Intense Pulsed Light

for Photorejuvenation

Sílvia Karina Kaminsky Jedwab and

Caio Roberto Shwafaty de Siqueira

Abstract The Biophysics Behind IPL . . . . . . . . . . . . . . . . . . . . . . . . . 50

Intense pulsed light (IPL) is a non-laser, versa- The Clinical Aspects of IPL on the Daily
tile light technology that is a key tool in derma- Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
tology. It is widely used for the treatment of Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
photoaged skin. Also, it is used for hair removal, References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
acne treatment, and treatment of vascular
lesions. IPL works through selective photo-
thermolysis to reduce dark spots, telangiectasia,
Introduction
wrinkles, and skin laxity (photorejuvenation)
caused by chronic sun exposure. This chapter
The appearance of the skin has been a constant
will discuss all the aspects about the physics
growing reason to visit dermatologist’s clinics not
behind the IPL technology, clinical indications,
only for aesthetics reasons aiming youth but also
treatment, and possible complications.
for medical reasons, such as treat and prevent skin
diseases. Therefore, the number of procedures to
Keywords
improve the quality of the skin with laser and
IPL • Photorejuvenation • Photoage • Dark
non-laser light devices grows each year
spots • Telangiectasia • Wrinkles • Skin laxity
(El-Domyati et al. 2015).
The main goal of this chapter is to discuss all the
Contents issues regarding the use of intense pulsed light
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 (IPL) for photorejuvenation of the skin. This modal-
Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 ity of treatment is popular because it doesn’t cause
The Biology of Photoaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 epidermis disruption, limiting adverse effects and
minimizing downtime (El-Domyati et al. 2015).

S.K.K. Jedwab (*)

Escola Paulista de Medicina, Universidade Federal de São
Basic Concepts
Paulo, São Paulo, Brazil
Skinlaser Brasil, São Paulo, Brazil
The Biology of Photoaging
e-mail: silvia@skinlaser.com.br
The aging process of the skin reflects both extrin-
C.R. Shwafaty de Siqueira
Faculdade de Medicina de Botucatu, Universidade sic and intrinsic factors (Table 1) (Balibas et al.
Estadual Paulista, São Paulo, Brazil 2010; Friedmann et al. 2014).
e-mail: caioshwafaty@me.com

# Springer International Publishing AG 2018 49

M.C.A. Issa, B. Tamura (eds.), Lasers, Lights and Other Technologies, Clinical Approaches and Procedures in
Cosmetic Dermatology 3, https://doi.org/10.1007/978-3-319-16799-2_2
50 S.K.K. Jedwab and C.R. Shwafaty de Siqueira

Table 1 Biologic factors behind skin aging

Intrinsic factors Extrinsic factors
Chronological senescence of dermal fibroblasts Chronic exposure to UV light
Lower production of collagen and hyaluronic acid Pollution
Poor extracellular dermal matrix Tobacco smoke
Production of reactive oxygen species and activator protein-I
Higher expression of metalloproteinases
Higher fragmentation of collagen fibers
Decreased TGF-β1 levels
Chronic inflammatory response
Defects on DNA repair system
UV ultraviolet, TGF transforming growth factor, DNA deoxyribonucleic acid

The intrinsic factors are related to chronolog- of damaged genes. Besides the obvious carcino-
ical senescence of dermal fibroblasts, leading to genic and mutagenic consequences, these events
lower collagen and hyaluronic acid production also change the normal half-life time of epidermal
that leads to poor extracellular dermal matrix cells, leading to excessive (or even abnormal)
(Goldberg 2012; Friedmann et al. 2014). proliferation of melanocytes and keratinocytes at
The extrinsic factors are related to long-term, the basal and Malpighi’s layers, respectively
chronic ultraviolet (UV) light exposure (usually (Bolognia et al. 2008).
by the sun), pollution, and tobacco smoke. All of Clinically, all these events result in laxity, chronic
them enhance the breakdown and fragmentation tanned skin, wrinkles, telangiectasia, rough and sag-
of collagen fibers through the production of reac- ging skin, and melanocytic lesions (like lentigos and
tive oxygen species and activator protein-I, which ephelides), all together named photoaging (Gold
upregulates abnormal expression of matrix meta- and Biron 2013; Sasaya et al. 2011).
lloproteinases, the main reason that destroys col-
lagen fibers (El-Domyati et al. 2015; Friedmann
et al. 2014). The Biophysics Behind IPL
In normal skin, the transforming growth factor-
β (TGF-β) upregulates the collagen production IPL devices are non-lasers, non-ablative sources
(Ali et al. 2013). At the photo-damaged skin, of high-intensity light that use a high-output
TGF-β1 has its levels decreased, causing reduced xenon flash pump light source to produce a poly-
collagen production. This results in poor levels of chromatic, noncoherent, non-collimated diffused
collagen I and III at the dermal matrix (Ali et al. light with broad wavelength (500 nanometers
2013; El-Domyati et al. 2015). (nm) – 1,300 nm). There are simultaneous emis-
Also, it is well-known that the chronic inflam- sions of green, yellow, red, and infrared wave-
matory response to long-term UV light exposure lengths (Mattos et al. 2009; Balibas et al. 2010;
leads to permanent DNA damage. Locally at the Goldberg 2012; Ali et al. 2013; El-Domyati et al.
skin, UV light may trigger DNA photoproducts, 2011; Friedmann et al. 2014).
isomerization of trans- to cis-isoform of urocanic IPL was first approved by the Food and Drug
acid in the stratum corneum, and UV-induced Administration (FDA – USA) in 1998 on the
alteration of the membrane redox potential. All treatment of photoaged skin.
these events lead to UV-induced immune Nowadays, there are more than 300 different
response that causes immunosuppressive effects, IPL devices available on the market. The last
UV mutagenesis, and UV carcinogenesis. The generation of devices is much safer because all
DNA repair pathways no longer are capable of of them have protective features to prevent epi-
detecting and repairing effectively the DNA dermal damage by excessive heat. Most of them
defects, leading to replication and transcription use cooling systems of sapphire or quartz
Intense Pulsed Light for Photorejuvenation 51

Fig. 1 Figure showing

special smaller tips (on the
left) and cut-off filters
(on the right)

interface to promote this safety at the epidermal IPL works at skin sites based on the principle
layer (Goldberg 2012). The light pulse is usually of selective photothermolysis, first described by
single, but they can be double or triple depending Anderson and Parrish with pulsed dye lasers
on the device, with smooth delivery of energy, (Railan and Kilmer 2000). The normal skin con-
with peak flow occurring at the early shot, squared tains substances that act as chromophores (i.e.,
shaped. It is not possible to deliver energy in substances that absorb energy depending on their
nanoseconds as the Q-switched lasers. This sys- intrinsic color, transforming them into heat), such
tem prevents prolonged heating of epidermis, as hemoglobin, carotene, melanin, and water
treating the majority of the chromophores at the (Fig. 2) (Goldberg 2012). Each substance has
same time with one single shot. The pulse dura- their own curve of maximum and minimum
tion time should be equal or below the thermal absorption of light (medium wavelengths of light
relaxation time (TRT) of the target structures to absorption for deoxyhemoglobin are 550–560 nm,
prevent unselected damage to the surrounding for oxyhemoglobin are 540 nm and 575–580 nm,
tissue, but should be at least 50 % of the TRT’s and for vascular lesions and melanin are
targets to generate their cell death (Mattos et al. 400–755 nm) (Friedmann et al. 2014). The photo-
2009; Balibas et al. 2010; Goldberg 2012). The damaged skin contains higher amounts of these
normal skin has an average of 10 milliseconds chromophores, distributed in different forms
(ms) of TRT. Vessels with diameter of 0.1 mm (localized spots or diffuse, multiple-layer manner).
have TRT of 10 ms; larger vessels (0.3 mm) have These substances have the capacity to absorb the
TRT of 100 ms (Goldberg 2012). photons, transforming it into heat, which destroys
The handpiece allows the physician to choose the colored target and dissipates the heat into the
which wavelength will be applied into the patients’ surrounding area, promoting the activation of col-
skin. These cut-off filters block the lower wave- lagen production by the fibroblasts (collagen I and
lengths that are not desired to the treatment, but III) through cytokine activation and upregulation
don’t filter the higher wavelengths. The usual fil- of TGF-β1 (Balibas et al. 2010; Ali et al. 2013).
ters available on the market are 400 nm, 515 nm, IPL light targets all the chromophores at the
540 nm, 550 nm, 560 nm, 570 nm, 590 nm, same time, specially melanin and hemoglobin.
595 nm, 615 nm, 650 nm, 695 nm, and 750 nm The overall immediate end point after the appli-
(Fig. 1). The energy fluency varies from 8 to cation of IPL into the skin is darkening of
100 joules (J), and the pulse time varies from 5 to melanocytic lesions, blurry telangiectasia, and
100 ms, depending on each device. light redness through all skin surface treated.
52 S.K.K. Jedwab and C.R. Shwafaty de Siqueira

(585, 595) (755)

Absorption (810)
(1064)
coefficient
Melanin
water
oxihemoglobin

nm
400 500 600 700 800 900 1000 1100
Wavelength (nm)

Fig. 2 Figure showing the absorption curves of skin chromophores

The goal of treating vascular lesions is to raise

the blood vessel temperature high enough to cause
its coagulation, leading to its destruction and
replacement by fibrous granulation tissue. Oxyhe-
moglobin (red lesions), deoxygenated hemoglobin
(blue lesions), and methemoglobin can be targeted
by IPL (peak absorption of 418 nm, 542 nm, and
577 nm, respectively). Therefore, the best IPL filters
to treat vascular lesions stay between 400 and
600 nm. Some devices allow the adjustment of a
vascular tip into the handpiece, to increase the
delivered energy only at the desired target (Fig. 1).
The goal of treating pigmentary lesions is to
elevate the rapid differentiation of keratinocytes Fig. 3 Patient laid down, with thin layer of transparent gel
induced by thermal heating, using melanin as at the skin face, receiving IPL treatment with IPL 695 nm
filter, sapphire cooling system on
target. This results in an upward transfer of
destroyed and non-destroyed melanosomes
along the necrotic keratinocytes, resulting in the dermal papillae and the interpapillary crests
their elimination as crusts that can be seen on the are more pronounced, showing the higher deposi-
days after the treatment session. Lower cut-off tion of collagen after IPL treatments. The melanin
filters are the usual best choice for treating pigment has a more homogenous distribution at
melanocytic lesions, usually around 400–540 nm the basal layer. The number and diameter of blood
(Goldberg 2012). vessels from the superficial plexus reduced, as
The goal of treating skin laxity and wrinkles is to well, in one-third of treated patients (Fig. 3)
heat dermal water to stimulate dermal fibroblasts, (Scattone et al. 2012; Friedmann et al. 2014).
which increases the synthesis of extracellular matrix
proteins, such as collagen I and III and elastin. The
higher cut-off filters are the best choice to achieve The Clinical Aspects of IPL on the Daily
these goals, usually around 600–1,200 nm (Gold- Practice
berg 2012; El-Domyati et al. 2011).
The histopathology findings that confirm all IPL is a key tool in the treatment of
these changes are seen as an increase in the num- photoaged skin.
ber of fibroblasts associated with an increase in In the first place, the physician should establish
collagen compaction, thickening, and density. the skin color type of the photoaged skin accord-
This also indicates collagen remodeling. Also, ingly to Fitzpatrick’s classification for skin types
Intense Pulsed Light for Photorejuvenation 53

Table 2 Fitzpatrick’s skin color classification

Skin type Skin color Characteristics
I White; very fair, red or blonde hair; blue eyes; freckles Always burns, never tans
II White, fair, red or blond hair; blue, hazel or green eyes Usually burns, tans with difficulty
III Cream white, fair with any eye or hair color (common) Sometimes mild burn, gradually tans
IV Brown; typical Mediterranean Caucasian skin Rarely burns, tans with ease
V Dark brown; mid-eastern skin types Very rarely burns, tans easily
VI Black Never burns, tans very easily

Table 3 Exclusion criteria’s for IPL treatments

the quantity of hemoglobin at the target site,
Pregnancy
reducing overall results (Mattos et al. 2009).
Lactation
The patient and the staff must use eye protec-
Infected skin
tion at all time during application. The skin should
Photosensitizing medications/oral retinoid
be covered with a thin layer of transparent gel
Photosensitivity
Surreal expectancies
(like those used for ultrasound exams), cooled
Scars: keloids, hypertrophic or not.
Suntan Before initiating the treatment, the doctor must
Photo-induced skin disorders tell the patient that the light will be triggered to
reduce patient anxiety (Fig. 5). Usually we start
the application with the chosen parameters at the
(Table 2). The use of IPL on higher skin color border of the area to be treated, specially covered
types (
IV) and on highly photo-damaged skin areas, to prevent any complications on exposed
(too much targets) demands lower fluencies, sites (Balibas et al. 2010). The handpiece should
higher milliseconds, cooling systems on, and mul- be applied perpendicularly to the skin surface,
tiple treatment sessions. gently touching it. After three to four shots, we
Pregnancy, lactation, infected skin, use of should stop the treatment and look into the skin.
photosensitizing medications or oral retinoid, The immediate end point should be slight redness
photosensitivity by any disease, surreal expectan- of the skin, darkening of brown spots, and blurri-
cies, keloids, hypertrophic scars, suntan, and ness of telangiectasias (Fig. 6). Each spot should
photo-induced skin disorders are exclusion overlap the previous one by 10 %. When treating
criteria for treatment (Table 3) (Balibas et al. isolated and resilient lesions, the physician may
2010). use a perforated plastic shield with varying aper-
The number of sessions varies depending on ture sizes (Fig. 7) or small special tips applied into
each patient, i.e., it depends on the skin color type the handpiece (Fig. 1), to deliver higher energy
and the degree of photoaging. Usually four to six only to that target (Balibas et al. 2010). If one sees
sessions are required to achieve the overall urticarias, blistering (Fig. 4), or gray-toned skin,
improvement of the skin (Fig. 4). then the treatment should stop immediately, the
Before the treatment starts at the office, one parameters should be reviewed, and ice or cooling
should lay down the patient into a comfort office substances and topic corticosteroid creams should
chair; clean the skin area to be treated with lotions be immediately applied, because these are signs of
without high concentrations of alcohol, removing excessive heating of the skin, with possible
makeup and sunscreen. Photos should be taken, as burning.
a term of consentient should be signed explaining In the areas that more results are needed, one
the possible outcomes and results from the treat- could apply the shots twice, but the second appli-
ment, as well as possible complications. The use cation should be perpendicular to the first one,
of topic cream with anesthetics is not necessary. In avoiding “zebra marking.” Usually the patients
fact, they can cause vasoconstriction, decreasing feel little discomfort, little heat, and little pain
54 S.K.K. Jedwab and C.R. Shwafaty de Siqueira

Fig. 4 (Left) Histopathology of photoaged skin (A) and compaction of collagen fibers. (Adapted from Scattone
before and (B) after 3 IPL treatments, stained with hema- L, Alchorne MMA, Michalany N, Miot HA, Higashi VS.
toxylin and eosin (HE), x 200. Note that were increase in Histopathologic Changes Induced by Intense Pulsed Light
interpapillary crests. (Right) The same sample as before, in the Treatment of Poikiloderma of Civatte. Dermatologic
stained with Masson´s trichrome, x 200. (A) before treat- Surgery. 2012;38:1010-1016.)
ment and (B) after 3 IPL treatments, showing thickening

during the session. Anything different from that (lower energies, higher pulse time duration) when
should alert the doctor to review the parameters the patient has too much targets at the skin area to
that has been used, because it can mean excessive be treated, to prevent excessive heating of the skin.
heating of the skin. For skin color types  III, we can start the
At the end of treatment, the staff should apply treatment by choosing the 515–540 nm filters,
spray thermal water and soothing creams to 10–20 ms, 10–15 J/cm2. If there is too much
reduce skin redness and discomfort and also targets, one should use 15–20 ms, 8–13 J/cm2
broadband sunscreen creams. (Table 4). With the progression of the treatment,
Overall, the physician should keep in mind that targets at the middle layers will reduce, so the
the targets should be treated in layers, because this physician can elevate the energy delivered and
is actually how the excessive pigments are reduce the pulse duration to target the remaining
displayed on the skin. First, we should reduce lighter chromophores (localized vessels, lighter
darker brown spots and superficial telangiectasia, dark spots) at the superficial layers, using lower
and then we can stimulate collagen at the deeper filters, usually applied specifically at the target.
layers. Most of the complications occur when one Also, the physician can elevate the energy deliv-
tries to destroy all the targets, at all layers, at the ered to the deeper layers, using higher filters and
same time, with the same high energy. Another higher milliseconds to stimulate the overall skin
reminder is that one should reduce the parameters tightening.
Intense Pulsed Light for Photorejuvenation 55

Fig. 5 Immediate end-point after IPL treatment: slightly Fig. 6 Perforated plastic shield with varying aperture
redness skin, darkening of brown spots, blurriness of sizes to isolate specific targets
telangiectasias

Fig. 7 (Left) Pretreatment and (Right) after treatment with IPL Harmony (Alma Lasers – Israel) 540 nm, 12 a 14 J/cm2,
12 ms

For skin color types
IV, we can start treat- durations, and overlapping the application of the
ment using 570–695 nm filters, trying to avoid the light so it doesn’t cause “zebra effect.” Usually it
natural higher concentrations of melanin pre- takes 7–10 days to complete healing of the facial
sented at the basal layer of the epidermis on skin; it may double that time of heal outside the
these color skin types, 20–100 ms, 6–10 J/cm2 facial area.
(Table 4). With the progression of the treatment, The authors use mostly the 540 nm and 695 nm
targets will reduce, so the physician can elevate filters at their routine dermatologic practice,
the energy (but maintaining the long millisec- because these two filters targets both superficial
onds) and deepen the light penetration using and deep chromophores in a global manner.
higher filters. IPL can be associated with other treatments,
The healing process of facial skin differs from with or without devices, at the same session. We
the skin of other areas, because the higher density must advise that the parameters chosen for these
of sebaceous glands at the facial skin provides multiple simultaneous treatments should be more
quicker healing by prompt cell restoration. So, conservative, since we are combining different
application of IPL outside the facial skin demands ways of treating the whole skin at the same time
higher caution, lower fluencies, higher pulse time session.
56 S.K.K. Jedwab and C.R. Shwafaty de Siqueira

Table 4 Initial parameters suggested for IPL treatments

Targets Skin color type  III Skin color type
IV
Little to moderate quantity 515–540 nm 570–695 nm
10–20 ms 20–100 ms
10–15 J/cm2 6–10 J/cm2
Moderate to high quantity 515–540 nm 570–695 nm
15–20 ms 100 ms
8–13 J/cm2 6–8 J/cm2
IPL intense pulsed light, nm nanometers, ms milliseconds, J joule

The authors have experience in combining at After treatment at home, patient must use prod-
the same session IPL with lasers, chemical peel- ucts to minimize excessive inflammation. For all
ings, and laser hair removal. situations, patient should use broadband sun-
Laser Alexandrite 755 nm may be used when screen, cleansing gel to wash the treated skin,
dark spots are resilient to IPL or to epilate few spray thermal water for burning relief, topical
facial hairs before any other laser is applied, for low-potency corticosteroid cream if the patient
angiomas or for larger telangiectasias. presents with higher burning sensation or itching
Laser Ruby 694 nm Q-switched (QS) and sensation, and herpes simplex prophylaxis if there
Laser KTP (potassium titanyl phosphate) is personal history of this disease (Balibas et al.
532 nm QS may be used to treat lighter brown 2010). If the patient was treated only with IPL
spots resilient to IPL and Laser Alexandrite. and/or non-ablative lasers, one should use simple
Laser Nd:YAG (neodymium-doped yttrium creams or gel creams, usually containing alpha-
aluminum garnet) 1,064 nm long-pulsed may be bisabolol, vitamin C, and essential oils (grape
used for telangiectasias larger than 0.1 mm and for seeds, sunflower seeds). If the patient was treated
epilation of facial hair in dark-skinned patients. with IPL associated with ablative lasers, one
Laser Nd:YAG QS device may be used for skin should use creams or ointments containing
tightening, to treat lighter freckles and dark spots healing substances, as well antimicrobials agents
and reduction of skin sebaceous pores. (copper, zinc, triclosan, vaseline).
Laser fractionated ablative (CO2 10,600 nm During the 7–15 days after the session, the
and erbium 2,940 nm) may be used for skin tight- treated skins will peel off gently. The dark spots
ening, wrinkle reduction, comedone reduction, will become darker with little crusts, and the
and rough-aged skin improvement. vanished telangiectasias may reappear blurred or
Also, IPL can be associated with all types of bluish. After the minimum period of 7 days after
chemical peelings, such as retinoid acid, glycolic initial treatment, the patient can be submitted to
acid, Jessner Solution (combination of resorcinol, other healing/tightening procedures, like radio-
salicylic acid, and lactic acid), salicylic acid, tri- frequency and micro-focused ultrasound.
chloroacetic acid (TCA), phenol acid, mandelic Possible side effects are (Table 5) blistering,
acid, and so on. One must point out that the purpura, excessive crusting, persistent erythema,
association between IPL and chemical peelings dyschromias, irritating contact dermatitis, atro-
should not occur when the end point has already phy, scarring, hypertrophy scarring, keloid forma-
been achieved by the IPL itself and/or the patient tion, and infection (bacterial and/or viral) (Balibas
refers that the skin is burning too much after IPL et al. 2010; Friedmann et al. 2014). All of these
treatment. Therefore, we prevent complications can be prevented through correct indication and
that may arise from overtreatment of the skin. individualization of parameters and respect to the
Applications with botulinum toxin and skin color type of the patient. We can divide these
hyaluronic acid fillers may be associated with complications in two groups: immediate compli-
IPL sessions, usually right after this ends. cations and late complications.
Intense Pulsed Light for Photorejuvenation 57

Table 5 Possible side effects of IPL treatment

Blister
Purpura
Excessive crusting
Persistent erythema
Dyschromias
Irritating contact dermatitis
Scars: atrophic, hypertrophic, keloid
Infections

Immediate complications are those related to

excessive energy delivered into the skin. Possible
causes are the following wrong parameters: exces-
Fig. 8 Acute immediate complication of IPL treatment:
sive joules delivered or little time for thermal blister and urticaria over a hemangioma lesion at the face of
relaxation, skin tanned or too many targets at the a male patient
skin location, and misclassification of the true skin
color type of the patient. show persistent erythema. This may sign out that
The patient may present with acute burning excessive inflammation is taking on, which may
pain, urticarias, purpura, gray skin, and blisters trigger the formation of the mentioned scars. To
right after the treatment (Fig. 4). prevent them, besides treating the immediate
When these occur, the physician must imme- complications, the physician should apply at the
diately stop the procedure, apply cooling sub- persistent erythematous area IPL as photody-
stances, and apply high-potency corticosteroid namic therapy every week (very low fluency
cream into the skin site. Low-intensity laser between 6 and 10 J, filters 540–695 nm, 100 ms
(LIL) can be applied into the burned areas, in a of time pulse), LIL on daily basis, and anti-
daily basis, until total healing, because this modal- inflammatory creams (medium-potency cortico-
ity of treatment blocks excessive inflammation. steroid creams, rose hip oil, silicone oil). If keloid
Patient should maintain use of medium- to high- scars or hypertrophic scars occur even after the
potency corticosteroid creams at home, twice a preventive treatment, the physician may treat the
day, until total healing (usually 7–10 days), and scars with local infiltration with injectable corti-
avoid sun by physical blocking and the use of costeroids or bleomycin, once a month until total
broadband sunscreens. regression. For cases of keloid scars resistant to
Late complications are scars (atrophy, keloids, infiltration therapy, surgical options may be indi-
hypertrophic scars), infections, allergy and cated, like shaving of the lesion associated with
dyschromias, and both postinflammatory hyper- beta therapy. If atrophic scars occur, the physician
cromia (PIHE) and hypochromia (PIHO). These may treat them with fractional ablative lasers and
usually are transient complications, resolving chemical peelings (like chemical reconstruction
spontaneously within 2–3 months after it started. of skin scars [CROSS] chemical peeling), in mul-
The scars (Fig. 8) usually occur after episodes tiple sessions, once a month (Fig. 9).
with burned skin, especially after blistering. Over- Infections are rare complications, but they can
all, the scars may become white and atrophic. be devastating since they may arise suddenly
Depending on the personal background of the without warnings. The most common one is acti-
patient, keloids and hypertrophic scars can vation of herpes simplex virus, which may lead to
develop on specific locations (the jaw line, ear- local or widespread infection at the treated area
lobe, chest, back, neck, upper arms, and abdo- (simulating Kaposi varicelliform eruption seen on
men). Just after the healing process has ended atopic skin). Bacterial infections are rare, taking
after the immediate complications, the skin may place most often around contaminated skin sites
58 S.K.K. Jedwab and C.R. Shwafaty de Siqueira

Fig. 9 Flowchart on how

to proceed on scars after Scars
IPL treatments

Atrophic Hypertrophic /
Persistent Erythema
Keloid

- Fractional - Infiltration - IPL as FDT

ablative Lasers
- Shaving - LIL
-Chemical
Peelings - Betatherapy - Topic
treatment

(perioral, paranasal, perineum, hands, feet, axil- can be treated with superficial chemical peelings
lae, skin site with bacterial folliculitis, or any other (like retinoid acid and Jessner Solution), asso-
bacterial skin infection), usually by Gram- ciated or not with Laser Nd:YAG QS 1,064 nm.
positive bacteria (Streptococcus sp., Staphylococ- At home, patients should use Kligman’s formula
cus sp.). Risk factors for them are high-energy ðretinoid acid 0, 05% þhydroquinone 4% þ
ablative fractionated lasers, high-energy IPL, acetonide fluorcinolona 0:05 % creamÞ or simi-
burning complications, medium-potency chemi- lar formulas. Persistent PIHE will heal within
cal peelings (Jessner Solution associated with 3–12 months after the complication.
TCA), and large areas treated at the same time. When persistent PIHO occurs, the physician
The most important measure to prevent them is to must examine the site through Wood’s lamp
anticipate them, by prescribing herpes simplex (WL). If the area is highlighted by the WL, it
prophylaxis for the patients with this background indicates that the hypochromia may be really per-
when they are submitted to the treatments above sistent; so it should be treated with phototherapy
listed (to be initiated 1 day before the treatment), narrowband UVB, weekly, until total healing.
as well as prescribe topical and/or oral antibiotics If the area is not highlighted by the WL, it
or antimicrobial topic creams to use after the indicates that it is transient, so the physician may
procedure, until total healing of the treated skin observe the natural healing or try to make the
site. We don’t recommend treating any skin site surrounding skin lighter with IPL and/or chemical
with IPL with evident infection of any kind. peelings.
Allergies are rare, it may occur when epidermal For all cases of PIHO, patients should also
disruption is seen, leading to possible higher avoid direct sun exposure, use broadband sun-
absorption of allergens and/or of irritating sub- screens, and use Kligman’s formula at home.
stances. In all cases, the physician should not use PIHO usually will heal within 3–15 months.
known allergenic substances referred by the IPL treatment sessions can be repeated at
patient; after the treatment, the use of creams for 30–45 days intervals. Normally, patients require
better healing of the skin minimizes the risks of three to six sessions to achieve global improve-
allergic contact dermatitis and/or irritating contact ment, but this must be pointed out that it depends
dermatitis. If it happens, the patient should apply on individual characteristics. Overall, treatment
to the skin low- to moderate-potency corticoste- results in better clinical appearance in skin tex-
roid creams, twice a day, for 7–10 days. ture, reduction in mottled appearance, and clear-
Dyschromias are the most common late compli- ance of pigmented and vascular lesions (Scattone
cation seen after IPL treatments. Persistent PIHE et al. 2012; Gold and Biron 2013).
Intense Pulsed Light for Photorejuvenation 59

Take Home Messages Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. 2nd
ed. London: Mosby; 2008. p. 1321–31.
El-Domyati M, El-Ammawi TS, Moawad O, Medhat W,
– IPL is a key treatment for patients with Mahoney MG, Uitto J. Intense pulsed light photo-
photoaged skin. rejuvenation: a histological and immunohistochemical
– IPL devices are versatile, but one should always evaluation. J Drugs Dermatol. 2011;10(11):1246–52.
keep in mind that the individualization of treat- El-Domyati M, El-Ammawi TS, Moawad O, Medhat W,
Mahoney MG, Uitto J. Expression of transforming
ment should be the leading role to success on growth factor-β after different non-invasive facial
achieving the goals of youth and healthy skin. rejuvenation modalities. Int J Dermatol. 2015;
– Defining the true patient’s skin color type is the 54:396–404.
main measure to avoid complications and to Friedmann DP, Fabi SG, Goldman MP. Combination of
intense pulsed light, sculptra, and ultherapy for treat-
achieve the main goals of the treatment. ment of the aging face. J Cosmet Dermatol.
– As with lasers, IPL works through selective 2014;13:109–18.
photothermolysis, in which the skin chromo- Gold MH, Biron JA. Safety and cosmetic effects of photo-
phores absorb photons from the IPL light, dynamic therapy using hexyl aminolevulinate and
intense pulsed light: a pilot study conducted in subjects
causing heat damage. with mild-to-moderate facial photodamage. J Clin
– The treatment support after sessions should be Aesthet Dermatol. 2013;6(10):27–31.
emphasized, because this measure helps the Goldberg DJ. Current trends in intense pulsed light. J Clin
quick healing of the skin, reducing the chances Aesthet Dermatol. 2012;5(6):45–53.
Mattos R, Filippo A, Torezan L, Campos V. Non-laser
of all complications. energy sources on rejuvenescence: part II. Surg Cosmet
Dermatol. 2009;1(2):80–6.
Railan D, Kilmer S. Treatment of benign pigmented cuta-
neous lesions. Goldman’s cutaneousand cosmetic laser
References surgery. Elsevier; 2000. p. 93–108.
Sasaya H, Kawada A, Wada T, Hirao A, Oiso N. Clinical
Ali MM, Porter RM, Gonzalez ML. Intense pulsed light effectiveness of intense pulsed light therapy for
enhances transforming growth factor beta1/Smad3 sig- solar lentigines of the hands. Dermatol Ther.
naling in acne-prone skin. J Cosmet Dermatol. 2011;24:584–6.
2013;12:195–203. Scattone L, Alchorne MMA, Michalany N, Miot HA,
Balibas P, Schreml S, Szeimies RM, Landthaler M. Intense Higashi VS. Histopathologic changes induced by
pulsed light (IPL): a review. Lasers Surg Med. intense pulsed light in the treatment of poikiloderma
2010;42:93–104. of civatte. Dermatol Surg. 2012;38:1010–6.