Journal of Cutaneous and Aesthetic Surgery

: 2015  |  Volume : 8  |  Issue : 4  |  Page : 230--232

Novel low fluence combination laser treatment of solar lentigines in type III Asian skin

Brian Wei Cheng Anthony Tian 
 Department of Surgery, Singapore General Hospital, Singapore

Correspondence Address:
Brian Wei Cheng Anthony Tian
02-417, Block 472, Sembawang Drive, S750472


Objective: To demonstrate a novel low fluence combination laser technique [Erbium-doped yttrium aluminum garnet (Erb:YAG) and neodymium-doped yttrium aluminum garnet (Nd:YAG)] to effectively treat solar lentigines in type III Asian skin in a single session. Design: A prospective study. Setting: A Singapore-based clinic. Participants: Five patients (all females) were enrolled into the study. The ages ranged 35-60 years; all patients had Fitzpatrick skin type III. Measurements: Photographs were taken at baseline and at 1-month follow-up. These were reviewed by two independent physicians who were blinded to the study. Changes in pigment severity were assessed by a 5-point scale (1: Aggravation of pigment, 2: No change, 3: 25-50% improvement, 4: 51-75% improvement, and 5: 76-100% improvement). Results: All patients received a single treatment session. At 1-month follow-up, a reduction in pigment was observed in all patients. Both physicians«SQ» reports were independently agreeable. All patients scored 5, having >90% improvement in pigment severity. No hypopigmentation, postinflammatory hyperpigmentation (PIH), or recurrence was seen. Conclusion: Low fluence combination laser is effective and safe for clearance of solar lentigines in type III Asian skin.

How to cite this article:
Tian BW. Novel low fluence combination laser treatment of solar lentigines in type III Asian skin.J Cutan Aesthet Surg 2015;8:230-232

How to cite this URL:
Tian BW. Novel low fluence combination laser treatment of solar lentigines in type III Asian skin. J Cutan Aesthet Surg [serial online] 2015 [cited 2019 Dec 10 ];8:230-232
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Solar lentigines are common among Asians and are caused by an increased number of epidermal melanocytes producing excessive quantities of melanin. [1] Q-switched (QS) lasers are a popular treatment method, [2],[3],[4],[5],[6],[7],[8],[9] but the results of this monotherapy are variable and typically require multiple sessions to achieve optimal results.

Studies have shown that ablative resurfacing with Erbium-doped yttrium aluminum garnet (Erb:YAG) laser effectively treats solar lentigines. [10],[11],[12],[13],[14] The Erb:YAG ablates away the pigment-containing epidermis as well as improves the overall brightness and texture of the skin. However, there are side effects such as postinflammatory hyperpigmentation (PIH).

Conceptually, combining lasers can potentially increase the effectiveness of treatment while reducing the risk of side effects. This is because each laser can be utilized at lower fluences, resulting in less severe complications such as PIH. By having two different yet complementary mechanisms, the treatment frequency and duration can be reduced as well.

Jun et al. [15] demonstrated a combination treatment using the 532 nm frequency-doubled QS Nd:Yag with an Erb:YAG laser. At 2 weeks, the combination therapy showed good results. However, at 1 month, PIH appeared in the combination therapy group. Jun et al. concluded that the fluence of their combination therapy might be too high.

In our center, we have been using combination therapy for solar lentigines to great effect. We combined the use of a frequency-doubled 532 nm QS Nd:YAG with a low fluence Erb:YAG micropeel technique (with lower settings than Jun et al.). In this paper, we demonstrate five cases where a single treatment with this technique is able to achieve a significant improvement in the lentigines. The effect is sustained at 3 months of follow-up without any demonstration of PIH or any other complications.

 Materials and Methods

This was a prospective study. Five females were recruited for the study after obtaining their written consents. Inclusion criteria included patients with solar lentigines otherwise in good health. Those with melasma, major sun exposures, or other major skin conditions were excluded from the study. Patients who used any topical bleaching creams and those who received laser treatment within the past 1 year were all excluded.

A single session of combination laser treatment was conducted for each patient. No topical anesthesia was used. The frequency-doubled 532 nm QS Nd:YAG (RevLite, Cynosure Co., Fremont, CA) was used at a fluence of 1.2 J/cm 2 , 2 Hz, 2 mm spot size on the specific lentigines. Subsequently, the fractional nonablative 2940 nm Erb:YAG laser (SP Spectro, Fotona, Ljubljana, Slovenia) was operated at a fluence of 0.7 J/cm 2 , spot size 12 mm, 15 Hz. A single full-face pass with 10% overlap was performed. Subsequent 2nd and 3rd passes were performed over the solar lentigines till a clinical end point of skin whitening was reached; no wiping was performed between the passes. Care was taken to keep the skin cool during the laser irradiation with cryogen spray cooling. After the laser treatment, patients applied topical antibiotic (fusidic acid) for 3 days and sun screens during day light (for 3 months after the laser treatment).

Photographs were taken at baseline and at 1 month follow-up. Clinically, the patients were seen monthly, up to 3 months -following the laser treatment. Patient photographs (at baseline and at 1 month) were reviewed by two independent physicians who were blinded to the study. Changes in pigment severity were assessed by a 5-point scale (1: Aggravation of pigment, 2: No change, 3: 25-50% improvement, 4: 51-75% improvement, and 5: 76-100% improvement). [15]


Five females were enrolled into the study. Their ages ranged 35-60 years; all patients had Fitzpatrick skin type III. The patients tolerated the procedure well, without anesthesia. After the treatment, for 5-7 days, they experienced erythema of the face associated with scaling. However, all recovered within a week.

At 1 month follow-up, photographs were taken. A reduction in pigment was observed in all patients. Both physicians' reports were independently agreeable. All patients scored 5, having >90% improvement [Figure 1] and [Figure 2]. After 3 months of follow-up, no hypopigmentation, PIH, or recurrence was seen. All patients expressed satisfaction with their outcomes. There was also feedback from the patients about the general improvement in skin tone and texture. {Figure 1}{Figure 2}


Solar lentigines are treated with a variety of ablative and nonablative lasers. The QS Nd:YAG laser is well absorbed by melanin and it selectively destroys melanosome-containing cells while preserving the surrounding tissue. [16],[17],[18] Er:YAG laser, on the other hand, is an ablative laser. [11],[12],[13],[14],[19],[20] Each pass of the Er:YAG laser removes a thin layer of skin with a controlled ablation depth. As monotherapy solutions, however, the QS Nd:YAG produces variable response and requires multiple sessions for a satisfactory clearance, with possible complications such as blistering and hypopigmentation. The Erb:YAG may conversely cause complications such as PIH, especially in Asian type III skin.

In our study, we demonstrated a combination technique that harnessed the effectiveness of both lasers, while keeping the fluence low. Thus, it delivers a satisfactory response in a single treatment session, with no complications thereafter.

Jun et al. studied the combination of the Erb:YAG and QS Nd:YAG on solar lentigines. [15] While combination therapy demonstrated superior results over Nd:YAG monotherapy at 2 weeks; there was an increase in PIH at 1 month. We proposed that the main problem was the usage of a fluence of 2.5 J/cm 2 for the Erb:YAG. In our center, we used the Erb:YAG at subablative thresholds of 0.7 J/cm 2 . In our own internal unpublished audits, we have utilized different settings for the Erb:YAG. We found that at 0.7 J/cm 2 , patients still experienced the benefits of the laser (improvement of dyschromia, rhytides, etc.). Downtime and complications were minimal and the procedure was well tolerated without anesthesia.

There are, however, limitations in this study. Due to strict selection criteria, we could only recruit five cases. We intend to follow up with further studies with a larger sample size and a longer term of follow-up to demonstrate the efficacy of our combination technique. We also need to evaluate the settings in skin type IV and greater, as risk of PIH is higher in these group of patients.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Hölzle E. Pigmented skin lesions as a sign of photodamage. Br J Dermatol 1992;127(Suppl 41):48-50.
2Kilmer SL, Wheeland RG, Goldberg DJ, Anderson RR. Treatment of epidermal pigmented lesions with the frequency-doubled Q-switched Nd:YAG laser. A controlled, single-impact, dose-response, multicenter trial. Arch Dermatol 1994130:1515-9.
3Wang CC, Sue YM, Yang CH, Chen CK. A comparison of Q-switched alexandrite laser and intense pulsed light for the treatment of freckles and lentigines in Asian persons: A randomized, physician-blind, split-face comparative trail. J Am Acad Dermatol 2006;54:804-10.
4Rosenbach A, Lee SJ, Johr RH. Treatment of medium-brown solar lentigines using an alexandrite laser designed for hair reduction. Arch Dermatol 2002;138:547-8.
5Chan HH, Fung WK, Ying SY, Kono T. An in vivo trial comparing the use of different types of 532 nm Nd:YAG lasers in the treatment of facial lentigines in Oriental patients. Dermatol Surg 2000;26:743-9.
6Rashid T, Hussain I, Haider M, Haroon TS. Laser therapy of freckles and lentigines with quasi-continuous, frequency-doubled, Nd:YAG (532 nm) laser in Fitzpatrick skin type IV: A 24-month follow-up. J Cosmet Laser Ther 2002;4:81-5.
7Todd MM, Rallis TM, Gerwels JW, Hata TR. A comparison of 3 lasers and liquid nitrogen in the treatment of solar lentigines: A randomized, controlled, comparative trial. Arch Dermatol 200;136:841-6.
8Li YT, Yang KC. Comparison of the frequency-doubled Q-switched Nd:YAG laser and 35% trichloroacetic acid for the treatment of face lentigines. Dermatol Surg 1999;25:202-4.
9Ho SG, Yeung CK, Chan NP, Shek SY, Chan HH. A comparison of Q-switched and long-pulsed alexandrite laser for the treatment of freckles and lentigines in oriental patients. Lasers Surg Med 2011;43: 108-13.
10Ortonne JP, Pandya AG, Lui H, Hexsel D. Treatment of solar lentigines. J Am Acad Dermatol 2006;54(Suppl 2):S262-71.
11Khatri KA. Ablation of cutaneous lesions using an erbium: YAG laser. J Cosmet Lasers Ther 2003;5:150-3.
12Khatri KA, Gordon J, Garamela L. Laser skin resurfacing with a novel portable erbium:YAG laser. J Cosmet Laser Ther 2006;8:23-5.
13Walsh JT Jr, Deutsch TF. Er:YAG laser ablation of tissue: Measurement of ablation rates. Lasers Surg Med 1989;9:327-37.
14Hantash BM, De Coninck E, Liu H, Gladstone HB. Split-face comparison of the erbium micropeel with intense pulsed light. Dermatol Surg 2008; 34:763-72.
15Jun HJ, Cho SH, Lee JD, Kim HS. A split-face, evaluator-blind randomized study on the early effects of Q-switched Nd:YAG laser plus Er:YAG micropeel (combined therapy) versus Q-switched Nd:YAG alone in light solar lentigines in Asians. Lasers Med Sci 2014;29:1153-8.
16Anderson RR, Parrish JA. Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524-7.
17Parrish JA, Anderson RR, Harrist T, Paul B, Murphy GF. Selective thermal effects with pulsed irradiation from lasers: From organ to organelle. J Invest Dermatol 1983;80(Suppl):75s-80s.
18Watanabe S, Anderson RR, Brorson S, Dlickas G, Fujimoto JG, Flotte TJ. Comparative studies of femtosecond to microsecond laser pulses on selective pigmented cell injury in skin. Photochem Photobiol 1991;53: 757-62.
19Somoano B, Hantash BM, Fincher EF, Wu P, Gladstone HB. The erbium micropeel: A prospective, randomized trial of the effects of two fluence settings on facial photoaging. J Drugs Dermatol 2011;10:179-85.
20Pozner JN, Goldberg DJ. Superficial erbium:YAG laser resurfacing of photodamaged skin. J Cosmet Lasers Ther 2006;8:89-91.