Escolar Documentos
Profissional Documentos
Cultura Documentos
BACKGROUND Picosecond pulse duration lasers (PS) have altered the field of dermatology. PS were initially
used in tattoo removal, to optimize efficacy and reduce side effects with nanosecond domain lasers. More
recently, they have been demonstrated to be effective in the treatment of pigmentary disorders, acne scarring,
and photoaging.
OBJECTIVE In this article, we critically analyze the published data on the many uses of picosecond lasers in
dermatology.
MATERIALS AND METHODS A systematic review of PubMed was conducted using the following search
terms: “picosecond,” “picosecond laser,” “picosecond laser dermatology,” “picosecond laser pigment/pig-
mentation,” and “picosecond laser tattoo removal.” Articles ranged from 1988 until 2017.
RESULTS Forty-one articles were identified, and 27 met inclusion criteria for review. Indications for the PS
included a variety of dermatologic applications include tattoo removal, benign pigmented lesions/pigmentary
disorders, acne scarring, and photoaging. Most studies demonstrated safe and effective treatment.
CONCLUSION The development of the picosecond pulse duration is a breakthrough innovation in laser
technology, changing the scope of laser treatment. Encouraging findings in tattoo pigment clearance spurred
the use of PS in a wider array of dermatologic issues. The increasingly positive results and low incidence of
adverse effects further substantiates PS efficacy for a variety of dermatologic uses.
asers and light-based technologies first appeared have been the workhorse lasers in the field of tattoo
L in the early 1960s with studies performed by
Goldman and colleagues.1 Early lasers used for tattoo
removal and treating pigmented lesions. They utilize
the concept of selective photothermolysis to target
removal and treating pigmented lesions were the argon tattoo pigments while also having a
and CO2 lasers.2 These lasers were not selective and photoacoustic/photomechanical effect to aid in
produced considerable side effects.3 A paradigm shift breaking up the targeted pigment particles. Relative to
in laser therapy occurred in the 1980s with the other chromophores, tattoo pigments have a very
description of selective photothermolysis by Drs. short TRT of 10 nanoseconds.4–6 Therefore, delivering
Anderson and Parrish. The theory of selective the energy within even shorter pulse durations,
photothermolysis allows for targeting specific measured in picoseconds, may enhance the efficacy of
chromophores by selecting an appropriate lasers in tattoo removal.
wavelength. As a result, there is target destruction, and
collateral damage is minimized by choosing a pulse In the late 1990s, picosecond lasers finally became
duration that is less than or equal to the target’s clinically available, helping to test this key concept. Ho
thermal relaxation time (TRT).7,8 Until recently, and colleagues evaluated the efficacy of picosecond
quality-switched (Q-switched) nanosecond lasers lasers initially through computer simulations, using a
*Department of Dermatology, Icahn School of Medicine Mount Sinai, New York, New York; †Maryland Dermatology
Laser, Skin, and Vein Institute, Hunt Valley, Maryland; ‡SkinCare Physicians, Chestnut Hill, Massachusetts; xDepartment
of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2019;45:183–194 DOI: 10.1097/DSS.0000000000001697
183
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
EVOLUTION OF THE PICOSECOND LASER
1,064-nm wavelength and graphite as the standard many small, single-center studies. The following lit-
pigment particle.10 These simulations revealed that it is erature review and critical analysis reviews the current
primarily a photomechanical effect, rather than pho- data available for picosecond lasers to further eluci-
tothermal, that leads to the successful elimination of date its role in dermatology.
pigment tattoo particles. The rapid rise in temperature
leads to a pressure wave that exceeds the tensile
Methods
strength of the pigment particles, causing it to shatter
into smaller fragments. Ho and colleagues found an A review of all the published literature on picosecond
optimal pulse duration range of 10–100 picoseconds, laser use in dermatology through PubMed was per-
which allows for effective pigment destruction and formed up until March 2017. The following terms were
clearance with little collateral heating or damage.10 searched: “picosecond” combined with “laser,” “der-
matology,” “pigment/pigmentation,” and “laser tattoo
The development of the picosecond laser has advanced removal.” Inclusion criteria were (1) article is a case
the field of tattoo removal. A majority of studies study, review of literature, case report, or commentary
comparing picosecond and nanosecond lasers have and (2) the use of picosecond lasers was discussed in the
shown greater effectiveness in tattoo pigment clear- article. Exclusion criteria were nonhuman (2 articles),
ance with no increase in adverse effects from picosec- non-English language, and articles that did not discuss
ond lasers.12,13 However, the small observed picosecond laser removal (Figure 1).
difference between the 2 lasers in tattoo removal needs
further evaluation to substantiate these initial findings.
Results
Since 2012, picosecond lasers have been FDA
approved for laser tattoo removal and treatment of The PubMed search for “picosecond” yielded 5,078
benign pigmented lesions.2,5 However, the applica- articles. A more focused set of articles was found when
tions of picosecond lasers continue to expand beyond using the following more specific search terms:
exogenous and endogenous pigment removal to acne “picosecond laser” (1982), “picosecond laser skin”
scarring, photoaging, rhytides, and more. Promising (49), “picosecond laser pigment” (17), “picosecond
results have been shown in a wide array of data, albeit laser dermatology” (38), “picosecond laser tattoo”
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
TABLE 1. Clinical Studies of Picosecond Laser for Tattoo Removal, Pigmented Lesions, and Novel Dermatologic Uses
10 mm.
TORBECK ET AL
185
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
186
DERMATOLOGIC SURGERY
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
TABLE 1. (Continued )
A–A, Alexiades–Armenakas Scale; AFR, ablative fractional resurfacing (CO2 laser); APS, Asian pigmentation scale; DLA, diffractive lens array; GPS, global photoaging scale; N, No; N/A, not
applicable; NS, nanosecond laser; PS, picosecond laser; Pt, Patient; Y, Yes.
45:2:FEBRUARY 2019
TORBECK ET AL
187
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
EVOLUTION OF THE PICOSECOND LASER
(25), and “picosecond laser pigmentation” (17). A recent randomized, single-blinded, split-tattoo
Twenty-seven articles met the inclusion criteria and comparative study between 1,064-nm nanosecond
were reviewed (Table 1). The laser treatment param- (MedLite C6; Hoya-ConBio, Inc., Fremont, CA) and
eters and goals can be divided into the following cat- picosecond lasers (PicoWay; Syneron Candela, Corp.,
egories: tattoo removal, pigmentation, and novel Wyland, MA) was performed by Pinto and colleagues,
applications (Table 1).11–29 involving 21 patients with 30 black tattoos of various
ages. After 2 treatments, spaced 6 weeks apart, there
Tattoo Removal was a 36% and 37% improvement seen with the
picosecond and nanosecond laser, respectively. This
Ross and colleagues performed the first comparative
difference did not reach statistical significance. How-
intratattoo study in human subjects. Each tattoo
ever, there was a significant decrease in pain in the
segment was treated using either an Nd:YAG
picosecond-treated sites.20
Q-switched laser (Model YG501; Quantel Technol-
ogies, Santa Clara, CA) at settings of 0.65 J/cm2, spot Success in treatment of green, blue, and black tattoos
size 1.4 mm, and a 35-picosecond pulsed duration; or spurred evaluation of a 532-nm picosecond laser to
an Nd:YAG Q-switched laser (Model NY82–10; remove more difficult pigments, including red and
Continuum, Santa Clara, CA) at the following set- yellow. In a small study, 6 patients with red and yellow
tings: fluence of 0.65 J/cm2, spot size 1.4 mm, and a tattoos were treated with the frequency-doubled 532-
10-nanosecond pulsed duration. In 12 of 16 tattoos, nm Nd:YAG picosecond laser. The settings used were
the picosecond laser treatment site, in comparison fluences between 1.1 and 1.4 J/cm2, spot size of 2.5 to
with the nanosecond laser, showed significant light- 3.3 mm, and pulse duration of 450 to 500 picoseconds
ening on blinded evaluation after 4 treatments.15 at every 6 to 8 weeks (4 treatment sessions). The results
There are several noncomparative studies demon- showed that patients reached 75% clearance in 2 to 4
strating the efficacy of picosecond lasers in the treatments.17 In a larger study, 21 patients with mul-
treatment of darker tattoo pigments. Bauer and col- ticolored tattoos were treated with an Nd:YAG pico-
leagues reported a case series of 10 patients with 12 second domain laser (PicoWay; Syneron Candela,
blue and/or green tattoos that were treated with a Corp). Thirty-one tattoos were treated. Black, blue,
755-nm alexandrite picosecond laser (PicoSure; green, and purple ink were treated with the 1,064-nm
Cynosure, Inc., Westford, MA). Eleven of the 12 laser, whereas red and yellow pigments were treated
patients had greater than 75% clearance with either 1 with the 532-nm laser. Blinded-scaled evaluation
showed an average 79% clearance score after 6.5
or 2 treatments at one-month follow-up.14 Saedi and
treatments. Tattoo pigment clearance varied by color,
colleagues evaluated the efficacy and safety of a
with black and purple showing the most
picosecond 755-nm alexandrite laser (PicoSure;
improvement.18
Cynosure, Inc) to treat blue and/or black tattoos.
Twelve patients were treated at the following set-
There is a paucity of data about the use of 532-nm
tings: fluences of 2.1 to 4.1 J/cm2, spot size between
picosecond lasers for tattoo removal in skin of color due
2.5 and 3.5 mm, and a pulse duration of 500 to 900
to higher risk of melanin absorption at that wavelength.
picoseconds. There was greater than 75% clearance Friedman evaluated the use of an Nd:YAG picosecond
in the tattoos with an average of 4.25 treatments. All laser (PicoWay; Syneron Candela, Corp) in a black and
side effects from the treatment were mild and tran- red tattoo on a single patient with skin type VI. The
sient in nature.15 A similar study, involving 6 Korean black tattoo was treated in the 1,064-nm domain with
patients (skin type IV), used the same device to treat the following parameters: fluence mean of 0.5 to 0.6
black and red tattoos. After 1 to 5 treatments, all J/cm2; repetition 3 Hz; and spot size of 10 mm. The red
patients had greater than 75% improvement. How- tattoo areas were treated with the 532 nm with a fluence
ever, 50% of patients had post-treatment mean of 0.25 to 0.3 J/cm2, repetition 1 Hz, and spot size
hypopigmentation.16 of 9 to 10 mm. After 3 treatments, at 3-week intervals,
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
TORBECK ET AL
improvements of 75% and 90% clearance were noted A similar study by Oshiro and Sasaki evaluated pico-
for the black and red tattoo pigments, respectively. Side second lasers for the treatment of nevi of Ota (n = 6)
effects were minimal and transient, including mild and Mongolian spots (n = 4). Seven patients were
erythema and edema.19 treated with a 755-nm alexandrite picosecond laser
(PicoSure; Cynosure, Inc), whereas 3 patients were
Finally, a retrospective review on adjuvant ablative treated with a1064-nm Nd:YAG picosecond laser
fractional resurfacing use to decrease the occurrence of (Enlighten; Cutera, Brisbane CA and PicoWay; Syn-
bullae after picosecond laser tattoo removal was per- eron Candela, Corp). After 3 treatment sessions at
formed. Patients were treated with either the picosec- varying intervals in all patients, the 1,064-nm laser
ond alexandrite laser alone with fluence of 2.67 to achieved a 50% to 94% improvement in 3 lesions and
3.37 J/cm2 and spot size 2.94 to 3.31 (n = 81) or the the 755-nm laser achieved mostly 50% to 94%
combination of picosecond laser with fractionated improvement at 3-month follow-up. Transient
CO2 laser (n = 21) setting of fractional CO2 were 10 to hyperpigmentation occurred in the 755-nm group,
60 mJ, with a coverage of 15% to 40%. Bullae and transient erythema/edema without pigment
occurred in 26/81 patients (32%) treated with pico- alteration in the 1,064-nm laser group.24
second alone, whereas no bullae developed in any
member of the combination group.21 The use of picosecond lasers in the skin of color for
treatment of pigmentation disorders was undertaken
by 2 retrospective reviews. Guss and colleagues ana-
Management of Epidermal and Dermal Pigment
lyzed 6 patients with 255 solar lentigines who
After tattoo removal, treating endogenous pigmenta- underwent a single treatment with the 532-nm
tion is the second most studied application of pico- Nd:YAG picosecond laser (PicoWay; Syneron Can-
second lasers in dermatology. Six studies have been dela, Corp). Treatment parameters were as follows:
published thus far, the first of which evaluated the use mean fluence of 0.65 J/cm2, pulse duration of 375
of a 755-nm picosecond for the clearance of a nevus of picoseconds, spot size to 4.50 mm, and a repetition
Ota in a small case series (n = 3) in 2015. Treatment rate of 1.67 Hz. At follow-up, 201/255 (78.82%)
parameters included fluences of 2.08 to 2.83 J/cm2, showed greater than 75% improvement. Only 2
spot size of 3 to 4 mm, and pulse duration of 450 to lesions had subsequent lasting hyperpigmentation.26
500 picoseconds. All patients achieved significant In the second review, Levin and colleagues compared
lightening and were satisfied with the results in 2 to 3 the safety and efficacy of the Q-switched ruby and
treatments. No repigmentation was noted on follow- Nd:YAG lasers (n = 25) with that of the 755-nm
up (2–7 months).22 alexandrite picosecond lasers (n = 17) for pigmentary
disorders in skin of color, namely nevus of Ota and
Only 2 studies have investigated the use of picosecond solar lentigines. Eight patients with facial pigmentary
lasers in the treatment of photoaging and pigmented lesions treated with the picosecond laser achieved a
lesions in an Asian population. Chan and colleagues score of 2.44 (50% clearance) on a visual analog scale.
retrospectively analyzed 13 patients treated with a Fifty percent of patients (n = 10) were satisfied to
755-nm picosecond laser (PicoSure; Cynosure, Inc). completely satisfy with the picosecond laser treatment
The following lesions were treated: nevus spilus (n = results. All adverse effects with the picosecond laser
1), nevus of Ota (n = 4), the Horii macules, café-au-lait were transient.39
patches (n = 5), lentigines (n = 1), and the Becker nevus
(n = 1). Six of 13 patients had at least 50% improve- Several additional studies investigated the use of
ment in pigmentation in 1 to 8 treatments. Adverse picosecond lasers in less common pigmentary
effects included transient erythema, post-treatment disorders. A small case series (n = 3) compared the 755-
crust formation, pain, and swelling, with no hyper- nm alexandrite picosecond laser (fluence range of 2.8–
pigmentation or recurrence appreciated at 6-month 3.0 J/cm2 and spot size of 3 mm) and the Q-switched
follow-up.23 Nd:YAG nanosecond laser in the treatment
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
EVOLUTION OF THE PICOSECOND LASER
of minocycline-induced pigmentation. Two patients patient had near-complete clearance of the infraorbital
achieved complete clearance with a single picosecond discoloration with no dyspigmentation or scarring.30
laser treatment, and the third required only 2 treat-
ments.27 Similarly, a case of minocycline-induced
Novel Applications of Picosecond Lasers
postsclerotherapy pigmentation was treated with the
755-nm alexandrite picosecond laser (PicoSure; The more recently investigated and sought after
Cynosure, Inc). Two treatments, with a fluence of 0.71 applications of the picosecond lasers include the
J/cm2 and spot size of 6 mm, resulted in complete treatment of photoaging and scarring. Studies
pigment clearance.28 In addition, 2 patients with par- involving photoaging have shown benefit beyond
adoxically darkening of red tattoos after previous laser dyspigmentation, both on and off the face. The first
tattoo removal were treated with a 532-nm and 1,064- study was a prospective open-label trial of 20 subjects
nm Nd:YAG picosecond laser (Cynosure, Inc). Both evaluating a picosecond laser in the treatment of
black paradoxical darkening and red tattoo pigment photoaging in the décolletage. All patients were trea-
were significantly improved at 1-month follow-up.25 ted with a 755-nm alexandrite picosecond laser with
The picosecond laser also demonstrated success in the DLA (PicoSure; Cynosure, Inc) using the following
management of recalcitrant argyria. The patient had parameters: fluence of 0.71 J/cm2, spot size of 6 mm,
significant improvement immediately after treatment and frequency of 10 Hz for 3,500 pulses. At 1 month,
and near 100% return to baseline at 1 week.29 Finally, there was significant improvement in most photoaging
the use of picosecond lasers for the novel application of categories (dyspigmentation, rhytides, texture, and
treating under eye hyperpigmentation in a patient with keratosis) except erythema. At 3 months, all categories
skin type IV was recently published. The patient were still significantly improved from baseline except
underwent 2 to 4 passes in one treatment session with rhytides after 4 treatment sessions.31 Ge and col-
the 755-nm alexandrite picosecond laser (PicoSure; leagues evaluated the use of the 755-nm alexandrite
Cynosure, Inc) with diffractive lens array (DLA) picosecond laser with DLA for improvement of facial
(Figure 2). This handpiece delivers highly concen- photoaging, as well as acne scarring, using a split-face
trated energy beams within the treatment window, at protocol in 10 patients. The blinded evaluation at 2-
regular spaced density. A majority of the treated area month follow-up showed an improvement in the
are exposed to low fluence energy where up to 10% of Global Photoaging Scale (2.67–1.44) and an
the treated area receives higher fluence levels.34 This is improvement in pigmentation (2.78–1.89 on the Asian
similar to density of microthermal zones of fractional Pigmentation Scale). Physicians also noted improve-
nonablative resurfacing. At 3-month follow-up, the ment in skin tightening. Only transient erythema,
Figure 2. Reprinted with permission from Elsevier from Haimovic A, Brauer JA, Cindy Bae YS, and Geronemus RG. Safety
of a picosecond laser with diffractive lens array (DLA) in the treatment of Fitzpatrick skin types IV to VI: A retrospective
review. J Am Acad Dermatol 2016;74:931–6. Copyright American Academy of Dermatology, Inc. All permission requests for
this image should be made to the copyright holder.
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
TORBECK ET AL
edema, and moderate treatment-associated pain were Several studies investigated the use of picosecond
noted as side effects.35 lasers with DLA for the treatment of scars. Brauer and
colleagues studied 20 patients with facial acne scar-
One of the original topics investigated beyond pigment ring, including rolling (94%), boxcar (24%), and ice
removal was the treatment of acne scarring with a pick (18%). Patients were treated with the 755-nm
picosecond laser using DLA. Analogous to fraction- alexandrite picosecond laser at the following treat-
ation in other laser devices, the DLA is used on the ment parameters: fluence of 0.71 J/cm2, spot size of
picosecond laser to provide a focal increase in fluence 6 mm, pulse duration of 750 picoseconds, and repe-
while maintaining overall reduction in treatment tition rate of 5 Hz (Cynosure, Inc). Mean masked
energy density.29,32,34–36 Notably, Khetarpal and col- assessment scores of 1.5 and 1.4 of 3 were achieved at
leagues prospectively demonstrated the safety of a 1 and 3 months, respectively (with 0 representing 0%–
shortened treatment interval (every 2–3 weeks) using 25% improvement and 3 representing >75%
the 755-nm picosecond alexandrite laser with DLA for improvement). Three-dimensional volumetric analy-
the treatment of photoaging in 20 patients. Patient sis revealed a mean scar volume improvement of
satisfaction was 81% at the 3-month follow-up and 24.3% by the sixth treatment. Histologic evaluation
93% of physicians were extremely satisfied and satis- showed increased elastic fibers and collagen in treated
fied. Similar minimal side effects were seen.36 areas.32 Tanghetti studied the specific mechanism of
collagen and elastic tissue stimulation and melanin
Weiss and colleagues investigated the utility of the clearance after picosecond laser treatment with DLA.
755-nm picosecond laser with DLA for the treatment Vacuoles, termed laser-induced optical breakdown
of facial wrinkles, specifically. Forty female subjects (LIOB), were identified through the histologic and
were treated with a fluence of 0.71 J/cm2, spot size of confocal imaging and are believed to stimulate repair
6 mm with DLA, pulse duration of 750 picoseconds, mechanisms. Melanin absorption of picosecond laser
and repetition rate 10 Hz (Cynosure, Inc). Fitzpatrick beams leads to the formation of plasma that results in
wrinkle score showed on average an improvement of photothermal and mechanical effects. Greater melanin
1.97 points from baseline. At 6-month follow-up, the concentration and/or higher fluence show a theoretical
treatment physician was extremely satisfied 97.4% of proportional relationship because of earlier LIOB
the time, whereas the 42.1% of patients were formation during treatment.33
extremely satisfied. Histology of the treated areas
showed increased collagen and elastin. There were no Haimovic and colleagues specifically analyzed the
permanent side effects noted. The investigators pro- safety of the 755-nm picosecond laser with DLA in the
posed that the photomechanical and photothermal treatment of acne scars (hypertrophic and atrophic),
effects on collagen turnover are critical for the treat- striae, and pigmented lesions in 56 patients of skin
ment of photoaging.37 types IV to VI. Clinical satisfaction was not evaluated.
Ten patients were lost to follow-up, and transient
Saluja further evaluated the efficacy and safety of “off adverse effects included erythema (n = 7), hyperpig-
the face” applications of the picosecond laser with mentation (n = 6), edema (n = 3), and scabbing (n = 1).
DLA, specifically skin texture and tightening. Twenty With respect to hyperpigmentation, it was more likely
female subjects were prospectively treated with the to be seen in lower-extremity laser treatments.34
755-nm alexandrite picosecond laser to the hands (n =
10) and décolletage (N = 10) with identical parameters
Discussion
(Cynosure, Inc). For the décolletage, a reduction to
1.05 on the A–A scale was achieved, from a baseline of The early success of picosecond lasers in exogenous
3.10. This was maintained at 3 months with a score of pigment removal has spurred evaluation of its use in
1.4 on the A–A scale. Investigators noted a 70% the treatment of unwanted endogenous pigmentation.
improvement of the hands at 3 months. No adverse Published studies in pigmented lesions range from
effects were noted during the study.38 nevus of Ito, congenital nevus, nevus spilus, nevus of
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
EVOLUTION OF THE PICOSECOND LASER
Ota, the Horii macules, café-au-lait patches, lenti- photorejuvenation, scarring, and dermal pigment to
gines, and the Becker nevus.21–23,25,26 In addition, recoup the lasers’ high associated costs. Picosecond
picosecond has been used for other types of pigmented lasers can be a promising treatment modality for
conditions including argyria, paradoxical darkening management of difficult to treat pigment conditions;
after laser tattoo removal, and minocycline-induced however, most studies conducted at this time are small
hyperpigmentation.24,26–29 and lack an adequate comparator.
An emerging indication for the picosecond laser includes Picosecond laser published data do show improved
that of photorejuvenation, encompassing improvement patient- and physician-rated results in comparison
in dyspigmentation, rhytides, skin texture, and skin with nanosecond lasers. However, in the head to head
tightening.30,34–37 Multiple studies have now demon- studies by Pinto and colleagues, there was no signifi-
strated statistically significant improvement in the vari- cant difference between the two. Based on the com-
ous facets of photoaging of the face, décolletage, and mentary by Ross, it seems that, at the present time,
hands.30,34–37 As a result, in 2014, the FDA gave clear- picosecond lasers for tattoo removal perform better
ance for picosecond laser with DLA in the treatment of in a few select scenarios. He states that these cases are
wrinkles and acne scarring in most skin types (I–IV).11 750-picosecond alexandrite versus 50-nanosecond
alexandrite lasers (even at higher nanosecond flu-
Laser use in dermatology, particularly in the treatment ences), yellow pigment tattoos treated with low-
of pigment or pigmentary disorders, has been associ- energy green-light picosecond laser, and successively
ated with possible consequences of hypopigmentation treated tattoos clearing faster with picosecond lasers.41
or hyperpigmentation, scarring, erythema, and With respect to all non–tattoo-related removal, there
edema. The preponderance of data reviewed in the has yet to be a large enough pool of data to make
literature has shown that picosecond lasers are safe to critical assessment on picosecond versus nanosecond
treat a wide array of conditions. However, appropri- lasers. A global view of the picosecond laser literature
ate treatment settings (e.g., fluence, spot size, pulse demonstrates a trend toward superiority in compari-
duration, and wavelength) needed to be used to pre- son with nanosecond lasers for tattoo removal, dermal
vent possible adverse effects. pigment management, and other treatments, but the
difference is not definitive. The paucity of well-
A retrospective chart review of 42 patients showed designed randomized clinical trials limits definitive
that picosecond lasers only had transient side effects statements on picosecond laser superiority over
such as erythema, edema, and transient pigmentary nanosecond pulse duration lasers.
alteration, in contrast to the nanosecond lasers, which
did have a few instances of permanent dyspigmenta-
Conclusion
tion.39 The safety of the picosecond lasers notably
extends to patients of skin types IV–VI as well, which Picosecond laser use for tattoo pigment removal has
several studies investigated. A retrospective review exhibited notable success, and the use for other entities
involving 56 patients of skin types IV–VI, treating a is expanding. Applications have now extended beyond
variety of conditions, observed only transient adverse tattoo removal to acne scarring, benign pigmented
effects including erythema, edema, scabbing, and lesions, other dyspigmentation, and photo-
hyperpigmentation.34 However, more studies are aging.16,19,23,25,34,35,40 In the small studies available,
needed to establish a robust safety profile with pico- patient satisfaction and clinical results have been
second laser’s novel use. encouraging for these challenging conditions. These
results have been associated with fewer side effects,
Picosecond laser use for tattoo removal has been suc- even in darker skin types, and the need for fewer
cessful, as shown in the literature; however, this is a treatments.9,10 More robust clinical studies are needed
niche market. To expand on this market, clinicians to appropriately evaluate picosecond pulse duration
and laser companies have explored other uses in laser role in dermatology.
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
TORBECK ET AL
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
EVOLUTION OF THE PICOSECOND LASER
the treatment of photodamage and textural improvement in “off the face” 41. Ross EV. The picosecond revolution and laser tattoo treatments:
applications. J Drugs Dermatol 2016;15:1398–401. are shorter pulses really better? Br J Dermatol 2017;176:299–
300.
39. Levin MK, Ng E, Bae YS, Brauer JA, et al. Treatment of pigmentary
disorders in patients with skin of color with a novel 755 nm picosecond,
Q-switched ruby, and Q-switched Nd:YAG nanosecond lasers:
Address correspondence and reprint requests to: Richard L.
a retrospective photographic review. Lasers Surg Med 2016;48:181–7.
Torbeck, MD, Department of Dermatology, Icahn School of
40. Forbat E, Al-Niaimi F. The use of picosecond lasers beyond tattoos. J Medicine at Mountt Sinai, 234 E. 85th St, 5th Floor, New
Cosmet Laser Ther 2016;18:345–7. York, NY 10028, or e-mail: Richard.Torbeck@mountsinai.org
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.