Intense Pulsed Light Therapy
Selina R. McGee
Karl Stonecipher
Intense pulsed light (IPL) therapy was initially developed for the treatment of leg telangiectasias and has become the standard treatment for rosacea, flushing, and facial redness, as well as manifestations of photodamage, including pigmented lesions.1 IPL therapy is utilized by eye care professionals to treat aging changes due to photodamage, ocular rosacea, and most recently meibomian gland dysfunction (MGD) in dry eye disease (DED). In the Tear Film and Ocular Surface Society (TFOS) International Dry Eye Workshop II (DEWS II) treatment algorithm, the management and therapy subcommittee placed IPL as a step 2 treatment for dry eye and MGD.2
MGD is a chronic diffuse disease, commonly characterized by terminal duct obstruction with qualitative or quantitative changes in the glandular secretion. It can result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.3 Increased tear evaporation, tear hyperosmolarity, increased ocular surface staining, increased inflammation, symptomatic irritation of the eyelid and globes, as well as decreased visual acuity have all been observed with MGD.4 MGD can be accompanied by ocular rosacea. One study reported that 80% of facial rosacea patients suffer from MGD and in 20% of patients, ocular rosacea precedes facial rosacea.5 IPL therapy is very effective in managing rosacea and is thought to minimize the blood vessels that are responsible for leaking inflammatory mediators onto the ocular surface.6
It is thought that there are many factors that contribute to MGD. Inflammation, microbial/Demodex infestation, enzyme changes, stasis, hyperkeratinization, temperature changes, and obstruction are thought to contribute whether individually or in conjunction with one another.7 IPL is still being studied on how it specifically improves MGD, but there are many retrospective and prospective studies in the literature that support the improvement in both signs and symptoms of MGD.8,9,10,11,12,13,14,15,16,17,18
MECHANISM OF ACTION, EFFICACY, AND SAFETY
An IPL unit consists of a flashlamp internally filtered to emit noncoherent light of wavelengths ranging from 500 to 1,200 nm, thereby targeting specific chromophores. Melanin absorption is in the range 400 to 700 nm and oxyhemaglobin absorption is in the range 900 to 1,200 nm. Of interest, the pigmented exoskeleton of Demodex
contains a chromophore that absorbs IPL energy. In fact, histologic analysis demonstrated that IPL induces coagulation and necrosis of Demodex.19
contains a chromophore that absorbs IPL energy. In fact, histologic analysis demonstrated that IPL induces coagulation and necrosis of Demodex.19
IPL is NOT a laser, as a laser emits coherent light. Quartz filters are available to remove wavelengths below 515, 550, 560, 570, 590, 615, 645, 690, and 755 nm depending on target, skin type, and desired outcome.
Modern IPL systems achieve efficacy and safety by selective photothermolysis, in which (1) target chromophores such as blood vessels (red’s), pigment (brown’s, including melanin in hair follicles) absorb more light energy than the surrounding tissue and (2) the energy is delivered and absorbed within the chromophore’s thermal relaxation time. The thermal relaxation time is the time for the structure to lose half of the delivered energy (i.e., to cool).20
During IPL treatment, energy is delivered in one to three synchronized pulses rather than continuously. This allows the epidermis to cool between pulses while the target continues to heat. Safety is further enhanced through appropriate wavelength selection and aggressive contact cooling (e.g., sapphire chill plate). Advantages of this technique are that posttreatment purpura, a common adverse effect of pulsed dye laser treatment utilized in dermatology, occurs only infrequently with IPL treatment.20
INDICATIONS
Common indications for IPL treatment include rosacea, melasma, and photodamage including poikiloderma, telangiectasias, and dyschromia. In addition, IPL has been used to treat port wine stains, rough skin texture, freckles, lentigines, superficial wrinkling, large pores, unwanted hair, MGD, hordeola, and chronic chalazia.21
PATIENT SELECTION
The easiest patients to treat with IPL have fair skin (Fitzpatrick skin types I-III) with telangiectasia of the eyelid and/or face or pigmentary abnormalities of the periocular region. Darker skin types can also be treated (Fitzpatrick skin type IV)—with caution—by using lower energies, longer pulse durations, longer delay times, and higher-wavelength filters (e.g., 590, 615, and 640 nm). Fitzpatrick skin types V could be treated with extreme caution and skin type VI should never be treated with IPL.21
Patients must be willing to undergo multiple treatments at two- to four-week intervals. Most patients need a series of four to five treatments and then will continue to need a maintenance treatment every four to six months. Since IPL treatments are currently not covered by private insurance, patients must be willing to assume responsibility for the cost of treatment. Patients’ medical history, medications, and previous cosmetic treatments must also be discussed.
FITZPATRICK SKIN TYPING SCALE
The Fitzpatrick skin phototypes were constructed based on an individual’s skin color and their tendency to burn or tan when exposed to sunlight. There are six skin types characterized by the following as shown in Table 22.122:
TABLE 22-1 FITZPATRICK SKIN TYPE SCALE | |||||||||||||||||||||||||||||||||||
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CONTRAINDICATIONS
Contraindications for IPL Treatment Include the Following:
Active herpes simplex virus (HSV) infection
Exposure to sun, remaining suntan or artificial tanning in the three to four weeks preoperatively
Active lupus erythematosus
A history of seizures induced by bright lights
Dysplastic nevi
Significant concurrent skin conditions or any inflammatory skin conditions
Open lacerations or abrasions
Chronic or cutaneous viral, fungal, or bacterial diseases
Tattoos
Unreasonable expectations
Skin type VI
To the best of the authors’ knowledge, IPL has not been studied in human pregnancy and therefore is not advised.
PRETREATMENT PATIENT EDUCATION
The following should be discussed with patients prior to performing IPL treatment:
Results are not guaranteed.
MGD and DED are multifactorial diseases in nature.
Adjunctive treatments may still be needed such as artificial tears, warm compresses, lid hygiene, antiinflammatories, immunomodulators, oral antibiotics, or thermal pulsation therapies. (This list is not meant to be all-inclusive.)
Not all red and brown areas will disappear. Red and brown spots removed by treatment may recur, especially with excessive sun exposure.
Deep wrinkle lines will not be removed by the treatment.
Adverse effects include redness, swelling, burning, pain, crust formation, bruising, hyperpigmentation and hypopigmentation, and scar formation.
Multiple treatment sessions (typically three to five) are required for optimal results.
Maintenance treatments are often recommended four to six months after the initial series. In addition, patients should be quoted a price for the treatment course.
PRETREATMENT PATIENT INSTRUCTIONS
Patients are given the following instructions prior to treatment:
Do not take isotretinoin (Accutane) for one month before your treatment. Of note, because Accutane targets sebaceous glands and meibomian glands are sebaceous glands, imaging and close monitoring should be performed while on isotretinoin as they can be entirely decimated with continued use of the medication.
Discontinue doxycycline medication two weeks before your treatment. The medication can be resumed post treatment if needed.
If you are tanned, please reschedule your appointment.
Do not apply makeup or lotions on your day of treatment, or be prepared to remove them at the clinic.
If you have a history of cold sores, take your prescribed medication (e.g., valacyclovir [Valtrex], famciclovir [Famvir], acyclovir [Zovirax]) on the day before, day of, and day after treatment. If any active lesions are present the appointment will need to be rescheduled.
Inform the technician before each appointment if you (1) are taking new medications or (2) have tattoos or beauty marks you do not want treated.
Inform the clinician immediately if the area being treated feels “too hot.”
INFORMED CONSENT CONSIDERATIONS
Informed consent should include a description of the procedure in plain language, for example, “IPL will be used to treat MGD related to keratoconjunctivitis sicca and/or ocular rosacea. This will help decrease inflammation and may help eye irritation related to ocular surface disease.”
Potential alternative treatments, such as prescription eye drops, oral medications, monitoring, or other in office procedures, should be listed. Risks and complications inherent to any IPL procedure include but are not limited to redness, swelling, burning, pain, crust formation, bruising, hyperpigmentation and hypopigmentation, and scar formation.
A note from the counseling practitioner should be included and phrased similar to “I have counseled this patient as to the nature of the proposed procedure, the attendant risks involved, and the expected results.” The patient’s and doctor’s name should be printed and signed with the date as well as a witness (typically a staff member).
As part of the informed consent, the patient needs to determine their skin typing with the assistance of the clinician. This should be in writing, and both patient and clinician should sign and date.
PROCEDURE PROTOCOL
Tray Setup
The setup tray may include IPL grade eye shields, cooled gel (clear only), tongue blade, washcloth, hair band, and nonsterile gloves. In addition, cleanser and sunscreen lotion may be available for use by the patient. See Figure 22.1.
Anesthesia
Topical anesthetic cream should not be used prior to treatment.21 Formulations of anesthesia typically contain a combination of benzocaine, tetracaine, and lidocaine, which can vasoconstrict blood vessels. When the blood vessels are constricted, there
are less chromophores to target, and the patient may be undertreated. Coach patients through the procedure and utilize frequent breaks to help with patient comfort if the need arises.
are less chromophores to target, and the patient may be undertreated. Coach patients through the procedure and utilize frequent breaks to help with patient comfort if the need arises.
 FIGURE 22-1 Shows a typical tray setup for intense pulsed light procedure including hair band, makeup remover wipes, tongue blade, clear ultrasound gel, comfort squeeze devices, intense pulsed light/laser grade pasties, laser grade corneal shields, corneal anesthetic, safety goggles, sunscreen, and postoperative skin care kit. |
Medications
Antiviral medications (valacyclovir, famciclovir, or acyclovir) may be prescribed prophylactically in patients with a history of HSV.
Safety Concerns
Patients, IPL operators, and assistants in the room should ALWAYS wear protective eye shields appropriate for the wavelengths used in treatment. In Dr. Selina McGee’s office, each patient contemplating IPL treatment that is high risk such as a skin type IV must undergo a test site treatment at least 48 hours before the initial treatment session. This is to check for a delayed reaction to treatment and to determine the appropriate treatment settings.
PROCEDURE
The first treatment begins after pretreatment photographs have been obtained, the test site has been evaluated, and appropriate treatment parameters have been selected. Treatment settings vary by device; an operator’s manual specific to the IPL unit should be consulted. A discussion of treatment parameters is presented here. As an example, Tables 22.2, 22.3, 22.4, 22.5, 22.6, 22.7 show treatment variables for a specific IPL device21 as well as the Protocol settings of pioneers Rolando Toyos15 and Laura Periman.23
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