Photon Lasers Med 1 (2012): 15–25 © 2012 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/plm-2011-0006
Review
Use of intense pulsed light sources in dermatology:
Update 2012
Der Einsatz der IPL-Technologie in der Dermatologie: Update 2012
Philipp Babilas
Department of Dermatology, University Hospital
Regensburg, Franz-Josef-Strauss-Allee 11, 93042
Regensburg, Germany,
e-mail: [email protected]
Abstract
Intense pulsed light sources (IPLs) consist of flash lamps with
bandpass filters and emit incoherent polychromatic pulsed
light of a high intensity and determined wavelength spectrum,
fluence, and pulse duration. The combination of prescribed
wavelengths, fluencies, pulse durations, and pulse intervals
facilitates the treatment of a wide spectrum of skin conditions. Hereby, IPLs follow the basic principle of a more or
less selective thermal damage of the target. This review discusses the current literature on IPLs with regard to the treatment of unwanted hair growth, vascular lesions, pigmented
lesions, and as a light source for photodynamic therapy and
skin rejuvenation. It also summarizes the physics of IPLs and
provides guidance for the practical use of IPLs.
Keywords: laser; dermatology; vascular lesions; pigmented
lesions; hair removal; skin.
Zusammenfassung
Hochenergetische Blitzlampen, auch „intense pulsed light
sources (IPLs)“, (intense pulsed light [IPL]) emittieren hochenergetisches, inkohärentes Licht, welches mit Filtersätzen
auf einen gewünschten Wellenlängenbereich eingegrenzt
werden kann. Die Energiedichte, die Intensität und die
Pulsdauer kann in Grenzen variiert werden. Somit können
hochenergetische Blitzlampen ein vergleichsweise breites
Indikationsfeld erschließen. Hierbei folgt die Technologie den
Prinzipien einer eingeschränkt selektiven Photothermolyse
der entsprechenden Zielstruktur. In diesem Review soll ein
Update der Literatur zu hochenergetischen Blitzlampen
geliefert werden. Schwerpunkte sind hierbei die Behandlung
unerwünschten Haarwuchses, vaskulärer Läsionen, pigmentierter Läsionen und der Einsatz als Lichtquelle zur photodynamischen Therapie und zur Photorejuvenation.
Schlüsselwörter: Laser; Dermatologie; Vaskuläre Läsionen;
Pigmentierte Läsionen; Haut.
1. Introduction
1.1. Technical aspects
After the introduction of polychromatic infrared light in 1976
by Mühlbauer et al. [1], Goldman and Eckhouse [2] described
in 1996 a new high-intensity flash lamp as a suitable tool for
treating vascular lesions. The basic principle was a rather
selective photothermolysis of pigmented structures, cells,
and organelles by selective absorption of pulsed radiation as
described in 1983 [3]. With the aid of flash lamps and computer-controlled capacitor banks, intense pulsed light sources
(IPLs), generate pulsed polychromatic high-intensity light.
The emission spectrum of IPLs ranges from 500 to 1300 nm.
Convertible cut-off filters adapt the polychromatic emission
spectrum to the desired wavelength to allow versatility. In the
new generation of IPLs, water filters suppress the infrared
light, thereby reducing the risk of side effects. The patient’s
skin type and the focused indication determine the cut-off filters used and thus the spectrum of emitted wavelengths as
well as the pulse duration. Similar to laser devices, the pulse
duration should be lower than the thermal relaxation time of
the target structure to prevent unselective damage to the surrounding tissue. Owing to a high degree of freedom in terms
of combining wavelengths, pulse durations, pulse intervals,
and fluencies, IPLs enable a successful treatment of a wide
spectrum of skin conditions, such as acne vulgaris, pigmented
lesions, vascular lesions, unwanted hair growth, photodamaged skin, scars [4], and angiokeratomas [5]. It is worth mentioning that the versatility of IPLs means that the risk of side
effects due to unspecific thermal damage is increased, especially if the devices are used by untrained physicians. Also,
the IPLs have a rather heavy handpiece and a large spot size,
which accounts for a certain limitation in maneuverability. On
the other hand, the large spot size enables a high skin coverage rate, which can be an advantage. Further advantages
are the low purchase price and a more robust technology
as compared with lasers. However, the fact that the emitted
spectrum and fluence can be inconsistent from pulse to pulse,
in particular, in IPLs containing a small capacitor bank [6],
can be considered disadvantageous. This point accounts for
the fact that different types of IPLs are hardly comparable. A
serious comparison should account for the fluence per area for
every emitted wavelength and for every possible pulse duration and pulse shape against the background of the real on-off
time, fluence, and spectral jitter during an impulse. This has
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16 P. Babilas: Use of intense pulsed light sources in dermatology
been impressively shown in the article by Maisch et al. [7],
who analyzed the emission spectrum of five different IPLs
all equipped with comparable cut-off filters. It was found
that the emission spectra of the IPLs showed a high degree
of divergence and that the induced photodynamic effect was
not predictable [7].
1.2. Practical aspects
Patient handling, pretreatment, and posttreatment are of great
importance using intense pulsed light (IPL) and are extensively
discussed in a previous review on IPLs in the preceding DGLM
journal Medical Laser Application [8] or in Babilas et al. [9].
The following sections discuss the current literature on IPLs
for the treatment of unwanted hair growth, vascular lesions,
pigmented lesions, acne vulgaris, and photodamaged skin as
well as light sources for photodynamic therapy (PDT) and
skin rejuvenation. Where available, we focus on controlled
studies comparing IPLs to the respective standard treatment.
2. Hair removal
Hair removal has become a key indication for IPLs. In a
recently published article, Alijanpoor et al. [10] report on a
randomized clinical trial on 62 hirsute patients with excessive white facial hair on the chin and cheeks. The patients
randomly colored their white hair with either black eyeliner
or black hair dye before IPL treatment (six times, at 4-week
intervals). In both groups, approximately 50% of patients
showed a good response of > 60% with no significant difference between both groups (p = 0.895). The authors concluded
that hair coloring might be an efficient and feasible technique
that can be combined with IPL treatment to eliminate white
facial hair. Haak et al. [11] compared the efficacy and safety
of an IPL device (525–1200 nm; StarLux IPL system; Palomar
Medical Technologies, Burlington, MA, USA) vs. a longpulsed diode laser (LPDL, 810 nm; Asclepion MeDioStar XT
diode laser) in 31 hirsute women with normal testosterone
levels in a split-face study. According to their results, IPL and
LPDL treatment significantly reduced hair counts (77%, 53%,
and 40% for IPL treatment vs. 68%, 60%, and 34% for LPDL
treatment) at 1, 3, and 6 months follow-up. Although there
was no significant difference between treatments in terms of
hair reduction (p = 0.427) and patient satisfaction (p = 0.125),
pain scores were higher for IPL treatment (median, 6; interquartile range, 4–7) than LPDL (median, 3; interquartile
range, 2–5) (p < 0.001).
Holzer et al. [12] used an IPL device (610–950 nm;
Energist VPL system) for the removal of unwanted nonfacial,
dark-pigmented, body hair in an uncontrolled study in 42 volunteers. They documented a very good ( > 75% hair reduction)
or good efficacy (51%–75% hair reduction) in 42.9% (n = 18)
and 33.3% (n = 14) of patients, respectively. Side effects were
a seldom occurrence.
In a split-face study with 9 female participants, Cameron
et al. [13] compared a diode laser (Lightsheer EC; Lumenis,
Santa Clara, CA, USA; 810 nm; fluence, 20–45 J/cm2; pulse
duration, 30 ms) with an IPL device (Luminette; Lynton
Lasers, UK; 625–1100 nm; fluence, 32 J/cm2; pulse train, 8 × 4
ms; total train time, 95 ms) for the removal of facial hair. Six
weeks after the treatments (three times, at 6-week intervals),
laser and IPL therapy had substantially reduced the average
hair counts in a 16-cm2 area, which were 42.4 and 10.4 (laser),
38.1 and 20.4 (IPL), and 45.3 and 44.7 (control) before and
after treatment, respectively.
Despite higher pain scores and more inflammation, laser
treatment was preferred by five patients; two patients preferred IPL treatment and one had no preference.
McGill et al. [14] conducted a randomized split-face
comparison of facial hair removal with an alexandrite laser
(GentleLASE®; Candela Laser Corp., Wayland, MA, USA;
755 nm; spot size, 15 mm; fluence, 10–30 J/cm2; pulse duration, 3 ms) and an IPL device (Lumina; Lynton Lasers; 650–
1100 nm; fluence, 16–42 J/cm2; three pulses of 55 ms; delay,
20 ms) in 38 women with polycystic ovary syndrome. The
authors reported that alexandrite laser treatment resulted in
longer median hair-free intervals than IPL therapy (7 weeks
vs. 2 weeks; p < 0.001). The decrease in hair counts was significantly higher after alexandrite laser treatment than after
IPL therapy at 1, 3, and 6 months (52%, 43%, and 46% vs.
21%, 21%, and 27%; p < 0.001). Patient satisfaction scores
were significantly higher for the alexandrite laser (p ≤ 0.002).
The authors assumed that the specific wavelength, short pulse
duration, and single pulse delivery of the alexandrite laser are
responsible for higher follicular destruction. Unfortunately,
no histological investigations were carried out at the time, and
the treatment duration was not documented.
Toosi et al. [15] compared the clinical efficacy and side
effects of an alexandrite laser (Cynosure, Langen, Germany;
755 nm; fluence, 16–20 J/cm2; spot size, 10 mm; pulse length,
2 ms), a diode laser (810 nm; Palomar diode laser), and an
IPL device (Medical Photo Bio Care, Sweden; filter, 650 nm;
fluence, 22–34 J/cm2; double pulse; pulse duration, 20 ms;
delay, 10–40 ms) for hair removal in 232 patients. Six months
after treatment (three to seven sessions), no significant difference could be seen among the average hair reduction by means
of IPL device (66.9±17.7%), alexandrite (68.8±16.9%), and
diode laser (71.7±18.1%) (p=0.194). The incidence of side
effects was significantly higher after diode laser treatment
(p=0.0001).
In a prospective comparison study, Amin et al. [16] evaluated the efficacy of an IPL device with red filter, an IPL device
with yellow filter, an 810-nm diode laser, and a 755-nm alexandrite laser in 10 patients with unwanted hair on the back or
thigh. Evaluation with a camera system at 1, 3, and 6 months
after the second treatment showed a significant decrease in
hair counts (approx. 50%) for all light devices (no statistical
difference).
An evidence-based review published by Haedersdal and
Wulf in 2006 [17] summarizes 9 randomized controlled
(RCTs) and 21 controlled trials (CTs) on the efficacy and
safety of hair removal by means of ruby, alexandrite, diode, or
Nd:YAG lasers and IPLs, whereas for IPLs, only limited evidence was available (only 1 RCT and 1 CT). Based on these
data, the authors concluded that no sufficient evidence exists
for long-term hair removal after IPL treatment. Bjerring et al.
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[18], in a split-face study, compared the effectiveness of an
IPL device (Ellipse Relax Light 1000; Danish Dermatologic
Development, Hoersholm, Denmark; 600–950 nm; fluence,
18.5 J/cm2; spot size, 10 × 48 mm) to a normal mode ruby laser
(Epitouch, ESC Sharplan, Tel Aviv, Israel; 694 nm; spot size,
5 mm; pulse duration, 0.9 ms) for hair removal in 31 patients
(three treatments). The authors reported an average hair count
reduction of 49.3% (IPL) vs. 21.3% (ruby laser) after three
treatments and concluded that IPL treatment was 3.94 times
more effective for hair removal than ruby laser therapy.
Some very recent papers have focused on the safety of
IPLs in hair removal. According to these articles, burning,
postinflammatory hyperpigmentation, bulla and erosion, leukotrichia, folliculitis, postinflammatory hypopigmentation,
very seldom scar formation, and paradoxical hypertrichosis
(1–10%) can be registered as side effects [19–22].
The market for portable devices for home use is increasing.
Even some works assess efficacy and safety [23, 24], and even
if the potential of self-administered home-use devices is obvious, further investigation of their safety and effectiveness in
a home setting is of the highest importance. A clear drawback
of this method is the fact that due to the size minimization of
the apparatus, a smaller capacitor bank has to be used, which
evokes fluence and spectral jitter within each pulse.
In conclusion, a number of medical papers document the
effectiveness of IPL treatment for hair removal, yet only few
provide data from RCTs or CTs. Level of evidence IIB is
reached.
3. Pigmented lesions
Several reports indicate the effectiveness of IPLs in the
treatment of pigmented lesions. Li et al. [25] published
recently a work on the efficacy and safety of an IPL device
(Lumenis One; Lumenis, Santa Clara, CA, USA; 590-/640-/
695-nm cut-off filters; fluence, 11–17 J/cm2, with triplepulse mode; pulse width, 3–4 ms; delay time, 35–40 ms) in
the treatment of Riehl melanosis in a split-face study of six
patients (Fitzpatrick skin type IV). In terms of histological
analysis, the authors reported significantly fewer melanin
granules and melanophages in the treated side as compared
with the control side after 10 IPL sessions. According to a professional assessment, five patients exhibited good improvements, whereas one patient showed excellent improvement,
whereby therapeutic efficacy was correlated to the number
of treatment sessions and anatomical sites. In another study,
Li et al. [26] reported on the efficacy and safety of the same
IPL device (fluence, 13–17 J/cm2; 560-/590-nm filters and
double pulse or 590-/615-/640-nm filters and triple pulse;
pulse duration, 3–4 ms; delay time, 25–40 ms) in the treatment of melasma in 89 Chinese patients. Patients received a
total of four IPL treatments at 3-week intervals. As a result,
69 (77.5%) of 89 patients showed an improvement of 51–
100% according to the overall evaluation by dermatologists.
Self-assessment by the patients indicated that 63 (70.8%)
of 89 patients considered that there was a 50% or more
17
improvement. Melasma area and severity index decreased
substantially from 15.2 to 4.5.
Park et al. [27] determined the effectiveness of a combined
IPL and Q-switched ruby laser (QSRL) therapy for targeting pigment dissolution and global photorejuvenation in 25
Korean women with more than two types of facial pigmentary disorders. Initial treatment was conducted with the IPL
device (560-/590-nm cut-off filter; fluence, 20–25 J/cm2 with
double pulse mode; pulse duration, 2.4–4 or 4–5 ms; delay
time, 15 ms) and followed by repeated treatments every 3 to 4
weeks as required. QSRL treatments (Lambda Photometrics,
Hertfordshire, UK; 694 nm; fluence, 4.5–6 J/cm2; spot size,
3–4 mm; pulse duration, 25 ns) were added either during
the same session or within 1 week after the IPL treatment.
According to their results, 19 (76%) of 25 patients reported
a good to excellent response. Two independent physicians
assessed that 15 (60%) of 25 patients showed a 76–100%
improvement, whereas 19 (76%) of 25 patients showed at
least an improvement of 50%. Side effects were minimal;
3 (12%) of 25 patients showed transient postinflammatory
hyperpigmentation and 1 (4%) of 25 patients had linear
hypopigmentation.
Galeckas et al. [28] conducted a multiple-treatment splitface comparison using a pulsed dye laser (PDL) (Perfecta;
Candela Laser Corp.; spot size, 10 mm; mean light dose,
9.36 J/cm2) with a compression handpiece vs. an IPL device
(StarLux; Palomar Medical Technologies; fluence, 35.6 J/cm2;
pulse duration, 10 ms). In total, 10 patients were treated three
times at 3- to 4-week intervals. One month after the final
treatment, improvement was assessed by blinded investigators who reported 86.5% vs. 82.0% for PDL vs. IPL treatment for dark lentigines, 65.0% vs. 62.5% for light lentigines,
85.0% vs. 78.5% for vessels < 0.6 mm, 38.0% vs. 32.5% for
vessels > 0.6 mm, and 40.0% vs. 32.0% for texture. Mean
third treatment times were 7.7 min for PDL vs. 4.6 min for the
IPL device (p = 0.005). Mean pain ratings were 5.8 for PDL vs.
3.1 for the IPL device (p = 0.007). The rate of side effects was
lower using the IPL device (infraorbital edema: 0% vs. 50%
for PDL, posttreatment purpura 0% vs. 10% for PDL).
Bjerring et al. [29] evaluated the effectiveness of an IPL
device (Ellipse Flex; Danish Dermatologic Development,
Hoersholm, Denmark; 400–720 nm; fluence, 10–20 J/cm2; spot
size, 10×48 mm; pulse duration, 2×7 ms; delay, 25 ms) in the
treatment of lentigo solaris (18 patients) and benign melanocytic nevi (8 patients). Two months after a single treatment,
evaluation by means of close-up photographs showed a pigment reduction in 96% of the patients. The average clearance
was 74.2% for lentigo solaris and 66.3% for melanocytic nevi.
In a case report by Pimentel and Rodriguez-Salido [30], an
IPL device (Harmony System; Alma Lasers Ltd., Caesarea,
Israel; filter, 570 nm; fluence, 10–12 J/cm2; pulse duration,
15 ms) was successfully used to treat pigmentary ochre
dermatitis secondary to chronic venous insufficiency. The
normal skin color was restored, no repigmentation was
observed within the 6-month follow-up period, and no side
effects occurred.
In contrast, dyschromasia of both upper eyelids was
reported as a noteworthy side effect after an IPL treatment
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18 P. Babilas: Use of intense pulsed light sources in dermatology
by Pang and Wells [31]. Both eyelids were treated with an
IPL device (Quantum SR; Lumenis, Santa Clara, CA, USA;
560–1200 nm; fluence, 24 J/cm2) at a beauty salon without the
application of eye shields. The iris has a high pigment content
and is therefore particularly vulnerable during light treatment.
The absorption of high intense light led to bilateral ocular
iritis with subsequent irreversible ocular damage.
In another report by Shin et al. [32] published in 2010, vitiligo was introduced as an acquired depigmenting disorder due
to IPL treatment for lentigines and dyspigmentation.
It should be emphasized that the first and foremost step in
the treatment of pigmented lesions is a doubtless diagnosis
and the exclusion of a malignant process. Besides, it has to
be emphasized that nevomelanocytic lesions are not a routine indication for laser treatment. For the treatment of benign
pigmented, nonnevomelanocytic lesions, Q-switched laser
systems are currently the method of choice.
4. Tattoos
Tattoo removal requires very short pulse duration and high
light intensities. Only Q-switched lasers fulfil these requirements. IPLs are not suitable for tattoo removal, as Q-switching
is not possible in incoherent light sources. IPLs emit pulse
durations in the millisecond range, resulting in a prolonged
heating of the pigment particles and subsequently in heating
of the surrounding tissue. This fact needs to be considered if
IPLs are used for hair removal on tattooed skin areas [33] or
for facial treatments in areas with permanent makeup.
(n = 11) and previously treated (n = 14) patients with PWS [47].
In previously untreated PWS as well as in pretreated PWS,
IPL treatments were rated significantly (p < 0.05) better than
treatments with the SPDL (585 nm; fluence, 6 J/cm2; pulse
duration, 0.45 ms). In both groups, IPL and LPDL (585-/590/595-/600-nm cut-off filters; fluencies, 12/14/16/18 J/cm2;
pulse duration, 1.5 ms), treatments did not differ significantly.
There were few side effects at all settings.
Besides multiple uncontrolled trials, two other works provide data from controlled side-by-side comparisons of IPLs
and the standard therapy, the PDL [48, 49]. Faurschou et al.
[48] treated 20 patients with PWS in a side-by-side trial with
a PDL (V-beam Perfecta; Candela Laser Corp.; 595 nm; pulse
duration, 0.45–1.5 ms) and an IPL device (StarLux; Palomar
Medical Technologies; 500–670 and 870–1400 nm; fluence,
7–14 J/cm2; pulse duration, 5–10 ms). The researchers found
that both PDL and IPL treatment significantly lightened
PWS, whereas median clinical improvements were significantly better with the PDL (65%) than with the IPL device
(30%). McGill et al. [49] compared a PDL, an alexandrite, a
KTP, and an Nd:YAG laser as well as an IPL device (Lumina;
Lynton Lasers, Cheshire, UK; 550–1100 nm; fluence, 28–34
J/cm2; spot size, 10 × 10 mm; double pulse; delay time, 10 ms)
in a split-lesion modus in 18 patients with PWS. In this study,
the alexandrite laser was most effective and resulted in fading
PWS in 10 patients, but hyperpigmentation (n = 4) and scarring (n = 1) were frequent. IPL treatment resulted in PWS fading in six patients; the KTP and Nd:YAG lasers were the least
effective with fading seen in two patients for both systems;
five patients showed further PWS fading after double-passed
PDL treatment.
5. Vascular lesions
5.2. Rosacea and erythrosis
There is evidence in the literature for successful treatment
of essential telangiectasias [34], rosacea [35, 36], port-wine
stains (PWS) [37–41], spider nevi [42], angiomas [43–45],
and erythrosis [34]. For the treatment of essential telangiectasias, PWS, and rosacea level of evidence IIB is reached. In
2007, the European Society for Laser Dermatology published
guidelines for the use of IPLs in the treatment of vascular
malformations [46].
In 2011, Kassir et al. [50] evaluated an IPL device (NaturaLight
IPL System; Focus Medical, Bethel, CT, USA; filter, 420 or
530 nm; fluencies, 10–20 or 10–30 J/cm2; 2.5/5 ms, double,
triple, or quadruple pulse; delay time, 20–30 ms) in 102
patients with mild to severe rosacea. A mean of 7.2 treatments
were applied in 1- to 3-week intervals. A reduction in redness was documented in 80% of patients, reduced flushing
and improved skin texture in 78%, and fewer acneiform were
achieved in 72% of patients. There were no complications or
adverse effects.
Papageorgiou et al. [36] assessed the efficacy of an IPL
device (Quantum SR; Lumenis, London, UK; 560–1200 nm;
fluence, 24–32 J/cm2; spot size, 34 × 8 mm, double pulses
of 2.4/4.0/5.0/6.0 ms depending on the skin type) for the
treatment (four treatments, 3-week interval) of stage I rosacea (flushing, erythema, and telangiectasia) in 34 patients.
Photographic assessment showed significant improvement
of erythema (46%) and telangiectasias (55%). The severity of rosacea was reduced on average by 3.5 points on a
10-point visual analogue scale (VAS). The results were
sustained at 6 months. Side effects were minimal and selflimiting.
Schroeter et al. [35] approved these positive results in the
treatment of rosacea, testing the effectiveness of IPL devices
5.1. Port-wine stains
In a controlled comparative split-face study, our research
group evaluated the efficacy and the side effects of IPL treatment (Ellipse Flex; Danish Dermatologic Development,
Hoersholm, Denmark; 555–950 nm; fluence, 11.0–16.9 J/cm2;
spot size, 10 × 48 mm; pulse duration, 8 or 10 ms) of PWS
in a direct comparison to a short-pulsed dye laser (SPDL)
(C-BeamTM; Candela Laser Corp.; 585 nm; fluence, 6 J/cm2;
spot diameter, 7 mm; pulse duration, 450 ms) and a long-pulsed
dye laser (LPDL) (Sclero; Candela Laser Corp.; wavelengths,
585, 590, 595, and 600 nm; fluence depending on the respective wavelength, 12 J/cm2 at 585 nm, 14 J/cm2 at 590 nm,
16 J/cm2 at 595 nm, and 18 J/cm2 at 600 nm; circular foot
print (diameter), 5 mm; pulse duration, 1500 ms) in untreated
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(PhotoDerm VL or Vasculight; Lumenis, London, UK; 515–
1200 nm; fluence, 25–35 J/cm2; pulse duration, 4.3–6.5 ms)
in the treatment of facial telangiectasia in 60 rosacea patients.
On average, 4.1 treatments were applied per area. In total,
n = 508 facial sites were treated and clinically as well as photographically evaluated. A mean clearance of 77.8% was
achieved and was maintained for a follow-up period averaging 51.6 months (range, 12–99 months). Within this remarkable long follow-up period, only 4 of the 508 treated areas
showed recurring lesions. Minimal side effects occurred.
In a randomized controlled single-blind split-face trial,
Neuhaus et al. [51] compared a PDL (V-beam; Candela Laser
Corp.; fluence, 7 J/cm2; spot size, 10 mm; pulse duration,
6 ms) with an IPL device (IPL Quantum; Lumenis, Santa
Clara, CA, USA; 560-nm filter; fluence, 25 J/cm2; pulse train,
2.4 and 6.0 ms; delay time, 15 ms) in the treatment of facial
erythematotelangiectatic rosacea. In total, 29 patients underwent 3-monthly treatment sessions. In this study, PDL and IPL
therapy significantly reduced cutaneous erythema, telangiectasia, and patient-reported associated symptoms. No significant
difference was noted between PDL and IPL treatments.
Campolmi et al. [52] used an IPL device (Minisilk FT;
DEKA Medical Inc., USA; 500-/520-/550 nm cut-off filters
dependent on the types of lesion and the patient’s skin types;
fluence, 16–23 J/cm2; pulse time, 3–8 ms; double pulse; pulse
delay, 10 ms) in patients with poikiloderma of Civatte (n = 28)
and rosacea (n = 35) repeatedly over a period of 2 years. They
assessed the efficacy and safety up to 12 months after treatment. In total, 51 patients showed a marked improvement, 10
a moderate improvement, and 2 a slight improvement. Side
effects were seldom.
Madonna Terracina et al. [53] used an IPL device (IPL
Quantum; Lumenis, Santa Clara, CA, USA; 560-nm filter;
fluence, 9–12 J/cm2; spot size, 20 × 50 mm; pulse duration,
10–20 ms) in the treatment of face and neck erythrosis in 22
female and 12 male patients who underwent five treatments
at 3-week intervals. In 22 patients, a total regression of the
erythrosis was achieved after five applications, whereas the
erythema persisted in five patients after the end of treatment.
Wenzel et al. [34] reported about the successful treatment
of patients with progressive disseminated essential telangiectasia (n = 4) and erythrosis interfollicularis colli (n = 5) by
means of an IPL device (Ellipse Flex; Danish Dermatologic
Development, Hoersholm, Denmark; 555–950 nm; fluence, 11.7–17 J/cm2; spot size, 10 × 48 mm; pulse duration,
14–18 ms). According to their results, clearance rates were
76–90% in six of nine patients, 51–75% in two patients,
and 50% in one patient. For both indications, 2.8 treatments
were applied on average. Adverse events were rare, only one
patient had transient crusts and blisters, which resulted in
transient hypopigmentation; another patient showed transient
hyperpigmentation.
or 555–950 nm; fluence, 8–20 J/cm2; spot size, 10 × 48 mm;
pulse duration, 10–20 ms) in a randomized, controlled splitface trial (three settings; 3-month follow-up) in 49 patients
with symmetrically located facial telangiectasias. According
to the blinded assessment, both treatments showed good or
excellent response in 30 of 39 patients. A 75–100% vessel
clearance rate was found in 18 (LPDL) vs. 11 (IPL) patients
(p = 0.01). LPDL was classified as less painful. No adverse
effects occurred. In another randomized split-lesion trial [55],
the same authors compared both devices in 13 patients with
telangiectasias after radiotherapy for breast cancer. Patients
underwent three split-lesion treatments at 6-week intervals. The authors reported median vessel clearances of 90%
(LPDL) vs. 50% (IPL) (p = 0.01) 3 months after treatment.
LPDL treatments were associated with lower pain scores than
IPL treatments. Even if the patients’ satisfaction did not differ
significantly, more patients preferred the LPDL (n = 9) to IPL
treatment (n = 2) (p < 0.01).
Bjerring et al. [56] evaluated the effectiveness and
side effects of the same IPL device (Ellipse Flex; Danish
Dermatologic Development, Hoersholm, Denmark; 555–
950 nm; fluence: 10–26 J/cm2, spot size: 10 × 48 mm, pulse
duration: 10–30 ms) in 24 patients with facial telangiectasias. On average, 2.54 ± 0.96 treatments were conducted at
1-month intervals; 79.2% of the patients obtained more than
50% reduction in a number of vessels and 37.5% obtained
reduction between 75% and 100% 2 months after the last
treatment. Side effects were rare (moderate erythema
and edema), and no scarring or pigmentary disturbances
occurred.
In a prospective side-by-side study, Fodor et al. [57] compared an IPL device (Vasculight; Lumenis, London, UK; filter: 515, 550, or 570 nm; fluence, 15–38 J/cm2; pulse duration,
not stated) to an Nd:YAG (Vasculight; Lumenis, London, UK;
1064 nm; fluence, 120–140 J/cm2) laser in 25 patients with
telangiectasias, leg veins, or cherry angiomas. Patients with
telangiectasias, cherry angiomas, or leg veins < 1 mm were
more satisfied after IPL treatment, whereas patients with leg
veins > 1 mm were more satisfied after Nd:YAG treatment.
Overall, satisfaction with treatment of vascular lesions was
greater with Nd:YAG laser, although this method was reported
to be more painful.
Retamar et al. [58] investigated the effectiveness and safety
of an IPL device (type unknown; 515–1200 nm) in the treatment of linear and spider facial telangiectasias in 140 patients.
In this study, 94 (67.1%) patients showed excellent (clearance
of 80–100%), 43 (30.7%) good (clearance of 40–80%), and
3 (2.1%) poor (clearance < 40%) results. Posttreatment side
effects were minimal and transient.
5.3. Telangiectasias
A key indication for PDT is the treatment of nonmelanoma
skin cancer such as actinic keratoses (AK) or superficial
basal cell carcinomas [59]. Aminolevulinic acid (ALA) or its
methyl ester (MAL) are prodrugs that have to be converted
into their active form, i.e., protoporphyrin IX (PpIX) [60, 61].
Nymann et al. [54] compared an LPDL (V-beam; Candela
Laser Corp.; 595 nm) to an IPL device (Ellipse Flex; Danish
Dermatologic Development, Hoersholm, Denmark; 530–750
6. PDT of nonmelanoma skin cancer
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P. Babilas: Use of intense pulsed light sources in dermatology
PpIX is particularly suitable for the activation with broadband IPL because the major absorption bands include 410,
504, 538, 576, and 630 nm. Both ALA and MAL are used
for PDT in combination with IPL for the treatment of nonmelanoma skin cancer [62]. Major side effects of PDT are
phototoxic reactions (erythema, edema, hyperpigmentation)
and pain during the treatment, which is dependent on the type
of photosensitizer used, the treatment area, and the type of
lesion treated [63].
Haddad et al. [64] evaluated the effect of increasing the
fluence (20, 25, 40, and 50 J/cm2) of an IPL device on the
outcome of ALA-PDT (single treatment, 2-h incubation) in
24 patients with AK and photodamaged skin. The assessment
8 weeks after treatment indicated that AK clearance improved
with increasing fluence. The mean posttreatment AK grade
was 56% lower in the 50-J/cm2 treatment group, 50% lower
in the 40-J/cm2 group, 32% lower in the 25-J/cm2 group, 20%
lower in the 20-J/cm2 group, and 7% lower in the control
group as compared with the mean pretreatment AK grades.
Erythema, edema, crusts and erosion, and pain did not cause
any patient to discontinue the study.
Our group compared the efficacy and painfulness of an
IPL device (Energist Ultra VPL; Energist Ltd., Swansea, UK;
610–950 nm; two pulse trains, each 15 pulses of 5 ms; delay,
20 ms; fluence, 40 J/cm2 per pulse train) to a standard light
source for PDT, an LED system (Aktilite®; Galderma, France;
635 ± 3 nm; 50 mW/cm2; 37 J/cm2), in a prospective randomized controlled split-face study [65]. In 25 patients with 238
AK lesions, topical PDT was applied followed by a reevaluation of up to 3 months. According to our results, IPL use for
PDT is an efficient alternative for the treatment of AK, resulting in complete remission and cosmesis equivalent to LED
irradiation but with significantly less pain [VAS, 4.3 (IPL) vs.
6.4 (LED); p < 0.001].
Kim et al. [66] conducted a clinical and histopathological trial to confirm the effectiveness of topical ALA-PDT
using an IPL device (Ellipse Flex; Danish Dermatologic
Development, Hoersholm, Denmark; 555–950 nm; fluence,
12–16 J/cm2; spot size, 10 × 48 mm; pulse duration, 20–30 ms;
two passes) as light source. In total, 12 AK lesions in 7
patients were treated. Eight or 12 weeks after treatment, the
clinical response was assessed, and histopathological examinations were conducted on clinically resolved lesions. As a
result, 6 (50%) of 12 lesions showed clinical clearance after
a single treatment, but histological examinations showed that
only 5 (42%) of 12 lesions had been removed. Complications,
such as pigmentary changes or scarring, were not observed.
According to these results, determining complete remission
in AK requires caution, and long-term follow-up or histological confirmation may be required.
Gold et al. [67] focused on the treatment of AK and associated photodamaged skin. In a split-face study involving 16
patients (three treatments, 1-month intervals), short-contact
(30–60 min) ALA-PDT with an IPL device (Vasculight;
Lumenis, Yokneam, Israel; 550- or 570-nm filter; fluence, 34
J/cm2; spot size, 8 × 16 mm; double pulsing; delay, 20 ms) as
light source in comparison to IPL alone was evaluated. Three
months after the final treatment, ALA-PDT-IPL showed a
significantly better improvement, compared with IPL alone,
in the clearance rate of AK lesions (78% vs. 53.6%) as well
as in the assessed facets of photodamage (crow’s feet appearance, 55.0% vs. 29.5%; tactile skin roughness, 55% vs. 29.5%;
mottled hyperpigmentation, 60.3% vs. 37.2%; telangiectasias,
84.6% vs. 53.8%). Thus, this study further proves the usefulness of ALA-PDT-IPL in the successful treatment of AK and
signs of photodamage. As to whether short-contact incubation is able to induce significant amounts of PpIX in the skin
has to be proven in additional experiments. However, the fact
that telangiectasias respond better to ALA is noteworthy, as
the creation of PpIX by endothelial cells cannot be expected
after such short contact incubation. Skin rubbing, which was
only done in the ALA-PDT site (methodical mistake) or light
coupling effects might have contributed to the clearance of
telangiectasias.
A level of evidence IIB supports the use of IPL as a light
source for PDT of AK.
7. Photorejuvenation/photodynamic
photorejuvenation
Photorejuvenation is the use of light devices to remove clinical signs arising from photoaging. If the process is combined
with a photosensitizer so that a photodynamic reaction takes
place, it is called photodynamic photorejuvenation. Clinical
hallmark features of photoaging are skin roughness, epidermal neoplasias, mottled pigmentation, telangiectasias, erythema, thin wrinkles, lax skin texture, and sebaceous gland
hypertrophy [68].
To define the mechanism of action of IPL application in
photorejuvenation, biopsies taken before and after IPL treatment were examined histologically [19]. Analysis showed
that both type 1 and type 3 collagens increased after treatment, whereas the elastin content decreased, but elastin
fibers were more neatly arranged. According to transmission
electron microscope investigations, the amount of fibroblast
activity increased, the fibroblasts were more active, and more
collagen fibers were neatly rearranged within the stroma
[19]. Wong et al. [69] examined the effects of IPL irradiation (triple pulses, 7 ms; pulse interval, 70 ms; fluencies, 20,
50, and 75 J/cm2) on normal human dermal fibroblasts grown
in contracted collagen lattices. Twenty-four hours after IPL
irradiation, a dose-dependent increase in viable cells as well
as an up-regulated expression of collagen III and TGF-β1 in
dermal fibroblasts could be observed. No significant change
in mRNA levels of collagen I and fibronectin was reported.
Cao et al. [70] evaluated the effects of IPL irradiation (double
pulses, 4/6 ms; pulse interval, 20 ms; fluencies, 18, 23, 28,
and 33 J/cm2). They were able to show that 24 h after irradiation, cell viability of skin fibroblasts improved in a dosedependent manner (increase of percentage of fibroblasts at the
S and G2/M stage of the cell cycle). IPL irradiation increased
the expression of collagen (types I and III) at the mRNA and
protein level. Thus, cytological and morphological evidence
exists for clinical improvement of the skin texture after IPL
irradiation. Regarding photodynamic photorejuvenation, Park
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P. Babilas: Use of intense pulsed light sources in dermatology
et al. [71] performed a study on 14 patients with photodamaged skin. Skin biopsies taken before and 1 month after PDT
revealed an increase in mean epidermal thickness, expression of types I and III procollagen, and dermal collagen
volume and a decrease in dermal elastotic material, expression
of matrix metalloproteinases 1, 3, and 12, and inflammatory
infiltrate.
Besides these histomorphological investigations, there
have been a couple of controlled clinical trials published so
far. Palm and Goldman [72] compared the effectiveness of
MAL-PDT with red vs. blue light for photodynamic photorejuvenation in 18 patients with moderate to severe facial photodamage. The authors did not find a statistically significant
difference between blue and red light in terms of efficacy and
side effects. The greatest improvement was achieved in pigmentation, AK, and erythema. Kosaka et al. [73] conducted
a comparative study with 16 Asian patients with facial photodamage to compare the effectiveness of photodynamic
photorejuvenation (5% ALA; 2-h incubation; IPL irradiation,
500–670 and 870–1400 nm; 23–30 J/cm2) and photorejuvenation under the use of IPL light only. Three treatments (4-week
intervals) were applied in a split-face modus. Although the
treatment results did not differ significantly between the two
sides in all subjects, 75% of the patients considered the ALAPDT-IPL treated side as better than the IPL-only treated side.
However, all ALA-PDT-IPL treated sides showed adverse
effects such as erythema and pain.
Shin et al. [74] treated 26 Korean women with wrinkles and
facial dyschromias at 4-week intervals using an IPL device
(Powerlite 600® EX, Scandinavia Corp., Japan; 530-nm cutoff filter; fluence, 15.5–17.5 J/cm2; pulse duration, 5 × 2 ms;
delay, 5 × 2 ms). The authors reported that pigmented lesions
(p < 0.05), skin elasticity, and wrinkles improved while sebum
secretion and water content of skin remained unchanged.
Butler et al. [75] performed a split-face comparison of IPL vs.
KTP laser treatment in 17 patients, of skin types I–IV, with
dyschromias and telangiectasias. The mean improvement 1
month after the treatment vascular/pigment lesions was 38%
and 35% for the IPL side vs. 42% and 30% for the KTP side.
The patients’ assessment revealed a mean global improvement of 66% (IPL) vs. 61% (KTP) and a higher rate of side
effects due to KTP treatment (pain, postprocedure swelling).
In a randomized controlled split-face trial, Jørgensen et al.
[76] evaluated the efficacy and adverse effects of an LPDL
(V-beam Perfecta; Candela Laser Corp.; 595 nm) and an IPL
device (Ellipse Flex; Danish Dermatologic Development,
Hoersholm, Denmark; 530–750 or 555–950 nm; fluence,
6–20 J/cm2; spot size, 10 × 48 mm; pulse duration, 2 × 2.5 ms;
delay, 10 or 8–20 ms) in the treatment (three treatments;
3-week intervals) of photodamaged skin in 20 women with
Fitzpatrick skin types I–III. One, three, and six months after
therapy, patients as well as blinded investigators assessed
the impact on telangiectasias, pigmentation, skin texture,
rhytides, treatment-related pain, adverse events, and the preferred treatment by means of photographs. LPDL rejuvenation showed advantages over IPL rejuvenation because of
considerably better vessel clearance and less pain. Irregular
pigmentation and skin texture improved with both treatments
21
without significant side-to-side differences. No reduction of
rhytides was seen in either treatment side.
Using the same IPL device with the same specifications,
Bjerring et al. [77] compared the clinical efficacy and safety
of two different filter sets of 555–950 nm (VL) and 530–750
nm (PR) in the treatment of photodamaged skin in 35 patients.
In this study, the use of the VL filter resulted in better clearance of irregular pigmentation, whereas the PR filter achieved
better clearance of telangiectasias and diffuse erythema.
According to their overall satisfaction, 66.7% (PR) vs. 76.2%
(VL) of patients reported fair, good, or excellent results. No
skin atrophy, scarring, or pigment disturbances were noted,
but swelling and erythema occurred in 66% (PR) vs. 33%
(VL) of patients.
Hedelund et al. [78] evaluated the efficacy and adverse
effects of the same IPL device (Ellipse Flex; Danish
Dermatologic Development, Hoersholm, Denmark; 530–750
nm; fluence, 7.5–8.5 J/cm2; spot size, 10 × 48 mm; pulse duration, 2 × 2.5 ms; delay, 10 ms) in a randomized controlled
split-face trial on skin rejuvenation (three treatments, 1-month
interval) in 32 women (Fitzpatrick skin type I–III) with class
I or II rhytides. Nine months after the final treatment, blinded
investigators and patients assessed significant improvement
in telangiectasias (p < 0.001) and in irregular pigmentation
(p < 0.03) between treated and untreated sides but no significant difference in rhytides.
Li et al. [79] evaluated the efficacy and safety of an IPL
device (Lumenis One; Lumenis, Santa Clara, CA, USA; 515–
1200 nm; fluence, 11–20 J/cm2; double- or triple-pulse mode;
pulse duration, 2.5–4 ms; delay time, 20–40 ms) in the treatment (four treatments, 3- to 4-week intervals) of photoaged
skin in 152 Asian patients. In this study, assessment showed
a score decrease of three or two grades in 91.4% of patients.
In total, 89.5% of patients rated their overall improvement as
excellent or good. Adverse effects were limited to mild pain
and transient erythema.
Kono et al. [80] compared in a split-face study the effectiveness of an IPL device (Smooth Pulsed Light; Palomar
Medical Technologies; 470–1400 nm; fluence, 27–40 J/cm2;
pulse duration, 20 ms) to an LPDL (V-beam; Candela Laser
Corp.; 595 nm; fluence, 9–12 J/cm2; spot size, 7 mm; pulse
duration, 1.5 ms) in the treatment (six treatment sessions) of
facial skin rejuvenation in 10 Asian patients (Fitzpatrick skin
types III–IV). Three months after the last treatment, lentigines
had improved by 62.3% (IPL) vs. 81.1% (LPDL). No significant difference was evident between IPL and LPDL treatment
in wrinkle reduction, and no scarring or pigmentary change
were seen with either device.
Sequential Er:YAG laser treatment vs. IPL treatment
(StarLux; Palomar Medical Technologies; 560-nm filter; fluence, 30 J/cm2; pulse duration, 2.4 and 4.0 ms; delay, 10 ms)
for mild to moderate facial photodamage was compared by
Hantash et al. [81] in a split-face randomized prospective trial
in 10 patients with facial dyschromia and rhytides. Assessment
3 months after the final treatment (three treatments, 1-month
intervals) showed that IPL and Er:YAG treatments did not
significantly improve rhytid scores. However, subjective
and blinded physician dyschromia scores improved by 26%
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and 38% (IPL) vs. 7% and 29% (Er:YAG). Subjective global
facial appearance scores worsened by 5% (Er:YAG) vs. 28%
(IPL), whereas blinded physician scores improved by 16%
(Er:YAG) vs. 20% (IPL). Adverse events occurred more frequently after Er:YAG than after IPL treatment (hyperpigmentation, 10% vs. 0%; exfoliation, 30% vs. 10%; blistering, 10%
vs. 0%; discomfort, 50% vs. 10%).
In most studies, data on the effectiveness of IPL in skin
rejuvenation are heterogeneous. Obviously, IPL treatment is
a good alternative to laser therapy in terms of vascular and
pigment disturbances rather than wrinkle reduction. The relatively low incidence of complications is advantageous when
compared with laser devices. The combination of IPL with
a suitable photosensitizer (ALA, MAL) seems to enhance
the impact on photodamaged skin. However, there is still no
standardized protocol for photodynamic photorejuvenation.
IIB (use of IPL as a light source for PDT of AK)
IIB
IIB (treatment of essential telangiectasias, PWS, rosacea)
P. Babilas: Use of intense pulsed light sources in dermatology
Evidence level
22
– IPLs are not suitable for tattoo removal.
– Method of choice: Q-switched lasers.
– There is evidence in the literature for successful IPL treatment of essential
telangiectasias, rosacea, PWS, spider nevi, angiomas, and erythrosis.
Tattoos
Vascular lesions
– Data on the effectiveness of IPL in skin rejuvenation are heterogeneous.
– A standardized protocol for photodynamic photorejuvenation is still missing.
– Exclusion of malignant processes is necessary by diagnosis.
– Nevomelanocytic lesions are not a routine indication for laser or IPL treatment.
– For the treatment of benign pigmented, nonnevomelanocytic lesions,
Q-switched laser systems are the methods of choice.
Pigmented lesions
Photorejuvenation/photodynamic
photorejuvenation
– IPL treatment is effective.
Hair removal
PDT of nonmelanoma skin cancer
Evaluation
Application/indication
Table 1 Level of evidence for IPL treatments.
8. Conclusions
Based on a large body of works, IPL devices can be considered as safe and effective in the treatment of a variety of skin
conditions (Table 1). Hereby, the effectiveness of IPLs seems
to be comparable to lasers, especially if treating vascular malformations or hypertrichiosis. However, there is still a need
for large, controlled and blinded, comparative trials with an
extended follow-up period. Most users of IPL devices are
impressed by the versatility and low cost of IPLs. If treating
large areas, IPLs may be advantageous because of their high
skin coverage rate.
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Unauthenticated
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Received October 11, 2011; revised December 6, 2011; accepted
December 9, 2011
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