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Lasers in Surgery and Medicine 9999:1–7 (2005)
Clinical Trial of a Novel Non-Thermal LED Array
for Reversal of Photoaging: Clinical, Histologic,
and Surface Profilometric Results
Robert A. Weiss, MD,1* David H. McDaniel, MD,2 Roy G. Geronemus, MD,3 and Margaret A. Weiss, MD1
1Maryland Laser Skin & Vein Institute, Hunt Valley, Maryland; Assistant Professor of Dermatology,
Johns Hopkins U School of Medicine, Baltimore, Maryland
2Laser Skin & Vein Center of Virginia; Assistant Professor of Clinical Dermatology and Plastic Surgery,
Eastern Virginia Medical School, Virginia Beach, Virginia
3Laser & Skin Surgery Center of New York; Clinical Professor of Dermatology,
New York University Medical Center, New York, New York
Background and Objectives: Photomodulation has
been described as a process which modifies cell activity
using light sources without thermal effect. The objective of
this study was to investigate the use of a non-thermal low
dose light emitting diode (LED) array for improving the
appearance of photoaged subjects.
StudyDesign/Materials andMethods:This prospective
study investigated a random cohort of patients (N¼ 90)
with a wide range of photoaged skin treated by LED
photomodulation1 using a full panel 590 nm non-thermal
full face LED array delivering 0.1 J/cm2 with a specific
sequence of pulsing. Subjects were evaluated at 4, 8, 12,
18 weeks and 6 and 12 months after a series of 8 treatments
delivered over 4 weeks. Data collected included stereotactic
digital imaging, computerized optical digital profilometry,
and peri-ocular biopsy histologic evaluations for standard
stains and well as collagen synthetic and degradative
pathway immunofluorescent staining.
Results: Digital imaging data showed a reduction of signs
of photoaging in 90% of subjects with smoother texture,
reduction of peri-orbital rhytids, and reduction of erythema
and pigmentation. Optical profilometry showed a 10%
improvement by surface topographical measurements.
Histologic data showed markedly increased collagen in
the papillary dermis of 100% of post-treatment specimens
(N¼ 10). Staining with anti-collagen I antibodies demon-
strated a 28% (range: 10%–70%) average increase in
density while staining with anti-matrixmetalloproteinase
(MMP)-1 showed an average reduction of 4% (range: 2%–
40%). No side effects or pain were noted.
Conclusions: Photomodulation to reverse photoaging is
possible with a specific array of LEDs with a specific fluence
using a precise pulsing or ‘‘code’’ sequence. Skin textural
improvement by digital imaging and surface profilometry is
accompanied by increased collagen I deposition with reduc-
ed MMP-1 (collagenase) activity in the papillary dermis.
This technique is a safe and effective non-painful non-
ablative modality for improvement of photoaging. Lasers
Surg. Med. 00:1–7, 2005. � 2005 Wiley-Liss, Inc.
Key words: light emitting diodes, photorejuvenation,
light therapy, laser, skin rejuvenation, pigmentation
INTRODUCTION
The use of light emitting diodes (LED) and low intensity
light therapy (LILT) for stimulating growth of cells has
been theorized for plant cell growth [1] and stimulation of
wound healing for oral mucositis [2]. The notion that cell
activity can be up or down regulated by low energy light has
been entertained in the past but consistent or impressive
results have been lacking [3]. Wavelengths previously
examined include a 670 nm LED array [4], a 660 nm array
[5], and higher infrared wavelengths [6]. Fluences in these
studies were variable with energy as high as 4 J/cm2
required for results [2].
Preliminary investigations by McDaniel et al. [7] demon-
strated that fibroblast activity could be regulated using
light at low fluence. Using a variety of LED light sources,
his group demonstrated that by varying fluence and other
parameters, procollagen synthesis could be upregulated in
human skin fibroblast culture. This was also found to cor-
relate with significant clinical changes in human skin [8].
In these preliminary investigations, collagen synthesis
was also accompanied by an opposite reaction involving
reduction or down regulation of several matrix metallo-
proteinases [8].
The investigation described here involves the use of an
array of LEDs with dominant wavelength of 590 nm for
clinical improvement of photoaged skin in a novel process of
This data was presented in abstract form at annual meetings of
ASLMS in 2002, 2003, and 2004.
R.A.W., D.H.M., and M.A.W. have disclosed potential financial
conflicts of interests with this study.
*Correspondence to: Robert A. Weiss, MD, Director, Maryland
Laser Skin & Vein Institute, LLC, 54 Scott Adam Road, Hunt
Valley, MD 21030. E-mail: rweiss@mdlaserskinvein.com
Accepted 31 August 2004
Published online in Wiley InterScience
(www.interscience.wiley.com).
DOI 10.1002/lsm.20107
� 2005 Wiley-Liss, Inc.
non-thermal photorejuvenation. Photorejuvenation typi-
cally involves a confined selective thermal injury to the
papillary and upper reticular dermis, without any epider-
mal damage leading to fibroblast activation and synthesis
of new collagen [9]. Thermal mechanisms involve both
dermal and blood vessel heating [10,11]. Categories of non-
ablative devices which affect the wound healing cascade
by a thermal or photothermolysis type of injury include
intense pulsed light, infrared lasers and visible light lasers
and radiofrequency as reviewed previously [12].
A photorejuvenation effect using a novel model of non-
thermal stimulation of cells requiring low energy, narrow
band light with specific pulse sequences and durations has
been termed photomodulation [8]. McDaniel et al. [13]
demonstrated that LEDs emitting in the 590 nm range
have beneficial effects for common patterns of photoaged
skin and that unless a specific sequence of pulsing (on time
and off or dark time) was utilized, there was dramatically
reduced effect on fibroblasts in culture. Application of
continuous LED light had minimal effect [7].
Photomodulation occurs via both stimulation of mito-
chrondrial cell organelles with the proper ‘‘packets’’ of
photons and the linked up or down regulation of mitochron-
drial gene activities. This results in upregulation of the
mitochrondrial cytochrome electron transport pathway
and associated mitochrondrial DNA gene modulation. This
theory would correlate well with recent findings by Larsson
et al. that accelerated signs of aging and premature cell
death correlate with genetic damage within mitochondria
[14].
The ability of mitochondria to utilize light via photo-
modulation as an energy source appears similar to electron
transport with a proton gradient in chloroplasts of plant
cells during photosynthesis [15]. The molecules responsible
for the absorption of light in mitochrondria are the
cytochrome species within the mitochondrial membrane
[15]. Both chlorophyll and cytochromes are synthesized
from protoporphyrin IX. It has been determined that cyto-
chrome molecules best absorb light from 562 to 600 nm.
Light absorption within the mitochrondrial membrane is
speculated to cause conformation changes in antenna
molecules. 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 non-mitotic cell processes. McDaniel et al. have
demonstrated the rapid production of ATP within mito-
chrondia within cultured fibroblasts exposed to LED light
with the proper sequence or pulsing ‘‘code’’ [7,16,17]. This
study reports the results of the original prospective multi-
center clinical study involving 90 subjects followed for
1 year. They were treated by a specific 590 nm LED array
with very specific parameters or sequence of light energy
delivery to reduce signs of photoaging by the mechanism of
photomodulation.
MATERIALS AND METHODS
Full patient consentto participate in the study was
obtained using an IRB approved protocol and consent form.
Patients (N¼ 90) with mild to moderate photoaging were
offered the opportunity to receive a series of eight 590 nm
LED array (Gentlewaves1 LED Photomodulation1 unit,
Fig. 1. Pulse sequence of light emitting diode (LED) pulsing.
Fig. 2. LED device.
TABLE 1. Reduction of Fitzpatrick Wrinkle Class
(N¼90)
Class
Percentage of subjects enrolled in each class
showing at least a one grade improvement
1 0a
2 14
3 65
4 49
5 38
6 93
7 100
8 89
9 0b
aClass 1 cannot improve to Class 0.
bNo patients enrolled as Class 9.
2 WEISS ET AL.
LightBioScience, LLC, Virginia Beach, VA) treatments
over a 4 week period. This unit is comprised of 2,040 LEDs
which emit a 590 nm wavelength as the predominant
wavelength. There are two pulses per cycle with 100 cycles
delivered over 35 seconds. The preset but modifiable on-
time for each pulse is 250 milliseconds and the off time or
‘‘dark time’’ is 100 milliseconds (Fig. 1). Total output of
fluence ranges from 0.1 to 0.9 J/cm2, althought the output
for this study was a cumulative 0.1 J/cm2 for a single
treatment.
Treatments were given with a minimum of 48 hours
separation. Skin types ranged from Fitzpatrick type I to IV.
No changes were allowed to the base skin care regimen
within 3 months prior to the study and for the duration of
the 12 month follow-up. All patients were provided with
and coached on the daily use of sunscreen with SPF of 30.
Stereotactic images were taken using the Canfield system
and a Fuji S1 digital camera at day 0, 30 days, 1, 2, 3, and 6
and 12 months at all three sites. 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 were
easily analyzed using high resolution baseline images for
comparison.
Skin surface topography measurements (N¼ 30) were
performed at one study site (VA) using digital optical
surface profilometry with the digital micromirror device
(DMD) coupled to a high-resolution rapid-video camera
with interpretation by analysis software (PRIMOS 3D,
Canfield Canfield Imaging Systems, Fairfield, NJ). Mea-
surements were performed at baseline and at 1 and
2 months post treatment.
A region just lateral to the left lateral canthus was
biopsied before treatment as a control and additional biop-
sies were performed 1 or 2 months following the series of
LED treatments. Biopsies were performed on 10 subjects
chosen and consented at random on initial enrollment. An
acetate tracing was used with the outline of the lateral eye
to accurate position the subsequent biopsy sites at the
follow-up visits. Biopsies were processed for H&E, Masson-
trichrome, and immunoflourescent (IF) staining. IF stain-
ing included collagen I and MMP-1 antibody staining.
Independent investigators graded images using a high
resolution CRT monitor at 1,280� 1,064 resolution in 32 bit
color mode. Images were shown in pairs, but not labeled pre
or post. They were randomized with computer generated
numbers as to which was pre or post for left or right viewing
so that graders would not know which was before or after
treatment. Changes were graded on a quartile scale for
peri-ocular wrinkles, reduction in Fitzpatrick photoaging
classification, skin texture, background erythema, pigmen-
tation, and global improvement. Patients also performed a
self-assessment of their own improvement on a quartile
scale.
Treatments were delivered using a full face panel device
similar to the commercial device shown in Figure 2.
Patients were positioned 2 cm away from the light source
with the chin fixed in a registration device. Pulsed 590 nm
LED light was delivered for a total of 0.1 J/cm2 using the
pulse sequence of 250 milliseconds ‘‘on’’ and 100 milli-
seconds ‘‘off’’ as previously reported and described above
TABLE 2. Statistical Analysis of Grading of 2 Blinded Observers Shown Images Randomly Placed on the Left and
Right Side of the Screens
Measurement
Summary of P-values for blinded image grading
Grader I Grader II Combined
Paired t Wilcoxon Paired t Wilcoxon Paired t Wilcoxon
Fitzpatrick periorbital classification 0.01 0.01 0.03 0.04 0.0025 0.0027
Fitzpatrick periorbital degree of
elastosis
0.002 0.003 <0.0001 0.0001 <0.0001 <0.0001
Global wrinkles 0.004 0.005 0.01 0.01 0.0002 0.0002
Global roughness <0.0001 <0.0001 0.0002 0.0003 <0.0001 <0.0001
Global elastosis 0.001 0.002 0.001 0.002 <0.0001 <0.0001
Global lentigines <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Global pores 0.02 0.02 <0.0001 <0.0001 <0.0001 <0.0001
Global redness NS NS <0.0001 <0.0001 <0.0001 <0.0001
*P-values shown are for a 2 tailed test.
NS, no statistically significant difference.
Fig. 3. Clinical improvement by months post-treatment
(N¼ 90).
CLINICAL TRIAL OF A NOVEL NON-THERMAL LED ARRAY FOR REVERSAL OF PHOTOAGING 3
[13]. This pulse sequence or ‘‘code’’ is pre-set to the sequence
yielding optimal 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.
RESULTS
Independent review of stereotactic digital images of the
peri-ocular region using the Fitzpatrick photoaging scale
showed a reduction of one wrinkle class in the vast majority
of subjects (Table 1). Detailed statistical analysis of results
are shown in Table 2. Analysis included paired two samples
for means t-test, and non-parametric Wilcoxon sign test.
Data was analyzed treating both graders as independent
and combining the datasets into one. The left and right side
of the subject where graded independently and combined
for the analysis.
The best results clinically were seen in the global
improvement category at 4 months post-treatment with
over 85% of patients showing at least a 25% improvement
(Fig. 3). Elastosis and redness also demonstrated improve-
ment. Results peaked at 4 months post-treatment.
Fig. 4. A, B, C: Examples of clinical results. Three sets of before and after at 2 months post a
series of 8 treatments over 1 month.
4 WEISS ET AL.
A reduction in clinical results was observed by month 12 but
these were still significantly above baseline. Clinical
results typical following a series of eight treatments is
shown in Figure 4. Patient self-assessments established
that 84% of patients noticed a significant improvement in
their skin texture.
Skin topography measurements showed at 1 week post
the series of LED treatments that 57% of patients showed
improvement over baseline. One month and two months
post it was 48% and 62%, respectively. The average
improvement over baseline was 10% and is shown graphi-
cally in Figure 5.
All biopsies showed significant collagen production by
Masson-trichrome stain. H&E staining also demonstrated
significant collagen deposition in the papillary dermis as
shown in Figure 6. Staining with collagen I antibodies
demonstrated a 28% (range: 10%–70%) average increase in
staining density while staining with matrixmetalloprotei-
nase-1 (MMP-1) showed an average reduction of 4% (range:
2%–40%). Typical results seen on IF staining for collagen I
are shown in Figure 7 and for MMP-1 in Figure 8.
No side effects were recorded by the investigators. No
pain during treatment was reported. Two patients reported
a temporary exacerbation of papular acne but 17 patients
reported a temporary quenching of papular acne.
CONCLUSIONS
This is the initial report of clinical use of the 590 nm
wavelength LED array to stimulate photomodulation of
cellular activity in a prospective clinical trial with objective
measurements of results. Photomodulation performed with
Fig. 5. Primos surface profilometry results.Fig. 6. Masson’s trichrome staining compared to control.
Arrows show new collagen formation (10�).
Fig. 7. Immunoflourescent (IF) staining for collagen I compar-
ison with control.
CLINICAL TRIAL OF A NOVEL NON-THERMAL LED ARRAY FOR REVERSAL OF PHOTOAGING 5
this specific device including this array of low intensity non-
thermal LEDs and a very specific pulsing time code of on
time and off time is highly effective for stimulation of
collagen synthesis and for production of clinical improve-
ment in photoaging. The initial starting regimen of eight
treatments over 4 weeks is highly effective for peri-ocular
rhytids. Results can be expected to peak between 4 and 6
months and slowly decline over the 6–12 month period
after completion of treatment. Furthermore, global
improvement in skin texture can be expected by most
patients with a reduction of elastosis and background
eythema and pigmentation. One of the reasons that this
device may stimulate net collagen synthesis is that the
histologic effects show a concomitant reduction in MMP-1
(collagenase) activity.
It is interesting that a light source can induce similar
findings for collagen synthesis and reduced MMP activity
as reported with retinoic acid [18–20]. The mechanisms of
action of a topical drug versus photomodulation are very
different yet yield similar effects. Based on cell culture
reverse transcriptase-polymerase chain reaction (RT-PCR)
analysis and immunofluorescent (IF) staining of skin
biopsies, the pathway that 590 nm LED photomodulation
is speculated to affect is shown in Figure 9. Laboratory
evidence on isolated patients and fibroblasts in culture
show that markers of extracellular signal regulated kinase
(ERK) and cytokine pathways such as cJun and cFos are
reduced by 590 nm LED array treatment with the ‘‘code’’ of
pulsing described [13]. Further investigation is ongoing
about these and other markers influenced by 590 nm LED
treatments.
The anti-inflammatory and erythema reduction effect of
LED photomodulation is presently under further investi-
gation. Some preliminary data indicates an anti-inflam-
matory effect for LED photomodulation following UV
induced erythema. Using a solar simulator, preliminary
findings indicate a photoprotective effect when delivered
after UV radiation [21]. This was predicted based on the
reduction of MMP-1 in this study. We have observed a
noticeable reduction in UV erythema when LED photo-
modulation is supplied within hours after UV exposure,
590 nm LED photomodulation produced significant down-
regulation of dermal matrix degrading enzymes which
were stimulated by the UV exposure [21]. Addtionally, a
pilot study with precise CO2 laser epidermal destruction
has shown promise with using this device for accelerated
wound healing. Further studies on wound healing and anti-
inflammatory applications are ongoing.
Photomodulation with a 590 nm LED array is not only
effective for collagen synthesis but it is a painless, safe, and
easy to administer therapy. It appears that this device
successfully modulates the activity of fibroblasts resulting
in smoother skin texture without inherent risks of other
thermal photorejuvenation devices presently in daily use.
Multiple trials at multiple centers are now ongoing to
confirm our results.
Our study also indicates that photomodulation treat-
ment has the potential to modulation the production of
MMPs following thermal injury. Therefore, combination
Fig. 8. IF staining for MMP-1 comparison with control.
Fig. 9. Some pathways of LED photomodulation showing
kinase and ERK pathway downreduction by specific pulsing of
590 nm LED light leading to reduction of MMP production and
of cFos/cJun gene expression. UV exposure activates these
pathways, while photomodulation downregulates them. A net
increase in collagen should be observed when upregulation of
collagen synthesis is accompanied by reduction degradation of
collagen.
6 WEISS ET AL.
treatments of LED with standard thermal non-ablative
techniques such as intense pulsed light or pulsed dye may
be of benefit since 590 nm LED treatment downregulates
MMP production. Further investigation is also ongoing
to examine whether 590 nm LED photomodulation may
enhance results after photothermal treatments by stimu-
lating more collagen synthesis and producing less collagen
degradation.
ACKNOWLEDGMENTS
Funding for this study was provided by the investigators
except for the Virginia Beach site which received funding
by LightBioScience, LLC for special clinical and immuno-
histochemical studies. The LED device was supplied at no
cost to all sites by LightBioScience, LLC. Dr. McDaniel has
equity in Light BioScience, LLC.
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