Shining new “lights” on an old disease
Acne is a universal disease. Everyone gets it in one form or another. The causes are thought to be a combination of age and hormones.
Most authorities agree that there is a genetic blueprint for the duration and severity of acne because it varies greatly from patient to patient. There is no ethnic predilection, but males are generally more severely affected because testosterone is an aggravating factor.
The transition to puberty causes an increase in the size of sebaceous (oil) glands and an increase in oil secretion. These changes, in addition to changes in the keratinization of hair follicles, cause occlusions that result in comedone (whitehead and blackhead) formation. These occlusions allow Propionibacterium acnes, the bacterium thought to cause larger acne lesions, to proliferate.
Immune-system response to the bacteria, inflammatory enzymes produced by the bacteria, or both—as well as perhaps undiscovered causes—may be the underlying cause of the lesions. Inflammatory reactions that cause tissue damage and scarring can also follow. Some physicians believe that the depth of the occlusion in the hair follicle determines the size of the resultant acne lesion, with a deeper occlusion resulting in a larger lesion.
External factors vary among patients, but stress is a universal aggravating factor. With the exception of dairy products in women, dietary triggers are more individual than universal. If this were not the case, there would be much less acne, because no one would consume the offending foods.
Cosmetics generally do not play a role; however, thick theatrical makeup, as well as normal cosmetics in the presence of perspiration, can aggravate the disease. Hair spray, hair oil, and mousse can exacerbate the condition, as can wearing hats and sweatbands, and having bangs or shoulder-length hair. Some observers believe that acne improves in the summer, possibly due to lack of stress or increased sun exposure.
Acne is a time-limited disease, but that “limit” can encompass a lifetime in some cases. It can start at age 8 or 80, and it can last from age 8 to 80. It can be socially devastating in teenagers; many teens manifest symptoms of depression, and some have suicidal thoughts.
New Therapies Needed
The cornerstone of acne therapy has been topical retinoids (with adjunctive help from various other agents), systemic antibiotics, and systemic retinoid therapy (tretinoin or isotretinoin). In recent articles, physicians have questioned the long-term use of antibiotics, stating concerns about increases in urinary-tract and upper-respiratory-tract infections, hypersensitivity reactions, birth-control-pill interactions, and pregnancy complications. The authors have also been concerned about an increased incidence of breast cancer with antibiotic use.
Retinoid side effects are too numerous to list, and suicidal depression is at the top. Thus, an alternative needs to be developed.
The alternative for acne therapy has come in various forms of energy delivered to the skin, predominantly via intense pulsed-light (IPL) systems and lasers, but also through some light-emitting diode (LED) systems and radio-frequency devices. Most energy-based systems derive their therapeutic benefits from a photochemical reaction in the blue-violet light range with porphyrins that are produced by the bacteria or are topically applied—in the latter case, oil glands are destroyed as well.
Another mechanism is a direct attack on the sebaceous glands using wavelengths predominantly in the IR region. Whether the therapeutic response is caused by heat or is a biological reaction has yet to be determined.
The best results appear to occur through a combination of both effects (bacterial-count reduction and oil-gland reduction). Multiple treatments have been required in all cases, and sustained remissions for periods of up to 1 year have been reported. Systems that incorporate topical porphyrins appear to have a faster onset of effect, with the result that fewer treatments are required.
Virtually all sources of energy have been reported to have a beneficial effect on acne by either mechanism of action. Unfortunately, there is a paucity of head-to-head studies as well as definitive treatment protocols, which has led to some confusion as to which system to use and how to use it.
For details concerning studies on the use of energy-based devices on acne, see the Recommended Reading list at the end of this article.
My preference is to use an IPL device that produces emissions over a wide range of wavelengths. I do not currently use topical porphyrin therapy because I am hesitant to destroy oil glands in teenagers. I am also concerned about severe burns when patients do not avoid the sun, as well as the possibility of long-term effects—such as excess skin cancers—from treatments such as psoralen–UVA therapy (PUVA).
In adults who have severe rosacea and acne, and who have large oil glands and sebaceous skin, topical porphyrins may be a more viable alternative. There is some evidence that the use of porphyrins topically creates a more rapid response than IPL and other therapies, but this has not been confirmed.
The IPL system I use allows me to treat patients with all skin types because of its range of pulse widths (1–500 milliseconds [ms]) and fluence (5–25 joules [J]). Over the past 3 years, I have performed more than 4,000 procedures using this system, and I have found it to be an outstanding treatment option for acne—especially the cystic type. The system has enabled me to eliminate or severely reduce the use of systemic antibiotics, and results appear in weeks rather than months.
I use IPL to treat acne on all affected areas, including the back and chest. I have found that the 100-ms pulse width at a fluence of 15–20 J, followed by a second pass at 20 ms and 15–18 J, is the most effective treatment regimen. I start at 10–13 J for the 100-ms pulse width and 8–10 J for the 20-ms pulse width. I increase the fluence by 1–3 J per treatment until I reach the preferred levels.
Comedones are more difficult to treat. Their purported responses to shorter pulse widths are being investigated.
The treatment interval is also important. I initially used an interval of 4–6 weeks, but I discovered that patients—mostly teenagers—would improve, but then flare up at about 2–3 weeks. When I reduced the treatment interval to 2–3 weeks, I obtained better results. Shorter intervals than this may be counterproductive in that “too much too fast” may cause a flareup as well, much as in the use of isotretinoin.
After about the fifth treatment, I try to extend the intervals by 2 weeks at a time, and I let the patient ask for an earlier treatment if a flareup occurs. Adults usually require fewer treatments for initial control, and more monthly treatments, than teens. There is some evidence in adults, primarily those with cystic acne, that a longer interval—such as 1 month—may be preferable to every 2 weeks.
It takes about 10 minutes to treat an entire face, and about 30 minutes to treat the face, back, and chest. Treatments are rarely longer unless the extent of the disease is quite severe.
I have found it imperative to continue topical retinoid therapy during and after treatment. IPL is compatible with all topical and systemic acne medications, including isotretinoin. I often prescribe oral antibiotics for use at the beginning of treatment, gradually reduce their dosage, and, in most cases, discontinue them completely by the end of treatment.
I continue cleansing and spot therapy as needed. IPL and other energy-based systems allow physicians to treat acne using no or greatly reduced dosages of systemic anti-biotics. Even patients that end up taking isotretinoin appear to respond to that drug more quickly than if the IPL were not used.
Sun Exposure Critical
When you use an IPL for acne treatment, you must always remember to ask about the patient’s sun-exposure history. Most patients will say that they have had no sun exposure, but you must press the issue because increased pigmentation from sun exposure will result in an uncomfortable treatment, or even a burn—especially on the forehead, which is more sensitive than the rest of the face.
The IPL setting that causes no discomfort in the winter may suddenly cause pain for the patient once he or she has a tan. Even self-tanning creams can cause this reaction.
Our IPL system is safer than most because it has built-in contact cooling, which protects the skin and eliminates the need for a cryogen spray. But it is still vital to assess skin type and color before each treatment session, especially during the summer.
Variations in Results
Occasionally, some patients develop an urticarial response to IPL treatment, usually during the first few pulses, that is unrelated to the power setting or the skin location. The rest of the treatment is uneventful. I usually give these patients a nonsedating antihistamine after therapy. I premedicate with the antihistamine if this phenomenon recurs. I also use an over-the-counter 1% hydrocortisone lotion that helps with redness, dryness, and burning—but does not worsen the acne.
In the case of overtreatment that results in redness or even burning, I use LED and clobetasol cream—a class I steroid. If a burn or blister develops, I treat it with clobetasol cream, mupirocin ointment, or both for a few days. I use LED for up to 4days after the irritation develops. Once the skin has healed, I may be-gin a bleaching-cream regimen to avoid hyperpigmentation.
I know that using a longer pulse duration with IPL greatly improves the treatment’s safety by allowing a higher fluence to be used. But I have not found that increasing the pulse duration beyond 100 ms is helpful. Instead, it may make the patient more susceptible to burning because the “on” time is too long. Most of our patients who have experienced a burn with a very long pulse duration did not complain of tenderness during treatment but rather felt it the next day.
As with conventional acne therapies, not everyone responds to IPL treatment. When the treatment regimen is followed correctly but the response is lagging, I push the oral therapy to standard levels—minocycline, 100 mg, twice per day. If this combination does not work, I consider isotretinoin.
As stated above, even patients who show a poor response to IPL treatments seem to respond faster to isotretinoin when used in conjunction with IPL. They frequently show remarkable improvement in the first 1–2 months. I often continue the light treatments for the first month or two of isotretinoin therapy. This helps with the erythema and the initial flareup typically seen with isotretinoin.
A “Bright” Future
In my opinion, IPL systems are comparable to oral antibiotics, and are better than systemic antibiotics because the effects are generally faster and remissions are induced. Also, most systems can be used in women who are pregnant or attempting to become pregnant without systemic effects, although topical porphyrins are obviously contraindicated for these women.
Because many systems are available, time will tell which ones are most beneficial, and under what guidelines. In my practice, the system is used all day long, 5days per week; on some days, two systems are in use. Patients have been very receptive to the treatment—who would not like to stop using systemic antibiotics and avoid isotretinoin?
Given the current concerns about isotretinoin-therapy side effects and registration requirements; the apparent increased risk of upper-respiratory-tract and urinary-tract infections resulting from taking antibiotics for years; birth-control-pill interactions; and drug use during pregnancy, this system is an effective first-line therapy that carries little risk. I envision that in the future I will rely increasingly on light-based systems as primary therapies, and decreasingly on systemic antibiotics—which is a positive step, in my opinion. PSP
Robert S. Berger, MD, FAAD, FASDS, is in private practice in Waldorf, Md, and is an assistant professor in the Department of Dermatology at Johns Hopkins University, Baltimore. He can be reached at [email protected] or (301) 374-9511.
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