Intense Pulsed Light (IPL) Therapy (2024)

Continuing Education Activity

Intense pulsed light (IPL) therapy was first developed in 1992 to treat leg telangiectasias, and initial studies were conducted on rabbit ear veins. Since then, studies have demonstrated IPL to be a safe and effective means of treating pigmented and vascular disorders, including melasma, post-inflammatory hyperpigmentation, lentigines, ephelides, telangiectasias, port-wine stains, rosacea, poikiloderma of Civatte, hemangiomas, and venous malformations, in addition to hair removal and photoaging. This activity reviews the physics of IPL therapy, its indications and contraindications, and technical aspects of IPL delivery and highlights the role of the interprofessional healthcare team in administering IPL treatments.

Objectives:

• Describe the difference between IPL and laser energy.

• Identify the indications for IPL therapy.

• Review the physics of the interaction between light energy and biological tissues.

• Summarize the role of the interprofessional team in the delivery of IPL treatment and the longitudinal care of the IPL patient.

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Introduction

Intense pulsed light (IPL) therapy was first developed in 1992 by Drs. Goldman, Fitzpatrick, and Eckhouse for the treatment of leg telangiectasias. Proof-of-concept studies were conducted on rabbit ear veins, demonstrating IPL's ability to thermocoagulate vessels while minimizing purpura or epidermal damage.[1]Since the first FDA-approved IPL device wasbrought to the market in 1995, thistechnology has undergonesignificant innovation and improvement in its clinical applicationsand affordability.[2][3]

IPL devices are unique in that they employ flashlamps and bandpass filters to produce pulsed light ofvarying wavelengths, durations, and fluences.These aspects promote its versatility in treating numerous dermatological diseases.[4][5]IPL issafe and effective in treating benign pigmented and vascular disorders and hairremoval and photoaging.[6]Currently, IPL is an invaluable tool in dermatology and is frequently used to address a broad range of medical and cosmetic concerns.[7]

Anatomy and Physiology

IPLuses aflashlamp to emit polychromatic light across a broadwavelength spectrum of approximately 400–1400 nm, which makes it fundamentally different from a laser (light amplification by stimulated emission of radiation), whose light is necessarily monochromatic (of a single wavelength), collimated (with waves running in parallel), and coherent (with waves in phase).[6] The advantage ofbroadband light is that it allows for greaterversatility in treating a variety of skin types and conditions. Furthermore, the wavelength of light emitted from an IPL machine can be adjusted by applying filters.

Lasers and light devices produceaclinical effect when their light is absorbed by the skin, resulting in the emission of photons that carry thermal energy.[8]Chromophores (e.g., hemoglobin, water, melanin) in the skin absorb the photons and are subsequently heated by thermal energy, causing their destruction through thermocoagulation. This phenomenon of selective photothermolysis is the underlying basis of IPL technology.[9]

Indications

The United States Food and Drug Administration (FDA) has approved IPL for telangiectasias,photorejuvenation, facial wrinkles, hyperpigmentation, lentigines, ephelides, melasma, rosacea, acne vulgaris, poikiloderma of Civatte, port-wine stains, hemangiomas, legveins, venous malformations, and removal of unwanted hair.[10] IPL was also recently introduced to ophthalmology to manage dry eye disease due to meibomian gland dysfunction.[11]

Contraindications

Intense pulsed light treatment sessions are relatively safe and tolerable. However, it may be beneficial toavoid IPL in certain individuals, such as those with a recent sunburn andin pregnant or breastfeeding women. IPL has also been found to induce reactivation of the herpes simplex virus (HSV) on the face or genitals via transient hyperthermia and activate latent HSV in the trigeminal ganglion.[12] In patients with a previous history of HSV infection, starting prophylactic antiviral therapy (oral acyclovir, valacyclovir, or famciclovir) may be warranted a day before IPL treatment and continue for up to two weeks afterward.[13][14]

Equipment

The underlying mechanism of IPL therapy involves four crucialconcepts (wavelength, pulse duration, fluence,and spot size):

Wavelength

Flashlamps emit polychromatic light within a wavelength spectrum of approximately 400to 1400 nm.[15] The wavelength of light can beadjustedusing cut-off filters, which allow certaintissues to be targeted via selective photothermolysis. The skin contains different chromophores, molecules that absorb light of a specific wavelength and convert it to thermal energy.Whenselecting a wavelength, the healthcare provider should be aware of competing chromophores within the treatment area. For example, melanin in the epidermismay shield the targetedchromophoreslocated in a deep layer of the skin. This concept is particularly important when administering IPL in patients withdarker skin types, as special attention must be given to treat them safely and prevent dyschromias. Since melanin tends to absorb light atshorter wavelengths, selecting longerwavelengths that penetrate deeper and spare the epidermis may benefit darker skin patients. Given this same principle, shorter wavelengths effectively treat pigmented lesions in patients withlighter skin.[16]

Pulse Duration

Pulse duration is based on the thermal relaxation time (TRT) of the chromophore, or the timerequired for the temperature in a heated tissue to decrease to 37%of its peak.[17]To minimizethermal damage to the target tissue, the pulse duration should be shorter than its TRT.If the target isheated for a longer period than the TRT, thesurrounding tissue may be impacted with subsequent scarring or hypopigmentation. Allowing appropriateTRT between pulses alsoprevents epidermal temperatures from rising above 70degrees C.Some IPL devicescan only producea single pulse, while others can produce multiple sequential pulses. Delay times between sequential pulses are routinely10to 12 ms to accommodate epidermal TRT, whereas a 20-40 ms TRT is advisedfor patients with darker skin types.Thermal relaxation time is also adjusted to account for chromophore and lesion size. Larger chromophores, such as hair follicles, require more time to cool down due to longer TRT.

Fluence

Fluence (J/cm2) describes the amount of energy delivered per unit area. IPLcan deliver afluence up to 40 J/cm^2, while pigmented lesionsare usuallytreated with a fluenceof only 16–20 J/cm2. A higher fluence may be used if a target is located deep within the skin or the chromophoresareinefficient at absorbing light. Importantly, side effectstend to occur more frequently at higher fluences and in darker-skinnedindividuals.[18] Cooling devices assist with the delivery of higher fluences while protecting the epidermis from damage (epidermal bypass), as thermal energy is delivered todeeper tissue.[19]

Spot Size

Spot size is the diameter of light that is emitted from the flashlamp. Increased spot size allows for light to penetrate deeper because scattering isminimized. Thus, a smaller spot size will require higher fluences to target deeper dermal targets effectively.

Cooling Systems

Cooling systemsprovide epidermal protection and permit greater fluences to reach deeper targets. Cooling systems can be internal, such as integrated chilled tips, pulsed cryogen sprays, or cooled glass chambers. External cooling methods include ice packs, forced-air cooling,or cold ultrasound gel applied to the skin before a treatment session. The cold gel reduces the friction of the handpieceon the skin, diffuses the surface heat releasedfrom the handpiece, anddecreases the refractive index between air and skin,allowing for better penetration and light absorption.

Personnel

IPL treatments, like many laser treatments, are typically provided in the outpatient clinic setting. A physician or surgeon may perform IPL treatments, but it is frequently a mid-level healthcare provider, such as a physician assistant or a nurse practitioner, providing the treatments. In some areas, registered nurses are permitted to provide laser and IPL treatments as well. Regardless, having a physician, such as a plastic surgeon or dermatologist, involved in the care team ensures that an experienced clinician can manage complications should they arise.

Preparation

Preparation for IPL treatment requires finding the patient a comfortable, private treatment room to expose whatever skin area is problematic without fear of embarrassment. The IPL machine requires a few square feet of floor space and frequently a 220 V outlet for power, which is not uniformly available in the United States. A cold gel is also helpful in improving energy transmission from the handpiece to the skin and patient comfort.

IPL can damage pigmented ocular tissues such as the retina; therefore, eye protection with the appropriate optical density is critical for the patient and the IPL treatment provider. Eye shields should not berepositioned mid-procedure, as this may interfere with the treatment session and lead to inadvertent ocular damage.

Pre-procedure informed consent is important for IPL treatments, as it is for any procedure, and the discussion should focus on the development of reasonable expectations, particularly with respect to final outcome, anticipated number of treatments required to achieve the desired result, post-procedure precautions, like avoiding sun exposure, and the potential for complications, such as temporary or permanent hyper or hypopigmentation, erythema, crusting, blistering, and scarring.[20][21]

Technique or Treatment

In contrast to lasers, IPL devices produce noncoherent, polychromatic light with a broadrange of wavelengths. Their fluence, pulse duration, spot size, and filter type can be adjusted for thegoal of targeting specific chromophores. Thus, IPL devices can treat a wide variety of lesions and skin types. Lesion clearance oftendepends on the frequency of treatment sessions as the effect of pulsed light is cumulative, routinely requiring 3to 6 treatments every2to 4 weeks for the full clinical effect to be achieved.[4] Lesions that are more heavily pigmented may require a higher number of treatment sessions.Lesions deeper within the dermis may also requiremore treatments asthey are more challenging to penetrate. Compared to laser devices, IPL is associated with a shorter recovery time and lower equipment costs. Disadvantages of IPL include incorporating the lampand cooling device into the handpiece, which contributes to device heaviness. Cold gel applied to the skinalso diminishesthe visibility of immediate local skin reactions.[6]

Complications

Although side effects of IPL are typicallyrare and minimal in severity, the most common adverse events include pain and erythema.Other reported side effects includeedema, bullae, hematoma, crusting, hyper/hypopigmentation, leukotrichia, scarring, keloid formation, and infection.[21]For untrained medical providers, theuse of inappropriatedevicesettings and administration of excess thermal energycanlead to nonspecific thermal damage and complications. IPLisparticularly challenging to use on dark-skinned individuals, and careful consideration must be given to these patients.

Shorter wavelengths are generally reserved for fair skin types, as these wavelengthsare absorbed bymelanin and lead to pigmentation changes in patients with darker skin. However, device-related cooling technology has helped minimize these side effectsin darker complexions. Skin reactions typically last for about 2to 48 hours posttreatment and often depend on the fluence, pulse duration, and specific treatment area. Higher fluences and pulse durations, thinner skin, and darker skin types may increase the likelihood of adverse events.

In patients undergoing hair removal, an adverse effect of paradoxical hypertrichosis may occur.[22] This phenomenon describes the growth of fine, dark hair in areas close to the target tissue, especially in patients with darker skin types (Fitzpatrick III-VI). The underlying mechanism has not been fully elucidated. Still, potential causes include IPL wavelengths stimulating hair follicular stem cells to promote hair growth, IPL inducing the release of cytokines and growth factors with the conversion of vellus hairs to terminal hairs, and varying patient characteristics.[23][24]Treatment options include increasing the energy, decreasing the interval between treatments, using more cooling, changing the wavelengths (e.g., from IPL to 1,064 nm Nd: YAG laser), and using topical eflornithine to slow down hair regrowth after treatments.

Clinical Significance

Intense pulsed light (IPL)utilizes high-intensity light sources to treat a wide range of dermatological diseases. IPL technology has evolved tremendously since the 1990s with theaddition of higher intensityflashlamps,cut-off filters, and cooling systems. These features haveenabledIPL to be an ideal tool fortreating a variety of pigmented lesions, including solar lentigines and ephelides, vascularlesions such as telangiectasias, port-wine stains, hemangiomas, and leg veins, as well as hair removal andphotoaging.[25][26] Newer IPL devices also allow for more specific targeting with increasedaccuracy and less light scattering.

Enhancing Healthcare Team Outcomes

Achieving the best outcomes with intense pulsed light therapy involves an interprofessional team ofhealthcareproviders, including a skilled dermatologist/plastic surgeon and often physicianassistant or nurse practitioner, aesthetician, medical assistant, and office staff. The patient should beeducated on what to expect during and after the procedure and potential side effects. For example, thepatient should be counseled on cold gel application before IPL treatment and usingprotective eyewear during treatment sessions. It is also important to gauge the patient's expectations andassess clinical improvement. Patients should be informed that thebest results are achieved after a series of at least two or more IPL treatments. [Level 1]

Review Questions

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References

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Disclosure: Anita Gade declares no relevant financial relationships with ineligible companies.

Disclosure: Gabriella Vasile declares no relevant financial relationships with ineligible companies.

Disclosure: Richard Rubenstein declares no relevant financial relationships with ineligible companies.