Winter White – Reversing Summer Pigmentation

Posted: Monday 31 May 2010 02:49pm

During summer, if you’re anything like me, you religiously slap sunscreen on your face and maybe your neck but are a bit slapdash about the chest/decollete, arms and hands. And unless you stay indoors throughout daylight hours, in Australia’s sunny clime, you’re likely to pick up incidental colour on your face anyway.

Entering winter, what seemed a healthy “glow” over summer has faded into patchy pigmentation (I speak entirely for myself here). Or perhaps, if you’ve neglected your suncare routine (or spent inordinate amounts of time in the sun through force or circumstance) , your problems need more  intensive treatment.

Winter provides the ideal opportunity to reverse the damage of the days of summer.The cooler weather means wer’re more likely to cover up and expose less skin to the elements; solar rays are also weaker (but don’t get cocky – they’re still active and you still need sunscreen!).

Depending on the severity of your condition, your budget, care factor and time constraints, there are multiple options for treating sun damage/pigmentation, from fractional lasers and light treatments to pigment-perfecting skincare.

Here, we talk to experts from around the country about fractional lasers:

Why is winter a good time to have laser treatments to correct sun damage?
Dr Garry Cussell, Facial Rejuvenation Clinic, Sydney:
We are just as confident in doing treatments in summer but clients are not as willing to stay out of sunlight and away from longer outdoor activities for 5-7 days in summer. So it is more a factor of more outside recreational activities in direct sunlight over summer. Most clients will book summer or

Associate Professor Greg Goodman, Dermatology Institute of Victoria, Melbourne:
Certain procedures such as tissue fillers, most lasers treating blood vessels and muscle relaxing injections may be performed at any time of the year but other procedures really benefit from sun avoidance or from being hidden away by clothing during their healing phase. Most skin resurfacing procedures, even including the new fractionated lasers, fall into this category.
Although colour changes after resurfacing procedures depend on the type of resurfacing technology used they also depend on the patients’ skin colour and sun reactivity. Whenever there is interaction with the top layer of the skin by a technology, care should be taken to limit sun exposure for a month or so after the procedure.
Fortunately, we have an array of resurfacing technologies that can target safely not only facial skin but also the delicate skin of the neck, chest and hands – and obviously winter fashions allow us to better cover these areas with clothing to limit exposure to the elements and to other peoples’ gaze.

Dr Michael Molton, principal doctor, Epiclinic, Adelaide:
If I had a choice I would prefer to treat hands in winter but the biggest reason is not what you might expect. Fine if we used sunscreen in summer at least twice a day but most people don’t.  All the time I hear, “I use sunscreen every day and also in my makeup/foundation”, but its effect is useless after four hours maximum. That’s just as much the take home message for avoiding sun damage. Also, with the Fraxel, we are not talking about “all-or-nothing” treatment that leaves your skin dangerously exposed. Fraxel means fractionated, that is, it is a progressive treatment, treating a fraction of the surface of the skin each time. The benefits are more gentle, same result. But, remember we still have to apply the same sunsmart principles.

What are the best types of laser used to treat hands, neck, chest/décollete and face for sun damage? How often and at what cost?
Dr Cussell:
The best laser for skin resurfacing for sun damage is the Fraxel Dual, especially with the new addition of the 1927 [nanometer] wavelength. It can repair most skin damage in one or two treatments. Cost, including aftercare facial, is $1650 for full face or chest. If part face, it is less (according to the area).  Hands and neck are $900 each. Treatments are best at least one month apart but can be delayed 6,12 or18 months according to affordability. After all, people delay for years whilst they accumulate skin damage, and this treatment removes almost all the epidermal and papillary dermis [uppermost layer of the dermis] in one or two laser treatments and stimulates new collagen tissue regrowth and replacement.

Associate Professor Goodman:
Fractionated lasers treat part of the skin each time therapy is performed.  In essence it is similar to the concept of aerating one’s lawns rather than removing the topsoil.  However, the other side of the coin is that one must treat a number of times to fill in the gaps.  The reason that fractionated resurfacing has been such a revolution is the safety that it brings to the consumer but at the same time it can deliver truly effective treatment if sufficient numbers of therapies are performed. Almost all fractionated devices (and there are now many wavelengths used) may be used relatively safely on all body parts. Different wavelengths have different qualities and different interactions with tissue, some being better at diseases like wrinkling and scarring such as fractionated CO2 laser, scarring and texture such as the non-ablative 1550nm wavelength (Fraxel 1550nm being an example) but for sun damage, I feel the new Thulium 1927 nm wavelength (Fraxel Dual) would seem to be the best fractionated device I have seen for this purpose.
Ballpark costs for a treatment with these technologies does vary a bit.  Many require the use of consumable items that contribute to the expense of the procedure. In general terms one is looking at $800-1500 per treatment and this is not recoverable from Medicare.

Dr Michael Molton:

For the decolettage I can tell you what I would not use: IPL [intense Pulsed Light] or heavy duty lasers. The skin will probably burn or scar if the settings are too high and there would be no result no result if too low. I will often use a 35 per cent TCA peel if there is a heavy build-up of cobblestoned skin, the result of the skin’s attempt to protect itself. Then the Fraxel.

Can you use fractionated lasers to remove skin cancers instead of burning them off with liquid nitrogen?
Dr Cussell:
We are removing most solar damage including multiple Aktinic Keratoses (pre-malignant sun spots) that are usually burnt off with liquid nitrogen individually. Fraxel treatment is far superior because it is also removing all the sun damage pigmentation as well as stimulating new collagen and refining skin texture.  Most importantly, it doesn’t leave the unsightly white de-pigmented scars that liquid nitrogen leaves. Even men wish for a younger looking texture on their face.

Associate Professor Goodman:
You would not be getting skin cancers removed with Fraxel, although there is some work suggesting that the new 1927 nm wavelength may be useful in treating widespread sun damage and sun spots. I think the most likely use of technology for skin cancers would be Photodynamic Therapy utilising various light systems with a stimulating chemical placed on the skin some time before the light exposure.

Dr Molton:
First of all, always check with your GP about what kind of skin condition that may have occurred. Some skin cancers, like deadly melanoma would not be treated with Fraxel. Sun spots that might turn into skin cancers later on can be treated with liquid N2 but the result is usually depigmentation. We use the Fraxel on these very effectively without losing pigment.
What precautions must one take with the skin after treatment, even in winter?
Dr Cussell:
Normal sunscreen and ongoing Vitamin A + B + C serums. Unlike ablative lasers such as CO2, that burn off the epidermis and leave prolonged redness for many months, this non-ablative laser does not cause prolonged redness and sun sensitivity after 10 days to two weeks.

Associate Professor Goodman:
Although there is less general sun intensity over winter, one must remember that the most common cause of concern after resurfacing is pigment or colour change.  Although, this is more likely in summer it is substantially due to longer range ultraviolet A which is present all year round with less decrease in winter than UVB and a wavelength that is more deeply penetrating to the skin and able to get through window glass and cloud cover quite easily.  Hence, one should avoid sun including skiing holidays and solarium use during winter for at least a month after these procedures, wear a sunscreen daily.

How long do the results usually last?
Dr Cussell:
Permanent until more sun damage is accumulated. We are virtually fully removing and renewing the damaged epidermal and papillary dermal layer. So new damage will only occur through new neglect after UV exposure.

Associate Professor Goodman:

Results from fractionated resurfacing like all resurfacing procedures would be expected to be long-lasting with little change over time once results are seen. The number of treatments to achieve these results depends a little bit on the technology and the wavelength used. Fractionated CO2 and the 1927 nm Fraxel Dual seem to need less treatments (2-3) than the Fraxel 1550 nm and similar equipment (5-6) but the down time is much more than experienced with the 1550 nm lasers (7-10 days versus 2-4 days).

Dr Michael Molton
Depends on what proactive steps the patient takes to avoid exposure, especially if their skin type is Fitzpatrick 1 or 2. That is, very fair skin, light coloured eyes, light hair, burn easily in the sun. Also the rate at which the patient is presently aging. Many patients come to see me when they have just entered that phase and are desperate for help. To everyone I say, you can’t stop the aging process but we can do a heck of a lot to slow it down to a crawl and whatever you do in the program I provide for you it will never suddenly wear off and you go back to where you were before you started. You will always be in front.

Once collagen and elastin has been increased as a result of Fraxel, does it make the skin more resilient to future “attack”?
Dr Cussell:
Yes. A younger skin is damaged more slowly than an already sun damaged skin. It is also easier to protect it and repair it with the most potent antioxidants, Vitamin A and B and C.
Associate Professor Goodman:
Collagen is a very long lasting material and once its production is stimulated, it may exist for 15 years or so before it is turned over. Sun damage affects both the top layer (the epidermis) and the second by of the skin (the dermis).  Collagen and elastin exist in the dermis and are responsible for many of the lines and wrinkles and yellowish looking skin seen with Sun damaged faces and bodies, however, it is the epidermis where our skin cancers and Sun spots start up. The 1927 nm technology really just targets the epidermis and will have limited or no effect on dermal collagen and elastin would be expected to do well with making the epidermis healthier.  The 1550 nm laser  (eg. Fraxel 1550 nm)  technologies really target the dermis mostly and without affects mostly on the dermal collagen elastin but little on the epidermis.  The fractionated CO2 is probably the one that is able to do both and would make the skin more resilient in both layers of the skin.
Dr Michael Molton:

Not resilient but restorative. Remember the sun-smart advice, get an early check on any spots that change or come up and most of all, don’t rely on your foundation to last all day and wear light gloves driving!

What else?
Dr Cussell:
The versatility of the Fraxel Dual by having the combination of both the 1927 as well as the 1550, allows us to treat not only to different exact depths into the skin, but also different total percentage of density coverage. Thus, we can selectively maximise treatment for lighter skin types, go deeper for more damaged skin, treat more safely for darker skin types and generally tailor treatments individually for different skin conditions and skin types. Also different areas of the body react differently to laser and require carefully selected settings. This all requires a great deal of experience to get it right and to maximise results.

by Jenni Gilbert

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