Freckles Removal Using Intense Pulsed Light in Chinese People

Case Report Freckles Removal Using Intense Pulsed Light in Chinese People October 2007 1

Freckles Removal Using Intense Pulsed Light in Chinese People Hangyan Shi, Meihua Wu, Sufan Wu Department of Plastic Surgery, Zhejiang Provincial People s Hospital, P.R.China ABSTRACT Background Freckles are a common skin disorder among the Chinese people. Patients may need to remove them for aesthetic purpose. Besides dermabrasion, chemical peeling and laser treatment, more effective approaches have been always searched for. Intensive pulse light (IPL) has been considered as a novel approach to treat freckles, which are less ablative, less timecostly, with less pain or minimal side effects. Objective To study the effectiveness and the proper parameters for the treatment of freckles in Chinese people using IPL. Methods Two hundred and fifty five patients with facial freckles were treated by an IPL system with a wavelength of 500 950 nm. The double-pulsed illumination was administered with a power density of 11.0~15.5 J/cm 2, a pulse width of 3.0~4.5 ms, a pulse duration of 30-50 ms. The results were evaluated independently by two attending physicians six months after sessions, according to the percentage of removed freckles. Results Among 225 patients, 93 cases (36.47%) were excellent, 126 cases (49.41%) were good, 29 cases (11.37%) were fair and 7 cases (2.75%) were poor. Conclusion IPL is an effective and safe method for removal of freckles in Chinese people. INTRODUCTION Freckles are common cutaneous disorder. They are flat tan or brown and black spots on the skin, which usually appear on the face and chest. Evidence shows that they are a result of mortality in combination with overexposure to the sunlight. In some areas of the world, people may take freckles as a cute sign. But in China, most people regard that beautiful skin is clean and white without freckles, they may need to remove the pigmented lesions for aesthetic purpose. Some methods were reported for treatment of freckles, including dermabrasion, chemical peeling, topical tretinoin and laser treatment using CO 2 laser or Q-switched 755nm and 532nm laser. Although these therapies do work, they need much recovery time and have such side effects as scarring, hyperpigmentation or hypo-pigmentation. So it is necessary to search a new method less ablative and time-costly, with less pain or minimal side effects, and high satisfaction. Intense pulsed light (IPL) systems are high intensity pulsed sources which emit polychromatic light in a broad wavelength spectrum. The mechanism of action of such light systems corresponds to the selective photothermolysis. As we know, when IPL is irradiated to the skin, the pigmented tissue may absorb more of the light energy whereas other normal tissues don t. So the temperature of the pigmented tissue may rise in a short period of time, to about 80 centigrade. So the freckles may be destroyed and got rid of. At the same time, the IPL systems cause no damage to the normal part of the skin. The research began in 2003, satisfactory results were achieved with few side-effects. It has become an effective method for the treatment of freckles. METHODS A total of 255 patients with freckles on the face were treated, aging from 16 to 58. Six were male and 249 were female. Skintypes are Fitzpatrick III-V, all without history of sunlight allergy. DEKA IPL system was adopted. Its wavelength is 500~950nm. The double-pulsed illumination was administered with a power 2

density of 11.0~15.5 J/cm 2, a pulse width of 3.0~4.5 ms and a pulse duration of 30~50 ms. Before treatment, the skin of face was thoroughly cleaned with cleanser. Cooled and transparent gel was applied to the area to be treated. The handpiece moved gently through the skin, delivering precise pulsed light. Skin cooling was recommended after treatment, in order to lessen the skin flush. The patients were asked to take 5 sessions, with an interval of four weeks. After treatment, sun protection is necessary. Sun block (SPF>30, PA+++) was recommended. No anesthesia was adopted during IPL treatment. Some patients complained of the feeling of burn while the pulsed light was irradiated to the skin. Immediately after treatment, skin flush or erythema could be observed in the treated area, which lessened in several hours or one day. On the next day, the freckles darkened and formed thin crusting, which usually detached from skin within one week. Then the freckles could be seen significantly bleached. RESULTS Six months after the five-session treatments, the results of the treatments were evaluated independently by two attending physicians according to the following criteria: Excellent: over 80% freckles disappear, and the result lasts for more than 6 months. Good: over 60% freckles disappear, and the result lasts for more than 6 months. Fair: over 40% freckles disappear, and the result lasts for more than 6 months. Poor: over 40% freckles remain, or the result lasts less than 6 months. The results of this study were that: 36.47% excellent (93 in 255); 49.41% good (126 in 255); 11.37% fair (29 in 255) and 2.75% poor (7 in 255). No blistering, scarring or hypopigmentation has been observed. Hyperpigmentation is rare. DISCUSSION Freckles are a result of inheritance in combination with skin over-exposure to sunlight. 1,2,3 Freckles may darken or increase in sum and size when people get aging or are exposed to more sunlight. Most of the Chinese people regard that the freckles are unhandsome that need to be treated. Traditionally, dermabrasion, chemical peeling, 4 topical tretinoin, 5 and laser treatment using CO 2 laser 6 or Q-switched 755nm 7 and 532nm laser 8 were adopted to remove freckles. But to Chinese people whose skin types are Fitzpatrick III~V, these ablative and invasive therapies have risks of inflammation, hyperpigmentation and even scarring. It is reasonable that the nonablative method would be suitable for the patients with a type of Fitzpatrick III~V. According to the mechanism of IPL, it is a kind of nonablative treatment for skin pigmentation. When a precise light is delivered to the skin, the pigmented tissue may absorb more of the light energy whereas other normal tissues don t. So the temperature of the pigmented tissue may rise in a short period of time, to about 80 centigrade, 9,10 which brought about selective pigmented tissue injury without epidermal damage. Then the freckles may be destroyed and got rid of. At the same time, the IPL causes no damage to the normal part of the skin. Intense pulsed light (IPL) systems are high intensity pulsed sources which emit polychromatic light in a broad wavelength spectrum of 500~1200 nm. 11 As we know, the using of visible light (400~800 nm) is the main power for treatment of skin pigmentation. On the other hand, when a light affects on the tissue, the longer the wavelength is, the deeper the light penetrates into tissue. For the treatment of the superficial pigmentation such as freckles, the light with a wavelength longer than 900 nm will have no effectiveness but possible to damage the deeper normal tissue. The DEKA IPL system chosen in this study emits noncoherent light with a wavelength of 500~950nm, which is an important advantage that differs from the traditional IPL ranging from 500~1200 nm. The infrared part of light ranging from 950 to 1200nm was filtered in DEKA IPL system. Compared with traditional IPL, the 500~950nm IPL caused less pain and flush during treatment. 12,13 3

During the treatments, double-pulsed IPL irradiation was adopted, with the power density of 11.0~15.5 J/cm 2, power width of 3.0~4.5ms, power duration of 30~50ms. In patients with darker skin (Fitzpatrick IV~V), we adopted lower power densities (11.0~14.0 J/cm 2 ), longer pulse widths (3.5~4.5 ms) and longer pulse durations (40~50ms). In patients with brighter skin (Fitzpatrick III~IV), we adopt higher power densities (13.0~15.5 J/cm 2 ), shorter pulse widths (3.0~4.0 ms) and shorter pulse durations (30~40 ms). As sessions go on, freckles diminish and the power density and pulse duration were adjusted to the new circumstance. We found that the most significant improvement was usually achieved during the first one or two sessions. This maybe caused by the great difference between the freckles and the normal skin at the time of the beginning of the treatment. Goldberg D reported the observation of new collagen formation in dermis after IPL treatment. 14 It was also found that in many patients, the IPL can also improve the skin texture, make it smoother and have the effect of skin rejuvenation. Also, we observed that much of the hair on cheeks or around lips was removed at the same time. IPL is efficient to the removal of freckles. It is almost painless, and costs no recovery time, but it still has its limits. Due to the large handpiece and strong light, the freckles on the eyelid and elbow were difficult to be treated, where the QS755 nm laser could be used as an alternative. The handpiece can be easily administered in flat areas such as the cheeks and the forehead, but not so easy around the nose. The bleached freckles may darken a little compared with the skin immediately after sessions even the patient underwent strict sun protection. Stratigos AJ reported that cholasma can be improved by many ways of treatment but often recur. 15 In the patients complicated with cholasma, although we adopted low-fluenced IPL, and there were no blistering or significant crusting or sunexposure, the pigmentation sometimes recur or even worsened. Then the treatment was abandoned. IPL is an efficient method to remove the freckles for the Chinese people. It is necessary to take a longer follow-up. If possible, the pathology changes need to be researched. REFERENCES 1.Rees J. Genes for freckles. J Invest Dermatol. 2004;123(2):414. 2. Zhang XJ, He PP, Liang YH, et al. A gene for freckles maps to chromosome 4q32-q34. J Invest Dermatol.2004; 122(2):286-290. 3. Bataille V, Snieder H, MacGregor AJ, et al. Genetics of risk factors for melanoma: an adult twin study of nevi and freckles. J Natl Cancer Inst. 2000;92(6):457-463. 4. Cotellessa C, Peris K, Onorati MT,et al. The use of chemical peelings in the treatment of different cutaneous hyperpigmentations. Dermatol Surg..1999; 25(6):450-454. 5. Samuel M, Brooke RC, Hollis S, Griffiths CE. Interventions for photodamaged skin. Cochrane Database Syst Rev.2005; (1):CD001782. 6.Ozbayrak S, Dumlu A, Ercalik-Yalcinkaya S. Treatment of melanin-pigmented gingiva and oral mucosa by CO 2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2000; 90(1):14-15. 7. Jang KA, Chung EC, Choi JH, et al. Successsful removal of freckles in Asian skin with a Q-switched alexandrite laser. Dermatol Surg. 2000;26(3):231-4. 8. Rashid T, Hussain I, Haider M, Haroon TS. Laser therapy of freckles and lentigines with quasi-continuous, frequency-doubled, Nd:YAG (532 nm) laser in Fitzpatrick skin type IV: a 24-month follow-up. J Cosmet Laser Ther.2002; 4(3-4):81-85. 9. Anderson RR, Parrish RR. Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220:524-527. 10. Goldman MP, Eckhouse S. Photothermal sclerosis of leg veins. Dermatol Surg. 1996;22:323-330. 11. Raulin C, Greve C. IPL technology: a review. Lasers Surg Med. 2003;32:78-81. 12. Huang YL, Liao YL, Lee SH, Hong HS. Intense pulsed light for the treatment of facial freckles in Asian skin. Dermatol Surg.2002; 28(11):1007-1012. 13. Wang CC, Hui CY, Sue YM, et al. Intense pulsed light for the treatment of refractory melasma in Asian persons. Dermatol Surg. 2004;30(9):1196-1200. 14. Goldberg D. New collagen formation after dermal remodeling with an intense pulsed light source. J Cut Laser Ther 2000;2:58-61. 15. Stratigos AJ, Katsambas AD. Optimal management of recalcitrant disorders of hyperpigmentation in darkskinned patients. Am J Clin Dermatol. 2004;5(3):161-8. 4

Fig. 1A Fig. 1B Figure 1 An 18-year-old female with freckles was treated with IPL and obtained an excellent result. 1A Before treatment. 1B After 2 sessions, the freckles were significantly removed. 1C After 4 sessions, most of the freckles were removed. Fig. 1C 5

Fig. 2A Fig. 2B Figure 2 A 27-year-old male with freckles was treated with IPL and obtained an excellent result. 2A - Before treatment. 2B - After 2 sessions, the freckles were significantly removed. 2C - Nine months after the last session, freckles did not recur. Fig. 2C 6