Erbium: YAG laser resurfacing of inflamed cystic acne

Erbium:YAG laser resurfacing in patients with inflamed cystic acne , Michelle Zaniewski Singh et al., Journal of Cosmetic and Laser Therapy.2006; 8: 163-166

Background: Inflammatory cystic acne has been treated by a variety of modalities including antibiotics, topical agents, isotretinoin and chemical peels with variable degrees of success. Erbium: YAG lasers have been used for the treatment of acne scarring and photoaged skin but have not been thought of as treatment for actively inflamed lesions.

Objective: We sought to ascertain the effectiveness of using very low fluence Erbium: YAG settings without any topical anesthesia for the treatment of two patients with inflamed cystic acne.

Methods: Two female patients skin type 4 of Hispanic (32 years old) and South Asian origin (21 years old were treated with the 2940 Erbium: YAG LaserPeel laser. The Hispanic patient used the 200mj setting. The Asian patient used a combination of 200 and 400 mJ for her first treatment and 400 mJ for the subsequent two treatments. The Asian patient was treated thrice at monthly intervals for the first two treatments and a two month interval between the second and third treatments. The Hispanic patient was treated with two treatments at a two month interval.

Results: Both patients healed within 6 days and were able to use makeup after two days. Results were excellent in both.

Conclusion: Low Fluence Erbium: YAG facial resurfacing was effective for the treatment of inflamed cystic acne. Its use as a treatment modality should be further explored.

Microdermabrasion and superficial chemical peels have been useful in the treatment of acne but have limited usefulness in inflamed cystic acne. Oral antibiotics and isotretinoin are commonly used. The safety of long term antibiotics has been questioned in reports linking this to an increased risk of breast cancer in females. Unfortunately, despite all warnings of teratogenic effects and a registry with mandated pregnancy tests women still conceive on isotretinoin therapy. A need exists for safer more effective therapy. Photodynamic therapy with aminolevulinic acid and various light modalities such as blue light, red light and Intense Pulsed Light has been useful. This treatment necessitates considerable effort to avoid light exposure afterwards and some pain and down time.

Other laser therapy for acne is usually aimed at treating scaring using infrared wavelengths such as the 1320 Nd: YAG and 1450 diode lasers. Pulsed Dye lasers were used for this purpose but the treatment has yielded inconsistent results (1). CO2 laser resurfacing is effective at treating laser scarring but the prolonged recovery time, possibility for pigmentary alterations, possibility of creating scarring and inadvisability of using repeated treatments are all disadvantages. Erbium: YAG resurfacing has been commonly used as an effective treatment for acne scars but not for active cystic or nodular acne. We decided to explore the use of the superficial Erbium “weekend peel” in two patients with inflamed cystic acne.

Both patients underwent low fluence full face single pass resurfacing using a 200 mJ setting, 6mm spot size, fixed 300 microsecond pulse duration using The LaserPeel Erbium:YAG laser The second patient was also treated at the 400mJ setting. Both patients were treated without any anesthesia. They were offered topical lidocaine but neither accepted the offer. We discussed with them the fact that the skin chromophore for the laser energy is water. We stated that we did not know if the use of topical lidocaine would limit the effectiveness of the treatment because of the water content of the product. The discomfort associated with the lower fluence setting of this machine is mild. It is significant with the higher settings. Neither patient received antibiotics or antivirals. We did not overlap pulses on the skin between pustules and did leave a small amount of untreated skin between laser pulses. We did overlap pulses and did multiple pulses over the pustular lesions. We pulsed the lesions, wiped off the frost and pulsed again a number of times using a freehand technique with no scanner. After treatment the patients were instructed to clean with only water until healed .They were given the option of using Aquaphor or Preparation H gel if their skin started to crack with healing. They were instructed to use dilute vinegar water if it helped with the sensations of itching or burning. They experienced facial swelling for one day after treatment. Neither required pain medication. On the evening of the second day they began to peel and they were healed by approximately six days. They were able to apply makeup and return to usual activities on the evening of the second day. The Hispanic patient returned to using her 2% glycolic salicylic was after 3 days and the South Asian patient used no other al treatment. She was previously using benzoyl peroxide gel for acne lesions but she no longer found this necessary.

Both patients were clinically greatly improved. We noted desiccation of the pustules during treatment. The Hispanic patient thought that there was 80% improvement after the first treatment. We noted that there were no new lesions and that her pustules became dry and flattened during the procedure and as she healed. Both patients had considerable improvement in acne scarring as well as dramatic reduction in the number and severity of lesions

This report has limitations. This is a retrospective review of two patients rather than a controlled randomized or split face study with larger numbers. We did not count lesions or biopsy affected areas. The number of patients is small. Nevertheless we and the patients thought that the results were spectacular and that this modality of treatment deserves further study.

Acne is one of the most common skin diseases affecting up to 80% of the population at some time and it is often refractory to treatment. (2) Microdermabrasion, topical therapies, oral antibiotics, isotretinoin and a variety of laser and light therapies have been employed. A variety of laser and light treatments have been used employing the 1320, 1064, 1450 wavelengths, intense pulsed light and red or blue LED light. Photodynamic therapy with topical 5-aminolevulinic acid has been used with blue light, red light, pulse dye lasers (2) and intense pulsed light. The results from the infrared wavelengths have been variable but somewhat beneficial in the treatment of acne scarring. The use of photodynamic therapy with ALA has been helpful but limited by photosensitivity reactions, blistering, edema, erythema and pigmentary disturbances.

The energy from the Erbium: YAG laser with the 2940 nm wavelength is avidly absorbed by water. The penetration of the laser beam is dependent on fluence and spot size but is more superficial than the CO2 Laser or the 1320(3), 1450 (4) and 1540 wavelengths. This modality of treatment has been effectively used for the treatment of superficial epidermal lesions, photodamage, some superficial scars and superficial rhytids associated with photoaging and lentigines. Because of low absorption by melanin this wavelength has been very safe and helpful in the treatment of patients with dark skin types. The use of short and long pulsed Er: YAG settings has been explored in the treatment of acne scarring (5) with satisfactory results. Compared to CO2 resurfacing the depth of ablation is less and hemostasis is not facilitated. The more superficial penetration leads to more rapid healing and less likelihood of pigmentary disturbances. The depth of thermal damage is determined by the usual parameters of fluence, spot size, pulse duration, overlap and pulse stacking. Superficial treatments are less likely to promote dermal remodeling while deeper treatments have the potential for some dermal effect.

The effect of the infrared wavelengths on acne is thought to be due to damage to the pilosebaceous unit while the effect of photodynamic therapy with aminolevulinic acid is thought to be due to a photochemical reaction with porphyrins produced by Propionibacterium acnes leading to the production of singlet oxygen and bacterial cell death (2),(6).

The mechanism of beneficial action of the Erbium YAG laser on active inflammatory acne is unknown. It could be due to desiccation of lesions, sterilization of lesions by direct photothermal killing of bacteria or some other unknown effect. One might think that the penetration of this wavelength might be too superficial to affect the sebaceous glands but it is possible that the depth of sebum presence may be more superficial within pustular lesions. We feel that further research should be done to resolve these issues.

has been a safe and effective treatment for active inflamed cystic acne as well as acne scarring in two patients with the Fitzpatrick 4 skin type. We feel that further studies are warranted to assess the usefulness of this modality of treatment.

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