Laser technologies in the treatment of resistant forms of acne and post-acne

Maxim Zapolsky, dermatologist, cosmetologist, MD, doctor of the highest category (Ukraine)

Olesya Mikhailets , dermatologist, cosmetologist

Sergey Korolyuk, surgeon, plastic, aesthetic and reconstructive surgeon of the highest category, certified member of the All-Ukrainian Association of Plastic, Reconstructive and Aesthetic Surgeons (Ukraine)

Of great interest are modern laser technologies that allow dosed influence on a biological object, taking into account the nature of changes in tissues (inflammation, hypo- and hyperpigmentation, pathological proliferation, neoangiogenesis, atrophy, etc.)

All over the world, lasers are widely used in the treatment of many pathological skin conditions, and an urgent task of modern dermatology and dermatocosmetology is to expand the therapeutic capabilities of modern laser technologies in the treatment of chronic dermatoses.

MEDICAL AND SOCIAL ASPECT OF ACNE

Most often, patients with acne and post-acne problems turn to dermatologists and dermatocosmetologists. Acne, or acne, is a chronic inflammatory disease of the sebaceous follicular structures of the skin, localized primarily in areas of high concentration of sebaceous glands: on the face, chest, and upper third of the back.

The duration and severity of acne depend on many factors: the level of tissue dihydrotestosterone, linolenic acid, the activity of the enzyme 5L-reductase and 17β-hydroxygenase, keratinization of the ducts of the sebaceous glands, characteristics of the skin microbiome, concomitant endocrine pathology, immunoinflammatory reactions in the lesion and the body as a whole. .

Currently, acne and post-acne are considered serious psychosocial problems, often complicated by social maladjustment, isolation and irritability, decreased self-esteem and self-realization, the formation of deep depressive states (especially when irreversible complications of post-acne develop) and even cases of suicide. At the same time, methods that help improve the rehabilitation of patients have not been studied enough.

DOT THERAPY IN ACNE TREATMENT

The use of controlled energy therapy in the form of dermal optical thermolysis (DOT) significantly increases the effectiveness of the treatment of atrophic and hypertrophic scars. This method provides a number of important therapeutic effects:

• skin contraction;
• carbonization in the energy impact zone and subsequent activation of dermal fibroblasts;
• stimulation of collagen production;
• sebostatic effect;
• eliminating traffic jams;
• moderate antibacterial effect (due to thermal effects on tissue);
• destruction of dermal microcysts;
• mediated activation of cell proliferation mediators and epidermal growth factors - EGF (bFGF, PDGF-AA, KGF).

According to existing protocols, limiting the use of DOT therapy during the period of early post-acne is associated with the risk of developing side effects in the form of post-traumatic hyperpigmentation, reactive edema, and pustulization in areas affected by the laser. However, the experience of using dermal optical thermolysis in patients with acne and post-acne has shown the high effectiveness of the method not only for eliminating complications of post-acne, but also for therapeutic purposes during the stage of reverse development of acne. In these cases, the pustular elements have already completely regressed, and scar changes are in the stage of formation. Tissue destruction in the post-acne area is associated with a previously suffered purulent-inflammatory process and a violation of the physiological integrity of collagen structures; the activity of fibroblasts slows down, and, accordingly, the synthesis and resorption of collagen.

Study of the effectiveness of DOT in early postacne

The purpose of our work was to analyze the possibility of performing dermal optical thermolysis (DOT) using the SmartXide Dot CO2 laser (DEKA) during the period of early convalescence of acne using low doses of isotretinoin (no more than 0.2 mg/kg).

From 2014 to 2017, we observed 215 patients with acne and post-acne (aged 17 to 45 years). They were conditionally divided into two groups: the main group, which included 115 patients (65 women and 50 men), and the control group, which included 100 patients (50 women and 50 men).

Patients of the main group during the period of early post-acne, against the background of low doses of isotretinoin (up to 0.2 mg/kg), underwent DOT therapy. Indications for inclusion in the study group were the absence of active inflammatory manifestations of acne (pustules, papules), the presence of atrophic, hypertrophic scars, and the use of maintenance doses of isotretinoin (no more than 0.2 mg/kg). Exclusion criteria were taking contraceptives, the presence of inflammatory elements on the skin of the face, a tendency to melasma, chronic autoimmune and infectious skin diseases.

In parallel, patients in the control group with post-acne symptoms received DOT therapy 3 months after the end of retinoid treatment.

When forming post-acne scars (atrophic and hypertrophic), dermal optical thermolysis was used with the above-mentioned fractional CO2 laser with varying modes depending on the nature of the post-acne (scar depth, vascularization, topographic localization, duration of existence, individual skin characteristics). Average parameters of DOT therapy: energy – 20 (25) W, distance between passes – 500 (700) µm, pulse delay – 700 (900) µs, pass depth – 1 (2–3) stacks.

A total of 3 procedures were performed with an interval of 30 days. Patients in both groups additionally received proteolytic enzymes, external benzoyl peroxide and clindamycin. The results of therapy were assessed 30, 90 and 180 days after the start of treatment.

Research results

In both observation groups, DOT therapy was well tolerated. The results are shown in Table 1. Side effects in the form of reactive edema, hyperemia, burning, pain were comparable in patients of the main and control groups. After six months of observation, post-traumatic hyperpigmentation developed in 7 patients (6.1%) of the main group and in 6 patients (6%) of the control group. The average rate of regression of post-traumatic hyperpigmentation in the main group was 75.6 ± 0.4 days, in the control group – 62.5 ± 0.63 days. Over the course of 6 months, there were 4 cases of exacerbation of acne (3.5%) in patients of the main group and 9 (9%) in patients of the control group. An increase in the secretory activity of sebum above the average permissible normal values 6 months after completion of retinoid therapy (assessed using the Omnivision sebum analyzer) was noted in 23 patients (20%) of the main group and in 35 patients (35%) of the control group.

Table 1. Analysis of criteria for the activity of acne and post-acne depending on the timing of the start of DOT therapy

Analysis of the regression of atrophic scars after acne showed greater effectiveness among patients in the main group. The assessment was carried out based on photo documentation data and the patients’ individual perception of their own atrophic skin changes. Thus, 30 days after the start of DOT therapy, improvement was noted by 17 patients (14.7%) of the main group and 19 patients (19%) of the control group, after 90 days - 49 (42.6%) patients of the main group and 52 (52% ) patient of the control group. Long-term observation results (after 180 days) indicated greater effectiveness of DOT therapy in patients of the main group, where regression of atrophic scars was noted by 89 (77.4%) patients, in the control group - only 73 (73%) patients. Photo 1.

Photo 1. Dynamics of regression of acne and post-acne keloid against the background of early DOT therapy. Patient: A – before treatment; B – 30 days after the start of therapy; C – after 90 days; D – after 180 days

An analysis of the dermatological quality of life index (DIQL) before the start of treatment, as well as 60 and 180 days after, was also carried out. The average DIQL values before therapy in patients of the main group were 14.9 ± 0.71 points, in the control group – 15.2 ± 0.43. 60 days after the start of treatment in the main group, the DIQL value was 11.81 ± 0.91, after 180 days – 5.3 ± 0.92. In patients in the control group after 60 and 180 days, the dermatological quality of life index decreased only to 12.3 ± 0.53 and 7.2 ± 0.74, respectively.

Thus, the use of modern laser technologies made it possible to increase the speed of rehabilitation of patients in the main and control groups. The use of DOT therapy in the early stages of acne regression (isotretinoin ˂ 0.2 mg/kg) had a positive effect on skin repair processes, improved the DIQ value in the main group to 5.3 (improvement by 71.1%), in the control group - to 7 .2 ± 0.74 (52.6% improvement).

conclusions

The use of modern laser technologies significantly reduces the rehabilitation time for patients with acne and post-acne, and further study of combined laser technologies in the treatment of exudative, proliferative, hypertrophic, atrophic processes of the facial skin will increase the effectiveness of the treatment of chronic dermatoses and improve the long-term prognosis of these diseases.

First published in Les Nouvelles Esthetiques 2018/№1