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8/12/2019 IPL - Skin Rejuvenation - PROTOCOL http://slidepdf.com/reader/full/ipl-skin-rejuvenation-protocol 1/45 Photoaging Training Manual USING iPULSE INTENSE PULSED LIGHT PHOTOAGING & SKIN REJUVENATION: A STEP-BY-STEP TREATMENT PROTOCOL FOR AESTHETICIANS, BEAUTY THERAPISTS AND OTHER MEDICAL PROFESSIONALS PROVIDING COSMETIC TREATMENT Author: Godfrey Town, Director of Clinical Affairs For further information see www.cyden.co.uk or www.ipulse.co.uk Customer support: +44-(0)1792-485755 E-mail: [email protected] PHOTOAGING TRAINING MANUAL Page 1 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I17002-0

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Page 1: IPL - Skin Rejuvenation - PROTOCOL

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Photoaging Training Manual USING iPULSE INTENSE PULSED LIGHT

PHOTOAGING & SKIN REJUVENATION:A STEP-BY-STEP TREATMENT PROTOCOLFOR AESTHETICIANS, BEAUTY THERAPISTS AND OTHER MEDICALPROFESSIONALS PROVIDING COSMETIC TREATMENT

Author: Godfrey Town, Director of Clinical Affairs

For further information see www.cyden.co.uk or www.ipulse.co.uk Customer support: +44-(0)1792-485755 E-mail: [email protected]

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IMPORTANT ADVICE FOR THE USER:

This Applications Manual provides guidance to assist in practical applications workwith iPulse intense pulsed light. The information contained herein reflects state of theart technology in this field. The author will assume no liability for errors, which,despite adequate care and attention, cannot be ruled out entirely. The user alonebears full responsibility for actions performed in conjunction with this Manual.

WARNING: 

This detailed applications training manual is intended for general guidance in the useof the iPulse intense pulsed light device for photoaging treatments and does notconstitute “A protocol produced by an expert medical or dental practitioner” asrequired by the Healthcare Commission for registration of an establishment inEngland and Wales under the Care Standards Act 2000 and described in the Dept ofHealth: National Minimum Standards and Regulations.

NOTICE:

 All information contained in this manual is supplied by Cyden Limited written in theEnglish medium and Cyden Limited will not be responsible in anyway whatsoever forany alterations, additions, omissions or errors of any nature arising from anytranslation and/or any reproduction of all or any part or parts of the informationcontained in this manual from English to another language or medium, including anyclaim arising for negligence, damage, injury or loss.

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GENERAL INTRODUCTION

Since the introduction of non-invasive laser and IPL treatments for skin rejuvenationexperience has shown that almost all skin types including European, Indian, East- Asian and Middle-Eastern, respond at least to some degree to treatment. Demandhas increased dramatically around the world from women and men for skinrejuvenation with varying cultural influences including traditional factors, fashion,sport, personal feelings of well being and health requirements.

Invasive procedures such as ablative laser resurfacing, surgical dermabrasion andpowerful acid peels have been used successfully to restore aging skin. Thesemethods remain as ‘last resort’ options particularly for elderly clients where minimallyinvasive treatments are inadequate.

IPL TECHNOLOGY ADVANCES - iPULSE

There are two key limitations to conventional IPL devices, an inability to produce a“true” long pulse matched to the thermal relaxation time of the target structure andsecondly, fluctuations in the output spectrum which can lead to ineffective treatmentwith increased risk of side-effects. An alternative approach to producing long pulse,constant spectrum optical pulses along is found in the iPulse technology employedby CyDen.

This novel IPL technology emits a wavelength range of between 530 and 1100nmand incorporates shorter, more efficient wavelengths for skin rejuvenation without theneed for cut-off filters. This is achieved by having a uniform temporal profile. Figure 1below shows a representation of the energy output from a traditional IPL and animproved, true long pulse model. As can be seen, in the traditional IPL, the outputconsists of a short, high intensity “spike” that gradually increases from zero tomaximum intensity and decays back to zero. To construct an overall pulse duration inthe order of the thermal relaxation time of the target structure, a series of pulses arerequired. In the case of the improved iPulse technology, the pulse shape is uniform,increasing from zero to maximum intensity almost instantaneously, remaining atmaximum for the entire duration of the pulse then dropping to zero again

instantaneously. The overall duration of the pulse is fully variable up to and beyondthe thermal relaxation time of the target. The ability to produce true long pulses canreduce the amount of energy required to achieve the necessary temperature profilewithin the target and accurately control the thermal profile within the skin.

This recent advance in IPL technology has resulted in a significant reduction of thecost, making square pulse, constant spectrum IPL more available to the therapistwishing to practice IPL skin rejuvenation techniques.

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Illustration:  Showing temporalprofile of energy output of atraditional and iPulse squarepulse IPL

Control over the energy discharge through the Xenon lamp also results in a constantspectral output across the 530 nm – 1200 nm produced by the new iPulsetechnology. Thus no treatment energy is wasted using ‘square pulse’ technology andthe constant distribution of light ensures a comfortable treatment for the client.

Description:  Time-resolved spectral measurements of a free discharge IPL (Chromolite,Chromogenex Ltd., Llanelli, UK) compared with a ‘Square Pulse’ pulse discharge profile of a constantcurrent IPL (iPulse, Cyden Ltd. Swansea, UK). The two measurements show differences in spatial andtemporal characteristics of the two types of IPL, confirmed by the “spectral jitter” seen in the shortplasma phase of the free discharge IPL during which most of the light energy is released in aninvariable 3-4 ms compared with the constant spectral output spread evenly across the entire pulse ofthe partial discharge IPL with a variable range of pulse durations 10-50 ms.

[Courtesy of: Ash C, Town G and Bjerring P. Relevance of the structure of time-resolved spectraloutput to light-tissue interaction using intense pulsed light (IPL). Lasers in Surg Med 2008; Vol 40:2:83-92.]

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Published studies in international peer-reviewed journals confirm that iPulse

constant spectrum IPL embodies the latest advances in light technology forefficient pulse structure, safety and its suitability for all skin types.

References:

Clement M, Daniel G & Trelles MA. Optimising the design of a broad-band light source for thetreatment of skin. Journal of Cosmetic and Laser Therapy. 2005; 7: 177-189.

Omi T and Clement M. The Use of a Constant Spectrum, Uniform Temporal Profile Intense Pulsed

Light Source for Long Term Hair Removal. Journal of Cosmetic and Laser Therapy 2006; 8: 138-145.

Town GA, Ash C, Eadie E, Moseley H. Measuring key parameters of intense pulsed light (IPL)devices: J Cosmetic Laser Therapy 2007; 9:3:148-160.

 Ancona D, Stuve R and Trelles MA.  A multi-centre trial of the epilation efficacy of a new large spotsize, constant spectrum emission IPL device.  Journal of Cosmetic and Laser Therapy 2007; 9:139-147.

 Ash C, Town G and Bjerring P. Relevance of the structure of time-resolved spectral output to light-tissue interaction using intense pulsed light (IPL). Lasers in Surg Med 2008; Vol 40:2: 83-92.

Vedamurthy M and Town G. Use of Intense Pulsed Light (IPL) in Skin Types IV and V: An IndianExperience. Australasian Journal of Cosmetic Surgery 2008; Vol 4:1: 64-73

FDA CLEARANCE 510k K080406

iPulse intense pulsed light is indicated for use in Dermatological and PlasticSurgery applications and specifically for long term stable, or permanent, hairreduction. In addition, iPulse is indicated for the treatment of benign cutaneousvascular lesions and the treatment of benign pigmented lesions. iPulse isindicated for the treatment of mild to moderate inflammatory Acne Vulgaris.

(Latest FDA updated clearance 10th March 2008)

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BEFORE YOU START USING iPulse IPL

TRAININGWhilst the technology has proved its efficacy in skin rejuvenation through numerousclinical trials, at present there is little formal training of operators (whether in thebeauty or healthcare sector) so results have often been variable. Therefore, trainingis a key factor in achieving successful treatment outcomes.

 As a minimum, all operators should receive basic training in light therapy theory andsafe use of laser / IPL devices. No two devices are identical in the way they deliverlight energy so it is vital to obtain user training by the supplier.(Contact your CyDen distributor for training opportunities)

ACCESSORIES An IPL treatment room must be fully equipped with all necessary accessories toensure successful and efficient treatments. In particular, this will include adequateprovision of skin cooling by use of refrigerated cooling gel packs, skin air-cooling, etc.

For optimal diagnosis before treatment, operators are encouraged to use advancedskin analysis techniques including detailed evaluation of melanin, erythema (redness)hydration and lipid levels as well as skin evaluation methods such as skin scannersand photo records. (See separate treatment room set-up information) 

ChromoTest skin melain / erythema measuring device

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UNDERSTANDING THE SKIN IN IPL SKIN REJUVENATION

Skin rejuvenation using iPulselight therapy consists primarily ofcreating sufficient heat in the redor brown sun-damaged structuresof the skin to reduce theirappearance or eliminate themcompletely. This is achieved bylight absorption in the melanin ofthe mottled pigmentation and theoxyhaemoglobin in the fine bloodvessels of general redness orbroken capillaries.

The light, which isn’t reflected off the skin’s surface (a), scatters beneath the skin’ssurface, (b) is then absorbed in the melanin and blood. The melanin is coagulated bythe absorbed heat energy and in blood vessels the heat absorbed by the blood isconducted to the delicate vessel walls (vascular endothelium), whose cells aredamaged by the heat causing the vessel to collapse or completely coagulate.

WAVELENGTH

Illustration: Example standardised spectral distribution of a typical xenon lamp IPL (iPulse, Cyden Ltd)measured in 20 nm bandwidths as a percentage of the total energy beneath the graph curve.

 Absorption curves for oxyhaemoglobin (red) melanin (black) and water (blue) have been overlaid toreference optimal absorption characteristics.

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IPL devices produce mostly visible broad-band wavelengths of light. Potentiallyharmful, short wave UV light is filtered out by the lamp itself and hardly any long-

wave infra-red light is produced by a Xenon lamp. The remaining wavelengthsbetween 500 nm and 1000 nm are all well absorbed by melanin and blood, so aresuitable for skin rejuvenation.

 As light scatters as it enters the skin, the longerwavelengths of this broadband light penetratemore deeply into the skin to reach deeperlocated structures. The shorter wavelengths oflight, which scatter more readily, are betterabsorbed in epidermal melanin and shallowervessels.

SPOT SIZEThe larger the spot size, the deeper thepenetration into skin and the less that energy islost at the edge of the treatment area. Unliketraditional IPL devices, the iPulse uses twin flashlamps to produce a large, rectangular spot sizeon skin of 8.9cm2 which ensures that light energy penetrates deeper into tissue toreach the deeper-lying vessels and pigment.

PULSE DURATIONGenerally, the pulse of IPL light used will be longer for larger structures like hair andtelangiectasia (broken capillaries) and shorter for epidermal pigment.

NB. By comparison, choosing long pulses of light for hair removal, the operator willavoid collateral damage to epidermal melanin as the tiny particles of melanin in theskin have time to lose absorbed heat during a long pulse (compared with, say, amuch larger hair follicle structure which will hold its heat longer). In skinrejuvenation, the process of selecting the blood structures to damage with thecorrect pulse length is called “selective photothermolysis” and depends upon the factthat smaller bodies (e.g. epidermal melanin) lose heat faster than larger bodies (e.g.

hair follicle) owing to the relative surface area of melanin particles losing heat faster.

With melanin the process is thought to be non-specific thermal coagulation ofmelanin since the melanin particles are so tiny that the theory of “selectivephotothermolysis” does not readily apply. Thus, great care must be taken to avoidover-treatment side effects.

TECHNOLOGY DIFFERENCESSome traditional IPL suppliers use coloured glass filters in the applicator to reduceepidermal absorption side effects. By using latest square pulse and constant spectraloutput technology multiple applicators may not be required and effective treatmentscan be performed more simply with a single, user-changeable flash lamp.

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ENERGY REQUIRED FOR SUCCESSFUL SKIN REJUVENATIONThere are several factors that determine choice of energy level. The overall objective

is to find the optimal “therapeutic window” where energy is sufficient to damage theblood vessels and/or the melanin in the skin blemish but avoid collateral damage tosurrounding tissue and consequential undesired side effects. Normally, the skin willonly feel warm temporarily after treatment and any redness will disappear withinminutes or a few hours.

Darker skin (including active suntan or spray-tan) reduces the amount of possibleenergy that can be used before side effects appear. This will vary from person toperson and body area to body area.

The constant spectral output of the iPulse IPL means that the iPulse produces thelowest possible intensity for a given energy density (fluence) thus minimisingdiscomfort and other side effects such as redness, pain and skin burns.

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IDENTIFYING TREATABLE CONDITIONS

WHAT IS PHOTOAGING?

Cutaneous aging is a complex biological process consisting of two independentcomponents: (a) intrinsic aging or "biological clock" aging, which affects skin by slowirreversible tissue degeneration; and (b) extrinsic aging, or "photoaging", the resultof exposure to outdoor elements, primarily ultraviolet (UV) irradiation. As a result ofthese processes, major aging changes are seen in the extracellular matrixcomponents of the dermis, i.e., the collagen meshwork and the elastic fibre system. As part of intrinsic aging, reduced rate of synthesis of collagen and elastin, canexplain the noticeable thinning and visible loss of elasticity of the skin in the elderly.

 At the same time as the collagen matrix deteriorates and the skin becomes roughand wrinkled, pigmentation changes, telangiectasias (thread veins) and sometimes,actinic keratoses and epidermal malignancies occur.

Photoaged skin is characterised by rough skin texture, mottled pigmentation,telangiectasia, mild to moderate rhytides (wrinkles), enlarged pores, acne scarringand skin laxity. The exact mix of these elements will depend upon age, sex andethnic background e.g. Asians predominantly exhibit pigmented dischromia whilstmany Caucasians have telangiectasia as the primary component of photoaging.

Therefore, a treatment modality is required that provides several differently targetedtreatments to deal with all of the presenting elements of photoaging. More aggressivedevice settings will result in more downtime for the client and more side effects suchas erythema, oedema (swelling), bruising and crusting of pigmented lesions whilstless aggressive treatments with less downtime will mean more treatments.

The treatment of superficial epidermal pigmented lesions is undertaken with the IPLas the first treatment step. Reduction of pigmented blemishes in the epidermis willallow deeper penetration of IPL at subsequent treatments using settings for vascularlesions and collagen stimulation. These treatment settings (typically used 4-6 weeksapart) will also have a favourable effect on any acne lesions by stimulating the body’s

natural porphyrins, positively treat any infected hair follicles (PFB) and stimulatecollagen neo-genesis. The end result over several months should deliver improvedstructural integrity resulting in enhanced skin texture and pore size, better skinhydration and elasticity and improved skin translucence. Reduction in theappearance of fine lines and wrinkles in the skin has been reported widely using IPLdevices as part of a comprehensive treatment regime.

When using IPL with Caucasian skin (Fitzpatrick I-IIIa), it probably matters very littlewhich specific condition is targeted first as broadband light contains wavelengths thatwill impact to some degree both pigmented and vascular anomalies in the skin. For

example, Caucasian skin with a high content of fine broken capillaries (0.1 - 0.3 mmin diameter) can be treated immediately for the vascular anomalies with someimmediate collateral effect on mottled pigmentation.

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GENERAL RECOMMENDATIONS

Every client seeking skin rejuvenation treatment must undertake a programme of skincare recommended by their therapist which will include as a minimum prerequisite,elimination of active tan through regular use of SPF 30+ sunscreen and routine useof skin cleansers and hydrating creams and lotions as well as fruit acid peels or otherskin treatments such as microdermabrasion.

Whilst specific “macro” vascular and pigmented conditions like poikiloderma ofCivatte, spider nevi, large telangiectasia, venus lakes, etc are often the result of ageand sun damage, they should be treated separately before undertaking a generaltreatment program of skin rejuvenation.

If a clearly identifiable medical condition is observed (such as a eczema,rosacae, port wine stain birthmark, suspicious mole, nevus spilus, sebborheicdermatitis, warts, etc) these should be referred to a dermatologist first fordiagnosis and treatment.

Raised benign melanocytic lesions such as naevi, pigmented skin tags, Seborrheickeratosis, Favre-Racouchot (solar comedones), etc, can only be removed by ablationor thermal coagulation and NOT using any IPL.

Examples of raised lesions that can’t be treated easily with iPulse or any IPL:

Benign mole (later removed by an ablativelaser):

Photo by courtesy of Dr S. McCoy, Adelaide

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Sebborheic keratosis: raised lesions removed using an ablative laser Pigmented lesionClinical Photography by Courtesy of Dr S. McCoy

The most difficult clients to treat are those with Fitzpatrick skin type I who have a longhistory of sun exposure. In these patients, connective tissue is so fragile that IPLparameters selected e.g. for optimal relief of redness, may damage the skin, withhigher incidence of bruising, swelling and blistering. In such cases, low energysettings must be used in early treatments until the supporting dermal connectivetissue is strengthened and the redness is reduced. A standard five-treatment program

is usually extended in this patient group. Very dark skin types, particularly Afro-Caribbean, are also problematic because of high levels of melanin in the epidermisabsorbing light energy in competition with the melanin in the targeted pigmentation orblood in any broken capillaries.

Darker Asian skin on the other hand, occurs largely in regions of the world withintense sunlight and features a naturally higher level of epidermal melanin andtreatment has to be modified to take these characteristics into account.

In any event, a patient has to present without any active suntan and be following astrict routine of using sunscreens and other skin care products professionallyrecommended for them for a minimum of two to four weeks before IPL treatmentcommences. If the patient isn’t going to adopt good skin care practices, the outcomeof treatment will be compromised and short-lived at best, therefore, an effectiveconsultation process is of paramount importance.

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PIGMENTATION COMPONENT – mottled pigmentation (freckles, sun spots, etc)

The treatment of superficial epidermal pigmented lesions is undertaken with iPulseas the first treatment step. Reduction of pigmented blemishes in the epidermis willallow deeper penetration of iPulse energy at subsequent treatments using settingsfor vascular lesions and collagen stimulation.

Forearm epidermal pigmentation treated with iPulse, before and after a single treatment at one weekand eight weeks. (Clinical photos by courtesy of USA Photonics)

Most successful IPL treatments of mottled blemishes are of epidermal pigmentation.However, combined treatments with topical anti-oxidants, polyphenols, hydroquinoneor other pigment lightening creams or peels are often necessary for good results.

In published literature, the evidence of success in post-inflammatory pigmentedlesions with a deeper pigment component (in the papillary layer of the dermis and

usually caused by chemical or physical trauma) is either anecdotal or on single orsmall-number case studies. Recurrence in 4-6 months is also common.

Topical treatments used together with iPulse include: bleaching agents such ashydroquinone, topical tretinoin and azeleic acid or chemical peels such as TCA,glycolic acid and Jessner’s solution. Q-switched ruby and Nd:YAG lasers have alsobeen reported in the literature as achieving moderately good results although with anincreased incidence of post-inflammatory hyper-pigmentation.

Only with proper diagnosis (or a great deal of diagnostic experience and skill) can auser determine how much superficial epidermal pigment there is in a lesion and howmuch is the more difficult dermal pigmentation. The optimal successful endpoint ofIPL pigment treatment is peri-lesional erythema (redness around the treated blemish)and/or  some darkening of the pigmented area within 20 minutes. This is followed by

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further darkening over 24-48 hours and exfoliation of the darkened areas over thenext 7-21 days leaving lightly hypopigmented areas which even-out to normal skin

colour during subsequent weeks. High-factor protective sunscreens, use of aparasol / sun shade and the wearing of hats and gloves (walking, driving andgardening) are a must to protect the sensitive ‘new’ skin.

Close-op photography showing before, immediately after and 7 days after iPulse treatment for facialpigmentation. (Clinical photography courtesy of Dr. Jesus Valdez, Mexico).

 Age spots, before and aftertreatment

Generally good clearanceof superficial epidermalpigmentation in most skintypes (1-5) includingfreckles (ephelides) andage spots (solar ands e n i l e l e n t i g o s ) i sachieved using iPulse. Ifthere is high contrastbetween underlying skincolour and the pigmentedblemish the treatmentu s u a l l y r e s u l t s i n

immediate darkening ofthe pigment with further

darkening over the next 24-48 hrs. If there is poor contrast between the pigmentedblemish (eg age spots) and normal skin, the pigment may not fully coagulate andonly lighten over the following 14-21 days. This means that high contrast blemishesmay only require 1-2 treatments to resolve satisfactorily while low contrast blemishesmay require 3-6 treatments. These coagulated epidermal blemishes usually slough-off (peel) in normal washing in 7-21 days depending on age, sex and skin conditionof the patient. Normally the underlying skin appears “pink” or hypopigmented but thenormal even skin colour returns over subsequent weeks. Do not to ‘pick’ at crusts toavoid scarring.

Remember:  It is important to protect the ‘new’ skin from sun-exposure withsunscreen or gloves until the even normal skin colour returns.

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PRESSURE TECHNIQUE

The skin surface may be pre-cooled by using clear ultrasound gel (at 4°C from therefrigerator). The use of cooling gel also assists in keeping the glass transmissionblock surface cool.

 A number of recently published clinical studies confirm that a pressure technique (i.e.pressing the glass transmission block firmly on the skin surface through the coolinggel) when treating epidermal pigmented blemishes will improve treatment results bycompressing capillaries to express blood and thereby removing competitiveabsorption of light energy by oxyhaemoglobin and concentrate all the light energyabsorption in the pigment target. (Intense pulsed light source for treatment of smallmelanocytic nevi and solar lentigines, Bjerring P, Christiansen K. Journal ofCutaneous Laser Therapy 2000; 2:177-181 & Q-Switched Ruby Versus Long-PulsedDye Laser Delivered With Compression for Treatment of Facial Lentigines in Asians,Kono T, Manstein D, Chan HH, Nozaki M and Anderson R. Lasers Surg Med 2006;38:94-97) The logic of this technique is easily demonstrated by applying thumb-pressure to the skin for a second and removing it, leaving a ‘blanched’ thumb-print fora brief period before the peripheral blood supply returns the skin colour to its ‘normal’mixture of melanin and blood.

PIGMENTATION IN DARKER SKIN TYPES

Illustration:  Female, skin type Vtreated 3 times with iPulse forepidermal pigmentation. (Clinicalphotography courtesy of Dr. M.Vedamurthy, Chennai).

Since IPL devices with wavelengths in the 530 - 1200 nm range are often successfulin treating superficial epidermal pigment in Fitzpatrick Skin Types I-IIIa, it is usuallyassumed  that similar results are not achievable with darker skin phototypes.However, Types IIIb, IV and V are more problematic as the increased level of

‘naturally occurring’ epidermal melanin competes with the pigmented lesion (typicallyseborrheic keratoses, sun and age spots), which may lead to either no improvementor increased risk of hyper- or even hypo-pigmentation.

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The ‘therapeutic window’ for successful iPulse treatment of darker skin types will, by

definition, always be small and must be established carefully with test areas andsteadily increased fluence to avoid hyper-pigmentation. However, good results intreating epidermal pigmentation in Indian and East-Asian skin types using iPulsehave been achieved.

MELASMA

One of the commonly presenting cases for IPL and laser treatment amongst darkerskin types is for melasma. It is nine times more common in females than males andincludes dermal hyperpigmentation, epidermal hyperpigmentation and mixedvariants. Typically, melasma presents as light to dark brown symmetrical hyper-pigmentation of the central face and cheeks but it may also occur just on the bridgeof nose, forehead or upper lip.

Modest improvement inmelasma following iPulsetreatment. Photo courtesy ofDr. M. Vedamurthy, Chennai,India.

The precise cause of melasma is unknown. Melasma is often common within thesame family and a change in hormonal status may trigger melasma. It is frequentlyassociated with pregnancy (also known as chloasma or ‘mask of pregnancy’). Birthcontrol pills may also cause melasma, however, hormone replacement therapy usedafter menopause has not been shown to cause the condition. Melasma is notassociated with any internal diseases or organ malfunction.

Sunscreens are essential in the treatment of melasma. They should be broadspectrum, protecting against both UVA and UVB rays from the sun. A SPF 30+ orhigher should be selected.

If epidermal and mixed variants of melasma hyper-pigmentation are present in theskin, it is likely that at least transient improvement (i.e. lightening) will be achieved

with iPulse treatment of the more superficial pigmentation but it is unclear whetherthere is a lasting effect on the dermal component of the melasma.

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The successful endpoint of iPulse treatment of melasma may not include anyimmediate colour change in such deeper-located pigment but only mild to moderate

erythema at the margins of the pigmented lesions. Lightening may then occur overthe succeeding weeks. High-factor protective sunscreens, using a parasole andwearing of hats or gloves (when driving or gardening) are a must to protect thesensitive treated skin areas. Multiple treatments (6-8) are usually required.

Improvement in melasma in Indian and Asian skin types using intense pulsed lighthas been reported but results can vary from good clearance to only a modestlightening of the melasma. It is therefore important to record good before and afterphotographs as clients often forget their appearance before iPulse treatment.

Moderate improvement in melasma following iPulse treatment. Clinical photography courtesy of Dr. M.Vedamurthy, Chennai, India.

POST INFLAMMATORY HYPERPIGMENTATION / CAFÉ AU LAIT MACULES

 A n e x a m p l e o f p o s t - i n f l a m m a t o r yhyperpigmentation with pigment at variable

depths in the epidermis

 As discussed in the literature, pigmentedblemishes with a deep epidermal ordermal component will be difficult to treatwith any IPL. Even powerful and deeplypenetrating wavelength lasers have hadmixed results with this type of lesion. Asthese blemishes contain pigment at

varying depths and concentrations, it is difficult for any operator to determine pigment

location. Even the use of magnification, cross-polarised light and/or a Woods Lamp(UV diagnostic lamp) does not give a complete picture of pigment location.

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 All IPL manufacturers have the same problem with pigmentation with a deep dermal

component or where the condition is recurring anyway (eg. Melasma and café au Laitmacules).

NEVUS OF OTA / NEVUS OF ITO

Examples of a café au Lait blemish and a nevus of Ito.

It is not recommended to attempt to treat either of these greyish or blue-brownpatches with any IPL.

SIDE EFFECTS IN DARKER SKIN TYPES

Care must be taken to exclude clients with active sun tan (it is a good idea to startnew subjects with a two-week course of sunscreen before iPulse treatment to reducerisk of side effects on the face) and to test-patch carefully to avoid side effects.

Hyper-pigemtation is the most common side-effect and is caused by over-treatment(too much energy), insufficient skin cooling, active suntan when treated or as areaction to undetected / un-declared photo-sensitivity due to drug or herbal remedyuse by the client (eg. St John’s Wort).

Hyper-pigmentation is usually transient and resolvesover subsequent weeks but can last severalmonths. The use of sunscreen, moisturisers andskin lightening creams will assist resolution ofhyper-pigmentation following iPulse treatment.

Illustration: Severe hyper-pigmentation following iPulsetreatment caused by unintentional sun exposure. Clinicalphotography courtesy of Dr Maya Vedamurthy, Chennai, India

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VASCULAR COMPONENT - General redness, telangiectasia (thread veins)

Whilst less prevalent in darker skin types, the natural colour of all skin includes avascular component and it is important when using iPulse skin rejuvenationtechnology to recognise that only vascular abnormalities in a certain range respondto IPL treatment. Very large arborising vessels (greater than 1 mm) cannot be treatedsuccessfully at all by IPL and require either sclerosing or treatment with a deeplypenetrating Nd:YAG laser. Very fine vessels (smaller than 0.1 mm diameter) aregenerally not cleared completely by IPL and require the use of a wavelength-specificlaser such as the pulsed dye or KTP laser. Vessel size is notoriously difficult for thetherapist to determine (even with a transparent mm ruler, skin scanner, magnificationor a Woods Lamp) and the haemoglobin target itself is ‘moving’ as the blood flowsalong the vessels. The most likely range of vessel sizes for effective treatment withIPL is 0.1 mm - 0.3 mm.

 Facial thread veins / broken capillaries General redness (erythema)(Photo by courtesy of Dr S. McCoy, Adelaide)

Examples of conditions that could be treated successfully with iPulse

Good results after one treatment in skin types Fitzpatrick I-III treating diffuse redness(such as acne rosacae) or telangiectatic matting of fine vessels with iPulse can beachieved. Small cherry angiomas (Campbell de Morgan spots) may also respondwell to iPulse treatment.

There have been several IPL studies showing efficacy in the treatment of Class I andII Portwine stain birthmarks.

Typically, higher fluences and multi-pulsing iPulse settings are used to achievevessel attenuation whilst allowing the epidermis to cool during inter-pulse delaytimes. Significant pre- and post-cooling of the skin is necessary.

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WRINKLE COMPONENT - MILD & MODERATE RHYTIDES

The fine lines found at the periphery of laughter lines may be improved but underlyingmuscles determine skin folds and large wrinkles. Frown lines will not respond to IPLtreatment alone.

Illustration: Before and after skin rejuvenation + botulinum toxin-right eye area-female (Clinical photoscourtesy of Dr Jesus. Valdez, Mexico)

Illustration: Before and after 5 iPulse treatments only every 2 weeks, showing shortening of peri-orbitalwrinkles (Clinical photos courtesy of Dr Jesus. Valdez, Mexico).

It is generally accepted that collagen stimulation following light-based therapy suchas iPulse results from damage to the micro-vasculature and the resultant release ofinflammatory and cytokine mediators leading to collagen neogenesis. It has alsobeen suggested that there may be some direct stimulation of certain cytochromes inthe fibroblasts of the mitochondria to increase collagen production.

In any event, increased collagen production in the skin leading to the improvement inthe appearance of fine lines and wrinkles takes weeks and months to develop andclients must be prepared to see only a subtle improvement at best. Laughter lines

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and frown lines are unlikely to show significant improvement as they are largely dueto the underlying musculature and nose/cheek folds and Marionette lines are only

likely to respond to ablative laser resurfacing techniques or the use of injectablecollagen-based or hyaluronic acid fillers and/or Botox®.

The results of iPulse technology in the treatment of photoaging are most noticeablein the early improvement of pigmented and vascular dischromia but later emergingsubtle enhancements in skin tone and texture resulting in enhancements of theappearance of fine lines and wrinkles are an important component in the overalltreatment.

 Acne scarring, which becomes more pronounced in the older patient as the facestarts to sag from the effects of gravity and sun damage, will also respond to iPulsetreatment. However, at best the improvement will be modest and acne patients’expectations must be carefully managed.

ACNE COMPONENT

 

Illustration: Before and after 4 iPulse treatments only. (Clinical photography courtesy of Dr MayaVedamurthy, Chennai, India)

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Whilst mild to moderate inflammatory acne is defined as a medical condition, clientsoften present with the side effects of acne seeking skin rejuvenation treatment. It has

been shown that broad-band intense pulsed light can relieve many of the symptomsof this type of acne and help in its management to avoid subsequent acne scarring.

Early inflammatory acne outbreaks are characterised by the pilosebaceous ductbecoming infected by Propionibacterium. These bacteria are capable ofspontaneously producing high concentrations of porphyrins, which are complex light-sensitive compounds that are normally used in the body as a component ofhemoglobin. They can absorb energy from light and transfer this energy tosurrounding oxygen molecules and toxic oxygen species such as singlet oxygen andfree radicals are thus formed. These chemicals are very reactive and can destroy theacne bacteria. The improvement of acne in individuals after exposure to sunlight isexplained by the photosensitivity of the P. acnes bacterium.

Clinical research has established the photosensitivity of protoporphyrin. Theabsorption characteristics for protoporphyrin IX (PpIX) include significant absorptionpeaks at 508 nm, 542 nm, 577 nm and 635 nm (the “Q-band”) and several of theseare covered by the high-energy output of broad-band light (530 – 950 nm) and aresufficient to stimulate a beneficial response. Early case study reports of IPL + 5-ALAPDT increases efficacy and reduces number of treatments required.

 As it has been reported that longer laser

wavelengths (630nm, 670nm, 810nm) havealso been successful in the treatment ofacne, it is reasonable to assume that themor e dee p ly pen e t r a t i ng lon ge rwavelengths of broadband light alsoachieve greater penetration depth toinclude reaching acne bacteria in thepilosebaceous duct.

With iPulse, appropriate long single ortriple pulses ensure delivery of sufficient

l ight energy to prov ide opt imumeffectiveness in stimulating the body’s ownimmune system response to fight thebacteria. Typically 5-6 treatments 1-2weeks apart are required and iPulse

treatment of acne should be considered an additional acne management tool that willreduce excessive use of antibiotics. Acne and post-acne pigmentation in darker skintypes may also be treated successfully using iPulse.

PHOTODYNAMIC THERAPY

Q-band wavelengths (508 nm, 542 nm, 577 nm and 635 nm) alone stimulate naturalbody porphyrins (PpIX).

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20% 5 amino-levulinic acid (5-ALA) stimulates fluorescence (Dusa LevulanKerasticks) artificially. Methyl aminolevulinate also gives similar results (Photocure

Metvix)

1% non-occluded liposome-encapsulated 5-ALA also shows similar results (EllipseIntense PhotoSpray) but with lower post-treatment toxicity.

Illustration:  Acne before and 13 months after a single IPL+PDT treatment   (Clinical photoscourtesy of Dr D. Fleming, Brisbane)

 

Further reading on acne treated with laser and IPL:

C. Dierikx reported clinically significant facial acne vulgaris clearance without side effects in a twentypatient study at 3 and 6 months post-treatment evaluated by pre- and post-treatment blindedassessors using an IPL device. Lasers in Surgery and Medicine, ASLMS Abstracts 24th  AnnualMeeting, March 21st – April 4th 2004.

C. Erdmann et al   reported effective treatment (average 72% clearance after 8 treatments in a 4

consecutive weeks period) for mild to moderate facial or dorsal Grade II-IV acne using a 400-1200nmbroadband IPL device using optical fluences of 3-10J/cm2 and a 35ms pulse. Lasers in Surgery andMedicine, ASLMS Abstracts 24th Annual Meeting, March 21st – April 4th 2004.

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R. Rox Anderson et al reported moderate improvement in acne in an eleven patient study with amoderate decrease in sebum measurements for at least one month post-treatment using a 532nmlaser. Lasers in Medical Science Abstracts, Joint International Laser Conference, 21-23 September

2003, Edinburgh, Scotland. Vol 18, Supplement 1 2003.

B. Zelickson and J. Counters reported on clinically significant acne reduction using an ALAphotosensitizer both with and without illumination from an incoherent light source. Lasers in Surgeryand Medicine, ASLMS Abstracts 24th Annual Meeting, March 21st – April 4th 2004.

PRE-TREATMENT DOCUMENTATION & ASSESSMENT

Provide the client with written information about the treatment.[See separate client information brochure]

Discuss and complete a full client history in private explaining as fully as possibleabout the treatment and noting any special circumstances applicable to the client. Ask the client about each contraindication individually and mark each one with theclient’s reply. If the client answers “yes” to any of the listed contraindications,document in full on the consent form. Act on the directions listed for that condition.i.e. ask the client to obtain a doctor’s letter on that medical condition in relation tolight-based therapy.[See separate Typical Client Consultation Form]

 All questions about the client must be answered in full.

 

Carefully record reaction to sun exposure (Fitzpatrick Scale), record eye colour andethnic origin to confirm skin type. If uncertain, treat as for the next darker skin type.Consider performing a full skin analysis using appropriate skin evaluation tools(Wood’s Lamp, skin analysers for hydration, lipid level, erythema and melanin).

Number of Treatments

TYPICALLY, SKIN REJUVENATION REQUIRES AT LEAST SIX TO EIGHT CLIENTTREATMENTS AT 4 – 6 WEEK INTERVALS.

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Normally, after a significant improvement in skin dischromia (vascular and pigmentedblemishes) improvements in skin texture which are much more subtle take many

weeks to develop fully.

 Answer any questions the client has regarding treatment and make sure the clienthas REALISTIC EXPECTATIONS of the outcome of the treatment.

 Ask the client to read, sign and date the General Medical History Questionnaire andConsent to Treatment Form if he/she has understood its contents. Counter-sign anddate the Consent to Treatment Form and give the client a copy if requested.

If the client is suitable for treatment continue with evaluation of test areas to establishpredicted treatment parameters. A test area must be performed on or as near aspossible to the area to be treated at least 3 to 7 days prior to any course of treatment(Skin types IV and V should be tested at least 2 weeks prior to treatment).

CONTRAINDICATIONS

Do not treat anyone who has known or reported the following unless a letter from theClient’s GP is available confirming that the medical condition(s) will not preventtreatment using intense pulsed light:

! tanned skin  (active tan) through sun exposure or tanning bed use in the

previous 30 days (because of increased risk of hyper pigmentation)! waxing, plucking, ‘sugaring’ or ‘threading’ depilation treatment of the area in

the previous week (because the skin will be sensitive from these treatments)! moles should not be treated (protect by covering with a white plaster)! hypo pigmentation (e.g. Vitiligo)! any inflammatory skin condition e.g. eczema, active Herpes Simplex, etc. at

the treatment site (because it may aggravate the condition)! skin cancer or any other cancer and / or who reports he/she is undertaking

any cancer drug therapy (such as Ducabaxine, Flurouracil, Methotrexate, etc.)! a history of keloid scarring (because any IPL burn may produce a keloid scar)! epilepsy (because repeated consecutive flashes may induce a fit)! using St. John’s Wort (herbal remedy) in the past 3 months for depression

(owing to photosensitivity)! who has used Isotretinoin – Roaccutane or Tretinoin – Retin A in the previous

3 – 6 months for the treatment of acne or other dermatological conditions! who is pregnant; until periods return and end of breast feeding (because

hormonal imbalance may reduce treatment effectiveness)! who takes drugs for diabetes (owing to possible photosensitivity and poor

wound healing)! taking anti-coagulant drugs (e.g. for heart disease)! wearing a pacemaker unless the IPL or pacemaker manufacturer confirms in

writing that it is safe to treat the client wearing the pacemaker ! taking any topical medication (e.g. hydrocortisone) or is wearing perfumes,

deodorants, sun block, essential oils or other skin lotions (which could causephotosensitivity)

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! surgical metal pins or plates under the tissue to be treated! to be under 18 years of age if the establishment is not registered to treat

children or if parental permission is withheld.

 A doctor’s letter should be obtained before treating clients who are reportedly usingQuinidine, any anti-psychotic medication or large combinations of cardiac / diureticdrugs, topical steroid creams in the area to be treated, general anaesthesia in thelast 3 months, local anaesthetic treated areas in the past month or where you areuncertain about any reported medical condition or medication.

Treat with caution and obtain a doctor’s letter if you are uncertain about anyone whohas fake tan, suffers with allergies, has hormone abnormalities, has cold sores in thetreatment area, has had previous skin rejuvenation treatments or has reported HIV orHepatitis.

[See separate Information on Drug-Induced Photosensitivity in the User Manual]

PRE-TREATMENT ADVICE TO CLIENTS

Clients should be instructed in pre-treatment skin care and should be provided withwritten take-home instructions recommending: ! Don’t expose skin to UV (sun exposure or the use of tanning beds) or self tan

for at least 4 weeks before and/or between IPL treatments,! don’t depilate with waxing, plucking or threading (shaving or depilatory creams

are acceptable) immediately before IPL treatment of the area,! don’t use bleaching creams, or perfumed products (e.g. aromatherapy oils) for

24-48 hrs before treatment sessions,! avoid swimming in strong chlorinated water immediately before an iPulse

treatment session,! avoid exfoliating, microdermabrasion or peels for 1 week before treatment

sessions,! keep the area clean and dry,! hydrate the body by drinking plenty of water and! protect the skin from sun exposure with suitable clothing and use of sun block

SPF 30+ before first treatment and between subsequent treatment sessionsbut do NOT use sun blocking creams within 24hrs of scheduled treatments.

Treatment programs will often include a preliminary 2-4 weeks course of fruit-acidpeels or microdermabrasion as well as sun protection, vitamin / moisturising and/orskin lightening creams depending on the degree of skin damage.

NB. Hot and humid weather conditions can aggravate skin in the period immediatelybefore treatment.

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THE THERAPEUTIC WINDOW – How to choose your parameters

This is determined by the therapist following a sequence of steps:

1. Exclude all unsuitable subjects due to age, recent surgery, pregnancy / breast-feeding, pre-existing medical conditions (e.g. skin disorders, cancer, severeheart disease, etc), contra-indicated drug or homeopathic / herbal therapy,recent active sun exposure (suntan), unsuitable recent depilation treatments,[See separate photosensitive drug lists, clinical protocol, etc.)

2. Determine underlying skin type of the client (Fitzpatrick Scale) AND  the skintype in the area to be treated. This can be assessed by use of differentmethods including simple evaluation against a chart, questionnaires with anumerical scale, skin diagnostic devices which measure melanin and skin

redness (skin reflectance spectrometers), etc. [See separate examples] A subject‘sgeneral Fitzpatrick Skin Type is assessed on a body area not normallyexposed to the sun as well as the subject’s ethnicity and tanning habits. Thearea to be treated may appear different from the underlying skin type due tosun damage, age or specific local skin tone and must be taken into account.

3. IPL manufacturers usually provide a list of treatment program options whichallow the operator to select a suitable skin rejuvenation program according toFitzpatrick Skin Type [See your iPulse User Manual ]

4. Undertake test areas  at several increasing energy density levels until asuitable starting energy level is determined. [See separate sheet “client preparation”]

5. The starting energy is that which will produce a heat response in the skinwhich feels hot or like a prickle to the client but is tolerable. In addition, theremay be some development of redness (erythema) in or around the treatedarea within a few minutes. If there is a strong histamine-like reaction withswelling and general ‘raw’ redness around the area, this is the first sign ofover-treatment.

NB. Thin skin areas over bone (e.g. jaw, décolleté) will not tolerate such high energylevels as thick or fatty areas. For this reason the available treatment energies in theprograms offered include lower fluence values to accommodate such cases andother types of treatment.

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iPULSE™ TREATMENT PROGRAMS Professional Mode

The iPulse Treatment Programs Chart provides a range of 16 available pulse lengths andenergy levels to suit individual client needs. Five programs are reserved for alternativeapplications.

COLUMN ONE lists the sixteen possible treatment programs including those programssuitable for pigmented blemishes  by skin type i.e. Light Skin Types 1 – 3a are programs 2,3, 4 and 5 and Dark Skin Types 3b – 5 are programs 10, 11, 12 and 16 and for vasculartreatments i.e. Light Skin Types 1 – 3 programs 5, 6, 7 and 8. The program numbercorresponds to the fixed pulse length and pulse type (single pulse or triple pulse).

COLUMN TWO gives the fixed length of the pulse (or pulses) and the range of energysettings which can be selected (in 0.5 J/cm2  increments). As stated in the NB above, theavailable range of energy settings includes low values for exceptional cases. Typically,

starting energies for hair removal will be 14 J/cm

2

 or higher.COLUMN THREE simply illustrates the pulse type (single or triple) against a millisecondscale but not the range of energy available.

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iPULSE TYPICAL TREATMENT PARAMETERS -PIGMENTED COMPONENT

This is the FIRST  target of skin rejuvenation as epidermal pigment will at leastpartially block the penetration of deeper penetrating light energy intended to treat thevascular component, stimulate collagen production or to tackle acne bacteria in thedeeper lying sebaceous ducts.

Light Skin

Light Skin Types 1 – 3Pigmented Blemishes

Single Pulse Programs 3 and 4Multiple Pulse Program 10

 Available Treatment Energy 4 to 20 J/cm2

Typical Treatment Energy 14 -17 J/cm2

Clinical data has shown that for lighter skin types (Fitzpatrick 1 to 3) single pulses of20 to 25 ms (Program 3 and 4) with energy ranges of 14 to 17 J/cm2 and multiplepulses (Program 10) with an energy range of 14 to 17 J/cm2  have proven to beeffective to treat mottled pigmentation.

Fitzpatrickskin type

P i g m e n tcolour 

Program J/cm2

1 Light 3 14 – 17

1 Medium 4 14 – 17

1 Dark 10 14 – 17

2 Light 3 14 – 17

2 Medium 4 14 – 17

2 Dark 10 14 – 17

3a Light 4 14 – 17

3a Medium 5 14 – 17

3a Dark 6 14 – 17

3b Light 6 14 – 17

3b Medium 7 14 – 17

3b Dark 10 14 – 17

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Dark Skin

Dark Skin Types 3b, 4 & 5Pigmented BlemishesMultiple Pulse Programs 10, 11, 12 and 15

 Available Treatment Energy 6 to 20 J/cm2

Typical Treatment Energy 12 to 17 J/cm2

Darker skin can react to light treatment by hyper- or hypo-pigmenting so it is besttreated with a longer pulse width (time span) to spread out the energy and make thetreatment safer and more comfortable. This means using a multi-pulsing program.

FitzpatrickSkin Type

P i g m e n tcolour 

Program J/cm2

3b Dark 7 14 – 17

4a Light 10 13 – 17

4a Medium 15 13 – 17

4a Dark 16 12 – 17

4b Light 10 13 – 16

4b Medium 12 12 – 16

4b Dark 15 12 – 165 Light 10 13 – 16

5 Medium 12 13 – 16

5 Dark 15 12 – 16

6 n/a n/a n/a

The modified and additional values suggested in the above table for darker skintypes is based upon clinical experience on Indian skin types (Fitzpatrick 5 & 6) by Dr.Maya Vedamurthy in Chennai, India in a study including 138 patients of skin types 5

& 6 treated for hair removal, pigmented lesions and acne.

Darker skin can react to light treatment by hyper- or hypo-pigmenting so it is besttreated with a longer pulse width (time span) to spread out the energy and make thetreatment safer and more comfortable. This means using a long single pulse or amulti-pulsing program.

THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BECONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHESIS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY

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iPULSE TREATMENT PARAMETERS –VASCULAR COMPONENT

 After any superficial pigmented dischromia has been treated and removed orreduced, vascular elements can be more easily reached by deeper penetratingwavelengths of light. Vascular dischromia and vascular blemishes are common inlighter skin types (Fitzpatrick 1 – 3) and are much less common in darker skin.

When treating vascular abnormalities with IPL, the skin colour is more important thanthe vessel size (which is notoriously difficult to determine anyway). Darker skin canreact to light treatment by hyper- or hypo-pigmenting so it is best treated with alonger pulse duration [time span] to spread out the energy and make the treatment

safer. This means using a longer pulse or multi-pulsing if available. Multi-pulsingprograms have the added advantage of also having gaps between the pulsesallowing a cooling time for the epidermis. The total amount of energy deliveredshould remain pretty much the same.

Light Skin

Light Skin Types 1 to 3Vascular BlemishesSingle Pulse Programs 4, 5 and 6

 Available Treatment Energy 4 to 20 J/cm2

Typical Treatment Energy 16 to 18 J/cm2

Fitzpatrickskin type

Blood vesselsize

Program J/cm2

1 Thin 4 16 - 17

1 Medium 4 16 - 17

1 Thick 4 16 - 17

2 Thin 5 16 - 18

2 Medium 5 16 - 18

2 Thick 5 16 - 18

3 Thin 6 16 - 18

3 Medium 6 16 - 18

3 Thick 6 16 - 18

THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BECONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHES

IS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY

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Dark Skin

 A smaller range of suggested parameters is given for vascular blemishes in darkerskin as they are much less common.

Dark Skin Type 4 - Vascular Blemishes

Multiple Pulse Program 16

 Available Treatment Energy 8 to 20 J/cm2

Typical Treatment Energy 16 to 18 J/cm2

Fitzpatrick

skin type

Blood vessel

size

Program J/cm2

4 Thin 16 16 - 18

4 Medium 16 16 - 18

456

Thickn/an/a

16n/an/a

16 - 18n/an/a

Note: When treating vascular abnormalities with iPulse, the skin colour is moreimportant than the vessel size (which is notoriously difficult to determineanyway). Darker skin can react to light treatment by hyper- or hypo-pigmenting

so it is best treated with a longer pulse width [time span] to spread out theenergy and make the treatment safer. This means using a higher numberprogram in the single shot section or go to multi-pulsing. The multi-pulsingprograms have the added advantage of also having gaps between the pulsesallowing a cooling time for the epidermis. The total amount of energy deliveredremains pretty much the same.

 THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BECONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHESIS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY

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TYPICAL iPULSE TREATMENT PARAMETERS –SKIN REJUVENATION

Normally, treatments will follow in sequence: pigmented, then vascular elements. Inso doing, the process of collagen stimulation for wrinkle reduction will already beunderway. When treating clients for skin texture improvement only, it is onlynecessary to repeat treatments using the same settings as for fine blood vessel (i.e.vascular) treatments.

 

Skin rejuvenation including reduced pigmentary dischromia andwrinkles showing a subtle improvement post-treatment

TYPICAL IPL TREATMENT PARAMETERS – ACNE

IPL treatment of acne is intended as an acne management option to allow relief fromcontinued use of anti-biotics or where Isotretinoin therapy is contra-indicated. Thebroadband light produced by iPulse includes light energy at all four peaks ofabsorption by protoporphyrin 9 (PpIX) in the so-called “Q-band” of wavelengths. IPLdoes not cure acne but assists the production of natural porphyrins to fight the acnebacteria by producing singlet oxygen which destroys the bacteria in situ.

Unlike blue light acne therapy where wavelengths used only penetrate the uppermostlayers of the skin, the longer wavelengths of iPulse will penetrate to the sebaceousduct and sebaceous gland where the bacteria propagates.

The treatment of acne is similar for most skin types. The objective is to deliver onlymoderate energy over a long pulse (or multiple pulses for very dark skin) to stimulateprotoporphyrin 9 production in the skin.

Skin types 1-3 Program 9, Energy density: 10-12 J/cm2

Skin types 4-5 Program 9 or 15, Energy density: 8-10 J/cm2

Skin types 6 Program 14, Energy density: 7-8 J/cm2

Note: If acne is inflamed and sensitive, use a lower fluence.

Usually 5-8 treatments are required at 2-3 week intervals to provide relief from mild tomoderate inflammatory acne.

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TEST AREAS

Test areas are required and are described in detail in the following section in order toestablish the best starting IPL energy level and to reduce the risk of unwanted sideeffects from over-treatment.

It is normal for the client to experience at least a sensation of warmth or heat duringeach IPL shot or a ‘ping’ like the flick of a rubber band on the skin. It is recommendedthat test-areas be evaluated on or near the treatment site using the lowestrecommended fluence for the skin type, increasing the fluence if necessary until theclient feels a ‘ping’, heat or mild discomfort (according to the individual’s paintolerance). Assess the immediate response and record the treatment parameters inthe client record. If in any doubt, do not perform a treatment.

When performing the first test area on a new client you have only 1-3 chances toestablish the energy level. For larger areas such as facial areas, décolleté, forearms,etc, it is easy to establish a test area. However, for small areas such as specificpigmented blemishes, spider nevi, etc, only one shot can be made. In that case, itshould be the best estimated shot.

On lighter skin (Types I/III), start with one shot at the lowest energy level predictedby skin type, then one shot 1 J/cm2  above the lowest predicted energy level andlastly 2 J/cm2  higher than the lowest predicted energy level to evaluate tissue

response.

Example: According to “Typical Treatment Parameters for PigmentedBlemishes” (section above) a Skin Type II client with a medium pigmented blemishwould need Program 4 predicting a start energy of 14.0 J/cm2 so, you choose energylevels: 14.0 J/cm2, 15.0 J/cm2 and 16.0 J/cm2 for the test area.

On darker skin (Types IV/V), start with one shot 0.5 J/cm2 below the lowest energylevel predicted by skin type, then one shot at the lowest predicted energy level andthen one shot 0.5 J/cm2 above the lowest predicted energy level to evaluate tissueresponse.

Example: According to “Typical Treatment Parameters for VascularBlemishes” (section above) a Skin Type IV client with fine blood vessel size wouldneed Program 16 predicting a start energy of 16.0 J/cm2  so, you choose energylevels: 15.5 J/cm2, 16.0 J/cm2 and 16.5 J/cm2 for the test area.

The choice to go higher with the second and third test shots will be based upon anumber of factors including, whether the client experienced the sensation of a ‘ping’or heat, if the area in question is definitely not tanned and if you have treated theclient previously and have experience with their skin response to treatment on other

body areas.

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The following points should also be observed when performing test areas:

- To be carried out on all patients before a full treatment commences- The area to be treated needs to be clean, free of cosmetics and creams

- The aim of test shots is to determine the most effective fluence settings for the patient

skin type and size of area without causing any adverse reactions

- Only a small area (3 or 4 shots in darker skin types, a few more in fair skinned patients)

should be treated. If possible this should be in an area that is not too obvious but

representative of the proposed treatment area

- Usually 3 settings are required

- Patient, operator and anyone else in the treatment room must wear appropriate IPL

safety eye-wear before treatment commences

- The applicator’s contact crystal (light guide) must be held flat on the surface being

treated with the contact crystal touching (but not compressing) the skin tissue

- Test area treatment should be ceased immediately if side effects occur 

- Patients must be given clear instructions on post iPulse skin care, in particular sun

avoidance and avoidance of injury to the skin.

Details of the treatment performed including treatment area, iPulse type, program,pulse width, fluence and number of shots should be accurately recorded in the

client’s record. The entry should be signed, timed and dated. The iPulse treatmentregister (log book) must be completed recording treatment in the same way.

With Skin Types I/III ask the client to return in 3-7 days for final evaluation andtreatment. Skin Types IV/V should wait for 14 days to be sure of no late emergingside effects.

iPULSE TREATMENT ROOM SET-UP CHECK LIST

1. Make sure any required IPL hazard warning notices are in place at entrances.2. Close window blinds and cover any mirror surfaces to reduce reflection hazard3. Check fire extinguisher location (suitable for electrical fires).4. Make sure all Local Rules, Treatment Protocols and client documentation is

available for reference.5. Check availability of all required supplies: couch roll, razors, gloves, tissues,

refrigerated clear ultrasound gel, wooden spatulas, skin cooling gel packs,white marker pencils, wipes, post-treatment skin calming lotion (eg aloe vera),etc.

6. Close the entrance door to prevent unauthorized entry and to protect theprivacy and dignity of the client by suitable means e.g. use towels duringintimate area treatment, eye safety, etc.

7. Check ventilation (extractor fan, air conditioning, etc).

  [Contact your Laser Protection Advisor for further assistance on safety issues] 

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CLIENT PREPARATION CHECK LIST

1. Ensure all patient questionnaires (general medical history) and consent formsare completed and signed by the client and the operator. Consent Formsshould ideally be signed each time before an IPL treatment. [See separate sheets] 

2. Ask client to remove all jewellery, make up, deodorant, etc in the treatmentarea.

3. The area should be cleaned with water only; any creams may leave a residue,which could affect the efficiency of the treatment.

4. Mark the extent of the skin area to be treated with a white eye liner pencil.5. In the area to be treated, ‘white-out’ small lesions, moles, etc and cover any

sensitive areas (tattoos, lips, etc) with cut-out adhesive white labels or white

card to protect them from absorbing light energy.6. Give the client and any assistant or observer present in the room suitableprotective safety glasses (e.g. broadband shade 5).

7. Close-fitting reusable metal or disposable adhesive ocular shields should beplaced over the eyes of the client if treating facial areas near to the eyeswhere safety glasses would allow light penetration under the rim.

8. Set up the IPL program and predicted energy setting (based on skin type, sizeof vessels, location of pigment, etc).

9. Cool the area with a cold pack if required (e.g. sensitive or dark skin).10. Either dispense sufficient ultrasound gel into a small container or deposit

‘blobs’ of clear  ultrasound gel directly onto the skin from the dispenser bottle

and using a clean wooden spatula, spread a layer of gel over the skinapproximately 2 – 3 mm thick. The gel must be kept cold (but not frozen) in afridge.

11. Do not ‘overwork’ the gel on the skin, as it will heat up. Do not reuse the gel(infection risk)

12. The operator must wear suitable safety glasses during IPL treatment (e.g.broadband shade 3) and “blink” during the flash to limit light entering theoperator’s eyes and thereby improve visibility of the treatment area after theflash.

The skin rejuvenation treatment sequence

Use refrigerated cooling gel packs for sensitive or darker skin types

Mark the skin with gridlines to assist with accurate placement of the contact crystalDispense cooled gel and apply with a wooden spatula Apply a layer of gel 2-3 mm thick

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USE OF iPULSE APPLICATOR CHECK LIST:

1. Place the light guide (crystal) flat to the skin.2. The light guide should NOT be pressed into the gel firmly but “float” just on the

skin surface (to avoid compressing the fine blood vessels). 3. Treatment spots are placed directly next to one another with minimal overlap.4. Make sure there are no gaps between the treatment spots.

The light guide will leave a track or mark in the gel, which will help show where youhave treated.

Do NOT press the light guide firmly into the clear ultrasound gel, allow it to contactthe skin only lightly.The light guide will still leave a ‘footprint’ in the gelCover any sensitive areas (tattoos, lips, etc) with cut-out adhesive white labels, white

‘Fibrella’ cloth or a spatula to protect them from absorbing light energy.

BEWARE IF:

1. The skin is treated without gel (more absorption in the epidermis on dry skinareas).

2. The light guide overlaps a previous treated area (over-treatment risk).3. The light guide treats skin with hair (may permanently remove hair), over

tattoos or tanned skin (over-treatment risk).4. The light guide leans to one side (insufficient energy delivered to the target).

5. Part of the light guide is not in contact with the skin (insufficient energydelivered to the target)

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PRACTICAL TIPS FOR SKIN REJUVENATION

 All areas of the body can be treated except inside the orbit of the eye (e.g.underneath the eyebrows) or on mucous membranes (e.g. inside nostrils, ears, etc.). As described in the Introduction, specific vascular and pigmented lesions should betreated first after diagnosis by a dermatologist.

Facial areaFor whole-face rejuvenation, make a line of treatment spots down the face along the jaw line and add rows above as necessary where skin rejuvenation is needed until allrequired cheek areas are covered. Then repeat the process on the forehead and chinareas. Pay particular attention to the following points:

1. Avoid accidentally treating the scalp hair by using a white hair band.2. Use a piece of white ‘Fibrella’ cloth, white card or white adhesive label to

shield areas if required.

When treating the upper lip (moustache area), remember that the central area belowthe nostrils (nasal alia) is particularly sensitive. Mostly the upper lip area can betreated with 2-3 shots (depending on spot size).

Following multiple treatments of the upper lip (moustache area) resulting in increasedcollagen in the skin tissue, it may be possible to observe an improvement in the lip

line (‘Cupid’s Bow’) with more lip vermilion newly exposed to give a ‘fuller’ look to thelip.

1. Remember to remove all lip-gloss, lip salve or make up.2. Apply white pencil to mask any semi permanent lip liner on the lip margin.3. Shield the lips with damp cotton wool or white adhesive label before treating.4. Use gel sparingly as it can easily obstruct the nostrils which is unpleasant for

the client.

To identify whether pigmentation is epidermal (e.g. freckles, age spots, epidermalmelasma, etc.) or dermal (post-inflammatory hyper-pigmentation, dermal melasma,

etc.) – the skin in the area to be treated can be stretched between the fingers. If thepigmentation lightens significantly on stretching, the pigmentation is mostlyepidermal. If there is little colour change, the pigmentation is deeper.

Treatment of Poikiloderma of Civatte (mostly found on the lateral lower third of theneck) should be undertaken carefully starting with lower fluences as the neck skin inthis area is particularly delicate.

Remember, fine lines and wrinkles will require multiple treatments and only improvefully over several months.

Facial treatments should be kept outside the orbital canthus (outer bony rim of theeye socket).

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Individual small pigmented blemishes may be treated easily using a paper maskmade from a small sheet of white folded paper (or white self-adhesive label) with the

corner cut-off.

Décolleté

The upper chest in female clients (between and above the breasts) can be treatedtaking care with energy settings as the chest bone (sternum) is close to the bodysurface in this area and may be sensitive. Moreover, the décolleté is often heavilytanned and sun-damaged and does not heal easily if over-treated. Therefore, treatwith caution, starting with lower fluence levels.

Nipple PigmentPost-breast feeding, some women (particularly East-Asian skin types) experience

significant darkening of the areola and seek skin lightening treatment. Cases ofsuccessful pigment lightening have been reported using programs and fluences fortype 5 skin. However, care should be taken when treating this sensitive intimate area.

ForearmsThe forearms may be covered with mottled pigmentation (freckles) from sunexposure. Care should be taken to eliminate active tan in advance of iPulsetreatment (particularly with the driving-side arm) through the use of high-factor sanlotion for at least two weeks before treatment commences.

1. Mark out the sub-divided area to be treated using a white pencil.2. It is preferable to treat around sections of the arm rather than along the lengthof the arm. If required you can treat around the elbow or wrist.

 

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AFTER USING IPL APPLICATOR

1. Ensure that the skin area is completely treated (no obvious gaps)2. Put the iPulse unit into STANDBY3. Remove safety eye wear 4. Once the area has been treated, remove the ultrasound gel using a spatula

and then tissues5. Check the area for redness and record in client notes6. Apply a cooling gel pack to any sensitive areas if required7. Apply a calming lotion such as Aloe Vera8. Complete the client treatment notes and record any unusual occurrence9. Provide post-treatment advice and take-home information sheet

10. Book your client’s next treatment11. Switch-off the iPulse, clean the crystal treatment guide with a moist tissue or

an isopropyl wipe and prepare the room for the next client.

REMEMBER YOUR CLIENT’S TREATMENT TIME INCLUDES:

- Meeting and greeting- Providing required information / answering questions- Preparation of treatment area / applying pre-cooling gel- The treatment- Post-cooling / use of soothing lotion or gel- Completing client record and rebooking the next appointment- Providing client with take-home instructions sheet

NB: Clients frequently loose take-home information. It is advisable to ask clients tosign a note that they have received return home-care instructions. This may beincluded in the consent form or general client questionnaire.

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RECOGNITION OF TREATMENT RELATED PROBLEMS

Normally, the skin will be no more than temporarily red and feel warm after treatmentwhich disappears within minutes or a few hours – at the most 24 hours.

Improper use of the iPulse system could result in possible side effects. Althoughthese effects are rare and expected to be transient, any serious adverse reactionshould be reported to the client’s own doctor. Side effects may be immediate orappear shortly post treatment (0 – 24 hrs); in rare cases, there may be late emergingside effects (typically 24 – 72 hrs) and include:

IMMEDIATE

- Excessive pain: Stop treatment, cool the skin and moisturise. Review after24hrs and re-start treatments at lower fluence. (Most common reasons:tanned skin, stress, menstruation and tiredness).

POST TREATMENT

- Excessive persistent heat and redness: Normally resolves in 24 hrs. If a burn-associated reaction is expected, a one-time application of a local steroidointment may be indicated (medical prescription). Cool the area regularlyusing cloth-wrapped ice packs or cooling gel and advise client to use pure

 Aloe Vera and skin protection as for mild sunburn until the sensationdisappears. If the reaction persists the client should consult his/her doctor.

- Damage to natural skin texture (crust, blister, burn): Cool area thoroughly forpain relief, if already blistered or burnt, recommend burn sprays and creamsfrom the pharmacy. Consult doctor and follow adverse incident procedure.

- Excessive swelling (oedema), fragile skin, bruising (purpura): Cool area forimmediate pain relief; Consult his/her doctor and follow  Adverse IncidentProcedure (see below).

LATE EMERGING

-Change of pigmentation (hyper- and hypo-pigmentation): Moisturise andprotect from sun exposure and further skin insult (i.e. leave alone and do notrub), consult his/her operator and doctor if condition persists.

- Excessive hypo-pigmentation or scarring: Consult doctor and follow adverseincident procedure. Avoid sun exposure and use a sun block for six months.

- Prolonged itching on the treatment area: Keep the area cool and apply pure Aloe Vera gel. If itching persists the client should consult his/her doctor.

- Ineffective skin rejuvenation: Reassess client history and increase fluencedepending on skin reaction.

NB. Only retreat an area where any problems or responses have healed fully andalways repeat testing.

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POST-TREATMENT CARE

Clients should be instructed in post-treatment skin care and should be provided withwritten take-home instructions recommending: ! Don’t expose skin to UV (sun exposure or the use of tanning beds) or self tan

for at least 2 weeks,! don’t shave for 48-72 hrs after facial treatment! don’t use bleaching creams, or perfumed products for 24-48 hrs,! don’t pick or scratch the treated area,! avoid rough handling of the area treated,! leave any skin responses alone, these are temporary and will subside,!

avoid very hot baths / showers / steam baths / sauna for 1 week,! avoid swimming in strong chlorinated water for 1 week,! avoid exfoliating or peels for 1 week,! avoid rough sports for 24-48 hrs,! avoid wearing tight clothing,! keep the area clean and dry,! hydrate the body by drinking plenty of water and! use of sun block min SPF 30+ and consider using protective cotton gloves for

driving, a hat to protect facial areas.

NB. Hot and humid weather conditions can aggravate skin in the period immediately

following treatment.

Immediately post-skin rejuvenation treatments, effective skin cooling of the epidermiscan be helpful. The use of ice or cooling gel packs, Aloe Vera gel etc., can improvepatient comfort and reduce post-operative redness (erythema).

ADVERSE INCIDENT PROCEDURE – What to do if anything goes wrong

If anything goes wrong during treatment such as untoward skin reaction, excessivepain, client taken ill, etc., treatment should be abandoned IMMEDIATELY. (NB. If

necessary, the iPulse may be switched-off and/or the key removed to prevent anyrisk of further emission of IPL energy). Appropriate information should be recorded inthe client notes of extent of the partially completed treatment with details of anyuntoward side effects. An ‘Untoward Incident Report’ should be completed.

Suspected eye damage or serious skin damage should be referred immediately tothe Accident & Emergency Dept. of the nearest hospital or via the client’s doctor toan appropriate medical specialist if necessary.

In all cases of suspected eye over-exposure to the iPulse flash to the operator or aclient, an immediate eye test by an ophthalmic specialist should be arranged through

the doctor or the Accident & Emergency Dept of the nearest hospital.

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RISK ASSESSMENTS

In England and Wales, Risk Assessments must be carried out under theManagement of the Health & Safety at Work Regulations 1999, Regulation 3.

ADVERSE INCIDENT REPORTING

The registered person in England and Wales is required to notify the HealthcareCommission within 24 hours of any death or serious injury to a patient as aconsequence of treatment, either in the establishment or within seven days oftreatment. Similarly, any allegation of misconduct resulting in actual or potential harmto a patient by the registered person or any person employed by the registered

person must also be reported to the Healthcare Commission (Regulation 28). Anysuch injury following laser or IPL treatment should also be reported to the Laserprotection Adviser.

 Appropriate details should be recorded in the client record of treatment and in the Accident Book.

In England and Wales, adverse incidents involving actual eye damage, serious skindamage, accidents or ill health at work must be reported under the Reporting ofInjuries, Diseases and Dangerous Occurrences Regulations 1995 by internet,telephone, fax or post to:

The Incident Contact CentreCaerphilly Business ParkCaerphillyWales, CF83 3GGwww.riddor.gov.uk/info.htmlTel: 0845 3009923Fax: 0845 3009924

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PROCEDURE IN THE EVENT OF EQUIPMENT FAILURE

In the event of equipment failure, treatment should be abandoned IMMEDIATELYand the emergency stop button pressed and / or the key removed to prevent any riskof further emission of iPulse energy. Remove the mains plug. Details should berecorded in the Client Record of the partially completed treatment with details of anyuntoward side effects. The appointed iPulse  factory service engineer should beinformed immediately of the circumstances of the equipment failure and an IncidentReport completed.

This treatment protocol should be adopted in conjunction with CyDen’s User Manual  and the ‘Local Rules’ governing the safe use of the device at the establishment, asthese will contain important information to be followed by the operator in respect of:

- potential hazards associated with this type of lPL- controlled and safe access to the Controlled Area- the authorised users’ responsibilities- methods of safe working and safety checks- normal operating procedures- personal protective equipment (eyewear)- prevention of use by unauthorised persons and- adverse incident procedure.

Treatment should only be restarted if the event was a false alarm.

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