The increasing demand by the client seeking noninvasive procedures for improving medical and aesthetic dermatologic conditions has led to the increased demand for light emitting diode (LED) therapy in aesthetics practices.
Research on LED mechanisms of action has shown to have multiple pathways in which there is quantifiable clinical benefit. The use of wavelengths has measurable benefits to both the client and the professional in terms of outcome with no side effects or complications. Modern LED devices are able to target large areas depending on the clinical condition being treated thereby reducing treatment time and improving outcomes.
There are numerous dermatological and medical conditions that benefit from the use of LED therapy. A 2018 study reviewed randomized controlled trials in medical and dermatological conditions.1 Their findings support the significant benefits in the use of LED for acne, herpes zoster, skin rejuvenation, and psoriasis. Medical conditions such as acute and chronic wound healing, management of pain, and inflammatory joints have all shown to be clinically benefited by LED. In cases of radiation dermatitis, oral mucositosis, and atopic dermatitis, further studies are required to demonstrate a statistical benefit.1
The depth of each wavelength adopted in LED therapy – blue, red, and near infrared – have differing primary targets and photoreactions in the target cells through photon absorption, intracellular signal transduction, and the cellular photo-response.
Visible wavelengths stimulate cellular metabolism by triggering intracellular photobiochemical reactions. The observed effects include increased adenosine triphosphate – an organic chemical that provides energy – modulation of reactive oxidative species, alteration of collagen synthesis, stimulation of angiogenesis, and increased blood flow. Studies have also demonstrated the increase in the production of multiple growth factors and the inhibition of apoptosis or cellular death. All studies have demonstrated a statistically significant improvement in skin rejuvenation, as well as enhancing existing rejuvenation treatments.3,4
Clinical studies in the use of red LED (630 to 700 nanometers) have demonstrated it activates fibroblast growth factors, increasing type 1 procollagen, an increase in matrix metalloproteinase-9 (MMP-9), and a decrease in MMP-1.2 These result in the reduction of fine lines and wrinkles, improvement in photoaging, a decrease in melanin, and softer, smoother, healthier looking skin. Skin analysis studies reveal an increased collagen density in the papillary and upper reticular dermis with the collagen bundles more packed and well organized. The thickness was observed to be greater than when evaluated before red LED treatment.
Red LED has also proven to extend the remission intervals in those with recurrent herpes simplex infections from 30 to 73 days. The mechanism of action is unclear but it is suggested that there is a delayed inhibitory effect of LED on hypersensitivity reactions.3
Yellow light penetrates a depth of 0.5-2 millimeters (570 to 590 nanometers) and has been shown to have benefit in treating skin conditions involving redness, swelling, and photoaging. However, due to its shallow reach, there is little evidence to support its use as a single modality, as the above mentioned benefits are better achieved with the application of red light, which carries additional stimulatory and anti-inflammatory benefits, and, more importantly, the red wavelength is capable of reaching deeper into the dermal layer and, therefore, reaching more of the target cells. The same argument applies to green wavelengths, which are simply too short to reach the target cells located in the dermis.
The management of inflammatory and autoimmune skin conditions, such as acne vulgaris, rosacea, and psoriasis, have shown dramatically significant improvement with LED therapy. In cases of acne, there is a multifactorial influence in the proliferation of acne: thickening of the epithelial layers in the follicles, increased sebum production due to androgenic hormone secretions, colonization of P.acnes bacteria, and inflammation. The bacterium plays a key role in the release of cytokines that, in turn, triggers the inflammatory reactions and alters keratinization. The use of topical and oral treatments currently available in the management of this debilitating condition can either be ineffective or poorly tolerated by the clients. This results in poor outcomes and a resurgence of the condition that has social and psychological impact on those affected by acne.
The use of blue light (400 to 470 nanometers) is most suitable for superficial conditions. Its depth of penetration is limited to less than 1 millimeter and a single modality has been clinically proven to be significantly effective in managing acne vulgaris. The mechanism of action responsible is the absorption of the light by porphyrins produced by the bacteria, which sets off a photochemical reaction and forms reactive free radicals and singlet oxygen species, which in turn leads to bacterial destruction. This appears to be highly effective in the management of non-inflammatory acne.
Given that acne is a multifactorial skin condition, treatments need to be able to target all four influences. Blue light emits an anti-inflammatory effect that appears to be a result of a shift in cytokine production. Red light stimulates the increase in collagen production, supporting wound healing necessary for resolution and a reduction in scarring.
The combination of red and blue light has been demonstrated to have a significant inhibitory effect on sebum production, as well as the reduction in the inflammatory processes associated with acne vulgaris. Red light has been proven to reduce sebum proliferation. Various studies have conclusively demonstrated a significant improvement in the use of combined red and blue light used twice weekly for six to eight weeks compared to the use of topical benzyl peroxide. A similar study comparing topical antibiotic with blue light found an overall reduction by 34% in inflammatory acne with blue light, compared to 14% for the topical antibiotic.3 Adopting both blue and red wavelengths in the management and treatment of inflammatory acne dramatically improves outcomes, psychological well-being, and quality of life.
More recent studies have shown promise in the benefits for those suffering from psoriasis and rosacea. Both conditions are autoimmune, inflammatory disorders with clinical symptoms of redness, flushing, and dryness. Evidence is scarce, yet there is supportive evidence to suggest that a combination of blue and red light helps to reduce the inflammatory process in psoriasis and rosacea. Some suggest the combination of red and near-infrared offers improvement. Evidence supports the amelioration of symptoms of both diseases, but in the case of psoriasis, there is the potential of the return of symptoms on cessation of treatment. It is incumbent that the professional manages expectations when managing complex autoimmune skin conditions, with the focus on improvement rather than resolution.
The management of deeper wounds, burns, ulcers, and lesions has proven to benefit from the use of the invisible wavelength, near-infrared light (800 to 1200 nanometers), the deepest penetrating wavelength. Numerous studies, however, suggest the combination of near-infrared and red light dramatically accelerates wound healing, reduces pain and erythema in tissue trauma, and chronic ulceration. There are also benefits in the use of near-infrared in post-surgery recovery to accelerate wound healing and reduce the risk of the development of keloids and hypertrophic scars. This is as a result of increased collagen and elastin synthesis and the stimulation of interleukin IL6, platelet derived growth factors (PDGF), and transforming growth factors (TGF) that has a direct impact on the increase of hyaluronic acid demand by the fibroblasts and subsequent increase collagen synthesis.
ASSESSMENT, DIAGNOSIS, AND PLANNING
The key to the successful management of any dermatologic skin concern relies on the accurate and detailed assessment of the skin, correct diagnosis, and an appropriate management plan. Most clients will present in-clinic with a skin concern of some degree and experienced professionals need to be mindful that most clients self-assess and diagnose and will present with preconceived ideas as to their skin disorder. This is based on a lack of understanding and the array of conflicting information available on the internet and social media. Many will have been down the pathway of disastrous purchases on the internet and buying into the latest wonder cream or treatment that promises a cure to their problems but fails to deliver on outcome and results.
While access to diagnostic equipment helps and supports the professional, a detailed understanding of the skin, as well as the intrinsic and extrinsic factors that attribute to the disorder, is the most valuable tool. Appropriate and closed questioning as to lifestyle, medical and medication history, diet, and social habits will lead the professional to the accurate diagnosis. It is worth exploring family history with regard to genetic influences, particularly those inflammatory conditions such as acne, rosacea and psoriasis.
Visual assessment is vital as this gives clear markers as to lifestyle and social habits. Visually assessing the Fitzpatrick skin type, degree of photoaging, and quality and integrity of skin are key indicators. Exploring their skin care routine will highlight whether they are likely to be compliant or not to any skin care regimen recommended to support treatments. Many will have treated their skin with over-the-counter products that may have been inappropriate in managing and improving their skin condition and appearance.
One skin disorder that is easily misdiagnosed by the clients is pustular rosacea. This condition mimics acne in appearance with pustules, redness, and sensitivity. Using aggressive over-the-counter products that target acne-prone skin may have exacerbated the condition, leading to a more chronically inflammatory, dehydrated, and reactive skin. Assessment of the texture and integrity of the barrier are key indicators of dry, sensitive, aggravated skin due to transepidermal water loss leading to an increase in sensitivity and inflammatory reactions at a cellular level. This creates a cascade of free radical activity, reactive oxidative stress, and an increase in MMP-1 that negatively impacts on cellular homeostasis and degradation of the extracellular matrix.
Managing and moderating expectations is a vital element of the consultation and assessment process. The client’s expectations need to be congruent with what the professional is able to deliver. When it comes to treating with LED, a sound understanding of the differing wavelengths, their varying depths of penetration, and the target cells will support the decision as to which wavelength or program will deliver the optimum outcome. When making a clinical judgement as to which is the most appropriate wavelength to use in the treatment plan, the decision will depend on the intended outcome. Does collagen production need to be increased for skin rejuvenation? Then, the support of the combination of near-infrared with red LED will be needed to achieve a better result. Is the skin damaged with a disrupted barrier and in need of greater wound healing and repair? Is the use of blue LED sufficient for the management of acne-prone skin or would the combination of blue and red LED aid wound healing, as well as regulate sebum production, eliminate P.acnes bacteria, and control breakouts? Would the use of near-infrared in combination with red give an improved outcome with those with severe photoaged skin? There is a plethora of scientific evidence to support the use of combination wavelengths for faster, better, and more longer-lasting results.
Compliance by the client is crucial to a successful outcome. No matter what the management plan, it needs to be mutually agreeable to both the professional and the client, and be manageable, achievable, and not a financial burden to the client. Time needs to be set aside to educate and inform the client of the benefits of the treatment, particularly in relation to the use of LED therapy, addressing concerns over risks or any contraindications that may apply.
LED therapy is proving to have more and more viable applications in the management of skin concerns. However, it must be remembered that not any LED device will do. Research should examine any device and should establish whether there is the scientific (not marketing) evidence to support their device. FDA-clearance means that the device has been reviewed for safety and efficacy. Ask if the LED device is FDA-cleared for the intended use. For example, a device cleared to treat only acne may not be the best choice if treating aging skin. How versatile is the device? Can it be used on other areas apart from just the face? Does it have the correct wavelengths for the target cells? Wavelengths between 830 and 880 nanometers are effective for all aspects of wound healing, inflammatory processes, and skin rejuvenation. A combination of blue (415 to 470 nanometers) and red (630 to 660 nanometers) is effective for the management of active inflammatory acne and skin rejuvenation. If the wavelength is incorrect, optimum energy absorption will not occur at the target cells and, therefore, no photochemical reaction will occur.
The ability to place the device in close proximity to the skin improves energy absorption. This, along with adequate treatment times, is an important factor in attaining optimal results. Cells need a certain amount of time in order to absorb enough of the emitted energy to achieve optimum results. The best LED devices recommend 20- to 30-minute treatment durations.
LED therapy is a safe, effective, and a pain-free treatment with scientific proven benefits in the management of the array of skin concerns and disorders that present in clients.
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2 Opel, D.R., E. Hagstrom, A.K. Pace, K. Sisto, S.A. Hirano-Ali, S. Desai, and J. Swain. “Light-
emitting Diodes: A Brief Review and Clinical Experience.” The Journal of Clinical and Aesthetic Dermatology 8, no. 6 (2015): 36-44.
3 Avci, P., A. Gupta, M. Sadasivam, D. Vecchio, Z. Pam, N. Pam, and M.R. Hamblin. “Low-
level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring.” Seminars in
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Pam Cushing is a registered nurse with over 35 years of experience in emergency medicine. She has worked in the field of aesthetics for over 15 years, full-time for the last five years. Cushing holds a degree at the master’s level, with commendation, as well as a post-graduate diploma in aesthetic medicine with merit. She is an independent nurse prescriber in the United Kingdom. Cushing is a consultant educator for companies educating in injectables, skin resurfacing and chemical peel, microneedling, and LED. She thrives on being able to educate, motivate, and encourage others to grow and develop professionally. She is passionate about skin and the benefits of aesthetics in improving the confidence and quality of lives. Cushing believes the professional’s key role is to educate the consumer on appropriate treatment modalities with the focus on maintaining skin health.