to 6 months after
treatment. Incremental improvement may progress for six months or longer.
Tightness of the treated area may be noticed immediately after treatment.

6. CONCURRENT PROCEDURES
COMBINATIONS – PROFILE Rejuvenation treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (light
chemical peel, microdermabrasion, 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. This is not a surgical process; collagen remodeling
takes time. You should help your patient understand that the results are long term.