Laser Therapy for Acne Treatment

1. Laser Therapy for Acne Treatment By Erin Broadus Spring 2007

2. References • Alam, Murad, Te-Shao Hsu, Jeffrey S. Dover, David A. Wrone, and Kenneth A. Ardnt. Nonablative laser and light treatments: histology and tissue effects – a review. 2003. Lasers Surg. Med. 33:30-39. • Battle Jr., Eliot F. Treating skin of color. 2006. Advance for Physician Assistants 14: 32-33. • Bernstein, Eric F. A pilot investigation comparing low-energy, double-pass 1450 nm laser treatment of acne to conventional single-pass, high-energy treatment. July 26, 2006. Available at www.interscience.wiley.com . Accessed 30 September 2006. • Elman, Monica and Joseph Lebzelter. Light therapy in the treatment of acne vulgaris. • 2004.Dermatol Surg. 30: 139-146.] • Epocrates Online, Acne Vulgaris. September 2006. Available at: http://online.epocrates.com. Accessed 30 September 2006. • Friedman, Paul M., Ming H. Jih, Arash Kimyai-Asadi, and Leonard H. Goldberg. Treatment of inflammatory facial acne vulgaris with the 1450-nm diode laser: a pilot study. 2004. Dermatol. Surg. 30:147-151. • Mariwalla, Kavita and Thomas E. Rohrer. Use of lasers and light-based therapies for treatment of acne vulgaris. 2005. Lasers Surg. Med. 37:333-342. • Nouri, Keyvan and Christopher J. Ballard. Laser therapy for acne. 2006. Clin Dermatol. 24:26-32. • Rotunda, Adam M., Anand R. Bhupathy, and Thomas E. Rohrer. The new age of acne therapy: light, lasers, and radiofrequency. 2004. J Cosmet Laser Ther. 6:191-200.

3. Epidemiology – Who It Affects • 40 million adolescents • Males > Females • 25 million adults • Females > Males • Geriatric population • Favre -Rocuchot • 15 % will seek Tx • 30% of all derm visits • ANYONE WITH SKIN!!

4. Pathophysiology – How Acne Develops • 1 - Androgens stimulate sebum production and proliferation of keratinocytes in hair follicles. • 2 - Sheets of desquamated keratin obstruct the follicle opening, which forms the precursor to acne • 3 - This results in sebum accumulation and swelling of the follicle. • 4 - P. acnes colonize and proliferate in the plugged follicle • 5 - This causes the hydrolyzation of sebum triglycerides into free fatty acids. This further plugs the follicle and pro-inflammatory mediators causes inflammation of the follicle and surrounding dermis.

5. Traditional Treatment Methods • Antibiotics - reduce inflammation caused by acne • Topical Agents - unplug follicles and kill bacteria • Accutane - decrease oil production

6. History of Laser Utilization • Used for almost the past 100 years • First therapies - simple conventional lamps controlled with a filter • In the past, lasers have used sunlight exposure as a way to treat acne due to its initial anti-inflammatory effects. However, this has proved to be potentially carcinogenic due to the exposure of UVA (aging) and UVB (burning) waves • Has become a more common modality in the last decade

7. How Lasers Work • P. acnes produce a type of chromophore, a molecule that is absorbed into the skin, called a porphyrins. • When these porphyrins are excited by the absorption of light (photoactivation), they form free oxygen radicals. • This causes membrane damage and cell death, which in turn kill the bacteria within (P. acnes). • Each chromophore has a specific absorption spectrum of its own. Porphyrins are absorbed the most at light wavelengths near 400 nm. The highest absorption occurs at around 415 nm (blue visible light), called the Soret band. • Porphyrins are well absorbed into the skin at the Q bands (purple & red visible light) between 450-700 nm.

8. Types of Lasers • Blue light: ClearLight, Blu-U, Omnilux Blue • Blue and red combination light: Acne Lamp • Broad-Spectrum: ClearTouch, StarLux • KTP (green light): Aura • Pulsed Dye Laser (yellow light): Photogenica VStar, N-Light, V-Beam • 1450 nm Diode Laser: Smoothbeam • Er:glass 1540 nm: Aramis

9. Blue Light Study • Blue light emits at wavelengths from 405-420 nm (should be the most effective to irradiate P. acnes). • 35 patients with mild-moderate lesions on the face and trunk over a 4-week period. • Benefits • 80% of patients saw an improvement in lesions

10. Blue-Red Combination Study • Light combination therapy reduced P. acnes colonization numbers more than blue light alone b/c its wavelength is 625-740 nm. At this longer wavelength, it penetrates better into the skin. • 12 weeks - 15 minutes each day. • Benefits • 58% reduction in non-inflammatory lesions • 76% reduction in inflammatory lesions.

11. KTP Study • KTP emits a wavelength of 532 nm (green visible light) and penetrates the skin 1-2 mm. • The KTP laser is able to also photoactivate bacterial porphyrins such as P. acnes. • 11 patients for 2 weeks twice weekly. • Benefits • No adverse effects • 36% saw a reduction in mild-mod. acne lesions • Sebum production decreased by 28% • Disadvantages • Little effect on P. acnes

12. Pulsed Dye Laser(PDL) • Emits a wavelength of 585 or 595 nm (yellow visible light). • Yellow light is applied to the skin to destroy P. acnes thereby creating oxygen because its chromophore is oxyhemoglobin. • AE - hyperpigmentation.. • 100% of patients reported an 80% decrease in inflammatory lesions. • @ 3 months - Patients still were improving.

13. 1450-nm Diode Laser • Penetrates to the level of the mid-dermis • Causes thermal damage to the sebaceous gland resulting in the destruction of sebocytes that contain P. acnes. • Benefits • More than half showed a 65% reduction in lesions. • Significant decreased lesion count in back acne • After 6 months, five of the patients did not need additional acne treatments. • AE – pain (Cooling spray used to preserve epidermis) and hyperpigmentation

14. Er:glass 1540 nm • It penetrates 0.4 to 2 mm and also has a target of intracellular water. • 20 patients over a two-month period w/ treatments every 2 weeks for a total of 4 treatments. • Benefits • There was a 70% decrease in lesion count after the first and third months. • Patients also reported a decrease in skin oiliness. • AE – pain (cooling spray used)

15. Advantages • It is also a noninvasive and sometimes pain free process • Patient eliminates the trouble of treating hard-to-reach areas, such as the back • Practitioner can control the depth of treatment • Faster response than antibiotics • Fewer treatments needed • Not having to remember to apply products or take any medication

16. Limitations • Cost: $250-1000/treatment • Inconvenience of traveling to the office • Safety of irradiation

17. Good Candidates • Some patients fail or will not tolerate other treatments • Side effects from non-laser treatments • Many patients face compliance challenges • Patients that have failed to do well on Accutane or as a last resort before Accutane • Lesions on difficult-to-reach areas: neck, upper chest, back and upper arms

18. Convincing Laser Evidence • Largest reduction in acne lesions: 1450 nm Diode Laser • 83% reduction in lesions seen after just three treatments. • Longest lasting effects: PDL • Patients were still seeing improvements at the 3 month mark. • Least number of adverse effects: KTP Laser • No adverse effects seen

19. Conclusions • MOA of Lasers - inactivation of P. acnes • It is important to treat both the cause and the symptoms of acne in order to successfully manage it. • Light-based therpaies and lasers should not be used to replace existing acne treatment. • They should be used to supplement and complement conventional medical treatment. • There are many different types of lasers that can be used in combination with conventional approaches.

20. Future Research • The exact wavelength in the spectrum for the most efficacious treatment of acne has not yet been determined. • Lasers should be made more available in Family Practice, Internal Medicine, and Pediatricians’ offices because a great majority of patients (85%) does not seek the expertise of a dermatologist for acne treatment