Because of the concerns and debates over the safety of Accutane and long-term antibiotic use in the treatment of acne, lasers and other newer technologies that work on the surface of the skin will probably play an ever-larger role as future therapies for acne. I describe the use of lasers and other light sources in the treatment of acne and go on to tell you about what is known about treating acne with chemical peels.

Light Up My Face

Using lasers and light therapies offers a promising, noninvasive alternative to treat acne. Lasers and lights show evidence of improving not only inflammatory acne, but can also lead to improvement in acne scars.

The long-term benefits of lasers and other light sources as methods for prevention and treatment of acne itself, is presently an open question, but the future appears bright. Until more is known, laser and light therapies may offer an alternative for people whose acne hasn’t responded to traditional acne therapies.

Lasers can be tuned to target specific structures. When used to treat acne, the beams are adjusted to penetrate below the epidermis without causing any injury to it. They travel into the dermis where they can zero in on hair follicles, sebaceous glands, and the P. acnes bacteria.

Certain lasers can also be used to destroy “broken” blood vessels (telangiectasias) in the dermis; some lasers, by heating dermal collagen, can help to “tighten” the dermis and result in less visible scarring. Lasers that are used in acne scar treatment are the resurfacing (ablative) lasers and the non-ablative lasers.

Researchers are hopeful that such treatments will lead to a reduction in the amount of drugs required to treat acne. At this stage of the game, laser and light therapy seem to be most helpful when used in combination with traditional acne medication treatments.

Most acne patients using these technologies generally must continue to use topical and oral medications; however, several investigators report that some patients tend to require less oral and topical antibiotic treatments when lasers or lights are effective.

There are two basic groups of acne-treating lights. One group of technologies inhibits the growth of the bacteria P. acnes and the other group of light sources aims to shrink the sebaceous oil glands that also play a pivotal role in causing acne.

Most insurance plans classify the light and laser treatments used to treat acne as “emerging technologies” and will probably not pay for your treatments. Many are still in the investigational stage and may not be the first choice for treating your acne.

All of these treatments are expensive, time-consuming, and some are still in the experimental stage. Many people who have dark skin have been told that laser treatment is not safe for them. However, in expert hands, very specific wavelengths of lasers can minimize complications such as PIP and scars.

Honing in on P. acnes with photodynamic therapy

Photodynamic therapy (PDT) involves applying a drug called a photosensitizing agent, which is then activated by exposure to a light source. Light sources used in PDT include visible (nonlaser) or laser light. This combined interaction of the solution and the light is what gives rise to the term “photodynamic therapy.”

The U.S. Food and Drug Administration (FDA) has approved a nonlaser, narrow-band, high-intensity visible blue-light therapy for treating inflammatory acne. It works by killing the acne-causing bacteria, P. acnes. The P. acnes that reside in your sebaceous glands produce chemicals known as porphyrins as a by-product of their metabolism.

Visible light — in this case blue light — seeks out the porphyrins that are in the bacteria. This high intensity light activates these porphyrins and thus kills the bacterial cells.

Researchers hope that the sebaceous gland is “knocked out” or at least slows down as a result of this procedure (as a sort of “collateral damage”); however, we don’t have hard evidence to actually document that this procedure succeeds in accomplishing it.

A doctor, nurse, or technician applies a clear, painless solution, aminolevulinic acid (ALA), to your skin. ALA is a potent, photosensitizing agent that increases sensitivity to light. It’s left on your skin for 15 to 60 minutes and allowed to accumulate in target cells — the sebaceous glands.

An intense, visible light source (usually a blue light) activates the ALA. This takes about eight to ten minutes. The chemical reaction that occurs produces heat and the bacteria are destroyed. Immediately after this treatment, if you go out in the sun — even for a few minutes — you can develop a significant sunburn and peeling.

For about two days after the photosensitizing agent is used, keep your face from being exposed to strong, direct light. Be sure to use sun protection. Other side effects tend to be mild and include temporary pigment changes, swelling of the treated areas, and dryness.

Many treatments may be necessary to achieve satisfactory results. Because this type of therapy appears to target only one cause, P. acnes, the acne may not respond in the long run. That’s because the destruction of these bacteria is only temporary; they revitalize rapidly, so ongoing treatments are necessary.

Microdermabrasion, is a gentle way to exfoliate the surface of the skin. Recently, some investigators have found that PDT can be performed on a “short contact” basis.

Using PDT after a light microdermabrasion allows for better penetration of the ALA. A new photosensitizing agent, known as lemuteporfin, that seems to better penetrate the sebaceous glands, is now being investigated as a potential acne photosensitizer.

Stopping oil at the source and other promising paths

For longer term results, it appears to be necessary to destroy the sebaceous gland as well as the bacteria. Various light sources are being tried in order to more deeply penetrate into the sebaceous glands. Technologies currently under consideration as potential acne treatment include:

• Intense pulsed light (IPL): These devices are similar to lasers, but they use a wider range of wavelengths as opposed to only a single beam of light. They employ a broad band of visible and near infrared wavelengths of light that block out other wavelengths.

Pulsed light can deliver hundreds or thousands of colors of light at a time. Pulsed light machines use “cut off” filters to selectively deliver the desired wavelengths. These wavelengths can be customized to reach the specific targets such as blood vessels or other skin components that are being treated.

IPLs can penetrate various depths into the skin, and by using longer wavelengths, they may able to affect the sebaceous glands’ growth and activity. Long-term studies are necessary to see how effective they will prove to be.

• Pulsed dye laser (PDL): Results for acne have so far been inconsistent. This laser is “tuned” to a specific wavelength of light. It produces a bright light that is absorbed by blood vessels. This laser is also being used to improve the appearance of acne scars and is effective in removing the enlarged blood vessels associated with rosacea.

• Pulsed light and heat energy (LHE) therapy: This treatment combines pulses of light and heat, which researchers believe target both P. acnes and the sebaceous glands, two of the main causes of acne.

• Diode laser: This laser uses infrared frequencies that are longer, invisible wavelengths. It appears to be effective on not only acne, but on the acne scars as well.

Avoiding ultraviolet light

There was a time that acne was routinely treated with ultraviolet (UV) lights. Acne sufferers would visit the dermatologist for their weekly dosage of sunburns from sunlamps. The results? It looked like they’d spent a long day at the beach — they’d be red and peeling for days afterward.

The treatment did make acne look better for a time and may have had some benefit as a peeling agent. It also helped to blend skin tones and hide the acne lesions. But as we now know, repeated exposure to high intensity UV rays should be avoided.

Frequent exposure to ultraviolet light can promote aging of the skin as well as certain skin cancers. The light sources used to treat acne today don’t contain UV light. For more information on UV light, the sun, and your skin. As for the proponents of tanning salons, they contend that:

• Exposure dries up acne and improves its appearance.
• Using artificial tanning equipment, like beds and lamps, as well as natural sunlight, can protect you against some forms of cancer by increasing your vitamin D levels.

Dermatologists (including myself) believe that artificial tanning equipment, such as beds and lamps, should be avoided particularly if you are at higher risk of sun damage.

Taking It from the Top

Chemical peels have become popular as anti-aging, facial rejuvenation procedures; however, they’re sometimes used to treat acne as well. In this procedure, a chemical acid solution is applied to your skin, causing the skin to peel off so that new skin can regenerate.

Some of the peels have fancy names, extravagant prices, and are associated with overstated expectations. In fact, many of them are just gimmicky variations on the basic peels I describe in this section.

The peels work on wrinkles by loosening the glue-like substances that hold the dead cells on the surface of your skin together, causing them to peel off (exfoliate). This allows the skin to renew itself and thus lessen the appearance of fine lines and wrinkles and balance out skin pigmentation.

Chemical peels also produce a similar exfoliating action in your hair follicles where the sticky dead cells congregate and block your pores, causing acne breakouts. Chemical peels are probably not effective for the treatment of inflammatory lesions of acne.

They seem to work best in the elimination of blackheads and whiteheads (comedonal acne). Peels for acne are generally superficial and less apt to cause complications such as pigmentary changes to the skin. Deeper peels, with stronger concentrations of acids, are sometimes used to treat acne scars.

Superficial peels don’t penetrate below the upper layers of skin and can sometimes also help to even irregular skin tones by lightening the dark spots of acne.

Finding the treatment that is right for you depends on your skin type, the activity of your acne, your degree of scarring, and of course — as with all cosmetic procedures — your ability to afford it, because most, if not all, health insurance plans don’t pay for them.

With chemical peels, persistent redness, permanent color change, and scarring are possible, especially with the deeper, highconcentration peels. Reactivation of cold sores has also been seen.

Most importantly, if you or anyone in your family has a history of keloids or other types of significant scarring tendencies, these procedures are probably not for you. Not only can peels reactivate cold sores, they can cause them to spread over your entire face.

If you have any evidence of active herpes blisters, don’t have any sort of peel (or microdermabrasion, regular dermabrasion, or laser abrasion). It’s important to protect your skin from the sun after any chemical peel.

Ask your doctor to recommend a sunblock with both UVA and UVB protection, and apply it daily for at least four weeks after the treatment. Occasionally, a topical retinoid such as Retin-A is used to pre-treat the skin by thinning the skin’s outer layer. This preparation allows for deeper penetration of the chemical solution.

The pre-treatment period may take up to a month before the chemical peel is actually performed. Chemical peels can be administered by a doctor, a nurse, or an aesthetician. Most states limit aestheticians to lower concentrations of these acids. The lower concentration peels that are much less potent than those used in doctors offices have little, if any, effect on acne.

Experiencing an AHA or BHA peel

The two most commonly used chemicals for peels are the alpha hydroxy acids (AHAs) and the beta hydroxy acids (BHAs). Procedures using these chemicals are commonly referred to as “lunch hour” peels because they’re the mildest of the chemical peels and show few after-effects; some folks get them on their lunch hours and are ready to go back to work right away.

Both of these acids are also found in many over-the-counter cosmetic products, such as moisturizers and sunscreens, but when a medical professional performs the peels, concentrations are much higher.

Lactic acid, a trendy AHA found in many over-the-counter products and prescription moisturizers, is hardly ever used for in-office peels. Lactic acid is not a “fruit acid” like other AHAs, because it comes from milk.

The two most commonly used acid peels are:

• Glycolic acid: Glycolic acid, an AHA, peels off dead layers of the skin and, typically, requires no downtime. These peels are performed every two to four weeks in a series of four to eight sessions.

• Salicylic acid: Salicylic acid, a BHA, is oil soluble and can therefore penetrate oil-plugged pores. When used as in-office peels, these treatments can hasten the response of acne to treatment by reducing the amount of sebum being trapped in your hair follicles. It is repeated at two- to four-week intervals. Typically, you combine this treatment with oral or topical acne medications.

The application of AHA and Beta peels are relatively fast and simple. No sedation or anesthesia is required, because you only experience a slight stinging when the solution is applied. The treatment usually takes about 10 to 15 minutes, but the concentration of the chemical solution or the length of time of the treatment may vary.

After treatment, apply generous amounts of moisturizer. The skin remains slightly pink for a few hours to a day, but you can use makeup to cover it up, if you like. Minimize (or completely avoid) sun exposure until the skin is completely healed.

Trying out a TCA peel

Trichloroacetic acid (TCA) peels are sometimes used for lightening areas of pigmentation. TCA penetrates more deeply than AHA and BHA and creates more active peeling, especially at higher concentrations. This method also carries a greater risk of scarring.

As a result, lasers and light therapies have mostly replaced these deeper peels for the treatment of acne and scars. TCA peels are medium-depth peels and should only be done in a doctor’s office or in an outpatient surgery center, because they produce deeper penetration and destruction of the skin and must be used with great caution.

TCA peels often don’t require anesthesia (because the solution itself has a numbing effect on the skin). When the TCA is applied, you may at first feel a warm or burning sensation, followed by stinging. Following the application, the skin develops a “frosted” appearance within a few seconds and the treatment is diluted with cool water.

Significant swelling may occur depending on the potency of the TCA that was used. Swelling should diminish after the first week and the skin will generally heal sufficiently to resume normal activities in approximately seven to ten days.

You shouldn’t have such a medium-depth peel if you have dark skin. Furthermore, wait at least a year or more after being treated with isotretinoin (Accutane) before having such a peel.