Medical Spas and a lot of aesthetic physicians have adopted IPL devices to treat a variety of skin conditions, from hair removal to age spots.

Intense Pulsed Light (IPL) is a non-laser flash lamp light source that emits broad spectrum, high-intensity visible and infrared (IR) light and is used for permanent hair reduction, acne (including photo dynamic therapy, aka PDT), Rosacea, dyschromias and telangiectasias, and age related treatment of facial lines and creases.

Wavelengths are chosen by selecting a particular wavelength filter or attaching a specific treatment head or hand piece that is configured with the filter already attached. Since IPL medical devices use a ‘pulse’ of light they deliver their energy into the dermis over a longer time than a laser, providing different treatments and usually resulting in significantly more pain for the patient.

Shorter wavelengths in the visible spectrum are used to target hemoglobin (red skin conditions like acne and Rosacea) and melanin (brown spots). Longer infrared (IR) wavelengths target water in the skin and can treat other conditions. Since IPL devices use a ‘pulsed’ light instead of a high-intensity focused beam like lasers do, IPLs emit more scattered light (feathering) and are less selective than a laser in heating the skin. With IPL devices there are often additional treatments needed to achieve optimal results than with lasers.

Practitioners more or less agree on the applications of different wavelength available in IPL devices:  

Major manufacturers of IPL Intense Pulsed Light devices: Candela, Palomar, Cutera, Lumenis and Sciton. 

IPL Pros

• Cheaper than lasers
• More compact than most lasers
• Results are comparable to the 810 nm Diode or the 770 nm Alexandrite lasers for hair and to the 532 nm KTP Laser, the 595 Pulsed Dye Laser for the treatment of Rosacea and vascular lesions

IPL Cons

• Cannot be used safely on darker skin types (IV-VI) or tanned skin
• Filters (heads) have a short life span (50,000-75,000 pulses)
• Filter/head replacement is expensive
• Many different wavelengths, settings, cooling requiremnts may be confusing for the operator
• Maintenance and service required

LaserOffers.com Comment:

More and more experts agree that from the practical standpoint Nd:YAG 1064 nm may have established itself as the single most versatile wavelength for all of the treatments mentioned above. For all skin types and tanned skin.

Ablative treatments smooth roughened skin, periorbital rhytids, remove pigmented lesions and minimise acne scarring. Dr Peter Crouch discusses the latest advances and the tried-and-tested methods

Until the development of laser skin resurfacing in the 1980s, mechanical abrasion and chemical peeling agents were the mainstay of treatments targeting acne scarring, wrinkles and tired, aged skin. Controlled ablation promised the prospect of restoring a more youthful, radiant appearance. Non-ablative remodelling of existing tissue is only one method of stimulating positive change and is the key strategy with IPL and radiofrequency treatments and has been outlined in previous articles in this series. The approach with most non-ablative treatments is to provide a controlled thermal stimulus sufficient to denature and contract collagen while avoiding surrounding tissue damage. Most non-ablative procedures utilise thermal (heat) energy for immediate tissue contraction (short-lasting), followed over the next few months by collagen remodelling and regeneration (longer-lasting).

Ablation literally means destruction, and there are several approaches for removing unwanted tissue and to promote increased tissue turnover as part of healing. Depending on the depth of ablation, skin resurfacing, smoothing of periorbital rhytids, removal of pigmented lesions and minimisation of acne scarring are all possible outcomes of expertly delivered skin ablation. In the months following ablative treatment, the body’s natural healing processes produce new replacement tissue, resulting in healthier, more even, smoother skin and a more youthful appearance.

The ideal tissue-ablation device would cause little pain and discomfort, have little or no downtime, be affordable, show demonstrable results after each session and cause no unwanted side-effects. As tissue ablation can effectively remove unwanted targets and the ablation is more related to tissue water content and is relatively more indiscriminate, ablative techniques rely more on targeting precisely where the treatment beam ablates rather than using the wavelength of the treatment beam to discern one target from another based on pigmentation—that is, a specific chromophore, or the presence of, for example, haemoglobin. Because the wavelengths often used for ablation specifically target tissue water, the fluence often determines, fairly precisely, the exact depth of ablation.

Treating colored skin poses difficulties, as many practitioners have experienced. Dr Mukta Sachdev says good technique hinges on good pre-, intra- and post-operative care and choice of patient.

Colored skin has the tendency to hyperpigment following trauma, so in the wake of procedures such as lasers, chemical peels or microdermabrasion, there is a chance that hyperpigmentation will occur at the treatment site. This post-inflammatory hyperpigmentation is a common adverse event in darker skin. According to one expert, maximising the success of an aesthetic procedure can be better achieved if the proper pre-, intra- and post-operative precautions are taken. Dr Mukta Sachdev, a consultant dermatologist at the Manipal Hospital in Bangalore, India, says that treating coloured skin can be particularly challenging, even for the most experienced cosmetic physician. “In India we have found that the patients do not use sunscreens as much as they should, as compared with the West, and Indian people are simply not aware of the benefits of these creams. The cosmetic implications—especially in darker skin—is that following a procedure, such as laser or microdermabrasion, the risks of hyperpigmentation will increase,” Dr Sachdev says.

According to Dr Sachdev, the use of sunscreens is mandatory before cosmetic procedures, and the patient should get into the habit of using these two to three times a day, at least 14 days prior to procedures. This gets the patient into the habit of using them, and they help in preventing unwanted hyperpigmentation post-procedure. Dermal filler procedures are also a common cause of post-inflammatory hyperpigmentation. Dr Sachdev says that perhaps a normal Caucasian skin might tolerate a Restylane or Perlane filler very well in terms of decreased risk of developing a post-procedural hyperpigmentation. However, in a darker skin, skin types IV to VI, patients can frequently have a pigmentation of the injection puncture wound where the filler was introduced into the skin.

LaserOffers.com

See post-op and other recommended skin care.

Fractional CO2 laser ablation has become very popular among cosmetic dermatologists and plastic surgeons.

Below is a list of tips from our medical panel.

Cosmetic conditions

1. Vertical lip (smokers) lines, deep wrinkles and acne scars require deep penetration to stimulates more collagen and ablate more tissue for better skin tightening.
2. Superficial pigment and surface textural problems will require less penetration and a mild ablation.
3. For Stria (Stretch Marks): mild penetration of 80-100 mj, deeper penetration may cause adverse effect.
4. Melasma: medical experts are not sure it will work and do not recommend treating Malasma at this time.
5. For Tattoo Removal: deep penetration might be good for resistant tattoos, results will vary as always with tattoos.

Pre / post-treatment tips for fractional CO2 laser treatments:

1. Mild moisturizers to avoid acne flare-ups
2. No aquaphor or vasoline. Beware of the Lanolin in the Aquaphor. Mild moisturizers are good enough.
3. Aveeno Water Gel may get your patient one less day of downtime.
4. Frequent saline soaks are good.
5. Cold ice packs or chilled air cooler for 30-45 min after treatment are good.
6. Valtrex for all patients! Acyclovir (cheaper) will also work.
7. No pain medications after treatment! Prolonged pain suggests infection: bacterial, viral, fungal. Follow up with your patients!
8. Pliaglis can be mixed with Cetaphil cleanser or moisturizer. 90% Pliaglis and 10% cleanser or moisturizer in the mix.
9. Experts worry about possible Lidocaine toxicity so excercise care. Compounded Lidocaine works as well or better than Pliaglis. Pliaglis costs $60 per treatment. Compounded Lidocaine costs about $6 per treatment.
10. Do not routinely use oral antibiotics unless indicated for acne outbreak prevention: Keflex 500 mg TID, Doxycycline 100 mg BID, Erythromycin can be used to prevent acne outbreak.
11. Sunscreens: every day and stay out of sun until the skin is healed up completely, and use good UVA blockers for further protection.

Fractional C02 lasers are not perfect but can produce great results if used correctly. Especially in a combination of treatments.

Patients with non-Caucasian skin represent a largely untapped market for aesthetic treatments. Many potential patients are still being told that they cannot get laser or light-based treatments because of their skin type.

Over one half of the world is brown-skinned. Imagine turning someone away from your practice because you can’t treat that skin type, when we have safe lasers that can treat the darkest Indian and African skin safely. You will never become an expert if you can’t treat brown skin. Dr Fitzpatrick devised his skin typing system of I-VI, with one (I) being your Scandinavian, blue-eyed person and six (VI) being as dark as you can get. Three or four through to six are the skin types that require attention and care. With the right technology and proper technique we can treat all skin types as safely and effectively as we can Caucasian skin (I and II).

People with colored skin have a thicker stratum corneum, and their fibroblast cells are much more robust. That is why, with skin tightening, people with darker skin can get better results with less energy (fluence). It is important to understand the difference between dark skin and ethnicity. If you had five people and one was an Indian (from India), one was African American, one Korean, one Japanese, and one was Brazilian, and they all had the same skin color, you wouldn’t be able to tell the difference. But if you treated them with the same lasers, with the same settings, the same chemicals , and cosmeceuticals, you would get five totally different results.

It’s not skin color we treat, it is the ethnicity and all hereditary background that comes with it!

Intense pulsed light (IPL) and laser devices, which target epidermal melanin, work well on fair Caucasian skin. However, since darker skin has more melanin than light skin, the risk of epidermal damage is higher. The dermis houses the blood vessels, hair follicles, sebaceous glands and fibroblasts, so the ideal device is one that can deliver energy to the dermal layer without damaging the epidermis.

When traditional devices are used on non-Caucasian skin, post-inflammatory hyperpigmentation (PIH) in the epidermis is the most common adverse effect. If the PIH is deep enough, it may become permanent. Even now, patients with non-caucasian skin treated with less invasive and less aggressive fractional devices experience PIH and erythema. Scarring and keloids may result from more aggressive treatments. One solution is to modify treatment settings to minimise possible adverse effects. When we do this, however, we risk reducing efficacy and wasting patients’ time and money.

Heavily filtered IPL and Nd:YAG lasers can be safely used on darker skin types. In cases of low light tolerance lasers can be combined with a bipolar radiofrequency (RF) energy for a more effective treatment of non-Caucasian skin.

How do you combine laser/IPL/RF treatments when multiple conditions co-present?

Consumers of cosmetic treatments present their conditions and issues, which can be grouped as follows:

• pigmentation (uneven, too dark, too light)
• age or “coffin” spots
• red face, flushing (basal redness/excessive redness when flushed)
• spider veins and prominent blood vessels
• tired-looking, sagging or lax skin of the face, neck, hands and body
• rhytids, wrinkles (at rest or dynamic)

Other than counselling or psychological support, which is always required, the options for treatment are:

A) Light-based

• intense pulsed light (IPL)
• 532nm KTP, 585/595nm pulse dye laser
• 1064nm Nd:YAG, 1320 Nd:YAG
• 2940nm erbium YAG
• 10,600nm carbon dioxide (CO2)

B) Radiofrequency (RF)

C) Dermabrasion

D) Chemical peels

E) Topical

F) Dermal fillers and injectables

Complicated skin conditions require complex approach and a program, which may include several treatment options.

Lasers almost always work. About the only serious contradiction for a light-based treatment is for the skin with unusually low light tolerance level. Such patient may not respond well to an IPL and, very rarely, even to a laser treatment. That’s why a test patching is always a good idea. The physician is then faced with a limited number of options. Each patient is different, and we have to deal with them one at a time.

The early 1980s brought about a revolution in dermatologic laser treatment with Anderson and Parrish’s1 publication detailing the theory of selective photothermolysis. Selective photothermolysis describes the use of specific absorptions of laser energy to achieve temperature-mediated localized injury in a target. This theory led to the invention of pulsed lasers that are target-specific and highly selective. Increased selectivity decreased the amount of thermal damage to healthy tissue, thereby decreasing scarring and other adverse effects.

The first laser used in the treatment of hypertrophic scars and keloids was a continuous-wave argon laser. While initial reports were encouraging, subsequent studies did not confirm its efficacy. Similarly, use of the continuous wave neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1064 nm), which selectively inhibits collagen production by a direct photobiologic effect and creates tissue infarction with subsequent charring and sloughing of the treated area, also showed initial clinical improvement. Results, however, were transient and scar recurrences were common. Similar recurrences were observed when hypertrophic scars and keloids were excised or vaporized with a continuous-wave carbon dioxide laser (CO2). When treated with the carbon dioxide laser, scars universally recurred within 1 year.

By the early 1990s, the effectiveness of the vascular-specific 585-nm pulsed dye laser (PDL) in treating a variety of vascular lesions (eg, port-wine stain, telangiectasia) was widely known. The first series of studies on the successful use of the 585-nm flashlamp-pumped PDL in the treatment of hypertrophic scars and keloids had been published. In 1993, Dr. Alster and colleagues reported prolonged improvement in argon laser–induced port-wine stain scars treated with PDL irradiation. Skin surface texture analysis performed by optical profilometry with accompanying clinical assessment revealed that laser-irradiated scars approximated normal skin characteristics. No scar recurrences were noted 4 years following treatment.

In 1994, Alster reported clinical and textural improvement in long-standing erythematous and hypertrophic scars. An improvement rate ranging from 57-83% was observed following 1-2 PDL treatments, respectively. Dierickx and colleagues corroborated these findings the following year; they reported an average scar improvement of 77% after 1.8 laser treatments. Not surprisingly, in 1995, Alster and Williams compared the clinical, textural, histologic, and symptomatic responses of irradiated scar halves with untreated control halves. Significant improvement was observed for all clinical parameters. Histologic evaluation revealed increased numbers of regional mast cells. Because mast cells also elaborate a variety of cytokines, the presence of mast cells following laser irradiation and accompanying tissue revascularization may provide an explanation for the therapeutic outcome following microvasculature destruction in terms of stimulating collagen remodeling.

Subsequent studies also showed improvement in keloid scars following PDL treatment. In 1996, Alster and McMeekin also reported improvement in erythematous and hypertrophic facial acne scars following 585-nm pulsed dye irradiation.

Improvement in nonerythematous, minimally hypertrophic scars was also achieved following combination treatment involving pulsed dye technology and carbon dioxide laser vaporization. In 1998, Alster and Lewis treated selected scars by performing carbon dioxide laser de-epithelialization followed by PDL irradiation. Significant and prolonged clinical and textural improvement was observed in all treatment areas. In a 1995 report, Goldman and Fitzpatrick also described a combination approach to scar management. They used intralesional corticosteroids concomitantly with 585-nm PDL irradiation in 11 of 37 patients with hypertrophic scars.

No consensus exists regarding the mechanism by which PDLs achieve these additional clinical effects. Plausible explanations include laser-induced tissue hypoxia (leading to collagenesis from decreased microvascular perfusion), collagen fiber heating with dissociation of disulfide bonds and subsequent collagen realignment, selective photothermolysis of vasculature, suppression of TGF-β1 expression, and mast cell factors (eg, histamine, interleukins, various immunofactors) that may affect collagen metabolism.

In 1996, McDaniel and colleagues reported using the same 585-nm PDL to effect an improvement in the appearance of striae. They observed an improvement not only in skin surface appearance, but also in increased dermal elastin after low-fluence laser irradiation. In a 1998 report, Alster and colleagues7 also found that low-fluence PDL irradiation was superior compared with pulsed dye treatment at regular (scar) fluences and pulsed carbon dioxide vaporization. Both groups postulate that the improvement may be due to laser-induced effects on elastin, collagen, or other undiscovered factors.

In 2003, Nouri and colleagues showed that the 585-nm PDL can improve the quality and appearances of surgical scars when used as early as the day of suture removal. Scars were treated 3 times at monthly intervals and were significantly more improved compared with controls in overall Vancouver Burn Scar Scale (ie, vascularity, pliability, height, and cosmetic appearance) comparisons.

More in Laser Revision of Scars (April 2008)