From scars to active acne: Technological treatment for hard-to-treat cases

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Lasers and photodynamic therapy are practical treatment options for acne patients who fail or aren’t compliant with traditional first-line therapies. Today’s energy devices might also enhance acne treatment as adjuvant therapy, according to a review of newer studies looking at acne vulgaris and laser or photodynamic therapy.

Researchers included studies on the topic from January 2015 to March 2016, excluding papers on acne scarring.

Keeping up with what’s going on in acne treatments is important for practicing dermatologists, according to the review’s lead author Marjon Vatanchi, M.D., senior dermatology resident, SUNY Downstate Medical Center, New

Dr. VatanchiYork City.

“I can’t imagine a skin condition more relevant than acne, about 90 percent of the population has had acne at one point or another in their lives. For the past 40 years, the mainstay of treatment has primarily included retinoid or antibiotic medications. Acne is a multifactorial process, so, in the past decade, we’ve seen acne research that has begun to look at new technologies,” Dr. Vatanchi says.

ENERGY DEVICES

Energy device progress has been made on two fronts:  In the advancement or creation of new energy devices or laser devices, and the discovery of new uses for existing technology. An example of the second, according to Dr. Vatanchi, is using photodynamic therapy, which is traditionally used in a practice for sun damage and actinic keratosis in an older population, to treat younger acne patients.

Initially, laser treatments for acne concentrated on treating acne scars - not so much treatment of active, inflammatory acne. Acne scar treatments included CO2 laser therapy, to improve scarring, or pulsed dye lasers, to treat redness or any vascular component that remains, she says.

In general, Dr. Vatanchi and colleagues note a transition from treating acne scars to treating active inflammatory acne lesions.

“Today we’re seeing a surge in clinical trials using energy devices to target the sebaceous glands or the inflammatory mediators,” Dr. Vatanchi says. “[Studies suggest that] with adequate treatment, red light can produce a brisk effect. The downsides are discomfort and downtime to heal. Blue light, which is more prevalent in the U.S., can also be used. While this is more tolerable or even painless, it does yield a more judicious result.”

Researchers also are looking at new laser options for acne.

“We’re seeing studies with animal and human models, such as evaluating the use of gold or silver microparticles. They’re used in conjunction with laser therapy,” she says. “Microparticles are light-absorbing. Through selective photothermolysis, [they] injure and denature sebaceous glands, thereby, hindering one of the key components of acne vulgaris. These trials have shown significant improvement. Patients in a lot of these studies were followed up to three to four months, with sustained results. As more research becomes available, it will be exciting to see what the long-term results show.”

NEXT:  An emphasis on scar prevention

AN EMPHASIS ON SCAR PREVENTION

A take-home for dermatologists, according to Dr. Vatanchi, is acne scarring remains difficult to treat, but now the focus has shifted more toward being more aggressive and trying to prevent acne scarring.

“When medical management of acne is not enough or doesn’t give us the results we hope for, we should, as physicians, widen our armamentarium to address our patients’ needs,” she says. “It is in our moderate-to-severe patients who are continuing to suffer with acne lesions that we should consider procedures, whether they be chemical peels, photodynamic therapy or laser treatment. Just like how a dermatologist may use light frosting as an endpoint with some chemical peels, it’s really important to know what the presumed or expected endpoint of each laser treatment is for different skin tones and for your specific population.”

CANDIDATES APLENTY

Acne patients who are likely to benefit from laser and photodynamic therapy treatment include the teenager who isn’t compliant with long-term medical or topical treatment. Or someone who has been compliant but has failed topical or oral treatment, she says.

“We’re also seeing a large number of patients who just don’t want to be on oral medications, due to the side effect profile. They don’t want to take long-term antibiotics, and the side effects of isotretinoin worries them,” Dr. Vatanchi says. “We also see teenagers with severe acne who want more aggressive treatment and who can afford the downtime. They can have these procedures done during summer or winter breaks. You also have a lot of older female patients who continue to get acne and have tried everything under the kitchen sink without resolution. I think all of these would be great candidates for exploring and using laser therapy or photodynamic therapy.”

The people who aren’t good candidates include aggressive pickers. Dermatologists who see that their patients have acne excoriée and acne scarring should consider those patients might pick during the healing process from energy device treatment, leaving permanent scars, she says.

“You also worry if the patient is noncompliant with their medical treatment, they may not be compliant with the post-procedure care--meaning they won’t put sunscreen on or can’t stop picking,” Dr. Vatanchi says. “If you also have a patient that has an ongoing medical issue, where acne is a symptom of that issue, such as polycystic ovarian syndrome, it’s important to treat the primary issue. In these patients, laser treatment may prove futile or at the very most be helpful but temporary.”

AS AN ADJUVANT

Dermatologists also might use lasers or photodynamic therapy in combination with medical and topical acne therapy options.

Dr. Vatanchi states that using photodynamic therapy can target the endogenous porphyrins produced by bacteria Propionibacterium acnes, or P. acnes, a causative factor in acne.

“You can also use pulsed dye laser to target the vasculature and redness that one would get. You could then combine infrared laser, that’s 1450 nm laser, and that can penetrate the sebaceous glands that contribute to acne,” she says. “With that said, you don’t want to rely on laser therapy, by itself.”

OTHER CONSIDERATIONS

Payers do not generally cover acne treatment with lasers and photodynamic therapy, as these therapies are viewed as cosmetic procedures, according to Dr. Vatanchi.

“One could attempt to achieve prior authorization for these treatments, however, it’s important to continue medical management with topical or systemic agents, again the retinoids, antibacterials, or, if they have mild acne, the over-the-counter products,” she says.

No matter which modality or combination a dermatologist might prefer, Dr. Vatanchi says treatment efficacy ultimately depends on treating patients with the optimal and appropriate dose or strength of the regimen.

“For instance, if you’re using red light photodynamic therapy and the patient does not develop crusting in the days that follow, then they may not have the brisk response that you would hope for. It’s important to be aware of the endpoints for each treatment,” she says.

Research on laser therapy for inflammatory acne lesion treatment is relatively new, and needs to continue with more robust studies, according to Dr. Vatanchi.

“Most of the studies look positive but the numbers of patients in the studies are small and we’re not seeing long-term follow up,” she says. “I think the research is still growing in this field. I think you should start with medical management and this should be added on as adjuvant therapy. The next step is to start to have insurance companies looking at the procedural treatment of acne vulgaris as medical management.”

REFERENCES

Vatanchi M, Ferzlie GM, Siegel D. “Updates on novel research in laser and photodynamic therapy for treatment of acne vulgaris,”Journal of the American Academy of Dermatology, Volume 76 , Issue 6 , AB275.

DISCLOSURES

Study authors Drs. Vatanchi and Georgina M. Ferzli, M.D., have none; however Daniel Siegel, M.D., also associated with SUNY serves on Biofronterra and DUSA’s scientific advisory boards.\