SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment

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1 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment Bettina Rümmelein 1, Tzu Chi Huang 2, Ratchathorn Panchaprateep 3, Seyed Alireza Miresmaeli 4, Boncheol Leo Goo 5 and R Glen Calderhead 6 Addressee for Correspondence: R Glen Calderhead MSc PhD DrMedSci FRSM, VP, Medical & Scientific Affairs Lutronic Corporation 219 Sowon-ro, Lutronic Center Deogyang-gu, Goyang-si, Gyeonggi-do, South Korea Tel: docrgc@lutronic.com 1 Medical Center See-Spital, Kilchberg/Zürich, Switzerland 2 Po Mei Dermatological Clinic, New Taipei, Taiwan 3 Isky Clinic, Bangkok, Thailand 4 Silver Sand Clinic, Tehran, Iran 5 Clinique L Dermatology, Lutronic Corporation, Goyang, South Korea 6 Medicoscientific Affairs, Lutronic Corporation, Goyang, South Korea

2 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment Abstract Background and Aims: Science and medicine are constantly on the move and the wise manufacturer moves with them, so there is a constant drive to develop novel systems even though existing systems are working well. On the other hand, it is logistically impossible for a manufacturer to try to keep launching completely novel devices without a great deal of system testing and clinical trials. Rather than struggling to achieve the latter goal, perhaps the appropriate concept should be; Take something that works really well, and, through applying science, make it work even better. This is exactly what Lutronic, Goyang, South Korea, has done with its tried, true and tested workhorse, the SPECTRA Q-switched Nd:YAG: the latest iteration, the SPECTRA XT, was launched at the Anti-ageing Medical World Congress (AMWC) in Monaco, at the beginning of April of The System: The SPECTRA XT represents a new paradigm in Nd:YAG-based multiplatform treatment. The SPECTRA XT offers two new Q-switched wavelengths, 595 nm New Generation Gold Toning and the 660 nm RuVY Touch (Ruby-like Versatile YAG) handpieces, with larger spot sizes. Technological advances include the Quick Pulse-To-Pulse (Q-PTP) option delivering higher fluences but with a more gentle approach for more sensitive or thinner skin, and Optimal Lattice Technology (OLT) ensuring even power distribution across all spot sizes at all fluences, including the large 10 mm spot size. Finally, the new Revital treatment technique utilizes the higher fluence of the XT, up to 45 J over 1 second, to deliver rejuvenation and tightening superior to the Genesis technique. Conclusions: Lutronic has thus extended the already wide scope of the SPECTRA family, so that the SPECTRA XT takes over and advances from the very high goals already reached by the proven SPECTRA family. In addition to the more efficient removal of tattoos, SPECTRA XT has added New Generation 595 nm Gold Toning as a novel and effective approach to recalcitrant post-acne redness, post-laser erythema and melasma with an underlying dermal vascular component, and 660 nm RuVY 2 Touch as a safer treatment for discrete epidermal pigmented lesions (freckles, lentigines) on and off the face, e.g., the neck, décolleté and dorsal aspect of the upper extremities. The 300 µs quasi long-pulsed mode delivering up to 45 J over 1 second offers flexible and tailored treatment for onychomycosis, and therefore even delivery of heat to the nail, nail bed and surrounding skin. The large 10 mm spot has proved ideal for low-fluence Q-switched 1064 nm laser toning with faster treatment times, and can be combined in Q-switched mode with the Q-PTP and Optimum Lattice Technologies for gentler and more efficient treatments. SPECTRA XT the extended platform offers the clinician and his or her patients extended functionality and efficacy with extended reliability and flexibility. Introduction It is very difficult to improve on perfection, but that is what Lutronic Corporation has succeeded in doing with its flagship and workhorse device, the SPECTRA dual mode Q- switched Nd:YAG (QSNY) system. A number of unique features has been added to extend the indications and capabilities of this well-tried and tested system to deliver the SPECTRA XT, the new paradigm in Nd:YAG-based multiplatform treatment. Lutronic is a great believer in making science work for the clinician and the patient, and the unique extended features of the SPECTRA XT are aimed at achieving just that. 595 nm New Generation Gold Toning: The solution to inflammation-associated problems With the addition of an appropriate dye handpiece a visible yellow beam at 595 nm can be produced. Considering the chromophores at this wavelength, namely blood and melanin (Figure 1), Lutronic R&D looked at the absorption characteristics of the target chromophores, and tuned the dye block to shift the wavelength by 10 nm to 595 nm (Figure 1, inset) from the 585 nm of the previous model. That 10 nm shift to the longer wavelength gives approximately 0.1 of an order of magnitude less absorption in both oxyhemoglobin and melanin,

3 January 2015 and a much larger difference in deoxyhemoglobin absorption. This potentially increases the safety of the 595 nm wavelength particularly in the epidermis, increases the depth of penetration into tissue of the 595 nm beam, and reduces the effect of deoxyhemoglobin as a competing chromophore thus allowing more light energy to reach the oxyhemoglobin in the target vessels in the superficial dermis. Figure 1 New Generation 595 nm Gold Toning compared with 585 nm relative to the absorption spectra of oxy-, deoxyhemoglobin and melanin. The main targets of this wavelength are the epidermal keratinocytes and the arterial microvessels in the superficial and upper dermis which exhibit abnormal inflammation-related activity, such as in rosacea, post laser erythema, acne vulgaris, post-acne redness and in melasma associated with such abnormal arterial behavior. When abnormal inflammation-related vascular activity is seen, a number of cytokines can be detected, for example vessel endothelial growth factor (VEGF), and up-regulation of cellular adhesion molecule (CAM) activity, particularly endothelial adhesion molecules (ELAMs) and intercellular adhesion molecules (ICAMs). These are known to encourage cross-talk between extracellular matrix cells (mast cells, macrophages and neutrophils) and the affected vessels so that a vicious circle is put in place which keeps the inflammatory process selfsustaining through synthesis of more proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interferongamma (IFN-γ), and interleukin 6 (IL6).[1] Keratinocyte growth factor (KGF)-mediated cross-talk also occurs between the affected fibroblasts and the mother keratinocytes in the epidermal stratum basale, in which keratinocyte synthesis occurs of more proinflammatory cytokines, including interleukin 1-alpha (IL-1α), and TNF-α. These descend into the dermis where they excite more inflammatory reactions at the level of T-cells. In addition, higher levels of all these inflammatory cytokines also support mast cell degranulation, releasing even more proinflammatory substances into the already inflamed area. This relationship between abnormal dermal vascular activity and certain types of melasma has already been shown by Kim and colleagues in their paper on the vascular characteristics of melasma, published in the Journal of Dermatological Science.[2] Rosacea of the erythematotelangiectatic type is recognized as an inflammation-mediated condition with neurovascular dysregulation resulting in ectatic microvessels in the papillary vasculature, and involvement of both the innate and adaptive immune systems and many of their related cells.[3] In the case of extended post-laser erythema, the laser treatment has left the skin in an extended state of inflammation which will not resolve because of the establishment of a vicious circle as above. The inflammation in acne is recognized as the result of the effect of the colonization of blocked follicles by Propionibacterium acnes (P. acnes), which results in recruitment of skin-homing T-cells.[4] These in turn are reprogrammed by the P. acnes so that, instead of fighting inflammation, the rogue T- cells mediate it so an autoimmune problem is added to the vicious circle. When large, pustular acne lesions have been successfully treated, in some cases areas of unsightly and persistent post-acne redness can be seen. These are not examples of scarring, but are caused by a combination of a thin, immature epidermis over angiogenesis as part of the wound healing process of the post-lesional damage in the dermis. This condition will spontaneously resolve as the epidermis matures and the blood vessel activity returns to normal, but it can take several weeks or even months. In all of these cases, application of New Generation 595 nm Gold Toning has successfully resolved the conditions, or speeded up their resolution, through normalization of epidermal and dermal homeostasis. Under a 3

4 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment normal state of affairs, the condition of the epidermis depends very much on nutritional and other support from the dermis as the epidermis itself is avascular: on the other hand, hyperactive epidermal keratinocytes can adversely influence the activities of the dermis through deposition of proinflammatory cytokines as discussed above.[5] It is hypothesized that visible light energy at 595 nm can affect both epidermal keratinocytes, and superficial dermal blood vessels, through normalization of the abnormal state of both targets through both a direct photothermal reaction and also a secondary photoactivative reaction. This hypothesis is backed up by the fact that the role of 595 nm from a pulsed dye laser in the release of matrix component normalizing immunological factors from blood vessel walls has been reported and proved.[6] Clinical results with 595 nm Gold Toning: The impetus to develop the SPECTRA XT 595 nm New Generation Gold Toning handpiece came from the excellent results achieved with the previous first generation 585 nm Gold Toning procedure associated with the SPECTRA system. As an example of this, Figure 2a shows a patient courtesy of Dr Seyed Alireza Miresmaeli, Silver Sand Clinic, Tehran, Iran, demonstrating a case of melasma associated with abnormal dermal vascular activity at baseline. The patient was treated with the combination method, whereby the first generation SPECTRA 585 nm Gold Toning was performed first to deal with the vascular component, followed immediately by 1064 Q- switched laser toning for any residual pigment. Figure 2b shows the very good result 1 week after three combination treatment sessions. Further sessions will give an excellent result. It was because of the success of the 585 nm Gold Toning with the SPECTRA that Lutronic developed the New Generation 595 nm Gold Toning handpiece for the SPECTRA XT, so the very good results seen in Dr Miresmaeli s patient can be expected to be even better with 595 nm New Generation Gold Toning. Figure 2 (a): Melasma associated with dermal vascular activity in an Iranian skin type 32 y.o. female at baseline. (b): Lightening is seen 1 week after 3 sessions of combined Laser Toning and 585 nm Gold Toning. Ratchathorn Panchaprateep MD PhD has her dermatological practice in the Isky Clinic, Bangkok, Thailand, and has been successfully using the original SPECTRA 585 nm Gold Toning for a variety of inflammation mediated conditions. A 20-year-old male presented with post-acne redness and a few active lesions on his temporal area, cheeks and white lip. The baseline findings are seen in Figure 3a. He was treated with SPECTRA 585 nm Gold Toning at Dr Panchaprateep s usual parameters, and an excellent result was achieved by 2 weeks after the 5th treatment session (Figure 3b). Figure 4 shows active acne lesions and post-acne redness on the forehead of a 22-year-old male at baseline (Figure 4a). The interim result after the 2nd treatment was good with some improvement (Figure 4b) and by 2 weeks after the 5th treatment session, complete clearance of both the acne and post-acne redness had been achieved (Figure 4c). Figure 3 Acne lesions and post-acne redness on the temporal area, cheek and white lip of a 20-year-old male. (a): Baseline findings. (b): Total resolution is seen 2 weeks after the 5th treatment session. 4

5 January 2015 Figure 4 Acne lesions and post-acne redness on the forehead of a 22-year-old male. (a): Baseline findings. (b): After the second treatment session, there is some improvement. (c) Total resolution is seen 2 weeks after the 5th treatment session. Dr Bettina Rümmelein, a dermatologist practicing in Kilchberg/Zurich, Switzerland and well experienced with the previous version of SPECTRA, has found the SPECTRA XT 595 nm New Generation Gold Toning ideal for any case where there is redness or pigmentation with an underlying vascular-related inflammatory component. The 4 mm handpiece is used at a fluence of from J/cm² with a repetition rate of 5 Hz and an overlap of approximately 30-50% to paint over the areas of interest with 2-4 passes. The endpoint is mild erythema in the treated areas. Figure 5 shows one of Dr Rümmelein s patients, a 29-year-old female who was previously treated for acne, showing residual mild acne lesions and areas of post-acne redness (Figure 5a). She was treated over 5 sessions at a fluence of 0.4 J/cm², 2 weeks apart. Figure 5b shows the result 6 weeks after the final treatment session, with resolution of the post-acne redness and no recurrence of the acne. A 40-year-old female is seen in Figure 6 with dark circles under the eyes having a vascular component visible with a dermatoscopic examination (Figure 6a, baseline). She was treated with 595 nm Gold Toning over 2 sessions at a fluence of 0.3 J/cm² (1st session) and 0.4 J/cm² (2nd session). Figure 6b shows the result at 5 weeks after baseline, 1 week after the second treatment session. The pigmentation cleared very well, leaving the residual dermal vascular component visible. After a further 4 weeks without any treatment (Figure 6c), the vascular activity has resolved even further. No recurrence of the pigmentation was seen. Figure 5 (a): 29 y.o. female with residual acne and post-acne redness at baseline. (b): Good results seen 6 weeks after the final treatment session with no recurrence. Figure 6 40 y.o. female with dark circles at baseline. (b): Good improvement in both pigmentation and vascular component 1 week after 2 treatment sessions. (c): After another 4 weeks, no further treatments, vascular activity is subsiding. No recurrence of pigmentation. 5

6 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment Dr Tzu Chi Huang is a dermatologist practicing in Po Mei Dermatological Clinic, New Taipei, Taiwan, and he has started using the 595 New Generation Gold Toning for both active acne and post-acne redness. Figure 7a is a 28-year-old female patient at baseline, with large areas of post-acne redness and some pustular active acne lesions involving the entire face. She was treated over 5 sessions with 0.5 J/cm², 5 stacked shots, 2 passes for the first 3 sessions, then 0.3 J/cm², 3 stacked shots and 1 pass for the final 2 sessions. The good result at 2 weeks after the 5th session is seen in Figure 7b. The post-acne redness has been eliminated, but the active acne needs some adjunctive treatment as can be seen from the lesion in the middle of the patient s cheek. The 595 nm Gold Toning can treat the inflammation caused by Propionibacterium acnes and the post acne redness, but cannot directly deal with all active P. acnes. In more severe cases of active inflammatory acne another modality is therefore required to target the causative bacterium together with 595 nm Gold Toning for the inflammatory-related components to achieve the best results. LED phototherapy with HEALITE II using 415 nm optionally followed by 830 nm offers a good combination approach adjunctive to 595 nm Gold Toning to target the active P. acnes. 660 nm RuVY Touch: A safer treatment for epidermal pigmented lesions Up till now, the 532 nm frequency-doubled beam of the 1064 nm QSNY has been the wavelength of choice for discrete epidermal pigmented lesions, such as freckles and lentigines. However, it is easy to cause epidermal damage with too high a fluence, and in darker skin types the formation of postinflammatory hyperpigmentation (PIH) is a distinct possibility as a side effect. To deal with these lesions in a safer way than the 532 nm beam, Lutronic developed the 660 nm RuVY Touch, where RuVY stands for Ruby-like Versatile YAG. The RuVY Touch handpiece emits a wavelength which more closely resembles the ruby laser wavelength of nm. Figure nm RuVY Touch wavelength compared with 532 nm relative to the absorption spectra of oxyhemoglobin, deoxyhemoglobin and melanin. Figure 7 Acne lesions and post-acne redness involving the entire face of a 28-year-old female. (a): Baseline findings. (b): 2 weeks after the 5th treatment session. The post-acne redness has been dealt with well, but the acne is still active (see the break-out on the cheek) and requires adjunctive treatment to target the P. acnes. Figure 8 compares the 532 nm and 660 nm RuVY wavelengths against the absorption curves of the biological pigments. As can be seen, the 660 nm beam is only around 0.5 of an order of magnitude less well absorbed by melanin than 532 nm, but it is still high on the melanin absorption curve. However, this is more than compensated for by the 660 nm energy being greater than 2 orders of magnitude less well absorbed in oxyhemoglobin, and greater than 1 order of magnitude less in deoxyhemoglobin compared with 532 nm. The absorption in melanin is still high enough to ensure selective photothermolysis in the target melanin compared with surrounding normal skin, but the significantly lower absorption in 6

7 January 2015 blood removes that element as a competing chromophore, and enhances the safety of the 660 nm beam in the treatment of freckles and lentigines by avoiding any potential damage to very superficial dermal blood vessels, and potential inflammation at the dermoepidermal junction which could result in postinflammatory secondary hyperpigmentation (PIH), particularly in darker Asian skin types. Clinical results with 660 nm Ruvy Touch: The SPECTRA XT Q-switched RuVY (rubylike versatile YAG) Touch was developed as a safer alternative for the treatment of discrete epidermal pigmented lesions, such as freckles (ephilides) and lentigines, compared with the frequency-doubled 532 nm which was one of the first treatments of choice for these lesions. Dr BC Leo Goo, Clinical Director of Clinique L Dermatology, Lutronic Corporation, carried out a number of in-house comparative studies to test the hypothesis that the 660 nm beam was safer than the 532 nm beam for discrete epidermal lesions, for all the reasons given above. Figure 9 shows the results of a split-face study on a volunteer patient, a 34-year-old female prone to freckle formation. The baseline findings are seen in Figure 9a. The right side of the face was treated with 532 nm and the left with 660 nm RuVY Touch, single session for both. The parameters used are seen in Figure 9a. Figure 9b is the condition 5 days after the treatment. The right side of the face demonstrates greater visible damage than the left side. Any epidermal damage in darker Asian skin types raises the potential for PIH formation. At 3 weeks after treatment (Figure 9c), clearance has been slightly better maintained on the 660 nm RuVY Touch side than on the 532 nm treated side. Dr Bettina Rümmelein (Kilchberg/Zurich, Switzerland) has also trialled the 660 nm RuVY Touch, and finds it particularly good for dealing with pigmented lesions on the back of the hands. Her opinion is that, compared with 532 nm treatment, the end results are comparable, but the short-term post-treatment results are very much in favor of the RuVY Touch in that the 532 nm treatment leaves the skin with very much more unsightly crusting than the RuVY Touch, so this is a great advantage in maintaining the quality of life of the older patients who want the pigmentation on the backs of their hands treated. Figure 10 illustrates the time course in the treatment and follow-up for pigmentation of the dorsal aspect of the hands in a 79-year-old female compared between 532 nm and 660 nm RuVY Touch treatment. Figure 10a,d shows the baseline condition, 10a to be treated with 532 nm and 10d with RuVY Touch. At 5 days posttreatment (10b,e) the lesions treated with the 532 nm beam are more visibly damaged with unsightly erythema and crusting shown more clearly in the insets at higher magnification. Figure 10c,f shows the findings at 24 days post- Tx. Lightening of the lesions is comparable, with slightly better results in the RuVY Touch treated hand, and no residual erythema. Figure 9 In-house comparisons of 532 nm vs 660 RuVY Touch in treatment of freckles in a 34 y.o. volunteer, Korean skin type III. (a): Baseline condition showing laser parameters. (b): 5 days post-tx. A greater degree of damage is seen on the right side of the face treated with 532 nm. (c): 3 weeks post Tx. Clearance has been well maintained with slightly better results with the 660 nm RuVY Touch treatment than seen on the 532 nm-treated sides. 7

8 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment Figure 10 Pigmented lesions on the dorsum of the hands in a 79 y.o. female, upper row treated with 532 nm (3 mm, 1.8 J/cm²) and lower with 660 nm RuVY Touch (2 mm, 2.6 J/cm²). (a, d): Baseline. (b, e) At 5 days post-tx, damage is more visible on the 532 nm-treated hand. (c,f) 24 days post-tx, the clearance is comparable between the two hands, with the 532- nm lesions a little more. The RuVY touch can be used safely and effectively for pigmented lesions on the face. Figure 11 is an example of lentigines on the face of a 71-year-old female, once again treated by Dr Rümmelein. Baseline findings are seen in Figure 11a, and the result 10 weeks after a single treatment in Figure 11b. Note that, in addition to clearance of the lesions, there is also improvement in the overall skin tone and texture. Figure 12 shows RuVY Touch for the hands of the same patient, 12a showing the left hand at baseline and 12b at 10 weeks posttreatment with excellent clearance and improved skin texture. Figure 11 RuVY Touch treatment for facial lesions in a 71 y.o. female. (a) Baseline findings. (b): 10 weeks after one RuVY Touch treatment. Good lesion clearance and improved skin tone and texture are seen. Figure 12 RuVY Touch treatment on the back of the left hand of the same patient as in Fig 11 (a) at baseline and (b) 10 weeks post-treatment with excellent results. 8 Dr Tzu Chi Huang (New Taipei, Taiwan) has found the 660 nm RuVY Touch safe and effective on and off the face, including the neck, décolleté and the dorsal aspect of the upper extremities. Figure 13a shows a 57-year-old female at baseline with a variety of facial nevi, including lentigines and seborrheic keratosis. Dr. Huang treated her with the RuVY Touch, 2 mm handpiece, J/cm² in a single session without any anesthetic, and the good result is seen in Figure 13b, 2 weeks after the treatment. Significant to complete clearance is seen in the majority of the lesions with no residual erythema. Treatment of lentigines on the dorsal aspect of the upper extremities of a 53-year-old female is illustrated in Figure 14, with the baseline findings seen in Figure 14a. RuVY Touch was indicated (2 mm handpiece, 2.6 J/cm²), and the result at 18 days post-treatment is shown in Figure 14b. Lightening is good, perhaps not quite as good as on the face, but conventional wisdom regarding treatment of lesions on the extremities with other wavelengths suggests that they do not respond quite so well, and require repeat treatment. On the other hand, there is no sign of secondary hyperpigmentation. A 67-year-old female is seen in Figure 15a with lentigines on her face at baseline. Treatment was performed with RuVY Touch (2 mm handpiece, 2.6 J/cm²), and Figure 15b shows the good results 5 weeks after treatment. Even larger lesions, such as the one in the area of the left eyebrow, lighten well with no PIH.

9 January 2015 above, so the risk of vascular damage with associated dyspigmentation, such as purpura and PIH, was lower. Overall, they concluded that the Q-switched 660 nm RuVY Touch handpiece was safe and effective for the treatment of various epidermal pigmented lesions. Figure 13 RuVY Touch treatment for a variety of facial lesions in a 57 y.o. female. (a): Baseline findings. (b): 2 weeks after one treatment. Figure 14 Lentigines on the upper extremities in a 53 y.o. female. (a) Baseline findings. (b): 18 days after one RuVY Touch treatment. Figure 15 RuVY Touch treatment for facial lentigines in a 67 y.o. female. (a): Baseline findings. (b): 5 weeks after one treatment. A recent study by Goo et al. examined the efficacy and safety of 660 nm RuVY Touch in a variety of pigmented lesions.[7] An overall improvement in the global aesthetic improvement score (GAIS) of 2.1± 1.1 was reported with good patient satisfaction. Sessions required were minimal with an average of just over 1 session per patient in 20 patients. The authors argued that, at the wavelength of 660 nm, there was a relatively weaker absorption rate by hemoglobin compared with 532 nm as already noted in the RuVY Touch discussion Other indications for SPECTRA XT: Onychomycosis The use of the 1064 nm wavelength for the treatment of onychomycosis has attracted a lot of attention, particularly with the 300 µs quasilong pulsed mode. The recent study by Moon et al. is typical whereby 22 of 43 nails had complete or near-complete remission with a long follow-up, and the result was classed as good in the remaining 21 nails.[8] This approach offers a valid alternative to the pharmaceutical approach, which can be complicated by potential drug interactions and systemic effects. The Spectra mode of the SPECTRA XT offers the 300 µs pulse, together with the unique optical lattice technology as explained below and a large range of spot sizes, coupled with the new higher fluence Revital Mode, delivering 45 J over 1 second, to give swift but effective treatment of this condition. Dr Rümmelein has some considerable experience of using Spectra mode, and is very satisfied with the efficacy and latency of the results. Dr Rümmelein s protocol involves putting the patients on a reduced dose of terbinafine tablets, and nibbling off as much of the diseased nail as possible with clippers. She then paints the affected nails and adjoining skin with 1064 nm at 300 µs using an appropriate spot size at 4-6 J/cm² and a repetition rate of 5 Hz. The endpoint is when the patient reports the nail has become almost too hot to bear: this ensures deactivation of the fungus both on and under the nail, and nail bed. Treatments are repeated 2-3 times a week for 2-3 weeks depending on the severity of the fungal infection. As the new normal nail grows from the root and matrix, it pushes the old formerly diseased nail ahead of it. Eventually the nail regrows completely. The process and some results are illustrated in Figure 16. 9

10 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment Figure 16 A diseased nail (a) is clipped back as much as possible (b), and the laser applied. The fungal infection is inactivated, and normal nail growth gradually replaces the old nail (c). (d, f): Examples of onychomycosis involving all 5 toenails. (e,g): The result following treatment with Spectra mode with complete regrowth of new nail, and no sign of recurrence. Quick Pulse-To-Pulse (Q-PTP) technology This is an optional addition to the Q-switched mode of SPECTRA XT, easily selected and deselected from the GUI control screen. Rather than delivering all of the Q-switched pulse energy in a single pulse, for example, 1200 mj, the Q-PTP mode delivers two ns-domain 850 mj pulses separated by only 80 µs (Figure 17). This is well below the 1.0 ms thermal relaxation time of skin so that the tissue is unaware that it has been hit by two pulses, and sees it as one pulse with a pulse energy equivalent to 1700 mj, compared with the 1200 mj true single pulse. This represents a more gentle way to deliver higher energies more safely to older, dry, sensitive or thin skin compared with the normal Q-switched mode Figure 17 Single Q-switched pulse of 1200 mj compared with Q-PTP comprising 2 ns pulses separated by 80 µs: the tissue sees the equivalent of a single 1700 mj pulse. 10 Optimal Lattice Technology The top hat beam profile of the SPECTRA family of systems was one of the advantages of SPECTRA over some other QSNY systems, whereby the energy was delivered evenly over the entire beam rather than having large and uneven spikes of energy which could induce hotspots in the treatment area, resulting in potential overtreatment and unwanted side effects. In fact, the flat top mode beam, when looked under magnification, was not truly flat, and consisted of multiple small spikes of peak power against the background of the base power. The result was that the tissue saw the average of the peaks and the base power. Although the SPECTRA top hat beam delivered excellent results, this combination of peaks and baseline power could be argued to be a somewhat inefficient way of delivering energy. Lutronic R&D then developed the Optimum Lattice Technology (OLT), whereby the difference between the spikes and baseline of the former flat top beam was evened out to give the same power as delivered by the former beam, but in a more homogeneous fashion, thereby further improving the beam delivery of the top hat mode. This OLT concept is illustrated in Figure 18. The homogeneity of the beam can be seen in laser impacts on footprint paper seen in Figure 19, comparing SPECTRA XT OLT with a competitor system at the same parameters.

11 January 2015 Conclusions Figure 18 Optimal Lattice Technology (OLT) illustrated. (a): Top hat beam of former SPECTRA, showing homogeneous distribution, but actually composed of many spikes against baseline power (b), delivering an average power as seen by skin. (c) SPECTRA XT OLT standardizes the peaks and baseline power to give the same output power as SPECTRA, but without the inefficient spikes. The lower parts of b,c show an enlarged schematical view of the SPECTRA Top Hat and XT OLT modes. In the case of OLT, this difference between peak and base power is evened out, and the laser energy is delivered more effectively. Figure 19 Laser impacts measured on footprint paper for the 1064 nm and 532 nm beams from SPECTRA XT with OLT and a typical competitor system without OLT. (a): SPECTRA XT OLT: 1064 nm Q-switched beam, 7 mm Ø, 2.4 J/cm² showing good beam definition with excellent homogeneity. (b): Competitor: 1064 nm Q-switched beam at the same parameters. Beam definition is good, but a nonhomogeneous delivery of laser energy is seen. (c): SPECTRA XT OLT: 532 nm Q- switched beam, 5.2 mm Ø, 0.3 J/cm² showing a homogeneous delivery of energy with good beam definition. (d): Competitor: 532 nm Q-switched beam at the same parameters, poor homogeneity and a distorted definition are apparent. Although it has been a only comparatively short period since the SPECTRA XT was officially launched at the beginning of 2014, the clinical results in a number of areas are already showing that the science on which the new wavelengths and technological advances were based has been vindicated with excellent clinical results, satisfied users and happy patients. The New Generation 595 nm Gold Toning has proved to be an effective approach for inflammationmediated conditions: recalcitrant post-acne redness, post-laser erythema and melasma with an underlying dermal vascular component all respond very well to the Q-switched 595 nm wavelength. The 660 nm RuVY Touch has been shown to be safer than the 532 nm wavelength for discrete epidermal pigmented lesions such as freckles and lentigines on and off the face, e.g., the neck, décolleté and dorsal aspect of the upper extremities. Although the end result may be comparable to that attained with the 532 nm beam, the short term appearance of the treated skin, without unsightly crusting and erythema, maintains the satisfaction and good quality of life of the patient. The 300 µs quasi long-pulsed mode deliverable at 45 J over 1 second offers flexible and tailored treatment for onychomycosis, and therefore gives even delivery of heat to the nail, nail bed and surrounding skin. The large 10 mm spot has proved ideal for low-fluence Q-switched 1064 nm laser toning with faster treatment times, and can be combined in Q-switched mode with the Q-PTP and Optimum Lattice Technologies for gentler and more efficient treatments. SPECTRA XT the extended platform offers the clinician and his or her patients extended functionality and efficacy with extended reliability and flexibility. 11

12 SPECTRA XT: The New Extended Paradigm In Nd:YAG-Based Multiplatform Treatment References 1: Zhang J, Alcaide P, Liu L, Sun J, et al. Regulation of Endothelial Cell Adhesion Molecule Expression by Mast Cells, Macrophages, and Neutrophils. PLoS ONE, 2011; 6: e : Kim EH, Kim YC, Lee ES, Kang HY. The vascular characteristics of melasma. J Dermatol Sci, 2007; 46: : Steinhoff M, Schauber J, Leyden JJ. New insights into rosacea pathophysiology: a review of recent findings. J Am Acad Dermatol, 2013; 69(6 Suppl 1): S : Jeremy AH, Holland DB, Roberts SG, Thomson KF, Cunliffe WJ. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol, 2003; 121: : McCully ML, Ladell K, Hakobyan S, Mansel RE, et al. Epidermis instructs skin homing receptor expression in human T cells. Blood, 2012; 120: Epub 2012 Oct 4. 6: Omi T, Kawana S, Sato S, Takezaki S, Honda M, et al. Cutaneous immunological activation elicited by a low-fluence pulsed dye laser. Br J Dermatol, 2005; Suppl 2: : Goo BL, Kang JS and Cho SB: Therapeutic efficacy and safety of wavelength-converted 660 nm Q-switched Ruby-Like Versatile YAG treatment on various skin pigmentation disorders. Med Laser, 2014; Epub July 14. 8: Moon SH, Hur H, Oh YJ, Choi KH, et al.: Treatment of onychomycosis with a 1,064-nm long-pulsed Nd:YAG laser. J Cosmet Laser Ther, 2014 Aug; 16: Epub 2014 Apr