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.)