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Core of Knowledge official syllabus

Approved by British Medical Laser Association, Institute of Physics and Engineering in Medicine, Society for Radiological Protection. December 2013.

Core of Knowledge syllabus

Core of Knowledge represents a body of knowledge that underpins the safe use of lasers in clinical practice. It is intended to be undertaken by all staff using laser (class 3 and 4) and non‐laser (IPL and LED) light sources in a range of applications, including medical, surgical, dental and aesthetic practices. Its aim is to provide users with an understanding of the basic principles of laser safety. It is essential that Core of Knowledge is supplemented by additional training in specific applications. Although exact content may differ slightly, the following syllabus is considered to be the minimum course content that may be covered by training centres. Course duration should total at least 3 hours.

After attending the course, each participant should understand:

  • Basic principles of laser generation and review of laser/IPL technology
  • Laser hazard classification
  • Meaning of associated warning labels
  • Principles of quality assurance
  • Emission characteristics of different types of equipment
  • Laser‐tissue interaction mechanisms
  • Penetration of light of different wavelengths through skin and eye
  • Dangers of central versus peripheral retinal damage
  • Hazards to eye and skin from accidental exposure
  • The concept of Maximum Permissible Exposure and Nominal Ocular Hazard Distance
  • Principles of risk assessment
  • Laser safety management including the role of the Laser Protection Adviser, Laser Protection Supervisor, Local Rules and Controlled Area
  • Risks associated with accidental reflections
  • Personal protection measures including eye protection
  • Hazards to the patient, e.g. endotracheal tube ignition
  • Incidental hazards, including electrical, fire explosion and plume emission
  • Relevant legislation, standards and guidelines
  • How to deal with an adverse event or accidental exposure

Course organisers should issue an attendance certificate and keep a record of attendees for a minimum of 5 years. There is merit in performing an assessment of understanding.
It is good practice for individuals to re‐attend Core of Knowledge courses every 5 years, or sooner following an extended absence or if there have been significant changes to equipment or practices affecting the individual.
It is recommended that the course should be approved by a recognised body such as the British Medical Laser Association.
It is the responsibility of the employer to ensure that adequate measures, including training, are in place to ensure safe use of lasers and IPL devices.

Laser/IPL Safety Awareness official syllabus

Approved by British Medical Laser Association, Institute of Physics and Engineering in Medicine, Society for Radiological Protection. December 2013.

Laser/IPL Safety Awareness

The ‘Core of Knowledge’ is intended for all staff using laser (class 3 and 4) and non‐laser (IPL and LED) light sources in a range of applications, including medical, surgical, dental and aesthetic practices. Other staff present during laser or IPL use (e.g. nursing staff, Theatre Assistants, trainees) should have a basic understanding of the risks they may face and how they can be prevented. The aim of Basic Laser/IPL Safety Training is to provide those staff groups with an understanding of the key principles of laser/IPL safety. It is essential that the training is supplemented by additional training in specific applications. Although exact content may differ slightly, the following syllabus is considered to be the minimum course content that may be covered by training centres. Course duration should be at least 1 hour.

After attending the course, each participant should have a basic understanding of the following:

  • Laser safety management including the role of the Laser Protection Adviser, Laser Protection
  • Supervisor, Local Rules, Controlled Area, Hazard Distance
  • Emission characteristics of laser and IPL equipment
  • Penetration of light of different wavelengths through skin and eye
  • Dangers of central versus peripheral retinal damage
  • Hazards to eye and skin from accidental exposure
  • Risks associated with accidental reflections
  • Personal protection measures including eye protection
  • Hazards to the patient, e.g. endotracheal tube ignition
  • Incidental hazards, including electrical, fire, explosion and plume emission
  • How to deal with an adverse event or accidental exposure

Course organisers should issue an attendance certificate and keep a record of attendees for a minimum of 5 years.
It is good practice for individuals to re‐attend Basic Laser/IPL Safety Training courses every 5 years, or sooner following an extended absence or if there have been significant changes to equipment or practices affecting the individual.
It is recommended that the course should be approved by a recognised body such as the British Medical Laser Association.
It is the responsibility of the employer to ensure that adequate measures, including training, are in place to ensure safe use of lasers and IPL devices.



BMLA Guidance on Drugs and Lasers/IPLs

Guidance provided by the British Medical Laser Association

Issued November 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 20091. 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 localised PDT5, e.g. Ameluz, Metvix.

2. Other drugs that may cause Photosensitivity
Any treatment should be performed with caution. Test 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 photosensitivity6,7.

b. Minocycline (Minocin) – risk of hyperpigmentation8. Recommend stopping 4 weeks prior to treatment or consider change to 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 include: isotretinoin (Roaccutane), acitretin (Neotigason), alitretinoin (Toctino)

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

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Medical Laser Pointers

Laser devices, which emit a potentially harmful laser beam, are now widely available to the general public. They are generally sold as laser pointers or laser keychains and are labelled as emitting 5 mW of laser power. According to the American National Standards Institute classification, they are Class 3A products and protection is afforded by the aversion response (including the blink reflex). However, it is the International Electrotechnical Committee (IEC) classification which applies in Europe, and this has an additional restriction. In the United Kingdom and the rest of Europe, for a Class 3A laser the irradiance should be less than 25 W/m2 averaged through a 7 mm diameter pupil. A quick calculation shows that, if the beam is less than 7 mm in diameter, then the laser output power should be no more than 1 mW (which is the Class 2 limit). This is the usual sort of laser pointer, which is in widespread use. A 5mW laser keychain is a Class 3B device, according to European classification. These devices are potentially hazardous and should only be used by persons who have received appropriate training.

During laser treatment of retinal abnormalities, permanent lesions are produced by focusing a laser beam of some 100 mW for 100 msec on to the retina. With a 5 mW beam, the exposure time required to achieve the same energy input will be 2 seconds. Since the eye is not held steady and there is no artificial focusing, the retinal spot size will be larger and so the time to achieve the same energy density will be longer than 2 seconds when using a laser keychain. However, it is quite possible that coagulation will occur after several seconds exposure. By contrast exposure to a 1 mW laser beam is unlikely to produce a thermal lesion because there is insufficient power to raise the temperature of the retina.

The normal aversion response takes about 0.25 sec but it is possible to force oneself to look longer into a bright beam. School children are playing a dangerous game of chicken to see how long they can stare into these laser beams. This means that the normal aversion response may not be assumed, and may not provide adequate protection.

Laser devices emitting more than 1 mW of laser power are potentially dangerous. Class 3B lasers should not be available to the general public, and incorrectly labelled Class 3A devices should be withdrawn from the market. Health professionals should be alerted to the problem, and the public should know that laser pointers and keychains are not playthings.

Harry Moseley(1),(2) and Charles McGhee(3)
The Photobiology Unit(1), Medical Physics Department(2), Eye
Department(3), University of Dundee
Ninewells Hospital & Medical School
Dundee DD1 9SY, United Kingdom
e-mail: H.Moseley@dundee.ac.uk
Tel: 01382 632240
Fax: 01382 646047

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All opinions expressed in the article are the author’s alone and not necessarily those of the BMLA, nor should this be taken as an endorsement by the BMLA.



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