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BELT STUDY 99 intradermal collagen density and reduced signs of aging.18 The proposed underlying mechanisms include the photo- stimulation of terminal molecules in the electron transport chain and the subsequent adenosine triphosphate (ATP) concentration increase,14 along with the selective light-driven activation of water molecules,19 thereby enhancing metabolic exchange and influencing the ion transporter systems found in cellular membranes.20 Detailed analysis of the gene ex- pression profiles in human fibroblasts revealed an influence of low-intensity red light with a 628-nm wavelength on 111 different genes that are involved in cellular functions, such as cell proliferation; apoptosis; stress response; protein, lipid and carbohydrate metabolism; mitochondrial energy me- tabolism; DNA synthesis and repair; antioxidant related functions; and cytoskeleton- and cell-cell interaction-related functions.21 A specific role of reactive oxygen species (ROS) in increasing fibroblast proliferation and motility has re- cently been reported, suggesting that the elevation of ROS via photodynamic therapy can enhance the cellular functions of dermal fibroblasts through specific mitogen-activated protein kinase (MAPK) signaling pathways in vitro.22 The light-induced free radical formation in human skin has been investigated in detail, demonstrating that red light with 620 and 670 nm wavelengths increases the concentration of ROS even without the influence of external photosensitizers.23 Because fibroblasts are responsible for collagen production in wound healing, dermal remodeling, and tissue repair, we decided to focus on increased collagen density as a surrogate marker for fibroblast activity, and abandoned such invasive monitoring methods as histologic examinations following skin biopsies for our study. Ultrasonographic collagen as- sessment is described as a feasible noninvasive methodol- ogy for monitoring dermal density during the senescence process.24 A report of the stimulatory effects of 660 nm wavelength laser light on scar fibroblasts25 could conceivably explain the potential reactivation of a>40-year-old knee injury, which occurred in one volunteer during the ELT treatment. There- fore, the influence of PBM on scar tissue should be subject to further investigation. Some authors emphasize the importance of distinct wavelengths for optimal results.16–18,26–28 In our study, the differences between the RLT and ELT treatments in clinical outcome and patient satisfaction were not significant, indi- cating that despite spectral differences, both light sources were commensurably effective regarding study objectives. Further studies of the treatment parameters are necessary. The evaluation of clinical photography revealed a partic- ular worsening of fine lines and wrinkles from t0 to t30 in the control group, which was not expected for a course of only 12 weeks. A possible explanation could be the seasonal variation of skin condition between winter and summer cli- mates and the influence of solar radiation, as the clinical photography revealed skin pigmentation as a consequence of exposure to sunlight. We observed a tendency that ELT/RLT treatment led to better results in female volunteers regarding the collagen density increase. This gender-specific response could con- ceivably be explained by physiological differences between male and female skin29,30 on endocrine and extracellular matrix levels. However, gender-specific differences should be evaluated in greater detail in further investigations. Conclusions RLT and ELT are large-area and full-body treatment modalities for skin rejuvenation and improvements in skin feeling and skin complexion. The application of RLT and ELT provides a safe, non-ablative, non-thermal, atraumatic photobiomodulation treatment of skin tissue with high pa- tient satisfaction rates. RLT and ELT can extend the spectrum of anti-aging treatment options available to patients looking for mild and pleasant light-only skin rejuvenation. Acknowledgments We thank Dr. Christine Fischer, Heidelberg, for help and advice regarding the statistical analysis of our data. We also thank all of the volunteers for their participation in this study. This study was fully funded by JK-Holding GmbH, Windhagen, Germany. All materials, light sources, and evaluation equipment were provided by the sponsor. Author Disclosure Statement The principal investigator (Alexander Wunsch) was mandated and remunerated by the sponsor to conduct the study. The authors have received funds to plan, conduct, and evaluate the study. References 1. Chung H., Dai T., Sharma S., Huang Y.Y., Carroll J., and Hamblin M. (2012). The nuts and bolts of low-level laser (light) therapy. Ann. Biomed. Eng. 40, 516–533. 2. Anderson R.R., and Parrish J.A. (1981). The optics of human skin. J. Invest. Dermatol. 77, 13–19. 3. Gupta A.K., Filonenko N., Salansky N., and Sauder D.N. (1998). The use of low energy photon therapy (LEPT) in venous leg ulcers: a double-blind, placebo-controlled study. Dermatol. Surg. 24, 1383–1386. 4. Minatel D.G., Frade M.A., Franca S.C., and Enwemeka C.S. (2009). Phototherapy promotes healing of chronic diabetic leg ulcers that failed to respond to other therapies. Lasers Surg. Med. 41, 433–441. 5. Barolet D., Roberge C.J., Auger F.A., Boucher A., and Ger- main L. (2009). Regulation of skin collagen metabolism in vitro using a pulsed 660nm LED light source: clinical correlation with a single-blinded study. J. Invest. Dermatol. 129, 2751–2759. 6. Huang, Y.Y., Chen, A.C.H., Carroll, J.D., and Hamblin, M.R. (2009). Biphasic dose response in low level lightherapy. Dose Response 7, 358–383. 7. Calderhead R.G. (2007). The photobiological basics behind light-emitting diode (LED) phototherapy. Laser Ther. 16, 97– 108. 8. Papadavid E., and Katsambas A. (2003). Lasers for facial rejuvenation: A review. Int. J. Dermatol. 42, 480–487. 9. Khoury J.G., and Goldman M.P. (2008). Use of light-emitting diode photomodulation to reduce erythema and discom- fort after intense pulsed light treatment of photodamage. J. Cosmet. Dermatol. 7, 30–34. 10. Smith K.C. (2005). Laser (and LED) therapy is phototherapy. Photomed. Laser Surg. 23, 78–80. 11. van Breugel H.H., and Ba ̈r P.R. (1992). Power density and exposure time of He-Ne laser irradiation are more important than total energy dose in photo-biomodulation of human fibroblasts in vitro. Lasers Surg. Med. 12, 528–537. 12. Shoshani D., Markovitz E., Monsterey S.J., and Narins D.J. (2008). The Modified Fitzpatrick Wrinkle Scale: A clinicalPDF Image | Trial to Determine the Efficacy of Red Near-Infrared Light Treatment
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