Journal of Cosmetic and Laser Therapy

ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: http://www.tandfonline.com/loi/ijcl20

Intense pulsed light (IPL) treatment for the skin

in the eye area – clinical and cutometric
analysis

Anna Augustyniak & Helena Rotsztejn

To cite this article: Anna Augustyniak & Helena Rotsztejn (2016): Intense pulsed light (IPL)
treatment for the skin in the eye area – clinical and cutometric analysis, Journal of
Cosmetic and Laser Therapy, DOI: 10.1080/14764172.2016.1247963

To link to this article: http://dx.doi.org/10.1080/14764172.2016.1247963

Accepted author version posted online: 20

Oct 2016.

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 Just Accepted by Journal of Cosmetic and Laser Therapy

Intense pulsed light (IPL) treatment for the skin in

the eye area – clinical and cutometric analysis
Anna Augustyniak, Helena Rotsztejn
Doi: 10.1080/14764172.2016.1247963
Abstract
Objective: The aim of the research was to establish the influence of
IPL treatment on skin aging in the eye area. Material and methods:
This study included 24 women, aged 38 – 63 years (mean age was
48.04) with Fitzpatrick skin type II and III who underwent 5
successive treatment sessions with an IPL in two-week intervals.
The Cutometer (Courage + Khazaka electronic) reference test was
an objective method for the assessment of the biomechanical
properties of the skin. The measurements were made in three places
around the eye. The photo documentation was used to compare
state of skin before and after three months of treatments.
Additionally, patients filled in a questionnaire which contained
questions concerning self-assessment of the procedure effects.
Results: Cutometric analysis showed significant improvement of
skin elasticity (statistical significance level is mostly < 0.0001). The
comparison of clinical changes in the therapy, based on photo
documentation, showed a 25% improvement. Conclusions: This
treatment was used in order to improve skin elasticity and decrease
the amount and depth of wrinkles. It is a non-invasive treatment, with
low risk of complications.

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 Intense pulsed light (IPL) treatment for the skin in the eye
area – clinical and cutometric analysis

Anna Augustyniak, Helena Rotsztejn

Chair of Cosmetology, Department of Cosmetology and Aesthetic Dermatology, Faculty of

Pharmacy, Medical University of Lódź, Muszyńskiego 1 Street, 91 - 151 Łódź (AA, HR),
Poland

Corresponding author: Anna Augustyniak, Chair of Cosmetology, Department of

Cosmetology and Aesthetic Dermatology, Faculty of Pharmacy, Medical
University of Łódź, Muszyńskiego 1 Street, 91-151 Łódź, Poland. phone: 42 272
55 96, E-mail: anna.maria.augustyniak@umed.lodz.pl

Short title: IPL treatment– clinical and cutometric analysis

Abstract
Objective: The aim of the research was to establish the influence of IPL
treatment on skin aging in the eye area. Material and methods: This study
included 24 women, aged 38 – 63 years (mean age was 48.04) with Fitzpatrick
skin type II and III who underwent 5 successive treatment sessions with an IPL
in two-week intervals. The Cutometer (Courage + Khazaka electronic) reference
test was an objective method for the assessment of the biomechanical
properties of the skin. The measurements were made in three places around the
eye. The photo documentation was used to compare state of skin before and
after three months of treatments. Additionally, patients filled in a questionnaire
which contained questions concerning self-assessment of the procedure effects.
Results: Cutometric analysis showed significant improvement of skin elasticity
(statistical significance level is mostly < 0.0001). The comparison of clinical
changes in the therapy, based on photo documentation, showed a 25%
improvement. Conclusions: This treatment was used in order to improve skin
elasticity and decrease the amount and depth of wrinkles. It is a non-invasive
treatment, with low risk of complications.
Key words: Intense Pulsed Light, Cutometer, eye area, skin rejuvenation

1
Introduction
Intense pulsed light (IPL) is a procedure used both in aesthetic dermatology and
cosmetology. IPL can be used for the treatment of skin aging, vascular lesions,
pigmented lesions, acne and unwanted hair. IPL devices emit a polychromatic (420–
1300 nm range), non-coherent and non-collimated light via a filtered, xenon flash
lamp light source [1, 2, 3]. This light allows for selective photothermolysis of
various cutaneous targets with polychromatic absorption spectra, including those of
oxyhemoglobin (540 and 575–580 nm), deoxyhaemoglobin (550–560 nm) and
melanin (400–755 nm) [2]. Various wavelengths can be obtained by the use of
selective filters that narrow the spectrum of wavelengths emitted from the device.
High cut-off filters allow for the emission of longer wavelengths, which reduce
relative absorption by melanin and water [3]. Individual light pulses are of a specific
intensity, duration and spectral distribution allowing for a controlled and confined
energy delivery into tissue [4]. IPL treatment uses short pulses of light to rejuvenate
skin. Skin is stimulated to increase its reproduction. During the treatment, the IPL
raises the temperature of the skin. The heat of skin stimulates renewal of the
epidermis and increases the production of collagen [5].
A clear cool gel should be applied to help to cool the skin and additionally
to facilitate the movement of the handpiece. A slight or more pronounced
discomfort may appear. Side effects are rare, but they are possible and include:
erythema, oedema, hyperpigmentation and hypopigmentation, crusts, blisters and
atrophic scars [6].
Material and Methods

This study included 24 women, aged 38 – 63 years (the mean age was
48.04) with Fitzpatrick skin type II - III. Patients with mild to moderate periorbital
wrinkles were enrolled in this study. Clinical evaluation of eye skin area was made
on the basis of Fitzpatrick Wrinkle Classification System (FWCS). Additionally,
some of patients presented typical hallmarks of periorbital aging (Table 1). There
were no contraindications for IPL treatment. None of the patients had been included
in any other cosmetology or aesthetic dermatology study before. Each patient was
provided with detailed information regarding post-treatment behaviour, for example
UV protection.

Intense Pulsed Light (IPL)

We used IPL device (MIMARI HM-IPL-B1) with handle 530-nm cut-off

filter which emitted light in the range of 530–1200 nm. The energy density (fluence)
ranged from 10 to 50 J⁄cm2. Sequence of impulses: 1 – 5 impulses. Impulse delay: 5-

2
60 ms. Time of the impulse: 2 -15 ms. Repeatability: 0.3-1Hz. Targeted area:
15×35mm. Treatment parameters varied due to different treatment response of each
patient (Table 2).
A cool colourless gel was applied to the eyes area. Patients wore external overlay
eye shields for eye protection during the treatment. Patients underwent five IPL
sessions in the eye area, separated by two-week intervals. The treated area was
purified using micellar water.
This research project and its procedures were approved by the Bioethics Committee
of the Medical University of Lodz (Protocol No. RNN/97/15/KE).

Cutometer

Cutometric measurement allowed to evaluate changes occurring during the

treatment sessions and after them. This device seems to be useful in the assessment of
skin elasticity improvement after cosmetology or aesthetic dermatology treatments.
Cutometer MPA 580 (Courage + Khazaka electronic GmbH, Germany) is used to
evaluate biomechanical skin properties. It measures elasticity of skin using negative
pressure which mechanically deforms the skin.
In our study the following parameters of the measurement were used:
measurement mode 1, negative pressure 450 mbar, on-time 3 seconds, off-time 3
seconds, repetitions 3. We analysed parameters R2 and R6. R2 is the most common
parameter in medical literature used to evaluate skin aging. R2 refers to gross-
elasticity of the skin, including viscous deformation (recovery/deformation). R6
parameter indicates a relative contribution of viscoelastic, viscous and elastic
deformation to total deformation (ratio of delayed-to-immediate distension).
Measurements were made at three sites in the eye area: first site - two
centimetres in a straight line from the outer corner of the eye, second site - 2 cm from the
pupil on the lower eyelid and third site - 2 cm down from the outer corner of the
eye.
Measurements were made:
1 - before the series of treatments (immediately before the first treatment),
2 - after three sessions of treatment (immediately before the fourth
treatment),
3 - after five sessions of treatment (two weeks after the fifth treatment)
4 - three months after the end of the treatment.

Results

3
 The results of R2 demonstrated significant differences between individual
measurements. First beneficial changes could be observed as early as after third
treatment (measurement 1) (Figure 1a).

Changes within the first analysed site occurred gradually after each
treatment, i.e. in 20 patients the improvement appeared after three sessions of
treatment (measurement 1 – measurement 2). In 16 patients, improvement was seen
after fifth treatment (comparison between measurement 2 and measurement 3).
Measurements were also performed after three months from the last treatment
session (measurement 4), however, only in 6 patients further improvement was
observed. However, the comparison of measurement 1 (before the series of
treatment) with measurement 4 (3 months after the last treatment) demonstrated
sustained improvement in the tension of the skin in 17 persons.

In case of the second measurement site, gradually changes after each

treatment were also observed, i.e. in 20 patients there was an improvement
after three sessions of treatment (comparison between measurement 1 and
measurement 2). In 17 patients progressive improvement after the fifth
treatment (comparison measurement 2 and measurement 3) was
demonstrated. In only 5 patients further improvement occurred after three
months after the last treatment. It is interesting that in 11 patients results of
the measurement 3 and 4 slightly differed from each other, which may mean
that the changes are sustained. However, the comparison of measurement 1 (before
the series of treatment) and measurement 4 (3 months after the last treatment)
revealed that in 17 patients permanent improvement in the tension of skin
occurred.

In case of third measured site, similarly to the aforementioned

analysed sites, gradual, progressive changes were demonstrated. In 21
patients there was an improvement after three series of treatment
(comparison between measurement 1 and 2).

In 21 patients progressive improvement after the fifth session of

treatment (comparison of measurement 2 with measurement 3) was seen. In 7
patients further improvement occurred three months after the last treatment.

4
 The comparison between measurement 1 (before the series of
treatment) and measurement 4 (3 months after the last treatment)
demonstrated a sustained improvement in the tension of the skin in 17
patients.

In all three measurement sites, the most significant changes occurred

during a series of treatment. The results of measurements after three months
were in many subjects similar to those before the series of treatment, which
may indicate the gradual return of the skin to the state before the treatment.
The results of the measurement of R6 (Figure 1b) which determines skin
viscoelasticity were not as significant and stable as the aforementioned
results of R2 analysis.

Results are presented as a mean value and standard deviation

(mean±SD). The significance of variations in the measured parameters (R2,
R6) at each time point was analysed with the use of repeated measures of
ANOVA with the Greenhouse-Geisser amendment and post-hoc test
comparisons with Bonferroni's amendment. Pearson's correlation was used to
assess the correlation between the results (Table 3, Table 4).

Additionally, effects were assessed on the basis of self-assessed

questionnaire using the four-point scale (0-20% improvement, 30-50%
improvement, 60-70% improvement and 80-100% improvement). Two subjects
manifested 60 – 70% improvement, fourteen subjects manifested 30 – 50%
improvement and eight 0 – 20% improvement. Fourteen of them observed changes
after the third treatment, four subjects after the second treatment, five after the fifth
treatment and one after the first treatment.

Most of patients (19 subjects) noticed redness, sometimes

accompanied by burning, which was mostly visible up to 1 hour after the
treatment. Additionally, seven patients reported excessive tenderness which
persisted up to approximately 3-12 hours after the treatment. Moreover, we

5
observed slightly darker colour of pigmented lesions which persisted up to 7
days after treatment.

Photo documentation is often used to compare clinical state of skin before

and after the series of treatment. In this study, it was assessed by three independent
dermatologists skilled in clinical research evaluations. They were unaware of the
treatment group of the photographed subjects. All photographs were taken with the
same camera SONY DSC-TX30 (18.2 megapixels) . Additionally, there were
standardised lighting conditions and we used non-reflective cape worn by the
volunteer being photographed. The wrinkles were analysed in terms of the
improvement in overall clinical appearance and the reduction in their depth and
length with the use of the following scale: 0-15% = no visible improvement, 20-25%
= minimal improvement, 30-35% = moderate improvement, 40-45% = good
improvement, 50-65% = excellent improvement, 70-100% = full/overall
improvement. In this study, the improvement was minimal (20-30%) in comparison
to the state before the beginning of the treatment (Figure 2, Figure 3).
Discussion
With the use of Cutometer, we have demonstrated the improvement in skin
elasticity, which may be associated with an increase in its density. Increase in skin
tension and its thickening occur as the result of contraction (shrinkage) and
thickening (condensation) of the ‘old’ collagen and the stimulation of fibroblasts to
produce new fibres. Higher wavelengths in the 1200 nm spectrum are absorbed by
water in the dermis. Thermal stimulation of fibroblasts results in partial replacement
of the lost dermal volume [4]. Histological evaluation (skin biopsies) after IPL
showed epidermal thickening by 100 to 300 m, new dermal collagen formation and
a decrease in proportion of degenerated elastic fibres [4, 7]. Zhong H et al.
compared Q-switched 1064 nm Nd:YAG laser to intense pulsed light in the non-
ablative rejuvenation on rat model. Histological evaluation and ultrastructure
examination with the use of transmission electron microscope demonstrated an
increase in the dermal thickness, the expression of III procollagen type III mRNA,
elevation of hydroxyproline contents and the dense arrangement of collagen. These
effects on synthesis and remodeling of collagen could last for at least 3 months after
treatment. YAG group is more efficient than the IPL group. The expressions of
procollagen reached peak level at 2 weeks [8]. Bedewi AE et al. used synchrotron
infrared microspectroscopy to demonstrate the effect of intense pulsed light on
dermal fibroblasts. In their histopathological examination, authors showed that
collagen deposition was increased after treatment with IPL (P values were < 0.001)
[9]. Cuerda-Galindo E. et al. showed that IPL applied in vitro cultured cells

6
increases fibroblasts activity (1BR3G human skin fibroblasts). It seems to be
produced more specifically in determined wavelengths (a biochemical mechanism
light depending) [10]. Luo D. et al. demonstrated mRNA expression levels of MMP-
1 and MMP-2 (matrix metalloproteinase) decreased progressively after IPL
irradiation. IPL can not only enhance new collagen production, but also decrease
collagen degradation [11].
IPL apart from remodeling of the dermis also influences the reduction of
discoloration and vascular lesions, which are often closely associated with
photoaging. There have been many studies demonstrating improvement of
photoaging after IPL treatment. The use of IPL allows to enhance these effects,
especially in skin pigmentation disorders and telangiectasia [2, 12, 13, 14, 15, 16,
17]. In our study, the reduction of discoloration and small vascular lesions was also
observed in several cases. According to Hedelund L. et al. IPL improved skin
texture, telangiectasia and pigmentation but had no efficacy on rhytids. They
performed 3 series of IPL treatment at 1-month intervals [18].
IPL is also associated with physiological effects related to the organism’s
thermoregulatory reaction. The increased temperature in tissues results in dilatation
of blood vessels, increased metabolism and oxygen transport. In our study, patients
frequently reported general improvement of skin appearance defined as healthy
appearance. It can be associated with the stimulation of skin microcirculation, and
further with ameliorated metabolism (improvement of skin nutrition and
oxygenation).

Kim’s JE et al. performed a retrospective study (phone interview with

patients) and reviewed photoaged skin lesions from 70 patients who were treated
with IPL. In their research, 61% of patients claimed higher satisfaction with
treatment efficacy on the wrinkles, wherein dermatologists did not notice any
improvement. Such discrepancy may be due to the limitation of the assessment of all
variables only by the comparison of photographs [13]. The cutometrical
measurement can be used as an objective and effective assessment method of skin
elasticity improvement after cosmetology or aesthetic dermatology treatments. Shin
JW. et al. evaluated changes in skin biophysical properties in patients with

7
photoaging after IPL treatments with the use of non-invasive, objective skin
measuring devices (Cutometer, Mexameter etc.). They assessed overall elasticity of
skin using Cutometer (R2) and net elasticity of skin using Cutometer (R5). R2
values showed a gradual but significant increase, whereas R5 exhibited considerable
and significant improvement, indicating that skin elasticity improved significantly
after IPL treatments. Moreover, colorimetric measurement demonstrated significant
improvement that was most remarkable after one session of IPL [12]. In our study,
there were significant differences in R2 values between individual measurements.
First beneficial changes were observed as early as after three series of treatment. It
was demonstrated that in majority of patients changes occurred gradually after each
treatment. In the Cutometeric study, viscoelasticity of skin on the basis of R6
parameter was also assessed. The results of R6 measurement were not as significant
as in the case of R2. Many authors [19, 20, 21] revealed that R6 parameter depends
on skin moisture. Water content in the dermis is frequently associated with the
hydration of epidermis. IPL can only indirectly influence the improvement of skin
hydration via affecting the stimulation of the production of water-binding
glycosaminoglycans. This is not the main objective of this method, therefore, the
treatment may improve skin moisturization only to a small extent.

Brazil J. et al. predicated that permanent skin rejuvenation was an unobtainable

goal, since UV damage was ongoing and its results cumulated over years [22]. In
our study, we observed that the improvement in skin elasticity in cutometric analysis
generally maintained for up to two weeks after last treatment. The results of
measurement performed three months after the series of treatment indicated the
reduction in skin elasticity in many patients. It may be a result of early end of
dermis remodelling. Numerous internal and external factors also influence
constantly occurring process of skin ageing.
Other authors compare different methods with IPL. The combination of a non-
ablative fractional laser with an IPL during the same treatment session is effective
and safe [23]. Combination of IPL, Ultherapy and Sculptra for the treatment of
aging face may be safely performed during a single treatment session [2]. Intense
pulsed light, near infrared pulsed light, and fractional laser combination therapy is
more effective strategy than IPL monotherapy for skin rejuvenation [24]. El-
Domyati M. et al. in clinical assessment of fotorejuvenation IPL treatment showed
mild improvement in skin texture, none of them reported improvement in skin
tightening or wrinkles. Moreover authors did not show statistically significant
histological changes after three months post IPL treatment [25]. On the other hand
Erol OO. et al. suggested that IPL was effective in improving the appearance of

8
keloids, hypertrophic scars and also in the reduction of the redness, height and
hardness of scars. The mechanism of IPL is not fully understood. It probably targets
vascular proliferation essential to collagen overgrowth and its effect on the
pigmentation [26].
Potential side effects after IPL treatments, such as hypopigmentation,
hyperpigmentation, wounds, and erythema are very rare [18]. In our research,
patients observed only redness, burning and skin tenderness.
Conclusion
Effects after series of IPL treatments appeared to be more remarkable in
terms of the improvement of skin elasticity rather than the reduction of wrinkles
depth and length. Objective measurement (cutometric) and subjective
(questionnaire) as well as clinical (photo documentation) assessment allowed for a
full analysis of anti-ageing effectiveness of IPL therapy. Results obtained after IPL
are often subtle and there is a need for multiple treatment sessions (min 5
treatments) to reach a goal. There were no complications during three months after
treatment.
Acknowledgements: This study was supported by statutory research activity Department of
Cosmetology and Aesthetic Dermatology, Faculty of Pharmacy, Medical University of Lodz
no.: 503/3-066-01/503-31-001 and 502-03/3-066-01/502-34-059.
Declaration of interest: The authors report no declarations of interest. The authors
themselves are responsible for the content and writing of the paper.

9
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Dermatolog Treat 2012; 23:472-6.

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14. Bitter PH.. Noninvasive rejuvenation of photodamaged skin using serial,
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15. Mezzana P, Valeriani M. Rejuvenation of the aging face using fractional
photothermolysis and intense pulsed light: a new technique. Acta Chir Plast
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16. Papageorgiou P, Clayton W, Norwood S, et al. Treatment of rosacea with
intense pulsed light: significant improvement and long-lasting results. Br J
Dermatol 2008; 159:628-32.
17. Dierickx CC, Anderson RR. Visible light treatment of photoaging.
Dermatologic Therapy 2005; 18:191– 208.
18. Hedelund L, Due E, Bjerring P, et al. Skin rejuvenation using intense pulsed
light: a randomized controlled split-face trial with blinded response
evaluation. Arch Dermatol 2006; 142:985-90.
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9.

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Table legends
Table 1 Characteristics of the study group.
Under- Small Dark
FWC eye- Periorbital Eyelid Hyperpigmen vascular circles
No. Age Sex Phototyp S** bags puffiness drooping tation changes under
e FC* the eyes
1 54 Female III III - - - - - -
2 61 Female III III - - - - + -
3 53 Female III II + + - + - -
4 57 Female II II - - - - - +
5 53 Female II II - + - - - -
6 44 Female III II - + + - - +
7 38 Female III I - - - + - -
8 43 Female III II - - - + - -
9 47 Female III II - - - + + -
10 46 Female III II - - + - - +
11 43 Female II I - + - + - -
12 47 Female II II - - - - - +
13 46 Female II II - - - + - +
14 48 Female III II - - - + - -
15 42 Female III III - - - - - -
16 43 Female II II - + - + + -
17 51 Female II III - - - - - -
18 40 Female III I - - - - - +
19 47 Female II II - - - - - -
20 56 Female II III + - - + - +
21 44 Female II I - - - - - +
22 43 Female III II - - - - - -
23 63 Female II III - - - + - -
24 44 Female II II + - - - - -

* Phototype FC – Fitzpatrick skin phototype classification

** FWCS - Fitzpatrick Wrinkle Classification System (I - fine wrinkles; II – fine to
moderately deep wrinkles, moderate number of lines; III – fine to deep wrinkles, numerous
lines and redundant folds)

12
 Table 2 Treatment parameters used in the therapy.

Treatment Energy Sequence Impulse Time of Recommendations according Number

parameters in of delay the to skin phototype of
J/ cm2 impulses impulse patients
A 16-20
3–4 18 -30 ms 4-6 ms Medium and dark III according 5
to Fitzpatrick

B 20-26 2–3 15-18 ms 4-8 ms Phototype ll and light III 15

according to Fitzpatrick

C 26-30 2 10-15 ms 7-10 ms Phototype II according to 4

Fitzpatrick

13
 Table 3 R2 and R6 parameters according to place and time of measurement.

N=2 Measureme Measuremen Measurement 3 Measuremen Significanc

4 nt 1 (*) t 2 (#) (^) t4 e
2 cm in a straight line from the outer corner of the eye
R2 0.358±0.110 0.403±0.101 *0.456±0.098 0.400±0.096 P=0.005
R6 0.540±0.281 0.399±0.175 0.396±0.148 0.420±0.228 P=0.014
2 cm from the pupil to the lower eyelid
R2 0.350±0.108 0.402±0.100 *0.439±0.091 0.408±0.111 P=0.005
R6 0.393±0.255 0.362±0.111 0.386±0.152 0.385±0.163 P=0.856
At the top of the orbital bone at the outer corner of the eye
R2 0.323±0.096 **0.403±0.07 ***0.500±0.084# 0.397±0.091^ P<0.0001
9 # ^
R6 0.561±0.190 0.545±0.174 0.634±0.180 0.660±0.250 P=0.073
Results are presented as a mean value ± SD (standard deviation)
*P<0.05; ** P<0.01; ***P<0.001 vs. measurement 1
#P<0.05 vs. Measurement 2

14
 Table 4 Pearson correlation coefficients (dependencies) between the R2 or R6 at
different time points (relative to 1).
Measurement 1 Measurement 2 Measurement 3 Measurement 4
2 cm in a straight line from the outer corner of the eye
Measurement 1 (R2) --- 0.716 -0.009 0.293
P<0.0001 P=0.966 P=0.164
Measurement 2 (R6) --- 0.453 0.262 0.564
P=0.026 P=0.217 P=0.004
2 cm from the pupil to the lower eyelid
Measurement 1 (R2) --- 0.398 0.144 0.289
P=0.054 P=0.503 P=0.171
Measurement 2 (R6) --- 0.581 0.549 0.490
P=0.003 P=0.005 P=0.015
At the top of the orbital bone at the outer corner of the eye.
Measurement 1 (R2) --- 0.511 0.294 -0.064
P=0.011 P=0.164 P=0.768
Measurement 2 (R6) --- 0.572 0.359 0.045
P=0.004 P=0.085 P=0.835
In all
Measurement 1 (R2) --- 0.540 0.087 0.192
N=72 P<0.0001 P=0.468 P=0.105
Measurement 2 (R6) --- 0.526 0.400 0.406
N=72 P<0.0001 P=0.001 P<0.0001

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Figure Legends
Figure 1a Graph of measured values of R2 in various time points.

Figure 1b Graph of measured values of R6 in various time points.

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 Figure 2 Patient AB, aged 54, before the first treatment session and 3 months
after the last one

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 Figure 3 Patient CD, aged 56, before the first treatment session and 3 months
after the last one.

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