Reference Section

Non-Traditional Acne Therapy: The Use of Lasers and Light-Based Therapies

K a v i t a M a r i w a l l a , M D , 1 and T h o m a s E R o h r e r , M D 2 , 3
1 Department of Dermatology, Yale School of Medicine, 2 Department of Dermatology, Boston University School of Medicine, 3 SkinCare Physicians of Chestnut Hill, Chestnut Hill, MA, USA

Thomas E Rohrer, MD works in the Department of Dermatology at Yale School of Medicine. He served as the Chief of Dermatologic Surgery at Boston University Medical Center and the Boston Veterans Administration Hospital for eight years, and the Director of the Boston University Center for Cosmetic and Laser Surgery. Dr Rohrer completed his internship in internal medicine at Yale University Hospital and completed a residency in dermatology at the combined Boston University-Tufts University program.

Acne vulgaris is thought to be patho-physiologic in adolescence because of its prevalence. It also affects upwards of 25 million adults in the US alone. For the subset of patients who fail standard topical or oral medications, laser and light-based systems have emerged as stand-alone and adjunct therapies for acne treatment. These devices work by targeting the pathogenic components that lead to acne lesions; namely the resident bacteria Propionibacterium acnes (P. acnes) or the pilo-sebaceous unit. Published data has focused on the non-cystic form of acne vulgaris on the face with limited studies of the chest and back. Success with these emerging technologies relies on appropriate patient screening. In our clinical practice, we use a series of simple guidelines before initiating laser or light-based therapies. Is the patient a topical or oral medication failure? Has the patient tried isotretinoin or are there contraindications for its use? Is the patients acne mainly comedonal or are there inflammatory acne papules or cysts? Does the patient also have acne scarring? It is crucial to manage patient expectations. Most laser systems will work to some extent and topical and oral medications should be optimized and continued during the initial phase of treatment with any of the devices. Patients should be aware that although this treatment method is easy to administer and does not require a daily routine, there is an expense and time commitment involved on the patients part. There may also be some discomfort along with downtime due to erythema.
Which Laser and When?

areas, light-based therapy with or without amenolevulinic acid can be used. In cases of significant acne scarring, infrared lasers can target acne and also improve the texture of the skin. Below, we present a short synopsis of each of the laser and light based systems currently available, describe their intended mechanism of action and in which settings they are best suited based on the currently available published data. In all scenarios, the patient should be evaluated in terms of what the treatment is targeting; the sebaceous gland or P. acnes itself.
P i c k i n g Yo u r T a r g e t : P . A c n e s

P. acnes produce endogenous porphyrins that absorb light energy at two main absorption peaks, the Soret (400420nm) and Q-band (500700nm), making them susceptible to excitation by lasers and light sources emitting wavelengths in the visible light spectrum (400 700nm). Once induced, porphyrins can generate highly reactive singlet oxygen radicals, which destroy lipids in the cell wall of P. acnes. Since P. acnes rapidly regenerates, acne clearance is short lived (at most three months) and treatments must be continued on an on-going basis. Given this limitation, it is questionable whether these laser and light-based systems are a significant enough improvement over topical therapies to justify the expense and time needed to treat.
Blue Light

Kavita Mariwalla, MD, is a second year Dermatology resident at Yale University and has written several articles with Dr Rohrer on the use of lasers and light based therapies for acne treatment. She completed an internship in Medicine at Massachusetts General Hospital after graduating from the Yale School of Medicine. In medical school, Dr Mariwalla was elected to the Alpha Omega Alpha Society and served as President of the Medical Student Council. She received a BA with Distinction from Yale University and was awarded the Norman Holmes Pearson Prize for her senior thesis.

Mechanism: Blue light (415nm) falls within the strongest porphyrin photo-excitation coefficient (407420nm) and is used bi-weekly over four to five weeks. Devices used in published studies: ClearLightTM, Lumenis Ltd., Santa Clara, CA; F-36 W/Blue V, Waldmann, Villingen-Schwenningen, Germany; BluU, DUSA Pharmaceuticals, Inc.,Wilmington, MA Indications: Blue light is effective for papules and pustules more than comedones and carries the risk of worsening nodulocystic acne. It is effective in varying skin types.

In most practices, the choice of device is dependent on what the practitioner has available. When multiple devices are available, it is crucial to keep in mind the area of involvement and the presence of scarring. Treatment with infrared lasers with a 46mm spot size is generally too time consuming and painful to undergo for large areas such as the back. For wide treatment

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Non-Traditional Acne Therapy: The Use of Lasers and Light-Based Therapies

Mechanism: Using the porphyrin excitation properties of blue light and the anti-inflammatory and increased depth of penetration of red light, this combination exerts both anti-bacterial and anti-inflammatory effects. Indications: Mild to moderate facial acne may improve. Significant change requires upwards of 80 treatment sessions so the patient must be compliant and diligent.
Ye l l o w L i g h t

optical penetration depth into skin than blue light, it has the innate ability to activate bacterial porphyrins along with some non-specific collateral thermal injury to sebaceous glands. Devices used in published studies: Aura KTP laser Laserscope, San Jose, CA. Indications: This laser can reduce inflammatory facial acne, although long-term suppression is variable. It is less successful in comedone treatment and may be best used as an adjunctive therapeutic with topical treatments.
Pulsed Dye Laser : 585nm and 595nm

Mechanism: Intense yellow light at 585nm theoretically penetrates deeper than blue light and uses the same principle of P acnes porphyrin excitation. Devices used . in published studies: LED Indications: Intense yellow light may improve mild acne though blue light and combination blue and red light, have been more successful. Long-term efficacy data is not yet available for the LED.
Intense Pulsed Light

Mechanism: In addition to P. acnes reduction through porphyrin excitation, the flash-lamp-pumped pulsed dye lasers (PDL) chromophore is oxyhemoglobin, making it particularly suitable for reducing the red component of acne lesions. Devices used in published studies: 585nm PDL NLite SystemTM, ICN Pharmaceuticals Inc., Costa Mesa, CA; 595nm VBeam, Candela Corp., Wayland, MA, and 595nm VStar, Cynosure Inc., Chelmsford, MA Indications: The PDL is well suited to treat the red component of acne in addition to mild to moderate inflammatory facial acne. Study results have been widely variable from no improvement to near 50% reduction.
P i c k i n g Yo u r T a r g e t : The Pilo-sebaceous Unit

Mechanism: Because intense pulsed light sources emit a broad band of light (5001200nm) that can be absorbed by many chromophores, IPL can be used to treat a variety of conditions including acne. Devices used in published studies: The Palomar LuxVO, Palomar Co., Burlington, MA (400700nm and 8701200nm hand-pieces). Indications: IPL is an effective and safe treatment option for mild to moderate facial inflammatory acne lesions in a variety of skin types with few side effects.
Pulsed Light and Heat

The increase in sebum production noted in acne makes targeting of the pilo-sebaceous unit itself an obvious choice. By reducing the size, and therefore sebum output of the gland, or by straightening out the tubule by which it drains, several devices have been shown to significantly reduce acne for extended periods of time.The following systems work through one of these mechanisms.
Photodynamic Therapy

Mechanism: This proprietary technology seeks to combine pulsed light at low wavelengths (and thus the highest excitation spectrum for porphyrins) with heat energy for greater depth of penetration into the skin. Devices used in published studies: ClearTouch system Radiancy Inc., Orangeburg, NY Indications: The technologic basis of pulsed light and heat makes intuitive sense for targeting both P. acnes and the sebaceous gland. This device is successful in treating both inflammatory and noninflammatory acne vulgaris.
5 3 2 n m Po t a s s i u m - t i t a n y l - p h o s p h a t e L a s e r

Mechanism: Photodynamic therapy (PDT) uses a photo-sensitizer and low intensity visible light to produce cytotoxic oxygen radicals. One of the advantages of this method is that the photo-sensitizer can be selectively applied and illumination can be focused. Photo-sensitizers include aminolevulinic acid (ALA) or indocyanine green. Adverse effects, often typical of ALA-PDT treatment, included erythema, crusting, pain, and hyperpigmentation.
Aminolevulinic Acid in Combination Therapy

Mechanism: The 532nm (green) potassium-titanylphosphate (KTP) laser has as its target chromophore oxyhemoglobin and melanin. Since this laser has a greater

Mechanism: Topical ALA is preferentially taken up by pilo-sebaceous units and incorporated into the heme
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synthesis pathway to produce protoporphyrin nine. When photo-activated, protoporphyrin nine produces singlet oxygen molecules and cytotoxic free radicals. The singlet oxygen then attacks not only p. acnes, but also the sebaceous gland itself. The end result is a decrease in acne, which varies depending on the light source used for illumination. ALA incubation followed by red, blue, or intense pulsed light, PDL, diode lasers, or light emitting diode (LED) sources have all been shown effective following a weekly treatment schedule. Devices used in published studies: CeramOptec GmbH, Bonn, Germany; IPL Ellipse, DDD, Denmark; ClearTouch system Radiancy Inc., Orangeburg, NY, 595nm PDL VBeam, Candela Corp, Wayland, MA, Lumenis IPL, Cost Mesa, CA.
Indications
Back and Chest Acne

to cause both photodynamic and photo-thermal effects within P acnes and the pilo-sebaceous unit. . Devices used in published studies: 803nm OPC-BO15MMM-FCTS diode laser, Opto Power Corp., Tucson, AZ; 809 nm diode laser, Palomar Medical Technologies, Inc., Burlington, MA; 810nm diode laser Cynosure, Inc., Chelmsford, MA. Indications: ICG is best used for body acne though incubation time with the use of the microemulsion is long (up to 24 hours). For moderate facial acne, the incubation period is short (five to fifteen minutes). There is pain associated with collateral heating. Lesions will clear through the bodys own healing process after treatment.
Infrared Lasers (1,320nm, 1,450nm and 1,540nm)

ALA can augment the properties of red light and is effective for back and chest acne although it requires long incubation periods (two to three hours). Prior to using the red light diode, similar incubation times are required (three hours).Total treatments are relatively few (three to five) for improvement of mild to moderate back acne. Oral delta-ALA administered at 10mg/kg followed by polychromatic visible light from a metal halide lamp can improve intractable body acne, though patients usually complain of more discomfort in terms of burning and stinging as compared with other modalities.
Facial Acne

Mechanism: Infrared lasers target water, which is the dominant chromophore in the sebaceous gland. These lasers are thought to either injure sebocytes, arresting the overproduction of sebum, or affect the infundibulum and improve sebum flow out of the gland. Infrared lasers have been shown to clear acne for extended periods of time with treatment intervals at four to six weeks.
1450nm Alone and in Combination Therapy

Devices used in published studies: Smoothbeam, Candela Corp.,Wayland, MA Indications: The 1,450nm diode may have clinical utility as primary therapy for inflammatory acne, or as an adjunctive acne treatment. It is efficacious with minimum side effects. One of the downsides is the level of discomfort reported by some patients. Widespread use of this laser in younger populations has been limited. This wavelength laser has also been trialed in combination with oral and topical acne treatments, micro-dermabrasion and the 595nm PDL. The laser-laser combination is thought to work through dual targeting of the sebaceous gland (1,450nm laser) and P. acnes (595nm PDL).
1540nm

In combination with blue light, moderate to severe facial acne can be treated with short incubation periods (15 minutes) and treatments are reported as pain-free. Studies have shown little difference between one- and four-hour Levulan incubation times, and given the risk of hyper-pigmentation, we advocate for short application periods on the face.With the IPL, the 600950nm applicator is more efficient than the 555950nm applicator in reduction of inflammatory acne when used with Levulan. Most recently, the 595nm PDL has been used with ALA for severe acne including cysts.This data is preliminary.
Indocyanine Green

Mechanism: Indocyanine green (ICG, a tricarbocyanine dye) is a chromophore with peak absorption at 805nm (a wavelength located within the optical window of 6001,300nm), which can be applied topically and is known to be preferentially accumulated by sebaceous glands. In combination with diode lasers, ICG is thought
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Devices used in published studies: 1,540 Erbium (Er): Glass laser Aramis, Quantel Medical, Med-Surge Technologies, Dallas,TX Indications: The 1,540nm Er:Glass laser may be appropriate for back and face acne in varying skin phototypes though only a few trials have been conducted with

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Non-Traditional Acne Therapy: The Use of Lasers and Light-Based Therapies

volumetric heating. Devices used in published studies: ThermaCool Thermage, Inc., Hayward, CA Indications: Given its mechanism of action, these devices are best used for moderate to severe acne and to alleviate and improve the texture and appearance of acne scarring.
S u m m a r y a n d F u t u r e Tr e n d s

Devices used in published studies: None, though the CoolTouch Laser Aesthetics, Inc., CA was FDA approved for this use in 2003. Indications: Most of the studies involving the 1,320nm device have evaluated its efficacy in acne scar remodeling through collagen stimulation.
Radiofrequency

Mechanism: Radiofrequency devices act as a physical method of treating moderate and severe acne through

Technologies are currently underway to introduce hand-held devices for home use. Trials are still pending. No one laser or light based device has proven superior in the treatment of acne on the face or body to date. If patients are properly screened, many of the systems discussed can be used as primary or even adjunctive treatment modalities. The key things to keep in mind are the target, treatment area, and presence of acne scarring.

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