Photorejuvenation

15.1 Introduction

The concept for rejuvenation of the face by using light sources has been present since the advent of laser technologies. Lasers used to accomplish this goal include the ablative (CO2 and erbium) and non-ablative lasers. However, the sequelae associated with ablative lasers and lack of compelling efficacy associated with nonablative lasers created a realization that non-laser light source might be the best means of accomplishing facial photorejuvenation. These pulsed light sources began to become popular in the cosmetic surgery community in 2004 and have since undergone various refinements.

Benefits of photorejuvenation are numerous and include: improvements of the tone and texture of the skin, diminished pigment irregularity, reduction of vascular lesions, improvement in the appearance of fine lines and wrinkles.

Intense pulsed light (IPL) differs from laser light in a number of theoretical and clinical aspects. Whereas laser emissions are coherent beams of the same wavelength and frequency, intense pulsed light contains light with a variety of wavelengths. Intense pulsed light used for photorejuvenation is light containing 500–1,200 nm [1]. As such, it targets numerous chromophores within the epidermis and dermis including melanin, vascular

K. Beer ( )

The Palm Beach Esthetic Center, 1500 North Dixie Highway, Suite 303, West Palm Beach, FL 33401, USA e-mail: kenbeer@aol.com

R.S. Narins

Dermatology Surgery and Laser Center, Clinical Professor of

Dermatology, New York University Medical Center,

New York, NY, USA

structures, collagen, and other structures. The use of filters to limit the spectra of light emitted enables one to focus on one particular aspect of the skin when using this device. Since the process of photoaging (and thus of photorejuvenation) affects each of these, it is worthwhile to consider the interaction of intense pulsed light as it interacts with each.

The actual IPL device consists of a flashlamp light source that produces polychromatic light [2]. Depending on the desired wavelength, filters may be introduced to remove light of a specific wavelength. It is this capability that enables IPL to provide diverse types of treatments with one device and is partially responsible for the popularity of IPL with physician and nonphysician practitioners alike.

One hallmark of aging skin is the pigmentary irregularity frequently seen after photodamage has occurred. The degree of pigment present is a function of the skin type of the individual in question, the amount of ultraviolet exposure they have sustained, mitigating treatments such as the use of topical retinoids, bleaching creams, chemical peels, or cosmeceuticals and the capacity for intrinsic rejuvenation that a given individual possesses.

Hypopigmentation associated with photodamage is, at present, not treated with intense pulsed light with any degree of success. To date, attempts to stimulate melanocytes to produce pigment once they have undergone apoptosis have not resulted in restoration of a normal complement of pigment producing cells within the basal layer of the epidermis.

Hyperpigmentation associated with a variety of conditions including photodamage, pregnancy, and postinflammation has been more effectively treated with

Reprinted with permission of Springer, Berlin

photorejuvenation. The absorption spectrum for melanin is continuous and thus IPL is well suited for this indication. Actinic lentigines, melasma, and post-inflammatory hyperpigmentation may be treated with IPL. When treating hyperpigmentation, it is critical to insure that patients have not had any significant ultraviolet exposure for the preceding several weeks (2–4), have used either broad spectrum sunscreen or physical barrier sunblocks, and that they have no planned sun exposure for a few weeks after the procedure. Prior sun exposure will prime the melanocytes to respond to the IPL by making more pigment as does sun exposure, following the treatment.

Skin types I, II, and III tend to develop telangiectasias with increased sun exposure and aging. In addition, these types of skin are prone to rosacea as the skin ages. IPL can address many of the vascular proliferations seen with both of these problems. Since hemoglobin has a series of absorption peaks including 585, the light from IPL is readily absorbed. One study evaluating the use of IPL for rosacea-associated telangiectasias found significant improvement after five treatments, each 3 weeks apart [3].

The addition of porphyrins to the skin may increase efficacy of this treatment [4]. This treatment is known as Photodynamic Therapy or PDT. The addition of this photosensitizer has increased the energy absorption for IPL, rendering it more effective at treating the various stigmata of photoaging. Various protocols may be utilized, each involving cleansing of the skin prior to application of the Amino levulinic acid (ALA) for an amount of time that may vary between 15 and 60 min. Energy levels and filters for IPL depend on the skin type, degree of damage present, degree of erythema present, tolerance for downtime by the patient, and goals of the treatment. The marriage of IPL with ALA may provide for highly effective photorejuvenation.

Under the microscope, photoaging is associated with disorganization and atrophy of the epidermis, degeneration of the papillary and reticular dermis as the collagen and elastic fibers diminish, and a host of other subtle and overt changes [5]. At a subcellular level, IPL treatments stimulate production of type I collagen transcripts [6]. Devices that optimize this collagen production stimulate elastin production, and remodeling will enhance the ability of IPL machines to perform photorejuvenation. The addition of medications such as low-dose antibiotics including doxycycline may inhibit collagenase and addition of this medication may improve patient outcomes.

IPL has been useful in reversing several of these signs of aging and it is in this category of photorejuvenation that the potential may be the greatest. After observations that non-ablative lasers in the 585 nm spectrum were able to cause collagen remodeling, other methods of accomplishing the same goals were investigated. Goldberg et al. demonstrated the efficacy of IPL for the treatment of rhytids, and since that time various devices and protocols have been utilized for this goal [7]. It is anticipated that this indication will most likely remain extremely popular.

15.2 Technique

The techniques for using IPL for photorejuvenation are as varied and diverse as the number of machines and operators using them and the goals of a treatment regimen for a given patient. Perhaps the most important part of the technique for photorejuvenation is the one that is sometimes overlooked – the consultation and consent process. During the consultation, it is important to listen to what the potential patient is saying about his or her expectations and tolerance for risk and downtime. One signal that the non-ablative photorejuvenation might be the wrong procedure for a particular patient are statements indicating that they want to “get rid” of wrinkles or that they want a nonsurgical facelift. Many of the patients that have these types of expectations are fed by the reports of various procedures in the popular media. Since these types of reports tend to present only the best cases, patients that demand these results are most likely going to be disappointed and thus, are not good candidates unless one can educate them about the realities of the procedure. Other signs that a patient might not be a good candidate for photorejuvenation are similar to warning signs to heed for any cosmetic patient: patients that speak poorly of other physicians, patients that are financially stretched for the procedure and cannot financially afford adjunct treatments such as Botulinum toxins or fillers that might be needed for optimal outcomes, and interactions with ancillary staff that simply gives reliable staff a sense of dread toward the individual.

Consent for photorejuvenation should include discussions of the risks, need for multiple treatments, the fact that each session has a cost, confirmation that the patient is required to avoid the sun, inform the physician

if she is pregnant or has certain types of photosensitive diseases, and other relevant considerations for the type of procedure being performed. Many physicians recommend photographic documentation of the patient’s baseline, and this should be seriously considered for each patient.

For a particular device, the initial technical considerations are the parameters for the treatment. The first parameter to consider is the reason the patient is undergoing the treatment. Since many devices are capable of emitting light from 400 to 1,200 nm, filters that limit the wavelengths emitted are used to emit light most appropriate for each indication. For instance, when treating vascular or red lesions, filters are used to limit the light emitted to wavelengths that will be efficacious. Other filters may be used when melanin is the target.

Once the proper handpiece is selected, energy settings must be considered. When beginning a treatment with a type I or II skin type that has not been exposed to recent ultraviolet light, settings can be at the upper end of recommended parameters. Darker skin types will need to be treated at the lower end of these settings.

The fluence, pulse duration, and size of the spot are technical considerations whose parameters change with each device. The presence and type of skin cooling available also help to determine the settings for each treatment. Depending on the manufacturer, fluences from 15 to 90 J/cm2 may be used. Spot size must be selected to best suit the area being treated and these may be as large as several centimeters or small as a few millimeters. Prior to using any IPL device, it is imperative to familiarize oneself with the particular recommendations and literature that are specific for it.

At each treatment, makeup and sunscreen should be removed before the treatment begins. A topical anesthetic cream may be applied for half an hour and removed before treatment begins. Once the treatment is completed, chemical free sunscreen should be applied if the patient will have any outdoor exposure. The patient should be positioned comfortably and the operator should be able to readily access the area undergoing treatment. Eye protection must be worn during the procedure.

Using a double-stacked IPL pulse instead of a single pulse may result in improvements in erythema, skin roughness, and in hyperpigmentation [8]. This protocol, using the Lux G handpiece from Palomar,

suggests that operator variables may strongly influence outcomes when treating the visible signs of aging and suggests that using two-stacked pulses is better than a single pulse when treating photoaging. Future devices or techniques will likely expand on this finding. Other devices, including the Quantum Intense Pulsed light (Lumenis, Santa Clara, CA), the Ellipse system (Candela, Wayland, MA), and several other systems offer a variety of light filters that are suitable for treating multiple skin issues including photorejuvenation, hyperpigmentation, telangiectasias, rosacea, and a host of other skin conditions. It is anticipated that advances in skin cooling, power delivery, and light filters will continue to make these products more effective and more versatile.

Prior to treatment, a chilled gel is applied to the skin. Following a few pulses of the treated area, inspection of the skin must be performed to insure that there are no blisters or incipient burns that are occurring. At the completion of the treatment, ice or cool gel packs may be applied to reduce the swelling. Posttreatment care instructions are provided, and documentation that this has been completed should occur in the patient’s record.

Treatments for photorejuvenation are usually separated by 2–4 weeks. Most devices recommend that a series of between four and six sessions are scheduled for maximum benefit.

Combining photorejuvenation with other types of cosmetic procedures may enhance the outcomes from each procedure and this is one technical consideration that only recently has begun to be explored. Carruthers and Carruthers [9] reported improvement of pore size, dyspigmentation, telangiectasias, and skin texture when Botulinum toxin A was used concomitantly with IPL.

15.3 Complications

Complications that may occur with IPL for photorejuvenation include common ones such as swelling, bruising, and transient erythema and less common ones including hyperpigmentation, infection, burns, and scarring. The incidence of transient crusting is reported as 2%, and Goldman et al. note that this superficial crusting is self-limited, lasting approximately 1 week [2]. The same authors report a 4% rate of purpura and a rate of swelling of 25% and these

are consistent with the experience of the authors [2]. Both purpura and swelling occur at a much higher rate in areas such as the eyelids, and care should be taken when treating the upper cheek/lower eyelid area.

The incidence of scarring is rare and it usually is the result of using excessive energy or from using the IPL device on someone that has been exposed to sun. Infections from herpes simplex may occur after treatment of an area prone to outbreaks and prophylaxis with antiviral medication is recommended for patients with a history of herpes. Bacterial infections are extremely rare with non-ablative photorejuvenation and they may be the result of patients that excoriate the skin following treatment. Any infection in a treated patient should be treated with appropriate antibiotic or antiviral medication. A single case of a vesiculobullous eruption, following IPL, performed by a nonphysician has been reported [10]. In this instance, the patient sustained significant vesicles and bulla that were thought to be a function of poor technique although other etiologies were also entertained.

In order to minimize the risks of complications, patient education and screening are important. Patients with increased ultraviolet exposure should not be treated as they are at significant risk for transient hyperpigmentation as well as for scarring due to the increased epidermal melanin with increased absorption of energy.

15.4 Discussion

The popularity of non-ablative photorejuvenation with physicians, nonphysician providers, and with patients attests to the excellent results, thereby increasing the demand for these types of treatments. Each of these devices, in conjunction with industry, is searching for better outcomes with less downtime. Recent IPL devices are now approaching the goal of improving photoaging with minimal risk and downtime.

Since IPL is a broad spectrum of light that can be administered with varied levels of fluence, its potential for treating telangiectasias, fine lines, hyperpigmentation, skin surface roughness, and other signs of aging continue to be realized (Fig. 15.1).

Results for the treatment of small blood vessels as well as the erythema associated with rosacea have approached those obtained with pulsed dye laser with

significantly less posttreatment purpura. The IPL is also useful for maintenance after using other lasers such as the Vbeam or NdYag. While not as dramatic as the outcomes that follow ablative skin resurfacing, the marked reduction of risk when compared to the latter procedure has made IPL extremely popular for the treatment of fine lines and skin surface roughness. The improvements of collagen fibers have been documented and modifications of both devices and protocols (including the adjunctive use of medications to foster collagen production) will continue to enhance outcomes. One likely scenario that will enhance non-ablative photorejuvenation will be the combination of various types of light for synergistic outcomes. Fractional ablation, infrared light, and radiofrequency are among the possible candidates for this. Results from one study have suggested that combing IPL with Botox will yield dramatically better results than the sum of their parts would suggest likely. Undoubtedly, other combinations including the use of other types of type A toxin, the use of fillers to stimulate collagen remodeling and to fill deep rhytids will also be explored.

Photoaging may stigmatize the skin with production of pigment on the face, neck, and dorsal hands. Poikilodermatous changes on the neck as well as the chest, arms, legs, and other parts of the body are amenable to treatment with IPL, and handpieces that can treat this are presently in use. The lentigines on the dorsal hands and face that serve notice of a life spent in the sun are also effectively treated with IPL, and the use of this device, in combination with prescription bleaching creams (including those with combinations of hydrocortisone, tretinoin, and hydroquinone) and sun blocks, have dramatically improved the appearance of both. Skin surface irregularity and roughness are similarly restored to a more youthful appearance following treatment with IPL and it remains to be considered whether pretreatment with topical vitamin C, tretinoin, green tea, or oral medications may enhance the outcomes obtained and if so, what the optimal parameters are.

One problem with the use of IPL for the treatment of photoaging involves not the actual devices but the regulations governing them. In many states, the use of these devices is not regulated to any large extent. This, in conjunction with what can graciously be termed “overly enthusiastic” marketing to the masses of nonspecialists that comprise the larger market for