Laser therapy in the complex treatment of acne

In most young people, acne is physiological in nature and goes away without a trace with the end of puberty, however, in some people, the involution of acne occurs more gradually, the disease becomes severe, recurrent, with the formation of persistent papulopustular, nodulocystic or cicatricial rashes, which do not dissolve even in adulthood. Acne typically affects the skin of the face and the upper half of the body.

Mechanism of disease development

Against the background of increased production of sebum, which is a substrate for the proliferation of P. acnes, increased keratinization of hair follicle cells is observed - follicular keratosis. In addition, the natural exfoliation of the surface layers of keratinized cells is slowed down by gluing with excessive amounts of sebum. This inevitably leads to a thickening of the stratum corneum of the epidermis, and a characteristic gray tint of the skin appears. Horny plugs form at the mouths of hair follicles. Perifollicular inflammation occurs. As a result of the latter, the inflammatory reaction directs components of the immune system into the damaged tissue due to increased blood supply, which increases the permeability of the capillary wall. Following this, due to sweating and extravasation (movement of phagocytes into the dermis), immunocompetent cells accumulate in the dermis - neutrophils (the first 30–60 minutes), macrophages, basophils, lymphocytes (in the next 5–6 hours), which, in turn, produce pro-inflammatory monokines and cytokines - interleukins-8,1-beta, cyclooxygenase activators. Then lysis of the walls of foreign agents and phagocytosis are triggered. Thus, the presence of a focus of chronic inflammation leads to a violation of the integrity of the follicular wall and the formation of the so-called lymphohistiocytic infiltrate, which serves as a reflection of the direct work of local immunity at the level of the dermis and at the same time a substrate for the development of post-acne phenomena, which also depends on the individual characteristics of the organism, the duration of the process and the depth location of inflammatory elements in the dermis.

In addition, the long-term presence of the source of inflammation in the deep layers of the dermis, in turn, leads to a shift in the self-regulation of the collagen-collagenase system towards increased collagen formation - this creates the prerequisites for the development of scar post-acne phenomena.

Acne is a multifactorial skin disease. Both genetic mechanisms and hormonal disorders, as well as various pathologies of the immune and digestive systems, and disorders of local microcirculation play a role in its development. In addition, the importance of local mixed infection and zinc deficiency in the body in the occurrence of this pathology has been proven.

There is currently no unified classification of the severity of acne, but most experts rely on the classification of the American Academy of Dermatology (AAD, 1990).

Table 1. Acne severity (AAD, 1990)

Modern acne therapy is based on hypotheses of the etiology and pathogenesis of this disease. At the same time, the rationality of its staged treatment has been proven, which is determined by the characteristics of the clinical picture of the lesion and the presence of complications in each specific clinical case.

A fairly large number of different medical and cosmetic measures are used to treat acne patients. The feasibility of using these measures is decided individually, depending on the identification of certain dominant influencing factors that are, respectively, of endogenous or exogenous origin.

Exogenous factors that are of significant importance in this disease include the following: nutritional, individual lifestyle characteristics, the presence of foci of concomitant damage of bacterial and parasitic origin. Among the latter, it is necessary to take into account the influence of Demodex folliculorum mites on the course of acne, the proliferation of Propionibacterium acnes on the surface of the skin and in the hair follicles, as well as the presence of Helicobacter pylori bacteria, which can infect the stomach and duodenum.

Among endogenous factors, the development of acne is influenced by disorders of the endocrine, immune, nervous, vascular systems, hyperfunction and hypersecretion of the sebaceous glands.

Possibilities of modern therapy

Rational therapy for patients with acne should include the following measures:

• treatment of “background” diseases: normalization of the state of the body’s functioning systems, sanitation of foci of focal infection (microbial, tick-borne, helminthic origin);
• correction of hormonal levels by prescribing antiandrogenic drugs;
• strengthening general and local immunity;
• elimination of increased sebum secretion, secondary infection of affected areas;
• preventing the development of post-acne phenomena - scars, dyschromia and recurrent congestive post-inflammatory elements - by prescribing external medications that affect the main pathogenetic links - hypersecretion of sebum, proliferation of Propionibacterium acnes, follicular hyperkeratosis, perifollicular inflammation, etc.

Modern approaches to acne treatment were proposed at the XX World Congress in Paris in 2002 (see Table 2).

Table 2. Acne treatment algorithm (Paris, 2002)

As can be seen from the recommendations given in the table, for more than 30 years in dermatology, the generally accepted method of treating mild to moderate acne has been the prescription, first of all, of systemic antibiotics. The first choice drugs include tetracyclines - antibiotics with a fairly long period of use (from 4 to 12 weeks), which can significantly reduce the severity of inflammatory phenomena.

However, long-term courses of systemic antibiotic therapy with drugs of this group lead to the development of systemic side effects, reduce the immune properties of the body as a whole, which, in turn, leads to a decrease in the protective properties of the skin, the development of phototoxic reactions, hepatitis, intracranial hypertension, pigmentation of the mucous membranes, as a result - to a worsening prognosis and prospects for recovery. And the use of topical antibiotics leads to the rapid development of addiction. In addition, today in the world the problem of the development of resistance of skin microflora (including cross-resistance) to the most commonly used first-line antibiotics is becoming increasingly urgent due to established RNA mutations, which reduces the effectiveness of treatment of this pathology and creates conditions for the disease to progress to a more severe one. severe forms, chronicity of the process, questionable treatment results with the subsequent development of gram-negative and pitirosporum folliculitis with a simultaneous negative effect on the body as a whole. In this regard, there is a need for an alternative selection of antibiotics.

Thus, despite the variety of proposed methods for treating acne, the therapy of this disease continues to remain a pressing issue in modern dermatology and cosmetology. Often, appropriate therapeutic measures achieve only a temporary or mild clinical effect, which can no longer satisfy the aesthetic requirements of modern patients with this disease. In our opinion, this problem requires the improvement of existing and the search for new effective local treatment methods, which would provide additional effective local effects directly on the affected skin. In our opinion, such a technique could be a comprehensive treatment of acne, including, in addition to generally accepted therapeutic measures, laser therapy.

Laser therapy in the treatment of acne

Laser therapy is a promising area of modern dermatology and cosmetology. The undoubted advantage of laser therapy is the targeted effect directly at the site of application, the absence of allergenicity and general damaging effects on the body as a whole. The interaction of a light beam with the skin is realized at the level of target structures, identical for almost any type of radiation used (UV, visible spectrum, IR). These include:

• Propionibacterium acnes, containing endogenous porphyrin (coproporphyrin III, uroporphyrin and protoporphyrin IX), other pathogens;
• walls of the sebaceous gland and sebum;
• hair shaft containing the chromophore melanin;
• vessels surrounding the pilosebaceous follicle;
• stagnant post-inflammatory spots and fresh scars in place of resolved inflammatory elements;
• areas of hyperpigmentation.

In the available scientific literature there is data on the use of laser therapy in the treatment of acne, but there is no consensus on the parameters of the laser installation that are optimal for the treatment of acne, as well as on the indications and standards for the use of laser therapy at different stages of the severity of this disease.

Based on the above, the goal of our work was to increase the effectiveness of acne treatment through scientific substantiation and practical development of a method for complex treatment of this disease, including laser therapy.

Materials and methods

At the first stage of achieving our goal, we needed to analyze the known data regarding existing laser systems to determine the possibility of use in the treatment of acne, as well as determine the indications for laser therapy for this disease. Based on the physical properties of laser systems presented in Table 3, it should be noted that the most pathogenetically justified in terms of in vivo effect and safety of use should be considered the use of laser systems that generate light in blue (420 nm - IPL) and infrared (1 064 nm – Nd:YAG) range. Moreover, taking into account the depth of light penetration, for mild forms of acne and superficial foci of inflammation, blue radiation devices should be preferred, and for moderate forms of acne with large depth and area of distribution, red and infrared lasers should be preferred.

Along with this, in terms of physical properties, a laser with a beam wavelength of 1,064 nm has an undoubted advantage in penetration depth over red lasers and does not require the introduction of additional photosensitizers into the body or skin during the treatment process.

Table 3. Physical properties of laser devices used in the treatment of acne

Thus, the effectiveness of laser therapy largely depends on the adequate selection and ability of the selected radiation spectrum to affect key target structures. In mild cases, such structures are primarily P. acnes, which are abundantly present on the surface and in the ducts of the sebaceous glands and contain endogenous photosensitizers - porphyrins. With a more severe course, the colonization of the sebaceous gland ducts by P. acnes is significantly reduced, and consequently, the level of porphyrins necessary for the implementation of photochemical reactions decreases. In such a situation, you should prefer equipment that will have a deeper effect on the sebaceous gland itself, reducing its activity and reducing perifollicular inflammation. An infrared laser at 1,064 nm sterilizes the inflammation site to a depth of 4 mm, and also provides resolution of lymphohistiocytic infiltrates and inhibition of the sebosecretory function of the sebaceous gland due to photothermal effects on the entire thickness of the dermis (that is, on all target structures).

The therapeutic effect in the case of using a 1,064 nm neodymium laser, in our opinion, is ensured not only due to the bactericidal effect on P. acnes, but also due to the uniform heating of the dermal structures, including the sebaceous gland and the entire pilosebaceous complex, which leads to significant improving metabolism at the site of inflammation and reducing sebum production. This mechanism is realized through coagulation of pathologically altered vessels and revascularization, as well as a direct effect on the walls of the sebaceous gland. Clinically, this is expressed in a significant regression of papulopustular rashes, compared with the results of acne treatment according to standard recommendations, without the use of laser systems.

Description of the study

During 2011–2012, we observed 38 patients with papulopustular acne of mild to moderate severity. The age of the experimental group was 18–26 years (22 ± 1.5). Among them there were 28 women and 10 men. The comparison group consisted of 20 patients. In terms of gender, age and clinical manifestations, they correlated with the experimental group. All patients under our supervision received acne treatment in accordance with recommended standards. In addition, patients in the experimental group received a course of appropriate laser therapy. They all signed an informed consent to carry out this treatment method.

The treatment protocol for patients with papulopustular acne included standard recommendations corresponding to the severity of the disease. However, instead of doxycycline, which is traditionally recommended in such cases for systemic therapy, we used an antibiotic from the macrolide group, josamycin. The refusal of doxycycline was dictated by the fact that the use of drugs of the tetracycline group is a direct contraindication for the prescription of laser therapy due to the pronounced development of severe photosensitivity of the skin and hyperpigmentation in patients. Josamycin, in turn, has a bactericidal effect on a wide range of gram-positive and gram-negative microorganisms, which is important for preventing the development of gram-negative folliculitis and does not stimulate the development of photosensitivity. In addition, there is evidence of the high effectiveness of the drug in the presence of resistance to erythromycin.

Josamycin was prescribed to all patients at a dosage of 500 mg 2 times a day for 14 days, benzoyl peroxide was applied topically 1 time a day 2-3 times a week during laser therapy and as maintenance treatment for up to 6 months. Laser therapy with a 1,064 nm neodymium laser (Fotona, Slovenia) was carried out according to the following scheme: 3 sessions in the first week, 2 in the second and 1 session in the third week. In total, patients received 6 sessions.

Laser parameters:

• power – 35–50 J/cm2;
• pulse duration – 25–30 ms;
• working spot diameter – 3 and 6 mm.

All inflammatory elements were processed in two passes using an S11 scanner with an overlap area of 20%. Maintenance treatment consisted of topical benzoyl peroxide once every 2–3 days for up to 6 months.

The control group of patients received josamycin at a dose of 500 mg 2 times a day for 14 days; benzoyl peroxide was applied topically once every 2–3 days both during treatment and as support for up to 6 months.
Treatment monitoring was carried out using patient questionnaires, counting inflammatory elements by zone using photography to record the results obtained before the start of treatment, 30 days and 6 months after its completion. The criterion for the success of treatment was considered to be significant regression or disappearance of papulopustular elements, and the absence of relapse of the disease within 6 months after the end of the course of complex acne treatment.

Results and its discussion

Having systematized and analyzed the literature data on the physical properties of laser devices used in the treatment of acne, we came to the conclusion that it is advisable to use a neodymium laser (with a laser beam wavelength of 1,064 nm) for the treatment of this disease. We determined that the use of laser therapy in the treatment of acne makes sense only for papulopustular forms of mild to moderate severity. Moreover, it seems most appropriate to use laser therapy in the complex treatment of moderate acne.

Based on the analysis of the questionnaire and study of photographs of patients in the experimental and control groups (Table 4), we were able to evaluate the results of their treatment. As can be seen from the table, as a result of our treatment according to the scheme described above, within six months after its completion, relapses of acne were observed in 7 patients of the experimental group, which amounted to 18.4%.

Table 4. Results of treatment of moderate acne with neodymium laser

In 8 patients in the control group (40%), exacerbations occurred within 2 to 5 months after the end of therapy. Our result indicates that the use of laser therapy in the combined treatment of patients with papulopustular acne of mild to moderate severity is an effective and safe method of local therapy for this disease (photos 1–3).

Photo 1. Patient A before and after a course of laser therapy with a 1,064 nm neodymium laser

Photo 2. Patient B before and after a course of laser therapy with a 1,064 nm neodymium laser

Photo 3. Patient C before and after a course of laser therapy with a 1,064 nm neodymium laser

Thus, the use of laser therapy with a 1,064 nm neodymium laser in the complex treatment of acne significantly increases its effectiveness. In addition, due to laser therapy, the total treatment time is significantly reduced, which makes it possible not to resort to the prescription of systemic antibiotics in the treatment of mild papulopustular forms of acne, as well as to reduce the course dose of systemic antibiotics in the treatment of moderate papulopustular forms of acne.

In our opinion, special attention is deserved by the fact that the rapid onset (after only 2-3 sessions of laser therapy) of clinical improvement in the condition of the skin in the lesions contributes to faster social adaptation of patients with acne. Reducing the duration of use of systemic antibiotics leads to a decrease in the load on the digestive organs, which minimizes side effects, improves the prognosis, and reduces the risk of developing scar post-acne.

Thus, we have substantiated, developed and tested a modern, effective and pathogenetically justified method of complex therapy for moderate acne, including both standard therapy for this disease and laser therapy with a 1,064 nm neodymium laser. Laser therapy using the method we proposed, in our opinion, can be recommended for widespread use in the practice of dermatovenerologists and cosmetologists, since it is safe, does not produce side effects and is applicable at almost any age for the treatment of acne.

The article was written in co-authorship with Lyudmila Fedorich, Ph.D., associate professor, associate professor of the course of dermatology and venereology at the Ukrainian Military Medical Academy and published in the journal "Les Nouvelles Esthetiques Ukraine" No. 2 (78) / 2013