1550nm飞梭点阵激光治疗仪治疗黑眼圈（论文）

CASE REPORT Fractionated 1550-nm Erbium-Doped Fiber Laser for the Treatment of Periorbital Hyperpigmentation MEGAN NICOLE MOODY, MD, MPH,* JENNIFER M. LANDAU, BS,* LEONARD H. GOLDBERG, MD,*†‡§ AND PAUL M. FRIEDMAN, MD†‡§¶ The authors have indicated no significant interest with commercial supporters. Periorbital hyperpigmentation is a commoncondition that involves darkening of the upper and lower eyelid skin; it is often refractory to treat- ment. Multiple treatment modalities have been used for periorbital hyperpigmentation, including bleaching creams, topical retinoic acid, chemical peels, laser therapy, and surgical correction. Lasers that have been used successfully include the Q-switched ruby laser1,2 and an ablative carbon dioxide (CO2) resurfacing laser, 3 yet they carry a risk of postinflammatory hyperpigmentation (PIH). Because of the complex etiology of the condition, a combination treatment approach may be most effective for targeting the contributing factors, such as dermal melanosis, PIH from atopic or allergic contact dermatitis, superficial vasculature, and skin laxity. Case Report A 44-year-old Caucasian woman (Fitzpatrick skin type II) with no significant past medical history pre- sented for evaluation of acne scars and periorbital irritation. According to the patient, she had under- gone two courses of oral isotretinoin (Accutane) 6 years before presentation for acne; after finishing the second course, she noted improvement of her acne, accompanied by gradual and unremitting swelling of her eyelids (facial swelling has been pre- viously reported as a side effect of isotretinoin4). She reported a prolonged history of “puffy eyelids” and progressive darkening of the skin around her eyes. She also reported multiple severe sunburns of her eyelids when she was younger. On presentation, she had significant bilateral periorbital splotchy hyperpigmented macules involving her upper and lower eyelids and her medial and lateral canthi. The hyperpigmentation extended to a level of approxi- mately 1 inch below her eyes (Figures 1 and 2A). After a thorough evaluation, we decided on a series of treatment sessions using a 1550-nm fractionated erbium-doped fiber laser (Fraxel re:store, Solta Medical, Haywood, CA). Over 4 months, she received four treatments with the laser for her eyelids and for acne scarring on her bilateral cheeks. Before each treatment, the area was cleansed with a mild soap (Cetaphil Gentle Skin Cleanser; Galderma Laboratories, L.P.). Triple anesthetic cream (benzacaine 10%, lidocaine 6%, tetracaine 4%; New England Compounding Cen- ter, Framington, MA) was applied to the treated area for 1 hour before treatment with the1550-nm fractionated erbium doped fiber laser (Fraxel re: *Derm Surgery Associates, Houston, Texas; †Department of Dermatology, Weill Cornell Medical College, New York, New York; ‡Department of Dermatology, Methodist Hospital, Houston, Texas; §Department of Dermatology, University of Texas, Houston, Texas; ¶Dermatology and Laser Surgery Center, Houston, Texas © 2011 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. � ISSN: 1076-0512 � Dermatol Surg 2011;1–4 � DOI: 10.1111/j.1524-4725.2011.02216.x 1 store). Eye shields were not used during the treat- ment sessions. The technique used for the upper eyelid skin was the same as that reported by Sukal and colleagues5 for eyelid tightening; we instructed the patient to keep her eyes closed while simulta- neously retracting the eyelid skin over the orbital rim for treatment. Treatments sessions using the 1550-nm fractionated erbium doped fiber laser used a 15-mm spot size and four passes, for a total of 4.67–5.51 kJ (includ- ing treatment of the entire face) at an energy fluence of 70 J/cm2 (Table 1). Treatment levels ranged from 10 to 11, corresponding to surface area cover- age of 29–32%. The treatments were spaced at an average of 4.8 weeks (range 3–6 weeks). A cooling device (Zimmer Elektromedizin Cryo 5; Zimmer Medizin Systems, Irvine, CA) was concomitantly used to protect the epidermis and minimize patient discomfort. After each treatment session, the patient was counseled on strict broad-spectrum sun protection using at least SPF 30 at all times and sun avoidance if possible. Two months after the fourth treatment, physician and patient noted significant improvement of the periorbital hyperpigmentation bilaterally (Figures 1B and 2B). Discussion Periorbital hyperpigmentation is a common prob- lem that has multiple etiologies (Table 2), includ- ing dermal melanosis, PIH from atopic or allergic contact dermatitis (people with allergies tend to (A) (B) Figure 1. Patient at baseline with periorbital postinflamma- tory hyperpigmentation (PIH) (A) and at 2 months after four treatments using a fractionated 1550-nm erbium- doped fiber laser with significant improvement of the peri- orbital PIH (B). (A) (B) Figure 2. Patient at baseline with periorbital postinflamma- tory hyperpigmentation (PIH) (A) and at 11 months after four treatments using a fractionated 1550-nm erbium- doped fiber laser with significant improvement of the peri- orbital PIH (B). TABLE 1. Treatment Parameters Session Energy, mJ Treatment Level Coverage,% 1 70 10 29 2 70 10 29 3 70 11 32 4 70 11 32 1550-NM ERBIUM-DOPED FIBER LASER FOR PIH DERMATOLOGIC SURGERY2 rub and scratch the periocular region and may sub- sequently develop an accumulation of fluid), super- ficial location of vasculature, and skin laxity.6 The condition may worsen with exhaustion and lack of sleep.6 The complex nature of periorbital hyperpig- mentation and lack of a clearly defined treatment regimen creates a challenge for the treating physi- cian. Multiple modalities have been used separately and in combination to treat dark circles under the eyes, with varying degrees of success, including bleaching creams, topical retinoic acid, chemical peels, lasers, and surgical excision. Because of the complex etiology of the condition, many suggest a combination treatment approach to target the vary- ing causes.7 For example, one group recommends the use of topical hydroquinone and tretinoin in addition to Q-switched ruby laser sessions; they postulate that these topical treatments not only enhance treatment efficacy, but also lower the risk for PIH secondary to laser treatments.8 Another study used a CO2 laser followed by a Q-switched alexandrite laser, effectively targeting pigmentation in the dermis and epidermis.9 Because a multitude of factors cause periorbital hyperpigmentation, the chosen treatment regimen should encompass as many of these factors as possible. The nonablative fractionated 1550-nm erbium-doped fiber laser preserves the stratum corneum while creating microscopic treatment zones (MTZs) of thermal injury in the epidermis and dermis. This modality has been proven to treat a variety of conditions effectively, including photo- aging, melasma, and acne scars. The laser functions to eliminate melanin pigment from the epidermis and dermis through a “melanin shuttle,” which exudes the pigment from the skin through the MTZs.10–12 Because dermal melanin deposition is recognized as one of the main factors contributing to periorbital hyperpigmentation, the 1550-nm erbium-doped fiber laser is an excellent treatment option because of its ability to reduce the overall dermal melanin content. A second contributing factor to periorbital hyperpigmentation is PIH from trauma (rubbing or scratching) of the skin around the eyes. Many lasers used today in dermatologic procedures are highly successful for treatment of dyschromia, yet they have the risk of causing new- onset PIH or the exacerbation of existing PIH. When considering this risk, laser therapy for PIH must be approached with caution. Again, the 1550- nm erbium-doped fiber laser remains an excellent option, for it not only has a low risk for new-onset PIH (0.73%),13 but it has also been used in the treatment of existing PIH.14 A final factor to con- sider when treating this multifaceted condition is skin laxity, which has been reported to contribute to the appearance of periorbital hyperpigmentation. The 1550-nm erbium-doped fiber laser has been shown to improve various aspects of photoaging through stimulation of collagen formation, decreas- ing skin laxity and diminishing the shadowing effect that exacerbates the appearance of dark skin around the eyes.11,12 We attribute the success of nonablative fractional photothermolysis for treat- ment of periorbital hyperpigmentation not only to the ability to target dermal and epidermal melanin, but also to its ability to tighten eyelid skin. TABLE 2. Etiologic Factors of Periorbital Postinflammatory Hyperpigmentation Dermal melanin deposition Shown histologically in multiple studies1,2,5 Postinflammatory hyperpigmentation Occurs secondarily to many inflammation-causing conditions that disrupt the dermo-epidermal junction, including atopic dermatitis and contact allergic dermatitis Vascular pigmentation Occurs because of the superficial location of periorbital vessels Skin laxity and periocular rhytides Photodamage and aging cause skin sagging and wrinkles, which create a shadowing effect that heightens the appearance of darkened periorbital skin Periorbital edema Periorbital edema ? thickening of the dermis ? light diffusion alterations, enhancing appearance of darked periorbital skin MOODY ET AL 2011 3 The 1550-nm fractionated erbium-doped fiber laser safely and effectively treated our patient’s bilateral periorbital hyperpigmentation without any complications. Larger prospective studies are indicated to better determine the efficacy rate and ideal treatment parameters for using this treat- ment modality for periorbital hyperpigmentation. References 1. Lowe NJ, Wieder JM, Shorr N, Boxrud C, et al. Infraorbital pigmented skin. Preliminary observations of laser therapy. Dermatol Surg 1995;21:767–70. 2. Watanabe S, Nakai K, Ohnishi T. Condition known as “dark rings under the eyes” in the Japanese population is a kind of dermal melanocytosis which can be successfully treated by Q-switched ruby laser. Dermatol Surg 2006;32:785–9. discussion 789. 3. West TB, Alster TS. Improvement of infraorbital hyperpigmentation following carbon dioxide laser resurfacing. Dermatol Surg 1998;24:615–6. 4. Scheinfeld N, Bangalore S. Facial edema induced by isotretinoin use: a case and a review of the side effects of isotretinoin. J Drugs Dermatol 2006;5:467–8. 5. Sukal SA, Chapas AM, Bernstein LJ, Hale EK, et al. Eyelid tightening and improved eyelid aperture through nonablative fractional resurfacing. Dermatol Surg 2008;34:1454–8. 6. Freitag FM, Cestari TF. What causes dark circles under the eyes? J Cosmet Dermatol 2007;6:211–5. 7. Momosawa A, Kurita M, Ozaki M, Miyamoto S, et al. Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for periorbital skin hyperpigmentation in Asians. Plast Reconstr Surg 2008;121: 282–8. 8. Manaloto RM, Alster TS. Periorbital rejuvenation: a review of dermatologic treatments. Dermatol Surg 1999;25:1–9. 9. Manuskiatti W, Fitzpatrick RE, Goldman MP. Treatment of facial skin using combinations of CO2, Q-switched alexandrite, flashlamp-pumped pulsed dye, and Er:YAG lasers in the same treatment session. Dermatol Surg 2000;26:114–20. 10. Manstein D, Herron GS, Sink RK, Tanner H, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004;34:426–38. 11. Tierney EP, Kouba DJ, Hanke CW. Review of fractional photothermolysis: treatment indications and efficacy. Dermatol Surg 2009;35:1445–61. 12. Sherling M, Friedman PM, Adrian R, Burns AJ, et al. Consensus recommendations on the use of an erbium-doped 1,550-nm fractionated laser and its applications in dermatologic laser surgery. Dermatol Surg 2010;36: 461–9. 13. Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments. Dermatol Surg 2008;34:301–5. discussion 305-7. 14. Katz TM, Goldberg LH, Firoz BF, Friedman PM. Fractional photothermolysis for the treatment of postinflammatory hyperpigmentation. Dermatol Surg 2009;35:1844–8. Address correspondence and reprint requests to: Paul M. Friedman, MD, Dermatology & Laser Surgery Center, 6400 Fannin St, Suite 2720, Houston, Texas 77030, or e-mail: drpaul@dermlasersurgery.com 1550-NM ERBIUM-DOPED FIBER LASER FOR PIH DERMATOLOGIC SURGERY4