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.
- 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.
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. Since the first FDA-approved IPL device was brought to the market in 1995, this technology has undergone significant innovation and improvement in its clinical applications and affordability.
IPL devices are unique in that they employ flashlamps and bandpass filters to produce pulsed light of varying wavelengths, durations, and fluences. These aspects promote its versatility in treating numerous dermatological diseases. IPL is safe and effective in treating benign pigmented and vascular disorders and hair removal and photoaging. Currently, IPL is an invaluable tool in dermatology and is frequently used to address a broad range of medical and cosmetic concerns.
Anatomy and Physiology
IPL uses a flashlamp to emit polychromatic light across a broad wavelength 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). The advantage of broadband light is that it allows for greater versatility 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 produce a clinical effect when their light is absorbed by the skin, resulting in the emission of photons that carry thermal energy. 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.
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, leg veins, venous malformations, and removal of unwanted hair. IPL was also recently introduced to ophthalmology to manage dry eye disease due to meibomian gland dysfunction.
Intense pulsed light treatment sessions are relatively safe and tolerable. However, it may be beneficial to avoid IPL in certain individuals, such as those with a recent sunburn and in 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. 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.
The underlying mechanism of IPL therapy involves four crucial concepts (wavelength, pulse duration, fluence, and spot size):
Flashlamps emit polychromatic light within a wavelength spectrum of approximately 400 to 1400 nm. The wavelength of light can be adjusted using cut-off filters, which allow certain tissues 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. When selecting a wavelength, the healthcare provider should be aware of competing chromophores within the treatment area. For example, melanin in the epidermis may shield the targeted chromophores located in a deep layer of the skin. This concept is particularly important when administering IPL in patients with darker skin types, as special attention must be given to treat them safely and prevent dyschromias. Since melanin tends to absorb light at shorter wavelengths, selecting longer wavelengths that penetrate deeper and spare the epidermis may benefit darker skin patients. Given this same principle, shorter wavelengths effectively treat pigmented lesions in patients with lighter skin.
Pulse duration is based on the thermal relaxation time (TRT) of the chromophore, or the time required for the temperature in a heated tissue to decrease to 37% of its peak. To minimize thermal damage to the target tissue, the pulse duration should be shorter than its TRT. If the target is heated for a longer period than the TRT, the surrounding tissue may be impacted with subsequent scarring or hypopigmentation. Allowing appropriate TRT between pulses also prevents epidermal temperatures from rising above 70 degrees C. Some IPL devices can only produce a single pulse, while others can produce multiple sequential pulses. Delay times between sequential pulses are routinely 10 to 12 ms to accommodate epidermal TRT, whereas a 20-40 ms TRT is advised for 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 (J/cm2) describes the amount of energy delivered per unit area. IPL can deliver a fluence up to 40 J/cm^2, while pigmented lesions are usually treated with a fluence of only 16–20 J/cm2. A higher fluence may be used if a target is located deep within the skin or the chromophores are inefficient at absorbing light. Importantly, side effects tend to occur more frequently at higher fluences and in darker-skinned individuals. Cooling devices assist with the delivery of higher fluences while protecting the epidermis from damage (epidermal bypass), as thermal energy is delivered to deeper tissue.
Spot size is the diameter of light that is emitted from the flashlamp. Increased spot size allows for light to penetrate deeper because scattering is minimized. Thus, a smaller spot size will require higher fluences to target deeper dermal targets effectively.
Cooling systems provide 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 handpiece on the skin, diffuses the surface heat released from the handpiece, and decreases the refractive index between air and skin, allowing for better penetration and light absorption.
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 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 be repositioned 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.
In contrast to lasers, IPL devices produce noncoherent, polychromatic light with a broad range of wavelengths. Their fluence, pulse duration, spot size, and filter type can be adjusted for the goal of targeting specific chromophores. Thus, IPL devices can treat a wide variety of lesions and skin types. Lesion clearance often depends on the frequency of treatment sessions as the effect of pulsed light is cumulative, routinely requiring 3 to 6 treatments every 2 to 4 weeks for the full clinical effect to be achieved. Lesions that are more heavily pigmented may require a higher number of treatment sessions. Lesions deeper within the dermis may also require more treatments as they 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 lamp and cooling device into the handpiece, which contributes to device heaviness. Cold gel applied to the skin also diminishes the visibility of immediate local skin reactions.
Although side effects of IPL are typically rare and minimal in severity, the most common adverse events include pain and erythema. Other reported side effects include edema, bullae, hematoma, crusting, hyper/hypopigmentation, leukotrichia, scarring, keloid formation, and infection. For untrained medical providers, the use of inappropriate device settings and administration of excess thermal energy can lead to nonspecific thermal damage and complications. IPL is particularly 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 wavelengths are absorbed by melanin and lead to pigmentation changes in patients with darker skin. However, device-related cooling technology has helped minimize these side effects in darker complexions. Skin reactions typically last for about 2 to 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. 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. 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.
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 the addition of higher intensity flashlamps, cut-off filters, and cooling systems. These features have enabled IPL to be an ideal tool for treating a variety of pigmented lesions, including solar lentigines and ephelides, vascular lesions such as telangiectasias, port-wine stains, hemangiomas, and leg veins, as well as hair removal and photoaging. Newer IPL devices also allow for more specific targeting with increased accuracy and less light scattering.
Enhancing Healthcare Team Outcomes
Achieving the best outcomes with intense pulsed light therapy involves an interprofessional team of healthcare providers, including a skilled dermatologist/plastic surgeon and often physician assistant or nurse practitioner, aesthetician, medical assistant, and office staff. The patient should be educated on what to expect during and after the procedure and potential side effects. For example, the patient should be counseled on cold gel application before IPL treatment and using protective eyewear during treatment sessions. It is also important to gauge the patient's expectations and assess clinical improvement. Patients should be informed that the best results are achieved after a series of at least two or more IPL treatments. [Level 1]