Immediate skin responses to laser and light treatments

Warning endpoints: How to avoid side effects

Molly Wanner, MD, MBA,a Fernanda H. Sakamoto, MD, PhD,a,b
Mathew M. Avram, MD, JD,a,b and R. Rox Anderson, MDa,b
Boston, Massachusetts

Learning objectives
After completing this learning activity, participants should be able to recognize warning endpoints for different laser applications; detail the laser tissue interaction underlying these
responses; and select the appropriate endpoints to optimize safety.

Disclosures
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).

Authors
The authors involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Lasers are versatile, commonly used treatment tools in dermatology. While it is tempting to follow
manufacturer’s guidelines or other ‘‘recipes’’ for laser treatment, this approach alone can be a recipe for
disaster. Specific and immediate skin responses or endpoints exist and are clinically useful because they
correlate with underlying mechanisms that are either desirable (ie, therapeutic), undesirable (ie, warning
signs of injury or side effects), or incidental. The observation of clinical endpoints is a safe and reliable
guide for appropriate treatment. This article presents the warning endpoints during specific dermatologic
laser treatments, and the accompanying article presents the therapeutic endpoints, their underlying
mechanisms, and the utility of these endpoints. ( J Am Acad Dermatol 2016;74:807-19.)

Key words: adverse effects; endpoint; laser; light; skin; warning.

INTRODUCTION
Key points Abbreviations used:
d Immediate or short-term tissue reactions, IPL: intense pulsed light
called endpoints, can provide a reliable in- MTZ: microthermal zone
Nd:YAG: neodymium-doped yttrium aluminum
dicator of desired treatment response or of garnet
unwanted tissue injury RF: radiofrequency
SP: selective photothermolysis

From the Department of Dermatologya and Wellman Center for Accepted for publication June 3, 2015.
Photomedicine,b Massachusetts General Hospital, Harvard Reprint requests: Molly Wanner, MD, MBA, Department of Derma-
Medical School, Boston, Massachusetts. tology, Massachusetts General Hospital, 50 Staniford St, Ste 200,
Drs Wanner and Sakamoto contributed to this article equally. Boston, MA 02114. E-mail: mwanner@partners.org.
Funding sources: None. 0190-9622/$36.00
Massachusetts General Hospital receives royalties from laser Ó 2015 by the American Academy of Dermatology, Inc.
companies, but none are related to this manuscript. Dr Avram http://dx.doi.org/10.1016/j.jaad.2015.06.025
is on the advisory board of and a consultant for Zeltiq, is a Date of release: May 2016
consultant for Kythera, and is an investigator for Cutera. The Expiration date: May 2019
other authors declare no conflicts of interest.

807
808 Wanner et al J AM ACAD DERMATOL
MAY 2016

d The specific endpoints vary with the type of inside the tissue. The absorbed energy is converted
laser, with proper use of the laser, and with to heat, mechanical motion, or chemical reactions.
the histologic target(s) involved Most laser- and other energyebased treatments in
d Observation of clinical endpoints is crucial dermatology work by creating heat within tissue at
for the adjustment of laser parameters dur- specific target locations or in specific patterns.
ing treatment, both to increase efficacy and When using light sources, basic parameters that
to avoid side effects describe the dosimetry of treatment must be under-
Lasers and other energy sources are frequently stood. These include wavelength of light (nm), pulse
used in dermatology to treat vascular lesions, hyper- duration (in seconds), frequency of pulse delivery
trichosis, tattoos, various pigmented lesions, scars, (Hertz [Hz]), energy (Joule [J]), fluence (the incident
photoaging, and skin laxity (Table I). Of all surgical energy per unit area, J/cm2), power (watts [W], the
tools, lasers are both the most precise and the most rate of energy delivery), power density or irradiance
selective. For many applications, there are specific (the rate of incident energy delivery per unit area,
‘‘target’’ structures or distinct patterns of intended W/cm2) and exposure spot size (cm). For fractional
skin injury that achieve the therapeutic response lasers, the area density (ie, the fraction of skin
without causing significant collateral injury or scar- treated, expressed as %) and pulse energy (ie, J per
ring. Different anatomic, physical, and physiologic pulse, corresponding to depth of treatment) are also
mechanisms are involved in these various applica- important.84
tions. As a result, specific immediate and early skin Many of the lasers used in dermatology affect
responses or ‘‘endpoints’’ are seen during various specific light-absorbing ‘‘targets’’ (eg, blood vessels,
laser treatments that correlate with therapeutic out- pigmented cells, hair follicles, or tattoo ink) based on
comes. Other early responses are harbingers of the process of selective photothermolysis (SP).1,85 SP
unwanted injury or phenomena that lead to side depends on the preferential absorption of light by
effects. the targets, provided by light-absorbing molecules
We present the clinically useful early response called chromophores. For example, blood vessels
endpoints and their mechanisms that arise during are treated using hemoglobin as the target chromo-
treatment with laser and other energy-based devices phores; melanin is the target chromophore for the
in dermatology. Knowledge of specific desired (ie, treatment of hair and for various pigmented lesions;
therapeutic) and undesired (ie, warning) endpoints and tattoo inks or exogenous pigments are the
is key for the proper clinical use of lasers in chromophores for tattoo and traumatic tattoo
dermatology. The mechanisms underlying these removal. Flashlamp sources (intense pulsed light
early response endpoints are also fundamental to [IPL]) mimic lasers to some extent, using broad
understanding laseretissue interactions. There are 2 spectrum light through cutoff filters to target chro-
articles in this series; the current article presents the mophores. By choosing different wavelengths of
warning endpoints, following an overview of lasers, light, different chromophores are affected. IPL sour-
other energy sources, and their tissue interactions ces are generally less selective than lasers and may
and laser safety. The accompanying article presents be associated with a greater number of side effects.86
the specific therapeutic endpoints that are correlated For SP, a brief pulse of light is used to limit damage
with providing effective treatment. to the tissue surrounding the targets. By delivering
the energy in a pulse, the light-absorbing targets
become hot before much heat can diffuse into the
LASEReTISSUE INTERACTIONS
surrounding tissue. This produces a specific reaction
Key points
in the target chromophore and in the skin called an
d Selective photothermolysis depends on the
endpoint. The pulse duration is chosen to be about
preferential absorption of light by the histo-
equal or somewhat less than the time needed for a
logic target or chromophore
target to cool, called the thermal relaxation time.
d The laseretissue reaction in the histologic
Smaller targets cool faster and need shorter pulse
target produces a specific endpoint in the
durations for SP. Dermatologic lasers for SP span a
skin
wide range of pulse durations. For example, a tattoo
d Nonselective devices produce nonspecific
ink particle (;0.05-1 m) cools in \1 microsecond;
endpoints
nanosecond and picoseconds laser pulses are there-
Light, radiofrequency, microwave, ultrasonogra- fore used for tattoo removal. In contrast, a terminal
phy, plasma, and other sources that transfer energy hair follicle (;75-200 m) takes several milliseconds
into the skin produce their various effects based on to cool, such that 1- to 100-millisecond laser or IPL
the location, amount, and rate of energy absorption pulses are typically used for permanent hair
J AM ACAD DERMATOL Wanner et al 809
VOLUME 74, NUMBER 5

Table I. Devices and potential applications (including off-label)

Devices Applications
Pulsed dye laser1-5 Vascular lesionsdtelangiectasia, port wine stain,
hemangioma, angioma, and venous lake; lentigines;
keratosis pilaris; photoaging; poikiloderma; pyogenic
granuloma; sebaceous hyperplasia; scars (red); stria
(red); and verruca
KTP laser6-9 Similar to pulsed dye laser, for KTP lasers with similar
pulse durations
Alexandrite, long pulsed10-16 Hair removal; vascular lesionsdhypertrophic port wine
stains and lentigines; and benign melanocytic nevi, if
appropriate
Q-switched (alexandrite, ruby, Nd:YAG, and frequency Pigmented lesionsdlentigines, nevus of Ota, caf
e au lait
doubled Nd:YAG) and picosecond lasers (alexandrite, macules, some nevi; tattoos; drug-induced
Nd:YAG, frequency doubled Nd:YAG)17-24 pigmentation (eg, minocycline and amiodarone);
melasma (low fluence)
810-nm diode15,16,25-27 Hair removal; venous lakes; veins; and venous
malformations
1064-nm Nd:YAG, long pulsed28-31 Hair removal; veins; photoaging; and laxity
Nonablative, nonfractional mid-infrared (1320- Acne; scars; rhinophyma; hidradenitis suppurativa; and
1550 nm)32-45 photoaging
Intense pulsed light46-51 Acne; lentigines; hair removal; photoaging; poikiloderma;
vascular lesionsdtelangiectasia, leg veins, and port
wine stains
Ablative resurfacing (eg, erbium and CO2 lasers)52 Photoaging; scars; actinic keratoses and cheilitis;
seborrheic keratoses; adnexal tumors; rhinophyma;
and verruca
Nonablative fractional (wavelengths: 1320, 1440, 1540, Scars; photoaging; lentigines; rhytides; poikiloderma;
1550, 1410, and 1927 nm)53-63 melasma; minocyline-induced hyperpigmentation;
residual hemangioma; telangiectatic matting;
granuloma annulare; milia; striae; and
postinflammatory hyperpigmentation
Ablative fractional (wavelengths: 2790, 2940, and Scars; striae; photoaging; laxity; lentigines; rhytides;
10600 nm)64-71 morphea; drug delivery; anetoderma; and residual
hemangioma
Radiofrequency72-76 Laxity; rhytides; and cellulite/body contouring
Ultrasonography77-83 Laxity; noninvasive fat reduction

KTP, Potassium titanyl phosphate; Nd:YAG, neodymium-doped yttrium aluminum garnet.

reduction. A millisecond is 1 million times longer ultrasonography. Nonselective treatment devices

than a nanosecond. The wide range of pulse heat tissue with a depth or pattern that depends on
duration correlates with different damage mecha- where the energy is delivered.
nisms and with different corresponding clinical Ablative treatments remove tissue by vaporizing
endpoints. Because IPLs emit broad spectrum light it. For example, laser skin resurfacing is a classic
in a range of wavelengths, endpoints can be less technique that ablates a thin layer of epidermis and
specific. superficial dermis, using CO2 or erbium lasers.52,87
Nonselective treatment devices emit energy that is These lasers emit at wavelengths that are strongly
absorbed by water. Because water is present absorbed by water.88 For laser skin resurfacing, the
throughout the skin, these wavelengths are not laser energy is delivered uniformly at the skin
selectively absorbed by specific targets in the skin. surface, and immediate response endpoints are
There are endpoints associated with these devices, used to verify treatment depth.
but they are, in general, nonspecific. These include Nonablative treatments are those that heat but do
infrared, ablative, and nonablative lasers emitting at not vaporize tissue. The immediate response end-
wavelengths absorbed by water, various electrosur- points for these devices typically relate to thermal
gical devices, radiofrequency, and focused coagulation of tissue. Lasers for nonablative
810 Wanner et al J AM ACAD DERMATOL
MAY 2016

treatments, including fractional nonablative lasers, America releases an annual Laser Safety Guide.91
emit at infrared wavelengths that are weakly or All operators should have eye protection, fire pre-
moderately absorbed by water. The nonablative cautions, and fume extraction. It is the responsibility
treatment devices in dermatology also include radio- of the operator to protect the patient and everyone
frequency and ultrasonography, which can produce present in the treatment room.
thermal coagulation of tissue deep in the dermis or The eye is particularly susceptible to irreversible
subcutaneous fat.72,73 Focused ultrasonographic en- damage.92 Eye damage and blindness can result with
ergy is able to create a pattern of small zones of even a nanosecond of laser exposure. Retinas,
thermal injury deep inside soft tissue, near a focal corneas, and lenses are all susceptible.
point.77,78 The endpoints described in these papers are often
Fractional laser treatments53 use ablative or non- best seen in visible light without laser goggles. It is
ablative lasers that are delivered in differing patterns paramount that the laser should be placed in the
to produce different clinical results. The laser energy ‘‘standby’’ mode when the endpoint is evaluated
is delivered as an array of small beams, creating a without goggles and that laser goggles are replaced
pattern of up to 1000 small wounds per square before firing the laser.
centimeter of skin called microthermal zones
(MTZs). A fraction (#50%) of the skin can be injured, The warning endpoints
but healing is rapid because each MTZ is surrounded Heat produces a wide range of tissue responses
by unexposed, intact tissue. Nonablative fractional depending on the location, temperature, duration,
lasers produce columns of thermal injury that extend and rate of heating. Well below the boiling point of
up to about 2 mm deep.53 Ablative fractional lasers water, heat can destroy the structure of macromole-
vaporize an array of small (0.1-0.3 mm in diameter) cules including enzymes, structural proteins, mem-
vertical channels into the skin that can extend up to branes, DNA, and RNA. At nonlethal temperatures
3 mm deep.89 Energy delivered per MTZ controls the above about 428C, cells go into ‘‘heat shock,’’ a survival
depth of treatment while the number of MTZ per unit response that potently inhibits normal metabolism
area of skin controls the treatment fraction or the and partially blocks apoptosis. Heat shock is a
fraction of the area treated. clinically invisible cellular response. From about
The laseretissue interaction between a target 508C to 1008C, most proteins denature and then
chromophore (or histologic target) and a light source coagulate (stick to one another), killing cells and
elicits a reproducible clinical response. Some clinical causing some visible changes. Protein denaturation is
responses are suggestive of a therapeutic treatment a rate-dependent process that depends on both tem-
that will result in removal or partial removal of the perature and time. As such, skin cells can withstand
intended target. Other clinical responses are warning high temperatures for short periods of time (eg, 1008C
signs of excess damage to the skin that may result in a for a few thousandths of a second) but are killed at the
scar or other adverse event. modest temperature of 558C in a few seconds.93,94
There is little difference among cutaneous cell types in
LASER SAFETY their tolerance for thermal injury.95,96
Key points
d Lasers and light sources pose serious Look for the Nikolsky sign
hazards Key points
d Lasers and intense pulsed lights can result in d Warning endpoints are skin responses seen

blindness and irreversible eye damaged immediately or soon after laser irradiation,
never fire a laser without eye protection suggestive of tissue injury
and fire precautions in place d The Nikolsky sign is an indication of
d Always place laser and light devices in epidermal necrosis, corresponding to loss
standby mode before removing goggles of dermoepidermal adhesion.
d Always replace goggles before firing a laser d The Nikolsky sign can be desirable in spe-

cific situations
Laser and IPL devices pose serious and potent
hazards, especially for eye injury. There are physical Keratinocyte necrosis is manifested by a positive
hazards, such as fire and electrocution, eye and skin Nikolsky sign appearing within 5 minutes. When
hazards, and biologic hazards, such as plume inha- lateral pressure is gently applied with the clinician’s
lation of infectious pathogens.90 Any individual finger, the epidermis separates from its underlying
working with these devices should receive compre- dermis.97 In this setting, the Nikolsky sign (Figs 1
hensive safety training. The Laser Institute of and 2 ; Table II) is caused by loss of the actively
J AM ACAD DERMATOL Wanner et al 811
VOLUME 74, NUMBER 5

Fig 2. Superficial erosion of the lip after unintended bulk

heating during treatment with a nonablative fractional
laser (1540 nm). This photograph was taken 20 minutes
posttreatment. The patient washed her face and removed
the epidermis in the process, eliciting a positive Nikolsky
sign.

cool the skin during treatment. Signs of a skin burn

can be difficult to assess because after laser/IPL
treatment, the entire field is usually erythematous
and edematous. The Nikolsky sign can be present
without any other detectable sign of a first- or
second-degree burn. Checking for the Nikolsky
sign about 5 minutes after a test spot exposure is
strongly recommended in these settings.
The Nikolsky sign can be a desired therapeutic
endpoint. After the first pass of laser resurfacing or
during treatment of congenital melanocytic nevi
using the Kono technique,103-105 the Nikolsky sign
Fig 1. Angioma before (A), immediately after (B), and is often present.106 Gently removing the epidermis
8 weeks after (C) treatment with an 810-nm diode laser. with a sterile gauze pad is performed in these
There was inadequate compression of the sapphire tip. procedures to allow for deeper penetration of a
Note the deep blue color of the angioma that was cooled second laser pass (Fig 3). The risk of side effects and
appropriately. In the areas that were not cooled, there is scarring in these procedures is strongly related to
the Nikolsky sign (arrow); dermal whitening and a subtle
clinical experience. Otherwise, there is no clinical
elevation of the skin (double arrow); and charring of the
skin (asterisk). C, Hypopigmentation is evident at 8 weeks
setting for which the Nikolsky sign is a desired
posttreatment. This hypopigmentation has persisted therapeutic endpoint during laser treatment.
1.5 years after treatment.
Skin cooling: Too little, or too much?
maintained adhesion between keratinocytes and
Key points
dermis. This endpoint is a warning that the epidermis d Second- and third-degree and ‘‘stamping’’
is necrotic and that an open wound is likely to follow
burns correspond to injury because of the
with blistering, erosion, or ulceration, along with an
failure or misuse of skinecontact window
increased risk of infection, pigmentary changes, or cooling or the use of an incorrect device
scarring. d Spotty or crescent-shaped burns or ery-
One should look for the Nikolsky sign especially
thema can indicate inadequate or misaligned
when the risk of unwanted epidermal necrosis is
skin cooling or poor application technique
high or if the patient reports strong pain during
treatment. Typical situations include treatments of Actively cooling the skin during laser, IPL, or other
tanned or pigmented skin with any visible or near- energyebased treatments is useful to protect the
infrared laser or flash lamps (IPLs); the use of high pigmented epidermis, to reduce pain, and to
fluences or energy settings with any nonablative decrease the risk of skin burns. Skin cooling is
device; inadvertent pulse stacking (rapidly repeating accomplished by applying a cold external medium,
exposure of a skin site); and a failure to adequately which can be solid (as with cold windows in some
812 Wanner et al J AM ACAD DERMATOL
MAY 2016

Table II. Warning endpoints*

Warning endpoint Description
Nikolsky sign (Figs 1 and 2) Epidermal separation upon lateral pressure, indicating
loss of adhesion between epidermis and dermis
because of epidermal necrosis
Second- and third-degree burns (Figs 4 and 5) Pain, erythema, edema, blistering, and erosion
Stamping epidermal burn (Fig 6) Epidermal injury caused by the presence of tissue or hair
residue on a skin contact window
Crescent mooneshaped injuries (Fig 7) Epidermal injury caused by cryogen/laser misalignment
Pucker sign (Fig 8) Immediate skin shrinkage caused by thermal injury of the
dermis
Charring (Figs 1 and 9) Black or brown carbon on the skin caused by tissue
carbonization
Chrysiasis98,99 (Fig 10) Immediate, blue-grey discoloration caused by a Q-
switched laser effect on gold particles in the skin
Immediate tattoo darkening100,101 Immediate dark discoloration caused by laser treatment
of ferric oxide or titanium dioxide
Metallic-gray blanching102 (Fig 11) Dermal blood and protein denaturation

*Level IV evidence.

Fig 3. A, Congenital nevus treated with a long pulse plus short pulse approach93 before
treatment on the left knee. B, The Nikolsky sign was induced after 3 milliseconds of exposure to
a 755-nm alexandrite laser. Gentle removal of the epidermis was performed with sterile wet
gauze in preparation for the second laser irradiation with a Q-switched 1064-nm laser.

IPL and laser delivery handpieces), liquid (as with This can occur with diode lasers, IPLs, and radio-
cryogen spray cooling) or gas (as with forced cold frequency (RF) or ultrasonographic treatments.
air). When operating properly, skin cooling reduces Deeply penetrating monopolar RF or ultrasono-
the risk of side effects and allows the use of higher graphic treatments can result in fat damage with
treatment fluence. However, injury can also occur by dimpling of the overlying skin. The warning end-
misuse or malfunction of skin cooling points of second- and third-degree burns are as
methods.98,107,108 The skin can be injured by either follows: severe pain, intense erythema, local edema,
too little cooling or by freezing from too much blistering, epidermal splatter (ie, pieces of epidermis
cooling. Freezing the skin is easily observed as a detach from skin and attach to the laser handpiece
frosty-white color change. window), erosion, or ulceration (Figs 4-6). These
With cold window devices, poor contact with iatrogenic burns may heal with erosion/ulceration,
the skin is an operator-dependent problem that can crusting, pigmentary changes, secondary infection,
cause skin burns immediately after exposure (Fig 1). and scarring.
J AM ACAD DERMATOL Wanner et al 813
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Fig 5. A second-degree burn showing the value of cool-

ing to protect pigmented epidermis. The arrow points to a
second-degree burn of porcine skin after failure of skin
cooling. The double arrow points to an area treated with
the same laser and proper epidermal cooling. There are no
signs of a burn.

Fig 4. A second-degree burn with blistering after the use

of a 755-nm alexandrite laser for the treatment of a deep, Skin shrinkage is a sign of dermal injury
unresponsive port wine stain. Key points
d Skin contraction and the ‘‘pucker sign’’ are

indications of a dermal burn, corresponding

Inappropriate use of cold window devices can
to thermal denaturation of collagen
pose additional risks. During laser/IPL hair removal, d Immediate shrinkage of the dermis can
when a piece of charred hair adheres to a contact
cause the skin to become slightly elevated
window device, energy is strongly absorbed by the
and firm
charred tissue with each laser pulse. This can cause a d Unintended ablation is an indication of ther-
‘‘stamping’’ burn pattern with each subsequent pulse
mal burn
(Fig 6). This potential adverse effect can be simply d ‘‘Charring’’ indicates a severe burn, corre-
avoided by cleaning the window both before and
sponding to carbonization of tissue
during treatment.
Some laser devices incorporate ‘‘dynamic’’ cryogen Type I collagen is the most abundant protein in
spray cooling, which coats the skin surface with a the dermis. When heated above about 708C, type I
spurt of very cold (approximately 508C) fluoro- collagen undergoes a helix-to-coil conformational
carbon liquid just before or just after the laser pulse change, leading to immediate skin shrinkage.94 This
is delivered. Cryogen spray cooling is available on endpoint is always an indication of significant ther-
some pulsed dye lasers, alexandrite, and neodymium- mal injury to the dermis. For some applications, a
doped yttrium aluminum garnet (Nd:YAG) lasers. moderate amount of immediate shrinkage is a useful
When used properly, cryogen spray cooling is therapeutic endpoint (eg, during the final pass of
extremely helpful in protecting the pigmented ablative laser resurfacing or during high-density
epidermis from laser-induced injury and reducing ablative fractional laser treatments). However, in
the risk of blisters, pain, and swelling. However, any application where dermal injury is unwanted,
excessive cryogen spray duration (eg, [100 ms) can immediate shrinkage is an ominous warning
freeze the skin, particularly if used in combination endpoint that should lead the clinician to stop
with other cooling devices, such as cold air. treatment and reassess the situation. For example,
The warning endpoint consists of a bright white immediate skin shrinkage should not be seen during
frosting that persists for several seconds (Fig 7). nonablative laser treatments or during any applica-
Misalignment between the cryogen spray and laser tion of selective photothermolysis (eg, vascular
beam can also cause arcuate or crescent ‘‘moon- lesions, pigmented lesions, tattoo removal, or hair
shaped’’ patterns of skin injury. Even if the device is removal). This warning sign is not limited to laser
properly aligned, moon-shaped injury can occur if treatments and can also occur during IPL, RF, ultra-
the laser handpiece is not held perpendicular to the sonographic, or plasma exposure.
skin surface. Sometimes it is unclear whether such Shrinkage can be observed in several ways. First,
arcuate injuries were caused by a cryogen injury or a the skin will visibly contract during laser exposure.
laser burn injury, but both mechanisms can be However, it can be difficult to see this endpoint
prevented by proper alignment and positioning of through protective laser goggles and impossible to
the laser/cryogen handpiece and close observation see when using an occlusive handpiece. The
of treatment endpoints. ‘‘pucker sign’’ is another, more reliable indicator of
814 Wanner et al J AM ACAD DERMATOL
MAY 2016

Fig 6. A, Stamping burn pattern after the use of an 800-nm diode laser with a dirty cold contact
window. B, Hair char is present on the cold window.

Fig 7. Freezing of the skin from excessive cryogen spray

cooling. In this case, 100-ms of cryogen spray was applied
both before and after delivery of an 8-mm diameter
alexandrite laser pulse. A halo of skin surrounding the Fig 8. ‘‘Pucker sign,’’ a radial pattern of superficial skin
laser exposure is frozen. When the frost persists for more lines caused by immediate skin shrinkage. The pucker sign
than a few seconds, freeze injury is likely to occur. The is illustrated by this test exposure using a defocused CO2
cryogen spray duration should be reduced. laser. Immediate shrinkage is a warning endpoint of
significant thermal injury to the dermis. Some immediate
skin shrinkagedthe skin surface lines assume a shrinkage is normally seen during ablative laser resurfac-
ing, but in most other settings this is an ominous endpoint.
radial pattern pointing to the center of the exposure
from a laser or other device (Fig 8 ). A more subtle
sign of immediate shrinkage of the dermis is slight laser treatment of tattoos, pieces of live tissue can be
elevation of the skin and firmness to palpation explosively expelled from the skin, flying rapidly
(Fig 1). toward the treating physician. Depending on
One unfortunately common and preventable country of origin, people with tattoos are more
cause of scarring is the use of any IPL device for likely to have viral hepatitis or HIV.100,101,109 If the
treatment of tattoos. The pulse duration of all IPL patient harbors viral hepatitis or HIV, health care
devices is too long for selective photothermolysis of personnel can be directly exposed to ablated, infec-
tattoos.99 The puckered lip sign is sometimes seen tious tissue fragments. In addition, laser plumes from
during this inappropriate use of an IPL. tissue ablation or from partial combustion of hair
Controlled tissue ablation is the goal during during laser or IPL hair removal can be irritating or
vaporization of verrucae and other lesions, during toxic.88
laser resurfacing, and during ablative fractional Charring is another warning endpoint. When
resurfacing; however, ablation during other types energy continues to be applied to tissue after most
of procedures is a sign of excessive tissue injury. of its water is removed, partial combustion occurs,
During any nonablative procedure, ablation of the and the tissue surface becomes charred. Charring
skin should not be seen. In addition to signaling a consists of a thin layer of black or dark brown carbon
thermal burn, tissue ablation poses a biohazard, and adhered to the tissue surface (Figs 1 and 9). Skin
protective measures should be taken whenever tis- charring is generally associated with excessive ther-
sue ablation is seen. For example, during Q-switched mal damage (eg, caused by the improper use or
J AM ACAD DERMATOL Wanner et al 815
VOLUME 74, NUMBER 5

Fig 9. Charring of the skin appears as black or dark brown

material adherent to the tissue surface (arrow). The
material is carbon released by partial combustion. During
ablative laser procedures, charring of the skin is a sign of
excessive thermal injury.
Fig 11. Metallic gray blanching of the skin after the use of
a high-fluence 755-nm alexandrite laser for the treatment
of port wine stain.

immediate, permanent blue-grey discoloration of

skin. This is laser-induced chrysiasis,110 a specific
warning endpoint created by the interaction of the
Q-switched laser with gold deposits that remain in
the skin for a lifetime. The situation can be avoided
by obtaining a history of gold therapy before any
Q-switched laser treatment. However, some patients
may not recall taking gold decades ago or may not
recognize gold exposure unless made aware that
‘‘aurothiomalate’’ is a gold-based medication used
Fig 10. Laser-induced chrysiasis is a blue-grey discolor- for arthritis, for example. Particularly in a patient
ation of the skin caused by Q-switched laser exposure. It with a history of rheumatoid arthritis, a good habit is
occurs in patients with a history of gold intake. Chrysiasis to deliver 1 test pulse in a hidden, nonesun exposed
is permanent and difficult to treat.
skin site, such as the inner upper arm, then look for a
blue-grey skin discoloration without laser goggles
malfunction of a resurfacing laser [conventional or (Fig 10). In some cases, laser-induced chrysiasis
fractional] or plasma device). can be improved by subsequent treatment with
long-pulse lasers or IPLs.102
Tattoo ink darkening is another warning endpoint
Other specific warning endpoints
that is specific to Q-switched laser treatment.111,112
Key points
d Immediate blue-grey darkening during Q-
Tattoo inks that contain red iron oxide or white
titanium dioxide generally turn black or dark gray
switched laser treatment indicates chrysia-
immediately upon exposure to a Q-switched laser.
sis, a potentially permanent side effect in
patients with a history of gold intake This darkening is thought to be caused by the
d Immediate
chemical reduction of ferric oxide to ferrous oxide.
tattoo darkening during Q-
Tattoo ink darkening is irreversible, but the dark-
switched laser treatment indicates a chemi-
ened tattoo ink can sometimes be removed by
cal alteration of tattoo inks that may not be
subsequent laser treatments.113 The most common
removed with subsequent treatments
d Immediate metallic-gray blanching of skin is
setting for laser-induced tattoo ink darkening is
during treatment of cosmetic tattoos used as perma-
a sign of dermal overheating
nent lip liner or for eyebrows. Common colors
Some warning endpoints are highly specific. include flesh, pink, rose, or reddish colors.114
Q-switched laser treatment of a patient who has Finally, when using vascular-targeting lasers, the
been treated at any time with gold often causes an immediate metallic-gray blanching of the vascular lesion
816 Wanner et al J AM ACAD DERMATOL
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can indicate nonspecific dermal injury and the need to with the 585 nm pulsed dye laser. J Am Acad Dermatol.
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5. Bernstein EF, Kligman A. Rosacea treatment using the
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Nd:YAG, or diode lasers for vascular destruction.10 6. Clark C, Cameron H, Moseley H, Ferguson J, Ibbotson SH.
Overheating the vessels will cause heat propagation Treatment of superficial cutaneous vascular lesions: experi-
beyond the target vessels, damaging the surrounding ence with the KTP 532 nm laser. Lasers Med Sci. 2004;19:1-5.
7. Pancar GS, Aydin F, Senturk N, Bek Y, Canturk MT, Turanli AY.
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responsibility to recommend and use appropriate 595-nm pulsed dye laser in the treatment of facial telangi-
devices for treatment of a given problem and individ- ectasias and diffuse telangiectatic facial erythema. Dermatol
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signs, stamping epidermal burns, immediate skin microdermabrasion treatment for keratosis pilaris. J Derma-
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We thank Steve Conley at the Massachusetts General 19. Taylor CR, Flotte TJ, Gange RW, Anderson RR. Treatment of
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Answers to CME examination

Identification No. JC0516
May 2016 issue of the Journal of the American Academy of Dermatology.

Wanner M, Sakamoto FH, Avram MM, Anderson RR. J Am Acad Dermatol 2016;74:807-19.

1. c 3. a
2. b