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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 39-45

A split-face study to evaluate the efficacy of Nd:YAG laser versus radiofrequency cauterization for the treatment of ephelides on face


Department of Dermatology, venereology and leprology, Muzaffarnagar Medical College, Muzaffarnagar, Chaudhary Charan Singh University (CCSU), Meerut, India

Date of Submission29-Jul-2020
Date of Decision08-Mar-2021
Date of Acceptance07-Jun-2021
Date of Web Publication16-May-2022

Correspondence Address:
Dr. Ambuj Singh
N 13/35, A-76 Brij Enclave Colony, Sunderpur, Varanasi 221005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


Background: Until recently, the removal of ephelides on face was predominantly carried out by using dermabrasion, chemical peeling, and radiofrequency cauterization. As these treatment modalities caused undesirable side effects such as scarring, this study is being performed to compare the effect of ND:YAG laser and radiofrequency to remove ephelides with laser showing better result and fewer side effects. Materials and methods: The present study was conducted in the department of dermatology, venerology, and leprology during the period 2017 to 2019 after obtaining clearance from Board of Studies and Ethical committee. Patient was thoroughly examined on the basis of history and examination for a confirm diagnosis. After confirming the diagnosis, the patient’s face was divided into left and right sides. On to the right-sided freckles of the face, radiofrequency cauterization was carried out and on left part, Nd:YAG was performed. The objective parameters were estimated at the end of 1 month using global improvement scale and also by evaluating patient’s satisfaction score. Photographs of both sides of the face were taken at 0, 1 week, and at 1 month under consistent background, position, and lighting and compared with the pretreatment images. Results: The study population consisted of 9 (18%) males and 41 (82%) females. Distribution of global improvement scores 3 and 4 was significantly more among Nd:YAG laser (65.0% and 10.0%, respectively) compared to radiofrequency ablation (2.5% and 0.0%, respectively). Mean freckle area severity index (FASI) score post-treatment and reduction in score were significantly more among Nd:YAG laser compared to radiofrequency ablation. Erythema, hyperpigmentation, and hypopigmentation were significantly more among radiofrequency ablation. Conclusion: Nd:YAG laser showed satisfactory result in removing freckles in comparison to radiofrequency ablation.

Keywords: Freckles, Nd:YAG laser, radiofrequency ablation


How to cite this article:
Singh A, Goyal T, Singh P. A split-face study to evaluate the efficacy of Nd:YAG laser versus radiofrequency cauterization for the treatment of ephelides on face. Pigment Int 2022;9:39-45

How to cite this URL:
Singh A, Goyal T, Singh P. A split-face study to evaluate the efficacy of Nd:YAG laser versus radiofrequency cauterization for the treatment of ephelides on face. Pigment Int [serial online] 2022 [cited 2022 Jun 29];9:39-45. Available from: https://www.pigmentinternational.com/text.asp?2022/9/1/39/345303




  Introduction Top


Freckles and solar lentigines are common and early signs of photoaging, which are major cosmetic concerns among oriental patients. Freckles tend to appear during childhood and adolescence and are relatively uniform in distribution, size, and color. Histologically, they are characterized by epidermal hypermelanosis without an increase in melanocyte numbers. In contrast, lentigines increase in number and prevalence with age. They tend to vary in size and color and are nonuniformly distributed. Both the number of melanocytes and degree of epidermal hypermelanosis are increased with elongation of epidermal rete ridges observed.[1]

Nonablative procedures used for treatment of freckles are sunscreens, topical lightening creams, topical retinoid, natural remedies, and chemical peels. Ablative procedures include laser treatments, cryosurgery, Nd:YAG laser, and radiofrequency (RF) cauterization. Shorter wavelengths (<600 nm) require relatively less energy fluence, whereas at longer wavelengths, higher fluence is required to produce an efficient photothermal reaction.[2]

The monopolar RF device is different from cosmetic lasers, as it produces an electric current rather than light. The energy produced is not liable to be diminished by tissue diffraction or absorption by epidermal melanin. As such, RF-based systems are appropriate for any skin type.[3] Monopolar RF therapy delivers uniform heat at controlled depth to dermal layers, causing direct collagen contraction and immediate skin tightening.[4],[5] Subsequent remodeling and reorientation of collagen bundles and the formation of new collagen is achieved over months after treatment.[6] RF surgery works well in the clinical setting as it causes minimal collateral thermal damage, resulting in rapid healing and aesthetically pleasant scars.

The RF energy heats hydrodermal collagen while the skin is cooled, promoting both collagen remodeling[7] and skin tightening.[8] This “tightening response” was considered unique to RF until a split-face study[9] showed that facial skin tightening after a single treatment with RF was comparable to facial skin tightening after a single treatment with the long-pulse Nd:YAG 1064-nm laser (LP Nd:YAG).

The present study was conducted to evaluate the efficacy of Nd:YAG laser and RF cauterization in treatment of freckles and to compare both modalities to see which one is better for the treatment of same.


  Materials and methods Top


The present study was conducted in the department of dermatology, venerology, and leprology, during the period 2017 to 2019 after obtaining clearance from Board of Studies and Ethical committee. The sample size was calculated with 80% of the power and 5% of the significance level. The sample size was estimated to be 50 patients with ephelides on face. Patient willing for the procedure, not taking any laser treatment for last 3 months, age group 16 to 40 years, Fitzpatrick skin types 3 to 5, and patient with freckles bilaterally were included in the study. Patient with features such as active herpes, chicken pox, viral exanthema infection, keloidal tendency, history of bleeding disorders or on anticoagulant medications, active infection at the local site, low pain threshold, taking isotretinoin from last 3 months, pregnancy, lactation, Fitzpatrick skin types 1, 2, and 6, freckles unilaterally on face were excluded from the study.

Patient was thoroughly examined on the basis of history and examination for a confirmed diagnosis. A written consent was taken prior to take pictures. After confirming the diagnosis, the patient’s face was divided into left and right sides. On to the right-sided freckles of the face, RF cauterization was carried out and on left part, Nd:YAG was performed. Both the procedures were performed once only and at the same time. There was no time gap. Before the procedure, the treatment areas were cleansed of debris, including dirt, makeup, and powder, using a mild cleanser and 70% isopropyl alcohol lidocaine 2.5% and prilocaine 2.5%, and cream was applied under occlusion to the right side of the face. After an hour of application, the anesthetic cream was gently removed and then, to obtain a completely dry skin surface, alcohol was used to degrease the skin. Eyes were protected with opaque goggles.

Procedure for radiofrequency ablation

The procedure was carried out under proper aseptic condition and under local anesthesia by using Megasurg Gold (M/s Dermaindia, 17, first main road, Bethal Nagar (Off IT Corridor), Perungudi, Chennai) with a frequency of 0.2 to 2.93 MHz, 230 volts using both cut (70% cut, 30% coagulation) and coagulation (60% coagulation, 40% cut) modes. Ablation was carried out initially under the cutting mode to flatten the skin and later, under the coagulation mode to smoothen the skin further and control the bleeding. The mild crusting which was collected initially was removed with fine-tipped Adson forceps and hydrogen peroxide. After the procedure, the patient was instructed to prevent sun exposure for the next 4 to 5 days and a topical nonocclusive antibiotic cream formulation was prescribed over this period.

Ice packs were applied over the treated areas. The subjects were instructed to follow strict photoprotective measures with UVA + UVB spectrum of sunscreens. The patient was reviewed after 1 week for any adverse effects. Any adverse effect that when occurred due to the treatment was noted down.

Procedure for Nd:YAG laser

Light pulses of Nd:YAG laser was directed into the epidermis for rejuvenation. It is a nonablative laser, which means that there is no break in the skin tissue continuity during the treatment. It is designed to target pigment cells. This specific wavelength is absorbed preferentially by pigments (melanin) and the resultant heat will cause generation and propagation of waves that damage to the cells containing pigment.

The damaged cells or the crusting will then be removed by gauge piece. Immediately following treatment, an ice pack was applied to soothe the treated area. The subjects were instructed to follow strict photoprotective measures with UVA + UVB spectrum of sunscreens. The patient was advised to come after 1 week and then after 1 month for adverse effect if any, and to take photograph. .

Evaluation of both procedures

The objective parameters were estimated at the end of 1 month using global improvement scale and also by evaluating patient’s satisfaction score (PSS). Photographs of both sides of the face were taken at 0, 1 week, and at 1 month under consistent background, position, and lighting and compared with the pretreatment images. The improvement on global improvement score was rated as worsened, minimal improvement, moderate improvement, marked improvement, and near-total improvement depending upon the change in grade of lesions by both treating physician and the patient.

Statistical analysis

The data were entered into the Microsoft excel and the statistical analysis was performed by statistical software SPSS version 21.0. The Student t test was used for comparing the mean values between the two groups, whereas Chi-squared test was applied for comparing the frequency. Nominal categorical data between the groups were compared using Chi-squared goodness-to-fit test.


  Results Top


The mean age of the study population was 35.06 ± 12.81 years. The study population consisted of 9 (18%) males and 41 (82%) females [Figure 1, [Table 1].
Figure 1 Gender-wise distribution

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Table 1 Gender-wise distribution of radiofrequency ablation and Nd:YAG laser groups

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Distribution of global improvement scores 3 and 4 was significantly more among Nd:YAG laser (65.0% and 10.0%, respectively) compared to RF ablation (2.5% and 0.0%), respectively [Figure 2] and [Figure 3], [Table 2],[Table 3],[Table 4].
Figure 2 Nd:YAG before and after

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Figure 3 RF before and after

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Table 2 Global improvement score between radiofrequency ablation and Nd:YAG laser groups

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Table 3 Global improvement score

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Table 4 Patient satisfaction score

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The distribution of PSS was compared between RF ablation and Nd:YAG laser using the Chi-squared test. The distribution of PSSs 6 and 8 was significantly more among Nd:YAG laser (45.0% and 47.5%, respectively) compared to RF ablation (7.5% and 0.0%, respectively), as shown in [Table 5].
Table 5 Patient satisfaction score between radiofrequency ablation and Nd:YAG laser groups

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The mean freckle area severity index (FASI) score at pretreatment, post-treatment, and reduction in score were compared between RF ablation and Nd:YAG laser using unpaired t test. Mean FASI score post-treatment and reduction in score were significantly more among Nd:YAG laser compared to RF ablation [Figure 4], [Table 6].
Figure 4 Comparison of mean pre- and post-treatment FASI score between radiofrequency ablation and Nd:YAG laser groups

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Table 6 Comparison of mean pre- and post-treatment FASI score between radiofrequency ablation and Nd:YAG laser groups

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Erythema, hyperpigmentation, and hypopigmentation were significantly more among RF ablation. Erythema was found among five (12.5%) cases with RF ablation and two (5.0%) cases with Nd:YAG laser. Hyperpigmentation was found among six (15.0%) cases with RF ablation and one (2.5%) cases with Nd:YAG laser [Figure 5], [Table 7] and [Table 8].
Figure 5 Comparison of mean percentage reduction in FASI score between radiofrequency ablation and Nd:YAG laser groups

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Table 7 Comparison of mean percentage reduction in FASI score between radiofrequency ablation and Nd:YAG laser groups

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Table 8 Complications between radiofrequency ablation and Nd:YAG laser groups

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  Discussion Top


A number of studies have reported the use of low-fluence Q-switched Nd:YAG laser treatment (laser toning) at weekly intervals for 8 to 10 sessions with some success. Though it is effective, the risk of mottled hypopigmentation following multiple Q-switched Nd:YAG laser sessions at frequent intervals has been reported. Hence, caution needs to be exercised while performing this procedure and the risks should be explained to the patients. In our experience, modified laser toning with low fluence and large spot size of 10 mm with treatments performed once in 2 weeks instead of weekly treatments for 6 to 8 sessions is better as it decreases the risk of hypopigmentation.[10]

In our study, global improvement scores 3 (near total improvement) and 4 (marked improvement) were significantly more among Nd:YAG laser (65.0% and 10.0%, respectively) compared to RF ablation (2.5% and 0.0%, respectively). Mean PSSs 6 and 8 were significantly more among Nd:YAG laser (45.0% and 47.5%, respectively) compared to RF ablation (7.5% and 0.0%, respectively). In the study by Chan et al.,[11] nine (45%) and eight (40%) patients had significant improvement at 4 and 12 weeks, respectively, based on Subject’s Global Assessment (SGA). Three (15%) patients felt no change at 12 weeks after final treatment. Majority of patients 15 (75%) were extremely satisfied or satisfied with the laser treatment at final review.

In the study by Key,[12] the patients were asked to compare the improvement in their RF-treated sides (facial and abdominal) with the improvement in their laser-treated sides by looking in a handheld mirror. More than half of patients (58.3%) stated that improvement in the laser-treated side was greater, despite greater (temporary) discomfort during laser treatment. Panelists, who evaluated only photographs, showed a stronger preference (10 of 12 patients, or 83.3%) for the laser-treated side.

In our study, mean FASI score post-treatment and reduction in score was significantly more among Nd:YAG laser compared to RF ablation. In the study by Köse[13] using the combined bipolar RF and optical energy, FASI was noted to be 65.15 at pretreatment, 25.60 at 12th week, and 27.40 at the end of the follow-up (1 year). Mean improvement rate (n = 30), as determined from the difference in mean FASI score, was 70% at 3 months and 66% at 12 months. In the study by Key,[12] for the lower face, the mean score difference was larger in the laser-treated side (2.11 vs. 1.39, or 35.7% vs. 23.8% improvement) although the difference did not reach statistical significance (P = 0.074).

Erythema, hyperpigmentation, and hypopigmentation were significantly more among RF ablation. In our study, hypopigmentation was found among 10.0% cases with RF ablation and 2.5% cases with Nd:YAG laser. Hofbauer Parra et al.[10] found no permanent adverse effects were found but the recurrence rate was 81%. These results confirm the safety and effectiveness of low-fluence Q-switched Nd:YAG laser for treating melisma. Chan et al.[11] reported a series of patients with facial depigmentation after the use of low fluence Q-switched Nd:YAG laser. They concluded that laser toning with low fluence Q-switched 1064-nm Nd:YAG laser for skin rejuvenation and melasma can be associated with mottled depigmentation.

In our study, hyperpigmentation was found among 15.0% cases with RF ablation and 2.5% cases with Nd:YAG laser. It was in accordance with the study by Wang et al.,[14] postinflammatory hyperpigmentation developed in one patient with freckles and eight patients with lentigines after Q-switched alexandrite laser (QSAL). However, this was in concordance with the study by Ho et al.,[15] where postinflammatory hyperpigmentation risk for patients treated with 532-nm QS Nd:YAG was found to be 10%. From our experience, QS Nd:YAG can sometimes result in dramatic improvement in superficial pigmentation after one to two treatments, especially in patients with low contrast lesions.

One of the concerns regarding the use of long pulsed lasers for the treatment of cutaneous pigmented lesions is the potential for thermal diffusion from the epidermis to the dermis, and the subsequent risk of scar formation. To prevent such occurrences, the pulse duration used should be shorter than the thermal relaxation time of the epidermis, which was estimated to be about 10 milliseconds for a 100-µm thick epidermis.[16],[17]


  Conclusion Top


The RF is cheap and easily available modality but does not show satisfactory result in removing freckles with high risk of scarring, whereas Nd:YAG, although being expensive when compared with RF, shows no scarring and less hypo and hyperpigmentation with better patient satisfaction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Holzle E. Pigmented lesions as a sign of photodamage. Br J Dermatol 1992;127(Suppl 41):48–50.  Back to cited text no. 1
    
2.
Margolis RJ, Dover JS, Polla LL, Watanabe S, Shea CR, Hruza GJ. Visible action spectrum for melanin-specific selective photothermolysis. Lasers Surg Med 1989;9:389–97.  Back to cited text no. 2
    
3.
Alster TS, Lupton JR. Nonablative cutaneous remodeling using radiofrequency devices. Clin Dermatol 2007;25:487–91.  Back to cited text no. 3
    
4.
Zelickson BD, Kist D, Bernstein E et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study. Arch Dermatol 2004;140:204-9.  Back to cited text no. 4
    
5.
Kist D, Burns AJ, Sanner R, Counters J, Zelickson B. Ultrastructural evaluation of multiple pass low energy versus single pass high energy radio-frequency treatment. Lasers Surg Med 2006;38:150-4.  Back to cited text no. 5
    
6.
Bogle MA, Ubelhoer N, Weiss RA, Mayoral F, Kaminer MS. Evaluation of the multiple pass, low fluence algorithm for radiofrequency tightening of the lower face. Lasers Surg Med 2007;39:210-7.  Back to cited text no. 6
    
7.
Zelickson BD, Kist D, Bernstein E et al. Histological and ultrastructural evaluation of the effects of a radiofrequency based nonablative dermal remodeling device: a pilot study. Arch Dermatol 2004;140:204-9.  Back to cited text no. 7
    
8.
Bassichis BA, Dayan S, Thomas JR. Use of a nonablative radiofrequency device to rejuvenate the upper one-third of the face. Otolaryngol Head Neck Surg 2004;130:397-406.  Back to cited text no. 8
    
9.
Taylor MB, Prokopenko I. Split-face comparison of radiofrequency versus long-pulse Nd-YAG treatment of facial laxity. J Cosmet Laser Ther 2006;8:17-22.  Back to cited text no. 9
    
10.
Hofbauer Parra CA, Careta MF, Valente NY, de SanchesOsório NE, Torezan LA. Clinical and histopathologic assessment of facial melasma after low-fluence Q-switched neodymium-doped yttrium aluminium garnet laser. Dermatol Surg 2016;42:507-12.  Back to cited text no. 10
    
11.
Chan MWM, Shek SY, Yeung CK, Chan HH. A prospective study in the treatment of lentigines in Asian skin using 532 nm picosecond Nd:YAG laser. Lasers Surg Med. 2019; 51 (9):767-73.  Back to cited text no. 11
    
12.
Key DJ. Single-treatment skin tightening by radiofrequency and long-pulsed, 1064-nm Nd:YAG laser compared. Lasers Surg Med 2007;39:169-75.  Back to cited text no. 12
    
13.
Köse O. Successful removal of freckles with the bipolar radiofrequency and optical energy. J Cosmet Laser Ther 2016;18:230-3.  Back to cited text no. 13
    
14.
Wang A, Marino AR, Gasyna Z, Gasyna E, Norris J Jr. Photoprotection by porcine eumelanin against singlet oxygen production. Photochem Photobiol 2008;84:679-82.  Back to cited text no. 14
    
15.
Ho SGY, Chan NPY, Yeung CK, Shek SY, Kono T, Chan HHL. A retrospective analysis of the management of freckles and lentigines using four different pigment lasers on Asian skin. J Cosmet Laser Ther 2012;14:74-80.  Back to cited text no. 15
    
16.
Anderson RR, Parish JA. The optics of human skin. J Invest Dermatol 1981;77:13-9.  Back to cited text no. 16
    
17.
Trelles MA, Verkruysse W, Pickering JW. Monoline argon laser (514-nm) treatment of benign pigmented lesions with long pulse lengths. J Photochem Photobiol. 1992;16:357-65.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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