Standardized Application of Advanced Optimal Pulse Technology for Erythromelanosis Follicularis of Faciei and Colli: A Split-face Method

Summary

This protocol demonstrates a randomized split-face method for evaluating the efficacy and safety of Advanced Optimal Pulse Technology compared with standard Optimal Pulse Technology for treating erythromelanosis follicularis of faciei and colli.

Abstract

Erythromelanosis follicularis of faciei and colli (EFFC) is a chronic dermatological disorder characterized by hyperpigmentation, erythema, and follicular papules. Management remains challenging, as conventional treatments such as pulsed dye lasers can induce purpura and pose a risk of post-inflammatory hyperpigmentation, particularly in individuals with darker skin types. This article presents a standardized and reproducible clinical protocol using Advanced Optimal Pulse Technology (AOPT), a tunable intense pulsed light system, to target the vascular and pigmentary components of EFFC. A randomized, split-face clinical study involving 14 patients is described. Specific parameter settings, including dual-band vascular filters and adjustable pulse structures, were applied to the intervention side and compared with standard Optimal Pulse Technology (OPT) on the contralateral side. Quantitative assessments were performed using a skin colorimetric probe and a digital skin analysis imaging system to objectively evaluate lesion clearance. All 14 patients completed follow-up without attrition. The AOPT-treated side showed statistically significant reductions in erythema and melanin indices compared with the OPT control, with substantial inter-rater reproducibility for clinical evaluations. Additionally, the procedure was generally well tolerated, with few adverse events and limited downtime. Methodological limitations of this study include the small sample size, the absence of long-term follow-up (>6 months) to assess recurrence rates, and the lack of prospective clinical trial registration. This protocol provides clinicians with a standardized approach for applying AOPT to EFFC and may help address some limitations of traditional laser modalities in selected patients.

Introduction

Erythromelanosis follicularis of faciei and colli (EFFC) is a distinct and persistent dermatological condition, particularly prevalent among young Asian males^1,2,3. It is defined by well-demarcated erythema (telangiectasia), hyperpigmentation, and follicular papules, typically presenting symmetrically on the preauricular areas, cheeks, and lateral neck^1,4. Although the etiopathogenesis is multifactorial, encompassing genetic predisposition and follicular keratinization abnormalities, the clinical impact can be substantial⁵. The reddish-brown plaques may cause aesthetic concern, and symptoms are frequently exacerbated by environmental triggers such as heat and sunlight, contributing to psychosocial distress and reduced quality of life^2,6. The complexity of EFFC arises from its mixed pathology: intertwined vascular (redness), pigmentary (melanin deposition), and textural (follicular roughness) components, requiring a treatment modality capable of addressing these features together⁷.

Current management strategies are often limited. Conventional topical therapies, including keratolytic agents (e.g., salicylic acid, urea) and retinoids, primarily address follicular hyperkeratosis but yield minimal improvement in vascular and pigmentary manifestations^8,9. For vascular lesions, the pulsed dye laser (PDL, 595 nm) has long been regarded as a standard treatment option^10,11. However, PDL presents notable drawbacks in this population: high-energy settings necessary for vessel coagulation frequently result in immediate purpura, leading to prolonged social downtime (7–14 days)¹¹. In patients with Fitzpatrick skin types III–IV, epidermal injury induced by PDL can also increase the risk of post-inflammatory hyperpigmentation (PIH), potentially exacerbating the pigmentation component of EFFC^12,13. Traditional intense pulsed light (IPL) has been used as a milder alternative, but outcomes vary due to inconsistent parameter selection and limited control over pulse configuration, which may result in suboptimal lesion clearance^13,14.

Advanced Optimal Pulse Technology (AOPT) is a tunable light-based modality that may help address some limitations of conventional treatments for EFFC¹⁵. Operating as an evolution of modern intense pulsed light (IPL) platforms, AOPT differs from traditional IPL and standard Optimal Pulse Technology (OPT) by enabling independent adjustment of sub-pulse duration, fluence, and waveband selection through specialized filters. This tunability may be useful for managing the complex pathology of EFFC. For example, dual-band vascular filters allow simultaneous targeting of superficial and deep vasculature, while optimized pulse delays, such as 25 ms, may help protect the melanin-rich epidermis common in Asian skin, thereby reducing the risk of post-inflammatory hyperpigmentation (PIH) while delivering thermal energy to target chromophores¹⁵. By integrating these capabilities, AOPT provides a multidimensional treatment approach that addresses both erythema and pigmentation in a single session with attention to safety.

Despite its technological advantages, a standardized protocol for applying AOPT to EFFC remains lacking. Current literature is largely limited to case reports or studies without controlled comparisons to earlier technologies^6,14. There is therefore a need for a reproducible clinical framework that specifies key parameters, including filter selection, pulse width, and energy density, to optimize the balance between efficacy and safety, especially in patients with darker skin types.

The primary objective of this study is to present a detailed clinical protocol for treating EFFC using AOPT. To evaluate its performance, a randomized split-face design was used to compare AOPT with standard OPT within the same individuals, thereby reducing inter-subject variability. The methodology includes pre-treatment assessment using a skin analysis imaging system and quantification via a skin colorimetric probe, followed by controlled application of dual-pulse parameter settings. By establishing a standardized treatment algorithm, this protocol provides clinicians with a reproducible approach that may reduce the prolonged downtime associated with PDL and the inconsistent outcomes reported with conventional IPL.

Protocol

All methods described in this protocol were approved by the Medical Ethics Committee of Huashan Hospital (Approval No.: KY2017-004). Written informed consent was obtained from all participants before enrollment (Figure 1).

1. Patient selection and preparation

1. Screen patients for inclusion based on a clinical diagnosis of Erythromelanosis Follicularis of Faciei and Colli (EFFC), characterized by reddish-brown pigmentation, telangiectasia, and follicular papules on the preauricular area, maxilla, or neck.
2. Exclude patients with a history of deep vein thrombosis, connective tissue disease, immunosuppression, or predisposition to hypertrophic scars/keloids.
3. Exclude patients who have used oral isotretinoin within the previous 2 months, received light-based facial treatments within the last 6 months, or are currently pregnant or lactating.
4. Instruct the patient to wash their face thoroughly with a mild cleanser and water to remove all makeup, sebum, and dirt.
5. Acclimatize the patient in a controlled environment with a temperature of 22–25 °C and relative humidity of 50–60% for 20 min before assessment to stabilize skin blood flow.

2. Pretreatment assessment and imaging

1. Quantitative skin analysis
   1. Launch the skin analysis imaging system software on the computer.
   2. Instruct the patient to remove all jewelry and pull hair back to fully expose the face and neck.
   3. Position the patient’s chin on the chin rest and forehead against the head support. Ensure the patient maintains a neutral expression and closes their eyes.
   4. Select Standard Light, Cross-Polarized, and UV Light modes in the software interface.
   5. Click Capture to take images from the front, left, and right angles.
   6. Use the software analysis tool to delineate the region of interest (ROI) on the cheeks. Apply the same anatomical ROI on both sides and at each visit when possible.
   7. Record the baseline quantitative values for “Red Areas” (representing hemoglobin) and “Brown Spots” (representing melanin).
2. Colorimetric measurement
   1. Calibrate the skin colorimetric probe according to the manufacturer’s instructions before each session.
   2. Place the probe perpendicular to the skin surface on the most prominent lesion area of the left cheek. Apply constant, gentle pressure until the device beeps to confirm measurement.
   3. Record the Erythema Index (EI) and Melanin Index (MI).
   4. Repeat the measurement on the symmetrical lesion area of the right cheek.
   5. Calculate the mean of three consecutive measurements for each side to minimize variability.

3. Preparation of the IPL system

1. Turn on the intense pulsed light (IPL) system.
   CAUTION: Ensure that both the operator and the patient wear appropriate wavelength-specific protective eyewear throughout the laser procedure to prevent retinal injury.
2. Clean the sapphire light guide of the handpiece with a saline wipe or saline-soaked cotton ball to ensure maximum light transmission.
3. Apply a layer of cold, colorless ultrasound transmission gel (approximately 2–3 mm thick) over the entire treatment area (cheeks and neck).
   NOTE: The gel acts as an optical coupling agent and protects the epidermis from thermal injury.

4. Split-face treatment procedure

1. Randomization
   1. Assign one side of the face (left or right) to the Advanced Optimal Pulse Technology (AOPT) group and the contralateral side to the Optimal Pulse Technology (OPT) group using a random number table.
   2. Record the assignment in the patient’s file to ensure consistency in subsequent sessions.
2. AOPT mode treatment (intervention side)
   1. Select the AOPT mode on the device interface.
   2. Insert the vascular filter (Dual-band: 530–650 nm and 900–1,200 nm) into the handpiece.
   3. Configure the pulse structure to Dual-Pulse mode. Set the pulse duration (width) to 4.0 ms for both pulses. Set the delay between pulses to 25.0 ms.
   4. Adjust the fluence based on the patient’s skin phototype (Fitzpatrick III-IV) and tolerance. Start at the lower end of the range for Fitzpatrick IV skin or low pain tolerance, and increase only within the specified range if the endpoint in Step 4.2.9 is not achieved.
      1. Set the first sub-pulse energy density to 9–12 J/cm².
      2. Set the second sub-pulse energy density to 7–9 J/cm².
   5. Place the sapphire crystal light guide perpendicular to the skin surface, ensuring full contact with the gel.
   6. Depress the hand switch to deliver the pulse.
   7. Move the handpiece to the adjacent area with approximately 10% overlap between light spots to ensure uniform energy distribution.
   8. Treat the entire affected area on the assigned side once.
   9. Observe the skin for the immediate endpoint, which is defined as mild transient erythema and slight darkening of pigmented lesions.
      ​NOTE: If distinct whitening (epidermal burn) or excessive pain occurs, decrease the fluence immediately and reassess before continuing.
3. OPT mode treatment (Control Side)
   1. Switch the treatment mode to OPT (or standard IPL mode) on the interface.
   2. Remove the vascular filter and insert the 560 nm cut-off filter.
   3. Configure the pulse structure to Dual-Pulse mode. Set the pulse duration to 4.0 ms and the pulse delay to 25.0 ms.
   4. Set the fluence to a total energy density of 16–20 J/cm².
   5. Perform the treatment on the contralateral side using the same technique (perpendicular contact, 10% overlap) described in steps 4.2.5–4.2.8.

5. Posttreatment care

1. Gently wipe off the ultrasound gel with a soft spatula or tissue. Clean the face with water to remove any residue.
2. Apply a cold compress (ice pack wrapped in sterile gauze) to the treated areas for 15–20 min to reduce heat accumulation and minimize the risk of purpura or blistering.
3. Inspect the skin for any immediate adverse reactions such as blistering or pronounced purpura.
   NOTE: If vesicles appear, instruct the patient not to scratch or puncture them. Prescribe a topical antibiotic ointment if necessary.
4. Instruct the patient to apply a broad-spectrum sunscreen (SPF ≥ 30) and avoid direct sun exposure for at least 4 weeks.
5. Advise the patient to use a gentle moisturizer and avoid using functional cosmetics (e.g., exfoliants, retinoids) for 1 week.

6. Follow-up and longitudinal analysis

1. Schedule the patient for follow-up treatment sessions at 4-week intervals.
2. Repeat the entire procedure (sections 1–5) for up to 3 sessions, depending on lesion clearance.
3. Perform data collection (imaging and colorimetric measurements as described in section 2) at each follow-up visit before the new treatment session begins.
4. Conduct the final assessment 1 month after the last treatment session.
5. Ask the patient to rate their satisfaction with the improvement on each side using a standardized quartile scale (0–3).
6. Have two blinded dermatologists evaluate the clinical improvement by comparing baseline and post-treatment photographs using a 4-point scale (Poor to Excellent).

Results

Baseline characteristics

A total of 14 patients with clinically diagnosed erythromelanosis follicularis of faciei and colli (EFFC) were enrolled in this split-face study. The enrollment, allocation, and follow-up processes are detailed in the study flowchart (Figure 1). The cohort consisted of 12 males and 2 females, with ages ranging from 16 to 31 years (mean disease duration: 12.2 ± 3.83 years). Before treatment, there were no statistically sign...

Discussion

EFFC remains a therapeutic challenge due to its multifactorial pathogenesis involving follicular hyperkeratosis, vascular dilation, and epidermal hyperpigmentation. While existing therapies such as topical keratolytics and pulsed dye laser (PDL) have demonstrated variable success, they are often constrained by limited efficacy or adverse effects, including purpura and PIH, particularly in Fitzpatrick skin types III–IV. In this randomized split-face study, AOPT showed greater clearance of both erythema and pigmentat...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Anthelios Melt-in Milk Sunscreen (SPF 60)	La Roche-Posay	https://www.laroche-posay.com	Generic name used in text: broad-spectrum sunscreen
Aquasonic 100 Ultrasound Transmission Gel	Parker Laboratories, Inc.	01-50	Generic name used in text: ultrasound transmission gel
CeraVe Moisturizing Cream	L'Oréal (CeraVe)	https://www.cerave.com	Generic name used in text: gentle moisturizer
Cetaphil Gentle Skin Cleanser	Galderma Laboratories, L.P.	https://www.cetaphil.com	Generic name used in text: mild cleanser
GraphPad Prism (Version 9.0)	GraphPad Software, LLC	https://www.graphpad.com	Statistical analysis and graphing software
IBM SPSS Statistics (Version 26.0)	IBM Corp.	https://www.ibm.com/products/spss-statistics	Statistical analysis software
M22 Universal IPL System (AOPT and OPT Modules)	Lumenis Be Ltd.	https://lumenis.com/aesthetics/products/m22/	Generic name used in text: intense pulsed light (IPL) system
Mexameter MX 18	Courage + Khazaka Electronic GmbH	MX 18	Generic name used in text: skin colorimetric probe
R (Version 4.1.2)	The R Foundation for Statistical Computing	https://www.r-project.org/	Statistical computing environment
VISIA Complexion Analysis System (Generation 7)	Canfield Scientific, Inc.	VISIA-7	Generic name used in text: skin analysis imaging system