Further Treatment Pearls

When treating pigmented lesions and tattoos, the laser handpiece should be held perpendicular over the area to be treated. Pulses should be delivered with 0-10% overlap until the entire lesion is treated.

The desired laser tissue interaction produces immediate whitening of the treated area with minimal or no epidermal damage or pinpoint bleeding. It is best to use the largest spot size to minimize epidermal damage. If epidermal debris is significant, the fluence should be lowered. Higher fluences may be needed with subsequent treatments when less pigment or tattoo ink particles are still present in the skin.

IPL treatment or Q-switched laser treatment of epidermal pigmented lesions rarely requires anesthesia. When needed, a topical anesthetic cream can be applied 1-2 hours before the procedure to reduce the discomfort. For more complete anesthesia, local anesthetic infiltration or regional nerve block can be used.

Treatment parameters are determined by the type of lesion and the patient's skin type. As discussed above, the ideal response is immediate whitening of the skin with little or no epidermal disruption. If the fluence is too low, the whitening will be minimal, whereas if the flu-ence is too high, the epidermis is ruptured and bleeding might occur. Following treatment with a 510-nm PDL or a QS 532-nm laser, pinpoint bleeding usually appears and lasts for 7-10 days. This occurs because of vessel rupture after hemoglobin absorption.

The whitening of the treated area lasts about 15 minutes and an urticarial reaction appears around the treated area. In the following days, the treated area usually becomes darker and develops a crust that falls off in 7-10 days (Fig. 3.10). The postoperative care consists of application of a healing ointment, and avoidance of sun exposure, in an effort to reduce the risk of postinflammatory hyperpigmentation.

Patients with darker skin types should be treated at lower fluences. Their threshold response will occur at lower fluences than is seen with patients with lighter skin types. Treatment of suntanned individuals should be avoided because of the high risk of laser-induced hypopigmentation.

While one to three treatments are sufficient to treat most lentigines, multiple treatments will be necessary for pigmented birthmarks like cafe-au-lait macules.

Anesthesia is rarely required for dermal pig-mented lesions. When treating larger areas, topical or intralesional anesthesia may be necessary. When treating nevus of Ota, regional nerve blocks usually provide adequate anesthesia.

Treatment parameters are again determined by the type of lesion and the patient's skin type. In general, higher fluences are necessary than those required for the treatment of epidermal lesions. The threshold response should be

Skin Cytosis

immediate whitening of the skin with little or no epidermal disruption. The same postoperative aftercare and precautions apply as for epidermal pigmented lesions. Dermal melano-cytosis require multiple treatment sessions, usually performed at 6-week intervals or longer. Lesions as nevus of Ota continue to lighten for several months after each treatment.

Anesthesia is usually not required for small tattoos. For certain individuals or for larger tattoos, topical or intralesional anesthesia might be necessary.

If adequate fluences are available, it is best to use the largest laser spot size. This will reduce backward scattering and therefore minimize epidermal rupture. Following treatment, wound care is required to help healing and prevent infection. An antibiotic ointment should be applied. A dressing should be worn for several days until healing has been completed.

Tattoo treatment usually requires multiple treatments to obtain adequate clearing. Amateur tattoos respond more quickly than do multicolored professional tattoos. Complete clearing of tattoos is not always possible. During the initial consultation, the patient should be informed about this. However, dramatic lightening can be expected.

Cosmetic tattoos should be approached with caution. When treating tattoos with colors that may darken (white, light pink, tan, or some brown colors), a single test spot should be performed to assess immediate darkening (Fig. 3.11,3.12). If darkening occurs, the same test site should be retreated to be sure the ink can be lightened before proceeding further. Although

Fig. 3.11. Cosmetic tattoo. Darkening of pigment after first treatment. Partial clearing after 6 treatments with Q-switched alexandrite laser

Color shift to green after laser test with Q-switched alexandrite laser

Color shift to green after laser test with Q-switched alexandrite laser

Laser Vaporization Skin

the darkened pigment may clear easily, it can sometimes be very recalcitrant to treatment. In this case, CO2 or erbium:YAG laser vaporization can be used, as an adjunctive treatment modality, by removing the epidermis immediately before Q-switched laser treatment and/or by facilitating transepidermal tattoo particle elimination.

Treatment sessions are performed at intervals of 6 weeks or greater. Waiting longer between treatment sessions might be even more beneficial as tattoos may continue to clear for several months following each treatment.

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