Lasers and Light Treatments for Acne Vulgaris Promising Therapies
September 2008
Therapeutic and Aesthetic Uses of Photodynamic Therapy
Part two of a five-part series
by Michael H. Gold, MD
Medical Director, Gold Skin Care Center and The Laser & Rejuvenation Center, Nashville, Tennessee
Disclosure: Dr. Gold is a consultant to, speaks for, and receives honoraria from Pharos Life.
Address correspondence to: Michael H. Gold, MD, Gold Skin Care, 2000 Richard Jones Road, Suite 220, Nashville, TN 37215; E-mail: goldskin@goldskincare.com
ABSTRACT
Acne vulgaris remains one of the most common dermatologic disorders. Clinicians are always searching for new therapies to utilize in their therapeutic armamentarium for this common skin concern. We have many medical therapies at our disposal and these have proven useful in many cases in controlling the disease process. However, some patients need or want other therapies, and laser and light treatments for acne vulgaris have become popular over the past several years. This manuscript will review some of these promising therapies.
(J Clin Aesthetic Derm. 2008;1(3):28–34)
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As dermatologists, we have known that exposure to ultraviolet (UV) light is effective in the treatment of acne vulgaris.[1] This phenomenon has been described as a natural photodynamic therapy (PDT) response in that there is selective destruction of the Propionibacterium acnes (P. acnes) bacteria within the pilosebaceous unit, the bacteria responsible for the inflammatory phase of acne vulgaris. Dermatologists, well aware of the potential damages associated with excessive UV exposure, do not regularly recommend this type of therapy for acne vulgaris because of the potential long-term adverse effects that are associated with this kind of therapy. These adverse effects include an increase in skin aging and in premalignant and malignant skin lesions.
The PDT reaction seen in acne vulgaris lesions involves the production of porphyrins by the P. acnes bacteria themselves during their growth and proliferation in the follicular units as noninflammatory acne lesions become inflammatory in nature. The porphyrins produced are known as protoporphyrin IX (PpIX) and coproporphyrin III. These porphyrins have an absorption spectrum in the near UV and visible spectrum of light, as shown in Figure 1. This figure demonstrates the absorption spectrum of PpIX; the absorption spectrum for coproporphyrin III is similar. The major absorption peak for these porphyrins is at 415nm, known commonly as the Soret Band, and is in the blue range of the visible light spectrum. A second peak, seen at 630nm, is also seen and corresponds to red light. Therefore, phototherapy devices have been developed that utilize either blue light or red light PDT for the treatment of inflammatory acne vulgaris lesions. The PDT process seen in this reaction involves the photo-excitation of the P. acnes porphyrins after exposure to the appropriate light source. This will then form singlet oxygen within the bacteria and the selective destruction of the bacteria. The reaction occurs rapidly and has been demonstrated in vivo. In addition, by utilizing a topical photosensitizer to the reaction, a synergistic effect has been demonstrated, making PDT a viable option for many suffering from inflammatory acne vulgaris.[2–4]
Lasers and light sources that have been developed to treat acne vulgaris are usually divided into two classes— those that destroy the sebaceous glands and the entire pilosebaceous unit and those that destroy P. acnes. Those that destroy the P. acnes bacteria include blue and red light sources, green light lasers, yellow light lasers, and intense pulsed light (IPL) sources. Those medical devices that destroy sebaceous glands include lasers in the near infrared spectrum of light and radiofrequency (RF) devices. Over the past several years, many of us have had an interest in utilizing PDT for inflammatory acne vulgaris, via a mechanism of destruction of P. acnes and a partial destruction of the sebaceous glands.
LASERS AND LIGHT SOURCES THAT DESTROY P. ACNES BACTERIA
Blue light systems. The first of the blue light devices approved by the FDA for the treatment of inflammatory acne vulgaris was a high-intensity, narrow-band, blue light source, known as the ClearLight Acne Photoclearing System (CureLight, Yokneam, Israel) as shown in
“href=”http://nearmyth.com/jcad/wp-content/uploads/2009/01/figure-3_jcad_0908_gold-2.jpg”>Figure 3
A third blue light system, the OmniLux Blue (Photo Therapeutics, Manchester, United Kingdom) has also shown effectiveness in the treatment of inflammatory acne vulgaris lesions. This LED blue system has demonstrated reductions in inflammatory acne vulgaris lesions by an average of 74 percent.[12] Other forms of this medical device are also available, which may increase the efficacy even further by adding additional wavelengths of light to the therapeutic options available.
Green light systems. Green light lasers with a wavelength of 532nm have been reported to be effective in treating inflammatory acne vulgaris lesions. They are effectively absorbed by P. acnes porphyrins, as shown in Figure 1. Bowes et al[13] evaluated 11 patients with mild-to-moderate inflammatory acne vulgaris lesions in a split-face, prospective, randomized, clinical trial with a 532-nm laser. Four total treatments were given with this laser and at the one-month follow-up evaluation, acne lesion counts decreased by 35.9 percent versus 11.8 percent on the control side. Sebum measurements were decreased by 28.1 percent on the laser-treated side versus 6.4 percent on the control side.
Yellow light systems. Yellow light pulsed dye lasers (585-595nm) can also be used by clinicians to treat inflammatory acne vulgaris. The first clinical trial[14] evaluated 41 individuals and showed the effectiveness of a low-fluence pulsed dye laser (PDL) in the treatment of inflammatory acne vulgaris lesions. This was a double-blind, randomized, clinical trial where 31 individuals received PDL and 10 patients received a placebo treatment. All of the patients in this trial received one treatment with the PDL or the placebo device and were followed for three months. Acne severity decreased from 3.8 to 1.9 in the PDL group versus 3.6 to 3.5 in the placebo group (using a modified Leeds grading system). Total lesion counts were 53 percent (49% inflammatory reduction) versus nine percent in the placebo group. A second clinical trial did not confirm these results.[15] This trial was a randomized, single-blind, controlled, split-face analysis of 40 individuals receiving 1 to 2 treatments with the PDL. No significant differences were achieved in Leeds grading scores or in lesional counts. More clinical work in this regard is needed; most clinicians who utilize PDLs are comfortable with its efficacy and safety profile.
Intense pulsed light systems. A variety of intense pulsed light (IPL) sources have been used to treat inflammatory acne vulgaris lesions. The first IPL system reported as being useful in the treatment of acne vulgaris was called the ClearTouch (Radiancy Inc, Orangeburg, New York), now known as SkinStation. This system uses light and heat energy, known as “LHE technology,” to trigger the destruction of the P. acnes bacteria. Elman et al[16] treated 19 patients and showed that 85 percent of the individuals had a greater than 50 percent improvement in their acne vulgaris lesions following therapy. The patients had twice weekly therapy for four weeks.
Other IPLs, although commonly used for acne, have little documented evidence. Dierickx[17] reported on the use of the Lux V handpiece on the Palomar Medical Technologies (Burlington, Massachusetts) IPL systems (EsteLux, MediLux, and StarLux Systems). Fourteen patients with mild-to-moderate inflammatory acne vulgaris lesions received five treatments, given every 2 to 4 weeks. Two to three passes were given with an average fluence of 10J/cm[2]. At six months post-therapy, clearance rates of 72 percent for non-inflammatory acne vulgaris lesions were seen and 73 percent were seen for inflammatory acne vulgaris lesions.
Photopneumatic system. A new light source, known as the Isolaz (Aesthera, Pleasanton, California), utilizes photopneumatic therapy, which involves a vacuum apparatus to bring the tissue closer to the light source. Several recent articles[18,19] support its use, including a recent clinical trial by Gold et al[19] in which 11 patients received four treatments at three-week intervals and were followed for three months after their last treatment. They found a 78-percent reduction in inflammatory acne lesions (p=0.0137) and a 57.8-percent reduction in non-inflammatory acne lesions (p=0.0383). The Isolaz (
“href=”http://nearmyth.com/jcad/wp-content/uploads/2009/01/figures-5a5b_jcad_0908_gold-3.jpg”>Figures 5a & 5b
LASERS THAT DESTROY SEBACEOUS GLANDS
Several laser systems have been reported to destroy the sebaceous glands to treat inflammatory acne vulgaris. These systems include the near-infrared lasers and possibly the radiofrequency devices currently used for skin tightening, which may also be useful for other indications. A new concept—partial destruction of the sebaceous glands along with the destruction of P. acnes—which utilizes 20-percent 5-aminolevulinic acid (ALA) with a variety of lasers and light sources has been found to be useful in the treatment of inflammatory acne vulgaris. This therapy is one of the more exciting new therapies being studied for moderate-to severe inflammatory acne vulgaris at this time.
The near-infrared lasers being studied for acne vulgaris are the 1320nm CoolTouch CT3 (CoolTouch Inc, Roseville, California), the 1450nm SmoothBeam (Candela, Wayland, Massachusetts), and the 1540nm erbium glass Aramis (WaveLight-Quantel, Clermont-Ferrand, France).
Paithankar et al[20] used the 1450nm SmoothBeam laser with its patented dynamic cooling device in 27 patients with inflammatory acne lesions on the back. Four treatments were given at three-week intervals and patients were followed for six months after their last treatment. Results showed a 98-percent reduction in inflammatory acne vulgaris lesions after four treatments. At the follow-up, 100-percent lesion clearance was seen in all but one of the study participants. A second study by Friedman et al[21] studied facial acne vulgaris. Nineteen patients were evaluated and lesion counts decreased by 37 percent after one treatment, 58 percent after two treatments, and 83 percent after three treatments. Transient erythema and edema were seen with the treatments, and topical anesthetics were utilized to minimize the discomfort routinely observed with these treatments. The SmoothBeam is an effective acne treatment, limited on occasion by pain associated with the treatment. Recent advances and protocols of lower energies and multiple passes are achieving good results and may be a new option for future use with this device. The SmoothBeam is shown in
“href=”http://nearmyth.com/jcad/wp-content/uploads/2009/01/figures-7a-7b_jcad_0908_gold-4.jpg”>Figures 7a & 7b
ALA-PDT IN THE TREATMENT OF INFLAMMATORY ACNE VULGARIS
The use of ALA-PDT in the treatment of inflammatory acne vulgaris has become a very exciting and new therapeutic option for the treatment of moderate-to-severe inflammatory acne vulgaris. ALA-PDT is FDA approved for the treatment of nonhyperkeratotic actinic keratoses (AKs) of the face and scalp with a blue light source for 16 minutes and 40 seconds. ALA is known to accumulate in actinically damaged skin cells, nonmelanoma skin cancer cells, and in the pilosebaceous unit. In the United States, the only currently available ALA at the time of this writing is known as Levulan® Kerastick™ (DUSA Pharmaceuticals, Wilmington, Massachusetts) (
“href=”http://nearmyth.com/jcad/wp-content/uploads/2009/01/figures-9a-9b_jcad_0908_gold-6.jpg”>Figures 9a & 9b
At the time of this writing, a large, multicenter, controlled, clinical trial is underway in the United States, which will further evaluate the use of ALA in the treatment of moderate-to-severe inflammatory acne vulgaris. The trial is studying the effectiveness of the blue light source in an FDA pivotal trial to determine what role ALA might have in the United States in the future. Also, ALA-PDT is now being utilized by clinicians in Central and South America as well as several countries in Asia, as Levulan® is becoming available in these markets.
In Europe, MAL has been evaluated in several small clinical trials for the treatment of inflammatory acne vulgaris. Wiegall and Wulf[38] evaluated 21 patients with moderate-to-severe inflammatory acne vulgaris. Two treatments were given two weeks apart. Twelve weeks after the treatments, there was a 68-percent reduction in inflammatory acne lesion counts, with no change in the control group. All patients in the study experienced a PDT effect consisting of severe erythema, pustular eruptions, and exfoliation of the skin. Moderate-to-severe pain during the treatments was also noted. A second clinical trial by Horfelt et al[39] looked at 30 individuals with moderate-to-severe inflammatory acne vulgaris lesions. This was a split-face analysis, with a three-hour, under-occlusion-drug-incubation exposure to red light and two treatments given at two-week intervals. At 12 weeks after the last treatment, there was a statistical reduction in acne lesions of 54 percent versus 20 percent in the control group. Pain and a PDT effect were once again seen in the patients treated. Additional clinical trials are underway in Europe to further evaluate what role the methyl ester of ALA will have in the treatment of moderate-to-severe inflammatory acne vulgaris.
Conclusion
The use of ALA-PDT in the treatment of moderate-to-severe inflammatory acne vulgaris has become a useful modality for many patients suffering from this disease. Some clinicians use this as first-line therapy in the treatment of moderate-to-severe inflammatory acne vulgaris and still others add this therapy if routine medical therapy does not provide the clinical results expected. Lasers and light sources, as well as ALA-PDT, are changing how acne vulgaris is treated.
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