What Causes Acne? Acne is one of the most common diseases with a point prevalence of up to 100% among adolescents and often persists into adulthood, with detrimental effects on self-esteem. Sixty percent of all acne cases are so-called ‘physiologic acne’, the other 40% are those that need continuous help by a specialist to prevent physical or psychological scarring. Acne is still the most frequent primary diagnosis for visits to dermatologists. Acne is currently understood as a chronic inflammatory disease of the pilosebaceous unit, characterized by androgen-induced increased sebum production, follicular hyperkeratinisation, inflammation and altered adaptive immune response. Bacterial colonization by Propionibacterium acnes definitely aggravates the course of the disease in various manners, but its role as a prerequisite of the induction of acne is disputable.
What are the Types of Acne? Non-inflammatory acne is characterized by both open and closed comedo formation The inflammatory lesions of acne originate with comedo formation but then expand to form papules, pustules, nodules and cysts of varying severity. As the severity of lesions progresses, nodules form and become markedly inflamed, indurated and tender. The cysts of acne are deeper and filled with a combination of pus and serosanguineous fluid. In patients with severe nodulocystic acne, these lesions frequently coalesce to form massively inflamed complex plaques that can include sinus tracts.
Acne Fulminans Acne fulminans is the most severe form of cystic acne and is characterized by the abrupt onset of nodular and suppurative acne in association with variable systemic manifestations. This uncommon variant affects primarily young men 13-16 years of age. While affected individuals often have typical mild to moderate acne prior to the onset of acne fulminans, without warning, micro-comedones erupt. These soon become markedly inflamed and coalesce into painful and oozing friable plaques with hemorrhagic crusts. The face, neck, chest, back and arms are all affected. The often ulcerated lesions can lead to significant scarring. Osteolytic bone lesions may accompany the cutaneous findings. Systemic manifestations include fever, arthralgias, myalgias, hepatosplenomegaly and severe prostration. Treatment depends on clinical severity and includes topical, intralesional or oral corticosteroids, oral isotretinoin, and oral antibiotics. Of note, isotretinoin has been reported paradoxically to induce acne fulminans in some patients. This may be avoided by the coadministration of an oral corticosteroid and low-dose systemic retinoid during the first month of therapy. Dapsone in conjunction with isotretinoin was reportedly beneficial in the treatment of acne fulminans associated with erythema nodosum
Acne Conglobata Severe, eruptive nodulocystic acne without systemic manifestations is termed acne conglobata. These recalcitrant lesions are part of the follicular occlusion tetrad, along with dissecting cellulitis of the scalp, hidradenitis suppurativa, and pilonidal cysts. The association of sterile pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA syndrome) is part of a related group of inflammatory disorders that includes inflammatory bowel disease, uveitis, and psoriasis.
Solid facial edema An unusual and disfiguring complication of acne vulgaris is solid facial edema (Morbihan's disease) Clinically, there is a distortion of the midline face and cheeks due to soft tissue swelling. The woody non-scaling induration may be accompanied by erythema. Similar changes have been reported with rosacea and Melkersson– Rosenthal syndrome. Although fluctuations in severity are common, spontaneous resolution does not occur. Treatment with isotretinoin (0.2-0.5 mg/kg/day), alone or in combination with ketotifen (1–2 mg/day), for 4-5 months has been reported to be useful. Higher doses of isotretinoin may also be tried.
Acne Mechanica Acne mechanica occurs secondary to repeated mechanical and frictional obstruction of the pilosebaceous outlet. Comedo formation is the result. Well-described mechanical factors include rubbing by helmets, chin straps, suspenders and collars. A classic example of acne mechanica is fiddler's neck, where repetitive trauma from violin placement on the lateral neck results in a well-defined lichenified, hyperpigmented plaque interspersed with comedones. Linear and geometrically distributed areas of involvement should suggest acne mechanica. Treatment is aimed at eliminating the inciting forces.
Acne Excoriée Fes Jeunes Filles Acne excoriée des jeunes filles, as the name implies, occurs primarily in young women. Typical comedones and inflammatory papules are systematically and neurotically excoriated, leaving crusted erosions that may scar. Linear erosions suggest self-mutilation, and an underlying psychiatric component should be suspected. Patients with an anxiety disorder, obsessive–compulsive disorder or personality disorder are particularly at risk. Antidepressants or psychotherapy may be indicated in such patients.
Drug-Induced Acne Acne lesions or eruptive acneiform lesions can be seen as a side effect of a number of medications, including anabolic steroids (e.g. danazol, testosterone), corticosteroids, corticotropin, phenytoin, lithium, isoniazid , iodides, and bromides. Less often, azathioprine, cyclosporine, tetracyclines, vitamins B1, B6, B12 and D2, phenobarbital, PUVA, propylthiouracil, disulfiram or quinidine are the cause. An abrupt, monomorphous eruption of inflammatory papules and pustules is often observed in drug-induced acne, in direct contrast to the heterogeneous morphology of lesions seen in acne vulgaris. This explains why some clinicians use the term ‘folliculitis’. Intravenous dexamethasone and high-dose oral corticosteroids commonly induce characteristic acneiform eruptions with a concentration of lesions on the chest and back. Steroid-induced acne (and rosacea) can also result from the inappropriate use of topical corticosteroids on the face. Inflamed papules and pustules develop on a background of erythema that favors the distribution of corticosteroid application. Lesions resolve with discontinuation of the corticosteroid, although steroid dependency can lead to prolonged and severe flares post withdrawal. When a history of prescription medication use is not elicited, a comprehensive review of all over-the-counter medications and supplements, as well as recent medical procedures, may reveal the responsible agent. Iodides are found in many cold and asthma preparations, contrast dyes, kelp and combined vitamin–mineral supplements. Sedatives, analgesics and cold remedies often contain bromides.
Occupational Acne Exposure to insoluble, follicle-occluding substances in the workplace is responsible for occupational acne. Offending agents include cutting oils, petroleum-based products, chlorinated aromatic hydrocarbons, and coal tar derivatives. Comedones dominate the clinical picture, with varying numbers of papules, pustules and cystic lesions.
Chloracne Chloracne, the term used to define occupational acne caused by exposure to chlorinated aromatic hydrocarbons, develops after several weeks of exposure. The malar, retroauricular and mandibular regions of the head and neck, as well as the axillae and scrotum, are most commonly afflicted with small cystic papules and nodules. The extremities, buttocks and trunk are variably involved. Cystic lesions can heal with significant scarring, and recurrent outbreaks can occur for many years following exposure. The following agents, found in electrical conductors and insulators, insecticides, fungicides, herbicides and wood preservatives, have all been implicated. Prevention of exposure is integral to the safety of at-risk employees. Treatment is aimed at vigorous removal of chemical agents at the time of exposure. Topical or oral retinoids and oral antibiotics may be necessary therapeutic interventions.
Neonatal Acne Neonatal acne occurs in more than 20% of healthy newborns. Lesions appear at about 2 weeks of age and generally resolve within the first 3 months of life. Typically, small, inflamed papules arise on the cheeks and across the nasal bridge. However, topical 2% ketoconazole and benzoyl peroxide have been shown to be effective therapies.
Infantile Acne If acne presents at 3-6 months of age, it is classified as infantile. Clinically, comedo formation is much more prominent than in the neonatal form and may lead to pitted scarring. Deep cystic lesions and suppurative nodules are occasionally seen. During the first 6-12 months of life, infant boys have elevated levels of luteinizing hormone (LH) and its stimulatory product testosterone, with levels transiently equivalent to those measured during puberty. In addition, the infantile adrenal gland is immature in both boys and girls, leading to elevated levels of DHEA. At approximately 12 months, these levels normally
decrease and remain at nadir levels until puberty, around 9 or 10 years of age. Testicular androgen is also minimal throughout most of childhood.
Premenstrual Flare About 70% of women complain of a flare 2–7 days premenstrual. It is unlikely that any possible variation in sebum excretion during the menstrual cycle could be substantial enough to explain the flare. Possibly, flaring is related to a premenstrual change in the hydration of the pilosebaceous epithelium. Progesterone and estrogen also have both proand anti-inflammatory effects.
Sweating and Acne
Up to 15% of acne patients notice that sweating causes a deterioration in their acne, especially if they live or work in a hot humid environment; for example, for a cook, ductal hydration may be the responsible factor.
Ultraviolet Radiation and Acne Patients and doctors alike accept that natural sunlight often improves acne, but there is no scientific c evidence for this belief. The cosmetic effect of tanning may be the entire explanation.
Diet and Acne Dermatologists can no longer dismiss the association between diet and acne. Compelling evidence exists that high glycemic load diets may exacerbate acne. Dairy ingestion appears to be weakly associated with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fiber remain to be elucidated
Recent Therapeutic Developments for Acne Topical Retinoids & Retinoid-Based Fixed Combination Therapies Topical retinoids act against comedones and microcomedones. Also they have direct immunomodulatory and anti-inflammatory effects without inducing bacterial resistance, which renders them uniquely suitable as adjunctive treatment in all combination therapies of acne, as well as a useful tool to prevent relapses during maintenance therapy of this chronic disease The drawback of low cutaneous tolerability of topical tretinoin is continuously improved by new delivery systems to facilitate controlled release, including;Retin-A Micro® gel 0.1% or 0.04%, Avita 0.025% gel or cream or micronized tretinoin Atralin® Gel 0.05%, . Another advantage of microsphere and micronized formulation is marked protection against tretinoin photodegradation and oxidation by BPO. Adapalene, a synthetic third-generation topical retinoid, is available as 0.1% gel, cream, solution and recently as lotion and as 0.3% gel (Differin®). Topical tazarotene is approved for acne treatment only in the USA (Tazorac®). A fixed combination is optimal to enhance patient adherence due to easy and reduced application modus and also avoids substance incompatibilities due to application errors (e.g., oxidation by using incompatible single agents). Recently introduced retinoid-based fixed combinations with high-quality clinical efficacy evidence include fixed combinations of tretinoin 0.025% and clindamycin phosphate 1.2% (Ziana®) and Veltin® Gel, and adapalene 0.1% and BPO 2.5% (Epiduo™, Tactuo™), representing the only fixed-dose combination product available that combines a topical retinoid with BPO.
Topical Antimicrobials & Their Fixed Combinations Topical antimicrobials are an essential part of the therapeutic armamentarium for mild-tomoderate acne vulgaris and represent an alternative for patients who cannot take systemic antibiotics. Clindamycin, erythromycin, tetracycline or nadifloxacin are bacteriostatic for P. acnes, and have also been demonstrated to have anti-inflammatory activities. Their use as monotherapy is no longer recommended, and they should be applied preferentially in combination with BPO – an approach that also reduces the emergence of P. acnes strains that are resistant or less sensitive to antibiotics. The combination of a topical retinoid plus an antimicrobial is a rational choice because of the complementary modes of action that
increase speed of response and enhance efficacy against comedones and inflammatory lesions. At the moment, three fixed combination products of clindamycin and BPO are on the market: two containing clindamycin 1% and BPO 5% (Duac®) and Benzaclin®) and an optimized formulation of clindamycin phosphate 1.2%/BPO 2.5% aqueous gel (Acanya®).
Other Topical Treatments Azelaic acid 20% in a cream formulation has been established as an efficacious and safe topical drug for almost two decades. Azelaic acid 15% gel is approved for the treatment of rosacea in the USA, but also has approval for the treatment of acne vulgaris in Europe and recently proved efficacious in the treatment of postinflammatory hyperpigmentation in acne patients after 16 weeks of treatment, which is related to its antityrosinase activity. Azelaic acid is currently recommended as second-line option for the treatment of mild-to-moderate papulopustular acne and comedonal acne, or also in combination with systemic antibiotics for severe acne forms as alternative treatment for isotretinoin. A new aqueous gel formulation of dapsone 5% (Aczone), was more effective than tazarotene monotherapy for treatment of comedonal acne, suggesting that anti-inflammatory agents such as dapsone might effectively treat early stages of acne (both comedonal and noncomedonal) when used in combination with a retinoid.
Oral Antibiotics Systemic antibiotics are recommended in the management of moderate-to-severe inflammatory acne, after failure of topical treatment and in acne covering large parts of the body surface. Substances reported to be effective in acne therapy are tetracycline, doxycycline, minocycline, lymecycline, trimethoprim-sulfomethoxazole, clindamycin, roxithromycin and azithromycin, but particularly minocycline and docycycline, with their potent anti-inflammatory effects on neutrophil chemotaxis or inhibitory effects on cytokines and matrix metalloproteinases. For this reason they are routinely used as the first-line oral antibiotic therapy in acne. Current treatment guidelines recommend the combination of oral antibiotics with retinoids, azelaic acid, BPO or a combination of retinoid/BPO for moderateto-severe forms of acne. Use of sub-antimicrobial doses of antibiotics may offer promise. Instead, the primary mechanisms of action of subantimicrobial-dose antibiotics are antiinflammatory mechanisms. To limit the emergence of resistant strains, the use of antibiotics should be restricted, and with regard to indication and duration, topical and systemic antibiotic therapy should always be combined with broad-spectrum antibacterial agents (e.g., BPO), and the combination of topical antibiotic and systemic antibiotic therapy as well as antibiotic monotherapy should be avoided.
Hormonal Therapy Androgens, estrogens, growth hormone and insulin-like growth factor, play an important role in the development of acne. Various systemic hormone preparations are available for acne in female patients. These may be indicated when: standard antibiotic regimens have failed, menstrual control and/or contraception are required alongside acne therapy and oral isotretinoin is inappropriate or not available. Topical therapy can and should be prescribed in conjunction with hormonal regimens. Potential hormonal treatments for acne include inhibitors of androgen production by the ovary (oral contraceptives) or adrenal gland (lowdose corticosteroids), androgen receptor blockers, and\antiandrogens that block the effect of androgens on the sebaceous gland.
Hormonal therapy represents an alternative or additional treatment regimen, especially in late-type female acne, polycystic ovary syndrome, other signs of hyperandrogenism, such as seborrhoea, androgenetic alopecia or hirsutism in combination with acne (SAHA syndrome) and in case of parallel wishes of contraception or as a requirement for a systemic isotretinoin treatment. It can be combined with topical therapy or systemic antibiotics in moderate-to-severe acne forms, but is not a primary monotherapy for uncomplicated acne. The combinations of ethinyl estradiol with cyproterone acetate, chlormadinone acetate, dienogest desogestrel and drospirenone have shown the strongest anti-acne activity. Gestagens or estrogens as monotherapy, spironolactone, flutamide, gonadotropin-releasing hormone agonists and inhibitors of peripheral androgen metabolism are not recommended according to the current stand of knowledge. Oral contraceptives generally contain oestrogen (most commonly ethinyl oestradiol) and a progestin. Oestrogens act on the liver to increase synthesis of sex hormone binding globulin (SHBG), which binds testosterone and reduces the level of free circulating testosterone, hence all oral contraceptives will potentially improve acne. In addition, oral contraceptives suppress ovulation by inhibiting the production of ovarian androgens which results in reduced serum androgens and lower sebum production. The dosage of oestrogen in oral contraceptives has been reduced over the years and many third-generation combined contraceptives contain 20 ug of ethinyl oestradiol. Progestins in combined oral contraceptives include estranes and gonanes, which are derivatives of 19-nortestosterone, cyproterone acetate and drosperinone. The thirdgeneration progestins (gestodene, desogestrel, norgestimate) are less selective for the androgen and more selective for the progesterone receptor. Drosperinone is a novel -spironolactone and as with the parent compound has antimineralocorticoid and antiandrogenic activity, making it potentially helpful in acne. Yasmin® contains drospirenone 3 mg combined with ethinyl oestradiol 30 ug and Yaz® contains the same dose of drospirenone with 20 ug of ethinyl oestradiol. Low-dose prednisolone is to only be administered at late-onset congenital adrenal hyperplasia and dopamine agonists at hyperprolactinemia. Low-dose glucocorticosteroids (i.e.2.5 mg prednisolone on waking and 5 mg on retiring) to suppress adrenal androgens, with or without a contraceptive pill, will reduce sebum production by up to 50% with a concomitant improvement in acne.
Androgen receptor blockers The anti-androgen CPA directly inhibits the androgen receptor and serves as a progestogen in oral contraceptives. Cocyprindiol (Dianette® and Estelle 35®) is an oral contraceptive that ameliorates acne. It is as effective as oral tetracycline 1 g/day given over a 6-month period. The clinical efficacy of this combination can be enhanced by giving an extra 50 mg or 100 mg CPA from the fifth to 14th day of the cycle. At this dosage, the reduction in sebum production is 50–67%. although it is slower in action . It is also of potential benefit in women with acne resistant to other therapies. Spironolactone is an effective treatment (it is not a contraceptive) and reduces sebum excretion by 30–75% depending on the dosage used. Its effects are dose dependent, and it is usually prescribed at a dose of 50–100 mg daily with meals, but many women with sporadic outbreaks do well with doses as low as 25 mg daily. The main side effects are menstrual irregularity, breast tenderness, occasional fluid retention and, rarely, melasma. Pregnancy should be avoided due to potential abnormalities to the male fetus and serum electrolytes should be monitored in older females who might have other medical problems due to potential risk of hyperkalaemia.
Flutamide is a potent antagonist of the androgen steroid. Although most commonly used in the treatments of prostatic conditions flutamide has been shown to be effi cacious in a number of androgen-mediated problems, including acne, administered at a dose of 250 mg daily. Fatal hepatotoxicity has been reported and therefore use in acne is not generally advocated. There is concern about the potential reduction in efficacy of oral contraceptives as a result of systemic antibiotics used in conjunction with COCs. The risk is theoretical, based on the hypothesis that broad-spectrum antibiotics reduce bacterial flora in the gut and thus interfere with oestrogen absorption.
Oral Isotretinoin Oral isotretinoin exhibits activity against all major etiologic factors involved in the pathogenesis of acne. It significantly reduces size and sebum production of sebaceous glands, normalizes follicular keratinization and prevents the development of microcomedones and comedones, indirectly inhibits P. acnes growth by changing the follicular milieu and upregulation of antimicrobial factors and exerts direct immunologic and anti-inflammatory activity. Isotretinoin is considered the first-choice treatment for severe papulopustular, moderate nodular and severe nodular/conglobate acne, especially when other complicating prognostic factors are present. The rationale behind this recommendation is that quick reduction of inflammation in acne may prevent the occurrence of clinical and psychological scarring. The recommended dose to start isotretinoin therapy is now 0.3–0.5 mg/kg for severe papulopustular acne/moderate nodular acne and 0.5 mg/kg for conglobate acne. The duration of the therapy should be at least 6 months and can be prolonged in case, of insufficient response. Side effects of isotretinoin include those of the mucocutaneous, musculoskeletal and ophthalmic systems, as well as headaches. According to currently available evidence, the prescription of oral isotretinoin be encouraged in severe acne patients who will normally experience both physical and psychological improvement of their disease. The most severe safety issue concerning oral isotretinoin is teratogenicity. Therefore, women of childbearing potential must be treated whilst adhering to the pregnancy-prevention program (PPP) or iPLEDGE, which requires mandatory registration of all patients receiving the drug. With regard to these legal issues, the use of propagated ‘off-label’ low-dose isotretinoin or intermittent regimens, are undoubtedly clinically effective and well tolerated in the control of moderate acne. An open question of these regimens yet to be resolved is the optimal cumulative threshold dose to prevent relapses.
What Does MSI Offer Acne Patients? Even before the advent of light, laser, and radiofrequency treatment modalities, physical therapies have been employed to complement medical therapy. Light cautery and aspiration followed by in situ injection of cortisone, respectively, are useful adjunctive therapies. Other adjunctive therapies, steam, facial masks, ultrasonophoresis, dermal rollers, comedone extraction, and chemical peels.
1. Steam
This process helps to free any dead cells, dirt, bacteria or other trapped matter that could be causing acne breakouts, by opening the pores, and it can allow your skin to better absorb any other products you might use after the steaming.
2. Facial Maska There are different kinds of masks for different purposes (cleansing, or exfoliating, brightening). Some masks are designed to dry or solidify on the face, almost like plaster; others just remain wet. Anti-acne masks suits oily or acne prone skin.
3. Ultra-sonophoresis Ultra-sonophoresis is a technology uses low frequency sound wave resonance of approximately 20,000 per second to the skin to increase skin permeability, thousands times. It helps to deep cleansing of the skin, open pores, and reduce the appearance of pigmentation. During your treatment, a soft high-pitched sound may be audible. The physical sensation felt is one of warmth. Some skins may experience a mild pinkness that resolves quickly. 4. Intralesional Injections Corticosteroids are injected intralesionally to provide a high concentration of steroid within the lesion with minimal systemic absorption. This modality is indicated when a quick response is required. Corticosteroid injections flatten most acne nodules in 48 to 72 hours.Marked improvement in nodular and cystic acne after intralesional steroid injections has been reported. Preparations usually come as triamcinalone acetonide in 10 mg/mL multiple-use vials that may be diluted with sterile normal saline to 5 or 3.3 mg/mL, two commonly used dilutions 5. Diamond Peel, Crystal Peel or Microdermabrasion At MSI we are happy to have the 3rd generation micro-dermabrasion device ”Diamond Tom”. Diamond Peel is similar to particle microdermabrasion in its result but without the adverse effects of loose particles, irritation and skin reaction. Unlike other exfoliation treatments, the Diamond Tom skin resurfacing system uses no loose abrasive to contaminate you or the environment. It removes this layer of skin by gently exfoliating the skin with natural diamond chips, while at the same time vacuuming the dead skin cells away in a sterile and controlled manner, leaving your skin smoother and healthier Microdermabrasion is an excellent procedure for exfoliating the skin, refreshing weathered skin. Similar to a light peel, it can improve superficial acne scars, some effects of sun-damage, fine lines and wrinkles, superficial pigmentation, enlarged pores, and blackheads and whiteheads. It also acts to stimulate formation of new collagen and elastin to improve skin texture and elasticity. The procedure is performed on the face, but may also be applied to other areas on the body. Micro-dermabrasion should improve the permeation of topical treatment. A normal course of treatments varies between 6-10 at approximately 2-3 week intervals. It is recommended that you schedule an additional treatment every 1-3 months to maintain your skins condition. Microdermabrasion may also enhance absorption of topically applied medications, as pretreatment for PDT or to increase the penetration of light into the epidermis.Prof Moawad may recommend micro-dermabrasion as a stand alone treatment or more commonly as an adjunct treatment with other nonablative resurfacing procedures.
6. Dermal Roller or Micro-needling Dermal roller is an option for those suffering from open pores, acne scars, fine wrinkles, stretch marks and even hairloss. Microneedling works by applying a device
that has multiple fine needles to the surface of the skin. This action induces fine shallow punctures on the skin and these micro wounds will promote the healing process. When the needle breaks the normal skin barrier, blood vessels will be injured thus releasing a multitude of repair cell in the blood. This repairing process will also stimulate collagen and elastin remodelling within the treated skin thus giving the thightening after effect. The procedure is done by applying a numbing cream to the skin first, so that you will be comfortable throughout the procedure. The after affects of the procedure is redness of the skin with mild swelling that will resolve in several hours. Microneedling is a great treatment to be combine with mesotherapy, electroporation or PRP for an enhanced effect. You can keep your own derma roller to further enhance the effect of prescribed home anti-acne skin care products for active acne lesions and continual scar enhancement at the same time.
7. No Needle Mesotherapy, Mesoderm or Electroporation
The skin acts as a natural barrier against the entry of foreign substances into the organism. In order for a substance applied to the skin to be absorbed transepidermally, it must pass the corneous stratum. No needle mesotherapy,Electroporation or mesoderm addresses this problem by using electrical currents that helps to increase absorption of any solution into the deeper layers of the skin (transdermal to be more specific). Compared to iontophoresis, it is 500 times more effective in delivering treatment trans-dermally. MSI Anti-acne topical therapy are not injected into the skin but painlessly passes through deep layers of the skin with the help of an electric current that creates temporary holes in your skin. These holes allow the passage of active ingredients that help to treat pimples, dark spots or rejuvenate your skin. In a novel approach Prof Moawad uses mesoderm to deliver your PRP deep into the skin where it is needed. Temporary holes closed immediately after treatment. It is done as a part of a complete MSI Skin Resurfacing Peel. Read more on MSI Skin Resurfacing Peel.
8. Platelet Rich Plasma (PRP)
Vampire Facelift is a name for a non-surgical cosmetic procedure involving the injection of a platelet rich plasma (PRP) derived from a patient’s own blood back into multiple areas of the skin of their face in an effort to treat wrinkles and “rejuvenate” the face and in a novel approach to treat inflammatory acne. By injecting PRP into the skin, we are injecting growth factors into the skin, that leads to a cascade of activity leading to cellular and tissue repair, anti-inflammatory and skin rejuvenation. The PRP is injected into the face with the help of mesogun. Alternatively, PRP is brushed on the face after the usage of dermal roller or recently with mesoderm virtually painless. A new advancement of better penetration of PRP is the use of fractional CO2 laser. Fractional CO2 Laser produce multiple thermal zones (MTZs) or holes in the skin for penetration and absorption of PRP. Fractional CO2 Laser has the added benefit in skin tightening and long term new collagen synthesis and hastening the healing process after a laser fractional improving inflammatory lesions, red spots, dark spots, and acne scars. The results are magnificent say Prof Moawad.
9. Chemical Peels At the time of treatment, the skin is thoroughly cleansed with an agent that removes excess oils, and the eyes and hair are protected. A chemical solution is applied to the
skin that causes it to "blister" and eventually peel off. Prof. Moawad may recommend a superficial or, medium chemical peel. He favor the medium-depth peel, the combination peel, and repeated lighter peeling regimens. He will select the proper mix of chemicals such glycolic acid, salicylic acid, lactic acid, TCA, PCA, Phytic acid, or Jessner solution. An excellent keratolytic agent, salicylic acid is useful against comedones due to its strong lipophilicity and ability to penetrate the pore. Salicylic acid has anti-inflammatory effects and is effective against both inflammatory and anti-inflammatory lesions. Although they do not replace topical or systemic medications, superficial glycolic and salicylic acid–based chemical peels are very effective adjunctive methods to enhance and speed resolution of acne, both inflammatory and comedonal. They also may be used safely in skin of color as well as to help resolve postinflammatory hyperpigmentation. Chemical peels require maintenance treatments to sustain their effect. On the basis of the limited literature, these appear to be more useful or better appreciated by patients than microdermabrasion for active acne. Most patients experience a warm to somewhat hot sensation that lasts about five to 10 minutes, followed by a stinging sensation. A deeper peel may require pain medication during or after the procedure. Depending upon the type of peel, a reaction similar to a sunburn occurs following a chemical peel. Superficial peeling usually involves redness, followed by scaling that ends within three to seven days. Medium-depth and deep peeling may result in swelling and the presence of water blisters that may break, crust, turn brown and peel off over a period of seven to 14 days. Following any skin peel, it is important that you avoid any exposure to the sun. Your new skin is very sensitive and susceptible to injury. Prof. Moawad will prescribe a proper home skin care treatment program that included cleansers, moisturizers, and sunscreens with or without anti-acne or bleaching agents to ensure proper healing and maintain the result of your peel. Following a chemical peel, your new skin will be tighter, smoother and may be slightly lighter than it was before surgery. Results of chemical peels may also be enhanced our by new laser/light-based rejuvenation techniques. 10. Comedon Exctraction Blackheads are not caused by dirt, sweat and poor hygiene (this is a myth that people spread) but are caused by the formation of a plug in pores due to abnormal skin cell growth which gets oxidized by sunlight and turns black. Comedo extraction is a widely used method of treatment for acne vulgaris. A dermatologist or cosmetologist may extract blackheads (open comedones) using gentle pressure around the pore opening, and whiteheads (closed comedones) by incision with a large needle or a blade. If performed skillfully, this treatment may be beneficial to the patient. It usually done after superficial salicylic acid peel which make extraction easier. 11. Oxygen Treatments Propionibacterium acnes lives in the skin and is the strain of bacteria that causes acne. For any acne treatment to be effective, it must kill these microbes, which thrive in the oxygen-deprived environment of a clogged pore. Oxygen has been used in the medical setting for years to speed healing. By introducing it deep into the follicle, it can destroy the acne bacteria. It can be used post peel or laser treatment to speed the healing process.
12. Optical
Treatment of Acne Light, Laser, PDT, and Radiofrequency Most acne patients notice an improvement in their acne over the summer, although unfortunately it does not last long. Ultraviolet light (phototherapy) has been used in the management of acne, however, the well-established long-term side effects of skin cancer risks of ultraviolet light/sun beds, have limited their use. More recently, light, heat, and radiofrequency energy devices as well as photodynamic therapy (PDT) have emerged as useful co-therapies or, in some cases, replacements for systemic medications. Ther are two main mechanisms that laser/light treatments may help acne; by destroying Propionibacterium acnes through a photodynamic therapy (PDT) reaction or by destroying the sebaceous glands / entire pilosebaceous unit or both. In general, light-based treatments target P. acnes levels and/or disruption of sebaceous gland function, and may also have anti-inflammatory effects via action on inflammatory cytokines. Similar to theeffect of antibacterial agents, reduction in P acnes levels by light therapy may play a role in improving acne lesions. Many light sources may affect P acnes, including narrowband light sources, IPL devices (broadband light), KTP lasers (532 nm), PDLs (585- 595 nm), and various orange/red light lasers or light sources (610-635 nm); these light sources have wavelengths that correspond to an absorption peak of P acnes porphyrins. Longer wavelengths penetrate more deeply into the skin, but are less effective at activating porphyrins.
i. Laser Treatment for Acne Several laser systems have been used to treat inflammatory acne vulgaris by destroying the sebaceous glands including near-infrared lasers, 1320nm CoolTouch®, 1450nm SmoothBeam®, 1540nm erbium glass Aramis®, and diode lasers. KTP 532nm and pulsed dye lasers appear to kill P. acnes, and hemoglobin absorbs laser energy, which reduces vascularity and modulates the inflammatory process associated with acne. Suppurative skin lesions, including inflammatory acne vulgaris, experienced clinical improvement in the number and severity of lesions after ablative 10,600- nm carbon dioxide fractional laser treatment. Ablative fractional CO2 laser is beneficial in our patients due to physical breakage of follicular plugging and thermal stimulation of follicular epithelium of pilosebaceous unit. ii. Blue Light, Red Light or Combination (Blue and Red) in
Photodynamic Therapy (PDT) It is known that the bacteria present in some acne lesions, P. acnes, produce chemicals called porphyrins during their growth and proliferation in the skin pore (follicular unit). These porphyrins may contribute to how non-inflamed acne lesions become inflamed. It is thought that the two main porphyrins involved are protoporphyrin IX (PpIX) and coproporphyrin III. Both of these chemicals absorb light at 415nm, which corresponds to the blue range of the visible light spectrum, and to 630nm, which corresponds to red light. Photo-excitation of these
porphyrins, from exposure to an appropriate light source, will form singlet oxygen (free radicals) within the bacteria, which then selectively destroy them, thereby improving the clinical signs of the acne. Recently, non thermal, non laser phototherapy (light emitted diode or LED) with visible light has attracted attention as a new treatment option. Using this property, blue visible light phototherapy has been shown to be an effective treatment for acne. Red visible light phototherapy improved non inflammatory and inflammatory acne lesions.. Phototherapy with mixed blue-red light showed better treatment response than blue light alone. Visible light as monotherapy is not recommended for the treatment of comedonal, severe papulopustular and conglobate acne. The effect of phototherapy is potentiated in photodynamic therapy. Photodynamic therapy(PDT) is a 2-step procedure. In the first step, the plant photosensitizer (mild reaction) or ALA (moderate to severe reaction) is applied to the skin and it is allowed to be taken ups. The second step involves the activation of the photosensitizer in the presence of oxygen with a specific wavelength of light (infrared light, IPL, Laser). Once delivered, the targeted tissue absorbs the light’s energy. Photodynamic therapy used to treat inflammatory acne and rosacea. PDT is effective for moderate to severe acne with long-term results. The versatility of PDT and the emergence of short acting photosensitizing agents that can be applied to skin before activation by light or laser devices has ‘‘revolutionized’’ the treatment of acne vulgaris and other cosmetic dermatologic conditions. The use of short (0.25–1-hr) incubation times and multiple treatment sessions provides optimal clinical efficacy and patient compliance, even in cases of recalcitrant acne.
iii. Radiofrequency (RF) Nonablative radiofrequency (NARF) devices have also been used effectively for the treatment of moderate to severe inflammatory acne vulgaris. It has been suggested that the mechanism of action of nonablative RF is mainly a reduction of sebaceous gland activity and the promotion of dermal architecture remodeling by bulk heating of the dermis. Excessive oiliness of the skin as seen in many of these patients is decreased. This reverts to normal after a few months. Furthermore, sebaceous glands appear to be decreased in volume after a few weeks after treatment with this device. Fractionated RF was used for inflammatory acne vulgaris and its related dermatologic conditions, including acne scars and enlarged facial pores. As in NARF the therapeutic effects of Fractional RF device may have been the result of volumetric tissue. In addition, making closer holes induces regeneration and realignment of irregular and thick collagen bundles through physical breakage, resulting in better clinical scar and skin texture.
iv. Electrical and Optical Synergy (ELOS) By combining light and RF current, less RF energy of both modalities is needed to provide the desired effect. Together, pulsed light and heat energy is thought to destroy P. acnes and shrink sebaceous glands, which decreases oil production. RF devices such as the Polaris™ and
ReFirme™ from Syneron™ utilize bipolar RF at the ends of laser systems (780–910nm diode for the Polaris and 700–2000nm infrared light for the ReFirme™. Aluma™ from Lumenis utilizes its bipolar RF energy with an accompanying vacuum apparatus, which takes the tissue into the vacuum and delivers it energy to the deep dermis. Photopneumatic therapy uses vacuum suction to remove the oil and dead skin cells from within the sebaceous glands. The targeted area is then treated with blue and red light therapy to destroy P. acnes and reduce inflammation.
Conclusion The conception of acne has been refined towards a ‘chronic disease’ and rather represents a condition that continuously changes in its clinical appearance than an acute, self-limited disease of teenagers. This means the strategy of acne treatment is not only an acute intervention, but also maintenance. It is important for dermatologists to take the lead in educating other clinicians that acne is often a chronic disease and not just a self-limiting disorder of teenagers. Why is this important? Because many of our medical colleagues and a significant proportion of the lay public dismiss acne as a natural part of growing up that has few real consequences. Yet considerable evidence shows that acne can be a psychologically damaging condition that lasts years. Acne medications are very efficacious, but only when patients use them correctly. Finally, patients should be taught the proper use of medications (topical agents should be spread over the entire involved area and oral medications should be taken as directed. Oral isotretinoin is the most effective acne treatment developed to date. Earlier procedural therapies were adjunctive to medical therapy, such as intralesional steroids, chemical peels, and microdermabrasion. Newer methods include radiofrequency, light or laser, and photodynamic therapy that represent treatment alternatives for systemic medications. Maintenance therapy to minimize the likelihood of relapse after initial successful treatment of acne is important, given the chronic nature of the disease. Use of a topical retinoid as monotherapy to maintain acne remission is a relatively new concept for many clinicians.
