Current trends in aesthetic treatment of facial skin call for an effective adjunct to laser skin resurfacing. Patients seek treatment that offers a return to a more youthful appearance through restoration of even color and smoothness, relief from pigmentary sun damage, and the redness and flushing associated with rosacea. In addition, this patient group requires treatments that are short and pain-free, and allow immediate return to all activities.
Following more than 20 years of treatment of vascular lesions using the pulsed dye laser, a new laser-like intense pulsed light (IPL) device was developed that treats these conditions with success and answers the essential lifestyle criteria when used in a carefully administered program. This new IPL skin rejuvenation technique called PhotoFacial™ now has a clinical history of more than 3,000 treatments with excellent patient acceptance.
Use of Intense Pulsed Light
IPL differs from laser light in that, rather than monochromatic single wavelength, IPL emits a non coherent, broad spectrum light. The MultiLight™ or EpiLight device used in the PhotoFacialSM procedure emits a spectrum extending from 500nm to 1200nm. To customize the light energy delivery for a given procedure, the operator employs a cutoff filter, or light guide, of designated wavelength, below which the spectrum is selectively eliminated.
The IPL system, as used in the PhotoFacialSM procedure, conforms to the principle of selective photothermolysis. For dilated vessels, as seen in patients with sun damage and rosacea, the light energy with high absorption by hemoglobin and oxyhemaglobin reaches the dermal capillary bed and selectively destroys the abnormal vessels.
The operator controls all aspects of the light pulse, including cutoff wavelength (nm), energy level (Joules/cm2), pulse duration (milliseconds), pulse pattern (single, double, or triple), and delay time between pulses (milliseconds). This allows for precise control of light energy, which in this procedure is utilized for customization for skin type, procedure progress, and other variables. All controls are computer driven, and the system houses a patient database that automatically records the parameters of the treatment and treatment history for each patient.
Facial Telangiectasia and Rosacea
The IPL system was developed specifically for the treatment of benign vascular lesions, such as facial telangiectasia. In initial studies, not only did IPL perform this successfully and without the unsightly purpura associated with the pulsed dye laser, it had the added benefit of reducing the redness associated with these conditions. It was soon recognized that this technology could be effective in relieving the redness and flushing of the face and chest associated with rosacea.
As reported by the Rosacea Society, rosacea sufferers number more than 13 million in the U.S. alone. This is a chromic skin disorder affecting the face, characterized by redness and telangiectasias, and is punctuated by episodes of inflammation with papules, pustules, and swelling. The underlying causes of rosacea have not been elucidated yet. It is most likely multifactor (e.g. , abnormality of facial blood vessels, nerves, connective tissue, locally released vasoactive factors, and complex interactions between each system). There are four basic stages through which rosacea sufferers may progress: pre-rosacea, mild, moderate, and severe forms. Pre rosacea refers to the stage where a person flushes or blushes to a stimulus, but returns immediately to normal when the stimulus is removed. The progression of pre-rosacea to bouts of flushing and blushing that do not dissipate for hours or days is now considered to be directly related to micro vascular dysfunction or damage. In support of this, Neumann and Frithz recently reported that biopsies of vascular lesions from rosacea patients demonstrated moderate to severe damage of endothelial and smooth muscle cells. In addition, these same biopsies showed evidence of abnormal fusion of capillaries and angiogenesis. Taken together, rosacea-related alterations in endothelial cells, vascular smooth muscle, formation of new inflammatory shunt vessels, and angiogenesis could explain why the rosacea-related red face, flushing, and blushing worsens over time. In effect, it is plausible that alterations in micro vascular structure and function allow for more intense bouts of blood flow and inflammation, resulting in even more micro vascular damage — a vicious and progressive cycle. Therefore, therapy should be centered around the removal of damaged and dysfunctional micro vessels such that new thicker walled micro vessels with normal plump endothelial cells are laid down. Previous treatment of the acute inflammatory episodes have consisted of avoidance of heat, cold, sunlight, alcohol, and stress. Physicians have used tetracycline’s, dapsone, erythromycin, chloramphenicol, metridonazole, clonidine and Accutane with limited success. Topical treatments with antibiotics, sulfa preparations, and topical steroids have also been used. Indeed, steroid use ultimately compounds the problem by causing more reddening, flaring, and atrophy. None of these treatments remove the abnormal vessels. Electrocautery treats only those larger visible vessels, and not without pain, bleeding, and frustration of both practitioner and patient.
It is extremely rare for an IPL patient to experience purpura. Following treatment, the patient may have mild redness and swelling overnight, but daily activities are not affected, and many patients can return to work within a few hours.
Skin Texture Abnormalities and Other Uses
IPL has demonstrated an improvement in fine lines and wrinkles, as well as reduction in pore size, possibly due to new collagen deposition in the dermis. This technique is not effective for treatment of deeper wrinkles and sagging skin treated with laser resurfacing and traditional surgical techniques. IPL has also been used effectively to treat psoriasis of the face, to reduce erythematic following laser skin resurfacing, and to treat acne scarring.
The Photofacial Technique
The PhotoFacial technique is a proprietary treatment protocol developed by Dr. Patrick Bitter, SR. It consists of a series of IPL treatments, usually five treatments over a period of 4 months. After a thorough consultation and discussion of risks and benefits, a full patient history and three high-quality facial photographs are taken. The IPL is performed on the full face after administration of topical analgesia. The parameters are set as follows:
a.Fitzpatrick skin type is entered.
b.Selected cutoff filter/ light guide is installed.
c.Energy level is entered. The variable depends on the skin type, progress, and other factors. It may be as low as 30J/cm2 to as high as 56 J/cm2. This is a key area for advanced training and patient experience. Excessive energy will burn the epidermis.
d. Pulse duration is entered.
e. Pulse pattern and pulse delay are entered. Higher energy levels are typically delivered in doule and triple pulses, allowing an interval for thermal realization of the vascular strictures.
f.The treatment is accomplished using a chilled gel to couple the rectangular light guide surface to the skin. A single pass is performed over the whole face with minimal overlap. It is important to note on occasion Dr. Bitter may do multiple passes on certain patients–this should not be attempted unless instructed by him.
Patient Satisfaction for Rosacea Sufferers
Fifty-seven patients with rosacea were chosen randomly and evaluated to determine the overall success with the PhotoFacial protocol. Patient satisfaction was high, as evidenced by improved scores for erythematic, flushing, eradication of telagiectasic vessels, uneven pigmentation, and skin texture. The reduction of fine lines and acne rosacea flares were not as dramatic.
Adverse Reactions and Evaluation of Results
The PhotoFacial technique has been remarkably free of adverse reactions. Practitioners are cautioned, however that pitfalls in treatment do exist.
The most difficult patients to treat are those with Fitzpatrick skin type I who have a long history of sun exposure. In these patients, connective tissue is so fragile that IPL parameters selected for optimal relief of redness may damage the skin, with higher incidence of purpura, swelling, and blistering. In such cases, sub optimal parameters must be used early in treatment until the connective tissue supporting the dermal architecture is strengthened and the target tissue is reduced in size. The standard five treatment program is usually extended in this patient group.