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Shining a light into the laser treatment of acne

Charlotte Waterworth
23 June, 2011  

Charlotte Waterworth
Healthcare writer

Acne vulgaris is a skin condition caused by a combination of excess skin oil, bacteria and other tissue leading to blockage of the pores, which leaves spots on the face, back, neck, chest and arms.

While not a serious health issue, it can make a person suffering from acne feel self-conscious, and often has a negative impact on self-esteem. As such, healthcare professionals recognise that the condition requires effective and at times, aggressive treatment.

Many acne treatment options are available such as prescription creams and antibiotics designed to treat the source of acne. Typically, mild acne is treated with topical retinoids, benzioids and azelaic acid, while antibiotics are usually reserved for moderate acne.

According to a 2007 review article published in Seminars in Plastic Surgery, traditional medical treatments for acne have a number of drawbacks, including poor compliance, lack of durable remission, and possible side-effects. As such, the authors state that laser surgery may be an effective treatment option for people who don’t respond to traditional acne treatments.1

Lasers for active acne
The use of lasers and light devices has increased dramatically in recent years due to the overall ease of treatment, predictable clinical efficacy and minimal adverse effects.

A variety of light and laser devices are used to treat acne. Laser devices are believed to target the underlying causes of acne such as colonisation of bacteria known as propionibacterium acnes, and over-active sebaceous glands.1

Active acne is often treated using two types of laser treatment – intense pulsed light lasers (IPL), and pulsed dye laser therapy (PDL). The basic principle of IPL is selective thermal damage of the target skin. IPL devices use band pass filters to emit polychromatic incoherent high-intensity pulsed light of determined wavelength spectrum and pulse duration.2

PDL devices, while technically not lasers, use light that works in a similar way to lasers. PDL devices emit high-energy light in very short pulses with a long pause between each pulse. Their main affect appears to be antibacterial.

Clinical efficacy
Several studies have sought to determine the efficacy of laser treatments for active acne. In 2009, dermatologists at the University of Kansas Medical Centre published an meta-analysis of their investigations of data from a number of clinical trials and case series of laser treatment. The authors found 21 clinical trials and case series of various designs.  

Eight studies employed a split-face design comparing photosensitiser to placebo, no treatment or another photosensitiser. Two trials used three test spots and one control spot per patient. Three studies utilised control subjects receiving no photo-sensitiser with or without light therapy. According to the authors, all 21 studies reported a reduction in inflammatory lesions and/or a significant improvement in acne.3

While these findings suggest lasers are an effective acne treatment, there have been very few randomised, controlled clinical trials to determine the efficacy of laser treatments. In addition, data from studies is somewhat conflicting.

One study, published in The Lancet in 2003, compared the efficacy and tolerability of PDL treatment with sham treatment, in patients with mild-to-moderate facial inflammatory acne in a double-blind, randomised controlled trial. The study authors randomly assigned patients to PDL or sham treatment. Treatment was given at baseline and patients were seen after two, four, eight, and 12 weeks.

After 12 weeks, acne severity (measured by Leeds revised grading system) was reduced from 3·8 to 1·9 in the PDL group and 3·6 to 3·5 in the sham group. In addition, total lesion counts fell by 53% in PDL patients and 9% in controls. Inflammatory lesion counts were reduced by 49% in PDL patients compared with only 10% in the control group. The authors conclude that PDL therapy improves inflammatory facial acne 12 weeks after one treatment with no serious adverse effects.4

In contrast, researchers from the University of Michigan Health System claim lasers have no benefit in active acne treatment. Their study, published in 2004 in the Journal of the American Medical Association, found PDL was not effective in treating acne.

University of Michigan researchers randomly assigned 40 patients with acne to receive treatment on one half of their face. The untreated half served as a comparison to take into account each person’s natural skin changes. Almost 400 laser pulses were delivered, each treatment lasting about 10 minutes.

Patients returned for clinical examinations, including counts of the number of acne lesions, every two weeks for 12 weeks. In addition, both sides of the face were photographed at each visit in order to allow a panel of three dermatologists to assess the overall severity of the acne.

According to the study authors, the dermatologists were not aware of which side of each person’s face had been treated. In addition, researchers found that, 12 weeks after treatment, the side of the face that received treatment showed the same degree of change as the untreated side. The authors concluded that laser therapy did not impact the course of the disease.5

Acne scarring
Lasers are a popular resurfacing treatment for many skin defects including wrinkles, hyper-pigmentation and birth marks. Shallow acne scars can also be treated with laser resurfacing. According to a 2001 review of laser resurfacing for facial acne scars, laser techniques may be more effective than chemical peels and dermabrasion.6

Popular laser types used for resurfacing of acne scars are carbon dioxide (CO2) and erbium:YAG (Er:YAG) lasers. These lasers are ablative in nature, which means they work by delivering an intense blast of energy onto the surface of the skin, which removes the outermost layers of the skin a precise and controlled way. The skin then heals itself over a period of time, by producing new layers of collagen.

As with laser treatment for active acne, few randomised controlled trials have examined the efficacy of lasers as acne-scarring treatments. That said, a number of case studies show that both CO2 and Er:YAG play a valid role in the treatment of acne scarring. Although CO2 and Er:YAG lasers are considered highly effective treatment options for skin resurfacing, post-treatment complications may occur that often require ongoing surveillance. As the skin heals, the wound produced by ablative lasers, such as CO2 and Er:YAG, often weeps and produces a crust that may predispose the wound to secondary infection. Other side-effects may include skin discomfort, pruritus, erythema, 
and oedema.7

To circumvent these possible side-effects, fractional lasers have been developed. Fractional lasers confine skin damage to miniscule zones within the selected target area that triggers the intact skin surrounding the wound to help smooth over the damaged area with new cells.

There are several fractional lasers available in the UK, including Fraxel™ SR, Pixel® 2940 and Lux 1540 Fractional. New improved versions are coming on to the market all the time, with more companies producing new fractional devices or modifying of existing machines. These include Affirm™ from Cynosure, Active FX from Lumenis and Profractional from Sciton.

The advantage of these types of lasers is that there is minimal downtime; patients can often go back to work immediately following fractional laser treatment.

While fractional lasers may achieve comparable skin improvements to traditional ablative lasers, there is no evidence to show they are effective as ablative lasers. In addition, fractional lasers are not entirely risk free. A 2008 study designed to assess the frequency and range of side-effects associated with fractional laser treatment found that 7.6% of procedures resulted in development of complications.

The most frequent complications were acneiform eruptions (1.87%) and Herpes simplex virus outbreaks (1.77%). However, the author notes that side-effects and complications were temporary and did not result in long-term problems.8 Ultimately, then, the choice of ablative versus fractional laser may largely come down to patient and surgeon preference.

Future trends and technologies
The use of laser treatments has traditionally been confined to the doctor’s office. However, they are increasingly becoming available at a variety of non-medical sites. As laser technology evolves, patients may even be able to treat their acne in the comfort of their own home.

Currently, laser devices for home use are limited to hair removal. However, the author of a 2008 article published in Seminars in Cutaneous Medicine and Surgery, believes that lasers for both acne scarring and active acne may soon be available for home use. The author, Darryl Shaw Hodson, notes that many laser experts feel that results from non-ablative devices can be improved with additional treatments beyond the three to four usually performed in an office-based treatment package. A home use device could facilitate a long-term treatment plan requiring multiple treatments, says Hodson.

On the downside, lasers for home use are unlikely to be as powerful as those found in the doctor’s office and patients may have unrealistic expectations as to what can be achieved at home.9

Whether the future of acne laser treatment lies in the doctors’ surgery or the home, there is no doubt that laser treatments cannot be ignored as a potential solution for active acne and acne scarring.

However, patient willingness to undergo surgical treatment for acne, and 
the cost versus benefit of laser therapy has yet 
to be determined.

References

  1. 
Jih MH, Kimyai-Asadi A. Semin Plast Surg 2007;21(3):167-74.
  2. 
Babilas P et al. Lasers Surg Med 2010;42(2):93-104.
  3. 
Riddle CC et al. J Drugs Dermatol 2009;8(11):1010-9.
  4. 
Seaton ED et al. The Lancet 2003;362(9393):1347-52r
  5. 
Orringer JS et al. JAMA 2004;291(23):2834-9.
  6. 
Jordan R et al. Cochrane Database of Systematic Reviews, 2001, Issue 1
  7. 
Batra RS. Advances in Dermatologic Surgery 2004; Vol 9
  8. 
Graber EM et al. Dermatol Surg 2008;34(3):301-5.
  9. 

Hodon DS. Semin Cutan Med Surg 2008;27:292-300