We developed a ruby laser system with a handpiece utilizing a “Kaleidoscope (Trade Mark pending)”, to produce a uniform intensity distribution over a square area for the purpose of treatment of nevus. In order to increase its maneuverability, we have improved the design of this handpiece by using a small “Kaleidoscope”, through which a laser beam becomes uniform with a square cross-section and is magnified to a desired area by a lens. By utilizing this handpiece we have been able to realize the following advantages.
(1) Irradiated area is easily adjusted by changing the position of the lens.
(2) A compact “Kaleidoscope” is used to make the handpiece light and comfortable to use.
(3) The “Kaleidoscope” does not contact the patient, so its output surface cannot become contaminated.
(4) Changeable positioning collars each with an irradiation window in a transparent disc allow quick and accurate adjustment of irradiation area and location

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一般的に色素性母斑に対してはレーザー治療の適応でないと言われている. 今回我々は2種類のレーザーを組み合わせ (コンバインド・レーザー), 同時期に照射することにより良好な結果を得られたので報告する.
ノーマルモード・20Jにて照射後, 表皮を用手的に剥離する. 即時的にQスイッチ・7Jにて多重照射 (4, 5回) する, これを3, 4週間ごとに繰り返す治療を行った. 著効30.5%, 有効53.9%, やや有効13.0%, 無効2.6%と従来に比べ高い有効率を示した.

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In cases of nevus spilus, in which the recurrence rate is high following treatment with long pulses of 2msec. alone, the recurrence rate was minimized by additional treatment using short pulses. The high effectiveness of this treatment method has been proven, particularly in cases of late nevus spilus or so-called Becker's nevus. This additional treatment permits cells with the ability to produce melanin relatively deep in the skin to be destroyed, resulting in further improvements in treatment effectiveness. Furthermore, treatment effectiveness was improved by additional laser treatment using short pulses at 10J/cm² within 3 weeks after the first treatment. However, particularly in cases of congenital nevus spilus of youg patients under 20 years of age, favorable results cannot be obtained and the recurrence rate is still high. We must strive to overcome this problem.

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We have used the Q-switched ruby laser in the treatment of pigmented skin lesions since 1991 to treat approximately 2,000 patients out of which more than 1,000 were treated for nevus of Ota. This laser was effective in treating almost all cases of nevus of Ota, ectopic mongolian spot, blue nevus, ephelides and aquired bilateral nevus of Ota-like macules, However, a large degree of variation was observed among individuals when treating pigmented nevus, and the laser was ineffective in some cases despite repeated irradiation of the affected area. Great care should be taken with patients with nevus spilus because reccurence was observed in many cases and sometimes the area actually became darker. It was found that the laser was effective in removing black tattoos, but the treated site was aggravated in many cases where the tattoo was red or yellow.

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A short pulse duration ruby laser with pulse duration of 200-400 microsec, was applied for treatment of nevus spilus. Nine out of twenty three cases of nevus spilus (40%) were effective after one or several shot. Six cases (26%) were not effective after one shot and 8 cases (35%) were not effective even after several shots,although the exanthema became lighter before irradiation. Histlogically the epidermal basal cells were damaged and “craster-like degeneration” was also observed in the incontinent areas in the upper dermis.

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扁平母斑に対するQスイッチ治療の有用性について検討した。
扁平母斑患者37名について, 治療効果の判定を行った結果, 著効14名 (38%), 有効6名 (16%), 無効17名 (46%) で有効率は54%であった。有効率を部位別にみると, 顔面では82%, 頚部では20%, 躯幹では25%, 四肢では36%であった。以上より, 顔面の扁平母斑に対してQスイッチ治療を行うことは, 有用性が高いと考えられる。

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今回, 固定薬疹の6症例の色素沈着斑に, Q-switched ruby laser (QSRL) 照射療法を行って良好な結果を得た. 1-3回のQSRL照射によって全例色素沈着が消失し正常皮膚色になることを確認した. 顔面の皮膚粘膜移行部に生じた固定薬疹後色素沈着の場合, 原因薬剤同定後自然消褪をいたずらに待つこととなりQSRL治療をすみやかに行った方がよいと考えられる. (皮膚, 41: 454-458, 1999)

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73歳，女性。約20年前，左頬部に黒褐色斑が出現した。近医で中央の黒色斑部のみにを照射したところ，一部がびらんとなったため，当科を受診した。上皮化後の臨床所見は，比較的境界明瞭な28×10mmの不整形，濃淡のある黒褐色斑で，レーザーを照射した中央部は，黒色斑と脱色素斑が混在していた。臨床所見および病理組織像からlentigo malignaと診断。治療は，全摘術施行後，インターフェロンβ局注を行った。現在，術後27ヵ月経過したが，再発はない。レーザー照射部の病理組織像では，異型メラノサイトの胞巣は極めて少なかったが，個別性異型メラノサイトは多数認められた。Lentigo malignaに対する照射は，根治的治療には不適当と思われた。

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The ruby laser irradiation causes selectively damages of the cutaneous melanin granules, but the cutaneous histological changes after the irradiation has not been well described. We applied the ruby laser to an excised skin using TOSHIBA Model LRT-301A. in this study, histological examinations were carried out light and electron microscopically. The results revealed as follows; exposure of 9J/cm²: Vacuolated changes were seen on the cells with melanin pigment in the basal layer. 16J/cm²: The vacuolation of cells among the basal cells were observed as elongated and degenerated in shape, The ring-like degeneration showing a crater was seen at the site of incontinentia pigmenti histologica in dermal papilla. 25J/cm²⁾: Diffuse degenerations were seen in the basal layer. Excoriation were most frequently seen at this energy radiated akin. 40J/cm²: Diffuse degenerations were also observed in epidermis and dermal papilla with subepidermal cleft. In patients with seborrheic keratosis, senile pigmentation, nevus pigmentosus and nevus Ohta treated using ruby laser, the almost similarly histological alterations were observed. The study demonstrated that in the therapeutic efficacy of ruby laser on the dermal pigment disorders, the high energy irradiation was not always necessary, because over dose of energy-irradiation was absorbed by epidermal melanin granules (epidermal trap) and the basement membrane was also damaged.

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Nevus spilus is known to have a high recurrence rate following treatment with dermabrasion, cryotherapy or laser irradiation therapy while we have got much highly effect on nevus of Ota. To minimize recurrence, laser treatment was performed using a normal-pulsed ruby laser system (dual pulse width: 240μs~2ms) and Q-switched ruby laser system (pulse width: 30ns). This therapy was revealed to be highly effective as demonstrated by clinical results obtained from 36 clinical cases, and was partically usefull in treating of face and neck. After the epidermis on the treated area had been completely removed with normal-pulsed ruby laser, the addition of short pulse treatment with normal-pulsed ruby laser and more addition of Q-switched ruby laser irradiation improved reducing recurrence rate. The protokol was further improved with additional laser treatment using short pulses of 10J/cm² and Q-switched ruby laser irradiation of 4~7J/cm², 3 weeks after the first irradiation. The efficacy of this treatment protokol was judged excellent or good in 23 out of 36 cases (63.9%).

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編平母斑は組織学的に表皮底層におけるhypermelanosisのみの変化で真皮には病変を認めない為, 皮膚剥削術, 冷凍療法, レーザー療法による治療効果が比較的容易に期待できるものと考えられがちであるが, 実際には再発率が高く治療に難渋することが多い.
われわれは平成2年よりによる扁平母斑の治療を始め, 治療法の検討を行ってきた結果, 以下の照射法をプロトコールにより治療し, 良好な結果を得ることが可能になった-つまり, まずノーマル発振パルス (ノーマルレーザー) による長パルス30～40J/cm2の照射により病変部を表皮剥離の状態とする. そのうえで生じた麋爛面に更にノーマルレーザー短パルス10J/cm2およびQ-Switched (Qレーザー) 4～7J/cmcm2で追加照射をする. 初回治療後3週間目に再発の有無にかかわらずノーマルレーザー短パルス10J/ccm2とQレーザー4～7J/ccm2の照射を行うようにしている. 以上を1クールとし, 6カ月程度の間隔で2クール以上の治療を行う. 再発傾向の強い難治性の病例は未だ存在するが, 以上のプロトコールにて治療することにより再発率を著しく低下させることができ, ほぼ安定した結果が得られるようになってきた.

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In the past several years, Q switched ruby lasers have been found to be effective in the treatment of deep dermal pigmented lesions of the skin, especially Ota's nevus. The recently developed Q-switched ruby laser is already to supersede the conventional therapeutic procedures such as dry ice, skin abrasion or skin grafting treatments, patients who had been treated by those procedures, which are difficult to treat, are also treatable with ruby laser. In those patients, it needs more times of irradiation and it takes about from 2 years to 3 years which requires 1 more year to diminish the lesion completely. However, we have designed a new therapeutic protocol which involves the combined use of both Q-switched and conventional normal-pulsed lasers, exploiting the specific advantages of each type.

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現在扁平母斑とベッカー母斑の治療法としては，Q スイッチ

（Q-Switched Ruby Laser: QSRL）が主流である．我々の施設におけるQSRL 単独の治療成績より，眼窩周囲や頬部に存在しかつ形状が地図状の扁平母斑やベッカー母斑ではある程度の有効率（約60%）が得られることがわかった．しかし，四肢に存在し形状が円形の扁平母斑に対しては，有効率が約20% と低かった．今後さらに治療効果を高めるためには，レーザー複合療法やハイドロキノン外用療法などの維持療法を含めた集学的治療が必要と考えられる．

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扁平母斑に対するレーザー治療は，再発率が高いために治療に難渋している．今回我々は，Qスイッチ

（Q-Switched Ruby Laser；以下QSRL）を用いた扁平母斑に対する治療有効性に影響する因子を検討した．QSRL治療終了3～6カ月後に性別，治療開始年齢，大きさ，臨床形態，照射部位別に治療効果を解析した．性別，治療開始年齢では有効性への影響はみられなかったが，頭頸部発症で，地図状の形をしたものでは高い有効性が得られることがわかった．

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The surgical treatment has been considered to be the first choice treatment for seborrheic keratosis and senile lentigo. It is, however, sometimes difficult to excise the big or multiple lesions simply. In these respects, the ruby laser treatment is advantageous, because it damages selectively the melanin pigments in the epidermis. In this study, the efficacy of the ruby laser radiation on seborrheic keratosis and senile lentigo using Toshiba model LRT-301A was determined. Single radiation of 9 or 16 J/cm2 has been performed for treatment of senile lentigo. On the other hand, following removal of the damaged tissue after one shot for the treatment of seborrheic keratosis radiation of 20 J/cm2, the second shot of same dosege was performed.
Twenty four cases of senile lentigo were treated and 15 cases (63%) were effective in our method. Twenty two cases (79%) out of 28 cases of seborrheic keratosis were also effective. No ulceration nor scar formation was observed in the patients after the treatment. The results revealed that the ruby laser radiationwas regarded as very safe and adequate treatment for these cutaneous lesions.

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By the use of a highly efficient optical system developed by calculation and experiment on a light source for pumping and its light collecting system, a new tandem type ruby laser unit has been devised.
For measuring the laser output, use of a photomultiplier with an interference filter is proposed whereby the peak value in a wide range of wattage and total output energy become measurable.
In normal operation with one head, the measured threshold input energy for laser oscillation is only 75 joules that makes a new record.
From far-field and interference patterns, the coherence of the laser output is determined.
In a light amplification experiment, in which one head with resonator is used as oscillator and the other head without resonator is used as amplifier, gain of 3.8 dB is obtained.

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We have developed new Ruby laser system (TMRL series) for the treatment of hyperpigmented skin lesions, such as pigmented nevus (melanin particle deposition), tattoos and so on. The prototype of this series invented in 1980 included a lens-type applicator, which was attached to the oscillator. In 1981 we developed a kaleidoscope (quartz square pillar), which enables us to obtain a homogenous output energy distribution. In addition, it provides a square area of irradiation. So, we can perform efficient treatment. In 1982 we also succeeded in developing a fiber optic induced system using quartz fibers, first in the world. The fiber manipulator and the handpiece separated from the oscillator assure us of much better handiness. After that we have improved the power supply into a smaller and lighter one and adopted a shorter irradiation interval. In 1987 we commenced delivery of commercial units, model LRT-301A, after obtaining the approval for its manufacture and clinical application from the Ministry of Health and Welfare of Japan. This equipment is characterized by the output energy of 20-40J/cm², pulse width of 2 msec, irradiation interval of 10 sec, irradiated area of 10×10 and 15×15mm, and electrical input of 100V (single phase), 30A, 50/60Hz. We can obtain far better results by ruby laser treatment than by the conventional methods, though we realized its limitation. We are now developing a shorter pulse width in expectation of better selective effects of laser treatment.

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