Clearing Acne with At-Home Devices
For many years dermatologists have used lasers, blue light therapy, pulsed light, radiofrequency energy and LHE therapy to target P. acnes, the acne-causing bacteria. These treatments have worked in the dermatologist’s office for years, but the technology to put these devices in the homes of acne sufferers was not yet available. Now due to breakthroughs in both the effectiveness of these devices and the ability to make them more cheaply and smaller, having the power of these acne fighters at home is finally possible.

The Patient’s Guide® to Acne
There are so many different acne creams, products and treatments, both at-home and in skin care clinics, it can be very difficult to know what is right and what is effective. Fortunately the Patient’s Guide®, the leading online publication in cosmetic dermatology has launched Acne.md, our newest website dedicated to educating patients about acne and acne treatments. The Patient’s Guide was launched in 2006 and now comprises more than 25 websites covering the range of skin care issues. We bring you the leading researchers and experts in the field of skin care so you can feel confident in the information we provide. While only a one-on-one consultation with a dermatologist can truly give you an idea of what treatments may be right for you, we aim to at least provide you with an idea of what’s now available.

This article points out that although acne is common in Western populations, it is rare in non-Western societies (for example, among the Inuit, Okinawan Islanders, and Kitaven Islanders)—until those societies adopt Western lifestyles. The article then discusses in detail the biological rationale for a possible connection between diet, hyperinsulinemia and acne.

“Recent evidence has demonstrated that the hormonal cascade triggered by diet-induced hyperinsulinemia elicits an endocrine response that simultaneously promotes unregulated tissue growth and enhanced androgen synthesis,” note the article’s authors. “Hence, hyperinsulinemic diets may represent a previously unrecognized environmental factor in the development of acne.”

Source: Berra B, Rizzo AM. Glycemic index, glycemic load, wellness and beauty: the state of the art. Clinics in Dermatology. 2009:27:230-235.

For the randomized, double-blinded, split-face study, which was published in the medical journal Dermatologic Surgery, researchers recruited 16 volunteers with mild to moderate acne. Each underwent 3 treatment sessions at 2-week intervals. At each session, half of their face was treated with a single pass of a combined 585/1,064-nm laser and the other half with a single pass of PDL. Follow-up occurred at 8 and 12 weeks after treatment began.

The results: The inflammatory acne lesions were reduced by 86% on the PDL-alone sides and by 89% on the 585/1,064-nm sides. The observed reductions in noninflammatory lesions was similarly equivalent: 69% and 64%, respectively.

The authors concluded that

“PDL and combined 585/1,064-nm laser were safe and effective for the treatment of inflammatory and noninflammatory acne lesions.”

Source: Jung JY, Choi YS, Yoon MY, Min SU, Suh DH. Comparison of a pulsed dye laser and a combined 585/1,064-nm laser in the treatment of acne vulgaris. Dermatol Surg. 2009. Jan 16.

Eighteen patients were enrolled in the 14-week, single-blinded, randomized, comparative split-face study. Each patient received 4 treatment sessions at 2-week intervals. The board-certified dermatologists who performed the treatments did not participate in outcome assessments. Follow-up occurred at 2-week intervals during the treatment period and at 4-week intervals for 8 weeks afterwards. Acne scar improvements were assessed and scored (based on the ECCA clinical evaluation scale) by two masked dermatologists.

The results: Both types of laser treatments produced notable and comparable improvement in the appearance of acne scars, especially superficial scars. Ice-pick scars (narrow, deeply pitted scars) and boxcar scars (round or oval scars) tended to respond better to PDL and Nd:YAG lasers, respectively.

The authors concluded that both lasers “are effective modalities for the treatment of acne scars. Optimal outcomes might be achieved considering scar types and responses to a specific laser.”

Source: Lee DH, Choi YS, Min SU, Yoon MY, Suh DH. Comparison of a 585-nm pulsed dye laser and a 1064-nm Nd:YAG laser for the treatment of acne scars: A randomized split-face clinical study. J Am Acad Dermatol. 2009 Feb 12. [Epub ahead of print].

The earlier study, known as the Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) trial, ran from 1998 to May 2004. It enrolled 1,131 veterans with an average age of 71. Most were men. The participants were randomly assigned to two groups. One group applied a cream containing 0.1% tretinoin (the highest dose available commercially) to their face and ears twice daily. The other group applied a placebo cream.

The retinoid tretinoin, an acid form of vitamin A, is a common topical treatment for acne. It’s sold under several brand names, including Retin-A, Avita and Renova.

The VATTC trial was designed to determine if a high dose of topical tretinoin could prevent certain types of skin cancer in high-risk people. The trial was stopped, however, when an unexpectedly high mortality rate was observed in the study’s treatment arm (82 deaths in the treatment arm versus 53 in the placebo arm).

The authors of the new analysis, which was funded by the U.S. Department of Veterans Affairs and published in the Archives of Dermatology, found no evidence for a cause-and-effect relationship between the tretinoin treatment and the increased risk of death. “We observed an association of topical tretinoin therapy with death, but we do not infer a causal association that current evidence suggests is unlikely,” they concluded.

Source: Weinstock MA, Bingham SF, Lew RA, et al. Topical tretinoin therapy and all-cause mortality. Arch Dermatol. 2009;145:18-24

Both the retinoid adapalen and the antimicrobial benzoyl peroxide have a long history of being used separately to treat acne. Studies have shown that the two treatments are more effective when combined than when either is used alone, reducing total acne lesions by about 18% as early as one week after the start of treatment.

Last year, a 517-patient study published in the Journal of the American Academy of Dermatology reported that Epiduo reduced the median number of total acne lesions by more than 50% over a 12-week period. Another study published in the Journal of Drugs in Dermatology reported that the discontinuation rate of the medication due to adverse events was a low 2%.

Common side effects include dryness, redness, scaling, stinging, and burning.  When using the medication, patients should minimize their exposure to sunlight and other skin products that contain resorcinol, salicyclic acid and sulfer.

Source: FDA: Label and Approval History: Epiduo.

Macrene Alexiades-Armenakas, MD, of the Yale University School of Medicine, reported on the findings from a small, preliminary study that investigated whether photodynamic therapy (PDT) combined with topical 5-aminolevulnic acid (ALA) and activated by a long-pulse, pulsed-dye laser could effectively clear mild to severe cases of acne.

Eighteen acne patients were recruited for the study. Fourteen received 1 to 6 treatments of ALA PDT, depending on the severity of their symptoms. Each was also prescribed a topical acne medication. The study’s control group consisted of 4 patients. They were treated either with systemic or topical medications or with non-ALA PDT laser therapy.

The acne cleared up completely among all 14 patients in the ALA PDT treatment arm. By contrast, none of the patients in the control group experienced a complete clearance of their acne.

Dr. Alexiades-Armenakas also found a significant improvement in the appearance of acne scars among the treatment group, a result attributed to the penetrating effects of the pulsed dye laser.

Side effects from the combination laser therapy were mild: a slight redness that lasted for about 2 days. No hyperpigmentation was observed, even among patients of color.

SOURCE: American Academy of Dermatology

In the study by Drs. Katsambas & Dessinioti from the University of Athens Department of Dermatology, treatments alternatives such as low-dose long-term isotretinoin are discussed. Here is an excerpt:

Topical retinoids, benzoyl peroxide, azelaic acid, and topical and oral antibiotics remain the milestone of treatment for mild to moderate acne vulgaris. Oral isotretinoin is useful for the treatment of severe nodular acne, treatment-resistant acne, and acne with a risk of physical or psychological scarring. Hormonal treatment in female acne is useful in resistant or late-onset acne.

With increasing concerns regarding teratogenicity of isotretinoin and increasing antibiotic resistance, there is a clear need for therapeutic alternatives to these long-used treatments. Research in the pathogenesis of acne has allowed for new therapies and future perspectives regarding acne to evolve. They include low-dose long-term isotretinoin regimens, insulin-sensitizing agents, 5alpha-reductase type 1 inhibitors, topical photodynamic therapy, new combination formulations, dietary interventions, and antiinflammatory agents such as lipoxygenase inhibitors.

Hopefully as we come to develop a better understanding of the pathogenesis of acne we can tailor even better treatment methods for this common and trouble skin disorder.

“More than 80% of the patients markedly improved with both treatments, without any adverse effects observed. Both TauBr and clindamycin produced a significant reduction in inflammatory skin lesion counts (papules/ pustules). After 6 weeks, comparable reductions of acne lesions, 65% and 68%, were observed in the TauBr and clindamycin groups, respectively. In conclusion, these data support our concept that TauBr can be used as a topical agent in the treatment of acne vulgaris, especially in patients who have already developed antibiotic resistance.”

Treatment of acne with topical antibiotics is a mainstay in dermatology, but the emergence of resistant bacteria require alternatives. We encourage anyone with experience in taurine bromamine to comment.

The study updates the previous work on PDT for acne. Here is an exerpt of the abstract:

Until recently, clinically approved indications have been restricted to actinic keratoses, nodular and superficial basal cell carcinoma, and - since 2006 - Bowen disease. However, the range of indications has been expanding continuously.

PDT is also used for the treatment of non-malignant conditions such as acne vulgaris and leishmaniasis, as well as for treating premature skin aging due to sun exposure. Here, PDT is used for the stimulation of immunomodulatory effects in contrast to the induction of necrosis and apoptosis as produced in the treatment of skin tumors. The porphyrin precursor 5-aminolevulinic acid (ALA) or its methyl ester (MAL, so far the only approved formulation in Europe) is applied topically as photosensitizer to exclude systemic reactions.

Possible light sources include lasers as well as incoherent light sources; irradiation with incoherent light sources is cheaper and more appropriate for large treatment areas. The main advantages of PDT in comparison to other treatment modalities are its excellent cosmetic results and its high remission rates despite low invasiveness.This article provides up-to-date information about PDT with focus on recently published studies.

It will be interesting to read the full study and see what new conclusions are drawn on the subject.