Dr. Jill Waibel discusses lasering responsibly to avoid hypopigmentation, including recommendations for continued training and colleague collaborations, as well as repigmenting solutions.
Jill S. Waibel, MD, Chief of Dermatology, Baptist Hospital; Voluntary Assistant Faculty, University of Miami Miller School of Medicine; and Owner, Miami Dermatology and Laser Institute, Miami, Florida
“I had a patient who had a laser treatment by an OB/GYN with a device, on which the doctor had one day of training. The treatment burned and disfigured the patient. The patient came to me for scar treatment twice. And not long after that she committed suicide. Her 8-year-old son found her dead with a note saying she didn’t want to live this disfigured,” said Jill S. Waibel, MD, who presented “When the Solution Becomes the Problem: Laser-induced Hypopigmentation” at the Pigmentary Disorders Exchange meeting in Chicago.
She’s seeing more severe complications by providers who are inexperienced and inadequately trained in cosmetic laser use, she said.
“It’s time to take a pause in the cosmetic industry. We are hurting a lot of patients, and this is unethical. It goes against our oath. It goes against our calling, goals, and reason for being physicians or providers, which is to help patients and improve life and health.”
Complications from energy-based treatment happen to the best of providers, said Dr. Waibel.
“My mentor Dr. Tina Alster said if you don’t have complications, you’re not doing enough laser treatments. But you shouldn’t have severe, life-ending, disfiguring complications in today’s age.”
Reasons and Solutions
Poor training is a primary reason for severe complications from laser use, said Dr. Waibel, who is an expert witness for these cases when they go to court.
She suggests dermatologists and providers go to meetings to learn about cosmetic treatment with energy-based devices.
“Most of us have to take time out of our schedules and go spend a week, a few days, a few times a year and learn from those above us. Medicine has always had a tradition of passing down knowledge. I am still listening and continually learning ….”
Another tip: Join professional organizations. The American Society for Laser Medicine and Surgery, (ASLMS), American Academy of Dermatology, and American Society of Dermatology Surgery (ASDS) have aesthetic and laser didactic and hands on sessions, she said.
“Do a mentorship or fellowship with a board-certified dermatologist who is an expert in the field. There are paid mentorships through the ASDS, ASLMS, [and] the Women’s Dermatologic Society. There are so many ways that you can interface with your colleagues. It’s fun. I love having people come to my office. We develop lifelong friendships and collaborations.”
Providers whose patients suffer severe hypopigmentation post-laser treatment often say it was the first or second time they used the device, or that the only training they received was from the company representative, said Dr. Waibel.
“Never get trained by the rep! Always learn from a board-certified dermatologist or plastic surgeon with extensive knowledge. The company and its representatives can be very important in understanding the technical parts of the device—maintenance, cleaning, error messages—but don’t rely on them for settings or treatment advice.”
Another problem that can cause serious complications is that practices don’t know much about the devices they purchase, she said.
“If you buy a device you need to train, read every article, understand it, and go slowly [to gain experience using it].”
Poor technique is yet another problem that can lead to hypopigmentation, said Dr. Waibel.
“Failure to pay attention to detail, whether it’s putting in the right settings or having the right safety equipment in the room [can lead to hypopigmentation]. Not having the right safety glasses on is a big one.”
4 Ways to Treat Hypopigmentation
Researchers, including Dr. Waibel, published a head-to-head trial1 looking at ways to re-pigment hypopigmentation in which they studied the use of the non-ablative fractional laser, ablative fractional laser, ablative fractional laser with laser-assisted delivered bimatoprost, and an epidermal harvesting system, she said.
“Using a fractional non-ablative laser or ablative laser alone can cause re-pigmentation by stimulating stem cells that are deeper in the hair follicle. If that doesn’t work, for some conditions we use the XTRAC laser, 308 nm excimer laser, and that will stimulate melanocytes,” she said.
There are various melanocyte transfer devices in clinical trials, but Dr. Waibel said her favorite approach and the one that showed the most significant improvement in pigment stimulation was laser-assisted delivery of bimatoprost.
“Grandma and grandpa were using drops of bimatoprost in their eyes for their glaucoma and noticed their eyelashes growing longer and darker. It turns out bimatoprost stimulates pigmentation. The late Dr. Fitzpatrick was the first to topically apply bimatoprost to patients with hypopigmentation, and I think we were the first that did laser-assisted delivery.”
Laser-assisted delivery of bimatoprost involves making tiny holes in the skin, she said.
“The pigment cells are only about 90 to 100 micrometers in depth. The melanocytes are in the basal layer. So, I create small channels and topically apply bimatoprost twice a day for 7 days, and we can re-pigment almost anything.”
Dr. Waibel said her takeaway message is this: “Laser responsibly. If you do get a complication, reach out to a colleague. There are ways to help those patients. Keep training, and let’s take better care of our patients.”
Reference:
Waibel JS, Rudnick A, Arheart KL, et al. Re-pigmentation of Hypopigmentation: Fractional Lasers vs Laser-Assisted Delivery of Bimatoprost vs Epidermal Melanocyte Harvesting System. J Drugs Dermatol. 2019;18(11):1090-1096.
Disclosures: Dr. Waibel is a speaker, consultant, and advisory board member for Candela; advisory board member and consultant for Cytrellis Biosystems; advisory board member for Sciton; consultant and clinical trial investigator for Lumenis; and clinical trial investigator and consultant for Skinceuticals.