Clinical Study: Photo rejuvenation utilizing a krypton light source: A clinical and histological study
PHOTO REJUVENATION UTILIZING A KRYPTON LIGHT SOURCE:A CLINICAL AND HISTOLOGICAL STUDY
Kathy L. Anderson D.O., Matt Leavitt, D.O., Nauman Nisar, M.D.
Advanced Dermatology (Clearwater, Tampa, Brandon, Seminole, St. Petersburg), Florida, Tampa Pathology Laboratory, Tampa, Florida
_____________________________________________________
Background: Treatment of skin irregularities due to aging, sunlight or congenital factors by noninvasive techniques is of growing interest. Solar lentigenes, telangiectasias, skin texture irregularities, enlarged pores, rhytides and generalized dyschromia contribute to the appearance of aging skin. Lasers as well as high intensity pulsed light devices have been used for non-ablative treatment of aging skin.
Objective: To evaluate the safety and efficacy of non-ablative photo rejuvenation treatments using a patented Krypton light source device by Novalis Medical utilizing means of histological changes, photographic documentation as well as patient satisfaction. Methods: 20 patients aged 15 – 66 years with varying degrees of skin irregularities and/or vascular lesions were treated with 1 – 3 treatments at 3 weeks intervals using a Krypton light source at fluencies varying from 10 – 19 J/cm2. Skin biopsies were performed, pre/post treatment photos were taken, and self-evaluating patient questionnaires were compiled to assess patient satisfaction regarding various aspects of the treatment results.
Results: All patients in this study reported moderate to extreme satisfaction with the overall results of their treatment. There was improvement in each category of telangiectasias, skin smoothness, pore size, pigmented irregularities and fine wrinkles for all patients treated in each applicable category. The subjects experienced no severe side effects and minimal down time. Histology showed new collagen formation with no damage to the epidermis or dermal appendages.
Conclusion: Treatment of telangiectasias, photo damaged, congenital and/or age related skin irregularities using the patented Krypton light source from Novalis Medical is a new, safe and effective method for non-ablative photo rejuvenation treatment.
_____________________________________________________
Skin rejuvenating procedures are concerned with skin irregularities caused by ultraviolet rays 1 (photo damage) and skin irregularities caused by genetic and/or age related factors2. Patients consult dermatologists and plastic surgeons daily with questions regarding the latest techniques available to retain their appearance of youthfulness. These techniques involve filling and smoothing defects, diminishing age spots and discoloration, and removing visible blood vessels. Today’s busy schedules don’t afford many patients the necessary down time for resurfacing techniques and invasive surgery as they did in the past. Many patients are now searching for a “minimal downtime” procedure with obvious beneficial results. Patients often have several cosmetic goals in mind: improvement of wrinkles, smoothing of skin texture, removal of age spots and blood vessels, and reduction of pore size. Frequently, multiple procedures and techniques are required to accomplish these goals; which in turn increases overall treatment time, treatment cost, and treatment downtime. The search for a nonablative technique that can accomplish several cosmetic goals with one treatment modality would be a strong step forward in meeting the needs of our cosmetic patients.
METHODS:
This study consisted of 20 patients (17 female; 3 male) ages 15-66 with varying degrees of photo damage/aging of the skin and/or congenital vascular lesions who had no previous treatments for these indications. All patients were Fitzpatrick skin types I – III and received 1 to 3 treatments, determined by the extent of the irregularity treated and the desired end result. All but one patient displayed some visible evidence of skin photo damage or aging. (i.e. dyschromia, wrinkles, laxity, and/or telangiectasias). Patients with a history of recent oral retinoid use, sensitivity to radiation light, suspicious lesions in the treatment area, neoplastic or inflammatory, or taking photosensitizing medications were excluded from the study. No patients had a history of previous laser or high intensity light treatment. Those patients with a history of herpes simplex where given prophylactic anti-viral medication prior to treatment. Patients using topical medication for acne or rosacea were allowed to continue as needed. Patients were instructed to use a mild cleanser and sunblock with moisturizer daily. Informed consent for the procedure and photographic documentation was obtained. Pre and posttreatment biopsies were performed on 6 patients. Pretreatment involved thorough cleansing of the skin followed by the application of a chilled clear plume barrier lotion (1mm thick) to the treatment area. Light is directed to the skin via a stainless steel and ceramic reflective light guide that is placed directly on the skin. The spot size of the light output is 1.3 x .6 inches. The light source is produced by a special Krypton flashlamp that produces a patented specific wavelength distribution pattern (Novalis Medical, LLC, Tampa, FL) in the range of 530nm – 1200nm (Fig. 1).
The Krypton light source device used in this study was developed by Novalis Medical, LLC. This device was the 1st generation of the company’s newer devices now called the Clareon® and Solarus®. This 1st generation device has two modes: mode 1 for pigmented / vascular lesion removal and mode 2 for hair removal. Mode 1 was selected for the patients in this study. In mode 1, the Krypton light source device delivers a “treatment shot” consisting of four 12ms pulses with no delay between pulses, creating a total “treatment shot” duration of 48ms. The device delivers 1 treatment shot every 3 seconds to allow time to move the delivery head to the next consecutive area. The eyes were protected from light using goggles or cotton pads. The treatment fluence setting varied between 10 and 19 J/cm2. Fluences were adjusted as necessary at successive treatments. Treatment fluences were chosen to minimize or prevent edema and purpura while still achieving the desired endpoint. The beard area on the males was avoided to prevent potential hair loss. Two consecutive treatment shots were applied to each spot area prior to moving to the next treatment area. Patient feedback regarding the pain experienced was elicited. The treatment ensued until a desired endpoint of slight erythema and/or darkening of the visible lentigenes/dyschromia within 90 seconds of the treatment was observed. A specific area was retreated at a higher fluence during the same treatment session if the tissue response appeared to be less than adequate. All patients experienced a sensation analogous to an rubber band slapping the skin with each treatment shot. The light guide is placed directly onto the area being treated and moved systematically across the entire treatment site. Large treatment areas are divided into sections. As each section is treated, additional cooled plume barrier lotion is applied before moving to the next section. This was done for patient comfort and to prevent plume from sticking to the device output window. After all sites are treated, the plume barrier lotion is wiped from the skin and a Class III topical corticosteroid is applied immediately post treatment, and the patient is given samples of the same to apply twice in the next 24 hours. Again, this will minimize the chance of any blistering secondary to epidermal heat transfer. Three patients requested some form of anesthetic to reduce the discomfort and a topical anesthetic cream was used on 3 patients (Ela-Max, Ferndale Labs). The anesthetic was applied 30 minutes prior to the procedure and removed prior to treatment.
Patients being treated for solar lentigenes were advised to expect superficial crusting of lesions that would resolve within 1 – 2 weeks. The patients being treated for telangiectasias and general dyschromia did not experience a distinct peeling effect, but did have the universally experienced post treatment state of mild exfoliation and a feeling of skin tightness. Erythema and slight purpura were experienced in all patients to varying degrees. The patients were advised to use the same mild soap, sunblock and moisturizer post-treatment as they used pre-treatment. The use of acne medication could be resumed in 3 days. Patients were strongly advised to avoid sun exposure to the treated area throughout the pre and post treatment time period.
The objective of the treatment protocol was to maximize improvement of pigmented and vascular lesions and over-all skin quality appearance with minimal down time. The pre and post treatment photos were taken with a Polaroid Macro-5 camera and were assessed by the investigators and patients for objective proof of improvement. Unalterable Polaroid pictures were used due to the increasing skepticism surrounding the ease of manipulation of digital photography. The patients were then asked to respond to a questionnaire (Table A) and subjectively evaluate their treatment in regards to various cosmetic irregularities (Table C). These evaluations were obtained 4 – 6 weeks after their final treatment when post-treatment photos were taken.
PHOTO REJUVENATION QUESTIONAIRE
Use the following scale from 1 through 10 to assess your Photo Rejuvenation treatment.
0 = Unsatisfied with the results.
5 = Moderately satisfied with the results.
10 = Extremely satisfied with the results.
NA=Not Applicable
How would you rate? :
1. Your overall results. (How happy you were with the results.) _____________
2. The clearing of any pigmented blemishes. (Freckles, Age spots, etc.) _____________
3. The change of smoothness of your skin _____________
4. The smoothing of the fine lines. _____________
5. Skin laxity: The change in tightness of your skin. _____________
6. The decrease in pore size. _____________
7. Did you have any visible blood vessels prior to treatment? _____________
If so, how would you rate the removal? _____________
TABLE A
RESULTS:
20 patients completed successive treatments for signs of photoaging such as freckles (Fig. 3a,b), solar lentigenes, course skin texture, fine wrinkles (Fig. 4a,b), telangiectasias (Fig. 5a,b), and rosacea. The patients were asked to rate their satisfaction regarding the improvement of the various aspects of their specific skin problems. All patients were moderately to extremely satisfied with their treatment. A questionnaire (Table A) was given to each patient for self-evaluation of the treatment. The area treated, age, condition treated, and number of treatments were noted for each patient (Table B). Patients were asked to rate their satisfaction with the treatment on a scale ranging from 0 to 10, with 0 being unsatisfied with the treatment and 10 being extremely satisfied (Table C).
BEFORE AFTER
Patients answered only those questions applicable to their specific complaint(s). Please note the overall column in Table C reflects the patient’s answer to question #1 of the questionnaire and does not reflect the average rating of the other questions. The Avg. row at the bottom of TABLE C reflects the average rating of all patients for that particular complaint treated. It is the opinion of the investigators that the average row in TABLE C is a good representation of how well the Krypton light device works in each of the categories judging from clinical observation.
Patient Breakdown
PATIENT Sex Age CONDITION TREATED AREA TREATED No. of Tx’s
1 F 45 Fine lines, course texture Face 3
2 F 15 Facial Telangectasia Face 1
3 F 55 Solar lentigenes, fine lines, course texture Face 4
4 F 47 Solar lentigenes, fine lines, course texture Face 2
5 M 63 Solar lentigenes, fine lines, course texture Face 2
6 F 44 Rosacea Face 3
7 F 32 Solar lentigenes, pore size, course texture Face 3
8 F 65 Solar lentigenes, wrinkles, course texture Neck, Chest 3
9 F 33 Acne damage w/hyperpigmentation/vascular Face 3
10 F 50 Wrinkles, course texture Face 3
11 F 26 Facial freckles Face 3
12 F 46 Freckles, fine lines, telangectasias Face 2
13 F 55 Solar lentigenes, wrinkles, Poikiloderma Face, Neck 2
14 M 43 Solar lentigenes, telangectasias Face 3
15 F 36 Solar lentigenes, freckles, fine lines Face 2
16 F 66 Solar lentigenes Chest, arms/hands,legs 2
17 F 46 Solar lentigenes Face, Chest 2
18 F 40 Solar lentigenes Face 2
19 M 32 Acne Scarring, pore size, coarse texture Face 2
20 F 55 Wrinkles, course texture, telangectasias Face 2
AVG. 2.45
PATIENT SATISFACTION RATING
PATIENT OVERALL Pigmentation Smoothness Fine Rhytides Skin Laxity Pore Size Vascularity
1 10 10 8 10 7
2 10 10
3 10 10 8 8 8 8
4 7 6 5 5 5 2
5 6 9 7 4 5 4 5
6 8 8 9 9
7 7 10 6 5 7
8 10 10 10 8 8
9 7 7 9 7 8 6 6
10 10 10 10 10 10
11 10 10 9 9 7 5
12 8 10 9 8 8 8 9
13 10 9 10 10 10 10
14 8 8 8 9 7 8
15 10 10 9 8 9 7
16 8 8 8 8
17 10 10 8 8
18 9 10 9 9 7 10
19 5 6 4 6 5
20 10 10 10 10 7 8 10
AVG. 8.7 9.1 8.4 7.6 7.8 6.9 8.4
0 = UNSATISFIED
5 = MODERATELY SATISFIED
10 = EXTREMELY SATISFIED
NOT APPLICABLE
TABLE C
One patient did experience slight blistering consisting of an area of 1 -2 cm2 on one cheek which resolved without sequelae within 2 weeks. This patient followed the post treatment protocol as previously described. One patient with severe freckling experienced edema infraorbitally that resolved in three days. More marked dyschromia, lentigenes or freckles increased the possibility of edema, erythema or blistering due to increased light absorption. Patients treated specifically for reduction in pore size, telangiectasias or fine wrinkles, had less post-treatment erythema. While the improvement of generalized dyschromia and poikiloderma was slightly less dramatic than the improvement of freckles and lentigenes, high patient satisfaction was realized in all subjects. While the erythema in all patients subsided in 24 – 48 hours, the peeling of solar lentigenes or freckles, which remain slightly darkened after treatment, occurred during the two weeks after treatment.
BEFORE AFTER
Six of the patients in this study allowed biopsies to be performed pre and post treatment. 4mm punch biopsies were obtained prior to any treatments; and post-treatment biopsies were performed 4 weeks after the final treatment.
HISTOLOGIC
Biopsies were performed on six patients. The patients biopsied had 2 to 3 full-face treatments. Punch biopsies of 4mm were obtained from the right cheek area before treatment. Four weeks after the final treatment, biopsies were taken from the left cheek area to prevent re-biopsy from same site. Biopsies were stained with hematoxylin and eosin and are evaluated by light microscopy. Results were evaluated by a dermatopathologist in a prospective single blind study. Histopathological sections of facial skin, before and after treatment with the Krypton light source device, revealed formation of new collagen in both the papillary dermis as well in the reticular dermis as well as an increase in the number of fibroblasts (Fig. 6a, b). The collagen bands were thicker, more compact and arranged somewhat haphazardly with no homogenization. The degree of collagen deposition was more pronounced in the papillary dermis as compared to the reticular dermis.
An inverse correlation was observed between the amount of collagen remodeling and the age of the patient in this study, as the remodeling of collagen was more pronounced in younger, middle aged patients compared to older subjects.
BEFORE AFTER
A proportional decrease in the amount of solar elastosis between the pre-treatment and post-treatment biopsies was noted. There was no appreciable difference in the amount or distribution of the superficial dermal perivascular lymphocytic infiltrate seen in both the pre-treatment and post-treatment biopsies, which is in contrast with some of the earlier observations 3. Similarly, no changes in the number and distribution of melanophages were noted in post-treatment biopsies. Evidence of any damage to the epidermis or the dermal appendages in the post-treatment biopsies was not seen. Furthermore, there was no evidence of endothelial swelling or fibrin thrombi. The nerve bundles appear unremarkable. Folliculosebaceous apparatus and eccrine ducts also remain intact
POST TREATMENT MAINTENANCE:
Following the Krypton light treatments, all patients were instructed regarding specific skin care to maintain the results and to help prevent future sun damage. The patients were advised to apply a sunblock routinely every day. In this group of patients, we utilized the products Ti-Silc® and Z-Silc® by Procyte® for daily sun protection. Our patients were also advised to continue with products that have been shown to be an effective agent in maintaining more youthful collagen density. Retinoids as well as Copper Peptide products such as the Neova line of therapies were recommended 4. Patients were also reminded that a healthy lifestyle where diet, exercise and avoidance of obvious detriments such as alcohol and smoking will help to maintain a more youthful appearance.
DISCUSSION:
This study is the first published clinical & histological evaluation utilizing a Krypton light source device. The results of this study demonstrate a high degree of patient satisfaction with this treatment and minimal downtime. This is a treatment modality that is safe & effective in treating superficial telangiectasias, hyperpigmented lesions and at the same time creating histological improvement in the collagen bundles to result in a smoother, less wrinkled skin texture 5. The Krypton light technology appears to require fewer treatment sessions (avg. of 2.5 Tx’s) than a Xenon light device (6 Tx’s), (Vasculight, by ESC) according to previously published reports 3. In this study, a variety of treatment situations were approached. The youngest patient was 15 years old, with a solitary spider angioma that resolved after one treatment. Other patients had combination problems- some related to photo damage or aging while other resulted from acne or rosacea damage. Treatment of the neck, hands, and legs for resolution of lentigenes was also performed. Very few studies have been published regarding rejuvenating treatments of these areas 6. Patient #16, treated for lentigenes of the extremities, was quite satisfied (See Table C). As seen with this study, the Krypton light technology is able to improve different skin irregularities with one modality. The Krypton light source device used for this study was very simple to operate in that it has only one output energy control and a choice of two modes, each selected by the push of a button. Mode 2 of the device, which is suitable for hair removal, was not used in this study. Mode 1, which was used on all patients in this study, consists of four 12 ms pulses of multiwavelength light with no delay between each pulse. This creates a 48ms quad-pulsed output in a sawtooth pattern. By having a multi-pulsed output, in combination with a long 12ms individual pulse duration, a temperature regulating effect is created. By taking advantage of tissue thermal relaxation time in this manner, high peak temperatures are avoided which significantly decreases the risk of tissue damage. Furthermore, the 48ms quad-pulsed output duration is designed to be effective on pigmented and vascular lesions eliminating the need for duration adjustment by the operator. The light produced by the device encompasses the range of 530nm to 1200nm. What is generally not discussed with multi-wavelength devices is the amount of light produced at each particular wavelength. Many assume the intensity output of a multi-wavelength device is distributed evenly throughout the spectrum range, when in fact, quite the opposite is true. The intensity of light can vary as much as ten fold from one wavelength to another. Since wavelength plays a large part in determining depth penetration and the level of heat produced in melanin, blood and tissue, the intensity distribution pattern of the wavelengths in a multi-wavelength device is extremely important. The absorption of melanin, hemoglobin, and water, as well as depth penetration, varies throughout the spectrum range (Fig. 2).
Pulse Dye Modified Nd:YAG
* Conceptual graph only
Shorter wavelengths have high melanin and blood absorption but low depth penetration 7. Conversely, longer wavelengths have greater depth penetration yet lack high melanin and blood absorption 7. Since a laser is single wavelength, one can see that no matter which wavelength is chosen, something must be sacrificed (Fig. 2). This wavelength conundrum is what creates the need for several lasers in an office. This problem is rectified with Krypton technology which creates a bell curve distribution of multi-wavelengths that produces the greatest amount of light in the mid-wavelength range and tailing off the intensity at each end of the spectrum range (Fig. 1). By having this distribution pattern of multi-wavelengths, a non-compromising output is created, utilizing all varying aspects of absorption and depth penetration.
Selective photothermolysis is generally achieved by matching the output duration of a laser or light device to the thermal relaxation time of the target, while also matching the absorptive wavelength of the target chromophore 7. The Krypton light technology developed by Novalis Medical seems to create a better wavelength distribution throughout the useful spectrum for more efficient chromophore absorption. Nonablative selective photothermolysis of pigmented lesions and superficial telangiectasias was accomplished with very little erythema to the surrounding normal skin. The specific pattern distribution of multiwavelengths (Fig. 1) is designed to have the perfect balance of hemoglobin and melanin absorbing wavelengths to achieve this goal. When using the Krypton wavelength distribution balance with a 530nm cutoff filter, fluence can also select the targeted chromophore. This simple factor allows a larger window of effectiveness as compared to other devices which must critically adjust pulse durations to obtain the peak temperatures necessary in the targeted lesion. At lower output energies of the device, pigmented lesions are destroyed without causing any vessel damage. By increasing the output energy of the device to the mid-level range, lighter pigmented lesions and generalized dyschromia are removed while still sparing blood vessels. At the higher output energy level, still lighter pigmented lesions are removed, while also removing superficial telangiectasias.
In using the Krypton light device in this study, we have found a high patient satisfaction treatment modality that has the ability to accomplish numerous cosmetic goals. Lentigenes and telangiectasias can be eliminated while simultaneously creating a smoother appearance and reduction in pore size through collagen remodeling. The effectiveness and speed of the clinical outcome from this technology certainly played a large role in the high patient satisfaction.
REFERENCES
1 Bernstein EF, Chen YQ, Kopp JB, et al. Long term sun exposure Alters the collagen of the papillary dermis. Comparison of sun-protected and photoaged skin by northern analysis, Immuno-Histochemical Staining and Confocal Laser Scanning Microscopy. J. Am. Acad. Derm. 1996; 34: 209-18.
2 Escoffier C, de Rigal J, Rockefort A, et al. Age-related mechanical properties of human skin:An in vivo study. J. Invert. Dermatol. 1989; 93: 353-7.
3 Bitter PH. Noninvasive Rejuvenation of Photodamaged Skin Using Serial, Full Face, intense Pulsed Light Treatments. Dematol. Surg. 2000. Sep; 26/9) : 8 35-42; discussion 843.
4 Lewis V:Aging Signs may be Treatable with Copper Peptide, Cosmetic surgery Times 2000: May; 32
5 Goldberg DJ. New collagen formation after dermal remodeling with an intense pulsed light source. J. Cutan Laser Ther 2000; 2: 59-61
6 McDaniel DH, Ash K, Lord J, et al. The Erbium:YAG Laser: a review and preliminary report on resurfacing of the face, neck and hands, Aesthetic Surgery J. 1997; 17: 157.
7 Anderson R: Laser Tissue Interactions. In Goldman M, Fitspatrick R, eds. Cutaneous Laser Surgery: The art and Science of Selective Photothermolysis. St. Louis, 1994, Mosby-Year Book, Inc.
