JUL-AUG 2017

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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PREPPING THE CANVAS 48 JULY/AUGUST 2017 | Med Esthetics © GETTY IMAGES Preventing PIH PIH is one of the most common complications with abla - tive skin resurfacing. To help reduce the risk of PIH, patients should avoid unprotected sun exposure for up to two months before an ablative procedure. Laser clinics routinely schedule promotions for laser resurfacing in the fall and win ter, noting fewer problems with hyperpigmentation when skin is less likely to be exposed to major doses of UV radia- tion both before and after the procedure. PIH is especially risky in darker skin types. Many doc- tors are reluctant to use ablative lasers on skin types 4 and above. "Patients come in and they look like a type 3, but they are really a type 4 or 5," says Dr. Heinrich, "and they end up looking worse after the treatment than before. Al - ways do photography before the procedure because it is easy to forget what the skin looked like originally. "If dark spots appear after laser treatments, we stop treat- ment and do a series of light chemical peels," he continues. "We especially like ones that include hydroquinone as well as Retin A. We also use the PicoSure FOCUS (Cynosure) to treat hyperpigmentation. It breaks up the pigmentation and clears the skin." Dr. Morgan recommends topical lightening products prior to treatment for patients with darker skin types. "In my experience, a six-week, pretreatment course that includes twice-daily application of a hydroquinone, tretinoin and glycolic acid preparation greatly reduces hyperpigmentation of dark skin after a procedure," she says. "For short-term application, I use 4% hydroquinone." Dr. Alster does not generally prescribe specifi c pre-treat- ment skincare regimens to reduce the risk of PIH before ablative laser treatments, "although many of my patients are already using topical antioxidants and sunscreen on a daily basis," she says. "The reason I don't prescribe anything in particular (except sunscreen) is because of a research study I published (West TB, Alster TS. "Effect of pretreatment on the incidence of hyperpigmentation following cutaneous CO 2 laser resurfacing," Dermatologic Surgery, January 1999)." For the study, Dr. Alster and Dr. West randomized 100 CO 2 laser resurfacing patients to undergo pretreatment with 10% glycolic acid cream twice daily (n=25), HQ 4% cream and tretinoin 0.025% cream twice daily (n=25) or no pretreatment (n=50). "We found that patients who used preoperative bleaching or retinoic acid preparations did not have a lower risk of developing post-laser ablation hyperpig- mentation than those patients who did not use any topical pre-treatment," says Dr. Alster. In the study, Dr. Alster and Dr. West posit that topical pretreatment may be ineffective in preventing PIH because "reepithelialization after cutaneous laser resurfacing includes follicular melanocytes that have not been affected by topical pretreatment. Therefore the most effective strategy for preventing PIH is careful patient selection, after care and follow-up." "The most important factors in minimizing the risk of PIH after laser or other treatments are ensuring that skin has not received recent sun exposure; application of SPF (phys- ical sunscreens recommended) and strict avoidance of sun exposure after treatment until all post-treatment erythema has resolved; application of skin lightening products (e.g. antioxidants, retinoic acid, non-hydroquinone faders such as kojic acid or arbutin) at the earliest sign of PIH; and use of a topical anti-infl ammatory (hydrocortisone) to diminish skin erythema that extends beyond the fi rst post-treatment week," says Dr. Alster. With a small, but growing body of literature on the use of pretreatment skin care in laser skin resurfacing, physicians do have some guidance available on how to deliver the best outcomes. But more—and larger—studies are needed to support or disprove the numerous topical ingredients prom- ising to stimulate collagen, inhibit melanogenesis and support faster wound healing. Linda W. Lewis is the contributing editor of MedEsthetics. Studies consistently support the use of tretinoin pre-ablative laser treatment to speed healing.

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