Intense Pulsed Light

Therapy
Barbara Soltes, MD

KEYWORDS
 IPL  Hirsutism  Acne  Phototherapy

The property of light has long been used as a tool for the restoration of health. Hippo-
crates wrote for decades about the elements of nature as essential components in
the balance of sickness and wellness. The healing powers of sunlight became one of
the earliest recorded treatments in modern medicine.1,2 In the early centuries, light treat-
ments were used to correct a wide variety of medical conditions, such as smallpox and
tuberculosis.2 With the advent of the twentieth century, the traditional light treatment
was altered and laser emerged as an aesthetic tool. In 1963, Goldman and colleagues3
first described ruby laser injury to pigmented hair follicles. In the following years, the ruby
laser was used to treat other conditions, with little regard for absorption of light energy
by various tissues. A historical case reported in 1983 was that of a young boy treated for
a vascular nevi with a high-intensity laser, which resulted in severe epidermal damage. In
the same year, Anderson and Parrish4 developed the theory of photothermolysis. This
theory was based on pulsed light of a specific wavelength and duration directed at
a particular chromophore (melanin, hemoglobin, and water) within the skin layer. The
chromophore within a designated tissue could be destroyed selectively, while leaving
surrounding tissue unaffected.4,5 With this concept came an explosion in the number
of new light sources in the twenty-first century. These light sources had different wave-
lengths to accommodate a spectrum of aesthetic procedures with minimal pain.6–8 In
2008, nearly 75 million aesthetic light procedures were performed, and the number is
expected to double because of a growing and demanding young consumer market.
Intense pulsed light (IPL) therapy is an example of an aesthetic light treatment. IPL
therapy was initially approved by the US Food and Drug Administration (FDA) in 1998
for photorejuvenation of the pigmented lesions of aging. Shortly thereafter, it was
approved for photoepilation and acne photoclearance. IPL therapy has a reputation
of being a safe, fast, and effective treatment with a reasonable cost. At present, there
are more than 300 registered IPL manufacturers in countries all over the world.6

IPL

IPL technology involves parallel xenon flash lamps and capacitors contained within
a handheld wand or an articulated arm, which is applied directly to the surface of

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Rush-

Presbyterian-St Luke’s Medical Center, Chicago, IL 60612, USA
E-mail address: [email protected]

Obstet Gynecol Clin N Am 37 (2010) 489–499

doi:10.1016/j.ogc.2010.09.005 obgyn.theclinics.com
0889-8545/10/$ – see front matter Ó 2010 Elsevier Inc. All rights reserved.
490 Soltes

the skin. Single or multiple pulses of high-intensity light are rapidly discharged to the
skin surface. The light travels through the skin at a selected wavelength until it strikes
the desired chromophore (Fig. 1). The pulsed light is converted to heat energy, which
coagulates the desired target, such as a hair bulb or capillary within the dermis of the
skin. It does not penetrate deep enough to cause thermal damage to the epidermis.
This technique is known as selective photothermolysis. In addition, the IPL wand
possesses a filter to remove any ultraviolet (UV) components that lead to UV damage.
The pulses of light produced are of very short duration, which minimizes skin discom-
fort and discoloration.9
IPL machinery range from large freestanding units to compact mobile units (Fig. 2).
The standard properties of an IPL machine provide a wide spectrum of optimal wave-
lengths, power, and pulse durations. These properties allow for selective photother-
molysis for a variety of skin conditions. The usual specifications are as follows:
 Light source delivering a full spectrum of filtered IPL
 Optical adapters or crystal filters with wavelengths of 410 to 1400 nm
 Variable power (energy) range from 26 to 40 J/cm2
 Variable pulse duration from 5 to 30 milliseconds
 Two pulse modes, single and multidose.
The variability of wavelengths achieved with a simple change of a crystal filter allows
for several aesthetic procedures to be done at one visit (Fig. 3).7,10,11

PATIENT PREPARATION

A complete written medical history is the first requirement of IPL treatment. Absolute
contraindications to IPL therapy include seizure disorder, skin cancer, systemic lupus
erythematosus, pregnancy, shingles, vitiligo, skin grafts, and open skin lesions. Medi-
cations that are associated with photosensitivity (tetracyclines, sulfonylureas, isotreti-
noin, thiazide diuretics, nonsteroidal antiinflammatory drugs, St John’s wort) should
not be used while undergoing photo treatments. A relative contraindication to IPL
therapy is tanning or sun exposure within 30 days of the procedure. It is important
to set expectations and estimate the number of treatments required for a desired

Fig. 1. Chromophore absorption in human skin.

 Intense Pulsed Light Therapy 491

Fig. 2. IPL system.

outcome. Generally, a plan consists of 4 to 6 treatments at monthly intervals. A

consent form that explains the potential risks should be obtained before any treat-
ment.11 The risks include alterations in skin pigmentation and, rarely, scarring at the
treatment site.12

Fig. 3. Wavelength spectrum for clinical indications.

492 Soltes

Skin assessment is essential for any phototherapy. The determination of a skin type
is made by a self-administered questionnaire. Points are assigned based on genetic
composition, reaction to sun exposure, and tanning habits. The final score designates
a Fitzpatrick skin type, which correlates well with one of 6 skin types, from very fair
(type 1) to very dark (type 6) (Table 1). This classification system has been used since
1975 as a proven diagnostic and therapeutic tool in all dermatologic conditions. It was
adopted by the FDA for the evaluation of sun protection factor values of current
sunscreens.11,13,14
Based on the skin type and the photo procedure to be performed, a filter is selected.
Filters are wavelength specific; that is, for acne photoclearance, a wavelength of
410 nm is needed, whereas for photoepilation, a wavelength of 640 to 690 nm is
selected. Adjustable energy or fluences (26–40 J/cm2), along with a variable pulse
duration (5–30 milliseconds), that is the safest and most efficacious for the desired
procedure must be selected. A single pulsed mode is used when higher energy is
required, such as photoepilation in a woman with a light skin tone. Multipulsed
mode delivers a minipulse, followed by a millisecond delay, and then a final minipulse.
The advantage of the multidose mode is that it allows for the epidermis to cool while
thermal energy accumulates in a larger chromophore, such as a blood vessel. The skin
to be treated must be clean and dry immediately before the photo treatment. No
acetone or alcohol should be used. A spot test may be done initially to determine
the most effective power level for a particular skin type and condition.11,14,15 Protec-
tive eyewear should be used to avoid retinal damage.
The FDA has approved 8 indications for IPL treatments. The 2 indications that would
be a suitable addition to any gynecologic practice are photoepilation (hair removal) and
acne photoclearance. Only these 2 indications are discussed in further detail. Other indi-
cations include photorejuvenation, photoclearance of pigmented lesions and vascular
lesions, rosacea, telangiectasias (spider veins), and solar lentigo (brown spots).7

Table 1
Fitzpatrick skin classification system

Skin Type Response to Sun Exposure Examples Susceptibility

I Always sunburn, never tan White, very fair and freckled Very high
Red or blond hair
Blue-eyed
Celts
II Usually sunburn, tan with White, fair High
difficulty Red or blond hair
Blue, hazel, or green eyes
Scandinavians
III Sometimes sunburn, tan Beige, fair Average
gradually Any hair color
Any eye color
Very common
IV Rarely sunburn, tan easily Brown Low
Dark hair
Brown-eyed
Mediterranean Caucasian
V Very rarely sunburn, tan very Dark brown Very low
easily Mideastern
Latin American
VI Never sunburn, tan very easily Black Minimal
 Intense Pulsed Light Therapy 493

APPLICATIONS IN GYNECOLOGY

Hyperandrogenism is a common endocrinopathy in women. Women may present to

their gynecologists with distressing signs of androgen excess. Hyperandrogenic
states such as acne and hirsutism are encountered and usually treated with a pro-
longed course of antiandrogenic agents with fair but delayed results. The addition
of an adjuvant treatment, such as phototherapy, would lead to a quicker and more
permanent solution. It is also a means to supplement revenue in these times of
medical reform.

ACNE

Nearly 90% of adolescents and 20% of all adult women experience acne at some
point in their lives. Many women complain of hormonal acne, which correlates to
hormonal changes in their menstrual cycle. Traditional therapies include topical
creams or lotions, which cause redness and irritation of the skin. Oral antibiotics are
also used, but recent studies indicate an associated 40% resistance rate. In the United
States, an estimated $1.4 billion is spent yearly on these treatments with less-than-
satisfactory results.8,15
Sunlight has long been known to improve acne. However, the visible violet light
present in sunlight also has long-term skin damaging effects that preclude it as
a reasonable treatment option. IPL therapy uses the same band of wavelength
(420 nm) along with filtering of UV rays to safely eradicate the sebum and bacteria
in skin pores leading to acne.16–18
Skin is composed of an epidermal layer of downward pegs interlocking with dermal
papilla of an underlying dermis, both resting on subcutaneous tissue. The outer
epidermis is covered by a layer of keratin, which acts as a barrier from outside injury
or infection. Within the epidermis are skin pores. Deep within the pores lie the seba-
ceous glands, which are angled between the hair follicle and epidermis. The glands
produce sebum, an oily substance of lipids and wax esters, responsible for skin
texture and moisture (Fig. 4).8,14
The hair follicle is located in both the upper layers of the skin. The depth of the follicle
varies at different body sites. The hair follicle undergoes a growth cycle that is influ-
enced by many factors, including hormones. Androgens determine the hair growth
rate and the transformation from soft, unpigmented, vellus hair to coarse, pigmented,
and permanent terminal hair. In women, the ovaries, the adrenal gland, and the

Fig. 4. Anatomy of skin.

494 Soltes

peripheral layer of the skin produce androgens. As hormones change, a hardening of

the keratin layer or hyperkeratinization of the skin may occur and result in increased
sebum production. This hardening may cause a blockage of the skin pore and hair
follicle, creating a closed anaerobic environment.
Propionibacterium acnes bacteria build up and rapidly replicate in an anaerobic
environment. These bacteria damage the follicle wall and initiate an inflammatory
reaction. In the metabolic processes of P acnes, porphyrins are produced. Porphyrins
absorb light with a wavelength in the UV range. When porphyrins become chemically
active, they induce a photodynamic reaction and subsequently release singlet oxygen
or free radicals. The free radicals destroy P acnes in the sebaceous glands. Most
studies show an 80% improvement with just 3 IPL treatments. IPL therapy has been
shown to be far superior to topical agents such as benzoyl peroxide (Fig. 5).17–19

HIRSUTISM

In the twentieth century, clothes became more revealing and women became focused
on the removal of visible body hair. Various types of temporary hair removal are widely
used on a seasonal basis, but conditions such as polycystic ovarian disease, in which
there is excessive body hair, require a more permanent hair removal solution.
Hirsutism is the presence of excessive hair growth in a typical male-pattern distribu-
tion. The distribution pattern includes the upper lip, upper arms, forearms, back of
neck, chin, central chest, midabdomen, entire pubic region, inner thighs, shoulders,
and back.20
Hirsutism occurs in 5% to 10% of women of reproductive age and is caused by an
excess of androgen. More than 70% of hirsutism in women is caused by polycystic
ovarian disease. Although benign, it is an extremely distressing condition because

Fig. 5. Acne photoclearance. (Courtesy of Sybaritic, Inc, MN; with permission.)

 Intense Pulsed Light Therapy 495

of the excessive hair growth. Antiandrogenic treatments are necessary, but photoepi-
lation is an excellent adjuvant for immediate and more permanent hair removal.20,21
A basic understanding of the hair follicle and its growth cycle is essential to the hair
removal process. The number of hair follicles is genetically influenced and determined
at birth. Women of all ethnicities may have similar estrogen and testosterone levels but
differ in the amount of body hair because of the number of hair follicles per unit skin.
Scalp hair grows at a rate of 0.4 mm/d or about 6 mm/y. Hair growth and loss is not
cyclic or seasonal. A random number of hairs are at various stages of growth and
shedding. At the base of the hair follicle is the dermal papilla, which is responsible
for the metabolism of nutrients essential for hair growth. It is also the site of androgen
receptors. The hair growth response is directly correlated to androgen excess.22
There are 3 stages of hair growth: anagen (growth phase), catagen (transitional
phase), and telogen (resting phase). Anagen is the active phase of the hair follicle.
The stem cells in the bulge are rapidly dividing, and eventually, new hair is formed, which
is pushed up the shaft and out the epidermis. Hair grows about 1 cm every 28 days.
Scalp hair can stay in this active phase for 2 to 6 years. Hair on the arms or legs has
a short anagen phase of 30 to 45 days. Hair loss can occur when the anagen phase
is interrupted by medications or various illnesses. Catagen is the transitional phase,
and it lasts for about 2 to 3 weeks. About 3% of all hairs are in this phase at any time.
During this phase, hair growth stops. Telogen is the resting phase and lasts for about
3 months for scalp hair and longer for arm or leg hair. Nearly 10% to 15% of all hair is
found in this phase. About 25 to 100 telogen hairs are shed daily. Excessive shedding
during this phase may result a few months after a stressful event, such as childbirth,
surgery, or weight loss. After telogen, the hair cycle is complete and anagen restarts.
Older hair is pushed out, new hair shafts form, and the cycle repeats itself (Fig. 6).22,23
Hair consists of 3 main parts, namely the shaft, bulge, and bulb (Fig. 7). The hair
shaft is the visible part of the hair, which has no influence on hair growth, and contains
the arrector pili and stem cells, which are important for hair regeneration. The hair bulb
is at the base of the follicle where it lies in contact with the dermal papilla. It contains
the chromophore melanin. Women with dark hair have greater amounts of melanin and
the best results with hair removal using IPL.22,24,25

Fig. 6. The hair growth cycle. (From Hunter JA, Savin JA, Dahl MV. The structure and function
of hair. In: Clinical dermatology. London: Blackwell Scientific; 1989. p. 4–18; with permission.)
496 Soltes

Fig. 7. Anatomy ofahair follicle.(FromHunterJA,SavinJA,DahlMV.Thestructureandfunction

of hair. In: Clinical dermatology. London: Blackwell Scientific; 1989. p. 4–18; with permission.)

The usual methods of hair removal may be classified into 2 main groups. The first
group includes temporary removal, such as depilation (shaving, chemical creams)
or epilation (tweezing, waxing). The second group is considered as permanent hair
removal, which includes photoepilation (laser or IPL) and electrolysis. For the sake
of discussion, photoepilation is the only method addressed in this article.23,24
There are many similarities between laser hair removal and IPL therapy. Both proce-
dures are based on selective photothermolysis and target the skin chromophores
(melanin, hemoglobin, and water). It is possible to remove 20% to 40% of the hair
in the anagen phase in a single treatment. The best results occur in short dark hair on
light skin. The results may last for 12 months or longer.21,24 In spite of the similar
actions of these 2 methods, there are some major differences, which are listed in
Table 2.
Overall, the results of hair removal are the same for both devices, but IPL therapy
has gained popularity because of its relatively low cost (about $500 for 6 sessions),
minimal discomfort, and the nominal amount of time needed per visit.21,24–26
The process of IPL treatment is simple and results in minimal discomfort. IPL is
adjusted to a wavelength between 640 and 690 nm in a single pulsed mode, then

Table 2
Comparison of photoepilation techniques

Characteristics Laser Photoepilation IPL Photoepilation

Color beam Monochromatic Polychromatic
Beam projection Convergent beam Divergent beam
Power source Stimulated emission Xenon flash lamps
Wavelength Specific wavelength Wavelength 400–1400 nm
Filter for wavelength No filters Always with a filter
Skin types I–VI I–VI
Cost and results Expensive, slow Less expensive, fast
Skin contact No contact with skin Direct contact with skin
Handpiece (wand) Small handpiece Large handpiece
 Intense Pulsed Light Therapy 497

Fig. 8. IPL photo epilation. (Courtesy of Sybaritic, Inc, MN; with permission.)

directed to the site of desired hair removal. The duration of pulse frequency correlates
positively with the length of the hair to be removed. The longer the hair the greater the
pulse frequency. The focused light travels through the skin until it strikes the bulb of
the hair. The bulb contains the highest concentration of melanin compared with the
rest of the hair shaft. As the light is converted to heat energy, the bulb and most of
the hair shaft are coagulated. The intense heat also destroys the hair-producing papilla
or the entire hair follicle. To be effective, an adequate amount of heat energy must
reach both structures to coagulate them and stop the hair growth. Effective hair reduc-
tion is best achieved with hair follicles in the anagen phase. In general, 4-week inter-
vals are required between treatments to yield the best hair removal results (Fig. 8).24–27

SUMMARY

Light therapy remains an important aspect of medicine. IPL therapy is based on selec-
tive photothermolysis, which allows for a rapid treatment with great results and
minimal discomfort. It has been proved to be a safe and efficacious phototherapy
498 Soltes

for a variety of dermatologic and aesthetic conditions. Gynecologists may easily incor-
porate IPL therapy into their practice with minimal training provided by the manufac-
turer. It is an acceptable mode of adjuvant therapy for all women who suffer the
distressing signs of hyperandrogenism. IPL therapy also carries an added benefit of
an additional source of revenue.

REFERENCES

1. Kelly K. The Middle Ages. The history of medicine: the Middle Ages. New York:
Infobase Publishing; 2009. p. 1–17.
2. Bettman O. Hippocrates. A pictoral history of medicine. New York: Charles
Thomas Publisher; 1979. p. 14–32.
3. Goldman L, Blaney DJ, Kindel DJ, et al. Effect of laser beam on skin. Preliminary
report. J Invest Dermatol 1963;40:121–2.
4. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by
selective absorption of pulsed radiation. Science 1983;220(4596):524–7.
5. Grossman MC, Dierickx C, Farinelli W. Damage to hair follicles by normal mode
ruby laser pulses. J Am Acad Dermatol 1996;35(6):889–94.
6. Tanzi EL, Jason R, Lupton M, et al. Lasers in dermatology: four decades of prog-
ress. J Am Acad Dermatol 2003;49:1–31.
7. Tseng SH, Bargo P, Durkin A, et al. Chromophore concentrations, absorption, and
scattering properties of human skin in vivo. Opt Express 2009;17:14599–617.
8. Bashkatov AN, Genina EA, Kochubey VI, et al. Optical properties of human skin,
subcutaneous and mucous tissues in the wavelength range from 400 to 2000 nm.
J Phys D 2005;38:2543–55.
9. Sakamoto FH, Wall T, Avram MM, et al. Lasers and flashlamps in dermatology. In:
Fitzpatrick’s dermatology in general medicine. New York: McGraw-Hill; 2008.
p. 2263–79.
10. Alster TS. Getting started: setting up a laser practice. In: Alster TS, editor. Manual
of cutaneous laser techniques. Philadelphia: Lippincott, Williams and Wilkins;
2004. p. 2–4.
11. Wausau WI. Standards of practice for the safe use of lasers in medicine and
surgery. American Society for Laser Medicine and Surgery; 1998. p. 1–10.
12. Moreno-Arias GA, Castelo-Branco C, Ferrando J. Side-effects after IPL photode-
pilation. Dermatol Surg 2002;28(12):1131–4.
13. Sachdeva S. Fitzpatrick skin typing: applications in dermatology. Indian J Derma-
tol Venereol Leprol 2009;75:93–6.
14. Dover JS, Arndt KA, Dinchart SM, et al. Task force guidelines of care for laser
surgery. J Am Acad Dermatol 1999;41:484–95.
15. Dierickx CC,Grossman MC. In: Goldberg DJ, editor. Laser hair removal, lasers
and lights. 2005. vol 2. p. 61–6.
16. Papageorgiou P, Katsambas A, Chu A. Phototherapy of blue and red lights in the
treatment of acne. Br J Dermatol 2005;142(5):973–8.
17. Ellman M. The effective treatment of acne vulgaris by a high-intensity, narrow
band 405–420 nm light source. J Cosmet Laser Ther 2003;2:111–7.
18. Ellman M, Lask G. The role of pulsed light and heat energy in acne clearance.
J Invest Dermatol 2004;2:91–5.
19. Cartier H. Use of intense pulsed light in the treatment of scars. J Cosmet Derma-
tol 2005;4:34–40.
20. Santali A, Shapiro J. Management of hirsutism. Skin Therapy Lett 2009;14(7):1–4.
 Intense Pulsed Light Therapy 499

21. Haedersdal M, Gotzche PC. Laser and photoepilation for unwanted hair growth.
Cochrane Database Syst Rev 2006;4:CD0046854.
22. Hunter JA, Savin JA, Dahl MV. The structure and function of hair. In: Clinical
dermatology. London: Blackwell Scientific; 1989. p. 4–18.
23. Martin KA, Chang RJ, Ehrmann DA, et al. Evaluation and treatment of hirsutism in
premenopausal women: an endocrine society clinical practice guide. Clin Endo-
crinol Metab 2008;93(4):1105–20.
24. Olsen EA. Methods of hair removal. J Am Acad Dermatol 1999;40:143–55.
25. Liew SH. Unwanted body hair and its removal: a review. Dermatol Surg 1999;
25(6):431–9.
26. Buddhadev RM. Standard guidelines of care: laser and IPL hair reduction. Indian
J Dermatol Venereol Leprol 2008;74:S68–74.
27. Amin SP, Goldberg DJ. Clinical comparison of four hair removal lasers and light
sources. J Cosmet Laser Ther 2006;8:65–8.