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Stria tedavisinde lazer

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1 Stria tedavisinde lazer
Dr. Sedat Akdeniz Dicle Üniversitesi Tıp Fakültesi, Diyarbakır

2 Stria tedavisinde kullanılabilen lazerler
Pulsed-Dye Laser (PDL) Excimer Laser Copper-Bromide Laser 1,450-nm Diode Laser 1,064-nm Nd:YAG Laser Fractional Photothermolysis

3 Stria tedavisinde lazer kullanımı
Son yılların popüler tedavi seçeneği PDL en sık kullanımı bildirilen lazer CO2 (Carbon dioxide) ve erbium-substituted yttrium aluminium garnet (YAG) gibi ablatif lazerlerin kullanılması kısa süreli heyecan oluşturmuş Uzamış yara iyileşmesi ve özellikle esmerlerde pigmentasyon değişikliği kullanımını sınırladı

4 Lazer kollajen üretimi
Kullanılan lazerlerin dalga boyu ve enerji düzeyine bağlı olarak kollajen ve elastin üretimi etkilenir Uygun enerji düzeyleri ile fibroblast ve endotel hücreleri stimüle olurken, yüksek enerji düzeyleri kullanıldığında bu hücrelerin proliferasyon, üretim ve fonksiyonlarının inhibe olduğu gözlenmiştir Bosatra M, Jucci A, Olliaro P, et al: In vitro fibroblast and dermis fibroblast activation by laser irradiation at low energy. Dermatolgica 168:157–162, 1984 Boulton M, Marshall J: He-Ne laser stimulation of human fibroblast proliferation and attachment in vitro. Laser Life Sci 1:125–134, 1986 Castor DJ, Abergel RP, Keeker C, et al: Effects of the Nd: YAG laser on DNA synthesis and collagen production in human skin fibroblast cultures. Ann Plast Surg 11:214–221, 1983 Colver GB, Priestley GC: Failure of a helium-neon laser to affect components of wound healing in vitro.Br J Dermatol 121:179–186, 1989

5 Yeni kollejen oluşumu - lazer
Kullanılan lazerin enerji düzeyinin iyi bilinmesi gerekiyor Birden fazla lazerin yeni kollajen oluşumunu uyardığı bildirilmiştir Michel JL. ED2000s: 585nm collagen remodelling pulsed dye laser. J Cosmet Laser Ther 2003;5:201–3. Fournier N, Dahan S, Barneon G, et al. Nonablative remodeling: clinical, histologic, ultrasound, imaging, and profilometric evaluation of a 1,540 nm Er:Glass laser. Dermatol Surg 2001;27: 799–806. Prieto VG, Diwan AH, Shea CR, et al. Effects of intense pulsed light and the 1,064 nm Nd:YAG laser on sun-damaged human skin: histologic and immunohistochemical analysis. Dermatol Surg 2005;31:522–5. Papadavid E, Katsambas A. Lasers for facial rejuvenation: a review. Int J Dermatol 2003;42:480–7.

6 Pulsed Dye Laser Striaların erken evresinde dilate kan damarlarının belirgin olması tedavide PDL uygulaması için iyi bir durum oluşturmaktadır McDaniel ve ark, Alster immatür stria (rubra), tedavisinde 585-nm flashlamp PDL’in etkili olduğunu bildirmişler Karsai S, Roos S, Hammes S, et al. Pulsed dye laser: what’s new in non-vascular lesions. JEADV 2007;21:877–90. McDaniel DH, Ash K, Zukowoski M. Treatment of stretch Marks with the 585 nm flashlamp pumped pulsed dye laser. Dermatol Surg 1996;22:332–7. Alster TS. Laser treatment if hypertrophic scars, keloids and striae rubra. Dermatol Clin 1997;15:419–29.

7 Pulsed Dye lazer Extraselülar matrixte kollajen miktarını artırmaktadır Jiminez ve ark’ları (deri tipi I –IV) 585 nm flashlamp PDL’in stria rubra ve alba tiplerinin tedavisinde etkili olduğunu bildirmişler Koyu tenli kişilerde (tip VI-VI) pigmentasyon değişikliklerinden dolayı dikkatli kullanılmalıdır Jiminez GP, Flores F, Berman B, et al. Treatment of striae rubra and stria alba with the 585-nm pulsed-dye laser. Dermatol Surg 2003;29:362–4. Nouri K, Romagosa R, Chartier T, et al. comparison of the 585 nm pulse dye laser and the short pulsed co2 laser in the treatment of striae distensae in skin types IV and VI. Dermatol Surg 1999;25:368–70.

8 A) Skin biopsy of normal appearing skin adjacent to striae (elastin, X40). B) An untreated abdominal striae adjacent to the normal skin shown in a (elastin, X4O). C) Biopsy of the same abdominal striae shown in B, 8 weeks after treatment with the 585-nm flashlamp-pumped pulsed dye laser at a fluence of 2.0 f/cm- and a spot size of 7 mm. McDaniel DH, Ash K, Zukowski M: Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser. Dermatol Surg 22:332–337, 1996

9 Elsaie ML, Baumann LS, Elsaie LT. Striae distensae
Hematoxylin and eosin stain of mouse skin taken at 4 weeks after the four laser treatment modalities. Collagen fibers in the irradiated sites showed a marked increase in the amount and a significant improvement in the organization with the high affinity for the stain; (A) the 595-nm pulsed dye laser (PDL), (B) 1,320-nm neodymium–yttrium–aluminum garnet (Nd:YAG) laser, (C) 1,064-nm long-pulsed Nd:YAG lasers, (D) 1,064-nm Q-switched laser; A0, B0, C0, and D0 were their respective controls. Elsaie ML, Baumann LS, Elsaie LT. Striae distensae (stretch marks) and different modalities of therapy: an update. Dermatol Surg 2009;35(4):

10 Stria tedavisinde 585-nm PDL
Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser. McDaniel DH, Ash K, Zukowski M. Dermatol Surg Apr;22(4):332-7.

11 39 stria 4 farklı protokole göre bir kere tedavi edilmiş
Tedavi edilen strialar aynı hastanın tedavi edilmeyen striaları ile karşılaştırılmış Striaların yaşı: ort: 14 yı( 8 ay- 32 yıl) Tedavi yanıtı klinik, fotoğraf, deri biopsileri ile değerlendirilmiş

12 Tüm protokollerle klinik yanıt alınmasına rağmen en belirgin iyileşme 3.0 J/cm2 ile elde edilmiş
Tedaviden 8 hafta sonra biopside dermal elastin artışı saptanmış

13 Stria tedavisinde 585-nm PDL kullanımı
2 uygulama 3 J/cm2, 10 mm spot size 20 hasta Striaların yaşı: ort: 6 ay- 20 yıl Tedavi etkili, koyu tenlilerde pigmentasyon önemli yan etki Jimenez GP, Flores F, Berman B, Gunja-Smith Z. Treatment of striae rubra and striae alba with the 585-nm pulsed-dye laser. Dermatol Surg 2003;29(4):

14 Excimer Laser Fokal olarak uygulanabilen UVB’ye yakın dalga boyu
Vitiligo tedavisinde etkilidir Matür strialarda etkili olduğunu bildiren çalışmalar var Shen Z, Gao TW, Chen L, et al. Optimal frequency of treatment with the 308-nm excimer laser for vitiligo on the face and neck.Photomed Laser Surg 2007;25:418–27.

15 Excimer Laser- stria Skar dokusunda melanosit var mı?
Melanosit veya prekürsorleinin saptanması için mel-5, c-kit and NKI/beteb kullanılmış Skar dokusu ve çevresindeki normal dokudaki melanosit sayısı eşit olarak saptanmış Skar dokusunun açık renkte görünmesinin nedeni vasküler yapıların azalması ve optik yanılgı (kollajen fibrillerinin paralel dağılımından kaynaklanmaktadır) Why are Scars Pale? An Immunohistochemical Study Indicating Preservation of Melanocyte Number and Function in Surgical Scars SHIREEN S. VELANGI1 and JONATHAN L. REES2 Acta Derm Venereol 2001; 81: 326–328.

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17 Hipopigmente strialarda excimer laser’in etkinliği araştırılmış
75 hasta, total 615 tedavi Tüm hastalarda ortalama 8.4 tedaviden sonra strialarda pigmentasyon gözlenmiş Klinik olarak %80 iyileşme Matür striaların tedavisinde etkili bulunmuş Deri atrofisinde düzelme gözlenmemiş 308-nm Excimer laser treatment of mature hypopigmented striae. Goldberg DJ, Sarradet D, Hussain M. Dermatol Surg Jun;29(6):596-8.

18 Skar ve Stria pigment bozukluğunu düzeltmek için excimer laser
Yüz, gövde ve extremitelerinde hipopigmente skarları bulunan 31 hasta 50 J/cm2 Lezyonlara %50 ve %75 pigmentasyon gelişene kadar (kalorimetrik), 2 hafta aralıklarla aynı doz tekrarlanmış (maksimum 10 tedavi) Tüm hastalarda %60-70 klinik iyileşme gözlenmiş The safety and efficacy of the 308-nm excimer laser for pigment correction of hypopigmented scars and striae alba. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, Geronemus RG. Arch Dermatol Aug;140(8):

19 Hypopigmented scars treated with the 308-nm excimer laser
Hypopigmented scars treated with the 308-nm excimer laser. Prominent hypopigmented facial scars present at baseline (A) demonstrated excellent pigment correction following 5 treatments (B). The visual pigment levels began to decline at the 2-month follow-up (C) and returned to near baseline levels at the 6-month follow-up (D)

20 Striae alba treated with the 308-nm excimer laser
Striae alba treated with the 308-nm excimer laser. Striae alba on the hip are shown at baseline (A) and following 5 treatments (B), with excellent pigment correction. The cosmetic benefit was maintained to the 2-month follow-up (C). Striae alba in a dark-skinned patient treated with the 308-nm excimer laser. Striae alba on the abdomen are shown at baseline (A) and following 9 treatments (B), with excellent pigment correction. The cosmetic benefit was well maintained to the 1-month follow-up (C).

21 Copper-Bromide Laser Tek çalışma
SD’lı 15 hasta CuBr laser ( nm) ile tedavi edilip 2 yıl takip ediliyor Etkili olduğu bildirilmiş Two-year follow-up results of copper bromide laser treatment of striae. Longo L, Postiglione MG, Marangoni O, Melato M. J Clin Laser Med Surg Jun;21(3):

22 1,450-nm Diode Laser Non-ablative 1,450-nm diode laser’in atrofik skarın tedavisinde etkili olduğu bildirilmiş 11 hasta, stria rubra ve alba 4, 8, veya 12 J/cm2, 6 hafta arayla toplam 3 kere Hiçbir hastada iyileşme gözlenmemiş %64 hastada hiperpigmentasyon gelişmiş Lasers in Surgery and Medicine 38:196–199 (2006) Non-Ablative 1,450-nm Diode Laser Treatment of Striae Distensae Yong-Kwang Tay, MD,* Colin Kwok, MD, and Eileen Tan, MD

23 1,064-nm Nd:YAG Laser Dermal kollajende artış yapıyor
İmmatür strialarda dilate venüller ve içerisindeki oksihemoglaobin hedefidir Vasküler yapılara iyi penetrasyon gösterir Bundan dolayı immatür striaların tedavisinde etkili olarak kullanılabilir Trelles MA, A ´ lvarez X, Martı´n-Va´squez MJ, et al. Assessment of the efficacy of nonablative long-pulsed 1,064 nm Nd:YAG laser treatment of wrinkles compared at 2,4, and 6 months. Facial Plast Surg 2005;21:145–53. Sadick NS. Laser treatment with a 1,064 nm laser for lower extremity class I-III veins employing variable spots and pulse width parameters. Dermatol Surg 2003;29:916–9

24 1,064 nm Nd: YAG laser 20 hasta İmmatür stria tedavisinde
Belirgin etki bildirilmiş Komplikasyonlar nadirdir, esmerlerde bile yan etkiler azdır Goldman A, Rossato F, Pratti C. Stretch marks: treatment using the 1,064 nm Nd:YAG laser. Dermatol Surg 2008;34:1–7.

25 Treatment Using the 1,064-nm long-pulsed Nd:YAG Laser
20 hasta İmmatür stria, 26 tedavi (10 breast, 5 abdominal, 2 chest, 4 buttock, 2 flank, 3 thighs) Tip II-IV 3-6 hafta arayla 3-4 tedavi 1,064-nm long-pulsed Nd:YAG laser, spot size 2.5-mm, fluences J/cm2 Stretch Marks: Treatment Using the 1,064-nm Nd:YAG Laser ALBERTO GOLDMAN, MD, FLA´VIA ROSSATO, MD, AND CLARISSA PRATI, Dermatol Surg 2008;34:686–692

26 (A) 19-year-old patient with recent striae of the breast
(A) 19-year-old patient with recent striae of the breast. (B) Result after four sessions Stretch Marks: Treatment Using the 1,064-nm Nd:YAG Laser ALBERTO GOLDMAN, MD, FLA´VIA ROSSATO, MD, AND CLARISSA PRATI, MD Dermatol Surg 2008;34:686–692

27 (A) Striae gravidarum of the abdomen. (B) Result after three sessions.

28 Fractional nonablative laser- stria
Fractional nonablative 1550-nm erbium-doped laser’in stria tedavisinde kullanımı ile ilgili farklı oranlarda etkili olduğu bildirilmiş Kim BJ, Lee DH, Kim MN, et al. Fractional photothermolysis for the treatment of striae distensae in Asian skin. Am J Clin Dermatol 2008;9(1):33-37. Stotland M, Chapas AM, Brightman L, et al. The safety and efficacy of fractional photothermolysis for the correction of striae distensae. J Drugs Dermatol 2008;7(9): Katz TM, Goldberg LH, Friedman PM. Nonablative fractional photothermolysis for the treatment of striae rubra. Dermatol Surg 2009;35(9): Bak H, Kim BJ, Lee WJ, et al. Treatment of striae distensae with fractional photothermolysis. Dermatol Surg 2009;35(8):

29 Fractional Photothermolysis
Epidermisten dermise uzanan kolon şeklinde (MTZ) mikroskobik doku hasarları oluşturur Sonrasında kontrollü yara iyileşmesi Sağlam epidermal keratinositler hızlı bir şekilde (24 h) reepitelize olarak yara iyileşmesini hızlandırır Stratum korneum korunur Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med 2006;38(3):

30 Lasers in Surgery and Medicine 38:142–149 (2006) Skin Responses to Fractional Photothermolysis Hans-Joachim Laubach, MD,* Zeina Tannous, MD, R. Rox Anderson, MD, and Dieter Manstein, MD A) Hour 1 after FP (200 H&E). Microthermal zones (MTZ, black outline) with columns of altered collagen (black arrow) can be distinguished. The entire stratum corneum remains intact even above the epidermal MTZs. There is no inflammatory infiltrate around the dermalMTZsyet. B) Hour 1 after FP (200 H&E) vessels in the MTZs are thermally destroyed (white arrows).

31 Day1 after FP (200H&E). MTZsare outlined in black
Day1 after FP (200H&E).MTZsare outlined in black. Microscopic epidermal necrotic debris (MENDs; black arrows) represents the elimination of thermally damaged keratinocytes. MENDs are loaded with melanin. Subepidermal clefting is evident from 1 hour after FP and lasts up to 5 days (stars). The dermal part of the MTZs appears unchanged from day 1, and shows thermally altered collagen and a lack of nuclear staining. Subtle perivascular inflammatory infiltrate begins to form in the dermis (white arrow).

32 Day 7 after FP (200—Elastica von Gieson)
Day 7 after FP (200—Elastica von Gieson). The regular candelabra arrangement of elastic fibers persists at all times after FP (white arrow). MTZs are outlined in black

33 1540-nm fractional nonablative Er:Glass laser
51 hasta 1540-nm fractional nonablative Er:Glass laser 10 mm optik başlık ile mJ/mb veya 15 mm optik başlık, mJ /mb 6-8 hafta arayla 2-4 tedavi Klinik iyileşme 3 doktor tarafından değerlendirilmiş Histolojik değerlendirme hemotoxylin, eosin ve orcein-giemsa Son tedaviden 6 ay sonra olguların tümünde %50’den fazla iyileşme Aestehetic Surgery Journal 31(4) , Fractional Nonablative 1540-nm Laser Treatment of Striae Distensae in Fitzpatrick Skin Types II to IV: Clinical and Histological Results rancesca de Angelis, MD; Larissa Kolesnikova, MD; Franco Renato, MD; and Giuseppina Liguori, PhD

34 Fractional nonablative lasers
Epidermis ve dermiste gelişen mikrotermal hasar kontrollü yara iyileşmesini uyararak dermal kollajen artışını sağlar

35 Neocollagenesis in the reticular dermis resulting from the 1540-nm treatment. (A) Untreated striae show an atrophied epidermis with degenerated and fragmented collagen fibers. (B) One month after the last of three treatments with the 1540-nm erbium:glass laser, significant neocollagenesis is demonstrated.

36 Increased amounts of elastic fibers following the 1540-nm treatment
Increased amounts of elastic fibers following the 1540-nm treatment. (A) Before treatment, elastic fibers (dark purple stain) in the reticular dermis appear fragmented and sparse in number. (B) One month after the last of three treatments with the 1540-nm erbium:glass laser, the elastic fibers appear uniformly increased in number.

37 (A) This 40-year-old woman presented with widespread, 12-year-old, pregnancy-related vertical striae alba across her lower abdomen. This patient had a Fitzpatrick III skin type. (B) Three months after the last of four treatments with the 10-mm tip of the 1540-nm erbium:glass laser at energy settings ranging from 45 to 55 mJ/μb and a 15-ms pulse width, the hypopigmentation and textural irregularities were significantly reduced and the patient’s skin appeared uniformly smooth Another notable feature of this patient’s clinical outcome was the marked decrease in pretreatment hypopigmentation; taken together, these improvements in pigment and texture contributed to an overall softening and smoothing of the striation-like appearance of the treated region

38 (A) This 30-year-old woman presented with one-year-old striae rubra spanning her breasts as a result of pubertal growth. This patient had a Fitzpatrick III skin type. (B) Four months after the last of three treatments with the 10 mm-tip of the 1540-nm erbium:glass laser at 40 mJ/μb and a 15-ms pulse width, the pinkish-red discoloration of the striae appeared markedly reduced.

39 Lazer - stria Birden fazla etkili lazer var
Striaların erken dönemde tedavi edilmesi önemlidir Koyu tenli kişilerde pigmentasyon değişikliklerine dikkat etmek gerekir Uzun süreli iyileşmeler için yeni uygulamalar gerekebilir Fractional nonablatif lazer daha etkili gibi görünmektedir

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