Berger-acne-wp-1553-0074

ACNE THERAPY
Experience with Palomar LuxV™ Intense Pulsed Light Therapy
Robert S. Berger, MD, FAAD, FASDS., Assistant Professor, Department of Dermatology, The Johns Hopkins University, Baltimore, Private Practice, Waldorf, Maryland Cathleen S. Berger, RN, BSN, Waldorf, Maryland Acne is a disease that affects almost 100% of the popu- hair (bangs as well as shoulder length). Some feel acne lation, from ages 8 to 80. The symptoms range from rare, improves in the summer, either due to lack of stress or mild disease to severe, disfiguring disease, resulting in scar- ring. The more severe the disease, the higher the incidence The treatment of acne is as varied as the clinical presen- of depression, even to the extent of suicidal thoughts.
tations. There are some absolute rules, however. First, The clinical presentation ranges from comedonal disease acne is not a disease of dirt. Over-washing the face, espe- (whiteheads and blackheads or “little bumps”), to red cially scrubbing with a rough cloth, will worsen the dis- papules and large cysts (“big bumps”). Scarring is associated ease, as that activity drives the bacteria deeper into the with cysts and “big bumps,” as well as scratching, picking, hair follicle. A gentle cleanser, using a face cloth or fin- or popping of lesions. The scarring can be extremely disfig- gers is all that is needed. Over-scrubbing makes the face uring. Adolescents with acne suffer greatly from their more sensitive to (and less likely to respond successfully disease, affecting their social and academic growth.
to) the topical products, especially the retinoids.
The cause is essentially unknown. Most authorities agree Topical retinoids are absolutely essential for the success- that there is a genetic blueprint for the duration and ful treatment of acne (second absolute rule). Retinoids act severity of acne, which varies greatly from patient to to remove and prevent micro comedones, as well as pig- patient. There is no ethnic predilection, but males are mentation. Currently there are three prescription types generally more severely affected since testosterone is (tretinoin, tazaratene, and adapalene), and numerous over-the-counter types of retinoid creams. Over-the-counter (OTC) retinoids may not deliver the consistent The transition into puberty causes an increase in the size levels of retinoid needed to be effective. This is because of sebaceous (oil) glands, as well as increased oil secretion.
most, if not all OTC retinoids have to be converted to These changes, as well as a change in the keratinization tretinoin to be effective. This conversion is never 100%, of the hair follicle, cause occlusion, which results in thus the end concentration of tretinoin, or other active comedone (whitehead and blackhead) formation. This compounds is difficult to quantify. I classify the three occlusion allows the proliferation of Propionibacterium Acnes bacteria. This bacteria is felt to be the cause oflarger acne lesions due to the immune system response Adapalene, the mildest, takes the longest to work (up to to the bacteria, inflammatory enzymes produced by the 12 weeks) and has the least documented cosmetic benefit Some feel the depth of the occlusion in the hair follicle Tretinoin is mid range, especially the .04% micro gel or determines the size of the resultant acne lesion, with a .05% cream (works in 6-8 weeks). I prefer the micro gel deeper occlusion resulting in a larger lesion. External as it is less irritating than the .05% cream.The microgel is factors vary from patient to patient. Stress is a universal also sun resistant and benzoyl peroxide does not affect its aggravating factor. With the exception of dairy products activity. The micro gel formulations are less irritating in women, dietary triggers are more individual than than the creams, which are less irritating than the gel for- universal (otherwise there would be no acne as no one mulations. I prefer to use them at bedtime, by themselves would eat the offending trigger). Cosmetics generally do Tazaratene is the strongest, working in 4-6 weeks. It has not play a role; however, thick theatrical make-up, as a cosmetic effect similar to tretinoin (including cosmetic well as general cosmetics while sweating can aggravate effects), but can be very irritating, especially the gel the disease. Hair spray, hair oil, and mousse can aggra- vate the condition as can hats, sweat bands, and long Tretinoin cream (not micro gel) is inactivated by sunlight All of the above therapies have been available with little and must be used at bed time. It is also inactivated by change for the past 10+ years. A new option for the treat- benzoyl peroxide preparations (again, not micro gel).
ment of acne, the Palomar LuxV™ Intense Pulsed Light Tazaratene must not be used during pregnancy. Tretinoin (IPL) Handpiece, is beginning to revolutionize the treat- has not shown itself to be hazardous during pregnancy, ment of acne. It has certainly changed my approach to but some prefer not to use it. Adapalene is best avoided during pregnancy until retrospective data demonstrate a I use this system to treat all types of acne (mild to conglo- bate), and all skin types (I-VI). It is perfect for those who Topical retinoids act on keratinization of the hair follicle, do not want to take antibiotics, are attempting to become helping to prevent occlusion. There is good evidence to or are pregnant, or who can’t or won’t take isotretinoin.
suggest that the use of retinoids for one year after clear- It can be used in the treatment of rosacea as well as acne ing reduces the recurrence of acne in patients that have vulgaris. It almost always allows me to lessen the amount completed isotretinoin (Accutane®). I recommend a topi- of antibiotics I have to use, if not stop them completely. cal antibiotic in the morning. I prefer Cleocin® lotion I have personally witnessed lesions treated by this system since it does not irritate the skin. I will also use a 10% fade in an hour. I have been told the same by patients and parents. In my opinion, the only treatment thatworks faster is systemic steroids.
The above is the basic topical therapy for mild acne. Thiswill effect “small bumps” (whiteheads, blackheads, and At the time of this writing, my office has administered very few small papules). As papules increase in size and more than 4,500 treatments, the bulk over the last 18 number I will add a systemic antibiotic, usually low dose months. The LuxV is compatible with every topical and doxycycline 50 mg/day (up to 200 mg/day) or tetracycline systemic acne therapy, both prescription and over the 250 mg/day (up to 1000 mg/day). If symptoms worsen counter. The only side effect is heat, which can result in (inflammatory cysts), I will use minocycline 75 mg/day, a “curling iron burn,” or even superficial blistering. This up to 200 mg/day. I prefer low dose doxycycline to begin is seen in type III-VI skin, especially when there is sun with because there seems to be more anti-inflammatory effect than tetracycline, and doxycycline is much more It can also occur with insufficient cooling of the handpiece when used with the Palomar EsteLux® and The chronic use of antibiotics in acne seems to be related MediLux™ Systems (especially EsteLux), and incomplete more to anti-inflammatory effect than antibiotic effect. One compression of the handpiece on the skin while adminis- must remember that doxycycline and tetracycline are photo- tering the treatments. One must be very cognizant of sun sensitizing, especially at higher doses. Minocycline is much exposure as a little sun will change the pigment in the less so. Minocycline has a longer list of side effects, some of skin enough to prevent you from increasing the power which are serious. Tetracycline must be taken on an empty settings, and may require a lowering of the settings. I stomach, while the others can be taken with food (low have not seen any scarring or permanent dyschromia iron), but it is best to avoid other medications. Minocycline should be discontinued after 18 months of continuous ther- The Palomar DermaType™ Skinphotometer is an excel- apy, especially at 200 mg/day since the incidence of serious lent tool to prevent burning. We take the approach that side effects increases at that time. Never take these right all teenagers go out in the sun during the summer and before bedtime as they can cause gastric irritation. therefore we proceed more slowly than during the winter If these “simple” systemic therapies fail, the next systemic months. Otherwise we generally start at the lower power therapy is isotretinoin, considered the last line of therapy settings depending upon skin type and increase as toler- for severe nodulocystic acne, unresponsive to the above ated. Patient response is important to determine if the therapies. The long list of side effects and great expense make this the last choice of therapies.
In general, we treat in 2 week intervals, with an average For those patients with rosacea, I will use Klaron/Cleocin of five sessions during the initial treatment period. After lotion, alternating with a mild topical steroid (hydrocorti- that we evaluate the response and extend the intervals by sone). I avoid retinoids in the early treatment of rosacea two weeks: four weeks, then six weeks, then eight weeks, etc. Once 10-12 week intervals are established, we let the patient call us when needed. We begin to taper and dis- difficult time getting up to button #4. Type IV skin usually continue oral therapy if the clinical response allows near the end of the first group of treatments. If we cannotextend the therapeutic interval we consider maximizing LuxV with MediLux System
oral therapy up to and including accutane. Most patientsare able to use minimal or no antibiotics (50 mg /day) The MediLux System still requires cooling of the crystal with 1-3 treatments/year as maintenance. (handpiece) and the skin. There is more available energy at the fixed settings with MediLux, allowing us to increase We continue topical therapy with a retinoid for up to one our starting settings with this next generation system. year after sessions have concluded. There are no issueswith birth control pill effectiveness as is sometimes impli- We were able to start with button #2 and even #3 for most cated with oral antibiotics. There seem to be no con- patients with I-II skin types. Skin type III without a tan traindications for women who are pregnant or are could also be started with button #2. We could more rap- idly advance the power settings due to the advanced cool-ing. The best results were seen with buttons #4-6. Darker I will now break down specific therapeutic recommendations skin types (IV-VI), could be treated, very carefully with a lot of cooling, but only with button #1, and rarely #2. LuxV with EsteLux System
LuxV with StarLux System
When using the EsteLux, cooling both the handpiece The StarLux System represents a tremendous advance (with coolant spray) and target skin (with ice bags or the over the other two systems. The flexibility of changing Palomar Cool Roller) is essential to prevent burning. This the fluence and pulse duration independently allows us is more critical in type III-IV skin, especially during sum- to safely treat all skin types with higher fluences. mer months when the skin darkens. I would not attemptto treat skin types V-VI with this unit as the power set- The StarLux uses integrated Active Contact Cooling to tings and cooling are too limiting to have an effect and cool the handpiece, which protects skin and eliminates the need for the cryogen spray. We still chose to use someauxiliary cooling (Cool Roller or ice packs) to pre-cool We usually start with button #1 (during winter months the skin for added patient comfort and protection at we can sometimes start with button #2). The first pass should cover the entire face. These settings use longerpulse durations (100 & 60 ms), which allow more energy We generally start with 100 ms pulse width and 10-12 to be delivered over a longer period of time. In the J/cm2 for a first pass, and 20 ms pulse width and 8-10 EsteLux and MediLux, the fluences are fixed at these J/cm2 second pass. At the second treatment, the first pass is done at 100ms and 13-15 J/cm2, with the second passat 20 ms and 10-12 J/cm2. Once we reach 15 J/cm2 at We then perform a second pass at button #2 over the “trou- 100 ms, we increase at 1 J/cm2 increments, as tolerated.
ble spots” (most involved). At the next treatment we use the The second pass is increased by 2 J/cm2 until 15 J/cm2 highest power setting at last treatment for the first pass (all is reached, then 1 J/cm2 increments are used. over), and increase the setting by one button, again overtrouble spots (i.e. button #2 for the first pass and button #3 We see our best results at 100 ms and 18-20 J/cm2, and for the second pass after treatment with button #1for the 20 ms and 15-18 J/cm2.This is again for types I-II skin (no first pass and button #2 for the second pass).
tans). For types IV-VI (and dark III), we rarely go over 13-15 J/cm2 at 100 ms and 10-12 J/cm2 at 20 ms. We found At each subsequent treatment, the power is increased by that increasing the pulse width allowed us to use slightly one button at the second pass. Once button #3 or #4 is higher settings in skin type III (with a tan) through VI, but reached, we usually do not increase the settings for the increased burning and even blistering in types IV-VI skin, first pass, but increase the settings for the second pass up especially on the forehead. We did not see much difference to button #6, usually using #5. We saw our best results at in efficacy, so we opted to lower the fluence (J/cm2) buttons #4-6. We usually did only two passes, but more instead of increasing the pulse width. Despite the lower severe cases sometimes received a third pass (without fluence (J/cm2), the darker skin types improved as well.
changing power setting). Please note that this is for typesI-II skin, III without tan. Dark type III patients had a Some General Facts
times per week). We are exploring lowering the pulsewidth to 10 ms which seems to benefit these patients.
Most patients improve in the 5-6 treatment range. If you do not increase the power settings to buttons Always cleanse before treating. Make sure all cosmetics, #4-6(MediLux/EsteLux), or 100 ms 18-20 j/cm2, 20 ms moisturizers and sunscreens are washed off before treating.
15-18 J/cm2 (StarLux) the patients do not improve, They may interfere with the light absorption.
and there is some evidence they may worsen. Conversely, if you advance too rapidly in someone with comedonal acne, they may worsen and develop more Always ask about sun exposure. Most patients say they papules and cysts. If improvement is not seen, make sure have had no sun exposure, but the Palomar DermaType you are pushing the settings. While we try not to burn, will tell you if the skin has darkened since the original some stinging is inevitable. Since pain thresholds are so base line reading. So will the patient by jumping off the variable there are no set guidelines. Sometimes you have table! Always assess skin type/color before each treatment to push the patient a little bit to accept the higher set- tings. Also make sure the patient is still on the prescribedregimen. Many feel that if they show improvement, they The Palomar DermaType is the most accurate barometer of color. If the skin has darkened, we do not increase thepower that day and we sometimes decrease the power.
The treatment interval is important. We started out at The forehead always has more color and is more sensitive 4-6 weeks, but discovered (mostly in teenagers) that they than the rest of the face. We would often turn the power would improve and flare at about 2-3 weeks. When we down a setting for the forehead. We also like to start reduced this interval to the 2-3 week time frame, the results treatments on the lower face first for that reason. The improved. Less than that may be counter-productive in that upper back/chest is much like the forehead in that it too-much-too-fast may cause a flare as well (much like usually has more color and is more sensitive.
Accutane). At about the fifth treatment we try to extendthe intervals, letting the patient call for an earlier treatment Even self-tanning creams are not allowed. Skin darkening if a flare occurs. Adults usually require less treatments to for any reason will cause us to use lower power settings settle down, but require more monthly- three month inter- or burning may result. I would not stop treatments in the val treatments than teens. There is some evidence in adults summer, but you my not be able advance as quickly as you (primarily cystic acne) that a longer interval (one month) like. We will sometimes use this as motivation: “Your acne may be preferable to every two weeks as some patients is going to take longer to go away and treatments hurt tell us they worsen at two-week intervals.
more with a tan.” We have been able to effectively treatlifeguards during the summer with a little precaution. A second pass is important. We saw our best results whenwe used a second pass with a different pulse duration and Occasionally, some patients develop an urticarial response fluence. My belief is that the 100 ms pulse width pene- to treatment pulses, usually on the first few pulses and trates deeper and produces more effect on cysts and seba- unrelated to power settings or location. The rest of treat- ceous glands by utilizing a longer heating time; the 20 ms ments are uneventful. We usually give them a non-sedat- pulse width helps the superficial lesions by utilizing a ing antihistamine after therapy. We will pre-medicate with higher peak power, but delivered more superficially.
the same if it is a recurrent phenomenon. We will use anover-the-counter hydrocortisone (aquanil–HC) to help When placing the handpiece, be aware of hair-bearing skin, with redness, dryness and burning (this will not make such as eyebrows, scalp line, beard, and moustache. There is some lateral spread of the light which will burn hair iftoo close. We usually placed it 2-3 mm away from hairy In the case of over-treatment resulting in redness or even borders. Have men shave the day of treatment. Longer hair burning, we will use Gentle Waves LED technology as is more sensitive in the beard area. Always advise patients well as clobetasol cream (class I steroid). If a burn or that there is possibility of reducing hair density if treating blister develops, we treat with clobetasol cream for a few over hair-bearing area, but it is not likely.
days and/or mupirocin ointment. We use Gentle Wavesfor up to four days after the irritation develops. Once Blackheads and whiteheads are the more difficult lesions the skin has healed we may begin a bleaching cream to treat with this system. That is why it is critical to maintain a topical retinoid regimen (even if only 1-2 We know that using longer pulse duration greatly We often continue the light treatments for the first month improves the safety of treatment, allowing higher fluence or two of isotretinoin therapy. This helps with the erythe- to be used. However, increasing the pulse duration ma and initial flair typically seen with Accutane. I have beyond 100 ms with the StarLux has not been helpful, included some representative before and after photos to and rather, may make the patient more susceptible to serve as examples. The first figure represents our typical burning. This is because the “on time” is too long. Most patient, the second a patient with very severe acne who of our patients that burned with very long pulse duration did not complain of tenderness during treatment, but they Given the current climate with isotretinoin (Accutane) felt it the next day, and some developed blisters.
therapy side effects as well as requiring registration, the As with any conventional acne therapy, not everyone apprehension of patients about taking antibiotics for responds to this treatment. When response is lagging, and years with an apparent increased risk of upper respiratory the parameters are followed correctly, I push the oral thera- tact infections, birth control pill interactions and preg- py to standard levels (i.e. Minocycline 100 mg bid). Should nancy, Palomar LuxV Intense Pulsed Light treatment is that not work in combination, I consider Isotretinoin an effective first line therapy with little risk.
(Accutane). Even those patients who fail the IPL treatmentsseem to respond faster to isotretinoin, often showingremarkable improvement in the first 1-2 months. Palomar Medical Technologies, Inc., Burlington, MA 01803 Tel. 800-PALOMAR (725-6627) or 781-993-2300Fax 781- 993-2330 www.palomarmedical.comPalomar StarLux, MediLux, EsteLux, and LuxV are registered trademarks of Palomar Medical Technologies, Inc.
2006, Palomar Medical Technologies, Inc. Printed in U.S.A. 1553-0074

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