ABSTRACT:
Background and Objectives: Q-switched 1064-nm lasers have been found effective for the treatment of mild-to-moderate inflammatory facial acne. This study was designed to evaluate the efficacy and safety of the combined treatment with the 660-nm Q-switched laser and the Q-switched 1064-nm laser for inflammatory acne.
Materials and Methods: Case series of three patients with inflammatory acne were treated with a combination of the 660-nm Q-switched laser and the 1064-nm Q-switched laser. Patients’ subjective response to treatment was evaluated regarding improvement in acne lesions, acne scarring, and redness of the skin.
Results: All patients had reductions in acne lesion counts. Mean lesion counts decreased 90%, after three treatments. Patients described marked improvement in acne lesions, acne scarring, and post-inflammatory erythema. Adverse effects were limited to mild, transient erythema.
Conclusions: The combination of the 660-nm Q-switched laser and the 1064-nm Q-switched laser is safe and effective for the treatment of inflammatory facial acne, acne scarring, and post-inflammatory erythema.
INTRODUCTION:
Acne is a chronic skin disease generated in the pilosebaceous units. The association of thick skin and hyperseborrhea generates comedones which are non inflammatory lesions because of the follicular plugging. The comedone is the precursor of other acne lesions. It can become infected by the cutibacterium acnes, whose cell wall and biological byproducts are chemoattractant and proinflammatory (1) generating papules and pustules which are inflammatory lesions. Inflammation increases the possibility of scarring and post inflammatory hyperpigmentation. Acne affects primarily the face, neck, chest and the back. These lesions can generate physical and mental anguish on the patients driving them to seek effective treatment. Controlling inflammation is mandatory in order to reduce acne sequelae. Multiple treatment options have been used to target one or more of acne´s pathogenic elements. These include topical preparations with topical antibiotics and retinoids, oral antibiotics like minocycline or tetracycline, and oral isotretinoin, which may be needed for long periods of time and is related to side effects like cheilitis, dry skin, nose bleeds, secondary infection, temporary worsening of lesions, photosensitivity, and increased serum lipids (2).
The use of lasers and optical treatments to treat acne is an increasing practice because of their minimal complications and limited number treatments required. Blue light, blue–red light and infrared radiation were more successful, particularly those using multiple treatments (3).
Treatments with the 1450-nm diode laser, 585- and 595-nm pulsed dye lasers (PDLs), near infrared diode lasers, 1320-nm Nd:YAG laser, 532-nm potassium titanyl phosphate laser, 1064-nm long-pulsed Nd:YAG laser, 1540 nm Erbium (Er):Glass Laser, and the 1550-nm Er:Glass fractional laser are among the most common lasers used to treat acne and acne scarring (4).
Here we report three cases of 1064-nm Q-switched laser treatments in conjunction with 660nm Q-switched laser for successful treatment for inflammatory acne on the face and back. The 1064-nm wavelength has affinity for water heating the dermis, and has also affinity for oxyhemoglobin in the near infrared spectrum (800-1100 nm) (5). The therapeutic effect on acne lesions is believed to be mediated by the selective photothermolysis of vessels and and the up regulation of TGF Beta, the reduction of interleukin-8 (IL-8), Toll-like receptors-2 (TLR-2), and the thermal destruction of sebaceous glands (6). The 660 nm wavelength may have anti-inflammatory properties by influencing the release of cytokines from macrophages (7).
CASE PRESENTAION:
Case 1
A 25-year-old Latin male (Phototype 3) with a 5 year history of acne vulgaris presented with inflammatory - papulopustular acne. In the past, he was unable to tolerate isotretinoin due to significant side effects. On presentation, the patient had erythematous papules and pustules on his cheeks, forehead, temples and chin. He had rolling and boxcar atrophic scars associated and were distributed bilaterally along the cheeks from prior acne lesions (Pic. 1). Prior treatments included the following: topical clindamycin, tetracycline, and isotretinoin for two months. He was on topical benzoyl peroxide for 1 month prior to procedure to decrease Cutibacterium acnes. As part of this protocol, he was pretreated with 1064 nm ND YAG Q-switched laser (Pastelle-Wontech) using a 7 mm spot with the Zoom handpiece, acne toning mode, 2.5 J/cm2 , frequency 8 Hz on the chin, cheeks, forehead, and perioral area where active inflammatory lesions were present. Red 660 nm laser handpiece (Pastelle-Wontech) was then applied directly and punctually 2 shots per inflammatory lesions with 0.3 J/cm2, spot 3mm frequency 2Hz. At the end of the session, the patient exhibited mild erythema and swelling of the face. Pictures were taken the next day of the first treatment showing reduction of erythema and reduction of the number of inflammatory lesions. (Pic. 1) Three treatments were performed every two weeks. One month after the last session the patient had its follow-up, showing significant improvement in the number of inflammatory lesions and the appearance of atrophic acne scars. This patient presented a reduction of 94.7% in the number of inflammatory lesions (38 to 2 lesions). Given marked resolution in acne inflammatory lesions the patient continued with topical treatment with benzoyl peroxide and tretinoin. He is now 6 months with this treatment without relapsing. After the last control, the patient reported a to be very satisfied when asked with a 5-point satisfaction scale.
Case 2
A 31-year-old Latino female (Phototype 4) with a 2 year history comedogenic acne vulgaris but consulted because of acne deterioration caused by the use of the face masks (mask acne) because of the Covid-19 pandemic. She presented moderate inflammatory acne especially in the chin area. She didn’t want any retinoid treatment because she was planning to try to get pregnant after the end of this treatment. On examination, she had multiple papulopustular lesions and comedone lesions on the cheeks and jawline (Pic. 2). At the time of treatment, the patient was applying azelaic acid topical treatment. Given a history of reactivated HSV-1, the patient was started on acyclovir one week prior to treatment. She was treated with the same protocol as above and tolerated the procedure well with mild erythema and no pain. In a 1- month follow-up after the last treatment, the patient demonstrated reduction of inflammatory lesions of 92% in the number of inflammatory lesions (25 to 2 lesions) even though she continued using a daily face mask because of covid 19 pandemic. (Pic. 2a). After the followup, she continued with topical treatment with punctual clindamycin cream if the lesions appeared and also associated the treatment with salicylic acid cleansing products. The patient hasn’t had any recurrence of lesions during follow-up at 3 months. At this time, the patient reported a to be very satisfied when asked with a 5 points satisfaction scale.
Case 3
A 22-year-old Latino female (Phototype 2) presented with papulopustular acne spread diffusely on the upper and lower back (Fig. 3). Her acne got worse after a trip to the Caribbean and did not show good results with topical tretinoin, and daily 100 mg of doxycycline for 6 weeks. She was initially treated with 1064-nm Q-switched ND YAG Laser, (Pastelle-Wontech) Acne toning mode using a 7 mm spot with the zoom handpiece, 2.5 J/cm2, frequency 8 Hz in the whole back area with three passes. This was followed by 660-nm laser handpiece (Pastelle-Wontech) was then applied directly and punctually 4 shots per inflammatory lesions with 0.3 J/cm2, spot 3mm frequency 2Hz. In a 1-month follow-up visit, the patient showed significant reduction in number of inflammatory lesions. There was a significant decrease in papulopustules in the back and also, a reduction of the post inflammatory hyperpigmentation spots. This patient presented a reduction of 95.2% in the number of inflammatory lesions (42 to 2 lesions). The patient completed three sessions every three weeks 2 and 6 months after the last session the results were maintained. After the third treatment, the patient was able to discontinue systemic antibiotics and maintain the results with only tretinoin gel application. After the three sessions, the patient reported a to be satisfied when asked with a 5-point satisfaction scale.
DISCUSSION:
Acne scars and inflammatory acne have important social implications, especially in young adults and adolescents. Severity of inflammatory lesions, family history of inflammatory acne and acne scars, duration longer than a year, and constant manipulation of acne lesions represent significant risk factors for scar-prone patients. Early intervention to inflammatory acne, reduces the scar or post inflammatory pigmentation onset and therefore will markedly improve quality of life of acne patients.
There has been extensive research into the role of laser therapy for the treatment of acne. There are various studies confirming laser therapy is a great alternative for the treatment of acne scars but, as we described before, it is important to prevent the scar appearance with anti inflammatory treatments. Up to 43% to 69% of patients presenting with inflammatory acne develop scars (8).
Jeremy et al found that proinflammatory cells and molecules like CD3+ and CD4+ T cells, number of macrophages, E-selectin, vascular adhesion molecule 1, and interleukin-1 (IL-1) were elevated in the uninvolved and involved skin of Acne Vulgaris patients concluding that the inflammatory environment is present from the earliest stages of Acne lesion development and during hyperkeratinization (9).
Acne Vulgaris is an inflammatory skin disorder with a proinflammatory molecular environment (10). It has been reported that only 54% of inflammatory lesions were preceded by comedones, Approximately one third of inflammatory lesions on acne patients were preceded by normal-appearing skin. This confirms that the pro inflammatory cellular changes are present at every stage of the disease, from scarce comedones to the clinical presentation of active inflammatory lesions like papules and pustules (11).
Although current systemic treatments may improve active inflammatory acne, they can take a long time to reduce their number of inflammatory lesions and the inflammatory cells and molecules present in acne skin.
Our study demonstrates that the combination of the 1064 nm ND YAG Q-switched acne toning and 660nm Q-switched punctual laser treatment is a safe and effective modality for treatment of inflammatory acne and post-inflammatory erythema with good results from the first session. Patients described also a reduction in oiliness of their skin, and improvement of the skin texture.
The 1064 nm ND YAG wavelength has proven effectiveness on inflammatory acne lesions because it generates induction of sebum output reduction due to sebaceous gland destruction, modulation of inflammation at the level of gene expression and reduction of cytokines and toll like receptors (activated by C.acnes) (12).
The addition of the 660nm punctual Q-switched laser treatment in this treatment, contributes with the significant reduction of the number of inflammatory lesions because of its anti inflammatory mechanism of action. Macrophages exposed to 660 nm wavelengths release cytokines which stimulate fibroblast proliferation and the production of growth factors, thus influencing repair mechanisms wound repair (13).
There are three studies describing acne treatment protocols with 660 nm red light with significant reduction on inflammatory lesion count (7,13). Here, we are the first to report the treatment for inflammatory acne with the combination of Q-switched 660nm wavelengths used to enhance the ND YAG 1064 nm toning treatment to offer promising results in patients with lesions like papules and pustules. Within 3 months post treatment patients showed a marked improvement in acne inflammatory lesions, and by 6 months acne lesions completely resolved without recurrence. This would suggest that the combination of both modalities is helpful for the clearance of acne lesions and therefore, the presentation of acne scars.
Our case series does not prove to be effective on the non inflammatory acne. This treatment is not indicated to comedogenic acne.
This study revealed a clinically significant reduction in acne lesions counted before and the combination laser sessions. After one treatment, a 44% reduction in mean lesion count. After the second session, a 60.5% reduction in mean lesion count. And the lesion reduction was clinically significant since the first session with a final reduction in the three cases with a mean of 90% (Fig 1).
Patients were satisfied or very satisfied with the results, not only because of the inflammatory lesions reduction but also because of an improvement of skin quality and reduction of acne pigmented scars. All of them reported that they would recommend these treatments to others. The treatments were well tolerated by the patients and did not need any topical anesthesia. Patients reported very mild discomfort or not discomfort at all during the treatments. Side effects were limited to transient erythema and mild edema that lasted no more than 24 hours after a treatment. No other side effects were observed. No long-term adverse effects were recorded.
The combination treatments of the 660nm Q-switched laser and the 1064 nm Q-switched laser should be considered as an alternative potentially to long-term antibiotic therapy and isotretinoin, because this treatment offers fast results reducing inflammatory lesions, post inflammatory erythema and therefore acne scarring. Because antibiotic and isotretinoin treatments are long term treatments, there is a potential to present dangerous side effects.
ABOUT THE AUTHOR:
Dr. Irene De La Peña is a certified dermatologist and talented, medical aesthetic doctor in Bogotá, Colombia. Her academic achievements and educational background, include a Medical Doctorate from Javeriana University in Bogotá, Colombia, a Masters in Aesthetic Medicine and Laser Therapy from Rosario University in Bogotá, and a Masters in Dermatology from CUYO University Argentina. She is currently the medical director of the Orbit Clinic and Director of Octa Professional Laser Training Program in Bogotá, Colombia. Dr. Irene is also a member of the Colombian Society of Aesthetic Medicine.
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