LASER FOCUS

Dermatologist experts discuss the latest advances in laser technology and offer tips on how to navigate the research and acquisition process

Feature

By Allison Evans, assistant managing editor, April 1, 2021

For the new dermatologist moving from residency to practice, or the established dermatologist simply seeking a challenge, lasers may offer new potential. With a steep upfront cost and an incredible array of devices and systems to sift through, it's easy to become overwhelmed by advertisements, sales representatives, and the pressure to have the latest and greatest.

In this month's DermWorld, dermatologist laser experts discuss recent advances in laser technology as well as points of consideration before purchasing a device to help their colleagues avoid what could be a costly mistake. 

Fractional lasers

One of the more important advances in laser technology occurred in the early 2000s, when fractional laser devices first entered the market — offering an alternative to patients who feared pain, potential complications, and lengthy recovery times.

The first commercial fractional device was a nonablative laser known as Fraxel®, which was FDA-cleared for the coagulation of soft tissue, skin resurfacing, and the treatment of periorbital rhytids, pigmented lesions, melasma, acne scars, and surgical scars.

"Lasers are a very exciting area. Just like computers and other electrical devices, lasers are also continually evolving and improving."

Soon after, ablative fractional devices — fractional erbium:YAG and fractional CO2 laser devices — came to market, and they were shown to be more effective than nonablative devices at improving facial lines, wrinkles, and scars, said Keyvan Nouri, MD, chair of the University of Miami Medical Group and director of Mohs micrographic surgery, surgical training, and the dermatology and cutaneous surgery programs at the University of Miami. 

Picosecond lasers

In terms of pigmented lesions and tattoos, one of the biggest advances recently was the launch of picosecond (pico) lasers, said Dr. Nouri. 

In 2012, the FDA cleared the first picosecond laser, a 755-nm alexandrite laser for the treatment of unwanted tattoos and pigmented lesions. "For some colored tattoos, picosecond lasers can achieve faster results," said Kristen Kelly, MD, chair of the department of dermatology at the University of California Irvine School of Medicine and clinical researcher at the UCI Beckman Laser Institute & Medical Clinic.

They are somewhat more effective for treating tattoos and pigmented lesions, said Dr. Nouri. "Some physicians use these devices in a slower mode to regenerate collagen and improve facial lines as well." 

Aside from tattoo removal, they are most often used to treat different kinds of pigmented lesions like nevus of Ota, Dr. Kelly added. "There is some evidence that you may get a better result for those kinds of pigmented lesions with picosecond lasers."

While Tina Alster, MD, director of the Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology at Georgetown University, owns a picosecond laser, she only uses it about once or twice a week. "This isn't because there aren't a lot of people with tattoos who may regret getting them. Removing a tattoo is very expensive and takes multiple treatments," she explained. "Just because there are a lot of people with tattoos does not mean they will come in and seek tattoo removal treatments," she said.

Vasculature

For Dr. Kelly, who is passionate about vascular disease targets, there have been improvements in laser technology such as devices with larger spot sizes and higher energy levels. "What is most exciting in the space is that we now have noninvasive ways of measuring the size of the blood vessels that allow us to inform our selection of settings. We're using optical coherence tomography to do that, although very few dermatologists currently have access to that technology in their clinic," she said.

While physicians have experimented with adjuvant topical medications with lasers for vascular lesions, it has not been very successful, with the exception of hemangiomas, Dr. Kelly said. "As we're getting more genetic information, we're going to better understand the aberration in the different pathways related to individual lesions. Then we'll ultimately develop treatments that will augment laser therapy. Eventually, we may be able to do fewer treatments that will be more effective, and we won't get the recurrence that we currently get now," 

Skin of color

"Addressing skin color is extremely important when dealing with lasers because if you have more melanin in your skin, for many of the wavelengths that we deal with, there's going to be more melanin absorption. As physicians, we want — and need — to be able to treat all patients," Dr. Kelly said.

"Lasers are a controlled injury to the skin," said Seth L. Matarasso, MD, clinical professor of dermatology at the University of California School of Medicine in San Francisco, "and darker skin types don't respond as well. We've learned that we often need to lower our settings and perhaps treat a little more conservatively, which may mean performing more treatments to get the desired effect."

According to Dr. Nouri, most vascular lasers are still not as safe for dark-skinned patients (Fitzpatrick IV–VI). There are, however, specific wavelengths that are safer to use, such as the Nd:YAG 1064, which doesn't get absorbed by the pigment as much. "It's probably the safest to use in a patient for hair removal." 

"Even before the commercial availability of Nd:YAG lasers," said Dr. Alster, "there are experts who have a deep understanding of laser-tissue interaction and can use traditional lasers at appropriate energies and pulse durations that are safe for patients with skin of color." Dr. Alster also cautions against the blanketed use of device presets, especially for skin of color patients. "I'll look at some of the suggested preset parameters for darker skin types and wonder who came up with that recipe because it certainly isn't something I would do."

Intense pulse light can be used quite successfully on skin of color, Dr. Matarasso said. Hair-removal lasers and gentler, low-frequency resurfacing laser treatments can also work well on patients with darker skin types. 

There are a lot of alternatives to light therapy, such as radiofrequency and ultrasound devices, since lasers are known to cause postinflammatory hyperpigmentation, especially in darker-skinned individuals, Dr. Nouri said.

"Another option would be to do something like radiofrequency microneedling, which can get a good result and may be a safer option in patients with darker skin types," Dr. Kelly added.

Considerations before purchasing

"As a physician, I find it very hard to keep up with laser technology," said Dr. Matarasso. "A lot of the manufacturers have fairly significant claims, and oftentimes it's not the case."

Consideration #1: Cost vs. utility

When dermatologists set out to purchase a laser for the first time, it may come as a shock that most lasers start at $50,000 or can easily go above $100,000, depending on the laser, said Dr. Matarasso.

"Just because a piece of equipment costs a lot doesn't mean it's the best," said Dr. Alster. "Being the latest device doesn't make it the greatest, either. In fact, my most-used devices are not my most expensive systems. It's not what one would expect." 

In addition to the outright cost of the laser, dermatologists should not forget about maintenance contracts, which can be thousands of dollars a month, Dr. Matarasso said. "Also, about 50% of lasers have consumables, so that is another cost to consider."

"On average, each laser or device will cost about $1,000 per month for the service contract," said Dr. Alster. "While I have many lasers, I don't hold contracts on all of them anymore. I've been doing this so long, that I know which ones break down most often (and therefore need a service contract) and how to fix others (for which a service contract is unnecessary)."

Consideration #2: Patient demographic

The first thing dermatologists may want to consider before purchasing a laser is their location and patient demographic. "If you're in the Sun Belt, like Florida, Texas, or perhaps California, you would probably want a resurfacing laser to treat sun damage," Dr. Matarasso said. "In addition to treating fine lines, I also like to use a resurfacing laser (at a 1550 nm wavelength) to treat actinic damage, especially for patients who come in every three months or so with keratoses and precancers."

The problem, explained Dr. Matarasso, is that the procedures can be very expensive, and while the treatments benefit patients, insurance companies don't view it that way. They're going to say it's a cosmetic procedure. 

"If you'd like to purchase a laser for hair removal, consider whether your patient demographic is likely to come to your office for that type of treatment," said Dr. Alster. "I hardly ever use my hair removal laser because there are a lot of medical spas that have it — they've become ubiquitous."

Aside from considering current and potential patients, Dr. Kelly recommends pursuing what you love and what interests you. "If you decide to focus on children rather than adults, you may be using different lasers to treat different conditions. Or if you decide you're interested in treating patients with hyperandrogenism, then you might be doing a lot of laser hair removal in your practice," she said. 

Consideration #3: Do your homework

There's so much noise in this space — you must do your homework, urged Dr. Alster. She recommends never purchasing a system that you haven't used or seen in action. Lasers differ in their clinical work; not all the devices have peer-reviewed papers to support their treatment claims and successes. The companies need to perform IRB-approved clinical research and have the results published in peer-reviewed medical journals, she said.

Many of the newer, more expensive devices have found ways to combine various types of lasers into one system. "Sure, you can purchase a picosecond laser and add a fractionated handpiece to it, but it will take you longer to perform each skin resurfacing treatment and will cost much more than a stand-alone fractional laser (without additional clinical benefit)," Dr. Alster said. 

"As a physician, I find it very hard to keep up with laser technology. A lot of the manufacturers have fairly significant claims, and oftentimes it's not the case."

"There are presently several hundred systems from which to choose — and everybody says this one is as good as (or better than) the next," Dr. Alster said. "My question is: 'What do you plan to do with the system?' To make these devices pay off, you have to perform a significant number of treatments on a daily basis." 

"Start small and find someone you'd like to emulate," Dr. Alster advised. "If you're able to test a device, that's even better, whether that's in training, a fellowship, or maybe knowing a really good laser representative in your area who'd be willing to bring in a device for you to test."

Consideration #4: Purchase or lease?

If the cost of lasers is not yet in the budget, there are still options. "Some physicians who are in the same building share lasers, although the transportation can wreak havoc on the machine," Dr. Matarasso said. 

Practices can also rent or lease a laser. "The manufacturer will often set up a schedule in which you get to use the laser on a designated day or two each month. This may not be as convenient for the patient, but it's certainly more cost effective for physicians just starting out, or for those who want to test different lasers before making a substantial purchase."

Lastly, physicians have the option of purchasing used machines. "I don't know if I would encourage this as they may be costly to repair and there may be liability issues," Dr. Matarasso said. "But it's something to look into."

Learning about lasers

For residents, learning about lasers can be difficult, said Dr. Matarasso, because every residency program will have a different laser, so there's no baseline. There's no course that all residents must take or guidelines for what residents must learn, he said. While most residency programs have at least one laser, they often don't have the finances to purchase whatever is cutting-edge at the time.

In one way, the pandemic's transformation of in-person meetings to virtual ones has made it easier and less costly for more people to attend. "Things are changing all the time," Dr. Kelly said. "It's what I do every day, and I still learn something new at every meeting I attend. With the pace at which laser technology changes, attending meetings allows people to not only learn about techniques and safety, but also about the latest technology," she said.

However, hands-on laser training is important, said Dr. Matarasso, because you need to learn about pain management, managing patient expectations, and complications. "You need to be able to recognize when something is not going according to plan, how to prevent it, and how to treat it," he explained. The AAD, the American Society for Dermatologic Surgery, and the American Society for Laser Medicine and Surgery all offer a variety of meetings, hands-on courses, and fellowships or preceptorships. 

The future of lasers

"The laser world has really made a very significant impact on how we can best treat our patients, but it's a double-edged sword because there is a financial tradeoff and a maintenance tradeoff. Keeping up with the technology can be overwhelming," Dr. Matarasso said.

"Lasers are a very exciting area," Dr. Nouri said. "Just like computers and other electrical devices, lasers are also continually evolving and improving." While lasers tend to be used primarily for cosmetic purposes, there are medical conditions that can and are being treated with lasers, such as scarring, in which lasers have become a standard of care, Dr. Nouri said.

Laser devices are also becoming smarter, Dr. Kelly said. "Not only are devices armed with the ability to make setting choices, robotics are also being used to control the devices for precision and consistency. Robots can't do everything, like talk to patients and get feedback as physicians can do, but when you combine it all, the hope is that these treatments are going to become safer and more effective over time."

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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