Achieving faster improvement for acne patients and higher rates of medication compliance is a challenge. By the time patients with significant acne see a dermatologist, they are very often frustrated after having tried many different over-the-counter regimens and therapies. As a result of this frustration, they often want to see quick results in the appearance of their acne. The reality, however, is that even prescription therapies (topical as well as oral) take several weeks to begin to lead to improvement, while some of the side effects, including dryness and irritation, can be seen within several days. This timeframe is frustrating and often unacceptable to patients. As a result, compliance often starts to drop off after a week or 2 due to a perceived lack of efficacy, as well as skin irritation that accompanies many of the topical medications, including topical retinoids and benzoyl peroxide.
In our experience, devices that combine suction with intense pulsed light can expedite improvement in acne vulgaris in the first few weeks, giving patients confidence in the prescribed acne regimen and resulting in increased compliance.
Here, we report the case of a 15-year-old male patient with moderate facial acne. Previous therapies for this patient included topical benzoyl peroxide preparations, topical retinoids and oral antibiotics, but therapy was discontinued by the patient each time due to lack of improvement within the first few weeks.
Acne vulgaris is a very common condition that affects millions of patients worldwide. In addition to its physical effect, acne can have profound psychological consequences due to embarrassment about acne lesions as well as the potential for disfiguring scarring.
Numerous therapeutic options are available for acne, including many oral and topical pharmaceutical agents, chemical peels, lasers, photodynamic therapy and other light-based treatments. In the past few years, several devices that combine broadband light and pneumatic suction — also known as photopneumatic therapy (Ppx) – have been introduced into the market. In the United States, Isolaz (Solta Medical Inc., Hayward, CA) and Acleara (Palomar Medical Technologies, Inc., Burlington, MA) devices are FDA-approved for the treatment of acne.
Unlike laser light, these broadband light devices typically emit wavelengths ranging from 400 nm to 1200 nm (with a peak between 440 nm and 500 nm). In the blue portion of the spectrum, this light is well absorbed by porphyrins and is thought to contribute to reduced numbers of P. acnes bacteria. When combined with suction, the light is more evenly distributed over the skin, with less absorption by the more dispersed melanin granules.1 Moreover, suction moves the sebaceous glands closer to the skin surface, allowing the practitioner to reduce the energy needed to cause significant clinical effect. This may result in safer therapy with less discomfort and fewer adverse pigmentary effects. In addition, suction may contribute to evacuation of comedone contents — leading to decreased both inflammatory and non-inflammatory lesions.2
On his first visit, the patient was started on a combination of oral doxycycline and topical benzoyl peroxide-adapalene gel. At the same time, he received a treatment using the Acleara device at 750-ms pulse duration, 4 J/cm2 of fluence and vacuum setting of 3 on the lower face and 500-ms pulse duration, 4 J/cm2 of fluence and vacuum setting of S3 (“sensitive mode”) on the forehead and temples. Immediately prior to Acleara treatment, a Dermasweep (Rocklin, CA) dermal infusion microdermabrasion with salicylic acid was performed. The patient returned weekly for 4 additional treatments that were performed at identical settings. At the conclusion of this treatment regimen, the patient noted significant improvement in his overall acne (see Figure 1 through 5), and was told to continue his oral and topical therapies for 2.5 months. At this time, the patient’s follow-up appointment led to the discontinuation of the oral antibiotics.
Figure 1: Patient at start of therapy.
Figure 2: 1-week follow-up.
Figure 3: 2-week follow-up.
Figure 4: 4-week follow-up.
Figure 5: 6-week follow-up.
A proper consent form is important and should not only explain the potential risks of Ppx treatment and the need for multiple sessions, but also clearly state that the Ppx treatments are meant to expedite improvement, working synergistically with traditional medical therapies. Pre-procedure photographs showing baseline severity are very helpful to evaluate improvement over the course of treatment. In addition, acne severity scales or acne lesion counts may also be used for an objective chronology of improvement.
The Ppx procedure is generally safe in patients of all skin types, though the Isolaz device requires a change in filters when treating patients with darker skin tones (skin types IV-VI). Male patients should be warned that treatment of the beard area may result in hair loss. In addition, patients with freckles or lentigines in the areas of treatment may see initial darkening of their pigmented lesions, followed by their eventual desquamation and overall lightening of freckles. If not properly forewarned, however, such patients may experience unnecessary concerns of “darkening of brown spots” for a few days after treatment.
Pre-treatment anesthesia or analgesia is typically not required. All makeup, facial creams and sunscreens are removed prior to treatment. During the treatment, cooling is employed to avoid damaging the epidermis. The Acleara device has integrated cooling as part of the handpiece itself, while the Isolaz requires the operator to spray coolant on the handpiece after about 5 to 7 pulses. The affected skin is evenly covered using non-overlapping pulses. When using the Acleara device, vacuum settings may be adjusted based on treatment site and patient tolerability. Thus, forehead temples and neck — areas prone to both pain and vacuum-induced purpura — may be treated using the “sensitive mode” setting.
Following Ppx treatment, sun protection is advised. Treatments are usually repeated every 1 to 2 weeks, and 3 to 5 sessions are typically needed to achieve significant improvement. However, emphasis must be placed on getting patients on a good therapeutic prescription regimen that continues during and after these sessions.
For those with a good response to Ppx therapy in our practices, topical agents are usually continued, while oral antibiotics are generally discontinued after about 3 months. We have found maintenance Ppx treatments to be helpful in some patients (often at least once every 3 months or more frequently for flares), though the optimal timing is currently unclear. On the other hand, for those with severe acne unresponsive to the combination of Ppx and prescription therapeutics in our practices, red-light photodynamic therapy3 may be attempted prior to oral isotretinoin.
1. Ppx therapy is best employed synergistically with traditional prescription acne regimens (oral as well as topical acne treatments).
2. Lower energy settings and longer breaks between treatments may be needed for darker skin tones.
3. Patients with hair or pigmented lesions within treatment areas should be warned of the potential impact to these areas by broadband light.
4. Patients should be advised that maintenance therapy (every few months) while on a good topical prescription regimen may be performed or, alternatively, used for flares only. n
Dr. Cohen is the Director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology.
Dr. Berlin is President of DFW Skin Surgery Center, PLLC, in Arlington, TX. He is also a Clinical Assistant Professor of Dermatology at the New Jersey Medical School in Newark, NJ.
Disclosure: Dr. Cohen is a speaker and trial participant for Palomar. Dr. Berlin has no disclosures to report.