Journal of Cosmetic and Laser Therapy, 2014; Early Online: 1–5
ORIGINAL RESEARCH REPORT
Variable pulsed light treatment of melasma and post-inflammatory hyperpigmentation – A pilot study
ANNA AUGUSTYNIAK, ANNA ERKIERT-POLGUJ & HELENA ROTSZTEJN
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Department of Cosmetology, Faculty of Pharmacy, Medical University of Lodz, Lodz, Poland Abstract Hyperpigmentation disorders are a serious aesthetic problem. Various therapies are applied to remove these lesions. The variable pulsed light (VPL) is similar to intense pulsed light (IPL), but instead of one flash of light, energy is provided in a few small and rapid micro-flashes. The aim of the study is a mexametric evaluation of results of the treatment of hyperpigmentation with the application of the VPL device as well as the patient’s opinion on this kind of treatment. The therapy with the VPL was administered twice within a period of three weeks. In order to evaluate the effectiveness of the treatment procedure, we carried out the mexametric measurements three times. Eighteen women with hyperpigmentation disorders were included in the study. The lesions were lightened in thirteen patients. Three patients demonstrated more intensive hyperpigmentation. Twelve patients assessed the effects of the therapy as good and excellent. In the patients, in whom the initial mexametric results confirmed the strongest changes, the effect of the VPL therapy appeared to be the greatest. The obtained results allow claiming that the VPL method is effective for treating hyperpigmentation. The level of the patients’ satisfaction after the therapy is equally important. Key Words: hyperpigmentation, melisma, variable pulsed light
Introduction Hyperpigmentation disorders are a serious aesthetic problem. These disorders affect a considerable number of people and are one of the most common cosmetic problems (1,2). Hyperpigmentation is treated not only by dermatologists, but also by specialists in aesthetic medicine and cosmetology. Mechanisms for appearance of these lesions can be varied in nature, and quite frequently there is more than one cause for these disorders. Skin changes include those which are connected with over-reactivity and an increased number of normal melanocytes. The most common are freckles, chloasma, melasma, senile lentigines and post-inflammatory hyperpigmented skin changes. Another mechanism for appearance of such disorders results from an increased production of melanosomes that are transferred to keratinocytes. A decreased number of melanosomes destroyed by keratinocytes and macrophages also contribute to the appearance of hyperpigmented changes (1–3). Identification and possible elimination
of factors predisposing the formation of hyperpigmentation affect the therapy. The factors include genetic predisposition, exposure to the sun, sunbeds, skin inflammations, mechanical/chemical injuries, the application of contraception/hormonal replacement therapy, thyroid, liver and adrenal gland diseases, ovarian functional disorders, and taking drugs or cosmetics which increase the sensitivity to ultraviolet (UV) radiation (1,2,4). Melasmic changes are isolated hyperpigmented foci, located mainly in the central area of the face (forehead, nose, cheeks, upper lip and chin). Their symmetry, number and colour (from yellowish to dark grey) are considerably different in different patients. From the histological point of view there are three types of melasma: epidermal, dermal and mixed (1,2,4). Treating pigmented changes is difficult due to the risk of post-inflammatory hyperpigmentation after the application of treatment procedures. A proper therapy should include a co-operation
Correspondence: Anna Erkiert-Polguj, Department of Cosmetology, Faculty of Pharmacy, Medical University of Lodz, Muszynskiego 1, 90-151 Łódź, Poland. E-mail: [email protected] (Received 10 December 2013 ; accepted 10 September 2014 ) ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd. DOI: 10.3109/14764172.2014.968576
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2
A. Augustyniak et al.
between the patient and the doctor, avoiding exposure to sun rays and applying preparations with UV filters. In the procedure of removing hyperpigmentation, specialists use depigmentation agents (e.g. hydrochinone and azelaic acid) and chemical peels (containing glycolic acid, betahydroxy acid, trichloroacetic acid and retinoids) (5). Opinions on the application of lasers are contradictory. 694-nmswitched laser and 510-nm dye laser appeared to be ineffective. What is more, they caused post-inflammatory hyperpigmentation (6–8). Many studies confirm that the following devices are commonly used: erbium laser, pulsed CO2 laser, ultrapulsed CO2 laser, Q-switched alexandrite laser and 1550-nm fractional erbium laser (9). Also, the intense pulsed light (IPL) is frequently applied in the treatment of hyperpigmentation. The IPL does not emit a coherent, but a broadspectrum collimated light beam (500–1200 nm). Both the methods use the light–tissue reaction and are based on photobiology. In these methods, light converts into heat, which is a result of the absorption of particular skin structures (skin chromophores) (9–11). The light in the IPL/variable pulsed light (VPL) devices is multi-coloured and the applied filters can be different for different purposes (removing hair, reduction of hyperpigmentation, acne, vascular and photoageing changes). Heads used to eliminate hyperpigmentation emit a 500/515/540–1200 nm light beam. In these devices it is possible to control/set a required wavelength, time of the impulses and intervals between them, and energy density depending on the need of the client and according to the thermal relaxation of the skin (9,11–13). Modern devices can also divide the main impulse into the so-called micro-impulses/sub-impulses. The VPL is a type of IPL, but during one flash of light it emits a lot of short, rapid micro-flashes. It allows using more energy during a treatment procedure and prevents overheating of the skin, which reduces side effects and lessens the pain. The aim of the study is a mexametric evaluation of results of the treatment for hyperpigmentation with the application of the VPL device as well as the patient’s opinion on this kind of treatment. Material and methods Eighteen women of 25–60 years of age, with phototypes II and III according to the Fitzpatrick Skin Classification were included in the study. In the period in which the patients were treated for hyperpigmented changes, they did not use hormonal contraception or hormonal replacement therapy. In most of the women exposure to solar radiation was the most possible cause for skin changes.
In two patients, the hyperpigmentations were post-inflammatory and post-acne. In one patient the changes were a result of a mechanical injury. Three patients claimed the changes were genetically conditioned; their family members were affected by similar hyperpigmentations. Three females developed the changes during the application of hormonal contraception and hormonal replacement therapy. In two patients, the changes appeared in the course of diseases of the thyroid, renal gland and liver; in two patients, the ovarian functional disorder was accompanied by skin changes and other two women developed them while taking photoreactive medications and herbs (Table I). The study followed principles in the Declaration of Helsinki. The study group was administered two procedures using the VPL device. The second procedure was applied three weeks after the first one. The patients were asked to apply UV-protective preparations, with a minimum sun protection factor (SPF) 30 and avoid sunbathing. We focused on changes located on the face, arms, décolleté and palms.
VPL energist ultraplus The source of light was a single flash lamp with a flash chamber and a filter. The wavelength of the tip reducing hyperpigmented changes is 530 nm, range: 530–950 nm. BK7 glass conductor is a conducting element. An absorption filter is the tip filter. Time of the impulse: 3, 5 and 7 ms. Sequence of impulses: 2–15 impulses. Impulse delay: 1–20 ms. Time of the sequence of impulses: 7–385 ms. Repeatability: up to 0.5 Hz. Targeted area: 5 cm2 (5 ⫻ 1 cm). Energy density (fluence): 51 J/cm2. We did not observe serious side effects, except for erythema which was visible for a few hours. In order to evaluate the effectiveness of the therapy, we used a mexametric probe to measure the degree of skin hyperpigmentation (Mexameter MX 18). We conducted the measurements three times: before the procedure, three weeks later – before the second procedure – and another three weeks later. Moreover, the results were recorded in the form of photographs and the patients were asked to assess the treatment procedures.
Mexameter Mexameter MX 18 is used to measure the concentration of melanin and haemoglobin in the skin and to identify the skin colour on the basis of only a few factors. The measurement is made
VPL treatment of hyperpigmentation
3
Table I. Patient characteristics.
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UV protection
Patient
Age
Skin colour Phototype Discolourations UV exposure
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
46 32 31 25 25 39 25 54 35 46 41 45 40 27 34 40 39 60
Fair Quite dark Quite dark Fair Quite dark Olive Fair Fair Quite dark Fair Olive Quite dark Quite dark Fair Fair quite dark quite dark olive
III III III III III III II II III II III III III II II III III III
Face, palms Face, décolleté Arms, décolleté Face Face Face Arms Face, palms Face Face Face Face Face, arms Décolleté Arms Décolleté Palms Face, décolleté
using the phenomenon of light absorption. A special probe emits three different wavelengths and the receptor measures the light reflected from the skin. Satisfaction analysis The patients were assessed at three-week intervals. We used a 4-point scale for assessment of satisfaction: 1 – poor, 2 – fair, 3 – good and 4 – excellent. Statistical analysis The statistical analysis was performed using GraphPad Prism 6.0 computer software. The single-factor analysis of variance for repeated measurements and post hoc Tukey tests were used in order to evaluate the differences observed between the procedures. The results were presented as median and standard deviation (median ⫾ SD).
Yes–often Yes–often Yes–seldom Yes–seldom Yes–often Yes–often Yes–seldom Yes–seldom Yes–seldom No No No Yes–often No Yes–seldom Yes–often Yes–seldom Yes–seldom
We noted statistically significant effect of the applied therapy both after the first and the second procedures. The final improvement (the lesions were lightened) was observed in thirteen patients. In two women, the results did not confirm differences and three patients demonstrated an increase in the degree of hyperpigmentation. In five patients, the skin hyperpigmentations became much less intensive after the application of the first procedure but after the second one, the skin changes became more visible. With regard to other five women in whom the measurement values were
Strong Strong Average Average Strong Strong Weak Strong Average – – – Strong – Weak Average Average Strong
While sunbathing In a year Yes Yes No No No Yes Yes Yes Yes – – – No – Yes No Yes No
No Yes No No No Yes No No Yes Yes Yes Yes No Yes No No No No
higher than 200 (which proved that the hyperpigmentations were highly intensive), the therapy appeared most effective. Twelve patients assessed the effects of the therapy as good and excellent. Clinical evaluation, mexameter results and patients’ self-assessment were correlated. Scores 3 and 4 in our self-assessment questionnaire correlated with mexameter results which showed significant improvement (p ⬍ 0.05). Three females, who developed the changes during the application of hormonal contraception and hormonal replacement therapy, were very satisfied with the procedure and clinical results were good. Patients with post-inflammatory, post-acne or mechanical hyperpigmentation assessed results as fair. The hyperpigmentation presented in hands and décolleté showed good results (Figure 1–3 and Table II). Changes in measurements of skin colour 300
Results
Intensity of exposure
Measurement 1 Measurement 2 Measurement 3
250 200 150 100 50 0
1
2
3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 18 people; three mexametric measurements
Figure 1. Changes in measurements of skin colour.
4
A. Augustyniak et al. Table II. The median results from the mexameter measurement. N ⫽ 18 Procedure 1
Procedure 2
Procedure 3 Significance
184.6 ⫾ 39.6 162.4 ⫾ 32.3* 162.2 ⫾ 31.0* P ⫽ 0.0111
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*p ⬍ 0.05 in comparison with Procedure 1.
Figure 2. A patient before VPL treatment.
Figure 3. A patient after two VPL procedures.
Discussion Skin hyperpigmentations are a complex aesthetic problem. They are difficult to treat and negatively affect the person’s psychological condition.
The intensive source of light was introduced into treatment methods in the 1990s and since then it has had a lot of applications. More and more sophisticated devices are being constantly implemented. They allow for performing more effective therapies and lessening side effects (14–17). Each impulse of light energy produced by the VPL device is a sequence of rapid micro-impulses, whose length, number and frequency can be set for an individual patient. It provides better absorption into selected skin layers and minimise at the same time the effect of heating the neighbouring tissues. The VPL technology was implemented so as to perform safe and effective therapies in patients with various phototypes and hair structure, where the risk of side effects is much smaller and the pain is less. The VPL technology is used to reduce unwanted hair (14,15), but some attempts have been made to use it for treating solar keratosis (16) or acne. The effectiveness of the application of the IPL technology in treating hyperpigmented changes (12,18,19) allows us to believe that the VPL technology will appear to be equally effective. Professional literature contains examples of studies which are based on the analysis of photographs or clinical evaluation of patients (19). Our study presents an objective evaluation of the degree of pigmentation measured with a mexameter and the patients’ subjective opinions on the applied therapy. There are a lot of methods for treating skin hyperpigmentation, but none of them is effective in all patients. Thus, specialists are constantly seeking new therapeutic options. Mixed-type hyperpigmentation are more difficult to treat. Skin hyperpigmentation easily becomes more intensive when they are affected by irritating factors. The IPL device might also contribute to slight hyperpigmentation, especially if it is not equipped with a cooling system (20). We cannot rule out that three patients, in whom previous skin changes became even more intensive, were affected by external factors which caused the exacerbation of their disorders. The patients did not take oral hormonal contraceptives or use hormonal replacement therapy. After the application of light generated by the IPL device, melanosomes in epidermal melasma quickly move to the surface of the skin, undergo desquamation and take a form of tiny crusts. As a result, the effect of lightening can be visible after the first procedure (21). Li et al. (21) studied patients with hyperpigmented changes, who were treated with the IPL technology. They observed better results in patients older than 45 and younger than 35 years of age. The authors explain this fact with a lower activity of mel-
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VPL treatment of hyperpigmentation anocytes in older women, especially in the postmenopausal period. On the other hand, in younger women concentration of melanin and melanosomes is lower. We did not observe any relationship between the age of the patients and the improvement in the skin condition, which corresponds to the observation made by Shin et al. (11) studying the general photorejuvenation effect. Similar to the study mentioned above, we did not note any relationship between the effect of the treatment and the duration of skin lesions. Sasaya et al. (22) used IPL device for the treatment of solar lentigines of the hands with good results. Also, in our study the effects of VPL treatment on hyperpigmentation in hands were satisfactory. In the patients, in whom the mexametric measurement values confirmed the highest intensity of hyperpigmentation, the therapy with the VPL technology appeared most effective. Good tolerance for treatment and no serious side effects allow considering the VPL method as a safe and well-tolerated therapeutic option. In comparison to lasers, this technology does not limit the patient’s life so considerably. The subjective level of satisfaction observed after the application of this state-ofthe-art technology is also very important. The obtained results allow us to say that the VPL method is an effective alternative in the treatment of hyperpigmentation. It is still debatable whether a combined therapy might contribute to a greater effectiveness of procedures applied in the treatment of hyperpigmentation disorders. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. The paper was supported by grant No. 503/3-066-01/503-01 from the Medical University of Łódź, Poland. Acknowledgements None. References 1. Grimes PE. Melasma: etiologic and therapeutic considerations. Arch Dermatol. 1995;131:1453–1457. 2. Victor FC, Gelber J, Rao B. Melasma: a review. J Cutan Med Surg. 2004; 8:97–102. 3. Pandaya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin. 2000;18:91–98. 4. Kang HY, Ortonne JP. What should be considered in treatment of melasma. Ann Dermatol. 2010; 22:373–378. 5. Ghersetich I, Troiano M, Brazzini B, Arunachalam M, Lotti T. Melasma: treatment with 10% tretinoin peeling mask. J Cosmet Dermatol. 2010;9:117–121.
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6. Fitzpatrick RE, Goldman MP, Ruiz-Espraza J. Laser treatment of benign pigmented epidermal lesions using a 300 nanosecond pulse and 510-nm wavelength. J Dermatol Surg Oncol. 1993;18:341–347. 7. Kopera D, Hohenleutner U. Ruby laser treatment of melasma and postinflammatory hyperpigmentation. Dermatol Surg. 1995;21:994. 8. Taylor CR, Anderson RR. Ineffective treatment of refractory post inflammatory hyperpigmentation by Q switched ruby laser. J Dermatol Surg Oncol. 1994;20:592–597. 9. Arora P, Sarkar R, Garg VK, Arya LJ. Lasers for treatment of melasma and post-inflammatory hyperpigmentation. Cutan Aesthet Surg. 2012;5:93–103. 10. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulse radiation. Science. 1983;220:524–527. 11. Shin J-W, Lee D-H, Choi S-Y, Na J-I, Park K-C, Youn S.-W, Huh, C-H. Objective and non-invasive evaluation of photorejuvenation effect with intense pulsed light treatment in Asian skin. J Eur Acad Dermatol Venereol. 2011;25: 516–522. 12. Li YH, Chen JZ, Wei HC, Wu Y, Liu M, Xu YY, et al. Efficacy and safety of intense pulsed light in treatment of melasma in Chinese patients. Dermatol Surg. 2008;34: 693–700. 13. Xi Z, Shuxian, Y, Zhong L, Hui Q, Yan W, Huilin D, et al. Topical 5-aminolevulinic acid with intense pulsed light versus intense pulsed light for photodamage in Chinese patients. Dermatol Surg. 2011;37:31–40. 14. Holzer G, Nahavandi H, Neumann R, Knobler R. Photoepilation with variable pulsed light in non-facialbody areas: evaluation of efficacy and safety. J Eur Acad Dermatol Venereol 2010;24:518–523. 15. Nahavandi H, Neumann R, Holzer G, Knobler R. Evaluation of safety and efficacy of variable pulsed light in thetreatment of unwanted hair in 77 volunteers. J Eur Acad Dermatol Venereol. 2008;22:311–315. 16. Babilas P, Knobler R, Hummel S, Gottschaller C, Maisch T, Koller M, et al. Variable pulsed light is less painful than lightemitting diodes for topical photodynamic therapy of actinickeratosis: a prospective randomized controlled trial. Br J Dermatol. 2007;157:111–117. 17. Li YH, Wu Y, Chen JZ, Gao XH, Liu M, Shu CM, et al. Application of a new intense pulsed light device in the treatment of photoaging skin in Asian patients. Dermatol Surg. 2008;34:1459–1464. 18. Zaleski L, Fabi S, Goldman MP. Treatment of melasma and the use of intense pulsed light: a review. J Drugs Dermatol. 2012;11:1316–1320. 19. Zoccali G, Piccolo D, Allega P, Giuliani M. Melasma treated with intense pulsed light. Aesthetic Plast Surg. 2010;34: 486–493. 20. Negishi K, Kushikata N, Tezuka Y, Takeuchi K, Miyamoto E, Wakamatsu S. Study of the incidence and nature of ‘‘very subtle epidermal melasma’’ in relation to intense pulsed light treatment. Dermatol Surg. 2004;30: 881–886. 21. Yamashita T, Negishi K, Hariya T, Kunizawa N, Ikuta K, Yanai M, Wakamatsu S. Intense pulsed light therapy for superficial pigmented lesions evaluated by reflectance-mode confocal microscopy and optical coherence tomography. J Invest Dermatol. 2006;126:2281–2286. 22. Sasaya H, Kawada A, Wada T, Hirao A, Oiso N. Clinical effectiveness of intense pulsed light therapy for solar of the hands. Dermatol Ther. 2011;24:584–586.
ORIGINAL RESEARCH REPORT
Variable pulsed light treatment of melasma and post-inflammatory hyperpigmentation – A pilot study
ANNA AUGUSTYNIAK, ANNA ERKIERT-POLGUJ & HELENA ROTSZTEJN
J Cosmet Laser Ther Downloaded from informahealthcare.com by Ondokuz Mayis Univ. on 11/05/14 For personal use only.
Department of Cosmetology, Faculty of Pharmacy, Medical University of Lodz, Lodz, Poland Abstract Hyperpigmentation disorders are a serious aesthetic problem. Various therapies are applied to remove these lesions. The variable pulsed light (VPL) is similar to intense pulsed light (IPL), but instead of one flash of light, energy is provided in a few small and rapid micro-flashes. The aim of the study is a mexametric evaluation of results of the treatment of hyperpigmentation with the application of the VPL device as well as the patient’s opinion on this kind of treatment. The therapy with the VPL was administered twice within a period of three weeks. In order to evaluate the effectiveness of the treatment procedure, we carried out the mexametric measurements three times. Eighteen women with hyperpigmentation disorders were included in the study. The lesions were lightened in thirteen patients. Three patients demonstrated more intensive hyperpigmentation. Twelve patients assessed the effects of the therapy as good and excellent. In the patients, in whom the initial mexametric results confirmed the strongest changes, the effect of the VPL therapy appeared to be the greatest. The obtained results allow claiming that the VPL method is effective for treating hyperpigmentation. The level of the patients’ satisfaction after the therapy is equally important. Key Words: hyperpigmentation, melisma, variable pulsed light
Introduction Hyperpigmentation disorders are a serious aesthetic problem. These disorders affect a considerable number of people and are one of the most common cosmetic problems (1,2). Hyperpigmentation is treated not only by dermatologists, but also by specialists in aesthetic medicine and cosmetology. Mechanisms for appearance of these lesions can be varied in nature, and quite frequently there is more than one cause for these disorders. Skin changes include those which are connected with over-reactivity and an increased number of normal melanocytes. The most common are freckles, chloasma, melasma, senile lentigines and post-inflammatory hyperpigmented skin changes. Another mechanism for appearance of such disorders results from an increased production of melanosomes that are transferred to keratinocytes. A decreased number of melanosomes destroyed by keratinocytes and macrophages also contribute to the appearance of hyperpigmented changes (1–3). Identification and possible elimination
of factors predisposing the formation of hyperpigmentation affect the therapy. The factors include genetic predisposition, exposure to the sun, sunbeds, skin inflammations, mechanical/chemical injuries, the application of contraception/hormonal replacement therapy, thyroid, liver and adrenal gland diseases, ovarian functional disorders, and taking drugs or cosmetics which increase the sensitivity to ultraviolet (UV) radiation (1,2,4). Melasmic changes are isolated hyperpigmented foci, located mainly in the central area of the face (forehead, nose, cheeks, upper lip and chin). Their symmetry, number and colour (from yellowish to dark grey) are considerably different in different patients. From the histological point of view there are three types of melasma: epidermal, dermal and mixed (1,2,4). Treating pigmented changes is difficult due to the risk of post-inflammatory hyperpigmentation after the application of treatment procedures. A proper therapy should include a co-operation
Correspondence: Anna Erkiert-Polguj, Department of Cosmetology, Faculty of Pharmacy, Medical University of Lodz, Muszynskiego 1, 90-151 Łódź, Poland. E-mail: [email protected] (Received 10 December 2013 ; accepted 10 September 2014 ) ISSN 1476-4172 print/ISSN 1476-4180 online © 2014 Informa UK, Ltd. DOI: 10.3109/14764172.2014.968576
J Cosmet Laser Ther Downloaded from informahealthcare.com by Ondokuz Mayis Univ. on 11/05/14 For personal use only.
2
A. Augustyniak et al.
between the patient and the doctor, avoiding exposure to sun rays and applying preparations with UV filters. In the procedure of removing hyperpigmentation, specialists use depigmentation agents (e.g. hydrochinone and azelaic acid) and chemical peels (containing glycolic acid, betahydroxy acid, trichloroacetic acid and retinoids) (5). Opinions on the application of lasers are contradictory. 694-nmswitched laser and 510-nm dye laser appeared to be ineffective. What is more, they caused post-inflammatory hyperpigmentation (6–8). Many studies confirm that the following devices are commonly used: erbium laser, pulsed CO2 laser, ultrapulsed CO2 laser, Q-switched alexandrite laser and 1550-nm fractional erbium laser (9). Also, the intense pulsed light (IPL) is frequently applied in the treatment of hyperpigmentation. The IPL does not emit a coherent, but a broadspectrum collimated light beam (500–1200 nm). Both the methods use the light–tissue reaction and are based on photobiology. In these methods, light converts into heat, which is a result of the absorption of particular skin structures (skin chromophores) (9–11). The light in the IPL/variable pulsed light (VPL) devices is multi-coloured and the applied filters can be different for different purposes (removing hair, reduction of hyperpigmentation, acne, vascular and photoageing changes). Heads used to eliminate hyperpigmentation emit a 500/515/540–1200 nm light beam. In these devices it is possible to control/set a required wavelength, time of the impulses and intervals between them, and energy density depending on the need of the client and according to the thermal relaxation of the skin (9,11–13). Modern devices can also divide the main impulse into the so-called micro-impulses/sub-impulses. The VPL is a type of IPL, but during one flash of light it emits a lot of short, rapid micro-flashes. It allows using more energy during a treatment procedure and prevents overheating of the skin, which reduces side effects and lessens the pain. The aim of the study is a mexametric evaluation of results of the treatment for hyperpigmentation with the application of the VPL device as well as the patient’s opinion on this kind of treatment. Material and methods Eighteen women of 25–60 years of age, with phototypes II and III according to the Fitzpatrick Skin Classification were included in the study. In the period in which the patients were treated for hyperpigmented changes, they did not use hormonal contraception or hormonal replacement therapy. In most of the women exposure to solar radiation was the most possible cause for skin changes.
In two patients, the hyperpigmentations were post-inflammatory and post-acne. In one patient the changes were a result of a mechanical injury. Three patients claimed the changes were genetically conditioned; their family members were affected by similar hyperpigmentations. Three females developed the changes during the application of hormonal contraception and hormonal replacement therapy. In two patients, the changes appeared in the course of diseases of the thyroid, renal gland and liver; in two patients, the ovarian functional disorder was accompanied by skin changes and other two women developed them while taking photoreactive medications and herbs (Table I). The study followed principles in the Declaration of Helsinki. The study group was administered two procedures using the VPL device. The second procedure was applied three weeks after the first one. The patients were asked to apply UV-protective preparations, with a minimum sun protection factor (SPF) 30 and avoid sunbathing. We focused on changes located on the face, arms, décolleté and palms.
VPL energist ultraplus The source of light was a single flash lamp with a flash chamber and a filter. The wavelength of the tip reducing hyperpigmented changes is 530 nm, range: 530–950 nm. BK7 glass conductor is a conducting element. An absorption filter is the tip filter. Time of the impulse: 3, 5 and 7 ms. Sequence of impulses: 2–15 impulses. Impulse delay: 1–20 ms. Time of the sequence of impulses: 7–385 ms. Repeatability: up to 0.5 Hz. Targeted area: 5 cm2 (5 ⫻ 1 cm). Energy density (fluence): 51 J/cm2. We did not observe serious side effects, except for erythema which was visible for a few hours. In order to evaluate the effectiveness of the therapy, we used a mexametric probe to measure the degree of skin hyperpigmentation (Mexameter MX 18). We conducted the measurements three times: before the procedure, three weeks later – before the second procedure – and another three weeks later. Moreover, the results were recorded in the form of photographs and the patients were asked to assess the treatment procedures.
Mexameter Mexameter MX 18 is used to measure the concentration of melanin and haemoglobin in the skin and to identify the skin colour on the basis of only a few factors. The measurement is made
VPL treatment of hyperpigmentation
3
Table I. Patient characteristics.
J Cosmet Laser Ther Downloaded from informahealthcare.com by Ondokuz Mayis Univ. on 11/05/14 For personal use only.
UV protection
Patient
Age
Skin colour Phototype Discolourations UV exposure
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
46 32 31 25 25 39 25 54 35 46 41 45 40 27 34 40 39 60
Fair Quite dark Quite dark Fair Quite dark Olive Fair Fair Quite dark Fair Olive Quite dark Quite dark Fair Fair quite dark quite dark olive
III III III III III III II II III II III III III II II III III III
Face, palms Face, décolleté Arms, décolleté Face Face Face Arms Face, palms Face Face Face Face Face, arms Décolleté Arms Décolleté Palms Face, décolleté
using the phenomenon of light absorption. A special probe emits three different wavelengths and the receptor measures the light reflected from the skin. Satisfaction analysis The patients were assessed at three-week intervals. We used a 4-point scale for assessment of satisfaction: 1 – poor, 2 – fair, 3 – good and 4 – excellent. Statistical analysis The statistical analysis was performed using GraphPad Prism 6.0 computer software. The single-factor analysis of variance for repeated measurements and post hoc Tukey tests were used in order to evaluate the differences observed between the procedures. The results were presented as median and standard deviation (median ⫾ SD).
Yes–often Yes–often Yes–seldom Yes–seldom Yes–often Yes–often Yes–seldom Yes–seldom Yes–seldom No No No Yes–often No Yes–seldom Yes–often Yes–seldom Yes–seldom
We noted statistically significant effect of the applied therapy both after the first and the second procedures. The final improvement (the lesions were lightened) was observed in thirteen patients. In two women, the results did not confirm differences and three patients demonstrated an increase in the degree of hyperpigmentation. In five patients, the skin hyperpigmentations became much less intensive after the application of the first procedure but after the second one, the skin changes became more visible. With regard to other five women in whom the measurement values were
Strong Strong Average Average Strong Strong Weak Strong Average – – – Strong – Weak Average Average Strong
While sunbathing In a year Yes Yes No No No Yes Yes Yes Yes – – – No – Yes No Yes No
No Yes No No No Yes No No Yes Yes Yes Yes No Yes No No No No
higher than 200 (which proved that the hyperpigmentations were highly intensive), the therapy appeared most effective. Twelve patients assessed the effects of the therapy as good and excellent. Clinical evaluation, mexameter results and patients’ self-assessment were correlated. Scores 3 and 4 in our self-assessment questionnaire correlated with mexameter results which showed significant improvement (p ⬍ 0.05). Three females, who developed the changes during the application of hormonal contraception and hormonal replacement therapy, were very satisfied with the procedure and clinical results were good. Patients with post-inflammatory, post-acne or mechanical hyperpigmentation assessed results as fair. The hyperpigmentation presented in hands and décolleté showed good results (Figure 1–3 and Table II). Changes in measurements of skin colour 300
Results
Intensity of exposure
Measurement 1 Measurement 2 Measurement 3
250 200 150 100 50 0
1
2
3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 18 people; three mexametric measurements
Figure 1. Changes in measurements of skin colour.
4
A. Augustyniak et al. Table II. The median results from the mexameter measurement. N ⫽ 18 Procedure 1
Procedure 2
Procedure 3 Significance
184.6 ⫾ 39.6 162.4 ⫾ 32.3* 162.2 ⫾ 31.0* P ⫽ 0.0111
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*p ⬍ 0.05 in comparison with Procedure 1.
Figure 2. A patient before VPL treatment.
Figure 3. A patient after two VPL procedures.
Discussion Skin hyperpigmentations are a complex aesthetic problem. They are difficult to treat and negatively affect the person’s psychological condition.
The intensive source of light was introduced into treatment methods in the 1990s and since then it has had a lot of applications. More and more sophisticated devices are being constantly implemented. They allow for performing more effective therapies and lessening side effects (14–17). Each impulse of light energy produced by the VPL device is a sequence of rapid micro-impulses, whose length, number and frequency can be set for an individual patient. It provides better absorption into selected skin layers and minimise at the same time the effect of heating the neighbouring tissues. The VPL technology was implemented so as to perform safe and effective therapies in patients with various phototypes and hair structure, where the risk of side effects is much smaller and the pain is less. The VPL technology is used to reduce unwanted hair (14,15), but some attempts have been made to use it for treating solar keratosis (16) or acne. The effectiveness of the application of the IPL technology in treating hyperpigmented changes (12,18,19) allows us to believe that the VPL technology will appear to be equally effective. Professional literature contains examples of studies which are based on the analysis of photographs or clinical evaluation of patients (19). Our study presents an objective evaluation of the degree of pigmentation measured with a mexameter and the patients’ subjective opinions on the applied therapy. There are a lot of methods for treating skin hyperpigmentation, but none of them is effective in all patients. Thus, specialists are constantly seeking new therapeutic options. Mixed-type hyperpigmentation are more difficult to treat. Skin hyperpigmentation easily becomes more intensive when they are affected by irritating factors. The IPL device might also contribute to slight hyperpigmentation, especially if it is not equipped with a cooling system (20). We cannot rule out that three patients, in whom previous skin changes became even more intensive, were affected by external factors which caused the exacerbation of their disorders. The patients did not take oral hormonal contraceptives or use hormonal replacement therapy. After the application of light generated by the IPL device, melanosomes in epidermal melasma quickly move to the surface of the skin, undergo desquamation and take a form of tiny crusts. As a result, the effect of lightening can be visible after the first procedure (21). Li et al. (21) studied patients with hyperpigmented changes, who were treated with the IPL technology. They observed better results in patients older than 45 and younger than 35 years of age. The authors explain this fact with a lower activity of mel-
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VPL treatment of hyperpigmentation anocytes in older women, especially in the postmenopausal period. On the other hand, in younger women concentration of melanin and melanosomes is lower. We did not observe any relationship between the age of the patients and the improvement in the skin condition, which corresponds to the observation made by Shin et al. (11) studying the general photorejuvenation effect. Similar to the study mentioned above, we did not note any relationship between the effect of the treatment and the duration of skin lesions. Sasaya et al. (22) used IPL device for the treatment of solar lentigines of the hands with good results. Also, in our study the effects of VPL treatment on hyperpigmentation in hands were satisfactory. In the patients, in whom the mexametric measurement values confirmed the highest intensity of hyperpigmentation, the therapy with the VPL technology appeared most effective. Good tolerance for treatment and no serious side effects allow considering the VPL method as a safe and well-tolerated therapeutic option. In comparison to lasers, this technology does not limit the patient’s life so considerably. The subjective level of satisfaction observed after the application of this state-ofthe-art technology is also very important. The obtained results allow us to say that the VPL method is an effective alternative in the treatment of hyperpigmentation. It is still debatable whether a combined therapy might contribute to a greater effectiveness of procedures applied in the treatment of hyperpigmentation disorders. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper. The paper was supported by grant No. 503/3-066-01/503-01 from the Medical University of Łódź, Poland. Acknowledgements None. References 1. Grimes PE. Melasma: etiologic and therapeutic considerations. Arch Dermatol. 1995;131:1453–1457. 2. Victor FC, Gelber J, Rao B. Melasma: a review. J Cutan Med Surg. 2004; 8:97–102. 3. Pandaya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin. 2000;18:91–98. 4. Kang HY, Ortonne JP. What should be considered in treatment of melasma. Ann Dermatol. 2010; 22:373–378. 5. Ghersetich I, Troiano M, Brazzini B, Arunachalam M, Lotti T. Melasma: treatment with 10% tretinoin peeling mask. J Cosmet Dermatol. 2010;9:117–121.
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6. Fitzpatrick RE, Goldman MP, Ruiz-Espraza J. Laser treatment of benign pigmented epidermal lesions using a 300 nanosecond pulse and 510-nm wavelength. J Dermatol Surg Oncol. 1993;18:341–347. 7. Kopera D, Hohenleutner U. Ruby laser treatment of melasma and postinflammatory hyperpigmentation. Dermatol Surg. 1995;21:994. 8. Taylor CR, Anderson RR. Ineffective treatment of refractory post inflammatory hyperpigmentation by Q switched ruby laser. J Dermatol Surg Oncol. 1994;20:592–597. 9. Arora P, Sarkar R, Garg VK, Arya LJ. Lasers for treatment of melasma and post-inflammatory hyperpigmentation. Cutan Aesthet Surg. 2012;5:93–103. 10. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulse radiation. Science. 1983;220:524–527. 11. Shin J-W, Lee D-H, Choi S-Y, Na J-I, Park K-C, Youn S.-W, Huh, C-H. Objective and non-invasive evaluation of photorejuvenation effect with intense pulsed light treatment in Asian skin. J Eur Acad Dermatol Venereol. 2011;25: 516–522. 12. Li YH, Chen JZ, Wei HC, Wu Y, Liu M, Xu YY, et al. Efficacy and safety of intense pulsed light in treatment of melasma in Chinese patients. Dermatol Surg. 2008;34: 693–700. 13. Xi Z, Shuxian, Y, Zhong L, Hui Q, Yan W, Huilin D, et al. Topical 5-aminolevulinic acid with intense pulsed light versus intense pulsed light for photodamage in Chinese patients. Dermatol Surg. 2011;37:31–40. 14. Holzer G, Nahavandi H, Neumann R, Knobler R. Photoepilation with variable pulsed light in non-facialbody areas: evaluation of efficacy and safety. J Eur Acad Dermatol Venereol 2010;24:518–523. 15. Nahavandi H, Neumann R, Holzer G, Knobler R. Evaluation of safety and efficacy of variable pulsed light in thetreatment of unwanted hair in 77 volunteers. J Eur Acad Dermatol Venereol. 2008;22:311–315. 16. Babilas P, Knobler R, Hummel S, Gottschaller C, Maisch T, Koller M, et al. Variable pulsed light is less painful than lightemitting diodes for topical photodynamic therapy of actinickeratosis: a prospective randomized controlled trial. Br J Dermatol. 2007;157:111–117. 17. Li YH, Wu Y, Chen JZ, Gao XH, Liu M, Shu CM, et al. Application of a new intense pulsed light device in the treatment of photoaging skin in Asian patients. Dermatol Surg. 2008;34:1459–1464. 18. Zaleski L, Fabi S, Goldman MP. Treatment of melasma and the use of intense pulsed light: a review. J Drugs Dermatol. 2012;11:1316–1320. 19. Zoccali G, Piccolo D, Allega P, Giuliani M. Melasma treated with intense pulsed light. Aesthetic Plast Surg. 2010;34: 486–493. 20. Negishi K, Kushikata N, Tezuka Y, Takeuchi K, Miyamoto E, Wakamatsu S. Study of the incidence and nature of ‘‘very subtle epidermal melasma’’ in relation to intense pulsed light treatment. Dermatol Surg. 2004;30: 881–886. 21. Yamashita T, Negishi K, Hariya T, Kunizawa N, Ikuta K, Yanai M, Wakamatsu S. Intense pulsed light therapy for superficial pigmented lesions evaluated by reflectance-mode confocal microscopy and optical coherence tomography. J Invest Dermatol. 2006;126:2281–2286. 22. Sasaya H, Kawada A, Wada T, Hirao A, Oiso N. Clinical effectiveness of intense pulsed light therapy for solar of the hands. Dermatol Ther. 2011;24:584–586.
