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Clinical Guidance for Laser Procedures during the COVID-19 Pandemic

Written by Tom Lister on 3rd April 2020. Posted in Blog.

Please note that this BMLA advice and guidance is produced for practitioners undertaking elective laser procedures. As this is a fluid situation, the guidance may change in the next few days. These guidelines have been adapted from the British Association of Dermatologists, British Association of Dermatologic Surgeons and British Association of Maxillofacial Surgeon’s guidance.

Most laser procedures are classed as routine or elective procedures. Whilst these won’t be classed as frontline or essential procedures, patient and staff safety is paramount when such procedures are undertaken.

The BMLA recommends that the following guidance is implemented:

Consider cancelling all elective laser procedures.
Practitioners undertaking laser procedures during the COVID-19 pandemic should clearly state why the procedure could not be deferred and clinical need for the laser procedure.
Current government recommendations state that all non-essential travel and contact should be avoided. As such, routine maintenance of equipment and visits from laser protection advisors should be avoided unless absolutely necessary. This decision should be informed by a risk assessment with all other possibilities, such as video conferencing and deferral of equipment use, being eliminated.

Personal Protective Equipment – PPE

The limited supplies of PPE mean that any patient who does not need to come to hospital or clinic should not.
All patients should be treated as potentially COVID-19 positive.
Most laser procedures are aerosol-generating. Laser plume may contain carcinogens, bioaerosols, viruses, blood fragments, and bacteria depending on the type of the procedure. They also contain carbon monoxide, polyaromatic hydrocarbons, and various toxic gases and vapours. Plumes may contain chemicals such as formaldehyde, hydrogen cyanide, acrolein, and benzene.
For all laser procedures deem to be producing laser plume, FFP3 masks, eye screens, full sleeve, disposable fluid-repellent surgical gowns and gloves should be worn by all practitioners present during the procedure.
Smoke extractor systems, in addition to laser masks, are the most effective way to minimise risk, as standard surgical masks alone are not sufficient to act as the primary method of particle filtration.
Only the absolute minimum number of healthcare professionals required for the procedure should be present.
For high-risk or known COVID-19 patients or invasive procedures, NHS England guidelines should be followed and where possible, laser procedures should be abandoned or postponed.
This will remain the case until the current trajectory of COVID-19 has flattened.

Advice and Supervision – requirements for independent clinics

Written by BMLA on 8th July 2019. Posted in Blog, Resources.

This post outlines the legal requirements as well as national recommendations for expert advice in cosmetic laser and IPL settings.

Health and Safety at Work Etc. Act

Laser and IPL treatments carried out in the UK, in a workplace with employees, fall within the scope of the Health and Safety at Work etc. Act 1974. This act is enforced by local councils.

This legislation requires appropriate systems of work, supervision and provision of training. National recommendations published by the BSI, MHRA, BMLA and SRP clearly define the standards for what is appropriate.

Systems of work should include Local Rules and treatment protocols. The Local Rules form part of an employer’s means of complying with the Health and Safety at Work Act, section 2(3). According to the MHRA, Local Rules should be produced for each installation, reflect safe working practices and relate to the day-to-day safety management of lasers, IPL systems and LEDs. They must be in place on-site and reviewed annually. The BMLA Essential Standards require a separate treatment protocol for each laser or IPL treatment. In particular, the protocol must address:

contraindications;
technique;
obtaining patient/client consent prior to treatment;
record keeping requirements and treatment process (step by step guidance);
cleanliness and infection control within the treatment environment;
pre-treatment tests;
post-treatment care;
recognition of treatment-related problems;
procedure if anything goes wrong;
permitted variation on machine variables.

The treatment protocol should be reviewed either when there is a change of treatments or if evidence comes to light that shows a change is in the clients’ interests.

Supervision must be performed by a suitably trained and knowledgeable individual. Laser safety supervision should be carried out by a certificated Laser Protection Adviser (LPA) who has demonstrable knowledge of safety requirements for cosmetic laser and IPL systems. Laser and IPL users must have access to safety advice from a certificated LPA, who is also responsible for writing and reviewing the Local Rules. Evidence of the LPA’s laser/IPL certification should be available for reference on site.

Clinical supervision is performed by an Expert Registered Healthcare Professional (ERHP). The EHRP should be registered with the General Medical Council, Health Professions Council, General Nursing Council or General Dental Council, as appropriate, and they must be able to demonstrate expertise in the area of treatment covered by the protocol. Treatment protocols must be traceable to the ERHP to confirm authorisation and validity along with evidence of the means by which the ERHP provides ongoing support and advice.

Training is required in:

the laser or IPL system(s) in use
the treatment(s) performed
laser safety.

Laser safety must include a BMLA approved course covering the Core of Knowledge curriculum. Evidence of training attendance certificates should be held within the establishment, as well as evidence of continuing professional development.

The Management of Health and Safety at Work Regulations, which forms part of the Health and Safety at Work family of legislation, requires that the employer appoints “one or more competent persons to assist him in undertaking the measures he needs to take to comply with the requirements” who has “sufficient training and experience or knowledge and other qualities” to do this. In the context of laser and intense light treatments, this role is fulfilled by a certificated Laser Protection Adviser.

Control of Artificial Optical Radiation at Work Regulations

The Control of Artificial Optical Radiation at Work Regulations (AORD) provides strict exposure limits for employees who may be exposed to artificial optical radiations, such as those produced by lasers, IPLs and LEDs. These limits are adhered to through appropriate risk assessment and the requirements described in the above section.

The Health Protection Agency (now Public Health England) produced a non-binding guide to help with implementation of the regulations. The non-binding guide recommends the use of Local Rules where the risk assessment identifies a potential for exposure to hazardous level of optical radiation, as well as either employing expert in optical radiation safety management or appointing an external adviser.

Recommendations

The BMLA Essential Standards form the basic set of requirements and mirror the legal requirements found in the Independent Health Care Regulations (Northern Ireland), the Independent Health Care (Wales) Regulations and the Regulation of Care (Scotland) Act. As such, they are commonly used by local councils in England when determining the suitability of a business or investigation complaints.

Councils also look to businesses offering laser and IPL therapy to be able to demonstrate competencies using the Health Education England training recommendations. This lays out a curriculum of work against which laser practitioners have to demonstrate compliance at varying levels of complexity, dependent upon the treatment being carried out. It also requires that all employers must appoint or consult a certified LPA where Class 3B and Class 4 lasers or IPL systems are being used, including to deliver teaching in laser safety and set out safe systems of work.

BMLA Treatment Guidelines

Written by Tom Lister on 8th May 2019. Posted in Blog, Resources.

Here is the BMLA Treatment Guidelines for the use of Laser and Intense Pulsed Light Devices for Hair Reduction and Treatment of Superficial Vascular and Benign Pigmented Lesions launched at the BMLA Annual Conference, May 2019.

Drugs and Lasers/IPLs

Written by BMLA on 30th November 2018. Posted in Blog, Resources.

There has been a general trend within the industry to provide end-users of laser devices with guidance on which drugs to avoid to minimise the possibility of drug-induced photosensitivity reactions. This guidance has often, in the opinion of the authors, been largely based on an inappropriately rigid interpretation of what data exists.

Drugs & Lasers/IPLs

Guidance provided by the British Medical Laser Association.

Version 2 issued May 2017.

Important

This advice relates to non-essential aesthetic laser applications and reflects the best data available at the time of this report. It updates earlier advice issued in December 2009. Caution should be exercised in interpretation; the results of future studies may require alteration of the recommendations in this document.

The following is a consensus opinion of interested parties from the laser and light source world in the UK and takes into account:

a) Personal opinions

b) Theoretical perspectives

c) Evidence from practical use over very large numbers of clients/patients

d) Reporting of adverse events in clinical trials and in post-marketing surveillance studies.

Background

There has been a general trend within the industry to provide end-users of laser devices with guidance on which drugs to avoid to minimise the possibility of drug-induced photosensitivity reactions. This guidance has often, in the opinion of the authors, been largely based on an inappropriately rigid interpretation of what data exists.

Reports of photosensitivity reactions as a result of drug administration do occur, but we believe that these reactions have been reported to regulatory bodies with no indication of the wavelength of light that has been responsible. Accurate data are often lacking2.

Phototoxicity generally results from exposure to UVA (315-400nm) radiation with some drugs showing sensitivity into the visible region of the spectrum up to about 460nm. For laser/IPL (intense pulsed light) devices emitting wavelengths above 500nm there is very little likelihood of such a reaction for the vast majority of drugs. Despite this, some centres continue to deny treatment to a patient/client who is on any medication with a known photosensitivity3. This is not at all in accord with the original BMLA guidelines nor with the current revision which sets out the evidence on which the guidance is based.

Other drugs may have an effect on the skin’s healing ability without causing photosensitivity.

Practical Advice

Information regarding all drugs a patient/client is taking should be recorded including:

a) Over the counter drugs

b) Prescribed drugs
c) Herbal remedies

1. Photosensitising drugs that are CONTRAINDICATIONS to laser therapy

a. Drugs causing marked whole body sensitivity – wait 6 months. Drugs administered for systemic Photodynamic Therapy (PDT)4, e.g. Photofrin, Foscan.

b. Drugs causing marked localised light sensitivity – wait 6 weeks. Drugs administered for topical PDT5, e.g. Ameluz, Metvix.

2. Other drugs that may cause Photosensitivity

Any treatment should be performed with caution. Test and assess results carefully and treat small areas initially. If in doubt, do not treat.

If the client/patient wishes to proceed with treatment, the increased risk of hyperpigmentation/photosensitivity should be emphasised and documented.

a. Amiodarone – risk of hyperpigmentation and photosensitivity^6,7

b. Minocycline (Minocin) – risk of hyperpigmentation⁸. Recommend stopping 4 weeks prior to treatment or consider change to an alternative. (It may be noted that lasers have been used successfully to treat minocycline-induced hyperpigmentation⁹.)

c. St John’s Wort – risk of photosensitivity¹⁰. Recommend stopping 4 weeks prior to treatment.

d. If taking other medications or herbal remedies of any sort then careful initial test patch, wait 4-7 days in the case of hair removal and 4-6 weeks in the case of vascular/pigmented treatments.

e. If a patient/client starts a BNF-named photosensitiser during a course of treatment then repeat test patch. It is likely, however, that the wavelength of laser / IPL will not induce a photosensitive response.

3. Drugs which may affect the healing of treated areas

Any treatment should be performed with caution. Test carefully and treat small areas initially. If in doubt, do not treat.

a. Oral Retinoids – There is some controversy around this. The British National Formulary (BNF) states that patients should be told to avoid laser skin treatments for 6 months, although it has been reported that many laser clinicians have treated within this time period without seeing any adverse effects¹¹.

Examples: Isotretinoin (Roaccutane), acitretin (Neotigason), alitretinoin (Toctino)

b. Topical Retinoids – stop use 2 weeks prior to laser, recommence once area is healed.

Examples: Tretinoin (Retin-A, Aknemycin Plus), isotretinoin (Isotrexin), adapalene (Differin)

c. Oral Steroids – Wound healing impairment is dependent on potency, dose and duration of use. It is advisable to check with the prescribing physician if laser treatment can proceed safely. When possible, wait 4 weeks off drug and avoid use immediately following laser therapy. Recommence use once treated area is healed.

Examples: Betamethasone, cortisone, deflazacort, dexamethasone, hydrocortisone, methyl prednisolone, prednisolone, triamcinolone

d. Topical Steroids – Wound healing impairment is dependent on potency, dose and duration of use. It is advisable to check with the prescribing physician if laser treatment can proceed safely. Wait 1 week prior to treatment and avoid use immediately following laser therapy. Recommence use once treated area is healed.

References

1. http://www.bmla.co.uk/resources/ downloaded 10/04/2017

2. Kerstein RL, Lister T, Cole R (2014) Laser therapy and photosensitive medication: a review of the evidence. Lasers Med Sci 29(4):1449-52

3. Moseley H, Lanigan S, Martin R (2015) Drugs and lasers/IPLs. Lasers Med Sci 30(8):2223-4

4. Hopper C (2000) Photodynamic therapy: a clinical reality in the treatment of cancer. Lancet Oncol Dec;1:212-9.

5. Morton CA et al (2008) Photodynamic Therapy (PDT) Guidelines for topical photodynamic therapy: update. Br J Dermatol 159:1245-66

6. Ferguson J (2002) Photosensitivity due to drugs. Photodermatol Photoimmunol Photomed 18(5):262-9

7. Chalmers RJ, Muston HL, Srinivas V, Bennett DH (1982) High incidence of amiodarone-induced photosensitivity in North-west England. Br Med J 285:341

8. Dwyer CM, Cuddihy AM, Kerr REI, Chapman RR, Allam BF (1993) Skin pigmentation due to minocycline treatment of facial dermatoses. Br J Dermatol 129(2):158-62

9. Alster TS, Gupta SN (2004) Minocycline-induced hyperpigmentation treated with a 755-nm Q-switched alexandrite laser. Dermatol Surg 10:1201-4

10. Onoue S, Seto Y, Ochi M, Inoue R, Ito H, Hatano T Yamada S (2011) In vitro photochemical and phototoxicological characterization of major constituents in St. John’s wort (Hypericum perforatum) extracts. Phytochemistry 72 (14-15):1814-20

11. Prather HB, Alam M, Poon E, Arndt KA, Dover JS (2017) Laser safety in Isotretinoin use: A survey of expert opinion and practice. Dermatol Surg 43:357-363

Disclaimer

This should not be considered as an exclusive list of drugs that may interact with the laser treatment. It does not replace any advice or instruction issued by a registered medical practitioner, pharmacist or other registered health professional. The information provided is without any implied warranty of fitness for any purpose or use whatsoever.

BMLA Essential Standards

Written by BMLA on 17th November 2017. Posted in Blog, Resources.

The BMLA Essential Standards Regarding Class 3B and Class 4 Lasers and Intense Light Sources in Non-surgical Applications.

Awards and prizes

Written by BMLA on 9th November 2017. Posted in Blog, Resources.

Vasant Oswal Oration

Vasant Oswal is a pioneer in the application of lasers in ENT surgery. He is co-author of the definitive work on Lasers in Otorhinolaryngology and Head and Neck Surgery and he has served on the Executive of BMLA for many years providing exceptional insight and energy in the various posts that he has occupied. BMLA is further indebted to Vasant and his wife Nirmal who provided a significant financial contribution to allow the society to invite an internationally-renowned speaker to attend the Annual Scientific Conference and deliver a guest lecture. It was the unanimous view of the Executive that this prestigious award should be given the name, the Vasant Oswal Oration.

Mr. Vasant Oswal, Vice President of BMLA, is Emeritus Consultant Otolaryngologist at the James Cook University Hospital in Cleveland, England. He has published widely, lectured world-wide and wrote and edited three books on

Lasers in ENT. He is actively involved in laser matters in a number of professional bodies the world over. In 2015, Royal College of Surgeons in England awarded him FRCS (Eng) by election.

Recent Vasant Oswal Oration Speakers:

2019 – The true history of Penicillin, Dr Eric Sidebottom, University of Oxford

2018 – Why are we still having difficulties treating port wine stains?, Sean Lanigan, SKiN

2017 – Advances in cutaneous rejuvenation, efficacy and validation: Personal experience, Dr Mario Trelles, Institut Mèdic Vilafortuny

2016 – Chris Smith, The Naked Scientists/ Cambridge University

2015 – A critical appraisal of lasers in dermatology, Keyvan Nouri, University of Miami Hospital, Florida

Educational Award

This award is to aid a researcher to visit an internationally recognised research institute in their field of study, or to aid in the oral presentation of an international conference paper. The award available is of the value of £1,000 towards such costs.

To apply for this award, please send your C.V., an accompanying letter detailing your plans for the award and how it relates to your current research, and a letter of support from your supervisor to Tom Lister at tomlister@nhs.net. The closing date for applications is Friday 30th March 2018.

Your application should be accompanied by a letter of support from a referee who is familiar with your work, preferably your head of department. Either the applicant or the referee must be a member of the BMLA. Priority will be given to junior applicants and to BMLA members.

You will be required to acknowledge support from the British Medical Laser Association, and, as a condition, submit a short report of your experience.

Results are announced at the Annual Conference of the BMLA (Amsterdam, 24th-26th May 2017).

The winner of the 2017 Award was Paul O’Mahoney. Paul plans to visit experts in optical diagnostics in Cork to help develop his skills and local services in real-time diagnostics of the brain.

Conference Awards

The 2017 BMLA conference featured many interesting and ground breaking talks from dermatologists, aestheticians, nurses and scientists. Congratulations to the following prize winners:

The BMLA presentation award for his talk on Low-Level Laser Therapy for oral mucositis: Jamal Noori Ahmed
The Photodiagnostics and Photodynamic Therapy Award, kindly sponsored by Elsevier for her talk on quantifying DNA damage caused by UV exposure: Isla Barnard.
The BMLA presentation award for his talk on combined PDL and Nd:YAG aser treatment for residual infantile haemangiomas: Ben Evans.
The Springer award for his talk on MRI imaging of ablative fractional laser effects: Matthew Marzetti.

A Burn within a Tattoo After IPL Epilation

Written by BMLA on 8th December 2014. Posted in Blog.

A case has recently been reported in which a patient undergoing hair removal treatment using an intense pulsed light (IPL) device sustained a second-degree skin burn. To read our thoughts on this click HERE.

Concerns around so-called ‘next generation’ PDT and sonodynamic therapy

Written by BMLA on 15th November 2012. Posted in Blog.

Photodynamic therapy (PDT) is a treatment option for some types of cancer that involves administration of a drug that is activated by light, usually from a laser. This causes cell death. The underlying scientific principles and numerous clinical studies have been published in peer-reviewed literature1 2 3. PDT can be curative. For example, in non-melanoma skin cancers, PDT has less morbidity than cryotherapy and avoids the need for skin grafts in surgical excision of large lesions. Often it is palliative where it can bring welcome symptomatic relief and precious extra months’ quality life to the patient.

PDT has several key attractions: there is minimal loss of normal tissue; PDT can be repeated in the same area as often as required; it can be used after conventional treatments have failed or as a stand-alone treatment in appropriate patients.

There are clinics providing what is sometimes called Next Generation PDT (NGPDT) or sonodynamic therapy (SDT). In general, the treatments provided do not have the necessary scientific rigour that is expected. Often the light is delivered externally and it is claimed that this reaches the tumour but light penetration to internal cancers is insufficient for effective PDT. A critical appraisal of a clinical application of SDT has been published4. This concludes that there is no convincing data that shows that treatment carried out as reported is effective in the treatment of primary tumour and multiple metastases. Without critical safety and efficacy information, it is unjustifiable to test unproven unconventional techniques and substances in patients, particularly those in terminal stages. PDT can be used effectively in the treatment and care of appropriate cancer patients. The use of so-called NGPDT or SDT cannot be recommended.

Prof Harry Moseley, Hon President British Medical Laser Association; Prof Sam Eljamel, Clinical Director Scottish PDT Centre; Prof Keyvan Moghissi, Clinical Director Yorkshire Laser Centre.

References

1. Moghissi K, Dixon K, Stringer M et al. Photofrin PDT for early stage oesophageal cancer: Long term results in 40 patients and literature review. Photodiagnosis and Photodynamic Therapy 2009; 6: 159-66.

2. Allison RR, Sibata C, Gay H. PDT for cancers of the head and neck. Photodiagnosis and Photodynamic Therapy 2009; 6: 1-2.

3. Morton CA, McKenna KE, Rhodes LE et al. Guidelines for topical photodynamic therapy: update. British Journal of Dermatology 2008; 159: 1245-66.

4. Huang Z, Moseley H, Bown S. Rationale of Combined PDT and SDT Modalities for Treating Cancer Patients in Terminal Stage: The Proper Use of Photosensitizer. Integrative Cancer Therapies 2010; 9: 317-9.