Lasers in Surgery and Medicine 28:141±144 (2001)

Intense Pulsed Light and Nd:YAG Laser Non-AblativeTreatment of Facial Rhytids

David J. Goldberg* and J.A. SamadyDivision of Dermatology, New Jersey Medical School, Newark, New Jersey 07103

Background and Objective: The aim of this study wasto evaluate the ef®cacy and safety of the intense pulsedlight source (IPL) and the Nd:YAG laser in the treatmentof facial rhytids. Both systems can be used in a non-abla-tive manner and cause a dermal wound. This is thought tostimulate the production of new collagen without epider-mal disruption. Non-ablative techniques eliminate thedowntime that must be endured by patients treated withablative methods such as the carbon dioxide and erbiumlasers.Study Design/Materials and Methods: Fifteen subjectswith perioral rhytids and Fitzpatrick skin types II and IIIreceived three-to-®ve treatments with the IPL using 590and 755 nm cut-off ®lters, and the 1,064-nm Nd:YAG laser.The subjects were evaluated at 2, 4, 8, 12, and 24 weeksafter the ®nal treatment for improvement in rhytids andpresence of any side effects.Results: At 6 months, the patient satisfaction score (1±10)was comparable in all three groups. Evaluator assessmentof improved skin quality was also similar in all three treat-ment groups. Side effects such as blistering and erythemawere most commonly seen in the subjects treated with theIPL. The least discomfort was seen with the Nd:YAG laser.Conclusion: Although both non-ablative treatment sys-tems improved facial rhytids presumably by causing anon-speci®c dermal wound, the Nd:YAG laser was bettertolerated and produced fewer side effects. Lasers Surg.Med. 28:141±144, 2001. ß 2001 Wiley-Liss, Inc.

Key words: non-ablative; laser resurfacing; intensepulsed light; Nd:YAG

INTRODUCTION

Several methods have been employed in the treatment ofphoto-aged induced facial rhytids. These methods, whichinclude dermabrasion, chemical peels, and ablative laserresurfacing, partially or completely destroy the epidermis[1,2]. The resulting erosions not only make patients sus-ceptible to complications such as infection, scarring, ordyspigmentation, but also require signi®cant time and careto promote appropriate wound healing recover. Theseproblems have led to the investigation of various non-ablative lasers and intense pulsed light sources for thetreatment of facial rhytids [3,4]. Many of the initial studieshave shown promise with these techniques, but optimalparameters have not yet been determined.

Intense pulsed light sources (IPL) are ¯ashlamp deviceswith several ®lters, which allow the release of wavelengthsof light between 550 and 1,100 nm. By utilizing theappropriate ®lters, many shorter wavelengths which maydamage the epidermis but do not penetrate to an adequatedepth to promote collagen remodeling [5], can be blocked.Although with all utilized ®lters, emitted wavelengths areskewed toward the visible light spectrum (personal com-munication, ESC Sharplan, Norwood, MA), the longerdelivered wavelengths are more likely to cause a non-speci®c wound in the dermis. This wound may result inincreased collagen production. Moreover, by utilizing theselonger wavelengths in combination with a contact coolingsystem, the epidermis is less likely to be injured. The 1,064nm wavelength of the Nd:YAG laser allows an even deeperpenetration into the dermis with relative sparing of theepidermis. Dermal wounding with this wavelength mayalso stimulate new collagen formation [7]. The purpose ofthis study was to evaluate the ef®cacy and side effects ofthe IPL used with two different sets of parameters and theNd:YAG laser in the treatment of photo-aged skin.

MATERIAL AND METHODS

Fifteen subjects of ages 40±75 year, with perioral rhy-tids and Fitzpatrick skin types II and III, were entered intothe study. Subjects were excluded if they had used oralretinoids within the past year, had a history of photo-sensitivity, or anticipated using other methods of skinrejuvenation during the treatment or follow-up period.The treatment area was divided into four quadrants asfollows: quadrant 1 ± IPL with a 590-nm ®lter; quadrant2 ± IPL with a 755-nm ®lter, quadrant 3±1,064 nmNd:YAG laser; and quadrant 4 ± control (no treatment)(IPL, ESC Sharplan, Norwood, MA). All subjects receivedthree-to-®ve treatments given at an arbitrarily deter-mined 2-week interval over an 8-week period. Energieswas delivered as a triple pulse with ¯uence, pulse width,and pulse delay increased, in subsequent visits, as tole-rated. The exact treatment parameters (Table 1) weredetermined by Fitzpatrick skin type. IPL delivered energywas delivered through an 8� 33-mm light guide with anattached bracketed cooling collar set to 4�C. A similar

*Correspondence to: David J. Goldberg, MD, Skin Laser &Surgery Specialists of New York & New Jersey, 250 Old Hook Rd.Westwood, NJ 07675.

Accepted 21 November 2000

ß 2001 Wiley-Liss, Inc.

contact cooling system was utilized with the Nd:YAG laser.In addition, a cooling gel was applied immediately beforetreatment. No other pretreatment was provided. Post-operatively, bacitracin ointment was applied to the treatedareas only if blistering occurred.

All subjects were evaluated and photographed at eachtreatment session as well as 2, 4, 8, 12, and 24 weeks afterthe ®nal treatment. At each follow-up visit, the subjectsranked their degree of satisfaction on a scale of 1 (lowest)to 10 (highest) for each of the treated areas. In addition,the investigator evaluated any improvement in pigmenta-tion, perceived quality of skin texture and rhytids on acombined scale of 1±4 (1, < 25%�mild improvement; 2,26±49%�moderate improvement; 3, 50±74%�markedimprovement; 4, 75±100%� total improvement). Finally,any side effects (erythema, blistering, pigmentary changes,etc.) were recorded. The controlled sites were only used asa basis of comparison when evaluating for complications atthe treated sites.

RESULTS

The number of treatments for patients ranged from fourto ®ve. The mean patient satisfaction score did showmoderate increases during the follow-up period using the590- 755-, and 1,064-nm wavelengths. There was no sta-tistically signi®cant difference in the subjective degree ofimprovement between the three groups (Table 2). Simi-larly, the evaluator assessment showed mild-to-moderateimprovement. No subjects showed marked or total im-provement.. (Figs. 1 and 2). However, side effects, parti-cularly persistent erythema and blistering, did differ

depending on wavelength (Table 3). The incidence ofside effects was inversely proportional to the wavelength(Fig. 3). The 1,064-nm setting resulted in only one case of

TABLE 1. Treatment Parameters

Skin type Filter Pulse duration (msec) Pulse Delays (msec) Fluence (J/cm2)

II 590 3±5 20±40 40±70

II 755 3±5 20±40 40±70

II 1,064 3±8 20 100±130

III 590 5±7 30±60 40±60

III 755 3±5 30±60 40±70

III 1,064 3±8 30 100±130

TABLE 2. Patient Satisfaction (1±10)

Wavelength (nm) 590 755 1,064

Before txa 2 1.3 1.5 1.2

Before tx 3 2.9 2.9 2.5

Before tx 4 3.3 3.3 2.6

Before tx 5 4 3.3 3.8

2 weeks after last tx 4.1 3.9 4.3

4 weeks after last tx 4.1 3.9 4.3

8 weeks after last tx 4.2 3.2 4.3

12 weeks after last tx 4.5 4.0 4.4

24 weeks after last tx 6.4 6.2 6.8

aTreatment.

Fig. 1. Perioral rhytids before treatment. Subjects's upper

right lip was treated with IPL using 590-nm ®lter (quadrant 1);

lower right lip/chin was treated with IPL using 755-nm ®lter

(quadrant 2); left upper lip was treated with millisecond

1,064-nm laser (quadrant 3); left lower lip was not treated

(quadrant 4). [Color ®gure can be viewed in the online issue,

which is available at www.interscience.wiley.com.]

Fig. 2. Similar improvement at all treated sites. [Color ®gure

can be viewed in the online issue, which is available at

www.interscience.wiley.com.]

142 GOLDBERG AND SAMADY

minor blistering which resolved without scarring. More-over, this wavelength caused little to no discomfort duringtreatment, as opposed to the 590 and 755-nm settingswhich were associated with greater discomfort.

DISCUSSION

One of the ®rst modalities utilizing the non-ablativeapproach to dermal remodeling was the Q-switchedNd:YAG laser. This study compared the ef®cacy of theQ-switched Nd:YAG with the carbon dioxide laser in treat-ing facial rhytids [6]. The endpoint for treatment was thepresence of pinpoint bleeding. All 11 patients in the carbondioxide group improved and 9 of 11 patients in the Nd:YAGgroup showed improvement. After 1 month, erythema waspresent in all patients treated with the carbon dioxidelaser, but only in 3 of the 11 treated with the Nd:YAG laser.Of the nine patients that improved with the Q-switchedNd:YAG laser, three had results comparable to the carbondioxide laser.

A similar study tested the ef®cacy of a low-¯uenceQ-switched Nd:YAG laser with an exogenous carbon sus-pension chromophore for the treatment of facial rhytids[7]. Since lower ¯uences were used, no pinpoint bleeding orlong-lasting erythema was present. Of the 78 class I and 72class II rhytid sites treated, 97 and 86% had at least slightimprovement, respectively.

Further attempts to protect the epidermis were testedusing a cryogen spray cooling system in conjunction withan Nd:YAG (l� 1,320 nm) laser [8]. Thirty-®ve subjectsreceived three treatments at 2-week intervals for perior-

bital rhytids. At 12 weeks, small but statistically signi®-cant improvement was seen in all rhytid groups, whereasonly the severe rhytid group showed statistical improve-ment after 24 weeks. Side effects were limited to transienthypopigmentation (5.6%) and pinpoint pitted scars (2.8%).Although other studies, using the same laser system andsimilar parameters, have shown some con¯icting results,histologic evidence of new collagen formation has beendocumented following use of this laser [9±14].

Pulse dye lasers have also been used to treat facialrhytids [15]. Induction of dermal collagen remodeling hasbeen demonstrated with the 585-nm pulsed dye laser whenused to treat hypertrophic scars and keloids [16,17]. Initialresults for treating rhytids are encouraging, but theunavoidable purpura associated with the use of pulseddye lasers may limit its usefulness for resurfacing.

Intense pulsed light has also been evaluated for itsdermal remodeling capacity [18]. Thirty subjects withclass I and II rhytids and Fitzpatrick skin types I and IIwere treated up to four times using a 645-nm cutoff ®lter.Twenty-®ve subjects showed some clinical improvement6 months after the ®nal treatment, although no subjectsshowed total improvement. Three patients had blisteringwhich healed without scarring.

In the current study, an intense pulsed light sourceusing 590 and 755 nm cutoff ®lters and an Nd:YAG laserwere evaluated for improvement in photodamaged peri-oral skin. Each of the chosen wavelengths were similar inef®cacy; none exhibiting more than mild-to-moderateimprovement. However, the Nd:YAG laser was bettertolerated and produced less side effects. It should be noted,though, that the IPL is more successful at removingepidermal signs of photodamage and associated solartelangiectases [19]. The mechanism by which the Nd:YAGlaser improves rhytids is unclear; its long wavelength doesallow for deeper penetration into the dermis. By usingcontact cooling in addition to a long pulse width and triplepulses, higher ¯uences may be used without injury to theepidermis. This may cause a non-speci®c dermal wound,which stimulates collagen remodeling.

More studies are needed to evaluate both of these treat-ment systems to ®nd optimal parameters that will lead togreater results. Currently, with all non-ablative dermalremodeling techniques, results are usually at best quitemodest. However, non-ablative resurfacing, whether withIPL or the long pulse millisecond Nd:YAG laser, showspromise as an alternative to other ablative approaches inthose individuals who wish cosmetic improvement withoutthe downtime associated with ablative procedures.

REFERENCES

1. Sumian CC, Pitre FB, Gauthier BE, et al. Laser skinresurfacing using a frequency-doubled Nd:YAG laser aftertopical application of an exogenous chromophore. Lasers SurgMed 1999;25:43±50.

2. Cisneros JL, Del Rio R, Palou J. The Q-switched neodymium(Nd):YAG laser with quadruple frequency. Dermatol Surg1998;24:345±50.

3. Hruza GJ, Dover JS. Laser skin resurfacing. Arch Dermatol1996;132:451±455.

TABLE 3. Side Effects

Wavelength (nm) 590 755 1,064

Blistering 8/15 (53%) 4/15 (27%) 1/15 (6%)

Erythema 8/15 (53%) 2/15 (13%) 0/15 (0%)

Fig. 3. Erythema seen after treatment with IPL; minimal

reaction noted after treatment with millisecond Nd:YAG

laser. [Color ®gure can be viewed in the online issue, which

is available at www.interscience.wiley.com.]

LASER TREATMENT OF RHYTIDS 143

4. Teikameyer G, Goldberg DJ. Skin resurfacing with theerbium:YAG laser. Dermatol Surg 1997;23:685±687.

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6. Goldberg DJ, Whitworth J. Laser skin resurfacing with theQ-switched Nd:YAG laser. Dermatol Surg 1997;23:903±907.

7. Goldberg DJ, Metzler C. Skin resurfacing utilizing a low-¯uence Nd: YAG laser. J Cut Laser Ther 1999;1:23±27.

8. Kelly KM, Nelson JS, Lask GP, et al. Cryogen spray coolingin combination with nonablative laser treatment of facialrhytids. Arch Dermatol 1999;135:691±694.

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13. Goldberg DJ. Subdermal resurfacing. Oper Tech OculoplstOrbital Recons Surg 1999;2:188±193.

14. Goldberg, DJ. Nonablative resurfacing. Clin Plas Surg2000;27:287±292.

15. Zelickson BD, Kilmer SL, Bernstein E, et al. Pulsed dye laserfor sun damaged skin. Lasers Surg Med 1999;25:229±236.

16. Alster TS. Improvement of erythematous and hypertrophicscars by the 585-nm pulsed dye laser. Ann Plast Surg 1994;32:186±190.

17. Alster TS, Williams CM. Treatment of keloid sternotomyscars with the 585-nm ¯ashlamp-pumped pulsed dye laser.Lancet 1995;345:1198±1200.

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