Aesthetic Dermatology

Laser treatment tips for pigmented lesions


 

EXPERT ANALYSIS FROM MOAS 2018

When it comes to treating pigmented lesions with laser and light, not all devices are created equal.

Dr. Victor Ross

Dr. Victor Ross

Victor Ross, MD, turns to the Q-switched alexandrite laser as his device of choice for most pigmented lesions. “I also use the Q-switched 1,064 nm Nd:YAG and sometimes use the Q-switched 532 nm Nd:YAG, particularly for lighter-skinned patients with lighter lesions,” he said at the annual Masters of Aesthetics Symposium.

Compared with long-pulsed devices, the Q-switched 532 nm neodymium:YAG laser is better for one-time pigment reduction and better for treating lighter pigmented spots, yet it’s associated with a higher risk of postinflammatory hyperpigmentation and short-term crusting. “The Q-switched 532 nm Nd:YAG laser will even treat very tight lentigines, but vascular effects tend to cause an immediate bright red color and more postinflammatory hyperpigmentation,” said Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego. He cautioned that the Q-switched 532 nm Nd:YAG laser may cause prolonged redness on the legs and arms of some patients. “This laser is best reserved for lighter skinned patients with very light lentigines – the brisk purpura can prove distasteful short term for cosmetic patients,” he said. “For darker lentigines, I prefer the IPL [intense pulse light], KTP [potassium titanyl phosphate] laser, or Q-switched alexandrite lasers.”

Meanwhile, treating pigmented lesions treated with long-pulse IPL, KTP, and pulsed dye lasers show less risk of postinflammatory hyperpigmentation and better coverage rates. However, they are sensitive to background color and are less likely to achieve complete one-time removal. The first treatment works the best because the “low hanging fruit” (darker lesions) will do well, he said.

For clinicians looking to improve their skills in treating pigmented lesions with lasers, Dr. Ross recommended using a skin meter such as Cynosure’s Skintel Melanin Reader, which measures the real-time pigment of skin. “You measure the pigment, and it gives you a reading,” he said. “It gives you a recommended setting based on the hand piece and the pulse duration.”

Melasma remains a difficult condition to treat with laser and light. In fact, Dr. Ross joked that he wouldn’t mind if the words “He cured melasma” graced his tombstone one day. “I have been treating melasma patients for 29 years now, and I’m not closer to a cure than when I started out,” he said. “I’ve tried lots of things. In my defense, I’ve made more people better than worse.”

His approach to treating melasma is to begin with a KTP laser or a gentle IPL if discrete lesions or telangiectasia are present. Next, he applies hydroquinone followed by a series of treatment sessions with the Q-switched Nd:YAG laser or a conservative fractional laser. “This tends to induce remission, but is associated with a high rate of relapse,” he said.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

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