Q switch laser. Why are you NOT getting results?

The Q switch laser is widely used by many doctors for many various reasons. Some doctors use them for acne, some for pigmentation while others use them for pores. Yet on numerous occasions, I get patients who tell me that they had done similar lasers and NOT see any results.  Yet they are somehow able to see a difference when the Q switch laser is performed by others. So what's the difference?
Why are some doctors able to get the desired eradication of pigments and even skin tone while others are unable to do so? What's the real secret?

The Q switch laser is essentially an ND-YAG laser. Being a ND-YAG laser, this means that the clinician has chosen the 1064nm wavelength to treat your skin. The choice of wavelength is dictated by the need for good absorption of the laser or light energy in the target structures deep in the skin, while avoiding unnecessary damage to the epidermis or the top most layer of the skin. For the treatment to be effective, the light energy needs to penetrate deeply into the skin because it is necessary to destroy or thermally affect specific skin structures. Depending on the location of the pigment or the end target in the body, the light energy must penetrate to at least 2-7mm in the skin to be effective.

This is dependent on 2 main properties of the laser. The absorption and the scattering of light.
Absorption of the light energy is dependent on numerous factors like the depth, absorption coefficient and intensity of the laser beam.

The absorption coefficient in real skin also vary from the absorption coefficient isolation. Chromophores do have very specific and selective absorption coefficient yet in real skin, this is influenced by numerous other factors. An example of one of this factors is skin colour. Skin colour affects the melanin concentration and this increase in darker individuals. This consequently results in greater penetration depth. Hence using a non Q-switch ND Yag laser results in increase thermal injury.

Scattering is yet another factor that affects the end result of treatments. Scattering of the laser light substantially influences the beam propagation through tissue and thus affects energy absorption in the skin. Once light penetrates through the skin, the depth of penetration becomes strongly influenced by scattering. The degree of laser light scatter before reaching the target is also dependent on the laser wavelength. It is important to know which laser is being used as this influences the amount the scatter. An example would be, when comparing the Q-switch laser to say an IPL or a ruby laser, a ruby laser would require a larger spot size and energy. This is the same if you are comparing an alexandrite laser to a diode laser.

With scattering, light no longer travels in a straight line. Its direction becomes random and causes the light to bounce back and forth inside the skin until it is absorbed. In order to penetrate deeply and unidirectionally, the wavelength and large spot size is important. The influence of spot size on the penetration depth and the energies require to achieve this is highly dependent on the machine and the experience of the doctor. Every single Q-switch laser in the market has a fixed spot size with a maximum energy and frequency it can be fired yet. So, not all Q-switch are equal! Some are indeed better than others. Each of these factors greatly influence the ability of your doctor to achieve the results you desire. With numerous lasers out there in the market, eg the IPL, Ruby laser, Erbium, Co2 etc etc etc... patients in the end really do need to trust the doctor they are seeing.

Pulse width, ... yet another factor I haven't even begun talking about. But by now, I am certain anyone reading up to this last paragraph is already already confused. And if you are a doctor reading my blog, at least I hope you gained some information reading on the 2 factors mentioned above. Absorption and scattering. Period.

Till then, treatment intervals, fluence and shot count.. more technical terms... keep it coming!

Adult acne - Permanent Results. Proven.

It's been a very long time since I've updated this blog. But I thought this was time I release an update on the treatment outcomes and methods that is used to treat Adult Acne.

Its great to see lovely outcomes from my patients with the clearance of their acne and the lack of recurrence especially with the use of the AGNES treatment.

AGNES was previously only exclusively available to my clinic but now I can see it being used widely in Singapore. This is good news as the local distributors have decided to sell his machine now to many other clinics.

AGNES is a treatment used to selectively destroy acne prone oil glands. It is quite common for one to then wonder, if doing AGNES will make the skin less oily or will it make it dry and wrinkled. This will not happen, as only very few oil glands are destroyed in proportion to the millions of oil glands located throughout the entire face. On the contrary, it is very likely that topical creams are the most likely cause of the dry skin. However, even through this is uncomfortable and make up often does not sit well on a extremely dry texture, the side effect is nevertheless temporary.

Why is it that sometimes the performance of AGNES varies? AGNES is a very specialized procedure. Accurate identification of the oil glands including direction of the oil glands and accurate selection of the energy required and number of shots needed for complete oil gland destruction takes experience and patience.

Is AGNES a miracle treatment in the treatment of acne and pimples? There are no miracles in treatment of this extremely difficult condition. Yet improvements in medical technology continuously pushes the boundary and allows us doctors to continuously do our best for our patients.

Acne has indeed multi causes. From hormones to genetics to the environment. Every doctor has their own way of treating acne. It is a constant battle to improve our methods and improve our techniques with research taking place regularly on how best to treat this.

I personally do not perform AGNES on all my patients either. Selection of the right candidate for the best outcomes depends on the expertise of your doctor. And again as mentioned, acne alone because has multiple causes, one really needs detailed and careful evaluation as to the likely cause of the pimple before knowing which treatment would work best.

Lastly, acne also has many different forms. Some are huge giant cystic nodules. Others may come as smaller papules or tiny red bumps. While others may appear primarily as bumps on the skin or commedonal acne. Some people describe their acne as fungal acne when it is really pityrosporum folliculitis. And then combined with Rocasea there is subtype 2 Rocasea with papularpustular rocasea or pimples associated with redness and flushing of the skin.

The diagnosis of acne is often straight forward yet it is really up to your doctor to identify the cause and treat it accordingly.

Another IMPOSSIBLE case of persistent nodular cystic acne

We have a case here of a patient with one of the worst case of nodular cystic acne. The left side had a huge nodular cystic collection that has been constantly flaring up over the past year. When I first saw him, it was actually his mother that was more bothered about his face than the son himself!
Glad he was convinced to come down anyway and finally receive treatment.

 

These are the pictures when I first saw him. All pictures posted here are posted with full consent of the patient. He has gladly allowed me to share his journey on how I treat a case of severe pimples or acne vulgaris.

What we are seeing here is evidence of massive nodular cystic acne on both sides of the cheeks. Also presence of multiple papules. If he doesn't receive prompt treatment, I am worried that either the acne may develop into a cheek abscess or he will be left with terrible scaring when it finally resolves by itself. Cheek abscesses can sometimes spread to the inner cheeks as well and may result in full facial infection or cellulitis if this is left untreated.

 

The nodule on the left side was so big that it required a small incision to drain out all the pus and necrotic debris. A tiny stab incision was made after injection of local anaesthesia and this allowed the rapid drainage of the pus to be expressed.

 

The wound was packed with gauze and required alternate day dressing. This particular abscess was eventually closed with interrupted stitches. It was a difficult journey that time with every alternate day dressing, but he could come to the clinic after school for a relatively quick procedure. After the wound showed more signs of healing, it was closed with interrupted stitches and for the wound to finally heal.

 

He was subsequently put on 3 round of AGNES treatment, Q-switch laser and V-beam laser treatment. This helped to resolve most of his other stubborn acne throughout the rest of the face and also with the laser treatment to resolve the scarring and also to suppress any active acne and inflammation. This continued for the next 5 months for him, seeing him at regular intervals.

 

It is an absolutely pleasure for me to report how happy he is that he has agreed to allow me to use his pictures to document his remarkable journey. With repeated AGNES treatment for permanent control for his acne and using a unique Q-switch protocol developed by myself combined with the V-beam laser.

 The most important aspect is also the prevention of depressed scars. The ice-picks and boxscar scars are very difficult to treat and I am glad early treatment of this case of nodular cystic Acne Vulgaris has resulted in an excellent result.

Lesson to learn. Early visit to the doctor can prevent future scaring, help achieve excellent outcomes for the skin and early resolution of even the most severe cases of acne or pimples.

Protecting Your Skin From The Haze in 4 Easy Skincare Tips

Haze and skincare tips

Is your skin looking dull and your pores getting clogged very quickly these days? I've got bad news for you-the haze is back. Again.

 

 

You may already be familiar with the damage that the haze does to our airways and eyes. However, the impact of the haze particles on our skin is not to be negated. Every year, I see an increase in haze-related dermatological problems in  my patients and so I've compiled a simple FAQ on how to protect your skin at home from the haze.

 

 

What are some of the common skin problems due to the haze?

·         clogged pores

·         blackheads

·         dry skin

·         skin redness

·         pimple/acne outbreaks

·         eczema flares

·         irritable/sensitive skin

·         rough skin texture

·         dull skin

·         premature skin aging (e.g. fine lines and wrinkles)

·         flare up of inflammatory skin conditions (e.g. psoriasis, eczema...etc)

What is haze?

To understand how haze wreaks havoc on the skin, it is important to understand what exactly haze is.

 

Haze is a mixture of air pollutants, dust particles and smoke suspended in air. These particles are usually less than 10mm in size. Haze resulting from forest fires has a high concentration of these fine particles and can remain in our atmosphere for weeks.

 

The air pollutants in haze are often referred to as "smog" and consist of a noxious chemical mixture of ozone, carbon monoxide, nitrogen dioxide, sulfur dioxide as well as other pollutants. Smog is what irritates our eyes and makes us cough.

How does haze affect my skin?

Haze damages our skin in more ways than one.

 

The toxic particles in the air contain free radicals that exhaust the skin's oxygen supply. Your skin cells need these oxygen molecules for normal functioning and when deprived of oxygen, premature aging results. Collagen and elastin in the skin become depleted and skin loses its elasticity and wrinkles can develop-Think of the discolouration that happens to an oxidised apple after it has been cut. Free radicals also cause DNA damage in cells, affecting their ability to heal. Diseases linked to free radical damage include cancer, heart disease and dementia.

The dust particles are also a major culprit in skin damage. You know that grime that you can wipe off from your face? Those clogged pores and dull skin? That's due to the dirt and dust in the air coming into contact with your skin and building. Unfortunately, this layer of gunk also irritates and destabilises skin, causing acne and pimple flares.

 

It is a myth that the haze blocks out UV rays. In fact, dust particles are also known to intensify sun damage from UV rays. UV rays bounce off dust particles and become scattered in the atmosphere- meaning that the UV rays are intensified because of the haze.

 

What can I do at home to protect my skin?

Maintaining good skin hygiene and skincare habits can reverse some of the damage done by the haze. Here are the 4 simple but crucial steps that I personally practice to protect my skin during the season of the haze:

 

1) Cleanse

Having clean skin vital to having healthy skin. Double cleanse your skin with a makeup remover and gentle facial cleanser to adequately remove all that dirt and grime that are causing your clogged pores and dull skin. Your skin may be more sensitive and irritable during this period, so please remember to be gentle with your skin!

 

2) Antioxidants

Free radicals in smog rob skin cells of their vital oxygen supply, causing accelerated skin aging and loss of collagen has been well documented in many studies. In recent years, there has a been a revolutionary development to defend against these harmful free radicals- Antioxidants.

 

There is an comprehensive article on the antioxidants and their mechanisms here

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249911/

 

In summary, antioxidants protect our skin at different levels by preventing free radical formation, scavenging free radicals and repairing DNA and cell damage. Some common antioxidants include Vitamin C (Ascorbic acid), Vitamin E, Niacinamide and Resveratrol.

 

My personal favourite, as you can see from this photo on my table  (excuse the amateur photography!), is Skinceuticals' CE Ferulic. This synergistic combination of antioxidants- 15% pure vitamin C, 1% vitamin E and 0.5% ferulic acid is my preferred choice in the day time to fight free radical damage.

 

At night, I switch to another potent antioxidant combination- Skinceuticals' Resveratrol B-E. This contains both Resveratrol and Vitamin E and works well for my sensitive skin.

3) Moisturise

Having well moisturised skin is especially important during this period. Moisturiser application acts as a physical barrier  between the skin and the environmental pollutants and free radicals, thereby acting as a double defense.

 

4) Sunprotection

Diligent sunprotection can minimise the damage by UV rays. Choose a broad spectrum sunblock with SPF above 30 and reapply every 3-4 hours if you can.

 

What else can I do for my skin?

So if you've done all that and your skin's still dull, dirty and irritable? Pimple and acne flares not getting better? It is worthwhile to consult your doctor to see how your skin can be treated in order to prevent your skin condition from worsening.

 

 

Some of the common treatments that I recommend my patients to clean and control their skin conditions are :

1) Hydrafacial

 

The Clifford Clinic's award winning Hydrafacial consists of a comprehensive, non invasive treatment that combines a patented hydrovortex exfoliation and extraction technique together with delivery of antioxidants and hyaluronic acid in to the skin. This works very well for clogged pores, blackheads and white heads, dull skin and pimple/acne outbreaks.

2) Dermaplaning

I've previously shared about dermaplaning here :

http://drgerardee.blogspot.sg/2016/03/dermaplanning-exclusive-treatment-in.html

 

By exfoliating the epidermis and removing the skin of dirt particles, skin is immediately cleaner and brighter. This is ideal for patients who have dull and rough skin. Also, without the dead skin cells and dirt particles, penetration of skincare products is improved.

3) Laser

With pimple and acne flares, laser is very helpful to improve control and prevent scaring.  Laser also promotes collagen rejuvenation, erasing away the effects of premature aging and achieve a more even skin tone.

4) Chemical Peel

http://drgerardee.blogspot.sg/2016/06/chemical-peels-for-acne-and-pigmentation.html

You can read about my comprehensive review of chemical peels here. Essentially, problems like pigmentation, clogged pores, dull skin, scars and acne control can be addressed with chemical peels

I hope you have found my tips useful in protecting your skin from the haze. Please stay healthy everyone!

Adult acne - Permanent cure - More updates

Around November 2015 I think.. patient with her latest pictures from my IPhone. Finally had the time to upload this. A happy patient is what drives me everyday in fine tuning and perfecting the cure for acne. It isn't perfect and acne is a journey of ups and downs with set backs. What works for one may not necessarily work for another, but I can safely say that with patience and trust, we will get there one way or another.

Have faith. Acne is curable!

Adult Acne Permanent Cure

More updates with regards to how Adult Acne is treated. Pictures on 10th September 2015. Acne is more stable. Reduction in post-inflammatory hyperpigmentation or acne marks.

 

PIH is primarily causaed by 2 main causes. The first is caused after the basal cell layer in the inflamed skin is destroyed leading to the accumulation of melanopahges containing a large amount of melanin in the upper dermins. The second is caused by an epidermal inflammatory response, leading to an accumulation of chemical mediators that stimulate the syntheses of melanin in the melanocytes that then transfer this pigment to the surrounding cells.

Q-switch laser is used in the treatment of her PIH. We have devised a fixed protocol using this laser to remove PIH without causing any complications. There was no rebound hyperpigmentation and no areas of hypopigmentation.

The next series of update will be the last set of pictures to conclude this series of adult acne treatment using AGNES and Q-switch laser.

Acne, the permanent cure with AGNES

For those who have seen SL's blog, I guess she gives an update of her acne progress much quicker than me, as I do not often have the time to log on to document her progress. Nevertherless, these are some of her old photos taken from my IPhone. Though it has been a few months since these photos are taken, but they still provide a good update on her progress through the treatments.

 

These were taken in 25th June 2015. Slow progress, but I can see the improvement she is getting. It would need time for the pigmentation to improve but we are getting there.

AGNES and Q-switch laser. The treatment for acne / pimples

It has been only a week since the previous photos were taken. These were taken on the 11th of June 2015. Currently a single session of AGNES has been completed and I have began her Q-switch treatment.

She has reported less commedones, although clearly there is still a lot of hyperpigmentation

The recovery post AGNES is actually quite fast. Initially you may notice a few rather raised spots, but that is expected even after a facial.

These spots usually calm down within about 2-3 days. After that the Q-switch laser would then be required to remove the pink / brown pigmentation.

Sometimes there is evidence of some pustules post agnes, but these do subside pretty quickly as well, which is also the reason why you would be required to return on the second day to extract these pustules.

 

A lot of the pustular nodular acne have calmed down, leaving behind post-inflammatory hyperpigmentation which are essentially acne scars or acne marks.

The Q-switch laser ND YAG is a laser used for pigmentation. It is used to remove haemoglobin and melanin, which are deposited in the skin.

Studies performed using the Q-switch have showed significant reduction in inflamed, non-inflamed lesions as well as sebum levels.

AGNES - The PERMANENT cure for adult acne / pimples

Let me talk about the AGNES and go through a case study with a patient whom I have treated recently. She was kind enough to allow me to take pictures for posting on the internet to educate my readers including those suffering from adult acne.

Here is Patient S. A young adult female whom has been battling with acne since her teenage years. I first met her in June and this pictures were taken on 5th of June 2015

 

You can see evidence of multiple papules and comedones. These comedones are evidence of congestion of the oil glands. The redness is due to inflammation as bacteria invades into the oil glands causing infection and inflammation.

 

 

As I go through with all of my patients who require acne treatment, acne is a multi-factorial condition caused by a few factors, from genetics to hormones and also life-style factors. The conditions in the skin or pathogenesis that promote acne include hyperkeratinisation ( Or excess skin growth ) , obstruction of sebaceous follicles resulting from abnormal keratinization of the infundibular epithelium ( congestion of the oil glands ), stimulation of sebaceous gland secretion by androgens (excess oil gland secretion ), and microbial colonization of pilosebaceous units by Propionibacterium acnes ( bacetria ), which promotes perifollicular inflammation.

 

 

Of course acne comes in many various severity and different treatment protocols and treatment methods can be used to treat acne with varying degree of effectiveness.

Over the next few weeks, I shall be writing on her progress as we have actually started treatment a few months ago and we have now started to see progress of the treatments.