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Visualization and quantification of the skin microvasculature are important for studying the health of the human microcirculation. We correlated structural and pathophysiological changes of the dermal capillary-level microvasculature with age and blood pressure by using the reactive hyperemia optical coherence tomography angiography (RH-OCT-A) technique and evaluated both conventional OCT-A and the RH-OCT-A method as non-invasive imaging alternatives to histopathology. This observational pilot study acquired OCT-A and RH-OCT-A images of the dermal microvasculature of 13 young and 12 old healthy Caucasian female subjects. Two skin biopsies were collected per subject for histological analysis. The dermal microvasculature in OCT-A, RH-OCT-A, and histological images were automatically quantified and significant indications of vessel rarefaction in both old subjects and subjects with high blood pressure were observed by RH-OCT-A and histopathology. We showed that an increase in dermal microvasculature perfusion in response to reactive hyperemia was significantly lower in high blood pressure subjects compared to normal blood pressure subjects (117% vs. 229%). These results demonstrate that RH-OCT-A imaging holds functional information of the microvasculature with respect to physiological factors such as age and blood pressure that may help to monitor early disease progression and assess overall vascular health. Additionally, our results suggest that RH-OCT-A images may serve as a non-invasive alternative to histopathology for vascular analysis.

Background and objectives A recent generation of 5,500 nm wavelength carbon monoxide (CO) lasers could serve as a novel tool for applications in medicine and surgery. At this wavelength, the optical penetration depth is about three times higher than that of the 10,600 nm wavelength carbon dioxide (CO2 ) laser. As the amount of ablation and coagulation is strongly influenced by the wavelength, we anticipated that CO lasers would provide extended coagulation zones, which could be beneficial for several medical applications, such as tissue tightening effects after laser skin resurfacing. Until now, the 1,940 nm wavelength thulium fiber (Tm:fiber) laser is primarily known as a non-ablative laser with an optical penetration depth that is eight times higher than that of the CO2 laser. The advantage of lasers with shorter wavelengths is the ability to create smaller spot sizes, which has a determining influence on the ablation outcome. In this study, the ablation and coagulation characteristics of a novel CO laser and a high power Tm:fiber laser were investigated to evaluate their potential application for fractional ablation of the skin. Study design/materials and methods Laser-tissue exposures were performed using a novel CO laser, a modified, pulse-width-modulated CO2 laser, and a Tm:fiber laser. We used discarded ex vivo human skin obtained from abdominoplasty as tissue samples. Similar exposure parameters, such as spot size (108-120 μm), pulse duration (2 milliseconds), and pulse energy (~10-200 mJ) were adjusted for the different laser systems with comparable temporal pulse structures. Laser effects were quantified by histology. Results At radiant exposures 10-fold higher than the ablation threshold, the CO laser ablation depth was almost two times deeper than that of the CO2 laser. At 40-fold of the ablation threshold, the CO laser ablation was 47% deeper. The ablation craters produced by the CO laser exhibited about two times larger coagulation zones when compared with the CO2 laser. In contrast, the Tm:fiber laser exhibited superficial ablation craters with massive thermal damage. Conclusions The tissue ablation using the Tm:fiber laser was very superficial in contrast to the CO laser and the CO2 laser. However, higher etch depths should be obtainable when the radiant exposure is increased by using higher pulse energies and/or smaller spot sizes. At radiant exposures normalized to the ablation threshold, the CO laser was capable of generating deeper ablation craters with extended coagulation zones compared with the CO2 laser, which is possibly desirable depending on the clinical goal. The effect of deep ablation combined with additional thermal damage on dermal remodeling needs to be further confirmed with in vivo studies. Lasers Surg. Med. © 2020 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Background/objectives Standard optical coherence tomography angiography (OCTA) has been limited to imaging blood vessels actively undergoing perfusion, providing a temporary picture of surface microvasculature. Capillary perfusion in the skin is dynamic and changes in response to the surrounding tissue's respiratory, nutritional, and thermoregulatory needs. Hence, OCTA often represents a given perfusion state without depicting the actual extent of the vascular network. Here we present a method for obtaining a more accurate anatomic representation of the surface capillary network in human skin using OCTA, along with proposing a new parameter, the Relative Capillary Capacity (RCC), a quantifiable proxy for assessing capillary dilation potential and permeability. Methods OCTA images were captured at baseline and after compression of the skin. Baseline images display ambient capillary perfusion, while images taken upon capillary refill display the network of existing capillaries at full capacity. An optimization-based automated vessel segmentation method was used to automatically analyze and compare OCTA image sequences obtained from two volunteers. RCC was then compared with visual impressions of capillary viability. Results Our OCTA imaging sequence provides a method for mapping cutaneous capillary networks independent of ambient perfusion. Differences between baseline and refill images clearly demonstrate the shortcomings of standard OCTA imaging and produce the RCC biometric as a quantifiable proxy for assessing capillary dilation potential and permeability. Conclusion Future dermatological OCTA diagnostic studies should implement the Capillary Refill Methods over standard imaging techniques and further explore the relevance of RCC to differential diagnosis and dermatopathology. Lasers Surg. Med. © The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals, Inc.

Intrinsic and extrinsic aging of human skin induces significant morphological changes to its surface. The most prominent and important feature in cosmetics and dermatology is the alteration of the wrinkles. Roughness parameters (Ra, Rmax) described by DIN/ISO disregard the skin’s micro-structure. Hence, we introduce an alternative method of skin roughness evaluation by analyzing the size and shape of micro-structures using optical coherence tomography. Measurements of young and elderly subjects were acquired. The skin of elderly subjects showed a decrease in micro-structures compared to the skin of young subjects which was predominated by triangular shapes, whereas rhomboids prevail among the elderly.

Optical coherence tomography angiography (OCTA) provides in-vivo images of microvasculature. In skin it often represents a dynamic perfusion state without depicting the actual extent of the vascular network. Here, we present the capillary refill method for obtaining a more accurate anatomic representation of surface capillary networks in human skin using OCTA. OCTA images were captured at baseline displaying ambient capillary perfusion and after compression and release of the skin representing the network of existing capillaries at full capacity. This method provides mapping of cutaneous capillary networks independent of ambient perfusion comparable to histological analysis of biopsies on identical skin sites.

BACKGROUND Traditionally, fractional laser treatments are performed with focused laser sources operating at a fixed wavelength. Using a tunable laser in the mid-infrared wavelength range, wavelength-dependent absorption properties on the ablation process and thermal damage formation were assessed with the goal to obtain customizable tissue ablations to provide guidance in finding optimized laser exposure parameters for clinical applications. METHODS Laser tissue experiments were carried out on full thickness ex vivo human abdominal skin using a mid-infrared tunable chromium-doped zinc selenide/sulfide chalcogenide laser. The laser has two independent channels: a continuous wave (CW) output channel which covers a spectrum ranging from 2.4 μm to 3.0 μm with up to 9.2 W output power, and a pulsed output channel which ranges from 2.35 μm to 2.95 μm. The maximum pulse energy of the pulsed channel goes up to 2.8 mJ at 100 Hz to 1,000 Hz repetition rate with wavelength-dependent pulse durations of 4-7 ns. RESULTS Total ablation depth, ablation efficiency, and coagulation zone thickness were highly correlated to wavelength, pulse width, and pulse energy. Using the same total radiant exposure at 2.85 μm wavelength resulted in 10-times smaller coagulation zones and 5-times deeper ablation craters for one hundred 6 ns pulses compared to one 100 ms pulse. For a fixed pulse duration of 6 ns and a total radiant exposure of 2.25 kJ/cm2 the ablation depth increased with longer wavelengths. CONCLUSION The tunable laser system provides a useful research tool to investigate specific laser parameters such as wavelength on lesion shape, ablation depth and thermal tissue damage. It also allows for customization of the characteristics of laser lesions and therefore facilitates the selection of suitable laser parameters for optimized fractional laser treatments. Lasers Surg. Med. 50:961-972, 2018.© 2018 Wiley Periodicals, Inc.

Background and Objective Fractional Photothermolysis (FP) is a method of skin treatment that generates a thermal damage pattern consisting of multiple columns of thermal damage, also known as microscopic treatment zones (MTZs). They are very small in diameter and are generated by application of highly focused laser beams. In order to obtain the smallest spot size, the treatment should be performed in the focal plane. Any deviation from the focal plane (DFP) results in an increase of spot size. FP devices typically utilize distance holders in order to facilitate exposures at this specific location. In spite of the use of distance holders, DFP can occur. In particular, variations of contact pressure to the skin surface and anatomical treatment areas of high surface curvature may be prone to DFP during FP treatments. The impact of such distance variation on lesion geometry, such as depth and diameter of the thermal injury, has not previously been evaluated. The objective of this study was to investigate the relation between DFP and the resulting lesion geometry for a selected ablative fractional device. Material and Methods A handpiece of an ablative fractional laser (DeepFX, UltraPulse Encore, Lumenis, Yokneam, Israel) was mounted to a rigid stand. Full thickness human skin obtained from abdominoplasty was mounted to a separate stand perpendicular to the handpiece. The tissue stand allowed the distance between the handpiece and the tissue to be adjusted to produce a variation up to ±3 mm from the focal plane. A 1 × 1 cm2 scanning area of 169 MTZs, 50 mJ energy per MTZ, 120 μm nominal spot size, was applied at −3, −2, −1, 0, +1, +2, and +3 mm deviated from the focal plane. Minus (−) and plus (+) signs indicate decreasing and increasing distance between the handpiece and the tissue, respectively. Depth and diameter of the laser induced tissue lesions were assessed and quantified. Results DFPs produced a significant alteration of the lesion geometry. DFPs of −3, −2, −1, 0, +1, +2, +3 mm resulted in average lesion depths of 1,020 (−40%), 1,180 (−31%), 1,400 (−18%), 1,700 (0%), 1,620 (−5%), 780 (−55%), 680 (−60%) µm, and average lesion diameters of 314 (+26%), 311 (+25%), 273 (+10%), 248 (0%), 256 (+3%), 316 (+27%), 359 (+44%) µm, respectively. The underlined values represent the focal plane. The percentage changes relative to values at focal plane are in parentheses. Conclusions A relatively minor DFP has a marked impact on the thermal injury profile, including lesion depth and diameter, of the laser-exposed tissue. Such marked changes of the thermal injury profile might affect the wound healing, safety, and efficacy of ablative fractional resurfacing procedures. Clinicians should carefully maintain the focal plane during ablative fractional treatment for reproducible results. The presented data are device specific and the clinical impact of such alteration of thermal injury profile warrants further investigation. Lasers Surg. Med. © 2016 Wiley Periodicals, Inc.

Background Lasers and intense pulsed light sources (IPLS) are proposed for the treatment of many pigmentary disorders. They are sometimes considered as magic tools able to remove any type of lesions. Although being the best option for several hyperpigmented lesions, they can also worsen some conditions and have potential side-effects. Objective The aim of this review was to give evidence-based recommendations for the use of lasers and IPLS in the treatment of hyperpigmented lesions. Methods These recommendations were produced for the European Society of Laser Dermatology by a consensus panel made up of experts in the field of pigment laser surgery. Recommendations on the use of lasers and light treatments were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Results Lasers and IPLS are very effective for treating many hyperpigmented lesions such as lentigos, dermal hypermelanocytosis or heavy metal depositions. In the other hand, they have to be considered with great caution for other disorders, such as cafe au lait macules, melasma or postinflammatory hyperpigmentation. After making the correct diagnosis, if lasers or IPLS are indicated, the optimal wavelengths and parameters will be chosen taking into account the skin phototype, origin and depth of the target pigments. Conclusion Although potentially very effective, lasers and IPLS cannot be proposed for all types of hyperpigmented lesions. In all cases, precise recognition of the disorder is mandatory for choosing between these devices and other therapeutic approaches.

Background Ablative fractional laser procedures have been shown to facilitate topical drug delivery into the skin. Past studies have mainly used ex vivo models to demonstrate enhanced drug delivery and in vivo studies have investigated laser created channels over a time course of days and weeks rather than within the first few minutes and hours after exposures. We have noticed rapid in vivo fibrin plug formation within ablative fractional laser lesions impairing passage through the laser created channels. Material and Methods In vivo laser exposures were performed in a porcine model. A fractional CO2 laser (AcuPulse™ system, AcuScan 120™ handpiece, Lumenis, Inc., Yokneam, Israel) was programmed in quasi-continuous wave (QCW) mode, at 40W, 50 mJ per pulse, 5% coverage, nominal 120 µm spot size, 8 × 8 mm square pattern, 169 MTZs per scan. Six millimeters punch biopsies were procured at 0, 2, 5, 10, 15, 30, 60, 90 minutes after completion of each scan, then fixed in 10% formalin. 12 repeats were performed of each time point. Skin samples were processed for serial vertically cut paraffin sections (5 μm collected every 25 μm) then H&E and special immunohistochemistry staining for fibrin and platelet. Dimensions of Microscopic Treatment Zones (MTZs) and extent of fibrin plug were assessed and quantified histologically. Ex vivo laser exposures of the identical laser parameter were performed on porcine and human skin at different storage conditions. Results Histology procured at various predetermined time intervals after in vivo fractional CO2 laser exposures revealed a rapidly forming fibrin plug initiating at the bottom of the MTZ lesions. At longer time intervals, the fibrin plug was extending towards the superficial sections. Within the first 5 minutes, more than 25% length of the entire laser-ablated channel was filled with a fibrin plug. With increased time intervals, the cavity was progressively filled with a fibrin plug. At 90 minutes, more than 90% length of the entire laser-ablated channel was occluded. Ex vivo exposures failed to produce any significant fibrin plug formation. Conclusions The current study has demonstrated rapid fibrin plug formation after ablative fractional laser procedures. It was shown that the passage through laser created pathways is critically time dependent for in vivo exposures. In contrast, ex vivo exposures do not exhibit such time dependent passage capacity. In particular, drug, substance, and cell delivery studies for ablative fractional laser treatments should take early fibrin plug formation into consideration and further investigate the impact on transdermal delivery. Lasers Surg. Med. © 2015 Wiley Periodicals, Inc.

Skin vaccination has gained increasing attention in the last two decades due to its improved potency compared to intramuscular vaccination. Yet, the technical difficulty and frequent local reactions hamper its broad application in the clinic. In the current study, micro-fractional epidermal powder delivery (EPD) is developed to facilitate skin vaccination and minimize local adverse effects. EPD is based on ablative fractional laser or microneedle treatment of the skin to generate microchannel (MC) arrays in the epidermis followed by topical application of powder drug/vaccine-coated array patches to deliver drug/vaccine into the skin. The novel EPD delivered more than 80% sulforhodamine b (SRB) and model antigen ovalbumin (OVA) into murine, swine, and human skin within 1 h. EPD of OVA induced anti-OVA antibody titer at a level comparable to intradermal (ID) injection and was much more efficient than tape stripping in both delivery efficiency and immune responses. Strikingly, the micro-fractional delivery significantly reduced local side effects of LPS/CpG adjuvant and BCG vaccine, leading to complete skin recovery. In contrast, ID injection induced severe local reactions that persisted for weeks. While reducing local reactogenicity, EPD of OVA/LPS/CpG and BCG vaccine generated a comparable humoral immune response to ID injection. EPD of vaccinia virus encoding OVA induced significantly higher and long-lasting interferon γ-secreting CD8 + T cells than ID injection. In conclusion, EPD represents a promising technology for needle-free, painless skin vaccination with reduced local reactogenicity and at least sustained immunogenicity.

The pathophysiology of acne vulgaris depends on active sebaceous glands, implying that selective destruction of sebaceous glands could be an effective treatment. We hypothesized that light-absorbing microparticles could be delivered into sebaceous glands, enabling local injury by optical pulses. A suspension of topically applied gold-coated silica microparticles exhibiting plasmon resonance with strong absorption at 800 nm was delivered into human pre-auricular and swine sebaceous glands in vivo, using mechanical vibration. After exposure to 10-50 J cm(-2), 30 milliseconds, 800 nm diode laser pulses, microscopy revealed preferential thermal injury to sebaceous follicles and glands, consistent with predictions from a computational model. Inflammation was mild; gold particles were not retained in swine skin 1 month after treatment, and uptake in other organs was negligible. Two independent prospective randomized controlled clinical trials were performed for treatment of moderate-to-severe facial acne, using unblinded and blinded assessments of disease severity. Each trial showed clinically and statistically significant improvement of inflammatory acne following three treatments given 1-2 weeks apart. In Trial 2, inflammatory lesions were significantly reduced at 12 weeks (P=0.015) and 16 weeks (P=0.04) compared with sham treatments. Optical microparticles enable selective photothermolysis of sebaceous glands. This appears to be a well-tolerated, effective treatment for acne vulgaris.

Light has long been used as a tool for the restoration of health. The healing powers of sunlight became one of the earliest recorded treatments in Western medicine (Bettman 1979; Kelly 2009), used for a wide variety of medical conditions, such as smallpox and tuberculosis (Bettman 1979). In 1963, Goldman et al. (1963a) first clearly described ruby laser-induced injury to pigmented skin, including hair follicles. In the following years, the ruby laser was explored as a treatment for many conditions, with little regard for absorption of light energy by various tissues. A historical case reported in 1983 was that of a young boy treated for a vascular malformation that resulted in severe epidermal damage. In the same year, Anderson and Parrish (1983) published the theory of selective photothermolysis (SP), which describes a strategy for using optical pulses to selectively affect pigmented “targets.” A wavelength(s) is chosen that is preferentially absorbed by a particular chromophore associated with the target (melanin, hemoglobins, tattoo inks, or other pigments), and a pulse duration is chosen that is sufficiently short to limit heat transfer from the target structure during the laser pulse. By providing a microscopic target-selective treatment, SP enabled new laser treatments to be developed with minimal risk of gross tissue injury, for example, treatment of microvascular skin malformations and removal of pigmented hair follicles, pigmented lesions, and tattoos (Anderson and Parrish 1983; Grossman et al. 1996). With this concept came an explosion in the number of lasers and light sources in dermatology to accommodate a spectrum of aesthetic procedures with minimal pain (Bashkatov et al. 2005; Tanzi, Lupton, and Alster 2003; Tseng etal. 2009). In 2008, nearly 75 million aesthetic light procedures were performed, and the number is expected to double because of a growing and demanding young consumer market. Herein we introduce the applications of lasers and intense pulsed light in dermatology, including the potential for further development.

The need for patient-specific photodynamic therapy (PDT) in dermatologic and oncologic applications has triggered several studies that explore the utility of surrogate parameters as predictive reporters of treatment outcome. Although photosensitizer (PS) fluorescence, a widely used parameter, can be viewed as emission from several fluorescent states of the PS (e.g., minimally aggregated and monomeric), we suggest that singlet oxygen luminescence (SOL) indicates only the active PS component responsible for the PDT. Here, the ability of discrete PS fluorescence-based metrics (absolute and percent PS photobleaching and PS re-accumulation post-PDT) to predict the clinical phototoxic response (erythema) resulting from 5-aminolevulinic acid PDT was compared with discrete SOL (DSOL)-based metrics (DSOL counts pre-PDT and change in DSOL counts pre/post-PDT) in healthy human skin. Receiver operating characteristic curve (ROC) analyses demonstrated that absolute fluorescence photobleaching metric (AFPM) exhibited the highest area under the curve (AUC) of all tested parameters, including DSOL based metrics. The combination of dose-metrics did not yield better AUC than AFPM alone. Although sophisticated real-time SOL measurements may improve the clinical utility of SOL-based dosimetry, discrete PS fluorescence-based metrics are easy to implement, and our results suggest that AFPM may sufficiently predict the PDT outcomes and identify treatment nonresponders with high specificity in clinical contexts.

The use of carbon dioxide (CO2) laser-mediated ablative fractional resurfacing (AFR) is currently under extensive clinical investigation, but the molecular mechanisms underlying this process are unclear.To determine the early expressed genes that are upregulated in human skin after treatment using a CO2 fractional laser.Whole human skin was irradiated using an AFR CO2 laser, and changes in gene expression after 2 and 24 hours were analyzed using microarray analysis. The results were validated using reverse transcriptase polymerase chain reaction (RT-PCR). Laser scanning confocal microscopy (LSCM) was used to investigate the expression of the validated proteins after AFR CO2 laser treatment of skin that had been biopsied from seven Korean patients.Gene expression profiling showed that the most significantly upregulated genes in these skin samples were those encoding Wnt5a, cysteine-rich angiogenic inducer 61 (CYR61), and heat shock protein (HSP) 90. These results were confirmed using real-time RT-PCR and LSCM.Irradiation using an AFR laser may induce the expression of Wnt5a, CYR61, and HSP90 in human skin during the early remodeling phases, suggesting that the induction of proteins may be the preceding event that is associated with the clinical effects of laser treatment.

Full-surface laser ablation has been shown to efficiently disrupt stratum corneum and facilitate transcutaneous drug delivery, but it is frequently associated with skin damage that hampers its clinic use. We show here that a safer ablative fractional laser (AFL) can sufficiently facilitate delivery of not only patch-coated hydrophilic drugs but also protein vaccines. AFL treatment generated an array of self renewable microchannels (MCs) in the skin, providing free paths for drug and vaccine delivery into the dermis while maintaining integrity of the skin by quick healing of the MCs. AFL was superior to tape stripping in transcutaneous drug and vaccine delivery as a much higher amount of sulforhodamine B (SRB), methylene blue (MB) or a model vaccine ovalbumin (OVA) was recovered from AFL-treated skin than tape-stripped skin or control skin after patch application. Following entry into the MCs, the drugs or OVA diffused quickly to the entire dermal tissue via the lateral surface of conical-shaped MCs. In contrast, a majority of the drugs and OVA remained on the skin surface, unable to penetrate into the dermal tissue in untreated control skin or tape stripping-treated skin. Strikingly, OVA delivered through the MCs was efficiently taken up by epidermal Langerhans cells and dermal dendritic cells in the vicinity of the MCs or transported to the draining lymph nodes, leading to a robust immune response, in sharp contrast to a weak, though significant, immune response elicited in tape stripping group or a basal immune response in control groups. These data support strongly that AFL is safe and sufficient for transcutaneous delivery of drugs and vaccines.