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Abstract
Background: Erbium-YAG laser has been the working horse in dermatology for years. Surprisingly, data on the efficacy and adverse effects of this novel resurfacing and ablative technique of erbium-YAG laser for superficial dermatoses in Indian skin is limited. Aim and Objective: To evaluate the efficacy and safety profile of erbium-YAG laser ablation in superficial cutaneous lesions. Materials and Methods: Two hundred and fifty patients of various superficial dermatoses, treatable by erbium-YAG laser, were recruited in the study. All the patients were subjected to erbium-YAG laser sessions. The number of laser sessions, fluence, frequency and other parameters were individualized as per the respective dermatosis. The clinical response was evaluated as grade 4 (100% lesion clearance), grade 3 (75–99%), grade 2 (50–75%) or grade 1 (<50%). Results: The overall mean age of our study group was 37.70 years. In our study, 52.38% cases of verruca plana, 36.84% cases of seborrheic keratosis, 56.4% cases of xanthelasma palpebrarum, 22% cases of acquired melanocytic nevus, 23.8% cases of plantar wart and 40% cases of sebaceous hyperplasia showed complete clearance. The most common adverse effect was post-laser erythema in 50.4% of cases, followed by pain in 36.8%. Besides this, scarring and dyspigmentation were observed in 11.6% and 12% of cases, respectively. The rate of recurrence on 3 months follow-up was 9 (23.07%) cases in xanthelasma palpebrarum, 11 (28.9%) cases in seborrheic keratosis, 10 (23.8%) cases in verruca plana and 9 (42.8%) cases in plantar warts. Conclusion: This study suggested that erbium-YAG ablation achieved good results for superficial lesions like verruca plana, seborrheic keratosis, xanthelasma palpebrarum, plantar wart, sebaceous hyperplasia and acquired melanocytic nevus. Thus, Er: YAG laser can offer a one-step procedure with better cosmetic results and a lesser rate of recurrence.
Keywords: Ablative laser, acquired melanocytic nevus, erbium-YAG ablation, laser, plantar wart, sebaceous hyperplasia, seborrheic keratosis, verruca plana, xanthelasma palpebrarum
Introduction 
In the last two decades, advances in laser technology have revolutionized their use in treating many skin conditions. Lasers can be ablative and non-ablative.[1] Ablative laser treatment is widely used in dermatology. Erbium-YAG (erbium-doped yttrium aluminium garnet) laser is one of them. In recent times, Er: YAG laser is proved to be equally efficacious and much safer than CO2 laser.[1],[2] In contrast to that, the medical publications on erbium-YAG laser in dermatology are few and often include small samples only. Thus, the erbium-YAG laser has been the working horse in many dermatology clinics for years. Surprisingly, studies on the erbium-YAG laser in dermatology are sparse.
Therefore, we aimed to conduct a study to evaluate efficacy and safety profile of erbium-YAG laser ablation in superficial cutaneous lesions.
Materials and Methods Two hundred and fifty patients of various superficial dermatoses of either sex attending the outpatient department of dermatology of tertiary care centre were included in this prospective observational study using consecutive sampling. Ethical approval was taken from the institutional ethics committee. Prior informed and written consent was obtained from all the patients included in the study.
Inclusion criteria included clinically diagnosed cases of any of the following superficial dermatoses:
Plantar wartsPerinugual wartsVerruca planaSeborrheic keratosisAcquired melanocytic nevusXanthelasma palpebrarumSyringomasAcne keloidalis nuchaeAcne scarsHypertrophic scarsAngiofibromaSebaceous hyperplasiaMiliaVerrucous epidermal nevus.Exclusion criteria were patients with keloidal tendency, history of connective tissue disorders, hypersensitivity to lignocaine, pregnant and breastfeeding female, patients with body dysmorphic disorder, skin infections in areas to be treated, recurrent viral herpes infection in past 6 months, immunocompromised patients, patients not giving consent and patients who had not taken any treatment for their dermatosis in last 6 weeks.
The laser model quanta system Q Plus was used. The wavelength of this laser was 2,940 nm. The size of the focus varied between 3.5 mm to 9 mm. Frequency varied from 5 to 50 Hz. The fluence was tailored to the skin type and type of lesion ranging from 1 to 11 J/cm2. The number of laser sessions varied according to the dermatosis. Two sessions were separated by a period of 7 to 10 days. Laser parameters used for different types of dermatoses were:
Acquired melanocytic nevus: The fluence between 5 to 10 J/cm2 was used with pulse duration of 0.3ms, frequency of 2 to 3 Hz and spot size varying from 3.5 to 9 mm. Multiple passes were given till the ablation of the lesion. The endpoint was the appearance of pinpoint bleeding and the absence of any remnants of nevi.Milia: First, each individual lesion was targeted directly by three to five passes with a 3.5 mm spot, a frequency of 2 to 3 Hz and a pulse energy of 5 to 8 J/cm2 until the whole keratin-filled cyst could be wiped off with a sterile sponge.Periungual wart: The lesion was ablated with erbium-YAG laser using 3.5 to 9 mm spot size, 0.3 ms pulse duration, 10 to 12 J/cm2 fluence and 2 to 3 Hz frequency. The endpoint was the appearance of pinpoint bleeding and the absence of any remnants of wart.Seborrheic keratosis: An erbium-YAG laser in short pulse duration (ablation) mode with 3 to 10 J/cm2 of fluence, a frequency of 2 to 3Hz and a 3.5 to 9 mm spot size. The lesions were removed on a layer-by-layer basis. The endpoint was pinpoint bleeding in each session.Xanthelasma Palpebrarum: The ablation of lesion was carried out by Er: YAG laser with short pulse, fluence ranging from 3 to 6 J/cm2, 1 to 3 Hz, 3.5 mm spot size, multiple passes according to lesion size and depth. The end point of treatment was determined either by the ablation of the lesion or by the appearance of pinpoint bleeding.Verruca plana: The average treatment parameters used with Er: YAG laser with a wavelength of 2940 nm were frequency of 2 to 3 Hz, 5 to 10 J/cm2, and a spot size of 3.5 mm. The lesions were removed on a layer-by-layer basis.Syringoma: Extirpation method in which Er: YAG laser was used, with an irradiation diameter of 3.5 mm and an irradiation intensity of 4 to 6 J/cm2.Acne Keloidalis Nuchae: The lesion was ablated with Er: YAG laser using 3.5 to 9 mm spot size, 0.3 ms pulse duration, 10 to 12 J/cm2, 2 to 3 Hz, multiple passes according to lesion size and depth.Verrucous Epidermal Nevus: The lesion was ablated with Er: YAG laser using 3.5 to 9 mm spot size, 0.3 ms pulse duration, 10 to 12 J/cm2, 2 to 3 Hz, multiple passes according to lesion size and depth. The end point was the appearance of pinpoint bleeding.Angiofibroma: The lesion was ablated with Er: YAG laser using 3.5 to 9 mm spot size, 4 to 8 J/cm2, 2 to 3 Hz, and multiple passes according to lesion size and depth.Hypertrophic scar: The lesion was ablated with Er: YAG laser using fractional handpiece, 4 to 6 J/cm2, 2 to 3 Hz, multiple passes according to lesion size.Plantar wart: The lesion was ablated with Er: YAG laser using 3.5 to 9 mm spot size, 0.3 ms pulse duration, 10 to 12 J/cm2, 2 to 3 Hz. The endpoint was the appearance of pinpoint bleeding and the absence of any remnants of the wart.Sebaceous hyperplasia: Each individual lesion was targeted directly by three to five passes with a 3.5 mm spot, a frequency of 2 to 3 Hz and a pulse energy of 4 to 8 J/cm2 until the whole keratin-filled cyst could be wiped off with a sterile sponge.Acne scars: The affected skin was anaesthetized with topical lignocaine and prilocaine cream application at least 45 min before the procedure. Fractional probe was used for skin resurfacing with fluence of 10 to 20 J/cm2 and frequency of 2 to 3 Hz.A larger handpiece with lower fluence was used to make the ablated area smoother and even, and edges were treated for blending. The surgical endpoint was judged by eliminating visible lesions or the presence of punctate bleeding. Photographs were taken before and after treatment at all follow-up visits.
All the patients were photographed before the initiation of laser sessions and after the completion of all laser sessions for the assessment of response. The results were assessed based on the grade of improvement according to a self-devised scale as follows by two independent dermatologists not involved in the study.
The clinical response was evaluated as grade 4 (100% lesion clearance), grade 3 (75–99%), grade 2 (50–75%), or grade 1 (<50%). The short and long-term side effects and complications such as scarring and pigment change or recurrence on the treated area were noted.
Results In our study, a total of 250 patients of various superficial dermatoses were included ranging from 12 years to 66 years. The overall mean age of our study group was 37.70 yrs, with a standard deviation of 14.88 years. Out of 250 patients included in the study, 113 (45.2%) were male and 137 (54.8%) were females. Erbium-YAG laser ablation was used in a wide range of indications [Figure 1]. Various forms of local anaesthesia were used in laser ablation [Figure 2]. The mean number of laser sessions varied according to the dermatosis [Figure 3].
Among 42 cases of verruca plana, 22 (52.38%) cases showed grade 4 response, 14 (33.33%) showed grade 3 response while only 6 (14.28%) showed grade 2 response [Figure 4].
Figure 4: Pre and post-treatment photo of verruca plana following erbium-YAG laser ablationA total of 38 cases of seborrheic keratosis were included in the study. Among these, 14 (36.84%) cases showed grade 4 response, 16 (42.1%) cases showed grade 3 response while only 8 (21.05%) cases showed grade 2 response [Figure 5].
Figure 5: Pre and post-treatment photo of seborrheic keratosis following erbium-YAG laser ablationA total of 16 patients with periungual warts were treated with laser sessions. Among these, only one (6.25%) case showed grade 4 response, three (18.7%) cases showed grade 3 improvement, 8 (50%) showed grade 2 response and 4 (25%) showed grade 1 response [Figure 6].
Figure 6: Pre and post-treatment photo of periungual wart following erbium-YAG laser ablationOut of 21 cases of plantar wart, only 23.8% cases showed grade 4 improvement, 38.09% showed grade 3 response and 38.09% showed grade 2 response.
Out of 39 cases of xanthelasma palpebrarum, 22 (56.4%) cases showed grade 4 response, 15 (38.5%) showed grade 3 response, while only 2 (5%) showed grade 2 response [Figure 7].
Figure 7: Pre and post-treatment photo of xanthelasma palpebrarum following erbium-YAG laser ablationA total of 22 cases of acquired melanocytic nevus were treated with erbium-YAG laser ablation. Among these, 5 (22.72%) cases showed grade 4 improvement, 7 (31.82%) cases showed grade 3 response, 7 (31.82%) showed grade 2 response and 3 (13.64%) showed grade 1 response.
Out of 17 cases of milia treated, 6 (35.3%) patients showed grade 2 response, and 11 (64.7%) patients showed grade 1 response. Complete clearance of lesions was not seen in any of the patients.
A total of 12 patients with syringoma were included in the study. Among these, 6 (50%) patients showed grade 3 response, 4 (33.33%) patients showed grade 2 response and 2 (16.67%) patients showed grade 1 response. Complete clearance of lesions was not seen in any of the patients.
All seven patients of acne keloidalis nuchae included in the study showed only grade 1 response.
Only grade 1 and grade 2 improvement was seen in 4 (66.67%) and 2 (33.34%) cases, respectively, in cases of hypertrophic scars.
Only one patient of verrucous epidermal nevus showed grade 3 response, while four out of seven cases (57.14%) showed only grade 1 improvement while two (28.57%) showed grade 2 response.
Out of total five cases of sebaceous hyperplasia, three (60%) and two (40%) showed grade 3 and grade 4 response, respectively.
A total of three patients with angiofibroma were studied. However, all the patients showed grade 1 response.
Out of 15 patients with acne scars included, 4 (26.67%) cases showed grade 1 improvement, 9 (60%) cases showed grade 2 response, and 2 (13.3%) showed grade 3 improvement.
The most common adverse effect was post-laser erythema in 50.4% of cases followed by pain in 36.8% [Figure 8]. The rate of recurrence was calculated only for the cases showing at least grade 3 and grade 4 response [Figure 9].
Discussion The erbium-YAG laser is an ablative laser that can be used safely for removal of benign, pre-malignant and malignant skin lesions. The major limitation of the erbium-YAG laser is its weakness in hemostasis.[3],[4] On the other hand, it offers a precise ablation with limited thermal damage to the neighbouring tissue.[4]
Major use of Er YAG laser is for the treatment of superficial cutaneous lesions and skin resurfacing. This laser can precisely ablate the lesion. On review of literature, many superficial lesions have been treated with ablative mode of Er YAG laser.[4],[5]
In our study, we aimed to study the efficacy and safety of erbium-YAG laser in the ablation of various superficial cutaneous lesions. We included a total of 250 cases in our study. We included a wide range of lesions in our study. Acquired melanocytic nevus, milia, periungual wart, seborrheic keratosis, xanthelasma palpebrarum, verruca plana, plantar wart, syringoma, acne keloidalis nuchae, verrucous epidermal nevus, angiofibroma, hypertrophic scar, acne scars, sebaceous hyperplasia etc., were the major indications of erbium-YAG laser ablation in our study.
Wollina et al.[6] conducted a study to demonstrate the versatility of classical erbium-YAG laser for medical conditions in dermatology in a single-centre study. Major indication for erbium-YAG laser treatment in their study were verrucae vulgaris, seborrheic keratosis on the lead. The complete clearance rate was 68% for plantar warts, 78% for periungual warts and 76% for subungual warts. In most cases a single laser session was effective to remove the lesions completely. Adverse effects were rarely seen, such as pigment changes.
Balevi et al.[7] conducted a randomized controlled study on 46 patients with recalcitrant facial verruca plana, used Er: YAG laser to treat warts, and noted complete response (100% clearance of lesion) in 62.5% of patients. In our study, 52.38% of cases of verruca plana showed complete clearance.
In a study by Borelli et al.[8] 15 patients, with a total of 33 xanthelasma lesions, were treated by an erbium-YAG laser. All lesions were removed without hyperpigmentation or scarring. In our study, 56% of cases of XP showed complete clearance.
Gruel et al.[9] conducted a study on 42 patients with seborrheic keratosis located on the back, chest, face and neck, comparing cryotherapy and erbium-YAG laser ablation. Following the first treatment, complete healing was detected in all of the lesions (100%) treated with Er: YAG lasers, while the healing rate was 68% in the cryotherapy group (P < 0.01). In our study, 36.84% of cases showed complete clearance.
Thus, in our study, superficial lesions like verruca plana, seborrheic keratosis, xanthelasma palpebrarum, plantar wart, sebaceous hyperplasia, acquired melanocytic nevus, etc., showed complete clearance on erbium-YAG laser ablation with fewer side effects. Major side effects were post-laser erythema and pain. Long-term complications included dyspigmentation and scarring.[10],[11] Therefore, Er: YAG laser is proved to be equally efficacious and much safer than CO2 laser.[11] In contrast to that, the medical publications on erbium-YAG laser in dermatology are few and often include small samples only. Our study is first of its kind to evaluate the versatility of erbium-YAG laser ablation in dermatosurgery.
Conclusion This study suggested that Er: YAG achieved good clinical results for superficial lesions including verruca plana, seborrheic keratosis, xanthelasma palpebrarum, plantar wart, sebaceous hyperplasia and acquired melanocytic nevus. Dermatoses like sebaceous hyperplasia, milia, syringoma, angiofibroma, hypertrophic scar, acne keloidalis nuchae, etc., which have been untagged or sparsely reported as authenticated indications of erbium-YAG laser were also studied. Although complete clearance could not be achieved in some of the conditions, cosmetically good results were noted with fewer side effects. Thus, Er: YAG laser can offer a one-step procedure and provides an alternative treatment method with better cosmetic results and a lesser rate of recurrence. Prospective studies comparing erbium-YAG laser and conventional alternative treatments would be required in future to confirm the effectiveness of this treatment modality.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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