Dermatography

Post-laser
Magic of the laserbeam

Short history

Since the 60’s there is eagerly experimented with many types of lasers. The Q-Switched laser was mainly used to remove tattoos. Most experiments took place in the US, fortunately.

As often happens in medicine, people were excited and almost magical properties were assigned to the laser beam. Because of extensive publicity campaigns from the industry the news was spread that there was so much possible with laser, even most unlikely treatments.

One of the pioneers who did serious research on lasers was Dr. Leon Goldman from Ohio (USA). After he had written many medical publications yet the result was disappointing him.

Even in the 70's many publications with promising results show up, but now about the treatment of warts, birthmarks and other skin disorders. New types of lasers were introduced, for instance the Argon laser, the Q-switched ruby laser and the CO2 laser. They also promised great results, but after 10 years they also were disappointing.

In the 80's research was done regarding the possibilities to improve the lasers. There were some new types on the market by then: the YAG laser, the new CO2 laser and the Tunable Dye Laser.

In 1980 Goldman became head of the Laser Laboratory at the University of Cincinnati, Ohio. After 15 years of research, he stated in a paper on the question where lasers are good for: The sign on my laser laboratory said, “If you don’t need the laser, don’t use it.”
Yet laser technology is seen and used as a toy by more than 80% of physicians. This becomes clear when in the beginning of the 90’s laser is used to treat the entire face - the so-called cosmetic laser treatments with the slogan “Laser makes face-lifts unnecessary “.

some of the often used laser machines





Cosmetic laser treatments

Deceptive wrinkles

Laugh wrinkles, frown lines, and even facial scars can disappear after a few treatments, thanks to the CO2 laser.

The advertisements sound so simple - and that is exactly the problem.








From about 1995 the hype about laser treatments has led to a proliferation of clinics and small practices, a development of which the result became slowly.

After years of warnings against this way of treatment - at medical conferences, lectures and publications and a big article in the science section of the Telegraph of February 9, 2002 - Eddy van der Velden was invited in Tros Radar on March 18 and April 8, 2002 to talk about his concern about this form of treatment by physicians, medical specialists, physiotherapists and skin therapists.

Because of great advertising campaigns the laser industry sold lasers by the dozens. With a correspondence course and exercises on oranges one could start to work.

In 1990, Van der Velden claimed in a scientific paper "that many of these techniques could even be learned by a monkey, but some monkeys apparently never learn.".

Those people forgot that lasers were machines with a very complex technology, not to be used by unqualified people. Its use requires an extensive knowledge of dermatology, pathology of the skin and of pigments.

See also the file tattoo removal.

True story...

Patient with extensive cafe-au-lait spot (actual indication: naevus of Becker) at shoulder and upper arm, treated in The Centre for Burns by a plastic surgeon who was obviously not an expert in the use of laser. When this treatment failed, a skin transplant (split skin graft) was applied. The final result was horrible, especially because in general, this form of pigmentation can be treated with dermatography without risks. In this case, treatment with dermatography was not recommended, because the total surface area was too large.

True story...

This tattoo was recently treated with lasers at the AMC and the Medical Laser Center in Amsterdam. The picture shows how it looks after 15 X Nd: YAG - laser and X 7 Ruby – laser

The Laser Industry

That the laser devices are terribly expensive, around € 50,000, was not important. The investment was recouped soon enough, and then you could start earning big money, so the laser industry said. Even non-physicians were trained urgently: the equipment was after all computer controlled and therefore the operation was a piece of cake!

A nice feature of the industry was that the devices renewed each year and were improved, i.e. you always had an outdated device. If it failed, the practitioner could always say "next year we will have a better one."

On the question to the Health Inspectorate who was allowed lasering the answer was easy:"anyone who can hold him" because "all these treatments do not fall under the heading of medical treatments or interventions.".

Victims

It was obvious that there were many victims: after the broadcast of Tros Radar on March 18 and April 8, 2002, there were more than 80 calls from distressed unsuspecting patients who all had the same problem.

Some examples of patients who have been with a CO2 lasers. It is clearly visible that the skin is severely burned and that hypertrophic scars are formed. Look at the depigmented skin that, despite the advice of practitioners to sit in the sun as much as possible, does not get tanned (see histopathology).

The inexperienced users of laser continued to persist against the unfortunate patients that "if you stay long enough in the sun the missing pigment will naturally come back." They meant that the melanin would again get active. However, research has shown that the tissue damage was too serious to be able to get any coloration (see histopathology).

Laser: In other cases, good results

The above does not mean that laser treatments will only produce bad results. In the hands of experienced specialists it is a very useful technique: in cardiovascular and vascular surgery, microsurgery, ophthalmology, urology, dental surgery and dermatology. It is the abuse by poor or non-trained inexperienced basic doctors, physiotherapists, skin therapists and others who use the laser who give the laser treatment a bad name. The profession "cosmetic surgery specialist" is a term that is completely free and does not mean anything.

Here is an example of how it could be. This patient was partially treated with CO2 laser in the department jaw and facial surgery, Eeuwfeestkliniek Antwerp. Pre-operatively, the patient received 0.1% tretinoin ointment, 2 weeks in advance. Subsequent treatment consisted of 2 months Edula® ointment, 3 times a day a thin layer. Depigmentation or hyperpigmentation have not occurred after this treatment.

Before CO2 laser treatment and 3 months after treatment

Before CO2 laser treatment and 3 months after treatment

Investigation of depigmentation and skin burns after laser

From 1995 to 2002, we got to see more and more patients in our clinic in Arnhem and in hospitals. At first sometimes patients were redirected to us, but that did not last long, because we warned the inexperienced users and reminded them of their lack of knowledge of the skin, the laser and the pre- and after treatment. Patients received too little information, too little time was devoted to them, wrong medication was applied.

It was noticeable that more than three-quarters of these patients were infected with a herpes virus, extreme swelling and infections. The condition of their skin (Fitzpatrick type I) was often not suitable for laser treatment.

Having taken skin punch biopsies from the most seriously damaged patients, histological examination showed that no more melanin was created by the melanocytes – one could sit for 100 years in the sun without something happening! Probably the transfer of melanin by melanocytes was damaged or blocked because of deep skin burns (further research should investigate this.) It is worth mentioning that this lasered skin is very similar to the vitiligo skin but in this case caused by burns (see also file Vitiligo skin discolorations)

Before and after treatment
That both the pre and after treatment with laser therapy often fails is evidenced by the many ointments that were prescribed to some patients. The number of tubes above was derived from ONE patient. This leads us to the professionalism of these so-called "laser specialists." In some cases, the patients were not outside their houses for months because they had serious burns.

Some patients even got a tube of scar gel to take home, to lubricate this gel on their hypertrophic scars. This scar gel consists mainly of a silicone fluid mixed with vaseline and unfortunately doesn’t do anything.

Histopathology of skin punch biopsies of skin that is lasered

When the skin is lasered incorrectly, it can cause serious burns, on the surface as well as deeper into the dermis. This normal process of melanin can be disrupted such that severe depigmentation occurs.

Skin punch biopsy 3mm taken for histopathology.

Histopathology of a normal skin. H.E. Coloring 120X.

Histopathology of lasered skin. Quantity of melanocytes as in normal skin. Mercury Melan-A coloring, 160X.

Histopathology of the same lasered skin. Little or no melanin present. Smorl coloring, 160X.

Conclusion histopathology
Probably the enzyme tyrosinase - which, among other things is responsible for the production of melanin - has been turned off by the heat of the laser. Further research is needed to determine this.

The media

After a major scientific article in the Telegraph newspaper of February 9, 2002 and a broadcast at Tros Radar on March 18 and April 8, 2002, the promotional ads are quickly disappeared and it became very quiet about the lasering of the face. Meanwhile, this hype is replaced by the Botox injections - with or without a party - and other smoothers that can be injected. New problems are emerging: The first facial paralysis has been spotted.

Dermatography as a treatment for skin discoloration after laser

Dermatography is a good alternative to treat these unfortunate patients. That this is not so simple, we can see in the file skin discolorations. Besides that there is no pigment present, there are often also the scars that need to be treated. Patience and mutual effort can eventually achieve very good results.

When other methods don’t have results, doctors and medical specialists can refer for dermatography treatment to one of the treatment centers in the Netherlands and abroad.