2017-18 HSC Section 4 Green Book

Clinical Review & Education Review

Energy-Based Facial Rejuvenation—Advances in Diagnosis and Treatment

Table 2. Selected Source Articles for Major Therapies Available

Sample Size and Characteristics

Fitzgerald Skin Type

Source by Category

Energy Used

Adverse Effects

Bottom Line

Laser Ablative

Triana et al, 5 2015

High satisfaction rate, but significant complications

III-V

Hyperpigmentation (30.4%), prolonged recovery

Carbon dioxide

665 Patient, retrospective, 80% full-face ablative resurfacing primarily for rhytids, single treatment 45 Patient, prospective single-blinded, 2-3 full-face treatments 9 Patients, prospective, full face, 1-2 treatments 58 Patients, retrospective, acne scarring

Fractionated ablative Tierney et al, 9 2011

I-III

None significant, erythema <7 d

Significant improvements in photoaging, minimal adverse effects Improvements in photoaging greater with 2 treatments 3 Treatments with AFL as effective as a single treatment with resurfacing lasers

Carbon dioxide

Khatri et al, 13 2012

Erbium:YAG

I-IV

3-4 d Downtime, moderate discomfort

You et al, 44 2016

IV

Increased downtime, erythema, and dyschromia in ablative group, more with carbon dioxide laser

Carbon dioxide, erbium:YAG, NAFL, and AFL

Fractionated nonablative Hong et al, 15 2015

III-IV

Mild pain, minimal downtime

Mild/moderate improvement in mild rhytids

LPND

20 Patient, prospective, split-faced study, 3 treatments 20 Patient, prospective, randomized, control is triple topical therapy

Kroon et al, 52 2011

II-IV

Mild erythema, burning sensation, edema, pain

Significant improvement compared with control in melasma, high recurrence

NAFL

Combination

Cohen et al, 19 2013

Improved, equivalent results in both groups; lower adverse effect profile in combined FLs There is a small risk of dyschromia with IPL use in patients with prior dyschromia Improvement in melasma vs bleaching cream alone, poor response in frontal and malar melasma

Reduced adverse effects, downtime in combined laser

Combined FL

8 Patients, prospective, split-face control is fractional ablative carbon dioxide laser

Intense pulsed light Fang et al, 24 2014

IPL

675 Patients, retrospective, 1-5 treatments

III-IV

Hyperpigmentation in 2.96% of patients, all had pigmentation issues before treatment Significant response to IPL therapy based on MASI vs control

II-V

62 Patients, prospective, randomized, control is triple-topical therapy alone, single-session, melasma 43 Patients, prospective, photodamage, 29 patients IPL/NAFL full-face, 14 patients split-face IPL/NAFL and IPL or NAFL alone, 4 wk later completion treatment 113 Patients, prospective, full-face combination, split-face combination vs IPL alone 14 Patients, prospective, single blinded, 4-6 treatments 17 Patients, prospective, 6 total treatments for 6 mo

Figueiredo Souza et al, 51 2012

IPL/triple combination treatment

Combination Kearney

Statistically superior results in combined IPL/NAFL group

NA

Combined group: 10% persistent erythema (≤10 d), 10% superficial pustule formation, 14% pruritus

IPL/NAFL

and Brew, 28 2012

Tao et al, 29 2015

Combination therapy statistically superior to IPL alone

III-IV

AFL: 3-5 d for reepithelialization, erythema for 1-2 d, 3.6% experienced hyperpigmentation

IPL/AFL/ Near infrared

Radiofrequency Nelson et al, 39 2015

NA

Minimal, transient erythema and edema

All experienced some improvement, no long-term data, weekly treatments Improvement out to 1 year that was mild and diminished from 6 mo

Bipolar RF

Taub et al, 41 2012

Monopolar RF

NA

Minimal, mild discomfort

Ultrasonography Fabi and Goldman, 37 2014

MFU Retrospective, most had mild improvement in appearance out to 6 mo, no longer-term data Abbreviations: AFL, ablative fractionated laser; erbium:YAG, erbium yttrium aluminum garnet; FL, fractionated laser; IPL, intense pulse light; LPND, long-pulsed Nd:YAG; MASI, melasma area and severity index; MFU, microfocused ultrasonography; RF, radiofrequency. 48 Patients, retrospective, face and upper neck skin laxity treated I-IV 1 Small pustule at treatment site, no permanent

were compared in several studies showing high recurrence rates with fractional therapy and a higher incidence in PIH. 60,61 Melasma continues to be a difficult problem, with frequent recurrence, but refinements in techniques are helping identify the optimal treat- ment to improve pigmentation without hypopigmentation or worsening PIH.

Ethnic Skin Darker skin types, Fitzpatrick type V and VI, have thicker and more compact skin layers with thicker collagen bundles, which increase the epidermal barrier and reduce skin sensitivity in addition to a higher density of larger melanosomes. 62-64 Ablative nonfraction- ated lasers, including the carbon dioxide and the erbium:YAG, can

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