D G C © 2008

Updated May 08

Referring for Skin laser treatments

R.A. SHEEHAN-DARE M.D. ChB F.R.C.P

This latest edition of the Skin Laser Directory provides a valuable resource for Clinicians considering referral of their patients for Laser treatment.

The Skin Laser Directory enables Clinicians to determine which services are available in relation to their locality. There is practical information on the types of laser or Intense pulsed light (IPL) available and the clinic facilities, with contact information. There is also useful background information and guidance on specific treatments and conditions.

What this Directory cannot do is provide patient specific information about the suitability and advisability of treatment for individual patients. The main problems which face patients interested in laser treatments are; what is the likelihood that the treatment will be helpful, are there significant hazards and what alternative treatments might be available for their problem?

The following I hope can provide a brief overview of the potential benefits and degree of risk of the more common laser treatments, and of the alternative treatments available.

Laser Hair removal

Laser or IPL hair removal is well established and generally successful in producing long term (but very rarely complete) hair reduction for dark hair whichever device is used. Pale or white hairs do not respond significantly. Adverse reactions are rare except in darker skin types who should generally only be treated with a long pulsed YAG laser. Electrolysis is an alternative but is laborious and most suited to small areas and lighter hair.

Telangiectasia

Laser or IPL treatment of facial telangiectasia is reliable and low risk whichever device is used. However, leg telangiectasia, (particularly larger vessels) respond less reliably and treatment is often best combined with or replaced by sclerotherapy.

Vascular birthmarks

Port wine stains respond most reliably to pulsed dye lasers and risks are low. Variable improvement is achieved but rarely complete clearing and top-up treatments are often required throughout life.

Skin pigmentation

Sun freckles respond reliably to most lasers or IPL devices and risks are few. Gentle cryotherapy is an equally effective alternative. Melasma may improve temporarily with resurfacing or fractional resurfacing, but rarely with other laser treatments. Gentle chemical peels can give a similar short term effect, but maintenance with sun avoidance and topical bleaching agents is required, and complete clearance is rare.

Moles

Lasers cannot fully remove moles although reduction in hair and pigment can sometimes be achieved. Fear of masking melanoma is also a significant consideration. Surgical removal where practical, is preferred, especially for smaller lesions.

Scarring

Lasers and IPL have limited roles to play in scarring although there are minimal risks. Modest reductions in redness and thickness of

hypertrophic scars are possible with a pulsed dye laser. Depressed scars may be improved to a modest degree  (less than 50%) by many non-ablative remodelling devices, resurfacing lasers and fractional resurfacing, but a significant proportion see no useful improvement even after a number of treatments. Risks are low if treatments are gentle, but permanent scarring and pigment disturbance may occur especially with resurfacing procedures

Alternatives which may also be used in combination with laser treatment are medium depth chemical peels, dermabrasion, surgical excision (although inherently more hazardous), and dermal fillers which are generally temporary.

Photoaging

Photoaging changes are improved to a variable extent with most non-ablative lasers, fractionated resurfacing and IPL which are all low risk, but most of the improvement is in telangiectasia and sun freckles rather than wrinkling. Only the finest wrinkles seem to be improved to a modest extent (less than 50%) and a significant proportion see no useful improvement. Laser resurfacing is more effective for fine to moderate wrinkling, although more hazardous, with risks of scarring and pigmentation disturbance. 

Alternatives which carry similar or greater risk are medium depth chemical peels and dermabrasion. Dermal fillers and botulinum toxin are low risk in the right hands and highly effective for localised changes, but temporary and need repeating indefinitely. Surgical lifting and blepharoplasty procedures carry risks which are minimized in experienced hands. They may give better results in some or may be used in conjunction with these procedures.

Acne

A range of mainly non-ablative lasers and IPL have been recommended for acne and these are generally low risk. There is evidence for short term improvement with pulsed dye lasers, IPL and

1450nm diode laser, although many do not respond, treatments can be painful, the acne may flare and there are no comparisons with conventional treatment.

 Alternatives are antibiotic/topical combinations or isotretinoin, which is more reliable long term therapy.

Patients deserve and should expect a full explanation of the benefits and risks of any laser or IPL treatment by the clinician offering treatment, but should also be fully briefed about alternative treatments or combinations of treatment which might benefit them by someone qualified to give this advice. This should include the advice to do nothing if in their best interests.

It is important to consider as much who to refer to as which treatment to refer for.

Dr R.A. Sheehan-Dare M.B. ChB. F.R.C.P.

Consultant Dermatologist

Hon. Snr. Clin. Lecturer Dermatology,

Leeds Dermatology Laser Centre,

Dermatology Department,

Leeds General Infirmary,

Great George Street,

Leeds LS1 3EX