newsletter

Sign up to receive the latest product training and update information

PHOTOREJUVENATION BY INTENSE PULSED LIGHT
DR. A. BALZANI, G. MONTESI, D. INNOCENZI, S. CALVIERI
Dipartimento di Malattie Cutanee-Veneree e Chirurgia Plastica-Ricostruttiva
Università degli Studi di Roma "La Sapienza"

In the previous edition we reported our experience of photo rejuvenation of type I with IPL. We recall briefly some fundamental concepts and we will present photo rejuvenation of type II with IPL, combined with Eporex K69 system.
Photo ageing is characterized by dry and fine skin (xerotic), dark spots, lines and wrinkles and skin damaged by tumors. Photo rejuvenation with IPL proved to be able to stop this multistep process and also to eliminate many of its manifestations.
Photo rejuvenation means a dynamic and non ablative process to rejuvenate the skin by using intense pulsed light and low pulsed light.
IPL is not a laser but a light source of broad spectrum which a emits light with a wavelength between 500 and 1200 nms non coherent and not collimated. This lightbeam can be 'cut' with quarz called filters to obtain the desired wavelength. According to the type of skindamage to be treated we can classify the photo rejuvenation in three types:
- type I is indicated for the treatment of irregular pigmentation and freckles. Other indications are for teleangectasie, rosacea, melasma, and erythema spread over the face.
- type II is indicated for skin that shows looseness, lines, wrinkles, actinic damage.
- type III is indicated for patients that show all the previous skin conditions of the other two types (I and II) in combination with the presence of pre carcinogenic and carcinogenic conditions.

Photo rejuvenation type II

Photo rejuvenation of type II induces dermo-epidermic changes and is indicated for loose skin, lines, wrinkles, actinic damage and acne scars. Excellent results are achieved combining retinoic acid and botulinum neurotoxins of type A with IPL treatment.
Retinoic acid is a natural derivative of vitamin A and is available for topic use in two isomeric forms: the all trans form and the 13-cis form. They perform through the interaction of nuclear receptors RARs and RXRs, present in the epidermic cells, the sebaceous glants and derma. Both isomers are used in topical treatments of moderate acne joined with systemic antibiotic therapy.
During the treatment of skinageing the two isoforms lead to a significant reduction of atipia of cheratinociti and melanociti and an increase of the thickness of collagene fibres.

Treatment with toxin botulinum type A (BTX/A), is commonly employed by dermatologists and plastic surgeons to eliminate the face wrinkles and, recently, the neck wrinkles, determined by the muscles contraction. Such toxin is a polypeptide consisting of a light chain and heavy chain, and it acts at the level of the neuromuscular junction. In correspondence of the neurons membrane, the toxin is internalized through a receptor-mediate endocytosis and released into the cytoplasm. Inside the cell the cleavage of the two chains happens, and the light chain binds the SNAP21, a protein involved in the acetylcholine release by the nervous terminations. The result of such trial is the block in the acetylcholine release with consequent muscular paralysis.

The protocol we applicated for photo rejuvenation type II was the use of VascuLight Plus (Lumenis), a multi device equipped with a IPL source with a spectrum of emission between 515 and 1200 Nm and a laser source ND-Yag with a wavelength of 1064Nm.
Amongst other technical specifications it is important to remind that the flow supplied in the form of impulses or 'blows' can be applied as one single impuls or repeated impulsed until a maximum of three. Furthermore it is possible to interfere with the length of time of every single impuls as well as the interval between the impulses, permitting to respect the time of termic relaxation of the tissue.

In combination with the VascuLight treatment we used a transdermal delivery system called Eporex K69 (Medical&Technology).
Our aim is to penetrate active substances into the skin in a absolute non-traumatic way but with a concentration sufficient to treat effectively the area. Recent studies show that the penetration into the skin of most dermatologic formulations on the market is only 1-5% of the applied dose.
The electronic transdermal delivery system has been used for decades for administration of painkilling drugs and rehabilitative therapy. Recently it was introduced in the field of dermathology with the adjustment of various methods of penetration, such as sonophoresis, ionophoresis, iontophoresis, electroporation etc.
The Eporex K69 uses a new method of transdermal delivery called isophoresis.
With isophoresis a pulsed and modulated current is used. A low fequency wave with an elastomodulated waveshape and a modulated intensity, which can be varied by the operator. In this way it is possible to electronically activate molecules with both high and low molecule weight. This allows them to pass into the extracellular compartment at the depth desired.
In this way we achieve a double objective: the increase in the permeability of skin tissue even at the deepest levels of the dermis and the capacity of introducing active hydrosoluble substances.
Eporex K69 has to important features:
1. The wave modularity non contineous, negative/positive or alternate, constituted by a pulse train with a sinusoidal mode, separated by intervals that can be modified in frequency according to the wave equation
Y = X - 180+2000
where Y is the frequency in Hz and X the depth in centimeters, enables the product to be carried without thermal damage for several centimeters. The wave modulation avoids the absorption of to much energy into tissue because of thermal recovery.
2. The presence of a ionisation chamber, in the handpiece that polarises and prepares molecules electrically and no ions, with the possibility of thereby carrying any hydrosoluble substance through the opening of the so called 'electropores' and easier intracellular penetration: the 'indissociated' molecules actively brought to into the cells will modulate the metabolism in relation to their characteristics and concentration and they will move towards the dermal matrix by electrosmosis.
In brief:
- ionisation of the substance: the elastopulsated current meets the molecule, then ionises it and makes it 'active' ready for transport.
- transmission: the isonised molecule is transferred to the optimal depth.
- electroporation: after around 10 minutes electropores are created and the molecules transfer the substances from one cell to another by osmosis.

At our department of skin and veneral diseases and plastic and reconstructive surgery we have treated 10 patients with photo damage type III according to the Glogau classification (dyscromia, teleangectasie, cheratosi visible and wrinkles even in a relaxed face.
Every patient is treated six times with IPL at intervals of three weeks.
The filter used for all treatments is the one with a wavelength of 590Nm; the flow varied between 35 and 45 J/cm2, with trains of double or triple impulses of 2,4-4,7 msec, with delays between 10 and 60 msec.
In combination with the IPL treatment we carried out 6 sessions with Eporex K69 at intervals of 10 days between one session and another.
The substances we transferred were: branched aminoacids, derivatives of placenta and the all-trans form of retenic acid.
We report the following significant cases:
Patient 1: with photoaging in fase III according to the classification of Glogau.
Patient 2: with photoaging fase III in particular in the cheekbone area.

All patients reported satisfaction valued from good to very satisfied. The side effects (eritema and a sense of tightness of the skin) reported by three patients were always transitory and did not need specific treatment. The clinical improvement we pointed out, such as a reduction of the number of lines and deepness of the wrinkles, iperpigmentation, teleangectasie was always of elevated degree.

In conclusion: Intensive Pulsed Light (IPL) in combination with this new transdermal delivery system is a valid therapeutic and non invasive method to obtain photo rejuvenation of the face and neck.