Thursday, March 24, 2011

How effective is laser treatment for acne

The advancement in science brings with it new modalities of treatment for medicine. One of it is laser technology. It has found application in various fields of medicine, such as surgery and dermatology. Laser is being used extensively in various surgical operations, liposuction, varicose veins ablation and aesthetic treatments.

Light therapy is the latest addition in the arsenal of treatment for acne. Laser, which produces a high-energy beam of light of precise wavelength, is the most common light source in acne therapy. It selectively damages Propionibacterium acnes, the bacteria responsible in the formation of acne.  It acts on the porphyrins, the pigment being produced by the said bacteria, which in turn causes sensitization and its subsequent destruction.  

The popularity of laser and other light-sources is prompting several studies regarding its application in acne treatment.  Under investigation are broad-spectrum continuous wave visible-light sources (blue light and blue-red light), specific narrow-band light, intense pulsed light (IPL), pulsed dye lasers (PDL), potassium titanyl phosphate lasers, infrared diode lasers and photodynamic therapy (PDT) with or without photosensitizing agents (aminolevulinic acid or methyl-aminolevullinic acid).

To date substantial evidence in support of light therapy as mode of treatment in acne is lacking. Outcomes of some trials are contradictory. In a study by Haedersdal , red-light-activated methyl-aminolevulinic acid-PDT and aminolevulinic acid-PDT were efficacious in 50-60% of patients up to 20 weeks after one to three weeks of treatment. In another study by Wiegell et al, effect lasted up to 1 year after treatment.  Moreover, IPL-assisted PDT seems to be more effective than IPL alone.

Some studies compared the efficacy of broad-spectrum light sources versus existing topical treatments. Blue light twice-weekly for 4 weeks was reported to be superior to topical clindamycin. Mixed blue-red light daily for 12 weeks reduced more acne lesions than BPO.

Kumaresan and Snirivas evaluated the efficacy of single against burst-pulse mode in IPL therapy. They have concluded that IPL as single therapy was beneficial in the treatment of acne. Results also showed that burst-pulse mode was better than the single pulse mode in clearing acne.

Despite the studies, laser treatment is not considered the first choice in the treatment of acne today. It only serves as an adjunct to medical therapy.  Significant improvement is observed when laser is utilized in combination with topical and systemic medications.


  1. Treating acne vulgaris: systemic, local and combination therapy: Adjunctive therapies. Medscape
  2. Kumaresan M, Srinivas CR. Efficacy of IPL in treatment of acne vulgaris : Comparison of single- and burst-pulse mode in IPL. Indian J Dermatol [serial online] 2010 [cited 2011 Feb 27];55:370-2. 
Related Articles:

Monday, February 28, 2011

Can chocolates cause acne flare-ups?

Ghirardelli chocolate

Have you ever noted pimple breakouts after indulging on your favorite brown sweets? Or have you ever associated zit eruptions with chocolates? Well, there may be truth in your observation after all.

Earlier studies revealed no direct connection between chocolate consumption and acne breakouts. Tests that were conducted before to suggest the association of diet and acne have used chocolate candies, containing added ingredients such as milk, sugar and nuts. So far only milk was proven to have a direct link to acne exacerbation.

However, at the recently concluded 69th Annual Meeting of the American Academy of Dermatology a report was presented associating acne with consumption of pure chocolate.

In a study conducted at the University of Miami Miller school of Medicine in Florida, researchers have involved 10 healthy male subjects between 18 to 35 years of age with a history of facial acne vulgaris, who had at least I, but no more than 4 acneiform lesions (blackhead or whiteheads, papule and cyst). They were instructed to consume 6 ounces of 100% Ghirardelli chocolate daily for duration of 1 week.

A significant increase in the number of lesions was found, suggesting a strong correlation between the amount of chocolate that was consumed and the amount of acneiform lesions developed.

Further studies though are needed to establish the relationship between chocolate and acne and the mechanism that is involved in it.


Sunday, January 30, 2011

Hormonal Treatment for Acne

oral contraceptive pills
I have mentioned in my earlier post “Why should acne be a cause for concern” that hormones play a role in the pathogenesis of acne. Even before the onset of puberty adrenal glands are already producing larger amounts of dehydroepiandrosterone sulfate (DHEAS), which can be metabolized into more potent androgens, leading to cascade of events that trigger acne formation. In women, excess production of androgens by the ovary as a result of Polycystic Ovary Syndrome may also cause acne. These are the reasons behind the use of hormones in the treatment of acne.

Hormonal therapy is most effective in adult females with persistent facial inflammatory papules and nodules. We may have heard of women complaining of acne flare before or during menstruation. Therefore, hormone intervention is an additional option in the therapeutic arsenal for female patients with acne. 

When should hormonal therapy be initiated in acne cases?
  • when acne has not responded to standard treatment (topical and oral antibiotics or its combination)
  • when there are contraindications to intake of isotretinoin
  • when rapid relapse has occurred after repeated courses of isotretinoin
  • when menstrual control and/or contraception are required alongside acne therapy
Nevertheless, it is also noteworthy that this kind of treatment can also be very effective in females with acne whether their serum androgens are normal or abnormal. Females with acne have higher levels of serum androgens compared with women without acne, though these levels are mostly within the normal range.

I.           Inhibitors of Adrenal Androgen Production

Glucocorticoids in low doses can suppress the adrenal production of androgens. They are indicated for patients, both male and female, who have an elevated DHEAS level associated with late-onset congenital adrenal hyperplasia, caused by an inherent deficiency of 11-hydroxylase or 21-hydroxylase enzymes. Low-dose prednisolone (2.5–5 mg) or dexamethasone (0.25–0.75 mg) given at night (or alternative nights) can be sufficient to suppress adrenal androgen production and subsequently reduce sebum (oil)production by up to 50% with a concomitant improvement in acne.

Several studies have shown that glucocortioids given alongside cyclical estrogen (i.e., oral contraceptives) can successfully reduce sebum production in recalcitrant acne via reduction in plasma androgen level than with either agent alone.
II.        Inhibitors of Ovarian Androgen Production

1.   Estrogen

Estrogens are particularly valuable in women with clinical evidence of hyperandrogenism ( e.g., hirsutism or excessive hair growth,  menstrual irregularity, acne and oily skin). It shows two-pronged action. First, estrogen increases the hepatic production sex hormone-binding globulin, which binds and thus reduces levels of free circulating testosterone. Second, estrogens suppress the ovarian production of androgens by suppressing gonadotrophin release from the pituitary, resulting in lower serum androgen levels, hence less seborrhea.
The ones recommended for the treatment of acne are usually oral contraceptives with combined preparation containing estrogen (most commonly ethinyl estradiol) and a progestin with anti-androgenic activity.

Oral contraceptive pills containing ethinylestrodiol (oestrogen) and an antiandrogenic progesterone  include cyproterone acetate (co-cyprindiol or Diane™-35, Estelle™ 35, Ginet-84™and Althea), drospirenone (Yasmin™, Yaz™) or dienogest (Valette™).

Combined oral contraceptives can increase the risk of thromboembolism (blood clots blocking blood vessels), especially in those with an inherited tendency ("thrombophilia"), or who smoke.  Minor side effects are breast tenderness (20%) and increase in bra size, Spotting" (irregular mild bleeding between periods) occurs in 10% of women in the first month, nausea and loss of appetite, headaches, increased appetite and weight increase (uncommon), mood changes including depression, melasma (facial pigmentation) and hair loss.

2.   Gonadotrophin-releasing Agonists

Gonadotrophin releasing agonists inhibit ovarian androgen production by interrupting the cyclical release of luteinizing hormone and follicle-stimulating hormone from the pituitary.  Nafarelin, leuprolide and buserelin are included in this group. They all have demonstrated efficacy in the treatment of acne and hirsutism in females both with and without endocrine abnormalities. . However, their use is limited somewhat by the potential for adverse effects including reduced bone mass, headache and menopausal symptoms, caused by the suppression of ovarian estrogen production.


III.     Androgen Receptor Blockers

1.   Cyproterone Acetate

Cyproterone acetate  (CPA) is a progestional anti-androgen that directly inhibits the androgen receptor. It  reduces sebum production by no more than 30%, but its success in acne is enhanced by its direct effects on androgen-mediated comedogenesis (i.e. blackhead and whitehead formation). . An overall improvement in acne has been reported in up to 90% of patients treated with higher doses of CPA (50–100 mg/day), with or without ethinyl estradiol.

Is it okay for men suffering from acne to take CPA? It has been demonstrated that 25mg of CPA can  improve acne in males. However, due to its feminization effects, such as reduced libido, gynecomastia (breast enlargemement) and azoospermia (absence of sperm in the ejaculate) this kind of treatment is not recommended for males. General side effects of CPA, although uncommon, include fatigue, headache, nausea, weight fluctuation, liver dysfunction and blood clotting abnormalities.

2.   Spironalactone

Spironolactone is a potassium-sparing medication used as a diuretic medication for heart failure, liver disease and high blood pressure. However, it has also been found useful for hirsutism, acne and seborrhoea because it has anti-androgenic properties. Spironolactone works by blocking androgen receptors.
                It can reduce sebum production by 30–75% depending on the dose. It is usually prescribed at a dose of 50–100 mg daily with meals, but many women with sporadic outbreaks can be successfully managed with as little as 25 mg daily. As with other hormonal therapies, response is slow and it may take up to 3 months of continuous treatment before any benefit is observed.

Menstrual irregularities, potential hyperkalemia, breast tenderness, fatigue, headache, fluid retention and, rarely, melasma are among the side effects.  Spironalactone should not be prescribed for male patients because like CPA it can also cause feminization. Females should be advised to avoid pregnancy owing to potential abnormalities to the male fetus. All patients should undergo regular monitoring of their electrolytes owing to the potassium-retaining effects of spironolactone on the kidney.

3.   Flutamide

Flutamide is a nonsteroidal potent androgen antagonist, most routinely used in the treatment of prostate cancer. It has been demonstrated to be efficacious in treating androgen-mediated acne and hirsutism when administered at a dose of 125–250 mg daily.
Like all hormonal agents, it should not be prescribed for male patients and owing to the risks of teratogenicity, pregnancy should be avoided.
Fatal hepatotoxicity has been reported with flutamide,  that is why many countries now ban the use of flutamide as a treatment for androgen-mediated acne and hirsutism.

Other skin/hair conditions, aside from acne aggravated by androgenic hormones and therefore hormonal therapy is applicable are:

  • Seborrhoea
  • Hirsutism
  • Female pattern hair loss
  • Hidradenitis suppurativa

Hormonal therapy carries multiple side effect, thus it requires monitoring. Patients therefore are advised not to self-medicate. Always seek advice from your dermatologist or gynecologist regarding the appropriate medicine for your condition.

Related articles:
  1. What is Hormonal Imbalance?
  2. Why should pimples be a cause for concern?

Tuesday, January 11, 2011

What are adjunctive therapies for acne?

A number of physical therapies are available for treating active acne.  These procedures aid in faster resolution of active lesions in acne, but should not be utilized as a first-line of treatment. They are recommended to be used in conjunction with medical therapy to prevent the development of new lesions.

These are office procedures that require skill, hence should be performed only by dermatologists and trained aesthetisticians.

1.      Acne surgery 
Using a comedone extractor, it facilitates immediate expulsion of comedones and drainage of pus in cystic lesions.

removal of comedones

2.      Hyperfrecation
Macrocomedones are usually closed comedones (whiteheads) but are occasionally open comedones (blackheads) up to 1.5 mm in diameter. Light cautery or hyfrecation after the application of local anesthetic cream (e.g., EMLA) has been demonstrated to be successful in the treatment of multiple macrocomedones. The topical anesthetic is applied for 60–90 min beneath an occlusive adhesive dressing, after which cautery is used to provide very low-grade thermal damage in order to stimulate the body's own defense mechanisms to induce resolution of the comedo. This takes seconds to perform and should be painless. There is very little associated scarring or postinflammatory hyperpigmentation and it is generally well tolerated.

3.      Chemical Peels
Glycolic acid and salicylic acid peels are also beneficial in mild-to-moderate comedonal acne in women aged 13–40 years. They promote desquamation, which reduces corneocyte adhesion and follicular plugging, enabling the extrusion of inflammatory contents.

application of glycolic acid

4.     Intralesional  Steroid Injections
Larger inflammatory nodules and cysts respond well to intralesional injections with triamcinolone acetonide, with a rapid reduction in pain and swelling. A 30-gauge needle is used to inject 1–2 mg/ml triamcinolone acetonide into the center of the lesion until the erythema blanches. Injections can be repeated if necessary every 3 weeks. 

injection directly into the lesion

5.      Cryotherapy
If large inflammatory lesions persist beyond 2 weeks, cryotherapy is the preferred option. Superficial freezing with liquid nitrogen will hasten the resolution of such lesions and is relatively painless. Two 15–30-s freeze–thaw cycles are recommended.

6.      Light therapy
Lasers are the most common light sources utilized in acne therapy, which produce a high-energy beam of light of a precise wavelength range. A range of treatments are currently being used, including broad-spectrum continuous wave visible light sources (blue light and blue–red light), specific narrow-band light, intense pulsed light (IPL), pulsed dye lasers (PDL), potassium titanyl phosphate lasers, infrared diode lasers and photodynamic therapy (PDT) with or without photosensitizing agents (aminolevulinic acid or methyl-aminolevulinic acid). Light therapy exerts a selective cytotoxic effect on the proprionibacteria, which appear to be more susceptible to short-term damage from light therapies than keratinocytes. Comedonal and proinflammatory cytokines are also suppressed.