Laser Treatment of Skin of Color for Medical and Aesthetic Uses With a New 650-Microsecond Nd:YAG 1064nm Laser
By: Wendy E. Roberts MD,a Michelle Henry MD,b Cheryl Burgess MD,c Nazanin Saedi MD,d Suneel Chilukuri MD,e Dr. Arusha Campbell-Chambers MBBS MScf
Description: Individuals with skin of color (SOC) are among the most rapidly growing portion of the cosmetic procedures market.1 In 2016, ethnic minorities received 24.5% of total cosmetic procedures compared to 22% in 2014 and 15% in 1997.1,2 SOC denotes people of Fitzpatrick skin types IV through VI. Worldwide, these groups include Asians, Latinos, Africans, African-Americans, Afro-Caribbeans, Native Americans, Middle Easterners, Pacific Islanders, Alaskan natives, Native Hawaiians, and Mediterraneans.3
Lasers in Skin of Color
In SOC patients, medical and aesthetic skin conditions have been treated with limited success using topical or systemic therapies. These disorders are also difficult to treat with light-based therapy due to significant risks of treatment pain, epidermal burns, and hypo- or hyper-pigmentation. Physicians continue to search for a go-to device to safely and effectively treat skin conditions in SOC patients.
Such a device is the 650-microsecond 1064-nm laser (LightPod Neo®, Aerolase Corp., Tarrytown, NY) with a collimated beam of light. With this device, practitioners can safely treat important conditions such as acne, melasma, pseudofolliculitis barbae, and even psoriasis in SOC patients. They can also remove hair and rejuvenate skin. The procedure is rapid and sanitary because the handpiece does not touch the skin during treatment.
Aerolase’s Neo Elite 650-Microsecond 1064nm Laser: A Safe, Effective Go-to Option to Treat Skin of Color
By: Wendy E. Roberts MD
Individuals with skin of color are the majority in California, New Mexico, and Texas and will soon will be the majority in Arizona, Nevada, Georgia, New York, and Florida. By 2050,
more than 50 percent of the US population will have skin of color, according to the Skin of Color Society.1
Traditionally these patients have benefited less from medical and aesthetic treatments, compared with their lighter-skinned counterparts. With light-based therapy, in particular, there were significant risks associated with treating skin of color, namely burning and/or hypo- or hyperpigmentation. As such, many physicians remained reticent to suggest laser treatments for rejuvenation, melasma, acne, post-inflammatory hyperpigmentation (PIH), and other skin concerns in skin of color patients.
Those days are over. The advent of devices like the Aerolase Neo Elite 1064nm laser has opened up the playing field for these patients and the doctors who treat them. Thanks to its long wave- length and short pulse duration, the Neo Elite offers increased treatment efficacy, a broader range of treatment options, and a gold-standard margin of safety for skin of color patients.
A BRIEF HISTORY OF LASER SURGERY IN SKIN OF COLOR
When lasers were first introduced in medical and aesthetic dermatology, they targeted chromophores—whether melanin, water, or hemoglobin. It was early and they did a great job. The issue with treating skin of color patients was that there was
no way to bypass the melanin at the bottom of the epidermis. As a result, melanocytes could be damaged, resulting in white spots or hyperpigmented patches. Skin could also be burned and damaged, leading to redness, post-inflammatory hyperpigmentation, and even scar formation.
The prevailing attitude at the time was, “if you have brown skin, you can’t do laser.” This was a huge barrier to access for patients with Fitzpatrick skin types IV through VI. Individuals with these skin types could not take advantage of the technology to treat skin conditions that have dramatic effects on their quality of life, such as melasma.
This is why Aerolase Neo Elite is a truly disruptive technology
The laser energy passes through the epidermis so quickly that it does not have time to overheat the epidermal melanocytes, thus avoiding the pigmentary risks associated with most laser systems in skin of color patients. The long 1064nm wavelength penetrates deep to target epidermal and dermal and vascular structures, and the quick 650microsecond pulse duration enters the skin so rapidly that there is no pain or bulk heating. The Neo Elite’s collimated beam enhances precision. There is no cooling required for this device. The distance from the handpiece does not matter, and fluence remains fixed regardless of handpiece distance.
The Neo Elite user manual is fail-safe. Following the settings in the manual virtually eliminates mistakes. The user manual is one of the best I have seen with any laser. You open the book, put those settings in, and do your case.
TREATING MELASMA IN SKIN OF COLOR
The Neo Elite can be used alone or in combination with other therapies to treat melasma, PIH, pseudofolliculitis barbae, acne keloidalis nuchae, and aging skin with unprecedented efficacy and safety in human skin of color.2
It is a common myth that melasma is just a minor concern for skin of color patients and that limited treatments exist. Melasma has dramatic effects on quality of life, and the Neo Elite is a highly effective treatment option.
When treating melasma, several treatments are usually required. There is no one-size-fits-all melasma protocol. I tell patients, “Let’s do one and see how much you clear.” If they clear 25 percent after one treatment, they will likely need a total of four treatments. If they have little or no change, we will try stronger settings.
Fitzpatrick skin types IV through VI now have the same access to laser technology as their lighter-skinned counterparts, and it’s time the word got out.
Neo Elite is a great laser for physicians who need a workhorse to treat core medical applications. It allows them to have just one laser for a multitude of conditions; and it is safe and effective in all skin types, from lightest to darkest. The Neo Elite clinical indications for patients with all skin types include acne, rosacea, melasma, PIH, psoriasis, photorejuvenation, skin rejuvenation and tightening, solar lentigines and/or redness.
If I were starting a new practice out of residency and wanted to build a diverse practice, the Neo Elite is the laser I would pick. Skin of color patients will increasingly become the majority, and having one laser to address all aesthetic and medical concerns in this population will provide a dramatic and rapid return on your investment. In our practice, I earned $178,000 with the Neo Elite last year, and I do not delegate these procedures.
Eliminating the Fear Factor
By Michelle F. Henry, MD
Physicians who treat skin of color patients are understandably concerned about the risk for complications when using lasers to address melasma, acne, and other skin concerns. Skin of color patients may be reticent to receive laser therapy. In the past, the risks of epidermal burns, scarring and/or hypo- or hyperpigmentation, were thought to outweigh the benefits of laser treatment—but that was then.
Aerolase’s Neo Elite, a 1064nm Nd:YAG laser with a 650-microsecond pulse, is changing all these preconceptions. Patient education is the key to increased access, as many of your patients may not know about this laser and its capabilities. Laser companies have not traditionally targeted skin of color patients with their marketing efforts. The Neo Elite is my go-to for treating skin of color. It has an unmatched safety profile for brown skin.
It’s important to note that a consultation with a skin type VI patient isn’t the same as a consultation with a skin type I. Patients may need some hand-holding so that they are comfortable and confident that today’s technologies are not only highly effective, but also extremely safe. I start by telling my skin of color patients that the Neo Elite was made with skin of color in mind. Neo Elite’s 1064nm wavelength is long enough and smart enough to bypass the dense melanin so it can target melanin in the hair follicle, but bypass it in the epidermis. The 650-microsecond pulse is rapid and precise so it gets to its target, hits it, and moves out quickly with no bulk heating or burning.
SEEING IS BELIEVING
With Neo Elite, I can do multiple pulses in a series without concern of burns or collateral damage. Most skin of color acne patients will see an improvement after the first treatment, but we typically recommend an average of two to four treatments for most indications. Once patients are happy with the results, I transition them to monthly treatment sessions.
The Neo Elite is safe and effective for skin of color. Many of my skin of color patients now ask for this laser by name because they have read about it online and in patient reviews. Once your skin of color patients are aware of this laser, its multitude of benefits, and its safety profile, they will become vocal ambassadors for your practice. Encourage them to tell their friends and to post reviews if they are happy with the results.
Michelle F. Henry, MD is a board-certified dermatologist in private practice at the Laser & Skin Surgery Center of New York.
Wendy Roberts, MD is a board-certified dermatologist and dermatopathologist. Her private practice is based in Rancho Mirage, CA.
1.Skin of Color Society. Statistics. https://skinofcolorsociety.org
2. Roberts WE, Henry M, Burgess C, et al. Laser treatment of skin of color for medical and aesthetic uses with a new 650-micro- second ND:YAG 1064nm Laser. J Drugs Dermatol. 2019; 18(4):s135-s137
Treatment of Hyperpigmentation on Skin of Color Using a 650 Microsecond Pulsed 1064nm Laser
By: Michelle Henry, MD
As published at the 2018 American Society of Dermatologic Surgery Annual Meeting
Description: Hyperpigmentation is a common cosmetic concern in skin of color, with the underlying cause often link to melasma or PIH (Post-Inflammatory Hyperpigmentation) from existing or past presence of conditions such as acne or pseudofolliculitis barbae (PFB). Clearance of hyperpigmentation in skin of color is a challenging application, as many modalities used in aesthetic medicine can exacerbate such conditions rather than clearing them. Subjects of Fitzpatrick Skin Types V-VI were enrolled to be treated using a 650 Microsecond 1064nm laser with a single handpiece (LightPod Neo, Aerolase, Tarrytown, NY). No anesthetics, cooling, or gels were needed. Subjects were treated 3-6 times with a treatment interval of 3-4 weeks. Using fluences ranging from 14-21 J/cm2, the laser energy was applied with a combination of painting techniques and spot treatments.
A Novel 0.65 Millisecond Pulsed 1064 nm Laser to Treat Skin of Color Without Skin Cooling or Anesthetics
By: Fran Cook-Bolden, MD, Dermatology, New York, NY
Journal of Drugs in Dermatology, December 2011
Description: The Nd:YAG 1064 nm has become the gold standard laser modality for safely treating all skin types and specifically skin of color. The 1064 nm laser technologies with ultra long pulse durations generally require anesthetics as well as skin cooling in order for patients to tolerate the treatment. The use of anesthetics and gels can involve considerable time, cost and mess. The development of a new 1064 nm laser technology with a unique 0.65 msec pulse duration now enables virtually pain-free treatment of skin of color, with no need for skin cooling or anesthetics and no skin contact during treatment by the handpiece. This uniquely gentle, sanitary, and effective laser treatment experience for patients of color can increase the likelihood that they will return for follow-up treatment sessions and also recommend the treatment to others.
Laser Treatment of Pseudofolliculitis Barbae
By: Dr. Arusha Campbell-Chambers, Dermatology, Jamaica, West Indies
American Journal of Aesthetic Medicine, May 2015
Description: Although traditional lasers and light devices use relatively long pulse durations for hair removal, a novel short pulsed 0.65ms portable Nd:YAG laser has been found to be safe and effective for hair removal.38 In addition, it carries the added benefit of gentler yet efficacious treatment,39 requiring no gels, no skin contact with the laser, no anesthesia and often no cooling.
There have been a number of studies on the efficacy of various laser systems for hair removal and PFB treatment. Some studies suffer from small sample sizes and follow-up is at times inadequate. Most studies use mean lesion count and percentage hair reduction as their measure of outcome.
In a small study using the 0.65ms Nd:YAG laser, one half of each axilla of six female patients was treated and the other side was monitored as a control.38 The treatment sides were treated with a fluence of either 21 J/cm2 or 36 J/ cm2 and a manual hair count was done before treatment and at each follow-up visit. Four months after four monthly treatments, the hair reduction was graded as five (75%-100% reduction) on the high fluence side and four (50%-75% reduction) on the low fluence end by individuals and investigators. On the high fluence side, the average hair count went from 114 to 28 (76% reduction) and in the low fluence areas from 135 to 38 (72% reduction).
Treatment of PFB with a 650-microsecond Pulsed Nd:YAG 1064nm Laser
By: Arthur J. Sumrall, MD, Dermatology, Indianapolis, IN
Published at the 2006 AAD Annual Meeting
Description: 16 female patients aged 25-69 and 6 males aged 34-58 were treated on the beard, anterior neck and chin areas. A portable MicroPulse™ 650μs Nd:YAG 1064nm laser was used. During treatment one pass was applied over the affected area. A fluence of 20-25 j/cm2 was used with a pulse duration of 650μs, spot size of 6mm and a repetition rate of 1Hz. 6 males with skin type VI were treated with a fluence of 25 j/cm2, while 10 females with skin type V and 6 females with skin type VI were treated with a fluence of 25 j/cm2.be safe and effective in removing PFB on patients of Fitzpatrick skin types V and VI. The device is portable and easy to use. The treatment is quick and practically painless.
Treatment of Pseudofolliculitis Barbae with a Compact Nd:YAG 1064nm Laser Using 650-microsecond Technology
By: Michael H. Gold, MD, Dermatology, Nashville, TN
Description: Pseudofolliculitis barbae (PFB) is a foreign body inflammatory reaction caused by ingrown hairs. PFB occurs most frequently in the beard areas of 45% to 83% of African-American men who shave.1 When coarse curled hair is shaved, the tips become pointed. These sharp tips, by either extrafollicular or transfollicular penetration, grow into the skin and lead to the formation of painful, pruritic pustules and papules.1, 2 In extrafollicular penetration, the sharp hair tip curves backward toward the skin and pierces the epidermis close to the hair follicle,3 then continues downward to the dermis. Inflammatory reactions occur in both the epidermis and dermis. Transfollicular penetration occurs when shaving is against the grain and the pointed hair tip grows downward and pierces the follicular wall, resulting in inflammatory papules.4
A variety of therapies are available for the treat- ment of PFB. Surgical depilation is associated with high morbidity,5 topical agents (corticosteroids, retinoids, and antibiotics) seldom clear all papules and pustules,6 chemical depilatories may irritate the skin,6 and electrolysis is labor-intensive.5 Alpha-hydroxy acid and chemical peels have been useful in some patients.1 Lasers, including the long- pulsed alexandrite,7 Q-switched Nd:YAG,8 ruby,9 and 800-nm diode 5,10,11 have also been used to treat PFB.
Traditional laser procedures, though effective, are limited by patient discomfort and prolonged healing times, both due to heat-induced skin damage. This report presents two of four case studies describing the use of a new compact Nd:YAG 1064-nm laser using micropulse technology for the treatment of PFB.
Skin Rejuvenation on Skin Types I to V Using a 300-microsecond Pulsed Er:YAG 2940nm Laser in Sub Ablative Mode
By: James Gordon, MD, Ophthalmology, White Plains, NY | Khalil Khatri, MD, Dermatology, Cambridge, MA | Viktor Moiseev, MD, Dermatology, Ryazan, Russia
Description: Laser resurfacing has been a popular procedure to reverse the effects of aging. CO2 and Erbium:YAG lasers are highly effective in treatment of wrinkles and acne scars. These ablative lasers have long down-time and limit patient’s activities. These lasers can result in significant pigmentary changes and if not used with a proper technique by well trained laser surgeons, it can result in disfiguring scarring. Due to these limitations, almost all available lasers were tried to be used for non-ablative resurfacing. These reduced the down-time and risk of complications but effectiveness was not comparable. Fractional lasers were introduced to get the same kind of results. Non-ablative fractional lasers did not produce the same effectiveness as ablative CO2 or Er:YAG lasers. This led to the development of Ablative fractional lasers. Ablative lasers have been used at low fluence, but in ablative mode to treat mild photoaging and acne scars. This study is to evaluate the use of an Erbium:YAG laser in a “sub-ablative” mode where there is a heating of the surface tissue with no ablation.
In this multi-center study 35 subjects were treated with 3 passes in a sub-ablative mode. The treatments were repeated 2-4 times. No topical anesthesia or skin cooling was required.
Subjects tolerated the procedure well. Subjects experienced slight peeling of facial skin, if any, for 2-4 days after the treatment. There was improvement in skin texture, pore size, pigmentation, etc. There were no complications, except one subject developing transitory mild hyperpigmentation. This study shows that Er:YAG laser in a sub-ablative mode is safe, gentle and effective for facial skin rejuvenation
Arthur J. Sumrall, MD, Dermatology, Indianapolis, IN
16 female patients aged 25-69 and 6 males aged 34-58 were treated on the beard, anterior neck and chin areas. A portable MicroPulse™ 650μs Nd:YAG 1064nm laser was used. During treatment, one pass was applied over the affected area. A fluence of 20-25 j/cm2 was used with a pulse duration of 650μs, spot size of 6mm and a repetition rate of 1Hz. 6 males with skin type VI were treated with a fluence of 25 j/cm2, while 10 females with skin type V and 6 females with skin type VI were treated with a fluence of 25 j/cm2.be safe and effective in removing PFB on patients of Fitzpatrick skin types V and VI. The device is portable and easy to use. The treatment is quick and practically painless.
Journal of Cosmetic Dermatology, July 2020
David J. Goldberg MD, JD; Katarina Kesty MD, MBA; Skin Laser and Surgery Specialists of NY & NJ, Hackensack, NJ, USA
Acne vulgaris is one of the most common conditions treated by dermatologists.1 The pathogenesis of acne is multifactorial. Epidermal hyperproliferation and excess sebum production result in blockage of the pilosebaceous units. This is followed by increased proliferation and activity of commensal skin bacteria Propionibacterium acnes, resulting in subsequent inflammation.2,3 Moderate acne is traditionally treated with topical cleansers, retinoids, and antibiotics. Moderate-to-severe acne may sometimes require additional treatment with systemic antibiotics or retinoids.4 Treatments can often be irritating, unsatisfactory, and the chronic exacerbations and remissions throughout adolescence and adulthood can have a major impact on patient quality of life.5,6 Devices and lasers are often employed as an adjunctive treatment for acne and acne scarring. Common treatments include chemical peels, nonablative radiofrequency, and microneedling with radiofrequency.7–11 Studies have reported some efficacy of laser treatment.12–16 Laser therapy can be successful in diminishing acne vulgaris lesions by halting overactive sebaceous gland activity and alleviating the effects of inflammation. The mechanism of action is thought to be by activation of porphyrins produced by Propionibacterium acnes, resulting in the destruction of cell membranes of these bacteria. Lasers with a 1064 nm wavelength have been studied for acne. One study done by Ballin and Ubelhoer treated one patient with 10 sessions of a laser with 1064-nm Nd:YAG and resulted in almost 100% clearance of lesions.17 Another study compared intense-pulsed light with 1064-nm Nd:YAG and found no significant difference in the treatment of acne.18
Typical Nd:YAG 1064nm lasers operate with longer pulse durations anywhere from 3 to 30 milliseconds. The laser used in this study has a 650-microsecond pulse duration. This is a new technology where all necessary power settings from 4 J/cm2 to 255 J/ cm2 can be delivered within a 650-microsecond pulse in a variety of spot sizes and at a fast repetition rate of up to 2.0 Hz. A total of 650 microseconds is below the thermal relaxation time of the skin tissue, so the skin has time to cool itself between pulses, thus confining the heat in the selectively absorbed target for higher clinical efficacy and safety to the surrounding skin.19 The high-energy pulse is delivered into the target in such a short-pulse duration. The targeted structure has less time to lose heat, through conduction, to the surrounding skin, so the target reaches a higher temperature.
A higher temperature in the targeted tissue translates into greater target tissue destruction for higher efficacy. We undertook a randomized controlled study evaluating the use of 650-microsecond 1064 nm Nd:YAG laser compared with a sham in the treatment of moderate-to-severe acne.
Tanya Greywal, MD, Arisa Ortiz, MD
Ortiz, A., Greywal, T. “1064nm Nd:YAG LASER WITH A 650ms PULSE DURATION FOR THE TREATMENT OF MELASMA: A CLINICAL EVALUATION.” Lasers Surg Med. 2019 Mar;51(S31):S13-14.
Background: The effective treatment of melasma remains a therapeutic challenge. The 1064nm Nd:YAG laser with a 650- microsecond pulse duration is safe for all skin types and is more tolerable then conventional long-pulsed Nd:YAG lasers. We aim to evaluate the efficacy and safety of the 1064nm Nd:YAG laser with a 650-microsecond pulse duration for the treatment of melasma.
Study Design/Materials and Method: Patients were treated with the 1064nm Nd:YAG laser with a 650-microsecond pulse duration. The energy mode ranged from 3 to 4, which corresponds to a fluence of 11 to 14 J/cm2 with a 6mm spot size, and 3 passes were performed per treatment session. Each treatment session was scheduled approximately 3-4 weeks apart, and photographs were taken prior to each treatment.
Melasma is widely known as a pigmentation disorder that has a profound effect on quality of life for those with the affliction(1). Studies report patients with pigmentation disorders feel self-conscious, unattractive, that it affected their daily activities and they felt the need to put effort into hiding their condition or else others would be attentive to it(1). While melasma affects people of all skin types, it is predominant in women with darker skin (Fitzpatrick III-VI)(2), which can add further difficulty to an already hard-to-treat, chronic disorder(3).
Melasma is becoming increasingly common. Some dermatologic centers cite it as being the most commonly seen condition next to acne(4), yet there is a large percentage of that population who are not seeking treatment largely due to unawareness of treatment options(5). For those that do seek treatment, a familiar, collective approach to address melasma (in the medical setting) has traditionally come in the form of hydroquinone or other topical compounds, chemical peels, microdermabrasion or Q-switched lasers(3).
Building upon these traditional treatment options, Aerolase, with the clinical expertise of Washington DC based dermatologist, Cheryl Burgess, MD, have developed a two-step, “one-two punch” protocol to effectively address melasma in all skin types within a single treatment session. First, Aerolase’s 650-microsecond 1064nm Nd:YAG laser technology offers a solution to address the deeper, dermal melanin and vascular components(6) of melasma, while also helping to break up the epidermal pigment. The laser energy is painted over the entire facial area at fluences of up to 28 J/cm2. Then, depending on the patient’s skin type and condition, either a light to medium chemical peel or hydroquinone compound is applied to address the remaining epidermal pigmentation.
“We have had great success removing dermal pigmentation with the Neo due to its depth of penetration and speed of the pulse,” says Dr. Burgess. “Then, we (typically) layer that with either a chemical peel or hydroquinone to generate a new epidermis to remove superficial pigmentary concerns and if blending is needed, we may use a hydroquinone compound,” she continues.
Published in Global Dermatology Volume 1(1): 9-12
Unwanted hair causes significant stress in patients resulting in anxiety, depression and overall reduced quality of life . Since their development in the 1960s, laser hair removal systems have continued to grow in popularity, as they are now one of the most common cosmetic procedures performed by dermatologists . Unlike other hair removal techniques such as waxing, shaving, and electrolysis, laser hair removal is an efficient way to permanently reduce hair growth and has thus become the gold standard . Laser, which stands for “light amplification stimulated emission of radiation” is a type of selective photothermolysis that targets light absorbing molecules or chromophores at a specific wavelength . Melanin found in hair follicles is the chromophore that absorbs the energy emitted by laser and transforms it into heat that selectively damages hair follicles . Today, there are a variety of laser hair removal systems used to target a variety of hair colors and skin types. Lasers utilizing shorter wavelengths such as the Ruby laser (694 nm) and Alexandrite laser (755 nm) have more superficial penetration into the epidermis and therefore have increased risk for epidermal melanin absorption and injury to the surrounding skin . Subsequently, these lasers are typically avoided in patients with darker skin types (Fitzpatrick phototypes III-VI). Lasers with longer wavelengths, such as the Nd:YAG 1064 nm laser, provide deeper epidermal penetration to target follicular melanin with less absorption of surrounding skin. These lasers have been shown to be safe and effective for removal of hair in darker skin types .
In addition to selecting lasers with the appropriate wavelengths, determining the pulse duration and fluence (energy per square area) to optimize results and minimize side effects is also of utmost importance. High fluence and long pulse duration allows heat to diffuse to surrounding tissue and increases the risk for side effects such as scarring . Pulse durations, in order to be effective should be shorter than or equal to the thermal relaxation time (TRT) of the hair shaft , which is estimated to be between 10 and 50 milliseconds . As a result, most currently available laser hair removal systems use millisecond pulse widths.
Similarly, the majority of the studies that exist on Nd:YAG lasers exist on traditional long pulsed Nd:YAG lasers that deliver pulse widths of 3 to 30 milliseconds of fluence. These long pulsed Nd:YAG lasers are typically used with cooling systems to further reduce the incidence of epidermal damage. However, a 650 microsecond (μs) technique Nd:YAG laser has recently been found to have comparable results to longer pulse duration Nd:YAG lasers without skin cooling measures . is study was conducted to evaluate the safety and patient satisfaction with laser hair removal using a novel portable and relatively inexpensive Nd:YAG laser with a short pulse of 650 μs.