Vol. 15 •Issue 5
• Page 69
Skin Is In
Laser Therapy in Primary Care
By Julie Caldwell, NP, and Susan Martin, NP
Therapeutic laser services are becoming more common in family practice, internal medicine and other primary care settings. Advances in technology have made these treatment options more accessible, affordable and effective for a variety of medical and cosmetic conditions.
This article provides an introduction to the clinical applications of basic light sources and lasers. Hair removal, facial rejuvenation and the treatment of vein discoloration are services that can benefit patients as well as a practice's financial bottom line.
A key component of any aesthetics service is education, since patients must have realistic expectations about results and time frames.1 Understanding what is actually achievable — and the length of time it will take to get there — is crucial to satisfaction and continued business.
Skin and Lasers
Healthy, young skin is smooth, firm, evenly colored, free of blemishes, free of wrinkles and free of sun damage.2 Like most things, the dermis changes with age. Perhaps the most predominant change is decreased production of collagen and elastin.2 In addition, ultraviolet damage can cause crosslinked and disorganized collagen fibers, accumulation of abnormal elastin and increased metalloproteinase, which breaks down collagen.2 All of this leads to drier, looser skin.2
Laser therapy works on multiple layers of the skin. One goal of laser therapy is the creation of a creamy, even skin tone and color.2 To achieve this, the laser targets diffuse redness, brown sun or age spots and mottled complexions.
Another target of laser therapy is texture. Laser treatment can correct large pores, fine lines, acne scars and uneven textures, resulting in smooth, even skin with tighter pores. The newest laser applications target loose, lax skin to create a more "lifted" look.2
Laser Physics
There are two light sources for most laser therapies used in primary care settings: lasers and lamps. Lasers offer a single wavelength or color.2 Lasers are a controllable beam of light that can be delivered via fiber. The delivery spot size on the body may be adjusted according to the target area.2
Lamps, on the other hand, have a range of wavelengths. They deliver highly divergent light. The lamp is placed on or near the target tissue, and the treatment area is fixed based on the size of the lamp window.2
Selective Photothermolysis
Selective photothermolysis uses appropriate laser wavelengths to reach the desired target without adversely or inappropriately affecting the surrounding tissue. When sufficient light reaches the target, light is then absorbed by the target, and the light converts to heat.2 The temperature rises in the target enough to provide the desired effect but minimizes overheating of surrounding tissue (Figure 1).2
The main targets of selective photothermolysis are chromophores.2 Three primary chromophores are present in the skin: melanin, hemoglobin and water. Melanin mainly occurs in hair, epidermal pigment and pigmented lesions.2 Hemoglobin is found in the vasculature.2 Water is found throughout the skin and is used for bulk heating.2
The key parameters of light sources are wavelength, spot size, pulse duration and fluence.2 Wavelength affects the depth of penetration: The shorter the wavelength, the more scattering occurs; the longer the wavelength, the deeper the target and the less the scattering.2
Spot sizes are affected by the depth of the target — large spot sizes for deep targets like hair removal and deep reticular veins and small spot sizes for shallow targets like telangectasias and superficial brown spots.
Pulse duration measures the "on time" of the pulse of light. The ideal pulse duration should be long enough to heat the target without overheating the surrounding epidermis. Fluence is the energy of the entire laser pulse divided by the light beam that strikes the skin (Joules/cm2).2 Selective photothermolysis requires the right combination of parameters for safe and effective treatments.2
Hair Removal
Humans have the same number of hair follicles at the end of life as they do at the beginning.3 Hair grows within these follicles in varying stages.3 The primary and longest growth phase is anagen. The end of the active anagen stage is called catagen and involves an involution of the follicle. The resting phase is called telogen, and it typically lasts several months.
Scalp hairs can spend years in anagen, but eyebrows and other facial hairs spend much shorter periods in this active growth phase.3 Hair is most responsive to hair removal techniques during anagen.3
Melanin is the target chromophore in laser hair removal.2 Infrared light passes through epidermal pigment, targeting the hair follicle. The penetration depth heats the melanin in the follicle. The challenge of light-based hair removal is proper wavelength selection.3
Melanin is present in both the epidermis and the hair. Higher amounts of melanin increase the amount of heat produced. Epidermal safety is determined by the amount of melanin in the surrounding tissues and the laser parameter settings. Skin type is also important, since the amount of melanin in the skin can easily overheat in people with darker skin.2
Assessment of skin type and response to the sun is important before laser or light treatment. The Fitzpatrick scale is a good guide for determining the skin type and parameter settings for the machine itself. Laser hair removal tends to be most effective in lighter-skinned patients with darker hair.
After a laser hair removal procedure, application of cold compresses or a cooling device can provide comfort to the treated skin. Most patients require four to six treatments to achieve the desired level of hair removal.
Leg Veins
Laser treatment of unwanted leg veins requires wavelengths with good hemoglobin absorption.2 Spot sizes may vary. For example, smaller spot sizes should be used for small, shallow vessels, and large spot sizes are more appropriate for larger, deeper vessels.2 The shallow vessels also require a higher fluence, while the deep, reticular vessels require a lower fluence.
Figure 2 depicts the various sizes and colors of vessels for which patients seek treatment. Most veins require one or two treatments to achieve desired results. Postprocedural cooling is needed for 10 to 30 minutes. Patients should wear compression stockings for up to 6 weeks after the procedure. Weight bearing should be limited for 6 weeks as well.
Textural Skin Rejuvenation
Textural skin rejuvenation can be achieved with the laser genesis procedure created by Cutera. In primary care practice, we have used this procedure to reduce pore size, smooth fine wrinkles and even skin texture. Laser genesis also helps flatten "cobblestoning" of the skin.4
The chromophore targets in laser genesis are hemoglobin and water.2 Water absorption is used to heat the upper dermis, which results in stimulation of new collagen production.2 Hemoglobin absorption is then used to heat (not damage) the fine upper vascular plexus.
Laser genesis can also improve skin laxity.2 This light-based approach provides uniform bulk heating independent of dermal thickness or fat layers.2
Most laser genesis procedures require four to six treatments and avoidance of the sun for at least 2 weeks before and after each treatment.
IPL Skin Rejuvenation
Intense pulsed light (IPL) treatment is also known as photogenesis. The goal of IPL treatment is to treat superficial dyschromias or solar lentigines.4 The dyschromias occur as a result of cumulative sun exposure or photoaging.4 The chromophore targets for this type of lamp source are hemoglobin and melanin in the epidermis layer.
Flash lamps are the most commonly used type of technology for this type of treatment.
The number of procedures required varies depending on the type and size of the lesions. Most lesions require two to six treatments and avoidance of the sun at least 2 weeks before and after the procedures. Photogenesis procedures produce dramatic and effective fading of most sun and age spots.
Research about IPL applications is ongoing. One focus is the use of small-tipped IPL hand pieces in the treatment of superficial pigmented and vascular lesions on darker skin.5
In addition, a study of short-pulsed IPL resurfacing lasers produced promising results when the therapy was used in conjunction with other cosmetic measures to treat skin issues such as hemangiomas.6
Costs
The start-up costs for adding laser equipment to a primary care practice can range from $80,000 to $100,000.
The biggest expense is the laser, and several options are available. Leasing, financing and purchasing a used laser are among the choices to consider.
In addition to acquiring a laser, protective eye equipment is needed for patients and providers, along with posttreatment cooling devices and materials. It is essential to spend time, money and effort training employees and marketing the aesthetic offerings to the public.
One examination room should be set aside for laser treatments. When launching this practice offering, consider set hours for laser appointments so that you can continue using the room for other office visits at other times. As patient interest in laser therapies increases, change the scheduling of the room accordingly.
The fees charged for laser treatments can be wide ranging. Hair removal services can range from $50 to $3,000, depending on the body part treated. Vein treatment charges usually range from $50 to $150 per treatment for superficial veins.
Laser genesis charges usually ranges from $150 to $300 per treatment. Photogenesis usually starts around $50 to $100 per lesion. These prices vary according to geographic area, competition and treatment setting.
Putting It Into Practice
Laser therapies can be an interesting and exciting addition to primary care services.
These treatment options are safe, affordable and effective. Nurse practitioners who provide laser services must obtain appropriate training and expertise and educate patients about safety and outcome expectations prior to treatment.
Laser therapy can become a rewarding part of any primary care practice.
References
1. Taub A, et al. Multicenter clinical perspectives on a broadband infrared light device for skin tightening. J Drugs Dermatol. 2006;5(8):771-778.
2. Shine R. Laser Physics 101. Slide presentation by Cutera Inc., 2006.
3. Shenenberger D. Removal of unwanted hair. UpToDate. Available with subscription at: http:/www.uptodate.com. Accessed Feb. 27, 2007.
4. Groot D, et al. 3-Dimensional (3D) skin rejuvenation. Cutera White Paper, 2006.
5. Lee M, et al. Use of a novel small-tip IPL handpiece for treatment of discrete pigmented and vascular lesions. Cutera White Paper, 2006.
6. Lipper G, et al. Nonablative acne scar reduction after a series of treatments with short-pulsed 1064-nm neodymium:YAG Laser. Dermatol Surg. 2006;32(8):998-1006.
Julie Caldwell is a family nurse practitioner at The Frist Clinic in Nashville. Prior to joining The Frist Clinic in mid-February, she provided laser treatments in a primary care setting in Nashville. Susan Martin is a family nurse practitioner at Jennings Family Medical Clinic in Parsons, Tenn. She obtained laser experience while practicing at Centennial Medical Center in Nashville.
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