BBI Contributing Writer

One of the most exciting aesthetic applications currently under development is broadly known as photorejuvenation. This new term has become an umbrella for an ever-expanding array of non-ablative light-based technologies used for skin renewal. In this report, we provide a current overview of the different approaches that are commercially available at this time.

ESC Sharplan (Norwood, Massachusetts) is actively commercializing intense pulsed light (IPL) technology for photorejuvenation. The IPL Quantum SR (skin rejuvenation) was launched in August at a price tag of $69,900. "This is really a new look for us," said Robert Levenson, global marketing manager for skin rejuvenation at ESC Sharplan. "The device is compact, colorful and designed for easy use. This system operates with a touch screen and has integrated skin cooling," he noted. But perhaps most importantly, "it is genuinely dedicated to this very new procedure called photorejuvenation."

Levenson envisions nothing but blue skies ahead for photorejuvenation. "The patient population is enormous, plus this is a no-downtime procedure which cosmetically improves facial skin," he said. "It also appeals to both men and women, whose ages range from the 30s to the 70s." Four to six treatments are recommended in three-week intervals.

Development of the CoolTouch by CoolTouch Corp. (Auburn, California) began in 1994. Through the years, "we've updated the ease of use and the feedback control," said company president Dale Koop. The list price is now $69,000. "Our technology is unique and an ideal base for the other complimentary laser technologies," Koop said. "We have an infrared laser. It is predominately absorbed in water and collagen, so a doctor has the ability to heat and treat a specific layer of the skin. The complementary modalities use wavelengths that are absorbed in pigment or blood."

Koop added: "Many of our customers use the CoolTouch in combination with some of the other facial and photorejuvenation methodologies to achieve a complete treatment." In addition, he said, "a wide range of skin types can be effectively treated with CoolTouch. Our results are not as dramatic as a chemical peeling or a surgical procedure, but most people prefer a long-term, more natural improvement." Furthermore, "we know that the vanity market is growing fairly large. We also have studies and research that indicate the market for facial rejuvenation is potentially greater than for hair removal. In essence, we are just at the beginning."

Robert Weiss, MD, an assistant professor of dermatology at Johns Hopkins University School of Medicine (Baltimore, Maryland), has clinical experience with both the CoolTouch and the IPL Quantum SR, as well as being a paid consultant to both companies. The main indication for CoolTouch in Weiss' practice is "very fine lines in the periorbital region," he said. "We are also using it in combination with microabrasion for scars on the cheeks." Weiss said he likes CoolTouch because "it is a very quick treatment. Patient downtime is zero. They are only red for 15 to 30 minutes." Moreover, "I believe the procedure has much less risk than a chemical peel and is more effective."

Weiss cautions, however, that in most instances CoolTouch users need to limit fluence to a range of 28 J/cm2 to 31 J/cm2 (closer to 28 J/cm2). "As long as you closely monitor the temperature sensor, there should not be any unpredictable results," he said.

The best patient candidates for the IPL Quantum SR, on the other hand, are those with sun-damaged skin. "The incredible speed of the new system and the fact that the handpiece crystal itself is ice cold for increased patient comfort are two advantages," Weiss said. "But you have to be very consistent with the distance of the crystal from the skin."

Douglas Key, MD, an associate clinical professor of dermatology at the University of Oregon Health Sciences Center (Portland, Oregon), uses both the CoolTouch and ESC Sharplan's IPL light source in the same session to achieve superior results. "I liken the various layers of the skin to a chocolate cake. You have icing and three layers," Key said. "By combing technologies, I believe we're able to treat all layers of the chocolate cake. I'm able to treat the outer skin boundary, the upper collagen level, and deeper into the skin to reach the mid- and lower-collagen levels."

Key first treats the second and third layer of the chocolate cake with CoolTouch, then the icing and first layer with the IPL laser. "It's unrealistic to think we can treat everything with a single device," said Key, whose patients have multiple sessions. "I've

labeled this concept layered light. We began this whole journey about a decade ago with one laser. But if we have multiple lasers that are very specific in their tasks, then why not combine multiple applications so they can become synchronous and enhance the process?"

Paul Cardarelli, director of marketing at Candela (Wayland, Massachusetts), said he is excited about the role of the pulsed dye laser in photorejuvenation. "The pulsed dye laser has been used for many years to treat various indications, primarily vascular lesions." He added, "Our new Vbeam vascular laser ($79,500) is a pulsed-dye laser, which doesn't cause purpura. Patients often comment to their physicians that the side of their face treated with the laser looks better. In general, that side of the face has better complexion, and the skin is tighter." As a stand-alone unit, the Vbeam vascular laser is "great," Cardarelli said. "But if you add photorejuvenation, it becomes an even more compelling laser because of its broad range of applications." He stressed that the Vbeam laser has yet to be FDA-approved for photorejuvenation.

Suzanne Kilmer, MD, is director of the Laser and Skin Surgery Center of Northern California (Sacramento, California). She conducted original research evaluating photorejuvenation with the pulsed dye laser. "We showed increased fibroblast activity with increased collagen formation and reduction of fine wrinkling," she said. The Vbeam laser "should have the same effect, but with fewer side effects, such as purpura and pigmentary changes that can be seen with pulsed-dye laser treatment."

Clinical studies are ongoing with the Vbeam laser for "stimulating collagen remodeling and helping with photorejuvenation," Kilmer said. "The decreased purpura seen with this laser has greatly enhanced its value for treating vascular lesions, as well as showing promise for photorejuvenation."

"It is encouraging to see these concepts beginning to have broad appeal in the marketplace," said David McDaniel, MD, director of the Laser Center of Virginia (Virginia Beach, Virginia). "Consumer demand has been there for some time." One area of research involves procedures to address pigment disorders and surface texture. Combining microdermabrasion and ultrasound "can significantly enhance the photorejuvenation processes while maintaining a no-recovery status," McDaniel said. "We have several as-yet-unpublished controlled, blinded clinical trials that show nice results with excellent patient satisfaction levels."

McDaniel also is involved in researching specially formulated skin-care products to complement and enhance the results of various devices. "We have just scratched the surface of what can be accomplished with these devices," McDaniel said. Moreover, "some of the devices will be able to be priced by the eventual manufacturer well below current market pricing, while maintaining good margins. I expect that our devices will have an appeal broader than has ever been seen before in the medical photonics market."

This past spring, ICN Pharmaceuticals (Costa Mesa, California) acquired SLS Biophile Ltd. (Swansea, Wales), which has a patented dye laser-based, non-ablative, wrinkle-reduction technology. SLS Biophile pioneered development of N-Lite (light initiated tissue enhancement) technology as an alternative to harsh chemical treatment of the skin. "The amount of collagen stimulation and deposition that our laser will produce" is impressive, "without damaging the surface of the skin," said Mark Taylor, executive vice president at ICN Pharmaceuticals. "We're most excited about patient outcome."

This marks ICN Pharmaceuticals' first entry into the laser field. Photorejuvenation "is substantially growing by every measure," Taylor said,. "A strategic priority of ICN in the fields of dermatology and plastic surgery is to offer the broadest possible product line." Last year the company introduced Kinerase, a wrinkle-reduction cream. "That product has done extremely well for us in anti-aging," he added. Once FDA-approved, "the laser will complement Kinerase."

In June, Radiancy (Orangeburg, New York) debuted the SpaTouch PhotoEpilation System, a non-laser, light-based technology for hair removal. "At this time, we are focused on hair removal, but we are hopeful that in the future this technology can be applied to skin rejuvenation and acne," said Eitan Nahum, president and CEO. The SpaTouch, which costs $15,000, has an exceptionally large spot size of 22 mm x 55 mm and weighs only 12 pounds. This portable unit is easy to use and has a single-dial control.

Mona Greene, RN, director of clinical development at Radiancy, added, "I believe light-based technology is a natural progression to photorejuvenation." However, "there is no way you can achieve the efficacy of the skin resurfacing lasers. But the downtime with those are so lengthy." Greene, former director of clinical development at CoolTouch, believes that practitioners "owe it to their patient population to offer photorejuvenation." Furthermore, "it is a perfect combination with the other modalities that are also non-invasive, such as botox injections."

The SmartSound Cosmetic Ultrasound System is the latest product for photorejuvenation from SoundSkin (Oswego, Illinois). "This is a medical-grade ultrasound unit that can be used in a cosmetic way," said president Michael Mosk. The SmartSound will be introduced at this month's American Society of Plastic and Reconstructive Surgeons (Arlington Heights, Illinois) meeting in Los Angeles, California.

Mosk notes that not all patients are suitable for microabrasion. "A person's skin might be very fine, or very thin skin," he said. "The Asian tends to be very sensitive and sometimes can over-react to microabrasion." For these groups of people, "the topical and ultrasound might be the way to go. Compared to microabrasion, ultrasound actually penetrates deeper into the tissue to stimulate blood flow and change cell permeability." Furthermore, from a patient's perspective, "ultrasound is probably less pricey because it is less time-consuming and technique-dependent."

In any event, Mosk downplays the specific technology used for photorejuvenation. "I feel the market is leaning very heavily toward quality ingredients in their topicals," Mosk said. "If you don't put something significantly good on the skin, not much is going to happen. Correcting skin damage is only part of the equation. You also want to prevent additional photo damage, so everything relates back to the topicals."

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