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Year : 2019 | Volume : 85 | Issue : 1 | Page : 24-31
Complications of laser and light-based devices therapy in patients with skin of color
BS Chandrashekar, Chaithra Shenoy, C Madura
Department of Dermatology, Cutis Academy of Cutaneous Science, Bengaluru, Karnataka, India
Correspondence Address:
Dr. B S Chandrashekar
5/1, 4th Main MC Layout, Near Veeresh Theatre, Vijay Nagar, Bengaluru - 560 040, Karnataka
India
Abstract
Lasers and light-based devices are indispensable to an aesthetic dermatology practice. The growing popularity of
lasers has been matched by a sharp increase in the incidence of complications. The Indian skin with its high
melanin content is more prone to injury and careful setting of laser parameters, early detection of complications
and immediate therapy are vital to avoiding permanent sequelae. We review the various complications that occur
during laser procedures and their management.
How to cite this article:

Chandrashekar B S, Shenoy C, Madura C. Complications of laser and light-based devices therapy in patients with skin of
color.Indian J Dermatol Venereol Leprol 2019;85:24-31
How to cite this URL:

Chandrashekar B S, Shenoy C, Madura C. Complications of laser and light-based devices therapy in patients with skin of color.
Indian J Dermatol Venereol Leprol [serial online] 2019 [cited 2020 Apr 28 ];85:24-31
Available from: http://www.ijdvl.com/text.asp?2019/85/1/24/247689
Full Text
Introduction
A laser complication has been defined as “any undesirable effect that occurs with laser treatment, even if
expected.”[1] It is mandatory that the laser physician be familiar with the basic principles of lasers, laser–tissue
interactions as well as the device being used in order to minimize complications. The principle of selective
photothermolysis proposed by Anderson and Parrish has revolutionized laser therapy and has enabled technology
that confines tissue injury to specifically targeted chromophores within the skin.[2] Advances in laser technology
have resulted in the development of more effective and safer lasers. Laser physicians need to constantly update
themselves to utilize these modern laser and light-based devices that have the potential to produce new and
unfamiliar complications.
Indian skin ranges from type IV to VI on the Fitzpatrick skin type scale and is more pigmented in comparison to
the Caucasian or Oriental skin types owing to presence of greater amounts of epidermal melanin and larger
melanosomes.[3] This makes it more vulnerable to post inflammatory hyperpigmentation following laser
treatment.[3] Pigmentary changes are the main manifestation of photoaging in the Indian skin and erythema is
usually masked by the darker tone. The degree of wrinkling is not as marked as in Caucasians[4] and melanoma
and nonmelanoma skin cancers are less common in Indians. A cavalier attitude toward sun exposure and
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avoidance of sunscreens is usual in India, and therefore, counseling patients before laser treatment is mandatory.
Complications Due to Lasers and Light-Based Devices
Complications occurring due to laser and light-based devices can be classified into two broad categories:
operator-dependent and patient-dependent. Operator-dependent variables include faulty parameters and poor
technique (such as the handpiece not being perpendicular to the skin, placing the probe too close or too far from
the skin while operating the laser, and not using adequate protection for operating personnel and patients).
Patient dependent variables include the skin type, the type of lesion, hormonal status (in female patients
undergoing laser hair reduction), inadequate or improper sunscreen application and recent tanning.
We propose that the complications of laser procedures may be classified as immediate (up to 7 days), transient
(1–6 weeks) and persistent (after 6 weeks) [Table 1].{Table 1}
Laser hair reduction
Laser hair reduction is a common procedure performed in the aesthetic clinic. Although the procedure is relatively
safe, complications are not infrequent [Table 2].[5],[6],[7] The devices used in the Indian skin include the long-
pulse Nd:YAG, diode and Alexandrite lasers and intense pulse light.[5]{Table 2}
Immediate complications such as a burning sensation, pain, edema and crusting can be reduced with a good
precooling and postcooling protocol. Laser burns [Figure 1] should be recognized early and treated immediately
with a moderate potency topical steroid such as mometasone for a few days to reduce the inflammation.{Figure
1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}
Acneform eruptions occur in 6% of the patients undergoing laser hair reduction.[9] They arise independently of
gender, the number of previous sessions or the presence of polycystic ovarian syndrome. Folliculitis and acneform
eruptions may be treated with oral doxycycline for 10–20 days along with topical antibiotics.[9]
Postinflammatory hyperpigmentation is treated with topical hydroquinone, kojic or glycolic acid creams. The
application of a broad spectrum sunscreen is mandatory. Post-laser hypopigmentation or depigmentation are
anxiety inducing complications which may result after laser hair reduction, pigment lasers or resurfacing lasers.
Appropriate delivery of energy using optimal laser settings may reduce the incidence of this complication.
Postinflammatory hypopigmentation may treated with topical tacrolimus, as it enhances both tyrosinase activity
and melanocyte migration.[10] The application of 65% trichloroacetic acid on depigmented spots may be
successful in repigmenting these patches.[11]
Paradoxical hypertrichosis may occur in 0.6–10% of patients undergoing laser hair reduction and is more common
after treatment with intense pulse light. It is more frequent in the head and neck areas (especially on the chin,
mandibular and zygomatic areas in patients with darker skin), and in patients with thick dark hair or underlying
hormonal imbalance.[12],[13] An uncorrected hormonal abnormality that might be triggering hair growth should
be eliminated before labeling a patient as having paradoxical hypertrichosis. It has been suggested that
subtherapeutic thermal injury to the surrounding vellus hair stimulates conversion into terminal follicles and
inflammatory mediators and upregulatory cytokines may also play a role. Protecting the nonlasered area with cold
packs during the procedure may help prevent this complication. Paradoxical hypertrichosis may be treated by
using a higher fluence and doubling the number of laser passes on the affected area.
Leukotrichia may develop following laser hair removal and may be temporary or permanent. Differences in the
thermal relaxation times of melanocytes and germinative cells may result in destruction or impairment of the
function of melanocytes without injury to the hair follicle cells.[15] Epilation or electro-optical synergy hair
removal technology may be employed for removal of gray hair.[16]
Undesired styling of hairline is a common complaint when shaping the eyebrows and side locks in women and
beard line in men. Drawing the desired hairline margin with a white marking pencil and photographing can
prevent future disputes.
Ocular complications have been reported mostly during epilation of the lower part of the eyebrow. When the
eyelid closes, the eyeball rolls up owing to the Bell's phenomenon making it vulnerable to laser damage. The
insertion of a metallic intraocular eye shield is mandatory during lower eyebrow hair removal.[14]
Cold urticaria, superficial thrombophlebitis and palpable purpura are uncommon, self-limiting side effects that
may be encountered on occasion.[6],[7],[8]
Pigment lasers
Lasers are now used to treat various pigmentary conditions such as nevus of Ota, acquired bilateral nevus of Ota-
like macules, freckles, lentigines, tattoos, melasma and postinflammatory hyperpigmentation. The 1064 nm Q-
switched Nd:YAG, 532 nm KTP (potassium titanyl phosphate) laser, 532 nm frequency doubled Q-switched
Nd:YAG, the 755 nm Q-switched alexandrite laser and intense pulse light are commonly used to treat pigmented
lesions in the Indian skin.
Q-switched lasers are precision devices and complications are dependent on the beam profile of the laser
machine. Devices with a Gaussian beam profile are more prone to adverse effects as compared to those a with a
Top hat beam. Pico-second lasers are superior to nanosecond devices in both efficacy and side effect profile.
Patient-dependent factors such as the type of lesions, its depth and the skin type of the patient may also
influence complications.
Complications that may occur during treatment with pigment lasers are listed in [Table 3].[1],[4],[17] Close
observation of the tissue response while performing the procedure is necessary to achieve the desired results.
Since responses vary widely among patients, a test spot is vital to determine the optimal parameters for the
lesion in that patient. It also allows the patient to become familiar with and understand the procedure.{Table 3}
Immediate complications such as pain, erythema, edema and blistering are directly related to the energy used
during the procedure. Application of a topical anesthetic cream 45 min prior to starting of the procedure and cold
compresses following the session may alleviate pain and discomfort. The application of a topical steroid and
antibiotic cream along with a short course of oral prednisolone in patients with immediate blistering helps relieve
the symptoms. Blistering or crusting usually resolves over a period of 7–10 days.
Acute compartment syndrome has been reported with treatment of decorative circumferential tattoos.[18]
Dividing the circumferential tattoo into different parts may prevent this complication.
Adverse reactions to tattoo ink after laser removal such as eczematous reactions and generalized urticaria are
well-known.[17] Anaphylaxis after laser removal of tattoos may be due to the release of ink particles into the
systemic circulation. Immediate cutaneous hypersensitivity and delayed anaphylaxis following laser for tattoo
removal have been rarely reported. In such cases, pretreatment with antihistamines and topical or oral
corticosteroids has been successful in suppressing allergic sequelae; other ablative modalities such as CO2 or
Erbium: YAG laser may then be used to remove the tattoo.[1],[19]
Hypertrophic scars and keloids following tattoo removal are rare. In a recent study of tattoo removal with a Q-
switched Nd:YAG laser in 1041 patients, keloids were not seen and hypertrophic scars were seen in 3 (0.28%)
patients.[20] Hypertrophic scars may be treated with intralesional triamcinalone acetonide injections.
Darkening of ferric oxide and titanium oxide tattoos after treatment with Q-switched Nd:YAG due to oxidation and
discoloration of the tattoo pigment may be noted. Oxidized tattoos can only be partially lightened with Nd:YAG
laser, and CO2 laser ablation or surgical excision may be necessary for complete removal.[1]
Ablative and fractional resurfacing lasers
Ablative and fractional lasers have evolved significantly over time and the current devices are not only more
effective but safer. In India, ablative lasers are mostly used to improve benign lesions. Ablative full-face
resurfacing is best avoided on the Indian skin owing to a significant risk of hyperpigmentation and scarring.
Fractional resurfacing, on the other hand, has gained popularity in the Indian scenario for the treatment of acne
scars and photo aging.[21]
A complete history prior to the procedure should include enquiry into occupational details (to determine the
number of hours the patient is exposed to direct or indirect sunlight), tendency to keloids, hypertrophic scars or
postinflammatory hyperpigmentation and a history of herpes simplex infections.[22] Old scars should be
examined for keloidal tendencies. The patient should be counseled regarding the downtime required after each
laser session and it is important to enquire about any significant life events (e.g. marriage) in the near future, to
avoid unpleasant surprises. Aggressive parameters, such as increased energy or density, are frequently
associated with complications with fractional and ablative lasers. [Table 4] lists the complications that may be
encountered during the use of ablative lasers.[22],[23]{Table 4}
Reactivation of the herpes simplex virus may occur after laser resurfacing leading to widespread facial lesions,
delayed epithelialization, and scarring. All at-risk patients undergoing laser resurfacing must be administered
antiviral prophylaxis (valacyclovir or famciclovir 500 mg twice daily in patients) starting a day before the
procedure and continued 10 days thereafter to prevent herpes simplex virus reactivation.[23],[24],[25],[26]
Prolonged redness may occur after resurfacing of the skin especially with ablative lasers. Temporary fragility of
skin and peeling can occur up to a month. Strict photoprotection and moisturizers are helpful in managing these
issues. Postinflammatory hyperpigmentation may occur in 26–36% of the patients undergoing laser resurfacing.
[27] Demarcation lines (areas of contrast in between the lased and nonlased skin) may be avoided by peripheral
feathering of the laser beam into the borders of the treated areas.
Vascular lasers
The flash lamp pumped pulsed dye laser was the first selective laser to be developed on the basis of the theory of
selective photothermolysis, for the treatment of port wine stains.[2] The chromophores in vascular lesions are
oxyhemoglobin (absorption peaks at 418, 542 and 577 nm) and deoxyhemoglobin (absorption peaks at 430 and
555 nm).[28]
Lasers used for treatment of vascular lesions are listed in [Table 5] and complications caused by these devices in
[Table 6].{Table 5}{Table 6}
The available vascular lasers are better suited for fairer skin and treatment parameters need to be tweaked for
the Indian skin. The pulsed dye laser is safer for superficial vascular lesions as compared to the longer pulse
width lasers. The desired endpoint for all vascular lasers is the appearance of purpura.
Multiple sessions over a prolonged period of time are necessary owing to the variable depth of the lesions,
locational anatomy and angiogenesis between sessions, and the patient needs to be carefully counseled in this
regard.[29] Uneven resolution of the vascular lesions may be seen -- port wine stains may resolve faster on the
lateral aspect of the face, and nonfacial lesions respond slowly with treatment with pulsed dye laser, due to the
presence of deeper subcutaneous vessels in the central face and in nonfacial lesions.[30]
Pyogenic granulomas may develop in port wine stains after treatment with pulsed dye lasers. These may be
treated with the pulsed dye laser itself or excised with a radiofrequency cautery.[31] “Laser imprints” are atrophic
scars sometimes seen at laser impact sites due to excessive delivery of energy, absence of cooling or spot
overlap.[27]
Excimer Laser and Lamp
The 308 nm Excimer laser and lamp have been used in various dermatological disorders including vitiligo and
psoriasis. Adverse effects are dose-dependent and self-limiting. A burning sensation, erythema, peeling of skin,
and perilesional hyperpigmentation have been described. The use of a rubber cut-out template during laser
delivery and gradual increase in the dose of radiation may help prevent these complications.[32],[33]
Ocular Complications Due to Lasers
Strict adherence to laser protection guidelines may prevent ocular injury.[1] Laser glasses are mandatory and are
rated by optical density at various wavelengths. An optical density of >4 for a particular wavelength is considered
safe. Ocular injury depends upon the wavelength of laser used, duration of exposure, beam size and incidence of
the laser beam. The major chromophores in the eye are water and melanin.[32],[33] Lasers in the 400–1100 nm
range target melanin present in the retina, iris, choroid and the sclera causing color flashes, afterimages (in the
color complementary to the color of the exposed beam) or immediate visual loss due to damage to the fovea.
Lasers of wavelengths between 1400 and 10600 nm may produce immediate burning pain and damage owing to
thermal damage of the cornea and lens.[32],[34]
Risks to Operating Personnel
Plume and tissue splatter are potential safety issues for laser operators. Particulate matter as small as 0.12 μm
containing bacteria, human papillomavirus, human immunodeficiency virus, carbon and live cellular particles have
been identified in surgical smoke. The appropriate use of smoke evacuators, gloves and masks can prevent
inhalation of particulate matter and skin contamination of the operator. Tissue splatter is a potential hazard with
Q-switched and Erbium:YAG lasers. Fire and electrical hazards are associated with some high-voltage lasers and
care must be taken to avoid exposure to flammable objects such as anesthetic gases, oxygen and alcohol-based
products during laser procedures.[33],[35]
Complications Due to Topical Anesthetic
Topical anesthetic agents such as EMLA cream (lidocaine and prilocaine cream) used for alleviation of pain during
nonablative laser treatments and limited ablative laser treatments may give rise to complications.
Hypersensitivity to topical anesthetic has been well documented [Figure 10]. If itching or erythema develops after
the application of topical anesthetic cream, the procedure must be postponed and other options such as
infiltration anesthesia or nerve blocks may be considered. Residual pigmentation in the seborrhoeic area [Figure
11] may arise after reaction to topical anesthetic creams. This should be recognized early and treated with topical
moderate potency corticosteroid creams, depigmenting creams and broad spectrum sunscreen.{Figure 10}
{Figure 11}
Methemoglobinemia may ensue when topical anesthetics are used on large areas especially when used with
occlusion. It is also more likely to occur in infants.[36]
General Considerations
Written instructions including do's and don'ts given to the patients after the procedure reinforces the
postprocedural care instructions given orally. The patients should be educated as to what is to be expected after
the procedure and has to report back immediately if any untoward reactions are suspected. Adequate priming
with sunscreen, topical retinoids and topical depigmenting agents such as kojic acid, glycolic acid and arbutin will
reduce the incidence of complications, especially postinflammatory pigmentary changes. The laser physician
should insist on frequent follow-ups in the immediate postlaser period to detect and manage complications early.
Conclusion
Advances in laser technology have not only allowed the development of new devices and expanded the scope of
these to target newer diseases more effectively, but has also resulted in a greater incidence of complications,
especially in skin of color. A thorough knowledge of basic laser physics, complete understanding of the device in
hand, optimal parameter settings, proper methods of laser beam delivery, strict adherence to the standard
protocols and early recognition of expected side effects and an intuition to look beyond the routine are the keys to
a safe trouble-free laser practice.
Acknowledgement
We are grateful to Dr. Venkataram Mysore for editing the manuscript and his valuable addition to it.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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4/28/2020 Indian Journal of Dermatology, Venereology and Leprology (IJDVL): Complications of laser and light-based devices therapy in patien…

How to cite this article:

How to cite this URL:

Complications Due to Lasers and Light-Based Devices

Laser hair reduction

Ablative and fractional resurfacing lasers

Excimer Laser and Lamp

Ocular Complications Due to Lasers

Risks to Operating Personnel

Complications Due to Topical Anesthetic

Financial support and sponsorship

There are no conflicts of interest.

Tuesday, April 28, 2020

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