Device-Based Treatment of Acne and Acne Scarring (Part 3)

Technological advances in treating acne do not only include medications.  They also include high tech equipment that can supplement medicine treatment to improve acne, especially acne scarring or provide even primary treatment, when medicine treatments are contraindicated for example when acne flares or continues in pregnancy...  Device-based treatment can also extend remission and improvement from medicine-based treatment, to further improve the quality of life for acne sufferers.

Numerous lasers can and have been used to treat the plaque of acne.  Pulsed-dye lasers were among the first lasers used to treat acne.  The treatment involved two to four treatments at 2-week intervals, with little down-time or discomfort and the ability to return to normal activities within hours and little after care.  It was and is most successful reducing acne papules and pustules for up to six weeks following treatments and then maintenance for up to six months.  It was also found to cause significant reduction in acne scarring, with an average volumetric reduction of 60% in depressed scars.  When used in conjunction with amino-levulinic acid derivatives, topically, with two treatments a month apart, even cystic acne responded, and remissions average a year.  This type of treatment can provide relief from acne for an entire pregnancy without medicine treatment.  Pulsed-dye lasers are under-utilized today.  Intense pulse light treatments have been used for twenty years for mild to moderate improvement in acne but are generally less effective than laser treatments.

More aggressive lasers are used primarily for acne scarring.  Traditional ablative CO2 and erbium lasers can reduce atrophic acne scars 50-80% and moderate to excellent improvement in acne but has an extended recovery and has a higher risk of post-inflammatory pigmentation than other options. Fractional ablative CO2 and erbium lasers can achieve moderate improvement in acne and atrophic scarring, have a shorter recovery time, but requires multiple treatments and have a similar risk of post-inflammatory pigmentation. (Thiboutot, D, et al. J AM Acad Dermatol, 2009;60:51-50, Kravvas G, et al. Scars Burn Hel. 2018;4:2059513118793420.)

Multiple fractional non-ablative lasers offer moderate improvement and a short treatment recovery but requires multiple treatments and has a risk of post-inflammatory pigmentation. (Kravvas G et al, Kaushik SB, J Clin Aesthet Dermatol. 2017;10:51-67.) Newer pico second lasers offer moderate outcomes in improvement, a short recovery time and no pigment changes from treatment, enabling more treatment options for use in skin of color.

Microneedling is an evolving technology that began twenty years ago with a needle-based roller to provide superficial damage to skin to generate new collagen and elastin and then became more specific with the development of various needle depths, density et cetera, administered with a powered pen.  By making portals of entry into the skin, controlled, site specific microneedling was found to increase penetration of skin collagen and elastin stimulators that enhanced the benefit of microneedling.  Microneedling was also found to enhance the clinical benefit of platelet-rich plasma therapy.  The latest and perhaps most effective iteration of microneedling is the development of Radio Frequency Microneedling that stimulates markedly increased collagen and elastin production when administered as the microneedling is performed. It has many applications, but for acne, it can achieve moderate improvements in acne and improvements in acne scarring that approaches benefits from more aggressive laser treatments. The treatments have a shorter recovery time, needs multiple treatments, but carry a lower risk of post-inflammatory pigmentation.  Needles are often insulated to limit specific effect on the skin and to mitigate healing time after treatment. Kravvas et al)

Hybrid lasers and combination of fractional devices are also used to treat acne and acne scarring with moderate to excellent improvement but require multiple treatments and result in mild epidermal and dermal wounding with increased recovery time. The common lasers in this category include fractional 1470nm and fractional erbium, and fractional 1540nm and fractional CO2 lasers. (Waibel S, et al. J Drugs Dermatol. 2018;17:1164-1168.)

Photodynamic therapy successfully treats acne by applying delta amino levulinic acid or a newer derivative that incubates on skin for an hour and then is exposed to laser light, blue light or red-light devices, causing it to react with skin to help reverse sun-damaged skin, but also reduce oil gland production and reduces bacteria involved in inflammation and causation of acne.  Recovery is about 5-7 days and usually two treatments about a month apart are needed. It can improve cystic ace, popular acne, blackheads, with remissions lasting a year in adolescents and two years in adults.

1320nm and 1450nm lasers are also used to treat acne occasionally.  Also, free electron lasers at 1720nm have been reported to improve acne.

An effective offbeat treatment for acne is the ultrasonic treatment that causes penetration of 150nm gold particles into sebaceous (oil) glands, then the residual particles are wiped off and the gold particles in the oil glands are heated by exposure to near infra-red lasers and damage the oil glands so they do not help cause acne. It is FDA approved for mild to moderate acne.

There are many choices for device-based therapeutic modalities to treat acne. Care providers need to consider many factors when deciding on device-based treatment regimen for patients to tailor treatment for optimal outcomes. (Tanghetti, E.)

Medical Treatment of Acne (Part 2)

The actual medical treatment of acne has undergone significant changes in the last few years for several reasons.   Prolonged antibiotic use was common in the past as sole or adjunctive treatment. Recent research has changed attitudes for using antibiotics long-term because their use has been associated with increasing resistance of bacteria to antibiotics, making treatment of bacterial infections more difficult.  Their prolonged use has been found to increase patient’s chances of developing IBS – inflammatory bowel disease years later, especially tetracyclines. Additionally, the medical importance of the microbiome of the skin and gut is increasingly being appreciated in our general and immune health and even our mental health, especially depression.  Antibiotic use changes the natural microbiome balance in the skin and gut, adversely affecting our immune and psychological health and ability to handle and prevent infections.  Even with a week of antibiotics, it takes the microbiomes three weeks to be restored and ironically if one takes the wrong pre or probiotics to restore the microbiome sooner, it can take as long as a year for the microbiome to recover. (People’s Pharmacy, WUNC) The longer-term use of antibiotics can be even more devastating.  Topical antibiotics have fewer adverse effects on the microbiome because of limited areas of use and little if any absorption through skin. 

The emphasis on early and aggressive medical treatment has also become more mainline with the realization of the adverse effects acne can have on the quality of a sufferer’s life and with the recent studies showing that scars and all the effects acne scar formation cause, can be significantly improved and often prevented with early aggressive treatment. It was also felt that topical treatment for truncal acne was not as important. Recent research has dispelled this as well, showing that truncal acne also adversely affects quality of life and that topical treatment can work well to treat truncal acne. (Tan J, et al. J AM Acad Dermatol. 2019 Epub) Acne has multiple factors at work to cause clinical disease, so it has also become obvious that acne will respond better to treatment if it is attacked therapeutically at multiple points, instead of just one point by single therapy. There is no place for single agent treatment of acne anymore, with exception of Accutane generics

So how is acne treated? First asking about how acne affects one’s life, how long it has lasted, how often and much it breaks out, the family history, any hormonal effects on the acne outbreaks and any other important history, including hat has been used or prescribed for prior treatment.  Then the type of acne is assessed clinically, whether it is mild, moderate or severe, the areas involved and scar potential. 

The mainstay of treatment of mild to moderate acne is a retinoid like adapalene or retinoic acid which is both therapeutic and preventative.  For adults with acne, they also help reverse sun damage and reduce wrinkle progression.  They also reduce scar development and can help reverse mild scarring.  They are effective for both blackhead and papules, pustules.  Usually they are used with benzoyl peroxides which help reduce the propionobacteria acnes that are involved in acne causation.  Often a combination agent of a retinoid and benzoyl peroxide is used for once a day usage and convenience. The strength of the gents can be individualized for each patient.  Azelaic acid cream can be substituted for one of the agents when there is also a problem with post-inflammatory hyperpigmentation. Retinoic acid also can help fade over pigmentation.  Topical antibiotics can be used occasionally such as clindamycin and dapsone. 

Similar or the same topical agents can be used for moderate to severe acne both on the face and truncal areas that are affected clinically.  As the acne worsens, antibiotics will often be used for 3 to 4 months to stabilize and improve the acne, seldom longer.  In women, spironolactone or birth control pills (4 kinds are approved for acne) in place of antibiotics or with the antibiotics and continued for maintenance after the antibiotics are discontinued.  In men, the presentation of severe acne with cysts makes Accutane generics the treatment of choice.  It is the treatment of last resort in women with severe acne that does not respond to antibiotics or hormonal therapy.

When pregnant women have acne that needs treatment, benzoyl peroxide agents can be used safely, but retinoic acid, azelaic acid, antibiotic topicals and dapsone are contraindicated as are hormonal treatments and the more effective antibiotics.  Pregnant women with acne can often be treated with light and laser treatments or with photodynamic therapy treatments before a planned conception, because the remission is often a year or longer and lasts through a pregnancy.

Mild, moderate or severe acne can also be treated with many different devices – lasers, photodynamic therapy with levulan and laser light, infra-red light following gold particle massage, LED lights and others to be discussed in the next blog installment. Acne surgical lesional removals and numerous chemical peels that physician offices and spas offer or home use products.

It should be noted that effective benzoyl peroxide medications are available over the counter and recently an effective retinoic acid-like medicine, Differin, has become available OTC. 

Acne treatment can be very effective, especially if started early and aggressively.  It is also most effective when the patient is included in the treatment decision making process by your professional providing your skin care.