Avoiding, treating fractional laser complications

Early recognition of fractional resurfacing complications can help patients avoid permanent scarring, says an expert.

Dr. Metelitsa“What's absolutely critical is that some complications of fractional laser complications are preventable,” says Andrei Metelitsa, M.D., co-director of the Institute for Skin Advancement and clinical associate professor of dermatology, University of Calgary. In this regard, he says, having a basic knowledge of what can happen, and having staff members call patients shortly after treatment, can avoid some long-term scars.

Recent literature includes a case of localized argyria exacerbated by ablative fractional resurfacing (AFR). In this case, a teenager who had previously survived full-body toxic epidermal necrolysis underwent fractional CO₂ resurfacing to improve scar texture and pliability.¹

The argyria was secondary to exposure to silver dressings used years earlier.

Her physicians noticed worsening hyperpigmentation after each laser treatment. Biopsy revealed pseudo-ochronotic fibers in hyperpigmented areas and evidence of dystrophic calcification in columns that corresponded directly with the laser application. Fortunately, says Dr. Metelitsa, treatment with an Nd:YAG laser resolved the hyperpigmentation. Sidestepping these complications requires avoiding fractional resurfacing in patients with previous argyria or a history of silver dressing use, he adds.

Scarring

Scarring

Among more commonly reported AFR complications, he says, hypertrophic scars occur rarely with fully ablative procedures, although they’ve been reported with non-ablative fractional resurfacing (NAFR) as well. These reports typically highlight overly aggressive fluence and/or density, unrecognized postoperative infection and a lack of technical finesse, says Dr. Metelitsa. Accordingly, “It's exceptionally important for all dermatologists who delegate procedures  - especially nonablative procedures - to train your staff properly.” Off-face sites - especially the neck - can be more vulnerable because these areas have thin skin and fewer pilosebaceous units and blood vessels, he says. Other common areas of post-treatment hypertrophic scarring include the periorbital and mandibular regions, he says.

Patients at high risk of such scarring include those who have a history of radiation treatment or surgery, particularly on the neck or eyelids. Red flags include a history of keloids, wound infection or contact dermatitis. “This is where early treatment is critical.” Options include topical and intralesional corticosteroids, silicone gel products and lasers, including fractionated and pulsed-dye lasers, says Dr. Metelitsa.

Ectropion - typically cicatricial ectropion of the lower eyelid - also has been associated with fractional CO₂ laser procedures. “This is where you must be extremely careful with anyone who has had previous eyelid surgery or limited preoperative skin elasticity in that region.” Avoiding this complication requires lowering fluence and density settings and watching intraoperatively for excess collagen contraction, says Dr. Metelitsa.

Regarding ulceration, two reported cases of focal ulceration occurring after non-ablative 1,550 nm fractional laser treatment for mature scars involved intralesional anesthesia.² In these cases, says Dr. Metelitsa, the ulceration resolved within a month, but left patients with hyperpigmentation.

“It's been postulated that, at least in animal models, intralesional lidocaine can enhance thermal-induced tumor regression. In a way, the scar tissue can trap the local anesthetic, increasing the target of these procedures.” To prevent ulceration, he suggests using topical anesthesia for thick scars. For deeper scars, “If you are using intralesional anesthesia, avoid superficial depot injections.” He also recommends allowing sufficient time after the injection to begin treatment, massaging the injected area pretreatment and lowering laser parameters. Conversely, he says, failure to remove topical anesthetics before treatment can result in percutaneous absorption and anesthesia toxicity.

Viral, Bacterial, Fungal Infections

Viral, Bacterial, Fungal Infections

Viral, bacterial and fungal infections also have been reported with NAFR. Such infections typically occur within the first week post procedure, says Dr. Metelitsa. Because early detection and treatment are critical in avoiding permanent sequelae, he adds, his practice follows patients closely during the first week post-treatment - particularly with ablative procedures.

Herpes simplex virus (HSV) infections have been associated with up to two percent of fractional resurfacing cases, says Dr. Metelitsa, although the risk can be as high as seven percent in patients with a previous history of HSV infection. While dermatologists are accustomed to the classic presentation of vesicular papules, he says, “When it comes to these resurfacing procedures, often the patient develops very superficial erosion.” He suggests avoiding resurfacing in patients with active HSV infections. Furthermore, he says that although dermatologists used to prescribe HSV prophylaxis only for ablative procedures, “Now we do it for nonablative fractional resurfacing as well.”

Bacterial infections - typically Staphylococcus aureus and Pseudomonas aeruginosa - affect only 0.1 percent of resurfacing cases, says Dr. Metelitsa. Due to the growing presence of antibiotic resistant microorganisms, “Prophylaxis is controversial, but if you have a high-risk patient, sometimes it's very useful.” Bacterial infections present with the classic signs, he says: pain, erythema, exudate, erosions and crusting that develops within one to three days post treatment. In such cases, “Start broad-spectrum antibiotics and take a culture.”

M. chelonae infection has been reported after ablative fractional CO₂ resurfacing.³ “This atypical mycobacteria has been described with other procedures as well, usually presenting one to two months post treatment,” though in one reported case the lesions appeared after nine days. “The sources are related to inadequate sterilization and sometimes use of tap water dressings. What's alarming is that these mycobacteria tend to be especially resistant to some of the more classic antibiotics we’re used to using. Again, maintain a low threshold for biopsy, perform tissue culture and, specifically with M. chelonae, a dual antibiotic approach using clarithromycin and linezolid appears promising.”

Rarely, physicians have reported Candida albicans infections appearing within seven to 14 days after fractional resurfacing. Delayed purpura also is possible, says Dr. Metelitsa, as was the case with a 68-year-old female patient in whom valsalva-induced purpura developed 16 days after fractional CO₂ treatment. To avoid this, Dr. Metelitsa says it’s very important that patients avoid NSAIDs, aspirin and other blood thinners in the immediate postoperative period.⁴ Additionally, “Tell patients to avoid traumatizing the treated skin, which is fragile immediately after resurfacing.”

Prolonged erythema is defined as redness lasting more than four days with nonablative fractional procedures, or one month with AFR, Dr. Metelitsa says. “It's often triggered by multiple laser passes or inadvertent pulse stacking.” In published reports and in his clinical experience, says Dr. Metelitsa, LED photomodulation (with an 830 nm or 590 nm device) can diminish the persistence of erythema.⁵ As an alternative, he says, topical calcineurin inhibitors also can help.

Other Complications

Other Complications

Postprocedural acne can occur in up to 10 percent of patients, and milia can affect up to 19 percent of patients, says Dr. Metelitsa. Disruption of the follicular unit and aberrant follicular epithelialization during healing can contribute to acne development, he explains. In such cases, “Typical acne treatments will be applicable.”

Trauma to the follicular unit from fractional laser treatment also can result in eruptive keratoacanthomas, he cautions. “Generally you must be very cautious if someone has extensive actinic photodamage, especially on the extremities.”⁶

Pigmentary alterations occur much less frequently (in one percent to 32 percent of patients, depending on the technology and parameters used) with AFR than with fully ablative resurfacing, adds Dr. Metelitsa. It's also less intense, typically affecting darker-skinned patients. To avoid postinflammatory hyperpigmentation, he suggests using higher fluences, lower treatment densities and longer inter-treatment intervals.

Dr. Metelitsa has been an advisor, researcher or consultant for Cutera, Cynosure, Sciton, Zeltiq, Clarion Medical and Lutronic.

1. Shaub AR, Brown PJ, Kobayashi TT, Lewin-smith MR, Lupton GP, Hivnor CM. Dystrophic calcification and accentuated localized Argyria after fractionated carbon dioxide laser therapy of hypertrophic scars. JAMA Dermatol. 2014;150(3):312-6.

2. Chuang GS, Manstein D, Tannous Z, Avram MM. Ulceration of mature surgical scars following nonablative fractional photothermolysis associated with intralesional lidocaine injections. Dermatol Surg. 2012;38(11):1879-81.

3. Palm MD, Butterwick KJ, Goldman MP. Mycobacterium chelonae infection after fractionated carbon dioxide facial resurfacing (presenting as an atypical acneiform eruption): case report and literature review. Dermatol Surg. 2010;36(9):1473-81.

4. Fife DJ, Zachary CB. Delayed pinpoint purpura after fractionated carbon dioxide treatment in a patient taking ibuprofen in the postoperative period. Dermatol Surg. 2009;35(3):553.

5. Metelitsa AI, Alster TS. Fractionated laser skin resurfacing treatment complications: a review. Dermatol Surg. 2010;36(3):299-306.

6. Mamelak AJ, Goldberg LH, Marquez D, Hosler GA, Hinckley MR, Friedman PM. Eruptive keratoacanthomas on the legs after fractional photothermolysis: report of two cases. Dermatol Surg. 2009;35(3):513-8.