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Journal of Cosmetic and Laser Therapy ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: Successful removal of freckles with the bipolar radiofrequency and optical energy To cite this article: Osman Köse (2016) Successful removal of freckles with the bipolar radiofrequency and optical energy, Journal of Cosmetic and Laser Therapy, 18:4, 230-233, DOI: To link to this article: Accepted author version posted online: 10 Published online: 21 Apr 2016.
Article views: 27 Ful Terms & Conditions of access and use can be found at Download by: [Gulhane Askeri Tip Akademesi ] Date: 05 August 2016, At: 06:41 JOURNAL OF COSMETIC AND LASER THERAPY2016, VOL. 18, NO. 4, 230–233http://dx.doi.org/10.3109/14764172.2016.1157358 ORIGINAL RESEARCH REPORT Successful removal of freckles with the bipolar radiofrequency and optical energy
ELOS Private Lazer Center, Ankara, Turkey Objectives: Freckles are melanocytic lesions frequently seen on the face with red or blond hair. We aim to
Received 16 March 2015 determine the effectiveness of combined bipolar radiofrequency (RF) and optical energy. Methods: Thirty
Accepted 11 January 2016 patients with facial freckles received four treatment at 3-week intervals with RF and optical energy, combi- nation of broadband light (580–980 nm)  bipolar RF energy 100 J/cmThe improvement of the freckles Bipolar radiofrequency; was evaluated using the Freckles Area and Severity Index (FASI), and physician and patient assessment at freckles; optical energy the end of the sessions, at Months 3 and 12 after the treatment. Results: By the end of the study, assess-
ment of results by physician for 83% at Week 12 and by patients for 70% at Week 52 was excellent or good. On the other hand, 88% at Week 12 and 76% at Week 52 of the patients reported that they were extremely or very satisfied. FASI was noted to be 65.15 at pre-treatment, 25.60 at 12th week, and 27.40 at the end of the follow-up (one year). Mean improvement rate (n  30), as determined from the difference in mean FASI score, was 70% at 3 months and 66% at 12 months. Conclusion: Bipolar radiofrequency and optical energy
can be accepted as an alternative treatment modality for the therapy of freckles with few adverse effects and high satisfaction levels.
Freckles are caused by an increase in melanin pigment in the patients were advised to stop all other topical treatments, to use melanocytes especial y on sun-exposed area in young people only sunscreens regularly and to avoid to sun exposure. All sub- with fair skin. Most common sites are nose, malar area, and jects were evaluated and did not have any photosensitivity, his- forehead ,Facial freckles are a real y cosmetic concern to tory of keloid scarring, use of topical retinoid in last 3 months, especial y young females. Different treatment modalities for and isotretinoin within the last year. Two energies are applied to freckles have been used such as chemicals like D-hydroxy acids, the skin using the handpiece (size 8  12 mm). The skin surface cryotherapy, trichloroacetic acid, Q-switched alexandrite laser, is cooled to 5qC by means of a contact cooling system. Contact CO2 laser, and intense pulsed light (IPL) for a long time (). gel was used to the skin before the application.
But except laser treatment, all these methods have not proved to The treatment protocol included the total of four treatment completely satisfactory and risk of post-inflammatory hyperpig- sessions with three week intervals. Each treatment consisted of mentation. Radiofrequency (RF) technology has become a stan- one passes over the treatment area using ELOS parameter that dard treatment in aesthetic medicine with many indications due were determined by the patients' skin phenotype and distribu- to its versatility, efficacy, and safety. electric light optical synergy tion of target chromophores. The physician's assessment consists (ELOS) technology combines pulsed light optical energy and of an estimate of percentage improvement as follows: excellent, Downloaded by [Gulhane Askeri Tip Akademesi ] at 06:41 05 August 2016 bipolar RF electrical energy in a way that is very efficient and 76–100%; good, 51–75%; fair, 26–50%; and poor, 0–25%. The safe (There is no clinical study on the treatment for freckles patient assessment is as follows: extremely satisfied, very satis- using with RF technology. Therefore, in this retrospective clini- fied, satisfied, slightly satisfied, and not satisfied. All patients cal study, we want to investigate the efficacy and safety of this completed a questionnaire using a grading system. Freckles treatment modality on facial freckles.
area and severity index (FASI) scales were used for the objective assessment of the lesions using the contrast, area, and density of freckles. Contrast is mean regarding the darkness of the freck- Patients and methods
les assessed on a five-point gray scale (, based on This study was carried out for a two-year period, from April 2012 comparison with the shade of different parts of the face using to April 2014. The study group was composed of 30 patients (11 the regular photography. Area explains the extension and distri- males, 19 females). The mean age 24.2 years (20–45 SD  7.8). bution of freckles was defined within nine different facial areas All patients had Fitzpatrick skin types I–III. Informed written [forehead (), eye (cheek nose lips (and chin )]. consent was obtained from all subjects. The treatment areas Also density expresses number of the macules on the face per were photographed and identified before the treatment. The square centimeter regarding cheek (right and left) and nose area CONTACT Osman Köse [email protected] ELOS Private Lazer Center, Ziya Gökalp Street 12/4, Ankara, 16180 Turkey.
Color versions of one or more of the figures in the article can be found online at http://www.tandfonline.com/ijcl.
2016 Taylor & Francis Group, LLC
JOURNAL OF COSMETIC AND LASER THERAPY ). The severity of freckling and improvement after radiofre- Table 2. Graduation of freckles improvement assessed by patients (n  30).
quency treatment can be measured objectively using the FASI Grade and percent Number of patient (%) Number of patient (%) scores. All of the participants were evaluated before and after clearance the therapy and twelve months after the last session using the Extremely satistified FASI scores, and physician and patient assessments. For first Very satistified sessions, RF energy was set at 20 J/cmand optical energy was Satistified set at 15 . If we did not observe any side effects such as Slightly satistified permanent erythema and hyperpigmentation on applied area, Not satistified we increased the doses 25 for RF and 20 J/cmfor opti- cal energy for the other three sessions. ISL/ISM was 30/0 for all extremities. Ephelides are largely genetical y determined but sessions. (eMax, "SR" handpiece by Syneron). Short pulse was induced by sunlight, whereas lentigines are induced by sun applied. For the periorbital region, we kept a distance of about exposure and photodamage of the skin. However, despite 1 cm from the eyelid as the RF energy to prevent side effects. being commonly observed, we know very little about them. For eye protection, we applied plastic eye-shields to the eyes. Freckles may vary somewhat in color—they may be reddish, We recorded datum for pain using a numerical analogue scale yel ow, tan, light brown, brown, or black but they are basical y (NAS) ranging from 0 (no pain) to 5 (maximal pain). For the slightly darker than the surrounding skin. Most freckles on a side effects, we recorded erythema, edema, and dysesthesia after skin are usual y uniform in color (. They tend to become each session. Photographic evaluation was carried out before darker and more apparent after sun exposure and lighten the sessions and three and twelve months after the last sessions in the winter months. Freckles are due to an increase in the using the EOS 400D (Canon USA, Inc, NY, USA). The pictures amount of dark pigment cal ed melanin and are not due to an of the patients were standardized using the same camera, ring increase in the total number of pigment producing cel s cal ed flash, and ambient light.
melanocytes. Unlike solar lentigines, freckles usual y present in early childhood (. Solar lentigines are considered as a sign of photodamage while ephelides are associated with fair skin type and red hair. The FASI is used to evaluate the sever- A total of 30 subjects completed the treatment course and ity of the freckles, based on the three important features of the answered the self-questionnaire. By the end of the study, freckles. These parameters based on the darkness of the freck- physician assessed the results for 83% at Week 12 and 70% les, the extension and distribution of the macules, and density at Week 52 of the subjects as excel ent or good (). On of the freckles ().
the other hand, 88% at Week 12 and 76% at Week 52 of the The treatment of the freckles is a challenge and also may be patients reported that they were extremely or very satisfied requested for cosmetic reasons. Many treatment modalities ). FASI was noted 65.15 at pre-treatment, 25.60 at have been used for the freckles but postinflammatory hyper- 12th week, and 27.40 at the end of the fol ow-up (one year). pigmentation still remain a main problem after the therapy. Mean improvement rate, as determined from the difference in But, in the past decade, freckles have been lightened and mean FASI score, was 70% at 12 weeks and 66% at 12 months. cleared with different types of lasers and IPL system (). shows the picture of one patient before treatment and Four different types of laser were used for the treatment of shows 12 months after treatment. During the all treat- the freckles such as long pulsed dye laser, alexandrite laser, ment sessions, we did not observe any severe side effects such Q-switched Nd:YAG laser, and potassium-titanyl-phosphate as blistering, crusting and pigmentary changes. As an adverse (KTP) laser. They found that long pulsed dye laser, Q-switched effects, we detected transient erythema in two patients (6%), Nd:YAG laser, and KTP laser were effective in the treatment of transient edema in one patient (3%), and burning sensation the freckles. But no significant improvement was found after Downloaded by [Gulhane Askeri Tip Akademesi ] at 06:41 05 August 2016 for a maximum 6 h in two patients (6%). With regard to pain, alexandrite laser treatment ). Carbon dioxide laser was 24 (80%) patients declared no pain and 6 patients (20%) with applied for freckles as a single session in Egyptian patients. minimal pain. The average pain score was 0.2.
It was found to be an effective and safe treatment option in skin phototypes II–IV (. IPL was found an effective and safe method with relatively few adverse effects and high satis- faction levels for face in Asian skin (). Freckles showed Freckles, can be used for ephelides and lentigines, are impor- good response almost completely to all types of therapies tant pigmentation characteristics of localized face and upper including laser and IPL. But, pain, postoperative punctate bleeding, purpura, and postinflammatory hyperpigmentation were reported as adverse effects Table 1. Graduation of freckles improvement assessed by physician (n  30).
On the other hand, the most common indication for bipo- Grade and percent Number of patient (%) Number of patient (%) lar RF technology is the tightening of tissue to improve skin laxity and reduce wrinkles (,,). The optical compo- Excellent, 76–100 % nent is light with a wavelength of 580–980 nm and the elec- trical component is bipolar RF at a frequency of 1 MHz ). The energy is applied to the skin for a duration of 20–200 milliseconds. Superficial melanin and hemoglobin absorb in Figure 1. A 24-year-old woman before therapy: extensive freckles involvement on her face.
the wavelength range of 580–980 nm and target lesions such of the procedure was relatively short, just only 10 min. Dark as freckles. The epidermis is cooled, increasing resistance and color freckles require more sessions than light color freckles lowering current flow; RF energy flows from the active to the instead of the this treatment protocol.
passive electrode and elevates the temperature of the target There are some limitations for this study. One of them is structures to a level of damage required for clearance ). number of the cases. Large group of the patients can give Also this system provides an impedance safety limit (ISL%) better results than limited number. Second limitation is lack to automatically shut off the RF energy pulse to prevent tissue of histopathologic evaluation. It can be helpful to deter- mine the underlying biological mechanisms in the treatment In the present study, a novel method was used to objec- course.
tively evaluate the severity of the improvement in freckling As a conclusion, in this study, we found that bipolar RF and using the FASI scores. Bipolar RF has been never used in the optic light therapy are very efficient regarding subjective and treatment of the freckles until today. The high satisfaction rate objective assessment. One-year follow-up is helpful to dem- assessment by physician and patients showed that this combi- onstrate the improvement on the freckles with therapy. Side nation should be a new therapeutic option. In some patients, effects were transient and tolerable. We have to emphasize that pigmentation of the freckles come back again, therefore, after avoiding the sun exposure is the important point for patient the treatment avoiding the sun exposure is really essential who have the freckles especial y in summer months after the all for all patients. No local or topical anesthetic agents were types of therapy. More RF sessions may get good results for dark needed; few side effects were observed. Transient erythema color freckles. Controlled prospective study with histopatho- was the most common side effect and disappeared in short logic evaluation helps us in the optimization of the treatment time duration. Also pain score was very low. The duration parameters. Downloaded by [Gulhane Askeri Tip Akademesi ] at 06:41 05 August 2016 Figure 2. After one-year follow-up, excellent result observed on her face.
JOURNAL OF COSMETIC AND LASER THERAPY Declaration of interest
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