A variety of laser, pulsed light and radiofrequency devices have been documented to improve acne vulgaris.1,2,3 Acne vulgaris is a multidimensional, not static, condition, and it is becoming increasingly evident that devices are best utilized as a part of multimodal therapy.
This article summarizes acne treatment devices based on their respective mechanisms of action and provides an algorithm for integrating such devices into the management of acne vulgaris.
MECHANISMS OF DEVICES
Table 1 summarizes proposed mechanisms of action of various devices for treating acne. These include co-incidental improvement of acne with devices primarily used for selective photothermolysis (SP) of vascular and pigmented lesions, endogenous photodynamic therapy, exogenous photodynamic therapy, selective photothermolysis of sebaceous glands, radiofrequency and Photoneu-matic therapy.
CO-INCIDENTAL IMPROVEMENT OF ACNE WITH SP DEVICES
Traditional vascular lasers (532-nm KTP, 585/595-nm pulsed dye lasers [PDL]) and pulsed light (traditional pulsed light with cutoff filters over 500 nm) sources are utilized to treat vascular and/or benign pigmented lesions.
Conflicting evidence exists regarding the true efficacy of these devices for the treatment of acne vulgaris, with some studies yielding significant benefits4 and others showing no significant improvement.5 The proposed mechanism of action may be due to nonselective bulk heating, which may affect the sebaceous gland and achieve a generalized improvement of erythema since these devices target vascular chromophores. The improvement of the erythema associated with acne is probably the best utilization for these devices. (See Figure 1.)
ENDOGENOUS PHOTODYNAMIC THERAPY
Observations that acne improves with sunlight exposure led investigators to study spectra of light that may specifically improve acne. The 415-nm blue light sources have demonstrated impressive in vitro destruction of Propionibacterium acnes.6 Endogenous porphyrins of P. acnes are absorbed by 420-nm light with selective destruction. Combined blue light (415 nm) and red light (633 nm) may show enhanced effects, with several studies showing combination wavelengths to result in improvement of mild to severe acne.7,8 These devices typically require multiple weekly or biweekly treatments and are best suited for mild acne as monotherapy. (See Figure 2.) The main advantages of these therapies are their lack of discomfort and safety in all skin types. The main disadvantages include the need for multiple weekly or biweekly treatments.
EXOGENOUS PHOTODYNAMIC THERAPY
An affinity for the sebaceous gland demonstrated by 5-aminolevulinic acid (5-ALA) has led to numerous studies using this as an activator prior to traditional laser- and light-based therapies with a variety of wavelengths. The best activator for 5-ALA is 420-nm blue light, but multiple other light sources including 532-nm KTP, 585/595-nm PDL and pulsed light, have shown effective activation due to the off-peak absorption of these wavelengths with 5-ALA.
The effects may be twofold: selective photothermolysis with P. acnes destruction as well as generalized bulk heating, which may produce transient improvement in acne.9,10 Concurrent cosmetic improvement of shallow acne scars and dyschromia with photodynamic therapy have also been noted.
The main advantages of exogenous photodynamic therapy are the need for fewer treatments, compatibility with a variety of laser and light sources and a broader range of acne severity for treatment. The main disadvantages include discomfort and recovery and higher incidence of post-inflammatory hyperpigmentation in darker skin types.
RADIOFREQUENCY DEVICES
A few studies have demonstrated the efficacy of unipolar radiofrequency for the treatment of acne. The proposed mechanism is modification of sebaceous glands by unipolar radiofrequency and neocollagenesis, leading to improvement of acne scars.
Due to the discomfort associated with traditional protocols of unipolar radiofrequency, this modality gained limited appeal. Newer treatment protocols with unipolar radiofrequency may alleviate this problem, but studies are needed to determine whether lower energies with unipolar radiofrequency can accomplish clinical results.11,12
NEAR INFRA-RED LASERS (1450 nm and 1540 nm)
The near infra-red nonablative lasers using 1450 nm and 1540 nm were, like radiofrequency, originally designed for nonablative improvement of rhytids. A co-incidental observation was the modification of sebaceous glands at these wavelengths, which led to some elegant studies showing efficacy of these wavelengths for the treatment of active acne and acne scarring.13,14,15
Advantages of these lasers include concurrent improvement of shallow acne scars due to neocollagenesis at these wavelengths and disadvantages include discomfort and the need for multiple treatments.
Photoneumatic Therapy
Photoneumatic therapy employs lower wavelength broad-band light (400 nm to 500 nm) with concurrent suction.
It was originally developed for hair reduction with reduced discomfort. In clinical studies for hair reduction in which treatments were stopped to gain FDA clearance for long-term hair reduction, patients noticed a flare of acne. This led to a multicenter trial studying the efficacy of photopneumautic therapy for acne. It is now cleared by the FDA for all four components of acne, comedonal, pustular, papular and cystic.16
The proposed mechanism is the pneumatic energy that allows dermal targets such as sebaceous glands to be closer to the surface, thereby making delivery of the light more effective. The lower wavelength photons have a better absorption for P. acnes. Three to five treatments administered 2 to 4 weeks apart are necessary.
The main advantage of photoneumatic therapy is the lack of discomfort, safety in all skin types, immediate (Figure 5) and delayed response to acne lesions and simultaneous cosmetic improvement with “pore cleansing” (Figure 6).
The term “porofacial” has been coined by the author for this treatment. The main disadvantages for photoneumatic therapy is the need for multiple treatments.
ALGORITHM
The best way to utilize devices for treating acne is proper patient selection and adjuvant therapy. The author has developed an algorithm that optimizes devices for acne vulgaris. (See Figure 7.)
For example, devices are best used as the first line of treatment for patients actively trying to get pregnant, patients who have failed traditional topical therapy and are reluctant to use systemic therapy, patients who are candidates for isotretinoin (Accutane) but refuse to take it for safety concerns and for patients who have failed all traditional acne therapies.
There is now enough evidence in the literature and in clinical practice to support the use of devices for acne vulgaris. However, it is absolutely evident that monotherapy for devices in acne yields variable results. This is not unique to acne, as we now recognize that global improvement for a variety of conditions requires multimodal therapy.
FITTING DEVICES INTO THERAPY
A multitude of devices have been shown to be effective for the treatment of acne vulgaris. Many “traditional” dermatologists have been wary of integrating devices for acne in clinical practice. Concerns include variability of clinical response, need for multiple treatments and maintenance treatments and costs.
If positioned properly, devices play a crucial role in the “management” of acne vulgaris, as acne is not a static condition and any treatment for acne requires compliance, maintenance and follow-up.
Devices are best used in combination with topical and or systemic therapy and the author often uses them as a “booster” to augment traditional therapies.
Further studies need to be performed to study the efficacy of device in combination with topical and systemic therapies to better develop a standardized algorithm for management of acne vulgaris.
A variety of laser, pulsed light and radiofrequency devices have been documented to improve acne vulgaris.1,2,3 Acne vulgaris is a multidimensional, not static, condition, and it is becoming increasingly evident that devices are best utilized as a part of multimodal therapy.
This article summarizes acne treatment devices based on their respective mechanisms of action and provides an algorithm for integrating such devices into the management of acne vulgaris.
MECHANISMS OF DEVICES
Table 1 summarizes proposed mechanisms of action of various devices for treating acne. These include co-incidental improvement of acne with devices primarily used for selective photothermolysis (SP) of vascular and pigmented lesions, endogenous photodynamic therapy, exogenous photodynamic therapy, selective photothermolysis of sebaceous glands, radiofrequency and Photoneu-matic therapy.
CO-INCIDENTAL IMPROVEMENT OF ACNE WITH SP DEVICES
Traditional vascular lasers (532-nm KTP, 585/595-nm pulsed dye lasers [PDL]) and pulsed light (traditional pulsed light with cutoff filters over 500 nm) sources are utilized to treat vascular and/or benign pigmented lesions.
Conflicting evidence exists regarding the true efficacy of these devices for the treatment of acne vulgaris, with some studies yielding significant benefits4 and others showing no significant improvement.5 The proposed mechanism of action may be due to nonselective bulk heating, which may affect the sebaceous gland and achieve a generalized improvement of erythema since these devices target vascular chromophores. The improvement of the erythema associated with acne is probably the best utilization for these devices. (See Figure 1.)
ENDOGENOUS PHOTODYNAMIC THERAPY
Observations that acne improves with sunlight exposure led investigators to study spectra of light that may specifically improve acne. The 415-nm blue light sources have demonstrated impressive in vitro destruction of Propionibacterium acnes.6 Endogenous porphyrins of P. acnes are absorbed by 420-nm light with selective destruction. Combined blue light (415 nm) and red light (633 nm) may show enhanced effects, with several studies showing combination wavelengths to result in improvement of mild to severe acne.7,8 These devices typically require multiple weekly or biweekly treatments and are best suited for mild acne as monotherapy. (See Figure 2.) The main advantages of these therapies are their lack of discomfort and safety in all skin types. The main disadvantages include the need for multiple weekly or biweekly treatments.
EXOGENOUS PHOTODYNAMIC THERAPY
An affinity for the sebaceous gland demonstrated by 5-aminolevulinic acid (5-ALA) has led to numerous studies using this as an activator prior to traditional laser- and light-based therapies with a variety of wavelengths. The best activator for 5-ALA is 420-nm blue light, but multiple other light sources including 532-nm KTP, 585/595-nm PDL and pulsed light, have shown effective activation due to the off-peak absorption of these wavelengths with 5-ALA.
The effects may be twofold: selective photothermolysis with P. acnes destruction as well as generalized bulk heating, which may produce transient improvement in acne.9,10 Concurrent cosmetic improvement of shallow acne scars and dyschromia with photodynamic therapy have also been noted.
The main advantages of exogenous photodynamic therapy are the need for fewer treatments, compatibility with a variety of laser and light sources and a broader range of acne severity for treatment. The main disadvantages include discomfort and recovery and higher incidence of post-inflammatory hyperpigmentation in darker skin types.
RADIOFREQUENCY DEVICES
A few studies have demonstrated the efficacy of unipolar radiofrequency for the treatment of acne. The proposed mechanism is modification of sebaceous glands by unipolar radiofrequency and neocollagenesis, leading to improvement of acne scars.
Due to the discomfort associated with traditional protocols of unipolar radiofrequency, this modality gained limited appeal. Newer treatment protocols with unipolar radiofrequency may alleviate this problem, but studies are needed to determine whether lower energies with unipolar radiofrequency can accomplish clinical results.11,12
NEAR INFRA-RED LASERS (1450 nm and 1540 nm)
The near infra-red nonablative lasers using 1450 nm and 1540 nm were, like radiofrequency, originally designed for nonablative improvement of rhytids. A co-incidental observation was the modification of sebaceous glands at these wavelengths, which led to some elegant studies showing efficacy of these wavelengths for the treatment of active acne and acne scarring.13,14,15
Advantages of these lasers include concurrent improvement of shallow acne scars due to neocollagenesis at these wavelengths and disadvantages include discomfort and the need for multiple treatments.
Photoneumatic Therapy
Photoneumatic therapy employs lower wavelength broad-band light (400 nm to 500 nm) with concurrent suction.
It was originally developed for hair reduction with reduced discomfort. In clinical studies for hair reduction in which treatments were stopped to gain FDA clearance for long-term hair reduction, patients noticed a flare of acne. This led to a multicenter trial studying the efficacy of photopneumautic therapy for acne. It is now cleared by the FDA for all four components of acne, comedonal, pustular, papular and cystic.16
The proposed mechanism is the pneumatic energy that allows dermal targets such as sebaceous glands to be closer to the surface, thereby making delivery of the light more effective. The lower wavelength photons have a better absorption for P. acnes. Three to five treatments administered 2 to 4 weeks apart are necessary.
The main advantage of photoneumatic therapy is the lack of discomfort, safety in all skin types, immediate (Figure 5) and delayed response to acne lesions and simultaneous cosmetic improvement with “pore cleansing” (Figure 6).
The term “porofacial” has been coined by the author for this treatment. The main disadvantages for photoneumatic therapy is the need for multiple treatments.
ALGORITHM
The best way to utilize devices for treating acne is proper patient selection and adjuvant therapy. The author has developed an algorithm that optimizes devices for acne vulgaris. (See Figure 7.)
For example, devices are best used as the first line of treatment for patients actively trying to get pregnant, patients who have failed traditional topical therapy and are reluctant to use systemic therapy, patients who are candidates for isotretinoin (Accutane) but refuse to take it for safety concerns and for patients who have failed all traditional acne therapies.
There is now enough evidence in the literature and in clinical practice to support the use of devices for acne vulgaris. However, it is absolutely evident that monotherapy for devices in acne yields variable results. This is not unique to acne, as we now recognize that global improvement for a variety of conditions requires multimodal therapy.
FITTING DEVICES INTO THERAPY
A multitude of devices have been shown to be effective for the treatment of acne vulgaris. Many “traditional” dermatologists have been wary of integrating devices for acne in clinical practice. Concerns include variability of clinical response, need for multiple treatments and maintenance treatments and costs.
If positioned properly, devices play a crucial role in the “management” of acne vulgaris, as acne is not a static condition and any treatment for acne requires compliance, maintenance and follow-up.
Devices are best used in combination with topical and or systemic therapy and the author often uses them as a “booster” to augment traditional therapies.
Further studies need to be performed to study the efficacy of device in combination with topical and systemic therapies to better develop a standardized algorithm for management of acne vulgaris.
A variety of laser, pulsed light and radiofrequency devices have been documented to improve acne vulgaris.1,2,3 Acne vulgaris is a multidimensional, not static, condition, and it is becoming increasingly evident that devices are best utilized as a part of multimodal therapy.
This article summarizes acne treatment devices based on their respective mechanisms of action and provides an algorithm for integrating such devices into the management of acne vulgaris.
MECHANISMS OF DEVICES
Table 1 summarizes proposed mechanisms of action of various devices for treating acne. These include co-incidental improvement of acne with devices primarily used for selective photothermolysis (SP) of vascular and pigmented lesions, endogenous photodynamic therapy, exogenous photodynamic therapy, selective photothermolysis of sebaceous glands, radiofrequency and Photoneu-matic therapy.
CO-INCIDENTAL IMPROVEMENT OF ACNE WITH SP DEVICES
Traditional vascular lasers (532-nm KTP, 585/595-nm pulsed dye lasers [PDL]) and pulsed light (traditional pulsed light with cutoff filters over 500 nm) sources are utilized to treat vascular and/or benign pigmented lesions.
Conflicting evidence exists regarding the true efficacy of these devices for the treatment of acne vulgaris, with some studies yielding significant benefits4 and others showing no significant improvement.5 The proposed mechanism of action may be due to nonselective bulk heating, which may affect the sebaceous gland and achieve a generalized improvement of erythema since these devices target vascular chromophores. The improvement of the erythema associated with acne is probably the best utilization for these devices. (See Figure 1.)
ENDOGENOUS PHOTODYNAMIC THERAPY
Observations that acne improves with sunlight exposure led investigators to study spectra of light that may specifically improve acne. The 415-nm blue light sources have demonstrated impressive in vitro destruction of Propionibacterium acnes.6 Endogenous porphyrins of P. acnes are absorbed by 420-nm light with selective destruction. Combined blue light (415 nm) and red light (633 nm) may show enhanced effects, with several studies showing combination wavelengths to result in improvement of mild to severe acne.7,8 These devices typically require multiple weekly or biweekly treatments and are best suited for mild acne as monotherapy. (See Figure 2.) The main advantages of these therapies are their lack of discomfort and safety in all skin types. The main disadvantages include the need for multiple weekly or biweekly treatments.
EXOGENOUS PHOTODYNAMIC THERAPY
An affinity for the sebaceous gland demonstrated by 5-aminolevulinic acid (5-ALA) has led to numerous studies using this as an activator prior to traditional laser- and light-based therapies with a variety of wavelengths. The best activator for 5-ALA is 420-nm blue light, but multiple other light sources including 532-nm KTP, 585/595-nm PDL and pulsed light, have shown effective activation due to the off-peak absorption of these wavelengths with 5-ALA.
The effects may be twofold: selective photothermolysis with P. acnes destruction as well as generalized bulk heating, which may produce transient improvement in acne.9,10 Concurrent cosmetic improvement of shallow acne scars and dyschromia with photodynamic therapy have also been noted.
The main advantages of exogenous photodynamic therapy are the need for fewer treatments, compatibility with a variety of laser and light sources and a broader range of acne severity for treatment. The main disadvantages include discomfort and recovery and higher incidence of post-inflammatory hyperpigmentation in darker skin types.
RADIOFREQUENCY DEVICES
A few studies have demonstrated the efficacy of unipolar radiofrequency for the treatment of acne. The proposed mechanism is modification of sebaceous glands by unipolar radiofrequency and neocollagenesis, leading to improvement of acne scars.
Due to the discomfort associated with traditional protocols of unipolar radiofrequency, this modality gained limited appeal. Newer treatment protocols with unipolar radiofrequency may alleviate this problem, but studies are needed to determine whether lower energies with unipolar radiofrequency can accomplish clinical results.11,12
NEAR INFRA-RED LASERS (1450 nm and 1540 nm)
The near infra-red nonablative lasers using 1450 nm and 1540 nm were, like radiofrequency, originally designed for nonablative improvement of rhytids. A co-incidental observation was the modification of sebaceous glands at these wavelengths, which led to some elegant studies showing efficacy of these wavelengths for the treatment of active acne and acne scarring.13,14,15
Advantages of these lasers include concurrent improvement of shallow acne scars due to neocollagenesis at these wavelengths and disadvantages include discomfort and the need for multiple treatments.
Photoneumatic Therapy
Photoneumatic therapy employs lower wavelength broad-band light (400 nm to 500 nm) with concurrent suction.
It was originally developed for hair reduction with reduced discomfort. In clinical studies for hair reduction in which treatments were stopped to gain FDA clearance for long-term hair reduction, patients noticed a flare of acne. This led to a multicenter trial studying the efficacy of photopneumautic therapy for acne. It is now cleared by the FDA for all four components of acne, comedonal, pustular, papular and cystic.16
The proposed mechanism is the pneumatic energy that allows dermal targets such as sebaceous glands to be closer to the surface, thereby making delivery of the light more effective. The lower wavelength photons have a better absorption for P. acnes. Three to five treatments administered 2 to 4 weeks apart are necessary.
The main advantage of photoneumatic therapy is the lack of discomfort, safety in all skin types, immediate (Figure 5) and delayed response to acne lesions and simultaneous cosmetic improvement with “pore cleansing” (Figure 6).
The term “porofacial” has been coined by the author for this treatment. The main disadvantages for photoneumatic therapy is the need for multiple treatments.
ALGORITHM
The best way to utilize devices for treating acne is proper patient selection and adjuvant therapy. The author has developed an algorithm that optimizes devices for acne vulgaris. (See Figure 7.)
For example, devices are best used as the first line of treatment for patients actively trying to get pregnant, patients who have failed traditional topical therapy and are reluctant to use systemic therapy, patients who are candidates for isotretinoin (Accutane) but refuse to take it for safety concerns and for patients who have failed all traditional acne therapies.
There is now enough evidence in the literature and in clinical practice to support the use of devices for acne vulgaris. However, it is absolutely evident that monotherapy for devices in acne yields variable results. This is not unique to acne, as we now recognize that global improvement for a variety of conditions requires multimodal therapy.
FITTING DEVICES INTO THERAPY
A multitude of devices have been shown to be effective for the treatment of acne vulgaris. Many “traditional” dermatologists have been wary of integrating devices for acne in clinical practice. Concerns include variability of clinical response, need for multiple treatments and maintenance treatments and costs.
If positioned properly, devices play a crucial role in the “management” of acne vulgaris, as acne is not a static condition and any treatment for acne requires compliance, maintenance and follow-up.
Devices are best used in combination with topical and or systemic therapy and the author often uses them as a “booster” to augment traditional therapies.
Further studies need to be performed to study the efficacy of device in combination with topical and systemic therapies to better develop a standardized algorithm for management of acne vulgaris.
