The latest chemical peels and lasers are revolutionizing the way dermatologists approach such basic skin conditions as acne and rosacea. Whether patients are dealing with acne that has not responded to topical or oral medications, or if they are looking to reduce the redness and dilated blood vessels of rosacea, dermatologists now have a variety of treatment therapies that can be used in combination to successfully treat acne, rosacea and residual scarring.
Speaking at the American Academy of Dermatology’s Derm Update in August 2001, dermatologist Allison T. Vidimos, MD, Staff Member, Department of Dermatology, Section of Dermatologic Surgery and Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, discussed the latest techniques for the successful management and treatment of acne and rosacea.
"Both of these conditions can have devastating effects on self-esteem because they are so noticeable," said Dr. Vidimos. "Teenagers and young adults who have acne often feel isolated and self-conscious. Adults with rosacea are often caught unaware because they assumed they had outgrown skin conditions. But now both acne and rosacea can be treated with combination therapies, such as chemical peels and lasers, that are having successful results."
ACNE
Acne is a chronic inflammatory disease of the sebaceous hair follicles. Each follicle contains a tiny hair and multiple sebaceous glands. Under normal circumstances, sebum, the oily substance made by the sebaceous glands, travels up the hair follicle and out to the skin’s surface. However, with acne, sebum is trapped within the follicle and skin bacteria multiplies within the clogged pores. Acne develops on those areas of the skin where sebaceous glands are most numerous: the face, scalp, neck, chest, back, and upper arms and shoulders. Acne typically begins in adolescence, although onset in the twenties or thirties is common.
Depending on the type of acne and the extent of the condition, acne can be treated with oral or topical antibiotics or topical retinoids, which may be used alone or in combination. Isotretinoin, a potent drug that requires close monitoring, is sometimes prescribed for severe cystic acne. "If antibiotics and retinoids are not successfully managing acne, dermatologists can utilize chemical peels to ‘unroof’ acne pustules and exfoliate the skin," said Dr. Vidimos. "This exfoliations allows antibiotics and topical retinoids to penetrate the skin more easily to control acne and prevent further outbreaks."
The glycolic acid peel is one of the most common peels to treat acne. Glycolic acid is an alpha hydroxy acid, which when used in combination with oral or topical medications, can hasten the response of acne to treatment by reducing the amount of sebum being trapped in the follicles. Glycolic acid peels exfoliate dead layers of the skin and, typically, require no downtime. These peels are performed every two to four weeks in a series of four-to-eight sessions.
The benefits of glycolic acid can also be found in cosmetic products, such as moisturizers and sunscreens, which when used daily, contribute to continued clearing of the skin. If patients are using a daily glycolic acid product, a topical or oral antibiotic can be added to this regimen, especially for those with red, swollen, or pus-filled lesions. Glycolic acid products are also considered safe for use during pregnancy.
Salicylic acid peels are also used to treat acne. Salicylic acid is a beta hydroxy acid that is oil soluble and can therefore penetrate oil plugged pores. When used as a peel, the treatment can be repeated at two-to-four week intervals. However, many cosmetic preparations now include alpha and beta hydroxy acids, allowing for exfoliation of the skin on a daily basis.
Though neither oral nor topical antibiotics improve the appearance of acne scars, dermatologists have a number of treatment options for these scars, which persist long after acne disappears.
"Acne scars are unique in their appearance and often have complex characteristics that must be taken into account, like depth, shape, and location," said Dr. Vidimos. "Treating acne scarring with dermatologic surgery involves determining the individualized treatment plan which will give the patient the most successful result."
The latest treatment options for acne scarring are lasers, such as the pulsed carbon dioxide (CO2) laser and the Erbium:YAG laser.
The CO2 laser vaporizes thin layers of the skin and tightens collagen fibers, which makes it an appropriate treatment for depressed acne scars. The Erbium:YAG laser vaporizes thinner layers per pass and produces very precise bursts of energy which allows for the sculpting of smaller, irregular scars. The CO2 laser treated skin heals in seven-to-10 days, while the Erbium:YAG laser treated sites heal in three-to-five days.
However, laser resurfacing is not always effective for acne scars, especially depressed, crater-like scars. An option for improving the appearance of these scars is soft tissue augmentation. Patients can opt to use their own fat from another part of their body to correct the deep contour, or they can use soft tissue fillers like collagen, hyaluronic acid or fascia lata. Because the replaced fat reabsorbs into the skin, this treatment typically lasts six-to-18 months.
"It is very important for patients to seek early treatment for acne in order to get the condition under control," said Dr. Vidimos. "By visiting a dermatologist as early as possible, many patients with acne may avoid permanent acne scarring."
ROSACEA
Lasers and chemical peels are also being used to successfully treat rosacea, a chronic and often progressive skin disease that causes redness and swelling on the face. As many as 14 million Americans have rosacea, most between the ages of 30 and 50. It most commonly affects fair-skinned individuals. Rosacea may begin as a tendency to flush or blush easily, and progress to persistent redness in the center of the face that may gradually involve the cheeks, forehead, chin, and nose. As the disease progresses, the redness becomes more severe and persistent, and small blood vessels, acne-like pimples, and nodules may become visible on the surface of the skin. Rosacea can be exacerbated by exposure to extremes of hot and cold, sunlight, emotional stress, hot beverages, alcohol, spicy foods and certain skin care products.
Treatment of rosacea includes avoidance of the known exacerbating dietary, environmental and emotional factors that may cause flare-ups, as well as utilizing smart sun safety including wearing a broad-spectrum sunscreen, protective clothing and hats, and avoiding the sun. Medical therapy includes oral and topical antibiotics.
Glycolic acid peels are often used in conjunction with antibiotics to hasten the control of rosacea. A series of peels are performed every two-to-four weeks and may be used in combination with low concentration glycolic acid washes and creams. Glycolic acid peels for rosacea are timed and generally take three-to-five minutes. The peeled facial skin will be red for a few hours following the treatment and makeup should be avoided during this time.
While topical or oral therapies do not remove the redness on the face or reduce the appearance of dilated blood vessels associated with rosacea, vascular lasers and intense pulsed light therapy are now being used to treat these conditions.
Vascular lasers emit specific wavelengths of light targeted for the tiny visible blood vessels just under the skin. Heat from the laser's energy builds in the vessels, causing them to collapse. The newest generation of vascular lasers does not produce any bruising, but may cause redness and minimal swelling that lasts approximately 24-to-48 hours.
Intense light and laser therapy uses multiple wavelengths of light to treat dilated blood vessels in the face. Both treatments, laser and intense light and laser sources, take 15-to-30 minutes and are performed at six-to-12 week intervals. Patients may require several treatments initially, and may return annually for treatment of new blood vessels.
In advanced cases of rosacea, rhinophyma may develop, a condition that occurs when oil glands enlarge on the face and a bulbous, enlarged red nose and swollen cheeks develops. This condition usually occurs in men over 40. The excess tissue can be surgically removed using lasers, dermabrasion or electrosurgery to sculpt the nose back down to a more normal shape and appearance. These procedures may be performed on an outpatient basis using local anesthesia, and healing generally takes seven-to-10 days.
"It’s important for individuals with acne or rosacea to seek treatment early to avoid progression of the conditions and avoid any permanent scarring to the face, " said Dr. Vidimos. "Today’s dermatology offers a variety of treatment options that can achieve successful results and fit into even the busiest lifestyle."
