You voluntarily consent to intense pulsed light treatment and understand that Intense pulsed light (IPL) therapy, aka photofacial or flash lamp therapy, is a medical procedure that is non-invasive and non-ablative. IPL uses high-intensity pulses of visible light to improve the appearance of multiple skin problems such as the color and texture of your skin. Because of its polychromaticity, IPL can target oxyhemoglobin (predominantly found in clinically red lesions), deoxygenated hemoglobin (predominantly in blue lesions), melanin, and methemoglobin, with absorption peak wavelengths of 418, 542, and 577.
The IPL device is FDA cleared. When a drug or device is approved for medical use by the FDA the manufacturer produces the label to explain its use. The use of a drug or device for conditions not listed on the label is considered to be not approved or off label use of the drug. Certain uses of intense pulsed light may be considered off label uses. When a drug is used off label, there is no tested information on use dosage and route administration that is provided in product labeling for approved indications. Furthermore, the efficacy of the unapproved use has not been established by adequate and well-controlled clinical trials.
You understand the treatment with intense pulsed light is not an exact science, and there is no guarantee or warranty that wrinkles will be improved or decreased.
IPL is not recommended for patients with:
Pregnancy
Under 18 years of age
Melanoma
3 or more dysplastic nevi- recommend dermatology clearance
Active cancer diagnosis/treatment
Active infection in the area
Active AIDS or immunocompromised (increased risk of folliculitis/infection)
HIV patients should have CD4 counts above 200
Isotretinoin (Accutane, Amnesteem, Claravis or Sotret) use in the last 3 months
Vitiligo
Photo induced seizures
Lymph node surgery, and or lymphedema
Abnormal response to sunlight
Hypertrophic scarring
Fitzpatrick skin types five and six
Melasma in the affected area
You understand that the following are treatment recommendations for intense pulsed light:
Your skin will likely be red, swollen and slightly tender after the IPL procedure. Your healthcare provider may recommend over the counter pain medication to help with any discomfort. If you notice swelling lasts longer than a week or worsens, contact your healthcare provider.
Patients will be educated to follow up with the prescribing physician if they experience: Infection, Skin Discoloration, or Scarring.
After 1 week: Redness and swelling should subside. You may notice enlarged pores or small whiteheads on your skin, which usually go away with the swelling. Don’t shave the treated area.
After 2 weeks: A scab may form over the treated area, which falls off. The skin underneath will look tight and pink. It might be itchy. Most people can return to work after two weeks, but you should avoid strenuous activities.
After 4–6 weeks: You can gradually get back to playing sports or other activities, but you should stay out of the sun.
After 6–12 months: Continue staying out of the sun until the treated area has returned to your normal skin color.
During treatment you may experience some discomfort, therefore, topical anesthesia may be applied prior to treatment. You understand that this is strictly a voluntary cosmetic procedure, that no treatment is necessary or required.
You understand that intense pulsed light services may involve the following risks or discomfort:
Expected reactions- tingling sensation, mild erythema, hypo/hyper pigmentation Purpura
Thermal Injury- Typically due to sun exposure or residue on the skin prior to treatment. These are painful in nature and will likely hyperpigment and then hypopigment. If the areas hypopigment then the patient will need a few minutes of sun exposure a few times a week to reactivate melanocytes. Apply Aquaphor and Bacitracin if any areas are open. Cleanse skin thoroughly prior to treatment & encourage sun protection for future prevention.
Folliculitis- Irritated and inflamed hair follicles post treatment can appear as white acne like bumps. These typically do not itch (like a Histamine Rxn) but can be painful to the touch. Keep the area clean with benzoyl peroxide or Hibiclens and apply topical Bacitracin as needed. Do not pick at the bumps and use warm salt water compresses. Cleanse the area with Hibiclens or alcohol prior to treatment to prevent in the future.
Histamine reaction- Itchy, red rash or bumps post treatment that are typically from an allergic reaction. Patients should keep the area cool, take antihistamine such as Benadryl at night and Claritin/Zyrtec during the day. Add in an H2 blocker like Pepcid/Zantac and utilize a topical steroid such as Hydrocortisone cream. In rare cases, a prescription for oral steroids may be needed. To prevent Histamine Reactions in the future, patients should premedicate 3 days before and after treatment with: Benadryl at night, Claritin/Zyrtec during the day along with Pepcid or Zantac. Use triamcinolone mixed with cold aloe post treatment to soothe areas.
You agree that we may take photos of the treatment area for medical reasons or for use in marketing materials provided such photos do not reveal your identity.
You authorize us to use or disclose your medical information as needed for payment or healthcare operations purposes.
You have read this agreement in full and understand the provisions, and have been given the opportunity to ask questions regarding the informed consent.
You understand that the provision of cosmetic services is not an exact science and providers cannot guarantee any results.
You understand that the goal of treatment is improvement and not perfection.
By signing the informed consent on the progress note, you grant authority for the treatment to be performed by a medical professional.
I hereby release the practitioner and staff from any liability associated with the treatment, except in the case of proven negligence.
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