Photoaging Training Manual

Transcription

1 PHOTOAGING TRAINING MANUAL Photoaging Training Manual USING ipulse INTENSE PULSED LIGHT PHOTOAGING & SKIN REJUVENATION: A STEP-BY-STEP TREATMENT PROTOCOL FOR AESTHETICIANS, BEAUTY THERAPISTS AND OTHER MEDICAL PROFESSIONALS PROVIDING COSMETIC TREATMENT Author: Godfrey Town, Director of Clinical Affairs For further information see or Customer support: +44-(0) general@cyden.co.uk Page 1 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

2 IMPORTANT ADVICE FOR THE USER: This Applications Manual provides guidance to assist in practical applications work with ipulse intense pulsed light. The information contained herein reflects state of the art technology in this field. The author will assume no liability for errors, which, despite adequate care and attention, cannot be ruled out entirely. The user alone bears full responsibility for actions performed in conjunction with this Manual. WARNING: This detailed applications training manual is intended for general guidance in the use of the ipulse intense pulsed light device for photoaging treatments and does not constitute A protocol produced by an expert medical or dental practitioner as required by the Healthcare Commission for registration of an establishment in England and Wales under the Care Standards Act 2000 and described in the Dept of Health: National Minimum Standards and Regulations. NOTICE: All information contained in this manual is supplied by Cyden Limited written in the English medium and Cyden Limited will not be responsible in anyway whatsoever for any alterations, additions, omissions or errors of any nature arising from any translation and/or any reproduction of all or any part or parts of the information contained in this manual from English to another language or medium, including any claim arising for negligence, damage, injury or loss. Page 2 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

3 TABLE OF CONTENTS GENERAL INTRODUCTION IPL TECHNOLOGY ADVANCES BEFORE YOU START USING IPL TRAINING ACCESSORIES UNDERSTANDING THE SKIN IN IPL SKIN REJUVENATION WAVELENGTH SPOT SIZE - PULSE DURATION TECHNOLOGY DIFFERENCES ENERGY REQUIRED FOR SUCCESSFUL SKIN TREATMENTS IDENTIFYING TREATABLE CONDITIONS WHAT YOU CAN & CAN T TREAT - PIGMENTATION COMPONENT VASCULAR COMPONENT WRINKLE COMPONENT ACNE PRE-TREATMENT DOCUMENTATION & ASSESSMENT CONTRAINDICATIONS PRE-TREATMENT ADVICE TO CLIENTS THE THERAPEUTIC WINDOW How to choose your parameters ipulse TREATMENT PROGRAMS TYPICAL ipulse TREATMENT PARAMETERS PIGMENTED COMPONENT TYPICAL ipulse TREATMENT PARAMETERS VASCULAR COMPONENT TYPICAL ipulse TREATMENT PARAMETERS WRINKLE COMPONENT TYPICAL ipulse TREATMENT PARAMETERS ACNE TEST AREAS TREATMENT ROOM SET UP CHECK LIST CLIENT PREPARATION CHECK LIST - USE OF IPL CHECK LIST - BEWARE IF - PIGMENTED COMPONENT - VASCULAR COMPONENT WRINKLE COMPONENT - PRACTICAL TIPS FOR SKIN REJUVENATION: Facial Areas Décolleté - Forearms AFTER USING IPL APPLICATOR - REMEMBER YOUR CLIENTS TREATMENT TIME INCLUDES: RECOGNITION OF TREATMENT RELATED PROBLEMS IMMEDIATE POST-TREATMENT LATE EMERGING POST-TREATMENT CARE ADVERSE INCIDENT PROCEDURE What to do if anything goes wrong RISK ASSESSMENT ADVERSE INCIDENT REPORTING PROCEDURE IN THE EVENT OF EQUIPMENT FAILURE Page 3 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

4 GENERAL INTRODUCTION Since the introduction of non-invasive laser and IPL treatments for skin rejuvenation experience has shown that almost all skin types including European, Indian, East- Asian and Middle-Eastern, respond at least to some degree to treatment. Demand has increased dramatically around the world from women and men for skin rejuvenation with varying cultural influences including traditional factors, fashion, sport, personal feelings of well being and health requirements. Invasive procedures such as ablative laser resurfacing, surgical dermabrasion and powerful acid peels have been used successfully to restore aging skin. These methods remain as last resort options particularly for elderly clients where minimally invasive treatments are inadequate. IPL TECHNOLOGY ADVANCES - ipulse There are two key limitations to conventional IPL devices, an inability to produce a true long pulse matched to the thermal relaxation time of the target structure and secondly, fluctuations in the output spectrum which can lead to ineffective treatment with increased risk of side-effects. An alternative approach to producing long pulse, constant spectrum optical pulses along is found in the ipulse technology employed by CyDen. This novel IPL technology emits a wavelength range of between 530 and 1100nm and incorporates shorter, more efficient wavelengths for skin rejuvenation without the need for cut-off filters. This is achieved by having a uniform temporal profile. Figure 1 below shows a representation of the energy output from a traditional IPL and an improved, true long pulse model. As can be seen, in the traditional IPL, the output consists of a short, high intensity spike that gradually increases from zero to maximum intensity and decays back to zero. To construct an overall pulse duration in the order of the thermal relaxation time of the target structure, a series of pulses are required. In the case of the improved ipulse technology, the pulse shape is uniform, increasing from zero to maximum intensity almost instantaneously, remaining at maximum for the entire duration of the pulse then dropping to zero again instantaneously. The overall duration of the pulse is fully variable up to and beyond the thermal relaxation time of the target. The ability to produce true long pulses can reduce the amount of energy required to achieve the necessary temperature profile within the target and accurately control the thermal profile within the skin. This recent advance in IPL technology has resulted in a significant reduction of the cost, making square pulse, constant spectrum IPL more available to the therapist wishing to practice IPL skin rejuvenation techniques. Page 4 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

5 PHOTOAGING TRAINING MANUAL Illustration: Showing temporal profile of energy output of a traditional and ipulse square pulse IPL Control over the energy discharge through the Xenon lamp also results in a constant spectral output across the 530 nm 1200 nm produced by the new ipulse technology. Thus no treatment energy is wasted using square pulse technology and the constant distribution of light ensures a comfortable treatment for the client. Description: Time-resolved spectral measurements of a free discharge IPL (Chromolite, Chromogenex Ltd., Llanelli, UK) compared with a Square Pulse pulse discharge profile of a constant current IPL (ipulse, Cyden Ltd. Swansea, UK). The two measurements show differences in spatial and temporal characteristics of the two types of IPL, confirmed by the spectral jitter seen in the short plasma phase of the free discharge IPL during which most of the light energy is released in an invariable 3-4 ms compared with the constant spectral output spread evenly across the entire pulse of the partial discharge IPL with a variable range of pulse durations ms. [Courtesy of: Ash C, Town G and Bjerring P. Relevance of the structure of time-resolved spectral output to light-tissue interaction using intense pulsed light (IPL). Lasers in Surg Med 2008; Vol 40:2: ] Page 5 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

6 Published studies in international peer-reviewed journals confirm that ipulse constant spectrum IPL embodies the latest advances in light technology for efficient pulse structure, safety and its suitability for all skin types. References: Clement M, Daniel G & Trelles MA. Optimising the design of a broad-band light source for the treatment of skin. Journal of Cosmetic and Laser Therapy. 2005; 7: Omi T and Clement M. The Use of a Constant Spectrum, Uniform Temporal Profile Intense Pulsed Light Source for Long Term Hair Removal. Journal of Cosmetic and Laser Therapy 2006; 8: Town GA, Ash C, Eadie E, Moseley H. Measuring key parameters of intense pulsed light (IPL) devices: J Cosmetic Laser Therapy 2007; 9:3: Ancona D, Stuve R and Trelles MA. A multi-centre trial of the epilation efficacy of a new large spot size, constant spectrum emission IPL device. Journal of Cosmetic and Laser Therapy 2007; 9: Ash C, Town G and Bjerring P. Relevance of the structure of time-resolved spectral output to lighttissue interaction using intense pulsed light (IPL). Lasers in Surg Med 2008; Vol 40:2: Vedamurthy M and Town G. Use of Intense Pulsed Light (IPL) in Skin Types IV and V: An Indian Experience. Australasian Journal of Cosmetic Surgery 2008; Vol 4:1: FDA CLEARANCE 510k K ipulse intense pulsed light is indicated for use in Dermatological and Plastic Surgery applications and specifically for long term stable, or permanent, hair reduction. In addition, ipulse is indicated for the treatment of benign cutaneous vascular lesions and the treatment of benign pigmented lesions. ipulse is indicated for the treatment of mild to moderate inflammatory Acne Vulgaris. (Latest FDA updated clearance 10th March 2008) Page 6 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

7 BEFORE YOU START USING ipulse IPL TRAINING Whilst the technology has proved its efficacy in skin rejuvenation through numerous clinical trials, at present there is little formal training of operators (whether in the beauty or healthcare sector) so results have often been variable. Therefore, training is a key factor in achieving successful treatment outcomes. As a minimum, all operators should receive basic training in light therapy theory and safe use of laser / IPL devices. No two devices are identical in the way they deliver light energy so it is vital to obtain user training by the supplier. (Contact your CyDen distributor for training opportunities) ACCESSORIES An IPL treatment room must be fully equipped with all necessary accessories to ensure successful and efficient treatments. In particular, this will include adequate provision of skin cooling by use of refrigerated cooling gel packs, skin air-cooling, etc. For optimal diagnosis before treatment, operators are encouraged to use advanced skin analysis techniques including detailed evaluation of melanin, erythema (redness) hydration and lipid levels as well as skin evaluation methods such as skin scanners and photo records. (See separate treatment room set-up information) ChromoTest skin melain / erythema measuring device Page 7 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

8 UNDERSTANDING THE SKIN IN IPL SKIN REJUVENATION Skin rejuvenation using ipulse light therapy consists primarily of creating sufficient heat in the red or brown sun-damaged structures of the skin to reduce their appearance or eliminate them completely. This is achieved by light absorption in the melanin of the mottled pigmentation and the oxyhaemoglobin in the fine blood vessels of general redness or broken capillaries. The light, which isn t reflected off the skin s surface (a), scatters beneath the skin s surface, (b) is then absorbed in the melanin and blood. The melanin is coagulated by the absorbed heat energy and in blood vessels the heat absorbed by the blood is conducted to the delicate vessel walls (vascular endothelium), whose cells are damaged by the heat causing the vessel to collapse or completely coagulate. WAVELENGTH PHOTOAGING TRAINING MANUAL Illustration: Example standardised spectral distribution of a typical xenon lamp IPL (ipulse, Cyden Ltd) measured in 20 nm bandwidths as a percentage of the total energy beneath the graph curve. Absorption curves for oxyhaemoglobin (red) melanin (black) and water (blue) have been overlaid to reference optimal absorption characteristics. Page 8 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

9 IPL devices produce mostly visible broad-band wavelengths of light. Potentially harmful, short wave UV light is filtered out by the lamp itself and hardly any longwave infra-red light is produced by a Xenon lamp. The remaining wavelengths between 500 nm and 1000 nm are all well absorbed by melanin and blood, so are suitable for skin rejuvenation. As light scatters as it enters the skin, the longer wavelengths of this broadband light penetrate more deeply into the skin to reach deeper located structures. The shorter wavelengths of light, which scatter more readily, are better absorbed in epidermal melanin and shallower vessels. PHOTOAGING TRAINING MANUAL SPOT SIZE The larger the spot size, the deeper the penetration into skin and the less that energy is lost at the edge of the treatment area. Unlike traditional IPL devices, the ipulse uses twin flash lamps to produce a large, rectangular spot size on skin of 8.9cm 2 which ensures that light energy penetrates deeper into tissue to reach the deeper-lying vessels and pigment. PULSE DURATION Generally, the pulse of IPL light used will be longer for larger structures like hair and telangiectasia (broken capillaries) and shorter for epidermal pigment. NB. By comparison, choosing long pulses of light for hair removal, the operator will avoid collateral damage to epidermal melanin as the tiny particles of melanin in the skin have time to lose absorbed heat during a long pulse (compared with, say, a much larger hair follicle structure which will hold its heat longer). In skin rejuvenation, the process of selecting the blood structures to damage with the correct pulse length is called selective photothermolysis and depends upon the fact that smaller bodies (e.g. epidermal melanin) lose heat faster than larger bodies (e.g. hair follicle) owing to the relative surface area of melanin particles losing heat faster. With melanin the process is thought to be non-specific thermal coagulation of melanin since the melanin particles are so tiny that the theory of selective photothermolysis does not readily apply. Thus, great care must be taken to avoid over-treatment side effects. TECHNOLOGY DIFFERENCES Some traditional IPL suppliers use coloured glass filters in the applicator to reduce epidermal absorption side effects. By using latest square pulse and constant spectral output technology multiple applicators may not be required and effective treatments can be performed more simply with a single, user-changeable flash lamp. Page 9 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

10 ENERGY REQUIRED FOR SUCCESSFUL SKIN REJUVENATION There are several factors that determine choice of energy level. The overall objective is to find the optimal therapeutic window where energy is sufficient to damage the blood vessels and/or the melanin in the skin blemish but avoid collateral damage to surrounding tissue and consequential undesired side effects. Normally, the skin will only feel warm temporarily after treatment and any redness will disappear within minutes or a few hours. Darker skin (including active suntan or spray-tan) reduces the amount of possible energy that can be used before side effects appear. This will vary from person to person and body area to body area. The constant spectral output of the ipulse IPL means that the ipulse produces the lowest possible intensity for a given energy density (fluence) thus minimising discomfort and other side effects such as redness, pain and skin burns. Page 10 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

11 IDENTIFYING TREATABLE CONDITIONS WHAT IS PHOTOAGING? Cutaneous aging is a complex biological process consisting of two independent components: (a) intrinsic aging or "biological clock" aging, which affects skin by slow irreversible tissue degeneration; and (b) extrinsic aging, or "photoaging", the result of exposure to outdoor elements, primarily ultraviolet (UV) irradiation. As a result of these processes, major aging changes are seen in the extracellular matrix components of the dermis, i.e., the collagen meshwork and the elastic fibre system. As part of intrinsic aging, reduced rate of synthesis of collagen and elastin, can explain the noticeable thinning and visible loss of elasticity of the skin in the elderly. At the same time as the collagen matrix deteriorates and the skin becomes rough and wrinkled, pigmentation changes, telangiectasias (thread veins) and sometimes, actinic keratoses and epidermal malignancies occur. Photoaged skin is characterised by rough skin texture, mottled pigmentation, telangiectasia, mild to moderate rhytides (wrinkles), enlarged pores, acne scarring and skin laxity. The exact mix of these elements will depend upon age, sex and ethnic background e.g. Asians predominantly exhibit pigmented dischromia whilst many Caucasians have telangiectasia as the primary component of photoaging. Therefore, a treatment modality is required that provides several differently targeted treatments to deal with all of the presenting elements of photoaging. More aggressive device settings will result in more downtime for the client and more side effects such as erythema, oedema (swelling), bruising and crusting of pigmented lesions whilst less aggressive treatments with less downtime will mean more treatments. The treatment of superficial epidermal pigmented lesions is undertaken with the IPL as the first treatment step. Reduction of pigmented blemishes in the epidermis will allow deeper penetration of IPL at subsequent treatments using settings for vascular lesions and collagen stimulation. These treatment settings (typically used 4-6 weeks apart) will also have a favourable effect on any acne lesions by stimulating the body s natural porphyrins, positively treat any infected hair follicles (PFB) and stimulate collagen neo-genesis. The end result over several months should deliver improved structural integrity resulting in enhanced skin texture and pore size, better skin hydration and elasticity and improved skin translucence. Reduction in the appearance of fine lines and wrinkles in the skin has been reported widely using IPL devices as part of a comprehensive treatment regime. When using IPL with Caucasian skin (Fitzpatrick I-IIIa), it probably matters very little which specific condition is targeted first as broadband light contains wavelengths that will impact to some degree both pigmented and vascular anomalies in the skin. For example, Caucasian skin with a high content of fine broken capillaries ( mm in diameter) can be treated immediately for the vascular anomalies with some immediate collateral effect on mottled pigmentation. Page 11 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

12 GENERAL RECOMMENDATIONS Every client seeking skin rejuvenation treatment must undertake a programme of skin care recommended by their therapist which will include as a minimum prerequisite, elimination of active tan through regular use of SPF 30+ sunscreen and routine use of skin cleansers and hydrating creams and lotions as well as fruit acid peels or other skin treatments such as microdermabrasion. Whilst specific macro vascular and pigmented conditions like poikiloderma of Civatte, spider nevi, large telangiectasia, venus lakes, etc are often the result of age and sun damage, they should be treated separately before undertaking a general treatment program of skin rejuvenation. If a clearly identifiable medical condition is observed (such as a eczema, rosacae, port wine stain birthmark, suspicious mole, nevus spilus, sebborheic dermatitis, warts, etc) these should be referred to a dermatologist first for diagnosis and treatment. Raised benign melanocytic lesions such as naevi, pigmented skin tags, Seborrheic keratosis, Favre-Racouchot (solar comedones), etc, can only be removed by ablation or thermal coagulation and NOT using any IPL. Examples of raised lesions that can t be treated easily with ipulse or any IPL: Benign mole (later removed by an ablative laser): Photo by courtesy of Dr S. McCoy, Adelaide Page 12 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

13 Sebborheic keratosis: raised lesions removed using an ablative laser Clinical Photography by Courtesy of Dr S. McCoy Pigmented lesion The most difficult clients to treat are those with Fitzpatrick skin type I who have a long history of sun exposure. In these patients, connective tissue is so fragile that IPL parameters selected e.g. for optimal relief of redness, may damage the skin, with higher incidence of bruising, swelling and blistering. In such cases, low energy settings must be used in early treatments until the supporting dermal connective tissue is strengthened and the redness is reduced. A standard five-treatment program is usually extended in this patient group. Very dark skin types, particularly Afro- Caribbean, are also problematic because of high levels of melanin in the epidermis absorbing light energy in competition with the melanin in the targeted pigmentation or blood in any broken capillaries. Darker Asian skin on the other hand, occurs largely in regions of the world with intense sunlight and features a naturally higher level of epidermal melanin and treatment has to be modified to take these characteristics into account. In any event, a patient has to present without any active suntan and be following a strict routine of using sunscreens and other skin care products professionally recommended for them for a minimum of two to four weeks before IPL treatment commences. If the patient isn t going to adopt good skin care practices, the outcome of treatment will be compromised and short-lived at best, therefore, an effective consultation process is of paramount importance. Page 13 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

14 PIGMENTATION COMPONENT mottled pigmentation (freckles, sun spots, etc) The treatment of superficial epidermal pigmented lesions is undertaken with ipulse as the first treatment step. Reduction of pigmented blemishes in the epidermis will allow deeper penetration of ipulse energy at subsequent treatments using settings for vascular lesions and collagen stimulation. Forearm epidermal pigmentation treated with ipulse, before and after a single treatment at one week and eight weeks. (Clinical photos by courtesy of USA Photonics) Most successful IPL treatments of mottled blemishes are of epidermal pigmentation. However, combined treatments with topical anti-oxidants, polyphenols, hydroquinone or other pigment lightening creams or peels are often necessary for good results. In published literature, the evidence of success in post-inflammatory pigmented lesions with a deeper pigment component (in the papillary layer of the dermis and usually caused by chemical or physical trauma) is either anecdotal or on single or small-number case studies. Recurrence in 4-6 months is also common. Topical treatments used together with ipulse include: bleaching agents such as hydroquinone, topical tretinoin and azeleic acid or chemical peels such as TCA, glycolic acid and Jessner s solution. Q-switched ruby and Nd:YAG lasers have also been reported in the literature as achieving moderately good results although with an increased incidence of post-inflammatory hyper-pigmentation. Only with proper diagnosis (or a great deal of diagnostic experience and skill) can a user determine how much superficial epidermal pigment there is in a lesion and how much is the more difficult dermal pigmentation. The optimal successful endpoint of IPL pigment treatment is peri-lesional erythema (redness around the treated blemish) and/or some darkening of the pigmented area within 20 minutes. This is followed by Page 14 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

15 further darkening over hours and exfoliation of the darkened areas over the next 7-21 days leaving lightly hypopigmented areas which even-out to normal skin colour during subsequent weeks. High-factor protective sunscreens, use of a parasol / sun shade and the wearing of hats and gloves (walking, driving and gardening) are a must to protect the sensitive new skin. Close-op photography showing before, immediately after and 7 days after ipulse treatment for facial pigmentation. (Clinical photography courtesy of Dr. Jesus Valdez, Mexico). Age spots, before and after treatment Generally good clearance of superficial epidermal pigmentation in most skin types (1-5) including freckles (ephelides) and age spots (solar and s e n i l e l e n t i g o s ) i s achieved using ipulse. If there is high contrast between underlying skin colour and the pigmented blemish the treatment u s u a l l y r e s u l t s i n immediate darkening of the pigment with further darkening over the next hrs. If there is poor contrast between the pigmented blemish (eg age spots) and normal skin, the pigment may not fully coagulate and only lighten over the following days. This means that high contrast blemishes may only require 1-2 treatments to resolve satisfactorily while low contrast blemishes may require 3-6 treatments. These coagulated epidermal blemishes usually sloughoff (peel) in normal washing in 7-21 days depending on age, sex and skin condition of the patient. Normally the underlying skin appears pink or hypopigmented but the normal even skin colour returns over subsequent weeks. Do not to pick at crusts to avoid scarring. Remember: It is important to protect the new skin from sun-exposure with sunscreen or gloves until the even normal skin colour returns. Page 15 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

16 PRESSURE TECHNIQUE The skin surface may be pre-cooled by using clear ultrasound gel (at 4 C from the refrigerator). The use of cooling gel also assists in keeping the glass transmission block surface cool. A number of recently published clinical studies confirm that a pressure technique (i.e. pressing the glass transmission block firmly on the skin surface through the cooling gel) when treating epidermal pigmented blemishes will improve treatment results by compressing capillaries to express blood and thereby removing competitive absorption of light energy by oxyhaemoglobin and concentrate all the light energy absorption in the pigment target. (Intense pulsed light source for treatment of small melanocytic nevi and solar lentigines, Bjerring P, Christiansen K. Journal of Cutaneous Laser Therapy 2000; 2: & Q-Switched Ruby Versus Long-Pulsed Dye Laser Delivered With Compression for Treatment of Facial Lentigines in Asians, Kono T, Manstein D, Chan HH, Nozaki M and Anderson R. Lasers Surg Med 2006; 38:94-97) The logic of this technique is easily demonstrated by applying thumbpressure to the skin for a second and removing it, leaving a blanched thumb-print for a brief period before the peripheral blood supply returns the skin colour to its normal mixture of melanin and blood. PIGMENTATION IN DARKER SKIN TYPES Illustration: Female, skin type V treated 3 times with ipulse for epidermal pigmentation. (Clinical photography courtesy of Dr. M. Vedamurthy, Chennai). Since IPL devices with wavelengths in the nm range are often successful in treating superficial epidermal pigment in Fitzpatrick Skin Types I-IIIa, it is usually assumed that similar results are not achievable with darker skin phototypes. However, Types IIIb, IV and V are more problematic as the increased level of naturally occurring epidermal melanin competes with the pigmented lesion (typically seborrheic keratoses, sun and age spots), which may lead to either no improvement or increased risk of hyper- or even hypo-pigmentation. Page 16 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

17 The therapeutic window for successful ipulse treatment of darker skin types will, by definition, always be small and must be established carefully with test areas and steadily increased fluence to avoid hyper-pigmentation. However, good results in treating epidermal pigmentation in Indian and East-Asian skin types using ipulse have been achieved. MELASMA One of the commonly presenting cases for IPL and laser treatment amongst darker skin types is for melasma. It is nine times more common in females than males and includes dermal hyperpigmentation, epidermal hyperpigmentation and mixed variants. Typically, melasma presents as light to dark brown symmetrical hyperpigmentation of the central face and cheeks but it may also occur just on the bridge of nose, forehead or upper lip. Modest improvement in melasma following ipulse treatment. Photo courtesy of Dr. M. Vedamurthy, Chennai, India. The precise cause of melasma is unknown. Melasma is often common within the same family and a change in hormonal status may trigger melasma. It is frequently associated with pregnancy (also known as chloasma or mask of pregnancy ). Birth control pills may also cause melasma, however, hormone replacement therapy used after menopause has not been shown to cause the condition. Melasma is not associated with any internal diseases or organ malfunction. Sunscreens are essential in the treatment of melasma. They should be broad spectrum, protecting against both UVA and UVB rays from the sun. A SPF 30+ or higher should be selected. If epidermal and mixed variants of melasma hyper-pigmentation are present in the skin, it is likely that at least transient improvement (i.e. lightening) will be achieved with ipulse treatment of the more superficial pigmentation but it is unclear whether there is a lasting effect on the dermal component of the melasma. Page 17 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

18 The successful endpoint of ipulse treatment of melasma may not include any immediate colour change in such deeper-located pigment but only mild to moderate erythema at the margins of the pigmented lesions. Lightening may then occur over the succeeding weeks. High-factor protective sunscreens, using a parasole and wearing of hats or gloves (when driving or gardening) are a must to protect the sensitive treated skin areas. Multiple treatments (6-8) are usually required. Improvement in melasma in Indian and Asian skin types using intense pulsed light has been reported but results can vary from good clearance to only a modest lightening of the melasma. It is therefore important to record good before and after photographs as clients often forget their appearance before ipulse treatment. Moderate improvement in melasma following ipulse treatment. Clinical photography courtesy of Dr. M. Vedamurthy, Chennai, India. POST INFLAMMATORY HYPERPIGMENTATION / CAFÉ AU LAIT MACULES A n e x a m p l e o f p o s t - i n f l a m m a t o r y hyperpigmentation with pigment at variable depths in the epidermis As discussed in the literature, pigmented blemishes with a deep epidermal or dermal component will be difficult to treat with any IPL. Even powerful and deeply penetrating wavelength lasers have had mixed results with this type of lesion. As these blemishes contain pigment at varying depths and concentrations, it is difficult for any operator to determine pigment location. Even the use of magnification, cross-polarised light and/or a Woods Lamp (UV diagnostic lamp) does not give a complete picture of pigment location. Page 18 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

19 All IPL manufacturers have the same problem with pigmentation with a deep dermal component or where the condition is recurring anyway (eg. Melasma and café au Lait macules). NEVUS OF OTA / NEVUS OF ITO Examples of a café au Lait blemish and a nevus of Ito. It is not recommended to attempt to treat either of these greyish or blue-brown patches with any IPL. SIDE EFFECTS IN DARKER SKIN TYPES Care must be taken to exclude clients with active sun tan (it is a good idea to start new subjects with a two-week course of sunscreen before ipulse treatment to reduce risk of side effects on the face) and to test-patch carefully to avoid side effects. Hyper-pigemtation is the most common side-effect and is caused by over-treatment (too much energy), insufficient skin cooling, active suntan when treated or as a reaction to undetected / un-declared photo-sensitivity due to drug or herbal remedy use by the client (eg. St John s Wort). Hyper-pigmentation is usually transient and resolves over subsequent weeks but can last several months. The use of sunscreen, moisturisers and skin lightening creams will assist resolution of hyper-pigmentation following ipulse treatment. Illustration: Severe hyper-pigmentation following ipulse treatment caused by unintentional sun exposure. Clinical photography courtesy of Dr Maya Vedamurthy, Chennai, India Page 19 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

20 VASCULAR COMPONENT - General redness, telangiectasia (thread veins) Whilst less prevalent in darker skin types, the natural colour of all skin includes a vascular component and it is important when using ipulse skin rejuvenation technology to recognise that only vascular abnormalities in a certain range respond to IPL treatment. Very large arborising vessels (greater than 1 mm) cannot be treated successfully at all by IPL and require either sclerosing or treatment with a deeply penetrating Nd:YAG laser. Very fine vessels (smaller than 0.1 mm diameter) are generally not cleared completely by IPL and require the use of a wavelength-specific laser such as the pulsed dye or KTP laser. Vessel size is notoriously difficult for the therapist to determine (even with a transparent mm ruler, skin scanner, magnification or a Woods Lamp) and the haemoglobin target itself is moving as the blood flows along the vessels. The most likely range of vessel sizes for effective treatment with IPL is 0.1 mm mm. Facial thread veins / broken capillaries (Photo by courtesy of Dr S. McCoy, Adelaide) General redness (erythema) Examples of conditions that could be treated successfully with ipulse Good results after one treatment in skin types Fitzpatrick I-III treating diffuse redness (such as acne rosacae) or telangiectatic matting of fine vessels with ipulse can be achieved. Small cherry angiomas (Campbell de Morgan spots) may also respond well to ipulse treatment. There have been several IPL studies showing efficacy in the treatment of Class I and II Portwine stain birthmarks. Typically, higher fluences and multi-pulsing ipulse settings are used to achieve vessel attenuation whilst allowing the epidermis to cool during inter-pulse delay times. Significant pre- and post-cooling of the skin is necessary. Page 20 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

21 WRINKLE COMPONENT - MILD & MODERATE RHYTIDES The fine lines found at the periphery of laughter lines may be improved but underlying muscles determine skin folds and large wrinkles. Frown lines will not respond to IPL treatment alone. Illustration: Before and after skin rejuvenation + botulinum toxin-right eye area-female (Clinical photos courtesy of Dr Jesus. Valdez, Mexico) Illustration: Before and after 5 ipulse treatments only every 2 weeks, showing shortening of peri-orbital wrinkles (Clinical photos courtesy of Dr Jesus. Valdez, Mexico). It is generally accepted that collagen stimulation following light-based therapy such as ipulse results from damage to the micro-vasculature and the resultant release of inflammatory and cytokine mediators leading to collagen neogenesis. It has also been suggested that there may be some direct stimulation of certain cytochromes in the fibroblasts of the mitochondria to increase collagen production. In any event, increased collagen production in the skin leading to the improvement in the appearance of fine lines and wrinkles takes weeks and months to develop and clients must be prepared to see only a subtle improvement at best. Laughter lines Page 21 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

22 and frown lines are unlikely to show significant improvement as they are largely due to the underlying musculature and nose/cheek folds and Marionette lines are only likely to respond to ablative laser resurfacing techniques or the use of injectable collagen-based or hyaluronic acid fillers and/or Botox. The results of ipulse technology in the treatment of photoaging are most noticeable in the early improvement of pigmented and vascular dischromia but later emerging subtle enhancements in skin tone and texture resulting in enhancements of the appearance of fine lines and wrinkles are an important component in the overall treatment. Acne scarring, which becomes more pronounced in the older patient as the face starts to sag from the effects of gravity and sun damage, will also respond to ipulse treatment. However, at best the improvement will be modest and acne patients expectations must be carefully managed. ACNE COMPONENT PHOTOAGING TRAINING MANUAL Illustration: Before and after 4 ipulse treatments only. (Clinical photography courtesy of Dr Maya Vedamurthy, Chennai, India) Page 22 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

23 Whilst mild to moderate inflammatory acne is defined as a medical condition, clients often present with the side effects of acne seeking skin rejuvenation treatment. It has been shown that broad-band intense pulsed light can relieve many of the symptoms of this type of acne and help in its management to avoid subsequent acne scarring. Early inflammatory acne outbreaks are characterised by the pilosebaceous duct becoming infected by Propionibacterium. These bacteria are capable of spontaneously producing high concentrations of porphyrins, which are complex lightsensitive compounds that are normally used in the body as a component of hemoglobin. They can absorb energy from light and transfer this energy to surrounding oxygen molecules and toxic oxygen species such as singlet oxygen and free radicals are thus formed. These chemicals are very reactive and can destroy the acne bacteria. The improvement of acne in individuals after exposure to sunlight is explained by the photosensitivity of the P. acnes bacterium. Clinical research has established the photosensitivity of protoporphyrin. The absorption characteristics for protoporphyrin IX (PpIX) include significant absorption peaks at 508 nm, 542 nm, 577 nm and 635 nm (the Q-band ) and several of these are covered by the high-energy output of broad-band light ( nm) and are sufficient to stimulate a beneficial response. Early case study reports of IPL + 5-ALA PDT increases efficacy and reduces number of treatments required. As it has been reported that longer laser wavelengths (630nm, 670nm, 810nm) have also been successful in the treatment of acne, it is reasonable to assume that the m o r e d e e p l y p e n e t r a t i n g l o n g e r wavelengths of broadband light also achieve greater penetration depth to include reaching acne bacteria in the pilosebaceous duct. With ipulse, appropriate long single or triple pulses ensure delivery of sufficient l i g h t e n e r g y t o p r o v i d e o p t i m u m effectiveness in stimulating the body s own immune system response to fight the bacteria. Typically 5-6 treatments 1-2 weeks apart are required and ipulse treatment of acne should be considered an additional acne management tool that will reduce excessive use of antibiotics. Acne and post-acne pigmentation in darker skin types may also be treated successfully using ipulse. PHOTODYNAMIC THERAPY PHOTOAGING TRAINING MANUAL Q-band wavelengths (508 nm, 542 nm, 577 nm and 635 nm) alone stimulate natural body porphyrins (PpIX). Page 23 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

24 PHOTOAGING TRAINING MANUAL 20% 5 amino-levulinic acid (5-ALA) stimulates fluorescence (Dusa Levulan Kerasticks) artificially. Methyl aminolevulinate also gives similar results (Photocure Metvix) 1% non-occluded liposome-encapsulated 5-ALA also shows similar results (Ellipse Intense PhotoSpray) but with lower post-treatment toxicity. Illustration: Acne before and 13 months after a single IPL+PDT treatment (Clinical photos courtesy of Dr D. Fleming, Brisbane) Further reading on acne treated with laser and IPL: C. Dierikx reported clinically significant facial acne vulgaris clearance without side effects in a twenty patient study at 3 and 6 months post-treatment evaluated by pre- and post-treatment blinded assessors using an IPL device. Lasers in Surgery and Medicine, ASLMS Abstracts 24th Annual Meeting, March 21st April 4th C. Erdmann et al reported effective treatment (average 72% clearance after 8 treatments in a 4 consecutive weeks period) for mild to moderate facial or dorsal Grade II-IV acne using a nm broadband IPL device using optical fluences of 3-10J/cm2 and a 35ms pulse. Lasers in Surgery and Medicine, ASLMS Abstracts 24th Annual Meeting, March 21st April 4th Page 24 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

25 R. Rox Anderson et al reported moderate improvement in acne in an eleven patient study with a moderate decrease in sebum measurements for at least one month post-treatment using a 532nm laser. Lasers in Medical Science Abstracts, Joint International Laser Conference, September 2003, Edinburgh, Scotland. Vol 18, Supplement B. Zelickson and J. Counters reported on clinically significant acne reduction using an ALA photosensitizer both with and without illumination from an incoherent light source. Lasers in Surgery and Medicine, ASLMS Abstracts 24 th Annual Meeting, March 21 st April 4 th PRE-TREATMENT DOCUMENTATION & ASSESSMENT Provide the client with written information about the treatment. [See separate client information brochure] Discuss and complete a full client history in private explaining as fully as possible about the treatment and noting any special circumstances applicable to the client. Ask the client about each contraindication individually and mark each one with the client s reply. If the client answers yes to any of the listed contraindications, document in full on the consent form. Act on the directions listed for that condition. i.e. ask the client to obtain a doctor s letter on that medical condition in relation to light-based therapy. [See separate Typical Client Consultation Form] All questions about the client must be answered in full. PHOTOAGING TRAINING MANUAL Carefully record reaction to sun exposure (Fitzpatrick Scale), record eye colour and ethnic origin to confirm skin type. If uncertain, treat as for the next darker skin type. Consider performing a full skin analysis using appropriate skin evaluation tools (Wood s Lamp, skin analysers for hydration, lipid level, erythema and melanin). Number of Treatments TYPICALLY, SKIN REJUVENATION REQUIRES AT LEAST SIX TO EIGHT CLIENT TREATMENTS AT 4 6 WEEK INTERVALS. Page 25 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

26 Normally, after a significant improvement in skin dischromia (vascular and pigmented blemishes) improvements in skin texture which are much more subtle take many weeks to develop fully. Answer any questions the client has regarding treatment and make sure the client has REALISTIC EXPECTATIONS of the outcome of the treatment. Ask the client to read, sign and date the General Medical History Questionnaire and Consent to Treatment Form if he/she has understood its contents. Counter-sign and date the Consent to Treatment Form and give the client a copy if requested. If the client is suitable for treatment continue with evaluation of test areas to establish predicted treatment parameters. A test area must be performed on or as near as possible to the area to be treated at least 3 to 7 days prior to any course of treatment (Skin types IV and V should be tested at least 2 weeks prior to treatment). CONTRAINDICATIONS Do not treat anyone who has known or reported the following unless a letter from the Client s GP is available confirming that the medical condition(s) will not prevent treatment using intense pulsed light: PHOTOAGING TRAINING MANUAL tanned skin (active tan) through sun exposure or tanning bed use in the previous 30 days (because of increased risk of hyper pigmentation) waxing, plucking, sugaring or threading depilation treatment of the area in the previous week (because the skin will be sensitive from these treatments) moles should not be treated (protect by covering with a white plaster) hypo pigmentation (e.g. Vitiligo) any inflammatory skin condition e.g. eczema, active Herpes Simplex, etc. at the treatment site (because it may aggravate the condition) skin cancer or any other cancer and / or who reports he/she is undertaking any cancer drug therapy (such as Ducabaxine, Flurouracil, Methotrexate, etc.) a history of keloid scarring (because any IPL burn may produce a keloid scar) epilepsy (because repeated consecutive flashes may induce a fit) using St. John s Wort (herbal remedy) in the past 3 months for depression (owing to photosensitivity) who has used Isotretinoin Roaccutane or Tretinoin Retin A in the previous 3 6 months for the treatment of acne or other dermatological conditions who is pregnant; until periods return and end of breast feeding (because hormonal imbalance may reduce treatment effectiveness) who takes drugs for diabetes (owing to possible photosensitivity and poor wound healing) taking anti-coagulant drugs (e.g. for heart disease) wearing a pacemaker unless the IPL or pacemaker manufacturer confirms in writing that it is safe to treat the client wearing the pacemaker taking any topical medication (e.g. hydrocortisone) or is wearing perfumes, deodorants, sun block, essential oils or other skin lotions (which could cause photosensitivity) Page 26 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

27 surgical metal pins or plates under the tissue to be treated to be under 18 years of age if the establishment is not registered to treat children or if parental permission is withheld. A doctor s letter should be obtained before treating clients who are reportedly using Quinidine, any anti-psychotic medication or large combinations of cardiac / diuretic drugs, topical steroid creams in the area to be treated, general anaesthesia in the last 3 months, local anaesthetic treated areas in the past month or where you are uncertain about any reported medical condition or medication. Treat with caution and obtain a doctor s letter if you are uncertain about anyone who has fake tan, suffers with allergies, has hormone abnormalities, has cold sores in the treatment area, has had previous skin rejuvenation treatments or has reported HIV or Hepatitis. [See separate Information on Drug-Induced Photosensitivity in the User Manual] PRE-TREATMENT ADVICE TO CLIENTS Clients should be instructed in pre-treatment skin care and should be provided with written take-home instructions recommending: Don t expose skin to UV (sun exposure or the use of tanning beds) or self tan for at least 4 weeks before and/or between IPL treatments, don t depilate with waxing, plucking or threading (shaving or depilatory creams are acceptable) immediately before IPL treatment of the area, don t use bleaching creams, or perfumed products (e.g. aromatherapy oils) for hrs before treatment sessions, avoid swimming in strong chlorinated water immediately before an ipulse treatment session, avoid exfoliating, microdermabrasion or peels for 1 week before treatment sessions, keep the area clean and dry, hydrate the body by drinking plenty of water and protect the skin from sun exposure with suitable clothing and use of sun block SPF 30+ before first treatment and between subsequent treatment sessions but do NOT use sun blocking creams within 24hrs of scheduled treatments. Treatment programs will often include a preliminary 2-4 weeks course of fruit-acid peels or microdermabrasion as well as sun protection, vitamin / moisturising and/or skin lightening creams depending on the degree of skin damage. NB. Hot and humid weather conditions can aggravate skin in the period immediately before treatment. Page 27 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

28 THE THERAPEUTIC WINDOW How to choose your parameters This is determined by the therapist following a sequence of steps: PHOTOAGING TRAINING MANUAL 1. Exclude all unsuitable subjects due to age, recent surgery, pregnancy / breastfeeding, pre-existing medical conditions (e.g. skin disorders, cancer, severe heart disease, etc), contra-indicated drug or homeopathic / herbal therapy, recent active sun exposure (suntan), unsuitable recent depilation treatments, [See separate photosensitive drug lists, clinical protocol, etc.) 2. Determine underlying skin type of the client (Fitzpatrick Scale) AND the skin type in the area to be treated. This can be assessed by use of different methods including simple evaluation against a chart, questionnaires with a numerical scale, skin diagnostic devices which measure melanin and skin redness (skin reflectance spectrometers), etc. [See separate examples] A subject s general Fitzpatrick Skin Type is assessed on a body area not normally exposed to the sun as well as the subject s ethnicity and tanning habits. The area to be treated may appear different from the underlying skin type due to sun damage, age or specific local skin tone and must be taken into account. 3. IPL manufacturers usually provide a list of treatment program options which allow the operator to select a suitable skin rejuvenation program according to Fitzpatrick Skin Type [See your ipulse User Manual] 4. Undertake test areas at several increasing energy density levels until a suitable starting energy level is determined. [See separate sheet client preparation ] 5. The starting energy is that which will produce a heat response in the skin which feels hot or like a prickle to the client but is tolerable. In addition, there may be some development of redness (erythema) in or around the treated area within a few minutes. If there is a strong histamine-like reaction with swelling and general raw redness around the area, this is the first sign of over-treatment. NB. Thin skin areas over bone (e.g. jaw, décolleté) will not tolerate such high energy levels as thick or fatty areas. For this reason the available treatment energies in the programs offered include lower fluence values to accommodate such cases and other types of treatment. THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BE CONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHES IS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY Page 28 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

29 ipulse TREATMENT PROGRAMS Professional Mode PHOTOAGING TRAINING MANUAL The ipulse Treatment Programs Chart provides a range of 16 available pulse lengths and energy levels to suit individual client needs. Five programs are reserved for alternative applications. COLUMN ONE lists the sixteen possible treatment programs including those programs suitable for pigmented blemishes by skin type i.e. Light Skin Types 1 3a are programs 2, 3, 4 and 5 and Dark Skin Types 3b 5 are programs 10, 11, 12 and 16 and for vascular treatments i.e. Light Skin Types 1 3 programs 5, 6, 7 and 8. The program number corresponds to the fixed pulse length and pulse type (single pulse or triple pulse). COLUMN TWO gives the fixed length of the pulse (or pulses) and the range of energy settings which can be selected (in 0.5 J/cm 2 increments). As stated in the NB above, the available range of energy settings includes low values for exceptional cases. Typically, starting energies for hair removal will be 14 J/cm 2 or higher. COLUMN THREE simply illustrates the pulse type (single or triple) against a millisecond scale but not the range of energy available. Page 29 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

30 ipulse TYPICAL TREATMENT PARAMETERS - PIGMENTED COMPONENT This is the FIRST target of skin rejuvenation as epidermal pigment will at least partially block the penetration of deeper penetrating light energy intended to treat the vascular component, stimulate collagen production or to tackle acne bacteria in the deeper lying sebaceous ducts. Light Skin Light Skin Types 1 3 Pigmented Blemishes Single Pulse Programs 3 and 4 Multiple Pulse Program 10 Available Treatment Energy 4 to 20 J/cm 2 Typical Treatment Energy J/cm 2 Clinical data has shown that for lighter skin types (Fitzpatrick 1 to 3) single pulses of 20 to 25 ms (Program 3 and 4) with energy ranges of 14 to 17 J/cm 2 and multiple pulses (Program 10) with an energy range of 14 to 17 J/cm 2 have proven to be effective to treat mottled pigmentation. Fitzpatrick P i g m e n t Program J/cm 2 skin type colour 1 Light Medium Dark Light Medium Dark a Light a Medium a Dark b Light b Medium b Dark PHOTOAGING TRAINING MANUAL Page 30 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

31 Dark Skin Dark Skin Types 3b, 4 & 5 Pigmented Blemishes Multiple Pulse Programs 10, 11, 12 and 15 Available Treatment Energy 6 to 20 J/cm 2 Typical Treatment Energy 12 to 17 J/cm 2 Darker skin can react to light treatment by hyper- or hypo-pigmenting so it is best treated with a longer pulse width (time span) to spread out the energy and make the treatment safer and more comfortable. This means using a multi-pulsing program. Fitzpatrick P i g m e n t Program J/cm 2 Skin Type colour 3b Dark a Light a Medium a Dark b Light b Medium b Dark Light Medium Dark n/a n/a n/a The modified and additional values suggested in the above table for darker skin types is based upon clinical experience on Indian skin types (Fitzpatrick 5 & 6) by Dr. Maya Vedamurthy in Chennai, India in a study including 138 patients of skin types 5 & 6 treated for hair removal, pigmented lesions and acne. Darker skin can react to light treatment by hyper- or hypo-pigmenting so it is best treated with a longer pulse width (time span) to spread out the energy and make the treatment safer and more comfortable. This means using a long single pulse or a multi-pulsing program. THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BE CONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHES IS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY Page 31 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

32 ipulse TREATMENT PARAMETERS VASCULAR COMPONENT After any superficial pigmented dischromia has been treated and removed or reduced, vascular elements can be more easily reached by deeper penetrating wavelengths of light. Vascular dischromia and vascular blemishes are common in lighter skin types (Fitzpatrick 1 3) and are much less common in darker skin. When treating vascular abnormalities with IPL, the skin colour is more important than the vessel size (which is notoriously difficult to determine anyway). Darker skin can react to light treatment by hyper- or hypo-pigmenting so it is best treated with a longer pulse duration [time span] to spread out the energy and make the treatment safer. This means using a longer pulse or multi-pulsing if available. Multi-pulsing programs have the added advantage of also having gaps between the pulses allowing a cooling time for the epidermis. The total amount of energy delivered should remain pretty much the same. Light Skin Light Skin Types 1 to 3 Vascular Blemishes Single Pulse Programs 4, 5 and 6 Available Treatment Energy 4 to 20 J/cm 2 Typical Treatment Energy 16 to 18 J/cm 2 Fitzpatrick Blood vessel Program J/cm 2 skin type size 1 Thin Medium Thick Thin Medium Thick Thin Medium Thick THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BE CONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHES IS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY Page 32 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

33 Dark Skin A smaller range of suggested parameters is given for vascular blemishes in darker skin as they are much less common. Dark Skin Type 4 - Vascular Blemishes Multiple Pulse Program 16 Available Treatment Energy 8 to 20 J/cm 2 Typical Treatment Energy 16 to 18 J/cm 2 Fitzpatrick Blood vessel Program J/cm 2 skin type size 4 Thin Medium Thick n/a n/a 16 n/a n/a n/a n/a Note: When treating vascular abnormalities with ipulse, the skin colour is more important than the vessel size (which is notoriously difficult to determine anyway). Darker skin can react to light treatment by hyper- or hypo-pigmenting so it is best treated with a longer pulse width [time span] to spread out the energy and make the treatment safer. This means using a higher number program in the single shot section or go to multi-pulsing. The multi-pulsing programs have the added advantage of also having gaps between the pulses allowing a cooling time for the epidermis. The total amount of energy delivered remains pretty much the same. THE PARAMETERS CONTAINED IN THESE TABLES ARE TO BE CONSIDERED AS GUIDELINES ONLY. THE USE OF TEST PATCHES IS STRONGLY ADVISED AS PATIENT-TO-PATIENT VARIATION MAY Page 33 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

34 TYPICAL ipulse TREATMENT PARAMETERS SKIN REJUVENATION PHOTOAGING TRAINING MANUAL Normally, treatments will follow in sequence: pigmented, then vascular elements. In so doing, the process of collagen stimulation for wrinkle reduction will already be underway. When treating clients for skin texture improvement only, it is only necessary to repeat treatments using the same settings as for fine blood vessel (i.e. vascular) treatments. Skin rejuvenation including reduced pigmentary dischromia and wrinkles showing a subtle improvement post-treatment TYPICAL IPL TREATMENT PARAMETERS ACNE IPL treatment of acne is intended as an acne management option to allow relief from continued use of anti-biotics or where Isotretinoin therapy is contra-indicated. The broadband light produced by ipulse includes light energy at all four peaks of absorption by protoporphyrin 9 (PpIX) in the so-called Q-band of wavelengths. IPL does not cure acne but assists the production of natural porphyrins to fight the acne bacteria by producing singlet oxygen which destroys the bacteria in situ. Unlike blue light acne therapy where wavelengths used only penetrate the uppermost layers of the skin, the longer wavelengths of ipulse will penetrate to the sebaceous duct and sebaceous gland where the bacteria propagates. The treatment of acne is similar for most skin types. The objective is to deliver only moderate energy over a long pulse (or multiple pulses for very dark skin) to stimulate protoporphyrin 9 production in the skin. Skin types 1-3 Program 9, Energy density: J/cm 2 Skin types 4-5 Program 9 or 15, Energy density: 8-10 J/cm 2 Skin types 6 Program 14, Energy density: 7-8 J/cm 2 Note: If acne is inflamed and sensitive, use a lower fluence. Usually 5-8 treatments are required at 2-3 week intervals to provide relief from mild to moderate inflammatory acne. Page 34 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

35 TEST AREAS Test areas are required and are described in detail in the following section in order to establish the best starting IPL energy level and to reduce the risk of unwanted side effects from over-treatment. It is normal for the client to experience at least a sensation of warmth or heat during each IPL shot or a ping like the flick of a rubber band on the skin. It is recommended that test-areas be evaluated on or near the treatment site using the lowest recommended fluence for the skin type, increasing the fluence if necessary until the client feels a ping, heat or mild discomfort (according to the individual s pain tolerance). Assess the immediate response and record the treatment parameters in the client record. If in any doubt, do not perform a treatment. When performing the first test area on a new client you have only 1-3 chances to establish the energy level. For larger areas such as facial areas, décolleté, forearms, etc, it is easy to establish a test area. However, for small areas such as specific pigmented blemishes, spider nevi, etc, only one shot can be made. In that case, it should be the best estimated shot. On lighter skin (Types I/III), start with one shot at the lowest energy level predicted by skin type, then one shot 1 J/cm 2 above the lowest predicted energy level and lastly 2 J/cm 2 higher than the lowest predicted energy level to evaluate tissue response. Example: According to Typical Treatment Parameters for Pigmented Blemishes (section above) a Skin Type II client with a medium pigmented blemish would need Program 4 predicting a start energy of 14.0 J/cm 2 so, you choose energy levels: 14.0 J/cm 2, 15.0 J/cm 2 and 16.0 J/cm 2 for the test area. On darker skin (Types IV/V), start with one shot 0.5 J/cm 2 below the lowest energy level predicted by skin type, then one shot at the lowest predicted energy level and then one shot 0.5 J/cm 2 above the lowest predicted energy level to evaluate tissue response. Example: According to Typical Treatment Parameters for Vascular Blemishes (section above) a Skin Type IV client with fine blood vessel size would need Program 16 predicting a start energy of 16.0 J/cm 2 so, you choose energy levels: 15.5 J/cm 2, 16.0 J/cm 2 and 16.5 J/cm 2 for the test area. The choice to go higher with the second and third test shots will be based upon a number of factors including, whether the client experienced the sensation of a ping or heat, if the area in question is definitely not tanned and if you have treated the client previously and have experience with their skin response to treatment on other body areas. Page 35 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

36 The following points should also be observed when performing test areas: - To be carried out on all patients before a full treatment commences - The area to be treated needs to be clean, free of cosmetics and creams - The aim of test shots is to determine the most effective fluence settings for the patient skin type and size of area without causing any adverse reactions - Only a small area (3 or 4 shots in darker skin types, a few more in fair skinned patients) should be treated. If possible this should be in an area that is not too obvious but representative of the proposed treatment area - Usually 3 settings are required - Patient, operator and anyone else in the treatment room must wear appropriate IPL safety eye-wear before treatment commences - The applicator s contact crystal (light guide) must be held flat on the surface being treated with the contact crystal touching (but not compressing) the skin tissue - Test area treatment should be ceased immediately if side effects occur - Patients must be given clear instructions on post ipulse skin care, in particular sun avoidance and avoidance of injury to the skin. Details of the treatment performed including treatment area, ipulse type, program, pulse width, fluence and number of shots should be accurately recorded in the client s record. The entry should be signed, timed and dated. The ipulse treatment register (log book) must be completed recording treatment in the same way. With Skin Types I/III ask the client to return in 3-7 days for final evaluation and treatment. Skin Types IV/V should wait for 14 days to be sure of no late emerging side effects. ipulse TREATMENT ROOM SET-UP CHECK LIST PHOTOAGING TRAINING MANUAL 1. Make sure any required IPL hazard warning notices are in place at entrances. 2. Close window blinds and cover any mirror surfaces to reduce reflection hazard 3. Check fire extinguisher location (suitable for electrical fires). 4. Make sure all Local Rules, Treatment Protocols and client documentation is available for reference. 5. Check availability of all required supplies: couch roll, razors, gloves, tissues, refrigerated clear ultrasound gel, wooden spatulas, skin cooling gel packs, white marker pencils, wipes, post-treatment skin calming lotion (eg aloe vera), etc. 6. Close the entrance door to prevent unauthorized entry and to protect the privacy and dignity of the client by suitable means e.g. use towels during intimate area treatment, eye safety, etc. 7. Check ventilation (extractor fan, air conditioning, etc). [Contact your Laser Protection Advisor for further assistance on safety issues] Page 36 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

37 CLIENT PREPARATION CHECK LIST 1. Ensure all patient questionnaires (general medical history) and consent forms are completed and signed by the client and the operator. Consent Forms should ideally be signed each time before an IPL treatment. [See separate sheets] 2. Ask client to remove all jewellery, make up, deodorant, etc in the treatment area. 3. The area should be cleaned with water only; any creams may leave a residue, which could affect the efficiency of the treatment. 4. Mark the extent of the skin area to be treated with a white eye liner pencil. 5. In the area to be treated, white-out small lesions, moles, etc and cover any sensitive areas (tattoos, lips, etc) with cut-out adhesive white labels or white card to protect them from absorbing light energy. 6. Give the client and any assistant or observer present in the room suitable protective safety glasses (e.g. broadband shade 5). 7. Close-fitting reusable metal or disposable adhesive ocular shields should be placed over the eyes of the client if treating facial areas near to the eyes where safety glasses would allow light penetration under the rim. 8. Set up the IPL program and predicted energy setting (based on skin type, size of vessels, location of pigment, etc). 9. Cool the area with a cold pack if required (e.g. sensitive or dark skin). 10. Either dispense sufficient ultrasound gel into a small container or deposit blobs of clear ultrasound gel directly onto the skin from the dispenser bottle and using a clean wooden spatula, spread a layer of gel over the skin approximately 2 3 mm thick. The gel must be kept cold (but not frozen) in a fridge. 11. Do not overwork the gel on the skin, as it will heat up. Do not reuse the gel (infection risk) 12. The operator must wear suitable safety glasses during IPL treatment (e.g. broadband shade 3) and blink during the flash to limit light entering the operator s eyes and thereby improve visibility of the treatment area after the flash. The skin rejuvenation treatment sequence Use refrigerated cooling gel packs for sensitive or darker skin types Mark the skin with gridlines to assist with accurate placement of the contact crystal Dispense cooled gel and apply with a wooden spatula Apply a layer of gel 2-3 mm thick Page 37 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

38 USE OF ipulse APPLICATOR CHECK LIST: 1. Place the light guide (crystal) flat to the skin. 2. The light guide should NOT be pressed into the gel firmly but float just on the skin surface (to avoid compressing the fine blood vessels). 3. Treatment spots are placed directly next to one another with minimal overlap. 4. Make sure there are no gaps between the treatment spots. The light guide will leave a track or mark in the gel, which will help show where you have treated. Do NOT press the light guide firmly into the clear ultrasound gel, allow it to contact the skin only lightly. The light guide will still leave a footprint in the gel Cover any sensitive areas (tattoos, lips, etc) with cut-out adhesive white labels, white Fibrella cloth or a spatula to protect them from absorbing light energy. BEWARE IF: 1. The skin is treated without gel (more absorption in the epidermis on dry skin areas). 2. The light guide overlaps a previous treated area (over-treatment risk). 3. The light guide treats skin with hair (may permanently remove hair), over tattoos or tanned skin (over-treatment risk). 4. The light guide leans to one side (insufficient energy delivered to the target). 5. Part of the light guide is not in contact with the skin (insufficient energy delivered to the target) Page 38 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

39 PRACTICAL TIPS FOR SKIN REJUVENATION All areas of the body can be treated except inside the orbit of the eye (e.g. underneath the eyebrows) or on mucous membranes (e.g. inside nostrils, ears, etc.). As described in the Introduction, specific vascular and pigmented lesions should be treated first after diagnosis by a dermatologist. Facial area For whole-face rejuvenation, make a line of treatment spots down the face along the jaw line and add rows above as necessary where skin rejuvenation is needed until all required cheek areas are covered. Then repeat the process on the forehead and chin areas. Pay particular attention to the following points: 1. Avoid accidentally treating the scalp hair by using a white hair band. 2. Use a piece of white Fibrella cloth, white card or white adhesive label to shield areas if required. When treating the upper lip (moustache area), remember that the central area below the nostrils (nasal alia) is particularly sensitive. Mostly the upper lip area can be treated with 2-3 shots (depending on spot size). Following multiple treatments of the upper lip (moustache area) resulting in increased collagen in the skin tissue, it may be possible to observe an improvement in the lip line ( Cupid s Bow ) with more lip vermilion newly exposed to give a fuller look to the lip. 1. Remember to remove all lip-gloss, lip salve or make up. 2. Apply white pencil to mask any semi permanent lip liner on the lip margin. 3. Shield the lips with damp cotton wool or white adhesive label before treating. 4. Use gel sparingly as it can easily obstruct the nostrils which is unpleasant for the client. To identify whether pigmentation is epidermal (e.g. freckles, age spots, epidermal melasma, etc.) or dermal (post-inflammatory hyper-pigmentation, dermal melasma, etc.) the skin in the area to be treated can be stretched between the fingers. If the pigmentation lightens significantly on stretching, the pigmentation is mostly epidermal. If there is little colour change, the pigmentation is deeper. Treatment of Poikiloderma of Civatte (mostly found on the lateral lower third of the neck) should be undertaken carefully starting with lower fluences as the neck skin in this area is particularly delicate. Remember, fine lines and wrinkles will require multiple treatments and only improve fully over several months. Facial treatments should be kept outside the orbital canthus (outer bony rim of the eye socket). Page 39 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

40 Individual small pigmented blemishes may be treated easily using a paper mask made from a small sheet of white folded paper (or white self-adhesive label) with the corner cut-off. Décolleté The upper chest in female clients (between and above the breasts) can be treated taking care with energy settings as the chest bone (sternum) is close to the body surface in this area and may be sensitive. Moreover, the décolleté is often heavily tanned and sun-damaged and does not heal easily if over-treated. Therefore, treat with caution, starting with lower fluence levels. Nipple Pigment Post-breast feeding, some women (particularly East-Asian skin types) experience significant darkening of the areola and seek skin lightening treatment. Cases of successful pigment lightening have been reported using programs and fluences for type 5 skin. However, care should be taken when treating this sensitive intimate area. Forearms The forearms may be covered with mottled pigmentation (freckles) from sun exposure. Care should be taken to eliminate active tan in advance of ipulse treatment (particularly with the driving-side arm) through the use of high-factor san lotion for at least two weeks before treatment commences. 1. Mark out the sub-divided area to be treated using a white pencil. 2. It is preferable to treat around sections of the arm rather than along the length of the arm. If required you can treat around the elbow or wrist. Page 40 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I

41 AFTER USING IPL APPLICATOR 1. Ensure that the skin area is completely treated (no obvious gaps) 2. Put the ipulse unit into STANDBY 3. Remove safety eye wear 4. Once the area has been treated, remove the ultrasound gel using a spatula and then tissues 5. Check the area for redness and record in client notes 6. Apply a cooling gel pack to any sensitive areas if required 7. Apply a calming lotion such as Aloe Vera 8. Complete the client treatment notes and record any unusual occurrence 9. Provide post-treatment advice and take-home information sheet 10. Book your client s next treatment 11. Switch-off the ipulse, clean the crystal treatment guide with a moist tissue or an isopropyl wipe and prepare the room for the next client. REMEMBER YOUR CLIENT S TREATMENT TIME INCLUDES: - Meeting and greeting - Providing required information / answering questions - Preparation of treatment area / applying pre-cooling gel - The treatment - Post-cooling / use of soothing lotion or gel - Completing client record and rebooking the next appointment - Providing client with take-home instructions sheet NB: Clients frequently loose take-home information. It is advisable to ask clients to sign a note that they have received return home-care instructions. This may be included in the consent form or general client questionnaire. Page 41 of 45 Issued: July 2006 Revised: March 2008 PHOTOAGING APPLICATIONS MANUAL I