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.

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

Helen: I think the first thing most people know, but laser is an acronym, Light Amplification for the Stimulated Emission of Radiation. And it’s about harnessing energy and using that in a useful way in lots of different fields, but obviously medicine’s the field I’ll be talking about. 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 of electricity. 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. 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. These are all called chromophores because they preferentially absorb different wavelengths of light. This is called selective photothermolysis; that different target chromophores in the skin are better at absorbing different wavelengths of light and that’s how you treat it. They can either be vaporised like with the water in the skin coagulated and like blood vessels in vascular malformations or blown up, like tattoo ink. And that’s how they work.

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, such as capillary vascular malformations or haemangiomas, that’s got lots of red oxygenated blood in it and the target wavelength for that is 595 nanometres, and that’s a Pulsed dye laser. If it’s deoxygenated blood, slightly further along about 755 nanometres, that’s a different laser called Alexandrite, and that can target venous malformations or venous lakes or blue veins.

Brown or black things such as birthmarks, café au lait, all the weird and wonderful things like naevus of ito/ota, traumatic tattoos, and professional tattoos – those can be targeted and blown up.

But the thing I’m really interested in is the water – most of our skin obviously is water. The CO2 laser targets that. 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 weird and wonderful things like xanthelasma cutaneous deposits around the eye or tuberous sclerosis. So there are all sorts of conditions that can be treated with laser.

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 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, a laser can do it, and if you’ve got someone with a keloid you know that that’s something that most doctors hate because you cut it out and it grows back larger. 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 injecting steroid can give you some atrophy around there. Laser is very low risk at that and improves it. It’s low downtime, and very useful as an adjunct to other therapies.

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. You might have heard about fractionated versus unfractionated lasers. They are a laser that’s just delivered to an area of skin essentially, if it’s unfractionated or continuous, it just burns off the top layer. That creates a loss of epidermis down to the 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 have all the keratinocytes 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 an 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 – that means delivering the same energy but in tiny columns about four millimetres deep into the skin, so it leaves undamaged areas of epithelium on each side so you can heal it very quickly but still perforate the scar and heat the collagen underneath.

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. This is really useful, we in WA have released two large randomised controlled trials on ResearchGate which are available if you search my name; looking at a split scar study of laser in mature and immature scars and it affected and improved both. And then early laser at three months randomising each scarred limb to either treatment or standard care with pressure garments. It showed that it improved significantly itch, pain, rated appearance and histological architecture. This has been confirmed and supported by other large series such as Andrea Issler-Fisher’s work over in Sydney.

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 Microthermal treatment zones or MTZs, with undamaged columns of skin on either side to heal quickly. And so melanin is still a concern if you’re treating it. 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.

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 remove 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 1-2 millimetres deep, and that’s absolutely fine if you’re looking to target surface vascular things 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 C02 laser can get 4 millimetres into the skin, it’s really good for thick tight scars. So any tight scars, any thick scars, good for the CO2 laser. Any red, blue or vascular lesions on the surface, like I say a pulse dye 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 the same applies to deep, old or amateur tattoos. If it’s down into the deep dermis or fat, then it’s not going to get exploded by the laser and they’re best off with surgery.

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 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 that.

When should a GP refer a patient for laser treatment?

Helen: 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, particularly if there’s a reason it healed poorly like, say, infection or delayed wound healing or not, because that could then be improved or could have the risks of it happening again lowered by using a laser rather than more surgery. Keloids, acne and harm scars are really difficult to treat. And anything tight over hands and joints I think to treat is really beneficial.

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 think about those chromophores and the selective photothermolysis

The CO2 laser is a total game changer in problematic scarring.

We’ve seen those advancements since we’ve been training, which is really exciting. And lots of types of scars can benefit from it, particularly tight raised and itchy scars; it can really give relief to patients.

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