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F. Malan
The therapeutic effect of light due to the presence in the tissues of endogenous molecules
capable of absorbing it occurs because the energy
conveyed by the light beam is absorbed by elements naturally present in the tissues, called
“chromophores,” and used to promote chemical
reactions or produce conformational changes in
some biomolecules.
This treatment brings therapeutic benets on
inammation and pain by promoting wound
healing and tissue regeneration.
These discoveries have produced a wave of
enthusiasm for a simple and relatively inexpensive therapy that is undoubtedly effective in most
cases.
Numerous authoritative colleagues have presented various case histories of signicant successes in the treatment of ulcers of various origins
with blue light.
The range of pathologies studied is wide:
chronic skin lesions such as ulcers of the lower
limbs (venous, arterial, and mixed ulcers), inammatory ulcers (from rheumatic diseases and
scleroderma), diabetic foot and pressure ulcers,
and skin lesions with extensive loss of substance
such as burns and trauma wounds, surgical dehiscence, and dermatological disorders. Thanks to
this activity, it was found that blue light, through
the photobiomodulation process, is able to
resolve inammation and stimulate the regeneration process of skin tissue.
Inammation is a necessary phase of the
wound repair process that should last as a whole
no more than 4 weeks; due to pathologies or particular physical conditions (such as advanced
age, nutritional deciencies, and mobility restrictions), the inammatory phase may stall, causing
the wound to become chronic. The most widespread and impacting chronic wound etiologies
are as follows: Ulcers of the lower limbs, originating mainly from venous insufciency, afict
1% of the adult population and 3.6% of the population over 65years of age; diabetic foot affects
one in three patients with diabetes mellitus and is
the most frequent cause of lower limb amputation
worldwide; and pressure ulcers or “decubitus” is
caused by the pressure of a bone pre-eminence in
people with limited mobility such as patients in
intensive care, which have an average prevalence
estimated in the European population of 13.7%.
An inammatory response, when it is not regulated, is also at the origin of the complication of
wounds characterized by extensive loss of substance, originating from trauma or a burn, and
surgical dehiscence.
Photobiomodulation with blue light, a therapy able to stimulate the transition of the inammatory phase, can make a contribution to the
resolution of wounds with a slowed or neverending healing process, an important medical–
health problem given the high management costs
and poor quality of life of patients affected by
this problem. As with any innovation, particularly in the medical eld, there is a risk of overestimating its benets, which leads to forcing
indications and consequently increasing the failure rate. Therefore, it is worth evaluating the
benets and issues related to photobiomodulation to improve its use and avoid improper or
useless use [3].
The possibility of using photobiomodulation
on an outpatient basis is certainly an advantage
even if it still requires dedicated time and space,
or in any case such as to allow an appropriate use
of the equipment, despite a good ease of use. An
advantage, already mentioned previously, is certainly given by the relatively low cost of the
treatments.
An advantage, certainly important in an era in
which ecological sensitivity is also increasing in
the health eld, is given by the production of
almost zero waste, which translates into signicant environmental and economic benets.
The use of photobiomodulation is practically
free of contraindications; however, it is not recommended in patients with neoplastic diseases
and, obviously, in patients with abnormal sensitivity to light, for example, in the case of some
porphyrias.
As for the benets, there is no uniformity of
results between the various studies conducted on
the subject.
Two studies carried out in Tuscany and
Piedmont provided signicantly different data on
the benets of the treatment of skin ulcers of different origins.
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165
A study by Dini etal., published in 2020 by
Minerva Medica, states that after 4 weeks of
treatment the healing rate was 0.089mm per day
for venous ulcers and 0.353mm per day for traumatic ulcers, while in another study, also published by Minerva Medica, from 2021,
Fraccalvieri etal. afrm that after 10 weeks signicant improvements have been observed,
especially in ulcers of venous origin in a picture,
however, of better efcacy than standard therapies [4, 5].
The limitation of these studies is given by the
fact that they are not multicentered, which can
lead to various biases related to the types of standard treatments, the type of patients, and the reference center itself [6, 7].
In essence, however, it can be said that photobiomodulation is a safe method, with low costs
and substantially free of contraindications,
which provides, on average, favorable results
[8–10].
In the presence of these characteristics, the
main risk is to force the indications with consequent lack or insufciency of results with
waste of time and slowdowns in the healing
processes.
The selection of patients is fundamental, as
always, for a correct application of the treatment
[11–13].
In perspective, the development of multicentered studies and an accurate meta-analysis
of the available data are the main streets to follow in order to draw up precise treatment protocols and for a selection of patients that optimize
the use and benets of photobiomodulation
[14–18].
Focusing on the photodynamic therapy, it
acts using 3 independent agents: light, molecular oxygen and a photosensitized agent. It is
based on the application of a non-toxic dye (the
photosensitized agent) only on the wound bed
(it shouldn’t touch the health skin). The gel
needs 30 minutes to be activated and during this
time the wound should be covered with a sterile
gauze. Then, uncover the wound and expose to
the light, the irradiation time is of 8 minutes.
The light source has to stay 10cm distant from
the wound bed, it emits a non-coherent light
radiation with a peak at 630 nm. The irradiator
doesn’t have to touch the wound. At the end of
the procedure wash with physiological solution
to remove the gel. During the procedure patient
and operator should wear protector glasses. The
most used light source is the one that generates
a red wave spectrum with a high potential of
tissue penetration. The photosensitized agent
applied on the wound bed absorbs the light and
then it activates and transfers energy and electrons to the molecular oxygen. The molecular
oxygen is now excited to a superior level and it
creates the ROS (reactive oxygen species).
Once the ROS ties on the cellular membrane of
the pathogenic agents, they cause their breaking but do not damage the non-pathogenic cells
of the organism. This is explained by the action
of ROS toward the ionic ties present in a higher
percentage in the pathogenic cells. When the
cells that needs to be killed are pathogenic
microorganisms we can talk about “photodynamic inactivation”. This mechanism at the
base of the PDT works on the following
microorganisms: GRAM+ and GRAMbacteria, S. Aureus, MRSA, Pseudomonas
Aeruginosa, Streptococcus Pyogenes,
Propionibacterium Acnes, Corynebacterium
minutissimum, Candida albicans, skin fungus,
virus, protozoans and biolm.
Photodynamic therapy can be used for the
treatment of the following illness:
• Chronic wounds
• BCC skin cancer
• Post-surgery wounds
• Surgical scars
• Non-hypertrophic actinic keratosis
• Acne Vulgaris
• Teeth infections
• Psoriasis
The PDT helps in different ways the healing
process causing cellular death, modulating the
inammation process, stimulating the broblast
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F. Malan
and supporting the deposition of collagen and
elastin. In addition, it also:
• Increases the ulcers healing
• Reduces the local microbic load and the
infection
• Works on every microorganism including the
resistant strain in biolm and planktonic
form
• Doesn’t induce any bacterial resistance and
reduces the necessity of systemic medications
• Improves the scar result
• Is a safe and well-tolerate technique
• Doesn’t cause any pain and it easy to use, so it
is possible to use in an outpatient setting
As every procedure, also PDT has some con-
traindications and possible adverse effects:
• The product doesn’t have to be used if there is
a known hypersensitivity to one of the
components
• Do not use the product if other topic dressing
are already applied on the wound bed, such as
hydrogel, silver bandage, antibiotics, soaps
etc. the use of these products should be
stopped before the treatment
• This treatment used on health skin can cause
redness and temporary rush
• Some patients may refer a complaint and heat
during the procedure but is stops at the end of
the treatment
• A green coloration of the skin may persist in
the application site for a couple of weeks
• Due to the lack of clinical study, it shouldn’t
be used in patients with less than 18 years old
and during pregnancy and breast feeding
References
1. Aliquò MS, et al. Clinical application of photobiomodulation with blue light on non-healing ulcers in
diabetic patients: a case series study. Wounds Int.
2021;12:4.
2. Anders JJ, et al. Low-level light/laser therapy versus photobiomodulation therapy. Photomed Laser
Surg. 2015;33(4):183–4. https://doi.org/10.1089/
pho.2015.9848.
3. Cicchi R, et al. Observation of an improved healing process in supercial skin wounds after irradiation with a blue-LED haemostatic device. J
Biophotonics. 2016;9(6):645–55. https://doi.
org/10.1002/jbio.201500191.
4. Dini V, et al. Blue light emission in the management of hard-to-heal wounds. Ital J Dermatol
Venereol. 2020;155:709. https://doi.org/10.23736/
S0392- 0488.20.06691- 2.
5. Fraccalvieri M, et al. Effectiveness of blue light
photobiomodulation therapy in the treatment
of chronic wounds. Results of the blue light for
ulcer reduction (B.L.U.R.) study. Ital J Dermatol
Venerol. 2021;157(2):187. https://doi.org/10.23736/
S2784- 8671.21.07067- 5.
6. Han G, Ceilley R.Chronic wound healing: a review
of current management and treatments. Adv Ther.
2017;34(3):599–610. https://doi.org/10.1007/
s12325- 017- 0478- y.
7. Khoo VB, et al. Use of blue light in the management of chronic venous ulcer in Asian patients: a
case series. Cureus. 2021;13(9):e17703. https://doi.
org/10.7759/cureus.17703.
8. Nair HK, Bin Sulong MAA.Effects of photobiomodulation with blue light on diabetic foot ulcers: a case
series report. Wounds Asia. 2021;4(3):42–7.
9. Magni G, etal. Blue LED light modulates inammatory inltrate and improves the healing of supercial
wounds. Photodermatol Photoimmunol Photomed.
2019;1:1–3. https://doi.org/10.1111/phpp.12527.
10. Magni M, et al. Experimental study on blue light
interaction with human keloid-derived broblasts.
Biomedicines. 2020;8:573. https://doi.org/10.3390/
biomedicines8120573.
11. Marchelli M, et al. Photobiomodulation with blue
light in non-healing wounds: case series evaluation.
Wounds Int. 2019;10(3):63–7.
12. Moore Z, etal. The prevalence of pressure ulcers in
Europe, what does the European data tell us: a systematic review. J Wound Care. 2019;28:11.
13. Mosti G, Gasperini S. Observations made on three
patients suffering from ulcers of the lower limbs
treated with blue light. Chronic Wound Care Manag
Res. 2018;5:23–38. https://doi.org/10.2147/CWCMR.
S172060.
14. Rastogi A, etal. Long term outcomes after incident
diabetic foot ulcer: multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology
of diabetic foot complications study: epidemiology of
diabetic foot complications study. Diabetes Res Clin
Pract. 2020;162:108113.
15. Rossi F, etal. Photobiomodulation of human broblasts and keratinocytes with blue light: implications
in wound healing. Biomedicines. 2021;9:41. https://
doi.org/10.3390/biomedicines9010041.
16. Shubhangi VA. Chronic leg ulcers: epidemiology, aetiopathogenesis, and management. Ulcers.
2013;9:413604. https://doi.org/10.1155/2013/413604.
17. Vernaci M, Vernaci PP.Contribution of photonic therapies to the healing process of chronic wounds: case
studies. Wounds Int. 2020;11:4.
18. Zhang Y, etal. Global disability burdens of diabetesrelated lower-extremity complications in 1990 and
2016. Diabetes Care. 2020;43(5):964–74.
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17.1 Laser inWound Care
Light Amplication by Stimulated Emission of
Radiation (LASER) is an optoelectronic device
capable of emitting a coherent beam of light,
according to the IUPAC denition. The rst
“maser” was built by Charles Hard Townes, J.P.
Gordon, and H.J. Zeiger at Columbia University
in 1953. The device was similar to a laser, but
concentrated electromagnetic energy in a considerably lower frequency range: It used stimulated
emission to produce microwave amplication
instead of infrared or visible waves. Townes and
colleagues’ maser could only deliver minimal
power, about 10 nW, but Nikolay Basov and
Aleksandr Prokhorov solved the problem by theorizing and developing a “pumping method” with
more than two energy levels [1].
The laser is essentially composed of three
parts: (1) an active medium, that is, a material
(gas, crystal, and liquid) that emits light; (2) a
pumping system, which provides energy to the
active medium; and (3) an optical cavity, or optical resonator, which is a light trap. In the laser,
the active medium is exploited, which has the
ability to emit electromagnetic radiation (photons) when activated. The wavelength of the
emission depends on the active medium. The
E. Ricci (*)
Difcult Wound Healing Unit, Policlinico Monza,
Vercelli, Italia, Italy
active medium, Table17.1, can be gaseous (e.g.,
carbon dioxide and mixture of helium and neon),
liquid (solvents, such as methanol, ethanol, or
ethylene glycol, to which chemical dyes such as
coumarin, rhodamine, and uorescein are added),
or solid (ruby, neodymium, semiconductors,
etc.). The pumping system supplies energy
(through different optical systems of lamps or
electrical stimulation) to the active medium
bringing it to excitation with photon emission.
The emitted radiation is normally concentrated
through an optical cavity with reective inner
walls and a semi-reective exit zone. This last
surface is the only one that allows the beam to
escape, which is subsequently processed and
repositioned through a series of lenses and mirrors to ensure that the resulting beam has the
desired position, concentration, and amplitude.
The spatial and temporal coherence of the laser
beam is related to its main properties: The temporal coherence, that is, the fact that the waves
retain the same phase in time, is related to the
property of lasers to emit beams of radiation in a
very narrow spectral range. It is therefore considered a monochromatic wave. Spatial coherence,
i.e., the fact that the phase difference is constant
between distinct points in a cross section of the
beam, is related to the possibility of having unidirectional and collimated beams, that is, parallel
even over long paths. Laser beams can be focused
on very small areas, even with dimensions of the
order of micrometers, impossible with non-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_17
167
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E. Ricci
Table 17.1 Media types and transmission systems
Media Active medium Delivery system
Solid state • Ruby
• Nd:YAG
• Ho:YAG
• Er:YAG
• Thulium:YAG
Gas • CO
Semiconductors • Diode
Liquid state • Dye Optical ber
Chemical • HF
2
• Argon
• Excimer
• HeNe
Optic ber
Optical ber
Optic ber
Optical ber
Articulated arm
Optic ber
Optic ber
coherent radiation. The unidirectional and coherent emission implies the possibility of reaching a
very high-power density compared to that of traditional light sources. These properties are the
basis of the wide range of applications that laser
devices have had and continue to have in the most
diverse elds. The higher the frequency (therefore the lower the wavelength) of the emitted
waves, the higher the energy produced by the
laser.
Lasers are classied according to the danger
to human health. The classication is carried out
by the manufacturer according to IEC 60825
standards harmonized in the European Union
with CENELEC EN 60825–1 standards. Before
2007, lasers were classied into ve classes (1, 2,
3a, 3b, and 4) depending on power and wavelength, considering that emissions in the visible
band were considered less dangerous thanks to
eyelid reection. The standards currently in force
divide lasers into seven classes [2], introducing
the parameters of:
• Accessible Emission Limit (LEA): The maxi-
mum level of accessible emission allowed in a
particular class.
• Maximum Permissible Exposure (MEP): The
level of laser radiation to which, under ordi-
nary conditions, people can be exposed without suffering harmful effects. MEP levels
represent the maximum level to which the eye
or skin can be exposed without suffering
short- or long-term damage. The MEP from
which the LEA of the different classes of
lasers is normally derived was derived from
the “Guidelines on exposure limits to laser
radiation of wavelengths between 180nm and
1 mm,” which was drawn up by the
International Commission on Non-Ionizing
Radiation Protection (ICNIRP).
• Nominal Optical Hazard Distance (DNRO):
distance from the output aperture where the
intensity or energy per unit area (irradiance or
radiance quantities) is equal to the maximum
exposure allowed to avoid corneal damage
(MEP).
The classication is shown in Table17.2.
Lasers are classied into high and low power.
The rst is generally applied for the removal, cutting, and coagulating of tissues, while the lowpower ones are more commonly applied in the
processes of tissue repair, such as muscle, joint,
nerve, bone, and skin injuries. Lasers are also
characterized by the duration of laser emission—
continuous wave or pulsed laser. A Q-switched
laser is a pulsed laser, which contains a shutterlike device that does not allow the emission of
laser light until opened. Energy is built up in a
Q-switched laser and released by opening the
device to produce a single, intense laser pulse
(Table17.3).
When we talk about lasers in medicine, we
can refer to the subdivision of use and denition
provided by the American FDA, which is shown
here in Table17.4.
The use in our sector can be found in surgical
denitions. In the vulnological eld, we can
dene two principal action: debridement with
ablator laser and biostimulation with LLLT.
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Table 17.2 Classication of lasers according to risk of injury
Class Description and warnings Wavelength
1 Accessible laser radiation is not dangerous. Lasers with emissions higher than
MEP are class 1A when enclosed in an inaccessible housing
1M Accessible laser radiation is harmless under normal conditions of use until there
are optical instruments such as magnifying glasses or binoculars that can
concentrate energy on the cornea. Do not look at the beam directly with
instruments with optical instruments
2 Laser radiation is accessible in the visible spectrum. It is harmless to the eye even
considering that the protection of the eye is normally ensured by defense reactions
including the eyelid reex (about o,25s) even if optical observation devices are
used. Do not observe the beam
2M Like class 2, beam vision can be more dangerous if the observer employs
observation optics within the beam. Do not x the beam or look at it directly
with optical instruments
3R Accessible laser radiation is potentially hazardous, LEA is less than ve times
LEA class 2in the wavelength range of 400 to 700nm, and less than ve times
LEA class 1 for other wavelengths. Avoid direct exposure of the eyes
3 B Accessible laser radiation is normally dangerous for the eyes if exposed at a
distance lower than DNRO and in special cases also for the skin. Exposure to
diffused or reection- dispersed light is usually safe. Avoid exposure to beam
4 Accessible laser radiation is very dangerous for the eyes and dangerous for the
skin. Diffuse radiation can also be dangerous. When using this laser, you can cause
res or explosions. Avoid exposing eyes or skin to direct or diffuse radiation
180nm–1mm
302,5nm–400nm
400nm–700nm
400nm–700nm
180nm–1mm
180nm–1mm
180nm–1mm
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Table 17.3 Classication of lasers by emission time
Continuous
wave (CW)
Single pulsed Lasers generally have pulse durations of a few hundred microseconds to a few milliseconds. This
Single pulsed
q-switched
Repetitively
pulsed
Mode locked Lasers operate as a result of the resonant modes of the optical cavity, which can affect the
Table 17.4 Different uses of lasers in the medical eld, from FDA classication
Cosmetic
surgery
Refractive eye
surgery
Dental
procedures
General surgery Tumor removal, breast surgery, plastic surgery, debridement, and most other surgical procedures
Biostimulation Also called low-level laser therapy (LLLT), cold lasers, soft lasers, or laser acupuncture devices
Lasers operate with a stable average beam power. In most higher-power systems, one is able to
adjust the power. In low-power gas lasers, such as HeNe, the power level is xed by design and
performance degrades with long-term use
mode of operation is sometimes referred to as long pulse or normal mode
Lasers are the result of an intracavity delay (Q-switch cell), which allows the laser media to store a
maximum of potential energy. Then, under optimum gain conditions, emission occurs in single
pulses, typically of 10(−8)-second time domain. These pulses will have high peak powers often in
the range from 10(6) to 10(9) Watts peak
Scanning lasers generally involve the operation of pulsed laser performance operating at a xed (or
variable) pulse rates, which may range from a few pulses per second to as high as 20,000 pulses
per second. The direction of a CW laser can be scanned rapidly using optical scanning systems to
produce the equivalent of a repetitively pulsed output at a given location
characteristics of the output beam. When the phases of different frequency modes are
synchronized, i.e., “locked together,” the different modes will interfere with one another to
generate a beat effect. The result is a laser output, which is observed as regularly spaced pulsations.
Lasers operating in this mode-locked fashion usually produce a train of regularly spaced pulses,
each having a duration of 10(−15) (femto) to 10(−12) (pico) sec. A mode-locked laser can deliver
extremely high peak powers than the same laser operating in the Q-switched mode. These pulses
will have enormous peak powers often in the range from 10(12) Watts peak
Remove tattoos, scars, stretch marks, sunspots, wrinkles, birthmarks, spider veins, or hair
Reshape the cornea in order to correct or improve vision
Endodontic/periodontic procedures, tooth whitening, and oral surgery, cataract removal
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17.2 Debridement Laser
First of all, we can distinguish two types of lasers
depending on the chromophore on which they
act:
• Ablators: Elective chromophore water (CO2,
holmium, and erbium).
• Coagulators: Elective chromophore hemoglobin (argon, krypton, KTP, diodes from 630 to
1500nm, neodymium).
In the literature, there are works that dem-
onstrate the effectiveness of this treatment,
and Hajhosseini [3] reports a reduction in bacterial load and better efficacy than traditional
surgical treatment. Jiang [4] in a randomized
trial of 60 patients with surgical debridement
vs. debridement on laser CO2 reports better
infection control, increased perfusion, and
faster repair in the laser group. The same
results are reported by Guan [5] and Phillips
[6]. In DULCIS 2 [7], using a CO2 scaler on
diabetic foot in 118 patients showed an acceleration of repair times. In vitro, the use of
scalers has demonstrated bactericidal and antibiofilm activity [8, 9].
Ablative lasers are characterized by high precision, high bleeding control, and lower pain than
conventional techniques. Figures17.1, 17.2, and
17.3 show some visual examples of interventions
performed using CO2 laser.
Fig. 17.1 Laser tenotomy
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Fig. 17.2 Removal of malacic bone by laser
Fig. 17.3 Biolm ablation by CO2 Laser
17.3 Biostimulation Lasers
Biostimulation with low-power lasers nds a
wide area of application in different sectors,
especially for pain control, physiotherapy, and
esthetics. The use of what is called low-level
laser therapy (LLLT) in wound care is currently
much discussed.
In the laboratory, various studies report [10,
11] an activity of increasing cellular metabolic
capacities, with a consequent increase in
proliferative capacities, and Besser [11] proposes
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Table 17.5 Results of some reviews from the literature
Authors/years Question mark Conclusions
Flemming 1999
[17]
Flemming 2000
[18]
2005 items [19] Mechanism and
Socorro da Silva
Dias Andrade
2014 [20]
Beckmann 2014
[21]
Percival 2015 [22] Infection and
Saltiel Machado
2017 [23]
Venous ulcers Were not found any evidence of the benet of low-level laser therapy
per se on venous leg ulcer healing
Venous ulcers
(Cochrane database)
efcacy
General evaluation When applied to skin wounds, is able to promote major physiological
Diabetic foot The available studies about LLLT as treatment methods for diabetic
biolm
Pressure sores Signicant results were observed in the use of LLT with a 658nm
Were found no evidence of any benet associated with low-level laser
therapy on venous leg ulcer healing
Future studies should be well-controlled investigations with rational
selection of lasers and treatment parameters. In the absence of such
studies, the literature does not appear to support widespread use of
LLLT in wound healing at this time
effects, such as anti- inammatory resolution, neoangiogenesis,
epithelial and broblast proliferation, collagen synthesis and
deposition, revascularization, and wound contraction
ulcers give positive results and encourage further investigations. In
order to obtain conclusive evidence of low-level laser in treating
diabetic foot ulcers
Efforts must be addressed to standardize phototherapy procedures as
well as to develop suitable invitro and invivo biolm models to test
LLLT efcacy in promoting biolm eradication and wound healing
wavelength, and no evidence was found for the use of wavelengths
above that for the treatment of PU
E. Ricci
its use for the prevention of infections in chronic
lesions. In studies on animal models, Rodrigo
[12] and Posten [13] report an efcacy of LLLT
and Do Nascimento [14] links its effectiveness
by stating that “it is more effective combining
higher intensity with short wavelength or lower
intensity with higher wavelength.” Gong [15]
reports a reduction in green light laser scarring,
and Gupta [16] nds inammation control in a
burn pattern on rats.
LLLT would therefore have a theoretical basis
of high application, but applied studies on
humans are contradictory. Table17.5 shows the
results of some reviews found in the literature; As
can be seen, there are some contradictions and, at
the present time, it is not possible to draw conclusions that give indications of use or conclusive
indications.
The same situation can be observed by analyzing the published studies, out of 11 RCTs
detected in the literature [24–34], only two report
statistically signicant results, and Basavaraj
[30] and Fonseca Santos [33] both studies on diabetic foot, while Saltmarche [26] reports a favorable trend for use. The other eight report no
results.
In the end, currently well-established use of
ablative lasers, especially CO2 that has been more
studied both as a debrider and for the removal of
biolm, has also shown a reduction in repair
times. For LLLT, the main confounders remain
the types of wavelength and the doses to be
administered in addition to the time and frequency of application. This fact could explain the
important difference between experimental work
and clinical application. However, there is an
increasing interest in additional treatments based
on the criteria of physics and therefore there will
probably be an increase in use and available studies in the next years.
References
1. Maiman TH. Stimulated optical radiation in ruby.
Nature. 1960;187:493–4.
2. Norme EN 60825–1 safety of laser products—part
1: equipment classication and requirements (IEC
60825–1:2007).
3. Hajhosseini B, Grace J, Chiou GJ, Dori G, Fukaya
E, Venita Chandra V, Meyer S, Gurtner CG.Er:YAG
laser vs. sharp debridement in management of chronic
wounds: effects on pain and bacterial load. Wound
Repair Regen. 2020;28(1):118–25.
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4. Jiang B, Tang R, Zheng D, Yang Y, Li Y, Yang R, Liu
L, Yan H. Evaluation of the efcacy of Ultrapulsed
CO2 laser in chronic wounds. Lasers Surg Med.
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