Ứng Dụng Laser Trong Da Liễu Và Y Học (2018)

87
lower threshold for whitening due to a higher epi-
dermal melanin content [11]. With increasing
wavelengths, melanin absorption decreases, and
the required threshold laser exposure dose
increases [12, 13]. Subthreshold fluences appear
to actually stimulate melanogenesis because of
activation of epidermal melanocytes after non-
lethal injury [14] (Fig. 6.4).
Q-switched and Pulsed Lasers
and Light Sources
Selective damage to melanosomes in human skin
was first demonstrated with a 351  nm XeF
excimer laser delivering 20  ns pulses [15].
Although light at 351  nm is well absorbed by
melanin, this short wavelength only penetrates
<100 μm into the skin due to light scattering [16].
It was subsequently found that selective melano-
some damage could be produced by also the
pulsed tunable dye laser [12, 17] (wavelength
435–750  nm, pulse width 300–750  ns),
Q-switched ruby laser [6] (wavelength 694 nm,
pulse width 40  ns) and the Q-switched
neodymium:YAG laser [13] (wavelength 355,
532, and 1064 nm, pulse width 10–12 ns). While
shorter wavelengths, such as 351 nm are better at
absorbing melanin, longer wavelengths penetrate
deeper into the skin, increasing their ability to
reach deeper melanosomes (Fig. 6.5).
Several lasers can be used today to treat pig-
mented skin lesions (Table  6.1). These include
lasers that are: 1) pigment nonselective, 2) highly
pigment selective, 3) and those that are somewhat
pigment selective.
Pigment Non selective Lasers
The carbon dioxide [4, 18] (10,600 nm), erbium-­
YAG (2940 nm) and Erbium glass (1540 nm) and
yttrium scandium gallium garnet (YSGG)
(2790 nm) lasers are pigment nonselective lasers
that remove epidermal pigment because of their
ability to target water and ablate the entire epi-
dermis, including melanocytes and melanized
keratinocytes.
Earlier
devices
removed
a
­relatively uniform layer of the epidermis and
with the epidermis went the associated pigment.
Depending on the amount of energy delivered a
thinner or thicker layer of the epidermis and adja-
cent dermis is affected by the treatment. Over
24–48 h the epidermis is shed, including melano-
cytes and pigment laden keratinocytes, and is
then regenerated, leaving behind a new epidermis
with less unwanted sun induced pigment. Newer
fractionated laser technologies damage columns
of the epidermis and dermis while leaving inter-
spersed areas unaffected. In this manner, there is
faster healing as the surrounding normal tissue
heals each light column of damage (Fig.  6.6).
Melanocyte
dendritic processes
Melanosomes
Melanocyte nucleus
Dermal-epidermal junction
Dermis
Epidermis
Fig. 6.2  Melanocyte residing
within the epidermis.
Melanosomes extend throughout
the dendritic processes and are
transferred to neighboring
keratinocytes (Modified from
)
6  Lasers and Lights for Treating Pigmented Lesions

88
The
fractionated
CO2
and
fractionated
erbium:YAG lasers work in the same manner as
their non-­fractionated counterparts but deliver
the light in many small columns. Because only
fractions of the pigmented epidermis are affected,
it stands to reason that a series of treatments is
necessary to achieve the desired result and at
least some of the original pigmented epidermal
lesion would remain even after a series of treat-
ments resulting in incomplete lesion removal.
The fractionated technology is also employed
with the 1927 nm thulium laser. Although a non-­
ablative laser, it targets waters and has a water
absorption coefficient that is 10 times that of the
a
b
c
d
Fig. 6.3  Electron
micrograph obtained
immediately after
Q-switched ruby laser
irradiation. The targeted
melanosome shows
membrane disruption
with disorganization of
its internal contents (a)
prior to irradiation; (b)
immediately after
irradiation showing
early melanosome
disruption; (c) more
disruption; (d) almost
complete disruption of a
melanosome
immediately after
irradiation (From Arndt
KA, Dover JS, Olbricht
SM. Lasers in
Cutaneous and Aesthetic
Surgery. Philadelphia:
Lippincott-Raven;
1997.)
E. M. Graber and J. S. Dover

89
1550 and 1540 nm non-ablative infrared lasers.
The 1927 nm thulium laser induces damage in
the epidermis and the upper dermis thereby non
selectively diminishing pigmented epidermal
lesions [19].
Highly Pigment Selective Lasers
Older technologies, such as continuous wave
(CW) and quasi-CW visible light lasers, including
the argon laser (488, 514 nm), copper vapor laser
(511 nm), and krypton laser (521, 530 nm), can be
a
b
Fig. 6.4  Histologic appearance of black guinea pig skin
immediately after irradiation with the Q-switched ruby
laser. (a) Characteristic “ring cell” formation in the basal
lamina, representing melanocytes and keratinocytes with
condensed nuclear and pigment material at their peripher-
ies. (b) Similar changes in a hair follicle (From Arndt KA,
Dover JS, Olbricht SM. Lasers in Cutaneous and Aesthetic
Surgery. Philadelphia: Lippincott-Raven; 1997.)
Excimer
193nm
Nd:YAG
2940nm
Nd:YAG
1064nm
CO2
10,600nm
Argon
488-514nm
KTP
532nm
PDL
585-600nm
Ruby
694nm
Alexandrite
755nm
Diode
800nm
Stratum comeum
Epidermis
Dermis
Dermal vessels
Subcutaneous fat
Fig. 6.5  Laser depth of penetration. Depth of penetration
for lasers of varying wavelengths. For lasers in the visible
and near infrared ranges, the depth of penetration increases
as the wavelength increases (From Bolognia, et  al.
Dermatology. 2003)
6  Lasers and Lights for Treating Pigmented Lesions

90
used to selectively remove epidermal pigmented
lesions. However, spatial thermal injury confine-
ment is not possible and unaffected adjacent skin
may also be damaged. The risk/benefit ratio is
higher with these CW and quasi-CW devices.
There are three short-pulsed, pigment selec-
tive lasers that are widely used today: 1) the
Q-switched ruby laser (QSRL) (694  nm), 2)
the Q-switched alexandrite laser (755 nm), and 3)
the Q-switched neodymium:YAG (Nd:YAG and
KTP) laser (1064, 532 nm). These lasers selec-
tively target melanin by delivering high-intensity,
short-pulsed radiation at varying wavelengths.
“Q-switched” is an abbreviation for “quality-­
switched” and refers to lasers which release an
extremely high powered pulse (109 W) with an
ultra-short pulse duration. Through the use of an
optical shutter, these lasers store large amounts of
energy in the laser cavity and then release the
stored energy when the laser fires.
Table 6.1  Lasers in the treatment of pigmented lesion
Device
Manufacturer Laser type
Wavelength
(nm)
Pulse
duration
Spot
size
(mm)
Maximum
repetition
rate(Hz)
Comments
Spectrum
RD-1200
Palomar
QS Ruby
694
28 ns
5, 6.5
0.8
Large spot size
promotes deeper
penetration
EpiTouch
Lumenis
QS Ruby
694
25 ns
5
0.8
Long pulse mode
available for hair
removal
Sinon
Wavelight
QS Ruby
694
15–40 ns
3–9
20
Long pulse mode
available for hair
removal
AlexLAZR
Candela
QS
alexandrite
755
50 ns
2, 3, 4
5
Fiberoptic delivery
system
VersaPulse
VPC
Lumenis
FD Nd:
YAG
532
2–50 ms
2–10
6
Four lasers within
one box
QS FD Nd:
YAG
532
4 ns
2–6
10
QS Nd:
YAG
1064
5 ns
2–6
10
QS
alexandrite
755
45 ns
2–6
10
Medlite C6
HOYA
QS FD Nd:
YAG
532
5–20 ns
2, 3, 4,
6
10
Handpiece
converts l–585 and
650 nm
ConBio
QS Nd :
YAG
1064
5–20 ns
3, 4, 6,
8
10
Alex
Candela
QS FD Nd:
YAG
532
50 ns
2, 3, 5
5
TriVantage
QS
alexandrite
755
2, 3, 4
5
QS Nd:
YAG
1064
2, 3, 5
5
SkinClear
Sybaritic
QS FD Nd:
YAG
532
10 ns
1, 2, 3
QS Nd:
YAG
1064
10 ns
1, 2, 3
Naturalase
Focus
QS FD Nd:
YAG
532
10–20 ns
7
Medical
QS Nd:
YAG
1064
10–20 ns
7
QS Q-switched, FD frequency doubled
E. M. Graber and J. S. Dover

91
The QSRL emits red light at a wavelength of
694  nm and a pulse duration of 28–40  ns
(Table 6.1). Light is delivered through a mirrored
articulated arm at a spot size of 5 or 6.5 mm and
a repetition rate of 2 Hz. The Q-switched alexan-
drite laser has a near infrared wavelength of
755 nm, pulse duration of 50–100 ns, spot size of
2–4  mm, and a repetition rate up to 10  Hz.
Depending on the exact device, light is delivered
either through an articulated arm or through a
semi-flexible fiber optic cable. The Q-switched
Nd:YAG laser emits infrared light at 1064 nm.
The wavelength can be halved by placing a
frequency-­doubling
KTP
(potassium-titanyl-­
phosphate) crystal in the laser beam’s path. Dye-­
impregnated handpieces can convert the 532 nm
wavelength to either 585 nm (yellow) or 650 nm
(red). An articulated arm delivers pulses with a
spot size to 1.5–8  mm, a pulse duration of
5–10 ns, and a repetition rate up to 10 Hz.
There are newer Q-switched lasers that emit
even shorter pulse durations, in the picosecond
range, as opposed to the nanosecond pulse dura-
tions of most Q-switched lasers. Picosecond
lasers were originally studied for tattoo removal
but more recently their effectiveness in the treat-
ment of epidermal and dermal pigmented lesions
has been demonstrated [20, 21].
Long-pulsed (millisecond rather than nano-
second domain) 532 nm (KTP) Nd:YAG lasers
and 595 nm pulsed-dye lasers, which are tradi-
tionally used to treat vascular lesions, can also be
used to treat superficial pigmented lesions.
However, the long pulse width of these lasers is
close to the thermal relaxation time of the entire
epidermis (about 10 ms) [22] and therefore does
not allow for selective damage to melanosomes.
Because of their longer pulse width, millisecond
domain lasers produce a purely thermal effect on
their target, unlike the photomechanical effect of
Q-switched lasers. The target in this case may in
fact be melanocytes rather than melanosomes.
Regardless, these longer pulse duration devices,
just like intense pulsed light devices are highly
effective in removing unwanted epidermal pig-
ment. These lasers are not suitable for treating
dermal pigmented lesions because of the limited
penetration depth [23] Although no longer manu-
factured, a pigmented lesion pulsed dye laser
(non-Q-switched) used a xenon flashlamp to
pump a coumarin-containing dye that expelled
pulses of green light at 510  nm. Although this
laser was useful for epidermal lesions, its shallow
penetration made it much less effective on dermal
lesions.
The Q-switched ruby, alexandrite and Nd:YAG
lasers also have long-pulsed counterparts with the
same wavelengths that operate in a normal (non-
Q-switched) mode. These normal mode lasers are
often used for laser hair removal because their
higher fluences and longer pulse durations target
large pigmented structures such as hair follicles or
nests of cells rather than individual melanosomes
Fig. 6.6  Fractionated erbium glass laser causing tissue
coagulation in a narrow microthermal zone of injury
(From Vikramaditya P, Bedi MS, et al. The effects of pulse
energy variations on the dimensions of microscopic ther-
mal treatment zones in nonablative fractional resurfacing.
Lasers Surg Med. 2007;39: 145–155, with permission of
John Wiley and Sons.)
6  Lasers and Lights for Treating Pigmented Lesions

92
or pigmented cells [24] Normal mode lasers have
been shown to be effective in the removal of epi-
dermal pigmented lesions but are not ideal
because damage may be imparted on surrounding
tissue.
Non-coherent light sources (intense pulsed
light or IPL) can also be used for pigment
removal. Polychromatic light is emitted ranging
from 515 to 1200 nm (visible to infrared) and fil-
ters are used to cut off the light above or below
predetermined wavelengths. Since melanin
exhibits a broad absorption spectrum, monochro-
matic laser devices are not necessary to target
superficial melanin. The shorter wavelengths
emitted by IPL devices are highly absorbed by
melanin. IPL devices release light as a series of
single, double, or triple pulses (millisecond
domain). Like the millisecond domain lasers, the
millisecond pulse width of IPL devices approxi-
mates the thermal relaxation time of the epider-
mis (10  ms) and produces a photothermal, not
photomechanical effect, on its target. To avoid
damage to normal surrounding epidermis, most
IPL devices have skin cooling during treatment
to protect the epidermis from excessive thermal
injury. The IPL devices should not be used for
dermal pigmented lesions.
Indications and Contraindications
• Ephelides, lentigines, and café au lait mac-
ules, are common epidermal pigmented
lesions that respond to laser and light
treatment.
• Melanocytic nevi, nevus of Ota and other
dermal
melanocytoses,
melasma,
post-­
inflammatory hyperpigmentation, and drug
induced pigmentation are dermal pigmented
lesions that can be treated with lasers. Of
these, only nevus of Ota and other dermal
melanocytoses
respond
predictably
and
favorably.
• Shorter laser wavelengths may suffice for epi-
dermal lesions as deep tissue penetration is
not necessary.
• Long wavelengths are required for dermal
pigmented lesions.
• Multiple treatments are often needed for com-
plete removal.
• Anesthesia may be needed for larger or der-
mal lesions.
Epidermal Pigmented Lesions
Many clinical studies have proven the efficacy
and safety of Q-switched lasers [25–27] and the
510 nm pulsed dye laser [28] in the treatment of
various epidermal pigmented lesions, including:
ephelides, lentigines, Café au lait macules, sebor-
rheic keratoses, nevi spilus, and Becker’s nevi.
Since pigment in epidermal lesions is found
superficially, shorter-wavelength devices can be
used successfully despite their limited penetra-
tion depth. For example, the 510 nm wavelength
of the pigmented lesion pulsed dye laser and
532 nm pulsed lasers are highly absorbed by mel-
anin but penetrates only about 250 μm into the
skin [16] The Q-switched ruby and alexandrite
lasers effectively treat both epidermal and dermal
pigmented lesions since their wavelengths are
still within the melanin absorption spectrum and
they penetrate deeply into the dermis. The
Nd:YAG (1064 nm) laser penetrates deeply but is
poorly absorbed by melanin, making the 532 nm
wavelength preferable for epidermal lesions.
When using the 510 nm and 532 nm wavelengths,
hemoglobin competes with melanin for absorp-
tion of light. Nanosecond pulses at these wave-
lengths causes rupture of superficial blood
vessels, manifesting clinically as purpura [12].
Lentigines
Lentigines are extremely common hyperpig-
mented macules that are most often due to
chronic sun exposure and are then referred to as
solar lentigines. On pathology lentigines dis-
play increased single melanocytes along the
basal layer with elongation of club-shaped rete
ridges. In addition to solar lentigines, there are
lentigines associated with a syndrome (e.g.
Peutz-Jeghers) and labial melanotic macules
(labial lentigines). All three Q-switched lasers
are highly effective for treating all types of len-
tigines [29, 30] Both 35% trichloroacetic acid
E. M. Graber and J. S. Dover

93
peels and cryotherapy are inferior to Q-switched
lasers in the treatment of lentigines [31, 32].
With one treatment using a Q-switched laser, at
least 50% clearing of lentigines is expected, and
additional treatments may be utilized to remove
remaining pigment (Figs. 6.7 and 6.8). Although
less selective, non Q-switched (millisecond
domain) KTP, 595 nm pulsed-dye, ruby, alexan-
drite, and diode lasers may also be used to treat
lentigines. A study of Asian patients with len-
tigines found a long-pulsed KTP (532 nm) laser
(without skin cooling) to be as effective as a
532 nm Q-switched Nd:YAG laser, and with less
risk of post-inflammatory hyperpigmentation.
Additionally, a study using a 595 nm pulsed-dye
laser on lentigines in Asian patients showed a
mean of 82% improvement in lentigines by
reflectance spectrometry [23]. Several studies
have also demonstrated the effectiveness of
broad band light sources (Intense Pulsed Light)
in clearing lentigines. Adjunctive use of 5-ami-
nolevulinic acid (5-ALA) with IPL provides
greater improvement of epidermal pigment than
with IPL alone [33–35].
The fractional 1927 nm thulium laser is highly
effective in treating lentigines and is safe for both
facial and non-facial sites. One study showed an
average of over 50% improvement of lentigines
after three treatments with a 1927 nm laser [36].
Its benefit is homogeneous improvement of the
entire treated area making it ideal for treating
dyspigmentation associated with photoaging of
the face, neck, chest and extremities.
Café au Lait Macules
Café au lait macules (CALMs) are well circum-
scribed, homogenous light brown macules that
occur as isolated lesions in the general popula-
tion. Their prevalence varies amongst ethnicities
but ranges from 0.2% to 18% [37]. Café au lait
macules may also be found as multiple lesions in
association with a syndrome (e.g. neurofibroma-
tosis, Noonan syndrome). Histologically, there is
an increase in melanocytes along the basal layer,
hypermelanosis of melanocytes and keratino-
cytes, and giant melanin granules. Treatment of
CALMs with lasers is minimally successful and
often unpredictable [38]. Temporary lightening
or clearing can be achieved after multiple treat-
ments (Fig. 6.9). However, recurrences are seen
in up to 50% of treated lesions, even when clear-
ing is initially achieved. Post-inflammatory
hyperpigmentation is frequent following laser
treatment of CALMs, especially in patients with
darker skin types. Alster demonstrated complete
elimination of most CALMs after an average of
8.4 treatment sessions with the 510  nm pulsed
dye laser, indicating that multiple treatments are
a
b
Fig. 6.7  (a) A woman in her early 40 s with significant
photoaging and numerous lentigines prior to treatment.
(b) Six weeks after one single treatment with a Q-switched
ruby laser. There is about 70% improvement of the lesion.
No further treatments were requested by the patient
6  Lasers and Lights for Treating Pigmented Lesions

94
needed for complete resolution [39, 40]. Er:YAG
resurfacing has also been shown to eliminate
CALMs [40].
Other Epidermal Lesions
Ephelides (freckles) are hyperpigmented small
macules located on sun-exposed skin and
become darker in the summer and lighter in the
winter. There is no increase in the number of
melanocytes on pathology, but there is an
increase in melanin. Ephelides respond well to
Q-switched laser treatment. Another common
lesion, seborrheic keratoses, may respond to
laser treatment. In general, thinner seborrheic
keratoses respond better to laser treatment than
thick lesions [28]. Cryotherapy or cryotherapy
in combination with laser treatment is preferred
to laser treatment alone for thick seborrheic ker-
atoses. A nevus spilus (speckled lentiginous
nevus) consists of a background CALM and
scattered nests of nevi cells. Successful clearing
of the darker nevocellular component has been
reported with the QSRL, but the CALM compo-
nent tends to recur [25]. A Becker’s nevus is a
hyperpigmented, hair-­bearing plaque that most
commonly occurs on the upper trunk or shoul-
der of males. These lesions may also be associ-
ated with a dermal smooth muscle hamartoma.
The hyperpigmented component of Becker’s
nevi respond similarly to laser treatment as
CALMs, having frequent recurrences (within
6–12 months) and post-­inflammatory hyperpig-
mentation [41].
Fig. 6.8  A patient’s right hand with copious solar lentigi-
nes and the patient’s left hand with significantly fewer
solar lentigines after two Q-switched alexandrite
treatments
a
b
Fig. 6.9  (a) A young Asian patient with a café au lait macule on her right cheek. (b) After a series of treatments with
the Q-switched laser, the café au lait macule has cleared markedly
E. M. Graber and J. S. Dover

95
Dermal Pigmented Lesions
Q-switched lasers have revolutionized the treat-
ment of dermal pigmented lesions including:
melanocytic nevi, nevus of Ota, and melasma.
Prior to the advent of Q-switched lasers, these
lesions were treated with nonspecific destructive
means such as excision [42, 43], dermabrasion
[44], salabrasion [45], cryotherapy [46], solid
carbon dioxide ice [47], or continuous wave laser
ablation [48]. These older methods were ineffec-
tive and often caused scarring or dyspigmenta-
tion. By selectively targeting dermal melanin,
Q-switched lasers provide effective treatment of
these lesions without risking textural or pigment
alteration. The Q-switched ruby, alexandrite and
1064 nm Nd:YAG are the most commonly used
lasers. All of these lasers are still within the
absorption spectrum of melanin yet also have
wavelengths that are long enough to penetrate
into the dermis. Broad band light sources (such
as IPL) lack wavelength specificity and have lon-
ger (millisecond range rather than nanosecond
range) pulse durations, making them unsuitable
for treating dermal pigmented lesions.
Melanocytic Nevi
Laser treatment of melanocytic nevi is controver-
sial since it is unclear whether laser irradiation
has any potential to induce malignant change in
nevus cells. In vitro studies of melanoma cells
treated with Q-switched lasers have found
changes in cell surface integrin expression, with
subsequent alteration of cell migration [49].
Another in vitro study found a significant increase
in p16INK4a in p16 positive cell lines following
irradiation with Q-switched laser light and sug-
gested that sub-lethal laser damage may increase
DNA damage leading to an increase in p16
expression [50]. In clinical practice, benign
appearing nevi that tend to recur following laser
treatment may show newfound clinical and histo-
logic atypia, referred to as pseudomelanoma
[51]. Despite this, there has never been a report of
true malignant transformation of a benign pig-
mented lesion following laser treatment [52].
Theoretically, laser treatment of melanocytic
lesions may decrease the risk of malignant trans-
formation of a benign pigmented lesion simply
by reducing the population of existing potentially
premalignant cells. One study reported that no
significant malignant markers (such as prolifera-
tion cell nuclear antigen, pyrimidine dimers,
8-OhdG, and p53) were found following treat-
ment of nevi with Q-switched lasers [53]. While
these findings are notable, additional study is
needed to assess the outcome of Q-switched laser
treatment of nevi. Until more is known, it is pru-
dent to perform a biopsy prior to laser treatment
to confirm the benign nature of the nevus. Laser
treatment should not be performed on nevi in
patients with a personal or family history of
malignant melanoma.
The Q-switched ruby, alexandrite, and
1064 nm Nd:YAG lasers all have some efficacy in
removing flat or slightly raised acquired nevi
[54–56]. Lighter nevi respond best to shorter
wavelengths that maximize melanin absorption,
while darker nevi typically respond to any wave-
length within the melanin absorption spectrum.
Multiple treatments are frequently necessary for
optimal lightening. Clinical lightening is also
associated with the development of a subtle
microscopic scar up to 1 mm thick that obscures
residual nevus cells. It is often unfeasible to attain
complete resolution of nevi [56], and recurrence
after laser treatment is common. There may be
persistence of nevus cells containing little pig-
ment located in the deeper dermis that are
shielded from laser radiation by the more pig-
mented superficial cells [54]. Q-switched laser
radiation does not penetrate sufficiently to effec-
tively treat thicker papillated or dome-shaped
dermal nevi. The short pulsed erbium:YAG laser
has been reported to be quite effective in remov-
ing flat or slightly palpable melanocytic nevi.
Single pulses of 5.2–14 J/cm2 were found to clear
27 of 28 nevi on follow-up and histological
examination [57]. The QSRL has been reported
to successfully eliminate flat blue nevi [58].
Although Q-switched lasers may effectively
lighten congenital nevi, there is frequently repig-
mentation due to persistence of nevus cells within
the deeper reticular dermis and within adnexae
[52, 59]. In a split nevus study on 15 patients,
Kono et al. showed greater clearing with combined
6  Lasers and Lights for Treating Pigmented Lesions

96
Q-switched and normal-mode ruby laser (NMRL)
than in NMRL alone. They also showed a marked
decrease in nevus nests at the dermal-­epidermal
junction, papillary and reticular dermis. In theory,
millisecond-domain pulses are more appropriate
than Q-switched pulses for treating thick lesions
such as congenital nevi because they produce less
selective thermal damage, destroying entire nests
of cells rather than individual pigmented cells.
Japanese investigators have reported impressive
long-term clearing of congenital nevi treated with
the millisecond-­domain normal-mode ruby laser
[24, 60]. However, other investigators have
reported poor results treating congenital nevi with
both Q-switched and normal mode ruby lasers
[61]. Long-pulse ruby lasers also offer the poten-
tial to reduce the amount of hair within congenital
nevi. In Japanese studies, no histological or clini-
cal evidence of malignancy has been demon-
strated up to 8 years after normal-mode ruby laser
treatment [24, 60]. However, since congenital
nevi have the potential to transform into malig-
nant melanoma, and residual nevus cells persist in
the dermis after laser treatment, cautious long-
term follow-up of nevi treated with lasers is
required.
Both continuous wave lasers [62, 63] and the
QSRL [64] have been used to treat lentigo
maligna. Nonetheless, there are several reports of
lentigo maligna recurring following laser treat-
ment, probably due to persistence of melanocytes
within deeper adnexal structures [65, 66]. Laser
treatment of lentigo maligna should be reserved
for extreme situations where surgical excision is
not feasible due to large lesion size, advanced
patient age, or underlying medical condition.
Close follow-up to detect any early recurrence is
critical.
Nevus of Ota
Nevus of Ota (also known as oculodermal mela-
noma or nevus fuscoceruleus ophthalmomaxil-
laris) is a mottled, blue-grey macule that is
usually located unilaterally within the distribu-
tion of the first and second branches of the tri-
geminal nerve. Lesions usually occur in a 5:1
female to male ratio. Asians are most commonly
affected, with an incidence of 1 in 500 reported in
Japan [67]. Nevus of Ota is congenital in about
50% of cases, with others appearing by the sec-
ond decade of life. Nevus of Ota may affect
mucosal surfaces such as cornea, sclera, nasal
and buccal mucosa, and tympanic membrane.
Histologically, elongated dendritic melanocytes
are scattered within the upper dermis. The occur-
rence of melanoma within nevus of Ota has been
reported [68] but is rare.
Q-switched lasers are extremely helpful in
treating Nevus of Ota. The degree of lightening is
usually directly proportional to the number of
treatments performed. Lightening of 70% or
more has been reported in the majority of patients
treated four or five times with the QSRL [69]
(Fig.  6.10). Post-treatment dyspigmentation
occurs occasionally, although textural change has
not been reported. Post-treatment biopsies have
revealed disintegration of melanocytes up to a
depth of 1.5  mm from the skin surface [69].
While the QSRL has been most widely used [69–
73], the Q-switched alexandrite [74] and Nd:YAG
[26] lasers seem as effective. Large-scale
­comparative trials between these lasers have not
been performed.
Acquired nevus of Ota-like macules (also
known as Hori’s nevus) differ from the classic
nevus of Ota in that they are bilateral, spare
mucosa, and occur later in life. Various
Q-switched lasers have been reported effective in
treating nevus of Ota-like macules [75–77].
Mauskiatti et al. demonstrated greater clearing of
bilateral nevus of Ota like macules with a combi-
nation carbon dioxide (CO2) and Q-switched
ruby laser (QSRL) treatment than with QSRL
alone [76]. Laser treatment of any pigmented
lesion is often complicated by post-inflammatory
hyperpigmentation. A recent study of Q-switched
Nd:YAG treatment for acquired nevus of Ota-like
macules suggests that epidermal cooling may be
associated with an increased risk of post-­
inflammatory hyperpigmentation [78].
Melasma and Post-inflammatory
Hyperpigmentation
Melasma is a common acquired hyperpigmenta-
tion, most often affecting adult females with skin
type III or higher. It occurs as brown to blue-grey
E. M. Graber and J. S. Dover

97
macules most frequently on the cheeks, forehead,
upper lip, nose, and chin. It is associated with sun
exposure, pregnancy, and use of oral contracep-
tives, although it can also be seen in patients
without any predisposing factor. Melasma can
have increased melanin in either the epidermis,
dermis or both. Initial management consists of
discontinuing any oral contraceptives or hor-
monal replacement, and strict sun avoidance.
Hydroquinone alone or in combination with topi-
cal corticosteroids or retinoids is the mainstay of
treatment. Azeleic acid, kojic acid, and superfi-
cial chemical peels also provide some benefit.
Melasma with dermal melanin is the most diffi-
cult to treat. Post inflammatory hyperpigmenta-
tion has a similar clinical and histology
morphology as melasma, but develops following
cutaneous injury or inflammatory process.
Studies have shown that Q-switched lasers are
largely ineffective in the treatment of melasma
and post-inflammatory hyperpigmentation [26,
79]. Q-switched laser treatment may actually
cause an increase in dermal melanophages and
worsening of hyperpigmentation. Carbon dioxide
or erbium:YAG [80] laser resurfacing provides
an alternative treatment modality for melasma,
but post-inflammatory hyperpigmentation is
extremely frequent in the postoperative period
and as a result these treatment modalities are not
recommended. Some of the newer laser technolo-
gies, such as the fractionated erbium fiber laser
(Fraxel), can be useful in treating melasma [81,
82]. A study of ten patients showed 75–100%
clearing of melasma in 60% of patients treated
with the fractionated erbium fiber laser (Fraxel)
[83]. These patients were treated at a low fluence
but a high density of microthermal zones.
Fractionated laser treatment may work by expel-
ling columns of microscopic epidermal debris
that contains melanin.
The 1927 nm thulium laser can also be used
for melasma with studies demonstrating varied
success. In one study, over half of the subjects
with melasma had at least a 50% improvement.
However, a significant number of patients experi-
enced rebound of their melasma in the months
after their treatment [84].
Infraorbital hyperpigmentation (dark circles)
may result from a variety of causes, including der-
mal melanin deposition, post-inflammatory hyper-
pigmentation from atopic or allergic contact
dermatitis, prominent superficial blood vessels,
and shadowing from skin laxity and infraorbital
swelling [74]. The QSRL has been reported to
effectively treat infraorbital hyperpigmentation
when due to deposition of dermal melanin [85].
a
b
Fig. 6.10  (a) A patient with a dark nevus of Ota extend-
ing over a significant portion of the face prior to treatment.
(b) After a series of treatments with the Q-switched ruby
laser, there is impressive lightening of the lesion with no
textural change
6  Lasers and Lights for Treating Pigmented Lesions

98
The other Q-switched lasers, especially the
Q-switched alexandrite laser, are also effective
treatments. Improvement of this condition has also
been reported following carbon dioxide laser resur-
facing [86] and the combination of carbon dioxide
laser followed by Q-switched Alexandrite laser. In
one study, a striking 75–100% clearing of perior-
bital hyperpigmentation was noted using a com-
bined CO2 resurfacing followed immediately by
Q-switched alexandrite laser treatment [87].
Blepharoplasty may be indicated when infraorbital
darkening is due to excessive skin laxity. Soft tissue
augmentation with fillers may be beneficial if there
is shadowing due to a hollow in the tear trough.
Drug Induced Pigmentation
Minocycline therapy may cause localized or dif-
fuse mucocutaneous pigmentation. Minocycline-­
induced pigmentation occurs in approximately
5% of acne vulgaris patients treated with the drug
after prolonged use [88]. Three patterns of pig-
mentation have been reported. In type I, focal
blue-gray pigmentation occurs in inflamed or
scarred skin, often in acne scars. Histologic stud-
ies show pigment within dermal macrophages
that stains positively for melanin and iron [89].
Types II and III consist of blue to brown discol-
oration that is more prominent on the anterior
shins and sun-exposed areas, respectively.
Histologically, epidermal and superficial dermal
pigment is present that stains for both melanin
and iron in type II only for melanin [89] in type
III.  Pigmentation will gradually fade after dis-
continuation of minocycline, but may take years.
The Q-switched ruby laser is effective in treating
minocycline-induced pigmentation, with clearing
occurring after one to four treatment sessions
[90–92]. Successful treatment has also been
reported with the Q-switched 532 nm, Q-switched
alexandrite [93] (Fig.  6.11), and 1064  nm
Nd:YAG laser [94, 95], although the latter wave-
length has not proved effective in several reports
[92, 94]. Amiodarone (an antiarrhythmic) and
imipramine (an antidepressant) can also induce
hyperpigmentation and have been treated effec-
tively with the Q-switched ruby laser [96, 97]. In
order to prevent recurrences, laser treatment of
these conditions should be deferred until the
offending medication has been discontinued and
sufficient time has elapsed to allow most of the
pigmentation to resolve spontaneously.
Q-switched laser treatment may induce para-
doxical hyperpigmentation in patients receiving
certain medications. In one report, localized chrysi-
asis developed in a patient on parenteral gold ther-
apy who underwent treatment with a Q-switched
ruby laser for post inflammatory hyperpigmenta-
tion [98]. This phenomenon is due to a laser-
induced alteration in the physiochemical properties
of dermal gold deposits. In the reported case, it was
found that the induction of this change in pigmen-
tation is irradiance-­dependent, i.e. related to the
power delivered per unit area (W/cm2) rather than
fluence-dependent. It was concluded that any
a
b
Fig. 6.11  (a) Minocycline pigmentation on the cheeks, upper lip, and chin. (b) Removal of pigmentation was achieved
after four Q-switched alexandrite laser treatments (From Alster et al. [101], with permission of Wolters Kluwer.)
E. M. Graber and J. S. Dover

99
millisecond laser emitting between 550 and
850 nm should clear this pigment, and subsequent
treatment with a normal mode (3 ms) ruby laser
resulted in substantial clearing [99].
Techniques
• It is important to obtain a medical history
prior to treatment and to educate patients
about the potential outcomes.
• Anesthesia may be needed for larger or der-
mal pigmented lesions.
• Appropriate protective eyewear should be on
all persons in the room.
• Laser parameters depend on the particular
laser, the patient’s skin phototype, and the
type of lesion.
• Adequate fluence will result in an immediate
uniform ash white color.
• Appropriate wound care is essential to ensur-
ing good outcomes. An occlusive ointment
should be applied and patients should be edu-
cated on the healing process.
Pre-operative Management
Patient Evaluation
A general medical history should be obtained
prior to treatment, including medication history,
information on wound healing (specifically a his-
tory of keloids), any bleeding diatheses, or his-
tory of infectious diseases, particularly hepatitis
and HIV infection. Patients with a recent history
of isotretinoin use or a history of hypertrophic or
keloidal scarring should be treated with caution
because they may have a higher risk of scarring
after laser treatment.
Before treating any pigmented lesion, it is
imperative to correctly diagnose the lesion in
question. A pre-treatment biopsy should be per-
formed if there is any possibility of atypia in a
pigmented lesion or if the diagnosis is at all in
question. Once the correct diagnosis has been
established, the appropriate laser can be selected
based on the probable depth and type of pigment
in the skin and on the patient’s skin phototype.
Many patients are ill informed and harbour
unrealistic expectations about the capabilities of
laser surgery. Patients should be fully informed
of what to expect from each treatment and the
potential side effects. It is vital that patients
understand that it will most likely take multiple
treatments and that the lesion may not clear
entirely. Pre-treatment photographs are essential
to document lesions prior to treatment.
Anesthesia
The need for anesthesia when treating pigmented
lesions depends on the location, size and depth of
the lesion as well as the pain threshold of the
patient. The sensation of a laser pulse at the low
fluences which are used for epidermal pigmented
lesions such as lentigines has been likened to a
rubber band snapping against the skin surface.
The higher fluences used in the treatment of der-
mal pigmented lesions such as nevus of Ota pro-
duce more discomfort and are more likely to
require some type of anesthesia. When limited
areas are treated, such as scattered lentigines,
many patients require no anesthesia at all. For the
treatment of larger pigmented lesions, one or
more of the following anesthetic techniques may
be required: topical anesthesia (e.g., LMX-5
cream), local infiltration of lidocaine with or
without epinephrine, regional nerve block, or oral
or intramuscular sedation. In many children and
rarely in adults, intravenous sedation or general
anesthesia may be necessary.
Safety
Laser safety concerns can be divided into beam
hazards, which are related to direct beam impact,
and non-beam hazards, such as plume hazards.
Beam hazards can include fire, thermal burns, and
ocular damage. The room should be designed in
such a way that all reflective surfaces and win-
dows are covered, the door is locked from the
inside, appropriate signs are posted, and no flam-
mable materials or anesthetics are present.
Flammability can occur when the laser is used in
the presence of oxygen (e.g. nasal cannula).
Drapes, towels and sponges may also be flamma-
ble and to avoid this wet or non-flammable mate-
rial should be used. A nonflammable, water-­based
6  Lasers and Lights for Treating Pigmented Lesions

100
lubricant such as Surgilube or K-Y Jelly should be
applied to the eyebrows to avoid singeing the hair.
Ocular risks may be encountered when the eye
is exposed directly in the laser beam’s path or indi-
rectly by a reflected beam. Recalling basic geo-
metric optics, a parallel beam of light (i.e. a laser)
that enters a convex element, such as the cornea,
will be focused down to a smaller geometric point.
This of course concentrates all the power in the
beam into a much smaller spot, and results in an
infinite irradiance causing more damage. Laser
light in the visible to near infrared spectrum (i.e.,
400–1400 nm) can cause damage to the retina that
is painless at the time of injury. For this reason,
this spectrum of light is also known as the “retinal
hazard region”. Without eye protection, observing
a laser beam in the visible spectrum of light is
detected as a bright color flash of the emitted
wavelength and an after-­image of its complemen-
tary color (e.g., a green 532 nm laser light would
produce a green flash followed by a red after-
image). When the retina is affected, there may be
difficulty in detecting blue or green colors second-
ary to cone damage, and pigmentation of the retina
may be detected. Exposure to the Q-switched
Nd:YAG laser beam (1064 nm) is especially haz-
ardous and may initially go undetected because
the beam is invisible (in the near-infrared spec-
trum) and the retina lacks pain sensory nerves.
Photoacoustic retinal damage may be associated
with an audible “pop” at the time of exposure.
Visual disorientation due to retinal damage may
not be apparent to the operator until considerable
thermal damage has occurred. Laser light in the far
infrared (1400–10,600  nm) spectrum can cause
damage to the cornea and/or to the lens because of
its preferential absorption of water. Exposure to
the
invisible
carbon
dioxide
laser
beam
(10,600 nm) can be detected by a burning pain at
the site of exposure on the cornea or sclera.
All persons in the room should wear protec-
tive goggles with the correct optical density for
the specific laser wavelength. When treating the
face, the patient should wear snug metal goggles.
If the immediate periocular area is to be treated,
protective metal eye shields should be inserted
over the conjunctiva after application of a topical
ophthalmic anesthetic agent.
Q-switched laser pulses may produce a sig-
nificant amount of blood and tissue splatter, espe-
cially the 1064  nm Nd:YAG laser. This is not
really an issue when treating epidermal pig-
mented lesions but is of more significance treat-
ing dermal lesions. Use of universal precautions
is mandatory, including use of gloves, goggles,
and laser masks. The protective plastic cone pro-
vided with most Q-switched lasers should always
be attached to the handpiece before use to mini-
mize tissue splatter and keep tissue debris off the
handpiece lens. The plastic cone must be placed
in direct contact with the skin to efficiently trap
tissue debris. To minimize tissue splatter, pulses
may be delivered through a clear hydrogel dress-
ing (e.g., Tegaderm, Second Skin) placed on the
skin, although this reduces transmission of light
into the skin and raises the risk of ocular injury
from reflection of light off the dressing surface.
Vacuum suction is useless at capturing tissue
splatter because it leaves the surface of the skin
far too rapidly—faster than the speed of sound.
Although there have been no cases of transmis-
sion, the presence of HIV proviral DNA has been
demonstrated in the laser plume generated by
carbon dioxide laser irradiation of HIV-infected
tissue culture [100].
All makeup and sunscreen should be removed
from the area to be treated, as these products will
prevent transmission of light to the skin surface.
Furthermore, many of these products contain
metal-based salts and oxides (such as titanium
dioxide) that may ignite following exposure to
Q-switched laser pulses.
Description of the Technique
Q-switched lasers should always be calibrated
prior to treatment and should be placed in
standby mode until ready for use. The laser
handpiece should be held perpendicular to the
skin with the attached plastic cone or guide rest-
ing on the skin to ensure that the laser beam is
focused on the area to be treated. Exact param-
eters vary depending on the particular laser, the
patient’s Fitzpatrick skin type, and the type of
lesion (Table 6.2). In general, lower fluence is
E. M. Graber and J. S. Dover

101
used for dark lesions that contain larger amounts
of absorbing chromophore.
One or two laser pulses should be fired at the
lesion to ensure that a threshold response occurs,
which is defined as immediate whitening of the
lesion. The optimal tissue end point is uniform
but faint immediate whitening without epidermal
disruption. The lowest fluence required to invoke
this response should be used. When the fluence is
too low, the whitening will be barely noticeable.
If using subthreshold fluences, post-­inflammatory
hyperpigmentation due to stimulation of melano-
genesis can result. If the fluence is too high, whit-
ening is a confluent bright white, and epidermal
damage with bleeding may occur. This may result
in tissue sloughing, prolonged healing, and also a
greater likelihood of post-inflammatory hyper-
pigmentation or hypopigmentation or textural
changes. After the optimal fluence is determined,
pulses can be delivered rapidly (up to 10  Hz,
depending on the laser), with overlapping of
about 10% to ensure confluent whitening.
In most cases, additional treatment sessions
may be safely performed 6 weeks after the original
treatment. While some pigmented lesions (e.g.,
lentigines) may require only one to two treatments,
other lesions (e.g., Café au lait macules) may need
multiple treatments. Another approach to tattoo
removal is to perform several treatments on the
same day at intervals of 20 min. This is referred to
as the R20 method. With this method, the typical
immediate whitening reaction will occur with the
first laser pass, but there will be little or no whiten-
ing with subsequent passes. There is more epider-
mal damage utilizing the R20 method than with
the traditional single pass method. This theoreti-
cally increases the risk of scarring with the R20
method but scarring has not been observed in clin-
ical trials. One study demonstrated that 3 months
after treatment with the R20 method, the R20
method was more efficacious than the conven-
tional single-pass laser treatment [101].
Unlike dermal pigmented lesions, epidermal
pigmented lesions can be treated with millisecond
domain lasers and intense pulsed light devices.
The clinical endpoint of treatment with these
devices is significantly different from that seen
after Q-switched laser treatment. Immediately
Table 6.2  Standard treatment parameters for pigmented lesions
Lesion
Laser
Spot size (mm)
Fluence (J/cm2)
Retreatment interval (weeks)
Lentigines
QS ruby
6.5
2.0–4.0
4–8 weeks
QS Nd:YAG (532 nm)
3
0.7–1.0
QS alexandrite
4
3.5–5.5
Pulsed dye (510 nm)
3
2.5
Café au lait macules
QS ruby
6.5
3.0–4.5
4–8 weeks
QS Nd:YAG (532 nm)
3
1.0–1.5
QS alexandrite
4
2.5–4.5
Pulsed dye (510 nm)
5
2.0–3.5
Becker’s nevus
QS ruby
6.5
3.0–4.5
4–8 weeks
QS Nd:YAG (532 nm)
3
1.5–1.8
QS Nd:YAG
(1,064 nm)
3
4.0–5.0
QS alexandrite
4
3.5–5.0
Nevus spilus
QS ruby
6.5
3.0–4.5
4–8 weeks
QS Nd:YAG (532 nm)
3
1.5–2.0
QS Nd:YAG
(1,064 nm)
3
4.0–4.4
QS alexandrite
3
5.0–6.0
Nevus of Ota
QS ruby
6.5
5.0–6.0
6–12 weeks
QS Nd:YAG
(1,064 nm)
3
4.0–7.0
QS alexandrite
3
5.5–6.5
QS Q-switched
6  Lasers and Lights for Treating Pigmented Lesions

102
after treatment there is a slight darkening of len-
tigines, although lighter lentigines may remain
unchanged. A faint erythema may also be
observed at the periphery of darker lentigines.
After treatment, pigmented lesions develop a
slight dark scale, which flakes away in a few days.
Active skin cooling is used during treatment with
most IPL devices to protect the epidermis from
excessive thermal injury. Multiple treatment ses-
sions with IPL are required for optimal clearing of
epidermal pigmented lesions. Lighter lentigines,
which contain less of the melanin chromophore,
may be more resistant to IPL treatment and may
respond better to Q-switched laser treatment.
In general, dermal lesions require higher flu-
ences than epidermal lesions. Larger spot sizes
have a greater depth of penetration, and are pre-
ferred to smaller ones. To achieve the same effect
in the dermis, a larger spot size will require lower
energy and therefore be gentler on the epidermis
and dermal-epidermal junction.
Lower fluences should be used in the treat-
ment of patients with darker skin types, since the
threshold response will likely occur at a lower
fluence. When treating both epidermal and der-
mal pigmented lesions, patients with darker skin
are at greater risk for postoperative hyperpigmen-
tation or hypopigmentation. It may be preferable
to use a longer wavelength device, such as the
1064 nm Nd:YAG laser, since longer wavelengths
penetrate more deeply than shorter wavelengths
and produce relatively less epidermal damage for
the same dermal effect. Patients with “suntans”
should not be treated because they are at risk of
spotty hypopigmentation, which can last for
weeks to months after treatment.
Topical anesthesia is required for fractional
non-ablative treatments. The 1927 Thulium laser
is best suited for w epidermal pigmented lesions.
Topical anesthesia usually left on for an hour
prior to treatment. Air cooling during treatment
makes the procedure far better tolerated. After
treatment ice is applied for an hour to reduce dis-
comfort which lasts about an hour and then dis-
sipated completely. Redness and swelling last an
average of 3 days. Bronzing starts on day 2 and
lasts 3–5 days, longer after the first treatment.
Post-operative Management
The white tissue reaction that occurs immedi-
ately after Q-switched laser treatment fades
within 20  min. An urticarial reaction, causing
erythema, edema, itching, and stinging, may
develop in and around the treated area. This may
last for several hours and can be treated, but not
prevented, by taking an antihistamine preopera-
tively. In all patients, the treated lesions appear
darker for several days then develop a thin crust
that flakes off in 7–10 days. The amount of crust-
ing that occurs depends on the aggressiveness of
treatment. Overly aggressive treatment may
result in vesiculation or frank blistering. The risk
of blistering is highest when shorter wavelength
devices (e.g., QSRL) are used to treat patients
with dark skin phototypes. Following treatment
with the Q-switched 532 nm Nd:YAG, purpura
usually develops after skin whitening has faded.
This occurs because these wavelengths are well
absorbed by both melanin and hemoglobin, caus-
ing rupture of blood vessels. Purpura lasts for
5–10 days, and is a notable disadvantage of treat-
ment with the above devices. Purpura can be
minimized by treating through a microscope
slide held firmly against the skin to compress
blood vessels and remove hemoglobin as a
target.
Postoperative discomfort may be treated with
application of cold water-soaked gauze, ice
packs, or a hydroocclusive dressing such as
Second Skin or Vigilon. Analgesics are usually
not needed. Antihistamines may be given if the
patient has an urticarial reaction. Patients should
be instructed to gently wash the treated area with
mild soap and apply an occlusive ointment (e.g.,
petrolatum or Aquaphor Healing Ointment) twice
a day. Any crusting should be allowed to slough
spontaneously. To minimize the risk of hyperpig-
mentation and recurrence, patients should avoid
excessive sun exposure and use a broad-spectrum
sunscreen of SPF 30 or higher for several months
after treatment.
Because dermal lesions typically require the
use of higher fluences, postoperative changes are
more apparent. In addition to the whitening
E. M. Graber and J. S. Dover

103
response, erythema and swelling are usually seen
in the immediate postoperative period, especially
in the periorbital region.
Adverse Events
• Post-inflammatory
hyperpigmentation,
hypopigmentation, an inadequate response
and recurrence of the lesion are the most com-
mon side effects.
• Using the appropriate laser and fluence can
reduce side effects.
• Educating patients regarding realistic expecta-
tions can help to reduce patient frustration and
complications.
Side Effects/Complications
Post-inflammatory hyperpigmentation is not a
rare side effect when treating pigmented lesions,
and is especially common in treating darker skin
types. Subthreshold fluences can stimulate mela-
nogenesis in dark skinned patients. While post-­
inflammatory hyperpigmentation is benign, it can
last several months and can be cosmetically both-
ersome. Topical hydroquinone containing creams
are
usually
effective
in
lightening
the
hyperpigmentation.
Although less common than post-­inflammatory
hyperpigmentation, hypopigmentation can also
occur, particularly when treating tanned patients.
For this reason, tanned patients should not be
treated.
A sub-optimal response to laser treatment is
another unwelcome outcome. Most pigmented
lesions require multiple treatments and some are
prone to recurrence.
Prevention and Treatment of Side
Effects/Complications
Hyperpigmentation and hypopigmentation can
be avoided by treating with appropriately high
fluences and by not treating tanned patients,
respectively. For many reasons, it is important to
take quality pre-treatment photographs from
multiple angles. Photographs can be used to
judge improvement, document baseline findings,
and may have medico legal importance. It is
important for patients to have a realistic
­understanding of potential outcomes prior to
beginning laser treatment. Potential laser candi-
dates should be educated regarding the need for
multiple treatments and should be made aware of
possible side effects. This patient education
should be documented in the patient chart. Side
effects and expectations should be reinforced in
writing on the consent form.
Future Directions
• Femtosecond (10−15) domain lasers are being
developed.
• Pico second (10−12) domain lasers currently
used for tattoo removal are being investigated
for pigmented lesion removal.
• Enhanced effectiveness with less side effects
in treating pigmented disorders in patients of
color
Manufacturers and scientists continue to
refine and optimize the current laser systems to
enhance outcomes with fewer side effects. By
adding cooling to many treatments systems the
risk of problems of pigmentation after treatment
have decreased. Encouraging work is presently
being done on lasers with even shorter pulse
durations than typical Q-switched lasers. Pulse
durations in the pico (10−12) and femtosecond
(10−15) domains may be more effective in disrupt-
ing pigment in resistant tattoos than the typically
used shorter pulse durations.
Conclusions
Pigmented lesions are an exceedingly com-
mon occurrence, and often are cosmetically
disturbing to the patient. Topical treatment
options are ineffective for almost all of these
conditions and surgical treatment options
often produce unacceptable results. Laser and
6  Lasers and Lights for Treating Pigmented Lesions

104
light therapy is often the preferred manner to
diminish a variety of pigmented lesions and
disorders of pigmentation. In order to obtain
the optimal outcome, the physician needs to
select the proper light source, the correct
patient and skin characteristics and provide
appropriate wound care to achieve optimal
results. Thought should be given to the depth
of the lesion, the patient’s skin phototype, and
the laser or light device parameters. Despite
the efficacy of laser and light treatments, they
are not without potential side effects and
complications. Prior to beginning treatment,
both the physician and the patient should be
well aware of the limitations and disadvan-
tages of laser therapy. Nevertheless, with a
thoughtful treatment plan and adequate
patient education, treating pigmented lesions
with laser therapy can result in a successful
outcome.
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3. Ohshiro T, Maruyama Y.  The ruby and argon
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6  Lasers and Lights for Treating Pigmented Lesions

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6  Lasers and Lights for Treating Pigmented Lesions

109
Laser Treatment of Tattoos
Voraphol Vejjabhinanta, Caroline V. Caperton,
Christopher Wong, Rawat Charoensawad,
and Keyvan Nouri
Abstract
Tattoos are a long-standing part of human
culture.
Techniques used in tattooing have evolved
over the centuries.
Although 24% of Americans between the
ages of 18–50 years have at least one tattoo,
28% of people who get tattoos regret the deci-
sion within the first month.
Keywords
Tattoo removal · Q-switched Nd laser · YAG
laser · Q-switched Ruby laser · Q-switched
Alexandrite laser
7
V. Vejjabhinanta (*)
Dermatologic Surgery and Lasers Unit, Department
of Medical Services, Ministry of Public Health,
Institute of Dermatology, Bangkok, Thailand
C. V. Caperton
WK Allergy, Asthma, and Immunology Center,
Willis-Knighton Health System,
Shreveport, LA, USA
e-mail: ccaperton@med.miami.edu
C. Wong
Orthopaedic Associates of South Broward,
Hollywood, FL, USA
e-mail: cwong@med.miami.edu
R. Charoensawad
Rawat Clinic, Bangkok, Thailand
Biophile Training Center, Bangkok, Thailand
K. Nouri
Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine,
Miami, FL, USA
e-mail: knouri@med.miami.edu
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,

110
Introduction
A tattoo is a mark created by pigments that per-
manently reside in the dermal layer of the skin.
The word tattoo has roots from the Polynesian
word “ta” which means “to strike” and the
Tahitian word “tatau” which means “to mark.”
The techniques of tattooing have changed over
the years, but the basic principle remains the
same. Dyes are manually applied through breaks
in the skin. By embedding the various pigments
below the epidermis, the pigments resist slough-
ing due to the natural growth cycle of the skin,
thus offering permanence. In the older methods,
dye-tipped needles were gently struck by stones
and hammers to introduce the dye into the skin.
Today, electrical tattoo machines utilize high-­
speed needle injections that minimize time and
pain.
In the United States, an estimated 7–20 mil-
lion people have at least one tattoo [1]. In a recent
study, the prevalence of tattoos among Americans
aged 18–50 years old was found to be 24% [2].
Reasons for tattoo application include: fashion,
peer pressure, rebelliousness, and romance. For
some individuals, regret appears as quickly as the
initial decision to get a tattoo. Approximately
28% of people who get tattoos regret the decision
within the first month. While the minimum age to
obtain a tattoo is 18  years old, 71% of people
requesting tattoo removal have had the ink
applied when they were under the minimum age.
The most common reason to seek tattoo removal
was to further enhance self-esteem by freeing
oneself from the stigmatizing lesion that was the
source of many years of regret. In addition, tattoo
owners felt their marks were socially discredit-
ing, perceived pressure by family members to
remove them, and believed improvement in
employment opportunities would result after
removal [3]. On average, actual tattoo removal
occurred 14 years later. Much of the delay can be
attributed to perceived high financial costs, phys-
ical pain, and risk of permanent disfigurement
associated with removal. Also, many potential
patients admit that they were unaware of the
availability of treatment options to remove their
tattoo [4].
Historical Perspectives
As evidenced by “Ötzi the Ice Man”, a
5000-year-­old man bearing 57 tattoos whose
body was discovered in 1991, tattoos have been
a part of human culture for a very long time.
Some anthropologists even speculate that the art
of tattooing began as early as 12,000 B.C. The
purpose of tattoos has varied from perceived
therapeutic benefits and religious or tribal iden-
tification symbols to self-expressions of unique-
ness and impulse. Regardless of their age or
purpose, tattoos are a large part of human cul-
ture today and are becoming more and more
popular.
The first tattoos from thousands of years ago
were created roughly. During bereavement cer-
emonies as signs of grief, primitive humans of
the Stone Age (12,000 B.C.) slashed their skin
and rubbed ash into the wounds [5]. It is highly
unlikely that the detail of the designs resembled
anything near the tattoos that we see
Box 1 Overview
• Tattoos are a long-standing part of
human culture.
• Techniques used in tattooing have
evolved over the centuries.
• Although 24% of Americans between
the ages of 18–50 years have at least one
tattoo, 28% of people who get tattoos
regret the decision within the first
month.
• The three lasers most commonly used
are the Q-switched Nd: YAG, Q-switched
Ruby, and Q-switched Alexandrite.
• Potential side effects of using lasers in
the removal of tattoos include discolor-
ation, redness, scarring, and rarely,
stimulating allergic reactions.
V. Vejjabhinanta et al.

111
today—although a few amateurs come close.
The discovery of crude needles and pigment
bowls in caves in France, Spain, and Portugal
provide circumstantial evidence that decorative
tattooing can be traced back to the Bronze Age
(8000 B.C.). More well known older techniques
were practiced elsewhere in the Ancient world.
The Japanese utilized a hand-based tattooing
technique that involved elaborate needle-tipped
bamboo handles. Samoans, among many other
Pacific cultures, used wooden hand tools such
as a bone-­tipped rake and a striking stick. The
ancient Thai employed a tool that closely
resembles the electric tattoo devices of today.
They used a long brass tube with a sliding
pointed rod that ran down the center.
Thomas Alva Edison, the famous inventor
of the light bulb, played an unexpected role in
the development of the tattoo. In 1891, Samuel
O’Reilly
modified
Edison’s
autographic
printer to become the electric tattoo machine
of today. It was a steel instrument that utilized
needles that traveled in a vertical direction to
pierce the skin at a rate up to 3000 times per
minute.
Techniques of Tattooing
The tattoo is actually the appearance through the
epidermis of the ink located in the dermis. During
the tattoo process, needles are dipped in various
inks. The electric tattoo device injects ink particles
from the epidermis to a constant depth (usually
1  mm) below the dermal-epidermal junction
(Fig.  7.1). As part of the skin’s natural growth
cycle, the epidermis is continually sloughed off. In
the layers of the dermis, macrophages recognize
the dye particles as foreign and attempt to remove
Tattoo
Nerves
Blood vessels
Sweat gland
Hair follicle
Dermis
Epidermis
Fat
Fig. 7.1  Placement of
tattoo ink within the
dermis
Box 2 Summary
• In order for a tattoo to be permanent, the
dye must be placed at a certain location
within the dermis – too superficial and it
will be sloughed off in the epidermis;
too deep and it will be taken up by
lymphatics.
• Risks of unsterile tattooing techniques
include transmission of bacteria, hepati-
tis B, hepatitis C, syphilis, and HIV.
7  Laser Treatment of Tattoos

112
the molecules. However, most of the dye is cap-
tured or ignored and remains in the dermis.
Therefore, it is essential that the dye reaches the
dermis in order to become a permanent mark.
In addition, it is important that the dye not be
injected too deeply into the dermis. More
­commonly reached by amateur-level tattoo art-
ists, these greater depths will increase the likeli-
hood of the dye being carried away by body fluids
or for the tattoo to be accompanied by scarring.
This can lead to blurring of the tattoo and reduc-
tion of its visualization.
Obtaining a tattoo carries with it inherent
risks. There have been reports that non-sterile tat-
tooing practices have led to the transmission of
infectious organisms such as bacteria, syphilis
and hepatitis B; furthermore, there is also the
potential for transmission of other blood-borne
pathogens such as HIV and hepatitis C [6].
Allergenicity
Some patients have allergic reactions to either
the pigments in the tattoo or to the additives that
can be mixed in with the dye. Even though 2001
marked the first report of an adverse reaction
following the application of a ‘black’ henna
tattoo darkened with paraphenylenediamine
(PPD)-based chemicals, the notoriety of PPD
had been previously established. In the 1930s,
the practice of tinting the eyelashes and eye-
brows with PPD dye was common. Many
adverse reactions to PPD became apparent, with
some women suffering serious blistering reac-
tions, blindness, and even death, most notably to
the product “Lash Lure.” Since there were no
laws in place to regulate these products, cos-
metic companies were not liable. By 1938, the
Food, Drug, and Cosmetic Act was initiated
with the first mandate: to remove “Lash Lure”
from the American market and ban the use of
PPD on the skin [7].
Other allergic reactions associated with tat-
toos can be linked to the specific color of pig-
ment that was injected into the skin. There
have been numerous reports of patients with
known allergies to mercury or cobalt experi-
encing type IV hypersensitivity allergic reac-
tions in areas tattooed with red or blue pigment,
respectively [8]. There are many common
allergenic substances included in common tat-
too dyes (Table 7.1).
It is important to note that tattoo pigments
have not FDA approved for intradermal injection.
Nevertheless, there have been dramatic advances
in the industry of body art, including the develop-
ment of a biodegradable and bioabsorbable
organic dye encapsulated in synthetic polymer.
The tattoo is permanent; yet, when targeted with
a laser, the beads disintegrate, exposing the ink to
be resorbed into the body, thereby completely
removing the tattoo [9].
Table 7.1  Tattoo
pigments
and
their
common
ingredients
Dye color
Dye content
Black
Carbon
Red
Mercury sulfide
Blue
Cobalt aluminate
Brown
Hydrate of iron oxide
Green
Chromium oxide
Lilac
Magnesium
White
Titanium oxide
Yellow
Cadmium sulfide
Box 4 Summary
• The most common medical techniques
currently used for tattoo removal are
laser surgery, surgical excision, and
dermabrasion.
• Complications of these procedures,
though rare, include discoloration,
incomplete
removal,
scarring,
or
infection.
• Topical products that lighten naturally
pigmented skin are generally not meant
for tattoo removal, although current
research is ongoing.
V. Vejjabhinanta et al.

113
Methods of Removal
Prior to current medical technologies, there was
not much available to the patient requesting
removal of their tattoo. The patient was offered
the choice of harsh exfoliation techniques, chem-
ical peels, thermal means, cryosurgery, or surgi-
cal resection. In lieu of medical treatment, many
patients today still opt for covering up the tattoo
with concealing makeup, or even voluntarily
obtaining more tattoos in an attempt to modify or
camouflage the original tattoo into a new, often
larger design.
Each tattoo is unique; so must each removal
technique match the demands of each individ-
ual situation. Tattoos that are professionally
applied tend to penetrate the deeper layers of
the skin at uniform levels. This uniformity
allows dermal surgeons to use techniques that
remove broader areas of inked skin at the same
depth.
Figure 7.2 shows tattoo granules present in the
dermis prior to treatment.
Currently, the most common tattoo removal
techniques employed by dermatological profes-
sionals are laser surgery, surgical excision, and
dermabrasion.
Laser Surgery
The tattoo is treated by targeting selective pig-
ments with a high-intensity laser beam. The type
of laser used generally depends upon the colors
to be removed. This modality offers a highly
effective approach with minimal side effects,
although frequently necessitates several treat-
ments for complete removal.
Fig. 7.2  Tattoo granules
present in the dermis
prior to treatment
Box 3 Summary
• Additives such as PPD can be mixed
with tattoo dye, causing allergic reac-
tions in patients.
• Allergic or pruritic reactions to tattoos
can be linked to certain colors used in
the design.
• No dye used in tattooing is FDA
approved for deposition into the
dermis.
7  Laser Treatment of Tattoos

114
Surgical Excision
The tattoo is cut out and either sutured or allowed
to heal, depending on size. The efficacy of this
technique is highly dependent upon the ­individual
surgeon, the size of the area to be resected, the
tension of the skin in the area, and the individu-
al’s tendencies toward scarring or developing a
keloid.
Dermabrasion
The tattoo is gradually removed via exfoliation
of the surface and middle layers of pigment by
machines, laser or salt. The upper layer of skin
is abraded or “sanded,” and the underlying lay-
ers of skin replace the damaged layers, allowing
the pigment to leach out of the skin. Side effects
and complications of this procedure are skin
discoloration (hyperpigmentation or hypopig-
mentation) at the treatment site, infection of the
tattoo site, incomplete pigment removal, or
scarring, even 3–6  months after the tattoo is
removed [10].
It is important to make the distinction between
residual tattoo and post inflammatory hyperpig-
mentation. Post inflammatory hyperpigmentation
is different from tattooing in that it is mainly a
result of melanocyte stimulation and is exacer-
bated by exposure to ultra-violet radiation.
Tattoos, on the other hand, are not associated
with melanocytes, but are rather made up of dyes,
which in contrast often fade with sun exposure as
the pigment is oxidized and always confined
within the previous tattoo position.
There are products available on the market
that purport to lighten skin. Products containing
hydroquinone are used to treat hyperpigmenta-
tion of the skin by reversibly depigmenting the
skin. This is accomplished by inhibiting the oxi-
dation of tyrosine to 3,4-dihydroxyphenyalanine
(DOPA) and other melanocyte metabolic
processes.
Recent data from Solis et al. demonstrated a
significant reduction of tattoo pigment in a
guinea pig model. Researchers treated the ani-
mals’ recent tattoos with imiquimod. After
1 week, the tattoos were no longer detectible
either clinically or histopathologically [11].
Although no human models have demonstrated
these results, imiquimod remains an attractive
non-invasive therapy for the treatment of tat-
toos. Ricotti and colleagues investigated
whether imiquimod in conjunction with laser
therapy would be more efficacious in tattoo
removal than laser alone. The authors con-
cluded that, in addition to having more adverse
reactions than placebo, imiquimod was not
an ineffective adjunct to laser treatment of
tattoos [12].
Lasers
Box 5 Summary
• Lasers are commonly used in various
medical
and
cosmetic
procedures,
including treatment of vascular lesions,
scars, dermal remodeling, hair removal,
and removal of pigmented lesions.
• Potential side effects of using lasers in
the removal of tattoos include discolor-
ation, redness, scarring, and rarely,
allergic reactions. These should be dis-
cussed with the patient so that an
informed decision may be made.
• Specific lasers and wavelengths are bet-
ter suited for targeted removal of certain
colors of pigment than others.
• The Q-switched lasers with pulse dura-
tions in nanosecond range are the main-
stay devices for tattoo removal.
• Q-switched Ruby (694 nm) is generally
used in the removal of black, blue and
green tattoos in individuals with fair
skin.
• Q-switched Alexandrite (755  nm) is
best for removing the green ink
• Q-switched Nd: YAG (1064 nm) is use-
ful for treatment black and blue ink in
individuals with darkly pigmented skin.
• Q-switched Nd: YAG (532 nm) is useful
for treatment red and orange ink.
V. Vejjabhinanta et al.

115
Laser is an acronym for Light Amplification by
Stimulated Emission of Radiation. The first
patient for the laser was obtained by Gordon
Gould in 1977, although his work on light lasers
dated back to 1958. The first medical application
of a laser was in 1987, when ophthalmologist
Steven Trokel performed refractive surgery on a
patient’s eyes. Originally designed to precisely
cut glass and metal, lasers have revolutionalized
the field of medicine with its numerous applica-
tions and possibilities.
There are many dermatologic uses of lasers,
including treatment of vascular lesions, hypertro-
phic or keloid scars, striae, acne, hair removal,
removal of pigmented lesions, and nonablative
dermal remodeling, to name a few. Lasers have
become widespread for use in the field for both
medical and cosmetic applications.
Due to the ability by some lasers to produce
pressure waves significant enough to penetrate the
stratum corneum, lasers have become attractive
new methods for transdermal drug delivery [13].
The first use of lasers for the treatment of tat-
toos was in the 1970s [14, 15]. Carbon dioxide
lasers, which emit a wavelength of 10,600 nm and
target water in the skin, and argon lasers, which
emit a continuous wavelength of either 488 or
514 nm, were used non-selectively in an attempt to
remove tattoo pigment from the dermis. The CO2
laser ablates the top layer of skin and often results
in scarring when used at a depth necessary for tat-
too removal. The argon lasers, due to their contin-
uous energy emitted, transmit heat to other tissue
areas, also resulting in hyperpigmented skin,
incomplete removal of the pigment, and scarring.
Modern lasers have become paramount in the
treatment and removal of tattoos. By selective
photothermolysis, lasers allow dermatologists to
selectively remove target pigments without
destroying the surrounding skin or tissue archi-
tecture dramatically. The short-pulse (nanosec-
ond or picosecond) lasers are optimal for tattoo
removal without significant scarring. The most
commonly used lasers for this purpose include
the Q-switched neodymium:yttrium-aluminum-­
garnet (Nd:YAG), alexandrite, and ruby lasers
[16]. Q-switching refers to a switch that allows
the release of energy in one pulse such that the
target is heated so quickly (within nanoseconds
or picoseconds [17]) that it shatters, allowing for
selective photothermolysis.
Depending on the wavelength used, the laser is
able to target the tattoo pigment while sparing other
chromophores in the skin, such as melanin. Due to
its primary purpose of absorbing damaging ultravi-
olet rays, melanin absorbs light, which can be detri-
mental when attempting to use light to remove a
tattoo. Nevertheless, this absorptive property of
melanin decreases with longer wavelengths, allow-
ing targeted removal of pigment by lasers without
interference or refraction. The biophysics underly-
ing the mechanism by which lasers are able to dis-
solve tattoos is not well understood, but the accepted
theory is that the pulse of light from the laser breaks
up the tattoo pigment into smaller components to be
digested by macrophages, taken up by scavenger
cells, or eliminated transepidermally [18].
How efficacious the laser treatment is in the
complete removal of the tattoo depends on mul-
tiple factors, including size, length of time since
application, depth of pigment, colors used, and
patient’s skin type. Laser removal of pigment is
highly color dependent, since the lasers used emit
certain wavelengths that are better able to target
certain colors.
The three lasers most commonly used are the
Q-switched Ruby, Q-switched Alexandrite, and
Q-switched Nd: YAG.
• Q-switched Ruby (694 nm)

Light from this laser is red. Because light is
absorbed by its opposite color and reflected by
its same color, this laser removes most ink
­colors well, except red. It is generally used in
the removal of blue and black tattoos. It is
especially effective in the removal of amateur
and traumatic tattoos. This was the first laser
to be used in the treatment of tattoos and pig-
mented lesions [19, 20].
• Q-switched Alexandrite (755 nm)

This laser emits a purple/red light and is there-
fore best for removing blue, black, and green
ink. This laser offers an advantage over older
models in that is reliable, with faster repetition
rates, and is the laser of choice in the removal
of green pigment.
7  Laser Treatment of Tattoos

116
• Q-switched Nd:YAG (1064 nm)

This laser emits light in the infrared range. It
removes black and blue ink best. Because this
wavelength is not well absorbed by melano-
cytes, it is useful for treatment in individuals
with darkly pigmented skin (Figs. 7.3 and 7.4).
• Q-switched Nd:YAG (532 nm)

This is an alteration of the 1064 nm Nd: YAG
laser made possible by using a potassium-­
titanyl-­phosphate crystal to double the fre-
quency, thus halving the wavelength to
532  nm. This laser emits a green light and
removes red and orange ink. This wavelength
is absorbed by hemoglobin and thus, may
result in temporary purpura after laser
treatment.
Amateur tattoos are generally easier to remove
since they usually contain only black or blue ink
and more superficial. Unfortunately, some ama-
teurs may tattoo too deeply, making the pigment
deposition irregular and difficult to target.
Professional tattoo artists often mix colors for a
gradation effect, which is also more difficult to
a
c
b
Fig. 7.3  Laser tattoo removal at the right wrist with Q-switches 1064 nm Nd: YAG; Amateur tattoo (a) Before treat-
ment (b) Two month after the first treatment (c) After three treatments
V. Vejjabhinanta et al.

117
remove, but will tattoo no deeper than the dermis
and at a consistent depth throughout the tattoo.
A minimum interval of 4 weeks is generally
required between laser sessions to allow the treat-
ment area adequate time to heal and the immune
system a sufficient period for macrophages to
phagocytize the broken pigment molecules [21].
An average tattoo with a surface area of two
square inches requires 6–7 months to be removed,
on average, with sessions scheduled every
6–8 weeks [16].
The absorption spectrum of tattoos is
unknown, with some colors responding better
than others. As a result, a combination of laser
systems may be used in stages for a single tattoo
(Table 7.2).
Although Q-switched lasers are now the main-
stay of treatment for the removal of tattoos, it is
important to note that there may be unwanted
complications associated with the practice. Most
commonly, patients experience hyper- or hypopig-
mentation reactions or immediate erythema at the
b
a
Fig. 7.4  Laser tattoo removal at the upper leg; professional tattoo (a) Before treatment and (b) the result after seven
treatments with Q-Switched 1064 nm Nd: YAG laser
Table 7.2  Choice of laser for removal of tattoo by ink color
Laser
Black
Blue
Green
Brown
Yellow
Purple
Red
Nd:YAG 532 nm
X (Light)
X
X
X
Ruby
694 nm
X
X
X
X (Dark)
Alexandrite 755 nm
X
X
XX
X (Dark)
Nd:YAG 1064 nm
X
X
X (Dark)
Adapted from Mariwalla K, Dover JS.  The use of lasers for decorative tattoo removal. Skin Therapy Lett. 2006
Jun;11(5):8–11 [22], with permission of SkinCareGuide
7  Laser Treatment of Tattoos

118
treatment site that generally subsides within min-
utes of treatment [23]. Some patients may experi-
ence scarring. Some patients, however, may
experience hypersensitivity reactions, especially
if they had previously experienced allergic reac-
tions upon application of the tattoo pigment [24].
A rare and controversial topic of debate is whether
or not laser removal of certain pigments may be
associated with the generation of carcinogenic or
hazardous compounds [25].
There are significant costs associated with
laser treatments of tattoos, which are not often
covered by health insurance companies. Most tat-
toos require multiple sessions for reasonably
anticipated pigment removal, which should be
communicated with the patient beforehand to
ensure the patient possesses adequate expecta-
tions about the outcome of the treatment. More
than half of all patients experience a 75–95%
reduction of tattoo pigment with a conventional
series of three to four laser treatments [16]. These
issues should be discussed with the patient in
order for an informed decision to be made about
his or her treatment and to ensure that realistic
expectations are set.
Conclusion
The information presented herein presents a
background on the history of tattooing, the
methods of removal currently available, and a
scientifically-­based rationale for why photo-
thermolysis via laser has become implemented
into mainstream treatment. Tattoos are widely
varied based on the individual patient, the
method used in injecting the pigment into the
skin, size of tattoo, spectrum of colors used in
the design, the duration of time that the patient
has had the tattoo, as well as any underlying
conditions the patient may have that could
affect healing or immune response to therapy.
All of these conditions must be taken into con-
sideration when selecting an individualized
treatment tailored to not only each patient, but
also to each patient’s specific tattoo that has
been selected for removal. Recently devel-
oped Freedom-2 ink technology uses micro-
encapsulated polymer beads of biodegradable
ink to allow complete clearance with just one
laser treatment. Whether or not the tattoo is
being removed out of necessity (employment
requirements, social situations, familial pres-
sures, etc.), it is important for the physician to
have an appreciation that the patient may
­experience some degree of anxiety about
becoming detached from a personal symbol
which was undoubtedly expected to be embed-
ded within him or her indefinitely. On the
other hand, it is a paramount achievement for
medicine that we are now able to safely
remove tattoos and skin markings that hold
negative connotations, that are regarded with
regret, or which have become irrelevant in the
patient’s current life setting.
References
1. Anderson RR. Tattooing should be regulated. N Engl
J Med. 1992;326(3):207.
2. Laumann AE, Derick AJ. Tattoos and body piercings
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3. Armstrong ML, Stuppy DJ, Gabriel DC, et  al.
Motivation for tattoo removal. Arch Dermatol.
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4. Varma S, Lanigan SW.  Reasons for requesting
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TattooRemovalInformation.aspx.
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and tretinoin. Dermatol Surg. 2002;28(1):83–6. dis-
cussion 86-7
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Inc.; 2006. p. 1679–704.
14. Apfelberg DB, Maser MR, Lash H. Argon laser treatment
of decorative tattoos. Br J Plast Surg. 1979;32:141–4.
15. Brady SC, Blokmanis A, Jewett L.  Tattoo removal
with the carbon dioxide laser. Ann Plast Surg.
1978;2:482–90.
16. Bernstein EF. Laser treatment of tattoos. Clin Derm.
2006;24:43–55.
17. Ibrahimi
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RR.  Picosecond laser pulses for tattoo removal: a
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DA. Laser-tattoo removal—a study of the mechanism
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RG. Radiation from a Q-switched ruby laser. Effect of
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7  Laser Treatment of Tattoos

121
© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Laser for Hair Removal
Voraphol Vejjabhinanta, Keyvan Nouri,
Anita Singh, Ran Huo, Rawat Charoensawad,
Isabella Camacho, and Ali Rajabi-Estarabadi
Abstract
Lasers for hair removal are a fast-growing
area in cosmetic dermatology. Selective pho-
tothermolysis allows for targeting of specific
chromophores while minimizing cutaneous
damage. Treatment of individuals should be
individualized based on anatomical area, skin
and hair color, by varying the wavelength, flu-
ence, pulse duration, spot size, and cooling
technique of the laser.
Keywords
Lasers · Hair removal · Cosmetic dermatology
Photothermolysis · Chromophores
• Lasers for hair removal are a fast-growing
area in cosmetic dermatology.
• Selective photothermolysis allows for target-
ing of specific chromophores while minimiz-
ing cutaneous damage.
• For best results, treatment should be individu-
alized based on anatomical area, skin and hair
color, by varying the wavelength, fluence,
pulse duration, spot size, and cooling tech-
nique of the laser.
• Adverse events to laser hair removal include
post-treatment erythema, edema, blistering,
hypo/hyperpigmentation, scarring, and skin
infections.
• Further standardized, well-controlled, and
long- term studies are needed to establish the
optimal treatment parameters for each laser
for each patient demographic.
V. Vejjabhinanta
Department of Dermatology, Siriraj Hospital,
Mahidol University, Bangkok, Thailand
K. Nouri · A. Rajabi-Estarabadi (*)
Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine,
Miami, FL, USA
e-mail: knouri@med.miami.edu;
arajabi@med.miami.edu
A. Singh
Montefiore Medical Center, Albert Einstein College
of Medicine, Bronx, NY, USA
R. Huo
Broward Dermatology Clinic,
Pembroke Pines, FL, USA
R. Charoensawad
Biophile Training Center, Bangkok, Thailand
I. Camacho
Georgetown University, School of Medicine,
Washington, DC, USA
e-mail: ivc5@georgetown.edu
8

122
Introduction
• Laser hair removal is the third most common
nonsurgical procedure performed in the U.S.
• Patients and physicians need to have realistic
expectations of results for laser hair removal.
The level of hair reduction may vary widely
amongst individuals.
• Lasers are advantageous because they are fast,
safe, and effective when used appropriately.
• Hair removal with lasers or pulsed light are
more advantageous than previous hair removal
methods such as shaving and waxing.
• The mechanism of selective photothermolysis
allows lasers to target specific cutaneous chro-
mophores while protecting the outer tissue.
• Active cooling devices, such as cryogen
sprays and contact cooling devices help to
minimize injury by protecting the epidermal
melanin, preventing adverse side effects.
The use of lasers for hair removal, or photo-
epilation, is becoming an increasingly popular
trend in the arena of cosmetic dermatology.
According to the American Society for Aesthetic
Plastic Surgery (ASAPS), 1,035,783 laser hair
removal procedures were performed in 2016 [1].
Laser hair removal is the top third most popular
nonsurgical procedure among Americans accord-
ing to ASAPS’s list of the top five most popular
nonsurgical procedures. There was a 37.2%
increase in hair removal, with laser or pulsed
light, from 2014 to 2015 [2, 3]. Interestingly,
even though there was a 7.3% increase in total
nonsurgical procedures from 2015 to 2016, the
number of laser or pulsed light hair removal pro-
cedures decreased 8.9%. Women had more hair
removal procedures in 2016 compared to men,
however, hair removal still ranked top third non-
surgical procedure in both men and women. Men
accounted for about 12% of the total laser hair
removal procedures that were performed.
Furthermore, individuals 35–50 years of age had
the most number of laser or pulsed light hair
removal procedures in 2016, followed by patients
between 19 and 34 years of age.
Hair removal has historically been of great
interest because excess hair, especially in patients
with hypertrichosis or hirsutism, can be troubling
both socially and psychologically [4]. Past and
present options for hair removal have included
shaving, epilation, depilatories, electrolysis and
now most currently, lasers [5]. All methods for
hair removal have side effects, but lasers are
advantageous because they are fast, safe, and
effective when used appropriately. With the
increased desire for and availability of laser hair
reduction around the world, it is necessary to
evaluate the current indications and potential side
effects of each laser.
The concept of hair removal was defined in
1998 by the US Food and Drug Administration
(FDA), which allowed some manufacturers of
hair removal lasers and flash lamps used for hair
removal to use the term “permanent hair reduc-
tion.” The agency defined permanent hair reduc-
tion as, “The long-term, stable reduction in the
number of hairs regrowing after a treatment
regime. The number of hairs regrowing must be
stable over a time greater than the duration of the
complete growth cycle of hair follicles, which
varies from 4 to 12 months according to body
location. Permanent hair reduction does not nec-
essarily imply the elimination of all hairs in the
treatment area.” [6]. In addition, there needs to be
a distinction made between permanent and com-
plete hair loss. Complete hair loss is defined as a
lack of regrowing hairs, but may be either tempo-
rary or permanent. Permanent hair loss is defined
as a lack of regrowing hairs indefinitely. Hair
removal with lasers usually produces complete
but temporary hair loss for 1–3 months. After this
time period, there is usually partial but perma-
nent hair loss [7].
The theory of selective photothermolysis
dictates the process of laser hair removal. By
varying specific parameters (wavelength, pulse
duration, and fluence), specific cutaneous chro-
mophores may be targeted while protecting the
outer lying tissue [8, 9]. Applying this theory
to laser hair removal, the wavelength should be
the same as the target chromophore, the pulse
duration should be less than the chromophore’s
thermal relaxation time (TRT), and the fluence
must be great enough to sufficiently destroy
the chromophore.
V. Vejjabhinanta et al.

123
In laser hair removal, the specific target is the
endogenous chromophore melanin. Melanin is
found in the bulb, bulge, and hair shaft of anagen
hair. Lasers for hair removal must emit light within
the absorption spectrum of melanin, 250–1200 nm,
to be effective [10]. In addition, vascular reduction
has also been proposed as a mechanism for long-
term epilation [11]. One obstacle to laser hair
removal is that melanin resides in the epidermis as
well. This is a twofold problem because epidermal
melanin not only interferes with the laser’s treat-
ment capabilities by detracting some of the laser’s
energy, but can also cause damage to the epider-
mis. Because pigmentation of the hair and skin
vary to such a great extent among patients, this is a
difficult problem to resolve.
Active cooling is an excellent method to mini-
mize injury to the epidermis. Many lasers today
are equipped with cooling devices such as cryo-
gen sprays or contact cooling devices. For exam-
ple, the long-pulsed 694 nm ruby lasers have a
cooling hand piece that is applied during treat-
ment to lower the temperature of the skin and
spare it from injury. This integrated cooling
device pre-cools the skin prior to laser pulse
delivery. The long-pulsed 755  nm alexandrite
lasers utilize a variety of cooling mechanisms.
These mechanisms include a cooling hand piece
that allows a continuous flow of chilled air to the
treatment area, and a dynamic cooling device that
uses short (5–100  ms) cryogen spurts that is
delivered to the skin surface through an electroni-
cally con- trolled valve. The 800 nm diode lasers
use a sapphire-cooled handpiece that is placed in
direct contact with the skin to cool the area. The
1064 nm Nd:YAG lasers uses a variety of cooling
mechanisms and is based on the laser used; cur-
rently available options include a chill tip cooling
device, pulsed cryogen delivery to the skin, con-
tact pre-cooling and air cooling. Finally, intense
pulsed light uses a chilled handpiece that cools
the skin and a transparent gel that provides opti-
cal coupling, as well as additional cooling [7]. In
addition to these methods, ice and refrigerated
gels can also provide relief [12].
A new technology called pneumatic skin flat-
tening (PSF) has been recently implemented to
reduce pain in hair removal with high energy
density lasers and intense pulsed light treatments.
PSF reduces post-treatment erythema and edema
via the use of the vacuum assisted treatment that
flattens the skin against the window. Treatment is
also faster, as it is not interrupted by acute pain
during the treatment [13]. A study demonstrated
that when using high energy Nd:YAG lasers, this
new technology also reduced pain without side
effects on darker skinned individuals, mainly
skin types IV–V [14]. In this study that used
Nd:YAG lasers, it is explained that PSF relieves
pain through the gate theory of pain transmis-
sion; it activates the pressure skin receptors right
before the laser is activated, blocking the pain
from the laser from being transmitted to the brain.
All 28 patients experienced less pain, and also
showed less erythema after treatment. Since hair
removal efficacy was found to be the same with
and without PSF, this new technology could be
very beneficial to patients by reducing pain of
laser treatments.
Another way to limit thermal injury to the epi-
dermis, in keeping with the theory of selective
photothermolysis, is to use a pulse duration
between the TRT of the epidermis (3–10 ms) and
that of the hair follicle (10–100  ms) [5, 12].
However, studies have sparked a reconsideration
of the original theory suggesting a modification
whereby the target isn’t destroyed by direct heat-
ing, but by diffusion from the pigmented area
[12, 15]. This requires long pulses upwards of
100 ms known as superpulses. These superpulses
would also damage other crucial targets, such as
stem cells, which may be another factor for per-
manent hair reduction [10].
The current market for laser hair reduction is
growing so rapidly that the FDA has not main-
tained an up-to-date listing of all approved laser
devices. Although new types of lasers are being
introduced into cosmetic dermatology, the com-
monly used lasers fall into one of four catego-
ries: the long-pulsed ruby laser (694  nm), the
long-pulsed alexandrite laser (755 nm), the long-
pulsed semiconductor diode laser (800–810 nm),
and the long-pulsed Nd:YAG laser (1064  nm).
Additionally, the Intense Pulsed Light (IPL) sys-
tem (500–1200  nm) is approved as a safe and
effective method for hair reduction (Table 8.1).
8  Laser for Hair Removal

124
Table 8.1  Laser and intense pulsed light systems for hair removal
Laser
Method of hair
removal
Example
Skin
type
Hair
color
Hair
diameter
Type of hair
removal
Hair
reduction
Side effects
Long-pulsed
Photothermal
E2000
I–III
Dark to
light
Fine
and
Long term
38–49%
hair
Treatment pain, erythema,
Ruby lasers
(694 nm)
destruction
Epitouch Ruby Ruby Star Sinon
brown
coarse
hair removal
reduction
edema, hypopigmentation,
hyperpigmentation, blistering, crusting,
erosions, purpura, folliculitis
Long-pulsed
Photothermal
Apogee
I–IV
Dark to
light
Fine
and
Long term
74–78%
hair
Treatment pain, erythema,
alexandrite
lasers
(755 nm)
destruction
Gentelase Epitouch ALEX
Ultrawave II/III Epicare
Arion
brown
coarse
hair removal
reduction
edema, hypopigmentation,
hyperpigmentation, blistering, crusting,
erosions, purpura, folliculitis
Pulsed diode
Photothermal
LightSheer
I–IV
Dark to
light
Coarse
Long term
70–84%
hair
Treatment pain, erythema,
laser (800 nm)
destruction
Apex-800 SLP1000
MedioStar
F1 Diode Laser
brown
hair removal
reduction
edema, hypopigmentation,
hyperpigmentation, blistering, crusting,
erosions, purpura, folliculitis
Long pulsed
Photothermal
CoolGlide
I–VI
Dark
Coarse
Long term
29–53%
hair
Treatment pain, erythema,
Nd:YAG lasers
(1064 nm)
destruction
Lyra
Ultrawave I/II/III Athos
Gentle Yag Varia Acclaim 7000
Smartepil II Dualis
Vasculight Elite Profile
Mydon
hair removal
reduction
edema, hypopigmentation,
hyperpigmentation, blistering, crusting,
erosions, purpura, folliculitis
Intense pulsed
Photothermal
EpiLight
I–VI
Dark to
light
Coarse
Long term
49–90%
hair
Treatment pain, erythema,
light source
(500–1200 nm)
destruction
Quantum HR Ellipse PhotoLight
Estelux ProLite Spatouch
Quadra Q4 SpectraPulse
brown
hair removal
reduction
edema, hypopigmentation,
hyperpigmentation, blistering, crusting,
erosions, purpura, folliculitis
Q-switched
Photomechanical
Softlight
I–VI
Dark to
light
Fine
and
Temporary
50–66%
hair
Treatment pain, erythema,
Nd:YAG
lasers
destruction
MedLite C6
brown
coarse
hair removal
reduction
edema, hypopigmentation,
hyperpigmentation, blistering, crusting,
erosions, purpura, folliculitis
V. Vejjabhinanta et al.

125
Indications/Contraindications
• Unwanted hair is a very common problem
affecting individuals from all demographics.
• The ideal candidate for laser hair removal is a
person with fair skin and dark terminal hair.
• Some contraindications include active cutane-
ous infections, history of keloid or hypertrophic
scar-ring, history of recurrent infections, and
active vitiligo and psoriasis in targeted areas.
Indications
Excess hair is an extremely common problem
affecting both men and women, of all ages, and
can have deep social and psychological impact
on the patient. Some scenarios associated with
unwanted hair include patients with hirsutism or
hypertrichosis, procedures that involve grafted
donor sites, and transsexual transformations from
male to female. The patient must have a realistic
expectation of the results, as the level of reduc-
tion in hair varies from individual to individual.
The ideal candidate for laser hair reduction is a
person with fair skin and dark terminal hair.
Contraindications
Patients with active cutaneous inflammation,
infection, or active sunburn should not be treated
until the area has resolved. A history of keloids
and hypertrophic scarring is not an absolute
contraindication, but these patients should be
treated less aggressively. Patients with a history
of recurrent infections (e.g., herpes simplex and
staphylococcal) should be started on prophy-
laxis to prevent outbreaks. Patients who are on
hormonal therapy should be advised on the limi-
tations of hair removal treatment. Also, people
with certain skin conditions such as vitiligo and
psoriasis should avoid laser hair removal in
affected areas, as it may lead to koebnerization.
Finally, patients taking minoxidil, or who have
spouses taking this medication, should be
warned that hair removal may be disrupted by
the stimulating effects of this drug [7].
Techniques
• The lasers used in hair reduction include the
694  nm ruby laser, the 755  nm alexandrite
laser, the 800 nm diode laser, and the 1064 nm
Nd:YAG laser. The intense pulsed light sys-
tem is also used in hair removal.
• Home-use laser hair removal devices, includ-
ing diode and IPL home-use devices, have
become increasingly popular due to its
convenience.
• Some of the parameters that must be opti-
mized for each patient include the wavelength,
pulse duration, cooling technique, and spot
size of the laser.
• Dark skinned individuals generally have more
side effects from laser hair removal.
• Patients must be notified at least 6 weeks prior
to treatment that they must not pluck, wax, or
use electrolysis in the targeted areas.
Pre-operative Management
Laser Treatment Approach
Obtaining an accurate patient history is very
important when interviewing a patient who is
considering laser hair removal. It is imperative
to clarify the patient’s expectations, what med-
ications they are currently taking, their history
of scarring, whether or not there is a local
infection in the targeted area, whether or not
they have tried other hair removal strategies in
the past, their endocrine status, and the amount
of sun exposure they have had recently.
Physical examination is also crucial and should
involve evaluation of the patient’s skin color,
skin condition, hair color, hair diameter, and
hair density.
Once a patient is determined to be a good can-
didate for hair removal, certain pre-operative
counseling must be done. The patient must be
notified that at least 6  weeks prior to the laser
treatment they must not pluck or use electrolysis
in the areas that they would like to undergo treat-
ment. They may, however, shave or use depila-
tory creams. It has been shown that greater hair
loss occurs at shaven rather than epilated sites. In
8  Laser for Hair Removal

126
addition, the treatment area should not be exposed
to the sun [7].
A few days prior to the laser treatment, the
patient should be instructed to shave or use a
depilatory cream on the treatment site (Fig. 8.1).
They should also be advised to start the use of
prophylactic antiviral agents, if there is a history
of recurrent HSV. On the day of treatment, the
area must be cleaned and free of make-up. A topi-
cal anesthetic may be applied 1–2 h before the
procedure [7].
Description of Techniques
Long-Pulsed 694 nm Ruby Laser
The ruby laser has the shortest wavelength of the
lasers available for hair reduction. Emitting light
at 694 nm, it has the best absorption by melanin
but the shortest penetration depth. Theoretically,
this would imply that the ruby laser should be the
most effective at hair reduction under the right
conditions, but it also means that there is a greater
potential for epidermal injury [16]. A cooling
hand piece is concomitantly applied during treat-
ment to lower the temperature of the skin and
spare it from injury.
Campos et al. reported very favorable results
for long-term hair reduction using higher flu-
ences of this laser system, with an average fol-
low-up time of about 8  months after the last
treatment [17]. Study patients who had received
treatment with a higher mean fluence of around
46 J/cm2 displayed sparse regrowth, as compared
with moderate regrowth in patients who had
received a lower mean fluence of around 39 J/cm
[3]. While an increase in fluence may contribute
to overall efficacy, it also increases the frequency
of side effects, which may include post-treatment
erythema, crusting, blistering, hypopigmenta-
tion, hyperpigmentation, and scarring [16]. These
side effects, especially pigmentary alteration and
scarring, were much more commonly seen in
darker skin, specifically skin types IV–VI [18].
This is due to the fact that shorter wave-length
leads to greater absorbance of the laser by skin
melanin, which is more abundant in darker skin
types. Consequently, studies with this laser pri-
marily involve lighter skin patients [16]. It should
also be noted that using a ruby laser with a pulse
duration of 1  ms (as compared to 20  ms) has
proven to cause greater epidermal damage in
patients with darker skin [19, 20].
Overall, most studies performed with the
694 nm ruby laser have shown it to be a safe
and effective method for non-permanent hair
reduction [16–18, 21, 22]. When comparing
three treatments using the ruby laser with three
treatments of waxing or electrolysis, it was
found that the laser provided a 38–49% hair
reduction while the alternatives provided no
significant change [19, 21]. Increasing the num-
ber of treatments appeared to correlate with a
decrease in overall hair count [19, 21–24]. Most
of these studies have also noted better results in
patients with light skin and dark hair [16, 18,
19]. These patients respond well to the laser
and experience fewer side effects because they
have the ideal combination of profuse deposits
of melanin in the hair with lesser amounts in
the epidermis [17].
Long-Pulsed 755 nm Alexandrite Laser
The long-pulsed alexandrite laser has a wave-
length of 755  nm. This slightly longer wave-
length allows a deeper penetration of the dermis
with less absorption by epidermal melanin, theo-
retically making adverse side effects less of a
concern for darker skin patients as compared to
the ruby laser. However, studies indicate that
blistering, hypopigmentation and hyperpigmen-
tation were still reported occurred in some
Fig. 8.1  Pretreatment of right axillary area 2 days after
shaving, only anagen hairs present
V. Vejjabhinanta et al.

127
patients with darker skin types [16, 18]. Results
have consistently shown good clearance rates for
hair reduction.
Lloyd and Mirkov reported a 78% clearance
of hair 1 year following five treatments (parame-
ters were 10  mm spot size, 20  J, 20-ms pulse
duration, and 3 week intervals) for their patients
[25]. Similarly, Eremia et al. noted an average of
74% hair reduction in all patients following three
treatments with the laser [26]. Patients with
lighter skin showed above average clearance
whereas those with darker skin showed below
average results, the latter of which may be due to
a lower fluence used for these patients. The
authors attribute their success partly to a larger
spot size which, at a given fluence, they believe
would deliver more energy per pulse with less
scatter and deeper penetration. Results of a study
by Nouri et al., supported their postulation, con-
cluding that a larger spot size is more effective
for laser hair reduction [27]. Three studies com-
paring various pulse durations of 2–20 ms found
no significant differences in hair reduction [16,
19, 28, 29].
As with the ruby laser, there is a positive cor-
relation between the number of treatments and
the overall efficacy of treatment with the alexan-
drite laser, in one study reaching a 55% hair
reduction in patients with skin types III–V [19,
30]. Also, when comparing three treatments
using the laser with four treatments of electroly-
sis, it was found that the alexandrite laser was not
only more effective (a 74% vs. 35% average hair
reduction), but also less painful [31].
In a meta-analysis of hair removal laser trials,
the hair reduction for the diode, Nd:YAG, alexan-
drite, and ruby lasers were 57.5%, 42.3%, 54.7%,
and 52.8%, respectively, at least 6 months after
the last treatment of at least three sessions. The
authors concluded that the diode laser is superior
for lighter skin, while the alexandrite laser is the
best choice for darker skin types [32].
800 nm Diode Laser
The 800  nm diode laser is comparable to the
755 nm alexandrite, and has become more popu-
lar along with the Nd:YAG laser for treating
patients with darker skin types. Both the diode
laser and the alexandrite laser produce light in the
middle of the spectrum and are well absorbed by
follicular melanin. Eremia et al. compared results
after 1 year using the alexandrite and diode lasers
and concluded that both were excellent (85% and
84% respectively) for long-term hair reduction
with no statistical difference between the two
laser systems [19, 33]. Furthermore, Bouzari
et  al. compared the alexandrite, diode and
Nd:YAG and found that the alexandrite and diode
lasers have similar efficacy [34].
The authors partially attribute the success of
their results to the use of relatively high fluences,
which they were able to use by carefully select-
ing patients who were untanned. Tanning
increases the chance of epidermal damage and
also lowers the laser’s effectiveness. Another
study found similar results between three treat-
ments of either the alexandrite laser or diode
laser. However, in this study, the hair reduction
was about 37–46% for the two lasers. Patients
from the study reported that the diode laser was
more painful and had greater side effects, partic-
ularly hyperpigmentation and blistering, as com-
pared with the alexandrite laser [19, 35].
A study comparing various spot sizes (8, 10,
and 14 mm) found that after three treatments and
at a 3 month follow-up, there was not a signifi-
cant difference in hair reduction [19, 36].
However, as with the ruby laser and the alexan-
drite laser, two treatments with the diode laser
resulted in a greater hair reduction (35–53%)
than one treatment (28–33%) after an average
2-month follow-up. Also in this study, the diode
laser lead to a significant hair reduction as com-
pared to shaving (13–36% vs −7%) [19, 37].
Shifting away from the standard, a recent
study suggests that low-fluence (5–15  J/cm2)
810 nm diode lasers has comparable hair reduc-
tion and less discomfort than high-fluence diode
lasers in phototype V skin type and tan patients
[38]. The study results showed that using a low-
fluence diode laser and high repetition rate was
safe and effective. Another study agrees with
these results, stating that a 810 nm diode laser
with 10 Hz at low-fluence has a high patient sat-
isfaction and efficacy. Data was collected from
368 body areas epilated in patients with skin
8  Laser for Hair Removal

128
types III–V after five treatments in a 6-month fol-
low up [39]. When combining treatment plans, it
was not found to be more beneficial to treat
patients with skin types I to IV with the diode
followed by the alexandrite laser, as it did not
produce greater hair reduction than the same
number of treatments using only the alexandrite
laser. Using the diode followed by the alexandrite
laser actually showed an increase in folliculitis
and blistering in patients [40].
1064 nm Nd:YAG Laser
The 1064  nm Nd:YAG has the longest wave-
length and deepest penetration amongst the
aforementioned laser systems available. It is not
very well absorbed by melanin, but is sufficient
in achieving selective photothermolysis and has
superior penetration [41]. The Nd:YAG is able to
penetrate the skin 5–7 mm, a depth at which most
of the target structures lay. Furthermore, the com-
bination of a low melanin absorption and deep
penetration leads to less collateral damage to the
melanin-containing epidermis (Fig.  8.2a, b).
These characteristics make this system the safest
choice for tanned or darker skinned patients [10,
41]. Long pulsed Nd:YAG has been shown to be
a safe and effective tool for hair reduction in skin
types IV and V, with long term hair reduction
after multiple sessions. Because skin types IV
and V have higher probability of post inflamma-
tory hyperpigmentation, adequate cooling is nec-
essary, hence the use of Nd:YAG laser with
sapphire tip cooling [42]. In general, lasers with
longer wavelengths such as the diode and
Nd:YAG laser have fewer potential negative
effects than lasers with shorter wavelengths [43].
While the Nd:YAG laser may be the safest
method to treat all skin types, it is not necessarily
the most effective. Bouzari et al. compared hair
reduction by the long-pulsed Nd:YAG, alexan-
drite, and diode lasers and found that after
3 months, the Nd:YAG was the least effective of
the three [36]. An interesting aspect of their study
was that the best results were seen in five patients
who underwent combination laser therapy that
included treatment with all three systems. They
hypothesize that using a variety of wavelengths,
they are able to damage hairs at different ranges
in the skin; longer wavelengths would damage
the deeper hairs and the shorter wavelengths
would damage the more superficial hairs. This is
analogous to laser tattoo removal, which incorpo-
rates a combination of lasers to remove the mul-
titude of pigments found in a given tattoo.
A study determining the safety and efficacy of
the long-pulsed Nd:YAG laser for all skin types
found that the treatments were more successful
(46–53% depending on location) in darker skin
patients (types V–VI). At 6 months, patients with
skin types I–II obtained a 41–43% hair reduction,
depending on location, while patients with skin
types III–IV obtained a 44–48% hair reduction
[44]. Another study comparing fluence levels
found similar hair reductions for fluences of 50,
80, and 100 J/cm2 (29%, 29%, and 27% respec-
tively) in patients with skin types II–IV [45].
a
b
Fig. 8.2  (a) Pretreatment of right axillary area with coarse hair. (b) Only fine hair exist after 3 months and five treat-
ments with 1064 Nd:YAG laser
V. Vejjabhinanta et al.

129
Intense Pulsed Light
The Intense Pulsed Light (IPL) system is not
technically a laser, but has recently entered the
hair removal arena as a competent contender.
In fact, it has been used for virtually all of the
same indications as laser systems (Fig.  8.3a,
b). Unlike lasers which emit monochromatic
light, IPL systems have flash lamps which
produce non-coherent light beams in the 500–
1200  nm spectrum [43]. IPL systems work
very similarly to lasers and rely on the princi-
ple of selective photothermolysis. The IPL
systems generally use millisecond pulse dura-
tion that is lower than the thermal relaxation
times of the targeted chromophores. IPL sys-
tems uses polychromatic light, which irradi-
ates multiple chromophores with both major
and minor absorption peaks, allowing for
greater selective energy absorption [7]. Today,
IPL is being used to cosmetically treat vascu-
lar and pigmented lesions in addition to
removing unwanted hair [46].
Results using this system have been compara-
ble to the more conventional lasers mentioned
(Fig.  8.4a, b). Similarly to lasers, dark-haired
patients responded better to IPL treatment than
did blonde or gray-haired patients, who also
required more treatment sessions [47]. IPL is not
capable of achieving permanent hair removal, but
long-term hair reduction with few side effects is
possible [48].
A randomized controlled trial on hirsute
women, with normalized testosterone levels,
reported that IPL and long-pulse diode laser both
obtained similar hair removal efficacies, with IPL
having a 77% to 40% hair reduction and the long
a
b
Fig. 8.3  (a) Pretreatment of perioral area. (b) Immediately after treatment with IPL system, with perifollicular ery-
thema and edema, as well as burning of hair shaft
a
b
Fig. 8.4  (a) Pretreatment of right axillary area. (b) Three months after three treatments with IPL system patient has fine
hair and delaying of hair growth
8  Laser for Hair Removal

130
pulse diode laser having 68% to 34% hair reduc-
tion. Although the efficacy declined in both treat-
ments after 6 months, it was still reduced from
baseline. Patient satisfaction scores were similar
at the 6-month follow up [49].
In a prospective randomized intrapatient com-
parison between Nd:YAG laser and IPL system,
it was concluded that in skin phototype II–III
individuals, IPL is a better choice than long
pulsed 1064 nm Nd:YAG laser [50]. IPL had a
statistically lower pain score and number of side
effects, leading to a higher patient satisfaction
score. In contrast, Nd:YAG-treated patients sta-
tistically showed higher side effects including
erythema, edema, and burning. With each
Nd:YAG-treatment, there was significant hair
reduction compared to IPL, which only showed
significant hair reduction after the third treat-
ment. Eight months after the last treatment, both
Nd:YAG and IPL treatments showed significant
hair reduction. Because IPL is shown to treat
larger areas at the same time with a lower cost,
IPL is beneficial. However, another study con-
cluded that in darker skinned individuals, the
long-pulse 1064  nm Nd:YAG laser had higher
levels of satisfaction and increased hair reduction
than IPL treatment [51].
A non-randomized controlled trial which
compared three treatments of IPL with three
treatments using a ruby laser found that in skin
types II–IV, 94% of patients obtained an average
49% hair reduction using the IPL system at
6-month follow-up, as compared with only 55%
of patients obtaining an average of 21% hair
reduction with the ruby laser [19, 52]. In a split-
face comparison of facial hair removal with the
IPL system and long pulsed alexandrite laser, 30
patients received six treatment sessions and data
was assessed at 1, 3, and 6 sessions. In compari-
son with the alexandrite laser, the IPL system
showed longer median hair-free intervals, larger
hair count reduction at the three sessions that data
was recorded, and a higher patient satisfaction
[53]. However, in a previous retrospective review
of long- and short-pulsed alexandrite lasers and
IPL, individuals needed a higher number of
­treatments with the IPL device for the same ben-
efit [48].
Home-Use Devices
Home-use devices have recently become very
popular due to their low cost and convenience.
Home-use devices use a lower fluence than stan-
dard 10–60  J/cm2 used in professional offices
[54]. As a result, there have been questions on
whether they only produce temporary growth
delay for several months rather than permanent
follicle destruction. Hession et  al. described a
few of the FDA-approved home-use hair removal
devices including diode lasers of 810 nm wave-
length with high, medium, and low fluence set-
tings (7, 12, 20 J/cm2) as well as a diode with
808 nm wavelength that could treat up to 60 and
20 hairs per pulse with a fluence below 5 J/cm2.
IPL home-use devices include treatment with
475–1200 nm wavelength, delivering up to 5 J/
cm2. Other available IPL devices emit similar
wavelengths of 400–1200 nm or 530–1100 nm
with a fluence up to 10 J/cm2 or up to 7–10 J/
cm2, respectively. Professional hair removal sys-
tems can vary widely in wavelengths; however,
the home-use hair removal systems are more
limited. For instance, the diode lasers have 800–
810  nm wavelength, and the IPL home-use
devices have a wavelength range mostly from
475 to 1200 nm.
The home- use diode laser, (Tria Beauty, Inc.,
Dublin CA), was found to be safe and effective
for hair reduction in individuals with Fitzpatrick
skin type I–IV after 8 monthly treatments [55].
Although the study sample size was 13 individu-
als, 546 active sites and 182 controlled sites were
analyzed. Low, medium, and high fluence (7, 12,
20  J/cm2) treatments demonstrated 47%, 55%,
and 73% mean hair count reduction 1  month
after the eighth treatment. At 12  months post
treatment, count hair reduction remained stable
at 44%, 49%, and 65% for low, medium, and
high fluences respectively. The only observed
side effects were mild transient erythema and
edema, more often seen in the higher fluence
sites. In another previous study, Wheeland con-
firmed that the 810 nm portable diode laser was
very effective at removing hair with a 33% mean
hair reduction 12  months after the third treat-
ment in 77 patients [56]. In addition, a random-
ized controlled trial with 32 women with skin
V. Vejjabhinanta et al.

131
phototypes I–IV treated with an 810 nm home-
use laser at 5.0–6.4 J/cm2 had a stable hair count
reduction and thickness during treatment [57].
After three treatments, hair reduction increased
to 38%, and with sustained usage reached a pla-
teau up to 59% hair reduction. However, hair
growth gradually returned to baseline 3 months
after the final treatment, regrowing beyond base-
line levels by 29% after treatment cessation.
An FDA-approved home-use IPL device for
hair removal, commercially known as IPL (Silk’n
device, home Skinovations, Kfar Saba, Israel),
uses a wavelength ranging from 475 to 1200 nm
and low fluences up to 5 J/cm2. A recent clinical
trial including 15 patients that received six
biweekly treatments with the home-pulsed light
device, concluded that this device is effective for
facial hair removal in skin types I–IV, indicating
a 78.1% mean percent hair count reduction at the
3 month follow up with no adverse effects [58].
Another study concluded that a novel low-energy
pulsed light device can effectively remove
unwanted non-facial dark terminal hair in indi-
viduals with skin type I–IV [59]. In 20 women,
after three treatments at 2-week intervals using
the handheld IPL device, hair counts reduced
37.8% to 53.6% 6 months after the three treat-
ments. Only 25% of the patients experienced
mild erythema, with no other side effects.
Side Effects
It is vital to provide education to patients on these
home-use devices in order to prevent injury.
Since home-use devices have brought safety con-
cerns, devices need to be easy to use and have
safety mechanisms built in. Because a potential
complication may be ocular damage due to the
laser or IPL emission, several home-use laser and
IPL packaging will provide protective eyewear
although it is not guaranteed that consumers will
use them [60]. Other safety mechanisms to
reduce the risk of ocular exposure include skin
contact sensors that do not allow the activation of
the laser unless in contact with the skin. It is nec-
essary to take precautionary measures to avoid
injury to retina and iris that may cause blind spots
or glaucoma. Since wavelengths above 750 nm
and below 400 nm can cause lens cataract or cor-
nea injury, many home-use devices will have
built in filters that do not enable them to emir
wavelengths below 450 nm [61].
Similar to standard professional laser devices,
darker skinned individuals need to be very care-
ful with home-use devices, because their greater
epidermal melanin content may increase their
risk for thermal burns. Some new models of
home-use IPL devices actually have a skin color
sensor, preventing the treatment of skin types V–
VI [43]. Since many studies of home- use devices
include skin types I–IV, more studies need to be
done with individuals of skin types V–VI in order
to better assess the risks of home-use laser hair
removal devices.
Overall, home-use devices within the scope of
hair removal continues to evolve and the increas-
ing popularity of home-use laser hair removal
devices due to their low cost, speed, and conve-
nience is important to consider in cosmetic der-
matology. In the future, optimizing their safety
and efficacy will probably have longer-lasting
treatment results while minimizing untoward
side effects.
Radiofrequency Combinations
Radiofrequency devices have been combined
with both IPL and diode lasers to provide optimal
hair removal treatments to a wider range of skin
types. The combinations are considered safe for
patients with darker skin types because the radio-
frequency energy is not absorbed by melanin in
the epidermis. This technology, termed electro-
optical synergy, or ELOS, has a dual mechanism
of heating the hair follicle with electrical energy
(namely radiofrequency) and heating the hair
shaft with optical energy.
A new evolution in photoepilation involves
removing nonpigmented hairs such as “peach
fuzz” which the previous lasers fail to remove. A
combination of radiofrequency (RF) and lasers
have been used for white or blonde hair, but with
low efficacy. Studies have shown that the com-
bined use of RF and optical energy has been found
to be successful, though various mechanisms have
been proposed to explain the success [62–65].
8  Laser for Hair Removal

132
Some claims of widespread safety have been
made because RF energy is not readily absorbed
by the melanin abundantly found in the epidermis
of darker skin types, theoretically sparing it from
damage. However, a low efficacy of this new tech-
nology has been reported so far. Results have indi-
cated that the majority of subjects achieved less
than 50% hair reduction after 3 months [63]. In
two other studies, average clearances of 48% [64]
and 75% [65] were seen at 18-months follow-up.
Because this is a relatively new technology, more
studies are clearly necessary to provide more reli-
able results for those with nonpigmented hair or
with darker skin types.
Other Removal Methods
for Nonpigmented Hair
Meladine, a topical melanin chromophore, has
been studied in Europe with interesting results.
The liposome solution dye, which is sprayed on,
is selectively absorbed by the hair follicle and not
the skin. This gives the follicles a temporary
boost of melanin to optimize laser hair removal
treatments. Clinical studies in Europe have shown
vast permanent hair reduction in patients who
used Meladine prior to treatment. However, other
studies have found Meladine to only offer a delay
of hair growth as opposed to permanent hair
reduction [7]. Sand et al. used a similar topical
liposomal melanin compound in a randomized,
controlled, double-blind study with blond and
white hair patients, and found that the substance
made almost no difference in treatment outcomes
for the patients [66].
Photodynamic therapy may be an effective
option for those with nonpigmented or light-col-
ored hair. Because of the lack or diminished amount
of a natural chromophore in the hair follicle, a topi-
cal photosensitizer 5-aminolevulinic acid (5-ALA)
is used. Light exposure activates 5-ALA, which
subsequently creates reactive oxygen and allows
for destruction of the hair follicle [7].
Post-operative Management
Post-operatively, ice packs can be used to reduce
pain and minimize edema. Analgesics are rarely
needed. Mild topical steroid creams may be given
to the patient to decrease post-treatment ery-
thema and edema. If any epidermal injury occurs
during the procedure, a topical anti-biotic can be
given to the patient. The patient should be noti-
fied that they must use sun block and avoid direct
sun exposure [7].
Adverse Events
• Some of the reported adverse events have
included post-treatment erythema, edema,
crusting, blistering, paradoxical hair growth,
hypo/hyperpigmentation, scarring, and skin
infections.
• Methods to decrease the risk of adverse events
include effective epidermal cooling, long
pulse duration, longer wavelength lasers, ice
packs, analgesics, steroid creams, topical anti-
biotics, and avoidance of sun exposure
Side Effects/Complications
Patients should be warned before the laser pro-
cedure that they might experience some discom-
fort during and after the procedure. Reported
adverse events have included post-treatment
erythema, edema, crusting, blistering, hypopig-
mentation, hyperpigmentation, and scarring
(Fig. 8.5a, b). Other complications include her-
pes simplex outbreaks in patients with a previ-
ous history of outbreaks, folliculitis in patients
who sweat excessively or swim, transient and
permanent pigmentary changes, temporary or
permanent leucotrichia, loss of freckles or light-
ening of tattoos, livedo reticularis, intense pruri-
tus, and urticaria [7].
In some cases, laser treatment has actually
been reported to induce hair growth, particu-
larly on the face and neck. For example, in one
study, this was noted in young females of
Mediterranean and Middle Eastern descent and
with darker skin types (III or IV) [67]. The
induction of hair growth occurred regardless of
the fluency or type of laser used for both
intense pulsed light and long-pulsed alexan-
drite laser. Because neo-genesis of hair folli-
cles after birth does not occur, it is likely that
the mechanism behind laser-induced hair
growth is that local vellus hair follicles trans-
V. Vejjabhinanta et al.

133
form into terminal pigmented hair follicles
[67]. Another theory is that the laser induces
synchronization of hair growth cycles by direct
light stimulation [68].
Prevention and Treatment of Side
Effects/Complications
Dark-skinned patients are more prone to the
adverse effects aforementioned. Several factors
may assist in minimizing these side effects.
Effective epidermal cooling can reduce epider-
mal damage from the laser treatment. A long
pulse duration allows the hair follicle to be
heated effectively while the effect of epidermal
cooling is at its peak. In addition, longer wave-
length lasers are associated with a lower degree
of epidermal damage. Ice packs, analgesics, and
mild topical steroid creams can be used post-
operatively to reduce pain and minimize ery-
thema and edema. In cases of epidermal injury, a
topical antibiotic can be given to the patient. The
patient should be advised to avoid sun exposure
after the procedure.
In a prospective, randomized, placebo-con-
trolled study, Akinturk et al. showed that piroxi-
cam gel provided adequate pain relief and lowered
inflammation after Nd:YAG laser hair removal in
patients as compared to placebo control [69].
Future Directions
• The FDA has approved lasers for permanent
hair reduction.
• Strong data from standardized, well-con-
trolled, long-term studies are needed to estab-
lish the optimal treatment parameters for each
laser.
Currently, the FDA has not approved lasers to
be marketed as a permanent hair removal option,
although manufacturers have been allowed to
claim permanent hair reduction based on safety
and efficacy. Permanent hair reduction involves
the stable reduction in the total amount of hair in a
given area over the long-term. To achieve the title
of permanent hair removal, future studies should
be concerned with the long-term efficacy of these
lasers. In general, the ruby laser can be used for
skin types I and II, although the alexandrite laser
and the diode laser are generally safer with less
side effects for skin types III–IV.  The Nd:YAG
laser is ideal for tanned skin and skin types IV, V
and VI, but has a lower efficacy in lighter skin
types. Current studies are beginning to investigate
the safety and efficacy of specific and newer lasers
for various skin types. This is important because as
the popularity of photoepilation continues to grow,
so will the population of patients interested in this
a
b
Fig. 8.5  (a) Blister formation, a complication of IPL treatment 3 days after treatment. (b) Residual hyperpigmentation
is still noticed 9 months after blister formation
8  Laser for Hair Removal

134
procedure. The challenge ahead lies in gathering
strong data from standardized, long- term studies
so that optimal parameters can be established. It
must be noted that current trends in laser treatment
choice and research have moved away from ruby
lasers and to the longer wavelength systems such
as the Alexandrite, diode and Nd:YAG lasers,
which allow for deeper penetration to the level of
hair bulbs [70].
Conclusion
Excess hair is an extremely common condi-
tion affecting both men and women of all
ages. Many of the previous options for people
seeking to remove or lessen the presence of
hair have been painful or have only resulted in
short-term effects. With the advent of laser
technology, the new generation nonablative
lasers and light systems have become some of
the most popular procedures in all of cosmetic
dermatology. Although lasers are not yet a
permanent solution for hair removal, they are
able to provide a safe, fast, and effective
method for hair reduction.
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© Springer International Publishing AG, part of Springer Nature 2018
K. Nouri (ed.), Lasers in Dermatology and Medicine,
Lasers for Resurfacing
Rungsima Wanitphakdeedecha and Tina S. Alster
Abstract
Many signs of cutaneous photodamage are
amenable to treatment with a variety of abla-
tive and non-ablative lasers, light sources, and
fractional photothermolysis. Ablative laser
skin resurfacing offers the most substantial
clinical improvement, but is associated with
several weeks of postoperative recovery.
Keywords
Lasers · Resurfacing · Ablative lasers · Non-
ablative lasers · Fractional lasers
Outline
• Many signs of cutaneous photodamage are
amenable to treatment with a variety of abla-
tive and non-ablative lasers, light sources, and
fractional photothermolysis.
• Ablative laser skin resurfacing offers the most
substantial clinical improvement, but is asso-
ciated with several weeks of postoperative
recovery
• Severe side effects and complications after abla-
tive laser skin resurfacing can be minimized by
careful patient selection, proper surgical tech-
nique, and meticulous postoperative care
• Non-ablative laser skin remodeling is a good
alternative for patients who desire modest
improvement of photodamaged skin without
significant post-treatment recovery
• The noninvasive nature of fractional photo-
thermolysis treatment, coupled with an excel-
lent side effect profile, makes it an attractive
alternative to ablative laser techniques.
• Good candidates for non-ablative laser and light-
source treatments are patients with cutaneous
photodamage and realistic clinical expectations
• With ongoing advancements in laser technol-
ogy
and
techniques,
improved
clinical
­outcomes with minimal postoperative recovery
will be realized
Introduction
R. Wanitphakdeedecha (*)
Department of Dermatology, Faculty of Medicine
Siriraj Hospital, Mahidol University,
Bangkok, Thailand
e-mail: rungsima.wan@mahidol.ac.th
T. S. Alster
Georgetown University Medical Center, Washington
Institute of Dermatologic Laser Surgery,
Washington, DC, USA
e-mail: talster@skinlaser.com
9
Summary Box
• A wide variety of lasers and light-based
sources is available to treat cutaneous
photodamage including ablative and
non-ablative lasers, light sources, and
fractional photothermolysis