Laser technology, according to Dr. Zachary, is better left in the hands of physicians and not in unregulated, under-supervised cosmetic spa environments.
Fixing the problem means getting beyond the marketing hype of laser companies and creating awareness that laser procedures are medical procedures with the potential to cause real complications, and all require realistic expectations. And in the medical spa setting, laser surgery should only be performed by experienced nurses or technicians under the supervision of a dermatologist or other appropriately trained physicians, according to Christopher B. Zachary, F.R.C.P., clinical professor of dermatology, co-director of the Dermatologic Surgery and Laser Center at University of California, San Francisco, department of dermatology.
"I think it is incredibly important that we be careful about new treatments, such as light-based treatments, because we are not sure what the long-term outcomes will be," Dr. Zachary tells Dermatology Times. "Most of the early reports in the literature simply talk about the positive outcomes and do not highlight complications."
"It seems recently to have taken hold, offering an amazing number of indications," he says. "The wide array of potential indications is almost too good to be true."
According to Dr. Zachary, PDT claims are conflicting. On one hand, the therapy is selective for premalignant cells. But when used for facial rejuvenation, it supposedly affects normal cells, too.
"There is a paradox here," Dr. Zachary says. "One of the major factors in normal photoaging is the development of reactive oxygen species ... which damage the skin. At the same time, people are saying PDT is good for you because it generates reactive oxygen species."
Dr. Zachary questions the therapy's long-term effects. When PUVA came out for the treatment of psoriasis, he says, dermatologists and their patients noticed immediate benefits. But three to five years later, many of those same people noticed extensive photoaging changes.
Long pulsed Nd:YAG 1064 nmAccording to Dr. Zachary, any laser surgeon who has experience with the long pulsed 1064 nm Nd:YAG lasers know they can cause some scarring.
"These lasers are unforgiving," he says. "Scarring is a very real complication of long pulsed 1064 nm treatment of hair or vascular problems."
Still, the technology is safer than other types of lasers for darker skin types.
"If you are treating darker skin types for hair removal, for instance, the long pulsed 1064 is going to be safer than the alexandrite or the 810 nm diode," he says.
Be conservative He warns, however, because dermatologists using the long pulsed 1064 tend to get deeper penetration with this technology's wavelength, they can get significant heating deep in the skin without much happening on the surface. It is critical, according to Dr. Zachary, that dermatologists use adequate cooling techniques and not over-treat patients.
"You must start conservatively and not expect some of the more dramatic changes that you might see with some of the lasers that work more superficially in the skin," he warns.
Dr. Zachary recommends dermatologists get thorough patient consents, covering the risks for ulceration, infection, pigmentary changes and scarring. And dermatologists should have direct supervision over the procedure if someone else in the office is performing laser procedures with the long pulsed 1064, making sure not to give that responsibility to inadequately trained personnel.
Treatment with the long pulsed 1064 laser may be appropriate for some vascular malformations, such as thick, dark, deep port wine stains.
Minimizing risks To minimize the risks of adverse events with the long pulsed 1064, he says that dermatologists should consider the nature of the target.