Lasers and lights have now been an integral part of dermatology practice.  The pace of innovation is exciting at the same time is depressing. A laser practitioner need to keep himself updated about whats happening in field of lasers and energy based devices. We will discuss top fifteen trends of innovation in our field.

  • Everything is going Fractional:

Now fractional lasers no more a new thing. It is well established. Fractional in not a separate laser energy. It is the mode of energy delivery. A solid beam of laser is fractionated into tiny beams. It’s the wound haling response of tissue changes from secondary intention to primary intention.  Fractional ultrapulse Co2, FractionalEr YAG, Fractional Q S YAG, Fractional excimer to name a few.  UVB, IPLs, RF and ultrasound also going fractional.

  • SCAARFX: ratio width to height.

Fractional microneedling RF

: Stands inbetween needling and fractional CO2. It has considerably less down time Vs Co2. Will it be an option to CO2 laser? Probably not, but have a possibility to combine with CO2 fractional to achieve superior results.

  • Fractional drug delivery

Lasersfor onychomycosis: How it works? 

  • Many of fungi are heat labile. So anythingthat heats up subungual region to 450C will inactivate the fungi. IPL, RF, Diode and LP Nd YAg lasers modified in pulse structure to use against fungi.
  • Many fungal hyphi are pigmented. So qswitched Nd YAG lasers will target cell wall. A quadri-pulse laser is provensuperior. Protocol: Though few companies claim fungus cure in single sessions. We prefer once weekly 5 weeks protocol.
  • A fractional CO2 laser on nail plate followed by traditional antifungal lacquer is still better option.

Laser sources are more confusing now: traditionally laser mediums used to be dye, gases and solids. Now, all wavelengths are possible to generate from solid state medium.

  1. Now diode can emit any wavelength.810nm, 1064nm and 755 are coming from diode source only. So no need ofAlexandrite crystals to generate 755nm wavelength. Even mixture of thesewavelengths is possible due diode source.
  2. Sandwich filter IPL are competing withDye VL lasers for Vascular effect. Previously IPL used to have only lower cut off filter with water being upper filter cutting off wavelength more than100nm. Now upper filters are also available making ‘narrow band IPL’ or ' sandwitch filter IPL’.
  3. Excimer laser now require no more Heliumgas. Comes through KTP like crystals
  • Now diode can emit any wavelength.810nm, 1064nm and 755 are coming from diode source only. So no need ofAlexandrite crystals to generate 755nm wavelength. Even mixture of thesewavelengths is possible due diode source.
  • Sandwich filter IPL are competing withDye VL lasers for Vascular effect. Previously IPL used to have only lower cutoff filter with water being upper filter cutting off wavelength more than100nm. Now upper filters are also available making ‘narrow band IPL’ or ‘sandwitch filter IPL’.
  • Excimer laser now require no more Heliumgas. Comes through KTP like crystals
  • Hair removal is more long pulsed now. RRox Anderson proposed his ‘Extended Theory of selective photo-thermolysis’ in2001 which supported pulse width more than thermal relaxation time TRT. Now LHR devices focusing on 10-30ms pulse are moving to 300-400ms pulses. What works best for Indian skin is 100-200ms pulse width. 
  • Pigmentary lasers becoming still shorter pulse. Q switched lasers have evolved from nanoseconds to picoseconds. 
  • Dermalheating protocols are becoming gentler now. Earlier Collagen remodeling and rejuvenation aimed at raising temperature of dermal collagen to 85oC. Arrheneus Rate equation states that denaturation of collagen after quick heating to higher temperature or slow longer hating to not very high temperature is same. So newer devices, newer protocols have evolved with better safety profile 

  • Stacking:Adam’s apple! Initial laser protocols were developed for single stack or single pass only. Only recently multiple stacks or repeat passes are ventured. LHR– repeat pass techniques, Multi-burst pulses in IPL, diodes are few examples.In treatment of  Tattoo – R20 is repeat pass technique making it possible to remove tattoo in single go. Multiplexingin PDL is another example where pulse dye and Nd YAg lasers are stacked oneafter other.

Newer trends in vascular lasers

  • LP NdYAG emerging as vascular laser for darker skin
  • Dualfilter IPLs are competing with pulse dye laser (DyeVL 550-650)
  • Evenpulse dye lasers are being multiplexed with Nd Yag laser
  • Oral or topical Rapamycin is used post-laser to inhibit neo-angiogenesis. This drug is in phase IV trial right now and will be very important adjuvent in vascular laser
  •  Newer energies are launched. Only light or heat is not enough to cater to all clinical indications. Many new energies are launched like Plasma, Microwaves, Ultrasonic , Heat, Cold, LED etc
  1. Cryolipolysis:Popsicle panniculitis. Seen in Frost bite. Controlled induction of cold induced apoptosis of fat cells is achieved in cryolipolysis. This is a promising modality for nonsurgical lipolysis.
  2. HIFU: a relly  deep still selective and color blind collagen remodeling tool is available. It can selectively tighten very deep SMASH facia.
  3. LEDis coming in medicine in big way. Its because overall interest and investmentin research on LED in other field is very high. Medical LEds are a byproduct ofthis industrial revolution.  Woundhealing, hair growth , acne and rejuvenations are promising indications
  4. Cryolipolysis:Popsicle panniculitis. Seen in Frost bite. Controlled induction of cold inducedapoptosis of fat cells is achieved in cryolipolysis. This is a promisingmodality for nonsurgical lipolysis.
  5. HIFU:a relly deep still selective and color blind collagen remodeling tool is available. It can selectively tighten very deep SMASH facia.
  6. LED is coming in medicine in big way. It's because overall interest and investment in research on LED in other field is very high. Medical LEds are a byproduct of this industrial revolution.  Wound healing, hair growth, acne and rejuvenations are promising indications.

What if we have one machine that can emit multiple wavelengths.  Each wavelength is a new laser. Frequency Tunable Lasers are in pipeline. Single line tuning, Multi-line tuning, Narrowband tuning and Widely tunable lasers are possible. Free electron laser, Multiple prism gating lasers are in pipeline. We may find a day when we have all lasers in same machine!

  • Micro wave for Axillary hyperhidrosisis a real break through innovation. The wavelength is around 50,000 MHz. Selectively targets sweat glands. Single session (sometimes two) will reduce axillary sweating for life long. It is US FDA approved and is launched first time in India in Skin city.
  1. As safer laser sweat ablation has come at 1470 wavelength and with silhouette optical fiber. This can ablate sweat glands in single session or two. 
  2. Microwaveand radiofrequency are being tried for palmar hyperhidrosis.

Assafer laser sweat ablation has come at 1470 wavelength and with silhouette optical fiber. This can ablate sweat glands in single session or two. 

Microwave and radio frequency are being tried for palmar hyperhidrosis.

  • Diagnostic robotics and smart devices: Realtime visualization of tissue before you fire will change the rules of game. Lasermicroscopy, Confocal microscopy will achieve visualization of Live normal human skin.
  1.  Feedback assisted targeting or structures like seb glands, white hair etc. is in pipeline. Imagine a robotic laser giving selectively different fluence to this hair and thick hair and avoiding structures like vessels and nerves under direct visualization.

Fractional skin grafting: Fractional wound heals by embryonic way of regeneration. It's in response to narrow tubular injury. Is it really necessary to ablate this column? Probably not. What if we instead of fractional ablation make a fractional harvesting of columns in agel. If these microscopic skin grafts are placed over a raw burn wound it will act as a skin grafts. This will revolutionize the treatment of burns and non healing wounds.

Laser vaginal rejuvenation. Post partumlaxity of vaginal wall is traditionally handled by surgery. Now lasers will replace this surgery with painless OPD procedure. Co2, Rf and many other energies are modified for intra-vaginal delivery to achieve vaginal wall tightening.

Evolution of dermatology practice. Avery low profile skin VD practice now has become highly earning, high profile page 3 practice. At the same time entry level for a beginner dermatologist are facing raised bar in term of huge investment and competition. In western countries very dermatologists being very busy in high earning cosmetic practice are not available for routine mole screening which is paid low.