P hotorejuvenation using intense pulsed light (IPL) is now the gold standard of non-ablative skin treatments, particularly for what has become known as type A photorejuvenation changes. These include vascular and pigmentary changes associated with photoaging, lentigines, telangiectasias and symptoms of rosacea.1 Numerous studies have been published outlining the clinical benefits of IPL skin treatments using photorejuvenation, and tens of thousands of patients have benefited from treatment over recent years.2,3,4

IPL photorejuvenation is a dynamic non-ablative process defined as a use of non-coherent intense pulsed light at a low fluence, non-ablative level to rejuvenate the skin. Most physicians administer a series of five procedures at 2- to 3-week intervals. Typically, the entire face is treated. However, a number of studies have shown that significant improvement can occur in areas other than the face, including the neck (a condition such as poikiloderma of Civatte), the chest (in patients with poikiloderma and/or photodamage, and areas of lentigines), as well as other types of damage on areas such as the hands and the arms.6

Recent Developments
In the past few years, photorejuvenation techniques have advanced, allowing significant improvements in the treatment of photoaging and associated pigmentary disorders, as well as intrinsic benign vascular disease processes and rosacea.5,6 The combined use of IPL photorejuvenation skin treatments with other treatments, including non-ablative laser treatments such as 1064 nm and 1320 nm lasers,7,8 microdermabrasion procedures,9 and the use of botulinum toxin A (Botox)10 can simultaneously improve many aspects of cutaneous photoaging conditions. Additionally, it has become clear that the marriage of IPL and pharmacologic treatments for disease conditions such as rosacea11 and melasma12 can dramatically improve overall results. These adjunctive procedures and procedural and pharmacologic methods have opened new possibilities for dramatic advancement and improvement in cosmetic treatment and disease therapy.

Early indications of studies now in progress show that the combination of IPL and photodynamic therapy sensitizers such as DUSA Pharmaceutical’s 5-amino levulinic acid (ALA) (Levulan) allow for new options in the treatment of severely photodamaged skin,13 and may offer a significant cosmetically beneficial alternative to photodynamic treatments with blue light for such conditions as actinic keratoses (AKs),14 early skin cancers15 and cystic acne.16

IPL photorejuvenation techniques may soon open the benefits of reversal of sun-induced changes to a range of patients far wider than those seeking conventional cosmetic treatment. We see clinical promise in these techniques that preserve the benefits of non-ablative IPL procedures, such as low discomfort, low risk and no down time.

IPL Photorejuvenation Technology
Over the past few years, IPL technology utilized by the VascuLight and Quantum platforms, manufactured by Lumenis Inc., offers what has become the standard of care for the photorejuvenation process. IPL is a filtered broad-spectrum light. The wavelengths are limited by various “cut-off” filters and treatment heads that further refine the spectrum to a controlled range of light from about 560 nm to 1200 nm. These wavelengths have been found to be ideal for type I and type II photorejuvenation (see Expanded Definitions above) when used in a series of straightforward non-ablative procedures, each of which usually takes less than 30 minutes for treatment of the full face.

Using the extreme flexibility of the VascuLight or Quantum platform, pulse durations and fluences can be extensively varied. Multiple studies have shown that IPL’s ability to join pulses in double and triple strings (and control the delay times between each pulse) adds to the unit’s ability to perform efficient selective photothermolysis for treatment. Such combined wavelength and pulse duration versatility gives IPL instrumentation the unique ability to treat pigmented and vascular changes associated with type A changes, which has come to define type I photorejuvenation. Additionally, the experience of hundreds of thousands of patients has shown that with a program of treatments at low fluences, dramatic clinical improvement and highly satisfying cosmetic result can be obtained in patients with varied conditions such as rosacea and hyperpigmentation with minimal, if any, down time.

Histologic evaluation of treated skin has also been shown to correlate with the significant clinical changes in cases with type B structural changes.4 Most importantly, because of the longer pulse widths and low fluences over multiple treatments, IPL skin treatments using photorejuvenation have been shown to be truly non-ablative. Simultaneous improvements to both vascular and pigmentary anomalies can be achieved without patient down time.

Photodynamic Skin Rejuvenation Using 5-ALA and IPL
In the most recent advance of photorejuvenation, we find great promise in the area of photodynamic therapy (PDT) used with IPL, known as photodynamic skin rejuvenation (PSR).

The PSR application of PDT involves activation of a specific photosensitizing agent, 5-ALA, activated by the conventional intense pulsed light as provided by the VascuLight or Quantum system. This process produces activated oxygen species within cells, thus resulting in their elimination or their destruction. The topically active agent, ALA, is the precursor in the heme biosynthesis pathway of protoporphyrin-9, which facilitates cellular destruction. Exogenous administration of ALA, along with 410 nm continuous blue light has been FDA cleared for the treatment of actinic keratoses and appears to have significant long-term efficacy.17 However, in clinical practice, various light sources have been used in photodynamic therapy in an effort to reduce time and discomfort for patients, and enhance the clinical and cosmetic outcome of the procedure.

Most recently, laser and IPL treatments are under study for such enhanced benefits of photodynamic therapy,18 including significant improvement in severe cystic acne. Short duration application of ALA for PDT, using Levulan for as brief a period as 15 minutes followed by a treatment of IPL using conventional parameters has shown significant benefit in the treatment of precancerous conditions such as AKs, actinically damaged skin and moderate to severe acne. Additionally, early evidence shows a significant degree of cosmetic enhancement, and is thus the newly designated type III photorejuvenation.

Looking Ahead
Overall, widespread physician experience, published studies and investigations into exciting new areas (yet unpublished) show that intense pulsed light using photorejuvenation — alone, in combination with other laser techniques or with the newly described photodynamic techniques incorporating topically applied pharmacologic medications — can dramatically improve patients with types A, B and C changes of photodamage, including both intrinsic and extrinsic aging.

Our original enthusiasm for IPL skin treatments using photorejuvenation has been shown to be well placed. IPL has clearly shown significant benefits as type I photorejuvenation for type A conditions such as lentigines, dyschromia, telangiectasias and symptoms of rosacea. Additionally, by itself, or in combination with other procedures significant type B changes have responded well to IPL photorejuvenation type II with excellent results.

We now call the attention of dermatologists to the potential advance represented by photodynamic skin rejuvenation, or type III photorejuvenation, for actinically damaged skin, AKs and potentially superficial skin cancers. We find this new technique to hold significant promise as a new, non-ablative or nearly non-ablative procedure in patients with severe photodamage, with enhanced properties in both clinical treatment for actinic keratoses, conditions such as severe cystic acne and rosacea, as well as improved cosmetic outcomes results in a majority of photorejuvenation techniques.