SOMA Skin & Laser has launched it’s Laser Tattoo Removal Service, ZapYourTattoo.com. Using state-of-the art tattoo removing Q-switched lasers, SOMA Skin & Laser offers tattoo removal of all types of tattoos, from amateur to professional. The ZapYourTattoo.com brand is a way to offer laser tattoo removal to a greater number of people in a more accessible fashion. All services are performed by a SOMA Skin & Laser dermatologist. Contact SOMA SKin & Laser for a free consultation.

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About Laser Hair Reduction and Laser Hair Removal

GentleLASE Hair Reduction

For both men and women, the removal of unwanted hair can be time-consuming, sometimes challenging, and uncomfortable.  In Laser Hair Reduction (LHR), a laser is used to target the hair-producing follicles, decreasing or eliminating hair in that area.  A laser is an intense beam of light. While passing through the skin, it heats the follicle, damaging it so that it can no longer produce hair. The unwanted hair can be anywhere, but common treatment areas are: legs, bikini, arms, back, upper lip, chin, and underarms. Laser Hair Reduction is also very useful for medical conditions such as chronic razor bumps.

Who can get Laser Hair Reduction?

Laser Hair Reduction works best in people with dark hair and light skin. This creates a clear “target” for the laser. However, people with dark skin and dark hair or lighter hair on light skin can still be treated with appropriate lasers and settings with proper consideration.

Is Laser Hair Reduction Permanent?

We use the term Laser hair Reduction and not Laser Hair Removal because permanent removal cannot be assured. Although the laser treatment slows hair growth and provides an extended period of reduced hair growth, it cannot be assured that hair growth will not recur in the future.

How many Laser Hair Reduction treatments are required?

Several treatment sessions of Laser Hair Reduction are required for a sustained result, typically 4 to 6 treatments spaced several weeks apart, but sometimes more.  Maintenance treatments may also be required.

Is Laser Hair Reduction Safe?

Laser Hair Reduction is a medical procedure and should be performed under medical supervision.  It is generally safe, but the following adverse effects may sometimes occur:

• The skin may get irritated, red, or crusted after Laser Hair Reduction.
• Pigment changes can occur, especially in those with darker skin types. Skin may be either darkened or lightened.  This effect is usually temporary.
• Less commonly, laser hair removal may result in burns, blisters, scarring or changes in skin texture.

How should I prepare for Laser Hair Reduction?

First choose a physician to perform your service, one with a specialty in dermatology or plastic surgery.  Laser Hair Reduction is a medical procedure and should not be entrusted to spas and salons.  Your physician will first schedule a consultation to review your medical history, skin history, and previous cosmetic and laser treatments.  Your physician will review with you the risks and benefits of the procedure, discuss the proposed treatment plan and associated costs, and take photographs for documentation.

After deciding on your course of care:

• Stay out of the sun for at least a week before your treatments.  A tan, either natural or from sunless tanners or tanning salons, increases your risk of side effects such as burning or pigment changes.
• Do not pluck, wax or perform electrolysis on the area to be treated.  These methods damage the follicle and can interfere with the effects of the laser.
• Shave the area a day or two before the treatment.  Long hairs interfere with the laser, can singe, and will produce odor when hit by the laser.

What happens during the Laser Hair Reduction treatment?

On the day of your treatment, you will be brought to a procedure room and made comfortable.  Sometimes an anesthetic cream will be applied to the area beforehand.  Your physician will discuss this with you if it is necessary.  Metal goggles will be placed over your eyes for protection.  During the laser treatment, your physician will press the laser tip against your skin. Depending on the laser, there is also a cooling system to protect the upper surface of your skin from the laser. This may be a cool gel, a cold tip, cold blown air, or a cold spray before each laser pulse. With each laser pulse you may feel some heat and a stinging or snapping sensation. Even with goggles on you may perceive flashes of light. Depending on the size of the area treated, treatment may take several minutes to several hours.

What to expect after Laser Hair Reduction

Immediately after the procedure, the treated area may be red and small swellings may occur around the hair follicles. The area may tingle for a day or two. The treated area may become crusty over the first day or two after treatment.  During this time just wash with gentle soap an water. Avoid picking at or manipulating the treated area. Do not tan during this period, and wear sunscreen.

Laser Hair Reduction results

Photos are provided courtesy of Candela Corporation and may not be representative of the results that you may experience.

GentleLASE Hair Reduction

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GentleMAX Laser
The GentleMAX laser is two lasers in one system, allowing the safe and effective treatment of all skin types form light to dark. The lasers in the GentleMAX are commonly used for:

-Laser Hair Reduction

-Leg Veins and Telangiectasia (small vessels)

-Certain Vascular Lesions

-Benign Pigmented Lesions (sun spots, seborrheic keratosis)

-Skin Tightening/Wrinkle Treatment

GentleLASE Hair Reduction

GentleYAG Rejuvenation

Your SOMA Skin & Laser physician will evaluate your skin type and condition and suggest the most appropriate treatment. Multiple treatment sessions are typically required for optimal results.

GentleLASE Hair Reduction

GentleYAG Blood Vessel Treatment

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V-Beam Perfecta
The V-Beam Perfecta is a pulsed dye laser that can be used to treat vascular lesions and some pigmented lesions. Common conditions we treat are:

-Rosacea

-Angiomas (small round red vascular lesions)

-Photorejuvenation

-Acne (Inflammatory)

-Poikiloderma of Civatte (mottled red and brown color of upper chest and neck)

-Facial Telangiectasia (small blood vessels on face)

-Scars and Striae

-Back of Hands (sun spots)

-Port Wine Stains

-Hemangiomas

-Warts

-Psoriasis

Treatment with the V-Beam feels something like being flicked with a rubber band, and you will feel some heat. Topical anesthesia is usually not required. Usually, a series of several treatments is necessary for optimal results.

V-Beam Treatment

V-Beam Treatment

V-Beam Treatment

V-Beam Treatment

Photos are courtesy of Candela Corporation and may not be representative of results you will achieve.

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About cyst excision

One of the most common dermatological procedures is cyst excision.  There are several different types of cysts that can occur on the skin or scalp, with the most common ones being an epidermal inclusion cysts and pilar cysts.  Most cysts are easily removed by your dermatologist.  After prepping the area, your dermatologist will numb the area with an injection of local anesthesia, such as lidocaine with epinephrine.  Your dermatologist will often try to keep the incision small and to “birth” the cyst whole through a small opening.  Sometimes, however, this is not possible.  In which case the material inside the cyst, typically a cheesy foul-smelling substance, will be extruded and then the cyst wall removed.  The cyst wall should be removed in its entirety to reduce the risk of recurrence.  If any cyst material has escaped the cyst, your dermatologist may irrigate the area with sterile saline to clean it and prevent any inflammation from developing to the cyst contents.  After the cyst has been completely removed, any bleeding will be stopped, and the wound evaluated for closure.  Usually cyst excisions are closed easily, but it is important to eliminate any dead space with deep sutures and to close the wound without tension by undermining the adjacent skin.  Depending on the cyst location, you will then return to your dermatologist in 5 days to two weeks for suture removal.

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About Mohs Micrographic Surgery

Mohs micrographic surgery is a procedure in which skin cancers are excised and immediately processed for review by light microscopy.  The Mohs surgeon evaluates the tissue to confirm that all of the tumor has been removed. During this time the patient is bandaged and waits for the results.  If the margins of the excised tissue is negative for tumor, then the resulting wound is repaired.  If the margins contain residual tumor cells then an additional piece of tissue is excised (termed a “stage”). This process continues until the margins are negative for tumor. The key to Mohs surgery is that it achieves complete “histological control” of the margins, due to the method in which the specimen is excised and processed. Mohs surgery achieves the lowest recurrence rate and simultaneously spares the maximum amount of healthy tissue.  This is especially important in cosmetically sensitive areas like the face.

Who should undergo Mohs surgery?

The decision as to which tumors should undergo Mohs surgery depends on the the nature of the tumor and the site. Established indications include:

• Recurrent basal cell carcinoma (BCC) or squamous cell carcinoma (SCC);
• BCC or SCC with clinically indistinct borders;
• Lesions in “high-risk” areas of the face;
• Cosmetically sensitive areas and areas with limited adjacent skin for repair, such as genitals, anal and peri-anal, hands, feet, and nail units;
• Rapidly growing tumors;
• Tumors >2cm in diameter;
• Tumors with certain aggressive histological subtypes;
• Tumors arising in sites of previous radiation treatment;
• Tumors in immunosuppressed patients; and
• Patients with basal cell nevus syndrome.

What will happen before, during and after Mohs surgery?

The dermatological surgeon will first review with the patient all relevant pre-operative details and medical history, including need for antibiotic prophylaxis, evaluation of clotting parameters, and the presence of implantable medical devices.

On the day of surgery, the patient is situated in the procedure room, informed consent signed, the lesion marked, and photographs taken.  The site is prepped and infiltrated with a local anesthetic, and the first “layer” excised at a 45 degree angle to the skin. The edges of the lesion and adjacent skin may be scored with a scalpel to preserve orientation. The surgical site is then temporarily bandaged while the tissue is processed and evaluated. Additional “layers” may be necessary until all of the tumor has been removed. Once the margins are “negative”, the surgeon will select an appropriate method to repair the wound, which may include primary closure, a flap or a graft. A dressing will be applied and wound care instructions provided.

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About Skin Cancer Surgery

Basal cell carcinoma, squamous cell carcinoma, and malignant melanoma are the common forms of skin cancer requiring surgical treatment. The cancer type, size, location, and histopathological features determine the treatment type advised by your dermatologist.

Simple excision is the cutting out of the tumor, with a scalpel or scissor, with a margin of healthy surrounding tissue. In preparing for skin cancer surgery, your dermatologist will first usually have performed a biopsy of the lesion and will know exactly what kind of skin cancer is present. During a pre-op meeting, your dermatological surgeon will review a complete medical history, including any need for antibiotics prior to surgery, medications taken, especially anticoagulants, and the presence of any implanted medical devices such as a pacemaker. Skin cancer surgery is an outpatient procedure performed under local anesthesia. On the day of your skin cancer surgery, you will be taken to a procedure room. After completing the informed consent, you will change into a gown and be positioned for the procedure. Your dermatological surgeon will mark the area and confirm the location by comparing with photographs taken previously. After that, the area will be numbed with injections of local anesthetic. Your dermatological surgeon will then prep the area with antiseptic, drape it, and start the surgery.  Most skin cancers will be excised as an ellipse around the lesion, resulting in a linear scar approximately 2.5-3.0 times as long as the original lesion. This is necessary to close the wound without leaving unsightly bunching of skin (called “dog ears”). After cutting out the skin cancer and a margin of healthy tissue, your dermatological surgeon will consider how best to repair the defect. This can include closure with subdermal and superficial sutures, flaps, grafts, or allowing to heal by “second intent”, meaning without further closure. Most excisions are closed with buried resorbable sutures, such as Vicryl, and a superficial layer of Nylon sutures, which must be removed 1-2 weeks after the procedure. After repairing the defect, a dressing and antibacterial ointment will be applied to the wound and wound care instructions provided.

Mohs Micrographic Surgery is a special form of skin surgery used for certain skin cancers.  See: http://somalaser.com/blog/2011/01/02/mohs-surgery/.

Other forms of skin cancer surgery include:

Electrodesiccation and curettage is the use of an electrosurgery device (the Conmed Hyfrecator is used at SOMA Skin & Laser) to generate an electric current to dehydrate/burn the tumor followed by scraping of the tumor with a curette. The area is first numbed with local anesthetic. This cycle of electrodessication and curretage is typically repeated three times, and includes a margin around the clinically apparent tumor. This method of treatment does not require suturing, but leaves a broad scar the shape of the area treated. The recurrence rate with electrodessication and curettage can be higher than with other methods. It is best used on superficial lesions (such as superficial basal cell carcinomas) or in elderly patients or those with comorbidities where the slightly increased recurrence risk is offset by the simplicity of the procedure.

Cryosurgery is the freezing of the tumor, typically with liquid nitrogen. Although large and deep tumors can be approached this way, cryosurgery is most often used for superficial cancers when excision cannot be performed and for actinic keratoses.

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About Sclerotherapy

In sclerotherapy a sclerosant is injected into unwanted superficial blood vessels, typically on the legs, to eliminate them. Although lasers are also widely used for the treatment of leg vessels, sclerotherapy remains the gold standard to which other treatments are compared.

When considering lower extremity blood vessels, they are divided based on size and color:

Telangiectasias are blood vessels less than 1 mm in diameter, flat and red.

Venulectasias are blue vessels, less than 2 mm, sometimes elevated above the skin surface.

Reticular veins are larger, 2-4 mm blood vessels, with a dusky blue/purple hue.

Sclerotherapy can improve the appearance of these blood vessels and also may reduce symptoms, such as pain or burning, if present. Generally, large varicosities are not as amenable to sclerotherapy as small ones.

Ultrasound and sclerotherapy

Most sclerotherapy is performed visually, based on the clinicians evaluation of the blood vessels, but duplex ultrasound is sometimes employed to visualize the blood vessels while injecting

Ultrasound evaluation is sometimes necessary prior to treatment to determine the extend of underlying venous disease.

Choice of sclerosing agents

The goal of sclerotherapy is to damage the injected blood vessel and not damage the surrounding skin or tissue. Sclerosants are categorized based on their method of action.

Detergents disrupt the cellular membranes of the cells lining the veins. These agents include: Sodium tetradecyl sulfate (Sotradecol), Polidocanol (Asclera), Sodium morrhuate (Scleromate), and Ethanolamine Oleate (Ethamolin). Detergents can be foamed by mixing with air, and this form of sclerosant is commonly used, especially for larger vessels.

Osmotic agents damage the cells by creating an electrolyte gradient, thereby dehydrating the cells. The classic hypertonic sclerosant is hypertonic saline or hypertonic saline with dextrose (Sclerodex).

Chemical agents directly damage the cells in a caustic fashion. These agents include chromated glycerin (Sclermo) and polyiodinated iodine.

Of the above sclerosants, hypertonic saline, sodium tetradecyl sulfate, and polidocanol are most commonly used.

Hypertonic Saline. Hypertonic saline (23.4%) is readily available, nontoxic, and inexpensive. It is widely used off-label for sclerotherapy but has some drawbacks. If it gets outside the blood vessel it can cause pain, burning or cramping. It is also likely to cause hemosiderin deposition and hyperpigmentation. Nevertheless, it is a good option for some, especially if cost is a factor. For larger veins, 23.4% saline is usually used, while telangiectasias are usually treated at half strength (11.7%).

Sodium tetradecyl sulfate is a synthetic detergent, and is FDA-approved for sclerotherapy in the U.S. as Sotradecol. The main issues with Sotradecol use are hyperpigmentation, tissue necrosis if it gets outside the blood vessel, and occassional allergic reactions, including anaphylaxis. Concentrations used range from 0.25-0.4% for reticular veins and venulectasias and 0.1-0.2% for telangiectasias.

Polidocanol (Asclera) is FDA-approved in the United States for sclerotherapy. Notable advantages are that it does not cause tissue necrosis if extravasated, is painless upon injection,and has a low incidence of allergic reaction, though cases of anaphylaxis has been reported. As with other agents, hyperpigmentation sometimes occurs. Concentrations of 0.5-1.0% are used for for reticular veins and venulectasias and 0.25-0.75% for telangiectasias.

The sclerotherapy procedure

After a pre-operative evaluation and consent, the patient is positioned appropriately and the sclerosant injected into the vessle using a 30G needle, typically 0.1-0.2 ml at 2-3 cm intervals along the vessel.  Larger vessels are treated first and then smaller ones. Pressure with taped cotton balls or a compression garment are applied immediately, and should be continued for several weeks.

Complications of sclerotherapy

Complications can occur. Hyperpigmentation is common and usually resolves over time. Allergic reactions can occur during treatment. Telangiectatic matting (a collection of new small vessels) sometimes occurs, and is thought to be due to injections that are too fast or too concentrated or to the presence of unrecognized feeder vessels. These sometimes resolve spontaneously, but are also amenable to treatment. An important potential complication is tissue necrosis, usually occurring when the sclerosant escapes or is injected into surrounding tissue, or injected into an arteriole. Immediate white blanching is an indication of impending necrosis. This can be treated with massage, topical nitroglycerine paste, hyaluronidase injection, or flushing with normal saline or lidocaine. Superficial thrombophlebitis (inflammation of the veins) can occurs when larger vessels are treated. This usually responds to compression and NSAIDs.  Deep venous thrombosus sometimes occurs, and must be treated with systemic anticoagulation. In addition to the above, foam sclerotherapy has unique possible adverse effects that can result from migration of foam bubbles. These include pulmonary symptoms, visual and neurological events.

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About phototherapy

Phototherapy is the use of non-ionizing electromagnetic energy, typically ultraviolet wavelengths, for therapeutic effect. Commonly used wavelengths are  broad band UVB (BB-UVB), narrow band UVB (nbUVB) and UVA. nbUVB is considered the safest and most effective wavelength for treatment of  psoriasis.  UVA is used primarily for photochemotherapy (PUVA), while UVA1 may be useful for atopic dermatitis and scleroderma. Ultraviolet radiation causes biological effects when it is absorbed by various molecules in the skin. Importantly, UVR produces alterations in both local and systemic immune response.

The conditions most commonly treated with phototherapy are:

• psoriasis (most common);
• vitiligo;
• atopic dermatitis; and
• other dermatitis.

Other possible indications include:

• alopecia areata;
• pityriasis rosea;
• parapsoriasis;
• cutaneous T-cell lymphoma (CTCL);
• polymorphous light eruption and other photodermatoses;
• lichen planus;
• generalised pruritus; and
• pityriasis lichenoides

During the course of treatment, patients typically are seen 3x/week for therapy. Treatment  may be either in a light box for widespread skin disease, or with a hand or foot unit for localized involvement. The Excimer laser can also be used for localized lesions.

Phototherapy is very effective in treating a variety of dermatoses, but a committed patient is required due to the frequency of required office visits. Home light-therapy units are available for use under physician supervision and will sometimes be reimbursed by insurance carriers.

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For information on photodynamic therapy at SOMA Skin & Laser click here. For general PDT information read below.

About Photodynamic Therapy

Photodynamic therapy (PDT) is a procedure involving the use of a photosensitizing agent plus light to treat various skin conditions, including skin cancer, acne, and photoaging. As used by dermatologists photodynamic therapy is a two step process. In the first step, a photosensitizer is applied to the patient’s skin (it can be topical, oral, or intravenous, but this post will focus on topical), where it is taken up by the target cells. In the second step the photosensitizer in the presence of oxygen is activated with a specific wavelength of light. Because the photosensitizer is preferentially absorbed by certain types of cells, such as skin cancer cells, and the activating light source is targeted only to certain areas, photodynamic therapy is selective, targeting the diseased tissue and minimizing damage to surrounding skin. The sensitizing agent is typically either aminolevulinic acid (ALA) or methylaminolevulinate (MAL). In the United States, the trade names are Levulan and Metvixia, respectively. In most practices, ALA is applied for a 30-90 minute incubation time for the treatment of actinic keratoses, though the product label calls for longer incubation.

Photodynamic therapy for acne

ALA and MAL when applied to the skin accumulates preferentially in sebaceous glands and the epidermis, as well as in P. acnes bacteria, allowing PDT to target acne. The use of PDT for acne is off-label but widely used by dermatologists. After a short incubation time (30-60 minutes) ALA is activated with a light source, either a laser or a blue light source. The resulting decrease in sebaceous glands and P. acnes bacteria can lead to significant acne improvement.

Photodynamic therapy for skin cancer and precancers

Cancer cells accumulate more porphyrins than normal cells, allowing photodynamic therapy (PDT) for the treatment of actinic keratoses, Bowen’s disease, and basal cell carcinoma. Treatment of actinic keratosis is the only FDA-approved indication. A phototoxic reaction with erythema, edema, crusting, and erosion occurs in most patients treated for these conditions, which is considered necessary to clear these lesions.

Light sources for PDT

The light used must be at a wavelength near a peak of porphyrin absorption in tissue. The Soret band at 405-420 nm is the key peak of protoporphyrin IX absorption. This wavelength  is included in the output of the Blu-U or ClearLight devices used to activate ALA. However, there is also a red peak at around  635 nm, which can be targeted by other light sources, especially the Pulsed Dye Laser, with an output at 595 nm.

How does PDT work?

Following light activation, porphyrins are excited to a higher energy state, which can result in generation of reactive oxygen species, such as singlet oxygen or free radicals. Porphyrins from ALA are concentrated near mitochondria, leading to cell death of malignant or pre-malignant cells upon light exposure. For the treatment of acne, preferential accumulation of ALA in sebaceous glands as well as reduction in Propionibacterium acnes, the bacteria implicated in acne, is thought to be the responsible mechanisms.  For treatment of photoaging, increased collagen synthesis following ALA photodynamic therapy may play a role.

During and after PDT

During PDT patients may feel a burning or stinging sensation.  A fan or misting of liquid nitrogen can be used to keep patients comfortable. After PDT patients must entirely avoid the sun for several days, as they can experience severe reactions since there is still photosensitizer on the skin. Erythema and edema often occur, followed by peeling. There can be a burning sensation, pain, crusting, and blister formation. Hyperpigmentation is sometimes seen after PDT, usually resolving over several months.  Hypopigmentation has also been reported.

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