ENERGY-BASED DEVICES ENERGY-BASED DEVICES LASER Plasma Radiofrequency Ultrasound ASSISTED MICRONEEDLING Electromagnetic Pulse Picosecond Acoustic Pulse Nd:YAG LED thulium IPL COMBINED ENERGIES CO2Superficial Radiation Blue Home-Use Laser and Light Devices: Just What the Doctor Ordered

Laser and light-based devices are more at home than ever as lightweight LEDs, wearable technology, and “smart” apps support adherence and enhance efficacy. BY MICHAEL GOLD, MD

The popularity of home-use laser and light-based devic- up” means a device is safe and effective, so guiding patients >> es for treatments such as growth, , toward this technology and away from items that have not and reduction has grown exponentially over the past 10 been sufficiently vetted means we can comfortably vouch for years and shows no signs of abating. Having been involved in the device’s safety and ability to provide results. the FDA studies of many of these devices, I was acutely aware of my peers’ earlier fears that these home-use devices (HUD) HAIR GROWTH would displace office visits. Over the years, these concerns have Androgenetic alopecia, which affects more than 80 million dissipated and been replaced by awareness that, when used as Americans and results in pattern in both men and an adjunct to in-office treatments, HUDs offer advantages to women is among the leading motivators of those who seek patients as well as to those of us who support their use. When help with hair growth or restoration. Hair growth in patients your patients ask you to recommend a home-use device or who have androgenetic alopecia has been successfully they mention that they’re already using one, just keep in mind achieved through a range of energy-based devices, includ- that the at-home aesthetic device market will always be as ing fractional lasers and home-use Low-Level Laser therapy robust as your clients’ desire to look good—so there will always (LLLT) devices. The delivery of this non-thermal, low intensity be plenty of business to go around. light (10mW–500mW) triggers biochemical changes whereby HUDs empower patients to play an integral role in their photons of light are absorbed by cellular photoreceptors and overall treatment plan. In some instances, these devices help result in downstream alterations to gene expression or cell patients achieve additional improvement when used in tandem signaling cascades.1 Light administered either through low with on-going office treatments; in other instances circum- powered lasers or LEDs with a wavelength in the red to near stances preclude patients from presenting for in-office treat- infrared region of the spectrum (660nm–905nm), had been ment, and in those cases HUDS help patients maintain and/ or achieve additional gains. Never has this been more relevant Home-use devices (HUDs) enable patients to continue their care than it is today: The COVID-19 pandemic and its associated while they’re at home and provide us with an opportunity to guide call to shelter in place make the ability for patients to perform our patients to options that will augment our onsite treatments and treatments at home an unanticipated benefit. No one could interventions. We must counsel patients who purchase HUDs to have foreseen that our offices would be closed for an extended have realistic expectations and must advise that they choose only period of time, or that routine, non-emergent care would be devices that are FDA approved or cleared. The FDA’s “thumbs up” temporarily halted. Despite these unprecedented circumstanc- means a device is safe and effective, so guiding patients toward es, HUDs enable our patients to continue treatment. this technology and away from items that have not been sufficiently HUDs provide patients with a vehicle to enable them to con- vetted means we can comfortably vouch for the device’s safety and tinue their care while they’re at home and provide us with an ability to provide results. opportunity to guide our patients to options that will augment our onsite treatments and interventions. First and foremost, we must counsel patients who purchase HUDs to have realistic expectations; second, we must advise that they choose only devices that are FDA approved or cleared. The FDA’s “thumbs thebottomline

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proven in clinical trials to have a good effect on pain, inflam- nitric oxide (NO). Simulation of NO leads to vasodilation mation and tissue repair before it became clear that low-level and increased blood flow, which is associated with renewal laser induced hair growth. Research suggests that when LLLT of cells that grow hair. is applied to the scalp, it acts to increase the number of hair follicles as well as hair’s tensile strength and that this is HAIR REMOVAL likely achieved through improved microvascular circulation, The global hair removal devices market was valued at USD reduced inflammation, and increased cell energy in the form 1.2 billion in 2017 and is expected to expand at a CAGR of of adenosine triphosphatase (ATP).2 14.9 percent throughout the period ending 2025. The home- Light therapy is an attractive option for patients in search use segment of the hair removal devices market is anticipated of hair growth solutions—especially those who are inter- to exhibit impressive growth over the forecast period, as well, ested in at-home treatment—and patients with patterned due to widespread demand and easy availability of these hair loss have impressive levels of success with at-home LLLT devices through retail and online distribution channels.5 devices. In 2007, the first at-home LLLT hair growth device, A number of at-home hair removal devices have been the HairMax Laser Comb, was cleared by the FDA. Patients developed in the past decade. These devices are based on using the comb had a greater increase in mean terminal the technology used in office-based devices that selectively hair density compared with those using a sham device,3 heat the hair follicles, minimizing injury to surrounding tissue. however, the device did not provide uniform light delivery Diode lasers held the maximum share of the global laser hair and was also limited by weak patient adherence. Laser hel- removal market in 2018 owing to their precision; these lasers mets and caps were among the products that followed the are mostly effective for dark . Lasers including laser comb, and research, as well as anecdotal experience, the ruby, the long-pulsed alexandrite, and the neodymium: indicates that light delivered in a wearable helmet or cap yttrium, aluminum, and garnet (Nd:YAG) have shown efficacy resolves the dose uniformity issue. in the reduction of unwanted hair, but the Intense Pulsed Lightweight LEDs make wearable light-based technol- Light (IPL) devices have shown both safety and efficacy in hair ogy, such as caps, less bulky, and integrated smart-device removal. I played an integral role as a clinical investigator in apps enable users to plan and monitor treatment sessions. many of the IPL clinical trials, and several of these devices have These features are among the trends supporting the ubiq- received FDA clearance for permanent hair reduction.5 uitous use of laser and light-based HUDs. Revian Red is an Silk’N (Home Skinovations Inc./Unilever) hair removal example of a HUD that incorporates both of those features, devices are an ideal example of IPL home use hand-held epila- as well as several other perks that make it a standout among tion technology. Silk’N was the first pulsed-light hair removal home-use hair growth devices. Revian Red is built around a product for home use, as well as the first to be cleared by wearable, wireless “smart cap” controlled by a mobile app. the FDA. The small, portable, low-energy IPL device is now Bluetooth connectivity keeps patients on track by both acti- among the main players in this sector. The specifications for vating and logging treatments. The FDA-cleared Revian Red the Silk’N device include wavelengths of light from 475nm system has demonstrated the ability to stop hair loss and to 1200nm, a maximum energy density of 5J/cm2, a spot size subsequently promote hair growth. Revian has proven that of 20x30mm, and a pulse rate of one pulse every 3.5 seconds. the more patients use the app, the more hair they will grow. Post-treatment cooling of the is not required because of The company conducted a double-blind, placebo-controlled the low energy utilized with this device, and protective eye- study to test the effectiveness of the dual band LED light wear is not required or necessary because the light delivered is therapy and found that subjects, on average, may experience self-contained within the device.5 These features make it user a greater net increase in total hair counts than those pub- friendly, while still effective. lished for alternative chemical-based topicals, prescription In one study of the Silk’N device by Mulholland and col- drugs, and laser devices, based on cross-study comparisons.4 leagues, 34 individuals utilized the Silk’N device, with each The lightweight, cordless cap is easy to use and gives subject receiving three treatments at two-week intervals; patients freedom of movement during treatment, which they were followed for three months. The two-week hair they say enables them to wear the cap while going about reduction was 74 percent, and the four-week reduction was their daily routines. This system is the first and only dual 84 percent. At the three-month follow-up mark, 95 percent band, all LED light therapy system. It features a pat- of all of the patients noted improvement with an average ented combination of two wavelengths of LED light— reduction of 64 percent.6 620nm and 660nm—that work together to unlock the Many laser-based home hair-removal devices are avail- body’s natural ability to accelerate healing by stimulating able outside the United States and it is imperative that we

52 PRACTICAL DERMATOLOGY AUGUST 2020 ENERGY-BASED DEVICES ENERGY-BASED DEVICES LASER Plasma Radiofrequency Ultrasound ASSISTED MICRONEEDLING Electromagnetic Pulse Picosecond Acoustic Pulse Nd:YAG LED thulium IPL COMBINED ENERGIES CO2Superficial Radiation Blue Light

stress to our patients that they choose only FDA- cleared or to understand that home use acne treatment devices do not approved devices that are available in the US. The clinical replace doctor visits or devices that can only be accessed outcomes of devices coming in from outside of the US may in the doctor’s office. Just as with laser and light-based hair not live up to their claims. growth and removal tools, acne HUDs can augment the IPL technology has been used in hair removal mainly for therapies that we provide. Price is very important in this sec- skin types I to IV (and occasionally on skin type V) when tor, because a large population of those interested in these appropriate cut-off filters were used.10 At-home devices solutions are teenagers or the parents of teenagers. Similarly, offer the advantage of constant availability and greater pri- safety is a crucial element for any HUD, but it is perhaps vacy,11 but as with all heat-producing light sources, these even more of priority in this category because of the vast devices are designed to cause biologic damage. As such, a number of young people who purchase these devices. level of caution is necessary when using these laser- or light- based hair removal devices.12,13 Although clinical results have HERE TO STAY confirmed the safety and efficacy of hair removal at home Home use laser and light based devices are here to stay. If in skin types I to IV, use of HUDs for hair removal of darker you want to ensure that your patients use devices that have skin types (V–VI) is more challenging. Combined electro- been cleared or approved by the FDA, your practice can act optical technology, integrating optical IPL energy with bipo- as the middle man between manufacturers and clients. By lar radio frequency (RF) energy, has shown significant results doing so, you guarantee that your patients are using safe in different dermatologic applications, such as hair removal and effective technology and that they will maintain their and skin rejuvenation.14-17 relationship with you and your practice while using HUDs as Performing hair removal with an at-home use device takes an adjunct to the treatments you provide. n a lot longer than it does in my office, but, for patients who Financial Disclosure: Dr. Gold is a consultant and performs are interested and are good candidates, we sell a HUD IPL clinical research for Home Skinovations and REVIAN. system as a maintenance device. If it ever becomes more than maintenance, then we get the patient back in the office Michael H. Gold, MD, is the founder of Gold Skin Care Center, to reestablish the primary treatment and once again relegate Advanced Aesthetics Medical Spa, The Laser & Rejuvenation the HUD to an adjunctive role. Center, and Tennessee Clinical Research Center in Nashville, Tennessee. Dr. Gold is also a Clinical Assistant Professor at AT-HOME ACNE DEVICES Vanderbilt University School of Nursing and an Adjunct Assistant A variety of home use devices are affective for mild to mod- Professor at Meharry Medical College, School of Medicine, in erate acne treatment. Demand for these devices is steady and Nashville. [email protected] will continue to flourish as long as there are teens and young 1. Hamblin MR. Photobiomodulation or low-level laser therapy. J Biophotonics. 2016;9(11–12): 1122–4. adults who are committed to perfecting the selfie. 2. Waiz M, Saleh AZ, Hayani R et al (2006) Use of the pulsed infrared diode laser (904 nm) in the treatment of alopecia Blue-light LED therapy has become widely used for the areata. J Cosmet Laser Ther 8:27–30. 3. Leavitt M, Charles G, Heyman E, Michaels D. Clin Drug Invest. 2009;29(5):283-292. treatment of inflammatory acne. One important study 4. PhotonMD data on file; ClinicalTrials.gov Identifier: NCT04019795. 5. Gold MH, Foster A, Biron JA. Low-energy intense pulsed light for hair removal at home. J Clin Aesthet Dermatol. where we evaluated the efficacy of a home use hand-held 2010;3(2):48–53. blue-light LED application found that using blue-light LED 6. Mulholland RS. Silk’n—a novel device using home pulsed light for hair removal at home. J Cosmet Laser Ther. 2009;11(2):1069.) therapy on a daily basis—which is possible with a HUD— 7. Dierickx CC. Hair removal by lasers and intense pulsed light sources. Dermatol Clin 2002; 20: 135– 46. 8. Troilius A, Troilius C. Hair removal with a second-generation broad spectrum intense pulsed light source-a long term resulted in better improvement and faster resolution of follow-up. J Cutan Laser Ther 1999; 1: 173– 8. inflammatory acne lesions. There was a significant difference 9. Sadick NS, Shea CR, Burchette JL, Prieto VG. High intensity flashlamp photoepilation. Arch Derma- tol 1999; 135: 668– 76.) in the response of lesions to the blue-light LED application 10. Weiss RA, Weiss MA, Marwaha S, Harrington AC. Hair removal with a non-coherent filtered flashlamp intense pulsed light source. Lasers Surg Med 1999; 24: 128– 32. as opposed to the placebo in terms of reduction in lesion 11. Alster TS, Tanzi EL. Effect of a novel low-energy pulsed-light device for home-use removal. Dermatol size and lesion erythema, as well as improvement in the Surg 2009; 35: 483– 9. 12. Town G, Ash C. Are home-use intense pulsed light (IPL) devices safe? Lasers Med Sci 2010; 25: 773– 80. overall . Signs of improvement were observed 13. Brown AS. At-home laser and light-based devices. Curr Probl Dermatol 2011; 42: 160– 5. 14. Sadick NS. Combination radiofrequency and light energies: electro-optical synergy technology in esthetic medicine. as early as after two treatments. Time to resolution was sig- Dermatol Surg 2005; 31: 1211– 7. nificantly shorter for the blue-light LED therapy.18 15. Sadick NS, Laughlin SA. Effective epilation of white and blond hair using combined radiofrequency and optical energy. J Cosmet Laser Ther 2004; 6: 27– 31. Researchers have used blue light, a combination of blue 16. Yaghmai D, Garden JM, Bakus AD, Spenceri EA, et al. Hair removal using a combination radio-frequency and intense pulsed light source. J Cosmet Laser Ther 2004; 6: 201– 7. and red light, and a combination of blue and infrared light 17. Goldberg DJ, Marmur ES, Hussain M. Treatment of terminal and vellus non-pigmented with an optical/bipolar radiofre- to treat acne. We like blue light sources and we did all the quency energy source‐with and without pre-treatment using topical aminolevulinic acid. J Cosmet Laser Ther 2005; 7: 25– 8. 18. Gold MH, Sensing W, Biron JA. Clinical efficacy of home-use blue-light therapy for mild-to moderate acne, Journal of original work evaluating blue light for home-use acne devic- Cosmetic and Laser Therapy, 2011;13:6, 308-314, es. Regardless of the device used, it’s important for patients

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