Use of Intense Pulsed Light Sources in Dermatology: Update 2012 Der Einsatz Der IPL-Technologie in Der Dermatologie: Update 2012

Review

Use of intense pulsed light sources in dermatology: Update 2012 Der Einsatz der IPL-Technologie in der Dermatologie: Update 2012

Philipp Babilas 1. Introduction Department of Dermatology , University Hospital 1.1. Technical aspects Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg , Germany, After the introduction of polychromatic infrared light in 1976 e-mail: [email protected] by M ü hlbauer et al. [1] , Goldman and Eckhouse [2] described in 1996 a new high-intensity fl ash lamp as a suitable tool for Abstract treating vascular lesions. The basic principle was a rather selective photothermolysis of pigmented structures, cells, Intense pulsed light sources (IPLs) consist of fl ash lamps with and organelles by selective absorption of pulsed radiation as bandpass fi lters and emit incoherent polychromatic pulsed described in 1983 [3] . With the aid of fl ash lamps and com- light of a high intensity and determined wavelength spectrum, puter-controlled capacitor banks, intense pulsed light sources fl uence, and pulse duration. The combination of prescribed (IPLs), generate pulsed polychromatic high-intensity light. wavelengths, fl uencies, pulse durations, and pulse intervals The emission spectrum of IPLs ranges from 500 to 1300 nm. facilitates the treatment of a wide spectrum of skin condi- Convertible cut-off fi lters adapt the polychromatic emission tions. Hereby, IPLs follow the basic principle of a more or spectrum to the desired wavelength to allow versatility. In the less selective thermal damage of the target. This review dis- new generation of IPLs, water fi lters suppress the infrared cusses the current literature on IPLs with regard to the treat- light, thereby reducing the risk of side effects. The patient ’ s ment of unwanted hair growth, vascular lesions, pigmented skin type and the focused indication determine the cut-off fi l- lesions, and as a light source for photodynamic therapy and ters used and thus the spectrum of emitted wavelengths as skin rejuvenation. It also summarizes the physics of IPLs and well as the pulse duration. Similar to laser devices, the pulse provides guidance for the practical use of IPLs. duration should be lower than the thermal relaxation time of the target structure to prevent unselective damage to the sur- Keywords: laser; dermatology; vascular lesions; pigmented rounding tissue. Owing to a high degree of freedom in terms lesions; hair removal; skin. of combining wavelengths, pulse durations, pulse intervals, and fl uencies, IPLs enable a successful treatment of a wide Zusammenfassung spectrum of skin conditions, such as acne vulgaris, pigmented lesions, vascular lesions, unwanted hair growth, photodam- Hochenergetische Blitzlampen, auch „intense pulsed light aged skin, scars [4] , and angiokeratomas [5] . It is worth men- sources (IPLs)“, (intense pulsed light [IPL]) emittieren hoch- tioning that the versatility of IPLs means that the risk of side energetisches, inkoh ä rentes Licht, welches mit Filters ä tzen effects due to unspecifi c thermal damage is increased, espe- auf einen gew ü nschten Wellenl ä ngenbereich eingegrenzt cially if the devices are used by untrained physicians. Also, werden kann. Die Energiedichte, die Intensit ä t und die the IPLs have a rather heavy handpiece and a large spot size, Pulsdauer kann in Grenzen variiert werden. Somit k ö nnen which accounts for a certain limitation in maneuverability. On hochenergetische Blitzlampen ein vergleichsweise breites the other hand, the large spot size enables a high skin cov- Indikationsfeld erschlie ß en. Hierbei folgt die Technologie den erage rate, which can be an advantage. Further advantages Prinzipien einer eingeschr ä nkt selektiven Photothermolyse are the low purchase price and a more robust technology der entsprechenden Zielstruktur. In diesem Review soll ein as compared with lasers. However, the fact that the emitted Update der Literatur zu hochenergetischen Blitzlampen spectrum and fl uence can be inconsistent from pulse to pulse, geliefert werden. Schwerpunkte sind hierbei die Behandlung in particular, in IPLs containing a small capacitor bank [6] , unerw ü nschten Haarwuchses, vaskul ä rer L ä sionen, pigmen- can be considered disadvantageous. This point accounts for tierter L ä sionen und der Einsatz als Lichtquelle zur photody- the fact that different types of IPLs are hardly comparable. A namischen Therapie und zur Photorejuvenation. serious comparison should account for the fl uence per area for every emitted wavelength and for every possible pulse dura- Schl ü sselw ö rter: Laser; Dermatologie; Vaskul ä re L ä sionen; tion and pulse shape against the background of the real on-off Pigmentierte L ä sionen; Haut. time, fl uence, and spectral jitter during an impulse. This has 16 P. Babilas: Use of intense pulsed light sources in dermatology

been impressively shown in the article by Maisch et al. [7] , Lasers, UK; 625– 1100 nm; fl uence, 32 J/cm2 ; pulse train, 8 × 4 who analyzed the emission spectrum of fi ve different IPLs ms; total train time, 95 ms) for the removal of facial hair. Six all equipped with comparable cut-off fi lters. It was found weeks after the treatments (three times, at 6-week intervals), that the emission spectra of the IPLs showed a high degree laser and IPL therapy had substantially reduced the average of divergence and that the induced photodynamic effect was hair counts in a 16-cm2 area, which were 42.4 and 10.4 (laser), not predictable [7] . 38.1 and 20.4 (IPL), and 45.3 and 44.7 (control) before and after treatment, respectively. 1.2. Practical aspects Despite higher pain scores and more infl ammation, laser treatment was preferred by fi ve patients; two patients pre- Patient handling, pretreatment, and posttreatment are of great ferred IPL treatment and one had no preference. importance using intense pulsed light (IPL) and are extensively McGill et al. [14] conducted a randomized split-face discussed in a previous review on IPLs in the preceding DGLM comparison of facial hair removal with an alexandrite laser journal Medical Laser Application [8] or in Babilas et al. [9] . (GentleLASE ®; Candela Laser Corp., Wayland, MA, USA; The following sections discuss the current literature on IPLs 755 nm; spot size, 15 mm; fl uence, 10 – 30 J/cm2 ; pulse dura- for the treatment of unwanted hair growth, vascular lesions, tion, 3 ms) and an IPL device (Lumina; Lynton Lasers; 650– pigmented lesions, acne vulgaris, and photodamaged skin as 1100 nm; fl uence, 16 – 42 J/cm2 ; three pulses of 55 ms; delay, well as light sources for photodynamic therapy (PDT) and 20 ms) in 38 women with polycystic ovary syndrome. The skin rejuvenation. Where available, we focus on controlled authors reported that alexandrite laser treatment resulted in studies comparing IPLs to the respective standard treatment. longer median hair-free intervals than IPL therapy (7 weeks vs. 2 weeks; p < 0.001). The decrease in hair counts was sig- 2. Hair removal nifi cantly higher after alexandrite laser treatment than after IPL therapy at 1, 3, and 6 months (52 % , 43 % , and 46 % vs. Hair removal has become a key indication for IPLs. In a 21 % , 21 % , and 27 % ; p < 0.001). Patient satisfaction scores recently published article, Alijanpoor et al. [10] report on a were signifi cantly higher for the alexandrite laser (p ≤ 0.002). randomized clinical trial on 62 hirsute patients with exces- The authors assumed that the specifi c wavelength, short pulse sive white facial hair on the chin and cheeks. The patients duration, and single pulse delivery of the alexandrite laser are randomly colored their white hair with either black eyeliner responsible for higher follicular destruction. Unfortunately, or black hair dye before IPL treatment (six times, at 4-week no histological investigations were carried out at the time, and intervals). In both groups, approximately 50 % of patients the treatment duration was not documented. showed a good response of > 60 % with no signifi cant differ- Toosi et al. [15] compared the clinical effi cacy and side ence between both groups (p = 0.895). The authors concluded effects of an alexandrite laser (Cynosure, Langen, Germany; that hair coloring might be an effi cient and feasible technique 755 nm; fl uence, 16 – 20 J/cm2 ; spot size, 10 mm; pulse length, that can be combined with IPL treatment to eliminate white 2 ms), a diode laser (810 nm; Palomar diode laser), and an facial hair. Haak et al. [11] compared the effi cacy and safety IPL device (Medical Photo Bio Care, Sweden; fi lter, 650 nm; of an IPL device (525– 1200 nm; StarLux IPL system; Palomar fl uence, 22 – 34 J/cm2 ; double pulse; pulse duration, 20 ms; Medical Technologies, Burlington, MA, USA) vs. a long- delay, 10– 40 ms) for hair removal in 232 patients. Six months pulsed diode laser (LPDL, 810 nm; Asclepion MeDioStar XT after treatment (three to seven sessions), no signifi cant differ- diode laser) in 31 hirsute women with normal testosterone ence could be seen among the average hair reduction by means levels in a split-face study. According to their results, IPL and of IPL device (66.9 ± 17.7 % ), alexandrite (68.8 ± 16.9 % ), and LPDL treatment signifi cantly reduced hair counts (77% , 53% , diode laser (71.7 ± 18.1 % ) (p = 0.194). The incidence of side and 40% for IPL treatment vs. 68% , 60% , and 34% for LPDL effects was signifi cantly higher after diode laser treatment treatment) at 1, 3, and 6 months follow-up. Although there (p = 0.0001). was no signifi cant difference between treatments in terms of In a prospective comparison study, Amin et al. [16] evalu- hair reduction (p = 0.427) and patient satisfaction (p = 0.125), ated the effi cacy of an IPL device with red fi lter, an IPL device pain scores were higher for IPL treatment (median, 6; inter- with yellow fi lter, an 810-nm diode laser, and a 755-nm alex- quartile range, 4– 7) than LPDL (median, 3; interquartile andrite laser in 10 patients with unwanted hair on the back or range, 2 – 5) (p < 0.001). thigh. Evaluation with a camera system at 1, 3, and 6 months Holzer et al. [12] used an IPL device (610 – 950 nm; after the second treatment showed a signifi cant decrease in Energist VPL system) for the removal of unwanted nonfacial, hair counts (approx. 50% ) for all light devices (no statistical dark-pigmented, body hair in an uncontrolled study in 42 vol- difference). unteers. They documented a very good ( > 75 % hair reduction) An evidence-based review published by Haedersdal and or good effi cacy (51 % – 75 % hair reduction) in 42.9 % (n = 18) Wulf in 2006 [17] summarizes 9 randomized controlled and 33.3 % (n = 14) of patients, respectively. Side effects were (RCTs) and 21 controlled trials (CTs) on the effi cacy and a seldom occurrence. safety of hair removal by means of ruby, alexandrite, diode, or In a split-face study with 9 female participants, Cameron Nd:YAG lasers and IPLs, whereas for IPLs, only limited evi- et al. [13] compared a diode laser (Lightsheer EC; Lumenis, dence was available (only 1 RCT and 1 CT). Based on these Santa Clara, CA, USA; 810 nm; fl uence, 20 – 45 J/cm2 ; pulse data, the authors concluded that no suffi cient evidence exists duration, 30 ms) with an IPL device (Luminette; Lynton for long-term hair removal after IPL treatment. Bjerring et al. P. Babilas: Use of intense pulsed light sources in dermatology 17

[18] , in a split-face study, compared the effectiveness of an improvement. Melasma area and severity index decreased IPL device (Ellipse Relax Light 1000; Danish Dermatologic substantially from 15.2 to 4.5. Development, Hoersholm, Denmark; 600 – 950 nm; fl uence, Park et al. [27] determined the effectiveness of a combined 18.5 J/cm2 ; spot size, 10 × 48 mm) to a normal mode ruby laser IPL and Q-switched ruby laser (QSRL) therapy for target- (Epitouch, ESC Sharplan, Tel Aviv, Israel; 694 nm; spot size, ing pigment dissolution and global photorejuvenation in 25 5 mm; pulse duration, 0.9 ms) for hair removal in 31 patients Korean women with more than two types of facial pigmen- (three treatments). The authors reported an average hair count tary disorders. Initial treatment was conducted with the IPL reduction of 49.3% (IPL) vs. 21.3% (ruby laser) after three device (560-/590-nm cut-off fi lter; fl uence, 20 – 25 J/cm2 with treatments and concluded that IPL treatment was 3.94 times double pulse mode; pulse duration, 2.4– 4 or 4– 5 ms; delay more effective for hair removal than ruby laser therapy. time, 15 ms) and followed by repeated treatments every 3 to 4 Some very recent papers have focused on the safety of weeks as required. QSRL treatments (Lambda Photometrics, 2 IPLs in hair removal. According to these articles, burning, Hertfordshire, UK; 694 nm; fl uence, 4.5 – 6 J/cm ; spot size, postinfl ammatory hyperpigmentation, bulla and erosion, leu- 3– 4 mm; pulse duration, 25 ns) were added either during kotrichia, folliculitis, postinfl ammatory hypopigmentation, the same session or within 1 week after the IPL treatment. very seldom scar formation, and paradoxical hypertrichosis According to their results, 19 (76 % ) of 25 patients reported (1 – 10 % ) can be registered as side effects [19 – 22] . a good to excellent response. Two independent physicians The market for portable devices for home use is increasing. assessed that 15 (60 % ) of 25 patients showed a 76 – 100 % Even some works assess effi cacy and safety [23, 24], and even improvement, whereas 19 (76 % ) of 25 patients showed at if the potential of self-administered home-use devices is obvi- least an improvement of 50% . Side effects were minimal; ous, further investigation of their safety and effectiveness in 3 (12% ) of 25 patients showed transient postinfl ammatory hyperpigmentation and 1 (4 % ) of 25 patients had linear a home setting is of the highest importance. A clear drawback hypopigmentation. of this method is the fact that due to the size minimization of Galeckas et al. [28] conducted a multiple-treatment split- the apparatus, a smaller capacitor bank has to be used, which face comparison using a pulsed dye laser (PDL) (Perfecta; evokes fl uence and spectral jitter within each pulse. Candela Laser Corp.; spot size, 10 mm; mean light dose, In conclusion, a number of medical papers document the 9.36 J/cm2 ) with a compression handpiece vs. an IPL device effectiveness of IPL treatment for hair removal, yet only few (StarLux; Palomar Medical Technologies; fl uence, 35.6 J/cm2 ; provide data from RCTs or CTs. Level of evidence IIB is pulse duration, 10 ms). In total, 10 patients were treated three reached. times at 3- to 4-week intervals. One month after the fi nal treatment, improvement was assessed by blinded investigators who reported 86.5% vs. 82.0% for PDL vs. IPL treat- 3. Pigmented lesions ment 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 Several reports indicate the effectiveness of IPLs in the vessels > 0.6 mm, and 40.0 % vs. 32.0 % for texture. Mean treatment of pigmented lesions. Li et al. [25] published third treatment times were 7.7 min for PDL vs. 4.6 min for the recently a work on the effi cacy and safety of an IPL device IPL device (p = 0.005). Mean pain ratings were 5.8 for PDL vs. (Lumenis One; Lumenis, Santa Clara, CA, USA; 590-/640-/ 3.1 for the IPL device (p = 0.007). The rate of side effects was 695-nm cut-off fi lters; fl uence, 11– 17 J/cm2 , with triple- lower using the IPL device (infraorbital edema: 0 % vs. 50 % pulse mode; pulse width, 3 – 4 ms; delay time, 35 – 40 ms) in for PDL, posttreatment purpura 0 % vs. 10 % for PDL). the treatment of Riehl melanosis in a split-face study of six Bjerring et al. [29] evaluated the effectiveness of an IPL patients (Fitzpatrick skin type IV). In terms of histological device (Ellipse Flex; Danish Dermatologic Development, analysis, the authors reported signifi cantly fewer melanin Hoersholm, Denmark; 400– 720 nm; fl uence, 10 – 20 J/cm2 ; spot granules and melanophages in the treated side as compared size, 10 × 48 mm; pulse duration, 2 × 7 ms; delay, 25 ms) in the with the control side after 10 IPL sessions. According to a pro- treatment of lentigo solaris (18 patients) and benign melano- fessional assessment, fi ve patients exhibited good improve- cytic nevi (8 patients). Two months after a single treatment, ments, whereas one patient showed excellent improvement, evaluation by means of close-up photographs showed a pig- whereby therapeutic effi cacy was correlated to the number ment reduction in 96 % of the patients. The average clearance of treatment sessions and anatomical sites. In another study, was 74.2 % for lentigo solaris and 66.3 % for melanocytic nevi. Li et al. [26] reported on the effi cacy and safety of the same In a case report by Pimentel and Rodriguez-Salido [30] , an IPL device (fl uence, 13– 17 J/cm 2; 560-/590-nm fi lters and IPL device (Harmony System; Alma Lasers Ltd., Caesarea, double pulse or 590-/615-/640-nm fi lters and triple pulse; Israel; fi lter, 570 nm; fl uence, 10 – 12 J/cm2 ; pulse duration, pulse duration, 3– 4 ms; delay time, 25– 40 ms) in the treat- 15 ms) was successfully used to treat pigmentary ochre ment of melasma in 89 Chinese patients. Patients received a dermatitis secondary to chronic venous insuffi ciency. The total of four IPL treatments at 3-week intervals. As a result, normal skin color was restored, no repigmentation was 69 (77.5% ) of 89 patients showed an improvement of 51– observed within the 6-month follow-up period, and no side 100 % according to the overall evaluation by dermatologists. effects occurred. Self-assessment by the patients indicated that 63 (70.8 % ) In contrast, dyschromasia of both upper eyelids was of 89 patients considered that there was a 50% or more reported as a noteworthy side effect after an IPL treatment 18 P. Babilas: Use of intense pulsed light sources in dermatology

by Pang and Wells [31] . Both eyelids were treated with an (n = 11) and previously treated (n = 14) patients with PWS [47] . IPL device (Quantum SR; Lumenis, Santa Clara, CA, USA; In previously untreated PWS as well as in pretreated PWS, 560 – 1200 nm; fl uence, 24 J/cm2 ) at a beauty salon without the IPL treatments were rated signifi cantly (p < 0.05) better than application of eye shields. The iris has a high pigment content treatments with the SPDL (585 nm; fl uence, 6 J/cm 2 ; pulse and is therefore particularly vulnerable during light treatment. duration, 0.45 ms). In both groups, IPL and LPDL (585-/590- The absorption of high intense light led to bilateral ocular /595-/600-nm cut-off fi lters; fl uencies, 12/14/16/18 J/cm 2 ; iritis with subsequent irreversible ocular damage. pulse duration, 1.5 ms), treatments did not differ signifi cantly. In another report by Shin et al. [32] published in 2010, viti- There were few side effects at all settings. ligo was introduced as an acquired depigmenting disorder due Besides multiple uncontrolled trials, two other works pro- to IPL treatment for lentigines and dyspigmentation. vide data from controlled side-by-side comparisons of IPLs It should be emphasized that the fi rst and foremost step in and the standard therapy, the PDL [48, 49] . Faurschou et al. the treatment of pigmented lesions is a doubtless diagnosis [48] treated 20 patients with PWS in a side-by-side trial with and the exclusion of a malignant process. Besides, it has to a PDL (V-beam Perfecta; Candela Laser Corp.; 595 nm; pulse be emphasized that nevomelanocytic lesions are not a rou- duration, 0.45 – 1.5 ms) and an IPL device (StarLux; Palomar tine indication for laser treatment. For the treatment of benign Medical Technologies; 500– 670 and 870– 1400 nm; fl uence, pigmented, nonnevomelanocytic lesions, Q-switched laser 7 – 14 J/cm2 ; pulse duration, 5 – 10 ms). The researchers found systems are currently the method of choice. that both PDL and IPL treatment signifi cantly lightened PWS, whereas median clinical improvements were signifi - cantly better with the PDL (65 % ) than with the IPL device 4. Tattoos (30% ). McGill et al. [49] compared a PDL, an alexandrite, a KTP, and an Nd:YAG laser as well as an IPL device (Lumina; Tattoo removal requires very short pulse duration and high Lynton Lasers, Cheshire, UK; 550 – 1100 nm; fl uence, 28 – 34 light intensities. Only Q-switched lasers fulfi l these require- J/cm2 ; spot size, 10 × 10 mm; double pulse; delay time, 10 ms) ments. IPLs are not suitable for tattoo removal, as Q-switching in a split-lesion modus in 18 patients with PWS. In this study, is not possible in incoherent light sources. IPLs emit pulse the alexandrite laser was most effective and resulted in fading durations in the millisecond range, resulting in a prolonged PWS in 10 patients, but hyperpigmentation (n = 4) and scar- heating of the pigment particles and subsequently in heating ring (n = 1) were frequent. IPL treatment resulted in PWS fad- of the surrounding tissue. This fact needs to be considered if ing in six patients; the KTP and Nd:YAG lasers were the least IPLs are used for hair removal on tattooed skin areas [33] or effective with fading seen in two patients for both systems; for facial treatments in areas with permanent makeup. fi ve 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 In 2011, Kassir et al. [50] evaluated an IPL device (NaturaLight of essential telangiectasias [34] , rosacea [35, 36], port-wine IPL System; Focus Medical, Bethel, CT, USA; fi lter, 420 or stains (PWS) [37 – 41] , spider nevi [42] , angiomas [43 – 45] , 530 nm; fl uencies, 10 – 20 or 10 – 30 J/cm2 ; 2.5/5 ms, double, and erythrosis [34] . For the treatment of essential telangiecta- triple, or quadruple pulse; delay time, 20 – 30 ms) in 102 sias, PWS, and rosacea level of evidence IIB is reached. In patients with mild to severe rosacea. A mean of 7.2 treatments 2007, the European Society for Laser Dermatology published were applied in 1- to 3-week intervals. A reduction in red- guidelines for the use of IPLs in the treatment of vascular ness was documented in 80% of patients, reduced fl ushing malformations [46] . and improved skin texture in 78 % , and fewer acneiform were achieved in 72 % of patients. There were no complications or 5.1. Port-wine stains adverse effects. Papageorgiou et al. [36] assessed the effi cacy of an IPL In a controlled comparative split-face study, our research device (Quantum SR; Lumenis, London, UK; 560– 1200 nm; group evaluated the effi cacy and the side effects of IPL treat- fl uence, 24 – 32 J/cm 2; spot size, 34 × 8 mm, double pulses ment (Ellipse Flex; Danish Dermatologic Development, of 2.4/4.0/5.0/6.0 ms depending on the skin type) for the Hoersholm, Denmark; 555– 950 nm; fl uence, 11.0 – 16.9 J/cm2 ; treatment (four treatments, 3-week interval) of stage I rosa- spot size, 10 × 48 mm; pulse duration, 8 or 10 ms) of PWS cea (fl ushing, erythema, and telangiectasia) in 34 patients. in a direct comparison to a short-pulsed dye laser (SPDL) Photographic assessment showed signifi cant improvement (C-BeamTM ; Candela Laser Corp.; 585 nm; fl uence, 6 J/cm2 ; of erythema (46 % ) and telangiectasias (55 % ). The sever- spot diameter, 7 mm; pulse duration, 450 ms) and a long-pulsed ity of rosacea was reduced on average by 3.5 points on a dye laser (LPDL) (Sclero; Candela Laser Corp.; wavelengths, 10-point visual analogue scale (VAS). The results were 585, 590, 595, and 600 nm; fl uence depending on the respec- sustained at 6 months. Side effects were minimal and self- tive wavelength, 12 J/cm2 at 585 nm, 14 J/cm2 at 590 nm, limiting. 16 J/cm2 at 595 nm, and 18 J/cm2 at 600 nm; circular foot Schroeter et al. [35] approved these positive results in the print (diameter), 5 mm; pulse duration, 1500 ms) in untreated treatment of rosacea, testing the effectiveness of IPL devices P. Babilas: Use of intense pulsed light sources in dermatology 19

(PhotoDerm VL or Vasculight; Lumenis, London, UK; 515– or 555 – 950 nm; fl uence, 8 – 20 J/cm2 ; spot size, 10 × 48 mm; 1200 nm; fl uence, 25 – 35 J/cm2 ; pulse duration, 4.3 – 6.5 ms) pulse duration, 10– 20 ms) in a randomized, controlled split- in the treatment of facial telangiectasia in 60 rosacea patients. face trial (three settings; 3-month follow-up) in 49 patients On average, 4.1 treatments were applied per area. In total, with symmetrically located facial telangiectasias. According n = 508 facial sites were treated and clinically as well as pho- to the blinded assessment, both treatments showed good or tographically evaluated. A mean clearance of 77.8 % was excellent response in 30 of 39 patients. A 75 – 100 % vessel achieved and was maintained for a follow-up period averag- clearance rate was found in 18 (LPDL) vs. 11 (IPL) patients ing 51.6 months (range, 12 – 99 months). Within this remark- (p = 0.01). LPDL was classifi ed as less painful. No adverse able long follow-up period, only 4 of the 508 treated areas effects occurred. In another randomized split-lesion trial [55] , showed recurring lesions. Minimal side effects occurred. the same authors compared both devices in 13 patients with In a randomized controlled single-blind split-face trial, telangiectasias after radiotherapy for breast cancer. Patients Neuhaus et al. [51] compared a PDL (V-beam; Candela Laser underwent three split-lesion treatments at 6-week inter- Corp.; fl uence, 7 J/cm2 ; spot size, 10 mm; pulse duration, vals. The authors reported median vessel clearances of 90% 6 ms) with an IPL device (IPL Quantum; Lumenis, Santa (LPDL) vs. 50 % (IPL) (p = 0.01) 3 months after treatment. Clara, CA, USA; 560-nm fi lter; fl uence, 25 J/cm2 ; pulse train, LPDL treatments were associated with lower pain scores than 2.4 and 6.0 ms; delay time, 15 ms) in the treatment of facial IPL treatments. Even if the patients’ satisfaction did not differ erythematotelangiectatic rosacea. In total, 29 patients under- signifi cantly, more patients preferred the LPDL (n = 9) to IPL went 3-monthly treatment sessions. In this study, PDL and IPL treatment (n = 2) (p < 0.01). therapy signifi cantly reduced cutaneous erythema, telangiecta- Bjerring et al. [56] evaluated the effectiveness and sia, and patient-reported associated symptoms. No signifi cant side effects of the same IPL device (Ellipse Flex; Danish difference was noted between PDL and IPL treatments. Dermatologic Development, Hoersholm, Denmark; 555 – Campolmi et al. [52] used an IPL device (Minisilk FT; 950 nm; fl uence: 10 – 26 J/cm2 , spot size: 10 × 48 mm, pulse DEKA Medical Inc., USA; 500-/520-/550 nm cut-off fi lters duration: 10– 30 ms) in 24 patients with facial telangiecta- dependent on the types of lesion and the patient ’ s skin types; sias. On average, 2.54 ± 0.96 treatments were conducted at fl uence, 16 – 23 J/cm2 ; pulse time, 3– 8 ms; double pulse; pulse 1-month intervals; 79.2% of the patients obtained more than delay, 10 ms) in patients with poikiloderma of Civatte (n = 28) 50% reduction in a number of vessels and 37.5% obtained and rosacea (n = 35) repeatedly over a period of 2 years. They reduction between 75% and 100% 2 months after the last assessed the effi cacy and safety up to 12 months after treat- treatment. Side effects were rare (moderate erythema ment. In total, 51 patients showed a marked improvement, 10 and edema), and no scarring or pigmentary disturbances a moderate improvement, and 2 a slight improvement. Side occurred. effects were seldom. In a prospective side-by-side study, Fodor et al. [57] com- Madonna Terracina et al. [53] used an IPL device (IPL pared an IPL device (Vasculight; Lumenis, London, UK; fi l- Quantum; Lumenis, Santa Clara, CA, USA; 560-nm fi lter; ter: 515, 550, or 570 nm; fl uence, 15 – 38 J/cm2 ; pulse duration, fl uence, 9 – 12 J/cm2 ; spot size, 20 × 50 mm; pulse duration, not stated) to an Nd:YAG (Vasculight; Lumenis, London, UK; 10 – 20 ms) in the treatment of face and neck erythrosis in 22 1064 nm; fl uence, 120 – 140 J/cm2 ) laser in 25 patients with female and 12 male patients who underwent fi ve treatments telangiectasias, leg veins, or cherry angiomas. Patients with at 3-week intervals. In 22 patients, a total regression of the telangiectasias, cherry angiomas, or leg veins < 1 mm were erythrosis was achieved after fi ve applications, whereas the more satisfi ed after IPL treatment, whereas patients with leg erythema persisted in fi ve patients after the end of treatment. veins > 1 mm were more satisfi ed after Nd:YAG treatment. Wenzel et al. [34] reported about the successful treatment Overall, satisfaction with treatment of vascular lesions was of patients with progressive disseminated essential telangi- greater with Nd:YAG laser, although this method was reported ectasia (n = 4) and erythrosis interfollicularis colli (n = 5) by to be more painful. means of an IPL device (Ellipse Flex; Danish Dermatologic Retamar et al. [58] investigated the effectiveness and safety Development, Hoersholm, Denmark; 555– 950 nm; fl u- of an IPL device (type unknown; 515 – 1200 nm) in the treat- ence, 11.7 – 17 J/cm2 ; spot size, 10 × 48 mm; pulse duration, ment of linear and spider facial telangiectasias in 140 patients. 14– 18 ms). According to their results, clearance rates were In this study, 94 (67.1 % ) patients showed excellent (clearance 76 – 90 % in six of nine patients, 51 – 75 % in two patients, of 80 – 100 % ), 43 (30.7 % ) good (clearance of 40 – 80 % ), and and 50% in one patient. For both indications, 2.8 treatments 3 (2.1% ) poor (clearance < 40 % ) results. Posttreatment side were applied on average. Adverse events were rare, only one effects were minimal and transient. patient had transient crusts and blisters, which resulted in transient hypopigmentation; another patient showed transient hyperpigmentation. 6. PDT of nonmelanoma skin cancer

5.3. Telangiectasias A key indication for PDT is the treatment of nonmelanoma skin cancer such as actinic keratoses (AK) or superﬁ cial Nymann et al. [54] compared an LPDL (V-beam; Candela basal cell carcinomas [59] . Aminolevulinic acid (ALA) or its Laser Corp.; 595 nm) to an IPL device (Ellipse Flex; Danish methyl ester (MAL) are prodrugs that have to be converted Dermatologic Development, Hoersholm, Denmark; 530 – 750 into their active form, i.e., protoporphyrin IX (PpIX) [60, 61] . 20 P. Babilas: Use of intense pulsed light sources in dermatology

PpIX is particularly suitable for the activation with broad- signifi cantly better improvement, compared with IPL alone, band IPL because the major absorption bands include 410, in the clearance rate of AK lesions (78% vs. 53.6% ) as well 504, 538, 576, and 630 nm. Both ALA and MAL are used as in the assessed facets of photodamage (crow ’ s feet appear- for PDT in combination with IPL for the treatment of non- ance, 55.0 % vs. 29.5 % ; tactile skin roughness, 55 % vs. 29.5 % ; melanoma skin cancer [62] . Major side effects of PDT are mottled hyperpigmentation, 60.3% vs. 37.2% ; telangiectasias, phototoxic reactions (erythema, edema, hyperpigmentation) 84.6% vs. 53.8% ). Thus, this study further proves the useful- and pain during the treatment, which is dependent on the type ness of ALA-PDT-IPL in the successful treatment of AK and of photosensitizer used, the treatment area, and the type of signs of photodamage. As to whether short-contact incuba- lesion treated [63] . tion is able to induce signifi cant amounts of PpIX in the skin Haddad et al. [64] evaluated the effect of increasing the has to be proven in additional experiments. However, the fact fl uence (20, 25, 40, and 50 J/cm2 ) of an IPL device on the that telangiectasias respond better to ALA is noteworthy, as outcome of ALA-PDT (single treatment, 2-h incubation) in the creation of PpIX by endothelial cells cannot be expected 24 patients with AK and photodamaged skin. The assessment after such short contact incubation. Skin rubbing, which was 8 weeks after treatment indicated that AK clearance improved only done in the ALA-PDT site (methodical mistake) or light with increasing fl uence. The mean posttreatment AK grade coupling effects might have contributed to the clearance of was 56 % lower in the 50-J/cm2 treatment group, 50 % lower telangiectasias. in the 40-J/cm2 group, 32% lower in the 25-J/cm2 group, 20 % A level of evidence IIB supports the use of IPL as a light lower in the 20-J/cm2 group, and 7 % lower in the control source for PDT of AK. 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. 7. Photorejuvenation/photodynamic Our group compared the effi cacy and painfulness of an photorejuvenation IPL device (Energist Ultra VPL; Energist Ltd., Swansea, UK; 610 – 950 nm; two pulse trains, each 15 pulses of 5 ms; delay, Photorejuvenation is the use of light devices to remove clini- 20 ms; fl uence, 40 J/cm2 per pulse train) to a standard light cal signs arising from photoaging. If the process is combined source for PDT, an LED system (Aktilite ®; Galderma, France; with a photosensitizer so that a photodynamic reaction takes 635 ± 3 nm; 50 mW/cm2 ; 37 J/cm2 ), in a prospective random- place, it is called photodynamic photorejuvenation. Clinical ized controlled split-face study [65] . In 25 patients with 238 hallmark features of photoaging are skin roughness, epider- AK lesions, topical PDT was applied followed by a reevalu- mal neoplasias, mottled pigmentation, telangiectasias, ery- ation of up to 3 months. According to our results, IPL use for thema, thin wrinkles, lax skin texture, and sebaceous gland PDT is an effi cient alternative for the treatment of AK, result- hypertrophy [68] . ing in complete remission and cosmesis equivalent to LED To defi ne the mechanism of action of IPL application in irradiation but with signifi cantly less pain [VAS, 4.3 (IPL) vs. photorejuvenation, biopsies taken before and after IPL treat- 6.4 (LED); p < 0.001]. ment were examined histologically [19] . Analysis showed Kim et al. [66] conducted a clinical and histopathologi- that both type 1 and type 3 collagens increased after treat- cal trial to confi rm the effectiveness of topical ALA-PDT ment, whereas the elastin content decreased, but elastin using an IPL device (Ellipse Flex; Danish Dermatologic fi bers were more neatly arranged. According to transmission Development, Hoersholm, Denmark; 555 – 950 nm; fl uence, electron microscope investigations, the amount of fi broblast 12 – 16 J/cm2 ; spot size, 10 × 48 mm; pulse duration, 20 – 30 ms; activity increased, the fi broblasts were more active, and more two passes) as light source. In total, 12 AK lesions in 7 collagen fi bers were neatly rearranged within the stroma patients were treated. Eight or 12 weeks after treatment, the [19] . Wong et al. [69] examined the effects of IPL irradia- clinical response was assessed, and histopathological exami- tion (triple pulses, 7 ms; pulse interval, 70 ms; fl uencies, 20, nations were conducted on clinically resolved lesions. As a 50, and 75 J/cm2 ) on normal human dermal fi broblasts grown result, 6 (50% ) of 12 lesions showed clinical clearance after in contracted collagen lattices. Twenty-four hours after IPL a single treatment, but histological examinations showed that irradiation, a dose-dependent increase in viable cells as well only 5 (42% ) of 12 lesions had been removed. Complications, as an up-regulated expression of collagen III and TGF-β 1 in such as pigmentary changes or scarring, were not observed. dermal fi broblasts could be observed. No signifi cant change According to these results, determining complete remission in mRNA levels of collagen I and fi bronectin was reported. in AK requires caution, and long-term follow-up or histologi- Cao et al. [70] evaluated the effects of IPL irradiation (double cal confi rmation may be required. pulses, 4/6 ms; pulse interval, 20 ms; fl uencies, 18, 23, 28, Gold et al. [67] focused on the treatment of AK and associ- and 33 J/cm2 ). They were able to show that 24 h after irra- ated photodamaged skin. In a split-face study involving 16 diation, cell viability of skin fi broblasts improved in a dose- patients (three treatments, 1-month intervals), short-contact dependent manner (increase of percentage of fi broblasts at the

(30 – 60 min) ALA-PDT with an IPL device (Vasculight; S and G2 /M stage of the cell cycle). IPL irradiation increased Lumenis, Yokneam, Israel; 550- or 570-nm fi lter; fl uence, 34 the expression of collagen (types I and III) at the mRNA and J/cm2 ; spot size, 8 × 16 mm; double pulsing; delay, 20 ms) as protein level. Thus, cytological and morphological evidence light source in comparison to IPL alone was evaluated. Three exists for clinical improvement of the skin texture after IPL months after the fi nal treatment, ALA-PDT-IPL showed a irradiation. Regarding photodynamic photorejuvenation, Park P. Babilas: Use of intense pulsed light sources in dermatology 21

et al. [71] performed a study on 14 patients with photodam- without signifi cant side-to-side differences. No reduction of aged skin. Skin biopsies taken before and 1 month after PDT rhytides was seen in either treatment side. revealed an increase in mean epidermal thickness, expres- Using the same IPL device with the same specifi cations, sion of types I and III procollagen, and dermal collagen Bjerring et al. [77] compared the clinical effi cacy and safety volume and a decrease in dermal elastotic material, expression of two different fi lter sets of 555– 950 nm (VL) and 530– 750 of matrix metalloproteinases 1, 3, and 12, and infl ammatory nm (PR) in the treatment of photodamaged skin in 35 patients. infi ltrate. In this study, the use of the VL fi lter resulted in better clear- Besides these histomorphological investigations, there ance of irregular pigmentation, whereas the PR fi lter achieved have been a couple of controlled clinical trials published so better clearance of telangiectasias and diffuse erythema. far. Palm and Goldman [72] compared the effectiveness of According to their overall satisfaction, 66.7% (PR) vs. 76.2% MAL-PDT with red vs. blue light for photodynamic photore- (VL) of patients reported fair, good, or excellent results. No juvenation in 18 patients with moderate to severe facial pho- skin atrophy, scarring, or pigment disturbances were noted, todamage. The authors did not fi nd a statistically signifi cant but swelling and erythema occurred in 66% (PR) vs. 33% difference between blue and red light in terms of effi cacy and (VL) of patients. side effects. The greatest improvement was achieved in pig- Hedelund et al. [78] evaluated the effi cacy and adverse mentation, AK, and erythema. Kosaka et al. [73] conducted effects of the same IPL device (Ellipse Flex; Danish a comparative study with 16 Asian patients with facial pho- Dermatologic Development, Hoersholm, Denmark; 530 – 750 todamage to compare the effectiveness of photodynamic nm; fl uence, 7.5 – 8.5 J/cm2 ; spot size, 10 × 48 mm; pulse dura- photorejuvenation (5% ALA; 2-h incubation; IPL irradiation, tion, 2 × 2.5 ms; delay, 10 ms) in a randomized controlled 500 – 670 and 870 – 1400 nm; 23 – 30 J/cm2 ) and photorejuvena- split-face trial on skin rejuvenation (three treatments, 1-month tion under the use of IPL light only. Three treatments (4-week interval) in 32 women (Fitzpatrick skin type I – III) with class intervals) were applied in a split-face modus. Although the I or II rhytides. Nine months after the fi nal treatment, blinded treatment results did not differ signifi cantly between the two investigators and patients assessed signifi cant improvement sides in all subjects, 75 % of the patients considered the ALA- in telangiectasias (p < 0.001) and in irregular pigmentation PDT-IPL treated side as better than the IPL-only treated side. (p < 0.03) between treated and untreated sides but no signifi - However, all ALA-PDT-IPL treated sides showed adverse cant difference in rhytides. effects such as erythema and pain. Li et al. [79] evaluated the effi cacy and safety of an IPL Shin et al. [74] treated 26 Korean women with wrinkles and device (Lumenis One; Lumenis, Santa Clara, CA, USA; 515– facial dyschromias at 4-week intervals using an IPL device 1200 nm; fl uence, 11 – 20 J/cm2 ; double- or triple-pulse mode; (Powerlite 600® EX, Scandinavia Corp., Japan; 530-nm cut- pulse duration, 2.5– 4 ms; delay time, 20– 40 ms) in the treat- off fi lter; fl uence, 15.5 – 17.5 J/cm 2 ; pulse duration, 5 × 2 ms; ment (four treatments, 3- to 4-week intervals) of photoaged delay, 5 × 2 ms). The authors reported that pigmented lesions skin in 152 Asian patients. In this study, assessment showed (p < 0.05), skin elasticity, and wrinkles improved while sebum a score decrease of three or two grades in 91.4% of patients. secretion and water content of skin remained unchanged. In total, 89.5% of patients rated their overall improvement as Butler et al. [75] performed a split-face comparison of IPL vs. excellent or good. Adverse effects were limited to mild pain KTP laser treatment in 17 patients, of skin types I– IV, with and transient erythema. dyschromias and telangiectasias. The mean improvement 1 Kono et al. [80] compared in a split-face study the effec- month after the treatment vascular/pigment lesions was 38 % tiveness of an IPL device (Smooth Pulsed Light; Palomar and 35% for the IPL side vs. 42% and 30% for the KTP side. Medical Technologies; 470 – 1400 nm; fl uence, 27 – 40 J/cm2 ; The patients ’ assessment revealed a mean global improve- pulse duration, 20 ms) to an LPDL (V-beam; Candela Laser ment of 66% (IPL) vs. 61% (KTP) and a higher rate of side Corp.; 595 nm; fl uence, 9 – 12 J/cm2 ; spot size, 7 mm; pulse effects due to KTP treatment (pain, postprocedure swelling). duration, 1.5 ms) in the treatment (six treatment sessions) of In a randomized controlled split-face trial, J ø rgensen et al. facial skin rejuvenation in 10 Asian patients (Fitzpatrick skin [76] evaluated the effi cacy and adverse effects of an LPDL types III– IV). Three months after the last treatment, lentigines (V-beam Perfecta; Candela Laser Corp.; 595 nm) and an IPL had improved by 62.3% (IPL) vs. 81.1% (LPDL). No signifi - device (Ellipse Flex; Danish Dermatologic Development, cant difference was evident between IPL and LPDL treatment Hoersholm, Denmark; 530– 750 or 555– 950 nm; fl uence, in wrinkle reduction, and no scarring or pigmentary change 6 – 20 J/cm2 ; spot size, 10 × 48 mm; pulse duration, 2 × 2.5 ms; were seen with either device. delay, 10 or 8 – 20 ms) in the treatment (three treatments; Sequential Er:YAG laser treatment vs. IPL treatment 3-week intervals) of photodamaged skin in 20 women with (StarLux; Palomar Medical Technologies; 560-nm fi lter; fl u- Fitzpatrick skin types I – III. One, three, and six months after ence, 30 J/cm2 ; pulse duration, 2.4 and 4.0 ms; delay, 10 ms) therapy, patients as well as blinded investigators assessed for mild to moderate facial photodamage was compared by the impact on telangiectasias, pigmentation, skin texture, Hantash et al. [81] in a split-face randomized prospective trial rhytides, treatment-related pain, adverse events, and the pre- in 10 patients with facial dyschromia and rhytides. Assessment ferred treatment by means of photographs. LPDL rejuvena- 3 months after the fi nal treatment (three treatments, 1-month tion showed advantages over IPL rejuvenation because of intervals) showed that IPL and Er:YAG treatments did not considerably better vessel clearance and less pain. Irregular signifi cantly improve rhytid scores. However, subjective pigmentation and skin texture improved with both treatments and blinded physician dyschromia scores improved by 26% 22 P. Babilas: Use of intense pulsed light sources in dermatology

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 fre- quently 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 rel- atively 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. Evidence level IIB (treatment essential of telangiectasias, rosacea) PWS, IIB IPL (use of as a light source AK) PDT of for 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.

References

[1] M ü hlbauer W, Nath G, Kreitmair A. Treatment of capillary hemangiomas and nevi ﬂ ammei with light. Langenbecks Arch Chir 1976;Suppl:91 – 4. [2] Goldman MP, Eckhouse S. Photothermal sclerosis of leg veins. ESC Medical Systems, LTD Photoderm VL Cooperative Study Group. Dermatol Surg 1996;22(4):323 – 30. [3] Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220(4596):524 – 7. [4] Erol OO, Gurlek A, Agaoglu G, Topcuoglu E, Oz H. Treatment of hypertrophic scars and keloids using intense pulsed light (IPL).

Q-switched laser systems are the methods choice. of telangiectasias, rosacea, spider nevi, angiomas, PWS, and erythrosis. Aesthetic Plast Surg 2008;32(6):902 – 9. – Nevomelanocytic lesions are not a routine indication laser for or IPL treatment. the– For treatment benign of pigmented, nonnevomelanocytic lesions, Method choice: of Q-switched lasers. – – Data on the effectiveness of IPL in skin rejuvenation are heterogeneous . – Data on the IPL effectiveness of in skin are rejuvenation heterogeneous – A standardized protocol photodynamic for is still photorejuvenation missing. [5] Morais P, Santos AL, Baudrier T, Mota AV, Oliveira JP, Azevedo F. Angiokeratomas of Fabry successfully treated with intense pulsed light. J Cosmet Laser Ther 2008;10(4):218 – 22. [6] Eadie E, Miller P, Goodman T, Moseley H. Time-resolved mea- surement shows a spectral distribution shift in an intense pulsed light system. Lasers Med Sci 2009;24(1):35 – 43. [7] Maisch T, Moor AC, Regensburger J, Ortland C, Szeimies RM, B ä umler W. Intense pulse light and 5-ALA PDT: phototoxic effects in vitro depend on the spectral overlap with protoporphyrin IX but do not match cut-off ﬁ lter notations. Lasers Surg Med 2011;43(2):176 – 82. [8] Babilas P. Light-assisted therapy in dermatology: the use of Level of evidence for IPL treatments. intense pulsed light (IPL). Med Laser Appl 2010;25(2):61 – 9. [9] Babilas P, Schreml S, Szeimies RM, Landthaler M. Intense pulsed Hair removalPigmented lesionsTattoosVascular lesions – – . IPL treatment malignant of Exclusion is effective. processes is necessary diagnosis by – There is evidence in the literature successful for IPL treatment essential of – IPLs are not suitable tattoo for removal. IIB Table 1 Table Application/indication Evaluation PDT of nonmelanomaPDT of skin cancer Photorejuvenation/photodynamic photorejuvenation light (IPL): a review. Lasers Surg Med 2010;42(2):93 – 104. P. Babilas: Use of intense pulsed light sources in dermatology 23

[10] Alijanpoor R, Bejehmir AP, Mokmeli S. Successful white [28] Galeckas KJ, Collins M, Ross EV, Uebelhoer NS. Split-face hair removal with combined coloring and intense pulsed treatment of facial dyschromia: pulsed dye laser with a com- light (IPL): a randomized clinical trial. Photomed Laser Surg pression handpiece versus intense pulsed light. Dermatol Surg 2011;29(11):773 – 9. 2008;34(5):672 – 80. [11] Haak CS, Nymann P, Pedersen AT, Clausen HV, Feldt [29] Bjerring P, Christiansen K. Intense pulsed light source for treat- Rasmussen U, Rasmussen AK, Main K, Haedersdal M. Hair ment of small melanocytic nevi and solar lentigines. J Cutan removal in hirsute women with normal testosterone levels: Laser Ther 2000;2(4):177 – 81. a randomized controlled trial of long-pulsed diode laser vs. [30] Pimentel CL, Rodriguez-Salido MJ. Pigmentation due to sta- intense pulsed light. Br J Dermatol 2010;163(5):1007 – 13. sis dermatitis treated successfully with a non-coherent intense [12] Holzer G, Nahavandi H, Neumann R, Knobler R. Photoepilation pulsed light source. Dermatol Surg 2008;34(7):950 – 1. with variable pulsed light in non-facial body areas: evalu- [31] Pang AL, Wells K. Bilateral anterior uveitis after intense pulsed ation of effi cacy and safety. J Eur Acad Dermatol Venereol light therapy for pigmented eyelid lesions. Dermatol Surg 2010;24(5):518 – 23. 2008;34(9):1276 – 9. [13] Cameron H, Ibbotson SH, Dawe RS, Ferguson J, Moseley H. [32] Shin JU, Roh MR, Lee JH. Vitiligo following intense pulsed Within-patient right-left blinded comparison of diode (810 nm) light treatment. J Dermatol 2010;37(7):674 – 6. laser therapy and intense pulsed light therapy for hair removal. [33] Wenzel S, Landthaler M, B ä umler W. Recurring mistakes in tat- Lasers Med Sci 2008;23(4):393 – 7. too removal. A case series. Dermatology 2009;218(2):164 – 7. [14] McGill DJ, Hutchison C, McKenzie E, McSherry E, Mackay [34] Wenzel SM, Hohenleutner U, Landthaler M. Progressive dis- IR. A randomised, split-face comparison of facial hair removal seminated essential telangiectasia and erythrosis interfollicularis with the alexandrite laser and intense pulsed light system. Lasers colli as examples for successful treatment with a high-intensity Surg Med 2007;39(10):767 – 72. fl ashlamp. Dermatology 2008;217(3):286 – 90. [15] Toosi P, Sadighha A, Sharifi an A, Razavi GM. A comparison [35] Schroeter CA, Haaf-von Below S, Neumann HA. Effective treat- study of the effi cacy and side effects of different light sources in ment of rosacea using intense pulsed light systems. Dermatol hair removal. Lasers Med Sci 2006;21(1):1 – 4. Surg 2005;31(10):1285 – 9. [16] Amin SP, Goldberg DJ. Clinical comparison of four hair removal [36] Papageorgiou P, Clayton W, Norwood S, Chopra S, Rustin M. lasers and light sources. J Cosmet Laser Ther 2006;8(2):65 – 8. Treatment of rosacea with intense pulsed light: signifi cant [17] Haedersdal M, Wulf HC. Evidence-based review of hair removal improvement and long-lasting results. Br J Dermatol 2008; using lasers and light sources. J Eur Acad Dermatol Venereol 159(3):628 – 32. 2006;20(1):9 – 20. [37] Raulin C, Schroeter CA, Weiss RA, Keiner M, Werner S. [18] Bjerring P, Cramers M, Egekvist H, Christiansen K, Troilius A. Treatment of port-wine stains with a non-coherent pulsed Hair reduction using a new intense pulsed light irradiator light source: a retrospective study. Arch Dermatol 1999; and a normal mode ruby laser. J Cutan Laser Ther 2000;2(2): 135(6):679 – 83. 63 – 71. [38] Bjerring P, Christiansen K, Troilius A. Intense pulsed light [19] Feng Y, Zhao J, Gold MH. Skin rejuvenation in Asian skin: the source for the treatment of dye laser resistant port-wine stains. analysis of clinical effects and basic mechanisms of intense J Cosmet Laser Ther 2003;5(1):7 – 13. pulsed light. J Drugs Dermatol 2008;7(3):273 – 9. [39] Ho WS, Ying SY, Chan PC, Chan HH. Treatment of port wine [20] Radmanesh M, Azar-Beig M, Abtahian A, Naderi AH. Burning, stains with intense pulsed light: a prospective study. Dermatol paradoxical hypertrichosis, leukotrichia and folliculitis are Surg 2004;30(6):887 – 90; discussion 890 – 1. four major complications of intense pulsed light hair removal [40] Reynolds N, Exley J, Hills S, Falder S, Duff C, Kenealy J. The therapy. J Dermatolog Treat 2008;19(6):360 – 3. role of the Lumina intense pulsed light system in the treatment [21] Radmanesh M. Paradoxical hypertrichosis and terminal of port wine stains – a case controlled study. Br J Plast Surg hair change after intense pulsed light hair removal therapy. 2005;58(7):968 – 80. J Dermatolog Treat 2009;20(1):52 – 4. [41] Ozdemir M, Engin B, Mevlito g˘lu I. Treatment of facial port- [22] Willey A, Torrontegui J, Azpiazu J, Landa N. Hair stimula- wine stains with intense pulsed light: a prospective study. tion following laser and intense pulsed light photo-epilation: J Cosmet Dermatol 2008;7(2):127 – 31. review of 543 cases and ways to manage it. Lasers Surg Med [42] Myers P, Bowler P, Hills S. A retrospective study of the effi cacy 2007;39(4):297 – 301. of intense pulsed light for the treatment of dermatologic disor- [23] Alster TS, Tanzi EL. Effect of a novel low-energy pulsed- ders presenting to a cosmetic skin clinic. J Cosmet Dermatol light device for home-use hair removal. Dermatol Surg 2005;4(4):262 – 6. 2009;35(3):483 – 9. [43] Jorge BF, Del Pozo J, Casti ñ eiras I, Mazaira M, Fern á ndez- [24] Mulholland RS. Silk’ n – a novel device using Home Pulsed Torres R, Fonseca E. Treatment of ulcerated haemangiomas Light for hair removal at home. J Cosmet Laser Ther with a non-coherent pulsed light source: brief initial clinical 2009;11(2):106 – 9. report. J Cosmet Laser Ther 2008;10(1):48 – 51. [25] Li YH, Liu J, Chen JZ, Wu Y, Xu TH, Zhu X, Liu W, Wei HC, [44] Chiu CS, Yang LC, Hong HS, Kuan YZ. Treatment of a Gao XH, Chen HD. A pilot study of intense pulsed light in the tufted angioma with intense pulsed light. J Dermatolog Treat treatment of Riehl ’ s melanosis. Dermatol Surg 2011;37(1): 2007;18(2):109 – 11. 119 – 22. [45] Poenitz N, Koenen W, Utikal J, Goerdt S. Angioma serpigino- [26] Li YH, Chen JZ, Wei HC, Wu Y, Liu M, Xu YY, Dong GH, sum following the lines of Blaschko – an effective treatment Chen HD. Effi cacy and safety of intense pulsed light in treatment with the IPL technology. J Dtsch Dermatol Ges 2006;4(8): of melasma in Chinese patients. Dermatol Surg 2008;34(5): 650 – 3. 693 – 700; discussion 700 – 1. [46] Adamic M, Troilius A, Adatto M, Drosner M, Dahmane R. [27] Park JM, Tsao H, Tsao S. Combined use of intense pulsed light Vascular lasers and IPLs: guidelines for care from the European and Q-switched ruby laser for complex dyspigmentation among Society for Laser Dermatology (ESLD). J Cosmet Laser Ther Asian patients. Lasers Surg Med 2008;40(2):128 – 33. 2007;9(2):113 – 24. 24 P. Babilas: Use of intense pulsed light sources in dermatology

[47] Babilas P, Schreml S, Eames T, Hohenleutner U, Szeimies [64] Haddad A, Santos ID, Gragnani A, Ferreira LM. The effect RM, Landthaler M. Split-face comparison of intense pulsed of increasing fl uence on the treatment of actinic keratosis light with short- and long-pulsed dye lasers for the treatment of and photodamage by photodynamic therapy with 5-aminole- port-wine stains. Lasers Surg Med 2010;42(8):720 – 7. vulinic acid and intense pulsed light. Photomed Laser Surg [48] Faurschou A, Togsverd-Bo K, Zachariae C, Haedersdal M. 2011;29(6):427 – 32. Pulsed dye laser vs. intense pulsed light for port-wine stains: a [65] Babilas P, Knobler R, Hummel S, Gottschaller C, Maisch T, randomized side-by-side trial with blinded response evaluation. Koller M, Landthaler M, Szeimies RM. Variable pulsed Br J Dermatol 2009;160(2):359 – 64. light is less painful than light-emitting diodes for topical [49] McGill DJ, MacLaren W, Mackay IR. A direct comparison of photodynamic therapy of actinic keratosis: a prospective pulsed dye, alexandrite, KTP and Nd:YAG lasers and IPL in randomized controlled trial. Br J Dermatol 2007;157(1): patients with previously treated capillary malformations. Lasers 111 – 7. Surg Med 2008;40(6):390 – 8. [66] Kim HS, Yoo JY, Cho KH, Kwon OS, Moon SE. Topical pho- [50] Kassir R, Kolluru A, Kassir M. Intense pulsed light for the todynamic therapy using intense pulsed light for treatment treatment of rosacea and telangiectasias. J Cosmet Laser Ther of actinic keratosis: clinical and histopathologic evaluation. 2011;13(5):216 – 22. Dermatol Surg 2005;31(1):33 – 6; discussion 36 – 7. [51] Neuhaus IM, Zane LT, Tope WD. Comparative effi cacy of [67] Gold MH, Bradshaw VL, Boring MM, Bridges TM, Biron JA. nonpurpuragenic pulsed dye laser and intense pulsed light for Split-face comparison of photodynamic therapy with 5-amino- erythematotelangiectatic rosacea. Dermatol Surg 2009;35(6): levulinic acid and intense pulsed light versus intense pulsed 920 – 8. light alone for photodamage. Dermatol Surg 2006;32(6):795 – [52] Campolmi P, Bonan P, Cannarozzo G, Bruscino N, Troiano M, 801; discussion 801 – 3. Prignano F, Lotti T. Intense pulsed light in the treatment of non- [68] Ruiz-Rodriguez R, Sanz-S á nchez T, C ó rdoba S. Photodynamic aesthetic facial and neck vascular lesions: report of 85 cases. photorejuvenation. Dermatol Surg 2002;28(8):742– 4; discus- J Eur Acad Dermatol Venereol 2011;25(1):68 – 73. sion 744. [53] Madonna Terracina FS, Curinga G, Mazzocchi M, Onesti MG, [69] Wong WR, Shyu WL, Tsai JW, Hsu KH, Pang JH. Intense pulsed Scuderi N. Utilization of intense pulsed light in the treatment of light effects on the expression of extracellular matrix proteins face and neck erythrosis. Acta Chir Plast 2007;49(2):51 – 4. and transforming growth factor beta-1 in skin dermal fi broblasts [54] Nymann P, Hedelund L, Haedersdal M. Long-pulsed dye laser cultured within contracted collagen lattices. Dermatol Surg vs. intense pulsed light for the treatment of facial telangiectasias: 2009;35(5):816 – 25. a randomized controlled trial. J Eur Acad Dermatol Venereol [70] Cao Y, Huo R, Feng Y, Li Q, Wang F. Effects of intense pulsed 2010;24(2):143 – 6. light on the biological properties and ultrastructure of skin der- [55] Nymann P, Hedelund L, Haedersdal M. Intense pulsed light mal fi broblasts: potential roles in photoaging. Photomed Laser vs. long-pulsed dye laser treatment of telangiectasia after Surg 2011;29(5):327 – 32. radiotherapy for breast cancer: a randomized split-lesion [71] Park MY, Sohn S, Lee ES, Kim YC. Photorejuvenation induced trial of two different treatments. Br J Dermatol 2009;160(6): by 5-aminolevulinic acid photodynamic therapy in patients with 1237– 41. actinic keratosis: a histologic analysis. J Am Acad Dermatol [56] Bjerring P, Christiansen K, Troilius A. Intense pulsed light 2010;62(1):85 – 95. source for treatment of facial telangiectasias. J Cosmet Laser [72] Palm MD, Goldman MP. Safety and effi cacy comparison of blue Ther 2001;3(4):169 – 73. versus red light sources for photodynamic therapy using methyl [57] Fodor L, Ramon Y, Fodor A, Carmi N, Peled IJ, Ullmann Y. aminolevulinate in photodamaged skin. J Drugs Dermatol A side-by-side prospective study of intense pulsed light and 2011;10(1):53 – 60. Nd:YAG laser treatment for vascular lesions. Ann Plast Surg [73] Kosaka S, Yasumoto M, Akilov OE, Hasan T, Kawana S. 2006;56(2):164 – 70. Comparative split-face study of 5-aminolevulinic acid photody- [58] Retamar RA, Chames C, Pellerano G. Treatment of linear and namic therapy with intense pulsed light for photorejuvenation spider telangiectasia with an intense pulsed light source. J of Asian skin. J Dermatol 2010;37(12):1005 – 10. Cosmet Dermatol 2004;3(4):187 – 90. [74] Shin JW, Lee DH, Choi SY, Na JI, Park KC, Youn SW, [59] Szeimies RM, Landthaler M. Photodynamic therapy and fl uo- Huh CH. Objective and non-invasive evaluation of photore- rescence diagnosis of skin cancers. Recent Results Cancer Res juvenation effect with intense pulsed light treatment in Asian 2002;160:240 – 5. skin. J Eur Acad Dermatol Venereol 2011;25(5):516 – 22. [60] Babilas P, Karrer S, Sidoroff A, Landthaler M, Szeimies RM. [75] Butler EG 2nd, McClellan SD, Ross EV. Split treatment of pho- Photodynamic therapy in dermatology – an update. Photo- todamaged skin with KTP 532 nm laser with 10 mm handpiece dermatol Photoimmunol Photomed 2005;21(3):142 – 9. versus IPL: a cheek-to-cheek comparison. Lasers Surg Med [61] Babilas P, Landthaler M, Szeimies RM. Photodynamic therapy 2006;38(2):124 – 8. in dermatology. Eur J Dermatol 2006;16(4):340 – 8. [76] J ø rgensen GF, Hedelund L, Haedersdal M. Long-pulsed dye [62] Tadiparthi S, Falder S, Saour S, Hills SJ, Liew S. Intense laser versus intense pulsed light for photodamaged skin: a pulsed light with methyl-aminolevulinic acid for the treat- randomized split-face trial with blinded response evaluation. ment of actinic keratoses. Plast Reconstr Surg 2008;121(5): Lasers Surg Med 2008;40(5):293 – 9. 351 – 2e. [77] Bjerring P, Christiansen K, Troilius A, Dierickx C. Facial [63] Steinbauer JM, Schreml S, Babilas P, Zeman F, Karrer S, photo rejuvenation using two different intense pulsed light Landthaler M, Szeimies RM. Topical photodynamic therapy (IPL) wavelength bands. Lasers Surg Med 2004;34(2): with porphyrin precursors – assessment of treatment-associ- 120 – 6. ated pain in a retrospective study. Photochem Photobiol Sci [78] Hedelund L, Due E, Bjerring P, Wulf HC, Haedersdal M. Skin 2009;8(8):1111 – 6. rejuvenation using intense pulsed light: a randomized controlled P. Babilas: Use of intense pulsed light sources in dermatology 25

split-face trial with blinded response evaluation. Arch Dermatol long-pulse pulsed dye laser in the treatment of facial skin reju- 2006;142(8):985 – 90. venation. Ann Plast Surg 2007;59(5):479 – 83. [79] Li YH, Wu Y, Chen JZ, Gao XH, Liu M, Shu CM, Dong GH, [81] Hantash BM, De Coninck E, Liu H, Gladstone HB. Split-face Chen HD. Application of a new intense pulsed light device in comparison of the erbium micropeel with intense pulsed light. the treatment of photoaging skin in Asian patients. Dermatol Dermatol Surg 2008;34(6):763 – 72. Surg 2008;34(11):1459 – 64. [80] Kono T, Groff WF, Sakurai H, Takeuchi M, Yamaki T, Soejima Received October 11, 2011; revised December 6, 2011; accepted K, Nozaki M. Comparison study of intense pulsed light versus a December 9, 2011