Better Together

It was 2009, and Jill Waibel, MD, had just treated identical triplets Trae, Jordan, and Chandra Berns for severe burns using an ablative fractional laser.

The triplets were 17 months old when they were trapped in a fire in their Texas home and had burns that covered up to 30 percent of their bodies.

One of the triplets experienced pronounced swelling on her arm after treatment. Dr. Waibel, medical director and owner of Miami Dermatology and Laser Institute in Florida, applied the corticosteroid triamcinolone (Kenalog) to the affected arm. “Two months later, the swollen arm looked about 80 percent better than her sisters’ arms,” she says.

This is where and how Dr. Waibel became intrigued with the concept of laser-assisted delivery. “Combination same-session therapy with laser-assisted delivery of triamcinolone acetonide offers efficient, safe, and effective treatment of challenging cutaneous scars,” she says.

Fast forward 13 years, and laser-assisted drug delivery, or LADD for short, is coming of age. It’s not just drugs like Kenalog that are being used with energy-based devices, either. There’s a growing list of cosmeceuticals that are being used synergistically and creatively with energy-based devices to maximize outcomes and minimize recovery.

This marriage of energy-based devices and medical-grade skincare makes sense, as both markets are experiencing exponential growth. The global aesthetic lasers and energy device market was valued at $4,593.38 million in 2019 and is expected to reach $9,543.87 million by 2027, registering a compound annual growth rate (CAGR) of 10.30% from 2021 to 2027, according to Report Ocean.

And the global cosmeceuticals market is poised to reach $19,190 million by 2027, up from $13,060 million in 2020 at a CAGR of 5.6% during 2021-2027, according to Market Growth Reports.

“This is a growing area of cosmetic and medical dermatology and it’s all about using energy- and laser-based technology alongside medical-grade skincare to maximize results and minimize the recovery time,” says Deanne Mraz Robinson, MD, FAAD, President and Co-Founder of Modern Dermatology in Westport, CT and an assistant clinical professor of dermatology at Yale-New Haven Hospital.

“Fractional ablative lasers CO2 (10,600nm) and Er:YAG (2940nm) are effective for this, as they create microscopic channels in the skin, providing access for the topical to the deeper skin layers that it wouldn’t otherwise be able to reach,” she says.

This approach can be useful for treating melasma, scarring, hyper- and hypopigmentation, alopecia, and aging skin and for improved wound healing.

Improving wound healing

Fractional resurfacing is a popular cosmetic procedure, but it does require downtime, which can be a deterrent, Dr. Waibel says.

Enter vitamin C.

Proper wound healing is a direct effect of vitamin C, which is also a potent collagen booster, she says. “Vitamin C has an undeniable role in promoting collagen synthesis and is vitally important in wound healing.”

In a split-face study comparing Aquaphor to SkinCeuticals CE Ferulic after fractional ablative laser resurfacing, CE Ferulic decreased downtime by two days. There was also decreased edema and erythema on the side of the face treated with CE Ferulic.

Moreover, research shows that CE Ferulic increased the expression of basic fibroblast growth factor (bFGF), Dr. Waibel says. bFGF is thought to boost collagen and elastin synthesis. “Application of CE Ferulic serum immediately postoperatively prevents downtime after laser resurfacing for photodamage and improves healing and overall efficacy of laser treatment,” she says.

Reducing downtime and improving the patient experience after energy-based treatments is an important niche for LADD, agrees Sherrif Ibrahim, MD, PhD, a dermatologist and Mohs surgeon at Rochester Dermatologic Surgery in Victor, New York, and an associate professor in the department of dermatology at University of Rochester Medical Center in Rochester, New York.

In recent years, newer barrier repair products that are petroleum-free and less messy have emerged that can aid healing following a procedure, Dr. Ibrahim says.

“They feel great, rub in nicer, smell nicer, and may make it more likely for patients to be adherent,” he says.

Some top sellers in this category include Alastin’s Nectar, EltaMD Laser Balm Post-Procedure Healing Ointment, and Jan Marini BioShield Rapid Recovery Complex.

Epicutis Lipid Recovery Mask and other cellulose masks such as Velez by Vesna, when worn immediately after treatment, can take the sting out of many procedures. “It takes a good hour for the burn to subside, and these masks have sped up the healing,” Dr. Ibrahim says.

Dr. Ibrahim recently conducted a study comparing results following two treatments with Sciton’s BroadBand Light (BBL) and the use of the Jan Marini Skin Care Management System, a 5-step skincare regimen, to those seen after three BBL treatments.

The results were the same, he says. “The skin is brighter,” he says. Patient preference may tip the scale in favor of the Jan Marini regimen. “The patients loved using the products, and their use contributes to the development of good skincare habits, especially after investing so much into an expensive laser treatment.”

Carboxytherapy is the therapeutic use of carbon dioxide (CO2) in its gaseous state, and topical carboxytherapy products, such as Lumisque’s CO2Lift carboxytherapy or transcutaneous CO2 carboxy gel can provide the benefits of CO2 infusion without any needles. When used on its own or pre- or post-procedure, the CO2Lift increases hydration by more than 117 percent compared to baseline, and these improvements last for up to three weeks, says Michael Gold, MD, founder of Gold Skin Care Center and Tennessee Clinical Research Center in Nashville, TN.

Other topical therapies can also help improve healing. Patients who used Stratacel, a silicone-based wound dressing, following fractional radiofrequency (RF) microneedling experienced less erythema than those who used a bland emollient, according to a split-face study in the Journal of Cosmetic Dermatology (February 2019). For this study, Dr. Gold and colleagues applied Stratacel or Aquaphor to patients’ skin immediately after the procedure and daily for seven days afterward. All patients healed well with no reported adverse reactions to the topical products. At each study visit, erythema on the Stratacel-treated area was significantly reduced compared to control. What’s more, patients also preferred Stratacel, citing parameters such as feel on the skin, drying time, and stickiness, he says.

Bruce Katz, MD, Director of Juva Skin & Laser Center in New York City, says that cosmeceuticals play a role after any procedure that can cause bruising, such as pulsed-dye laser treatment. To that end, “Silagen Topical Recovery Gel contains Arnica Montana, Bromelain, and Vitamin K and works really well to reduce bruising and swelling after treatment when applied twice a day,” he says.

Targeting hyperpigmentation

The use of medical-grade skincare or drugs with energy-based devices can also help prevent post-inflammatory hyperpigmentation (PIH) and post-inflammatory erythema (PIE).

Dr. Waibel presented data on SkinCeuticals Silymarin CF for post-inflammatory hyperpigmentation and post-inflammatory erythema after acne at the IMCAS World Congress 2022 in Paris. Silymarin CF combines 0.5% silymarin (milk thistle extract), 15% l-ascorbic acid, 0.5% ferulic acid and 0.5% salicylic acid.

“It’s not the acne that causes the scarring and hyperpigmentation, it’s the inflammation,” she says. “If a person is genetically prone to acne scars and develops PIE or PIH, they will get a scar, so if we can jump in and intervene early on, hopefully, we will prevent scarring,” she says.

This seems to work “really well,” she says. “Silymarin decreased inflammation, but patients haven’t been followed long enough to see if it prevents scarring yet,” says Dr. Waibel of her study.

It’s all about prevention, she says. “We are really getting to a place where we learn how to prevent and stop scars or aging using energy-based devices and medical-grade skincare.”

Another popular assisted drug delivery combination involves radiofrequency (RF) microneedling, which can be paired with platelet-rich plasma (PRP) or Platelet-Rich Fibrin Matrix, topical tranexamic acid, or topical neuromodulator. “Specifically, I use the Cynosure Potenza RF microneedling system, which has a Fusion tip that utilizes pneumatic pressure to assist in delivering the topical 67 percent deeper into the dermal layer when compared to traditional microneedling,” Dr. Robinson says.

“The benefits can include enhanced healing, synergistic neocollagenesis with PRP/PRFM, targeting of melasma with tranexamic acid, and decreased erythema and pore size with topical neuromodulators,” Dr. Robinson says.

The overarching goal is to enhance wound healing and improve skin color, so it is more uniform and less red, says Nadia Abidi, MD, a Mohs surgeon and dermatology surgery fellow in New York City. “Tranexamic acid can be applied topically after fractional or picosecond laser treatment to reduce dark spots,” she says.

Fading scars

Treating scars is one of the main uses of laser-assisted drug delivery, agrees Dr. Gold. “We can create channels through fractional lasers and then put 5FU on the skin to help reduce the size of scars,” he says.

Dr. Katz also combines fractional CO2 laser and steroids for keloid scars. “We use a laser to create the zones of ablation or channels in the skin, and then use the steroid because the channels allow the steroid to penetrate better.”

Dr. Waibel and David Ozog, MD published a pilot study using topical Sculptra (Poly-L-lactic acid) with laser treatment to volumize depressed scars in in Dermatology Surgery (June 2014).

Re-pigmenting skin

The combination approach of laser-assisted delivery can also help address hypopigmentation, Dr. Waibel says. The combination of laser-assisted delivery with bimatoprost (Latisse) stimulates melanocytes.

“A novel use for Latisse is to repigment hypopigmentation and vitiligo after ablative fractional resurfacing at a superficial depth,” she says. In clinical trials, Latisse caused darkening of the eyelid skin.

Post-laser photoprotection

The original power combination is the use of broad-spectrum sunscreen following any type of laser resurfacing, Dr. Ibrahim says.

Many energy-based devices work by stimulating controlled wound healing. “This process also makes it possible to develop pigmentary changes with no or minimal sun exposure and most likely with lots of sun exposure,” he says.

This is why sunscreen following laser skin rejuvenation is essential, he says. “Darker-skinned patients should consider postponing laser skin resurfacing until after summer or sunny months due to the higher risk for pigmentary changes,” he says. Some commonly recommended sunscreens include Total Defense + Repair Broad Spectrum SPF 34/PA++++ Sunscreen, Epionce Daily Shield.

Supercharged rejuvenation

If a patient is bothered by crepey skin on their neck, upper arm, and knees, Dr. Katz may treat the area with Aerolase Era Erbium:YAG laser followed by topical application of Sculptra, an off-label use, to stimulate the body’s collagen production process.

“By applying Sculptra topically on the skin during microneedling or another treatment, we greatly enhance the collagen stimulation within the dermis, which in turn gives smoother looking skin,” he says. “It goes deeper and also penetrates very evenly all over the entire area that is treated.”

Another product that is often paired with energy-based devices for enhanced rejuvenation is PRP. “We apply it on the face to improve texture and fine lines, so it gets absorbed in the channels, and then follow with another pass of laser to make sure that it penetrates,” Dr. Katz says.

Timing is of the essence, he says. “We want to apply the topicals right after the laser when the holes are open.”

Neck rejuvenation is a hot area in aesthetics, and New York City dermatologist Neil Sadick, MD, a Clinical Professor of Dermatology at Weill Cornell Medical College, often uses Skin Medica’s Neck Correct after neck tightening with suture suspension to optimize outcomes.

Jeremy Brauer, MD, Founder and Director of Spectrum Skin and Laser in New York City, recommends Skinbetter Science’s Alpharet Overnight Cream for Fraxel patients once they have fully recovered from the laser treatment.

“Fraxel and Alpharet are complementary because they both stimulate the production of new collagen, and result in a reduction of fine lines, wrinkles, and uneven pigmentation,” he says. “Following up a Fraxel treatment with the regular use of Alpharet can increase the longevity of the Fraxel results.”

Optimizing skin before treatment

Prepping the skin so it is in optimal condition before a procedure is always a great idea. Dr. Sadick suggests pretreatment with hydroquinone or another skin lightener before treating pigment issues with a laser. “This is common and may help augment results,” he says.

Before laser skin rejuvenation, he may suggest a retinoid or alpha-hydroxy acid (AHA). “The concept of laser-assisted drug delivery or targeted drug delivery is still in early stages and there is uncertainty about how effective it is in aesthetics,” he says.

Michael Somenek, MD, a facial plastic surgeon in Washington DC, often recommends conditioning skin before initiating treatments with Cutera’s Secret Pro to ensure that the skin will recover optimally.

“To do this, I recommend the ZO Retinol Brightening Serum because this improves skin tone and smoothness while encouraging exfoliation,” he says. “For those who are prone to hyperpigmentation, I use the ZO Skin Health Pigment Control Creme for four weeks before treatment because this adequately suppresses the melanocytes and markedly reduces the risk of PIH post-treatment.”

“Along with a high SPF, I like to start patients on the DefenAge Clinical Power Trio to use before and after treatments,” says New York City plastic surgeon Bryan Forley, MD. “This system works synergistically to improve tone and texture and to reduce the appearance of dark spots, redness, pores, and fine lines,” he says. “This protocol has been very effective in my practice and our patients respond well to it.”

In his practice, Dr. Forley treats many patients with the Nordlys system, which comprises Ellipse IPL, Frax 1550, Frax 1940, and Nd: YAG 106. “It is a workhorse in my practice due to its versatility.”

Dr. Robinson recommends Alastin’s Regenerating Skin Nectar with TriHex Technology for use during the two weeks leading up to a laser skin rejuvenation procedure and for at least two weeks following laser skin rejuvenation. “This formula is designed to encourage the regeneration of elastin and collagen, calm skin redness, and support optimal results and healing time,” she says. “It is also packed with antioxidants and peptides that protect the skin barrier while the skin is healing.”

“I will also oftentimes recommend applying Alastin’s Soothe + Protect Recovery Balm to boost hydration and add more moisture and calming properties to the mix.”

Reversing hair loss

Channels can be created with microneedling or laser on the scalp, and finasteride, minoxidil, or PRP can then be applied to enhance hair growth, Dr. Sadick says.

“These multimodal approaches are synergistic and able to deliver active ingredients to the desired tissue to augment results,” he says.

Enhancing the results of body contouring

Dr. Robinson recommends Alastin TransFORM Body Treatment for use after body contouring treatments. “The clinically proven formulation helps accelerate the body’s natural removal process of broken-down fat cells while also encouraging healthy collagen and elastin production to improve skin laxity, texture, and tone,” she says.

Dendy Engelman, MD, Director of Dermatology and Laser Medicine at Shafer Clinic in New York City, is also a fan of the Alastin Skincare TransFORM Body Treatment after treatment with BTL’s Emsculpt NEO for simultaneous fat elimination and muscle building. “The Alastin Skincare TransFORM Body Treatment can be applied following the treatment to help speed up and maximize results; this formula targets dead fat cells while tightening skin at the same time,” she says.

The great thing about Emsculpt NEO is that it does not require much maintenance other than making sure you keep up with the weekly treatments, she says. Other than that, it is great because patients can keep their routine and use products as normal.

Julius Few, MD, Founder of the Few Institute for Aesthetic Plastic Surgery in Chicago and New York City, agrees. “The ability to combine treatment/therapeutic application allows for targeting of the various tissue layers, skin, fascia, and fat,” he says.

Dr. Few frequently combines cannabidiol (CBD)/retinol, transcutaneous radiofrequency, and laser to the skin of the abdomen or an extremity. “Because the different modalities are targeting the various components of the soft tissue, there is a natural synergy and enhanced lifting and repositioning effect,” he says.

First, do no harm

Energy-based-device-assisted drug or skincare delivery is still in its infancy. “It is incumbent that we understand the science as there are many cosmeceuticals, and we have to be careful about what we put on the face post-procedure,” Dr. Waibel cautions.

There are safety issues to keep in mind, she says. “You don’t want unskilled practitioners to put certain cosmeceuticals on after a laser because those ingredients aren’t supposed to go into the dermis and that can cause all types of issues.” Risks may include infection and hypersensitivity reactions.

Of note, there are no FDA-approved drug-device combinations in aesthetic dermatology. As it stands, the federal watchdog group is allowing such use, but it could require full-fledged approval of combination in the future if people behave irresponsibly, Dr. Waibel says.

“As long as we are combining devices with cosmeceuticals and drugs responsibly to help the patient heal better, we are in a good position. If we breach safety, then the FDA will take this ability away from everyone,” she observes. “And we don’t want this to happen.”

Dr. Gold warns, “You have to be very careful just slapping something on treated skin. These products should be sterile or come from a sterile container to help reduce any potential infection or inflammation. That’s important.”