|Year : 2018 | Volume
| Issue : 3 | Page : 159-164
Intense pulsed light therapy for acne-induced post-inflammatory erythema
Minu L Mathew, R Karthik, M Mallikarjun, Soumya Bhute, Aiswarya Varghese
Department of Dermatology, Venereology and Leprosy, K.V.G Medical College and Hospital, Sullia, Karnataka, India
|Date of Web Publication||2-May-2018|
Minu L Mathew
Department of Dermatology, Venereology and Leprosy, K.V.G Medical College and Hospital, Sullia - 574 239, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Intense pulsed light (IPL) is a comparatively new system of practice in treating acne-induced post inflammatory erythema (PIE) which is a difficult condition to treat, and variations exist in the results from published studies with insufficient or limited scientific evidence of IPL on Indian skin. Aim: To study the efficacy of IPL in the treatment of acne-induced PIE and to document adverse effects of the procedure. Settings and Design: A hospital-based retrospective observational study on 33 patients with acne-induced PIE who completed treatment with IPL during the time period of July 2015 to June 2017. Patients and Methods: All 33 patients were treated with vascular mode of IPL using 560-nm filter every 3 weeks for three to six sessions. Grading of PIE was done by Clinician Erythema Severity Score, and the objective parameters were assessed statistically for improvement using photographs. Adverse effects were noted and followed up. Statistical Analysis: Wilcoxon sign rank test and Pearson's correlation. Results: There was statistically significant reduction in mean erythema score from 2.57 ± 0.66 to 1.21 ± 0.48 following IPL (Z = −5.295, P < 0.001—Wilcoxon sign rank test). Excellent improvement was noted in 11 (33.33%), good in 15 (45.45%), fair in 4 (12.12%), and poor in 3 (9.09%), and the results were consistent on follow-up. Adverse effects included erythema, hyperpigmentation, and hypopigmentation which were all transient and resolved completely in all patients on follow-up. Conclusion: IPL is an effective and safe alternative to otherwise difficult-to-treat acne-induced PIE.
Keywords: Acne, erythema, grading, intense pulsed light
|How to cite this article:|
Mathew ML, Karthik R, Mallikarjun M, Bhute S, Varghese A. Intense pulsed light therapy for acne-induced post-inflammatory erythema. Indian Dermatol Online J 2018;9:159-64
|How to cite this URL:|
Mathew ML, Karthik R, Mallikarjun M, Bhute S, Varghese A. Intense pulsed light therapy for acne-induced post-inflammatory erythema. Indian Dermatol Online J [serial online] 2018 [cited 2018 Aug 17];9:159-64. Available from: http://www.idoj.in/text.asp?2018/9/3/159/231724
| Introduction|| |
Topical and oral formulations are often ineffective in “acne erythema” or “post inflammatory erythema (PIE) due to acne” which has paved the way for lasers and light therapy for the same., Although pulsed dye lasers are considered as the main stay of treatment for acne erythema, they are expensive machines with a smaller spot size and are not free from side effects., Hence, this study aims at evaluating the efficacy of IPL in acne-induced PIE and to document adverse effects if any, as variations exist in the results from published studies with limited scientific evidence of IPL especially on Indian skin.
| Patients and Methods|| |
A retrospective analysis of all patients diagnosed with acne-induced PIE, who attended the outpatient department and were treated with IPL for the same during the time period of July 2015 to June 2017, was done and the patients were included in the study. All the 33 patients included in the study had completed all sessions of IPL and follow-up. The study included patients above 15 years and below 40 years of age of either sex with persistent facial erythema following resolution of inflammatory acne. Both new and already treated patients with topical or oral therapy who stopped treatment 1 month before the procedure were included. Patients below 15 years and above 40 years of age, those who underwent laser procedures in the past for PIE, patients with keloidal tendencies, photosensitivity and other facial dermatoses, pregnant and lactating mothers, and those who had taken isotretinoin within previous 6 months were excluded from the study. An ethical committee clearance for the study was obtained from the institution.
First, the patients were elaborately explained about the procedure and were asked to give an informed consent for their participation in the study. A questionnaire was used to record the demographic and clinical details of all patients. Information was also noted regarding any precipitating factors, drug intake, and associated cutaneous or systemic disease. After thorough evaluation, grading of erythema and assessment of objective parameters were done based on Clinician Erythema Assessment Scale (CEAS) [Table 1]. The patient was explained about IPL, its benefits, duration of the treatment, its cost, possible side effects, and prognosis of the treatment. Use of sunscreens was advised 2 weeks before the procedure and thereafter. Digital photographs of the concerned area were taken before and after each session.
Before procedure, the treatment area was gently cleansed and make up was removed if any. A third-generation IPL system manufactured by NIKKISO—Zigma with Radio Frequency and inbuilt cooling was used for the study. IPL system was started 2 min before the procedure. Appropriate safety goggles were provided to the patient and staff. Patient's Fitzpatrick's skin type was determined and the number of stacked pulses was set accordingly as two, three, or four. Test dose of IPL was given on forearm of the patient. Pre-procedure ice packs were not applied as it would vasoconstrict the vessels and reduce the target chromophores. For dark skin types, lower fluence with shorter pulse width and longer pulse delay was preferred. For lighter skin types, higher fluence with longer pulse width and shorter pulse delay was used. A 560-nm filter was used for treating post acne redness. Fluence ranged from 25 to 46 J/cm 2, whereas pulse width ranged from 4.5 to 5 ms. Pulse delay was kept at 10-20 ms.
Post procedure, patient was advised on sun protection and to never pick scabs if any. Any post procedure side effects such as erythema, blistering, scarring, hypopigmentation, or hyperpigmentation were noted and followed up. Topical steroid-antibiotic cream was applied over the treated site immediately after the procedure in all patients followed by sunscreen. Epidermal growth factor gel was used in those who developed hyperpigmentation with scabbing following the procedure. IPL was administered every 3 weekly and the number of sessions depended on the severity in each patient which varied between three and six sessions.
Each of the participants was followed up for a period of 12 weeks. The photographs taken before the first session and after the final session were compared. The objective parameters were estimated at the end of the last session and assessed statistically for effectiveness of IPL in each patient of acne erythema using Wilcoxon sign rank test. The data obtained from all the patients were tabulated on Microsoft Excel 2010, and IBM SPSS Version 20 was used for analysis. The physician's assessment of degree of improvement based on Investigator's Global Assessment (IGA) scale [Table 2] was done at the completion of last session and graded as Poor (<25%), Fair (25%-50%), Good (51%-75%), and Excellent (>75%) improvement. Patients also assessed treatment outcome as No improvement, Slight improvement, Good improvement, and Excellent improvement after the last session.
|Table 2: Physician's assessment of improvement based on Investigator's Global Assessment Scale|
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| Results|| |
The mean age of the study group was 23.54 ± 4.677 years, minimum being 18 years and maximum being 39 years of age. Our study included 7 males and 26 females. The mean duration of PIE due to acne in the study group was 2.987 ± 2.97 years. The majority of patients belonged to Fitzpatrick's skin type III (n = 24) followed by type IV (n = 9). The patients with oily, combined, dry, and normal skin type were 21, 7, 4, and 1, respectively.
The average fluence used for treatment was 38.994 J/cm 2 with an average number of sessions of 4.93 ± 0.788. The average pre-treatment erythema score by CEAS was 2.57 ± 0.66 which reduced to 1.21 ± 0.48 following treatment. This reduction in erythema score was found to be statistically significant by Wilcoxon sign rank test (Z = −5.295, P < 0.001) [Figure 1].
Physician's assessment of treatment outcome based on IGA scale showed Excellent improvement in 33.33% (n = 11), Good in 45.45% (n = 15) Fair in 12.12% (n = 4), and Poor improvement in 9.09% (n = 3). Subjective improvement noted by the patients showed Excellent improvement in 36.36% (n = 12), Good in 39.39% (n = 13), Slight in 15.15% (n = 5), and No improvement was noted by 9.09% (n = 3).
There was no correlation between mean improvement in erythema score with duration of PIE (r = 0.1098, P = 0.5430, not significant) or number of sessions of IPL done (r = −0.02849, P = 0.8753, not significant).
Transient erythema was the most common adverse effect (93.94%, n = 31) following IPL with an average of 3.91 days of erythema followed by hyperpigmentation (15.15%, n = 5) with an average of 23 days and hypopigmentation (12.12%, n = 4) lasting for an average of 21 days. The down time was minimal in majority as erythema was mild and transient. In those who developed hyperpigmentation with scabbing and hypopigmentation following IPL, downtime varied from 5 to 7 days although it took longer for complete resolution of lesions. All the adverse effects were transient and cleared completely on follow-up.
Additional benefits such as improvement in skin tone and reduction in oiliness of skin were also noted; 27 out of 33 patients (81.82%) noted an improvement in their skin tone and texture, whereas 19 out of the 21 (90.48%) patients who had oily skin noted reduction in oiliness of skin following IPL [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7].
|Figure 2: (a) A 22-year-old female showing complete clearance of acne-induced PIE following three sessions of IPL—full face. (b) A 22-year-old female showing complete clearance of acne-induced PIE following three sessions of IPL—right side of the face|
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|Figure 3: A 27-year-old female showing excellent response after five sessions of IPL|
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|Figure 4: A 24-year-old male of Fitzpatrick skin type 4 showing hyperpigmentation and hypopigmentation following IPL|
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|Figure 7: A 23-year-old female showing good improvement following three sessions of IPL|
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| Discussion|| |
Acne vulgaris can be a challenging condition to treat as the problem of acne is not confined to skin alone but also affects the psyche, and the disease burden of acne ranges from facial scarring and dyspigmentation to social, psychological, and emotional distress as well as self-perception of poor health., Post inflammatory dyspigmentation due to acne presents as post inflammatory hyperpigmentation in darken skin types, whereas they present as discrete erythematous macules or scars in lighter skin types. Acne-induced PIEs in majority are resistant to available topical and oral drug formulations which is distressing to the patients and the treating physicians., The laser and light-based systems are preferred by the consumer who demands more than what creams and topical drugs can offer and also by physicians who need a better therapeutic response beyond what conventional modalities can deliver.
IPL is a flash lamp pumped light source which provides a non-coherent polychromatic source of intense light from 400 to 1200 nm that can be modified by filters to provide irradiation with specific wavelengths of light unlike PDL which uses monochromatic light that cannot be adjusted. IPL can be delivered by splitting the energy into two, three, or four pulses with different pulse delays which allow the skin to be cooled between pulses thereby preventing adverse effects. The advantage of IPL is that it takes care of acne and acne-associated redness in a single sitting. IPL devices have a large spot size (7-8 mm × 40 mm) which covers 2.8 cm 2 of skin surface in a single shot which is a much larger surface when compared to smaller spot sizes of argon laser or PDL (3-10 mm)., Hence, on an average, three times the same number of shots as in IPL would be needed for PDL to cover the same area increasing the treatment cost per se ssion for PDL. Larger spot size of IPL results in the delivery of greater amount of energy and greater damage to the deeper dermal target and enables the use of lower fluence which reduces the side effects of the procedure. As a result, there will be larger and uniform skin coverage per se ssion thereby reducing the number of shots fired per se ssion to cover the concerned area and the total number of sessions required for a therapeutic response. IPL has a lower purchase price (5-25 lakh rupees) compared to PDL (45-60 lakh rupees). The lesser number of shots per se ssion together with the lower cost of machine makes IPL economical for the patient and the treating physician and hence aptly called the “poor man's laser.”
Acne erythema consists of telangiectasia and erythematous papules, without a comedone, which occur as a result of inflammatory acne. Acne-associated flushing and erythema are vascular components and represent increased numbers of erythrocytes in mildly inflamed and enlarged blood micro capillaries which were produced around the acne lesion due to localized inflammation during the acute acne condition. These vessels are located mainly in very close proximity to the skin surface and have a smaller diameter giving the skin a red appearance due to high concentration of minor blood vessels in that area.
IPL works by the principle of selective photothermolysis wherein laser energy is being absorbed by a target chromophore without significant damage to the surrounding tissue. IPL targets the chromophores oxy- and deoxy-hemoglobin in the blood vessels which are the main chromophores for vascular lasers. The major absorption peaks of oxy-hemoglobin are 418, 542, and 577 nm, whereas deoxygenated hemoglobin has absorption peaks around 450 and 560 nm. Longer wavelength like 577 nm is preferred as they penetrate more deeply to reach the vessels and do not interfere with epidermal melanin, thereby reducing adverse effects following the procedure especially in Indian skin types. The vascular mode of IPL uses a 560-nm cut-off filter which filters out all wavelengths lower than 560 nm and allows a wavelength of 577 nm, corresponding to the third absorption peak of oxy-hemoglobin to pass through resulting in selective thermal damage to the superficial vessels producing coagulation and thrombosis of vessel wall. These defective venules are then removed over time which is clinically seen as clearance of erythema.
In our study, among the 33 patients with acne induced PIE who underwent treatment with vascular mode of IPL using 560nm filter for three to six sessions, 78.78% of patients showed more than 50% improvement in their erythema scores and the results were consistent after 12 weeks of follow up.
Chang et al. evaluated an IPL device (530-750 nm, 7.5-8.0 J/cm 2) in 30 Korean females with mild to moderate acne associated with PIE. After three sessions in 3 weeks, red macules, irregular pigmentation, and skin tone improved in 63% of the study population although they used a lower fluence for the procedure.
Madonna Terracina et al. used IPL in the treatment of persistent face and neck erythema in women (n = 22) and men (n = 12). Patients underwent five treatments at intervals of 3 weeks. In 22 patients (64.7%), regression of the erythema was achieved after five applications, while the erythema persisted in five (14.7%) patients. In our study, three patients (9.09%) had poor response following IPL.
Wenzel et al. reported successful treatment of patients with progressive erythema using IPL with 560-nm filter in nine patients. According to their results, improvement in erythema was obtained in all the nine patients with very good results in eight patients.
Neuhaus et al. and Tangheiit compared PDL with IPL and found that both modalities were equally effective in reducing cutaneous erythema and telangiectasia with a similar side-effect profile in rosacea., Kassir et al. noted that 80% of patients with rosacea had reduction in redness, and 78% of patients had reduced flushing and improved skin texture following IPL.
Erythema (n = 31, 93.94%), hyperpigmentation (n = 5, 15.15%), and hypopigmentation (n = 4, 12.12%) were the adverse effects noted in our study following IPL, all of which were transient and resolved completely on follow-up. Babilas, Moreno-Arias et al., and Sadick et al. also observed that transient erythema was the most common adverse effect post IPL, followed by hyperpigmentation, hypopigmentation, blistering, and scarring.,, The findings of our study were consistent with that of Kawana et al. who noted that darker skin types had more chances of adverse effects. Adverse effects were noted more on bony prominences such as mandibular and temporal area especially in patients with Fitzpatrick skin type 4, and hence lower fluences have to be used over bony prominences to reduce adverse effects along with stringent sun protection.
In our study, 81.82% (n = 27) noted improvement in their skin tone and texture, whereas 90.48% (n = 19) of patients who had oily skin (n = 21) noted reduction in oiliness of skin following IPL. Kassir et al. noted improvement in skin texture in 78% of patients following IPL. Chang et al., Jorgensen et al., and Hantash et al. all have noted improvement in skin tone and texture following treatment with IPL.,,
The shortcoming of this study was that no control group was included. Furthermore, larger, placebo-controlled studies using parallel, cross-over, matched, or split-face designs are required to confirm our conclusions. Consistency of the results for longer periods is to be elucidated.
We consider that IPL can be used as an alternative in patients with persistent acne erythema as it simultaneously takes care of acne and erythema with additional advantages such as reduction in oiliness of skin with improvement in skin tone and texture and transient adverse effects when used optimally. Overall, IPL appears to be an effective, well-tolerated, economical, and a safe treatment and may be viewed as a viable alternative to PDL, but optimization of treatment parameters and operator experience are essential in achieving desired results as observed by Clementoni et al.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]