Are resurfacing lasers safe for patients with Sjögren's (Sjögren's syndrome) syndrome?

Safety of Resurfacing Lasers in Patients with Sjögren's Syndrome

Resurfacing lasers are generally not recommended for patients with Sjögren's syndrome due to the high risk of severe dry eye exacerbation and poor wound healing.

Understanding the Risks

Sjögren's syndrome presents several challenges that make laser resurfacing procedures particularly risky:

1. Compromised Ocular Surface

   • Patients with Sjögren's syndrome already suffer from severe dry eye disease due to autoimmune-mediated lacrimal gland destruction 1
   • The ocular surface is already compromised with decreased tear film stability and increased corneal staining 1

2. Impaired Healing Capacity

   • The inflammatory nature of Sjögren's syndrome affects wound healing throughout the body
   • Skin recovery after ablative procedures may be significantly delayed

3. Risk of Severe Exacerbation

   • Case reports have shown that even less invasive procedures like LASIK can cause severe and refractory dry eye in patients with well-controlled early-stage Sjögren's syndrome 2
   • If LASIK can trigger such reactions, more aggressive ablative resurfacing lasers pose an even greater risk

Types of Resurfacing Lasers and Their Specific Concerns

Ablative Lasers (CO2, Erbium:YAG)

• These create the highest risk due to:
  • Complete removal of the epidermis
  • Significant thermal damage to surrounding tissues
  • Extended healing time (weeks to months)
  • High risk of triggering severe inflammatory response

Non-Ablative Lasers

• While less aggressive, these still pose significant risks:
  • Heat generation can trigger inflammatory cascade
  • May worsen existing dryness of skin and mucous membranes

Fractional Lasers

• Even with smaller treatment zones:
  • Healing is still compromised in Sjögren's patients
  • Risk of prolonged erythema and hyperpigmentation is increased

Evidence-Based Recommendations

The European League Against Rheumatism (EULAR) guidelines for Sjögren's syndrome management emphasize the importance of avoiding procedures that could exacerbate dry eye symptoms 3. While the guidelines don't specifically mention laser resurfacing, they highlight the vulnerability of the ocular surface in these patients.

For patients with Sjögren's syndrome seeking skin rejuvenation:

1. Consider Alternative Treatments

   • Autologous platelet concentrates may offer a safer alternative for facial rejuvenation 1
   • Non-laser based treatments should be prioritized

2. If Laser Treatment is Strongly Desired

   • Perform comprehensive baseline assessment of ocular surface health
   • Measure tear film stability and ocular staining score (OSS) 1
   • Consider prophylactic treatment with:
     • Increased frequency of preservative-free artificial tears
     • Topical cyclosporine A or autologous serum eye drops 1

3. Post-Procedure Management

   • Intensify dry eye management with increased frequency of preservative-free artificial tears 1
   • Close monitoring for signs of ocular surface deterioration
   • Have rescue treatments ready (topical steroids, serum tears)

Special Considerations

• Disease Activity: Patients with active systemic disease (high ESSDAI score) are at even higher risk for complications
• Medication Effects: Immunosuppressive medications may further impair healing
• Anatomic Location: Periocular treatments pose the highest risk due to proximity to the already compromised lacrimal system

Common Pitfalls to Avoid

1. Underestimating Baseline Dryness: Even "well-controlled" Sjögren's patients may have significant underlying ocular surface disease
2. Inadequate Pre-Treatment: Failing to optimize ocular surface health before considering any procedure
3. Insufficient Follow-Up: Not monitoring closely enough for delayed complications
4. Ignoring Early Warning Signs: Dismissing initial symptoms of worsening dryness

The evidence from related procedures like LASIK 2 strongly suggests that even patients with mild, well-controlled Sjögren's syndrome can develop severe, refractory dry eye after procedures that affect the ocular surface or nearby tissues. Given these risks, the safest approach is to avoid resurfacing lasers entirely in this population.