Hardware treatments for acne

So much has already been said and written regarding acne treatment methods that this topic is quite boring. But there is a strange pattern: almost all patients who come to see us have already been treated, more than once, and by more than one dermatologist. And their prescription lists not only do not comply with international protocols - patients are often “treated” for some mythical parasitic diseases.

We know that the most effective treatment is etiotropic, but acne is not pyoderma or a fungal disease, where the result depends solely on the correctly selected antibacterial or antifungal agent. The triggering factor for acne is almost always a hormonal imbalance, but, unfortunately, it is not always possible to correct it. Therefore, treatment in this case should be at least pathogenetic.

Pathogenesis of acne development

To understand what is basic in the treatment of acne, we suggest recalling the pathogenesis of the development of this disease.

1. Hyperfunction and hypersecretion of the sebaceous glands

Sebaceous glands are located on the entire surface of the skin, except the palms and soles. But their maximum density (400–900 per 1 cm2) is observed on the skin of the face. There are age-related features of the structure of the sebaceous glands. For example, during puberty they grow and function intensively, and by the age of 40 their number decreases due to atrophy of small glands.

Sebum secretion is stimulated by free testosterone of testicular or ovarian origin, and dehydroepiandrosterone of adrenal origin. Progesterone also enhances the function of the sebaceous glands due to androgenic and antiestrogenic activity. This explains the increase in skin greasiness and the appearance of acne before menstruation.

The composition of sebum includes free and bound fatty acids, triglycerides, metabolites of steroid hormones, squalene, cholesterol, etc. The secretion of the sebaceous glands is a substrate for the reproduction of P. acnes , which are anaerobic in nature. Free fatty acids are irritating and cause inflammation. Moreover, with increased sebum secretion, the concentration of linolenic acid decreases, which leads to an increase in skin pH, changes in epithelial permeability and microbial growth.

2. Follicular hyperkeratosis

The lumen of the follicular canal, where the excretory duct of the sebaceous gland opens, is covered with a thin layer of corneocytes, which normally peel off easily. With acne, the composition of intercellular lipids changes, and disintegration of keratinocyte desmosomes in the stratum corneum is observed, resulting in the development of retention hyperkeratosis. Relatively speaking, the excretory duct of the sebaceous gland becomes clogged with horny masses, and a comedon is formed. Sebum is not secreted, and the absence of oxygen becomes the optimal environment for the reproduction of P. acnes .

3. The role of microorganisms

The microbiology of the follicular canal includes the following groups of microorganisms: gram-positive cocci (staphylococcus and micrococcus), anaerobic diphtheroids ( Proprionibacterium acnes and Proprionibacterium granulosum ), lipophilic yeast-like fungi (genus Pityrosporum ). And this flora is qualitatively identical to that of a normal sebaceous follicle. Staphylococci and micrococci are aerobes, and therefore cannot develop in anaerobic conditions in the infrainfundibulum , where the inflammatory reaction in acne occurs. Therefore, their role in the development of acne is insignificant.

The same applies to fungal flora: micellized forms, which are usually associated with pathological processes, are not found in acne patients.

The only microorganism that is involved in the development of acne is P. acnes . But its reproduction directly depends on anaerobic conditions, and therefore on hyperkeratosis and increased secretion of sebum. Therefore, antibacterial treatment for acne gives only short-term results. Its use is justified only in combination, as well as during exacerbations with a predominance of pustular elements, but again in combination with other pathogenetic methods of treatment.

4. Inflammation and immune response

In response to the vital activity of P. acnes, the complement system is activated, cytokines are produced and the chemotactic activity of immune cells is activated. But there are a number of studies that prove the possibility of synthesizing inflammatory factors by both sebocytes themselves and keratinocytes without the presence of microorganisms.

As a result, we observe an inflammatory process, which is sometimes not entirely adequate and leads to the development of abscesses and cystic elements with further formation of scars.

What's left behind the scenes?

We will not dwell on the classification of acne: we all know it, just as we know that the choice of therapy should always be based on the predominance of certain elements of the skin rash on the patient’s skin. However, based on the above, the main points of application in the pathogenetic treatment of acne should primarily be the secretion of sebum and hyperkeratosis.

In this article we are also not talking about hormonal therapy for acne. Although in most adult women (but teenagers are no exception), the most popular cause of acne is hyperandrogenism of various origins. And in these cases there is no way to do without correction of hormonal levels. Therefore, dermatologists should always address the problem of acne in cooperation with a gynecologist.

Laser treatment in the system of acne therapy methods

Treatment methods for acne can be divided into the following types:

• systemic therapy : systemic retinoids, hormonal therapy (COCs, antiandrogens), antiandrogens of non-hormonal origin (flutafarm, spironolactone), antibacterial drugs (as part of complex therapy);
• topical agents: topical retinoids, benzoyl peroxide preparations, azelaic acid, topical antibiotics (usually included in preparations containing benzoyl peroxide or retinoids), etc.;
• physiotherapeutic treatment (artificial ultraviolet, IPL, non-ablative lasers 1,450, 1,390 nm, photodynamic therapy);
• cosmetic procedures: therapeutic skin cleansing, peelings containing salicylic acid, retinol, etc.

In reality, it is rarely possible to achieve good results using only one treatment method. We usually combine topical therapy with physiotherapy or cosmetic procedures, or systemic hormone replacement therapy with topical therapy. The exception is the use of systemic retinoids, where, as a rule, no additional interventions are required.

A large and very promising section is laser treatment . Let me make a reservation right away that we will call laser treatment all the light techniques used, which are not always laser (for example, broadband light), but for ease of understanding, primarily by patients, we propose to combine these methods with one term. The acne treatment method described below is our own development and allows, in one procedure, to influence all parts of the pathogenesis of acne development and achieve maximum results in a fairly short period of time.

Personal experience

In our clinic, we have been using phototherapy for the treatment of acne for a long time, and also use ablative lasers to eliminate the consequences of acne (secondary pigmentation, scars). Therefore, when developing this technique, we combined three methods of influence:

• infrared lifting;
• superficial laser peeling;
• phototherapy with a 420 nm filter.

Infrared lifting

The mechanism of action is the absorption of a wavelength of 1,400 nm by water in the deep layers of the skin. As a result, active heating of the sebaceous glands occurs and a decrease in the secretion of sebum, as well as a reduction in the glands in volume. In addition, due to the effect of heat on extracellular structures, denaturation of collagen occurs, as well as stimulation of fibroblasts. Thanks to this, the patient sees not only a decrease in sebum secretion, but also a decrease in the depth of atrophic scars, narrowing of pores and overall skin lifting. Thus, the first and main pathogenetic mechanism of acne development is subject to active therapy at this stage of the procedure.

We carried out infrared lifting in in - motion mode (in motion) with parameters of 150 J, 15 ms, 30 ° C, while using a special smoothing adapter to avoid skin trauma. This technique allows you to maintain the temperature at the treatment site for a long time and is absolutely comfortable for the patient. Temperature was monitored with an infrared thermometer. The target skin surface temperature is 40–42 °C.

Laser peeling

This is the second stage of the procedure. The wavelength of 2,940 nm is very actively absorbed by water, which allows skin resurfacing with virtually no coagulation of surrounding tissues, and the evaporation is very “clean”. This minimizes the recovery period and possible side effects of ablative procedures.

A scanner with adjustment of the depth of exposure and the size of the treated skin area allows the procedure to be carried out precisely and with uniform coverage. We used a grinding depth of 10 microns, which corresponds to the stratum corneum of the epidermis. The skin lesion is small, the procedure is carried out without any anesthesia, the rehabilitation period is short. For areas of skin with more active acne, severe hyperkeratosis and congestive spots, we increased the grinding depth to 20 microns. We consider a deeper effect inappropriate, since the next stage of the procedure involves phototherapy with a 420 nm filter, and this spectrum is very close to ultraviolet.

This stage allows you to significantly reduce keratinization, including at the mouths of the follicles, sebum discharge improves, the inflammatory process decreases, and the color is evened out and secondary pigmentation is lightened.

Broadband pulsed light

Immediately after laser peeling, the entire skin surface was treated with a nozzle with a 420 nm filter. This is the spectrum of visible light, but it lies on the border with ultraviolet, therefore it has all the antiseptic properties of the latter. The target for this step of the procedure is P. acnes . In addition to being bactericidal, this light has an anti-inflammatory effect and significantly reduces the number of inflammatory elements on the skin.

Two passes were made with a power of 4–6 J, a pulse duration of 150 ms, and a nozzle temperature of 10 °C.

At this stage, it would be very effective to use a photosensitizing substance, thereby making the procedure also a photodynamic treatment. But the use of photosensitizers significantly increases the cost of the procedure, as well as the rehabilitation period.

The entire complex laser treatment procedure takes about an hour, does not even require topical anesthesia and is very well tolerated by patients. The rehabilitation period averages five days and consists of slight erythema and peeling, which begins on the second day. During the rehabilitation period, patients took antiherpetic drugs in a prophylactic dosage (Valtrex, 500 mg per day), and also used a topical antibacterial drug and sunscreens.

The procedure is carried out once a month. In between procedures, patients continue topical acne therapy.

Treatment results

All patients who underwent treatment noted a significant decrease in the number of comedones, pustules and inflammatory elements. Skin greasiness decreases. Secondary pigmentation is lightened and resolution of stagnant spots is accelerated. All patients also noted a reduction in pores and a smoothing of the skin surface; small atrophic lesions became somewhat less noticeable.

This procedure affects all parts of the pathogenesis of acne development. Of course, like all other methods, it works well in combination with the use of topical remedies at home. And most importantly, it is a competent approach to the complex treatment of the disease, which allows us to achieve rapid and pronounced remission in the majority of patients suffering from acne.

Literature:

Daria Sharapova, dermatologist, member of the American Society of Laser Medicine and Surgery, chief physician of the Goravsky Center for Aesthetic Medicine (Ukraine)

Les Nouvelles Esthetiques Ukraine, No. 5 (87), 2014, pp. 58-52