Beruflich Dokumente
Kultur Dokumente
Department of Dermatology, University of Connecticut Health Center, 21 South Road, Farmington, Connecticut
Division of Ophthalmology, University of Connecticut Health Center, Department of Surgery, 263 Farmington Avenue,
Farmington, Connecticut
b
Abstract Advances in laser technology in recent decades have increased the options for the treatment of
dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and
vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review
treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions
including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal;
laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic
keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically
decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing
has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin
of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient
preparation, safety precautions, and risksintraocular and extraocularare discussed herein. As laser
technology continues to advance, we are sure to see improvements in current treatments, as well as development
of new applications of cutaneous lasers.
2015 Elsevier Inc. All rights reserved.
Introduction
Advances in laser technology in recent decades have
increased options for the treatment of dermatologic conditions of the eye and eyelid. This review will discuss laser
treatment of a variety of periocular cutaneous lesions,
including vascular lesions, pigmented lesions, periocular
tumors, and laser treatment of rhytides.
The foundation of laser therapy is based on the principle
of selective photothermolysis,1 which asserts that precise
tissue damage can be achieved by applying laser energy of
the appropriate wavelength and pulse duration. This
principle guides the selection of laser best suited for a
particular cutaneous lesion. First, the wavelength of the laser
must be preferentially absorbed by its target, a light Corresponding author. Tel.: +1 8606794600; fax: + 1 8606797534.
E-mail address: finch@uchc.edu (J.J. Finch).
http://dx.doi.org/10.1016/j.clindermatol.2014.10.011
0738-081X/ 2015 Elsevier Inc. All rights reserved.
198
Table
B. Yates et al.
Lasers used in treatment of periocular skin conditions
Laser
Wavelength (nm)
Main chromophore
KTP
PDL
Ruby
Alexandrite
Diode
Nd:YAG
Er:Glass
Er:YAG
CO2
532
595
694
755
810
1064
1440, 1550
2960
10600
Hemoglobin, Melanin
Hemoglobin
Melanin
Melanin
Melanin
Melanin
Water
Water
Water
199
with a female predominance. Nevus of Ota usually has a blueblack or gray-brown appearance and appears along the
distribution of the first and second branches of the trigeminal
nerve (see Figure 2). The pathogenesis involves incomplete
migration of melanocytes between the neural crest and
epidermis during embryonic development.20 Nevus of Ota
has been called an oculodermal melanosis because it affects the
skin and the eye. In the eye, it has been reported to have 100%
episcleral involvement, 10% conjunctival involvement, and
18% retinal involvement.20 The ocular component is not
amenable to treatment with laser therapy; however, cutaneous
involvement can be targeted with Q-switched lasers.
Q-switched-Alexandrite and QS-Nd:YAG can be efficacious in the treatment of nevus of Ota. In a large study
involving 806 patients with nevus of Ota, 93.9% achieved
complete clearance after an average of 5.2 sessions with the
QS-Alex, and no patient had any long-term adverse effects
more than 3 years after treatment.21 The QS Nd:YAG (1064
nm) is at times preferable due to its longer wavelength and
therefore deeper penetration. A recent study compared the QSNd:YAG (1064 nm) with the QS-Alex (755 nm) and with the
QS-KTP (532 nm) on 15 patients with nevus of Ota over an 8year period. Twenty percent of patients responded better to
QS-Nd:YAG-1064 nm compared to the QS-Alex or the shorter
wavelength QS-Nd:YAG.22 Another study documented more
than a 70% improvement in nevus of Ota lesions treated with
the Nd:YAG laser.23
Treatments are generally spaced widely apart, every 3-6
months, with the majority of patients showing improvement
after 4 to 8 treatment sessions. 21,22 Fluences typically range
from 4-11 J/cm2. Fluences as low as 2.5 J/cm2 can also be
effective and less likely to result in side effects, but require
many more treatment sessions.24
Q-switched lasers are among the most dangerous to the eye.
A QS-Nd:YAG laser, if used incorrectly without the proper
eye protection, can ablate the retina, cause vitreous hemorrhage, and result in permanent damage for either the physician
or the patient;2527 yet, none of the case reports have reported
these kinds of intraocular complications.2124,2830 In all the
case reports involving laser treatment for nevus of Ota,
Nevus of Ota
Nevus of Ota is a benign dermal melanocytic nevus that
usually appears at birth. It is seen most commonly in Asians,
Fig 2 Nevus of Ota along the distribution of the first and second
branches of the trigeminal nerve.
200
protective goggles were used by the physician and metal
shields by the patient. The only major patient side effects
recorded from the lasers were hypopigmentation (15.3%),
hyperpigmentation (2.9%), texture changes (2.9%) and
scarring (1.9%) of the skin.28
B. Yates et al.
cosmetically displeasing. Due to their malignant potential,
excision followed by histologic examination is the current
treatment of choice for melanocytic nevi. A number of laser
modalities have also been used, including ablative (CO2 and
Er:YAG) and pigment-specific lasers (QS-Alex, QS-ruby,
QS-Nd:YAG, and QS-KTP). Some authors recommend that
lasers be reserved for cases in which excision is not an option
because lasers make subsequent clinical monitoring difficult,
and the effect of laser energy on melanocytes is unknown.19
A number of considerations must be taken into account
before treating CMN including the size, location, cosmesis,
and risk of malignancy.34 Excision may not be a viable option
for nevi located in complex areas like the periorbital region.
Recently, combination laser therapy using ablative and
pigment-specific lasers has been successful in treating
complex medium to large CMN. Combination therapy is
based on the principle that initial ablative lasers will expose
underlying and deeper melanocytes making them more
available to pigment-specific lasers.
Among 52 patients with a total of 314 CMNs treated with
an Ultrapulse CO2 laser with or without a QS-KTP laser, a
reduction in pigment without any recurrence occurred in
81% of the patients and 94.6% of the lesions treated.35
Patient satisfaction was high (87%) at a mean follow-up of 8
years. The most common complications were recurrence and
hypertrophic scars in 5 lesions each. Unfortunately, this
treatment approach is operator-dependent and other studies
have been less promising. Another study using CO2 and
pigment-specific lasers (QS-Alex, QS-KTP, and QS-Nd:
YAG) in 55 medium-sized CMN36 achieved an excellent
response (N 75% reduction) in only 55% of the lesions
treated, with a recurrence rate of 11%.
201
most common location (Figure 3).47 Clinical variants have
also been described including localized, generalized, familial, and trisomy 21-associated forms. They typically present
as asymptomatic discrete soft 2-4 mm flesh to yellowish
colored papules.48 Although benign, syringomas can pose
significant cosmetic concerns, given the exposed periorbital
location and the tendency to have multiple lesions. Several
treatment modalities have been described with varying
degrees of success including excision, dermabrasion,
electrodesiccation with curettage, and topical retinoids.
Laser ablation with CO2 and Er:YAG lasers has now
surpassed these at the treatment of choice for syringomas.
The use of CO2 laser vaporization for the treatment of
multiple syringomas was initially described with promising
results.49 In 1999, ten cases of periorbital syringomas were
treated with two passes of a CO2 laser at the settings of .2
second pulse duration, 5 watts, and 3-mm spot size. Nine
patients treated with either one or two sessions had
successful destruction of all lesions at a median follow-up
of 16 months. The most common side effect was prolonged
erythema lasting from 6-12 weeks in all patients without any
scarring.50 Another study of 11 patients treated using an 80mm drilling hand piece, demonstrated excellent clinical
response in 7 patients and good response in the remainder.
Again, no serious complications were reported, including
scarring or pigmentary changes.51
Fractionated CO2 lasers can also improve syringomas, but
multiple passes and consecutive treatments are needed for
fractional lasers for complete destruction.52 In 2011, a
prospective analysis was performed in 35 patients with
multiple periorbital syringomas treated with an ablative CO2
fractional laser system. Patients were treated at 1-month
intervals with pulse energy of 100 mJ and density of 100
spots/cm2 over two sessions. Evaluation 2 months after the
final treatment showed a near complete or marked
improvement in 18 (51.4%), moderate improvement in 12
(34.3%), and minimal improvement in 5 (14.3%) patients.53
A secondary benefit of the fractional laser system was the
skin tightening and improvement in wrinkles.
In addition to ablative CO2 laser therapy, unique
alternatives and combination methods have been described.
Syringomas
Syringomas are benign adnexal tumors of eccrine sweat
duct origin that typically affect women in their adolescence
and early adulthood, with the periorbital region being the
Fig 3
Periocular syringomas.
202
B. Yates et al.
Xanthelasma
Xanthelasmas are a form of plane xanthoma that typically
present on the eyelids of middle-aged and elderly individuals
with the characteristic histologic finding of lipid-laden
macrophages known as foam cells. Clinically, they appear
as soft yellow papules and plaques most commonly on the
medial aspect of the eyelids (Figure 4). Typically, they pose
no complications themselves but can have a negative
cosmetic impact.56 Before laser therapy, surgical excision,
electrodessication, and trichloroacetic acid were the classic
treatment modalities for xanthelasmas. A number of lasers
including CO2, Er:YAG, PDL, QS-Nd:YAG, and a 1450-nm
diode laser have been described in treating xanthelasmas.
Ablative lasers were some of the first lasers described in
the treatment of xanthomas. In 1985, the use of a superpulsed
CO2 laser in the treatment of nine patients with xanthelasmas
was described, with a high degree of patient satisfaction.57 In
1996, the use of a high energy pulsed CO2 laser was
evaluated at 400 and 500 mJ in the treatment of two patients
with bilateral xanthelasmas. Complete eradication was
observed at three and four passes with no recurrence at a
follow-up of 8 and 12 months.58 A larger cohort in 1999,
which consisted of 23 patients (52 periorbital xanthelasmas)
treated with an ultrapulsed CO2 laser with complete removal
on first pass. Of the 23 patients treated, only three patients
had recurrence at 10 months.59
In addition to ultrapulsed CO2 lasers, Er:YAG lasers have a
good clinical response in ablation therapy of xanthelasmas. In
2001, 30 patients (70 xanthelasmas) treated with an Er:YAG
laser showed good clinical results without any serious side
effects including scarring or dyspigmentation.60 Similar results
were obtained in another study after the treatment of 15 patients
(33 xanthelasmas) with the Er:YAG laser. All lesions were
Fig 4
Milia
Milia are small benign keratinaceous cysts.63 Typically
they present as 1-3 mm white dome shaped papules that can
occur at any age and in various locations. Benign primary
milia typically present on the cheeks and eyelids, but other
variants have also been described with periorbital involvement including milia en plaque, multiple eruptive milia, and
milia associated with genodermatoses.63 Various methods
are used in treating milia including nicking with extraction,
topical retinoids, electrodesiccation, dermabrasion, and
cryotherapy, but only a few reports have described ablative
therapy with CO2 and Er:YAG lasers.
Using the Er:YAG laser, a group reported their results of
benign lesions treated with laser ablation, including four patients
with milia. A total of 78 milia were treated during one session (25 passes) with a fluence of 3-4 J/cm2. At a mean follow-up of 8
months, no recurrence was seen.64 A recent case report in 2011
described the successful treatment of periocular milia en plaque
with Er:YAG laser ablation during two sessions.65
In 2010, a case report described the use of CO2 laser
vaporization in treating a patient with spontaneous periorbital
multiple eruptive milia. After failed treatments with topical
isotretinoin and erythromycin, the patient was treated for 12
sessions with complete destruction of the periocular milia.66
Seborrheic keratoses
Seborrheic keratoses (SKs) are one of the most common
skin lesions a dermatologist may encounter and, although
benign, can be worrisome for patients due to their pigmented
color and undesirable cosmetic appearance. SKs are benign
epidermal tumors that can have a variable clinical presentation
but typically present as sharply demarcated, waxy, stuck on
papules and plaques. SKs can present nearly anywhere on the
body including the face and periorbital region. Dermatosis
papulosa nigra (DPN) is a very common clinical variant of SKs
in darkly pigmented individuals, with a predilection for the
face including the periorbital region.67 The incidence of DPN
in African Americans can be as high as 77%.68
Early laser therapy for SKs consisted of laser tissue
ablation. A large study reported complete removal of 690
Laser resurfacing
Traditional versus fractional resurfacing
Advancements in ablative resurfacing technology using the
pulsed CO2 and Er:YAG lasers have resulted in significant
improvements in clinical outcomes when treating periorbital
photo-aging including rhytides.7780 Due to their effectiveness, ablative lasers are typically considered the gold standard
for laser resurfacing. The target chromophore is water in the
epidermis and dermis, and the resultant tissue injury leads to
epidermal turnover and collagen regeneration. Although
effective, traditional fully ablative resurfacing, in which the
entirety of the skin surface area is vaporized, comes with
significant adverse effects, including prolonged healing time,
erythema, edema, and risk of hypopigmentation.81
The concept of fractional photothermolysis, in which only a
fraction of the skin surface area is targeted, was introduced to
combat these prolonged and unwanted side effects while
maintaining clinical effectiveness.82,83 Fractional photothermolysis creates microscopic columns of tissue injury (microscopic
thermal zones), leaving intervening tissue intact, which leads to
faster re-epithelialization and thus quicker healing times.84
Lasers that are highly absorbed by water, including the Er:
YAG (2,940 nm) and CO2 (10,600 nm) are termed ablative;
lasers which are only moderately absorbed by water are
nonablative, eg, Er:glass (1410 -1550 nm). Ablative lasers
vaporize columns of tissue with a surrounding microscopic
zone of thermal damage, whereas nonablative lasers create
columns of thermal damage and controlled denaturing of
collagen without a true hole of vaporization.
203
204
B. Yates et al.
Patient preparation
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Successful laser treatment of skin diseases in the
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