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    Acne responds to energy-based therapies

    Energy-based devices can be used to treat a variety of dermatological conditions including acne and melasma, according to Christopher Zachary M.B.B.S., F.R.C.P., professor and chair, department of dermatology, University of California, Irvine, Calif.

    He advocates for the use of daylight photodynamic therapy (PDT) to treat cystic acne. Speaking in Toronto, Canada, on a panel about the management of dermatological conditions at the 2016 annual meeting of the Canadian Association of Aesthetic Medicine, Dr. Zachary suggests that the energy-based treatment offers an alternative to systemic treatment like oral isotretinoin.

    "If you can't put a patient on Accutane, you can use daylight PDT to dramatically affect cystic acne," Dr. Zachary says in an interview with Dermatology Times.  "I have not had a patient who has not done well with it (daylight PDT)."

    An advantage of PDT over systemic therapy is that it will offer an assurance of compliance to therapy, he says. "It is a fail safe," Dr. Zachary adds, noting compliance to oral therapy can be less than optimal in dermatology in general and with acne in particular.

    Data from a retrospective chart review of patients with acne treated at a university dermatology clinic showed that more than a quarter (27%) did not fill all their prescriptions. They had been prescribed one, two, or three or more treatments.1

    Melasma can be treated with topical agents like hydroquinone, but energy-based devices like the Clear + Brilliant™ laser or Fraxel™ 1927 non-ablative laser can be employed to treat the hormonally-driven condition, but Dr. Zachary cautions to be careful in the selection of energy-based devices.

    "A lot of devices can make melasma worse," explains Dr. Zachary. "They can induce post-inflammatory hyperpigmentation. There is no real magic to treating melasma. It is very difficult to treat. These are patients who come in with very high expectations."

    Melasma management

    Melasma will often recur even with minimal sun exposure, which will be a frustration for patients, Dr. Zachary says.

    Active acne with scars first requires treatment of the active acne before treatment of the scars, notes Jaggi  Rao M.D., F.R.C.P.C., a dermatologist in Edmonton, Alberta, Canada, and founder and director of Rao Dermatology.

    "You should bring the acne under control before treating scars, even if it means delaying the energy-based treatment," Dr. Rao says. "You need to deal with the active process (of inflammation) and then deal with the aftermath (the scars)."

    To manage the inflammation associated with active acne, Dr. Rao says one of several modalities can be used including topical or systemic therapies.

    "Even injectable therapies like cortisone injections can be used to bring down the inflammation," Dr. Rao explains.

    Scar treatment

    Scars are managed differently depending on whether they are elevated or indented, according to Dr. Rao.    "If they are elevated, we can use topical or injectable cortisone," he says.

    Another approach to manage elevated scars is to employ 5-fluorouracil

    with cortisone to reduce the thickness of the scars, Dr. Rao says.

    "For depressed scars, we can use laser resurfacing, either fractionated or confluent," Dr. Rao says. "They (lasers) smooth out and even out scars. Injectable agents that are pro-fibrotic and stimulate collagen like Sculptra (poly-L-lactic acid) can also be used."

    A newer treatment for managing depressed, indented scars is to use platelet-rich plasma (PRP) injections. "That may be another (established) option in the future," Dr. Rao says.

    Dr. Rao and other panelists agree that microneedling or dermal rolling would not offer benefit in managing depressed scars.

    Affecting hair loss

    Male-patterned hair loss involves two objectives: preventing further hair loss and promoting hair gain, according to the panel.

    "Medical therapy like propecia (finasteride) can prevent further hair loss and to promote hair gain, a treatment like rogaine (minoxidil) or red light phototherapy or PRP (injections)  are all options," Dr. Rao explains.

    Vitiligo      

    Similar to managing male-patterned hair loss, the management of vitiligo should involve a two-pronged approach: preventing further pigment loss and promoting pigment gain, explains Dr. Rao.

    "Cortisone stops the immune attack on the skin," Dr. Rao says. "Calcineurin inhibitors like Protopic (tacrolimus ointment) or Elidel (pimecrolimus 1% cream) are other treatment choices. Unlike cortisone, the calcineurin inhibitors avoid thinning of the skin. Using them should help prevent further pigment loss."

    To promote pigment gain, light therapies can be considered, Dr Rao notes. "Narrow-band UVB (ultraviolet B) is better than PUVA (psoralens ultraviolet A).  The excimer laser is another option."

    A topical therapy that offers the potential for re-pigmenting the skin in vitiligo is bimatoprost ophthalmic solution 0.03% (Latisse), which had been observed to cause darkening of the skin when used for ophthalmological conditions.

    "When put on top of the skin, it stimulates pigment," Dr. Rao says. "This is off-label use, but it appears very promising."

    When treating patients with vitiligo, clinicians should also screen for thyroid disease or other auto-immune diseases, Dr. Zachary says. "You need to check for other conditions," Dr. Zachary notes.

    Indeed, a retrospective investigation found autoimmune thyroid disease and thyroid nodules were significantly linked to adult-onset vitiligo. Biomed Res Int. 2016;2016:8065765. Moreover, a chart review of more than 1,000 patients with vitiligo showed that nearly 20 per cent of patients had at least one co-morbid autoimmune disease. 2

    Preventing complications

    Patients can develop complications if they are not treated by a clinician with experience in using energy-based devices. Blistering can occur when using energy-based devices for hair removal with inappropriate parameters, for example.

    "Cooling the skin, moisturizing the skin, and avoiding sun exposure are the steps to take (to manage adverse reactions)," Dr. Rao says.

    Keratosis pilaris is a condition that mimics rosacea, but should not be treated like rosacea, Dr. Rao notes. "It is commonly mistaken for rosacea," Dr. Rao says. "Anti-keraloytic agents like lactic acid and alpha-hydroxy acids can be used as well as moisturizer (to treat keratosis pilaris)."

    Energy-based devices like fractional, ablative lasers or radiofrequency devices can be employed to treat stretch marks, Dr. Rao says, noting the presence of stretch marks denotes a deficiency in collagen.

    Patient counseling

    Clinicians need to be careful about their messaging to patients to avoid confusion about the impact of sun exposure depending on the condition of the patient, stresses Trina Stewart M.D., C.C.F.P., F.C.F.P., a family physician in Summerside, Prince Edward Island, Canada, who acted as moderator of the panel.

    While patients with melasma are discouraged from exposing themselves to the sun, patients with a condition like vitiligo experience improvement and regain pigment with sun exposure. "We may seem like we are talking out of both sides of our mouths sometimes (to patients)," Dr. Stewart says.

    Energy-based devices can be used in combination with medical therapies to manage a variety of medical conditions, offers Toronto-based dermatologist Sam Hanna M.D., F.R.C.P.C., who sat on the panel.

    "Different modalities such as lasers and light sources can assist with medical therapies as adjuncts for melasma and for acne," says Dr. Hanna, president of the Toronto Dermatological Society.

    A takeaway message from the panel discussion was that patients who present with conditions such as melasma or acne or vitiligo will not just require acute care, observes Julia Carroll M.D., F.R.C.P.C., a dermatologist, panelist and founder of Compass Dermatology in Toronto, Canada.

    "A lot of these conditions are chronic, and they need long-term follow-up," Dr. Carroll says. "These are relatively common conditions, and we will be seeing these patients on a regular basis. It is important that we counsel the patients and that we let them know that they are not going to be cured of conditions like melasma or vitiligo."

    Disclosures: Dr. Stewart, Dr. Carroll, Dr. Hanna, and Dr. Rao had no relevant disclosures. Dr. Zachary is a member of the scientific advisory boards of  Solta, Sciton, and Zeltiq.

    1Anderson KL, Dothard EH, Huang KE, Feldman SR. Frequency of Primary Nonadherence to Acne Treatment. JAMA Dermatol. 2015;151(6):632-6.

    2 Gill L, Zarbo A, Isedeh P, Jacobsen G, Lim HW, Hamzavi I. Comorbid autoimmune diseases in patients with vitiligo: a cross-sectional study. J  Am      Acad Dermatol. 2016 Feb;74(2):295-302.

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