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Erbium-doped yttrium-aluminum-garnet (Er:YAG) laser skin resurfacing is an effective means of managing a number of cutaneous conditions and lesions. Its main indications include treatment of photoaging, rhytids, and benign and malignant cutaneous lesions. For many years, carbon dioxide (CO2) lasers (wavelength 10,600 nm) were the only lasers available for laser skin rejuvenation; nowadays, there are many more options, including the solid-state erbium-doped yttrium aluminum garnet Er:YAG (2,940 nm), diode (810 and 940 nm), and erbium:glass lasers (1,540 and 1,550 nm). This activity reviews the indications and technique for Er:YAG laser facial resurfacing and highlights the role of the interprofessional team in evaluating and treating patients who undergo Er:YAG laser treatments. Objectives: Identify the indications for Er:YAG laser resurfacing. Outline the relevant anatomy and mechanism of action of Er:YAG laser treatments. Describe the technique of Er:YAG laser resurfacing. Explain the potential complications of Er:YAG laser resurfacing and summarize their management. Access free multiple choice questions on this topic.

With the passage of time, skin ages and accumulates photodamage. This results in loss of elasticity, changes in pigmentation, and the development of scarring from trauma, acne, and other insults.[1] Laser skin resurfacing has become a gold standard option for the rejuvenation of facial skin’s texture, tone, and elasticity.[2] For many years, carbon dioxide (CO2) lasers (wavelength 10,600 nm) were the only lasers available for laser skin rejuvenation; nowadays, there are many more options, including the solid-state erbium-doped yttrium aluminum garnet Er:YAG (2,940 nm), diode (810 and 940 nm), and erbium:glass lasers (1,540 and 1,550 nm).[2] Er:YAG lasers were first FDA approved in 1996 for cutaneous resurfacing, and a comparative trial with CO2 lasers demonstrated that Er:YAG had equal efficacy with a trend towards more rapid recovery. Initially, short-pulse Er:YAG lasers were approved, with pulse lengths of 250-350 μs; however, variable and longer-pulse Er:YAG lasers with pulse widths of 500 μs to 10 ms were subsequently approved in 1999. The long-pulse and variable-pulse lasers introduced in 1999 were designed to provide enhanced coagulation, reducing bleeding compared to short-pulse Er:YAG treatments.

Short-term complications of Er:YAG therapy include the development of erythema and bleeding, as well as reactivation of herpes simplex virus infection. In some cases, bacteria (such as Staphylococcus sp) or even fungi (such as Candida sp) may cause secondary facial infections, but these are usually managed easily with appropriate antimicrobials. Post-inflammatory changes in pigmentation and the development of scarring may also occur. Hypo- and hyperpigmentation are among the most common side effects of ablative laser therapy.[16] Compared to CO2, Er:YAG is considered less likely to cause hyperpigmentation of treatment areas, although some studies have demonstrated similar side effect profiles for the two modalities of laser skin resurfacing.[17] Increased Er:YAG pulse duration is associated with an increased risk of pigment changes, potentially because a longer pulse duration deposits more energy per pulse and thereby causes more thermal damage to surrounding tissue. The use of a fractionated beam delivery system decreases the risk of pigmentary changes. Pigmentary changes often fade with time; hyperpigmentation is more common than hypopigmentation and more likely to resolve. For persistent hyperpigmentation, 4% topical hydroquinone will help lighten the skin. For hypopigmentation, which is thought to result from inflammation that compromises melanocyte function, topical steroids may be helpful. Other options include sun exposure, blue laser therapy, intense pulsed light, and fractionated CO2 laser treatments.[18] The risks of prolonged post-procedure erythema and pigment changes are greater in patients with darker skin (Fitzpatrick skin types III-VI). Other noted complications include the appearance of acne, milia, and dermatitis in the treated region. Some patients will complain of a persistently visible grid or checkerboard pattern after fractionated beam treatment, but this usually fades over time. It may be addressed with topical steroids or additional laser resurfacing when it does not resolve spontaneously. More problematic is when too much energy is delivered, resulting in a burn and subsequent scar. This may also be treated with laser resurfacing, as any other scar could be, but patients are often understandably reluctant to pursue this option due to prior experience with adverse laser treatment outcomes.

The risks of prolonged post-procedure erythema and pigment changes are greater in patients with darker skin (Fitzpatrick skin types III-VI). Other noted complications include the appearance of acne, milia, and dermatitis in the treated region. Some patients will complain of a persistently visible grid or checkerboard pattern after fractionated beam treatment, but this usually fades over time. It may be addressed with topical steroids or additional laser resurfacing when it does not resolve spontaneously. More problematic is when too much energy is delivered, resulting in a burn and subsequent scar. This may also be treated with laser resurfacing, as any other scar could be, but patients are often understandably reluctant to pursue this option due to prior experience with adverse laser treatment outcomes. Ocular injury is among the most serious complications that may result from Er:YAG laser treatment. The cornea is the most likely structure to be damaged because of the Er:YAG laser's chromophore water. Ocular injury may be prevented with the use of ocular lubricant and corneal shields for the patient during treatment. Members of the healthcare team should wear protective glasses that will block light at 2,940 nm. An ophthalmologist should be consulted in the event of corneal injury. The risk for complications can be reduced by performing a thorough pre-procedure history and physical examination. Appropriate patient selection is critical. Patient education also improves the chance of achieving satisfactory outcomes. The importance of sun protection in reducing the occurrence of post-inflammatory pigmentation changes should be emphasized. Patients should be educated on post-procedure wound care and informed about the normal post-treatment course and changes that occur during healing. The risk for infection, scarring, and delays with healing should be clearly outlined.

A well-integrated, multi-disciplinary health care team will maximize patient outcomes after treatment with Er:YAG laser resurfacing. Additionally, a thorough patient evaluation that follows a well-established routine is essential for achieving optimal outcomes. Dermatologists, plastic surgeons, and laser operators, when working together as a team, are ideally suited to determine whether Er:YAG laser treatment is the appropriate treatment modality to address patient concerns. Pharmacy and anesthesiology can provide recommendations for pre-procedure and post-procedure management. Patient education regarding what to expect during the treatment and pre-procedure and post-procedure care is important to optimize outcomes for patients and health care providers. Equally important is ensuring that the patient and clinician share a common picture of the goals and expectations for treatment to avoid dissatisfaction with the result. Nurses and physician assistants are also critical for supporting patients, particularly during the post-treatment period, when patients often have second thoughts about the procedure, discomfort, and, rarely, complications. Utilizing an interprofessional health care team to deliver Er:YAG laser treatments improve situational awareness regarding the progression of recovery and the development of complications, facilitating a more timely response to any adverse events.[21] [Level 4]