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Introduction
Topical and oral formulations are often
ineffective in “acne erythema” or “post
inammatory erythema (PIE) due to acne”
which has paved the way for lasers and light
therapy for the same.[1,2] Although pulsed
dye lasers are considered as the main stay
of treatment for acne erythema, they are
expensive machines with a smaller spot size
and are not free from side effects.[3,4] Hence,
this study aims at evaluating the efcacy of
IPL in acne-induced PIE and to document
adverse effects if any, as variations exist
in the results from published studies with
limited scientic evidence of IPL especially
on Indian skin.
Patients and Methods
A retrospective analysis of all patients
diagnosed with acne-induced PIE, who
attended the outpatient department and
were treated with IPL for the same during
the time period of July 2015 to June
2017, was done and the patients were
included in the study. All the 33 patients
Address for correspondence:
Dr. Minu L. Mathew,
Department of Dermatology,
Venereology and Leprosy, K.V.G
Medical College and Hospital,
Sullia ‑ 574 239, Karnataka,
India.
E‑mail: minulizmathew@yahoo.
co.in
Access this article online
Website: www.idoj.in
DOI: 10.4103/idoj.IDOJ_306_17
Quick Response Code:
Abstract
Background: Intense pulsed light (IPL) is a comparatively new system of practice in treating
acne-induced post inammatory erythema (PIE) which is a difcult condition to treat, and variations
exist in the results from published studies with insufcient or limited scientic evidence of IPL on
Indian skin. Aim: To study the efcacy of IPL in the treatment of acne-induced PIE and to document
adverse effects of the procedure. Settings and Design: A hospital-based retrospective observational
study on 33 patients with acne-induced PIE who completed treatment with IPL during the time period
of July 2015 to June 2017. Patients and Methods: All 33 patients were treated with vascular mode of
IPL using 560-nm lter every 3 weeks for three to six sessions. Grading of PIE was done by Clinician
Erythema Severity Score, and the objective parameters were assessed statistically for improvement
using photographs. Adverse effects were noted and followed up. Statistical Analysis: Wilcoxon sign
rank test and Pearson’s correlation. Results: There was statistically signicant reduction in mean
erythema score from 2.57 ± 0.66 to 1.21 ± 0.48 following IPL (Z = −5.295, P < 0.001—Wilcoxon
sign rank test). Excellent improvement was noted in 11 (33.33%), good in 15 (45.45%), fair in
4 (12.12%), and poor in 3 (9.09%), and the results were consistent on follow-up. Adverse effects
included erythema, hyperpigmentation, and hypopigmentation which were all transient and resolved
completely in all patients on follow-up. Conclusion: IPL is an effective and safe alternative to
otherwise difcult-to-treat acne-induced PIE.
Keywords: Acne, erythema, grading, intense pulsed light
Intense Pulsed Light Therapy for Acne‑induced Post‑inammatory Erythema
Original Article
Minu L. Mathew,
R. Karthik,
M. Mallikarjun,
Soumya Bhute,
Aiswarya Varghese
Department of Dermatology,
Venereology and Leprosy, K.V.G
Medical College and Hospital,
Sullia, Karnataka, India
How to cite this article: Mathew ML, Karthik R,
Mallikarjun M, Bhute S, Varghese A. Intense pulsed
light therapy for acne-induced post-inflammatory
erythema. Indian Dermatol Online J 2018;9:159-64.
Received: November, 2017. Accepted: March, 2018.
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included in the study had completed all
sessions of IPL and follow-up. The study
included patients above 15 years and below
40 years of age of either sex with persistent
facial erythema following resolution of
inammatory acne. Both new and already
treated patients with topical or oral therapy
who stopped treatment 1 month before
the procedure were included. Patients
below 15 years and above 40 years of
age, those who underwent laser procedures
in the past for PIE, patients with keloidal
tendencies, photosensitivity and other facial
dermatoses, pregnant and lactating mothers,
and those who had taken isotretinoin within
previous 6 months were excluded from the
study. An ethical committee clearance for
the study was obtained from the institution.
First, the patients were elaborately
explained about the procedure and were
asked to give an informed consent for their
participation in the study. A questionnaire
was used to record the demographic and
clinical details of all patients. Information
was also noted regarding any precipitating
factors, drug intake, and associated
Mathew, et al.: Intense pulsed light in acne‑induced post‑inammatory erythema
160 Indian Dermatology Online Journal | Volume 9 | Issue 3 | May-June 2018
cutaneous or systemic disease. After thorough evaluation,
grading of erythema and assessment of objective parameters
were done based on Clinician Erythema Assessment
Scale (CEAS) [Table 1].[5] The patient was explained
about IPL, its benets, duration of the treatment, its cost,
possible side effects, and prognosis of the treatment. Use of
sunscreens was advised 2 weeks before the procedure and
thereafter. Digital photographs of the concerned area were
taken before and after each session.
Before procedure, the treatment area was gently cleansed
and make up was removed if any. A third-generation IPL
system manufactured by NIKKISO—Zigma with Radio
Frequency and inbuilt cooling was used for the study. IPL
system was started 2 min before the procedure. Appropriate
safety goggles were provided to the patient and staff.
Patient’s Fitzpatrick’s skin type was determined and the
number of stacked pulses was set accordingly as two,
three, or four. Test dose of IPL was given on forearm of
the patient. Pre-procedure ice packs were not applied as
it would vasoconstrict the vessels and reduce the target
chromophores. For dark skin types, lower uence with
shorter pulse width and longer pulse delay was preferred.
For lighter skin types, higher uence with longer pulse
width and shorter pulse delay was used. A 560-nm lter
was used for treating post acne redness. Fluence ranged
from 25 to 46 J/cm2, whereas pulse width ranged from
4.5 to 5 ms. Pulse delay was kept at 10-20 ms.
Post procedure, patient was advised on sun protection and
to never pick scabs if any. Any post procedure side effects
such as erythema, blistering, scarring, hypopigmentation,
or hyperpigmentation were noted and followed up. Topical
steroid-antibiotic cream was applied over the treated site
immediately after the procedure in all patients followed by
sunscreen. Epidermal growth factor gel was used in those
who developed hyperpigmentation with scabbing following
the procedure. IPL was administered every 3 weekly and
the number of sessions depended on the severity in each
patient which varied between three and six sessions.
Each of the participants was followed up for a period
of 12 weeks. The photographs taken before the rst
session and after the nal session were compared. The
objective parameters were estimated at the end of the
last session and assessed statistically for effectiveness
of IPL in each patient of acne erythema using Wilcoxon
sign rank test. The data obtained from all the patients
were tabulated on Microsoft Excel 2010, and IBM SPSS
Version 20 was used for analysis. The physician’s assessment
of degree of improvement based on Investigator’s Global
Assessment (IGA) scale [Table 2] was done at the
completion of last session and graded as Poor (<25%),
Fair (25%-50%), Good (51%-75%), and Excellent (>75%)
improvement.[6] Patients also assessed treatment outcome as
No improvement, Slight improvement, Good improvement,
and Excellent improvement after the last session.
Results
The mean age of the study group was 23.54 ± 4.677 years,
minimum being 18 years and maximum being 39 years
of age. Our study included 7 males and 26 females. The
mean duration of PIE due to acne in the study group was
2.987 ± 2.97 years. The majority of patients belonged
to Fitzpatrick’s skin type III (n = 24) followed by
type IV (n = 9). The patients with oily, combined, dry, and
normal skin type were 21, 7, 4, and 1, respectively.
The average uence used for treatment was
38.994 J/cm2 with an average number of sessions of
4.93 ± 0.788. The average pre-treatment erythema score
by CEAS was 2.57 ± 0.66 which reduced to 1.21 ± 0.48
following treatment. This reduction in erythema score was
found to be statistically signicant by Wilcoxon sign rank
test (Z = −5.295, P < 0.001) [Figure 1].
Physician’s assessment of treatment outcome based on IGA
scale showed Excellent improvement in 33.33% (n = 11),
Good in 45.45% (n = 15) Fair in 12.12% (n = 4), and Poor
improvement in 9.09% (n = 3). Subjective improvement
noted by the patients showed Excellent improvement
in 36.36% (n = 12), Good in 39.39% (n = 13), Slight
in 15.15% (n = 5), and No improvement was noted by
9.09% (n = 3).
Table 2: Physician’s assessment of improvement based on Investigator’s Global Assessment Scale
Investigator’s Global Assessment Scale Physician’s assessment of improvement
Complete 100% clearance, with no residual erythema Excellent (>75%-100%)
Excellent Up to 90% clearance of erythema from baseline
Marked Up to 75% improvement from baseline Good (51%-75%)
Moderate Up to 50% improvement from baseline Fair (25%-50%)
Minimal Up to 25% improvement from baseline Poor (0 to<25%)
No change Erythema severity similar to baseline
Worse Worse than baseline
Table 1: Clinician Erythema Assessment Scale
Score Clinician Erythema Assessment Scale
0 Clear Clear skin with no signs of erythema
1Almost clear Slight redness
2 Mild Denite redness
3 Moderate Marked redness
4 Severe Fiery redness
Mathew, et al.: Intense pulsed light in acne‑induced post‑inammatory erythema
161Indian Dermatology Online Journal | Volume 9 | Issue 3 | May-June 2018
There was no correlation between mean improvement
in erythema score with duration of PIE (r = 0.1098,
P = 0.5430, not signicant) or number of sessions of IPL
done (r = −0.02849, P = 0.8753, not signicant).
Transient erythema was the most common adverse effect
(93.94%, n = 31) following IPL with an average of
3.91 days of erythema followed by hyperpigmentation
(15.15%, n = 5) with an average of 23 days and
hypopigmentation (12.12%, n = 4) lasting for an average
of 21 days. The down time was minimal in majority as
erythema was mild and transient. In those who developed
hyperpigmentation with scabbing and hypopigmentation
following IPL, downtime varied from 5 to 7 days although
it took longer for complete resolution of lesions. All the
adverse effects were transient and cleared completely on
follow-up.
Additional benets such as improvement in skin tone
and reduction in oiliness of skin were also noted; 27 out
of 33 patients (81.82%) noted an improvement in their
skin tone and texture, whereas 19 out of the 21 (90.48%)
patients who had oily skin noted reduction in oiliness of
skin following IPL [Figures 2-7].
Discussion
Acne vulgaris can be a challenging condition to treat
as the problem of acne is not conned to skin alone
but also affects the psyche, and the disease burden of
acne ranges from facial scarring and dyspigmentation
to social, psychological, and emotional distress as well
as self-perception of poor health.[7,8] Post inammatory
dyspigmentation due to acne presents as post inammatory
hyperpigmentation in darken skin types, whereas they
present as discrete erythematous macules or scars in lighter
skin types.[2] Acne-induced PIEs in majority are resistant
to available topical and oral drug formulations which is
distressing to the patients and the treating physicians.[9,10]
The laser and light-based systems are preferred by the
consumer who demands more than what creams and topical
drugs can offer and also by physicians who need a better
therapeutic response beyond what conventional modalities
can deliver.
IPL is a ash lamp pumped light source which provides a
non-coherent polychromatic source of intense light from
400 to 1200 nm that can be modied by lters to provide
irradiation with specic wavelengths of light unlike PDL
which uses monochromatic light that cannot be adjusted.
IPL can be delivered by splitting the energy into two, three,
or four pulses with different pulse delays which allow
the skin to be cooled between pulses thereby preventing
adverse effects.[11] The advantage of IPL is that it takes care
of acne and acne-associated redness in a single sitting. IPL
devices have a large spot size (7-8 mm × 40 mm) which
covers 2.8 cm2 of skin surface in a single shot which is
a much larger surface when compared to smaller spot
sizes of argon laser or PDL (3-10 mm).[12,13] Hence, on an
average, three times the same number of shots as in IPL
would be needed for PDL to cover the same area increasing
the treatment cost per session for PDL. Larger spot size of
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
13579111315171921232527293133
Erythema score
Series1
Series2
Figure 1: Improvement in erythema score in each patient after IPL
Figure 2: (a) A 22‑year‑old female showing complete clearance of
acne‑induced PIE following three sessions of IPL—full face. (b) A 22‑year‑old
female showing complete clearance of acne‑induced PIE following three
sessions of IPL—right side of the face
b
a
Mathew, et al.: Intense pulsed light in acne‑induced post‑inammatory erythema
162 Indian Dermatology Online Journal | Volume 9 | Issue 3 | May-June 2018
IPL results in the delivery of greater amount of energy and
greater damage to the deeper dermal target and enables the
use of lower uence which reduces the side effects of the
procedure. As a result, there will be larger and uniform skin
coverage per session thereby reducing the number of shots
red per session to cover the concerned area and the total
number of sessions required for a therapeutic response. IPL
has a lower purchase price (5-25 lakh rupees) compared to
PDL (45-60 lakh rupees). The lesser number of shots per
session together with the lower cost of machine makes IPL
economical for the patient and the treating physician and
hence aptly called the “poor man’s laser.”[12]
Acne erythema consists of telangiectasia and erythematous
papules, without a comedone, which occur as a result
of inammatory acne.[1] Acne-associated ushing and
erythema are vascular components and represent increased
numbers of erythrocytes in mildly inamed and enlarged
blood micro capillaries which were produced around the
acne lesion due to localized inammation during the acute
acne condition.[11] These vessels are located mainly in very
close proximity to the skin surface and have a smaller
diameter giving the skin a red appearance due to high
concentration of minor blood vessels in that area.
IPL works by the principle of selective photothermolysis
wherein laser energy is being absorbed by a target
chromophore without signicant damage to the surrounding
tissue.[14] IPL targets the chromophores oxy- and
deoxy-hemoglobin in the blood vessels which are the main
chromophores for vascular lasers. The major absorption
peaks of oxy-hemoglobin are 418, 542, and 577 nm,
Figure 4: A 24‑year‑old male of Fitzpatrick skin type 4 showing
hyperpigmentation and hypopigmentation following IPL
Figure 3: A 27‑year‑old female showing excellent response after ve
sessions of IPL
Figure 6: A 21‑year‑old male showing transient erythema following IPL
Figure 5: A 19‑year‑old boy showing hypopigmentation following IPL
Mathew, et al.: Intense pulsed light in acne‑induced post‑inammatory erythema
163Indian Dermatology Online Journal | Volume 9 | Issue 3 | May-June 2018
whereas deoxygenated hemoglobin has absorption peaks
around 450 and 560 nm. Longer wavelength like 577 nm
is preferred as they penetrate more deeply to reach the
vessels and do not interfere with epidermal melanin,
thereby reducing adverse effects following the procedure
especially in Indian skin types.[15] The vascular mode
of IPL uses a 560-nm cut-off lter which lters out all
wavelengths lower than 560 nm and allows a wavelength
of 577 nm, corresponding to the third absorption peak
of oxy-hemoglobin to pass through resulting in selective
thermal damage to the supercial vessels producing
coagulation and thrombosis of vessel wall.[11] These
defective venules are then removed over time which is
clinically seen as clearance of erythema.
In our study, among the 33 patients with acne induced PIE
who underwent treatment with vascular mode of IPL using
560nm lter for three to six sessions, 78.78% of patients
showed more than 50% improvement in their erythema
scores and the results were consistent after 12 weeks of
follow up.
Chang et al. evaluated an IPL device (530-750 nm,
7.5-8.0 J/cm2) in 30 Korean females with mild to moderate
acne associated with PIE.[16] After three sessions in
3 weeks, red macules, irregular pigmentation, and skin tone
improved in 63% of the study population although they
used a lower uence for the procedure.
Madonna Terracina et al. used IPL in the treatment of
persistent face and neck erythema in women (n = 22)
and men (n = 12). Patients underwent ve treatments at
intervals of 3 weeks.[17] In 22 patients (64.7%), regression
of the erythema was achieved after ve applications, while
the erythema persisted in ve (14.7%) patients. In our
study, three patients (9.09%) had poor response following
IPL.
Wenzel et al. reported successful treatment of patients
with progressive erythema using IPL with 560-nm lter in
nine patients. According to their results, improvement in
erythema was obtained in all the nine patients with very
good results in eight patients.[18]
Neuhaus et al. and Tangheiit compared PDL with IPL
and found that both modalities were equally effective in
reducing cutaneous erythema and telangiectasia with a
similar side-effect prole in rosacea.[19,20] Kassir et al. noted
that 80% of patients with rosacea had reduction in redness,
and 78% of patients had reduced ushing and improved
skin texture following IPL.[12]
Erythema (n = 31, 93.94%), hyperpigmentation
(n = 5, 15.15%), and hypopigmentation (n = 4, 12.12%)
were the adverse effects noted in our study following
IPL, all of which were transient and resolved completely
on follow-up. Babilas, Moreno-Arias et al., and Sadick
et al. also observed that transient erythema was the
most common adverse effect post IPL, followed by
hyperpigmentation, hypopigmentation, blistering, and
scarring.[21-23] The ndings of our study were consistent
with that of Kawana et al. who noted that darker skin
types had more chances of adverse effects.[24] Adverse
effects were noted more on bony prominences such as
mandibular and temporal area especially in patients with
Fitzpatrick skin type 4, and hence lower uences have to
be used over bony prominences to reduce adverse effects
along with stringent sun protection.
In our study, 81.82% (n = 27) noted improvement in their
skin tone and texture, whereas 90.48% (n = 19) of patients
who had oily skin (n = 21) noted reduction in oiliness of
skin following IPL. Kassir et al. noted improvement in
skin texture in 78% of patients following IPL.[11] Chang
et al., Jorgensen et al., and Hantash et al. all have noted
improvement in skin tone and texture following treatment
with IPL.[16,25,26]
The shortcoming of this study was that no control group was
included. Furthermore, larger, placebo-controlled studies
using parallel, cross-over, matched, or split-face designs
are required to conrm our conclusions. Consistency of the
results for longer periods is to be elucidated.
We consider that IPL can be used as an alternative in
patients with persistent acne erythema as it simultaneously
takes care of acne and erythema with additional advantages
such as reduction in oiliness of skin with improvement in
skin tone and texture and transient adverse effects when
used optimally. Overall, IPL appears to be an effective,
well-tolerated, economical, and a safe treatment and may be
viewed as a viable alternative to PDL, but optimization of
treatment parameters and operator experience are essential
in achieving desired results as observed by Clementoni
et al.[12]
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
Figure 7: A 23‑year‑old female showing good improvement following three
sessions of IPL
Mathew, et al.: Intense pulsed light in acne‑induced post‑inammatory erythema
164 Indian Dermatology Online Journal | Volume 9 | Issue 3 | May-June 2018
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