Photorejuvenation of the skin utilizing intense pulsed light sources (IPL) has become a mainstay of dermatologic cosmetic surgery over the past several years. The first major report of IPL photorejuvenation by Bitter et al1 in 2000 helped define the usefulness of this technology for cosmetic dermatologic surgeons and determined appropriate IPL parameters needed for successful photorejuvenation. His patients had varying degrees of facial erythema, flushing, dyschromias and photodamage. A treatment protocol of five full-face treatment sessions, at monthly intervals, was used with IPL parameters of a 550 nm cut-off filter, double or triple pulses, pulse durations be-tween 2.4 and 3.0 milliseconds, and fluences ranging from 30 J/cm2 to 42 J/cm2. These fluences were gentler parameters than previously reported for individual lesion treatments. Results from this clinical trial showed that 90% of patients reported greater than 75% improvement in rosacea symptoms (facial erythema and flushing), 84% improvement in fine wrinkles, 78% improvement in skin coarseness and 49% improvement in pore size.
Further Study of Photorejuvenation
Using IPL Other investigators have also reported on their use of IPL therapy for photorejuvenation. Goldberg et al2 studied the effects of the IPL device in treating facial rhytids with four treatment sessions for his evaluations. Substantial clinical improvement in facial rhytids was noted in nine of 30 individuals; 16 of 30 had some improvement in facial rhytids. A further comparison3 study between IPL and 1064 nm Nd:YAG lasers showed equally successful mild to moderate improvement in facial rhytids. The 1064 nm Nd:YAG laser, however, was reported to be better tolerated by patients in this trial. Negishi et al used the IPL system to treat photodamage on patients with skin types IV and V in three to six treatment sessions. Their first clinical trial of 97 patients showed improvement in pigmentation (90%), telangiectasias (83%) and in skin texture (65%).4 A second trial of 73 patients showed a combined 60% improvement in photorejuvenation parameters in more than 80% of patients.5 Sadick et al6 performed a multicenter trial utilizing the IPL device for photorejuvenation. Of Sadick’s patients, 17 completed a full series of IPL treatments; 47% achieved more than 50% improvement in photorejuvenation parameters studied. Moreover, more than 90% of patients had improvement in their wrinkle appearance. Hernandez-Perez et al7 studied the effects of the IPL device on five Hispanic women; moderate to very good improvement in all photorejuvenation parameters were seen. Weiss et al8 reported a 5-year analysis of IPL therapy for photodamaged skin on the face, neck and chest. Eighty patients were evaluated 4 years after their photorejuvenation treatments with the IPL device. Textural skin improvement was noted in 83% of patients, improvement in telangiectasias in 82%, and dyschromia improvement in 79%. The facial areas improved more so than the neck or chest in this population. Using ALA for Improved Results Are there ways to improve results demonstrated by IPL therapy alone for photorejuvenation? What about associated changes commonly seen in patients with photodamaged skin, such as actinic keratoses (AKs)? Previous investigations on therapies for photorejuvenation have not reported data on associated AK changes in patients with photodamage. Perhaps the incorporation of a synergistic therapy of 20% topical 5-aminolevulinic acid (ALA) (Levulan) photodynamic therapy (PDT) with IPL may solve this dilemma in treating associated AKs and, at the same time, improve the cosmetic outcome of IPL photorejuvenation treatments. PDT refers to the therapeutic use of photochemical reactions. It involves the use of photosensitizing drugs, application of light and production of singlet oxygen for tissue destruction. Dermatologic applications of PDT include eradication of AKs, basal cell carcinomas and squamous cell carcinomas. There are anecdotal reports describing the successful use of PDT in treating Kaposi’s sarcoma, cutaneous T-cell lymphoma, verrucae vulgaris, molluscum contagiosum, acne vulgaris, rosacea, actinic cheilitis, Bowen’s disease and alopecia areata, among others.9,10
Treating AKs
Protoporphyrin IX (Pp IX) is a potent photosensitizer. Focal accumulation of Pp IX in dysplastic and neoplastic dermatologic lesions and epidermal appendages such as sebaceous glands and hair follicles (pilosebaceous unit) can be induced with the topical application of 5-ALA, the biological precursor of the porphyrin. This exogenously induced photosensitization targets the tissue for PDT. During PDT, the porphyrin molecule is photoactivated by exposure to visible light, resulting in the production of a cytotoxic oxygen product that kills the abnormal cells where the Pp IX was concentrated. There is minimal damage to the surrounding unaffected skin and only transient photosensitivity. In mice and in normal human skin, Pp IX is almost always cleared from the skin within 24 hours of treatment. Thus, use of topical ALA avoids persistent generalized photosensitivity seen after systemically administered agents.9, 10 Currently, an FDA-approved form of ALA, a 20% topical solution, is available for the treatment of non-hyperkeratotic AKs on the face and scalp areas.11 During the original Phase III clinical trials12 of topical 20% ALA-PDT and a blue light source, more than 80% of patients treated showed 100% clearance of AKs at 12 weeks post-therapy. Of interest, 92% to 94% of patients noted cosmetic results, or improvement in their skin texture, as good to excellent. The major drawback for dermatologists to the routine use of this therapy is the long incubation time required for the ALA to be placed on the skin prior to light therapy used in the FDA approved treatment paradigm. This incubation time is from 14 hours to 18 hours before exposure to blue light. The second drawback for treatment is that blue light therapy was determined to be needed for 16 minutes, 40 seconds for proper AK destruction. This time period is too long for most moderately to severely sun-damaged patients to tolerate without a significant degree of associated morbidity (i.e., pain, crusting, downtime). Making the Procedure More Practical Anecdotal reports have shown that shorter-contact ALA incubation (from 15 minutes to 1 hour), broad-area application of the ALA itself to the entire face, and exposure to either blue light or other light sources, such as the IPL device, can create a shortened therapy course. This would make it more practical for dermatologists to perform these procedures in their offices. The shorter incubation time still allows for the proper photochemical reaction to occur and for successful results from the resulting light procedures. Several investigators, including myself13, Goldman14 and Nestor,15 have performed clinical evaluations using shorter incubation times, full-face application of ALA-PDT in combination with IPL or blue light therapy for photorejuvenation, improvement in AKs, as well as for active acne vulgaris and other cosmetic conditions. In my experience, an initial evaluation of 10 patients was undertaken utilizing short-contact ALA-PDT and IPL.14 The ALA-PDT was applied for 15 minutes to 30 minutes prior to therapy with IPL. Parameters for IPL were 550 nm to 570 nm cut-off filters, double pulsing, 3.5 millisecond pulse durations, and fluences of 34 J/cm2. Patients received their ALA-PDT/IPL treatments at 1 month intervals for 3 months and had follow-ups 3 months following the last treatment. Preliminary data from this trial shows overall improvement (global response to treatment) as compared to baseline. Improvements were also noted in fine wrinkling, skin roughness and hyperpigmentation. Actinic keratoses also improved, with patients noting improvement in skin texture and disappearance of the target AKs. All of the patients tolerated this therapy and noted rapid healing without downtime. Mild erythema was noted in some patients at 24 hours post-therapy, but there’s been no evidence of other adverse events such as burning, stinging, crusting, erosion, edema or mottled hyperpigmentation — all previously seen with traditional ALA-PDT blue light therapy. All of the patients noted decreased skin sallowness and an increased “youthful tone” to their skin. (See photos on page 61.)
Taking Photorejuvenation to The Next Level
The data from this initial clinical trial and the work of others clearly show that the combination of short contact, broad-area ALA-PDT with the IPL device or blue light for photorejuvenation and actinic keratosis therapy improves all variables evaluated. Combining these therapies yields a synergistic effect that results in photorejuvenation and eradication of AKs. The combination also appears to shorten the number of sessions with IPL/blue light therapy required to achieve photorejuvenation and to yield a cosmetic improvement superior to either agent alone. The potential for patients to see significant improvements in three or less treatments by combining IPL with ALA-PDT versus IPL alone could allow dermatologists to advance photorejuvenation to the next level. Further clinical evaluations will define the usefulness of this new therapeutic approach to photorejuvenation and AKs — a multicenter clinical trial is scheduled to verify these initial results.
Photorejuvenation of the skin utilizing intense pulsed light sources (IPL) has become a mainstay of dermatologic cosmetic surgery over the past several years. The first major report of IPL photorejuvenation by Bitter et al1 in 2000 helped define the usefulness of this technology for cosmetic dermatologic surgeons and determined appropriate IPL parameters needed for successful photorejuvenation. His patients had varying degrees of facial erythema, flushing, dyschromias and photodamage. A treatment protocol of five full-face treatment sessions, at monthly intervals, was used with IPL parameters of a 550 nm cut-off filter, double or triple pulses, pulse durations be-tween 2.4 and 3.0 milliseconds, and fluences ranging from 30 J/cm2 to 42 J/cm2. These fluences were gentler parameters than previously reported for individual lesion treatments. Results from this clinical trial showed that 90% of patients reported greater than 75% improvement in rosacea symptoms (facial erythema and flushing), 84% improvement in fine wrinkles, 78% improvement in skin coarseness and 49% improvement in pore size.
Further Study of Photorejuvenation
Using IPL Other investigators have also reported on their use of IPL therapy for photorejuvenation. Goldberg et al2 studied the effects of the IPL device in treating facial rhytids with four treatment sessions for his evaluations. Substantial clinical improvement in facial rhytids was noted in nine of 30 individuals; 16 of 30 had some improvement in facial rhytids. A further comparison3 study between IPL and 1064 nm Nd:YAG lasers showed equally successful mild to moderate improvement in facial rhytids. The 1064 nm Nd:YAG laser, however, was reported to be better tolerated by patients in this trial. Negishi et al used the IPL system to treat photodamage on patients with skin types IV and V in three to six treatment sessions. Their first clinical trial of 97 patients showed improvement in pigmentation (90%), telangiectasias (83%) and in skin texture (65%).4 A second trial of 73 patients showed a combined 60% improvement in photorejuvenation parameters in more than 80% of patients.5 Sadick et al6 performed a multicenter trial utilizing the IPL device for photorejuvenation. Of Sadick’s patients, 17 completed a full series of IPL treatments; 47% achieved more than 50% improvement in photorejuvenation parameters studied. Moreover, more than 90% of patients had improvement in their wrinkle appearance. Hernandez-Perez et al7 studied the effects of the IPL device on five Hispanic women; moderate to very good improvement in all photorejuvenation parameters were seen. Weiss et al8 reported a 5-year analysis of IPL therapy for photodamaged skin on the face, neck and chest. Eighty patients were evaluated 4 years after their photorejuvenation treatments with the IPL device. Textural skin improvement was noted in 83% of patients, improvement in telangiectasias in 82%, and dyschromia improvement in 79%. The facial areas improved more so than the neck or chest in this population. Using ALA for Improved Results Are there ways to improve results demonstrated by IPL therapy alone for photorejuvenation? What about associated changes commonly seen in patients with photodamaged skin, such as actinic keratoses (AKs)? Previous investigations on therapies for photorejuvenation have not reported data on associated AK changes in patients with photodamage. Perhaps the incorporation of a synergistic therapy of 20% topical 5-aminolevulinic acid (ALA) (Levulan) photodynamic therapy (PDT) with IPL may solve this dilemma in treating associated AKs and, at the same time, improve the cosmetic outcome of IPL photorejuvenation treatments. PDT refers to the therapeutic use of photochemical reactions. It involves the use of photosensitizing drugs, application of light and production of singlet oxygen for tissue destruction. Dermatologic applications of PDT include eradication of AKs, basal cell carcinomas and squamous cell carcinomas. There are anecdotal reports describing the successful use of PDT in treating Kaposi’s sarcoma, cutaneous T-cell lymphoma, verrucae vulgaris, molluscum contagiosum, acne vulgaris, rosacea, actinic cheilitis, Bowen’s disease and alopecia areata, among others.9,10
Treating AKs
Protoporphyrin IX (Pp IX) is a potent photosensitizer. Focal accumulation of Pp IX in dysplastic and neoplastic dermatologic lesions and epidermal appendages such as sebaceous glands and hair follicles (pilosebaceous unit) can be induced with the topical application of 5-ALA, the biological precursor of the porphyrin. This exogenously induced photosensitization targets the tissue for PDT. During PDT, the porphyrin molecule is photoactivated by exposure to visible light, resulting in the production of a cytotoxic oxygen product that kills the abnormal cells where the Pp IX was concentrated. There is minimal damage to the surrounding unaffected skin and only transient photosensitivity. In mice and in normal human skin, Pp IX is almost always cleared from the skin within 24 hours of treatment. Thus, use of topical ALA avoids persistent generalized photosensitivity seen after systemically administered agents.9, 10 Currently, an FDA-approved form of ALA, a 20% topical solution, is available for the treatment of non-hyperkeratotic AKs on the face and scalp areas.11 During the original Phase III clinical trials12 of topical 20% ALA-PDT and a blue light source, more than 80% of patients treated showed 100% clearance of AKs at 12 weeks post-therapy. Of interest, 92% to 94% of patients noted cosmetic results, or improvement in their skin texture, as good to excellent. The major drawback for dermatologists to the routine use of this therapy is the long incubation time required for the ALA to be placed on the skin prior to light therapy used in the FDA approved treatment paradigm. This incubation time is from 14 hours to 18 hours before exposure to blue light. The second drawback for treatment is that blue light therapy was determined to be needed for 16 minutes, 40 seconds for proper AK destruction. This time period is too long for most moderately to severely sun-damaged patients to tolerate without a significant degree of associated morbidity (i.e., pain, crusting, downtime). Making the Procedure More Practical Anecdotal reports have shown that shorter-contact ALA incubation (from 15 minutes to 1 hour), broad-area application of the ALA itself to the entire face, and exposure to either blue light or other light sources, such as the IPL device, can create a shortened therapy course. This would make it more practical for dermatologists to perform these procedures in their offices. The shorter incubation time still allows for the proper photochemical reaction to occur and for successful results from the resulting light procedures. Several investigators, including myself13, Goldman14 and Nestor,15 have performed clinical evaluations using shorter incubation times, full-face application of ALA-PDT in combination with IPL or blue light therapy for photorejuvenation, improvement in AKs, as well as for active acne vulgaris and other cosmetic conditions. In my experience, an initial evaluation of 10 patients was undertaken utilizing short-contact ALA-PDT and IPL.14 The ALA-PDT was applied for 15 minutes to 30 minutes prior to therapy with IPL. Parameters for IPL were 550 nm to 570 nm cut-off filters, double pulsing, 3.5 millisecond pulse durations, and fluences of 34 J/cm2. Patients received their ALA-PDT/IPL treatments at 1 month intervals for 3 months and had follow-ups 3 months following the last treatment. Preliminary data from this trial shows overall improvement (global response to treatment) as compared to baseline. Improvements were also noted in fine wrinkling, skin roughness and hyperpigmentation. Actinic keratoses also improved, with patients noting improvement in skin texture and disappearance of the target AKs. All of the patients tolerated this therapy and noted rapid healing without downtime. Mild erythema was noted in some patients at 24 hours post-therapy, but there’s been no evidence of other adverse events such as burning, stinging, crusting, erosion, edema or mottled hyperpigmentation — all previously seen with traditional ALA-PDT blue light therapy. All of the patients noted decreased skin sallowness and an increased “youthful tone” to their skin. (See photos on page 61.)
Taking Photorejuvenation to The Next Level
The data from this initial clinical trial and the work of others clearly show that the combination of short contact, broad-area ALA-PDT with the IPL device or blue light for photorejuvenation and actinic keratosis therapy improves all variables evaluated. Combining these therapies yields a synergistic effect that results in photorejuvenation and eradication of AKs. The combination also appears to shorten the number of sessions with IPL/blue light therapy required to achieve photorejuvenation and to yield a cosmetic improvement superior to either agent alone. The potential for patients to see significant improvements in three or less treatments by combining IPL with ALA-PDT versus IPL alone could allow dermatologists to advance photorejuvenation to the next level. Further clinical evaluations will define the usefulness of this new therapeutic approach to photorejuvenation and AKs — a multicenter clinical trial is scheduled to verify these initial results.
Photorejuvenation of the skin utilizing intense pulsed light sources (IPL) has become a mainstay of dermatologic cosmetic surgery over the past several years. The first major report of IPL photorejuvenation by Bitter et al1 in 2000 helped define the usefulness of this technology for cosmetic dermatologic surgeons and determined appropriate IPL parameters needed for successful photorejuvenation. His patients had varying degrees of facial erythema, flushing, dyschromias and photodamage. A treatment protocol of five full-face treatment sessions, at monthly intervals, was used with IPL parameters of a 550 nm cut-off filter, double or triple pulses, pulse durations be-tween 2.4 and 3.0 milliseconds, and fluences ranging from 30 J/cm2 to 42 J/cm2. These fluences were gentler parameters than previously reported for individual lesion treatments. Results from this clinical trial showed that 90% of patients reported greater than 75% improvement in rosacea symptoms (facial erythema and flushing), 84% improvement in fine wrinkles, 78% improvement in skin coarseness and 49% improvement in pore size.
Further Study of Photorejuvenation
Using IPL Other investigators have also reported on their use of IPL therapy for photorejuvenation. Goldberg et al2 studied the effects of the IPL device in treating facial rhytids with four treatment sessions for his evaluations. Substantial clinical improvement in facial rhytids was noted in nine of 30 individuals; 16 of 30 had some improvement in facial rhytids. A further comparison3 study between IPL and 1064 nm Nd:YAG lasers showed equally successful mild to moderate improvement in facial rhytids. The 1064 nm Nd:YAG laser, however, was reported to be better tolerated by patients in this trial. Negishi et al used the IPL system to treat photodamage on patients with skin types IV and V in three to six treatment sessions. Their first clinical trial of 97 patients showed improvement in pigmentation (90%), telangiectasias (83%) and in skin texture (65%).4 A second trial of 73 patients showed a combined 60% improvement in photorejuvenation parameters in more than 80% of patients.5 Sadick et al6 performed a multicenter trial utilizing the IPL device for photorejuvenation. Of Sadick’s patients, 17 completed a full series of IPL treatments; 47% achieved more than 50% improvement in photorejuvenation parameters studied. Moreover, more than 90% of patients had improvement in their wrinkle appearance. Hernandez-Perez et al7 studied the effects of the IPL device on five Hispanic women; moderate to very good improvement in all photorejuvenation parameters were seen. Weiss et al8 reported a 5-year analysis of IPL therapy for photodamaged skin on the face, neck and chest. Eighty patients were evaluated 4 years after their photorejuvenation treatments with the IPL device. Textural skin improvement was noted in 83% of patients, improvement in telangiectasias in 82%, and dyschromia improvement in 79%. The facial areas improved more so than the neck or chest in this population. Using ALA for Improved Results Are there ways to improve results demonstrated by IPL therapy alone for photorejuvenation? What about associated changes commonly seen in patients with photodamaged skin, such as actinic keratoses (AKs)? Previous investigations on therapies for photorejuvenation have not reported data on associated AK changes in patients with photodamage. Perhaps the incorporation of a synergistic therapy of 20% topical 5-aminolevulinic acid (ALA) (Levulan) photodynamic therapy (PDT) with IPL may solve this dilemma in treating associated AKs and, at the same time, improve the cosmetic outcome of IPL photorejuvenation treatments. PDT refers to the therapeutic use of photochemical reactions. It involves the use of photosensitizing drugs, application of light and production of singlet oxygen for tissue destruction. Dermatologic applications of PDT include eradication of AKs, basal cell carcinomas and squamous cell carcinomas. There are anecdotal reports describing the successful use of PDT in treating Kaposi’s sarcoma, cutaneous T-cell lymphoma, verrucae vulgaris, molluscum contagiosum, acne vulgaris, rosacea, actinic cheilitis, Bowen’s disease and alopecia areata, among others.9,10
Treating AKs
Protoporphyrin IX (Pp IX) is a potent photosensitizer. Focal accumulation of Pp IX in dysplastic and neoplastic dermatologic lesions and epidermal appendages such as sebaceous glands and hair follicles (pilosebaceous unit) can be induced with the topical application of 5-ALA, the biological precursor of the porphyrin. This exogenously induced photosensitization targets the tissue for PDT. During PDT, the porphyrin molecule is photoactivated by exposure to visible light, resulting in the production of a cytotoxic oxygen product that kills the abnormal cells where the Pp IX was concentrated. There is minimal damage to the surrounding unaffected skin and only transient photosensitivity. In mice and in normal human skin, Pp IX is almost always cleared from the skin within 24 hours of treatment. Thus, use of topical ALA avoids persistent generalized photosensitivity seen after systemically administered agents.9, 10 Currently, an FDA-approved form of ALA, a 20% topical solution, is available for the treatment of non-hyperkeratotic AKs on the face and scalp areas.11 During the original Phase III clinical trials12 of topical 20% ALA-PDT and a blue light source, more than 80% of patients treated showed 100% clearance of AKs at 12 weeks post-therapy. Of interest, 92% to 94% of patients noted cosmetic results, or improvement in their skin texture, as good to excellent. The major drawback for dermatologists to the routine use of this therapy is the long incubation time required for the ALA to be placed on the skin prior to light therapy used in the FDA approved treatment paradigm. This incubation time is from 14 hours to 18 hours before exposure to blue light. The second drawback for treatment is that blue light therapy was determined to be needed for 16 minutes, 40 seconds for proper AK destruction. This time period is too long for most moderately to severely sun-damaged patients to tolerate without a significant degree of associated morbidity (i.e., pain, crusting, downtime). Making the Procedure More Practical Anecdotal reports have shown that shorter-contact ALA incubation (from 15 minutes to 1 hour), broad-area application of the ALA itself to the entire face, and exposure to either blue light or other light sources, such as the IPL device, can create a shortened therapy course. This would make it more practical for dermatologists to perform these procedures in their offices. The shorter incubation time still allows for the proper photochemical reaction to occur and for successful results from the resulting light procedures. Several investigators, including myself13, Goldman14 and Nestor,15 have performed clinical evaluations using shorter incubation times, full-face application of ALA-PDT in combination with IPL or blue light therapy for photorejuvenation, improvement in AKs, as well as for active acne vulgaris and other cosmetic conditions. In my experience, an initial evaluation of 10 patients was undertaken utilizing short-contact ALA-PDT and IPL.14 The ALA-PDT was applied for 15 minutes to 30 minutes prior to therapy with IPL. Parameters for IPL were 550 nm to 570 nm cut-off filters, double pulsing, 3.5 millisecond pulse durations, and fluences of 34 J/cm2. Patients received their ALA-PDT/IPL treatments at 1 month intervals for 3 months and had follow-ups 3 months following the last treatment. Preliminary data from this trial shows overall improvement (global response to treatment) as compared to baseline. Improvements were also noted in fine wrinkling, skin roughness and hyperpigmentation. Actinic keratoses also improved, with patients noting improvement in skin texture and disappearance of the target AKs. All of the patients tolerated this therapy and noted rapid healing without downtime. Mild erythema was noted in some patients at 24 hours post-therapy, but there’s been no evidence of other adverse events such as burning, stinging, crusting, erosion, edema or mottled hyperpigmentation — all previously seen with traditional ALA-PDT blue light therapy. All of the patients noted decreased skin sallowness and an increased “youthful tone” to their skin. (See photos on page 61.)
Taking Photorejuvenation to The Next Level
The data from this initial clinical trial and the work of others clearly show that the combination of short contact, broad-area ALA-PDT with the IPL device or blue light for photorejuvenation and actinic keratosis therapy improves all variables evaluated. Combining these therapies yields a synergistic effect that results in photorejuvenation and eradication of AKs. The combination also appears to shorten the number of sessions with IPL/blue light therapy required to achieve photorejuvenation and to yield a cosmetic improvement superior to either agent alone. The potential for patients to see significant improvements in three or less treatments by combining IPL with ALA-PDT versus IPL alone could allow dermatologists to advance photorejuvenation to the next level. Further clinical evaluations will define the usefulness of this new therapeutic approach to photorejuvenation and AKs — a multicenter clinical trial is scheduled to verify these initial results.
