Treats and traps of Intense Pulsed Light Therapy by Dr Francis Pitsilis

Intense Pulsed Light (IPL) treatments can give very good results when applied to the right problem in the right skin type and in the right person. Beauty therapists have the opportunity to explore the modality of IPL as a logical add-on to the treatments they already offer their clients.
Before explaining what intense pulsed light is, a brief explanation of lasers and lights is in order. The term LASER stands for Light Amplification by the Stimulated Emission of Radiation. Laser is a single wavelength of light. For example, one form of laser hair removal is at the 1064nm level, which means it’s in the infrared spectrum.

A brief history of lasers and lights
Simulated emission of a laser was first proposed by Albert Einstein in 1917, then research and application of lasers started in the 1950s. The first laser invented in the 1960s was a Ruby Laser. In 1964, CO2 Laser and Nd: Yag were invented. Laser hair reduction treatments started experimentally in the 1950s and then laser hair reduction became commercially available in the 1970s.
In New Zealand, the first laser hair removal machine was a Ruby Laser which commenced treatments in the 1990s. After that, other lasers such as Alexandrite laser became available for hair reduction because they had a more specific wavelength for hair removal. Until then, most hair removal machines were laser machines. There would be a specific wavelength used for a specific purpose. For hair removal, around 700nm was used for skins of Type I and II, for veins, it would be around 532nm.

What is IPL?
IPL is not a single wavelength of light, but consists of a wide range of wavelengths for versatility. Most IPL machines deliver wavelengths between 500 – 1200 nm. This means that at the low end, the machine delivers blue light, and at the higher end, it goes well into the infrared part of the spectrum.
IPL machines do not contain a laser generating mechanism but use a flash lamp. The flash lamp was invented in the 1930s. It is an electric glow discharge lamp designed to produce intense incoherent (not a single wavelength), full spectrum white light for short durations. It is made of a length of glass tubing with electrodes at each end and filled with a gas that ionises (becomes charged) when triggered and conducts a high-voltage pulse to produce the light. Part of the spectrum of light produced is cut off, producing a ‘band of light’ that the tissue is exposed to. This is IPL.
When using IPL, a range of wavelengths is selected for what you are trying to treat. The concept is that if your target tissue is brown or black, as in hair, a wavelength that is attracted to that coloured target tissue (called a chromophore) is selected.

What IPL can treat
IPL is better than any other treatment for superficial redness and brown blotches, especially in lighter skins. As part of a facial rejuvenation treatment to get rid of superficial brown and red blotches, your client will notice an increase in collagen in their skin with an accompanying reduction of fine wrinkles. Experienced operators know not to promise complete eradication of all redness in case some of it is deep. You may not know this until after the treatment and recovery period.

Superficial redness
Brown discolouration
This is especially the case with Rosacea, a deeply reddening condition of the face that sits across the cheeks and nose. IPL can give pleasing results if you manage your clients’ expectations well, even if you do not eradicate all the redness.
Telangiectasia refers to a fine smattering of superficial veins. Superficial veins can be eradicated by IPL, but veins larger than 1mm wide may not respond, depending on the machine. This is when a vascular laser is required. However, you will not harm the skin to try clearing veins around the nose, for example.
Poikiloderma is a condition that you see daily. It is a brown / red discolouration of the neck and chest that results from long term sun exposure and damage. IPL works well here, but prepare the client for several treatments a month apart. This is because your handpiece will leave rectangular pale ‘stamps’ across the skin, necessitating several treatments to completely clear the discolouration. Winter time is a good time to plan these treatments.
Photo ageing and actinic bronzing refer to the overlay of extrinsic (smoking and sun exposure) onto intrinsic ageing (age related). These clients may have thick, leathery skin or many brown blotches mixed with red patches.

Only treat Melasma if it’s superficial, and only in Types I-III skin.
Acne Vulgaris will be improved temporarily. Do not promise a cure to acne clients unless they have been able to correct any underlying hormonal or other imbalances, or their condition will reoccur.
Port wine stains are a dense, deep dark red or purple birthmark. Some advanced medical IPL systems are able to treat these in the hands of experienced doctors. Otherwise, vascular lasers are used.
IPL can also reduce hair growth. It is important to know that no laser or IPL can permanently remove hair. You can only ever promise 85% eradication at best, and anyone claiming permanent hair reduction is misleading. Depending on your machine, several treatments will be needed to achieve the 85% hair reduction goal. Your client should be informed that they will need periodic treatments every few months to maintain the effect. As is well known, even though hair follicles may have been completely destroyed by light based therapies, new hair follicles will develop in time.
IPL machines were developed after lasers. Until then, cosmetic lasers were either the hair removal lasers or the ablative (burning lasers). Each laser could treat only one problem. When IPL came along, it was a ‘jack of all trades but master of none’. This means that if you are serious about treating darker skins for hair removal, you need to have a top-line, programmable medical IPL which can enable you to treat type IV skins. Or even consider a 1064nm Laser with which you can treat type V skin for hair removal.

What can IPL NOT treat
If you choose your clients wisely at the beginning, you will avoid the headaches of bad outcomes, complications or complaints. If you have a complication that you could have avoided, the money is never worth it. You need a pre-treatment questionnaire to help exclude clients who shouldn’t be treated either this time, or ever. If in doubt, don’t treat.
• Veins over 1-2mm wide
• Darker skins above type III
• Deeper wrinkles
• Sagging skin

As mentioned, once veins are over 1-2mm wide, a vascular laser is required. IPL works at the most superficial level of the skin, so the good news is that the risk of scarring is extremely low if used properly. However, this is also the reason you will not be able to influence sagging skin or deeper than superficial wrinkles. For deeper layers, other modalities are needed.
You should not treat a pregnant or planning to be pregnant client because there is no evidence that it is safe to do so. Always check if your client has a pacemaker or implanted defibrillator, because your machine may interfere with the signal of these devices.
If you treat someone who has active cold sores, you are at risk of spreading them all over the area you treat. If your client has had recent sun exposure, you must wait four weeks for the pigment to subside, or you will make the treatment more dramatic and increase the risk of hyper or hypopigmentation.
A client on Roaccutane (Isotane) will have thinner skin and you are at risk of burning them. You must wait six months after the Roaccutane has finished. Do not treat over a mole, as some may be melanomas – if you are uncertain, refer them to a doctor.
Never use IPL over a tattoo or permanent makeup, as you will heat up the tattoo and burn the skin.
Vitiligo is an autoimmune disease that causes pale areas on the skin that never tan. These patients may react to IPL by developing vitiligo where you have treated them. Scleroderma is an unusual autoimmune disease whereby the skin makes excessive collagen and tightens up. These clients should never be treated by IPL or any form of light therapy as it will worsen their condition.
Relative risks are clients who have had surgical implants (includes dermal fillers in the last two weeks) in the area you are planning to treat. Do not treat these clients and save yourself the risk of problems.
During your pre-treatment consultation, explain the benefits and risks of the procedure. Advise if there is another way to give the same or similar result. Explain how many treatments might be required.
Always take before and after photos. If you don’t, that will be the client that will return and complain that there has not been a result. If you don’t have photos, you are merely relying on your memory against her memory and that is not professional.
Your actual consent form should contain statements about the procedure to be performed. It should state the possible risks and side effects, that you have discussed them all with your client and that the client understands and has had time to ask questions.

Fitzpatrick skin types
Type I  Always burn, never tan
Type II Tan only with difficulty and usually burn
Type III Tan, but sometimes burn
Type IV Rarely burn and tan with ease
Type V Tan very easily and very rarely burn
Type VI Tan very easily and never burn

IPL can comfortably be used to treat type I and II skins. Caution is needed for type III skins because there will be a need to use more energy to treat a discolouration or hair against a darker skin background. Before treating a client with IPL, several important points need to be established.
The client must have the following:
• A condition that can be successfully treated by IPL.
• A safe skin type i.e. I-II and with care, type III.
• Has prepared their skin for optimum results.
• Understand what is involved and the treatments benefits and limitations.
• Signed a consent form.

Exclude a client that is really a type IV that looks like a type III.
To help you decide if a client who looks like having type III skin may really have type IV skin, ask them a couple of questions. What is their heritage? If it is a dark-skinned heritage, then they may hypopigment after IPL. Ask them what happens to a scar or scratch on their skin? If it goes dark, then they may hyperpigment.

Preparing your client to get the best out of IPL treatment
As well as having the right skin type and a condition that can be successfully treated by IPL, your client should follow your pre-treatment preparations as well as your post-treatment advice. The client should also allow photos. In my clinic, if a client refuses photos, we ask them to sign a disclaimer.
For the best success, a client that will follow your advice about skin care and preparation for IPL will make you both satisfied. Your two major goals in doing this are to prepare the stratum corneum (top layers of the skin) and to prevent post-inflammatory pigmentation (over or under pigmentation). This applies even more if the skin is type III.

Prepare the skin for at least two weeks with topical preconditioning skincare that will include:
• A retinoid, for example Retinol.
• Glycolic acid or an exfoliative preparation.
• Tyrosinase inhibitor – stops the skin making pigment.

By exfoliating the skin and reducing pigmentation, the outcome of any skin treatment will be enhanced.
These skin care regimes will also allow the skin to heal more quickly after treatment. The Tyrosinase inhibitor helps to reduce risk of hyperpigmentation. Sebaceous skin responds better when primed with retinoids.
In addition, if your client suffers a lot from cold sores it may be advisable to ask them to obtain an oral antiviral medicine from their doctor to start taking before the treatment. This will prevent a full face breakout.

Post treatment advice
Warn your client about how their skin will look afterwards and how long it will take to heal. After IPL, redness gets redder initially and then fades as it heals. Brown blotches get darker and then flake off over a few days. The face generally recovers in seven to  ten days, but hands can take a month to recover. These details are important if someone is preparing for a special event.
In-treatment cooling as well as post-treatment cooling is important in protecting the skin from damage. You will prefer to own a machine that has good built in cooling. Use ice afterwards in your clinic and advise your client about cooling afterwards until the heat in the skin resolves.

What to do in an emergency
An example is that a client is burned during a treatment.
First, keep calm. As the operator, you must be in control and are relied on to take remedial action.
Focus on what is required to enhance client’s safety and get them out of harms way. In the case of a burn, being able to immediately put ice on the skin will prevent epidermal damage and give a good outcome. In the case of the machine malfunctioning and requiring an evacuation, appropriate action should be taken.
This is why clinic protocols should be written and reviewed regularly. In addition, rehearsing what to do in an emergency is useful – like a fire drill.

 

 

Author: Dr Francis Pitsilis

 

 

 

 

 

 

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