Avoiding PIH after laser treatment
Identifying past sites of PIH on the body useful for screening at-risk patients with skin of colour (1,765 words, 8 minutes, 50 seconds)
The idea that laser treatments can never be used on darker skin without causing post-inflammatory hyperpigmentation (PIH) is a myth, Dr. Vincent Richer said during his presentation at the 7th annual Skin Spectrum Summit on Nov. 6.
Dr. Richer is an assistant professor in the Department of Dermatology & Skin Science at the University of British Columbia and in practice at the Pacific Derm clinic in Vancouver.
He said that PIH and other forms of post-inflammatory pigment alteration are very difficult to treat and devastating for patients of colour. But that does not mean laser treatment should be abandoned.
“The initial concern when we are balancing [efficacy vs. risk of PIH] is over-treatment,” he said. “We do not want to expose our patients with skin of colour to unnecessarily high risks, especially pigmentary risks. But the other side of that equation is that under-treatment is just as problematic if treatment is not offered when it can be provided safely.”
Dr. Richer said physicians should look at patient characteristics.
“We can, in theory, cause PIH in all of our patients,” he said. “But the personal history of PIH is going to be a really good indication of the risk of it developing. This could be from acne, other procedures or from scars. Sometimes patients will volunteer that information quite readily, but sometimes we can just physically look for it.”
He suggested that the face, the chest, the upper back, the hands and the pretibial skin would all be valuable sites to check for signs of PIH. Dr. Richer also suggested physicians could look at hyperpigmentation of the palmar creases. The more pigmentation, the greater the risk of PIH after laser treatment.
Choosing the proper treatment and device is crucial, he said.
“We are going to try to avoid targeting our patient's endogenous melanin in the basal layer. We do not want to deliver too much thermal energy there,” Dr. Richer said.
“As we increase the wavelength, the affinity for melanin is going to have a monotonic decrease. But as we increase the wavelength within the visible range, we are also going to be increasing the depth of penetration of those photons and bypassing that basal layer.”
For non-laser treatments, Dr. Richer suggested that radiofrequency microneedling with insulated needles will bypass the basal layer.
Dr. Richer said he always asks himself if another technique might do a better job than a laser in any given indication.
“Will the tincture of time and sun protection help? Will prescription topicals do better? Do you have microneedling available, and could that be helpful? Are you proficient using chemical peels, injectables or subcision, or would a prescription drug potentially do the trick?”
Doctors also should consider lowering device settings and treatment coverage area to minimize PIH risk, said Dr. Richer.
“We might need a few more treatments to reach the outcome,” he said. “We can increase our settings progressively if things go well. And even though this is not a laser setting, we can think about what time of year it is and how easy it is to avoid direct sunlight.”
Bottom Line: Lasers can be used on dark skin, but there is a risk of post-inflammatory hyperpigmentation. Consider melanin when planning treatments and select devices and settings to minimize PIH. Think about the time of year for treatments and use strict sun protection before and after treatment. Post-treatment, topical steroids can be considered.
From the literature on energy devices in skin of colour
Treatment of abdominal striae distensae in Fitzpatrick skin types IV to V using a 1064-nm picosecond laser with a fractionated microlens array
This study aimed to evaluate the long-term efficacy and safety of a fractional 1064-nm picosecond laser for treating striae alba in individuals with dark skin types.
A total of 20 volunteers with Fitzpatrick skin types IV-V who presented with striae alba were enrolled and treated with the laser over four sessions at four-week intervals.
The investigators observed significant improvement in skin texture one month after the final treatment, and texture continuously improved until the last six-month follow-up visit.
The volunteers’ average melanin index significantly increased one month after the final treatment, and melanin variation decreased throughout the follow-up period. Most of the subjects (90%) had moderate or marked improvement in the appearance of their striae, and only two (10%) experienced transient post-treatment post-inflammatory hyperpigmentation.
Evaluation of the cumulative effect of radiofrequency microneedling and fractional erbium:glass,565 laser in moderate to severe acne scars in skin of colour
In this study, 20 patients with Fitzpatrick skin types III-V were enrolled. Each patient underwent four sessions of non-ablative fractional erbium:glass 1,565 nm laser, alternating with four sessions of fractional radiofrequency microneedling once a month over eight months.
Of those 20 patients, 18 completed the protocol, and two were withdrawn because they could not attend follow-up sessions.
All of the participants who completed the study period experienced statistically significant improvement in their acne scars, and no patient's scars became worse.
Efficacy of a laser with a pulse duration of 300 ps in skin rejuvenation and treatment of pigmentation disorders in Asians: A series of four cases
This report describes a 300 ps Nd:YAG laser for treating pigment disorders and skin rejuvenation in four Asian patients. The paper's authors write that picosecond lasers are widely used for pigment treatment due to reduced side effects compared to nanosecond lasers.
However, they note no studies on a laser with a pulse duration of 300 ps.
The four patients in this study did not experience side effects after being treated with
the 300 ps laser.
Effectiveness of an epidermal growth factor-containing cream on postinflammatory hyperpigmentation after 1064-nm Q-switched neodymium-doped yttrium aluminum garnet laser treatment of acquired bilateral nevus of Ota-like macules (Hori's nevus) in Asians: A split-face, double-blinded, randomized controlled study
The authors of this study investigated whether an epidermal growth factor (EGF)-containing cream could prevent post-inflammatory hyperpigmentation (PIH) after treatment with a 1,064 nm Q-switched Nd:YAG laser for Hori’s nevus.
A total of 30 subjects with bilateral Hori’s nevus were included and treated with the laser. Afterwards, they were randomized to apply the EGF cream to one side of their face and a placebo cream on the other side for eight weeks.
They found that the incidence and intensity of PIH were slightly higher on the EGF cream-treated sides. Post-laser erythema was not statistically different between the two sides. While the EGF cream did appear to alleviate trans-epidermal water loss better than the placebo, the difference was not statistically significant.
However, patient satisfaction scores were significantly higher with the EGF cream-treated sides than those treated with placebo.
VIDEO: Pico lasers for skin conditions, dermatologist reviews
At the intersection of skin and society
The Black Screen Office (BSO) has released a report titled “Being Seen: Directives for Creating Authentic and Inclusive Content.” This report discusses how Canada’s screen industries—such as television and film—represent people from Black, People of Colour, 2SLGBTQIA+, and People with Disabilities communities. The report also provides guidelines for industry leaders to engage with these groups.
BSO is an advocacy group to make Canada’s screen industry practices and policies equitable and free of anti-Black racism.
“BSO formed out of the knowledge that underrepresentation of the Black community is a significant issue in Canada’s screen industries,” said Joan Jenkinson, Executive Director of BSO, in a press release. “With Being Seen, we gain a clearer understanding of the scope and impact of this issue for various marginalized groups. We know many structural interventions are needed to dismantle entrenched practices; Being Seen is one of those interventions, offering practical, immediate steps that producers, creators, broadcasters, funders and others can take to create equitable opportunities, produce authentic content, and reach untapped audiences who don’t see themselves reflected in Canadian film, television and digital media.”
To develop the report, BSO conducted English and French consultations with more than 400 industry workers and members of the public, both adults and children, who identify as Black, people of colour, 2SLGBTQIA+ or people with disabilities. The participants provided opinions on the representation of their communities onscreen and behind the scenes at all levels of the production process. Those perspectives then informed the 52 directives in the Being Seen report.
“Studies like Being Seen are essential to help identify priorities and gaps in order to better support both Black creators and Black audiences,” said Cathy Wong, Vice President, Equity, Diversity & Inclusion and Official Languages at Telefilm Canada, in the release. “This significant work helps make greater steps towards fostering a more authentically told and respectfully representative screen-based industry in Canada.”
This is the first of six planned Being Seen reports that BSO will issue. It highlights common themes such as one-dimensional onscreen portrayals, the importance of authentic casting, the intersectionality of identities, regional challenges, and the impact of poor or missing representation on Canadian audiences.
“Participants in our conversations were extremely open and thoughtful about their experiences as members of underrepresented groups working in film, television and digital media and as consumers of Canadian entertainment,” said Kelly Lynne Ashton, Lead Researcher for the Being Seen project. “They were passionate about the need for change, and shared clear ideas for how industry creators can work with communities other than their own, depict culturally sensitive content, identify when a story is theirs to tell and when it is not, and create content that avoids stereotypes.”
Planned Being Seen reports address the unique experiences and expectations of specific underrepresented groups, and their expected release dates include:
Representation in Children’s Media (February)
Black Canadians (March 2022)
People of Colour (April)
2SLGBTQIA+ (May)
People with Disabilities (May)
The Being Seen reports can be downloaded at www.beingseen.ca
Vender on Psoriasis: Episode five
The Chronicle Podcast System’s program about psoriasis with Dr. Ronald Vender, based on Dr. Vender’s popular column in The Chronicle of Skin & Allergy, continues. In this fifth episode, Dr. Vender talks about breastfeeding with psoriasis, the potential link between childhood psoriasis and tobacco exposure, and treating plaque psoriasis with tapinarof cream.
Listen here:
This week
Feb. 18 is National Caregivers Day in the US
Feb. 20 is World Day of Social Justice
Something to think about in the week ahead…
Next week
Skin Spectrum Weekly will not appear Feb. 21, due to the Family Day holiday in Ontario. We’ll return Feb. 28, when we will cover cosmeceuticals in skin of colour, leading with a talk by Dr. Heather Woolery-Lloyd that she presented at the 7th annual Skin Spectrum Summit. Dr. Woolery-Lloyd’s discussion touches on alternatives to hydroquinone for the management of hyperpigmentation.