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Nordic Course on Laser Dermatology

Programme & Presentations

www.nordicdermatologycourses.org

16 - 17 November 2018Bispebjerg Hospital

Copenhagen, Denmark

Nordic Course on Laser Dermatology is initiated by the Nordic Dermatology Association

Index

Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

General information . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Faculty Information . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79


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Welcome

Dear ParticipantIt is a great pleasure to welcome you to the

1st Nordic Course on Laser Dermatology in Copenhagen.

The 2 day course will offer 12 lectures, given by internationally recognized speakers, hands-on exercises and case-based interaction . You will achieve up-to-date theoreti-cal knowledge on lasers and energy based devices in dermatology and gain clinically relevant skills about practical procedures, tips and tricks .

We look forward to provide you with the theoretical and practical skills, required to practice laser dermatology in your own setting .

A warm welcome to Copenhagen, enjoy the course!

On behalf of the entire faculty,

Merete Haedersdal, MD, Ph .D, DMSc

4

Programme

Friday 16th November

9:00 Registration and coffee

9:50 Welcome and introduction to scientific faculty

Part 1: Basics

10:00 Lecture 1 Devices overview, Laser-tissue interactionsImmediate skin responses, Therapeutic endpoints and warning signs

Albert Wolkerstorfer

11:00 Lecture 2 Laser safety

Merete Haedersdal

11:30 Lecture 3 Side effects – and how to avoid them

Christine Dierickx

12:00 - 12:45 Lunch

Part 2: Clinical Indications I

12:45 Lecture 4 Vascular lesions – How to optimize treatment outcomes

Merete Haedersdal

13:15 Lecture 5 Hair removal – Procedures and different patient groups

Christine Dierickx

13:45 Lecture 6 Surgical procedures with ablative lasers . Fractional and full ablative


14:15 Questions and Catch up

14:30 – 15:00 Coffee break Walk to Derm Department, Laser Unit, Entrance 4, 1st floor

Part 3: Hands on

15:30 – 17:30 Clinical exercises, Laser unit, Derm Department, Bispebjerg Hospital

Katrine Karmisholt

17:30 – 19:00 Welcome reception: Wine and snacks

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Saturday 17th November

Part 4: Clinical indications II

9:00 Lecture 7 Lasers for the treatment of skin (pre)-malignancies

Merete Haedersdal

9:30 Lecture 8 Pigmented lesions and tattoos


10:00 Lecture 9 Treatment of the ageing face and neck

Christine Dierickx

10:30 Coffee break

11:00 Lecture 10 Scar treatment - different approaches to different types of scars

Merete Haedersdal

11:30 Lecture 11 Hyperhidrosis

Christine Dierickx

12:00 Lecture 12 Cutting edge – New treatments in the pipeline

Merete Haedersdal

12:30 - 13:15 Lunch

Part 5: Clinical Cases

13:15 Case-based interaction with participants Albert Wolkerstorfer,

Christine Dierickx,

Katrine Karmisholt,

Merete Haedersdal

15:00 Test, self-assessment Katrine Karmisholt

15:30 Evaluation, thank you and good bye

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General information

Certificates of AttendanceCertificates of attendance will be available for download after the course . A link will be sent to you shortly after the end of the course .

Conference venueBispebjerg HospitalEsther Ammundsens vejUddannelsescenter, building 502400 CopenhagenDenmark

ContactCourse Secretariatc/o CAP Partner Nordre Fasanvej 113, 2nd floor 2000 Frederiksberg C Denmark T: +45 70 20 03 05 info@cap-partner .eu or ks@cap-partner .eu

Language The language of the course is English .

EntitlementsThe registration fee includes:

4 Admission to the full course programme

4 All course materials

4 Lunches and break refreshments

4 Welcome reception on November 16 2018

4 Certificate of attendance

Lost and Found Found items should be returned to the registration desk . If you lose something, please report to this desk for assistance .

Mobile phones All mobile phones must be on silent mode during the sessions .

Wi-FiFree Wi-Fi is provided throughout the venue . Connect to BBH guest net and follow the steps provided .

Social Event

Welcome receptionFriday 16th November Auditorium hallway

Join your colleagues for snacks and wine/soft drinks . Included in the registration fee . Please note that the reception is not a dinner .

8

Faculty Information

Christine C. Dierickx, MD

Christine C. Dierickx finished her dermatology residency in Belgium . Subsequently, she completed a fellowship in phlebology in the Netherlands, a clinical laser fellowship with Dr . R . Fitzpatrick in San Diego, CA and a Mohs fellow-ship with Dr . F . Mohs in Madison, Wi .

During a 2-year laser fellowship with Dr . R . Anderson at Massachusetts General Hospital of Harvard University, she developed research laser expertise in various fields. For her work on the thermal relaxation time of ectatic blood vessels, she received the Best Basic Science Award of the American Society for Laser Medicine and Surgery . Subsequently, she became a full-time staff member of the Wellman Laboratories at Harvard . During this time, she conducted the research projects with long pulsed ruby and diode lasers for hair removal that led to approval for permanent hair reduction .

She returned to Europe in 2000 where she is in private practice in Luxembourg .

In 2006, Dr . Dierickx was vice-president of the “American Society of Laser Medicine and Surgery, Inc” and afterwards a board member of the International Committee . In 2013 she was the recipient of the Vasant Orwal Oration van de British Medical Laser Society . In April 2016, she was granted the Leon Goldman memoriam award . This award recognizes a practicing physician whose career demonstrates excellence in clinical research, patient care, or education, related to medical lasers .

Dr . Dierickx remains actively involved in research on various energy based devices and its applications . She has published and lectured nationally and internationally in the field of la-ser surgery, energy based devices and photodynamic therapy .

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Merete Hædersdal, MD, Ph.D, DMSc

Dr . Merete Haedersdal, MD, PhD, DMSc, is clinical professor of dermatology at University of Copenhagen, senior consult-ant at Dept of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark .

Dr . Haedersdal directs the Laser Dermatology Clinic at Bispebjerg University Hospital, and she is affiliated visiting scientist at Wellman Center for Photomedicine, Massachu-setts General Hospital, Harvard Medical School, pioneering “laser-assisted drug delivery” together with Dr . R . Rox Ander-son and his team .

Professor Haedersdal has published > 150 scientific papers and lectures internationally . Her research team focuses on translational medicine in the field of laser dermatology, frac-tional laser-assisted drug delivery, photodynamic therapy, and treatment of skin cancer with light-based devices .

Katrine Elisabeth Karmisholt, MD, Ph.D

Dr. Karmisholt is a Danish board-certified specialist in dermatology at Bispebjerg Hospital . Since Dr . Karmisholt specialized in dermatology, almost 6 years ago, she has worked with a wide range of laser devices .

On a regular base, Dr . Karmisholt treats vascular lesions, acne scars, burn scars, rhinophyma as well as performs minor surgery with lasers .

Dr . Karmisholt has received expert training with the Miami-based international laser expert in scar treatments Dr . J . Waibel . Furthermore, Dr . Karmisholt’s research com- prises laser treatment of scars with her Ph .D . thesis focusing on laser treatment in early wound healing and the clinical effect on scar formation .

Additionally, Dr . Karmisholt speaks at and attends interna-tional and national laser conferences and laser meetings .

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Faculty Information

Albert Wolkerstorfer, MD, Ph.D

Albert Wolkerstorfer works as dermatologist at the Department of Dermatology/Netherlands Institute for Pigment Disorders, Amsterdam University Medical Centre in the Netherlands .

His academic fields of interest are laser dermatology and pigmented disorders. In both fields, he combines experi- mental and clinical research with clinical activities at the outpatient department .


12

Lecture 1 Devices overview, Laser-tissue interactions Immediate skin responses, Therapeutic endpoints and warning signs


Albert WolkerstorferNetherlands Institute for Pigment Disorders

Dept DermatologyAmsterdam University Medical Centre

Devices - Tissue interaction - Immediate skin responses

Lasers – The Basics1

• Disclosures– Research grant: AvitaMedical

Devices - Tissue interaction - Immediate skin responses2

• Introduction• Devices• Laser – tissue interaction• Immediate skin responses


1960 –First Laser

Laserdermatology - history4

November 1916 ‘A splendid light has fallen on me

about the absorption and emission of radiation’.

L ightA mplification byS timulatedE mission of R adiation

Laser History5




Laser History6

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First laser - 1960“A solution looking for a problem"

Laser History7

• 1961: laser for retinatumor by Charles Campbell• 1961: laser for melanoma by Leon Goldman• 1966: 1e operation without bleeding

• Patent jurisdiction 30 years

Laser History8

Laserdermatology Today

• Innovative• Technical refinements• New devices

9

Laserdermatology Today

But….• Fake news• Glamour & Glitter• Many claims – few proof• Personal experience• Cosmetic• Desinformation

10

Desinformation

Company

Distributor

Expert

Congresses

Practitioner

Approval• FDA approval– Pre Market Approval– 510(k) Pre Market Notification

• ...demonstrate substantialequivalence to a legally marketeddevice.

11

SolidLiquid Gas


Laserdermatology - basics12

14






Laser light is different!

Normal light Laser light

16

•monochromatic

•coherent

•parallel

Laserdermatologie SNIP

Laser light is different!

Laser

17

Electromagnetic Radiation

Ultraviolet

X-Ray

Visible Light Nanometers Invisible Light

AM Radio

Microwave

NdY

AG(1

064n

m)

Alex

andr

iet

lase

r (75

5nm

)

CO

2 la

ser

(106

00nm

)

Vbea

m(5

95)

TV and FM Radio

Cosmic

400 500 600 700 1,000 10,000


18

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Laserdermatology - Future

More wavelengths

19

Laser – Tissue Interaction20

• Absorption• Energy of photons

transfered to tissue

Lasers – tissue interaction21

(A)thermal Processes

>43°C Enzyme induction>60°C Protein denaturation and

coagulation>100°C Dehydration and vacuolization>150°C Carbonization und Pyrolysis>300°C Vaporization, Ablation>1000°C Ionization, Disruption

22

Unselective heating

Thermal damage

23

Selective Photothermolysis

Tattoos

Vascular

Melanin

Hair

Sucutaneous tissue

24

16



Anderson & Parish – 1983

• Different chromophores absorb different wavelengths of light

• Use laser with wavelength of light preferentially absorbed by target

Selective Photothermolysis25

Absorption curve

Absorption of light

Different chromophores absorb different wavelengths

26

514 nmArgon

Absorption of light

Vascular Lasers

532 nmKTP

595 nmPDL

27

1064 nm

Absorption of light

Alexandrite Nd:YagRuby

694 nm

755 nm

28

High water absorption

Absorption of light29

Absorptiespectra

0,00010,0010,010,1

110

1001000

10000100000

1000000

0,1 1 10Golflengte [µm]

Abso

rptie

coëf

ficie

nt [1

/cm

]

bloed met O2

bloed zonder O2

watermelanosoomeiwit

30

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• Selectively heat target• Keep the pulse short – only to heat target


• Pulse duration is critical

Lasers – The Basics

Target Target Target

Pulse duration optimal Pulse duration too long

Short pulse duration

33


Parish & Anderson (1983)

Concept of selective destruction of tissue, sparing surroundingstructures through light with a specific wavelenght.

Pulse duration must match thethermal relaxation time.

34

Pulse duration is critical

Hair removalTRT 100ms

Pigmented lesions TRT 250ns

Alexandriet 755nm 2-40ms 50-100nsNdYAG 1064nm 10-100ms 5-7nsRuby 694nm 1-3ms 25-40ns

35

Pulse duration36

18



Many devices

Tattoos

Vascular

Melanin

Hair

Sucutaneous tissue

• …in order to match• Target absorption• Size of target• Depth of target• Spare the skin surface• Surrounding heat

37

Many devices

Tattoos

Vascular

Melanin

Hair

Sucutaneous tissue

• Vascular lasers• Pigment lasers• Hair reduction lasers• Ablative lasers• Fractional lasers • Lasers for subcutis

38

Absorption curve

Intense Pulsed Light (IPL)39

400 600 800 1000 1200 1400 1600 1800 2000

5

4

3

2

1

0

Dep

th (m

m)

Wavelength (nm)

Penetration of light in skin40

Absorption curve

Absorption of light41

Lasers – The Basics

Farkas et al. Aesthetic Surg J. 2013.

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Laser – Tissue Interaction43

(A)thermal Processes

>43°C Enzyme induction>60°C Protein denaturation and

coagulation>100°C Dehydration and vacuolization>150°C Carbonization und Pyrolysis>300°C Vaporization, Ablation>1000°C Ionization, Disruption

44

• Photobiomodulation• Gen expression

• Photothermal• Light energy transformed to heat

• Photomechanical / Photoacoustic• Light energy creates shockwave

• Photochemical• Light starts chemical reaction (PDT)

• Photoablation• Removal of tissue

Lasers – Tissue Interaction45

1. Light enters skin

2. Absorptie in melanine(koelen met spray)

3. Absorptie in bloed waardoorbloedvaten kapot gaan

Photothermal Interaction46

Completely occluded

Incompletely occluded

Voorbeeld:behandeling van wijnvlekken

Photothermal Interaction47

Photodynamic Therapy (PDT)

Application Occlusion Photo-activativation Selectievedestruction

Photochemical Interaction48

20



Photablative Interaction49

Cataract reoccurrence

Stone pulverization

Tattooremoval

Phototmechanical Interaction50

• Wavelength• Pulse duration• Spotsize• Cooling• Fluence (J/cm2)

Five parameters for optimal results51

Spot size - Penetration52

Cooling Devices

Cryogen

Contact Cooling

Air Cooling

53

Large-diameter vessels Small-diameter vesselsHigher vascular volume Lower vascular volume

Pink or red vessels Purple or blue vesselsSmall-diameter vessels Large-diameter vessels

Deep vessels Superficial vesselsSmall spot sizes Large spot sizes

High-pressure vessels Flaccid vessels

Deep vessels Superficial vesselsLarge-diameter vessels Small-diameter vessels

Pulse Duration

Spot Size

Fluence

Parameters Pulsed Dye Laser


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Laser - complications55

…can help to achieveoptimal outcomes

Immediate Skin Responses56

WHAT ARE IMMEDIATE SKIN RESPONSES

• Tissue responses based on laser-tissue interaction

• Directly after laser• Bio-endpoints, biological endpoints,

immediate skin responses, clinicalendpoints………


WHY SHOULD WE USE THEM• Improve outcomes• Choosing settings is complex


Port Wine Stains59

Settings for telangiectasia

Nymann et al. Britsh J Dermatol 2009

60

22



WHY• Improve outcomes• Choosing settings is complex• Laser manuals + knowledge + algorithms

can not stand alone• Tailor-made settings• Prevent side effects


Subpurpuric PDL - telangiectasia


Temporary darkening

595nm PDL10mm6ms DCD 30-20

7.25J/cm2 sec

4 sec

63

Temporary darkening

595nm PDL10mm6ms DCD 30-20

7.25J/cm2 sec

7.5J/cm2 sec

4 sec

6 sec4 sec

64

Izikson L, Anderson RR. Journal of Cosmetic and Laser Therapy. 2009; 11: 52–55

755 nm alexandrite:

Watchful waiting

Transient grey colorthat evolves intodeep purpura


1064 nm NdYAG - FEEL & SEE & HEAR


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1064 nm Nd:YAG – subtle purpura, no greying


Q-switched 694 nm ruby - lentigo


Q-switched 694 nm ruby - lentigo



Q-switched 694 nm ruby – Hori’s nevus



24



Intense Pulsed Light (IPL)

On-site biological endpoints73




CO2 laser - endpoint77

Erb:YAG laser - endpoint78

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Ablative laser endpoint

Erb:YAG laser CO2 laser

79


Basic knowledge• Knowledge of skin• Knowledge of laser devices• Knowledge of laser – tissue interaction• Laser manuals + laser algorithms

Experience• Tailor-made settings• Prevent side effects

Optimal outcomes81

Epidermis Dermis Total ThicknessChin 149 1375 1524Forehead 202 969 1171Upper lip 156 1061 1217Lower lip 113 973 1068Nasal tip 111 918 1029Neck 115 138 253Cheek 141 909 1050Glabella 144 324 468Eyelids 130 215 351

Facial skin thickness

Freeman SM. Plast Surg Clinics North AM: 425-42; 1996

82

Cosmetic Unit83


26



Albert WolkerstorferNetherlands Institute for Pigment Disorders

Dept DermatologyAmsterdam University Medical Centre

Devices - Tissue interaction - Immediate skin responses


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Lecture 2 Laser Safety

Merete Haedersdal

Laser Safety

NDA Laser Course 2018

Department of Dermatology, Bispebjerg Hospital

Merete HaedersdalProfessor, PhD, DMSc

Bispebjerg HospitalUniversity of Copenhagen Denmark

Wellman Center for PhotomedicineMGH, Harvard Medical SchoolBoston, USA

1

1. Laser Classification

2. Beam hazards - Ocular injuries

- Skin damage

3. Non-beam hazards

4. Practical safety guidelines

Agenda


2

1: Laser Classification

Class 1 laser: Low power

Considered safe

Class 2 laser: Visible and continuous lasers only (<1 mW)

Eye protection afforded by the eye blink response

Class 3 laser: Medium power

3R & 3B Hazard to the eye from direct exposure

3R: 1-5mW

3B: <0.5W

Class 4 laser: High power (>0.5 W)

Hazard to eye and skin from direct and reflected exposure

Fire hazard

3


Wavelength

Absorption

Penetration

4


Skin Cornea Lens Retina<300 nm yes yes no no

300-400 yes yes yes no

400-600 yes no no yes

600-1400 yes no no yes

1400-10600 yes yes no no

All devicesUV

CO2 laser UV

IPL systems

IPL systems

Pulsed dye laser

Near IR: Alex, Nd:YAG

5

Ocular injuries

2: Beam Hazards

Direct and reflected light

Inappropriate use of glasses and goggles

- Wavelength dependent

- Removal of glasses, blinking

Never treat within orbital rim with Near IR wavelengths, incl. IPLs

- Retinal injury

- Iris defect, coloboma,

Use shields inside orbital rim: PDL, CO2, YAG lasers

6

28

Protective Eyewear

Alexandrite

CO2 Er:YAG

CO2 Er:Glass Q-switched

Ruby Nd:YAG

Dye laser

Wear appropriate

protective eye wear!

7

Glasses, glasses, and glasses……

Wavelength-specific eyewear

Wavelength(s) & optical density (OD) should be clearly written

OD > 4-6

Check OD yourself !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Attenuation is given in Optical Density “OD” An OD of 4 means that the irradiance of the beam passing through

the eyewear is attenuated by 104 = 10,000 times

8

Risk of Ocular Hazards – Professional devices

9

Eye Injury

Nd:YAG (1064 nm) - Permanent damage

Individual saw a white flash, heard a click, then immediately a dark spot

in visual field

(www.ucl.ac.uk/uro-neph/ppt/lm221102.ppt)

10

11 12


Merete Haedersdal

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13

Skin injuries

2: Beam Hazards

Visible and IR lasers can cause mild to severe erythema,

blisters and scarring.

Depigmentation, ulceration and scarring may be permanent

Usually caused by high powered lasers

14

Do Your Homework….

JAAD, 2016

CME papers

15

Standard Settings, but….

do better than cook-book approach

16

Biological End-Point = Immediate Skin Reaction

17

Cooling

2: Beam Hazards

Air cooling

Contact cooling

Cryo spurt

18


Merete Haedersdal

30

3: Non-Beam Hazards

Electrical hazards

High voltage.

Laser capacitors can retain high energy charges even when the power is off

Know where the kill switch is!!!!

Know Your Kill switch

3: Non-Beam Hazards

Fire

Ignition of materials can occur from direct,intense reflected or scattered beams- Hair, paper, textiles- Make sure hitting right foot pedal

- Always go to standby when not using laser

Protect flammable areas with wet drapes- Endotracheal tube- Perianal region / methane

Electrical equipment fire extinguisher should be conveniently located in case of fire

3: Non-Beam Hazards

Plume - contaminants

Bacterial sporesBacterial spores survive low CO2 irradiances

Papilloma VirusHPV cultured from plume after CO2 tx of warts

HIVHIV not cultured

3: Non-Beam Hazards

Plume - avoidance

Special laser mask

Filter to 0.3 – 0.1 microns

Smoke evacuator

Held close to surgical field

Flow rate

Best if filters out particles > 0.1 microns

(HIV 0.18 microns)

4: Practical Guidelines for Daily Use

Room - Warning sign

- Smoke evacuator

Staff - Protective eyewear

- Masks

- Education

Patients - Information

- Cooling

- Protective eyewear

Device - Check device before starting out

- Off patient test – optical alignment


Merete Haedersdal

19 20

21 22

23 24

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4: Trouble shooting

Log books

Nurse

Medicotech ingeneer

Support service

We’re Prepared – Ready to Shoot…..

Thank youfor listening & wearing glasses.

25 26

27

32

Lecture 3 Side effects and how to avoid them

Christine Dierickx

Side effects and how to avoid them

Dr. Christine Dierickx | 2018 Nordic laser course, Copenhagen

1

Side effects

1. Expected side effects: based on proper TX parameters

2. Complications that occur : based on inappropriate TX parametersbut can be avoided based on inproper pre & post-TX measurements

based on device failurebased on inproper medical history

3. Complications that occur: despite proper TX parameters

can not be avoided

4. Side effects specific for laser procedure

2

1. Expected Side Effects

- Based on mechanism of action the following adverse events may be expected after :

EBD Hair removal:- Vaporization of hair shaft

- Perifollicular Erythema- Perifollicular Edema

- Sunburn feeling

Pigment/ tattoo removal:

- Whitening- Wheal and flare

- Pinpoint bleeding- Sunburn feeling

3

2. Side effects that can be avoided

• Based on inappropriate Tx parameters for patient’s skin color– Epidermal damage (erosions/ crusting)

– Pigment changes (hypo/hyperpigmentation)– Scarring

• Based on device failure:– Failure of cooling modality– Accumulated debris on contact tip– Non uniform spatial beam profile

• Based on lack of taking a proper history, proper aftercare, proper clinical examination:– Infections: herpes flare up– Koebner: vitiligo, psoriasis, perforating collagenosis– Presence of a tattoo in tx area: scarring

4

3. Complications that occur despite appropriate TX parameters

1. Paradoxical hair growth2. Livedo reticularis3. Urticaria4. Darkening of pigment5. Paradoxical hyperplasia

Induced by laser procedure itself

5

Pearls

1. 1064 nm Nd-YAG laser2. Eye Protection3. Local anesthesia

Things to know when you start using EBD

6

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Importance of good eye protection

1. Wrong gogglesPlastic internal eyeshields

1. Wrong indication2. Patient related eye disease

Even with eye protection

Eye injury can occur

Take care of good eye protection!for the patient and for yourself

7

No plastic intra-ocular

Eyeprotection

8

“Nothing worthwhile is ever without complications.”

Nora Roberts

9 10

34

Lecture 4 Vascular lesions – How to optimize treatment outcomes

Merete Haedersdal

Vascular Lesions

How to Optimize Treatment Outcomes


Dr. Merete HaedersdalProfessor, PhD, DMSc

University of Copenhagen, Bispebjerg Hospital, Denmark

Wellman Center for Photomedicine,MGH, Harvard Medical School, Boston, USA


1

Classification of Vascular Anomalies

The International Society for the Study of Vascular Anomalies (ISSVA)

Diagosis is

important

Lasers and energy-

based devices are

not the only options

2

Common Vascular Lesions, referred to Tx with Laser

Telangiectatic lesions

Venous malformations / Venous lake

Capillary malformations / Port-wine stains

Angiomas / angiokeratomas

Hemangiomas

Erythematous scars

3


1. Wavelength

• Strong absorption by blood and good

penetration

2. Pulse duration

• Confines thermal damage to vessels

3. Energy

• Sufficient energy for irreversible

damage

Ref: Anderson, Parish, Science 1983

4

1. Wavelength

2. Pulse duration

3. Spot size

4. Pulse energy

5. Skin coolingVascular network: Bolognia Dermatology:

Ex literature reviews:

Valdebran M, Martin B, Kelly KM. State-of-the-art-lasers and light treatments for vascular

lesions: From red faces to vascular malformations. Semin Cutan Med Surg 2017; 36 (4):

207-12.

Garden BC, Garden JM, Goldberg DJ. Light-based devices in the treatment of cutaneous

vascular lesions: An updated review. J Cosmet Dermatol 2017; 16 (3): 296-302.

Parameters to consider

5

Wavelength

KTP: 532 nm

Pulsed dye: 595 nm

IPL: ~500-1200 nm

Alexandrite: 755 nm

Nd:YAG: 1064 nmIPL

Absorption Spectra for Skin Chromophores

6

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Wavelength Depth of Penetration

FH Sakamoto, Wellman Center MGH, Boston

Uwe Paasch, Leipzig

7

Pulse duration

Confine thermal damage to vessels

Tr = d2/16k d=diameter, K=thermal diffusivity

Tr is the time it takes a laser-heated object to cool by half its value

Pulse duration must be shorter than Tr

Vessel diameter (µm)

Thermal relaxation time (msec)

30 0.86

50 2.40

150 21.6

300 86.2

Ref: Dierickx C, J Invest Dermatol 1995

8

Spot size

Advantages of larger spot size

Increase depth of photon penetration

Increase effective fluence

Avoids reticulation

Ref: Dierickx C, J Invest Dermatol 1995

9

Fluence and Cooling

Fluence must be high enough to cause irreversible vessel damage

Cooling helps avoid melanin-related epidermal injury

Contact cooling Cryogen Air cooling

10

Telangiectasia

Pulsed dye (585/595 nm)

KTP (532 nm)

IPL (filtered)

Alexandrite (755 nm)

Nd:YAG (1064 nm)

Penetration to 2.0 mm

Pulse durations 6 – 20 ms

Trace linear or arborizing vessels with

small spot

Cover entire area with large spot

IPLs have large foot prints

Deeper penetration

Weaker absorption

Best for large purple vessels (nose)

11

Biological end point:

Immediate vessel clearance

Transient purpura

Ellipse IPL: PR applicator 14 ms, 12 J/cm2

Telangiectasia - Rosacea

12

36

Phlebectasia

Pulsed dye laser, 595 nm: 3x10 mm elliptical spot, 40 ms, 16 J/cm2

13

Nyman et al.

British J Dermatol 2009; 160: 1237-41.

Telangiectasia – Individualised Tx settings

3 IPL Txs vs 3 PDL Txs

14

Alexandrite

755 nm

8 mm spot, 3 ms, 45 J/cm2

DCD 60/40

Nd:YAG laser

1064 nm

5 mm spot, 55 ms, 140 J/cm2

Continuous steam of air cooling

Venous malformations – Venous lake

15

Venous malformations – Venous lake

Mucosa

responds very

well

Don’t do

gingiva!

16

Port Wine Stains

1st choice Tx = Pulsed Dye Laser

Post-capillary venular malformation

Faurschou A, Olesen AB, Leonardi-Bee J, Haedersdal M. Lasers or light sources for port wine staind.

Cochrane Database Syst Rev 2011; 11: CD007152

Ortiz AE, Nelson JS. PWS laser treatments and novel approaches. Facial Plast Surg 2012; 28 (6): 611-20

Brightman LA, Geronemus RG et al. Laser treatment of PWS. Clin Cosmet Investig Dermatol 2015; 8: 27-33

17

PDL J/cm2Pulse Cooling EndpointPasses

18


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Bulk heating – watch out!

Near IR lasers

• Avoiding going over the same area twice.

• Give the skin time to cool down.

• Respect timing between shots.

Use cautiously !

Settings: 8 mm, 3 ms, 30-40 J/cm2,

no overlap

Cooling important (60-40 ms with cryo spray)

19

Before After 2 Tx

Alexandrite, 755 nm, GentleLase

8 mm, 50 J/cm2, DCD 30ms-20ms

Venous malformation

Christine Dierickx, MD

20

PDL 595 nm

5 & 7mm spot; 1.5ms; 14J/cm, DCD 30/20

Angiokeratoma of Fordyce

21

Haemangiomas

Vascular lasers / devices

Residual telangiectatic component Propanolol

Systemic treatment

Treatment of choice

hemangiomas in proliferative phase

22

Erythematous Scars

Vascular lasers standard treatment to relieve erythematous component

23

Tips and Tricks

Increase amount of chromophore

- Heat blankets

- Briskly pat the skin before treatment

- Posture – take advantage of gravity

Reduce postop erythema and swelling

- Air cooling

- Cold packets

- Consider topical Brimonidine

24

38

Facial teleangiectasias

Spider angiomas

Cherry angiomas

Venous lakes

Pyogenic granulomas

Angiokeratomas

Rosacea

Poikiloderma of Civatte

Radiation induced telangiectasia

CREST syndroma

Adenoma sebaceum

Hemangiomas

Port Wine Stains

Lasers and IPL devices are the Tx of choice

for a large number of vascular lesions

Thank You!

25


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Lecture 5 Hair removal – Procedures and different patient groups

Christine Dierickx

HAIR REMOVAL BY LIGHT

Christine C. DierickxNordic Laser course 2018

Copenhagen

1

Different Techniques

• Photomechanical

� Photochemical

� Photothermal

2

Q‐switched pigment lasers produce

short, very high energy laser pulses causing

photoacustic disruption of hair follicle

1. Photomechanical

3

pre post

photoacustic disruption of hair follicle

1. Photomechanical

4

Q‐switched 1064nm Nd‐YAG Lasers

� Advantage: All Skin types

� Disadvantage: No long term hair lossOnly temporary hair removal

5


• Photomechanical

� Photochemical

� Photothermal

6

40

2. Photochemical

Photochemical destruction of hair follicle

630 nm

Photosensitizer and Light

Excited oxygen species

ALA PPIX

7

ADVANTAGE

� All skin colors� All hair colors

PHOTODYNAMIC THERAPY

DISADVANTAGE

� Side effects�Mild to moderate pain�Transient hyperpigmentation

�Time consuming procedure�Limiting factor: conversion ALA to PPIX �High Dose required: long exposure time

8


• Photomechanical

� Photochemical

� Photothermal

9

3. Photothermal

chromophore

2. Diffusion of heat1. Absorption by chromophore

Photons

3. Destruction of stemcells in bulge/bulb

stem cells

target

Melanin in Hair shaft

10

•Wavelength

• Spotsize

• Pulse Duration

•Cooling method

LASER HAIR REMOVAL

11

Hair RemovalDevices

• 694 nm Ruby Lasers

• 755 nm Alexandrite Lasers

• 800 nm Diode Lasers

• 1064 nm Nd‐YAG Lasers

• Pulsed, Non‐Coherent Flashlamps

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Wavelength (nm)

103

102

101

100

10‐1

10‐2200 300 500 1000700

Abso

rption Coefficient

Laser Wavelength

600 1100

rubyalexandrite

diode

Nd‐YAG

flashlamp

13

•Wavelength

• Spotsize

• Pulse Duration

•Cooling method

LASER HAIR REMOVAL

14

Size of Spotsize

For dermal targets, larger spots are better

improved radiation distribution

deeper depth of penetration

15 16

•Wavelength

• Spotsize

• Pulse Duration

•Cooling method

LASER HAIR REMOVAL

17

Evolution of Pulse Duration

L A S E R P U L S E

D U R A T I O N

( M S E C )

Q S - N d : Y A G

T h e r m o l a s e1 0 - 5

R u b y

P a l o m a r. 3

L P - R u b y

P a l o m a r3

L P - A l e x a n d r i t e

C y n o s u r e2 0

L i g h t S h e e r

P a l o m a r / S t a r / C o h e r e n t3 0

L P - N d : Y A G

L a s e r S c o p e / A l t u s5 0 / 1 0 0

L i g h t S h e e r X C

C o h e r e n t1 0 0

S L P 1 0 0 0 1 0 0 0

18

42

Shaft

Stem Cells

Motivation for Long PulseChromophore and target are separated

Heat needs to diffuse from chromophore to target

Long PulseHeat

Diffusion

19

� 10 ‐ 100 ms

� based on TRT of hair follicle

� 100 ‐ 500 ms

� based on TDT of hair follicle

Modified Selective Photothermolysis

“Thermal Damage Time”

Pulse Duration > Thermal Relaxation Time

20

•Wavelength

• Spotsize

• Pulse Duration

• Cooling method

LASER HAIR REMOVAL

21

Laser Hair Removal

� Chromophore:

melanin in hair shaft and/or follicle� Epidermis:

contains the same pigment as hair

need for protecting epidermis

HOW?

22

Skin CoolingMethod: ice

gel

cold liquid (cryogen)

cold air flow

glass chamber

sapphire window

23

Patient Assessment

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History

• Endocrine historyHormonal check‐up

•History of herpes simplex

Antiviral medication day before Tx

•History of recent UV exposure

DELAY TREATMENT

•History of hair removal methods

Shave or chemical depilatory

Don’t bleach, pluck or wax

25

Physical Examination•Hair:

Hair ColorHair TypeHair Density

� Skin:

Skin TypeSkin Color

26

Procedure

27

Pre‐Operative

•Anesthesia (optional)Emla creamLidocaine injection

� Shave

�Optional: gel , oil

28

How do I set the

treatment fluence ?

29

Test Sites• Single pulses

•Within or near treatment area

• In small J/cm2 increments

• Signs of epidermal damage

30

44

• Ablation

• Blistering

• Immediate whitening

• Positive Nikolsky sign

Signs of epidermal damage

31

Treatment Fluence• Epidermal injury

5 J/cm2 less than threshold

fluence for epidermal damage

•No epidermal injuryhighest fluence

32

• Sliding Technique

• Firm Pressure

•Adjacent pulses

• Look for responses

Treatment Techniques

33

Immediate Skin Response

• Expectedvaporization of hair shaftserythema

perifollicular edema

34

• Sunburn Feeling: 1‐2 hours

• Swelling & erythema: few hours

Cold compresses/steroid crème

• “Shedding” of hair casts

Follow ‐Up

35

•Antiseptic Ointment

•Make‐up is ok

•Avoid sun exposure

•Call if problems

Post ‐Treatment Care

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Side Effects

� Desired side effect:Erythema, edema = 100%

� Inappropriate pulse duration and fluence for patient’s skin color:

Epidermal damage

Transient pigment changeScarring

37

Safety Considerations•High Risk for Eye hazard:

Wear goggles Don’t treat in bony orbit

• Plume: irritatingWear mask

Smoke evacuator system• Infectious risk:

Clean handpiece

38

• Return for treatment:

when hairs start to grow back

• If treating sooner:

no additional benefit

Re ‐Treatment

39

Suggested Tx intervalsArea

� Face

� Axilla

� Inguinal

� Back

� Legs

Tx Interval

� 4‐6 wks

� 4‐8 wks

� 4‐8 wks

� 8‐12 wks

� 8‐12 wks

40

Summary of Clinical Results•Temporary hair loss:

100% and lasts for 1 ‐ 3 months

• Significant Permanent hair loss with 1 Tx:20 ‐ 40 %

•Additional hair loss with each treatment:20 ‐ 40 %

� Regrowing hairs:thinner and lighter

• # Tx for complete, permanent hair loss:usually 52 ‐ 7 or more

41

Ideal Hair Removal Laser ?

� Safe on Dark Skin

� Effective on Light Hair

� Effective on Thin Hair

� Effective on Coarse Hair

� Safe on Tanned Skin

Ruby Alexandrite SP‐Diode LP‐Diode SLP‐Diode Nd:YAG

42

46

Laser Hair Removal

Good alternative for hair removal:

•Minimally invasive

• Shorter treatment time

•Proven efficacy and safety

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Lecture 6 Surgical procedures with ablative lasers. Fractional and full ablative


Albert WolkerstorferDept. of Dermatology

Academic Medical Center, Amsterdam

Surgical Procedures with AblativeLasersFractional and Full Ablative

1

• Conflict of interest:

Research grant AvitaMedical

Ablative lasers

2

Ablation ‐ Ablatio• Ablatio (lat): To remove

• Ablative lasers

• Surgical lasers

• Vaporizing lasers

3

• Two ablative lasers in dermatology

• CO2 laser (10600 nm)

• Erbium:YAG laser (2940 nm)

Surgical procedures with ablative lasers

4

Surgical procedures ‐ ablative lasersKey points

• Two ablative lasers in dermatology


• Erbium:YAG laser (2940 nm)

5

Surgical procedures ‐ ablative lasers

Key points

• Ablative lasers cause:

• Ablation

• Necrosis

• Surrounding thermal damage

• Risk of scarring depends on:

• Mainly the depth of ablation/necrosis & location

• Many other risk factors: skin type, medication, wound care, age, medical history, constitutional…

6

48

Surgical lasers ‐ absorption

0,0001

0,001

0,01

0,1

1

10

100

1000

10000

100000

1000000

0,1 1 10Golflengte [m]

Absorp

tion c

oëffic

ient[1

/cm

]

blood + O2

blood - O2

water

melanin

proteins

2940 nm

Erb:YAG laser

10600 nm

CO2 laser

7

Necrosis in different surgical procedures

• Standard electrocautery: 270 m

• Microneedle electrocautery: 180 m

• CO2 laser: 150 m

• ErbYAG laser: 15 m

8

CO2 vs Erb:YAG ‐ Neocollagenesis

Baseline CO2 laser ErbYAG laser

9

Techniques with ablative lasers

• Superficial ablation

• Deep ablation

• Drilling ablation

• Fractional ablation

• Laser excision

10

Fractional laser

Fractional Photothermolysis

A New Concept for Cutaneous

Remodeling Using Microscopic Patterns of

Thermal InjuryDieter Manstein, Scott Herron, R. Kehl Sink, Heather

Tanner and R. Rox Anderson.

Lasers Surg Med. 2004;34(5):426-38.

11

Fractional laser


A New Concept for Cutaneous

Remodeling Using Microscopic Patterns of

Thermal InjuryDieter Manstein, Scott Herron, R. Kehl Sink, Heather

Tanner and R. Rox Anderson.

Lasers Surg Med. 2004;34(5):426-38.

12



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Fractional lasers – wavelength (nm)

915

294010600

2790

15501064

1440

1410

1064

13

Nonablative Fractional laser

14

30W CO2 laser

10600nm

A. 9.2mJB. 13.8mJ

C. 18mJ

D. 23.3mJ

Hantash et al.LSM 2007

Ablative Fractional laser

15

40m 400 m

CO2 laser

10600nm 18J

Ablative Fractional Laser

Ex Vivo Histological Characterization of a

Novel Ablative Fractional Resurfacing Device

Hantash et al.Lasers in Surgery and Medicine 39:87–95 (2007)

16

17

2 days 1 month 3 month

Ablative Fractional Laser – Healing response

18

50

Fractional laser ‐ settings• Type ablative laser• Density Channels

• Depth channels

19

Fractional laser ‐ settings• Type ablative laser

• Density Channels• Depth channels

20

Fractional laser ‐ settings• Type ablative laser

• Density Channels

• Depth channels

21

Avram MM et al. (2009)

Hypertrophic scarring of the neck following

ablative fractional carbon dioxide laser

resurfacing.

Lasers in Surgery and Medicine. 2009;

41: 185–188.

Fife DJ et al. (2009)

Complications of fractional

CO2 laser resurfacing: Four

cases.

Lasers in Surgery and

Medicine. 2009; 41: 179–184.

Complications

Cave:

• ↑energy & ↑density

• Off the face

22

• Remove

• Regenerate

• Deliver

Ablative Fractional Laser - mechanisms

23

Fractional Lasers for scars24



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Take Home Message

• Ablative lasers: ablative + thermal damage

• Two types:


• Erb:YAG laser (2940 nm)

• Indication for various skin disorders

• Fractional ablative lasers

• ↑ safety, ↓ down�me

• Rejuvenation, scars

25

Albert WolkerstorferDept. of Dermatology

Academic Medical Center, Amsterdam

Surgical Procedures with AblativeLasersFractional and Full Ablative

26

52

Lecture 7 Lasers for the treatment of skin (pre)-malignancies

Merete Haedersdal

Lasers for the Treatment of Skin (Pre)-Malignancies






1

Disclosures

Cynosure-Hologic Loan of equipment

Galderma Research grant

Leo Pharma Research grant

Lutronic Research grant, Loan of equipment

Novoxel Research grant, Loan of equipment

PerfAction technologies Research grant, Loan of equipment

Procter & Gamble Research grant

Sebacia Research grant

2

3 4

LADD – Potentials for Dermatology

Bridging medicine with technology

o Str. Corneum major barrier

o Low cutaneous bioavailability

~ 1-5% of applied drug

o Large, hydrophilic drugs

not suited for topical delivery

o Enhanced drug penetration

o Enhanced bioavailability

o Empower topical Tx regimens

o New available drugs

5 6

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Actinic keratoses

CIS

Basal cell carcinoma

Photodynamic therapy

5-FU

Ingenol mebutate

Combination chemotherapy



7

ACKNOWLEDGEMENTS

Bispebjerg Hospital

Derm. Research Unit

Copenhagen University

Wellman Center of Photomedicine,

Massachusetts general Hospital,

Harvard Medical School

8

54

Lecture 8 Pigmented lesions and tattoos


Pigmented Lesions and Tattoos


Netherlands Institute for Pigment Disorders

Dept Dermatology

Amsterdam University Medical Centre

1

• Conflict of interest:

No potential conflict of interest

Pigment lasers2

Lasers & Pigment

Q switched lasers

• 694 nm Robijn laser

• 755 nm Alexandriet laser

• 1064 nm Nd:YAG laser

• 532 nm Nd:YAG laser

Melanin – a broad absorption spectrum

3

• Q-switched lasers result in

fragmentation of pigment granules

• Subsequent elimination via

– Vascular system

– Lymphatic system

– Rephagocytosis

Q-switched lasers4

Lasers & Pigment

Q-switched lasers - short pulse duration

Photoacoustic effect

Steam formation (whitening)

Banging sound

Pinpoint bleeding

Erosions

5

Epidermal- Melasma

+ Lentigo

+ Dermatosis pap. nigra

± Cafe au lait macula

± Nevus spilus

- Becker nevus

Mixed- Melasma

± Nevus

± Postinflamm. hyperpigment

- Congenital

nevus

Dermal+ Hori nevus

+ Ota nevus

± Blue nevus

- Postinflamm.

hyperpigment.

+ Tattoo

+ Good result± Variable result- Poor result

Indications Lasers & Pigment

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Melasma - Consensusus

• 1st choice: topical– triple therapy

– Hydroquinon, tretinoin, azelaic acid

• 2nd choice: peelings (glycol)– Eventually combination topicals

• 3rd choice : lasers, IPL

Exacerbation!

Pigmentary Disorders Academy

Rendon et al. J Am Acad Dermatol. 2006; 54: S272-81.

7

Laser & Bleaching regimens

Momosawa et al. in Asians.Plast Reconstr Surg. 2008 Jan;121(1):282-8.

Yoshimura et al.

Dermatol Surgery. 2006 Mar;32(3):365-71

Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for dermal hyperpigmentation

Repeated treatment protocols for melasma and acquired dermal melanocytosis

8

Tattoos• Types: cosmetic, traumatic, iatrogenic,

decorative– Professional versus amateur tattoos

• Depth, density, composition

• Cave compounds: ferric oxide, titanium dioxide

• Color– Green, blue, black: 694 nm, 755nm, 1064 nm

– Red: 532 nm

– Yellow, orange: pico lasers

9

Lasers & Pigment

Indications

• Lentigines always improve

• Melasma can improve, however temporary

• Lasers in congenital nevi are controversial

• Becker nevus does not improve

• Cafe au lait macules: effect highly variable

• Tattoos: effect depends on many variables

10

Recent trends

• Picosecond and femtosecond lasers

• Low fluence Q-switched laser

• Optical clearing agents

• Repeated exposures at single session

• Fractional mode

• Combination with fractional lasers

11

Pigmented lesions and tattoos

Key points

• Not all brown patches (hyperpigmentations) improve by

lasertherapy

• Epidermal pigmented lesions can be treated with lasers and

Intense Pulsed Light

• Dermal pigmented lesions & tattoos can only be treated with Q-

switched lasers

• Laser induced whitening is an important biological endpoint for Q-

switched lasers

12

56

Lecture 9 Treatment of the ageing face and neck

Christine Dierickx

TREATMENT OF AGING FACE AND NECK

WITH ENERGY BASED DEVICES

Dr. Christine Dierickx | 2018 Nordic laser course, Copenhagen

1

Treatment of Skin Aging

Many different aspects to consider

Each aspect has its specific treatment modality

2

Fillers

Toxins

Plastic Surgery

Treatment of Skin Aging

Cosmeceuticals

Peelings

Energy Based Devices

3

Energy Based Rejuvenation

Highly selective treatment modalitySpecific energy – based devices to treat:

• Solar lentigines & telangiectasia:pigment & vascular lasers / IPL

4

IPL

TELANGIECTASIA

Rosacea

Broken vesselsBerloque dermatitis

The redIRREGULAR PIGMENTATION

Lentigines

Freckles

Melasma

Berloque dermatitis

The brown

Treatment of uneven skin tone

Pigment lasers

694 nm755 nm1064 nm

Vascular lasers

532 nm585 nm1064 nm

5

Specific energy – based devices to treat:


• Epidermal and Dermal rejuvenation: non‐ablative fractional lasers

Highly selective treatment modality


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• New concept for cutaneous remodeling:

Fractionated laser beam creates thousandsof microscopic wounds surrounded by viable

tissue for rapid healing

• Non‐ablative Tissue is coagulated, not vaporized

• Induces a unique biological wound healing response

Manstein DD, Anderson RRLasers Surg Med 2004; 34:426‐438


7

Results:

• MicroThermal Zone(MTZ) formation

• Clear collagen denaturation from papillary dermis into mid reticular dermis Controlled Zones of

Denatured Collagen in the Dermis

Photo Courtesy of D. Manstein, MD


8

Dermal collagen remodeling & neovascularisation

Strong staining with procollagen III around the MTZ.

9

Laser Wavelength (nm)

Non‐ablative


(NAFX)

Thulium

Erbium doped fiber

Nd:YAG

Er:glass rod

Er:glass fiber

1927

1410

1440

1540

1550

Non‐ablative Fractional Technologies

10

• No severe side effects

• Rapid healing

• No long lasting down time

Unique aspects of treatment

11

1. Epidermal and dermal rejuvenation

2. All anatomical areas can be treated

Indications

12

58


• 30‐40 year old patientPhotodamage

Fine wrinkles

• 3‐5 Tx are requiredWith minimal side effectsWith little downtime

13


2. All anatomical areas can be treated

Indications

14

Advances in non‐ablative fractional

Fractionated picosecond lasers

15

Fractionated Picosecond Lasers

� ‐Tattoo removal� Nanosecond v. Picosecond� Photoacustic rupture� Faster clearance

‐ Skin remodeling � Focus optic

10‐9 sec = nanosec= one billionth of a second10‐12 sec = picosec= one trillionth of a second

Advances in non‐ablative fractional

16

Fractionated Pico second

Focus Lens Array

Fluence distribution created on the skin surface

Holographic Fractional Technology

Uniform Top Hat ProfileAll peaks have the same energy.

No energy is lost as background energy.

Focus lens Array

Comprised of hundreds of microlenses per cm2

that redistribute the Picosecond pulse : highly concentrated beams & lower fluence background

17

Fractionated Picosecond pulses

LIOB

Controlled high intensity injuries limited to the epidermis cause a LASER INDUCED OPTICAL BREAKDOWN (LIOB) generating

significant pressure waves which propagates through the tissueand induces optimal cell signaling

18


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FOCUS Lens Array

H&E 100X H & E 400X

• Pockets of intra‐epidermal necrosis with prominent pigment

• Junctional melanocytes are undamaged

• Resolves in normal epidermal turn over cycle• Contributes to no downtime

Vacuoles caused by Laser induced Optical Breakdown (LIOB)

Immediate Post Treatment

Dr. Emil Tanghetti

19

H & E Inflammation 100X H & E Inflammation 400X• Superficial perivascular lymphocytic inflammatory process• No vasculitis• Sustained dermal inflammation = new collagen and elastin

Dr. Emil Tanghetti

24 hours Post Treatment

“Elegant Injury” caused by PicoSure with the Optic

FOCUS Lens Array

20

Collagen: increased collagen production

Elastin: more dense elastin fibersDr. D. Mc Daniel

Effect on dermal compartmentincrease in collagen and elastin

Before

After

21

• Fractionated Picosecond• Revitalization:

‐ With little discomfort/ downtime

‐ On face and off‐ face‐ Safe to use on darker skin types ( IV‐VI)

• Indications:

‐ Acne Scars ‐ FDA Cleared‐ Wrinkle reduction – FDA Cleared‐ Photorejuvenation: Pico toning

Diversified Applications

22

Treatment of Wrinkles with PicoSecond 755nm and Focus

Safety and Efficacy of a Novel Diffractive Lens Array Using a Picosecond 755 nm Alexandrite Laser for

Treatment of Wrinkles

Robert A.Q3 Weiss, MD, FAAD,1 David H. McDaniel, MD, FAAD,2 Margaret A. Weiss, MD, FAAD,1Anne Marie Mahoney, MD, FAAD,1 Karen L. Beasley, MD, FAAD,1 and Christian Halvorson, MD, FAAD

• Statistically significant improvement of wrinkles

• 1.97 change in Fitzpatrick Wrinkle Score• Pigment improvement was rated as high‐moderate

• Post treatment erythema lasted only for hours on average• Histology demonstrated increase of collagen and elastin

23

Coagulation zoneAblation zone

From “Bulk Ablation”

to “Localized Ablation”

Ablative (Fractional) Resurfacing

24

60

Device Wavelength (nm)

Ablative


(AFX)

YSCG

Erbium

CO2

2790

2940 10,600

Device Company

Fractional Bipolar RF E‐matrix

Venus VivaLegato

Syneron/candela

Venus ConceptAlma

Ablative Fractional Technologies

25

Fractional Ablative Resurfacing

• 40‐60 year old patientPhotodamage

Fine wrinkles

• Single Treatment

With minimal side effectsWith reduced downtime

26

Ablative resurfacing

• > 60 year old patientPhotodamage

Deep wrinkles

• Single Treatment

With side effectsWith downtime

27




• Wrinkles:ablative (fractional) lasers

• Sagging: High Intensity Focussed UltrasoundIn situ bipolar RF



28

UltheraTM System Components

CONTROL UNIT HANDPIECE/TRANSDUCER

• One handpiece

• Multi‐patient transducers

• Region specific

‐ Forehead: 7MHz at 4.5 mm depth

‐Cheeks/preauricular: 4MHz at 4.5 mm depth

‐Temple/infraorbital: 7MHz at 3.0 mm depth

‐ Periorbital: 10 MHz AT 1.5 mm depth

29

Deposition of Micro‐Focused Ultrasound at Precise Depth

Lines of discrete thermal

coagulation points

form a consistent matrix

on the targeted plane

30


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Discrete Thermal Coagulation Points

Approximately 10,000 discrete coagulation points are placed at dual depths,causing immediate tissue contraction and initiating neocollagenisis

31








32

Needles are inserted in the skin

with in situ

delivery of bipolar radiofrequency

In situ Fractional Resurfacing

33

RF fractional microneedle devices

Device Technology Needles Length

Profound

Syneron Candela

In situ bipolar RF 5 pairs of electrically‐ isolated 32 Gauge needles

6 mm length

Infiny

Lutronic

In situ bipolar RF Unique 7x7 array of insulated microneedles

Only the needle tip (300 µm) is the active electrode

Intensif RF microneedle handpiece

Endymed

In situ bipolar RF 25 gold plated microneedles

fractionated pulse mode deliveryGold Plated Microneedle

(300 microns )

Fractora

Invasix

In situ bipolar RF Variable pin configurations ( 20,24,60 & 126)

Variable TX depths

34

• Multilayer Approach• Multiple Passes• Selectable Depths: 0.5‐3.5 mm

1st Pass2nd Pass3rd Pass

MicroFractional RF

35

Fractional RF Thermal Zones (65°C, 4 sec)

Pilot clinical study of a novel minimally invasive bipolar microneedle radiofrequency device.

Hantash BM, Renton B, Berkowitz L, Stridde BC, Newman J. Lasers Surg Med. 2009;41:87‐95

36

62

Full Dermal Structure

• Collagen, hyaluronic acid, and elastin content increased

• Unique wound healing response ‐ Low catabolic activity

‐ Increased anabolic activity adding new dermal volume

Old Collagen

Mixed

New Collagen

New Elastin

New Hyaluronic AcidHistology courtesy ofBasil Hantash,

37

• Study of 33 Patients, – 26 F , 7 M – Age 37‐74

• Three Infini Treatment – 1 Tx per Month, 3 passes each

• Photos and Grading at 6 Months Post– Independent Graders gave 81% Moderate to Excellent Results– Patient satisfaction at 87% at 12 Months

Laser Surg Med, 2016;48(5):461‐70

38






• Submental fat: Cryolipolysis



39

Introducing the CoolMini Applicator

• Designed for submental fat

• Optimized for smaller bulges

• Treat new areas of undesirable fat

40

Submental Studies

• Submental Area

– IDE Pilot – 15 subjects– Mexico Feasibility Study – 32 Subjects– US Pivotal Study – 60 Subjects– European Pilot – 125+ Subjects

41

CONCLUSION

WHAT WE CAN LEARN FROM THIS SESSION

‐Treatment of ageing, is the same as ageing itself:

It‘s a stepwise process

‐A combination of different treatments

‐Try to get a rejuvenated face which matches patients‘ expectations

“ NO TRACE FACE “

42


Christine Dierickx

WelcomeInformationFaculty informationPresentationsNotes Programme

63

Thank yo

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Before

43

64

Lecture 10 Scar treatment - different approaches to different types of scars

Merete Haedersdal

Scar Treatment - Different Approaches

to Different Types of Scars






1

Each year 100 million scars are caused…

55 million from elective surgery

25 million from trauma

11 million keloids

4 million burn scars

70% in children

Hot

topic

2

Guidelines

Select refs:Anderson RR et al. JAMA Dermatol. 2014;150(2):187-93.

Monstrey S et al. J Plast Reconstr Aesthet Surg. 2014;67(8):1017-25.

Gold MH et al. Dermatol Surg. 2014;40(8):817-2.

Gold MH et al. Dermatol Surg. 2014;40(8):825-31.

Karmisholt K et al. Ugeskr Laeger 2016;178(32).

3

Several players

o Pulsed dye laser

o Nonablative fractional lasers - NAFXL

o Ablative fractional lasers - AFXL

o Microneedle RF

o Laser-assisted drug delivery

o Early intervention

Established > 20 years

~ 10 years

~ 10 years

New technique

Evolving technique

- // -

Lasers are part of standard care for scar management

4

Management Algorithms

Ref Karmisholt K et al. Ugeskr Laeger 2016;178(32).

5

Erythematous Scars


Select refs: Anderson RR, Parrish J. Science 1983; 220: 429-7Alster TS. Ann Plast Surg 1994; 32(2): 186-90Nouri K et al. Derm Surg 2003; 29(1): 65-73

and …… many, many more refs

PDL and vascular lasers, IPL are the treatment of choice

6

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Shoot profile characteristics

o Controlled zones of denatured collagen / ablation zones

o Induces a unique biological wound healing response

DERMAL COLLAGEN REMODELING

HSP, MMPs, collagenases, fibroblasts

Strong staining with procollagen III

around the MTZ.

8

Needles are inserted in the skin

with in situ delivery of bipolar radiofrequency

Microneedle RF

In situ Fractional Resurfacing

• Multilayer Approach

• 1 – 3 passes

• Select depths: 0.5-3.5 mm

1st Pass2nd Pass3rd Pass

Ref: Cohen J et al. J Drugs in Dermatology 2016; 15 (11): 1308-12

9

© Palomar Medical Technologies 2008. All rights reserved.| www.palomarmedical.com


o Game changer for cutaneous remodeling

o Fractionated laser beam creates microscopic wounds surrounded by viable tissue for rapid healing

o Induces a unique biological wound healing response

Manstein DD, Anderson RRLasers Surg Med 2004; 34:426-438

7

Fractional RF Thermal Zones (65°C, 4 sec)

Pilot clinical study of a novel minimally invasive bipolar microneedle radiofrequency device.

Hantash BM, Renton B, Berkowitz L, Stridde BC, Newman J. Lasers Surg Med. 2009;41:87‐95

10

Burn Scars Which Lasers to Use?

Multi-modal approach

o What type of scar are you treating?

o Is there a color problem?

o Is there a collagen problem?

Courtesy to Jill Waibell

11

Laser repairs BURN ScarsBurn Scar – 12 years after injury

Jill Waibel

Combo: Thulium 1.927 nm

PDL 595 nm

AFL 10.600 nm

12

66

Significant response:

o More even and smooth textur

o Improvement

7 to 2 (1540 nm) vs 7 to 7 (no tx)

Pre

12 w postop

Patients with meshed skin responded more favourably

Ref. Haedersdal et al.Las Surg Med 2009; 41: 189-95

8/17 patients evaluated

moderate or significant

improvements

13

Improved range of motion

Chef at 5 star hotel Photocourtesy Jill Waibel

14

CONCEPT

©Courtesy of Uwe Paasch, University of Leipzig

Drug Delivery Through Fractional Holes

15

Laser Assisted Drug Delivery for Burn Scars

Post-op topically applied substances into fractional tunnels Triamcinolone injectable suspension 5FU

Waibel J, MD

16

Laser Assisted Drug Delivery for Burn Scars

Post-op topically applied substances into fractional tunnels

Triamcinolone injectable suspension, 40 mg/ml

5FU 50 mg/ml

17

Baseline

3 mth

8 mth

6/9 cleared 9/9 visible

- Tx+ Tx

Appetizer for Early Scar Treatment

18

Lecture 10 Scar treatment - different approaches to different types of scars

Merete Haedersdal

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Lecture 11 Hyperhidrosis

Christine Dierickx

Dr. Christine Dierickx

Nordic laser courseCopenhagen

Microwave technology in the treatment of

unwanted sweat, hair and odor

1

Sweating is a Real Problem Wide range of sweat‐bothered patients

Patients with excessive sweating

Patients who sweat normally, but are bothered by their sweatYoung Adult ‐ sweating is affecting her confidence

Professional ‐ sweating projects the wrong image

Organically Minded ‐ hate the chemicals applied daily

Wardrobe ‐ too many yellowed whites, can’t wear silks

2

Most Embarrassing ?

Source: 2008 Harris Interactive US rep pop survey 2897 adults 18+ conducted for International Hyperhidrosis Society

60% Underarm Sweat

58% Overweight

47% Acne

43% Cold Sore

38% Dandruff

3

CE and FDA‐cleared microwave energy procedure for lasting underarm sweat reduction

4

Microwave energy: Mechanism of Action

CoolingCooling

HeatingHeating

Tx applies:• Suction

• Cooling

• Microwave (heat)

heat at dermal/hypodermal interface where sweat glands reside, results in thermolysis of sweat glands

5

MiraDry ProcedureThree Easy Steps

Mark customized treatment area

Administer

local anesthesiaTreat with

miraDry System

• Patients require as little as one treatment

• Each appointment typically lasts 60–75 minutes, depending on the size of treatment area

• Able to delegate to PA, NP or RN where local laws allow

Pre‐ProcedurePreparation Procedure

6

68

Microwave technology

1. Sweat Reduction

2. Hair Reduction

3. Odor reduction

Long term Efficacy for

7

miraDry® Long‐term Efficacy Study 1,2

� 2 sites in Canada: Drs. Chih‐ho Hong and Mark Lupin� Single‐group, open‐label study, n = 31� Follow‐up for 24 months

� Multiple efficacy measures – HDSS

– Gravimetric assessment

– Patient Satisfaction– Dermatology Life Quality Index (DLQI)

1. H. Chih‐Ho Hong, MD, Mark Lupin, MD et al;

Dermatol Surgery 2012; 38:728‐735

2. Lupin MS and Hong C‐H. OʼShaughnessy KF

Dermatol Surg. 2014 ;40: 805‐807

12 month data published May 2012

24 month data published July 2014

8

1. Gravimetric % sweat reduction only obtained at in‐office visits through 12 months

93%97% 96% 100% 100% 100% 100% 100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 mon… 3 mon… 6 mon… 12 mon… 15 mon… 18 mon… 21 mon… 24 mon…

% with HDSS1 or 2

82%Sweat Reduction

At 12 mos

100% No longer

bothered by sweat at 24 mos

LupinM, Hong HC‐H, O’Shaughnessy KF. Long‐term Efficacy and Quality of Life Assessment for Treatment of Axillary HyperhidrosisWith a Microwave Device. Dermatol Surg 2014; 40: 805‐807.

Long‐Term Results HDSS Improvement and Gravimetric Sweat Reduction

9

Dermatology Life Quality Index (DLQI)

• Highly validated

• 10 questions that cover all aspects of quality of life

• Scores range from 0 (no problem) to 30 (huge problem)

• Used for many dermatologic conditions

Psoriasis = 10.5, Severe acne vulgaris = 7.5

10

DLQI Results

Clinically meaningful change is 5 points*

DLQI = Dermatology Life Quality Index; ranges from 0 (no problem) to 30 (worst) *Kowalski et al. JAAD 2007; 53: AB52. Poster at AAD2006.

0

2

4

6

8

10

12

14

Baseline 1 mon(n=30)

3 mon(n=29)

6 mon(n=27)

12 mon(n=26)

15 mon(n=18)

18 mon(n=18)

21 mon(n=18)

24 mon(n=17)

Dermatology Life Quality Index (DLQI)

11

Gravimetric

Efficacy

82%average

DLQI Satisfaction

90%

HDSS Efficacy

90%

12 Month Results Summary

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1. Sweat Reduction

2. Hair Reduction

3. Odor reduction


13

FDA and CE Mark cleared microwave energy procedure for lasting underarm sweat reduction.

FDA Cleared for permanent reduction of underarm hair of all colors.

14

• Multi‐center study, n=56 subjects enrolled for hair reduction

− 80% female, average age 32, 38% had light hair, Fitz I ‐V

• 43 patients received 2 treatments, 13 received 1 treatment

− treatment parameters same as used for sweat reduction

� Quantified & Qualified axillary hair reduction :

− FU at 3,6,9 and 12 months

− blinded hair counts & blinded side by side

− Subgroup analysis of patients with light‐colored axillary hair

A Prospective Study of Axillary Hair Reduction in Patients Treated With Microwave Technology.Brauer JA, Neckman JP, Zelickson B, Vasily DB, Geronemus RG.

Dermatol Surg. 2017 43(4):558‐565.

15

Average Hair Reduction from Quantitative Assessment

0%

20%

40%

60%

80%

100%

3 mon

n=42

6 mon

n=40

9 mon

n=38

12 mon

n=44

Average % Reduction

"All"

"Light"

"Dark"

Average reduction was approx. 70% independent of hair color

16

0%

20%

40%

60%

80%

100%

3 mon

(n=85)

6 mon

(n=83)

9 mon

(n=85)

12 mon

(n=93)

Side‐by‐Side Qualitative Analysis per Axilla

% axilla blindedreviewer correctly chose the baseline photo

% where assessor rated the reduction as being at least 50%

17

Baseline 12 month follow‐up;94% reduction

Results – dark hair

18

70

Results – light hair

Baseline 12 month follow‐up; 84% reduction

19

Baseline

Results – dark hair

12 month follow‐up; categorized as 76‐100 % reduction

20

Baseline 12 month follow‐up; categorized as 76‐100 % reduction

Results – light hair

21

Side‐by‐side Analysis

>50% reduction

70%approximately

Hair

Reduction at 12 months

74.9%average

Results Summary

Quantitative Qualitative

22

Microwave technology and Hair

1. Long term efficacy for hair reduction

2. Potential for 90‐100 % hair reduction in a single Tx

3. Colorblind Technology

23


1. Sweat Reduction

2. Hair Reduction

3. Odor reduction


24


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25

Odor Reduction Peer Reviewed Publications

� Long‐term Efficacy and Quality of Life Assessment for Treatment of Axillary Hyperhydrosis With a Microwave Device‐ Lupin et al. Derm Surg 2014; 40: 805‐807 ‐ 2 year data from Commercial device study

� The efficacy of a microwave device for treating axillary hyperhidrosis and osmidrosis

in Asians: a preliminary study‐ Lee et al. J Cosmet and Laser Ther 2013; 15(5):255‐9

� A prospective clinical and histologic study of axillary osmidrosis treated with the microwave‐ based device‐ Chang YY, et al. Dermatologica Sinica 2015 ;33:134‐141

25

Long‐Term Results Odor Reduction

16%

80% 83% 81%88%

83%89% 89% 89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline(n=31)

1 mos(n=30)

3 mos(n=29)

6 mos(n=27)

12 mos(n=26)

15 mos(n=18)

18 mos(n=18)

21 mos(n=18)

24 mos(n=19)

% of subjects without problematic odor

89%Patients without

Problematic odor

at 2 years

LupinM, Hong HC‐H, O’Shaughnessy KF. Long‐term Efficacy and Quality of Life Assessment for Treatment of Axillary Hyperhidrosis With a Microwave Device. Dermatol Surg

2014; 40: 805‐807.

26

Chang et al Study Overview

� Prospective, Single Center Study� Population: n=7 (2 male;5 female)/ 22‐53 y.o./ axillary osmidrosis

� Primary Objective: To investigate the efficacy, safety, and histological changes of microwave‐based devices in treating axillary osmidrosis.

� Endpoints at 90 day FU visit:� Reduction of at least 3 points on the odor‐10 point score

� 10‐point scale (1 stands for completely no odor and 10 for severe odor)� HSSD score of 1 or 2 � Biopsy

27

Chang et al Study Results� Results:

‐ 6/7 patients (85.7%) met the primary endpoint of sweat and odor reduction‐ Mean percentage of reduction in odor‐10 scale was 76.4% and 61.8% at 30‐day and 90‐day visits

respectively

28

Chang et al Study Results ‐ Biopsy

� Immunohistochemistry staining using CAM5.2 to highlight apocrine sweat glands (A, C, E, G) were from Patients 6, 7, 2, and 5, respectively, preoperatively. (B, D, F, H) from Patients 6, 7, 2, and 5, respectively, postoperatively.

� Method used: Immunohistochemically, apocrine glands react strongly to CAM5.2 with heavy staining of the nucleus and cytoplasm whereas eccrine glands showed only little reactivity

Skin biopsies specimens revealed 93% reduction in apocrine glands

29

� A non‐invasive solution for underarm sweat and odor

‐ Side effects mild and transient

‐ A significant reduction of underarm sweat ‐ 82%average reduction*

� Permanent results in as little as 1 treatment

‐ Sweat glands are destroyed and do not regenerate� Reduction in underarm hair� High patient satisfaction procedure

* Hong et al. Dermatol Surg 2012; 38: 728‐735

What Patients Can Expect

30


Christine Dierickx

72

Thank you!

31


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Lecture 12 Cutting edge – New treatments in the pipeline

Merete Haedersdal

Cutting Edge

New Treatments in the Pipeline






1

Disclosures

Cynosure-Hologic Loan of equipment

Galderma Research grant

Leo Pharma Research grant

Lutronic Research grant, Loan of equipment

Novoxel Research grant, Loan of equipment

PerfAction technologies Research grant, Loan of equipment

Procter & Gamble Research grant

Sebacia Research grant

2

1: Laser-assisted drug delivery – New indications

2: Gold-coated Microparticles and Laser

in Treatment of Facial Acne

3: Early scar treatment

Agenda

3



o Str. Corneum major barrier

o Low cutaneous bioavailability

~ 1-5% of applied drug

o Large, hydrophilic drugs

not suited for topical delivery

o Enhanced drug penetration

o Enhanced bioavailability

o Empower topical Tx regimens

o New available drugs

4

CONCEPT

©Courtesy of Uwe Paasch, University of Leipzig

Combo of Laser and Drug

Drug Delivery Through Fractional Holes

5


LADD – Status

Evidence evolving

PubMed > 100 publications

PhotosensitizersPDT

Corticosteroids

5FU

PLLA

Botulinum toxin

Vit C and E

Amorolfine

Terbinafin

Finasteride

Without exception,

Ablative Fractional Laser

enhanced

drug accumulation

in the skinof any drug or substance

applied to the skin

6

74

AFXL assisted drug delivery

7

Acne is still the #1 reason to see a dermatologist

Inflammatory disease of

the pilosebaceous unit

Follicular hyperkeratosis and occlusion

Increased sebum production

Proliferation of P. acnes

Inflammation

8

GOLD MICROPARTICLES:

Silica core, gold shell 0.150 micron diameter Efficient near-IR absorber

Selective Targeting of Sebaceous Glands with Externally Added Gold Chromophore

Refs: Paithankar DY et al. J Invest Dermatol. 2015;135(7):1727-34Paithankar DY et al. J Contr Release. 2015; 206: 30-36

Approval status: EU, CE mark, CE 612960, received 07 March 2016US, Investigational Use Only

9

Efficacy to treat acne with selective photothermolysis using gold microparticles

a 3-center European trial

Study Design Uncontrolled trial

3 EU centres

Good Clinical Practice, EC approved

ClinicalTrials.gov Id: NCT02758041

3 Tx sessions at 1-week intervals

Primary outcome:

> 40% improvement at 12 week FU

810 nm diode laser

Mean fluence 32 J/cm2

Pulse duration 30 ms

Spot size: 9x9mm,12x12mm

Integrated contact cooling

23 patients per protocol

IGA 3, IGA 4

Wash out period prior to study

Tx Period

Isotretinoin 6 months

Systemic medication 4 weeks

Topical retinoids,

antibiotics

2 weeks

OTC 1 week

Light based Txs 8 weeks

10

% Change Weighted Lesion Count (WLC) at 12w No other acne interventions

Responder> 40% improvement

n = 18/23 (78%)

Sub-responder < 40% improvementn = 5 (22%)

Median reduction62%

Rank ordered graph for each individual per protocol patient

Scale adapted from Hongcharu,

Anderson, et al., JID 2000

11

Hypothesis: Pre-conditioning the skin makes pores more accessible

Delivering more chromophore to target anatomy, sebaceous gland, may boost clinical effect

Hypothesis:

Daily application of a topical retinoid and BPO will “empty” the pores and increase the delivery of particles to the follicles

+

12


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Morphological changes in skin after tretinoin treatment, case study: RCM imaging

Reduced content within follicles after topical tretinoin application

Week 0

Hair follicles with sebum and keratinous content

1st week tretinoin

Hairfollicles with less content

2nd week tretinoin

Hairfollicles with less content

Mette

MogensenChristine

Fuchs

13

Real World Preconditioning Data (Interim Results) vs. Historical Gold Microparticle Treatment w/o Preconditioning

Preconditioning Period

Tx x3

% C

han

ge I

LC

Historical Monotherapy Data: Paithankar, et al., JID 2015

N=26

0.0%

N=26

-44.0% N=25

-49.0%

N=23

-65.0%

N=71

-12%

N=67

-63.2% N=58

-66.1%N=38

-78.5%-90%

-80%

-70%

-60%

-50%

-40%

-30%

-20%

-10%

0%

BL1 (~-1m) BL2 2m 3m 6m

No preconditioning, monothe rapy (historical)

Preconditioning, polytherapy

14

Gold Microparticles with Preconditioning Results

3 months

Lesion Count: 1

∆Lesions: -93%

IGA: 0

OS23-0021(Age 17)

Baseline

Lesion Count: 15

IGA: 2

3

MO

BL

15

Gold Microparticles with Preconditioning Results

3 months

Lesion Count: 0

∆Lesions: -100%

IGA: 0

OS23-0103(Age 19)

Baseline

Lesion Count: 25

IGA: 3

3

MO

BL

16

Thank you!

• England– Skin 55

– The Skincare Network

– London Dermatology Centre

– Kosmesis

• France– CLIPP

• Poland– Novaderm

– Miracki Clinic

– Murano Clinic

– Dermedicus

Mette Mogensen

Christine Fuchs

MauriceAdatto

HansLomholt

17

Early scar treatment

18


Merete Haedersdal

76

Paradigm Shift towards Scar Prevention

Laser tx of mature scars established

Early intervention emerging procedure

Literature heterogeneous

No standard protocols

Upregulated cytokine environment may benefit skin healing

19


WOUND HEALING PHASES

Inflammation < 3 days- Cascade of cytokines

Proliferation 4-21 days- Granulation tissue

Remodeling > 21 days- New collagen

Katrine Karmisholt

Ref: Karmisholt K et al. JEADV. In press

20

o PubMed 1997 -2017

o Interventions < 3 months after wounding

o 22 of 25 studies were controlled

o 17 of 25 studies compared intervention versus untreated control

Body of Evidence

21

o Inflammation phase: 3 of 4 studies

o Proliferation phase: 6 of 16 studies

o Maturation phase: 2 of 5 studies

Studies with Significant Improvement on

Laser Tx Scar Side vs Untx Control Side

Early laser intervention has the potential to reduce scar formation

No consensus

We need standard protocols

22

o Split-scar design

o Three NAFL exposures vs no Tx

o Target all 3 separate wound healing phases

o 30/32 patients completed study

o Benign, premalignant, NMSC lesions

o 3 mth FU

Real Life Setting

Ref: BJD In press

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Study procedures:Target all 3 wound healing phases with NAFL 1540 nm Er:glassDeep Fx: 50 mJ/mB, 3 stacks / 2 passes Superficial: 40 mJ/mB, 50% overlap, 1 pass

# 1 Immediately before excision Inflammation phase

# 2 At suture removal Proliferation phase

#3 6 weeks after excisionRemodelling phase

ControlNAFL-Tx

24


Merete Haedersdal


77

78

No Tx

No Tx

Three Txs

Three Txs

Good Responders

25

Clinical evaluations Observer part of Patient Observer Scar Assessment Scale (POSAS) Vancouver Scar Scale

(VSS) at 3 months follow-up.

POSAS VSSTreated scar Control scar P* Treated scar Control scar P*

Vascularity

3 month 2 (1-3) 2.5 (2-4) 0.005 1 (0-1) 1 (1-1) 0.031

Pigmentation

3 month 1 (1-1) 1(1-1) 0.125 0 (0-0) 0 (0-0) 0.219

Thickness /height

3 month

1 (1-1) 1 (1-2) 0.125 0 (0-0) 0 (0-0.25) 0.250

Relief

3 month 2 (2-3) 3 (2-3) 0.023 NA NA NA

Pliability

3 month 2 (1-2) 2 (2-3) 0.037 1 (0-1) 1 (1-1) 0.344

Surface Area

3 month 2 (2-3) 2 (2-3) 0.016 NA NA NA

Overall Opinion

3 month 2 (2-3) 3 (2-4) 0.003 NA NA NA

Total Score

3 month 11 (9-12) 12 (10-16) < 0.001 2 (1-2.25) 2 (1.75-3) 0.007

Treatment Effects - Statistics

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Variation in Treatment Efficacy

Poor Responder1 point difference,favouring untreated control

Average Responder3 point difference,favouring NAFL

Good Responder11 point difference,favouring NAFL

NAFL superior 63% of patients

No difference 26% -//-

NAFL worse 10% -//-

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ACKNOWLEDGEMENTS

Bispebjerg Hospital

Derm. Research Unit

Copenhagen University

Wellman Center of Photomedicine,

Massachusetts general Hospital,

Harvard Medical School

28


Merete Haedersdal


79

No

tes

80

Notes


81

82

Notes

Nordic Course on Laser Dermatology is initiated by the Nordic Dermatology Association, which was founded in 1910 in Copenhagen, Denmark . The aim of the association is to promote Nordic cooperation in scientific, educational and clinical aspects of dermatology and venereology, mainly by arranging congresses in the Nordic countries .

More information about the Association is available on www .nordicdermatology .com


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