Cosmetic Improvement of Acne With Lasers David J. Goldberg, MD, JD Skin Laser & Surgery Specialists of NY/NJ
Disclosures • Research Grants: Sebacia, Sienna Labs, Aerolase
1. Hypercornification of pilosebaceous duct Bolongia. Dermatology ed. 3. Ch. 36 2. Ductal colonization by P. acnes 3. Inflammation 4. Increased sebum production
Why use energy based devices? • Don’t require patient compliance • Don’t require systemic medications • Patients may have adverse reactions • Many patients don’t want to ingest medications • The energy is targeted to the affected area • They Work!
Intense Pulsed Light (IPL) Intense Pulsed Light 100% • Photoactivates porphyrins stored by P. 90% acnes resulting in production of singlet 80% oxygen which destroy sebaceous 70% glands. 60% • Destruction of sebaceous glands lead 50% to decreased sebum. 40% • Excellent for inflammatory and non ‐ 30% inflammatory acne. 20% • Effective and safe up to skin type V 10% 0% • Pneumatic models exist boost efficacy Lowest reported reduction Greatest reported reduction IPL IPL + Pneumatic
Infrared lasers (IR) Infrared Lasers, Inflammatory lesion reduction 100% • Near infrared (700 ‐ 1064nm), 90% 80% penetrates deeper into dermis than 70% light 60% • Target is water in sebaceous gland, 50% decreases sebum output 40% 30% 20% 10% 0% Lowest reported reduction Greatest reported reduction 890 nm 1320 nm Nd:YAG 1450 nm Nd:YAG
1320 nm
1450nm
BEFORE AND AFTER: ACNE -1064nm -650 microsecond Before 13 Months After 5 Tx Photos Courtesy of Michael Gold, MD
Acne on Skin of Color After 3 rd Treatment Before
650usec, 1064nm laser vs Sham • 20 subjects • Moderate to severe acne • 3 txs – 2 weeks apart • Evaluated inflammatory lesions, comedones, porphyrin score and sebum score
650usec, 1064nm laser vs Sham • Inflammatory and comedonal lesions (62% more improvement in laser treated group vs. sham) • Porphyrin score (92% more improvement in laser treated group vs. sham) • Sebum score (100% more improvement in laser treated group vs. sham)
Sham Tx Baseline Post 3 Treatments (6 weeks after the baseline visit)
Sham Tx Baseline End of Study
Active Tx Baseline Post Treatment 1 (2 weeks after the baseline visit)
Active Tx Baseline End of Study (6 weeks after the baseline visit)
Active Tx Baseline Post Treatment 2 Post Treatment 3 End of Study (6 weeks after the baseline visit) (8 weeks after the baseline visit)
Active Tx Post Treatment 3 Baseline
Active Tx Baseline Post Treatment 2 Post Treatment 1 (2 weeks after the baseline visit) (4 weeks after the baseline visit)
Active Tx Baseline Post Treatment 1 Post Treatment 2 Post Treatment 3 (6 weeks after the baseline visit) (2 weeks after the baseline visit) (4 weeks after the baseline visit)
Pulsed Dye Laser
Pulsed Dye Laser (PDL) PDL 100% 90% • 595 nm 80% • Usually for vascular lesions 70% 60% • Evaluated after only 1 treatment 50% • Mechanism of action in acne unknown 40% 30% 20% 10% 0% Lowest reported reduction Greatest reported reduction PDL
Potassium titanyl phosphate KTP 532nm laser (KTP) 100.00% 90.00% • 535 nm 80.00% • Traditionally for rosacea and 70.00% telangiectasias 60.00% • Studies showed similar results if 1 or 2 50.00% times per week treatment for 2 ‐ 4 40.00% weeks 30.00% • Mechanism may result from 20.00% destruction of blood vessels 10.00% • Increased efficacy if area pre ‐ treated 0.00% Lowerst reduction Greatest reported with 5 ‐ aminolevlinic acid (ALA) reported reduction KTP 532nm
Radiofrequency (RF) RF on inflammatory acne 100.00% 90.00% • RF produces a thermal injury 80.00% • RF coagulates sebaceous glands 70.00% • Addition of microneedling 60.00% 50.00% increases efficacy for both inflammatory and non ‐ 40.00% inflammatory acne 30.00% 20.00% 10.00% 0.00% Greatest Reduction Reported RF RF with microneedling RF with Pulsed light
Before After 4 Treatments Before After 4 Treatments
Photodynamic Therapy • Photo ‐ oxidation and cytotoxicity via a sensitizing substance
Photodynamic Therapy (PDT) Photosensitizing Compound + Light • Administer a photosensitizing agent • Allow it to accumulate in target cells • Activate it by irradiation with visible light • Facilitate destruction of target cells through activated photosensitizer
PDT with various energy PDT with various energy devices 120% devices 100% • Activation of protoporphyrin IX can be achieved by many energy 80% modalities • Many devices work very well 60% 40% 20% 0% Greatest reduction reported IPL PDL Blue LED Red LED
Clinical Experience – ALA PDT + IPL Before 12 wks after 4 treatments Photos courtesy Michael H. Gold, MD
ALA ‐ PDT
Photodynamic acne treatment Before After
Photodynamic acne treatment Before After 12 months
Particle ‐ assisted silica ‐ gold nanoshell + 800 nm diode Laser Treatment laser 100% • Exogenous chromophore is placed into 90% sebaceous unit 80% 70% • Laser or light heats particle destroying the 60% proximal sebaceous gland 50% • Silica ‐ gold nanoshells with 800 nm diode 40% has demonstrated reduction of 30% inflammatory lesions by 61% with one 20% treatment 10% • Well tolerated by patients 0% Efficacy with 2 passes silica ‐ gold nanoshell + 800 nm diode laser
Studies with Particle ‐ assisted Laser Treatment in Acne Vulgaris Author of Trial Type of Study Device Number of Duration of % Reduction in Patients in study Treatment inflammatory (Inf) or Non ‐ inflammatory (NI) Paithankar DY et SBRCT Silica ‐ gold 48 Once with 2 laser 61% (inf) al nanoshells + passes Trial 1 800 nm diode laser Paithankar DY et SBRCT Silica ‐ gold 51 1 treatment every 53% (inf) al nanoshells + 2 weeks for 3 total Trial 2 800 nm diode treatments laser SBRCT = Single blinded randomized controlled; DBRCT = Double blinded randomized controlled; OL = Open label; RSB = Randomized single ‐ blinded
Metallic Microparticles • Sebacia ‐ gold • Sienna ‐ silver
Plasmon Resonance: Strong absorption at 800 nm Light, e.m. wave particle heated particle Particle: silica core: gold shell, 0.150 m diameter, engineered for surface plasmon resonance at 800 nm wavelength (hair removal wavelength) Light causes electrons ‐ oscillation and conversion to heat 42
Selective Photothermolysis of Sebaceous Follicles with Externally Added Gold Chromophore Penetration assist Particles • Apply particle suspension to skin; Laser deliver to sebaceous follicle Formulation • Wipe off surface particles • Laser tuned to absorption peak • Key: selectivity into follicle Preferential heating – Not in epidermis/dermis and inactivation of – Low pain sebaceous follicle – No collateral or epidermal damage 43
Pre ‐ and post ‐ auricular histology showing consistent sebaceous follicle photothermal damage J Invest Dermatol. 2015 Jul;135(7):1727-34. Scale bar: 100 microns; arrows delineate areas of photothermal damage
Topical Application of Microparticles followed by wiping off of surface particles 45
Laser Treatment after infusing particles to sebaceous follicles 46
Mean inflammatory lesion count change vs baseline, Treated versus Sham Statistically significant change between Tx and Sham at 8, 12, 16 wks Standard errors of mean and p ‐ values are shown. 47
01 ‐ 51 ‐ KC ‐ D Baseline SEB ‐ 003 Inflammatory: 69 IGA: 4 12 Weeks Δ from baseline: ‐ 80% IGA: 2 48
01 ‐ 56 ‐ MB ‐ D Baseline SEB ‐ 003 Inflammatory: 52 IGA: 3 12 Weeks Δ from baseline: ‐ 87% IGA: 1 49
Silver Silv er plasm plasmonic nic nanopla anoplates are ultr ultra eff efficient, near near in infr frared lig light ab abso sorber rbers Near-IR Light Heat E-field Oscillations of Electrons • Contained in a topical pre ‐ treatment solution • Activation by a pulse of laser light causes a burst of energy • Targeted thermal tissue injury for clinical applications
tion a SNA SNA ‐ 001: 001: Ligh Light Absorp Absorption 755nm 810nm 1064nm Alexandrite Diode Nd:YAG 1200 SNA-001.755 SNA-001.810 • SNA ‐ 001 silver nanoplates are tuned to 1000 SNA-001.1064 Absorbance (cm -1 ) b specific wavelengths Gold c Melanin 800 • 1,000 – 10,000X greater absorbance than 600 melanin 400 • 4X greater absorbance than gold 200 nanoshells 0 400 500 600 700 800 900 1000 1100 Wavelength (nm) Visible Light Near Infrared Light a Data on file. Sienna Biopharmaceuticals, Inc. b Absorbance normalized to 1% wt/wt metal (Au, Ag) or melanin c Gold nanoshells
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