Keywords
Intense pulsed lightLaserPhotorejuvenationPhotodamagePhotoagingHyperpigmentationSun exposureIPLCO2 Laser resurfacingRhytidsPigmentationSun damageSkin rejuvenationSkin typeSunburn19.1 Normal Skin Aging and Skin Type
Normal skin begins to show signs of aging at around 30–35 years old, even in people who have little previous sun exposure. Aging skin becomes more fragile and hair follicles, sweat glands, and sebaceous glands begin to shrink. These changes result in a reduced sebum production and drier skin (Habif 2016). During normal aging, subcutaneous fat is decreased, the epidermis thins , and fine wrinkles begin to appear. However, this process is accelerated with sun exposure and this exposure promotes photodamage. Photodamage leads to pigmentary and texture changes and loss of resilience in the skin (Habif 2016).
Fitzpatrick sun reactive skin typesa
Skin color—unexposed skin | Sunburn | Tan |
|---|---|---|
White: Type I | Yes | No |
Type II | Yes | Minimal |
Type III | Yes | Yes |
Type IV | No | Yes |
Brown: Type V | No | Yes |
Black: Type VI | No | Yes |
Erythema and tanning reactions type to first exposure in summera
Type I | Always burn, never tan |
Type II | Usually burn, tan less than average (with difficulty) |
Type III | Sometimes mild burn, tan about average |
Type IV | Rarely burn, tan more than average (easily) |
Sun avoidance is the most efficient way to decrease the amount of sun exposure and skin damage from harmful UV radiation. Sunscreen applied to exposed areas several times a day while outside is vital to prevent skin changes and skin cancers. Physical sun blocks such as ultraviolet protection factor (UPF) clothing, hats, and sunglasses can provide greater protection than sunscreen lotions (Kullavanijaya and Lim 2005). Clothing might be more convenient and better utilized because there is no re-application required. In addition, long sleeved UVP tops and swimming suits are believed to be less harmful than chemical sunscreens to the environment, delicate ocean coral reefs, and marine life (Kullavanijaya and Lim 2005; Raffa et al. 2019).
19.2 Photodamage
Ultraviolet light is responsible for most visible skin changes and skin cancer formation. The unit measure of light wavelength is the nanometer (nm). The wavelengths of sunlight that reach the Earth are from 290 nm to 400 nm. The UV light is divided into UVA, UVB, and UVC (Habif 2016). The UVA wavelength is considered long wave and is between 320 and 400 nm. The UVB wavelength is considered medium wave and is between 290 and 320 nm. The UVC wavelength is considered short wave and is between 100 and 290 nm; however, this wavelength is almost completely absorbed by the ozone layer (Habif 2016; Kullavanijaya and Lim 2005).
UVA radiation is constant throughout the day and year and its levels remain stable. The longer wavelengths of UVA penetrate deeply and can reach the dermis and subcutaneous fat levels of the skin (Habif 2016). About 50% of the radiation from UVA penetrates the skin in the absence of direct sunlight, i.e., in the shade (Schaefer et al. 1998). This explains why patients occasionally report darkening of their skin but insist they have been in the shade. Also, UVA rays penetrate glass windows and car windshields so these clear barriers do not offer any protection from UVA. Furthermore, UVA are the specific UV rays that cause dermal photoreactions to medications and products (Habif 2016).
UVA and UVB rays work synergistically to produce changes in the skin that can lead to skin cancer (Habif 2016; Addison 2016). The shorter wavelengths of UVB radiation produce more harmful effects than UVA and UVB is worse in the summer months (Habif 2016). In addition, UVB rays are more intense during the hours of 10:00 AM and 2:00 PM (Habif 2016).
The skin responds to UVB radiation with erythema, sunburn, suntan, inflammation, and pigmentary changes (Habif 2016; Quevedo et al. 1975). It is important to realize that snow, water, and sand reflect UVB radiation and many outdoor activities expose the skin to these harmful rays (Habif 2016). In addition, sunbeds that supply UVA and UVB through artificial sunlight cause three times as many deoxyribonucleic acid (DNA) photoproducts that lead to DNA mutation than natural light, and this increases the risk of skin cancer (Barnard et al. 2018).
Chronic ultraviolet (UV) light exposure results in photodamage and thinning of epidermal and dermal layers (Habif 2016). Additional characteristic skin changes from UV exposure include the formation of pigmented lesions and telangiectasia, changes in skin texture, and epidermal malignancies (Habif 2016; Bitter 2000). The visible signs of photodamage include chronic redness, freckles, lentigines, wrinkles, and formation of yellow papules called solar elastosis (Habif 2016).
19.3 Intense Pulsed Light (IPL)
Electromagnetic spectrum illustration showing visible spectrum location. Note the shorter wavelengths toward the ultraviolet (UV) spectrum and the longer wavelengths toward the infra-red (IR) spectrum. Shorter wavelengths of UV cause damage to human skin. Source: Spectre InfraRed.svg
The IPL uses a process called selective photothermolysis where energy is absorbed by molecules, known as chromophores, in the skin and tissue (Kullavanijaya and Lim 2005; Friedmann and Goldman 2016; Hare 2013). Chromophores absorb the energy from the ILP and those cells are destroyed or altered (Kullavanijaya and Lim 2005). Common chromophores in human skin are hemoglobin, water, and melanin (Hare 2013). As an example, energy from the IPL is absorbed by the melanin in a lentigo , but because there are fewer or absent chromophores in the surrounding skin, the lentigo is affected and the surrounding skin is spared (Lin et al. 1998; Parrish et al. 1983).
Common uses for IPL are to decrease erythema from rosacea and to lighten pigmented lesions from sun exposure. Because of selective photothermolysis technology, melanocytes and blood vessels in the skin are affected but the surrounding tissue is not, and the outcome is a more even skin tone (Parrish et al. 1983; Anderson and Parrish 1983).
Example of an intense pulsed light device (IPL) . Photo: Beth Haney, DNP, FNP-C, FAANP
Longer wavelength filters can decrease light absorption by epidermal melanin. Unfortunately, these filters are not always able to prevent shorter wavelengths from leaking through and being absorbed by the skin. This leakage can cause excessive temperatures in the skin that can lead to burns (Ciocon et al. 2009; Augustyniak and Rotsztejn 2017; Li et al. 2016). For this reason, careful patient selection, skin type assessment, and a spot test in the treatment area prior to embarking on the entire procedure is essential (Li et al. 2016; Thaysen-Petersen et al. 2017).
The IPL treatment is effective in treating vascular and pigment concerns associated with photoaging and, with repeated sessions, can improve skin texture through collagen stimulation (Bitter 2000; Ciocon et al. 2009; Li et al. 2016; Ping et al. 2016). Careful skin evaluation and typing is essential to provide safe and effective IPL treatments. There is an increased risk of adverse outcomes such as hyperpigmentation, crusts, blisters, and scars in darker skinned patients because of increased light (heat) absorption by melanin (Ciocon et al. 2009; Thaysen-Petersen et al. 2017). Higher cutoff filters, i.e., 690 nm, allow the emission of longer wavelengths, which reduce light absorption by melanin and provide safer treatment for darker skin types. Alternatively, patients with light skin can tolerate higher energy levels and shorter wavelengths, i.e., 560 nm (Ciocon et al. 2009; Augustyniak and Rotsztejn 2017; Ping et al. 2016).
It is not recommended to provide IPL treatments to patients with a suntan because the amount of melanin is increased in sun exposed skin, and therefore, treatment could result in burns (Addison 2016). Moreover, patients who continue to expose their skin to the UV radiation of the sun further the photoaging process. Patients who are interested in IPL treatment for photodamage should make the commitment to protect their skin from UV radiation.
IPL treatment uses short pulses of light to deliver heat energy into the skin. During treatment, the IPL raises the temperature of the skin and stimulates renewal of the epidermis and production of collagen (Bitter 2000; Ciocon et al. 2009; Augustyniak and Rotsztejn 2017; Ping et al. 2016). Eye protection for the patient and the practitioner is required due to the intense brightness of the flash during treatment. A clear gel is applied to clean skin prior to treatment to help keep the skin cool and protected. Colored gel is not recommended because the light energy could be absorbed by the color and lead to epidermal injury.
The IPL procedure is not an entirely pleasant one. Throughout the IPL treatment, the patient will experience sudden and warm snaps, and unexpected, simultaneous bright flashes during each pulse. Because of the startling nature of IPL treatment, the patient should be informed of this sensation beforehand. In addition, pain from the IPL procedure should be addressed. Pain tolerance of each individual can vary and the level of discomfort during IPL treatment can range from slight discomfort to moderate pain. Topical anesthetic may be used before treatment to enhance patient comfort although it is not always necessary.
When treatment is complete, the gel is removed, and sunscreen is applied if there is a chance of sun exposure. The patient should be given post-treatment instructions that include (1) sun avoidance tips, (2) skin cleansing and moisturizing instructions, (3), sunscreen instructions, (4) possible skin responses, (5) topical product instructions/recommendations, (6) follow-up instructions, and other pertinent information.
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