Laser treatment of acquired forms of lentigo

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1. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 20 LASER TREATMENT OF ACQUIRED FORMS OF LENTIGO LASER TREATMENT OF ACQUIRED FORMS OF LENTIGO Open Access Article Natalia Vladimirovna Volkova 1 , Natalia Gennadievna Kalashnikova 2 , Anna Alexandrovna Tyurina 3 1 Aesthetic Medicine Department of Ural State Medical University of Ministry of Healthcare of the Russian Federation, Yekaterinburg, Russian Federation. 2 ”Linline” Network of Clinics, Moscow, Russian Federation 3 ”Linline” Network of Clinics, Voronezh, Russian Federation Corresponding author: Natalia Vladimirovna Volkova, 620075, Belinskogo Str. 32–7, Yekaterinburg, Russian Federation Phone: +7-912-28-65-340 E-mail: Clinical study Keywords: lentigo, laser treatment of lentigo. Abstract Lentigo is one of the most frequent causes of visiting a dermatologist. Laser therapy is a modern treatment of acquired forms of this disease, and the article presents the advantages of laser treatment. The practical aspects and clinical examples have been given and reviewed. Choosing an adequate method of laser treatment and an individual approach to a patient when determining the required number of procedures makes it possible to obtain the desired cosmetic effect. Cite this article : Natalia Vladimirovna Volkova, Natalia Gen- nadievna Kalashnikova, Anna Alexandrovna Tyurina. Laser treatment of acquired forms of lentigo. RoJCED 2017;1(4):20-25. 1. Clinical manifestations Lentigo is caused by local melanin skin hyper- chromatism, and it is characterized by the ap- pearance of small fl at hyperpigmented spots with 0.5–1.5 cm in diameter. The color ranges from yellow-brown to brown-black, hyperpigmentation foci/areas can be single and/or multiple, located on any skin area and mucous membranes. Lentigi- nes can be congenital or acquired (1-4). According to the common nosology, there are different clinical diseases/presentation forms: • Lentigo simplex • Solar lentigo • PUVA lentigo • Speckled lentiginous nevus • Perigenital-axillary lentiginosis • Generalized lentigo • Lentiginous syndromes (1, 2) Lentigo simplex (juvenile lentigo) is the most common form of the disease, manifested immedi- ately after birth or in early childhood. So far, stu- dies have failed to demonstrate a connection be- tween lentigo simplex and exposure to sunlight or systemic diseases. Clinical manifestations: Single or multiple hyper- pigmented oval or round spots, 3–15 mm in dia me- ter, with toothed or smooth edges. The pigment is spread uniformly within the elements making them brown or black, with various localizations. The histological picture is characterized by elon- gation of epidermal outgrowths, increased num- ber of melanocytes in the basal layer of the epi- dermis, increased melanin content in melanocytes and adjacent keratinocytes. The lymphohistiocytic infi ltrates of varying density with melanophage ad- mixture are found in the underlying dermis (1, 2, 4). Solar lentigo (actinic lentigo, senile lentigo, liver spots) is a result of exposure to sunlight (1-3). Solar lentigo is common for middle-aged people. The prevalence among fair-skinned individuals over 60 years old reaches 90%, while for patients under 35 it is 20%. Solar lentigines tend to become more frequent in younger populations, aged between 20 and 30 years old, due to frequent use of tanning bads and longer sun exposure habits (1, 4). According to a number of epidemiological studies, the preva- lence of this pathology among the Asian nations is higher compared to European nations (5, 6). The pathogenesis of this form of the disease is based on the following processes: the ultraviolet radiation impacts biologically active molecules which produce the keratinocytes of the epidermis and the fi broblasts of the dermis (endothelin-1, stem cell factor, hepatocyte growth factor and ke- ratinocyte growth factor), which in turn stimulate the proliferation and differentiation of melano- cytes from the stem cells and fi broblasts. The sun- light also produces damage of the cellular DNA and activation of the aryl hydrocarbon receptors (7, 8). In addition, it is suggested that environmen- tal factors (NO 2 and other products), when pene-

2. 1/March/2017 21 trating through the skin, can promote lentigo de- velopment (9). Clinical manifestations: Persistant small spots varying from light brown to black, increasing in color intensity and size, which can merge forming large foci (1, 2) located on the lips, back, shoulders, the back of hands. Histologically, solar lentigines are characterized by hyperkeratosis, elongation of interpapillary epi- thelial outgrowths in the form of drum sticks con- sisting of signifi cantly pigmented basaloid cells interspersed with melanocytes. The number of melanocytes is slightly increased (1, 2). PUVA-induced lentigo affects 1,5–4% of patients receiving long-term treatment with long-wave- length ultraviolet rays. Clinical manifestations: Dark brown spots with indistinct borders (similar to ephelide borders), usually generalized, including palms and soles, persisting up to six months or longer after the ini- tiation of PUVA therapy for psoriasis (1, 4). Histologically it is characterized by hypertrophy and hyperplasia of the melanocytes; in some cases cellular atypia is detected (1). Other rare varieties of lentigo include: • Perigenital-axillary lentigo located in areas with apocrine secretion, occurs sporadically; • Generalized lentiginosis is characterized by multiple lesions that are not associated with systemic disorders, manifested at birth or du- ring the fi rst years of life; it can be inherited in a dominantly pattern; • Lentiginous syndromes include centrofacial len tiginosis, Peutz-Jeghers-Touraine and Soto syndromes, LEOPARD syndrome, lentiginosis with nystagmus and strabismus, etc. Lentiginous syndromes are hereditary and accompanied by systemic lesions of various organs (1). Lentigo diagnosis is established based on cha- racteristic clinical fi ndings. A differential diagnosis distinguishes lentigo from ephelides, senile kera- tosis, lentigo maligna melanoma (1, 3, 4). If a con- genital lentiginous syndrome is suspected, inter- disciplinary consultations are required (physician, neurologist, geneticist, etc.). Modern methods of acquired lentigo treatment are essentially designed to the destruction of cells containing large amounts of melanin and suppres- sion of excessive melanogenesis. Medical devices (cryotherapy, laser methods), drugs for external use containing hydroquinone, azelaic acid, and retinoids as well as chemical peels, “mesotherapy bleaching cocktails”, are currently widely used. It is very important to apply sunscreen during sun ex- posure to reduce the risk of lentigo recurrence or progression (2, 8, 9). 2. Laser methods of lentigo treatment Laser methods have taken the lead in treating skin hyperpigmentations of nonneoplastic origin in the last decade and they are preferred proce- dures when dealing with the local forms of this no- sology, including acquired lentigines. Melanin, as a chromophore for the laser radiation, is able to absorb light waves in a wide spectral range. High absorptive capacity of melanin is observed in the ultraviolet (351–400 nm) and visible (400–760 nm) spectral ranges. The absorption capacity decrea- ses with increasing wavelength. Melanin light ab- sorption decreases in the near-infrared spectral range, from 900 nm. Various types of lasers are applied to treat hyper- pigmentations of nonneoplastic origin: • Pulsed dye laser (595 nm) • Long-pulse diode laser (810 nm) • Nd: YAG/Q-switch (1064 nm) with doubled frequency • Ruby Q-switch (694 nm) • Long-pulse Alex (755 nm) • Alex Q-switch (755 nm), etc. (10-14) The main side effects of hyperpigmentation la- ser treatment are: • Thermal damage • Burns • Scarring • Hypopigmentation Long-pulse laser systems When applying long-pulse laser systems, the ex- posure time is much longer than the melanin ther- mal relaxation time (about 1 μs). As a result, mela- nin absorbing laser pulse heats up and begins to give up energy intensively to the surrounding tissues. The resulting heat wave is evenly spread from the melanin granules in all directions. The longer the exposure time, the greater the zone of thermal damage of the surrounding tissues. In the case of epidermal hyperpigmentation treatment, it can lead to surface burns without scarring. If the pulse duration is increased, the heating will affect the deeper layers of skin and, in the case of hyper- pigmentation in the dermal layer, there will be a high risk of scar complications (10, 13). Short-pulse Q-switch lasers Hyperpigmentation treatment using short-pulse Q-switch lasers is based on the effect of generating acoustic waves capable to mechanically destroy the cells with high melanin content. Unfortunately, there are no methods of controlling the adequate energy density level, so the treatment is performed until signifi cant frosting appears. Therefore, both cells with high melanin content and all the surrounding tissues are mechanically destroyed. Such exposure can result in the development of wound surfaces and later in hypopigmentation and scarring (10, 13). Q-switch lasers with packets of nanosecond pulses (Multiline method) This technology is exclusive patented as "spot coagulation" method and characterized by selec- tive effect on the excess pigment in the tissues (10, 14). The "spot coagulation" method is imple- mented in Multiline device using two types of laser emitters: • Ruby Q-switch (694 nm, 3 mm, 6 mm) Natalia Vladimirovna Volkova, Natalia Gennadievna Kalashnikova, Anna Alexandrovna Tyurina

3. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 22 LASER TREATMENT OF ACQUIRED FORMS OF LENTIGO • Alexandrite Q-switch (755 nm, 3 mm, 6 mm) Laser radiation is applied in the form of wave trains (”packets”) of nanosecond pulses. When mel- anin grain is exposed to the wave train’s fi rst pulse, it receives some energy and warms up. Due to short thermal relaxation time (1 μs), melanin grain rapidly cools down and transfers heat to the surrounding tissues after laser exposure. But heat outfl ow from melanin grain is uneven in different directions. Collision of thermal waves coming from the adjacent melanin grains occurs in the areas with higher pigment concentration; therefore, the temperature in these areas is higher than in the surrounding tissues with normal pigmentation. When melanin absorbs the following laser wave train pulse in the hyperpigmented spot, the areas between the mela nin grains fail to cool down to the initial temperature. So, heating of these areas starts with higher temperature by the next wave train pulse. Consequently, while wave train pulses keep co ming, the temperature locally increases step by step to the coagulation level. In the areas with normal pigment concentration, thermal waves do not collide because of large distances between melanin grains. As a result, the temperature of these areas after each pulse is lower and they manage to cool down to the initial temperature within the interpulse interval. So, the surrounding tissues do not experience a signifi - cant thermal exposure because no heat is gradu- ally accumulated in them. The spot coagulation effect is manifested in the hyperpigmented spot only where melanin concentration is excessive. This method can be used for coagulating mela- nin on the entire depth of the pigment occurrence in the skin, which reduces the number of proce- dures. No signifi cant thermal damage of the sur- rounding tissues or acoustic damage of hyper- pigmented areas are observed, which makes this method safe (10, 11, 14, 15). We further present our own clinical observations of the solar lentigines treatment using the Q-switch method with packets of nanosecond pulses (Ruby Q-switch 694 nm, 3 mm and emitter Alex Q-switch 755 nm, 3 mm). 3. Case presentation Clinical case 1 Female patient R.L., 32 years old. The patient had com- plained about a pigmented spot on her right cheek. Anamnesis: The element appeared a few years ago, the patient cannot specify the reasons. She did not visit a dermatologist before. Status: The skin process is localized, represented by irregularly shaped brown spot with clear bor- ders on the right cheek skin. The element surface is 3 cm 2 (Figure 1A). Diagnosis: Solar lentigo. Treatment: Single laser pigment removal was performed using (Multiline device) Ruby Q-switch laser (694 nm, 3 mm) at frequency 2 Hz, energy density 20.5 J/cm 2 . Result: Examination after two weeks — almost com- plete regression of the pigmented spot (Figure 1B). Clinical case 2 Female patient K.M., 58 years old. The patient had complaints of pigmentation on the nasal wing. Anamnesis: The spot of a rice grain size fi rst ap- peared approximately 10 years ago. The patient does not know what could be the reason for the disease. The pigmented lesion began to increase in size four years ago, when menopause occurred. Status: The bright brown spot with clear borders is visible on the nasal dorsum skin. The element is uniformly colored. The surface is 2 cm 2 (Figure 2A). Diagnosis: Solar lentigo. Treatment: Seven laser pigment removal pro- cedures were performed using (Multiline device) Alex Q-switch laser (755 nm, 3 mm) at frequency 3 Hz, energy density 25 J/cm 2 . The interval be- tween the procedures was 2–3 weeks. Result: Complete regression of the element (Figure 2 B). Clinical example 3 Female patient Sh.P., 35 years old. The patient had complaints of/ about the brown spot on the right eyebrow skin. Anamnesis: The spot fi rst appeared two years ago. The patient thinks it was caused by multiple visits to the tanning salon. She has not visited a dermatologist before. Status: The brown round spot with clear borders is visible on the right eyebrow skin, its coloring is slightly uneven. The element surface area is 1 cm 2 (Figure 3A). Diagnosis: Solar lentigo. Treatment: Two laser pigment removal proce- dures were performed using (Multiline device) Alex Clinical study Figure 1. Female pa Ɵ ent R.L. Before (A) and a Ō er (B) treatment Figure 2. Female pa Ɵ ent K.M. Before (A) and a Ō er (B) treatment

4. 1/March/2017 25 Q-switch laser (755 nm, 3 mm) at frequency 3 Hz, energy density 17 J/cm 2 . The interval between the procedures was two weeks. Result: Examination three weeks later after the second procedure revealed that the pigment spot was pale with indistinct borders (Figure 3B). The eyebrow growth and the hair were not changed, which demonstrated a high degree of selectivity of Alex Q-switch laser radiation (Multiline device) on the pigment in the spot without affecting the surrounding tissues in the treatment area. The spot appearance did not trouble the patient, so she dis- continued the treatment. Clinical example 4 Female patient S.N., 51 years old. The patient had complaints of/about the spot on the left cheek. Anamnesis: The spot fi rst appeared three years ago for no apparent cause. She used depigmenting cosmetics from the pharmacy at home without effect. Status: The skin process is localized. The pig- mented rounded spot is on the left cheek skin. It is light-brown with uneven coloring, hyperpig- mentation in the central part of the spot is missing. The borders are clear. The element surface area is 4 cm 2 (Figure 4A). Diagnosis: Solar lentigo. Treatment: Four laser pigment removal proce- dures were performed using (Multiline device) Alex Q-sw laser (755 nm, 3 mm) at frequency 3 Hz, energy density 25 J/cm 2 . The interval between the procedures was 2–3 weeks. Result: Almost complete regression of the ele- ment was achieved after four treatments. The residu- al effects are identifi ed as a faint, ill-defi ned hyper- pigmented area with indistinct borders (Figure 4 B). 4. Conclusion The presented clinical cases demonstrate high effectiveness and safety of the “spot coagulation” laser method (with packets of nanosecond pulses realized in Q-sw regimen) for the treatment of so- lar lentigines. Two types of emitters, Ruby Q-sw (694 nm) and Alex Q-sw (755 nm), have been used. The number of procedures in the hyperpigmenta- tion treatment course is determined individually. The uniqueness of the “spot coagulation” method is based on a high selectivity of the exposure, cau- sing no damage to the surrounding tissues and not affecting hair growth in the treatment area. Pigment removal using this method can be carried out year-round, including spring and summer. Financial disclosure: none declared. Patient consent: All patients consented to give the clinical data and photos for publication in this article. Confl icts of interest: none declared. 1. Elkin VD, Mitryukovsky LS, Sedova TG. Elected dermatology. Rare Dermatoses and Dermatological Syndromes. Perm 2004. 2. Vivier A. Atlas of Clinical Dermatology . Elsevier, 2013. 3. White GM, Cox NH. Diseases of the skin. A Color Atlas and text . Second Edition. Philadelphia, Elsevier, 2006. 4. Electronic source: 5. Nouveau-Richard S, Yang Z, Mac-Mary S, Li L, Bastien P, Tardy I, Bouillon C, Humbert P, de Lacharrière O. Skin ageing: a comparison between Chinese and European populations. A pilot study. J Dermatol Sci 2005;3:187-193. 6. Perner D, Vierkötter A, Sugiri D, Matsui M, Ranft U, Esser C. Association between sun-exposure, smoking behavior and plasma antioxidant levels with the different manifestation of skin ageing signs between Japanese and German women — a pilot study. J Dermatol Sci 2011;2:136-140. 7. Berneburg M, Plettenberg H, Medve-König K, Pfahlberg A, Gers-Barlag H, Gefeller O, Krutmann J. Induction of the photoaging-associated mitochondrial common deletion in vivo in normal human skin. J Invest Dermatol 2004;5:1277-1283. 8. Jux B, Kadow S, Luecke S, Rannug A, Krutmann J, Esser C. The aryl hydrocarbon receptor mediates UVB radiation-induced skin tanning. J Invest Dermatol 2011;1:203-210. 9. Hüls A, Vierkötter A, Gao W, Krämer U, Yang Y, Ding A, et al. Traffi c-Related Air Pollution Contributes to Development of Facial Lentigines: Further Epidemiological Evidence from Caucasians and Asians. J Invest Dermatol 2016;5:1053-1036. 10. Khomchenko VV, Pozdeeva EV, Urakova DS, et al. Study Guide on Using Multifunctional Laser Device Multiline in Aesthetic Medicine . Moscow, 2013. 11. Kalashnikova NG. Laser Correction of Acquired Hyperpigmentation in Connection with Couperosis: Examples from Practice. Device-based Cosmetology and Physiotherapy 2010;2:32-37. 12. Shepty OV. Basic Principles and Biological Mechanisms of Laser Radiation Effects on Skin. Lasers and Aesthetics 2012;(3)1. 13. Seirafi H, Fateh S, Farnaghi F, Ehsani AH. Noormohammadpour P. Effi cacy and safety of long-pulse pulsed dye laser delivered with compression versus cryotheorapy for treatment of solar lentigines. Indian J Dermatol 2011;1:48-51. 14. Khomchenko VV, Kotaev GG. Method of Therapeutic Intervention on Pigmented Lesions and Tattoos. Patent of invention No. 209605. 15. Khomchenko VV. Using High-Energy Lasers in Cosmetology. Bulletin of Aesthetic Medicine 2010;2:6-11. This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit Natalia Vladimirovna Volkova, Natalia Gennadievna Kalashnikova, Anna Alexandrovna Tyurina Figure 3. Female pa Ɵ ent Sh.P. Before (A) and a Ō er (B) treatment Figure 4. Female pa Ɵ ent S.N. Before (A) and a Ō er (B) treatmement Bibliography


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