INTRODUCTION

The term laser in dermatology is an acronym that means “light amplification by the stimulated emission of radiation.” It is based on the use of a high energy beam at low wavelength that produces a thermal impact into the skin aimed to destroy altered cutaneous structures. Lasers can be accurately focused into small spots due to their monochromatic, coherent, and collimated properties. This allows the performance of radiation beams at a single wavelength, in-phase waves, and parallel traveling, respectively.[1] In the last years, laser technology has been adapted for the treatment of many skin conditions including vascular and pigmented lesions, tattoo removal, scars, and wrinkles. There are several types of lasers that work at different wavelength peaks, pulse durations, and absorption range that determine their clinical application.[2]

Nonablative lasers, create microscopic heat columns causing areas of thermal damage separated by normal skin that are a healthy reservoir for tissue regeneration. Ablative lasers lead to full-thickness tissue destruction over areas to be deeply remodeled. Nonablative lasers leave a functionally and histologically intact stratum corneum with minimal disruption of the epidermis.[3] They work by delivering a precise wavelength light below the skin’s surface that is absorbed by specific dermal structures. This destroys target areas that do not harm the surrounding tissue. In addition, short pulses decrease de amount of heat transferred to cells thereby reducing thermal damage that could result in scarring. This type of treatment is usually aimed to improve skin texture and tone, reduce fine lines and mild wrinkles or eliminate pigmentation and vasculature issues such as capillaries.[4]

Nonablative lasers are comparatively less invasive, and they are usually associated with lesser efficacy as they need several sessions to achieve significant results. Moreover, despite the reduction in adverse symptoms, post-treatment events still arise due to the repeated dosage. These include temporary hyperpigmentation, persistent erythema, edema, swelling, and redness with an incidence of 15%.[5] Hence, new custom-tailored treatments with optimal safety profile and therapeutic efficacy are demanded by clinicians as adjunctive tools to boost the resurfacing effect of nonablative lasers and minimize adverse reactions.

In this line, the progression in the field of autologous treatments has led to the emergence of products based on the patient’s own proteins. Preparations like platelet-rich plasma (PRP) have shown their efficacy and safety in different dermatological applications.[6] In fact, numerous findings reveal that the combination of ablative lasers and platelet-based formulations promotes cutaneous remodeling more efficiently.[7] When managing atrophic lesions such as acne scars or facing cutaneous resurfacing, studies report shorter downtime, better tolerability, and improved skin quality after PRP treatment.[89] However, these interventions require repeated blood extractions and invasive and painful intradermal injections of PRP during the treatment period to reach the desired effect.

In this sense, a topical formulation based on plasma rich in growth factors technology (PRGF) has been recently developed.[10] This product, known as Endoret-Serum (ES), is 100% autologous and can be in situ prepared after a single session of blood withdrawal.[11] ES maintains its physicochemical and biological properties after long-term storage and contains a pool of growth factors that undergo a sustained percutaneous absorption playing a major role in cutaneous regeneration.[12] Unlike other PRPs, ES has been designed for a home care and topical needle-free application with no need of physician intervention or repeated blood extractions. Thus, ES provides a minimally invasive approach for maintaining a constant dosage of growth factors that might boost the resurfacing effect of lasers and minimize adverse reactions. The aim of this study was to preliminarily assess the clinical performance of a single session of the combined therapy with nonablative laser and ES in the management of facial rejuvenation.

MATERIALS AND METHODS

RESULTS

The study included nine women whose age ranged from 29 to 63 years being the average 54 ± 11 years. Patients presented slight-to-moderate skin aging signs such as pigmented lesions, redness, and capillaries (Goglau’s grade I–II). The main clinical symptoms to be treated included cutaneous vascular lesions like telangiectasis (11%), age spots related to solar lentigines (55%), and dermatoses like rosacea (34%). During the follow-up period no adverse effects related to the treatment were observed. Moreover, patients did not need maintenance therapy after the follow-up period.

Results showed that the combined therapy improved cutaneous spots, wrinkles, and texture after 8 weeks, whereas significant pore reduction was observable at 1 week [Figure 1] (P ≤ 0.05). Spot, wrinkle, and texture index showed a significant fold improvement of 1.95 ± 2.6, 1.42 ± 1.4, and 1.8 ± 0.8 compared to baseline, respectively. Pore reduction showed a significant fold improvement of 1.33 ± 0.5. Similarly, UV spot and porphyrin decrease reached statistically significant values at 1 week, whereas red area improvement was noticeable after 8 weeks [Figure 2] (P ≤ 0.05). UV spot and porphyrin showed a significant fold improvement of 4.42 ± 3.4 and 1.85 ± 1.7, respectively. Red area showed a 1.8 ± 1.2-fold improvement compared to baseline. Although brown spots showed a slight improvement after 1 week, the statistical significance was not reached (3.76 ± 6.4-fold improvement).

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Figure 1

Skin complexion analysis using the VISIA-CR System. (A and B) Combined treatment showed to improve spot percentile after 8 weeks. (C and D) Wrinkle reduction was noticeable at 8 weeks. (E and F) Texture improvement achieved the statistical significance after 8 weeks. (G and H) Pore index decreased 1 week after treatment. *Statistically significant differences compared to baseline (*P ≤ 0.05)

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Figure 2

Skin complexion analysis using the VISIA-CR System. (A and B) Combined treatment showed to improve UV spot percentile after 1 week. (C and D) Although brown spots showed a slight improvement after 1 week, the statistical significance was not reached. (E and F) Red area improvement achieved the statistical significance after 8 weeks. (G and H) Porphyrin index decreased 1 week after treatment. *Statistically significant differences compared to baseline (*P ≤ 0.05)

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Standardized images revealed that after the laser session, mild erythema, local edema, and slight redness and bruising occurred over the facial area. However, following ES treatment these symptoms disappeared after 24 or 48 h, and the final clinical outcome revealed a noticeable skin quality improvement [Figure 3]. At the end of the follow-up period, overall wrinkle amelioration, periorbital hyperpigmentation decrease, softened skin, and tone recovery was observed. Moreover, the combined therapy helped in the lessening of facial static lines and the reduction of the uneven surface texture. The skin brightness also improved [Figure 3]. Pigmented lesions and vasculature issues like redness and capillaries decreased noticeably.

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Figure 3

Standardized facial photographs of patients during the study at baseline, just after the laser treatment and at the end of the follow-up period

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Patients fulfilled a personal satisfaction survey during the study based on a Likert’s 10-point scale. After 1 and 8 weeks, patients referred to be satisfied and very satisfied, respectively [Table 1]. Regarding the global impression of improvement, patients also referred that their cutaneous condition was much better after the combined therapy compared to baseline [Table 1]. Moreover, two trained specialists checked the follow-up images of each patient and concluded that subjects presented minimal dermatological symptoms of skin aging compared to the baseline status [Table 1].

DISCUSSION

Previous studies have investigated the role of PRGF as an assisted therapy for laser resurfacing.[15] These types of treatments are usually based on the extraction of a limited plasma volume which is intradermally injected in combination with a variety of lasers for managing cutaneous conditions such as atrophic post-acne scars or irradiation symptoms.[16] The therapy combines ablative CO₂ and erbium YAG lasers, which are based on the concept of selective photo-thermolysis, with autologous platelets and growth factors due to their regenerative potential once released at the site of injection.[8] In this sense, the bioactive molecules derived from the patient’s own blood have been shown to reduce fibrotic tissue and to decrease the duration and severity of laser-related side effects.[9]

Platelet-derived bioproducts have also been used as an adjuvant therapy among less potent lasers with the aim of promoting cutaneous repair during repeated irradiation sessions.[1718] In this study, nonablative alexandrite and PDLs were used for the management of facial resurfacing. These lasers were cleared by the FDA to manage cutaneous inflammatory conditions and treat pigmented lesions. Today these lasers are considered the laser of choice for most congenital and acquired vascular lesions as they promote skin remodeling by direct cutaneous immunologic activation. Several skin conditions have been successfully treated with alexandrite and PDLs including acne, psoriasis, spider veins, or age spots showing improvements in dyspigmentation and new collagen and elastic tissue deposition.[1920]

The alexandrite laser incorporates specific crystals as the laser source and produces an infrared wavelength of light to treat pigmented lesions without affecting the surrounding skin. The micro-damaged areas launch the healing process so that the collagen is restructured, the skin is tightened, and the skin texture is improved. Hence, this technique involves the controlled destruction of the superficial layers of the skin, by means of successive passes of the laser beam over the area to be treated.[20] The PDL penetrates the skin to reach target chromophores at the blood vessels. Its energy is absorbed by oxyhemoglobin to coagulate and cleanse the capillaries with a great tolerance and low melanin absorption. The absorbed light is converted in thermal energy thereby damaging surrounding cells. The pulse duration is shorter than the thermal relaxation time, which is the time taken for cooling after irradiation, ensuring that the impact is limited to the target structure. PDL allows to treat scars caused by acne, spider veins, spots, and birthmarks.[19]

However, these types of lasers usually require repeated sessions and when the energy beam is nonselectively diffused and is absorbed by surrounding tissues, complications and adverse effects may occur. These include pain, redness, swelling, itching, blistering, hyperpigmentation, bruising, and infection.[5] In addition, PRP-derived formulations are invasively injected at a dermal level following varying treatment regimens which may lead to discomfort and aggravate the damaged surface condition of the skin. In this study, a novel topical formulation (ES) has been tested as an autologous adjunctive therapy for nonablative resurfacing to promote facial rejuvenation after a single session of fractional laser. ES derives from PRGF, which is a specific type of PRP. PRGF allows versatile modifications of plasmatic physicochemical properties with the aim of designing custom-tailored bio-products that meet specific clinical needs.[21] In fact, other formulations derived from PRGF such as eye drops, gel-like fillers, or fibrin clots have been already evaluated in different medical fields including ophthalmology, oral surgery, traumatology, and dermatology.[22232425] For this purpose, ES provides a home care, storable and topical needle-free application that can be used in combination with laser rejuvenation.

Results of the skin complexion analysis presented herein showed that ES boosted the resurfacing effect of a single session of nonablative laser. Patients fulfilled specific surveys and dermatological life quality questionnaires regarding the clinical outcome of the combined therapy. In line with previous reports, participants and physicians referred a noticeable improvement of the aging signs and final satisfaction with no reported side effects.[262728]

Data from high-resolution topography of the skin showed that spots and UV marks, which are related to altered pigmentation and melanin accumulation below the cutaneous surface, improved significantly. This is consistent with other reports in which PRGF shown to reduce cutaneous photo-oxidative damage and actinic elastosis.[2930] In fact, ES downregulates UV-derived free radical accumulation and prevents DNA cleavage that occurs after solar exposure by means of antioxidant enzyme activation.[3132]

Wrinkled surface and skin texture, detected as irregular and uneven topography of the skin, also presented a noticeable improvement. These results are consistent with previous studies where high-resolution imaging revealed both an increased skin quality and hydration restoration after PRGF.[33] The high load of growth factors of ES has been shown to penetrate the stratum corneum in a sustained manner after smooth surface extension and might be involved in the remodeling of the dermal extracellular matrix. These growth factors include epidermal growth factor (EGF), insulin-like growth factor-I (IGF-I), platelet-derived growth factor-AB (PDGF-AB), and transforming growth factor-β1 (TGF-β1).[12] Moreover, these bioactive proteins promote dermal fibroblast activity by inducing cell proliferation and migration while increasing the biosynthesis on new collagen and hyaluronic acid which may explain the clinical outcomes observed herein.[10]

In addition, red areas associated with undelaying vascular conditions such as telangiectasis and rosacea that are common in the aged skin also proved to improve significantly after the combined therapy. Skin redness usually develops after papillary dermal vasodilation with an increased local level of hemoglobin. In this study, a single laser session and topical ES showed to modulate the inflammatory response of the skin and ameliorate laser side effects such as local erythema, burning, and redness. In fact, previous studies have shown the anti-inflammatory potential of ES which may be related to the downregulation of the nuclear-factor-κβ (NF-κβ) pathway and the reduction of inflammatory cytokines such as IL-1, IL-8, or TNF-alpha in response to autologous proteins.[3435]

In line with previous reports, skin pore number and porphyrin reduction were also observed during the follow-up period.[33] Pores are an important entrance way of bacteria which may lead to over-colonization and acne development thus enhancing porphyrin production. In this sense, the combined therapy might help in the renewal of the dermo-epidermal layers of the skin and prevent commensal bacterial growth and sebum overproduction. In fact, previous studies have shown the antibacterial activity of several proteins within PRGF and derivatives, which may help in the prevention of surface infection.[36]

To the best of author’s knowledge, this is the first study where a platelet-based 100% autologous topical product is used in combination with laser therapy for the management of pigmented and vasculature issues. However, it presents important limitations in the design such as the low sample size, the short follow-up period, and the absence of a control group. Hence, additional randomized and controlled clinical trials are needed to clearly assess the efficacy and safety of ES as an adjuvant therapy for laser. Nevertheless, this pilot study provides valuable preliminary data that would support further research involving the therapeutic use of ES. Results presented herein suggest that one session of laser resurfacing in combination with ES provides a good clinical outcome.