Use of Intense Pulsed Light (IPL) in Indian Skin Types - ResearchGate

Intense Pulsed Light DeviceAn iPulse i200 (CyDen Ltd., Swansea, United Kingdom) intense pulsed light device was used for all treatments. This novelIPL was chosen because of its constant spectral output profile and it was hypothesized that the time-resolved constantspectrum output between 530 nm and 1200 nm for the entire pulse duration claimed by the manufacturer would ensureefficient and stable delivery of energy to the dark Indian skin types in the study and reduce the side effects often associatedwith conventional, free-discharge IPL devices when used to treat dark skins [24].Treatment procedurePre- and post-treatment photography was used. The treatment area was shaved and cleaned and the area covered withchilled ultrasound gel. The IPL treatment program and fluence was chosen based on skin condition, skin type and reactionto initial test patch treatments. After treatment, cooling gel packs were applied to the area. Aloe vera cream was gentlyrubbed into the treated area when the treatment session was completed. No other creams or preparations were usedexcept in cases of melasma where hydroquinone (2%) cream was used as an adjunctive treatment. Those who weresatisfied with results at follow-up or did not wish to continue received no further treatment. Patients who were not satisfiedcould receive further treatment sessions with the same protocol as above, until the final assessment point when the patientand dermatologist felt satisfied with the result, or agreed that no further improvement could be seen.Figure 1—iPulse i200+(CyDen Ltd., Swansea, UK) twin-lamp, constantspectrum IPL system used in the study.Figure 2—(Above) Schematic illustration of the difference in spatialand temporal profile of a free discharge and partial discharge pulse.(Below) Time resolved spectral measurements using an OceanOpticsspectrometer and Spectrasuite counterpart software showing spectral “jitter”versus constant spectral emission [24].4

Results & DiscussionThe groups comprised hair removal: n=53; acne: n=35 and pigmentation: n=59. The overall average fluence used was11.6, 10.5 and 12.3 J/cm 2 respectively.The study was conducted in Chennai city in Southern India where the normal range of skin types of patients seeking treatmentis Fitzpatrick IV-V and the sunny climate is constantly hot and humid with an average ambient temperature even in airconditionedrooms above 25ºC. These climatic conditions increase treatment-related problems and increase the incidence ofpost-treatment side effects aggravated by sun exposure to skin areas exposed to intense pulsed light or laser wavelengths.It is reasonable to assume that certain pigmented lesions may be diagnosed accurately by an expert dermatologist asbenign without the benefit of histological validation (impossible where the treatment with light therapy is entirely non-invasiveand no tissue is removed during the procedure).The generally poor response after only one or two treatments confirms the importance of completing a course of IPLtreatments at regular intervals. Patients who failed to attend sufficient treatment sessions, showed reduced effectiveness asassessed by the expert clinician. Where more treatment sessions were given, in most cases better results were observed.In common with other anecdotally reported experience with laser and IPL devices in India, a conservative approach isnormally taken to choosing treatment parameters and it is generally found that numbers of treatments needed to achievesatisfactory results are greater than in countries with lighter skin types and even where treatment energy levels are similar,more treatments appear to be necessary.EfficacyTreatment outcomes were only assessed and recorded atthe end of a treatment or course of treatments when thepatient and/or dermatologist were satisfied that no furtherimprovement could be achieved, where the patient did notwish to continue or where the patient simply failed to appearfor further scheduled treatments. The standard descriptionsof efficacy used in this study by the expert clinical assessorwere graded and assessed as follows:Hair Reduction:Grade 0 = No reduction (25%),Grade 2 = Moderate Reduction (>50%),Grade 3 = Good Reduction (>70%).As expected, where multiple treatments were given thegreatest degree of hair reduction was achieved. In general,there was little reduction in regrowth of hair follicles after asingle treatment, a moderate reduction only after 3-4treatments and in two cases of thick, facial hair, a goodreduction after 7 treatments. Table 2 indicates better results infewer treatments for cosmetic hair removal versus hirsutism.Intervals between treatments needed to be 3-4 weeks and thetrial subjects did not always follow this.There were fewer cases of cosmetic hair removal on bodyareas than might be seen in comparable studies in lighter skintypes. This is probably explained by cultural preferences andtraditional Indian garment design.Figure 3—Hirsutism: Female, age 20 yrs, skin type V, 50% reduction withregrowth of finer lighter hair. 6 treatments at irregular intervals over 10 monthsusing a fluence of 11-13 J/cm2, triple sub-pulses: 14 ms on, 7 ms off.Satisfaction3Significantreduction2Moderatereduction1Somereduction0No reductionCosmeticHisuitism1 2 3 4 5 6 7No. of treatmentsFigure 4—Hair Removal: Graph showing patient satisfaction,with progressively better results with increasing numbers of treatmentsin both hirsutism and purely cosmetic hair removal cases5

No. treatments 1 2 3 4 5 6 7Hirsutism 0.1 0.4 1.2 1.5 2.5 1.0 3.0Acne Improvement:(n = 16) (n = 7) (n = 5) (n = 4) (n = 2) (n = 1) (n = 2)Cosmetic 0.5 1.0 2.0 2.3 - - -(n = 6) (n = 20) (n = 3) (n = 3) - - -0 = No reduction (25%),2 = Moderate Reduction (>50%),3 = Significant Reduction (>70%).The improvement in results with increasing numbers of treatments was best shown in acne improvement grades with somereduction achieved in only two treatments.3SignificantreductionTable 2—Hair removalAverage treatment grading scores with different numbers of treatments for hirsutism and cosmetic facial hair removal.0 = No reduction (25%), 2 = Moderate Reduction (>50%), 3 = Good Reduction (>70%).Satisfaction2Moderatereduction1Somereduction0No reduction1 2 3 4 5 7 10No. of treatmentsFigure 5—Acne improvement: Graph showing patient satisfaction withsome reduction achieved in only two treatments.Figure 6—Acne: Female, age 20 yrs, skin type V, before and three monthsafter (5 treatments at 2-3 week intervals using a fluence of 10 J/cm 2 ,single 50 ms pulse).No. treatments 1 2 3 4 5 7 10Facial acne 0.4 1.2 1.7 2.0 3.0 3.0 3.0Pigmented Lesions:0 = No Lightening (25%),2 = Moderate Lightening (>50%),3 = Good Lightening (>70%)4 = Complete Clearance (>90%).(n = 18) (n = 9) (n = 3) (n = 2) (n = 1) (n = 1) (n = 1)Table 3—AcneAverage treatment grading scores for facial acne. 0 = No reduction (25%),2 = Moderate Reduction (>50%), 3 = Significant Reduction (>70%)Clinically assessed improvement (lightening) of pigmented lesions ranged from “no lightening” at all to “complete clearance”.Where multiple treatments were undertaken the greatest degree of lightening was achieved. With freckles, melasma andpost-inflammatory hyperpigmentation (PIH), multiple treatments were needed to produce satisfactory results.Café au lait did not respond even after 3 treatments.6

Becker’s Naevus – Single treatments were completely ineffective, multiple treatments on the thigh of one patient weresimilarly ineffective and one case showed darkening of the naevus at 4 weeks post treatment. This was probably due to thedeep location of the pigment.Figure 7—Freckles: Female, age 23 yrs, skin type V, before and one monthafter (two treatments at 2 week intervals using a fluence of 13 J/cm 2 ,triple sub-pulses: 10 ms on, 15 ms off).Figure 8—Melasma: Female, age 30 yrs, skin type IV, before and sevenweeks after (five treatments at weekly intervals using a fluence of 13 J/cm 2 ,triple sub-pulses 10 ms on, 20 ms off.)Figure 9—Melasma: Female age 56 yrs, skin type V, before and after48 weeks (three treatments at 40 day intervals, 12-14 J/cm2,triple sub-pulses 14 ms on, 7 ms off).Figure 10—Melasma Side Effects: Female, age 42 yrs, skin type V, beforeand 4 days post treatment showing typical temporary depigmentationfollowing crusting 13 J/cm 2 , triple sub-pulses: 14 ms on, 7 ms off.No. treatments 1 2 3 4 5 6Becker’s 0.0 - - 0.0 - -(n = 2) - - (n = 1) - -Freckles 0.3 1.2 2.0 1.5 - -(n = 7) (n = 5) (n = 1) (n =2) - -Melasma 0.1 1.0 1.0 1.0 2.0 -(n = 7) (n = 1) (n = 1) (n = 1) (n = 1) -Pigment 0.1 1.0 0.8 2.2 - 0.0(n = 12) (n = 4) (n = 4) (n = 5) - (n = 1)PIH 0.0 - - - 2.0 -(n = 0) - - - (n = 2) -Total scores 0.1 1.1 1.0 1.7 2.0 0.0(n = 30) (n = 10) (n = 6) (n = 9) (n = 3) (n = 1)Table 4—PigmentationAverage treatment grading scores for pigmentation. 0 = No Lightening (25%),2 = Moderate Lightening (>50%), 3 = Good Lightening (>70%) 4 = Complete Clearance (>90%).7

Satisfaction3Significantreduction2Moderatereduction1SomereductionTotal scoresPIHPigmentMelasmaFreckles0No reduction1 2 3 4 5 6No. of treatmentsFigure 11—Pigmentation: Graph showing patient satisfaction, with some reduction in PIH, pigment,melasma and freckles after only two treatments and progressively better results with more treatments.Side Effects & Treatment-related ProblemsSide effects and treatment-related problems were assessed to range from “none” to “severe superficial burns” across alltreatment types included in the study. Treatment-related problems are considered to be normal in IPL treatments and in thisstudy included skin reactions following treatment up to and including severe erythema in hair removal, mild to normalerythema in acne cases and darkening of pigmented areas or temporary crusting. In the case of pigmentation treatments,temporary crusting of epidermal lesions, which sloughs off within 7-10 days during normal washing was distinguished fromtransient hyperpigmentation that lasted several weeks to several months and was considered a true side effect.T. Alster reported a significant incidence of side effects [25] in darker skin phototypes following laser treatment andrecommended prophylactic application of SPF30+ sun screen initiated at least three to four months before laser surgery toavoid post-inflammatory hyperpigmentation. No such precautions were taken in this study when using IPL therapy.Normal side effects No. Patients (%) No. incidents Av. pain score Areas Side effect(s)Acne 5 (14.3) 5 39.8 Face Mild erythemaHair removal 12 (28.8) 17 45.5 Face Mild erythemaPigment 20 (33.9) 21 46.6 Face, thigh (1), chest (1) Mild erythemaTrue side effectsAcne 0 (0) 0 n/a n/a n/aHair removal 3 (5.7) 5 47.5 Face, legs (1) Burns (1), erythemaPigment 2 (3.7) 3 48.7 Face Burns (1), erythema (2)The standard descriptions of side effects used in this study by the expert clinical assessor were graded as follows:Hair Removal:Table 5—Side effects0 = None,1 = Mild Erythema,2 = Erythema (e.g. Perifollicular Oedema),3 = Severe Erythema,4 = Crusting (eg. including transient hyperpigmentation),5 = Severe Superficial Burns (eg. including hypopigmentation).8

Acne:0 = None,1 = Mild to Normal Erythema,2 = Hyperpigmentation,3 = Severe Superficial Burns.All acne patients showed a reduction in the number of inflamed lesions with no side effects. The reduction of acne spotsobserved was similar to results reported in the literature for lighter skin types treated with IPL.Pigment:0 = None,1 = Mild to Normal Erythema / darkening of pigmented lesion / crusting,2 = Hyperpigmentation,3 = Severe Superficial Burns,4 = Hypopigmentation.Normal erythema was only seen in about one third of patients suggesting an over-cautious approach. Side effects wereseen with increased fluence. Two cases of post hair removal treatment burns were reported. The consequentialhyperpigmentation resolved in both of these cases within 3 months (See figures 7-9).PainPain experienced by the patients during all of the treatments was graded using a blank visual analogue scale (0 = no painat all and 10 = worst pain imaginable). Average pain scores for hair removal, acne and pigmentation were 4.5, 4.7 and 4.2respectively. Most subjects found the level of discomfort easily tolerated and no subjects felt the pain was unbearable as noscores were recorded above 7.0 (See figure 10).9

ConclusionsWhen a sufficient number of treatments were performed, the iPulse constant spectrum IPL was found to be effective in thispreliminary study in the treatment of benign pigmented lesions, acne and in the long-term delay of hair regrowth in hirsutism.Normal treatment related problems including patient assessed pain response and side effects using the iPulse IPL with itsconstant spectral output, large 8.9 cm 2 spot size and relatively low fluence characteristics, were found to be comparablein dark Indian skin to those reported in the literature in lighter skin types with conventional IPL devices. Early indicationsof efficacy in the treatment of hirsutism, pigmentation and acne were broadly similar to lasers and other IPL systems inlighter skin types.Both the follow-up period and the number of lesions included in the present study may not be sufficient to fully evaluatethe potentials of this treatment modality as well as the true incidence of recurrence of the original condition. Therefore, theresults obtained should be confirmed in larger studies.10

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