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Clinics in Dermatology (2015) 33, 197206

Laser treatment of periocular skin conditions


Breton Yates, MD a , Syril Keena T. Que, MD a , Logan DSouza, MD a ,
Jeanine Suchecki, MD b , Justin J. Finch, MD a,
a

Department of Dermatology, University of Connecticut Health Center, 21 South Road, Farmington, Connecticut
Division of Ophthalmology, University of Connecticut Health Center, Department of Surgery, 263 Farmington Avenue,
Farmington, Connecticut
b

Abstract Advances in laser technology in recent decades have increased the options for the treatment of
dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and
vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review
treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions
including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal;
laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic
keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically
decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing
has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin
of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient
preparation, safety precautions, and risksintraocular and extraocularare discussed herein. As laser
technology continues to advance, we are sure to see improvements in current treatments, as well as development
of new applications of cutaneous lasers.
2015 Elsevier Inc. All rights reserved.

Introduction
Advances in laser technology in recent decades have
increased options for the treatment of dermatologic conditions of the eye and eyelid. This review will discuss laser
treatment of a variety of periocular cutaneous lesions,
including vascular lesions, pigmented lesions, periocular
tumors, and laser treatment of rhytides.
The foundation of laser therapy is based on the principle
of selective photothermolysis,1 which asserts that precise
tissue damage can be achieved by applying laser energy of
the appropriate wavelength and pulse duration. This
principle guides the selection of laser best suited for a
particular cutaneous lesion. First, the wavelength of the laser
must be preferentially absorbed by its target, a light Corresponding author. Tel.: +1 8606794600; fax: + 1 8606797534.
E-mail address: finch@uchc.edu (J.J. Finch).
http://dx.doi.org/10.1016/j.clindermatol.2014.10.011
0738-081X/ 2015 Elsevier Inc. All rights reserved.

absorbing molecule called a chromophore. The three main


chromophores targeted by lasers are water, hemoglobin, and
melanin (Table). Second, the duration of the laser pulse must
be short enough to affect the target before heat energy
dissipates to the surrounding tissue (a process called thermal
relaxation). A 0.5-m melanosome, for example, dissipates
heat much more quickly than a 300-m hair follicle, and
must, therefore, be targeted with much shorter laser pulse.
Finally, the fluence, or energy delivered per unit area, should
be high enough to have a therapeutic effect but below a level
that causes nonspecific thermal damage.
Clinical application of the principle of selective photothermolysis has evolved considerably as laser technology has
progressed, particularly in terms of minimizing side effects
like erythema, infection, dyspigmentation, and scarring. The
development of quality-switched (QS) lasers, which produce
very short laser pulses at a very high peak power, has
allowed the targeting of small particles like melanosomes or

198
Table

B. Yates et al.
Lasers used in treatment of periocular skin conditions

Laser

Wavelength (nm)

Main chromophore

KTP
PDL
Ruby
Alexandrite
Diode
Nd:YAG
Er:Glass
Er:YAG
CO2

532
595
694
755
810
1064
1440, 1550
2960
10600

Hemoglobin, Melanin
Hemoglobin
Melanin
Melanin
Melanin
Melanin
Water
Water
Water

KTP, potassium-titanyl-phosphate; PDL, pulsed dye laser; Nd:YAG,


neodymium-doped yttrium aluminum garnet; Er:Glass, erbium-doped
glass fiber; Er:YAG, erbium-doped yttrium aluminum garnet; CO2,
carbon dioxide

tattoo pigment. In the last decade, laser surgery has been


further transformed by the design of fractional photothermolysis, wherein microscopic gridded columns of thermal
injury stimulate dermal collagen 2 and elastic tissue 3
formation while minimizing widespread tissue damage.
Despite these advances, lasers can pose a great risk to the
unprotected eye, and appropriate safety precautions are
paramount. Our goal, herein, is to provide a comprehensive
review of lasers, old and new (Table), used to treat periocular
skin condition lesions, as well as to review adverse effects
and laser safety.

Laser treatment of vascular lesions


The yellow light-emitting pulsed dye laser (PDL) (585600 nm) was the first laser designed specifically for vascular
lesions.4 To this day, the PDL remains the treatment of
choice for port wine stains (see Figure 1), telangiectasias, and
infantile hemangiomas.
Infantile hemangiomas affect 10% of infants, and
approximately 16% of facial hemangiomas involve the
upper or lower eyelid.5 Because infantile hemangiomas will
spontaneously involute, most do not require treatment. On
the other hand, if there is rapid proliferation of the infantile
hemangioma at a critical location, near the eye for example,
early intervention is considered. The proliferation of infantile
hemangiomas in this region can lead to complications
including amblyopia and strabismus due to obstruction of the
visual axis.6
Similar to infantile hemangiomas on other parts of the
body, those on the eyelid can be categorized as superficial,
deep, or compound (which describes hemangiomas with a
superficial and deep component). Due to its shallow depth of
penetration, the PDL is most successful at targeting
superficial infantile hemangiomas. In one prospective,
randomized controlled trial, superficial infantile hemangiomas treated with PDL showed reduced redness and a six

Fig 1 A, PWS of right temple and lateral canthus; B, immediate


purpura after PDL; C, clinical improvement after three treatments
with PDL.

times greater rate of complete clearance at 1 year compared


to untreated lesions.7
Aside from the PDL, the potassium titanyl phosphate
(KTP) laser (532 nm) can be used to treat vascular tumors
and malformations, but this laser usually has a smaller
therapeutic window and is generally limited to use in
Fitzpatrick skin types I-III.8 One study showed that the KTP
laser can help reduce postoperative swelling and bruising in
aesthetic facial surgery. In this study, 30 patients receiving
laser-assisted surgery (where dissection and hemostasis was
accomplished with a laser) were compared to patients who
had similar operations using scissor/scalpel dissection with
electrocautery for hemostasis. Evaluations were performed
by comparing patient self-assessment and postoperative
photographs. Patients whose procedures were performed
with the help of the KTP laser showed a noticeable reduction
in swelling, bruising, and discomfort.9

Laser treatment of periocular skin conditions


Although the PDL and KTP laser can help with superficial
vascular lesions, such as port wine stains and superficial
infantile hemangiomas, venous malformations and deep
hemangiomas lie deeper in the dermis or subcutaneous tissue
and require a laser with a longer wavelength, such as the
alexandrite (Alex) (755 nm) or neodymium-doped yttrium
aluminum garnet (Nd:YAG) (1064 nm). Venous malformations are compressible, blue-purple vascular nodules or
plaques present at birth. Patients may request treatment of
these vascular lesions for cosmetic purposes or for relief of
pain or functional impairment. The Nd:YAG laser is safe and
efficacious for the treatment of a venous malformation.10,11
The main disadvantage of using the Nd:YAG is the higher
incidence of scarring and dyspigmentation. To reduce the risk
of scarring, test pulses can be used and tissue response assessed
before treating the whole lesion. Treatment parameters should
also be adjusted before treating patients with darker skin.
In contrast to the Nd:YAG, scarring and ulceration rarely
occur with the PDL, with rates of occurrence ranging from 0%
to 4%.1215 One study looked at 22 patients with periocular
superficial hemangiomas and noted that even hemangiomas in
this location responded well to PDL, with no reported cases of
scarring, atrophy, hypopigmentation, or ulceration.16
When using PDL around the eye, there is the potential for
permanent loss of eyelashes. PDL has a high absorption
coefficient for melanin, and although the PDL typically has a
wavelength that is not able to reach deep enough into the hair
follicle for hair removal, the eyelashes are an exception. At
this site, the hairs are oriented horizontally and located on
thin skin, which places them within the range of the PDL.17
Another reported complication that occurs with the use of
PDL in periorbital skin is the development of vitreous
floaters. Although the exact mechanism is not known, it is
proposed that in individuals without the proper eyewear,
whether patient or laser operator, the PDL can induce a shock
wave which disrupts the vitreous gel and releases floaters.18

Laser treatment of pigmented lesions

199
with a female predominance. Nevus of Ota usually has a blueblack or gray-brown appearance and appears along the
distribution of the first and second branches of the trigeminal
nerve (see Figure 2). The pathogenesis involves incomplete
migration of melanocytes between the neural crest and
epidermis during embryonic development.20 Nevus of Ota
has been called an oculodermal melanosis because it affects the
skin and the eye. In the eye, it has been reported to have 100%
episcleral involvement, 10% conjunctival involvement, and
18% retinal involvement.20 The ocular component is not
amenable to treatment with laser therapy; however, cutaneous
involvement can be targeted with Q-switched lasers.
Q-switched-Alexandrite and QS-Nd:YAG can be efficacious in the treatment of nevus of Ota. In a large study
involving 806 patients with nevus of Ota, 93.9% achieved
complete clearance after an average of 5.2 sessions with the
QS-Alex, and no patient had any long-term adverse effects
more than 3 years after treatment.21 The QS Nd:YAG (1064
nm) is at times preferable due to its longer wavelength and
therefore deeper penetration. A recent study compared the QSNd:YAG (1064 nm) with the QS-Alex (755 nm) and with the
QS-KTP (532 nm) on 15 patients with nevus of Ota over an 8year period. Twenty percent of patients responded better to
QS-Nd:YAG-1064 nm compared to the QS-Alex or the shorter
wavelength QS-Nd:YAG.22 Another study documented more
than a 70% improvement in nevus of Ota lesions treated with
the Nd:YAG laser.23
Treatments are generally spaced widely apart, every 3-6
months, with the majority of patients showing improvement
after 4 to 8 treatment sessions. 21,22 Fluences typically range
from 4-11 J/cm2. Fluences as low as 2.5 J/cm2 can also be
effective and less likely to result in side effects, but require
many more treatment sessions.24
Q-switched lasers are among the most dangerous to the eye.
A QS-Nd:YAG laser, if used incorrectly without the proper
eye protection, can ablate the retina, cause vitreous hemorrhage, and result in permanent damage for either the physician
or the patient;2527 yet, none of the case reports have reported
these kinds of intraocular complications.2124,2830 In all the
case reports involving laser treatment for nevus of Ota,

The Q-switched (QS) lasers are frequently used in the


treatment of pigmented lesions. These lasers work by
producing rapid, nanosecond bursts of energy that match
the thermal relaxation time of the small particles of melanin
or tattoo pigment.19 In this section, we will focus on the use
of the Q-switched lasers for treating nevus of Ota,
melanocytic nevi, and for the removal of cosmetic eyeliner
tattoos. In all cases, it is vital to use metal corneal shields
under the patients eyelids. Permanent visual loss and retinal
damage can occur if the proper eyewear is not used.

Nevus of Ota
Nevus of Ota is a benign dermal melanocytic nevus that
usually appears at birth. It is seen most commonly in Asians,

Fig 2 Nevus of Ota along the distribution of the first and second
branches of the trigeminal nerve.

200
protective goggles were used by the physician and metal
shields by the patient. The only major patient side effects
recorded from the lasers were hypopigmentation (15.3%),
hyperpigmentation (2.9%), texture changes (2.9%) and
scarring (1.9%) of the skin.28

Eyeliner tattoo removal


In recent years, permanent tattoos have been increasingly
used for cosmetic reasons, to enhance or reshape the natural
eyelids and eyebrows. At the same time, the demand for
tattoo removal has increased due to dissatisfaction in the
application or positioning of the tattoos.31 Previous methods
of eyelid tattoo removal included surgical excision, carbon
dioxide laser vaporization, and cryotherapy. All of these
methods were very likely to result in scarring and/or the loss
of eyelashes. More recent advances in laser therapy have
decreased the incidence of these side effects.
Eyeliner tattoos can be removed using nanosecond pulses
of energy to induce photomechanical damage. This breaks up
the tattoo particles and the lysosomes of macrophages,
fibroblasts, and mast cells that contain the pigment.
Disrupted tattoo pigment is then shuttled to regional lymph
nodes by host macrophages. The three lasers that are most
useful for removing the dark blue or black pigment in most
eyeliner tattoos are the QS-ruby (694 nm), QS-Alex (755 nm),
and QS-Nd:YAG (1064 nm).32
Caution must be exercised in the removal of flesh-toned
and white tattoos, as the application of Q-switched laser
pulses can cause darkening of the tattoo. This effect is
probably due to the oxidation of red ferric oxide to black
ferrous oxide (in the case of flesh-toned tattoos) or white
titanium oxide to black dititanium trioxide (in the case of
white tattoos). For this reason, we recommend performing
test spots before proceeding with full treatment.
As long as the appropriate metal corneal shields are used,
studies have shown good results and the absence of
intraocular complications. One report describes a patient
treated with QS-Nd:YAG with a 1.5-mm spot size at 6 J/cm2
who experienced complete removal of the eyeliner tattoo in 2
months, with no complications.32 In another case, a patient
was treated with a QS-Alex laser (755 nm), with a fluence
range of 6.75-7.5- J/cm2. After five treatments, there was
noticeable pigment lightening and no side effects.33 Notably,
there are only a few case reports and no large scale studies
examining the safety and efficacy of eyeliner tattoo removal.

Melanocytic nevi, acquired and congenital


Melanocytic nevi are benign neoplasms of the skin
composed of nevus cells, which can either be acquired or
congenital. Congenital melanocytic nevi (CMN) are typically present at birth or shortly thereafter. Acquired and CMN
can occur anywhere on the body, and when present near
sensitive or exposed areas they can be disfiguring and

B. Yates et al.
cosmetically displeasing. Due to their malignant potential,
excision followed by histologic examination is the current
treatment of choice for melanocytic nevi. A number of laser
modalities have also been used, including ablative (CO2 and
Er:YAG) and pigment-specific lasers (QS-Alex, QS-ruby,
QS-Nd:YAG, and QS-KTP). Some authors recommend that
lasers be reserved for cases in which excision is not an option
because lasers make subsequent clinical monitoring difficult,
and the effect of laser energy on melanocytes is unknown.19
A number of considerations must be taken into account
before treating CMN including the size, location, cosmesis,
and risk of malignancy.34 Excision may not be a viable option
for nevi located in complex areas like the periorbital region.
Recently, combination laser therapy using ablative and
pigment-specific lasers has been successful in treating
complex medium to large CMN. Combination therapy is
based on the principle that initial ablative lasers will expose
underlying and deeper melanocytes making them more
available to pigment-specific lasers.
Among 52 patients with a total of 314 CMNs treated with
an Ultrapulse CO2 laser with or without a QS-KTP laser, a
reduction in pigment without any recurrence occurred in
81% of the patients and 94.6% of the lesions treated.35
Patient satisfaction was high (87%) at a mean follow-up of 8
years. The most common complications were recurrence and
hypertrophic scars in 5 lesions each. Unfortunately, this
treatment approach is operator-dependent and other studies
have been less promising. Another study using CO2 and
pigment-specific lasers (QS-Alex, QS-KTP, and QS-Nd:
YAG) in 55 medium-sized CMN36 achieved an excellent
response (N 75% reduction) in only 55% of the lesions
treated, with a recurrence rate of 11%.

Laser epilation of eyebrows


Laser therapy has been used commonly for hair removal
and involves the selective targeting of pigmented hair follicles,
with melanin in the hair matrix and bulb serving as the targeted
chromophore. The most common laser described in the case
reports of laser epilation is the diode (810 nm), which is
considered to have the highest efficacy for hair reduction and
can also be used in dark skin types.3739 Other types of lasers
used for hair removal include the ruby (694 nm), Alexandrite
(755 nm) laser, and Nd:YAG (1064 nm).40 The difficulty in
removing hair from the eyebrows lies in the anatomic structure
of the supraorbital ridge and orbital rim and most protective
eyewear tends to get in the way of the laser hand piece.40
Lasers have been used successfully to reduce synophrys and to
sculpt and reshape the eyebrows. Due to the scattering of laser
light within the skin, the high degree of precision necessary for
cosmetically satisfactory epilation in this region can be
difficult to achieve.
Of the laser procedures targeting melanin as a chromophore, laser epilation has the most literature on intraocular

Laser treatment of periocular skin conditions


complications. Patients who experience damage to the eyes
during this procedure usually complain immediately of severe
ocular pain, reduced visual acuity, photophobia, and a
deformed pupil. Case reports have documented multiple
complications, including iris atrophy with deformed pupils
as well as anterior chamber inflammation and cataracts.38,41,42
Such damage can occur even when the patient closes his eyes.
The diode laser can penetrate 3 to 4 mm, right through the thin
eyelids, which offer insufficient protection from the laser
beam.41 What further exacerbates the problem is a condition
known as Bells phenomenon, the tendency for the eye to roll
upwards when the eyelids are closed. This upward roll brings
the patients iris closer to the laser light, further promoting the
atrophy of the iris and the development of anterior uveitis, as
well as posterior synechiae.42,43
These disastrous ocular complications occur in cases of
negligence, when protective eyewear was not used, when it
was used improperly, or when there was a malfunction in the
eyepiece.37 One common mistake involves the temporary
removal of the patients protective glasses to have better
access to the area near the eyes. In procedures where
protective eyewear may interfere with treatment, one
alternative is to fit patients for metal contact lenses.39

Ablative laser treatment


Ablative lasers have become a common and increasingly
used modality for the treatment of focal benign epidermal,
adnexal, and hyperplastic lesions. Laser ablation is built on
the principle of selective photothermolysis with the targeted
chromophore being water, the major constituent of skin.
Multiple laser modalities are available for ablation therapy
including the carbon dioxide (CO2) and erbium-doped
yttrium aluminum garnet (Er:YAG) lasers. CO2 lasers
discharge a 10,600 nm infrared beam, causing tissue
vaporization when a minimum fluence of 5 J/cm2 is met.44
The Er:YAG emits a wavelength of 2940 nm, which is near
the peak absorption of water, thus having a coefficient for
water which is nearly 12 to 18 times greater than that of the
CO2 laser.45 Due to these differences, both lasers have their
distinctive advantages. CO2 lasers produce better tissue
contraction and hemostasis, whereas Er:YAG lasers have
shown faster healing times with less pain and complications.46 Both lasers have been widely used for decades, and
with the continual advancements in laser technology, the
scope of their practical uses increases. Recently, numerous
cases and studies have reported the effective use of ablative
lasers in treating periorbital lesions.

201
most common location (Figure 3).47 Clinical variants have
also been described including localized, generalized, familial, and trisomy 21-associated forms. They typically present
as asymptomatic discrete soft 2-4 mm flesh to yellowish
colored papules.48 Although benign, syringomas can pose
significant cosmetic concerns, given the exposed periorbital
location and the tendency to have multiple lesions. Several
treatment modalities have been described with varying
degrees of success including excision, dermabrasion,
electrodesiccation with curettage, and topical retinoids.
Laser ablation with CO2 and Er:YAG lasers has now
surpassed these at the treatment of choice for syringomas.
The use of CO2 laser vaporization for the treatment of
multiple syringomas was initially described with promising
results.49 In 1999, ten cases of periorbital syringomas were
treated with two passes of a CO2 laser at the settings of .2
second pulse duration, 5 watts, and 3-mm spot size. Nine
patients treated with either one or two sessions had
successful destruction of all lesions at a median follow-up
of 16 months. The most common side effect was prolonged
erythema lasting from 6-12 weeks in all patients without any
scarring.50 Another study of 11 patients treated using an 80mm drilling hand piece, demonstrated excellent clinical
response in 7 patients and good response in the remainder.
Again, no serious complications were reported, including
scarring or pigmentary changes.51
Fractionated CO2 lasers can also improve syringomas, but
multiple passes and consecutive treatments are needed for
fractional lasers for complete destruction.52 In 2011, a
prospective analysis was performed in 35 patients with
multiple periorbital syringomas treated with an ablative CO2
fractional laser system. Patients were treated at 1-month
intervals with pulse energy of 100 mJ and density of 100
spots/cm2 over two sessions. Evaluation 2 months after the
final treatment showed a near complete or marked
improvement in 18 (51.4%), moderate improvement in 12
(34.3%), and minimal improvement in 5 (14.3%) patients.53
A secondary benefit of the fractional laser system was the
skin tightening and improvement in wrinkles.
In addition to ablative CO2 laser therapy, unique
alternatives and combination methods have been described.

Syringomas
Syringomas are benign adnexal tumors of eccrine sweat
duct origin that typically affect women in their adolescence
and early adulthood, with the periorbital region being the

Fig 3

Periocular syringomas.

202

B. Yates et al.

In 2001, six cases of periorbital syringomas were treated using


temporary tattooing followed by a Q-switched Alexandrite
laser with clinical improvement.54 Pretreatment with trichloroacetic acid followed by CO2 laser was also described in a
case report in 2001 with improved clinical results but without
complete destruction of the targeted lesions.55

Xanthelasma
Xanthelasmas are a form of plane xanthoma that typically
present on the eyelids of middle-aged and elderly individuals
with the characteristic histologic finding of lipid-laden
macrophages known as foam cells. Clinically, they appear
as soft yellow papules and plaques most commonly on the
medial aspect of the eyelids (Figure 4). Typically, they pose
no complications themselves but can have a negative
cosmetic impact.56 Before laser therapy, surgical excision,
electrodessication, and trichloroacetic acid were the classic
treatment modalities for xanthelasmas. A number of lasers
including CO2, Er:YAG, PDL, QS-Nd:YAG, and a 1450-nm
diode laser have been described in treating xanthelasmas.
Ablative lasers were some of the first lasers described in
the treatment of xanthomas. In 1985, the use of a superpulsed
CO2 laser in the treatment of nine patients with xanthelasmas
was described, with a high degree of patient satisfaction.57 In
1996, the use of a high energy pulsed CO2 laser was
evaluated at 400 and 500 mJ in the treatment of two patients
with bilateral xanthelasmas. Complete eradication was
observed at three and four passes with no recurrence at a
follow-up of 8 and 12 months.58 A larger cohort in 1999,
which consisted of 23 patients (52 periorbital xanthelasmas)
treated with an ultrapulsed CO2 laser with complete removal
on first pass. Of the 23 patients treated, only three patients
had recurrence at 10 months.59
In addition to ultrapulsed CO2 lasers, Er:YAG lasers have a
good clinical response in ablation therapy of xanthelasmas. In
2001, 30 patients (70 xanthelasmas) treated with an Er:YAG
laser showed good clinical results without any serious side
effects including scarring or dyspigmentation.60 Similar results
were obtained in another study after the treatment of 15 patients
(33 xanthelasmas) with the Er:YAG laser. All lesions were

Fig 4

Xanthelasmas of the medial aspect of the upper eyelids.

completely removed during one session with multiple passes


until no visibly identifiable lesion remained. No recurrences
were reported at follow-up periods of 7 to 12 months.61
More recently, PDL lasers have been evaluated and used for
the treatment of xanthelasmas. In 2010, a prospective study
reported the results of 20 patients (38 xanthelasmas) treated
with a 585-nm PDL. Patients were treated for five sessions at a
fluence of 7 J/cm2 and pulse duration of 0.5 ms with two passes
at each session. Evaluation at 4 weeks after the last treatment
session showed a good clinical response (N 51% cleared) in
two-thirds and an excellent clinical response (N 75% cleared)
in one quarter of xanthelasmas treated.62

Milia
Milia are small benign keratinaceous cysts.63 Typically
they present as 1-3 mm white dome shaped papules that can
occur at any age and in various locations. Benign primary
milia typically present on the cheeks and eyelids, but other
variants have also been described with periorbital involvement including milia en plaque, multiple eruptive milia, and
milia associated with genodermatoses.63 Various methods
are used in treating milia including nicking with extraction,
topical retinoids, electrodesiccation, dermabrasion, and
cryotherapy, but only a few reports have described ablative
therapy with CO2 and Er:YAG lasers.
Using the Er:YAG laser, a group reported their results of
benign lesions treated with laser ablation, including four patients
with milia. A total of 78 milia were treated during one session (25 passes) with a fluence of 3-4 J/cm2. At a mean follow-up of 8
months, no recurrence was seen.64 A recent case report in 2011
described the successful treatment of periocular milia en plaque
with Er:YAG laser ablation during two sessions.65
In 2010, a case report described the use of CO2 laser
vaporization in treating a patient with spontaneous periorbital
multiple eruptive milia. After failed treatments with topical
isotretinoin and erythromycin, the patient was treated for 12
sessions with complete destruction of the periocular milia.66

Seborrheic keratoses
Seborrheic keratoses (SKs) are one of the most common
skin lesions a dermatologist may encounter and, although
benign, can be worrisome for patients due to their pigmented
color and undesirable cosmetic appearance. SKs are benign
epidermal tumors that can have a variable clinical presentation
but typically present as sharply demarcated, waxy, stuck on
papules and plaques. SKs can present nearly anywhere on the
body including the face and periorbital region. Dermatosis
papulosa nigra (DPN) is a very common clinical variant of SKs
in darkly pigmented individuals, with a predilection for the
face including the periorbital region.67 The incidence of DPN
in African Americans can be as high as 77%.68
Early laser therapy for SKs consisted of laser tissue
ablation. A large study reported complete removal of 690

Laser treatment of periocular skin conditions


SKs when comparing continuous versus superpulsed CO2
lasers in 1994.69 Another study in 2003 reported a 100%
clearance after a single session of 79 SKs treated with an Er:
YAG laser without any recurrence or serious side effects.70
In addition to ablative lasers, pigment-specific lasers have
been shown to be effective in treating SKs. Using the
alexandrite laser, a single patient with over 100 SKs was
successfully treated during four treatment sessions. With a
fluence of 100 J/cm2 and spot size of 8 mm, excellent
cosmetic results were obtained at 2 months follow-up.71
Another study demonstrated complete resolution of 93% of
1,567 SKs treated after one session with two diode lasers
(532 nm) and a red color enhancement.72
A study comparing KTP laser to electrodessication in
fourteen patients with DPN found no difference in clinical
outcomes, with 76-100% improvement in 75% of the
subjects treated with the KTP laser.73 Recently, another
group compared PDL (585 nm) with electrodessication and
found an 88% clearance rate with the PDL laser, again
without any difference compared with electrodessication.74
A few case reports have also described successful treatment
of DPN using Er:YAG and Nd:YAG lasers.75,76

Laser resurfacing
Traditional versus fractional resurfacing
Advancements in ablative resurfacing technology using the
pulsed CO2 and Er:YAG lasers have resulted in significant
improvements in clinical outcomes when treating periorbital
photo-aging including rhytides.7780 Due to their effectiveness, ablative lasers are typically considered the gold standard
for laser resurfacing. The target chromophore is water in the
epidermis and dermis, and the resultant tissue injury leads to
epidermal turnover and collagen regeneration. Although
effective, traditional fully ablative resurfacing, in which the
entirety of the skin surface area is vaporized, comes with
significant adverse effects, including prolonged healing time,
erythema, edema, and risk of hypopigmentation.81
The concept of fractional photothermolysis, in which only a
fraction of the skin surface area is targeted, was introduced to
combat these prolonged and unwanted side effects while
maintaining clinical effectiveness.82,83 Fractional photothermolysis creates microscopic columns of tissue injury (microscopic
thermal zones), leaving intervening tissue intact, which leads to
faster re-epithelialization and thus quicker healing times.84
Lasers that are highly absorbed by water, including the Er:
YAG (2,940 nm) and CO2 (10,600 nm) are termed ablative;
lasers which are only moderately absorbed by water are
nonablative, eg, Er:glass (1410 -1550 nm). Ablative lasers
vaporize columns of tissue with a surrounding microscopic
zone of thermal damage, whereas nonablative lasers create
columns of thermal damage and controlled denaturing of
collagen without a true hole of vaporization.

203

Ablative fractional resurfacing


Currently, ablative fractional lasers are approved by the U.
S. Food and Drug Administration (FDA) for the treatment of
rhytides, furrows, fine lines, and textural irregularities.85 A
number of recent studies have shown the clinical improvements in periorbital photo-aged skin including rhytides, laxity,
and dyschromia when treated with ablative fractional CO2
lasers. In 2010, a study using a dual-depth fractional CO2 laser
in 15 patients reported a 53.1% improvement in eyelid skin
rhytides after 6 months.86 In 2011, another study described
their results of 45 patients with moderate to severe photo-aged
skin treated with an ablative fractionated CO2 laser. At a 6month follow-up, patients achieved a 48.5% improvement for
skin texture, 50.3% improvement for skin laxity, and a 53.9%
improvement in dyschromia. Post-treatment side effects
including edema, erythema, crusting, and bronzing all resolved
within 7 days after initial treatment.87
Er:YAG fractionated laser systems have also had promising
results in treating photo-aged skin. Of 28 patients with mild-tomoderate actinic damage treated with Er:YAG laser over one
to four sessions, 21 had excellent results and 7 had good results
at 2 months after their final session. Erythema was the most
common reaction and ranged from 2-10 days without any
permanent complications including scarring.88
In 2010, a double blind split-face trial compared the
fractional CO2 and Er:YAG lasers for periorbital wrinkles in
28 patients. Both systems had significant reduction in wrinkle
depth, comparable patient satisfaction, cosmetic results, and
healing times. No statistical difference could be appreciated
between the two modalities.89
Although reports of ocular complications from the use of
erbium-doped lasers are rare, we know that they are capable of
ocular damage. The Er:YAG laser has been historically used in
ophthalmology for corneal and scleral ablation.90 It has a
wavelength of 2940 nm, which corresponds to the maximum
water absorption peak. This allows it to be strongly absorbed in
tissue with high water content (such as the human lens, cornea,
and vitreous humor). For this reason, the Er:YAG laser has been
used in small incision cataract surgery,91 pterygium removal,92
sclerotomy in cases of glaucoma,93 and vitrectomies (which
may be necessary in cases of retinal detachment or for removal
of vitreous floaters).94 Today, however, other treatment
modalities have supplanted this laser for ocular treatment.

Nonablative fractional resurfacing


The concept of nonablative fractional photothermolysis is
relatively recent, introduced in 2003.82 It is currently FDAapproved for the treatment of pigmented lesions, periorbital
rhytides, skin resurfacing, melasma, acne and surgical scars,
and actinic keratoses.95 Fractional nonablative laser treatments typically result in quicker healing and less down time
than ablative lasers but require more treatments to achieve
similar results.

204

B. Yates et al.

One study described the treatment of lateral periorbital


rhytides in 30 patients with four nonablative fractional lasers
over a period of 2-3 weeks, with improvement in wrinkles
when patients were assessed 3 months after the last
treatment.83 This study showed that the periorbital treatments
were tolerated well, with no complications involving the eye.
Some of the most common cutaneous side effects from
nonablative fractional resurfacing include transient erythema, edema, and bronzing, and acneiform eruptions. A large
study of nearly 1000 patients found a 1.77% incidence of
resulted in herpes simplex reactivation.96

lysis and a careful respect for the sensitive structures nearby,


namely, the eye. Through careful application of selective
photothermolysis, periocular tumors, vascular lesions, pigmented birthmarks, tattoos and even wrinkles can be
improved. Vigilant adherence to safety recommendations
can prevent many cutaneous complications and can mitigate
the most egregious risk of vision loss. As laser technology
continues to advance, we are sure to see improvements in
current treatments, as well as development of new applications of cutaneous lasers.

Patient preparation

References

The use of proper eye protection when performing laser


procedures is paramount. Wavelength-specific goggles must be
worn by the provider and staff at all times during a laser procedure,
and metal goggles should be fitted over the patients eyes. When the
area to be treated is on the eyelid or near the orbit (as with all of the
treatments discussed herein), opaque metal corneal shields must be
placed beneath the eyelids to protect the patients eyes.
To prepare the patients' eyes for placement of corneal
shields, the patients conjunctiva are anesthetized and an
ophthalmic ointment is used to protect the cornea. One author
(J.F.) instills two drops of ophthalmic tetracaine into each eye
and then places Lacrilube ophthalmic ointment into the concave
surface of each corneal shield. The patients lower lid is then
retracted, and the patient is asked to look up. The lower edge of
the corneal shield is inserted beneath the lower eyelid. Then, the
patient is asked to look up, and the superior edge of the corneal
shield is slipped beneath the patients upper eyelid.
The placement of corneal shields can be unnerving for the
patient, and the complete obstruction of vision that results can
be further frightening. For this reason, we sometimes employ
pre-procedure anxiolytic medication, such as 5-10 mg oral
diazepam. Patients should be counseled that they may
experience blurred vision post-procedure due to the ophthalmic ointment. They also should plan on having a ride home.
Approaches to anesthesia vary widely. Small lesions
requiring a limited number of pulses can frequently be treated
without anesthesia. Topical anesthesia can be beneficial for
larger treatment areas. For more painful treatments, such as
resurfacing procedures, we employ a combination of topical
anesthesia, nerve blocks, local anesthesia, systemic opiates,
and/or intramuscular nonsteroidal anti-inflammatory drugs. In
infants and young children, general anesthesia should be
considered to avoid the fear and pain associated with corneal
shield placement and with the laser treatment itself.97

Conclusions
Successful laser treatment of skin diseases in the
periocular region requires an understanding of laser thermo-

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