Joint publication in Laser Partner and Laser World 
(www.laser.nu/lllt/lllt_editorial.htm)

R. Smucler, M.D., Ph.D., 1st Medical Faculty, Charles University, Prague + ASKLEPION Group, Prague, CZ,

M. Buchta, Galena Opava, CZ

M. Gregor, ASKLEPION Group, Prague, CZ

smucler@asklepion.cz

 

ABSTRACT

Low Level Laser Therapy (LLLT) has been winning recognition as a therapeutic alternative, especially thanks to its minimum side-effects and contra-indications. Increasing the therapeutic potential of LLLT with no complications growth is the key point of further development of this method. Laser Mask with hydrogencarbonate anions increases the efficacy of laser in cosmetology, as well as it widens therapeutic capabilities of laser. The efficacy of the method, its specification as an alternative, and the objectives of further research have been set up on model indications of acne and chronic dermatitis.

 

INTRODUCTION

The use of low energy lasers for biostimulation has become an established method with extensive literature, scientific societies, and specialized congresses. On the other hand, it is not possible to overlook a number of negative placebo double-blind studies, or some unsuccessful comparative studies with more traditional therapeutic methods. LLLT has not yet been fully accepted by American FDA. It can be said that although the phenomenon of photo-biostimulation has been ascertained, as well as its numerous indications and minimun side-effects, there are only few indications where LLLT can be recommended as therapy of the first choice. Thus the increasing of therapeutic effect, with minimum or even no side-effects, is the main chalenge for us.

Why does LLLT fail sometimes? Apart from unsuitable indications, non acurate choose of the wavelength of the source, and exaggerated expectations of the patient, the main problem can be seen in too low light flow (given in J/cm²). Although some earlier papers claimed the opposite in the past, it is sure now that, within a certain interval, any known effect of LLLT increases in accordance with the light flow. A number of low-priced lasers in common use have so low power output (usually tens of mW only) that it is scarcely conceivable to reach sufficient value of light flow (say 5 J/cm²) on rather large areas (for example face or ulcus cruris) in times not exceeding hours. Thus many "laser therapies" can be obviously compared to therapy of tonsillitis with a single pill of penicilin per week. Results look accordingly. A clear way how to improve the results of LLLT is using lasers with more output power for large area treatments. However, this leads to the domaine of high power lasers with prices reaching to the orders of tens of thousands dollars. Furthermore, introducing more powerfull lasers does not necessarily solve the problem of LLLT having a limited spectrum of effects (as all other methods do, incidentally). That was why decided to find a synergic agent, which would be able not only to increase the effects of LLLT, but to widen the spectrum of these effects, too. We are of the opinio that searching for suitable combinations of LLLT and other methods should be one of the key directions of further development of biostimulation laser therapy.

What are the alternatives to increase the effect of a laser with its given output and wavelength?

a)      decrease reflection and scattering

working in contact mode, adjusted handpieces, increased beam diameter, chemical preparation of skin

b)    higher optical permeability of skin

G. Vargas of University of Texas, Austin, Tx, has proven that using hyperosmotic matters (glycerol, DMSO, manitol) reduces scattering of light, and their application into the skin increases the effective dosage of laser energy in target structures

c)    synergic agent

physical - bio-lamps, magnetic field, electrical current, heat gradient ...

mechanical - massage, acupressure, acupuncture...

chemical - the most significant - always necessary to consider the effect/side-effect ratio

Taking maximum care to decrease scattering and reflection we have decided for a chemical synergic agent, as it offers the best possible broadening of spectrum of effects. From among many chemical substances theoretically suitable we have chosen hydrodencarbonate anions. They represent a substance which is natural for the body, physiologically working as a blood buffer system (stabilization of pH). These characteristics result in high safety with no alergy testing being therefore necessary. Biostimulation with the hydrogencarbonate anion - carbon dioxide system has been proven through centuries, with deep traditions in balneology and dermatology, with a  thoroughly analyzed mechanism of action. The reaction proceeds under natural physiological conditions. As a carrying media a gel was chosen, as it creates a humid-cell effect, can be applied simply, can be removed simply with water, and, when applied in a thin layer, can be easily permeable for red and especially infrared light. With its mass it can hold carbon dioxide between the gel and the skin. Let us summarize expected effects of both the agents.

Laser Therapy & Gel with Hydrogencarbonate Anions

       Effects of a laser:

• biostimulation
• skin regeneration
• improved metabolism
• healing of inflammatory foci
• immunomodulation
• myorelaxation (ease of muscle tonus)

       Effects of hydrogencarbonate anions in the gel:

• non toxic in a wide spectrum, commonly existing in the body
• decomposition leads into carbon dioxide
• reactions do not create dangerous substances
• reactions proceed under natural physiological conditions
• neutralizes acidic metabolites

THERAPY MODEL TAKEN OVER FROM COSMETOLOGY

Le Masque de Laser Asklepio (Laser Mask) is applied on clean skin, having been disinfected with a skin lotion with a chloridehexidindigluconate solution in order to suppress biostimulation of pathogenics. The gel is applied in a thin layer, approx. 5 - 7 ml. on the face. Afterwards a biostimulation laser with 670 nm wavelength is applied, preferrably with a scanner so that an even dosage of energy be ensured. Optimum light flow, and thus the time of the treatment, have not yet been exactly verified (with constant treatment area and laser output). Our experiment has been conducted in two directions:

a)    with the use of an indicator, loosing its red color and changing into transparent gel indicated the reaction having passed, or

b)    giving all patients constant time duration of therapy - usually 20 - 30 minutes.

In order to verify the effect we had been using the method sub a) at first. By comparing the effect to irradiation of Laser Mask applied on a non-living surface (desktop etc.) the biostimulation effect on tissue was confirmed. However, significant individual time differences, even more than 100 per cent, were noticed in the speed of the reaction (all other parameters being constant)!! In practical cosmetology and dermatology we eliminated application of the indicator in order to reduce the number of chemical substances in contact with the skin, and that was why we had to use constant time for only this enabled us to plan therapy procedures (otherwise duration of procedures oscillated between 22 - 58 minutes). At present, the indicator is in use only in patients who seek another exact evidence of functioning of Laser Mask, apart from initial improvement of their looks, and who are not sensitive to pH gradient (which is in fact the initial indicator).

 

How to apply Laser Mask in cosmetology

• Remove the make-up and apply gently and evenly a thin layer of Laser Mask (a thicker layer on dry skin) on the face, on the neck and décolté possible, too.
• Activate with a biostimulation laser (or biolamp).
• Duration of the laser irradiation approx. 20 - 30 minutes.
• Remove the gel with lukewarm water.
• Treat the skin with a cream

There are two steps of application of Laser Mask in cosmetology:

1)    Intensive care - beginning of therapy, sun damaged skin

• 2 - 3 applications of Laser Mask during the first week.
• 4 - 5 applications of Laser Mask during the two following weeks.

2)    Following intensive care or long-term skin appearance care

• 1 application every 2 - 3 weeks
• After 3 - 4 months repeat intensive therapy

Detail of application of Laser Mask

General view of scanning the patient

 

Multicenter experience based on questionnaire inquiry after two years of application of 2000 Laser Masks in total:

• Laser Mask can cause a slight worsening of the look of the skin after intensive care as a lot of grease and/or impurities is eliminated on neglected skin.
• Thus Laser Mask represents perfect preparation for mechanical cleansing. Immediately after the first or second application clean the skin mechanically.
• Do not clean the skin mechanically during the following applications, apply slight massages only and do not exert the skin.
• Laser Mask is highly successful in rehydratation therapy.
• Laser Mask is being positively accepted by the clients.
• In all 42 workplaces Laser Mask has become the main applied mask, as well as the mask of the first choice.
• The number of clients visiting regularly has increased significantly thanks to Laser Mask (visiting only occasionally before).
• Laser Mask should be applied always at the end of classical cosmetological treatment.
• Do not apply creams with active components simultaneously.
• Laser Mask is a part of the conception of laser rejuvenalization.

APPLICATION OF LASER MASK IN DERMATOLOGY

Excellent experience in cosmetology as well as several "mishaps" during which Laser Mask got by an oversight  on skin afflicted by dermatitis or acne, and an improvement of patient`s condition  could be seen (some of them even required application of Laser Mask on pathologic lesions), led us to examination of possible therapeutic effect on these pathologies. We have been proceeding on the following assumptions:

• biostimulative effect of CO₂
• biostimulative, immunostimulative, and antiphlogistic effects of LLLT (see Simunovic, Z., LLLT of Acne and Scars Applied as Monotherapy and Complementary Treatment Modality to Tetracycline: a Multicenter Clinical Study of 80 Patients with Control Group, Lasaewr Surg. Med., vol. 12, 2000)
• high hydratation ability of the gel
• wash out of lipophylic components - "dessication of skin" without ethanol
• humid-cell effect - locally optimized microclimate for improved healing
• disinfective skin lotion
• no dyes, no fragrances present

Three retrospective groups of patients were created in three centers. Monotherapy was the main condition for incorporation in the study, i.e. at least a month before the experiment all other therapies had been cut out. In cases of chronic diseases LLLT was combined with regime measures, with the aim being to find out whether a synergic effect can be reached by an adapted regime. Due to ethic reasons patients with substantial forms of acne with a potential risk of scarring were excluded. Patient`s consent with the experiment was a precondition.

RESULTS

Therapy of acne and chronic dermatitis - acute incidence - monotherapy

169 patients

• Fully satisfied                29 %
• Very satisfied                47 %
• Slight improvement        19 %
• Dissatisfied                     5 %

Conclusion: A non-agressive method, well accepted by patients, substantial therapeutic effect, results significantly exceeding the limits of placebo however not reaching therapeutic success of combination of antibiotics or Roaccutan, no negative effects noticed.

 

Therapy of acne and chronic dermatitis - chronic treatment - monotherapy (together with regime measures)

280 patients

• Fully satisfied                29 %
• Very satisfied                44 %
• Slight improvement        27 %
• Dissatisfied                     0 %

Conclusion: A highly accepted long-term therapy, yo-yo effect decreased, regular therapy supporting regime therapy, suitable for reaching a stable level of therapy which can be further improved with other methods, no negative effects, general conclusion: supplement or alternative of conventional methods.

Therapy of acne and chronic dermatitis - definite conclusions:

• therapeutic alternative with a promising therapeutic effect
• no specific contraindications and side effects

 

THE COURSE OF FURTHER RESEARCH

Only one of theoretically indefinite number of senzibilizers has been used, possible interactions with medicaments as well as further possibilities of increasing the potential have not been fully revealed yet. From many scientific papers we can assume that the blue part of the spectrum, close to UV light, will destroy propionibacterium acne by means of photodynamic therapy (PDT). Thus we are standing at the door of further development of photo-medicine - light therapy. We have in our hands a very interesting alternative for many patients, provided minimum side effects are kept, and effectivness improved. It is not likely that photo-therapy can become a universal method being able to eliminate other therapeutic methods, however it has already become a significant and useful help in treatment of minor conditions. Studies on bringing off even severe forms of acne with PDT with the use of delta-aminulevate and appropriate laser irradiadion. Results are being compared with ATB or Roaccutane, but the effect lasting for a year or two. Combinations of these methods might bring a new quality of therapy. Or it might not.

What are our tasks on our way to further development of the method?

• Double blind studies - acne, dermatitis
• Combined therapies with hyperosmotic accelerators
• Studies on interactions of medicaments
• Research of limits of indications
• Combination with "blue light" - photodynamic elimination of initial agents of pathologies
• PDT of lesions with delta-aminolevulates