LASERS IN DERMATOLOGY

 The word LASER is an acronym for “LIGHT AMPLIFICATION BY STIMULATED EMMISION OF RADIATION”.
 The RUBY LASER was developed first (1959)
 Nd:YAG in 1961
 Argon in 1962
 Carbon dioxide in 1964.
 Laser light as a form of light is a part of the EMS.
 LASER light difers from standard light eg. sunlight or incandescent light in the following ways:
 The LASER light is formed of monochromatic photons ( ie. Light from a given source is all of one
wavelength).
 LASER light is coherent ( i.e. The waves of energy are in phase with each other both in time and space)
 LASER light is also COLLIMATED ( i.e. The laser beam component waves are highly parallel, producing a
narrow beam that can be propagated for long distances with minimal divergence or convergence)
 The components of the LASER are :
 Lasing medium : THIS DITERMINES THE WAVELENGTH OF THE RADIATION . it can be SOLID ( e.g. ruby),
GAS ( argon or carbon dioxide) or LIQUID ( e.g. rhodamine dye laser)
 OPTICAL CAVITY : Encloses the lasing medium and the amplification process takes place here.
 ENERGY SOURCE : This is required for the amplification process. This may be a direct electric current,
optical flash or energy derived from chemical reactions.
 DELIVERY SYSTEM : To bring the laser beam from the machine to the patient, the laser systems that
create visible and near infrared lasers of shorter wavelengths are transmitted via fibreoptic systems. The
carbon dioxide laser which produces far infrared light of longer wavelengths uses a series of articulating
joints and mirrors for this purpose.

 Basic physics about LASER :

 ENERGY is contained in the light and is expressed in JOULES.

 POWER is defined as the time rate at which energy is emitted and is measured in watts ( joules/sec).

 IRRADIANCE OR POWER DENSITY is the concentration of the beam of light and is expressed as the power
applied per unit area( watts/ sq.cm). this determines the ability of the LASER to coagulate, vaporize or incise
tissue.

 FLUENCE or energy density is the actual amount of energy delivered to the unit area of target tissue and
depends on the EXPOSURE TIME. FLUENCE = POWER × EXPOSURE TIME .

 TRANSVERSE ELECTROMAGNETIC MODE (TEM) is the distribution of energy across the laser beam diameter.
The types of TEM are TEM00 ( the most fundamental mode used, the energy distribution follows a bell
shape in which the peak power density is at the centre of the beam) and TEM01( the energy distribution
has a doughnut shape with a “cold” spot in the center; this is less suitable for incisional work.

 TEMPORAL MODES OF OUTPUT: the LASER light is delivered in 2 broad categories: CONTINOUS WAVE
MODE AND PULSE WAVE MODE. In the continuous wave mode, there is an uninterrupted beam of
radiation of relatively low power. This requires a great deal of operative skills to deliver energy uniformly at
the required dose over the area to be treated. However the advantages are that larger areas can be treated
rapidly. Disadvantage is the lesser safety profile.
In the pulsed mode, the continuous beam can be interrupted to form pulses when the light is emitted
in bursts of low energy but with peak powers. This is done by cutting the beam either with simple mechanical
shutters or electronically operated switches or through mode locking or Quality switching or through controlled
pumping and discharge. Simple pulsed lasers produce the same peak power as continous wave, whereas
superpulsed or ultrapulsed lasers produce higher peak power with lesser pulse durations. The PULSED SYSTEMS
ALLOW IMPROVED ENERGY DELIVERY SYSTEMS WITH UNIFORM DOSE OF RADIATION ACROSS THE
TREATMENT AREA AS COMPARED TO CONTINOUS WAVE LASER. THERE IS A HIGHER SAFETY PROFILE BECAUSE
THESE SYSTEMS MINIMISE THERMAL INJURY BY ALLOWING THE TISSUE FOR A “COOLING PHASE” DURING THE
“OFF” PORTION OF THE CYCLE. IT IS MORE TIME CONSUMING THAN CONTINOUS WAVE SYSTEM.
 The tissue effects of LASER are as follows : TISSUE EFFECTS DEPEND ON
 TYPE OF LASER
 ANGLE OF INCIDENCE
 BASIC PROPERTIES OF SKIN
THE LASER ENERGY AFTER ABSORPTION IS CONVERTED TO THERMAL ENERGY AND IS MAINLY RESPONSIBLE FOR ALL THE
THERAPEUTIC ( BIOLOGICAL) EFFECTS PRODUCED BY THE LASER DIRECTLY OR INDIRECTLY( following conduction). The
therapeutic effects are as follows

(A) PHOTOTHERMOLYTIC EFFECT :

 The laser energy is converted to heat energy. Denaturation of proteins occurs at 40-90 degree C. they are reversible
if early and the temp. is < 50 degrees. Once the temp. is > 50 degrees, the tissue concentration of denatured proteins
increases--- the process becomes irreversible( COAGULATIVE TISSUE DAMAGE ---- LEADS TO CELL NECROSIS, HEMOSTASIS). If
the temp. reaches > 100 degrees, there occurs vaporization with tissue ablation. To achieve localized ablation with
minimal residual thermal damage, sufficient energy ( which achieves rapid cooling ) is rapidly delivered to the superficial
layers of the tissue( depth of penetration) for a short period of time( the time of exposure should be equal to or less than
thermal relaxation time i.e. Tr time). { Tr is the time taken to dissipate half its thermal energy and cool to 50% of its initial
temperature achieved immediately after exposure. The magnitude of relaxation time depends on the depth of penetration . for
human skin, the Tr is roughly 0.1 sec}. During vaporization, the tissue is rapidly brought to 100 degree centigrade and the
CELLULAR AND EXTRACELLULAR WATER IS CONVERTED TO STEAM WHICH BRINGS ABOUT EXPLOSION OF THE CELL WALLS.
THIS TYPE OF DESTRUCTION MINIMISES THERMAL DAMAGE TO ADJACENT TISSUES. To produce coagulation in soft tissue ,
irradiance of greater than 10 W/sq.cm are required; irradiance between 10-150W/sq.cm produces thermal necrosis and
coagulation . Rapid vaporization of tissue is achieved with irradiance more than 150W/sq.cm. irradiance of greater than 50,000
W/sq.cm will cut through the tissue. Next to vaporized ablated zone is the region of residual thermal damage which is 2-4
times the depth of penetration. The unwanted effects of LASER like desiccation and charring can be avoided by RAPID
VAPORIZATION.

(B) THERMOMECHANICAL EFFECT : Apart from direct effects of heat, ultra rapid heating in pulsed irradiation ---- causes
tearing of the tissue structures by pressure waves, cavitation or rapid differential expansion.

(C) PHOTOACOUSTIC EFFECT : The high energy rapidly pulsed lasers mechanically fragment and shatter pigment
chromophore( melanin) or pigmented particles ( tattoo ink). These smaller fragments are then cleared away from the tissue by
the body lymphatics, vasculature etc.

(D) PHOTOCHEMICAL EFFECT : LASER can cause a series of chemical reaction in the tissue either directly or through internal
conversion of energy to chemical energy.

(E) SELECTIVE PHOTOTHERMOLYSIS : The theory of selective thermolysis postulates that light of a wavelength which is
absorbed by a target chromophore will selectively damage or destroy that chromophore if the fluence is sufficiently high and
the pulse duration less than or equal to the thermal relaxation time of that chromophore. This has been successfully used to
treat superficial vascular malformations, certain benign pigmented lesions and for removal of hair or exogenous tattoos.

Target chromophore Selective absorption wavelength in

nanometer

Melanin 700-1000
Oxyhemoglobin 585, 577, 532
Water above 1100-2940, 10,600
Tattoos Variation as per individual color.

 AIM OF LASER THERAPY : uniform deposition of energy over a site in a manner that does not cause undue
charring or excessive coagulation injury.
 Types of LASERS are:
 THOSE THAT EMIT VISIBLE LIGHT : These are primarily used to treat vascular and benign pigmented
conditions, these include ---- ARGON, ARGON PUMPED TUNABLE DYE, FLASH LAMP PUMPED PULSED
DYE COPPER VAPOR, COPPER BROMIDE AND KRYPTON LASERS. These devises emit visible light
ranging from blue to red portions of the EMS. They are absorbed by the natural chromophores of the skin
----- hemoglobin and melanin.
 THOSE THAT EMIT INFRARED LIGHT : these include Carbon Dioxide and Neodymium: yttrium-
aluminium garnet laser.these are not absorbed by the skin chromophores ---- melanin and hemoglobin.
Carbon dioxide is selectively absorbed by water. The efficacy of Nd: YAG laser depends on the volume of the
tissue.
 THOSE THAT PRODUCE VISIBLE OR INFRARED LIGHT IN EXTREMELY SHORT AND INCREDIBLY
POWERFUL PULSES. This group of devices are known as Q switched lasers. As the wave moves through
the tissue, kinetic energy is produced which can fracture or disintegrate particles like tattoo and melanin.
These fractures allow Q switched lasers to be used clinically for the treatment of benign pigmented lesions
and the scarless removal of tattoos.
 COMPLICATIONS ARE:
 Scarring
 Pigmentary alterations
 Altered texture
 Local infection
 ADVANTAGES ARE :
 Office procedure
 Good and can be used in patients with pacemakers and anticoagulant therapy.
 Multiple lesion can be treated in the same setting
 Bloodless field.
  DISADVANTAGES ARE:
 Expensive
 All types of lesions cannot be treated by the same type of LASER
 SAFETY MEASURES DURING USE OF LASER : Goggles , mask, smoke evacuators, labeling the operating room.
Keeping the door and windows of the operating room covered.

Type laser wavelength mode absorption Lasing medium Depth of Scatte Clinical use
of penetratio r in
light n tissue
visibl argon 448-514 cw Hemoglobi Argon gas 1-2 mm mod Vascular lesions,
e n pigmented lesions
melanin
visibl ruby 694( red) Q Melanin Ruby crystal 1mm mod Tattoos and hair
e switched tattoos removal
visibl dye 577-585( Q Melanin Copper vapor 1.2 mm min Vascular lesions, few
e pulsed) switched Tattoos Rhodamine G pigmented lesions and
570-630( hemoglobi tattoos
tunable) n
visibl alexandrit 755 Q Melanin Alexandrite 1.5mm mod Tattoos and hair
e e switched tattoos crystals removal
Near DIODE 810 CW,pulse Melanin Diode crystals 4 mm min Hair removal and few
IR d hemoglobi vascular lesions
n
Near Nd:YAG 1064 CW, Q Melanin Neodymium & 5 mm high Very powerful and
IR switched tattoos YAG crystals effective tissue
coagulator. In Q mode,
removes black tattoos
and recalcitrant
keloids.
Mid Er: YAG 2940 CW, Q water Erbium+ yttrium 0.03 mm min Superficial skin
IR switched aluminium pass surfacing of rhytides,
garnet crystals atrophic scars,
syringomas and
xanthelesma
Far IR Carbon 10600 CW & water Mixture of 1 part 0.1mm per min Excisional mode :
dioxide Super carbon dioxide, pass blepharoplasty, scalp
pulse 1.5 parts reduction, keloids,
nitrogen and 4 rhinophyma, hair
parts helium transplantation.
Vaporization mode :
vascular lesions,
pigmented lesions,
appendage lesions.

GIST :
 For vascular lesions : ARGON, DYE, Nd: YAG, CARBON DIOXIDE
 For pigmented lesons : ARGON, CARBON DIOXIDE.
 For tattoo removal : ARGON( green), RUBY, ALEXANDRITE ( esp. green), Nd:YAG ( black), CARBON DIOXIDE.
 For hair removal : RUBY, ALEXANDRITE, DIODE
 For superficial skin surfacing : Er: YAG, CARBON DIOXIDE.
 HIGH TISSUE SCATTER : Nd: YAG
 MINIMAL TISSUE SCATTER : DYE, DIODE, Er: YAG.