Treatment of Facial Acne Papules and Pustules in KoreanPatients Using an Intense Pulsed Light Device Equipped witha 530- to 750-nm Filter

SUNG-EUN CHANG, MD,� SOO-JIN AHN, MD,� DO-YOUNG RHEE, MD,� JEE-HO CHOI, MD,�

KEE-CHAN MOON, MD,� HO-SEOK SUH, MD,y AND SOYUN-CHO, MDz

BACKGROUND A rising number of laser- or light-based therapies are addressing the need for effectiveacne treatments with minimal downtime.

OBJECTIVE The purpose of this study is to evaluate an intense pulsed light (IPL) equipped with a 530- to750-nm filter for inflammatory acne treatment.

PATIENTS AND METHODS Thirty female patients (mean age, 25.7 years) with mild-to-moderate acnewere enrolled. While using benzoyl peroxide (BP) gel, one side of the face was treated with the PR filter(acne filter) of the IPL.

RESULTS All patients experienced the reduction of inflammatory lesion counts in both sides of face.There was no significant difference between IPL-treated and untreated sides of the face for mean papuleplus pustule counts, 3 weeks after three sessions. As to red macules, 63% were good or excellent on thelaser-treated side compared to 33% on the untreated side. Improvement of irregular pigmentation andskin tone was detected on the laser-treated side than the untreated side.

CONCLUSION This new wavelength band of IPL system was safe and effective in improving acne redmacules, irregular pigmentation, and skin tone but did not affect inflammatory acne lesion counts on theskin of Asian persons.

The authors have indicated no significant interest with commercial supporters.

At our dermatology outpatient clinic, one of the

biggest hospitals in Korea, the most common

complaint from 1994 to 2005 was acne.1,2 Most of

the acne patients who sought cosmetic procedures

were socially active women often with significant

psychological and physical morbidity associated

with acne.1,2 Acne has been conventionally treated

with various topical and oral therapies; however,

these might induce significant side effects. Further-

more, Korean patients traditionally refuse oral ther-

apies and want to avoid irritating antiacne

topicals.1,2 A rising number of laser- or light-based

therapies are addressing the need for effective and

safe acne treatments with minimal downtime.3–5

Many patients in our clinic today seek the least

invasive treatments possible for improving inflam-

matory acne and the sequelae of acne.2 It has been

controversial, however, whether dye laser therapy,

the most commonly used device for acne treatment,

can reduce the number of inflammatory acne le-

sions.6,7 The purpose of this study was to evaluate an

intense pulsed light (IPL) system equipped with a

530- to 750-nm filter (I2PL, Ellipse Flex, DDD,

Horsholm, Denmark)8 for treatment of inflamma-

tory acne.

Patients and Methods

Thirty female patients (mean age, 25.7 years; range,

23–32 years) with acne of Grade 2 according to

Korean acne grading system4 (Table 1) were en-

rolled. Exclusion criterion was previous oral

& 2007 by the American Society for Dermatologic Surgery, Inc. � Published by Blackwell Publishing �ISSN: 1076-0512 � Dermatol Surg 2007;33:676–679 � DOI: 10.1111/j.1524-4725.2007.33142.x

6 7 6

�Department of Dermatology, Asan Medical Center; yUlsan University Hospital, University of Ulsan College ofMedicine; and zBorame Hospital Seoul National University, Seoul, Korea

antiacne medication in less than 1 month before this

IPL trial. Patients were instructed to use topical

benzoyl peroxide (BP) gel on the lesions of both sides

of face once a day.

While using the BP gel, randomly selected side of the

face was treated with the IPL. Baseline lesion counts

of papules and pustules right before the first session

of IPL treatment were performed. Lesion counts on

treatment and control sides were almost equivalent.

For lesion counts at baseline and 3 weeks after the

third session, two blinded raters (dermatologic resi-

dents) did lesion counts and means were recorded.

The PR filter (acne filter) of IPL system equipped with

a 530- to 750-nm filter (Ellipse Flex, DDD) was used

to target the blood vessels that supply the sebaceous

glands according to the manufacturer’s instructions.8

No topical anesthesia was used; the energy fluence

was 8.0 J/cm2 for skin type III (11 patients) and

7.5 J/cm2 for skin type IV (19 patients) using pulse

durations of 2.5 ms and double light pulse with 10-ms

interval. Enough cooling gel was applied immediately

before IPL treatment and no pressure was applied to

the handpiece. The patients were treated with three

sessions of IPL, 3 weeks apart.

Three weeks after the last treatment, lesion counts

of inflammatory acne papules and pustules were

determined. Comedone were not counted because

comedone cannot be easily identified, and the Kor-

ean acne grading system2 covers only papules and

pustules for acne severity. Comparison of the change

from baseline between the IPL-treated sides and

untreated sides of the face was performed.

We compared these differences using the paired t

test. The red macules were evaluated with digital

photography with scoring and a colorimeter (Chro-

mameter-CR221, Minolta, Tokyo, Japan). Irregular

brownish pigmentation with skin tone was evaluated

based on photography, and improvement scoring

(Table 2) was made by two independent dermatol-

ogists. Evaluation of patient’s subjective response to

treatment was performed by a questionnaire ranking

the degree of satisfaction as highly satisfied, satisfied,

neutral, or dissatisfied at baseline and at each visit.

Informed consent was obtained from all subjects.

The study protocol conformed to the guidelines of

the 1975 Declaration of Helsinki and was approved

by our institutional review board.

Results

All patients experienced a reduction in inflammatory

lesion counts on both sides of the face. There was no

significant difference between IPL-treated and un-

treated sides of the face for changes in mean papule

plus pustule counts (�3.2 vs. �3.1; p4.05; Figures 1

and 2). Although patients were uniformly satisfied

with their treatment, IPL treatment did not give any

additional benefit to reduction of papules and pus-

tules. As for red macules, 63% was good or excellent

(by improvement scoring, Table 2) on the laser-

treated side compared to 33% on the untreated side.

The results of colorimeter were compatible with the

clinical improvement of red macules. Improvement

of irregular pigmentation and skin tone was scored

good or excellent in 63% of the laser treated side and

in 16.7% of the untreated side. Pain was well tol-

erated in all patients without any topical anesthesia.

No side effects were seen except a few, mild

postinflammatory hyperpigmented spots lasting for

less than 2 weeks in three patients (10%).

TABLE 1. Korean Acne Grading System

Grade 1 Papules r10

Grade 2 Papules 11–30

Grade 3 Papules � 31, nodules r10

Grade 4 Nodules 11–207mild ongoing scars

Grade 5 Nodules 21–307moderate ongoing scars

Grade 6 Nodules � 317 severe ongoing

scars7 sinus tracts

TABLE 2. Improvement Scoring

No improvement 0%

Poor o25%

Fair 25%–50%

Good 50%–75%

Excellent 475%

3 3 : 6 : J U N E 2 0 0 7 6 7 7

C H A N G E T A L

Discussion

Because most patients nowadays tend to seek the

least invasive treatments possible for improving in-

flammatory acne, a rising number of laser- or light-

based therapies have been introduced as effective

and safe acne treatments with minimal downtime.3–5

It has been controversial, however, that dye laser

therapy, the most commonly used device, can reduce

the number of inflammatory acne lesions or not.6,7

Recently, a 1,450-nm diode laser has been used for

the treatment of acne on the back, and the mecha-

nism of this deeply penetrating infrared laser to treat

inflammatory acne has been suggested as selective

photothermolysis of the sebaceous glands.4,5 The

acne (PR) filter of the IPL device we used (restricted

wavelength bands from 530 to 750 nm)8 was ori-

ginally made and proposed as a device for selective

photothermolysis targeting the small vessels supply-

ing the sebaceous glands based on the hypothesis of

mechanism which is similar to that of lasers for

treatment of inflammatory acne.3–6,9 Pathogenesis of

acne, however, is rather complex, necessitating var-

ious combination therapies.10

In our study, the PR filter which is known to be

difficult to apply to the skin of Asian persons8 was

safe and effective in improving acne red macules,

irregular pigmentation, and skin tone but did not

affect short-term inflammatory acne lesion counts.

Interestingly, 10 patients (33%) in our study re-

ported that within 1 week after IPL treatment, they

noticed an obvious and rapid reduction of acne le-

sions on the laser-treated side. They informed us that

they felt more rapid disappearance of newly occur-

ring acne lesions and reduction of oiliness. These

improvements, however, did not persist throughout

the intertreatment interval. The fluences up to

8 J/cm2 of PR filter used in our study seemed lower

compared to that of other IPL systems, but double

water-cooled filter with relatively narrow wave-

length bands could explain the low fluence of this

IPL system, without compromising the clinical effi-

cacy.8 In our study enrolling mild-to-moderate

inflammatory acne, no more benefit of IPL

combination over BP gel alone was shown for re-

duction of the papule and pustule counts 3 weeks

after the three sessions of treatment. The frequent

and fast recurrence, despite mild-to-moderate

Figure 1. (A) Before treatment. (B) Multiple facial acne papules, postinflammatory hyperpigmentation, and erythema are stillevident on the untreated right side after 9 weeks’ use of benzoyl peroxide gel.

D E R M AT O L O G I C S U R G E RY6 7 8

I P L T R E AT M E N T O F A C N E

severity, may be attributed to the nature of postad-

olescent acne (mean age, 25.7 years), which tends to

be cyclic and flare up premenstrually,1 and the fact

that our subjects were working women including the

nurses in our hospital under substantial physical and

psychosocial stress. The low morbidity and down-

time of IPL with minimal pain and the additional

benefit of simultaneously treating acne sequelae such

as pigmentation and erythema make this therapy

attractive and satisfying to socially active women.

Our study is the first one, to our knowledge, to show

the safety of this new IPL device with 530- to 750-

nm infrared laser filter for use on the skin of Asian

persons.

References

1. Jeong EG, Park HJ, Lee JY, et al. The study of post-adolescent

acne in nurses. Korean J Dermatol 2004;42:1255–63.

2. Sung KJ, Rho YS, Choi EH, et al. Korean acne grading system.

Korean J Dermatol 2004;42:1241–7.

3. Bhardwaj SS, Rohrer TE, Arndt K. Lasers and light therapy for

acne vulgaris. Semin Cutan Med Surg 2005;24:107–12.

4. Paithankar DY, Ross EV, Saleh BA, et al. Acne treatment with a

1,450 nm wavelength laser and cryogen spray cooling. Laser Surg

Med 2002;31:206–14.

5. Friedman PM, Jih MH, Kimyai-Asadi A, et al. Treatment of in-

flammatory facial acne vulgaris with the 1450-nm diode laser: a

pilot study. Dermatol Surg 2004;30:147–51.

6. Orringer JS, Kang S, Hamilton T, et al. Treatment of acne vulgaris

with a pulsed dye laser: a randomized controlled trial. JAMA

2004;291:2834–9.

7. Seaton E, Charakida A, Mouser P, et al. Pulsed-dye laser treatment

for inflammatory acne vulgaris: randomized controlled trial.

Lancet 2003;362:1347–52.

8. Bjerring P, Christiansen K, Troilius A, Dierickx C. Facial photo

rejuvenation using two different intense pulsed light wavelength

bands. Laser Surg Med 2004;34:120–6.

9. Lloyd JR, Mirkov M. Selective photothermolysis of the sebaceous

glands for acne treatment. Lasers Surg Med 2002;31:115–20.

10. Coates P, Vyakrnam S, Ravenscroft JC, et al. Efficacy of oral

isotretinoin in the control of skin and nasal colonization by an-

tibiotic-resistant propionibacteria in patients with acne. Br J

Dermatol 2005;153:1126–36.

Address correspondence and reprint requests to: Sung-EunChang, MD, Department of Dermatology, Asan MedicalCenter, University of Ulsan College of Medicine, Seoul,Korea, or e-mail: cse@amc.seoul.kr

Figure 2. (A) Before treatment. (B) Marked improvement of skin, hyperpigmentation, and erythema on the intense pulsed light(IPL)-treated left side 3 weeks after three sessions of IPL treatment and 9 weeks’ use of benzoyl peroxide gel. The reduction ofnumber of papules was not different between IPL-treated left side and IPL-nontreated right side seen in Figure 1.

3 3 : 6 : J U N E 2 0 0 7 6 7 9

C H A N G E T A L