Laser treatment of cutaneous conditions

Posted on November 14, 2023 by - Medical Podcast, Plastic Surgery, Podcasts

In this episode of PodMD, Specialist Plastic Surgeon Dr Helen Douglas will be discussing the topic of laser treatment of cutaneous conditions, including what laser treatment is, the types of conditions that can be treated, the risks of laser treatment, when a GP should refer and more.


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  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Helen Douglas

    Dr Helen Douglas is a Specialist Plastic Surgeon at The Scar Clinic Perth, specialising in burns, scarring and laser treatments.

    Dr Douglas graduated in medicine in 2004, before starting her specialist plastic surgery training in the UK in 2011 which she completed in Perth, WA. Helen is a Fellow of the Royal Australasian College of Surgeons and the Royal College of Surgeons of England and was awarded the prestigious Ian McGregor Gold Medal for outstanding performance in her specialist examinations in 2015. Helen is currently a Senior Lecturer at The University of Western Australia and a Clinical Tutor at Cardiff University where she undertook her Master’s degree in Laser and Wound Healing and has done 2 laser fellowships.

    Today, we’ll be discussing the topic of laser treatment for cutaneous conditions.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Question 1
    The topic of today’s discussion is laser treatment for cutaneous conditions. Helen, can you give us a brief overview about laser treatment?

    Helen: And yeah, so I think the first thing is most people know, but laser is an acronym, light amplification for the stimulated emission of radiation. And it’s about harnessing energy and to use that in a useful way in lots of different fields, but obviously medicines the field I’ll be talking about. So it’s an idea that was conceptualised and discussed by Einstein, but was actually put into practice in 1960 by an American called Theodore Maiman using a Ruby. So to make a laser you need an excitation source, which is usually a flash lamp or some form electricity too. You need a lasing medium that can basically use that excitation source to produce a single wavelength of light and that could be a gas like CO2. It can be a liquid like dye. Or it can be solid like Ruby.

    And then you need a delivery mechanism, and that usually involves a series of mirrors to focus the beam of energy, and then you have your laser. So the idea is that the laser energy is absorbed by the target. So, in our skin, which is what I’ll be talking about, we’ve got different targets. We’ve got blood, we’ve got melanin, and we’ve got water. So these are all called chromophores because they preferentially absorb different wavelengths of light. And this is called selective photothermolysis , so that different target chromophores in the skin are and better absorbing different wavelengths of light. And that’s how you treat it. And they can either be vaporised like with the water in the skin coagulated and like blood vessels in vascular malformations or blowing up, like tattooing. And that’s how they work.

    Question 2
    What are some common cutaneous conditions that can be effectively treated with laser therapy?

    Helen: Well, going back to that, it depends on the target and that’s about the wavelength of light that we use. And so as I said in vascular conditions, so such as capillary vascular malformations or haemangionas, that’s got lots of red oxygenated blood in it and the target wavelength for that is 595 nanometres, and that’s a dye laser. If it’s deoxygenated blood, slightly or further along about 755 nanometres, that’s a different laser and alexandrite, and that can target venous malformations or Venus lakes blue veins.

    Brown or black things such as birth marks, café au lait, all the weird and wonderful things like naevus of ito/ota, traumatic tattoos, professional tattoos, and those can be targeted and blown up. But the thing I’m really interested in is the water, so most of our skin obviously is water. The CO2 laser targets that. And it can ablate things such as precancerous lesions, it can resurface things so scars and collagen. And that’s for things like acne scars or wrinkles or normal scarring and also some things that you might have heard of, like the rhinophyma, the big bulbous noses and the with wonderful things like xanthelasma cutaneous deposits around the eye or tuberous sclerosis. So there’s all sorts of conditions that can be treated with laser.

    Question 3
    Can you explain the benefits of laser treatment compared to traditional methods for treating cutaneous conditions?

    Helen: Sure. So I think it’s a really good option. For those that either don’t have any options or that the options aren’t ideal and I’ll give you an example. So if someone in particularly in my practice is a burn surgeon who’s got a very large burn scar, so covering the whole of their arm, we can’t just cut that out and start again. You know that it’s going to be the same. So what else can we do to improve that scar? Well, laser can do it, and if you’ve got someone with a keloid who’s got you know that that’s something which you know, most doctors hate because you cut it out and it grows back larger.

    And so you don’t want to be doing that. And we need a way of treating that that’s low risk and high return. Any kind of surgical scar can get thick, even if it’s treated really well and that’s difficult to treat otherwise, because cutting out again, you’d have to be convinced you’ll have a different result and an injecting steroid can give you some atrophy around there. Lasers very low risk at that and improves it. And it’s low downtime, very useful as an adjunct to other therapies.

    Question 4
    Have there been any developments in laser treatment in the last years or are there any in trials or development now?

    Helen: So laser initially involved, I’m going to concentrate on the collagen and the scar treatments here because they’ve all got different risks, but particularly in my field where I’m using it for scars and cutaneous conditions targeting water, previously it was the delivery method. So, you might have heard about fractionated versus unfractionated laser. So, laser that’s just delivered to an area of skin essentially, just if it’s unfractionated or continuous, it just burns off the top layer. And that creates loss of epidermis down to superficial dermis that then heals and produces a smoother line. Whether you’re looking at that for acne scars, scarring or wrinkles.

    Now it was very good for skin that could regenerate very quickly. So normal skin could do that. You could burn off the top layer, it would heal and look better. If you tried that with scarring, it would be very risky because the skin appendages underneath, such as the hair follicles, the sweat glands and the nerve endings that have got all the correctness sites that heal the skin. They’re not there in the same quantity as normal skin, so if you burn off the top layer of a scar, it’s not going to heal as quickly. That’s going to be increased risk of infection and more scarring. So even though we had all these lasers, it was still very limited up until about 10 years ago in the use for decent sized scars. And that totally changed when they introduced fractionated laser and that means delivering the same energy but in tiny columns about four millimetres deep into the skin, so it leaves undamaged areas of epithelium each side so you can heal it very quickly but still perforate the scar and heat the collagen underneath.

    And that has been an absolute game changer for us, really. And so all of the big burns units have bought one of these lasers for fractionated CO2. And which is really useful, and we in WA have released two large randomised controlled trials on ResearchGate which is available if you search my name. And looking at Split Scar steady of laser and mature and immature scars and it affected and improved both. And then early layers are at three months randomising each limb to either treatment or standard care with pressure garments. And it showed that it improved significantly itch, pain, rated appearance and histological architecture. And this has been confirmed and supported by other large series such as Andea Isler Fisher’s work over in Sydney.

    Question 5
    What are the risks of using laser treatment?

    Helen: The risks are a lot less with fractionated laser treatment because of the rapid healing profile. Because you’ve got these targeted, we call them thermal treatment zones or empty zeds with undamaged columns of skin either side to heal quickly. And so melanin is still a concern if you’re treating. So I think we’ll discuss this more later. But in fractionated laser delivery, you can still deliver this kind of treatment to darker skin types and it doesn’t affect the pigmentation.

    Question 6
    Are there any key indicators that a patient may benefit from laser treatment

    Helen: So any cutaneous condition where you’re trying to treat something on the surface I think is the first thing. Most lasers particularly, and then we’re talking about ablative versus non ablative lasers. So ablative lasers removes a portion of the epithelium on the skin, whether it’s fractionated or you know, continuous. But most lasers, particularly non ablative ones, can only get 2 millimetres deep, and that’s absolutely fine if you’re looking to target surface vascular chairs such as a child with a spider nevus or a vascular malformation. But anything that’s deeper into the skin is probably going to struggle.

    So the 02 laser can get 4 millimetres into the skin. So it’s really good for thick tight scars. So any tight scars, any thick scars, good for CO2 laster. Any red, blue or vascular lesions on the surface. Like I say a pulse Dyer and alexandrite laser. And if it’s melanin, it kind of has to be thin. So if something is hairy, then the pigment goes deep into the hair follicles and you can’t explode that with the laser because you’re just going get those nests of melanocytes coming back up. So if it’s a café au lait macule, yes, you can get rid of that or the equivalent. But if it’s a thick, hairy, Becker naevus that’s not going to work with laser, and I think you know just. The same applies for deep or old or amateur tattoos. If it’s down into the deep demos or fat, then it’s not going to get exploded by the laser and they’re best off with surgery.

    Question 7
    Are there any specific skin types or conditions that are not suitable for laser treatment?

    Helen: Covered that a little bit before. So I would say caution with Fitzpatrick 4 plus skin, so. Any skin type more than sort of Southeast Asian in terms of pigments and so those, those darker skin types you need to be cautious and I would do a test patch, but as I said, OK, with fractionated lower densities as they heal within two days and that’s the difference. And deep lesions aren’t reached. And also I think it’s important you know where you want a histological diagnosis because the label the laser will vaporise things. So if you’ve already got a diagnosis of you know, so it’s quite frequently used on the lower lip for mucus cutaneous, skin precancerous lesions. But if you want histology, it’s not going to. Be useful for.

    Question 8
    When should a GP refer a patient for laser treatment?

    Helen: So I think again, concentrating on the water target, if they feel in their clinical assessment that there’s a scar that can be improved or a skin condition, a surface skin condition that could be improved. And they could refer them for an opinion, and particularly if there’s a reason. And that it healed poorly like, say, infection or delayed wound healing or not, because that could then be improved or could be have the risks of it happening again lowered by using laser rather than more surgery. Keloids, acne and all these difficult scars harm scars and that are really difficult to treat. And anything tight over hands and joints I think are really beneficial.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on laser treatment of cutaneous conditions.

    Helen: So I think the first one is lasers can treat all kinds of cutaneous targets and thinking about those chromophores and the selective photothermolysis and that CO2 laser is a total game changer in problematic scarring. And we’ve seen those advancements since we’ve been training, which is really exciting. And also lots of types of scars can benefit from it, and particularly tight raised and itchy scars. And it can really give relief to patients.

    Thanks for your time and the insights you’ve provided.

    Helen: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.