Use of the KTP Laser in the Treatment of Rosacea and Solar Lentigines

Abstract

Numerous techniques have evolved in facial plastic surgery to treat rosacea and solar lentigines. The treatment regimens range from avoidance of causative factors to the use of topical agents or other modalities that target the superficial layers of the skin. Of the modalities that target the epidermis, lasers offer the physician and patient the ability to target specific chromophores in the skin. Advances in laser technology led to the implementation of targeting certain characteristic pigments of abnormal areas with minimal damage to surrounding normal tissue. Rosacea and solar lentigines have characteristic cells that are targeted by a potassium-titanyl-phosphate (KTP) laser. The lesions are different in their origins but share the ability to be treated successfully with the KTP laser. A review of both conditions and other treatment options is discussed.

Full text

Use of the KTP Laser in the Treatment
of Rosacea and Solar Lentigines
Benjamin A. Bassichis, M.D.,
1
Ravi Swamy, B.A., M.P.H.,
2
and Steven H. Dayan, M.D., F.A.C.S.
3
ABSTRACT
Numerous techniques have evolved in facial plastic surgery to treat rosacea and
solar lentigines. The treatment regimens range from avoidance of causative factors to the
use of topical agents or other modalities that target the superficial layers of the skin. Of the
modalities that target the epidermis, lasers offer the physician and patient the ability to
target specific chromophores in the skin. Advances in laser technology led to the
implementation of targeting certain characteristic pigments of abnormal areas with
minimal damage to surrounding normal tissue. Rosacea and solar lentigines have char-
acteristic cells that are targeted by a potassium-titanyl-phosphate (KTP) laser. The lesions
are different in their origins but share the ability to be treated successfully with the KTP
laser. A review of both conditions and other treatment options is discussed.
KEYWORDS: Potassium-titanyl-phosphate laser, rosacea, solar lentigines
SOLAR LENTIGINES
Solar Effects on the Skin
Ultraviolet irradiation has many adverse affects on the
skin, including skin cancer, sunburn, and photoaging.
An individual’s risk for accelerating photoaging corre-
lates with baseline pigmentation. The Fitzpatrick clas-
sification system stratifies individuals into six skin types
based on their skin color and reaction to sun exposure. It
has become a useful tool for correlating skin type with
skin cancer risk and response to photoaging therapy.
Fitzpatrick skin types I and II with baseline minimal
pigmentation are at particular risk for photoaging.
Actinically damaged or photoaged skin, also
known as dermatoheliosis, is morphologically and histo-
logically distinct from non–solar-exposed aged skin. Aged
skin that has received minimal sun exposure is thin with
reduced elasticity but smooth and unblemished. In con-
trast, photoaged skin contains wrinkles, uneven pigmen-
tation, brown spots, and a leathery appearance. The main
differences can be found in the dermal connective tissue
where ultraviolet irradiation causes damage. The histolo-
gical change is a disorganization of the collagen fibrils and
the accumulation of abnormal elastin-containing mate-
rial.
1
The alterations include reduced levels of type I
collagen, type III collagen precursors,
2
and collagen cross-
links.
3
Additionally there is an increased ratio of type III
to type I collagen
4
and an increased level of elastin.
5
The
exposure to ultraviolet irradiation also leads to increases in
matrix metalloproteinases that degrade collagen and may
contribute to aging.
6
Dermal hemosiderosis from actinic
purpura can occur as well as solar lentigines.
7
Minimally Invasive Office-Based Procedures; Editors in Chief, Fred Fedok, M.D., Gilbert J. Nolst Trenite, M.D., Ph.D., Daniel G. Becker, M.D.,
Roberta Gausas, M.D.; Guest Editors, Deborah Watson, M.D., Steven H. Dayan, M.D. Facial Plastic Surgery, Volume 20, Number 1, 2004.
Address for correspondence and reprint requests: Steven H. Dayan, M.D., F.A.C.S., 2913 Commonwealth Street, Suite 430, Chicago, IL 60657.
Email: Docdayan@aol.com.
1
University of Texas-Southwestern Medical Center; Division of Facial Plastic and Reconstructive Surgery, Veterans
Administration Hospital, Dallas, TX;
2
University of Chicago-Pritsker School of Medicine, Chicago, IL;
3
Division of Facial Plastic Surgery,
Department of Otolaryngology, University of Illinois, Chicago, IL. Copyright # 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001 USA. Tel: +1(212) 584-4662. 0736-6825,p;2004,20,01,077,084,ftx,en;fps00494x.
77

Clinical Characteristics
Solar lentigines, also known as old-age spots or liver
spots, appear as flat, oval, evenly pigmented macules in
areas of chronic sun exposure. Solar lentigines are among
the most common benign lesions of the skin. The lesions
are often described as tan- to brown-colored macules.
The most common areas affected are the dorsum of the
hands, shoulders, back, and the face. The hyperpigmen-
tation may vary from light to dark brown but is uniform
within the individual lesion. The clinical appearance of
solar lentigines at times may be similar to the lentiginous
portion of melanocytic neoplasms or lentigo maligna,
resulting in a tendency to excessively biopsy a benign
process. However, missing an early melanoma has more
severe consequences.
8
Microscopic Characteristics
Solar lentigines are made up of collections of very active
melanocytes producing dense melanin pigment in their
associated keratinocytes. The features of solar lentigenes
are mostly limited to the epidermis and, although there
is a great deal of melanization of the epidermis, the
number of melanocytes is not increased irrespective of
skin color. The solar lentigo is a localized focus of highly
active melanocytes that results in a focal hyperpigmenta-
tion of keratinocytes.
Treatment Options
No treatment is necessary for solar lentigenes. However,
if cosmetic removal is desired, treatment options include
topical agents, such as a light freeze with liquid nitrogen,
the application of hydroquinone for bleaching, or che-
mical peels. Short freeze times are used to avoid hypo-
pigmentation with liquid nitrogen, which necessitate
multiple procedures. The hydroquinone (3 to 4%) can
result in some lightening of the solar lentigines, but
the results are less than acceptable. The concentration
and duration of therapy are usually limited by the side
effects. They consist of irritation, depigmentation, and
exogenous ochronosis. Phenol and trichloroacetic acid
peels have been used for treatment of solar lentigines.
However, the side effects include hyperpigmentation,
hypopigmentation, scarring, persistent erythema, and,
with phenol, cardiac arrhythmias. Another topical solu-
tion, tretinion, has shown very favorable results in the
lightening of facial solar lentigines.
The use of lasers in the treatment of pigmented
lesions began in the 1960s by
Goldman
Q1
. Numerous
lasers can be currently used to treat pigmented lesions,
including red light lasers (ruby, alexandrite) and green
light lasers (510-nm pulsed-dye, 532-nm frequency-
doubled Nd:YAG). The wide range of treatment options
stems from the broad absorption spectrum of melanin.
The argon laser, which contains green and blue light
(488 and 514 nm), is specifically absorbed by melanin.
However, because it is a continuous-wave laser, the heat
production causes thermal damage, which can lead to
scarring and hypopigmentation.
9
The goal of laser treatment is to target the pig–
mented lesion without causing disruption of the normal
surrounding tissues. Short laser pulses can be used in a
wide range of visible light wavelengths. Pigment-specific
lasers can be subdivided into three main groups: green,
red, and near infrared. The red and near-infrared sys-
tems can be pulsed or Q-switched systems. The green
light lasers do not penetrate as deeply, secondary to the
shorter wavelength, but are effective in treatment of
epidermal pigmented lesions.
10
Green light pulsed lasers produce energy with
pulses that are shorter than the thermal relaxation time
of the melanosomes. The pulsed-dye (510 nm) and the
frequency-doubled, Q-switched Nd:YAG (532-nm)
lasers have produced excellent results. However, oxyhe-
moglobin absorbs the green wavelength, which may
cause purpura formation. The purpura usually resolves
within 1 to 2 weeks and resolution or lightening of the
lesions within 4 to 8 weeks.
11
The green pulsed lasers do
not penetrate very deeply and are ineffective for treating
dermal pigmented lesions.
There are two red light pulsed lasers that had been
used for pigmented lesions: the Q-switched ruby
(694 nm) and the Q-switched alexandrite (755 nm).
The longer wavelengths allow deeper penetration into
the dermis. The mechanism of action involves selective
photothermolysis, photoacoustical mechanical disrup-
tion, and chemical alteration of the melanin-containing
melanosomes and melanocytes. These lasers can also
treat epidermal lesions without the purpura because of
the lack of hemoglobin absorption at the higher wave-
lengths. The major advantage of the red light lasers over
the green light lasers is the treatment of dermal pig-
mented lesions, such as congenital nevi.
12
The near-
infrared pulsed laser, such as the Nd:YAG, produces a
wavelength of 1064 nm. Although not as well absorbed
by melanin, the ability to penetrate deeper into the
dermis has an advantage. By definition, solar lentigines
are located in the epidermis; therefore, lasers that pene-
trate into the dermis have the potential to injure normal
cells.
Recently, the potassium-titanyl-phosphate (KTP;
532-nm) laser has been used with success in the treat-
ment of solar lentigines. Treatments are performed in
the office and can be completed in minutes without
significant discomfort. Topical anesthetic cream is rarely
needed but can be used without adversely affecting the
treatment. Patients who are Fitzpatrick I to III can
expect the best outcome because the pigmented lenti-
gines starkly contrast to those fair skin types. In the event
that a fair-skinned patient has a suntan, we counsel these
patients to return following dissipation of their tan. We
Q1
78 FACIAL PLASTIC SURGERY/VOLUME 20, NUMBER 1 2004

do treat skin types IV, and occasionally V; however, they
are at increased risk for epidermal injury. The skin
pigment chromophores compete with the solar lenti-
gines, absorbing a significant amount of the laser energy.
Therefore, darker-skinned patients are treated more
conservatively, often requiring multiple treatments.
However, they can expect a modest and cosmetically
satisfactory improvement. Skin preparation is not neces-
sary other than removing all topical preparations. A
parallel cooling device may be helpful in darker-skinned
patients by providing added protection to the epidermis.
In our practice, we do not routinely use the cooling
device. Our preference is a 2-mm hand piece and low
energy settings. Each lesion is treated separately with
one pass. Immediately following treatment the lesion
appears ashlike with a circumferential area of erythema.
Patients are instructed to avoid makeup for 6 to 12 hours
and not to expose the area to sun. Rarely, a blister may
form, more likely in a darker-skinned or tanned patient.
Should a blister form, patients are instructed to not
puncture it. If it ruptures then topical antibiotic oint-
ments are recommended. Permanent hyperpigmenta-
tion, hypopigmentation, and permanent scarring are
possible but, to our knowledge, have yet to be encoun-
tered in our practice. Most people feel comfortable
returning to their routine schedule within a few hours.
Over the next week, the lesion transiently becomes
darker before beginning to fade. Occasionally, the lesion
will slough off in the 2nd week. Subsequent treatments
are spaced 2 to 4 weeks apart and are necessary to further
fade the lesions. Most people are satisfied after three
treatments. Results continue to improve over a 3-month
period of time. Posttreatment maintenance includes a
detailed skin care regimen and sunscreens (Figs. 1–6).
ROSACEA
President Clinton as well as 13 million other Americans
are affected by rosacea. The word rosacea is derived from
the Latin word rosaceus, meaning ‘‘rosy.’’ Rosacea is a
chronic, acneiform disorder that is characterized by
vascular dilation of the central face, including the nose,
check, eyelids, and forehead. The goal of current thera-
pies is control rather than cure.
Clinical Characteristics
Generally associated with people of Celtic or Scandina-
vian ancestry, rosacea has an inverse relationship with
increased epidermal pigmentation.
13
Thus, rosacea is
uncommon in the African-American population. The
population between 30 and 60 years of age is most
commonly affected.
The cause of the vascular dilation is not known.
Patients affected by rosacea have increased numbers of
hair follicle mites, such as Demodex folliculorum and
D. brevis.
14
However, other studies have not shown
decreases in mite populations despite improvement of
rosacea symptoms.
15
Clinical features are characterized by periods of
exacerbation and remission. The spectrum of the clinical
findings can vary from recurrent flushing episodes to
Figure 1 Solar lentigines patient A. Right oblique view
pretreatment.
Figure 2 Solar lentigines patient A. Right oblique view
posttreatment.
USE OF THE KTP LASER IN THE TREATMENT OF ROSACEA AND SOLAR LENTIGINES/BASSICHIS ET AL 79

rhinophyma. The recurrent flushing, or stage I, may be
provoked by a variety of stimuli, including alcohol, spicy
foods, and emotional moods. The facial erythema, or
stage II, is particularly evident on the nose and cheeks.
Telangiectasias are observed to affect the cheeks. These
symptoms may worsen with heat exposure. Patients with
worsening rosacea may develop severe sebaceous gland
growth, characterized by pustules, papules, nodules, and
Figure 3 Solar lentigines patient B. Frontal view pretreatment.
Figure 4 Solar lentigines patient B. Frontal view posttreatment.
Figure 5 Solar lentigines patient C. Left oblique view
pretreatment.
Figure 6 Solar lentigines patient C. Left oblique view
posttreatment.
80 FACIAL PLASTIC SURGERY/VOLUME 20, NUMBER 1 2004

cysts. The lesions can be very similar to those of acne
vulgaris, but there is a lack of a comedome in rosacea.
In patients with rosacea, 20 to 58% develop ocular
symptoms that may occur in combination with skin
symptoms.
16
The eye findings include foreign body
sensation, telangiectasia, blepharitis, keratitis, conjunc-
tivitis, meibomian gland dysfunction, and irregularity of
the lid margin. Rhinophyma, or stage III, is hyperplasia
of the soft tissue of the nose and usually occurs in
middle-aged men.
17
Treatment
The treatment of rosacea is based on managing the
symptoms rather than a complete cure of disease. The
initial therapy should be patient education and the use of
sunscreens, mild cleansers, and avoidance of irritants.
Topical antibiotics are the first choice to relieve the
inflammatory lesions of rosacea. Metronidazole can be
used with or without oral antibiotics to decrease the
lesion counts by as much as 60%.
18
Other topicals that
have been used with varying amounts of success are
azelaic acid, sulfacetamide, clindamycin, erythromycin,
and benzoyl peroxide. The agents should be used for at
least 4 to 6 weeks before assessing the results.
When the symptoms of rosacea persist, despite
topical therapy a stronger treatment is required such as
tretinoin cream. The treatment with this medication
starts with application at bedtime two or three times
per week and increasing the frequency to nightly. Oral
antibiotics are used in combination with tretinoin if the
disease is recalcitrant or if symptoms of nodular rosacea
or ocular symptoms occur. Oral antibiotics that have
shown usefulness are tetracycline, erythromycin, and
minocycline. Dermabrasion and carbon dioxide lasers
can be used to surgically treat advanced rhinophyma.
Intense pulsed light (IPL) has been used with
some success in the treatment of rosacea. IPL, with
filters bracketing the visible light spectrum, emits light
energy that is absorbed superficially in the epidermis and
dermis by pigmented melanin and hemoglobin chromo-
phores. The heat deposited within the dermis works in
three different ways, the first being to initiate a sub-
clinical wound-healing response leading to a repair
mechanism of fibroblast activation and collagen remo-
deling. The second is the displacement of actinically
damaged dermis. The third is cytokine activation leading
to secondary collagen remodeling via heat shock protein
vascular endothelial modulation.
19
The KTP laser, which targets the chromophore
hemoglobin, is particularly effective at treating rosacea.
The most prominent telangiectactic lesions characteris-
tic of rosacea are treated first. Vessels between 1 and
3 mm respond well to the laser. Laser spot-size dia-
meters and pulse widths are adjusted to match the vessel
size. For example, if the vessel diameter is 3 mm, then a
spot size of 3 mm is chosen. With increasing vessel
diameter, the pulse width is also increased, depositing
energy over a longer period of time. Significant advances
had been made over previous laser methods. The earlier
pulse-dye laser treatments of telangiectactic lesions in-
volved the use of ultrashort pulse widths in the nanose-
cond range. These lasers deposited a large amount of
energy in a short period of time, often leading to vessel
rupture and purpura formation. Therefore, pulse-dye
lasers are no longer a first choice for telangiectatic or
rosacea treatment.
Prior to treatment, the skin is washed of all debris
and topical preparations. Discomfort from the procedure
is minimal and pretreatment with topical anesthetic
cream is not necessary. Additionally, prilocaine, com-
mon to many topical anesthetics, may cause vasocon-
striction, which would be counterproductive. Our
preference is for parallel cooling of the skin, which not
only protects the epidermis from injury when higher
energies are used but also provides hypoesthesia. The
vessel is viewed through a chilled window within a
sapphire tip. The vessel is traced and treated from lateral
to medial. A chilled water-based gel facilitates the laser
hand-piece movement as well as soothes the skin. The
end point is reached when the vessel is no longer seen or
a grayish hue is noted over the vessel. Multiple passes
with focused energy delivered thru the 2-mm hand piece
are not recommended and may lead to injury. Following
treatment of individual lesions, a larger-diameter hand
piece is used and energy settings are decreased. The laser
is passed over the affected area three times in a painting
Figure 7 Rosacea patient D. Frontal view pretreatment.
USE OF THE KTP LASER IN THE TREATMENT OF ROSACEA AND SOLAR LENTIGINES/BASSICHIS ET AL 81

motion. The diffuse laser treatment is intended to even
out erythema and blend in the skin tones. Posttreatment
patients appear slightly red and flushed, but purpura
formation is uncommon. An ice pack is given to cool the
area, and the redness usually resolves within a couple
hours. Blister formation and permanent scarring are rare
and avoidable with proper patient selection and low-
energy laser settings. Most patients feel comfortable
returning to regularly scheduled activities that day.
Improvement from flushing, pain, and the deep redness
of rosacea can be expected within a week. Most patients
prefer a series of three treatments to reach stable control
of the rosacea. This seems to provide a plateau in
symptoms for many months after which time patients
may return for maintenance series (Figs. 7–10).
CONCLUSION
The knowledge of using lasers to treat cutaneous lesions
continues to advance. The ability to target chromo-
phores specific to a lesion allows clinicians to treat
abnormal cells, with as little damage as possible to the
surrounding normal cells. Rosacea is a very common
condition that adversely affects millions of individuals.
Solar lentigines are a cosmetic nuisance resulting from
too much sun exposure. Both conditions can be treated
safely and efficaciously with the KTP laser. Our results
from clinical experience using the laser in the office have
been very promising. Patient satisfaction from the pro-
cedure is very high and is well tolerated.
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Figure 8 Rosacea patient D. Frontal view posttreatment.
Figure 9 Rosacea patient D. Left oblique view pretreatment.
Figure 10 Rosacea patient D. Left oblique view posttreatment.
82 FACIAL PLASTIC SURGERY/VOLUME 20, NUMBER 1 2004

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USE OF THE KTP LASER IN THE TREATMENT OF ROSACEA AND SOLAR LENTIGINES/BASSICHIS ET AL 83

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