Tailoring your treatment regimens to each patient before and after laser resurfacing can be as important as the technology you choose in striving to help patients recapture the more youthful appearance they seek.
“We learned a long time ago through studies with Retin-A back in the 80s and early 90s, that if you prepare the skin, the epidermis allows these light treatments or other procedures to be much more effective,” says Michael Gold, MD, Medical Director of Gold Skin Care Center and the Tennessee Clinical Research Center, and assistant clinical professor, Vanderbilt University Medical School. “It sort of gets rid of some of the damaged cells. It opens the pores. It just allows things to work better.”
After laser treatment, skincare routines promote rapid healing, and enhance and reduce the risk of complications such as infection, pigmentary changes and scarring. Here, experts share their pre- and post-op regimens to optimize treatment success.
Dr. Gold emphasizes that routines be customized to each patient’s needs. “You need to look at the patient as an individual. And you need to look at what’s bothering them and what they are there for, and then come up with a treatment regimen that is useful for them before, during and after your procedures,” Dr. Gold says. He always prescribes sunscreen. He mixes and matches skincare products to a patient’s problems, possibly choosing from glycolic acid, fruit acids, antioxidants, hydroquinone, retinoid or microdermabrasion. “If you come in and you have actinic damage, I want products that have glycolic acids or retinoid,” he says. “But if you come in and you have a lot of pigment, I want to make sure that prepackage has hydroquinone or something that is going to be anti-bleaching.”
He continues retinoid treatment until procedures; however, he waits to add it after treatment. “But skin care continues throughout the whole healing process,” he says. Furthermore, he uses antioxidants before and during treatment and products with epidermal growth factors as wound-healing agents. To facilitate healing, he incorporates skincare brushes like the Clarisonic system.
Pre-Op Regimens Before Non-Ablative Treatments
Pre-op regimens often are not necessary before non-ablative laser resurfacing, most dermatologists interviewed explain, but they generally prescribe a variety of products for ongoing care. Before discussing procedures with patients, Christopher B. Zachary, MD, Professor and Chair, Department of Dermatology, University of California, Irvine, usually prescribes a regimen of topical agents that can have some long-term benefits, including moisturizers, retinoids, sunblock, hydroquinone and/or alpha hydroxy acids.
Richard Fitzpatrick, MD, La Jolla Cosmetic Surgery Center, and Clinical Associate Professor, University of California, San Diego, recommends ongoing collagen-producing regimens that may include a retinoid, TNS (SkinMedica), topical vitamin C and 4% hydroquinone (EpiQuin Micro, SkinMedica) for patients with darker skin or pigment problems. He also prescribes sunscreens with micronized zinc oxide or titanium dioxide, reminding patients to use a mirror to apply them evenly.For patients with a history of facial herpes simplex or cold sores, he prescribes 500 mg Valtrex twice a day beginning the evening before the procedure.
Suzanne Kilmer, MD, Associate Clinical Professor, Department of Dermatology, University of California, Davis, School of Medicine and Director of the Laser and Skin Surgery Center of Northern California, tends to prescribe zinc oxide, which, she explains, blocks UVA rays best. She also prescribes tretinoin or tazarotene to help normalize cells, Remergent DNA Repair Formula and topical vitamin C, which she continues until treatment. She also recommends the Clarisonic brush. “It keeps the pores clean, it keeps everything open, and it actually helps products to get in better as well,” she says. She may recommend Botox treatment to patients before laser treatments. “The way I explain it is that the lasers can help with the drape of the skin and smooth things out, but they are not doing anything to the underlying muscles,” she says.
Zakia Rahman, MD, Clinical Instructor of Dermatology, Stanford University, stresses pre-op and post-op sun protection with sun-protective clothing and sunblock. She prefers Coolibar clothing, with a +50 UPF factor, and recommends that patients having facial treatments wear hats with at least a 4-inch brim while outdoors. She prescribes sunblock (EltaMD and Colorescience Sunforgettable) rather than sunscreens, which absorb UV light and release heat. “When you are treating with lasers, you want to avoid excess heat into the skin because there is some evidence that just heat alone can induce post-inflammatory pigmentation or melasma in subjects who are prone to it.” Two weeks before treatment, Dr. Rahman also discontinues topical retinoids, which can blunt the heat-shock protein response. “What we’ve found with fractional lasers is that you are really dependent on the heat-shock protein response after treatment for rapid healing, because you’re dependent on that normal skin surrounding the highly damaged tissue,” she says. “What I’ve experienced initially was patients who were on topical retinoids had significantly more erythema and sometimes even crusting after treatment because they weren’t able to heal as quickly.”
Before non-ablative and ablative treatments, Dr. Zachary instructs patients to avoid aspirin, non-steroidal anti-inflammatories, vitamin E, gingko or other agents that may induce more bleeding or bruising unless they are medically necessary. Immediately before procedures, patients wash their faces thoroughly with a terry towel, soap and warm water for 5 minutes so the topical anesthetic is absorbed evenly. Although Dr. Gold stresses that his regimens vary, he may use Allergan’s Vivité GLX kit for mild to moderate photo damage before and after non-ablative resurfacing, Nia24 Skin Strengthening Complex and Sun Repair for Décolletage and Hands for photo damage and repair after non-ablative procedures, Obagi C for dyschromia and to brighten skin after non-ablative procedures, and Obagi Nu-Derm Kit or Condition & Enhance System with Tretinoin 0.05% before treatment with ablative and non-ablative lasers and after healing.
Before and after each ablative and non-ablative treatment and with every post-op visit after ablative treatments, Roy G. Geronemus, MD, Director of the Laser and Skin Surgery Center of New York and Clinical Professor of Dermatology, New York University Medical Center, gives patients a GentleWaves LED (Light BioScience) light treatment to reduce redness and facilitate healing. Before Ablative Laser Procedures Physicians stress the importance of antiviral and antibiotic medications and possibly anti-yeast treatments immediately before and 7 to 10 days after treatment with ablative lasers to prevent infection. “Anytime you do an ablative or non-ablative treatment, there is potential for herpes simplex virus infection and that can lead to scarring,” Dr. Geronemus says. He also prescribes fluorinated steroids 2 to 3 days before an ablative treatment.
Dr. Kilmer explains that anti-yeast medications are particularly important for fully ablative procedures. In addition, she continues anti-virals for at least 14 days if patients are treated very aggressively or are very prone to herpes infection.
When he sees patients well in advance of treatments with the fractionated CO2 laser, Dr. Zachary begins treatment with a retinoid, moisturizer and sunblock. Some experts have disputed the value of retinoids or hydroquinone before traditional laser treatments, Dr. Zachary says, but this changes with fractionated ablative devices, where you’re treating part of the skin. “You might treat 10%; you might treat 30%. But 70% in that case will remain untreated, and if you have a reservoir of hydroquinone or other agents, it is likely that they’ll be able to work immediately on the skin in terms of reducing post-inflammatory hyperpigmentation.” On the day of surgery Dr. Zachary uses topical anesthesia, meperidine 50 mg (Demerol), hydroxyzine 25 mg (Vistaril) and possibly 60 mg ketorolac (Toradol), and he may also give the patient lorazepam (Ativan) orally.
In addition to discontinuing retinoids or glycolic acids 2 weeks before fractionated ablative laser treatment and prescribing sunblock, Dr. Rahman prescribes a hydroquinone in patients with hyperpigmentation or melasma. She also prescribes clobetasol propionate the day before the procedure. “I found initially, when doing some split-face evaluations, that people who didn’t use the clobetasol on one side of the face actually had more swelling and bleeding on that side of the face,” she says. Her patients also take Benadryl the night before the procedure. Like Dr. Zachary, she instructs patients to discontinue medications that increase the risk of bleeding unless medically necessary.
Dr. Kilmer and Dr. Fitzpatrick prescribe the same topical pre-op regimen as they do for non-ablative procedures to aid in collagen formation.
Post-Op Care After Non-Ablative Treatment
After a non-ablative procedure, Dr. Fitzpatrick prescribes ceramide cream containing TNS (SkinMedica) beginning the day of the procedure and for 1 to 2 weeks to help reestablish the lipid barrier function of the skin surface layer. Patients resume pre-op regimens, including hydroquinone if necessary, after 1 to 2 weeks. Then they use TNS twice a day for at least 3 months. Dr. Fitzpatrick also tells them to apply thinner preparations first, then creamier ones and then oil- or petrolatum-containing products.
Dr. Geronemus also prescribes post-op ceramide cream and sunblock (Anthelios with Mexoryl). He prescribes prophylactic valacyclovir (Valtrex) for non-ablative procedures and may prescribe prednisone.
Dr. Zachary prescribes moisturizers after non-ablative rejuvenation and adds a hydroquinone at the first sign of increased pigmentation, particularly if he treated aggressively. If he anticipates significant swelling, he injects Celestone 6 mg intramuscularly or prescribes 40 mg oral prednisone for 2 or 3 days. He may prescribe antihistamine for itching. His staff also teaches patients how to use camouflage makeup during the post-op period.
Dr. Rahman recommends applying cooling masks or ice packs for 10-minute periods to reduce the heat in the skin and provides topical clobetasol in patients with significant erythema or risk of hyperpigmentation. Her patients can apply sunblock or makeup immediately after treatment.
For a few days after non-ablative procedures, Dr. Kilmer delays potentially irritating products. If the skin is injured, she uses a bland regimen. Her patients return to their normal regimen once their skin is back to normal.
Dr. Gold continues pre-op regimens after non-ablative laser resurfacing.
After Ablative Procedures
“With the ablative fractional resurfacing, it is important to recognize that there is a variable response depending upon the technology that is used and also the technique within each particular technology,” Dr. Geronemus says, explaining that some technologies penetrate more deeply, causing more bruising or redness, whereas others cause more peeling, for a more significant healing process. So there’s no “cookbook answer.” His post-op regimen depends on the extent and depth of the procedure. “Generally, we use Aquaphor Healing Ointment, and once the patient is re-epithelialized we get them off the Aquaphor and switch over to the ceramide cream,” he says. “Healing is very rapid with the ablative fractional resurfacing.”
Dr. Zachary applies zinc oxide cream, such as Desitin, to the skin immediately after treatment with a fractionated CO2 ablative laser and prescribes it for the first 48 hours after treatment. “Desitin stays in place and is absorbent,” he says. “It’s a cream. It stops the patient from drying out and it’s a very bland agent. It’s important to remember that many things that you’re going to put on the skin will be absorbed.” He then switches to Aquaphor, but he says it may cause acne. He recommends avoiding moisturizers with fragrances or complex moisturizers, which can be irritating. Dr. Zachary stresses careful monitoring, seeing patients the day after the procedure, at 1 week, 2 weeks and 4 weeks. “Every patient is going to heal just a little bit differently, and the fractionated CO2 lasers are real lasers with real results and the potential for real complications,” he says. After fractionated ablative procedures, hydroquinone can be applied 1 week after treatment or at the first sign of hyperpigmentation, much earlier than after traditional CO2 or erbium:YAG lasers, Dr. Zachary says. “So after 5 to 7 days, if you apply these topical agents, two things are going to happen. First, it will have its effect much sooner, and, secondly, the penetration of these agents in fractionated laser-treated skin is going to increase by 20 to 30 times, so it’s going to be much more effective, whatever agent you put on the skin.”
After fractionated procedures, most of the dermatologists interviewed prescribe dilute vinegar/water soaks every 2 hours; however, Dr. Geronemus prefers cool water soaks if he treated the patient aggressively and then switches to lukewarm water soaks after a few days.
Immediately after treatment, after washing the skin with dilute vinegar water, Dr. Rahman applies Aquaphor or petrolatum ointment. Patients continue washing with vinegar water and applying Aquaphor for 2 to 3 days, until re-epithelialization occurs, and then resume using makeup and sunblock. Dr. Rahman reminds patients that handwashing is essential to avoid infection when applying products. At the 7-day point, Dr. Rahman’s staff shows patients how to cover erythema with camouflage, such as Lycogel, which she says is creamier and thicker, or Colorescience Mineral Makeup, which is very lightweight and doesn’t cause milia or acne. “After you treat the patient’s skin with laser, there is a delicate balance in the immune response,” Dr. Rahman says. “So you need to up-regulate the immune response, which causes collagen production; however, you don’t want to overexcite the immune system because that can lead to post-inflammatory pigmentary alteration.” She uses Neocutis Bio-restorative Skin Cream and Line Tamer by Colorescience. At the 2-week mark, she re-institutes topical retinoids.
After fractionated ablative laser treatment, Dr. Kilmer’s patients use dilute vinegar soaks and Aquaphor, Vaseline or Elta emollient until the skin stops oozing and is healed. Then they begin using sunscreen and gradually return to normal routines, adding retinoid after 3 or 4 weeks.
For fully ablative CO2 procedures, wound care continues for 7 to 10 days, she says. Dr. Fitzpatrick administers 4 or 6 mg dexamethasone intramuscularly at the time of fractionated ablative procedures to reduce swelling. After using dilute vinegar water soaks for 3 to 5 days and Aquaphor or another ointment for 3 to 7 days, his patients switch to his non-ablative post-op regimen, with TNS ceramide cream for 1 week and then just TNS twice a day for at least 3 months to maximize collagen stimulation. Patients also begin using a full-spectrum sunblock approximately 1 week after treatment (TNS Ultimate Daily Moisturizer with an SPF of 30).
Dr. Gold may use Neocutis PSP cream immediately after ablative procedures for healing and collagen promotion, or he may use Hyalis hyaluronic acid gel. In addition, he may use Journée SPF 15 for day cream. He emphasizes that it is important to keep the skin moist after laser procedures. “We want a moist wound environment so that the epidermal cells can migrate in that wet environment,” he says.
Increasing Patient Compliance
Patient compliance with post-op regimens is essential. To that end, Dr. Fitzpatrick has patients return at 1 and 2 weeks, and 1, 3 and 6 months.
Dr. Rahman stresses the importance of simple regimens. “There is lots of data out there that shows that the greater number of medications that people have to take, the less likely they are to be compliant with their regimen,” she says.
Dr. Kilmer also has patients bring their prescriptions and products when they arrive for the procedure, so her staff can check them. In addition, to keep patients on track, dermatologists often provide detailed patient handouts with regimens and diary-like forms that patients complete as they continue with their skin care.
Pre-Op and Post-Op Regimens Essential
Post-operative care is critical after ablative procedures for patients to return to work and to avoid potential complications, Dr. Fitzpatrick says. “Having the skin re-epithelialize rapidly and having the initial inflammatory response settle down to a controlled level is important in reaching those goals, so the prophylactic antibiotics and antivirals may be critical in that situation. Also proper wound care postoperatively, especially in that first week, can make a big difference as far as the ultimate healing, as well as the rapidity with which the skin recovers. Particularly with the ablative procedures it’s going to be important.” However, postoperative regimens are also important after non-ablative procedures, he says. “It’s going to be more significant as far as the degree of new collagen formation that results over the next 3 to 6 months, so using these products that help stimulate new collagen will allow a much higher percentage of patients to reach the goals that they’re trying to achieve with smoothing their skin, tightening it and getting more youthful-looking skin.”
“The patients that I have seen that have post-inflammatory pigmentary alteration are those patients who have not been good with sun protection before and immediately after their treatments, so that’s when you can really see negative side effects,” Dr. Rahman says. In addition, she says, it’s important to up-regulate collagen production, but not so much that you cause greater disruption and greater inflammation. “When you have disruption of the dermal/epidermal junction, you can actually get pigment dropout, and so that’s what leads to hyperpigmentation in the dermis and that can be much harder to treat. So that’s why these regimens are so critical for patients. And what’s actually interesting is sometimes the patient factors and what they do before and after are as important if not more important than the device that’s used.”
Disclosures: Dr. Kilmer serves on the medical advisory boards for Lumenis, Rhytec, Candela, Cutera and Ellipse, and receives research support from these companies as well as Palomar, Sciton, Reliant and Cynosure. Dr. Zachary is an unpaid consultant for Sciton, Thermage, and Reliant, and has received speaking honoraria, grant support and equipment loans from these companies as well as other laser companies. Dr. Fitzpatrick has a financial interest in SkinMedica and a potential financial interest in Reliant. Dr. Gold has performed skincare research for many companies or sells their products in his practice, including Vivité, Obagi, Niadyne, Neocutis and many others. Dr. Rahman is a consultant for Reliant, Ellipse and Colorescience. Dr. Geronemus is on the medical advisory board for Lumenis and is an investigator for Reliant.