Future Technologies in Future Technologies in DermatologyDermatology

Dieter Dieter MansteinManstein, M.D. Ph.D., M.D. Ph.D.

Wellman Center for Wellman Center for PhotomedicinePhotomedicine Massachusetts General HospitalMassachusetts General Hospital

Harvard Medical SchoolHarvard Medical School

DisclaimerDisclaimer

Presentation is intended to stimulate use of Presentation is intended to stimulate use of new technologies & concepts.new technologies & concepts.

The selection of is based on authorThe selection of is based on author’’s s assessment and not complete.assessment and not complete.

General Objectives

Efficacy Selectivity, safety Side effects, down time Pain Overcoming skin barrier

getting things in or out Skin ‘rejuvenation’ Costs

Cooling is the New Hot - Selectivity without Laser -

Typically cooling as adjunct with SP (Epidermal protection for laser)

Selective Cryolipolysis:

Selective Selective CryolipolysisCryolipolysis Yucatan PigYucatan Pig

A

B

C

D

Manstein et al., ASLMS 2008

Untreated 16 Days Post Treatment

CryolipolysisCryolipolysis CoolsculptingCoolsculpting -- ZeltiqZeltiq

Control Unit

Cooling is the New Hot - Selectivity without Laser -

Typically cooling as adjunct with SP (Epidermal protection for laser)

Selective Cryolipolysis: Selective effects on fat, biological selectivity

rather than selective temperature field Other indications (Acne, Xanthelasma,

Cryoneuromoduloation, etc.) Modify geometry, T/t, T

Pain Management w/o Drugs

Cooling

Surface cooling with laser (epidermal protection)

Cryoanalgesia

Very small laser spots

No pain due to lack of spatial or temporal summation

Gate control

Competitive pain blockage (distraction)

Repetitive exposures / treatments

Repetitive Pulses = Enhanced Efficacy Pulse stacking (quick, high energy, bulk heating, To ) Repetitive pulses (quick, low energy)

EN =Es x N-1/4

N=16 2x

N=81 3x

N=256 4x

N=615 5x

Repetitive pulses (slow, minutes)

Altered tissue optics (erythema, edema)

Altered chromophores (rupture, stasis, color change)

Altered biological response (HSP, sub-lethal damage)

Multiple treatments (slow, days)

Tissue repair limitations

*Roider J, Hillenkamp F, Flotte T, Birngruber R. Microphotocoagulation: selective effects of repetitive short laser pulses. Proc Natl Acad Sci U S A. 1993 Sep 15;90(18):8643-7.

Variation of Treatment Interval & Energy / Tx

Time

Energy / TX

Energy / TX

Total Energy40 U

Total Energy40 U

Combination: 1+1=3Combination: 1+1=3

Cooling and massageCooling and massage Heating and massageHeating and massage Preheating and SPPreheating and SP

RF & SPRF & SP US & SPUS & SP IR & SPIR & SP

1111

Skin as a Barrier

Limited drug delivery (SC) Limited light penetration

Absorption of melanin & blood Scattering of shorter wavelengths Small beams rapidly diverge

Limited trans(epi)dermal elimination Tattoo ink, lipids

Skin without Barriers -Getting Things in and out-

Small diameter holes as a gateway

1414

Small Diameter Holes as a GatewaySmall Diameter Holes as a GatewayIncreasing Laser Pulse Energy

Small Diameter Holes A new Gateway into the Skin (?)

Skin without Barriers -Getting Things in and out-

Small diameter holes as a gateway Drug delivery Optical energy delivery

Needle Arrays Fractional RF Optical fiber arrays Drug delivery

Getting things out

True Rejuvenation

Currently ‘rejuvenation’ used vaguely and no accepted standards by FDA

True rejuvenation by (fractional) laser procedures (?) Regeneration by controlled destruction Reduction of senescent skin cells Allowing for controlled cell proliferation from

SCs Rejuvenation hallmarks of aging

Smart DevicesSmart Devices

Smart is saferSmart is safer RealReal--time pigmentation feedbacktime pigmentation feedback Aim and shootAim and shoot Tracking (avoid bulk heating) Tracking (avoid bulk heating)

Smart saves energySmart saves energy Most of SP energy is not utilizedMost of SP energy is not utilized More energy efficient More energy efficient == more cost effectivemore cost effective

1818

2 x 2 splitter

Broadban d light source

Light to reference arm

Light focused on skin

mirrorBroadband Light (1

OCT OCT -- Schema Schema --

Detection of interference fringes= one A-line

0 1.2 mm

Group: Johannes F. de Boer

OCTOCT Examples of Skin ImagingExamples of Skin Imaging

platematrixnail bed

Eccrine ducts

1.2 mm

HairPhotos: John Strasswimmer Group: Johannes F. de Boer

Fluorescence and Fluorescence Anisotropy Imaging of Nonmelanoma

Skin Cancer

Fluorescence Emission

FluorescenceAnisotropy

Micronodular BCC

Fluorescence confocal image;stain MB

Collagen

Cancer

Histopathology; Stain: H&E

Yaroslavsky et al., 2006Group: Anna Yaroslavsky

Robotic DevicesRobotic Devices -- Putting Diagnostic and Treatment Putting Diagnostic and Treatment

Together Together --

1 Month post TX, 1 Month post TX, =1206 & 1065 nm=1206 & 1065 nmP= 1.5 & 10 W ,t= 1.5 sP= 1.5 & 10 W ,t= 1.5 sE= 17.25 J, focusingE= 17.25 J, focusing

H & E stain1 mm

OCT device and imaging:

Johannes F. de Boer & Mark Pierce

ASLMS 2001: SPATIALLY CONFINED PHOTOTHERMOLYSIS OF DERMAL TARGETS USING AN IR-FIBERLASER IN COMBINATION WITH FOCUSING AND CONTACT COOLINGD. Manstein, M. Poureshagh, R. R. Anderson, I. Yaroslavsky, G. B. Altshuler

The Future TrendThe Future Trend -- Driven by Market Size Driven by Market Size --

Dermatologists and Plastic Surgeons (Special(max. ~10.000 users)

General practitioners and other physic

Spas and Salons

Consumers

Adva

nces

in te

chno

logy,

enha

nced

safet

y and

cost

redu

ction

(mas

s pro

ducti

on)

Market Size

173 million15 - 60 years old

(US Census 2000)

Marke

t-driv

en tr

end

Specific Needs for Different Specific Needs for Different MarketsMarkets

SpecialistSpecialist’’s Devices Device EfficacyEfficacy OthersOthers

Home use DeviceHome use Device SafetySafety SafetySafety Safety Safety OthersOthers

Summary

Cooling from a new perspective Pain management Skin without borders Repetitive pulses/ treatments Combination: 1+1=3 True skin rejuvenation Smart devices (Imaging & Tx) Home use devices

ThanksThanks

Wellman Center for Photomedicine, BostonHarvard Medical School