The Benefits of different energy-based treatments for acne
By Chesahna Kindred, M.D., M.B.A, FAAD
Acne vulgaris, a widespread inflammatory dermatosis of the pilosebaceous unit, is one of the most prevalent skin concerns globally. In the United States alone, it affects approximately 50 million individuals annually. While traditionally associated with adolescents, this condition extends into adulthood, impacting individuals in their 20s and 30s. Acne constitutes the primary reason for seeking dermatological treatment, with over 85% of adolescents and young adults aged 12 to 24 years experiencing some degree of acne, and its incidence among adults continues to rise. Notably, over 90% of acne cases are classified as mild to moderate.
The landscape of acne therapy encompasses diverse treatments, including retinoids, antibiotics, hormones, light, lasers and various combinations of these modalities. However, utilizing only topical and oral medications to treat acne comes with challenges. These therapies often come with adverse effects, incomplete response, contraindications and the problem of recurrence. Oral antibiotics carry the risk of bacterial resistance and disruption of the skin’s microbiome. Despite the efficacy demonstrated by current acne therapies, the rising apprehension around antibiotic resistance, particularly concerning Cutibacterium acnes (C. acnes), is discernible. The resistance to antibiotics like erythromycin has surged by more than 50%. Moreover, the adherence of patients to topical therapy, often demanding daily applications, is notably problematic, especially among younger demographics. While oral isotretinoin is the most effective systemic medication for moderate-to-severe acne, its usage entails significant risks.
Laser & Light-Based Therapies
In 2009, the Global Alliance reported that laser and light-based therapies, including photodynamic therapy (PDT), proved most valuable as supplementary measures to medical therapy or for individuals unable or unwilling to undergo medical therapy. These modalities reduce levels of C. acnes by exciting light-sensitive porphyrins, disrupting sebaceous gland activities and potentially affecting inflammatory cytokines. A range of light sources and lasers with wavelengths absorbed by porphyrins were identified, including narrowband and broadband light, pulsed dye lasers (PDLs) at 585 nm, potassium titanyl phosphate (KTP) lasers at 532 nm and lasers and light sources in the range of 610 to 635 nm. Longer wavelengths from 1064 to 1726nm are shown to be less absorbed by porphyrins; however, they heat the sebaceous glands, resulting in reduced gland size and sebum output.
The pursuit of effective light-based interventions for acne has taken various avenues, including blue and red light, ultraviolet light and intense pulsed light. Mid-infrared lasers have been used to treat acne in clinical trials. These lasers, including 1320, 1450 and 1540nm, target the depth of skin where sebaceous glands reside. They have been classified as lasers that destroy sebaceous glands. Treatment is accompanied by cryogen spray cooling to protect the epidermis and increase patient comfort. While the target of the first acne lasers was to destroy the sebaceous gland, it is theorized that the objective of the therapy is to suppress sebum output without destroying sebaceous glands since sebum production is critical for maintaining skin homeostasis, lubrication and physiological defense against environmental and infectious insults.
Neo Elite Treatment
Studies have noted the effectiveness of neodymiumdoped yttrium aluminum garnet (Nd:YAG) lasers in acne management. In particular, it has garnered support from high- level studies compared to other laser devices. There is strong evidence of the efficacy and tolerability of Neo Elite by Aerolase, a 650-microsecond pulsed 1064nm Nd:YAG laser therapy for mild to severe facial acne vulgaris that has been well-evaluated in patients aged 19 to 40 years. Its treatment advantages for acne are diverse. The Neo works by reducing excess sebum production rather than destroying the sebaceous gland, reduces the effects of inflammation and reduce inflammatory lesions. A recent clinical study showcases a median reduction of 84% in lesion count after six weeks and 87% at 90 days, boasts 90% patient satisfaction at six weeks and 90 days post- treatment and remarkably, does not cause edema, erythema, acne flare-ups, dryness, scarring or hyperpigmentation during or after treatment.* This novel laser employs a short-pulse duration and delivers high energy within this short pulse, making it a noninvasive and safe option for moderate-to-severe acne treatment. The laser’s unique advantages are particularly beneficial for patients with darker skin tones, as its shorter pulse duration prevents excessive heating of the surrounding skin, minimizing the risk of pigmentary changes.
AviClear Acne Treatment
The evolution of energy-based devices in acne treatment has ushered in promising developments. The AviClear laser by Cutera, operating at a wavelength of 1726nm, has gained FDA clearance for mild-to-severe acne treatment. Sebum, which has an absorption coefficient slightly higher than water at 1726nm looks viable for sebaceous gland selective photothermolysis. The selective targeting of the sebaceous glands using photothermolysis allows maximum damage to the sebaceous gland while preserving other skin structures. Early evaluations showed histologic changes of 1726nm laser selective destruction of sebocytes and clinical improvement that can last two years after treatment. Clinical trials involving this technique showcased a significant reduction in inflammatory acne lesions with multiple treatments at 4-week intervals. A study by Goldberg, et al., shows a reduced total number of inflammatory lesions by more than 52% within one month of treatment and improved further to 56% by the third-month post final-treatment session, with high patient satisfaction. The Accure System by Accure Acne Inc., is another 1726nm laser that has recently received FDA clearance for mild to severe inflammatory acne vulgaris.
Combination Energy-Based Therapies with Other Treatments
Energy-based therapies, often used with systemic therapies and at-home skin care regimens, offer potential benefits even for patients on antibiotics, as the laser energy complements the antibiotics’ effects.
This innovative landscape of energy-based acne treatments holds particular promise for patients with limited options, such as individuals who cannot tolerate the adverse effects of oral or topical therapies. Moreover, the synergistic effects achievable by combining energy-based therapy with other treatments offer exciting future prospects. Although further research and long-term safety data are needed, lasers represent a significant leap in the effective treatment of acne.
Educating and Preparing Patients
As clinicians embrace energy-based options for acne treatment, several vital considerations come to the fore. Patients must be informed that while these treatments offer considerable clearing, they may not guarantee complete resolution. Multiple treatment sessions often yield more significant results than a single session, with sustained improvement often observed weeks after the last treatment. Dermatologists should ensure that patients follow pre- and post-treatment instructions meticulously to minimize side effects and maximize outcomes. Furthermore, adjunctive skin care tailored to acne-prone skin is essential for maintaining results and preventing new breakouts.
The realm of energy-based devices is transforming acne management, providing new avenues of treatment that complement traditional approaches. With their potential to mitigate adverse effects associated with antibiotics and topicals, energy-based therapies stand as promising solutions, particularly for individuals with limited treatment options. While the long-term safety and efficacy of these modalities require further exploration, their integration into acne treatment regimens heralds a significant advancement in improving patient outcomes and quality of life.
Board-certified dermatologist Chesahna Kindred, M.D., M.B.A., practices in Columbia, Maryland, at Kindred Hair & Skin Center — the first dermatology office with a full-service salon specializing in hair loss. She grew up in South Central Los Angeles, earned her BS with a minor in Spanish at the University of Southern California, was the third person in the history of the University of Cincinnati to earn an M.D./M.B.A. degree, and later completed dermatology training at Howard University Department of Dermatology. Dr. Kindred is the immediate past chair of the dermatology section of the National Medical Association and founder and president of Onyx Medical Society.