Experience of using RSL sculpting for treating post-inflammatory hyperpigmentation

Abstract

Post-inflammatory hyperpigmentation (PIH) is a frequent complication of various non-surgical cosmetic procedures. Therapeutic strategies for patients with PIH usually include a combination of some laser treatment, topical depigmenting agents, and/or chemical peels. RSL sculpting has a potential to become an alternative treatment method. The procedure affects many components of post-inflammatory hyperpigmentation pathogenesis and thus leads to pronounced clinical results, has a wide range of indications, minimal number of contraindications, and is compatible with other treatment methods. Clinical cases are provided.

Introduction

Post-inflammatory hyperpigmentation (PIH) is a frequent complication of various non-surgical cosmetic procedures [1–3]. PIH is an acquired hypermelanosis with melanin deposition in epidermis or dermis resulting from inflammation or injury [3]. This kind of hyperpigmentation can persist for several months or years causing extra psychological distress in patients [4, 5]. 

PIH is most frequently described as a complication after a laser treatment. According to the literature sources, it occurs in 80% of cases of CO₂ laser treatment and can occur in up to 60% of cases of Er:YAG laser treatment [6].

Post-inflammatory hyperpigmentation: different views on pathophysiology

Pathophysiology of PIH is still not fully understood. Some authors consider this type of hyperpigmentation to be induced by an inflammatory reaction which occurs due to the influence of external aggressive factors, while other assume that it may be caused by mechanical injury. Inflammation that occurs as a response to an effect of an external aggressive factor is considered to involve the basal layer of the epidermis and acts as a trigger for melanocytes resulting in melanosomes transferring the pigment into neighboring skin cells. In course of inflammatory reaction, cytokines, chemokines, and reactive oxygen species (ROS) are released and stimulate the growth of melanocytes, as well as melanin synthesis and transfer to neighboring keratinocytes. Physiological factors that facilitate those phenomena include epidermal growth factor (EGF), interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor (TNF-α), as well as such leukotrienes as LTc4 and LTd4, prostaglandin E2 and D2, and thromboxane-2 [7–9]. Damage to the basal membrane and basal keratinocytes that release a great amount of melanin in response to inflammation, can also cause pigmentation. Macrophages phagocytize the pigment in the upper layer of dermis. This type of pigmentation is accompanied by increased perivascular lymphocytic infiltration and increased expression of CD68, a macrophage marker, and c-kit mast/stem cell growth factor receptor (Fig. 1) [10]. PIH as a complication after non-surgical aesthetic treatments occurs as per the mechanism described above; in the majority of cases it is associated with overly aggressive treatment (laser treatment parameters too high, high concentration of acids, etc.) or is a consequence of insufficient clinical experience of aesthetician.

Fig. 1. Post-inflammation hyperpigmentation pathogenesis [10]

Some authors have another opinion on mechanisms of PIH development and consider not inflammation but skin injury of treatment area to be of primary importance in its pathogenesis. M. Kurita et al. [11] have demonstrated the influence of cyclic stretching occurring as a result of a constant mechanical irritation of skin on expression of melanogenic cytokines (especially ET-1) that are secreted in a paracrine mode. Increased expression of ET-1 as a reaction to an injury may play an important role in pathogenesis of pigmentation disorders. Many years of my own clinical observations also support this hypothesis. It happens quite often that after correctly followed aesthetic treatment protocol patients with normal past medical history develop hyperpigmentation. It mostly happen when the procedure has been performed in an area of skin folds or where it often rubs against clothes. Pigmentation also occurs when a patient injures the skin in the treatment area, as he or she thinks this will shorten rehabilitation period. 

An interesting research has been published recently that proved a joint participation of melanocytes and fibroblasts in the regulation of skin repair [12]. This epithelial mesenchymal interaction can be especially important for slowly healing wounds. The authors of another study suggest that dermal fibroblasts are able to regulate melanocytic response to skin injury [13].

Post-inflammatory hyperpigmentation treatment

Currently, there are a lot of methods of treating post-inflammatory hyperpigmentation (Tables 1, 2). The use of laser technologies allows to achieve the most pronounced clinical results due to the absorption of light energy by skin chromophores [14, 15]. Thus, Q-Switch Laser which is used as the main method of treatment demonstrates high effectiveness. However, a combined therapy (the use of both a laser and a depigmentation product) demonstrates higher effectiveness in PIH treatment than the use of separate products or methods [16–18]. 

Table 1. Light therapy of post-inflammatory hyperpigmentation [14, 15]

Table 2. Modes of action of the main depigmentation agents [16–18]

Laser technologies have a number of absolute and relative contraindications that are to be considered when prescribing them [19–23]. 

Absolute contraindication are:

• infectious diseases
• decompensation of somatic disorders
• predisposition to keloid scars
• malignant neoplasms
• use of cardiac pacemaker. 

Relative:

• pregnancy and breastfeeding
• mental illnesses
• photodermatosis 
• use of some medications (photosensitizers). 

It is especially problematic to treat PIH in cases when a patient has contraindications to laser treatment or when a patient with hyperpigmentation that occurred as a complication after using laser refuses treatment with an appropriate light method due to the precious negative experience. Moreover, not all specialists know the light methods for post-inflammation hyperpigmentation treatment. Therefore, a doctor has to answer the question “what to do?”, especially taking in account the fact that light methods are the most effective in PIH treatment, and the combined method that includes their use together with depigmentation agents demonstrates the most pronounced therapeutic effect. To answer this question it is necessary to understand what happens in tissues as a result of influence of bioactive substances that are released in case of inflammation and/or injury. 

Blood and lymph vessels take an active part in inflammation pathogenesis. Elasticity of blood vessel walls decreases and their permeability increases under the influence of inflammatory mediators. Fluid accumulates in the surrounding tissues due to impaired lymphatic drainage. As a result, an edema occurs and can potentially also lead to impairment of metabolic processes in them. Neurohumoral regulation dysfunction associated with inflammation leads to persistent angiectasia which results in blood stasis. All of the phenomena mentioned above lead to erythema and increase of tissue regeneration period [24–26]. Based on the information above, it can be assumed that the methods aimed at tissue decongestion together with the use of depigmentation products can have positive influence on PIH even when it is not possible to perform light treatments.

 RLS sculpting

One of the proven safe and efficient procedures which allows to decrease tissue congestion and which positively influences regeneration is RSL sculpting. The procedure combines vibrocompression with spheres and LED therapy (treatment with red light at a wavelength of 650 nm). Its use improves blood circulation in tissues by accelerating the flow of blood and lymph and decreasing congestion and edema. Squeezing out lymph from connective tissue gaps and venous blood from capillary tubes during the procedure facilitates emptying not only the vessels that are directly affected, but also those located above and below the treatment area. Such vessel emptying leads to general increase in blood and lymph circulation which, on the one hand, promotes more active transfer of nutrients to tissues and organs of the treatment area, and, on the other hand, removes degradation products [27–33].

According to numerous studies, light stimulation at a wavelength of 650 nm facilitates fibroblast activation (increases expression of fibroblast growth factor, FGF) and stimulates procollagen type I synthesis [34–36]. A positive effect of red light on mitochondrial activity, leading to an increase in the production of adenosine triphosphate (ATP) and a change in the potential of the mitochondrial membrane has also been demonstrated. Regenerative processes in tissues get optimized under the influence of the LED-lamp built into the handpiece of the device [37, 38]. Moreover, C.T. Oh et al. [39] have demonstrated decrease of hyperpigmentation under the influence of red light due to inhibiting action of radiation with a wavelength of 660 nm on the level of expression of the main melanogenic enzymes: tyrosinase and its associated proteins TRP-1 and TRP-2. 

Thus, the use RSL sculpting as part of the combined PIH treatment programs is pathogenetically reasonable, which is confirmed by a number of clinical cases from our experience. 

It is possible to use RSL sculpting not only for post-inflammation hyperpigmentation treatment, but also generally in aesthetic medicine for: 

• cellulite treatment (including grades 3–4)
• body fat reduction
• skin quality improvement, skin relief smoothing, turgor improvement
• muscle tone increase
• reduction of visible signs of fibrosis.

The procedure is characterized by the absence of severe side effects and a minimum number of contraindications, including only: 

• oncological diseases with a remission of less than 5 years
• acute infectious and viral diseases
• exacerbation of chronic diseases
• hyperthermia 
• exacerbation of skin diseases.

In the majority of cases the procedures can be combined with indication of topical depigmentation products, mesotherapy, and chemical peels (even in the course of one session). RSL sculpting procedure has a good safety profile and influences various components of PIH pathogenesis, and thus has a strong potential for use and significantly expands the range of alternatives that an aesthetician can choose from.

Clinical cases

1. Patient K., male, age 24 

Symptoms: stretch marks on arms and abdomen. 

Medical history: stretch marks first appeared on the abdomen, then on hands when the patient was 18; he associates it with weight gain. Used topical products for stretch mark treatment (does not remember the names) that he chose by himself with no effect, has not consulted other specialists regarding the problem, decided to make an appointment as his mother recommended it. No accompanying somatic disorders detected. 

Dermatological status: at the time of appointment, the skin pathological process is localized in the region of the inner surface of the shoulder on the right and left, on the anterior and lateral surfaces of the abdomen; it is represented by numerous white stripes level with the surrounding skin ranging in size from 1 to 8 cm in length and from 1 to 3 mm in width. The surface of the damaged skin in some places resembles crepe paper. 

Diagnosis: Stretch marks (ICD-11 code ЕЕ40.1Y) (Fig. 2а). 

Indications: a course of sessions with spatially-modulated irradiation of Er:YAG laser for stretch mark treatment, No. 3–5 at the interval of at least 1.5 months; in between the laser treatment sessions — sessions of mesotherapy with combined products No. 5 with a 7-day interval, starting from the 7^th day after the laser treatment session.

Laser settings for treatment: 

• laser: Er:YAG (2936 nm)
• energy density: 3.21 J/cm²
• pulse energy: 0.1–2 J
• pulse length: 0.1–0.3 ms
• SMA handpiece: 6 mm
• frequency: 3 Hz
• treatment in scanning mode by applying pulses in a pattern of Olympic rings in one pass.

Mild hyperemia, slight white or sometimes brown frosting, moderate tissue swelling are detected in the application area immediately after the treatment (Fig. 2b).

Recommendations after the treatment: do not wet the treatment area for one day, do not injure it, use chlorhexidine aqueous solution and bepanthen cream twice a day for 5 days, avoid bathing, visiting solarium, sauna for 14 days.

Examination after 1.5 months (Fig. 2c): white marks remain in the area of ​​the inner surface of the shoulder on the right and left, the anterior and lateral surfaces of the abdomen, but some of the marks are fragmented, others have become less visible. The surface of the damaged skin in some places resembles crepe paper. Quite wide areas of darker skin are well visible around white stripes of stretch marks.

Diagnosis: Hyperpigmentation after a cosmetic procedure (ICD-11 ЕL73.5). The analysis of causes of hyperpigmentation showed that energy density setting recommended for the type of laser device used was exceeded. Treatment: the patient was offered a course of rehabilitation with RUBY-Qsw laser (5 sessions with a 2–3-week interval, which the patient refused as he was afraid to receive any more laser treatment. He also refused a course of lighting chemical peels. As the stretch marks and hyperpigmentation still bothered him, a course of RSL sculpting was recommended (10 sessions with a 2–3-day interval). For home care, a product containing a tyrosinase inhibitor isobutylamido-thiazolyl-resorcinol (Thiamidol) was prescribed. A positive effect was noted after the 4^th RSL sculpting session already; after the treatment course had been completed, damaged skin areas were notable lighter in color (Fig. 2d).

Fig. 2. Patient K., male, age 24. Stretch marks before treatment (а); the state of the skin immediately after the treatment with the Er:YAG laser (2936 nm), 1,5 months after the laser treatment (c), and after 4 sessions of RSL sculpting treatment (d)

Patient N., female, age 27 

Symptoms: long rehabilitation after a laser treatment, cellulite on buttocks and thighs. 

Medical history: a focus of hyperpigmentation appeared after a laser procedure performed 10 days prior to treat a normotrophic scar after removal of a hemangioma using cryodestruction in childhood. She had not attempted to remove the scar earlier. The laser treatment was performed in other clinic; information about the device used is not available. She decided to visit another clinic as during the consultation she was told that rehabilitation would last for 5 days, but it is the 10^th day already, and the treated area looks bad. The patient assumes that something has been done wrong, she cannot trust doctors in that clinic and the clinic itself, and does not want to visit it anymore. 

Concomitant somatic disorder: according to the patient, angina pectoris, takes nifedipine regularly.

Dermatological status: at the time of appointment, the skin pathological process is localized in the region of the anterior surface of the left thigh; it is represented by a brown spot with clear boundaries, white scales on the surface and bright red erythema in the central part of the spot.

Diagnosis: Hyperpigmentation after a cosmetic procedure (ICD-11 ЕL73.5) (Fig. 3a), gynoid lipodystrophy (ICD-11 EF02.3).

Considering the symptoms, the clinic, and the medical history (regular use of the drug nifedipine, which is a photosensitizer) it was decided not to use laser for hyperpigmentation treatment. Instead, it was recommended to start a 10-session course of RSL sculpting with an interval of 2–3 days after complete epithelialization of the surface. 

The RSL sculpting treatment course was started 4 days after the visit, that is on day 14 after the laser treatment procedure performed in other clinic (Fig. 3b). The sessions were being performed twice a week; the results were photographed after each session (Fig. 3c–i). No additional methods and products were used for hyperpigmentation treatment and tissue regeneration improvement.

Fig. 3. Patient N., female, age 27. Treatment of hyperpigmentation induced by laser removal of an old scar. The view of the defect on day 10 (а) and 14 (b) after laser treatment before RSL sculpting. State of the skin after one, 2, 3, 4, 5, 6, 7, and 8 RSL sculpting sessions (c–i)

As the patient was satisfied with the results after 8 sessions, the course of RSL sculpting session was ended.