THE MEDICAL BULLETIN OF

SISLI ETFAL HOSPITAL

DOI: 10.14744/SEMB.2018.46548
Med Bull Sisli Etfal Hosp 2020;54(2):193–196

Original Research

A Retrospective Analysis of Er:YAG Laser Treatment in Solar

Lentigines: Our Clinical Observations
Ezgi Aktas Karabay, Neslihan Fisek Izci
Department of Dermatology and Venereology, Bahcesehir University Faculty of Medicine, Istanbul, Turkey

Abstract
Objectives: To investigate the efficacy of erbium-doped yttrium aluminium garnet (Er:YAG) laser in the treatment of solar lentigines.
Methods: A retrospective study was conducted on patients treated with the only Er:YAG laser. In this study, 14 patients with multiple
solar lentigines before treatment were included. Treatment parameters and all side effects were recorded. One independent, blinded
dermatologist evaluated the clinical improvement and the patients also scored their satisfaction degree with the treatment.
Results: The mean age of the patients was 41.07±7.16 years. The number of mean treatment session for each patient was 1.79±1.05.
At the final visit, excellent improvement (76–100% clearance) was reached in eight (57.1%) patients, while good improvement (51-
75% clearance) was achieved in five (35.7%) patients. Ten patients (71.4%) were very satisfied and four (28.5%) patients were satis-
fied with the results of the treatment. No side effects occurred.
Conclusion: Er:YAG laser treatment may be an effective and safe optional modality for solar lentigines.
Keywords: Erbium:YAG laser; lentigo; therapy.
Please cite this article as ”Aktas Karabay E, Fisek Izci N. A Retrospective Analysis of Er: YAG Laser Treatment in Solar Lentigines: Our Clinical
Observations. Med Bull Sisli Etfal Hosp 2020;54(2):193–196”.

S olar lentigos are benign hyperpigmented macules

that often occur due to sun exposure. In solar len-
tigo, melanin accumulation is observed in keratinocytes
treatment due to the esthetic concerns of the patients, as
it is a significant finding of photoaging. Many treatment
options, such as skin peeling creams, cryotherapy, exfoli-
due to different degrees of melanocyte proliferation. ating agents, and recently various lasers and light sources,
[1]
In histological examination, narrowing of rete ridges, have been applied in solar lentigos and acceptable results
pigmentation, increase in the number of melanocytes have been reported.[1]
and melanophages are frequently observed.[2] In these Topical creams, mainly tretinoin and hydroquinone, tri-
lesions, dermoscopic features, such as pseudonetwork, chloracetic acid applications, cryotherapy, are being used
light brown fingerprint appearance, hairpin-shaped veins, for years for the treatment of solar lentigo. In addition, topi-
have been defined.[3] We should note that the diagnosis cal tyrosinase inhibitors and different combinations of ac-
of solar lentigo is almost always made clinically.[1, 2] Solar ids causing ablation have been used in its treatment. The
lentigos are completely benign; they do not show prema- use of ablative and pigment-specific laser systems in solar
lign features.[1] Despite this, there is an investigation for lentigos has been reported in few studies or frequently in

Address for correspondence: Ezgi Aktas Karabay, MD. Bahcesehir Universitesi Tip Fakultesi, Dermatoloji ve Venereoloji Bolumu, Istanbul, Turkey
Phone: +90 505 585 35 61 E-mail: [email protected]
Submitted Date: July 23, 2018 Accepted Date: September 20, 2018 Available Online Date: May 18, 2020
©
Copyright 2020 by The Medical Bulletin of Sisli Etfal Hospital - Available online at www.sislietfaltip.org
OPEN ACCESS This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
194 The Medical Bulletin of Sisli Etfal Hospital

case reports.[5] There are publications reporting that erbi- Clinical Evaluation
um-doped yttrium aluminum garnet (Er: YAG) lasers[6] have Patients were photographed with a digital camera be-
been used in the treatment of solar lentigo.[7, 8] fore treatment and after each procedure applied to the
We also use the Er: YAG laser device in the treatment of patient. The effectiveness of the treatment was evaluated
solar lentigo in our clinic. In this study, we retrospectively by comparing the photos taken before and three months
analyzed the results of Er: YAG treatment that we applied after the treatment. These photographs were evaluated
in solar lentigo. by a neutral dermatologist who did not know about the
treatment applied to the patient(s). The patients were
Methods evaluated based on a total of 4 points according to the
rate of regression in pigmentation as follows: 0: mild
The Study Plan
(0-25%) improvement, 1: mild-moderate (25-50%) im-
Patients who underwent Er: YAG laser treatment due to provement, 3: good (51-75%) improvement, 4: excellent
their solar lentigo were retrospectively analyzed in this (76-100%) recovery. In addition, patients evaluated their
study. Patients who did not receive any treatment for so- level of satisfaction with the results of the treatment on a
lar lentigo before and patients received only Er: YAG laser 4-point scale as follows. 1: not satisfied, 2: fairly satisfied,
treatment were included in this study. Cases with miss- 3: satisfied, 4: very satisfied.
ing file information were not included in this study. Age,
gender, localization of solar lentigo, number of laser treat- Statistical Analysis
ments and treatment parameters were recorded. As with all SPSS 17 (Statistical Package for Social Sciences SPSS Inc.,
sunlight-dependent diseases and laser procedures, Fitzpat- Chicago, IL) program was used for statistical analysis.
rick skin types were recorded. This classification describes Complementary data were expressed as mean±standard
six different skin types based on the color of the skin of the deviation, quantitative variables and percentages. The dif-
people and their response after exposure to sunlight. This ferences between the two independent groups were ana-
typing is as follows: Type I: Very white or freckled skin al- lyzed by the nonparametric Mann-Whitney U test. P<0.05
ways burns, but does not tan when exposed to sunlight; was considered statistically significant.
Type II: Fair skin, burns easily tans poorly; Type III: Darker
white skin, tans after initial burn; Type IV: light brown skin,
Results
burns minimally, tans easily; Type V: Brown skin, rarely The demographic characteristics of the patients included
burns, tans easily; Type VI: Dark brown or black skin, never in this study are shown in Table 1.
burns; always tans darkly.[9] Solar lentigo patients who received Er: YAG laser ther-
Consent was obtained from all patients who participated apy between July 2017 and July 2018 participated in
in this study, indicating that their medical data could be this study. Fourteen female patients were included in
shared at the first application. This study was approved this study. The mean age of the patients was 41.07±7.16
by the hospital ethics committee and conducted in accor- (33–52 years). The skin type of all patients included in this
dance with the Principles of the Helsinki Declaration. study was Fitzpatrick skin types II and III (four patients
with skin types II, and 10 patients with skin types III). The
Laser Therapy solar lentigos of nine patients were located on the face,
Er: YAG laser (Fotona SP Dynamis, Ljubljana, Slovenia) treat- four patients on the chest, three patients on the back and
ment was applied to all patients by the same dermatolo- one patient on the hand.
gist. Laser was applied after skin cleaning of the areas to Mean number of 1.79±1.05 (1–4) treatment sessions were
be treated.
Laser parameters were determined according to the char- Table 1. Demographic features of the patients
acteristics of the patient's skin and the response in the Age (years) Min–max 33-52
previous session. The parameters of 2940 nm Er: YAG laser Mean±SD 41.07±7.16
therapy were as follows: R11 head, 4-6 J/cm2 energy, 5 mm Gender Female 14
diameter head, 3-5 Hz frequency, short pulse (SP) mode. Male 0
Epidermal cooling device was used simultaneously during Fitzpatrick skin type II % (n=4)
laser treatment, and all patients wore protective glasses. III % (n=10)
After the procedure, all patients were prescribed epithelial Number of treatment sessions Min–max 1-4
creams and patients were warned to avoid sun exposure. Mean±SD 1.79±1.05
Aktas Karabay et al., A Retrospective Analysis of Er:YAG Laser Treatment in Solar Lentigine / doi: 10.14744/SEMB.2018.46548 195

applied to the patients. Three months after the last treatment gon, 532 nm Q-switched Nd: YAG, Q-switched ruby laser,
session, all patients showed improvement after treatment. Q-switched alexandrite laser and long-pulsed Alexandrite
Eight patients (57.1%) had excellent recovery (76–100%), laser are also reported to be used in the treatment of solar
while five patients (35.7%) had a good recovery. Ten patients lentigos.[4] Schoenewolf et al.[13] compared the efficacy of
(71.4%) were very satisfed with the treatment results and 694 nm Q-switched ruby laser and fractional CO2 laser in the
four patients (28.5%) were satisfied with the treatment re- treatment of solar lentigo and reported better response to
sults (Table 2). The mean score of the response to the treat- treatment in the Q switched ruby laser group. In the study
ment evaluated by the dermatologist was 3.5±0.65 points, where Vachiramon et al.[1] compared the efficacy and devel-
whereas the mean score of the patients showing their satis- opment of postinflammatory hyperpigmentation (PIH), Q-
faction with the treatment results was 3.64±0.497. There was switched Nd: YAG and fractional CO2 lasers in solar lentigo;
a positive correlation between between the evaluations of Nd: YAG laser was found to be more effective. In addition,
dermatologist and patients (p<0.05). the mean pain score was found to be higher, and recovery
All patients were followed for at least three months after time was longer in the Nd: YAG group compared to the CO2
treatment. No side effects were observed. laser group, without any significant difference between the
two groups in terms of PIH development.[1] Imhof et al.[14]
Discussion compared the topical mixture of Q-switched ruby laser and
In this study, where we retrospectively evaluated 2940 nm hydroquinone 5%, tretinoin 0.03%, and dexamethasone
Er: YAG laser applications in the treatment of solar lentigo 0.03% in solar lentigos located on the back of the hand. Ac-
in our clinic, we have shown that Er: YAG laser therapy can cording to the needs of the patient, Q- switched ruby laser
be a safe and effective treatment method in the treatment treatment was applied for one or two sessions, and topi-
of solar lentigo. cal treatment was applied once a day for a total of seven
weeks. The Q-switched ruby laser has been found to be
Solar lentigos are small, brown and benign lesions that are
more effective than topical treatment.[14]
formed in adulthood due to sun exposure.[5]
Tian et al.[7] reported good results in five Asian lentigo pa-
Most solar lentigo patients seek treatment because of their
tients who received the combination of 532 nm Q-switched
cosmetic appearance. Although there are many chemi-
Nd: YAG and then fractional non-ablative 2940 nm Er: YAG
cal or physical treatment options, the treatment of solar
laser for the treatment of solar lentigo. In a study where
lentigo is still a considerable challenge for physicians.[4,
Alexandrite laser was applied to 11 solar lentigo patients,
10]
Topical hydroquinone and tretinoin, chemical peeling
more than 50% improvement was reported in the treat-
agents, cryotherapy, laser treatments, and intense pulsed
ment of the lesions of the patients. Fractional ablative la-
light (IPL) treatments have been used in solar lentigos.[11]
sers are used in photodamage treatment. Lomeo et al.[8]
There are studies in which various laser treatments, such
compared the efficacies of microfractional Er: YAG laser
as pulsed dye laser (PDL), Q-switched ruby, Q-switched Nd:
and microfractional CO2 laser treatment in 10 photodam-
YAG, Alexandrite, Er: YAG, and CO2 lasers, have different de-
aged patients, and reported significantly more successful
grees of effectiveness in the treatment of solar lentigos.[5, 12]
results with microfractional CO2 laser. Manstein et al.[15] re-
Lentigos can be treated with many ablative and non-ab- ported the effectiveness of the fractional laser as 34-66% in
lative lasers. Although 532 nm Q-switched Nd YAG laser 30 patients with solar lentigo. Recently, ablative lasers such
is generally reported as the first-choice device due to its as ablative 10.500 nm fractional CO2 laser and non-ablative
high level of evidence, use of various lasers such as CO2, ar- 1.927 nm fractional thulium lasers have also been used in
the treatment of lentigo.[16] In a study comparing the effi-
Table 2. Evaluation of the treatment effectiveness by the cacy of Q-switched Nd: YAG laser, krypton laser and cryo-
physicians, and patients three months after treatment
therapy in solar lentigo, Q-switched Nd: YAG laser treat-
Assessments of the physicians ment was found to be more effective.[17]
Mild recovery Mild-moderate Good recovery Excellent recovery Er: YAG lasers are used for controlled surface ablation. Since
(0-25%) recovery (51-75%) (76-100%) the thermal damage caused by Er: YAG lasers are more su-
(26-50%)
perficial than that of other ablative laser systems, Er: YAG
0 7.14 % (n=1) 35.7% (n=5) 57.1% (n=8)
laser treatment requires a shorter reepithelization time and
Assessment of the patients’ levels of satisfaction is a less painful procedure.[18]
Not satisfied Fairly satisfied Satisfied Very satisfied
In this study, the results of solar lentigo patients who were
0 0 28.5% (n=4) 71.4 % (n=10)
treated with Er: YAG were examined. Thirteen of fourteen
196 The Medical Bulletin of Sisli Etfal Hospital

patients showed good and excellent recovery. All of the 6. Fitzpatrick RE. CO2 and Er:YAG laser resurfacing: practical ap-
patients reported that they were satisfied or very satisfied proaches. The use of lasers in dermatology. Dermatol Ther
with the treatment results. No side effects were reported. 2000;13:102–13.
However, as a limitation of this study, all patients participat- 7. Tian WC. Novel technique to treat melasma in Chinese: The com-
ing in this study had skin types II and III, which restricted bination of 2940-nm fractional Er:YAG and 1064-nm Q-switched
us from commenting on how the treatment results will be Nd:YAG laser. J Cosmet Laser Ther 2016;18:72–4.
in darker-skinned people. In addition, the response of solar 8. Lomeo G, Cassuto D, Scrmali L, Sirago P. Er:YAG versus CO2 abla-
lentigo to treatment by location could not be investigated tive fractional resurfacing: a split face study. Abstract presented
because it was not statistically significant due to the lim- at American Society for Laser Medicine and Surgery Conference.
ited number of patients in the groups. The small size of this Kissimmee, F; Apr 2008.
study group and the short follow-up period are other limi- 9. Fitzpatrick TB. The validity and practicality of sun-reactive skin
tations of this study. types I through VI. Arch Dermatol 1988;124:869–71.
10. Campanati A, Giannoni M, Scalise A, De Blasio S, Giuliano A, Gi-
As a result, we believe that 2940 nm Er: YAG laser can be
uliodori K, et al. Efficacy and Safety of Topical Pidobenzone 4% as
an effective treatment for the elimination of solar lentigo
Adjuvant Treatment for Solar Lentigines: Result of a Randomized,
lesions.
Controlled, Clinical Trial. Dermatology 2016;232:478–83.
Disclosures 11. Seirafi H, Fateh S, Farnaghi F, Ehsani AH, Noormohammadpour P.
Ethics Committee Approval: Bahcesehir University Faculty Efficacy and safety of long-pulse pulsed dye laser delivered with
of Medicine, Clinical Research Ethics Committee. Approval no: compression versus cryotherapy for treatment of solar lentigines.
22481095-020-1241, date of approval: 12/06/2018. Indian J Dermatol 2011;56:48–51.
12. Karsai S, Roos S, Hammes S, Raulin C. Pulsed dye laser: what's
Peer-review: Externally peer-reviewed.
new in non-vascular lesions?. J Eur Acad Dermatol Venereol
Conflict of Interest: None declared.
2007;21:877–90.
Authorship Contributions: Concept – E.A.K.; Design – E.A.K., 13. Schoenewolf NL, Hafner J, Dummer R, Bogdan Allemann I. Laser
N.F.I.; Supervision – E.A.K., N.F.I.; Materials – E.A.K., N.F.I.; Data col-
treatment of solar lentigines on dorsum of hands: QS Ruby laser
lection &/or processing – E.A.K.; Analysis and/or interpretation –
versus ablative CO2 fractional laser - a randomized controlled
E.A.K.; Literature search – E.A.K.; Writing – E.A.K.; Critical review
trial. Eur J Dermatol 2015;25:122–6.
– E.A.K., N.F.I.
14. Imhof L, Dummer R, Dreier J, Kolm I, Barysch MJ. A Prospective
References Trial Comparing Q-Switched Ruby Laser and a Triple Combination
Skin-Lightening Cream in the Treatment of Solar Lentigines. Der-
1. Vachiramon V, Panmanee W, Techapichetvanich T, Chanprapaph matol Surg 2016;42:853–7.
K. Comparison of Q-switched Nd: YAG laser and fractional carbon 15. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fraction-
dioxide laser for the treatment of solar lentigines in Asians. Lasers al photothermolysis: a new concept for cutaneous remodeling
Surg Med 2016;48:354–9. using microscopic patterns of thermal injury. Lasers Surg Med
2. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin 2004;34:426–38.
Clinical Dermatology. 10th ed. Canada: WB Saunders Company; 16. Hunzeker CM, Weiss ET, Geronemus RG. Fractionated CO2 laser
2006. resurfacing: our experience with more than 2000 treatments.
3. Lallas A, Argenziano G, Moscarella E, Longo C, Simonetti V, Za- Aesthet Surg J 2009;29:317–22.
laudek I. Diagnosis and management of facial pigmented mac- 17. Todd MM, Rallis TM, Gerwels JW, Hata TR. A comparison of 3 lasers
ules. Clin Dermatol 2014;32:94–100. and liquid nitrogen in the treatment of solar lentigines: a random-
4. Ortonne JP, Pandya AG, Lui H, Hexsel D. Treatment of solar lentigi- ized, controlled, comparative trial. Arch Dermatol 2000;136:841–6.
nes. J Am Acad Dermatol 2006;54:S262–71. 18. Lim JY, Jeong Y, Whang KK. A Combination of Dual-mode 2,940
5. Polder KD, Landau JM, Vergilis-Kalner IJ, Goldberg LH, Friedman nm Er:YAG Laser Ablation with Surgical Excision for Treating
PM, Bruce S. Laser eradication of pigmented lesions: a review. Medium-sized Congenital Melanocytic Nevus. Ann Dermatol
Dermatol Surg 2011;37:572–95. 2009;21:120–4.