The centers are transforming the lives of patients with disabling and disfiguring skin conditions in Kaiser Permanente Northern California.
December 20, 2024
If you ask dermatologist Akhil Wadhera, MD, about the patients he’s been able to help with the Laser Surgery program he pioneered in The Permanente Medical Group (TPMG), he likely will show you lots of before-and-after photographs of consenting patients, with a moving story about each one. But you can be certain he’ll begin with the patient who started it all — a woman who came into his office in 2011 with a rare, pigmented birthmark called nevus of Ota, which had caused the skin around her left eye to turn a dusky gray-blue color in her early teens. Although the condition typically presents at birth or in the first few years of life, it can also appear in puberty or during pregnancy, and is often mistaken for a bruise.
Akhil Wadhera, MD
“The common story for individuals with this birthmark — one that my clinical staff and I hear from tearful patients all the time — is that people assume they’re being abused,” says Dr. Wadhera, who practices at Kaiser Permanente Union City and Fremont. “This particular patient, who was 31 years old by the time she came to see me, had endured nearly two decades of questions and concern from well-meaning friends, teachers, neighbors, employers, and colleagues about parental and intimate partner violence. Some of these individuals had even called the police to her house to check on her.
“These experiences traumatized her and changed her way of interacting with the world,” Dr. Wadhera continues. “She never left the house without makeup, and she was constantly scanning to see where others were looking, ready to quickly move away from anyone who might ask intrusive questions.”
This patient had been under the impression since her teens in the 1990s that her condition was considered cosmetic, and that treatment would be an out-of-pocket expense. But in the summer of 1999, California’s state legislature enacted a reconstructive surgery statute, mandating health insurance coverage for surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, and disease, with the goal of restoring function or appearance, to the extent possible.
Bringing passion to light
Dr. Wadhera recognized that the patient’s condition fell under the reconstructive surgery statute and referred her for a series of laser treatments, which restored her skin color without any scarring and dramatically improved her quality of life. He then set out to make sure that every member in Kaiser Permanente Northern California who could be helped by laser technology under this statute would get the care they needed.
“My goal was to keep patients within our system for treatment, eliminate any confusion about medical versus cosmetic indications for laser surgery, and help make sure we don’t miss any opportunities to provide prompt, state-of-the-art care,” Dr. Wadhera says.
He delivered on this goal — and then some. Thanks to his dedication and the support of local and regional physician leaders, TPMG built a cutting-edge, regional program that has been providing evidence-based laser surgery to patients with medically indicated conditions for over a decade. Most recently, Dr. Wadhera spearheaded the construction of two dedicated Laser Surgery Centers, the only ones of their kind within Kaiser Permanente nationally. The primary center at Union City, which opened its doors in 2022, has 10 different types of lasers to treat more than 30 medically indicated conditions — from burn scars to vascular malformations — for patients across the region. The second laser center at Rancho Cordova opened last year to further increase access for patients with a debilitating skin disorder called hidradenitis suppurativa, for which Dr. Wadhera helped create a multidisciplinary program of its own.
Brian Missett, MD
“I have an enormous amount of admiration for Dr. Wadhera, who is always looking for the next innovation to deliver better care,” says Brian Missett, MD, TPMG associate executive director. “It was not only his vision, but also his perseverance and commitment to our patients that enabled these programs to be stood up within TPMG. He’s a wonderful example of how we have a path in our organization for developing novel ideas and programs, and bringing our passions to light.”
Visions of an emerging leader
When Dr. Wadhera first proposed the development of a laser surgery program, he did so as a member of the inaugural cohort of the TPMG Emerging Leaders program. Physicians in this selective two-year program are nominated by their medical center’s physician-in-chief. In addition to attending residential sessions taught by business school faculty, participants work with their physician-in-chief to complete a change initiative over the program’s duration.
“At the time, we had an existing regional laser program at Kaiser Permanente Fremont exclusively for port wine stain birthmarks,” says Dr. Wadhera, adding that this program had been launched in the 1990s in compliance with the California reconstructive surgery statute. “Patients with most other types of laser-treatable conditions under this statute, however, were being referred outside Kaiser Permanente.”
Sameer Awsare, MD
This led Dr. Wadhera to wonder, how many patients were being referred out for laser treatments each year? And what was the impact, both on patient experience and cost to the organization? He reached out to Sameer Awsare, MD, TPMG associate executive director who oversees outside referrals, to collect some data. Then, as part of the Emerging Leaders program, Dr. Wadhera gave a presentation to the chiefs of dermatology in 2012, sharing the story of his patient with nevus of Ota, his vision to expand the Port Wine Stain program into a regional Laser Surgery program, and the data to support the need for such a service.
Ngoc Pham, MD
TPMG Chair of Dermatology Ngoc Pham, MD, one of the chiefs in the room at the time, describes the response as unanimously supportive — “without any reservations.”
“We all were moved by Dr. Wadhera’s passion and immediately saw the value for patients and the organization,” says Dr. Pham, who practices at Kaiser Permanente Santa Clara and has served as chair since 2014. “This program would fill clinical and service gaps, as well as a subspecialty niche within dermatology. When you bring in the armamentarium of a laser service, you are augmenting the potential breadth of therapies available to a patient with any particular skin condition.”
Birth of a new service
The program was launched a few months later, with the enthusiastic support of executive and local leadership. Dr. Wadhera worked to establish a subspecialty referral pathway within eConsult for dermatologic laser surgery, and then delivered trainings to educate dermatologists and primary care physicians about the new pathway and appropriate referrals.
Over the next three years, he worked with Dr. Missett to acquire the different types of lasers needed, which were initially housed in the medical and cosmetic dermatology spaces in the Greater Southern Alameda service area. But by 2019, regional demand for the laser surgery service was outpacing space and staffing, especially for patients with hidradenitis suppurativa (HS), for whom laser hair removal can be a lifechanging treatment.
“To better support the HS patient population, and all our patients treated in the laser surgery program, I created a proposal to build dedicated laser centers,” says Dr. Wadhera. (Read “Rays of Hope” at the bottom of this article to learn more about how HS was key in bringing Dr. Wadhera’s vision for regional laser centers to fruition.)
With the support of TPMG executive leaders, including Drs. Missett and Awsare, as well as partnership from Kaiser Foundation Health Plan and Hospitals, he was successful. The Laser Surgery Center at Union City opened its doors two years ago. Dr. Wadhera spends half of his clinic time treating patients there, with the support of several registered nurses, physician assistants, and medical assistants. A second center at Rancho Cordova, which opened a year later with similar staffing, focuses exclusively on patients with HS.
Individualized care by the thousands
In 2022 and 2023 alone, the Laser Surgery Center at Union City delivered more than 4,300 treatments for a variety of medically indicated dermatologic conditions, including birthmarks, vascular malformations, trauma scars, and certain skin conditions. (For a full list, see “What’s Treated at the Laser Center” at left.)
“The excellent care we provide to so many patients would not be possible without my amazing team,” says Dr. Wadhera. “Our nurses Michelle Menezes and Dorothy Laine, and my medical assistant Elizabeth Paradela, have been on this journey with me from the beginning.”
A question Dr. Wadhera receives often is how lasers are able to treat so many different kinds of skin problems. His answer is simple: “the amazing selectivity of laser light.”
For indications such as birthmarks and hair removal, he explains, he uses lasers that target chromophores, which are the molecules in tissue that absorb specific wavelengths of light and reflect visible color.
“We can also titrate the intensity and depth of the laser, so we can treat a problematic area without damaging the overlying normal skin or intervening tissues,” says Dr. Wadhera. “For a vascular lesion like a port wine stain or venous malformation, for example, we can target the red or purple chromophores in the blood vessels that are located several millimeters below the skin.”
For hair removal — such as from a skin graft that had previously been placed inside a patient’s mouth or on the palm — he uses a laser whose target chromophore is melanin.
To treat patients with scarring from severe burns or trauma, who often have restricted movement, Dr. Wadhera uses a different type of laser that works by poking tiny holes in the scarred skin. “The procedure can immediately increase mobility, and as the skin heals, it repairs itself with a different, less restrictive subtype of collagen,” he says.
As an example, he shows a “before” photograph of a patient who couldn’t lift her left arm past her shoulder because her burn scars were so severe. In the photo taken right after the laser procedure, she can extend her arm straight up and bend her elbow across her head.
“To treat this same patient surgically, you would have to take a graft or tissue flap from elsewhere on her body, and then remove the scarred skin from her left arm and place the graft or flap,” Dr. Wadhera explains. “She would then have to do physical therapy and wear a compression garment for several months to years, after which she may see a similar level of improvement in mobility.”
Restoring patients’ self-confidence
Another subset of patients treated at the center have disfiguring or disabling benign tumors, which may be limited to a single growth, or cover large areas of skin on the face, scalp, and body. For many of these patients, Dr. Wadhera uses an erbium or CO2 laser that targets water as a chromophore in the tissue.
“When I fire the laser, it evaporates skin,” he explains. “I keep firing until I get a smooth surface or reach the desired depth.”
Dr. Wadhera (right) and patient Linda Emanuele crossed paths on an airplane two years after he treated her for a disfiguring growth on her nose. “To me, he’s more than a doctor, he’s a miracle worker,” she says. “He gave me my life back.”
For patient Linda Emanuele, this ablative treatment had a huge impact on her quality of life. She came to see Dr. Wadhera in 2022 for a trichoepithelioma, a type of tumor that originates from hair follicles and has a rare risk of malignant transformation. (For patients with certain genetic syndromes, these growths
can cover the entire face.) Ms. Emanuele’s grape-sized tumor was located on the side of her nose, pressing against her nostril. Although it was not yet impeding her breathing, it soon would be.
“My bump, as I called it, was getting larger and larger,” she says. “I tried not to let it get in my way of living a full life, but it affected my self-confidence, and I started avoiding going to social events. I did my best to cover it with masks and large sunglasses — I didn’t want anyone to ask me about it. I delayed going to the doctor for a long time.”
After a biopsy to confirm diagnosis, Dr. Wadhera completed the series of treatments that effectively erased the tumor that Ms. Emanuele had lived with for 20 years. Then in an odd twist of fate, she ran into him on an airplane two years later.
“I was the last passenger to get on a connecting flight on my way home from North Carolina, so I took an open middle seat up front,” Ms. Emanuele said. “After I sat down, the gentleman next to me put his hand on my shoulder and said, ‘Well, Linda, how are you doing?’ I realized, it’s Dr. Wadhera! I was overjoyed to see him — I was hugging him, thanking him — the flight attendant even came over to see what all the fuss was about.
“To me, he’s more than a doctor, he’s a miracle worker. He gave me my life back. I don’t have to hide anymore.”
Making waves into the future
Dr. Wadhera has given presentations at many national dermatologic society meetings, both on the impact of the TPMG Laser Surgery program in general, and on specific cases. One of these will soon be published: a novel case study of a young man whose allergic reaction to the blue ink in his tattoos was causing him to go blind.
“This patient had developed bilateral uveitis and iritis, ocular hypertension, and glaucoma about six months after getting the tattoo,” Dr. Wadhera says, adding that this is an extremely rare late sequela of tattooing, caused by an inflammatory response to certain inks. “The patient had failed the recommended systemic steroid and immunosuppressive treatments, so his TPMG ophthalmologist called me to see if I could help.”
Dr. Wadhera using a laser to treat a patient.
Dr. Wadhera treated the patient with four ablative CO2 laser treatments — stronger than the type of laser typically used to remove tattoos — and specifically targeted the blue ink. The results were unmistakable: The patient’s eye symptoms improved significantly, his vision stabilized, and he got off all immunosuppressive medications. Dr. Wadhera hopes this case study will serve to help others in the future.
In addition to sharing his expertise with colleagues and the broader field of dermatology, Dr. Wadhera teaches medical students and residents from Drexel University, Stanford University, and the University of California, Davis. He also has begun consulting with other Kaiser Permanente regions, including Southern California and Northwest, who are interested in launching laser services of their own. And as the program continues to grow in Kaiser Permanente Northern California, he has plans to add a third laser center in another service area.
When asked if he has any takeaways from all that he’s accomplished, Dr. Wadhera points to the integrated, physician-led organization that made it all possible.
“The Permanente Medical Group is a great place to practice medicine,” he says. “When I joined the medical group, I didn’t know I would be doing any of this work. I just saw an opportunity to improve care and said, how can I help with this? And what I found was supportive physician leadership and colleagues, and a system designed to help me be successful. It was a breath of fresh air.
“My hope is to inspire other people to do similar things in their field of expertise. So I would say to my colleagues, if you have the skill set and passion, say something and do something. It’s possible here.”
This article originally appeared in Permanente Excellence, the magazine for physicians in The Permanente Medical Group.
Rays of Hope
Dr. Dhingra (left), physician-in-chief of the Greater Southern Alameda service area, stands with Dr. Wadhera in front of the Laser Center at KP Union City. “Dr. Wadhera is a true visionary,” he says.
Of all the skin conditions seen by dermatologists, hidradenitis suppurativa (HS) is among the most debilitating. This chronic inflammatory disease causes painful, recurrent boil-like nodules in hair follicles and ranges in severity from mild disease, characterized by a few papules and pustules, to severe cases, presenting with malodourous abscesses, draining skin tunnels, and thick scars. It arises in areas where skin rubs together, most commonly in the underarms, but also the groin, breast, and genital areas. HS is more common in people of color, particularly in Black and Latino populations, who often experience more severe forms of the disease.
“This patient population is highly complex, because of not only the clinical acuity and chronicity of their condition, but also the psychosocial factors, including social isolation and mental health issues,” says Ngoc Pham, MD, chair of dermatology with The Permanente Medical Group (TPMG).
“Patients with HS have the lowest quality of life and highest suicide rates of any skin condition,” adds Akhil Wadhera, MD, dermatologist and director of the TPMG Laser Surgery program. “It primarily impacts young adult patients, and more commonly women. If uncontrolled, HS can cause permanent disability.”
Expanding treatment options
For many years, treatment for patients with HS was limited to topical and systemic medications, such as antibiotics and immunosuppressants, and wide surgical excision of skin tunnels, known as deroofing, for severe cases. However, laser hair removal has been gaining traction, especially in the last decade, as another treatment option for patients with mild-to-moderate disease.
Research shows that the destruction of hair follicles can significantly reduce disease severity, and lead to complete remission in many cases. The treatment also helps speed healing of open sores.
“Laser hair removal is significantly safer and better tolerated than systemic treatments, and it avoids the morbidity and cost burden of biologic medications,” says Dr. Wadhera. “But its use in treating HS is considered off-label by the FDA [Food and Drug Administration], and many health insurance companies deny coverage.”
Within Kaiser Permanente Northern California, however, laser hair removal has been offered to patients with HS since Dr. Wadhera launched the Laser Surgery program in 2012. (Learn more about this program in the article above.)
He explains that as word spread about this safe and effective treatment option, he began seeing a much higher volume of patients with HS. And in hearing all these patients’ stories, he saw an opportunity to enhance their care.
“It became clear that we needed a standardized care pathway, with coordinated multidisciplinary collaboration and increased access to this treatment modality,” Dr. Wadhera explains. Collaborating across specialties Dr. Wadhera engaged the support and thought partnership of Dr. Pham and the chiefs of dermatology in 2019. He then teamed up with a few other TPMG dermatologists with special interest in treating HS, including Barbara Garcia, MD, who practices at Kaiser Permanente Antioch, and Farzam Gorouhi, MD, at Kaiser Permanente South Sacramento. Together they developed an evidence-based treatment algorithm for dermatologists to use at each stage of the disease — Hurley stages I, II, and III — with escalating treatment options for each one.
Dr. Wadhera and the team also collaborated with physician leaders from every specialty involved in the care of HS patients, including colorectal surgery, general surgery, gynecology, infectious diseases, plastic surgery, urology, wound care, and pharmacy. Together, they defined when and how each service line would get involved.
“The patient enters this longitudinal care path with us — the dermatologists — first,” says Dr. Pham. “We own their care. But if a patient is not responding to our standard therapy or if their care requires the involvement of other disciplines, then we engage the right specialists to escalate it.”
To that end, Dr. Wadhera developed two case conferences. The first is a monthly complex HS case conference, led by him and four other dermatologists who have a special interest in HS.
“The five of us stay abreast of all the latest therapeutics, technology, and data, so that we can advise our dermatology colleagues on challenging HS cases,” says Dr. Wadhera. “This helps us provide state-of-the-art care, spread expertise across the region, and ensure patients’ disease is managed in the most efficient and safe manner.”
The second case conference is multidisciplinary, comprising the dermatology HS team and members of the other specialties previously mentioned. They meet every other month to develop coordinated treatment plans for patients with the most complex or severe disease.
Passion meets persistence
But Dr. Wadhera wasn’t finished yet. After completing this work, he set out to increase access to laser hair removal (LHR) for patients with HS by building dedicated laser centers in Kaiser Permanente Northern California. Dr. Wadhera conducted extensive research to illustrate the value to patients and the organization, including an internal study on the effect of LHR on pharmaceutical prescribing in Kaiser Permanente Northern California. He found that 57% of patients treated with LHR as a first-line therapy between 2015 and 2019 never progressed to biologic medications. Of patients who received treatment with both LHR and biologics during the same time period, 52% of them were deprescribed the medications after laser treatment.
He also investigated the prevalence of HS in Kaiser Permanente Northern California and found it had more than doubled between 2013 and 2021 — with the use of biologic medications increasing in tandem. (This growth in disease prevalence is consistent with national trends — a result, in part, of greater awareness of the disease, improved diagnostics, and more HS research.)
Dr. Wadhera presented his findings and proposal for the centers to TPMG Associate Executive Directors Brian Missett, MD, and Sameer Awsare, MD, who got behind the work without hesitation.
“In The Permanente Medical Group, we are committed to equitable, inclusive care, and we put our patients first,” says Dr. Awsare. “We look at the evidence, and we do what is right and clinically correct.”
Dr. Missett agrees. “This cutting-edge technology saves patients from having to take a number of pharmaceuticals, which have a range of associated side effects,” he says. “It’s simply better care.”
Changing the care paradigm
Dr. Missett helped secure the capital to build and staff the first Laser Surgery Center at Kaiser Permanente Union City, which offers the laser technology to treat not only HS, but also the more than 30 other skin conditions within the Laser Surgery program. Local leaders, including Kapil Dhingra, MD, physician-in-chief of the Greater Southern Alameda service area, were also essential in advancing the project and securing the physical space. Dr. Awsare was instrumental in engaging support from pharmacy leaders and executives in Kaiser Foundation Health Plan and Hospitals to help build the second center, which opened at Rancho Cordova in 2023 and exclusively treats patients with HS.
Thanks to these centers, Dr. Wadhera is now also able to offer laser-assisted deroofing for HS patients with severe disease. This technique has lower recurrence and complication rates compared to surgical deroofing with primary closure. He also trained dermatologist Sarah Truong, MD, who oversees care at the Rancho Cordova center, to conduct it.
“Dr. Wadhera is a true visionary,” says Dr. Dhingra. “He took an idea from concept to reality, such that today every Kaiser Permanente Northern California member has access to world-class care for difficult-to-treat skin conditions like hidradenitis suppurativa. The centers are helping us close equity gaps, and they exemplify the center of excellence model, in which we consolidate for volume and expertise.”
Dr. Wadhera has presented the HS work at dermatology conferences across the country — and may well soon be helping change the care paradigm nationwide. He says that this past summer at the Pacific Dermatologic Association conference in San Francisco, “several national experts came up to me afterwards and said, ‘Please publish your data so that other insurance companies will start covering laser hair removal for HS.’
“It will take a little more time,” he told them, but “we’re working on it.” He’s also teaming up with a fellow HS physician expert at the University of North Carolina, Chapel Hill, to conduct a national survey of dermatologists about using laser hair removal for HS, to further add to the body of literature. And next year, he will be presenting our innovative HS work at the annual American Academy of Dermatology conference in Orlando.
“Dr. Wadhera simply doesn’t give up on doing the right thing for patients,” says Dr. Missett. “And simultaneously, he’s laid out a model path for how we might roll out other new programs for similar-size patient populations in TPMG.”
This article originally appeared in Permanente Excellence, the magazine for physicians in The Permanente Medical Group.
