The concept of rejuvenation of aged and sun damaged skin is currently receiving considerable interest. There exists today a rapidly growing demand for safe, simple techniques for improving skin textures, colour, pore size, broken blood vessels and wrinkles. Until the recent introduction of Intense Pulsed Light (IPL™) the only available treatment techniques included chemical peeling, ablative and non-ablative resurfacing, dermabrasion and various visible light and near IR laser treatments. The term Skin Rejuvenation applies to any form of procedure that improves the texture and look of the skin, whereas Photorejuvenation means the use of a light-based therapy to induce these improvements.
Photo-damaged skin occurs as the result of excessive exposure to ultraviolet (UV) light, which induces epidermal and dermal changes. Skin affected in this way is characterised by thinning of the epidermis and dermis, coarse skin texture, wrinkling, telangiectasias and changes in pigmentation.
The overall appearance of photo-damaged or sun exposed skin relates to the resultant UV damage of structural components such as collagen and elastin fibres. Appearance, however, is also affected by genetic factors, intrinsic factors, disease process such as rosacea, and the overall loss of cutaneous elasticity associated with age. More people now have extended periods of sun exposure and, coupled with the thinning of the ozone layer and other factors, this has resulted in visible signs of ageing, damage and disease evident in ever-younger people. People in their twenties and thirties are now witnessing solar elastosis, telangiectasias, solar lentigines and rhytide formation.
Treatment for photo-damaged skin involves more than simply addressing wrinkles, which will produce limited results in one aspect only. Rather, treating each of the different components of photo-damaged skin will result in a more dramatic visible improvement.
Up until recently, the ‘in vogue’ techniques for reducing or eliminating facial rhytides or wrinkles included various topical agents such as glycolic acid, retinoids, ascorbic acid, a variety of chemical peeling agents, dermabrasion and laser skin resurfacing. Of these techniques the most effective methods for improving photo-damaged skin were invasive, which had major disadvantages of requiring a significant recovery period following procedures such as laser skin resurfacing.
The thermal effects on tissue are both time and temperature dependent.
As a result of the problems and risks associated with lasers, there has been great interest in the development of non-invasive and non-ablative methods to effectively improve the appearance of photodamaged skin, without the need for patient downtime. Recently, Nd:YAG lasers, pulsed dye lasers and electro-surgery have been used to treat selected conditions associated with ageing and sun exposure.
Evaluation of facial skin pigmentation prior to treatment is necessary if successful results are to be obtained. Pigment can be inherited ethnically or acquired, such as in melasma or Addison disease. A higher degree of normal pigmentation increases the risk of hyperpigmentation and hypopigmentation following treatment. Hormonal changes during pregnancy can also vary the amount of pigmentation. The Fitzpatrick Skin Type Classification is used to assess an individual’s skin type as follows:-
- Type I Always burn, never tan
- Type II Sometimes burn, then tan
- Type III Always tan, rarely burn, light Mediterranean
- Type IV Rarely burn, Dark Mediterranean, light Asian
- Type V Very rarely burn, Dark Asian
- Type VI Never burn, Afro-Caribbean
Photo rejuvenation is based on selectively transmitting light through the epidermis to the dermis for selective absorption by chromophores. Whilst the process has shown to be effective in white skin with minimal epidermal melanin, in dark skin with dense epidermal melanin, much of the light energy is absorbed by the epidermis thereby allowing only a small amount to pass through. To reduce this side effect, low energy is recommended for dark skin, however, this also results in low efficacy.
Sun damage treatment includes aspects of both pigmentation treatment and thread vein treatment but also includes fine lines and wrinkles. Exposure to UV light destroys skin cells thereby slowing down the growth of new skin and the production of collagen. Light energy in the wavelength range 500 to 550nm is known to have a stimulating effect on fibroblasts thereby increasing their production of collagen. The increase in blood flow to the region will also bring fresh supplies of oxygen and nutrients to the cells, which will assist in the removal of waste. By traumatising the epidermis and dermis the skin will be encouraged to go into ‘repair mode’ to reduce fine lines and wrinkles.
The client preparation begins with an initial consultation which is one of the most crucial aspects of any cosmetic procedure. A clear idea of each individual client’s expectations is assessed and a comprehensive educational consultation follows explaining what is realistically achievable. Occasionally photographs are used to illustrate achievable results. An abridged explanation of how the treatment works is then explained in an easy to understand format.
There are a number of questions that you may like to ask yourself / be asked at this stage:
- What do you expect the procedure to accomplish?
- In which way do you think the procedure will help you?
- Can you show the Practitioner what it is that bothers you?
- When do you expect the results to show?
- Do you know anyone who has undertaken the procedure?
- Have you seen this procedure advertised in magazines or newspaper articles?
The education process of the treatment ensures that the client is fully informed about how the treatment works and any possible side-effects. A comparison with other procedures is useful as this helps to alleviate any fears held by Clients.
It is of paramount importance that the individual client understands the procedure, achievable results, side effects and therefore may like to ask themselves the following questions
- Have you understood the information presented to you with regards to the treatment?
- Have you only absorbed certain parts of the information presented?
- Do you over-identify with a specific look?
- Are your concerns about minor blemishes reasonable?
- Are you prepared to undertake the treatments as a continuing maintenance program?
There are certain conditions which may exclude an individual from treatment.
- History of keloids (scarring)
- Oral acne medication in the last six months (Accutane)
- Photosensitivity in the last six months / history of light sensitive rashes
- Medication for which sunlight is a contraindication (See Drug Information)
- Kaposi’s Sarcoma (malignant lesions)
- Tanned Skin
- Malignant or suspicious tissues
- History of poor wound healing
- Tattoo over treatment area
- Under taking treatment involving blood thinning medication
The initial stage of the process is to assess and fill out forms detailing the client’s health and skin history. This will ensure that there are no underlying medical conditions which may exclude them from treatment.
The Practitioner must be shown the site where treatment is to be carried out. Any pre-existing scars, moles or pigmentary inconsistencies will be documented before testing or treating.
Good clinical photographs are taken, using a camera with a macro facility, in the same position and same lighting to ensure parity at the review stage of the treatment. The clinical photographs are kept with the client’s record and are taken to ensure that:
- Clinic has a record of any existing scars or pigmentary changes
- Clients have a visual record of the condition being treated prior to treatment
As clients see themselves every day there is a tendency to forget how the skin was initially, thus the photographs provide the opportunity to review a visual record of the area side by side at the end of the course of treatments.
The client should now understand the treatment and have realistic expectations. This is a key element to a successful treatment!
A review date must be set within the treatment regime to allow the clinic to meet with the client and review the results to ascertain how the treatment is progressing. At this stage any remedial action can be undertaken and amendments to the protocol can be made.
Treatment Test Patches
Test patches are recommended prior to all treatment sessions, but are essential when treating skin type II and above. The purpose of a test patch is to verify that permanent pigmentation changes will not take place and the client is not sensitive to the treatment. Clients must be aware that treatments carried out at higher energy fluencies may induce pigmentary changes.
A suitable area representing the area to eventually be treated is selected and the test patch carried out using a few shots at the recommended system settings and energy fluency. The area is observed visually.
The treatment area should be free from cosmetic make-up and all hair is removed from the treatment area to avoid burning or unwanted long-term hair removal.
Cooled gel is then applied to the area in order to provide the required optical coupling and to also maintain a ‘cool’ sensation on the skin being treated.
A sterilised applicator head is ‘hovered’ over the area to be treated so that it is barely touching the skin.
After firing the first treatment pulse the area treated is left for a short period and then checked for reddening, at this point the operator ensures that the Client is comfortable with the procedure and little or no discomfort is present.
Ideally, a small amount of reddening should be seen as this indicates successful treatment. If reddening is not evident then the energy setting can be raised. Once reddening is evident and provided the Client is feeling no discomfort, treatment can continue at this setting.
Treatment is conducted with each pulse overlapping the previous by about 1mm; for large areas a red (or white), water soluble marker (no other colour since they will absorb the light energy and heat up the skin) can be used to mark out sections.
What to Expect Following Treatment
The immediate after effect is that the treated area should become slightly red and occasionally there may be some swelling evident. Typically, this redness will disappear in a matter of a few hours at most (and often in just a few minutes) with the skin then returning to its normal colour.
It is important to follow any aftercare advice your practitioner may give you verbally or in writing to aid the healing process or to reduce the risks of infection or scarring occurring. If you have any concerns post treatment you should contact the clinic immediately for further advice.
Number of treatment sessions required
Generally, between four to six treatment sessions are required, although it depends upon the treatment type and the area being treated. Normally, these treatment sessions are carried out at three weekly intervals
Note: At the start of each subsequent treatment the same safety steps that are recommended for the first treatment are completed. To ensure that subsequent treatments produce favorable results, the Client must inform the Operator if any pigmentary changes have occurred. If so then these are assessed individually, but generally an increase in the amount of melanin in the skin would indicate that a lower energy should be used.
Immediately following the treatment session, or at regular intervals in the case of treatment of large areas, soothing gel is applied to the treated area. These gels or after care products have the effect of cooling the area and generally include antiseptic properties to protect the damaged skin against opportunistic infections. You may be advised to carry on cooling the area treated after you have left the clinic.
The client is advised to refrain from using cosmetic make-up, perfumed soaps and similar products for about 24 hours following treatment. Also, exposure to the sun should be avoided for about one month unless a high factor sun block is used as a precaution against exacerbating any pigmentary changes which may not be immediately evident.
Anything that may exacerbate the heat in the area may also slow down the healing process. Avoid hot baths, vigorous exercise etc. for 24 / 48 hours post treatment.
For vascular treatments it is of paramount importance not to rub or stimulate the area for 24 / 48 hrs after treatment.
If the area is over treated and small blisters, or crusting, is evident the client should take greater care and must not pick at these, as this may increase the risk of superficial scarring. Preparations which have good antiseptic properties should be used.