Op-Med is a collection of original articles contributed by Doximity members.
This talk was presented to the Society of Plastic Surgical Skin Care Specialists on Thursday, April 26 at the New York Marriott Marquis Hotel in New York, NY. For the purposes of this article, the term ‘laser’ includes any skin treatments, such as intense pulse light, chemical peels and radiofrequency, which damage the epidermal layers.
In 2011, the latest year with a presumed complete data set, non-physician operators (NPO’s) accounted for 77.8 percent of malpractice cases caused by laser treatments. Two-thirds of these occurred outside a traditional medical practice.
The main complications of laser treatments are hyperpigmentation, hypopigmentation, burns, scars and malpractice. If the procedures are performed in a medical practice which has a physician on site, it should be mandatory that the doctor evaluates the patient and has a face to face discussion with the NPO concerning the treatment settings. Objective skin assessment using devices, such as the Visia by Canfield Scientific, can be an excellent way of monitoring progress and giving feedback to the patient.
The physician (and NPO’s) should have an in-depth knowledge and understanding of laser physics and the treatment parameters of the devices used and should be able to perform a treatment. All patients should be skin typed. Manufacturers, physicians and NPO’s often use the Fitzpatrick Skin Typing System (FST). This system grades patients according to their tolerance to ultraviolet radiation (UVR) from light (Type I) to dark (Type VI). The darker the skin, the higher dose of UV tolerated. This is the opposite of the tolerance to laser setting in which lighter skin types tolerate the higher setting. I call this the ‘Skin Typing Paradox’ and it is a constant source of confusion.
- Skin typing Types I and II and Types V and VI is straightforward. Type I & II is white skin with minimal hint of pigmentation (Germanic-Northern European/ Scandinavian). Type V and VI are West Asian (India, Pakistan) and African.
On the other hand, Types III and IV are often difficult to distinguish. Type III sometimes have a mild burn and tan uniformly (cream white; fair with any hair or eye color) (Mediterranean, Olive). Type IV burns minimally and always tan well (moderate brown). The most common skin type in the USA is Type III. This means that depending on your geographic location, that patient with FST III will be frequent visitors to your practice.
- Most common skin types (USA): FST III — 48 percent FST I or II — 35percent
Most Laser Companies group Types I-III together as tolerating higher setting and Type IV -VI as less tolerant, with lower settings. The risks of treating a darker skin type with settings that are too high are hyperpigmentation, hypopigmentation, burns, scars and malpractice suits. Before the advent of Fractional lasers in 2004 by Huzaira and Manstein, resurfacing lasers, such as the CO2 laser, applied a one-time blanket coverage which almost completely removed the dermis and epidermis (Ablative) in a confluent pattern with hypopigmentation as a common side effect. The results could be dramatic, but recovery lasted several weeks keeping the patient at home and away from their regular activities. Few patients or physicians are willing to accept that, along with the added risks of infection and scarring. With fractionated laser, the skin is treated in columns (Micro-Thermal Zones- MTZ’s) with skipped, intact normal skin left behind, preserving melanocytes and adnexal structures so that there is rapid re-epithelization and little risk of hypopigmentation. Fractional lasers require 4–6 treatments as compared to one treatment with the confluent, non-fractional laser.
Skin Typing FST IV as an FST III and setting laser setting accordingly can result in an inappropriately high setting with resultant complications. Short of using spectrophotometry, there is no fool-proof way to skin typing accuracy and even dermatologists disagree as to the correct skin type in a particular patient. Given that NPO’s account for 77.8 percent of Malpractice cases caused by Laser Treatments and two-thirds of these occurred outside a traditional medical practice, a simpler skin typing classification is urgently needed in the clinical setting.
I suggested a simpler three-tier classification, Types A, B and C. Type A includes FST I and II, Type B, FST III and IV and Type C, FST V and VI. All Type B patients are treated as a Type C initially. Once the response has been evaluated, then further treatment parameters can be increased. If in doubt, choose not to treat with light-based therapies and instead opt for topical skin products and/or radiofrequency.
Dr. Laurence Kirwan is a board-certified plastic surgeon who specializes in Cosmetic Surgery. He has published extensively and have been in private practice since 1987.
Disclaimer: The Author has no affiliations or Financial arrangements with Canfield Scientific or any other manufacturer and no off-label uses are recommended in this article.