This document discusses future technologies in dermatology. It outlines how cooling can selectively target fat without lasers through techniques like cryolipolysis. It also discusses how repetitive pulses, combinations of technologies like heating and massage, and creating small holes in the skin can enhance treatments and drug delivery while reducing pain. True skin rejuvenation may involve fractional lasers and reducing senescent skin cells. Imaging technologies like OCT and fluorescence can be combined with robotic treatment devices to precisely diagnose and treat skin conditions. Home use devices will be important to address the large consumer market for dermatology.

1. Future Technologies in
Dermatology
Dieter Manstein, M.D. Ph.D.
Wellman Center for Photomedicine
Massachusetts General Hospital
Harvard Medical School

2. Disclaimer
 Presentation is intended to stimulate use of
new technologies & concepts.
 The selection of is based on author’s
assessment and not complete.

3. General Objectives
 Efficacy 
 Selectivity, safety 
 Side effects, down time 
 Pain 
 Overcoming skin barrier
 getting things in or out
 Skin‘rejuvenation’
 Costs 

4. Cooling is the New Hot
- Selectivity without Laser -
 Typically cooling as adjunct with SP
 (Epidermal protection for laser)
 Selective Cryolipolysis:

5. Selective Cryolipolysis
Yucatan Pig
Untreated 16 Days Post Treatment
A C
B D
Manstein et al., ASLMS 2008

6. Cryolipolysis
Coolsculpting - Zeltiq
Control Unit

7. 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

8. 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

9. 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.

10. Variation of
Treatment Interval & Energy / Tx
Total Energy
Energy / TX 40 U
Energy / TX Total Energy
40 U
Time

11. Combination: 1+1=3
 Cooling and massage
 Heating and massage
 Preheating and SP
 RF & SP
 US & SP
 IR & SP
11

12. 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

13. Skin without Barriers
-Getting Things in and out-
 Small diameter holes as a gateway

14. Small Diameter Holes as a Gateway
Increasing Laser Pulse Energy
14

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

16. 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

17. 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 

18. Smart Devices
 Smart is safer
 Real-time pigmentation feedback
 Aim and shoot
 Tracking (avoid bulk heating)
 Smart saves energy
 Most of SP energy is not utilized
 More energy efficient = more cost effective
18

19. OCT
- Schema - Light to reference arm
mirror
Broadband
Broadban
Light (1
d light
source 2 x 2 splitter
0 1.2 mm Light focused on skin
Detection of interference fringes
= one A-line
Group:
Johannes F. de Boer

20. OCT
Examples of Skin Imaging
plate
nail bed matrix
1.2 mm
Eccrine ducts Hair
Photos: John Strasswimmer Group: Johannes F. de Boer

21. Fluorescence and Fluorescence
Anisotropy Imaging of Nonmelanoma
Micronodular BCC Skin Cancer
Fluorescence confocal image; Fluorescence Fluorescence
stain MB Emission Anisotropy
Collagen
Cancer
Histopathology; Stain: H&E
Group: Anna Yaroslavsky
Yaroslavsky et al., 2006

22. Robotic Devices
- Putting Diagnostic and Treatment
Together -
H&E OCT device and imaging:
1 stain
mm Johannes F. de Boer & Mark Pierce
ASLMS 2001: SPATIALLY CONFINED PHOTOTHERMOLYSIS
1 Month post TX, =1206 & 1065 nm
OF DERMAL TARGETS USING AN IR-FIBERLASER IN
P= 1.5 & 10 W ,t= 1.5 s COMBINATION WITH FOCUSING AND CONTACT COOLING
E= 17.25 J, focusing D. Manstein, M. Poureshagh, R. R. Anderson, I. Yaroslavsky, G.
B. Altshuler

23. The Future Trend
- Driven by Market Size -
Dermatologists and Plastic Surgeons (Special
(max. ~10.000 users)
ro d c y,
cti t
General practitioners and other physic
s p an og
nd
du os
)
on
tre
as ty nol
en
(m safe ech
riv
-d
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t
t
ke
cti ced in
ar
du n es
M
re ha nc
en va
on
Ad
173 million Consumers
15 - 60 years old
(US Census 2000)
Market Size

24. Specific Needs for Different
Markets
Specialist’s Device Home use Device
 Efficacy  Safety
 Others  Safety
 Safety
 Others

25. 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

26. Thanks
Wellman Center for Photomedicine, Boston
Harvard Medical School