TREATMENTS
Fractional laser for solar keratoses and field cancerisation
Fractional laser treatment treats solar keratoses and sun-damaged skin while improving skin health and appearance and reducing skin cancer risk.
- Eliminates most solar keratoses in the treatment area
- Reduces future solar keratoses and skin cancer risk
- Skin is clearer, smoother and healthier after treatment
Solar keratoses and sun-damaged skin are common in white-skinned Australians over 40. They may require treatment to prevent them from developing into squamous cell carcinoma, a potentially serious form of skin cancer.
Many treatment options are available, and each case is unique. Treatments should be discussed with a doctor to decide on the best way to take into account:
- safety of treatment
- clinical effect (i.e. how well it works)
- the patient’s risk of skin cancer
- side effects of treatment
- cosmetic outcome
- other co-existing skin conditions
- budget.
Laser treatment is a good choice for people who wish to obtain a good cosmetic outcome and reduce the risk of future skin cancers with minimal downtime and side effects.
Field treatment vs. lesion treatment
Individual solar keratoses appear as rough, dry patches in sun-exposed areas They are usually pink, but many have darker pigmentation. Some have a thick crust on the surface. The surrounding skin may not have visible solar keratoses, but it is almost always sun damaged. There may be subclinical (early) solar keratoses developing and about to appear.
Treating an individual solar keratosis, for example with cryotherapy (freezing), prevents it from developing into skin cancer, but this treatment doesn’t prevent further solar keratoses from developing.
To treat larger numbers of solar keratoses, reduce the number of new solar keratoses, reduce skin cancer risk and improve skin appearance, field treatment is required. This means treating the entire sun-damaged area, not just individual spots.
What is fractional laser treatment?
Our fractional laser uses an extremely narrow beam of light, arranged in a 9 × 9 grid, to make tiny cavities in the skin. With each pass of the laser, about 3% of the total skin area is damaged by the laser. We normally treat the area 2 or 3 times so the total treatment area is 6-9 per cent.
The treatment stimulates the growth of new healthy skin in place of the solar keratoses and sun damaged skin.
Ablative vs. non-ablative
According to the intensity of the treatment, the surface layer may or may not be damaged, causing bleeding, redness and inflammation. A deep treatment that causes bleeding and visible skin damage is referred to as ablative. Ablative treatment can be used as spot treatment for existing solar keratoses.
Non-ablative treatment mainly affects deeper structures in the skin without damaging the surface. It’s commonly used for larger areas of skin without active solar keratoses, especially if the patient wants to minimise facial redness after treatment.
If desired, ablative treatment can be used over the entire skin surface for a stronger effect and better cosmetic benefits. It requires an anaesthetic cream to be applied before treatment and there is bleeding across the treated area at the conclusion of treatment. The skin remains red for about a week.
Non-ablative treatment can be provided without anaesthetic, and redness usually settles in 1-2 days.
Both ablative and non-ablative treatments are suitable for field treatment of solar keratoses. Typically, we treat visible solar keratoses with ablative and other sun-exposed skin with non-ablative laser.
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Ten minutes after fractional laser treatment. The cheek was treated with a deep ablative setting and the nose and forehead with a shallow ablative setting. Redness of the forehead nose and temples settled in two days, redness of the cheek resolved in a week.
While one session of fractional laser usually leads to a noticeable improvement in sun-damaged skin, we normally recommend a course of four sessions.
Evidence
Fractional laser treatment has been shown to:
- Eliminate the majority of solar keratoses (Pour 2020, Chen 2018)
- Reduce the number of future solar keratoses (Benson 2020)
- Reduce skin cancer risk in the treated area by up to 50 per cent for some patients (Benson 2020, McCormick 2023)
This treatment has been shown to be as effective as other forms of treatment for solar keratoses (Worley 2023). Treatment benefits have been shown to persist for up to 36 months (McCormick 2023).
Additional benefits
Fractional laser has positive effects on skin texture, wrinkles and pigmentation. During a laser treatment session, we can address cosmetic concerns such as unwanted age spots and capillaries by using different laser settings.
Treatment alternatives
Other methods for treating individual solar keratoses include:
- Cryotherapy (freezing): quick, inexpensive, not always effective, risk of scarring.
- Diathermy (burning with an electric current): effective for thick solar keratoses, requires anaesthetic, risk of scarring.
- Surgical removal by excision or shave: highest cure rate, requires anaesthetic, risk of scarring, expensive.
Other methods for field treatment of sun-damaged skin include:
- Prescription cream: cheaper than other options, causes inflammation which can last weeks.
- Photodynamic therapy: expensive, can be painful, downtime of 1-2 weeks.
Skin cancer risk can be reduced with oral vitamin B3 (nicotinamide). This treatment may be recommended for some patients with solar keratoses in conjunction with other treatments.
Recent evidence suggests a possible link between high-dose vitamin B3 treatment and elevated levels of certain proteins that may increase blood vessel inflammation, which may theoretically increase the risk of heart attack or stroke (Ferrell 2024). We are uncertain about the implications of these findings for patients taking nicotinamide for skin cancer and solar keratoses management, but we currently don’t recommend this treatment for patients with any cardiovascular risk factors such as high blood pressure, high cholesterol, strong family history of cardiovascular disease and age over 65.
With no treatment, there is a small risk (about 1-5%) that an individual solar keratosis could develop into squamous cell carcinoma. About 5% of solar keratoses resolve without treatment.
Conditions treated
How to prepare
Get better result and reduce downtime by following these steps.
Keep your skin as pale as possible. Avoid unprotected sun exposure on the area to be treated. Wear sunscreen and a hat if your face will be treated.
Don’t apply fake tan or take supplements that promote tanning.
Don’t apply tinted cosmetics, tinted moisturiser or tinted sunscreen.
Don’t apply any of the following to your face (or other treatment area):
- Topical products containing retinoids, tretinoin, vitamin C, AHAs, BHAs.
- Perfume or essential oils.
Stop taking medications that increase your skin’s sensitivity to light (more information below).
In the morning, wash your skin using a gentle, non-soap cleanser.
Don’t apply any skin products to the area other than low-irritant sunscreen with no pigment.
Please don’t apply make-up on the day of treatment.
If you get cold sores, take famciclovir (Famvir), one 500mg tablet twice daily for 3 days before your procedure. You can buy two packets of 3 tablets without a prescription.
It’s important to avoid medications that can make your skin sensitive to light before you have a laser or IPL/BBL procedure.
If you are taking medication, check the list at Dermnet and if you are taking any of these medications, ask your prescribing doctor if it’s safe to stop taking it for 2-3 days before your laser procedure. If not, contact us, and our doctor or registered nurse will provide advice.
How it’s done
Fractional laser appointments usually last about 1 hour. If you would like to have numbing cream applied before your treatment (recommended for ablative treatments to large areas), your appointment lasts about 2 hours.
A thick layer of numbing cream is applied to the treatment area. It is then covered with cling wrap and left to incubate.
The treatment area is then cleaned, and you will be asked to wear glasses or goggles to protect your eyes.
To further reduce discomfort, the treatment area will be covered with a cooling gel, and you will be able to direct chilled air over your skin with a hand-held device.
The treating doctor or nurse will systematically guide the laser over the treatment area.
The fractional laser emits a pulse of light in a grid of 9 × 9 pixels about 1 cm in diameter. The pulses are about 1 second apart. Each pulse makes a snapping sound; this can be quite loud in the case of deep ablative treatments, so we may provide you with earplugs.
Once the treatment area is completely covered, your skin will be cleaned, and a soothing balm or silicone gel and sunscreen will be applied.
After the procedure
For the first few days, you need to manage discomfort and inflammation. Following that, avoid sunlight and skin irritants for several weeks.
Learn more
Side effects and warnings
Side effects of fractional laser treatment include:
- Pain and bleeding during and immediately after treatment
- Sunburn-like discomfort and redness of the treated area, lasting up to a week for aggressive ablative treatments (usually 1-2 days for non-ablative)
- Pin-point crusts or scabs
- Swelling
- Bruising
- Darkening, flaking and crusting of pigmented freckles, age spots, seborrheic keratoses, etc
- Increased or decreased pigmentation
Exclusion criteria
Laser treatments may not be safe if you:
- have a medical condition made worse by bright or flashing lights, e.g. epilepsy, migraine, porphyria, photosensitive rash
- are taking medication where light exposure may cause a rash or other problems, e.g doxycycline
- are pregnant or breastfeeding
- are suntanned or wearing pigmented products or fake tan
In these situations, we may have to defer laser treatment or consider safer alternatives.
Avoid known photosensitising drugs and chemicals before light-based treatments such as laser, IPL/BBL and LED light therapy. If you are taking these medications, be sun smart every day.
More infoCold sores are a known side effect of surgical, laser and IPL treatments. You can reduce the risk by taking antiviral medication before treatment, or immediately if you notice the onset of cold sore symptoms after your treatment.
More infoRedness, swelling, blisters and sores are often a common result of aesthetic and skin cancer treatments. In most cases, they can be managed easily and settle gradually over the following weeks. However, it’s important to notify the clinic if you are very uncomfortable or concerned about your reaction being abnormal.
More info
References and footnotes
Benson, T. A., Hibler, B. P., Kotliar, D., Avram, M. (2020). Non ablative fractional laser treatment is associated with a decreased risk of subsequent facial keratinocyte carcinoma development. Dermatologic Surgery, 49(2), 149-154. https://pubmed.ncbi.nlm.nih.gov/36728065/
Chen, A., Goldenberg, G. (2018). Energy-based devices for actinic keratosis field therapy. Cutis, 101(5), 355-360. https://cdn.mdedge.com/files/s3fs-public/Document/May-2018/CT101005355.PDF
Ferrell, M., Wang, Z., Anderson, J.T. et al. A terminal metabolite of niacin promotes vascular inflammation and contributes to cardiovascular disease risk. Nat Med 30, 424–434 https://www.nature.com/articles/s41591-023-02793-8
McCormick ET, Desai S, Nelson K, et al. Fractional laser for prevention of non-melanoma skin cancer. J Drugs Dermatol. 2023;22(9):953-954. doi:10.36849/JDD.2023.NVRN0923 https://jddonline.com/articles/fractional-laser-for-prevention-of-non-melanoma-skin-cancer-S1545961623P0953X
Pour, P. N., Esmaili, N., Ehsani, A., Hamzelou, S., Nasimi, M. (2020). Non ablative fractional laser therapy for treatment of actinic keratosis with 3-months follow-up. Journal of Cosmetic Dermatology, 19(11), 2893–2897. https://doi.org/10.1111/jocd.13350
Worley B, Harikumar V, Reynolds K, Dirr MA, Christensen RE, Anvery N, Yi MD, Poon E, Alam M. Treatment of actinic keratosis: a systematic review. Arch Dermatol Res. 2023 Jul;315(5):1099-1108. https://doi.org/10.1007/s00403-022-02490-5
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