2019皮秒肝斑論壇專區（限參加醫師登入）

2019皮秒肝斑論壇會議摘要重點及講師治療參數，請點選連結閱讀（限當日有報名的醫師登入，持續更新）：

各講師習慣使用皮秒雷射機器：Kitae Kim (Discovery pico); Lin, Jeng-Hsien (Discovery pico); Geun-Soo Lee (Lutronic Picoplus); Nariaki Miyata (Candela Picoway); Wichai Hongcharu (Candela Picoway); Wang, Chao-Chin (Candela Picoway); Woraphong Manuskiatti (Cutera Enlighten); Hsu, Che-Hao (Cutera Enlighten); Niwat Polnikorn  (Cynosure Picosure); Ko, Shin-Chung (Cynosure Picosure); Huang, Yung-Hsueh (Cynosure Picosure) ; Lee, Mei-Ching (Cynosure Picosure and Picoway)

Ｑ1. 請問講師們皮秒肝斑治療使用的機器種類及參數？（handpiece type? wavelength? flat or fractional ? spot size? energy setting and frequency (Hz) ? passes? overlapping or not?)

李美青醫師回覆：
1. Picosure. Pleases follow previous publish paper. Prefer flat (Lasers Med Sci. 2018 Nov;33(8):1733-1738. doi: 10.1007/s10103-018-2529-2.)
2. Picoway. Processing research. Prefer 532 resolve
Frequency depending on each doctor’s experience. I use 10. But if could not move quickly, suggest 5 Hz or less than 5.
The key point as my presentation: don’t put too much fluence in the same area.
(再麻煩跟所有的參加的人說很抱歉因為有一些都是在寫論文中投稿還不太能夠去跟大家講但是我們會發表)

林政賢醫師回覆：
Discovery PICO,
Step 1: 1064 toning. 1064 flat, 9mm/0.8J or 7.5mm/1.16J, 10Hz, 2 passes, overlapping
Step 2: 532 intensification. 532 fractional, 0.05-0.1J, 5Hz, 1 pass, no overlapping

Dr. Wichai的回覆：
I use non fractional zoom HP . Start with 1064, 450ps at 0.2-0.35 J/cm2 10HZ.and 532 nm , 0.03J/Cm2 with the help of 2ND filter 8-10 Hz try tge largest spot size. 1_2 passin melasma area. Can do overlapping since that is the propose of 10 Hz technique.

Dr. Ｍiyata的回覆：
My parameter is 1064 nm zoom (flat) hand piece,  6 mm spot size, 0.5-0.6 J/cm2, 8-9 Hz, and 3 -5 passes(no overlap). Sometime I add modified fractional 532 nm hand piece (coming soon), parameter is; 0.4mJ, 8 Hz, 3 passes.

Dr. Woraphong的回覆：
Enlighten, Cutera
Picotoning with full beam maximum 2~4 pass 1.0J/cm2 without overlapping
Or 8mm full beam 1 pass+ 1 pass MLA 1.0J/cm2

許哲豪醫師回覆：
PicoLaser : Enlighten, Cutera / IPL: M22, Lumenis
1st step M22 , Lumenis
Skin type III~IV : filter 590 nm, 3pulses mode, 4/6/6ms pulse width,
 delayed time 30/30ms  12~14 J/cm2 , 1pass (20~40 shots)
Skin type V:    filter 640 nm, 3pulses mode, 4/6/6ms pulse width,
 delayed time 40/40ms  12~14 J/cm2 , 1pass (20~40 shots)
2nd step Enlighten, PicoGenesis
1064 nm 8mm 10 Hz 0.5~0.8/ J 10 Hz , minimal overlapping, 2~4 passes
(if no IPL treatment, plus focus lens-MLA 1064nm 8mm 10Hz 0.3~05 J/cm2 10Hz minimal overlapping 1 pass)

黃勇學醫師回覆：
PicoSure (Picosecond Alexandrite laser), diffractive lens array, 755nm, spot size 8mm, pulse duration 750 ps, energy fluency 0.4 J/cm2, repeated two pass to the whole face.

王昭欽醫師回覆：
Picoway  1064zoom 532 fractional 1064 frational
詳細的parameters 請見 Picoway Asian Patameter 圖檔（這個是當時round table meeting的結果，這部分用的剛好是我的參數）

點圖檔可放大，看得更清楚！

柯適中醫師回覆：

Dr. Kim的回覆：
I used picosecond Nd-YAG and Q switched ruby laser. 1st step: Discovery Pico 532nm, 9mm Round handpiece, 0.05J, 5Hz, 500shots, not overlapping, 2nd step: Discovery Pico 1064nm, 9mm round handpiece, 0.6J, 10Hz, 1500shots, 3rd step: C-plus R Evo 694nm, 8mm Fractional Handpiece, 0.4J, 3Hz, 300shots, 4th Step:Discovery Pico 1064nm, 8mm Fractional Handpiece, 0.2J, 10Hz, 500shots, not overlapping. Every step treatment is not overlapping, only single pass.


Ｑ2. 請問講師們皮秒肝斑治療的 End point?

李美青醫師回覆：
End point: mild erythema

林政賢醫師回覆：
Step 1: Mild erythema
Step 2: No crust. Mild erythema after minutes.

Dr. Wichai的回覆：
No end point but you can see the color is slightly faded in the real time a little bit.

Dr. Ｍiyata的回覆：
End-point is “slightly redness”, however it depends on patient skin type and condition.
Sometime we cannot find redness immediately. In that case, we should wait about a few minutes, then decide to add more passes or stop.

許哲豪醫師回覆：Minimal erythema

黃勇學醫師回覆：Mild erythema

王昭欽醫師回覆：slight erythema (E1)

柯適中醫師回覆：

Dr. Kim的回覆：
Every treatment was performed with protocol. After single Quattro toning, I observe skin response.

Ｑ3. 請問講師們使用皮秒治療肝斑病患的建議治療間隔為多久（treatment interval）?

李美青醫師回覆：4-8weeks interval

林政賢醫師回覆：every 4-6 wks

Dr. Wichai的回覆：
2-4 weeks interval but it is not necessary . If the parameter is right , melasma fades in the first one or two treatments. So patients may miss the treatment because they are happy and commonly they come back more that 6 months for other things

Dr. Ｍiyata的回覆：
My recommended interval is 4 weeks. However some patients cannot wait.

Dr. Woraphong的回覆：Interval : 4~6 wk

許哲豪醫師回覆：

If only Picotoning: > 2wk  If combine IPL or MLA: >4wk

黃勇學醫師回覆：4 weeks

王昭欽醫師回覆：4-6 weeks

柯適中醫師回覆：

Dr. Kim的回覆：
Quattro toning is at least 4wks interval. For example, 1st week: Quattro toning, 2nd week: F/U and skin care. 3rd week: skin care. 4th week: dual toning, 5th week: evaluation for result. Decision to treatment protocol. If not response, I will try Quattro toning again. If response, I perform Dual toning for Stabilization.

Ｑ4. 請問講師們皮秒肝斑治療的criteria for case selection為何？ 

李美青醫師回覆：Criteria: Patients with high expectation was not proper.

林政賢醫師回覆：Melasma without obvious inflammation or rosacea

Dr. Wichai的回覆：
Patients must fail from transxaminics treatment or worsen from other lasers. So called refractory melasma or difficult melasma

Dr. Ｍiyata的回覆：
About criteria, most important thing is that laser is not magic wand. I select no responder of other treatment.  Basically, at first we should educate patient. I teach them how to wash face and how to moisturize, how to avoid UV light, etc.
Then next step is oral medicine, tranexamic acid for 2 months, at least. Finally I add laser treatment.
Of course some patients cannot accept oral medicine due to her health condition.
At that time, I select laser mono therapy. It’s effective.

Dr. Woraphong的回覆：
Patient role: Understanding melasma/eliminating precipitating factor/follow doctor instruction

許哲豪醫師回覆：

Skin barrier intact / Good compliance.

Exclusion criteria included active inflammation/infection, malignancy, photosensitivity, pregnancy and breast-feeding

黃勇學醫師回覆：
Inclusion criteria:
（1) presented with melasma
（2) age > 20 y/o

Exclusion criteria:
（1) facial wound without complete epithelialization
（2) face with inflammation, infection from trauma, acne, or iatrogenic
（3) systemic diseases such as SLE, CKD, liver diseases, or thyroid diseases
（4) had received other cosmetic treatments such as hydroquinone, Kojic acid, Arbutin, or tranexamix acid via topical, or injection.
（5) phototherapy such as intensive pulse light, laser within a year prior to the enrollment
（6) history of photosensitivity, abnormal scarring, or poor wound healing
（7) intake of oral contraceptive pill or hormone replacement therapy a year prior

王昭欽醫師回覆：who wish to have rapid improvement with realiastic expectation

柯適中醫師回覆：

Dr. Kim的回覆：
The patient choice of Quattro toning treatment is to give priority to patients who do not respond to other treatment.

5. 講師們本次演講的精華摘要（約3-5個重點）

李美青醫師回覆：Lower fluence, longer interval, multiple sessions

林政賢醫師回覆：
a. Pico-toning with 1064 flat beam can have good results for melasma, with faster results and less recurrence rate than Q-switch toning. The mechanism is its more photomechanical effect to fracture the pigment, and its effects to reverse the photoaging in the dermis.
b. Additional 1064 fractional toning has ambiguous results, either better or worse.
c. 532 fractional toning seems to have additional beneficial effect for melasma at low fluence without producing LIOB.

Dr. Wichai的回覆：
Keep low fluence with high peak power machine. Treat individual melanosome with 450ps and cluster melanin with 300_375 ps and that will give long term results

Dr. Ｍiyata的回覆：
 1. Please consider about stress relaxation time. Target is malanosome. Never kill melanocytes.
 2. Short pulse duration, wavelength ( low absorption rate for melanosome) and low fluence is key to success.
 3. Picosecond laser is now stage in development. After waiting for a while, new technology will come into our market.

Dr. Woraphong的回覆：
Recipe for melasma
1st line therapy : oral tranexamic acid/triple combination cream/topical tyrosinase inhibitor/keratolytic agents/sunscreen
2nd line therapy : light treatment: picotining, non-ablative laser, IPL, psychological support
Maintenance therapy:
Whitening agents+sun protection , Light therapy , education , psychological support

許哲豪醫師回覆：

1. Inapporapirate setting or too many shots of picosecond laser will make melasma worsening
2. Given the multifactorial etiology of melasma, a multimodal combination therapeutic generally result in better efficacies than monotherapy 
3. Combined 1064nm PicoLaser and IPL treatment is safe and effective treatment modality for melasma
4. Using 1064nm focus lens on melasma is debating, The consensus is lower energy or fewer passes if using it to treat melasma. 
5. Oral tranexamic acid might be a worthwhile adjunct in the treatment of refractory melasma

黃勇學醫師回覆：

1. Our study is the first globally trial using VISIA® analysis to show that signs of photoaging could be reversible by a picosecond 755 nm alexandrite laser with a diffractive lens array and achieved comparable efficacy to that of triple combination cream in the treatment of female Asian patients with melasma. 
2. This study proved that melasma can be treated as a photo-aging skin disorder, thus treating the skin environment can provided improvement.
3. More laser treatment sessions with PicoSure with DLA could produce better photo-aging reversibility outcome.
4. Patients with melasma lesions exhibiting telangiectasia may benefit from an increased number of laser treatment sessions.

王昭欽醫師回覆：

• Holistic approach to the pathogenesis of melasma
• Never forget the photothermal effect of the commercially available picosecond lasers
• Clinical-Histological correlation

柯適中醫師回覆：

Dr. Kim的回覆：

1. The Quattro toning treatment was designed to treat whole skin layers at once, because pigment diseases including melasma can occur in the whole layer of the skin. 
2. The skin color can be brightened quickly by targeting the whole layer of skin on piegmented lesions, including those that have not been correctly diagnosed. This also enables diagnosis of pigment lesions at the same time as pigmentation therapy. 
3. I think too many session treatment of same wavelength was not effective and economic. Quattro toning uses somewhat higher fluence than conventional laser toning, but it acts on each designated skin layer, performs at sufficient intervals, and improves dermal environment through interactions based on various theories.