The Pulsed Dye Laser (PDL) is one of the most commonly used lasers in cosmetic surgery. It was originally developed to treat cutaneous vascular lesions such as telangiectasias (spider veins) and port wine stain vascular birthmarks. Technical advances and refinements in recent years have greatly expanded its use to include preventing scar formation following surgery and treating facial acne. The main advantage to the pulsed dye laser is that it is a quick office procedure with minimal to no discomfort and essentially no down time. It is extremely safe and so very gentle on the skin that it can be used to treat a baby’s face. It is the laser that we use most frequently in our practice.
How Does It Work?
A laser is a device that emits light through a process of optical amplification which is based upon the stimulated emission of electromagnetic radiation. Thus, the term “laser” which is actually an acronym for “light amplification by stimulated omission of radiation”. The first laser was developed in 1960 by Ted Maiman at the Hughes Research Laboratories. He retired to Santa Barbara, California, and we had the privilege of being a faculty member with him for many years at an annual facial plastic surgery laser meeting in Santa Barbara where he shared stories regarding developing that first laser over 50 years ago.
The Pulsed Dye Laser consists of a medium, in this case an organic dye mixed in a solvent. The organic dye is energized by an electrical charge which stimulates the dye to release energy in the form of light (photons). This light beam is unique compared to nature light in that the wavelength of the light are al the same – coherent. This property allows the laser to be used for medical purposes because the light can be focused to a precise location and light energy is absorbed uniformly. Specific tissues absorb specific light waves which enables the doctor to treat specific tissues in our body. In the case of the pulsed dye laser, the wavelength is 585-595 nm. This is the wavelength that is absorbed by oxyhemoglobin in the blood and to some degree melanin pigment in the skin. The concentrated beam of light targets blood vessels in the skin. Light is converted into heat, destroying the blood vessels a leaving the surrounding skin undamaged – a process called “selective photothermolysis”. Recent studies suggest that the pulsed dye laser may also stimulate growth factors (cytokines) in the skin which can stimulate collagen formation.
PDL treatments usually take only a few minutes and are an office procedure. The patients wash the treatment area to remove facial oils and makeup. A topical anesthetic cream is then applied to the treatment area and is left in place for 10–15 minutes to numb the area. The anesthetic cream is removed, and the patient’s eyes are covered to protect from the laser’s yellow light. The machine produces a cold spray just before the laser pulse, diminishing any sense of discomfort. If a large area is treated, moisturizing lotion such as Eucerin is applied to the treated area, and the patient is able to return to their normal activities.
Most people find PDL laser treatments painless. Some describe a sensation similar to that of the “snap of a rubber band”. Even though the eyes are covered, many patients describe the sense of a bright flash of light. There is no pain following treatment, and most patients are able to apply makeup and return to normal activities immediately following the procedure. It is usually recommended to avoid rejuvenation creams such as Retin-A until the day following treatment. Some patients may have a transient splotchy redness to their face which resolves 1-2 hours following treatment. A few patients who have large, dilated vessels close to the surface may develop purpura. Purpura is a purplish colored spot that looks similar to a bruise, but is not the result of trauma, as is the case with a bruise. Purpura is discoloration as a result of fluid leaking from the destroyed blood vessels. The purpura is transient, lasting 1-3 days in most cases. It is very unusual to have any skin irritation following treatment. The PDL laser is so gentle on the skin that it can be used to treat skin vascular lesion on infants less than one month old.
What is The Difference Between Intense Pulsed Light and The Pulsed Dye Laser?
Intense Pulsed Light therapy or IPL is also called a photo facial. An IPL machine omits polychromatic light, which means it emits several wavelengths at once. Various filters are inserted to block certain wavelengths and allow other wavelengths to pass through. Because of the many wavelength, this machine can be used to treat a variety of conditions.
A Pulsed Dye Laser is a laser that produces only one wavelength of light. Therefore, it has a more focused use and is used to treat a more limited number of conditions. The light it produces is stronger and more intense than that produced by IPL. Thus, it is usually more effective than IPL, which means the patient will need fewer treatments to obtain the result they desire.
Photodynamic Therapy (PDT)
The pulsed dye laser is also used in photodynamic therapy (PDT). Photodynamic therapy is used to treat various dermatological conditions including severe acne and precancerous lesions such as actinic keratoses. It can also be used in facial cosmetic surgery to stimulate collagen to help improve skin elasticity and obtain results similar to those of the medium depth chemical peel.
In photodynamic therapy, a photosensitizer such as 5–aminolevulinc acid (ALA) is applied to the skin. The skin interacts with the 5–ALA which is selectively absorbed by rapidly dividing cells. The cells convert 5–ALA into protoporphyrin within the cell. When the skin cells containing protoporphyrin are exposed to the pulsed dye laser light, they generate oxygen radicles which have a toxic effect on the abnormal cells. Various light sources can be used to activate the photosensitizer. However, PDL–mediated photodynamic therapy is generally faster and with fewer side effects, making it an ideal light source for treating certain dermatologic conditions.
Typically, the 5–ALA photosensitizing agent is applied to the face and neck areas to be treated. Following this, a topical anesthetic cream is applied. The patient is placed in a dimly limit room for approximately 1 hour to allow the photosensitizer to incubate with the skin. After an hour, the topical photosensitizer and anesthetic agents are removed from the skin, and the patient is treated in the usual manner with the pulsed dye laser. Following the laser treatment, a thick layer of Vaseline or Aquaphor is placed over the treated areas. Patients made experience a mild sunburn-like discomfort for several hours after treatment, but most patients do not note any discomfort. Because the skin has been photosensitized, the patient needs to avoid being in strong indoor light or in sunlight for 4–5 days following treatment. During this time, the patient applies Vaseline or Aquaphor 3-4 times a day to keep the skin moist. Essentially, the only thing that touches the treated skin for 3–5 days is Vaseline and water. In most cases, after 4 days the skin has a slight red glow which subsides over the next 1-2 days. While makeup can usually be applied after 4–5 days, skin rejuvenation creams and lotions are usually avoided for 1–2 weeks following treatment and diligent use of sunscreens is recommended for 1-2 months following PDT treatment.
The pulsed dye laser which is originally develop to treat congenital vascular disorder such as port-wine stains and hemangiomas in children. The wave length of the pulsed dye laser is selectively absorbed by the hemoglobin blood vessels, so is especially effective in treating cutaneous vascular lesions. Some vascular lesions resolve immediately upon treatment. Others gradually fade away several weeks after treatment. However, depending upon the type of vascular lesion, size, and skin type, multiple treatment sessions spaced 1–2 months apart may be necessary.
Facial telangiectasias (spider veins) telangiectasias or small spider-like proliferation of veins that are superficial in the skin. They may develop as a result of the normal aging process or secondary to inflammatory disorders and the skin such as rosacea. 1–2 treatments are usually necessary to obtain the desired results.
While telangiectasias on the face respond extremely well to treatment with the pulsed dye laser, spider venison the lower extremities are more difficult to eradicate. This is because they tend to lie deeper in the skin and have more of a venous component. While the pulse dye laser can be used to treat spider veins in the legs, it is not considered the optimal treatment.
Hemangiomas or blood vessel growth switch usually are noted in the facial area shortly after birth. They can continue to increase in size until approximately the age of 10 and then many well gradually regress (involute) in some cases they completely resolve. However as they grow they can stretch the dermal skin tissues and results in some facial scarring which becomes more obvious when the hemangioma involutes. The number of treatment sessions depends upon sized hemangioma in intensity of the blood vessel density. However, most people see significant improvement if not complete resolution in 3–4 treatments spaced 1–2 months apart.
Cherry angiomas are small, bright cherry–red spots they are noncancerous skin lesions. They are essentially a collection of compacted blood vessels and are also known as senile angiomas or Campbell de Morgan spots. They seem to be related to aging, and there may be a genetic correlation. Cherry angiomas appear to be more common in people over the age of 40 and at least one published medical study (American Family Physician) noted that they occur in up to 50% of adults. The main reason to treat cherry angiomas is cosmetic. While they can be treated by excision or electrocautery, the pulse dye laser is a very effective and virtually painless way to remove these vascular lesions with immediate recovery and virtually no scarring.
Post Wine Stains (PWS)
A port–wine stain (nevus flammeus) is a malformation of the capillary blood vessels in the skin which results in discoloration of the skin with a color similar to port wine, a red wine from Portugal. These vascular lesions are seen at the time of birth, and the skin affected grows in proportion to general growth. Port-wine stains can be tremendously disforming and have significant adverse psychological effects on children. They commonly occur on the face, but can develop on any area of the body. They are usually flat and pink in appearance in babies, and as the child grows the color deepens to dark red or purplish color. Port–wine stain “birthmarks” occur in approximately 3–5 cases per 1000 newborn babies. One of the first uses of the pulse dye laser was to treat port-wine stains in infants. Today it is the gold standard for the treatment of port-wine stains. Significant improvement can be obtained in the majority of the cases. However, multiple treatments spaced 1–3 months apart may be necessary. Because the pulse dye laser is so gentle on the skin, treatment can begin when the child is only several months old.
The pulsed dye laser has obtained FDA approval for the treatment of numerous non-vascular skin conditions such as benign epidermal pigmented lesions, rhytids (wrinkles), and benign cutaneous lesions such as acne, warts, psoriasis, and scars.
Improving the Appearance of Scars
The pulse dye laser is one of the most important tools that we use and cosmetic surgery to improve the appearance of both old scars secondary to trauma or skin cancer removal as well as to promote optimal healing of recent incisions or traumatic injuries to the skin. It is not exactly clear how the pulse dye laser works, but is felt to influence the proliferation of blood vessels and in some way help to stimulate growth factors of help to remodel old scars promote healing in newly traumatized skin. The results can be dramatic. The main benefit is that treatments are virtually painless and there is no down time.
Tina Alster, a dermatologist in Washington DC, was the first to publish about using the pulse dye laser to treat keloids and hypertrophic scars. In 1994 in the Annals of Plastic Surgery, she reported being able to obtain improvement in median sternotomy scars after open-heart surgery. Frequently these incisions would develop into hypertrophic scars or keloids which were both uncomfortable and unsightly. With multiple treatments spaced 1-2 months apart she is able to obtain significant improvement. The only problem with this early treatment was that the skin developed a bluish-like purpura in the treatment area that could take days to weeks to resolve.
In the late 1990s in conjunction with Dr. William Hanke and the Department of Dermatology at Indiana University, we conducted studies on methods to improve wound healing and noted that performing a light dermabrasion, ablative laser resurfacing, or chemical peel of incisional scars 6–8 weeks following the initial injury markedly improve the final aesthetic result. Patient’ were required to keep a thick layer of Vaseline over the treated area for the first 7 days following treatment, after which they can start applying makeup. A few years later, researchers noted that if they could pulse a cold spray on the skin surface for several milliseconds immediately prior to treating with the pulsed dye laser beam, they could eliminate the discoloration (purpura) associated with treatment. Mitch Goldman and Richard Fitzpatrick from La Jolla, California reported their experience of treating scars at 2-3 weeks with the pulsed dye laser and obtaining dramatic improvement with no down time. They noted that 2-3 treatments spaced a month apart markedly improve the final aesthetic result. Since that time, we have found this to be an important treatment modality. We recommend doing PDL treatment of surgical incisions starting at approximately one month and continuing at monthly intervals for 3-6 sessions.
Rhytids (Facial Wrinkles)
We have found the pulse dye laser to be an important component in the overall skin rejuvenation treatment regimen. We find that not only does it help to improve skin tone by removing telangiectasias and other vascular lesions, but it also helps to stimulate collagen formation and improved skin elasticity. These treatments have the advantage of minimal or no discomfort and virtually no down time. People are able to resume their normal activities immediately after treatment. Studies by Dover published in the medical journal, Dermatologic Surgery showed significant improvement in facial wrinkling after treatment with PDL. They reported on a multi-center, randomized split–face study where wrinkling around the eyes were treated with the pulse dye laser. After 1-2 sessions, statistically significant improvement was noted according to both clinical and topographical evaluation. The histologic studies show that there is an increase in type III pro collagen, and type I collagen mRNA. Significant improvement in reducing facial wrinkles and improving skin texture and tone was also reported by Moody in Dermatologic Surgery. Because traditional photographs can be difficult to use to demonstrate improvement, they utilized sophisticated ultrasound studies to evaluate dermal collagen after treatment with the pulse dye laser. They reported increase in dermal collagen demonstrated by ultrasonography after only one pulsed dye laser treatment. These studies and others provide support for the use of the pulsed dye laser as an effective, noninvasive treatment for facial rhytids (wrinkling).
Other Skin Conditions
Sebaceous glands are oil glands in the skin, and sebaceous hyperplasia is essentially a condition of overactive or enlarged oil glands. They typically occur on the face as small yellow papules with a central depression. Sebaceous hyperplasia is a benign condition, so treatment is primarily for cosmetic concerns. Treatments can include cryotherapy (freezing), electrodesiccation (cautery), excision, and ablative laser treatment. However, all these have a risk of inducing scar formation. For that reason, pulsed dye laser treatment either alone or in combination with photodynamic therapy is frequently the treatment of choice.
Dermatosis Papulosis Nigra (DPN) and Lentigines
Although the pulsed dye laser is most commonly used to treat vascular lesions, it can be used to treat certain non-vascular disorders. Although hemoglobin is known to absorb the pulsed dye laser admitted energy, the pigment in our skin (melanin) can also absorb PDL laser beam energy. Transit hyperpigmentation can be a part of the post treatment healing process. The advantages of the PDL over the standard treatments such as cryotherapy, electrosurgery, and shave excision, is that the treatment sessions are short and there is no need for anesthesia.
Actinic keratoses photodynamic therapy activated by the pulsed dye laser light source is known to be an effective treatment for actinic keratoses. Studies reported by Roy Geronemus in the Journal of Drugs in Dermatology noted that photodynamic therapy with topical 5 – ALA followed by pulsed dye laser photo activation resulted in complete clearance in 68% of patients after an average of only 1.8 treatments.
The pulsed dye laser has become an alternative treatment for acne vulgaris, because there is no need for strict adherence to a treatment schedule, there is less irritation than with many topical agents, and there are no systemic side effects. The main disadvantages are the cost and the time involved.
Studies have compared pulsed dye laser with intense pulse light therapy (IPL) in managing acne. In general, pulsed dye lasers are noted to have better outcomes. In a study published in the Journal of Drugs in Dermatology, investigators compared pulsed dye laser, IPL, and blue–red combination light admitting diode treatment. Although major improvements were observed in all treated groups, significantly fewer pulsed dye laser treatments were required to reach 90% or greater clearance than with the other treatment devices.
Photodynamic therapy can utilize different light sources including blue light, red light, IPL, and pulsed dye laser. All of these have been shown to be effective in treating acne and found to have significant results. Some practitioners believe that pulsed dye laser therapy mediated photodynamic therapy provides the best results for treating acne.
Psoriasis is an inflammatory condition of the skin which is characterized by localized plaque–like reddish colored lesions. It is known to have an underlying vascular component. Pulsed dye laser has been shown to be of therapeutic benefit in helping to decrease plaque severity, but multiple treatment sessions are required.
Verruca Vulgaris (Warts)
Verruca vulgaris is a common viral condition. Topical agents can be utilized to treat the area, but a prolonged treatment course is required. Destructive modalities such as cryotherapy and carbon dioxide laser treatments are effective, but can be associated with pain, scarring, and longer recovery periods. Pulsed dye laser treatment has been shown to be effective and is thought to work by means of interrupting blood supply to the lesion. A study reported by Park in the Journal of Dermatology noted a 49.5% clearance of lesions with an average of 2.8 sessions in the study group of 120 patients with viral warts.
Molluscum contagiosum is a subcutaneous viral infection caused by the pox virus. It typically appears as dome–shaped papules with a central umbilication. Pulsed dye laser treatments have been shown to be effective, but require 1–3 treatment sessions.
Risks Associated With Treatment
Every cosmetic procedure involves a small degree of risk, although exceedingly uncommon. It is important that each patient understands and accepts the risks involved with medical treatment. It is important to realize that no one can guarantee results and no two people react or heal the same or obtain the same results. An individual’s informed decision to undergo any cosmetic procedure is based upon the comparison of the risks against the potential benefits, alternatives and cost. Potential risk include, but are not limited to, anesthetic risks, bleeding, infection, wound healing, scar formation, injury to muscles and nerves, pigmentation changes, lack of improvement, or the need for additional treatment. The practice of medicine and surgery is not an exact science. Although good results are expected, there is not a guarantee or warranty expressed or implied as to the results that may be obtained. Infrequently, it is necessary to perform. Additional treatment to improve your results.
Discomfort– you may experience minor tolerable degree of burning and/or tingling discomfort associated with each treatment.
Skin Wound– is very unusual for treatments to cause blistering or skin wounding. Individuals with dark or tanned skin have more of a risk. If a blister develops it may take 5-14 days to heal and in very rare cases may leave noticeable whitening or darkening of the skin or in even more rare cases a scar. Blistering or skin wounds are much more common if the patient does not follow recommended avoidance of sunlight, self tanners, ultraviolet light and fluorescent light exposure.
Scarring– if you developed a wound and a scar; the scar may end up being flat and quite large and red or extend beyond the margins of the injury. Subsequent treatment or surgery may be required to improve the appearance of the scar. The scar may be permanent. Not following pre- and post treatment instructions may increase the likelihood of a skin wound or scar.
Pigment Change– there is a small risk of hyperpigmentation [increased pigment or brown discoloration] or hypopigmentation [whitening of the skin]. These pigment effects are usually temporary and resolve over several weeks or months. Pigmentation changes are very rare, but can occur. The use of medical skin care products is important to obtain optimal results and to reduce the chance of pigmentation changes. Sun precautions are also important to obtain optimal results and to reduce the chance of pigmentation changes.
Tanning– it is important that you not tan your skin are use tanning creams prior to PDL or ALA-PDL treatments as the pigment in your skin will absorb some of the laser energy and this will increase your risk of pigmentation change or skin wound. You should not have laser treatments if you have tanned skin until the tan has significantly faded [usually 6 weeks], and you should avoid tanning for 2 weeks following treatment. If you use artificial tanning creams, you should allow these to fade [for to 3 weeks] prior to beginning treatment.
Bruising– can occur following treatment, but is very unusual. If bruising does occur, it can be camouflaged immediately and usually resolves in 7-10 days. In some rare cases there may be temporary hyperpigmentation, which may occur as the bruising resolves.
Infections– are very rare because there is no actual cutting or penetrating of the skin. However, individuals who have a history of herpes simplex infections [fever blisters] may develop an outbreak. Individuals who have a history of such infections may benefit from preventive therapy with acyclovir. Be sure to inform the doctor if you have a history of such infections and if you desire prophylactic therapy.
Redness and Swelling– a minor degree of redness and swelling of the skin may follow treatments and usually resolves within one to 2 hours. This minor redness is usually easily camouflaged with makeup. In some cases redness and swelling may persist for 1-2 days. A mild steroid cream [hydrocortisone] and ice will usually accelerate the resolution of most redness and swelling. ALA Photodynamic Therapy treatments will leave your skin photosensitizes for 72 hours after each treatment. It is essential to avoid light. Failure to do so will result in significant inflammation and swelling of the skin that may increase the risk of complications such as blistering, scarring, and pigmentation changes.
Fragile Skin– following treatments, the skin may temporarily be fragile and become reddened with the outer layer of the skin peeling off, much like a blister. This usually resolves in several days. Fragile skin or blisters are more common after ALA photodynamic therapy, especially if post ALA instructions are not followed.
Accutane- this acne medication must be stopped at least 6 months prior to treatment as it can adversely affect wound healing and increase the chance of skin wound or scar.
Additional Treatment– no one can guarantee results or how one will heal or the results of one will obtain with any medical treatment. Over time, with gravity, sun exposure, hormonal influences and normal aging, your wrinkles, large pores, texture abnormalities, vascular and pigment blemishes will reappear. Continued maintenance therapy is recommended in order to maximize the cosmetic facial enhancement of treatments. In some cases, treatment protocols may need to be revised in order to obtain maximum results due to individual variations in aging and healing.
Lack of Satisfaction– no facial wrinkling, blemishes and skin types respond the same to rejuvenation treatments. Your response may be subject to variation, but on average, almost all patients who undergo treatment report noticeable improvement in the appearance, quality, and youthful vitality of their skin. However, there is a risk you may not see an appreciable improvement in the quality and appearance of your skin.
Pregnancy– although no known adverse reactions upon the fetus are known to resolve, we do not recommend proceeding with treatments if you are known to be pregnant.
An Alternative to Treatment– the easiest and safest alternative is to leave your cosmetic concerns alone and camouflaged them with makeup. Topical rejuvenation creams, laser resurfacing, chemical peels, injectable fillers, micro-fat injections, and cosmetic surgery are all alternative therapies. However, each of these treatment alternatives will require some recovery time as well as risk and cost.
Financial Responsibilities and Health Insurance– facial wrinkles, pores, textural irregularities, vascular and pigment blemishes are cosmetic concerns and poses no medical or healthcare threat. Most health insurance companies exclude coverage for these treatments. Complications that may occur from such treatments and in some cases may be considered a healthcare concern and may be covered by some insurance. However, this is no guarantee, and some insurance companies will not cover such concerns. Please carefully review your health insurance subscriber information pamphlet if you have a private insurance carrier to make a determination as to possible coverage. Regardless of whether the cost of treatment is covered by your insurance plan, you will be responsible for necessary payments. Additional costs may occur should complications develop from treatment.
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