Journal of the Laser and Health Academy

ISSN 1855-9913 Vol. 2020, No.1; www.laserandhealth.com

CASE REPORT: StarWalker VERDE for Treatment of

Ephelides and Lentigo

Chua Cheng Yu
Veritas Clinic, Singapore

ABSTRACT Lentigines are epidermal pigmented lesions, and are

extremely common hyperpigmented macules that most
Long-pulsed KTP is a modality usually used for
often result from chronic sun exposure [2]. They
treatment of superficial vascular lesions, but it has been
contain melanin within keratinocytes and melanocytes
used also for removal of epidermal pigmented lesions
[1]. Histologically, melanocytes in the basal layer are
such as ephelides and lentigos.
increased in number without nesting and rete ridges are
elongated [2]. Lentigines can be classified into several
Three female patients, aged from 32 to 46 years, had
categories, including those due to chronic sun exposure
facial pigmented lesions removed for aesthetic reasons.
(solar lentigines), those associated with a syndrome
The removal of lentigines and ephelides was performed
(e.g., Peutz-Jegher), and the labial melanotic macule.
in a single treatment session using long-pulsed 532 nm
Use of a broadband sunscreen helps prevent new
KTP (VERDE, StarWalker, Fotona, Slovenia).
lentigines from occurring as well as the recurrence of
All three patients showed almost complete clearance treated lesions [1]. Correct diagnosis is a primary
of the lesions, and patient who received full-face concern when treating lentigines, as lentigo maligna
treatment, presented with improved skin texture and should not be treated with laser [1].
tone. There were no adverse effects observed.
Ephelides (freckles) are small hyperpigmented
Three cases presented in this report show that use of macules located on sun-exposed skin [2]. Histologically,
long-pulsed KTP is safe and effective for removal of there is hyperpigmentation of the basal layer but no
epidermal pigmented lesions and improvement of skin tone increase in the concentration of melanocytes [2]. Patients
and texture in patients with Fitzpatrick skin type III–IV. who tend to freckle are more likely to develop new
freckles with any sun exposure [1]. The use of a
Key words: StarWalker, VERDE, LP KTP, broadband sunscreen is therefore indicated [1].
Pigmented Lesions, Ephelides, Lentigo.
There are several treatment options available for
Article: J. LA&HA, Vol. 2020, onlineFirst. management and removal of pigmented lesions, from
Received: September 23, 2019; Accepted: October 7, 2020 topical tretinoin, cryotherapy and various laser modalities
[3]. Even though the long-pulsed (millisecond domain)
© Laser and Health Academy. All rights reserved. 532 nm (KTP) (a frequency doubled Nd:YAG) laser is
Printed in Europe. www.laserandhealth.com more commonly used to treat vascular lesions, it has
been successfully used to treat superficial pigmented
lesions, such as ephelides and lentigos [3–5]. The theory
I. INTRODUCTION of selective photothermolysis suggests that laser therapy
There are many types of pigmented lesions and each would be the treatment of choice because of its ability to
varies in the amount, depth, and density of melanin selectively destroy pigment without injuring the
distribution [1]. The approach to the treatment of surrounding tissue. Melanin is the main chromophore in
cutaneous pigmentation depends on the location of the solar lentigines, and therefore is the target of selective
pigment (epidermal, dermal, or mixed), and the way it is destruction [4]. Equally important in achieving selective
packaged (intracellular, extracellular) [1]. Many photothermolysis of melanin is the pulse duration.
pigmented lesions are benign and are removed for Ideally, the pulse duration of the laser should be shorter
aesthetic reasons only. However, some pigmented than the thermal relaxation time of the target to achieve
lesions have a high risk of malignant transformation. In selective photothermolysis [4]. Q-switched and long-
general, epidermal pigment is easier to eradicate than pulsed lasers differ in the effect on the target
dermal pigment because of its proximity to the skin’s chromophore; the first one has a photothermo-
surface. The goal is to remove unwanted epidermal mechanical effect, whereas the second one has a
pigmentation, and as long as the injury is above the photothermal effect only. The photomechanical effect of
dermal-epidermal junction, it will heal without scarring [1]. Q-switched lasers is generally the accepted mode of

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 CASE REPORT: StarWalker VERDE for Treatment of Ephelides and Lentigo

action when treating the epidermal pigmented lesions, (532 nm) (StarWalker, Fotona, Slovenia) using R58
however it may not be desirable when treating the handpiece. Post-treatment cooling with Zimmer Cryo 6
patients with higher Fitzpatrick (FP) skin types and ice packs was applied over the treated area. Patients
(especially IV and above) [4], as the incidence of were advised to apply creme containing dexpantenol
pigmentary changes following the treatment, despite (Bepanthen®, Bayer, Germany) couple times a day for
their transient nature, is higher when using Q-switched the next two days. Patients were also advised to avoid
KTP laser in such patients [6]. Such patients may sun exposure and to use sun protection. All patients
therefore benefit more from the long-pulsed laser were followed-up after 6 weeks to assess the
application. effectiveness of the laser procedure and detect any
potential side effect of laser treatment.
II. METHODS
III. CASES
Three female patients, aged from 33 to 47, with FP
skin type (III–IV) are included in this case series. The a) a) Case 1: VERDE for treatment of lentigines
exclusion criteria were: a history of photosensitivity or and rough skin texture
the use of photosensitizing medication, recent history Case 1 is a 46 year old, FP skin type IV female
of previous laser therapy at the planned treatment site, patient with a complaint of lentigines and rough skin
existing or planned pregnancy, diabetes, autoimmune texture (Figure 2). The patient has previously received
disease, breastfeeding, acute skin diseases requiring multiple Q-switched Nd:YAG laser treatments with
dermatological treatment, or a history of malignant unsatisfactory outcome, that has rendered the patient to
disease in the area to be treated. All patients signed stop with the treatments for few years.
informed consent for the treatment and for the use of
data and photographs. All three patients wished to have Full face treatment with no overlapping was applied
their pigmented lesions located on the face removed for in a single session, using the parameters presented in
aesthetic reasons. Table 1. Treatment was performed without anesthesia.
Immediate post-treatment cooling with Zimmer Cryo 6
The treatment of choice was long-pulsed KTP laser and ice packs was applied over the treated area.

Fig 1: Case 1 – Patient complaining over lentigines and rough skin tone: before (left) and 6 weeks after single session (right)

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 CASE REPORT: StarWalker VERDE for Treatment of Ephelides and Lentigo

Fig 2: Case 2 – Patient complaining over ephelides before (left) and 6 weeks after single session (right)

b) Case 2: VERDE for removal of ephelides c) Case 3: VERDE for removal of ephelides and
Case 2 is a 35 year old, FP skin type III female with solar lentigo
unwanted ephelides on her cheeks. After uneventful Case 3 is a 32 year old, FP skin type IV female with
test spots, the ephelides were removed using the long- ephelides and a solar lentigo on her upper cheek, that
pulsed KTP (StarWalker, Fotona, Slovenia) and the she wished to have removed. Removal was performed
parameters used are presented in Table 1. with long-pulsed KTP (StarWalker, Fotona, Slovenia)
using the parameters reported in Table 1.
Single non-overlapping pulse was applied directly
over each lesion while stretching the skin. Treatment Single non-overlapping pulse was applied directly
was performed without anaesthesia and no cooling was over each lesion while stretching the skin. No
used during the procedure. Immediately after the anesthesia was needed or used, but immediate post-
procedure, the treated areas were cooled with Zimmer treatment with Zimmer Cryo 6 and ice packs were
Cryo 6 and ice packs. applied.

Fig 3: Case 3 – Patient complaining of ephelides and lentigo: before (left) and after 6 weeks after single session (right)

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 CASE REPORT: StarWalker VERDE for Treatment of Ephelides and Lentigo

Table 1: Summary of the parameters used for VERDE should be a mild darkening or greying of the
treatment of patients. pigment, with no audible snap or aggressive scabbing of
Case Indication Spot Fluence Pulse Frequency the pigmentation spots. In the literature there have been
size [J/cm2] duration [Hz] some reports of mild erythema and oedema present
[mm] [ms] immediately after the treatment with long-pulsed KTP,
1 Lentigines, 6 5.4 15 1 but these were resolved using cold air cooling or cooling
rough skin pads [5]. Cooling pads are more recommended than the
texture use of cool air cooling, since the latter can result in
2 Ephelides 3 4.4–4.8 15 1 significant skin dehydration which is not ideal for post
3 Ephelides, 2–3 4.4–5.2 15 1 treatment recovery. Post-treatment cooling is essential for
lentigo minimization of thermal injury and potential subsequent
scarring and PIH.
IV. DISCUSSION
In conclusion, we have shown that long-pulsed KTP
Long-pulsed KTP (532 nm) is commonly used for can be safely and effectively used for removal of ephelides
treatment of superficial vascular lesions, but owing to the and solar lentigos in patients with FP skin type IV, with no
broad absorption spectrum of melanin, it can be used also long-lasting adverse effects. Full-face application of long-
for removal of epidermal pigmented lesions, with excellent pulsed KTP can result in improved skin texture and tone.
results when used for lentigines and ephelides [7]. Another
532 nm KTP modality using shorter pulse durations, Q-
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The intent of this Laser and Health Academy publication is to facilitate an
reasons: pressure on skin layers so to evacuate the next exchange of information on the views, research results, and clinical
most susceptible competing chromophore from the experiences within the medical laser community. The contents of this
treatment field (haemoglobin), as well as providing better publication are the sole responsibility of the authors and may not in any
circumstances be regarded as official product information by medical
index matching for transition of laser energy to the target. equipment manufacturers. When in doubt, please check with the
manufacturers about whether a specific product or application has been
approved or cleared to be marketed and sold in your country.
The endpoint of epidermal pigment treatment with