ORIGINAL ARTICLE

Intense Pulsed Light Treatment of Photoaged Facial SkinDOUGLAS E. KLIGMAN, MD, PHD, AND YAXIAN ZHEN, MD, PHD

SKIN, Inc., Conshohocken, Pennsylvania

BACKGROUND. It has been reported that intense pulsed light is

efficacious for rejuvenation of photoaged skin, specifically theimprovement of appearance of telangiectases and solar lent-igines.

OBJECTIVE. The objective was to define the treatment variablesfor photodamaged facial skin using a newer intense pulsed lightsystem.

METHODS. Twenty-three female subjects received three treat-ments using double-stacked pulses with fluences of 24 and

30 J/cm2. Response to treatment was evaluated using digital

photography. Three signs of photoaging were evaluated: surfacetexture/roughness, mottled hyperpigmentation, and erythema/telangiectases.

RESULTS. There was a shift in clinical grading from more to lesssevere on all three measures of photoaging.

CONCLUSION. Intense pulsed light therapy was efficacious in

ameliorating the clinical signs of photoaging. The device waswell tolerated with minimal side effects.

THIS STUDY WAS FUNDED BY PALOMAR MEDICAL TECHNOLOGIES

INTENSE PULSED light uses a noncoherent filteredflashlamp that emits broadband light in the 500- to1200-nm range.1 Cutoff filters are used to narrow thespectral range for a given chromophore with longerwavelengths penetrating more deeply. Intense pulsedlight has been used to treat a variety of dermatologicdisorders including erythema/telangiectases,2 solar lent-igines,3 and photoaged skin.4,5 We investigated theEsteLux system (Palomar Medical Technologies, Inc.,Burlington, MA). This system uses a range of energyfluences that are preset by varying the pulse durationbetween 10 and 100msec. There are 10 button settingsthat yield different fluences on the machine. The buttonnumber, i.e., fluence, is chosen to match the subject’sphototype and severity of the clinical condition to betreated. Several interchangeable handpieces deliveringlight of different spectral wavelengths are available forthis device. In this study we used the LuxG handpiece,which has a treatment window of 12� 12mm and aspectral output of 500 to 690 and 890 to 1200nm andis currently used to treat vascular and pigmentedlesions. We sought to standardize and optimize treat-ment parameters for three clinical signs of photoaging:namely, surface roughness/texture, hyperpigmentation/solar lentigines, and telangiectases/erythema.

In this study we report that all three measures ofphotoaging; namely, surface texture/roughness, mot-tled hyperpigmentation/solar lentigines, and erythema/telangiectases are ameliorated by intense pulse light

treatment with the LuxG handpiece. In addition, wesee a diminution in the diameter of follicular in-fundibula referred to as ‘‘pore size.’’

Materials and Methods

Twenty-three female subjects ranging in age from 30 to60, Fitzpatrick phototype I to III, were enrolled in thestudy using the EsteLux system with the LuxG hand-piece (Palomar Medical Technologies, Inc.). Informedconsent was obtained from all study subjects. Theyqualified for inclusion if they had significant tel-angiectases either from rosacea or from photodamageand/or mottled hyperpigmentation due to solar lent-igines, melasma, or diffuse melanin deposition second-ary to photoaging. Any subjects using oral or topicalmedications that could affect the response to visible lightwere not included in this study. The use of aspirin andother anticoagulants was also an exclusion criterion.

Evaluation was performed at each visit clinically bytwo dermatologists. Subjects received three treatmentswith 2- to 3-week intervals between treatments. Digitalphotographs using a Canfield setup with twin flash-lamps with and without polarizing filters were obtainedbefore treatment, between each treatment, and 1 monthafter the end of the third treatment from the right andleft sides of the face at 451 angles. Clinical grading wasperformed before and 1 month after three treatmentsby comparing digital photographs using a rating scaleof 0 to 3 for each photoaging parameter: 05no find-ings, 15minimal, 25moderate, and 35 severe.

Test spots on the preauricular cheek were performedinitially so that fluences ultimately used in the study

r 2004 by the American Society for Dermatologic Surgery, Inc. � Published by Blackwell Publishing, Inc.ISSN: 1076-0512/04/$15.00/0 � Dermatol Surg 2004;30:1085–1090

Address correspondence and reprint requests to: Douglas E. Kligman,

MD, PhD, SKIN, Inc., 151 East Tenth Avenue, Conshohocken, PA

19428, or e-mail: skininc1@aol.com.

could be narrowed down and also to eliminate the riskof side effects at a given fluence. Subjects were seenimmediately after and over the next half-hour and thenwithin 24 to 48 hr to assess any side effects such asvesiculation, crusting, erythema, pigmentary changes,purpura, and discomfort. Test spots were done on allsubjects only to evaluate them for side effects, not ef-ficacy. In the initial phase of the study, four subjectsreceived two or three stacked pulses using the ma-chine’s 4, 5, and 6 buttons corresponding to fluences of19, 24, and 30 J/cm2 and were evaluated at 1 month.We found that triple pulses were not well tolerated andresulted in a higher level of discomfort so we useddouble pulses in the study. We also found that usingthe lowest fluence with the number 4 button, 19 J/cm2,was not effective. Therefore, we performed the studyusing double-stacked pulses with either the number 5button at 24 J/cm2 or the number 6 button at 30 J/cm2

for three treatments. The delay time between pulseswas 2 sec with the number 6 button at 30 J/cm2 and 1sec with the number 5 button at 24 J/cm2. We alsofound that double-stacked pulses were much more ef-ficacious than single pulses or two nonstacked pulseswhich were obtained by crossing the subject’s cheek inthe horizontal axis and following back in the verticalaxis. The right side of the face received 24 J/cm2 andthe left side 30 J/cm2 for three treatments.

Cryogen spray to decrease epidermal thermal dam-age was applied to the handpiece treatment windowbefore treatment. The cooling system has a color sens-ing indicator to ensure that the handpiece is adequatelychilled. One can achieve approximately 16 to 20 pulsesbefore cryogen needs to be reapplied with the number 5button and 8 to 10 pulses with the number 6 button.We found that in many subjects application of a chilledroller to the face before treatment decreased discomfort.

The area treated extended horizontally from thepreauricular cheek to the nasolabial fold and verticallyfrom the tragus to the mandibular angle. The nose wasalso treated; however, the chin, forehead, and upper lipwere not evaluated in this study. We used eye protec-tion during this study by the use of goggles and the12 � 12 size handpiece could be placed fairly close tothe lower lid margin without risk. Nevertheless, we didnote that subjects were more sensitive around the nose,eyelids, and medial cheeks than elsewhere. All subjectswere asked to apply a sunscreen and refrain from ex-cessive sun exposure during the course of the study.

Results

We observed a diminution of all three measures ofphotoaging, surface roughness/texture, hyperpigmen-tation/solar lentigines, and telangiectases/erythema in

both the left (Figure 1) and right (Figure 2) sides of theface after three courses of treatment in almost all sub-jects. This is seen as a shift to more minimal findingsfrom more severe after treatment.

Interestingly, we found that surface texture respond-ed fairly dramatically as seen by increased reflectanceat the same settings for digital photography (Figures 3,4A, and 4B) The subjects reported a significantsmoothing after treatments, however, no clinical des-quamation was observed. The etiology of this changein surface texture remains unknown but it is mostlikely due to smoothing of the stratum corneum. Whilewe did not examine ‘‘pore’’ size because not all patientshad enlarged pores, we noted that all who did showedsignificant diminution in the clinical noticeabilityof pores on digital photography. This is most likelydue to smoothing of the ostium of the follicular in-fundibulum. In addition, nasal trichostasis was improved.

There was a diminution of telangiectases (Figures4C, 4D, 5, 6C, and 6D) as evidenced by cross-polar-ized photography, which allows greater visualizationof the subsurface vasculature. There was also a de-crease in hyperpigmentation and solar lentigines afterthree treatments (Figures 6A, 6B, and 7). We coinci-dentally noted that photoepilation is also seen with theLuxG handpiece (not shown).

There was some variability in response to treatment.This may be due to the preexisting level of photodam-

Figure 1. (A) Clinical grading, left (before treatment). (B) Clinicalgrading, left—30 J/cm2 fluence (1 month after three treatments). (&)Surface texture; ( ) hyperpigmentation/solar lentigines; ( ) erythema/telangiectases.

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age and skin phototype. In some subjects, telangiectasesresolved more rapidly than hyperpigmentation and insome other subjects, this trend was reversed. We foundthat the response of pigmentation and telangiectasias/erythema was slightly better using the highest fluence,30 J/cm2 (Figure 1). Nevertheless, the difference wasnot noticeably significant in many subjects between thisand the next highest setting, 24 J/cm2 (Figure 2). Theoperator can choose the higher fluence for treatment ofmore severely photodamaged skin. There is a tradeoffin that it takes longer to use the number 6 button be-cause of the increased delay time between pulses. Ad-ditionally, the subjects experience less discomfort with

the lower fluence during treatment. Side effects werelimited to focal vesiculation and superficial crustingfocally in two subjects that resolved over time. Nosubject exhibited sustained posttreatment hyperpig-mentation or hypopigmentation. Temporary darkeningof lentigines is frequently seen after treatment. Imme-diate blanching of vessels was also noted; however,purpura was not seen. Most subjects reported feeling asunburn sensation with erythema and warmth lasting afew hours to 1 day after treatment. We noted that thelevel of discomfort was less with each subsequenttreatment. Some subjects did not report any erythemawhatsoever nor any posttreatment sensory changes.

Discussion

We have presented data showing the efficacy of theEsteLux system intense pulsed light device with theLuxG handpiece at the fluences of 24 and 30 J/cm2

using double-stacked pulses in the treatment of threemeasures of photoaging: telangiectases/erythema, sur-face roughness, and mottled hyperpigmentation. Thisstudy demonstrated some standardized parameters fortreatment using the LuxG handpiece with this device.How long the clinical benefits of treatment are main-tained has not been assessed. We expected to see dim-inution in telangiectases and pigmentation; however,the dramatic change in surface texture using this de-vice was unexpected. Further clinical and basic studiesmay elucidate the mechanism of this change. As statedearlier, no desquamation was seen clinically.

The device was well tolerated and most subjectswere pleased with the results and would recommend itto others. We saw no significant change in periorbitalrhytides/fine lines using this device at the above-men-tioned fluences for three treatments. This contrastswith some prior studies claiming nonablative treat-ment of rhytides with intense pulsed light.4 Neverthe-less, it is in consonance with prior published studiesshowing benefits in texture, telangiectases, and pig-mentation.5 Using fluences of 24 and 30 J/cm2 with thedouble-stacked pulse has a good safety profile andminimizes the risk of epidermal injury. Prechilling thesubject’s skin and the use of the cryogen undoubtedlyis also beneficial in this regard. Although only threetreatments were given, we suspect that the use of afourth and fifth treatment would even further improvethe clinical results. Expected temporary side effectssuch as erythema after treatment of vascular lesionsand slight darkening of pigmented lesions after treat-ment usually rapidly resolved.

We and others have demonstrated that intensepulsed light adds to other techniques in dermatologywhen considering a course of photorejuvenation.4,5

There are now a number of manufacturers of intense

Figure3. Diminution of surface roughness and follicular pore size (A)before treatment and (B) after treatment.

Figure2. (A) Clinical grading, right (before treatment). (B) Clinicalgrading, right—24 J/cm2 fluence (1 month after three treatments). (&)Surface texture; ( ) hyperpigmentation/solar lentigines; ( ) erythema/telangiectases.

Dermatol Surg 30:8:August 2004 KLIGMAN AND ZHEN: INTENSE PULSED LIGHT TREATMENT OF PHOTOAGED FACIAL SKIN 1087

pulsed light devices for photorejuvenation. These de-vices differ in their ability (by using cutoff filters) todeliver different wavelengths, pulse durations, flu-ences, spot sizes, and cooling devices, as well as dif-fering in cost. Nevertheless, they all have the ability tobe tailored to the individual device operator’s prefer-ences and individual patient’s needs. For example, inone study that used the Vasculight (ESC/Sharplan,

Norwood, MA),4 the treatment fluences varied be-tween 30 and 50 J/cm2 using double or triple pulses of2.4 to 4.7 msec with pulse delays of 10 to 60msec andcutoff filters of 550 or 570 nm. Four to six full-facetreatments were administered to 49 subjects at 3-weekintervals. Comparing these treatment variables to ours,one can see that they are different yet the clinical im-provement is comparable. A retrospective study of 80

Figure5. Using cross-polarized filters, diminution of erythema and telangiectases (A) before treatment and (B) after treatment.

Figure4. Diminution of surface roughness and follicular pore size (A) before treatment and (B) after treatment. Using cross-polarized filters,diminution of telangiectases and erythema (C) before treatment and (D) after treatment.

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subjects used the Photoderm VL (Lumenis, Needham,MA),5 wavelength 550–590 nm, double pulsing with ashorter 2.4-msec pulse, and a 10-msec delay followedby a longer 6.0-msec pulse at fluences of 30 to 44 J/cm2. The improvements in texture, telangiectases, andpigmentation were comparable to results of our cur-rent study.

One can postulate that there are multiple targetchromophores within the skin (which include melaninand hemoglobin) and that coagulation due to photo-thermolysis is seen with subsequent resolution by re-

pair processes. Studies using histology6,7,8 and video-microscopy6 have been reported. More studies alongthese lines will be helpful to elucidate the mechanismof action of intense pulsed light.

References

1. Raulin C, Greve B, Grema H. IPL technology: a review. Lasers SurgMed 2003;32:78–87.

2. Mark KA, Sparacio RM, Voigt A, et al. Objective and quantitativeimprovement of rosacea-associated erythema after intense pulsedlight treatment. Dermatol Surg 2003;29:600–4.

Figure7. Diminution of solar lentigines and mottled hyperpigmentation (A) before treatment and (B) after treatment.

Figure6. Diminution of mottled hyperpigmentation and solar lentigines (A) before treatment and (B) after treatment. Using cross-polarized filters,diminution of telangiectases and erythema (C) before treatment and (D) after treatment.

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3. Kawada A, Shiraishi H, Asai M, et al. Clinical improvement of solarlentigines and ephelides with an intense pulsed light source. Der-matol Surg 2002;28:504–8.

4. Bitter PH. Noninvasive rejuvenation of photodamaged skin usingserial, full-face intense pulsed light treatments. Dermatol Surg2000;26:835–43.

5. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5years results with intense pulsed light of the face, neck, and chest.Dermatol Surg 2002;28:1115–9.

6. Kawada A, Asai M, Kameyama H, et al. Videomicroscopic and his-topathological investigation of intense pulsed light therapy for solarlentigines. J Dermatol Sci 2002;29:91–6.

7. Hernandez-Perez E, Isiett EV. Gross and microscopic findings in pa-tients, submitted to nonablative full-face resurfacing using intensepulsed light: a preliminary study. Dermatol Surg 2002;28:651–5.

8. Prieto VG, Sadick NS, Lloreta J, et al. Effects of intense pulsed lighton sun-damaged human skin, routine and ultrastructural analysis.Lasers Surg Med 2002;30:82–5.

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