Tropical and Subtropical Agroecosystems, 1 (2003): 295 - 307 INDOLEALKYLAMINES IN MUCUNA SPECIES N. J. Szabo Tropical and Analytical Toxicology Core Laboratory, Center for Environmental and Human Toxicology, University of Florida, P.O.Box 110885, Gainesville, FL 32611-0885, USA E-mail: [email protected]
Light-assisted therapy in dermatology the use of intense pulsed light (ipl)
Medical Laser Application 25 (2010) 61–69 Light-assisted therapy in dermatology: The use of intense pulsedlight (IPL) Department of Dermatology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg, Germany Received 21 September 2009; accepted 8 January 2010 Light is electromagnetic radiation and human beings encounter it on a number of levels. The versatility of the cutaneous biological effects allows the medical utilization of light to be used as a potential diagnostic and therapeutictool. In almost all cases the light used is restricted to certain wavelengths and deﬁned photophysical parameters.
In terms of diagnostic purposes photo testing, Wood's light diagnostics and ﬂuorescence diagnostics are frequentlyused tools. The therapeutic use of incoherent light can be divided in four main groups: (1) UV phototherapy,(2) photodynamic therapy (PDT), (3) treatment with light-emitting diodes (LEDs), and (4) treatment with intensepulsed light (IPL). Intense pulsed light (IPL) devices use ﬂashlamps and bandpass ﬁlters to emit polychromatic,incoherent, high-intensity pulsed light of a determined wavelength spectrum, ﬂuence, and pulse duration. Similar tolasers, the basic principle of IPL devices is the selective thermal damage of the target structure. This review summarizesthe practical use of IPL devices and the current literature on IPL with regard to the treatment of unwanted hairgrowth, vascular lesions, pigmented lesions, acne vulgaris, and as a light source for PDT.
& 2010 Published by Elsevier GmbH.
Keywords: Light source; IPL; Laser; Dermatology; Vascular lesions; Pigmented lesions; Hair removal; Skin absorption of pulsed radiation was described in detailin 1983 In 1990, Goldman and Eckhouse described Light is electromagnetic radiation. If a range of a new high-intensity ﬂashlamp as a suitable tool for wavelengths is emitted, the waves are incoherent.
treating vascular lesions. This led to IPL being launched Examples of incoherent light sources are broadband commercially as a medical device in 1994 IPL devices ultraviolet (UV) light sources, low pressure ﬂuorescent use ﬂashlamps and computer-controlled capacitor banks lamps, high pressure mercury/xenon lamps, light-emitting to generate pulsed polychromatic high-intensity light.
diodes (LEDs), and intense pulsed light (IPL) devices.
The emission spectrum of IPLs ranges from 500 to The use of polychromatic infrared light was ﬁrst 1300 nm. With the aid of convertible cut-off ﬁlters, IPLs introduced in 1976 by Muhlbauer et al. for the treatment can be adapted to the desired wavelength. In IPL devices, of vascular malformations The photothermolysis of as is the case in lasers, the basic principle is the absorption pigmented structures, cells, and organelles by selective of photons by endogenous or exogenous chromophoreswithin the skin and the transfer of energy to these chromophores. This transfer generates heat and subse- Tel.: þ49 941 944 9605; fax: þ49 941 944 9532.
E-mail address: quently destructs the target structure. As IPL devices emit 1615-1615/$ - see front matter & 2010 Published by Elsevier GmbH.
P. Babilas / Medical Laser Application 25 (2010) 61–69 a spectrum of wavelengths the three key chromophores, Comparison of IPL vs. laser technology.
hemoglobin, melanin, and water, can be activated with asingle light exposure. The choice of suitable cut-off ﬁlters is determined by the patient's skin type and the existing skin condition. Depending on the particular device, the Inconsistence of emitted pulse duration can be set in the millisecond (ms) range.
spectrum and ﬂuence The combination of particular wavelengths, pulse dura- Pulse duration: in ms range tions, pulse intervals, and ﬂuences facilitates the treat- ment of a wide spectrum of skin conditions, such as acne Smaller spot size vulgaris, pigmented lesions, vascular lesions, unwanted High weight of handpiece hair growth, photodamaged skin, scars , and angioker- atomas However, the wide range of selectable treatment settings carries the risk of evoking side effects because of nonspeciﬁc thermal damage, especially for High skin coverage rate untrained physicians and even more, for non-medical staff. This situation is even more complicated as a large Gel application required number of IPL devices exist and comparison of IPLs on Direct contact of handpiece to the basis of their wavelength spectrum, ﬂuence ranges, pulse durations, etc. does not provide any evidence for Economics Robust technology their clinical effectiveness. A serious comparison is more complex and should account for the ﬂuence per area Lower purchase price for every emitted wavelength, for every possible pulse duration, and for every possible pulse shape against the background of the real on-off time, ﬂuence, and spectral aDisallows observation of immediate local response.
jitter during an impulse. For example, the emission of asigmoidal-shaped pulse is disadvantageous because sucha pulse means a shift in the spectral and ﬂuence (RCT) or controlled trials (CT). The level of evidence distribution within the pulse. Eadie et al. measured reached is IIB.
the spectral and temporal characteristics of an IPL device Cameron et al. compared in a split-face study with and showed a shift in spectral distribution within a pulse female participants (n=9) a diode laser (Lightsheer EC, and between the pulses, which is caused by a variable current delivered to the xenon ﬂashlamp. Favorable 20–45 J/cm2, pulse duration: 30 ms) with an IPL device characteristics of IPLs are a large capacitor bank allow- (Luminette, Lynton Lasers, Cheshire, UK; lem=625– ing a constant current to be delivered to the ﬂashlamp 1100 nm, 32 J/cm2, pulse train: 8 4 ms, total train time: and thus the emission of a roughly square-shaped pulse.
95 ms). Six weeks after the treatments (three treatments Also desirable is the omission of wavelengths beyond at six-week intervals), IPL therapy and laser had 950 nm as higher wavelengths are preferentially absorbed substantially reduced the hair count (average hair counts by water and therefore contribute to signiﬁcant epidermal in a 16 cm2 area; laser vs. IPL vs. control: 42.4 vs. 38.1 vs.
heating. A comparison of IPL characteristics with the 45.3 (baseline) and 10.4 vs. 20.4 vs. 44.7 (after treatment)).
laser technology is given in .
Despite subjecting the patients to higher pain scores and The following sections discuss the current literature on more inﬂammation, laser was preferred by ﬁve patients; IPL for the treatment of unwanted hair growth, vascular two preferred IPL and one had no preference.
lesions, pigmented lesions, acne vulgaris, and photoda- A randomized split-face comparison of facial hair maged skin as well as light sources for photodynamic removal was conducted by McGill and co-workers therapy (PDT) and skin rejuvenation. Where available, using an alexandrite laser (GentleLASE, Candela Corp., we focus on controlled studies comparing IPL devices to Wayland, MA, USA; lem=755 nm, 15 mm spot size, the respective standard treatment.
ﬂuence: 10–30 J/cm2; pulse duration: 3 ms) and an IPLdevice 650–1100 nm, ﬂuence: 16–42 J/cm2; 3 pulses of 55 ms,delay: 20 ms) in women (n=38) with polycystic ovary syndrome (PCOS). The authors reported that alexan-drite laser treatment resulted in longer median hair-free Hair removal is clearly a key indication for IPL intervals than IPL therapy (seven weeks vs. two weeks; devices A number of medical publications document po0.001). The decrease in hair counts was signiﬁcantly the effectiveness of IPL treatment for hair removal, yet higher after alexandrite laser treatment than after IPL only few provide data from randomized controlled therapy at one, three, and six months (52%, 43%, and P. Babilas / Medical Laser Application 25 (2010) 61–69 46% vs. 21%, 21%, and 27%; po0.001). Patient pigmented lesions. Q-switched laser systems are clearly satisfaction scores were signiﬁcantly higher for the the method of choice for the treatment of benign pig- alexandrite laser (pr0.002). The authors assumed that mented, non-nevomelanocytic lesions. Nevomelanocytic the speciﬁc wavelength, short pulse duration, and single lesions are generally not a routine indication for laser pulse delivery of the alexandrite laser is responsible for treatment. However, several reports indicate the effec- higher follicular destruction. Unfortunately, no histolo- tiveness of IPL devices in the treatment of pigmented gical investigations were done and the treatment lesions. These indications should only be treated by duration was not documented. Toosi et al. board-certiﬁed dermatologists as the ﬁrst and foremost compared the clinical efﬁcacy and side effects of an step is a doubtless diagnosis of the entity to be treated alexandrite laser (Cynosure Inc., Westford, MA, USA; and the exclusion of a malignant process.
lem=755 nm, pulse length: 2 ms, spot size: 10 mm, Li et al. studied the safety and efﬁcacy of an IPL ﬂuence: 16–20 J/cm2), a diode laser (Palomar Medical device (Lumenis One, Lumenis Inc., Santa Clara, CA, Technologies, Burlington, MA, USA; lem=810 nm, USA; ﬂuence: 13–17 J/cm2; 560/590 nm ﬁlters, double pulse duration: 12.5 ms, ﬂuence: 40–64 J/cm2) as well pulse or 590/615/640 nm ﬁlters and triple pulse, 3–4 ms as an IPL device (Medical Bio Care, Sweden; ﬁlter: pulse duration; 25–40 ms pulse delay) in the treatment 650 nm, ﬂuence: 22–34 J/cm2, double pulse, pulse dura- of melasma in Chinese patients (n=89). The patients tion: 20 ms, delay: 10–40 ms) for hair removal in 232 received four IPL treatments at three-week intervals.
patients. Six months after treatment (3–7 sessions), no 69 out of 89 patients (77.5%) showed 51–100% signiﬁcant difference could be seen between the average improvement according to the overall evaluation by hair reduction of IPL (66.9717.7%), alexandrite dermatologists. Self-assessment by the patients indi- cated that 63 of 89 patients (70.8%) considered there (p=0.194). The incidence of side effects was signiﬁcantly had been a 50% or more improvement. Melasma area higher after diode laser treatment (p=0.0001). In a CT, and severity index (MASI) decreased substantially from Amin et al. evaluated the efﬁcacy of an IPL device 15.2 to 4.5.
(red ﬁlter), an IPL device (yellow ﬁlter), a 810 nm diode The effectiveness of combined IPL and Q-switched laser, and a 755 nm alexandrite laser in patients (n=10) ruby laser (QSRL) therapy in Korean women (n=25) with unwanted hair on the back or thigh. Hair counts at with facial pigmentary disorders was determined by one, three, and six months after the second treatment Park et al. According to their results, 19 out of 25 showed a signiﬁcant decrease in hair counts (approxi- patients (76%) reported a good to excellent response.
mately 50%) for all light devices (no statistical Two independent physicians assessed that 15 out of 25 difference). An evidence-based review published in patients (60%) showed a 76–100% improvement, 2006 summarizes 9 RCTs and 21 CTs on the efﬁcacy whereas 19 out of 25 patients (76%) showed an and safety of hair removal by means of ruby, improvement of at least 50%. Side effects were minimal.
alexandrite, diode, or Nd:YAG lasers or IPL (for IPL Galeckas et al. conducted a multiple-treatment only 1 RCT and 1 CT) Based on the data available split-face comparison using a ﬂashlamp-pumped pulsed for IPL, the authors concluded that no sufﬁcient dye laser ((FPDL), Perfecta, Candela Corp., Wayland, evidence exists for long-term hair removal after IPL MA; lem=595 nm, ﬂuence: 36 J/cm2, pulse duration: treatment. Bjerring et al. compared the effectiveness 10 ms) with a compression handpiece vs. an IPL device of an IPL device (Ellipse Relax Light 1000, Danish (Starlux, Palomar Medical Technologies, Burlington, Dermatologic Development, Hoersholm, Denmark; MA, USA; lem=525–1200 nm, ﬂuence: 35.6 J/cm2, pulse lem=600–950 nm; 10 48 mm spot size; 18.5 J/cm2) to duration: 10 ms). Ten patients were treated three times a normal mode ruby laser (Epitouch, ESC Sharplan, Tel at three to four-week intervals. One month after the Aviv, Israel; lem=694 nm, spot size: 5 mm, pulse ﬁnal treatment, improvement was assessed by blinded duration: 0.9 ms) in a split-face study for hair removal investigators who reported 86.5% vs. 82.0% for FPDL in 31 patients (three treatments). The authors reported vs. IPL for dark lentigines, 65.0% vs. 62.5% for light an average hair count reduction of 49.3% (IPL) vs.
lentigines, 85.0% vs. 78.5% for vessels o0.6 mm, 38.0% 21.3% (ruby laser) after three treatments and concluded vs. 32.5% for vessels 40.6 mm, and 40.0% vs. 32.0% that IPL treatment was 3.94 times more effective for hair for texture. Mean third treatment times were 7.7 removal than ruby laser therapy.
(FPDL) vs. 4.6 (IPL) min (p=0.005). Mean pain ratingswere 5.8 (FPDL) vs. 3.1 (IPL) (p=0.007). The rate ofside effects was lower with the IPL (infraorbital edema:50% vs. 0%, post-treatment purpura 10% vs. 0%; Pigmented lesions FPDL vs. IPL).
Bjerring et al. evaluated the effectiveness of an The fact that IPL devices emit light pulses within the IPL device (Ellipse Flex, Danish Dermatologic Devel- ms range makes them second best for the treatment of opment, Hoersholm, Denmark; lem=400–720 nm; spot P. Babilas / Medical Laser Application 25 (2010) 61–69 size: 10 48 mm; pulse duration: 2 7 ms, delay: 25 ms; spectrum including the near infrared range, which could ﬂuence: 10–20 J/cm2) in the treatment of lentigo solaris be a reason for the lower clearance. Bjerring et al.
(18 patients) and benign melanocytic nevi (8 patients).
treated 15 patients with dye laser-resistant PWS Two months after a single treatment, evaluation by four times with an IPL device (Ellipse Flex, Danish means of close-up photographs showed a pigment Dermatologic Development, Hoersholm, Denmark; reduction in 96% of the patients and an average lem=555–950 nm; spot size: 10 48 mm; pulse duration: clearance of 74.2% for lentigo solaris and 66.3% for 13–22 J/cm2).
reported 7 out of 15 patients exhibiting a lightening ofmore than 50%, which corresponds with our ownexperience. No scarring was observed, hypopigmenta- tion (9%) or hyperpigmentation (3%) occurred onlyrarely. McGill and co-workers compared a pulsed Vascular malformations are another key indication dye, an alexandrite, a KTP, and a Nd:YAG laser as well for IPL therapy. The mechanism of the action of IPLs is as an IPL device (Lumina, Lynton Lasers, Cheshire, related to their selective absorption by hemoglobin UK; lem=550–1100; spot size: 10 10 mm, ﬂuence: within the blood vessels. The thermal effect of IPLs on 28–34 J/cm2, double pulsed;10 ms delay) in a split-lesion skin vessels (diameters: 60, 150, 300, 500 mm) was modus in patients (n=18) with PWS. In this study, the calculated for different wavelengths by Ba¨umler et al.
alexandrite laser (GentleLASE, Candela Corp., Way- by means of the ﬁnite element method (pulse land, MA, USA; lem=755 nm, pulse duration: 3 ms) duration: 30 ms; ﬂuence: 15 or 30 J/cm2). These authors was the most effective and resulted in fading PWS in 10 found that the investigated spectra provided homoge- patients, although both hyperpigmentation (n=4) and neous heating in the entire vessel that was sufﬁcient for scarring (n=1) were frequent. IPL resulted in PWS coagulating vessels 460 mm. There is evidence in the fading in six patients, the KTP and Nd:YAG lasers literature for successful treatment of essential telangiec- (Laserscope UK Ltd., Cwmbran, Gwent, Wales, UK; tasias rosacea , port-wine stains (PWS) lem=1064 nm) were the least effective with fading seen nevi angiomas and in two patients for both systems; ﬁve patients showed erythrosis For the treatment of essential telangiec- further PWS fading after double-passed PDL (SLS tasias, PWS, and rosacea, the level of evidence IIB Biophile, Wales, UK; lem=585 nm, pulse duration: 0.45 ms) treatment.
Laser Dermatology (ESLD) published guidelines forthe use of IPLs in the treatment of vascular malforma-tions .
There is evidence in the literature for the successful treatment of rosacea. Papageorgiou et al. assessed Regarding PWS, two works provide data from the efﬁcacy of an IPL device (Quantum SR, Lumenis, controlled side-by-side comparisons of IPL and the London, UK; lem=560–1200 nm, spot size: 34 8 mm, standard therapy with the dye laser . Faurschou double pulses of 2.4 and 4.0, 5.0, or 6.0 ms (depending et al. treated 20 patients with PWS in a side-by-side on the skin type), ﬂuence: 24–32 J/cm2) for the treatment trial with a pulsed dye laser ((PDL), V-beam Perfecta, (four treatments at three-weeks interval) of stage I Candela Corp., Wayland, MA, USA; lem=595 nm, rosacea (ﬂushing, erythema, and telangiectasia) in 34 pulse duration: 0.45–1.5 ms) vs. IPL (StarLux, Palomar patients. Photographic assessment showed signiﬁcant improvement of erythema (46%) and telangiectasias lem=525–1200 nm, pulse duration: 5–10 ms, ﬂuence: (55%). The severity of rosacea was reduced on average 7–14 J/cm2). The researchers found that both PDL and by 3.5 points on a 10-point visual analog scale (VAS).
IPL signiﬁcantly lightened PWS, whereas median The results were sustained at six months. Side effects clinical improvements were signiﬁcantly better with the were minimal and self-limiting.
PDL (65%) than with the IPL (30%). The lower Schroeter et al. approved these positive results in effectiveness of the IPL in that paper might be explained the treatment of rosacea, testing the effectiveness of by the fact that the authors did not only include IPL devices (PhotoDerm VL or Vasculight, Lumenis, previously untreated (n=8) but also previously treated lem=515–1200 nm; pulse duration: (n=12) patients in this study without distinguishing 4.3–6.5 ms; ﬂuence: 25–35 J/cm2) in the treatment of between the two groups. Also Faurschou et al. used an facial telangiectasia in rosacea patients (n=60). On IPL that emitted light of 500–670 and 870–1400 nm.
average, 4.1 treatments were applied per area (n=508) Therefore, the IPL used by Faurschou et al. divided and clinically, as well as photographically, evaluated.
the applied energy over a much broader wavelength A mean clearance of 77.8% was achieved and was P. Babilas / Medical Laser Application 25 (2010) 61–69 maintained for a follow-up period averaging 51.6 angiomas. Patients with telangiectasias, cherry angio- months (range: 12–99 months). Within this remarkable mas, or leg veins o1 mm were more satisﬁed after IPL long follow-up period, only 4 of the 508 treated areas treatment, whereas patients with leg veins 41 mm were showed recurring lesions. Minimal side effects occurred.
more satisﬁed after Nd:YAG treatment. The Nd:YAG In a randomized controlled single-blind split-face treatment was reported as being more painful.
trial, Neuhaus et al. compared a pulsed dye laser Retamar et al. investigated the effectiveness and (PDL, spot size: 10 mm, ﬂuence: 7 J/cm2, pulse duration: safety of an IPL device (515–1200 nm) in the treatment 6 ms) with an IPL device (560 nm ﬁlter, pulse train: 2.4 of linear and spider facial telangiectasias in 140 patients.
and 6.0 ms, delay: 15 ms, ﬂuence: 25 J/cm2) in the In this study, the response of 94 (67.1%) patients was treatment of facial erythematotelangiectatic rosacea.
excellent (80–100%), 43 (30.7%) was good (40–80%) Patients (n=29) underwent three-monthly treatment and 3 (2.1%) had poor clearance (o40%). Post- sessions. In this study, PDL and IPL therapy signiﬁ- treatment side effects were minimal and transient.
cantly reduced cutaneous erythema, telangiectasia, andpatient-reported associated symptoms. No signiﬁcant difference was noted between the PDL and IPLtreatments.
There is evidence in the literature for successful treatment of erythrosis. Madonna Terracina and co-workers used IPL (ﬂuence: 9–12 J/cm2, pulse duration: 10–20 ms, spot size: 20 50 mm) in thetreatment of face and neck erythrosis in women There is evidence in the literature for successful (n=22) and men (n=12). Patients underwent ﬁve treatment of telangiectasias. In a randomized split- treatments at intervals of three weeks. In 22 patients, a lesion trial, Nymann et al. compared the efﬁcacy total regression of the erythrosis was achieved after ﬁve and side effects of a long-pulsed dye laser ((LPDL), applications, while the erythema persisted in ﬁve V-beam Perfecta, Candela Corp., Wayland, MA, patients after the end of treatment. Wenzel et al. USA; lem=595 nm, pulse duration: 6–20 ms; ﬂuence: reported successful treatment of patients with progres- 6–12 J/cm2) with an IPL device (Ellipse Flex, Danish sive disseminated essential telangiectasia (n=4) and Dermatologic Development, Hoersholm, Denmark; erythrosis interfollicularis colli (n=5) by means of an lem=530–750 or 555–950 nm; spot size: 10 48 mm; IPL device (Ellipse Flex, Danish Dermatologic Devel- pulse duration: 10–20 ms; ﬂuence: 8–20 J/cm2) in pa- opment, Hoersholm, Denmark; lem=555–950 nm; spot tients (n=13) with telangiectasias after radiotherapy for size: 10 48 mm; pulse duration: 14–18 ms; ﬂuence: breast cancer. Patients underwent three split-lesion 11.7–17 J/cm2). According to their results, clearance treatments at six-week intervals. The authors reported rates were 76–90% in six out of nine patients, 51–75% in median vessel clearances of 90% (LPDL) vs. 50% (IPL) two patients, and 50% in one patient. For both (p=0.01) three months after treatment. LPDL treat- indications, 2.8 treatments were applied on average.
ments were associated with lower pain scores than IPL Adverse events were rare, only one patient suffered from transient crusts and blisters, which resulted in transient differ signiﬁcantly, more patients preferred the LPDL hypopigmentation; another patient showed transient (n=9) to IPL (n=2) (po0.01). Bjerring et al. evaluated the effectiveness and side effects of the sameIPL device (Ellipse Flex, Danish Dermatologic Devel-opment, Hoersholm, Denmark; lem=555–950 nm; spotsize: 10 48 mm; pulse duration: 10–30 ms; ﬂuence: IPL as a light source for photodynamic therapy 10–26 J/cm2) in patients (n=24) with facial telangiecta- of non-melanoma skin cancers sias. In total, 2.5470.96 treatments were conducted atone-month intervals. 79.2% of the patients obtained a PDT is an approved treatment option of non- more than 50% reduction in the number of vessels, and melanoma skin cancers such as actinic keratoses (AK) 37.5% obtained a reduction between 75% and 100% or superﬁcial basal cell carcinomas Aminolevulinic two months after the last treatment. Side effects were acid (ALA) or its methyl ester (MAL) are prodrugs that rare (moderate erythema and edema), and no scarring or are converted into their active form, i.e. protoporphyrin pigmentary disturbances occurred.
IX (PpIX) within the altered epidermal cells . The In a prospective side-by-side study, Fodor et al. major absorption bands of PpIX include 410, 504, 538, compared an IPL device (Vasculight, Lumenis, London, 576, and 630 nm and are therefore particularly suitable UK; ﬁlter: 515, 550, or 570 nm, ﬂuence: 15–38 J/cm2; for the activation with broadband IPL. Both ALA and pulse duration not stated) to a Nd:YAG laser in patients MAL are used for PDT in combination with IPL, e.g.
(n=25) with telangiectasias, leg veins, or cherry for the treatment of non-melanoma skin cancers P. Babilas / Medical Laser Application 25 (2010) 61–69 Pain is a major side effect of PDT and is dependent on absorption leads to the generation of reactive oxygen the type of photosensitizer (PS) used, the treatment area species (ROS) with subsequent bactericidal effects.
and the type of lesion treated Another pathway is based on the selective photother- Our group compared the efﬁcacy and painfulness of molysis of blood vessels that supply sebaceous glands, an IPL device (Energist Ultra VPL, Energist Ltd, which reduces the sebum secretion rate. A third Swansea, UK; 610–950 nm, two pulse trains, each 15 mechanism of action requires an exogenous PS which pulses of 5 ms, delay: 20 ms, ﬂuence: 40 J/cm2 per pulse is applied to the skin surface. The PS accumulates in the train) to a standard light source for PDT, a LED-system sebaceous glands and leads to the destruction of (AktiLites, Galderma, France; 63573 nm, 50 mW/cm2; sebaceous glands after light activation . The use 37 J/cm2), in a prospective randomized controlled split- of IPL offers the possibility to match the absorption face study In 25 patients with AK, topical PDT was peaks of the porphyrins and hemoglobin and may be applied followed by a re-evaluation of up to three therefore a suitable tool for acne treatment. In a months. According to our results, IPL use for PDT is an randomized split-face trial, Yeung et al. evaluated efﬁcient alternative for the treatment of AK, resulting in the effect of IPL therapy alone vs. MAL–PDT–IPL vs.
complete remission and cosmesis equivalent to LED control on moderate acne vulgaris in Asian patients irradiation but with signiﬁcantly less pain (VAS: 4.3 (n=30) with skin type IV or V. Incubation time was (IPL) vs. 6.4 (LED); po0.001). Kim et al. 30 min in the PDT group. IPL treatment (Ellipse Flex, performed a clinical and histopathological trial (n=7 Denmark; lem=530–750 nm; spot size: 10 48 mm; ALA–PDT using an IPL device (Ellipse Flex, Danish pulse duration: 2 2.5 ms, delay: 10 ms; ﬂuence: 7–9 J/ Dermatologic Development, Hoersholm, Denmark; cm2) was applied four times at three-week intervals. The lem=555–950 nm; spot size: 10 48 mm; pulse duration: response was evaluated by two blinded investigators 20–30 ms; ﬂuence: 12–16 J/cm2, two passes) as a light based on photographs 4 and 12 weeks after the ﬁnal source in the resolution of AK (n=12 lesions). Eight or treatment. In this study, a signiﬁcant reduction of non- 12 weeks after treatment, the clinical response was inﬂammatory lesions was observed in the MAL–PDT assessed and histopathological examinations were con- group (38%, pr0.05) and IPL groups (43%, pr0.01), ducted on clinically resolved lesions. Six out of 12 (50%) whereas the control group showed an increase of 15% lesions showed clinical clearance after one single of non-inﬂammatory lesions 12 weeks after treatment.
treatment, but histological examinations showed that No statistically signiﬁcant differences existed between only 5 of the 12 (42%) lesions had been removed.
the intervention groups (PDT: 65%; IPL: 23%) and the Complications, such as pigmentary changes or scarring, control group (88%) in the mean reduction of inﬂam- were not observed. These results show that studies using matory lesions. However, 25% of patients treated with different IPL devices are not comparable. Especially PDT withdrew because of treatment-associated discom- if treating an oncologic indication such as AK, the fort. Sami et al. compared the effectiveness of PDL, physician has to know the exact dosimetry which makes LED, and IPL (lem=550–1200 nm, ﬂuence: 22 J/cm2, the used light source an effective one. Therefore more pulse duration: 30 ms) treatment in a controlled controlled and systematic studies that deﬁne the effec- randomized clinical trial. Patients (n=45) with moder- tive photophysical parameters for different IPL devices ate to severe acne were randomly divided into three are needed. LEDs or gas-discharge lamps are currently equal groups (PDL vs. IPL vs. blue-red combination the standard light sources for PDT of non-melanoma LED). Clearance of Z90% of lesions was achieved skin cancers. However, even a laser (e.g. FPDL) can be after 4.171.4 (PDL) vs. 672.1 (IPL) vs. 1073.3 (LED) used as a light source. From a physical point of view sessions (one treatment per week). At mid-point lasers have advantages over IPL due to their reliable evaluation, the percent reduction in acne lesions was dosimetry and to the fact that coherence accounts for Z90.0% (PDL) vs. 41.7% (IPL) vs. 35.3% (LED). All a higher penetration depth.
treatments were well-tolerated. Taub comparedthe for ALA–PDT in treating moderate to severe acne vulgaris. Patients (n=22) were randomly assigned toIPL (lem=600–850 nm), Targeting acne by laser or light devices is widely (lem=580–980 nm) and bipolar radiofrequency (RF) accepted in the literature. Two mechanisms of action energies, or blue light (417 nm). Each patient received target acne lesions: a photodynamic effect is evoked by three ALA–PDT sessions at two-week intervals. Follow- the use of both UV light and visible light that is up evaluations were conducted one and three months absorbed by porphyrins (PpIX, coproporphyrin III; after the ﬁnal treatment. The author reported that absorption peaks: 400, 510, 542, 578, 630, and 665 nm) ALA–PDT with activation by IPL provided better, that are produced by Propionibacterium acnes. This longer-lasting, and more consistent improvement than P. Babilas / Medical Laser Application 25 (2010) 61–69 RF-IPL or blue light activation. Chang et al. following treatment, the patient should avoid sunlight or, at least, use sufﬁcient UV protection during this Dermatologic Development, Hoersholm, Denmark; lem=530–750 nm; spot size: 10 48 mm; pulse duration: Recent information in terms of hazard analysis and 2 2.5 ms, delay: 10 ms; ﬂuence: 7.5–8 J/cm2) in female determining of safety measures for IPL use are given patients (n=30) with mild to moderate acne. One side of the face was treated with benzoyl peroxide gel only andon the other side, IPL treatment was also applied. Afterthree sessions in three weeks, no signiﬁcant difference could be detected with regard to a possible reduction ofinﬂammatory lesions on either side of the face. How- The effectiveness and safety of IPL devices in a variety ever, red macules, irregular pigmentation, and skin tone of skin conditions has been proven by a large number of improved in 63% of the laser-treated sides vs. 33% on studies. Many controlled trials attest a similar effective- the control side.
ness of IPLs to lasers. Others show that the lasers are The heterogeneous results in current clinical trials clearly superior. Vascular lesions as well as hypertri- show that acne treatment with IPL is far from being a chiosis are deemed to be the key indications for IPL standard treatment. Most studies lack sufﬁcient treat- treatment. The major advantages of IPLs are their ment durations and follow-up periods. This is highly large spot size together with their versatility and their relevant, particularly with regard to the treatment comparatively low purchase price. However, large impact against P. acnes and inﬂammatory acne lesions.
controlled and blinded comparative trials with an P. acnes levels only remain reduced if light treatments extended follow-up period are needed to provide a are applied over a longer period of time, similar to the greater number of evidence-based data.
need for prolonged courses of antibiotics.
Licht-assistierte Therapie in der Dermatologie: Einsatz Safety aspects of IPL treatment are comparable to von hochenergetischen Blitzlampen (IPL) laser treatment Both verbal and writteninformation on the nature of IPL treatment, the chance Die vielfa¨ltigen biologischen und physikalischen Ef- of success, and alternative treatment options have to be fekte, welche aus der Interaktion zwischen Licht als provided. Signed informed consent of the patient is elektromagnetische Strahlung und unserer Haut als mandatory. Possible therapy sequelae, such as blister- Grenzorgan hervorgehen, lassen sich sowohl diagnostisch ing, purpura, or crusting, and potential side effects, such als auch therapeutisch nutzbar machen. Hierbei entschei- as erythema, hypopigmentation, hyperpigmentation, det die Fragestellung bzw. die Indikation u¨ber das zu atrophia, scarring, hypertrophic scarring, or keloid verwendende Lichtspektrum und die Dosimetrie. Zu formation, as well as the risk of infection should be diagnostischen Zwecken ﬁndet Licht maßgeblich in Form mentioned. Diagnosis and clinical appearance have to der Phototestung, der Fluoreszenzdiagnostik und als be documented in the patient record. Photo documenta- Wood-Licht Verwendung. Der therapeutische Gebrauch tion is mandatory prior to each single treatment. For inkoha¨renten Lichtes kann in vier Hauptgruppen un- IPL treatment itself, an optical coupling gel needs to be terteilt werden: (1) UV-Phototherapie, (2) Photodyna- applied and eye protection with the appropriate goggles is mandatory . However, polychromatic light cannot Leuchtdioden (light-emitting diodes, (LEDs)) und die be ﬁltered out as effectively as monochromatic light so Behandlung mit hochenergetischen Blitzlampen (intense that the goggles that now comply with the safety pulsed light, (IPL)). Bei IPL-Gera¨ten wird mittels standards need to be improved. More rapid shutting wechselbarer Lichtﬁltersa¨tze das von Blitzlampen emit- glasses are currently being developed and it is hoped tierte polychromatische, inkoha¨rente Licht auf den that they might provide a solution to this problem.
gewu¨nschten Spektralbereich eingeengt. Das Wirkprinzip Whenever treatment parameters are introduced for the von IPL-Gera¨ten basiert auf der bedingt selektiven ﬁrst time, they should be tested on an inconspicuous site thermischen Scha¨digung der Zielstruktur und a¨hnelt within the treatment area and the skin reaction should damit dem Wirkprinzip der Lasertechnologie. Die be observed. If a melanocytic lesion is apparent within ¨ bersichtsarbeit fokussiert auf den Einsatz the treatment area, the nevus should be omitted from von IPL-Gera¨ten in der Dermatologie. Neben den the treatment or covered with wet white gauze or grundlegenden physikalischen Aspekten werden die non-absorbent white paper. If desired, the treated wichtigsten Indikationen (unerwu¨nschtes Haarwachstum, area can be cooled after IPL therapy. For 8 weeks pigmentierte La¨sionen, vaskula¨re Malformationen, Akne P. Babilas / Medical Laser Application 25 (2010) 61–69 vulgaris) und der Einsatz als Lichtquelle bei der PDT auf dyspigmentation among Asian patients. Lasers Surg Basis der aktuellen Literatur diskutiert.
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A Guide to the Diagnosis & Management of Myasthenia GravisJoël Oger, MD, FRCPC, FAA. Dr. John Newsom-Davis 1932-2007 Expert reviews: J. Newsom-Davis CBE, MA, FRCP, FRS, Design & illustration: L.Waters, MFA, MScBMC, Waters Biomedical Acknowledgements:I thank Talecris Biotherapeutics for making this booklet possible through an unrestricted educational grant, and Kim Fisher, PhD, for her support. I would also like to thankLori Waters for the illustration and design.