Procedural Treatments for Acne

by

Michael H. Berkson, M.D.

Although topical and systemic ( oral) medications form the backbone of most acne treatment programs, there are a variety of procedures that can be used to complement the medical treatment of acne. The most common procedures that are used to treat acne are cortisone injections, acne “surgery”, chemical peels, microdermabrasion,  and various types of light sources including blue light and lasers.

Intralesional Steroid ( cortisone) Injections

An injection of a dilute concentration of steroid directly into an inflamed acne nodule is the single most effective and dramatic form of “first aid” for select acne lesions, and thus tops the the list for most useful adjunctive procedure for the treatment of acne.  Using a very fine needle, a tiny amount of triamcinolone (Kenalog) suspension is introduced into the nodule resulting in very rapid (within hours) decrease in inflammation and shrinkage. The procedure is associated with minimal discomfort, and once someone discovers this unique trick for making acne nodules disappear, they keep coming back for more!  People will often come in for an injection before an important event like a wedding or photo shoot. The downside of this procedure is that it can only be used selectively on isolated or small numbers of highly inflamed nodules, and like other acne procedures, it does not prevent or alter the course of subsequent acne.

Acne “Surgery”

Acne surgery refers to the mechanical removal or extraction of open and closed comedones (blackheads and whiteheads). The contents of open comedones can usually be removed by the use of an instrument called a comedone extractor which exerts pressure over the opening of the blackhead and pushes out the material that is impacted in the follicle. Closed comedones typically require a small nick or incision with the tip of a needle or scalpel blade to open the whitehead after which the comedone extractor can be used to remove the material.

Acne surgery can be repeated as often as monthly, or on an as needed basis. Although acne surgery can be a very effective way to quickly clear the skin of blackheads and whiteheads, the improvement is temporary unless some form of medical treatment such as the use of a topical retinoid is in place to help prevent the formation of new comedones.

Chemical Peels

A chemical peel involves the application of an acid to the skin which results in a mild wounding of the upper layers of the skin, the epidermis and superficial dermis, with resultant exfoliation and subsequent skin renewal.

The most common chemical peels used for the treatment of acne are the superficial peels which utilize either salicylic acid or glycolic acid. Both are naturally derived, from tree bark and sugar cane, respectively. Salicylic acid and glycolic acid are common ingredients in over the counter acne products, but are used in higher concentrations in chemical peels.

During the procedure, the peeling agent is uniformly layered on the skin using a sponge applicator and typically remains in contact with the skin for several minutes after which time the acid self neutralizes or in the case of glycolic acid, is neutralized with water. A mild stinging sensation typically accompanies the procedure, and one can expect some facial redness and peeling for several days after the procedure.

Like acne surgery, chemical peels are a rapid method of removing comedones. They can also temporarily reduce inflammatory acne lesions and can help fade the hyperpigmentaion and blemishes that often outlasts the original acne. Chemical peels can be repeated periodically at 4-6 week intervals as the effect is temporary. They are best used in conjunction with topical and/or systemic treatment which is better able to reduce the frequency and intensity of future breakouts.

Microdermabrasion

Microdermabrasion is a procedure which utilizes a device that combines abrasive crystals and suction to mechanically abrade the superficial layers of the skin. The effect is similar to that of superficial chemical peels, as is the recovery after the procedure. Like peels, microdermabrasion can be repeated periodically, the effect is temporary, and it is best used in combination with other treatments. In recent years, several hand- held home microdermabrasion units have come on the market. They generally offer more modest results compared to the devices used in medical settings.

Blue Light

Blue light treatment has been available for years for the treatment of mild to moderate acne. The principle is that the blue light activates compounds called porphyrins that are produced by the P. acnes bacteria, one of the factors that are involved in the causation of acne. These activated porphyrins are toxic to the bacteria and cause their destruction. Less bacteria in the follicle results in less inflammation and less acne. The blue light is administered with a special device in a medical setting. The length of exposure is about fifteen minutes per session, and the recommended frequency is twice weekly for eight weeks.

Although blue light is extraordinarily safe and free of side effects, it is expensive and inconvenient logistically. Furthermore, the efficacy approximates that of the topical antibiotic, clindamycin, so in most cases, it is only mildly beneficial. Continued treatment is necessary to maintain the effect, and like all procedural treatments it is best used in combination with other medical therapies.  Devices that emit blue and/or red light are now available for purchase and use at home.  These devices are generally not as strong  as those used in a medical setting.

Photodynamic Therapy (PDT)

Photodynamic therapy or PDT is a procedure that combines the application of a chemical called 5-ALA ( 5-aminolevulanic acid) to the acne prone skin and then uses a light source such as blue light, red light, or a laser to activate the ALA. The ALA then gets converted to porphyrins that are toxic to both the P. acnes bacteria as well as the sebaceous glands.

PDT is a more aggressive treatment than blue light by itself and it can be effective for moderate or even more severe acne. The main disadvantages are side effects and cost. After PDT one can expect facial redness and swelling that can be severe for up to a week after the treatment. A moderate amount of facial peeling is also common starting several days after the treatment. One needs to avoid sunlight as well as intense visible light for two days after the treatment as the 5-ALA remains active in the skin for several days and light can keep the reaction going for that period of time resulting in even more redness and discomfort. More than one treatment is usually necessary for optimal results and periodic repeat treatments can help maintain the improvement.

Lasers and Intense Pulse Light (IPL)

There are several types of lasers and laser type devices that have been studied for the treatment of acne.. The 1450 nm diode laser has been shown to damage the sebaceous glands leading to less oil production and indirectly to less bacteria in the follicle. The downside of this laser is that is expensive, has limited availability, and the treatments are painful. Repeat treatments are usually needed for optimal results.

Intense Pulse Light (IPL) is a laser-like device that can be combined with suction, so called photopneumatic IPL, to treat non inflammatory and mild inflammatory acne. Like the laser, the utility of IPL is limited by cost and availability of the device. The need for repeat treatments with IPL is a given.

The role of lights and lasers in the treatment of acne has yet to be fully established. They are expensive and inconvenient and at this time should be considered ancillary procedures to standard medical treatment. The exception to this is the use of lasers to treat acne scars which is now accepted as one of the standard treatments for certain types of scarring.

Microneedling is an emerging treatment that has proven to be highly effective for acne scars.  For more information on microneedling, please see the article on this website titled Microneedling: A New Treatment for Acne Scars, authored by Dr. Sheila Krishna.

The next article will focus on my treatment approach to acne which has been developed and refined over twenty five years in the practice of dermatology.

References:

Efficacy and safety of superficial chemical peeling in treatment of active acne vulgaris. Al-Talib H et al. An Bras Dermatol. (2017).

Superficial chemical peels and microdermabrasion for acne vulgaris.  Kempiak SJ, Uebelhoer N.  Semin Cutan Med Surg. 2008 Sep;27(3):212-20.

The Role of Photodynamic Therapy in Acne: An Evidence-Based Review. Boen M et al. Am J Clin Dermatol. (2017)

Acne vulgaris and light-based therapies. Momen S et al. J Cosmet Laser Ther. (2015)