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Pigmentation Selective Photothermolysis or Non-specific Skin Necrosis Using Different Intense Pulsed Light Systems - RUSSELL EMERSON, CAERWYN ASH,, GODFREY TOWN,, KELVIN DONNE, ToKUYA OMI & GWENAELLE DANIEL

Pigmentation Selective Photothermolysis or Non-specific Skin Necrosis Using Different Intense Pulsed Light Systems - RUSSELL EMERSON, CAERWYN ASH,, GODFREY TOWN,, KELVIN DONNE, ToKUYA OMI & GWENAELLE DANIEL

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Published by Caerwyn Ash
This was a clinical test to validate my PhD Hypothesis, conceived and finished within 12 months between 2007 and 2008.
This was a clinical test to validate my PhD Hypothesis, conceived and finished within 12 months between 2007 and 2008.

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Categories:Types, Research
Published by: Caerwyn Ash on Mar 04, 2013
Copyright:Attribution Non-commercial

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 Correspondence: Godfrey Town, University of Wales, Global Academy, Swansea Metropolitan University, Faculty of Applied Design & Engineering,Swansea, SA1 6ED, UK. Tel:
ϩ
44-1444-484911. E-mail: godfreytown@mac.com
(Received 8 September 2012 ; accepted 3 December 2012 )
Introduction
Photo rejuvenation has become increasingly popularwith women and men seeking methods to counteractaging through enhancements to their appearance.Photo rejuvenation is a general term for a range of light based techniques to remove vascular blemishes,pigmented lesions, fine lines and wrinkles and toimprove overall skin texture and elasticity. The exactmix of these characteristics depends upon age, sexand ethnic background. Pigmented lesions are acommon condition found in all skin types and maybe the result of intrinsic aging which affects the skinby slow, irreversible tissue degeneration or extrinsic-aging resulting from exposure to outdoor elementssuch as sun, wind, pollution etc. However, Asiansgenerally exhibit more pigmentary dischromiawhereas telangiectasia and diffuse redness arethe primary component of photo-aging amongstCaucasians. Pigmented blemishes can vary in colour,size and depth. Several different types of laser andintense pulsed light (IPL) devices have been usedsuccessfully to remove skin pigment (1 – 5) and it isassumed that the mode of action is coagulation orphoto-oxidation of groups of melanosomes in thetarget lesion under the influence of radiant energy.Because such lesions usually darken rapidly, crustand slough-off within a matter of days after treat-ment, it is often believed amongst clinicians that highenergy, short sub-pulse duration, ‘free discharge’ IPL systems are the best type of IPL device to eliminate
 Journal of Cosmetic and Laser Therapy,
2013; Early Online: 1–10
ISSN 1476-4172 print/ISSN 1476-4180 online © 2013 Informa UK, Ltd.DOI: 10.3109/14764172.2012.758381
 ORIGINAL RESEARCH REPORT
Pigmentation: selective photothermolysis or non-specific skinnecrosis using different intense pulsed light systems?
RUSSELL EMERSON
1
 , CAERWYN ASH
2
 , GODFREY TOWN
3
 , KELVIN DONNE
4
 ,TOKUYA OMI
5
& GWENAELLE DANIEL 
4
 
1
 Consultant Dermatologist, Hove Skin Clinic, Hove, UK,
2
 Cyden Institute of Light Therapy, Institute of Life Sciences,Swansea University,UK,
3
 University of Wales, Global Academy, Swansea Metropolitan University, Faculty of Applied Design & Engineering, Swansea, UK,
4
 Swansea Metropolitan University, Faculty of Applied Design & Engineering,Swansea Metropolitan University, Swansea, UK, and 
5
 Department of Dermatology, Queens Square Medical Center,Yokohama, Japan
Abstract
Background and objective:
This study considers end point tissue responses and side effects to determine whether ‘squarepulse’ IPL is more or less effective than the traditional IPL. Supporting histological data and computational modellingresults are provided. It provides guidance for IPL users unfamiliar with constant spectrum IPL devices and redirects atten-tion to treatment end points.
 Materials and methods:
Twenty subjects of Fitzpatrick Skin Types I – III, presenting with variousepidermal pigmented lesions, were treated 1 – 3 times with two different IPLs. Coupling gel was used and firm pressure wasapplied to exclude blood from the treatment area. Immediate and post-treatment side effects, degree of discomfort andend results at fourteen and thirty days were evaluated by professional observation, digital photography and a patient ques-tionnaire.
Results:
Both IPLs showed a mean clearance of over 80% after 1 – 3 treatments but the free discharge IPL dem-onstrated a greater side effect profile with a higher incidence of ulceration, crusting and erythema.
Conclusions:
Clinicalobservation and mathematical modelling suggests that the square pulse, partial discharge IPL system may provide the IPL operator with greater control over the coagulation of pigment and is therefore the more efficient device for effective pigmentlightening with fewer side effects.
Key Words:
coagulation , lasers and light sources (constant spectrum) , selective photothermolysis , tissue necrosis
   J   C  o  s  m  e   t   L  a  s  e  r   T   h  e  r   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   2 .   5 .   1   5   2 .   1   7   7  o  n   0   2   /   2   7   /   1   3   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
 
2
R. Emerson et al.
epidermal pigmentation such as ephilides and len-tigines. As low energy, constant spectrum ‘squarepulse’ IPL systems deliver their spectral energy moreevenly, with fewer and less pronounced side effects,there has been conjecture that they are therefore lesseffective. Epidermal pigmented lesions, such as agespots, are prime targets for photo rejuvenation andtheir removal contributes to the overall cosmetic out-come for the patient. These pigmented lesions aretypically superficial and respond well to laser andIPL in the range of 530 – 1100 nanometres (nm)where there is broad absorption by melanin. Accord-ing to the theory of selective photothermolysis pro-posed by Anderson and Parish in 1983 (6), by usingvery short pulsing lasers such as the frequency dou-bled Q-switched Nd:YAG, Q-switched ruby andalexandrite lasers, light can be targeted to differentchromophores at various depths in the skin by usingthe appropriate wavelength, pulse duration and pulseenergy. The flash lamp pulsed dye laser was the firstlaser developed on the principle of selective photo-thermolysis (7). Following this theory, matching thethermal relaxation time (TRT) of melanosomes, inthe targeting of pigmented lesions suggests that mel-anonosomes can only be destroyed optimally at pulsedurations between 40 and 750 nanoseconds (8).More recently, IPL devices have also been shown tobe effective in the removal of pigmented blemishesalthough pulse durations are all in the millisecond(ms) domain. In conventional ‘free discharge’ IPLs,trains of short sub-pulses separated by extendedinter-pulse delays are produced giving overall pulsedurations in tens of milliseconds. In this case, theprinciple of selective photothermolysis is assumed toapply to the thermal coagulation of ‘clumps’ of mel-anosomes in aggregated groups comprising the pig-mented patch, which takes place within the unwantedblemish while normal pigment in the surroundingskin is spared through rapid loss of heat from themore widely distributed melanosomes in the epider-mal tissue. It is therefore more likely that themechanism of destruction with IPL leading to photo-oxidation and blackening of lesional melanin is non-specific thermal denaturation or necrosis of themelanosomes rather than clearly defined photother-molysis. Haemoglobin, melanin, and water are theprimary absorbing chromophores in human skin.Each chromophore has specific peak absorptionwavelengths in the electromagnetic spectrum (9).Melanin and haemoglobin absorb well in the wave-length range of 530 – 950 nm (Figure 1) in targetlesions such as solar and senile lentigines,
caf é au lait 
 macules, melasma and post-inflammatory hyperpig-mentation as well as Campbell de Morgan spots,telangiectasia and cuperosis. The optical energyis absorbed as heat, raising the temperature of the
Figure 1. Absorption coefficients for melanin, oxyhaemoglobin and water with the measured spectra of both square pulse and free dischargesystems used in this study.
   J   C  o  s  m  e   t   L  a  s  e  r   T   h  e  r   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   2 .   5 .   1   5   2 .   1   7   7  o  n   0   2   /   2   7   /   1   3   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
 
Pigmentation treatment using different IPL systems
3target and hence denaturing the key structural pro-teins. There is greater absorption of epidermal mela-nin in darker skin types, whether ethnic or sun-inducedand this restricts the available ‘therapeutic windowand along with it the IPL s effectiveness with Fitzpat-rick Skin Types IV – VI. Typical IPL systems employhigh intensity flash lamps that emit polychromaticlight. Contrasting with a laser system, these flashlamps work with incoherent light in a broad wave-length spectrum of 500 nm to over 1100 nm at ener-gies up to 60 J/ cm
2
(10). They have options of variouswavelengths that can be emitted using a selection of reflectance or absorption filters. These reflectance orabsorption filters generally range between 520 and650 nm with higher cut off filters used to protectdarker skin from thermal damage caused by shorterwavelengths. The intense light can be delivered assingle, double, or multiple sub-pulses within the mil-lisecond domain. The inter-pulse delay and trains of sub-pulses are intended to protect the superficial epi-dermis from excess thermal absorption and conse-quential damage. These adjustable wavelengths and
Figure 2. Immediately following IPL exposure, damage to epidermal cells and differentiation of keratinocytes can be observed usingtransmission electron microscopy (TEM). Melanin granules are evident in the intracellular spaces of keratinocytes indicating rupture of melanocytes or keratinocytes. CyDen Ipulse treatment (left, a) shows slightly milder changes than treatment with Lumenis Quantum SR (right, b).Figure 3. A fibroblast in edematous dermal tissue (left, a) can be seen using transmission electron microscopy (TEM) at 1 month afterIPL exposure, normal epidermis can be seen with melanin-laden macrophages or fibroblasts observed in the upper dermis. Collagenbundles and middle dermal structures show almost no transformation compared with normal dermis (right, b).
   J   C  o  s  m  e   t   L  a  s  e  r   T   h  e  r   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   2 .   5 .   1   5   2 .   1   7   7  o  n   0   2   /   2   7   /   1   3   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .

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