Aesthetic Applications of Intense Pulsed Light

Aesthetic Applications of Intense Pulsed Light

Lucian Fodor  •  Yehuda Ullmann Monica Elman

Aesthetic Applications of Intense Pulsed Light

Authors Dr. Lucian Fodor Department of Plastic Surgery Rambam Health Care Campus Haifa, Israel

Dr. Monica Elman Maccabbi Insurance Tel Aviv, Israel

Dr. Yehuda Ullmann Department of Plastic Surgery Rambam Health Care Campus Haifa, Israel

ISBN  978-1-84996-455-5 e-ISBN  978-1-84996-456-2 DOI: 10.1007/978-1-84996-456-2 Springer London Dordrecht Heidelberg New York British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2010937624 © Springer-Verlag London Limited 2011 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Cover design: eStudioCalamar, Figueres/Berlin Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

There is a steady increase in aesthetic procedures nowadays. Many patients desire a minimally invasive procedure with long-lasting results. The Intense Pulsed Light (IPL) technology has proved to be of real benefit in satisfying patient demands. The main advantages of this noninvasive technology are the minimal recovery downtime, fast and easy performance and long-term improvement. The field of light therapy has grown and the literature must reflect the advancement and direction of the light field. However, not much has been written about IPL applications. This book is written in a format to allow not only physicians dealing with IPL cosmetic procedures but also mid-level providers to understand and perform this treatment. The topics covered in this book are the main cosmetic applications of IPL. The book is structured around nine chapters. Skin anatomy. This chapter describes the pertinent anatomy related to IPL applications. In addition to the main structural elements of the skin described, the chapter contains important points about skin aging and histological aspects which can help the reader to a better understanding of the etiology of skin lesions and the need for IPL treatment. Light-tissue interaction. This chapter describes the interaction between IPL and different skin structures. Target skin structures (chromophores) are described in detail. The results of this interaction are described as being important to understanding the goals and principles of treatment. IPL safety and legal issues. This chapter describes the needs of the environment for a safe treatment. The necessary equipment and how to avoid pitfalls which may lead to lawsuits are described. Several aspects of IPL legal issues are also discussed: how to avoid medical liabilities and how to manage them are also included in this chapter. How to organize the IPL treatment room. This is a very important aspect since “the action” takes place in this setting. This topic describes the necessary equipment for performing the treatment; the possibilities of acquiring the equipment, and how to arrange the room. The room can be a “mess” or a friendly working environment when all the tools are available and ready to use. Patient selection. This chapter is unique and describes the pearls and pitfalls in selecting patients for IPL treatment. This is not an easy task, and proper patient selection is extremely important to have satisfied patients. Problematic patient types are also described here. Skin rejuvenation. This chapter starts with a description of skin aging. Intrinsic and extrinsic mechanisms are detailed. The most common skin lesions related to aging that can benefit from IPL treatment for rejuvenation are detailed. The chapter

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Preface

continues with treatment protocols which describe strategies for achieving optimal results. A review of the literature is included, presenting the treatment parameters of different studies and their results. Hair removal. This chapter starts with a description of the hair follicle cycle, hair types and important structures for treatment. Treatment strategies are emphasized and detailed, starting from choosing the right parameters to post-treatment recommendations. A literature review is presented regarding treatment parameters and results according to various authors. Vascular lesions treatment. This chapter describes the types of vascular lesions that can benefit from IPL treatment. The treatment protocol is emphasized and describes in detail all the steps for performing this application. A literature review is presented and different results are compared regarding treatment parameters. Complications. It is inevitable that complications can result from any medical treatment. The possible complications of the most common IPL applications (skin rejuvenation, hair removal, pigmented and vascular lesion treatment) are detailed. How to avoid them and how to handle them is also described. The practical points section ends each chapter and emphasizes the most important factors for achieving the best results. The goal of this manuscript is to provide an up-to-date book which will help clinicians, residents, fellows and mid-level providers to understand IPL and perform treatments for various cutaneous conditions. The way it is written, the in-depth analysis, and the practical approach make this text a useful reference and a teaching instrument for both beginner and experienced physician in the field of aesthetic medicine. Lucian Fodor, M.D. Yehuda Ullmann, M.D. Monica Elman, M.D.

Acknowledgements

I have learned life experience and medicine from many excellent doctors, but first place among them belongs to Yehuda Ullmann, not only my teacher and a co-editor of this book, but also a sincere friend. Because I cannot repay him for all that he has given me, with this book I share my experience with beginners in this field of medicine. Lucian Fodor, MD The editors would like to thank Myrna Perlmutter for her help in the preparation of the manuscript. Grant Weston, Cate Rogers and the other people at Springer Publisher have been patient, helpful and very professional. We are deeply grateful to Carmen Ciplea and Alina Vesa for the quality of diagrams and pictures. A special thanks goes to Adriana Fodor who was very helpful and typed the original manuscript. Dr. Yoram Levi was always a great supporter of this book. Lucian Fodor, MD Yehuda Ullmann, MD Monica Elman, MD



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Contents

1

Skin Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

2

Light Tissue Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

3

Intense Pulsed Light Safety: Legal Issues . . . . . . . . . . . . . . . . . . . . . . . .

21

4

How to Organize the IPL Treatment Room . . . . . . . . . . . . . . . . . . . . . .

27

5

Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31

6

Skin Photorejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37

7

Hair Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

61

8

IPL Treatment for Vascular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79

9

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131



ix

List of Abbreviations

ALA AM AVF BDD CLM CM EMR IPL MAL PpIX PTD PWS TRT VM VPL



5-aminolevulinic acid Arterial malformations Arteriovenous fistula Body dysmorphic disorder Capillary lymphatic malformation Capillary malformations Electromagnetic radiation Intense pulsed light Methyl aminolevulinate Protoporphyrin IX Photodynamic therapy Port-wine stains Thermal relaxation time Venous malformations Variable pulsed light

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1

Skin Anatomy

Contents 1.1 Epidermis................................................................ 1.1.1 Keratinocytes............................................................ 1.1.2 Melanocytes.............................................................. 1.1.3 Langerhans Cells......................................................

2 2 2 2

1.2 Dermoepidermal Junction.....................................

2

1.3 Epidermal Appendages.......................................... 1.3.1 Eccrine Sweat Glands............................................... 1.3.2 Appocrine Glands..................................................... 1.3.3 Hair Follicles............................................................

2 2 3 4

1.4 Dermis...................................................................... 1.4.1 Collagen Fibers......................................................... 1.4.2 Elastin Fibers............................................................ 1.4.3 Ground Substance..................................................... 1.4.4 Dermal Muscle Cells................................................ 1.4.5 Aging and Skin Structure Changes...........................

5 5 5 6 6 6

1.5 Blood Vessels........................................................... 1.5.1 Aging and Cutaneous Vasculature............................

6 7

1.6 Dermal Lymphatics................................................

8

1.7 Nerves and Sense Organs.......................................

8

References............................................................................

9

Abstract The skin is composed of three layers: epidermis, dermis and subcutaneous tissue. The thickness of the layers varies with different anatomical regions. The epidermis is thickest on the palm and soles, and very thin on the eyelids, while the dermis is thickest on the back. Keratinocytes are the main component of the epidermis. Melanocytes are the cells located in the epidermis whose function it is to produce pigment. The ratio is about one in every ten basal keratinocytes. Differences in skin color according to race are explained by the number of melanosomes. Langerhans cells represent 3–5% of the cells of the stratum spinosum where they are situated between the keratinocytes. The dermis consists of a supporting matrix (ground substances) in which polysaccharides and proteins act to produce proteoglycans. The protein fibers inside the dermis are represented by collagen, elastin and other components, such as fibrillin and microfibril proteins. The blood supply to the skin comes from the deep plexuses located at the fascia and subcutaneous level. With aging, there is a decrease in total collagen content in the skin, an increased amount of type III collagen, decreased number and diameter of elastin fibers, and a lack of interaction between water and surrounding molecules which contribute to the dry and wrinkled aspect.

The skin is composed of three layers: epidermis, dermis and subcutaneous tissue. The epidermis is the outer layer and is formed mainly by keratinocytes whose main function is to synthesize keratin. The ­dermis is the middle layer and its main component is collagen. This layer lies on lobules of lipocytes. The thickness of the layers varies with different anatomical regions. The epidermis is thickest on the palm and soles, and very thin on the eyelids, while the dermis is thickest on the back. L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_1, © Springer-Verlag London Limited 2011

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1.1 Epidermis The epidermis is the outer part of the skin and is composed of three basic cell types: keratinocytes, melanocytes and Langerhans cells. Merkel cells can be found on the palms and soles and are located directly above the basal membrane.

1.1.1 Keratinocytes Keratinocytes are the main component of the epidermis. Their function is to produce keratin, a complex filamentous protein that forms the stratum corneum of the epidermis. The epidermis is composed of several layers, beginning with the innermost as follows: basal layer, malpighian layer, granular layer and horny layers (stratum corneum). The palms and soles have also a clear layer called stratum lucidum (above the granular layer). The horny layer and granular layer are the thickest on the palms and soles and are almost absent on the flexor aspect of the forearms. Cycling stem cells, located at the basal layer, provide a pool for epidermal regeneration. As the basal cells divide, they flatten and move upward (Wolff and Wolff-Schreiner 1976). The process of desquamation implies degradation of the lamellated lipid from the intercellular space and loss of desmosomal interconnections. The keratinocytes play an important role in the immune function of the skin.

1.1.2 Melanocytes Melanocytes are the cells located in the epidermis whose function it is to produce pigment. The ratio is about one in every ten basal keratinocytes. The face and genitalia have a greater amount of these cells. The melanocyte cell is a dendritic type, extending for long distances within the epidermis and in close contact with the keratinocytes. Together they form the “epidermal melanin unit”. Melanin is synthetized by melanocytes in the basal layer of the epidermis and transferred to surrounding keratinocytes in melanosomes. Differences in skin color according to race is explained by the number of melanosomes. People with fair skin have fewer melanosomes which are smaller and packaged within

1  Skin Anatomy

membrane complexes. People with darker skin have more melanosomes which are larger and not packed. Sun exposure (Fig 1.1a, b) stimulates melanocytes to produce larger melanosomes (Cochran 1970).

1.1.3 Langerhans Cells Langerhans cells represent 3–5% of the cells of the stratum spinosum where they are situated between the keratinocytes. They are responsible for the immunological response of the skin.

1.2 Dermoepidermal Junction The dermoepidermal junction represents the junction between the epidermis and the dermis. It is located at the basement membrane zone and resembles a semipermeable filter which allows cells and fluids to travel between epidermis and dermis (Briggaman and Wheeler 1975). It also serves as a structural support for the epidermis.

1.3 Epidermal Appendages The eccrine and appocrine glands, ducts and pilosebaceous units constitute the skin adnexa. All have a role in epidermis regeneration (reepithelization). When an injury occurs, the keratinocytes from the adnexa migrate to the skin surface (Kollar 1970).

1.3.1 Eccrine Sweat Glands These glands have three main components: • The intraepidermal spinal ducts which open directly onto the skin surface • The straight dermal portion of the duct composed of cuboidal epithelial cells • The secretory zone located in the superficial panniculus. In the back region, this zone is situated in the deep dermis

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1.3  Epidermal Appendages Fig. 1.1  (a) Significant photoaging and numerous lentigines prior to treatment. (b) Eight weeks after a single IPL treatment

a

b

The role of these glands is also to produce sweat which is similar in composition to plasma with regard to the electrolytes. They are important in thermoregulatory function and are present in great amounts in the palms, soles and axillae. Some eccrine glands from the axillae have widely dilated secretory coils in patients with hyperhidrosis.

1.3.2 Appocrine Glands Appocrine glands develop on the infundibular upper portion of the hair follicle. They are intimally related to the pilar units. The coiled secretory gland is present at the junction of the dermis and subcutaneous fat. Appocrine secretion is odorless and episodic.

4

1  Skin Anatomy

The appocrine units of the human body are generally confined to the axillae, areolae, genital region, ear canal and eyelids. The glands start to function after puberty.

1.3.3 Hair Follicles Hair follicles develop in rows of three. Primary follicles are surrounded by the appearance of two secondary follicles. The amount of pilosebaceous units decreases throughout life mainly because of poor formation of secondary follicles. The hair follicle has three main components: • The lower part beginning at the base of the follicle and extending to the insertion of the arrector pili muscle • The middle portion, also called the isthmus, from the arrector pili to the entrance of the sebaceous duct • The upper part, called the infundibulum, extends to the follicular orifice The lower part of the hair follicle is also subdivided into five components: the dermal hair papilla; the hair matrix; the hair; the inner root sheath and the outer

a

Fig. 1.2  (a) Coarse hair in the axilla prior to IPL treatment. (b) One year after six treatments

root sheath. The formation of the hair starts at the level of bulb, from the pluripotential cells. The melanin produced by the melanocytes is incorporated into the cells of the future hair through phagocytosis. At the level of the isthmus, the outer root sheath is no longer covered by the inner root. The outer root undergoes keratinization. The bulge cells posses stem cell properties, having the proliferative capacity to regenerate not only hair follicles but also sebaceous glands and epidermis (Ohyama 2007). The rate of hair growth depends on the mitotic activity of the cells of the bulb matrix. Hair growth is a cycle having three phases: anagen, catagen and telogen. The histological aspect of the hair follicle is different for each of the phases. The anagen is the growth phase, the catagen represents the regression phase, and the telogen is the rest phase. The hair follicle is the most susceptible to IPL treatment during the anagen phase (Fig. 1.2a, b). During the anagen phase, the stem cells differentiate into eight different cell types (Krause and Foitzik 2006). From the bulge area, the stem cells ascend into the outer root sheath. Those which reach the hair germ transform into matrix keratinocytes to rebuild the hair shaft (Panteleyev et al. 2001). The pigmentation and hair shaft synthesis take place in this phase. Three types of melanosomes are present in the hair. The erytomelanin granules are seen in red hair while the pheomelanin granules are found in blond and

b

5

1.4  Dermis

dark hair. In dark hair there are more melanosomes than in light hair. In white or grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes (Slominski and Paus 1993). Melanin synthesis and pigment transfer to bulb keratinocytes depends on the precursors and their regulation is receptor dependent (Slominski et al. 2005). The transition from the anagen to the catagen phase varies from one skin region to another (Alonso and Fuchs 2006). There are several molecular regulators of this transition (Andl et al. 2004; Alonso and Fuchs 2006). The catagen phase consists of involution of the hair follicle, apoptosis and terminal differentiation. The first sign of catagen is the cessation of melanin production in the hair bulb. As the lower follicle recedes, a temporary structure, called the “epithelial strand”, forms and is considered to be unique to this phase. After the catagen phase, the hair follicles enter into the telogen phase. In this phase, the follicle has a depigmented proximal hair shaft called “club hair”. This club hair most often remains in the hair canal. The transition from telogen to anagen occurs when a few stem cells at the base of the follicle near the ­dermal papilla are activated (Blanpain et  al. 2004). The new follicle takes place adjacent to the old pocket. The hair cycle is a process influenced by many mediators and receptors (Stenn and Paus 2001). The same author (Stenn and Paus 1999) suggested an inhibitiondisinhibition system that has the epithelial stem cells from the bulge region as the central pacemaker. It seems that the hair cycle clock is located in the dermal papilla (Krause and Foitzik 2006). The hair follicle has a strong influence on skin biology and plays an important role in the reparative process, especially in the outer root sheath which provides epithelial cells to cover wounds (Eisen et  al. 1955; Lenoir et al. 1988). The hair follicle has regenerative proprieties also. It has the ability to regenerate itself with the initiation of each cycle. The regenerative potential is demonstrated after massive damage during chemotherapy treatment (Maurer et  al. 1997). It has been shown that the hair follicle influences the angiogenesis process (Stenn et al. 1988). The dermis in the proximity of anagen follicles is more vascularized than that around telogen follicles. Blood vessel changes in the skin during the hair cycle are also controlled by the follicle.

1.4 Dermis The dermis consists of a supporting matrix (ground substances) in which polysaccharides and proteins act to produce proteoglycans. The protein fibers inside the dermis are represented by collagen, elastin and other components, such as fibrillin and microfibril proteins.

1.4.1 Collagen Fibers The collagen fibers within the dermis are 2–15µm wide (Ottani et al. 2001). The thin, finely woven meshwork of collagen fibers is found in the papillary dermis. The collagen fibril diameter increases progressively with the depth of the dermis. The rest of the dermis, called the reticular dermis, has collagen fibers united into thick bundles. This part is composed primarily of type I collagen. There are several types of collagen (Stenn 1979). Type I collagen is predominant in the postfetal skin. Type III is found mainly in reticular fibers and is prevalent in early fetal life. In postfetal life, it is mainly located in the subepidermal area. Type IV collagen is present in the basement membrane. The fetus has predominantly type III collagen while the skin of the adult contains mainly type I collagen. Collagen is primarily responsible for the skin’s tensile strength. In young adults, collagen from the papillary dermis is organized as a meshwork of randomly oriented thin fibers and small bundles (Lavker et al. 1987).

1.4.2 Elastin Fibers Elastin fibers are mixed collections of various distinctive glycoproteins which have a microfibrilare structure. They are thin in comparison with collagen bundles and measure from 1–3µm. The fibers are thickest in the lower portion of the dermis. At the level of the papillary dermis, they form an intermediate plexus of thinner elaunin (Hashimoto and DiBella 1967). During life, the elastic fibers undergo significant changes. In young children, the fibers are not fully mature, so the microfibrils predominate. With aging, there is gradual decrease in the number of peripheral

6

microfibrils and the surface of elastic fibers appears irregular and granular. In very old people, some elastin fibers undergo fragmentation and disintegration.

1.4.3 Ground Substance The ground substance is an amorphous structure present between the collagen fibers and the collagen bundles. It consists of glycosaminoglycans and mucopolysaccharides (Ruoslahti 1989). In healing wounds, the ground substance contains sulfated and nonsulfated acid muco­ polysaccharides.

1.4.4 Dermal Muscle Cells Smooth muscles are present as arrectores pilorum in the tunica dartes of the external genitalia and in the areolae of the breast. The muscle fibers of the arrectores pilorum start in the connective tissue and insert in the hair follicle in an obtuse angle below the sebaceous glands. By contraction, they pull the hair follicle into a vertical position. Aggregates of smooth muscle cells are present between the arterioles and the venules. They are called “glomus bodies” and serve to shunt blood from the arterioles to the venules. Most are located in the digits. Striated muscles are present in the skin of the neck as platysma and the skin of the face (superficial face muscles of expression). Their origin is the fascia or periostum and travel through the subcutaneous tissue into the lower dermis.

1.4.5 Aging and Skin Structure Changes Skin, like any other organ, undergoes alterations with aging. Several changes have been proved. The collagen matrix starts to defragment although the ­cross-links prevent complete removal of collagen fragments. The fragments cannot be incorporated into new collagen fibrils and cause defects in the collagen matrix (Vater et al. 1979). The fibroblasts cannot attach to the fragmented collagen and the loss of attachments leads to collapse. This will produce less collagen and more collagen-degrading enzymes (Fisher et  al. 1997). In

1  Skin Anatomy

aged skin, the collagen networks appear to be increased but this is due to adherence to ground substance (Lavker et al. 1987). Increased age is associated with decreased collagen content and straightening of collagen fibers organized in loose bundles. There is also an increase of type III collagen observed mainly in subjects over the age of 70 (Waller and Maibach 2006). The elastin component starts to show degradation of fibers, resulting in decreased number and diameter (Fig. 1.3a, b). In photoexposed areas, there is an increase in abnormal elastin which is predominantly localized in the upper dermis (Bernstein et al. 1994). Increasing age does not alter the water structure of the skin (Gniadecka et  al. 1998). However, there is an increase in total water content in photoaged skin. This is paradoxical as aged skin seems dry. The lack of interaction between the water and the surrounding molecules in photoaged skin contributes to its characteristically dry and wrinkled appearance.

1.5 Blood Vessels The blood supply to the skin comes from the deep plexuses located at the fascia and subcutaneous level (Fig. 1.4). Once the vessels enter the space between the subcutaneous tissue and corium they branch out to various cutaneous appendages. The ascending arterioles supply a subpapillary plexus and form capillary loops in the papillary layer between the ridges. From these capillaries, the blood is drained by venules which descend to the plexuses (Braverman and Yen 1977). The blood flow through the superficial layer of the dermis is controlled by arteriovenous anastomoses which can act as shunts to short circuit the flow. These anastomoses are well demonstrated at the level of the fingers. The peripheral nerves influence the pattern of blood vessel branching and differentiation by secreting the vascular endothelial growth factor (Mukouyama et al. 2002). The small arteries of the deep vascular plexus and the arterioles present in the dermis have three layers: (1) intima, composed of endothelial cells and internal elastic lamina; (2) media, with at least two layers of muscle cells in the small arteries and one layer of muscle cells in arterioles; and (3) adventitia of connective tissue. The capillaries located in the dermis have a layer of endothelial cells and a layer of pericytes. The walls of the veins

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1.5  Blood Vessels

a

b

Fig. 1.3  (a). Early signs of aging. (b) Skin tightening after two IPL treatments

are thinner than those of the arteries and do not have a clear structure of three layers. The postcapillary venule has endothelial cells, pericytes and a basement membrane. A special vascular structure called glomus is present within the reticular dermis of the nail beds, fingers and toes, ears, and face, and is important in thermal regulation. It represents a special arteriovenous shunt that connects the arterioles with the venules.

1.5.1 Aging and Cutaneous Vasculature

Fig. 1.4  Numerous vascular networks located at different levels between the fascia and the epidermis

With aging, there is a dependent reduction in the total number of papillary loop microvessels, decreased thickness of microvessel basement membrane and decreased number of perivascular cells (Braverman and Fonferko

8

1  Skin Anatomy

a

b

Fig. 1.5  Teleangiectasia of the nostril before (a) and 8 weeks after a single IPL treatment (b)

1982). These changes lead to decreased perfusion and increased capillary fragility. The clinical manifestation of these changes are purpura (Montagna and Carlisle 1979), teleangiectasia (Fig. 1.5a, b), pallor (Tsuchida 1993), angioma and venous lake formation. The function of the skin microvessels is affected by the aging process and leads to decreased vasoreactivity (Algotsson et  al. 1995) and impaired wound repair (Schafer et al. 1994).

1.6 Dermal Lymphatics Dermal lymphatics are often hard to see in the normal skin because they do not have the well-developed walls that blood vessels have. They first appear at the subpapillary dermis. When they are seen in the dermal papillae, it is considered abnormal (Skobe and Detmar 2000). The initial lymphatic vessels are cylindrical microtubules and are composed of attenuated endothelial cells. They form a mesh-like network of about 200–500µm in the human scalp (Wenzel-Hora et al. 1987). Occasional valves can be seen emerging from the endothelial lining. The dermal lymphatics are easily detected in conditions associated with increased lymphatic drainage, as occurs in urticaria or inflammations.

1.7 Nerves and Sense Organs The skin is supplied by sensory nerves and autonomic nerves which permeate the entire dermis. The sensory nerves have a myelin sheath. The face and extremities

have the highest density of sensory branches. These branches have two main endings: corpuscular, which embrace non-nervous elements, and free, which do not (Iggo and Muir 1969). Examples of corpuscular branches are: Pacinian, Golgi-Mazzoni, Krause or Meissner. In the Ruffini structures, (abundant in human digits) several expanded endings branch from a single myelinated afferent fibre. The “free nerve-endings” are located in the superficial dermis and in the overlying epidermis (Compton et al. 1990). In the dermis, they are arranged in a tuft-like manner. Hair follicles also have nerve terminals which run parallel to and encircle the hair follicles.

Practical Points

›› The thickness of the epidermis is variable. It is

››

››

››

very thick on the palms, soles and other friction surfaces. These areas are more resistant to treatments using light sources. The thickness of the dermis is also variable. In the eyelid, the dermis is thinnest; on the back, it is the thickest. This variable is important when considering IPL treatment in different anatomical regions. People with fair skin have fewer melanosomes which are smaller and packed, while people with dark skin have more melanosomes which are larger and not packed. IPL has the best results in fair skinned people. The hair follicles and vascular dermal elements are not uniformly distributed at the same level. This is important to take into consideration when choosing IPL parameters.

References

›› In white and grey hair, the melanocytes of the

›› ››

››

hair matrix are much reduced and show degenerative changes. They are the most resistant to IPL hair removal. Hair follicles in the anagen phase are the most susceptible to IPL treatment. With aging, there is a decrease in total collagen content in the skin, an increased amount of type III collagen, decreased number and diameter of elastin fibers, and a lack of interaction between water and surrounding molecules which contribute to the dry and wrinkled aspect. The face and the hands have the highest density of sensory nerves and are the most painful areas in IPL treatment.

References Algotsson A, Nordberg A, Winblad B. Influence of age and gender on skin vessel reactivity to endothelium-dependent and endothelium-independent vasodilators tested with iontophoresis and a laser Doppler perfusion imager. J Gerontol A Biol Sci Med Sci. 1995;50(2):M121–127. Alonso L, Fuchs E. The hair cycle. J Cell Sci. 2006;119(Pt 3): 391–393. Andl T, Ahn K, Kairo A, et al. Epithelial Bmpr1a regulates differentiation and proliferation in postnatal hair follicles and is essential for tooth development. Development 2004;131(10): 2257–2268. Bernstein EF, Chen YQ, Tamai K, et al. Enhanced elastin and fibrillin gene expression in chronically photodamaged skin. J Invest Dermatol. 1994;103(2):182–186. Blanpain C, Lowry WE, Geoghegan A, et al. Self-renewal, multipotency, and the existence of two cell populations within an epithelial stem cell niche. Cell. 2004;118(5):635–648. Braverman IM, Fonferko E. Studies in cutaneous aging: II. The microvasculature. J Invest Dermatol. 1982;78(5):444–448. Braverman IM, Yen A. Ultrastructure of the human dermal microcirculation. II. The capillary loops of the dermal papillae. J Invest Dermatol. 1977;68(1):44–52. Briggaman RA, Wheeler CE, Jr. The epidermal-dermal junction. J Invest Dermatol. 1975;65(1):71–84. Cochran AJ. The incidence of melanocytes in normal human skin. J Invest Dermatol. 1970;55(1):65–70. Compton CC, Regauer S, Seiler GR, et al. Human Merkel cell regeneration in skin derived from cultured keratinocyte grafts. Lab Invest. 1990;63(2):233–241. Eisen AZ, Holyoke JB, Lobitz WC, Jr. Responses of the superficial portion of the human pilosebaceous apparatus to controlled injury. J Invest Dermatol. 1955;25(3):145–156. Fisher GJ, Wang ZQ, Datta SC, et al. Pathophysiology of premature skin aging induced by ultraviolet light. N Engl J Med. 1997;337(20): 1419–1428.

9 Gniadecka M, Nielsen OF, Wessel S, et  al. Water and protein structure in photoaged and chronically aged skin. J Invest Dermatol. 1998;111(6):1129–1133. Hashimoto K, DiBella RJ. Electron microscopic studies of normal and abnormal elastic fibers of the skin. J Invest Dermatol. 1967;48(5):405–423. Iggo A, Muir AR. The structure and function of a slowly adapting touch corpuscle in hairy skin. J Physiol. 1969;200(3): 763–796. Kollar EJ. The induction of hair follicles by embryonic dermal papillae. J Invest Dermatol. 1970;55(6):374–378. Krause K, Foitzik K. Biology of the hair follicle: the basics. Semin Cutan Med Surg. 2006;25(1):2–10. Lavker RM, Zheng PS, Dong G. Aged skin: a study by light, transmission electron, and scanning electron microscopy. J Invest Dermatol. 1987;88(3 Suppl):44s–51s. Lenoir MC, Bernard BA, Pautrat G, et al. Outer root sheath cells of human hair follicle are able to regenerate a fully differentiated epidermis in vitro. Dev Biol. 1988;130(2): 610–620. Maurer M, Handjiski B, Paus R. Hair growth modulation by topical immunophilin ligands: induction of anagen, inhibition of massive catagen development, and relative protection from chemotherapy-induced alopecia. Am J Pathol. 1997; 150(4):1433–1441. Montagna W, Carlisle K. Structural changes in aging human skin. J Invest Dermatol. 1979;73(1):47–53. Mukouyama Y S, Shin D, Britsch S, et al. Sensory nerves determine the pattern of arterial differentiation and blood vessel branching in the skin. Cell. 2002;109(6):693–705. Ohyama M. Hair follicle bulge: a fascinating reservoir of epithelial stem cells. J Dermatol Sci. 2007;46(2):81–89 Ottani V, Raspanti M, Ruggeri A. Collagen structure and functional implications. Micron. 2001;32(3):251–260. Panteleyev AA, Jahoda CA, Christiano AM. Hair follicle predetermination. J Cell Sci. 2001;114(Pt 19):3419–3431. Ruoslahti E. Proteoglycans in cell regulation. J Biol Chem. 1989;264(23):13369–13372. Schafer BM, Maier K, Eickhoff U, et al. Plasminogen activation in healing human wounds. Am J Pathol. 1994;144(6): 1269–1280. Skobe M, Detmar M Structure, function, and molecular control of the skin lymphatic system. J Investig Dermatol Symp Proc. 2000;5(1):14–19. Slominski A, Paus R. Melanogenesis is coupled to murine anagen: toward new concepts for the role of melanocytes and the regulation of melanogenesis in hair growth. J Invest Dermatol. 1993;101(1 Suppl):90S–97S. Slominski A, Wortsman J, Plonka PM, et al. Hair follicle pigmentation. J Invest Dermatol. 2005;124(1): 3–21. Stenn K. Collagen heterogeneity of skin. Am J Dermatopathol. 1979;1(1):87–88. Stenn KS, Fernandez LA, Tirrell SJ. The angiogenic properties of the rat vibrissa hair follicle associate with the bulb. J Invest Dermatol. 1988;90(3):409–411. Stenn KS, Paus R. Controls of hair follicle cycling. Physiol Rev. 2001;81(1):449–494. Stenn KS, Paus R. What controls hair follicle cycling? Exp Dermatol. 1999;8(4):229–233; discussion 233–226. Tsuchida Y. The effect of aging and arteriosclerosis on human skin blood flow. J Dermatol Sci. 1993;5(3):175–181. Vater CA, Harris ED, Jr., Siegel RC. Native cross-links in collagen fibrils induce resistance to human synovial collagenase. Biochem J. 1979;181(3):639–645.

10 Waller JM,Maibach HI. Age and skin structure and function, a quantitative approach (II): protein, glycosaminoglycan, water, and lipid content and structure. Skin Res Technol. 2006; 12(3):145–154. Wenzel-Hora B I, Berens von Rautenfeld D, Majewski A, et al. Scanning electron microscopy of the initial lymphatics of

1  Skin Anatomy the skin after use of the indirect application technique with glutaraldehyde and MERCOX as compared to clinical findings. Lymphology. 1987;20(3): 126–144. Wolff K, Wolff-Schreiner EC Trends in electron microscopy of skin. J Invest Dermatol. 1976;67(1):39–57.

2

Light Tissue Interactions

Contents 2.1 Heating..................................................................... 13 2.2 Skin Properties Regarding ­Light-Tissue Interaction............................................................... 15 2.3 Chromophores of Human Skin.............................. 17 References............................................................................ 20

Abstract The effects of light on skin are due to various degrees of absorption of electromagnetic radiation. The visible light spectrum has a 400–760 nm wavelength. The light-tissue interaction effects are due to absorption and excitation of photons. The Intense Pulse Light is situated in the visible light of the electromagnetic spectrum. Once the light reaches the skin, part of it is absorbed, part is reflected or scattered, and part is further transmitted. Selective photothermolysis is the basic principle of Intense Pulsed Light treatment. It consists of matching a specific wavelength and pulse duration to obtain optimal effect on a target tissue with minimal effect on the surrounding tissues. The structures of the tissue that absorb the photons are known as chromophores. They have different wavelengths of absorption. The most common chromophores encountered in the skin are: hemoglobin and its derivates, melanin, water and foreign pigmented tattoos. The main target structures for Intense Pulsed Light treatment are melanin and blood vessels. The fluence delivered to the chromophores must be high enough to destroy them. In order to enhance the photodynamic therapy effect which is based on selective phothermolysis, photosensistizers can be used as adjuvants.

The effects of light on skin are due to various degrees of absorption of electromagnetic radiation (EMR). The EMR represents the fundamental form of energy having wave and particle properties. According to Plancks law, long wavelength photons carry less energy than short wavelength photons. The EMR includes radiowaves, microwaves, infrared radiation, visible light, ultraviolet radiation and x-rays (Fig. 2.1). EMR is generally classified according to wavelength. The visible light spectrum has a 400–760 nm wavelength. The light-tissue interaction effects are due to absorption L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_2, © Springer-Verlag London Limited 2011

11

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2  Light Tissue Interactions

Fig. 2.1  Electromagnetic spectrum (Printed with permission of Lumenis company, Yokneam, Israel)

Fig. 2.2  Visible light spectrum (Printed with permission of Lumenis company, Yokneam, Israel)

and excitation of photons. The Intense Pulse Light is situated in the visible light of the ­electromagnetic spectrum (Fig. 2.2). To understand the effects of light on tissue, it is necessary to define some terms: • Fluence (F) represents the amount of energy measured in Joules (J) per unit area, measured in cm2: F = J/cm2. • Power measured in watts (W) represents the amount of energy delivered over a certain period of time: W=J/s. • Thermal relaxation time (TRT) is the time necessary for an object to cool down to 50% of its original temperature. TRT is further detailed in this chapter. • Wavelength influences selective light absorption by a certain target and also influences the depth of

t­issue penetration (Fig. 2.3). The majority of light ­systems have different filters which allow certain wavelengths to enter the tissue, thus producing the selection of the desired light spectrum. • Footprint (device spot) size has an important role  in light penetration into the tissue. When a small spot size is used for light emission, only a small part will reach the deep target structures (Fig. 2.4a, b). A larger footprint offers a more planar geo­metry of light penetration and better efficacy (Fig. 2.5) (Keijzer et al. 1989). A spot size of about 7–10 mm is needed for maximal light penetration to the mid-dermal structures. The bigger the spot, the deeper the level of penetration (Carroll and Humphreys 2006). • Pulse duration. Light can be delivered in a pulsed or continuous wave. The intense pulsed light devices

2.1  Heating

13

Fig. 2.3  Depth of light penetration into the skin, at various wavelengths

are based on pulsed delivery that allows more selective tissue damage. Pulse duration represents the time of exposure to the light beams. Laser and pulsed light systems enable the selection of pulse duration, which is influenced by the TRT of the target. • Pulse delay represents the time that allows the skin and blood vessels to cool down between pulses, while the heat is retained inside the targets. When the pulse is shorter than the thermal relaxation time (TRT), the heat will act mainly on the target structures. When the pulse is longer than the TRT, the heat will be conducted to the surrounding structures. It is recommended that the pulse timing be higher than the skin cooling time to avoid damage to the surrounding structures.

2.1 Heating Heating is one of the effects induced by light ab­sorption. It is not uniformly distributed inside the skin. This process is more representative around the

target cells. The temperature is directly related to the excitation of molecules. As the temperature is raised, different changes take place at the molecular level. DNA, RNA and some proteins are affected by the heat which causes them to unwind or even melt at  varying temperatures. The final result would be  denaturation and coagulation of the above-­ mentioned structures. These effects are dependent on temperature and length of exposure. Depending on the target tissue, the light-tissue interactions will cause tissue necrosis, blood coagulation and structure alterations. Some of the heating effects are beneficial at the level of the target tissues but are dangerous to the surrounding tissue. This should always be kept in mind when choosing the treatment parameters. The coagulation damage depends not only on the temperature but also on the exposure time. For instance, a high temperature and a short exposure can be less aggressive than a lower temperature with a longer period of exposure. The dermis, being rich in collagen and elastin, is more thermally stable than the epidermis, mainly due to elastin proprieties.

14 Fig. 2.4  (a) Light distribution of a small spot. (b) Light distribution of a large spot (Printed with permission of Lumenis company, Yokneam, Israel)

2  Light Tissue Interactions

a

b

Fig. 2.5  Deeper light penetration using a large footprint (Printed with permission of Lumenis company, Yokneam, Israel)

15

2.2  Skin Properties Regarding L­ ight-Tissue Interaction

2.2 Skin Properties Regarding ­ Light-Tissue Interaction Once the light reaches the skin, part of it is absorbed, part is reflected or scattered, and part is further transmitted. The scattering process takes place when the photon particles change the direction of propagation (Fig. 2.6a). This phenomenon takes place inside the skin where different structures have different indices of refraction. The scattering effect makes the light spread out and limits the depth of light penetration. It seems that the dermal collagen is responsible for most of the scattering. The amount of scattering is inversely proportional to the wavelength of the light (Herd et al. 1997). Some (4–7%) of the light is reflected, this phenomenon being produced by a change in the air and stratum corneum refractive index. The amount of light that is reflected decreases with the decreasing angle of incidence (Fig. 2.6b). The least reflection occurs when the light is perpendicular to the tissue. A very small amount of light is further transmitted (Fig. 2.6c). It has been proved that transmission of the light varies according to the skin type (Everett et  al. 1966). The white dermis transmits from about 50% at 400 nm to 90% at 1,200 nm, while the black epidermis transmits less than 40% at 400 nm and 90% at 1,200 nm. In

Fig. 2.6  (a) Scattering effect (printed with permission of Lumenis company, Yokneam, Israel). (b) Reflection of the light (printed with permission of Lumenis company, Yokneam, Israel). (c) Light transmission (printed with permission of Lumenis company, Yokneam, Israel). (d) Light absorption (printed with permission of Lumenis company, Yokneam, Israel)

general, there is a gradual increase in skin penetration at longer wavelengths. Most of the light is absorbed by the skin (Fig. 2.6d). This phenomenon is responsible for the desired effects on the tissue. The structures of the tissue that absorb the photons are known as chromophores. They have different wavelengths of absorption. The most common chromophores encountered in the skin are: hemoglobin and its derivates, melanin, water and foreign pigmented tattoos (Fig. 2.7). Once the light is absorbed, the chromophores become excitated. For wavelengths varying from 300–1,200 nm, melanin is the dominant absorbent. Light-tissue effects can be grouped in: • Photothermal – represented mainly by coagulation or vaporization of tissue based on absorption • Photomechanical – tissue disruption often encountered by pulsed laser beams • Photochemical – direct breakage of chemical tissue bonds or chemical interaction with an applied drug • Photobiostimulation – tissue stimulation with very low level laser light • Selective photothermolysis – The concept of photothermolysis was introduced for the first time by Parrish and Anderson in 1983 (Anderson and Parrish 1983). According to their description,

a

b

c

d

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2  Light Tissue Interactions

Fig. 2.7  Light absorption for different chromophores (Printed with permission of Lumenis company, Yokneam, Israel)

three effects are necessary to produce selective photothermolysis: • Absorption of a specific wavelength by the target structures • The exposure time should be less than or at least equal to the time of cooling of the target structures • There is a need for enough fluence to produce a damaging temperature within the target structures The main target structures for Intense Pulsed Light treatment are melanin and blood vessels (Fig. 2.8a, d). To understand the relation between exposure time and extent of thermal damage, it is important to detail the “thermal relaxation time” (TRT). This represents the time required to cool a small target structure. The cooling is achieved by conduction, convection and  radiation. Conduction is the main component of cooling. Smaller objects cool faster than larger objects. The TRT is proportional to the square of the size (van Gemert and Welch 1989). T = d 2 /ka

Where: T = relaxation time D = size of the heated object a = thermal diffusivity (about 2 × 10−3 cm2/s for dermis) K = geometrical factor (for a cylindrical object is 16)

To allow enough time for the epidermis and other skin structures to cool down, the pulse duration should be shorter than the cooling time of the target but longer than the cooling time of the skin. This has clinical implications especially for hair removal. The hair follicles are grossly grouped as coarse and fine. They have different sizes and consequently different TRTs. An epidermal thickness of 0.1 mm has a TRT of about 1 ms while a vessel of 0.1 mm has a TRT of about 4 ms (Goldman et  al. 2005). A vessel three times bigger­ (0.3 mm) has a TRT of approximately 10 ms. Larger structure targets cool down slower and need increased delay time and multiple pulsing. Theoretically, most vessels smaller than 0.3 mm require only a single pulse. It is recommended that pulses be spaced at 10  ms or longer to accommodate normal epidermal TRT (Goldman et  al. 2005). Patients more prone to thermal injuries should have at least 20–30 ms of TRT. When the pulse width is greater than the TRT, nonspecific thermal damage occurs because of heat diffusion. The fluence delivered to the chromophores must be high enough to destroy them. In order to enhance the photodynamic therapy effect which is based on selective phothermolysis, photosensitizers have been introduced as adjuvants. There are topical and systemic photosensitizers. The first generation of photosensitizers was developed about 30 years ago and belongs to the porphyrin family. 5-aminolevulinic acid (ALA) and methyl aminolevulinate (MAL)

17

2.3  Chromophores of Human Skin

a

b

c

d

Fig. 2.8  (a) Various chromophores in the skin (printed with permission of Lumenis company, Yokneam, Israel). (b) Light interaction with various chromophores (printed with permission of Lumenis company, Yokneam, Israel). (c) Immediate response to

light–tissue interaction (printed with permission of Lumenis company, Yokneam, Israel). (d) Late response with destruction of the chromophores (Printed with permission of Lumenis company, Yokneam, Israel)

are the most common sensitizers. Second generation photosensitizers have the advantage of having a limited effective period. ALA is not a photosensitizer by itself, but it is metabolized to photosensitizing protoporphyrin IX (Piacquadio et al. 2004). The spectrum of absorption of protoporphyrin IX is in the visible spectrum. The peak of absorption is 405 nm (Nyman and Hynninen 2004). Systemic sensitizers are administered intravenously since they do not penetrate the skin. Hematoporphyrin and photofrin have been thoroughly studied (Nyman and Hynninen 2004) with regard to their peak of absorption. Applications of these photosensitizers in association with Intense Pulse Light may increase the efficacy of the treatment (Marmur et al. 2005). This concept of combining light with a photosensitizing agent known as photodynamic therapy has wider applications, including tumor treatment (Pervaiz and Olivo 2006).

2.3 Chromophores of Human Skin The human skin has several major ultraviolet radiation absorbing endogenous chromophores. Among them are urocanic acid, aminoacids, melanin and its precursors. The chromophore identification can be done by action spectroscopy. Theoretically, an action spectrum for a given photobiological endpoint will be the same as the absorption spectrum of its chromophore. The skin chromophores have an overlying spectra (Young 1997). From all chromophores present in the skin, the melanin and hemoglobin with its derivates are the most important regarding light pulsed treatment. The term melanin is widely used to describe the skins red-brown pigment which resides in the epidermis. The biosynthesis of melanin within melanocytes is a complex process and is incompletely understood.

18

It is believed that they are polymers with multiplemonomer units linked by non-hydrolysable bonds (Young 1997). There are two major classes of natural malanins: the black-brown eumelanin and the yellow-red pheomelanin. They are differentiated by their molecular building blocks (Wakamatsu and Ito 2002; Ye et  al. 2008). Eumelanin is the dominant pigment. Human skin coloration is dependent on spatial distribution of the melanin and haemoglobin chromophores (Anderson and Parrish 1981; Zonios et  al. 2001). Eumelanin plays a fundamental role in skin appearance and photoprotection. A weak correlation was noticed between the scattering properties of skin and tissue type with the average scatter size higher in patients with higher melanin content (Zonios et  al. 2001). The skin has a multilayered structure. The two main chromophores in the skin, melanin and hemoglobin, are present in different layers, with the melanin found in the top layer (mainly epidermis) and the hemoglobin found in the bottom layer (vascular network of the dermis) (Figs. 2.9a, b, 2.10a, b, 2.11a, b). To avoid skin damage, higher cut-off filters, multiple pulses and increased delay time should be chosen

a

2  Light Tissue Interactions

a

b

Fig 2.9  (a) Café-au lait in a young person. The melanin is the main chromophore. (b) Good result after two IPL treatments

b

Fig 2.10  (a) Hypertrichosis. The light energy is absorbed by the melanin (endogenous chromophore) present in the hair shaft, outer root sheath of the infundibulum and matrix area pigment from the hair bulb. (b) Good result after five IPL treatments

19

2.3  Chromophores of Human Skin

b

a

Fig 2.11  (a) PWS – adult type over the nose. The chromophore is the hemoglobin. (b) Good result after ten IPL treatments

Table 2.1  Data derived from Fitzpatrick-skin color types (Fitzpatrick 1988) Skin type Skin color Susceptibility to sun burn

Susceptibility to skin cancer

Type I

Blond or red hair (freckles, fair skin, blue eyes)

Always burns easily; never tans

High

Type II

Blond or red hair (freckles, fair skin, blue eyes)

Usually burns easily; tans with difficulty

High

Type III

Darker Caucasian, light Asian

Burns moderately; tans gradually

Low

Type IV

Mediterranean, Hispanic, Asian

Rarely burns; always tans well

Low

Type V

Latin, light-skinned black, Indian

Very rarely burns; tans very easily; dark skin tone

Very low

Type VI

Dark-skinned black

Never burns; very dark skin tone

Very low

for darker skin types. The Fitzpatrick skin typing system (Table 2.1) from I to IV has different skin colors according to pigment intensity (Fitzpatrick 1988). Although it is a widely used scale, it has been criticized that human eye evaluation is subjective and ­confounded by the presence of hemoglobin (Matts et al. 2007). Although the human eye can distinguish adjacent brown and red colors, it is almost impossible to distinguish the relative contribution of melanin and  hemoglobin when they overlay one another, as often happens in young and photoprotected skin (Matts et al. 2007).

There are elaborated methods which try to evaluate skin color objectively. These are based on spectrophotometric or colorimetric techniques. Although these methods are more objective, they still cannot completely separate the individual contributions of the chromophores (Moncrieff et  al. 2002; Ito and Wakamatsu 2003; Matts et al. 2007). Exogenous chromophores can be administered to the skin to prevent sunburn (exogenous chromophores from sunscreens) or in combination with ultraviolet radiation for therapeutic benefit (Thompson et  al. 1993; Naylor et al. 1995).

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2  Light Tissue Interactions

Practical Points

›› The intense pulsed light is situated in the visi›› ››

›› ››

››

ble light of the electromagnetic spectrum. Heating is an important effect induced by light absorption. This often leads to cell necrosis, blood coagulation and structure alterations. The light interacts with the skin and part of it is absorbed, part reflected or scattered, and part is ­further transmitted. The absorption is responsible for the desired effect on the tissue. The two main skin chromophores present in the skin and responsible for the light effects are melanin and hemoglobin. Selective photothermolysis is the basic principle of Intense Pulsed Light treatment. It consists of ­matching a specific wavelength and pulse duration to obtain optimal effect on a ­target tissue  with minimal effect on the surrounding tissues. Melanin is located within the top layer of the skin (epidermis) and hemoglobin is found in the bottom layer (vascular network of the dermis).

References Anderson RR, Parrish JA. The optics of human skin. J Invest Dermatol. 1981;77(1):13–19. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220(4596):524–527. Carroll L, Humphreys TR. LASER-tissue interactions. Clin Dermatol. 2006;24(1):2–7. Everett MA, Yeargers E, Sayre RM et al. Penetration of epidermis by ultraviolet rays. Photochem Photobiol. 1966;5(7):533–542. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869–871. Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a nonablative approach to photoaging. Dermatol Surg. 2005; 31(9 Pt 2):1179–1187; discussion 1187.

Herd RM, Dover JS Arndt KA. Basic laser principles. Dermatol Clin. 1997;15(3):355–372. Ito S, Wakamatsu K. Quantitative analysis of eumelanin and pheomelanin in humans, mice, and other animals: a comparative review. Pigment Cell Res. 2003;16(5):523–531. Keijzer M, Jacques SL, Prahl SA et  al. Light distributions in artery tissue: Monte Carlo simulations for finite-diameter laser beams. Lasers Surg Med. 1989;9(2):148–154. Marmur ES, Phelps R Goldberg DJ. Ultrastructural changes seen after ALA-IPL photorejuvenation: a pilot study. J Cosmet Laser Ther. 2005;7(1):21–24. Matts PJ, Dykes PJ Marks R. The distribution of melanin in skin determined in vivo. Br J Dermatol. 2007;156(4):620–628. Matts PJ, Fink B, Grammer K et  al. Color homogeneity and visual perception of age, health, and attractiveness of female facial skin. J Am Acad Dermatol. 2007;57(6):977–984. Moncrieff M, Cotton S, Claridge E et  al. Spectrophotometric intracutaneous analysis: a new technique for imaging ­pigmented skin lesions. Br J Dermatol. 2002;146(3): 448–457. Naylor MF, Boyd A, Smith DW et al. High sun protection factor sunscreens in the suppression of actinic neoplasia. Arch Dermatol. 1995;131(2):170–175. Nyman ES, Hynninen PH. Research advances in the use of tetrapyrrolic photosensitizers for photodynamic therapy. J Photochem Photobiol B. 2004;73(1–2):1–28. Pervaiz S, Olivo M. Art and science of photodynamic therapy. Clin Exp Pharmacol Physiol. 2006;33(5–6):551–556. Piacquadio DJ, Chen DM, Farber HF et al. Photodynamic therapy with aminolevulinic acid topical solution and visible blue light in the treatment of multiple actinic keratoses of the face and scalp: investigator-blinded, phase 3, multicenter trials. Arch Dermatol. 2004;140(1):41–46. Thompson SC, Jolley D Marks R. Reduction of solar keratoses by regular sunscreen use. N Engl J Med. 1993;329(16): 1147–1151. van Gemert MJ, Welch AJ. Time constants in thermal laser medicine. Lasers Surg Med. 1989;9(4):405–421. Wakamatsu K, Ito S. Advanced chemical methods in melanin determination. Pigment Cell Res. 2002;15(3):174–183. Ye T, Pawlak A, Sarna T et al. Different molecular constituents in pheomelanin are responsible for emission, transient absorption and oxygen photoconsumption. Photochem Photobiol. 2008;84(2):437–443. Young AR. Chromophores in human skin. Phys Med Biol. 1997;42(5):789–802. Zonios G, Bykowski J Kollias N. Skin melanin, hemoglobin, and light scattering properties can be quantitatively assessed in  vivo using diffuse reflectance spectroscopy. J Invest Dermatol. 2001;117(6):1452–1457.

3

Intense Pulsed Light Safety: Legal Issues

Contents 3.1 Safety Issues............................................................ 21 3.2 Legal Issues............................................................. 23 References............................................................................ 26

Abstract Light and laser devices have common considerations and include hazards both to the patient and to the medical staff. The operating manual of the IPL device should be read by all personnel manipulating the device. Personnel in the treatment room should have protection against accidental exposure to the IPL, either directly or indirectly from a reflecting device. The visual hazard seems to be the main danger. Inadvertent exposure of the eyes during treatment may damage some eye structures. During treatment, wearing specially designed protective eyeglasses is important not only for the patient but also for the staff present in the room. Due to inadvertent “advertising” of IPL or laser technologies and unrealistic expectations by the public, physicians may run the risk of being sued for the results. Avoiding malpractice lawsuits implies acting correspondingly and adapting the treatment to the patient’s needs. Informed consent for any treatment is a must. Although there are reports of informed verbal consent, written consent is mandatory in today’s litiginous society. Protection against lawsuits lies also in the ability of the physician to recognize problematic patients.

3.1 Safety Issues Light and laser devices have common considerations and include hazards both to the patient and to the medical staff. Intense Pulsed Light (IPL) is widely used in many medical and aesthetic centers. IPL wavelengths range from 550 to 1200nm. Most IPL devices have the ability to perform self-testing when the system is turned on. If an error occurs, the message is displayed on the screen. The newest devices automatically shut down when exposed to a light overdose. Some devices have an emergency shutoff knob. It is recommended that L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_3, © Springer-Verlag London Limited 2011

21

22

treatment be done by a trained physician or at least by a trained nurse supervised directly by a physician. The main responsibility belongs to the physician who should be the one to adjust the device parameters. The operating manual of the IPL device should be read by all personnel manipulating the device. Personnel in the treatment room should have protection against accidental exposure to the IPL, either directly or indirectly from a reflecting device. Handling the treatment head should be done cautiously to avoid discharges into free space. Since some of the devices that emit IPL also have laser treatment heads, the warning and hazards should also be addressed to them. The devices should comply with international standards. (A) Treatment room. Treatments should be carried out in a specially designed room that respects the safety of light and laser radiation. The entrance should be clearly labeled with signs indicating high intensity light. The number of people in the treatment room should be limited and related to the procedure. The system should not be used in the presence of flammable materials. The doors of the treatment room should be closed when the device is in use and a special sign reading “Danger” should be placed outside the treatment room (Fig. 3.1). (B) Optical safety. The visual hazard seems to be the main danger. Inadvertent exposure of the eyes during treatment may damage some eye structures. The light beam danger comes when the applicator is directed by mistake at the eye or is reflected off an

Fig. 3.1  Warning sign should be displayed on the door

3  Intense Pulsed Light Safety: Legal Issues

instrument. The treatment head should be directed only to the treatment area. Reflective objects, such as watches, jewelry, and shiny instruments, should be kept away from the light beam. Do not look directly at the light emission head. During ­treatment, wearing specially designed protective eyeglasses is important not only for the patient but also for the staff present in the room (Fig. 3.2). Usually, the patient wears goggles which allow the doctor to perform treatments in the periorbital area easily (Fig. 3.3).

Fig. 3.2  Wavelength-specific eye protection should be used by the staff in the treatment room

Fig. 3.3  Goggles are worn by patients for eye protection during treatment

3.2  Legal Issues

(C) Electrical safety. Some devices produce high voltages which can be retained by some components after the power supply has been turned off. IPL devices need appropriate electrical safety precautions. Fluid containers should be kept away from the devices. Any repairs to the IPL device should be done by authorized and trained people. Keep the device covers closed during functioning. An emergency shutoff knob is often present and it bypasses the controlled power. When the machine is not in use, always turn the system off. Untrained personnel should not operate the IPL devices. Doctors, midlevel providers and technicians should work together to monitor the equipment, the patient and the environment for safety. (D) Theoretical potential risk of infection transmission is another hazard (Gregory 1999). To diminish this risk, in addition to wearing regular gloves, footprints are cleared using chlorhexidine solution between treatments. Although some authors (Burkhart 2007) raise the question about the long-term safety of lasers and IPL, including the possible risk of melanoma, no reports of this association can be found in the medical literature. While there are no reports on the use of IPL treatment in pregnant women, we do not recommend its use under these circumstances.

3.2 Legal Issues Due to inadvertent “advertising” of IPL or laser technologies and unrealistic expectations by the public, physicians may run the risk of being sued for the results. Avoiding malpractice lawsuits implies acting correspondingly and adapting the treatment to the patient’s needs. In the last decade, the cost of medical malpractice and lawsuits has been impressive and continuously increasing (Resneck 2006). Informed consent for any treatment is a must. Although there are reports of informed verbal consent, written consent is mandatory in today’s litiginous society (Goldberg 2007). The goals are to include the patient in the decision-making process, to inform the patient of the various methods and instruments, and to inform the patient about the potential benefits and hazards of the treatment (Goldberg 2007). Most informed consent dealing with aesthetic procedures includes the possibility of patient photography or videotaping. Photodocumentation as well as record storage are important for follow-up and possible liability

23

problems. The majority of the devices are built to store this information. We advise introducing as much data as possible into the patient record (anesthetic type, reason for treatment, treatment parameters, cooling method, side effects, complications, recommendations, etc.). Protection against lawsuits lies also in the ability of the physician to recognize problematic patients. These are patients with Body Dysmorphic Disorder (BDD) or “Beauty Hypochondriasis”. BDD represents preoccupation with an imagined defect in a normal appearing person or, if a mild physical anomaly is present, the concern is disproportional. “Beauty hypochondriasis” refers to a preoccupation centering usually on one part of the body that is experienced as repulsive and deformed. Both conditions lead to impairment in social and occupational activities and distress. These patients have also a feeling of inferiority, guilt, or altered body image (Olley 1974). The incidence of BDD in the general population was found to be up to 2.4%, with a higher prevalence of 7–15% among patients seeking cosmetic surgery procedures (Ishigooka et  al. 1998; Sarwer et  al. 1998; Koran et  al. 2008). Since these patients have an emotional rather than a physical problem, they are rarely satisfied with cosmetic procedures (Andreasen and Bardach 1977). The obligation of a doctor performing IPL treatments is to do his work in accordance with the standard of care. It is important to be on the safe side and avoid lawsuits. The ‘standard of care’ is often described by some as whatever an expert in the field says it is, and the jury believes that. For instance, in a case against an IPL procedure, the doctor performing this procedure must have the skills ordinarily possessed by a specialist in this field. The standard of care should be included in the patient’s record or informed consent form and refers to the explanations that a reasonable medical practitioner would provide patients. The term of ‘negligence’ requires fulfillment of four elements: duty, breach of duty, causation and damages (Furrow et al. 2004). Duty refers to the treatment performed by another reasonable physician by the same method. Breach of duty refers to the fact that the negligent physician did not perform the same type of treatment in the same manner as another reasonable physician would. Causation refers to the relation between duty and damage. Damages can be economic or non-economic, such as emotional. In some instances, there can be two or more methods for treating the same pathology. In this situation, the doctor does not fall below the standard of care with any of the acceptable methods even if one is less effective than

24

another (Goldberg 2006). For instance, someone may be sued after using IPL for hair removal instead of Nd:Yag laser. Since both are accepted and recognized methods, the physician is within the standard of care. Inevitably, IPL as a laser procedure has adverse effects and complications (Nanni and Alster 1998, 1999). These can be the trigger of malpractice lawsuits. Complications, such as skin thermal injury that can appear after IPL treatments, are not by definition medical malpractice. It often happens in these cases that the patients seek legal advice. In such a situation, the patient who likes the doctor and communicates easily with him is less likely to sue even when a complication occurs (Goldberg 2007). Professional errors can be related to deficient training, inadequate patient information, or inappropriate treatment. To diminish professional errors, guidelines and instructions are necessary (Greve and Raulin 2002). Training for IPL technology or laser procedures refers not only to device-handling and indications but also to a wider area such as: identifying possible skin lesions (malignancies) which should not be treated in this manner or skin conditions that need further attention (e.g.,

3  Intense Pulsed Light Safety: Legal Issues

blisters, crusts, minor burns) after IPL. Greve (Greve and Raulin 2002) underlines the importance of continuous medical education and board examinations. Although there is an increase in the involvement of mid-level providers with these procedures (physician assistants, nurse practitioners), there are some concerns that this may decrease the overall quality of treatment as these people may have less experience (Clark et  al. 2000; White and Geronemus 2002). Without appropriate training and supervision, physician extenders can have a higher incidence of complications (Goldberg 2005). When a physician extender is involved in performing treatments, he might be found liable for negligence according to the law of that area (Goldberg 2006). It is mandatory to know beforehand if an extender is allowed to perform the treatments and under what circumstances. Nevertheless, when treatments are performed by physician extenders, this does not release the doctor from malpractice liability. In most cases, the physician is sued along with the extender (Crane 2000; Nestor 2005). Following is the informed consent that we suggest for IPL treatment.

25

3.2  Legal Issues

Intense Pulsed Light Treatment. Informed Consent The Intense Pulse Light Treatment is based on the light emitted by a flash lamp. Using different wavelengths, the device has proved to be useful in the treatment of vascular lesions, pigmentary lesions and hair removal. Partial skin rejuvenation can be obtained sometimes. More than one treatment may be needed in order to obtain the desired effect. Patients should not be tanned at the treatment. If they are tanned, delaying the treatment for a few weeks is recommended to diminish the rate of complications. Immediately after the treatment, blue or red discoloration may appear. Usually this disappears within a few days. Most procedures do not necessitate anesthesia. Topical anesthetic creams can be used before the procedure. Eye protection will be used by the patient and the staff for the entire treatment period. Although no reaction on a developing fetus has been reported, the procedure is not recommended for pregnant women. No guarantees can be made of the exact results from this treatment. Although the treatment is safe, some complications may appear: • Pigmentary changes can be either of increased pigment (hyperpigmentation) or decreased pigment (hypopigmentation). Most of the time, these color changes are temporary and resolve over several weeks to months. Permanent pigmentary changes may also appear. • Pain. The level of sensation during treatment varies from person to person. A warm or burning sensation can be reduced by using topical anesthetics before the procedure and ice packs after the treatment. • Excessive redness or swelling. In some instances, excessive redness or swelling can persist for up to a few days after treatment. In certain cases, mild topical steroids can be used to hasten recovery. • Infection is extremely rare as the technology does not break the skin. • Blisters can be encountered in certain people, especially in those with higher sensitivity. • Scarring is possible. Normally, the IPL technology does not produce scarring. However, there are a few reports in the medical literature of scarring. • Lack of satisfaction. Different patients respond differently to IPL treatment. Most people report significant improvement after a series of treatments. While positive changes can be expected, no changes may occur for reasons beyond the physicians control. To obtain the best results, the skin should be thoroughly protected from sun exposure after the treatment, using sunscreens with SPF 30 or higher. There is no restriction on washing the treated area right after the procedure. I declare that the above treatment procedure has been explained to me, along with alternative methods of treatment and the risks of the procedure, and all my questions have been answered. I consent to photographs of the treatment areas before and after in order to document the treatment process. I consent to the Intense Pulsed Light Treatment and the above listed items. Signature of Patient or Legal Guardian

Printed name

Physicians Signature

Printed name

Date

Hour

26

3  Intense Pulsed Light Safety: Legal Issues

Practical Points

›› The ›› ›› ›› ›› ››

››

visual hazard is the main danger when performing IPL treatments. Because of “inadvertent advertising” and unrealistic expectations by the public, physicians may run the risk of being sued for the results. Photodocumentation is as important as record storage. Written informed consent is mandatory in today’s litiginous society. Identify problematic patients (Body Dysmorphic Disorder, beauty hypochondriasis) – and stay away from them. Communication with the patient is essential. A patient who likes the doctor and communicates easily with him is less likely to sue even when a complication occurs. When treatments are performed by mid-level providers, the doctor is not released from ­malpractice liability.

References Andreasen NC, Bardach J. Dysmorphophobia: symptom or ­disease? Am J Psychiatry. 1977;134(6):673–676. Burkhart CG. Need for physician monitoring of long-term safety with lasers and intense pulsed light. Int J Dermatol. 2007; 46(2):210–211. Clark AR, Monroe JR, Feldman SR et al. The emerging role of physician assistants in the delivery of dermatologic health care. Dermatol Clin. 2000;18(2):297–302.

Crane M. NPs and PAs: whats the malpractice risk? Med Econ. 2000;77(6):205–208, 215. Furrow BF,. Greaney TL, Johnson SH. Liability in Health Care Law. St. Paul: West Publishing Co; 2004. Goldberg DJ. Laser physician legal responsibility for physi­cian extender treatments. Lasers Surg Med. 2005;37(2):105–107. Goldberg DJ. Legal issues in laser operation. Clin Dermatol. 2006;24(1):56–59. Goldberg DJ. Legal issues in dermatology: informed consent, complications and medical malpractice. Semin Cutan Med Surg. 2007;26(1):2–5. Gregory RO. The risks of laser surgery. Clin Plast Surg. 1999;26(1):109–113, viii. Greve B, Raulin C. Professional errors caused by lasers and intense pulsed light technology in dermatology and aesthetic medicine: preventive strategies and case studies. Dermatol Surg. 2002;28(2):156–161. Ishigooka J, Iwao M, Suzuki M et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci. 1998;52(3):283–287. Koran LM, Abujaoude E, Large MD et  al. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr. 2008;13(4):316–322. Nanni CA, Alster TS. Complications of cutaneous laser surgery. A review. Dermatol Surg. 1998;24(2):209–219. Nanni CA, Alster TS. Laser-assisted hair removal: side effects of Q-switched Nd:YAG, long-pulsed ruby, and alexandrite lasers. J Am Acad Dermatol. 1999;41(2 Pt 1):165–171. Nestor MS. The use of mid-level providers in dermatology: a liability risk? Semin Cutan Med Surg. 2005;24(3):148–151. Olley PC. Aspects of plastic surgery. Psychiatric aspects of referral. Br Med J. 1974;3(5925):248–249. Olley PC. Aspects of plastic surgery. Social and psychological sequelae. Br Med J. 1974;3(5926):322–324. Resneck JS, Jr. Trends in malpractice premiums for dermatologists: results of a national survey. Arch Dermatol. 2006; 142(3):337–340. Sarwer DB, Wadden TA, Pertschuk MJ et al. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101(6):1644–1649. White SM, Geronemus R. Should non-physicians perform cosmetic procedures? Dermatol Surg. 2002;28(9):856–859.

4

How to Organize the IPL Treatment Room

Contents 4.1 Necessary Equipment............................................. 4.1.2 Protective Devices.................................................... 4.1.3 The Room and Auxiliary Equipment........................ 4.1.4 Documentation.......................................................... 4.1.5 Photography and Computer Imaging........................

27 28 28 30 30

References............................................................................ 30

Abstract The prices for IPL equipment vary from a few thousand dollars to more than $100,000, depending on the producer and the properties of the device. Acquisition of the equipment can be made by purchase, lease or rental. In analyzing which method is most feasible for his/her office, one must take into consideration the capital investment, maintenance costs, costs of treatment, and an estimation of the number of patients expected. Before purchasing the device, the physician should compare vendors, extent of warranties and service availability. The room should be large enough to accommodate the treatment table, IPL device, stand tables, small stores cupboards, refrigerator and anesthesia equipment. Written informed consent, medical history, physical examination findings, and data on previous treatments should be recorded. Digital cameras replace in most cases 35 mm cameras for private offices. Although there are simulation programs to show the patient the possible result, these should be used cautiously since the result might not match the simulation.

4.1 Necessary Equipment 4.1.1 The Device The prices for IPL equipment vary from a few thousand dollars to more than $100,000, depending on the producer and the properties of the device. Acquisition of the equipment can be made by purchase, lease or rental. In analyzing which method is most feasible for his/her office, one must take into consideration the capital investment, maintenance costs, costs of treatment, and an estimation of the number of patients L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_4, © Springer-Verlag London Limited 2011

27

28

4  How to Organize the IPL Treatment Room

expected. If the number of treatments is not significant, one might consider rental of the equipment. Before purchasing the device, the physician should compare vendors, extent of warranties and service availability. Renting the device has the advantage of obtaining the latest technology while, after purchasing, it might not be worthwhile economically to renew the equipment.

room as they might reflect the light. We strongly ­recommend plastic shields and non-reflecting surgical instruments. Non-sterile gloves are suitable for performing the treatment. Warning signs should be posted inside the room as well as on the door outside. Doors should be locked when the device is in use.

4.1.2 Protective Devices

4.1.3 The Room and Auxiliary Equipment

Protective devices include ocular protection, gloves, other disposables and warning signs. Ocular protection is available as glasses or goggles. When several devices or lasers are available in the same room, attention should be paid not to mix the protective devices between them (Ben-Zvi 1989). Many goggles are wavelength specific and should be used only with the proper device. Several pairs of goggles or glasses should be available for the patient, physician, assistant and all other persons in the room (Fig. 4.1). Plastic eye shields are recommended. These come in several sizes (small, medium and large) and are light-weight. They are used when eyelid treatment is performed. A topical corneal anesthetic should be used prior to eye shield insertion. Glossy metal eye shields, as other glossy instruments, should be avoided in the laser

The room should be large enough to accommodate the treatment table, IPL device, stand tables, a cupboard for small stores, refrigerator and anesthesia equipment when needed (Fig. 4.1). Each country will have its own regulations regarding the size of the room that should be used. A minimum of 30 m2 is desired if general anesthesia is to be performed. If the treatment room has windows, drapes should be used to cover them to avoid IPL scattering or reflection. If there are mirrors in the room, they should be hidden from the light beam. The treatment table should be placed so as to allow enough space around it for movement. A central position is better when a general anesthesia machine is used. Various types of tables are available, from simple to flexible. The more flexible the table, the greater the patient’s comfort. Manually controlled tables provide

Fig. 4.1  Various IPL devices

29

4.1  Necessary Equipment

flexible articulated posturing of the patient. Some tables can be operated by a pedal shaft selector and foot pump. Other equipment that is used such as trays and holding devices should be mobile so they can be located easily as needed (Maloney 1991). The anesthesia machine and additional monitors should be mobile as well, to adjust their position when treating the head or extremities. A recovery room with the necessary equipment should be available next to the treatment room (Ball 1995). A specialized nurse is required to take care of the patient until he/she becomes ambulatory. A refrigerator is used to store the transparent gel, cooling gels and other medications. A powerful light should be mounted on top of the table for better lighting. A magnifier can be attached to the table side to enhance precision. Several cupboards for storage of disposable products should be available. Among the important items are: • Razor blades for completing hair removal in cases where epilation was not properly done by the patient

• • • • • • • • •

•

•

a

b

c

d

Fig. 4.2  (a) EMLA anesthetic cream applied on the skin before the procedure. (b) The anesthetic cream is covered by a thin plastic sheath. (c) The anesthetic cream is wiped off and a

Gauze, sterile and non-sterile, in various sizes Cotton pads Make-up removal solutions Anesthetic creams (Fig. 4.2a) Plastic sheaths to cover the anesthetic cream on the area prior to treatment (Fig. 4.2b) Rolls Gloves Spatula for spreading the anesthetic cream and the gel Transparent gel for application as interface between the device head and skin; using the gels provided by the company is advised (Fig. 4.2c) Gel masks, usually made of propylene glycol and water with plastic coverings; there are different designs (eye mask, full face mask) which provide the cooling needed immediately after the treatment. Wet gauze or rolls placed in the refrigerator present a cheap alternative for cooling the treated area (Fig. 4.2d). Disposable panties, bras, bikini briefs

t­ransparent gel is used before the treatment. (d) Immediate cooling with wet gauze on the treated area

30

4.1.4 Documentation Written informed consent as well as medical history, physical examination findings, and data on previous treatments should be kept (Dover et al. 1999). Except for the informed consent, all other information can be stored on a computer program. Treating children requires general anesthesia in most cases. A meeting with the anesthesiologist, blood tests and informed consent for general anesthesia should be considered for these cases. A treatment report should be recorded either on a special chart or on the computer. Treatment parameters, such as fluence, pulse duration and delay, should be recorded. It is important to assess and correlate the parameters of the previous treatment with the result. The parameters should be adjusted according to the result obtained. Written instructions should be given to the patient after the procedure - verbal instructions are not always remembered.

4  How to Organize the IPL Treatment Room

Practical Points

›› The acquisition of IPL equipment can be made ›› ››

›› ››

›› ››

4.1.5 Photography and Computer Imaging A digital camera is mandatory. Digital cameras have replaced in most cases 35 mm cameras. The digital image can be immediately seen on a computer with an excellent view of the details. The higher the resolution of the digital camera, the better the view of the details. We recommend using at least 3 mega pixel digital cameras. A computer and monitor are necessary to process and view the digital images. Both laptop and desktop computers can be easily used. Several software programs are available for accessing the pictures, arranging and editing them. They also have the advantage of adjusting brightness, contrast and gamma corrections. Annotation on pictures and measuring tools are also possible. Although there are simulation programs to show the patient the possible result, these should be used cautiously since the result might not match the simulation (Greve and Raulin 2002). A printer is helpful to obtain hard copies of the patient record, recommendations after treatment, and pictures before and after treatment.

››

by purchase, lease or rental. One must analyze which method is best for his/her office. If the number of treatments is not significant, one might consider rental of the equipment. When several devices or lasers are available in the same room, attention should be paid not to confuse their protective devices (goggles or glasses). Plastic eye shields are recommended when treating the periorbital area. The room should be large enough to accommodate the treatment table, IPL device, stand tables, small stores cupboards, refrigerator and anesthesia equipment. Written informed consent, medical history, physical examination findings, and data on previous treatments should be recorded. Digital cameras replace in most cases 35 mm cameras for private offices. Although there are simulation programs to show the patient the possible result, these should be used cautiously since the result might not match the simulation.

References Ball K. Lasers: The Perioperative Challenge. St Louis: Mosby; 1995. Ben-Zvi S. Laser safety: guidelines for use and maintenance. Biomed Instrum Technol. 1989;23(5):360–368. Dover JS, Arndt KA, Dinehart SM et al. Guidelines of care for laser surgery. American Academy of Dermatology. Guidelines/ Outcomes Committee. J Am Acad Dermatol. 1999;41(3 Pt 1):484–495. Greve B, Raulin C. Professional errors caused by lasers and intense pulsed light technology in dermatology and aesthetic medicine: preventive strategies and case studies. Dermatol Surg. 2002; 28(2):156–161. Maloney M. The Dermatologic Surgical Suite Design And Materials. New York: Churchill Livingstone; 1991.

5

Patient Selection

Contents 5.1 Treatment Protocol................................................. 33 References............................................................................ 36

Abstract Patient selection is one of the most important parts of a successful aesthetic procedure. There are two main categories that make a patient an unlikely candidate for cosmetic procedures. One is anatomical unsuitability and the other is psychological unsuitability. Problematic patients are usually those with high expectations, excessive demands, indecisive or immature personalities, secretive or “surgiholics”, those with factitious diseases, and those with familial disapproval. Patient evaluation regarding health status should be done thoroughly and include a search for conditions that contraindicate IPL treatments. A pregnant woman or a patient with significant venous insufficiency and dilated veins might not be suitable for IPL treatment. The local area examination can also reveal conditions, such as skin malignancy, for which IPL would not be the proper treatment. Conversing with the patient and getting to know his/her expectations might be the key to avoiding liability. All patient data and photodocumentation are kept in a separate record for each patient.

Patient selection is one of the most important parts of a successful aesthetic procedure. There are two main categories that make a patient an unlikely candidate for cosmetic procedures (Gorney and Martello 1999). One is anatomical unsuitability and the other is psychological unsuitability. A well-motivated patient seems to have better satisfaction. During consultation, the physician should observe the patient’s behavior (Martello and Bailey 1999). The typical complaint that “the doctor didn’t spend enough time with me” means that the patients emotional needs were not satisfied (Goldwyn 1991). According to Gorney (Gorney and Martello 1999), there are patients with a major deformity and minimal concern. For these patients, any degree of L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_5, © Springer-Verlag London Limited 2011

31

32

improvement will lead to satisfaction. However, there are also patients with a minor deformity and extreme concern, who are likely to be dissatisfied (Figs. 5.1a,b and 5.2a,b). Potential problematic patients are those with unrealistic expectations, excessive demands, indecisive or immature personalities, secretive or “surgiholic” patients, those with factitious diseases and those with familial disapproval (Goldwyn 1991; Gorney and Martello 1999). Patient evaluation regarding health status should be done thoroughly and include a search for conditions that contraindicate IPL treatments. A pregnant woman or a patient with significant venous insufficiency and dilated veins might not be suitable for IPL treatment. The local area examination can also reveal conditions, such as skin malignancy, for which IPL would not be the proper treatment. Particular care should be paid to a

5  Patient Selection

pigmentary changes. Dermatoscopy or skin biopsy can help in making the correct diagnosis before treatment. Sometimes patient expectations might be higher than the possible IPL results. A woman with severe rhytides is not a suitable candidate for IPL treatment if the expectation is to be rid of the wrinkles. Conversing with the patient and getting to know his/her expectations might be the key to avoiding liability. All patient data and photodocumentation are kept in a separate record for each patient. The discussion with the patient should include explaining the diagnosis (e.g., why pigmented spots appear), the principle of IPL treatment, treatment alternatives (laser, peelings, surgeries), anesthesia type, length of treatment, recovery period, long-term results, possible side effects and complications, and expected costs. After the first consultation, the patient takes the informed consent home, reads it carefully, and completes it. Very rarely do we perform treatment the same day. We prefer to do a test and invite patient to return in one week for reevaluation. When larger areas (face, hands, legs) are planned for treatment, the test is mandatory. The device is set with the patient parameters and a single a

b

b

Fig. 5.1  (a) Port-wine stain over the nose and forehead; (b) Although partial response was encountered after eight treatments, the patients was very satisfied

Fig. 5.2  (a) Hypertricosis – before IPL treatment; (b) Partial response after five IPL treatments. The patient was unhappy with the result and stopped the treatments

5.1  Treatment Protocol

light pulse is applied to the area. The reason for doing this test is not to see the possible result but to evaluate the possible side-effects and complications. This test helps in preventing professional errors. In the presence of complications, the treatment parameters are adjusted (e.g., decrease the fluence; increase the pulse delay) and a second test is performed on a different area. Patients should understand that multiple treatments are needed and permanent results should not be expected even after multiple treatments. More precautions should be taken when treating patients with Fitzpatrick skin types IV–VI. The possibility of more complications should also be explained before treatment. Although topical anesthesia will be used before every treatment, patients should be told that some amount of pain can be expected during treatment. A written informed consent is obtained before any treatment. It is important to maintain post-treatment communication. A patient who experiences a difficult posttreatment course or complications needs more contact with the physician. These patients are usually more demanding and the temptation to avoid them should be resisted (Webb 1999).

5.1 Treatment Protocol The basic treatment protocol is herein described. Specific differences for hair removal, rejuvenation or vascular treatment will be described in the corresponding chapter. Once the test result shows no sign of complications, the patient is accepted by the assisting nurse. The area that needs to be treated is cleaned with wet gauze. Special attention is paid to removing make-up from the face. Make-up can interfere with light transmission and absorption. Topical anesthetics are widely used for these procedures. Pain perception varies from individual to individual. We have encountered patients who did not need topical anesthetic before IPL treatment as well as patients who complained of pain after topical anesthetics were used. We have found that longer wavelengths and higher fluences are associated with more pain. Topical anesthetics are typically constructed of three main components: an aromatic ring, an ester or amide linkage, and a tertiary amine. They prevent the initiation and transmission of nerve impulses by targeting free nerve endings in the dermis (Friedman et al. 2001). Although there are many topical anesthetics, such as Betacaine-LA, Tetracaine, Topicaine, and S-Caine, EMLA (Astra Phar­ maceuticals) and ELA-MAX (Ferndale Laboratories) are

33

the most widely used for topical anesthesia (Friedman et al. 2001). Although many topical anesthetics are effective in reducing pain associated with cutaneous procedures, many necessitate a prolonged application time (more than 1 h) (Lener et al. 1997; Huang and Vidimos 2000). ELA-MAX and EMLA have superior anesthetic effects 60 min after application when compared to Tetracaine and Betacaine-LA ointment (Friedman et al. 1999). Invasive anesthesia methods, such as nerve blocks or intravenous sedation, is not needed for IPL treatment. EMLA cream is a 5% mixture of lidocaine and prilocaine. It consists of 25mg/mL lidocaine and 25 mg/mL prilocaine in an oil-in-water emulsion cream (Friedman et al. 1999). Most dermal anesthesia under occlusive dressing is obtained after 60 min. Inadequate analgesia after application for only 30 min has been reported (Evers et al. 1985; Greenbaum and Bernstein 1994). The analgesic effect of EMLA cream was shown to increase 15–30 min after its removal, probably due to continuous release from a reservoir of anesthetic located in the stratum corneum (Evers et  al. 1985; Arendt-Nielsen and Bjerring 1988). ELA-MAX is made up of 4% lidocaine cream in a liposomal vehicle. No occlusion is required and the application time is 15–45 min. ELA-MAX is less expensive than ELA (Friedman et al. 2001). The use of topical anesthetic is helpful before the procedure and provides effective dermal anesthesia with rapid onset of action and minimal side effects. The most encountered side effects are erythema, edema and skin blanching (Fig. 5.1). Among the patients who used EMLA, Alster (Alster and Lupton 2002) found 10% erythema and 90% skin blanching. Among the most serious EMLA complications is the possibility of hemoglobin conversion to methemoglobin and consecutive tissue hypoxia (Guardiano and Norwood 2005). It seems that this complication is more frequent in infants, patients with glucose-6phosphate dehydrogenase or methemoglobinemiainducing drugs (Guardiano and Norwood 2005). Melanin and hemoglobin are the two dominant chromophores in the skin, both having a significant impact on the reflection spectra. Immediate posttreatment bluish appearance (Fig. 5.2), perilesional erythema, blanching (Fig. 5.3a, b) or “urticariform” reaction (Fig. 5.4a,b) are signs of good response for vessels. The different forms of hemoglobin exhibit different characteristic absorption spectra. Any change in hemoglobin concentration will affect the absorption spectra (Haggblad et  al. 2001). Arildsson postulated

34

Fig. 5.3  Skin whitening after EMLA application

Fig. 5.4  Immediate bluish appearance after port-wine stain treatment

that there is an increase in perfusion in the deep vessels in anesthetized skin, compensating for the decrease in number of physiologically active capillaries (Arildsson et al. 2000). A different study (Haggblad et al. 2001) demonstrated that the blood flow in EMLA analgesized skin increased through dilatation of larger deeper skin vessels. We have observed that EMLA works faster on the face than in other areas, most probably due to higher vascularity and greater absorption in this area. Once the area is anesthesized, the patient is brought into the treatment room and laid on a special table to be comfortable during the treatment. The anesthetic cream is removed and the area cleaned with wet gauze. A thin layer (2–3 mm) of cold transparent gel is applied to the skin. Skin cooling during and/or after treatment

5  Patient Selection

helps to protect the epidermis from unwanted thermal injury. Contact skin cooling is sometimes used for anesthesia during dermatological procedures. The cooling process is important for most IPL applications. The epidermal temperature is decreased by the cooling method, while the chromophore temperature remains unchanged and effective for the treatment. The cooling method also allows the delivery of higher fluencies with fewer side effects. There are three main methods of surface cooling during IPL or laser treatment: precooling, parallel cooling and postcooling (Anderson 2000). Precooling refers to decreasing the temperature of the epidermis immediately before the pulse. Parallel cooling takes place at the same time as the pulse. It is preferable for devices with a longer pulse duration (Carroll and Humphreys 2006). Postcooling refers to decreasing the temperature immediately after the treatment, usually done with ice packs. Spray and contact cooling are the main methods used for most light pulsed and laser devices (Zenzie et al. 2000). Both methods necessitate control of precooling time to achieve selectivity and to prevent the epidermis from frost injuries. The precooling time of the spray cannot be easily controlled (Altshuler et  al. 1999; Zenzie et  al. 2000). It seems that an external cooling medium around – 50 for 1 s of precooling is ideal to avoid frost injuries. The size, energy and discharge specifications of most IPL devices require a cooling circuit where water is pumped around the flash lamp to cool it (Ash et  al. 2007) (Figs. 5.5 and 5.6). Protective eyeglasses are used by the patient and medical staff for the entire period of the treatment. Particular attention should be paid to selecting proper parameters, taking into consideration the test result. Choosing too short treatment intervals can lead to more complications. At the end of the treatment, the area is wiped and cooled with ice packs for about 15 min. When larger areas are treated, the ice packs are placed immediately as each anatomic region is completed. For instance, when IPL is used for leg hair removal, the ice packs are applied as soon as one anatomic area is treated (i.e., anterior or posterior calf, anterior or posterior thigh). Cooling during and after treatment is essential for most procedures. When cooling is not performed, the thermal injury can affect not  only the chromophores but also the surrounding tissue. Epidermal damage can be seen easily (Greve and Raulin 2002).

35

5.1  Treatment Protocol

a

b

Fig. 5.5  (a) Appearance of reticular veins on the leg before treatment; (b) The whitening effect immediately after IPL treatment

a

b

The patient is allowed to use make-up immediately. Avoiding sun exposure or photosensitizing medication is strongly recommended between treatments. We usually perform treatments 1 month apart but, in cases of complications, this interval is lengthened. The relatively short time for the procedure and the quick recovery have  led IPL treatments to be considered a “weekend procedures”.

Practical Points

›› A well motivated patient seems to have better satisfaction.

›› Identifying ››

Fig. 5.6  (a) Small size leg veins before treatment; (b) “Urti­ cariform” reaction immediately after treatment

the anatomical or psychological unsuitability of the patient is the key to patient selection. Problematic patients are usually those with high expectations, excessive demands, indecisive or immature personalities, secretive or “surgiholics”, those with factitious disease, and those with familial disapproval.

36

5  Patient Selection

›› Particular attention should be paid to ruling out ›› ››

›› ›› ›› ›› ››

skin malignancies in the area that needs to be treated. Conversation with the patient, getting known his/her expectations, might be the key to avoiding liabilities. A short test before starting the treatment provides details about skin reactivity and response. In the presence of side effects, the treatment parameters are adjusted. Posttreatment communication with the patient is also important in avoiding liabilities. EMLA and ELA-Max are the most used topical anesthetics for IPL procedures. Skin cooling during and/or after treatment helps to protect the epidermis from thermal injury. Particular attention should be paid to selecting proper parameters, taking into account the test result. Avoiding sun exposure or photosensitizing medication is strongly recommended between treatments.

References Alster TS, Lupton JR. Evaluation of a novel topical anesthetic agent for cutaneous laser resurfacing: a randomized comparison study. Dermatol Surg. 2002; 28(11):1004–1006; ­discussion 1006. Altshuler GB, Zenzie HH, Erofeev AV, et al. Contact cooling of the skin. Phys Med Biol. 1999;44(4):1003–1023. Anderson RR. Lasers in dermatology-a critical update. J Dermatol. 2000; 27(11):700–705. Arendt-Nielsen L, Bjerring P. Laser-induced pain for evaluation of local analgesia: a comparison of topical application (EMLA) and local injection (lidocaine). Anesth Analg. 1988;67(2):115–123.

Arildsson M, Asker CL, Salerud EG, et al. Skin capillary appearance and skin microvascular perfusion due to topical application of analgesia cream. Microvasc Res. 2000; 59(1):14–23. Ash C, Town GA, Martin GR. Preliminary trial to investigate temperature of the iPulse intense pulsed light (IPL) glass transmission block during treatment of Fitzpatrick II, IV, V, and VI skin types. Lasers Med Sci. 2007;22(1):4–9. Carroll L, Humphreys TR. LASER-tissue interactions. Clin Dermatol. 2006; 24(1):2–7. Evers H, von Dardel O, Juhlin L, et al. Dermal effects of compositions based on the eutectic mixture of lignocaine and prilocaine (EMLA). Studies in volunteers. Br J Anaesth. 1985; 57(10):997–1005. Friedman PM, Fogelman JP, Nouri K, et al. Comparative study of the efficacy of four topical anesthetics. Dermatol Surg. 1999; 25(12):950–954. Friedman PM, Mafong EA, Friedman ES, et  al. Topical anesthetics update: EMLA and beyond. Dermatol Surg. 2001; 27(12):1019–1026. Goldwyn R. The Patient and the Plastic Surgeon. Boston: Little, Brown and Co. Gorney M, Martello J. Patient selection criteria. Clin Plast Surg.1999;26(1):37–40, vi. Greenbaum SS, Bernstein EF. Comparison of iontophoresis of lidocaine with a eutectic mixture of lidocaine and prilocaine (EMLA) for topically administered local anesthesia. J Dermatol Surg Oncol. 1994; 20(9):579–583. Greve B, Raulin C. Professional errors caused by lasers and intense pulsed light technology in dermatology and aesthetic medicine: preventive strategies and case studies. Dermatol Surg. 2002; 28(2):156–161. Guardiano RA, Norwood CW. Direct comparison of EMLA versus lidocaine for pain control in Nd:YAG 1,064 nm laser hair removal. Dermatol Surg. 2005; 31(4):396–398. Haggblad E, Larsson M, Arildsson M, et al. Reflection spectroscopy of analgesized skin. Microvasc Res. 2001;62(3): 392–400. Huang W, Vidimos A. Topical anesthetics in dermatology. J Am Acad Dermatol.2000; 43(2 Pt 1):286–298. Lener EV, Bucalo BD, Kist DA, et al. Topical anesthetic agents in dermatologic surgery. A review. Dermatol Surg. 1997; 23(8):673–683. Martello J, Bailey CW, Jr. Doctor-patient relationship. The consultation. Clin Plast Surg. 1999; 26(1):53–55, vi. Webb MS. Failure in communication. The common denominator. Clin Plast Surg. 1999;26(1):41–51, vi. Zenzie HH, Altshuler GB, Smirnov MZ, et  al. Evaluation of cooling methods for laser dermatology. Lasers Surg Med. 2000;26(2):130–144.

6

Skin Photorejuvenation

Contents 6.1 Skin Aging............................................................... 6.1.1 Rhytides.................................................................... 6.1.2 Pigmented Lesions.................................................... 6.1.3 Vascular Lesions.......................................................

37 38 38 41

6.2 Histological Aspects of Skin Treated with IPL.... 42 6.3 Treatment Strategies............................................... 43 6.4 Literature Review................................................... 6.4.1 Skin Texture.............................................................. 6.4.2 Vascular Lesions....................................................... 6.4.3 Pigmented Lesions....................................................

44 47 50 50

References............................................................................ 58

Abstract The term ‘photorejuvenation’ describes the simultaneous improvement of various epidermal changes related to aging. Sun exposure and smoking are the main factors that induce premature skin aging. Rhytides are due to a decrease in facial skin elasticity causing accentuation of lines and wrinkles. There are three main mechanisms of non-ablative technology involved in skin rejuvenation: • Heating that leads to fibroblast activation, remodeling of collagen and increased synthesis of pro-­ collagen III • Dermatologic regression, represented by displacement of photodamaged dermis and improvement of epidermal and dermal parameters • Endothelial disruption, cytokine activation and ­collagen remodeling. Hemoglobin and melanin are the primary chromophores involved in skin rejuvenation. Type I photorejuvenation refers to vascular anomalies, pigmentary changes or pilosebaceous changes, while Type II is related to dermal and subcutaneous senescence. The main advantages of IPL skin rejuvenation are minimal downtime recovery, fast and easy to perform, minimal complications, minimal interference with lifestyle and long-term improvement.

6.1 Skin Aging The term ‘photorejuvenation’ describes the simultaneous improvement of various epidermal changes related to aging (Rokhsar et al. 2005). Sun exposure and smoking are the main factors that induce premature skin aging (Kadunce et  al. 1991; Fisher et  al. 1997; Yin et  al. 2001). With age, there is increased L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_6, © Springer-Verlag London Limited 2011

37

38

sun exposure. Among the ultraviolet (Bernstein et al.) radiations, UVB is considered the most damaging (Rokhsar et al. 2005). UVA can also produce burns if it is administered at high levels. The extent of sun damage is proportional to the amount of exposure. Thus as one ages, areas such as face, neck, upper chest and hands are more prone to photoaging. These alterations are more frequent in persons who are fairskinned (Fisher et al. 2008). Intrinsic skin aging refers to structural changes that are independent of environmental influences. Often the skin has a mottled appearance due to a decrease in melanocytes (Castanet and Ortonne 1997). Over the age of 30, the melanocytic number decreases 10–20% per 10-years (Lawrence 2000). However, there is an irregular melanosome distribution to the adjacent keratinocytes (Castanet and Ortonne 1997). Xerosis is typically found with aged skin and is due to decreased sebaceous and eccrine gland function. It is especially evident on the hands and face. The rough aspect of photoaged skin is due to changes in the stratum corneum and the amount of glycosaminoglycan in the dermis (Bernstein et al. 1996). Dermal changes include accumulation of fibrous material, especially in the superficial reticular dermal layer. These changes are known as elastosis due to the high uptake of the elastic tissue stains (Greenbaum and Bernstein 1994; Talwar et al. 1995; Fisher et al. 1997; Uitto 1997). Degenerative changes are evident in the collagen structure also. All these changes produce various clinical presentations represented by mottled pigmentation, teleangiectasia, wrinkled and dry skin (Fig. 6.1a–d) (Fusco 2001). The changes in the epidermis are represented by irregular pigmentation, atrophy and cellular atypia. Both extrinsic and intrinsic aging is associated with the production of excessive amounts of free radicals (Rokhsar et al. 2005). The three main expressions of aged skin are rhytides, pigmented lesions and vascular lesions.

6.1.1 Rhytides Rhytides are due to a decrease in facial skin elasticity causing accentuation of lines and wrinkles (Fusco 2001). Dermal elastic fibers initially thicken. Because the skin loses its elasticity, gravity leads to a sagging effect, especially visible on the neck and jaw line

6  Skin Photorejuvenation

(Gilchrest 1996; Lawrence 2000). Repeated facial muscle movements accentuate the lines of expression (Lawrence 2000).

6.1.2 Pigmented Lesions Lentigines are light-to-medium brown benign hyperpigmented macules (Fig. 6.2a, b). Lentigo simplex arises in childhood and does not have a predilection for sun-exposed areas. The pigment is uniformly distributed throughout the lesion. Solar lentigo is an acquired lesion present on sun-exposed areas such as face, chest, and hands. They usually appear in middle age and are due to an increased number of melanocytes and melanin deposition in the basal layer. Histologic examination reveals parakeratosis and epithelial acanthosis. Café-au-lait macules are light tan-to-brown hypermelanotic flat lesions with a clear demarcation from surrounding skin (Figs. 6.3a, b and 6.4a, b). They can appear at birth or later, especially in the first 2 decades of life. Histology shows hypermelanosis in the basal layer of the epidermis including basal melanocytes and keratinocytes. These lesions do not have a malignant potential. Poikiloderma of Civatte appears as a rusty-brown hyperpigmentation and telangiectasia. It is more frequently located on the neck, chest and lateral side of the face. Although its origin is suggested as a hormonal imbalance associated with menopause, its location on sun-exposed areas suggests that sun has an important contribution. Pulsed light or laser treatments have proved to be useful in treating these lesions (Potozkin and Geronemus 1991; Alora et al. 1999). Ephelides, commonly called freckles, are small tan-brown macules that occur on sun-exposed areas (Fig. 6.5a, b). Histology shows hypermelanization confined to the basal cell layer. The melanosomes and melanocytes appear to be enlarged. Melasma is represented by irregular brown or grayish facial hypermelanosis and is more often present in women with Fitzpatrick skin type IV to VI (Gupta et al. 2006). The condition is more evident in UV-exposed areas, worsening in the summer and improving in the winter. Genetic predisposition, oral contraceptives, pregnancy or endocrine dysfunction have been related to its appearance. When it is related to pregnancy, it usually resolves within a few months after delivery.

39

6.1  Skin Aging

a

b

c

d

Fig. 6.1  (a) Rough aspect of photoaged skin; front view; (b) After two IPL treatments; (c) Same patient; lateral view; (d) After two treatments; lateral view

40

a

6  Skin Photorejuvenation

b

Fig. 6.2  (a) Lentigines over the forehead and scalp area; (b) Slight improvement after one IPL treatment

a

b

Fig. 6.3  (a) Café au lait in an adult – located on the upper lip; (b) Good response after two IPL sessions

Nevus of Ota is a bluish-gray macular lesion present on the face, in the area innervate by the trigeminal nerve. It is more commonly seen in Asians and Blacks. The lesion often varies in color and the edges are usually not well-demarcated. Histology shows bipolar dermal melanocytes distributed largely in the upper part of the dermis. The epidermis and dermis are usually normal. Nevus of Ito is a grayish-blue discoloration with histological aspects similar to nevus of Ota. It is

frequently located on the shoulder or upper arm and is seen more often in Japanese. Baker nevus is a light to medium brown patch, usually of a few centimeters, that appears frequently in childhood. The lesions are hyperkeratotic and covered by coarse hair. The histological aspect shows acanthosis, hyperkeratosis, rete ridge elongations, increased number of melanocytes and thickening of the dermis. This lesion is considered to be an organoid hamartoma (Chapel et al. 1981).

41

6.1  Skin Aging

a

b

Fig. 6.4  (a) Café au lait in a child; (b) After two IPL treatments

a

6.1.3 Vascular Lesions Telangiectasia refers to superficial cutaneous vessels typically up to 1mm in diameter (Fig. 6.6). The vessels can be of arteriole, capillary or venule origin. The arteriolar type is bright red and protrudes above the skin surface. The capillary type is red. These lesions are often located on the face in light skinned patients. They are mainly distributed on the nose and mid-cheeks. They are also associated with rosacea, pregnancy, steroids or actinic damage. There are four clinical types: simple or linear, arborizing, spider and papular (Goldman and Bennett 1987). The red/blue linear and arborizing lesions are often present on the face and legs while the papular type is part of syndromes such as Osler-WeberRender or associated with collagen vascular diseases. Venous lakes are dilated venules in the upper dermis. They are commonly located on the ears or lips. They appear as dark-blue soft nodules of a few millimeters size. They are present in severe solar elastosis when the stromal support is diminished. Senile purpuras are purple-red echymoses due to the loss of subcutaneous tissue and a predisposition to vascular damage. Their fragility is due to flattening of the dermal-epidermal junction (Gilchrest 1996).

b

Fig. 6.5  Before (a) and after (b) two IPL treatments, showing marked improvement of lesions

42

6  Skin Photorejuvenation

or pilosebaceous changes, while type II is related to dermal and subcutaneous senescence (Sadick 2003). Type I may be categorized into three subtypes. Type 1a includes rosacea and telangiectasis, Type 1b refers to pore size and skin roughness, and Type 1c includes pigmentary changes. There are three main mechanisms of non-ablative technology involved in skin rejuvenation (Sadick 2003): • Heating that leads to fibroblast activation, remodeling of collagen and increased synthesis of pro-­ collagen III • Dermatologic regression, represented by displacement of photodamaged dermis and improvement of epidermal and dermal parameters • Endothelial disruption, cytokine activation and ­collagen remodeling

6.2 Histological Aspects of Skin Treated with IPL Fig. 6.6  Teleangiectasia of the nose

Antiaging treatment, such as lights, lasers and creams, stimulate the production of new collagen. It seems that the fibroblast attachment to the new collagen allows stretching and balances collagen production (Fisher et al. 2008). Many methods of improving photoaged skin have been reported. Intense Pulsed Light is a non-coherent light produced by a flash lamp. This is a relatively recent technology used for skin rejuvenation. The quality of aging skin can be improved by ablative or non-ablative treatments. The difference between these two methods is that the epidermis is not disrupted in non-ablative treatments (Alam et  al. 2003), and the recovery time is incomparably faster than in ablative treatments. The appearance and quality of skin is improved by IPL through stimulating the body’s natural wound healing mechanism (Clement et al. 2005). The light targets the microvasculature and the pigmented lesions; and is responsible for initiation of the described process. Hemoglobin and melanin are primary chromophores involved in skin rejuvenation. The peak of hemoglobin absorption is around 580 nm, while for melanin it ranges from 400 to 750nm (Raulin et al. 2003). Photorejuvenation can be categorized in two types: type I refers to vascular anomalies, pigmentary changes

Several authors have reported the histological changes after IPL treatment. Most reported collagen improvement. In an animal study (Kunning mouse model), it was found that non-ablative laser improved the thickness of the dermal layers and collagen fiber density. The amount of hydroxyproline content and collagen synthesis (type I, III) increased (Liu et  al. 2008). Biopsies from three patients after five treatments showed significant deposition of collagen in the superficial layer of the dermis (Negishi et al. 2002). Collagen type I and III were identified. The activation of intracellular fibroblast activity and collagen proliferation is initiated by thermal injury to the collagen fibers caused by heat conducted from the chromophores (Negishi et al. 2002). The collagen fibers are also damaged by their light absorption and by the non-selective heating of the dermis. Negishi (Negishi et al. 2002) considered that wavelengths between 400 to 600nm are absorbed by the collagen fibers and cause the injury. An increase of procollagen type I, III collagenase, elastin and hyaluronate receptor has been noticed after IPL (Zelickson 2000). New collagen formation was observed by Goldberg (Goldberg 2000) after treatment. One study examined the malar skin histologically one week after IPL treatment (Hernandez-Perez and Ibiett 2002). The telangiectasia, inflammation,

6.3  Treatment Strategies

elastosis changes, epidermal atrophy, rete ridge flattening and basal cell necrosis were found to be improved. The epidermal thickness increased to a range from 0.01–0.03mm. The greatest improvement was observed in the degree of elastosis. The effect of IPL on the skin structure of five women was evaluated by Prieto (Prieto et al. 2002). He analyzed skin punch biopsies before treatment, 1 week, 3 months and 12 months after five treatments. In three patients he found at least one follicle containing Demodex organisms and perifollicular lymphoid infiltrate but no significant perifolicular infiltrate 1 week later. Biopsies done later showed Demodex and mild perifolicular lymphoid infiltrate. The author concluded that IPL induces coagulation necrosis of Demodex organisms. It seems that Demodex contains some chromophore that makes the parasite more sensitive to IPL. On a fibroblast culture, it was shown that IPL inhibits the MMPs (Wong et al. 2008). MMPs are a family of zinc-containing proteases with different substrate specificities and inducibility. The mechanism by which IPL improves pigment lesions was investigated by Yamashita (Yamashita et  al. 2006). Solar lentigines were treated with three sessions of IPL and observed on consecutive days, using reflectance-made confocal microscopy and optical coherence tomography. It was found that the melanosomes from the epidermal basal layer migrated towards the skin surface. Electron microscopy of the desquamated crusts showed numerous melanosomes.

6.3 Treatment Strategies Skin rejuvenation should achieve reduction of visible pigmentation and vessels and improve skin texture. The physician must thoroughly explain to the patient the difference in the expected results between IPL technology and other ablative technologies (i.e., CO2 laser, chemical peelings). The fact that vascular and pigmented improvement will be noted a few months later and the fact that minimal wrinkle and skin texture improvement will be seen almost one year later should be emphasized during consultation. During the physical examination, special attention should be paid to ruling out skin malignancies. If the patient is taking retinoids (isotretinoin) or other photosensitizing medication, delaying treatment for at least 6 months is suggested. Pregnant women or the presence of active

43

infectious disease are contraindications to treatment. Particular care must be paid to sun-tanned patients. Treatment is performed only if the patient is willing to avoid sun exposure or to use sunscreens for the entire treatment period. Patients with a history of herpes simplex infection require prophylaxis. Most of our patients request facial rejuvenation. The area should be cleaned and free of make-up before starting the treatment. We are in favor of using topical anesthetics (EMLA or ELA-Max) before the treatment. The basic treatment protocol is followed, as detailed in another chapter. The first parameter introduced to the machine is the skin type according to Fitzpatrick classification. Then the SR parameter is set up. The treated area is covered by a single pass. The mode for dealing with vascular lesions can also be used in a different session to enhance the results. A single pass is performed during one session. Large footprints are used for large areas. Thus, the treatment is faster and the light distribution into the skin is more uniform with better effects. Small footprints are used when the anatomic region is curved, as on the eyelids, nose, upper lip or ears. When performing eyelid treatment, plastic eye shields are used as protectors. The patient is strongly encouraged to keep the eyes closed during the procedure. The footprint is always placed perpendicular to the skin (Fig. 6.7). In areas with hyperpigmentation, slight pressure is used; in areas with predominant vascular abnormalities, no pressure is applied. In this way, the blood vessels are not emptied and the treatment is more effective. When approaching the hair-bearing area on the face, such as the eyebrows, this is covered by white gauze and the IPL footprint is placed 2–3mm from the edge. Unintended hair removal in this area can

Fig. 6.7  Zebra appearance as a result of avoiding overlapping of treated areas

44

appear if precautions are not taken. At times, uneven edges of the treated area can be noticed in the treatment of Poikiloderma of Civatte (Dierickx and Anderson 2005). Performing treatment of the entire cosmetic anatomical units is recommended in such a situation. Treatments are performed one-three months apart. If almost no change in the pigmentation or vascular lesion is noted after the first treatment, the fluence is increased by 2–4J/cm2 for the next session. A good response can be seen immediately after treatment when blanching of the vessels, “urticaria” type reaction or slight darkening of the pigmented lesions appears (Fig. 6.8a, b). Treatment time varies according to the anatomical area, from a few minutes to more than 15 min for the neck and chest. Ice packs are always used at the end of the treatment and are intended to reduce the burning sensation and decrease the swelling. Almost all patients are able to resume normal activities after the procedure. Some patients experience a burning sensation that disappears within minutes. Erythema and edema are present in most patients and resolve within a

b

Fig. 6.8  (a) Pigmented skin lesion over the dorsum of the hand; (b) Darkening of the lesion 3 days after IPL treatment

6  Skin Photorejuvenation

hours to 2–3 days. The reaction of the pigmented lesions usually causes their darkening for the next 7–8 days. We do not consider this as signs of complications unless the unwanted effect lasts for more than a few days. These are part of the normal skin response after IPL treatment. The skin is not a uniform structure and lesions are present at different levels of the dermis. This is why we prefer to alternate the cutoff filters instead of using a single wavelength for every treatment. Regression of the results is a normal process that occurs after any cosmetic procedure. The regression is usually visible from one to a few years after treatment. Maintenance treatments every year are recommended to continue seeing positive effects (Sadick 2003).

6.4 Literature Review Many studies have confirmed the effectiveness of photorejuvenation (Table 6.1). Women seek this treatment more frequently. The request for IPL procedures from men is less than 10% of all requests. However, men are self-conscious and cautious. They are often concerned about a few lesions (i.e. lentigines) (Fig. 6.9a, b) although they have diffuse dyschromias (Fig. 6.10a, b) (Ross 2007). Unlike women, they often prefer to have the lesions treated instead of having a full face treatment. Men are less willing to return to work if significant swelling is present after treatment (Ross 2007). Particular attention should be paid to hair-bearing areas (chin, cheeks, preauricular and perioral areas). A lesion located in this area can be treated with the price of hair removal. Race also has an influence on skin response to treatment. In Asians, pigmentary problems are more frequently encountered than wrinkling (Chung et al. 2001). Among pigmented lesions, nevus of Ota is more frequently present in Asians. There are a variety of IPL devices on the market (Ross 2006), and parameters vary widely from one device to another. Certain fluences which are safe for a particular application in one device may be dangerous with other IPL devices; modern IPL devices deliver a constant spectrum emission at low fluences (Trelles et al. 2007). Former generations of IPL systems had variations of the beam as the pulse progressed, with the end of the pulse more in the red/infrared spectrum; modern IPL devices have a computer system that reduces this socalled “spectral jitter” (Ross 2006; Trelles et al. 2007).

IPL device

Vasculight

IPL Quantum (Lumenis)

Vasculight

Quantum SR

Vasculight (ESC/Sharplan)

Photoderm VL (Lumenis)

IPL (ESC Medical)

Photoderm VL (Lumenis)

Photoderm VL and Vasculight

Vasculight (ESC/Sharplan)

IPL (ESC/ Sharplan)

Author/year

Fodor et al. 2004

Alster et al. 2005

Hernandez-Perez and Ibiett 2002

Negishi et al. 2002

Bitter 2000

Weiss et al. 2002

Goldberg and Cutler 2000

Mark et al. 2003

Schroeter et al. 2005

Huang et al. 2002

Goldman and Weiss 2001

Poikiloderma of Civatte

Facial freckles

Rosacea and telangiectasia

Rosacea

Class I-II facial rhytids

Face, neck, chest rejuvenation Poikiloderma of Civatte

Face rejuvenation

Face rejuvenation

Face rejuvenation

Face rejuvenation

Skin rejuvenation (face, neck, chest, hands)

Indication

Table 6.1  Various results after IPL treatment

66

17

60

4

~2.8

1–3

~4

5

1–4

3

80

30

>4

>5

5

49

73

5

2

1–4

59

10

No tt.

Pat.

1 month

1 month

NA

3 weeks

2 weeks

1 month

3 weeks

3–4 weeks

2 weeks

1 month

1 month

Treat. interval

NA

III-IV

I-IV

NA

I-II

I-IV

I-III

III-V

NA

NA

II-IV

Fitzpatrick type

515 nm mostly 30–34 J/cm2

550–590 nm 25–35 J/cm2

550 nm 25–35 J/cm2

515 nm 22–25 J/cm2

645 nm 40–50 J/cm2

550,590 nm 22–44 J/cm2

550–570 nm 30–50 J/cm2

560 nm 28–32 J/cm2

645 nm > 25 J/cm2

560 nm 27–30 J/cm2

560, 640 25–45 J/cm2

Cutoff filter/ Fluences

(continued)

75–100% significant reduction observed in 28 patients

86.1% had excellent or good results

77.8% mean clearance for average 51.6 months Recurrence in 4 patients

30% decrease in blood flow 29% decreased area occupied by telangiectasia 21% decrease in intensity of erythema

9 patients had substantial improvement 16 – had some improvement 5- no improvement

Better results on the face than neck and chest 83% skin texture improvement 82% telangiectasia improvement 79% pigment improvement

Visible improvement in > 90% 88% were satisfied

Most patients had more than 60% improvement

Moderate to very good improvement

Better improvement of 5-ALA plus IPL side

Good to very good in 93.1%

Results/satisfaction

6.4  Literature Review 45

Multilight (ESC Med System)

Natulight (Lumenis)

Vasculight (ESC/Sharplan)

IPL

Lumenis One (Tokyo)

Paquet and Pierard 2004

Kawada et al. 2002

Wang et al. 2004

Moreno Arias and Ferrando 2001

Konishi et al. 2008

Facial pigmentary lesions

Melanocytic lesions

Refractory melasma

Facial pigmentary lesions

Persistent facial hypermelanosis

Poikiloderma of Civatte

Indication

NA Not available; tt treatment; Pat Number of patients

IPL (ESC/ Sharplan)

Weiss et al. 2000

Table 6.1  (continued) Author/year IPL device

18

20

17

60

2

135

Pat.

3–5

2–4

4

3–5

5

1–5

No tt.

2–3 weeks

4–8 weeks

1 month

2–3 weeks

1 month

1 month

Treat. interval

NA

II-IV

III-IV

NA

II

NA

Fitzpatrick type

560 nm 12–14 J/cm2

590 nm–34 J/cm2 615 nm–38 J/cm2

570, 590, 615 nm 26–33 J/cm2

560 nm 20–24 J/cm2

550, 590, 615 nm 25–32 J/cm2

515, 550, 570 nm 20–24 J/cm2

Cutoff filter/ Fluences

28% had marked improvement 39% had slight improvement

76–100% clearance for superficial lesions 51–75% clearance for nevus spilus

39.8% improvement in relative melanin index 35% had more than 50% improvement

48% had more than 50% improvement 20% had more than 75% improvement

80% decrease in hypermelanosis

Grade 4 (75–100%) improvement in 82% of patients

Results/satisfaction

46 6  Skin Photorejuvenation

47

6.4  Literature Review

a

b

I.J. Peled, Y. Rissin, Y. Ramon, O. Shoshani, L. Eldor, A. Gaiman, Y. Ullmann; Using Intense Pulsed Light for Cosmetic Purposes: Our Experience. Plast Reconstr Surg, 2004;113:1789–1795)

Fig. 6.9  (a) Numerous lentigines prior to treatment; (b) After a  single IPL treatment (Reprinted with permission of Wolters Kluwer Health/Lippincott Williams & Wilkins: L. Fodor,

a

b

Fig. 6.10  (a) 54-year old woman with photodamage prior to  treatment (b) Three months after two IPL treatments (Reprinted with permission of Wolters Kluwer Health/Lippincott Williams & Wilkins: L. Fodor, I.J. Peled, Y. Rissin, Y. Ramon,

O. Shoshani, L. Eldor, A. Gaiman, Y. Ullmann; Using Intense Pulsed Light for Cosmetic Purposes: Our Experience. Plast Reconstr Surg, 2004;113:1789–1795)

6.4.1 Skin Texture

(Dierickx and Anderson 2005). In a long-term followup study, Weiss (Weiss et  al. 2002) reported skin ­textural improvement in 83% of patients. The evaluation was done four years after the IPL procedure, with a chart review of 80 randomly selected patients. The face responded slightly better than the chest or neck with a 90% texture improvement. After four IPL treatments, Bitter (Bitter 2000) reported wrinkle improvement from a score of 5 (moderate) to 2.83

Skin texture improvement has been reported by several authors. Non-ablative photorejuvenation is considered to “remodel” the dermis due to the thermal injury to the papillary and upper reticular dermis, sparing the epidermis (Nelson et al. 2002). Collagen remodeling continues for up to one year after the end of IPL treatment (Figs. 6.11a, b, 6.12a, b, 6.13a, b)

48

a

6  Skin Photorejuvenation

b

Fig. 6.11  (a) The appearance before treatment; (b) Three months after a single IPL treatment

a

Fig. 6.12  (a) 56-year-old woman with mainly pigmentation changes (b) Same patient, 6 months after the third treatment (Reprinted with permission of Wolters Kluwer Health/Lippincott Williams & Wilkins: L. Fodor, I.J. Peled, Y. Rissin, Y. Ramon,

b

O. Shoshani, L. Eldor, A. Gaiman, Y. Ullmann; Using Intense Pulsed Light for Cosmetic Purposes: Our Experience. Plast Reconstr Surg, 2004;113:1789–1795)

49

6.4  Literature Review

a

b

Fig. 6.13  (a) The appearance of photodamaged skin; (b) Skin tightening and dyschromia improvement demonstrated after three IPL sessions

post-treatment (mild). The patients also reported some degree of improvement in skin laxity. The level of satisfaction was as high as 88%. A higher satisfaction rate after skin rejuvenation was reported by Fodor et  al. (2004) with the 5-point Likert scale to evaluate the results; 93.2% of the patients felt they had good to very good results, with better improvement in pigmented and vascular lesions compared to skin texture. We have not seen significant skin texture improvement after IPL treatment. The lighter skin color obtained should not be confused with skin texture and rhytid improvement. During consultation, we strongly emphasize that significant skin texture improvement will not be achieved with this method. If the patient understands this, the satisfaction level is high. The association of ALA and IPL has been successfully used to improve skin texture (Gold et al. 2004; Taub 2004; Alexiades-Armenakas 2006). 5-ALA is a photosensitizing agent often used to treat acne vulgaris, skin carcinomas, psoriasis or other dermatologic conditions. Its application was extended recently by using it for skin rejuvenation in combination with IPL.

The topical application of ALA produces an accumulation of the endogenous photosensitizer protoporphyrin IX (PpIX). The maximum absorption of PpIX induced by 5-ALA is at 410, 630 and 690 nm (DeHoratius and Dover 2007). The free radicals resulting from ALA metabolisation have a selective action based on accumulation mainly in the pilosebaceous units and hyperproliferative keratinocytes (Uebelhoer and Dover 2005). IPL decreases the amount of Propionibacterium acne and reduces the size of sebaceous glands and the amount of sebum production (Heymann 2007). When ALA is combined with IPL for photodynamic therapy, it is applied for a relatively short period of about one hour before the procedure. This short incubation time is enough to improve IPL results (Avram and Goldman 2004). The positive sideeffects of ALA and IPL combination were recorded after treatment of actinic keratosis (Ruiz-Rodriguez et al. 2002). Improvement of skin elasticity, wrinkles and pigmentary changes have been noticed. Good results of rejuvenation after ALA and IPL have been recorded for patients with photoaging (Gold and Goldman 2004). A split-face comparison study of IPL

50

alone or combined with 5-ALA for photorejuvenation was reported by Alster (Alster et  al. 2005). Better results were observed after two treatments with the 5-ALA-IPL combination although desquamation was observed in these areas. The same combination was reported to be useful for treatment of acne vulgaris (Heymann 2007). It proved to be more efficient than IPL alone, although the level of improvement was 66.8%. A clearance rate of 71.8% for the same condition was reported in another study (Alexiades-Armenakas 2006). There are no data on humans but Hedelund (Hedelund et al. 2006) demonstrated that IPL has no carcinogenic potential in mice. The main advantage of combining 5-ALA with IPL is a reduced number of treatments and better clinical outcome. Photodynamic therapy with ALA is not widely approved and most countries restrict its use to the experimental level (Calzavara-Pinton et al. 2007).

6.4.2 Vascular Lesions With its ability to emit a wide spectrum of wavelengths and adjustment of pulse duration, delay and fluences, IPL has proven to be useful for treating various vascular and pigmented lesions (Dierickx and Anderson 2005). There are several reports of vascular lesion improvement when performing skin rejuvenation (Table 6.1). Most report on telangiectasia improvement. When using Vasculight or Quantum to treat telangiectasia, Goldman (Goldman et al. 2005) prefer to use a double pulse of about 2.4–4ms duration, with a delay time of 10ms in light skin and 20–40ms in darker skin. The fluences are usually between 28 and 35J/cm2. Our experience with Vasculight for photorejuvenation shows that fluences between 25 and 45J/cm2, cutoff filters of 560 and 640nm, a pulse duration of 2.4–7ms, and a pulse delay of 15–75ms are the parameters most often employed. Using Lumenis One, the fluences delivered are less than with Vasculight. Negishi (Negishi et al. 2001, 2002) performed photorejuvenation on 73 patients using the original IPL or Quantum IPL. The fluences varied from 23 to 27J/cm2, pulse duration varied from 2.8 to 6ms and the pulse delay from 20 to 40ms. Excellent results for small red telangiectasias were obtained by using synchronized pulses with an initial short 2.4–3ms followed by a second longer

6  Skin Photorejuvenation

4–8ms pulse (Goldman et al. 2005). Weiss (Weiss et al. 2002) reported 82% telangiectasia improvement. The evaluation was done four years after IPL treatment by reviewing the charts of 80 randomly selected patients. The face responded slightly better than the chest or neck with a 90% texture improvement. There is limited data in the literature regarding treatment of rosacea with IPL. Rosacea is a common condition and includes stages such as facial flushing, erythema, edema or rhinophyma, but its exact etiology is not clear (Schroeter et al. 2005). Mark (Mark et al. 2003) reported good results on a small number of patients, and a mean clearance of 77.8% was reported by Schroeter (Schroeter et  al. 2005). The clearance time persisted for an average of 51.6 months. A recurrence rate of about 7% was observed 3 years posttreatment. A higher cutoff filter, longer pulse duration and longer pulse delay has a better effect on deeper vessels with large diameters, while a shorter cutoff filter, shorter pulses and shorter delay has a greater effect on superficial dermal melanin and superficial small vessels (Bitter 2000).

6.4.3 Pigmented Lesions Pigmentary improvement when performing skin rejuvenation is almost invariably reported. Melanin is the target chromophore of pigmentary lesions (Fig. 6.14a, b). The majority of the melanin is concentrated in the basal layer of the epidermis and has the highest absorption spectrum in the UV. The melanin pigment is packed within melanosomes which are found within the melanosytes. The melanosome has a Thermal Relaxation Time (TRT) of about 10–100ns. Watanabe (Watanabe et al. 1991) found that melanosomal injury is independent of pulse width at 694, 630 or 532nm, if the pulse is below 1µs. He concluded that 1 µsec is the effective TRT of the melanosome. The shorter the pulse width, the more localized the damage. The absorption coefficient of melanin decreases as the wavelength increases. Thus, greater energy for longer wavelengths is required to injure the melanosome. The repigmentation after treatment occurs from residual melanocytes from the adnexal structures or migration from non-treated areas (Margolis et al. 1989).

51

6.4  Literature Review

a

b

Fig 6.14  (a) Posttraumatic hyperpigmentation; (b) Excellent result after two IPL treatments

a

Fig. 6.15  (a) Solar lentigines before treatment; (b) After two treatments

When treating pigmentary lesions, the natural response includes the formation of tiny crusts that peel off within a few days. Performing an examination using Woods lamp to establish the depth of melanin pigmentation prior to treatment has been suggested (Gilchrest et  al. 1977). There are three histological types: epidermal, dermal and mixed (Kang et al. 2002). It is important to adjust the device parameters and alternate the cutoff filters and fluences for efficient treatment of resistant melasma. Lesions located at different levels respond differently. When treating melasma patients with IPL, we always ask the patient to discontinue birth control pills and avoid sun exposure. The results of pigmentary lesions are demonstrated in Table 6.1. Using a single IPL treatment, Bjerring (Bjerring and Christiansen 2000) obtained 96% pigment reduction with a higher clearance rate for lentigo solaris. Kawada (Kawada et  al. 2002) reported solar lentigines and ephelides improvement after 3–5 sessions of IPL treatment. 48% of patients reported more than 50% improvement and 20% had more than 75% improvement (Kawada et  al. 2002). Better response rate was noticed for small plaques. Excellent results are reported for lentigines and other pigmentary lesions (Fig. 6.15–6.18). When treating

b

52

6  Skin Photorejuvenation

b

a

Fig. 6.16  (a) Solar lentigines before treatment; (b) Improvement after a single IPL treatment

a

b

Fig. 6.17  (a) Lentigines are frequently located on the dorsum of the hands (sun exposed area); (b) Excellent result after two sessions

pigmentary lesions (solar lentigines and ephelides) using Lumenis One, Konishi (Konishi et  al. 2008) obtained clinical improvement by choosing low fluences (12–14J/cm2), double pulses of 4ms and a pulse delay of 20ms. He reported a decrease in the melanin index. Pigmentary changes were treated by Huang using fluences of 25–35J/cm2, 4ms single or double pulses, 20–40ms pulse delay and 550, 590nm cutoff filters (Huang et  al. 2002). Freckling and lentigines

were treated by Kawada using a Quantum IPL (Kawada et al. 2002). He used smaller fluences of 20–24J/cm2, 2.6–5ms pulse duration, 20ms pulse delay and 560nm cutoff filter. He also noticed a better response for small lesions. Bitter treated 49 patients with Vasculight for photodamage (Bitter 2000). He used fluences from 30–50J/cm2, pulse durations of 2.4–4.7ms, pulse delays of 10–60ms and cutoff filters of 550 and 570nm. Although IPL requires more sessions to treat lentiges,

53

6.4  Literature Review Fig. 6.18  (a) Lentigines located on the dorsum of the hands; (b) Good response after a single IPL session

a

b

it is associated with a lower risk of post-inflammatory hyperpigmentation (Chan et  al. 2002). In general, patients with epidermal melasma have a better response than those with mixed-type melasma (Wang et  al. 2004). The superficial lesions (Fig. 6.19–6.22) (café au lait, ephelides, epidermal melasma) have a better response to IPL while deeper lesions (nevus of Baker, mixed melasma) are more resistant to the procedure (Fig. 6.23a–c) (Moreno Arias and Ferrando 2001). More treatments are needed for deeper pigmented

lesions (Moreno Arias and Ferrando 2001). Nevus spilus was successfully treated by Gold (Gold et al. 1999) using a 590nm cutoff filter. According to Huang (Huang et  al. 2002), among all pigmentary lesions, freckles seems to respond the best to IPL treatment. Poikiloderma of Civatte is a combination of telangiectasia, atrophy and pigmentary changes. The recent discovery of familial cases of Poikiloderma of Civatte shows that it also has a genetic component transmitted as an autosomal dominant trait (Katoulis et al. 1999).

54 Fig. 6.19  Before (a) and after (b) IPL treatment

6  Skin Photorejuvenation

a

a

Fig. 6.20  Before (a) and after (b) two treatments, showing significant improvement

b

b

55

6.4  Literature Review

a

b

Fig. 6.21  (a) Sun damage of the chest skin before treatment; (b) After two treatments

a

b

Fig. 6.22  Before (a) and after (b) treatment

Several authors have reported Poikiloderma improvement with IPL treatment. Multiple sessions are usually necessary (Ross 2007). Goldman (Goldman et al. 2005) recommends starting treatment with a 550 or 560nm filter to prevent too much epidermal absorption. In a different study, the same author reported good improvement in 42% of patients after an average of 2.8 treatments; fluences between 30 and 34J/cm2 were used (Goldman and Weiss 2001). When 50% improvement was noticed on the previous treatment, either the same fluence was used or it was increased by 5%. Significant improvement of Poikiloderma of Civatte (grade 4: 75–100%) after IPL was seen in 82% of patients (Weiss et al. 2000). Clearance of telangiectasia and hyperpigmentation was noted in more than 75% of patients. Paquet (Paquet and Pierard 2004) obtained an 80% clinical, histologic and spectrophotometric decrease in

hypermelanosis in two patients following drug-induced toxic epidermal necrolysis. Although the literature is limited, IPL systems with an ability to adjust wavelength, pulse width and delay are useful for treating facial hypermelanosis (Paquet and Pierard 2004). The treatment intervals for skin rejuvenation are reported to vary from 2 weeks (Goldberg and Cutler2000; Hernandez-Perez and Ibiett2002; Kawada et al.2002) to 8 weeks (Moreno Arias and Ferrando 2001). Most physicians perform treatments one month apart (Table6.1). We also prefer performing the treatment every month, although this interval is arbitrary. For people with posttreatment side effects or higher skin sensitivity, we extend the interval between treatments. In our experience, highest patient satisfaction is for pigmented or ­vascular lesions as a part of photodamaged skin (type I rejuvenation) (Fig. 6.24–6.26). Shorter wavelengths are

56

6  Skin Photorejuvenation

b

a

c

Fig. 6.23  (a) Hyperpigmentation located on the forehead area; (b) After one treatment; (c) After two treatments

a

Fig. 6.24  (a) Pigmentary changes; (b) Good response after IPL treatment

b

57

6.4  Literature Review Fig. 6.25  Pigmentary improvement and light skin texture improvement in a 62-year-old woman. (a) Before treatment; (b) After treatment

a

a

b

b

Fig. 6.26  Significant pigmentary improvement after two IPL treatments. (a) Before; (b) After. Note also some tightening of the skin

58

6  Skin Photorejuvenation

better for treatment of these lesions; longer wavelengths penetrate deeper and are better for wrinkle reduction and texture improvement (Sadick 2003). Noninvasive methods for rejuvenation, such as IPL, need to compete with laser resurfacing, chemical peels and dermabrasion. Ablative procedures injure the epidermis and produce changes in the dermis followed by an inflammatory response that stimulates fibroblasts to produce scar collagen. In these situations, the skin is more sensitive, there is prolonged healing time and a need for wound care (Fernandes and Signorini 2008). The main advantages of IPL skin rejuvenation are the minimal downtime recovery, fast and easy to perform, minimal complications, minimal interference with lifestyle and long-term improvement.

Practical Points

›› A good response immediately after treatment is ›› ›› ›› ›› ››

››

›› Sun exposure and smoking are the main fac-

tors that induce premature skin aging. the age of 30, the melanocytic number decreases 10–20% per 10 years. Dermal changes in the aged skin are responsible for various clinical presentations, such as mottled pigmentation, telangiectasia, wrinkles and dryness. Hemoglobin and melanin are the primary chromophores involved in skin rejuvenation. Type I photorejuvenation refers to vascular anomalies, pigmentary changes or pilosebaceous changes, while Type II is related to ­dermal and subcutaneous senescence. Most histological studies show collagen improvement after IPL treatment. Skin rejuvenation is aimed at reducing visible pigmentary changes and blood vessels and at improving skin texture. The face is the most frequently treated area. Overlapping during treatment should be avoided. Large footprints are more efficient for treating large areas. The light distribution into the skin is more uniform, resulting in a better effect. Hair-bearing area should be protected during treatment. Special attention should be paid to men who have large hair-bearing areas.

›› Over ››

›› ››

›› ›› ›› ›› ›› ››

››

blanching of the vessels, “urticaria” type reaction or slight darkening of pigmented lesions. Erythema and edema are present in most patients and resolve within hours to 2–3 days. Adjusting wavelengths according to the type and depth of the lesion may improve the results. There is a variety of IPL devices on the market. The treatment parameters from one device do not fit other devices. In our experience, pigmented and vascular lesions respond better after IPL treatment compared with skin texture improvement. The association of ALA and IPL has been successfully reported to improve skin texture but it is not widely approved and most countries restrict its use to the experimental level. Superficial pigmented lesions, such as ephelides and epidermal melasma, have a better response to IPL while deeper lesions are more resistant. The main advantages of IPL skin rejuvenation are minimal downtime recovery, fast and easy to perform, minimal complications, minimal interference with lifestyle and long-term improvement.

References Alam M, Hsu TS, Dover JS, et al. Nonablative laser and light treatments: histology and tissue effects–a review. Lasers Surg Med. 2003;33(1):30–39. Alexiades-Armenakas M. Laser-mediated photodynamic therapy. Clin Dermatol. 2006; 24(1):16–25. Alora MB, Dover JS, Arndt KA. Lasers for vascular lesions. Dermatol Nurs. 1999; 11(2):97–102, 105–107; quiz 108–109. Alster TS, Tanzi EL, Welsh EC. Photorejuvenation of facial skin with topical 20% 5-aminolevulinic acid and intense pulsed light treatment: a split-face comparison study. J Drugs Dermatol. 2005; 4(1):35–38. Avram DK, Goldman MP. Effectiveness and safety of ALA-IPL in treating actinic keratoses and photodamage. J Drugs Dermatol. 2004;3(1 Suppl):S36–39. Bernstein EF, Chen YQ, Tamai K et  al. Enhanced elastin and fibrillin gene expression in chronically photodamaged skin. J Invest Dermatol. 1994;103(2):182–186. Bernstein EF, Underhill CB, Hahn PJ et al. Chronic sun exposure alters both the content and distribution of dermal glycosaminoglycans. Br J Dermatol. 1996. 135(2):255–262.

References Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg. 2000;26(9):835–842; discussion 843. Bjerring P, Christiansen K. Intense pulsed light source for treatment of small melanocytic nevi and solar lentigines. J Cutan Laser Ther. 2000;2(4):177–181. Calzavara-Pinton PG, Venturini M, Sala R. Photodynamic therapy: update 2006. Part 2: Clinical results. J Eur Acad Dermatol Venereol. 2007;21(4):439–451. Castanet J, Ortonne JP. Pigmentary changes in aged and photoaged skin. Arch Dermatol. 1997;133(10):1296–1299. Chan HH, Alam M, Kono T et al. Clinical application of lasers in Asians. Dermatol Surg. 2002;28(7):556–563. Chapel TA, Tavafoghi V, Mehregan AH et al. Beckers melanosis: an organoid hamartoma. Cutis. 1981;27(4):405–406, 410, 415. Chung JH, Lee SH, Youn CS et al. Cutaneous photodamage in Koreans: influence of sex, sun exposure, smoking, and skin color. Arch Dermatol. 2001;137(8):1043–1051. Clement M, Daniel G, Trelles M. Optimising the design of a broad-band light source for the treatment of skin. J Cosmet Laser Ther. 2005;7(3–4):177–189. DeHoratius DM, Dover JS. Nonablative tissue remodeling and photorejuvenation. Clin Dermatol. 2007;25(5):474–479. Dierickx CC, Anderson RR. Visible light treatment of photoaging. Dermatol Ther. 2005;18(3):191–208. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin Dermatol. 2008;26(2): 192–199. Fisher GJ, Varani J, Voorhees JJ. Looking older: fibroblast ­collapse and therapeutic implications. Arch Dermatol. 2008;144(5):666–672. Fisher GJ, Wang ZQ, Datta SC et al. Pathophysiology of premature skin aging induced by ultraviolet light. N Engl J Med. 1997;337(20):1419–1428. Fodor L, Peled IJ, Rissin Y et al. Using intense pulsed light for cosmetic purposes: our experience. Plast Reconstr Surg. 2004;113(6):1789–1795. Fusco FJ. The aging face and skin: common signs and treatment. Clin Plast Surg. 2001;28(1):1–12. Gilchrest BA. A review of skin ageing and its medical therapy. Br J Dermatol. 1996;135(6):867–875. Gilchrest BA, Fitzpatrick TB, Anderson RR et al. Localization of malanin pigmentation in the skin with Woods lamp. Br J Dermatol. 1977;96(3):245–248. Goldberg DJ. New collagen formation after dermal remodeling with an intense pulsed light source. J Cutan Laser Ther. 2000;2(2):59–61. Goldberg DJ, Cutler KB. Nonablative treatment of rhytids with intense pulsed light. Lasers Surg Med. 2000;26(2):196–200. Goldman MP, Bennett RG. Treatment of telangiectasia: a review. J Am Acad Dermatol. 1987;17(2 Pt 1):167–182. Goldman MP, Weiss RA. Treatment of poikiloderma of Civatte on the neck with an intense pulsed light source. Plast Reconstr Surg. 2001;107(6):1376–1381. Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a nonablative approach to photoaging. Dermatol Surg. 2005;31(9 Pt 2):1179–1187; discussion 1187. Gold MH, Bradshaw VL, Boring MM et al. The use of a novel intense pulsed light and heat source and ALA-PDT in the treatment of moderate to severe inflammatory acne vulgaris. J Drugs Dermatol. 2004;3(6 Suppl):S15–19.

59 Gold MH, Foster TD, Bell MW. Nevus spilus successfully treated with an intense pulsed light source. Dermatol Surg. 1999;25(3):254–255. Gold MH, Goldman MP. 5-aminolevulinic acid photodynamic therapy: where we have been and where we are going. Dermatol Surg. 2004;30(8):1077–1083; discussion 1083–1074. Greenbaum SS, Bernstein EF. Comparison of iontophoresis of lidocaine with a eutectic mixture of lidocaine and prilocaine (EMLA) for topically administered local anesthesia. J Dermatol Surg Oncol. 1994;20(9):579–583. Gupta AK, Gover MD, Nouri K et al. The treatment of melasma: a review of clinical trials. J Am Acad Dermatol. 2006;55(6): 1048–1065. Hedelund L, Lerche C, Wulf HC et al. Carcinogenesis related to intense pulsed light and UV exposure: an experimental animal study. Lasers Med Sci. 2006;21(4):198–201. Hernandez-Perez E, Ibiett EV. Gross and microscopic findings in patients submitted to nonablative full-face resurfacing using intense pulsed light: a preliminary study. Dermatol Surg. 2002;28(8):651–655. Heymann WR. Intense pulsed light. J Am Acad Dermatol. 2007;56(3):466–467. Huang YL, Liao YL, Lee SH et al. Intense pulsed light for the treatment of facial freckles in Asian skin. Dermatol Surg. 2002;28(11):1007–1012; discussion 1012. Kadunce DP, Burr R, Gress R et  al. Cigarette smoking: risk ­factor for premature facial wrinkling. Ann Intern Med. 1991;114(10):840–844. Kang WH, Yoon KH, Lee ES et al. Melasma: histopathological characteristics in 56 Korean patients. Br J Dermatol. 2002;146(2):228–237. Katoulis AC, Stavrianeas NG, Georgala S et al. Familial cases of poikiloderma of Civatte: genetic implications in its pathogenesis? Clin Exp Dermatol. 1999;24(5):385–387. Kawada A, Shiraishi H, Asai M et al. Clinical improvement of solar lentigines and ephelides with an intense pulsed light source. Dermatol Surg. 2002;28(6):504–508. Konishi N, Kawada A, Kawara S et al. Clinical effectiveness of a novel intense pulsed light source on facial pigmentary lesions. Arch Dermatol Res. 2008;300:Suppl 1: S65–67. Lawrence N. New and emerging treatments for photoaging. Dermatol Clin. 2000;18(1):99–112. Liu H, Dang Y, Wang Z et al. Laser induced collagen remodeling: a comparative study in  vivo on mouse model. Lasers Surg Med. 2008;40(1):13–19. Margolis RJ, Dover JS, Polla LL et al. Visible action spectrum for melanin-specific selective photothermolysis. Lasers Surg Med. 1989;9(4):389–397. Mark KA, Sparacio RM, Voigt A et al. Objective and quantitative improvement of rosacea-associated erythema after intense pulsed light treatment. Dermatol Surg. 2003;29(6): 600–604. Moreno Arias GA, Ferrando J. Intense pulsed light for melanocytic lesions. Dermatol Surg. 2001;27(4):397–400. Negishi K, Tezuka Y, Kushikata N et al. Photorejuvenation for Asian skin by intense pulsed light. Dermatol Surg. 2001;27(7):627–631; discussion 632. Negishi K, Wakamatsu S, Kushikata N et al. Full-face photorejuvenation of photodamaged skin by intense pulsed light with integrated contact cooling: initial experiences in Asian patients. Lasers Surg Med. 2002;30(4):298–305.

60 Nelson JS, Majaron B, Kelly KM. What is nonablative photorejuvenation of human skin? Semin Cutan Med Surg. 2002;21(4):238–250. Paquet P, Pierard GE. Intense pulsed light treatment of persistent facial hypermelanosis following drug-induced toxic epidermal necrolysis. Dermatol Surg. 2004;30(12 Pt 2):1522–1525. Potozkin JR, Geronemus RG. Treatment of the poikilodermatous component of the Rothmund-Thomson syndrome with the flashlamp-pumped pulsed dye laser: a case report. Pediatr Dermatol. 1991;8(2):162–165. Prieto VG, Sadick NS, Lloreta J et al. Effects of intense pulsed light on sun-damaged human skin, routine, and ultrastructural analysis. Lasers Surg Med. 2002;30(2):82–85. Raulin C, Greve B, Grema H. IPL technology: a review. Lasers Surg Med. 2003;32(2):78–87. Rokhsar CK, Lee S, Fitzpatrick RE. Review of photorejuvenation: devices, cosmeceuticals, or both? Dermatol Surg. 2005;31(9 Pt 2):1166–1178; discussion 1178. Ross EV. Laser versus intense pulsed light: Competing technologies in dermatology. Lasers Surg Med. 2006;38(4):261–272. Ross EV. Nonablative laser rejuvenation in men. Dermatol Ther. 2007;20(6):414–429. Ruiz-Rodriguez R, Sanz-Sanchez T, Cordoba S. Photodynamic photorejuvenation. Dermatol Surg. 2002;28(8):742–744; discussion 744. Sadick NS. Update on non-ablative light therapy for rejuvenation: a review. Lasers Surg Med. 2003;32(2):120–128. Schroeter CA, Haaf-von Below S, Neumann HA. Effective treatment of rosacea using intense pulsed light systems. Dermatol Surg. 2005;31(10):1285–1289. Talwar HS, Griffiths CE, Fisher GJ et  al. Reduced type I and type III procollagens in photodamaged adult human skin. J Invest Dermatol. 1995;105(2):285–290. Taub AF. Photodynamic therapy for the treatment of acne: a pilot study. J Drugs Dermatol. 2004;3(6 Suppl):S10–14.

6  Skin Photorejuvenation Trelles MA, Mordon S, Calderhead RG. Facial rejuvenation and light: our personal experience. Lasers Med Sci. 2007;22(2): 93–99. Uebelhoer NS, Dover JS. Photodynamic therapy for cosmetic applications. Dermatol Ther. 2005;18(3):242–252. Uitto J. Understanding premature skin aging. N Engl J Med. 1997;337(20):1463–1465. Wang CC, Hui CY, Sue YM et al. Intense pulsed light for the treatment of refractory melasma in Asian persons. Dermatol Surg. 2004;30(9):1196–1200. Watanabe S, Anderson RR, Brorson S et al. Comparative studies of femtosecond to microsecond laser pulses on selective pigmented cell injury in skin. Photochem Photobiol. 1991;53(6): 757–762. Weiss RA, Goldman MP, Weiss MA. Treatment of poikiloderma of Civatte with an intense pulsed light source. Dermatol Surg. 2000;26(9):823–827; discussion 828. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest. Dermatol Surg. 2002;28(12):1115–1119. Wong WR, Shyu WL, Tsai JW et al. Intense pulsed light modulates the expressions of MMP-2, MMP-14 and TIMP-2 in skin dermal fibroblasts cultured within contracted collagen lattices. J Dermatol Sci. 2008;51(1):70–73. Yamashita T, Negishi K, Hariya T et  al. Intense pulsed light therapy for superficial pigmented lesions evaluated by reflectance-mode confocal microscopy and optical coherence tomography. J Invest Dermatol. 2006;126(10):2281–2286. Yin L, Morita A, Tsuji T. Skin aging induced by ultraviolet exposure and tobacco smoking: evidence from epidemiological and molecular studies. Photodermatol Photoimmunol Photomed. 2001;17(4):178–183. Zelickson BKD. Effect of pulsed dye laser and intense pulsed light source on the dermal extracellular matrix remodeling. Lasers Surg Med. 2000;12(Suppl):17.

7

Hair Removal

Contents 7.1 Hirsutism................................................................. 61 7.2 Hypertrichosis......................................................... 62 7.3 Other Conditions.................................................... 62 7.4 Histological Data..................................................... 63 7.5 Treatment Strategy................................................. 64 7.6 Literature Review................................................... 7.6.1 Hair Removal in Light Skin Types........................... 7.6.2 Hair Removal in Dark Skin Types............................ 7.6.3 Comparative Studies on IPL and Lasers................... 7.6.4 Extended Applications of Hair Removal.................. 7.6.5 Photodynamic Therapy (PDT) and Variable Pulsed Light (VPL)...................................................

66 67 70 75 76 76

References............................................................................ 77

Abstract Hirsutism is represented by excessive growth of the coarse hairs in women, distributed in a male-like pattern. Hypertrichosis is represented by excessive growth of coarser and longer hair than is normal for the age, sex and race of the person. The hair growth cycle has three phases: anagen, catagen and telogen. The anagen phase is the growth phase, the catagen phase is the regression phase and the telogen phase is the rest phase. The hair follicle is the most susceptible to IPL treatment during the anagen phase. The melanin is the target chromophore for hair removal. There are three types of melanosomes present in the hair. Erythromelanin granules are present in red hair while eumelanin and pheomelanin granules are found in varying proportions in blond and dark hair. The targets for hair removal are the dermal papilla and the bulge area. The heat-induced destruction of the hair shaft leads to hair “dropout”. The partial injury to the germinative zone leads to telogenshock response, prolonged telogen dropout, and development of dystrophic hairs which are thinner in texture and have variable pigmentation. Multiple IPL treatments are usually needed. If no improvement is obtained after 5–6 sessions, interrupting the treatment should be considered. The darker the skin and the brighter the hair (Fig. 7.1), the less effective the treatment will be.

7.1 Hirsutism Hirsutism is represented by excessive growth of the coarse hairs in women, distributed in a male-like pattern. There are racial and ethnic differences in hair distribution (Muller 1969). The most frequently used method to grade hirsutism is the Ferriman-Gallwey scoring scale (Ferriman and Gallwey 1961). According to Ehrmann (Ehrmann and Rosenfield 1990), 5% of L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_7, © Springer-Verlag London Limited 2011

61

62

Fig. 7.1  Typical fine hair - the hair is more delicate than the coarse type and has a lighter color

women in the United States suffer from hirsutism. Age also influences hair distribution, and unwanted facial hair is more common in postmenopausal women. Endocrine disorders characterized by hyperandrogenemia are responsible for increased hair growth. The source of the endocrinological problem can be found in the pituitary gland (Cushing disease), the adrenal gland (hyperplasia or tumors) or in the ovaries (polycystic ovary disease, tumors). Exogenous anabolic steroids are also associated with hirsutism. The most common hormonal cause of hirsutism is polycystic ovary disease (Liew 1999). Testing of elevated androgen levels in woman with moderate or severe hirsutism that appears suddenly and is rapidly progressive or associated with menstrual dysfunction or obesity is recommended prior to starting hair removal treatment (Martin et al. 2008). However, the severity of hirsutism is not well correlated with the androgen level. The response of the follicle to androgen excess varies among persons (Rosenfield 2005). Oral contraceptives and antiandrogen drugs are the most used pharmacological therapy (Conn and Jacobs 1997; Martin et  al. 2008). Hirsutism treatment in patients with polycystic ovary disease is difficult and there are reports showing 25% hair growth after 36 months of treatment (Falsetti and Galbignani 1990).

7.2 Hypertrichosis Hypertrichosis is represented by excessive growth of coarser and longer hair (Fig. 7.2) than is normal for the age, sex and race of the person. Although there are

7  Hair Removal

Fig. 7.2  Typical coarse hair - the hair is rough and has a dark color

described mechanisms of hypertrichosis, the triggers that initiate these mechanisms are unknown (Wendelin et al. 2003). The congenital forms of hypertrichosis include nevocellular nevus, hamartoma, hemihypertrophy, hypertrichosis cubiti, neurofibroma, hairy cutaneous malformations of palms and soles, spinal hypertrichosis, anterior cervical hypertrichosis and several congenital syndromes in which generalized hypertrichosis is a primary feature. The acquired disorders associated with hypertrichosis include Becker nevus, hypertrichosis of pinna, hypertrichosis associated with local inflammation, pharmacological hypertrichosis (cyclosporine, cortisone, streptomycin) and other acquired disorders associated with generalized hypertrichosis (dermatomyositis, hyperthyroidism, hypothyroidism).

7.3 Other Conditions Sometimes, hair removal can also have non-cosmetic applications. For instance, hair removal of flaps or treatment of areas with recurrent folliculitis can be of real benefit for the patient (Moreno-Arias et al. 2002). Digestive reconstruction with a hair-bearing pectoralis flap can lead to disfagia and even halitosis (Kuriloff et  al. 1988). Urethral or vaginal reconstruction with scrotal or pudendal hairy flaps may obstruct urinary flow or increase the risk of infection (Gil-Vernet et al. 1995; Karacaoglan 1997). Older methods of hair removal include shaving, plucking, waxing, depilatory creams and electrolysis.

7.4  Histological Data

Galvanic, electrolysis, thermolysis and blend methods are three types of electrosurgical epilation. Most are temporary methods, relatively inexpensive. Among the common side effects (Warner et al. 2006) encountered are: • Shaving: dermatitis, minor cuts and pseudofolliculitis • Waxing: pain, minor burns, irritation, folliculitis, post-inflammatory hyperpigmentation • Electrolysis: edema, erythema, pain, scarring, postinflammatory pigmentary changes • Topical creams: acne, pseudofolliculitis, burning There are three methods of permanent hair removal: electrolysis, IPL and laser treatment. Although widely used in the past, electrolysis is sometimes poorly tolerated by patients and has 15–50% permanent hair loss per treatment (Gorgu et al. 2000). The pulsed light and laser treatments seem to be more reliable and more ­frequently used than electrolysis recently.

7.4 Histological Data Detailed histology and biology of the hair follicle was described in Chapt. 1 (Skin anatomy). Herein we emphasize the most important facts that influence treatment. There are three main components of the hair follicle: the infundibulum, the isthmus and the hair bulb with dermal papilla. The bulge area is located about 1–1.5mm below the skin surface near the follicle bulb. Recent evidence shows that follicular stem cells are located in the bulge and the outer root sheath (Ross 2001; Mandt et al. 2005; Warner et al. 2006; Ohyama 2007). They have the capacity to regenerate not only the hair follicles but also sebaceous glands and epidermis. The follicle depth varies according to the anatomical area. The hair growth cycle has three phases: anagen, catagen and telogen. The anagen phase is the growth phase, the catagen phase is the regression phase and the telogen phase is the rest phase. The hair follicle is the most susceptible to IPL treatment during the anagen phase. This phase is variable in duration and can last up to 6 years (Goldberg 2007). The catagen phase is the relatively constant phase, usually lasting for about 3 weeks. Most follicles, most of the time, are in the anagen phase (80–85%) while the remaining follicles are either in the catagen (2%) or the telogen phase (10–15%) (Goldberg 2007). The transition from one

63

hair follicle phase to another varies according to the anatomical region (Alonso and Fuchs 2006). The percentage of hair follicles in the telogen phase is about 15% in the scalp and 75% in the extremities (Greppi 2001; Sadick and Prieto 2003; Warner et al. 2006). The anagen phase duration varies from 2 month to 1 year in the face, from 1 month to 6 month in the extremities. This is why more IPL treatments are needed for each area in order to catch the hair follicles in the anagen phase. Factors such as age, gender, anatomical region and hormones affect the duration of anagen phase. During the hair cycle, there are also changes in vascularization. These changes seem to be related to the hair cycle regulation process (Godynicki et al. 1997). The hair follicle is well vascularized during the anagen phase, while vascularization is much reduced during the catagen phase. The lights as lasers have a similar mechanism of acting on the chromophore. The melanin is the target chromophore for hair removal (Liew 2002). For selective damaging of the hair follicle, the light energy is absorbed by the melanin (endogenous chromophore) present in the hair shaft, outer root sheath of the infundibulum and matrix area (Ross et al. 1999; Sand et  al. 2007). There are three types of melanosomes present in the hair. Erythromelanin granules are present in red hair while eumelanin and pheomelanin granules are found in varying proportions in blond and dark hair. In white or grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes (Slominski and Paus 1993). Eumelanin and pheomelanin have different wavelength absorption peaks. It has been shown that the absorbance rate is 30 times lower at a wavelength of 694nm for pheomelanin compared to eumelanin. The light absorption of pheomelanin is very low at wavelengths from 750 to 800nm (Ross et  al. 1999). Because blonde or whitegrey hair has a paucity of melanin, they are less susceptible to IPL treatment. The targets for hair removal are the dermal papilla and the bulge area. The heatinduced destruction of the hair shaft leads to hair “dropout”. The partial injury to the germinative zone leads to telogen-shock response, prolonged telogen dropout, and development of dystrophic hairs which are thinner in texture and have variable pigmentation (Sadick et al. 2000). Dark-skinned people have a high content of melanin within the epidermis. This absorbs the energy, resulting in possible heating and damage of the surrounding skin. Extra care must be taken when treating patients with Fitzpatrick skin type V and VI.

64

A histological examination study performed on nine subjects after a single IPL treatment showed clumping of melanin, hair shaft follicles and coagulative necrosis of the hair shaft (Sadick et al. 1999). At 48 h, half the follicles contained apoptotic keratinocytes and had perifollicular edema. Some hair follicles presented perifollicular hemorrhage. At a longer posttreatment interval (2 weeks–20 months), many follicles had apoptotic keratinocytes, perifollicular fibrosis and melanophages.

7.5 Treatment Strategy During consultation, taking a detailed medical history can be of extreme importance. Specific questions to identify endocrinological problems leading to hirsutism should be asked. Obese people, those with polycystic ovary syndrome or other endocrinological disorders should be referred first to an endocrinologist. This does not mean that they cannot benefit from IPL treatment (Moreno-Arias et al. 2002). Most authors refrain from using light or lasers for patients undergoing isotretinoin therapy. It is also our protocol to delay treatment from 6–12 month after stopping drug intake. The reasons for delaying treatment are seen in several reports that showed delayed healing and scarring (Roenigk et  al. 1985; Zachariae 1988; Bernestein and Geronemus 1997). However, Khatri (Khatri and Garcia 2006) reported good results in six patients taking isotretinoin, and no complications were reported. It is our recommendation not to perform treatment in these patients until large studies demonstrate its safety. Other contraindications to treatment are patients with a history of keloids and connective tissue disorders (Warner et al. 2006). The physical examination should be done carefully for the desired anatomic region. It is important to rule out skin malignancies and active skin infection. Particular attention should be paid to the presence of pigmented lesions or tattoos in the area. Treatment can alter the pigment. We recommend covering the lesions with a small white pad during treatment. Treatment to tanned people is delayed for a few weeks to diminish the chances of side effects, especially hypopigmentation. A careful analysis of the distribution of unwanted hair should be done. The quantity, color and quality of hair follicles should be compared with healthy people having normal hair distribution.

7  Hair Removal

All this information should be explained to the patient, as his hair distribution, perception or expectations can be disproportional. People coming for epilation desire definitive hair removal. According to the FDA, “permanent hair removal” refers to a significant reduction of hair follicles, stable for a period of time longer than the complete growth cycle of the hair follicle (Dierickx 2000). This should be explained to the patient, as most interpret the same sentence as no hair regrowth ever (Haedersdal and Wulf 2006). Educating patients and explaining the expected outcomes and possible complications is very important. We explain to patients that multiple treatments are needed and even then a ­permanent result should not be expected (Figs. 7.4a, b, and 7.5a, b). The results of each treatment are marked on the chart. If no significant improvement is obtained after 7–8 treatments, we suggest stopping treatment. Any method of hair removal except shaving should be stopped at least 2 months prior to treatment. Shaving is the only method which does not remove the hair bulb. With other methods, the target structures are removed and treatment is in vain. Two or 3 days before the treatment, the area should be shaved. Performing treatment on an unshaved area can lead to more complications. The long dark hair lying on the skin absorbs the energy and may burn the epidermis. For bikini area treatment, patients are told to wear white undergarments as black ones are more prone to reacting to the treatment. If small areas are treated, this can be done without topical anesthesia. The bikini and periareolar areas are the most sensitive. In these areas or other large areas, we always recommend an EMLA or ELAMax application one hour prior to treatment. When larger areas are treated, necessitating more time, breaks for ice pack cooling are taken. Cooling is continued for 15 min after finishing the treatment. A test is always performed before starting the procedure. The IPL device is relatively easy to handle. The computer software provides suggested treatment parameters based on patient hair color, type, and skin type. The degree of contrast between skin and hair, the type of hair color and the amount of melanin content are important factors in the success of IPL hair removal (Sanchez et  al. 2002). The light penetration depth is limited by irradiating areas of the skin that are too small. To avoid the effect of radial dissipation of energy, the spot size should be larger than the light penetration depth into the tissues, about 5–10mm (Lask et al. 1999).

65

7.5  Treatment Strategy

a

b

Fig. 7.3  (a) Appearence on the 4th day after hair removal procedure. Note the exaggerated response of the skin; (b) The result after 1 year. In this case, the parameters were decreased twice as recommended in the treatment protocol (Reprinted with permission of

Lippincott, Williams & Wilkins, Wolters Kluwer L. Fodor, M. Menachem, Y. Ramon, O. Shoshani, Y. Rissin, L. Eldor, D. Egozi, I.J. Peled, Y. Ullmann. Hair Removal Using Intense Pulsed Light (Epilight), Ann Plast Surg, 2006;54:11)

The possibility of double or triple pulse distribution causes the hair follicle to heat up in a stepwise fashion. Lengthening the pulse duration carries a risk of epidermal damage. A pulse delay over 3ms is recommended to allow the epidermis to cool down (Weir and Woo 1999). Longer wavelengths are preferred, as the chromophore is situated deep in the skin. The longer the wavelength, the deeper the light penetration into the skin. Shorter wavelengths are more effective for light and thin brown hairs (Drosner and Adatto 2005). Applying slight pressure on the skin is recommended when performing the treatment. This will empty the blood vessels from underneath and minimize the absorption of light energy by hemoglobin. Treatment parameters need to be adjusted according to the skin response from the anterior session. When side-effects or complications are encountered after one session, the fluence is decreased by about 2–4J/cm2 and the pulse delay is increased by 10%

(Fig. 7.3a, b). Future treatment parameters are adjusted according to the previous response. We always recommend recording the patient evaluation and side-effects for the whole treatment period. The presence of certain side-effects as a paradoxical effect indicates interruption of the treatment. For further details, please see Chapt. 9 on Complications. The timing of multiple treatments varies according to the hair growth cycle in that region and the hair type. In general, treatments to the face (Fig. 7.6a, b), neck, axilla (Fig. 7.7a, b) and bikini area are done at 5–6 week intervals. The extremities (Figs. 7.8a, b and, 7.9a, b) and thorax (Figs. 7.10a, b and, 7.11a, b) are treated with a 7–8 week interval (Warner et  al. 2006). Almost all patients experience edema and erythema for a short period of time after treatment, which is considered a normal response. Patients should be reminded that they will have hair growth in the days after treatment. This is a normal response and represents the extrusion of the

66

a

7  Hair Removal

b

Fig. 7.4  (a) Coarse hair on the calf before IPL treatment B: Excellent result after five treatments (2 years later)

a

b

Fig. 7.5  (a) Before treatment; typical coarse hair; (b) After seven treatments. Marked improvement is demonstrated but some hair follicles remain, usually with a lighter color and smoother

damaged hair from the follicle. It should not be interpreted as failure of the treatment. Dark skin phenotypes remain problematic for IPL-assisted treatments. Sunscreens are essential to protect the skin from sun during the treatment period.

7.6 Literature Review Haedersdal (Haedersdal and Gotzsche 2006; Haedersdal and Wulf 2006) identified controlled clinical trials of hair removal between 1990 and 2004 and compared the

67

7.6  Literature Review Fig. 7.6  Before (a) and after (b) five treatments. Note the residual hair follicles at the periphery of the upper lip. This area is more difficult to treat due to skin irregularities

a

b results of hair removal using lasers and light by studying nine randomized controlled trials and 21 controlled trials, which included only two studies on IPL (Table 7.1). It is difficult to integrate the data as there are many factors that can influence outcome: fluence, wavelengths, spot size, pulse duration, presence or not of skin cooling, and patient parameters. Many studies confirmed the long-term hair removal efficacy of the IPL system.

7.6.1 Hair Removal in Light Skin Types Most literature studies report on hair removal for patients with skin type I–IV. The clearance rate after IPL hair removal varies widely from 20–93.5% (Table 7.2), (Figs. 7.12a, b and, 7.13a, b). As can be seen, various cutoff filters and a wide range of fluences are used by different authors. These vary also according to the IPL device. Performing two treatments with fluences of 40–42J/cm2, Weiss (Weiss et al. 1999) noticed a 33% hair count reduction at 6 months. A reduction in the remaining hair follicles was also recorded. A relatively low hair reduction (27%) was reported by Goldberg (Goldberg and Silapunt 2001) after one to three

treatments. The fluences used ranged from 6.25–6.45J/ cm2 with a pulse duration of 35ms. Using high fluences of up to 55J/cm2, Gold (Gold et  al. 1997) obtained a 60% hair reduction at 12 weeks post hair removal. 80.2% hair clearance at 8 months post-treatment was obtained by Troilius (Troilius and Troilius 1999). The parameters used were a cutoff filter of 600nm; mean fluence of 19.3J/cm2 and a pulse duration of 44.5ms. No significant difference in hair loss after single (54% reduction) or multiple treatments (64% reduction) was observed by Sadick (Sadick et  al. 1999) 6 months post-treatment. The fluence used varied from 40–42J/cm2 and cutoff filters used were 590nm for skin type I, 615nm for skin type II, 645nm for type III, and 695nm for type IV. In a different study (Sadick et al. 2000), the same author reported 76% hair removal after a mean of 3.7 treatments. He used 615nm cutoff filters and 39–42J/cm2 for Fitzpatrick skin type II; 645 nm and 34–40J/cm2 for skin type III-IV, and 695nm and 38–40J/cm2 for skin type V. Maximal benefit of photoepilation was achieved from the initial 1–3 treatments. The level of patient satisfaction is hard to anticipate. In a retrospective study, Lor (Lor et  al. 2002) evaluated the satisfaction level of 207 patients: 22% were very satisfied, 45% satisfied and 33% unsatisfied.

68

7  Hair Removal

a

b

Fig. 7.7  Before (a) and after (b) six IPL treatments

a

Fig. 7.8  Before (a) and after (b) five treatments

b

69

7.6  Literature Review Fig. 7.9  (a) Hair on the legs several days after shaving and prior to treatment; (b) Appearance after five treatments (2 years later)

a

a

Fig. 7.10  Before (a) and after (b) six IPL treatments

b

b

70

a

7  Hair Removal

b

Fig. 7.11  (a) Hypertrichosis in the presacral area in a teenager; (b) After five treatments

Using fluences between 35–39J/cm2, 645 and 695nm cutoff filters and pulse delays 40ms (36.2% cases), Fodor (Fodor et al. 2005) evaluated the satisfaction level of 80 treated patients. The patients who had fewer treatments (1–3) were more satisfied than those who had more than seven treatments. The author’s clinical impression was that the best response was noticed after first few treatments, which explained the satisfaction level. One of the limiting factors that prevent the physician from applying higher fluences to make the treatment more effective is pain (Gerardo et  al. 2002). Shorter wavelengths are more painful, probably because the epidermis absorbs most of them. It has been shown on skin biopsies that light produced by “Photoderm” will reach a depth of 1.3mm (Tse 1999). There are recommendations to perform at least three treatments (Drosner and Adatto 2005) but there are no recommendations about when to stop the treatment. Usually we stop after 7–8 treatments, unless significant improvement is gained. When treating various body areas, the interval between treatments should be adjusted according to the resting period of the hair follicles. Most authors prefer to perform treatments at 4–6 week intervals (Table 7.2).

7.6.2 Hair Removal in Dark Skin Types Studies on IPL hair removal for dark skin types have been reported. Most IPL devices enable a wide range

of wavelengths by choosing different cutoff filters, thereby sometimes being effective in dark skins. Johnson (Johnson and Dovale 1999) reported a 85–100% clearance in three patients with skin types V and VI. Long pulse delays (>80ms) were used. Temporary hyperpigmentation was encountered in one case. Lee evaluated the results after treating 28 Asian patients who have a higher epidermal melanin content than Caucasians (Lee et al. 2006). A higher clearance of axillary hair of 83.4% was observed for the group with higher cutoff filters (645–950nm). The average fluence for this group was 17.1J/cm2. For dark skinned patients, the pulse duration should be extended, thereby producing gradual heating and less damage to the epidermal layer (Clement et  al. 2005). When the same fluence was distributed to the skin at a duration of 15ms compared to 30ms, it was found that the shorter duration had a 6°C higher temperature of the skin surface. Low fluences and longer pulse delays are recommended for dark skin types. A device combining the optical energy and radiofrequency was used in a study (Yaghmai et  al. 2004) to perform hair removal in darker skin types. Although less optical energy was needed for treatment, only 46% hair removal was obtained 3 months after a single treatment. There are only limited studies on this topic. At present, we recommend IPL hair removal without reservations for patients with skin types I–IV and fine or coarse black hair type. The darker the skin and the brighter the hair, the less effective the treatment will be. We do not perform IPL hair removal for skin types V or VI or for blond or white hair. For darker skin

• Randomization unclear • Blinding unclear

• Randomization unclear • + blinding

• Coin tossing (personal communication) • + blinding

• IPL, 1 tx

• Alexandrite laser 2–3 tx

• Alexandrite laser 1 tx + preop. wax

• Shave

• Long-pulsed Nd:YAG laser 1 tx

• Alexandrite laser 1 tx

• Alexandrite laser 1 tx + preop. shave

• Diode laser24, 38, 48J/cm2

Goh 2003

Hussain et al. 2003

Lehrer et al. 2003

Baugh et al. 2001

• Clockwise rotation(personal communication) • + blinding

• Randomization unclear • Blinding unclear

• Diode laser 3 tx

• Diode laser 3 tx

Fiskerstrand et al. 2003

• Coin tossing • Blinding unclear

• Ruby laser 3 tx

• Ruby laser 2 tx

Allison et al. 2003

Blinded response evaluation

• n= 36 • Mean age: 31 years • Back, thigh, bikini area • Brown–black hair colour • Skin types I–IV

• n= 13 • Age: 19–42 years • Back • Brown–black hair colour • Skin types I–III

• n= 144 • Age: 18–48 years • Axilla, extremities, face • Asian patients • Skin types III–V

• n = 11 • Age: unmentioned • Black hair colour • Face, axilla, legs • Skin types IV–VI

• n = 29 • Age: 23–69 years • Upper lip • Brown-black hair colour • Skin types II–IV

• n= 69 • Age: unmentioned • Hair colour unmentioned • Lip, axilla, legs • Skin types I–III

Table 7.1  An overview of clinically controlled, randomized trials (RCTs) in laser and photoepilation Subjects Study Intervention Comparative Study design N, age, hair colour, intervention Randomization treatment site, skin type method

• 1, 3 months

• 1 month

• 1, 2, 3, 6, 9 months

• 2, 6 weeks

• 6 months

• 8 months

Follow-up

(continued)

• Fluence-dependent hair reduction significantly better than shave • A mean hair reduction of 43% (1 month postop, mean of 1.6 tx) and 34% (3 months postop, mean of 2.0 tx) at the highest fluence level.

• In 12 of 13 subjects the reduction in hairiness was better in wax + laser-treated areas than shave + laser-treated areas

• 9 months postop: (i) 3 tx: overall 55% hair reduction (ii) 2 tx: overall 44% hair reduction (iii) 1 tx: overall 32% hair reduction

• 6 weeks postop: (i) 64% (IPL) and 73% (Nd:YAG laser) of patients obtained < 20% hair reduction (p=ns) (ii) Postinflammatory pigmentation: 45% (IPL) and 0 (Nd:YAG laser)

• 6 months after first tx: 49% vs. 48% hair reduction with the two different diode laser systems (p=ns)

• 5 months postop: (i) 3 tx upper lip: overall 18.5% hair reduction (ii) 2 tx upper lip: overall 6.3% hair reduction

Major results

7.6  Literature Review 71

• Blinded card draw (personal communication) • + blinding

• Wax

• Q-switched Nd:YAG laser 1 tx ± preop. wax, carbon solution

Nanni and Alster 1997

• n = 12 • Mean age: 32 years • Face, truncus, legs • Brown-black hair colour • Skin types I–IV

• n=17 • Age: unmentioned • Pubic region • Red-blonde-brown-black

• n=20 • Age: 20–60 years • Axilla • Brown–black hair colour • Skin types I–IV

Subjects N, age, hair colour, treatment site, skin type

• 1, 3, 6 months

• 3 months

• 1, 3, 6 months

Follow-up

• 6 months postop: (i) similar hair reduction (37–46%) for the two lasers (ii) similar clinical improvement scores on a 0–4 arbitrary scale (3.4–3.5 corresponding to>51% improvement) • Side-effects: (i) pain: alexandrite laser mild to moderate; diode laser moderate to severe (ii) slightly more hyperpigmentation and blistering after diode laser than alexandrite laser (iii) no scarring or atrophy. • Side-effects: (i) hyperpigmentation: 1/51 laser areas, 0/17 shave control areas (ii) hypopigmentation: 5/51 laser treated areas, 1/17 shave control areas (iii) no texture changes • 3 months postop: (i) overall -2–21% hair reduction (ii) better clearing for Q-switched Nd:YAG laser treated areas vs. wax alone • 6 months postop: full hair regrowth in all test areas • Patient subjective evaluations of hair density closely approximated hair count data

Major results

tx treatment; IPL intense pulsed light; postop postoperative (Grossman); ns not significant Source: Reprinted with permission of Wiley-Blackwell: M. Haedersdal, H.C. Wulf, Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol. 2006;20(1):9–20

• List of random allocation • + blinding

• Shave

• Ruby laser 1 tx

Haedersdal et al. 1999

• Blinded card draw • + blinding

• Diode laser 3 tx

Blinded response evaluation

method

Study design Randomization

• Alexandrite laser 3 tx

Comparative intervention

Handrick and Alster 2001

Table 7.1  (continued) Study Intervention

72 7  Hair Removal

Ellipse, Relax/ Denmark

Epilight

Bjerring et al. 2000

Lask et al.1999

Hair removal, multiple sites

Hair removal, chin, neck

Hair removal, multiple sites

Ellipse, Relax/ Denmark

Goh 2003

154

31

11

34

Hair removal, multiple sites

Sadick et al. 2000 Epilight, ESC Med Systems

1

3

1

multiple

2

2

67

2–18

77

Facial hypertrichosis, hirsutism

Hair removal, multiple sites

VPL (Variable Pulsed Light)/ Energyet, UK

Nahavandi et al. 2008

3–9

49

Facial hirsutism

1–13

80

Sadick et al. 1999 Epilight, ESC Med Systems

IPL Epilight/ Lumenis

Moreno-Arias et al. 2002

Hair removal, face, trunk, extremities

4

No of tx

55

6

IPL Epilight/ Lumenis

Fodor et al. 2005

Hair removal, axillae

No of pts

Hair removal, multiple sites, Isotretinoin intake

Ellipse Flex

Lee et al. 2006

Indication

Khatri and Garcia EsteLux, 2006 Palomar

IPL device

Author/year

Table 7.2  Literature review

–

2 month

–

>1 month

NA

NA

4–6 weeks

8 weeks

1 month

4–6 weeks

Treat. interval

NA

NA

IV–VI

II–V

I–IV

II

II-VI

I-V

II–V

II–IV

Fitzpatrick type

22–27

NA

40–43

77.8%: 35–39 21.3%: 25 J/cm

645 nm

27–30 J/cm

560 nm

25–45 J/cm

560, 640

Cutoff filter/ fluences

1 temporary hypopigmentation

5 patients with footprints marks

1 case of blisters

NA

3 cases of blistering

15% erythema 6% purpura

19% mild crusting

21% severe swelling

16% mild blisters

66% temporary discoloration

Minor complications: burning sensation and erythema

NA

Erythema and desquamation more often after 5ALA IPL

One hyperpigmentation

One hypotrophic scar

3.3% crusts

8.5% small blisters

Complications

114 9  Complications

IPL (ESC/ Sharplan)

IPL (ESC/ Sharplan)

Multilight (ESC Med System)

Natulight (Lumenis)

Vasculight (ESC/ Sharplan)

IPL

Lumenis One (Tokyo)

Goldman and Weiss 2001

Weiss et al. 2000

Paquet and Pierard 2004

Kawada et al. 2002

Wang et al. 2004

Moreno Arias and Ferrando 2001

Konishi et al. 2008

Facial pigmentary lesions

Melanocytic lesions

Refractory melasma

Facial pigmentary lesions

Persistent facial hypermelanosis

Poikiloderma of Civatte

Poikiloderma of Civatte

18

20

17

60

2

135

66

3–5

2–4

4

3–5

5

1–5

~2.8

2–3 weeks

4–8 weeks

1 month

2–3 weeks

1 month

1 month

1 month

NA

II–IV

III–IV

NA

II

NA

NA

12–14 J/cm

560 nm 2

2

615 nm–38 J/cm

590nm–34 J/cm2

26–33 J/cm2

570, 590, 615nm

20–24 J/cm2

560 nm

25–32 J/cm2

No complications

Postinflammatory hyperpigmentation in patients with mixed melasma

2 patients with transient postinflammatory hyperpigmentation

1 patient had erosion

Temporary blisters and crusts

7 cases of crusting

20–24 J/cm2 550, 590, 615nm

20 cases of temporary mild purpura

15 cases of mild purpura resolved within 3–5 days 4 cases of temporary hypopigmentation 2 cases of persistent hypopigmentation

515, 550, 570 nm

30–34 J/cm 2

515nm mostly

9.1  Major Complications 115

IPL device

Ellipse Flex

IPL Epilight/ Lumenis

IPL Epilight/ Lumenis

VPL (Variable Pulsed Light)/ Energyet, UK

EsteLux, Palomar

Epilight, ESC Med Systems

Epilight, ESC Med Systems

Author/year

Lee et al. 2006

Fodor et al. 2005

Moreno-Arias et al. 2002

Nahavandi et al. 2008

Khatri and Garcia 2006

Sadick et al. 1999

Sadick et al. 2000

Hair removal, multiple sites

Hair removal, multiple sites 34

Multiple

2

2

6

67

2–18

77

Facial hypertrichosis, hirsutism Hair removal, multiple sites, Isotretinoin intake

3–9

1–13

80

49

4

# of txs.

55

# of pts

Facial hirsutism

Hair removal, face, trunk, extremities

Hair removal, axillae

Indication

Table 9.2  Complications after hair removal

>1 month

NA

NA

4–6 weeks

8 weeks

1 month

4–6 weeks

Treatment interval

II–V

I–IV

II

II-VI

I–V

II–V

II–IV

Fitzpatrick type

615, 645, 695

590, 615, 645, 695

NA

610 nm

695, 755

645, 695

27 pts645–950

28 pts600–950

Cutoff filter (nm)

34–42

40–42

22–27

NA

3 patients had temporary hyperpigmentation 2 patient with superficial crusting

All patients had transient erythema

Transient mild erythema

10 patients had reversible leukotrichia

61.2% transient erythema 6.1% had late erythema 16.3% transient hyperpigmentation 18.4% crusts 2% transient hypopigmentation 6.1% vesicles 10% paradoxical effect 2% minimal scar

6.25% blisters 8.7% temporary hyperpigmentation 1 case of leukotrichia 1 case of persistent hypopigmentation

21.3%: