What treatments do you recommend during this time of year?
Dr. Bhatia In the fall, people often want to repair the damage that their skin has suffered during the summer months from outdoor activities such as boating, golfing, swimming, being outside in the garden and playing with their kids. It’s really a time of rejuvenation and restoring the health of the skin. There are several popular treatments performed this time of year, and all are done after the tans have faded.
- Intense pulsed light (IPL): One common treatment is IPL; it’s a nice treatment that can be done in the office, usually in a series of three to five treatments. It targets brown spots (age spots) in the skin that have come up as well as some of the fine blood vessels. A lot of people come in and get IPL done on the face and chest area, and sometimes on the back of the hands, since these are areas that suffer the most sun damage over the summer.
- Chemical peels: Another procedure done more in the fall is a chemical peel. The more superficial chemical peels target the epidermal problems, such as brown spots, textural irregularities, and general sun damage. For minimal downtime, people get mild peels every 2 to 4 weeks. If they can afford the downtime, they may choose to have a more intense chemical peel only once or twice in the fall.
- Fractional ablative therapies: This is also a popular time for the fractional ablative therapies, such as fractionated CO2 or fractionated erbium lasers. These do a really good job of not only cleaning up the textural abnormalities and brown spots and getting rid of a lot of the photo damage, but they also serve to stimulate new collagen synthesis. Even though they are associated with a little more down time, which is usually 7 days, patients feel fine after the treatments. It’s just that they look a little pink and sunburned, and all the brown spots get very dark, but then they peel off within a week. These treatments really give people a renewed freshness to their skin.
With all of these treatments, most women feel like makeup goes on better and their skin just feels softer and healthier.
- Skincare tips: Even in the fall and winter, and even on cloudy days, 80% of UV rays go through the clouds. So, if people want to protect themselves really well, sunscreen should be worn—SPF 30 or higher on the face, ears, and neck every day. The sunscreen should be reapplied frequently when outside or near windows or in a car, even in the fall and winter months. In fact, in the winter, sometimes the UV rays are more intense when there’s snow outside because the light will reflect off the snow and increase the intensity of the UV radiation that reaches the skin.
- Moisturizing: This time of year, it becomes a little more important to moisturize. The skin tends to become drier and more affected by the elements, such as wind and cold. So moisturizing—moisturizing with a day cream that’s hydrating and preferably has an SPF in it—is important.
Which medical treatments also have cosmetic benefits?
Dr. Bhatia: There are a number of topical treatments for various conditions that have actually been shown to give a cosmetic improvement in the skin as well. One of the most well-known is a topical retinoid, such as Retin-A. When used consistently over time, it’s been shown to help improve the skin’s texture and help with fine lines and also help control some oil production. Another topical treatment is photodynamic therapy (PDT), which is commonly used to treat patients who have extensive actinic keratoses. Studies have shown that many patients treated with PDT for their actinic keratoses also report improvement in the texture and color of their skin as well. So, that’s a little added benefit. A similar type of added benefit can be seen with several of the topical therapies for actinic keratoses, such as imiquimod and 5-fluorouracil. Even though the therapies are very intense and cause a lot of inflammation, most patients have some degree of peeling after these treatments, which helps improve the color and the texture of their skin.
How can dermatologists better use the lasers that they already have in their practice?
Dr. Bhatia: A number of lasers that many dermatologists have in their practice can be used for procedures beyond those they are traditionally used for.
One of the most common lasers found in practices is a pulsed-dye laser, which is traditionally used for treating vascular lesions. For years, it’s been the workhorse for treating angiomas, telangiectasias, and even hemangiomas and small vascular malformations in adults and children. This laser is actually pretty versatile because, with the cooling on, the epidermis is protected, and the light is not absorbed by superficial pigment; it goes right down through the skin and into the blood vessels and treats them for the vascular applications. But, when the cooling is off, and the area being treated is compressed, which can be done with either a glass slide or with the compression tip that is available on some of the lasers, brown spots can be treated too. The 585 nm to 595 nm wavelength is still very well absorbed by pigment. So, with the cooling off, the wavelength is absorbed and heats up the superficial pigment, which is useful in removing brown spots, such as lentigines on the back of the hands or the face. Also, when the skin is compressed, all the blood is pushed out of the way. Even though some of the light is transmitted through the brown spot, there won’t be a vascular target underneath to hit.
Many of the hair lasers, such as the alexandrite laser, can be used to treat brown spots when the cooling is off as well.
How do you optimize treatment with lasers while minimizing complications?
Dr. Bhatia: There are some ways to really increase the safety of a laser. The first is good cooling. Use effective cooling to avoid burning the epidermis. Another is to avoid treating patients who are tan with lasers that are readily absorbed by pigment. The third tip is, in darker-skinned patients, use longer wavelengths, such as the 1064, and use longer pulse durations to avoid burning the superficial pigment.
Which lasers do you recommend purchasing and for which treatments?
Dr. Bhatia: First of all, the choice of laser depends on what kind of patients you treat in your practice. Second, most lasers are quite expensive to buy, but there is also a lot of cost to maintaining them. Service contracts on a laser range from $5000 to $10,000 per year, and, when they break down, they get very expensive to repair, just like most medical devices. So it’s not a decision to be taken lightly.
Some people choose to go with an IPL, which is a broadband-like device with multiple wavelengths in it. The advantage of this is that it can do the work of several different kinds of lasers. However, it generally doesn’t do the work as well as a targeted laser would, since a targeted laser only has one or maybe two wavelengths in the box. The IPL’s are more of a “jack of all trades.” However, it may require multiple treatments.
Some devices come with multiple attachable hand pieces; so, one box can drive several different wavelength lasers. This is very desirable in some practices. The benefits of this type of system are that, in the footprint of one device, you can have multiple types of treatments. The downside comes when there are multiple providers in an office, and one provider is using the device for a particular application and it’s not available to the second provider to use at the same time. So if you do have multiple providers and the devices are commonly used by all of them, then you may want to have separate lasers for each application. Some practices just choose to make a schedule for the IPL, so the doctors know when it is in use, and don’t book a treatment at the same time as another provider.
What kind of laser you buy often depends on what type of problems you treat in your practice. If you have a primarily Caucasian patient population with a lot of telangiectasias and angiomas, and you want to treat blood vessels of all sizes, you can pick one of the vascular lasers, such as a pulsed-dye laser or a Nd:YAG laser, which has two wavelengths, 532 nanometers and 1064 nanometers. Both are very versatile and allow you to treat a variety of vascular conditions. If you primarily have darker-skinned population or have a mixed population, you may want to go with a 1064 laser because it can be used in darker-skinned patients for hair removal as well as for treatment of vascular conditions. If a lot of your population is concerned with photo damage and photo aging, an IPL broadband light device might be a good choice. One of the fractionated ablative lasers, such as a fractionated CO2 or erbium laser, may be a good choice as well.
It’s hard to say which single laser to buy because each practice varies so much, and a lot of it depends on what you want to treat and how you want to treat it, as well as other considerations in your practice, such as space, number of providers, and how much overhead you want to carry.