Dermatologic surgery
Intraepidermal erbium:YAG laser resurfacing: Impact on the dermal matrix

https://doi.org/10.1016/j.jaad.2010.02.058Get rights and content

Background

Various minimally invasive treatments enhance the skin's appearance. Little is known about the molecular mechanisms whereby treatments working at the epidermal level might alter the dermis.

Objective

We sought to quantify the molecular changes that result from erbium:yttrium-aluminium-garnet (Er:YAG) laser microablative resurfacing.

Methods

We performed biochemical analyses after intraepidermal Er:YAG laser resurfacing of 10 patients. Immunohistochemical analysis and polymerase chain reaction technology were utilized to measure key biomarkers.

Results

The basement membrane remained intact after intraepidermal microablation, as demonstrated by laminin γ2 immunostaining. Epidermal injury was demonstrated with acute up-regulation of keratin 16. An inflammatory response ensued as indicated by increases in cytokines interleukin 1 beta (IL-1β) and IL-8 as well as a substantial neutrophil infiltrate. Levels of cJun and JunB proteins, components of the transcription factor AP-1 complex, were also elevated. Up-regulation of extracellular matrix degrading proteinases matrix metalloproteinase 1 (MMP-1), MMP-3, and MMP-9 was noted. A transient increase in keratinocyte proliferation, as indicated by staining for Ki67, was observed. Increased expression of type I and type III procollagen was demonstrated.

Limitations

The data presented are those that resulted from a single treatment session.

Conclusions

Although microablation was confined to the uppermost epidermis, marked changes in epidermal and dermal structure and function were demonstrated after Er:YAG laser microablative resurfacing. We demonstrated substantial dermal matrix remodeling, including a degree of collagen production that compares favorably with some more invasive interventions. Dermal remodeling and stimulation of collagen production are associated with wrinkle reduction. Thus these results suggest that the skin's appearance may be enhanced by creating dermal changes through the use of superficially acting treatments.

Introduction

Capsule Summary

  • Various minimally invasive treatments enhance the skin's appearance, but little is known about the associated molecular changes.

  • Intraepidermal Er:YAG laser resurfacing resulted in molecular alterations associated with an improved appearance of photodamaged skin.

  • Although microablation was confined to the uppermost epidermis, marked changes in epidermal and dermal structure and function were demonstrated. This suggests that enhanced appearance may be achieved via superficially acting treatments.

  • These results may have significant implications for future device/procedure development.

In recent years, there has been intense interest in developing increasingly less invasive techniques to improve the clinical signs of photoaging. Many nonablative laser systems have been utilized with these goals in mind.1, 2, 3 Although nonablative lasers have an impressive safety profile because the epidermis of treated skin generally remains intact, clinical results have been modest in terms of textural improvement. Alternatively, while traditional ablative laser resurfacing is, in many respects, the gold standard for facial rejuvenation, the procedure is fraught with the risk of significant complications and results in substantial down time.4, 5, 6

To mitigate against the potential drawbacks of procedures that result in complete epidermal ablation, lower powered ablative erbium:yttrium-aluminium-garnet (Er:YAG) lasers have recently been used in an attempt to improve the appearance of human skin while largely preserving epidermal integrity. Superficial Er:YAG laser resurfacing employs technology with a long track record of efficacy now modified to produce a minimally invasive treatment. With respect to improving the uniformity of skin texture, this strategy theoretically relies on the ability of an intervention that acts primarily through intraepidermal injury to drive dermal extracellular matrix changes. To date, no study has produced detailed quantification of the dermal alterations that may result from such intraepidermal damage. Demonstration that controlled, superficial cutaneous injury results in significant dermal changes could result in the development of a paradigm shift in treatment strategies for photoaging. We thus sought to assess and quantify whether minimally invasive Er:YAG laser resurfacing has the ability to stimulate dermal matrix remodeling.

Section snippets

Human subject description, treatment, and tissue procurement

This study was approved by the Institutional Review Board of the University of Michigan Medical School, and written informed consent was obtained from all study subjects prior to entry into the study. Patient recruitment occurred between Sept 1, 2007 and Nov 12, 2007. Patients included in the study were those of either gender of any racial/ethnic group who were at least 18 years of age with clinically evident photodamage of the forearm skin globally rated by investigators as at least moderate

Results

A total of 10 patients 44 to 75 years of age, with clinically significant photodamage of the forearm skin, were enrolled in the study and provided skin samples. Three patients were female and 7 were male. Patients tolerated the treatment well with no need for anesthesia. The procedure resulted in initial “frosting” of the treated skin, as expected. At initial follow-up visits, all patients were found to have erythema at the treatment sites that gradually resolved over the first 1 to 2 weeks

Discussion

Treatments such as dermabrasion, medium depth and deep chemical peels, and traditional fully ablative carbon dioxide and erbium laser resurfacing have been utilized to physically or chemically remove the epidermis, wound the dermis, and thereby stimulate collagen production and dermal remodeling. Alternatively, nonablative laser and light-based therapy is intended to heat the dermis while sparing the epidermis, thus creating changes in the dermal matrix with less risk and minimal down time.10,

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    Supported by the University of Michigan Department of Dermatology Laser Research Fund.

    Conflicts of interest: None declared.

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