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APPLICATION IN DERMATOLOGY
PRESENTED BY:
Dr Shaza Mohammed Yousif
MD.Dermatology 1
What is a laser?
Outlines:
•Laser basic
•Applications of lasers dermatology and beauty therapy and
new trends.
•Low level laser therapy
•Laser hazards
Common Components of all Lasers
Active Medium
may be
Solid crystals such as ruby or Nd:YAG,
Liquid dyes,
Gases like CO2 or Helium/Neon
Semiconductors such as GaAs.
Active mediums Contain atoms whose electrons may be excited to a metastable energy
level by an energy source.
5
Excitation Mechanism
Excitation mechanisms pump energy into the active medium by one or
more of three basic methods;
optical
electrical
chemical.
8
Lasing Action Diagram
Excited State
Spontaneous
Energy
Emission
Metastable State
Introduction
Energy
Ground State
Excited State
Spontaneous
Energy
Emission
Metastable State
Introduction
Energy
Stimulated
Emission of
Radiation
Ground State 10
If the energy from this photon is of the precise
A population inversion is achieved when the Lasing action occurs when an electron
wavelength, it will stimulate the production of
majority of atoms have reached this metastable spontaneously returns to its ground state and
another photon of the same wavelength and resulting
state. produces a photon.
in a cascading effect.
Optical pumping
Only those perpendicular to the mirrors will be reflected back to the active
medium, They travel together with incoming photons in the same direction, this is
the directionality of the laser.
Optical pumping
The highly reflective mirror and partially reflective mirror continue the reaction by
directing photons back through the medium along the long axis of the laser.
The partially reflective mirror allows the transmission of a small amount of
coherent radiation that we observe as the “beam”.
Energy
(Joules)
Energy (Watts)
Time
Time
watt (W) - Unit of power or radiant flux (1 watt = 1 joule per second).
Joule (J) - A unit of energy
Energy (Q) The capacity for doing work. Energy content is commonly used to characterize the
output from pulsed lasers and is generally expressed in Joules (J). 13
Irradiance (E) - Power per unit area, expressed in watts per square centimeter.
continuous wave (CW) lasers
versus pulsed lasers
.
Directional, that is, laser light is emitted as a relatively narrow beam in a
specific direction.
Coherent, which means that the wavelengths of the laser light are in phase in
space and time.
15
Laser Tissues Interaction
Mechanisms of laser interaction with human tissues
:
When a laser beam projected to tissue
Five phenomena
Reflection, Transmission,
Scattering, Re-emission,
Absorption.
•
Laser light interacts with tissue and
transfers energy of photons to tissue
Because absorption occurs.
•
What is a coagulation?
A slow heating of muscle and other tissues is like a cooking of meat in
everyday life.
Like egg whites coagulate when cooked, red meat turns gray because coagulation
during cooking.
Destroy tumors
Photo- General
vaporization heating
Moderate (10 –
100)
Photocoag
ulation
Photochemical ablation
laser procedures in darker skinned patients are challenging but can be successfully
achieved if certain treatment guidelines are followed..
Pre- and post laser cooling can be helpful to minimize side effects and improve
patients' comfort. This is especially true with laser hair removal.
Photorejuvenation can be successfully achieved with low risk when appropriate
settings are used. Fractional technology has increased treatment options for rhytides
and atrophic scars.
The 532 nm laser has proved to be risky in skin of color.
On the other hand, the 1064 nm laser may offer greater safety when treating ethnic
skin still risky in type VI skin.
What skin conditions can be treated with lasers?
Vascular lesions
Vascular skin lesions contain oxygenated haemoglobin, which strongly absorbs visible light at
Removal of
Seborrheic keratosis
skin wrinkles psoriasis patches
C02 laser is the treatment of choice for
hypertrophic lesions Of lichen planus treatment of actinic cheilitis.
Facial wrinkles, scars, and sun-damaged skin
Facial laser resurfacing uses high-energy, pulsed and scanned lasers.
Pulsed CO2 and erbium:YAG lasers have been successful in reducing and removing facial
wrinkles, acne scars and sun-damaged skin.
High-energy, pulsed, and scanned CO2 laser is generally considered the gold standard
against which all other facial rejuvenation systems are compared.
Typically a 50% improvement is found in patients receiving CO2 laser treatment.
Side effects of treatment include post-operative tenderness, redness, swelling and scarring. The
redness and tenderness last several weeks, while new skin grows over the area where the damaged
skin has been removed by the laser treatments (ablative laser systems). Secondary skin infection
including reactivation of herpes is also a potential problem until healing occurs. Extreme caution
is needed when treating darker skinned individuals as permanent loss or variable pigmentation
may occur longterm.
Erbium:YAG produces similar results and side effects to CO2. Despite their side effect profile and
long recovery time these ablative laser systems, when used properly, can produce excellent
results.
Laser skin rejuvenation
Recently non-ablative lasers have been used for dermal modeling; 'non-ablative' refers to heating
up the dermal collagen while avoiding damage to the surface skin cells (epidermis) by cooling it.
Multiple treatments are required to smooth the skin.
Irradiation provides long-lasting stimulation of elastin, and thus increase elastin in the dermis,
and achieve skin rejuvenation.
Long-term stimulation of elastin is beneficial for improving dilated pores, skin texture, and
wrinkles.
Keloids and hypertrophic scars
Keloids and hypertrophic scars are difficult to eradicate and traditional
treatments are not always successful.
Vaporising lasers (CO2 and erbium:YAG) have been useful as an alternative to
conventional surgery.
More recently PDL has been used to improve hypertrophic scars and
keloids. This may require multiple treatment sessions or the simultaneous use
of intralesional injections to gain good results. The PDL has been reported to
reduce the redness as well as improving texture and pliability of the scar.
Benign dermal tumors:
Neurofibromas
myxoid cysts
granuloma faciale.
Actinic keratosis
squamous cell carcinoma.
Other uses
The CO2 laser can be used to remove a variety of skin lesions including seborrhoeic keratoses and
skin cancers by vaporization or in cutting mode. However, conventional surgery or electrosurgery
can also be used and is generally less expensive.
Violet-blue metal halide light (407-420 nm) has been used to treat acne, because it has a toxic
effect on the acne bacteria, Proprionibacterium acnes.
The Excimer laser uses noble gas and halogen to produce ultraviolet radiation (308 nm) that will
clear psoriasis plaques. However the small spot size and the tendency to cause blistering makes
treatment time-consuming and difficult to perform.
Warts treatment: of different sizes can be easily and effectively vaporized by
C02 laser. It is recommended to use a magnifying lens during vaporization of
warts. Warts typically bubble on evaporation . Precautions should be taken
during vaporization of warts by using a special laser mask to filter wart
particles during vaporization in order not to inhale the particles, which
may cause infection to the surgeon.
The surface of the wart is better shaved before laser vaporization to remove the
dry hyperkeratotic surface, which requires much high energy because of its
lower water content.
Peri ungual warts can be vaporized and if the lesion is extending beneath and
around the nail , the overlying nail can be evaporated to avoid nail avulsion.
Pigmented lesions and tattoos
Pigmented skin lesions contain melanin, which has a broad range of absorption in
the :
visible
infrared wavebands.
Melanin-specific, high energy, QS laser systems can successfully lighten or
eradicate a variety of pigmented lesions. Pigmented lesions that are treatable
include freckles and birthmarks including some congenital melanocytic naevi,
blue naevi, naevi of Ota/Ito and Becker naevi. The short pulse laser systems
effectively treat the lesions by confining their energy to the melanosomes,
which are the tiny granules containing melanin inside the pigment cells. The
results of laser treatment depend on the depth of the melanin and the colour of
the lesion and is to some degree unpredictable. Superficially located pigment
is best treated with shorter wavelength lasers whilst removal of deeper
pigment requires longer wavelength lasers that penetrate to greater tissue
depths. Caution is needed when treating darker-skinned people as permanent
hypopigmentation and depigmentation may occur. Successfully treated lesions
may recur.
Prior to any laser treatment of pigmented lesions, any lesion with atypical features
should be biopsied to rule out malignancy. The treatment of congenital melanocytic
naevi is a controversial issue. The long-term effect of using lasers on promoting
melanoma is not known but the treatment is thought to be low risk.
The QS laser systems can selectively destroy tattoo pigment without causing much
damage to the surrounding skin. The altered pigment is then removed from the skin
by scavenging white blood cells, tissue macrophages. The choice of laser depends
on the colour, depth and chemical nature of the tattoo ink. Two to ten treatments are
often necessary. Yellow, orange and green colours are the most difficult to remove.
Black: QS ruby, alexandrite or Nd:YAG
Blue and green: QS ruby, alexandrite
Yellow, orange, red: QS Nd:YAG or PDL
As with other laser treatments, pigmentary and textural changes including scars
may occur.
Tattoo can be removed with variety of laser depending on the
presence of inks in the tattoo.
Laser removal of tattoo Other types of lasers such as Q-switched lasers are more
efficient in removing tattoos without skin scarring
Hair removal
Lasers can be used to remove excessive and cosmetically disabling hair due to
hypertrichosis or hirsutism.
Laser treatments remove dark hair quickly and it may take 3 to 6 months before
regrowth is evident.
Several treatment cycles are required with the spacing between treatments
dependent on the body area being treated. Laser treatments are less painful and much
quicker than electrolysis.
Complications are rare but superficial burns, pigmentary changes and even scarring
may occur. Increased growth of fine dark hair in untreated areas close to the treated
ones has been reported. Both increased and reduced localised sweating have been
reported after treatment.
Suitable devices include long-pulsed ruby and alexandrite lasers, diode (810nm),
millisecond Nd:YAG and non-laser intense pulsed light.
Laser hair removal
Laser hair removal
sufficient tissue
is the part of the spectrum that has maximum tissue penetrance in the dermis
nail plate is similar to the epidermis. To date, most laser systems for treating
onychomycosis have
Spot size: This refers to the diameter of the laser beam. For treating
Laser Vagina Tightening
natural aging.
How does It work?
remodeling and the synthesis of new collagen fibers in the vaginal mucosa
vaginal canal.
Clinical results show a tightened vaginal canal, greater sexual satisfaction and
Laser lipolysis is a therapeutic modality that is currently used to treat localized fat
Applying laser directly to adipose tissue causes fat liquefaction, blood vessel
Photochemical Interaction
The laser energy is absorbed by metabolically active pigments of the
mitochondria in various cutaneous and subcutaneous layers:
Here involved are the two enzymes of the oxidation chain, Cytochrome
a/a3 and Flavoprotein with absorption maxims of wavelengths applied.
It is supposed that the changes in the stereochemical conformation induced by
an electro magnetic field leads to an increase in activity and improves the
concentration of ATP by up to 200%.
In addition, an increase in oxygen and glucose metabolism is observed. The
main effect is an optimized function of the Na-K pump at the cell membrane,
an increased protein synthesis (prostaglandin, enzyme) and a significantly
higher rate of mitosis.
Cellular Activities
Increase in b-Endorphins.
Blocked depolarization of C-fiber afferent nerves.
Increased nitric oxide production.
Increased nerve cell action potential.
Axonal sprouting and nerve cell regeneration.
Decreased Bradykinin levels.
Increased release of acetylcholine.
Ion channel normalization.
Reduces healing time by:
96
Types of Laser Hazards
Eye :
Acute exposure of the eye to lasers of certain wavelengths and power can cause
corneal or retinal burns (or both).
Chronic exposure to excessive levels may cause
corneal or lenticular opacities (cataracts) or retinal injury.
Skin :
Acute exposure to
high levels of optical radiation may cause skin burns
carcinogenesis may occur for ultraviolet wavelengths (290-320 nm).
Chemical :
Some lasers require hazardous or toxic substances to operate (i.e., chemical dye, Excimer lasers).
97
Electrical :
Most lasers utilize high voltages that can be lethal.
Fire :
The solvents used in dye lasers are flammable. High voltage pulse or flash lamps
may cause ignition. Flammable materials may be ignited by direct beams or
specular reflections from high power continuous wave (CW) infrared lasers.
Laser hazards and protections
The retina
The directionality of a laser beam
permits the ray to be focused to an
extremely small spot on the retina. A
collimated laser will be concentrated
by a factor of 100,000 when passing
from cornea to retina.
Laser light in the ultraviolet (290 - 400 nm) or far infrared (1400 -
10,600 nm) spectrum can cause damage to the
Cornea and/or to the Lens.
Photoacoustic retinal damage may be associated with an audible "pop" at the
time of exposure.
Visual disorientation due to retinal damage may not be apparent to the
operator until considerable thermal damage has occurred.
101
Laser Class
The following criteria are used to classify lasers:
Wavelength. If the laser is designed to emit multiple wavelengths the classification is based on the
most hazardous wavelength.
For continuous wave (CW) or repetitively pulsed lasers the average power output (Watts) and
limiting exposure time inherent in the design are considered.
For pulsed lasers the total energy per pulse (Joule), pulse duration, pulse repetition frequency
and emergent beam radiant exposure are considered.
102
CONTROL MEASURES
Eye protection
Eyewear (goggles) is the most common laser
Engineering Controls
protective measure, especially for open laser Interlocks
beams. It should be good design with all around
shielding and adequate visible light Enclosed beam
transmission.
Administrative Controls
Identification of the eyewear : Standard Operating Procedures
All laser protective eyewear shall be clearly (SOPs)
labelled with information adequate to ensure
the proper choice of eyewear with particular Training
lasers.
Personnel Protective Equipment (PPE)
Eye protection
103
Common Laser Signs and Labels
104