Protocol for Laboratories

Aesthetic Laser Lab

Post Graduate Department of Cosmetology & Health Care

Dev Samaj College for Women, Ferozepur City

Re-accredited ‘A’ grade (2nd Cycle) with 3.75/4 CGPA (Highest in India, 2013-14) by NAAC Bangalore

College with Potential for Excellence & Star Science Department Status – Awarded by UGC, New Delhi

College of Excellence status awarded by UGC, New Delhi

A unique prestigious Post Graduate Institution of Northern India

LAB COURSE ON AESTHETIC LASERS

Objectives of this protocol

—1. To constitute and perform the Lab course as unified whole rather than secluded contingent parts.

—2. To constantly plan lab work on lines of class work and course outline to augment the intensity of learning

—3. To connect, engage and involve the students to make them more ingenious, imaginative and independent in trouble shooting through "Design and Planning" of experiments rather than just performing experiments.

—4. To actively involve the students in experimentation by making them sense that they are accomplishing a major assignment in the lab and corresponding theory class.

—5. To impress the values by incorporating the use of conventional and classical lab concepts and skills during logical and manual ‘Dexterity’ resources in the lab.

Lab Resources
Medical supplements

—Optional topical anaesthetics

—Tyrosinase inhibitor if needed (from skin types IV onwards)

—Soothing gel/cream

—Anti-inflammatory and antibiotic creams

—Sunscreen of SPF 30-50 

                             Aesthetic Laser 

Lab Intense pulsed light (IPL)

Intense pulsed light (IPL) is a technology used by cosmetic and medical practitioners to perform various skin treatments for aesthetic and therapeutic purposes, including hair removal, photorejuvenation as well as to alleviate dermatological diseases such as acne.

—The technology uses a high-powered, hand-held, computer-controlled flashgun to deliver an intense, visible, broad-spectrum pulse of light, generally in the visible spectral range of 400 to 1200 nm.

—Various cutoff filters are commonly used to selectively filter out shorter wavelengths, especially potentially damaging ultra violet light. 

Applications of IPL in Cosmetic Dermatology

—The Intense Pulsed Light and its nine filters are indicated for the treatment of:

—Benign epidermal pigmented lesions, including - but not limited to - dyschromia and hyperpigmentation

—Permanent hair reduction

—Benign cutaneous vascular lesions, including - but not limited to - port wine stains, haemangioma, telangiectasias, rosacea, angiomas, poikiloderma of Civatte and venous malformation

—Mild to moderate inflammatory acne

Applications of IPL in Cosmetic Dermatology

 Principle of operation

Light has a dual definition as:

Particles – photons Electromagnetic wave, defined by its: Amplitude (intensity) Wavelength, λ(nm) or frequency, f(Hz) (oscillations/s)

                      Electromagnetic spectrum

                                


                                   Light sources

                   

                
               Two distinctive light emissions

                                 Skin structure

                          Light/Skin interaction 

                         Light/tissue interaction

                                IPL components

                        IPL spectral selectivity

                              7 Expert Filters

                  Clinical advantage of pulse trains

Optimized thermal control as a function of :

— Skin type

—Type of chromophore

—Chromophore density

—Lesion depth

—Sensitivity of anatomical area

—For a gradual heat generation into the target while maintaining a safe heat level in target surroundings and epidermis

—SapphireCool™ light guides provide additional parallel epidermal cooling during the pulse train delivery

                                 Universal IPL handpiece

                                    Fluence

—Highest tolerable fluence generates the best response

—Increased fluence - risk of side effects also increases

—Decreased fluence - probable inefficiency

—Lower fluence is suitable for:

— Dark skin - safety

—Dense lesion - good light absorption

—Shallow lesion - no need to compensate for depth

—Higher fluence levels are possible and necessary with the optional 6mm light guide

— With default OPT, M22 suggests presets producing optimal fluence matching skin type and lesion features

                                  

                           Patient consultation

—Full medical history

—Assess skin type

—Diagnose condition/lesion and its severity

—Review

—Expectations and compliance

—Contra-indications

—Potential complications

—Pre- and post-treatment instructions

—Pre- and post-treatment medication and care

—Plan follow-up visits

—Plan multisession treatment

—Average intersession interval: 3-10 weeks as per procedure .

             Patient selection

—Get a fully-detailed medical history

—Use of a medical questionnaire and informed consent form is advised

—Exclude any lesion with malignant potential

—For any suspicion on cancerous lesion, excision biopsy may be considered

—Patients with unrealistic expectations should be identified during the consultation and discouraged

—Light/laser treatments treat the effect, not the cause E.g. solar habits will not hinder the occurrence of new solar spots!

—Need of multiple sessions with occasional “touch-ups” Is very individual and cannot be predicted accurately


Realistic expectations

—Percent clearance may vary according to:

—Skin type

—Difference between skin and lesion color

—Lesion size and density

—Physiological condition – genetics, age, gender, hormonal status, general health

—There may be some discomfort and transient redness and/or swelling associated with treatment

—There is a small risk of adverse reaction .

Realistic expectations

—Percent clearance may vary according to:

—Skin type

—Difference between skin and lesion color

—Lesion size and density

—Physiological condition – genetics, age, gender, hormonal status, general health

—There may be some discomfort and transient redness and/or swelling associated with treatment

—There is a small risk of adverse reaction

Before any treatment

—Proper skin type assessment is first essential factor to determine for effective and safe treatment choice

—Incidence of skin reaction to sun (Fitzpatrick)

—Incidence of ethnics origin (Lancer ethnicity scale)

—Incidence of solar habits

—Some skin typing assessment tools exist but remain informational only.  They cannot substitute for professional medical diagnosis

—For any doubt in-between 2 skin types, overestimate for safer treatment

Skin type classification

Precautions & Contra-indications

Precautions

—Patients with a medical history or presence of the following conditions should be treated with caution and per the physician’s discretion:

—Bleeding coagulopathies

—Keloid scarring

—Herpes simplex; treatment can trigger a herpes outbreak; prophylactic antiviral therapy may be prescribed

—Systemic Lupus Erythematosus or Porphyria

—Immunosuppressive diseases, including AIDS and HIV infection

—Uncontrolled systemic diseases such as diabetes, epilepsy or congestive heart disease

—Photosensitivity in general, or any sensitivity to the sun that causes a rash or an allergic reaction

—Hormonal disorders, such as polycystic ovary syndrome, unless under control

—Gold therapy

—Radiation therapy

—Prior use of collagen, fat injections or other methods of skin augmentation .

Precautions

—Patients who use any of the following should be treated with caution and per the physician’s discretion:

—Anticoagulants; avoid usage of anticoagulants prior to treatment

—Immunosuppressive medications

—Herbal supplements, perfumes or cosmetics that may affect sensitivity to light

—Oral Isotretinoin (such as Accutane)

—Patients with the following conditions should be treated with caution and per the physician’s discretion:

—Damage to natural skin texture and/or very dry skin

— Highly vasculated area in the lesion's immediate proximity

—Treatment within the orbital rim: patient should wear intraocular shields to protect the eyes from direct or indirect IPL exposure

Contra-indications

—Treatment should not be attempted on patients with the following conditions in the treatment area:

—Active infections

—Dysplastic nevi

—Significant concurrent skin conditions or any inflammatory skin conditions

—Active cold sores, open lacerations or abrasions

—Chronic or cutaneous viral, fungal, or bacterial diseases

—Exposure to sun, remaining suntan or artificial tanning in the 3-4 weeks pre-op plan

—Tattoos

—Treatment should not be attempted on patients with a history of skin cancer or pre-cancerous lesions on the treatment area

Safety

IPL beam hazards

Patient eye protection

Clinician and attending staff eye protection

Integrity of Universal IPL treatment head component

Skin preparation

—4-6 weeks pre-op – optional skin care preparation programs

—Tyrosinase inhibitor to reduce the risk of PIH on darker skin types

—Sun block SPF 30-50

—Immediately before treatment

—Thoroughly cleanse the entire area to be treated with fragrance-free make-up cleanser, micellar cleansing water or cleansing towelettes

—Using the white eyeliner, mark your treatment area and cover the nevi to be protected

—Put eyewear on the patient as per treatment area (ref. eye protection section)

—Using a spatula, spread a 1-2mm uniform layer of clear coupling gel onto the test area for the test patch .

                             Test patch

—Prior to full treatment, test patch shall be conducted with treatment desired/relevant parameters in a small inconspicuous area but still in the requested anatomical treatment zone

—Use same technique and parameters as for overall treatments

—Selection of treatment parameters should be considered carefully and care should be employed to evaluate test patching following an appropriate period of time

—At least 15 to 30 minutes for skin types I to III

—At least 24-48 hours for skin type IV

—At least 48 to 72 hours for skin types V after test patches, to observe tissue reaction

—Patients, in particular with darker skin types (Fitzpatrick IV to V), with sensitive skin or without pre-treatment regimen, may develop delayed healing, hyper or hypopigmentation

General treatment considerations 

Is usually not required, nor necessary

—If requested, follow the guidelines of the manufacturing healthcare professional for application dosage, occlusion, timing and removal

—The vasoconstrictor effect of lidocaine in most of the topicals is not suited for VL or ST treatments as they modify the targeted chromophore

—Pre-cooling – but limited to PL and HR – may help improving patient comfort .

General warnings 

—Do not allow any cream, body lotion, make-up, deodorant or fragrance on the area to be treated even when applied a long time prior treatment

—Do not overlap tattoos and keep some 2mm off the tattoo contours

—Also be careful when treating the upper lip not to cover permanent lip liners

—Over hairy areas, even when HR is not the requested procedure, shave closely prior to treatment

—Bear in mind that melanin absorbs light in the entire IPL™ spectrum

—For ex. treating rosacea on a man’s cheeks lead to concurrent hair removal

Demonstration

on

IPL Treatment

—After the test patch has been duly performed, spread a uniform layer (1-2mm) of clear fresh coupling gel

—Over large areas, apply gel band-wise as you proceed with the treatment as it may dry out if left too long onto the skin

—For a single lesion (PL for ex.) either use the 6mm* light guide or punch a hole in a pure white cardboard to adjust to the treatment area. Also apply gel onto the cardboard

—In STANDBY mode, always check for light guide cooling with the palm of your hand .

Demonstration on IPL Treatment

Demonstration on IPL Treatment

Demonstration on IPL Treatment

—Move to adjacent location without sliding but in a “pick and place” technique to leave clear footprints in the gel for easier detection of the areas being treated

—Do not overlap treatment sites by more than 1mm

—Wipe the light guide regularly with a soft tissue since hair may stick to it

—Do not re-use the gel as it may accumulate singed hair

Post-treatment

—At treatment termination, wipe off the gel

—Apply immediate post-cooling (cold packs not frozen) for 5-10 minutes

—For mild erythema/edema

—Apply a soothing gel/cream and/or sun block if required

—For stronger reactions without skin damage (ex. strong perifollicular papules)

—Apply anti-inflammatory creams (dermocorticoids)

—For stronger reactions with skin alteration (blisters for ex.)

—Apply antibiotic cream to prevent infection

Potential Side effects

Possible short- to mid-term reactions

—Erythema

—Post-treatment erythema might be observed on sensitive light skin and may typically last from 1 to 3 days

—Purpura

—Often results from the use of too short pulse durations and excessive fluence

—Might turn into hemosiderin stains

—Edema

—Swelling might be observed on sensitive anatomical areas and may typically last from a few hours to 2 days

—Scabbing

—Likelihood is higher after a PL treatment and may typically last up to 7 days .

Possible mid- to long-term reactions

—Very rarely:

—Burns

—Likelihood of burns is extremely rare and highly reduced by following all treatment instructions and by adopting test patches

—They may often result from the underassessment of the skin type and/or presence of tanning

—Might turn into PIH or hypopigmentation

—Post-inflammatory hyperpigmentation or hypopigmentation

—Likelihood of transient PIH or hypopigmentation is highly reduced by following all treatment instructions

—Risk is higher on darker skin types

—Scarring

—Is extremely rare and mostly result from poor technique, poor post- operative care

—Risk is higher on darker skin types

—To reduce the chance of scarring, it is important to carefully follow all post- treatment instructions and exclude patients who have a genetic tendency for scarring

Equipment maintenance

Turn the M22 off

—Clean external surface of system

—Wipe with cloth dampened with non-caustic cleaning solution

—Wipe the operating screen with a dedicated LCD cleaning solution

—Accessories

—IPL light guides

IPL Expert Filters and notch filter

Cleaning of IPL filters

—Gently wipe off gel and fingerprints from the filter surface with a moist lint-free cloth or with alcohol if needed

—Wipe dry with a lint-free cloth

—Store the filters in their plastic sleeves when not in use

—Use a dust blower if required to remove any debris that would be stuck in the plastic sleeves