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 (63.8% cases) and >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%: <34

14.917.1

Fluences (J/cm2)

NA

600

600

615, 645, 695

NA

18.5

12–14

34–42

590, 615, 645, 695 40–42

NA

610 nm

695, 755

645, 695

28 pts-600–950 27 pts-645–950

Cutoff filter (nm)

(continued)

Average clearance was 57% at 12 week interval

93.5% had hair reduction

64% had hair reduction <20% after 6 weeks

Mmean clearance was 76% after 3.7 treatments

Mean hair loss after 6 months was 54% after single treatment; 64% after multiple treatments

All patients were satisfied with the degree of hair removal

More than 50% clearance observed in 88.3% of cases

NA

60% good to excellent results; More satisfaction for fewer treatments

First group (28 pts) had 52.8% clearance; Second group (27 pts) had 83.4% clearance

Results/satisfaction

7.6  Literature Review 73

Hair removal Hair removal, 4 grafts and flaps Hair removal, multiple sites

Hair removal Back, thigh hair removal

Epilight ESC Sharplan

NA

EpilightESC Sharplan

NA

EpilightESC Med Syst

IPL RF, Aurora DS (Syneron Ltd)

Palomar/Starlux Rs

Palomar/Starlux Y

IPL (Medical Bio Care, Sweden)

Ellipse Relax Light 1000

SpaTouchRadiancy NY

Photoderm Epilight

Johnson and Dovale 1999

Moreno-Arias and Ferrando 2001

Weiss et al. 1999

Moreno-Arias et al. 2002

Gold et al. 1997)

Yaghmai et al. 2004

Amin and Goldberg 2006

Amin and Goldberg 2006

Toosi et al. 2006

Troilius and Troilius 1999

Goldberg and Silapunt 2001

Lor et al. 2002

Hair removal, multiple sites

Hair removal, multiple sites

Hair removal, bikini

Hair removal face, neck

Back, thigh hair removal

31

Hair removal

207

12

10

232

10

10

69

3–9

49

Facial hirsutism (hormonal imbalance)

NA

1–3

4

3–7

2

2

1

1

2

1–6

5–7

2–18

No of tx

48

3

25

Hair removal, transsexuals

Photoderm VLESC Med

Schroeter et al. 2003

No of pts

Indication

Table 7.2  (continued) Author/year IPL device

1 month

1 month

1 month

4–6 weeks

1 month

1 month

–

–

2 months

1 month

1 month

1 month

4–6 weeks

Treat. interval

I–V

I–IV

II–IV

II–IV

I–III

I–III

I–VI

NA

I–IV

I–V

II–III

V–VI

II–IV

Fitzpatrick type

40–43

40–42

38–42

28–45

37.2

Fluences (J/cm2)

6.25–6.45

~18.3

22–34

35

65

IPL: 14–30 RF: 10–20

570, 590, 645, 695 32–5533–50

NA

600

650

NA

NA

NA

590, 615, 645, 690 34–55

695–755

615, 645

695, 755

645, 695, 755

Most often 590

Cutoff filter (nm)

22% very satisfied; 45% satisfied; 33% unsatisfied

Average 27% clearance at 4 months

80.2% reduction at 8 months

66.9% hair reduction at 6 months

50% reduction

About 50% hair reduction at day 210

Average 46% reduction at 3 months

60% hair reduction at 12 weeks

NA

At 6 months, reduction of hair counts was 33%

No regrowth observed after 8 months

85–100% clearance

90% clearance rate

Results/satisfaction

74 7  Hair Removal

75

7.6  Literature Review

a

b

Fig. 7.12  Before (a) and after (b) sideburn hair removal. Excellent clearance

a

b

Fig. 7.13  Before (a) and after (b) treatment of fine hair follicles. Improvement obtained but not as in coarse hair types

types, some authors prefer using Nd:Yag laser (Weaver and Sagaral 2003). Identification of patients with unrealistic expectations increases the satisfaction level. For more details, see Chapt. 5 (Patient Selection).

7.6.3 Comparative Studies on IPL and Lasers Both IPL devices and lasers are currently used for hair removal. The effectiveness of different devices varies according to fluence, wavelength, pulse duration and delay. It is hard to compare the results of different studies as different devices, fluences and cutoff filters are used.

The efficacy of IPL, diode laser and Alexandrite laser was studied on 232 patients with skin types II–IV. At 6 months, optimal hair removal reduction was noticed with no significant differences between the sources (IPL: 66.9% clearance; Alexandrite: 68.7%; diode: 71.7%) (Toosi et al. 2006). Amin (Amin and Goldberg 2006) evaluated the results of epilation by comparing two IPL devices (Palomar/Starlux Rs, Palomar/ Starlux Y) a diode laser and an Alexandrite laser. The results were evaluated 210 days later by photographing the treated area. There was about 50% hair count reduction in all four areas but the Alexandrite laser had the highest pain score. Eleven patients were treated by Goh (2003) in a site-by-site manner using IPL and Nd:Yag laser. No significant differences were

76

noticed in the results. The Nd:Yag laser was more painful than IPL. Bjerring (Bjerring et al. 2000) evaluated side-by-side the IPL and the Ruby laser for hair removal. After three treatments, hair reduction was obtained by 93.55% of IPL treated patients and by 54.8% of Ruby laser treated patients. Additional IPL treatments resulted in only 6.6% further hair reduction. The pain level in the Ruby laser group was 3.5 times higher than with IPL treatments. Having a wide spectrum of wavelengths (500– 1,200nm), the IPL device has better penetration than Alexandrite or Ruby lasers. Shorter wavelengths can be used to target red-brown hair in individuals with light skin type, although the result is not as good as for dark hair.

7  Hair Removal

to cause selective tissue destruction. More details about photosensitizing drugs are described in Chapt. 2. Grossman (Grossman 1995) applied the principles of PDT to treat 11 hirsute patients. The area was first epilated and 20% topical ALA was used. Three hours later, the area was treated (wavelength of 630nm; fluence of 100–200J/cm2). A 50% reduction in hair regrowth was obtained after 3 months. Nahavandi (Nahavandi et  al. 2008) evaluated the efficacy of VPL in the treatment of unwanted hair in 77 volunteers. VPL delivers a pulsed train of light, each train containing up to 15 micro pulses. More than 50% hair clearance was observed in 88.3% of patients.

Practical Points

7.6.4 Extended Applications of Hair Removal

›› Hirsutism is represented by excessive growth

Most studies report hair removal from body areas that are most requested for treatment, such as the face, axilla and bikini. However, successful treatment with IPL of a relapsing hairy intradermal nevus after shave excision was reported by Moreno-Arias (MorenoArias and Ferrando 2001). IPL was also successfully used to correct improper hairline placement after hair transplantation (Moreno-Arias et al. 2000); three treatment sessions were enough to correct the problem. IPL applications have been extended to treat hairy grafts and flaps (Moreno-Arias et  al. 2002). Four patients who needed facial or breast reconstruction with flaps after cancer excision were successfully treated for hair removal. The authors noticed simultaneous improvement of skin coarseness, pigmentation and erythema. Excellent results were reported by Schroeter (Schroeter et al. 2003), who obtained 90% hair removal in transsexual patients. The average follow-up period was 44 months. The same author reported a negative correlation between hair removal and age of patient. This seems to be the single study that reports a correlation between age and amount of hair clearance.

››

7.6.5 Photodynamic Therapy (PDT) and Variable Pulsed Light (VPL) PTD implies the application of a photosensitizing drug (e.g., ALA) and appropriate selection of wavelengths

›› ›› ›› ›› ››

›› ›› ›› ›› ›› ››

of coarse terminal hair in women and distributed in a male like pattern. Hypertrichosis is represented by excessive growth of coarser and longer hair than is normal for the age, gender and race of the person. The hair follicle is most susceptible to IPL treatment during the anagen phase. The transition from one hair follicle phase to another varies according to the anatomical area. The anagen phase varies according to the anatomical area. Melanin is the target chromophore for hair removal. In white or grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes. These types of hair are less susceptible to IPL treatment. The targets for hair removal are the dermal papilla and the bulge area. Identify endocrinological problems before treatment. Refrain from using IPL in patients currently taking isotretinoin. Treatment of tanned skin is delayed for a few weeks. Defining the term “permanent hair removal” before starting treatment might increase the satisfaction level. Multiple treatments are usually needed. If no improvement is obtained after 5–6 sessions, interrupting the treatment should be considered.

References

›› Shaving ›› ›› ›› ››

is the only recommended method before IPL treatment. Treatment parameters need to be adjusted according to the previous results. Most physicians perform treatments 4–6 weeks apart. Hair removal efficacy increases with the darkness of the hair color and with the amount of fluence. The darker the skin and the brighter the hair, the less effective the treatment will be.

References Allison KP, Kiernan MN, Waters RA et  al. Evaluation of the ruby 694 Chromos for hair removal in various skin sites. Lasers Med Sci. 2003;18(3):165–170. Alonso L, Fuchs E. The hair cycle. J Cell Sci. 2006;119 (Pt 3):391–393. Amin SP, Goldberg DJ. Clinical comparison of four hair removal lasers and light sources. J Cosmet Laser Ther. 2006;8(2): 65–68. Baugh WP, Trafeli JP, Barnette DJ, Jr. et al. Hair reduction using a scanning 800 nm diode laser. Dermatol Surg. 2001; 27(4):358–364. Bernestein LJ, Geronemus RG. Keloid formation with the 585nm pulsed dye laser during isotretinoin treatment. Arch Dermatol. 1997;133(1):111–112. Bjerring P, Cramers M, Egekvist H et al. Hair reduction using a new intense pulsed light irradiator and a normal mode ruby laser. J Cutan Laser Ther. 2000;2(2):63–71. 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. Conn JJ, Jacobs HS. The clinical management of hirsutism. Eur J Endocrinol. 1997;136(4):339–348. Dierickx C. Laser-assisted hair removal: state of art. Dermatol Ther. 2000;13:80–89. Drosner M, Adatto M. Photo-epilation: guidelines for care from the European Society for Laser Dermatology (ESLD). J Cosmet Laser Ther. 2005;7(1):33–38. Ehrmann DA, Rosenfield RL. Clinical review 10: An endocrinologic approach to the patient with hirsutism. J Clin Endocrinol Metab. 1990;71(1):1–4. Falsetti L, Galbignani E. Long-term treatment with the combination ethinylestradiol and cyproterone acetate in polycystic ovary syndrome. Contraception. 1990;42(6):611–619. Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab. 1961;21:1440–1447. Fiskerstrand EJ, Svaasand LO, Nelson JS. Hair removal with long pulsed diode lasers: a comparison between two systems with different pulse structures. Lasers Surg Med. 2003;32(5): 399–404.

77 Fodor L, Menachem M, Ramon Y et  al. Hair removal using intense pulsed light (EpiLight): patient satisfaction, our experience, and literature review. Ann Plast Surg. 2005;54(1):8–14. Gerardo A, Camil CB, Juan F. Side-effects after IPL photoepilation. Dermatol Surg. 2002;28:1131–1134. Gil-Vernet A, Arango O, Gil-Vernet J, Jr. et al. Scrotal flap epilation in urethroplasty: concepts and technique. J Urol. 1995;154(5):1723–1726. Godynicki S, Gasse H, Schwarz R et al. Nutritional and functional blood vessels of anagen and telogen vibrissal follicles in the cat. Acta Anat (Basel). 1997;160(2):83–87. Goh CL. Comparative study on a single treatment response to long pulse Nd:YAG lasers and intense pulse light therapy for hair removal on skin type IV to VI–is longer wavelengths lasers preferred over shorter wavelengths lights for assisted hair removal. J Dermatolog Treat. 2003;14(4): 243–247. Gold MH, Bell MW, Foster TD et al. Long-term epilation using the EpiLight broad band, intense pulsed light hair removal system. Dermatol Surg. 1997;23(10):909–913. Goldberg DJ. Laser- and light-based hair removal: an update. Expert Rev Med Devices. 2007;4(2):253–260. Goldberg DJ, Silapunt S. Histologic evaluation of a Q-switched Nd:YAG laser in the nonablative treatment of wrinkles. Dermatol Surg. 2001;27(8):744–746. Gorgu M, Aslan G, Akoz T et  al. Comparison of alexandrite laser and electrolysis for hair removal. Dermatol Surg. 2000;26(1):37–41. Greppi I. Diode laser hair removal of the black patient. Lasers Surg Med. 2001;28(2):150–155. Grossman MC, Wimberley J, Dwyer P, Flotte T, Anderson RR. PDT for hirsutism. Lasers Surg Med. 1995;7(Suppl):44. Haedersdal M, Egekvist H, Efsen J et al. Skin pigmentation and texture changes after hair removal with the normal-mode ruby laser. Acta Derm Venereol. 1999;79(6):465–468. Haedersdal M, Gotzsche PC. 2006;Laser and photoepilation for unwanted hair growth. Cochrane Database Syst Rev. (4): CD004684. Haedersdal M, Wulf HC. Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol. 2006;20(1):9–20. Handrick C, Alster TS. Comparison of long-pulsed diode and long-pulsed alexandrite lasers for hair removal: a long-term clinical and histologic study. Dermatol Surg. 2001;27(7): 622–626. Hussain M, Polnikorn N, Goldberg DJ. Laser-assisted hair removal in Asian skin: efficacy, complications, and the effect of single versus multiple treatments. Dermatol Surg. 2003;29(3):249–254. Johnson F, Dovale M. Intense pulsed light treatment of hirsutism: case reports of skin phototypes V and VI. J Cutan Laser Ther. 1999;1(4):233–237. Karacaoglan N. Hair growth in the vagina after reconstruction with pudendal thigh flaps in congenital vaginal agenesis. Plast Reconstr Surg. 1997;100(6):1618. Khatri KA, Garcia V. Light-assisted hair removal in patients undergoing isotretinoin therapy. Dermatol Surg. 2006;32(6): 875–877. Kuriloff DB, Finn DG, Kimmelman CP. Pharyngoesophageal hair growth: the role of laser epilation. Otolaryngol Head Neck Surg. 1988;98(4):342–345.

78 Lask G, Eckhouse S, Slatkine M et  al. The role of laser and intense light sources in photo-epilation: a comparative evaluation. J Cutan Laser Ther. 1999;1(1):3–13. Lee JH, Huh CH, Yoon HJ, Cho KH Chung JH. Photoepilation results of axillary hair in dark-skinned patients by IPL: a comparison between different wavelength and pulse width. Dermatol Surg. 2006;32(2):234–240. Lehrer MS, Crawford GH, Gelfand JM et al. Effect of wax epilation before hair removal with a long-pulsed alexandrite laser: a pilot study. Dermatol Surg. 2003;29(2):118–122; discussion 122–113. Liew SH. Unwanted body hair and its removal: a review. Dermatol Surg. 1999;25(6):431–439. Liew SH. Laser hair removal: guidelines for management. Am J Clin Dermatol. 2002;3(2):107–115. Lor P, Lennartz B, Ruedlinger R. Patient satisfaction study of unwanted facial and body hair: 5 years experience with intense pulsed light. J Cosmet Laser Ther. 2002;4(3–4): 73–79. Mandt N, Troilius A, Drosner M. Epilation today: physiology of the hair follicle and clinical photo-epilation. J Investig Dermatol Symp Proc. 2005;10(3):271–274. Martin KA, Chang RJ, Ehrmann DA et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(4):1105–1120. Moreno-Arias G, Castelo-Branco C, Ferrando J. Paradoxical effect after IPL photoepilation. Dermatol Surg. 2002;28(11): 1013–1016; discussion 1016. Moreno-Arias GA, Castelo-Branco C and Ferrando J. Sideeffects after IPL photodepilation. Dermatol Surg. 2002;28(12):1131–1134. Moreno-Arias GA, Ferrando J. Noncoherent-intense-pulsed light for the treatment of relapsing hairy intradermal melanocytic nevus after shave excision. Lasers Surg Med. 2001;29(2):142–144. Moreno-Arias GA, Navarra E, Vilalta A et  al. Corrective ­photoepilation for improper hairline placement after hair transplantation. Dermatol Surg. 2000;26(8):790–792; ­discussion 792. Moreno-Arias GA, Vilalta-Solsona A, Serra-Renom JM et  al. Intense pulsed light for hairy grafts and flaps. Dermatol Surg. 2002;28(5):402–404. Muller SA. Hirsutism. Am J Med. 1969;46(5):803–817. Nahavandi H, Neumann R, Holzer G et al. Evaluation of safety and efficacy of variable pulsed light in the treatment of unwanted hair in 77 volunteers. J Eur Acad Dermatol Venereol. 2008;22(3):311–315. Nanni CA, Alster TS. Optimizing treatment parameters for hair removal using a topical carbon-based solution and 1064-nm Q-switched neodymium:YAG laser energy. Arch Dermatol. 1997;133(12):1546–1549. Ohyama M. Hair follicle bulge: a fascinating reservoir of epithelial stem cells. J Dermatol Sci. 2007;46(2):81–89. Roenigk HH, Jr., Pinski JB, Robinson JK et al. Acne, retinoids, and dermabrasion. J Dermatol Surg Oncol. 1985;11(4): 396–398.

7  Hair Removal Rosenfield RL. Clinical practice. Hirsutism. N Engl J Med. 2005;353(24):2578–2588. Ross EV. Extended theory of selective photothermolysis: a new recipe for hair cooking? Lasers Surg Med. 2001;29(5): 413–415. Ross EV, Ladin Z, Kreindel M et al. Theoretical considerations in laser hair removal. Dermatol Clin. 1999;17(2):333–355, viii. Sadick NS, Prieto VG. The use of a new diode laser for hair removal. Dermatol Surg. 2003;29(1):30–33; discussion 33–34. Sadick NS, Shea CR, Burchette JL, Jr. et  al. High-intensity flashlamp photoepilation: a clinical, histological, and mechanistic study in human skin. Arch Dermatol. 1999;135(6): 668–676. Sadick NS, Weiss RA, Shea CR et al. Long-term photoepilation using a broad-spectrum intense pulsed light source. Arch Dermatol. 2000;136(11):1336–1340. Sanchez LA, Perez M, Azziz R. Laser hair reduction in the ­hirsute patient: a critical assessment. Hum Reprod Update. 2002;8(2):169–181. Sand M, Bechara FG, Sand D et al. A randomized, controlled, double-blind study evaluating melanin-encapsulated liposomes as a chromophore for laser hair removal of blond, white, and gray hair. Ann Plast Surg. 2007;58(5):551–554. Schroeter CA, Groenewegen JS, Reineke T et al. Ninety percent permanent hair reduction in transsexual patients. Ann Plast Surg. 2003;51(3):243–248. 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. Toosi P, Sadighha A, Sharifian A et al. A comparison study of the efficacy and side effects of different light sources in hair removal. Lasers Med Sci. 2006;21(1):1–4. Troilius A, Troilius C. Hair removal with a second generation broad spectrum intense pulsed light source–a long-term ­follow-up. J Cutan Laser Ther. 1999;1(3):173–178. Tse Y. Hair removal using a pulsed-intense light source. Dermatol Clin. 1999;17(2):373–385, ix. Warner J, Weiner M, Gutowski KA. Laser hair removal. Clin Obstet Gynecol. 2006;49(2):389–400. Weaver SM, 3rd, Sagaral EC. Treatment of pseudofolliculitis barbae using the long-pulse Nd:YAG laser on skin types V and VI. Dermatol Surg. 2003;29(12):1187–1191. Weir VM, Woo TY. Photo-assisted epilation–review and personal observations. J Cutan Laser Ther. 1999;1(3):135–143. Weiss RA, Weiss MA, Marwaha S et  al. Hair removal with a non-coherent filtered flashlamp intense pulsed light source. Lasers Surg Med. 1999;24(2):128–132. Wendelin DS, Pope DN, Mallory SB. Hypertrichosis. J Am Acad Dermatol. 2003;48(2):161–179; quiz 180–161. Yaghmai D, Garden JM, Bakus AD et al. Hair removal using a combination radio-frequency and intense pulsed light source. J Cosmet Laser Ther. 2004;6(4):201–207. Zachariae H. Delayed wound healing and keloid formation following argon laser treatment or dermabrasion during isotretinoin treatment. Br J Dermatol. 1988;118(5):703–706.

8

IPL Treatment for Vascular Lesions

Contents 8.1 Types of Vascular Lesions...................................... 80 8.2 IPL Effect on Vascular Lesions............................. 87 8.3 Treatment Protocol................................................. 88 8.4 Literature Review................................................... 91 8.4.1 Hemangioma Treatment........................................... 91 8.4.2 Capillary Malformations........................................... 93 8.4.3 Telangiectasias.......................................................... 98 8.4.4 Leg Veins.................................................................. 100 8.4.5 Treatment of Other Vascular Lesions....................... 101 8.4.6 Using the IPL for the Management of Acne Vulgaris....................................................... 102 8.4.7 IPL Versus Lasers..................................................... 102 8.4.8 Treatment of Dark Skinned Patients......................... 104 8.4.9 Satisfaction after IPL Treatment of Vascular Lesions................................................... 104 References............................................................................ 105

Abstract According to the International Society of the Study of Vascular Anomalies, vascular anomalies can be classified as vascular tumors (origin in the endothelial hyperplasiate and vascular malformations (normal endothelial turnover). Hemangiomas are the most common benign vascular tumors of infancy. Portwine stains are present in 0.3–0.5% of newborns and are congenital malformations of the superficial dermal capillaries. The vascular lesions that most benefit from IPL treatment are: hemangiomas, PWS, angiomas, telangiectasias, leg veins, rosacea and Poikiloderma of Civatte. Angiofibroma, cutaneous lesions of Kaposi sarcoma, Blue Rubber Nevus syndrome, hereditary hemorrhagic telangiectasias and stria distensia may also have some benefit. The main chromophores are oxyhemoglobin and deoxyhemoglobin. Superficial red vascular lesions have a high amount of oxyhemoglobin. The pulse duration should be shorter than the thermal relaxation time of the chromophore to preferentially protect the surrounding tissue from heat damage. The need for multiple treatments should be emphasized to the patient. For deep hemangiomas, IPL treatment alone is not effective. Capillary malformations on the limbs have less response to treatment compared to those on the head and neck.

Vascular lesions have been reported as treated with technologies that emit green light (532 nm), yellow light (578–600 nm), red light (755–810 nm), near infrared light (1,064 1993nm), and broad spectrum IPL (range 500–1200 nm) (Chess and Chess ; Sadick 2002). To understand the effect of IPL on vascular lesions, it is important first to become familiar with these conditions.

L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_8, © Springer-Verlag London Limited 2011

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8  IPL Treatment for Vascular Lesions

8.1 Types of Vascular Lesions

II Vascular malformations (normal endothelial turnover)

According to Mulliken (Mulliken 1998), vascular lesions can be classified based on cell kinetics. There are three main categories of lesions:

(A) Low flow

I Hemangiomas which have endothelial hyperplasia II Malformations which have normal endothelial turnover III Ectasias which have normal endothelial turnover but vascular dilatation Vascular malformations can be further classified into: (A) Capillary malformations (CM) −− Port-wine stains (PWS) −− Telangiectasias (B) Venous malformations (VM) −− Localized −− Diffuse (C) Arterial malformations (AM) −− Bonnet-Dechaume-Blanc syndrome −− Cobb syndrome (D) Lymphatic malformations −− Localized −− Diffuse (E) Combined −− −− −− −− −− −− −− −− −−

Capillary lymphatic malformation (CLM) Regional Klippel-Trenaunay Syndrome Parkes-Weber syndrome Diffuse Maffucci syndrome Solomon syndrome Riley-Smith syndrome Bannayan syndrome

−− −− −− −−

CM VM LM Combined

(B) High flow −− AVM −− Arteriovenous fistula (AVF) Hemangiomas are the most common benign vascular tumors of infancy. They are proliferative, have plump endothelium and can appear on the skin, mucosa or other soft tissues. Most are located in the head and neck areas and occur with a higher frequency in females. There are three types of hemangiomas: superficial, deep and mixed (Al Buainian et  al. 2003). Superficial hemangiomas are found in the papillary dermis and have a bright red color. Deep hemangiomas are present in the reticular dermis and subcutaneous fat and have a bluish appearance (Fig. 8.1). The overlying skin might have a network of telangiectasias. At first, it can be difficult to distinguish hemangioma from vascular malformation. Hemangiomas are rarely present at birth. They appear after 3–4 weeks and have a rapid growth during the next few weeks. Vascular malformations are usually present at birth and increase in size as the child grows. Hemangiomas have a bright red color that deepens by the second half of the first year of life, while the hue aspect of a vascular malformation ­persists. Usually hemangiomas have a firm rubbery

According to the International Society of the Study of Vascular Anomalies (Adamic et al. 2007), vascular anomalies can be classified as following: I Vascular tumors (origin in the endothelial hyperplasia) −− Hemangioma

Fig. 8.1  Typical deep hemangioma (note bluish appearance)

81

8.1  Types of Vascular Lesions

consistency while vascular malformations are soft and easily compressed. Hemangiomas have usually three stages: a growing, rapid proliferative phase usually during the first six months of life; a stable period and an involution period (Glassberg et  al. 1989; Fishman and Mulliken 1993; Astner and Anderson 2005). During the involution phase, there are color changes and superficial lesions have a flaccid waxy yellow skin (Fig. 8.2). About 30% of involuting hemangiomas will leave some marks of atrophy, fibrosis or telangiectasia (Glassberg et  al. 1989). It has been estimated that hemangiomas involute by 10% of their volume per year. Lesions on the nose and lips involute more slowly. If there are no signs of regression by age 6–8 years, they are not likely to completely regress. Adult hemangiomas consist of mature capillary-size vessels of about 100 µm. At times, hemangiomas may complicate. About 5–11% can ulcerate, become infected or bleed. Usually these complications appear during the proliferative phase. However, in certain circumstances, they can lead to significant morbidity, impairing vision (in the periorbital area), interfering with feeding or respiration (in the nose or mouth areas), impairing hearing (in the auditory canal) or can even be life threatening, necessitating early intervention. Skeletal distortion is rare but can appear as a mass effect of large hemangiomas. IPL or lasers (Argon; Pulsed Dye Laser- PDL; Nd:Yag) have been reported as treatment tools for hemangiomas (Al Buainian et al. 2003; Witman et al. 2006).

Fig. 8.2  Atrophic skin in a child after involution of the hemangioma

Port-wine stains are present in 0.3–0.5% of newborns and are congenital malformations of the superficial dermal capillaries (Fig. 8.3, 8.4). The ectatic capillaries have different sizes and depths, most varying from 10–150 µm in diameter and 300–600 µm in depth (Viator et  al. 2002; Sivarajan et  al. 2006; Jasim and Handley 2007). Videomicroscopy analysis of PWS shows three types of vascular ectasia located at the vertical loops of the papillary plexus, deeper horizontal vessels in the papillary plexus and combined vertical and

Fig. 8.3  Port wine stain – child type

Fig. 8.4  Port wine stain – adult type

82

horizontal vessels involvement (Barsky et  al. 1980; Astner and Anderson 2005). Clinically, they appear as pink macules which progressively dilate to become red (Klapman and Yao 2001). These lesions do not spontaneously resolve. They should be differentiated from other pink stains as nevus flammens or salmon patch; these lesions usually disappear within the first year of life. PWS are predominantly located in the head and neck area, are well delineated and commonly involve the distribution area of the trigeminal nerve. PWS lesions can be associated with other medical conditions. SturgeWeber syndrome is one of the most common. They also can be associated with varicose veins and skeletal tissue hypertrophy in Klippel-Trenaunay syndrome. Telangiectases are characterized by permanent dilation of vessels with diameters ranging from 0.1–1 mm. Most originate in a dilated venule but capillaries and arterioles are sometimes affected. The arteriolar type has a bright red color and protrudes above the skin surface. The capillary type is red. These lesions can be seen in numerous conditions such as collagen vascular diseases, post-trauma, after sun damage or radiodermatitis. Most often they are present in the upper part of the body. There are four clinical types: simple or linear, arborizing (Fig. 8.5), spider (Fig. 8.6) and popular. Entities in which telangiectasias are the main pathologic process are: unilateral nevoid telangiectasia, generalized essential telangiectasia,

Fig. 8.5  Teleangiectasia – arborizing type

Fig. 8.6  Teleangiectasia – spider type

8  IPL Treatment for Vascular Lesions

hereditary benign telangiectasia and cutaneous collagenous vascular diseases. It has been shown that a red telangiectasia has a higher concentration of oxygenated hemoglobin while a blue venulectasia has a higher concentration of deoxygenated hemoglobin (Goldman and Bennett 1987; Goldman and Eckhouse 1996; Sommer et  al. 1997). Most telangiectases tend to become darker and larger with advancing age, due to the progressive vessel ectasia (Hercogova et al. 2002). Cherry angiomas are often present in the trunk during adulthood (Fig. 8.7a, b). They are small red papules which do not change color on compression. They consist of dilated capillary blood vessels located within the superficial dermis. Spider angiomas are present in about 10–15% of adults and children. They are predominantly located on the face, neck and upper trunk. Pregnant women or patients with liver diseases have a higher incidence of these lesions. Spider angiomas have a main vessel located in an arteriola, from where the blood flows to the peripheral capillaries. They have a central slightly elevated red punctum from which the blood vessels radiate (“spider legs”) (Fig. 8.8a, b). Rosacea is a chronic inflammatory eruption of the flushing areas of the face. In a histological study it was found that deranged connective tissue is secondary to damaged capillaries. The primary cause of the damage seems to be the environment, mainly the sun (Neumann and Frithz 1998). Most often the lesion involves the nose and cheeks. In the mild form, it appears as slight flushing of the area but, as the process becomes more severe, the lesions are deeper (red-purple) with dilated superficial capillaries (Fig. 8.9a, b). In severe cases, pustules may develop. Piogenic granuloma is an acquired vascular lesion, usually solitary and bright red colored. The lesion is considered to be a hyperplastic process. It grows rapidly, especially in places of trauma and can easily bleed. Cutaneous lesions are most often encountered but mucosal location is not rare. Venous malformations are easily recognized due to their blue hue appearance and are easily compressible. Small venous malformations have a good response to IPL treatment. Leg veins are caused by gravitational dilatation, reflux and incompetent valves. These veins are connected to larger reticular or a varicose “feeding” vein

83

8.1  Types of Vascular Lesions

a

b

Fig. 8.7  Before (a) and after (b) single IPL treatment

a

b

Fig. 8.8  (a) Spider angioma before treatment; (b) After a single IPL treatment

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a

8  IPL Treatment for Vascular Lesions

b

Fig. 8.9  (a) Rosacea; (b) Two months after two IPL treatments

Fig. 8.10  Leg veins

(Figs. 8.10, 8.11). Their structure is similar to telangiectasias or venous lakes. They have a thicker adventitia and increased basal lamina when compared to facial veins (Adamic et al. 2007). Venous lakes most often appear in the fourth or fifth decade of life. They are commonly located on the face, neck and oral mucosa. With time they tend to enlarge and may bleed. They are venous ectasia. Scar telangiectasias. Frequently, hypertrophic or keloid scars have telangiectasias on their surface. This is a result of neovascularization initiated by angiogenic stimuli. As the scar matures, the angiogenesis decreases. Sometimes the scar has a red color for a longer period of time due to persistence of stimuli or delayed regression of capillaries. The vascular lesions that most benefit from IPL treatment are: hemangiomas (Fig. 8.12a, b), PWS (Figs. 8.13a, b, 8.14a, b), angiomas (Fig. 8.15a, b), telangiectasias (Fig. 8.16a, b), leg veins (Figs. 8.17a, b,

Fig. 8.11  Leg veins

8.18a, b, 8.19a, b), rosacea and Poikiloderma of Civatte. Angiofibroma, cutaneous lesions of Kaposi sarcoma, Blue Rubber Nevus syndrome, hereditary hemorrhagic telangiectasias and stria distensia may also have some benefit (Adamic et al. 2007).

85

8.1  Types of Vascular Lesions

a

b

Fig. 8.12  (a) Hemangioma of the lower lip; (b) After five treatments (combined IPL and intralesional steroids)

a

Fig. 8.13  (a) PWS child type; (b) After eight IPL treatments

b

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a

8  IPL Treatment for Vascular Lesions

b

Fig. 8.14  (a) PWS child type; (b) Excellent result after six IPL treatments. Sedation was used for each treatment

a

b

Fig. 8.15  (a) Angioma on the trunk; (b) After a single treatment

a

b

Fig. 8.16  (a) Numerous teleangiectasia on an erythematous area (rosacea); (b) After two treatments

87

8.2  IPL Effect on Vascular Lesions

a

b

Fig. 8.17  Before (a) and after (b) four IPL treatments, 1 month apart

a

b

8.2 IPL Effect on Vascular Lesions The IPL system acts on the principle of selective photothermolysis and has proved to be useful in treating many vascular lesions. The main chromophores are oxyhemoglobin and deoxyhemoglobin. Superficial red vascular lesions have a high amount of oxyhemoglobin (Fig. 8.20). The wavelength absorption peaks of oxyhemoglobin are: 418, 542 and 577 nm (Railan et  al. 2006). Deoxyhemoglobin is predominantly located in deeper vascular lesions and mainly in the lower extremities (Fig. 8.21). It has an absorption spectrum in the 600–750 nm range (Goldman et  al. 2005). However, oxyhemoglobin and deoxyhemoglobin are not the only chromophores present in the skin. The light absorption by the melanin causes some

Fig. 8.18  Leg veins before (a) and after (b) three treatments

a

b

Fig. 8.19  Leg veins before (a) and after (b) four treatments

Fig. 8.20  Red vascular leg veins with high oxyhemoglobin concentration

88

8  IPL Treatment for Vascular Lesions

Baumler (Baumler et al. 2007) elaborated a mathematical model for investigating the effect of IPL on blood vessels of 60, 150, 300 and 500 µm. The two extremities of the IPL spectrum (near infrared and near visible range) were studied. Both provided homogenous heating of the blood vessels. Small vessels (<60 µm) had only a moderate increase in temperature. The effective time interval to raise the temperature in larger vessels (>60 µm) was shorter than the pulse duration. Effective coagulation was difficult to achieve at the bottom area of the vessels (Baumler et al. 2007). This can explain the refractory of some lesions to treatment. It was postulated that coagulation of the blood occurs at temperatures higher than 70°C (Black and Barton 2004). Fig. 8.21  Leg veins with high deoxyhemoglobin concentration (lower part of photo)

limitations in penetration depth. The “perfect” wavelength of different lasers used in the past (e.g., Argon 577 nm) were recently replaced by other lasers (e.g., Pulse dye, Alexandrite, 1,064 nm Nd:Yag) or IPL devices (Railan et al. 2006). Based on a mathematical model, Ross (Ross et al. 2005) concluded that, with an optimal set of parameters, IPL devices and lasers are comparable in the treatment of vascular and pigmented lesions regarding the efficiency and safety. However, unlike lasers, IPL devices have a wide spectrum of wavelengths with different depth penetration, different absorption by the skin and more complex tissue response. The pulse duration should be shorter than the TRT of the chromophore in order to preferentially protect the surrounding tissue from heat damage. The long delay between pulses and the long pulse durations offer enough cooling of the epidermis and small vessels without a significant decrease in temperature for large vessels (Goldman and Eckhouse 1996). As a consequence, high fluences can be applied for heating large vessels without injuring the epidermis. For a vessel of 0.1 mm diameter, the TRT is about 4 ms, and for a 0.3 mm vessel the TRT is about 10 ms. This shows that larger vessels cool more slowly than epidermis for a single pulse (Goldman et al. 2005). For these vessels, multiple pulses are preferred (longer than 10 ms).

8.3 Treatment Protocol The initial consultation should establish the correct diagnosis of the vascular lesion. In case of a vascular malformation, parental education about the lesion, treatment options and possible results should be addressed. The need for intravenous sedation or general anesthesia for multiple treatments should also be emphasized. We always refer a child with a vascular malformation to a pediatric consultation. The possibility of associated abnormalities including neurological disorders should be ruled out first (Enjolras et al. 1985). In certain conditions, such as Sturge-Weber syndrome, patients may have seizures. Because the epilepsy can be initiated by the intense light, it is our protocol not to perform treatment in these situations unless an informed release from the neurologist is obtained. Patients with PWS distribution to the lower limbs should be evaluated for underlying Klippel Trenaunay syndrome (Chapas and Geronemus 2005). Patients with a history of oral conceptive use, pregnancy, recent thrombophlebitis, or lower extremities venous insufficiency are not good candidates for IPL treatment, and we refrain from performing it in any of these circumstances. Patients who are tanned, have a history of keloids or postinflammatory hyperpigmentation are also not good candidates for treatment. Although there are authors (Adamic et al. 2007) who recommend bleaching agents prior to treatment, we prefer delaying treatment for 4–6 weeks.

8.3  Treatment Protocol

Fig. 8.22  Eyelid hemangioma. IPL treatment was not performed due to high risk of eye complications

In most cases, the treatment of vascular lesions is mainly cosmetic. Only when the lesion interferes with the functioning of an organ (eye, mouth) does the IPL treatment have a functional correction component. It is important to correctly diagnose the vascular lesion and evaluate the suitability of the patient for IPL treatment (Fig. 8.22). Special attention should be paid to patients with unrealistic expectations. They are not good candidates for IPL treatment. The success rate can also be affected by previous treatments, such as intralesional steroid injection for hemangiomas or previous irradiation. These produce fibrotic changes which make the lesion more resistant to treatment. Some patients have undergone previous treatments with lasers and have pigmentary alterations or scarring at the time of examination. These side effects should be mentioned and noted in the patient’s record, explaining that this may alter the efficacy of treatment in that area. There is no clear definition of when to start treating PWS lesions. We prefer starting treatment early in childhood when they are smaller and more superficially located. With age, they become thicker, darker and harder to treat. Local anesthetics that produce vasoconstriction are to be avoided in order to enhance to the maximum the light distribution to the chromophores. In children, intravenous sedation or general anesthesia is emp­ loyed. Most of the time, teleangiectasias and super­ ficial reticular leg veins can be treated without

89

anesthetics. We prefer to use only ELA-Max as a local anesthetic as it causes minimal vasoconstriction. Other factors that induce vasoconstriction, such as decreased room temperature, should be avoided prior to treatment. After entering into the IPL device the patient’s skin type and lesion type, the computer automatically selects the wavelength, pulse duration, delay and fluence. These parameters can be further adjusted from treatment to treatment. Sometimes it is difficult to categorize a certain lesion in a category (e.g., PWS can be superficial, medium or deep). Treatment para­ meters need to be adjusted to the clinical response. For superficial lesions, the transparent gel to use should not be cold to avoid vasospasm. Most IPL devices are equipped with a cooling facility to decrease the epidermal temperature during treatment. Applying cooling on small superficial vascular lesions may cause vasoconstriction and result in a less beneficial therapeutic effect. We do not use cooling in these situations but always use it immediately after treatment. The immediate appearance of local bruising (Fig. 8.23a–c) or a bluish aspect is a sign of a good clinical response to the treatment. Perilesional erythema (Fig. 8.24a, b), blanching or “urticariform” reaction (Fig. 8.25a, b) or vein thrombosis (Fig. 8.26­a–d) are also signs of good response for linear vessels. When performing the treatment, the hand piece is placed in contact with the transparent gel without any pressure. Even small pressure can empty the vessels by diverting the blood into collaterals and causing the treatment to be less effective. Care is taken to avoid overlapping the treated areas. Larger spot sizes have deeper penetration into the lesion with a better response (Grossman 1997; Chapas and Geronemus 2005). The usual treatment interval is 4–6 weeks. Avoiding sun exposure between treatments is important. There is no restriction to using make-up immediately after treatment. To be efficient in treating vascular lesions, the IPL device should produce a wavelength having the best absorption by the target (oxyhemoglobin, deoxyhemoglobin), have the ability to reach the depth of the blood vessels, produce enough energy to damage the vessels with limited harm to the surrounding tissue, and enough exposure to coagulate the vessel. Pulses that are shorter than the TRT of a vessel will not produce enough heating of the vessel to be therapeutically effective. On the other hand, excessively long pulse

90

a

8  IPL Treatment for Vascular Lesions

b

c

Fig. 8.23  (a) Patient with leg veins before treatment; (b) Bruising 5 days after treatment; (c) One year later (Reprinted with permission of Lippincott, Williams & Wilkins, Wolters Kluwer. L. Fodor, Y. Ramon, A. Fodor, N. Carmi, I.J. Peled,

a

Y. Ullmann. A side-by-side prospective study of Intense Pulsed Light and Nd:Yag Laser Treatment for vascular lesions. Ann Plast Surg, 2006;56:164–170)

b

Fig. 8.24  (a) Leg veins; (b) Immediate perilesional erythema as a sign of good response

durations produce heat diffusion to the surrounding tissues. Patients with superficial vascular lesions, such as teleangiectasias, require a few treatments (usually up to three) to achieve result. Other lesions, such as  PWS and hemangiomas, require many more

treatments, often more than ten to achieve the desired result. The treatment period will take more than a year, and this should be emphasized to the patient before starting treatment. Larger and deeper vessels require higher fluences and usually have a poor result.

91

8.4  Literature Review

a

b

Fig. 8.25  (a) Leg veins before treatment; (b) Immediate “urticariform reaction” as a sign of good response

8.4 Literature Review IPL devices with a wide range of wavelengths (500– 1200 nm) by using different cutoff filters are able to eliminate shorter wavelengths and allow deeper dermal penetration. By selecting multiple pulses and longer pulse durations, more heating is produced which is important for the treatment of large caliber vessels.

8.4.1 Hemangioma Treatment The literature is limited in describing the treatment of hem­angiomas with IPL. Therapeutic tools for heman­ giomas include pulsed light devices, pulse dye lasers,

Nd:Yag lasers and other methods such as cryotherapy and local or systemic steroid injections (Raulin et  al. 2003). Although there is a debate between the “wait and see” strategy and the active method, there is no question about treating hemangiomas with functional and structural impairment (Landthaler and Hohenleutner 2006). Some authors strongly recommend treating the hemangiomas at the very early stage (macular stain) in order to stop their growth (Astner and Anderson 2005). Treatment may be useful even during the active proliferative phase (month 3–9), when they show ulceration and bleeding. Two cases of ulcerated hemangiomas were treated by Jorge (Jorge et al. 2008). Good results were obtained after two to four sessions. Complete epithelization was obtained at between 1 and 2 months.

92

8  IPL Treatment for Vascular Lesions

a

b

c

d

Fig. 8.26  (a) Medium size leg veins; (b) Immediate thrombosis; (c) Temporary hyperpigmentation; (d) One year later

93

8.4  Literature Review

a

b

Fig. 8.27  (a) Deep hemangioma; (b) One year after five treatments of combined IPL and intralesional steroids

a

b

Fig. 8.28  (a) Hemangioma of the upper limb; (b) Several years after treatment. Systemic steroid administration and IPL were combined

Less efficient is treatment performed during the involution phase due to the altered fibrofatty structure. It is our belief that superficial hemangiomas, especially in the proliferative phase of growth, respond better to treatment. It is for this reason that we prefer to treat these lesions as soon as possible. For deep hemangiomas, IPL treatment alone is not effective (Chapas and Geronemus 2005). In this situation, we combine IPL, Nd:Yag laser and intralesional steroid injections (Figs. 8.27a, b, 8.28a, b).

8.4.2 Capillary Malformations The results of PWS treatment with IPL are various as reported in the literature (Table 8.1). Most PWS lesions are located in the head and neck (Jacobs and Walton 1976) (Figs. 8.29a, b, 8.30a, b, 8.31a, b) These lesions do not regress over time and usually hypertrophy in

adulthood, making treatment more difficult. Twentytwo patients with PWS were treated by Ho (Ho et al. 2004), five to seven times, using cutoff filters of 550, 570, and 590 nm and fluences from 35 to 75 J/cm2. Most patients (81.8%) obtained little to moderate improvement. Little improvement was also reported by Reynolds (Reynolds et  al. 2005), who treated 12 subjects with IPL (Lumina device). At fluences lower than 26 J/cm2, there was no clinical response. The patients who failed to show any response had pink PWS. According to the author, the darker the PWS, the better the fading that was seen. Moderate impro­ vement was reported in 47% of the patients treated by Ozdemir (Ozdemir et  al. 2008) with IPL (Lumina, Lynton). Complete clearing was seen in only one patient of 12. On a small number of patients with mature PWS treated with a 515 nm cutoff filter and fluences from

Angermeier 1999

Clementoni et al. 2006

Clementoni et al. 2005

Sadick 2002

Green 1998

Reticular veins

Vasculight 1064 nm.

PhotDerm VL

(Lumenis)

PhotDerm VL

(Lumenis)

PhotDerm VL

Facial telangiectasia, hemangioma, rosacea, PWS

Facial telangiectasia

Facial telangiectasia

Blue venulectases

ESC Sharplan

ESC Sharplan

Red telangiectasia

Telangiectasia of lower extremities

Facial, leg telangiectasia; spider nevi; erythrosis interfollicularis; senile angiomas.

PhotoDerm VL

(ESC Med system)

PhotoDerm VL

(ESC Med system)

PhotoDerm VL

(<3 mm)

(ESC Med system)

Schroeter and Neumann 1998

Leg veins

PhotoDerm VL

Goldman and Eckhouse 1996

Dyschromia (vascular lesions, pigmented lesions)

Venous malformations

Medilux Starlux (Palomar)

ESC Sharplan

PhotoDerm VL

Butler et al. 2006

Raulin and Werner 1999

188

1000

518

50

72

120

(369 lesions)

159

17

11

Table 8.1  Different results after IPL vascular lesions treatment Author/year Device Indication Pat.

1–4

1–9

1–9

up to 3

1–5

NA

5

1

~2

No. tt.

550, 570, 590 nm

570, 590 nm

36–60 J/cm2

38–56 J/cm2

40–56 J/cm2

140 J/cm2 for 1,064 nm selection

1,064 for blue lesions

570, 590 nm

40 J/cm2

25–70 J/cm2

22–50 J/cm2

25–70 J/cm2

21–40 J/cm2

~80.4 J/cm2

Fluence

550

515, 550, 570, 590 nm

590, 550, 570, 515 nm

515, 550, 570, 590 nm

NA

590 nm, most often used

Cutoff filter

I-III

I-IV

I-IV

II-V

I-III

NA

NA

I–IV

I–IV

Skin type

174 patients had 75–100% clearance

7.4% had a clearance of

89.7% had clearance of 75–100%

87.6% presented a clearance of 75–100% (2 months after treatment)

76% reported great satisfaction

75–100% clearing in 80% of patients.

Complete clearance in 10% of patients

Highest clearance (90%) for facial telangiectasia and erythrosis interfollicularis

Immediate clearing in 73.6%

79% had clearance of 75–100%.

94% had more than 50% clearance.

38.1% improvement at 1 month, judged by the physician.

65.% improvement, judged by the patient.

70–100% clearance was obtained in 8 lesions <100 cm2

Results

NA

months

NA

6 weeks

–

NA

2–4 weeks

–

1–8 weeks

Tt. interval

94 8  IPL Treatment for Vascular Lesions

Face and neck erythrosis

IPL

Vasculight (Lumenis)

Vasculight (Lumenis)

IPL Quantum

Vasculight (Lumenis)

Madonna Terracina et al. 2007

Fodor et al. 2006

Bellew et al. 2005

Erol et al. 2008

Hernandez-Perez et al. 2002

Striae distensae

Hypertrophic keloid scars

Hypertrophic scars

Various vascular lesions

PWS

Lumina (Lynton Lasers of Cheshire)

Reynolds et al. 2005

PWS

PWS resistant to PDL treatment

Mature PWS

Poikiloderma of Civatte

Essential telangiectasia of face, legs

Multilight (ESC Med System)

(EllipseFlex System)

IPL

(ESC Med system)

PhotoDerm VL

(ESC Ltd.)

PhotoDerm VL

Ho et al. 2004

Bjerring et al. 2003

Cliff and Misch 1999

Raulin et al. 1997

15

109

15

25

34

12

22

15

3

14

5

1–24 (mean 8)

2

1–4

5

2–9

3–8

4

3

1–10

645 nm

550–590 nm

570 nm

515, 550, 570 nm

560

NA

550, 570, 590 nm

NA

515

515, 550, 570 nm

>30 J/cm2

30–40 J/cm2

40–65 J/cm2

15–38 J/cm2

9–12 J/cm2

16–40 J/cm2

35–75 J/cm2

13–22 J/cm2

25–30 J/cm2

21.5–40 J/cm2

III, IV

NA

NA

II, III

II-IV

I-III

II, IV

I,II

NA

NA

A decrease in the number of striae from 117 to 94 was noted

34% had moderate improvement

25.7% had good improvement

31.2% had excellent improvement

IPL as PDL are equally effec­tive in improving the appearance of hypertrophic surgical scars

Mild or good improvement was obtained in 72% (patient evaluation)

2 patients had improvement

24 patients had total clearance

8 patients had some degree of fading

25–50% clearance in 50% patients

50–75% clearance was obtained in 31.1%

75–100% clearance was obtained in 9% patients

Average clearance of all patients was 44.2%

At least 50% improvement

3 patients showed good results

10 patients showed excellent results

2 weeks

2–4 weeks

2 months

1 month

3 weeks

NA

3–4 weeks

2 months

6 weeks

NA

8.4  Literature Review 95

96

a

8  IPL Treatment for Vascular Lesions

b

Fig. 8.29  Before (a) and after (b) 8 IPL treatments for PWS

a

b

Fig. 8.30  (a) PWS on the neck; (b) Marked improvement after ten IPL treatments

97

8.4  Literature Review

a

b

Fig. 8.31  (a) PWS – child type; (b) After several treatments

25 to 30 J/cm2, Cliff (Cliff and Misch 1999) reported at least 50% improvement after three treatments. Some of the patients with PWS had previous laser treatment. Bjerring (Bjerring et al. 2003) reported the results in a series of 15 patients with PWS resistant to PDL. After four treatments, about half the patients obtained clinical clearance. Eight patients had less than 25% clearance after IPL treatment. In these cases, the PWS was located in the central part of the face (second branch of the fifth cranial nerve). It seems that the lesions in this area are more resistant to treatment. It was reported by the patients that IPL was less painful than PDL treatment. Raulin (Raulin et al. 1997) successfully treated with IPL a PWS resistant to PDL. Dealing with previously treated PWS is difficult because the lesions usually have hypertrophic scarring and skin textural changes. Higher energies are required to be efficient and the results cannot be anticipated. Some PWS lesions or congenital vascular malformations may be resistant to therapy (Verkruysse et al. 2008). It seems that the depth and heterogeneity of lesions causes an unpredictable response. The deeper and smaller the capillary malformation, the more

heterogenous, the harder to treat (Dierickx et al. 1995; Lanigan 1998). It is believed that vessels smaller than 50 µm are less suitable for treatment due to insufficient intravascular heat generation (Shafirstein et al. 2004). The need to predict the results of treatment was behind the drive to find a device suitable for this task. Pulsed photothermal radiometry is a noncontact technique by which the skin is exposed to laser light. The temporal evaluation of the surface radiometric temperature is evaluated with an infrared detector (Tam 1983; Verkruysse et al. 2008). The laser light being absorbed by the lesion chromophores causes a spatial distribution of temperature. Although promising results have been reported, as with any diagnostic tool, it is recommended to have a realistic overview of its accuracy (Verkruysse et al. 2008). There are some reasons why PWS are resistant to treatment: inadequate depth of light penetration (most PDL have up to 1 mm penetration), inadequate conduction of heating from the chromophore to the vessel wall, inadequate blood volume (small diameter capillaries do not have enough hemoglobin) and inadequate fluence entering the capillary (Jasim and Handley 2007).

98

Capillary malformations on the limbs have a poor response to laser treatment compared to those located on the head and neck (Renfro and Geronemus 1993; Lanigan 1996; McGill and Mackay 2007). There is little evidence to explain this phenomenon. However, it was proved that cutaneous blood flow of the lesions situated in the head and neck increased with the ambient temperature, unlike those present on the limbs (McGill and Mackay 2007). Those observations might suggest a reason for the better response of capillary malformations of the head and neck to light and laser therapy. Pink PWS are more difficult to lighten than mature red PWS (Adamic et al. 2007). Deep and nodular PWS are more resistant to treatment (Fig. 8.32a–c). Photodynamic therapy has also been used for treating PWS. The principle is to add an exogenous chromophore into the capillaries, either transcutaneous or systemically. Most chromophores used have porphyrin precursors. Porphyrins have a wide spectrum of absorption with large peaks in the blue and red spectrum and a smaller peak in the yellow range (Lin et  al. 1997;

a

Fig. 8.32  (a) Immediate reaction in a case of PWS resistant to several treatments. Higher fluences were used; (b) Local wounds 7 days after treatment; (c) Wound healing and final results after

8  IPL Treatment for Vascular Lesions

Evans et al. 2005; Jasim and Handley 2007). The light acting on the capillaries generates a photochemical reaction. It was reported that capillary destruction is more efficient in this way.

8.4.3 Telangiectasias The flashlamp PDL has been proved to be effective for facial vascular lesions, including telangiectasias. However, significant side effects have been reported, such as pronounced purpura and changes in pigmentation. Angermeier (1999) reported his experience in treating the following facial vascular lesions: 79 telangiectasias, 74 rosaceas and 45 hemangiomas. Facial telangiectasia was treated with double pulse, 550 nm cutoff filter and fluences of 36–45 J/cm2. Most patients required single or double treatments in order to achieve 75–100% clearance. Less aggressive parameters were correlated with a higher number of treatments.

b

12 treatments. The fluence was decreased and then progressively increased for each treatment

99

8.4  Literature Review

c

a

b

Fig. 8.32  (continued)

One of the largest studies on facial telangiectasia treatment with IPL was reported by Clementoni (Clementoni et al. 2005). He evaluated 518 consecutive patients who had between one to nine treatments (average 1.6). Large facial veins were treated with triple pulses, 590 cutoff filter and a fluence rate of 50–56 J/cm2. Fine lesions were treated with double pulses, 570 nm cutoff filter and 40–43 J/cm2. Significant clearance (75–100%) was obtained in 87.6% of patients. In a different study (Clementoni et  al. 2006), the same author evaluated the results after treating 1,000 consecutive patients with facial telangiectasias. 89.7% had a clearance rate of 75–100%; 23.8% had lesion clearance after a single treatment, while 45.2% required two treatments to achieve the same result. According to the author, there was no correlation between the skin type and the clearance rate, but the result was influenced by the operator experience. Other authors reported good results for telangiectasia (Fig. 8.33a, b). Raulin (Raulin et al. 1997) reported on the treatment of essential telangiectasia and Poikiloderma of Civatte with IPL. Ten of fourteen

Fig. 8.33  Before(a) and after (b) a single IPL treatment

patients showed excellent results and three had good results. The single treatment of lower extremity telangiectasias is not enough, according to Green (Green 1998). Only 10% of lesions had complete clearing. The study was performed at the beginning of the IPL era. The same study showed a 21% scarring rate, which was not even close to the complication rate in other studies (Chapt. 9). Among facial or leg telangiectasias, spider nevi, erythrosis interfollicularis and senile angioma treated with IPL, the highest clearance (90%) was observed for facial telangiectasias and erythrosis interfollicularis (Schroeter and Neumann 1998). Facial telangiectasia is easier to treat than leg veins (Eremia and Li 2001). The forehead location when associated with rosacea had the best clearance

100

8  IPL Treatment for Vascular Lesions

(87%), as reported by Schroeter (Schroeter et  al. 2005). According to Goldman, bright red lesions are better treated with 515 and 590 nm filters and blue lesions with 590 nm or higher filters (Goldman et al. 2005).

8.4.4 Leg Veins Leg veins with different diameters respond differently. Most IPL studies were done on leg veins having a less than 3 mm diameter. The larger the vein, the lesser the response to treatment (Raulin and Werner 1999) (Fig. 8.33a, b). Sclerotherapy is known to be effective in the treatment of vascular lesions located on the legs. However, some patients are fearful of needles, and there are patients with superficial vessels smaller than the diameter of a 30 gauge needle or are resistant to sclerotherapy and who would benefit from light or

a

Fig. 8.34  (a) Medium size leg veins; (b) Improvement after five IPL treatments

laser treatement (Dover et al. 1999). The pulse duration should mach the diameter of the vascular lesion and be about the same as the thermal relaxation time for the lesion diameter. If the pulse duration is too short, the heating will be located mainly in the upper part of the skin and might not reach deep lesions. Unlike PDL, the IPL system has the advantage of using longer pulses. In order to destroy blood vessels larger than 100 µm in diameter, it has been calculated that the pulse duration should be in the 3–10 ms range (Alora et al. 1999). Goldman reported 94% clearance of leg veins for more than 50% of his patients (Goldman and Eckhouse 1996), and 79% had a high rate of clearance (75– 100%). The treated lesions and parameters used were as following: leg veins <0.4 mm: 550 nm cutoff filter and 50 ms delay; leg veins between 0.4–1 mm: 570 nm cutoff filter and 50–100 ms delay; leg veins between 1–3 mm: 590 nm cutoff filter and 150 ms delay. In all the lesions, the least responsive to treatment were leg veins with a 1–3 mm diameter. Shorter wavelengths

b

101

8.4  Literature Review

(500–600 nm) are preferred for treating class I superficial red telangiectasias (Adrian 1998; Bernstein et al. 1998), while longer wavelengths (>750 nm) are effective for class II–III, deeper blue reticular veins (McDaniel et al. 1999; Weiss and Weiss 1999; Sadick 2002). Superficial and small sized vessels are best treated with longer pulses. Triple pulses and higher fluences are also preferred (Dover et al. 1999). Using a dual wavelength approach, Sadick (2002) obtained a 75–100% clearance of leg veins in 80% of patients. An average of 2.5 treatments were needed, using 550 nm (Photoderm) and 1,064 nm (Vasculight). The short wavelength was addressed to the red vascular lesions and the long wavelength was addressed to the blue vascular lesions. The overall satisfaction level was reported to be 76%. When leg veins do not respond well to IPL or have a deeper location or larger caliber, Nd:Yag laser can be of real benefit (Fig. 8.35a–d)

a

b

c

d

Fig. 8.35  (a) Before IPL on the right leg; (b) Clinical response 1 year after 4 IPL treatments; (c) Before Nd: Yag laser on the left thigh; (d) Same patient 1 year after 4 Nd:Yag laser treatments (Reprinted with permission of Lippincott, Williams & Wilkins,

(Weiss and Weiss 1999; Bernstein 2001; Omura et al. 2003). Some IPL platforms are also equipped with Nd:Yag laser.

8.4.5 Treatment of Other Vascular Lesions The results of treating Poikiloderma of Civatte and rosacea were presented in Chapt. 6 (Skin rejuvenation). Treatment of tufted angioma is usually unsatisfactory. However, Chiu (Chiu et  al. 2007) reported a case of tufted angioma that was successfully treated with IPL. Four treatments were performed at 3–4 week intervals. The fluence used was 40 J/cm2 with a 560 nm cutoff filter. Facial and neck erythrosis were treated by Terracina (Madonna Terracina et  al. 2007) with IPL.

Wolters Kluwer. L. Fodor, Y. Ramon, A. Fodor, N. Carmi, I.J. Peled, Y. Ullmann. A side-by-side prospective study of Intense Pulsed Light and Nd:Yag Laser Treatment for vascular lesions. Ann Plast Surg, 2006;56:164–170)

102

Complete clearance was obtained in 24 patients while another two had some improvement. When treating venous malformations with IPL, Raulin (Raulin and Werner 1999) was able to obtain a 70–100% clearance in eight malformations smaller than 100 cm2. Three malformations larger than 100 cm2 needed more ­treatments (up to 18 sessions). A 590 nm cutoff filter and an average 80.4 J/cm2 were most often used parameters. Small venous malformations have a good response to IPL. Large lesions require sclerotherapy, embolization or surgical excision. Lym­phatic malformations, and deep venous or venolymphatic lesions do not respond well to IPL treatment. We do not perform IPL treatment in these conditions. Striae distensae on 15 women was treated by Hernandez-Perez (Hernandez-Perez et  al. 2002) by IPL. After five treatments spaced at 2 week intervals, a decrease in the number of striae from 117 to 94 was noted. Microscopic changes were found. Improvement of elastosis, edema and atrophy was reported. Inflammation and collagen fiber quality were also improved. From all parameters, the dermal thickness had the best improvement. We refrain from treating striae with IPL. Red scars, and hypertrophic or keloid scars which often contain telangiectasias may benefit from IPL treatment. The concept is to reduce the number of containing blood vessels (neocapillaries) which can stop the growing process and improve the color. Bellew (Bellew et al. 2005) compared in a side-by-side manner the effect of PDL and IPL on hypertrophic scars after breast reduction and mastopexy. After two treatments, improvement was obtained in both groups with no significant differences between them. Erol (Erol et al. 2008) treated with IPL 109 patients with hypertrophic scars after surgeries, trauma, acne and burns. Five patients had keloids. The average number of treatments was eight and they were performed at 2–4 week intervals. Overall clinical improvement was found in 92.5% of the patients, while 65% had good to excellent results.

8.4.6 Using the IPL for the Management of Acne Vulgaris Acne vulgaris is frequently encountered in young ­people. Several factors have been incriminated in its

8  IPL Treatment for Vascular Lesions

pathogenesis including; abnormal desquamation of the follicular keratinocytes and presence of bacterial infection caused mainly by Propionebacterium acnes. Acne scarring is produced by the destruction of the collagen fibers and subsequent fibrosis formation. Increased sebum production and inflammatory response are considered to be the main cause of the disease. The most vulnerable lesions for the IPL treatments are the red macules (Figs. 8.36a, b, 8.37a, b, 8.38a, b) as reported by Chang (Chang et  al. 2007). A side-by-side study was performed by Rojanamatin (Rojanamatin and Choawawanich 2006) who compared the effect of the IPL alone or in combination with the ALA on inflammatory facial acne vulgaris. Although reduction in the number of acnea lesions was present on both sides, the combined ALA and IPL treatments had better results after three sessions compared to IPL alone. Several other authors reported good results using IPL-ALA for the management of acne vulgaris (Gold et  al. 2004; Santos et  al. 2005; Taub 2007; Sami et  al. 2008). Pretreatment of acne lesions with methyl aminolevulinate (Wendelin et al. 2003) is also postulated to respond better than the IPL alone (Yeung et al. 2007). On an evidence-based review of lasers and lights, Haeders­dal (Haedersdal et  al. 2008) found that photodyna­mic therapy is superior to other methods for acnea treatment. Inflammatory lesions are responding better than non-inflammatory lesions. It should be emphasized that Acne vulgaris responds well to systemic therapy using antibiotics and retinoids. The photodynamic therapy is a good alternative for the treatment of resistant cases of acnea or for patients who refuse to take systemic retinoids.

8.4.7 IPL Versus Lasers There is scant literature comparing the effect of IPL and laser on the same vascular lesions. A comparison of different devices - PDL, Alexandrite, KTP, Nd:Yag and IPL - on previously treated capillary malformations was made by McGill (McGill et al. 2008). The study was performed on 18 patients and the results were evaluated by videomicroscopy and color measurements. Four patients failed to respond to any technology. The Alexandrite laser had the largest mean improvement in color but it was associated with more complications

103

8.4  Literature Review

a

b

Fig. 8.36  (a) Acne vulgaris with red macules; (b) After two IPL treatments

a

b

Fig. 8.37  (a) Acne vulgaris; (b) Improvement after two IPL treatments. The result is poorer than the red macules

(scarring and pigmentation) than the others. The IPL was better than KTP and Nd:Yag laser. On a split treatment of patients with dyschromia (vascular and pigmented lesion), it was found that KTP laser and IPL

achieved marked improvement (Butler et al. 2006). At 1 month post-treatment, patient evaluation showed a 65.5% improvement for IPL and 60.8% for KTP laser. The KTP laser caused slightly more discomfort.

104

a

8  IPL Treatment for Vascular Lesions

b

Fig. 8.38  (a) Before and (b) after two IPL treatments. Significant improvement of the red macules

8.4.8 Treatment of Dark Skinned Patients One of the challenges is treating vascular lesions in dark skinned patients. When the lesions are deep, the chance of success is minimal. On one side, skin with a high amount of melanin needs to be protected, but on the other side, low fluences or changes in pulse duration and delay reduce the efficacy of treatment. These patients have the highest risk of pigmentary alterations. Higher fluences are needed to produce similar effects in dark skinned patients but it should be used cautiously so as not to injure the epidermis. Longer pulse durations and longer pulse delays are preferred. Large footprints are preferred for large lesions for a more uniform light distribution. A decrease in the fluence by 10–20% is recommended when treating areas prone to scarring, such as the anterior chest (Adamic et al. 2007).

after PDL treatments, although 62% had color improvement. Most patients were satisfied or neutral with regard to satisfaction with therapy. Men were more likely to be dissatisfied. Fodor (Fodor et  al. 2006) reported that 72% of patients treated with IPL considered the results as mild to excellent. In the same study, when comparing side-by-side with Nd:Yag for the same lesion, higher satisfaction was reported by the patients for the laser treatment area. However, this was more painful than IPL. There are hybrid devices that combine the IPL and Nd:Yag laser treatment for a better result and a higher level of satisfaction.

Practical Points

›› Superficial ››

8.4.9 Satisfaction after IPL Treatment of Vascular Lesions There are very few studies on psychological scoring before and after treatment of vascular lesions (Gupta and Bilsland 2000). The psychological distress was significantly reduced after treatment of less severe facial vascular lesions (telangiectasia, spider vein, cherry angioma) (Gupta and Bilsland 2000). Patient satisfaction after PWS treatment is rarely reported in the literature. Hansen (Hansen et al. 2003) carried out a satisfaction survey for these patients and found that most noted little or no change in texture or dimension

›› ››

›› ››

red vascular lesions have a high amount of oxyhemoglobin. Deoxyhemoglobin is predominantly located in deeper vascular lesions and mainly in the lower  extre­mities. The initial consultation should establish the correct diagnosis of the vascular lesion. Do not hesitate to refer a child with vascular malformations (especially of the head) to a pediatrician for a thorough check-up. Associated abnormalities including neurological disorders are sometimes present. The need for multiple treatments should be emphasized to the patient. In children, there is need for sedation or general anesthesia. The pulse duration should be shorter than the TRT of the chromophore to preferentially protect the surrounding tissue from heat damage.

References

›› The success rate of the treatment can be altered ›› ››

›› ›› ›› ›› ›› ›› ›› ›› ›› ››

by previous other treatments which produce fibrotic changes. Any factor that produces vasoconstriction should be avoided prior to treatment. The immediate occurrence of local bruising, a bluish aspect, perilesional erythema, blanching or “urticariform” reaction are signs of a good clinical response. No pressure should be placed on the hand piece during treatment. During the involution phase of hemangioma, treatment is less effective. For deep hemangiomas, IPL treatment alone is not effective. Capillary malformations on the limbs have less response to treatment compared to those on the head and neck. Deep and nodular PWS are more resistant to treatment. Most cherry angiomas and telangiectasias have excellent results from IPL treatment. Facial telangiectasia is more responsive to treatment when compared to leg veins. Superficial and small sized leg veins are best treated with shorter pulses. Deeper and large size vessels are best treated with longer pulses. In dark skinned patients, longer pulse durations and longer pulse delays are preferable.

References Adamic M, Troilius A, Adatto M et al. Vascular lasers and IPLS: guidelines for care from the European Society for Laser Dermatology (ESLD). J Cosmet Laser Ther. 2007; 9(2): 113–124. Adrian RM. Treatment of leg telangiectasias using a long-pulse frequency-doubled neodymium:YAG laser at 532 nm. Dermatol Surg. 1998;24(1):19–23. Al Buainian H, Verhaeghe E, Dierckxsens L et al. Early treatment of hemangiomas with lasers. A review. Dermatology. 2003;206(4):370–373. Alora MB, Stern RS, Arndt KA et al. Comparison of the 595 nm long-pulse (1.5 msec) and ultralong-pulse (4 msec) lasers in  the treatment of leg veins. Dermatol Surg. 1999; 25(6):445–449.

105 Angermeier MC. Treatment of facial vascular lesions with intense pulsed light. J Cutan Laser Ther. 1999;1(2):95–100. Astner S, Anderson RR. Treating vascular lesions. Dermatol Ther. 2005;18(3):267–281. Barsky SH, Rosen S, Geer DE et al. The nature and evolution of port wine stains: a computer-assisted study. J Invest Dermatol. 1980;74(3):154–157. Baumler W, Vural E, Landthaler M et al. The effects of intense pulsed light (IPL) on blood vessels investigated by mathematical modeling. Lasers Surg Med. 2007;39(2): 132–139. Bellew SG, Weiss MA, Weiss RA. Comparison of intense pulsed light to 595-nm long-pulsed pulsed dye laser for treatment of hypertrophic surgical scars: a pilot study. J Drugs Dermatol. 2005;4(4):448–452. Bernstein EF. Clinical characteristics of 500 consecutive patients presenting for laser removal of lower extremity spider veins. Dermatol Surg. 2001;27(1):31–33. Bernstein EF, Lee J, Lowery J et al. Treatment of spider veins with the 595 nm pulsed-dye laser. J Am Acad Dermatol. 1998;39(5 Pt 1):746–750. Bjerring P, Christiansen K, Troilius A. Intense pulsed light source for the treatment of dye laser resistant port-wine stains. J Cosmet Laser Ther. 2003;5(1):7–13. Black JF, Barton JK. Chemical and structural changes in blood undergoing laser photocoagulation. Photochem Photobiol. 2004;80:89–97. Butler EG, 2nd, McClellan SD, Ross EV. Split treatment of photodamaged skin with KTP 532 nm laser with 10 mm handpiece versus IPL: a cheek-to-cheek comparison. Lasers Surg Med. 2006;38(2):124–128. Chang SE, Ahn SJ, Rhee DY et al. Treatment of facial acne papules and pustules in Korean patients using an intense pulsed light device equipped with a 530- to 750-nm filter. Dermatol Surg. 2007;33(6):676–679. Chapas AM, Geronemus RG. Our approach to pediatric derm­ atologic laser surgery. Lasers Surg Med. 2005;37(4): 255–263. Chess C, Chess Q. Cool laser optics treatment of large telangiectasia of the lower extremities. J Dermatol Surg Oncol. 1993;19(1):74–80. Chiu CS, Yang LC, Hong HS et al. Treatment of a tufted angioma with intense pulsed light. J Dermatolog Treat. 2007; 18(2): 109–111. Clementoni MT, Gilardino P, Muti GF et al. Facial teleangectasias: our experience in treatment with IPL. Lasers Surg Med. 2005;37(1):9–13. Clementoni MT, Gilardino P, Muti GF et al. Intense pulsed light treatment of 1,000 consecutive patients with facial vascular marks. Aesthetic Plast Surg. 2006;30(2):226–232. Cliff S, Misch K. Treatment of mature port wine stains with the PhotoDerm VL. J Cutan Laser Ther. 1999;1(2):101–104. Dierickx CC, Casparian JM, Venugopalan V et  al. Thermal relaxation of port-wine stain vessels probed in vivo: the need for 1–10-millisecond laser pulse treatment. J Invest Dermatol.1995;105(5):709–714. Dover JS, Sadick NS, Goldman MP. The role of lasers and light sources in the treatment of leg veins. Dermatol Surg. 1999;25(4):328–335; discussion 335–326. Enjolras O, Riche MC, Merland JJ. Facial port-wine stains and Sturge-Weber syndrome. Pediatrics. 1985;76(1):48–51.

106 Eremia S, Li CY. Treatment of leg and face veins with a cryogen spray variable pulse width 1064-nm Nd:YAG laser-a prospective study of 47 patients. J Cosmet Laser Ther. 2001; 3(3):147–153. Erol OO, Gurlek A, Agaoglu G et  al. 2008:Treatment of Hypertrophic Scars and Keloids Using Intense Pulsed Light (IPL). Aesthetic Plast Surg. Evans AV, Robson A, Barlow RJ et al. Treatment of port wine stains with photodynamic therapy, using pulsed dye laser as a light source, compared with pulsed dye laser alone: a pilot study. Lasers Surg Med. 2005;36(4):266–269. Fishman SJ, Mulliken JB. Hemangiomas and vascular malformations of infancy and childhood. Pediatr Clin North Am. 1993;40(6):1177–1200. Fodor L, Ramon Y, Fodor A et  al. A side-by-side prospective study of intense pulsed light and Nd:YAG laser treatment for vascular lesions. Ann Plast Surg. 2006;56(2):164–170. Glassberg E, Lask G, Rabinowitz LG et  al. Capillary hemangiomas: case study of a novel laser treatment and a review of therapeutic options. J Dermatol Surg Oncol. 1989; 15(11): 1214–1223. 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. Goldman MP, Bennett RG. Treatment of telangiectasia: a review. J Am Acad Dermatol. 1987;17(2 Pt 1):167–182. Goldman MP, Eckhouse S. Photothermal sclerosis of leg veins. ESC Medical Systems, LTD Photoderm VL Cooperative Study Group. Dermatol Surg. 1996;22(4):323–330. 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. Green D. Photothermal removal of telangiectases of the lower extremities with the PhotodermVL. J Am Acad Dermatol. 1998;38(1):61–68. Grossman MC. What is new in cutaneous laser research. Dermatol Clin. 1997;15(1):1–8. Gupta G, Bilsland D. A prospective study of the impact of laser treatment on vascular lesions. Br J Dermatol. 2000; 143(2): 356–359. Haedersdal M, Togsverd-Bo K, Wulf HC. Evidence-based review of lasers, light sources and photodynamic therapy in the treatment of acne vulgaris. J Eur Acad Dermatol Venereol. 2008;22(3):267–278. Hansen K, Kreiter CD, Rosenbaum M et al. Long-term psychological impact and perceived efficacy of pulsed-dye laser therapy for patients with port-wine stains. Dermatol Surg. 2003;29(1):49–55. Hercogova J, Brazzini B, Hautmann G et al. Laser treatment of cutaneous vascular lesions: face and leg telangiectases. J Eur Acad Dermatol Venereol. 2002;16(1):12–18. Hernandez-Perez E, Colombo-Charrier E, Valencia-Ibiett E. Intense pulsed light in the treatment of striae distensae. Dermatol Surg. 2002;28(12):1124–1130. Ho WS, Ying SY, Chan PC et al. Treatment of port wine stains with intense pulsed light: a prospective study. Dermatol Surg. 2004;30(6):887–890; discussion 890–881. Jacobs AH, Walton RG. The incidence of birthmarks in the neonate. Pediatrics. 1976;58(2):218–222.

8  IPL Treatment for Vascular Lesions Jasim ZF, Handley JM. Treatment of pulsed dye laser-resistant port wine stain birthmarks. J Am Acad Dermatol. 2007; 57(4):677–682. Jorge BF, Del Pozo J, Castineiras I et al. Treatment of ulcerated haemangiomas with a non-coherent pulsed light source: brief initial clinical report. J Cosmet Laser Ther. 2008; 10(1):48–51. Klapman MH, Yao JF. Thickening and nodules in port-wine stains. J Am Acad Dermatol. 2001;44(2):300–302. Landthaler M, Hohenleutner U. Laser therapy of vascular lesions. Photodermatol Photoimmunol Photomed. 2006;22(6):324–332. Lanigan SW. Port wine stains on the lower limb: response to pulsed dye laser therapy. Clin Exp Dermatol. 1996; 21(2):88–92. Lanigan SW. Port-wine stains unresponsive to pulsed dye laser: explanations and solutions. Br J Dermatol. 1998; 139(2): 173–177. Lin XX, Wang W, Wu SF et al. Treatment of capillary vascular malformation (port-wine stains) with photochemotherapy. Plast Reconstr Surg. 1997;99(7):1826–1830. Madonna Terracina FS, Curinga G, Mazzocchi M et  al. Utilization of intense pulsed light in the treatment of face and neck erythrosis. Acta Chir Plast. 2007;49(2): 51–54. McDaniel DH, Ash K, Lord J et al. Laser therapy of spider leg veins: clinical evaluation of a new long pulsed alexandrite laser. Dermatol Surg. 1999;25(1):52–58. McGill DJ, Mackay IR. Capillary vascular malformation response to increased ambient temperature is dependent upon anatomical location. Ann Plast Surg. 2007; 58(2): 193–199. McGill DJ, MacLaren W, Mackay IR. A direct comparison of pulsed dye, alexandrite, KTP and Nd:YAG lasers and IPL in patients with previously treated capillary malformations. Lasers Surg Med. 2008;40(6):390–398. Mulliken JB. Classification of vascular birthmarks. In “Vascular birthmarks, hemangiomas and maformations”. Philadelphia: W.B. Saunders; 1998. Neumann E, Frithz A. Capillaropathy and capillaroneogenesis in the pathogenesis of rosacea. Int J Dermatol. 1998; 37(4):263–266. Omura NE, Dover JS, Arndt KA et al. Treatment of reticular leg veins with a 1064 nm long-pulsed Nd:YAG laser. J Am Acad Dermatol. 2003;48(1):76–81. Ozdemir M, Engin B, Mevlitoglu I. Treatment of facial portwine stains with intense pulsed light: a prospective study. J Cosmet Dermatol. 2008;7(2):127–131. Railan D, Parlette EC, Uebelhoer NS et al. Laser treatment of vascular lesions. Clin Dermatol. 2006;24(1):8–15. Raulin C, Greve B, Grema H. IPL technology: a review. Lasers Surg Med. 2003;32(2):78–87. Raulin C, Hellwig S, Schonermark MP. Treatment of a nonresponding port-wine stain with a new pulsed light source (PhotoDerm VL). Lasers Surg Med. 1997;21(2):203–208. Raulin C, Weiss RA, Schonermark MP. Treatment of essential telangiectasias with an intense pulsed light source (PhotoDerm VL). Dermatol Surg. 1997;23(10):941–945; discussion 945–946. Raulin C, Werner S. Treatment of venous malformations with an intense pulsed light source (IPLS) technology: A retrospective study. Lasers Surg Med. 1999;25(2):170–177.

References Renfro L, Geronemus RG. Anatomical differences of port-wine stains in response to treatment with the pulsed dye laser. Arch Dermatol. 1993;129(2):182–188. Reynolds N, Exley J, Hills S et  al. The role of the Lumina intense pulsed light system in the treatment of port wine stains-a case controlled study. Br J Plast Surg. 2005;58(7): 968–980. Rojanamatin J, Choawawanich P. 2006;Treatment of inflammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study. Dermatol Surg 32(8): 991–996; discussion. 996–997. Ross EV, Smirnov M, Pankratov M et  al. Intense pulsed light and laser treatment of facial telangiectasias and dyspigmentation: some theoretical and practical comparisons. Dermatol Surg. 2005;31(9 Pt 2):1188–1198. Sadick NS. A dual wavelength approach for laser/intense pulsed light source treatment of lower extremity veins. J Am Acad Dermatol. 2002;46(1):66–72. Sami NA, Attia AT, Badawi AM. Phototherapy in the treatment of acne vulgaris. J Drugs Dermatol. 2008;7(7):627–632. Santos MA, Belo VG, Santos G. Effectiveness of photodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study. Dermatol Surg. 2005;31(8 Pt 1):910–915. Schroeter CA, Haaf-von Below S, Neumann HA. Effective treatment of rosacea using intense pulsed light systems. Dermatol Surg. 2005;31(10):1285–1289. Schroeter CA, Neumann HA. An intense light source. The photoderm VL-flashlamp as a new treatment possibility for vascular skin lesions. Dermatol Surg. 1998;24(7):743–748. Shafirstein G, Baumler W, Lapidoth M et al. A new mathematical approach to the diffusion approximation theory for selective photothermolysis modeling and its implication in laser

107 treatment of port-wine stains. Lasers Surg Med. 2004; 34(4):335–347. Sivarajan V, Maclaren WM, Mackay IR. The effect of varying pulse duration, wavelength, spot size, and fluence on the response of previously treated capillary vascular malformations to pulsed-dye laser treatment. Ann Plast Surg. 2006; 57(1):25–32. Sommer A, Van Mierlo PL, Neumann HA et al. Red and blue telangiectasias. Differences in oxygenation? Dermatol Surg. 1997;23(1):55–59. Tam AS, Sullivan B. Remote sensing applications of pulsed photothermal radiometry. Appl. Phys. Lett. 1983;43:333–335. Taub AF. A comparison of intense pulsed light, combination radiofrequency and intense pulsed light, and blue light in photodynamic therapy for acne vulgaris. J Drugs Dermatol. 2007;6(10):1010–1016. Verkruysse W, Choi B, Zhang JR et al. Thermal depth profiling of vascular lesions: automated regularization of reconstruction algorithms. Phys Med Biol. 2008;53(5):1463–1474. Viator JA, Au G, Paltauf G et al. Clinical testing of a photoacoustic probe for port wine stain depth determination. Lasers Surg Med. 2002;30(2):141–148. Weiss RA, M A Weiss. Early clinical results with a multiple synchronized pulse 1064 NM laser for leg telangiectasias and reticular veins. Dermatol Surg. 1999;25(5):399–402. Wendelin DS, Pope DN, Mallory SB. Hypertrichosis. J Am Acad Dermatol. 2003;48(2):161–179; quiz 180–161. Witman PM, Wagner AM, Scherer K et al. Complications following pulsed dye laser treatment of superficial hemangiomas. Lasers Surg Med. 2006;38(2):116–123. Yeung CK, Shek SY, Bjerring P et al. A comparative study of intense pulsed light alone and its combination with photodynamic therapy for the treatment of facial acne in Asian skin. Lasers Surg Med. 2007;39(1):1–6.

9

Complications

Contents 9.1 Major Complications.............................................. 110 9.2 Minor Complications.............................................. 122 9.3 How to Avoid and Deal with Complications......... 125 References............................................................................ 127

Abstract As with any other medical technology, side effects and complications can occur after IPL treatment. Some complications can be prevented by knowing the principles of therapy and treatment strategies, and from having experience with the device. The complications caused by IPL treatments may be divided into two groups: those which are due to errors in ­handling of the device and those which are patientdependent. Improper training of operators and insufficient experience may lead to undesirable results. Not infrequently there are “profit motivated “cosmetic centers” where IPL technology is used by people with minimal training and background. The second type of complication which is related to the patient’s skin reactivity is harder to be anticipated. The major complications are permanent pigmentary changes, hair stimulation, paradoxical effect, leukotrichia, uveitis and iritis and scarring. The minor complications are erythema and purpura which last more than three days, blisters, ­temporary pigmentary changes and temporary hair discoloration.

As with any other medical technology, side effects and complications can occur after IPL treatment. Some complications can be prevented by knowing the principles of therapy and treatment strategies, and from having experience with the device. The following side effects and complications are the most often encountered after IPL treatments: • Erythema, characterized by redness that usually appears a few minutes after the treatment, which may last for a variable period of time. It is the most common reaction after this treatment. • Edema is characterized by local swelling which appears within minutes after the treatment and usually

L. Fodor et al., Aesthetic Applications of Intense Pulsed Light, DOI: 10.1007/978-1-84996-456-2_9, © Springer-Verlag London Limited 2011

109

110

•

•

•

• •

•

• •

•

•

9  Complications

is discrete. It is more visible in areas with lax connective tissue, such as the eyelids, and it subsides in a few days. Purpura/bruising is the appearance of a bluish discoloration in the treatment area. It turns yellow within days, as the hemoglobin metabolizes. It may take a few days up to 2 weeks until it disappears. Hematoma is caused by a small amount of blood that accumulates in the subcutaneous tissue. It is a rare phenomenon, but may occur when treating vascular lesions, especially leg veins. It is self limited and takes days to weeks to resorb. Blisters are the consequence of the accumulation of clear fluids at the dermo-epidermal level or within the dermis. Crusts are the brown scaling tissues which may easily peel off from healthy skin. Infection is characterized by redness, increasing local pain and edema, with or without fever. Reactivation of herpes simplex infection can be encountered in some patients. Hyperpigmentation is a darkening of the skin, usually transitory, fading spontaneously within a few months. Patients with darker skin are more prone to this reaction. Paradoxical effect is defined as growing of new fine hair in the proximity of the treated area. Leukotrichia represents the growth of white hair following IPL treatment. This phenomenon is explained by the difference in thermal relaxation time of the melanocytes and the germinative cells. It can be temporary or permanent (Radmanesh et al. 2002). Temporary hair discoloration is a very rare phenomenon and refers to a yellow appearance of black hair after IPL treatment. Scarring is also a rare complication after IPL treatment. Although an exact explanation is not yet available, post-treatment blisters, infection or high energies may lead to scar healing.

The complications caused by IPL treatments may be divided into two groups: those which are due to errors in handling of the device and those which are patient-dependent. Improper training of operators and insufficient experience may lead to undesirable results. Not infrequently there are “profit motivated “cosmetic centers” where IPL technology is used by people with minimal training and background. Complications like the “zebra” appearance (Figs. 9.1, 9.2a, b) can easily

Fig. 9.1  “Zebra” appearance due to improper training and handling of the device

be avoided by proper training of personnel (Fig. 9.3a– d). The second type of complication which is related to the patients skin reactivity is harder to be anticipated (Fig. 9.4a–c). It is obvious that patients with darker skin should be treated more cautiously. Another measure that should be adopted is readjusting the parameters of the device according to the response during the previous treatment. Patient-related complications may also be subdivided into major and minor complications:

9.1 Major Complications Most of the major complications may appear within weeks from the treatment and include: Permanent pigmentary changes. The incidence of pigmentary changes varies widely in the literature (Tables 9.1–9.3). These studies were not performed under standardized conditions and many parameters differ from one study to another. Most commonly,

111

9.1  Major Complications

a

b

Fig. 9.2  Temporary “Zebra” appearance (a) that was corrected (b) by placing the footprint between the treated areas

hyperpigmentation is caused by vessels destruction and, hence, hemosiderin deposits within the dermis (Figs. 9.5a, b, 9.6, 9.7). Dark-skinned patients are more prone to pigmentary changes (Fig. 9.8a, b); it seems that their melanocytes are more reactive to the heating stimulation (Chan et al. 2002). Hair growing stimulation following IPL and laser treatment has been reported in 10.5% of patients coming for epilation (Kontoes et  al. 2006; Willey et  al. 2007). This phenomenon was mainly observed in areas with fine hair, such as the face and neck (Fig. 9.9a, b). The new growing hair appears to be thicker and darker. This reaction has also been reported to be induced when the IPL was used for the treatment of vascular lesions or tattoo removal (Vlachos and Kontoes 2002). Paradoxical effect. The exact cause of this phenomenon is not known but it is believed that the light energy activates the dormant hair follicles (Moreno-Arias

et al. 2002). The incidence of this very unpleasant side effect was reported to be up to 10.2% in one study (Moreno-Arias et  al. 2002). It seems that hormonal imbalance has an influence. Leukotrichia: the incidence of this complication is reported to be up to 3.5% in patients treated with IPL for hair removal; 31% of the patients have this condition temporarily and return to their previous color within a few months (Radmanesh et al. 2002). Uveitis and iritis can be induced by treating lesions on the eyelids, or by avoiding the use of eye protection (Fig. 9.10). It is more often encountered after long wavelength applications (Goldberg 2007). Iris melanin absorption seems to be responsible for this effect. The treatment might be performed under the supervision of an ophthalmologist. Scarring is seldom reported in the literature (Fig. 9.11a, b) (Tables 9.1–9.3). There is only one study on

112

a

9  Complications

b

c

d

Fig. 9.3  (a) Before IPL treatment; (b) Inappropriate selection of treatment parameters; (c) Blisters appeared after the treatment; (d) Six month later

113

9.1  Major Complications

a

b

c

Fig. 9.4  (a) Immediate reaction in a case of PWS resistant to several treatments. Higher fluences were used; (b) Burns, 7 days after the treatment; (c) Wound healing and final results after 12

treatments. The fluence was decreased and then progressively increased for each treatment

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)

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

Facial freckles

Rosacea and teleangiectasia

Rosacea

Class I–II facial rhytids

Poikiloderma of Civatte

Face, neck, chest rejuvenation;

Face rejuvenation

Face rejuvenation

Face rejuvenation

Face rejuvenation

Skin rejuvenation (face, neck, chest, hands)

Indication

Table 9.1  Complications after skin rejuvenation

17

60

4

30

80

49

73

5

1–3

~4

5

1–4

3

>4

>5

5

2

1–4

59

10

# of txs.

# of pts.

1 month

NA

3 weeks

2 weeks

1 month

3 weeks

3–4 weeks

2 weeks

1 month

1 month

Treatment Interval

III-IV

I-IV

NA

I–II

I–IV

I–III

III–V

NA

NA

II–IV

Fitzpatrick type

2

2

2

2

2

2

2

25–35 J/cm2

550–590 nm

25–35 J/cm

550 nm

22–25 J/cm

515 nm

40–50 J/cm

645 nm

22–44 J/cm

2

550, 590 nm

30–50 J/cm

2

550–570 nm

28–32 J/cm

560 nm

>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%: <34

40–43

16.25% had erythema for more than 7 days

1 had hypopigmentation

17.1

77.8%: 35–39

1 had hyperpigmentation

Complications

14.9

Fluences (J/cm2)

116 9  Complications

Ellipse, Relax/ Denmark

Epilight

Photoderm VL

Bjerring et al. 2000

Lask et al. 1999

Schroeter et al. 2003

multiple sites

Facial hirsutism (hormonal imbalance)

ESC Sharplan

NA

Epilight

Moreno-Arias et al. 2002

Gold et al. 1997

Amin and Goldberg 2006

Amin and Goldberg 2006

Yaghmai et al. 2004

Hair removal

Epilight

Weiss et al. 1999

Starlux Y

Palomar/

Starlux Rs

Palomar/

Aurora DS (Syneron Ltd)

IPL RF

ESC Med Syst

Hair removal, grafts and flaps

NA

Moreno-Arias and Ferrando 2001

Back, thigh hair removal

Back, thigh hair removal

Hair removal

Hair removal

Hair removal

Epilight ESC Sharplan

Hair removal, transsexuals

Hair removal, multiple sites

Hair removal, chin, neck

Hair removal, multiple sites

Johnson and Dovale 1999

ESC Med

Ellipse, Relax/ Denmark

Goh 2003

10

10

69

31

49

48

4

3

25

154

31

11

2

2

1

1

3–9

2

1–6

5–7

2–18

1

3

1

1 month

1 month

–

–

2 months

1 month

1 month

1 month

4–6 weeks

–

2 month

–

I–III

I–III

I–VI

NA

I–IV

I–V

II–III

V–VI

II–IV

NA

NA

IV–VI

NA

NA

NA

590, 615, 645, 690

695–755

615, 645

695, 755

645, 695, 755

Most often 590

NA

600

600

35

65

IPL: 14–30 RF: 10–20

34–55

40–43

40–42

38–42

28–45

37.2

NA

18.5

12–14

(continued)

No complications

1 case of hypopigmentation

NA

3% hyperpigmentation

8% blisters

5 patients had paradoxical effect

12% had crusting Temporary hyperpigmentation that cleared in 2 month

2 sites had blisters

1 patient had erythema for more than 48 hours

Temporary hyperpigmentation

NA

NA

NA

45% had transitory hyperpigmentation

9.1  Major Complications 117

NA

Lumina 650 (Lynton lasers)

Radmanesh 2004

Nd:Yag

Alexandrite

Epilight

Epilight

Photoderm

Radiancy NY

SpaTouch

IPL (Medical Bio Care, Sweden) Ellipse Relax Light 1000

Moreno-Arias et al. 2002

Willey et al. 2007

Lor et al. 2002

Goldberg and Silapunt 2001

Troilius and Troilius 1999

Toosi et al. 2006

Table 9.2  (continued) Author/year IPL device

Hair removal

Hair removal in hirsute patients

Hair removal, face, neck

Hair removal, multiple sites

Hair removal, multiple sites

821

49

543

207

12

10

232

Hair removal face, neck Hair removal, bikini

# of pts

Indication

NA

3–9

3–23

NA

1–3

4

3–7

# of txs.

NA

2 month

NA

1 month

1 month

1 month

4–6 weeks

Treatment interval

II–IV

NA

NA

I–V

I–IV

II–IV

II–IV

Fitzpatrick type

650

695–755

NA

570, 590, 645, 695

NA

600

650

Cutoff filter (nm)

4–24

40–43

NA

33–50

32–55

6.25–6.45

~18.3

22–34

Fluences (J/cm2)

3.5% leukotrichia

10.2% had paradoxical effect

10.5% had hair stimulation

NA

­–

2 cases of folliculitis 2 cases of blisters

2.8% blisters 2.8% crusts

Complications

118 9  Complications

Device

PhotoDerm VL; ESC Sharplan

Medilux Starlux (Palomar)

PhotoDerm VL (ESC Med System)

PhotoDerm VL (ESC Med System)

PhotoDerm VL (ESC Med System)

PhotoDerm VL; ESC Sharplan; Vasculight 1064nm; ESC Sharplan

PhotDerm VL (Lumenis)

PhotDerm VL (Lumenis)

Author/ year

Raulin and Werner 1999

Butler et al. 2006

Goldman and Eckhouse 1996

Schroeter and Neumann 1998

Green 1998

Sadick 2002

Clementoni et al. 2005

Clementoni et al. 2006

50

Red telangiectasia Blue venulectases Reticular veins

Facial telangiectasia

1000

518

72

Telangiectasia of lower extremities

Facial telangiectasia

NA

120

Facial, leg telangiectasia; spider nevi; erythrosis interfollicularis; senile angiomas.

1–9

1–9

up to 3

1–5

515,550, 570,590 nm

5

159 (369 lesions)

Leg veins (<3 mm)

570, 590 nm

570, 590 nm

1064 for blue lesions

550

515,550, 570, 590 nm

590,550,570, 515 nm

NA

1

17

590nm, most often used

Cutoff filter

Dyschromia (vascular lesions, pigmented lesions)

# of txs. ~2

# of pts. 11

Venous malformations

Indication

Table 9.3  Complications after vascular lesions treatment

38–56 J/cm2

40–56 J/cm2

40 J/cm2 140 J/cm2 for 1064nm selection

25–70 J/cm2

22–50 J/cm2

25–70 J/cm2

21–40 J/cm2

~80.4 J/cm2

Fluence

I-IV

I-IV

II-V

I-III

NA

NA

I-IV

I-IV

Skin type

7 patients with blisters 15 patients with temporary hyperpigmentation

2 patients with blisters that evolved into hypopigmentation; 55 patients had edema for more than a week

2% teleangiectatic matting resolved after additional IPL treatment

14% temporary hyperpigmentation

21% scarring 50% hyperpigmentation 20% hypopigmentation

5 cases of temporary hypopigmentation

4 cases of focal scar

Erythema for a few minutes: “peppering”

4.7% crusting 1% scarring 1% hypopigmentation

Complications

(continued)

months

NA

6 weeks

–

NA

2–4 weeks

–

1–8 weeks

Treatment interval

9.1  Major Complications 119

PhotDerm VL

PhotoDerm VL (ESC Ltd.)

Angermeier 1999

Raulin et al. 1997

Table 9.3  (continued) Author/ year Device 1–4

188

Poikiloderma of Civatte

1–10

# of txs.

# of pts.

Essential telangiecta- 14 sia of face, legs

Facial telangiectasia, hemangioma, rosacea, PWS

Indication

515, 550, 570 nm

550, 570, 590 nm

Cutoff filter

21.5–40 J/cm2

36–60 J/cm2

Fluence

NA

I-III

Skin type

3 patients had transient hypopigmentation

1 case of conjunctival injection

3 transient hypopigmentation

Complications

NA

NA

Treatment interval

120 9  Complications

121

9.1  Major Complications

a

b

Fig. 9.5  (a) Hyperpigmentation 3 weeks after treatment of vascular lesions; (b) Permanent hyperpigmentation 2 years later

a

Fig. 9.6  Permanent slight hyperpigmentation after IPL for leg veins

b

Fig. 9.8  (a) Leg veins in a dark-skinned patient; (b) Hypo­ pigmentation, 2 years after IPL treatment

Fig. 9.7  Permanent hyperpigmentation after IPL skin rejuvenation

122

a

9  Complications

a

b

b

Fig. 9.11  (a) Wound on the calf after IPL treatment for leg veins; (b) Minimal scarring after secondary healing (10 months later)

Fig. 9.9  (a) Before IPL hair removal on the face; (b) Hair growing stimulation after first IPL treatment. No further treatment was advocated

dealing with telangiectases removal from the lower extremities which reported a 21% incidence of scarring (Green 1998). This study was performed in the beginning of the IPL era and newer literature fails to report such a high incidence of this annoying complication. The same study reported a 50% rate of hyperpigmentation which is much higher than other reports on this complication (Table 9.1–9.3).

9.2 Minor Complications

Fig. 9.10  Treatment in this case was not performed due to high risk of eye complications

Most of the minor complications occur within minutes to days after the completion of the treatment. Pain or local discomfort during treatment is not considered to be a complication and depends on the pain threshold of each patient. It can be easily lowered by using local anesthetics. Erythema and purpura: Some articles mention redness and purpura as side-effects. We prefer to consider them as side effects only when they persist for more than 3 days. Otherwise, it is a normal skin response to the IPL energy; purpura (Figs. 9.12, 9.13a, b), or minimal bruising which are described as “urticariform”

123

9.2  Minor Complications

Fig. 9.12  Few days after treatment, resulting purpura and echimoses

reactions (Fig. 9.14a, b), may be considered as signs of the effectiveness of treatment. Those signs are seen immediately during the treatment mainly after treating vascular lesions. Erythema and perifollicular edema are the most common side effects after hair removal (Figs. 9.15, 9.16). A shorter pulse duration has a higher risk of epidermal injury (Drosner and Adatto 2005). Purpura is rarely encountered, and it is scattered and associated with short pulse duration (Goldman et al. 2005). Blisters: Studies have demonstrated the presence of subepidermal necrosis in areas of blistering induced by lasers (Goldberg 2007). These histological findings are similar to those observed in burns (Foley 1970) (Figs. 9.17a–c, 9.18, 9.19, 9.20a, b). Temporary pigmentary changes. The occurrence of hypopigmentation (Fig. 9.21) after IPL or laser treatment seems to be related to the suppression of melanogenesis and is not due to melanocytes destruction

a a

b b

Fig. 9.13  (a) Echimoses and small hematomas after IPL treatment for leg veins; (b) Complete disappearance several weeks later

Fig. 9.14  (a) Leg veins before IPL treatment; (b) “Urticariform” reaction immediately after treatment

124

9  Complications

a

b

Fig. 9.15  Local erythema on left chin immediately after treatment

c

Fig. 9.16  Perifollicular edema and erythema after IPL hair removal

Fig. 9.17  (a) Leg veins before treatment; (b) Local blisters a few days after treatment; (c) Blisters disappeared before next treatment

(Liew 2002). This might explain the temporary character of the hypopigmentation. The mechanism of hyperpigmentation was described above (Fig. 9.22a–c, 9.23a, b). Often, this side effect is transitory and disappears once the hemoglobin and the hemosiderin are meta­ bolized. Temporary hair discoloration. Only one case of temporary yellow discoloration of the hair after IPL treatment has been reported (Radmanesh 2004). The growing proximal part of the hair was yellow, which makes it difficult to differentiate from the distal hair bleaching induced by sun exposure. A decrease in eumelanin production and an increase in the pheomelanin amount seems to explain this result. Other complications. Temporary alopecia is the result of IPL treatment in hair bearing areas (Fig. 9.24a, b).

Fig. 9.18  Example of local blisters in a dark-skinned patient

9.3  How to Avoid and Deal with Complications

Fig. 9.19  Crusts after blister disappearance (two weeks after treatment)

a

b

Fig. 9.20  (a) Crusts after hair removal; (b) After 1 year

9.3 How to Avoid and Deal with Complications With modern IPL devices, the incidence of side effects and complications is reduced. It is always better to be cautious and recognize those patients who are prone to develop complications. Dark skinned patients and those with a history of complications after IPL treatment belong in this category. Careful adjustments of the IPL parameters should be made, and this was described in previous chapters. Most often, the erythema and the edema are selflimited to hours or days. In patients with a history of

125

Fig. 9.21  Temporary hypopigmentation after IPL treatment for leg veins

prolonged edema, topical steroid creams help to make the recovery shorter. The crusts after pigmentary lesions treatment or after blisters tend to peel off. Usually, there is no need for a topical moistener to hasten the process. In the presence of perilesional erythema or oozing, we recommend topical antibiotics. Antiviral prophylactic treatment is prescribed for patients with a past history of herpes. Treatment of the new hair growth is not easy but shorter cutoff filter may improve the result (Moreno-Arias et  al. 2002). Treatment of scars caused by the IPL is not well defined. Usually these scars are slightly depres­ sed and hypopigmented. CO2 lasers, dermabrasion or chemical peelings can help to make the skin color uniform and improve the aesthetic result. The “zebra” appearance is due to poor footprint application when overlapping is avoided and strips of untreated area are seen between the treated areas. This unpleasant appearance can be improved by treating the previous sparse area. The size of the footprint should be adjusted to match the area. In the presence of complications, extending the time intervals between the treatments is recommended, to allow skin recovery. There are no clear recommendations in the literature for the optimal time interval to the next treatment after the occurrence of any complication event. We postpone the next treatment for a few weeks. The fluence and pulse delay are also adjusted to reduce the energy inflicted on the skin. More details can be found in previous chapters. The cooling methods and avoidance of sun exposure before and after treatment are important to avoiding side effects.

126

a

c

9  Complications

b

d

Fig. 9.22  (a) Medium size leg veins; (b) Immediate thrombosis; (c) Temporary hyperpigmentation; (d) One year later

127

References

a

a

b

b

Fig. 9.24  (a) Temporary alopecia after treatment of scalp angioma; (b) Three months later

›› Dark skinned patients are more prone to suffer ››

Fig. 9.23  (a) Before leg veins treatment; (b) Slight temporary hyperpigmentation between procedures

Practical Points

›› There ›› ››

››

are two types of complications: one which is due to errors in handling of the device and another which is patient-related. The major complications are permanent pigmentary changes, hair stimulation, paradoxical effect, leukotrichia, uveitis and iritis and scarring. The minor complications are erythema and purpura which last more than 3 days, blisters, temporary pigmentary changes and temporary hair discoloration. Purpura, minimal bruising or “urticariform” reaction are signs of effective vascular lesions.

from side effects. In the presence of complications, the treatment parameters need to be adjusted.

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Index

A Abnormalities, 88, 104 Absorption spectrum, 17, 33 Accidental exposure, 22 Acne vulgaris, 102, 103 Actinic keratosis, 49 Aesthetic procedure, 31 5-Aminolevulinic acid (ALA), 49, 50, 58 Anagen phase, 4, 5, 9, 63, 76 Anatomical area, 63, 76 Anatomical unsuitability, 31, 35 Angiomas, 82, 84, 105 Appocrine glands, 2–4 Autonomic nerves, 8 Avoiding sun exposure, 35, 36

Costs of treatment, 27 Cutaneous vessels, 41 Cutoff filters, 44, 50–53, 67, 70, 75, 91, 93, 98–102

B Blood vessel, 5–8 Body dysmorphic disorder (BDD), 23, 26 Bulge area, 61, 63, 76

D Dark skin, 66, 70–75 Dark skin patients, 102, 105 Delay, 30 Deoxyhemoglobin, 87, 88, 104 Dermabrasion, 125 Dermal anesthesia, 33 Dermal changes, 38, 58 Dermal layer, 38, 42 Dermal papilla, 63, 76 Dermis, 1–3, 5–8, 38, 40, 42, 44, 47, 58 thickness, 5, 8 Dermoepidermal junction, 2 Detailed medical history, 64 Digital camera, resolution, 30 Diode laser, 71, 72, 75

C Capillary, 41 blood vessels, 82 malformations, 80, 93–98, 102, 105 type, 82 Capital investment, 27 Catagen phase, 4, 5, 63 Chemical peelings, 125 Chromophores, 15–20, 42, 43, 50, 63, 76, 87–89, 97, 98, 104 Coagulation, 13, 15, 20 Coarse hair, 61, 62, 66, 70, 76 CO2 lasers, 125 Collagen fibers, 5, 6, 42 improvement, 42, 58 matrix, 6 vascular diseases, 41 Complications, 32–35, 109–125 Congenital malformations, 81, 97 Cooling gels, 29 Cooling method parallel cooling, 34 postcooling, 34 precooling, 34 Cooling time, 13, 16

E Eccrine sweat glands, 2–3 Edema, 63–65, 109–110, 123–125 ELA-Max, 43 Elastic fibers, 38 Elastin fibers, 5–6, 9 Electrical safety precautions, 23 Electromagnetic radiation (EMR), 11 Electromagnetic spectrum, 12, 20 Emergency shutoff knob, 21, 23 EMLA, 43 EMLA cream, 33 Endocrinological problems, 62, 64, 76 Ephelides, 38, 51–53 Epidermal absorption, 55 Epidermal damage, 65, 70 Epidermal layer, 70 Epidermis, 1, 2, 4, 7, 38, 40, 42, 47, 50 thickness, 8 Equipment lease, 27, 30 purchase, 27, 30 rental, 27, 28, 30 Errors in handling of the device, 110, 127 Erythema, 63, 65, 76, 109, 122–125, 127

131

132 Erythromelanin, 63 Eumelanin, 18 Expected costs, 32 F Facial skin elasticity, 38 Fibrotic changes, 89, 105 Fine hair, 62, 70 Fitzpatrick skin type, 38, 63, 67 Fitzpatrick skin type IV-VI, 33 Flaps, 62, 76 Fluence, 30, 73–75 decrease, 33 Follicle, 62–67, 75, 76 Footprints, 12, 14, 43, 58, 111, 125 G Gloves, 28, 29 Ground substance, 5, 6 H Hair discoloration, 110, 124, 127 follicles, 3–6, 8 growth, 4 removal, 61–77 stimulation, 111, 122, 127 Hairy grafts, 76 Heating, 13–14, 20 Hemangiomas, 80–81, 84, 89–91, 93, 98, 105 Hemoglobin, 15, 17–20, 33, 42, 58, 110, 124 Hemosiderin, 111, 124 Hirsutism, 61–62, 64, 76 Hypermelanosis, 38, 55 Hyperpigmentation, 38, 43, 51, 53, 56, 63, 70, 110, 111, 121, 126, 127 Hypertrichosis, 62, 70, 76 I Ice packs, 34 Impaired wound, repair, 8 Infundibulum, 63 Intense pulsed light (IPL) treatment, 3, 4, 7–9 IPL-ALA, 102 IPL devices, 21–23, 34, 44, 58, 64, 67, 70, 75, 76, 88, 89, 91, 102 IPL equipment, 27, 30 IPL treatment, 18, 19, 22–26, 32–35, 39–42, 44–58, 63, 64, 66, 68, 69, 76, 77, 79–105, 109, 110, 112, 121–125 IPL wavelengths, 21, 22, 25 Iritis, 109, 111, 127 Isotretinoin, 64, 76 Isthmus, 4 K Keratinocytes, 1, 2, 4 L Langerhans cells, 2 Laser devices, 21 Laser treatment, 63, 76

Index Lawsuits, 23, 24 Leg veins, 82–84, 87–92, 99–101, 105 Length of treatment, 32 Lentigo solaris, 51 Leukotrichia, 110, 111, 127 Lights, 21–26 Long-term results, 32 M Maintenance costs, 27 Melanin, 15–20, 33, 42, 50–52, 58, 63, 64, 70, 76 Melanocytes, 2, 4, 9, 38, 40, 50 Melanogenesis, 123 Melanosomes, 2, 4, 5, 8, 38, 43, 50 Melasma, 38, 51, 53, 58 Microvessel, 7, 8 MMPs, 43 Mottled pigmentation, 38, 58 Multiple treatments, 33 Muscle cells, 6 N Nd:Yag laser, 81, 88, 90, 91, 93, 101–104 Neurological disorders, 88, 104 O Ocular protection glasses, 28, 30 goggles, 28, 30 Oxyhemoglobin, 87, 89, 104 P Papilla, 63, 76 Papillary plexus, 81 Paradoxical effect, 110, 111, 127 Patient evaluation, 65, 70 Patient selection, 31–36 PDL treatment, 97, 102 Peak of absorption, 17 Perifollicular edema, 123, 124 Pheomelanin, 18 Photoaged skin, 6, 38, 39, 42 Photodocumentation, 23, 26, 32 Photodynamic therapy, 49, 50, 76 Photons, 11, 12, 15 Photorejuvenation, 37–58 Photothermal radiometry, 97 Photothermolysis, 15, 16, 20, 87 Pigmentary changes, 25, 110–111, 123–124, 127 Pigmented lesions, 38–40, 42, 44, 49–58 Plastic eye shields, 43 Polycystic ovary disease, 62, 64 Possible side effects, 32, 33 Posttreatment communication, 36 Premature skin aging, 58 Preventing professional errors, 33 Problematic patients, 32, 35 Protection, 22, 23, 25 Protective eyeglasses, 22, 34 Psychological unsuitability, 35 Pulse

133

Index delay, 13 delay, increase, 33 duration, 12–13, 16, 20, 30, 88–91, 100, 104, 105 Purpura, 110, 122–123, 127 PWS (port-wine stains) lesions, 80–82, 84–86, 88–90, 93, 96–98, 104, 105 R Recovery period, 32 Redness, 25 Reflecting device, 22 Reflection spectra, 33 Rhytides, 38 Risk of infection transmission, 23 S Scarring, 110, 111, 122, 127 Sebaceous glands, 38, 49 Secondary follicles, 4 Sensory branches, 8 Sensory nerves, 8, 9 Separate record, 32 Side effects, 33, 34, 36 Skin color, 18, 19 Skin malignancy, 32 Skin rejuvenation, 42, 43, 49, 50, 55, 58 Skin texture, 43, 47–50, 57, 58 Software programs, 30 Standard of care, 23, 24 Stem cells, 63 Subcutaneous tissue, 1, 6, 110 Subepidermal necrosis, 123 Sun exposure, 37, 38, 43, 51, 52, 58 Sunscreens, 66 T Telangiectases, 122 Telangiectasia, 38, 41, 42, 50, 55, 58, 80, 82, 84, 98–102, 105

Telogen phase, 4, 5, 63 Temperature, 12, 13, 16 Test, 32–34, 36 Thermal relaxation time (TRT), 12, 13, 16, 110 Topical anesthesia, 33 Transparent gel, 29, 89 Transsexual patients, 76 Treatment protocol, 33–35 Treatment room anesthesia equipment, 28, 29 IPL device, 28, 30 refrigerator, 28–30 small stores cupboards, 28, 30 stand tables, 28, 30 U Uveitis, 111, 127 V Vascular anomalies, 80 Vascular ectasia, 81 Vascular lesions, 38, 41–44, 49, 50, 55, 58, 79–105, 111, 119–121, 123, 127 Vascular malformations, 80–82, 102 Vascular structure, 7 Vascular tumors, 80 Vasculight, 50, 52 Vasoconstriction, 89, 105 Venous lakes, 84 Vessels, 16, 41, 43, 44, 50, 58 Visible light spectrum, 11, 12 W Warning sign, 22 Wavelengths, 11–13, 15, 16, 20, 42, 44, 50, 55, 58, 63, 65, 67, 70, 75, 76 Wet gauze, 33, 34 Wrinkles, 38, 49, 58 Written informed consent, 23, 26, 33