Fractional ablative lasers can increase the bioavailability of topically applied agents. Laser-assisted drug delivery (LADD) is an evidence-based modern application in laser medicine, and recent study data provide promising insights.
During the SGML19 Laser & Procedures in Zurich, information was also provided that a physician’s proviso for ablative laser procedures is under consultation with the Federal Office of Public Health [1]. It is planned that this regulation will be approved in the first quarter of 2019, as Dr. Bettina Rümmelein, specialist in dermatology FMH and president SGML, informed at the opening of the congress. Obtaining a specialty credential remains an optional qualification for dermatologists [3]. In Germany, a physician proviso is already enshrined in law.
Future-oriented application areas
Laser-assisted drug delivery (LADD) and photodynamic therapy (PDT) are particularly important among the new areas of application (box), explained Joachim Krischer, MD, specialist in dermatology and venereology FMH, Meyrin, in his presentation. LADD can increase the bioavailability of externally applied agents (e.g., cortisone, anesthetics, antitumor agents, botulinum toxin, antioxidants, etc.) [4]. As topically applied topical preparations are a central element of dermatological therapy, this is an extremely important optimization of dermatological therapy options. LADD allows controlled and standardized overcoming of the epidermal barrier function and has so far proven to be particularly useful in PDT [5].
As an example of a successful application of LADD (CO2 laser or erbium YAG laser), Dr. Krischer cites the treatment of cheilitis in the area of the upper lip with the result of the absence of lesions over several years. Regarding vitiligo, repigmentation was observed after about ten sessions. With regard to the risk of melanoma being induced in the process, there is currently still a need for research, said the speaker.
Combination therapy with vascular laser has been shown to be effective, for example, in the treatment of angiomas that were refractory to vascular laser monotherapy. Traumatic hypertrophic or keloid scars are treated with a combination of fractional laser treatment and cortisone injections (administered beforehand). For scars after basal cell carcinoma, good results are obtained by starting in fractional mode and treating the redness with a vascular laser. Treatment with theCO2 or Erbium YAG laser has also proven effective for cosmetically disturbing skin changes such as xanthelasma or sebaceous gland hyperplasia (benign skin tumors).
Among the classic indications, the following are particularly common in everyday practice, according to the speaker: Warts, small cysts (e.g. in the eye area), wounds (traumatic, surgical), acne scars. In addition, fractional ablative laser continues to be routinely used to treat loss of elasticity, wrinkles, and other signs of photoaged skin) [3].
Fractional lasers: favorable benefit-risk profile
The advent of fractional lasers (on the market since 2004) revolutionized laser medicine [2]. Micro-pulses can be used to specifically destroy defined target structures. Unlike non-fractional lasers, the post-treatment period is less stressful and there are fewer complications (scars, infections, etc.). This has a positive effect on quality of life and patient satisfaction and outweighs the slightly better results of non-fractionated laser treatments. Side effects that may occur in fractional mode (usually within 24h): Wound healing disorders, scarring, and hypo- or hyperpigmentation [6]. To minimize risks and undesirable side effects of ablative laser treatments, the following safety-related factors should be considered (Cave):
- Phototypes: use only for type I-III (light skin types).
- Clinical diagnosis: examine for atypical or tumoral lesions (e.g., melanoma in situ).
- Season: not in summer; autumn/winter is more suitable (UV exposure).
- Sun exposure: several weeks before and min. avoid one month after treatment (risk for hyperpigmentation)
- Herpes risk: history and prophylaxis, if treatment face or genitals.
- Eye protection: use laser goggles (patient and practitioner)
- Informed consent: providing patients with sufficient information
- Laser smoke: shield from exposure (carcinogenic particles)
- Local anesthesia: only if necessary
- Unrealistic expectations: refer patients if necessary.
- Photo documentation: comparison before/after
Source: SGML19 Laser & Procedures, 17 January 2019, Zurich
Literature:
- Federal Office of Public Health: Legislative project on non-ionizing radiation and sound. www.bag.admin.ch/bag/de/home/gesund-leben/umwelt-und-gesundheit/strahlung-radioaktivitaet-schall/nissg.html, last accessed Jan. 23, 2019.
- Manstein D, et al: Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004; 34: 426-438.
- SGML (Swiss Society for Medical Laser Applications), http://new.sgml.ch, last accessed Jan. 20, 2019.
- Wenande E, Erlendsson AM, Haedersdal M: Opportunities for laser-assisted drug delivery in the treatment of cutaneous disorder. Sem Cut Med Surg 2017; 36 (4), 192-201.
- Braun SA, et al: Laser assisted drug delivery: principles and practice. Journal of the German Society of Dermatology 2016; 14(5): 480-489. https://doi.org/10.1111/ddg.12963_g
- Paasch U, Bodendorf M, Grunewald S: Dermatologic laser therapy: fractional lasers. Indications, settings, outcomes. KVM Publishing 2012: 58.
DERMATOLOGIE PRAXIS 2019; 29(1): 32-33
