Download LED Photomodulation.v4.pub

A Novel Non-Thermal Non-Ablative LED Photomodulation®
Device for Reversal of Photoaging: Digital Microscopic &
Clinical Results in Various Skin Types
Clinical Use of Gentlewaves® LED Photomodulation®
Abstract.
Photomodulation is a process which manipulates
or regulates cell activity using light sources without thermal effect. Previous studies of LED Photomodulation®
have shown skin textural improvement accompanied by
increased collagen deposition with reduced MMP-1
(collagenase) activity in the papillary dermis. The purpose of this study was to investigate a cohort of patients
(N=93) with a wide range of Fitzpatrick skin types
treated by LED Photomodulation® using the Gentlewaves® full panel 590nm high energy LED array with a
specific sequence of pulsing. Results showed improvement of signs of photoaging in 90%. No side effects were
noted. LED Photomodulation® is a safe and effective
non-painful non-ablative modality for improvement of
photoaging.
Robert A. Weiss, M.D.
Director, Maryland Laser Skin
& Vein Institute, Hunt Valley,
Maryland
Assistant Professor of Dermatology, Johns Hopkins U School
of Medicine, Baltimore, MD
Margaret A. Weiss, M.D.
Co-Director, Maryland Laser
Skin & Vein Institute, Hunt Valley, Maryland
Assistant Professor of Dermatology, Johns Hopkins U School
of Medicine, Baltimore, MD
Roy G. Geronemus, M.D.
Director, Laser & Skin Surgery
Center of New York
Clinical Professor of Dermatology, New York University Medical Center, New York, New
York
David H. McDaniel, M.D.
Director, Laser Skin & Vein
Center of Virginia
Assistant Professor of Clinical
Dermatology and Plastic Surgery, Eastern Virginia Medical
School, Virginia Beach, Virginia
2
Introduction
Photorejuvenation is the process whereby light energy sources are utilized to reverse the process
of sun induced aging or environmental damage to the skin. Non-ablative photorejuvenation accomplishes this without disturbance of the overlying epidermis. Categories of non-ablative devices include
those that affect the wound healing cascade by a thermal or photothermolysis type of injury, but we describe here a new category of non-wounding or non-thermal light based treatments which has been
termed photomodulation (1).
The primary goal of non-ablative rejuvenation is induction of new collagen and dermal extracellular matrix substance which visibly improves the appearance of rhytids without disturbance or
damage to the overlying epidermis. An additional goal includes the reversal of pigmented and vascular
signs of photoaging which include reduction of superficial dyspigmentation (both dermal and epidermal), reduction of dermal telangiectasias and the appearance of an overall smoother texture.
Until now our thinking about how to accomplish this has involved primarily thermal mechanisms, whether it is heating of the dermis to stimulate fibroblast proliferation or heating blood vessels
for photocoagulation. (2;3) Although some interest in non-thermal low-intensity laser therapy (LILT)
or cold laser (very low doses of laser) has occurred, key elements required for understanding mechanisms and successful application for cell growth stimulation have been lacking. In fact red laser wavelengths have been reported as failures or with mixed results for stimulation of wound healing. (4;5)
The first experiments performed with low laser doses were revealing. McDaniel et.al. demonstrated while using various lasers at lower fluence that fibroblast activity could be regulated. (1) Using a
variety of LED light sources or monochromatic laser sources, his group demonstrated that by varying
fluence, procollagen synthesis could be upregulated in fibroblast culture. A clinical correlation was also
shown. (6) Procollagen was measured by microarray assays. Collagen synthesis was accompanied by
an equal and opposite reaction involving reduction or down regulation of matrix metalloprotease-1
(MMP-1 or collagenase). Figure 1 demonstrates results of several experiments in which procollagen is
3
measured by stimulation of fibroblasts in culture with a wide range of operating fluences of the pulsed
dye laser. However, there is also a broad peak of collagen stimulation at fluences previously thought to
be too low to produce an effect. This concept of using low energy, narrow band or coherent light with
specific pulse sequences and durations
has been termed photomodulation. (6) The
concept that cell activity can be up or down
regulated by light has
been confirmed by
other groups performing NASA funded research. (7;8)
Figure 1
Cultured fibro-
blasts can be stimulated by using a narrowband light emtting diode (LED) light source of various wavelengths. Based on extensive experiments by McDaniel et al beginning several years ago , LEDs emitting
in the 590nm range were discovered to have the greatest effects. (1) Even more critical were results
demonstrating that unless a specific sequence of pulsation was utilized, there was minimal effect on fibroblasts in culture (9) The curve in Figure 1 could be reproduced for LED by using a specific “code”
of on-time and off-time (dark time). Application of continuous LED light had no effect. This mechanism of non-thermal stimulation of fibroblast growth with the specific “codes” of pulsing is now termed
and patented as LED Photomodulation®.
Using many of the parameters developed in the laboratory, a multi-center clinical trial was performed on 90 patients with a series of 8 treatments over 4 weeks.(9;10)
Patients were followed using
stereotactic digital images, high resolution ultrasound and biopsy for Masson-trichrome, anti-collagen
4
and anti-MMP antibodies as well as digital profilometry. Follow-up of clinical results continued for 1
year. (11,12) This study showed very favorable results with over 90% of patients improving by at least
one Fitzpatrick photoaging category and 65% of the patients demonstrating global improvement in facial texture, fine lines, background erythema and pigmentation. Results peaked at 4 – 6 months following a series of 8 treatments.
The underlying mechanism for LED Photomodulation® was determined to be stimulation of mitochrondrial cell organelles with the proper “packets” of photons. This is similar to photosynthetic electron transport with a proton gradient in chloroplasts of plant cells. (13) Chloroplasts and mitochrondia
share very similar membrane architectures. The principle photoreceptor
is chlorophyll which is cyclic tetrapyrrole, like the heme group of cytochromes, while the molecules responsible for the absorption of light in mitochrondria are the cytochrome species
within the mitochondrial membrane
Figure 2
(13)(shown in Figure 2). Both chlorophyll and cytochromes are synthesized
from protoporphyrin IX. The cytochrome molecules best absorb light from 562nm to 600nm.
It is believed that light absorption causes conformation changes in antenna molecules within the
mitochrondrial membrane. Translocation of protons begins a pump which ultimately leads to energy
for conversion of ADP to ATP, essentially recharging the cell battery and providing more energy for
growth. Elegant experiments by McDaniel et al. have demonstrated the rapid production of ATP
within mitochrondia within cultured fibroblasts exposed to LED light only with the proper pulsing
5
“code”. (1;10) New ATP production occurs within seconds of LED Photomodulation® and this triggers
subsequent metabolic activity of fibroblasts. (10)
This paper reports the results of an additional clinical study involving another cohort of 93 patients. They were treated by Gentlewaves® LED Photomodulation® and followed for 6 months by
stereotactic digital imaging and digital microscopy. This is an additional cohort not previously reported
in the 90 patient multi-center clinical trial.
Material and Methods Random patients (N=93) with mild to moderate photoaging were offered
the opportunity to receive 8 LED Photomodulation® treatments over a four week period. Treatments
were given with a minimum of 48 hours separation. Prior to the first treatment, the skin was cleansed
with a topical masque (Gentlewaves® masque, LightBioScience, Virginia Beach, VA) Skin types
ranged from Fitzpatrick type I to V. Use of OTC topicals and topical retinoids was permitted as long as
no changes were made to the topical regimen within 3 months prior to the study and for the duration of
the six month follow-up. All patients were coached on the daily use of sunscreen with SPF of 30 or
higher. Stereotactic images were taken using the Canfield system and a Fuji S1 digital camera at day 0,
30 days, 1, 2, 3 and 6 months. The Fuji S1 CCD has 3.5 million actual photosensitive pixels on its surface, producing an effective 6 megapixel file size. Subtle changes in skin texture and other signs of
photoaging are easily analyzed using high resolution baseline images for comparison.
A region just lateral to the left lateral canthus was imaged using digital microscopy using 30X
and polariscopic light magnification ( DG-2 Digital Microscope, Scalar America, Video Microscopes &
Imaging Systems, Sacramento, CA)
An acetate tracing was used with the outline of the lateral eye to
accurate position the digital microscope in the follow-up visits. The position of the examined region was
2.5 cm lateral to the left lateral canthus. The resolution of the digital microscope is 330 lines at 2.3
Megapixels which allowed a detailed analysis of skin texture.
Patients performed a self-assessment of their improvement on a quartile scale and independent
investigators graded images using a LCD monitor at 1280x 1064 resolution in 32 bit color mode.
6
Changes were graded on a
Figure 3
quartile scale for peri-ocular
wrinkles, reduction in Fitzpatrick photoaging classification, skin texture, background erythema and pigmentation.
Treatments were
given with the Gentlewaves®
LED Photomodulation®
unit (LightBioScience, Virginia Beach, VA) with a full face panel device as shown in Figure 3. Patients were positioned 2 centimeters away from the light source. Pulsed 590nm diode light was delivered in the standard treatment regimen as previous reported. (9) Fluence range is typically from 0.1 to 0.8 Joules/cm2. The pulse sequence or “code” is pre-set to the sequence yielding maximal effect in previous clinical trials and use on
fibroblasts in cell culture. No user changes from pre-sets were required or permitted. All adverse
events following treatment were recorded.
Photoaging Class
% of Subjects Reduced
One Photoaging Scale
Category
Non-responders
9
2 to 1
26
3 to 2
31
4 to 3
17
The Fitzpatrick scale evaluations showed a reduction of one
5 to 4
11
class in over 90 percent of subjects. These results are
6 to 5
8
shown in Table I.
Total
100 %
Table I
Results
7
Results at 6 months
The best results clinically were seen in the
noted by 87% of patients. (Figure 4).
% Patients Showing Improvement
category of skin texture with improvement
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Peri-ocular
wrinkles
Smoother texture
Pigmentation
Redness
Figure 4
Notably African-American and Asian skin types responded as well as Caucasian skin types in the textural improvement category
(Figure 5).
At 6 months, independent
review of images also showed reduction of peri-ocular rhytids was
in 56%, reduction of background
erythema in 65% and reduction of
background pigmentation in 62%.
Figure 5
A self-assessment by patients for
global improvement of skin appearance at 3 months revealed that they judged the improvement as none,
mild, moderate and excellent in 8, 14, 41, 38% respectively. At 6 months the percentages fell slightly
(Figure 6) .
8
50
Figure 6
45
Digital microscopy in 10 patients
% of patients (N=93)
40
revealed a 50 to 90% (mean tex-
35
tural improvement) as judged by
30
3 Months
25
6 Months
the investigators evaluation depth
20
of fine lines. An example of an
15
10
excellent response as seen by digi-
5
tal microscopy is shown in Figure
0
None
Mild
Moderate
There were no adverse
Excellent
7.
Figure 7
events. One patient believed
that she had a flare of acne
while 9 others reported an improvement in acne. Two patients noticed improvement of small patches of atopic eczema. One patient believed her eyebrows grew
more thickly but this was not substantiated by the digital images. No pain or heat sensation was reported during treatment. No adverse events such as skin burning or pigmentation changes were noted
in any of the subjects. Clinical results typical at 3 – 6 months following a series of 8 treatments is shown
in Figure 8.
Figure 8
9
Conclusions
LED Photomodulation® performed with this specific device including this array of high energy
LEDs and a very specific sequencing time code is highly effective. The initial starting regimen of 8
treatments over 4 weeks is effective for the treatment of typical signs of photoaging. The need for maintenance treatments may begin at 4 -6 months. It is unclear how often maintenance treatments will be
required but our clinical experience to date suggests once a month.
It is interesting that a light source can induce similar findings for collagen synthesis and reduced
MMP activity as reported with retinoic acid. (15-17) The mechanisms of a topical drug versus photomodulation are very different yet yield similar
effects. It has been proposed that these effects
may be synergistic, specifically with topical
retinol(14). Further investigation is ongoing
about these additive effects.
An anti-inflammatory effect of LED
Photomodulation® was reported by one patient
in the present investigation. Some preliminary
data now indicates an anti-inflammatory effect
for LED Photomodulation® as well. Using a
solar simulator to create UV erythema, pre-
Figure 9
liminary findings indicate a very noticeable re-
duction in UV erythema when LED Photomodulation® is supplied within hours after UV exposure. In
addition low intensity light therapy with LED Photomodulation® after acute UV exposure produced significant downregulation of dermal matrix degrading enzymes which were stimulated by the UV exposure. (11)
10
LED Photomodulation® is painless, safe and easy to administer. It appears that this device successfully modulates the activity of fibroblasts resulting in smoother skin without the inherent risks of
other thermal devices which may burn the skin or require complicated application techniques. Our results with parameters developed by fibroblast stimulation in culture appear to translate into a positive
and noticeable clinical response in all skin types. Multiple trials at multiple centers are now ongoing to
confirm these results. Combination treatments with standard thermal non-ablative techniques such as
intense pulsed light or pulsed dye are being performed to determine whether this device may enhance
results after photothermal treatments by stimulating more collagen synthesis and producing less collagen degradation.
References
(1) McDaniel DH, Weiss RA, Geronemus R, Ginn L, Newman J. Light-tissue interactions I: photothermolysis vs photomodulation laboratory findings. Lasers Surg.Med. 14, 25. 2002.
(2) Weiss RA, Goldman MP, Weiss MA. Treatment of poikiloderma of Civatte with an intense pulsed light
source. Dermatol Surg 2000 Sep;26(9):823-7.
(3) Fatemi A, Weiss MA, Weiss RA. Short-Term Histologic Effects of Nonablative Resurfacing: Results with
a Dynamically Cooled Millisecond-Domain 1320 nm Nd:YAG Laser. Dermatol Surg 2002 Feb;28
(2):172-6.
(4) Walker MD, Rumpf S, Baxter GD, Hirst DG, Lowe AS. Effect of low-intensity laser irradiation (660 nm)
on a radiation-impaired wound-healing model in murine skin. Lasers Surg Med 2000;26(1):41-7.
(5) Sommer AP, Pinheiro AL, Mester AR, Franke RP, Whelan HT. Biostimulatory windows in low-intensity
laser activation: lasers, scanners, and NASA's light-emitting diode array system. J Clin Laser Med Surg
2001 Feb;19(1):29-33.
(6) McDaniel DH, Weiss RA, Geronemus R, Ginn L, Newman J. Light-tissue interactions II: photothermolysis vs photomodulation clinical applications. Lasers Surg.Med. 14, 25. 2002.
(7) Whelan HT, Buchmann EV, Dhokalia A, Kane MP, Whelan NT, Wong-Riley MT, et al. Effect of NASA
light-emitting diode irradiation on molecular changes for wound healing in diabetic mice. J Clin Laser
Med Surg 2003 Apr;21(2):67-74.
(8) Whelan HT, Connelly JF, Hodgson BD, Barbeau L, Post AC, Bullard G, et al. NASA light-emitting diodes
for the prevention of oral mucositis in pediatric bone marrow transplant patients. J Clin Laser Med
Surg 2002 Dec;20(6):319-24.
11
(9) McDaniel DH, Newman J, Geronemus R, Weiss RA, Weiss MA. Non-ablative non-thermal LED photomodulation - A multicenter clinical photoaging trial. Lasers Surg.Med. 15, 22. 2003.
(10) Geronemus R, Weiss RA, Weiss MA, McDaniel DH, Newman J. Non-ablative LED photomodulationLight activated fibroblast stimulation clinical trial. Lasers Surg.Med. 25, 22. 2003.
(11) McDaniel DH, Geronemus R, Weiss RA, Weiss MA, Newman J. LED photomodulation reverses acute
UV induced skin damage. Lasers Surg.Med. 16, 30. 2004.
(12) Weiss RA, McDaniel DH, Geronemus R, Weiss MA, Newman J. Non-ablative, non-thermal light emitting
diode (LED) phototherapy of photoaged skin. Lasers Surg.Med. 16, 31. 2004.
(13) Voet D, Voet JG. Biochemistry. 2nd ed. New York: John Wiley & Sons, Inc.; 1995.
(14) Weiss RA, Weiss MA, McDaniel DH, Newman J, Geronemus R. Comparison of non-ablative fibroblast
photoactivation with and without application of topical cosmeceutical agents. Lasers Surg.Med. 15, 23.
2003.
(15) Fisher GJ, Voorhees JJ. Molecular mechanisms of photoaging and its prevention by retinoic acid: ultraviolet irradiation induces MAP kinase signal transduction cascades that induce Ap-1-regulated matrix
metalloproteinases that degrade human skin in vivo. J Investig Dermatol Symp Proc 1998 Aug;3
(1):61-8.
(16) Fisher GJ, Talwar HS, Lin J, Lin P, McPhillips F, Wang Z, et al. Retinoic acid inhibits induction of c-Jun
protein by ultraviolet radiation that occurs subsequent to activation of mitogen-activated protein
kinase pathways in human skin in vivo. J Clin Invest 1998 Mar 15;101(6):1432-40.
(17) Varani J, Perone P, Griffiths CE, Inman DR, Fligiel SE, Voorhees JJ. All-trans retinoic acid (RA) stimulates events in organ-cultured human skin that underlie repair. Adult skin from sun-protected and sunexposed sites responds in an identical manner to RA while neonatal foreskin responds differently. J
Clin Invest 1994 Nov;94(5):1747-56.