Laser Therapy: Intense Pulsed Light

Intense Pulsed Light (IPL)

As opposed to a laser, which emits a beam of light of a specific wavelength, IPL emits a high intensity light that contains multiple wavelengths, more like the daylight. This allows for greater variability in selecting treatment settings and adapting to different skin types and indications.

The wavelength of light determines how deep the light beam will penetrate and what targets it will be absorbed by. Filters are placed on the primary beam to limit the light wavelengths delivered to target more specific structures with in the skin, like hair follicles or blood vessels. The plate the laser fires through, comes in contact with the skin. It is cooled to keep the outside layer of the skin from being damaged by laser energy as it penetrates to damage deeper targets in the skin like unwanted hair follicles or blood vessels.

IPL is used for abnormal blood vessel collections in the skin like hemangiomas, rosacea, spider telangiectasias, abnormal or unwanted veins, Poikiloderma of Civatte, and port wine stains. It can treat pigmented lesions like brown spots, unwanted hair, wrinkles, acne and scars. It can be used for photorejuvenation to reverse the signs of aging and sun damage. IPL destroys pigmented lesions, telangiectasias, and uneven skin tone. It stimulates collagen formation to tighten loose skin, reduces fine wrinkles, and tightens pores to improve skin texture. This method involves a series of 5 or more treatments 2 weeks apart. There is minimal discomfort. Results vary from subtle to impressive with a minimum of downtime or maintenance. Treatments are done every 3-12 months.

Benign pigmented lesions

These include actinic lentigo, senile lentigo, age spot, lover spots, or sunspot. Other lesions include actinic keratosis, ephilides and nevi. Safety, test patches are done and response evaluated before entire treatment is delivered. Treating over tattoos and permanent makeup is avoided. No active tanning during IPL treatments is advised. Sun block should be used during IPL course of treatment

PROFILE™ BBL™ PULSED LIGHT MODULE:
NON-ABLATIVE PIGMENTED LESION/SKIN TREATMENT

Introduction
Pigmented lesions can be treated with the selective absorption of light in melanin. This process was described as early as 1968 using ruby (694 nm) and Nd:YAG (1064 nm) lasers (Solomon et al., J Inv Derm, 1968, 50:141-146). The absorption converts light into heat energy, which raises the temperature of the target. With appropriate selection of fluence and pulse width the temperature will be high enough to alter and damage the target resulting in its elimination.
Pigmented lesions are treated by selective destruction of melanin or melanocytes with short high intensity light pulses.
The theory of Selective Photothermolysis explains how wavelength, energy, pulse width and thermal relaxation time all play a part in the destruction of a target and the preservation of surrounding tissue. Because of the large surface area-to-volume ratio, melanin and microvessels rapidly lose absorbed energy (heat) into the surrounding tissue. The thermal relaxation time of very small vessels is less than 1 millisecond, while that of larger vessels and hair can be 20 -100 milliseconds (ms) depending on size, and the thermal relaxation time of the epidermis is 3 -10 ms.
The PROFILE BBL can deliver enough energy or fluence to effectively target melanin and surface vessels, and has variable pulse widths for treating a range of target sizes. When the BBL is used to treat pigmented lesions there is heat build-up in tissue from the absorption of light energy in melanin and surrounding melanocytes. The heat dissipates into surrounding tissue. Absorption of the BBL light in melanin can be substantial, and a longer pulse width and lower fluence are recommended for darker skin.

Surface Cooling
Although absorption of the BBL light in melanin may be desirable, some epidermal cooling may be beneficial to protect the skin. The amount of cooling required will vary with the depth of the lesion. Lighter skin types require less cooling and darker skin types require more cooling for deep lesions. The BBL contact cooling plate insures that the epidermis is adequately protected from overheating regardless of skin type. When the BBL is used to treat pigmented lesions in dark skin, there is heat build-up in tissue from the absorption of light energy in normal melanin. Surface cooling can do little to differentiate between normal melanin and the lesion if they are at the same depth in
skin, however lengthening the pulse width can provide some selectivity,

Pulse Width
Pigmented lesions are darker than normal melanin in skin. The melanin in the lesion occurs at a higher density giving the lesion a darker appearance. The principal of selective photothermolysis can be used to preferentially treat the darker lesions. Since the epidermis normally has a thermal relaxation time of 3-10 milliseconds, using pulse widths of 20 ms or longer can avoid damage to normal melanin during treatment.

Fluence
The amount of energy per unit area applied to skin during the treatment pulse is the fluence. The heat build up in skin is directly proportional to the fluence. Darker targets absorb more energy and will reach higher temperatures. Therefore darker lesions require less fluence than lighter colored lesions to reach the same therapeutic level. An important consideration is skin type since pigmented lesions in light skinned individuals can be lighter than normal skin color in dark skinned individuals.

Classification of Skin Types
The following table offers a broad guidance to identifying skin types based on hair, skin and eye color as well as sun reaction.
Fitzpatrick Scale
Type Hair Color Skin Color Eye Color Sun Reaction
I Red Light Blue-green Burn, never tan
II Blonde Light Blue Burn, may tan
III Brown Medium Brown Burn, then tan
IV Brown-black Moderate brown Brown-black Tan
V Black Dark brown Dark Tan
VI Black Black (African) Dark Tan

Consultation / Treatment
The consultation or initial visit allows an exchange of views between case provider and
patient in an attempt to reach a decision regarding treatment. The patient must understand
the procedure, pre and post care instructions, and expectations before the procedure is
performed.
Patient Education (Expectations)
The BBL is used to reduce flushing, telangiectasia, redness, dyspigmentation, and improve skin tone. Patients must understand that results vary with each individual. Multiple treatments may be necessary over a time span (2-4 week intervals) to reduce pigmented lesions in most areas. Results should be evaluated several weeks post treatment. The BBL light pulse is often described as a wave of heat with the sensation of a pinprick. A topical anesthetic may be necessary.

Patient Documentation Forms
• Consent: the process of accepting and confirming treatment must be reviewed,
understood and signed by the patient prior to treatment. This document must review
the topics discussed during consultation. It acknowledges that the patient understands
the procedure and that all questions have been answered.
• Review post care instructions and confirm that the patient will adhere to such
instructions throughout the course of their treatment.
• Post-treatment appointments are scheduled for: treatment assessment, patient
evaluation and routine therapy.
Photographs
Before and after photographs should be taken throughout the course of the treatment to
monitor patient response to therapy. Photographs should be taken prior to treatment,
immediately after treatment and during follow-up visits. Camera settings should be the same to maintain photographs of similar quality. Photographs are useful in demonstrating efficacy of treatment to the patient.
Pre Treatment Procedure
• For better results, patients should avoid sun exposure, tanning beds and tanning creams
for 2-3 weeks prior to treatment and throughout the course of their BBL treatment. Sunless tanning lotions must also be avoided for 2-3 weeks prior to treatment. However, if sun exposure is not avoidable treatment sessions need to be increased since treatments on sun-exposed skin will require lower fluence settings to protect the epidermis.
• Instruct the patient that recent sun exposure may result in cancellation of the treatment.
Post Testing Evaluation
• If a test area was done than an evaluation of the tested area usually occurs 1-2 weeks
post treatment.
• Verify that any hypo/hyperpigmentation has been transient (to date). If the patient is
concerned about the pigmentary changes, further treatments may be delayed. Once
the area returns to normal skin tone, treatments may be resumed.
• Further testing may be indicated depending on the results seen from the first tested
area(s).
Determination of Clinical Endpoint
Caution: Treating with excess energy levels can result in adverse effects
such as abnormal pigmentation, blistering and scarring.
• Darkening of the pigmented lesion and mild erythema should be noted in the skin. If
the treatment area has even the slightest tan, the erythema response may be greater.
If blistering occurs, treatment should be stopped immediately. Treatment can resume
when the tan has faded.
Treatment Procedures
• The highest energy density determined through test spots should be utilized. An
increase in fluence should be tolerated after 2-3 consecutive treatments.
• Double treatment of the same area is not recommended and can increase the chances
of post treatment complications.
• Treatments are scheduled at 2 to 4 week intervals for most areas, 6 to 8 weeks for hair
removal.
Sun Protection
• A broad spectrum (UVA/UVB) sun block with an SPF of 30 must be applied 15
minutes prior to casual sun exposure.
• Prolonged sun exposure requires repeated applications of sun block every 2 hours
(e.g. yard work, beach activities, etc.).
• Sun block must be reapplied after swimming.
• Sun exposure to the treatment area should be avoided at least 2-3 weeks prior to
treatment.
Adverse Effects
Complications, though rare, can occur and should be discussed and understood. The patient
must understand the importance of the post-care instructions, and that failure to comply may
increase the probability of complications.
• Scarring, though rare can occur following any intense light procedure.
• Histamine/Hives: some patients develop raised papules similar to hives. This irritation
usually subsides in a few hours.
• Pigmentary changes: hyperpigmentation or hypopigmentation may occur. There is a
higher risk in darker skin types.
Post Treatment Skin Care
Patients should receive post skin care instruction following each laser treatment.
Application of an ointment or aloe vera:
I. Ointment may be applied to the area to prevent drying. Ointment applied
following the laser treatment can have a soothing effect.
II. An antibiotic ointment should be utilized if there is any blistering or break
in the skin, and the patient should be instructed to contact the office.

PROFILE™ BBL™ PULSED LIGHT MODULE:
NON-ABLATIVE PIGMENTED LESION/SKIN TREATMENT
SAFE START PROTOCOL
The following protocol is a safe start guide based upon the clinical observations of
experienced physicians.
IMPORTANT: Treating with too high of a fluence or overlapping pulses may lead to undesirable outcomes, including blisters, depressions and transient
hyperpigmentation, all due to overheating of tissue.

1. PRE-TREATMENT CONSIDERATIONS
1.1. CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment
area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use
special care around the eyes.
1.2. PATIENT EXAMINATION
Shave the area to be treated. Lesion type, size , and color; veins and telangiectasias;
wrinkles; and skin tone should be classified prior to treatment according to size and
depth. A pre-treatment photo will help to assist in evaluating the effectiveness of the
treatment.
1.3. ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or
sensitive areas prior to treatment. Remove before treatment with mild soap and
water or an alcohol swab, then plain water. Dry the area thoroughly before treatment.
1.4. EYEBROWS AND BEARDED AREAS
Use caution when treating over beards – fluence should be lowered, and there is a
small possibility of alopecia. A small test area is recommended.
Eyebrows should be protected as there is a small possibility of alopecia.
1.5. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the treatment
room during the treatment.
1.6. TREATMENT OF AREAS WITH ARTIFICAL MAKE-UP, TATTOOS AND
DARKENED MOLES.
Areas tattooed with designs or artificial make-up should be avoided. Not only do they
create an additional and unwanted target for deposition of heat, but those targets with
red or frosty white appearance commonly have iron or titanium in their composition.
The red or white pigment will often oxidize and turn black from exposure to high
intensity light. If you must treat those areas, a test spot with close monitoring for one
to four days is recommended.

2. SETTING TREATMENT PARAMETERS
2.1 FLUENCE
Starting fluence will be will depend on the condition and the skin type. The
parameters in Table 1 are safe start parameters. Patient response can vary, so
fluence setting should begin low and be increased gradually after assessing the
individual patient response. The desired response is spontaneous erythema at the
sight of the lesion. Fluence and pulse widths may change for a patient during the
series of treatments. Be sure to properly evaluate the treatment parameters before
each treatment based on previous successes, or complications, and the response
of the patient to questions about the first 24 hours after the previous treatment.
Those who respond with no irritation, and without prolonged erythema for the first
24 hours after treatment are within a safe, and possibly low, fluence range.
Note: Increase fluence in 1-J/cm2 increments.
Excessive fluence or pulse stacking can lead to dermal injury or blisters.
2.2 COOLING
Cooling is recommended for patient comfort and for protecting the surface of dark
skin with deeper lesions. Treating with lower COOLING temperatures will require
treating with higher FLUENCE settings. The inverse also applies. Most treatment
can be performed at the 25°C setting. A thin coating of colorless gel, KY, or
surgilube should be used in conjunction with the system for better heat removal,
improved optical coupling, and lubrication for sliding the plate over skin.
Note: Treating with cooler temperatures requires good contact with the skin
surface. Changing cooling temperature by as little as 4°C will influence
immediate clinical results.
2.3 PULSE WIDTH
Select the starting pulse width from the table. It may be necessary to change the
pulse width and fluence to achieve the desired amount of erythema. Shorter pulse
width and higher fluence settings are more aggressive. Longer pulse width and
lower fluence settings are less aggressive.
2.4 FILTER SELECTION
The 515-nm filter is used for treating pigmented lesions. If a 420-nm filter is
available it can be used to treat superficial pigmented lesions in light skin at lower
fluence levels.

3. TECHNIQUE
3.1. PATIENT POSITION
Position is based on the area to be treated. Patient should be in a comfortable
position. The treatment area should be presented to the BBL user at a convenient
height and position.
3.2. TEST AREA
Treating a test area before a patient’s first treatment can establish their response
threshold and help establish safe starting parameters. The test area should be
monitored for response for a period of five to ten minutes. Blistering or the
immediate grey or white presentation of the skin is the immediate concern.
TEST AREA should reach the desired response of lesion darkening and mild
overall erythema within a few minutes. Increase fluence in small increments until
the desired response is achieved.
CAUTION: Use only enough fluence to achieve the desired endpoint of lesion
darkening and mild erythema. Keep fluence conservative for the first treatment
session, and monitor the patient for any evidence of prolonged erythema,
swelling, urticaria or blistering.
3.3. HANDPIECE POSITION
Position the patient so the BBL can be held perpendicular to the skin surface. Move
the patient if necessary so that the treatment area is easy to reach.
Position the BBL so the cooling plate is in full contact with the skin. For highly
curved regions, use the edge of the cooling plate while pushing the skin upward
with your other hand to insure proper cooling.
The BBL must remain in contact with skin long enough before and after the light
pulse to cool the surface of the skin and reduce the heat sensation. It will take
several seconds for the deeper heat to propagate to the surface after the light
pulse. A coating of colorless gel, KY, or surgilube should be used in conjunction
with the system for better heat removal, improved optical coupling, and lubrication
for sliding the plate over skin.
3.4. TREATMENT METHOD
Match the “trailing edge” of the next treatment area to the “leading edge” of the
previous treatment. The BBL will give a uniform treatment with uniform fluence
within the treatment area.
Make certain to maintain complete skin contact with the treatment area before,
during and after the treatment pulse. A coating of colorless gel, KY, or surgilube
should be used in conjunction with the system for better heat removal, improved
optical coupling, and lubrication for sliding the plate over skin.
Do not overlap or immediately repeat BBL pulses.
For small isolated pigmented lesions a mask can be used to protect surrounding
skin. Use a white card and cut out an area corresponding to the size of the lesion.
Place the card over the lesion exposing such that only it is exposed to direct light
from the BBL. Higher fluences can be used since the surrounding skin is shielded
from intense light.

4. TREATMENT GOALS
The immediate goal is lesion darkening and light erythema a few minutes after
treatment. Patients will typically report feeling tighter skin or the sensation of mild
sunburn following treatment.

5. POST-TREATMENT CONSIDERATIONS
5.1. OBSERVATIONS
Erythema or a mild sunburn sensation should be noticed in the treatment area for up
to two hours after treatment. Patients should not feel any significant discomfort after
treatment.
5.2. INTERVENTION
While not often used, cold compresses can provide some comfort after treatment. If
blistering occurs, aggressive wound treatment should be administered, i.e. Vigilon,
Second Skin, silastic sheeting or other intervention.
5.3. INTERVAL
Recommended time interval between treatments is 2-4 weeks. 3 to 5 treatments may
be necessary.
6. CONCURRENT PROCEDURES
COMBINATIONS –treatments may be given in combination with other minimally invasive therapies. If a patient is to receive another treatment (Botox, collagen injection) in conjunction with the PROFILE, it is advisable to perform the PROFILE treatment first. There may be increased sensitivity in the treated areas for an hour or two.
7. CONCLUSIONS
Do not be overly aggressive. Begin conservatively and be patient. Results are determined
by the physiology of the patient’s skin. Patients will usually notice a change in their darker pigmented lesions after the second treatment It will take longer for lighter pigmentation to resolve.