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
Spas and Salons
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